Coronary artery bypass surgery anesthetic considerations

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Varun Kumar, M.B.B.S. [2] Anahita Deylamsalehi, M.D.[3]

Overview

There are some critical anesthetic considerations for coronary artery bypass surgery. Based on the 2021 ACA Revascularization guideline, usage of fast-track cardiac anesthesia which uses short-acting anesthetic agents is recommended due to a better outcome. Furthermore, it is recommended to avoid opioid medications and replace them with non-opioid options, such as acetaminophen, ketamine, and dexmedetomidine, and/or regional techniques such as truncal nerve blocks. There is evidence supporting that Volatile anaesthetic may facilitate earlier extubation compared to intraveous choices. Furthermore, it is recommended to utilize an intraoperative lung-protective ventilation strategy, which is associated with better pulmonary mechanics and reduced postoperative pulmonary complications.

CABG Anesthetic Considerations

2021 ACA Revascularization Guideline

Perioperative Analgesia Usage of non opioid medications such as acetaminophen, ketamine, and dexmedetomidine, and/or regional techniques such as truncal nerve blocks (especially as part of a multimodal analgesic approach) have been shown to reduce perioperative opioid use.
Maintenance Analgesia Currently evidences are reporting that choice of maintenance anesthetic likely does not impact mortality rate. On the other hand, there is evidence supporting that Volatile anaesthetic may facilitate earlier extubation compared to intraveous choices.
Mechanical Ventilation An intraoperative lung-protective ventilation strategy has been shown to be associated with better pulmonary mechanics and reduce postoperative pulmonary complications. This strategy consists of a tidal volume of 6–8 mL/kg predicted body weight plus positive end-expiratory pressure.
Goal-directed Therapy This protocol which is for fluids and vasopressors usage with a specific hemodynamic goal showed different results in different studies, therefore, more studies are required.

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery (DO NOT EDIT)[28]

Class I
"1. Anesthetic management directed toward early postoperative extubation and accelerated recovery of low to medium-risk patients undergoing uncomplicated CABG is recommended.[29][4][30] (Level of Evidence: B)"
"2. Multidisciplinary efforts are indicated to ensure an optimal level of analgesia and patient comfort throughout the perioperative period.[31][32][33][34][35] (Level of Evidence: B)"
"3. Efforts are recommended to improve interdisciplinary communication and patient safety in the perioperative environment (eg, formalized checklist-guided multidisciplinary communication).[36][37][38][39] (Level of Evidence: B)"
"4. A fellowship-trained cardiac anesthesiologist (or experienced board-certified practitioner) credentialed in the use of perioperative transesophageal echocardiography (TEE) is recommended to provide or supervise anesthetic care of patients who are considered to be at high risk.[40][41][42] (Level of Evidence: C)"
Class III: HARM
"1. Cyclooxygenase-2 inhibitors are not recommended for pain relief in the postoperative period after CABG.[43][44] (Level of Evidence: B)"
"2. Routine use of early extubation strategies in facilities with limited backup for airway emergencies or advanced respiratory support is potentially harmful. (Level of Evidence: C)"
Class IIa
"1. Volatile anesthetic-based regimens can be useful in facilitating early extubation and reducing patient recall.[4][45][46][47] (Level of Evidence: A)"
Class IIb
"1. The effectiveness of high thoracic epidural anesthesia/analgesia for routine analgesic use is uncertain.[48][49][50][51] (Level of Evidence: B)"

Sources

  • 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines[28].
  • 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.[52]

References

  1. ↑ 1.0 1.1 Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG; et al. (2011). "2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons". J Am Coll Cardiol. 58 (24): e123–210. doi:10.1016/j.jacc.2011.08.009. PMID 22070836.
  2. ↑ 2.0 2.1 Williams JB, McConnell G, Allender JE, Woltz P, Kane K, Smith PK; et al. (2019). "One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program". J Thorac Cardiovasc Surg. 157 (5): 1881–1888. doi:10.1016/j.jtcvs.2018.10.164. PMID 30665758.
  3. ↑ 3.0 3.1 Li M, Zhang J, Gan TJ, Qin G, Wang L, Zhu M; et al. (2018). "Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: a randomized clinical trial". Eur J Cardiothorac Surg. 54 (3): 491–497. doi:10.1093/ejcts/ezy100. PMID 29514224.
  4. ↑ 4.0 4.1 4.2 4.3 Myles PS, Daly DJ, Djaiani G, Lee A, Cheng DC (2003). "A systematic review of the safety and effectiveness of fast-track cardiac anesthesia". Anesthesiology. 99 (4): 982–7. doi:10.1097/00000542-200310000-00035. PMID 14508335.
  5. ↑ 5.0 5.1 Grant MC, Isada T, Ruzankin P, Whitman G, Lawton JS, Dodd-O J; et al. (2020). "Results from an enhanced recovery program for cardiac surgery". J Thorac Cardiovasc Surg. 159 (4): 1393–1402.e7. doi:10.1016/j.jtcvs.2019.05.035. PMID 31279510.
  6. ↑ 6.0 6.1 Wong WT, Lai VK, Chee YE, Lee A (2016). "Fast-track cardiac care for adult cardiac surgical patients". Cochrane Database Syst Rev. 9: CD003587. doi:10.1002/14651858.CD003587.pub3. PMC 6457798. PMID 27616189.
  7. ↑ Silbert BS, Scott DA, Evered LA, Lewis MS, Kalpokas M, Maruff P; et al. (2006). "A comparison of the effect of high- and low-dose fentanyl on the incidence of postoperative cognitive dysfunction after coronary artery bypass surgery in the elderly". Anesthesiology. 104 (6): 1137–45. doi:10.1097/00000542-200606000-00007. PMID 16732083.
  8. ↑ Ender J, Borger MA, Scholz M, Funkat AK, Anwar N, Sommer M; et al. (2008). "Cardiac surgery fast-track treatment in a postanesthetic care unit: six-month results of the Leipzig fast-track concept". Anesthesiology. 109 (1): 61–6. doi:10.1097/ALN.0b013e31817881b3. PMID 18580173.
  9. ↑ Borde DP, Futane SS, Asegaonkar B, Apsingekar P, Khade S, Khodve B; et al. (2017). "Effect of Perioperative Pregabalin on Postoperative Quality of Recovery in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting (OPCABG): A Prospective, Randomized, Double-Blind Trial". J Cardiothorac Vasc Anesth. 31 (4): 1241–1245. doi:10.1053/j.jvca.2016.09.029. PMID 27939574.
  10. ↑ Jelacic S, Bollag L, Bowdle A, Rivat C, Cain KC, Richebe P (2016). "Intravenous Acetaminophen as an Adjunct Analgesic in Cardiac Surgery Reduces Opioid Consumption But Not Opioid-Related Adverse Effects: A Randomized Controlled Trial". J Cardiothorac Vasc Anesth. 30 (4): 997–1004. doi:10.1053/j.jvca.2016.02.010. PMID 27521969.
  11. ↑ Joshi SS, Jagadeesh AM (2013). "Efficacy of perioperative pregabalin in acute and chronic post-operative pain after off-pump coronary artery bypass surgery: a randomized, double-blind placebo controlled trial". Ann Card Anaesth. 16 (3): 180–5. doi:10.4103/0971-9784.114239. PMID 23816671.
  12. ↑ Khalil MA, Abdel Azeem MS (2013). "The impact of dexmedetomidine infusion in sparing morphine consumption in off-pump coronary artery bypass grafting". Semin Cardiothorac Vasc Anesth. 17 (1): 66–71. doi:10.1177/1089253212463969. PMID 23108415.
