What are the recommendations for anesthesia management in redo cardiac surgeries?

Anesthesia Management for Redo Cardiac Surgeries

Redo cardiac surgeries require a multimodal enhanced recovery approach with careful attention to hemodynamic stability, cardioprotection, and comprehensive blood management, following the same ERACS principles as primary cardiac surgery but with heightened vigilance for technical challenges and increased bleeding risk.

Enhanced Recovery Framework

Implement an Enhanced Recovery After Cardiac Surgery (ERACS) program for all redo cardiac procedures to reduce postoperative complications, ICU length of stay, and hospital duration. 1

• ERACS programs in cardiac surgery demonstrate strong evidence for reducing mechanical ventilation time, ICU stay, and overall hospitalization length 1
• The 2022 SFAR/SFCTCV guidelines provide 33 recommendations with strong agreement for optimizing perioperative management, with 10 having high-level evidence (GRADE 1+ or 1) 1
• These recommendations apply equally to redo procedures, though redo status increases baseline risk 1

Preoperative Risk Stratification

Calculate the EuroSCORE to quantify perioperative risk, recognizing that redo cardiac surgery independently increases risk by 3 points. 1

• Redo coronary artery bypass grafting (CABG) carries a risk score of 3 points in the EuroSCORE system 1
• Preoperative BNP levels >385 pg/mL independently predict need for intra-aortic balloon pump, prolonged hospital stay, and 1-year mortality 1
• NT-pro-BNP is equivalent to EuroSCORE and more accurate than left ventricular ejection fraction for predicting postoperative complications 1

Anesthetic Induction and Maintenance

Primary Anesthetic Approach

Use volatile anesthetic agents (sevoflurane preferred) combined with high-dose opioids for cardioprotection and hemodynamic stability in redo cardiac surgery. 2, 1

• Volatile anesthetics like sevoflurane decrease troponin release, enhance left ventricular function, and provide myocardial preconditioning compared to propofol 2
• The American College of Cardiology recommends sevoflurane (0.5-1 MAC) with remifentanil (0.15-0.25 μg/kg/min) or fentanyl (1-2 μg/kg slow IV) for balanced anesthesia 2
• Start with low concentrations (0.25-0.5 MAC) and gradually increase to minimize hemodynamic fluctuations 2

High-Dose Opioid Technique for Complex Redo Cases

For complex redo procedures requiring cardiopulmonary bypass, consider sufentanil 8-30 mcg/kg with 100% oxygen to attenuate sympathetic responses and maintain favorable myocardial oxygen balance. 3

• Sufentanil at 25-30 mcg/kg blocks sympathetic response including catecholamine release, indicated for major cardiovascular surgery 3
• High-dose opioid technique provides hemodynamic stability but requires planned postoperative mechanical ventilation 2, 3
• Maintenance doses of 0.5-10 mcg/kg may be administered in anticipation of surgical stress such as sternotomy or cardiopulmonary bypass 3

Specific Challenges in Redo Surgery

Hemodynamic Management

Maintain strict blood pressure control throughout the perioperative period, as redo procedures carry increased risk of catastrophic bleeding during sternal re-entry. 4

• Deepening of anesthesia is the most commonly used antihypertensive measure (68% of cases), usually combined with vasodilator therapy 4
• Nitroglycerin (53%) or sodium nitroprusside (28%) are most frequently used vasodilators 4
• Avoid prophylactic intravenous nitroglycerin as it is not effective in reducing myocardial ischemia and may cause cardiovascular decompensation through preload reduction 2

Monitoring Considerations

Use transesophageal echocardiography (TEE) for emergency hemodynamic instability management, but not routinely. 2

• Emergency TEE use is reasonable in patients with hemodynamic instability if expertise is readily available 2
• Routine intraoperative TEE during cardiac surgery is not recommended 2
• Consider pulmonary artery catheterization when underlying medical conditions significantly affect hemodynamics and cannot be corrected before surgery 2

Multimodal Analgesia Strategy

Regional Anesthesia Techniques

Consider chest wall blocks (serratus anterior plane, erector spinae plane, or pectoral nerve blocks) for postoperative pain management, particularly advantageous in patients on antiplatelet therapy or anticoagulation. 5, 6, 7

• Regional anesthesia techniques reduce perioperative opioid consumption and enhance recovery after cardiac surgery 6
• Ultrasound-guided peripheral regional anesthesia techniques like serratus anterior block offer advantages over neuraxial techniques in anticoagulated patients 7
• Redo cardiac surgery causes significant postoperative pain requiring analgesic management similar to thoracic operations 7

Neuraxial Anesthesia Considerations

Neuraxial anesthesia (thoracic epidural) can be considered for postoperative pain control but requires careful risk-benefit assessment given anticoagulation requirements in cardiac surgery. 1, 6

• Neuraxial anesthesia for postoperative pain relief can be effective to reduce MI in patients undergoing major vascular procedures (Class IIa, Level B evidence) 1
• However, there is no evidence of cardioprotective benefit from intraoperative neuraxial anesthesia in cardiac surgery 1
• Thoracic epidural anesthesia, spinal anesthesia, and thoracic paravertebral blocks are established options but require careful timing relative to anticoagulation 5, 6

Cardioprotective Strategies

Implement cardioprotective measures beyond volatile anesthetics, including consideration of levosimendan for patients with significant left ventricular dysfunction. 1

• Levosimendan has demonstrated cardioprotective properties and improves cardiac performance in myocardial stunning 1
• Volatile anesthetics provide cardioprotection through preconditioning and postconditioning mechanisms 2
• Aggressive preservation of heart function during cardiac surgery is a major goal, particularly important in redo procedures 1

Blood Management

Implement comprehensive patient blood management (PBM) protocols, as redo cardiac surgery carries substantially higher bleeding risk due to adhesions and previous surgical trauma. 1

• Patient blood management is one of six key fields in ERACS guidelines 1
• Redo procedures have increased risk of bleeding complications requiring meticulous surgical technique and blood conservation strategies 1

Temperature Management

Maintain normothermia throughout the perioperative period to potentially reduce cardiac events. 2

• Maintenance of normothermia may be reasonable to reduce perioperative cardiac events (Class IIb, Level B evidence) 2

Critical Pitfalls to Avoid

• Do not use excessive fluid administration to counteract anesthetic-induced hypotension, as this may lead to fluid overload in patients with compromised cardiac function 2
• Avoid routine pulmonary artery catheterization (Class III: No Benefit, Level A evidence) 2
• Do not administer prophylactic nitroglycerin as it is ineffective for reducing myocardial ischemia 2
• Recognize that high-dose opioid techniques require planned postoperative ventilation and should not be used if rapid extubation is planned 2, 3
• Be prepared for catastrophic bleeding during sternal re-entry with immediate access to cardiopulmonary bypass and blood products 1