Circ arrest

[gasdoc77]

for my fellow cardiac peeps, anybody have any tricks they like to do before/after circ arrest? (Propofol burst suppression, antioxidants, etc.)

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[OB1🤙]

We very rarely do true DHCA anymore (that is, 18-20 degrees and everything off). Our shop's standard is antegrade cerebral perfusion via some right access (axillary cutdown vs. direct innominate cannulation in the chest depending on the operator). Usually around 28 degrees or so.

These are one of the few cases I'll use BIS, and I'll give propofol until isoelectricity before clamping the innominate and running the antegrade perfusion- just in case the circle of Willis is sketch. I give some lidocaine too based on some marginal data that it might possibly help, and it definitely doesn't hurt.

That's about it. I don't believe in putting the head in ice, but I'll do it for a true circ arrest case ("preventing rewarming"- whatever, I think it's voodoo, messy puddle-making voodoo) if the surgeon cares. I don't do it for antegrade cerebral perfusion cases though I've had surgeons ask me to, because surgeons are silly sometimes.

For true circ arrest, you're usually isoelectric at 20 degrees anyway but I'll give some extra propofol before turning the pump off because why not.

I think one of the more important things with these cases is not to rewarm too fast or too much. Cerebral hyperthermia is definitely bad during/after these cases.

I had no teaching re: antioxidants and can't recall reading anything important about them either. Is there some data out there that they're helpful? Our trauma ICU loves that stuff, but they're a bunch of lunatics and I don't trust anything they do. I'm open to the idea if there's good data for it.

 

[Noyac]

I did two circ arrest cases my first year in PP one right after the other from two separate MVAs where both pts had aortic arch injuries.

For the life of me I can't remember anything I did other than the mess of melting ice packed around the pts head. What a mess.

Both pts walked out of the hospital within 5 days. It's good to be young if you decide to run your car into a tree.

 

[deleted171991]

High dose methylprednisolone. And ice packs around the head.

 

[deleted171991]

Our trauma ICU loves that stuff, but they're a bunch of lunatics and I don't trust anything they do.

 

[ymgc]

High dose methylprednisolone. And ice packs around the head.

At my shop, just some roc prior to shutting the pump off at 20 degrees to prevent shivering on rewarming. We don't pack the head with ice primarily because it does nothing. The cranium is a very very poor conductor for heat exchange so you just end up with frostbite on the scalp. The pump itself does all the brain cooling/heating that you need. No trial has ever shown topical head cooling to improve outcomes or achieve anything meaningful

 

[anes121508]

I've done and seen all kinds of stuff (lido, mag, precedex, head ice, cerebral sats) , but based on the last couple of reviews on this topic that I read:
Moderate hypothermia + antegrade
Make sure bis is isoelectric (ISO electric happens at different temps for different people)
Circ arrest time <30 min
Don't rewarm too fast
Control glucose <180

I like the roc idea someone mentioned, can't recall reading about it or being taught that but makes sense.

 

[deleted162650]

We did a butt ton of DHCA in residency (more PTE's than everywhere else combined). They got an induction dose of prop after confirmation of an isoelectric EEG before stopping the pump. Instead of ice bags, we put one of those "Poler Shoulder" ice wraps around the head that the orthopods use after shoulder cases. At least it was mess free. We also had to ritualistically make sure that stopcocks were off to the patient.

 

[drmwvr]

We don't pack the head with ice primarily because it does nothing. The cranium is a very very poor conductor for heat exchange so you just end up with frostbite on the scalp. The pump itself does all the brain cooling/heating that you need. No trial has ever shown topical head cooling to improve outcomes or achieve anything meaningful

Indeed...ditto on the high dose steroids.

 

[pgg]

We circ arrest cteph patients getting pulmonary thrombectomies. Usually about 20-25 minutes per side. No ice around the head. We don't give steroids or extra propofol.

The rest of our "circ arrest" cases are a couple of minutes at most for arch cases. Right axillary cannulation for antegrade perfusion.

 

[OB1🤙]

Re: steroids- I have never been convinced of any real neuroprotective effect. I have definitely been convinced of a neurotoxic effect of hyperglycemia, which they certainly produce.

IF steroids are given, and IF they are in fact beneficial, what's out there says they need to be given way in advance. Giving at the time of CPB is worthless. Because we usually don't have that kind of time, I generally don't give steroids in these cases.

 

[dhb]

We circ arrest cteph patients getting pulmonary thrombectomies. Usually about 20-25 minutes per side. No ice around the head. We don't give steroids or extra propofol.

The rest of our "circ arrest" cases are a couple of minutes at most for arch cases. Right axillary cannulation for antegrade perfusion.

Your surgeons are slow i used to do 30min for both sides

 

[thinkorswim]

We do moderate hypothermia with antegrade perfusion from right axillary/subclavian artery cannulation for our arches. Ice bags around the head, midazolam, and rocuronium. No steroids or propofol.