Coronary artery bypass graft - Revision history

Elee88: Consideration for a-line placement if radial artery grafts are used

2025-12-13T22:11:39Z

Consideration for a-line placement if radial artery grafts are used

← Older revision		Revision as of 15:11, 13 December 2025
Line 105:		Line 105:
	* 2 large bore PIVs		* 2 large bore PIVs
	* Arterial line - often these are placed awake, especially if there are athersclerotic lesions along Left Main artery or concern for Right ventricle failure		* Arterial line - often these are placed awake, especially if there are athersclerotic lesions along Left Main artery or concern for Right ventricle failure
			**''Radial artery grafts for CABG are infrequently used but are typically taken from the non-dominant hand''
	* CVP		* CVP
	* Cordis		* Cordis

Shayxlung at 19:41, 26 October 2024

2024-10-26T19:41:27Z

← Older revision		Revision as of 12:41, 26 October 2024
Line 49:		Line 49:
	\|-		\|-
	\|Gastrointestinal		\|Gastrointestinal
	\|		\|Evaluate for dysphagia, difficulties swallowing and hx of esophageal/gastric surgery (TEE carries a risk of esophageal rupture)
	\|-		\|-
	\|Hematologic		\|Hematologic
Line 120:		Line 120:

	* Redo sternotomies have higher risk of significant bleeding		* Redo sternotomies have higher risk of significant bleeding
	**type and ~~screen or~~ cross with anticipation of early blood loss		**type and cross with anticipation of early blood loss
			**consider having a cooler of blood in the room
	*Patients that have been on heparin leading up to the procedure may have developed resistance to heparin via ATIII depletion. If the max dosage of heparin has been given and ACT is still below goal at time of full heparinization, you may need to give ATIII concentrate		*Patients that have been on heparin leading up to the procedure may have developed resistance to heparin via ATIII depletion. If the max dosage of heparin has been given and ACT is still below goal at time of full heparinization, you may need to give ATIII concentrate
	*If procedure uses bypass, have a plan for what drips to use coming off of pump.		*If procedure uses bypass, have a plan for what drips to use coming off of pump.

Drew: Added emergency medications to have ready in OR setup. Mentioned the need to tailor a plan for drips coming off pump if CPbypass was utilized. Mentioned the consideration of amnesia while transferring an intubated patient to the ICU. Also, added parastern

2022-10-13T02:25:02Z

Added emergency medications to have ready in OR setup. Mentioned the need to tailor a plan for drips coming off pump if CPbypass was utilized. Mentioned the consideration of amnesia while transferring an intubated patient to the ICU. Also, added parastern

← Older revision		Revision as of 19:25, 12 October 2022
Line 77:		Line 77:
	** Epi, norepi, carrier, insulin (some institutions use phenylephrine in place of norepi)		** Epi, norepi, carrier, insulin (some institutions use phenylephrine in place of norepi)
	** Consider ketamine, precedex, ancef		** Consider ketamine, precedex, ancef
	* Drugs:		* Drugs:
			**Emergency medications (bolus):
			***Epi, atropine
			***Other bolus vasopressors (e.g. vaso, phenylephrine, NE)
			***+/- Esmolol, nicardinpine, and nitroprusside
	** Heparin, protamine, calcium		** Heparin, protamine, calcium
			**+/- Magnesium
	* Perfusion technician should be available along with cell saver		* Perfusion technician should be available along with cell saver
	* Fluid warmer		* Fluid warmer
Line 92:		Line 97:

	*Pre-Op: Erector Spinae Plane Block -- check departmental policy as institutions vary on candidacy for pre-op block based on vessel pathology		*Pre-Op: Erector Spinae Plane Block -- check departmental policy as institutions vary on candidacy for pre-op block based on vessel pathology
			*Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

	== Intraoperative management ==		== Intraoperative management ==
Line 98:		Line 104:

	* 2 large bore PIVs		* 2 large bore PIVs
	* Arterial line - often these are placed awake, especially if there are athersclerotic lesions along Left Main artery		* Arterial line - often these are placed awake, especially if there are athersclerotic lesions along Left Main artery or concern for Right ventricle failure
	* CVP		* CVP
	* Cordis		* Cordis
Line 113:		Line 119:
	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

