B-PO01-005 STRATEGIES FOR PROVIDING ANESTHESIA TO POOR-CARDIAC-FUNCTION PATIENTS IN AN EP ASC

Abstract

The patient population in the EP lab is a challenging one from an anesthesia perspective. Many patients requiring ICD implants and ablations have LV dysfunction, sometimes to a remarkable degree (10-15% LVEF). Negative inotropic effects of anesthetic agents can exacerbate cardiac dysfunction, in some cases leading cardiogenic-shock-like symptoms and even death. The SARS-CoV-2 and the Hospital Without Walls program by CMS brought a significant number of these patients to our EP-dedicated ambulatory surgery center (ASC). In this setting without the support of an ICU or prolonged stays, complication avoidance is paramount. We present our lessons learned and specific suggestions for caring for patients with poor cardiac function in an EP-lab, particularly in a freestanding ASC. In a freestanding facility, an easy-to-understand paradigm for anesthetic optimization was taught to other providers in order to minimize complications and facilitate same-day discharges for even complex ablative procedures. A nurse anesthesiologist with a decade of EP-dedicated experience, developed and taught this paradigm for use in an EP ASC. We suggest a primary anesthetic goal of "unloading the LV" (decrease LVEDP) prior to any insult that will further decrease the inefficient heart's efficiency. Thus prior to any anesthetic delivery or arrhythmia induction, a loading dose and drip of milrinone to improve contractility and decrease afterload. Pre- and post-operative anxiolysis is avoided. Baseline heart rate is noted, and epinephrine drip is titrated after induction of anesthesia to maintain baseline heart rate and contractility. Propofol dose is often attenuated with the admixture of ketamine. Arterial lines are used on all high-risk patients, and more than one IV is obtained prior to induction. TEE monitoring after induction is helpful. By using these strategies and dedicated anesthesia providers, the operating physicians report improved safety and hemodynamic stability compared to what they have generally experienced in the hospital setting. The improved anesthesia safety helps our patients and has given our practice the confidence to care for patients that had previously been deemed too sick for an ASC EP lab.