Coronary artery bypass grafting in the awake patient combining high thoracic epidural and femoral nerve block: first series of 15 patients.

Background: We present a 15-patient series of awake 'off-pump' [without cardiopulmonary bypass (CPB)] coronary artery bypass graft surgery, facilitated by thoracic epidural analgesia (TEA) and femoral nerve block.

Methods: Surgery was performed with a conventional median sternotomy. Analgesia was provided with TEA at T1-2 or 2-3 interspace, using bupivacaine 0.5% and sufentanil 1.66 microg ml(-1), initially at 20 ml litre(-1) until T1-10 dermatomal block was achieved, then maintained at 2-14 ml litre(-1) throughout surgery. Femoral nerve block was performed before operation with neuro-stimulation at the saphenous vein harvest site with 10 ml each of bupivacaine 0.25% and lidocaine 2%. Successful awake surgery, avoiding general anaesthesia (GA) with adequate surgical conditions, without CPB was the primary end point.

Results: Fifteen men, mean (sd) age of 63 (9) yr (range 49-81 yr), weight 78 (10) kg, underwent surgery. Three patients (20%) needed conversion to GA: one patient due to insufficient thoracic analgesia, another required initiation of CPB, and the third needed stabilization of the heart for graft suturing due to profound respiratory movements. All three were successfully extubated immediately after surgery. Awake surgery was successful and uneventful in 80% of cases.

Conclusions: Combined TEA and femoral block is a novel anaesthetic technique, and is feasible, for cardiac surgery. However, certain technical limitations need to be overcome to evaluate the full potential of 'awake' cardiac surgery.