Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.


How common are cardiac arrests during surgery? Uncommon, but the incidence is not zero and the outcome is usually dire.

ventricular fibrillation

In 2004 the Japanese Society of Anesthesiologists reported 2,443 cardiac arrests (6.34 per 10,000 anesthetics) and 2,638 deaths (6.85 per 10,000 anesthetics) among 3,855,384 anesthetics. The majority of deaths were due to preoperative health complications (64.7%) and surgical problems (23.9%). The main preoperative problem leading to death was hemorrhagic shock, and the main surgical problem leading to death was excessive surgical bleeding. The incidence of cardiac arrest totally attributable to anesthesia mismanagement was low (0.47 per 10,000 anesthetics), and anesthesia mismanagement was responsible for only 1.5% of deaths. (1)

The American College of Surgeons National Surgical Quality Improvement database from 2005 to 2007 documented the incidence of intraoperative cardiac arrest in non-cardiac surgery as 7.22 per 10,000 cases. Intraoperative blood loss, represented by the amount of blood transfused, was the most important risk factor. Patients receiving over 10 units of blood had greater than 10 times the risk of those receiving 1-3 units of blood. Two other significant risk factors were emergency surgery and the patient’s preoperative health as assessed by the American Society of Anesthesiologists (ASA) physical status ranking. Of the 262 patients with intraoperative cardiac arrests, 44% died within 24 hours and 62% died within 30 days. (2)

From 2010 to 2013 the National Anesthesia Clinical Outcomes Registry reported the risk of intraoperative cardiac arrest as 5.6 per 10,000 cases. Fifty-eight percent of these patients died. The incidence of cardiac arrest increased with age and ASA physical status ranking, with the majority occurring in patients with an ASA physical status of 3-5. (3)

Physicians from a Thai teaching hospital reviewed 44,339 emergency surgery patients from 2003 to 2011, and found the incidence of perioperative cardiac arrest in emergency surgery was 163 per 10,000 cases. Risk factors were age 2 years or younger, an ASA physical status of 3-4, risky anatomic sites of surgery (upper abdomen, intracranial, intrathoracic, cardiac, or major vascular), cardiac or respiratory comorbidities, and shock prior to anesthesia. (4)

A Brazilian study documented a higher incidence of perioperative cardiac arrest in children than in adults. From 1996 to 2004, 15,253 anesthetics were performed in children. There were 35 cardiac arrests (22.9 per 10,000) and 15 deaths (9.8 per 10,000). Risk factors for cardiac arrest were children under one year of age, emergency surgery, ASA physical status 3-5, and general anesthesia. There were 11 cardiac arrests related to anesthesia care. Seventy-one per cent of these were caused by airway management/respiratory events, and 28% were caused by medication-related events. There were zero deaths attributed to anesthesia. (5).

What does all this mean?

If you’re an anesthesia provider, know that that the risk of cardiac arrest during surgery and anesthesia is low. The average reported incidence is in the ballpark of 6 to 7 per 10,000 cases, higher in children (22.9 per 10,000), and highest in emergency surgeries (163 per 10,000).

A busy anesthesiologist doing his or her own cases performs 1000 anesthetics per year. A predicted experience would be one cardiac arrest every 6-7 years, or 4-5 cardiac arrests in a 30-year career. A physician anesthesiologist supervising four CRNAs in four operating rooms could do four times as many cases per year, so a predicted incidence would be 16-20 cardiac arrests in a 30-year career.
Anesthesiologists should be prepared to promptly manage cardiac arrests in the patients at highest risk, which include: those with extensive bleeding and transfusion requirements; patients in shock; emergency surgeries; particularly emergency surgeries involving the upper abdomen, craniotomies, cardiac, intrathoracic, and major vascular vessels; patients with preoperative physical status limitations (ASA physical status 3-5); and children under one year of age.

In 30+ years of administering approximately 25,000 anesthetics I’ve seen cardiac arrests in three cases, for a personal anecdotal incidence of 1.2 per 10,000. All were in the high-risk categories above. One patient was in hemorrhagic shock prior to surgery because of an acute bleed from a ruptured aortic aneurysm, one patient was undergoing aortic artery bypass surgery, and one patient was a sick end-stage renal disease dialysis patient undergoing vascular surgery.

If you’re a patient, realize that your risk of having a cardiac arrest under anesthesia is low. If you have any of the risk factors described above, your risks are higher. Trust that the surgeon and physician anesthesiologist who take care of you will be well prepared, aware of this data, and will take excellent care of you while you are asleep.

In the future, physician anesthesiologists will have an abundance of “Big Data” on clinical issues such as this one. The ASA and its affiliate, the Anesthesia Quality Institute (AQI), are compiling the National Anesthesia Clinical Outcomes Registry (NACOR), which has been designated as a Qualified Clinical Data Registry (QCDR) by the Centers for Medicare & Medicaid Services for Physician Quality Reporting System (PQRS).

Can we lower the incidence of perioperative cardiac arrest? Perhaps, as we gain more understanding of risk factors. But as the Baby Boomer population in the United States ages, there will be more old patients, more patients with multiple medical problems, and more emergency surgeries on older, sicker patients.
Anesthesiologists will continue to be challenged.

1. Irita K, et al. Annual mortality and morbidity in operating rooms during 2002 and summary of morbidity and mortality between 1999 and 2002 in Japan: a brief review. Masui. 2004 Mar;53(3):320-335.

2. Goswami S, Brady JE, Jordan DA, Li G. Intraoperative cardiac arrests in adults undergoing noncardiac surgery: incidence, risk factors, and survival outcome. Anesthesiology. 2012 Nov;117(5):1018-26.

3. Nunnally ME, O’Connor MF, Kordylewski H, Westlake B, Dutton RP. The incidence and risk factors for perioperative cardiac arrest observed in the national anesthesia clinical outcomes registry. Anesth Analg. 2015 Feb;120(2):364-70.

4. Siriphuwanun V, et al. Incidence of and factors associated with perioperative cardiac arrest within 24 hours of anesthesia for emergency surgery. Risk Manag Healthc Policy. 2014 Sep 4;7:155-62. doi: 10.2147/RMHP.S67935. eCollection 2014.

5. Gobbo Braz L, et al. Perioperative cardiac arrest and its mortality in children. A 9-year survey in a Brazilian tertiary teaching hospital. Paediatr Anaesth. 2006 Aug;16(8):860-6.


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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.


In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:


Learn more about Rick Novak’s fiction writing at by clicking on the picture below: