while technical modifications such as off - pump technique have reduced the postoperative complications and surgical mortality of coronary artery bypass grafting ( cabg ) , awake cabg using thoracic epidural analgesia ( tea ) alone opens the opportunity of surgery for those patients who are not suitable candidates for general anesthesia ( ga ) . a 56-year - old male , weighing 55 kg and 165 cm tall was posted for cabg . he had a history of koch 's chest . pulmonary function tests showed moderate obstructive pathology ( post - bronchodilator forced expiratory volume in 1 s 50% of predicted and reversibility postbronchodilator therapy of 15% ) . functional capacity of the patient was nyha class ii and objective assessment was class c. all medications were continued till the morning of surgery except for aspirin and clopidogrel , which were stopped for 1-week . a day prior to the surgery the patient was counseled for the procedure and an epidural catheter placed at t2-t3 interspace . on the day of surgery after applying electrocardiograph and pulse oximetry , premedication with 1 mg midazolam , 5 mg ondansetron and 50 g fentanyl was given . this was followed by placement of the arterial cannula , central venous catheter , and swan - ganz catheter under local anesthesia . epidural was activated with a mixture of 0.375% ropivacaine ( 10 ml ) and 5 g / ml fentanyl followed by infusion of the solution at the rate of 10 ml / h . a sensory block of c7 to t10 level the occlusive screen was placed and patient kept on inhaled oxygen at 4 l / min by ventimask . planned bypass graft of left internal mammary artery ( lima ) to lad artery could not be achieved due to lima injury during harvesting . the saphenous vein from the right leg hemodynamic and respiratory parameters were monitored and well maintained during the procedure . immediately after surgery patient could sit upright with support as well as inhale deeply without any discomfort . postoperatively the epidural infusion was continued for 72 h using a mixture of 0.25% ropivacaine and 5 g / ml fentanyl at the rate of 8 - 10 ml / h . the only complaint in the immediate postoperative period was nausea , which responded to 5ht3 antagonist . epidural catheter , all invasive lines and chest drain were removed on 3 postoperative day and aspirin - clopidogrel started . he was mobilized on the same day and discharged from the hospital on the 7 day . since the first cabg in an awake patient was performed in october 1998 with high tea block , occasional cases have been reported in the literature with varying success . a few have reported conversion rate to ga of 7 to 20% . awake cabg using high thoracic epidural has several benefits including avoidance of ga and positive pressure ventilation . t1-t5 tea also reduces the endogenous stress response , heart rate , and arrhythmias during manipulation of the heart , and also reduces the risk of myocardial ischemia and postoperative atrial fibrillation . several studies have shown epidural catheter placement to be safe in patients undergoing surgery if the asra guidelines are strictly adhered to . epidural catheters should be inserted not less than one hour before anticoagulation . in case of bloody tap the surgery should be delayed for 24 h. postoperatively the catheter should not be removed if the international normalized ratio is > 1.5 . verbal reassurance during surgery , music through headphones or sedation with iv midazolam or propofol infusion may be employed . another issue is the presence of  patchy  block unidentified during routine preoperative pin - prick testing . we found our first experience of awake cabg satisfying as the patient was pain - free and remained hemodynamically stable .
conventionally general anesthesia has been the preferred anesthetic technique for coronary artery bypass grafting ( cabg ) . 
 ever since the first awake cabg the concept though appearing promising is still being continually evaluated . from the indian perspective , the practice has been largely limited to certain institutions and seems to be not widely practiced across india . 
 this case reports our experience with this technique from the western part of the country .