Difference between revisions of "Coronary artery bypass graft"

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{{Infobox surgical case reference
{{Infobox surgical case reference
| anesthesia_type =  
| anesthesia_type = GA
| airway =  
| airway = ETT
| lines_access =  
| lines_access = PIV x2
| monitors =  
Arterial line
| considerations_preoperative =  
Central line [often 2]
| considerations_intraoperative =  
Introducer
| considerations_postoperative =  
± PA catheter
| monitors = Standard
5-lead ECG
Temperature
ABP
CVP
TEE
NIRS
± PAP
| considerations_preoperative = beta-blocker
discussion with surgeon regarding any regional anesthesia adjuncts
| considerations_intraoperative = Heparinization for graft harvest
Full heparinization prior to coming on CPB
Hemodyamics and cardiac function coming off CPB
Reversal of heparin with protamine
Discussion with surgeon regarding extubation in OR
| considerations_postoperative = transfusion and vasopressor requirements
inotropic support
}}
}}
'''Coronary Artery Bypass Graft''', also known as '''CABG''', is a common cardiac surgery procedure in which vein or artery is used as a conduit and is either grafted from the aorta (or if using left internal mammary artery, used in situ) to a coronary artery beyond a blockage in the vessel, with goal of improving blood flow to the heart, i.e. surgical coronary re-vascularization. The left internal mammary artery (LIMA) is considered first choice of graft due to high patency rate of > 90% at 10 years, though saphenous vein grafts are often used as well. It is most often indicated for individuals with significant multi-vessel Coronary Artery Disease, in particular those with Diabetes Mellitus or left main coronary vessel disease; it can also be used on a more emergent basis for those with Acute Coronary Syndrome and ST-Elevation Myocardial Infarction cases that are refractory to PCI or maximal medical management. It can be described by the number of vessels to be bypassed (single, double, triple, quadruple) as well as the technique (traditional on-pump, off-pump or minimally invasive direct).
'''Coronary Artery Bypass Graft''', also known as '''CABG''', is a common cardiac surgery procedure in which vein or artery is used as a conduit and is either grafted from the aorta (or if using left internal mammary artery, used in situ) to a coronary artery beyond a blockage in the vessel, with goal of improving blood flow to the heart, i.e. surgical coronary re-vascularization. The left internal mammary artery (LIMA) is considered first choice of graft due to high patency rate of > 90% at 10 years, though saphenous vein grafts are often used as well. It is most often indicated for individuals with significant multi-vessel Coronary Artery Disease, in particular those with Diabetes Mellitus or left main coronary vessel disease; it can also be used on a more emergent basis for those with Acute Coronary Syndrome and ST-Elevation Myocardial Infarction cases that are refractory to PCI or maximal medical management. It can be described by the number of vessels to be bypassed (single, double, triple, quadruple) as well as the technique (traditional on-pump, off-pump or minimally invasive direct).
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|-
|-
|Neurologic
|Neurologic
|
|cognitive function
Identify any atherosclerotic lesions along carotid vessels
|-
|-
|Cardiovascular
|Cardiovascular
|
|Identify diseased vessels & any associated collaterals
Evaluate LVEF, wall thickness and valve functionality
 
All antianginal medications should be given day of surgery
|-
|-
|Pulmonary
|Pulmonary
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|-
|-
|Gastrointestinal
|Gastrointestinal
|
|Evaluate for dysphagia, difficulties swallowing and hx of esophageal/gastric surgery (TEE carries a risk of esophageal rupture)
|-
|-
|Hematologic
|Hematologic
|
|Confirm T+S and at least 4 units pRBCs are on hold, as well as FFP
Anticoagulation is common in these patients
|-
|-
|Renal
|Renal
|
|Evaluate for any pre-operative renal insufficiency
|-
|-
|Endocrine
|Endocrine
|
|Evaluate HgbA1c and if Insulin-dependent diabetic, note current insulin regimen
|-
|-
|Other
|Other
|
|Redo sternotomies have a greater risk of significant bleeding and complication
|}
|}


=== Labs and studies ===
=== Labs and studies ===
* CBC, CMP
* PT, PTT
* CXR: to evaluate for abnormalities (cardiomegaly, pleural effusions)
* EKG: check for LBBB. If a PA catheter is planned, occasionally patients with LBBB may develop a third degree block as a consequence of PA catheter placement


=== Operating room setup ===
=== Operating room setup ===
* Have at least 5-8 channels for infusions
** Epi, norepi, carrier, insulin (some institutions use phenylephrine in place of norepi)
** Consider ketamine, precedex, ancef
* Drugs:
**Emergency medications (bolus):
***Epi, atropine
***Other bolus vasopressors (e.g. vaso, phenylephrine, NE)
***+/- Esmolol, nicardinpine, and nitroprusside
** Heparin, protamine, calcium
**+/- Magnesium
* Perfusion technician should be available along with cell saver
* Fluid warmer
* Triple transducers primed and zeroed
* Internal defibrillator/pacer available in room
* TEE machine with appropriately sized probe


=== Patient preparation and premedication ===
=== Patient preparation and premedication ===
* All cardiac medications should be continued on day of surgery except ACE inhibitors which should be stopped 24h prior to surgery


=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
*Pre-Op: Erector Spinae Plane Block -- check departmental policy as institutions vary on candidacy for pre-op block based on vessel pathology
*Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence


== Intraoperative management ==
== Intraoperative management ==


=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
* 2 large bore PIVs
* Arterial line - often these are placed awake, especially if there are athersclerotic lesions along Left Main artery or concern for Right ventricle failure
* CVP
* Cordis
* +/- Pulmonary artery catheter


=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
*Cardio-protective induction with etomidate vs standard induction with propofol depending on patient's cardiac function and pathology


=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
*Supine position


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
* Redo sternotomies have higher risk of significant bleeding
**type and cross with anticipation of early blood loss
**consider having a cooler of blood in the room
*Patients that have been on heparin leading up to the procedure may have developed resistance to heparin via ATIII depletion. If the max dosage of heparin has been given and ACT is still below goal at time of full heparinization, you may need to give ATIII concentrate
*If procedure uses bypass, have a plan for what drips to use coming off of pump.
**Tailor medications based on hemodynamic needs. (e.g. if there is need for inc afterload, inotropy, both, ect.)
**Have other agents readily available such as - Milrinone, dobutamine, Vasopressin, angiotensin II


=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
*Consider parasternal intercostal blocks pre-emergence/prior to transport to CVICU
*Patients will usually remain intubated and sedated through transit to cardiac ICU, though in certain cases & institutions, emergence and extubation may be considered
**Sedation during ICU transfer with gtt - use what is safest for the patient while providing amnesia
**Consider utilizing gtt that will be used by ICU staff after handoff


== Postoperative management ==
== Postoperative management ==


=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
* Cardiac ICU


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
*Can consider regional anesthesia with parasternal intercostal plane blocks [completed pre-emergence] , or Erector Spinae block (pre-induction)


=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
* MI 6%
* CVA 5%
* Mild neuropsychatric effects 90%
* Death 1-3% (preop-risk dependent)
* Transfusion 40-90%
* Delirium 8%-15%
* Atrial fibrillation Up to 35%
* Renal failure 1%
* Mediastinitis 1-2%


== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

Latest revision as of 11:41, 26 October 2024

Coronary artery bypass graft
Anesthesia type

GA

Airway

ETT

Lines and access

PIV x2 Arterial line Central line [often 2] Introducer ± PA catheter

Monitors

Standard 5-lead ECG Temperature ABP CVP TEE NIRS ± PAP

Primary anesthetic considerations
Preoperative

beta-blocker discussion with surgeon regarding any regional anesthesia adjuncts

Intraoperative

Heparinization for graft harvest Full heparinization prior to coming on CPB Hemodyamics and cardiac function coming off CPB Reversal of heparin with protamine Discussion with surgeon regarding extubation in OR

Postoperative

transfusion and vasopressor requirements inotropic support

Article quality
Editor rating
In development
User likes
0

Coronary Artery Bypass Graft, also known as CABG, is a common cardiac surgery procedure in which vein or artery is used as a conduit and is either grafted from the aorta (or if using left internal mammary artery, used in situ) to a coronary artery beyond a blockage in the vessel, with goal of improving blood flow to the heart, i.e. surgical coronary re-vascularization. The left internal mammary artery (LIMA) is considered first choice of graft due to high patency rate of > 90% at 10 years, though saphenous vein grafts are often used as well. It is most often indicated for individuals with significant multi-vessel Coronary Artery Disease, in particular those with Diabetes Mellitus or left main coronary vessel disease; it can also be used on a more emergent basis for those with Acute Coronary Syndrome and ST-Elevation Myocardial Infarction cases that are refractory to PCI or maximal medical management. It can be described by the number of vessels to be bypassed (single, double, triple, quadruple) as well as the technique (traditional on-pump, off-pump or minimally invasive direct).

