Mr Joel Dunning tag:blogs.ctsnet.org,2007:/joeldunning//18 2007-12-21T23:37:00Z I am a Cardiac Surgery registrar in Middlesbrough in the UK. I feel that we should have a protocol for the resuscitation of patients who arrest in the Cardiac Intensive care unit, written by our own specialty. Together with some enthusiastic colleagues we have been running a course incorporating our ideas on this subject and now I would like your help to tell me how you think that we should run cardiac arrests in our intensive care units Movable Type 3.2 Resuscitation after Cardiac Surgery tag:blogs.ctsnet.org,2007:/joeldunning//18.111 2007-12-21T21:13:12Z 2007-12-21T23:37:00Z Welcome to this Blog which I am hoping to use to tell you about the progress of a guideline for resuscitation after Cardiac Surgery. International resuscitation guidelines changed in 2005 for all specialties, but cardiac surgery essentially 'missed out' from being considered as a 'special' case, despite the fact that we have the highest success rate for survival following an arrest. There are a very large number of special considerations... Joel Dunning http://www.ctsnet.org/home/joeldunning Welcome to this Blog which I am hoping to use to tell you about the progress of a guideline for resuscitation after Cardiac Surgery.
International resuscitation guidelines changed in 2005 for all specialties, but cardiac surgery essentially 'missed out' from being considered as a 'special' case, despite the fact that we have the highest success rate for survival following an arrest.
There are a very large number of special considerations after cardiac surgery and thus I feel that it is not acceptable to use guidelines that are not specifically tailored to our patients in the cardiac intensive care.
I would like us all as a specialty to write our own guidelines on this subject. I would also like the writing of these guidelines to be very different, as I think that rather than having an 'expert group' telling the speciality how to run arrests, we all need to get together and listen to everyones views on this important subject to create a workable guideline that we can all use.

As a first step, CTSNET has worked hard to provide a questionnaire on this subject so that we can hear your views and how you would like arrests to be conducted.
CTSNET would be very grateful if you could spend a few minutes to complete the survery.

You can find it here : http://www.ctsnet.org/announcements/announcement666.html

I stress that this is a first step. We hope to engage our representative bodies to endorse these guidelines but they will need input from you at every stage as published papers will be of very limited use to them and it is your views that they will need to write a workeable guideline. Thus if you give us your E-mail at the end of the survey we will keep you up to date with the current thinking and the 'hot topics' that are causing controversy in creating the guideline.

BACKGROUND

In 2002, I was a junior doctor in a Cardiac Surgical Unit. The year before however I was a medical junior doctor and was proud of the way that I could be called to a cardiac arrest in a medical ward, perform my role perfectly... and if the worst outcome occurred and the patient died, I was still proud of the way that I had performed my role exactly as trained and walked off pleased that I had intubated or defibrillated well.

However when I came to Cardiac Surgery, my first arrest was mayhem ! I had no idea what to do and when the consultant surgeon took over, the staff behind him were not organised and everyone found this to be a very stressful situation.
I realised that this was because we had no protocol and did not practice in the same way that other physicians practice for arrests on the medical wards.
Thus I designed a protocol and together with some enthusiastic colleagues, we set up a course to teach this protocol.

THE COURSE
We have now conducted this course 16 times including 12 three day courses and 4 in-house courses and we have had over 150 candidates on the course.
This has helped us to better understand all the practical issues around an arrest in a cardiac intensive care unit. We have found many situations that we have learnt from as a result of our arrest practices :

Sometimes emergency sternotomy sets have the retractor in 3 pieces in the set.
Most sternotomy sets have 30 instruments, all clipped together which is highly confusing in an arrest.
If you have a side room and the overhead light comes in then the diathermy then the defibrillator then there is no room for the sternotomy trolley !
Many people forget to connect the temporary pacing wires for asystole or PEA
Many people forget to turn the oxygen to 100%
Briefly washing your hands and then trying to put sterile gloves on while your hands are wet does not work.
If some of the team follow a 3 shock protocol and others a 1 shock protocol, serious critical incidents can happen
If pads and paddles are both available on a unit this causes confusion.
With only 3 practises for an emergency chest reopening, the time taken for your team to perform this task halves.

