Defibrillation/Pacing First for Witnessed Cardiac Arrest in Post-cardiac Surgery Patients

  • Lu Wang
  • Joel DunningEmail author
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)


Witnessed cardiac arrest in post-cardiac surgery patients is different from other cardiac arrest in many ways. Whether external cardiac massage should be deferred for immediate defibrillation/pacing is one of the difficult decisions which has been debated in the last few decades. Among the 1785 papers identified in the literature search, 9 clinical studies and 4 systematic reviews were pertinent to answer this question. As no studies were performed in patients after cardiac surgery, we extrapolated our findings from the general literature. The in-hospital cardiac arrest data suggests that a better survival outcome is associated with immediate defibrillation and the out-of-hospital cardiac arrest data show no difference in survival outcome between external cardiac massage first and immediate defibrillation first, if the rhythm is amenable to defibrillation. Taking into consideration the highly monitored environment, readily available resources, and common causes of cardiac arrest in this group of patients, as well as the potential complications caused by external cardiac massage, we recommend providing defibrillation/pacing first for witnessed cardiac arrest in post-cardiac surgery patients.


Defibrillation Pacing External cardiac massage Cardiopulmonary resuscitation (CPR) Post-cardiac surgery 


  1. 1.
    Dunning J, et al. Guideline for resuscitation in cardiac arrest after cardiac surgery. Eur J Cardiothorac Surg. 2009;36:3–28.CrossRefGoogle Scholar
  2. 2.
    Soar J, et al. European resuscitation council guidelines for resuscitation 2005: section 7. Cardiac arrest in special circumstances. Resuscitation. 2005;67:S155.CrossRefGoogle Scholar
  3. 3.
    Soar J, et al. European resuscitation council guidelines for resuscitation 2015. Section 3. Adult advanced life support. Resuscitation. 2015;95:100–47.CrossRefGoogle Scholar
  4. 4.
    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;7:878–85.CrossRefGoogle Scholar
  5. 5.
    Davis D, Aguilar SA, Sell R, Minokadeh A, Husa R. A focused investigation of expedited, stack of three shocks versus chest compressions first followed by single shocks for monitored ventricular fibrillation/ventricular tachycardia cardiopulmonary arrest in an in-hospital setting. J Hosp Med. 2016;11:264–8.CrossRefGoogle Scholar
  6. 6.
    Mhyre JM, Ramachandran SK, Kheterpal S, Morris M, Chan PS. Delayed time to defibrillation after intraoperative and periprocedural cardiac arrest. Anesthesiology. 2010;113:782–93.CrossRefGoogle Scholar
  7. 7.
    Chan PS, Krumholz HM, Nichol G, Nallamothu BK, American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358:9–17.CrossRefGoogle Scholar
  8. 8.
    Spearpoint KG, McLean CP, Zideman DA. Early defibrillation and the chain of survival in ‘in-hospital’ adult cardiac arrest; minutes count. Resuscitation. 2000;44:165–9.CrossRefGoogle Scholar
  9. 9.
    Jost D, et al. DEFI 2005: a randomized controlled trial of the effect of automated external defibrillator cardiopulmonary resuscitation protocol on outcome from out-of-hospital cardiac arrest. Circulation. 2010;121:1614–22.CrossRefGoogle Scholar
  10. 10.
    Baker PW, et al. Defibrillation or cardiopulmonary resuscitation first for patients with out-of-hospital cardiac arrests found by paramedics to be in ventricular fibrillation? A randomised control trial. Resuscitation. 2008;79:424–31.CrossRefGoogle Scholar
  11. 11.
    Jacobs IG, Finn JC, Oxer HF, Jelinek GA. Original Research CPR before defibrillation in out-of-hospital cardiac arrest: a randomized trial. Emerg Med Aust. 2005;17:39–45.CrossRefGoogle Scholar
  12. 12.
    Wik L, Hansen TB, Fylling F, Steen T, Vaagenes P, Auestad BH, Steen PA. Delaying defibrillation to give basic with out-of-hospital ventricular fibrillation. J Am Med Assoc. 2003;289:1389–95.CrossRefGoogle Scholar
  13. 13.
    Freese JP, et al. Waveform analysis-guided treatment versus a standard shock-first protocol for the treatment of out-of-hospital cardiac arrest presenting in ventricular fibrillation: results of an international randomized, controlled trial. Circulation. 2013;128:995–1002.CrossRefGoogle Scholar
  14. 14.
    Huang Y, et al. Cardiopulmonary resuscitation (CPR) plus delayed defibrillation versus immediate defibrillation for out-of- hospital cardiac arrest (review). Cochrane Libr. 2014;
  15. 15.
    Meier P, et al. Chest compressions before defibrillation for out-of-hospital cardiac arrest: a meta-analysis of randomized controlled clinical trials. BMC Med. 2010;8:52.CrossRefGoogle Scholar
  16. 16.
    Simpson PM, Goodger MS, Bendall JC. Delayed versus immediate defibrillation for out-of-hospital cardiac arrest due to ventricular fibrillation: a systematic review and meta-analysis of randomised controlled trials. Resuscitation. 2010;81:925–31.CrossRefGoogle Scholar
  17. 17.
    Nolan JP, et al. European resuscitation council guidelines for resuscitation 2010 section 1. Executive summary. Resuscitation. 2010;81:1219–76.CrossRefGoogle Scholar
  18. 18.
    Richardson L, Dissanayake A, Dunning J. What cardioversion protocol for ventricular fibrillation should be followed for patients who arrest shortly post-cardiac surgery? Interact Cardiovasc Thorac Surg. 2007;6:799–805.CrossRefGoogle Scholar
  19. 19.
    Miller AC, Rosati SF, Suffredini AF, Schrump DS. A systematic review and pooled analysis of CPR-associated cardiovascular and thoracic injuries. Resuscitation. 2014;85:724–31.CrossRefGoogle Scholar
  20. 20.
    Rudinska LI, et al. Intra-thoracic injuries associated with cardiopulmonary resuscitation – frequent and serious. Resuscitation. 2016;103:66–70.CrossRefGoogle Scholar
  21. 21.
    Dunning J, et al. The society of thoracic surgeons expert consensus for the resuscitation of patients who arrest after cardiac surgery. Ann Thorac Surg. 2017;103:1005–20.CrossRefGoogle Scholar
  22. 22.
    Pottle A, Bullock I, Thomas J, Scott L. Survival to discharge following Open Chest Cardiac Compression (OCCC). A 4-year retrospective audit in a cardiothoracic specialist centre – Royal Brompton and Harefield NHS Trust, United Kingdom. Resuscitation. 2002;52:269–72.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Cardiothoracic SurgeryFreeman HospitalNewcastle upon TyneUK
  2. 2.Department of Cardiothoracic SurgeryJames Cook University HospitalMiddlesbroughUK

Personalised recommendations