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Role of Anesthesiologist in Cath Lab

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  • 1. Role of Anesthesiologist in Cardiac Catheterization Laboratory
    Dr Abhijit Nair
    Dr SomitaChristopher
    Consultant Anesthesiologist,
    Care Hospital,
    Banjara Hills,
    Hyderabad.
  • 2.
  • 3. Equipments:
    Fluoroscope
    Procedure table
    Sterile table
    Wires, cables, stents, medicines
    Monitors
    Anesthesia workstation +/-
  • 4. Space is always an issue as the lab is designed for the convenience of cardiologist and not the needs of Anesthesiologist
    Claustrophobia for Anesthesiologist
    One has to become familiar with
    the workspace and the personnel
    working there
  • 5. Specialists encountered:
    Cardiologist: Adult, Pediatric,
    Electro physiologist
    Gastroenterologist
    Interventional Radiologist
    Vascular Surgeon
    Neurosurgeon
    Interventional Pain specialist
  • 6. Radiation hazards:
    Ionizing radiation in CCL
    Increased exposure due to:
    Configuration of equipment
    Number of cases per day
    Duration of screening
    Modes of radiation generation:
    Fluoroscopy
    Cine angiography
    DSA
  • 7. Fluoro:
    Used for catheter placement
    95% of X ray operation time
    40% of total radiation exposure
    Cine:
    For acquiring diagnostic images
    To generate permanent record of procedure
    5% of X ray operation time
    60% of total radiation exposure
    Radiation dose is directly related to cine frame rate
  • 8. It is important to measure radiation doses acquired by cath lab personnel
    Exact doses difficult to derive due to:
    Non uniformity of radiation,
    Differences in X ray intensity
    Low energy generated by modern devices
  • 9. Unit of absorbed radiation : Grey( Gy)
    Absorbed dose of radiation is expressed as
    “ EFFECTIVE DOSE”
    ED is expressed in Sievert units ( SI unit)
    rem( roengten equivalent in man/mammal) :
    Non SI measure of ED
    1 Sv = 100 rem
    1 Gray unit = 0.75 Sv
    1 Sv = 1000 mSv
  • 10. ED: Measure of whole body radiation from local radiation source
    ICRP ( International Commission on Radiation Protection) recommends use of effective dose to evaluate the effects of partial exposure and relate this to the risk of equivalent whole body exposure
  • 11. The radiation is associated with a small but definite risk of inducing a malignant disease
    Low-dose radiation exposure has also been shown to induce an increase in the number of circulating lymphocytes and chromosome aberrations, which represent surrogate biomarkers of cancer risk
    Venneri L, Rossi F, Botto N et al.: Cancer risk from professional exposure in staff working in cardiac catheterization laboratory: insights from the National Research Council's Biological Effects of Ionizising Radiation VII Report. Am. Heart J. 157, 118–124 (2009)
  • 12. Symptoms of acute radiation:
    0-0.25 Sv : None
    0.25-1 Sv : Nausea, loss of appetite, bone marrow, LN
    1-3 Sv : Bone marrow, LN, Spleen, severe nausea
    3-6 Sv : Infection, diarrhoea, sterility, skin peeling
    6-10 Sv : Above + CNS impairment
    > 20 Sv : Death
  • 13. Organs involved:
    Skin:
    1 minute screening- 20 mGy skin dose
    Threshold for shin erythema- 2 Gy
  • 14. Eye:
    Conjunctiva, iris, sclera, retinal vessels
    Lens:- critical
    Damage irreversible
    Radiation induced cataracts are
    distinct from naturally occuring
    cataract as they form in posterior
    surface
  • 15. E Vanoetall,Eye lens exposure to radiation in interventional suites- Caution is required.Radiology: Volume 248: Number 3—September 2008
  • 16. Carcinogenesis:
    Brain, skin, Thyroid
    Gonads : Lower risk of malignancy
    Prolonged exposure leads to infertility
  • 17. Methods of reducing radiation exposure:
    Decrease exposure tome
    Distance
    Barriers: Shields, thyroid collar, leaded gloves
    Apron - 0.25 mm Pb equivalent
    Gloves - 0.35 mm Pb equivalent
    18% of active bone marrow is exposed to effects of radiation even with proper lead apparel
  • 18.
