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PeRLS: Perioperative Resuscitation and Life Support

Talia K. Ben-Jacob MD, MSc, FCCM Camden, New Jersey

Introduction

The care of patients who have had cardiac arrest continues to evolve. While the American Heart Association’s
ACLS guidelines continues to be the consensus opinion of a large group of experts, each successive iteration has
been informed by a literature that has increased in both size and quality. Over the past 30 years, the literature basis
for BLS and ACLS guidelines has exploded. The overall quality of the guidelines has been dramatically improved
by increasing numbers of high quality database studies and randomized prospective studies. In the more recent
iterations of BLS and ACLS guidelines, the differentiation between healthcare providers and lay rescuers has been
emphasized, with different recommendations for each in BLS. Going forward, it is very likely that ACLS will
differentiate between different environments as well as different providers. While it was once focused very
narrowly on interventions during cardiac arrest, ACLS guidelines have now expanded beyond the immediate arrest
period to encompass post-arrest management. This trend is likely to continue, and may extend to both avoiding
cardiac arrest in-hospital, and earlier termination-of-resuscitation outside of the hospital.

Efforts to train practitioners in the clinical practice of ACLS resulted in the creation of the first and most commonly
used “team training” experience in healthcare. It continues to be the standard for all such training experiences in
health care. Practitioners have come to expect the assignment of roles and tasks, the communications routines, and
the imposed order amidst chaos that were first brought into medicine via ACLS training. Indeed, ACLS training is
likely where simulation and team training were first introduced into modern medicine on a large scale; enthusiasm
for both likely stems from the high quality of the ACLS training experience.

As with every set of guidelines, ACLS is only as good as the scientific and clinical literature used as its basis. While
the literature is constantly growing, ACLS guidelines (thus far) are only updated every 5 years. The authors of the
guidelines have to arrive at consensus for recommendations, in essence, deciding on their resolution for an area of
controversy. While these decisions resolve these controversies for the purposes of the guidelines, it is likely that the
literature about them will continue to evolve. The remainder of this chapter will discuss areas that may be
controversial in the authoring of the next iteration of ACLS guidelines.

Why Perioperative Resuscitation and Life Support?

Cardiac arrest in the perioperative period is rare. The estimate is about 5.1 cardiac arrests per 10,000 anesthetics,
with further analysis revealing that only 0.74 per 10,000 were thought to be associated with anesthesia-related
causes (1,2,3). PeRLS guidelines were created to aid in the management of perioperative arrest specifically because
causes of cardiopulmonary arrest in the operating room are often specific to the procedure, anesthetic technique, or
known patient comorbidities, and are usually different from causes in other inpatient hospital areas or outside the
hospital (4,5, 6). Management of perioperative arrest can also be different from outside hospital arrest as well as
within the inpatient wards.

Hypoxemia, acidosis, and hypovolemia due to blood loss and fluid shifts are often contributory factors to
perioperative arrest whereas intraoperative causes of cardiac arrest consist of excessive intravenous (IV) or
inhalation anesthetic doses, local anesthetic toxicity, malignant hyperthermia, anaphylaxis, auto-positive end-
expiratory pressure (auto-PEEP), bronchospasm, embolism (air, fat, thrombus), severe bradycardia or asystole due

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to vagal reflexes, sympathectomy from neuraxial anesthesia, unopposed parasympathetic tone during neuraxial
anesthesia, or tension pneumothorax (4,5, 7-10).

Another difference between out of hospital arrest and perioperative arrest requiring the need for PeRLS is the
differential diagnosis for intraoperative cardiopulmonary arrest is typically limited. This is because the precipitating
cause may be known and rapidly reversible. Arrests in the operating room is almost always witnessed by the care
team already familiar with the patient's medical history. Help is usually readily available in the operating and so
initiation of correct treatment is usually timely and focused, resulting in better outcomes in terms of survival or
residual neurologic deficits than seen in other settings (4,11). In one retrospective registry study of patients
suffering a perioperative cardiac arrest, one-third survived to hospital discharge, with good neurologic outcomes
seen in two-thirds of the survivors (12).

