Guideline for resuscitation in cardiac arrest after cardiac surgery

Abstract

The Clinical Guidelines Committee of the European Association for Cardio-Thoracic Surgery provides this professional view on resuscitation in cardiac arrest after cardiac surgery. This document was created using a multimodal methodology for evidence generation including the extrapolation of existing guidelines from the International Liaison Committee on Resuscitation where possible, our own structured literature reviews on issues particular to cardiac surgery, an international survey on resuscitation hosted by CTSNet and manikin simulations of potential protocols. This protocol differs from existing generic guidelines in a number of areas, the most import of which are the following: successful treatment of cardiac arrest after cardiac surgery is a multi-practitioner activity with six key roles that should be allocated and rehearsed on a regular basis; in ventricular fibrillation, three sequential attempts at defibrillation (where immediately available) should precede external cardiac massage; in asystole or extreme bradycardia, pacing (where immediately available) should precede external cardiac massage; where the above measures fail, and in pulseless electrical activity, early resternotomy is advocated; adrenaline should not be routinely given; protocols for excluding reversible airway and breathing complications and for safe emergency resternotomy are given. This guideline is subject to continuous informal review, and when new evidence becomes available.

Standards for Resuscitation After Cardiac Surgery

“…3 Therefore, the recommendation to initially withhold epinephrine in VT/VF arrest appears consistent with the European guideline: "Neither adrenalin nor vasopressin should be given during the cardiac arrest unless directed by a senior clinician experienced in their use." 2 Although epinephrine is not indicated during cardiac arrest, it may be useful prior to cardiac arrest to support the circulation and distinguish patients who are inotrope responsive. In these situations, the ERC guideline advocates reduced doses of 100 μg or less, whenever epinephrine is used in a postoperative cardiac surgical patient.…”

“…In VF or pulseless VT, emergency resternotomy should be performed after 3 failed attempts at defibrillation. 2 When defibrillation occurs soon after the onset of VT/VF, neurological recovery is more likely regardless of diagnosis or subsequent revascularization, and defibrillation without delay is the accepted standard of care. Strategies that optimize electrical therapy for VT/VF prior to potential disruption of the sternotomy are reasonable for these patients.…”

“…Undesirable epinephrine effects of particular concern include increased myocardial oxygen demand and stimulation of dysrhythmias. 2,3 After cardiac surgery, this "standard" epinephrine dosing can contribute to profound rebound hypertension with potential disruption of grafts and suture lines and subsequent hemorrhage. In reviewing the special circumstance of postoperative cardiac arrest, the AHA acknowledges the potential for vasopressorinduced bleeding, but cites insufficient evidence on epinephrine dose, antiarrhythmic use, and other routine pharmacological interventions to recommend deviating from standard resuscitation guidelines when cardiac arrest occurs after cardiac surgery.…”

“…2 The ERC guideline further recommends gauging the effectiveness of ECC by using the arterial pressure waveform, ensuring generation of a systolic blood pressure greater than 60 mm Hg for optimal cerebral perfusion. 1 If external compressions fail to restore an adequate blood pressure, the chest should be reopened immediately, as this may indicate tamponade or extreme hypovolemia from internal bleeding.…”

“…If perfusion is inadequate in the absence of readily reversible causes, resternotomy within 5 minutes is the optimum strategy for neurologically intact recovery. 1,2 Cardiac surgical patients present a unique opportunity for high survival thanks to optimal monitoring and immediate recognition of cardiac arrest from predictable causes, coupled with highly trained practitioners in an environment conducive to specialized interventions such as emergency resternotomy. In contrast to survival rates of 18% to 39% cited for in-hospital cardiac arrest, 4,5 Dimopoulou et al 6 reported that 79% (23/29) of their cardiac surgery patients who had a cardiac arrest survived to discharge, with 55% of these patients still alive at 4-year follow up.…”