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Ann Thorac Surg 2002;74:1544-1547
© 2002 The Society of Thoracic Surgeons

Original article: cardiovascular

Routine immediate extubation for off-pump coronary artery bypass grafting without thoracic epidural analgesia

Zbynek Straka, MD, PhDa*, Petr Brucek, MDa, Tomas Vanek, MD, PhDa, Jan Votava, MDa, Petr Widimsky, MD, PhDb

a Department of Cardiac Surgery, Kralovske Vinohrady University Hospital, 3rd Medical School of Charles University, Prague, Czech Republic
b Department of Cardiology, Kralovske Vinohrady University Hospital, 3rd Medical School of Charles University, Prague, Czech Republic

Accepted for publication June 20, 2002.

* Address reprint requests to Dr Straka, Department of Cardiac Surgery, Kralovske Vinohrady University Hospital, Srobarova 50, 100 34 Prague, Czech Republic.
e-mail: straka{at}fnkv.cz


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
BACKGROUND: The expansion of coronary surgery on the beating heart without cardiopulmonary bypass has led to increasing interest in ultra-fast track anesthesia, allowing extubation of the patient in the operating theater. The techniques described to date combined general anesthesia with thoracic epidural analgesia. We report the routine application of a technique that allows immediate extubation in the majority of patients undergoing off-pump coronary artery bypass grafting without thoracic epidural analgesia.

METHODS: Fast-track anesthesia using an ultra-short-acting opiate remifentanil, without epidural catheter insertion, was used in 160 unselected patients undergoing off-pump coronary artery bypass grafting (aged 43 to 83 years, mean 65 years). There were an average of 2.2 bypass procedures per patient, with the left internal mammary artery used in 93%. Contraindications to immediate extubation were (except for failure to meet standard extubation criteria) hemodynamic instability and persistent bleeding at the end of operation. Satisfactory postoperative pain control was achieved by continuous remifentanil (0.0125 to 0.05 µg · kg-1 · min-1).

RESULTS: Operating theater extubation within 10 minutes of the end of operation was feasible in 150 patients (94%). Five patients (3%) were extubated within 2 hours, and the remaining 5 patients (3%) were converted to standard anesthesia. There were no deaths during hospitalization. Major complications included myocardial infarction and transient ischemic attacks (2 patients each). No pulmonary complications were seen. Episodes of atrial fibrillation occurred in 21% of the patients undergoing operation.

CONCLUSIONS: Immediate extubation is possible in most patients after off-pump coronary artery bypass grafting even without thoracic epidural analgesia. We believe this type of less invasive cardiac anesthesia is safe and promising.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
Off-pump coronary artery bypass grafting, which has gradually become an alternative to standard techniques, is used to a varying extent by a number of centers (between 0% and >90% of patients undergoing operation for coronary heart disease) [1]. Avoidance of cardiopulmonary bypass and operation on the beating heart, possibly using a smaller incision, should reduce the surgical trauma to the patient, thereby decreasing the incidence of postoperative complications and shortening the duration of intensive care and overall length of stay in hospital. Recently, it has been shown that this requires modification of both anesthetic techniques and postoperative intensive care, with extubation in the operating theater, reduced intensity of immediate postoperative care, and rapid postoperative mobilization [2].

The commonly used techniques combine general anesthesia with high thoracic epidural analgesia to allow immediate extubation of the patient in the operating room (OR), along with high-quality postoperative analgesia accompanied by quick rehabilitation [3–5].

Thoracic epidural anesthesia in the conscious patient for extrapleural coronary artery bypass was described by Karagoz and colleagues [6] in 2000 and for minimally invasive direct coronary artery bypass by Anderson and associates [7] in 2001. Last year, our own group [8] also reported its use for multiple off-pump myocardial revascularization (off-pump coronary artery bypass grafting) in patients with preexisting pulmonary dysfunction.

However, in early 2001, we also started to evaluate the use of ultra-fast track anesthesic techniques to permit extubation in the OR without the use of epidural anesthesia [9]. Herein we report the technique and our initial results.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
Patients and procedures
From July 1 through December 31, 2001, a total of 477 patients with coronary heart disease were operated on in our center. In 160 unselected consecutive patients referred to off-pump coronary artery bypass grafting, ultra-fast track general anesthesia was used, with a view to extubation in the OR immediately after chest closure.

The basic characteristics of the group of patients are shown in Table 1. Midline sternotomy was the operating approach in all patients. Two- or three-vessel coronary artery bypass grafting was performed in 54 (34%) and 59 (37%) patients, respectively, with an overall average of 2.2 bypass procedures per patient. Revascularization of branches of the circumflex artery and the right coronary artery was undertaken in 61 and 45 patients each. The mammary artery was used in 93% of procedures. In 3 patients (1.9%), hemodynamic instability during operation required conversion to cardio pulmonary bypass.


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  		Table 1. Demographic Data

 
Anesthetic protocol
After premedication with pethidine (50 mg) and atropine (0.5 mg), general anesthesia was started by continuous infusion of remifentanil (Ultiva Glaxo Wellcome, Greenford, UK) at a dose of 0.5 µg/kg per minute with boluses of 40 mg of propofol (Diprivan, AstraZeneca, Macclesfield, UK). Atracurium (Tracrium Glaxo Wellcome, Greenford, UK) at a dose of 0.6 mg/kg was used as a muscle relaxant. Anesthesia was maintained by further continuous remifentanil and inhaled isoflurane (Forane Abbott, Queenborough, UK) with an oxygen and air mixture at a 1:1 ratio. Intravenous atracurium at a dose of 0.3 mg/kg per hour was given to continue muscle relaxation.

Patient monitoring
Standard monitoring (five-lead electrocardiogram, invasive arterial and venous central pressure, pulse oximetry, and central/nasopharyngeal temperature) was used in all patients. Swan-Ganz catheterization was not performed.

Postoperative analgesia
For postoperative analgesia, intramuscular metamizole at a dose 2.5 g (Novalgin Hoechst, Frankfurt am Main, Germany) was administered and intravenous remifentanil was continued at a dose 0.0125 to 0.05 µg/kg per minute.

Criteria for extubation in the OR
Patients were only extubated in the OR if they met standard extubation criteria, were hemodynamically stable, and showed no evidence of early surgical complications. These criteria are summarized in Table 2.


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  		Table 2. Criteria for Suitability for Extubation in the Operating Room

 
Surgical protocol
Midline sternotomy was followed by simultaneous harvesting of the left mammary artery and venous grafts. After heparin administration (100 IU/kg), the first anastomosis to be constructed was that of mammary artery to the left anterior descending artery. This was followed by other peripheral anastomoses to the areas supplied by the circumflex artery and the right coronary artery. "Verticalization" of the heart was achieved using an Axius Xpose Device (Guidant, Cupertino, CA) while an Ultima Vacuum Assist (Guidant) device was used for stabilization of the anastomosis site. In some patients, an intraluminal FloCoil Shunt (Guidant) was implanted. In other patients, bleeding from the arteriotomy was controlled by silicone surgical tape (Quest Medical, Allen, TX) placed above and below the anastomosis. After suturing the central anastomoses, the heparinization was reversed with protamine (1 mg/100 IU) and the sternum was closed in the standard manner.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
The results are summarized in Table 3. Extubation in the OR within 10 minutes of skin closure was achieved in 150 patients (94%). Another 5 patients (3%) were extubated within 2 hours of the end of operation. Four required conversion to standard anesthesia because of hemodynamic instability during or toward the end of the procedure, and 1 patient with transient cerebral ischemia was ventilated for 24 hours because of impaired consciousness. No patient required reintubation for respiratory insufficiency but 5 required reintubation for reoperation for mediastinal bleeding. These patients were reextubated between 5 minutes and 4 hours after the end of revision. One patient required reintubation 12 hours postoperatively for hemodynamic instability secondary to myocardial infarction and one for confusion with loss of cooperation caused by intensive care unit (ICU) psychosis.


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  		Table 3. Results and Complications

 
Preoperative, intraoperative, and postoperative arterial blood gas measurements are shown in Figure 1. Mean values for partial pressure of oxygen and partial pressure of carbon dioxide before extubation (177 ± 59 mm Hg, 38 ± 5 mm Hg) were almost identical with values after extubation (161 ± 76 mm Hg, 43 ± 6 mm Hg) and 30 minutes later (185 ± 79 mm Hg, 41 ± 5 mm Hg).



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  		Fig 1. Preoperative, intraoperative, and postoperative arterial blood gas results. Time 1: before operation (FiO2 0.21); time 2: before extubation (FiO2 0.50); time 3: 10 minutes after extubation (oxygen face mask, O2 supply 8 L/min); time 4: 30 minutes later (oxygen face mask, O2 supply 6 L/min). (pCO2 = partial pressure of carbon dioxide; pO2 = partial pressure of oxygen; FiO2 = fractional concentration of oxygen.)

 
There was no postoperative death. Mean total blood loss was 614 mL (150 to 2,500 mL), blood products were given in the postoperative course to 63 patients (39%). A total of 154 patients (96%) were discharged from the ICU within 24 hours postoperatively; hospital stay was 6 days.

Postoperative complications were as follows. Acute myocardial infarction developed in 2 patients and two had transient cerebral ischemic events (resolved by time of discharge). One patient devolped acute renal failure requiring hemodialysis. Seven patients (4%) needed additional circulatory support with medium and high doses of catecholamines (>5µg/kg per minute), but postoperative complications necessitated mechanical ventilation for more than 24 hours in only 4 patients. No pulmonary complications were noted. A transient atrial fibrillation occurred in 33 (21%) patients.


   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
As recently reported, standard (fentanyl, sufentanil) anesthesia is still associated with at least 3 to 5 hours of postoperative artificial pulmonary ventilation and a 24-hour ICU stay [10]. The first step toward further reduction of the invasiveness of cardiac surgery by using a "less invasive cardiac anesthesia" was general anesthesia with intubation combined with thoracic epidural anesthesia, allowing immediate extubation in most patients undergoing cardiac procedures [3]. However, this broadens the spectrum of potential complications inherent in the use of both techniques.

The main advantage of thoracic epidural anesthesia without intubation is that it obviates the need for general anesthesia in cardiac operations with all its attendant risks. This technique is particularly suitable for patients in whom altered pulmonary function constitutes a contraindication to standard operation (with the use of extracoprporeal circulation and standard anesthesia) [8, 11].

The use of remifentanil in fast-track cardiac operation was recently reported by Engoren and colleagues [10] with a median ventilation time of 234 minutes.

Our technique of ultra-fast track anesthesia made it possible for extubation of 94% of patients, in the OR, within 10 minutes of skin closure, without epidural catheter insertion. In many patients, extubation could be performed with the last stitch and some started to talk immediately to the health-care staff. Subsequently, the patients are transported to the ICU, thus preventing any delays resulting in prolongation of OR time.

The problem of adequate postoperative analgesia associated with the use of an ultra-short opioid anesthetic was eliminated by intramuscular administration of the nonopioid analgesic metamizole with continued remifentanil infusion. This combination is effective in pain control and enables deep breathing and active movement immediately after operation.

Normothermia in patients without extracorporeal circulation was maintained using heated pads and preheating of infusion solutions, with the operating theater air conditioning system set to a higher temperature.

No specific complications were noted in connection with this type of anesthesia. The leading cause of reintubation was the need for postoperative revision for hemostasis. There is no doubt that the number of revisions and the need for blood products was because almost all of the 39% of patients undergoing nonelective operation were still under the influence of antiaggregation therapy.

