| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
| ||||||||||||||
| ||||||||||||||
|
|
|
|
||||||||||||
|
||||||||||||||
*Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh School of Medicine; and VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania
Address correspondence and reprint requests to Juhan Paiste, MD, Assistant Professor of Anesthesiology, University of Pittsburgh, Staff Anesthesiologist, VA Medical Center, University Drive C, Pittsburgh, PA 15240. Address e-mail to jupst8{at}imap.pitt.edu
 |
Abstract |
|---|
 Top Abstract IntroductionCase ReportDiscussionReferences |
|---|
|
Introduction |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
Although the effectiveness of hTEA for thoracoscopic procedures (10) and mini-thoracotomy (11) has been reported in the literature, these procedures usually require the addition of endotracheal intubation. In July 2000, Karagoz et al. (11) reported the first successful coronary artery grafting using only a regional anesthetic technique. Under hTEA, this group was able to perform mini-thoracotomy and using a short segment of radial artery inserted a jump-graft between the internal thoracic artery and the left anterior descending artery (LAD).
We hypothesized that hTEA could be used for mini-thoracotomy and minimally invasive direct coronary artery bypass (MID-CAB) with left internal mammary artery (LIMA) mobilization and direct grafting to LAD. We report a case of a MID-CAB that was managed with hTEA.
|
Case Report |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
His medical history was significant for hypertension, hypercholesteremia, and peptic ulcer disease. The patient had a history of cigarette smoking (1 pack per day for 25 yr) and pulmonary function testing showed forced vital capacity of 4.8 L (89% predicted) and forced expiratory volume (1 s) of 2.6 L (74% predicted). The patient coagulation profile indicated a partial thromboplastin time 32.6 s, prothrombin time 13.1 s, international normalized ratio 1.0, and platelet count 253 K/mm (3). The patient was fully informed and understood all the risks and alternatives to the proposed anesthetic technique. IRB-approved informed consent was obtained from the patient for the MID-CAB procedure using hTEA with option for general anesthesia as a backup technique in case of patient discomfort or hemodynamic instability.
In the OR after standard monitoring (heart rate [HR] 82 bpm, blood pressure [BP] 93/51 mm Hg, oxygen saturation [SaO2] 99%) and IV catheters were established, a 17-gauge Tuohy needle was used to localize the epidural space at the T1/2 interspace using a midline loss-of-resistance technique with the patient in the sitting position. A 19-gauge epidural catheter was then inserted 3 cm into the epidural space, and a test dose (3 mL 1.5% lidocaine with epinephrine 1:200,000) was administered to eliminate intravascular or intrathecal placement.
The patient was then returned to the supine position and hemodynamic monitoring devices were placed, including a pulmonary artery catheter. Over the next 30 min, epidural anesthesia was established using carefully titrated small boluses of mixed local anesthetic solution (20 mL bupivacaine 0.5%, 20 mL of lidocaine 2%, and 5 mL fentanyl 0.005%) delivered in sequential 3–5 mL boluses (total 15 mL). The objective of this approach was to achieve both somatosensory (assessed by temperature and pinprick discrimination) and motor block (assessed by observation of intercostal paralysis) between C7 and T7 while preserving diaphragmatic breathing. After epidural block was established, the following hemodynamic profile was recorded: HR 62 bpm, BP 96/49 mm Hg, pulmonary artery pressure (PAP) 20/6 mm Hg, cardiac output (CO) 7.0 L/min, SaO2 99%, pH 7.37, partial carbon dioxide tension in arterial blood (PCO2) 52.1 mm Hg. Supplemental 3–5 mL boluses of local anesthetic solution were used throughout the procedure to maintain adequate epidural block (total 20 mL).
A total of 4 mg midazolam and 200 µg fentanyl were administered for sedation during surgery. The patient maintained spontaneous ventilation throughout the operation, receiving only supplemental oxygen via nasal cannula (4 L/min). The patient was draped in a manner that gave unrestricted access for the anesthesiologist to manipulate the airway if tracheal intubation became necessary.
The surgeon entered the left fourth intercostal space through a 6-cm incision and exposed the pleural space to the atmosphere. The left lung collapsed partially but the patient reported no trouble breathing. After the LIMA was mobilized, the surgeon opened the pericardium longitudinally and identified the LAD. After anticoagulation with 7000 U heparin (activated clotting time 266 s), the LAD was occluded proximally without electrocardiographic or hemodynamic changes (HR 68 bpm, BP 113/62 mm Hg, PAP 31/15 mm Hg, CO 6.4 L/min, SaO2 99%, pH 7.37, PCO2 52.1 mm Hg) and end-to-side direct anastomosis was performed between the LIMA and the LAD.
