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CONTINUING EDUCATION
Perioperative
Cardiopulmonary Arrest
Competencies
2.5
DARLENE B. MURDOCK, BSN, BA, RN, CNOR
www.aorn.org/CE
Continuing Education Contact Hours
Accreditation
indicates that continuing education (CE) contact hours are
available for this activity. Earn the CE contact hours by
reading this article, reviewing the purpose/goal and objectives,
and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the
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of completion.
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education by the American Nurses Credentialing Center’s
Commission on Accreditation.
Event: #13524
Session: #0001
Fee: Members $15, Nonmembers $30
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This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
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Conflict of Interest Disclosures
The CE contact hours for this article expire August 31, 2016.
Purpose/Goal
To enable the learner to participate more effectively in
cardiopulmonary resuscitation (CPR) that occurs during the
intraoperative period.
Objectives
1. Describe the components of CPR.
2. Discuss factors that increase the risk of a patient experiencing a cardiac arrest.
3. Identify when it is appropriate to defibrillate a patient who
is experiencing cardiac arrhythmias.
4. Discuss the importance of timing during administration
of CPR.
5. Explain the roles of perioperative team members during
a cardiopulmonary arrest that occurs in the OR.
Ms Murdock has no declared affiliation that could be perceived
as posing a potential conflict of interest in the publication of
this article.
The behavioral objectives for this program were created
by Rebecca Holm, MSN, RN, CNOR, clinical editor, with
consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative Education. Ms Holm and Ms Bakewell have
no declared affiliations that could be perceived as posing
potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support
No sponsorship or commercial support was received for this
article.
Disclaimer
AORN recognizes these activities as CE for registered nurses.
This recognition does not imply that AORN or the American
Nurses Credentialing Center approves or endorses products
mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2013.06.008
116 j AORN Journal
August 2013
Vol 98 No 2
Ó AORN, Inc, 2013
Perioperative Cardiopulmonary
Arrest Competencies
2.5
DARLENE B. MURDOCK, BSN, BA, RN, CNOR
www.aorn.org/CE
ABSTRACT
Although basic life support skills are not often needed in the surgical setting, it is
crucial that surgical team members understand their roles and are ready to intervene
swiftly and effectively if necessary. Ongoing education and training are key elements
to equip surgical team members with the skills and knowledge they need to handle
untimely and unexpected life-threatening scenarios in the perioperative setting.
Regular emergency cardiopulmonary arrest skills education, including the use of
checklists, and mock codes are ways to validate that team members understand their
responsibilities and are competent to help if an arrest occurs in the OR. After a mock
drill, a debriefing session can help team members discuss and critique their performances and improve their knowledge and mastery of skills. AORN J 98 (August 2013)
117-127. Ó AORN, Inc, 2013. http://dx.doi.org/10.1016/j.aorn.2013.06.008
Key words: cardiac arrest, basic life support, cardiopulmonary resuscitation, CPR,
code blue.
C
ardiac arrest (ie, the sudden failure of
cardiac function) is considered rare in
the surgical setting because of improved
patient monitoring systems and advancements in
anesthesia.1 Research conducted in the past decade
shows that the incidence of cardiac arrest attributable to anesthesia is approximately 0.5 to one time
per 10,000 adult procedures and 1.4 to 4.6 times per
10,000 pediatric procedures.2 These statistics may
appear to be low, but there is still a distinct possibility that a patient may experience a cardiac arrest
during the intraoperative phase of surgery; thus, the
surgical team must be prepared to provide basic life
support (BLS).1,2 For the purposes of this article,
the intraoperative phase is defined as beginning
when the patient is transferred from one of a variety
of areas (eg, preoperative area, intensive care unit,
emergency department) to the OR and lasting until
the patient is transferred to the next level of care
(eg, postanesthesia care unit, intensive care unit).3
All surgical team members should be prepared
to assist in the event that a patient experiences
cardiac arrest in the OR. There are several important steps for ensuring a team is prepared to handle
a life-threatening emergency like cardiac arrest.
Understanding which patients are at risk for cardiac
arrest is one important step. In addition to identifying patients who are at risk, perioperative team
members should be competent in maintaining
an airway and providing ventilation and cardiac
compression. Education and training, such as mock
drills, can reinforce team members’ roles and
responsibilities to minimize chaos during an
actual emergency. Finally, after a mock drill,
http://dx.doi.org/10.1016/j.aorn.2013.06.008
Ó AORN, Inc, 2013
August 2013
Vol 98 No 2 AORN Journal j 117
August 2013 Vol 98 No 2
holding a debriefing session can help team members
discuss and critique their performances and improve their knowledge and mastery of skills.
