June Journal Club

[katevaughn]

This month's journal club is presented by Beth Medina. She chose a great article that provides an update on VT ablation procedures and the anesthetic considerations. This will be a great month for our EP colleagues to respond and contribute their "tips and tricks". Enjoy!

Here is a link to the article.

Six years ago was my last time I gave anesthesia in the EP lab for atrial fibrillation. It was the practice to give GA and completely paralyze the patient as requested by the cardiac electrophysiologist. I would like to know the current practice of anesthesiologists and CRNAs
in our institution.


1. Is VT ablation being done in our institution?

2. What are the considerations compared to
this article?

[krechti1]

I think the anesthesia considerations for EP have changed more than any other department over the past 5 years. Since the formation of the EP cohort, I have not done EP on a regular basis, so I cannot speak for current practices. However, I have been present for the presentations about the jet ventilator and most recently the new CO2 monitor. I feel that the level of care provided to the EP patients is definitely superior to what it used to be back when I did EP and we intubated and paralyzed everybody, and placed a regular temp probe. Kudos to Lin and the EP cohort for stepping up and making changes to improve patient care for these patients.

[nanci]

VT ablation is still being done in our institution and in more numbers now than a few short years ago. I think the numbers are up now in Zayed 5th floor compared to when we were still in the older building. Sometimes when Facilitating I see 2-3 rooms with the ablations at once with cases to follow.

I too, like Kelly, have not done EP in years and can not speak for current practices. The jet ventilator and the use of different practices (when Dr. Marine came over from Bayview) and head pieces, etc... must really increase patient safety and allow more patients to successfully undergo these procedures. Back in the old building we would definitely use muscle relaxant (esp for transeptal ablations) and the older temp probes were being phased out for the newer ones. I believe the pharmacologic support they undergo is similar, hemodynamic support may be about the same (communicating with them when wanting to support blood pressure while they are mapping) but again, it has been awhile. It will be interesting to hear from those who work up in EP regularly to hear what the differences are.

[mscotth2]

I think it is amazing how so much is moving out of the traditional operating rooms into procedure areas. EP is one of many areas we are now covering; sometimes in more austere conditions. Would love to see the EP group out publishing and lecturing on what they are doing!

Beth, I can't answer your questions as I haven't done adult EP in several years

[Ben Waldbaum]

1.) Yes, VT ablations are being done

2.) It seem to me the overlying principle in the article is that "less is more." a simpler anesthetic provides the best opportunity for a successful procedure. I personally haven't done EP in a while and cannot speak to the most recent practice at our institution.

[Andy Benson]

Thanks Beth for the article recommendation. I agree with others that the way that we give anesthesia in the EP lab has drastically changed over the last several years. We have implemented jet ventilation however not for these cases (SVT or VT ablations). These cases are usually green mask generals with a propofol drip. We don't administer any versed or fentanyl because it can suppress the VT and will interfere with mapping. These are some of the longest cases especially if they can't map or stimulate the arrhythmia. An arterial line is not required, neither is esophageal temperature monitoring unlike an afib ablation case.

From our website, members of the EP cohort have been approached to give lectures at regional conferences. Our first poster presentation at the IHI national conference was from these EP initiatives. I would like to see more publications and presentations from this cohort since it is ground breaking.

[faresha]

1. VT ablation is done at Hopkins on 5th floor. From the few times that I have wandered on 5th floor, it's obvious that EP is a rapidly evolving area especially for anesthesia providers. I was truly shocked to discover that the majority of these procedures are not necessarily performed with 0/0 twitches. It was just a few years ago that complete paralysis was required.

2. For all of us, the considerations are that we continue to have a lead crna that is passionate and dedicated to this area ensuring that our group remains up-to-date and setting trends for other institutions to follow. Having a good lead crna, Wailin Lau, keeps us current for those that provide care in this area. 

[BrittneyKeating]

Beth, Thanks so much for posting this article! I work in EP usually 1 day per week and found this article extremely helpful as a review of some of the language used frequently in the EP lab, specifically that in reference to mapping systems, mapping strategies and VT classifications.



I am a new to practice CRNA who just joined the EP cohort in January of this year, so I cannot speak directly to the changes in anesthetic management that have occurred rapidly over the past few years. However, I can endorse the fact that having such a knowledgeable and approachable lead, such as Wailin Lau, who is genuinely devoted to keeping the anesthesia team up to date, and competent with new practices and technologies being incorporated in our anesthetic management is key to the fast-paced and well executed roll out of changes that have occurred. Big kudos to Wailin for all the extra time and effort that she devotes to this patient population and CRNA cohort!



The article does a great job at highlighting the importance of light anesthesia for the majority of these VT ablations. One challenge that I see frequently in the EP lab is the disparity between patient’s expectations in terms of the depth anesthesia and the providers plan for anesthesia depth at the different key points of the procedure (i.e. from catheter insertion, to mapping, to ablation). This is where communication between the patient, anesthesia team, and proceduralist are key to providing the best anesthesia experience for the patient, while providing optimal conditions for the proceduralist so that a good outcome can be achieved. The article provided a great review of the different agents used frequently in the EP lab, including propofol, benzodiazepines, volatile agents, opioids and dexmedetomidine and their effect on the ANS and specific ECG changes. I found it very interesting how dexmedetomidine has such a pronounced effect on the ANS and its antiarrhythmogenic properties, such that it has been used in the management of patients with VT storm.

[Soo-Ok Kim]

This article is good simple summary and overview of EP procedure and anesthesia implication. Even though I did fair amount of EP cases before we moved to new building, I am new to new technique like jet ventilator and etc. As a new EP cohort member, I hope I can get to see more cases and learn/practice some of the rstablished technique. VT ablation techniques the article mentioned, I gave anesthesia for it one with GA and the other sedation. As the article mentioned, it can vary based in patient's characteristics and VT morphology. I am glad this article was picked for June.
Soo-Ok