Difference between revisions of "Coronary artery bypass graft"
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| anesthesia_type = GA | | anesthesia_type = GA | ||
| airway = ETT | | airway = ETT | ||
| lines_access = | | lines_access = PIV x2 | ||
| monitors = Standard | 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). | ||
| Line 19: | Line 36: | ||
|- | |- | ||
|Neurologic | |Neurologic | ||
| | |cognitive function | ||
Identify any atherosclerotic lesions along carotid vessels | |||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
|Identify diseased vessels | |Identify diseased vessels & any associated collaterals | ||
Evaluate LVEF, wall thickness and valve functionality | |||
All antianginal medications should be given day of surgery | All antianginal medications should be given day of surgery | ||
| Line 34: | Line 52: | ||
|- | |- | ||
|Hematologic | |Hematologic | ||
|Confirm T+S and at least | |Confirm T+S and at least 4 units pRBCs are on hold, as well as FFP | ||
Anticoagulation is common in these patients | 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 | ||
| Line 57: | Line 75: | ||
* Have at least 5-8 channels for infusions | * Have at least 5-8 channels for infusions | ||
** Epi, norepi, carrier, insulin | ** Epi, norepi, carrier, insulin (some institutions use phenylephrine in place of norepi) | ||
** Consider ketamine, precedex, ancef | ** Consider ketamine, precedex, ancef | ||
* Drugs: | * Drugs: | ||
** Heparin, protamine, calcium | ** Heparin, protamine, calcium | ||
* Perfusion technician should be available | * Perfusion technician should be available along with cell saver | ||
* Fluid warmer | * Fluid warmer | ||
* Triple transducers primed and zeroed | * Triple transducers primed and zeroed | ||
| Line 72: | Line 90: | ||
=== 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 | |||
== Intraoperative management == | == Intraoperative management == | ||
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* 2 large bore PIVs | * 2 large bore PIVs | ||
* Arterial line | * Arterial line - often these are placed awake, especially if there are athersclerotic lesions along Left Main artery | ||
* CVP | * CVP | ||
* Cordis | * Cordis | ||
| Line 84: | Line 104: | ||
=== 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 | * Redo sternotomies have higher risk of significant bleeding | ||
*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 | |||
=== 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 | |||
== Postoperative management == | == Postoperative management == | ||
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=== 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] | |||
=== 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. --> === | ||
Revision as of 19:29, 13 August 2022
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 | |
| 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 | |
| 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:
- Heparin, protamine, calcium
- 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
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
- 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
- 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
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
Postoperative management
Disposition
- Cardiac ICU
Pain management
- Can consider regional anesthesia with parasternal intercostal plane blocks [completed pre-emergence]
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 |