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Anesthesia for coronary artery bypass grafting surgery

Authors
Atilio Barbeito, MD, MPH
Ryan Konoske, MD
Section Editor
Jonathan B Mark, MD
Deputy Editor
Nancy A Nussmeier, MD, FAHA

INTRODUCTION

Coronary artery bypass grafting (CABG) is the most commonly performed cardiac surgical procedure in the United States [1]. Anesthetic planning depends partially on the expected surgical approach to revascularization. CABG is typically performed via a midline sternotomy incision with the aid of cardiopulmonary bypass (CPB). In selected patients, off-pump coronary artery bypass (OPCAB) without CPB may be accomplished via either a full sternotomy or a small anterior left thoracotomy incision, termed a minimally invasive direct coronary artery bypass (MIDCAB) approach.

This topic will discuss anesthetic management of patients undergoing on-pump or off-pump CABG surgery. Management of CPB and weaning from CPB are reviewed separately. (See "Management of cardiopulmonary bypass in adults" and "Weaning from cardiopulmonary bypass (CPB)".)

Postoperative complications after on-pump or off-pump CABG surgery are also addressed separately:

(See "Early cardiac complications of coronary artery bypass graft surgery".)

(See "Early noncardiac complications of coronary artery bypass graft surgery".)

                               

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Literature review current through: Nov 2016. | This topic last updated: Wed Nov 23 00:00:00 GMT+00:00 2016.
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References
Top
  1. Types of heart surgery. https://www.nhlbi.nih.gov/health/health-topics/topics/hs/types (Accessed on June 28, 2016).
  2. American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring. www.asahq.org/Search.aspx?q=standards+basic+anesthetic+monitoring (Accessed on March 29, 2016).
  3. Brzezinski M, Luisetti T, London MJ. Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations. Anesth Analg 2009; 109:1763.
  4. Scheer B, Perel A, Pfeiffer UJ. Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care 2002; 6:199.
  5. Mann S, Jones RI, Millar-Craig MW, et al. The safety of ambulatory intra-arterial pressure monitoring: a clinical audit of 1000 studies. Int J Cardiol 1984; 5:585.
  6. Kedev S, Zafirovska B, Dharma S, Petkoska D. Safety and feasibility of transulnar catheterization when ipsilateral radial access is not available. Catheter Cardiovasc Interv 2014; 83:E51.
  7. Lanspa TJ, Williams MA, Heirigs RL. Effectiveness of ulnar artery catheterization after failed attempt to cannulate a radial artery. Am J Cardiol 2005; 95:1529.
  8. Gokhroo R, Kishor K, Ranwa B, et al. Ulnar Artery Interventions Non-Inferior to Radial Approach: AJmer Ulnar ARtery (AJULAR) Intervention Working Group Study Results. J Invasive Cardiol 2016; 28:1.
  9. Mangin L, Bertrand OF, De La Rochellière R, et al. The transulnar approach for coronary intervention: a safe alternative to transradial approach in selected patients. J Invasive Cardiol 2005; 17:77.
  10. Slogoff S, Keats AS, Arlund C. On the safety of radial artery cannulation. Anesthesiology 1983; 59:42.
  11. American Society of Anesthesiologists Task Force on Central Venous Access, Rupp SM, Apfelbaum JL, et al. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology 2012; 116:539.
  12. Bodenham Chair A, Babu S, Bennett J, et al. Association of Anaesthetists of Great Britain and Ireland: Safe vascular access 2016. Anaesthesia 2016; 71:573.
  13. Hillis LD, Smith PK, Anderson JL, et al. 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 2011; 124:e652.
  14. Bignami E, Belletti A, Moliterni P, et al. Clinical practice in perioperative monitoring in adult cardiac surgery: is there a standard of care? Results from an national survey. J Clin Monit Comput 2016; 30:347.
  15. Kastrup M, Markewitz A, Spies C, et al. Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany: results from a postal survey. Acta Anaesthesiol Scand 2007; 51:347.
  16. Brovman EY, Gabriel RA, Dutton RP, Urman RD. Pulmonary Artery Catheter Use During Cardiac Surgery in the United States, 2010 to 2014. J Cardiothorac Vasc Anesth 2016; 30:579.
  17. Judge O, Ji F, Fleming N, Liu H. Current use of the pulmonary artery catheter in cardiac surgery: a survey study. J Cardiothorac Vasc Anesth 2015; 29:69.
  18. Binanay C, Califf RM, Hasselblad V, et al. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA 2005; 294:1625.
  19. Harvey S, Harrison DA, Singer M, et al. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial. Lancet 2005; 366:472.
  20. Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003; 348:5.
  21. Xu F, Wang Q, Zhang H, et al. Use of pulmonary artery catheter in coronary artery bypass graft. Costs and long-term outcomes. PLoS One 2015; 10:e0117610.
