Cathlab Manual

CATHLAB MANUAL
DATE OF
ISSUE
ISSUE NO
APPROVED
BY MEDICAL DIRECTOR
1|Page
CONFIDENTIALITY NOTICE AND DISCLAIMER
These documents are confidential and a property of SRM Hospitals, Ramapuram, Chennai. These policies
and guidelines have been prepared specifically for stakeholders, process owners and other staff of SRM
Hospital, to enable them to carry out their day today duties.
SRM Hospital has exercised reasonable care in the preparation of contents. These policies and procedures
cannot replace a physician’s independent judgment about the appropriateness of risks of a procedure but
is intended to serve only as process guidelines.
Any photocopying or duplication of this manual by a third party person is strictly prohibited and shall be
liable for legal action.
ISSUE NO
ISSUE DATE
AMMENDMENT NO
Preparation Approval Issue
SIGNATURE SIGNATURE SIGNATURE
2|Page
Table contents:
S.NO PARTICULARS PAGE NO

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Amendment sheet:
S.N PAGE SECTION/ DATE OF AMENDME REASONS AMEND SIGNAT

O NO. CLAUSE/ AMENDME NT MADE OF MENT URE OF
PARA/LINE NT AMENDM MADE THE
ENT BY PERSO
N
AUTHO
RIZING
AMEND
MENT
3|Page
1. Guideline For Using Amendment Record Sheet:
Amendments made in QSM/ Quality Improvement Manual / Departmental manuals from time to time will be
traced through the Amendment Record sheet maintained in the respective Department manuals. Amendment
Record sheet will show the current Amendment No. & Amendment date. The arrangement of the Amendment
details would be such that the latest amendment (decided by Date) will be mentioned first followed by the other
Amendments arranged in the reverse chronological order and the first Amendment will be shown as the last
item. Whenever the issue changes for any of the reasons mentioned above, the Amendment Record Sheet will
start afresh, not indicating the amendments made in the previous issue. The previous issued document will be
stamped as obsolete and retained under the custody of the NABH Coordinator.
1.1 Control of Issue Number & Amendment Number
a. Any new document like QSM, Quality Improvement Manual, and Departmental Manual issued for
the first time shall have ‘Issue No. 01’ and ‘Amendment No. 00’ with an ‘Issue Date’ only and no
‘Amendment date’. Any change in the document will be reflected in ‘Amendment Number’. The
‘Issue No.’ and ‘Issue date’ will remain the same.
b. The Cover page / Top Sheet of such a manual shall have the same ‘Issue No. 01’ with the same
Issue Date
c. For Example, whenever there is a change in a document or a complete section of the document,
having an ‘Issue No. 01’ and ‘Amendment No. 00’, the new amended document will have the
same ‘Issue No. 01’ but, the ‘Amendment No.’ becomes 01, indicating the ‘Date of Amendment’.
d. The detail of the amendment is recorded in the respective amendment record sheet.
e. Whenever any document is re-issued, the issue number is increased incrementally by 1. For
example, if ‘Issue No. 01’ is re-issued, the next issue will be ‘Issue No. 02’. The Amendment No.
reverts to Amendment No. 00 in such cases. The circumstance under which there is fresh issue of
documents is mentioned below. This is only an illustrative one and the issuing authority has
powers to define a new issue.
f. The ‘Issue No.’ of any Manual or Document will change only whenever:
There is a change in the requirements of the NABH standard, either in part or whole.
Periodical review of manual / document (once in a year)
4|Page
Major change in the scope of accreditation
Major Change in the document control procedure
Abbreviations:
S.No Abbreviations Expansion
Policy on intra aortic balloon pump management

1. Purpose
1.1 Intra-aortic balloon pump (IABP) therapy is designed to increase coronary artery,
increase systemic perfusion, decrease myocardial workload and decrease afterload.
2. Policy
2.1 A trained registered nurse assists in the procedure. Patients on IABP will be managed by
a nurse who is ICU trained
5|Page
3.Equipment
3.1 IABP, gas supply.
3.2 ECG and arterial pressure monitoring supplies.
3.3 IAB catheter (size range 8 to 10 Fr for adults; balloon catheters vary in balloon volumes.)
3.4 IAB catheter insertion kit.
3.5 Povidone-iodine solution sterile gowns, gloves and drapes.
3.6 Sterile dressing supplies.
3.7 O-silk suture on a cutting needle, used to suture catheter to skin.
3.8 Number – 11 scalpel, used for skin entry.
3.9 1% lidocaine without epinephrine, one 30 - mL vial.
3.10 Stopcocks, one 2-way and one 3-way.
3.11 One luer-lok plug.
3.12 500 mL normal saline with 1000 units of heparin or the flush solution recommended
according to institution standards.
3.13 Hemodynamic monitoring tubing with transducer.
3.14 Analgesics and sedatives as prescribed.
3.15 Lead apron (needed if procedure is performed using fluoroscopy)
3.16 Prescribed intravenous (IV) solutions.
3.17 Emergency medications and resuscitation equipment.
3.18 Additional equipment to have available depending on patient status includes the
following.
3.19 Vasopressors as prescribed.
3.20 Antibiotics as prescribed.
3.21 Heparin infusion or dextran if prescribed.
6|Page
4. Procedure
4.1 Procedure for assisting with IAB Catheter Insertion.
4.2 Wash hands and don caps, goggles, masks, sterile gowns and gloves for all health care
personnel involved in the procedure.
4.3 Turn on gas supply.
a. Activates the gas driving the balloon pump.
b. Check manufacturer’s recommendations.
4.4 Sedate the patient as needed; the affected extremity may need to be restrained.
a. Movement of the lower extremity may inhibit insertion of the catheter or contribute
to catheter kinking once the IAB is in place.
b. A sheet placed over the affected leg and tucked in or a knee immobilizer may
minimize movement of the affected leg.
4.5 Establish ECG input to IABP console and obtain ECG configuration with optimal ECG
configuration with optimal R wave amplitude and absence or artifact. Indirect ECG input
can be obtained via “slave” of bedside ECG to IABP console.
a. The R wave, QRS complex or arterial pressure waveform may be the trigger for
balloon inflation and deflation. Patient cable from console establishes ECG.
b. A secondary ECG source is desirable in the event of lead disconnection or loss of

trigger. Review manufacturer’s instructions for selecting the appropriate trigger
control. If the patient has a pacemaker, the trigger should be set to reject the
pacemaker artifact.
4.6 Assist with placement of hemodynamic monitoring lines if they are not already present.
4.6.1 Hemodynamic monitoring is necessary for assessment and management of the

patient requiring IABP therapy.
4.6.2 A radial arterial line is commonly inserted. The arterial line tracing is used to
access and optimize timing and also may be used as a trigger source.
7|Page
4.7 Complete IABP console preparation.
a. Ensures adequate functioning if the IABP device.
b. Models of the pump console vary. Review of manufacturer’s instructions is

recommended.
4.8 Remove IAB catheter from sterile packing and place the catheter and insertion tray on the
sterile field.
a. Makes supplies available while maintaining sterility. Select the most appropriate size
of balloon catheter. Most adult balloons are 40 ml in size. However, smaller balloon
volumes (30 to 34 ml) are commonly placed in adults 5 ft 4 in and under, whereas
larger balloon volumes (50 ml) are commonly placed in adults 6 ft and taller.
b. Catheters vary in volume of the balloon. An adequate volume is necessary to achieve

optimal hemodynamic effects from IABP therapy.
4.9 Administer heparin bolus before arterial puncture, if prescribed.
a. Anticoagulation may decrease the incidence of thromboemboli related to the

indwelling IAB catheter.
b. Systemic anticoagulation may not be used in all patients.
4.10 Attach the supplied one-way valve to the Luer tip of the distal end of the balloon lumen.
a. Creates a device for air removal from the balloon catheter.
b. Maintains wrap of balloon for insertion.
4.11 Pull back slowly on the syringe until all air is aspirated.
a. Removes air from the balloon, creating a vacuum.
4.12 Disconnect the syringe only.
a. Prevents air entry back into the balloon.
b. Leave the one-way valve in place.
4.13 Lubricate the IAB catheter with sterile saline.
a. Decreases “drag” on the catheter during insertion.
8|Page
4.14 The central lumen of the IAB catheter should be flushed with heparinized saline before
insertion.
a. Removes air from the central lumen.
b. If the catheter is not flushed before insertion, allow backflow if arterial blood before
connection to the flush system.
4.15 Assist with introducer sheath or dilator assembly and insertion.
a. Prepares for balloon catheter entry.
b. Some IABs are inserted without a sheath. If the IAB is inserted via the sheath less
method, only the dilator will be used.
4.16 Assist with balloon catheter insertion.
a. Catheter placement is a necessary part of IAB setup.
4.17 Assist with removal of the one-way valve according to manufacturer’s recommendations.
a. Release the vaccum and readies the balloon for counter pulsation.
4.18 If the central lumen of a double-lumen catheter is used to monitor arterial pressure, attach
a three-way stopcock with continuous heparinized flush and transducer to the monitor.
Set the alarms.
a. Monitors arterial pressure.
b. The central lumen, if used must be attached to an alarm system because undetected
disconnection could result in life-threatening hemorrhage.
4.19 Avoid fast flush and blood sampling from the central aortic lumen.
a. Air may enter the system during fast flush and also during blood sampling, resulting
in air emboli.
b. Some manufacturers and institutions recommend hourly manual flush of central

lumen lines. If fast flush is required, ensure that the IABP is “on standby” (not
pumping) during the flush. However, the risk of air embolus entry or dislodging a
thrombus at the lumen tip is a major concern.
4.20 Attach the balloon-lumen tubing to the pump console.
9|Page
a. Attachment is necessary because the console programs and operates balloon counter
pulsation.
4.21 Follow steps for timing, troubleshooting, and patient monitoring.
a. Provides for appropriate operation of counter pulsation.
b. Many IABP consoles have features for automatic timing. Refer to specific
manufacturer instructions.
4.22 Zero the pressure transducer.
a. Ensures accurate arterial pressure measurement, timing, maintenance and functioning

of the IABP.]
b. Refer to specific manufacturer instructions.
4.23 Obtain a portable chest X-ray as soon as possible.
a. Correct IAP catheter position must be confirmed to prevent complications associated

with interference of the arterial blood supply.
b. If fluoroscopy is used for insertion of the catheter, an X-ray immediately after

placement is not necessary.
4.24 Apply a sterile dressing to the catheter insertion site.
a. Allows for aseptic management.
4.25 Remove and discard personal protective equipment and wash hands.
4.2 Procedure for Timing of the IABP
1) Select an ECG lead that optimizes the R wave and decreases artifact.
a. The R wave is usually used to trigger the balloon.
b. An alternate trigger can also be used if necessary.
2) Time the IABP using the arterial waveform.
a. The arterial waveform assists in identifying accurate IAB inflation and deflation.
b. Refer to specific manufacturer instructions for automatic timing.
3) Set the IABP frequency to the every other beat setting (1:2 or 50%).
10 | P a g e
a. Comparison can be made between the assisted and unassisted arterial.
4) Inflation
a. Identify the dicrotic notch of the assisted systolic waveform.
i. The dicrotic notch represents closure of the aortic valve.
b. Adjust inflation later to expose the dicrotic notch of the unassisted systolic
waveform.
i. Identifies landmark for accurate inflation.
c. Slowly adjust inflation earlier until the dicrotic notch disappears and a sharp V wave
forms.
i. Balloon augmentation should occur after the aortic valve closes.
ii. A sharp V wave may not be seen in patients with low systemic vascular
resistance.
d. Compare the augmented pressure with the patient’s unassisted systolic pressure.
i. Balloon augmentation should be equal to or greater then the patient’s unassisted

