On arrival in the recovery unit in the late evening a patient was found to be unresponsive with shallow breathing and unrecordable SpO2. They rapidly went into cardiac arrest, requiring advanced life support. After return of spontaneous circulation, the patient was transferred intubated and ventilated, with vasopressor support to critical care. The anaesthetic team was present during the incident.

Commentary

The NAP 7 audit described 30 cardiac arrests in recovery, 10 of which would have been prevented with better patient monitoring in theatre and during transfer from theatre to the recovery area¹.  Patients should not be transferred from theatre to recovery after extubation until there is a patient airway, adequate respiratory effort and cardiovascular stability. All patients should be monitored during transfer.²

1. Cordingly, J; Nolan, J; Soar, J and Cook, T. Chapter 39: Postoperative cardiac arrests in recovery, critical care and ward areas. At the Heart of the Matter: Report and findings of the 7^th National Audit Project of the Royal College of Anaesthetists examining perioperative cardiac arrest. Royal College of Anaesthetists, Nov. 2023
2. Klein, AA et al. Recommendations for standards of monitoring during anaesthesia and recovery, 2021. Guideline from the Association of Anaesthetists. 2021 May. 76(9): 1212-1223