What are the key steps in providing advanced life support for post cardiac surgery complications?

Post Cardiac Surgery Advanced Life Support

For patients experiencing cardiac arrest after cardiac surgery, immediate implementation of specialized protocols including external chest compressions, rapid defibrillation for VF/VT, pacing for bradyarrhythmias, and early resternotomy in appropriate settings is essential to improve survival. 1

Initial Response to Cardiac Arrest

• External chest compressions should be performed immediately if emergency resternotomy is not immediately available 1
• In witnessed arrest with VF/VT, immediate defibrillation should be performed; if unsuccessful within 1 minute, CPR should be initiated 1
• For asystolic or bradycardic arrest in patients with pacer wires already in place, immediate pacing should be attempted; if unsuccessful within 1 minute, CPR should be initiated 1
• Activate the emergency response system and apply cardiac monitor/defibrillator immediately 2

Unique Considerations in Post-Cardiac Surgery Arrest

Cardiac arrest occurs in 1-8% of cardiac surgery cases with unique etiologies requiring specialized management 1:

• Common causes include tachyarrhythmias (VT/VF), bradyarrhythmias (heart block/asystole), tamponade, pneumothorax, valve dysfunction, graft occlusion, and bleeding 1
• Unlike standard ACLS protocols, post-cardiac surgery patients require specific interventions due to their recent sternotomy and unique pathophysiology 3
• These patients typically arrest in highly monitored settings (ICU) with trained staff available for specialized rescue therapies 1

Advanced Airway Management

• Ensure proper airway management with continuous waveform capnography to confirm airway placement and assess CPR quality 2
• For intubated patients, check for disconnection, obstruction, or equipment failure 2
• Use lower tidal volumes, lower respiratory rates, and increased expiratory time to minimize risk of auto-PEEP and barotrauma in patients with respiratory complications 1

Resternotomy and Open-Chest CPR

• Early resternotomy is reasonable in an appropriately staffed and equipped ICU (Class 2a recommendation) 1
• Open-chest CPR is useful if cardiac arrest develops during surgery when the chest is already open or in the early postoperative period 1
• Resternotomy should be performed within 5 minutes if prior interventions are unsuccessful 3
• Studies have documented improved outcomes in patients treated with resternotomy and internal cardiac compression when administered by experienced personnel in ICUs 1

Mechanical Circulatory Support

• In post-cardiac surgery patients refractory to standard resuscitation, mechanical circulatory support may improve outcomes 1
• Options include extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass 1
• Early institution of extracorporeal cardiopulmonary resuscitation should be considered instead of chest reopening in certain cases 4

Medication Considerations

• Establish IV/IO access if not already present 2
• Administer epinephrine 1 mg IV/IO every 3-5 minutes for pulseless arrest 2
• Use epinephrine cautiously due to potential rebound hypertension in post-cardiac surgery patients 3
• For patients with cardiac decompensation due to depressed contractility, dobutamine may be indicated for short-term inotropic support 5

Monitoring During Resuscitation

• Use continuous waveform capnography to confirm airway placement and assess CPR quality 2
• Utilize arterial line monitoring to assess blood pressure during CPR 2
• Monitor for signs of ROSC including pulse, blood pressure, abrupt sustained increase in PETCO2, or spontaneous arterial pressure waves 2
• Consider rescue-focused cardiac ultrasound to aid in early identification of underlying pathology and guide resuscitation 4

Modern Approach to Post-Cardiac Surgery Arrest

• Traditional ACLS protocols have significant limitations in post-cardiac surgery patients 3
• The Cardiac Advanced Life Support-Surgical (CALS-S) guideline provides a standardized algorithm approach specifically for these patients 6
• Recent advances include incorporating rescue-focused cardiac ultrasound and early extracorporeal support 4
• When treated promptly with specialized protocols, 17-79% of patients who experience cardiac arrest after cardiac surgery survive to discharge 6

Post-Resuscitation Care

• Elevate head of bed 30° if tolerated 2
• Avoid hyperventilation and maintain PETCO2 between 35-40 mmHg 2
• Titrate oxygen to maintain arterial oxygen saturation ≥94% 2
• Consider therapeutic hypothermia for comatose survivors 2
• Identify and treat the underlying cause of arrest, which is often reversible in post-cardiac surgery patients 6

Training and Implementation

• Ensure all staff are trained in high-quality CPR and advanced airway management 2
• Minimize interruptions in chest compressions during CPR 2
• Change compressors every 2 minutes to maintain high-quality compressions 2
• Consider implementing specialized Cardiac Surgical Unit-Advanced Life Support courses for staff 3, 7