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

Dexmedetomidine in Adult Patients in Cardiac Surgery Critical Care: An Evidence-Based Review

Although several options are available for postoperative sedation in the intensive care unit, the selective α2-adrenoceptor agonist dexmedetomidine may offer advantages for patients after cardiac surgery. The author conducted a review of the literature on the use of dexmedetomidine in the cardiac surgery population to determine possible advantages and disadvantages in this patient population. Although the use of dexmedetomidine has not been conclusively shown to change overall morbidity and mortality and may be associated with higher drug cost, its other demonstrated effects offer advantages for postoperative cardiac surgery patients that other forms of sedation cannot match.

Crisis management during anaesthesia: myocardial ischaemia and infarction

BACKGROUND

Myocardial ischaemia and infarction are significant perioperative complications which are associated with poor patient outcome. Anaesthetic practice should therefore focus, particularly in the at risk patient, on their prevention, their accurate detection, on the identification of precipitating factors, and on rapid effective management.

OBJECTIVES

To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK" supplemented by a specific sub-algorithm for myocardial ischaemia and infarction in the management of myocardial ischaemia and/or infarction occurring in association with anaesthesia.

METHODS

The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved.

RESULTS

Of the 125 incidents retrieved from the 4000 reports, 40 (1%) were considered to demonstrate myocardial infarction or ischaemia. The use of the structured approach described in this paper would have led to appropriate management in 90% of cases, with the remaining 10% requiring other sub-algorithms. It was considered that the application of this structured approach would have led to earlier recognition and/or better management of the problem in 45% of cases.

CONCLUSION

Close and continuous monitoring of patients at risk of myocardial ischaemia during anaesthesia is necessary, using optimal ECG lead configurations, but sensitivity of this monitoring is not 100%. Coronary vasodilatation with glyceryl trinitrate (GTN) should not be withheld when indicated and the early use of beta blocking drugs should be considered even with normal blood pressures and heart rates.

Bispectral index-guided anesthesia in patients undergoing aortocoronary bypass grafting

In this prospective, randomized study, we compared hemodynamics, oxygenation, possible intraoperative awareness, and costs in 62 patients undergoing first-time elective coronary artery bypass grafting at 2 different levels of anesthesia. Depth of anesthesia was assessed with bispectral index (BIS). All patients were anesthetized with sufentanil/midazolam. The dosage of sufentanil/midazolam was adjusted to achieve a BIS level of 45-55 in 32 patients (Group BIS 50), whereas in 30 patients a BIS level of 35-45 was intended (Group BIS 40). Data were obtained at six different time points before, during, and after surgery. All patients were asked about possible intraoperative awareness on the third postoperative day. There were no significant differences of any hemodynamic or oxygenation variables at any time between the two groups. BIS 40 patients received significantly (P < 0.05) more sufentanil (BIS 40, 888 +/- 211 microg; BIS 50, 514 +/- 99 microg) and midazolam (BIS 40, 22.4 +/- 5.6 mg; BIS 50, 16.6 +/- 3.7 mg) than BIS 50 patients. The reduction in anesthetic drugs used saved euro;13.78/US$12.54 per patient (P < 0.05) in Group BIS 50, but one BIS electrode caused additional costs of 19.95 Euros/18.15 US dollars. Time to extubation was not significantly prolonged in Group BIS 40 (BIS 40, 14.3 +/- 4.6 h; BIS 50, 11.8 +/- 3.8 h). There was no explicit memory during anesthesia in either group. BIS-guided reduction of anesthetic medication saved costs and did not increase the risk of intraoperative awareness. However, total costs were increased by monitoring BIS, because of the BIS electrodes.

Anesthesia for robotic repair of the mitral valve: a report of two cases

IMPLICATIONS

We describe the anesthetic management of two patients who underwent successful mitral valve repair with use of a robot-assisted cardiac surgical technique. We describe the robot used, as well as the surgical procedure, and highlight aspects of the anesthetic management, in particular the need for one-lung ventilation and the utility of transesophageal echocardiography.

Comparative efficacy and safety of remifentanil and fentanyl in 'fast track' coronary artery bypass graft surgery: a randomized, double-blind study

This multi-centre, parallel group, randomized, double-blind study compared the efficacy and safety of high-dose remifentanil administered by continuous infusion with an intermittent bolus fentanyl regimen, when given in combination with propofol for general anaesthesia in 321 patients undergoing elective coronary artery bypass graft surgery. A significantly lower proportion of the patients who received remifentanil had responses to maximal sternal spread (the primary efficacy endpoint) compared with those who received fentanyl (11% vs 52%; P<0.001). More patients who received remifentanil responded to tracheal intubation compared with those who received fentanyl (24% vs 9%; P<0.001). However, fewer patients who received remifentanil responded to sternal skin incision (11% vs 36%; P<0.001) and sternotomy (14% vs 60%; P <0.001). Median time to extubation was longer in the subjects who received remifentanil than for those who received fentanyl (5.1 vs 4.2 h; P=0.006). There were no statistically significant differences between the two groups in the times for transfer from intensive care unit or hospital discharge but time to extubation was significantly longer in the remifentanil group. Overall, the incidence of adverse events was similar but greater in the remifentanil group with respect to shivering (P<0.049) and hypertension (P<0.001). Significantly more drug-related adverse events were reported in the remifentanil group (P=0.016). There were no drug-related adverse cardiac outcomes and no deaths from cardiac causes before hospital discharge in either treatment group.

Pharmacokinetics and pulmonary extraction of clevidipine, a new vasodilating ultrashort-acting dihydropyridine, during cardiopulmonary bypass

Clevidipine is a new vascular-selective, calcium channel antagonist of the dihydropyridine type with an ester side chain susceptible to esterase metabolism. In healthy volunteers, it has high clearance (0.069 litres min-1 kg-1) with a small volume of distribution at steady state (0.19 litres kg-1). The half-lives of the two initial rapid phases, accounting for approximately 95% of the area under the curve after an i.v. bolus, are 0.7 and 2.3 min, respectively. The aims of this study were to determine the pharmacokinetics and the pulmonary extraction ratio of clevidipine in patients undergoing cardiac surgery. Seventeen patients received clevidipine as an i.v. infusion before cardiopulmonary bypass (CPB), and eight of these patients were also given clevidipine during hypothermic CPB. Mixed venous and arterial blood samples were taken for pharmacokinetic analysis and calculation of pulmonary extraction ratio. A two-compartment pharmacokinetic model with zero-order input was used to describe the pharmacokinetics of clevidipine before and during CPB. Virtually identical concentrations in mixed venous and arterial blood suggest negligible pulmonary metabolism of clevidipine. The total blood clearance of clevidipine is extremely high (0.055 litres min-1 kg-1). During CPB, clearance of clevidipine was significantly reduced, to 0.03 litres min-1 kg-1 (P < 0.005), probably as a consequence of reduced body temperature.

Prophylactic nitroglycerin did not reduce myocardial ischemia during accelerated recovery management of coronary artery bypass graft surgery patients

OBJECTIVE

To evaluate the use of a high dose of nitroglycerin (NTG) for prophylaxis against myocardial ischemia and infarction in patients undergoing coronary artery bypass graft (CABG) surgery with accelerated recovery.

DESIGN

Prospective, double-blind, placebo-controlled randomized study.

SETTING

A university-based medical center.

PARTICIPANTS

Forty adult patients presenting for elective CABG surgery.

INTERVENTIONS

Forty patients were divided into 2 blinded study groups. Twenty patients received 2 microg/kg/min of NTG starting before induction of anesthesia and continuing for 6 hours after extubation in the intensive care unit. The placebo group (n = 20) received normal saline during this same interval.

MEASUREMENTS AND MAIN RESULTS

Hemodynamics, incidence and severity of myocardial ischemia, and myocardial infarction rates were determined. There were no differences in hemodynamic parameters between groups. The incidence of ischemia was approximately 35% in each group. Myocardial infarction (as determined by elevated creatine kinase-MB fraction, troponin I, and electrocardiogram criteria) was 10% in the placebo group and 5% in the NTG group (p = 0.234).

CONCLUSIONS

This study shows a high incidence of myocardial ischemia and infarction in patients presenting for CABG surgery with an accelerated recovery management scheme. NTG was well tolerated clinically; however, it was not found to be protective against myocardial ischemia or infarction in this setting.

Calcium chloride minimizes the hemodynamic effects of propofol in patients undergoing coronary artery bypass grafting

OBJECTIVE

To assess the hemodynamic effects of propofol and the counteracting effect of calcium chloride (CaCl2) in patients undergoing coronary artery bypass grafting (CABG).

DESIGN

Prospective, randomized study.

SETTING

University hospital, department of cardiac surgery.

PARTICIPANTS

Fifty-eight patients undergoing elective CABG, divided into group A (n = 29) and group B (n = 29).

INTERVENTIONS

Anesthesia was induced with a combination of fentanyl, 7 microg/kg; pancuronium, 0.1 mg/kg; and propofol, 1.5 mg/kg, administered over 60 seconds. A blinded investigator administered saline in group A patients and 10 mg/kg of CaCl2 in group B patients at the same speed and same time as propofol administration through another lumen of the central venous catheter.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic data were obtained at baseline (T0), 2 minutes after anesthesia induction (T1), and 2 minutes after tracheal intubation (T2). Heart rate decreased significantly in group A patients (86.2+/-11.3 beats/min at T0 and 72.8+/-7.5 beats/min at T2; p < 0.001). Mean arterial pressure decreased significantly in patients in both groups (group A, 108.0+/-12.0 mmHg at T0; 74.6+/-14.6mmHg at T2;p < 0.001 and group B, 106.0+/-10.2 mmHg at T0; 90.4+/-10.0 mmHg at T2; p < 0.05). Stroke volume index, cardiac index, and cardiac output decreased in group A patients (39.4+/-4.1 mL/beat/m2 at T0 and 28.8+/-5.2 mL/beat/m2 at T2; p < 0.05; 3.4+/-0.6 L/min/m2 at T0 and 1.9+/-0.3 L/min/m2 at T2; p < 0.001; 5.9+/-0.9 L/min at T0 and 3.4+/-0.4 L/min at T2; p < 0.001, respectively), whereas in group B patients, changes were negligible (38.1+/-7.0 mL/beat/m2 at T0 v 35.7+/-6.6 mL/beat/m2 at T2; (NS) 3.3+/-0.5 L/min/m2 at T0 v 2.7+/-0.3 L/min/m2 at T2; (NS) 5.7+/-0.9 L/min at T0 v 4.7+/-0.5 L/min at T2; (NS), respectively).

CONCLUSION

Simultaneous administration of CaCl2 during the induction of anesthesia minimizes the potential negative effect of propofol on cardiac function in cardiac patients.

Early versus late extubation after coronary artery bypass grafting: effects on cognitive function

OBJECTIVE

To compare the effects of a short period of mechanical ventilation and sedation and a longer one on cognitive functioning of patients exposed to cardiopulmonary bypass (CPB).

DESIGN

A randomized, prospective study.

SETTING

Tertiary-care university hospital.

PARTICIPANTS

Forty-eight adult patients with surgical coronary artery disease.

INTERVENTION

Elective coronary artery bypass surgery.

MEASUREMENT AND MAIN RESULTS

Patients (n = 48; mean age, 60.12+/-9.30 years) were randomized to either group I (mean delay, 3.49+/-2.21 hours) or group II (mean delay, 10.32+/-1.75 hours). Cognitive functioning was evaluated before surgery, postoperatively, and at the 8-week follow-up. Tests included measures of central nervous system integrity, attention/concentration and psychomotor performance, verbal fluency, visual scanning speed, mental flexibility, auditory and visual attention, and verbal memory. Covariance analyses were used for group comparisons. Covariates were age, education, and baseline or postoperative performance. No differences in cognitive functioning were found between the two groups. Globally, performance deteriorated for 34.1% of the patients at the posttest evaluation, whereas 2.3% improved and 63.6% remained unchanged. At follow-up, nearly 40.5% of the patients showed an improvement from baseline, 2.4% still had deficits, and 57.1% had no change. None of the cognitive functions appeared to be more affected than others.

CONCLUSION

Early extubation and a shortened period of anesthesia/analgesia do not appear to positively or negatively affect cognitive functioning at 3 to 5 days and 8 weeks postoperatively. Early extubation is suggested because it has no deleterious effect (besides the low risk for reintubation) and it may facilitate patients' care in the intensive care unit.

Change in anaesthesia practice and postoperative sedation shortens ICU and hospital length of stay following coronary artery bypass surgery

We randomized prospectively 144 patients, undergoing elective coronary artery bypass surgery, to either early or to routine extubation [mechanical ventilatory support for 4-7 h (Group A), or 8-14 h (Group B)]. Anaesthesia was modified for both groups. The groups were well matched in terms of sex, age, NYHA class, preoperative left ventricular ejection fraction, bypass time and aortic cross-clamp time, number of grafts used, and blood units transfused. All patients had normal preoperative respiratory, renal, hepatic and cerebral functions. Mechanical ventilatory support (mean +/- SD) was 6.3 +/- 0.7 h for Group A and 11.6 +/- 1.3 h for Group B. Mean ICU stay was 17 +/- 1.3 h for Group A and 22 +/- 1.2 h for Group B, while the mean hospital stay was 7.3 +/- 0.8 days and 8.4 +/- 0.9, respectively. There were no statistically significant differences in the frequency of all postoperative complications among the two groups. There were no reintubation, readmission to the ICU or death in either group. We concluded that change in anaesthesia practice and early postoperative sedation in patients undergoing elective coronary artery bypass graft (CABG) surgery resulted in earlier tracheal extubation, shorter ICU and hospital length of stay without organ dysfunction or postoperative complications. Early extubation was only possible due to the modification of anaesthesia and ICU sedation regime.

Relationship of age, sex, and procedure type to extubation outcome after heart surgery

OBJECTIVE

To identify the relationship of age, sex, and type of procedure to extubation outcome (< or = 8 hours or > 8 hours), and to identify barriers to extubation after heart surgery.

DESIGN

Quasi-experimental, prospective study.

SETTING

Ten-bed cardiothoracic intensive care unit.

SAMPLE

Sixty-two consecutive patients undergoing heart surgery.

OUTCOME MEASURES

Early (< or = 8 hours) versus delayed (> 8 hours) extubation.

RESULTS

Patients in the delayed extubation group were older (69.1 +/- 11.3 years) than the patients in the early extubation group (59.6 +/- 8.0 years, p = 0.01). Univariate logistic regression comparing age (< 70 or > or = 70 years), sex, and procedure (coronary artery bypass graft or other procedure) identified only age 70 years or older as a predictor of delayed extubation. The unadjusted odds ratio of delayed extubation in patients 70 years or older was 11.25.

CONCLUSIONS

Age is a powerful predictor of delayed extubation after heart surgery. Only postoperative somnolence distinguished barriers to extubation in younger and older patients.

Early vs conventional extubation after cardiac surgery with cardiopulmonary bypass

OBJECTIVES

Sedation and ventilation overnight after cardiac surgery is common practice. However, early extubation may be feasible with no increase in postoperative complications. This study examines (1) if early extubation is possible in a significant number of patients, (2) if it reduces ICU stay, and (3) if this practice increases postoperative complications.

DESIGN

Prospective, controlled, randomized clinical trial.

PATIENTS AND METHODS

We randomized 404 consecutive patients to early extubation (7 to 11 h postoperatively) (group A, 201 patients) or conventional extubation (between 8 and 12 AM the following day) (group B, 203 patients). Variables included type and severity of the disease, surgical risk, type of operation, operative incidences, postoperative complications, duration of mechanical ventilation, intubation and ICU stay, bleeding, reoperation, vasoactive drugs, and mortality.

RESULTS

Groups were comparable. Extubation within the preestablished time was successful in 60.2% of patients in group A and 74.4% in group B. Median ICU stay was 27 h in group A and 44 h in group B (p=0.008). Discharge from ICU within the first 24 h postoperatively was 44.3% in group A and 30.5% in group B (p=0.006). There was no significant difference in complications between groups. Successfully extubated patients in group A had more reintubation and prolonged ventilation than in group B.

CONCLUSIONS

(1) Sixty percent of our patients were extubated within 11 h of operation. (2) As a result, the length of stay in ICU was reduced and the percentage of patients discharged within 24 h was increased. (3) There was no increase in clinically important postoperative complications.

Propofol or midazolam for sedation and early extubation following cardiac surgery

PURPOSE

The purpose of this randomized, double-blind study was to evaluate the efficacy of midazolam and propofol for postoperative sedation and early extubation following cardiac surgery.

METHODS

ASA physical status II-III patients scheduled to undergo elective first-time cardiac surgery with an ejection fraction > 45% were eligible. All patients received a standardized sufentanil/isoflurane anaesthesia. During cardiopulmonary bypass 100 micrograms.kg-1.min-1 propofol was substituted for isoflurane. Upon arrival in the Intensive Care Unit (ICU), patients were randomized to either 10 micrograms.kg-1.min-1 propofol (n = 21) or 0.25 microgram.kg-1.min-1 midazolam (n = 20). Infusion rates were adjusted to maintain sedation within a predetermined range (Ramsay 2-4). The infusion was terminated after four hours. Patients were weaned from mechanical ventilation and their tracheas extubated when Haemodynamic stability, haemostasis, normothermia and mental orientation were confirmed. Haemodynamic measurements, arterial blood gas tensions and pulmonary function tests were recorded at specified times.

RESULTS

There were no differences between the two groups for the time spent at each level of sedation, number of infusion rate adjustments, amount of analgesic and vasoactive drugs, times to awakening and extubation. The costs of propofol were higher than those of midazolam. There were no differences in haemodynamic values, arterial blood gas tensions and pulmonary function.

CONCLUSION

We conclude that midazolam and propofol are safe and effective sedative agents permitting early extubation in this selected cardiac patient population but propofol costs were higher.

Hemodynamic effects, myocardial ischemia, and timing of tracheal extubation with propofol-based anesthesia for cardiac surgery

Recent interest in earlier tracheal extubation after coronary artery bypass graft (CABG) surgery has focused attention on the potential benefits of a propofol-based technique. We randomized 124 patients (34 with poor ventricular function) undergoing CABG surgery to receive either a propofol-based (5 mg.kg-1.h-1 prior to sternotomy, 3 mg.kg-1. h-1 thereafter; n = 58) or enflurane-based (0.2%-1.0%, n = 66) anesthetic. Induction of anesthesia consisted of fentanyl 15 micrograms/kg and midazolam 0.05 mg/kg intravenously in both groups. The enflurane group received an additional bolus of fentanyl 5 micrograms/kg prior to sternotomy and fentanyl 10 micrograms/kg with midazolam 0.1 mg/kg at commencement of cardiopulmonary bypass (CPB). Patients receiving propofol were extubated earlier (median 9.1 h versus 12.3 h, P = 0.006), although there was no difference in time to intensive care unit (ICU) discharge (both 22 h, P = 0.54). Both groups had similar hemodynamic changes throughout (all P > 0.10), as well as metaraminol (P = 0.49) and inotrope requirements (P > 0.10), intraoperative myocardial ischemia (P = 0.12) and perioperative myocardial infarction (P = 0.50). The results of this trial suggest that a propofol-based anesthetic, when compared to an enflurane-based anesthetic requiring additional dosing of fentanyl and midazolam for CPB, can lead to a significant reduction in time to extubation after CABG surgery, without adverse hemodynamic effects, increased risk of myocardial ischemia or infarction.

Comparison of sevoflurane/fentanyl and isoflurane/fentanyl during elective coronary artery bypass surgery. Sevoflurane Venture Group

PURPOSE

Due to the progressive aging of the surgical population, the proportion of patients with coronary artery disease (CAD) is likely to increase. The effects of the new inhalational anaesthetic sevoflurane must be determined in patients with known CAD.

METHODS

This multicentre, randomized, open-label study compared the haemodynamic and cardiovascular effects of sevoflurane and isoflurane with fentanyl in 284 ASA physical status II-IV patients undergoing elective coronary artery bypass graft (CABG).

RESULTS

Satisfactory records were available in 272 patients, 139 sevoflurane (Group S) and 133 isoflurane (Group I). There were no differences between groups for demographic data except that more patients in Group S were taking preoperative beta-blockers (P = 0.03). The mean end-tidal MAC and MAC.hr requirements between groups were not different (Group S received 0.63 +/- 0.02 MAC and 1.00 +/- 0.05 MAC. hr while Group I received 0.58 +/- 0.02 MAC and 0.92 +/- 0.05 MAC. hr P = NS). The preCPB use of intravenous fentanyl was not different between groups. There was a similar decrease in haemodynamic variables in both groups after induction that persisted throughout the preCPB period. The incidence of preCPB myocardial ischaemia, adverse haemodynamic events and use of vasoactive drugs did not differ between groups. The incidence of postoperative myocardial infarction was 2.2% for Group S and Group I was 4.5% (P = NS). There were five postoperative deaths, one of which was attributed to a cardiac cause (Group I).

CONCLUSION

In patients undergoing elective CABG with low risk factors, either sevoflurane or isoflurane, combined with fentanyl, provided an acceptable preCPB haemodynamic profile and cardiac outcomes.