PATIENTS AT RISK FOR CARDIAC ARREST
Certain patients are at increased risk for cardiac
arrest.1 When performing the preoperative assessment, the perioperative nurse should assess patients
for potential risks of cardiac arrest,4,5 which include
the following:
n
age (ie, men older than 45, women older than 55),
obesity or a sedentary lifestyle,
n certain habits (eg, smoking, alcohol abuse,
illegal drug use),
n a previous history of myocardial infarction, and
n a family history of cardiovascular disease (eg,
coronary artery disease, cardiomyopathy, valvular or congenital heart disease).1
n
An abnormal increase or decrease in blood pressure
and the presence of edema, indigestion, dizziness,
and headache may be factors that also increase the
potential for cardiac arrest.1 Some symptoms (eg,
abnormal increase or decrease in respiratory rate,
difficulty breathing) may present as warning signs
of impending cardiac arrest, especially if the patient
has chest pain or discomfort.1
In the perioperative setting, the incidence of
cardiac arrest increases in trauma patients and
MURDOCK
patients who are critically ill.5 The American
Society of Anesthesiologists (ASA) Physical Status
Classification System6,7 is an assessment tool that
also may indicate whether a patient is at risk for
cardiac arrest (Table 1). Patients with an ASA score
of 3 or higher are considered to be at greater risk
for cardiac arrest.2 An “E” is added to the classification for emergency procedures (eg, 1E equals
a healthy patient undergoing an emergency
appendectomy).6
CARDIOPULMONARY RESUSCITATION
Basic life support provides cardiopulmonary
resuscitation (CPR) to a patient who is experiencing cardiac or respiratory arrest. The goal
of CPR is to restore heart and lung function by
providing artificial ventilation and to restore circulation to vital organs through closed-chest cardiac massage.8 Although providing ventilation and
chest compressions are the two primary interventions used to sustain life during CPR,9 compressions are the most important because blood flow
to vital organs depends on these compressions.10
Open-chest cardiac massage is an option during
surgery if the chest is already open.11 Early defibrillation (ie, applying an electrical shock to the
heart with a defibrillator to attempt to convert it to
a normal sinus rhythm) is also an important part of
CPR and should be used immediately if indicated.9
TABLE 1. American Society of Anesthesiologists (ASA) Physical Status Classification System
1 Patient has no systemic disease.1,2
2 Patient has mild systemic disease (eg, well-controlled diabetes, asthma, hypertension).1,2
3 Patient has moderate to severe systemic disease that is limiting to lifestyle but not incapacitating (eg, stable angina, diabetes
with systemic complications).1,2
4 Patient has incapacitating disease that is a conceivable threat to life (eg, end-stage renal failure, severe congestive heart
failure).1,2
5 Patient is not expected to live without surgery or risk of death is significant within the next 24 hours.1,2
6 Patient has been declared brain dead and is undergoing organ procurement.2
Note: An “E” is added to the classification for emergency procedures (eg, 1E equals a healthy patient undergoing an emergency appendectomy). Adapted
and reprinted with permission from ASA Physical Status Classification System/1991, American Society of Anesthesiologists, Park Ridge, IL.1
1. ASA classification. Anestesia. http://www.brandianestesia.it/english/ASAclass.html. Accessed May 8, 2013.
2. ASA Physical Status Classification System. American Society of Anesthesiologists. http://www.asahq.org/Home/For-Members/Clinical-Information/
ASA-Physical-Status-Classification-System. Accessed May 8, 2013.
118 j AORN Journal
CARDIAC ARREST COMPETENCY
Defibrillation can be performed during open chest
massage using sterile paddles and adjusting the
electrical charge appropriately.12
According to the American Heart Association,
the earlier CPR is initiated after an arrest, the better
the patient’s outcome; therefore, all surgical team
members should be prepared to act immediately
when cardiac arrest occurs. Surgical team members
should initiate CPR within 10 seconds of cardiac
arrest recognition because the first few minutes
of resuscitation are crucial in helping the patient
survive.10 Although discussion of advanced cardiac
life support emergency medication is beyond the
scope of this article, team members also should be
familiar with emergency medications (Table 2).13
To provide optimal life-sustaining emergency
care, all surgical team members should be competent
in maintaining an airway and providing ventilation
and cardiac compression.10 The team member performing chest compressions should provide hard,
fast compressions in the center of the patient’s
chest.1 These compressions should depress the
chest of an adult by at least two inches and should
be provided at a minimum rate of 100 compressions
per minute, allowing for complete chest recoil.1,10
To maximize the effectiveness of compressions,
team members should rotate often so the team
member providing the compressions does not get too
tired.1 Other team members should stand near the
patient’s side to be available to relieve the team
member who is performing the compressions. By
standing on the opposite side of the person performing compressions, personnel can rotate with
minimal interruption, which helps ensure the quality
of CPR, and these rotations should not take more
than 10 seconds to complete.10
In the perioperative setting, the anesthesia professional usually manages the patient’s airway;
however, unanticipated incidents may occur. Therefore, all perioperative team members should be
competent to properly use the bag-valve-mask
ventilating device.1 To provide the most effective
ventilation with a bag-valve-mask ventilating device, two health care providers may be neededd
www.aornjournal.org
one person to ensure that the airway is open and
that a seal is maintained on the patient’s face and
one to squeeze the bag to produce a visual rise
in the patient’s chest. The person administering
the breaths should provide two breaths, each of
one-second duration, during a brief pause after
every 30 chest compressions.14
Ventricular fibrillation (Figure 1) and pulseless
ventricular tachycardia (Figure 2) are the most
common initial rhythms after cardiac arrest. Immediate defibrillation is the recommended therapy
for these dysrhythmias because the chance for
successful defibrillation declines over time.13,15
When ventricular fibrillation is present, the heart
is quivering rather than contracting in its usual
manner and is not pumping blood.16 Pulseless
ventricular tachycardia quickly deteriorates to
ventricular fibrillation, and ventricular fibrillation
then deteriorates to no cardiac electrical activity
(ie, asystole), which is not a shockable rhythm.
Asystole, however, can be treated with medications.1,15,17 Team members must remember that
irreversible tissue damage and brain death occur
within four to six minutes after circulation stops.1
To help improve the patient’s chances for survival, defibrillation should be performed as soon
as a shockable rhythm (eg, ventricular fibrillation,
pulseless ventricular tachycardia) is noted on the
electrocardiogram.1,10 Manufacturers recommend
120-joule to 300-joule shocks when using a biphasic defibrillator, with subsequent shocks of
the same or higher doses to terminate ventricular
fibrillation.13,15 With a monophasic defibrillator,
manufacturers recommend a dose of 360 joules for
initial and subsequent shocks.13,15 If the manufacturer’s recommended energy doses are unknown,
deliver the maximum shock possible.17 Compressions should be stopped immediately before the
shock is delivered; the person delivering the shock
should announce “charging” and then “all clear”
immediately before delivering the shock. Compressions should be resumed immediately after
a shock is delivered. If defibrillation converts
ventricular fibrillation to a perfusing rhythm but
AORN Journal j 119
Medication
Amiodarone
1-3
Indication
n
n
Pulseless ventricular
tachycardia (PVT)
Ventricular fibrillation (VF)
Dose
n
n
n
Atropine
n
Symptomatic bradycardia
(ie, heart rate < 60 beats
per minute)
n
n
n
Epinephrine
(1:10,000)
n
n
n
n
Lidocaine
n
n
PVT
VF
Asystole
Pulseless electrical activity
(PEA)
n
PVT
VF
n
n
n
n
n
n
Magnesium
sulfate
n
n
n
Comments
Actions
300 mg IV push
Repeat doses at 150 mg
every 3 to 5 minutes
May initiate a continuous
IV infusion for restoration
of perfusion rhythm
0.5 mg
Repeat every 3 to 5
minutes up to 3 doses
Maximum dose: 3 mg
1 mg IV push
Repeat every 3 to 5
minutes
May give 2 mg to 2.5 mg
via endotracheal tube
n
Antiarrhythmic
n
Unfavorable effects
include postoperative
respiratory distress
syndrome and pulmonary
toxicity
n
Blocks potassium,
sodium, and calcium ion
channels of the cell to help
curb or convert some
dysrhythmias
n
Anticholinergic
Antispasmodic
n
If ineffective, consider
transcutaneous pacing or
dopamine infusion
n
n
Relaxes smooth muscle
and increases heart rate
n
Vasoconstrictor
n
n
Increases cardiac and
cerebral perfusion during
cardiac arrest
1 mg/kg to 1.5 mg/kg
IV push for first dose
Repeat at 0.5 mg/kg to
0.75 mg/kg in 5- to
10-minute intervals
thereafter
Maximum of 3 doses or
3 mg/kg
May initiate a continuous
IV infusion for restoration
of perfusion rhythm
1 g to 2 g diluted in 10 mL
of 5% dextrose in water
Infuse IV over 5 to 20
minutes
n
Flush IV with 10 mL to
20 mL of normal saline
after each dose
Raise the patient’s IV arm
for 10 to 20 seconds for
faster absorption
An alternative to
amiodarone
Signs of toxicity include
confusion, blurred or
double vision, nausea,
vomiting, or ringing in the
ears
n
Blocks sodium channels
to help control the firing
and depolarization of the
heart
Reverses hypomagnesemia, which increases
the potential of QT interval
prolongation and TdP
n
Combines with adenosine
triphosphate to drive the
sodium-potassium pump,
which is essential for the
heart muscle to rest after
depolarization
n
Antiarrhythmic
n
n
n
n
Antiarrhythmic
Electrolyte replenisher
n
MURDOCK
Ventricular tachycardia or
VF associated with
torsades de pointes (TdP),
an uncommon, distinct
form of ventricular
tachycardia
Class
August 2013 Vol 98 No 2
120 j AORN Journal
TABLE 2. Resuscitative Medications
n
n
n
1. Reynolds IG. Cardiac arrest in the OR. OR Nurse. 2011;7(5):16-22.
2. Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation. 2010;122(18 suppl 3):S729-S767.
3. Atropine. mediLexicon. http://www.medilexicon.com/medicaldictionary.php?t¼8499. Accessed May 8, 2013.
Increases cardiac and
cerebral perfusion during
cardiac arrest
May be given instead of
the first or second dose of
epinephrine
Peripheral vasopressor;
acts as a coronary and
renal vasoconstrictor in
high doses
40 units IV push in one
dose only; medication has
a long half-life (ie, 10 to 20
minutes)
Vasopressin
n
PVT
VF
Asystole
PEA
n
Dose
Indication
Medication
TABLE 2. (continued ) Resuscitative Medications
1-3
n
Class
n
Comments
n
Actions
CARDIAC ARREST COMPETENCY
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fibrillation returns, the patient should be shocked at
the previously successful energy dose until a perfusing rhythm is established again.13,15
TEAM MEMBER EDUCATION
Education is a key component in establishing
and maintaining competencies for managing lifethreatening crises such as cardiac arrest in the
surgical setting. Education must be evidence
based, consistent, and frequent and must help team
members achieve demonstrable competencies.18
Certification and competency in CPR are job
requirements for perioperative nurses and nonlicensed surgical team members13,19; nonetheless,
knowledge of advanced cardiac life support and
pediatric advanced life support guidelines may
allow for better preparation to handle cardiac
arrest. Typically, nurses are required to undergo
BLS training and recertification every two years;
nevertheless, research reveals that the retention
of BLS knowledge and competencies deteriorates
within weeks after training.18 The American Heart
Association advocates quality education, frequent
BLS retraining, and the use of checklists (Figure 3)
to improve health care providers’ proficiency.18
Team Member Roles During an Arrest
It is essential that each surgical team member understand his or her responsibilities during an arrest
(ie, code blue), so that when an arrest is announced
over the hospital paging system, surgical team
members know how to respond.1,13,15 Hospital-wide
announcements of an arrest are rarely made when an
arrest occurs in the OR; however, an arrest may be
announced within the department. If each surgical
team member knows his or her specific role and how
to use resuscitative equipment, chaos can be minimized.1,5,13,15 During an arrest, team members
should collaborate with each other and also be
familiar with other team members’ responsibilities
(Table 3) so that they can anticipate what another
team member might need and provide it.15
During an arrest, a code leader coordinates
activities. Typically, the anesthesia professional is
AORN Journal j 121
MURDOCK
August 2013 Vol 98 No 2
Figure 1. Ventricular fibrillation.
Figure 2. Ventricular tachycardia.
defibrillator models provide time annotations on the
monitor strip.20 The RN circulator should document all resuscitation events in sequence, as they
occur, noting the time of interventions and the
patient’s response to each, including any medications that are administered.21,22 When documenting
an arrest, the RN circulator should avoid using
long narrative accounts and should record only
the pertinent details.21 Arrest documentation should
include, but not be limited to, the following:
n
the leader; however, if an arrest takes place during
a procedure in which an anesthesia professional
is not present (eg, a local anesthesia procedure),
the surgeon becomes the code leader.1,4 The code
leader is responsible for initiating and evaluating
interventions, identifying the patient’s cardiac
rhythm, and assigning and defining clear tasks for
the other team members (ie, scrub person, surgeon,
OR manager or charge nurse, RN first assistant,
RN circulator).1,4
If an arrest occurs during the surgery itself, the
main duty of the scrub person is to maintain the
sterility of the surgical field and the surgical site;
however, maintaining the sterile field is secondary
to performing life-saving interventions.19 The
surgeon’s primary responsibility is closing the
surgical wound, if possible, and doing whatever is
necessary to prepare the patient for resuscitation,
which may include repositioning the patient.1,4
The OR manager’s or charge nurse’s immediate
duty is to assign more perioperative personnel,
residents, and physician assistants to assist with
the arrest. The RN first assistant’s duties are to assist
with the code as directed by the code leader.1,4
Depending on the events of surgery and other
available perioperative personnel, the RN circulator
is usually the non-sterile team member who activates the resuscitation, facilitates and delegates
the retrieval of essential equipment and medications, and documents all interventions and events
of the resuscitation.1,4 For documentation, the defibrillator is the best source for the nurse to use to
time-synchronize all documentation, because most
122 j AORN Journal
n
n
n
n
n
n
patient identification according to facility
protocol22;
the names of all participants22;
the time that
20,21
n the arrest began,
20,22
n compressions were started and stopped,
n the patient was intubated or a notation that
the patient was already intubated,21,22
n defibrillation was attempted, including joules
and the patient’s cardiac rhythm before and
after defibrillation with an attached rhythm
strip,21,22
n any essential interventions (eg, insertion of
balloon pump, pacemaker, central lines,
chest tubes, nasogastric tube) were
completed or attempted,20,22 and
n all medications and fluids were administered
(ie, dose, route, effect) as obtained from the
anesthesia record21,22;
the patient’s vital signs, which often can be
obtained from the anesthesia record22;
laboratory test values22;
the outcome, if positive,20,21 or the time resuscitation efforts were stopped, including the time
of death and which team member called an end
to the resuscitation20,21; and
any other required facility documentation.21
Mock Codes
Research has shown that repetition of skills through
interactive learning (eg, mock codes or drills) is
an effective teaching method when training adult
students.13 Mock codes can be staged monthly,
quarterly, or yearly, depending on the facility’s
CARDIAC ARREST COMPETENCY
Name:
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Date:
Step Skill/criteria
1
2
Met
Not met
Verbalizes how to call an arrest, including telephone numbers to call1
Emergency cart1
• Identifies the locations of all emergency carts in the OR.
• Identifies the location of the cardiac arrest form and open crash cart.
• Identifies the location of emergency medications.
• Identifies the location of airway supplies.
• Demonstrates proper use of bag-valve-mask ventilating device.
• Describes the protocol for replacing and restocking the emergency cart.
Compression demonstration (ie, high-quality cardiopulmonary resuscitation [CPR])2
3
• Demonstrates proper hand placement: middle of chest, lower half of breast bone.
• Performs at least 100 compressions per minute (ie, 30 compressions in 18 seconds or less).
• Ensures a compression depth of at least 2 inches (5 cm).
• Allows for complete chest recoil.
• Rotates staff members with minimal interruptions (ie, < 10 seconds).
Defibrillator demonstration3
4
• Turns on the defibrillator.
• Places the defibrillator in manual test mode.
• Identifies and changes joule settings.
• Identifies the charge button.
• Announces “charging,” then “all clear” with visual checks before pressing the charge button.
• Identifies and locates appropriate paddles (ie, external and internal), gel, or gel pads.
• Demonstrates proper external paddle placement with 20 lb to 25 lb of pressure.
• Resumes chest compressions after defibrillation with non-perfusing rhythm.
• Re-analyzes patient’s heart rhythm after 2 minutes of chest compressions.
• Demonstrates how to
▫ change adult paddles to pediatric paddles,
▫ change the cord adapter for internal paddles, and
▫ properly insert internal paddles.
• Identifies the location of extra monitor paper and describes how to refill the monitor paper.
Automatic external defibrillator (AED) mode4
5
• Turns the defibrillator to AED mode.
• Demonstrates proper application of gel pads.
• Announces “analyzing,” then “all clear” with visual checks.
• Announces “charging,” then “ all clear” with visual checks and removes the oxygen source if needed.
• Identifies location of and how to discharge the shock button.
• Resumes chest compressions after defibrillation with a non-perfusing rhythm.
• Re-analyzes the patient’s heart rhythm after 2 minutes of chest compressions.
Synchronized cardioversion4
6
• Demonstrates proper application of gel pads and electrocardiogram leads.
• Presses the “sync” button (ie, “in-sync” is indicated by a triangle on every R wave).
• Selects energy and charges after stating “charging” and “all clear” with visual checks.
• Describes how to
▫ press and hold the charge button until a shock is delivered and
▫ press “sync” for subsequent cardioversion.
Transcutaneous pacing4
7
Pass
• Demonstrates proper application of pads and electrocardiogram leads.
• Presses the pacer button.
• Selects
▫ demand rate and
▫ current until captured beats are confirmed.
Fail
Remediation needed:
Yes
No
Validation signature:
1. Fitzgerald Chase AM. Mock code training. Zoll Code Communications. http://www.zoll.com/codecommunicationsnewsletter
/ccnl12_09/ZollMockTrainingArticle12_09.pdf. Accessed May 8, 2013.
2. Berg RA, Hemphill R, Abella BS, et al. Part 5: adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 suppl 3):S685-S705.
3. Cardiology in critical care: defibrillation. Medical Intensive Care Unit Nursing. http://micunursing.com/defib.htm. Accessed May 8,
2013.
4. Advanced Cardiovascular Life Support Provider Manual. Dallas, TX: American Heart Association; 2011.
Figure 3. Perioperative arrest competency checklist.
AORN Journal j 123
Code leader
(eg, anesthesia
professional,
surgeon)
n
n
n
n
n
n
Initiates and evaluates
interventions
Identifies cardiac rhythm
Assigns and defines
clear tasks
Fulfills other roles as
needed
Reviews events after
the arrest
Reviews and finalizes
code documentation
and electrocardiogram
strips
Surgeon
n
n
n
n
n
Closes the wound if
possible
Assists with repositioning
the patient, if needed, to
facilitate cardiopulmonary
resuscitation (CPR)
Performs chest
compressions as needed
Leads the code if
necessary
Fulfills other roles as
needed
RN circulator
n
n
n
n
n
n
n
n
n
n
n
Scrub person
n
n
n
n
n
Maintains the sterility
of the surgical field
and site
Packs or covers the
surgical incision per
the surgeon’s
directions
Helps maintain the
accuracy of surgical
counts
Performs chest
compressions as
needed
Performs tasks as
assigned by the code
leader
Residents, physician
assistants, RN first
assistants
n
n
n
Performs tasks as
directed by the code
leader
Assists the RN
circulator as needed
Performs chest
compressions as
needed
OR manager
or charge nurse
n
n
n
n
Assigns additional
personnel to assist
Notifies the operations
administrator of the
arrest
Assists with the arrest
in whatever way is
needed
Revises the immediate
surgical schedule if
necessary
Reynolds IG. Cardiac arrest in the OR. OR Nurse. 2011;7(5):16-22.
Advanced Cardiovascular Life Support Provider Manual. Dallas, TX: American Heart Association; 2011.
Guideline statement of the surgical technologist’s role during a code blue. Association of Surgical Technologists. http://www.ast.org/pdf/Standards_of_Practice/Guideline_Code_Blue.pdf. Accessed May 8, 2013.
Woolson P. Responding to cardiac arrest. OR Nurse. 2007;1(3):31-36.
Nursing standard of care and practice. Code blue documentation. The University of Toledo Medical Center. http://www.utoledo.edu/policies/utmc/nursing/standards/A/pdfs/A19.pdf. Accessed May 8, 2013.
MURDOCK
1.
2.
3.
4.
5.
Retrieves the emergency
cart
Assists with repositioning
the patient, if needed, to
facilitate CPR
Notifies the OR manager
or charge nurse of the
arrest and requests
assistance
Informs the code leader
when tasks begin and
end
Controls traffic in the room
Helps maintain the
accuracy of surgical
counts
Helps maintain the sterility
of the surgical field
Performs chest
compressions as needed
Documents all
interventions and
events
Reviews and finalizes
arrest documentation
Updates the patient’s
family members
1-5
August 2013 Vol 98 No 2
124 j AORN Journal
TABLE 3. Surgical Team Member Responsibilities During a Cardiopulmonary Arrest
CARDIAC ARREST COMPETENCY
needs. The use of mock codes helps team members
gain hands-on experience with resuscitative equipment and medications. Mock codes allow team
members to rehearse their responsibilities and
identify areas of educational or competency needs.
