CASE 1

A patient in their 80s was admitted for Hemiarthroplasty on the trauma list. Spinal anaesthesia and sedation were administered. After bone marrow cementing the patient suffered a cardiac arrest. CPR followed the advanced life support guidelines. Within a minute the patient showed signs of life but required pharmacological support to maintain their blood pressure. The lead anaesthetist was present throughout and the intensivist team were consulted about ICU/HDU admission. A decision was made not to offer Level 2 or 3 critical care due to the presence of multiple co-morbidities and reduced functional capacity. The patient recovered full consciousness and was transferred to recovery.

The patient’s family were subsequently contacted and following discussion a ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) form and DNCPR were documented. The family were allowed to join the patient for few hours in recovery. Shortly after weaning IV vasoactive medication the patient passed away.

CASE 2

A patient in their 90s underwent surgical stabilisation of a hip fracture during which they suffered a 2000ml blood loss. A metaraminol infusion was required to support their blood pressure, which had to be increased on admission to recovery. Despite this, the patient deteriorated and died. The anaesthetic team were present throughout.

Commentary

Authors of the NAP7 report on Perioperative cardiac arrest¹ suggest that a discussion about management of cardiac arrest during surgery should be had with any patient with a clinical frailty score of 5 or more; ASA score of 5 or objective risk scoring for early mortality of more than 5%. This would almost certainly include these two cases. The national audit data however showed that there was a DNACPR recommendation in only 25% of older, frail patients who suffered perioperative cardiac arrest.

The Association of Anaesthetist’s recommend that anaesthetists should have an early pre-operative discussion about peri-operative management including CPR.² Because survival rates from peri-operative cardiac arrest are higher than in other settings, it is recommended that DNACPR orders are suspended peri-operatively in most cases.  The Resuscitation Council devotes a chapter to decisions about CPR in their Advanced Life Support Manual,³ including suggestions for how to undertake discussion based on shared decision making, and when it is appropriate not to attempt CPR.

Any discussion should be documented in detail, including the understanding, values and fears of the patient. Such records (or DNACPR forms) are not legally binding instructions but instead have the status of recommendations to guide decision making.

1. Royal College of Anaesthetists. At the Heart of the Matter. Report and findings of the 7th National Audit Project of the Royal College of Anaesthetists examining Perioperative Cardiac Arrest, London, 2023
2. Meek T, Clyburn P, Fritz Z, Pitcher D, Ruck Keene A, Young PJ. Implementing advance care plans in the peri-operative period, including plans for cardiopulmonary resuscitation: Association of Anaesthetists clinical practice guideline. Anaes 2022; 77(4): 456-62
3. Resuscitation Council UK. Advanced Life Support (8^th), 2021