Chapter 4

In decades past, the otherwise healthy patient for coronary bypass surgery was the "ideal" patient for cardiac surgery/anesthesia teams. Such patients often presented with one or two vessel coronary artery disease in need of surgical revascularization. Perhaps the patient had suffered a myocardial infarction but overwhelmingly, ventricular function tended to be preserved. Free from both systolic and diastolic ventricular dysfunction, such patients tolerated anesthesia induction, maintenance, and emergence easily. Often these patients were relatively young, in their forties, fifties, and sixties and lacked other organ system diseases. Time on cardiopulmonary bypass tended to be short since the patients often required only one or two vessel revascularizations.

Today, patients presenting for coronary artery surgery are anything but "routine." Frequently they will have already undergone numerous percutaneous coronary interventions (PCIs) prior to being referred for surgery. Many patients will have had a history of recurrent small myocardial infarctions, anginal episodes, and catheterizations. Over time myocardial damage accrues, leaving the patient with both systolic and diastolic dysfunction. Other patients are referred for coronary bypass surgery because they have complex coronary artery lesions not readily amenable to PCI or they have concurrent valvular heart disease.

Although few of today's patients for coronary revascularization are "easy" to manage, review of the anesthesia management for this surgical procedure provides an overview of the anesthesia maneuvers necessary in the management of almost all cardiac surgical procedures. In other words, the skills and techniques applied in managing the "routine" coronary artery bypass (CAB) also apply when managing anesthesia for more complex procedures.

Warning: There is no such thing as routine cardiac anesthesia.

Increasingly, patients are admitted to hospital for elective CAB on the day of surgery. In that instance, the anesthesiologist may have very few moments to meet and to assess the patient for cardiac surgery. Most institutions operating a same day admission cardiac surgery program will have arranged for the patient to be evaluated in a preoperative anesthesia clinic well before the day of surgery. If that is the case, the anesthesiologist reviews the evaluative work completed in the outpatient clinic. Still, it is critically important that the anesthesiologist completes an immediate assessment prior to preparing the patient for surgery.

The patient should be questioned regarding any change in their overall health since their preoperative evaluation. They are asked if they are currently experiencing any dyspnea or anginal pain. Patients should be monitored at this time with electrocardiogram, pulse oximeter, and automatic blood pressure cuff. Supplemental oxygen should be provided.

Most patients will have continued their medications on the morning of surgery as instructed including beta-blockers. Angiotensin converting enzyme inhibitors can lead to perioperative hypotension and many patients will have been instructed to discontinue these medications. Nevertheless, a review of the patient's current medical regimen is warranted especially regarding beta blockade and any diabetes-related medications. Both hyper and hypoglycemia can occur perioperatively in diabetic patients. Close ...

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