Postoperative Considerations

Pain and anxiety should be carefully controlled in the postoperative period because the stress response and myocardial ischemia are of greatest concern at this time. Intravascular volume should be optimized, significant anemia avoided (hemoglobin < 9.0 g/dL), and heart rate and blood pressure carefully controlled. Computerized ST segment analysis is helpful in identifying ischemic changes. Peripheral pulses should be checked frequently to verify lower extremity graft patency. Blood pressure augmentation and anticoagulants may be necessary when peripheral perfusion is limited. Urgent surgery may be required to reopen clotted or stenotic grafts.

Postoperative analgesia can be provided by intravenous or epidural opioids delivered by patient-controlled analgesia or epidural opioids with local anesthetics delivered by continuous infusion or patient-controlled analgesia. For epidural patient-controlled analgesia, a dilute concentration of local anesthetic should be used to allow neurologic evaluation of the lower extremities to rule out spinal/epidural hematoma. Bupivacaine (0.0625%) is ideal in this regard. Fentanyl (5 μg/mL) can be added and the solution infused at 2 mL/hour, with an on-demand (i.e., patient-controlled analgesia) bolus of 2 to 4 mL and a lockout interval of 10 minutes.