Early postoperative care is a critical factor in determining successful outcomes following cardiac surgery. With increasing pressure for efficiency while ensuring patient safety is maintained, it is vital that healthcare professionals are familiar with the pathways and protocols designed to allow for rapid recovery of patients. At the same time it is important that complications are detected early, escalated appropriately and intervened upon in a timely fashion.

An ASD is a common congenital cardiac lesion, comprising 6–10% of such anomalies at birth, although diagnosis may not occur until adulthood. The lesion may present as an atrial arrhythmia, paradoxical embolic stroke or exercise limitation secondary to RV volume overload. ASDs may be single or multiple and are associated with additional cardiac lesions in 30% of cases.

Cardiomyopathy is a disease spectrum that alters the shape, function and conduction of cardiac muscle. Affecting 1 in 500 people it is often incurable; however, symptom control can improve life quality and expectancy.

The ideal operating conditions to enable cardiac surgery are a bloodless and motionless field. This requires both cardiac arrest and the drainage of blood from the heart. In order to provide these conditions a separate means of maintaining nutrient supply to the rest of the body is needed. In addition, the heart must be prevented from becoming sufficiently ischaemic as to infarct previously viable muscle.

The first successful human-to-human heart transplant was performed by Christiaan Barnard in 1967 but the initial outcomes were poor. The introduction of ciclosporin resulted in a significant improvement in survival, leading to an increase in heart transplantation through the 1980s. A total of 5,149 heart transplants, including 4,547 adult transplants, were performed at 302 transplant centres worldwide in the year to July 2017, with 86% 1-year survival, just over 50% survival at 10 years and a median survival of 11 years.

Pain after cardiac surgery is common; 75% of patients recall experiencing moderate to severe pain on the cardiac ICU. This has significant physiological and psychological consequences, potentially leading to chronic pain, affecting up to 50% of patients. Adequate treatment is essential to recovery.

The institution of CPB has profound effects on the plasma concentration, distribution and elimination of drugs. The major factors responsible for this are haemodilution, altered plasma protein binding, altered regional blood flow, hypothermia, isolation of the lungs from the circulation and sequestration of drugs into components of the extracorporeal circuit. These changes, which are influenced by physicochemical and pharmacokinetic characteristics, result in an alteration in free drug and effector-site concentration.

Monitors of neurological function have been available since the 1950s. Until recently, however, many have remained in the hands of enthusiasts at academic centres. Many laboratory methods are not readily adaptable for intraoperative use or cannot be practically used routinely because of cost or the need for expert interpretation. The invasive nature of other monitors (e.g. cerebral microdialysis) precludes their use in the setting of systemic anticoagulation. Emerging evidence suggests that modern neuromonitoring technologies – particularly when used together – can be used both to predict and to modify clinical outcome.

Mechanical circulatory support (MCS) can be used in a setting of either acute or chronic heart failure in selected patients refractory to medical management, to augment the failing circulation due to pump failure and to avert organ failure. There are a variety of devices available, which may be employed for short- or long-term support. Longer-term support may only be afforded by a ventricular assist device (VAD) or cardiac transplantation. VADs are used most commonly for left ventricular support (LVADs), but may also be used for the RV (RVADs) or for biventricular support (BIVADs).

Over the last decade, there have been three major developments in perioperative blood management. Firstly, the recognition of preoperative anaemia and perioperative transfusion as risk factors for perioperative morbidity and mortality. Secondly, there is much greater involvement of haematologists in preoperative planning and perioperative care. Thirdly, there has been a widespread introduction of point-of-care testing and aggressive, protocol-driven blood component use in the management of perioperative bleeding.

Cardiac surgery induces profound sympathetic nervous system and inflammatory responses. This so-called ‘stress response’ to surgery causes a multitude of adverse haemodynamic, metabolic, haematological, endocrine and immunological effects. In the setting of cardiac surgery, the attenuation of pain and sympathetic autonomic activity has many theoretical attractions. The introduction of high-dose opioid techniques into cardiac anaesthesia was based, in part, on the belief that they would inhibit the stress response. Failure to block the stress response completely, combined with equivocal evidence of clinical benefit and the need for prolonged postoperative mechanical ventilation, made the technique unpopular. The demonstration that thoracic sympathetic blockade improves the blood flow in severely diseased coronary arteries, the emergence of less invasive cardiac surgical techniques and economic pressures have prompted renewed interest in regional anaesthetic techniques.

Knowledge of infections encountered in the setting of cardiac surgery, and their prevention and treatment, is essential for health professionals working in this area.

The aims of anaesthesia for cardiac surgery are: prevention of perioperative cardiac ischaemia and arrhythmias, tight haemodynamic control, avoidance of non-cardiac complications and early tracheal extubation. This chapter deals with the management of low-risk patients undergoing elective CABG surgery.