Role of Anesthesiologist in Cath Lab

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Role of Anesthesiologist in Cath Lab

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

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