The AHA Guidelines and Scientifi c Statements Handbook
there is no demonstration of increased risk of infec-
tion with glucocorticoids, it may be prudent to
avoid administration in the diabetic patient [1].
Timing of administration and duration of treatment
remain incompletely elucidated.
The serine protease inhibitor, aprotinin, has been
withdrawn by the federal drug administration at the
time of writing secondary to potential increased
mortality risk demonstrated during a recent ran-
domized study.
Perioperative leukocyte depletion prior to CABG
performed with CPB may offer benefi t, but concerns
remain regarding thrombotic complications [50].
Reducing the risk of perioperative infection
Class I
1 Preoperative antibiotic administration should be
used in all patients to reduce the risk of postopera-
tive infection. (Level of Evidence: A)
2 In the absence of complicating circumstances,
a deep sternal wound infection should be treated
with aggressive surgical debridement and early
revascularized muscle fl ap coverage. (Level of Evi-
dence: B)
Class IIa
The risk for deep sternal wound infection is reduced
by aggressive control of perioperative hyperglycemia
by using a continuous, intravenous insulin infusion
[51]. (Level of Evidence: B)
Skin and nasopharyngeal Gram-positive organ-
isms are the leading cause of deep sternal wound
infection or mediastinitis. Preoperative antimicro-
bial administration (within a 30–60 minute window
prior to skin incision) reduces the risk of postopera-
tive infection 5-fold [52]. The timing of administra-
tion is crucial [1]. If antibiotics are administered
outside the 30–60 minute window, the benefi cial
effect is negated. The cephalosporin class is cur-
rently the agent of choice for infection prophylaxis
in cardiac surgery [1]. Skin preparation with topical
antiseptics, clipping hair instead of shaving, avoid-
ance of hair removal, reduction of operating room
traffi c, laminar fl ow ventilation, shorter operations,
minimal electrocautery, avoidance of bone wax, use
of double-gloving barrier techniques for the operat-
ing team, and limiting homologous blood transfu-
sions when possible have all been shown to reduce
postoperative infection [1].
When sternal wound infection is identifi ed,
prompt aggressive treatment with debridement and
muscle-fl ap closure is indicated [53].Prevention of postoperative arrhythmias
Class I
Preoperative or early postoperative administration
of beta-blockers in patients without contraindica-
tions should be used as the standard therapy to
reduce the incidence and/or clinical sequelae of
atrial fi brillation after CABG. (Level of Evidence: B)Class IIa
1 Preoperative administration of amiodarone reduces
the incidence of postcardiotomy atrial fi brillation
and is an appropriate prophylactic therapy for
patients at high risk for postoperative atrial fi brilla-
tion who have contraindications to therapy with beta-
blockers. (Level of Evidence: B)
2 Digoxin and nondihydropyridine calcium-
channel blockers are useful for control of ventricular
rate but at present have no indication for prophy-
laxis. (Level of Evidence: B)Class IIb
Low-dose sotalol can be considered to reduce the
incidence of atrial fi brillation after CABG in patients
who are not candidates for traditional beta-blockers.
(Level of Evidence: B)
Postoperative atrial fi brillation increases the
length of stay after CABG by up to 5 days, increases
hospital charges, and is associated with a 2- to 3-fold
increase in postoperative stroke [54,55]. If atrial
fi brillation after CABG persists into a second day,
warfarin anticoagulation with a goal of an interna-
tional normalized ratio (INR) of 2.0 to 3.0 should
be considered [56].Strategies to reduce perioperative bleeding and
transfusion
Predisposing risk factors for transfusion after CABG
include advancing age, lower preoperative red blood
cell volume, preoperative aspirin therapy, priority of
operation, duration of CPB, recent fi brinolytic
therapy, reoperative CABG, and differences in
heparin management [1,57].
In certain patients in a appropriate clinical setting,
including chronic stable angina, low-risk plaque
morphology, and others, cessation of aspirin and