"Anaesthetist to the cath lab. Primary PCI, five minutes." Then the pause, while everyone waits to hear whether the patient is self-ventilating or intubated.

This episode is about anaesthesia for primary PCI — one of the few places where you're surrounded by people and still somehow on your own. We cover the range of patients the call can mean, from mid-arrest on a mechanical compression device to the agitated patient trying to climb off the table, and why the walk to the lab is the time to make your plan.

Then the room itself: why the cath lab isn't built for anaesthetists, why you and your assistant may be the only people thinking about the airway, and why help has to be asked for by name. What to do as you arrive — lead on before you go through the door, read the room, and ask what's needed. How to read the cardiology arterial trace when it has no alarms and a strange scale, and how to find and use the patient's access.

The central decision is the airway: if you've been called and you're not sure, intubate, and say so out loud so the room can stop for you. We cover gentle induction in a failing heart, getting a femoral central line from the cardiologist before the gloves come off, why not to delay the case for your own arterial line or keep the radial sheath, and careful fluids.

Finally, spotting cardiogenic shock early with the SCAI stages, voicing it, and escalating to mechanical support in time — then packaging the patient properly for intensive care. We finish with the walk to the lab: the plan to have in your head before you open the door.

Chapters

• (00:00) Cold open — the bleep
• (00:40) Who could be waiting for you
• (01:40) Assessing the patient on arrival
• (02:25) The cath lab: a room not built for us
• (04:05) Lead on, read the room, ask what's needed
• (05:10) Reading the cardiology monitoring
• (06:05) Finding and using access
• (06:40) To intubate or not
• (08:10) Central access and fluids
• (09:10) Arterial lines and radial sheaths
• (10:20) Spotting cardiogenic shock
• (11:20) Packaging for intensive care
• (12:10) The walk to the lab

Key takeaways

• The call can mean anything from mid-arrest to combative — use the walk to the lab to plan for each
• On arrival: quick A to E, including supraglottic airways, aspiration, pulmonary oedema, shock and what drugs have already been given
• Everyone else is focused on the artery; ask for help specifically, by name and task
• Wear lead before you go through the door, read the room, introduce yourself and ask what's needed
• Learn to read the cardiology arterial trace — scale, interruptions and no alarms — and tell the room you're watching it
• Find the cannula, bring an extension to you, use a low-volume line, and close infusions after boluses
• If you've been called and you're unsure, intubate — announce it so screening stops and the C-arm moves
• Induce gently with a combination of agents, with a vasopressor drawn up first
• Ask the cardiologist for a femoral central line; remind them before the gloves come off
• Don't delay the case for your own arterial line, and don't keep a large radial sheath for monitoring
• Use the SCAI shock stages, say "cardiogenic shock" out loud, and escalate to mechanical support early
• Package the patient before leaving: arterial line, catheter, nasogastric tube, infusions, and an intensive care bed ready

References / further reading

• Baran DA, Grines CL, Bailey S, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock. Catheter Cardiovasc Interv 2019; 94: 29–37
• Naidu SS, Baran DA, Jentzer JC, et al. SCAI SHOCK stage classification expert consensus update: a review and incorporation of validation studies. J Am Coll Cardiol 2022; 79: 933–46
• Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44: 3720–826

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This podcast is for medical education for healthcare professionals. It is not clinical advice.