1. Managing Vascular Complications of Cardiac Catheterization: Your First Aid Kit Presented by Helen Condry, RN

2. WHY ARE YOU HERE?

3. Objectives Be able to briefly describe the process of a cardiac catheterization. List possible vascular complications. Describe the management of vascular complications. Demonstrate how to hold manual pressure for a hematoma. Discuss discharge teaching.

4. Cardiac Cath: Why is it done ? Chest pain Shortness of breath Fatigue Positive stress test Dizziness CMC.northeast.org

5. How is it done? Sheath to artery Wires to aorta to heart Dye injected Alltebfamily.com

6. Most Common Complication? Bleeding! 1% risk of bleeding for cath’s. 3% risk of bleeding for PCI’s. (Batyraliev et al., 2005) Azheart.com

7. Hematomas/Bleeding Very Large Hematoma Hematomas-bleeding under the skin with pain For either one, your first job is to find the arterial pulse and press hard! For hematomas- someone else may have to press out the hematoma while you put pressure on the artery.

8. What else needs to be done? Get assistance from other nurses Pain medicine-very important for hematomas Monitor heart rate and bp while holding arterial pressure Notify the doctor Outline hematoma with marker, measure the arm if applicable. Once bleeding stopped, then may apply sandbag or pressure dressing May call prep & recovery for assistance

9. Pseudoaneurysm Encapsulated hematoma that has branched off from the artery Call MD who may order a vascular ultrasound to diagnose Can be injected with thrombin by vascular surgeon or special procedures to resolve it Caused by inadequate compression or by the cardiologist’s technique (Beattie, 1999)

10. Retroperitoneal Bleeding Incidence is 0.15% (Sedlacek & Newsome, 2010) S/S- hip, back, & abd. pain, low bp unresponsive to fluid bolus, tachycardiac, drop in H&H, bruising. Call Md. Confirmed by CT scan. Transfer to ICU, blood transfusions, possible surgery.

11. Arteriovenous Fistula Rare complication if both artery and vein have been punctured. Blood flows directly from the artery to the vein causing pain, swelling, and purplish, bulging veins that look like varicose veins. Can cause heart failure if not treated. Hospital policy dictates that the arterial line is removed with hemostasis prior to removing the venous line to prevent an AV fistula. Fixed through a stent or OR.

12. Angiograms show arteriovenous fistula in the deep femoral artery before and after implantation of a covered stent. ( Thalhammer, Kirchherr, Uhlich, Waigand, & Gross, 2000 )

13. Radial Approach Less risk of complications but still at risk. The patient needs to use that hand minimally for 24 hours. No blood draws, bp’s or IV’s in that arm x 1 week. If hematoma is suspected, measure arm.

14. Contrast Induced Nephropathy Occurs between 1- 10% of all cases depending on preexisting conditions (Parfrey et al., 1989) Report any increase of creatinine to MD Protect the kidneys w/ mucomyst, IV fluids, Na bicarb.

15. Loss of Peripheral Pulses Check pulses with the groin checks For new onset of absent pulses, call Md immediately who will consult a vascular surgeon Pt needs to go to OR Occurs from a clot, or cholesterol breaking off. gla.ac.uk

16. Stroke Strokes rates after cardiac cath range from 0.03% to 0.3% (Lazar et al., 1995) Ischemic stroke can be caused by plaque that is dislodged during the cath or from thrombus on the catheters or guide wires. If a stroke is suspected, call rapid response team. healthmango.com

17. Your First Aid Kit Monitor groin and peripheral pulses. Monitor vital signs, labs, pain, restlessness, hematoma’s. Mark areas of swelling and measure arm if brachial or radial. Call prep & recovery for assistance or questions. Give IV fluids as ordered. Maintain bedrest or light activity with arm as ordered. Monitor bp and pulse while holding arterial pressure.

18. Discharge Instructions Radial’s-no blood draws or BP’s that arm x 1 week Femoral sheaths-may shower the next day, remove dressing and leave open to air, no lifting more than 5 lbs x 1 week. Closure devices-wait 24 hours for shower, apply clean band-aid daily until healed and no lifting more than 10 lbs x 3 days. Bruising may continue up to 1 week for all patients. (mmc.org)

19. Questions? Comments?

20. CASE STUDIES Now it is your turn to talk! Tell me stories of cases you have seen.

21. Case Study # 1 You received report from prep & recovery that your female patient had a negative cath, had a arterial sheath in the right groin that was removed at 0900 with hemostasis at 0930. The vital signs are: 130/76, SR 76. It is now 1030 and your patient just arrived on a stretcher. You couldn’t find the slide board so your co-workers and you pulled and tugged her over onto the bed. You check the groin and it is soft with no bruising. You come back to the room at 1100 and find the patient with both knees bent. What do you do?

22. Case study # 1 continued You check the groin and find a hard knot below the exit site. What happened? What do you do?

