Transcript Non-OR Anesthesia - Stepping outside of the OR -

Anesthesia in
Electrophysiology
© 2016 Mark S Weiss, MD
Department of Anesthesiology and Critical Care
Goals of an EP lab
 Diagnostic
• Conduction studies / Arrhythmia induction
• Device interrogation
 Therapeutic
• Tachyarrhythmia treatment
• Ablation
• Device implantation
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EP Growth at UPenn
3500
3000
2500
2000
1500
1000
TOTAL EP
CASES
ANESTHESIA
COVERAGE
500
0
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Communication disconnect
Anesthesia’s view
Control Room’s view
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Preoperative Evaluation
 Airway
• challenges can be amplified in NORA environments
 Allergies
• Shellfish -> Contrast Dye
• Fish -> Protamine
• Antibiotics -> surgical site infection prevention protocols
 Cardiac
• Ejection Fraction – selecting pressor agents/anesthetic agents
• Congestive heart failure – tolerance of supine position
• Pulmonary HTN – sedation induced hypercarbia and hypoxia
 Pulmonary
• OSA/Morbid obesity - requirement for CPAP
 Gastrointestinal
• GERD – increased importance with sedation
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Preanesthetic Preparation
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Machine –positive pressure ventilation
Suction – sometimes shared with proceduralist
Monitors – basic ASA and others as needed
Airway
IV –Sedation and TIVA common
Drugs – resuscitation drugs
Special equipment – jet ventilator, esophageal temperature
probes, warming/cooling devices
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Emergency Airway Equipment
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Positioning and Padding
 Padding
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Head
Neck
Shoulder
Arms
Legs
Knees
 Restraints
• Wrists
 Patient Comfort
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Continuum of sedation
Mild
Sedation
Moderate
Deep
Anesthesia
(General)
Procedure
Length
Cardioversion (CVN)
15 minutes
Noninvasive Programmed Stimulation (NIPS)
30 minutes
Defibrillator Threshold testing (DFT)
15 minutes
Pacemaker +/- Generator Change
1-6 hours
Lead extraction +/- Laser
3-6 hours
SVT/WPW radiofrequency ablation
2-4 hours
AFib radiofrequency ablation
6-12 hours
Ventricular radiofrequency ablation
6-12 hours
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Holding Room Procedures
Mild
Sedation
Moderate
Deep
Anesthesia
(General)
Cardioversion (CVN)
Procedure
Length
15 minutes
 Bolus dose propofol/etomidate + soft bite block
 EF guides selection of anesthetic agent
Noninvasive Programmed Stimulation (NIPS)
30 minutes
 1-2 days post VT ablation
 Pacing-induced Ventricular arrhythmia
 Anti-tachycardia pacing or shock to terminate
Defibrillator Threshold Testing (DFT)
15 minutes
 Usually at time of ICD placement, but not always
 Similar anesthetic as cardioversion
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Device Placement
Mild
Sedation
Moderate
Deep
Anesthesia
(General)
Pacemaker +/- Generator Change
Procedure
Length
1-6 hours
 Device Placement – Pectoral vs. Subcutaneous
• Symptomatic Bradycardia: Pacemaker
• Tachyarrhythmia: ICD
• Cardiac resynchronization therapy (CRT): BiV-ICD
 Generator Change
• Shorter procedure
• May require DFT
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Device Removal
Mild
Sedation
Moderate
Deep
Anesthesia
(General)
Lead extraction +/- Laser
Procedure
Length
3-6 hours
 Indications
• System infection
• Lead malfunction (fracture/failure/erosion)
 Considerations
• Leads > 1 year old can have adhesions
– May lead to cardiac/vascular avulsion or injury
• Blood / Rapid infuser availability
• Cardiac surgery backup
• May have to be done in main OR
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Radiofrequency ablation (RFA)
Mild
Sedation
Moderate
Deep
Anesthesia
(General)
Procedure
Length
SVT/WPW radiofrequency ablation
2-4 hours
AFib radiofrequency ablation
6-12 hours
Ventricular radiofrequency ablation
6-12 hours
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Esophageal Temperature Probes
 26% of patients with esophageal injuries without luminal
esophageal monitoring during RFA
“ Preventions of Esophageal Injury during Radiofrequency Ablation for Atrial Fibrillation” Enzhao L, Shehata
M, Liu T, et al - J Interv Card Electrophysiol 2012; 35: 35-44.
