Post Cardiac Surgery Arrest Guidlines

Summary by Madison Tenbarge MD, 05.16.22

https://pubmed.ncbi.nlm.nih.gov/28122680/

The American Heart Association (AHA) has created guidelines for cardiopulmonary resuscitation, however, these guidelines do not provide guidance for patients who arrest after cardiac surgery. This patient population is significantly different from the general population and warrant their own treatment algorithm.

The incidence of cardiac arrest after cardiac surgery is 0.7 to 8%, however, they have a relatively good outcome with approximately half surviving to hospital discharge. The Society of Thoracic Surgeons Task Force has created a protocol for these patients who experience a cardiac arrest within ten days postoperatively.

Take Home Point:

  • -After cardiac surgery, External Cardiac Massage is associated with potentially fatal complications, and may not be necessary in situations where the cardiac arrest can be immediately reversed by defibrillation or pacing.

  • "We therefore recommend that if defibrillation or pacing (as appropriate) can be performed within 1 minute, then it is preferable to defer ECM until they have been attempted."

Guidelines

VFIB/Pulseless VT:

  1. Perform 3 sequential attempts at defibrillation.

  2. After three failed attempts at defibrillation, an amiodarone bolus of 300mg IV can be administered.

  3. Do NOT delay BLS for more than one minute, in the absence of a defibrillator. External Cardiac Massage (ECM) can be delayed for up to one minute if a defibrillator is readily available. Use External Cardiac Massage (standard chest compression rate of 100 to 120 beats per minute) as a bridge to resternotomy.

  4. Perform emergency resternotomy within five minutes of cardiac arrest which can be performed by any trained practitioner.

  5. Recommend against the routine use of epinephrine and vasopressin in all arrest due the the development of severe hypertension and bleeding in patients who achieve ROSC.

Asystole or Extreme Bradycardia:

  1. Set epicardial pacing wires to dual chamber pacing at a rate of 80-100 bpm using maximal atrial and ventricular outputs

  2. If unable to pace with epicardial wires or transcutaneously, External Cardiac Massage should be performed immediately followed by emergency resternotomy within 5 minutes of arrest.

  3. Atropine is not routinely recommended

  4. Do NOT delay BLS for more than one minute, in the absence of a pacing.

Remember, in both cases, delay in obtaining the equipment is an indication for immediate ECM.

PEA Arrest

(ECG demonstrating QRS complexes without pulsatile waveforms or ETCO2):

  1. Quickly identify reversible causes of PEA arrest and intervene (H’s and T’s) --> [hypoxia, hypovolemia, hypokalemia or hyperkalemia, hypothermia, hydrogen ions, tension pneumothorax, thromboembolism, tamponade, and toxins—the so-called “H”s and “T”s.] Tamponade requires immediate resternotomy; it is the most common cause of non-VF/VT arrest after cardiac surgery and is the reason that a resternotomy team must always be available within 5 minutes. Rapid initiation of extracorporeal membrane oxygenation (ECMO) is an acceptable alternative within the same time frame in expert institutions who have the availability of rapid ECMO deployment.

  2. Prompt resternotomy if no reversible causes can be identified.

Emergency Resternotomy:

  1. Don sterile gown and gloves

  2. Pause ECM and remove sternal dressing

  3. Apply sterile drape and prep skin

  4. Recommence ECM sterilely

  5. When equipment is ready, cease ECM, use scalpel to cut stenotomy incision down to sternal wires

  6. Use wire cutters to cut all sternal wires and use heavy needle holder to pull them out

  7. Use suction to clear excessive blood or clot

  8. Place retractor between sternal edges and open (Cardiac output may be restored at this point)

  9. If no return of cardiac output, initiate internal cardiac massage and defibrillation as appropriate.

Internal Cardiac Massage:

Two-handed technique is the safest for those who do not routinely handle the heart.

Pass right hand over apex of heart then advance to the back of the heart twitch palm up. Left hand is placed onto anterior surface and the two hands are squeezed together utilizing flat palms and straight fingers.

Benefits of internal cardiac massage include better coronary perfusion pressure, increased return of spontaneous circulation, superior organ blood flow, and better survival rates as compared with ECM.