Coronary artery bypass grafting surgery : Colligative - Practical Wisdom in Anesthesia, Surgery, and Medicine.

May 05, 2012

May be performed "on pump" utilising cardiopulmonary bypass, or "off pump" utilising techniques to physically stabilise the myocardium.

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Sep 24, 2011

The 2009 ROOBY trial randomising 2200 patients into either "On pump" or "Off pump" suggested better 1 year outcomes in the "On pump" group. refl.in/ix

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Indications, Relevant Conditions

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Complications, Contraindications

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Ask about contraindications for TOE/TEE: Oesophageal/ hiatus hernia surgery; oesophageal strictures/varices; previous mediastinal irradiation; history suggestive of pharyngeal pouch

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Dec 19, 2011

Cease long acting antiplatelet therapy (clopidogrel) 7-10 days before surgery where possible

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May 18, 2011

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Assessment, Workup

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Carotid doppler ultrasound may be indicated to tailor cerebral perfusion pressure if there is evidence of carotid stenosis

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May 04, 2012

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Recent ECG/EKG

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May 18, 2011

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Standard blood workup (FBE/FBC, electrolytes, urea, creatinine) clotting (INR, APTT), thyroid function (TFTs) & hepatitis status

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May 18, 2011

A recent echocardiogram is indicated for all patients with suspected valvular lesions and heart failure

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May 18, 2011

Assess for co-morbidities associated with coronary artery disease, particularly cerebro-vascular, respiratory and renal disease

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Jul 07, 2011

Assess for severity of heart failure and murmurs clinically

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May 18, 2011

If a patient presents with an anterior AMI with AV nodal blockade, it is likely that there is a dominant left coronary artery vascular supply with significant left main coronary artery disease. These patients are at high risk of developing cardiogenic shock requiring insertion of an IABP.

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Feb 25, 2012

Recent chest xray (CXR) mandatory

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May 18, 2011

Preoperative Optimisation

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Consent, Discussion

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If patient's cardiac performance is severely compromised with low left ventriclar ejection fraction or acidaemia, consider inviting the experienced cardiac surgeon to place an IABP in the OR prior to induction of anesthesia.

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Dec 14, 2011

Medication management, Premed

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Coordinating

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Cease warfarin/coumadin 5-7 days before surgery, place on heparin/clexane/LMWH protocol if high risk for thromboembolism

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May 18, 2011

Withhold aspirin on day of surgery

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May 18, 2011

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Equipment, Preparation

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Duration

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Anatomy

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IV access

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Clarify graft donor sites with surgeons and keep those sites clear. Do not place arterial or intravenous lines in those sites.

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May 18, 2011

If grafts are being taken from both arms, consider using a 9fr MAC line for the swan-ganz catheter to provide additional lumens for volume administration.

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Dec 14, 2011

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Monitoring

Consider "Afterdrop" phenomenon. Core heat redistributes to cool periphery at separation from bypass. Rapid 1-2°C fall in temp. refl.in/afterdrop

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Jul 07, 2011

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Special drugs

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Do not draw up protamine until the heart is fully decannulated. Inadvertant administration prior to decannulation of the heart will result in thrombosis at the cannulation sites that may result in death.

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Jan 24, 2013

If arterial grafts are utilised, consider continuing a GTN infusion postoperatively to reduce the risk of arterial spasm #ref

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Jan 24, 2013

If patient already heparinised, may be heparin resistant & may require a higher dose to reach target pre bypass ACT. This is partially due to consumptive ATIII deficiency

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Jul 07, 2011

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Airway, Ventilation

When reinflating lungs after bypass, manually ventilate initially and check to ensure grafts (especially LIMA) aren't disrupted by their inflation.

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Dec 19, 2011