What are the key preparations for patients undergoing Coronary Artery Bypass Grafting (CABG)?

Key Preparations for Patients Undergoing Coronary Artery Bypass Grafting (CABG)

Proper preoperative preparation is essential for reducing morbidity and mortality in patients undergoing CABG surgery. The following guidelines outline the key preparations required for optimal outcomes.

Medication Management

Antiplatelet and Anticoagulant Management

• Aspirin (100-325 mg daily) should be administered preoperatively and continued to reduce operative morbidity and mortality 1
• For elective CABG:
  • Discontinue clopidogrel and ticagrelor for at least 5 days before surgery 1
  • Discontinue prasugrel for at least 7 days before surgery 1
• For urgent CABG:
  • Discontinue clopidogrel and ticagrelor for at least 24 hours to reduce major bleeding complications 1
• For patients on intravenous glycoprotein IIb/IIIa inhibitors:
  • Discontinue eptifibatide or tirofiban for at least 2-4 hours before surgery 1
  • Discontinue abciximab for at least 12 hours before surgery 1

Other Medications

• Beta blockers should be administered for at least 24 hours before CABG to reduce the incidence of postoperative atrial fibrillation 1
• The safety of preoperative ACE inhibitors or angiotensin-receptor blockers is uncertain; their use should be evaluated on a case-by-case basis 1

Infection Prevention

• Administer prophylactic antibiotics to all patients to reduce the risk of postoperative infection 1
• Use first- or second-generation cephalosporins for patients without methicillin-resistant Staphylococcus aureus (MRSA) colonization 1
• Consider vancomycin alone or in combination with other antibiotics for patients with proven or suspected MRSA colonization 1

Cardiovascular Assessment and Preparation

• Perform routine epiaortic ultrasound scanning to evaluate the presence, location, and severity of plaque in the ascending aorta 1
• Consider carotid revascularization in patients with bilateral severe carotid stenoses or unilateral severe stenosis with contralateral occlusion 1
• Consider intra-aortic balloon insertion for high-risk patients (e.g., those undergoing reoperation or with LVEF <30% or left main coronary artery disease) 1

Renal Protection

• For patients with preoperative renal dysfunction:
  • Consider off-pump CABG to reduce the risk of acute kidney injury 1
  • Maintain perioperative hematocrit >19% and mean arterial pressure >60 mm Hg 1
  • Consider delaying surgery after coronary angiography until the effect of contrast material on renal function is assessed 1

Blood Conservation

• Implement aggressive blood conservation strategies to limit hemodilutional anemia and the need for transfusions 1
• Use lysine analogues intraoperatively and postoperatively in patients undergoing on-pump CABG 1
• Employ a multimodal approach with transfusion algorithms and point-of-care testing 1

Monitoring

• Continuous electrocardiogram monitoring for arrhythmias should be performed for at least 48 hours after CABG 1
• Consider continuous ST-segment monitoring for detection of ischemia in the intraoperative period 1
• Place pulmonary artery catheters in patients with cardiogenic shock or acute hemodynamic instability 1

Special Considerations

• For smokers, provide in-hospital educational counseling and offer smoking cessation therapy 1
• Consider cognitive behavior therapy or collaborative care for patients with clinical depression 1
• For hybrid coronary revascularization (combining minimally invasive CABG and PCI), consider performing CABG before PCI to allow verification of graft patency and minimize perioperative bleeding risk 1

Postoperative Preparation

• Plan for early reinstitution of beta blockers after CABG to reduce the incidence of atrial fibrillation 1
• Prepare for measurement of biomarkers of myonecrosis (e.g., creatine kinase-MB, troponin) in the first 24 hours after CABG 1
• Establish a cardiac rehabilitation program referral process, as this reduces cardiovascular mortality by 26% and overall mortality by 20% 2

Common Pitfalls and Caveats

• Delaying elective CABG for less than 5 days after discontinuing clopidogrel or ticagrelor may increase bleeding risk and transfusion requirements 1
• The effectiveness of pharmacological agents for renal protection during cardiac surgery remains uncertain 1
• Despite low ejection fraction, patients without heart failure symptoms may undergo CABG with relatively low mortality 3
• Gaps often exist in the use of recommended medications after CABG, particularly in older patients and those not regularly visiting a cardiologist 4

By following these evidence-based preparations, healthcare providers can optimize outcomes for patients undergoing CABG surgery, reducing perioperative complications and improving long-term results.