The Basics

So what is cath lab?

The "cath lab" is short for catheterization laboratory. Catheterisation is the medical procedure where a thin, flexible tube called a catheter is inserted into a body cavity, duct, or vessel for various purposes, including diagnosis, treatment, or drainage. In the context of the cath lab, catheterisation refers to the minimally invasive procedure to diagnose and treat cardiovascular diseases using catheters.

Why "lab"? In medicine, "laboratory" doesn't always refer to a space solely dedicated to scientific research. It also denotes a specialized room equipped for specific procedures or tests.

A bit of history...

In 1929, Werner Forssmann performed the first human cardiac catheterization on himself by inserting a catheter into his own antecubital vein (as in the img below) and advancing it toward his right atrium. To verify its position, he walked to the radiology department and used X-ray imaging to take a fluoroscopic image of the catheter reaching his right atrium. Other key milestones include the introduction of right heart catheterisation (cardiac output and pulmonary pressures) by Mason Sones and Dickinson Richards in 1945, the first balloon angioplasty by Andreas Grüntzig in 1977, and the development of stents in the 1980s.

Who's in the cathlab?

Everyone has their own responsibilties in cathlab. As always, it is our responsibility to work together as a team and assist each other when needed to improve workflow and ultimately better outcomes for the patient.

Doctors (2)
- Fellow: Cardiologists who have completed general training and are now specialising and advancing their skills in interventional studies. Typically the main physician performing the examinations.
- Consultant: Fully qualified cardiologists who have extensive experience in the cathlab. Typically sit outside the lab and give direction to the fellows. Decisions are ultimately based on their advice.
- Registrar: Not as often in the labs, junior doctors who usually start off by performing diagnostic LHCs (no PCI). May not be as quick and need assistance with the equipment/common errors!
Nurses (2-3)
- Scrub: Assist the cardiologist in the procedure.
- Scout: Assist with various tasks such as opening sterile packages, communicating with the pt and scribing.
Cardio physiologists or techs (1)
- Monitor patients' vital signs, operate specialized equipment (e.g. IVUS) and scribe during procedure. Typically sit outside the lab by the door.
Radiographers (1)
- Assist with C-arm control, screen displays and imaging related tasks (e.g. referencing, image labelling, radiation safety).

PSAs
- Assist with pt transfer and turnover as well as transporting pts if required.
Echocardiologists
- Present when TOE is used e.g. TAVI, mitral-clip insertion.
- Confirm presence of abnormalities in the heart structure or clots prior to beginning procedures.
Anaesthetist
- Present for GA/heavy sedation cases, intubated pts from ICU or ED and when airway support is required.
- May also assist with TOE in certain cases.
Medical device reps
- More commonly present in TAVI and EP studies, assisting the doctors and nurses with new and emerging devices / trial cases!

What are the different start times?

8:00am - Put pedals out for the labs which are running (look at the whiteboards and check EMR) and check rooms are ready (e.g. plastic covers on lead shielding). Turn on LCD/inside screens (using smaller touch-screen next to Sony Screen) and CR screens (white wall switches). Put armboards on table if LHC first exam/radial access.
8:15am - Main start time, see supervisor and get assigned a lab.
9:00am - [Float] Start in x-ray and call cath lab to see if you are needed.
9:30am - See supverisor and usually begin relieving people for breaks starting with the 8:00am person. Finish the day by checking all labs are cleaned and machines/screens turned off.
4:00pm - Typically need to head up to the labs at 4:30 to finish any cases still going on (usually CRM labs 6/7).

Layout

The cath lab is a big rectangle. When you arrive from the in-pt elevators, you are at a corner of the rectangle. At the junction in the photo below, keep going straight to get to the back of the labs, or turn right to the front of the labs and IRC across the hall.

In the main storage room near the lockers, you will find most of our necessities in the back left shelf (gloves, masks, Clinell, scrub hats, rubbish bags, pt belonging bags). The hover mats are in the front right section (used for pts >100kg and cannot shuffle back e.g. EP/PPMs, fem access)

In the nurses storage room (we don't have access) behind lab 3 is where the hover machine is stored and usually extra hover mats, otherwise get one from the main storage room

Hot blankets are kept outside lab 4 (check the 'use this side first'!)

Workflow

Before the pt comes to the lab, they will be consented (either in the ward or IRC), prepared with medications (e.g. antiplatelets/aspirin).

All examinations begin with first helping bring the pt into the room (check ID) and only then coming back to the console area to set up the computers. After the examination, help bring the pt out before closing the pt on the Siemens system/completing documentation. Our role in the cathlab as radiographers can at times be quite passive. However a big part of our job is to help the team and improve workflow with small actions! :)

1. Prepare Patient in the Room

Ideally be in room for time-out prior to pt transfer (and confirm ID of pt!)
Help transfer pt to table
Set up armboard with blue cover/a bluey (typically right radial access), foot pedal, and control panel
- Unscrew lock on RHS and drag to the left (with your left hand lift the lead to make it easier), ensuring arrow does NOT reach end of metal bar. Leave the end of lead shield sticking out so nurse can easily drape!
Introduce yourself and ask for height/weight (+ pregnancy if required)
Confirm correct pt (ideally be there during timeout! Or check wristband)
Move the bed back out into holding bay and get it ready for end of examination (e.g., flatten and prepare pat-slide if femoral access/PPM/GA pt etc.)

2. Set Up X-ray Equipment

Do this first before documentation stuff to ensure the room is ready for xrays asap!
Open patient on Siemens Artis Q screen

Find the pt in scheduler (will only appear if arrived by nurses/tech on Health Track)

Reference with sticker and enter carefully:

Height and weight
(Will be used for dose modulation! Can enter in feet/inches and convert to metric on the system!)
Consultant's name
They will be annoyed if incorrect❗
Ward

Bring the tube in by selecting bottom left button (custom preset 1) and pushing joystick forward.
Once the cardiologist starts scrubbing in, bring the table up to elbow height so its more comfortable for them.
Once the cardiologist has inserted the sheath (will pull out a green tube and put on teggy dressing), you can dim the lights.
Open the pt on the Sony screen (controls what appears on monitors inside and outside the lab)

Left Lab screen: Split screen live x-ray and haemo
Left CR: Live x-ray and right CR: Assist screen
In lab 3, set the right CR to the camera to see better inside the lab
Bring up previous imaging on connected PC and be ready to display on Sony 1 if needed
Change the screen display setting (e.g., half/half live and assist screens)

3. Set Up Documentation

Open EMR cathlab list (perioperative tracking at VHH) and add documentation for radiation dose and protocol (do this first to ensure EMR accurately displays the radiation use/justification as per time!)

Open pt file by double-clicking the first column arrow
Go to documentation and click the + sign to add a new entry
Title: Radiation dose and protocol (cardiac)
Using auto-text (supervisor will show you how to set up), pre-fill with date + consultant's initials (can be found on EMR)
Save and close (only sign at the end once dose details are typed in. Once saved, the title cannot be edited so double-check!)

Open Microsoft Teams and add the case to the excel spreadsheet, copy and paste pt details from EMR (this is for our own record-keeping purposes, not as important - do EMR first)

4. During the Examination

Changes depending on procedures and cardiologists workflow, but generally:

Before turning radiation on, check everyone has lead on. Then when turning it on, speak clearly into mic 'turning x-rays on' to make sure everyone is aware.
Be ready to save reference images (e.g. contrast runs showing stenosis or region of interest) in initial runs. Otherwise, can open on syngo, flick through the run and choose a good reference image - then go back to Artis to quickly reference when you have the chance (e.g. while setting up for ballooning/exchanging wires).
Listen out for the cardiologist asking to 'fluorosave', 'fluorograb', 'fluororecord' or 'fluorostore' (saving fluoro runs, not acquisitions which are auto-saved. For record keeping, fluorosave when a wire has been inserted into a vessel, balloon inflated (althought usually acquired) or good contrast run showing flow)
Move filter to block glare and collimate to the border of the heart when possible (for most drs just the spider view)
Start on 25 mag, then go down to 20 once engaged in artery and beginning to take diagnostic shots. (most drs will change on their own)
Be ready to change the screen display setting (e.g. if doing FFR select screen with Coreventis/FFR etc. if unsure check the screen inside if its correct!)
Change acquisition rate/dose as needed (e.g. BMI+ for spider view)
Label images and send to PACS (or take note of run # and label at the end)

5. Ending the Examination

Disable radiation and bring the tube out (preset position: transfer patient)
Remove plastic cover over II and store it in the drawers to re-use as foot pedal cover!
Help transfer pt back into bed/turnover

Bring the bed back in
When pt is moving across, make sure they do not use their wrist!
Remove armboard (place on end of bed) and move pedal out of the way
Wipe down armboards, table and tube*. Help the tech wipe down the BP cuff and ECG leads if they are busy too
Change bin liners (bottom corner cupboards, fit with the blue band)
Grab new bedsheet, blanket, and 2 saline bags for the techs from the adjacent storeroom if they haven't already got it themselves

Close patient on the computer after they have left the room , once closed cannot be opened again ❗ before going back to fill in the excel spreadsheet

Add any intervention performed in comments (e.g., Stent x 2 to LAD)
Update the procedure if necessary (e.g., LHC PCI)

Complete EMR dose documentation (click sign to complete)

*For end of day clean, rotate the tube so you can clean the very bottom which is usually dirty!
Try your best to clean the metal side rails as well