Cardiac resuscitation in the operating room: reflections on how we can do better.

‘‘The man who comes to the hospital carrying his valise should walk out of the hospital carrying his valise.’’ These wise words were told to me long ago by a mentor who was advising me that our first obligation is to heal our patients and, in the course of that healing, to keep our patients safe from harm. That advice applies to all of medicine. Since their initial use, the administration of anesthetic agents has been accompanied with tremendous benefit and considerable risk. Not long after ether was introduced, the deaths of patients were reported, many young and undergoing minor procedures. As medical knowledge has developed, anesthesia has become safer, but risk remains. Cardiac arrest in the operating room, the most severe expression of that risk, remains an infrequent but catastrophic event, and many factors can contribute when it occurs. There are many causes of cardiac arrest in the operating room; nevertheless, reversible causes are of primary concern here, particularly those that may be related to the anesthetic. Cardiac arrest in the operating room is different from cardiac arrest occurring elsewhere in the hospital or outside the hospital environment. In the operating room, arrests are generally recognized quickly, mainly because of sophisticated physiologic monitoring, with pulse oximetry, capnography, and end-tidal CO2 complementing routine blood pressure and electrocardiogram measurements. Patients are in an ideal setting for the rapid administration of oxygen, often with secure controlled airways and immediate intravenous access. Defibrillators and resuscitation drugs are usually readily available along with personnel who are familiar with their use, and chest compressions can be initiated immediately. The foregoing factors taken together facilitate generally higher survival rates from operating room cardiac arrests, particularly if the arrest is related to anesthesia. Thus, general guidelines for treating cardiac arrest in general hospital wards or outside the hospital do not necessarily translate well to the operating room setting. In this issue of the Journal, two articles deal with an aspect of this problem. In their article, Moitra et al. focus on the treatment of cardiac arrest in the operating room. They specifically address how such events differ from their occurrence in other locations, and they provide an in-depth discussion of the special characteristics. They propose a set of algorithms designed to guide anesthetic care, first to avoid cardiac arrest and second to treat it if it should occur. Moitra et al. make a significant contribution to the management of this problem, but there is still a significant step to accomplish. Even armed with these modified algorithms, we still face a considerable challenge to make the algorithms easily usable in the clinical setting. In a recent editorial, de Caen and Bhanji extend the discussion on resuscitation to include children and infants, and they provide a practical update on pediatric resuscitation for the anesthesiologist. They concisely summarize the most current scientific evidence and expert opinion, and they encourage anesthesiologists to adopt the new rearrangement of the classic airway-breathing-circulation (ABC) approach to cardiopulmonary resuscitation (CPR) to a compression first approach, i.e., compressions-airwaybreathing, making CPR more consistent across age groups. Also in the current issue of the Journal, an article by Charapov and Naveen presents a case of prolonged and successful resuscitation of a patient undergoing an urgent abdominal procedure. The case report joins others in the W. R. Berry, MD (&) Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA e-mail: wberry@hsph.harvard.edu