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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 2 EP Growth at UPenn 3500 3000 2500 2000 1500 1000 TOTAL EP CASES ANESTHESIA COVERAGE 500 0 3 Communication disconnect Anesthesia’s view Control Room’s view 4 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 5 Preanesthetic Preparation 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 6 Emergency Airway Equipment 7 Positioning and Padding Padding • • • • • • Head Neck Shoulder Arms Legs Knees Restraints • Wrists Patient Comfort 8 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 9 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 10 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 11 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 12 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 13 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. 14 High Frequency Jet Ventilation (HFJV) Increases efficiency/efficacy by decreasing respiratory motion artifacts Requires GA with ETT and TIVA 15 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 16 PVC and Vfib ablation Mild Sedation Moderate Deep Ventricular radiofrequency ablation 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 17 Hemodynamic stability 18 Isoproterenol (Isuprel) Basic concepts • • • • • 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 19 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 20 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 21 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 22 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 23 Tamponade 24 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 25 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 26 27