What is the role of premedication in coronary artery bypass grafting (CABG)?

Updated: Dec 04, 2019
  • Author: Rohit Shahani, MD, MS, MCh; Chief Editor: Karlheinz Peter, MD, PhD  more...
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The aims of premedication are to minimize myocardial oxygen demands by reducing heart rate and systemic arterial pressure and to improve myocardial blood flow with vasodilators.

Before the advent of coronary artery bypass grafting (CABG), the majority of patients with coronary artery disease (CAD) received beta-adrenoceptor blocking drugs and calcium channel antagonists or nitrates. These drugs were continued until the point of surgery because sudden withdrawal of the medications could cause tachycardia, rebound hypertension, and a loss of coronary vasodilatation.

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

In patients referred for CABG, aspirin should be continued up to the time of surgery, especially in those who present with an acute coronary syndrome (ACS). In patients receiving a thienopyridine (eg, clopidogrel or prasugrel) in whom elective CABG is planned, the drug should be withheld if possible for either 5 days (for clopidogrel) or 7 days (for prasugrel) before the procedure.

Each patient should be cross-matched with 2 units of blood (for simple cases) or 6 units of blood, fresh frozen plasma, and platelets (for complex cases). [3, 6, 7] Tranexamic acid (1-g bolus before surgical incision followed by an infusion of 400 mg/hr during surgery) may be considered to reduce the amount of postoperative mediastinal bleeding and the quantity of blood products used (ie, red blood cell and fresh frozen plasma) [8]

Antidepressant treatment for 2-3 weeks before undergoing CABG and continued for 6 months afterward may foster a faster postoperative mental health recovery and have a beneficial effect on postoperative pain. [47, 48]

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