Serum lipid and glucose concentrations with a propofol infusion for cardiac surgery

OBJECTIVE

To document changes in serum lipids and glucose with a propofol infusion technique for cardiac surgery.

DESIGN

Prospective cohort.

SETTING

University teaching hospital.

PARTICIPANTS

22 elective cardiac surgical patients.

INTERVENTIONS

Frequent venous blood sampling.

MEASUREMENTS AND MAIN RESULTS

Serum lipids and glucose were measured at 10 time periods perioperatively, from preinduction until 4 hours post-cardiopulmonary bypass. Plasma propofol concentrations were also measured in 10 of these patients. There was a significant increase in glucose (P < 0.0005) and decreases in cholesterol (P < 0.0005), high-density lipoprotein (P = 0.004), and low-density lipoprotein (P < 0.0005); there was no significant change in triglycerides (P = 0.39). The propofol infusion resulted in acceptable plasma levels throughout the procedure and allowed early extubation in the intensive care unit, after a mean (SD) of 7.14 (5.9) hours. There was a strong correlation between triglyceride and propofol levels at most time periods (r = 0.38 to 0.98).

CONCLUSIONS

This study demonstrates that a propofol infusion technique does not result in elevation of serum lipids and supports its increased popularity in maintenance of anesthesia for cardiac surgery.

Timing of tracheal extubation in adult cardiac surgery patients

In this article, we examine 14 studies conducted from 1974 to 1994 on "early" endotracheal extubation (0 to 12 hours postoperatively) in adult cardiac surgery patients. Aspects reviewed include: criteria for patient selection; criteria for extubation; analyses of feasibility and safety; effects of anesthetic technique; and patient morbidity. Advantages and disadvantages of early or "fast-track" extubation are discussed as are directions for future research. Selection criteria varied among studies; patients were most commonly excluded because of severe, preexisting pulmonary disease or ventricular dysfunction. Based on the studies examined, however, at least 70% to 80% of adult patients would meet selection criteria. Three universal criteria were applied in all studies: (1) patient is awake and responsive; (2) adequate gas exchange while breathing spontaneously; and (3) cardiovascular stability. To facilitate early extubation in appropriately selected patients, the choice of anesthetic technique and postoperative sedation technique appears to be important. Anesthetic techniques based on inhalational anesthetic agents, supplemented by moderate doses of narcotics, are more appropriate than high-dose narcotic anesthesia for early extubation protocols. Postoperative sedation with propofol, which has a rapid offset of action, may be particularly advantageous. Every published investigation has concluded that early extubation is safe, feasible, and desirable. Morbidity and mortality have not been shown to be affected by early extubation. Anesthetic technique and the patient's medical condition are the two major factors to consider in accomplishing early extubation.

Anaesthesia for coronary artery bypass surgery supplemented with subarachnoid bupivacaine and morphine: a report of 18 cases

We report our experience with general anaesthesia (GA) supplemented with subarachnoid bupivacaine and morphine for coronary artery bypass surgery (CABG) in 18 patients. Fifteen patients were male, and mean age was 62 yr. Anaesthesia (GA) was induced with alfentanil 97 +/- 22 micrograms.kg-1 and midazolam 0.04 +/- 0.02 mg.kg-1 supplemented with a muscle relaxant, and maintained with isoflurane (0.25-0.5%) in oxygen throughout surgery. Spinal anaesthesia (SA) was then performed at a lumber level using hyperbaric bupivacaine (23-30 mg) and/or lidocaine (150 mg) with morphine (0.5-1 mg). Pooled data showed the following haemodynamic results (P < 0.05). Induction of GA produced a decrease in mean arterial pressure (MAP). Addition of SA produced a decrease in heart rate. Heart rate and MAP did not change with sternotomy. Phenylephrine support of arterial blood pressure was used at some time during operation in 17 patients. Supplementation of GA was minimal. Patients received 2.7 +/- 0.7 coronary grafts. Operating room time was 3.9 +/- 0.6 hr. Postoperative analgesic requirements were minimal, and in half of the patients tracheal extubation occurred on the day of surgery. Complications included one myocardial infarction, one resternotomy, a metabolic encephalopathy in a dialysis-dependent patient, and one case of herpes labialis. No patient recalled intraoperative events. Combined GA with SA may be an effective technique for CABG surgery. Further study of the cardiovascular, neurological and metabolic effects of the technique is required.