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.

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The Society of Thoracic Surgeons Task Force on Resuscitation After Cardiac Surgery provides this professional society perspective on resuscitation in patients who arrest after cardiac surgery. This document was created using a multimodal methodology for evidence generation and includes information from existing guidelines, from the International Liaison Committee on Resuscitation, from our own structured literature reviews on issues particular to cardiac surgery, and from an international survey on resuscitation hosted by CTSNet. In gathering evidence for this consensus paper, searches were conducted using the MEDLINE keywords "cardiac surgery," "resuscitation," "guideline," "thoracic surgery," "cardiac arrest," and "cardiac massage." Weight was given to clinical studies in humans, although some case studies, mannequin simulations of potential protocols, and animal models were also considered. Consensus was reached using a modified Delphi method consisting of two rounds of voting until 75% agreement on appropriate wording and strength of the opinions was reached. The Society of Thoracic Surgeons Workforce on Critical Care was enlisted in this process to provide a wider variety of experiences and backgrounds in an effort to reinforce the opinions provided. We start with the premise that external massage is ineffective for an arrest due to tamponade or hypovolemia (bleeding), and therefore these subsets of patients will receive inadequate cerebral perfusion during cardiac arrest in the absence of resternotomy. Because these two situations are common causes for an arrest after cardiac surgery, the inability to provide effective external cardiopulmonary resuscitation highlights the importance of early emergency resternotomy within 5 minutes. In addition, because internal massage is more effective than external massage, it should be used preferentially if other quickly reversible causes are not found. We present a protocol for the cardiac arrest situation that includes the following recommendations: (1) successful treatment of a patient who arrests after cardiac surgery is a multidisciplinary activity with at least six key roles that should be allocated and rehearsed as a team on a regular basis; (2) patients who arrest with ventricular fibrillation should immediately receive three sequential attempts at defibrillation before external cardiac massage, and if this fails, emergency resternotomy should be performed; (3) patients with asystole or extreme bradycardia should undergo an attempt to pace if wires are available before external cardiac massage, then optionally external pacing followed by emergency resternotomy; and (4) pulseless electrical activity should receive prompt resternotomy after quickly reversible causes are excluded. Finally, we recommend that full doses of epinephrine should not be routinely given owing to the danger of extreme hypertension if a reversible cause is rapidly resolved. Protocols are given for excluding reversible airway and breathing complications, for left ventricular assist device eme...

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Our rule identifies 14% of all our patients as high risk and 50% of these required prolonged ventilation. Such a rule allows more efficient use of scarce CSU resources by appropriate surgical scheduling.

Transfusion related acute lung injury (TRALI) is an uncommon complication following administration of blood products. It is often difficult to differentiate from other commoner causes of cardio-respiratory instability. However, prompt diagnosis and management is associated with favorable outcome.

SummaryA best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether prophylactic tranexamic acid can safely reduce bleeding without increasing thrombotic complications in patients undergoing cardiac surgery. Altogether 334 papers were found using the reported search, of which 12 represented the best evidence on this topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that tranexamic acid clearly reduces blood loss, requirement for blood transfusion, and the risk of reoperation for bleeding, and although no study has yet looked directly at vein graft patency with tranexamic acid, no randomized studies have raised concerns over its safety. q

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was which (if any) vasodilator prevents spasm of the internal mammary artery in patients undergoing coronary artery bypass grafting. Two hundred papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that mammary arteries often have low flow initially, but invariably will double their flow after 15-20 min even with no treatment. The strongest evidence for safe prevention of spasm is for papaverine given topically and periarterially, however many studies have also shown no benefit and thus no treatment at all is an entirely acceptable strategy.