23. Case study # 1 continued You start pressing out the hematoma and the patient starts crying from the pain. What do you do? The hematoma resolves in 5 minutes. What do you teach the patient?

24. Case study # 1 continued You come back in one hour (because you had something else happen in another room) and find the swelling has returned and it is bigger! What do you do?

25. Case study # 1 continued You start pressing it out again and the patient says, “I don’t feel good. I am going to throw up.” What is probably happening? What do you do?

26. Case study #1 continued You put oxygen on, open up your IV fluids, immediately check the bp and pulse. The bp is 70/40 and the pulse is 56. If those things don’t work, what is next?

27. Case study #1 continued Atropine 0.6mg IVP quickly-you are covered with the post cardiac cath orders and you can override med from pixus.

28. Case study # 2 You receive report that your patient had a negative cath with a right radial access. The patient had a TR band on for 2 hours and air was gradually removed until the TR band was removed at 3 ½ hours at 1300. You receive the patient at 1330. The patient steps off the stretcher onto his bed. He is careful with not using his right arm or putting pressure on it. You check the radial and ulnar pulses and find both are strong and he has good capillary refill. You check him at 1430, he complains of some numbness in his fingers and pain. What might be going on?

29. Case study # 2 continued You check the pulses and there isn’t any change. You don’t see any swelling so decide to check it again soon. 1 hour later, you find that the arm has swelling above radial access site, on the forearm. What do you do?

30. Case study # 2 continued Measure swelling and mark it. Listen for bruit. You do not hear a bruit. What is the next step?

31. Case study # 2 continued Hold pressure on artery and try to press out the hematoma. Call MD

32. Case study # 2 continued The hematoma won’t press out. He is c/o pain, numbness & swelling. What do you think it is? What test might the doctor order?

33. Case study # 2 continued Vascular ultrasound to check for pseudoaneurysm. How would it be treated?

34. Case study # 2 continued Treated with thrombin injection by vascular surgeon or special procedures. What would the symptoms of an AV fistula be?

35. Case study # 2 continued Pain, tingling, numbness, and itching in the hand and arm with generalized edema. Pt has to go to OR or special procedures for stent.

36. Questions?

37. References Batyraliev, T., Ayalp, M. R., Sercelik, A., Karben, Z., Dinler, G., Besnili, F., Perchucov, I. (2005). Complications of cardiac catheterization: a single-center study. Angiology, 56, 75-80. doi: 10.1177/000331970505600110 Beattie, S. (1999, January). Cut the risks for cardiac cath patients. RN, 62(1), 50-55. Retrieved from http://www.rnjournal.com/http://www.rnjournal.com/ Herrada, B., Agarwal, J., & Abcar, A. (2005, Spring). How can we reduce the incidence of contrast-induced acute renal failure? The Permanente Journal, 9(3), 58-60. Retrieved from http://xnet.kp.org/permanentejournal/sum05/renal.pdfhttp://xnet.kp.org/permanentejournal/sum05/renal.pdf Lazar, J. M., Uretsky, B. F., Denys, B. G., Reddy, P. S., Counihan, P. J., & Ragosta, M. (1995, May 15). Predisposing risk factors and natural history of acute neurologic complications of left-sided cardiac catheterization. The American Journal of Cardiology, 75, 1056-1060. doi: 10.1016/S0002-9149(99)807424-3

38. References Parfey, P. S., Griffiths, S. M., Barrett, B. J., Paul, M. D., Genge, M., Withers, J.,...McManamon, P. J. (1989, January 19). Contrast material-induced renal failure in patients with diabetes mellitus, renal insufficiency, or both. New England Journal of Medicine, 320, 143-149. Retrieved from http://www.nejm.org.ezproxy.lib.ucf.edu/doi/full/10.1056/NEJM19890119320030 3 http://www.nejm.org.ezproxy.lib.ucf.edu/doi/full/10.1056/NEJM19890119320030 3 Sedlacek, M., & Newsome, J. (2010, May/June). Identification of vascular bleeding complications after cardiac catheterization through development and implementation of a cardiac catheterization risk predictor tool. Dimensions of Critical Care Nursing, 29(3), 145-152. doi: 10.1097/DCC.0b013e3181d24e31 Sanmartin, M., Cuevas, D., Goicolea, J., Ruiz-Salmeron, R., & Gomez, M. (2004). Vascular complications associated with radial artery access for cardiac catheterization. Revista Espanola De Cardiologia, 57(6), 581-584. Retrieved from http://www.revespcardiol.org/en http://www.revespcardiol.org/en

39. References Thalhammer, C., Kirchherr, A. S., Uhlich, F., Waigand, J., & Gross, M. (2000, January). Post catheterization pseudoaneurysms and arteriovenous fistulas: repair with percutaneous implantation of endovascular covered stents. Radiology, 214, 127-131. Retrieved from radiology.rsna.org