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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 atrial-esophageal 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 The temperature probe may need to be advanced or withdrawn to the area of the ablation.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.

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