How should we manage arrest following cardiac surgery?

Perioperative arrest occurs in thousands of cardiac surgical patients annually, yet standard resuscitation methods are ineffective or potentially harmful. These "high risk, low volume" events typically occur in well-monitored patients in the highly specialized environment of the operating room or intensive care unit, with a short list of likely causes of arrest, making a protocolized approach to management feasible and desirable. An evidence-based guideline for resuscitation specific to the cardiac surgical patient was first published by Dunning et al in 2009 and adopted by the European Resuscitation Council the following year. It emphasizes important deviations from advanced cardiac life support, including immediate defibrillation or pacing of arrhythmias before external compressions, if feasible within 1 minute, and avoidance of epinephrine due to potential rebound hypertension. In standard fashion, the rapid exclusion of reversible causes of arrest is followed by chest reopening within 5 minutes. This approach is now standard of care in most European countries and is under review for use in the United States by the Society of Thoracic Surgeons. The anesthesiologist, as either team leader or participant, plays a critical role in optimally managing arrests after cardiac surgery. Their familiarity with this new standard is essential to optimal patient outcomes.