Role of Anesthesiologist in Cath Lab
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Transcript of Role of Anesthesiologist in Cath Lab
ROLE OF ANESTHESIOLOGIST IN CARDIAC CATHETERIZATION
LABORATORY
Dr Abhijit Nair Dr Somita Christopher
Consultant Anesthesiologist,Care Hospital,Banjara Hills,Hyderabad.
Equipments:
Fluoroscope Procedure table Sterile table Wires, cables, stents, medicines Monitors Anesthesia workstation +/-
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
Specialists encountered:
Cardiologist: Adult, Pediatric, Electro physiologist Gastroenterologist Interventional Radiologist Vascular Surgeon Neurosurgeon Interventional Pain specialist
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
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
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
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
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
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)
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
Organs involved: Skin: 1 minute screening- 20 mGy skin dose Threshold for shin erythema- 2 Gy
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
E Vano etall,Eye lens exposure to radiation in interventional suites- Caution is required.Radiology: Volume 248: Number 3
—September 2008
Carcinogenesis: Brain, skin, Thyroid Gonads : Lower risk of malignancy Prolonged exposure leads to infertility
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
Dosimeter: Body dosimeter Ring dosimeter
Classified as: Single badging Double badging Fetal dosimeter
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
Professional Certificate in Radiation
Safety!
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)
Anesthesia medications: Thiopentone Propofol Benzodiazepines Opioids NMDA receptor antagonist Dexmedetomidine Inhalational
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
Percutaneous VAD/ IABP:
In hemodynamically compromised patients- Cardiogenic shock
May require ETT ( solves the problem) Co-ordinate inotropes/vasopressors Inform ICCU/OT
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
CARTO:
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
Copyright ©2003 American Heart Association
Shea, J. B. et al. Circulation 2003;108:e64-e66
Schematic representation of CRT pacemaker showing 3 leads in the heart
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
Gastroenterology: ERCP, esophageal stenting: Mild- moderate sedation
Vascular surgery: Angioplasty: LA +/- MAC EVAR: Anesthesia management: LA, GA ( LMA, ETT), Regional ( SAB, Epidural, CSE ) There is no evidence to suggest that outcome
is better/ worse with any of the type of anesthesia management
Interventional radiology: Sedation GA with ETT wherever indicated ( Liver RFA, Carotid body tumor)
Neurosurgery: Angio: LA +/- MAC Aneurysm coiling: GA with ETT
Guglielmi detachable coils ( GDC ):GAProlonged procedureVentilation post procedure ? Vasospasm!HHH therapy
Interventional pain procedures:
MAC
Hybrid theatre complex: