Episode #264 Rethinking Resuscitation in the Operating Room: Beyond ACLS

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are excited to be kicking off our series on the June 2025 APSF Newsletter. There are so many good articles and so much to talk about as we work towards improved patient safety.

Before we dive further into the episode today, we’d like to recognize Vertex, a major corporate supporter of APSF. Vertex has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Vertex – we wouldn’t be able to do all that we do without you!”

To kick off our series we are starting with the Editorial. Our featured article today is “Editorial: Cardiac Arrest in the Operating Room: Reevaluating Advanced Cardiovascular Life Support” by Zachary Smith. To follow along with us, head over to APSF.org and click on the Newsletter heading. The first one down is the current newsletter. Then, scroll down until you get to our featured article today. I will include the link in the show notes as well.

Before we get into the article, we are going to hear from the author. Let’s take a listen now.

[Smith]  Hi there. My name is Zachary Smith. I am a CRNA, working at First Health of the Carolinas, over in Pinehurst, North Carolina, and I am non-regular ranked faculty at Duke University’s nurse anesthesia program. Additionally, I’m currently going for my PhD at East Carolina University.”

[Bechtel] I asked Smith why he feels so passionate about this topic. Here is his response.

[Smith]  “Well, I’m passionate about this because as anesthesia providers, we’re constantly playing the what if game. We have to be ready for the rare but life-threatening emergencies that can unfold without warning at any time. Unfortunately, the research shows that our biannual BLS and ACLS training just isn’t enough to keep those critical skills sharp.

Events like malignant hypothermia, LAST, or intraoperative MI demand immediate expert action. And that’s why I believe in pushing for better training and more specifically, more relevant preparation. Because when the moment comes, we don’t get that second chance.

[Bechtel] Thank you so much to Smith for helping to introduce this important topic. Are you uptodate with your ACLS and BLS certification? When was the last time you completed your training? When was the last time that you had to provide advanced cardiac life support in the operating room? Were you prepared? These are important questions for anesthesia professionals who need to be prepared for emergencies in the operating room when time is of the essence. And now its time to get into the article.

Advanced Cardiovascular Life Support or ACLS guidelines are the global standard for resuscitation efforts for sudden cardiac arrest and emergency interventions. For those of us who work in the operating room, there may be some limitations of ACLS in the intraoperative environment. Specialized guidance from the American Society of Anesthesiologists, ASA, Perioperative Resuscitation and Life Support certification is an important resource to help guide resuscitation efforts in the unique setting of the operating room and can help keep patients safe during surgery and anesthesia. I will include a link to this resource in the show notes as well.

Before we talk more about this resource from the ASA, let’s return to the ACLS guidelines. The ACLS guidelines were developed initially to help manage out of hospital cardiac arrest and in-hospital emergencies. The focus of the guidelines is to have a standard protocol that can be universally applied. The foundation of the ACLS guidelines includes the following:

Early recognition of cardiac arrest

High-quality chest compressions

Airway management

The use of defibrillation and pharmacologic support.

While the principles of ACLS are important for cardiac arrest and emergencies that occur in the operating room, there are often complex variables and specific interventions that need to be addressed as well. We can see this difference if we look at the etiology of cardiac arrest that occurs in different locations. Cardiac arrest outside the operating room is often from an acute arrhythmic event. In the operating room, cardiac arrest may be from major hemorrhage, embolism, hypoxemia, or drug reaction including malignant hyperthermia, local anesthetic systemic toxicity, or anaphylaxis.

The interventions for many of these perioperative emergencies go beyond the standard ACLS algorithm, but anesthesia professionals need to be able to act immediate and deliver the precise intervention. A good example of this is the resuscitation efforts for patients with local anesthetic systemic toxicity or LAST. ACLS guidelines highlight early administration of epinephrine following cardiac arrest. In the case of LAST, the epinephrine dose is much smaller, less than 1 mcg/kg, and this must be followed by administration of lipid emulsion therapy without delay and in the correct bolus and infusion doses. Repeated doses of epinephrine during ungoing resuscitation for LAST have been shown to decrease the effectiveness of lipid emulsion therapy with the potential for worse outcomes. Another important consideration for LAST cases is the avoidance of certain medications that may be recommended in the ACLS guidelines including calcium-channel blockers, beta blockers, and lidocaine. It is important to use the specific interventions and protocols for cardiac arrest due to LAST rather than just the standard ACLS guidelines.

The physical environment of the operating room often complicates intraoperative resuscitation efforts. Patients may be positioned prone, lateral, or steep Trendelenburg initially and traditional chest compressions and defibrillation may be impossible or less effective. For patients who have a cardiac arrest in the prone position, repositioning supine may be impractical or delay life-saving interventions. There is new research that reveals that prone CPR can be effective but it requires modifications to the technique and training. This is not included in the ACLS guidelines. Outside the operating room, patients may be repositioned supine safely, but this is not always the case depending on the surgery or the patient. Repositioning may not be possible if surgical hemostasis is not achieved and surgical access is needed to control bleeding.