Man vs Machine: which is better?

It has been the consensus of experts that high quality of chest compressions is of paramount importance in patients
with cardiac arrest. Multiple studies have suggested that human operators fail to conform to recommendations with
respect to both depth of compressions and rate of compressions (13). There has been widespread belief that better
compressions would be associated with better outcomes, and that a mechanical device would generate outcomes that
are substantially better than those generated by human rescuers. Unfortunately, a recent large, randomized trial
failed to demonstrate any meaningful benefit from a machine generating mechanical chest compressions (14,15).
While it is true that the human operators in this study gave chest compressions in accordance with guidelines, the
absence of an outcome difference does suggest that chest compressions that are reasonably close to guidelines are
likely to generate acceptable outcomes. In spite of the negative results of this study, chest compression machines
may still be adapted in selected clinical settings, as their performance does not decline over time, while the
performance of human operators does.

CPR may also be performed in unusual positions as patient are often positioned prone or lateral in the operating
room. Case reports, simulation-based studies, and cadaver feasibility studies have described return of spontaneous
circulation (ROSC) (16-18). In addition, for cardiopulmonary arrest in the pregnant patient, left lateral uterine
displacement is necessary if fundal height is at or above the umbilicus. This is done to optimize venous return
(preload) by minimize aortocaval compression, and generate adequate stroke volume during CPR (19).

How fast?

As with every other recommendation in BLS and ACLS, recommendations about the rate of compressions have
evolved over time, from 80-100 per minute in 1986, to a recommendation of at least 100 per minute in the 2010
revision. Two recent papers that analyzed chest compressions performed during out-of-hospital cardiac arrest on
more than 10,000 patients demonstrated that survival was best at rates between 100 and 120 per minute, and
decreased at rates higher than 120 or lower than 100 (20,21). As with any re-analysis of a large scale study database,
there are some limitations to the quality of the data and the inferences that can be drawn from it (the authors are very
sanguine about this). In spite of this, it is possible that future guidelines about chest compressions may be more
permissive than the present (2020) guidelines.

Epi, Vaso, Nothing, or something else?

As with every other aspect of ACLS, the role that pharmacotherapy might play has been difficult to study. Because
such a small percentage of patients survive to discharge from hospital with good functional status, studies powered
to detect even large differences have necessarily been very large and expensive (and plagued by the kinds of
protocol compromises required for any study conducted at multiple centers over a long time). This has in turn made
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studies targeted at more proximate endpoints, especially Return-Of-Spontaneous-Circulation (ROSC) much more
common in the literature. As a consequence, there is a paucity of literature that tests different doses, different
treatment regimens, and different combinations of various pharmacotherapies for cardiac arrest. Recent literature
has even called into the question of any of the measures associated with ACLS (22), and specifically the benefits of
anti-arrhythmics (23). While epinephrine has long been a mainstay of ACLS, recent re-analysis of the published
literature by Callaway has provoked a reconsideration of how and when it might be used (24). In specific,
Callaway’s study suggests that the use of epinephrine in cardiac arrest likely increases the rate of ROSC, but does
not appear to convey any longer term benefit to survival, and may even be associated with worse functional
outcomes (25). Ironically, a similar study of vasopressin for cardiac arrest by Layek et al suggested that its use might
be associated with a higher rate of ROSC for in-hospital patients, a higher rate of survival to hospital admission for
out-of-hospital patients, and that repeated doses might convey both survival and functional benefits to a sub-group
of patients (26). A relatively recent study of a protocol that employed a protocol of epinephrine, vasopressin, and
steroids for in-hospital cardiac arrest demonstrated significantly improved survival compared to standard ACLS
(27). As with every other aspect of ACLS, opinions about the role of pharmacotherapy will continue to evolve as the
literature does.

