3/29/2014 • In the immediate postop recovery in a cardiac surgery patient is typically related to reversible causes •Tamponade •Bleeding •Ventricular arrhythmias •Blocks associated with conduction problems • Survival to discharge can be up to 79% • If treated promptly UnityPoint Health-Methodist, Peoria Heart of IL AACN –President www.cherylherrmann.com • Pros •EBP resuscitation guidelines •Standardized approach • Hospitals developed own guidelines and protocols •Easy to teach and implement • No standardization • Cons: •Do not specifically address cardiac surgery arrests 2009 European Association for Cardio-Thoracic Surgery 1 3/29/2014 California Pacific Medical Center/Sutter Health Mayo Clinic Duke University Medical Center Temple University Hospital Beth Israel Deaconess Medical Center Society of ‘Thoracic Surgeons (STS) soon! www.csu-als.com • CALS • CSU-ALS •CALS- S Cardiac Advanced Life Support - Surgery • Assess Rhythm • Ventricular Tach or Fib • Shock before • Asytole or severe Compressions bradycardia • Pace/Atropine –not Epi • Pulseless Electrical • Identify reversible causes Activity • Early resternotomy 2 3/29/2014 • No evidence to support CPR prior to defibrillation for in-hospital arrests • Best survival for in-hospital arrests is when defibrillation occurs within two minutes of VF/VT Sternum during CPR • Successful restoration of rhythm may occur after the first defibrillation Rewired sternum in 86-96% of patients • Success declines with each sequential shock with unlikely success after the fourth shock • Potential trauma or complications from the compressions. •The unstable sternum or sternal wires may cause disruption of vascular sutures RV tear after sternum recoils or right ventricular tear. • Thus, defibrillation is recommended first, if it can be achieved within sixty seconds References listed in EACTs Cardiac Surgery Guideline Photos courtesy of Jill Ley • Restoration of sinus rhythm after early defibrillation or resternotomy is highly successful • Iwf idtheinf ib3r0il lsaetcoorn advsailable • Administration of epinephrine may result in X • 3sequential shocks severe rebound hypertension leading to • Compressions suture line disruption or aortic rupture • Amiodarone • Prepare for resternotomy • CPR with shock every two minutes 2ndperson manages airway • Pace if wires available • DDD 90 bpm and max MA • CPR • Atropine 3 mg IV • Consider external pacing • Prepare for resternotomy • CPR 2ndperson manages airway 3 3/29/2014 • No evidence available in favor of atropine in cardiac surgery arrests • Relatively benign drug with • CPR • If paced, turn off pacer few side effects to assess for VF • Thus recommended for • Prepare for resternotomy asystole or extreme • Determine and treat bradycardia causes –H & Ts 2ndperson manages airway • Cardiac surgery patients who arrest with PEA are typically Hs Ts Four Four experiencing treatable causes Hypoxia * Tamponade * •Hypovolemia --severe •Hypoxia •Tamponade Hypovolemia* Tension •Tension pneumothorax Pneumothorax • Prompt treatment results in good outcomes Hypokalemia/ Thromboembolism • To assess for causes of PEA/nonschockablerhythm Hyperkalemia •Consider the 4 “Hs” and 4 “Ts Hypothermia Toxin * = Most common causesof cardiac surgery arrests Hypoxia Hypovolemia and Tamponade • Treat per airway • Severe hypovolemia is management and assessment typically due to bleeding • If ventilated, turn Fi02 • Severe hypovolemia and to 100% and turn off tamponade both require PEEP • Assess for airway emergent resternotomy to patency and lung correct sounds 2ndperson manages airway 4 3/29/2014 • Check endotracheal tube (ET) position and end tidal • Feel the trachea to verify it is midline. carbon dioxide (EtCO2) waveform and reading • If a tension pneumothorax is suspected, insert a large • Listen for an ETT airleakand verify that is properly bore needle into the 2ndintercostal space, mid- inflated