Coronary revascularization

Coronary revascularization accounts for approximately 70 per cent of adult cardiac surgery in the Western world, including repeat procedures. Specific ventilatory implications in coronary revascularization relate to the use of arterial conduits. The internal mammary artery is employed in the majority of patients. During harvesting, which may be bilateral, the pleural cavity is often breached. Extrapulmonary collections commonly result and may be associated with lobar collapse. The internal mammary graft usually remains attached proximally at its pedicle and, on some occasions, may be short and under tension with chest closure. Excessive tidal volumes may compromise the graft and even avulse it. Tidal volumes should be limited to 10 to 12 ml/kg and excessive hyperinflation avoided with manual ventilation (e.g. with physiotherapy techniques). Peak pressure should be limited to 30 cmH 2O in patients with chronic obstructive pulmonary disease to avoid hyperinflation; a lower limit may be necessary with severe emphysema.

The gastroepiploic artery and, more recently, the inferior epigastric artery are used for revascularization. Although intra-abdominal manipulation is limited, some patients develop a paralytic ileus which may last for several days and compromise respiratory function. Thus nasogastric drainage should be available in all patients until normal gut function is restored.

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