Start Resuscitation Immediately
You should initiate full resuscitative efforts (Answer B) because DNR orders are typically suspended during the perioperative period when cardiac arrest results from reversible procedural causes, and this suspension should have been discussed and documented before the surgery. 1, 2
Rationale for Perioperative DNR Suspension
The operating room represents a unique clinical context where cardiac arrest has fundamentally different characteristics and outcomes compared to other settings:
Intraoperative cardiac arrest has substantially higher survival rates because arrests typically result from readily reversible causes including cardiovascular response to anesthesia induction, vagal responses, hypoxia, hypovolemia, and hemorrhage—not from underlying terminal disease progression 1
Continuous monitoring and immediate presence of trained personnel allow for instant detection and treatment, fundamentally changing the risk-benefit calculation compared to ward-based arrests 1
The American Heart Association explicitly mandates that DNR orders must be reviewed before surgery by the anesthesiologist, attending surgeon, and patient or surrogate to determine their applicability in the operating suite 2
Standard Practice Guidelines
The evidence strongly supports a default position of resuscitation in the OR:
It is usually appropriate to suspend a DNR recommendation during the perioperative period when cardiac arrest results from treatable and potentially reversible procedural causes 1
The suspension should have been discussed and agreed upon with the patient prior to the procedure, with clear documentation in the medical record 1
DNR orders are recommendations rather than legally binding directives, allowing clinical judgment in emergency situations 1
Immediate Actions Required
Proceed with standard ACLS protocol:
Maintain high-quality chest compressions at a rate of at least 100/minute with adequate depth (at least 2 inches in adults) 1
Minimize interruptions in compressions and allow complete chest recoil after each compression 1
Rapidly assess for procedure-specific causes: vagal response from surgical manipulation, anesthesia-related cardiovascular depression, hemorrhage, or other surgical complications 1
The benefit of providing CPR outweighs any potential risk, as the risk of injury from CPR is low (rib/clavicle fractures 1.7%, with no visceral injuries typically reported) 1
Post-Cardiac Surgery Context
If this was cardiac surgery specifically, additional considerations apply:
For patients with cardiac arrest following cardiac surgery, it is reasonable to perform resternotomy in an appropriately staffed and equipped intensive care unit (Class IIa recommendation) 3
The incidence of cardiac arrest following cardiac surgery is 1-3%, with causes including readily reversible conditions such as ventricular fibrillation, hypovolemia, cardiac tamponade, or tension pneumothorax 3
Documentation Requirements
After successful resuscitation:
Document the cardiac arrest event, duration of CPR, interventions performed, and outcome 1
Record the rationale for continuing resuscitation despite DNR status, citing the perioperative exception 1
Once the patient is stabilized and has capacity, or when surrogate decision-makers are available, discuss whether the DNR order should be reinstated 1
Critical Pitfall to Avoid
The most common error is assuming that a pre-existing DNR order automatically applies in the OR without prior discussion. The American Heart Association guidelines are clear that three options exist for managing DNR orders during surgery: full suspension, procedure-directed approach, or full continuation of DNR—but each requires explicit preoperative discussion and documentation 2. In the absence of documented evidence that the patient specifically wanted the DNR to remain in effect during surgery, the default position is to resuscitate 1, 2.
What DNR Does NOT Prohibit
Even if there was ambiguity about the DNR status:
Use of drugs from the cardiac arrest algorithm (epinephrine, atropine, antiarrhythmics) to treat bradycardia, hypotension, or arrhythmia during anesthesia is not prohibited by DNR orders 1
Defibrillation or synchronized cardioversion for suddenly occurring arrhythmia is not prevented by advance decisions to refuse CPR 1
Giving chest compressions to expedite circulation of drugs in the face of low cardiac output (distinct from cardiac arrest) is not considered CPR and is not covered by DNR orders 1