Pre-procedural Consideration

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1 Coronary Intervention : Pre and Post-procedural Consideration 강북삼성병원심장센터 RN 김태우

2 Pre-procedural Consideration

3 Indications for cardiac cath. - Suspected or known coronary artery Dx. ( new-onset angina, UAP. SAP. Atypical chest pain or varient Angina, Evaluation before a major Op.) - Myocardial infarction or Cardiomyopathy - Valvular Dx. - Congenital heart abnormal - Aortic dissection - Pericardial constriction or tamponade

4 Contraindications to cardiac cath. - Inadequate equipment or Cath. Facility - Acute gastrointestinal bleeding or Anemia - Uncontrolled bleeding diathesis - Electrolyte imbalance - Fever

5 Contraindications to cardiac cath. - Medication intoxication (e.g., digitalis, phenothiazine) - Pregnancy - Recent CVA (< 1month) - Uncontrolled CHF. High BP. Arrhythmias - Uncooperative patient

6 Complication of Cardiac cath. - Cerebrovascular accident - Death - Myocardial infarction - Ventricular tachycardia, Fibrillation or serious arrhythmia

7 Complication of Cardiac cath. - Aortic dissection - Cardiac perforation, temponade - CHF. - Contrast reaction ( anaphylaxis, nephrotoxicity ) - Heart block, asystole - Hemorrhage( local, retroperitoneal, pelvic )

8 Complication of Cardiac cath. - Infection - Protamine reaction - Supraventricular tachyarrhythmia, atrial fibrillation - Thrombosis, embolus, air embolus - Vascular injury, pseudoaneurysm - Vasovagal reaction

9 Major Complication of diagnostic Cath. Number Percent Death Myocardial infarction Neurologic Arrhythmia Vascular Contrast Hemodynamic Perforation Other Total (patients) Modified from Noto TJ, Johnson LW, Krone R, et al: Cardiac catheterization 1998; a report of the Registry of the Society for Cardiac angiography and intervention (SCA&I) ; Cardiac catheterization: concepts, techniques, and applications, Walden, Mass, 1997, Blackwell Science.

10 Preparation of the Patient - Simple terms - Risks for routine cardiac Cath. - Explain any portions of the study used for research and the associated risks - Provide the necessary information and explanation but do not overwhelm the patient

11 Preparation of the Patient - Patient s ID band, - BP & baseline ECG - Baseline peripheral pulses - Known allergies - Determine recent anticoagulation therapy. ( INR. PTT.) - Check Female Pt. β-hcg levels - Check laboratory results - Check IV in Pt. (18 or 20G) - Check premedication

12 Medical Conditions Ⅰ Allergy ü Contrast ü Aspirin Cardiovascular ü CHF., decompensated ü Severe Hypertention ü Uncontrolled arrhythmias ü A V block ( Type Ⅱ 2 or 3 ) Electrolyte abnormalities ü K+ <3.3 or > 6.0 meq/l ü Na+ <125 or >155 meq/l Hemotologic ü Platelet count <50,000/ul ü Leukocytosis, unexplained ü Hemoglobin < 10gm/dl, acute ü Prothrombi time > 16 seconds

13 Medical Conditions Ⅱ Gastrointestinal ü Acute hepatitis ü Active GI bleeding Neurologic ü Neurologic deficit, unexplained or progressive ü Cerebral hemorrhage, recent Pulmonary Disease, decompensated DM. poorly controlled Renal ü Renal insufficiency, ü unexplained or progressive Systemic ü Bacterial infection ü Unexplained Fever

14 Preprocedual Medication Routine pre-ptca; NPO after midnight except medications Aspirin 325mg & clopidogrel 300mg P.O. Nitroglycerin and/or Calcium channel antagonist Sedative/anxiolytic on call to the lab Diabetics; Insulin ½ usual A.M. IV fluids should contain dextrose If possible, PTCA early in the day Coumadin Patients; Stop 4~6days prior to the procedure If necessary IV heparin Renal insufficiency; The patient must be well hydrated prior to PTCA IV crystalloids are usually administered for 6~12hrs (100~150ml/hr) Serum creatinine > mg/dl and diabetic nephropathy Mannitol( g IV over 30min)

15 Preprocedual Medication Dye allergy; premedication regimens- Prednisone 60mg, Diphenhydramine 50mg Cimetidine 300mg Prior to PTCA Hydrocortisone (100mgIV) Diphenhydramine 25-50mg/dl Aspirin - allergy; ticlopidine 250mg QD. Start at least 72h. Before PTCA

16 Transfemoral acess 0 : not palpable 1 : faintly palpable(week & thready) 2 : palpable (normal) 3 : full, increased 4 : bounding(hyperdynamic)

17 Transfemoral acess Claudication Absent popliteal pulses Femoral bruits Absent femoral pulse Prior femoral artery surgery Extensive inguinal scarring (radiation therapy, surgery, or prior cath.) Excssively tortuous or diseased iliac artery Severe back pain, inability to lie flat Patient request Morbid obesity

18 Transfemoral acess

19 Transradial acess 1) The hand is elevated and the patient/person is asked to make a fist for about 30 seconds. 2) Pressure is applied over the ulnar and the radial arteries so as to occlude both of them. 3) Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the finger nails). 4) Ulnar pressure is released and the color should return in 7 seconds.

20 Post-procedual Consideration

21 Post procedure List Vital signs - Low BP - Tachycardia Check up - indicates blood loss Arterial access - Pain, hematoma and DPA. - Local hemorrhage & hematoma - Retroperinoneal hematoma - Pseudoaneurysm - Cholesterol embolism

22 Post procedure List Check up Urine output - 30ml/hr - unsatisfactory volume replacement - contrast induced renal failure Cool extremity - thrombus - spasm - vasoconstriction (arterial occulsion)

23 Sheath removal - 시술후헤파린사용을중단한뒤 4~6hr. 후에 - ACT < 140~160sec - INR < INR > 2.0 경우 FFP투여또는 aterial closure device 사용 - Fibrinogen > 150mg/dl

24 Sheath removal - 일반적으로검사후바로 sheath 제거하며, 지혈시간은 2~3 시간정도.

25 Vascular compression Manual pressure C-clamp Femo-stop pressure system

26 Vascular compression

27 Vascular compression Atherosclerotic disease Small vessel( < 5mm) diameter Bifurcation puncture Heavy scarring by previous acess

28 Complication of Arterial access 빈도 Ø 0.5~7% 발생군 - 여자, 저체중, 고령, 응급시술, 빈혈, 시술시간, - sheath 의크기, 헤파린의용량, 혈전용해제의사용, - 다혈관의질환 증상 치료방법 - 저혈압, 빈맥, 혈종으로인한신경의압박통증 - Manual compression, - 사용하고있는항응고제투여중단 예방법 - 정확한천자, - 적절한헤파린사용

29 Complication of Arterial access 빈도 Ø 1% 미만 발생군 - high femoral A. puncture 증상 치료방법 - 복부팽만, 통증, 둔한복부, 골반통증, 혈색소치감소 - 치명적일수있으나 3~4pint 수혈후저절로멈출수있다. - Manual compression 을매우오랜시간시행 - 혈류학적으로불안정할경우수술을용함. 예방법 - Inguinal ligament 하부의 common femoral artery

30 Complication of Arterial access 빈도 Ø 0.03~0.04% 발생군증상치료방법예방법 - 심한말초혈관질환, Sheath 길이가긴경우 - 장시간유지한경우, 조기보행, 항응고제사용 - 혈소판기능장애 - 수축기잡음을동반한통증, 박동성이있는종괴, - 대퇴신경과상완신경의마비, - 파열시심한통증과부종 - 직경 < 3cm 미만인경우 -> 1~2주후자연치유 - 직경 > 3cm 이상인경우 -> 파열의위험성으로수술필요수술하지못하는경우 -> 공기압박, coil 주입,stent 삽입 - 적절한크기의 sheath 사용 - 적절한시간에 sheath 제거및고혈압조절 - PCI 후항응고제자제

31 Complication of Arterial access 빈도 발생군 증상 Ø radial approach 0.96 % Ø femoral approach 0.22 % - 혈관직경이작은경우 - 고령, 심근증, 말초혈관질환, 과응고상태, 저체중, - 위험인자가없더라도혈관박리, spasm - 갑작스런 or 점진적인통증발생, 저림, 청색증, - 창백, 말단부위의맥박손실및저온증 치료방법 - 즉각적인헤파린사용및혈전제거, 예방법 - 고위험환자에서작은직경의 sheath 사용주의 - 시술중주기적인 sheath 의세척 - 적절한항응고제사용및 sheath 제거

32 Complication of Arterial access Quiz? Radial approch 후 sheath 를제거하고 지혈을하였다. 이후 2, 3, 4 번째손가락의저림을호소하는경우. Ular artery 가 Radial artery 와같이 Compression 되었기때문이다? 1. YES 2. NO

33 Complication of Arterial access

34 Anaphylactoid reaction to Contrast medium - Angioedema - Flushing - Laryngeal edema - Pruritus - Urticardia

35 Anaphylactoid reaction to Contrast medium - Bronchospasm - Gastrointestinal spasm - Uterine contraction - Arrhythmia - Hypotension(shock) - Vasodilation

36 Anaphylactoid reaction to Contrast medium Minor Rash Uticaria Pruritus Nausea Flushing Major Coughing Dyspnea Wheezing Syncope Shock Stridor Seizure Check Airway Breathing Circulation CPR

37 References 1. Sajja LR, Mannam G, Pantula NR, Sompalli S. Role of radial artery graft in coronary artery bypass grafting. Ann Thorac Surg Jun;79(6): PMID ^ Cohen G, Tamariz MG, Sever JY, Liaghati N, Guru V, Christakis GT, Bhatnagar G, Cutrara C, Abouzahr L, Goldman BS, Fremes SE. The radial artery versus the saphenous vein graft in contemporary CABG: a case-matched study. Ann Thorac Surg Jan;71(1):180-5; discussion PMID ^ Rutherford RB (June 2006). "Randomized EVAR trials and advent of level i evidence: a paradigm shift in management of large abdominal aortic aneurysms?". Semin Vasc Surg. 19 (2): doi: /j.semvascsurg PMID ^ Routine screening in the management of AAA, UK Department of Health study Report 5. ^ Abdominal Aortic Aneurysm screening, a review by Bandolier, a UK independent source of evidence-based healthcare information for both healthcare professionals and consumers. Bandolier 27-3 Article 6. 관상동맥조영술과관련된간호관리 지혈기구선택과주의사항 - ; The 2nd Cardiovascular technologist & Nurese Encore Symposium ; 영동세브란스김경애

39 Thank you for listening.

노영남

노영남 Purpose: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding