Anesthesia for CABG, whats New; Old Issues

and New Challenges in Cardiac Anesthesiology

Presented By : Dr Sunil D. Thakur

JR Anesthesiology
Dr RPGMC Tanda
Contents

Introduction
History
Indications CABG
Anatomy of Coronay circulation
Contraindications
Anesthetic Considerations
Types of CABG
CPB Management
Off Pump CPB
Whats New
OLD Issues and New Challenges
Introduction

Cardiac surgery is a complex field of medicine with significant morbidity and mortality.
Quality anaesthetic care with specific attention to detail can greatly enhance patient safety
and outcome.
Details that are ignored can lead to disaster.
History

In 1951 vineburg implanted the LIMA to myocardium

First successful OPCAB was performed in 1961
Kolesov (1964) performed first successful anastomosis of left internal mammary
artery(LIMA) to left anterior descending artery (LAD)
In 1967 Favalaro and effler performed reversed saphenous vein grafting
History continue…..

1990s- The concept of fast tract anaesthesia focusing on:

Early extubation (with in 6 hrs)
Mobilization
Ambulation
The recent concept is ultra fast track cardiac anaesthesia (UFTCA)
Extubation with in two hours of surgery
Indications for CABG

CABG can be done for both symptomatic and prognostic reasons.

Indications for CABG have classified by american college of Cardiology (ACC) and
American Heart Association (AHA) according to level of evidence Supporting the
usefulness and efficacy of procedure
Class I - III
Class I - Indications

Left main coronary artery stenosis >50%

Stenosis of proximal LAD & Proximal circumflex >70%
Triple vessel disease:
In asymptomatic patients / those those with mild to moderate angina
With proximal LAD stenosis in patient with poor LV function
1 or2 vessel disease & large area of viable myocardium in high risk area in patients with
stable angina
Class I – Indications Continue….

70% proximal LAD stenosis with either EF <50% or demonstrable ischemia on non-
invasive testing
Disabling angina
Ongoing ischemia in setting of non- ST segment elevation MI that is unresponsive to
medical therapy
Poor LV function but with viable, non- functioning myocardium above the anatomic
defect that can be revascularised
Class I – Indications Continue…

As an emergency procedure in context of ST segment elevation MI (STEMI) in cases

where:
PCI is not possible to perform
Failed PCI
There is persistent pain and ischemia threatening a significant area of myocardium despite
medical therapy.
Anatomy of Coronary Circulation Continue…
Anatomy of Coronary Circulation
Contraindications

Very small arteries (<1mm)

Calcified arteries
Poor conduits
Huge hearts
Haemodynamic instability/ ischemia
Cardiogenic shock
Asymptomatic pts who are at low risk of MI or death
Who will experience little benefit from coronary revascularisation
Elderly age - not really contraindication
Types of CABG

ON Pump
Off Pump
MIDCABG
Hybrid techniques (bypass plus stenting)
Total Endoscopic Robotic CABG
Anaesthetic Considerations
Preop and Perioperative Consedrations

History
Examination
Investigations - CHG, RBS, RFTs, LFTs, T3, T4, TSH, Urine routine and ME,
Coagulation profile, CxR, Ecg, ECHO, Myocardial perfusion scan, Coronary Angiography
Premedication
Risk Assessment
Perioperative

ASA Basic monitoring

Intra-arterial lines Radial & Femoral
CVL Rt. IJV
Temperature Monitoring
Depth of Anaesthesia Monitoring
TEE
PAC
Induction

Goal:
To avoid undue hypotension
To attenuate hemodynamic response to laryngoscopy & intubation
Fall in BP >20% of baseline needs use of inotropes
Selected agent – small incremental doses and titrated first against loss of consciousness
then to an acceptable fall in BP
Muscle relaxation + controlled ventilation ensures adequate oxygenation and prevent
hypercapnia
Methods of Induction

High dose Narcotics:

Fentanyl 50 to 100 mcg/kg or sufentnyl 15 - 25mcg/kg
But it produces prolonged post – operative respiratory depression, high incidence of
awareness, fail to control hypertensive response to stimulation
Methods of Inductions continue…

TIVA :
Infusion of Propofol 0.5-2mg/kg F/B 25 -100mcg/kg/min
Remifentanil 1mcg/kg bolus F/b 0.25 – 1 mcg/kg
Use of shot acting agents results in early extubation and lesser hospital stay
Drugs are costier and remifentanil should be supplimented with morphine at the end for
post operative pain relief.
Methods of Inductions continue…

Mixed IV
Midazolam 0.05mg/kg for sedation.
Propofol 0.5 – 1.5mg/kg or Etomidate (0.1 – 0.3mg/kg) for induction.
Opioids are given intermittently and total dose of fentanyl and remifentanyl should not
exceed 15 and 5 mcg/kg respectively ( fast track management)
Rocuronium ( 0.6 – 1.2 mg/dl) is used as muscle relaxant to facilitate intubation
Maintenance of Anesthesia

Volatile agents {0.5 – 1.5 MAC for maintainace of anesthesia and sympathetic response
suppression ( MAC BAR)}
Isoflurane , Sevoflurane or desflurane are used for maintenance.
It results in easy control of deapth of anesthesia and hemodynamic stability and early
extubation.
Haemodynamic Effects of AA
Management of CPB
Management of CPB

Pre – CPB Check list

Anticoagulation with heparin
Check ACT (goal >450sec)
Supplemental medications (neuromuscular blockers, anesthetics, analgesics & amnestics)
PAC withdrawn back 3 – 5cm to prevent pulmonary artery injury during manipulation of heart
Absence of bubbles in airline
All monitoring / Access catheters are functional
Anticoagulation

Heparin
Administration before initiation of CPB – to prevent DIC and formation of clot in the pump
Dose 300 – 400 U/kg before arterial cannulation
Administer in reliable line ( usually central)
Activated Cloting Time (ACT)
>400 – 480 sec
Measure ACT for 3 to 5 mins
If ACT < 400 sec – additional 100 Units/kg Heparin
Measured every 30min to 1 hr while on CPB
Anticoagulation continue…

Heparin resistance - anti thrombin thrombin III deficiency

Overcomed By administering antithrombin III infusion or FFP
Milder form - Increase heparin dose
Patient with HIT
If hx is remote and no antibody detected – can safely adminster
Alternative – Hirudin, bivarudin, Anacrod, Argatroban
Cannulation

Arterial - Ascending aorta, femoral or axillary artary

Venous – RA. IVC, SVC
Limit the SBP 100mmHg to minimise risk of aortic dissection
Achieved by increasing the inhaled anaesthetc concentration or using vasodilators such as
NTG.
After aortic cannulation pressure is raised back
Venous cannulation has minimal risk
Retrograde autologous priming is initiated
Cannulation continue…
Cannulation continued
Bypass Period

Loss of arterial pulsatile wave form

Taken up by perfusionist
Main concern for anesthesiologist;
cerebral perfusion
Default systemic perfusion
Aim-
MAP 50 – 100mmHg, 60mm Hg for hypertensive
Insulin administration RBS > 180mmHg
Vaporizer – reduce to1%
If problem with vaporizer – IV anesthetics
Dose reduced during hypothermia and increased during rewarming
Initiation
CPB Circuit
Prime

The fluid contained with in the CPB tubing is called prime

Prior to use CPB circuit must be primed with fluid _ should be devoid of bubbles and ( Microimboli)
Fluid:
1. BBS/ RL
2. Albumin
3. Mannitol
4. Electrolyte
5. Heparin
Volume: Standard Vs minimum
On Average : 1500ml
Blood: used in anemic and pediatc population
CPB Circuit continue…
Cross Clamping
Cardioplegia

Procedure to produce asystole by infusing cold cardioplegic solution into coronary

arteries
Protects myocardium from damage during ischemia
Concept – increased K+ extracellulary – reduces transmembrane K+ - cardiac arrest
during diastole
 Cardioplegic Solution

Basic Components Remarks

1. Potassium (10 – 40mEqu/ml) Decreases transmembrane potential
2. Sodium <140mEq/L(conc < plasma) Ischemia increases intracellular Na+
3. Calcium 0.7-1.2mmol/l Maintains cellular integrity
4. Magnesium 1.5- 14mmol/l Control excessive i/c influx of calcium
5. Buffers- Bicarbonate, histidine, THAM TROMETHAMINE Prevent excessive buildup of acid metabolites
6. Hypertonic agents – Maninitol Control cellular edema
7. Lignocaine and Glucocortcoids Membrane stabilizing agents
8. Glucose, Glutamate. Aspartate Energy Substarates
9. Vehicles/ Solvents Crystalloids or Blood
10.

