Coronary Intervention : Pre and Post-procedural Consideration 강북삼성병원심장센터 RN 김태우
Pre-procedural Consideration
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
Contraindications to cardiac cath. - Inadequate equipment or Cath. Facility - Acute gastrointestinal bleeding or Anemia - Uncontrolled bleeding diathesis - Electrolyte imbalance - Fever
Contraindications to cardiac cath. - Medication intoxication (e.g., digitalis, phenothiazine) - Pregnancy - Recent CVA (< 1month) - Uncontrolled CHF. High BP. Arrhythmias - Uncooperative patient
Complication of Cardiac cath. - Cerebrovascular accident - Death - Myocardial infarction - Ventricular tachycardia, Fibrillation or serious arrhythmia
Complication of Cardiac cath. - Aortic dissection - Cardiac perforation, temponade - CHF. - Contrast reaction ( anaphylaxis, nephrotoxicity ) - Heart block, asystole - Hemorrhage( local, retroperitoneal, pelvic )
Complication of Cardiac cath. - Infection - Protamine reaction - Supraventricular tachyarrhythmia, atrial fibrillation - Thrombosis, embolus, air embolus - Vascular injury, pseudoaneurysm - Vasovagal reaction
Major Complication of diagnostic Cath. Number Percent Death 65 0.11 Myocardial infarction 30 0.05 Neurologic 41 0.07 Arrhythmia 229 0.38 Vascular 256 0.43 Contrast 223 0.37 Hemodynamic 158 0.26 Perforation 16 0.03 Other 166 0.28 Total (patients) 1184 1.98 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.
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
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
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
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
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 >2.5-3.0mg/dl and diabetic nephropathy Mannitol(12.5-25g IV over 30min)
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
Transfemoral acess 0 : not palpable 1 : faintly palpable(week & thready) 2 : palpable (normal) 3 : full, increased 4 : bounding(hyperdynamic)
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
Transfemoral acess
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.
Post-procedual Consideration
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
Post procedure List Check up Urine output - 30ml/hr - unsatisfactory volume replacement - contrast induced renal failure Cool extremity - thrombus - spasm - vasoconstriction (arterial occulsion)
Sheath removal - 시술후헤파린사용을중단한뒤 4~6hr. 후에 - ACT < 140~160sec - INR < 2.0 - INR > 2.0 경우 FFP투여또는 aterial closure device 사용 - Fibrinogen > 150mg/dl
Sheath removal - 일반적으로검사후바로 sheath 제거하며, 지혈시간은 2~3 시간정도.
Vascular compression Manual pressure C-clamp Femo-stop pressure system
Vascular compression
Vascular compression Atherosclerotic disease Small vessel( < 5mm) diameter Bifurcation puncture Heavy scarring by previous acess
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
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
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
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
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
Complication of Arterial access
Anaphylactoid reaction to Contrast medium - Angioedema - Flushing - Laryngeal edema - Pruritus - Urticardia
Anaphylactoid reaction to Contrast medium - Bronchospasm - Gastrointestinal spasm - Uterine contraction - Arrhythmia - Hypotension(shock) - Vasodilation
Anaphylactoid reaction to Contrast medium Minor Rash Uticaria Pruritus Nausea Flushing Major Coughing Dyspnea Wheezing Syncope Shock Stridor Seizure Check Airway Breathing Circulation CPR
References 1. Sajja LR, Mannam G, Pantula NR, Sompalli S. Role of radial artery graft in coronary artery bypass grafting. Ann Thorac Surg. 2005 Jun;79(6):2180-8. PMID 15919345 2. ^ 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. 2001 Jan;71(1):180-5; discussion 185-6. PMID 11216742 3. ^ 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): 69 74. doi:10.1053/j.semvascsurg.2006.03.001. PMID 16782510. 4. ^ 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
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