systolic blood pressure.
ii. If balloon augmentation is less than the patient’s systolic pressure, consider that
the balloon is positioned too low, the patient is hypovolemic or tachycardia, or
the balloon volume is set too low.
5) Deflation
a. Identify the assisted aortic end-diastolic pressures and the assisted and unassisted
systolic pressures.
i. These landmarks are important in determining accurate IAB deflation.
b. Set the balloon to deflate so that the balloon-assisted aortic end-diastolic pressure is
as low as possible (lower that the patient’s unassisted diastolic pressure) while still
maintaining optimal diastolic augmentation and not impending on the next systole
(the assisted systole.)
11 | P a g e
i. The assisted systolic pressure will be less than the unassisted systolic pressure as
a result of a decrease in after load, thus
6) Set the IABP frequency to 1:1 (100%)
i. Ensures accurate timing and optimal functioning of the IABP.
4.25.1 Problem: Early inflation. Intervention: Move Inflation later.
i. Inflation occurs before closure of the aortic valve, leading to

premature aortic valve closure, increased left ventricular volume, and decreased
stroke
4.25.2 Problem: Late inflation. Intervention: Adjust Inflation earlier.
i. A delay in inflation leads to a decrease in coronary artery perfusion.
4.25.3 Problem: Early deflation. Intervention: Adjust deflation later.
i. Deflation occurs before the aortic valve opening, leading to low balloon
augmentation and less or no after load reduction; coronary artery perfusion may
also be decreased.
ii. Note the sharp diastolic wave after augmentation and the increase in the assisted
systolic pressure.
4.25.4 Problem: Late deflation. Inflation: Adjust deflation earlier.
i. Deflation occurs after the aortic valve has opened, leading to an increase in the
aortic end-diastolic pressure and an increase in after load.
ii. Note the delayed diastolic wave after augmentation and the diminished assisted
systole. If using the real – time method of timing, late deflation is not identified
by changes in the aortic end-diastolic pressure but is identified by diminished
assisted systolic pressure, increase in heart rate, increase in filling pressures, and
decrease in cardiac output and cardiac index.
4.3 Procedure for Balloon Pressure Waveform
1. Determine if the IABP console has a balloon pressure waveform.
a. Hellium is shuttled in and out of the IAB catheter, and the balloon pressure waveform
represents this movement.
12 | P a g e
b. Refer to specific manufacturer instructions regarding the balloon pressure waveform.
2. Assess the balloon pressure waveform.
a. Reflects pressure that is in the IAB.
3. Determine if the balloon pressure waveform is normal. A normal balloon pressure waveform.
i. A normal balloon pressure waveform reflects that the IAB is inflating and deflating
properly.
A. Has a highly pressure (baseline pressure) slightly above zero.
a. Reflects pressure in the tubing between the IAB and the IABP driving
mechanism.
B. Has a sharp upstroke.
a. Occurs as gas inflates the IAB catheter.
C. Has peak inflation artifact.
a. This overshoot pressure artifact is caused by gas pressure in the pneumatic

line.
D. Has a pressure plateau.
a. This plateau is created, as the IAB remains inflated during diastole.
b. The plateau indicates the length of time of inflation as well as whether full
inflation (volume) has been delivered to the IAB. If there is no plateau
pressure, the IAB may not be fully inflated.
E. Has a rapid deflation.
a. Gas is quickly shuttled from the IAB.
F. Has a negative deflection below baseline, then returns to baseline.
a. Gas returns to the IABP console, then stabilizes within the system.
4. Compare the balloon pressure waveform with the arterial pressure waveform. Note the similarity
in the width of the balloon pressure waveform and the augmented arterial waveform.
a. Demonstrates the relationship between the balloon pressure waveform. Reflects

the effect of the balloon on the augmented arterial pressure.
13 | P a g e
5. Determine if the balloon pressure waveform does not meet the description above.
a. Abnormally balloon pressure waveforms may indicate problems with the IAB or
the IABP console.
b. Refer to specific manufacturer instructions regarding troubleshooting abnormal

balloon pressure waveforms.
4.4 Procedure for Troubleshooting
1. Atrial Fibrillation: Set the IABP to inflate and deflate the majority of the patient’s beats.
a. IABP therapy will not be 100% effective during atrial fibrillation (AF) because of the
irregular rhythm.
b. The underlying cause of the AF should be treated. IABP’s will automatically deflate the
balloon on the R wave. Use the atrial fibrillation trigger mode or the R wave deflation
mode. The real-time method of timing may track dysrrhythmias better than traditional or
conventional IABP timing.
2. Tachycardia: change the IABP frequency to 1:2
a. Because diastole is shortened during tachycardia, the balloon augmentation time is

shortened. Pumping every other beat may improve MAP.
b. The underlying cause of the tachycardia should be treated.
3. Asystole:
A. Switch trigger to arterial pressure.
a. This trigger can be used if there is at least a 15-mm Hg rise in arterial pressure.
b. Refer to the manufacturer’s manual for this information because the minimum mm
Hg needed to use this feature varies.
B. Set inflation to provide diastole augmentation and set deflation to occur before upstroke
of the next systole.
a. Programs the machine for appropriate preset timing.
b. Preliminary research suggests that when used during cardiopulmonary resuscitation,

IAB counterpulsation increases cerebral and coronary perfusion.
14 | P a g e
C. If chest compressions do not provide an adequate trigger.
a. Turn to internal trigger.
b. The internal trigger will keep the catheter moving so clot formation is minimized.
c. Set the rate at 60 to 80 beats per minute.
a. Maintains consistent movement of IAB catheter.
d. Set the IABP frequency to 1:2.
a. A 1:2 frequency is adequate to prevent thrombus formation on the IAB catheter.
i. Turn the balloon augmentation down to 50%.
a. Slight inflation and deflation of the IAB catheter will prevent clot formation
4. Ventricular tachycardia or ventricular fibrillation.
A. Ensure that personnel are cleared from the patient and equipment before carioverting or
defibrillating.
i. Prevents spread of energy to health care personnel. Maintains electrical safety.
B. Cardiovert or defibrillation as necessary.
i. Converts rhythm.
5. Loss of vacuum or IABP failure
A. Check and tighten connections on pneumatic tubing.
i. A loose connection may have contributed to loss of vaccum.
B. Check the compressor power source.
i. Ensures that power is available to drive helium.
C. Hands inflate and deflate the balloon every 5 minutes with half the total balloon
volume if necessary.
i. Prevents clot formation along the dormant balloon.
D. Change the IAB console.
i. Establishes power source and effective IABP therapy.
6. Suspected balloon perforation.
15 | P a g e
A. Observe for loss of augmentation.
i. Gas may be gradually leaking from the balloon catheter.
ii. Always set the alarms so the alarm will sound if there is a 10-mm Hg drop in diastolic
augmentation.
B. Check for blood in the catheter tubing.
i. Blood in the tubing indicates that the balloon has perforated and that arterial
blood is present.
ii. It is possible for a balloon leak to be self-sealing as a result of the surface tension
between the inside and the outside of the IAB membrane. This may be evidenced by
the presence of dried blood in the catheter tubing. The dried blood may appear as a
brownish, coffee-ground-like substance.
C. Assess for changes or lack of normal balloon pressure waveforms.
i. The balloon pressure waveform may be absent if the balloon is unstable to retain gas,
or the pressure plateau may gradually decreasing if the IAB is leaking gas.
7. Balloon perforation.
B. Place the IABP on standby.
i. Prevents further IAB pumping and continued gas exchange.
ii. Some IABP consoles will automatically shut off if a leak is detected. The IAB
catheter should be removed within 15 to 30 minutes.
C. Clamp the IAB catheter.
i. Prevents arterial blood back up.
D. Disconnect the IAB catheter from the IABP console.
i. Prevents blood from backing up into the IABP console.
E. Notify the physician.
i. The IAB catheter will need to be removed or replaced immediately.
ii. If the IAB leak has sealed itself off, this may result in entrapment of the IAB in
the vasculature. Surgical removal may be required.
16 | P a g e
F. Prepare for IAB catheter removal or replacement.
i. The IAB catheter should not lie dormant for longer than 30 minutes.
G. Discontinue anticoagulation therapy.
i. Clotting will occur more readily if anticoagulation is stopped (necessary if

removing the catheter.)
4.5 Procedure for Weaning and IAB Catheter Removal.
1. Assess clinical readiness for weaning.
a. Optimal clinical and hemodynamic parameters validate readiness for weaning.
b. Patient hemodynamic status should be optimal before weaning of IABP therapy.

Signs of clinical readiness include the following: no beats per minute, absence of
lethal or unstable dyshythmias, MAP greater than 70 mm H with minimal or no
vasopressor support, PAWP less than 2.4, mixed venous oxygen saturation
between 60% and 80%, capillary refill less than 2 seconds, and urine output
greater than 0.5 mL/kg per hour.
2. Change assist ration to 1:2 and monitor patient response for 1 to 6 hours or as noted
per institution’s protocol.
a. Length of time required to wean from IABP therapy depends on hemodynamic

response of patient and length of time patient has been receiving IABP therapy.
3. If hemodynamic parameters remain satisfactory further change ratio from 1:3 to 1:8
(depending on patient and balloon console assist frequencies, or as prescribed.)
a. IABP consoles vary in assist ratios.
b. Refer to the institution’s on weaning procedures.
4. Discontinue heparin or dextran 4 to 6 hours before IAB catheter removal, or reverse

heparin with protamine (as prescribed) just before catheter removal).
a. This will decrease the likelihood of bleeding after balloon removal.
5. Turn the IABP to standby or off.
a. Ensures deflation of IAB catheter.
17 | P a g e
6. Assist the physician or advanced practice nurse with removal of the percutaneous
balloon.
a. Facilities removal.
7. Ensure that pressure is held on the insertion site for 30 to 45 minutes after the IAB
catheter is withdrawn. Ensure that hemostasis is obtained.
a. Decreases the incidence of bleeding and hematoma formation.
8. Assess insertion site for signs of bleeding or hematoma formation before application
of a sterile pressure dressing.
a. Assists in the detection of bleeding.
9. Apply pressure dressing to the insertion site for 2 to 4 hours.
a. Minimizes bleeding from the insertion site.
10. Monitor vital signs and hemodynamic parameters every 15 minutes x 4, every 30
minutes x 2, then every hour as the patients condition warrants.
a. Validates patient stability or identifies hemodynamic compromise.
11. Assess the quality of perfusion to the decannulated extremity immediately after
removal and a very 1-hour x 2 then every 2 hours.
a. Removal of the IAB catheter may dislodge thrombi on the catheter and lead to
arterial occlusion.
12. Maintain immobility of decannulation extremity and bed rest with the head of the bed
no greater than 30 degrees for 8 hours.
a. Promotes healing and decreases stress at the insertion site
5.0 DOCUMENTATION
5.1 Patient and family education and response to education.
5.2 Insertion of IAB catheter (including size of catheter used and balloon volume.)
5.3 Peripheral pulses and neurovascular assessment of affected extremity.
5.4 Any difficulties in insertion.
18 | P a g e
5.5 IABP frequency.
5.6 Patient toleration.
5.7 Confirmation of placement (eg. Chest X-ray).
5.8 Insertion site assessment.
5.9 Hemodynamic status.
5.10 IABP pressures (unassisted systolic pressure, balloon augmented pressure, assisted
systolic pressure, assisted end-diastolic pressure, and MAP)
5.11 Occurrence of unexpected outcomes.
5.12 Additional nursing interventions taken.
Patient Monitoring and Care.
Patient Monitoring and Care Rationale Reportable Conditions
1. Perform systematic
cardiovascular, peripheral
vascular and hemodynamic
assessments every 15 to 60
minutes, as patient status
requires.
a. Level of consciousness.
a. Change in level of consciousness
a. Assesses for adequate

cerebral perfusion,
thrombi may develop b. Unstable vital signs and
and dislodge during significant changes in
IABP therapy; the IAB hemodynamic pressures, lack of
may migrate, decreasing response to IABP therapy.

