Coronary artery bypass graft

Coronary artery bypass graft

Anesthesia type
Airway
Lines and access
Monitors
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
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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
Cardiovascular	Identify diseased vessels Note the EF All antianginal medications should be given day of surgery
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

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
  • Consider ketamine, precedex, ancef
• Drugs:
  • Heparin, protamine, calcium
• Perfusion technician should be available
• 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

Procedure variants

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