Circ arrest 2025

[castafari]

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What are the latest recommendations for circ arrest management these days? I’m 10 years out of training and only done a handful of these cases the past 10 years.
-high dose steroids still given?
-ice packs to head during circ arrest?
-propofol bolus just prior to circ arrest for burst suppression?
Seems like some these practices were controversial “voodoo” 10 years ago. Just looking for more current practice at academic centers these days

 

[dannyboy1]

What are the latest recommendations for circ arrest management these days? I’m 10 years out of training and only done a handful of these cases the past 10 years.
-high dose steroids still given?
-ice packs to head during circ arrest?
-propofol bolus just prior to circ arrest for burst suppression?
Seems like some these practices were controversial “voodoo” 10 years ago. Just looking for more current practice at academic centers these days

Not a cardiac guy but don’t see any of those things doing harm….

 

[coolforschool]

What are the latest recommendations for circ arrest management these days? I’m 10 years out of training and only done a handful of these cases the past 10 years.
-high dose steroids still given?
-ice packs to head during circ arrest?
-propofol bolus just prior to circ arrest for burst suppression?
Seems like some these practices were controversial “voodoo” 10 years ago. Just looking for more current practice at academic centers these days

Not a cardiac guy but don’t see any of those things doing harm….

We do CTEPHs here. Still dose steroids but not super high (methylpred 500 mg). We have a polar ice head wrap device, but it’s still mostly voodoo. I do it just for appearances sake. Recent evidence says propofol bolus/burst suppression may do harm with little benefit, so we stopped doing that in our practice (I never did it personally since we use Sedline/EEG monitoring and found it 100% unnecessary).

 

[Teillard]

Still do steroids, propofol but not the ice thing since A/R cerebral perfusion with most guys.

 

[pgg]

Last couple I've done, I've asked the surgeon what their preference was, and they just say "do what you normally do" ...

I put ice around the head. The data isn't compelling AFAIK, but it makes intuitive sense to me. During circ arrest obviously there isn't any blood flow to the brain. If the head is exposed, during that time it could passively rewarm. So I put the ice there more to prevent passive rewarming than to do any kind of additional cooling.

That's all I normally do.

 

[anesthesiologyperson21]

what are you guys doing for your dose of steroids? My surgeon routinely asks for 1000 mg methylprednisolone.

 

[DolphinVA]

We do lots of arches around here. It's been a looong time since we've had to do true circ arrest. Most cases are either antegrade or retrograde CP. We ice the head for true arrest, but otherwise none of those other interventions are of proven benefit. Besides optimizing your O2 delivery to the head, your fate is determined by surgeon speed.

 

[AdmiralChz]

As long as you’re doing ACP (antegrade cerebral perfusion) which I imagine most are in this day and age not much else is needed.

 

[Twiggidy]

As long as you’re doing ACP (antegrade cerebral perfusion) which I imagine most are in this day and age not much else is needed.

This and cooling to 28 or below (probably lower than 28 in my opinion). If they go retrograde, definitely cold. If is fine but not proven to improve outcomes. Throw on some head sats

 

[Twiggidy]

We do lots of arches around here. It's been a looong time since we've had to do true circ arrest. Most cases are either antegrade or retrograde CP. We ice the head for true arrest, but otherwise none of those other interventions are of proven benefit. Besides optimizing your O2 delivery to the head, your fate is determined by surgeon speed.

Exactly, if they want a good outcome they need to be done in 30 mins….45 at most

 

[Gern Blansten]

We use these red light therapy helmets. The neurologic outcomes have not improved, but the additional luxurious hair growth has been a real crowd pleaser.

 

[2buckchuck]

What I was taught that really mattered was being cold and selective cerebral perfusion. All the other stuff was fluff.

 

[abolt18]

Selective antegrade perfusion on every arch case I've done out of training, so not much more than some ice like PGG said, and even that's nebulous.

 

[DesiredMemberName?]

We do a fair amount of arch work. They always get SACP w cerebral oximetry and tympanic temp monitoring. If you’re perfusing the brain, it stays cold without adding ice. I would add ice for a true total circ arrest (e.g. pulm endarterectomy).

We don’t do any of the other stuff.

 

[PpfSuxTube]

Just 1000 methylpred and acp. Most of our guys are super fast. 20 30 mins max circ arrest. 1 guy is slower 40 mins to an hour. Still not bad. We had loads of dissections this last 3 weeks. Loads of badness in general

 

[caligas]

My understanding is these patients will certainly perish if they don’t have at least 4 stickers on their forehead

 

[DesiredMemberName?]

My understanding is these patients will certainly perish if they don’t have at least 4 stickers on their forehead

I don’t think the processed eeg adds much (besides reassurance), but the cerebral oximetry can tell you if the circle of Willis is providing adequate perfusion of the left hemisphere when doing SACP from the innominate.

We’ve had cases with significant drops in left side sats that recovered with direct perfusion to the left carotid.

 

[Iso4ane]

My understanding is these patients will certainly perish if they don’t have at least 4 stickers on their forehead

I like these stickers.

 

[sevoflurane]

Ice, cerebral oximetry routinely.
I haven’t given steroids in 15 years.

 

[Gern Blansten]

I haven’t given steroids in 15 years.

BALCO?

 

[sanityonleave]

Just cerebral oximetry here - no ice, steroids, propofol, or other nonsense. Patients are all isoelectric if they're cold enough anyway, though we do keep EEG on to check.

We do a lot of straight circ arrest for PTEs and hemiarches, but we try and move fast to keep time down. Def under 30 minutes, ideally under 20 for a hemi. For total / zone IIs we usually cannulate R ax and do SACP (10-15cc/kg/min) which is where the cerebral sats come in - can help identify if you need field cannulation of the LCCA.

My bias is all the rest is fluff. A few folks in our group were icing the head until we had a consensus meeting and decided to stop - data doesn't support it. Haven't given steroids or extra anesthetic since I started practicing, but I'm not that many years into the game.

We are participating in an RCT of moderate hypothermia (28) versus DHCA for short circ arrest cases - looking forward to seeing what the data shows.

 

[DrN2O]

I put ice around the head. The data isn't compelling AFAIK, but it makes intuitive sense to me. During circ arrest obviously there isn't any blood flow to the brain. If the head is exposed, during that time it could passively rewarm. So I put the ice there more to prevent passive rewarming than to do any kind of additional cooling.

What is the brain going to rewarm to, room temperature? I rarely see true circ arrest, without ACP, so not 18C. My OR is colder than that already. Ice, in theory, could cause local vasoconstriction and uneven cooling, so I agree it could be done, AFTER cooling, to prevent rewarming, not DURING cooling down.

 

[sevoflurane]

Just cerebral oximetry here - no ice, steroids, propofol, or other nonsense. Patients are all isoelectric if they're cold enough anyway, though we do keep EEG on to check.

We do a lot of straight circ arrest for PTEs and hemiarches, but we try and move fast to keep time down. Def under 30 minutes, ideally under 20 for a hemi. For total / zone IIs we usually cannulate R ax and do SACP (10-15cc/kg/min) which is where the cerebral sats come in - can help identify if you need field cannulation of the LCCA.

My bias is all the rest is fluff. A few folks in our group were icing the head until we had a consensus meeting and decided to stop - data doesn't support it. Haven't given steroids or extra anesthetic since I started practicing, but I'm not that many years into the game.

We are participating in an RCT of moderate hypothermia (28) versus DHCA for short circ arrest cases - looking forward to seeing what the data shows.

Surgeon dependent. You’ll need big numbers and appropriately stratified.

 

[pgg]

What is the brain going to rewarm to, room temperature? I rarely see true circ arrest, without ACP, so not 18C. My OR is colder than that already. Ice, in theory, could cause local vasoconstriction and uneven cooling, so I agree it could be done, AFTER cooling, to prevent rewarming, not DURING cooling down.

That's a fair point. I'm not married to the idea of ice.

Usually our rooms are fairly cold, temp in the 60s. Passive rewarming shouldn't be too much of a concern, though I wouldn't place $ on the microclimate under the drapes being room temp.