almost everything has been covered

1. ANESTHESIA FOR CORONARY ARTERY BYPASS
GRAFTING
Presenter -Dr Aparna Jayara (pg-Iiyr)
Moderater –Dr Urmila Palaria (professor)
Dept. of anesthesiology and critical care
Govt. medical college haldwani uttarakhand

2. THE BEGINNING
▪ First open heart surgery - performed by John Gibbon in 1952
using cardiopulmonary bypass
▪ First successful OPCAB was performed in 1961 and Kolesov in
1964 performed the first successful anastomosis of left internal
mammary artery (LIMA) to left anterior descending artery
(LAD)
▪ In 1967, Favalaro and Effler performed reversed saphenous vein
grafting.
▪ In 1968, Green performed anastomosis of the internal mammary
artery to the coronary artery .
▪ In 1998, Jansen and coworkers clinically used novel suction based mechanical CA
stabilizing system ( medtronic octopus system)

3. Indications of CABG
▪ CABG is performed for both symptomatic and prognostic reasons. Indications for
CABG have been classified by the American College of Cardiology (ACC) and the
American Heart Association (AHA) according to the level of evidence supporting the
usefulness and efficacy of the procedure [1, 2] :
▪ Class I - Conditions for which there is evidence and/or general agreement that a given
procedure or treatment is useful and effective
▪ Class II - Conditions for which there is conflicting evidence and/or a divergence of
opinion about the usefulness or efficacy of a procedure or treatment
▪ Class IIa - Weight of evidence or opinion is in favor of usefulness or efficacy
▪ Class IIb - Usefulness or efficacy is less well established by evidence or opinion
▪ Class III - Conditions for which there is evidence and/or general agreement that the
procedure/treatment is not useful or effective, and in some cases it may be harmful

4. Indications of CABG
▪ Class I indications for CABG from the American College of Cardiology (ACC) and the
American Heart Association (AHA) are as follows [1, 2] :
▪ Left main coronary artery stenosis >50%
▪ Stenosis of proximal LAD and proximal circumflex >70%
▪ 3-vessel disease in asymptomatic patients or those with mild or stable angina
▪ 3-vessel disease with proximal LAD stenosis in patients with poor left ventricular (LV)
function
▪ 1- or 2-vessel disease and a large area of viable myocardium in high-risk area in
patients with stable angina
▪ >70% proximal LAD stenosis with either ejection fraction < 50% or demonstrable
ischemia on noninvasive testing
▪ Other indications for CABG include the following:
▪ Disabling angina (Class I)
▪ Ongoing ischemia in the setting of a non–ST segment elevation MI that is
unresponsive to medical therapy (Class I)
▪ Poor left ventricular function but with viable, nonfunctioning myocardium above the
anatomic defect that can be revascularized
▪ CABG may be performed as an emergency procedure in the context of an ST-
segment elevation MI (STEMI) in cases where it has not been possible to perform
percutaneous coronary intervention (PCI) or where PCI has failed and there is
persistent pain and ischemia threatening a significant area of myocardium despite
medical therapy.

5. contraindications
▪ CABG is not considered appropriate in asymptomatic
patients who are at a low risk of MI or death. Patients who
will experience little benefit from coronary revascularization
are also excluded.
▪ Although advanced age is not a contraindication, CABG is
less commonly performed in the elderly. Because elderly
patients have a shorter life expectancy, CABG may not
necessarily prolong survival. These patients are also more
likely to experience perioperative complications after CABG

6. Types of cabg
▪ It is usually conducted with the use of a cardio- pulmonary
by-pass.
Alternative techniques include surgery on the beating heart
without bypass aka off pump cabg
It can be done through a median sternotomy or left anterolateral
thoracotomy and laser re- vascularisation
▪ Alternative approaches to CABG include the following:
▪ Totally endoscopic CABG
▪ Hybrid technique (bypass plus stenting

7. Basic circuit of cardiopulmonary
bypass

8. ▪ Prior to use , CPB circuit must be primed with fluid that is
devoid of bubbles. A balanced salt solution such as RL is
generally used
▪ RESERVOIR- recieves blood from the patient via one or two
venous cannulaes placed in RA, the svc and ivc or a
femoral vein.
▪ OXYGENATOR-drains blood by gravity from the bottom of
the resevoir. It contains a blood gas interface which that
allows blood to equilibriate with gas mixture (primarily o2)

