Beating Heart CABG under Thoracic Epidural Block Combined with Light General Anesthesia in Renal Transplanted Patient / 대한마취과학회지

Beating heart CABG is defined as a CABG without cardiopulmonary bypass (CPB). Therefore there are no complications associated with CPB. So it is possible to extubate simultaneously with the end of the operation, and also it is effective to reduce the ICU time and the cost. Our team performed a beating heart CABG on a patient who had a history of renal transplantation, to avoid the renal complication due to CPB. We chose the thoracic epidural block combined with light general anesthesia as an anesthetic technique. We managed the patient successfully with consistent hemodynamic stability without the need of any drugs to induce bradycardia. We returned the patient to consciousness before extubation and extubated concurrently with the end of the operation. The patient maintained stable hemodynamics throughout the postoperative period, especially during the ICU stay and we controlled the pain via an epidural catheter with morphine and 0.125% bupivacaine for 3 days. The patient stayed in ICU only one day and was mobile on the second postoperative day. The patient was discharged without any complications, especially renal.

The Effect of Acute Normovolemic Hemodilution on Cardiopulmonary Bypass in Coronary Artery Bypass Grafting Surgery / 대한마취과학회지

BACKGROUND: Systemic arterial hypotension is relatively common following initiation of cardiopulmonary bypass (CPB). Decreased blood viscosity is induced by acute normovolemic hemodilution (ANH) and by the use of crystalloid oxygenator prime. The purpose of this paper is to study the effect of ANH on mean arterial pressure, perfusion flow index and PaO2/FiO2 upon initiation of CPB, and on homologous blood usage during CPB in coronary artery bypass grafting (CABG) surgery. METHODS: We reviewed 30 patients constituting an ANH group, and 30 patients in a control group who had undergone CABG surgery within the past 2 years. In the ANH group, 1 or 2 units of fresh autologous whole blood were sequestrated following induction of anesthesia. We compared mean arterial pressure, perfusion flow index, PaO2/FiO2, and hematocrit on the initiation of CPB, and homologous blood usage during and post CPB periods between the groups. RESULTS: Upon initiation of CPB, hematocrit in the ANH group was significantly less than in the control group, but there was no significant difference in mean arterial pressure, perfusion flow index or PaO2/FiO2 between the groups. The use of homologous blood during CPB in the ANH group was not significantly higher than in the control group. CONCLUSIONS: Acute intraoperative normovolemic hemodilution in CABG surgery was safely performed without significant hypotension and increased homologous blood usage during CPB.

Hemodynamic Evaluation of Thoracic Epidural Analgesia Combined with General Anesthesia in Coronary Artery Bypass Surgery / 대한마취과학회지

BACKGROUND: High dose fentanyl anesthesia has been recommended for circulatory stability during coronary artery bypass grafting (CABG), but hypertension and tachycardia in response to noxious stimulation have been noted. The purpose of this study was to evaluate the hemodynamic effects of extensive thoracic epidural analgesia (TEA) combined with general anesthesia (GA). METHODS: The hemodynamic effects in CABG were evaluated in 30 patients. They were randomized into two groups ; the GA group receiving high dose fentanyl (50-70 mcg/kg), the TEA group receiving 10 ml bupivacaine 5 mg ml 1 followed by 5 ml every two hours epidurally GA (N2O-O2). The hemodynamic parameters were evaluated before induction of anesthesia, 20 minutes after induction of anesthesia, after sternotomy, and 30 minutes after end of cardiopulmonary bypass. RESULTS: Heart rate and mean arterial pressure were significantly lower after sternotomy in the TEA group compared to the GA group. Significant increase in cardiac index and decrease in central venous pressure, mean pulmonary arterial pressure, pulmonary capillary wedge pressure were found after induction of anesthesia and sternotomy in the TEA group compared to the GA group. Especially, the pulmonary vascular resistance was significantly lower during all the period in the TEA group compared to the GA group. No differences were observed in stroke volume index, systemic vascular resistance, left ventricular stroke work index between two groups. CONCLUSIONS: The present study suggests a more effective blockade of the stress response during CABG with TEA than with GA. So, we consider that TEA could be used as an adjunctive anesthetic method during CABG.

Comparison of Hemostatic Effects between Aprotinin and Tranexamic Acid during Open Heart Surgery in Adults / 대한마취과학회지

BACKGROUND: Antifibrinolytics such as aprotinin and tranexamic acid have been administered to reduce blood loss of cardiac surgery, but opinions differ regarding the efficacy of each drug. This study was performed to compare the hemostatic effects between aprotinin and tranexamic acid on adult open heart anesthesia and to evaluate their additive effects. METHODS: We randomly allocated 73 patients undergoing coronary artery bypass grafting or double valve surgery to 4 groups. Group I was non-medicated control(n=15), group II(n=21)patients were recipients of a high dose of aprotinin, group III(n=16) patients were recipients of a conventional dose of tranexamic acid, and group IV(n=21) were recipient of both drugs. Cardiopulmonary bypass time, total operation time, hematocrit, platelet count, transfusion amount and 6 hours of postoperative chest tube drainage were measured. RESULTS: The medicated three groups significantly demonstrated less amounts of blood transfusion and blood loss over the first 6 hours at ICU compared to the nonmedicated control group. Total operation times were shorter in group II, III, and IV compared to group I. Use of both agents together was more effective in reducing the total operation time and blood loss compared to tranexamic alone. CONCLUSIONS: We conclude that the use of aprotinin and tranexamic acid result in significant positive hemostatic effects but superiority of one agent vs. the others is not proved. Use of two agents together yield a more positive effective in reducing the operation time and the blood loss compared to single agent alone but further study would be needed to fully confirm.

Comparison of Femoral to Radial Artery Pressure during Coronary Artery bypass Graft and Valvular Surgery / 대한마취과학회지

BACKGROUND: It has been known that pressure gradient(PG) between systolic radial arterial pressure(RAP) and systolic aortic pressure(AP) is often altered after cardiopulmonary bypass(CPB). In this study, we compared radial to femoral arterial pressure(FAP) difference between valve replacement(VR) group(n=189) and coronary artery bypass graft (CABG) group(n=90). METHODS: With IRB approval, anesthesia management followed the standard method for cardiac surgery. Heart rate, RAP, FAP, cardiac index(CI), forearm skin temperature, hematocirt and systemic vascular resistance index(SVRI) were recorded at before-CPB, after-CPB and after sternal closure. RESULTS: In CABG group, there was no change of PG between RAP and FAP before and after CPB. In VR group, systolic RAP was similar with FAP before CPB but the radial-femoral arterial pressure gradient was reversed with statistical significance after bypass. Compare with CAGB group, change of pressure gradient after CPB cousiderded statistical significant in valve replacement group. CI was increased and SVRI was decreased with statistical significance. CONCLUSION: In our study, patients in VR group who demonstrated high CI and low SVRI showed reversal of PG upon cessation of CPB. Reversal of PG at post-CPB probably partially depends on the degree of systemic vasodilation upon discontinuation of CPB.