clavicularline. • Listen and look for bilateral breath sounds. • If unable to ventilate the patient with a bag-mask- •Consider removing the patient from the ventilator and give 100% oxygen valve, attempt to suction the ET tube. via bag-mask-valve to more easily assess lung sounds and determine lung • If unable to pass the suction catheter, ETT occlusion or malposition should compliance be suspected. •If bilateral lung sounds are present, reconnect the ETT to ventilator. •Remove the ETT and ventilate with a bag-mask-valve. Team leader 1. External cardiac • Conducts the management of the massage arrest • Ensures the protocol is followed 2. Management of • Assigns roles airway and breathing ICU nursing Coordinator 3. Defibrillation • Manages the arrest from the 4. Team leader peripheral bedside • Resternotomy preparation 5. Medication • Managing additional personnel administration • Calling for expert assistance as needed 6. ICU nursing • Reporting back to the team leader Coordinator Medication Administration • CALS-S recommends as best practice to stop all medication infusions • In all three arms of the algorithm, prepare for • Continuing pre-arrest medication emergent resternotomy if: infusions is unlikely to assist resolution of the cardiac arrest •The initial treatment is unsuccessful • An inadvertent flushing of a •Resuscitation efforts are likely to last longer than 5 –10 vasodilator or residual medication in minutes a central line lumen causing the arrest • May be restarted as needed for • Internal cardiac massage is superior to external hemodynamic stability cardiac massage in cardiac surgery patients • Sedative infusions may be continued if there is a concern about patient awareness. 5 3/29/2014 Open Chest Cart Cart & SternalSaw Top of Cart • Sterile all-in-one thoracic drape • Scalpel • Wire cutter • Heavy needle holder • Sternal retractor. Drawer #1: Drapes, Towels Drawer #2: SternalSaw Photos courtesy of Jill Ley Photos courtesy of Jill Ley Drawer #3: SternotomySet Drawer #4: IntPaddles & Headlamp Upon calling of cardiac arrest, prepare for emergent resternotomy • Emergent situation –Aseptic Technique -- hand washing is not necessary prior to • EACTS guidelines suggest if a sterile gloves surgeon is not immediately • Two staff members available resternotomy by •Put on sterile gowns and gloves another staff member maybe •Prepare the emergency sternotomy set be lifesaving. • A third person should be the circulator to hand-in or open sterile equipment. • State licensure regulations • The surgeon and all assistants determine who is eligible to •Wear sterile gowns and gloves, but face-masks perform the resternotomy and and surgical caps are not essential per EACTS internal massage. guidelines. •However, CDC guidelines for invasive procedures recommend personnel wearing face-masks and surgical caps. Photos courtesy of Jill Ley Photos courtesy of Jill Ley The sternotomy manikin Photos courtesy of Jill Ley www.csu-als.com Photos courtesy of Jill Ley 6 3/29/2014 • Bleeding • Ischemia • Tamponade • Respiratory failure • High output failure • Acute mitral regurgitation • Bradyarrhythmia • Ventricular tachycardia • Supraventricular tachycardia Photos courtesy of Jill Ley Photos courtesy of Jill Ley CALS-S ACLS • Review equipment For VF/VT •Internal paddles, cart trays Defibrillation takes priority; may defer Externalmassage should be performed on •Pacemakers massage for up to 1 minute all patients • Resuscitation responses 3 successiveshocks before CPR CPR fi 1 shock fi CPR •Defibrillation/pacing For Asystole •Code management DDD pacing at maximal output External massage & vasopressor •Teamwork For VF/VT, Asystole, Pulseless Electrical Activity • Pre-resuscitation management No vasopressor unless seniorMD Epinephrine 1000 mcg every 3-5 minutes Pre-arrest: Epidose < 100 mcg +/-vasopressin 40units x 1 •Early recognition and management of