Difference between revisions of "Coronary artery bypass graft"
From WikiAnesthesia
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{{Infobox surgical case reference | {{Infobox surgical case reference | ||
| anesthesia_type = | | anesthesia_type = GA | ||
| airway = | | airway = ETT | ||
| lines_access = | | lines_access = 2 x PIV, A-line, Cordis, CVP, +/- PA catheter | ||
| monitors = | | monitors = Standard, TEE | ||
| considerations_preoperative = | | considerations_preoperative = | ||
| considerations_intraoperative = | | considerations_intraoperative = | ||
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|- | |- | ||
|Hematologic | |Hematologic | ||
| | |Confirm T+S and at least 2 units pRBCs are on hold | ||
Anticoagulation is common in these patients | |||
|- | |- | ||
|Renal | |Renal | ||
| Line 43: | Line 44: | ||
|- | |- | ||
|Other | |Other | ||
| | |Redo sternotomies have a greater risk of significant bleeding and complication | ||
|} | |} | ||
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=== 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 | |||
* 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. --> === | ||
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=== 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 | |||
=== 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. --> === | ||
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=== 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. --> === | ||
=== 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). --> == | ||
Revision as of 10:54, 14 March 2022
Coronary artery bypass graft
| Anesthesia type |
GA |
|---|---|
| Airway |
ETT |
| Lines and access |
2 x PIV, A-line, Cordis, CVP, +/- PA catheter |
| Monitors |
Standard, TEE |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative | |
| Postoperative | |
| 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 | |
| Cardiovascular | Identify diseased vessels
Note the EF All antianginal medications should be given day of surgery |
| Pulmonary | |
| Gastrointestinal | |
| Hematologic | Confirm T+S and at least 2 units pRBCs are on hold
Anticoagulation is common in these patients |
| Renal | |
| Endocrine | |
| 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
- 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
Regional and neuraxial techniques
Intraoperative management
Monitoring and access
- 2 large bore PIVs
- Arterial line
- CVP
- Cordis
- +/- Pulmonary artery catheter
Induction and airway management
Positioning
Maintenance and surgical considerations
- Redo sternotomies have higher risk of significant bleeding
Emergence
Postoperative management
Disposition
- Cardiac ICU
Pain management
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 |