ORIGINAL ARTICLE – ADULT CARDIAC
Interposed abdominal compression-cardiopulmonary resuscitation after cardiac surgery Ji-ke Li, Jun Wang and Tian-fa Li* Cardiovascular Center of Hainan Medical College, Affiliated Hospital of Hainan Medical College, Haikou, China * Corresponding author. Cardiovascular Center of Hainan Medical College, Affiliated Hospital of Hainan Medical College, 31 Longhua Road, Haikou 570102, China. Tel: +86-898-66725370; fax: +86-898-66500144; e-mail: [email protected] (T.-f. Li). Received 29 April 2014; received in revised form 7 July 2014; accepted 10 July 2014
Abstract OBJECTIVES: The management of cardiac arrest after cardiac surgery differs from the management of cardiac arrest under other circumstances. In other studies, interposed abdominal compression-cardiopulmonary resuscitation (IAC-CPR) resulted in a better outcome compared with conventional CPR. The aim of the present study was to determine the feasibility, safety and efficacy of IAC-CPR compared with conventional CPR in patients with cardiac arrest after cardiac surgery. METHODS: Data on all cardiac surgical patients who suffered a sudden cardiac arrest during the first 24 h after surgery were collected prospectively. Cardiac arrest was defined as the cessation of cardiac mechanical activity with the absence of a palpable central pulse, apnoea and unresponsiveness, including ventricular fibrillation, asystole and pulseless electrical activity. Forty patients were randomized to either conventional CPR (n = 21) or IAC-CPR (n = 19). IAC-CPR was initially performed by compressing the abdomen midway between the xiphoid and the umbilicus during the relaxation phase of chest compression. If spontaneous circulation was not restored after 10–15 min, the surgical team would immediately proceed to resternotomy. The endpoints of the study were safety, return of spontaneous circulation (ROSC) >5 min, survival to hospital discharge and survival for 6 months. RESULTS: With IAC-CPR, there were more patients in terms of ROSC, survival to hospital discharge, survival for 6 months and fewer CPR-related injuries compared with patients who underwent conventional CPR. CONCLUSIONS: IAC-CPR is feasible and safe and may be advantageous in cases of cardiac arrest after cardiac surgery. Keywords: Interposed abdominal compression-cardiopulmonary resuscitation • Conventional cardiopulmonary resuscitation • Cardiac arrest • Cardiac surgery
INTRODUCTION Cardiac surgery confers a great risk of cardiac arrest during the postoperative period [1]. The incidence rate of cardiac arrest after cardiac surgery is 0.7–2.9% [2]. The chance of survival after an in-hospital cardiac arrest post-cardiac surgery is poor. Several issues in the management of cardiac arrest after cardiac surgery differ from the management of cardiac arrest under other circumstances [3]. Over the past 30 years, a variety of alternatives to conventional manual cardiopulmonary resuscitation (CPR) have been developed in an effort to enhance perfusion during attempted resuscitation after cardiac arrest and to improve survival [4]. The maintenance of vital organ perfusion during cardiac arrest is critical for successful resuscitation. However, studies have shown that standard CPR provides only 15–20% of normal myocardial perfusion and only 25–30% of normal cerebral perfusion [5]. Interposed abdominal compression (IAC)-CPR is a three-rescuer technique (an abdominal compressor plus the chest compressor and the rescuer providing ventilations) that includes conventional chest compressions combined with alternating abdominal compressions [6].
Patients recovering from cardiovascular surgery have been studied under various in-hospital resuscitation circumstances. However, no available studies have addressed the relative contributions of conventional manual CPR and IAC-CPR in patients undergoing cardiovascular surgery. The aim of the present study was to determine the feasibility, safety and efficacy of IAC-CPR compared with conventional CPR in patients with cardiac arrest after cardiac surgery in the intensive care unit (ICU).
PATIENTS AND METHODS Study population This prospective, observational study was conducted at the Cardiovascular Center of Hainan Medical College, where >400 cardiac operations are performed annually. From April 2009 to March 2014, 40 patients who experienced a postoperative cardiac arrest were included in this study. The patients were randomized by sealed envelopes to either conventional CPR (n = 21) or IAC-CPR (n = 19). Specifically, patients were included in this study
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ORIGINAL ARTICLE
Interactive CardioVascular and Thoracic Surgery 19 (2014) 985–989 doi:10.1093/icvts/ivu255 Advance Access publication 27 August 2014
986
J.-k. Li et al. / Interactive CardioVascular and Thoracic Surgery
if they had undergone a technically successful operation, had a cardiac index of at least 2.0 l/min/m2 upon transfer to the ICU and had not had massive bleeding (>400 ml/h for the first 2 h) that required emergency thoracotomy in the ICU. Patients receiving maximal inotropic and intra-aortic balloon pump support or those supported by ventricular assistance devices were not included in the study. The study was approved by the Institutional Review Board.
Treatment protocol All cases of cardiac arrest were jointly managed by the medical and surgical team. The surgical ICU is located next to the operating room and is staffed with 24-h on-site critical care specialists. Surgical coverage is provided by full-time cardiac surgeons around the clock. CPR was initially performed by the same group on all patients. If spontaneous circulation was not restored after 10–15 min, the surgical team would immediately proceed to resternotomy and internal cardiac massage.
Inclusion and exclusion criteria Cardiac arrest was defined as the cessation of cardiac mechanical activity with the absence of a palpable central pulse, apnoea and unresponsiveness, including ventricular fibrillation, asystole and pulseless electrical activity. Subjects were excluded if resuscitation began outside the ICU, if the cardiac arrest occurred during the inpatient preoperative period or if the cardiac arrest occurred after the first 24 h in the ICU. The endpoints of the study were safety, return of spontaneous circulation (ROSC) >5 min, survival to hospital discharge and survival for 6 months.
Abdominal cardiopulmonary resuscitation techniques The dedicated rescuer who provides manual abdominal compressions will compress the abdomen midway between the xiphoid and the umbilicus during the relaxation phase of chest compression [5]. The hand position, depth, rhythm and rate of abdominal compressions are similar to those for chest compressions, and the force required is similar to that used to palpate the abdominal aorta [6]. The rescuer’s hands are positioned on the abdomen with the left hand caudad and the other hand craniad to the umbilicus. The heels of the hands are placed 3 cm to the left of the midline, and the fingers are rested gently on the abdomen. In this manner, the abdomen is compressed via the hypothenar and thenar hand pads along a craniad–caudad line overlying the abdominal aorta.
Statistical analysis The values of continuous variables are given as the mean ± SD. We used the χ 2 test with continuity correction for dichotomous variables and the Wilcoxon test for continuous variables for group comparisons. Statistical significance was considered as P
Interposed abdominal compression-cardiopulmonary resuscitation after cardiac surgery Ji-ke Li, Jun Wang and Tian-fa Li* Cardiovascular Center of Hainan Medical College, Affiliated Hospital of Hainan Medical College, Haikou, China * Corresponding author. Cardiovascular Center of Hainan Medical College, Affiliated Hospital of Hainan Medical College, 31 Longhua Road, Haikou 570102, China. Tel: +86-898-66725370; fax: +86-898-66500144; e-mail: [email protected] (T.-f. Li). Received 29 April 2014; received in revised form 7 July 2014; accepted 10 July 2014
Abstract OBJECTIVES: The management of cardiac arrest after cardiac surgery differs from the management of cardiac arrest under other circumstances. In other studies, interposed abdominal compression-cardiopulmonary resuscitation (IAC-CPR) resulted in a better outcome compared with conventional CPR. The aim of the present study was to determine the feasibility, safety and efficacy of IAC-CPR compared with conventional CPR in patients with cardiac arrest after cardiac surgery. METHODS: Data on all cardiac surgical patients who suffered a sudden cardiac arrest during the first 24 h after surgery were collected prospectively. Cardiac arrest was defined as the cessation of cardiac mechanical activity with the absence of a palpable central pulse, apnoea and unresponsiveness, including ventricular fibrillation, asystole and pulseless electrical activity. Forty patients were randomized to either conventional CPR (n = 21) or IAC-CPR (n = 19). IAC-CPR was initially performed by compressing the abdomen midway between the xiphoid and the umbilicus during the relaxation phase of chest compression. If spontaneous circulation was not restored after 10–15 min, the surgical team would immediately proceed to resternotomy. The endpoints of the study were safety, return of spontaneous circulation (ROSC) >5 min, survival to hospital discharge and survival for 6 months. RESULTS: With IAC-CPR, there were more patients in terms of ROSC, survival to hospital discharge, survival for 6 months and fewer CPR-related injuries compared with patients who underwent conventional CPR. CONCLUSIONS: IAC-CPR is feasible and safe and may be advantageous in cases of cardiac arrest after cardiac surgery. Keywords: Interposed abdominal compression-cardiopulmonary resuscitation • Conventional cardiopulmonary resuscitation • Cardiac arrest • Cardiac surgery
INTRODUCTION Cardiac surgery confers a great risk of cardiac arrest during the postoperative period [1]. The incidence rate of cardiac arrest after cardiac surgery is 0.7–2.9% [2]. The chance of survival after an in-hospital cardiac arrest post-cardiac surgery is poor. Several issues in the management of cardiac arrest after cardiac surgery differ from the management of cardiac arrest under other circumstances [3]. Over the past 30 years, a variety of alternatives to conventional manual cardiopulmonary resuscitation (CPR) have been developed in an effort to enhance perfusion during attempted resuscitation after cardiac arrest and to improve survival [4]. The maintenance of vital organ perfusion during cardiac arrest is critical for successful resuscitation. However, studies have shown that standard CPR provides only 15–20% of normal myocardial perfusion and only 25–30% of normal cerebral perfusion [5]. Interposed abdominal compression (IAC)-CPR is a three-rescuer technique (an abdominal compressor plus the chest compressor and the rescuer providing ventilations) that includes conventional chest compressions combined with alternating abdominal compressions [6].
Patients recovering from cardiovascular surgery have been studied under various in-hospital resuscitation circumstances. However, no available studies have addressed the relative contributions of conventional manual CPR and IAC-CPR in patients undergoing cardiovascular surgery. The aim of the present study was to determine the feasibility, safety and efficacy of IAC-CPR compared with conventional CPR in patients with cardiac arrest after cardiac surgery in the intensive care unit (ICU).
PATIENTS AND METHODS Study population This prospective, observational study was conducted at the Cardiovascular Center of Hainan Medical College, where >400 cardiac operations are performed annually. From April 2009 to March 2014, 40 patients who experienced a postoperative cardiac arrest were included in this study. The patients were randomized by sealed envelopes to either conventional CPR (n = 21) or IAC-CPR (n = 19). Specifically, patients were included in this study
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ORIGINAL ARTICLE
Interactive CardioVascular and Thoracic Surgery 19 (2014) 985–989 doi:10.1093/icvts/ivu255 Advance Access publication 27 August 2014
986
J.-k. Li et al. / Interactive CardioVascular and Thoracic Surgery
if they had undergone a technically successful operation, had a cardiac index of at least 2.0 l/min/m2 upon transfer to the ICU and had not had massive bleeding (>400 ml/h for the first 2 h) that required emergency thoracotomy in the ICU. Patients receiving maximal inotropic and intra-aortic balloon pump support or those supported by ventricular assistance devices were not included in the study. The study was approved by the Institutional Review Board.
Treatment protocol All cases of cardiac arrest were jointly managed by the medical and surgical team. The surgical ICU is located next to the operating room and is staffed with 24-h on-site critical care specialists. Surgical coverage is provided by full-time cardiac surgeons around the clock. CPR was initially performed by the same group on all patients. If spontaneous circulation was not restored after 10–15 min, the surgical team would immediately proceed to resternotomy and internal cardiac massage.
Inclusion and exclusion criteria Cardiac arrest was defined as the cessation of cardiac mechanical activity with the absence of a palpable central pulse, apnoea and unresponsiveness, including ventricular fibrillation, asystole and pulseless electrical activity. Subjects were excluded if resuscitation began outside the ICU, if the cardiac arrest occurred during the inpatient preoperative period or if the cardiac arrest occurred after the first 24 h in the ICU. The endpoints of the study were safety, return of spontaneous circulation (ROSC) >5 min, survival to hospital discharge and survival for 6 months.
Abdominal cardiopulmonary resuscitation techniques The dedicated rescuer who provides manual abdominal compressions will compress the abdomen midway between the xiphoid and the umbilicus during the relaxation phase of chest compression [5]. The hand position, depth, rhythm and rate of abdominal compressions are similar to those for chest compressions, and the force required is similar to that used to palpate the abdominal aorta [6]. The rescuer’s hands are positioned on the abdomen with the left hand caudad and the other hand craniad to the umbilicus. The heels of the hands are placed 3 cm to the left of the midline, and the fingers are rested gently on the abdomen. In this manner, the abdomen is compressed via the hypothenar and thenar hand pads along a craniad–caudad line overlying the abdominal aorta.
Statistical analysis The values of continuous variables are given as the mean ± SD. We used the χ 2 test with continuity correction for dichotomous variables and the Wilcoxon test for continuous variables for group comparisons. Statistical significance was considered as P
