Emergency reinstitution of cardiopulmonary bypass following cardiac surgery: outcome justifies the cost

Resuscitation after cardiac surgery awareness: an Egyptian national survey

Background

Cardiac surgery patients have different resuscitative needs than other patients who experience in-hospital cardiac arrest; this was addressed in the guidelines. However, it is unknown how widely the guidelines are practiced, or a training protocol is followed in different cardiac surgery units in Egypt.

Methods

A 21-question survey was created and included: Participant demographics, prevalence of cardiac arrest, cardiac arrest protocol, emergency resternotomy technique, training protocols. Survey was disseminated through social media messaging platforms during the period between November 2020 and January 2021.

Results

Ninety-five responses were from 11 centres across Egypt. In total, 68.5% of the respondents were surgeons, 76.8% of participants were junior surgeons. For patients who go into VF after cardiac surgery, respondents would attempt a median of 3 shocks with only 24.2% commencing defibrillation shocks before external cardiac massage, whilst the majority initiating CPR immediately and performing emergency resternotomy in a median time of 10 min. In total, 56.8% would give 1 mg of adrenaline as soon as the cardiac arrest was established. If a surgeon was not available, only 36.8% of respondents would allow any trained personnel to perform the emergency resternotomy. Only 9.5% practice regularly on emergency sternotomies. Seventy-five percent think tailored training is important and staff should be oriented about it in the future.

Conclusion

An action plan is required to improve the training of the junior surgeons regarding the Cardiac Advanced Life Support Protocol to implement it in a timely organised manner. This should be endorsed and audited by a national society or body by keeping a national registry and mandatory recertification.

Cardiac Arrest After Cardiac Surgery: An Evidence-Based Resuscitation Protocol

More than 250 000 cardiac surgical procedures are performed annually in the United States. Postoperative cardiac arrest rates range from 0.7% to 5.2%. This article reviews current evidence for cardiac arrest resuscitation after cardiac surgery. The evaluation included resuscitation guidelines and 22 studies identified through a MEDLINE search. Evidence-based resuscitation differs from advanced cardiovascular life support guidelines. European Resuscitation Council guidelines include correcting reversible causes of arrest, applying defibrillation/pacing before external cardiopulmonary resuscitation, resternotomy within 5 minutes if electrical therapies fail, and restricting epinephrine use to avoid rebound hypertension. A 2017 Society of Thoracic Surgeons protocol derived from European Resuscitation Council guidelines is now standard of care in the United States. Evidence-based practices can improve survival and reduce resternotomy rates. This article describes the clinical implementation of the Society of Thoracic Surgeons guidelines.

Hyperbaric Oxygen Preconditioning Attenuates Myocardium Ischemia-Reperfusion Injury Through Upregulation of Heme Oxygenase 1 Expression: PI3K/Akt/Nrf2 Pathway Involved

BACKGROUND

With the rise of the burden of ischemic heart disease, both clinical and economic evidence show a desperate need to protect the heart against myocardium ischemia-reperfusion injury-related complications following cardiac surgery or percutaneous coronary intervention. However, there is no effective intervention for myocardium ischemia-reperfusion injury as yet.

METHODS

We pretreated mice with 4 daily 2.0 absolute atmosphere (ATA) hyperbaric oxygen, then observed its effects on heart function parameters and infarct size following in situ ischemia-reperfusion. Multiple oxidative and inflammation products were measured in the myocardium. Next, we investigated the expression of heme oxygenase 1 (HO-1), phosphatidylinositol 3-kinase (PI3K)/serine/threonine protein kinase (Akt) pathway, and NF-E2-related factor 2 (Nrf2) in the presence of myocardium ischemia-reperfusion injury, hyperbaric oxygen preconditioning, and their inhibitors and their effects on heart function parameters.

RESULTS

Hyperbaric oxygen preconditioning ameliorated the cardiac function and histological alterations induced by myocardium ischemia-reperfusion injury, decreased oxidative products and proinflammatory cytokine. Hyperbaric oxygen preconditioning increased expression of HO-1, which was suppressed by PI3K inhibitor LY294002, Nrf2 knockout, and Akt inhibitor triciribine. The expression of Nrf2 was enhanced by hyperbaric oxygen preconditioning, but decreased by LY294002 and triciribine. The Akt was also activated by hyperbaric oxygen preconditioning but suppressed by LY294002. The hemodynamic assays showed that cardiac function was suppressed by LY294002, Nrf2 knockout, and triciribine.

