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Ann Thorac Surg 2001;71:2084-2085
© 2001 The Society of Thoracic Surgeons
a Department of Anaesthesia & Critical Care, The Glenfield Hospital NHS Trust, Groby Rd, Leicester, LE3 9QP, United Kingdom
b Department of Cardiothoracic Surgery, The Glenfield Hospital NHS Trust, Groby Rd, Leicester, LE3 9QP, United Kingdom
e-mail: skinner{at}dial.pipex.com
To the Editor
Craver and colleagues [1] concluded that in selected octogenarians, cardiac surgery can be performed with acceptable mortality and excellent 5-year survival. In their practice, patients with a forced expiratory volume in 1 second of less than 1000 mL were usually refused cardiac surgery.
We wish to report successful coronary artery bypass surgery in an 80-year-old man referred with ischemic heart disease. Angiography revealed two vessel disease with mildly impaired left ventricular function. The patient also suffered from severe chronic obstructive airways disease reflected in a forced expiratory volume of 830 mL in 1 second. He was incapacitated by his disease, with angina at rest and dyspnea on minimal exertion. He required home oxygen on a daily basis. He was, however, well motivated and after consultation he accepted the high risk of surgery to potentially improve his quality of life.
After premedication with 1 mg lorazepam and normal daily medication, the patient was transferred to the anesthetic room. An arterial line, internal jugular line, and thoracic epidural catheter (level T6) were inserted under local anesthetic. Over the next 20 minutes a sensory block T2 to T10 was established by 60 mg bupivacaine and 200 µg fentanyl. The patient was then induced with 60 mg propofol and 8 mg vecuronium after which a size 4 laryngeal mask airway was inserted and the patient mechanically ventilated.
Coronary artery bypass surgery was carried out using two vein grafts and normothermic cardiopulmonary bypass. After surgery neuromuscular blockade was reversed with neostigmine and glycopyrrolate, and the patient was allowed to breathe spontaneously. The laryngeal mask was removed once the patient regained consciousness and he was transferred to the intensive care unit. Epidural analgesia was maintained by a background infusion of 5 µg/mL fentanyl in 0.1% bupivacaine and patient-controlled boluses. His recovery was pain-free even during physiotherapy and he was transferred to the cardiac ward on the second postoperative day. The epidural catheter was removed on day 4 and after 6 days the patient walked 200 yards without angina or dyspnea. He was discharged home the following day.
It has been found that pulmonary function tests preoperatively do not necessarily predict the need for extended mechanical ventilation after cardiac surgery [2]. Weissman [3] suggests that the major determinant of poor pulmonary outcome after cardiac surgery is poor cardiac function.
Using the laryngeal mask in combination with a thoracic epidural offered distinct advantages over a conventional technique with endotracheal intubation and intravenous morphine: The absence of a marked pressor response during both intubation and extubation and an established epidural block at the time of sternotomy obviated the need for large amounts of opioids. This in turn allowed resumption of spontaneous breathing at the conclusion of surgery. Good pain control optimized chest wall mechanics and ensured cooperation with physiotherapy.
We feel that octogenarians should not necessarily be refused cardiac surgery on the grounds of poor preoperative lung function tests alone and that they may have a good outcome, provided that measures are taken to restore respiratory function early.
References
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