Preoperative management

Patient evaluation

System Considerations
Neurologic cognitive function

Identify any atherosclerotic lesions along carotid vessels

Cardiovascular Identify diseased vessels & any associated collaterals

Evaluate LVEF, wall thickness and valve functionality

All antianginal medications should be given day of surgery

Pulmonary
Gastrointestinal Evaluate for dysphagia, difficulties swallowing and hx of esophageal/gastric surgery (TEE carries a risk of esophageal rupture)
Hematologic Confirm T+S and at least 4 units pRBCs are on hold, as well as FFP

Anticoagulation is common in these patients

Renal Evaluate for any pre-operative renal insufficiency
Endocrine Evaluate HgbA1c and if Insulin-dependent diabetic, note current insulin regimen
Other Redo sternotomies have a greater risk of significant bleeding and complication

Labs and studies

  • CBC, CMP
  • PT, PTT
  • CXR: to evaluate for abnormalities (cardiomegaly, pleural effusions)
  • EKG: check for LBBB. If a PA catheter is planned, occasionally patients with LBBB may develop a third degree block as a consequence of PA catheter placement

Operating room setup

  • Have at least 5-8 channels for infusions
    • Epi, norepi, carrier, insulin (some institutions use phenylephrine in place of norepi)
    • Consider ketamine, precedex, ancef
  • Drugs:
    • Emergency medications (bolus):
      • Epi, atropine
      • Other bolus vasopressors (e.g. vaso, phenylephrine, NE)
      • +/- Esmolol, nicardinpine, and nitroprusside
    • Heparin, protamine, calcium
    • +/- Magnesium
  • Perfusion technician should be available along with cell saver
  • Fluid warmer
  • Triple transducers primed and zeroed
  • Internal defibrillator/pacer available in room
  • TEE machine with appropriately sized probe

Patient preparation and premedication

  • All cardiac medications should be continued on day of surgery except ACE inhibitors which should be stopped 24h prior to surgery

Regional and neuraxial techniques

  • Pre-Op: Erector Spinae Plane Block -- check departmental policy as institutions vary on candidacy for pre-op block based on vessel pathology
  • Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

Intraoperative management

Monitoring and access

  • 2 large bore PIVs
  • Arterial line - often these are placed awake, especially if there are athersclerotic lesions along Left Main artery or concern for Right ventricle failure
  • CVP
  • Cordis
  • +/- Pulmonary artery catheter

Induction and airway management

  • Cardio-protective induction with etomidate vs standard induction with propofol depending on patient's cardiac function and pathology

Positioning

  • Supine position

Maintenance and surgical considerations

  • Redo sternotomies have higher risk of significant bleeding
    • type and cross with anticipation of early blood loss
    • consider having a cooler of blood in the room
  • Patients that have been on heparin leading up to the procedure may have developed resistance to heparin via ATIII depletion. If the max dosage of heparin has been given and ACT is still below goal at time of full heparinization, you may need to give ATIII concentrate
  • If procedure uses bypass, have a plan for what drips to use coming off of pump.
    • Tailor medications based on hemodynamic needs. (e.g. if there is need for inc afterload, inotropy, both, ect.)
    • Have other agents readily available such as - Milrinone, dobutamine, Vasopressin, angiotensin II

Emergence

  • Consider parasternal intercostal blocks pre-emergence/prior to transport to CVICU
  • Patients will usually remain intubated and sedated through transit to cardiac ICU, though in certain cases & institutions, emergence and extubation may be considered
    • Sedation during ICU transfer with gtt - use what is safest for the patient while providing amnesia
    • Consider utilizing gtt that will be used by ICU staff after handoff

Postoperative management

Disposition

  • Cardiac ICU

Pain management

  • Can consider regional anesthesia with parasternal intercostal plane blocks [completed pre-emergence] , or Erector Spinae block (pre-induction)

Potential complications

  • MI 6%
  • CVA 5%
  • Mild neuropsychatric effects 90%
  • Death 1-3% (preop-risk dependent)
  • Transfusion 40-90%
  • Delirium 8%-15%
  • Atrial fibrillation Up to 35%
  • Renal failure 1%
  • Mediastinitis 1-2%

Procedure variants

Variant 1 Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

Top contributors: Chris Rishel, David Leon, Olivia Sutton, James Phillips, Eeshwar Chandrasekar and Shay Lung

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