Spontaneous diaphragmatic breathing caused additional cardiac excursions; therefore, the patient was asked to hold his breath for short periods to allow the surgeon to complete the anastomosis. Once the anastomosis was complete, it was tested and found to be technically correct. No protamine was administered for heparin reversal. The anastomosis time was 26 min. The operative time was 134 min, and the anesthetic time was 220 min.
During the procedure, verbal communication was constantly maintained with the patient, who noted a zero level of pain or breathing discomfort. The patient was hemodynamically stable throughout and maintained spontaneous respirations at 12–18 breaths per minute. Postoperative pain management was achieved using 0.125% bupivacaine with fentanyl 5 µg/mL in an epidural infusion administered at 8 mL/h. The infusion was maintained for three days with good pain control visual analog scale (VAS) 1–2/10 throughout. The patient was discharged home on postoperative day 3 and continued to do well 3 mo after his surgery.
|
Discussion |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
Being aware of potential risks involved with epidural catheter placement and systemic anticoagulation, we used the following criteria: 1) normal preoperative coagulation profile; 2) surgery should be delayed for 24 hours in the event of an arterial puncture; 3) time from epidural placement to systemic heparinization should exceed 60 minutes; 4) heparin effect and reversal should be tightly controlled; 5) epidural catheters should be removed when normal coagulation is restored, and the patients should be closely monitored postoperatively for signs of hematoma formation (12).
There are no case reports of epidural hematomas associated with intraoperative full anticoagulation (2,12). In our case, the objective of hTEA was to achieve a somatosensory block from C7 to T7 dermatomes while preserving diaphragmatic breathing. After the mini-thoracotomy, the partial collapse of the left lung (on surgical entry into the pleural space) was well tolerated by the patient. In addition, as he received minimal sedation throughout the procedure his normal physiologic response to hypercarbia was only mildly impaired. This resulted in only mild carbon dioxide accumulation during the procedure. From the surgical point of view, the spontaneous diaphragmatic breathing did have some negative consequences, as it caused additional cardiac displacement and made completion of the distal anastomosis surgically more challenging. Patient cooperation in this stage was paramount, as it was necessary to request the patient to hold respirations for short periods to allow for completion of anastomosis. However, the development of robotic assistance combined with image stabilization could potentially make it surgically more feasible via either a mini-thoracotomy or thoracoscopic approach.
Alternatively, as this approach may not always be feasible because of reduced patient cooperation or exaggerated heart movement, sedation can be temporarily deepened and then ventilation assisted either with a nasal BiPAP device or via a standard face mask during completion of the distal anastomosis. The well-documented benefit of better pain control associated with the use of hTEA technique for MID-CAB could also see an expanded role by potentially shortening the required hospitalization as well as increasing patient satisfaction.
On the basis of our preliminary experience, we conclude that MIDCAB using hTEA is feasible. However, extensive clinical research is indicated to validate any potential benefits or possible risks involved with this technique. Until such data become available, we recommend that hTEA for cardiothoracic surgery should be used only by the institutions with extensive experience in this area.
|
References |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  T. C. Mineo Epidural anesthesia in awake thoracic surgery Eur. J. Cardiothorac. Surg., July 1, 2007; 32(1): 13 - 19. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. A. Chaney Intrathecal and Epidural Anesthesia and Analgesia for Cardiac Surgery Anesth. Analg., January 1, 2006; 102(1): 45 - 64. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. Kirali, T. Kocak, F. Guzelmeric, D. Goksedef, N. Kayalar, and C. Yakut Off-Pump Awake Coronary Revascularization Using Bilateral Internal Thoracic Arteries Ann. Thorac. Surg., November 1, 2004; 78(5): 1598 - 1602. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. Y. Karagoz, M. Kurtoglu, B. Bakkaloglu, B. Sonmez, T. Cetintas, and K. Bayazit Coronary artery bypass grafting in the awake patient: Three years' experience in 137 patients J. Thorac. Cardiovasc. Surg., June 1, 2003; 125(6): 1401 - 1404. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Kessler, G. Neidhart, D. H. Bremerich, T. Aybek, S. Dogan, V. Lischke, and C. Byhahn High Thoracic Epidural Anesthesia for Coronary Artery Bypass Grafting Using Two Different Surgical Approaches in Conscious Patients Anesth. Analg., October 1, 2002; 95(4): 791 - 797. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
