What is Lazarus Syndrome?
Lazarus syndrome/ phenomenon is a rare and probably under reported condition where delayed return of spontaneous circulation (ROSC) after cessation of cardiopulmonary resuscitation (CPR) is seen. This was first reported in 1982, so far 38 cases of delayed ROSC have been published and majority of them come from anaesthesia and critical care literature.
In the cases reported so far, ROSC very often occurred within 10 minutes of stopping CPR. Less than half of them achieved good neurological recovery following ROSC and the rest died soon after.
What are the possible mechanisms that explain Lazarus Syndrome?
The exact mechanism of delayed ROSC is unclear and not well understood. This is possibly multifactorial:
1. Positive end expiratory pressure
Dynamic hyperinflation of the lung causing increased positive end expiratory pressure (PEEP) is one of the proposed mechanisms.
2. Delayed action of drugs
Some authors suggest delayed action of drugs administered during CPR as a mechanism for delayed ROSC.
It is possible that drugs injected through a peripheral vein are
inadequately delivered centrally due to impaired venous return, and when
venous return improves after stopping the dynamic hyperinflation,
delivery of drugs could contribute to return of circulation.
3. Myocardial stunning
Prolonged
myocardial dysfunction can occur following myocardial ischaemia, taking
up to several hours before normal function returns. Myocardial Infarction was present in about 1/3 of the cases reported so far which could have contributed to transient myocardial
ischaemia and stunning.
What can be the implications for emergency health care providers with delayed ROSC?
Delayed
ROSC can lead to serious professional and legal consequences. Questions can be raised about the quality of resus and whether
it was stopped too soon. The physicians might also be accused of
negligence or incompetence and even be sued for the damages.
In such a scenario, the
conduct of resuscitation can only be assessed from the documentation, so it is
vital to record the events during cardiac arrest as accurately as
possible. It
is absolutely essential to get a consensus from the arrest team and to
document the reason for termination of CPR.
So, What makes Lazarus Syndrome important for us?
We need to realize that death is not an event, but a process. It is a
process during which various organs supporting the continuation of life
fail. Cessation of circulation and respiration is such an example. The
physical findings to support this—absence of heartbeat and
respiration—are the traditional and the most widely used criteria to
certify death. Since these findings alone are not a sign of definitive
death, it is quite possible to declare death in the interval between
cessation of CPR and delayed ROSC.
Some recommend that the patients should be passively monitored for few minutes following unsuccessful CPR. It should
also be mentioned that the patient is being closely monitored to
establish death. Death should not be certified in any
patient immediately after stopping CPR, and one should wait at least 5-10
minutes, if not longer, to verify and confirm death beyond doubt.
The time honoured
criteria of the stoppage of the heart beat and circulation are
indicative of death only when they persist long enough for the brain to
die.
KEY POINTS
- Lazarus phenomenon is delayed ROSC after cessation of CPR.
- Understand death: It is a process, Stop looking at it like a single event.
- Observe the patients for 5-10 minutes the cessation of CPR before confirming death. (Get an EKG or bedside ECHO before you declare death)
- Re-read and scrutinise the chart before signing it off.
References:
- Adhiyaman V, Adhiyaman S, Sundaram R. The Lazarus phenomenon. Journal of the Royal Society of Medicine. 2007;100(12):552-557.Bray JG. The Lazarus phenomenon revisited. Anesthesiology 1993;78: 991
- Linko K, Honkavaara P, Salmenpera M. Recovery after discontinued cardiopulmonary resuscitation. Lancet 1982;1: 106-7
- Martens P, Vandekerckhove Y, Mullie A. Restoration of spontaneous circulation after cessation of cardiopulmonary resuscitation. Lancet 1993;341: 841
- Braunwald E, Kloner RA. The stunned myocardium: prolonged, postischemic ventricular dysfunction. Circulation 1982;66: 1146-9
- De Salvia A, Guardo A, Orrico M, De Leo D. A new case of Lazarus phenomenon? Forensic Sci Int2004;146: S13-5
- Monticelli F, Bauer N, Meyer HJ. Lazarus phenomenon. Current resuscitation standards and questions for the expert witness (German). Rechtmedizin 2006;16: 57-63
- Lantos JD. The Lazarus Case: Life and Death Issues in Neonatal Intensive Care. Baltimore: Johns Hopkins University Press, 2001
- Conference of Medical Royal Colleges and their Faculties in the United Kingdom 1979. Diagnosis of death. BMJ 1979;1: 332.
- Sweet WH. Brain death. NEJM 1978;299: 410-2