CONCLUSION

These data present a novel signaling mechanism by which hyperbaric oxygen preconditioning protects myocardium ischemia-reperfusion injury via PI3K/Akt/Nrf2-dependent antioxidant defensive system.

Postoperative cardiac arrest after heart surgery: does extracorporeal perfusion support a paradigm change in management?

Early institution of extracorporeal perfusion support (ECPS) may improve survival after cardiac arrest. Two patients sustained unexpected cardiac arrest in the Intensive Care Unit (ICU) following cardiac interventions. ECPS was initiated due to failure to restore hemodynamics after prolonged (over 60 minutes) advanced cardiac life support (ACLS) protocol-guided cardiopulmonary resuscitation. Despite relatively late institution of ECPS, both patients survived with preserved neurological function. This communication focuses on the utility of ECPS in the ICU as a part of resuscitative efforts.

The Cardiac Surgery Advanced Life Support Course (CALS): Delivering Significant Improvements in Emergency Cardiothoracic Care

BACKGROUND

A 3-day cardiac surgery advanced life support course was designed with a series of protocols to manage critically ill cardiac surgical patients and patients who suffer a cardiac arrest. We sought to determine the effect of this course on the management of simulated critically ill and cardiac arrest patients.

METHODS

Twenty-four candidates participated in the course. Critically ill patients were simulated using intubated mannikins, with lines and drains in situ, and a laptop with an intensive care unit monitor simulation program. Candidates were tested before and after the course with rigidly predesigned clinical situations. Candidates were split into groups of 6, and cardiac arrests were simulated in the same fashion, with all required surgical equipment immediately available. All scenarios were videotaped, and after blinding, an independent surgeon assessed the times to achieve predetermined clinical endpoints.

RESULTS

The time to successful definitive treatment was significantly faster postcourse for the critically ill patient scenarios: (565 secs [SD 27 secs] precourse, compared with 303 secs [SD 24 secs] postcourse; p < 0.0005). In addition, the times taken to achieve a wide range of predetermined objectives, including airway check, assessing breathing, circulation assessment, treating with oxygen, appropriate treatment of the circulation, and requesting blood gases, chest radiographs, and electrocardiograms, were also significantly faster in the postcourse scenarios. Times to successful chest reopening and internal cardiac massage were also significantly improved in cardiac arrest patients: (451 secs [SD 39 secs] precourse and 228 secs [SD 17 secs] postcourse; p = 0.011).

CONCLUSIONS

Structured training and practice in the management of critically ill cardiac surgical patients and patients suffering a cardiac arrest leads to significant improvements in the speed and quality of care for these patients.

In-hospital cardiac arrest

To review the current management of in-hospital cardiac arrest and to identify variables that influence outcomes, OLDMEDLINE from 1950 to 1966 and MEDLINE from 1966 to March 2005 were searched using the keywords cardiopulmonary resuscitation, cardiac arrest, in hospital, and adult. Secondary sources were derived from review publications and personal communications by one of the authors. There is no secure evidence that the ultimate outcomes after cardiopulmonary resuscitation in settings of in-hospital cardiac arrest have improved in the >40 yrs that followed the landmark report by Kouwenhoven, Jude, and Knickerbocker, which launched the modern era of cardiopulmonary resuscitation. A paucity of objective measurements preclude secure protocols for sequencing of interventions and, even more, when to initiate and discontinue cardiopulmonary resuscitation. The preparedness of both physicians and nursing professionals to implement the published guidelines has itself been questioned. Whereas early access defibrillation with automated external defibrillators may be of benefit in out-of-hospital settings, there has as yet been no secure evidence that automated external defibrillators have had a favorable impact on in-hospital cardiopulmonary resuscitation when used on infrequent occasions by first responders. This contrasts with the much greater success of advanced life support providers and especially when electrical defibrillation is promptly performed by expertly trained personnel after onset of cardiac arrest. Outcomes are therefore improved in critical care settings and especially in coronary care units in which patients are continuously monitored.