New Protocol Increases Postoperative Survival Rates After Cardiac Arrest

Jill Ley, RN, MS

Jill Ley, RN, MS set out to increase survival for cardiac surgery patients who experience a cardiac arrest while in an ICU. By implementing a new protocol, she helped reduce mortality rates from cardiac arrest by nearly half at California Pacific Medical Center in San Francisco.

Ley had witnessed how Advanced Cardiac Life Support (ACLS)—while the gold standard for emergency responders—has significant shortcomings after cardiac surgery, including a greater risk of mortality and morbidity. To combat this issue, she learned about Cardiac Surgery Unit-Advanced Life Support (CSU-ALS), a European protocol that provides an evidence-based approach for the management of cardiac arrest after cardiac surgery.

Joel Dunning, PhD, FRCS

“Jill came over and saw our course on CSU-ALS. After she implemented the protocol, mortality rates from arrest fell from 65% to 35% at her institution,” said Joel Dunning, PhD, FRCS, Consultant Cardiothoracic Surgeon at James Cook University Hospital in Middlesbrough, United Kingdom, who developed CSU-ALS with his colleagues. Their protocol was adopted by the European Resuscitation Council in 2010 after several years of in-depth review.

Learn About CSU-ALS

Dr. Dunning will be the moderator and Ley will be among several speakers at a new hands-on session, Resuscitation of Patients Who Arrest After Cardiac Surgery, which will be held from 1:15 p.m. to 4:30 p.m. on Sunday, January 24. Attendees will learn how this method of resuscitating postoperative cardiac surgery patients can rapidly reverse the causes of arrest.

Faculty members, including cardiothoracic surgeons, an anesthesiologist, and a physician’s assistant, will cover how to perform an emergency resternotomy using a team-based approach, internal massage, emergency pacing, standardized equipment, and medication strategies, which are targeted to achieve optimal survival in this population. Attendees will have the opportunity to participate in simulated arrest scenarios using resternotomy manikins. The session will conclude with information on how to implement the resuscitation protocols and how to become an instructor.

“I originally went to the United Kingdom to learn about the protocol and bring it back to my own center. It became clear that this was a much bigger initiative. I realized what a tremendous opportunity we have to save lives in the United States,” said Ley, Clinical Nurse Specialist in Surgical Services at California Pacific Medical Center.

Protocol Goes Beyond ACLS

ACLS has a number of limitations when responding to patients who experience postoperative cardiac arrest after a major cardiac operation.

“For two of the three most common causes of arrest—tamponade and hypovolemia—the use of external cardiac massage as done with ACLS is ineffective. For both of these causes, the only treatment is to reopen the chest so you can fix the problem in about 5 minutes. Otherwise, the patient is going to have irreversible brain damage,” said Dr. Dunning, adding that ACLS also doesn’t address individuals with temporary pacing wires, endotracheal tubes, ventricular assist devices, and infusions.

Also, what may appear to be pulseless electrical activity may rather be a function of the patient’s pacemaker responding to an underlying ventricular fibrillation, which is not addressed in ACLS, but is in CSU-ALS. The protocol also includes information on how to gown and glove quickly, as well as how to mobilize and work as a team.

The protocol calls for a person trained in CSU-ALS, who could be a physician’s assistant or a nurse practitioner, to be available 24 hours a day.

“The first steps of reopening the chest are straightforward, and, if practiced on a manikin simulation, can be performed safely,” Dr. Dunning said. “In the United Kingdom, at least three nurses have opened a chest with successful outcomes.”

The Cardiac Surgery Unit-Advanced Life Support course gives participants the opportunity to train on a manikin as a group.

Manikins like the one session attendees will practice on have been sent to about 50 institutions throughout the United States.

“The need is not in the 20% of large units; it is in the 80% of small units, where patients are going to mixed critical care units instead of specialized cardiac intensive care units,” he said.

Knowing that cardiac arrests typically happen within the first few hours after cardiac surgery, when patients are still in the ICU, Ley said she is grateful for this protocol.

“Why would we call on a protocol designed for people on the street when we have completely different patients, environments, and resources when these cardiac events occur,” she said. “People who have cardiac surgery are vulnerable to these events, but with this protocol, we can respond with the most evidence-based approach that is going to give us good outcomes.”

View an image illustrating a proposed protocol for Cardiac Surgery Unit-Advanced Life Support for the management of patients who arrest after cardiac surgery.