Complete myocardial revascularization on the beating heart with epicardial stabilization: Anesthetic considerations

Objective: To describe an anesthetic management protocol for patients undergoing cardiac surgery with multiple coronary artery bypass grafts without cardiopulmonary bypass (off-pump CABG surgery) by median sternotomy with mechanical stabilization. Design: Retrospective nonrandomized analysis. Setting: Tertiary care hospital. Participants: Sixty-six consecutive patients on whom off-pump CABG surgery by median sternotomy was attempted. Interventions: Anesthesia was induced with a combination of etomidate and fentanyl; pancuronium bromide was given for muscle relaxation; and anesthesia was maintained with isoflurane, desflurane, or sevoflurane in 100% oxygen. Maintenance of normothermia was attempted by keeping the room temperature at 70 degrees F, warming all fluids to 41 degrees C, and using 2.5 L/min of fresh gas flows and a heat and humidity exchanger. When available, a convective forced-air blanket was used to cover patients' head and shoulders. Patients who were not slated for revascularization of the circumflex vessels and who had good ventricular function received central venous pressure monitoring (26%); all other patients received a pulmonary artery catheter. Measurements and Main Results: Of the 66 patients, 36% required an epinephrine infusion at a mean rate of 1.45 +/- 2.05 mu g/min intraoperatively to maintain hemodynamic stability; 25% required inotropic support for < 12 hours in the intensive care unit. Conclusion: Institution of systematic hemodynamic management was associated with the successful completion of the surgical procedure in 61 patients (92%), Only 5 patients required conversion to regular CABG surgery with cardiopulmonary bypass. Copyrights 2000 by W.B. Saunders Company.