11.

12.
Cadioplegia
Pumps: Roller & Cetrifugal
CPB Machine
Weaning From CPB Machine

THEIVES
Temperatue – normothermic
Hemoglobin – atleast 7 gm/dl
Infusion - if on inotropic support restart after removal of aortic cross clamp
Electrolytes - K+ should be normal range of 4 – 5 Eq/L
Ventilation – lungs fully expandaed, ventilated, and volatile agents being delivered
ECG – paced at 90 bpm
Special consideration – intraaortic balloon pump/VAD needed, effectiveness of valve repaired
Reversal of Heparin - Protamine

Heparin reversed with Protamine when no longer needed for CPB Before aortic
decannulation.
Dose 0.6 – 1.3mg per 100units of heparin
Test dose of 10 to 20 mg over 60 min before full dose
Weaning From CPB Machine Continued

Close loop communication between perfusionist, anesthesiologist & surgeon

During weaning perfusionist systemic output through aortic cannula while surgeon applies clamp to
venous return – fills heart
Role of anesthesiologist:
On Aortic cross clamp removal NTG infusion to be start to reduce coronary artery spasm
Monitor BP, cardiac contrctility, titrating vasoactive infusions, increase systemic vascular resistance
Defibrillation is spontaneous, VF is treated with internal paddles delivering 5 to 10J
Additional Lignocaine, Magnesium 1–2gm IV slowly or Amiodarone 150mg IV bolus F/B infusion@
1mg/min for 6hrs then 0.5mg/min may be required
CPB Effects

Physiological Effects
Pharmacokinetcs
Physiological Effects by CPB

Increase stress hormone and systemic inflammation

Stress hormones – catecholamines, cortisol, arginine vasopressin, and angiotensin
Others – humoral systems ( compliments, coagulation, fibrinolysis, kallikrein)
Released when blood contacts with internal surfaces of CPB
Free radicals
Systematic inflammatory respone is similar to sepsis and develop same complications
(ARDS, coagulopathy, AKI)
Physiological Effects by CPB Continued

Modulators:
Leukocyte – depleted cardioplegia
Ultrafiltration ( hemofiltration)
High dose vitC & E, mannitol – free radical scavenger
Systemic steroids before and during CPB – modulate inflammatory response
Aprotinin ( protease inhibitor)-
1.Reduces inflammation & bleeding
2.Increases mortality
3.No longer available in USA
RCT failed to prove its benefits
Pharmacokinetic Effects of CPB

Plasma & serum concentration of most water soluble drugs acutely decreased at the
onset of CPB ( eg Nondepolarizing muscle relaxants)
Lipid soluble drugs have minimal effects eg. Fentanyl, sufentanil)
Effects of CPB Complex:
1. Sudden increase in volume of distribution with hemodilution
2. Decrease in protein binding (eg Heparin)
3. Changes in perfusion and redistribution
Reduced elimination ( reduced BF to liver & kidney)
Reduced metabolism ( Hypothermia)
Off Pump Coronary Artery Bypass Surgery
Off Pump CABG (OPCABG)

Avoids
Cannulation
Cross clamping
Systemic inflammatory response
Coagulation disoders Multiple organ dysfunction
OPCABG - Rationale

Global Mortality & Morbidity

Mortality & Morbidity in high – risk patients Pulmonary Functions
Mortality & Morbidity in eldery patients
In ICU/ Hospital length of stay
Global cost
Transfusion rate Infarction rate
Two types of OPCABG Techniquies

Off- Pump Coronary Artery Bypass (OPCAB) (Conventional)

