title: Routine immediate extubation for off-pump coronary artery bypass grafting without thoracic epidural analgesia.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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)).
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Cardiac Surgery, Kralovske Vinohrady University Hospital, Prague, Czech Republic. straka@fnkv.cz
authors.forename: Zbynek
authors.initials: Z
authors.lastname: Straka
authors.forename: Petr
authors.initials: P
authors.lastname: Brucek
authors.forename: Tomas
authors.initials: T
authors.lastname: Vanek
authors.forename: Jan
authors.initials: J
authors.lastname: Votava
authors.forename: Petr
authors.initials: P
authors.lastname: Widimsky
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015360:Analgesia, Epidural; D000762:Anesthesia Recovery Period; D018686:Anesthetics, Intravenous; D002315:Cardiopulmonary Bypass; D001026:Coronary Artery Bypass; D003327:Coronary Disease / Q000401:mortality / Q000601:surgery*; D005240:Feasibility Studies; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007442:Intubation, Intratracheal; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010880:Piperidines; D000077208:Remifentanil; D015996:Survival Rate; D013996:Time and Motion Studies
chemical_list: D018686:Anesthetics, Intravenous; D010880:Piperidines; D000077208:Remifentanil