Preparing for rare but life-threatening anesthesia emergencies
Ambulatory surgery centers urged to standardize response to high-severity emergencies.
When ambulatory surgery centers (ASCs) face rare but high-severity emergencies, patient outcomes depend both on clinical knowledge and on an organization’s ability to execute a well-rehearsed response under pressure.
That response should be guided by a documented plan and standardized checklists, according to Sher-Lu Pai, MD, FASA, Associate Professor of Anesthesiology at the Mayo Clinic in Jacksonville, Florida. Dr. Pai is among the panelists at the Sunday session, “Are You Prepared for Code ASC: Anticipate and Act, Stabilize, Command – Leading Crisis in Ambulatory Anesthesia.”
The session will focus on four critical domains within an ASC: malignant hyperthermia (MH), perioperative anaphylaxis (POA), hemodynamic shock, and facility crises (fire, oxygen/power failure, active shooter).
“The practical framework for ASC teams is about recognizing these events [and also] creating a systematic, checklist-driven response where there is essentially no margin for error,” Dr. Pai said. “The overarching theme is that patient survival depends on early recognition, prompt treatment, and timely transfer to a facility with critical care capabilities.”
Developing reliable systems for managing rare but potentially catastrophic perioperative events under pressure requires a team’s ability to recognize warning signs early, initiate treatment protocols immediately, and transfer patients to facilities with higher levels of critical care capabilities successfully, she said. Although ambulatory surgery is predictable most of the time, Dr. Pai said this proactive approach can significantly improve patient outcomes.
“When a crisis occurs, success depends on transforming complex guidelines into simple, actionable workflows built on early recognition, clearly defined roles, drill-based readiness, and systemic handoffs. This is particularly true when preparation gaps pose serious risks to patients and the center’s accreditation,” she said. “For ASC anesthesiologists and surgical leaders, the value of these guidelines or checklists is that they transform theoretical knowledge into actionable operational processes. Most physicians know that dantrolene treats MH, and epinephrine treats anaphylaxis. The real challenge lies in how quickly the team can execute treatment under stress.”
Dr. Pai noted that ASC readiness guidelines should focus on the following key elements:
- High vigilance on clinical presentation: Physicians must rapidly identify the earliest warning signs and activate emergency protocols immediately. Plans must be initiated at the first credible suspicion.
- Predefined management plans: Successful management requires clear, predefined actions and responsibilities instead of ad hoc responses. Knowledge alone is insufficient. Teams must rehearse these events until the response becomes operationally automatic.
- Systemic hand-offs and transfer processes: Because definitive critical care resources may not be available on-site, patient survival depends on initial stabilization and a smooth transition to higher-acuity care.
Two highly dangerous, yet rare, anesthesia-related emergencies are MH and POA.
“For MH, warning signs include rising end-tidal carbon dioxide levels, tachycardia, muscle rigidity, hyperkalemia, acidosis, dysrhythmias, and rhabdomyolysis,” Dr. Pai said. “For POA, clinicians should be alert for sudden hypotension, tachycardia, bronchospasm, oxygen desaturation, cutaneous manifestations such as urticaria and angioedema, and, in severe cases, cardiovascular collapse.”
Rapid recognition of these symptoms is considered essential because both conditions can deteriorate quickly if treatment is delayed, she said.
As such, successful crisis management relies on predefined roles and standardized procedures rather than improvised responses, Dr. Pai said.
For MH, facilities must ensure staff are trained to locate and deploy MH carts and are familiar with proper dantrolene preparation and dosing. For perioperative anaphylaxis, teams should know ASC-specific treatment algorithms and be prepared to administer epinephrine as first-line therapy.
Transforming crisis response from a reactive process dependent on individual memory into a standardized, success-under-pressure approach includes a plan for the recognition and management of sudden hypotension and hypoperfusion in ASCs, too.
According to session panelist Jagan Devarajan, MB, BS, FASA, an Anesthesiologist with the Cleveland Clinic in Ohio, the two events are caused by four high-risk conditions: hypovolemia, acute blood loss, cardiogenic decompensation, and local anesthetic systemic toxicity (LAST). Although uncommon, these emergencies can escalate rapidly and leave little margin for error.
“A crisis is not the time to demonstrate how much we can remember. It is the time to demonstrate how reliably our team and system can perform,” Dr. Devarajan said. “Expertise remains essential, but expertise supported by a practiced system is safer than expertise dependent on memory alone. Our goal should therefore be to move ASC crisis management from reactive and variable to proactive, standardized, and assured. We want the emergency response to become almost predictable.”
According to Dr. Devarajan, early recognition is critical. Warning signs include significant drops in blood pressure, evidence of impaired tissue perfusion, rapidly increasing blood loss, pulmonary edema with hemodynamic compromise, or neurological and cardiovascular symptoms following local anesthetic administration.
Once a crisis is identified, Dr. Devarajan encourages physicians to explicitly declare the emergency using phrases such as, “We have significant hemorrhage,” “This is cardiogenic shock,” or “I am concerned about LAST.”
“Such declarations immediately shift the event from an individual concern to a coordinated team response,” he said.
Dr. Devarajan advocates for a defined framework for managing an ASC crisis. Assignments under the proposed framework include:
- Anesthesiologist (team leader): Directs overall crisis management, coordinates team actions, and leads decision-making regarding patient stabilization and transfer.
- CRNA: Manages airway and ventilation, administers medications, and assists with ongoing resuscitative efforts.
- Anesthesia technician: Retrieves and prepares the code cart, intravenous fluids, blood products, and the LAST rescue kit as needed.
- Surgical technologist/technical support: Assists the surgeon with procedural interventions and source control measures when indicated.
- Operating room registered nurse: Coordinates documentation, facilitates communication, and provides support to the surgical team.
- PACU registered nurse: Activates EMS when required and coordinates patient transfer logistics to the receiving facility.
- Designated checklist reader: Reads crisis management checklists aloud to the team, ensuring that critical steps and interventions are completed and not overlooked.
The approach reflects recommendations from the Anesthesia Patient Safety Foundation, which advocates for the use of cognitive aids during infrequent high-acuity events. Additionally, Dr. Devarajan said simulation studies found that crisis checklists significantly reduce missed critical actions during emergencies.
“For rare, high-consequence ASC emergencies, preparation is part of the treatment. We cannot control whether every crisis will occur, but we can control whether the team is ready for it,” Dr. Devarajan said. “Proactive, standardized, practiced, and reliable response makes every patient safer. Each ASC should establish procedure- and population-appropriate activation thresholds.”
The panel also includes presenter Mark Phillips, MD, FASA, Professor of Research and Clinical Interests in the Department of Anesthesiolgy and Perioperative Medicine at the University of Alabama at Birmingham.
