Title of Guideline (must include the word Guideline (not. Guidelines. Contact Name and Job Title (author)

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1 Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and Job Title (author) Directorate & Speciality Date of submission Date on which guideline must be reviewed (this should be one to three years) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Cardiac Advanced Life Support Resusitation Guidelines Christopher Green, Ward Manager CICU Nicola Audas, Ward Manager CICU Joan Guevarra, Dept Sister CICU Cardiac Surgery TBC 10 May 2016 (Last reviewed 10 May 2013) Cardiac surgery patients (with sternotomy) up to 5 days post op. Abstract This guideline describes the actions to be taken in the event of an arrest in post cardiac surgery patients with a sternotomy up to five days post surgery. Key Words Cardiac surgery Emergency resternotomy Resuscitation Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-5) 1a meta analysis of randomised controlled trials 1b at least one randomised controlled trial 2a at least one well-designed controlled study without randomisation 2b at least one other type of well-designed quasiexperimental study 3 well designed non-experimental descriptive studies (i.e. comparative / correlation and case studies) 4 expert committee reports or opinions and / or clinical experiences of respected authorities 5 recommended best practise based on the clinical experience of the guideline developer Consultation Process Target audience These guidelines are based on research and work carried out by Mr Joel Dunning et al. Dunning J, et al. Guideline for resuscitation in cardiac arrest after cardiac surgery. Eur J Cardiothorac Surg (2009), doi: /j.ejcts Adam Z, et al. Resusitation after cardiac surgery: results of an international survey. Eur J Cardiothorac Surg (2009), doi: ?j.ejcts Dunning J, et al. The Cardiac Surgery Advanced Life Support Course. 2 nd Edition These guidelines have been peer reviewed by: Cardiac Consultant Surgeons Cardiac Consultant Anaesthetists Cardiac Registrars Ward Managers Senior Staff Nurses Matron Heart Services Clinical Lead DIRC As Above CICU Staff

2 This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

3 GUIDELINES FOR EMERGENCY RESTERNOTOMY AS AN EXTENDED ROLE FOR SENIOR NURSES / CICU PRACTITIONERS FOLLOWING CARDIAC SURGERY BACKGROUND There is recognition that, after cardiac surgery, certain variables may dictate differences in the management of cardiac arrest. The incidence of cardiac arrest after cardiac surgery is around % and has reduced in recent years. A higher proportion of patients suffering arrests post cardiac surgery survive to hospital discharge than patients suffering cardiac arrest in other settings. The reason for this superior survival is the high incidence of reversible causes for the arrest. Ventricular fibrillation (VF) accounts for the rhythm in 25-50% of cases and, in the intensive care unit (ICU) setting; this is immediately identified and treated. In addition, tamponade and major bleeding account for many arrests and both conditions may be quickly relieved by prompt resuscitation and emergency resternotomy where appropriate. In situations where a cardiac surgical registrar is not immediately available, an emergency resternotomy by other trained personnel in ICU may be lifesaving. (1) BOUNDARIES OF PRACTICE Role Experience Training Optional Update CICU Nurse Practitioners, Band 7 and 6 Nurses in CICU/CHDU Current ALS provider Successful completion of Cardiac Surgical Unit Advanced Life Support Course (CALS). Annual attendance of CALS refresher day Cardiac Theatres Annual in-house update facilitated by Mr I Mitchell and Dr H Skinner PATIENT GROUP Post cardiac surgery via sternal approach. Emergency resternotomy should form part of the cardiac arrest protocol up to 5 days post op.

4 Emergency resternotomy should be performed after 3 unsuccessful attempts at defibrillation for VF or pulse less VT. Emergency resternotomy should be immediately performed for non-shockable cardiac arrest which does not resolve after pacing and atropine. STATEMENT OF INTENT The intention of these guidelines is to provide guidance on all matters relating to emergency resternotomy following cardiac arrest as laid out by the European Association for Cardiothoracic Surgery (EACTS) Guidelines. EMERGENCY TEAMS Second on-call anaesthetist and Consultant via switch board. Consultant Surgeons Re-opening team and Perfussionist on-call via switch board. (1) Dunning J, et al (2009). European Association for Cardiac and Thoracic Surgery (EACTS) Clinical Guidelines for the Resuscitation of Patients who Arrest after Cardiac Surgery. European Journal of Cardio- Thoracic Surgery. EJCTS-687

5 Guideline for Cardiac Advanced Life Support (CALS) resuscitation on CICU/CHDU Action Establish patient has had a cardiac arrest and fits protocol for CALS resuscitation Shout for help and request emergency equipment Team leader to allocate the six key roles, plus two staff members to perform resternotomy. Role 1 bedside nurse: Switches IABP to pressure trigger. Deflate air mattress Performs CPR. A pericardial thump may be performed within 10 secs of the onset of VF or pulseless VT as long as defibrillation is not delayed. Role 2 airway nurse: For ventilated patient increase oxygen to 100% and reduce PEEP to 0.( remove) Check correct position of ET tube. If you can not ventilate via the ET tube and a suction catheter cannot be passed down ET tube remove ET tube and ventilate with a bag, mask and airway adjuncts. Rationale To establish if CALS resuscitation is required/ appropriate To ensure people and equipment are available To ensure everyone knows what they are supposed to be doing. To ensure adequate cardiac output is maintained. To ensure adequate oxygenation during resuscitation. For non ventilated patient secure and maintain airway until anaesthetist arrives. Listen for bilateral breathe B

6 Action sounds to establish correct position of ET tube and rule out a tension pneumothorax. Rationale Role 3 defib/pacing nurse: If shockable rhythm deliver shocks as required. If PEA rhythm turn off any pacing to exclude underlying VF. If asystolic rhythm pace at 90 bpm at maximum output. Change to internal paddles when required and charge paddles when asked. Role 4 Team leader: Leads the resuscitation as per protocol. Role 5 drugs nurse: Turn off all infusions except propofol. Administer drugs when required i.e. amiodarone 300mg, atropine 3mg, & propofol as per PGD. Role 6 CICU coordinator: Phone 2 nd on call anaesthetist, consultant anaesthetist, consultant surgeon and reopening team. Prepare kit for resternotomy. Ensure safe running of the rest of the unit during the resuscitation. To ensure a well co-ordinated resuscitation. To ensure correct drugs are given at the right time. To ensure further help is on the way. To maintain the safety of other patients. Resternotomy pair: Prepare selves and patient for resternotomy.

7 Action Rationale If rhythm is VF/VT and the defibrillator is ready, give three shocks (200j, 300j, 360j). Prepare for resternotomy. If output has not returned following third shock commence CPR. Administer 300mg amiodarone. Continue CPR with single shock (360j) every two minutes until resternotomy is carried out. If rhythm is asystole/severe bradycardia and a pacing box is available (the pt needs to have pacing wires) pace at 90bpm at maximum output. Prepare for resternotomy. Give 3mg atropine and consider external pacing. Continue CPR until resternotomy is carried out. If rhythm is PEA start CPR. Turn off any pacing box. Prepare for resternotomy. Continue CPR until resternotomy is carried out. Three successive attempts at defibrillation will increase the likelihood of restoring cardiac output after a VF/VT arrest and reduce the risk of trauma to recently operated cardiac structure and suture lines. In VF or pulseless VT, emergency resternotomy should be performed after three failed attempts at defibrillation. To maintain cardiac output. To improve the response to further shocks. To maintain cardiac output. In an arrest after cardiac surgery, external cardiac massage can be deferred until initial pacing has been attempted, provided this can be done immediately. External pacing may restore cardiac output. To ensure adequate cardiac output. To ensure adequate cardiac output. To exclude an underlying VF. To ensure adequate cardiac output.

8 Action Rationale SCOOP AND RUN GUIDELINE FOLLOWING CARDIAC ARREST POST OPEN HEART SURGERY FROM MORRIS WARD TO CICU PROCEDURE In the event of an arrest call in Morris Nurse in charge or Practitioner will attend to the call Nurse in charge or Practitioner will liaise with CICU staff to organise scoop and run to: Cardiac Theatre if appropriately trained staff available. CICU bed space CHDU bed space Otherwise if no bed available as above, continue ALS. DO NOT SCOOP & RUN Transfer patient to area identified. Then, identify the six key roles in the CALS cardiac arrest team. Follow procedure for CALS algorithm. RATIONALE To assess the patient to see if they met the criteria as per emergency re-sternotomy protocol. To be able to perform resternotomy in an appropriate clinical environment. Theatre provides sterile environment, availability of equipment for the procedure and trained staff). Preferred area during out of hours. If no CICU bed available. It would be inappropriate to do re-sternotomy if no theatre beds or CICU/CHDU beds available, therefore ALS algorithm should be followed in Morris ward. To allow the re-sternotomy to be performed. To allow smooth flow of the procedure optimising teamwork. [Appendix D]

9 Emergency Resternotomy guidelines In the event of a CALS Resuscitation. Action Don a gown and gloves in a sterile fashion, using the closed glove technique. Do not wash your hands. Continue CPR until you are ready to apply the all-in-one sterile thoracic drape When ready ask the person performing CPR to remove the sternal dressing and stand aside. Apply thoracic drape, the clear adhesive window should cover the sternal wound, ensuring the whole bed is covered. Commence sterile CPR until resternotomy set is ready. Use scalpel to cut the sternotomy incision, including all sutures, down to the sternal wires. Remove sternal wires using wire cutters and needle holder. Rationale To reduce risk of infection. Washing hands will take too much time and if hands are damp it will be difficult to put on gloves. To optimise resuscitation To allow access to the sternum. Anti septic skin preparation is not required as it only sterilises the skin as it dries, this would take too much time. The window is sterile and covers the skin To optimise resuscitation. To provide access to the sternal wires. To provide access for the retractors.

10 Use sterile suction to remove excess blood and clots. Place the retractor between the sternal edges and open the sternum. If cardiac output is restored you should await expert assistance. If cardiac output is not restored lift drains out of the wound and place to one side. Identify the position of any grafts. Perform internal cardiac massage and/or defibrillation. If there is an obvious bleeding point from the front of the heart, aorta or a graft, put your finger over the hole. The surgeon must stand to the right of the patient. Once cardiac output is restored commence a propofol infusion as per PGD. To provide good visibility. To provide access to the heart. To improve visibility and access. To avoid detaching any grafts. To restore or maintain circulation. To stop a bleeding point. It is impossible to perform internal cardiac massage from the left. To ensure patient is kept asleep and comfortable.

11 EMPLOYEE RECORD OF HAVING READ THE GUIDELINE I have read and understand the principles contained in the named policy. PRINT FULL NAME SIGNATURE DATE

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