Coronary Artery Bypass Grafting Medication

Updated: Apr 04, 2014
  • Author: R H Bilal, MBBS, MRCS; Chief Editor: Richard A Lange, MD, MBA  more...
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Medication

Medication Summary

The aims of premedication are to minimize myocardial oxygen demands by reducing the heart rate and systemic arterial pressure and to improve myocardial blood flow with vasodilators.

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Anxiolytics, Benzodiazepines

Class Summary

Administration of temazepam immediately before CABG can decrease the risk of tachycardia and hypertension resulting from anxiety regarding the operation. In the operating room, intravenous (IV) administration of a small dose of midazolam before arterial line insertion can also reduce anxiety, tachycardia, and hypertension.

Temazepam (Restoril)

Temazepam depresses all levels of the CNS (eg, limbic and reticular formation), possibly by increasing the activity of GABA.

Midazolam

Midazolam is a short-acting benzodiazepine with a rapid onset of action.

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Opioid Analgesics

Class Summary

Induction of anesthesia is accomplished by using high doses of opioid (usually fentanyl or remifentanil) to minimize the dose of propofol, etomidate, or thiopental and thereby maximize cardiovascular stability.

Fentanyl citrate (Duragesic, Abstral, Actiq, Fentora, Onsolis)

Fentanyl citrate is a synthetic opioid that has 75-200 times more potency and a much shorter half-life than morphine sulfate. It has fewer hypotensive effects than morphine and is safer in patients with hyperactive airway disease because of minimal or no associated histamine release. By itself, fentanyl citrate causes little cardiovascular compromise, although the addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.

Fentanyl citrate is highly lipophilic and protein-bound. Prolonged exposure to it leads to accumulation of the drug in fat and delays the weaning process. Consider continuous infusion because of the medication's short half-life.

Remifentanil (Ultiva)

Remifentanil binds mu-opioid receptors at various sites within the CNS.

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Anesthetic Agents

Class Summary

After standard monitoring equipment is attached and peripheral venous access achieved but before the arterial line is inserted, the midazolam dose is administered. Before placement of the arterial line, it should be ensured that a radial artery graft will not be used for CABG.

Propofol (Diprivan)

Propofol is a phenolic compound unrelated to other types of anticonvulsants. It has general anesthetic properties when administered intravenously. Propofol IV produces rapid hypnosis, usually within 40 seconds. The effects are reversed within 30 minutes, following the discontinuation of infusion. Propofol has also been shown to have anticonvulsant properties.

Etomidate (Amidate)

Amidate is a nonbarbiturate imidazole compound with sedative properties. It is short-acting and has a rapid onset of action; the duration of action is dose dependent (15-30 minutes). Its most useful feature as an induction agent is that it produces deep sedation while causing minimal cardiovascular effects.

The major application of amidate is induction for endotracheal intubation, particularly in patients with, or at risk for, hemodynamic compromise. Amidate has been shown to depress adrenal cortical function; however, this effect is not significant clinically during short-term administration. Since the drug is mixed in propylene glycol, continuous infusion is not recommended.

Thiopental

Thiopental is a short-acting barbiturate sedative-hypnotic with rapid onset and a duration of action of 5-20 minutes. Like methohexital, it is most commonly used as an induction agent for intubation. To use thiopental as a sedative, titrate in dosage increments of 25 mg (adjust to lower dose in children).

Isoflurane (Forane, Terrell)

Isoflurane is an inhalation anesthetic. It may have a myocardial protective effect and therefore is especially useful in off-pump surgery. Isofluranse potentiates the effects of muscle relaxants. Small doses of muscle relaxants can achieve complete paralysis when administered concomitantly with isoflurane.

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Neuromuscular Blockers, Nondepolarizing

Class Summary

Nondepolarizing neuromuscular blockers are used in combination with a sedative as part of the rapid-sequence intubation process.

Pancuronium

Vecuronium may increase myocardial oxygen demand. It is used to facilitate endotracheal intubation and provide neuromuscular relaxation during intubation and mechanical ventilation. It is given as an adjunct to a sedative or hypnotic agent.

Vecuronium

Vecuronium may cause bradycardia in association with opioids. It is used to facilitate endotracheal intubation and provide neuromuscular relaxation during intubation and mechanical ventilation. It is given as an adjunct to a sedative or hypnotic agent.

Rocuronium (Zemuron)

Rocuronium may cause tachycardia. It is used to facilitate endotracheal intubation and provide neuromuscular relaxation during intubation and mechanical ventilation. It is given as an adjunct to a sedative or hypnotic agent.

Atracurium

Atracurium is not considered suitable for operations of long duration. It can cause hypotension secondary to histamine release. It is used to facilitate endotracheal intubation and provide neuromuscular relaxation during intubation and mechanical ventilation. It is given as an adjunct to a sedative or hypnotic agent.

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Anticoagulants, Hematologic

Class Summary

Anticoagulants prevent recurrent or ongoing thromboembolic occlusion of the vertebrobasilar circulation.

Heparin

Heparin augments the activity of antithrombin III and prevents conversion of fibrinogen to fibrin. It does not actively lyse but is able to inhibit further thrombogenesis. It prevents the recurrence of a clot after spontaneous fibrinolysis.

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