ASA PeRLS — Perioperative Resuscitation & Life Support

Protocol Map · 2025 Guideline Update (Moitra et al., Anesthesiology)
ASA + SOCCA GRADE Methodology ACLS Alternative 17 International Experts 97 Clinical Questions 5.75–6.25 CME
4
Core Modules
8
Special Situations
2–13
Arrests per 10k anesthetics
32–75%
Mortality pre-discharge
Core Curriculum — 4 Modules
1 Pre-Arrest
The Rescue Concept
  • Early recognition of deterioration
  • Pre-arrest interventions to delay/prevent arrest
  • Rescue vs. resuscitation philosophy
  • Monitoring thresholds & trigger criteria
  • Team activation and communication
  • Proactive hemodynamic support
2 Pre-Cardiac Arrest in OR
Intraoperative Crisis Management
  • Shock states → arrest continuum
  • Airway & ventilation failure management
  • Gas trapping / auto-PEEP recognition
  • Hemodynamic instability workup
  • Hypovolemia and hemorrhage control
  • Surgical & anesthetic contributing factors
3 Arrhythmias
Perioperative Dysrhythmia Management
  • Tachydysrhythmia treatment algorithms
  • Bradydysrhythmia treatment algorithms
  • PEA — perioperative etiologies
  • Pump failure / cardiogenic shock
  • ACLS algorithm annotation for OR context
  • Cardioversion & pacing indications
4 Conditions Complicating Arrest
Arrest in OR / Periprocedural Setting
  • CPR modifications for surgical patients
  • Open cardiac massage — indications
  • TEE integration in arrest algorithms
  • ECMO / ECPR rescue pathways
  • Post-cardiac arrest management
  • Targeted temperature management
8 Special Situations
🔴 Anaphylaxis
🔵 Gas Embolism
🟡 Hyperkalemia
🩷 Transfusion Reaction
🟣 Traumatic Cardiac Arrest
🩵 LAST — Local Anesthetic Systemic Toxicity
🟢 Neuraxial Anesthesia
🔥 Malignant Hyperthermia
PeRLS vs. Standard ACLS — Key Distinctions
Standard ACLS (AHA)
  • Designed for out-of-hospital / ward arrests
  • Assumes unwitnessed or delayed discovery
  • Epinephrine 1 mg IV q3–5 min standard dose
  • Airway training emphasized (redundant for anesthesiologists)
  • Generic shockable / non-shockable algorithm
  • No surgical or anesthetic etiologies built in
  • POCUS not integrated into arrest pathways
  • "One-size-fits-all" resuscitation approach
PeRLS (ASA)
  • Designed for OR, ICU, periprocedural settings
  • Assumes witnessed arrest, cause often known
  • Lower epinephrine doses recommended (titrated)
  • Skips basic airway — assumes provider proficiency
  • Etiology-driven, diagnosis-first algorithms
  • Surgical & anesthetic causes explicitly addressed
  • POCUS / TEE integrated into arrest management
  • Open cardiac massage, ECMO/ECPR as rescue options
Guiding Principles
🎯
Rescue First — Prevent the Arrest
PeRLS emphasizes pre-arrest intervention. Early recognition and targeted treatment of deteriorating hemodynamics can abort arrest entirely. The "rescue" concept frames resuscitation as a continuum starting before cardiac standstill.
🔍
Diagnosis-Driven Resuscitation In the perioperative setting the cause of arrest is frequently known or immediately discoverable. PeRLS algorithms branch by etiology, not just rhythm. POCUS and TEE are first-line diagnostic tools integrated directly into arrest pathways.
⚡
Contextual Epinephrine Dosing
Unlike ACLS's fixed 1 mg q3–5 min, PeRLS recommends lower, titrated epi doses in perioperative cardiac arrest. Witnessed arrest with a known cause often requires less vasopressor than an out-of-hospital event with prolonged no-flow time.
🫀
Advanced Rescue Techniques
PeRLS specifically includes ECMO/ECPR, resuscitative thoracotomy, open cardiac massage, REBOA, and intraoperative TEE as tools beyond ACLS scope — options uniquely available in the perioperative environment.
🏥
Whole-Team Training
Designed for anesthesiologists, CRNAs, AAs, OR nurses, surgeons, and intensivists. Growing hospital acceptance as a full ACLS/BLS alternative. Optional Physical Resuscitation module satisfies BLS requirements.
🔄
Maintenance of Expertise
PeRLS offers an annual maintenance-of-expertise model with content delivered over 12 months — designed for high-stakes, low-frequency skills that deteriorate without regular reinforcement.
+ Optional: Physical Resuscitation Module — Covers proper chest compression technique; satisfies BLS requirements at many institutions. Enables hospitals to accept PeRLS as a complete BLS + ACLS alternative. Available as a bundle ($158–$200 depending on ASA membership and pathway).
Treatment Algorithms
PeRLS 2025 · Moitra et al., Anesthesiology 143(6):1453–1483 · Perioperative & ICU-specific protocols
Master Algorithm — Perioperative Cardiac Arrest
PeRLS Perioperative Cardiac Arrest Algorithm (Witnessed, Cause-Driven)
CARDIAC ARREST RECOGNIZED IN OR / PERIPROCEDURAL SETTING
IMMEDIATE ACTIONS (simultaneous)
Call for help · Designate team leader · Note time · Stop surgical bleeding if applicable · Note last anesthetic agents
START HIGH-QUALITY CPR
Rate 100–120/min · Depth ≥2 in · Full recoil · Minimize interruptions (<10 sec pauses)
100% FiO₂ · Confirm ETT position · Disconnect N₂O if in use
⚡ PeRLS KEY STEP: Immediate Etiology Search
Ask: What caused this arrest? — Anesthetic overdose? Hemorrhage? VAE? Anaphylaxis? LAST? MH? High spinal? Airway loss? Pneumothorax? Tamponade?
Deploy POCUS / TEE immediately to guide diagnosis
Rhythm Check — Shockable or Non-Shockable?
VF / Pulseless VT (Shockable)
Defibrillate — 200 J biphasic (escalate PRN)
Resume CPR × 2 min immediately
After 2nd shock if refractory:
Epi 100–300 mcg IV (PeRLS lower dose)
Repeat q3–5 min PRN
After 3rd shock — antiarrhythmic:
Amiodarone 300 mg IV then 150 mg
or Lidocaine 1.5 mg/kg IV
Rhythm check q2 min · Treat reversible cause
PEA / Asystole (Non-Shockable)
CPR × 2 min · Establish IV/IO access
Epi 100–300 mcg IV as soon as possible
(PeRLS: lower dose than ACLS 1 mg standard)
Repeat q3–5 min
Rhythm check q2 min
⚡ PeRLS PEA Differentials in OR:
Hypovolemia · Hypoxia · Pneumothorax · Tamponade
VAE · LAST · Anaphylaxis · MH · High spinal
Anesthetic overdose · PE · Hyperkalemia
Treat underlying cause · Consider POCUS/TEE
ROSC Achieved?
NO — continue loop
Continue CPR · Reassess etiology · Consider escalation:
Open cardiac massage · ECMO/ECPR · TEE guidance
YES — post-arrest care
ROSC → Post-Arrest Management Protocol ↓
Perioperative Reversible Causes — The PeRLS "OR H's & T's"
Perioperative "H's"
Hypovolemia Hemorrhage, anaphylaxis, third spacing
Hypoxia ETT displacement, circuit disconnect, bronchospasm
Hydrogen ion (acidosis) Metabolic, respiratory, sepsis, MH
Hypo/Hyperkalemia Succinylcholine + denervation, renal failure
Hypothermia Prolonged exposure, major trauma, irrigation
High spinal / Hypotension Neuraxial anesthesia spread, vasodilation
Perioperative "T's" + Anesthesia-Specifics
Tension pneumothorax Central line, laparoscopy, auto-PEEP, trauma
Tamponade TEE diagnostic; pericardiocentesis / open drainage
Thrombosis (PE / AMI) Massive PE, coronary occlusion during case
Toxins / Drugs LAST, anesthetic overdose, MH, adverse drug reaction
Transfusion reaction ABO incompatibility, TRALI, hemolysis
VAE (gas embolism) Venous air — seated, laparoscopic, craniotomy
Special Situation Treatment Algorithms
🔴 Anaphylaxis
  1. Declare emergency · call for help · identify & stop trigger (NMBs most common)
  2. Stop surgical procedure if possible · 100% FiO₂
  3. Turn off volatile anesthetic if severe hemodynamic compromise
  4. If hypotensive: Epi 1–10 mcg/kg IV bolus (IV access present in OR = IV preferred over IM)
  5. If no IV: Epi 10 mcg/kg IM
  6. Start Epinephrine infusion if multiple boluses required
  7. Volume: Isotonic saline 10–30 mL/kg IV rapid
  8. Adjuncts: Methylprednisolone 2 mg/kg IV · Diphenhydramine 1 mg/kg IV
  9. Bronchospasm: Albuterol 4–10 puffs
  10. Send serum tryptase within 30 min–2 hrs to confirm diagnosis
  11. If cardiac arrest → standard CPR + consider ECMO
⚠ If cardiac arrest: standard CPR + vasopressors. No dose reduction in arrest — but treat the anaphylaxis simultaneously.
🩵 Local Anesthetic Systemic Toxicity (LAST)
  1. Declare emergency · call for help · stop LA injection immediately
  2. 100% FiO₂ · Airway control · Secure IV access
  3. Seizures: Benzodiazepine — avoid propofol in hemodynamic instability
  4. 20% Lipid Emulsion (Intralipid) bolus: 1.5 mL/kg IV over 1 min
  5. Follow with lipid infusion: 0.25 mL/kg/min (upper limit ~10–12 mL/kg total)
  6. If cardiac arrest: Epi 100–300 mcg IV (NOT standard 1 mg — impairs lipid rescue)
  7. Avoid: vasopressin · calcium channel blockers · beta-blockers · propofol
  8. If refractory: ECMO/ECPR — prolonged ACLS justified (LA redistributes)
  9. Monitor for recurrence 4–6 hours post-event
⚠ LAST-specific epi rule: ≤1 mcg/kg (or 100–300 mcg). Standard ACLS 1 mg epi impairs lipid emulsion efficacy and worsens outcomes.
ASRA checklist available at asra.com/guidelines/last — print and post in every anesthetizing location.
🔥 Malignant Hyperthermia (MH)
  1. Declare MH emergency · get help · surgeon stops procedure if possible
  2. Stop all triggering agents immediately — volatiles, succinylcholine
  3. Attach activated charcoal filters to anesthesia circuit · O₂ flush 10 L/min
  4. Hyperventilate to normalize EtCO₂ (or below target)
  5. Dantrolene 2.5 mg/kg IV bolus — repeat q5 min until EtCO₂ <45 mmHg, HR normalizes, rigidity resolves
  6. Continue dantrolene until response — up to 10 mg/kg cumulative (if no response, reconsider diagnosis)
  7. Maintenance: Dantrolene 1 mg/kg IV q6h × 24h (prevent recrudescence)
  8. Active cooling: ice packs, cold saline irrigation, cooling blankets — target <38.5°C
  9. Hyperkalemia: CaGluconate 30 mg/kg IV · NaHCO₃ 1–2 mEq/kg · Insulin 0.1 U/kg
  10. Arrhythmia: Amiodarone 5 mg/kg IV — do NOT use calcium channel blockers (hyperkalemia risk)
  11. Urinary catheter — maintain UO >2 mL/kg/hr (rhabdomyolysis / renal protection)
  12. If cardiac arrest → CPR + consider ECMO
⚠ Ryanodex (new formulation) mixes in 5 mL sterile water in <1 min vs. Dantrium's 60 mL — critical time savings.
MHAUS Hotline: 1-800-MH-HYPER · mhaus.org · European: emhg.org
🟢 High / Total Spinal — Neuraxial Anesthesia
  1. Recognize: rapid hypotension + bradycardia + respiratory distress / apnea after neuraxial block
  2. Call for help · lay patient supine (Trendelenburg if tolerated)
  3. Airway first: if apneic/unconscious → immediate RSI and intubation
  4. 100% FiO₂ · Assisted ventilation
  5. Epinephrine 10–100 mcg IV bolus for hemodynamic collapse (titrate to effect)
  6. Severe bradycardia: Atropine 0.5–1 mg IV · Epinephrine infusion if persistent
  7. Aggressive IV fluid resuscitation for preload support
  8. Leg elevation to augment venous return
  9. If cardiac arrest: CPR + vasopressors. Epinephrine dose per arrest algorithm.
  10. Reassure patient if conscious — block resolves with time
Distinguish from anaphylaxis: no urticaria/bronchospasm; onset immediately after neuraxial. Timing and procedure type are key diagnostic clues.
🔵 Venous Air Embolism (VAE)
  1. Recognize: sudden ↓ EtCO₂ · ↓ SpO₂ · hypotension · "mill-wheel" murmur · TEE shows air in RV
  2. Alert surgeon — flood operative field with saline · pack wound
  3. Stop N₂O immediately · 100% FiO₂
  4. Place patient in left lateral decubitus + Trendelenburg (Durant's maneuver) — traps air in RV away from RVOT
  5. Aspirate air via central venous catheter (right atrial aspiration)
  6. POCUS/TEE to confirm and guide — RV dilation, air visualization
  7. Vasopressors for hemodynamic support: Norepinephrine or Phenylephrine
  8. CPR if cardiac arrest — may mobilize air
  9. Consider ECMO if refractory
⚠ High-risk positions: seated craniotomy, laparoscopy, hip arthroplasty. Precordial Doppler most sensitive early monitor.
🟡 Hyperkalemia-Induced Arrest
  1. Recognize risk: succinylcholine in burn/denervation patients, renal failure, rhabdomyolysis (MH)
  2. ECG changes: peaked T-waves → widened QRS → sine wave → arrest
  3. Membrane stabilization: Calcium gluconate 1–2 g IV (or CaCl 500–1000 mg) — give over 5–10 min, repeat PRN · obtain ECG before and after
  4. Shift K⁺ intracellular: Sodium bicarbonate 1–2 mEq/kg IV
  5. Shift K⁺: Insulin 10 units IV + Dextrose 50% 50 mL
  6. Bronchodilator shift: Albuterol 10–20 mg nebulized
  7. Eliminate K⁺: dialysis if refractory and available
  8. Standard CPR if arrest — calcium and bicarb during resuscitation
Succinylcholine in burns/SCI can release K⁺ 5–14 mEq — can be immediately lethal. Avoid succinylcholine >24–48h post-burn or SCI.
🟣 Traumatic Cardiac Arrest
  1. Simultaneously: hemorrhage control + CPR — in trauma arrest, the cause (hemorrhage) must be controlled for ROSC to be sustained
  2. Permissive hypotension pre-hemorrhage control (SBP 80–90 before definitive bleeding control)
  3. Massive transfusion: 1:1:1 ratio pRBC:FFP:Plt · TXA 1g IV (within 3h)
  4. Calcium: CaCl 1g IV (dilutional hypocalcemia during MTP)
  5. Bilateral needle decompression if tension pneumothorax suspected — clinical diagnosis, no time for CXR in arrest
  6. Consider resuscitative thoracotomy in refractory traumatic arrest (trained surgeon present)
  7. Consider REBOA (Resuscitative Endovascular Balloon Occlusion of Aorta) for hemorrhage control
  8. Epinephrine: use judiciously — vasoconstrictors in distributive/hemorrhagic arrest may be harmful; control the source first
  9. ECMO if available and cause reversible
⚠ Standard ACLS epinephrine emphasis is LEAST appropriate in traumatic arrest — hemorrhage control and volume are the priority.
🩷 Hemolytic Transfusion Reaction
  1. Stop transfusion immediately · keep IV line open with saline
  2. ABO incompatibility: fever, hemoglobinuria, hypotension, DIC — classically masked by GA
  3. Aggressive IV fluids: maintain UO >1 mL/kg/hr (renal protection from free Hgb)
  4. Vasopressors if hypotensive: Norepinephrine
  5. Monitor for DIC: coag panel, fibrinogen, TEG/ROTEM
  6. Send blood bank specimens: repeat type & screen, Coombs, return transfused unit
  7. TRALI: bilateral pulmonary infiltrates + hypoxia within 6h — supportive care, no diuresis
  8. Standard CPR if arrest + treat underlying cause
Under GA the classic symptoms (back pain, anxiety, dark urine) are masked. Unexplained intraoperative hypotension with ongoing transfusion = stop and investigate.
Post-Cardiac Arrest Management — PeRLS Framework
Hemodynamic Targets
Oxygenation & Ventilation
Temperature & Neuro
Diagnostic Workup
Coronary / Intervention
PeRLS Escalation Options
Evidence note: Many PeRLS 2025 recommendations are conditional due to low or very low certainty of evidence — reflecting the scarcity of RCTs in perioperative resuscitation. The GRADE framework was applied to 97 clinical questions; 12 were prioritized. Four underwent formal Cochrane systematic reviews. The conditional nature of recommendations underscores the importance of clinical judgment and etiology-specific decision-making over rigid protocol adherence.
ASA PeRLS · Developed with SOCCA & ASA Critical Care Committee · 2025 Update: Moitra et al., Anesthesiology 143(6):1453–1483 · Algorithms compiled from primary guideline sources for educational reference
The Critical Vector · Direction and magnitude.