Overview

This page addresses frequently asked questions about the Cardiac Surgical Unit Advanced Life Support (CALS) programme and its North American counterpart, CSU-ALS. It provides clarity on training expectations, operational parameters, and regulatory frameworks governing CALS delivery. The responses reinforce the ethos of structured, protocol-driven resuscitation after cardiac surgery, emphasising teamwork, credentialing integrity, and adherence to CALS-aligned governance.

1. Team-Based Training, Not Independent Credentialing

   CALS does not credential nurses or allied health professionals to perform independent emergency resternotomies. Rather, it equips all team members—regardless of discipline—with the knowledge, skills, and situational awareness required to support the procedure effectively. Nurses play a pivotal role in assisting surgical providers, managing equipment, and facilitating a rapid, safe chest reopening. The focus is on team integration, not isolated task delegation.



2. Resternotomy by Non-Surgeons in Post-Operative Cardiac Arrest: A Critical Life-Saving Intervention

   Overview

   Emergency resternotomy following cardiac surgery is a time-critical, life-saving intervention. In the event of cardiac arrest post-cardiac surgery, the window for effective intervention is narrow and unforgiving. Delays beyond five minutes can result in irreversible neurological injury or death. In this context, empowering trained non-surgeons—particularly intensive care and theatre staff—with the skills and mandate to perform emergency resternotomy is both clinically necessary and ethically sound.

   
   

   Rationale for Non-Surgical Resternotomy

   • Surgeon unavailability is a frequent and unpredictable risk. Cardiac arrests may occur at night, during handovers, or in remote units where the on-call surgeon is off-site.
   • In the first 5-7 minutes of a post-operative cardiac arrest, timely resternotomy can significantly improve survival. It enables direct cardiac massage, identification of tamponade, internal defibrillation, pacing, and haemorrhage control.
   • Limiting resternotomy only to surgeons creates unacceptable treatment delays in situations where immediate intervention is vital.
   
   

   Clinical Governance and Risk Management

   • CALS protocols and national guidance—including those from the European Association for Cardio-Thoracic Surgery (EACTS) and the Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS), the Australian and New Zealand Society of Cardiothoracic Surgery (ANZSCTS) and the Australian and New Zealand Intensive Care Society (ANZICS)—now explicitly support trained non-surgeons undertaking emergency resternotomy where delays would compromise patient survival.
   • The procedure must be part of a formal institutional standard operating procedure (SOP), supported by appropriate training, access to necessary equipment, simulation practice, and governance oversight.
   • Practitioners who perform emergency resternotomy must be:
     • Clinically competent in the CALS protocol.
     • Familiar with the technical and human factors involved in managing a resternotomy arrest.
     • Embedded in a multidisciplinary team culture that supports immediate, protocol-driven action.
   • BEING A CALS PROVIDER DOES NOT AUTOMATICALLY 'CREDENTIAL' A PRACTITIONER TO PERFORM A RESTERNOTOMY
   
   

   Education, Training, and Credentialing

   • All non-surgeons expected to respond to cardiac surgical emergencies must undergo CALS Provider training, which includes:
     • E-learning preparation.
     • Hands-on simulation of chest reopening.
     • Crisis resource management and scenario training.
   • Institutions should maintain a register of trained personnel, ensure annual revalidation, and provide refresher moulage-based training at least every 12 months.
   • A trained team—regardless of whether it includes a surgeon—must be able to safely open the chest within 5 minutes of arrest in designated post-operative cardiac patients.
   • LOCAL CENTRES NEED TO PROVIDE A ROBUST GOVERNANCE-BASED MECHANISM TO ALLOW ALL STAFF TO HAVE CONFIDENCE IN THE ABILITY OF A NON-SURGEON TO SAFELY PERFORM AN EMERGENCY RESTERNOTOMY.
   
   

   Equipment, Environment and Support

   • To perform resternotomy safely, designated units must:
     • Use fourth-generation training manikins.
     • Maintain a fully stocked emergency resternotomy trolley with appropriate instruments.
     • Position patients in environments (ICU, HDU, PACU) that allow for immediate access to sterile packs, pacing equipment, defibrillators and internal paddles.
   
