OBSERVATIONAL REPORT

ON
CARDIAC CATHETERIZATION
LABORATORY

SUBMITTED TO:

SUBMITTED BY:

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INTRODUCTION:
Cardiac Catheterization Laboratory is an examination room in a hospital or clinic with
diagnostic imaging equipment used to support the catheterization procedure. Cardiac
catheterization is the insertion of a catheter into a large artery, and various wires and devices
can be inserted through the body via the catheter which is inside the artery. The artery most
used is the femoral artery. the radial artery, as an alternative site (to introduce radiopaque dye
into a chamber or vessel of the heart.) This is done for both diagnostic and interventional
therapeutic purposes.

Myself Rumela Chakraborty from M.Sc Nursing 2 nd year (Medical Surgical Nursing)
was posted in Cardiac Catheterization Laboratory of B. M. Birla Hospital, Kolkata from
18/01/2021 to 12/01/2021 for Medical Surgical Nursing-II curriculum. In that week I have
learnt as per objective different procedures, staffing pattern of the nurses and role of different
members of the unit including physician, nurses, technicians and other members of the unit. I
have also learned the preparation of the procedure room, maintenance of registers,
preparation of the patient for the procedure and after procedure care of patient, the articles
used and the post procedure documentation.

OBJECTIVES
After the end of my posting, I am able to-

 Describe the physical setup of the Cath lab.

 State the organizational and staffing pattern of CATH LAB.
 List down the various activities carried out in various department of CATH LAB.
 List down the various facilities and resources available in the CATH LAB.
 Get the basic understanding about the preparation of unit before every procedure.
 Receive a patient and prepare for different procedures.
 Understand how to handle the machines.
 Monitor and observe for any complication during procedures going on.
 Provide necessary care during and after the procedures.

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  Integrate knowledge from nursing practice, medicine in nursing care of patients
undergoing procedures.
 Assist the staffs during starting and end of the procedures.

PHYSICAL SETUP
 The CATH LAB is situated in the 1st floor of B. M. Birla Hospital, Kolkata. near
CSSD
 1 reception area for receving the patients from various unit of hospital.
 3 Cath lab
 3 control room area
 1 doctor’s room.
 2 changing room for staff nurse (Male & Female).
 1 report typing room/ computer room.
 2 washrooms.

STAFFING PATTERN
Head of the department

Medical officer

Sister in-charge / Nurse Manager

Nursing staff

SERVICES AND PROCEDURES:

The cath lab provides a number of invasive procedures that enable a cardiologist to
check the heart and coronary arteries, measure blood flow and inter-cardiac pressure,
assess how well the heart valves work, and check for structural defects.
The procedures performed are categorized as either diagnostic or interventional.
Diagnostic procedures help the physician to determine the cause of a patient‟s
condition, while

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 interventional procedures attempt to cure the condition

Diagnostic

 CAG Coronary Angiography – ( Radial & Femoral) Insertion of a catheter into heart
to deliver contrast.
 Electrophysiology Testing OR Electro Physiological st – Tests electrical conduction
within the heart.
 Cardiac Cath (cardiac Catheterization)

 DSA ( Digital Subtraction Angiography )

 FFR ( Fractional Flow Reserve)

 Cardiac Shunt Detections – Blood flow analysis to identify a shunt.

 Structure Assessment and Confirmation – Verify structure of heart and veins.

 Intravascular Ultrasounds – Determine plaque buildup.

Interventional

 PTCA (Radial & Femoral) (Percutaneous Transluminal Coronary Angioplasty) –

Balloon insertion to open an obstructed artery.
 PTMC (Percutaneous Transluminal Mitral Commissurotomy)
 AICD/ ICD (Automated Implantable Cardioverter Defibrillator)
 CRT-D/ CRT-P (Cardiac Resynchronization Therapy Defibrillator/ Pacemaker)
 PGR (Pulse Generator Replacement)
 PDA D/C (Patent Ductus Arteriosus Device Closure)
 VSD D/C (Ventricular Septal Defect Device Closure)
 ASD D/C (Atrial Septal Defect Device Closure)
 BPV & BAV (Balloon Pulmonary Valvuloplasty & Aortic Valvuloplasty)
 Coil Embolization (PDA Coiling, MAPCA Coiling, cerebral coiling Aneurysm
coiling)

Other

 PPI ( Permanent Pacemaker Implantation) Pacemaker Implantations – Implant device

to regulate beating of the heart.

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  Internal Cardiac Defibrillator Implants – Implant device to jolt heart in case of
cardiac arrest.

EQUIPMENT USED IN CATHLAB:

1. ANGIOGRAPHY MACHINE SYSTEM: This machine system have single plane

X- Ray generator source (Fluoroscope) and an X- Ray image intensifier for
fluoroscopic imaging with hemodynamic monitoring system.

