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eComment: Avoiding the adverse consequences of external cardiac massage during in-hospital resuscitation after cardiac surgery

The Ohio State University Medical Center, 410 West Tenth Avenue, Columbus, OH 43210-1228, USA

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

Lockowandt and colleagues [1] published results from their ‘best evidence’ search, which addressed whether it is acceptable to delay cardiopulmonary resuscitation (CPR) if a patient arrests after cardiac surgery in order to attempt defibrillation or pacing prior to performing external cardiac massage (ECM). They recommended that guidelines for immediate ECM prior to defibrillation in-hospital should be followed as the evidence that significant trauma to the myocardium due to ECM has been reported in cardiac surgery patients is not yet strong enough to recommend a change in practice. The adverse consequences caused by ECM, however, can be avoided by using alternative CPR methods.

The likelihood of achieving return of spontaneous circulation (ROSC) and surviving a cardiac arrest has been linked to the ability to achieve and maintain coronary perfusion pressure (CPP) adequately above a threshold level of 15 mmHg prior to defibrillation [2]. One can argue that failure to achieve ROSC despite prompt defibrillation is possible in many post-cardiac-surgery patients due to some level of impaired left ventricular diastolic filling, which likely more rapidly decreases CPP to below threshold levels. Therefore, to avoid unnecessary defibrillation, which can increase the already existing myocardial dysfunction, and to avoid the potential adverse consequences of ECM and the subsequent need for sternal rewiring, two alternative methods of CPR [3] can be utilized to maintain adequate CPP before defibrillation.

First, minimally invasive direct cardiac massage (or MID-CM) is a technique that uses a commercially available hand-held device (TheraCardia, Inc) that is introduced through a small thoracostomy to manually achieve direct cardiac compression with a 4-cm up-and-down stroke at a rate of 80–100 compression-decompressions per min. It has been pointed out that a human pre-hospital pilot study of 25 patients concluded that MID-CM produces greater blood flow than conventional CPR.

Second, abdominal compressions-only CPR (or ACO-CPR) (with an open airway possibly maintained by head rotation during single-rescuer CPR [4] or by manual airway maneuvers during two-rescuer CPR) is a new resuscitation method that can be applied immediately to circulate oxygenated blood to the heart and brain, which may improve the chances of successful pacing or defibrillation on the first attempt, in patients suffering an arrest after cardiac surgery. High-frequency compressions of the abdominal aorta (due to rhythmic compression by compressing the mid-abdomen) produce resonant pressure-volume waves within the aorta that drive blood flow. Because there is no direct pressure over the heart to empty the left ventricle with each compression during ACO-CPR and because left ventricular volume will increase as a result of flow from the higher-pressure pulmonary arteries to the lower-pressure left atrium and left ventricle, the heart acts as a conduit, thereby allowing significant increases in ventricular volume during ACO-CPR [5], which would compensate for the impaired left ventricular diastolic filling found in many post-cardiac-surgery patients. However, cardiac compressions with MID-CM may still be necessary because ACO-CPR engorges the heart with blood; a blood-engorged heart cannot be successfully defibrillated and circulation cannot return without first decompressing the heart with cardiac compressions [4, 5].

	References

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1. Lockowandt U, Levine A, Strang T, Dunning J. If a patient arrests after cardiac surgery is it acceptable to delay cardiopulmonary resuscitation until you have attempted either defibrillation or pacing? Interact Cardiovasc Thorac Surg 2008;7:878–887.[Abstract/Free Full Text]
2. Paradis NA, Martin GB, Rivers EP. Coronary perfusion pressure and the return of spontaneous circulation in human cardiopulmonary resuscitation. J Am Med Assoc 1990;263:1106–1113.[Abstract/Free Full Text]
3. Rottenberg EM. eComment: Alternative methods of resuscitation for patients suffering a cardiac arrest after cardiac surgery. Interact Cardiovasc Thorac Surg 2008;7:156–157.[Free Full Text]
4. Rottenberg EM. The need for head rotation and abdominal compressions during bystander cardiopulmonary resuscitation. Am J Emerg Med 2006;24:573–576.[CrossRef][Medline]
5. Rottenberg EM. Cardiopulmonary resuscitation using only rhythmic abdominal compressions: Are chest compressions still necessary? Am J Emerg Med 2008;26:375–376.[Medline]

This article has been cited by other articles:

				E. M. Rottenberg eComment: Questioning a 'best evidence' search arguing against abdominal-only cardiopulmonary resuscitation and for external cardiac massage Interactive CardioVascular and Thoracic Surgery, January 1, 2009; 8(1): 151 - 152. [Full Text] [PDF]

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