   

   Cultural and Professional Considerations

   • Encouraging non-surgeons to perform resternotomy challenges historical hierarchies but aligns with modern, patient-centred models of care.
   • The key determinant must always be clinical competence, not professional title.
   • An inclusive, protocol-led model empowers nurses, perfusionists, anaesthetists and ICU physicians to take decisive action in the interests of patient survival.


3. Limitations of E-Learning in Trainer Pathway

   The CALS e-learning component is an essential pre-course preparation tool, but does not confer trainer status. Becoming a CSU-ALS/CALS trainer requires completion of the in-person Train the Trainer (TTT) course and supervised teaching practice. No part of the e- learning module can substitute for this structured, proctored process. Certification pathways are detailed under the 'Certification' tab on the CALS/CSU-ALS website.



4. Venue Flexibility for Course Delivery

   CALS is designed for adaptability. It can be delivered in high-fidelity simulation centres or basic venues such as hospital meeting rooms or hotel ballrooms. Essential equipment is commonly found in most ICUs or education departments. The TTT programme prepares faculty to optimise delivery regardless of the environment. This flexibility enables broader global access without compromising educational standards.



5. Approach to Minimal Access Cardiac Surgery

   The current CALS protocol is designed for patients who have undergone median sternotomy. However, its principles—preparedness, role clarity, and early intervention—apply to minimal access cardiac surgery (e.g., mini-thoracotomy). Surgeons performing such procedures must ensure staff are trained in how to approach emergency re-entry in the event of cardiac arrest. Detailed guidance is available in the companion document “CALS and Minimal Access Cardiac Surgery.”



6. Gowning and Gloving Protocols

   All attempts at emergency resternotomy should be performed with full gowning and gloving, unless these actions would delay intervention beyond the critical five-minute window. Most ICUs have this equipment readily accessible. Gowning and gloving are incorporated into the practical skills taught on the CALS Provider Course to ensure practitioners are proficient, even if these actions are infrequent in their routine clinical roles.



7. Application to Ward / Floor or Step-Down Patients

   CALS is intended for use in ICU patients within the first 10 days post-op. Beyond this window, pericardial adhesions reduce the safety and effectiveness of emergency re-entry, and cardiac arrest etiologies shift toward non-surgical causes. In such cases, standard ALS should be applied, with an emphasis on:

   • Delivering 3-stacked DC shocks for VF/VT.
   • Attempting emergency pacing in Asystole.
   • Delaying CPR to defibrillate when appropriate.
   There are several situations (including late Tamponade after epicardial pacing wire removal) where emergency resternotomy is appropriate; thus, immediate consultation with the appropriate surgical team is mandatory. While CALS is not routinely applied to ward patients, some of its principles—particularly early pacing and defibrillation—may be adapted at local discretion.



8. Manikin Procurement and Certification Restrictions

   The CALS manikin, a key component of moulage training, is exclusively available from CALS Australia PTY LTD. CALS holds global distribution rights, and centres seeking procurement should contact adrian.levine@csu-als.org..
   Furthermore, centres may not deliver CSU-ALS or CALS-certified training unless formally accredited. The use of proprietary materials, branding, and certification processes without authorisation is prohibited.



9. Trainer Mobility and Centre Affiliation

   Trainer accreditation is linked to a specific CALS Australia PTY LTD Centre of Excellence (COE). Trainers cannot independently teach at alternate locations without prior invitation or authorisation from CALS Australia PTY LTD. This ensures that all courses meet CALS quality standards and are delivered within the correct educational governance framework.
   Trainers can apply to become 'travelling trainers' by emailing adrian.levine@csu-als.org..



10. CALS vs CSU-ALS Branding

    CALS is the global standard nomenclature for post-cardiac surgery resuscitation training. Due to trademark limitations in the United States, the programme is marketed as CSU-ALS within the Americas. The educational content and underlying protocol remain aligned across both programmes. The CALS protocol, now 20 years in development, was adopted by CSU-ALS in 2014 and has since been integrated into training systems across the United States, Canada, and Latin America.



