CASE 1

Whilst waiting for a spinal block to develop the patient began coughing but remained cardiovascularly stable. Treatment for anaphylaxis followed advanced life support guidelines, and assistance was sought via the emergency buzzer. The patient become unresponsive and cardiac arrest was confirmed. A decision was made to stop resuscitation after two cycles as the patient was not for cardiopulmonary resuscitation and no reversible causes were identified. Death was confirmed.

CASE 2

The patient passed away in theatre following surgery, still intubated. A Consultant Anaesthetist, another anaesthetist, and an anaesthetic nurse were present.  A DNACPR was in place for the patient and had been discussed and agreed during the team brief. No CPR was performed, as the plan was to provide reversible treatment only.

CASE 3

A patient, in their late 90s, underwent a six-hour intramedullary nail procedure. They had extensive comorbidities including bowel cancer (elected not for intervention), a clinical frailty score of 7 and a DNACPR for ward-level care. The patient could only mobilise with a walking frame and required assistance for personal care.

On arrival in recovery, the patient had a Glasgow coma score of 14, and an infusion of metaraminol had to be increased to support the BP. A few moments after being given a 50mcg bolus of fentanyl the low oxygen saturation alarm sounded, the saturation trace was lost and arterial trace became obtunded. A central pulse was present. The patient became bradycardic, then transiently asystolic, before ROSC with persisting bradycardia.  Despite DNACPR it was decided this was a reversible medication-related event. The patient received 400 mcg naloxone, 200 mcg adrenaline, and oxygen via a Waters circuit. The patient rapidly started self-ventilating with a heart rate  of 70–90 bpm.

Commentary:

In the first case the presumed cause of cardiac arrest was anaphylaxis. ROSC is more likely after anaphylaxis-induced cardiac arrest than other causes.  It occurred because the patient was anaesthetised. In the light of both, suspension of pre-existing DNAR order should have been considered, especially if the peri-operative situation had not been specifically addressed.  Research from NAP 7 showed that very few patients who have a pre-existing DNAR in place have a perioperative cardiac arrest and when cardiac arrest did occur, ROSC was achieved in 57%¹.  

Reference

1. Nolan JP, Soar J, Kane AD, Moppett IK et al. Peri-operative decisions about cardiopulmonary resuscitation among adults as reported to the 7th National Audit Project of the Royal College of Anaesthetists. Anaes, 2024, 79: 186-192. https://doi.org/10.1111/anae.16179