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If a patient arrests after cardiac surgery is it acceptable to delay cardiopulmonary resuscitation until you have attempted either defibrillation or pacing?

^a Department of Cardiothoracic Surgery and Anaesthesiology, Karolinska University Hospital, 171 76 Stockholm, Sweden
^b Department of Cardiothoracic Surgery, North Staffordshire University Hospital, Stoke on Trent, UK
^c Department of Cardiothoracic Anaesthesia, Wythenshawe Hospital, Manchester, UK
^d Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK

Received 15 May 2008; accepted 19 May 2008

*Corresponding author. Tel.: +46 8 51770834; fax: +46 8 322701.

E-mail address: ulf.lockowand{at}ks.se (U. Lockowandt).

	Abstract

Top Abstract 1. Introduction 2. Three-part question 3. Clinical scenario 4. Search strategy 5. Search outcome 6. Results 7. Clinical bottom line References

 
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is acceptable to delay cardiopulmonary resuscitation if a patient arrests after cardiac surgery in order to attempt defibrillation or pacing, prior to performing external cardiac massage. Altogether 550 papers were found in Medline and 990 in Embase using the reported search, of which 22 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. We conclude that current resuscitation guidelines state that there is no evidence to support or refute external cardiac massage prior to defibrillation in-hospital, although a benefit has been shown for patients out-of-hospital if the response time is over 4–5 min. In addition, four large studies including the AHA National Registry of Cardiopulmonary Resuscitation, who reported the findings of 6789 in-hospital arrests, emphasise the importance of early defibrillation within 1–2 min. More concerning in patients post-cardiac surgery are four case reports after cardiothoracic surgery and five in the non-surgical literature where significant harm has been caused from external cardiac massage, although equally we found cohort studies of cardiac surgical patients who had external cardiac massage followed by re-sternotomy and found no trauma due to external cardiac massage. We recommend that guidelines for immediate external massage should be adhered to currently as the evidence that these guidelines may do harm is not yet strong enough to recommend a change in practice. However, we acknowledge that there are no in-hospital data to support very short periods of external massage prior to defibrillation and there have been examples of damage to the myocardium due to external massage. This should be borne in mind when external massage is being performed on a patient after cardiac surgery.

Key Words: Cardiopulmonary resuscitation; Ventricular fibrillation; Electrical countershock; Cardiac surgical procedures

	1. Introduction

Top Abstract 1. Introduction 2. Three-part question 3. Clinical scenario 4. Search strategy 5. Search outcome 6. Results 7. Clinical bottom line References

 
A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1]. The quality of each study was assessed using the International Liaison Committee on Resuscitation 2005 protocol [2].

	2. Three-part question

Top Abstract 1. Introduction 2. Three-part question 3. Clinical scenario 4. Search strategy 5. Search outcome 6. Results 7. Clinical bottom line References

 
In [patients after cardiac surgery who suffer an arrest] is [Immediate cardiopulmonary resuscitation (CPR)] vs. [Immediate defibrillation or pacing] the most effective strategy to optimise [survival to discharge].

	3. Clinical scenario

Top Abstract 1. Introduction 2. Three-part question 3. Clinical scenario 4. Search strategy 5. Search outcome 6. Results 7. Clinical bottom line References

 
You have just performed CABGx2 on a 67-year-old gentleman with triple-vessel disease. His obtuse marginal artery was too small to graft. Unfortunately, 2 h postoperatively he suddenly goes into ventricular fibrillation. The staff perform external cardiac massage for 30 s until the anaesthetist gives a single biphasic 150J DC shock which converts him back into sinus rhythm and his blood pressure quickly recovers. With amiodarone loading he remains stable and is discharged from the ICU two days later, however, on day 4 you have to take him back to theatre for sternal rewiring. You feel the CPR should have been avoided but the nurses tell you that immediate CPR is a key part of current guidelines.

	4. Search strategy

Top Abstract 1. Introduction 2. Three-part question 3. Clinical scenario 4. Search strategy 5. Search outcome 6. Results 7. Clinical bottom line References

 
Medline 1950 and Embase 1980 to April 2008 using OVID-SP Interface.

[ventricular fibrillation.mp OR exp Ventricular Fibrillation/] AND [exp Electric Countershock/OR Defibrillation.mp OR exp Defibrillators/OR Defibrillators.mp] AND [exp Cardiopulmonary Resuscitation/OR cardiopulmonary resuscitation.mp OR CPR.mp OR Cardiac Massage.mp]LIMIT to Human studies.

	5. Search outcome

Top Abstract 1. Introduction 2. Three-part question 3. Clinical scenario 4. Search strategy 5. Search outcome 6. Results 7. Clinical bottom line References

 
Five hundred and fifty papers were found in Medline and 990 in Embase using the reported search. From these 22 papers were identified. These are presented in Table 1.

	6. Results

Top Abstract 1. Introduction 2. Three-part question 3. Clinical scenario 4. Search strategy 5. Search outcome 6. Results 7. Clinical bottom line References

In 2005, the International Liaison Committee on Resuscitation (ILCOR) task force [4] recommended that for out-of-hospital arrests where the response time is more than 4–5 min, a 1.5–3 min period of external cardiac massage may be of benefit. They also state that there is no evidence to support or refute the use of CPR before defibrillation for in-hospital cardiac arrest. This is based on the worksheet by Gazmuri et al. [3]. This reviewed 14 papers, including 2 randomized trials, 2 cohort studies, and 10 experimental studies in coming to its conclusions. The 10 experimental studies showed that attempting defibrillation upon initiation of resuscitation is more efficacious than CPR first if the duration of untreated ventricular fibrillation is 5 min or less.

