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ANESTHESIA MANAGEMENT

The use of short-acting anesthetic agents for induction and maintenance allows for earlier emergence from anesthesia and the possibility of earlier extubation. The possibility of earlier extubation is further increased by the reduction in pulmonary complications provided by beating heart CABG. In addition, utilizing IV nonsteroidals for pain management (to reduce the need for narcotics) also helps prevent respiratory depression and leads to a quicker return to normal levels of activity.
"Our protocol for managing these patients is not to use beta-blockers at all. I think that it is detrimental, particularly with elderly patients. Elderly patients have two problems. One is that they have stiff ventricles, and usually they are Type 2 diabetics. For that reason, we like to use milrinone and Levophed ®. They are useful drugs because they change the compliance of the ventricle and allow the ventricle to beat when the heart is up. If you give neosynephrine in the elderly population, it is very detrimental. The other thing we do is give large doses of magnesium preoperatively. Magnesium stimulates prostacyclin and vasodilates the ventricle. We also use insulin very aggressively to keep the sugars under 200 and control acidosis." 13 - David Perkowski, M.D., Surgeon

Introduction and Maintenance of Cardioprotective
Anesthesia by Arno P. Nierich, M.D.

General Induction
The following is a suggested protocol for general induction:14

  • Propofol 12mg/kg
  • Pancuronium 0.1mg/kg
  • Sufentanil 0.25mg/kg
  • Continuation with air/oxygen and propofol 23mg/kg/hr Heparinization
  • Maintain ACTs greater than 250 seconds. Less heparin (100200 units/kg as opposed to the standard 300 units/kg) is required, and protamine reversal is thereby reduced to 2/3dose.15

Heparinization
Maintain ACTs greater than 250 seconds. Less heparin (100200 units/kg as opposed to the standard 300 units/kg) is required, and protamine reversal is thereby reduced to 2/3 dose.15

Normothermia
Use the following techniques to keep the patient normothermic:

  • Warm IV fluids
  • A heating mattress or warm air under the drapes
  • A humidified airway
  • A warm OR

Monitoring Hemodynamic Stability

  • Arterial line and/or CV line
  • SvO2 - When oxygenation and hemoglobin are constant, SvO2 is a good indicator of hemodynamic performance.
  • EKG - Used to monitor rhythm and analyze ST segment trends
  • TEE - Used to monitor regional wall motion and status of ventricular volume

Maintaining Hemodynamic Stability
Hemodynamic stability is easily maintained with the use of the simple techniques described below:

  • Trendelenburg position- Increases preload and allows gravity to assist in supporting the heart in the vertically displaced position
"[T]he Trendelenburg position increases the filling pressure and helps maintain hemodynamic stability. I believe this is an important maneuver for every surgeon to remember who wishes to use [beating heart CABG].:"16 -Kit V. Arom, M.D., Surgeon
  • Table rotation - Minimizes the required cardiac manipulation and aids in exposing the lateral wall
  • Nitrates - Maximize coronary perfusion
  • Vasopressors and/or intropes - Maintain mean arterial pressure
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