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McGill University, Montreal General Hospital, 1650 Cedar Ave, Room D10-145-3, Montreal, H3G 1A4 Canada
(Email: david.bracco{at}mcgill.ca).
Of 234 million surgical procedures performed worldwide each year, approximately 1 million are cardiac patients. The incidence of cardiac arrest after cardiac surgery is between 1% and 3% and shows a decrease in recent years. By extrapolation, 10,000 to 30,000 cardiac arrests occur after cardiac surgery yearly. Observed survival after in-hospital cardiac arrest is poor. It ranges from 11% for pulseless electrical activity or asystole to 36% at best for ventricular tachycardia or ventricular fibrillation. These outcomes have remained roughly unchanged for the last 40 years. Expected survival-to-hospital discharge after cardiac surgery due to cardiac arrest ranges between 20% and 80%. This is a better prognosis due to the highly monitored settings in which cardiac arrest occurs, as well as the high prevalence of conditions that may be rapidly improved, such as ventricular fibrillation, hypovolemia, cardiac tamponade, or tension pneumothorax. Unfortunately, there are still unmet needs pertaining to cardiac arrests after cardiac surgery.
Several case series of patients presenting with cardiac arrest after cardiac surgery have been reported. These case series show the diversity of causes and variability of outcome. A first concern is inclusion criteria; the present article [1] includes all patients requiring cardiopulmonary resuscitation. Other investigators included patients requiring sternum reopening or chest opening plus reinstitution of bypass, and for patients on this path, the chances of survival decreases. Some episodes of ventricular tachycardia requiring external defibrillation or episodes of asystole requiring resumption of pacing are probably not recorded in this case series. There is a need for clear nomenclature and definitions. Once these definitions are adopted, data can be widely collected to better understand cardiac arrest after cardiac surgery.
Most in-hospital cardiac arrests are preceded by physiologic deterioration. Detection and treatment of these physiologic abnormalities decreases the incidence of cardiac arrest and improves outcomes. This realization led to the concept of rapid response teams for regular hospital wards. Most cardiac arrests after cardiac surgery occur in the first 24 hours after skin closure. Half of the cardiac arrests occur in the first 3 hours after intensive care unit (ICU) admission. The high incidence of events during this short period of time underscores the need for close senior staff supervision when a newly operated cardiac patient arrives in the ICU. High acuity in the ICU is amplified by a variety of ways to monitor the patients' electrocardiographic measurements, arterial pressure, central venous pressure, cardiac output, and so forth. Although the monitors connected to the patient are working, unfortunately there are few data regarding physiologic conditions shortly before cardiac arrest occurs. Perhaps continuous recordings, as opposed to merely displaying the information (ie, the aviation "black box") should be implemented. This information could provide antecedent signs of an impending cardiac arrest. The ICU teams could provide a rapid response within 30 to 60 seconds, and this intervention could take place before an arrest occurs, which could improve outcomes.
Standardization of cardiopulmonary resuscitation has improved outcomes. However, several specifics pertaining to patients recently operated on for cardiac surgery must be kept in mind. Among other risks, sternal wires, venous grafts, and the left internal mammary arteries are at high risk of avulsion and injury during external chest compression, and adrenalin-induced hypertension may rupture arterial suture lines. Resources that are not available to noncardiac surgical patients are available in cardiac patients. Most patients have atrial and ventricular pacing wires in place to permit rapid (sequential) pacing. The chest can be reopened in 60 seconds to inspect the heart and perform internal cardiac massage. Cardiopulmonary bypass can rapidly assist the circulation. The European Association for Cardio-Thoracic Surgery just published specific resuscitation guidelines for cardiac surgical patients.
"Mishaps are like knives that either serve us or cut us, as we grasp them by the blade or the handle." This quote by James Russell Lowell can be applied to cardiac arrest after cardiac surgery. This is part of implementing a safety culture. Actual systems are often reactive (ie, when accidents occur, they generate a lot of action and reaction). Systematic, prospective data collection approaches a calculative culture, but this is difficult for rare events, such as cardiac arrest in which there are multiple causes. There is a definite need for more proactive and generative systems in the ICU, and also for instituting a nonpunitive culture of safety in the delivery of care. Cardiac arrest after cardiac surgery is serious enough to trigger a complete root cause analysis and debriefing.
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