Haemodynamic Monitoring Since the detection and aggressive management of ischaemia is an important goal of anaesthesia, ECG monitoring is of vital importance. Slogoff and Keats demonstrated that the adverse outcome as measured by postoperative MI was increased in patients who developed pre-CPB ischaemia. 65,66 Subsequently, however, it was demonstrated that ischaemia that occurs prior to CPB may not be as predictive of outcome as was once thought. Majority of the episodes of ischaemia are also not associated with haemodynamic changes. These findings do not suggest that tight haemodynamic control is unnecessary ECG A multilead ECG system is useful in managing patients with CAD. The American Heart Association recommends that ischaemia should be diagnosed when a 0.1 mV horizontal or down-sloping ST segment depression occurs 60 to 80 milliseconds after the ‘J’ point. 70 For unipolar leads, lead V5 has the greatest sensitivity (75 percent) and the combination of leads V4 and V5 has greater sensitivity (90 percent) than either a single lead or the combination of leads II and V5 (sensitivity 80 percent). 71 Monitors having online ST segment analysers with trending facilities that are currently available can be useful in patients undergoing CABG. Arterial pressure For arterial pressure monitoring, radial artery is usually cannulated. Sternal retraction during internal mammary artery (IMA) dissection compromises the flow in the radial artery. Therefore, at some centres, the radial artery opposite to that of the proposed IMA dissection is cannulated. With the growing popularity of total arterial revascularisation, one or both radial arteries may be used for myocardial revascularisation. In such a situation, femoral artery should be cannulated. Accurate, beat to beat monitoring of BP is essential, as many important decisions regarding drug selection and anaesthetic depth are based on BP readings. After hypothermic CPB, radial arterial pressure may be less than the central aortic pressure. For this reason, at some centres, both radial and femoral arterial cannulations are performed. Femoral arterial cannula also provides a ready access for the insertion of intra-aortic balloon pump (IABP) catheter during post-CPB period, if the need arises. Central venous pressure The placement of CVCs is a standard practice for measurement of central venous pressure (CVP) as well as infusions of inotropes or other medications. A single multi-lumen catheter or 2 single lumen catheters can be inserted through the right internal jugular vein (IJV). Pulmonary Artery Catheter When the LV fails and dilates or becomes ischaemic and less compliant, the pressure required to fill it to the same degree rises. In such a situation, left atrial (LA) or pulmonary capillary wedge pressure (PCWP) will increase, but the CVP may be unchanged. The LV filling pressure in the left heart failure can be measured by monitoring the PCWP. PACs have thus, become a routine at many centres. Studies on PAC use have demonstrated that they do not have any effect on outcome72,73 or may even lead to adverse outcome in terms of higher risk of mortality, longer length of stay and higher total costs. 74 Whereas another study has suggested that a more selective use of PACs (in patients with multiple cardiac risk factors) is safe. 75 The existing literature is inconclusive and it is not possible to give clear guidelines regarding the PAC use in CABG surgery. However, most cardiac anaesthesiologist would agree that PAC provides useful information that can change the management strategies, especially in patients having poor LV function, having high-risk of intraoperative ischaemia, severe comorbidities, emergency surgery, combined procedures and reoperation. The PACs are also commonly used is patients undergoing OPCAB. Pre-induction placement of the PAC provides valuable, objective information to the cardiac anaesthesiologist without incurring significant risk to the patient. 76 However, it has been shown that placement of PAC before the induction of anaesthesia consumes more time and fails to improve haemodynamic stability or lessen vasoactive drug use during the induction of anaesthesia in patients with normal LV function undergoing elective CABG. 77 PACs having specialised functions, such as pacing port, continuous cardiac output (CO) and mixed venous oxygen saturation (SVO2) monitoring facility and right ventricular ejection fraction measurement capacities are also available. The SVO2 PACs have not been shown to provide any additional benefit over the routine PAC. 78 Transoesophageal Echocardiography Segmental wall motion abnormalities occur within seconds of coronary occlusion and are the earliest indication of myocardial ischaemia. These can be easily detected on TOE, however, TOE requires considerable expertise for reliable interpretation. The short-axis mid-papillary view is commonly used, because it includes the myocardium supplied by three major coronary arteries. Assessment of global and regional LV function using this view has been shown to be an effective method in patients undergoing CABG. 79 It also provides an accurate estimate of LV preload by measuring LV end-diastolic area. 80 TOE provides valuable information in terms of the preload and contractility. It gives a far more accurate estimate of the preload as compared to the PAC. In addition, TOE can be used to verify PAC location, placement of retrograde cardioplegia cannula, LV vent or IABP tip, detection of atheromas in the ascending aorta, intracardiac air, and valve function. Therefore, the use of TOE is increasing rapidly. The PAC derived haemodynamic data can also be obtained by TOE, but PAC insertion will still be required for the postoperative management in the intensive care unit (ICU). The requirement of specialised training and the cost of equipment are two major hurdles in its use as a routine monitoring tool inside the OT. Nevertheless, more and more cardiac centres are now using TOE routinely during cardiac surgery. Depict the above data into flowchart