Technique of awake cardiac surgery

Coronary artery bypass surgery is conventionally performed using cardiopulmonary bypass (CPB). The complications due to CPB by aortic cannulation, cross clamping, immunological changes, and organ injuries (pulmonary, renal, cardiac, and cerebral) have been avoided to some extent in recent times by performing off-pump coronary artery bypass (OPCAB). Availability of surgeon-friendly epicardial stabilization devices has made it possible for surgeons to perform OPCAB frequently. Documented benefits of thoracic epidural anesthesia (TEA) are superlative intra- and postoperative analgesia, hemodynamic stability, reduced oxygen demand, optimization of coronary blood flow, improved pulmonary function, early extubation, and attenuation of stress response. Despite these potential benefits, anesthesiologists are reluctant to use TEA in cardiac surgical patients, fearing the occurrence of symptomatic epidural hematoma. Combining the minimal invasive nature of OPCAB and the possibility of avoiding endotracheal general anesthesia (GA), a few workers, including the author, reported performing OPCAB without endotracheal GA under TEA. Cardiac surgery can also be performed under CPB solely using TEA. The purpose of this review is to answer the questions that may arise in the minds of the surgeons and anesthesiologists who wish to start the relatively novel awake cardiac surgery program. Patient selection, technique of TEA, intraoperative management, and monitoring are discussed. Management of complications, such as pneumothorax and diaphragmatic paralysis, is included. The review also incorporates the indications and technique of conversion to GA and management of cardiac surgery requiring CPB under TEA in awake patients.