The arrested heart surgery patient is a unique beast in surgery and critical care. Dr Nikki Stamp gives a whirlwind tour of post cardiac surgery resuscitation. She will discuss how to spot the potential arrest, how to manage it and some special situations to be aware of in this special group of patients Post cardiac surgery resuscitation is complex. Nikki describes them as “brown trouser moments”. She highlights this with three cases. A15-year-old girl who exsanguinated on Day 12 after dissection repair in the community. A 40-year-old female arrested within an hour of a re-do aortic root procedure. A 72-year-old lady who arrested after a bradycardic arrest following an aortic valve replacement. Only one survived – this is serious business. Cardiac arrest post cardiac surgery is relatively uncommon. The survival rate is also quite high. This is due to it being recognised and treated early with a high proportion of reversible causes. The key is to think of these causes and treat them as a team. Nikki breaks the causes into four groups. Ischemia, mechanical, arrhythmia and unknown. It is important to recognise that cardiac arrest in this population is differs to a typical scenario of cardiac arrest. As such, there is a different algorithm. This hinges on assessing the rhythm in the first instance and consider defibrillation fist if appropriate. One should also consider the use of pacing wires if they are still in post-operatively. Nikki provides a great number of clinical pearls, discussing care of the right heart, use of chest compressions and cardiac massage, use of ECMO and considerations if a left ventricular assistance device is in place. Her take home points include being alert to these situations but not alarmed! Practice these resuscitations as a team. Shock early and pace early and remember most people should not die with a closed chest!

1. THE EVERYWOMAN’S GUIDE TO
RESUSCITATION
POST CARDIAC SURGERY
Dr Nikki Stamp MBBS(Hons) GradDipSurgAnat FRACS
Cardiothoracic and Transplant Surgeon
Fiona Stanley Hospital, Perth, Australia
@drnikkistamp @nikkistamp

2. DISCLOSURES
I am a surgeon at a critical care conference

3. Bleeding Pump failure Bradycardia

4. Survival – 17-
79%
0.7-2.9% all
patients

5. Ischaemia
Mechanical
Arrhythmia
Unknown
Incomplete revascularisation
Graft failure
Coronary complication
Hypoperfusion
Tamponade/bleeding
Right heart failure
Valve dysfunction
Pump failure
VT/VF/Asystole/Bradycardia
It means we don’t know*

6. SPOTTING TROUBLE
Rising lactate
Rising vasopressors
Unstable rhythm
Chest drainage – too high or abrupt cessation
Rising filling pressures
Falling cardiac output/index & SvO2
Loss of pacing capture
Transoesophageal echocardiogram*

8. ELECTRICITY
VF or
pulseless
VT?
3 Sequential
Shocks
External
Cardiac
Massage

9. PACING
Asystole or
bradycardia
Pacing
spikes
Pace
Asynchronous
Turn off and
check underlying

10. THE BATTLE TO SAVE THE RIGHT HEART
Empty-ish but adequately filled
Sinus rhythm or AV paced
Pulmonary vasodilatation
Perfusion pressure
Inotropy

11. CHEST COMPRESSIONS

13. Emergency
Resternotomy:
• Continue CPR
• Rapid prep
• Knife to wires
• Cut wires
• Retractor – care with
grafts
• TURN DOWN
PRESSORS

14. ECMO

15. VAD VEXATIONS
‘Arrested’ or
unresponsiv
e
VAD
Call for
help
Airway
Breathing
Circulation
Check the
LVAD
Flow <1.5L
CPR (ACLS)
+/- ECMO
Flow 1.5-2.5L
MAP<40
No CPR
Fluid bolus
Adrenaline
Echo
Flow >2.5L
No CPR

16. TAKE HOME MESSAGES
Be alert, not alarmed
Shock early, pace early
Nobody should die with a closed chest*
ECMO/CPB is there to be used
Battle to save the right heart
LVAD = CPR and expert advice
Manage the at risk patient as a team

17. TAKE HOME MESSAGES
Be alert, not alarmed
Shock early, pace early
Most should not die with a closed chest
ECMO/CPB is there to be used
Battle to save the right heart
LVAD = CPR and expert advice
Manage the at risk patient as a team

18. Call your
friendly*
neighborhood
heart surgeon
*Disclaimer: May or may not be friendly but can operate

19. @drnikkistamp @nikkistamp
#ILookLikeASurgeon