Utilize 6key roles during arrest Similar roles withemphasis on team leader hypotension Additional 2 people gown & glove •Avoidance of full blown arrest Rapidresternotomy (<5 min) if no N/A •Critical thinking skills! response to defib/pacing Recopied with permission from Kiermani B, Ley J, Bartley T, Strang T, Levine A, Dunning J. The Cardiac Surgery Photos courtesy of Jill Ley Advanced Life Support Course, 2nded. Lulu Publishers at www.lulu.com. 2012. • Recommended up to POD #10 • What happens when we get standardized, “bundle” • Beyond POD #10, senior clinician should decide approaches to patient care? • Internal cardiac massage should still be considered in •VAP preference to prolonged external compressions especially if a •Sepsis reversible cause is suspected •CAUTI • EACTs recommends only use in the ICU •May consider use in progressive units in early post op days •Cardiovascular ICU nurses would respond and direct the emergent resternotomy 7 3/29/2014 • Literature • Thorough review of the guidelines to determine the •Published guidelines applicability to your institution’s cardiac surgery population •Pocket guide • Identify a change champion and key team members •Course book •Listserve • Get approval Medical Executive Committee • Web •Not currently a course in the USA •Create written approved internal protocols for management of cardiac •csu-als.com surgery arrest patients •Youtube • Attend CALS-S or create your own •www.lulu.com • Practice • Other Herrmcnn, C. Cardiac Advanced Life Support-Surgical Guideline. AACN Advanced Critical Care 2014: 26 (2). • Assess Rhythm • Shock before Compressions • Pace/Atropine –not Epi • Identify reversible causes • Early resternotomy Conquering Complications: Cheryl Herrmann, APN, CCNS-CSC-CMC 8 3/29/2014 Trauma Triad of Death Coagulopathy Death Hypothermia Acidosis Decreased myocardial performance Cardiac Surgery Hypoperfusion Starts Triad of Disaster the Triad of Disaster Coagulopathy Coagulopathy (cid:1)LOS (cid:1)LOS Complications Complications Hypothermia Death Metabolic Hypothermia Death Metabolic Acidosis Acidosis Decreased myocardial performance Decreased myocardial performance Hypoperfusion Starts Cardiac Surgery the Triad of Disaster Triad of Disaster Coagulopathy Coagulopathy (cid:1)LOS (cid:1)LOS Complications Complications Hypothermia Death Metabolic Hypothermia Death Metabolic Acidosis Acidosis Decreased myocardial performance Decreased myocardial performance 9 3/29/2014 Hypothermia Causes of Heat Loss ♥ Cooled during CPB ♥ Cold OR room ♥ Cool room and/or fan on ♥ Cold fluids • 1 unit of pRBC can lower body Temp 0.25o C • 1 liter of fluids unit can lower body Temp 0.5o C ♥ No blankets ♥ Head uncovered Ugly consequences of hypothermia Causes of Heat Loss 1. Increased oxygen debt • Cold hemoglobin can not release oxygen to the cells ♥ Cooled during CPB 2. •IncrLeeafst sehdi ftla ocft tich ea ocxidy hpermodougclotbioinn dissociation curve ♥ Cold OR room • Change from aerobic to anaerobic metabolism • Leads to acidosis ♥ Cool room and/or fan on 3. Coagulopathy ♥ Cold fluids • Prolonged clotting cascade • Platelet dysfunction –platelets are extremely temperature dependent • 1 unit of pRBC can lower body Temp 0.25o C • Altered fibrinolytic system • 1 liter of fluids unit can lower body Temp 0.5o C 4. •AlteDreedc recaasrdeido cvaarsdciaucla oru ftupnucttion ♥ No blankets • Risk of arrhythmias • Increased SVR due to vasocontriction ♥ Head uncovered 5. Hyperglycemia • Decrease insulin production 6. Decreased cerebral blood flow • 6 –7% decrease in CBF with body temp decrease of 10C Cardiac Surgery Rewarming techniques Triad of Disaster Coagulopathy ♥ Warm room –no fan ♥ Warm blankets –keep patient covered ♥ Bare Hugger ♥ Use blood warmer to give blood products • Have blood warmer and bare hugger in room (cid:1)LOS Complications Metabolic Hypothermia Death Acidosis Decreased myocardial performance 10