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Resuscitation of Patients Who Arrest After Cardiac Surgery (2017)

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Resuscitation of Patients Who Arrest After Cardiac Surgery (2017) STS EXPERT CONSENSUS STATEMENT The Society of Thoracic Surgeons Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery The Society of Thoracic Surgeons Task Force on Resuscitation After Cardiac Surgery* Executive Summary importance of early emergency resternotomy within 5 minutes. In addition, because internal massage is The Society of Thoracic Surgeons Task Force on Resus- more effective than external massage, it should be used citation After Cardiac Surgery provides this professional preferentially if other quickly reversible causes are not society perspective on resuscitation in patients who arrest found. after cardiac surgery. This document was created using a We present a protocol for the cardiac arrest situation multimodal methodology for evidence generation and that includes the following recommendations: (1) suc- includes information from existing guidelines, from the cessful treatment of a patient who arrests after cardiac International Liaison Committee on Resuscitation, from surgery is a multidisciplinary activity with at least six key our own structured literature reviews on issues particular roles that should be allocated and rehearsed as a team on to cardiac surgery, and from an international survey on a regular basis; (2) patients who arrest with ventricular resuscitation hosted by CTSNet. fibrillation should immediately receive three sequential In gathering evidence for this consensus paper, attempts at defibrillation before external cardiac massage, searches were conducted using the MEDLINE keywords and if this fails, emergency resternotomy should be per- “cardiac surgery,”“resuscitation,”“guideline,”“thoracic formed; (3) patients with asystole or extreme bradycardia surgery,”“cardiac arrest,” and “cardiac massage.” Weight should undergo an attempt to pace if wires are available was given to clinical studies in humans, although some before external cardiac massage, then optionally external case studies, mannequin simulations of potential pro- pacing followed by emergency resternotomy; and (4) tocols, and animal models were also considered. pulseless electrical activity should receive prompt rest- Consensus was reached using a modified Delphi ernotomy after quickly reversible causes are excluded. method consisting of two rounds of voting until 75% Finally, we recommend that full doses of epinephrine agreement on appropriate wording and strength of the should not be routinely given owing to the danger of opinions was reached. The Society of Thoracic Surgeons extreme hypertension if a reversible cause is rapidly Workforce on Critical Care was enlisted in this process to resolved. provide a wider variety of experiences and backgrounds Protocols are given for excluding reversible airway in an effort to reinforce the opinions provided. and breathing complications, for left ventricular assist We start with the premise that external massage is device emergencies, for the nonsternotomy patient, and ineffective for an arrest due to tamponade or hypo- for safe emergency resternotomy. We believe that all REPORT volemia (bleeding), and therefore these subsets of cardiac units should have accredited policies and pro- patients will receive inadequate cerebral perfusion dur- tocols in place to specifically address the resuscitation of ing cardiac arrest in the absence of resternotomy. Because patients who arrest after cardiac surgery. these two situations are common causes for an arrest after cardiac surgery, the inability to provide effective (Ann Thorac Surg 2017;103:1005–20) external cardiopulmonary resuscitation highlights the Ó 2017 by The Society of Thoracic Surgeons he American Heart Association (AHA) issued its surgery. The European Resuscitation Council (ERC) Tlatest edition of guidelines for resuscitation in guidelines were published simultaneously and, in October 2015 [1]. These guidelines do not provide contrast, included a detailed section on the resuscitation specialist guidance for patients who arrest after cardiac of patients who arrest after cardiac surgery [2].TheERC guidelines recommend resternotomy within 5 minutes of a cardiac arrest, allowing any trained practitioner to *A complete list of the authors for The Society of Thoracic Surgeons Task Force on Resuscitation After Cardiac Surgery appears at the end of this article. The STS Executive Committee approved this document. Drs Dunning and Levine disclose a relationship with fi Address correspondence to Dr Dunning, Department of Cardiothoracic CALS-S UK Ltd. Dr Arora discloses a nancial rela- Surgery, James Cook University Hospital, Marton Rd, Middlesbrough TS4 tionship with Pfizer and Mallinckrodt Pharmaceuticals. 3BW, United Kingdom; email: [email protected]. Ó 2017 by The Society of Thoracic Surgeons 0003-4975/$36.00 Published by Elsevier http://dx.doi.org/10.1016/j.athoracsur.2016.10.033 1006 STS EXPERT CONSENSUS STATEMENT DUNNING ET AL Ann Thorac Surg RESUSCITATION AFTER CARDIAC SURGERY 2017;103:1005–20 pediatric, minimal access, left ventricular assist device, and Abbreviations and Acronyms transplant patients. It does not include patients undergoing AHA = American Heart Association pulmonary surgery. Issues regarding the treatment of ECG = electrocardiogram patients in mixed specialty areas are discussed. ECM = external cardiac massage In the generation of The Society of Thoracic Surgeons ECMO = extracorporeal membrane (STS) expert consensus statement, we support and follow oxygenation the American College of Cardiology Foundation/AHA ERC = European Resuscitation Council clinical practice guidelines methodology [22], including IABP = intraaortic balloon pump the grading of recommendations. ICU = intensive care unit VF = ventricular fibrillation VT = ventricular tachycardia Protocol for Cardiac Surgical Patients in the Intensive Care Unit The recommended modification of the AHA algorithm to be applied in cases of cardiac arrest after cardiac surgery perform this task. They warn against full-dose is presented in Figure 1. We recommend that this pro- epinephrine and allow external cardiac massage to be tocol be used in the ICU in preference to the Adult deferred while three-stacked shocks are given or pacing Advanced Cardiovascular Life Support algorithm that is is begun. The ERC guidelines fully support the guide- currently advocated [1]. Major differences between the lines published by the European Association of Cardio- protocols are addressed below. Furthermore, we recom- thoracic Surgery in 2009 [3]. These documents have mend that emergency resternotomy be a standard part of stimulated many clinicians managing cardiac surgical the resuscitation protocol until 10 days after surgery. For patients to evaluate more carefully how cardiac arrests patients beyond day 10, the protocol should still be are managed in their own units. There is now recogni- followed but a senior clinician should decide whether tion that patients having a cardiac arrest after cardiac resternotomy is indicated. For these later postsurgical surgery are sufficiently different from patients in general patients, the perceived benefit of resternotomy must to warrant their own treatment algorithm to optimize be balanced against the increased difficulty of open their survival after arrest. resuscitation owing to the development of pericardial Every year, more than 400,000 patients undergo car- adhesions. diac surgery in the United States at one of approximately – 1,200 medical centers [4 6]. The incidence of cardiac fi arrest after cardiac surgery is 0.7% to 8% [7–16].Themost De brillation/Pacing Before External Cardiac remarkable statistic regarding these patients is their Massage relatively good outcome. Approximately half survive to One major change is the speed and priority with which hospital discharge, a far higher proportion than is defibrillation for ventricular fibrillation (VF) or pacing for reported when cardiac arrest occurs in other settings. asystole is performed. Before this guideline, a patient in Reasons for this superior survival include the high inci- VF after cardiac surgery was to receive external cardiac dence of reversible causes of the cardiac arrest. massage (ECM), then a single attempt at defibrillation Ventricular fibrillation (VF) is the cause of cardiac arrest followed again by ECM for 2 minutes [23]. Thereafter, the in 25% to 50% of cases. In the intensive care unit (ICU) rhythm is reassessed and ECM ceased if evidence of setting, that can be immediately identified and treated. spontaneous circulation is present. The AHA makes no Cardiac tamponade and major bleeding account for recommendations for the use of temporary pacing wires REPORT another large percentage of the additional arrests. Both in asystolic cardiac arrest. conditions can be quickly relieved by prompt resuscita- Cardiac surgical patients are sufficiently different from tion and emergency resternotomy to relieve tamponade noncardiac surgical patients to recommend an important and control bleeding. departure from the AHA guideline. In recommending Prompt recognition and treatment by ICU staff trained three sequential shocks for VF or the initiation of tem- in the recognition and management of these arrests im- porary pacing for asystole before ECM, we have consid- proves survival. Practicing protocol-based arrest man- ered several factors, as follows. agement has been shown to reduce by 50% the time to chest reopening and reduce complications resulting from Is ECM Required Before Defibrillation? the resternotomy after cardiac surgery [16–21]. We sought evidence to
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