2026; 9(2): 20-27
DOI: 10.32114/CCI.2026.9.2.20.27
Published online: 2026-06-30 (first online 2026-06-21)
The Lazarus phenomenon – coming back from the underworld: current knowledge and novel perspectives.
George Karlis [1]
,
Frantzeska Frantzeskaki [1] ,
Iraklis Tsangaris [1] .
[1] Second Department of Critical Care Medicine, National and Kapodistrian University of Athens, Athens, Greece.
Abstract:
Abstract [EN] -
Death is a process, rather than a time specific event. Lazarus phenomenon/syndrome is a rare occurrence of restoration of spontaneous circulation after a patient has been declared dead. It is also known as autoresuscitation. We sought to review the relevant literature to investigate the features, frequency, pathophysiology and clinical implications of the syndrome. It seems that autoresuscitation usually takes place in the first few minutes after termination of resuscitation efforts. Approximately 82% of reported cases occur within 10 min of CPR discontinuation. There are a few outliers of Lazarus phenomenon appearing as late as 20 to 50 minutes. The prognosis of the syndrome is dismal, as the majority die before hospital discharge. However, studies report full recovery in 14-28% of patients. The exact cause of Lazarus phenomenon is not fully understood. Several theories have been proposed (e.g. hyperventilation/air trapping, delayed drug action, myocardial stunning), but it is likely that the mechanism is multifactorial. The resumption of cardiac activity after withdrawal of life-sustaining measures has been studied. All the cases occurred within 4 minutes and 20 seconds after a period of pulselessness. We would like to emphasize that autoresuscitation is possible in any cardiac arrest victim, regardless of whether CPR was applied. Current evidence suggests that a “no touch” period of no less than 5 minutes is sufficient for controlled donation after circulatory death (DCD). However, in the case of uncontrolled DCD (organ donation after unsuccessful CPR), a longer “no touch” period may be needed to exclude Lazarus phenomenon.
Streszczenie [PL] -
Śmierć jest procesem, a nie zdarzeniem specyficznym dla danego czasu. Zjawisko/zespół Łazarusa to rzadkie zjawisko powrotu spontanicznego krążenia po stwierdzeniu zgonu pacjenta. Jest ono również znane jako autoresuscytacja. Staraliśmy się dokonać przeglądu odpowiedniej literatury, aby zbadać cechy, częstość występowania, patofizjologię i kliniczne implikacje tego zespołu. Wydaje się, że autoresuscytacja zwykle ma miejsce w ciągu pierwszych kilku minut po zakończeniu resuscytacji. Około 82% zgłoszonych przypadków występuje w ciągu 10 minut od zakończenia RKO. Istnieje kilka przypadków odstających od zespołu Łazarusa, pojawiających się dopiero po 20–50 minutach. Rokowanie w tym zespole jest niepomyślne, ponieważ większość pacjentów umiera przed wypisaniem ze szpitala. Jednak badania wskazują na pełny powrót do zdrowia u 14–28% pacjentów. Dokładna przyczyna występowania zjawiska Łazarusa nie jest w pełni poznana. Zaproponowano kilka teorii (np. hiperwentylacja/uwięzienie powietrza, opóźnione działanie leków, ogłuszenie mięśnia sercowego), ale prawdopodobne jest, że mechanizm jest wieloczynnikowy. Przebadano powrót czynności serca po odłączeniu aparatury podtrzymującej życie. Wszystkie przypadki nastąpiły w ciągu 4 minut i 20 sekund od momentu braku tętna. Pragniemy podkreślić, że autoresuscytacja jest możliwa u każdej osoby z zatrzymaniem krążenia, niezależnie od tego, czy zastosowano resuscytację krążeniowo-oddechową (RKO). Aktualne dowody sugerują, że okres „bezdotykowy” trwający co najmniej 5 minut jest wystarczający do kontrolowanego pobrania krwi po zatrzymaniu krążenia (DCD). Jednak w przypadku niekontrolowanego DCD (pobranie narządów po nieskutecznej RKO) dłuższy okres „bezdotykowy” może być konieczny, aby wykluczyć zjawisko Łazarza.
Citation:
VANCOUVER FORMAT
Karlis G, Frantzeskaki F, Tsangaris I. The Lazarus phenomenon – coming back from the underworld: current knowledge and novel perspectives.
Crit Care Innov. 2026; 9(2): 20-27.
DOI: 10.32114/CCI.2026.9.2.20.27
Download article (PDF file): click here
Read article:
Additional materials:
No files
References:
| [1] |
Baldi E, Wnent J, Caputo ML, Haywood KL, Lilja G, Masterson S, et al. European Resuscitation Council Guidelines
2025 Epidemiology in Resuscitation. Resuscitation. 2025; 215 Suppl 1: 110733.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [2] |
Nabecker S, de Raad T, Abelairas-Gomez C, Breckwoldt J, Chakroun-Walha O, Farquharson B, et al. ERC
Education for Resuscitation Collaborators. European Resuscitation Council Guidelines 2025 Education for
Resuscitation. Resuscitation. 2025; 215 Suppl 1: 110739
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [3] |
Nishiyama C, Kiguchi T, Okubo M, Al-Araji R, Amorim E, Alihodžić H, et al. Characteristics of out-of-hospital cardiac
arrest from 2018 to 2021 across the world: third report from the International Liaison Committee on Resuscitation
(ILCOR) research and registries committee. Resuscitation. 2025; 217: 11085.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [4] |
Heydari F, Nasr Isfahani M, Masoumi B, Khajebashi SH, Hajian F, Soleimani F. The role of serial point-of-care
ultrasound during cardiac arrest to predict termination of resuscitation. Scand J Trauma Resusc Emerg Med. 2025;
33(1): 129.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [5] |
Raffay V, Wittig J, Bossaert L, Djakow J, Djärv T, Estella Á, et al. ERC Ethics in Resuscitation Collaborators.