Mock codes also can decrease team member anxiety,
build team member confidence, improve response
times, enhance critical thinking skills, and improve
teamwork.13,23 All of these benefits help create
a positive outcome for the patient who has a
cardiopulmonary arrest.
Obstacles to conducting mock codes include
n
n
n
n
n
time constraints,
room availability,
shortage of team members,
personal performance anxiety, and
unwillingness of team members to participate.23
The perioperative educator should plan and prepare
carefully to help overcome these obstacles. To
deal with time constraints, the educator should
consider limiting the mock code to 10 minutes. The
educator can help reduce team members’ performance anxiety and unwillingness to participate
by providing educational lectures, handouts, skill
stations, and opportunities for return demonstrations on proper use of resuscitative equipment.
These educational opportunities should be held
before the mock code is scheduled and should
include a review the facility’s resuscitation policies
and protocols. The goal of these educational sessions
is to build team members’ confidence, reduce their
fears, and increase their knowledge related to CPR
so that they know and understand their roles and
responsibilities during a code. Laminated reference
cards may be designed to place on employees’
badges to serve as visual reminders for key information such as protocols and resuscitative medications and dosages.13
After educational sessions have been completed,
the educator should
n
assess team member willingness to participate
in a mock code;
www.aornjournal.org
n
form a team of willing mock code participants;
n prepare checklists, an evaluation tool, and
a scenario; and
n verify the availability of the proposed mockcode location, team members, supplies, and
equipment.23
To ensure that patient care is not interrupted, the
perioperative director may consider scheduling
extra personnel on the day of the mock code.
During the subsequent mock code, the manager
should ensure that personnel who were working
during the previous mock code are scheduled to
participate. At the completion of the mock code,
the manager and educator should provide team
members with immediate straightforward feedback
in a nonjudgmental fashion, making sure to acknowledge and praise individual and team efforts.13
When conducting a mock code, personnel should
adhere to facility policies and procedures, and mock
interventions should be based on the American
Heart Association’s BLS and advanced cardiac life
support principles and algorithms. During a mock
code, team members should become familiar with
their facility’s emergency cart; the standard defibrillator; and the automatic external defibrillator,
if available, and where these are located. The
perioperative educator should review equipment
functions and discuss issues such as
n
transcutaneous pacing (ie, a temporary means
of pacing a patient’s heart by delivering pulses
of electric current through the patient’s chest,
which stimulates the heart to contract13,17) and
n synchronized electrical cardioversion (ie, delivering a therapeutic dose of electric current to
the heart at a specific moment in the cardiac
cycle to convert an abnormally fast heart rate
or cardiac arrhythmia to a normal rhythm13,17).
In the OR, team members should be familiar
with the use of internal defibrillator paddles and
where these are kept.13 Anesthesia professionals
usually manage the patient’s airway during an
arrest in the OR1; however, all team members
AORN Journal j 125
MURDOCK
August 2013 Vol 98 No 2
should train on and become competent in the
proper use of the bag-valve-mask ventilating
device in case an anesthesia professional is not
present during an arrest.13,14 Vials of empty or
expired resuscitative medications should be available during a mock code so that team members can
become familiar with them and their indications
for use.13 Most facilities have an arrest report form,
and that should be completed during the mock code
as it would be during an actual arrest.
Debriefings
A debriefing should occur within five working days
after a real arrest occurs24; therefore, the educator
should conduct a debriefing with all team members
immediately after completion of the mock code to
allow personnel to review their performances and
determine ways to improve.18 The arrest report form
can be reviewed during the debriefing for accuracy
of events and interventions.21,22,24 It is important
for the educator and perioperative manager to provide a nonthreatening atmosphere during debriefing
sessions to help team members discuss and critique
their performances and to improve their knowledge
and mastery of skills without fear of criticism or
reprisal.13,18,23
Additional Education
The perioperative educator should provide classes
on emergency resuscitative medications to appropriate surgical team members. The educator also
should provide basic and advanced classes on
arrhythmia recognition personalized to team
members’ roles, educational levels, and scopes
of practice. Other helpful educational exercises
to reinforce CPR skills and team member responsibilities include
n
scavenger hunts,
return demonstrations on the use of resuscitative
equipment,
n use of interactive computer- and video-based
practice scenarios, and
n simulation centers where team members can
practice what they have learned.13,18,23
n
126 j AORN Journal
CONCLUSION
The chance that a patient may experience an arrest
in the OR is small but very real. Surgical team
members should be consistently and continuously
educated about BLS techniques, use of resuscitative equipment, facility protocols, medications
used during arrests, and team members’ roles and
responsibilities during an emergency. To reinforce
didactic education, mock codes allow team members
to practice their clinical, critical thinking, and
teamwork skills in a non-threatening learning
environment. All surgical team members must
know their facility policies and procedures and,
as health care professionals, should take responsibility for pursuing their own educational needs to
provide the care all patients deserve.
References
1. Reynolds IG. Cardiac arrest in the OR. OR Nurse. 2011;
5(5):16-22.
2. Zuercher M, Ummenhofer W. Cardiac arrest during
anesthesia. Curr Opin Crit Care. 2008;14(3):269-274.
