Cardiac arrest in adult patients receiving anaesthetic care for cardiology procedures

Abstract

We read with interest the article by Agarwal et al. highlighting the findings of the 7th National Audit Project (NAP7), particularly for adult patients experiencing intra-operative cardiac arrest during cardiology procedures [1]. The overrepresentation of these patients relative to the broader NAP7 cohort, their inferior outcomes in terms of both initial arrest and hospital survival, and the prevalence of these events during procedures in cardiology suites identifies a subset of patients in need of a different approach from an anaesthesia and multidisciplinary perspective. We commend the authors on this novel finding.

The expansion of novel transcatheter techniques and the evolution of electrophysiology programmes have led to a significant increase in the number of minimally invasive cardiology procedures being performed [2, 3]. With increasing numbers of interventions performed under local anaesthesia, the cases requiring general anaesthesia tend to be either highly complex, emergent or involving particularly high-risk patients, all of which are risk factors for cardiac arrest. Anaesthetic representation in cardiology suites can be inconsistent, making critical incidents particularly challenging. The combination of unfamiliar cases, environments and teams increases the risk of cardiac arrest and lowers survival rates.

The inferior outcomes when these patients experience cardiac arrest are undoubtedly multifactorial and suggest that the management is suboptimal. Designing safer systems in cardiology suites for delivering routine and emergency care is crucial. The overrepresentation of incidents must be addressed and efforts should focus on reducing cardiac arrest incidence and improving outcomes when it occurs. Interprofessional simulation offers multidisciplinary education that improves patient safety [4], especially in remote locations with infrequent emergencies where teams are less familiar with each other. An embedded simulation programme helps to promote better teamwork, understanding and communication in this environment, and we suggest it should be a mandatory component of an anaesthesia delivery service.

In situ simulation training has also been shown to identify critical latent threats which traditional reporting systems miss [5]. Our hospital's joint cardiology, intensive care and anaesthesia catheter laboratory simulation programme has identified medication, monitoring, communication and leadership issues, thus prompting service improvements. In an environment with limited clinical interactions, it is beneficial to identify these threats safely and mitigate them before any patient is exposed to harm. We should have a greater emphasis on the prevention of cardiac arrest and not just on effective management when it occurs.

We wholeheartedly agree with the authors' recommendations regarding guidelines, skill levels and training for anaesthetists responding to cardiac arrest in the catheter laboratory [1]. They highlight that simulation may be included in this training. We would go one step further and advise that providing a robust multidisciplinary simulation training programme should be mandatory. The focus must also be on developing team-working skills and knowledge to prevent cardiac arrest in this rising high-risk population.