European Resuscitation Council Guidelines 2025 Ethics in Resuscitation. Resuscitation. 2025; 215 Suppl 1:
110734.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [6] |
Huang SX, Ray S, Brown D, Kopar P. When Are Patients Dead? The Cost of Lingering Ambiguity. J Clin Ethics.
2025; 36(3): 263-267.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [7] |
Rzeźniczek P, Gaczkowska AD, Kluzik A, Cybulski M, Bartkowska-Śniatkowska A, Grześkowiak M. Lazarus
Phenomenon or the Return from the Afterlife-What We Know about Auto Resuscitation. J Clin Med. 2023; 12(14):
4704.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [8] |
Linko K, Honkavaara P, Salmenpera M. Recovery after discontinued cardiopulmonary resuscitation. Lancet. 1982;
1(8263): 106-107.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [9] |
Bray JG Jr. The Lazarus phenomenon revisited. Anesthesiology. 1993; 78(5): 991.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [10] |
Wijdicks EF, Diringer MN. Electrocardiographic activity after terminal cardiac arrest in neurocatastrophes.
Neurology. 2004; 62(4): 673-674.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [11] |
Gordon L, Pasquier M, Brugger H, Paal P. Autoresuscitation (Lazarus phenomenon) after termination of
cardiopulmonary resuscitation - a scoping review. Scand J Trauma Resusc Emerg Med. 2020; 28(1): 14.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [12] |
Fujiuchi B, Miyashita A, Hirao Y, Benavente K. The Lazarus Phenomenon - A Remarkable Case of Spontaneous
Recovery from Cardiac Arrest in a Do-Not-Resuscitate Patient. Eur J Case Rep Intern Med. 2025; 12(5): 005308.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [13] |
Mavrovounis G, Kontou M, Tsiotsikas O, Mermiri M, Tsolaki V, Beltsios E, et al. From flatline to lifeline: A scoping
review of the Lazarus phenomenon. Am J Emerg Med. 2023; 72: 44-57.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [14] |
Soar J, Böttiger BW, Carli P, Jiménez FC, Cimpoesu D, Cole G, et al. European Resuscitation Council Guidelines
2025 Adult Advanced Life Support. Resuscitation. 2025; 215 Suppl 1: 110769.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [15] |
Laina A, Karlis G, Liakos A, Georgiopoulos G, Oikonomou D, Kouskouni E, et al. Amiodarone and cardiac arrest:
Systematic review and meta-analysis. Int J Cardiol. 2016; 221: 780-788.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [16] |
Chalkias A, Xanthos T. Pathophysiology and pathogenesis of post-resuscitation myocardial stunning. Heart Fail
Rev. 2012; 17(1): 117-128.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [17] |
Foggle JL. Accidental Hypothermia: 'You're Not Dead Until You're Warm and Dead'. R I Med J (2013). 2019; 102(1):
28-32.
| PubMed (NCBI) | Scholar Google | |
| [18] |
Pana R, Hornby L, Shemie SD, Dhanani S, Teitelbaum J. Time to loss of brain function and activity during
circulatory arrest. J Crit Care. 2016; 34: 77-83.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [19] |
Kovoor JG, Santhosh S, Stretton B, Tan S, Gouldooz H, Moorthy S, et al. Near-death experiences after cardiac
arrest: a scoping review. Discov Ment Health. 2024; 4(1): 19.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [20] |
Costantini S, Iwanaga J, Totlis T, Apaydin N, Loukas M. Lazarus Sign, a Misnomer to an Anatomical Spinal Reflex.
Clin Anat. 2026; 39(4): 430-435.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [21] |
Thuong M, Ruiz A, Evrard P, Kuiper M, Boffa C, Akhtar MZ, et al. New classification of donation after circulatory
death donors definitions and terminology. Transpl Int. 2016; 29(7): 749-759.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [22] |
Croome KP, Barbas AS, Whitson B, Zarrinpar A, Taner T, Lo D, et al. American Society of Transplant Surgeons
recommendations on best practices in donation after circulatory death organ procurement. Am J Transplant. 2023;
23(2): 171-179.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [23] |
Dhanani S, Hornby L, van Beinum A, Scales NB, Hogue M, Baker A, et al. Canadian Critical Care Trials Group;
Canadian Donation and Transplantation Research Program. Resumption of Cardiac Activity after Withdrawal of Life
- Sustaining Measures. N Engl J Med. 2021; 384(4): 345-352.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [24] |
Zorko DJ, Shemie J, Hornby L, Singh G, Matheson S, Sandarage R, et al. Autoresuscitation after circulatory arrest:
an updated systematic review. Can J Anaesth. 2023; 70(4): 699-712.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [25] |
Lizza JP. Why DCD Donors Are Dead. J Med Philos. 2020; 45(1): 42-60.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |