Reviewed and revised 6 March 2016
Cardiac arrest occurs after 0.7 – 2.9% of cardiac surgery cases
- Usually preceded by physiological deterioration but can occur in previously stable patients
- Often distinct causes are present such as tamponade, hypovolaemia, myocardial ischaemia, tension pneumothorax, or pacing failure
- Survival is ~80%
- Emergency re-sternotomy should form a standard part of the arrest protocol up to the 10th postoperative day
- Provide the definitive therapy quickly: open chest or defibrillate (if indicated)
- Timely re-sternotomy is an important goal as CPR is ineffective if tamponade or haemorrhage is the cause
- Call a surgical emergency (get surgeon there ASAP & prepare OT)
The roles, stepwise approach and re-sternotomy procedure describeld below are derived from Dunning et al, 2009.
There are 6 key roles in the management of cardiac arrest after cardiac surgery (see here for the diagram of the roles from Dunning et al, 2009):
- External cardiac massage
- Once the arrest has been established one person is allocated to ECM. This should commence immediately at a rate of 100/min while looking at the arterial trace to assess effectiveness. The only exception to this is when immediate defibrillation or pacing is appropriate prior to ECM.
- Airway and breathing
- The oxygen must be turned up to 100% and airway and breathing checked as per protocol, specifically to exclude pneumothorax, haemothorax or endotracheal tube problem.
- The defibrillator should be connected and shocks administered if required. This person should also check the pacing, and if emergency resternotomy is being performed, should ensure that internal defibrillators are available and connected.
- Team leader
- This senior person should conduct the arrest management, ensuring that the protocol is being followed and that there is a person allocated to each role.
- Drug administration
- This person stops all infusions and syringe drivers and administers atropine, amiodarone and other drugs as appropriate.
- ICU co-ordinator
- This role, by a senior member of ICU staff coordinates activity peripheral to the bedside. This includes preparing for potential resternotomy as soon as an arrest is called, managing the additional available personnel and calling for expert assistance if not immediately available while continually reporting progress to the team leader.
STEP-WISE APPROACH TO CARDIAC ARREST MANAGEMENT AFTER CARDIAC SURGERY
Coordinated, team-based approach in an area equipped and staffed for resuscitation and emergency re-sternotomy:
- Call the code, notify cardiothoracic surgeon, intensivist and OT
- A & B
— check and secure ETT
— give FiO2 of 1.0
— turn off PEEP
— seek and treat hemo/pneumothorax
- Connect defibrillator, emergency pacing button
— give 3 stacked shocks if VT/VF and defibrillator is readily available (within 1 minute; otherwise may commence external cardiac massage)
— 150-200J shocks if external defibrillation, 20J shocks if internal defibrillation, 5J if placed on bypass
— attempt to pace if bradycardia/ asystole (set epicardial pacing to DDD with maximum A and V output voltages at 100/min)
— if already paced and in PEA, turn off pacing to exclude VF
— aim systolic BP 60
— commence at 100/min
— can defer external cardiac massage if defibrillation/ pacing can be started within 1 minute
— if IABP in situ change to pressure trigger
— stop infusions & sequentially check & re-start
— 1000mL crystalloid (warm)
— give amiodarone 300 mg for VT/VF after the 3rd failed defibrillation attempt but do not delay resternotomy
— atropine 3mg for bradycardia/ asystole (note that this is the recommendation by Dunning et al, 2010, though ICOR guidelines do not recommend atropine for bradycardia/asystole for post-cardiac surgery cardiac arrest)
— use adrenaline very cautiously and titrate to effect (IV doses of up to 100mcg in adults)
- Perform resternotomy
— immediately after 3 stacked external shocks if possible
— required if likely to need more than 5-10 min CPR, even if surgical cause unlikely
The steps are shown in the EACTS flowchart by Dunning et al, 2009 – see flowchart here.
