The Society of Thoracic Surgeons Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery
Summary
Defibrillation/Pacing Before External Cardiac Massage
- If the electrocardiogram (ECG) shows VF/pulseless ventricular tachycardia (VT), you may delay external cardiac massage for up to one minute to administer shocks. (Class IIA, Level B)
- If the ECG shows asystole, you may delay external massage for as long as a minute to maximize the temporary pacemaker output. (Class IIA, Level C)
Number of Attempts at Defibrillation Before Resternotomy
- For patients with VF or pulseless VT, three sequential shocks should be given without intervening ECM. (Class I, Level B)
- For VF or pulseless VT, emergency resternotomy should be performed after three failed attempts at defibrillation, with ECM started as a bridge to internal massage. (Class I, Level B)
Basic Life Support in the ICU
- If the ECG shows VF or asystole, call cardiac arrest immediately. (Class I, Level C)
- If the ECG is compatible with a cardiac output, look at the pressure traces. If arterial and other pressure waveforms, including end-tidal carbon dioxide, are pulseless, then call cardiac arrest immediately. (Class I, Level C)
- Feeling for a central pulse should only be used if there is significant doubt about the diagnosis. (Class I, Level C)
Administration of Epinephrine or Vasopressin
- We recommend that neither epinephrine nor vasopressin be given during the cardiac arrest unless directed by a clinician experienced in their use. (Class III [harm], Level C)
Infusions
- In an established cardiac arrest, all infusions before arrest should be stopped. (Class IIA, Level C)
- If there is concern about awareness, it is acceptable to continue the sedative infusions. Other infusions can be restarted as indicated by the clinical situation by an experienced clinician. (Class IIA, Level C)
Cardiac Arrest in Patients With Intraaortic Balloon Pump
- In cardiac arrest with an IABP in place, the IABP should be set to pressure trigger mode. (Class IIA, Level C)
- If there is a significant period without massage, triggering should be changed to an internal mode at a rate of 100 beats per minute until massage is recommenced. (Class IIA, Level C).
Amiodarone
- After three failed attempts at defibrillation for VF/pulseless VT, a bolus of 300 mg intravenous amiodarone should be given through the central line. (Class IIA, Level A)
Automated External Defibrillators
- Automated external defibrillators should not be used in cardiac surgical patients in the ICU when a manual defibrillator is available. (Class III [harm], Level C)
Automatic External Compression Devices
- Automated external compression devices should not be used on cardiac surgical patients. (Class III [harm], Level C)
Pacing
- For asystole or severe bradycardia, connect the epicardial pacing wires and set to DDD mode at 80 to 100 beats per minute at the maximum atrial and ventricular output voltages. If the pacing generator has an emergency pacing button, it may be used. (Class I, Level C)
- If the rhythm is pulseless electrical activity and a pacemaker is connected and functioning, then briefly turn off the pacemaker to exclude underlying ventricular fibrillation. (Class IIA, Level C)
Atropine
- For patients with asystole or extreme bradycardia, atropine is not recommended as a routine part of the protocol. (Class III [no benefit], Level C)
Emergency Resternotomy After Non-VF/VT Arrest
- In a non-VF/VT cardiac arrest that does not resolve after pacing and exclusion of readily reversible causes, emergency resternotomy should be performed within 5 minutes. (Class I, Level C)
Conduct of Emergency Resternotomy
- Internal cardiac massage is superior to external cardiac massage. In patients with a recent sternotomy in whom resuscitative efforts are likely to last more than 5 minutes, emergency resternotomy is indicated to perform internal cardiac massage. (Class IIA, Level C)
- Emergent Resternotomy Set
- A small emergency resternotomy set should be available in every ICU, containing only the instruments necessary to perform the resternotomy. They should include a disposable scalpel attached to the outside of the set, a wire cutter, a heavy needle holder, a single piece sternal retractor, and a sucker. An all-in-one drape and scissors is also very useful.
- This small set should be in addition to a full cardiac surgery sternotomy set, which need not be opened until after the emergency resternotomy has been performed.
- These sets should be clearly marked and checked regularly. (Class I, Level C)
- Preparation for Emergency Resternotomy
- Two to three staff members should put on gown and gloves as soon as a cardiac arrest is called, and prepare the emergency resternotomy set. (Class IIA, Level C)
- Handwashing is not necessary before closed-sleeve donning of gloves. (Class IIA, Level C)
- Cardiac Arrest Protocol and Emergency Resternotomy Outside ICU
- In mixed ward areas outside of the ICU, it may not be appropriate to follow this guideline. Immediate defibrillation or pacing, and epinephrine dosing, as described here, is preferred in lieu of the 2015 AHA guidelines.
- Local protocols for emergency resternotomy outside of the ICU should be drawn up and rehearsed.
- How Long After Cardiac Surgery Is Emergency Resternotomy No Longer Indicated?
- Emergency resternotomy should form an integral part of the cardiac arrest protocol until the 10th postoperative day. (Class IIA, Level C)
- Beyond the 10th postoperative day, a senior clinician should decide whether emergency resternotomy should still be performed. (Class IIA, Level C)
Cardiopulmonary Bypass After Emergency Resternotomy
- In addition to an immediate dose to the patient of 30,000 IU heparin as early as possible before commencement of cardiopulmonary bypass, we recommend that 10,000 IU heparin be added to the bypass machine reservoir. (Class IIA, Level C)
Should Patients After Emergency Resternotomy Receive Additional Antibiotics?
- It is common practice to perform an antiseptic washout after emergency resternotomy and to give additional intravenous antibiotics. That is reasonable and is indicated if the resternotomy has not been performed using full aseptic techniques. (Class IIA, Level B)
Induced Hypothermia After Resuscitation From Prolonged Cardiac Arrest
- Current AHA guidelines recommend that comatose (ie, lack of meaningful response to verbal commands) adult patients with return of spontaneous circulation after cardiac arrest have targeted temperature management. It is recommended to select and maintain a constant temperature between 32° and 36°C during targeted temperature management. Targeted temperature management should be maintained for at least 24 hours after achieving target temperature.
- Vollroth and colleagues described a protocol for cooling after cardiac surgery, and targeted temperature management should be considered if it is thought that there has been a significant period of poor cerebral perfusion during the resuscitation period.
Article Resource
- Reference
- AuthorsSociety of Thoracic Surgeons Task Force on Resuscitation After Cardiac Surgery.
- Date PublishedMarch 1, 2017
- PMID
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cardiac arrest, CPR, Defibrillation, PEA, Surgery, VT
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