The Procedure and Procedural Care Tortorici Chapter 19 Pre-procedure * Interview patient, take Hx * Signed informed consent * 4-8 hour fast with water * Stop anticoagulant therapy * Start heparin 4 hours prior and continue 6-24 hrs. after Protomine Sulfate (coagulant) for heparin OD Lab tests * BUN/Creatinine * Clotting factors: Prothrombin time (PT) Partial Thromboplastin time (PTT)

Pre-procedure sedation Conscious sedation * Valium (diazepam): a benzodiazepine * Demerol: a synthetic opioid * Narcan: for opioid OD

Procedure * Establish rapport with patient * Review chart * Baseline vitals/neurologic tests Vitals Adult BP = Elderly BP = Pulse = (rate, rhythm, volume) Respiration = Temp. = 90/60 - 140/90 140/92 – 170/100 55-90 ¼ pulse or 12-20 97.6, 98.6, 99.6

Procedure * Establish rapport with patient * Review chart * Baseline vitals/neurologic tests * Vitals/neurologic tests * Take scouts * Prep injection site * Drape * Needle puncture and catheter placement

Introducing the Catheter

Lumen Arterial Anatomy Tunica Adventitia Tunica Media (muscular) Elastic, fibrous tissue See Chapter 10 Tunica Intima (Endothelium)

The Judkins Technique of Catheterization Utilizing the Seldinger Technique of Arterial Puncture Cecum of colon Ala (wing) of ilium Coronal MRI demonstrating the femoral artery pulse point, where arterial puncture is most commonly performed Uterus Thigh muscle Bladder Adipose of thigh (white on MRI) Original

Cannula Stylet Seldinger Needle Stylet, with beveled point down, is inserted into cannula for puncture

Disposable needle used for femoral puncture Cannula Disposable needle used for femoral puncture Stylet Aids insertion of wire into hub of cannula Guide wire: Teflon wrapped wire used to introduce and manipulate catheter. This wire has a J tip to skim over the intimal lining with minimal damage. Pushing from the other end, the solid wire core is advanced to stiffen the tip for better control.

Seldinger Technique of Arterial Puncture 1. Lidocaine injection 2. small incision 3. spread with misquito forceps 4. needle in incision, pulse felt 5. 45o cephalad, 25-30 medial Original method: front and back wall of the artery is punctured. to lessen the risk of introducing the guide wire into the wall and dissecting the vessel. The risk hematoma forming from the hole in the back wall is minimal.

Seldinger Technique of Arterial Puncture 6. The stylet is removed 7. Cannula is withdrawn, arterial return of blood

Judkins Technique of Arterial Catheterizaton Guide Wire 8. Tilt needle, insert guide wire

Judkins Technique of Arterial Catheterizaton 9. The cannula is removed. Arterial bleeding stops as the puncture site forms a seal around the guide wire

Judkins Technique of Arterial Catheterizaton 10. Dilate puncture site with a vessel dilator 11. A sheath is inserted to protect the puncture site during catheter changes and manipulations

A sheath A vessel dilator for widening the puncture hole to accommodate a larger catheter Guide wire

Judkins Technique of Arterial Catheterizaton 12. The catheter is threaded through the sheath The catheter is then advanced through the iliac arteries, up the abdominal and thoracic aorta.

Procedure * Establish rapport with patient * Review chart * Baseline vitals/neurologic tests * Vitals/neurologic tests * Take scouts * Prep injection site * Drape * Needle puncture and catheter placement * Hook up manifold

Manifold connected to catheter forms a closed system Strain gauge transducer Contrast Heperinized Saline flush Waste fluid Systolic pressure measured through the catheter in the left ventricle. Manifold Syringe for hand injections of contrast and flushing catheter

Procedure * Establish rapport with patient * Review chart * Baseline vitals/neurologic tests * Vitals/neurologic tests * Take scouts * Prep injection site * Drape * Needle puncture and catheter placement * Hook up manifold * Set filming and injector parameters * Position patient * Film a run

Intraprocedural Care Document * Catheter in/out time * CM volume * Meds * Fluoro time * Hemodynamic pressures * Instruments used Monitor * Vitals * ECG (EKG) * 02 (90% saturation)

Postprocedural Care * Remove catheter * Apply pressure (direct, mechanical device, closure device) * Final vitals/pedal pulse If admitted Overnight bedrest Monitor vital, pressure dressing, pedal pulse Hydrate

Complications * Embolus/thrombus * Internal hemorrhage * Hematoma at puncture site * Cardiac events * Vessel dissection * CM reaction