Cardiac Arrest in the Cardiac Surgery Candidate

What factors must be considered to ensure optimal management of perioperative cardiac arrest in the cardiac surgery patient?

Up to 8% of cardiac surgical patients experience perioperative cardiac arrest, and roughly 20% of these patients die. Advanced cardiac life support (ACLS) represents the standard of care for most adults who need resuscitation, but ACLS has less robust outcomes and can be harmful in patients with recent sternotomies. Many case reports have described acute right ventricular lacerations followed by massive bleeding with application of as few as 5 chest compressions in cardiac surgery patients. In the June 2015 issue of Seminars in Cardiothoracic and Vascular Anesthesia, S. Jill Ley from the California Pacific Medical Center, San Francisco, CA, discusses optimal management of perioperative arrest in the cardiac surgery patient.

Cardiac arrest is designated a high risk/low volume event. When it occurs in the operating room or intensive care unit, clinicians are usually monitoring patients closely and prepared to act immediately. Probable causes in cardiac surgery patients usually include electrical (arrhythmia) or mechanical (tamponade, profound hypovolemia due to bleeding, or tension pneumothorax) origins. The relatively few causes make this area ideal for the use of protocols or flowcharts.

The European Resuscitation Council adopted an evidence-based guideline specific to the cardiac surgical patient in 2010. Ley enumerates its advantages:

  • It recommends immediate defibrillation or pacing of arrhythmias before external compressions, if feasible within 1 minute. This is a deviation from standard ACLS.
  • Epinephrine and other vasopressors may cause rebound hypertension, may not be effective, and must be avoided. Epinephrine’s other potential adverse effects include proarrhythmia and increased myocardial oxygen demand.
  • As with standard ACLS, if reversible causes are ruled out, the surgeon should reopen the patient’s chest within 5 minutes and use internal massage. Reopening even a portion of the sternotomy in the presence of tamponade often leads to immediate hemodynamic improvement.

The Society of Thoracic Surgeons is reviewing this guideline for use in the United States with an eye toward standardizing cardiac surgical emergencies across the nation.