9. ▪ HEAT EXCHANGER- blood can be cooled or warmed
depending on the temperature of the exchanger. Heat
transfer occurs by conduction.
▪ Pump- double armed roller or centrifugal pump.
▪ Arterial filter- particulate matter may enter the cbp from
cardiotomy suction line . Final in line arterila filter helps to
reduce systemic embolism
▪ The filter is always in parallel with a bypass limb in case the
filter becoms clogges and develops an increased resistance

10. Accessory pumps and devices
▪ 1. cardiotomy suction – aspirates blood from the surgical
field during CPB and returns it diirectly to the main pump
reservoir
▪ Potential port of entry for fat and other debris to the pump
that could embolize to the organs
▪ Cell saver suction device may also be used to aspirate
blood from surgical field.it is sent to separate resevoir and
when enough amt is accumulated , its is cenrifuged ,
washed and sent back to the patient.

11. ▪ 2.left ventricular vent- with time even with total CPB , blood
reaccumulates in LV as a result of residual pulmonary flow from
the bronchial arteries . Via rt superior pulonary vein to LA to LV
▪ Cardioplegic pump- for the administration of cardioplegic
solution (cardioplegia – the m.c. procedureto accomplish
asystoleby infusing cold cardioplegic solution into coronary
arteries, it protects myocadiumfrom damage during ischemia. It
containspotassium (10-40meq), sodium(less tha 140 meq),
calcium (0.7-1.2meq), magnesium(1.5-15meq),buffers(histidine
and THAM..concept- potassium when increased extracellularly
, reduces transmembrane pot. And heart is arrested in diastole.
▪ THAM-proton acceptor

12. On pump cabg
Advantages
 The surgeon is provided with the still heart
 Absence of blood in the anastomotic area
 Empty flaccid heart can be manipulated easily to expose all coronary branches
Adverse effects
 Initiation of CPB associated with marked increased in stress hormone including catecholamine, cortisol,
argenine, vasopressin, angiotensin
 Complement and neutrophil activation- increase in cappillary permeability- increase risk of micro-emboli
 Haemo dilution
 Electrolyte and acid base disturbances
 Metabolic disturbances

13.  The contact activation with the extracorporeal circuit, shear
forces, activation of compliment system, fibrinolysis and
extrinsic factors all contribute to platelete dysfunction
 Hypothermia can lead to platelete dysfunction reversible
coagulopathy, potentiation of citrate toxicity, altered glucose
transport and depression of myocardial contractility
 Alteration in cardial function- decrease cardiac output, cardiac
arrythmias, hypoxic subendocardial necrosis, release of
myocardial enzymes and compromised cardiac performance
 Neurologic complications- 40%. changes in cognitive function
to organic brain damage and stroke. Results mainly from
embolic gas, atheromatous debris, fat or ischaemic events

14. Post op lung dysfunction- pulmonary edema, ARDS,
atelectasis, anoxia
GI dysfunction- splanchnic vasoconstriction leading to bowel
ischaemia and bleeding

15. Off pump cabg
▪ Development of advanced epicardial stabilizers such as octopus has
facilitated CABG withot the use of CPB, also known as OPCAB
▪ Low morbidity , low mortality with faster recovery and reduced
procedural costs.
▪ Midline sternotomy-traditional approach
▪ Source of bypass grafts –rt and lt mammary arteries, saphenous v. and
radial arteries
▪ Pericardium incised, reflected and secured to the edges of mediastinum
▪ Special sternal retractors allows the placement of adjustment of flexible
fixation devices that work by direct surface pressure on myocardium..
▪ These devices stabilize and verticalize the apex of heart
▪ When the targeting vessel and surrounding myocardium are stabilized
elastic ligature is placed on coronary artery as arteriotomy is performed
then distal anastomosis is performed

16. Off Pump CAB Surgery
Indications-
 Single as well as multivessel CAD or as a hybrid procedure with PTCA
 contra indications/ increased risk for CPB-
1. severe myocardial dysfunction
2. Immuno suppression
3. H/O TIA/CVA
4. Heavily calcified aorta
5. Aortic dissection
6. Impaired renal function/need for dialysis
7. H/O previous cardiac surgery

17.  Pts who are Jehovah/s witnesses
 High risk patients eg. Advanced age, respiratory
problem, other systemic ds.

18. COMPARING ON AND OFF PUMP
CABG
1. Systemic inflammatory response syndrome (SIRS) -A
combination of non pulsatile flow, myocardial ischaemia,
hypothermia and contact of the patient blood with the
artificial surface of the extra corporeal circuit is
responsible for the inflammatory process.
2. Coagulopathy-disruption of the coagulation system and
haemodilution after cardiopulmonary bypass is avoided in
OPCAB
Less blood loss in OPCAB
Ascine – Eur. J. Cardioth. Surg. 1999
Puskas – Ann. Thor. Surg. 1998
DR GEETANJALI S VERMA

19. 3. Neurologic dysfunction- due to embolization,
inflammation, hypoperfusion and hyperthermia.
Type 1 - Death either due to stroke or hypoxic
encephalopathy, stupor & coma. (Risk factors are DM,
atherosclerosis in the proximal aorta and pre existing
impairment of cerebral blood flow)
Type 2 - Intellectual dysfunction - memory deficits,
confusion or agitation - due to small micro emboli and
inadequate perfusion
The incidence of stroke after OPCAB is about 1% when
compared to 9% after ON pump CABGDR GEETANJALI S VERMA

20. Neurological Outcome
Only few prospective Randomized Trials showed superiority of OPCAB Vs CABG.
1. Sedrakan - Stroke 2006
41 randomized trials – 50% reduction of stoke in OPCAB
2. Glenville – Ann. Thor. Surg. 2004
Elderly P. Stroke CABG – 3% OPCAB 1%
3. Mohr – Ann. Thor. Surg. 2003
16,184 p. Stroke CABG - 3.8% OPCAB 1.9%
Others
1. Alamanni – Eur. J. Cardioth. Surg. 2007
No difference stroke rate
2. Lund – Ann. Thorac. Surg. 2005
DR GEETANJALI S VERMA

21. 4. MYOCARDIAL INJURY as assessed by biochemical
markers is much less after OPCAB when compared to
CABG. Rastan – Eur. J Cardioth. Surg. 2005
5. PULMONARY DYSFUNCTION caused by
atelectasis, inflammation, increased shunting and
volume infusion. Reddy. Eur. J. Cardthor. Surg.
2006
6. RENAL DYSFUNCTION - lower in patients
undergoing OPCAB.
DR GEETANJALI S VERMA

22. Preop optimization
Before CABG, the patient’s medical history should be carefully examined for factors that might predispose to
complications, such as the following:
▪ Recent MI
▪ Previous cardiac surgery or chest radiation
▪ Conditions predisposing to bleeding
▪ Renal dysfunction
▪ Cerebrovascular disease including carotid bruits and TIA
▪ Electrolyte disturbances that might predispose the patient to dysrhythmias
▪ Infection, including urinary tract infection and dental abscesses
▪ Respiratory function, including the presence of COPD or infection [3]
▪ Routine preoperative investigations include the following [3] :
▪ Full blood count (abnormalities corrected)
▪ Clotting screen
▪ Creatinine and electrolytes (abnormalities corrected and discussed with the anesthetist)
▪ Liver function tests
▪ Screening for methicillin-resistant Staphylococcus aureus
▪ Chest radiography
▪ ECG
▪ Echocardiography or ventriculography (to assess LV function)

23. PRE MEDICATION
- Ideally two large bore (16 gauge or larger) intravenous catheters
should be placed.one of these should be in a large central vein.
- Anti aspiration prophylaxis: Ranitidine (150mg) / Pantoprazole
(40mg) + prokinetic (Metochlopramide 10 mg)
- Anti anxiety: tab Alprazolam 0.5-1mg oral
- 0.05mg.kg -1 of midazolam + 1µg.kg -1 of fentanyl IV 30minutes
prior to surgery with supplemental oxygen.
- Regular medn:
- Beta blockers should be continued in same dosage
- Anti platelet medications - stopped atleast 1 week prior to
surgery
- ACE inhibitors may be stopped 24 to 36 hours prior to surgery
(substituted with calcium channel blockers)
- For DM patients – conversion to short acting InsulinDR GEETANJALI S VERMA

24. INTRA OP MONITORING
- ECG – 5 lead electrode system.an electrode is placed on each extremity and
1 precordial lead is placed in V5 position (on lt ant axillary line at 5th
intercoastal space) ischemia detection is greatest(75%)with v5 lead. This
sensitivity is increased to 80%when lead II is paired with a V5 lead .hence
continuous monitoring with lead II and V5, the addition of a second
precordial lead V4 can detect 100% ischemic episodes.
- well visualized 'P' wave and QRS complex prior to commencing the
surgery
- Invasive blood pressure (IBP) monitoring –
- Cont. real time , beat to beat assesment of arterial perfusion pressure and
waveform throughout suurgery
- Most comonly assesed site- radial artery but femoral artery, brachial, ulnar ,
dorsalis pedis , posterior tibial and axillary artery can also be used.If radial
artery cannulation is planned the Allen's test must be performed prior to
performing cannulation.if radial artery graft is to be harvestedthe arterial line
will be placed in dominant hand.
- The cannulation of the femoral artery not only permits access to the
central arterial tree but provides access to quick insertion of an intra aortic
DR GEETANJALI S VERMA

25. Central venous pressure
▪ Monitoring of CVP
▪ Portal for intravascular volume replacement, pharmacologic
therapy and insertion of other invasive monitors such as
pulmonary artery catheters.
▪ To measure the filling pressure of rt ventricle and estimate
intravascular volume status.
▪ It gives an estimate of lt. sided pressures in patient with good lt.
ventricular fn.
▪ IJV is most commonly selected one (ease of approach and
distance from operative field)
▪ Femoral or subclavian vein can also be used but subclavian
can get obstructed during sternal retraction.. And
▪ Groin assess can be challenging in obese patients and may be
inappropriate if femoral bypass cannula placement or vein
grafting is necessary.

26. Pulmonary artery catheter
(PAC)
Usually placed via the right internal jugular vein.
Indications:
 Ejection fraction <0.4
Significant abnormality of the left ventricular wall motion.
LVEDP > 18 mm Hg at rest.
Recent MI and unstable angina.
DR GEETANJALI S VERMA

27. Transesophageal echocardiography
(TEE)
Advantages:
- Identify myocardial ischaemia early by detecting regional wall motion
abnormalities.
- Assess left ventricular dysfunction intra operatively.
- Assessing the improvement in myocardial function after the completion
of revascularization.
Disadvantage
Inability to image the required part of the heart during grafting .
DR GEETANJALI S VERMA

28. - SpO2, ETCO2
- Temperature monitoring
- Urinary output monitoring
- ACT- normal range is 80-120 seconds , heparin dosing for
extracorporeal circulation is targeted to maintain ACT values
longer than 480 seconds.

29. INDUCTION
▪ Induction should be slow
▪ By intravenous (Propofol/ Etomidate/ Thiopentone + Opioids (fentanyl /
morphine) +BZD) or inhalational method (Sevo/Iso in 1-2 MAC)
▪ Neuromuscular blockade - 0.7 mg/kg Rocuronium IV or Vecuronium 0.08-0.1
mg/kg IV (Pan/atrac – tachy)
▪ An endotracheal tube is inserted and secured and mechanical
ventilation is started.
MAINTENANCE
▪ Infusion of fentanyl, atracurium +/- Midazolam
▪ Isoflurane / O2/ air
▪ continuous very slow injection of Propofol.
DR GEETANJALI S VERMA

30. ▪ The chest is opened via a median sternotomy with the
sternal saw and the heart is examined by the surgeon.
▪ Ventilation of the lung is halted during sawing to avoid injury
to pleura.(oscillating saw in previous sternotomy (redo)), if
it’s a redo 2 units of blood must be arranged because of
perforation of RV, damage to existing v. grafts.
▪ Heparin administration usually occurs before the IMA
pedicle is clamped

31. ▪ In the case of "off-pump" surgery, the surgeon places devices to stabilize the heart.
▪ If the case is "on-pump", the surgeon sutures cannulae into the heart and instructs
the perfusionist to start cardiopulmonary bypass (CPB).Anticoagulation is
established before CPB ,heparin given through central line.ACT longer than 400-
800s is achieved Once CPB is established, the surgeon places the aortic cross-
clamp across the aorta and instructs the perfusionist to deliver cardioplegia (a
special potassium-mixture, cooled) to stop the heart and slow its metabolism.
Usually the patient's machine-circulated blood is cooled to around 84 °F (29 °C)
▪ After heparinization,aortic cannulation done first in ascending aorta
▪ 1 or two venous cannulae are put in RA. (hypotenssion can occur this time)
▪ Before aortic cannulation TEE or epiaortic echocardiography or both provides
critical information regarding the presence and precise location of calcification and
mobile atheromas in aortic arch

32. 8. One end of each graft is sewn on to the coronary arteries beyond the
blockages and the other end is attached to the aorta.
9. The heart is restarted; or in "off-pump" surgery, the stabilizing devices are
removed. In cases where the aorta is partially occluded by a C-shaped
clamp, the heart is restarted and suturing of the grafts to the aorta is done
in this partially occluded section of the aorta while the heart is beating.
10. Protamine is given to reverse the effects of heparin.
11. Chest tubes are placed in the mediastinal and pleural space to drain blood
from around the heart and lungs.
12. The sternum is wired together and the incisions are sutured closed.

