Download Anesthesia Suggestions for Dr. Peykar`s cases: Dr. Peykar performs

Anesthesia Suggestions for Dr. Peykar’s cases:
Dr. Peykar performs 4 different types of ablations: Atrial fibrillation (persistent and
paroxysmal), Atrial Flutter, PVC, and Ischemic Ventricular Tachycardia.
Atrial Fibrillation: General endotracheal anesthesia with an arterial line:
1. Dr. Peykar performs his AFib ablations while the patients have a therapeutic
INR. His highest acceptable INR is 3.5.
2. Patients with persistent Atrial Fibrillation frequently have cardiomyopathy as
well. As such, these patients definitely need arterial lines. The SAPA policy
is to place arterial lines for all patients for any atrial fibrillation ablations.
Start the arterial line in the cath lab holding area. The right side is more
convenient. However, if you use the left side, just make sure there is an
extension on the line. If an anesthesia provider in unable to get the arterial
line on one arm, he/she should call another anesthesiologist to attempt the
arterial line on the opposite side.
3. TEE and Temperature monitoring: After induction, Dr. Peykar inserts a TEE
probe. Patients may cough at this point so the anesthesia provider may want to
give a little muscle relaxant prior to insertion. (see muscle relaxant section
below). After the initial TEE is completed, place an esophageal stethoscope.
A potentially catastrophic complication of the ablation is creation of an atrialesophageal fistula. One way to screen for this complication is to monitor the
temperature in the esophagus. The temperature probe may need to be
advanced or withdrawn to the area of the ablation. Since the esophageal temp
probes become somewhat flimsy after being in the body, the esophageal
stethoscope is a better choice. Dr. Peykar should be informed of any 0.1
degree rise in temperature to ensure that the heat to the esophagus is limited.
He will warn you to “Keep an eye of the temperature” when he begins
ablating.
4. After TEE he starts either a right internal jugular or right femoral venous
introducer. They will give you sterile IV tubing to attach to 500ml NS (they
provide). Run this at KVO.
5. IV medications usually provided and managed by the EP RN staff, but, just in
case:
a. Heparin bolus followed by a heparin infusion. Start the infusion in
your peripheral IV. Heparin is 50 units/ml. He usually asks for 1000
units/hr which is 20ml/hr on infusion pump.
b. Adenosine: He may ask for 12 mg adenosine (via central line) to stop
heart and get a good angiogram.
c. Isoproterenol: He will ask to start an Isuprel infusion to help him
locate the foci in the pulmonary veins. Put this in the central line.
Isuprel is 1mg/250ml. He usually asks for 5mcg which is 75ml/hr on
infusion pump (1 mcg/hr = 15 cc/hr)
6. Blood pressure management: Possible etiologies of a sudden decrease in
blood pressure include pericardial effusion or effects of Isoprel. A pericardial
effusion may present as a sudden drop in BP, followed by an increase, then a
sudden drop again in BP. Any decrease in blood pressure should be
communicated to Dr. Peykar. Dr. Peykar will then make a determination to
stop the procedure to rule out an effusion, or, in the event of the Isoprel, he
may choose to decrease or stop the infusion.
7. Fluid Management: The ablation catheter is multi-orifice cooling catheter and
constantly administers normal saline to cool probe. Therefore, a patient may
receive 2-3 liters of IVFs during an ablation. It is important for anesthesia to
minimize the amount of IVFs given. Midway through the case, it is important
to communicate with the EP staff and Dr. Peykar the amount of fluid given
through the ablation catheter to determine if Lasix is needed.
8. Phenylephrine drips: Because the patients are under GETA with minimal
sedation, most patients require a phenylephrine drip to maintain blood
pressure.
9. Muscle Relaxants: Dr. Peykar may need to stimulate the phrenic nerve.
Therefore, he may not want the patient paralyzed after the first hour of the
procedure. A single initial dose of muscle relaxant should be sufficient.
Discuss muscle relaxant with him before the case begins.
Atrial Flutter:
1. Are performed under conscious sedation.
2. Patients may experience mild to moderate chest pain during the ablation.
3. TEEs are frequently performed at the beginning of the case to rule out left
atrial appendage thrombus.
PVC Ablations:
1. Right sided ablations are performed under minimal conscious sedation with
Versed and Fentanyl. Propofol should be avoided because the case may need
to be converted to a left sided ablation. (see below)
2. Left sided ablations are performed under GETA. Propofol can suppress
PVCs. Therefore, it is important to avoid propofol and lidocaine for these
cases. Brevital is a good choice for an induction agent in these cases.
Ischemic Ventricular Tachycardia:
1. This is the highest risk procedure; therefore these patients have an arterial
line.
2. V tach is induced during the study and usually high doses of phenylephrine
are needed to maintain blood pressure.
EP Study/Loop recorder: is a device placed sub-cutaneously near the sternum. There is
no lead associated with the device. Its purpose is to record the heart rhythm for a period
up to 3 years.
1. Are performed under IV sedation with propofol.
2. Dr. Peykar uses Isuprel for a short period.