Anaesthesia for off-pump coronary artery bypass grafting surgery

Coronary artery bypass grafting (CABG) surgery may be undertaken with or without cardiopulmonary bypass (CPB) that is on- or off-pump. Although off-pump has a slightly higher mortality, it associated with a lower incidences of short-term complications, compared with on-pump CABG surgery favouring enhanced recovery. High-dose opioid techniques of general anaesthesia should be avoided and either inhalation or total intravenous (IV) anaesthesia may be used. Monitoring should include a five-lead electrocardiograph and invasive systemic arterial pressure measurement. Effective communication between anaesthetist and surgeon is essential. Maintenance of diastolic arterial pressure (DAP) underpins prevention of myocardial ischaemia and cardiovascular collapse. Surgical positioning of the heart so as to minimize hypotension is paramount and IV fluid loading or vasoconstrictors and positive inotropes are effective. Correction of bradycardia with atropine 0.3 mg IV or epicardial pacing also helps to maintain DAP. Persisting hypotension requires intra-aortic balloon pumping or conversion to on-pump CABG surgery. As there is less blood loss, minimal requirement for cardiovascular support and earlier recovery of consciousness associated with off- compared with on-pump CABG surgery, patients may be managed in a recovery room then transferred to a high-dependency unit, thus bypassing ICU.