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Anaesthesia Management for off-pump CABG.pptx
- 1. Anaesthesia Management for off-pumpCABG Dr Indira Rajani Senior Consultant Cardiac Anaesthesia
- 2. • Coronary Anatomy •Coronary Physiology • Coronary Artery Disease (pathology) • Surgical Approach to CAD (treatment ) • Anaesthesia for OPCAB ◦ Preop ◦ Intraop ◦ Postop TO BE DISCUSSED...
- 3. Coronary Anatomy • Threezones of perfusion.
- 4. Coronary blood flow •Max coronary blood flow to left ventricle is during diastole • Blood flow to right ventricle is during systole and diastole • CPP=DBP-LVEDP • Hence to optimize CBF: ◦ (SUBENDOCARDIUM) • Mainatin DBP • Hr 60-80m • Lower LVEDP
- 5. CBF determinants Myocardial oxygendemands • Heart rate • Wall tension (pre and afterload) • Contractility Myocardial oxygen supply • Heart rate (diastolic time) • CPP(Lvedp and aortic diastolic pressure)(subendocardium at risk) • Arterial oxygen content (Hb*O2 sat*1.34 + 0.003*PaO2) • Coronary artery diameter
- 6. Heart Innervation • VAGUS. •through acetylcholine • reduces inotropy • reduces chronotropy, • reduces dromotrorpy • SYMPATHETIC... • Through NE • cardioaccelerator fibers T1-4 • increases inotropy, • Increases chronotropy, • Increases dromotropy(beta receptors) Cardiac receptors are found in atria,ventricles,pericardium and coronary arteries Extra cardiac receptors in great vessels and carotids These form loops between heart and cns to regulate physiology Response varies with age and duration of disease CARDIAC REFLEXES • Baroreceptor reflex • Chemoreceptor reflex • Bain Bridge reflex • Bezold Jarish rfelex • Valsalva reflex • Cushing reflex • Occulocardiac reflex...
- 7. Systolic and diastolicdysfunction • Systolic...diuretics,inotropes,pressors • Diastolic..not relaxing well..chronic hypertension..bb,acei
- 8. Coronary artery disease •Atherosclerotic changes in coronary blood vessels leading to their narrowing and limiting blood flow to heart • Presentation can be variable from no symptoms to myocardial infarction or even sudden death • Treated by lifestyle modifictaions,medication and INTERVENTIONS
- 9. History of OPCAB •AlexisCarell noting that blood vessels can be anastamosed...... • Use of CPB by Gibbon • First OPCAB by Kolesov in 1964 • Use of RSVG by Favalaro and Effler • 1968 Green anastamosed LIMA to LAD • .......newer stabiliser devices....more expertise...
- 10. • Coronary arterybypass graft (CABG) surgery was the first intervention for coronary artery disease associated with a survival benefit over medical therapy in randomized trials • the most common cardiac operation, with more than 20 million procedures performed worldwide. • CABG is particularly beneficial for patients with complex multivessel disease, left main disease, diabetes, and left ventricular systolic dysfunction. Surgical intervention to CAD: CABG
- 11. CABG:Coronary artery bypassgrafting • On pump : use of CPB • Off pump: ◦ Sternotomy ◦ Minimal access. (hemisternotomy or thoracotomy) ◦ Total endoscopic (SAFE AND COST EFFECTIVE) • The future role of CABG surgery will depend on continued improvements in technique, bypass conduits, and emerging evidence.
- 12. Why do Off– pump cabg? Advantages • Reduced SIRS response, renal dysfunction, short- term neurocognitive dysfunction • Reduced need for transfusion, reoperation for bleeding • Reduced incidence of atrial fibrillation • Reduced need for inotropes • Shorter period of postoperative ventilation • Reduced intensive care unit (ICU) and hospital stay and cost Disadvantages • High skill and experience • Compromise on graft due to hemodynamic instability (less exposure in mics) • Device induced myocardial damage Contraindicated in: • Intracardiac thrombus • Malignant arrythmias • Intramyocardial vessels • Concomitant open heart surgery
- 13. PREOPERTIVE PHASE Role ofanesthesiologist • HEART TEAM • Discuss with surgeon on optimisation of the patient • Check on the angiogram • Discuss the order of vascularisation • Discuss conduits to be harvested.. (in case of radial artery harvest...) • Risk stratify the patient!
- 14. Patient risk stratification •Online tool of STS • 2021 guidelines by ACCAHA
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- 17. Goals of anesthesia •Safe anesthesia with maximum cardiac protection • Hemostability • Fast track recovery • Early ambulation and return to functional life • Postop analgesia
- 18. Preop evaluation ( Assessmentand optimisation) • Routine history taking of past medical and surgical experiences, • Allergies • Functional capacity • Smoking • Physical examination ◦ Airway ◦ Venous access ◦ Arterial pulse site...if radial is being harvested,Allen’s
- 19. PREOPERATIVE WORK UP.... •Ecg • Echocardiogra m
- 20. Also... • BLOOD WORKUP ◦ CBC,RFT,LFT, ◦ SEROLOGY for viral markers ◦ PT-INR,aPTT ◦ HbA1C, GRBS as per protocol for diabetic pt ◦ Thyroid profile ◦ Blood grouping,Rh typing and crossmatching • OTHERS ◦ Urine routine µscopy(albumin a marker of AKI) ◦ Radiology.....chest xray, USG(ab&pelvis) aortic CT scan,dopppler(carotids,radi al) ◦ Pulmonary function test
- 21. Also.... • OSA.....STOP-BANG questionnaire •Discuss pain management • Assess end organ damage caused by systemic illnesses. • Hypertension • Diabetes • Thyroid • CRF • COPDasthma,PVD,CVATIA...
- 22. Preop orders • Fasting •Chlorhex bath • Mupirocin nasal ointment • Parts preparation • Preop beta blocker (ACC/AHA 2014) • Informed consent • ? Carbohydrate loading TO BE DISCUSSED • Perioperative physician • Functional capacity • PREHABILITATION • Incentive spirometry • ICU care and ventilator • Early ambulation with sternal support • Family counselling
- 23. nt Medication manageme prior tosurgery • Beta blockers...to continue • Antiplatelets..aspirin to continue • ACEI..stopped for 24 hours • LMWH..to be stopped 12 hours prior • Unfractionated heparin...to be stopped 6 hours prior • Thyroid medications..continue • Statins...to continue • Diuretics..as per protocol,s.k+ • Others..antipsychotics,antidepressants.. • Premedication..anxiolytics,antacids
- 24. Patient with diabetesmellitus • OHAs to be stopped previous evening to surgery • Instituitional protocol with fast acting insulin • Regular monitoring
- 25. Patient with renalfailure • Consult nephrology team • Understand course of treatment • AV Fistula and care • Dialysis charts • Pre and post weight patterns • Nutritional level • Electrolyte status • STERILITY.... • ?transplant work up
- 26. Pacemakers and devicesin-situ • Perioperative programming • Understand the indication and duration of use • ECG monitoring with filter on pacemaker detection • Back up temporary pacemaker • Do not put paddles on the generator
- 27. Frail and agedpatient • Upgrading the eyeball test
- 28. Obesity and cardiacsurgery • Airway challenges • Vascular Access challenges • Positioning • RehabilitationPREHAB • Monitoring • Pharmacotherapy challenges • Musculoskeletal issues as arthritis
- 29. Stroke risk inOPCAB PRE-OP FACTORS • Age>75y • Previous CVA • Carotid disease • PVD • Smoking • Lv dysfunction+-lv clot • Dm,crf,htn,copd POST-OP FACTORS • AF •MI INTRA-OP • Aortic clampin g and manipul ation PREVENTION IS BETTER THAN CURE
- 30. INTRA OPERATIVE PHASE • Inductionof anaesthesia • Insertion of lines and catheters • Patient preparation • Conduit harvesting • Anticoagualtion • Grafting phase • Graft check • Reversal of anticoagulation • Surgical closure • Shifting patient to icu
- 31. Induction of anaesthesia •Preop checklist • Establish large gauge iv line, • Insert A line, • Connect monitors ....watch and listen all the time!! • SAFE...SLOW N STEADY INDUCTION • Midazolam,fentanyl,prop ofol • Rocuronium,vecuronium • Intubation(single lumen tube,bb or dlt for mics) • Ventialtion with low tv • Insert CVPPA (under USG guidance) •MAINTENANACE...INHALATION , PROPOFOL,FENTANYL
- 32. Maintenace of anesthesia •Inhalational and or intravenous • Fluid management... ◦ ?goal directed, ◦ CVP or PAP guided ◦ TEE to assess preload ◦ CCO..CI ◦ ABG... lactate ◦ Overall hemodynamic stability ◦ ?field of surgery • Tranexamic acid infusion • Connect vasopressor and vasodilator of choice to centra line • Transfusion trigger...8gmdl • Pacing wire....A,V
- 33. Intraop care andmonitoring • ECG, • IAP • CVPPACO • Etco2 • Temp • Spo2 • TEE • Urine output • ABG • ACT
- 34. Ecg monitoring • 5lead ECG –Upto 90% of ischemic events can be picked up except posterior • RATE,RYTHMN, • ST SEGMENT FOR ISCHEMIA • ANTERIOR WALL-V3,4 • SEPTAL-V1,2 • INFERIOR WALL-II,III,aVF • LATERAL WALL-I,aVL,V5,V6 • ECG..5 LEAD..May be distorted during positioning for anastamosis
- 35. Intra-arterial pressure monitoring •RADIAL • FEMORAL...IABP • Skill in insertion is a must...so is interpretation!!
- 36. Pulmonary artery catheter •Helps to assess volume status perioperatively • CCO and Svo2 can be used • Hemodynamic data • Detects myocardial ischemia...LVEDP
- 37. P A Catheterindications • Post MI • Low EF • VSR • LV aneurysm • EMERGENCY SURGERY • REDO SURGERY • CABG+ VALVE • Ischemic Mitral regugitation
- 38. IABP • Intra AorticBalloon Pump is used as a mechanical circulatory support device. • Works by inflating a balloon placed in descending aorta during diastole,to increaseCPP by increasing DBP and rapidly deflates in systole to reduce aferload faced by LV, thus improving CO
- 39. Our analysis suggeststhat preoperative prophylactic implantation of an IABP is associated with several beneficial outcomes in patients undergoing CABG. These outcomes include a reduction in hospital mortality, shortened ICU hospitalization time, and a decrease in the incidence of LCOS% and MACCE%. However, preoperative IABP has little effect on renal dysfunction, the need for ventilation support for 24 h or more, and bleeding events. ESCEACTS Guideline considers it class iia ,level C recommendation for patients with mechanical complications papillary muscle rupture with severe mr,vsd,free wall rupture IABP?
- 40. TransEsophageal Echocardiography • Closerto the heart.. • 3D • Tissue doppler • Strain pattern • Speckle tracking.... INFORMATION: • New RWMA(earlier than ecg ischemia is detected) • Decrease in systolic wall thickening • Acute MR • Assess preload • IABP Positioning • Mechanical effects of OPCAB • Diastolic dysfunction • During OPCAB image capture not easy
- 41. Other monitoring.... • Urineoutput • Temperature • ABG • ACT • Alarms...disconnections... • Patient.. • Nursing team...sterility,warm saline • SURGEON!!!!!
- 42. Inotropic and vasoactivegents •Increase contractility Adrenaline,dobutamine,milrino ne •Maintain MAP Noradrenaline,phenylepherine,vasopress in •Reduce PAP(RV afterload) MILRINONE,vasodilators • Inodilator...levosimendan
- 43. OPCAB = Hemodynamiccompromises • Blood loss • IVC or ventricular compression, • Mechanical compression • Electrolyte disturbances leading to arrythmias • Resistant bradycardia may need epicardial pacing • Verticalisation of heart or intra- op MI leading to severe MR....
- 44. Intraop events • Sternotomy...watchvitals,/bradycardia,hypertensive response • Conduit harvesting...heparin for evh,calcium channel for radial.. • Grafting...sequenc e Lima to lad Om,pda...shunt placement,deairing,occlusion Proximal grafting Graft flow check, distal anastamosis are checked Protamine closure
- 45. Conduit harvesting stage •Arterial conduits Lima Rima Radial artery Inferior epigastric.... • Venous Saphenous vein • Heaprin for evh • Diltiazem for radial
- 46. Anticoagulation • Heparin 100Units per Kg body weight • TARGET ACT 250-300s
- 47. During graftinganastamosis • LAD..easierto position....if calcified,shunt insertion is difficult • OM...head low and rt tilt may cause incresed filling of heart,pa and rvot compression ...opening right pleura helps...high ramus difficult to position RCA...verticalisation...bradycardia, h ypotension..atropine, pacing,pressors
- 48. • For grafting(RCA) and circumflex (CFX), the posterior and lateral walls, respectively, must be exposed. To achieve this, the heart is lifted with a surgical spongemop and then angled up vertically with the atria at the base. • Blood must flow uphill and thus a significant increase in atrial pressures is observed, with inevitable impairment of ventricular filling. • Stabilisers are placed at the site of grafting on the epicardial vessel.
- 49. Intraop management • HYPOTENSION.. ◦Ot table positioning ◦ pressors ◦ fluids ◦ Pacing ◦ Relief of mechanical pressure of sponge or octopus... ◦ IABP • ARRYTHMIAS.. ◦ electrolytes,reperfusion,handling of heart ◦ lignocaine,amiodarone,pacing...... • Intraop MI........ ◦ pressors for MAP of 60- 70mmhg, ◦ hr of 60-70, ◦ use of intracoronary shunt to avoid ischemia by maintaining native flow and a bloodless field for smooth anastamosis • Hypertension...deeper plane of anaesthesia , vasodilator,BB..