	* Redo sternotomies have higher risk of significant bleeding		* Redo sternotomies have higher risk of significant bleeding
			**type and screen or cross with anticipation of early blood loss
	*Patients that have been on heparin leading up to the procedure may have developed resistance to heparin via ATIII depletion. If the max dosage of heparin has been given and ACT is still below goal at time of full heparinization, you may need to give ATIII concentrate		*Patients that have been on heparin leading up to the procedure may have developed resistance to heparin via ATIII depletion. If the max dosage of heparin has been given and ACT is still below goal at time of full heparinization, you may need to give ATIII concentrate
			*If procedure uses bypass, have a plan for what drips to use coming off of pump.
			**Tailor medications based on hemodynamic needs. (e.g. if there is need for inc afterload, inotropy, both, ect.)
			**Have other agents readily available such as - Milrinone, dobutamine, Vasopressin, angiotensin II

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
Line 120:		Line 130:
	*Consider parasternal intercostal blocks pre-emergence/prior to transport to CVICU		*Consider parasternal intercostal blocks pre-emergence/prior to transport to CVICU
	*Patients will usually remain intubated and sedated through transit to cardiac ICU, though in certain cases & institutions, emergence and extubation may be considered		*Patients will usually remain intubated and sedated through transit to cardiac ICU, though in certain cases & institutions, emergence and extubation may be considered
			**Sedation during ICU transfer with gtt - use what is safest for the patient while providing amnesia
			**Consider utilizing gtt that will be used by ICU staff after handoff

	== Postoperative management ==		== Postoperative management ==
Line 129:		Line 141:
	=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

	* Can consider regional anesthesia with parasternal intercostal plane blocks [completed pre-emergence]		*Can consider regional anesthesia with parasternal intercostal plane blocks [completed pre-emergence] , or Erector Spinae block (pre-induction)

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

David.Leon at 02:29, 14 August 2022

2022-08-14T02:29:41Z

← Older revision		Revision as of 19:29, 13 August 2022
Line 98:		Line 98:

	* 2 large bore PIVs		* 2 large bore PIVs
	* Arterial line		* Arterial line - often these are placed awake, especially if there are athersclerotic lesions along Left Main artery
	* CVP		* CVP
	* Cordis		* Cordis
Line 114:		Line 114:

	* Redo sternotomies have higher risk of significant bleeding		* Redo sternotomies have higher risk of significant bleeding
			*Patients that have been on heparin leading up to the procedure may have developed resistance to heparin via ATIII depletion. If the max dosage of heparin has been given and ACT is still below goal at time of full heparinization, you may need to give ATIII concentrate

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

	*Patients ~~are not emerged~~ and ~~instead remain under anesthesia during~~ transit to cardiac ICU		*Consider parasternal intercostal blocks pre-emergence/prior to transport to CVICU
			*Patients will usually remain intubated and sedated through transit to cardiac ICU, though in certain cases & institutions, emergence and extubation may be considered

	== Postoperative management ==		== Postoperative management ==
Line 127:		Line 129:
	=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

	* Can consider regional anesthesia with parasternal intercostal plane blocks		* Can consider regional anesthesia with parasternal intercostal plane blocks [completed pre-emergence]

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

Eeshwar.Chandrasekar at 02:35, 18 July 2022

2022-07-18T02:35:15Z

← Older revision		Revision as of 19:35, 17 July 2022
Line 75:		Line 75:

	* Have at least 5-8 channels for infusions		* Have at least 5-8 channels for infusions
	** Epi, norepi, carrier, insulin		** Epi, norepi, carrier, insulin (some institutions use phenylephrine in place of norepi)
	** Consider ketamine, precedex, ancef		** Consider ketamine, precedex, ancef
	* Drugs:		* Drugs:
	** Heparin, protamine, calcium		** Heparin, protamine, calcium
	* Perfusion technician should be available		* Perfusion technician should be available along with cell saver
	* Fluid warmer		* Fluid warmer
	* Triple transducers primed and zeroed		* Triple transducers primed and zeroed
Line 90:		Line 90:

	=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===		=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===

			*Pre-Op: Erector Spinae Plane Block -- check departmental policy as institutions vary on candidacy for pre-op block based on vessel pathology

	== Intraoperative management ==		== Intraoperative management ==
Line 102:		Line 104:

	=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===		=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===

			*Cardio-protective induction with etomidate vs standard induction with propofol depending on patient's cardiac function and pathology

	=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===		=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===

			*Supine position

	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
Line 110:		Line 116:

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

			*Patients are not emerged and instead remain under anesthesia during transit to cardiac ICU

	== Postoperative management ==		== Postoperative management ==
Line 118:		Line 126:

	=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

			* Can consider regional anesthesia with parasternal intercostal plane blocks

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

David.Leon: additions to preop, additions to template

2022-06-24T19:53:51Z

additions to preop, additions to template

← Older revision		Revision as of 12:53, 24 June 2022
Line 4:		Line 4:
	\| lines_access = PIV x2		\| lines_access = PIV x2
	Arterial line		Arterial line
	Central line		Central line [often 2]
	Introducer		Introducer
	± PA catheter		± PA catheter
Line 13:		Line 13:
	CVP		CVP
	TEE		TEE
			NIRS
	± PAP		± PAP
	\| considerations_preoperative =		\| considerations_preoperative = beta-blocker
	\| considerations_intraoperative =		discussion with surgeon regarding any regional anesthesia adjuncts
	\| considerations_postoperative =		\| considerations_intraoperative = Heparinization for graft harvest
			Full heparinization prior to coming on CPB
			Hemodyamics and cardiac function coming off CPB
			Reversal of heparin with protamine
			Discussion with surgeon regarding extubation in OR
			\| considerations_postoperative = transfusion and vasopressor requirements
			inotropic support
	}}		}}
	'''Coronary Artery Bypass Graft''', also known as '''CABG''', is a common cardiac surgery procedure in which vein or artery is used as a conduit and is either grafted from the aorta (or if using left internal mammary artery, used in situ) to a coronary artery beyond a blockage in the vessel, with goal of improving blood flow to the heart, i.e. surgical coronary re-vascularization. The left internal mammary artery (LIMA) is considered first choice of graft due to high patency rate of > 90% at 10 years, though saphenous vein grafts are often used as well. It is most often indicated for individuals with significant multi-vessel Coronary Artery Disease, in particular those with Diabetes Mellitus or left main coronary vessel disease; it can also be used on a more emergent basis for those with Acute Coronary Syndrome and ST-Elevation Myocardial Infarction cases that are refractory to PCI or maximal medical management. It can be described by the number of vessels to be bypassed (single, double, triple, quadruple) as well as the technique (traditional on-pump, off-pump or minimally invasive direct).		'''Coronary Artery Bypass Graft''', also known as '''CABG''', is a common cardiac surgery procedure in which vein or artery is used as a conduit and is either grafted from the aorta (or if using left internal mammary artery, used in situ) to a coronary artery beyond a blockage in the vessel, with goal of improving blood flow to the heart, i.e. surgical coronary re-vascularization. The left internal mammary artery (LIMA) is considered first choice of graft due to high patency rate of > 90% at 10 years, though saphenous vein grafts are often used as well. It is most often indicated for individuals with significant multi-vessel Coronary Artery Disease, in particular those with Diabetes Mellitus or left main coronary vessel disease; it can also be used on a more emergent basis for those with Acute Coronary Syndrome and ST-Elevation Myocardial Infarction cases that are refractory to PCI or maximal medical management. It can be described by the number of vessels to be bypassed (single, double, triple, quadruple) as well as the technique (traditional on-pump, off-pump or minimally invasive direct).
Line 29:		Line 36:
	\|-		\|-
	\|Neurologic		\|Neurologic
	\|		\|cognitive function
			Identify any atherosclerotic lesions along carotid vessels
	\|-		\|-
	\|Cardiovascular		\|Cardiovascular
	\|Identify diseased vessels		\|Identify diseased vessels & any associated collaterals
	~~Note the EF~~		Evaluate LVEF, wall thickness and valve functionality

	All antianginal medications should be given day of surgery		All antianginal medications should be given day of surgery
Line 44:		Line 52:
	\|-		\|-
	\|Hematologic		\|Hematologic
	\|Confirm T+S and at least 2 units pRBCs are on hold		\|Confirm T+S and at least 4 units pRBCs are on hold, as well as FFP
	Anticoagulation is common in these patients		Anticoagulation is common in these patients
	\|-		\|-
	\|Renal		\|Renal
	\|		\|Evaluate for any pre-operative renal insufficiency
	\|-		\|-
	\|Endocrine		\|Endocrine
	\|		\|Evaluate HgbA1c and if Insulin-dependent diabetic, note current insulin regimen
	\|-		\|-
	\|Other		\|Other

Chris.Rishel: Text replacement - "Art line" to "Arterial line"

2022-04-05T19:40:14Z

Text replacement - "Art line" to "Arterial line"

← Older revision		Revision as of 12:40, 5 April 2022
Line 3:		Line 3:
	\| airway = ETT		\| airway = ETT
	\| lines_access = PIV x2		\| lines_access = PIV x2
	~~Art~~ line		Arterial line
	Central line		Central line
	Introducer		Introducer

Chris.Rishel at 06:17, 5 April 2022

2022-04-05T06:17:04Z

← Older revision		Revision as of 23:17, 4 April 2022
Line 2:		Line 2:
	\| anesthesia_type = GA		\| anesthesia_type = GA
	\| airway = ETT		\| airway = ETT
	\| lines_access = ~~2 x~~ PIV~~, A-~~line~~, Cordis, CVP, +/-~~ PA catheter		\| lines_access = PIV x2
	\| monitors = Standard, TEE		Art line
			Central line
			Introducer
			± PA catheter
			\| monitors = Standard
			5-lead ECG
			Temperature
			ABP
			CVP
			TEE
			± PAP
	\| considerations_preoperative =		\| considerations_preoperative =
	\| considerations_intraoperative =		\| considerations_intraoperative =

Oliviamsutton at 17:54, 14 March 2022

2022-03-14T17:54:04Z

← Older revision		Revision as of 10:54, 14 March 2022
Line 1:		Line 1:
	{{Infobox surgical case reference		{{Infobox surgical case reference
	\| anesthesia_type =		\| anesthesia_type = GA
	\| airway =		\| airway = ETT
	\| lines_access =		\| lines_access = 2 x PIV, A-line, Cordis, CVP, +/- PA catheter
	\| monitors =		\| monitors = Standard, TEE
	\| considerations_preoperative =		\| considerations_preoperative =
	\| considerations_intraoperative =		\| considerations_intraoperative =
Line 34:		Line 34:
	\|-		\|-
	\|Hematologic		\|Hematologic
	\|		\|Confirm T+S and at least 2 units pRBCs are on hold
			Anticoagulation is common in these patients
	\|-		\|-
	\|Renal		\|Renal
Line 43:		Line 44:
	\|-		\|-
	\|Other		\|Other
	\|		\|Redo sternotomies have a greater risk of significant bleeding and complication
	\|}		\|}

Line 75:		Line 76:

	=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===		=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===

			* 2 large bore PIVs
			* Arterial line
			* CVP
			* Cordis
			* +/- Pulmonary artery catheter

	=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===		=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
Line 81:		Line 88:

	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

			* Redo sternotomies have higher risk of significant bleeding

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
Line 87:		Line 96:

	=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===		=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===

			* Cardiac ICU

	=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

			* MI 6%
			* CVA 5%
			* Mild neuropsychatric effects 90%
			* Death 1-3% (preop-risk dependent)
			* Transfusion 40-90%
			* Delirium 8%-15%
			* Atrial fibrillation Up to 35%
			* Renal failure 1%
			* Mediastinitis 1-2%

	== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==		== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

Oliviamsutton at 17:46, 14 March 2022

2022-03-14T17:46:37Z

← Older revision		Revision as of 10:46, 14 March 2022
Line 22:		Line 22:
	\|-		\|-
	\|Cardiovascular		\|Cardiovascular
	\|		\|Identify diseased vessels
			Note the EF

			All antianginal medications should be given day of surgery
	\|-		\|-
	\|Pulmonary		\|Pulmonary
Line 44:		Line 47:

	=== Labs and studies ===		=== Labs and studies ===

			* CBC, CMP
			* PT, PTT
			* CXR: to evaluate for abnormalities (cardiomegaly, pleural effusions)
			* EKG: check for LBBB. If a PA catheter is planned, occasionally patients with LBBB may develop a third degree block as a consequence of PA catheter placement

	=== Operating room setup ===		=== Operating room setup ===

			* Have at least 5-8 channels for infusions
			** Epi, norepi, carrier, insulin
			** Consider ketamine, precedex, ancef
			* Drugs:
			** Heparin, protamine, calcium
			* Perfusion technician should be available
			* Fluid warmer
			* Triple transducers primed and zeroed
			* Internal defibrillator/pacer available in room
			* TEE machine with appropriately sized probe

	=== Patient preparation and premedication ===		=== Patient preparation and premedication ===

			* All cardiac medications should be continued on day of surgery except ACE inhibitors which should be stopped 24h prior to surgery

	=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===		=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===