MACHINE USED IN BMB CATHLAB:

1. Phillips Allura X per FD10C (Lab-1)

2. Ge- Innova IG520 (Lab-2)
3. Phillips Allura clarity (Lab-3)

2. PRESSURE INJECTOR: A high pressure contrast media injector is needed to

administer the large bolus od contrast media into the ventricle, pulmonary artery,
aortic arch etc.
3. DEFIBRILLATOR: A defibrillator is a life saving device. It is use to give shock
during cardiac arrest (VT/ VF) and also ECG monitoring purpose. In cathlab
defibrillator should be changed and checked daily.
4. VENTILATOR:
5. SYRINGE PUMP:
6. ACT MACHINE:
7. CRASH TROLLY & MEDICINE TROLLY:
8. STERILE EQUIPMENTS:

PLANNING CONSIDERATIONS:

 Planning a catheterization laboratory depends on various factors like the, the need for
interventional procedures, types of angiography procedures, building size, and the
budget available for equipment and running costs.
 Usually the suppliers of the angio-equipment will play an integral part in planning and
developing a catheterisation laboratory.

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  Cath lab planning is also based on projected volumes for inpatient and outpatient
volumes.
 Workload aggregated into average procedure time and distribution between inpatient
and outpatient volume.

CAG CORONARY ANGIOGRAPHY:

Coronary angiography remains the gold standard for detecting clinically significant
atherosclerotic coronary artery disease The technique was first performed by Dr. Mason
Sones at the Cleveland Clinic in 1958.

GOALS:

 To visualize coronary arteries, branches, collaterals and anomalies

 Precise localization relative to major and minor side branches, thrombi and areas of
calcification

 To visualize vessel bifurcations, origin of side branches and specific lesion

characteristics (length, eccentricity, calcium etc).

INDICATION

1. Diagnosis of CAD in clinically suspected pts.

2. Providing peri-interventional information for percutaneous coronary intervention

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 3. Coronary anomalies
4. To exclude stenoses before non-coronary cardiac surgery (valve surgery after 40 yrs
of age)
5. Determine patency of coronary artery bypass grafts
6. In patients with non–ST-segment elevation acute coronary syndromes with high-risk
features (e.g., ongoing ischemia, heart failure)
7. In patients with acute ST-segment elevation myocardial infarction (STEMI)
8. Primary percutaneous intervention (PCI) is usually performed in the same procedure,
immediately after the diagnostic procedure.

CONTRAINDICATIONS:

- Coagulopathy
- Decompensate congestive heart failure
- Uncontrolled Hypertension
- CVA
- GI Hemorrhage
- Pregnancy
- Inability for patient cooperation
- Active infection
- Renal Failure
- Contrast medium allergy

RESPONSIBILITIES BEFORE THE PROCEDURE:

• After patient is properly identified, the procedure must be explained before consent can be
signed.

• Baseline vital signs will be done and as long as these are within the doctor’s interest, can
proceed with the procedure

• Blood tests must be done including BUN, creatinine, PTT, INR, insulin/sugar levels.

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LIST OF ITEMS AND EQUIPMENT:

- sterile drapes to cover the patient and radiation-protection screens,

- sterile swabs for cleaning the arterial access site,

- a bowl of Betadine solution for cleaning the arterial access site,

- lidocaine for local anesthesia, 15-20 ml of 2% solution (in some cases, for more sensitive
patients, more may be needed)

- punction neelde for arterial cannulation,

- an 11-mm or 15-mm blade, - syringes and needles,

- two containers, one with 500 ml of saline solution with 5,000 U of heparin added, - arterial
sheath with a dilator,

- a J-shaped guidewire,

-diagnostic catheters for coronary angiography; start with the most common JL4 and JR4
with angulated pigtail if left ventriculography and/or aortography is planned,

- a three-outlet manifold which is to be connected to pressure transducer, saline solution

container, and radiocontrast container on side-outlets, to the syringe for radiocontrast
application on the proximal end, and with its distal end to diagnostic/therapeutic catheters
during the procedure.

PATIENT PREPARATION:

• After patient is put on table, the area being puncture must be free from hair

• Hair removal done by disposable electric razor and removed by sticky side of cloth tape

• Patient must be surgically cleaned with hospital approved sterile surgical prep solution.

• The scrub nurse working with the cardiologist must be scrubbed in following basic sterile
surgical technique

• The patient is then draped from neck down with sterile drapes

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• All equipment (radiation shields, image intensifier, equipment used to manipulate machine)
must be prepped with sterile covers.

