What is the treatment for cardiac arrest following open heart surgery?

Treatment for Cardiac Arrest Following Open Heart Surgery

For patients experiencing cardiac arrest after cardiac surgery, immediate intervention should follow a specialized protocol including external chest compressions if emergency resternotomy is not immediately available, immediate defibrillation for VF/VT, immediate pacing for asystole/bradycardia if pacer wires are in place, and consideration of early resternotomy in an appropriately staffed ICU. 1

Initial Response Algorithm

• External chest compressions should be performed immediately if emergency resternotomy is not immediately available 1
• For witnessed VF/VT arrest, perform immediate defibrillation; if unsuccessful within 1 minute, initiate CPR 1
• For asystolic or bradycardic arrest with pacer wires already in place, attempt immediate pacing; if unsuccessful within 1 minute, initiate CPR 1
• Rapidly identify and correct potential causes of arrest including tamponade, pneumothorax, valve dysfunction, graft occlusion, or bleeding 1

Specialized Interventions

Resternotomy Considerations

• 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 by experienced providers, as good outcomes have been observed with rapid resternotomy protocols 1

Mechanical Support Options

• For patients refractory to standard resuscitation procedures, mechanical circulatory support including ECMO or cardiopulmonary bypass may improve outcomes 1
• Consider mechanical circulatory support when the suspected etiology is potentially reversible during a limited period of mechanical support 1

Respiratory Management During Resuscitation

• Use lower tidal volumes, lower respiratory rates, and increased expiratory time to minimize risk of auto-PEEP and barotrauma 1
• Evaluate for tension pneumothorax, which can be a rare but life-threatening complication 1
• Brief disconnection from the ventilator or pause in bag-mask ventilation with thoracic compression may relieve hyperinflation if present 1

Team Roles and Preparation

• Cardiac arrest after cardiac surgery requires a multidisciplinary approach with at least six key roles that should be allocated and rehearsed regularly 2
• All cardiac units should have accredited policies and protocols specifically addressing resuscitation after cardiac surgery 2
• Full doses of epinephrine should not be routinely given due to the risk of extreme hypertension if a reversible cause is rapidly resolved 2

Special Considerations

• Cardiac arrest occurs in 1-8% of cardiac surgery cases, typically in highly monitored settings with trained staff available 1
• The incidence of mechanical causes (tamponade or graft malfunction) precipitating sudden cardiac arrest is approximately 28%, highlighting the importance of early resternotomy 3
• Survival rates are significantly higher with early open-chest CPR in post-cardiac surgery patients compared to standard CPR approaches 3
• For patients with epicardial pacing wires, immediate pacing should be attempted before external cardiac massage in cases of asystole or extreme bradycardia 4

Pitfalls to Avoid

• Delaying resternotomy beyond 5 minutes can significantly reduce chances of successful resuscitation 2
• Failure to recognize mechanical causes of arrest (tamponade, bleeding, graft occlusion) that require surgical intervention 1, 3
• Routine administration of full-dose epinephrine, which can cause dangerous hypertension if a reversible cause is quickly corrected 2
• Prolonged closed-chest CPR when open-chest CPR would be more effective for post-cardiac surgery patients 2, 3