Another consideration in the operating room is the availability of advanced monitoring that is not included in the ACLS guidelines. Anesthesia professionals are trained to use invasive monitors including arterial blood pressure, central venous pressure and echocardiography to help guide resuscitation in real time and use this data to understand the immediate response to treatment. ACLS guidelines depend on simplified measures of pulse checks and waveform capnography. In the operating room environment, anesthesia professionals are trained to gather and interpret data from additional monitors to make informed decisions during emergencies. Keep in mind that ACLS protocols are often designed for unwitnessed cardiac arrest events whereas in the operating room, cardiac arrest events are witnessed.

As we can see, there is a need for a specialized approach to resuscitation in the intraoperative environment. And now we have made it back to talk about the ASA’s Perioperative Resuscitation and Life Support certificate. This certificate program was created to address perioperative emergencies with the principles of ACLS combined with the knowledge of surgery and anesthesia and the resources available in the operating room. With this training, clinicians practicing in the perioperative environment learn to recognize and treat life threatening conditions that may occur during surgery and anesthesia using tools and strategies that are more applicable to the operating room. There is an focus on rapid identification of the underlying cause of the cardiac instability to help guide resuscitation. This is not the first example of adapting standard resuscitative protocols to the specific needs of the patients. Pediatric and neonatal resuscitation as well as trauma life support all differ from the standard ACLS in order to provide the best possible outcomes for these specific patient populations. The same is true for patients in the perioperative environment. There are limits to the one-size-fits-all strategy when it comes to the unique physiology of neonates or traumatic cardiac arrest and drowning. If we return to the operating room, we can see that the stakes are quite high during a perioperative cardiac arrest with a high risk for significant morbidity and mortality. Anesthesia professionals, surgeons, and perioperative nurses all need to be able to apply rapid and precise management that recognizes the impact of anesthetic pharmacology, surgical factors, and patient positioning. The Perioperative Resuscitation and Life Support certificate provides this necessary training.

The author reminds us that this does not diminish the importance of ACLS but acknowledges the limitations of applying a generalized protocol in a highly specialized environment. Going forward, advanced life support and resuscitation in the operating room should incorporate the principles of ACLS when applicable but not stop there. The highly specialized operating room environment requires a highly specialized approach to advanced cardiac life support that highlights the impact of patient, surgical, anesthetic, and positioning factors.

Smith leaves us with this call to action that I am going to read now: “Adapting resuscitative protocols to specific patient populations and scenarios will ultimately bridge the gap between standardized emergency care and the specialized needs of perioperative patients, ensuring that practitioners are equipped not just to respond, but to do so with precision and efficacy.”

This is an important consideration as we work to improve anaesthesia patient safety.

If you get a chance, we hope that you will check out the ASA’s Perioperative and Life Support Certificate Program which provides training on rescue, unique presentations, and special situations with a web-based curriculum that allows you to learn at your own pace. Upon completion of the course, you will earn a digital eCard that validates your competency in ACLS in the perioperative setting. The course curriculum includes 4 main modules and 8 special situations. Module 1 is Pre-Arrest: The Rescue Concept. Module 2 is Pre-cardiac Arrest in the OR. Module 3 is Arrhythmias and module 4 is Conditions Complicating Arrest in the OR and Periprocedural setting. The special situations include anaphylaxis, gas embolism, hyperkalemia, transfusion reaction, traumatic cardiac arrest, local anesthestic systemic toxicity, neuraxial anesthesia, and malignant hyperthermia. As you can see this training is very applicable for anesthesia professionals. Is this something that you would consider completing? Did I mention that you can earn between 5.75 and 6.25 Patient Safety CME credits? For more details and information, check it out by following the link in the show notes.

Before we wrap up for today, we are going to hear from Smith again. I also asked him what is next for his upcoming research and projects. Let’s take a listen to what he had to say.

[Smith] “I’m currently in school for my PhD at East Carolina University, where I’m looking at the physiologic basis for prone CPR. My DNP research was focused on managing intraoperative cardiac arrest wall prone through the use of prone CPR. During my literature review for that project, I found that prone CPR has actually been associated with higher hemodynamic values compared to traditional CPR, but no one’s really looked into why.

So, I’m really excited to dig a little deeper into the physiological basis for how prone CPR works and what might explain its better hemodynamic profile.

[Bechtel] Thank you so much to Smith for contributing to this show today and for highlighting these important considerations when it comes to responding to cardiac arrest in the operating room.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

The APSF is delighted to announce the inaugural Digital Editor Program. This is a paid, one year program for an anesthesia professional or anesthesia professional in training with a talent for medical communications and digital media. Grow your skills in medical journalism and launch your career with networking and mentorship from the APSF. Deadline is August 1! Check out the link in the show notes or head over to APSF.org for more information.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2025, The Anesthesia Patient Safety Foundation