Cover

Cardiac Arrest After

Cardiac Surgery:
An Evidence-Based
Resuscitation Protocol
Patrick Michaelis, BSN, RN
Richard J. Leone, MD, PhD

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 cardio-
vascular life support guidelines. European Resuscitation Council guidelines include correcting reversible
causes of arrest, applying defibrillation/pacing before external cardiopulmonary resuscitation, resternot-
omy within 5 minutes if electrical therapies fail, and restricting epinephrine use to avoid rebound hyper-
tension. 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. (Critical Care Nurse. 2019;39[1]:15-25)

A
ccording to the Society of Thoracic Surgeons (STS), 286 149 adult cardiac surgical procedures
were performed in the United States in 2015,1 including coronary artery bypass grafts, heart
valve replacements, heart valve repairs, and combined procedures.1 Since 1998, postoperative
cardiac arrest rates have ranged from 0.7% to 5.2%.2-7 Most cardiac arrests occur within the first 24 hours
after skin closure, and up to half of cardiac arrests occur within the first 3 postoperative hours.2,8

CE 1.0 hour, CERP A

This article has been designated for CE contact hour(s). The evaluation tests your knowledge of the following objectives:
1. Explain the rationale for defibrillation of ventricular fibrillation and ventricular tachycardia before initiation of cardiopulmonary resuscitation
2. Differentiate the restricted use of epinephrine in cardiac arrest after cardiac surgery from advanced cardiovascular life support–dosed epinephrine
administration in other cardiac arrest situations
3. Describe the 6 key team roles for clinical staff treating patients who are experiencing cardiac arrest after cardiac surgery
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 Cardiac arrest after cardiac surgery presents unique
challenges and opportunities that are not addressed by
the current advanced cardiovascular life support (ACLS)
algorithms. Some of the standard interventions (eg,
immediate cardiopulmonary resuscitation [CPR] and
aggressive vasopressor therapy) may even be harmful.
Before 2009, expert opinions for resuscitating cardiac
surgery patients emphasized CPR and resternotomy.
Investigators concluded, perhaps unsurprisingly, that
early CPR is associated with better survival than is
delayed CPR, brief CPR is preferable to prolonged CPR,
and early resternotomy yields better outcomes than
does delayed resternotomy.
Evidence-Based Guidelines
To review the current evidence for resuscitation of
cardiac arrest after cardiac surgery, we searched the
MEDLINE database with the PubMed search engine.
Key words were cardiac surgery, cardiac arrest, cardiac arrest
after cardiac surgery, resuscitation, defibrillation, epinephrine
in cardiac arrest, and guidelines. We identified 22 relevant
studies and also searched their reference lists along with
reviews, editorials, and resuscitation guidelines.
The seminal 2009 study by Dunning et al9 provided
a systematic, evidence-based approach to resuscitating
cardiac arrest after cardiac surgery. The European Resus-
citation Council (ERC) incorporated Dunning’s recom-
menda-
If available within 1 minute, defibrillation tions into
should be performed before CPR in VF its 2010
and pulseless VT arrests. guidelines
for resusci-
tation, which were updated in 2015 and are now the
standard of care in most European countries.10,11 In 2012,
the European Association for Cardio-Thoracic Surgery
(EACTS) integrated the ERC guidelines into the Cardiac
Surgery Advanced Life Support course, now the Cardiac
Surgical Unit Advanced Life Support (CSU-ALS) course,
which uses best evidence to train clinicians in the resus-
citation of cardiac arrest in postoperative cardiac surgery
Authors
Patrick Michaelis is a private consultant in Bellingham, Washington.
Richard Leone is a cardiothoracic surgeon, Skagit Regional Health, Mount Vernon, and Kadlec Regional Medical Center, Richland, Washington.
Corresponding author: Patrick Michaelis, BSN, RN, 594 Summit Place, Sedro Woolleey, WA 98284 (email: p.michaelis@me.com).
To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or
(949) 362-2050 (ext 532); fax, (949) 362-2049; email, reprints@aacn.org.
16 CriticalCareNurse Vol 39, No. 1, FEBRUARY 2019
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patients.12 In 2015, Ley13 published standards for resus-
citating patients after cardiac surgical procedures.
In 2017 the STS published an expert consensus arti-
cle on resuscitating patients who experience cardiac
arrest after cardiac operations.14 The consensus article is
derived from the 2016 STS/EACTS protocol that distilled
the current evidence into a set of guidelines for manag-
ing cardiac arrest and prearrest after cardiac surgery. It
begins with the premise that CPR is ineffective in patients
with tamponade, hemorrhagic hypovolemia, or tension
pneumothorax. Tamponade and hemorrhage are 2 com-
mon causes of arrest after cardiac surgery. Without
immediate resternotomy, patients with these conditions
experience critically inadequate cerebral perfusion. Ten-
sion pneumothorax is usually treated with needle or
tube thoracostomy, but if this condition is present but
unrecognized, resternotomy will also decompress the
chest and potentially restore a pulse.
Patients who have undergone cardiac surgical proce-
dures are clearly differentiated from all others who expe-
rience cardiac arrest. Key STS/EACTS recommendations
include the following: apply defibrillation and pacing before
CPR if these modalities are available within 1 minute,
perform resternotomy within 5 minutes if electrical ther-
apies fail or are not indicated, use CPR as a bridge to rapid
resternotomy, establish 6 key roles on the resuscitation
team, and restrict the use of epinephrine.14 In contrast, the
American Heart Association has yet to differentiate the
cardiac surgery patient subset from the general popula-
tion in its ACLS algorithms. The STS/EACTS protocol is
now the standard of care in the United States for cardiac
arrest after cardiac surgery. Table 1 shows ERC/STS/
EACTS modifications to the ACLS universal algorithm.
The ACLS and CSU-ALS approaches to resuscitation
of postoperative cardiac surgery patients are quite differ-
ent. The ACLS algorithms tend to focus on people who
experience arrest outside the hospital and are resusci-
tated by bystanders or first responders who initiate CPR,
use automated external defibrillators, and administer
drugs recommended by ACLS, if available. The CSU-ALS
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 Table 1 Modifications to the Advanced Cardio-
vascular Life Support universal cardiac arrest
algorithm recommended by the European
Resuscitation Council, European Association
for Cardio-Thoracic Surgery, and Society of
Thoracic Surgeons for cardiac arrest occurring
after cardiac surgical procedures
Atropine is removed from the algorithm.
VF/pVT: Administer 3 shocks before CPR.
VF/pVT: Perform resternotomy after third shock.
Pulseless electrical activity: Perform resternotomy within 5
minutes.
Routine administration of epinephrine is not recommended.
Abbreviations: CPR, cardiopulmonary resuscitation; pVT: pulseless ventricular
tachycardia; VF, ventricular fibrillation.
guidelines address postoperative cardiac surgery
patients who experience a witnessed arrest in the hospi-
tal and are resuscitated by experienced clinicians who
apply defibrillation or pacing immediately and can
administer CPR and rapid resternotomy if needed.
These patients are often intubated and highly moni-
tored. Clinicians have a wide range of treatment options.
Emergency resternotomy is a standard component of the
resuscitation protocol. The protocol does not recom-
mend administering epinephrine at the ACLS dose.
Characteristics of Cardiac Arrest After
Cardiac Surgical Procedures
Ngaage and Cowen8 studied 7209 patients who
underwent coronary artery bypass grafting or aortic
valve replacement between April 1999 and June 2008.
One hundred eight patients experienced cardiorespira-
tory arrest. Eighty-six of these patients experienced car-
diac arrest only, an overall cardiac arrest rate of 1.2%.
Perioperative myocardial infarction accounted for approx-
imately one-half of the arrests, and surgical problems
(tamponade and hemorrhage) caused almost one-fourth.8
Although postoperative myocardial infarction is a rela-
tively rare complication of cardiac surgery, it is a frequent
cause of perioperative cardiac arrest (Figure 1).
Arrhythmia rates vary from study to study. Ngaage
and Cowen8 described the frequency with which each
of the major disturbances of electrical rhythm occur.
Ventricular fibrillation (VF) or ventricular tachycardia
(VT) accounted for 70% of the cardiac arrests in patients
in their study. Asystole caused 17% of the cardiac arrests.
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12%
5%
6%
53%
24%
Myocardial infarction Tamponade/hemorrhage
Hypokalemia Complete heart block
Unknown
Figure 1 Causes of cardiac arrest after cardiac
surgical procedures.
Pulseless electrical activity (PEA) occurred in 13% of
the cardiac arrests.8
When defibrillation is performed immediately, patients
with VF and pulseless VT (pVT) have a high rate of sur-
vival. In patients who experience out-of-hospital arrests,
asystole carries a dismal prognosis, but in postoperative
cardiac surgery patients, asystole can often be corrected
by temporary cardiac pacing. In postoperative cardiac
surgery patients, PEA is often caused by tamponade or
hemorrhage. Rapid resternotomy can decompress the
heart and great vessels, restoring spontaneous circula-
tion while revealing the underlying problem.
If the electrocardiogram (ECG) and pressure waveforms
are incompatible with viable cardiac output, for example
during VF or asystole, the arrest protocol can be initiated
without first checking a pulse. If the waveforms suggest
perfusion but cardiac arrest is suspected, briefly palpate a
carotid or femoral pulse while comparing the ECG tracings
to pressure waveforms. In cardiac arrest, all waveforms,
including those for arterial pressure, central venous pres-
sure, pulmonary artery pressure, pulse oximetry, and
end-tidal carbon dioxide, eventually become nonpulsatile.
An ECG trace showing a sinus rhythm at a reasonable
rate (approximately 50 to 120/min) in the absence of
CriticalCareNurse Vol 39, No. 1, FEBRUARY 2019 17
 CARDIAC ARREST

assess rhythm

ventricular asystole or
severe pulseless
fibrillation or electrical
tachycardia bradycardia
activity
DC shock pace
(3 attempts) (if wires
available)

start basic life support

amiodarone if paced, turn

consider off pacing to
300mg
external exclude
via central
pacing underlying VF
venous line

prepare for emergency resternotomy

continue CPR with

continue CPR continue CPR
single DC shock
until until
every 2 minutes until
resternotomy resternotomy
resternotomy

airway and ventilation

• If ventilated turn Fio2 to 100% and switch off PEEP.
• Change to bag/valve with 100% O2, verify ET tube position and cuff inflation
and listen for breath sounds bilaterally to exclude a pneumothorax or haemothorax.
• If tension pneumothorax suspected, immediately place large bore cannula in the
2nd rib space anterior mid-clavicular line.
DO NOT GIVE ADRENALINE unless a senior doctor advises this.
If an IABP is in place change to pressure trigger.
Do not delay basic life support for defibrillation or pacing for more than one minute.

Figure 2 The STS/EACTS protocol for treating cardiac arrest after cardiac surgical procedures. This
protocol stops after resternotomy.
Abbreviations: CPR, cardiopulmonary resuscitation; ET, endotracheal tube; Fio2, fraction of inspired oxygen; IABP, intra-aortic balloon pump; O2, oxygen; PEEP,
positive end-expiratory pressure.
Reprinted with permission from The Annals of Thoracic Surgery.14

pulsatile pressure waveforms should be considered a
cardiac arrest (ie, PEA). Early identification and correc-
tion of reversible problems can eliminate the need for
resuscitation. Endotracheal tube malposition, intravenous
infusion errors, and tension pneumothorax should be
ruled out during every patient assessment. Figure 2 shows
the STS/EACTS protocol for cardiac arrest in patients
after cardiac surgery.
The interval between cardiac arrest and resuscitation
is one of the strongest predictors of survival. Early

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resuscitation yields the best outcomes. In 2002, Weis-
feldt and Becker15 proposed a 3-phase, time-sensitive
model of cardiac arrest and indicated the most effective
therapy during each phase. In 2006, Gilmore et al16
found that although CPR offers no benefit over defibril-
lation during the first 5 minutes of cardiac arrest, CPR
is of considerable benefit between 5 and 15 minutes
after arrest begins.
1. Electrical phase (0 to 5 minutes after onset of arrest):
During this phase the body still has oxygenated blood,
and immediate defibrillation or pacing yields a higher
survival rate than does CPR. However, if electrical thera-
pies either fail or are not indicated (as in patients with
PEA), CPR should be initiated immediately and the resus-
citation team should prepare for rapid resternotomy.
2. Circulatory phase (5 to 15 minutes after onset of
arrest): CPR is important during this phase because it
restores oxygenated blood to the vital organs. After car-
diac surgical procedures, the main role of CPR is to sup-
port circulation as a bridge to resternotomy. The early
onset of the circulatory phase underscores the impor-
tance of resternotomy within 5 minutes.
3. Metabolic phase (more than 15 minutes after onset
of arrest): Therapy, at least the type that is supported by
current science, may be less effective during this phase
because of cellular damage. The intra-aortic balloon pump
is an effective first-line treatment. Mechanical circulatory
support can provide myocardial salvage while ensuring
adequate circulation and protecting end organs. Extra-
corporeal membrane oxygenation may be employed to
support the heart and lungs during periods of cardio-
genic shock and poor oxygenation even in the presence
of mechanical ventilation. A left ventricular assist device
can help off-load the left ventricle. Induced hypothermia
may also be of benefit during this phase. Figure 3 This stand-alone defibrillator configu-
ration provides a stable platform and a small
Management of Arrhythmias During bedside footprint.
Cardiac Arrest After Cardiac Surgery
In VF or pVT, up to 3 stacked shocks, if available Early defibrillation is crucial. In an observational study
within 1 minute, should be administered before CPR of a mixed population of 6789 inpatients with cardiac
and resternotomy are performed.17,18 A dedicated, bed- arrest due to VF or pVT, defibrillation within 2 minutes
side, stand-alone defibrillator facilitates delivery of the resulted in a return of spontaneous circulation in 66.7%
first shock within 1 minute (Figure 3). After 3 failed of patients, and 39.3% of patients survived to hospital
attempts at defibrillation, CPR should be initiated, a discharge. When defibrillation occurred more than 2
bolus of 300 mg of amiodarone should be given through minutes after arrest, the rate of return of spontaneous
a central catheter, and resternotomy should be performed circulation dropped to 49.0%, and 22.2% of patients sur-
within 5 minutes.14 vived to hospital discharge.17

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 In 2007, Richardson et al18 constructed a best evidence
topic according to a structured protocol. The authors
investigated the number of defibrillation attempts that
should be made before reopening the chest in postop-
erative cardiac surgery patients who experience cardiac
arrest. The authors identified 1183 relevant articles and
selected 15 as best evidence on the subject. These studies
demonstrated that the first shock in patients with VF
or VT had a success rate of about 78%; the second shock,
about 35%; the third shock, about 14%. No significant
benefit was seen after a fourth shock. The combined
defibrillation success rate of the 3 shocks was around
88%. Almost 9 of 10 patients successfully regained
spontaneous circulation through defibrillation.18 The
unfortunate 10th patient became a candidate for rapid
resternotomy, with CPR bridging the interval between
defibrillation and chest reopening.
In asystole or severe bradycardia, cardiac pacing, if
available within 1 minute, should be administered before
CPR and resternotomy are performed. Transcutaneous
pacing may be implemented before CPR, but only if it is
available within 1 minute. With transcutaneous pacing,
assess sedation needs. If pacing attempts are unsuccess-
ful, CPR should be initiated and resternotomy should
be performed within 5 minutes (Table 2).
After cardiac surgical procedures, asystole is usually
an electrical—rather than a metabolic—problem. For
example, sinus arrest, sinus exit block, or atrioventricular
block in the absence of viable escape rhythms can cause
ventricular asystole, which can often be corrected by epi-
cardial or transcutaneous pacing. Bradycardia usually
responds well to artificial cardiac pacing. Atropine has
not been shown to improve outcomes in cardiac surgery
patients with asystole or severe bradycardia, and its
administration may delay resternotomy. Therefore, the
STS/EACTS protocol states that atropine should not be
a routine part of the resuscitation protocol for cardiac
surgery patients.14
If PEA is present, initiate CPR immediately while pre-
paring for emergency resternotomy. The STS/EACTS
protocol recommends that emergency resternotomy be
performed within 5 minutes in a patient with arrest that
is not caused by VF or VT and does not resolve after pacing
and exclusion of readily reversible causes. Resternotomy
is mandatory if external CPR does not generate a systolic
pressure of at least 60 mm Hg. If CPR consistently main-
tains a systolic pressure above 60 mm Hg, resternotomy
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Table 2 Cardiac pacing settings for patients
in arrest
Epicardial pacing within 1 minute of arrest
DDD mode
Maximum atrial and ventriuclar outputs
80/min to 100/min
Transcutaneous pacing within 1 minute of arrest (alternative:
initiate cardiopulmonary resuscitation until transcutaneous
pacing is available and prepare for resternotomy)
1:1 capture
80/min to 100/min
may be deferred beyond 5 minutes if necessary.14 Exter-
nal CPR usually generates a cardiac index of around
0.6 L/min per square meter.19 If the external cardiac pace-
maker is connected and functioning before the arrest,
consider turning the pacemaker off briefly to exclude
underlying VF: pacing spikes may mimic narrow ven-
tricular complexes on the ECG.
In patients who experience cardiac arrests in which
defibrillation and pacing are not indicated, potential causes
of PEA should be assessed. In patients undergoing non-
cardiac surgical procedures, arrests due to PEA are associ-
ated with poor outcomes. In contrast, PEA arrest after
cardiac surgery is likely due to tension pneumothorax, tam-
ponade, or hemorrhage. Prompt decompression of tension
pneumothorax and rapid resternotomy to treat tamponade
and hemorrhage are associated with excellent outcomes.
Reversible causes of hypoxia were most likely addressed
during the patient’s routine care. Acidosis (hydrogen ions),
hyperkalemia, and hypokalemia are unlikely causes of
PEA because serum pH and potassium are carefully moni-
tored after a surgical procedure. Hypothermia is also
unlikely to cause cardiac arrest, but if hypothermia occurs,
active rewarming is recommended instead of the passive
rewarming that would have already been implemented
in the intensive care unit.
Similarly, PEA due to drug effects (toxins) is unusual,
but the STS/EACTS protocol recommends ceasing all
drug infusions unless a specific drug is suspected as the
causative agent. Thromboembolic or mechanical obstruc-
tion (eg, pulmonary embolus, coronary thrombosis, or
valve obstruction) is difficult to treat without resternot-
omy and cardiopulmonary bypass.
In patients with PEA or ventricular arrest during
epicardial pacing, ECG traces are either absent or highly
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variable and are subject to chest compression artifact,
rendering the ECG unreliable as a trigger for an intra-
aortic balloon pump. The intra-aortic balloon pump
trigger should be changed to pressure mode at a fre-
quency of 1:1 and at maximal augmentation. These set-
tings allow cardiac massage to be intensified without
interference from the ECG trace and may improve mean
blood pressure and coronary artery perfusion. If cardiac
massage is interrupted for a significant period, trigger-
ing should be changed to an internal mode at 100/min
until massage is restarted.14
Epinephrine and Infusions
When cardiac arrest occurs shortly after a surgical
procedure, defibrillation, pacing, and/or rapid rester-
notomy can restore spontaneous circulation. In these
situations, epinephrine can be dangerous. Consider a
