The Society of Thoracic Surgeons Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery

Abstract

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...

Management of cardiac arrest following cardiac surgery

“…This is because the precipitants of arrest are commonly reversible and include: ventricular fibrillation (VF) in up to 25e50% of cases, with bleeding and tamponade accounting for a significant proportion. 9 The Cardiac Advanced Life Support (CALS) protocol (Fig. 2) was designed for use in all CICUs for any cardiac surgical patient (excluding pulmonary surgery).…”

“…This occurs in up to 50% of postoperative cardiac arrests or in 2.7% of all patients undergoing cardiac surgery. 9 The procedure should be performed seamlessly with simultaneous preparation occurring during initial resuscitation efforts by a minimum of two people.…”

“…In the absence of pacing wires, external transcutaneous pacing should be attempted, following ECC commencement. 6,9 A paced rhythm at the time of arrest may mask underlying VF; therefore, a pacing pause should be performed. During pacing failure, preparations should be made in anticipation of future treatments including: internal pacing, replacing wires, and new pacing boxes in order to reduce non-circulatory time.…”

Cardiopulmonary Resuscitation: Recent Advances

“…Timely resuscitation is possible in the presence of expertise with easy access to defibrillator or pacing facility, early CPR, and rapid sternotomy. About 8% of the cardiac surgery patients suffer from perioperative cardiac arrest, with a shockable rhythm in 30-50% and mechanical causes like cardiac tamponade or graft failure in 28% of the cases [104]. The incidence of different arrhythmias varies in different studies.…”

“…Cardiac arrests in post-cardiac surgery patients is a unique entity that mandates necessary changes in conventional resuscitation protocols to improve their outcome [104,117].…”