Brief Overview
- Higher incidence of reversible causes
- Higher survival rate for post-cardiac surgery patients
- AHA algorithm for the post-cardiac surgery within the first ~10 days
First steps:
Hold compressions
Code cart
Maintain finger on pulse
Check your chest tubes
Recs for epi in cardiac arrest in post-cardiac surgery
- European Society Cardiology guidelines
- Some addressed in AHA
- Mostly based off expert opinion
- Don’t give full code-dose epi -> b/c there’s high likelihood for re-sternotomy or restoring sinus rhythm via defib -> can give 100 mcg (i.e. one full stick of push dose epi)
- Also in the Duning Ann Thorac Surg 2017 -> 50 mcg – 300 mcg
- Caution with too much epinephrine in these post-cardiac surgery pts -> increases O2 consumption and demand -> can also cause severe hypertension which causes bleeding
- Can counteract with vasodilator prn
Approach to external cardiac massage/compressions is different in the post-cardiac surgery patient
- Deviates from ACLS normal cardiac arrest algorithm
- Can attempt defib or pacing prior to initiating compressions
- Provided that can be done in less than one minute
- Prior to compressions, you can do three stacked shocks <- defib first prior to the ACLS algorithm
- Asynch pace (i.e. DDD mode or aka “emergency” mode) -> careful if the pacer is in AAI mode and getting amio or something blocking the node <- need to be able to pace the ventricles (i.e. hit up that DDD mode but really all you really need is the V-wires to be working)
HOW-TO -> it’s all about the rhythm
Vfib or pulseless vtach
- Instead of ext cardiac massage, should try to defib (if available within the first minute); also, can administer three stacked shocks prior to external cardiac massage
- Amiodarone 300 mg via CVC
- Eventually c/w resternotomy
Asystole or profound bradycardia
- DDD pacing at max output if available within 1 min
- Atropine 3mg <- took out of the European guidelines; still in there for the American STS guidelines
- Eventually c/w resternotomy
All pulseless cardiac arrests
- No epi; no vaso <- reduce epi dose to 100 mcg pre-arrest
- Take the pacing wires out with PEA <- need to make sure it is not fine vfib
- Rapid re-sternotomy if no response to initial therapies (<5 min)
- Lidocaine evidence decent for post-cardiac surgery patients
CODE with a IABP
- Pause the IABP to make sure you’re actually pulseless
CRITICAL CARE BY CLARK 