Anesthesia in Electrophysiology - PowerPoint Presentation

355 views
Uploaded On 2020-04-04

Anesthesia in Electrophysiology - PPT Presentation

Copyright 2015 Mark S Weiss All R ights Reserved The role of anesthesia in the EP lab EP labs were originally developed for diagnostic procedures EP lab are now used primarily for therapeutic procedures treatment of ID: 775297

Link:

Copy

Embed:

<iframe width="560" height="315" src="https://www.docslides.com/embed/775297" frameborder="0" allowfullscreen></iframe>

Download Presentation from below link

Download Presentation The PPT/PDF document " Anesthesia in Electrophysiology" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.

Presentation Transcript

Slide1

Anesthesia in Electrophysiology

All

ights Reserved

Slide2

The role of anesthesia in the EP lab

EP labs were originally developed for diagnostic proceduresEP lab are now used primarily for therapeutic procedures – treatment of tachyarrhythmias and device implantation Procedures becoming more complex with a sicker & less stable populationAnesthesiologists used to cover ~20% of cases, but now staff 98%Like it or not NORA is the wave of the future-> it is the fastest growing segment of anesthesia care

All

ights Reserved

Slide3

EP Lab – Lay of the Land

Anesthesia personnel provide care in both the recovery room and EP LabsUnfamiliar territory -> arrive early to ensure time for fundamental safety checksCases may not be as “complex” in terms of fluid shifts or blood loss, but emphasis must be paid to ensure identical standards to OR CARE

As in all NORA cases:

Equipment check (MSMAIDS)Machine, Suction, Monitors, Airway, IV meds, “Special” (jet ventilator, cerebral oximetry)Ensure availability and delivery of supplemental O2

All

ights Reserved

Slide4

EP Lab – Location Challenges

Unlike any other anesthetizing location in the hospital, due to the impressive but intrusive amount of equipmentSpace is designed for the often complex work of the cardiologists with anesthesia as an afterthought – lab space often retrofitted with anesthesia equipmentMoving anesthesia equipment during different parts of a case is often necessary to accommodate the procedure Intubation is performed straddling the lower arm of the x-ray equipment, ducking under the upper arm, and squeezed by the two side arms

All

ights Reserved

Slide5

EP Lab - Layout

Typically each EP procedure room has a “control room” where an electrophysiologist can monitor advanced imaging, mapping and ablation activities without having to be “hands on”During a case, personnel should only enter through the control roomHeadphone walkie talkies can be used to optimize team communication due to increased noise level, obstructed vision between team members and dim lighting

All

ights Reserved

Slide6

EP Anesthetic Expectations

VT and AF ablation are typically performed with general anesthesia for patient comfortAnesthetic method best studied in the AF population257 AF pts for RFA: GA higher success rate, reduced PV reconnection, shorter fluoroscopy time - Di Biase, et al. Heart Rhythm. 2011; 8: 368.Most other procedures can be done with minimal to moderate sedationGenerally, prefer minimal sedation when trying to induce SVT or for PVC mapping

All

ights Reserved

Slide7

Pre-Op Evaluation Focus Points

Airway - identify challenges which may be amplified in NORA environmentPrevious anesthetics - review management with focus on sensitivity to sedativesAllergies - focus on shellfish (contrast dye), fish (protamine), antibioticsCardiac Hx - note EF, CHF (ability to tolerate supine position), arrhythmia classification, pulmonary HTN (avoid hypercapnia/hypoxemia)OSA/morbid obesity - important if sedation plannedPositioning - peripheral neuropathy, back pain- peripheral extremity position/paddingGERD - important if sedation planned

All

ights Reserved

Slide8

EP Cases and Locations

EP Cases outside the EP labCardioversionsTEENon-Invasive Programmed Stimulation (NIPS)Defribillator Threshold Testing (DFT)

EP Cases in EP labArrhythmia deviceplacement Radiofrequency Ablation (RFA)Lead extraction cases (if placed <1 year)

All

ights Reserved

Slide9

Anesthetic approach for cases outside the EP lab

Cardioversions (~ 15 minutes)Short period of deep sedation/general anesthesia, usually using bolus dose of propofol/etomidate depending on ejection fractionA soft bite block should be placedTransesophageal Echocardiograms (~ 60 minutes)More prolonged sedation may be required in some TEE patients who are unable to tolerate the procedure with the usual non-anesthesiology provider Blunt gag reflex (can topicalize with Cetacaine spray)Keep airway open (chin lift/jaw thrust, soft suction if necessary)

All

ights Reserved

Slide10

Anesthetic approach for cases outside the EP lab (cont’d)

Non-Invasive Programmed Stimulations (NIPS) (~20 minutes)Programmed pacing stimulation is in an attempt to elicit ventricular arrhythmias. This usually occurs 1-2 days post VT ablation. If the ICD functions properly, it will anti-tachycardia pace or shock the patient out of the arrhythmia. If not, external defibrillation/cardioversion with high joule shocks may be needed. In either case appropriate sedation/general anesthesia will be required. Again, use of a soft bite block can prevent tongue and cheek lacerationsDefibrillator Threshold Testing (DFT) Often, but not always performed at the time of ICD placement within the EPS lab. The anesthetic approach is similar to that described for NIPS above.

