Difference between revisions of "Coronary artery bypass graft"

From WikiAnesthesia
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Art line
Arterial line
Central line
Central line
Introducer
Introducer

Revision as of 12:40, 5 April 2022

Coronary artery bypass graft
Anesthesia type

GA

Airway

ETT

Lines and access

PIV x2 Arterial line Central line Introducer ± PA catheter

Monitors

Standard 5-lead ECG Temperature ABP CVP TEE ± PAP

Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
Article quality
Editor rating
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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 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

References