Cardiopulmonary Resuscitation in the PACU

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Cardiopulmonary emergencies are not uncommon in the postanesthesia care unit (PACU). Perianesthesia nurses must keep their cardiopulmonary resuscitation (CPR) skills and knowledge base current to most effectively respond to this potentially devastating event. In October 2020, the 2020 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care were published in Circulation. This CPR update was based on an international evidence-based evaluation process involving hundreds of resuscitation experts.1

This chapter examines CPR based on the 2020 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care as it applies to the PACU. In areas in which the 2020 AHA Guidelines did not elaborate or alter previous recommendations, references will be made to the previous 2015 AHA Guidelines. Although this chapter highlights the responsibilities of the health care provider during a cardiopulmonary emergency, it is not designed to replace formal training in either basic life support or advanced cardiopulmonary life support as offered through the AHA.


Antiarrhythmics A group of drugs used to suppress abnormal rhythms of the heart.

Cardiopulmonary Arrest The cessation of normal circulation of the blood because of failure of the heart to contract effectively.

Cardiopulmonary Resuscitation (CPR) An emergency procedure performed in an effort to return life to a person in cardiac arrest.

Chest Compression An emergency procedure performed on a person in cardiac arrest in an effort to create artificial circulation by manually pumping blood through the heart.

Defibrillation A treatment for the life-threatening cardiac arrhythmias that consists of delivering a therapeutic dose of electrical energy to the heart, which depolarizes a critical mass of the heart muscle, terminates the arrhythmia, and allows normal sinus rhythm to be reestablished via the patient’s sinoatrial node.

Differential Diagnosis A systematic method, essentially a process of elimination, used to identify unknowns.

Vasopressors Sympathomimetic drugs that mimic the effects of the sympathetic nervous system.

Ethical issues related to cardiopulmonary resuscitation

Since the passage of the Patient Self-Determination Act in 1991, patients may choose to accept or refuse treatment including resuscitation efforts.2 The immediate necessity of initiation of CPR creates numerous ethical concerns and considerations, particularly when the patient’s wishes are unknown to the provider. Living wills, advance directives, and do-not-resuscitate (DNR) orders may not be known to the lay provider responding to cardiopulmonary arrest in the field, but these documents should be available to all medical personnel in an in-hospital setting.

For patients entering the operating room for surgery, there has long been controversy concerning the suspension of existing DNR orders as many of the routine interventions of surgery and anesthesia (e.g., endotracheal intubation) may be explicitly contrary to the patient’s stated wishes. Recommendations regarding suspension of a patient’s advance directives or DNR orders include documentation of a discussion of some of the many intraoperative and postoperative events that may occur and the consideration and wishes of the patient or family members regarding intervention should such events occur.3 The 2020 AHA Guidelines also reviewed the ethical decision to incorporate the use of extracorporeal CPR (ECPR) for in-hospital cardiac arrest (IHCA) in both adults and pediatric patients. It was determined there is not sufficient evidence to recommend the routine use of this effort with the potential for harm that must be weighed against the possibility of benefit.4 More in-depth discussion of the many ethical considerations arising from the conflict of the ethical principles of autonomy and beneficence exceeds the scope of this chapter.3 PACU nurses are encouraged to be thoroughly familiar with the policies and procedures of their individual institutions regarding such issues.

Cardiopulmonary resuscitation

The prompt provision of CPR has been reaffirmed through updated evidence from analysis of over 12,500 patients.4 It is imperative that the PACU nurse remain vigilant and prepared to respond quickly and efficiently to any cardiopulmonary emergency.

Indications for Resuscitation

Numerous precipitating events are associated with cardiopulmonary arrest. These events include respiratory compromise, circulatory or cardiac compromise, metabolic imbalances, medication or anesthetic overdoses or toxicity, and anaphylaxis. All these events have the potential to occur in the PACU.

Respiratory compromise appears to be the primary cause of morbidity in the PACU. Respiratory compromise can result from residual anesthesia, upper airway obstruction, laryngeal edema, laryngospasm, bronchospasm, noncardiogenic pulmonary edema, and aspiration.5

One of the most common causes of upper airway obstruction in the postanesthetic patient results from mechanical obstruction from the tongue. This situation occurs when the tongue falls back into a position that mechanically obstructs the pharynx, blocking the passage of air to and from the lungs. The underlying cause of this obstruction may be the result of residual anesthetics, opioids, or muscle relaxants administered during surgery. The tongue may also be edematous from surgical manipulation, anatomic deformities, or allergic reaction. Clinical signs of this type of obstruction include snoring, flaring of the nostrils, use of accessory muscles for ventilation, retraction of the intercostal spaces and suprasternal notch, asynchronous movements of the chest and abdomen, tachycardia from hypoxia, and decreased oxygen saturation.6,7

Arterial carbon dioxide pressure (Paco2) increases 6 mm Hg during the first minute of total obstruction with an additional increase of 3 to 4 mm Hg each passing minute.8 If the obstruction is not corrected, the patient’s condition will continue to deteriorate, resulting in cardiopulmonary arrest. This occurrence is especially tragic when the obstruction could have been corrected by simply stimulating the patient to take deep breaths or by repositioning the airway via a chin lift or jaw thrust. Additional techniques include the use of a nasal or oral airway. When deciding which of these two airways to use, the PACU nurse should remember that the nasal airway is usually less stimulating and thus tolerated better in the patient emerging from general anesthesia. The nasal airway should not be used with patients with known or suspected basal skull fractures because of the possibility of inadvertent intracranial placement of the airway. Nasal airways should also not be used with patients presenting with severe coagulopathy due to the increased incidence of nasal bleeding associated with insertion of the nasal airway.8

If the obstruction persists, advanced airway management procedures with the esophageal-tracheal Combitube, Laryngeal Tube or King LT, laryngeal mask airway, or endotracheal tube may be indicated. Obviously, prevention of cardiopulmonary arrest is more desirable than treatment. When a cardiopulmonary arrest does occur, emergency procedures must be administered rapidly and decisively before irreversible damage occurs.8

Emergency Equipment

The perianesthesia nurse, faced with a cardiopulmonary arrest, has an obvious advantage over a layperson or health care provider faced with a similar event outside the hospital. This advantage is based on the numerous resources available to the PACU nurse to aid in the diagnosis and treatment of an actual or pending adverse cardiopulmonary event. These resources include monitoring modalities, medications, essential equipment, and access to the patient’s medical history, which can give valuable insight into possible underlying causes and pathology leading up to the adverse event. Another advantage is the availability of assistance and consultation from other health care professionals.

The routine use of various monitoring modalities in the PACU is invaluable for the diagnosis of many developing patient complications that could precipitate a cardiopulmonary arrest. The use of pulse oximetry, for example, can be extremely helpful in the diagnosis of problems concerning patient oxygenation as in the case of a progressing airway obstruction. The use of a capnograph may be helpful in the early detection of adverse respiratory events such as hypoventilation. The routine use of an electrocardiogram (ECG) monitor assists the nurse in identifying life-threatening arrhythmias such as pulseless ventricular tachycardia (VT), ventricular fibrillation (VF), asystole, and pulseless electrical activity (PEA). These and other monitoring modalities provide the nurse with a more definitive means of diagnosis and opportunity for early intervention.9

All advanced cardiac life support equipment should be immediately available to the perianesthesia nurse. This equipment is usually found on a designated code cart or tray located in a designated area of the PACU. The cart should contain various emergency items including a defibrillator and monitor; emergency pharmacologic agents; equipment for circulatory, airway, and respiratory management; and specialty trays for various emergency procedures. Usually, the individual PACU or health care institution establishes the general setup and contents of the cart. Each PACU nurse must be familiar with the location of the cart, its contents, and their proper use. The immediate availability of emergency equipment and pharmacologic agents is essential for successful CPR.

Management of Cardiac Arrest

Adult Chain of Survival

The 2020 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care state that the main focus of cardiac arrest management is to enhance the effectiveness of all critical steps to improve outcomes. These include activation of the emergency response, provision of high-quality CPR and early defibrillation, Advanced Life Support (ALS) interventions, effective post-Return of Spontaneous Circulation (ROSC) care including careful neurologic prognostication, and support during recovery and survivorship.4

Urgency of Cardiopulmonary Resuscitation

Typically, some event occurs that alerts the PACU nurse to the onset of a cardiopulmonary emergency. This event may be in the form of a witnessed collapse of a patient or the onset of a life-threatening arrhythmia such as pulseless VT, VF, asystole, or PEA.

Assess for Responsiveness

At the first sign of potential trouble, the nurse should immediately assess the responsiveness of the patient. Vigilance and attentiveness to the patient, accompanied by establishment of responsiveness, can prevent premature and/or unnecessary activation of the emergency response team. At the same time, the PACU nurse checks the patient’s responsiveness. The patient’s breathing status should also be assessed; this should be a visual inspection for abnormal (only gasping) or lack of breathing.9

Activation of the PACU Emergency System

When unresponsiveness has been determined, the nurse should follow unit protocol to activate the emergency response system, retrieve a defibrillator, and provide CPR and defibrillation as indicated. In most PACUs, the nurse can get another colleague’s help by simply calling out for assistance. In some settings, assistance can be obtained by activating a wall switch or pushing a button on the telephone in the room. In the highly unlikely event the PACU nurse is alone (American Society of Perianesthesia Nurses’ Practice Recommendation states that two RNs should be in the same room/unit with a patient in the PACU),10 the nurse must activate the emergency response system, retrieve the defibrillator, and start CPR. If two rescuers are present, one should begin CPR while another activates the emergency response system and retrieves a defibrillator. Activation of the emergency response system brings help in the form of necessary emergency equipment and essential personnel to the patient’s bedside. Assistance from other health care team members serves many purposes including the ability to perform many essential tasks simultaneously, availability of various knowledge backgrounds and experience levels for consultation, and overall support. Nursing personnel should be thoroughly familiar with the unit’s specific protocols for initiating a code and obtaining needed assistance.

Circulatory Assessment

Once unresponsiveness has been confirmed and the emergency system has been activated, the PACU nurse should immediately proceed with the AHA Basic Life Support and Advanced Cardiac Life Support protocols. The nurse should now proceed to evaluate the patient’s circulatory status. For an adult and child, this assessment is performed by palpating the carotid artery for no more than 10 seconds. If the patient is an infant, the brachial artery should be palpated.11

If a pulse is detected, the patient’s lungs should be ventilated using one of the unit’s readily available bag-mask devices. Respirations should be delivered at a rate of 1 breath every 6 seconds or approximately 10 breaths/min. Each breath should be given over 1 second and cause a visible chest rise. The patient’s pulse should be checked every 2 minutes. This process should continue until the emergency response team can determine and correct the underlying cause of the respiratory arrest or initiate more advanced treatment.1

If no pulse is detected within 10 seconds, cardiac arrest should be assumed, and CPR initiated immediately. The guidelines recommend initiating a CPR sequence of (1) chest compressions, (2) airway, and (3) breathing (CAB). Any time during this sequence, defibrillation should be initiated as soon as a defibrillator is available.1

Cardiopulmonary Resuscitation

Chest Compressions

Cardiac arrest can be caused by four heart rhythms: VF, pulseless VT, PEA, and asystole. VF consists of disorganized electrical activity, while VT consists of organized electric activity of the ventricular myocardium. The mechanical activity exhibited in these rhythms is insufficient to generate enough forward blood flow to sustain life. PEA encompasses a group of organized electrical rhythms with insufficient or absent mechanical ventricular activity. Although this rhythm may generate ventricular electrical activity on the monitor, the ventricle does not mechanically respond, resulting in the absence of a clinically detectable pulse. PEA has previously been referred to as electromechanical dissociation or nonperfusing rhythm. Asystole, also known as ventricular asystole, consists of the absence of detectable ventricular activity with or without atrial electrical activity.9

Ventricular fibrillation and pulseless ventricular tachycardia

During the first few minutes of witnessed VF cardiac arrest, the primary limiting factor for the delivery of oxygen to the heart and brain is blood flow and not arterial oxygen content. As a result, in the initial step of CPR, uninterrupted chest compressions take priority over positive pressure ventilation. In an in-hospital setting, compressions—while of primary importance—should also be accompanied by rescue breathing, ideally with a bag-valve-mask device.1 External cardiac compression should be performed with the patient in a horizontal position on a firm surface. If a bed board is to be used, care must be taken not to delay the initiation of compressions while one is being retrieved. If the patient is on an air-filled mattress, the mattress should be deflated when performing CPR. Studies that focus on the optimal surface for CPR have only been conducted with mannequins but stress the importance of effective compressions.12

CPR is the “single most important intervention for a patient in cardiac arrest, and chest compressions should be provided promptly.”1 Chest compressions are considered the most critical aspect of CPR.

To begin compressions, the rescuer should be positioned at the patient’s side. The rescuer should place the heel of one hand on the center (middle) of the chest between the patient’s nipples (the lower half of the sternum; Fig. 57.1). The heel of the rescuer’s free hand should be placed on top of the hand already positioned on the patient’s chest. The rescuer should keep the arms straight with shoulders directly over the adult patient’s sternum. Providers are to push hard against the adult sternum, compressing at least 2 inches (5 cm) and fast (100–120/minute; see Fig. 57.1; see EbP Box), allowing for complete chest recoil. Evidence supports the premise that this rapid compression rate effectively benefits the patient in terms of blood flow and blood pressure. More rapid rates of compressions have been indicated in rescuer fatigue with a decrease in the depth of compressions. Depth of compression is recommended to be at least 2 inches (5 cm) and no greater than 2.4 inches (6 cm).1 Interruptions to chest compression should always be minimized to as few as possible, with each interruption lasting less than 10 seconds. The chest should be allowed to completely recoil after each compression. Incomplete recoil has been associated with high intrathoracic pressures and decreased hemodynamics including decreased coronary perfusion, cardiac index, myocardial blood flow, and cerebral perfusion. Rescuers are advised to avoid leaning on the chest either between compressions or during the 10-second pulse check at the end of each cycle.

Close-up of rescuer’s both gloved hands, one above the other, pressing the sternum of a patient, lying supine on hospital bed. A health care profession on head side is putting patient on ventilator.

Close-up of rescuer’s both gloved hands, one above the other, pressing the sternum of a patient, lying supine on hospital bed. A health care profession on head side is putting patient on ventilator.

Fig. 57.1 Rescuer’s free hand should be placed on top of hand already positioned on patient’s chest so that hands are overlapped and parallel. Rescuer should keep arms straight and shoulders directly over adult patient’s sternum while pressing down on sternum least 2 inches (5 cm) and fast at a rate of 100 compressions/min. Allow full recoil of the chest between compressions. (From Roberts JR, et al. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Elsevier; 2019. Fig. 12.4.)

Evidence-based practice

With the 2020 update to the recommendations to the AHA Adult Basic and Advanced Life Support guidelines, the focus has turned to adherence to the “Chain of Survival.” For “in-house” arrest, this recommendation consists of:

  1. 1. Early recognition and prevention
  2. 2. Activation of emergency response
  3. 3. Provision of high-quality CPR
  4. 4. Early defibrillation
  5. 5. Effective post-ROSC care, including prognostication
  6. 6. Support during recovery and survivorship

Implications for Practice

Perianesthesia nurses play an integral role in early recognition and prevention of cardiac arrest, and the best outcomes for CPR involve avoiding arrest. Recommendations to remember include the following: agonal or gasping breaths are not to be considered breathing, as they are not effective to sustain ventilation and are present in 40%–60% of victims of arrest. Treat patients with agonal gasps as if they were apneic. Maintenance of an open airway for adequate ventilation and oxygenation are high priorities in CPR but should not delay or impede chest compressions. Ventilation should not be excessive in volume, with 500–600 mL as the recommended optimal volume to prevent excessive intrathoracic pressure which could impede venous return to the heart.

Effective CPR is identified as the most important intervention in cardiac arrest, and chest compressions are the most important component of high-quality CPR. Breaks in chest compressions for more than 10 seconds are strongly discouraged, even for airway management with an advanced airway. Chest compression depth and quality begins to diminish after 90 to 120 seconds, so providers are recommended to rotate the designated compressor at least every 2 minutes, keeping interruptions in compressions to less than 10 seconds to maintain a chest compression fraction of at least 60%. It is also advisable to use audiovisual feedback devices or a “CPR Coach” to monitor quality of compression.

Source: Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142: S366–S468.

If two rescuers are present, it is recommended that they rotate giving compressions every 2 minutes. This is done to prevent rescuer fatigue, which can lead to decreased compression effectiveness such as insufficient rate, depth of compression, and incomplete recoil of the chest as mentioned previously. Significant fatigue and shallow compressions are common after 1 minute of CPR, although the rescuer might not recognize that fatigue affecting effective compressions is present. Rescuers should consider switching roles during any intervention associated with appropriate interruptions in chest compressions such as defibrillation. The rescuers should strive to accomplish this switch in less than 5 seconds.9 The ratio between ventilations and chest compressions is recommended to be 30 compressions to 2 ventilations (30:2).

In children, the sternum is compressed with the heel of only one hand (Fig. 57.2). In infants, the sternum is compressed with the tips of two fingers for one rescuer or the thumbs of the encircling hands of the rescuer when two rescuers are present (Figs. 57.3 and 57.4).13 The compression depth for children should be one third the anteroposterior (A-P) diameter of the chest or approximately 2 inches (5 cm). When treating an infant, the compression depth should be one third the A-P diameter or approximately 1.5 inches (4 cm). As in adults, a rate of at least 100 to 120 compressions/min is also recommended for children and infants.13

A rescuer’s hand applies pressure on head of child while pressing the sternum with other palm. Two dotted line fingers also compress the base of sternum.
Fig. 57.2 Locating the hand position for chest compression in a child. (From Kliegman RM, St. Geme JW, Blum NJ, et al. Nelson’s Textbook of Pediatrics. 21st ed. Elsevier; 2020. Fig. 81.17.)

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May 20, 2023 | Posted by in NURSING | Comments Off on Cardiopulmonary Resuscitation in the PACU

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