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Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

ESAIC/ESTES · 2023 · Europe

Source and licence

Authors
Jochen Hinkelbein, Janusz Andres, Bernd W Böttiger et al.
Title
Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery
Journal
European Journal of Trauma and Emergency Surgery, 2023
DOI
10.1007/s00068-023-02271-3
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC10520188

Licence statement of the original publication

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Monitoring

  • Studies evaluating standard and haemodynamic monitoring are animal based. These are not comparable with human studiesEvidence: Recommendations based on expert opinion only
  • Use of end-tidal CO2 monitoring in intubated patients during CPR may help to predict the likelihood of return of spontaneous circulation and survival as well as guiding CPR, despite the lack of absolute cut-off valuesEvidence: Weak recommendation moderate quality evidence (2B)
  • Invasive blood pressure monitoring during closed chest compression could potentially improve quality and optimise the timing of adrenaline administrationEvidence: Weak recommendation, low quality evidence (2C)
  • Besides standard (and invasive) monitoring, if the expertise is present, the equipment available, and the patient’s condition allows it, transoesophageal echocardiography is suggested during a peri-procedural cardiac arrest to identify the aetiology of the arrest and guide further managementEvidence: Weak recommendation, low-quality evidence (2C)

Introduction

  • We recommend closed chest cardiac compression for patients with cardiac arrestEvidence: Strong recommendation, low quality evidence (1C)
  • Open chest cardiac massage should be considered if return of spontaneous circulation has not been achieved with closed chest cardiac compression and VA-ECMO is not availableEvidence: Weak recommendation, low quality evidence (2C)

Gas embolism during laparoscopy

  • We recommend closed chest cardiac compression for patients with a gas embolism who develop a cardiac arrestEvidence: Strong recommendation, low quality evidence (1C)

Pulmonary Embolism

  • VA-ECMO should be considered for restoring circulation and oxygenation as a bridge to definitive treatment. Also consider thrombolysis if extra-corporeal membrane oxygenation is not availableEvidence: Strong recommendation, low quality evidence (1C)

Pulseless rhythms

  • Cardiac arrest presenting with ventricular fibrillation in the perioperative setting should be treated with immediate defibrillationEvidence: Strong recommendation, moderate quality evidence (1B)
  • Cardiac arrest presenting with pulseless ventricular tachycardia in the perioperative setting should be treated with immediate defibrillationEvidence: Strong recommendation, moderate quality evidence (1B)
  • For asystole with p-waves, emergency temporary pacing should be performed. Reversible causes should be addressed without delayEvidence: Weak recommendation, moderate‐quality evidence (2B)

Haemorrhage

  • We suggest simultaneous haemorrhage control, massive transfusion, and closed chest compressionsEvidence: Strong recommendation, low quality evidence (1C)
  • We suggest simultaneous volume replacement and closed chest compressionsEvidence: Weak recommendation, low quality evidence (2C)
  • If there is no return of spontaneous circulation despite adequate volume therapy, open chest cardiac massage may be consideredEvidence: Weak recommendation, low‐quality evidence (2C)

Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy

  • In patients with exsanguinating infra-diaphragmatic haemorrhage uncontrollable by other means we suggest immediate use of resuscitative endovascular balloon occlusion of the aortaEvidence: Weak recommendation, low quality evidence (2C)
  • We suggest the use of either resuscitative thoracotomy with cross-clamping of the descending aorta or resuscitative endovascular balloon occlusion of the aortaEvidence: Weak recommendation, low quality evidence (2C)

Tension pneumothorax

  • We recommend immediate decompression of suspected tension pneumothoraxEvidence: Strong recommendation, low quality evidence (1C)
  • We recommend needle decompression immediately if tension pneumothorax is the proven or suspected cause of the cardiac arrestEvidence: Strong recommendation, low quality evidence (1C)
  • We recommend finger thoracotomy or a chest tube insertion after any needle decompression attemptEvidence: Strong recommendation, low quality evidence (1C)

Cardiac tamponade

  • In suspected cardiac tamponade, point of care ultrasound should be used to confirm the diagnosisEvidence: Strong recommendation, low-quality evidence (1C)

CCC or OCCM

  • We recommend closed chest compressions for patients with cardiac arrestEvidence: Strong recommendation, low quality evidence (1C)
  • Open chest cardiac massage may be considered if return of spontaneous circulation has not been achieved with closed chest compressions and if VA-ECMO not availableEvidence: Weak recommendation, low quality evidence (2C)

Pericardiocentesis

  • In the case of cardiac tamponade, we recommend immediate decompression of the pericardiumEvidence: Strong recommendation, low-quality evidence (1C)
  • Immediate decompression can be achieved by either ultrasound guided pericardiocentesis or, in the case of a haemopericardium, by resuscitative thoracotomyEvidence: Strong recommendation, low-quality evidence (1C)

Cardiac arrest team training

  • When training for peri-operative cardiac arrest, we suggest a co-ordinated protocol to improve the quality of mechanical cardiopulmonary resuscitationEvidence: Weak recommendation, low‐quality evidence (2C)
  • We suggest simulation training since experience and training of healthcare providers increases the likelihood of return of spontaneous circulationEvidence: Weak recommendation, low‐quality evidence (2C)

Haemorrhage

  • We suggest simultaneous volume replacement and closed chest compression.

Training of healthcare providers

  • We suggest simulation training since experience and training of healthcare providers increases the likelihood of the return of spontaneous circulation.

Abstract

Introduction: Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines.

Material And Methods: The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.

Results: This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy.

Conclusions: Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.

Supplementary Information: The online version contains supplementary material available at 10.1007/s00068-023-02271-3.

Contents of the original publication

The section headings of the original.

  • Introduction
  • Material and methods
  • Objectives
  • Definitions
  • Criteria for considering studies for data analysis
  • Types of interventions
  • Search methods for identification of studies
  • Electronic searches
  • Additional resources
  • Data collection and analysis
  • Assessment of quality of the evidence
  • Development of recommendations
  • Results
  • Identification of cardiac arrest
  • Management of cardiac arrest
  • Management of complications during surgery
  • Pulmonary embolism
  • Pulseless rhythms
  • Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy
  • OR
  • Tension pneumothorax
  • Cardiac tamponade
  • Pericardiocentesis
  • Preparational aspects of cardiac arrest
  • Training of healthcare providers
  • Clinical best practice statements
  • Withdrawing therapy
  • Conclusions

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