Anesthesia Patient Safety Podcast
The official podcast of the Anesthesia Patient Safety Foundation (APSF) is hosted by Alli Bechtel, MD, featuring the latest information and news in perioperative and anesthesia patient safety. The APSF podcast is intended for anesthesiologists, anesthetists, clinicians and other professionals with an interest in anesthesiology, and patient safety advocates around the world.
The Anesthesia Patient Safety Podcast delivers the best of the APSF Newsletter and website directly to you, so you can listen on the go! This includes some of the most important COVID-19 information on airway management, ventilators, personal protective equipment (PPE), drug information, and elective surgery recommendations.
Don't forget to check out APSF.org for the show notes that accompany each episode, and email us at podcast@APSF.org with your suggestions for future episodes. Visit us at APSF.org/podcast and at @APSForg on Twitter, Facebook, and Instagram.
Anesthesia Patient Safety Podcast
#264 Rethinking Resuscitation in the Operating Room: Beyond ACLS
Cardiac arrest in the operating room presents unique challenges that standard Advanced Cardiovascular Life Support (ACLS) protocols simply were not designed to address. This eye-opening exploration with APSF author, Zachary Smith, reveals why traditional resuscitation guidelines fall short when emergencies strike during surgery and anesthesia care.
The dynamics of cardiac arrest differ dramatically in the perioperative environment. While out-of-hospital arrests typically stem from arrhythmic events, OR emergencies often result from hemorrhage, embolism, hypoxemia, or critical drug reactions like malignant hyperthermia or local anesthetic toxicity. These scenarios demand immediate, specialized interventions beyond standard ACLS algorithms.
Physical constraints further complicate matters. What happens when cardiac arrest occurs while a patient is positioned prone, lateral, or in steep Trendelenburg? Traditional compressions become impossible, and emerging research suggests prone CPR might actually be superior in some scenarios. Moreover, the advanced monitoring capabilities in the OR – arterial lines, central venous pressure readings, and echocardiography – provide critical data not incorporated into standard protocols.
The American Society of Anesthesiologists has responded with their Perioperative Resuscitation and Life Support Certificate program, addressing these gaps through specialized training that combines ACLS principles with OR-specific knowledge. Ready to enhance your skills beyond basic ACLS? Explore the ASA's certificate program to earn patient safety CME credits while gaining life-saving expertise tailored to the unique challenges of the operating room. Your specialized knowledge could make all the difference when seconds count.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/264-rethinking-resuscitation-in-the-operating-room-beyond-acls/
© 2025, The Anesthesia Patient Safety Foundation
You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.
Speaker 2:Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. We are excited to be kicking off our series on the June 2025 APSF Newsletter. There are so many good articles and so much to talk about as we work towards improved patient safety. Before we dive further into the episode today, we'd like to recognize Vertex, a major corporate supporter of APSF. Vertex has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, vertex. We wouldn't be able to do all that we do without you.
Speaker 2:To kick off our series, we are starting with the editorial. Our featured article today is Editorial Cardiac Arrest in the Operating Room Cardiac Arrest in the Operating Room Re-Evaluating Advanced Cardiovascular Life Support by Zachary Smith. To follow along with us, head over to APSForg and click on the newsletter heading. The first one down is the current newsletter. Then scroll down until you get to our featured article today, and I will include a link in the show notes as well. Before we get into the article, we are going to hear from the author. Let's take a listen now.
Speaker 3:Hi there, my name is Zachary Smith. I am a CRNA working at First Health of the Carolinas over in Pinehurst, north Carolina, and I am non-regular ranked faculty at Duke University's Nurse Anesthesia Program. Additionally, I am currently going for my PhD at East Carolina University.
Speaker 2:I asked Smith why he feels so passionate about this topic. Here is his response.
Speaker 3:Well, I'm passionate about this because, as anesthesia providers, we're constantly playing the what-if game. We have to be ready for the rare but life-threatening emergencies that can unfold without warning at any time. Unfortunately, the research shows that our biannual BLS and ACLS training just isn't enough to keep those critical skills. Sharp Events like malignant hypothermia, last or intraoperative MI demand immediate expert action, and that's why I believe in pushing for better training and, more specifically, more relevant preparation, because when the moment comes, we don't get that second chance. More relevant preparation because when the moment comes.
Speaker 2:We don't get that second chance. Thank you so much to Smith for helping to introduce this important topic. Are you up to date with your ACLS and BLS certification? When was the last time you completed your trainings? When was the last time that you had to provide advanced cardiac life support in the operating room? Were you prepared? These are important questions for anesthesia professionals who need to be prepared for emergencies in the operating room when time is of the essence. And now it's time to get into the article.
Speaker 2:Advanced cardiovascular life support, or ACLS guidelines, are the global standard for resuscitation efforts for sudden cardiac arrest and emergency interventions. For those of us who work in the operating room, there may be some limitations of ACLS in the intraoperative environment. Specialized guidance from the American Society of Anesthesiologists ASA, perioperative Resuscitation and Life Support Certification is an important resource to help guide resuscitation efforts in the unique setting of the operating room and can help keep patients safe during surgery and anesthesia. Don't worry, I will include a link to this resource in the show notes as well. Before we talk more about this resource from the ASA, let's return to the ACLS guidelines. The ACLS guidelines were developed initially to help manage out-of-hospital cardiac arrest and in-hospital emergencies. The focus of the guidelines is to have a standard protocol that can be universally applied. The foundation of the ACLS guidelines includes the following Early recognition of cardiac arrest, high-quality chest compressions, airway management and the use of defibrillation and pharmacologic support.
Speaker 2:While the principles of ACLS are important for cardiac arrest and emergencies that occur in the operating room, there are often complex variables and specific interventions that need to be addressed as well. We can see this difference if we look at the etiology of cardiac arrest that occurs in different locations. Cardiac arrest outside the operating room is often from an acute arrhythmic event. In the operating room, cardiac arrest may be from major hemorrhage, embolism, hypoxemia or drug reaction, including malignant hyperthermia, local anesthetic, systemic toxicity or anaphylaxis. The interventions for many of these perioperative emergencies go beyond the standard ACLS algorithm, but anesthesia professionals need to be able to act immediately and deliver the precise intervention. A good example of this is the resuscitation efforts for patients with local anesthetic systemic toxicity, or LAST. Acls guidelines highlight early administration of epinephrine following cardiac arrest. In the case of LAST, the epinephrine dose is much smaller, less than 1 mic per kg, and this must be followed by administration of lipid emulsion therapy without delay in the correct bolus and infusion doses. Repeated doses of epinephrine during ongoing resuscitation for LAST have been shown to decrease the effectiveness of lipid emulsion therapy, with the potential for worse outcomes. Another important consideration for LAST cases is the avoidance of certain medications that may be recommended in the ACLS guidelines, including calcium channel blockers, beta blockers and lidocaine. It is important to use the specific interventions and protocols for cardiac arrest due to LAST rather than just the standard ACLS guidelines.
Speaker 2:The physical environment of the operating room often complicates intraoperative resuscitation efforts. Patients may be positioned prone, lateral or in steep Trendelenburg initially, and traditional compressions and defibrillation may be impossible or less effective. For patients who have a cardiac arrest in the prone position, repositioning supine may be impractical or delay life-saving interventions. There is new research that reveals that prone CPR can be effective, but it requires modifications to the technique and training. This is not included in the traditional ACLS guidelines. Outside the operating room, patients may be repositioned supine safely, but this is not always the case, depending on the surgery or the patient. Repositioning may not be possible if surgical hemostasis is not achieved and surgical access is needed to control the bleeding. Another consideration in the operating room is the availability of advanced monitoring that is not included in the ACLS guidelines. Anesthesia professionals are trained to use invasive monitors, including arterial blood pressure, central venous pressure and echocardiography, to help guide resuscitation in real time and use this data to understand the immediate response to treatment. Acls guidelines depend on simplified measures of pulse checks and waveform capnography In the operating room environment. Anesthesia professionals are trained to gather and interpret data from these additional monitors to make informed decisions during emergencies.
Speaker 2:Keep in mind that ACLS protocols are often designed for unwitnessed cardiac arrest events, whereas in the operating room the cardiac arrest events are witnessed. As we can see, there is a need for a specialized approach to resuscitation in the intraoperative environment. And now we have made it back to talk about the ASA's Perioperative Resuscitation and Life Support Certificate. This certificate program was created to address perioperative emergencies with the principles of ACLS combined with the knowledge of surgery and anesthesia and the resources available in the operating room. With this training, clinicians practicing in the perioperative environment learn to recognize and treat life-threatening conditions that may occur during surgery and anesthesia, using tools and strategies that are more applicable in the operating room.
Speaker 2:There is a focus on rapid identification of the underlying cause of the cardiac instability to help guide resuscitation. This is not the first example of adapting standard resuscitative protocols to the specific needs of the patients. Pediatric and neonatal resuscitation, as well as trauma life support, all differ from standard ACLS in order to provide the best possible outcomes for these specific patient populations. The same is true for patients in the perioperative environment. There are limits to the one-size-fits-all strategy when it comes to the unique physiology of neonates or traumatic cardiac arrest and drowning. If we return to the operating room, we can see that the stakes are quite high during a perioperative cardiac arrest, with a high risk for significant morbidity and mortality.
Speaker 2:Anesthesia professionals, surgeons and perioperative nurses all need to be able to apply rapid and precise management that recognizes the impact of anesthetic, pharmacology, surgical factors and patient positioning. The Perioperative Resuscitation and Life Support Certificate provides this necessary training. The author reminds us that this does not diminish the importance of ACLS, but acknowledges the limitations of applying a generalized protocol in a highly specialized environment. Going forward, advanced life support and resuscitation in the operating room should incorporate the principles of ACLS when applicable, but not just stop there. The highly specialized operating room environment requires a highly specialized approach to advanced cardiac life support that highlights the impact of patient surgical, anesthetic and positioning factors. Smith leaves us with this call to action that I'm going to read now. Adapting resuscitative protocols to specific patient populations and scenarios will ultimately bridge the gap between standardized emergency care and the specialized needs of perioperative patients, ensuring that practitioners are equipped not just to respond, but to do so with precision and efficacy. This is an important consideration as we work to improve anesthesia patient safety.
Speaker 2:If you get a chance, we hope that you will check out the ASA's Perioperative and Life Support Certificate Program, which provides training on rescue, unique presentations and special situations with a web-based curriculum that allows you to learn at your own pace. Upon completion of the course, you will earn a digital e-card that validates your competency in ACLS in the perioperative setting. The course curriculum includes four main modules and eight special situations. Module one is pre-arrest the rescue concept. Module two is pre-cardiac arrest in the OR. Module three is arrhythmias and Module 4 is conditions complicating arrest in the OR and periprocedural setting. The special situations include anaphylaxis, gas embolism, hyperkalemia, transfusion reaction, traumatic cardiac arrest, local anesthetic, systemic toxicity, neuraxial anesthesia and malignant hyperthermia.
Speaker 2:As you can see, this training is very applicable for anesthesia professionals. Is this something that you would consider completing? Did I mention that you can earn between 5.75 and 6.25 patient safety CME credits. For more details and information, check it out by following the link in the show notes. Before we wrap up for today, we are going to hear from Smith again. I also asked him what is next for his upcoming research and projects. Let's take a listen to what he had to say.
Speaker 3:I'm currently in school for my PhD at East Carolina University, where I'm looking at the physiologic basis for prone CPR. My DNP research was focused on managing intraoperative cardiac arrest while prone through the use of prone CPR. Doing my literature review for that project, I found that prone CPR has actually been associated with higher hemodynamic values compared to traditional CPR, but no one's really looked into why. So I'm really excited to dig a little deeper into the physiological basis for how prone CPR works and what might explain this better hemodynamic profile.
Speaker 2:Thank you so much to Smith for contributing to the show today and for highlighting these important considerations when it comes to responding to cardiac arrest in the operating room. If you have any questions or comments from today's show, please email us at podcast at apsforg. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apsforg for detailed information and check out the show notes for links to all the topics we discussed today. The APSF is delighted to announce the inaugural Digital Editor Program. This is a paid one-year program for an anesthesia professional or anesthesia professional in training with a talent for medical communications and digital media. Grow your skills in medical journalism and launch your career with networking and mentorship from the APSF. The deadline is August 1st. Check out the link in the show notes or head over to apsforg for more information. The link in the show notes or head over to apsforg for more information. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.