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High Frequency Jet Ventilation (HFJV)
 Increases efficiency/efficacy by decreasing respiratory motion
artifacts
 Requires GA with ETT and TIVA
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SVT and Afib ablation
Mild
Sedation
Moderate
Deep
Anesthesia
(General)
SVT/WPW radiofrequency ablation
Procedure
Length
2-4 hours
 Deep sedation suppresses autonomic system
 Light sedation (remi) +/- short acting bolus (propofol)
 Avoid long-acting sedatives like benzodiazepines
AFib radiofrequency ablation
6-12 hours
 GETA + Arterial line + foley catheter
 Consider HFJV
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PVC and Vfib ablation
Mild
Sedation
Moderate
Deep
Ventricular radiofrequency ablation
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Anesthesia
(General)
Procedure
Length
6-12 hours
Deep sedation suppresses autonomic system
Usually have low EF ( < 10%)
Light narcotic sedation used (remifentanil infusion)
Mental status during V-tach assesses need for defibrillation
If GETA, cerebral oximetry used to guide decision
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Hemodynamic stability
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Isoproterenol (Isuprel)
 Basic concepts
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Nonspecific beta agonist
Positive chronotropic, dromotropic, and inotropic effects
Used to induce ventricular arrhythmias
Beta2-mediated hypotension
Can cause an increase in the MAC requirement
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Isoproterenol challenge
 Requires invasive blood pressure monitoring
 Increased MAC requirement
• If under GETA:
– Remi > 0.15 mcg/kg/min and propofol > 80mcg/kg/min
– Or as required by patient
 Ensure adequate IV flow rate
 Keep SBP > 140 prior to isoproterenol challenge
• Provides buffer for isoproterenol-induced hypotension
 Listen for subtle heart rate increase
• Pre-emptive management is key
• Increase phenylephrine ; high individual variability, but increase by 50100mcg/kg/min
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Isoproterenol challenge - cont
 Isoproterenol challenge doses
• 6 -> 12 -> 20 -> 30 -> 40 mcg/min
 Decrease systolic goals at higher isoproterenol doses
• SBP 110-120 for isoproterenol doses 20-40mcg/min
• Isoproterenol metabolized faster than phenylephrine and abrupt
challenge end can lead to rebound hypertensive crisis
 At end of isoproterenol challenge
• Stop phenylephrine infusion
• Return IV flow rate to initial settings
• As blood pressure decreases, restart phenylephrine. at pre-challenge
rates
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Isoproterenol challenge - sedation
 Patient may not be able to tolerate GETA
• “too sick”
 Isoproterenol challenge doses
• 3- 12 mcg/min
 Less hypotension
• Can usually react to change as opposed to pre-empt
• Moderation in reaction to changes
 Consider Epinephrine infusions
• Pt may have Low EF
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Hemodynamic changes
 Infusions:
• phenylephrine
• epinephrine
 Volume status:
• Ablation catheter can deliver >3L of fluid
• The patient may require diuresis
 Labile hemodynamics
• May be due to the electrophysiologist
• Communication is key
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Tamponade
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Postoperative Pain management
 Pain generators
• Back pain/Extremity pain for laying supine for prolonged period
• Foley catheter
• Intravascular Catheters in groin, need to hold pressure
 Typical Pain medications:
• Ketorolac typically given (avoid in renal impairment)
• Morphine/Dilaudid to be considered
 Ondansetron for PONV
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Tips for success
 Communication
 Understanding procedures and their effects on hemodynamics
as much as possible
 Preparation and ensuring proper positioning, line set up
 Comfort in a NORA setting
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