All

ights Reserved

Slide11

Anesthetic approach for cases in the EP lab (cont’d)

Arrhythmia device placement3 types of device functions: Permanent Pacemaker (PPM) [for symptomatic bradycardia], Implantable Cardioverter-Defibrillator (ICD) [for tachyarrythmias] and devices capable of cardiac resynchronization therapy (CRT) Types of procedures: placement, generator/battery changes, lead placements, defibrillator testing (DFT), 1 loop placement in superficial abdominal area, subcutaneous (along the sternum) placement of AICD with abdominal wall generator placementMost cases are performed via a transvenous approach with the generator implanted in pectoral regionCases infrequently performed via an epicardial approach (5%)

All

ights Reserved

Slide12

Anesthetic approach for cases in the EP lab (cont’d)

Anesthetic approach to arrhythmia device placement (2 to 4 hours)Typically MAC cases requiring mild to moderate sedation: fentanyl/midazolam with local or infusions of propofol/remifentanilBiV ICD placements may require GA under certain circumstances (ex. OSA, intolerance of supine position)Antibiotic prophylaxis per guidelinesOccasionally patient’s require a conversion to GA EMERGENTLY (prepare ahead of time) Perforation of heart with tamponade is an infrequent but known risk, so be prepared for volume expansion and vasoactive medication resuscitation

All

ights Reserved

Slide13

Anesthetic approach for cases in the EP lab (cont’d)

Radio Frequency AblationCan identify mechanisms of tachyarrythmias and map out arryhthmogenic foci (anatomically and in relationship to EKG) with subsequent catheter-directed ablation via radiofrequency energy

3 Broad Procedural Categories

Supraventricular Tachycardia (SVT), Atrial Flutter, WPW Atrial FibrillationVentricular Tachycardia (Vtach), Premature Ventricular Contraction (PVC), ventricular nodal re-entrant tachycardiaCases may have epicardial approach

All

ights Reserved

Slide14

Scar-related

, reentrant

monomorphic ventricular tachycardia

QRS

Photo courtesy of Dr. William Stevenson

Myocardial Scar from Infarction

Healthy Myocardium

All

ights Reserved

Slide15

Anesthetic approach for cases in the EP lab (cont’d)

Anesthetic approach to RFA proceduresWide variety in length, complexity and critical nature of arrhythmia-> must discuss with proceduralistSurface defibrillator/pacing pace should be applied in all cases with functioning debrillator availableSome arrhythmias are frequently medication/sedation-sensitive and the proceduralist may wish to give NO sedation at the beginning or throughout the case Use solely remifentanil infusion in these cases LV assist devices (ex. Impela) may be placed during the procedure for patients with low EF or severe VTIf used, cerebral oximetry should be employed

BE PREPARED TO CONVERT TO

GENERAL ANESTEHSIA EMERGENTLY

All

ights Reserved

Slide16

Common anesthetic approaches to specific RFA procedures

Supraventricular Tachycardia (SVT), Atrial Flutter, WPW (2-4 hours)MAC- mild- moderate sedation, need sedation bolus for local femoral access and if Foley catheter placedAtrial Fibrillation (6-10 hours)General Anesthesia with an ETT and jet ventilation, radial arterial lineVtach, PVC (6-10 hours)Most complex- start with MAC (mild-mod sedation) during the mapping phase . Assess mental status during Vtach to determine need to cardiovert/treat hypotensionPatient factors may preclude MAC (anxiety, obesity). Use cerebral oximetry to determine need to treat hypotensionFemoral arterial access (may not need radial Aline), if patient unstable at end of case, may need rad Aline for post-op careGA with ETT during RFA ablation or epicardial approach

All

ights Reserved

Slide17

RFA complications

Vascular (hematoma, bleeding, vascular injury) - most common Cardiac tamponade, perforationComplete heart blockLine insertion related (air embolism, pneumothorax)Airway trauma/ hematoma Traumatic intubation followed by heparinzationNerve palsy as a result of improper positioning

All

ights Reserved

Slide18

RFA complications (cont’d)

Esophageal Stricture/PerforationRisk reduction: Esophageal temperature probe is positioned directly behind the atrium with fluoroscopic guidance and temperature closely monitored particularly during ablationPhrenic Nerve InjuryThe electrophysiologist can avoid harming the phrenic nerve by identifying its location with pacing and observing where the pacing causes the diaphragm to move  avoid muscle relaxants

All

ights Reserved

Slide19

Common anesthetic approaches to specific RFA procedures

Lead Extraction +/- laser (3-6 hours)Usually performed due to system infection, lead malfunction (fracture/failure/erosion)Leads older than 1 year may lead to adhesions and removal risks cardiac or vascular avulsion or other injuries. This is typically performed in main ORsALL require GA with ETT using intravenous or Inhalational agents. Blood should be IMMEDIATELY available and cardiac surgical back-up should have been arranged by the EPS staff.Rapid Infuser available

All

ights Reserved

Slide20

Airway Management

Intubations performed with glidescope to decrease change of airway traumaHeparinzation during the procedure may lead to airway bleeding -> impacts extubationMAC cases: must be prepared for EMERGENT intubation (with glidescope)Have nasal airways easily accessibleInduction technique: if EF <40% consider using etomidate (or etomidate + propofol)

All

ights Reserved

Slide21

High Frequency Jet Ventilation

Used to minimize respiratory movement during AF ablationDecreases atrial motion, promotes intra-cardiac instrument stability

Should be a joint decision with

proceduralist in advance Requires GA with ETT and TIVA

All

ights Reserved

Slide22

Anesthetic Drug Choices

The electrophysiologist may have preferences in regard to avoiding certain anesthetics, as some agents may suppress an arrhythmia. It is important to discuss with proceduralist at the start of each case.Very light anesthetic is desirable when trying to elicit a premature ventricular contraction or ventricular tachycardia in order to determine the focus from which the arrhythmia is arising. Consider using only remifentanil and no midazolamIn most general anesthesia cases, inhalational agents should be avoided because of anti-arrhythmic effectsAVOID long-acting muscle relaxation to help monitor phrenic nerve activity

All

ights Reserved

Slide23

Patient Positioning

An arterial line should be placed on the opposite side from which the electrophysiologists operate in case adjustment is neededA soft bite block should be placed for possible cardioversions/defibrillations Double check proper position of extremities as arms are typically tucked at sidesSee positioning figure: pillow under knees, roll under neckPatients are not paralyzed. With cardioversion/defibrillation, there can be significant muscular contracture  wrists must be restrained and extremities paddedAccess to the stopcocks, IV lines and monitors will be limited once the patient is draped

All

ights Reserved

Slide24

Shared Drug Administration

Oftentimes, Cardiology nurses may be assigned to administer various medicationsHeparin, vasoactive inotropesCardiologists may administer drugs directly into cardiac cathetersNitrogylcerine, Calcium Channel BlockersHemodynamically acting meds and anesthetics may interact with procedure COMMUNICATON IS PARAMOUNT

All

ights Reserved

Slide25

ISUPREL Challenge

One of the most difficult times in managing hemodynamics is when the electrophysiologist wishes to evaluate the induction of an arrhythmia using increasing doses of Isuprel. Normally Isuprel is started at 3 mcg/min by the EPS lab nurses and titrated to 6, 12, 20, 30 mcg/min, although the dosing is variable. This typically produces a significant loss of peripheral resistance and drop in blood pressureThe anesthesiologist will likely need to start phenylephrine to support a SBP 130-140 Along with the drop in blood pressure, the heart rate will increase to uncomfortably high levels and occasionally ventricular tachycardia or fibrillation will ensue. The electrophysiologists are able to treat arrhythmiasPreventing the severe rebound hypertension that occurs once the Isuprel is discontinued is a challenge. Phenylephrine should be turned off immediately when the Isuprel is discontinued

All

ights Reserved

Slide26

Hemodynamic Management

Patients may become part extremely labile hemodynamically. Reactions to these drastic changes at times needs to be tempered (look for underlying cause of vital sign instability) as well as determine when rapid intervention is neededElectrophysiologists are very involved in the patient’s hemodynamic managementWhen needed, theu can control the heart rate with pacing or cardioversionCommunication is critical, particularly when making significant changes to the level of anesthesiaHypotension may be caused by tamponade or retroperitoneal bleeding and masking these changes with medication can delay a timely diagnosis. In the routine case, the patient will receive a large amount of volume by the electrophysiologist during the ablation process, so fluid management by anesthesia should be conservative

All

ights Reserved

Slide27

Post- Op Management

Pain generators Back pain/Extremity pain for laying supine for prolonged periodFoley catheterIntravascular Catheters in groin, need to hold pressureTypical Pain medications:KETOROLAC typically given (avoid in renal impairment)Morphine/Dilaudid to be considered Ondansetron for PONV

All

ights Reserved

Slide28

TIPS for Success

CommunicationUnderstanding procedures and their effects on hemodynamics as much as possiblePreparation and ensuring proper positioning, line set upComfort in a NORA setting

All

ights Reserved

Anesthesia in Electrophysiology - PowerPoint Presentation

Anesthesia in Electrophysiology - PPT Presentation

Share:

Link:

Embed:

Related Contents