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Introduction: Despite emphasis on incorporating “code status” into pre-operative informed consent discussions, the risks and outcomes of cardiopulmonary resuscitation (CPR) for vascular surgery patients who suffer cardiac arrest (CA) remain poorly defined. We sought to identify risk factors and define outcomes for post-operative CA requiring CPR in patients undergoing vascular surgery, to provide an evidence base for informed consent discussions and implementation of perioperative "do not resuscitate” (DNR) orders.
Methods: 2007-2010 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) public utilization files were utilized to develop a multi-institutional database of patients undergoing vascular surgery (N=123,621). Univariate analyses identified risk factors associated with post-operative CA requiring CPR and assessed outcomes of resuscitation. Multivariate logistic regression models were developed for post-operative CA requiring CPR and resuscitation outcomes.
Results: Post-operative cardiac arrest requiring CPR was seen in 1236 of 123,621 (1.0%) patients after vascular surgery at a mean of 7.2 (median 4) days. 30-day mortality was 73.4% compared to 2.7% among patients who did not experience this adverse outcome (P<.001). Patient characteristics independently associated with post-operative CPR are shown (Table 1). Procedures associated with the highest risk included thoracic aortic surgery (OR 6.9, [95% CI: 4.8-9.9]; P <.001), open abdominal procedures (3.7, [3.1-4.4]; P <.001), axillary-femoral bypass, (2.1 [1.3-3.2]; P=.001), and peripheral embolectomy (1.5 [1.2-1.9]; P=.002). At least one major complication preceded cardiac arrest in 47.7% of patients including sepsis (23.5%), renal failure (14.5%), and myocardial infarction (12.1%). Patients with DNR orders were significantly less likely to undergo CPR (0.59 [0.39-0.93]; P=0.021). Of CPR survivors, 102 (12.1%) were still hospitalized at 30 days.
Discussion: Informed consent necessitates patients and surrogates understand the risks and outcomes of procedures, including the risk of post-operative CA requiring CPR. Vascular surgeons routinely perform high-risk procedures on elderly patients with severe co-morbidities, who are unlikely to survive post-operative CA. Our data provides an evidence base to facilitate individualized discussions regarding goals of care and DNR orders after major vascular procedures.

Multivariate Predictors of Post-operative Cardiac Arrest (OR, 95% CI, P-value)

Total Functional Dependence	2.9	2.3-3.6	<.001
Dialysis	2.7	2.3-3.2	<.001
Emergency Case	2.2	1.9-2.5	<.001
Partial Functional Dependence	2.0	1.7-2.4	<.001
Preoperative ventilation	2.0	1.5-2.7	.001
History of MI	1.8	1.4-2.3	<.001
Dyspnea on Exertion	1.5	1.2-1.9	.001
Prior Cardiac Surgery	1.5	1.3-1.6	<.001
Recent Weight Loss	1.4	1.1-1.9	<.001
CHF	1.4	1.1-1.8	.005