What should be done if a patient with a Do Not Resuscitate (DNR) order goes into cardiac arrest during surgery in the Operating Room (OR)?

Start Resuscitation Immediately in the Operating Room

For a patient with a DNR order who experiences cardiac arrest during surgery in the OR, you should initiate full resuscitation measures immediately. The DNR order should be suspended during the perioperative period unless explicitly discussed and documented otherwise before the procedure. 1

Rationale for Suspending DNR During Surgery

Pre-Surgical DNR Discussion Requirements

• The anesthesiologist, attending surgeon, and patient (or surrogate) must review DNR orders before surgery to determine their applicability in the operating suite and immediate postoperative recovery period. 1
• This discussion should occur preoperatively because the context of intraoperative cardiac arrest is fundamentally different from medical cardiac arrest—causes are often immediately reversible (hypovolemia, anesthesia complications, surgical bleeding, tamponade) and witnessed by expert providers. 2

Higher Success Rates in the OR

• Cardiac arrest in the OR represents a "higher-success" situation where CPR has substantially better outcomes than typical cardiac arrest scenarios. 3
• The arrest is witnessed, the cause is frequently known, providers have immediate access to advanced interventions, and reversible etiologies are common. 2
• Patients' DNR preferences are typically based on low-success scenarios; when informed about higher-success situations like OR arrests, many patients would consent to resuscitation. 3

Immediate Resuscitation Protocol for Intraoperative Arrest

For Cardiac Surgery Patients Specifically

If this arrest occurred during or immediately after cardiac surgery, follow this algorithm:

• For witnessed VF/VT: Perform immediate defibrillation; if unsuccessful within 1 minute, initiate CPR. 4
• For asystole/bradycardia with pacing wires in place: Attempt immediate pacing; if unsuccessful within 1 minute, initiate CPR. 4
• If initial interventions fail within 5 minutes, proceed to emergency resternotomy (if chest was recently closed) to enable open-chest CPR, which generates superior hemodynamics. 5, 6

For Non-Cardiac Surgery

• Apply standard ACLS protocols with modifications for the perioperative setting. 2
• Rapidly identify and treat reversible causes specific to the OR: hypovolemia, gas embolism, hyperkalemia, anaphylaxis, local anesthetic toxicity, or surgical complications. 2
• The surgical team should immediately address any surgical source of arrest (bleeding, vascular injury, etc.). 2

Critical Ethical and Legal Considerations

Why DNR Suspension is Standard Practice

• A DNR order does not automatically apply during surgery unless this was explicitly negotiated and documented preoperatively. 1
• The American Heart Association guidelines explicitly state that DNAR orders should be reviewed before surgery to determine perioperative applicability. 1
• Proceeding with surgery while maintaining an active DNR creates an ethical contradiction—the patient consented to surgical intervention with its inherent risks, implying acceptance of resuscitation for procedure-related complications. 3

Documentation Requirements

• If the patient had wanted the DNR to remain in effect during surgery, this should have been documented as a specific limitation (e.g., "DNR to remain in effect intraoperatively"). 1
• Without such explicit documentation, the standard of care is to suspend DNR and provide full resuscitation. 1

Common Pitfalls to Avoid

• Never assume DNR applies intraoperatively without explicit preoperative discussion and documentation. 1
• Do not delay resuscitation to seek family clarification—in the OR, immediate action is required for reversible causes. 2
• Avoid giving full-dose epinephrine in post-cardiac surgery arrests due to risk of rebound hypertension and bleeding, but this doesn't apply to withholding resuscitation entirely. 5
• Failure to have the preoperative DNR discussion is the root cause of this dilemma; this conversation should be standard practice before any surgery in DNR patients. 1

Post-Resuscitation Management

After achieving return of spontaneous circulation:

• Immediately discuss with the patient (if able) or surrogate whether to reinstate the DNR order. 1
• Document the intraoperative arrest, resuscitation efforts, and updated goals of care discussions. 1
• The DNR can be reinstated postoperatively if that remains consistent with the patient's wishes. 1