Procedure performed as follows:
- Sterile technique (best to use all in one-dressing – then cut through adhesive plastic, no need for skin prep)
- Adhesive dressing
- Scalpel through dressing to wires
- One person cuts the wires with the wire cutter and a second assistant removes the wires with the heavy needle holder (this may relieve tamponade)
- Suction any clot
- Spreader just beneath sternum
- remove clot and identify the position of any grafts
- Internal cardiac massage
— two handed (gentle even pressure) OR use internal paddles (can shock during the decompression phase)
— Pass the right hand over the apex of the heart (minimising the likelihood of avulsing any grafts, as grafts are rarely placed near the apex)
— The right hand is then further advanced round the apex to the back of the heart, palm up and hand flat
— The left hand is then placed flat onto the anterior surface of the heart and the two hands squeezed together
— Flat palms and straight fingers are important to avoid an unequal distribution of pressure onto the heart, thereby minimising the chance of trauma
— If there is a mitral valve replacement or repair, care should be taken not to lift the apex by the right hand, as this can cause a posterior ventricular rupture
— Squeeze your hands together at a rate of 100/min and look at the arterial trace to verify adequate internal massage
— You should try to obtain a systolic impulse of more than 60 mmHg (i.e. SBP >60 mmHg)
- Internal defibrillation
— 20J shocks if performing internal defibrillation, 5J if placed on bypass
- Antiseptic washout and IV antibiotics are commonly given before reclosure
Mini-resternotomy kit is shown here (from Dunning et al, 2009)
Open versus closed chest cardiac massage:
- Closed chest massage generates a cardiac index of around 0.6 L/min/m2 which rises to 1.3 l/min/m2 or more with open-chest-CPR, accompanied by even bigger improvements in coronary perfusion pressure (Twomey et al, 2008)
- The risk of harm from external cardiac massage post-cardiac surgery is difficult to quantify and is likely low, however there have been case reports of significant cardiac injury (Lockowandt et al, 2008)
- The success rate of 3 stacked shocks for VF/VT is: ~78% for the 1st shock, ~35% for the 2nd stacked shock and ~14% for the 3rd stacked shock. A 4th shock would have <10% chance of success, so should not be performed without intervening CPR (Richardson et al, 2007)
- If a patient arrests shortly after cardiac surgery the chance of restoring sinus rhythm either by defibrillation or by an emergency re-sternotomy is generally high (Tsagkataki et al, 2008)
- Adrenaline could be highly dangerous once sinus rhythm is restored (e.g. hypertensive crisis, myocardial dysfunction, worsening arrhythmias, increased myocardial oxygen demand and graft disruption) (Tsagkataki et al, 2008)
- Adrenaline has not been proven to improve patient outcomes after cardiac arrest (Tsagkataki et al, 2008)
- not included in ILCOR guidelines
- Dunning et al (2009) acknowledge that 5 RCTs in post-cardiac surgery patients have failed to demonstrate a benefit for atropine, however they argue that atropine is a relatively benign drug and it should still be considered as a 3mg IV dose for bradycardia/ asystole in the setting of post-cardiac surgery cardiac arrest)
Interposed abdominal compression-cardiopulmonary resuscitation (IAC—CPR) is a potential alternative for CPR after cardiac surgery (Li et al, 2014)
This video shows an emergency resternotomy cart and the various roles and steps in resternotomy:
This is a video from the Cardiac Surgery Advanced Life Support Course (real footage starts at 5min 24 sec):
References and Links
- Adam Z, Adam S, Khan P, Dunning J. Could we use abdominal compressions rather than chest compression in patients who arrest after cardiac surgery? Interactive cardiovascular and thoracic surgery. 8(1):148-51. 2009. [pubmed]
- Dunning J, Fabbri A, Kolh PH. Guideline for resuscitation in cardiac arrest after cardiac surgery. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 36(1):3-28. 2009. [pubmed] [free full text]
- Leeuwenburgh BP, Versteegh MI, Maas JJ, Dunning J. Should amiodarone or lidocaine be given to patients who arrest after cardiac surgery and fail to cardiovert from ventricular fibrillation? Interactive cardiovascular and thoracic surgery. 7(6):1148-51. 2008. [pubmed]
- Ley SJ. Standards for resuscitation after cardiac surgery. Critical care nurse. 35(2):30-7; quiz 38. 2015. [pubmed] [free full text]
- Li JK, Wang J, Li TF. Interposed abdominal compression-cardiopulmonary resuscitation after cardiac surgery. Interactive cardiovascular and thoracic surgery. 19(6):985-9. 2014. [pubmed]
- Lockowandt U, Levine A, Strang T, Dunning J. If a patient arrests after cardiac surgery is it acceptable to delay cardiopulmonary resuscitation until you have attempted either defibrillation or pacing? Interactive cardiovascular and thoracic surgery. 7(5):878-85. 2008. [pubmed]
- Richardson L, Dissanayake A, Dunning J. What cardioversion protocol for ventricular fibrillation should be followed for patients who arrest shortly post-cardiac surgery? Interactive cardiovascular and thoracic surgery. 6(6):799-805. 2007. [pubmed]
- Tsagkataki M, Levine A, Strang T, Dunning J. Should adrenaline be routinely used by the resuscitation team if a patient suffers a cardiac arrest shortly after cardiac surgery? Interactive cardiovascular and thoracic surgery. 7(3):457-62. 2008. [pubmed]
- Twomey D, Das M, Subramanian H, Dunning J. Is internal massage superior to external massage for patients suffering a cardiac arrest after cardiac surgery? Interactive cardiovascular and thoracic surgery. 7(1):151-6. 2008. [pubmed]
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.