Anesthesia for off-pump coronary artery bypass surgery

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Review Article

Anesthesia for off‑pump coronary artery bypass surgery Thomas M. Hemmerling, Gianmarco Romano1, Nora Terrasini2, Nicolas Noiseux3 Department of Anesthesia, McGill University, Montreal, Canada, 1Anesthesia , University of Naples Federico II, 2 Anesthesia, University of Pisa, Pisa, Italy, 3Cardiac Surgery, University of Montreal, Canada

ABSTRACT

Received: 20‑06‑12 Accepted: 08‑09‑12

The evolution of techniques and knowledge of beating heart surgery has led anesthesia toward the development of new procedures and innovations to promote patient safety and ensure high standards of care. Off‑pump coronary artery bypass (OPCAB) surgery has shown to have some advantages compared to on‑pump cardiac surgery, particularly the reduction of postoperative complications including systemic inflammation, myocardial injury, and cerebral injury. Minimally invasive surgery for single vessel OPCAB through a limited thoracotomy incision can offer the advantage of further reduction of complications. The anesthesiologist has to deal with different issues, including hemodynamic instability and myocardial ischemia during aorto‑coronary bypass grafting. The anesthesiologist and surgeon should collaborate and plan the best perioperative strategy to provide optimal care and ensure a rapid and complete recovery. The use of high thoracic epidural analgesia and fast‑track anesthesia offers particular benefits in beating heart surgery. The excellent analgesia, the ability to reduce myocardial oxygen consumption, and the good hemodynamic stability make high thoracic epidural analgesia an interesting technique. New scenarios are entering in cardiac anesthesia: ultra‑fast‑track anesthesia with extubation in the operating room and awake surgery tend to be less invasive, but can only be performed on selected patients. Key words: Coronary artery bypass, Fast‑track cardiac surgery, High thoracic epidural anesthesia, Intraoperative monitoring, Off‑pump coronary artery bypass

INTRODUCTION

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Off‑pump coronary artery bypass (OPCAB) surgery was first performed in 1967[1] but only recently has been used in a more widespread way.[2] Potential benefits of avoiding cardiopulmonary bypass (CPB) consist in reducing postoperative complications, such as generalized systemic inflammation,[3] atrial fibrillation,[4] bleeding,[5] kidney dysfunction,[6,7] and cerebral injury.[8] However, the usefulness of this technique is still controversial; long‑term graft patency rates have shown to be better after on‑pump coronary artery bypass grafting.[9,10] On the other hand, OPCAB has demonstrated to produce better outcome in high‑risk patients.[11] The specific positioning of the heart during OPCAB can produce hemodynamic instability which anesthesiologists are required to deal with. The key to hemodynamic management

is good communication between surgeon and anesthesiologist. The choice of anesthetic technique may also influence the outcome of the patient; fast‑track anesthesia in OPCAB surgery has produced excellent results.[12] The purpose of this review is to focus on the anesthetic assessment and management in OPCAB surgery. Preoperative assessment An accurate preoperative assessment of p a t i e n t s u n d e rg o i n g O P CA B s u rg e r y requires careful history taking and thorough physical examination. Anesthesiologists should investigate the presence of risk factors associated with increased perioperative morbidity and mortality.[13] In choosing the appropriate anesthetic approach, both the severity and location of the coronary lesions and the surgical plan should be considered.[14] It is important to discuss with the patient

Address for correspondence: Prof. Thomas M. Hemmerling, Department of Anesthesiology (McGill University), Montreal General Hospital, 1650 Cedar Avenue Montreal, H3G 1A4, Canada. E‑mail: [email protected]

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Annals of Cardiac Anaesthesia  Vol. 16:1  Jan-Mar-2013

[Downloaded free from http://www.annals.in on Monday, June 11, 2018, IP: 189.237.130.10] Hemmerling, et al.: Off-pump coronary artery bypass anesthesia: A review

the specific anesthetic technique and its risks before obtaining informed consent. The risk of death should be calculated using “scoring systems” to stratify and inform patients of their individual risk. These systems range from simple additive scores (Parsonnet Score)[15] to more complex system (EuroSCORE).[16] The most recent guideline on perioperative blood transfusion and blood conservation identifies patient risk factors for transfusion. The guideline considers OPCAB as a means to decrease that risk: “OPCAB is a reasonable means of blood conservation, provided emergent conversion to on‑pump bypass is unlikely either based on surgeon experience or patient characteristics (Level of evidence A).”[17] Other techniques described are: use of drugs that increase preoperative blood volume or decrease postoperative bleeding, correct management of antiplatelet and antithrombotic drugs before surgery, preoperative autologous blood donation, normovolemic hemodilution, and routine use of cell‑saving devices. Premedication and monitoring Adequate premedication can reduce the patient’s anxiety. An intermediate‑acting benzodiazepine (e.g., temazepam or lorazepam) is commonly administered orally 1 h before surgery. It may also be appropriate to prescribe a β‑blocker such as atenolol, 50 mg per os, at the time of premedication in order to prevent arrhythmias – unless the patients already are on β‑blockers.[18] Cornerstones of monitoring include [Table 1]: 1. 5‑lead surface electrocardiogram (ECG) with automated ST segment analysis 2. Pulse oximetry 3. Continuous urinary output 4. Esophageal and rectal temperature 5. Arterial blood pressure by cannulating radial and/or femoral artery 6. Central venous catheter (CVC) and/or Pulmonary artery catheter (PAC) 7. Transesophageal echocardiography (TEE) 8. Depth of unconsciousness in patients operated under general anesthesia (GA) 9. Neuromuscular monitoring, and 10. Coagulation profile monitoring The ECG is a standard diagnostic tool, which becomes of limited use during heart manipulations. In fact, during heart lifting, ECG shows a reduction in amplitude which renders it difficult for anesthesiologists to assess signs of myocardial ischemia [Figure 1].[19] Invasive arterial Annals of Cardiac Anaesthesia  Vol. 16:1  Jan-Mar-2013

blood pressure monitoring is mandatory to evaluate beat to beat changes in the blood pressure. Mixed venous oxygen saturation (SvO2), evaluated using CVC and/or PAC, might be helpful to determine the global tissue oxygenation. Moreover, SvO2, partial pressure of carbon dioxide (PaCO2), and central venous pressure (CVP) can be used as proxy measures of changes in jugular bulb oxygen saturation (SjO2). The SjO2 desaturation is used as a predictor of possible postoperative cognitive dysfunction, due to a lack in global cerebral oxygen balance. However, routine monitoring of SjO2 is invasive and expensive. A CVP of ≥ 8 mmHg, SvO2 ≤ 70%, and

Figure 1: A reduction in ECG voltages with “Heart tilting” (note the marked difference in ECG amplitude before and after heart displacement)

Table 1: Preoperative anesthetic assessment, premedication, operating room readiness and intraoperative monitoring Preoperative assessment

Evaluation of the patient, risks, and co‑morbidities Discuss with the surgeon about the surgical plan and the anesthesia management

Premedication

Temazepam (0.5-1 mg/kg per os), atenolol (50 mg per os);

Operating room readiness

CPB machine ready for quick setup with a perfusionist in attendance Temperature up to 24°C, place warming pad or mattress on the operating table, use air warming device External pads connected to a defibrillator (internal pads and a pacemaker should be also available)

Monitoring

5‑lead surface ECG with automated ST segment analysis Pulse‑oximetry; unconsciousness monitoring system Radial arterial cannula 4‑lumen central line via right internal jugular vein 8.5 F via right internal jugular vein to be used for inserting pulmonary artery catheter (if necessary) Stroke volume and pulse pressure variation monitoring Foley catheter TEE, pulmonary artery catheter, esophageal and rectal temperature

CPB: Cardiopulmonary bypass, TEE: Transesophageal echocardiography

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PaCO2 ≥ 40 mmHg are associated with jugular bulb desaturation (SjO2 ≤ 50%) during OPCAB surgery.[20] On the other hand, standard preload indices, such as CVP and pulmonary capillary wedge pressure (PCWP), often fail to provide reliable information about cardiac preload and are not capable of predicting a cardiac response to fluid therapy, [21‑23] particularly during verticalization of the heart.[24] Unnecessary fluid loading could cause adverse clinical outcomes, such as acute heart failure.[25] Stroke volume (SV) and pulse pressure variation (PPV)[26,27] or TEE[28] should be considered in guiding fluid management during OPCAB surgery. During GA, the SV and PPV are influenced by positive pressure mechanical ventilation; SV variations and PPV are greater when the patient is hypovolemic. During chest opening, PPV can decrease even if the hypovolemic condition is not corrected. TEE is the key monitoring technique in modern cardiac surgery. It provides detailed information about left and right ventricular function, regional wall motion, valve(s) functions, and overall cardiac performance. [29] A complete TEE examination should be done at the beginning of the surgery to establish a baseline. TEE allows evaluation of effectiveness of maneuvers such as Trendelenburg position or pleural incision in the management of hypotension. TEE may facilitate the detection of worsening cardiac function as evidenced by weakening of myocardial contraction, ventricular dilatation, or increasing mitral/tricuspid regurgitation during coronary occlusion.[29] New segmental wall motion abnormalities are the most sensitive indicator of intraoperative myocardial ischemia.[30] Routine use of TEE in OPCAB has often lead to change in the planned operative strategy and the intraoperative management and has been shown to reduce morbidity and improve patient outcome.[28] The TEE image quality during coronary artery bypass construction may be impaired by the use of posterior swabs, different positions of the heart, and air in the pericardial cavity. The most common parameter for coagulation monitoring is the activated clotting time (ACT). However, there is no standardized ACT target value for OPCAB: an ACT value of ~300 s is accepted by approximately 80% of US/Canadian surgeons and 60% of European surgeons. [31] An increased pro‑coagulant activity can occur in the postoperative period in patients who underwent OPCAB. Hence, an anticoagulation prophylactic regimen is mandatory.[32] During awake OPCAB, there seems to be less pro‑coagulant activity than in OPCAB with GA.[33] 30

Anesthetic technique and fast‑track anesthesia for OPCAB surgery Anesthesia during OPCAB surgery has the objective of ensuring maximum cardiac protection, maintaining stability of both hemodynamic and cardiac rhythm, and promoting early ambulation in combination with excellent postoperative analgesia.[34] The aims of fast‑track anesthesia are early extubation (within 0-6 h postoperatively), decreased length of intensive care unit (ICU)/hospital stay, improved outcome, and subsequent cost reduction of health care.[12,35‑38] Fast‑track anesthesia in cardiac surgery has proven to be safe and cost‑effective,[12,39‑41] and presently considered the standard of care.[42] There are three anesthetic approaches in OPCAB: 1. GA with opioids and inhalation anesthesia or total intravenous anesthesia (TIVA); 2. Combined GA with controlled ventilation and neuraxial blockade using high thoracic epidural analgesia (TEA) or combined GA/intrathecal morphine (ITM); 3. Awake regional anesthesia with spontaneous ventilation using TEA alone. In the GA regimen, volatile anesthetics offer the advantages of pharmacological ischemic preconditioning. [43] Propofol has not shown cardioprotective effects.[44,45] The use of long‑acting neuromuscular blocking agents, such as pancuronium in fast‑track cardiac surgical patients may be associated with delays in recovery and tracheal extubation. [46,47] Thus, cisatracurium or rocuronium is recommended for neuromuscular blockade.[48] Minimally Invasive Direct Coronary Artery Bypas (MIDCAB) surgery requires collapse of one lung (more commonly the left lung), so a double‑lumen endobronchial tube or a bronchial blocker is required. Anesthesiologists should avoid the use of high doses of long‑acting opioids which potentially prolong respiratory depression, mandates ventilatory support, cause hypotension during or after sternotomy resulting in myocardial ischemia and infarction,[49] and delay bowel movement recovery.[50] Remifentanil provides excellent hemodynamic stability and rapid time to extubation,[51‑53] making it suitable for fast‑track anesthesia in OPCAB.[52] Also, fentanyl and sufentanil have shown comparable effects to remifentanil in fast‑track cardiac anesthesia. [51,54] However, the ultra‑short action of remifentanil requires careful management of postoperative analgesia and the use of additional therapies.[55,56] The risk of insufficient postoperative pain control is usually prevented by using Annals of Cardiac Anaesthesia  Vol. 16:1  Jan-Mar-2013


