Lazarus Syndrome: Clinical Recognition and Management Protocol
Definition and Clinical Significance
Lazarus syndrome (autoresuscitation) is the spontaneous return of circulation after cessation of cardiopulmonary resuscitation, occurring in approximately 76 documented cases worldwide as of 2022, with return of spontaneous circulation (ROSC) typically occurring within 10 minutes of stopping CPR. 1, 2
The phenomenon was first described by K. Linko in 1982 and named by J.G. Bray in 1993 after the biblical resurrection story. 1 Cases have been reported in patients ranging from 9 months to 97 years old, following resuscitation attempts lasting 6 to 90 minutes. 1
Pathophysiological Mechanisms
The most plausible scientific explanation involves auto-PEEP (positive end-expiratory pressure) and impaired venous return during active chest compressions. 2 When CPR is discontinued, the release of intrathoracic pressure allows improved venous return and cardiac filling, potentially triggering spontaneous cardiac activity. 2, 3
Additional proposed mechanisms include:
- Dynamic hyperinflation causing mechanical impediment to venous return during active resuscitation 2
- Delayed drug action from medications administered during CPR (epinephrine, amiodarone) reaching effective concentrations after cessation 1, 3
- Hyperventilation-induced alkalosis during resuscitation efforts 1
- Hypothermia providing myocardial protection 1
- Metabolic disorders (particularly hyperkalemia) 1
- Unobserved minimal vital signs during the declaration of death 1
Clinical Characteristics
Most documented cases share these features:
- Non-shockable rhythms (asystole or pulseless electrical activity) were present at the time of cardiac arrest in the majority of cases 1
- Multiple comorbidities were present in most patients 1
- Acute myocardial infarction was a common precipitating event, particularly in elderly patients 4, 3
- Agonal respirations may persist or gradually become more regular before ROSC 3
Critical Management Protocol
Mandatory Post-Resuscitation Monitoring Period
After discontinuing CPR and declaring death, patients must be continuously monitored with ECG and pulse checks for at least 10 minutes before confirming death. 1, 2 This recommendation is based on the observation that ROSC occurred within 10 minutes in most documented cases. 2
Specific Intervention Before Stopping CPR
In patients with pulseless electrical activity (PEA) or asystole, consider a trial period of apnea (30-60 seconds) before declaring death to allow resolution of potential auto-PEEP. 2 This brief cessation of positive pressure ventilation may relieve dynamic hyperinflation and restore venous return.
Post-ROSC Care When Lazarus Phenomenon Occurs
If spontaneous circulation returns after cessation of CPR, immediately implement standard post-cardiac arrest care:
- Avoid hypoxia by ensuring adequate oxygenation 5
- Avoid hyperoxia once arterial oxygen can be measured reliably 5
- Use 100% inspired oxygen until arterial oxygen saturation or partial pressure can be measured 5
- Maintain PaCO2 within normal physiological range as part of post-ROSC bundle 5
- Target hemodynamic goals including mean arterial pressure and systolic blood pressure 5
- Implement targeted temperature management (TTM) between 32°C and 36°C for at least 24 hours in patients who remain unresponsive 5
- Treat seizures if they occur, but do not use routine seizure prophylaxis 5
Prognostication Considerations
Do not use clinical criteria alone before 72 hours after ROSC to estimate prognosis, particularly in patients treated with TTM. 5 A multimodal approach incorporating clinical examination, biomarkers, electrophysiology, and imaging should be used for prognostication. 5
Six patients with documented Lazarus phenomenon achieved full neurological recovery, demonstrating that favorable outcomes are possible. 1 One case report documented complete recovery without neurological sequelae after hospital discharge. 3
Practical Implications for Death Certification
The phenomenon has significant medicolegal implications, as premature death certification can result in allegations of medical negligence. 4 One forensic case documented a patient who was found moving in the hospital mortuary 20 minutes after death declaration, subsequently surviving 4 additional days. 4
Recommended Death Confirmation Protocol
- Continue ECG monitoring for minimum 10 minutes after cessation of resuscitation 1, 2
- Observe for agonal respirations that may become more regular, heralding ROSC 3
- Perform serial pulse checks during the observation period 2
- Document absence of cardiac electrical activity throughout the monitoring period 4
- Exercise particular caution in elderly patients with acute myocardial infarction 4
Special Considerations in COVID-19
The Lazarus phenomenon has been documented in COVID-19 patients, with one case reporting ROSC 20 minutes after 40 minutes of unsuccessful resuscitation in a 79-year-old patient with septic shock. 6 The pathophysiological changes in COVID-19 may warrant even more cautious approaches to terminating resuscitation. 6
Reporting and Documentation
Lazarus phenomenon is likely significantly underreported in medical literature. 1, 2 Healthcare providers should document and report cases to improve understanding of this phenomenon and refine clinical protocols. 1