Case 1: “During performance of spinal anaesthetic under sedation patient became bradycardic with no palpable pulse. DNACPR was in place and current. Discussion with Dr [PERSON 1]: usual practice to give sedation to the patient and position them for the spinal anaesthetic with the fractured hip on the lower side. After the sedation had been given and patient positioned for the procedure, the patient developed a bradycardia. Given the frailty of the patient and the pre existing DNACPR order, the team decided not to proceed with the anaesthetic and surgery. The patient's next of kin was informed of the events and the decision not to proceed."

Case 2: “Patient undergoing (cemented) distal femoral replacement for periprosthetic distal femoral fracture.
Procedure performed under GA with invasive arterial pressure monitoring, cell salvage and metaraminol infusion. Relatively stable intra-op but when tourniquet deflated at end of procedure (prior to surgeons closing) patient developed progressive hypotension which was not responsive to fluid bolus, metaraminol or ephedrine and progressed to PEA cardiac arrest.”

The regular reminder of the frailty of hip fracture patients. It is usual [1] to suspend advance care plans in the peri-operative period and to treat deteriorations that are directly related to our intervention and are reversible. Even if an advance care plan was in place, treating the bradycardia would not have been ruled out by its existence. It is not clear whether the patient’s bradycardia was treated. Tourniquet use is implied in case 2, potentially for an extended period. Release of tourniquet with subsequent systemic release of potassium could have been an indication to try calcium administration during this cardiac arrest.

1. Implementing Advance Care Plans In The Perioperative Period Including Plans For Cardiopulmonary Resuscitation, Association of Anaesthetists, 2022.