  13. ↑ Menda F, Köner O, Sayın M, Ergenoğlu M, Küçükaksu S, Aykaç B (2010). "Effects of single-dose gabapentin on postoperative pain and morphine consumption after cardiac surgery". J Cardiothorac Vasc Anesth. 24 (5): 808–13. doi:10.1053/j.jvca.2009.10.023. PMID 20056448.
  14. ↑ Lahtinen P, Kokki H, Hakala T, Hynynen M (2004). "S(+)-ketamine as an analgesic adjunct reduces opioid consumption after cardiac surgery". Anesth Analg. 99 (5): 1295–1301. doi:10.1213/01.ANE.0000133913.07342.B9. PMID 15502020.
  15. ↑ Subramaniam B, Shankar P, Shaefi S, Mueller A, O'Gara B, Banner-Goodspeed V; et al. (2019). "Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial". JAMA. 321 (7): 686–696. doi:10.1001/jama.2019.0234. PMC 6439609. PMID 30778597.
  16. ↑ Grant MC, Isada T, Ruzankin P, Gottschalk A, Whitman G, Lawton JS; et al. (2020). "Opioid-Sparing Cardiac Anesthesia: Secondary Analysis of an Enhanced Recovery Program for Cardiac Surgery". Anesth Analg. 131 (6): 1852–1861. doi:10.1213/ANE.0000000000005152. PMID 32889848 Check |pmid= value (help).
  17. ↑ Landoni G, Biondi-Zoccai GG, Zangrillo A, Bignami E, D'Avolio S, Marchetti C; et al. (2007). "Desflurane and sevoflurane in cardiac surgery: a meta-analysis of randomized clinical trials". J Cardiothorac Vasc Anesth. 21 (4): 502–11. doi:10.1053/j.jvca.2007.02.013. PMID 17678775.
  18. ↑ Landoni G, Guarracino F, Cariello C, Franco A, Baldassarri R, Borghi G; et al. (2014). "Volatile compared with total intravenous anaesthesia in patients undergoing high-risk cardiac surgery: a randomized multicentre study". Br J Anaesth. 113 (6): 955–63. doi:10.1093/bja/aeu290. PMID 25186820.
  19. ↑ Landoni G, Greco T, Biondi-Zoccai G, Nigro Neto C, Febres D, Pintaudi M; et al. (2013). "Anaesthetic drugs and survival: a Bayesian network meta-analysis of randomized trials in cardiac surgery". Br J Anaesth. 111 (6): 886–96. doi:10.1093/bja/aet231. PMID 23852263.
  20. ↑ Landoni G, Lomivorotov VV, Nigro Neto C, Monaco F, Pasyuga VV, Bradic N; et al. (2019). "Volatile Anesthetics versus Total Intravenous Anesthesia for Cardiac Surgery". N Engl J Med. 380 (13): 1214–1225. doi:10.1056/NEJMoa1816476. PMID 30888743.
  21. ↑ Symons JA, Myles PS (2006). "Myocardial protection with volatile anaesthetic agents during coronary artery bypass surgery: a meta-analysis". Br J Anaesth. 97 (2): 127–36. doi:10.1093/bja/ael149. PMID 16793778.
  22. ↑ Zamani MM, Najafi A, Sehat S, Janforooz Z, Derakhshan P, Rokhtabnak F; et al. (2017). "The effect of intraoperative lung protective ventilation vs conventional ventilation, on postoperative pulmonary complications after cardiopulmonary bypass". J Cardiovasc Thorac Res. 9 (4): 221–228. doi:10.15171/jcvtr.2017.38. PMC 5787335. PMID 29391936.
  23. ↑ Zochios V, Klein AA, Gao F (2018). "Protective Invasive Ventilation in Cardiac Surgery: A Systematic Review With a Focus on Acute Lung Injury in Adult Cardiac Surgical Patients". J Cardiothorac Vasc Anesth. 32 (4): 1922–1936. doi:10.1053/j.jvca.2017.10.031. PMID 29199052.
  24. ↑ Sundar S, Novack V, Jervis K, Bender SP, Lerner A, Panzica P; et al. (2011). "Influence of low tidal volume ventilation on time to extubation in cardiac surgical patients". Anesthesiology. 114 (5): 1102–10. doi:10.1097/ALN.0b013e318215e254. PMC 3500383. PMID 21430518.
  25. ↑ Yang D, Grant MC, Stone A, Wu CL, Wick EC (2016). "A Meta-analysis of Intraoperative Ventilation Strategies to Prevent Pulmonary Complications: Is Low Tidal Volume Alone Sufficient to Protect Healthy Lungs?". Ann Surg. 263 (5): 881–7. doi:10.1097/SLA.0000000000001443. PMID 26720429.
