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Should adrenaline be routinely used by the resuscitation team if a patient suffers a cardiac arrest shortly after cardiac surgery?

^a Department of Cardiothoracic Surgery, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK
^b Department of Cardiothoracic Surgery, North Staffordshire Hospital, Stoke-on-Trent, UK
^c Department of Cardiothoracic Anaesthesia, Wythenshawe Hospital, Manchester, UK

*Corresponding author. Tel./fax: +44 780 1548122.

E-mail address: joeldunning{at}doctors.org.uk (J. Dunning).

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether adrenaline might be a useful addition to a protocol for the management of cardiac arrests for patients shortly after cardiac surgery. Altogether 889 papers were found using the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The quality and level of evidence was assessed using the International Liaison Committee on Resuscitation guideline recommendations. We conclude that the European Resuscitation Council and the American Heart Association both recommend 1 mg of adrenaline as soon as pulseless electrical activity or asystole is identified or after the second failed shock if the rhythm is VF/pulseless VT. However, they acknowledge that the evidence behind this recommendation is lacking and based entirely on animal studies which have as yet not been successfully replicated in human studies to show a benefit of survival to hospital discharge. They acknowledge that the current evidence is insufficient to support or refute the use of adrenaline in arrests and the International Liaison Committee on Resuscitation grade the recommendation to give adrenaline in cardiac arrests as ‘indeterminate’. Thus, in the particular situation of a patient who arrests shortly after cardiac surgery where the chance of restoring sinus rhythm either by defibrillation or by an emergency re-sternotomy is high, and where adrenaline could in this situation be highly dangerous once sinus rhythm is restored, we recommend that 1 mg of adrenaline forms no part of the resuscitation protocol for patients who arrest after cardiac surgery.

Key Words: Thoracic surgery; Cardiopulmonary resuscitation; Epinephrine; Adrenaline; Evidence based medicine

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