Median Sternotomy
Multiple vessels grafting
Minimumally Invasive Direct - access Coronary artery Bypass ( MIDCAB)
Mini Thoracotomy
Anteriorly located Single or two vessel Surgery e.g Anastomasing coronary artery
Hybrid Coronary Revascularization
Combine MIDCAB techniques with catheter based interventions
Pt. undergoing OPCAB, MIDCAB or Hybrid Coronary revascularization do not under go
CPB, and thus may suffer from temperature alterations so heating blankets and warm OR
environment are essential to prevent unacceptable hypothermia
Indication for OPCAB

Presence of ischaemic heart diseases

Contraindication for CABG
Graftable Coronay Artery
Significant Stenosis in diameter (>50%)
Cotraindications For OPCAB

Intracavitary thrombi
Malignant Venticular Arrythmias
Deep Intramyocardial vessels
Procedures combined with valve Replacement or Ventricular Aneurysmectomy
Problems Associated with OPCAB

Obtaining adequate exposure of the anastomise site due to cardiac motion

Hemodynamic alterations with cardiac manipulations
1.Increased atrial size and pressure
2.Marked decrease in cardiac output
3.Reduced mixed venous saturation (SvO2), <70%
4.Vertical position of heart distorts valvular annuli
Mitral, tricuspid & aortic valve – significant regugitation & stenosis
AV annulus – significant stenosis
Anticoagulation In OPCAB Surgery

ACT – 250 to 300 sec

Lower than CPB – no contact with foreign surface
Intraoperative Complications
Intraoperative complications

1. Hypotension : Management
1. Volume loading
2. Maintain adequate HR in sinus rhythm
3. Increase afterload to maintain systemic perfusion pressures
4. Inotrpes therapy – dopamin. Epinephrin, dobutamine infusion
5. Phenylephrine
6. Inform surgeon – cottonpacks under heart and epicardial stabilizer repositioning
7. Resting heart in pericardial activity
If no improvement – intra aortic balloon pump
Intraoperative complications Continue…

2. Arrythmias ; Causes
MI, electrolyte imbalance, hypothermia
Use Lidocaine ( without preservative) infusion if patient has arrythmia caused by
MI
Electrolyte imbalance- potassium chloride, magnesium sulfate, calcium,
bicarbonate – as suggested by ABG
Temperature correction
Intraoperative complications Continue…

3. Hypothermia
Warm blanket cover
OT room temperature (22 – 25C)
The time taken for sterile preparation by painting and draping by sterile sheets should be
kept to the minimum
Warm IV fluids
Low fresh gas flow
Intraoperative complications Continue…

4. Myocardial Ischaemia: Prevention

Maintataining SBP (+/- 10%), keeping MAP of atleast 70mmHg at all times
Reduction in myocardial oxygen consumption by avoiding tacycardia using intra
operative beta – blockers or calcium channel blockers.
Ischemia during distal anastomosis can be prevented by using intraluminal coronary
shunts
Intraoperative complications Continue…

5. Haemodynamic Changes related to Heart position

Lifting and rotating the heart during OPCAB – changes in CO, SV, LEDP & RAP
During grafting of right coronary artery – bradycardia ( reduction in blood supply to sinus
and AV nodes) if required use atropine and atrial pacing
Post Operative Care
PostOp Management

Monitoring
5 lead ECG monitoring – for any fresh changes like ischemia or MI
Rx - LMWH, antiplatelet medications, insertion of IABP or revision of graft
Continuous monitoring of Spo2, ETCO2, temperature, ABG.
Always carry prefilled syringes of diluted adrenaline (1:200,000), 1mg of atropine and
100mg lidocaine to treat crisis during the transfer phase
PostOp Management Continue…s

Post Operative Pain Management

Epidural Analgesia
Thoracic epidural can be started with Ropivacaine 0.1% + fentanyl 2mcg/ml @ 5 to
10ml/hr.
Intravenous Opioids:
Fentanyl IV in syringe pumps @ 0.25 to ).5mcg/kg/hr
Multimodal Analgesia Approach
ICU Management

Ventilation
Fio2 of 0.7 to be titrate down
VT 6 to 10mlkg
RR 12 to 15/min
I:E ratio of 1:2
To continue with Controlled Mode of ventilation
ABG performed every 30min
Fio2 reduced to 0.4 if oxygenation, carbon dioxide elimination and tissue perfusion
maintained
ICU Management Continue…s

Assessment done after 30minutes

Blood loss ( not > 10% of BV)
Fluid balance (not < 10 – 15ml/kg)
Core temperature ( not <35C)
Arrythemias
UOP (at least 1 – 2 ml/kg/hr)
Residual neuromuscular blockade – reversed with Neostigmine and Glycopyrrolate
After confirming adequacy of reversal , ventilatory mode is switched to spontaneous modes of ventilation,
such as PS, or CPAP
30mins after supported ventilation – ABG repeated _ satifactory values of oxygenation, co2 elimination and
metabolism - extubation
Fast Tract Anaesthesia ( FTCA)

Defined as tracheal extubation within 6 hrs after cardiac surgery, early mobilization
of patient and early discharge from hospital
Use of short acting opioids
Long acting sedative medications should be avoided
Early extubation resultrd in regaining the cough reflex and thus a lower incidence of
atelectesis and pneumonia
Patients not suitable – bleeding, dysrhythmias and hemodynamic instability
Whats New
Whats New

Emergence of Robotic Era

In 2002 the FDA has approved the Da Vinci system of robots for use in cardiac sugery
Minimally invasive CABS (MIDCAB)
Left anterior thoracotomy – direct access to IMA and grafting to LAD
Total Endoscopic Robotic Coronary Revascularisation
Old Issues and New Challenges

Present and Future of Cardiothoracic anesthesia

Most Traditional Sub - specialty
Intubate Almost Every one
Do very little Locoregional anesthesia
Still long way from fashionable “ Opioid free Anesthesia” concept
Some still use Pulmonary Artery catheter and some would say it old dinosaur
destined for extinction just like cardiac surgery itself.
Research and innovation in Cardiac Anesthesia to improve the
outcome is associated with
Hemodynamic impairment
Major bleeding
Life- threatening complications due to increased age frailty,
comorbidities or critical illness
Hence

Increasingly refined and extensive monitoring

Specific pharmacological and non - pharmacological perioperative interventions
Defined organ protection strategies
Availability of more sophisticated and effective mechanical circulatory support devices
Minimally invasive. Hybrid and robotic procedures are becoming more common
These developments allow complex invasive cardiothoracic surgery procedures to be performed
relatively safely in elderly patients and in patients with poor myocardial systolic functions.
But at the same time these newer procedures have there own limitations, complications and so
the challenges.
Future

Cardiothoracic surgery of Future will no longer be opposite to intervention cardiology.

Rather will become part of Dynamic Multidisciplinary Approach involving:
Cardiologist
Cardiothoracic surgeons
Cardiac anesthetists / Intensivist / Critical care specialist
Outcome after Cardiothoracic Surgery
 Haemodyanamic Management and outcome ; other issues looking for
Answer

Hemodynamic Targets e.g. MAP during CPB

Administration of inotropic drugs and calcium to CPB separation
Use of “Goal - Directed Therapy” or “Goal directed Perfusion” protocols
Monitoring devices to be used during and after Cardiac surgery
All these concerns are variable among the centers worldwide.
Changes underway are:
Traditional ‘inotropes-to all’ strategy is giving its way to ‘ inotropes sparing approach’ Which did not show an increase in mortality
in recent relative small RCT [26] rather could even improve survival.
In the same way calcium salts are routinely used with the aim of hemodynamic support during CPB separation, although calcium
may worsen myocardial ischemia/ reperfusion injury [8], a 2021 RCT suggesting possible harm from calcium infusion in out-of
hospital cardiac arrest [27].
A currently ongoing large multicentric RCT the ICARUS trial [28] will hopefully through some light on usefulness and safety of
calcium
Organ Protection during cardiothoracic surgery

