What is the immediate management for a patient with a history of heart failure (ejection fraction 20%), hypertension (HTN), diabetes mellitus (DM), and previous coronary artery bypass graft (CABG) who experiences cardiac arrest during dialysis?

Immediate Management of Cardiac Arrest During Dialysis in High-Risk Patient

Stop dialysis immediately, initiate standard ACLS with high-quality CPR and rapid defibrillation, and assume hyperkalemia as the precipitant until proven otherwise—administer calcium chloride 10% 10 mL IV push immediately while continuing resuscitation. 1, 2

Initial Emergency Response (First 60 Seconds)

• Stop the dialysis machine immediately and activate the emergency response system while shouting for help 1, 2
• Begin CPR immediately if no pulse is felt within 10 seconds, performing cycles of 30 compressions and 2 breaths at 100-120/min with depth of at least 2 inches 2
• Apply AED pads without delay, as 62% of dialysis-related cardiac arrests present as shockable rhythms (VF/VT), and mortality increases 7-10% per minute without defibrillation 1, 2
• Bring the crash cart with emergency medications to the bedside 1

Rhythm-Based ACLS Protocol

For Shockable Rhythms (VF/VT - 62% of cases)

• Deliver one shock immediately (biphasic 120-200J or monophasic 360J), then resume CPR for 2 minutes before checking rhythm 2
• Administer epinephrine 1 mg IV/IO every 3-5 minutes starting after the second shock 1, 2
• Consider amiodarone 300 mg IV bolus (followed by 150 mg second dose) for refractory VF/VT 2
• Bystander CPR combined with rapid defibrillation achieves 38% survival in VF/VT cases during dialysis 1, 2

For Non-Shockable Rhythms (PEA/Asystole)

• Continue high-quality CPR and administer epinephrine 1 mg IV/IO every 3-5 minutes immediately 2
• Focus aggressively on reversible causes, particularly hyperkalemia and acute coronary ischemia 1

Address Dialysis-Specific Precipitants Immediately

Assume Hyperkalemia Until Proven Otherwise

• Hyperkalemia is the most common life-threatening electrolyte disturbance causing cardiac arrest in dialysis patients, accounting for at least 40% of cardiovascular deaths 3, 2
• Administer calcium chloride 10% 10 mL IV push immediately (or calcium gluconate 10% 30 mL IV) if hyperkalemia is suspected or ECG shows peaked T waves, widened QRS, or sine wave pattern 1, 2
• Give sodium bicarbonate 50 mEq IV bolus to shift potassium intracellularly 1
• Administer regular insulin 10 units IV with dextrose 50% 50 mL (D50W) to further shift potassium intracellularly 1

Consider Acute Coronary Syndrome

• This patient with EF 20%, old CABG, HTN, and DM has severely compromised myocardium that cannot tolerate the combined stress of rapid ultrafiltration and cardiac arrest 3
• Coronary ischemia is the most common underlying cause of cardiac arrest in dialysis patients 2

Post-ROSC Management (If Resuscitation Successful)

Immediate Assessment

• Obtain urgent 12-lead ECG to assess for STEMI, as patients with STEMI who achieve ROSC should undergo primary PCI if awake or have favorable prognostic features 4
• Obtain portable echocardiogram to assess for acute MI, severe valvular dysfunction, or massive pericardial effusion 1
• Check stat electrolytes (K, Mg, Ca), glucose, and arterial blood gas immediately 1, 2

Targeted Electrolyte Management

• Maintain potassium 3.5-4.5 mmol/L, as this range shows the lowest risk of recurrent VF, cardiac arrest, or death in dialysis patients 3, 1, 2
• Correct magnesium before attempting to correct potassium or calcium, as hypokalemia and hypocalcemia will be refractory to replacement without adequate magnesium 3, 1
• Monitor electrolytes during and for 4-5 hours post-dialysis, as dynamic electrolyte fluctuations create a dysrhythmogenic state that persists after dialysis 3

Ventilation and Oxygenation

• Avoid hyperventilation—ventilate at 10-12 breaths/min and titrate to PETCO2 of 35-40 mm Hg to avoid decreasing cerebral blood flow 2
• Titrate FiO2 to maintain SpO2 ≥94% to avoid oxygen toxicity 2

Coronary Intervention Decision-Making

• If patient is awake after ROSC with STEMI on ECG, proceed to primary PCI as outcomes are comparable to STEMI patients without cardiac arrest 4
• If patient remains comatose with STEMI, perform individualized assessment for survival and futility before proceeding with PCI, considering poor prognostic features: unwitnessed arrest, no bystander CPR, nonshockable rhythm, CPR >30 minutes, time to ROSC >30 minutes, arterial pH <7.2, lactate >7 mmol/L, age >85 years, and end-stage renal disease on dialysis 4
• If patient is comatose without STEMI but electrically and hemodynamically stable, immediate angiography is not recommended due to lack of benefit 4

Critical Prognostic Considerations

• Overall survival to hospital discharge after dialysis-related cardiac arrest is only 30%, with 15% survival at 1 year 2
• The combination of cardiac arrest during dialysis in a patient with EF 20% (severe cardiac dysfunction) carries extremely high mortality 1
• Cardiac arrest rate during hemodialysis is 7 events per 100,000 dialysis sessions 3, 1

Prevention Strategies for Future Dialysis Sessions (If Patient Survives)

Dialysis Prescription Modifications

• Avoid aggressive ultrafiltration in patients with severe cardiac dysfunction (EF 20%), as increased ultrafiltration volumes are strongly associated with sudden cardiac arrest 1, 5
• Consider cooler dialysate temperature to improve vascular stability and reduce risk of hemodynamic instability and arrhythmias 3
• Avoid low potassium dialysate (<2 mEq/L), as exposure is significantly associated with sudden cardiac arrest even in patients with higher predialysis serum potassium 5
• Avoid low calcium dialysate, as exposure is strongly associated with sudden cardiac arrest 5
• Consider transitioning to peritoneal dialysis or more frequent/longer duration hemodialysis with slower ultrafiltration rates, as these modalities are better tolerated in patients with severe heart failure 6

Device Therapy Consideration

• An implantable cardioverter-defibrillator (ICD) is recommended as secondary prevention for patients with current or prior symptoms of HF and reduced LVEF who have a history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia 4
• However, consider ICD only if patient has reasonable expectation of survival with good functional status for >1 year, as insufficient data exists to recommend routine ICD implantation in ESRD patients on dialysis, and ESRD patients have increased risk of ICD-related complications 3

Ongoing Medical Optimization

• Beta-blockers are recommended for all stable patients with current or prior symptoms of HF and reduced LVEF (bisoprolol, carvedilol, or sustained-release metoprolol succinate), unless contraindicated 4
• ACE inhibitors are recommended for all patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated 4
• Aldosterone antagonists are recommended in selected patients with moderately severe to severe symptoms if creatinine ≤2.5 mg/dL in men or ≤2.0 mg/dL in women and potassium <5.0 mEq/L, with careful monitoring 4

Common Pitfalls to Avoid

• Do not delay defibrillation to obtain IV access or administer medications—defibrillation is the definitive treatment for VF/VT 1, 2
• Do not treat hypokalemia or hypocalcemia without checking and correcting magnesium first, as these will be refractory to replacement 3, 1
• Do not rush to ICD implantation without optimizing medical therapy and correcting reversible causes first 3
• Do not use sotalol in ESRD patients with systolic dysfunction or heart failure, as it has been associated with pro-arrhythmia 3
• Do not perform early cardioversion without appropriate anticoagulation or transesophageal echocardiography if atrial fibrillation duration exceeds 24 hours 3