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Complete myocardial revascularization on the beating heart with epicardial stabilization: anesthetic considerations
F G Resano1, S C Stamou, R C Lowery
1Section of Cardiac Surgery, Washington Hospital Center, DC 20010-2975, USA.
Insights
This study details an anesthetic protocol for off-pump coronary artery bypass grafting (CABG) surgery. A systematic approach successfully completed surgery in 92% of patients, minimizing the need for cardiopulmonary bypass.
Area of Science:
- Anesthesiology
- Cardiac Surgery
- Cardiovascular Medicine
Background:
- Off-pump coronary artery bypass grafting (CABG) surgery offers advantages by avoiding cardiopulmonary bypass.
- Median sternotomy with mechanical stabilization presents unique anesthetic challenges.
- Standardized anesthetic management is crucial for successful off-pump CABG procedures.
Purpose of the Study:
- To describe a specific anesthetic management protocol for off-pump CABG surgery via median sternotomy.
- To evaluate the efficacy and safety of this protocol in a clinical setting.
Main Methods:
- Retrospective analysis of 66 consecutive patients undergoing off-pump CABG surgery.
- Anesthesia induction with etomidate and fentanyl, muscle relaxation with pancuronium bromide.
- Maintenance with volatile anesthetics (isoflurane, desflurane, or sevoflurane) in 100% oxygen.
- Normothermia management using warmed fluids, high fresh gas flows, and convective warming.
- Hemodynamic monitoring via central venous pressure or pulmonary artery catheter based on surgical plan and ventricular function.
Main Results:
- 36% of patients required intraoperative epinephrine infusion for hemodynamic stability.
- 25% of patients needed postoperative inotropic support for less than 12 hours.
- Successful completion of off-pump CABG surgery was achieved in 92% of patients.
Conclusions:
- Systematic hemodynamic management is associated with successful off-pump CABG surgery.
- Conversion to cardiopulmonary bypass was required in only 5 patients (8%).
- The described anesthetic protocol facilitates the safe and effective performance of off-pump CABG surgery.
Objective:
To describe an anesthetic management protocol for patients undergoing cardiac surgery with multiple coronary artery bypass grafts without cardiopulmonary bypass (off-pump CABG surgery) by median sternotomy with mechanical stabilization.
Design:
Retrospective nonrandomized analysis.
Setting:
Tertiary care hospital.
Participants:
Sixty-six consecutive patients on whom off-pump CABG surgery by median sternotomy was attempted.
Interventions:
Anesthesia was induced with a combination of etomidate and fentanyl; pancuronium bromide was given for muscle relaxation; and anesthesia was maintained with isoflurane, desflurane, or sevoflurane in 100% oxygen. Maintenance of normothermia was attempted by keeping the room temperature at 70 degrees F, warming all fluids to 41 degrees C, and using 2.5 L/min of fresh gas flows and a heat and humidity exchanger. When available, a convective forced-air blanket was used to cover patients' head and shoulders. Patients who were not slated for revascularization of the circumflex vessels and who had good ventricular function received central venous pressure monitoring (26%); all other patients received a pulmonary artery catheter.
Measurements And Main Results:
Of the 66 patients, 36% required an epinephrine infusion at a mean rate of 1.45+/-2.05 microg/min intraoperatively to maintain hemodynamic stability; 25% required inotropic support for < 12 hours in the intensive care unit.
Conclusion:
Institution of systematic hemodynamic management was associated with the successful completion of the surgical procedure in 61 patients (92%). Only 5 patients required conversion to regular CABG surgery with cardiopulmonary bypass.