Anaesthesia for coronary artery surgery--a plea for a goal-directed approach.

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.