**2.4.3 Fast-track cardiac anesthesia (FTCA)**

FTCA contributes to an anesthetic management with a goal of allowing rapid recovery after surgery (Bainbridge&Cheng,2009). Fast-tracking with early extubation (4-8 hours postoperatively) has become the standart of care recently. The patients with normal LV function preoperatively and an uneventful intraoperative course, as long as the hemodynamic stability is ensured, by avoiding high doses of respiratory depressant anesthetics, with adequate rewarming and postoperative analgesia may be candidates for early extubation (London et al,2008).

The two most actively investigated methods in FTCA practice are; intraoperative narcotic that best facilitates FTCA and the pain control during the recovery period. The narcotics examined for their efficacy are fentanyl, remifentanil and sufentanil, which have been found to result in similar times to extubation (Cheng et al,2001;Engoren et al,2001;Mollhoff et al,2001). TEA has been reported to be superior to placebo and spinal narcotics in terms of pain control (VAS), narcotic consumption, pulmonary complications, dysrhythmias and time to tracheal extubation. However, the risk of epidural hematoma formation limits its usage (Liu et al,2004;Ho et al,2000). A meta-analysis demostrated that PCA in cardiac surgical patients has little benefit whereas NSAIDs provide a reduction in VAS scores and morphine consumption (Bainbridge et al,2006a,2006b). Nurse administered or patient administered narcotics combined with NSAIDs (if there is no contraindication) is the recommended approach for postoperative pain management (Bainbridge &Cheng,2009).

The delay in tracheal extubation may be caused by many factors such as; age, female sex, postoperative bleeding, inotrope use, IABP and atrial arrhythmias (Wong et al,1999). During the operation, the usage of low dosage of narcotics balanced with inhaled agents and/or propofol providing a rapid reversible state facilitates early extubation. The complications associated by inadequate control of temperature, hemodynamics, and/or coagulation may also result in delayed extubation (Bainbridge &Cheng,2009).

The criteria that is suggested for early tracheal extubation includes a stable body temperature of 36-38 C, an arterial pH >7.30, adequate arterial blood gases contributing to PaO2>70-80 mmHg (Fio2=0.4-0.5), PaCO2<40-45 mmHg. The patient should be awake, cooperative, alert and able to move all extremities with adequate motor strenght. The hemodynamic parameters should be stable with minimal or no need for inotropes with stable rhythm or good response to pacing. The patient should be spontaneously breathing with minimal respiratory support at a rate of >10-12 and <25-30 breaths/min with a VC>10 ml/kg, a maximal negative inspiratory force>-20 cmH2O and a chest radiograph without major abnormalities such as atelectasis. Also adequate urine output, stable electrolytes, adequate hemostasis should be achieved (London et al,2008).

#### **2.4.4 Regional anesthesia techniques**

Advances in anesthesiology improves outcome after cardiac surgeries by combining the regional anesthesia techniques with general anesthesia. Thoracal epidural anesthesia (TEA) may enhance coronary perfusion, improve myocardial oxygen balance, reduce the incidence of tachyarrhythmias, perioperative myocardial ischemia through sympaticolytic effects; and also by providing superior analgesic effect it facilitates early tracheal extubation and may prevent respiratory complications (Svircevic et al,2011). However, because of the complications especially the epidural hematoma or abcess formation, TEA usage in cardiac surgeries is controversial. Moreover, the chronic use of antiplatelet agents, use of systemic anticoagulation and platelet inhibition for acute therapy of unstable angina and systemic anticoagulation and potential coagulopathy induced by CPB may increase the incidence of these complications (Ho et al,2000;London et al,2008). Also the systemic hypotension caused by intense sympaticolysis may be difficult to correct. The beneficial effects on respiratory system has also been shown to be provided by other strategies; such as spinal anesthesia (Cheng et al,1996; Silbert et al,1998). A meta-analysis by Liu reported that pulmonary complications can also be reduced by spinal anesthesia; as the incidence of hematoma formation is lower after a single spinal injection, this technique can be a choice for cardiac surgical patients at risk for pulmonary complications (Liu et al,2004). Also, modern general anesthetics can also provide other beneficial effects such as earlier extubation. TEA should be used with caution until its benefit-harm profile is clearly demonstrated (Svircevic et al, 2011).

narcotics in terms of pain control (VAS), narcotic consumption, pulmonary complications, dysrhythmias and time to tracheal extubation. However, the risk of epidural hematoma formation limits its usage (Liu et al,2004;Ho et al,2000). A meta-analysis demostrated that PCA in cardiac surgical patients has little benefit whereas NSAIDs provide a reduction in VAS scores and morphine consumption (Bainbridge et al,2006a,2006b). Nurse administered or patient administered narcotics combined with NSAIDs (if there is no contraindication) is the recommended approach for postoperative pain management

The delay in tracheal extubation may be caused by many factors such as; age, female sex, postoperative bleeding, inotrope use, IABP and atrial arrhythmias (Wong et al,1999). During the operation, the usage of low dosage of narcotics balanced with inhaled agents and/or propofol providing a rapid reversible state facilitates early extubation. The complications associated by inadequate control of temperature, hemodynamics, and/or coagulation may

The criteria that is suggested for early tracheal extubation includes a stable body temperature of 36-38 C, an arterial pH >7.30, adequate arterial blood gases contributing to PaO2>70-80 mmHg (Fio2=0.4-0.5), PaCO2<40-45 mmHg. The patient should be awake, cooperative, alert and able to move all extremities with adequate motor strenght. The hemodynamic parameters should be stable with minimal or no need for inotropes with stable rhythm or good response to pacing. The patient should be spontaneously breathing with minimal respiratory support at a rate of >10-12 and <25-30 breaths/min with a VC>10 ml/kg, a maximal negative inspiratory force>-20 cmH2O and a chest radiograph without major abnormalities such as atelectasis. Also adequate urine output, stable electrolytes,

Advances in anesthesiology improves outcome after cardiac surgeries by combining the regional anesthesia techniques with general anesthesia. Thoracal epidural anesthesia (TEA) may enhance coronary perfusion, improve myocardial oxygen balance, reduce the incidence of tachyarrhythmias, perioperative myocardial ischemia through sympaticolytic effects; and also by providing superior analgesic effect it facilitates early tracheal extubation and may prevent respiratory complications (Svircevic et al,2011). However, because of the complications especially the epidural hematoma or abcess formation, TEA usage in cardiac surgeries is controversial. Moreover, the chronic use of antiplatelet agents, use of systemic anticoagulation and platelet inhibition for acute therapy of unstable angina and systemic anticoagulation and potential coagulopathy induced by CPB may increase the incidence of these complications (Ho et al,2000;London et al,2008). Also the systemic hypotension caused by intense sympaticolysis may be difficult to correct. The beneficial effects on respiratory system has also been shown to be provided by other strategies; such as spinal anesthesia (Cheng et al,1996; Silbert et al,1998). A meta-analysis by Liu reported that pulmonary complications can also be reduced by spinal anesthesia; as the incidence of hematoma formation is lower after a single spinal injection, this technique can be a choice for cardiac surgical patients at risk for pulmonary complications (Liu et al,2004). Also, modern general anesthetics can also provide other beneficial effects such as earlier extubation. TEA should be used with caution until its benefit-harm profile is clearly demonstrated (Svircevic et al,

also result in delayed extubation (Bainbridge &Cheng,2009).

adequate hemostasis should be achieved (London et al,2008).

**2.4.4 Regional anesthesia techniques** 

2011).

(Bainbridge &Cheng,2009).