Risk of Neurological complications

Delirium
Neurodegenerative dysfunctions
Stroke
Coma
OPDCS Continue…s

Available Neuromonitoring Devices

Electroencephalography
Evoked potentials
Transcranial doppler
Near infra-red spectroscopy cerebral oximetry
They may favorably affect clinically relevant outcome after cardiac surgery.
A patient Tailored approach to MAP during CPB based on Near IF Spectroscopy and Transcranial
Dopplar to estimate the lower limit of cerebral autoregulation and aimed at reducing the risk of post-
operative stroke, is particularly intriguing but very far from entering common clinical practice.
OPDCS Continue…s

Pharmacological interventions
Most promising ( but still deserving further studies) is intra-operative infusion of
Dexmedetomidine which has been shown in a 2020 Meta-analysis [31] and in a
subsequent single center RCT[32] to possibly reduce postoperative delirium.
OPDCS Continue…s

Strategies to reduce the incidence and severity of postoperative AKI

Most are proved to be useless e.g. Dopamine agonists [33] or even harmful like prophylactic NaHCO3
infusion[34].
More recently, a goal directed perfusion strategy aimed at maintaining indexed oxygen delivery above
280ml/min/m2 was shown GIFT trial[35] reduce AKIN stage 1 but not stage 2 & 3.
Administration of NaHCO3 to maintain a PH >7.3 may reduce mortality in intensive care unit patients
with severe metabolic acidosis and AKI {BICAR-ICU} [36] these finding need to be confirmed in
further studies.
Intra and post operative infusion of amino-acids currently ongoing multicenter RCT the
PROTECTION Trial [37]
OPDCS Continue…s

Ventilatory Strategies
NMBA and ventilatory strategies are gradually changing
Although still no evidence that avoiding NMBA or any ventilatory strategy may may affect
PPO, despite couple of RCTs [1,8]
Prevention of Major Bleeding

Traditionally a large number of blood products are consumed every day during CT procedures.
Reducing Bleeding and transfusion is a compelling challenge
Several RCTs providing evidence based strategies with a goal of ; 0.8:1 protamine: heparin ratio
compared to a 1.3:1 ratio [38]
The use of Point of care coagulation monitors [39]
Fibrinogen concentrate supplementation ( ZEPLAST Trial) [40]
Tranexamic Acid (ATACAS Trial) [41]
However there is still a long way to go since none of them shows outstanding effects on clinically
relevant outcomes such a survival except ATACUS but it is a relatively small study.
Along the road towards less invasivity: Loco- regional Anesthesia

Use of neuraxial and regional anesthetic /Analgesic techniques in cardiac surgeries is limited due to concerns
of potential serious complication eg. haemotoma formation
Increasingly aggressive use of antithrombotic agents
Lack of clear evidence of favorable impact on outcome.
However there is recent renewed enthusiasm for Loco- regional anesthesia due to :
spread and refinement of US- guided techniques
General tendency towards opioid sparing
Optimization of times and quality of recovery after surgery i.e. ERAS
Use of various Myofascial plane blocks i.e. ESP, SAP, parasternal Block
These have greater rationale in less invasive surgeries like mini thoracotomy .
Which would certainly be a thriving field of clinical research in cardiothoracic anesthesia in near future
New Challenges
New Challenges for Anesthesiologists

Challenges during MIDCAB surgeries include one lung ventilation as deflation of left lung is required during
anastomosis
Use of bronchial blocker or DLT is needed
In addition to Standard ASA monitors , IBP, CVL & PAC must be needed
BIS
Hemodynamic control can be achieved by fluids , vassopressors/ dilators & inotropes
TECAB can be performed in Arrested heart, Beating heart with CPB or Beating heart without CPB
Defibrillation pads are placed on patients chest in preoperative period
TEE to guide placement of Endoaortic occlusional balloon clamp in Arrested heart ion TECAB
ULTRA FAST TRACT Anesthesia
References

Miller’s Anaesthesia 9th Edition

KAPLAN’S Essentials of Cardiac Anesthesia for Cardiac surgery 2nd Edition
Pisano A, Angelini M, Vlasakov I and Landoni G (2023) Old issues and new challenges in
cardiothoracic anesthesiology: Work in progress… Front. Anesthesiol. 1:1115750
Thank You