hypothetical 70-year-old patient who experiences cardiac
arrest 1 hour after 3-vessel coronary artery bypass graft-
ing. The patient’s cardiac rhythm is PEA. Cardiopulmo-
nary resuscitation is initiated and, according to ACLS
guidelines, 1 mg of epinephrine is administered. The
surgeon performs emergency resternotomy and relieves
the causative tamponade. Spontaneous circulation is
restored but unfortunately the patient’s blood pressure
rapidly rises to 300/150 mm Hg because of the epineph-
rine. Several of the proximal graft anastomosis sutures
fail, and the patient hemorrhages. After resuscitating
the patient, repairing the anastomoses, and restoring
circulating volume, the surgeon wonders what possible
benefit epinephrine has bestowed.
Epinephrine was introduced as a treatment for car-
diac arrest before clinical trials were common. A grow-
ing body of evidence suggests that epinephrine may
not be effective and that it may even be harmful. Many
research studies suggest that although epinephrine
may restart the heart initially, it may also lower overall
survival rates and increase brain damage. There are
real concerns among clinicians and researchers that the
current practice may be harming patients. After analyz-
ing 889 studies (16 of which were identified as best evi-
dence), Tsagkataki et al20 wrote: “We recommend that 1 mg
of adrenaline forms no part of the resuscitation protocol
for patients who arrest after cardiac surgery.”
In patients in whom arrest is impending, epinephrine
may provide a benefit if given in smaller boluses (eg,
50-300 µg). These small boluses may provide circulatory
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support while identifying patients with inotrope-responsive
conditions. A positive hemodynamic response suggests a
medical problem (eg, low-output states resulting from
poor baseline function). Absence of hemodynamic
response suggests a surgical problem (eg, tamponade).
However, epinephrine should not be included in the
resuscitation protocol and should be given only if ordered
by an experienced clinician.
In PARAMEDIC2, a prospective, randomized, double-
blind, controlled trial, researchers investigated epineph-
rine for the treatment of out-of-hospital cardiac arrest.21
A total of 8014 patients were enrolled in the study and
received either epinephrine (4015 patients) or a saline
placebo (3999 patients). The primary outcome was the
30-day survival rate; the secondary outcome was survival
to hospital discharge with a modified Rankin scale score
of 3 or less, where 0 is associated with no symptoms,
and 6 represents death. At 30 days, 130 patients (3.2%)
in the epinephrine group and 94 patients (2.4%) in the
placebo group were alive. However, of the survivors to
hospital
discharge,
the epi- Epinephrine should not be included in the
nephrine resuscitation protocol and should be given
group only if ordered by an experienced clinician.
included
significantly more patients with severe neurological
impairment: 39 of 126 patients (31.0%) versus 16 of 90
patients (17.8%).21
Some unpublished anecdotal reports describe post-
operative cardiac arrest due to drug administration.
Another potential drug-related cause of cardiac arrest is
flushing a vasodilator or residual drug through a central
catheter. Continued infusion of a drug that was initiated
before the arrest is unlikely to assist the resuscitation
effort. Many sedatives and anesthetics are vasodilators,
and stopping these infusions in patients with low cere-
bral perfusion is thought unlikely to cause awareness.
The STS/EACTS protocol recommends that all existing
infusions be discontinued in patients experiencing car-
diac arrest. Sedative infusions may be continued if patient
awareness is a concern. Infusions can be restarted if
ordered by a senior clinician.14
Key Staff Roles
The STS/EACTS protocol identifies 6 key roles for
clinical staff treating patients who are experiencing
Vol 39, No. 1, FEBRUARY 2019 21
cardiac arrest after cardiac surgery. These roles should
be regularly rehearsed. Additional roles (eg, scribe,
equipment runner, or crowd controller) may be added to
this team if desired.
1. External CPR: After cardiac arrest has been identi-
fied and electrical therapies either have failed or are not
indicated, the team member in charge of CPR immedi-
ately begins external cardiac massage. Cardiac massage
should be performed at a rate of 100/min to 120 beats/
min with zero pressure on the chest between compres-
sions. During external cardiac massage, the arterial pres-
sure waveform should be monitored. The target systolic
pressure is at least 60 mm Hg. If CPR is being per-
formed correctly but the systolic pressure is less than 60
mm Hg, the team leader should be notified at once
because this scenario suggests a surgical problem (eg,
tamponade or hemorrhage).
2. Airway and breathing: The team member respon-
sible for the patient’s airway increases the fraction of
inspired oxygen to 100%, discontinues positive end-
expiratory pressure, and assesses tracheal position and
lung sounds to exclude pneumothorax and hemothorax.
If the patient is intubated, this team member connects
the bag/valve to the endotracheal tube and performs
ventilation at 6 or more breaths per minute.
3. Defibrillation and pacing: This person provides
electrical therapies including defibrillation, cardiac pac-
ing, and management of the internal defibrillator. In
patients with VF or pVT, 3 stacked shocks are delivered
before CPR is begun if defibrillation if available within 1
minute. Upon resternotomy, this team member converts
the defibrillator to deliver internal defibrillation at an
initial setting of 20 J or as ordered by the senior clini-
