Coronary artery bypass surgery anesthetic considerations

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Varun Kumar, M.B.B.S. [2] Anahita Deylamsalehi, M.D.[3]


There are some critical anesthetic considerations for coronary artery bypass surgery. Based on the 2021 ACA Revascularization guideline, usage of fast-track cardiac anesthesia which uses short-acting anesthetic agents is recommended due to a better outcome. Furthermore, it is recommended to avoid opioid medications and replace them with non-opioid options, such as acetaminophen, ketamine, and dexmedetomidine, and/or regional techniques such as truncal nerve blocks. There is evidence supporting that Volatile anaesthetic may facilitate earlier extubation compared to intraveous choices. Furthermore, it is recommended to utilize an intraoperative lung-protective ventilation strategy, which is associated with better pulmonary mechanics and reduced postoperative pulmonary complications.

CABG Anesthetic Considerations

2021 ACA Revascularization Guideline

Perioperative Analgesia Usage of non opioid medications such as acetaminophen, ketamine, and dexmedetomidine, and/or regional techniques such as truncal nerve blocks (especially as part of a multimodal analgesic approach) have been shown to reduce perioperative opioid use.
Maintenance Analgesia Currently evidences are reporting that choice of maintenance anesthetic likely does not impact mortality rate. On the other hand, there is evidence supporting that Volatile anaesthetic may facilitate earlier extubation compared to intraveous choices.
Mechanical Ventilation An intraoperative lung-protective ventilation strategy has been shown to be associated with better pulmonary mechanics and reduce postoperative pulmonary complications. This strategy consists of a tidal volume of 6–8 mL/kg predicted body weight plus positive end-expiratory pressure.
Goal-directed Therapy This protocol which is for fluids and vasopressors usage with a specific hemodynamic goal showed different results in different studies, therefore, more studies are required.

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery (DO NOT EDIT)[28]

Class I
"1. Anesthetic management directed toward early postoperative extubation and accelerated recovery of low to medium-risk patients undergoing uncomplicated CABG is recommended.[29][4][30] (Level of Evidence: B)"
"2. Multidisciplinary efforts are indicated to ensure an optimal level of analgesia and patient comfort throughout the perioperative period.[31][32][33][34][35] (Level of Evidence: B)"
"3. Efforts are recommended to improve interdisciplinary communication and patient safety in the perioperative environment (eg, formalized checklist-guided multidisciplinary communication).[36][37][38][39] (Level of Evidence: B)"
"4. A fellowship-trained cardiac anesthesiologist (or experienced board-certified practitioner) credentialed in the use of perioperative transesophageal echocardiography (TEE) is recommended to provide or supervise anesthetic care of patients who are considered to be at high risk.[40][41][42] (Level of Evidence: C)"
"1. Cyclooxygenase-2 inhibitors are not recommended for pain relief in the postoperative period after CABG.[43][44] (Level of Evidence: B)"
"2. Routine use of early extubation strategies in facilities with limited backup for airway emergencies or advanced respiratory support is potentially harmful. (Level of Evidence: C)"
Class IIa
"1. Volatile anesthetic-based regimens can be useful in facilitating early extubation and reducing patient recall.[4][45][46][47] (Level of Evidence: A)"
Class IIb
"1. The effectiveness of high thoracic epidural anesthesia/analgesia for routine analgesic use is uncertain.[48][49][50][51] (Level of Evidence: B)"


  • 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines[28].
  • 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.[52]


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  52. Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM; et al. (2022). "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006. PMID 34895950 Check |pmid= value (help).

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