  22. Whitener S, Konoske R, Mark JB. Pulmonary artery catheter. Best Pract Res Clin Anaesthesiol 2014; 28:323.
  23. Gidwani UK, Mohanty B, Chatterjee K. The pulmonary artery catheter: a critical reappraisal. Cardiol Clin 2013; 31:545.
  24. Mark JB. Multimodal detection of perioperative myocardial ischemia. Tex Heart Inst J 2005; 32:461.
  25. American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 2010; 112:1084.
  26. Kertai MD, Whitlock EL, Avidan MS. Brain monitoring with electroencephalography and the electroencephalogram-derived bispectral index during cardiac surgery. Anesth Analg 2012; 114:533.
  27. American Society of Anesthesiologists Task Force on Intraoperative Awareness. Practice advisory for intraoperative awareness and brain function monitoring: a report by the american society of anesthesiologists task force on intraoperative awareness. Anesthesiology 2006; 104:847.
  28. Engelman R, Baker RA, Likosky DS, et al. The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines for Cardiopulmonary Bypass--Temperature Management during Cardiopulmonary Bypass. J Extra Corpor Technol 2015; 47:145.
  29. Engelman R, Baker RA, Likosky DS, et al. The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines for Cardiopulmonary Bypass--Temperature Management During Cardiopulmonary Bypass. Ann Thorac Surg 2015; 100:748.
  30. Saad H, Aladawy M. Temperature management in cardiac surgery. Glob Cardiol Sci Pract 2013; 2013:44.
  31. Nussmeier NA, Cheng W, Marino M, et al. Temperature during cardiopulmonary bypass: the discrepancies between monitored sites. Anesth Analg 2006; 103:1373.
  32. Akata T, Setoguchi H, Shirozu K, Yoshino J. Reliability of temperatures measured at standard monitoring sites as an index of brain temperature during deep hypothermic cardiopulmonary bypass conducted for thoracic aortic reconstruction. J Thorac Cardiovasc Surg 2007; 133:1559.
  33. Rhee AJ, Kahn RA. Laboratory point-of-care monitoring in the operating room. Curr Opin Anaesthesiol 2010; 23:741.
  34. Howie MB, Cheng D, Newman MF, et al. A randomized double-blinded multicenter comparison of remifentanil versus fentanyl when combined with isoflurane/propofol for early extubation in coronary artery bypass graft surgery. Anesth Analg 2001; 92:1084.
  35. Slogoff S, Keats AS. Randomized trial of primary anesthetic agents on outcome of coronary artery bypass operations. Anesthesiology 1989; 70:179.
  36. Bennett JA, Abrams JT, Van Riper DF, Horrow JC. Difficult or impossible ventilation after sufentanil-induced anesthesia is caused primarily by vocal cord closure. Anesthesiology 1997; 87:1070.
  37. Coruh B, Tonelli MR, Park DR. Fentanyl-induced chest wall rigidity. Chest 2013; 143:1145.
  38. Gravlee GP, Ramsey FM, Roy RC, et al. Rapid administration of a narcotic and neuromuscular blocker: a hemodynamic comparison of fentanyl, sufentanil, pancuronium, and vecuronium. Anesth Analg 1988; 67:39.
  39. Mark JB, Greenberg LM. Intraoperative awareness and hypertensive crisis during high-dose fentanyl-diazepam-oxygen anesthesia. Anesth Analg 1983; 62:698.
  40. Philbin DM, Rosow CE, Schneider RC, et al. Fentanyl and sufentanil anesthesia revisited: how much is enough? Anesthesiology 1990; 73:5.
  41. Bovill JG, Sebel PS. Pharmacokinetics of high-dose fentanyl. A study in patients undergoing cardiac surgery. Br J Anaesth 1980; 52:795.
  42. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2215.
  43. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:e77.
  44. Kristensen SD, Knuuti J. New ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Eur Heart J 2014; 35:2344.
  45. Uhlig C, Bluth T, Schwarz K, et al. Effects of Volatile Anesthetics on Mortality and Postoperative Pulmonary and Other Complications in Patients Undergoing Surgery: A Systematic Review and Meta-analysis. Anesthesiology 2016; 124:1230.
  46. Jakobsen CJ, Berg H, Hindsholm KB, et al. The influence of propofol versus sevoflurane anesthesia on outcome in 10,535 cardiac surgical procedures. J Cardiothorac Vasc Anesth 2007; 21:664.
  47. Hare GM. Studying propofol-induced cardioprotection: from mechanism to clinical phenomenon and back again. Can J Anaesth 2016; 63:392.
  48. Ansley DM, Raedschelders K, Choi PT, et al. Propofol cardioprotection for on-pump aortocoronary bypass surgery in patients with type 2 diabetes mellitus (PRO-TECT II): a phase 2 randomized-controlled trial. Can J Anaesth 2016; 63:442.
  49. Hickey C, Gugino LD, Aglio LS, et al. Intraoperative somatosensory evoked potential monitoring predicts peripheral nerve injury during cardiac surgery. Anesthesiology 1993; 78:29.
  50. Chong AY, Clarke CE, Dimitri WR, Lip GY. Brachial plexus injury as an unusual complication of coronary artery bypass graft surgery. Postgrad Med J 2003; 79:84.
  51. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 2014; 118:21.
  52. Matyal R, Hess PE, Subramaniam B, et al. Perioperative diastolic dysfunction during vascular surgery and its association with postoperative outcome. J Vasc Surg 2009; 50:70.
  53. Hartman GS, Yao FS, Bruefach M 3rd, et al. Severity of aortic atheromatous disease diagnosed by transesophageal echocardiography predicts stroke and other outcomes associated with coronary artery surgery: a prospective study. Anesth Analg 1996; 83:701.
  54. Royse AG, Royse CF. Epiaortic ultrasound assessment of the aorta in cardiac surgery. Best Pract Res Clin Anaesthesiol 2009; 23:335.
  55. Glas KE, Swaminathan M, Reeves ST, et al. Guidelines for the performance of a comprehensive intraoperative epiaortic ultrasonographic examination: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists; endorsed by the Society of Thoracic Surgeons. J Am Soc Echocardiogr 2007; 20:1227.
  56. Wilson MJ, Boyd SY, Lisagor PG, et al. Ascending aortic atheroma assessed intraoperatively by epiaortic and transesophageal echocardiography. Ann Thorac Surg 2000; 70:25.
  57. Gold JP, Torres KE, Maldarelli W, et al. Improving outcomes in coronary surgery: the impact of echo-directed aortic cannulation and perioperative hemodynamic management in 500 patients. Ann Thorac Surg 2004; 78:1579.
  58. Emmert MY, Seifert B, Wilhelm M, et al. Aortic no-touch technique makes the difference in off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg 2011; 142:1499.
  59. Silvestry FE, Cohen MS, Armsby LB, et al. Guidelines for the Echocardiographic Assessment of Atrial Septal Defect and Patent Foramen Ovale: From the American Society of Echocardiography and Society for Cardiac Angiography and Interventions. J Am Soc Echocardiogr 2015; 28:910.
  60. Krasuski RA, Hart SA, Allen D, et al. Prevalence and repair of intraoperatively diagnosed patent foramen ovale and association with perioperative outcomes and long-term survival. JAMA 2009; 302:290.
  61. Burchardi H, Kaczmarczyk G. The effect of anaesthesia on renal function. Eur J Anaesthesiol 1994; 11:163.
  62. Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Brown JR, et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91:944.
  63. Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Ferraris SP, et al. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007; 83:S27.
  64. Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013; 41:1774.
  65. Warren J, Fromm RE Jr, Orr RA, et al. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med 2004; 32:256.
  66. Nagpal K, Arora S, Abboudi M, et al. Postoperative handover: problems, pitfalls, and prevention of error. Ann Surg 2010; 252:171.
  67. Segall N, Bonifacio AS, Schroeder RA, et al. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth Analg 2012; 115:102.
  68. Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med 2014; 371:1803.
  69. Hudson CC, McDonald B, Hudson JK, et al. Impact of anesthetic handover on mortality and morbidity in cardiac surgery: a cohort study. J Cardiothorac Vasc Anesth 2015; 29:11.
  70. Catchpole KR, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth 2007; 17:470.
  71. Bonifacio AS, Segall N, Barbeito A, et al. Handovers from the OR to the ICU. Int Anesthesiol Clin 2013; 51:43.
  72. Dixon JL, Stagg HW, Wehbe-Janek H, et al. A standard handoff improves cardiac surgical patient transfer: operating room to intensive care unit. J Healthc Qual 2015; 37:22.
  73. Nagpal K, Abboudi M, Manchanda C, et al. Improving postoperative handover: a prospective observational study. Am J Surg 2013; 206:494.
  74. Joy BF, Elliott E, Hardy C, et al. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med 2011; 12:304.
  75. Segall N, Bonifacio AS, Barbeito A, et al. Operating Room-to-ICU Patient Handovers: A Multidisciplinary Human-Centered Design Approach. Jt Comm J Qual Patient Saf 2016; 42:400.
  76. Diegeler A, Börgermann J, Kappert U, et al. Off-pump versus on-pump coronary-artery bypass grafting in elderly patients. N Engl J Med 2013; 368:1189.
  77. Lamy A, Devereaux PJ, Prabhakaran D, et al. Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year. N Engl J Med 2013; 368:1179.
  78. Lamy A, Devereaux PJ, Prabhakaran D, et al. Five-Year Outcomes after Off-Pump or On-Pump Coronary-Artery Bypass Grafting. N Engl J Med 2016.
  79. Menkis AH, Martin J, Cheng DC, et al. Drug, devices, technologies, and techniques for blood management in minimally invasive and conventional cardiothoracic surgery: a consensus statement from the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) 2011. Innovations (Phila) 2012; 7:229.
  80. Myles PS, Smith JA, Forbes A, et al. Tranexamic Acid in Patients Undergoing Coronary-Artery Surgery. N Engl J Med 2016.
  81. Chassot PG, van der Linden P, Zaugg M, et al. Off-pump coronary artery bypass surgery: physiology and anaesthetic management. Br J Anaesth 2004; 92:400.
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