Figure 2: High thoracic epidural anesthesia performed at the level T2-T3

Figure 3: Awake cardiac surgery performed using high thoracic epidural anesthesia

intravenous morphine with or without nonsteroidal anti‑inflammatory drugs (NSAIDs) prior to the end of surgery[53] or prolonging the infusion of remifentanil using higher doses to achieve an adequate level of analgesia. [56] The use of dexmedetomidine during OPCAB might lead to a better postoperative pain control by reducing intra‑and postoperative consumption of opioids.[57‑59] OPCAB using dexmedetomidine is related to better hemodynamic stability: it is a good anesthetic adjuvant[57,60] and does have antiemetic effects. [58] High TEA combined with GA provides better analgesia, better pulmonary outcome, reduction in perioperative morbidity and mortality, reduction in extubation time, and possibly shorter hospital stay than standard GA alone[61‑67] [Figure 2].[68] High TEA attenuates neuro‑hormonal response, provides thoracic sympatholysis (which improves coronary and mammary artery perfusion), ensures hemodynamic stability and decreases myocardial oxygen demand, improves myocardial blood flow, reduces the risk of perioperative arrhythmia and myocardial ischemia, improves renal function, and significantly decreases heart rate.[64,69‑75] Thus, the use of TEA in OPCAB surgery can be beneficial.[76,77] Performing TEA the day before surgery or at least 1 h before the administration of heparin might reduce the risk of epidural hematoma although there is no scientific proof about the minimum and safe time waiting between the insertion of the catheter and heparinization.[68] It is mandatory to assess the patient’s preoperative anticoagulation status before TEA, and surgery should be delayed for 24 h in the event of a traumatic tap.[78] It is also important to coordinate the postoperative course and drug therapy (particularly anticoagulant therapies) with the timing of catheter removal and monitor new sensory and/or motor deficit for the entire postoperative period until at least 12 h after catheter removal. Preoperative administration

of ITM in OPCAB surgery seems to facilitate early extubation, improve postoperative pulmonary function, and reduce postoperative analgesic requirements.[79‑82] The low doses of morphine used in ITM do not provide a full analgesic coverage, so this technique requires to be accompanied by intravenous infusion of opioids (e.g., remifentanil, fentanyl). Further studies are required to verify the effectiveness of this technique and to determine the optimal dose of morphine, which provides adequate analgesia with minimal risk of respiratory depression that appears to be the most important side effect during the postoperative period. Awake OPCAB is a promising modality of minimally invasive cardiac anesthesia[83] which uses a combined femoral block/TEA[84] or spinal anesthesia/TEA[85] or TEA alone, associating local anesthetic infiltration if required for the vessel graft harvesting[86‑88] [Figure 3].[83] Awake cardiac surgery might have some benefits, such as short ICU stay. Maintenance of spontaneous respiration avoids the disadvantages of mechanical ventilation and GA in high‑risk patients.[83,89] There is no study focusing on the psychological impact of awake cardiac surgery on patients; however, several studies pointed out that patients who are very cooperative and willing to undergo awake cardiac surgery describe the fear of not waking up after GA as the main motivating factor.[87,90] One study even presented patients who had previous experience of cardiac surgery with GA; these patients preferred the experience of awake cardiac surgery. [88] Awake cardiac surgery is feasible, but should be performed only in selected patients by highly specialized and experienced health care teams.[88,91] Further studies are necessary to determine its role and utility in cardiac surgery.[84] Opening of pleura is a major concern during awake cardiac surgery and the surgeons should take care to avoid this to prevent pneumothorax and internal mammary artery should


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be harvested extrapleural without opening the pleura. Temperature management is particularly challenging in OPCAB as the absence of CPB removes the possibility to warm up the patient with a heat exchanger. In addition, considering that the thorax is opened and the extremities are exposed for vessel harvesting, the surface area of the body for heat dispersion is high.[92] Once the patient becomes hypothermic it may be difficult to increase the core temperature until after surgery and the risk of complications increases.[93,94] In order to maintain temperature homeostasis fluid warming is useful.[92] Hemodynamic changes during off-pump coronary artery bypass Hemodynamic instability in OPCAB may be due to myocardial ischemia during anastomosis or due to mobilization and stabilization of the heart required for exposing the posterior wall of the heart.[95] Most surgeons approach the left anterior descending coronary artery (LAD) without displacing the heart. In multiple coronary revascularizations involving the circumflex coronary artery and/or the posterior inter‑ventricular coronary artery (posterior descending artery), the full exposure of the artery is possible only with the use of stabilization systems that restrict regional wall motion either by suction or by mechanical compression. These procedures require significant mobilization and tilting the heart.[96] Such positioning can lead to reduced SV and arterial blood pressure (ABP), and increases CVP and right ventricle (RV) end‑diastolic pressure. [97] A decrease in coronary blood flow of 25-50% is documented.[98] The pathogenesis of hemodynamic changes during heart tilting is the compression of the RV free wall, which is thin and easily deformable, against the interventricular septum [Figure 4];[99] this leads to a restrictive, impaired diastolic filling[97,100,101] associated with an obstruction of the RV outflow tract.[95,102] When the heart is tilted and verticalized, normal blood flow from the atria to the ventricles is impaired. The blood has to flow upward into the ventricular cavities. Thus, the atria increase their size and their filling pressure and become larger than the ventricles, contributing to the reduction in cardiac output.[24] Another causative factor which contributes to the hemodynamic instability during heart displacement is the distortion of mitral and tricuspid annuli that leads to a regurgitation flow (most often in already leaky valves), and enlargement of atria and pulmonary veins.[103] Mitral regurgitation, which is clinically associated with falling peripheral oxygen saturation,[104] could be also a consequence of myocardial ischemia [Figure 5].[105] Trendelenburg positioning to 20° head down appears to be an efficient technique to 32

Figure 4: Right ventricular compression (arrow) during heart displacement and partial restoration of its volume after the Trendelenburg maneuver (VS = Ventricular septum; RV = Right ventricle; LV = Left ventricle)

improve preload and increase cardiac output.[98,106,107] The use of inotropes and/or vasopressor like dopamine, epinephrine, or norepinephrine, associated with an adequate and cautious fluid management is helpful.[24,96] An α‑adrenergic agent, such as phenylephrine, is indicated when mean arterial pressure (MAP) remains low due to reduction of peripheral resistances in order to avoid large fluid administration. If hypotension persists, ischemia should be investigated using ST segment changes on the ECG or with TEE evaluating the presence of new wall motion abnormality (RWMA). In fact, when the heart is displaced, the ECG frequently shows low voltages, which do not provide useful information regarding myocardial ischemia. The stabilizer itself may induce regional defects in TEE scans.[14] Some surgical procedures may be useful to stabilize the patient’s hemodynamic state including pleuropericardial incision, which decreases abnormal wall motion of the RV and the kinking of veins, or simply Annals of Cardiac Anaesthesia  Vol. 16:1  Jan-Mar-2013


Figure 6: Coronary artery bypass graft and stabilization device

Figure 5: Intraoperative transesophageal echocardiography shows a worsening of a preexisting mitral regurgitation (upper TEE image) after heart displacement (lower TEE image)

heart repositioning.[102,108] When severe hemodynamic instability is expected as in case of OPCAB in high‑risk patients, the placement of an intra‑aortic balloon pump (IABP) should be considered.[109,110] Elective IABP use in high‑risk patients has shown to provide hemodynamic stability without additional inotropic support during the dislocation of the heart.[111] Conversion to CPB is mandatory when profound unresponsive hypotension, malignant arrhythmias, new extensive regional wall motion abnormalities, or complete cardiovascular collapse occur.[112,113] Conversion to CPB has been shown to increase morbidity and mortality with operative mortality ranging from 8.5 to 18%.[113‑115] Congestive heart failure,[114,116] redo surgery,[114] low ejection fraction, recent myocardial infarction,[116] mitral regurgitation, and chronic obstructive pulmonary disease[105] have been reported as independent predictors of emergency conversion to CPB. Management of ischemia Temporary occlusion of the target coronary artery is a technique used by some surgeons during OPCAB to create a precise anastomosis in a bloodless surgical field [Figure 6]. [117] Good collaboration between anesthesiologist and surgeon is necessary to reduce Annals of Cardiac Anaesthesia  Vol. 16:1  Jan-Mar-2013

the consequences of coronary blood flow interruption. The key issue during distal anastomosis is to maintain hemodynamic stability, to reduce the myocardial oxygen consumption, and to provide myocardial protection. Maintaining an MAP >70 mmHg allows an adequate coronary perfusion;[24] cautious fluid loading, Trendelenburg position, and the use of vasopressor and/or inotropes (phenylephrine, dopamine, or norepinephrine) are useful in managing hypotension. The severity of the stenosis of the coronary artery influences the hemodynamic response; modest degrees of stenosis tend to produce significant changes when the coronary artery is occluded, whilst a severe stenosis produce little hemodynamic changes. The effect of coronary blood flow interruption can be mitigated by collateral circulation.[118,119] Changes in SvO2 and PaCO2 are associated with changes in SjO2: Maintaining a value of SvO2 > 70% may be important to prevent reduction in cerebral blood flow during OPCAB.[20] Anesthesiologists should keep a heart rate between 70 and 80 bpm[120] and treat tachycardia using esmolol or diltiazem.[24] Prophylactic administration of anti‑arrhythmic agents during the preoperative and the intraoperative period might also be an option. Lidocaine[121] and magnesium[122] are both used, and the latter seems to be more efficient.[123] Prophylactic use of β‑blockers reduces the incidence of postoperative atrial fibrillation (POAF). [124,125] The use of magnesium for preventing POAF is controversial.[126,127] Ventricular tachycardia and fibrillation or complete atrioventricular block (AVB) may develop during coronary artery occlusion. AVB occurs especially during the right coronary artery occlusion as a consequence of the interruption of blood flow to the AV node. To maintain the myocardial perfusion, the surgeon can insert a small shunt into the coronary artery, which prevents deterioration in the ventricular 33


function and stabilizes the hemodynamic state.[128,129] Ischemic preconditioning is an attractive method for decreasing the myocardial damage during the ischemic period. Ischemic preconditioning is a rapid, adaptive response to a brief ischemic insult which slows the rate of cell death during a subsequent, prolonged period of ischemia.[130] Ischemic preconditioning could be elicited by the surgeon through a short period of coronary vessel occlusion followed by reperfusion, effectuated before the bypass grafting. This technique enhances myocardial performance[131] and suppresses arrhythmias.[132] Reperfusion and postoperative evaluation The ischemic changes observed on the ECG during anastomosis tend to disappear after reperfusion. After revascularization, the surface ECG frequently demonstrates significant T‑wave inversion; TEE shows new RWMA which may be associated with reperfusion injury and myocardial stunning.[24] Persistent and severe new RWMA have a significant prognostic value for postoperative cardiac complications[133] and adverse outcome. [28] Electrolytes, particularly potassium [34] and magnesium[134] should be kept close to normal in order to avoid reperfusion arrhythmias which might be life‑threatening. The protamine dose for heparin reversal should be specifically evaluated.[135] Finally, to evaluate the graft patency, angiography or ultrasound Doppler flow is usually used.[136] Extubation and intensive care unit management The majority of patients can be considered for early extubation unless their intraoperative or postoperative course suggests otherwise.[35,37,137,138] Ultra‑fast‑track anesthesia with immediate patient extubation in OPCAB appears feasible and most probably safe. Immediate extubation may reduce nurse dependency, prevent airway and lung trauma, improve cardiac output by spontaneous breathing, and decrease patient stress.[139‑141] Immediate extubation requires a stable, warm, normovolemic, pain‑free and alert patient at the end of surgery; neuromuscular blockade should be reversed. It is imperative to include preoperative, intraoperative, and postoperative predictors as essential components of risk assessment to determine the feasibility of extubation in the operating room.[142,143] Immediate extubation can be part of a resource management system, which might include the possibility of sending the patient in the ICU, intermediate care unit, or directly to the ward. New models for postoperative cardiac care setting have been proposed with interesting prospects.[144] Table 2 summarizes an anesthetic protocol during OPCAB. 34

CONCLUSIONS OPCAB surgery presents special challenges and difficulties, which require collaboration between all health care staff and acquisition of specific knowledge. Anesthesiologists play an important role Table 2: Anesthetic protocol – example with or without thoracic epidural analgesia Induction

General anesthesia

Fentanyl 2-4 µg/kg, propofol 1-2 mg/kg (BIS‑titrated to obtain BIS < 60) + rocuronium 0.6 mg/kg or cisatracurium 0.1 mg/kg

Maintenance of anesthesia

Bolus TEA (e.g., bupivacaine 0.5% 6-8 ml, followed by bupivacaine 0.1% 6-12 ml/h), or repetitive doses of fentanyl in increments of 50-150 µg in decreasing dose, sevoflurane titrated to maintain BIS at approximately. 45; air-oxygen;

High thoracic epidural anesthesia (T2- 6) may be performed the day before surgery. The evaluation of the patient’s preoperative anticoagulation status is mandatory

Baseline transesophageal echocardiography

Perform baseline transesophageal echocardiography for assessing ventricular and valvular function

During ischemia

Heparin 1-2 mg/kg (150-200 IU/kg) with target ACT value > 300 s, prior to grafting

Maintain heart rate between 70 and 80 bpm, MAP > 70 mmHg, SvO2 > 70%

Ensure adequate preload (infuse colloid if necessary)

Use Trendelenburg position, reposition the heart in the holding device, vasopressors and/or inotropes (phenylephrine, dopamine, or norepinephrine) to treat hypotension (a microdrip of phenylephrine diluted to 40 µg/100 ml, flow adjusted manually is an easy way to increase MAP whilst avoiding overshooting

Prevention and treatment of arrhythmias

Monitor serum potassium and magnesium

Treat sinus or supraventricular tachycardia using esmolol or diltiazem

Use DC shock for ventricular tachycardia and fibrillation

Use pacemaker for complete atrioventricular block

Reperfusion and post‑grafting evaluation

Heparin should be partially or fully reversed

Post‑anastomosis TEE exam should be performed to check new and persistent regional wall motion abnormalities

Postoperative course

ICU or intermediate care unit: The patient is transferred to the ICU, extubated in 0-6 h

