Resurrection from the dead is more of a subject for science fiction and horror movies. There is a great interest for anything related to resurrection from the general public. According to the Google keyword tool, there were more than 2.7 mil searches on just the word “resurrection” in the past month.

In the Critical Care Medicine we do not practice science fiction or, hopefully, not horror. The process of being dead and able to come to life without any outside intervention is called autoresuscitation. A more scientific definition of autoresuscitation is a resumption of spontaneous circulation without CPR in the patient who previously met criteria for cardiac death. The criteria for cardiac death in these cases, primarily, based on circulatory death – lack of pulse.

The term “autoresuscitation” is much less sexier and less known to the general public. According to the same Google tool, the term has been searched for just 58 times in the last month. Compare that to 2.7 million plus for “resurrection”.

So, what is the significance of autoresuscitation in daily clinical practice?

If you practice Critical Care long enough and have run enough cardiac arrest codes, you will have a couple of “Oops moments” when the patient comes after you have pronounced him dead. I know a case of the patient coming back after the family had been notified.

For the most part, though, autoresuscitation is a rare occurrence in clinical practice. It is, however, a very important consideration for organ donation purposes.

If the patient is brain dead, the organs could be taken at any point as long as the patient remains hemodynamically stable. Donation after cardiac death or DCD has been gaining popularity due to a huge shortage of donors. In the nutshell, for DCD purposes, the patient is taken off life support in the operating room. As soon as the patient meets criteria for circulatory death (lack of pulse) the organs could be harvested.

The tricky part about DCD is to determine how soon it is “safe” to take the organs once the patient is pronounced dead. In other words, how long do you have to wait to rule out the possibility of autoresuscitation? You don’t want to wait too long since every minute of ischemic time will decrease the viability of the organs. At the same time, if the patient regains pulse during the donation process, it will violate the federal “dead donor” rule. Taking organs from an “alive” or not yet dead person is simply illegal – and for a good reason.

The current wait time is anywhere from two to ten minutes. This recommended time interval is primarily based on some previous observations of autoresuscitation after cardiac death.

A study published in the May 2010 issue of the Critical Care Medicine Journal attempts to systemize the literature available on this topic and come up with reasonable recommendations.

According to this study, there were 32 cases of autoresuscitation reported in the literature. The times of occurrence range from a few seconds to 33 min. When the appropriate monitoring was utilized, the longest time to spontaneous resumption of circulation was 7 minutes.

The interesting part is that all 32 cases were reported after failed CPR. No cases of autoresuscitation were ever reported after a controlled withdrawal of care without CPR. What that means is that autoresuscitation is possible not because of the general tendency of dead patients to “come back”, but because CPR itself could preclude the patient from regaining circulation. And once the CPR is stopped…the patient comes back.

This drives home the point that, when performed unskillfully, CPR and resuscitation in general can cause more harm. CPR and hyperventilation during resuscitation is known to create a positive intrathoracic pressure, diminishing venous return to the heart. The case of autoresuscitation that I previously described was due to air trapping and auto-PEEP in the patient with preexisting COPD.

In conclusion, there are no cases of autoresuscitation ever described after withdrawal of care without CPR. In the cases that were described, CPR was attempted or performed prior to the “miraculous” come back. CPR was likely attributed to the problem.

As far as daily clinical practice goes – sorry, we don’t do resurrection…