OR Team Roles During Intraoperative CPR

Intraoperative cardiac arrest is a rare but high-stakes event that surgical teams must be prepared to manage effectively. Cardiopulmonary resuscitation (CPR) is already a complex, team-based intervention requiring rapid coordination under pressure. In the operating room (OR), however, this complexity is amplified by environmental and logistical constraints, including maintenance of a sterile field, limited physical access to the patient due to positioning and equipment, and the presence of multiple teams with overlapping responsibilities. These factors can complicate the delivery of timely, effective resuscitation and increase the risk of adverse outcomes. To minimize risks and improve patient outcomes, individual roles and alignment across the entire OR team should be clearly defined during intraoperative CPR. 

Core functional roles in resuscitation include team leader, compressor, airway manager, medication administrator, defibrillator operator, and recorder. While intraoperative cardiac arrest is relatively uncommon—estimated at approximately 90 per 100,000 procedures in a contemporary cohort (Fuchs et al., 2023)—its severity necessitates clear role allocation and team preparedness. For comparison, other rare intraoperative emergencies such as malignant hyperthermia are routinely anticipated and rehearsed despite similarly low incidence, underscoring the importance of preparation for low-frequency, high-acuity events. 

One of the challenges in intraoperative CPR is the limited availability of a formalized, widely adopted delineation of team roles specific to the OR. Unlike standard hospital code responses, where roles are often predefined, intraoperative cardiac arrest frequently relies on implicit role assumption shaped by routine OR responsibilities. In this context, understanding baseline roles provides a useful framework for anticipating behavior during resuscitation. This is supported by simulation-based evidence demonstrating that predefined and rehearsed team roles improve performance and efficiency during resuscitation scenarios, including in settings outside the OR environment (Colman et al., 2019). 

Baseline role assignment is particularly important given the patient population in which intraoperative cardiac arrest occurs. In a large national audit, perioperative cardiac arrest was associated with increased patient comorbidity burden and higher ASA physical status, with hemorrhage identified as one of the most common etiologies (Armstrong et al., 2024). 

The anesthesiologist is primarily responsible for continuous physiologic monitoring, airway management, and hemodynamic control throughout the procedure. Anesthesiologists are often among the first to recognize deterioration and are typically well positioned to coordinate resuscitative efforts. In many settings, they function as the de facto team leader during intraoperative CPR. 

The surgeon, by contrast, is responsible for management of the operative field and the underlying surgical pathology. During cardiac arrest, this role shifts toward rapid cessation of the procedure, control of hemorrhage if present, and facilitation of resuscitative access. This may include adjusting the surgical field to allow chest compressions or addressing reversible surgical causes of arrest. 

Nursing and technical staff team roles are often less formally defined in intraoperative CPR. Circulating nurses typically coordinate communication, call for additional support, and manage equipment, while scrub nurses maintain the sterile field and assist the surgeon. However, qualitative studies suggest that these roles may become variably defined during emergencies, with differences in participation and responsibility across institutions. 

Intraoperative CPR represents a context-specific adaptation of standard Advanced Cardiovascular Life Support principles within a constrained and highly specialized environment. Variability in role delineation may contribute to inefficiencies in care delivery during time-critical events. As such, there is increasing recognition of the need for structured role assignment, simulation-based training, and OR-specific resuscitation protocols to improve team performance and patient outcomes. 

References 

1. Fuchs A., Franzmeier L., Cheseaux-Carrupt M., et al. Characteristics and neurological survival following intraoperative cardiac arrest in a Swiss University Hospital: a 7-year retrospective observational cohort study. Front Med (Lausanne). 2023;10:1198078. doi:10.3389/fmed.2023.1198078 
2. Colman N., Figueroa J., McCracken C., Hebbar K. Simulation-Based Team Training Improves Team Performance among Pediatric Intensive Care Unit Staff. J Pediatr Intensive Care. 2019;8(2):83–91. doi:10.1055/s-0038-1676469 
3. Armstrong RA., Soar J., Kane AD., et al. Peri-operative cardiac arrest: epidemiology and clinical features of patients analysed in the 7th National Audit Project of the Royal College of Anaesthetists. Anaesthesia. 2024;79:18–30. doi:10.1111/anae.16156