Together with Oxelbark and colleagues [5], our results to date support redefinition of the premise that fast-track anesthesia is only appropriate for the lower risk patient. In our series, 27% of patients required operation for unstable angina; 9% had severe preoperative left ventricular dysfunction, and 35% were 70 years or older. Our anesthetic technique provided hemodynamic stability throughout the procedure and allowed extubation in the OR even in these patients. Only 2 patients with acute myocardial infarction required high doses (10 µg/kg per minute) of catecholamines in the postoperative course.

We conclude that remifentanil-based anesthesia can be recommended for all off-pump coronary revascularizations. Contraindications to extubation in the OR (except for failure to meet standard extubation criteria) include hemodynamic instability and persistent bleeding at the end of operation.

Although initially we used this technique exclusively for beating heart procedures, we now have initial experience with extubation in the OR with coronary reconstruction procedures on cardiopulmonary bypass, with aortic and mitral valve procedures, and with combined operations including the Bentall procedure. This anesthetic technique is steadily becoming part of our routine practice in all kinds of open heart operation.

Judging from our results, the technique is safe, without specific complications, and allows early recovery. Immediate extubation and early mobilization of patients substantially reduce the need for intensive postoperative care. Local reimbursement regulation require a minimum ICU and hospital stay to register for a fee for bypass grafting and therefore, we have not demonstrated shorter ICU or hospital stay in this study. However, from a medical perspective, few patients required ICU stay longer than 6 hours.

Definition of the ultimate potential and limitations of this technique will require larger series of patients and multicenter evaluation. However, based on our own results, we consider the technique of ultra-fast track anesthesia to be the method of first choice for off-pump coronary revascularization on the beating heart.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Yacoub M. Off-pump coronary bypass surgery. In search of an identity. Circulation 2001;104:1743-1745.[Free Full Text]
  2. Borst C., Gründeman P.F. Minimally invasive coronary artery bypass grafting. An experimental perspective. Circulation 1999;99:1400-1403.[Free Full Text]
  3. Royse C.F., Royse A.G., Soeding P.F. Routine immediate extubation after cardiac operation: a review of our first 100 patients. Ann Thorac Surg 1999;68:1326-1329.[Abstract/Free Full Text]
  4. Niereich A.P., Diephus J., Jansen E.W., et al. Embracing the heart: perioperative management of patients undergoing off-pump coronary artery bypass grafting using the octopus tissue stabilizer. J Cardiothorac Vasc Anesth 1999;13:123-129.[Medline]
  5. Oxelbark S., Bengtsson L., Eggersen M., et al. Fast track as a routine for open heart surgery. Eur J Cardiothorac Surg 2001;19:460-463.[Abstract/Free Full Text]
  6. Karagoz H.Y., Sonmez B., Bakkalogu B., et al. Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia. Ann Thorac Surg 2000;70:91-96.[Abstract/Free Full Text]
  7. Anderson M.B., Kwong K.F., Furst A.J., Salerno T.A. Thoracic epidural anesthesia for coronary bypass via left anterior thoracotomy in the conscious patient. Eur J Cardiothorac Surg 2001;20:415-417.[Abstract/Free Full Text]
  8. Vanek T., Straka Z., Brucek P., Widimsky P. Thoracic epidural anesthesia for off-pump coronary artery bypass without intubation. Eur J Cardiothorac Surg 2001;20:858-860.[Abstract/Free Full Text]
  9. Vanek T., Brucek P., Straka Z. Fast track as a routine for open heart surgery. Eur J Cardiothorac Surg 2002;21:369.[Free Full Text]
  10. Engoren M., Luther G., Fenn-Buderer N. A comparison of fentanyl, sufentanil, and remifentanil for fast track cardiac anesthesia. Anesth Analg 2001;93:859-864.[Abstract/Free Full Text]
  11. Aybek T., Dogan S., Neidharat G., et al. Coronary artery bypass grafting through complete sternotomy in conscious patients. Heart Surg Forum 2002;5:17-21.[Medline]



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