Extubation criteria

Patient should be awake, warm, pain free, and hemodynamically stable

MAP: Mean arterial pressure, SvO2: Mixed venous oxygen saturation



in the perioperative and postoperative management of patients. The use of anesthetic techniques which enable fast‑track and ultra fast‑track pathways is recommended. Case scenario Finally, we would like to present a case scenario as an example of management of a patient undergoing OPCAB surgery. A 64‑year‑old man with 3‑vessel coronary artery disease is scheduled for OPCAB of LAD, left circumflex artery, and posterior descending artery. The patient is interviewed 2 days before surgery by an attending anesthesiologist. The history is remarkable for significant chronic pulmonary disease and hypertension. The patient has no allergies, no previous surgeries, and uses several bronchodilatatory inhalers on a daily basis, as well as a b‑blocking agent. His respiratory function is reduced to 50% of the normal values; within the restrictions of his pulmonary disease, his cardiac functional status is satisfactory, his left ventricular ejection fraction is normal. The LAD will be grafted using the left internal mammary artery, whereas all other grafts will be venous grafts taken from the left leg. The surgical team consists of two surgeons with more than 20 years of experience in OPCAB. During the preoperative visit, the anesthesiologist mentions the possibility of using TEA for intra‑ and postoperative pain control as well as immediate extubation. Ultra‑fast‑track anesthesia has been practiced in that center for more than 5 years. There exists necessary infrastructure in specfically trained nursing personnel as well as rapid access to magnetic resonance imaging (MRI) facilities. The anesthesiologist explains the risk of TEA in cardiac surgery, estimating the risk of epidural hematoma as 1:12,000, comparing it to the risk in obstetric anesthesia. The anesthesiologist makes sure not only that the patient understands the risk, but also that continuous neurological supervision will occur during the time of the hospital stay of the patient. The anesthesiologist explains the possible scenario of an epidural hematoma, including possible MRI and neurosurgical intervention. The anesthesiologist points out the specific advantages for this patient with significant chronic obstructive pulmonary disease. He also offers the possibility of immediate extubation. The patient consents for both TEA and immediate extubation. On the day before surgery, a high thoracic epidural catheter is inserted at T3-4 with the intent to cover T1-T8; great care is taken to avoid any vascular damage, TEA is tested Annals of Cardiac Anaesthesia  Vol. 16:1  Jan-Mar-2013

with 3 ml of lidocaine 2% with epinephrine 1:200,000. There is no bloody tap and the TEA test reveals good efficacy. On the day of surgery, the patient is admitted to the operating room. A large‑bore peripheral venous access (14‑G) is obtained in the left hand. Under local anesthesia, an indwelling arterial catheter is inserted in the left femoral artery. The epidural catheter is again tested to rule out inadvertent intravascular placement and for functionality. Bispectral index monitoring is applied in order to allow a BIS‑titrated anesthesia induction. After applying routine monitoring - 5‑lead ECG, arterial pressure and pulse oximetry, anesthesia is induced with fentanyl 8 µg/kg, given slowly. Two minutes later, hypnosis is induced using propofol 1 mg/kg, and additional 0.5 mg/kg is given to achieve a BIS target below 60. Thereafter, rocuronium 0.6 mg/ kg is injected. Neuromuscular monitoring at the corrugator supercilii muscle is used to assess full relaxation of the vocal cords. Once adequate muscle relaxation is ensured, endotracheal intubation is performed. A right internal jugular central venous catheter is inserted. Anesthesia is maintained using sevoflurane in oxygen/air (50%) titrated to maintain a BIS of 45 and lungs are ventilated intermittently to normocapnea. At the beginning of skin desinfection, 8 ml of bupivacaine 0.5% is injected into the thoracic epidural space, followed by a continuous infusion of bupivacaine 0.1% at 10 ml/h. The Local Anesthetic (LA) bolus is timed so that the peak effect concides with the skin incision and sternotomy. A TEE probe is inserted for continuous hemodynamic monitoring. The temperature in the operating room is maintained at 22°C; after saphenous vein harvesting, a lower body warming blanket is applied. Surgery unfolds without problem. At the end of surgery, the hemodynamic status of the patient is stable, without inotropic support, the urinary temperature probe shows normal body temperature, the PO2 is at 120 mmHg at 50% oxygen with an otherwise normal blood gas analysis. After the wound dressing is applied, emergence from anesthesia occurs at BIS levels above 65: Before extubation, the anesthesiologist makes sure that neuromuscular transmission at the adductor pollicis muscle is normal and the patient obeys commands. An awake and alert patient is then extubated in the operating room and transferred to the ICU for further observation. It should be noted here that a well‑informed patient, TEA, an experienced OPCAB surgical and anesthetic team, an infrastructure for ultra‑fast‑track anesthesia, and 24 h availability for MRI are the key requirements for ultrafast-tracking in OPCAB surgery. 35


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Cite this article as: Hemmerling TM, Romano G, Terrasini N, Noiseux N. Anesthesia for off-pump coronary artery bypass surgery. Ann Card Anaesth 2013;16:28-39. Source of Support: Nil, Conflict of Interest: None declared.

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