ACLS - Post-Cardiac Surgery

Patients often have unique causes of the arrest related to surgical complications. The incidence of arrest is 0.7-8% following cardiac surgery. Unlike most cardiac arrests – cardiac arrest following cardiac surgery often have better outcomes in terms of return of spontaneous circulation (ROSC) and neurological outcome.

VF arrest accounts for 25-50% of the cardiac arrests. Cardiac tamponade and other major bleeding account for large portion of other cardiac arrests.

Algorithm (up until they leave ICU or 10 days post cardiac surgery)

• shockable rhythm
  • Perform 3-stacked DC shocks prior to initiation of CPR
• nonshockable rhythm
  • PEA
    • If paced, turn off pacing to exclude VF
  • Bradycardia/Asystole
    • Trial pacing (as the native conduction system may be damaged)
• refractory to above
  • emergency resternotomy and cardiopulmonary bypass are indicated and should be performed ASAP within 5 minutes of cardiac arrest if refractory to defibrillation, CPR, medications, and pacing
  • continue CPR +/- single DC shocks until this happens
  • Once the chest is open internal cardiac massage can be performed by experienced clinicians.

Adjunct considerations

• Consider heavily tension PTX, tamponade
• avoid full-dose cardiac epinephrine as this can lead to severe hypertension and worsening bleeding if ROSC is achieved, unless a senior clinician instructs otherwise
• IABP - turn to pressure trigger mode to help facilitate CPR. If performing emergency sternotomy then set the IABP to internal mode (rate = 100)\
• FiO2 1.0, turn off PEEP

References

1. Handbook of ICU Therapy
2. Resuscitation After Cardiac Surgery – Cardio Guide
3. Cardiac Arrest Management After Cardiac Surgery • LITFL • CCC
4. Guideline for resuscitation in cardiac arrest after cardiac surgery | European Journal of Cardio-Thoracic Surgery | Oxford Academic