3. Lesson 8: perioperative patient care. In: Nursing
Fundamentals e II. Winnetka, IL: Brookside Associates; 2007. http://www.brooksidepress.org/Products/
Nursing_Fundamentals_II/lesson_8_Perioperative_Care
.htm. Accessed June 5, 2013.
4. Woolson P. Responding to cardiac arrest. OR Nurse.
2007;1(3):31-36.
5. AORN guidance statement: Preoperative patient care in
the ambulatory surgery setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN,
Inc; 2012:681-684.
6. ASA classification. Anestesia. http://www.brandianestesia
.it/english/ASAclass.html. Accessed May 8, 2013.
7. ASA physical status classification system. American
Society of Anesthesiologists. http://www.asahq.org/
Home/For-Members/Clinical-Information/ASA-PhysicalStatus-Classification-System. Accessed May 8, 2013.
8. Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation. 2010;
122(18 suppl 3):S640-S656.
9. Travers AH, Rea TD, Bobrow BJ, et al. Part 4: CPR overview: 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 suppl 3):S676-S678.
10. Berg RA, Hemphill R, Abella BS, et al. Part 5: adult
basic life support: 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation. 2010;
122(18 suppl 3):S685-S705.
11. Cave DM, Gazmuri RJ, Otto CW, et al. Part 7: CPR
techniques and devices: 2010 American Heart Association
CARDIAC ARREST COMPETENCY
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13.
14.
15.
16.
17.
18.
19.
20.
Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation. 2010;
122(18 suppl 3):S720-S728.
Definition of defibrillation. MedicineNet.com. http://www
.medterms.com/script/main/art.asp?articlekey¼11137. Accessed June 5, 2013.
Fitzgerald Chase AM. Mock code training. Zoll Code
Communications. http://www.zoll.com/codecommunica
tionsnewsletter/ccnl12_09/ZollMockTrainingArticle12
_09.pdf. Accessed May 8, 2013.
Neumar RW, Otto CW, Link MS, et al. Part 8: adult
advanced cardiovascular life support: 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care. Circulation. 2010;
122(18 suppl 3):S729-S767.
Advanced Cardiovascular Life Support Provider Manual.
Dallas, TX: American Heart Association; 2011.
Ventricular fibrillation. American Heart Association. http://
www.heart.org/HEARTORG/Conditions/Arrhythmia/About
Arrhythmia/Ventricular-Fibrillation_UCM_324063_Article
.jsp. Accessed June 5, 2013.
Link MS, Atkins DL, Passman RS, et al. Part 6: electrical
therapies; automated external defibrillators, defibrillation,
cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care. Circulation. 2010;
122(18 suppl 3):S706-S719.
Bhanji F, Mancini ME, Sinz E, et al. Part 16: education,
implementation, and teams: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care. Circulation. 2010;
122(18 suppl 3):S920-S933.
Guideline statement of the surgical technologist’s role
during a code blue. Association of Surgical Technologists. http://www.ast.org/pdf/Standards_of_Practice/
Guideline_Code_Blue.pdf. Accessed May 8, 2013.
American Heart Association. Recommended guidelines
for reviewing, reporting, and conducting research on
in-hospital resuscitation: the in-hospital “Utstein Style”.
Acad Emerg Med. 1997;14(6):623-627.
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21. Nursing standard of care and practice. Code blue documentation. The University of Toledo Medical Center.
http://www.utoledo.edu/policies/utmc/nursing/standards/
A/pdfs/A19.pdf. Accessed May 8, 2013.
22. Nursing Practice Manual e code blue documentation. The
University of Connecticut Health Center. http://nursing
.uchc.edu/nursing_standards/docs/Code%20Blue%20
Documentation.pdf. Accessed June 5, 2013.
23. Schweinfurth M, Orledge J, Lerant A, Bollaert A.
Simulator-based mock code drills to improve code team
performance. Docstoc. http://www.docstoc.com/docs/
87570055/Simulator-based-Mock-Code-Drills-to-ImproveCode-Team-Performance. Accessed June 5, 2013.
24. Central State Hospital Procedure e Cardiopulmonary
resuscitation code blue. Central State Hospital. http://
www.centralstatehospital.org/policy/Proced%205%20
20A%20Code%20Blue%203-28-08_2.pdf. Accessed
June 5, 2013.
Resources
BLS for healthcare providers course: 1- and 2-rescuer adult
BLS with AED skills testing sheet. American Heart Association. http://www.niacc.edu/ahatc/pdf/1_and_2_rescuer
_adult_with_aed.pdf. Accessed June 5, 2013.
Sprung J, Flick RP, Gleich SJ, Weingarten TN. Perioperative
cardiac arrests. Signa Vitae. 2008;3(2):8-12. http://www
.signavitae.com/component/content/article/3-review-articles/
56-perioperative-cardiac-arrests. Accessed May 8, 2013.
Darlene B. Murdock, BSN, BA, RN, CNOR, is
a clinical staff nurse IV at Memorial Hermann
Hospital-TMC, Houston, TX. Ms Murdock has
no declared affiliation that could be perceived
as posing a potential conflict of interest in the
publication of this article.
