Management of anesthesia for coronary artery surgery

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Ten years ago anesthesiologists managed patients with coronary artery disease with a great deal of apprehension because of the high incidence of repeated myocardial infarction.1 However, with the increased number of operations for myocardial revascularization, cardiac anesthesiologists contributed much to our knowledge of the physiology of circulation, hemodynamic changes during myocardial ischemia, the use of inotropics, vasodilator drugs, and mechanical support of the circulation.

The appropriate management of patients receiving anesthesia for coronary artery surgery depends upon (1) the variable clinical picture and the unpredictable hemodynamic status of the patient; (2) the effect of anesthetic agents and techniques on myocardial oxygen consumption and availability; (3) the individualized choice of anesthetic agents and techniques; and (4) prevention, early detection, and treatment of myocardial ischemia and dysfunction during surgery.

Clinical picture

Coronary artery disease may affect young, aggressive adults in their 30s, or its symptoms may not be apparent until age 60. It is more common in smokers, diabetics, the obese, and hypertensives.2 Frequently the patient has chronic obstructive airway disease, or may even have chronic renal failure. Because of the pathologic changes, the carotid arteries are frequently atherosclerotic and this adds to the risk. Usually the patient is receiving drugs such as digitalis, beta blockers, anti-hypertensives, antiarrhythmics, and tranquilizers. More important is the degree of coronary artery disease and how it affects the hemodynamic status. Bradycardia and conduction defects are common in patients with right coronary artery disease; in patients with left coronary artery disease, varying degrees of myocardial impairment and . . .