- 50. Cell saver • Autotransfusion •Cost effective • Heparin in collected blood Not to be used if: • Blood contaminated with GI content • Blood with infective material • Blood with malignant content • Blood with abnormal hemoglobin
- 51. Proximal grafting • Reversetrendelenberg • Adequate depth of anesthesia •Sbp < 90mmHg Location of atheroma • Surgeon’s finger • TEE • Epiaortic...
- 52. No touch • Arterialgrafts • Anastamotic devices
- 53. Graft flow check •Transit time flowmeter • Information on flow rate,PI,DF • Avoids inspectionpalpation of graft
- 54. Conversion to CPB •Any severe hemodynamic instability , not reversing in a short period of time...or by agreement by team • Hemodynamic parameter which persist Cardiac index below 1.5 l/min/m^2 SvO2 < 60% MAP< 50mmHg ◦ ◦ ◦ ◦ New RWMA by TEE or new onset LV dysfunction ◦ Malignant arrhythmias ◦ Persistent ST segment elevation over 2mV
- 55. Minimal access CABG •One lung ventilation • Positioning semilateral • External defib paddles • Right femoral site exposure • Proximal grafts first • Intense monitoring • Good surgical skill • Patient selection!
- 56. Reversal of anticoagulation •REVERSAL...1:1Protamine reaction
- 57. Transport to icu •Ultimate test of team coordination • Stable patient...fit for transfer • Inotropes on infusion pump(battery!!!) • Ventilation(oxygen supply!!!) • Monitor (battery!!) • Drains...?clamp • IABP..
- 58. POSTOPERATIVE PHASE • GOAL:FAST TRACKING • Hemodynamic monitoring • Ventilation • Bleeding,tamponade,chest tubes • Blood gases optimisation,electrolyte& glucose • Temperature • Analgesia • STRICT ASEPSIS
- 59. Hemodynamic monitoring • Ecg (rate,rythmn...ST analysis) • CVP or PA... (guides volume status,detects tamponade) • Saturation by pulse oximetry • Etco2 (adequacy of ventilation) • Temperature, • Urine output....
- 60. Ventilation • Ventilation...elective tosettle postop issues • Early extubation...6 hours postop • Tv 4-6mlkg (not to stretch LIMA) • PEEP 4-5 cm of water • Abg,act,chest xray for guidance
- 61. Chest drains • Bleeding...amount,colour,rate •Check xray for ◦ Chest tube placements ◦ Endotracheal tube position ◦ CVPPA line placement ◦ Nasogastric tube, ◦ Effussions,Tamponade, ◦ Atelectasis or lobar collapse, ◦ Pulmonary Edema
- 62. Blood gases • Arterialblood gases and metabolic status • Helps to interpret the internal milieu of the patient Temperature • Monitoring peripheral temperatur e • Forced warming blankets • Warm IV fluids
- 63. Analgesia • Patient controlledanalgesia,with opioids • Intravenous infusion ,FENTANYL • REGIONAL... -Thoracic epidural -Paravertebral block -Intercostal block –S A block
- 64. • Triggered by ◦pericardial and SIRS ◦ sympathetic surge, ◦ beta blocker withdrawal, ◦ reperfusion, ◦ metabolic derangements • High risk for postop stroke • Treated by correcting cause or medicinescardioversion • Hypotension and low cardiac output • Increases postop stay and cost Postop Atrial Fibrillation (CHA2DS2-VASc score)
- 65. Neurological dysfunction • Type1 ◦ Stroke ◦ Transient ischemic attack ◦ Coma • Type 2 ◦ Cognitive decline ◦ Memory deficit ◦ Confusion,agitation,deliriu m ◦ Seizures ◦ Altered consciuosness
- 66. Postop delirium • Variedclinical features may be noted -acute change or fluctuating course of mental status -inattention -altered consciuosness -disorganized thinking -assessment tool can be used
- 67. Electrolyte and ECG •Hypocalcemia......ffp,prc.. • Hypercalcemia..rare,hyperparathyroidis m • Hypokalemia...diuretics,insulin • Hyperkalemia...low CO.,reduced UO,IV overcorrection,acidosis • Hypermagnesemia..rare, antacid ingestion,CRF • Hypomagnesemia...CRF
- 68. Surgical Site InfectionBundle • PREOP ◦ Smoking cessation 4 weeks ◦ Intra nasal staph aureus prophylaxis ◦ Chlorhex bath AM,PM • INTRAOP ◦ Iv antibiotic,redose ◦ Clipping not shaving ◦ Chlorhex Scrub ◦ Strict Asepsis ◦ Insulin Infusion.. • POSTOP ◦ Avoid hyperglycemia ◦ Maintain normothermia ◦ Strict asepsis with lines
- 69. OPCAB needs analert anaestheiologist with good skill set and a complete involvement in every stage of surgery......most importantly excellent communication with the surgeon at every critical juncture. Take home message
- 70.