  26. ↑ Aya HD, Cecconi M, Hamilton M, Rhodes A (2013). "Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis". Br J Anaesth. 110 (4): 510–7. doi:10.1093/bja/aet020. PMID 23447502.
  27. ↑ Li P, Qu LP, Qi D, Shen B, Wang YM, Xu JR; et al. (2017). "Significance of perioperative goal-directed hemodynamic approach in preventing postoperative complications in patients after cardiac surgery: a meta-analysis and systematic review". Ann Med. 49 (4): 343–351. doi:10.1080/07853890.2016.1271956. PMID 27936959.
  28. ↑ 28.0 28.1 Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG; et al. (2011). "2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e31823c074e. PMID 22064599.
  29. ↑ Hawkes CA, Dhileepan S, Foxcroft D (2003). "Early extubation for adult cardiac surgical patients". Cochrane Database Syst Rev (4): CD003587. doi:10.1002/14651858.CD003587. PMID 14583985.
  30. ↑ van Mastrigt GA, Maessen JG, Heijmans J, Severens JL, Prins MH (2006). "Does fast-track treatment lead to a decrease of intensive care unit and hospital length of stay in coronary artery bypass patients? A meta-regression of randomized clinical trials". Crit Care Med. 34 (6): 1624–34. doi:10.1097/01.CCM.0000217963.87227.7B. PMID 16614584.
  31. ↑ Bainbridge D, Martin JE, Cheng DC (2006). "Patient-controlled versus nurse-controlled analgesia after cardiac surgery--a meta-analysis". Can J Anaesth. 53 (5): 492–9. doi:10.1007/BF03022623. PMID 16636035.
  32. ↑ Brennan F, Carr DB, Cousins M (2007). "Pain management: a fundamental human right". Anesth Analg. 105 (1): 205–21. doi:10.1213/01.ane.0000268145.52345.55. PMID 17578977.
  33. ↑ Serfontein L (2010). "Awareness in cardiac anesthesia". Curr Opin Anaesthesiol. 23 (1): 103–8. doi:10.1097/ACO.0b013e328334cb75. PMID 19949325.
  34. ↑ Lahtinen P, Kokki H, Hynynen M (2006). "Pain after cardiac surgery: a prospective cohort study of 1-year incidence and intensity". Anesthesiology. 105 (4): 794–800. PMID 17006079.
  35. ↑ Taillefer MC, Carrier M, Bélisle S, Levesque S, Lanctôt H, Boisvert AM; et al. (2006). "Prevalence, characteristics, and predictors of chronic nonanginal postoperative pain after a cardiac operation: a cross-sectional study". J Thorac Cardiovasc Surg. 131 (6): 1274–80. doi:10.1016/j.jtcvs.2006.02.001. PMID 16733157.
  36. ↑ Martinez EA, Marsteller JA, Thompson DA, Gurses AP, Goeschel CA, Lubomski LH; et al. (2010). "The Society of Cardiovascular Anesthesiologists' FOCUS initiative: Locating Errors through Networked Surveillance (LENS) project vision". Anesth Analg. 110 (2): 307–11. doi:10.1213/ANE.0b013e3181c92b9c. PMID 20081130.
  37. ↑ Wadhera RK, Parker SH, Burkhart HM, Greason KL, Neal JR, Levenick KM; et al. (2010). "Is the "sterile cockpit" concept applicable to cardiovascular surgery critical intervals or critical events? The impact of protocol-driven communication during cardiopulmonary bypass". J Thorac Cardiovasc Surg. 139 (2): 312–9. doi:10.1016/j.jtcvs.2009.10.048. PMID 20106395.
  38. ↑ Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH; et al. (2010). "Association between implementation of a medical team training program and surgical mortality". JAMA. 304 (15): 1693–700. doi:10.1001/jama.2010.1506. PMID 20959579.
