The incidence of cardiac arrest after cardiac surgery is around 0.7‑7% [8,9,10,11,12,13,14,15,16], EACTS, ERC and AHA endorsed resuscitation guidelines for this special group. Our survey gives an insight into current practices and adoption of guidelines of the Egyptian cardiac surgery centres. To our knowledge, there were no studies on a national level to address post cardiac surgery resuscitation practices.
In our study, 68.5% of the respondents were cardiac surgeons, of which 76.8% middle grade/resident/junior doctors. This is representative of first responders to cardiac arrest call in a routine practice thus it is crucial to identify knowledge and practices to evaluate the quality and safety of patient care. However, we found no significant differences in practices amongst respondents from various institutions, consultant and non-consultants, surgeons and non-surgeons.
Our respondents will act in a VT/VF cardiac arrest situation as follows, 75% will start CPR, 57% will give adrenaline immediately. All of which are more in line with Advanced Life Support (ALS) or Advanced Cardiac Life Support (ACLS) protocols and not the protocol dedicated for cardiac surgery.
The current guidelines advocate, once cardiac arrest is identified, to assess the rhythm first and not to commence chest compressions, reason being the possibility of presence of shockable rhythm such as VF or pulseless VT in 25‑50% of cases. If a shockable rhythm is identified, chest compressions could be delayed for up to 1 min to deliver 3 shocks as this might spare the traumatic chest compressions to a fresh sternotomy wound and avoid complications of cardiac/graft injury [17, 18].
In the cardiac surgical patient, the efficacy of defibrillation reduces by 10% for every minute delay, in addition, success rates for immediate sequential shocks for VF or pVT decline from 78% with the first shock to 14% with the third, therefore, immediate defibrillation with three sequential attempts at 150 Joules is advised [19]. Whilst in severe bradycardia or asystole, it is advisable before starting chest compressions to turn the pacing to emergency setting or DDD mode, 90 beats, maximum amplitude.
No study concluded benefit or harm of administering adrenaline during resuscitation of the postoperative cardiac surgical patient; however, the risk of administering adrenaline in conventional doses is with profound hypertension, bleeding or tearing of vessel anastomoses on return of spontaneous circulation (ROSC), which can precipitate catastrophic harm or further cardiac arrest [20]. Therefore, the recommendation to administer adrenaline is to be delayed until reversible causes of arrest are excluded and directed by a senior clinician experienced in their use. Adrenaline remains a useful drug in peri-arrest situations in smaller doses.
Of concern, almost 60% would not prefer anyone but the surgeon to perform a resternotomy, we believe the main culprit is medicolegal claims and pursuits. Nonetheless, 17.9% would allow intensive care doctors trained for emergency sternotomy to perform it in case of cardiac arrest. This stems from the fact that junior surgeons in many Egyptian cardiac units are allocated to manage cardiac intensive care, thus, being familiar with surgical problems and have enough skills to perform an emergency sternotomy.
In total, 70.5% of respondents advocate the current guidelines for resuscitation yet only 10% train regularly. Practicing protocol-based arrest management has been shown to reduce by 50% the time to chest reopening, reduce complications resulting from the resternotomy after cardiac surgery and improve survival [21,22,23,24,25]. Thus, the need to raise the awareness and training of the junior surgical doctors and intensive care staff with current guidance and emergency sternotomy protocols is paramount.
A structured national registry and regular auditing are key features to achieve the compliance, training, and monitoring of trainees; in addition, regular mandatory recertification is crucial to maintain an up-to-date knowledge of the current pool of surgeons and fellows. This could be endorsed by the cardiothoracic society body or national health service in the country.
The core message for our trainees and fellows; external chest compressions are ineffective in tamponade, extreme hypovolemia due to bleeding. Brain damage will occur in 5 min; the only way to save those patients is to perform a rapid smooth emergency resternotomy.
Limitations
Our study has several limitations. Survey respondents are almost always self-selected, not everyone who receives a survey is likely to answer it despite offered incentives, which explains the small number of respondents. However, this was the best available alternative for multi-centre data collection due to COVID-19 pandemic and the national guidance for social distancing.
Data regarding the number of procedures, closed chest compressions, resternotomy and going back on bypass rates may not represent the actual figures and numbers as 77% of the respondents are middle-grade doctors and might not be able to access these institutional numbers readily. Moreover, COVID-19 pandemic has significantly impacted the number of procedures performed and could be a valid reason for the heterogeneity of data from respondents from the same centre.