Cardiosurgery - Skopje

Coronary Artery Bypass Grafting in Awake Settings

Special hospital for Cardiosurgery “Filip II”

Skopje - Macedonia

Mitrev Z, Anguseva T

Cardiosurgery - Skopje

Myocardial revascularisation

in awake patients:

1.Avoidance of extracoropreal circulation,

2.General anesthesia, endotracheal intubation and mechanical ventilation unnecessary

3.Complete off-Pump revascularisation possible

Cardiosurgery - Skopje

Material and Metods

High epydural analgo-anesthesia

N= 10 pts ( 2 femail, 8 mail)

- Epidural catheter in place: Th1-Th2 - Main targed: somatosensory and

motor block - Applied medicaments: 20ml 0.25%Bupivacain 100gr. Fentanyl, 5ml/min - Sternotomy: patient being without

intubation- CABG

Cardiosurgery - Skopje

Schematic view

The catheter is placed in the high epidural space Th1-Th2 one day preoperatively, using the loss of resistance method, or method of getting a drop

Cardiosurgery - Skopje

Age (years) 62.2 ± 7.8

Sex (f/m) 2/8

BSA (cm2) 1.76 ± 0.2

Unstable angina n : 5pts

Previous myocardial infarction n : 4pts

Coronarography finding Comorbidities:LAD 100% (n : 10) Hyperlipidemia – 7ptsLAD 100%; Cx 90% (small) Diabetes disease- 4pts

(n:2) Hypertension – 8pts COPD – 2pts Adiposity – 1pts Smokers – 6pts

Patient demographics (N : 10)

Cardiosurgery - Skopje

Management procedures

• First step: epidyral catheter the day before surgery

• Second step: The operative day-.Analgosedation with: mixture 1 : 0.5% Bupivacain and 1.66g/ml Su-Fentanyl – starting at

sternotomy till sternal rewiring mixture 2 : 0.125%Bupivacain and 1 g/ml Su-Fentanyl Day 1 to 3 after

surgery- Dosage of the analgosedativa is correlated with: Pts haemodynamic stability Blood-gas analyses Visual analgoscala. Target: pain index 1to3

Third step: Postoperative analgosedatia with mixture 2 (first day)

Cardiosurgery - Skopje

AWAKE SURGERY

Cardiosurgery - Skopje

Postoperative management

- Third step: Postoperative analgosedatia with mixture 2 (first day)

• Epidural cathether pull out after 24 hours• No need of cathecholamine support• No need of other additional sedation except epidural

mixture 2 (0.125%Bupivacain and 1 g/ml Su-Fentanyl)

Cardiosurgery - Skopje

Results I –intraoperative data

• Complete sternotomy 10 pts• CABG x1 (LITA - LAD) – 10pts• Mean time of bypassing 7.9±0.8min• Mean time of op.duration 71.7 ± 22.1min• Without intubation 9pts • 1patient intubated after sternotomy: pain index >7• Entered left pleural spaces 2 pts• Hemodynamical stability in 10 pts

Cardiosurgery - Skopje

Results II-ICU events

• Two patients left the operating room by walk.

• Drains were pull out first post op. day in all pts• Hemodynamical stability 9pts• In hospital stay 2,5days 9pts• Without any significant postop. Complications

• Follow up – 2 – 42months

Cardiosurgery - Skopje

Complications:

Perforation of the internal dura (1) Intensive headache after punction

of the dura interna (1) Collaps due to the Puncture (2) Radicular pain and back pain (7)

Epidural catheter misplacement

(2) The risk of od epidural-spinal

hematoma - decreased, following the recommendations of DGAI:

--atraumatic inplacement -- appropriate interval of the last

anticoagulant therapy

Cardiosurgery - Skopje

AWAKE SURGERY

Respiratory and haemodynamic stability

Decreased stress Good ( pre-and postoperative )

Analgesie Early mobilisation possible Quick and effective recovery Better economic side with a

exellent clinical outcome

Cardiosurgery - Skopje