Question 30.2

Created on Thu, 09/14/2017 - 06:37
Last updated on Tue, 12/19/2017 - 16:46
Pass rate: 49%
Highest mark: 7.0

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c) List the important differences in managing a cardiac arrest in a post-operative cardiac surgical
patient in ICU as compared to a non-cardiac surgical patient. (40% marks)

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College answer

c)                                                          
•    Immediate VF or pacing (if indicated) before external cardiac massage – can delay ECM up to one minute to administer shock/pace 
•    No need for pulse check – observe monitored waveforms/ECG sufficient for diagnosis • Avoid adrenaline/vasopressin bolus 
•    Cease all infusions until reviewed 
•    If IABP in situ set to pressure trigger 
•    If PEA and paced, turn off pacemaker to exclude underlying VF 
•    Plan for emergency re-sternotomy, ideally within five minutes. 
 

Discussion

For a definitive resource, one should read the 2015 or 2009 ERC guidelines (they did not change much).

In short, the basic differences are:

  • You do not use full dose adrenaline (rather, give smaller doses)
  • You do three "stacked shocks"
  • You try pacing in asystole if pacing wires are available; if they are already paced and in PEA, you turn off the pacing to "unmask" VF.
  • These shocks and attempted pacing are all measures you take before  starting CPR, which is a departure from the ACLS norms.
  • If you can't control a shockable rhythm with three stacked shocks, you give amiodarone immediately rather than after three cycles.
  • CPR is something you do while waiting to re-open the chest. After five minutes of unsuccessful resuscitation the chest should be re-opened.
  • Non-surgical staff are encouraged to re-open the chest in an emergency

References

Dunning, Joel, et al. "The Society of Thoracic Surgeons Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery." The Annals of Thoracic Surgery103.3 (2017): 1005-1020.

Dunning, Joel, et al. "Guideline for resuscitation in cardiac arrest after cardiac surgery." European Journal of Cardio-Thoracic Surgery 36.1 (2009): 3-28.

Neumar, Robert W., et al. "Part 1: Executive Summary." Circulation 132.18 suppl 2 (2015): S315-S367.

Truhlář, Anatolij, et al. "European resuscitation council guidelines for resuscitation 2015." Resuscitation 95 (2015): 148-201.

Böhrer, H., R. Gust, and B. W. Böttiger. "Cardiopulmonary resuscitation after cardiac surgery."Journal of cardiothoracic and vascular anesthesia 9.3 (1995): 352.

Kempen, Paul Martin, and Richard Allgood. "Right ventricular rupture during closed-chest cardiopulmonary resuscitation after pneumonectomy with pericardiotomy: a case report." Critical care medicine 27.7 (1999): 1378-1379.

Kim, Heung Ki, et al. "Left Ventricular Rupture during Closed-chest Cardiopulmonary Resuscitation after Pneumonectomy-A case report." Korean Journal of Anesthesiology 53.1 (2007): 123-126.

Richardson, Lydia, Arosha Dissanayake, and Joel Dunning. "What cardioversion protocol for ventricular fibrillation should be followed for patients who arrest shortly post-cardiac surgery?."Interactive cardiovascular and thoracic surgery 6.6 (2007): 799-805.

Webb ST. "Caution in the administration of adrenaline in cardiac arrest following cardiac surgery." Resuscitation 2008;78:101.

Leeuwenburgh, Boudewijn PJ, et al. "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 (2008): 1148-1151.

Twomey, Darragh, et al. "Is internal massage superior to external massage for patients suffering a cardiac arrest after cardiac surgery?." Interactive cardiovascular and thoracic surgery 7.1 (2008): 151-157.

Vallejo-Manzur, Federico, et al. "Moritz Schiff and the history of open-chest cardiac massage."Resuscitation 53.1 (2002): 3-5.

Stephenson Jr, Hugh E., L. Corsan Reid, and J. William Hinton. "Some common denominators in 1200 cases of cardiac arrest." Annals of surgery 137.5 (1953): 731.

Stephenson Jr, H. E. "Open-Chest Cardiopulmonary Resuscitation." Emergency and Disaster Medicine. Springer Berlin Heidelberg, 1985. 373-377.