Robotic Cardiac Surgery Part II: Anesthetic Considerations for Robotic Coronary Artery Bypass Grafting

Bhatt, Himani V.; Schuessler, Martha E.; Torregrossa, Gianluca; Fitzgerald, Meghann M.; Evans, Adam S.; Narasimhan, Seshasayee; Ramakrishna, Harish

doi:10.1053/j.jvca.2019.11.005

Cited by 5 publications

(5 citation statements)

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“…initiating or discontinuing partial LLV or increasing the tidal volume) are made jointly to avoid sudden loss of exposure or risk of injury to the heart and lungs. 7 We did not experience any lung injuries as a result of using this approach.…”

Section: Discussionmentioning

confidence: 92%

“…[2][3][4] When performed without cardiopulmonary bypass (CPB) on the beating heart, TECAB usually requires single-lung ventilation (SLV) to facilitate surgical exposure and permit successful completion of the procedure. [5][6][7] Normal lung function is thus considered a prerequisite for patients undergoing beating-heart TECAB, and intolerance of SLV during surgery has traditionally led to conversion to sternotomy or the institution of CPB. As our experience with off-pump TECAB has increased, we have found that initial intolerance of SLV often did not require conversion, and that in many cases partial ventilation of the left lung allowed for sufficient exposure to successfully complete the procedure.…”

Section: Introductionmentioning

confidence: 99%

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Does Intolerance of Single-Lung Ventilation Preclude Robotic Off-Pump Totally Endoscopic Coronary Bypass Surgery?

Balkhy

Nisivaco

Tung

et al. 2020

Innovations�(Phila)

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Objective Robotic off-pump totally endoscopic coronary artery bypass (TECAB) usually requires isolated single (right) lung ventilation to adequately expose the surgical site. However, in some patients, persistent oxygen desaturation may occur and conversion to cardiopulmonary bypass (CPB) or sternotomy may be necessary. We reviewed the characteristics and clinical outcomes in patients who did not tolerate single-lung ventilation during TECAB surgery. Methods After Institutional Review Board approval we reviewed 440 patients undergoing robotic TECAB at our institution between July 2013 and April 2019. Patients were separated into 2 groups based on their ability to tolerate single-lung ventilation during the procedure. Group 1 included patients able to tolerate single-lung ventilation and Group 2 were patients who required double-lung ventilation to tolerate the procedure. Early and mid-term outcomes were compared. Results Group 2 (121 patients) had higher Society of Thoracic Surgeons scores, higher body mass index, and more triple-vessel disease than Group 1 (319 patients). Group 2 had more bilateral internal mammary artery use, multivessel grafting, and longer operative times. One patient underwent conversion to sternotomy and 5 required CPB (all in Group 1). Intensive care unit and hospital length of stay were longer in Group 2. Observed/expected mortality did not differ between groups (1.06% in Group 2 vs 0.4% in Group 1; P = 0.215). At mid-term follow-up, cardiac-related/overall mortality and freedom from major adverse cardiac events were similar. Conclusions In our cohort, intolerance of single-lung ventilation did not preclude robotic off-pump TECAB. Double-lung ventilation is feasible during the procedure and may prevent conversions to sternotomy or use of CPB, resulting in excellent early and mid-term outcomes.

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Section: Discussionmentioning

confidence: 92%

Section: Introductionmentioning

confidence: 99%

Does Intolerance of Single-Lung Ventilation Preclude Robotic Off-Pump Totally Endoscopic Coronary Bypass Surgery?

Balkhy

Nisivaco

Tung

et al. 2020

Innovations�(Phila)

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“…Robotik kardiyak cerrahi işlemlerin yapılabilmesi için akciğer izolasyonu gerekmektedir. Tek akciğer ventilasyonunu sağlamak için ÇLT ve endobronşial blokörler kullanılmaktadır (5) . Hangi akciğer izolasyon tekniğinin kullanılacağı anestezistin tecrübesine ve elde bulunan tüpe göre değişebilir (6) .…”

Section: Gereç Ve Yöntemunclassified

Anesthetic Management in Robotic Cardiac Surgery: Our Clinical Experiences

Ince¹,

Ors²,

Özkan³

et al. 2020

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Minimal invaziv cerrahi yaklaşımlar çeşitli potansiyel yararlarının yanı sıra anestezi ve cerrahi ekipleri için yeni zorlukları da beraberinde getirmiştir. Bu çalışmada, kliniğimizde gerçekleştirilen robotik kardiyak cerrahi işlemlerindeki anestezi deneyimimizi güncel bilgiler eşliğinde sunmayı amaçladık. Yöntem: Bu çalışma, Ekim 2014-Aralık 2019 tarihleri arasında sağ torakotomi ile robotik kardiyak cerrahi geçiren 227 (120 erkek, 107 kadın) hastayı içermektedir. Hastalara ait demografik veriler, cerrahi tipi, EuroSCORE değerleri, kros-klemp ve pompa süresi, postoperatif komplikasyonlar, yoğun bakımda ve hastanede kalış süreleri hasta dosyalarından ve anestezi takip formlarından taranarak elde edildi. Bulgular: Robotik kardiyak cerrahi ile 101 hastaya ASD-VSD, 114 hastaya kapak cerrahisi ve 13 hastaya intrakardiyak kitle eksizyonu işlemi yapıldı. Bu işlemlerden 15'i atan kalpte gerçekleştirildi. Ameliyat sonrası hastaların median ekstübasyon süresi 5 saat, median yoğun bakım kalış süresi 1 gün ve median hastanede kalış süresi 7 gün idi. Postoperatif dönemde uzamış mekanik ventilasyon gereksinimi nedeniyle 3 hastaya trakeostomi açıldı. Kapak cerrahisi yapılan hastalardan 10'una kalıcı kalp pili implantasyonu yapıldı. Sonuç: Hem torasik hem de kardiyak cerrahinin tüm özelliklerini içeren robotik kardiyak cerrahide anestezistlerin oluşabilecek komplikasyonları bilmesi ve bunlara karşı önceden plan yapması gerekmektedir. Ayrıca özellikli bu cerrahinin ayrılmaz bir parçası olan tek akciğer ventilasyonu ve transözofageal ekokardiyografi için gerekli olan bilgi birikiminin kazanılması gerekmektedir.

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“…2–4 While median sternotomy pain may be severe, pain after minimally invasive cardiac surgery (anterior minithoracotomy and/or robotic thoracic ports) seems consistently more intense and challenging to control. 5,6 In the current era of enhanced recovery after surgery, adequate postoperative analgesia allowing immediate tracheal extubation is oftentimes difficult to achieve in patients undergoing minimally invasive cardiac surgery. 7,8…”

mentioning

confidence: 99%

“…As minimally invasive cardiac surgery has become increasingly utilized, numerous regional analgesic techniques have been applied without reliable success. 5,6,9,10 Reasons for inconsistency include the wide variety of thoracic incisions used and technical difficulty/unreliability of the regional techniques. Intrathecal morphine has numerous potential advantages during minimally invasive cardiac surgery, yet has not been adequately evaluated in the current enhanced recovery after surgery era.…”

mentioning

confidence: 99%

Intrathecal Morphine for Analgesia in Minimally Invasive Cardiac Surgery: A Randomized, Placebo-controlled, Double-blinded Clinical Trial

et al. 2021

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Background Intrathecal morphine decreases postoperative pain in standard cardiac surgery. Its safety and effectiveness have not been adequately evaluated in minimally invasive cardiac surgery. The authors hypothesized that intrathecal morphine would decrease postoperative morphine consumption after minimally invasive cardiac surgery. Methods In this randomized, placebo-controlled, double-blinded clinical trial, patients undergoing robotic totally endoscopic coronary artery bypass received either intrathecal morphine (5 mcg/kg) or intrathecal saline before surgery. The primary outcome was postoperative morphine equivalent consumption in the first 24 h after surgery; secondary outcomes included pain scores, side effects, and patient satisfaction. Pain was assessed via visual analog scale at 1, 2, 6, 12, 24, and 48 h after intensive care unit arrival. Opioid-related side effects (nausea/vomiting, pruritus, urinary retention, respiratory depression) were assessed daily. Patient satisfaction was evaluated with the Revised American Pain Society Outcome Questionnaire. Results Seventy-nine patients were randomized to receive intrathecal morphine (n = 37) or intrathecal placebo (n = 42), with 70 analyzed (morphine 33, placebo 37). Intrathecal morphine patients required significantly less median (25th to 75th percentile) morphine equivalents compared to placebo during first postoperative 24 h (28 [16 to 46] mg vs. 59 [41 to 79] mg; difference, –28 [95% CI, –40 to –18]; P < 0.001) and second postoperative 24 h (0 [0 to 2] mg vs. 5 [0 to 6] mg; difference, –3.3 [95% CI, –5 to 0]; P < 0.001), exhibited significantly lower visual analog scale pain scores at rest and cough at all postoperative timepoints (overall treatment effect, –4.1 [95% CI, –4.9 to –3.3] and –4.7 [95% CI, –5.5 to –3.9], respectively; P < 0.001), and percent time in severe pain (10 [0 to 40] vs. 40 [20 to 70]; P = 0.003) during the postoperative period. Mild nausea was more common in the intrathecal morphine group (36% vs. 8%; P = 0.004). Conclusions When given before induction of anesthesia for totally endoscopic coronary artery bypass, intrathecal morphine decreases use of postoperative opioids and produces significant postoperative analgesia for 48 h. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Robotic Cardiac Surgery Part II: Anesthetic Considerations for Robotic Coronary Artery Bypass Grafting

Cited by 5 publications

References 32 publications

Does Intolerance of Single-Lung Ventilation Preclude Robotic Off-Pump Totally Endoscopic Coronary Bypass Surgery?

Does Intolerance of Single-Lung Ventilation Preclude Robotic Off-Pump Totally Endoscopic Coronary Bypass Surgery?

Anesthetic Management in Robotic Cardiac Surgery: Our Clinical Experiences

Intrathecal Morphine for Analgesia in Minimally Invasive Cardiac Surgery: A Randomized, Placebo-controlled, Double-blinded Clinical Trial

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