cian. Conversion may involve disconnecting the external
defibrillation cable and attaching an internal defibrilla-
tion cable that connects to the internal paddles. Because
the internal paddles are in direct contact with heart tis-
sue, this cable is typically modified to limit maximum
output to a predetermined level (eg, 50 J). If epicardial
pacing is employed, the pacemaker is briefly turned off
to assess for underlying VF. In patients with asystole or
severe bradycardia, epicardial pacing is initiated if it is
available within 1 minute. Transcutaneous pacing may
also be used (Table 2).
4. Team leader: The team leader is a senior staff
member in overall charge of the resuscitation, making
sure the team follows the protocol and that a team
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member is assigned to each role. The leader also ensures
that team members prepare for rapid resternotomy.
The team leader focuses on the clinical aspects of
the resuscitation.
5. Drug administration: This team member discon-
tinues all intravenous drug infusions if initial resuscita-
tion efforts are unsuccessful, administers amiodarone
if indicated, and manages other drugs and infusions as
appropriate. Supplemental drug therapy may be imple-
mented at the discretion of the team leader. The only
drug included in the protocol is 300 mg amiodarone
intravenously to treat patients who experience VF or
pVT. Epinephrine is not given unless a senior clinician
requests it. If epinephrine is ordered, the dose should
be reduced (eg, 50-300 µg intravenous boluses).
6. Intensive care unit coordinator: This team member
is usually a charge nurse or senior nursing unit leader
who manages activities other than those at the bedside
and reports progress to the team leader. This role
includes planning for resternotomy when arrest is iden-
tified, directing team members, and requesting expert
help when needed. The intensive care unit coordinator
focuses on the operational aspects of the resuscitation.
In addition to these 6 team members, a resternotomy
team should also immediately don gowns and gloves in
preparation for emergency resternotomy. The STS/
EACTS protocol does not recommend washing hands
before gloving because time is of the essence and glov-
ing over damp hands is difficult. The resternotomy team
should assemble as soon as the arrest is identified instead
of waiting until initial resuscitation attempts are unsuc-
cessful. This team should be ready to perform a rester-
notomy within 5 minutes of arrest.
Group simulation training for implementing these 6
key functions should be regularly conducted. This edu-
cation should be reinforced in the units through regular
open-chest code drills on all shifts. The protocol can be
initially presented in a classroom where participants
learn the protocol, key roles, and supporting evidence.
They also become familiar with the open-chest code cart,
sterile-instrument tray, internal defibrillation paddles,
epicardial pacemaker, and stand-alone defibrillator. If
time allows, participants can practice sterile gowning
and gloving, which can be reinforced in the units by at-the-
elbow return demonstrations. Additional resources are
available at the Cardiac Surgery Advanced Life Support
website (https://www.csu-als.com).
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Emergency Resternotomy
The usual end point in the resuscitation of cardiac
arrest after cardiac surgery is either the return of
spontaneous circulation or resternotomy. In patients
with tamponade, hemorrhage, or undetected tension
pneumothorax, resternotomy can decompress the chest
and restore a pulse while the surgeon addresses the
underlying abnormalities. Compared with CPR, internal
cardiac massage is associated with better coronary per-
fusion pressure, increased return of spontaneous cir-
culation, superior organ blood flow, and better survival
rates. Internal cardiac massage usually generates a car-
diac index of around 1.3 L/min per square meter.19
Resternotomy consists of 2 stages: access and man-
agement. During the access stage, the chest is opened,
the thoracic compartment is decompressed, and the
surgical field is exposed. The STS/EACTS protocol does
not recommend the application of a skin preparation
solution if a single, full-bed, sterile drape with an opera-
tive plastic window is used. None of these solutions dry
immediately, yet drying is their antimicrobial mode of
action. Emergency resternotomy is best accomplished
by using a dedicated emergency resternotomy set con-
taining a scalpel, a wire cutter, a heavy needle holder, a
single-piece sternal retractor, and a sterile suction can-
nula (Figure 4). Resternotomy is often enough to restore
a viable pulse while underlying problems are addressed.
The management stage addresses resuscitation and
surgical issues. Operative principles include relief of
tamponade, hemorrhage control, restoration of circulat-
ing volume, and circulatory support. Operative interven-
tions include internal defibrillation, internal cardiac
massage, epicardial pacing, correction of vascular abnor-
malities, initiation of cardiopulmonary bypass, intra-
aortic balloon counterpulsation, and mechanical
circulatory support.
Although resternotomy is a critical element of resus-
citation, by postoperative day 10 the chance of cardiac
arrest resulting from a resternotomy-correctable cause
is reduced. After day 10, the benefits of resternotomy
must be weighed against the risk of pericardial adhe-
sions having developed. Routine resternotomy is not
recommended after day 10, but the physician may elect
to open the chest if delayed tamponade due to pacing
