What is the standard pre-operative and post-operative management for patients undergoing Coronary Artery Bypass Grafting (CABG)?

Standard Pre-operative and Post-operative Management for CABG

Preoperative and postoperative management of CABG patients should follow evidence-based protocols focusing on medication management, risk reduction, and monitoring to optimize outcomes and reduce complications.

Preoperative Management

Medication Management

• Beta blockers should be administered for at least 24 hours before CABG to all patients without contraindications to reduce the incidence of postoperative atrial fibrillation 1
• ACE inhibitors and angiotensin-receptor blockers should be given before CABG 1
• If clinical circumstances permit, clopidogrel should be withheld for 5 days before CABG surgery 1
• Short-acting glycoprotein IIb/IIIa inhibitors (eptifibatide or tirofiban) should be discontinued for at least 2-4 hours before surgery, and abciximab for at least 12 hours beforehand to limit blood loss 1
• For patients with an intra-aortic balloon pump (IABP), unfractionated heparin infusion should be continued until surgery 2

Preoperative Assessment

• Carotid duplex ultrasound is recommended in patients with recent (<6 months) history of stroke/TIA 1
• Routine epiaortic ultrasound scanning is reasonable to evaluate aortic plaque to reduce atheroembolic complications 1
• Patients with severe aortic stenosis (mean gradient ≥50 mm Hg) who meet criteria for valve replacement should have concomitant aortic valve replacement 1
• For patients with moderate to severe mitral regurgitation, concomitant mitral correction at the time of CABG is indicated 1

Risk Reduction

• All smokers should receive educational counseling and be offered smoking cessation therapy during CABG hospitalization 1
• Statins should not be discontinued before or after CABG in patients without adverse reactions 1

Intraoperative Management

Myocardial Protection

• Blood cardioplegia is indicated in patients with chronically dysfunctional left ventricle 1
• Prophylactic intra-aortic balloon pump (IABP) is indicated in patients with evidence of ongoing myocardial ischemia and/or patients with subnormal cardiac index 1

Monitoring

• Continuous ST-segment monitoring for detection of ischemia is reasonable in the intraoperative period 1
• Placement of a pulmonary artery catheter is indicated in patients in cardiogenic shock undergoing CABG 1

Postoperative Management

Immediate Postoperative Care

• Continuous monitoring of the electrocardiogram for arrhythmias should be performed for at least 48 hours in all patients after CABG 1
• Beta blockers should be reinstituted as soon as possible after CABG to reduce the incidence of atrial fibrillation 1
• Use of continuous intravenous insulin to achieve and maintain early postoperative blood glucose concentration ≤180 mg/dL while avoiding hypoglycemia is indicated to reduce complications including deep sternal wound infection 1

Infection Prevention

• Preoperative antibiotic administration should be used in all patients 1
• Deep sternal wound infections should be treated with aggressive surgical debridement and early revascularized muscle flap coverage 1
• Aggressive control of perioperative hyperglycemia with continuous intravenous insulin infusion reduces risk of deep sternal wound infection 1

Medication Management

• Aspirin is the drug of choice for prophylaxis against early saphenous vein graft closure and should be continued indefinitely 1
• Beta blockers should be prescribed to all CABG patients without contraindications at hospital discharge 1
• ACE inhibitors should be reinstituted postoperatively once the patient is stable 1

Special Considerations

Cardiogenic Shock

• Emergency CABG is recommended for patients with cardiogenic shock if the coronary anatomy is not amenable to PCI 1
• After infarction leading to clinically significant right ventricular dysfunction, it is reasonable to delay surgery for 4 weeks to allow recovery 1

Chronic Kidney Disease

• Use of low- or iso-osmolar contrast media is recommended for patients with moderate-to-severe CKD 1
• Volume of contrast media should be minimized 1
• Hemodialysis therapy is not recommended as a preventative measure 1

Common Pitfalls to Avoid

• Discontinuing anticoagulation completely before surgery in patients with an IABP could lead to device thrombosis 2
• Discontinuation of statin therapy before or after CABG is not recommended 1
• Postmenopausal hormonal therapy (estrogen/progesterone) should not be administered to women undergoing CABG 1
• Routine use of IABP in patients with cardiogenic shock due to ACS is not recommended 1

Quality Measures

• All cardiac surgery programs should participate in a state, regional, or national clinical data registry and should receive periodic reports of their risk-adjusted outcomes 1
• When credible risk-adjusted outcomes data are not available, volume can be useful as a structural metric of CABG quality 1