Of the 2 randomized studies, Wik et al. [5] reported the results of a study in 200 patients who suffered an out-of-hospital VF arrest randomized to immediate defibrillation then CPR or 3 min of CPR then defibrillation. There was no difference between groups if the response time was <5 min. However, in the remaining patients, the return of spontaneous circulation was 58% in the CPR group compared to 38% in the defibrillation group.

In the second RCT by Jacobs et al. [6], 256 patients who suffered a VF arrest were randomized to immediate defibrillation, or 90 s of CPR, followed by defibrillation. The mean response time was 9 min but no differences in either group were shown in resuscitation or survival.

Of the cohort studies, Cobb et al. [7] in Seattle looked at the implementation of AEDs for non-paramedic Emergency Medical Teams in over 1000 arrests. In the first period of the study, there was no improvement in survival, which led to a change in practice with the recommendation of 90 s of CPR before defibrillation resulting in an increase in survival to discharge of 24–30%.

Stotz et al. [8] retrospectively examined the implementation of AEDs in Basel. They found that conversely the survival to discharge dropped from 24–14% after implementation of early defibrillation instead of CPR.

Considering studies of in-hospital arrests, the largest was by the AHA national registry of cardiopulmonary resuscitation [9] in 2008 who reported data on 6789 patients who suffered an in-hospital VF arrest across 369 hospitals. Of note, 61% of arrests were in intensive care units and 10% were in patients after cardiac surgery. The best survival was in patients defibrillated in under 1–2 min (39%). There was a significant reduction in survival if defibrillation was over 2 min (22%) and prognosis worsened the longer defibrillation was delayed.

Spearpoint et al. [10] reported that in 2 years of VF arrests in 124 patients at the Hammersmith hospital, survival to discharge was 48% with defibrillation in <2 min compared to 14% if defibrillation was delayed. Of note 15 patients had defibrillation with no CPR and 80% survived to discharge. Fredriksson [11, 12] reported that in 910 consecutive arrests, the survival to hospital discharge was 34%. This was thought to be in part due to fast defibrillation times (median 2 min). Hajbaghery et al. [13] reported 206 patients who arrested in an Iranian hospital. Survival to discharge was 33% if defibrillation was under 4 min, but only 5% if over this. Zafari et al. [14] reported 569 in-hospital arrests. Of defibrillated patients only 2.2% survived, but after initiation of an early defibrillation programme this increased to 16%. Skrifars et al. [15] analysed risk factors for survival at 12 months among 441 patients who suffered an in-house arrest. Although arrests in a cardiac surgical unit had a better outcome, delay to defibrillation did not come out as a predictor. Of note, apart from 15 patients, none of these in-hospital studies contained patients who had CPR deferred until after defibrillation.

Considering possible harm from external cardiac massage, the most concerning report was from Bohrer and B;auottiger [16]. They reported 3 patients who after cardiac surgery suffered a VF-arrest. They all had brief periods of external CPR and died from massive haemorrhage resulting from mechanically induced rupture of vascular sutures. They specifically describe a patient who had only 5 compressions before 1500 ml of blood suddenly came down the drains in 30 s. In addition, Kempen and Allgood [20] reported a right ventricular tear secondary to external CPR in a patient who arrested shortly after a right pneumonectomy. We also identified 5 case reports of cardiac damage due to external cardiac massage in the non-surgical literature [17–19, 21, 22].

Several cohort studies report the results of cardiac arrest after cardiac surgery but none mention significant complications due to the external CPR. El-Banayosy and colleagues [24] reported 113 patients who underwent at least 20–30 min of external CPR, with a survival of 70% without any complications due to external CPR. Raman reported 39 patients who suffered a cardiac arrest after cardiac surgery. Twenty-four had emergency resternotomy and the authors specifically stated that ‘no significant damage to the myocardium was considered to have occurred as a result of direct cardiac compression’.

We found no studies reporting cohorts of patients resuscitated by external pacing or temporary wire pacing. Thus we considered this intervention to be equivalent to defibrillation in patients with asystole or bradycardic pulseless electrical activity in arrests after cardiac surgery as there may be a short delay in obtaining the required specialist equipment during which CPR would normally be considered.

	7. Clinical bottom line

Top Abstract 1. Introduction 2. Three-part question 3. Clinical scenario 4. Search strategy 5. Search outcome 6. Results 7. Clinical bottom line References

 
We recommend that guidelines for immediate external massage should be adhered to currently as the evidence that these guidelines may do harm is not yet strong enough to recommend a change in practice. However, we acknowledge that there are no in-hospital data to support very short periods of external massage prior to defibrillation and there have been examples of damage to the myocardium due to external massage. This should be borne in mind when external massage is being performed on a patient after cardiac surgery.

	References

Top Abstract 1. Introduction 2. Three-part question 3. Clinical scenario 4. Search strategy 5. Search outcome 6. Results 7. Clinical bottom line References

 

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