The document discusses the role of anesthesiologists in cardiac catheterization laboratories. It covers: 1) Anesthesiologists must work in a small space not designed for anesthesia and must become familiar with the workspace and personnel. 2) They provide anesthesia support for a variety of cardiac and non-cardiac specialists performing procedures and must consider issues like radiation exposure, patient comorbidities, and different anesthesia approaches for each type of procedure. 3) Radiation exposure is a risk in catheterization labs and anesthesiologists must take precautions like protective equipment, monitoring radiation doses, and obtaining radiation safety certificates.

1. Role of Anesthesiologist in Cardiac Catheterization Laboratory Dr Abhijit Nair Dr SomitaChristopher Consultant Anesthesiologist, Care Hospital, Banjara Hills, Hyderabad.

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

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

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

36. GA ( LMA, ETT),

37. Regional ( SAB, Epidural, CSE )

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: