Emergency Resternotomy in Post-operative Cardiac Surgery Patients Who Suffer Cardiac Arrest

Abstract

The Society of Thoracic Surgeons (STS) expert consensus statement published in 2017 established an algorithm of resuscitation for patients who suffer a cardiac arrest after cardiac surgery, based on best evidence available. These recommendations commence by aiming to address all possible quickly reversible causes of the arrest such as endotracheal tube displacement, tension pneumothorax, arrhythmia or pacing complication. However, once all quickly reversible causes of an arrest have been addressed, then early resternotomy is recommended for two reasons. First, the two most common causes for the irreversible arrest are that of a cardiac tamponade and a catastrophic bleeding event. For either of these eventualities, there is no alternative emergency treatment other than immediate resternotomy to relieve the tamponade or to stop the bleeding. Second, even in those patients who do not have a tamponade or bleeding event, cardiac massage is significantly more effective if performed internally rather than externally. We performed a literature review of studies exploring the outcomes of patients who arrest after cardiac surgery. We found 12 papers that are reviewed here to answer the clinical questions presented. Using these papers, we explored the rationale for early resternotomy. We also considered the alternatives, such as subxiphoid finger sweep and extracorporeal cardiopulmonary resuscitation (eCPR) with the use of extracorporeal membrane oxygenation (ECMO).

Appendices

Appendix 1

The Society of Thoracic Surgeons protocol for the organisation of the six key roles for resuscitation and two additional members for resternotomy in the cardiac arrest situation after cardiac surgery [2]

Appendix 2

A small resternotomy set packed with a scalpel on top (above) and opened (below) [2]