1. Cardiosurgery - Skopje Coronary Artery Bypass Grafting in Awake Settings Special hospital for Cardiosurgery “Filip II” Skopje - Macedonia Mitrev Z, Anguseva T

2. Cardiosurgery - Skopje Myocardial revascularisation in awake patients: 1.Avoidance of extracoropreal circulation, 2.General anesthesia, endotracheal intubation and mechanical ventilation unnecessary 3.Complete off-Pump revascularisation possible

3. Cardiosurgery - Skopje Material and Metods High epydural analgo-anesthesia N= 10 pts ( 2 femail, 8 mail) - Epidural catheter in place: Th1-Th2 - Main targed: somatosensory and motor block - Applied medicaments: 20ml 0.25%Bupivacain 100  gr. Fentanyl, 5ml/min - Sternotomy: patient being without intubation - CABG

4. Cardiosurgery - Skopje Schematic view The catheter is placed in the high epidural space Th1-Th2 one day preoperatively, using the loss of resistance method, or method of getting a drop

5. Cardiosurgery - Skopje Age (years) 62.2 ± 7.8 Sex (f/m) 2/8 BSA (cm 2 ) 1.76 ± 0.2 Unstable angina n : 5pts Previous myocardial infarction n : 4pts Coronarography finding Comorbidities: LAD 100% (n : 10) Hyperlipidemia – 7pts LAD 100%; Cx 90% (small) Diabetes disease- 4pts (n:2) Hypertension – 8pts (n:2) Hypertension – 8pts COPD – 2pts COPD – 2pts Adiposity – 1pts Adiposity – 1pts Smokers – 6pts Smokers – 6pts Patient demographics (N : 10)

6. Cardiosurgery - Skopje Management procedures First step: epidyral catheter the day before surgery Second step: The operative day-.Analgosedation with: mixture 1 : 0.5% Bupivacain and 1.66  g/ml Su-Fentanyl – starting at sternotomy till sternal rewiring mixture 2 : 0.125%Bupivacain and 1  g/ml Su-Fentanyl Day 1 to 3 after surgery -Dosage of the analgosedativa is correlated with: Pts haemodynamic stability Blood-gas analyses Visual analgoscala. Target: pain index 1to3 Third step: Postoperative analgosedatia with mixture 2 (first day)

7. Cardiosurgery - Skopje AWAKE SURGERY

8. Cardiosurgery - Skopje Postoperative management -Third step: Postoperative analgosedatia with mixture 2 (first day) Epidural cathether pull out after 24 hours No need of cathecholamine support No need of other additional sedation except epidural mixture 2 ( 0.125%Bupivacain and 1  g/ml Su- Fentanyl)

9. Cardiosurgery - Skopje Results I –intraoperative data Complete sternotomy 10 pts CABG x1 (LITA - LAD) – 10pts Mean time of bypassing 7.9±0.8min Mean time of op.duration 71.7 ± 22.1min Without intubation 9pts 1patient intubated after sternotomy: pain index >7 Entered left pleural spaces 2 pts Hemodynamical stability in 10 pts

10. Cardiosurgery - Skopje Results II-ICU events Two patients left the operating room by walk. Drains were pull out first post op. day in all pts Hemodynamical stability 9pts In hospital stay 2,5days 9pts Without any significant postop. Complications Follow up – 2 – 42months

11. Cardiosurgery - Skopje Complications: Perforation of the internal dura (1) Intensive headache after punction of the dura interna (1) Collaps due to the Puncture (2) Radicular pain and back pain (7) Epidural catheter misplacement (2) The risk of od epidural-spinal hematoma - decreased, following the recommendations of DGAI: --atraumatic inplacement -- appropriate interval of the last anticoagulant therapy

12. Cardiosurgery - Skopje AWAKE SURGERY Respiratory and haemodynamic stability Respiratory and haemodynamic stability Decreased stress Decreased stress Good ( pre-and postoperative ) Analgesie Good ( pre-and postoperative ) Analgesie Early mobilisation possible Early mobilisation possible Quick and effective recovery Quick and effective recovery Better economic side with a exellent clinical outcome Better economic side with a exellent clinical outcome

13. Cardiosurgery - Skopje