Anesthesia management for robotically assisted endoscopic coronary artery bypass grafting on beating heart

To outline the initial anesthetic experience for robotically assisted coronary artery bypass grafting surgery on beating heart using the da Vinci surgical system.

Between February 2007 and September 2009, 76 patients received the surgery with the da Vinci S Surgical System. The crucial issue of anesthesia for the surgery is to deal with the hemodynamic compromise, hypoxia and hypercarbia relevant to one-lung ventilation (OLV), and intrathoracic insufflation of CO2 with positive pressure (CO2 pneumothorax).

After initiation of OLV and CO2 pneumothorax, PaO2 and mixed venous saturation showed a significant decrease. Meanwhile, the SpO2 decreased to 92% in 14 of the 76 patients. In these patients, application of continuous positive airway pressure setting 5 to 15 cm H2O to the collapsed lung resulted in an increase in PaO2 from 59 ± 12 to 115 ± 23 mm Hg (P < 0.05). Moreover, at the beginning of CO2 pneumothorax, the most dramatic fall in mean arterial pressure and cardiac index was showed with an increase in mean pulmonary artery pressure and heart rate. The hemodynamic compromise was counteracted by transfusion and inotropes/vasopressors. Postoperatively, the average extubation time was 7.5 ± 3.1 hours, and median intensive care unit length of stay was 21 hours. One patient remained in the intensive care unit for 3 days for treatment of a postoperative pneumonia. There were two cases of new onset postoperative atrial fibrillation. All patients were discharged home 4 to 7 days after surgery.

Anesthetic management for the procedures requires detailed knowledge of OLV and CO2 pneumothorax in addition to expertise required in conventional cardiac surgery.