Abstract
The purpose of the current literature review was to examine whether changes in current anaesthetic techniques are warranted for patients undergoing coronary artery surgery in light of recent information presented in the literature. The objectives of a cardiac anaesthetic technique are to maintain haemodynamic stability and myocardial oxygen balance, minimize the incidence and severity of ischaemic episodes, be aware of cardiopulmonary bypass-induced pharmacokinetic changes, and facilitate early tracheal extubation if appropriate. Many techniques have been utilized. Provided attention is paid to the details of managing myocardial oxygen supply and demand, none has emerged as superior in preventing intraoperative myocardial ischaemia. Silent myocardial ischaemia (i.e., ischaemia occurring in the absence of haemodynamic aberrations) is common throughout the perioperative period and may occur even in the presence of an appropriately used anaesthetic technique. The incidence and severity appear to be greatest in the postoperative period when the effects of anaesthesia are dissipating. The use of high-dose opioid anaesthesia may no longer be the most appropriate technique to facilitate the anaesthetic objectives. The role of pain management in altering the incidence of ischaemia requires further study. Increased waiting lists for cardiac surgery and ever-diminishing resources should prompt a re-evaluation of early extubation (i.e., within eight hours) as a method of improving utilization of scarce ICU resources. It is suggested that this should be possible with currently available agents to achieve the anaesthetic objectives. Future suggestions for research in this area are made.
Résumé
Le but de cette revue de la littérature courante est de vérifier si, en chirurgie des artères coronaires, les modifications apportées aux techniques anesthésiques usuelles se justifient à la lumière des informations récentes de la littérature. Les objectifs de l’anesthésie cardiaque consistent à maintenir la stabilité hémodynamique et l’équilibre de l’oxygène myocardique, à abaisser l’incidence et la gravité des épisodes ischémiques, à reconnaître l’évolution pharmacocynétique pendant la chirurgie sous CEC et à effectuer l’extubation précocement lorsque nécessaire. On a utilisé plusieurs techniques anesthésiques. En autant qu’on prend bien soin de toutes les facettes de la gestion de l’apport et de la demande du myocarde en oxygène, aucune technique spécifique n’est considérée comme supérieure pour la prévention de l’ischémie myocardique peropératoire. L’ischémie coronarienne silencieuse (i.e., celle qui survient sans aberrations hémodynamiques) est fréquente pendant toute la période périopératoire et peut survenir même avec une technique anesthésique appropriée. Son incidence et sa gravité paraissent plus importantes à la période postopératoire lorsque les effets de l’anesthésie se dissipent. L’utilisation de doses élevées d’opiacés ne semble plus la technique la plus appropriée pour obtenir les meilleurs résultats. L’influence du traitement de la douleur sur l’incidence ischémique nécessite des études supplémentaires. L’augmentation des listes d’attente pour la chirurgie associée à une réduction des ressources nécessite une réévaluation de l’extubation précoce (en de-ça de huit heures) pour mieux utiliser les ressources trop peu abondantes des soins intensifs. On suggère que ceci soit possible avec les agents actuellement disponibles. Des suggestions sont proposées pour la recherche dans ce but.
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Supported by the New Brunswick Division of the Canadian Heart and Stroke Foundation.
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Hall, R.I. Anaesthesia for coronary artery surgery — a plea for a goal-directed approach. Can J Anaesth 40, 1178–1194 (1993). https://doi.org/10.1007/BF03009608
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DOI: https://doi.org/10.1007/BF03009608