Straka Zbynek, Brucek Petr, Vanek Tomas, Votava Jan, Widimsky Petr
Department of Cardiac Surgery, Kralovske Vinohrady University Hospital, Prague, Czech Republic.
Ann Thorac Surg. 2002 Nov;74(5):1544-7. doi: 10.1016/s0003-4975(02)03934-6.
The expansion of coronary surgery on the beating heart without cardiopulmonary bypass has led to increasing interest in ultra-fast track anesthesia, allowing extubation of the patient in the operating theater. The techniques described to date combined general anesthesia with thoracic epidural analgesia. We report the routine application of a technique that allows immediate extubation in the majority of patients undergoing off-pump coronary artery bypass grafting without thoracic epidural analgesia.
Fast-track anesthesia using an ultra-shortacting opiate remifentanil, without epidural catheter insertion, was used in 160 unselected patients undergoing off-pump coronary artery bypass grafting (aged 43 to 83 years, mean 65 years). There were an average of 2.2 bypass procedures per patient, with the left internal mammary artery used in 93%. Contraindications to immediate extubation were (except for failure to meet standard extubation criteria) hemodynamic instability and persistent bleeding at the end of operation. Satisfactory postoperative pain control was achieved by continuous remifentanil (0.0125 to 0.05 microg x kg(-1) x min(-1)).
Operating theater extubation within 10 minutes of the end of operation was feasible in 150 patients (94%). Five patients (3%) were extubated within 2 hours, and the remaining 5 patients (3%) were converted to standard anesthesia. There were no deaths during hospitalization. Major complications included myocardial infarction and transient ischemic attacks (2 patients each). No pulmonary complications were seen. Episodes of atrial fibrillation occurred in 21% of the patients undergoing operation.
Immediate extubation is possible in most patients after off-pump coronary artery bypass grafting even without thoracic epidural analgesia. We believe this type of less invasive cardiac anesthesia is safe and promising.
非体外循环下心脏不停跳冠状动脉手术的开展，使得人们对超快速通道麻醉越来越感兴趣，这种麻醉方式可使患者在手术室即行拔管。迄今为止所描述的技术是将全身麻醉与胸段硬膜外镇痛相结合。我们报告一种技术的常规应用，该技术可使大多数非体外循环冠状动脉搭桥术患者在不使用胸段硬膜外镇痛的情况下即刻拔管。
160例未经过挑选的非体外循环冠状动脉搭桥术患者（年龄43至83岁，平均65岁）采用了使用超短效阿片类药物瑞芬太尼的快速通道麻醉，未插入硬膜外导管。每位患者平均进行2.2次搭桥手术，93%使用了左乳内动脉。即刻拔管的禁忌证（除不符合标准拔管标准外）为血流动力学不稳定和手术结束时持续出血。通过持续输注瑞芬太尼（0.0125至0.05μg·kg⁻¹·min⁻¹）实现了满意的术后疼痛控制。
150例患者（94%）在手术结束后10分钟内在手术室可行拔管。5例患者（3%）在2小时内拔管，其余5例患者（3%）改为标准麻醉。住院期间无死亡病例。主要并发症包括心肌梗死和短暂性脑缺血发作（各2例）。未观察到肺部并发症。21%的手术患者发生房颤。
即使不使用胸段硬膜外镇痛，大多数非体外循环冠状动脉搭桥术后患者也可行即刻拔管。我们认为这种侵入性较小的心脏麻醉是安全且有前景的。
