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eComment: Early emergency resternotomy is crucial in cardiac arrest after cardiac surgery

James Cook University Hospital, Middlesbrough, TS4 3BW, UK

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

The above best evidence topic [1] reminds me of a patient I have beeninvolved with recently. This lady had a cardiac arrest five days followingaortic valve surgery. She suffered a witnessed cardiac arrest for which shehad one minute of cardiopulmonary resuscitation (CPR) which was successfulin returning a spontaneous cardiac output with a good blood pressure. Post-resuscitationshe was found to have a left pneumothorax with a small leftpleural effusion. A chest drain was inserted and the pneumothorax resolved.The patient remained stable and was transferred to cardiothoracic intensivecare unit (CICU). In CICU her haemoglobin was 5.5 g/dl therefore, shereceived a blood transfusion. She remained stable for 24 h. She had minimaldrainage and was discharged from CICU back to high dependency unit (HDU).The following day on HDU she arrested again. She received prolonged CPRfor 25 min during which 1.5 l suddenly drained down the pleural drain as aresult of the CPR. This patient died of an aortic dissection confirmed onemergency resternotomy.

So what did we learn from this case? The first arrest was attributed to thepneumothorax but in retrospect the main cause for the cardiac arrest musthave been the aortic dissection. However, when in the CICU, we did notfully investigate this possibility. Then evidently the second period of 25 minof external cardiac massage caused this dissection to rupture.

In conclusion, prolonged massage in our experience did cause a severehaemorrhagic complication and thus early resternotomy would both reducethis trauma and also allow full inspection of the mediastinal contents. Ifthis had been performed on the first arrest, then the aortic dissection mayhave been discovered. Even if a patient is successfully resuscitated withoutthe need for emergency resternotomy we believe that these patients shouldbe thoroughly investigated for all causes of this arrest, including a CTangiogram to exclude dissection if no other apparent cause has been foundto explain the arrest.

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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]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ahmad Al Khaddour Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Al Khaddour, A. Search for Related Content PubMed PubMed Citation Articles by Al Khaddour, A. Related Collections Related Article