  39. ↑ Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP; et al. (2009). "A surgical safety checklist to reduce morbidity and mortality in a global population". N Engl J Med. 360 (5): 491–9. doi:10.1056/NEJMsa0810119. PMID 19144931.
  40. ↑ Cahalan MK, Stewart W, Pearlman A, Goldman M, Sears-Rogan P, Abel M; et al. (2002). "American Society of Echocardiography and Society of Cardiovascular Anesthesiologists task force guidelines for training in perioperative echocardiography". J Am Soc Echocardiogr. 15 (6): 647–52. PMID 12050607.
  41. ↑ Mathew JP, Glas K, Troianos CA, Sears-Rogan P, Savage R, Shanewise J; et al. (2006). "American Society of Echocardiography/Society of Cardiovascular Anesthesiologists recommendations and guidelines for continuous quality improvement in perioperative echocardiography". J Am Soc Echocardiogr. 19 (11): 1303–13. doi:10.1016/j.echo.2006.08.039. PMID 17098131.
  42. ↑ Thys DM (2009). "Cardiac anesthesia: thirty years later--the second annual Arthur E. Weyman lecture". Anesth Analg. 109 (6): 1782–90. doi:10.1213/ANE.0b013e3181be4002. PMID 19923503.
  43. ↑ Nussmeier NA, Whelton AA, Brown MT, Langford RM, Hoeft A, Parlow JL; et al. (2005). "Complications of the COX-2 inhibitors parecoxib and valdecoxib after cardiac surgery". N Engl J Med. 352 (11): 1081–91. doi:10.1056/NEJMoa050330. PMID 15713945.
  44. ↑ Ott E, Nussmeier NA, Duke PC, Feneck RO, Alston RP, Snabes MC; et al. (2003). "Efficacy and safety of the cyclooxygenase 2 inhibitors parecoxib and valdecoxib in patients undergoing coronary artery bypass surgery". J Thorac Cardiovasc Surg. 125 (6): 1481–92. PMID 12830070.
  45. ↑ Dowd NP, Cheng DC, Karski JM, Wong DT, Munro JA, Sandler AN (1998). "Intraoperative awareness in fast-track cardiac anesthesia". Anesthesiology. 89 (5): 1068–73, discussion 9A. PMID 9821994.
  46. ↑ Groesdonk HV, Pietzner J, Borger MA, Fassl J, Haentschel D, Paarmann H; et al. (2010). "The incidence of intraoperative awareness in cardiac surgery fast-track treatment". J Cardiothorac Vasc Anesth. 24 (5): 785–9. doi:10.1053/j.jvca.2010.03.018. PMID 20537922.
  47. ↑ Cheng DC, Karski J, Peniston C, Raveendran G, Asokumar B, Carroll J; et al. (1996). "Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial". Anesthesiology. 85 (6): 1300–10. PMID 8968177.
  48. ↑ Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT; et al. (2010). "Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition)". Reg Anesth Pain Med. 35 (1): 64–101. PMID 20052816.
  49. ↑ Murphy GS, Szokol JW, Marymont JH, Vender JS, Avram MJ, Rosengart TK; et al. (2003). "Recovery of neuromuscular function after cardiac surgery: pancuronium versus rocuronium". Anesth Analg. 96 (5): 1301–7, table of contents. PMID 12707123.
  50. ↑ Nygård E, Kofoed KF, Freiberg J, Holm S, Aldershvile J, Eliasen K; et al. (2005). "Effects of high thoracic epidural analgesia on myocardial blood flow in patients with ischemic heart disease". Circulation. 111 (17): 2165–70. doi:10.1161/01.CIR.0000163551.33812.1A. PMID 15851604.
  51. ↑ Tenenbein PK, Debrouwere R, Maguire D, Duke PC, Muirhead B, Enns J; et al. (2008). "Thoracic epidural analgesia improves pulmonary function in patients undergoing cardiac surgery". Can J Anaesth. 55 (6): 344–50. doi:10.1007/BF03021489. PMID 18566197.
  52. ↑ Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM; et al. (2022). "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006. PMID 34895950 Check |pmid= value (help).

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