Anesthetic Management for Off-Pump Coronary Artery Bypass Graft Surgery

Kwak, Young Lan

Abstract

Off-pump coronary artery bypass graft surgery (OPCAB) may be of benefit overall for the patient and surgical techniques for OPCAB have been developed markedly. The development of surgical techniques without severe hemodynamic instability allows surgeons to access to all coronary arteries. Hemodynamic instability due to the displacement and restraining of the heart and transient ischemia during anastomoses are major problems associated with OPCAB. The maintenance of stable hamodynamic and minimization of cardiac dysfunction during anastomosis should be stressed in the anesthesia for OPCAB. The baseline anesthetic methods and monitoring for OPCAB are the same as for conventional coronary artery bypass graft surgery (CABG). The temperature management is a significant problem and appropriate provision is needed for defibrillation and pacing during anastomosis because rhythm problems are not uncommon. Prevention and treatment of hypotension, low cardiac output, and dysrhythmia is a major focus of anesthetic management. Volume loading and Trendelenberg position is helpful maintaining cardiac output and perfusion pressure. If hemodynamic deterioration occurs, quickly progress to potent vasopressors/ inotropic agents. Treatment of myocardial ischemia must be guided by the patient's overall hemodynamic status. Therapies to consider include titrated beta-adrenergic blockers, increasing blood pressure to improve collateral flow, treating the spasm of native coronaries or arterial conduits, reversing Trendelenberg to reduce left ventricular filling and wall stress and shunting. Close observation for surgical field and open communication with surgeon is essential to predict the patients most likely to need above modalities and bearing similarities with anesthesia for CABG in mind will help the anesthesiologist to be more comfortable with anesthesia for OPCAB.