AORN Journal j 127
EXAMINATION
2.5
CONTINUING EDUCATION PROGRAM
Perioperative Cardiopulmonary
Arrest Competencies
www.aorn.org/CE
PURPOSE/GOAL
To enable the learner to participate more effectively in cardiopulmonary resuscitation (CPR) that occurs during the intraoperative period.
OBJECTIVES
1. Describe the components of CPR.
2. Discuss factors that increase the risk of a patient experiencing a cardiac arrest.
3. Identify when it is appropriate to defibrillate a patient who is experiencing
cardiac arrhythmias.
4. Discuss the importance of timing during administration of CPR.
5. Explain the roles of perioperative team members during a cardiopulmonary
arrest that occurs in the OR.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.
3.
QUESTIONS
1.
2.
The perioperative nurse should assess patients for
potential risks of cardiac arrest, which include
1. age.
2. smoking, alcohol abuse, or illegal drug use.
3. a family history of cardiovascular disease.
4. obesity or a sedentary lifestyle.
5. a previous history of myocardial infarction.
a. 4 and 5
b. 1, 2, and 3
c. 1, 2, 3, and 4
d. 1, 2, 3, 4, and 5
The American Society of Anesthesiologists
(ASA) Physical Status Classification System is an
assessment tool that may indicate whether
a patient is at risk for cardiac arrest.
a. true
b. false
128 j AORN Journal
August 2013
Vol 98 No 2
The most important intervention used to sustain
life during CPR is/are __________________
a. cardioversion.
c. compressions.
b. ventilations.
d. defibrillation.
4.
Surgical team members should initiate CPR
within _________________of cardiac arrest
recognition.
a. 10 seconds
b. 60 seconds
c. 2 minutes
d. 4 minutes
5.
To maximize the effectiveness of compressions,
team members should rotate often, and these
rotations should not take more than _____to
complete.
a. 60 seconds
b. 45 seconds
c. 30 seconds
d. 10 seconds
Ó AORN, Inc, 2013
CE EXAMINATION
6.
Immediate defibrillation is the recommended
therapy for
1. asystole.
2. atrial flutter.
3. pulseless ventricular tachycardia.
4. ventricular fibrillation.
a. 1 and 2
b. 3 and 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
7.
Irreversible tissue damage and brain death occur
within eight to 10 minutes after circulation stops.
a. true
b. false
8.
9.
All surgical team members are required to have
knowledge of advanced cardiac life support and
pediatric advanced life support guidelines.
a. true
b. false
The RN circulator is usually the non-sterile team
member who
1. activates the resuscitation.
2. acts as the code leader if an anesthesia
professional is not present.
www.aornjournal.org
assigns more personnel to assist with the
arrest.
4. documents all interventions and events of the
resuscitation.
5. facilitates and delegates the retrieval of
essential equipment and medications.
6. maintains the sterility of the surgical field
and the surgical site.
a. 1, 2, and 6
b. 1, 4, and 5
c. 2, 3, 5, and 6
d. 1, 2, 3, 4, 5, and 6
3.
10.
The use of mock codes helps team members
1.
2.
rehearse their responsibilities.
decrease anxiety and build confidence.
gain hands-on experience with resuscitative
equipment and medications.
4. identify areas of educational or competency
needs.
5. improve their response times.
a. 4 and 5
b. 1, 2, and 3
c. 1, 2, 3, and 4
d. 1, 2, 3, 4, and 5
3.
AORN Journal j 129
LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM
Perioperative Cardiopulmonary
Arrest Competencies
T
his evaluation is used to determine the extent to
which this continuing education program met
your learning needs. Rate the items as described
below.
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Describe the components of cardiopulmonary
resuscitation (CPR).
Low 1. 2. 3. 4. 5. High
2. Discuss factors that increase the risk of a patient
experiencing a cardiac arrest.
Low 1. 2. 3. 4. 5. High
3. Identify when it is appropriate to defibrillate
a patient who is experiencing cardiac arrhythmias.
Low 1. 2. 3. 4. 5. High
4. Discuss the importance of timing during administration of CPR. Low 1. 2. 3. 4. 5. High
5. Explain the roles of perioperative team members
during a cardiopulmonary arrest that occurs in the
OR. Low 1. 2. 3. 4. 5. High
CONTENT
6. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
7. To what extent were your individual objectives met?
Low 1. 2. 3. 4. 5. High
8. Will you be able to use the information from this
article in your work setting? 1. Yes 2. No
130 j AORN Journal
August 2013
Vol 98 No 2
2.5
www.aorn.org/CE
9. Will you change your practice as a result of reading
this article? (If yes, answer question #9A. If no,
answer question #9B.)
9A. How will you change your practice? (Select all that
apply)
1. I will provide education to my team regarding
why change is needed.
2. I will work with management to change/
implement a policy and procedure.
3. I will plan an informational meeting with
physicians to seek their input and acceptance
of the need for change.
4. I will implement change and evaluate the
effect of the change at regular intervals until
the change is incorporated as best practice.
5. Other: ________________________________
9B. If you will not change your practice as a result of
reading this article, why? (Select all that apply)
1. The content of the article is not relevant to my
practice.
2. I do not have enough time to teach others
about the purpose of the needed change.
3. I do not have management support to make
a change.
4. Other: _______________________________
10. Our accrediting body requires that we verify
the time you needed to complete the 2.5 continuing education contact hour (150-minute)
program: _________________________________
Ó AORN, Inc, 2013