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The moderate use of adrenaline in arrest of patient shortly after cardiac surgery

Cardiothoracic Surgery Department, University Hospital of Patras, 22500 Rion Patras, Greece

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

Your article [1] is very interesting as it fills a gap of knowledge about the correct administration of adrenaline in postoperative cardiac patients suffering from cardiac arrest. According to the European Resuscitation Council [2] and the American Heart Association [3], a bolus of 1 mg of adrenaline is indicated as soon as pulseless electrical activity or asystole is identified or after the second failed shock, if the rhythm is VF or pulseless VT. The target of this administration is double: firstly to induce ventricular fibrillation or tachycardia (for a successful subsequent defibrillation), and secondly to increase the systemic vascular resistance and restore through this way, a better tissue perfusion. The most important of the targets mentioned above is the first, because the main demand in an asystolic patient in arrest is to retrieve any cardiac activity, even a ventricular fibrillation. However, the second target (to increase the systemic vascular resistance) is achieved much later, either after retrieving a normal rhythm or restoring the circulation by heart massage. In our opinion, adrenaline is indicated ONLY in the patients with no ventricular activity. If ventricular activity is recognized, the so called pulseless electrical activity (ventricular fibrillation or tachycardia), as in the patient in your scenario, the administration of adrenaline does not take place in CPR. Besides, in case of cardiac tamponade, we usually have an empty heart with no myocardial dysfunction, and the rhythm is mostly normal, or later (due to either myocardial hypoperfusion or/and metabolic acidosis) ventricular fibrillation is observed. In contrast, a myocardial dysfunction with dilation is observed in case of a rhythm characterized by junctional bradycardia, or asystolia. Especially in the cardiac surgical patient, the asystolic arrest is not rare. Systemic influences that increase extracellular K+ concentration, such as low PO₂, metabolic acidosis, renal failure, hypothermia, hemolysis and myocardial trauma, contribute to a partial depolarization of normal or already diseased His-Purkinje system [4]. In this case of arrest, the administration of adrenaline and the abrupt performance of external cardiac massage, may ‘brake down’ the vicious circle until the reopening of sternotomy for a more effective massage. Obviously, after recovery of VT or VF and an unsuccessful defibrillation, administration of 1 mg adrenaline every 3 to 5 minutes is clearly indicated [2, 3]. While the moderate use of adrenaline during post-cardiac surgery arrest is desirable; as we avoid all its adverse effects on the myocardium (increased myocardial oxygen consumption, sustained arrhythmias, and further dysfunction), as well as on the brain (decreased cerebral flow, worsening of brain ischemia) [5].

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1. Tsagkataki M, Levine A, Strang T, Dunning J. Should adrenaline be routinely used by the resuscitation team if a patient suffers a cardiac arrest shortly after cardiac surgery? Interact CardioVasc Thorac Surg 2008;7:457–463.[Abstract/Free Full Text]
2. Nolan JP, Deakin CD, Soar J, Bottiger BW, Smith G, European RC. European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support. Resuscitation 2005;67(Suppl_1, 210 S39–S86.[CrossRef][Medline]
3. American Heart Association. Part 7.2: Management of cardiac arrest. Circulation 2005;112(Suppl):IV-58–IV-66.
4. Myerburg R, Castellanos A. Cardiac arrest and sudden cardiac death. In: Zipes D, Libby P, Bonow R, Braunwald E, (Eds), Braunwald's Heart Disease, 7th Ed, Elsevier Saunders; 2005:884.
5. Ristagno G, Sun S, Tang W, Castillo C, Weil MH. Effects of epinephrine and vasopressin on cerebral microcirculatory flows during and after cardiopulmonary resuscitation. Crit Care Med 2007;35:2145–2149.[CrossRef][Medline]

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