To cool or not to cool?

Perhaps the most important change in the 2010 revision of the ACLS guidelines was the incorporation of post-
resuscitation care into the guidelines, with therapeutic hypothermia (more correctly referred to as targeted
temperature management) as the mainstay of such care (28, 29). The studies that formed the basis of this
recommendation were strongly positive in favor of moderate hypothermia, but were confounded by the protocol
which permitted hyperthermia to occur in the control group (30, 31). A more recent study that incorporated
temperature control to normo-thermia in the control group was convincingly negative, and has called into question
the logistic effort, expense, and risk-benefit ratio of cooling survivors of cardiac arrest (32, 33). Therapeutic
hypothermia is not without risk: a recent meta-analysis suggested that there is an increased risk of pneumonia and
sepsis in patients who are cooled after cardiac arrest (34). In spite of the recent negative study, there is still
widespread interest in using moderate hypothermia to improve outcomes in survivors of cardiac arrest in various
situations (35). Absent new studies that document a substantial benefit to moderate hypothermia, it is likely that the
clinical use of hypothermia will decline over time.

Echocardiography in Perioperative Cardiac Arrest

Transthoracic echocardiography (TTE) and Urgent and emergent transesophageal echocardiography (TEE), also
termed rescue TEE, have been endorsed by international guidelines as a potentially useful diagnostic modality for
the evaluation of patients in cardiac arrest and/or peri-arrest period. (36,37) Echocardiography can identify
organized cardiac activity vs. standstill, effectively used for determining the cause of unexpected hemodynamic
instability or cardiopulmonary arrest during cardiac and non-cardiac surgical procedures, and to facilitate ongoing
management(38,39). However, the process of TTE image acquisition has been observed to cause prolonged pauses
in the delivery of vital chest compressions and reduce hands-on time (40). Notably, TEE probe placement may be
challenging in the intraoperative setting due to the position of the patient (eg, prone or lateral body position), or the
presence of surgical drapes or equipment (41). Currently, the existing evidence to support echocardiography in peri-
arrest or cardiac arrest period arises from case reports and case series, making it difficult to determine whether a
patient-oriented benefit exists (42,43,44). There is no randomized, blinded or controlled study has demonstrated
superior outcomes using TTE or TEE to guide resuscitation.

ECMO: is it the future?

The cost, complexity, and size of Extra-corporeal Membranous Oxygenators (ECMO) has dramatically decreased
over the past decade, and this technology is enjoying increasing use in both in-hospital and even out-of-hospital
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cardiac arrest. Its application in the in-hospital setting is often in cardiogenic shock that is on a trajectory toward
cardiac arrest, thus, in this setting, it is employed to avoid or avert BLS and ACLS. In this context, this technology
is often referred to as Extra-Corporeal Life Support (ECLS) or Extra-Corporeal CPR (E-CPR). In these scenarios,
veno-arterial ECMO is far more commonly employed than veno-venous ECMO, as veno-arterial ECMO can be used
to both oxygenate the blood and generate arterial flows comparable to the resting cardiac output. The body of
literature describing its use in these settings is now large enough to permit meta-analysis to evaluate for both
complications and outcomes (45,46). When used in-hospital for cardiogenic shock, the outcomes can be quite good
(45,46). Ethical considerations may preclude randomized trials of this technology. Nevertheless, well-conceived
prospective evaluations of its employment are being performed, with an excellent example being the CHEER trial
(47). The preliminary results of this trial are quite impressive.

Summary
The explosion of basic science, translational, and clinical studies of cardiac arrest and its causes has produced
dramatic changes in ACLS over the past several decades. This rate of change is likely to continue for the near future
and further differentiate between in-hospital and out-of-hospital cardiac arrest. The literature is likely to continue to
specialize, and already includes guidelines intended for use in the perioperative setting. (4,5). It is very likely that
PeRLS will enjoy more widespread use as practitioners and health care systems explore its use.

References:

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