We have found that it is especially the nursing staff who appreciate the practise, as surgeons tend to be confident in these situations but the staff around them feel much more confident if they have a well-rehearsed protocol that they can rely on.

We have also now been practising this protocol in Middlesbrough Hospital in the UK for 2 years and for the first time on the 20th of September 2007, we had a sudden arrest in a patients post-aortic valve replacement that was both managed and re-opened entirely by the nursing staff on the CICU while a surgeon was called from theatre.
The patient had previously had a liver transplant in 2005, and despite this emergency re-sternotomy, internal massage and even a period on bypass in the CICU, it is our belief that due to the excellent early resuscitation by the nursing staff and the rapid chest reopening within 2 minutes of the arrest, this was a major reason that this patient went home 15 days later with no cognitive or other impairment.

Our survey will ask you what you think should happen if a patient arrests after cardiac surgery.

Perhaps before you complete it, you may want to think about these issues : ( Let me know if you have strong views on any of them ) :

Current guidelines ( ERC and AHA 2005 ) state that if the rhythm is not shockable, epinephrine (adrenaline) at a dose of 1mg should be given immediately. If this is due to a temporary pacing problem, and one of your staff follow these guidelines, what will be the blood pressure when you switch the pacing back on ??

Current guidelines recommend immedate chest compressions , and a single shock followed by 2 minutes massage without checking to see if the shock worked.
Most arrests are witnessed in our intensive care units and deferring massage for 20 or so seconds while you defibrillate the patient may avoid your sternotomy being potentially disrupted.

I would perform 3 shocks, one after another, but my nurses are being taught to do a single shock and rush straight back to the patients to recommence massage. If they are going back to perform massage as I recharge to perform a second shock might this be potentially dangerous ??

Current guidelines make no mention of ventilated patients, what you should do with the ventilator, what you should do with the infusions, what you should do with the temporary wires, should you try external pacing ?

When should you call for a chest reopening ?

Who would you let perform an emergency re-sternotomy ? Of the people you would allow to do this, how sterile would you want them to be, and have you told them your preferred protocol ?

If it just requires 5 instruments to perform an emergency re-sternotomy, why to most emergency re-sternotomy sets have at least 30 items on it, most of which are inconveniently clipped together delaying the time to chest reopening. Why not just have a single 5 item set for the reopening and then a larger set below once you have the chest open ?

I would like as many people to get involved in this project as possible. I am a full time registrar in the UK and I cannot teach other countries this protocol and I need help in my own country also. If you would like to take our course away and go and teach it in your area then I would be more than happy to let you do this.
Also I need as many opinions as possible about alll the issues around cardiac arrest after cardiac surgery. I have a rough protocol that I can let you look at if you like.

To find out more by looking at the Cardiac Portal for the survey or our website at http://www.csu-als.com

We also have some resuscitation based papers being published in the ICVTS , Best Bets Section and I would appreciate your views on these also. I will post the links to these as they become available for comment. The current ones are :

What cardioversion protocol for ventricular fibrillation should be followed for patients who arrest shortly post-cardiac surgery?
http://icvts.ctsnetjournals.org/cgi/content/full/6/6/799

Is internal massage superior to external massage for patients suffering a cardiac arrest after cardiac surgery?
http://icvts.ctsnetjournals.org/cgi/content/abstract/icvts.2007.170399v1


Once we have a consensus, we hope to write a protocol with EACTS on this subject and in 2010 the International Liaison Committee on Resuscitation will update their guidelines and hopefully with your input, they will be incorporated into these guidelines.

Thank you for your attention and please get involved

Yours sincerely

Joel Dunning
http://www.ctsnet.org/home/joeldunning
http://www.csu-als.com
E-mail : joeldunning@doctors.org.uk

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