11. The Role of ECMO in Early Post-Operative Cardiac Arrest: Strategic Deployment for Salvageable Physiology

    Overview

    Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as a powerful adjunct in the resuscitation of patients who suffer cardiac arrest in the early post-operative period following cardiac surgery. While conventional interventions such as defibrillation, pacing, and emergency resternotomy remain first-line treatments, ECMO offers the opportunity to provide full circulatory and respiratory support in cases where return of spontaneous circulation (ROSC) is not rapidly achieved. When deployed judiciously, ECMO serves as a bridge to recovery, decision, or definitive intervention.

    Context and Indications

    • The majority of cardiac arrests in the early post-operative period are reversible if recognised and treated within minutes. Common causes include tamponade, severe arrhythmia, graft occlusion, bleeding, or myocardial stunning.
    • In rare cases, these conditions persist despite maximal resuscitation and resternotomy. In such scenarios—particularly in patients with previously good cardiac function, minimal comorbidity, and witnessed arrests—VA-ECMO can be life-saving.
    • The most appropriate candidates are those with salvageable pathology, short no-flow times, and prompt initiation of the CALS protocol.
    
    

    Physiological Rationale

    • ECMO allows for complete cardiopulmonary bypass, offloading both the right and left heart and providing oxygenated blood to the brain and vital organs.
    • It reduces myocardial oxygen demand and allows for myocardial recovery while enabling ongoing diagnostic assessment and treatment (e.g. revascularisation, pacing, surgical re-intervention).
    • In early post-operative patients, ECMO may also stabilise haemodynamics sufficiently to allow transfer to the theatre or cath lab if needed.
    
    

    Cannulation and Deployment

    • Most commonly, central cannulation is performed in the theatre or ICU post-resternotomy. Alternatively, peripheral cannulation (femoral-femoral) may be used in a deteriorating patient where central access is not immediately feasible.
    • In the arrested patient, central cannulation is the means of choice.>
    • Rapid deployment is essential. For optimal outcomes, ECMO should be initiated within 30-60 minutes of arrest, ideally sooner.
    
    

    Governance, Team Training and Protocols

    • ECMO should be incorporated into the CALS resuscitation algorithm as a final-tier intervention for refractory cardiac arrest when reversible causes have been addressed.
    • Decision-making must be multidisciplinary, involving the ICU consultant, cardiothoracic surgeon, anaesthetist, and perfusionist.
    • All ECMO-capable centres should have a clear SOP for:
      • Patient selection
      • Cannulation technique
      • Anticoagulation management
      • Post-ECMO monitoring and decision-making for weaning or withdrawal
    
    

    Limitations and Ethical Considerations

    • ECMO is not appropriate for patients with irreversible pathology, prolonged low-flow states, or severe neurological compromise.
    • It should not be used to prolong futile care but rather to support carefully selected patients for whom a meaningful recovery is possible.
    • Survivors of ECMO in this context often recover to a good neurological outcome, particularly when initiated early with preserved organ function.
    
    

    Conclusion

    ECMO plays a critical, albeit selective, role in the resuscitation of patients who arrest early after cardiac surgery. Its success hinges on timing, patient selection, and institutional preparedness. When integrated into a well-governed, protocolised approach, ECMO offers a bridge to life in patients where conventional strategies alone are insufficient.

Key Takeaways

• CALS is a multidisciplinary, protocol-driven training programme. It does not promote independent practice but instead fosters effective team roles in emergency resternotomy.
• Training integrity is paramount. Certification requires face-to-face instruction and cannot be earned through e-learning alone.
• Venue flexibility supports global reach. Simplicity of setup does not compromise quality when faculty are properly trained.
• Post-operative period specificity is critical. The protocol is validated for ICU use within 10 days post-cardiac surgery; beyond this, standard ALS applies.
• Governance is tightly regulated. Trainers must operate within accredited centres. Materials, branding, and certification remain the intellectual property of CSU- ALS/CALS.