Fig. The patient in supine position on the cardio-angiograph table

PROCEDURE:

- Coronary angiography is performed under local anesthesia. The procedure is sterile,

and all potential access sites must be disinfected, shaved, and sterilized.
- At the beginning of the procedure, the patient lays down in supine position on the
cardioangiograph table, and is prepared for the procedure in sterile conditions
- During the procedure, the patient must be monitored by several systems, and the ECG
is absolutely essential.
- The patient also must have an ECG recording done just before the procedure actually
starts.
- For practical reasons, during the angiography itself, there is really no need to apply
the precordial leads, since the basic four electrodes can provide enough information
for ECG monitoring during coronary angiography and percutaneous coronary
interventions (PCI).
- Four electrodes should be placed on the calf or thigh and on the shoulders or upper
arms .
- The area of the puncture site must be shaved, disinfected, then anesthetized, and only
then punctured.
- The center of the field for shaving and disinfection is the puncture site.
- The disinfection is performed starting at the center, and spiraling outwards, at least
twice, using Betadine.
- Thereafter, the site is wiped off with a third swab.

- If the procedure is planned to be performed via the femoral artery, than both right and
left groins must be shaved and disinfected, in case that the operator must switch to
contralateral artery. In case of redial artery then both hand must be disinfected.

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 - Only after the disinfection of the puncture site, the patient is covered with a sterile
drape. Most centers today use single-use pre-packed sterile drapes.
- These drapes have openings conveniently placed at the location of patient's left and
right inguinal area.
- pressure monitoring.

POSSIBLE COMPLICATIONS

• Femoral : Dissection of femoral / iliac artery or aorta , Haematoma

• Aorta : Damage to aortic intima , Embolus to head and neck vessels, aortic root dissection.

• Coronary : Ostial dissection, coronary embolus, arrhythmia due to catheter wedging or

contrast medium, spasm due to catheter or contrast medium.

• General : Hypotension, left heart failure – contrast overload, Contrast allergy

PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY

(PTCA):

PTCA Is performed to open blocked or narrowed coronary arteries caused by coronary artery
disease (CAD) and to restore arterial blood flow to the heart tissue without open heart
surgery.

PROCEDURE:

 A special catheter is inserted into the coronary artery to be treated in the femoral
artery in the groin
 First a guide wire is inserted and then a catheter which injects a dye.
 This catheter has a tiny balloon as its tip

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  The balloon is inflated once the catheter has been placed into the narrowed area of
the coronary artery

 The inflation of the balloon compresses the fatty tissue in the artery and makes a
larger opening inside the artery for improved blood flow

STENT PLACEMENT:

 It is s a procedure used in PTCA

 A tiny, expandable metal coil (stent) is inserted into the newly opened area of the
artery to help keep the artery from narrowing or closing again.

PERMANENT PACEMAKER IMPLANTATION:

Permanent pacemaker implantation, this procedure was only performed by the cardiac
surgeons because of the initial mandate for epicardial lead implantation. Further
advancements in the pacing hardware and percutaneous venous catheterization simplified the
implantation technique and made it feasible to implant the transvenous leads. Simultaneously,
further innovations in the pulse generator and its circuitry extended the utility of the
percutaneous technique even in the very young patients.

EQUIPMENTS

- The pacemaker implantation can be performed in electrophysiology (EP) laboratory,

catheterization laboratory, or operating room.
- Pacemaker implantation by interventional electrophysiologist in EP lab or
catheterization laboratory resulted in a significant reduction in medical cost and
hospital stay.
- Minimum required personnel for pacemaker implantation consist of implanting
physician, scrub nurse, and circulating nurse or technician.
- Scrub nurse is required to help the implanter throughout the procedure.
- The circulating nurse or technician is required to prepare and administer medications,
and to operate pacing system analyzer

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PATIENT PREPARATION :

- Before pacemaker implantation, an informed consent should be obtained.

- Any anticipated risks and benefits should be honestly discussed with patient or the
patient’s family.

- The indication for pacing should be thoroughly described to the patient.

- The need for lifelong follow-up should be emphasized and patient should be
informed about the generator change and possible lead replacement in the future.

- Any physical or occupational restrictions related to the pacemaker implantation

including rules regarding the driving should be discussed in detail with the patient.

- Routine pre-implant lab tests are 12-lead ECG, chest x-ray, complete blood count,
prothrombin and partial thromboplastin times, serum electrolytes, blood urea nitrogen,
and serum creatinine.

CONCLUSION:

The cath department is an important part of any hospital for several reasons. First, coronary
catheterization one of the most common interventional procedures practiced, which leads to
high volumes and high revenues. Second, the procedures conducted in a cath lab are far less
invasive than those performed in the operating room, which means that patients can often be
treated as outpatients, which results in reduced costs for the hospital.

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