33. Brief overview of cabg

34. OPCAB tissue stabilization and heart positioning devices.
Verma S et al. Circulation. 2004;109:1206-1211
Copyright © American Heart Association, Inc. All rights reserved.
Genzyme Immobilizer
utilizes a stabilization platform and silastic vessel loops
the Medtronic Octopus4 tissue stabilizer and Starfish2 heart positioner
utilize vacuum suction to stabilize and position the heart.
Coro-Vasc System (CoroNeo Inc)
illustrates silastic snares that are looped around the target coronary vessel
and then fixed to a small immobile plate, thus directly immobilizing the target vessel.

35. Weaning from cardiopulmonary
bypass
▪ TERMINATION OF CPBRewarming, evacuation of air from heart and
graft,removal of aortic cross clampand lung ventilation is resumed
▪ MNEMONIC CVP
▪ C- COLD , temp should be 36-37 degree celsius
▪ C-CONDUCTION, cardiac rate and rhythm , target rate 80-100 per
minute,
▪ C-CO or contractility, estimated from TEE or PA catheter
▪ C-CELLS , hb conc shud be equal or more tha 7-8 gm%
▪ C-CALCIUM, Immediately available to treat hyperkalemia and
hypocalcemia
▪ C-COAGULATION, after protamine admin. ACT is measured

36. ▪ V-VENTILATION of the lungs
▪ V- VISUALIZATION of the heart directly as well as through
TEEto estimate global and regional contractlity
▪ V-VAPORIZER, reinstitution of low dose of volatile agent
immediately after weaning.
▪ V-VOLUME EXPANDERS, after all products from pump has
been exhausted and and if BT is not indicated ,
crystalloid/albumin/hetastarch should be available to
increase preload

37. ▪ P-PREDICTORS OF adverse cardiovascular outcome,
▪ P-PRESSURE,TO RECOGNIZE ANY DISCREPANCY IN
CENTRAL AORTIC PRESSURE AND RADIAL ARTERY
PRESSURE
▪ P-PRESORS, vasopressors and ionotropic agents must be
easily available
▪ P-PACER an external pacer shold be readily available
▪ P-POTASSIUM, hypokalemia may contribute to
dysrhytmiasand hyperkalemai may cause conduction
abnormality
▪ P-PROTAMINEsugeon, anesthesiologist and perfusionist
should decide when to administe rprotamine.

38. INTRAOP PROBLEMS
1. HYPOTENSION
▪ treated with volume loading
▪ Maintain adequate heart rate in sinus rhythm.
▪ increasing afterload to maintain systemic perfusion
pressures.
▪ Inotrope therapy - dopamine, epinephrine, dobutamine
infusion.
▪ Phenylephrine
▪ Inform surgeon - cotton packs can be placed under the heart
and the epicardial stabilizers should be repositioned.
▪ resting the heart in the pericardial cavity.
▪ If there is no improvement, an intra aortic balloon pump
support can be instituted.
DR GEETANJALI S VERMA

39. 2. ARRYTHYMIAS
- Rule out causes: MI, electrolyte imbalance, hypothermia
- Use lidocaine (without preservative) infusion if patient
has arrhythmia caused by myocardial ischaemia.
- Electrolyte imbalance - potassium chloride, magnesium
sulfate, calcium, bicarbonate – as suggested by ABG
- Temperature correction
DR GEETANJALI S VERMA

40. 3. HEPARINIZATION
- Dose of heparin is 2mg.kg -1 (200 units.kg -1 ) intravenously.
- ACT performed 3 minutes after administration.
- The goal is to keep the ACT between 250 - 300 seconds.
- ACT repeated hourly and repeat bolus of 5000 units
Heparin is essential if ACT <250 seconds.
- Heparin is reversed with protamine sulfate (1 mg/1mg of
heparin. )
- Acceptable ACT – upto 140 seconds after protamine
administration.
- A high ACT will require additional protamine in a dose of
25 to 50 mg.
DR GEETANJALI S VERMA

41. 4. HYPOTHERMIA
- Warm blanket covers
- OT room temp
- The time taken for sterile preparation by painting
and draping by sterile sheets should be kept to the
minimum.
- Warm IV fluids
- Low fresh gas flows
DR GEETANJALI S VERMA

42. 5. MYOCARDIAL ISCHEMIA
- PREVENTION
- Maintaining systemic blood pressure (+/- 10%), keeping
MAP of at least 70 mm Hg at all times
- Reduction in myocardial oxygen consumption by
avoiding tachycardia using intra operative beta-blockers
or calcium channel blockers.
- Ischaemia during distal anastomosis can be prevented
by using intraluminal coronary shunts .
DR GEETANJALI S VERMA

43. 6. Haemodynamic changes related to
heart position
Lifting and rotating the heart during OPCAB can alter the
haemodynamics such as cardiac output, stroke work, left
ventricular end diastolic pressure and right atrial pressure.
 During grafting of right coronary artery, bradycardia can
occure due to reduction in blood supply to the sinus and AV
nodes, so if required use atropine and atrial pacing
During grafting of the right coronary artery and obtuse
marginal branches "verticalization" of the heart is required, so
posterior pericardial stitches and a gentle retracting socket will
greatly facilitate haemodynamics
Reduction in the dose of intravenous vasodilators can increase
the haemodynamic changes. During such times it may be
essential to reduce the dose of the vasodilator and add a
vasoconstrictor.DR GEETANJALI S VERMA

44. POST OP MGMT
▪ MONITORING
▪ 5 lead ECG monitoring - for any fresh changes like
ischaemia or myocardial infarction - treated with LMWH,
anti platelet medications, insertion of an intra aortic
balloon pump or revision of grafting.
▪ SpO2, ETCO2, IBP, Temp., ABG
▪ Always carry prefilled syringes of diluted 1:200,000
adrenaline, 1.2mg of atropine and 100mg of lidocaine
(preservative free) to treat a crisis during the transfer
phase.
DR GEETANJALI S VERMA

45. POST OP PAIN MGMT
▪ Epidural analgesia: epidural fentanyl infusion
with Fentanyl 3000 mcg (60 ml), 0.5%
bupivacaine 55ml and saline 155ml are added to
make a final total volume 265 ml & start at a rate
of 2ml.hour -1
▪ Intravenous opioids: Fentanyl 3000mcg and
saline 215ml are added to make a final con-
centration 11 mcg.ml -1 of fentanyl.
DR GEETANJALI S VERMA

46. ICU MGMT
VENTILATION
FiO2 of 0.8
▪ Vt 6-10 ml/kg
▪ RR: 12- 15/min
▪ I:E ratio of 1:2
▪ controlled mode of ventilation.
▪ ABG performed after thirty minutes.
▪ FiO2 is reduced to 0.4 if oxygenation, carbon dioxide
elimination and tissue perfusion maintained
DR GEETANJALI S VERMA

47. Thirty minutes later, assessment of foll done:
 blood loss (not more than 10% of blood volume)
 fluid balance (not more than 10-15 ml.kg- 1 body weight)
 core temperature ( not less than 35 deg Celsius ),
 arrhythmias
 urine output (at least 1-2 ml.kg -1 .hr -1 )
If the residual neuromuscular blockade is present then reversed
by injecting a combination of neostigmine and glycopyrrolate.
After confirming adequacy of reversal ventilatory mode is
switched to the spontaneous modes of ventilation, such as
pressure support, or continuous positive airway pressure.
Thirty minutes after supported ventilation, ABG analysis is
repeated and if the analysis shows satisfactory values of
oxygenation, carbon dioxide elimination and metabolism, theDR GEETANJALI S VERMA

48. FAST TRACK ANESTHESIA
▪ Defined as tracheal extubation within 8 hours after
cardiac surgery, early mobilization of patient and
early discharge from the hospital.
▪ Use of short acting opioid medications
▪ Long acting sedatives should be avoided
▪ Early extubation resulted in regaining the cough
reflex and thus a lower incidence of atelectasis and
pneumonia.
▪ Patients not suitable - bleeding, dysrryhtmias and
haemodynamic instabilityDR GEETANJALI S VERMA

49. THANK YOU