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Cardiosurgery - Skopje
Coronary Artery Bypass Grafting in Awake Settings
Special hospital for Cardiosurgery “Filip II”
Skopje - Macedonia
Mitrev Z, Anguseva T
Cardiosurgery - Skopje
Myocardial revascularisation
in awake patients:
1.Avoidance of extracoropreal circulation,
2.General anesthesia, endotracheal intubation and mechanical ventilation unnecessary
3.Complete off-Pump revascularisation possible
Cardiosurgery - Skopje
Material and Metods
High epydural analgo-anesthesia
N= 10 pts ( 2 femail, 8 mail)
- Epidural catheter in place: Th1-Th2 - Main targed: somatosensory and
motor block - Applied medicaments: 20ml 0.25%Bupivacain 100gr. Fentanyl, 5ml/min - Sternotomy: patient being without
intubation- CABG
Cardiosurgery - Skopje
Schematic view
The catheter is placed in the high epidural space Th1-Th2 one day preoperatively, using the loss of resistance method, or method of getting a drop
Cardiosurgery - Skopje
Age (years) 62.2 ± 7.8
Sex (f/m) 2/8
BSA (cm2) 1.76 ± 0.2
Unstable angina n : 5pts
Previous myocardial infarction n : 4pts
Coronarography finding Comorbidities:LAD 100% (n : 10) Hyperlipidemia – 7ptsLAD 100%; Cx 90% (small) Diabetes disease- 4pts
(n:2) Hypertension – 8pts COPD – 2pts Adiposity – 1pts Smokers – 6pts
Patient demographics (N : 10)
Cardiosurgery - Skopje
Management procedures
• First step: epidyral catheter the day before surgery
• Second step: The operative day-.Analgosedation with: mixture 1 : 0.5% Bupivacain and 1.66g/ml Su-Fentanyl – starting at
sternotomy till sternal rewiring mixture 2 : 0.125%Bupivacain and 1 g/ml Su-Fentanyl Day 1 to 3 after
surgery- Dosage of the analgosedativa is correlated with: Pts haemodynamic stability Blood-gas analyses Visual analgoscala. Target: pain index 1to3
Third step: Postoperative analgosedatia with mixture 2 (first day)
Cardiosurgery - Skopje
Postoperative management
- Third step: Postoperative analgosedatia with mixture 2 (first day)
• Epidural cathether pull out after 24 hours• No need of cathecholamine support• No need of other additional sedation except epidural
mixture 2 (0.125%Bupivacain and 1 g/ml Su-Fentanyl)
Cardiosurgery - Skopje
Results I –intraoperative data
• Complete sternotomy 10 pts• CABG x1 (LITA - LAD) – 10pts• Mean time of bypassing 7.9±0.8min• Mean time of op.duration 71.7 ± 22.1min• Without intubation 9pts • 1patient intubated after sternotomy: pain index >7• Entered left pleural spaces 2 pts• Hemodynamical stability in 10 pts
Cardiosurgery - Skopje
Results II-ICU events
• Two patients left the operating room by walk.
• Drains were pull out first post op. day in all pts• Hemodynamical stability 9pts• In hospital stay 2,5days 9pts• Without any significant postop. Complications
• Follow up – 2 – 42months
Cardiosurgery - Skopje
Complications:
Perforation of the internal dura (1) Intensive headache after punction
of the dura interna (1) Collaps due to the Puncture (2) Radicular pain and back pain (7)
Epidural catheter misplacement
(2) The risk of od epidural-spinal
hematoma - decreased, following the recommendations of DGAI:
--atraumatic inplacement -- appropriate interval of the last
anticoagulant therapy
Cardiosurgery - Skopje
AWAKE SURGERY
Respiratory and haemodynamic stability
Decreased stress Good ( pre-and postoperative )
Analgesie Early mobilisation possible Quick and effective recovery Better economic side with a
exellent clinical outcome