High Thoracic Epidural anaesthesia for Off-pump CABG in a spontaneously breathing (conscious) patient (ACAB)

Abstract

A 68 yr old man with ischemic heart disease (IHD) affecting triple vessels was admitted in National Institute of Cardiovascular Diseases & Hospital (NICVD), Dhaka for Coronary artery bypass grafting (CABG). He had been suffering from angina with minimal exercise with mild left ventricular systolic dysfunction. He was also suffering from hypertension and mild obstructive airway disease for the last ten years. He underwent off-pump CABG on beating heart using high thoracic epidural anaesthesia (TEA) without intubation. The patient was awake and breathing spontaneously, tolerated each phase of the operation without having any harmful effect. The effect of movement of the chest wall and the heart during spontaneous respiration did not influence the conduction of the operation. Epidurall catheter was placed at TI-2 interspace, in lateral decubitous position. After a test dose of 2% lignocaine 5ml, 0.5% Bupivacaine 14 ml + Fentanyl 2 ?gm/ml was injected epidurally. Central venous catheter was placed under local anaesthesia and inj Morphine 7.5 mg was given intramuscularly. After mid sternotomy left internal mammary artery (LIMA) and venous grafts were anastomozed to coronary arteries on beating heart. Haemodynamically patient was stable throughout the procedure and oxygenation was maintained by assisted facemask ventilation. At the end of operation laryngeal mask airway (LMA) was used for better oxygenation, which was withdrawn one hour later in the postoperative period. After transferring to the ICU, the patient was fully conscious, oriented, responds to commands, capable of coughing and clearing of secretions and pain free. He didn't require any ionotropic support or any systemic analgesic. Postoperative analgesia was maintained by continuous epidural infusionn of local anaesthetic mixture (0.5% Bupivacaine 20 ml + 2% Lignocaine 20 ml + Fentanyl (50?gm) I ml + NS 9 ml= 50 ml) via syringe pump at 1ml /hour. Liquid diet was allowed to the patient from the first POD and epidural analgesia was provided upto the third POD. Patient was shifted to HDU from ICU on the third POD. The patient was highly satisfied about the anaesthetic and operative procedure.

DOI: http://dx.doi.org/10.3329/jbsa.v17i1.4052

Journal of BSA, Vol. 17, No. 1 & 2, 2004 p.48-51