wire removal or anticoagulant issues is suspected or if
resternotomy and internal cardiac massage are deemed
preferable to prolonged external CPR.8 If spontaneous
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Downloaded from http://ccn.aacnjournals.org/ by AACN on June 30, 2019
Figure 4 This resternotomy set contains a scal-
pel, a wire cutter, a heavy needle holder, a single-
piece sternal retractor, and a sterile suction
cannula. A single, full-bed, sterile drape with an
operative plastic window may also be used.
circulation is restored, implement the ACLS guidelines
for immediate post–cardiac arrest care.22
Outcomes of Protocol-Driven
Management of Cardiac Arrest
In 2009, Ngaage and Cowen8 reported a resternotomy
rate of 52% in 108 patients experiencing cardiorespira-
tory arrest after cardiac surgical procedures over a 9-year
study period. The rate of survival to hospital discharge
was 50%, consistent with the findings of other studies
in which survival rates varied between 30% and 56%.3-6
Resuscitation was based on the Advanced Trauma Life
Support protocol. When external CPR failed to restore
spontaneous circulation or when an anatomic defect
was suspected, resternotomy was performed. Ventricular
fibrillation and VT were present in 70% of patients who
experienced cardiac arrests, but early defibrillation was
not mentioned as part of the resuscitation protocol. Of
note, this study was published before the release of the
2010 ERC guidelines.
In 2013, Maccaroni et al23 published the results of a
5-year evolving approach to resternotomy in patients
who experienced cardiac arrest after cardiac surgery.
The primary outcome measure was survival to hospital
discharge. The secondary outcome measure was the
trend in emergency resuscitative resternotomy. During
the first 2 years (2008-2009), conventional resuscitation
CriticalCareNurse Vol 39, No. 1, FEBRUARY 2019 23
 practices were implemented. During that period, senior
nursing staff, trainee physicians, consultant surgeons,
and anesthetists attended the Cardiac Surgery Advanced
Life Support course. This training was then cascaded
and adopted as routine practice. All ward staff completed
the training and participated in ongoing simulation train-
ing. During the subsequent 3 years (2010-2012), protocol-
based resuscitation procedures were employed. These
procedures
Group simulation training for the 6 key included
roles for clinical staff treating patients immediate
who are experiencing cardiac arrest defibrillation
should be regularly conducted. with up to 3
stacked
shocks, immediate cardiac pacing if wires were available,
early resternotomy, implementation of the 6 key roles, and
epinephrine use restricted to smaller doses if used at all.
Survival to hospital discharge increased from 36.3%
in the first 2 years to 63.8% in the subsequent 3 years,
and the resternotomy rate dropped from 66.7% to 47.3%.
The authors concluded that bringing practice in line
with the guidelines and training the staff increase aware-
ness and empower staff members to better manage
arrest and prearrest situations. Implementing the guide-
lines may have affected survival to hospital discharge
and resternotomy rates because of improved management
of cardiac arrests, prearrests, and clinical deterioration.23
In 2015, Ley and colleagues24 reported the significance
of the organizational response to cardiac arrest after
cardiac surgical procedures. A review of the literature
revealed that individual hospitals, but not patient risk
profiles or individual surgeons, were strongly associated
with mortality. The authors studied the incidence and
outcomes of cardiac arrest after cardiac surgical proce-
dures at their medical center over an 8-year period during
which the ERC protocol was implemented. During the
4 years after implementation, the cardiac arrest rate fell
from 3.4% (31 of 900 patients) to 2.9% (26 of 907 patients),
and mortality fell from 64.5% to 34.6%.24 These results
suggest that after training, hospital staff members were
better able to recognize and correct prearrest clinical
deterioration and were more successful in conducting
resuscitations after cardiac arrest.
The findings of these studies are strong arguments
in support of the benefits of a protocol-driven response
to cardiac arrest in patients who have undergone cardiac
surgical procedures. Hospitals that have implemented
24 CriticalCareNurse Vol 39, No. 1, FEBRUARY 2019
Downloaded from http://ccn.aacnjournals.org/ by AACN on June 30, 2019
the ERC guidelines have reported decreased arrest rates,
decreased resternotomy rates, and improved survival rates.
Conclusion
Cardiac arrest after a cardiac surgical procedure is a
unique event in which implementation of the standard
ACLS guidelines may cause harm. The STS/EACTS pro-
tocol and the STS consensus paper apply the available
evidence and describe resuscitation guidelines specific
to this patient population. Adherence to the protocol
has been shown to improve outcomes. CCN
Financial Disclosures
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See also
To learn more about cardiac arrest in the critical care setting, read
“Improving Providers’ Role Definitions to Decrease Overcrowding
and Improve In-Hospital Cardiac Arrest Response” by Leary et al in
the American Journal of Critical Care, July 2016;25:335-339. Available
at www.ajcconline.org.
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Cardiac Arrest After Cardiac Surgery: An Evidence-Based Resuscitation Protocol
Patrick Michaelis and Richard J. Leone
Crit Care Nurse 2019;39 15-25 10.4037/ccn2019309
©2019 American Association of Critical-Care Nurses
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