  • 19.
  • 20. Dosimeter:
    Body dosimeter
    Ring dosimeter
    Classified as:
    Single badging
    Double badging
    Fetal dosimeter
  • 21. Dosimeter is a must for people working in CCL, to track cumulative radiation exposure
    Occupational limit of radiation exposure in UK : 20 mSv/year averaged over 5 consecutive years
    Katz etall ( 2005 ): Radiation exposure to anesthesia department had doubled after the introduction of EPL
  • 22. Professional Certificate in Radiation Safety!
  • 23. PAC:
    Co- morbidities
    Optimization ( if time permits)
    List of medications, interactions
    Airway
    Note necessary labs
    Highlight renal function
    Explain procedure ( Duration, areas of puncture, prolonged supine position, disturbing discussions, AC etc)
  • 24. Anesthesia medications:
    Thiopentone
    Propofol
    Benzodiazepines
    Opioids
    NMDA receptor antagonist
    Dexmedetomidine
    Inhalational
  • 25. Anesthesia considerations:
    PCI/CAG:
    Sedation by Cardiologist
    Special considerations:
    Respiratory insufficiency
    Anticipated catastrophies- LMCA lesions, tight lesions, multiple/ critical lesions, bad LV
    Primary PTCA
    VIP
    Close communication with Cardiologist
    Prefer ETT over LMA
  • 26. Percutaneous VAD/ IABP:
    In hemodynamically compromised patients- Cardiogenic shock
    May require ETT ( solves the problem)
    Co-ordinate inotropes/vasopressors
    Inform ICCU/OT
  • 27. Catheter Ablations:
    RFA for AVNRT, AF, Afl, accessory pathways, VT
    CARTO
    Prolonged procedures, cold fluids for irrigation
    Insist on Foleys
    Several punctures:
    Groins B/L, Neck B/L,
    Sternum ( pericardial mapping)
    Sedation:
    Boluses ( have to sit there),
    infusion ( can be mobile),
    ETT when nothings working
  • 28. CARTO:
  • 29. CRTD/ CRTP/ ICD:
    Sick patients, can’t lie supine
    Multiple problems:
    Geriatric, Bad LV, Several medications,
    Renal dysfunction, redo procedures
    Elective NIV
    Mild- moderate sedation
    Avoid Propofol
    Insist on ABP/ arrange NIBP
    ETT when airway management is getting difficult
  • 30. Schematic representation of CRT pacemaker showing 3 leads in the heart
    Shea, J. B. et al. Circulation 2003;108:e64-e66
    Copyright ©2003 American Heart Association
  • 31.
  • 32. Pediatric Cardiology:
    Sedation: ASD/VSD device closure, Cath study, PDA device/coil closure
    GA: PBAV, PBPV, PBMV, PDA stenting, Caths
    ( especially post ICR patients)
    Post procedure ventilation:
    PDA stenting, procedural complication
    GA vs sedation:
    for ASD/VSD debatable, due to the use of TEE
  • 33. Gastroenterology:
    ERCP, esophageal stenting:
    Mild- moderate sedation
  • 34. Vascular surgery:
    • Angioplasty: LA +/- MAC
    • 35. EVAR:
    Anesthesia management:
    • LA,
    • 36. GA ( LMA, ETT),
    • 37. Regional ( SAB, Epidural, CSE )
    • 38. There is no evidence to suggest that outcome is better/ worse with any of the type of anesthesia management
  • 39. Interventional radiology:
    Sedation
    GA with ETT wherever indicated
    ( Liver RFA, Carotid body tumor)
  • 40. Neurosurgery:
    Angio: LA +/- MAC
    Aneurysm coiling: GA with ETT
    Guglielmi detachable coils ( GDC ):
    GA
    Prolonged procedure
    Ventilation post procedure ?
    Vasospasm!
    HHH therapy
  • 41. Interventional pain procedures:
    MAC
  • 42. Hybrid theatre complex: