How to evaluate, triage, and sedate a patient in the congenital cardiac catheterization laboratory

The congenital cardiac catheterization laboratory (CCCL) has evolved into one of the most physiologically demanding environments in pediatric cardiovascular care for not only the interventional cardiologist, but also the anesthesiologist. Once primarily diagnostic, the CCCL now functions as a high-acuity interventional laboratory capable of treating both acquired and congenital heart disease (CHD), through the entire lifespan of patients with CHD. Technological innovation in device design, advanced imaging modalities, and hybrid surgical collaboration has expanded the therapeutic scope to include ductal stenting in neonates, atrial and ventricular defect closure, pulmonary artery and pulmonary vein dilations, transcatheter valve implantation, and complex hybrid surgical-catheter palliation strategies. For the anesthesiologist, the CCCL environment combines the high-acuity demands of an operating room (OR) with several unique features, including: limited access to the airway once sterile fields are established, exposure to radiation, confined workspace, and often prolonged procedural times. In addition, significant hemodynamic instability and arrhythmias may occur in the setting of catheters and sheaths within the cardiac chambers. Certain interventional procedures can transiently obstruct cardiac output, resulting in profound hemodynamic compromise. All of this occurs without the safety net of cardiopulmonary bypass (CPB) in the cardiac OR. This requires the anesthesia team to anticipate rapid physiological changes and respond immediately to maintain cardiovascular stability.