b. Vital signs and pulmonary artery
blood flow to the carotid c. Difficult achieving effective
pressures.
19 | P a g e
arteries. IABP therapy.
d. Abnormal cardiac output, cardiac
c. Arterial line and IABP waveforms. b. Demonstrates
index, and systemic vascular
effectiveness of IABP
d. Cardiac output, cardiac index, and resistance values.
therapy.
systemic vascular resistance. e. Capillary refill greater than 2
seconds.
e. Circulation to extremities.
i. Diminished or absent pulses
(eg, antecubital, radial,
c. Ensures effectiveness popliteal, tibial, pedal)
of IABP timing and ii. Color pale, mottled or
therapy. cyanotic.
iii. Diminished or absent
d. Demonstrates
sensation.
effectiveness of IABP
iv. Pain.
therapy.
v. Diminished or absent
movement.
vi. Cool or cold to touch.
e. Validates adequate
f. Urine output. vii. Urine output <0.5 mL/kg per
peripheral perfusion. If
hour.
reportable conditions are
found, they may indicate
catheter to embolus
obstruction of perfusion
to extremity.
Specifically, decreased
perfusion to the left arm
may indicate
misplacement of the IAB
catheter.
f. Validates adequate
20 | P a g e
perfusion to the kidneys.
2. Assess heart and lung sounds Abnormal heart and a. Abnormal heart and lung sounds.
every 4 hours and as needed. lung sounds may
indicate the need for
additional treatment.
CRITICAL CARE
Note: When patient’s
condition permits, place
the IABP on standby to
accurately auscultate
heart and lung sounds,
because IABP therapy
creates extraneous
sounds and impairs
heart and lung sound
assessments.
2. Assess heart and lung sounds Abnormal heart and a. Abnormal heart and lung sounds.
every 4 hours and as needed. lung sounds may
indicate the need for
additional treatment.
CRITICAL CARE
Note: When patient’s
condition permits, place
the IABP on standby to
accurately ausculate
heart and lung sounds,
because IABP therapy
creates extraneous
sounds and impairs
21 | P a g e
heart and lung sound
assessments.
3. Maintain head of bed at less than Prevents kinking of the

45 degrees. IAB catheter.
4. Monitor for signs of The IAB catheter may a. Diminished or absent antecubital
inappropriate IAB placement. be positioned too high or radial pulse.
or too low, thus
b. Color of left arm pale, mottled,
occluding at the left
cyanotic.
subclavian, celiac,
inferior or superior b. Diminished or absent sensation
mesenteric or renal to left arm.
arteries. c. Dampened radial arterial
pressure waveform.
d. Diminished or absent
movement of left arm.
e. Diminished or absent bowel
sounds.
f. Increased abdominal girth.
g. Abdomen firm to touch.
h. Tympany.
i. Abdominal pain.
j. Decreased urine output, less
than 0.5 mL/kg per hour.
k. Increased urine osmolality.
l. Increased blood urea nitrogen
or creatinine.
m. Reduced IABP augmentation.
5. Monitor for signs of balloon In the event of balloon a. Blood or brown flecks in tubing.
perforation. perforation, a very small
b. Loss of IABP augmentation.
amount of helium will
c. Control console alarm
22 | P a g e
be released into the activation (eg, gas loss)
aorta, potentially
causing an embolic
event.
6. Maintain accurate IABP timing. If timing is not accurate,

cardiac output may
decrease rather than
increase.
7. Log roll patient every 2 hours. Promotes comfort and

Prop pillows to support patient skin integrity and
and to maintain alignment. prevents kinking of the
Consider use of pressure-relief IAB catheter.
devices.
CRITICAL CARE
Note: Logrolling may
not be tolerated in
severely
hemodynamically
compromised patient;
low-pressure beds are
necessary for these
patients. Low-pressure
ulcers in patients
requiring IABP therapy.
8. Immobilize the cannulated Prevents dislogment and

extremity with a draw sheet migration of the IAB
tucked under the mattress or by catheter.
using a soft ankle restraint or a
CRITICAL CARE
knee immobilizer.
Note: Assess skin
intergrity and perfusion
23 | P a g e
distal to the restraint
every hour.
9. Initiate passive and active range- Prevents venous stasis

of-motion exercises every 2 hours and muscle atrophy.
to extremities that can be
mobilized.
10.Assess the area around the IAB IAB catheter inflation a. Bleeding at insertion.
catheter insertion site every 2 and deflation traumatize
b. Hematoma at insertion site.
hours and as needed for evidence red blood cells and
of hematoma or bleeding. platelets.
Anticoagulation therapy
may alter hemoglobin
and hematocrit and
coagulation values.
11. Maintain anticoagulation as Prophylactic a. Abnormal coagulation studies.

prescribed and monitor anticoagulation may be
coagulation studies. used to prevent thrombi
and emboli
development.
12. Monitor patient for systemic Hemotologic and a. Bleeding from IAB insertion site.
evidence of bleeding or coagulation profiles may
b. Bleeding from incisions or
coagulation disorders. be altered as a result of
mucous membranes.
blood loss during
balloon insertion, c. Petechiae or ecchymoses.
dysfunction as a result d. Cuaiac-positive nasogastric
of mechanical trauma by aspirate or stool.
balloon inflation and e. Hematuria
deflation. f. Decreased hemoglobin or
hematocrit.
24 | P a g e
g. Decreased filling pressures.
h. Increased heart rate.
i. Retroperitoneal hematoma.
j. Pain in the lower abdomen,
flank, thigh, or lower extremity.
13. Change the IAB catheter site Decreases incidence of a. Signs or symptoms of infection.
dressing every 24 hours. infection and allows an
opportunity for site
i. Cleanse site with normal
assessment.
saline.
ii. Cleanse site with povidone-
iodine solution for 1 minute.
iii. Apply a sterile dressing;
label with date, time, and
nurse’s initials.
14. Monitor for signs and symptoms Aortic dissection may a. Acute back, flank, testicular, or
of aortic dissection. occur as a result of IAB chest pain.
placement into a false
b. Decreased pulses.
lumen in the aorta.
c. Variation in blood pressure
between left and right arms.
d. Decreased cardiac output.
k. Increased heart rate.

l. Decreased hemoglobin and
hematocrit.
m. Decreased filling pressures.
15. Assess and manage patient’s The patient may a. Unrelieved pain.
pain. experience pain from
angina, IAB placement,
or limited mobility.
25 | P a g e
16. Identify parameters that Close observation of the a. No angina.
demonstrate clinical readiness to patient’s tolerance to
b. Heart rate less than 110 beats per
wean from IABP theapy. weaning procedures is
minute.
necessary to ensure that
the body’s oxygen c. Absence of lethal or unstable
demands can be met. dyshythmias.
The presence of these
d.MAP greater than 70 mm Hg
reportable conditions
with little or no vasopressor
indicates that
support.
consideration should be
e. PAWP less than 18 mm Hg.
given to weaning the
f. Cardiac index greater than 2.4
patient form the IABP.
g.Svo2 between 60% and 80%.
h.Capillary refill less than 3
seconds.
i. Urine output greater than 0.5
mL/kg per hour.
Policy on PDA closure
1.0 Purpose:
Coil closure of patent ductus arteriosus (PDA has become an accepted alternative to surgical closure.
Most children who become seriously ill with congestive heart failure in the new-born period are
premature infants in whom the ductus does not close at all.
2.0 Scope:
Management of PDA Coil / Device Closure.
26 | P a g e
3.0 Procedure:
Things required for Coil:
 Venous sheath (appropriate size)
 Arterial sheath (appropriate size)
 RCA Catheter (appropriate size)
 Pigtail catheter (appropriate size)
 0.035 Teflon guide wire (145CM)
 Judkins right catheter(5F)
 0.035 (260cm) terumo guide wire.
 0.038 straight tip Teflon (145cm) guide wire for adults.
 10ml syringes-2
 20ml syringes-1
 Device delivery system.
 Nitionol PDA occluder.
 0.035Amplate guide wire(260cm)
Before the procedure:
 Doctor will explain the procedure as well as the likelihood of complication
related procedure to patient.
 Patient will be asked to sign a consent form that gives his/her permission to do the
procedure.
 Notify patient have ever had a reaction to any contrast dye, or allergic to
iodine.
 Patient need to fast for a certain period of time prior to the procedure.
 Notify patient have a history of bleeding disorders.
 Patient requires blood test prior to the procedure.
 Based on patients’ medical condition, doctor may request other specific
preparation.
 Patient asked to remove jewelry or other objects that may interfere with the
procedure.
Procedure steps:
27 | P a g e
 Place the patient in a supine position.
 Connect the patient to a cardiac monitor and check blood pressure and
pulse.
 Anti-microbial (Betadine solution) painting (from umbilicus to knee joint).
 Draping the patient in such a way that inguinal fold lies diagonal to the side hole.
 Load 10ml of xylocaine and Inj.Heparin 5000 IU.
 The right or left femoral artery and venous in the most commonly used
access site.
 Flush the puncture needle, sheath, dilator, and catheter.
 Inj.xylocaine 2% administered insensitive to pain to blocking the nerve.
 Making a small incision with scalpel.
 Puncturing femoral artery with puncture needle(18G)
 Remove puncture needle.
 Introduce the sheath with dilator.
 Remove the dilator with wire and flush the sheath.
 After the sterile preparation of groin area, sheath is introduced through
percutaneous access of the femoral vein and femoral artery. (Systemic
heparinisation to be done 100IU/KG)
a. RCA or multi-catheter used for right side of the heart.

b. Right Ventricle, pulmonary artery, pressures and oxygen saturation to be measured.
c. Left side of the heart will then be reached through the femoral artery using a pigtail catheter with
appropriate wire.
d. Angiogram is performed in the descending aorta to visualize and measure the PDA in the lateral
projection.
e. After the measurement of the PDA, the cardiologist selects the device size. PDA with an internal
diameter of < 3mm can be closed with an occlusion coil.
PDA with an internal diameter of > 3mm can be closed with device closure (occluding soring coil
are made of surgical stainless steel covered with Dacron strands to promote thrombus formation)
 PDA Coil Closure.
28 | P a g e
 RCA catheter with 0.035 terumo wire is forwarded from the descending
aorta through PDA, to the duct (for adults).
 Terumo wire to be removed and then the coil is loaded into the RCA
catheter with hard end of the .038 straight Teflon wire (for adults)
 Then the coil is advanced with soft end of the 0.038 straight Teflon.
 With the catheter in place, the delivery wire releases the coil slowly until a
loop remains in the pulmonary end.
 As the catheter is slowly retracted through the duct, more coil loops are released.
 Angiogram is done after 10 mins pigtail in then arch of aorta.
 Remove sheath and obtain hemostasis.
PDA Device Closure: Nitinol PDA Occluder Device. PDA with a internal diameter of 9-10mm
can be successfully closed with Nitinol PDA occlude.
NOTE: PAD occlude consists of two discs with central waist.
 RCA catheter or multi catheter is introduced with a 0.035 exchange Teflon guide
wire.
 The wire passes from the right of the heart, through the PDA into the
descending aorta.
 With wire in place, the catheter and sheath were removed and exchange for
a device delivery sheath.
 This sheath is long with dilator and follows the wire into the descending aorta.
 Device and Delivery system completely flushed with heparinized saline and then the
device is introduced into the delivery system and advanced to the tip of catheter.
 The sheath is then retracted allowing distal part of the device to form in the
descending aorta. The delivery sheath is withdrawn until device is in aortic
ampulla.
 Then the proximal disc is released.
 Once the angiogram conform that the device is in the correct position, the
device is completely released from delivery cable by rotating the delivery
wire in a anti clockwise movement.
29 | P a g e
 Whole system is pulled back to the IVC. And then an angiogram of the
descending aorta is done to document complete occlusion
Post Procedure Care:
 Patient shifted to post procedure care room.

 Check pulse and blood pressure with the support of monitor.
 Ensure no bleeding or hematoma formation in puncture site.
 Advise to keep the leg straight for first 2 hours.
 Advise to drink plenty of fluids in order to prevent hypotension
5.0 DOCUMENTATION
5.1 Record administration on the patient’s Medication Chart and Cath Lab monitoring
5.2 Document in the Doctor’s progress notes/ Nurses notes.
6.0 COMMENTS
6.1 Not applicable.
Policy on peripheral Angiogram
1.0 Purpose:
It is commonly performed to identify vascular abnormalities in patients with leg
claudication/swelling/discoloration due to trauma.
2.0 Scope:
To diagnose and plan the treatment of the peripheral arterial diseases like Aneurysm, AVM,
30 | P a g e
stenosis / occlusion, arterial trauma
3.0 Procedure:
3.1 Patient Assessment:
 Determine the patient's past medical, allergy, medication history.
 Assess the patient’s cardiac and pulmonary status.
 Assess vital signs.
 Explain and discuss the procedure with the patient/relatives & get his or her Consent.
3.2 Articles Needed:

 5F sheath.
 0.035terumo guide wire.
 5F Judi’s right (JR3.5) catheter.
 4F cobra catheter.
 4F Sim 1 catheter.
 4F vertebral catheter.
 Diluted non- ionic contrast ominipaque (or) visipaque (100:30).
 Inj. Xylocaine
 Inj. Heparin 2500 IU
 2cc Syringe
 3 Way stopcock – 1
3.3 Preparation:
 Sterile scrubbing, Gowning, Gloving.
 Preparation of the sterile trolley.
3.4 Procedure Steps:

 Connect the patient to a cardiac monitor and check blood pressure and pulse.
31 | P a g e
 Draping the patient in such a way that inguinal fold lies diagonal to the side hole.
 Load 10ml of xylocaine and Inj. Heparin 100IU/KG
 The Right (or) left femoral artery in the most commonly used access site.
 Flush the puncture needle, sheath, dilator and catheter.
 Inj. Xylocaine 2% administered insensitive to pain to blocking the nerve.
 Puncturing femoral artery with puncture needle (18G), & 0.038 guide wire.
 Remove puncture needle.
 Making a small incision with scalpel.
 Introduce the sheath with dilator.
 Remove the dilator with wire and flush the sheath.
 Administer Inj. Heparin 100IU/KG
 Introduce the 5FRCA catheter and wire into the bilateral arteries of extremities.
 Check injections with 8-10ml of diluted contrast.
 Pressure injector help the dye to reach the peripheral branches.
 A Series of radiographs are taken as the contrast agent spread the arterial system.
 Introduce the guide wire and remove the catheter.
 Check the hemostasis.
 Remove the catheter, sheath& apply pressure bandage.
3.5 Post procedure care:

 Advise to keep the leg straight for 24 hours.
 Advise to drink plenty of fluids in order to prevent hypotension.
Policy on Peripheral Angioplasty
1.0 Purpose:
1.1 Peripheral angioplasty was developed as treatment for peripheral arterial disease.
32 | P a g e
Catheter based intervention provide symptomatic relief of claudication and prevention of
embolization limb ischemia.
2.0 Scope:
2.1 Management of peripheral arterial disease.
3.0 Procedure
 Articles needed.
 Y connector
 10cm extension-1
 Torque-1
 Guide wire Introducer needle.
 7F sheath with back-bleed valve.
 Puncture needle(18G)
 Inflation device.
 Extra sponges.
 I.V set-2
 10ml luerlocksyringe-4
 10ml dispoven syringe-1
 5ml dispovan syringe-1
 5ml Leurlock Syringe-1
 RCA or Multipurpose catheter.
 3way manifold-1
 0.035 double length terumo guide wire(260cm)

 0.035 terumo (260cm)
 Guiding catheter (EBU, JR, JL)
 0.014” PTCA guide wire(190cm)
 PTCA balloon (e.g. sprinter, voyager,)
33 | P a g e
 Doctor will explain the procedure, as well as the likelihood of complication related procedure to
patient.
 Patient will be asked to sign the consent form that gives his / her permission to do the procedure.
 Notify patient have ever had a reaction to any contrast dye, or allergic to iodine.
 Patient need to fast for 4 to 6 hours of time prior to the procedure.
 Notify patient have a history of bleeding disorders
 Patient requires blood investigations prior to the procedure.
 Based on patients’ medical condition’ doctor may request other specific preparation.
 Patient asked to remove jewelry or other objects that may interfere with the procedure.
 Inj.xylocaine & contrast test dose given before procedure.
PREPARATION:
 Sterile scrubbing, gowning & gloving.
 Load Inj. Xylocaine, Inj.Heparin, and Inj. NTG
 Connect 10cm extension with manifold & Y connector
a. Manifold 1st port (yellow) – pressure line.
b. Manifold 2nd port (blue) – NS- mounted on inflatable bay.
c. Manifold 3rd port (Red) – contrast.
 Flush the entire connection with saline for air free continuity
 Flush puncture needle & sheath.
 Aspirate contrast in inflation device & de air it
 Place sponge near puncture area & keep ready things for arterial puncture 10ml of 2%
xylocaine in 10cc syringe attached with 21needle.
 0.038” Teflon introducer wire.
 Sheath & dilator.

 Puncture needle 18G.
Procedure steps:
 Place the patient in a supine position.

 Connect the patient to a cardiac monitor and check blood pressure and pulse.
34 | P a g e
 Anti-microbial (Betadine solution) painting (from umbilicus to knee joint).
 Load Inj. Xylocaine 10ml and inj. Heparin.
 Inj.Lignocaine 2% administered insensitive to pain to blocking the nerve.
 Puncturing femoral artery with puncture needle(18G)
 Arterial access to be taken & indwelled with 7F sheath.
 Remove the dilator with wire, flush the sheath & give Inj.Heparin asper body
weight
 Introduce Multipurpose or RCA with 0.035 exchange length Terumo wire to
cross the bifurcation & to cross the other lesion.
 Now 7F sheath is removed & with wire in place& 7 F long sheath (75CM TO
90CM) is introduced up to the maximum length.
 Again sheath to be aspirated and aspirate discarded. The Sheath is flushed &
again Multipurpose or RCA catheter is introduced with 0.035 double length wire
through the sheath.
 Once the catheter reaches its maximum level, remove .035Terumo & attach
Manifold along with Y connector to make the whole system air free check angio
to be taken.
 0.18” double length wire to be given with torque device.
 Wire is threaded across the lesion.

 Once again check angio to be taken to measure the lesion length.
 According to the lesion severity pre-dilatation can be done with balloon.
 It should be prepared with diluted contrast without any air inside balloon & attach inflation
device.
 Once the balloon placed at the lesion site balloon to be inflated up to the nominal atmosphere
pressure slowly, deflate the balloon.
35 | P a g e
 Remove the balloon & wipe the wire with wet gauze piece. Check angio to be done.
 Appropriate stent to be selected & prepared (stent to be prepared with diluted contrast and attach
the inflation device).
 A series of radiographs are taken as the contrast agent spread the arterials & venous system.
 Stent over wire to be placed at diseased area of the artery & implantation of stent is to be done
slowly.
 Remove the balloon and check angio to be done. (If needs post dilatation) sheath to be removed
according to the coagulation factor.
 Check Hemostasis and apply pressure bandage.
 Patient shifted to post procedure care room for sheath removal.

 Check pulse and blood pressure with the support of monitor.
 Ensure no bleeding or hematoma formation in puncture site
 Compression dressing done.
 Advice to keep the leg straight for first 8 hours.
 Advice to drink plenty of fluids in order to prevent hypotension.
5.0 DOCUMENTATION
5.1 Record administration on the patient’s Medication Chart.
5.2 Document in the Doctort’s progress notes/ Nurses Notes.
Policy on Coronary Angiogram
Definition:
A medical procedure in which a thin, flexible catheter is inserted through an artery or vein (as of the
arm or leg) and passed into the heart for the diagnosis and treatment of heart conditions
Purpose: To diagnose blockages in the blood vessels
36 | P a g e
Radial Approach:
 Radial approach is one of the percutaneous vascular access approaches for coronary angiography.
 Before attempting for radial artery access, an ALLEN’s TEST should be carried out to ensure that
the ulnar artery and collaterals are patent in the event of radial artery occlusion.
Materials Needed.
 5F for radial cannulation terumo Sheath-1
 20G (32min) jelco-1
 5F tig catheter (for LCA & RCA)
 0.035 terumo / Teflon guide wire(150cm)
a. Inj. Heparin – 5000 i.u.
b. Inj. Dilzem -5mg-1cc
c. Inj.Nitroglycerine-100mcg
d. Inj.xylocaine - 5cc
e. 10ml- leurlock-2
f. 2ml-syringe-1, 5ml-syringe-2
g. IV set-2
h. Scalpel blade-11 size-1
i. Disposable needle 26G-1(or) tuberculin syringe - 1
j. Manifold-3 port-1
k. Pressure monitoring line-1(200cm)
l. Betadine solution/Micro shield PVP
Preparation
Painting –from middle ventral part of forearm to fingers
Procedure:
37 | P a g e
Radial artery angiography needs careful advancement and removal of catheter which should always be
done over the wire only. Remove Radial artery sheath and apply Trans Radial band (TR band).
FEMORAL APPROACH:
 The right or left femoral artery is the most commonly used access site for coronary angiography.
 The common femoral artery (CFA) course medially to femoral head and the bifurcation of CFA into
branches is generally distal to the middle 1/3rd of femoral head.
 The anterior wall of CFA is to be punctured several levels below the inguinal ligament; but
proximal to the bifurcation of superficial femoral and profound an arterial branch.
Articles Needed :
 Puncture needle (18x7 cm).
 Introducer wire .038' Teflon (45cm).
 6F Sheath (11 cm) with dilator.
 0.035' Teflon guide wire (145cm).
 Judkins left and right catheter (6F).
 21 Gauze Needle – 1
 20 ml syringe - 1
 10 ml syringe – 2, 5ml syringe - 1
 2 ml syringe – 2
 IV set – 2
 Scalpel Blade – size 11
 Pressure monitoring line – 200 cm- 1
 Manifold 1 – 3 port.
Preparation:
 Sterile Scrubbing, Gowning, Gloving.

 Preparation of Sterile Trolley.
 Antimicrobial painting (from umbilicus to knee joint).
38 | P a g e
 Draping the patient in such a way that inguinal fold lies diagonal to
 the side hole.
 Load 10ml of Xylocaine in 10 ml syringe and.
 Flush the puncture needle, sheath, and dilator and Judkin's left and right catheter.
Prepare manifold
 First port with Pressure line
 Second port with contrast
 Third port with heparinized saline and Attach 10ml luerlock syringe
Procedure:
 Puncturing femoral artery with puncture needle (18 G).
 Introducing 0.38' Teflon introducer wire.
 Removing puncture needle.
 Making a small incision with scalpel blade.
 Introducing the sheath with dilator.
 Remove the dilator with wire & flush the sheath.
 Check the pressure.
 Administer 5000 IU of Heparin.
 Introducing LCA catheter with 0.035 Teflon guide wire.
 Introduce the wire till it reaches the ascending aorta & hold the wire
 Till the catheter reaches the ascending aorta then remove guide wire.
 Aspirate 2 ml of blood in 2cc empty syringe & flush the catheter with Hepsol.
 Connect manifold to the catheter, Aspirate some blood & discard.
 Flush with fresh saline.
 Open the pressure line & aspirate contrast.
 Check whether the catheter hooks the coronary artery by giving small test
 Injection and open the pressure line to check pressure damping.
 Inject contrast 3 ml for three cardiac cycles.
 Introduce guide wire & remove the catheter.
 Introduce RCA catheter with guide wire.
 Once it is hooked, give test injection then inject only 0.5 ml of contrast.
39 | P a g e
 For LIMA injection diluted contrast to be injected.
 For renal injection give 2 ml for each renal artery.
 Remove the catheter, sheath, check hemostasis & apply pressure bandage.
Post procedure care:
 Patient shifted to post procedure care room for sheath removal.

 Ensure no bleeding or hematoma formation in puncture site
 Compression dressing done.
 Advice to keep the leg straight for first 8 hours.
 Advice to drink plenty of fluids in order to prevent hypotension
5.0 DOCUMENTATION
5.2 Document in the patient’s progress notes/ Daily Nurses Flow Sheet.
Policy on Right Heart Catheterization
1.0 Purpose:
Right Heart catheterization is performed to measure intra cardiac pressure and oxygen saturation to
diagnose abnormal shunts and flow patterns and to assess the pulmonary vascular resistance.
2.0 Scope:
To diagnose and monitor the cardiac disorders.
40 | P a g e
3.0 Procedure:
3.1 Articles needed:

 Puncture needle
 Introducer wire.
 6f Sheath (or) appropriate size.
 10cc syringe-1
 3-way stopcock-1
 1cc syringes-10(heparinized syringes), to take Samples.
 Cournand, NIH catheter.
 Pressure Monitoring Line 200cm.
3.2Before the procedure:

 Patient will be asked to sign a consent form that gives his/ her permission to do the
procedure.
 Based on patients’ medical condition, doctor may request other specific preparation.
 Inj.Xylocaine & contrast test dose given before procedure.
3.4 Preparation:
 Sterile scrubbing, gowning and gloving.

 Clean the inguinal region of both sides (from umbilicus to knee joint).
 Load Inj.Xylocaine in 10cc syringe
 Then load heparin in a 2cc syringe (100IU / kg) and flush all sample syringes with heparin.
41 | P a g e
 Flush the necessary catheter with heparinized saline.
 Flush the sheath & puncture needles.

 Anti-Microbial (betadine solution) painting (from umbilicus to knee joint)
 Load 10ml of xylocaine and Inj. Heparin 2500IU.
 The Right (or) left femoral artery for LHC (left heart catheterization) or left femoral vein for
RHC in the most commonly used access site.
 Flush the puncture needle, sheath, dilator and catheter.
 Inj.xylocaine 2% administered to reduce pain during the procedure.
 Getting venous access & indwelling 6F sheath or appropriate sheath, introduce Cournand
catheter till its reaches the SVC.
 Advance the catheter till it reaches IVC to RA to PA to pulmonary capillary wedge pressure.
 When the catheter is in PA perform an oxygen saturation study.
 Take Samples from PA, RV, RA and SVC and IVC.
3.6 Pressure study should be done from:
a. RA pressure (Phasic and mean)
b. RV pressure (phasic only).
c. PCW to PA pullback pressure (mean PCW to pullback)
d. PA pressure (systolic and diastolic, mean)
e. FA pressure (systolic, diastolic and mean)
 Expel air label the sample and sent it to lab. Withdraw the catheter.
42 | P a g e
 Flush the sheath catheter and remove the sheath, apply pressure for 10mins.
 Apply tight bandage and assess the patency of distal pulse.
3.7 Post Procedure Care:

Policy on Spinal Angiogram
1.0 Purpose:
Spinal angiography accomplishes the same goal for arteries which supply the spine and para spinal
regions .There are usually 31 vertebrae in the body , and most have 1 or 2 individual arteries feeding
them, which means the entire spine vasculature need to be visualized. To diagnose spinal vascular
disorders.
2.0 Scope:
To diagnose and plan the treatment for spinal cord vascular abnormalities such as AVM, AV Fistula,
Spinal Dural fistula& in Spinal tumors.
3.0 Procedure:
3.1 Patient Assessment:

 Explain and discuss the procedure with the patient/relatives& get his or her consent.
 Puncture needle 18G x 7cm.
 Introducer wire 0.038.
 5F sheath (11cm) with dilator.
43 | P a g e
 0.035 terumo guide wire (145cm).
 Judkins right, 4F vertebral, 4F cobra catheter, 4F Sim1catheters.
 2ml &10ml disposable syringe with 3way stop lock.
 Inj.heparin-2500IU&Inj.xylocaine.
 10ml leurlock syringes-2.
3.3 Preparation:
 Preparation of sterile trolley.

 Connect the patient to a cardiac monitor and check blood pressure and
pulse.
 Anti-microbial ( Betadine solution) painting (from umbilicus to knee joint).
 Draping the patient in such a way that inguinal fold lies diagonal to the
side hole.
 Load 10ml of xylocaine and Inj. Heparin 2500 IU.
 The Right (or) left femoral artery in the most commonly used access site.
 Inj.Lignocaine 2%administered insensitive to pain to blocking the nerve.
 Puncturing femoral artery with puncture needle (18G), &0.038 guidewire.
 Administer 2500IU of heparin .
 Introduce 5F RCA/4F vertebral catheter &with 0.035 terumo guide wire.
 Introduce the catheter with wire till it reaches selectively into the
 bilateral vertebral arteries, thyro and costo cervical arteries.
44 | P a g e
 Introduce 4F cobra/4FSim1 selectively into bilateral spinal arteries from
dorsal to
 lumbar regions and bilateral internal iliac arteries
 Inject 4-5 ml of dilute contrast.
 A Series of radiographs are taken as the contrast agent spread in the
arterials & venous system.
 Introduce guide wire and remove the catheter.
 Remove the catheter, sheath, check hemostasis and apply pressure
bandage.
 Post procedure instruction and advice given to the patient.
 Patient shifted to post procedure care room.

 Ensure no bleeding or hematoma formation in puncture site.
 Advise to keep the leg straight for 24 hours.
 Advise to drink plenty of fluids in order to prevent hypotension.
Policy on PPI
1.0 Purpose:
The pacemaker is usually implanted in the upper chest preferable left Subclavian and the leads are
threaded a vein into the heart, the generator is a metal case containing the power source and a timer
that regulations how often the pacemaker sends out electrical signals. To do the Permanent
Pacemaker Implantation (PPI) for management of rhythm disorder.
2.0 Scope:
This describes the procedure to treat symptomatic sinus bradycardia and significant sinus pauses
with syncope, complete heart block, and sinus node dysfunction syndrome.
45 | P a g e
3.0 Procedure:
Articles required.
 PPI tray.
 Inj.xylocaine 2% 30ml.
 Betadine soaked gauze piece-3
 10cc BD syringe-2
 10cc L/L syringe-1
 5cc BD syringe-1
 2-0 silk (no absorbable, round body)
 3-0 vicryl (absorbable).
 2-0 monocryl (absorbable)
 Blade#11.
 Sheath pack.
 Puncture Needle.
 6F Sheath.
 Lead and stylet pack.
 Device pack.
 BP handle – 2
 Scissors Straight – 2
 Curved - 2
 Artery Forceps Straight – 4
 Curved - 4
 Thumb forceps Toothed -2
 Non-toothed- 2
 Allis forceps – 4
 Self-retaining retractor – 1
 Hand held retractor – 1
 Tissue holding forceps – 2
 Needle holder – 2
46 | P a g e

 Patient will be asked to sign a consent form that gives his/her permission to do
the procedure.
 Patient require blood test prior to the procedure.
 Based on patient’s medical condition, doctor may request other specific preparation.
procedure.
 Antibiotic should be given.
Procedure Steps:
 Connect the patient to a cardiac monitor and check blood pressure, pulse & 02 saturation.
 Positioning and scrubbing with an anti- septic scrub solution over the chest specially
concentrated on pectoral region, extending from the angle of mandible above to the
umbilicus below posterior axillary fold on right to that on the left and including top of
shoulder and arms upto mid arm level and both axillae and nipples.
 Inj.xylocaine 2% administered to reduce pain during procedure.
Access obtained in the right femoral vein.
 Temporary pacemaker to be kept in position
 Scrubbing once again with spirit and then painting with Betadine solution.
 Drape the patient (draping should be done to expose the area from lateral border of
47 | P a g e
sternum medially, clavicle above and axillary groove) laterally and up to 10cms evolves
the clavicle inferiorly.
 Take 20 cc inj. xylocaine in two 10ccsyringe and attach 21G needle.
 Give local anesthesia to the particular area where pocket is to be made.
 A skin incision suitable for pacemaker about 6 cm long is made with a No.22 blade.
 After an incision, mop the area to remove blood and if any small arterioles cut give small
mosquito forceps to tie that particular bleeder.
 Give curved artery forceps to clear out the subcutaneous fat and make a pocket below that
and above the fascia.
 Provide scissors to cut down the hard fatty tissue, pocket to be made of a size that will fit
the device without tension in tissue planes.
 Moping should be done to arrest oozing of blood and if necessary cauterize.
 Place 2-3 betadine soaked gauze pieces or [gentamicin soaked] inside the pocket.
 Open a sheath pack and prepare the sheath guide wire, needle. The needle attached with a
10 cc saline is used as in standard subclavian puncture technique to get subclavian venous
access.
 Once the access is made, introduce the wire and sheath is introduced over that.
 The leads are taken out and stylet introduced to the tip and prepare to introduce the lead in
to the RV: lead should be wiped with wet gauze and push stylet inside.
 Once the lead is ready, remove the dilator and wire from the sheath insert the lead and
maneuver to the IVC as soon as possible tear out the sheath by placing the lead inside.
 Remove the straight stylet and put the curved stylet, position the lead into the RV apex.
 If position is acceptable check the parameters by attaching the programming cable, black to
the tip and red to the proximal area of the lead.
 If lead parameters are acceptable, screw the lead in the position with stylet.
 Remove the stylet and suture the lead with 2-0 silk, again check the parameters
to confirm lead position.
 Get the device pack and attach the lead into the device and screw the lead.
 Check the parameters remove the gauze pieces in the pocket and take a count to see that all
the gauzes are removed.
48 | P a g e
 Cleanse the pocket, place device inside the pocket and check under fluoroscopy to see the
leads loop.
 Suture device with same suture material 2-0 silk, once again parameters to be checked.
 Close the pocket in layers, subcutaneous with 2-0 vicryl by interrupted method and skin
with 3-0 monocryl by subcuticular method.
 Once the incised area closed completely wipe it with gauze piece, apply anti biotic
ointment and put me pore dressing.
 Keep 4-6 gauze piece over that and put pressure dressing.
Special Instruction:
 Suture needle to be holed ¾ with a needle holder.

 For absorbable sutures cut it close to the knot.
 For non-absorbable sutures cut it above the knot.
 Patient shifted to post procedure care room.

 Advise to immobilize the left upper limb for 2days.
5.0 DOCUMENTATION
Policy on PTCA
49 | P a g e
1.0 Purpose:
It is minimal invasive procedure that is used to open narrowed coronary arteries.
2.0 Scope:
It can reduce the risk of atherosclerosis, decrease the chance of re-blockage and treatment for certain
coronary artery disease.
3.0 Procedure:
Articles needed:
o Y connector
o 10cm extension-1
o Torque-1
o Guide wire Introducer needle.
o 6F sheath with back-bleed valve.
o Puncture needle (18G)
o Inflation device.
o Extra Sponges.
o I.V.set-2
o 10ml luerlock syringe-4
o 10ml dispovan syringe-1
o 5ml Leurlock syringe-1
o 2ml dispovan syringe-2
o Manifold -1 (3 port)
o Pressure monitoring line 200cm-1
o Inj.xylocaine 2%
o Inj Heparin
o Inj N T G
o 0.035 guide wire.
o Guiding catheter (EBU, JR, JL)
o 0.014 “PTCA guide wire(190cm).
50 | P a g e
o PTCA balloon (e.g. sprinter, voyager) and stent.
o 0.014” PTCA guide wire- 175 to 195cm (e.g., ACS H1 Torque floppy, BMW,
persuader or standard).
Before the Procedure:
 Doctor will explain the procedure as well as the likelihood of complication related procedure
 the patient.
 Patient will be asked to sign the consent form that gives his / her permission to do the procedure.
 Patient need to fast for 4 to 6 hours of time prior to the procedure.
 Patient requires blood investigation prior to the procedure.
 Based on patients’ medical condition, doctor may request other specific preparation.
 Asked to empty his / her bladder prior to the procedure.
 Patient asked to remove clothing and will be given a gown to wear.
Pre- procedure preparation:
 An Intravenous (IV) line will be started in hand or arm prior to the procedure for injection
of medication and to administer IV fluids.
 Keep ready things for puncture.
 Prepare manifold ready for use.
 10ml syringe attach with manifold.
 Connect the pressure line to the 1st port of manifold and the other end to pressure transducer
 Open the pressure line & flush the line so that all air is expelled.
 Connect IV set which is connected to the 2nd port of manifold & connect with contrast after all the
air is expelled.
51 | P a g e
 Heparinized saline bottle which is connected to 3 rd port of the manifold & and the connecting
tube.
 Now attach the 10cm extension to the manifold & Y-connector to the other end.
 Now open the 3rd port of manifold to flush out the whole system at the same time close
 the center port of the Y connector with one finger & open the side port valve fully & close
tightly. Close the 3rd port and open the pressure line & take 5ml saline from the 3rd port
 In 10cc syringe & close that & keep it ready to flush the catheter.
 Take 20ml contrast in the bowl & dilute it in 1:1ratio (means 20cc contrast in 20ml of saline)
 Aspirate the contrast into the inflation device up to 10cc & deair it by tapping it & expelling the
air out holding the indeflator device with its spout upwards.
 Take diluted contrast in 10cc L/L syringe (up to 3cc) & attach the long needle & keep it ready to
prepare the balloon.
 Take 5ml of 500 micrograms NTG in a 5cc L/L syringe & from that take 1cc in 10cc L/L Syringe
& dilute that into 4cc & keep it ready to give intracoronary injection.
 Take 5-10 gauze pieces & dip it in the basin containing saline & keep it ready to wipe the PTCA
wire frequently.
Procedure steps:
 Place the patient in a supine position
 Connected to a monitor that records the Heart Rate, Respiration rate, Blood pressure and Spo2
during the procedure using small, adhesive electrodes.
 Both sides of the groin to be painted in femoral as well as both side in radial approach with
 Betadine, paint should be from fingers to forearm, & drape the patient.
 Inj.Xylocaine 2% is administered to reduce pain during the procedure.
 Puncturing femoral artery with puncture needle(18G) and introduce 0.35 wire then remove the
puncture needle then appropriate sheath is to be introduced.
 Flush the sheath & Inj.Heparin given according to the body weight.
52 | P a g e
 Prepare the guiding catheter & wire.
 Introduce the wire 0.035’Teflon along with catheter & remove the wire, attach the manifold Y
Connector & open the Y connector valve & let the blood come out through that valve.
 close the valve & then aspirate the blood & flush in to the value do the same twice.
 Once the catheter hooks the coronary check to be given to confirm the flow.
 Two or three views to be taken & PTCA wire to be introduced along with introducer through Y-
connector valve.
 Remove the wire introducer & close the valve.
 Put the torque device on the wire & be ready for check angio.
 Once the wire crossed over the lesion, angiograms are taken in various views.
 The lesion size is to be measured and if appropriate, direct stenting can be done.
 If pre dilatation is required, balloon is prepared by following these steps take the balloon from the
cover & remove inner stylet of the balloon & the flush the inner port, take 3ml diluted ‘contrast’
in a 10ml luerlock syringe with 21G long needle, with this fill the hub of the balloon so that the
air is displaced. Remove the needle from the eye syringe & attach with the balloon put it in
negative two to three times. If the balloon is a re-used one the balloon has to be inflated and
checked. Again aspirate the contrast out & remove the syringe from the balloon.
 Attach the indeflator device with the balloon & put it in negative pressure.
 Wipe the PTCA wire with wet gauze & thread the balloon over the wire.
 Y connector valve to be open & introduce the balloon into the catheter & it should be closed.
 Be ready to give check angio when the balloon is being managed across the lesion.
 Once the balloon has positioned on the lesion check angio to be taken.
 The Inflation device is inflated up to its nominal pressure.
 Wait for 30 secs during that time ECG, BP & saturation to be noticed.
 Deflate slowly & put it in negative pressure.
 Remove the balloon by keeping the wire in position.
 Check angio to be done to assess the result and dissections if any in multiple views.
 Wipe the wire with wet gauze piece. Appropriate stent to be selected.
 Take out the stent from the cover & remove the stylet & flush.
53 | P a g e
 Fill up the hub of the stent with diluted contrast & connect the indeflator device in positive
pressure. (Do not put the indeflator device in negative pressure for stent).
 Put the stent over the wire & introduce it into the catheter through y connector valve.
 Close the valve and push the stent into the lesion, position the stent properly, (to be covered fully)
taking care to see that the inflated area is adequately covered.
 Deploy the stent by inflating with inflation device up to its normal pressure or more than that.
 Wait for some time and deflate it slowly then remove the stent catheter.
 Check angiogram to be performed, if post dilatation is required it can also be done by same
method of pre dilatation.
 Remove the wire and again check angio is performed in different views.
 Remove guiding catheter with 0.035 Teflon guide wire.
 Suture is used to secure the sheath to the patient.

 Remove the sheath after 6hours asper ACT.
 Advice to keep the leg straight till the sheath is removed.
5.0 DOCUMENTATION
5.2 Document in the Doctor’s progress notes/ Nurses Notes.
Policy on PTMC
54 | P a g e
1.0 Purpose:
Balloon mitral valvotomy study to relieve mitral valve obstruction, immediate improvement in LA
mean pressure gradient with a gradual decrease in PAP and an increase in cardiac output is noticed.
2.0 Scope:
To treat mitral valve stenosis.
3.0 Procedure:
Articles required.
 6F Arterial Sheath
 7F Venous sheath.
 0.035 Teflon wire (145-150cm).
 6F Pigtail.
 Mullins sheath with 0.032 guide wire (145cm)
 Septal puncture needle or broken borough needle.
 LA wire or spring coil guidewire.
 Septal dilator(12F).
 PTMC Balloon (Percutaneous trans venous mitral commissurotomy).
 Accura or Innoue balloon selected according to the patient height.
 Balloon stylet both inner and outer.
Inj. Xylocaine 2% 10cc.
 Inj.Heparin 100IU/Kg
 I.V.Stylet.
 Balloon Syringe.
 Vernier scale.
 10cc BD syringe-3
 10Leurlock syringe-2
 3-way 10cm extension-1
 5cc BD syringe-1
 21 Gauge long needle-1
 11#Blade-1
55 | P a g e
 3-way stopcock-2
 Pressure line-2(200cm)

 Patient will be asked to sign a consent form that gives his/her permission to do
the procedure.
procedure.
 Premedication Antibiotic should be started ½ hr before procedure.
Preparation:
 Sterile scrubbing, gowning & gloving.
 Load Xylocaine (10ml), Heparin (5000IU)
 Take 10ml of ionic dye in a bowl and dilute in 1:4 dilutions (10ml of contrast in
40ml saline)
 Aspirate the diluted contrast in 30cc syringe.
 Attach the syringe and 10cm extension with PTMC balloon fill with contrast.
 Flush the inner port of the balloon and attaché the syringe in balloon port.
 Inflate the balloon and keep the balloon upside down then deflate it fully (do it
again)
 Remove the air from syringe and inflate the balloon, close three-way and
measure the balloon with Vernier scale.
 Once the balloon is inflated up to required size remaining contrast in syringe to
be discarded along with any air.
56 | P a g e
 Deflate the balloon fully and insert inner stylet of the balloon when the 0.032
wires is well in to the balloon.
 Attach the inner stylet with (silver color) outer stylet (gold color)and then both
into balloon.
 Flush inner port and keep it ready for use.
Procedure Steps:
Place the patient in a supine position.
Connect the patient to a cardiac monitor and check blood pressure, pulse & 02 saturation.
 The Right (or) left femoral artery and vein is the most commonly used access site.
 Inj.Xylocaine 2% administered insensitive to pain to blocking the nerve.
 Puncturing femoral artery vein with puncture needle(18G).
a. Obtain arterial and venous access, introduce 6F sheath for artery and 7F sheath for venous.
b. Flush the sheaths and connect the pressure to the arterial sheath
c. Introduce pigtail catheter with 0.035Teflon guide wire to the ascending aorta and measurement
of LV pressure and pull back of ascending and pressure to be done and keep the catheter there
with pressure attached.
d. Mullen’s sheath with 0.032 Teflon guide wire through the venous access.
e. When the guide wire reaches the left subclavian vein remove the guide wire and the sheath.
f. Introduce septal puncture needle into the Mullen’s sheath with 10cc L/L syringe for non-ionic
dye.
g. Once septal puncture is done, inject contrast and see whether it is going to LA, then remove the
needle, introduce LA wire into the LA.
h. Inj.Heparin 5000IU/IV to be given.
i. Remove the 7F Venous sheath, Mullin’s sheath and let the LA wire remains in LA itself.
j. Now #11 Blade and artery forceps to be given to dilate skin and under structure.
57 | P a g e
k. Wipe the LA wire with wet gauze.
l. Put the 12F dilator skin and septum.
m. Replace dilator with prepared BMV balloon into LA and remove the LA wire along with inner
stylet and inflate the distal balloon.
n. Put the LV stylet into the balloon to introduce the balloon into LV across the mitral valve.
o. Once the balloon crossed the valve inflate the distal portion and see whether the balloon is
holding the valve.
p. Inflate the balloon without waist at a stretch and deflate the balloon as soon as possible.
q. Remove the balloon from the LV to LA, attach the pressure line and flush. Note LA pressure
and aortic pressure.
r. Introduce the LA wire with inner stylet of the balloon and remove the balloon, let the LA wire
is inside the LA.
s. Put the same 7F venous sheath to maintain hemostasis; do post study of PA pressure.
t. Remove both venous and arterial sheath, apply pressure bandage.
 Advise to drink plenty of fluids in order to prevent hypotension
Policy on Cardiac Catheterization
1.0DEFINITION:
1.1 Cardiac catheterization (kath-uh-tur-ih-ZAY-shun) is a procedure used to diagnose and treat

cardiovascular conditions. During cardiac catheterization, a long thin tube called a catheter is inserted in
an artery or vein in to groin, neck or arm and threaded through the blood vessels of the heart for
investigational and interventional purpose.
58 | P a g e
2.0 PURPOSE :
To outline the standard nursing management of patient before and immediately following cardiac
catheterization.
SCOPE:
Cath lab
PRE CATH
 Check the order for procedure

 Refer history regarding anticoagulant (blood-thinning) medications, aspirin, or other medications that
affect blood clotting
 Ensure that consent is taken by the doctor
 Ensure that all the investigations are done as per CAG package.
 Ensure that patient is Nil by mouth.
 Ensure part preparation as per the procedure.
 Follow infection control practices
 Ensure the IV line is patent
 Ensure that patient is not wearing any valuables e.g. Jewelry and not having artificial dentures. If
present hand it over to the relatives and get their signatures in the designated space
INTRA CATH/IN THE PROCEDURE ROOM
 Follow infection control practices

 Enquire and document the following:
 Allergy to contrast agents
 Allergy to seafood or any medicines
 Use any medicines, including Viagra or other drugs for erectile dysfunction
 Probability of pregnancy
 Follow time-out procedure to avoid wrong patient, wrong site & wrong procedure
 Ensure the presence of a female attended if there is any female patient (As per unit policy)
59 | P a g e
 Prepare procedure trolley as per the requirement of the procedure
 Assist the primary operator /the interventional cardiologist during the cardiac procedures
 Do continuous monitoring during the procedure and document every 15 minutes
 After procedure shift the patient to recovery area and hand over to concerned nurse
POST CATH
 Make the patient comfortable and provide privacy

 Check vital signs as per policy (with/without sedation)
WITHOUT SEDATION (Monitor - Vital Signs and pain)
 Pre-procedure – Once
 Intra-procedure – Every 15 minutes
 Post-procedure – Once
WITH SEDATION (Monitor – Vital Signs / pain / level of consciousness/ SPO2 / ECG if advised / others
if specified)
 Pre-procedure – Once
 Intra-procedure – Every 15 minutes
 Post-procedure
– In the procedure room - every 15 minutes for 30 to 60 minutes (As per patients stay or
discharge)
– At the bed side – Every 15 minutes for 1 hour
 Explain the procedure to the patient and remove the sheath

 Apply pressure till the bleeding stops followed by application of pressure bandage.
 If the insertion site is groin - A small sandbag may be placed on top of the bandage for additional
pressure on doctors’ advice
 If the insertion site is arm - by placing patient arm in an arm guard for several hours /as per doctors
advise
 Check the site for bleeding and hematoma, and report if any.
 Instruct the patient to keep the involved leg in a straight position in case of femoral approach. Ensure
that patient will not bend his leg for 6 hours /as per doctors’ advice
60 | P a g e
 Instruct the patient to avoid pressure over the particular hand in case of radial approach. Ensure that
patient arm is kept elevated on pillows and kept straight
 (Check dorsalis Pedi’s and posterior tibia Lis pulse in the limbs in case of femoral approach &
brachial or radial pulse in case of radial approach.
 Ensure that ‘procedure with/ without sedation form is complete.
 Monitor urinary output strictly especially if dye is used for the Cath procedure
 Complete the In-house transfer form if required.
 Possible complications of any type of catheterization include the following:
 Bleeding, infection, and pain at the IV or sheath insertion site
 Damage to the blood vessels
 Blood clots
 Kidney damage due to the contrast dye (more common in people with diabetes or kidney
problems)
 Once NBM over give orally and check patient tolerance level
 Document the patient condition in the Nurses chart
5.0 DOCUMENTATION
5.2 Document in the Doctors progress notes/ Nurses notes.
Policy on chemo embolization
Purpose:
61 | P a g e
Anti-cancer drugs are administered directly into the blood vessel feeding a cancerous tumor.
Scope:
Palliative procedure primarily used in treatment of hepatocellular carcinoma.
Procedure:
Patient Assessment:

 Assess vital signs.,
 Explain and discuss the procedure with the patient/relatives & get his or her consent.
Articles Needed
 6F sheath.
 Puncture needle.
 4F Sim 1 catheter.
 4F Cobra catheter.
 Progreat micro catheter.
 0.035 team guide wire.
 PVA particles 300microns, Gel foam.
 10ml syringe – leurlock –1.
 1ml leurlock syringes-4nos.
Preparation :

 Preparation of the sterile trolley.
Procedure Steps :

62 | P a g e
 Draping the patient in such a way that inguinal fold lies diagonal to the side
hole.
 Load 10ml of xylocaine and Inj. Heparin 100IU/KG
 The Right (or) left femoral artery in the most commonly used
 access site
 Inj. Xylocaine 2% administered insensitive to pain to blocking the nerve.
 Puncturing femoral artery with puncture needle.
 6F sheath introduced – Inj. Heparin 2500IU given.
 4F Sim1 catheter selectively introduced taken up to the common hepatic branch
of the coeliac.
 Through the 4F catheter progreat micro catheter is super selectively introduced in
the branches supplying the tumour.
 Check injection performed with diluted contrast confirms the tumour vascularity.
 Chemotherapeutic agent mixed with lip idol and
 injected through the micro catheter.
 Embolization of the target vessel diffusing PVA particles, gel foam.
 Check injection confirms the embolization of the feeding artery to the tumor.
 Remove the catheter with guide wire.
 Remove the catheter, sheath, check hemostasis and apply pressure bandage.
Post procedure care:
 Patient shifted to post procedure care room/ ICU for observation.

 Advise to keep the leg straight for 24 hours.
63 | P a g e
Policy on COA Stenting
1.0 Purpose:
This procedure is to relieve the severe narrowing in the aorta by percutaneous balloon dilatation /
stenting.
2.0 Scope:
To treat Aortic disease.
3.0 Procedure:
Articles required.
 RCA or multi catheter (6F).
 0.035 thermo guide wire (150cm).
 0.035 Teflon guide wire (145cm).
 6F pigtail.
 6F sheath.
 CP stent pack.
 Balloon catheter.
 0.035 Teflon double length (260cm).
 10ml syringes-1(local anesthesia).
 10ml leurlock-2.
 20ml syringes-1.
 Inj. Heparin-100 IU/KG
 2ml syringe-1.
 Inflation device-1.

 Doctor will explain the procedure as well as the likelihood of
complication related procedure to patient.
64 | P a g e
 Patient will be asked to sign a consent form that gives his/her permission
to do the procedure.
 Remove jewelry or other objects that may interfere with the procedure.
Preparation :
 Sterile scrubbing, gowning & gloving.

 Load Xylocaine (10 ml), Heparin (100 IU/KG), NTG – (500 mics).
 Flush the entire connection with saline for air free continuity.
 Flush puncture needle & sheath.
 Aspirate contrast in inflation device & de air it.
 Place sponge near puncture area & keep ready things for arterial puncture 10 ml of 2%
xylocaine in 10 cc BD syringe attached with 21 G needle.
 0.038’’teflon introducer wire.
 Sheath & dilator.
 Puncture needle 18G
Procedure Steps :
 Place the patient in a supine position.

 Connect the patient to a cardiac monitor and check blood pressure and pulse.
 Anti-microbial (Betadine solution) painting (from umbilicus to knee joint).
 Load 10ml of xylocaine and Inj. Heparin 2500 iu.
65 | P a g e
 Inj.Lignocaine 2%administered insensitive to pain to blocking the nerve.
 Sterile scrubbing, gowning and gloving.
 Clean the inguinal region of both sides (from umbilicus to knee joint).
 Load local in 10 cc syringe (30 mg /kg).
 Getting an arterial access, introduce guide wire and sheath and remove the dilator, flush
the sheath and give inj. heparin 100 IU/KG
 Cross the coarcted area with a RCA with 0.035 terumo and measure pull backpressure.
 Exchange with exchange length 0.035 Teflon and remove the RCA.
 Take the pigtail over that exchange length and do pressure injection.
 If pullback gradient pressure is less than 20mm no need for stenting and if it is more than
20 mm stenting to be done.
 This can also be done after balloon dilatation according to the constricted area
(measurement of coarcted area and normal aortic diameter).
 Balloon to be prepared as usual as any other balloon, remove the pigtail and keep the
exchange wire inside.
 Remove the sheath and introduce the balloon across the coarcted area, Inflate the balloon
slowly and deflate it.
o Measure the pull backpressure and the coarcted area.
o Get the stent pack and prepare the long sheath, dilator and balloon.
o Introduce the sheath and dilator. Remove the dilator and keep the wire across the coarcted
area.0
o Prepare the stent material.
 Prepare the balloon and keep it in negative pressure.
 Crimp the stent over the balloon.
 Prepare inflation device.
 Put the stent introducer.
o Insert the balloon stent up to the sheath tip.
 Position the stent across the area and inflate the outer balloon (monitor pressures)
and deflate both slowly.
o Remove the balloon and exchange wire, flush the sheath and connect pressure line.
66 | P a g e
o Check angio to note the corrected area, and then remove the sheath and obtain
hemostasis.
o Apply pressure bandage and shift the patient to ICU for observation.
Post procedure care :

5.0 DOCUMENTATION
Policy on ASD Closure
1.0 Purpose:
Atrial septal defect (ASD) is a form of congenital heart defect that enables blood flow between two
compartments of the heart called the left and right atria, due to interatrial septum deficient.
2.0 Scope:
Atrial septal defect (ASD) is a form of congenital heart defect that enables blood flow between two
compartments of the heart called the left and right atria, due to interatrial septum deficient
management of ASD Closure.
67 | P a g e
3.0 Procedure:
Articles required:
 Venous sheath – 8F & appropriate size.
 Multipurpose catheter (end hole) / right judkins catheter (RCA catheter).
 0.035 teflon guide wire (150cm)
 0.035 Amplatz guide wire (260cm)
 Devise delivery sheath with dilator.
 Devise delivery system.
 Devise Introducer.
 Syringes-10ml-1, Leurlock-2.
 Syringes2ml-1.
 Inj.Heparin-100 I.U./KG
 Inj.xylocaine
Before the Procedure:

 Doctor will explain the procedure as well as the likelihood of
complication, related procedure to the patient.
 Patient will be asked to sign a consent form that gives his / her permission
iodine.
 Based on patient’s medical condition, doctor may request other specific
preparation.
procedure.
Procedure steps:
68 | P a g e
 Place the patient in supine position.
 Connect the patient to a cardiac monitor and check blood pressure, pulse &
02 saturation.
 Anti-microbial (Betadine solution) painting (from umbilicus to knee join).
 Draping the patient in such a way that inguinal fold lies diagonal to the
side hole.
 Load 10ml of xylocaine and Inj. Heparin 100 I.U./Kg
 The Right (or) left femoral vein is the most commonly used access site.
 Puncturing femoral vein with puncture needle (18G)
a. A diagnostic multipurpose catheter with 0.035 terumo guide wire to be passed through the IVC
up to left (upper pulmonary vein) preferably UPV)
b. Once the wire crossed the ASD, place the catheter in the left upper pulmonary vein.
c. 0.035 wire to be removed and 0.035 Amplatz guide wire to be introduced.
d. Remove multipurpose catheter.

Prepare the device delivery system:
a. Long sheath with dilator (flushed).

b. Device introducer.
c. Device delivery cable.
Perform TEE to confirm the size of the ASD device, wherever necessary.
Loading of the device:
69 | P a g e
The size of the device to match the diameter of the defect. Pass the device cable through the
device introducer and screw it (anti clockwise) to device pull the cable till the device comes
in the introducer.
 Introduce the long sheath in to ASD through the wire and remove dilator
with wire.
 Pass the device through sheath and advanced to the left atrium.
 The sheath is then retracted allowing the LA disc of the device to unfold.
 The whole unit is then pulled back until the LA disc fits snugly against the defect in the internal
septum.
 The sheath is further retracted allowing the RA disc to unfold in the mid
right atrium after positioning the device across the ASD, Minesotta
Wiggle is done to confirm that the device is fitting appropriately.
 TEE and Fluro is done to confirm the position and absence of the
obstruction to SVC, IVC, pulmonary venous, coronary sinus flow.
 Later the device is released and the whole system is removed. Once
hemostasis is achieved, apply pressure dressing.
5.0 DOCUMENTATION
5.1 Record administration on the patient’s Medication Chart and Cath lab monitoring
5.2 Document in the patient’s progress notes/ Nurses Notes.
Policy on VSD Closure
70 | P a g e
1.0 Purpose:
In normal development, the wall between the chambers closes before the fetus is born, so that by
birth, oxygen- rich blood is kept from mixing with the oxygen-poor blood. When the hole does not
close, it resulting in shunting a blood from one circulation to another resulting in reduced oxygen to
the body.
2.0 Scope:
Management of VSD Closure / ventricular septal defect. Ventricular septal defect is usually symptomless at
birth. It usually manifests a few weeks after birth. VSD operating with a left – to- right shunt, now becomes a
right-to- left shunt because of the increased pressures in the pulmonary vascular bed.
3.0 Procedure:
Things needed:
 5F Sheath – 1.
 6F Sheath – 1.
 5F Pigtail – 1
 0.035’Teflon Amplazter stiff wire (260cm)-1
 5F RCA – 1
 0.035 terumo wire (150cm)-1
 Snare catheter-1
 Noodle wire double length (300CM)-1
 Device delivery system (preferable French)
 Pressure monitoring line - 2
 Mullin sheath
 10ml syringes-1
 10ml leurlock syringe-2
 2ml syringe-2
 Surgical blade-11

related procedure to the patient.
71 | P a g e
 Patient will be asked to sign a consent form that gives his/ her permission
 Based on patient’s medical condition, doctor may request her specific preparation.
Preparation:
 Both the sides of the groin to be prepared with antimicrobial solution and
right side of the neck from lower part of jaw to upper chest.
 Drape the patient with drape sheet.
 Prepare big trolley & procedure table as for any other device closure
procedure.
 Pre-catheterization to be done to define the no, location & size of the VSD and
relationship of these defect to the atrio ventricular and semi lunar valves.
Procedure:
 Place the patient in a supine position

 Anti-microbial (Betadine solution)
hole.
 Load 10ml of xylocaine and Inj.Heparin 100 I.U./KG
72 | P a g e
 Puncturing femoral artery and venous & right jugular vein with puncture
needle (18G)
 Right Femoral artery accessed. Right internal jugular vein punctured and sheath is introduced.
 Via venous access 6F multi catheter is to be introduced into the PA to measure the PA pressures
& wedge pressure.
 Pressures to be notified &the swan’s catheter removed.
 Introduce the pigtail catheter with 0.035 Teflon stiff wires into the LV. Remove Teflon wire &
attach the pressure line.
 Monitor the pressure and done pressure injection in LV to define VSD.
 Then remove the catheter along with 0.035 Teflon stiff wires.
a. Introduce RCA catheter with 0.035 terumo wire into the aorta to LV to RV to PA.
b. Track the catheter into the PA & remove the terumo wire and exchange for the double
length Noodle wire.
c. Once the noodle wire is in PA remove the RCA catheter.
d. Take snare catheter & wire via venous route to RA to RV to PA.
e. Snare the noodle wire tip into the snare catheter & pull that wire into the catheter and
exteriorize the wire out of the jugular vein.
f. Now the noodle wire is out through the venous access.
g. Get the device delivery system and prepare it.

h. Get the device and load the device into the loader and keep it ready for use.
i. Introduce the sheath and dilator via venous access over the noodle wire into RV to aorta.
j. Remove the dilator and wire, flush the sheath properly without any air and attach
hemostatic value.
k. Introduce device with loader & introducer in to the sheath. Push device with loader up to
the tip.
l. Pull back the sheath into the LV & push the device.
m. The sheath is then retracted allowing the distal portion of the device to unfold.
73 | P a g e
n. The whole unit is slowly pulled back until the distal device fits snuggly against the
defect in the LV.
o. The sheath is further retracted allowing for the proximal device to unfold in the mid right
ventricle.
p. With the correct positioning of the device confirmed, the device is released and the
delivery cable is pulled back to the sheath.
q. A control LV angiogram is performed to confirm the closure of VSD with pigtail.
r. Measure LV systolic/ diastolic, LV-EDP & pull back aortic pressure also to be done with
pigtail.
s. Measure PA pressure, PA wedge pressure & RV pressure with swans.
t. Remove both venous and arterial sheath.
u. Once the hemostasis is obtained, apply pressure bandage.

Patient shifted to post procedure care room.
Check pulse and blood pressure with the support of monitor.
Ensure no bleeding or hematoma formation in puncture site.
Advise to keep the leg straight for first 8 hours.
Advise to drink plenty of fluids in order to prevent hypotension.
5.0 DOCUMENTATION
5.1 Record administration on the patient’s Medication Chart and cath lab Monitoring chart
5.2 Document in the Doctor’s progress notes/ Daily Nurses Notes.
Policy on coil embolization
1.0 Purpose:
The goal of endovascular coiling is to isolate an aneurysm from the normal circulation without
blocking off any small arteries nearby or narrowing the main vessel. Endovascular describes the
minimally invasive technique of accessing the aneurysm within the bloodstream, specifically by
74 | P a g e
angiography.
2.0 Scope:
Useful in treatment of patients with subarachnoid hemorrhage due to ruptured intracranial
aneurysms as well as in the treatment of unretired incidental aneurysms.
3.0 Procedure:
3.1Patient Assessment:
Determine the patient's past medical, allergy, medication history.
Assess the patient’s cardiac and pulmonary status.
 Explain and discuss the procedure with the patient/relatives& get his or her consent.
 A ruptured aneurysm is life threatening, and every patient is assessed for medical
stability and treated as necessary.
 A patient with an unruptured aneurysm has time to prepare for a scheduled surgery
and will typically undergo tests (e.g., blood test, electrocardiogram, chest X-ray)
several days before surgery.
 7F femoral sheath.
 0.035 Terumo wire 145cm, 260cm.
 5F JR 3.5 catheter.
 6F/7F guiding catheter.

 Aneurysm remodeling balloons with micro guide wire [0.010].
 Self-expanding intracranial stents.
 Platinum coils of various sizes.
 Coil detachable device/cables.
 Inj. Nimodipine, Inj. Heparin 5000 iu/ iv set, 100cm, Extensions – 10cm – extensions.
 Y- connector – 3 way lumen-1, 2 way – 1.
 1ml luerlock syringe – 1.
 10ml luerlock syringe – 3.
75 | P a g e
 1 litre-pressure bag-2.
 Normal saline-1000ml-2.
 Micro catheter, micro guide wire – 0.014
3.3 Preparation:

 Preparation of sterile trolley.
 Patient prepared on his supine position & head is fixed with head ring.
 Inj. Heparin 100IU/KG
 Bilateral femoral puncture done with 18G.
 Remove the dilator with wire and flush the sheath
 One femoral artery is used for arterial pressure monitoring (5F sheath).
 Through the Right femoral arterial sheath (7F) Diagnostic catheter introduced
selectively in to the diseased artery along with 3.5 guide wire
 Check injection confirms the location of the aneurysm in the carotid / vertebral
circulation.
 6F / 7F guiding catheter was exchanged for diagnostic catheter and placed in the
internal carotid artery (C2 level) / vertebral artery.
 (Guiding catheter connected to the Inj. Nimodipine. & Inj. Heparin flush continuously
to prevent thrombo embolic phenomenon and less vasospasm.
76 | P a g e
 Through the guiding catheter under road map control remodeling balloon was placed
across the neck of the aneurysm with the help of micro guide wire.
 The aneurysm was accessed with micro guide wire& micro catheter combination
under road map control.
 Micro guide wire removed and the aneurysm was emboli zed using varying sizes of
detachable platinum coils with balloon remodeling technique.
 Check injection confirm total occlusion of the aneurysm and filling up of normal
intracranial branches.
 Micro catheter removed with the help of micro guide wire.
 Balloon with micro guide wire removed.
 Guiding catheter removed.
 Femoral sheath sutured in place to be removed after coagulation parameter becoming
normal.
 Pressure is applied to the groin for hemostasis. After hemostasis compression dressing
is done.
 Patient shifted to post procedure care room /ICU.
 Check pulse and blood pressure with the support of monitor for 24-48hrs.

 Advise to keep the leg straight for 24 hours.
 Post procedure CT scan to rule out fresh bleed.
 Extubation of the patient after assessment by critical care intensivists.
3.6 Discharge instructions
 Mild headache can develop after the procedure.

 Drink plenty of fluids, especially water for the next few days; this will help flush out
the contrast dye.
77 | P a g e
 Pea-size lump in your groin or mild tenderness and bruising at the incision site is
normal.
Policy on IVC Filter
1.0 Purpose :
A vena cava filter is an expandable metal device specially designed to trap blood clots before they
reach the lungs. The filter is placed in the inferior vena cava (IVC) – the large vein that carries
blood from the lower extremities back to the heart and lungs – and remains in place to trap clots
before they move further up towards the lungs.
2.0 Scope:
Preventing Acute Proximal DVT & Acute Pulmonary Embolism
Recurrent pulmonary embolism despite well documented anti coagulation in DVT of lower limbs.
3.0 Procedure:
3.1 Articles required:
 Pigtail with 0.035 Teflon.
 Filter size catheter according to IVC diameter.
 6F sheath pack.
 Puncture needle –18 G.
 IVC filter pack contains long guiding sheath, dilator, guiding wire 0.035
Teflon, filter, and pusher.
 10ml syringes-2.
 Inj. Xylocaine-10ml.
 5ml-syringes-1.
3.2 Before the procedure:

78 | P a g e
 Patient will be asked to sign a consent form that gives his/her permission to
do the procedure.
iodine.
 Based on patient’s medical condition, doctor may request other specific
preparation.
 Remove jewelry or other objects that may interfere with the procedure.
3.3 Procedure steps :

 Connect the patient to a cardiac monitor to check blood pressure, pulse 02
saturation.
hole.
 The Right (or) left femoral vein in the most commonly used access site.
 Inj.Lignocaine 2%administered insensitive to pain to blocking the nerve.
 Puncturing femoral vein with puncture needle (18G).
 Pressure injector to be prepared with contrast, pigtail with .035 Teflon also to
be prepared.
 Getting a venous access by an 18G needle attached with syringe, and introduce
guide wire and sheath. Flush the sheath, give inj.Heparin 100 IU/Kg and flush.
79 | P a g e
 Introduce pigtail with 0.035 Teflon guide wire and position the pigtail at the level
of the renal vein. Remove the guide wire and flush catheter and then attach the
pressure injector.
 Injection to be done to detect the renal vein drainage into IVC, measure IVC
diameter, identify bifurcation and according to that select appropriate filter.
 Position the filter according to marker given in the filter; proximal one is above
the bifurcation, distal one is to be placed below the site of attachment of renal
veins.
 Prepare the renal or filter guiding by flushing that long sheath and dilator,
introduce the 0.035 Teflon guide wire and remove the 6F sheath.
 Introduce the prepared guiding sheath with dilator only up to lower IVC and then
remove the dilator and wire, flush the sheath.
 Prepared device to be pushed in to the sheath with a pusher given in that pack.
 Implantation of filter to be done by push and pull method, pull the catheter out
and push the stent with the help of pusher and implant the filter.
 Check angio to be taken, remove the sheath and apply pressure bandage.
Patient shifted to post procedure care room.

 Advise to keep the leg straight for first 2 hours.
80 | P a g e
81 | P a g e

Cathlab Manual

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cathlab Manual

Uploaded by

Copyright:

Available Formats

CATHLAB MANUAL

Preparation Approval Issue

SIGNATURE SIGNATURE SIGNATURE

S.NO PARTICULARS PAGE NO

S.N PAGE SECTION/ DATE OF AMENDME REASONS AMEND SIGNAT

1.1 Control of Issue Number & Amendment Number

Periodical review of manual / document (once in a year)

Major Change in the document control procedure

S.No Abbreviations Expansion

Policy on intra aortic balloon pump management

3.1 IABP, gas supply.

3.2 ECG and arterial pressure monitoring supplies.

3.4 IAB catheter insertion kit.

3.5 Povidone-iodine solution sterile gowns, gloves and drapes.

3.6 Sterile dressing supplies.

3.7 O-silk suture on a cutting needle, used to suture catheter to skin.

3.8 Number – 11 scalpel, used for skin entry.

3.9 1% lidocaine without epinephrine, one 30 - mL vial.

3.10 Stopcocks, one 2-way and one 3-way.

3.11 One luer-lok plug.

3.13 Hemodynamic monitoring tubing with transducer.

3.14 Analgesics and sedatives as prescribed.

3.15 Lead apron (needed if procedure is performed using fluoroscopy)

3.16 Prescribed intravenous (IV) solutions.

3.17 Emergency medications and resuscitation equipment.

3.19 Vasopressors as prescribed.

3.20 Antibiotics as prescribed.

3.21 Heparin infusion or dextran if prescribed.

4.1 Procedure for assisting with IAB Catheter Insertion.

4.3 Turn on gas supply.

a. Activates the gas driving the balloon pump.

b. Check manufacturer’s recommendations.

b. A secondary ECG source is desirable in the event of lead disconnection or loss of

4.6.1 Hemodynamic monitoring is necessary for assessment and management of the

a. Ensures adequate functioning if the IABP device.

b. Models of the pump console vary. Review of manufacturer’s instructions is

b. Catheters vary in volume of the balloon. An adequate volume is necessary to achieve

4.9 Administer heparin bolus before arterial puncture, if prescribed.

a. Anticoagulation may decrease the incidence of thromboemboli related to the

b. Systemic anticoagulation may not be used in all patients.

a. Creates a device for air removal from the balloon catheter.

b. Maintains wrap of balloon for insertion.

a. Removes air from the balloon, creating a vacuum.

4.12 Disconnect the syringe only.

a. Prevents air entry back into the balloon.

b. Leave the one-way valve in place.

4.13 Lubricate the IAB catheter with sterile saline.

a. Decreases “drag” on the catheter during insertion.

a. Removes air from the central lumen.

4.15 Assist with introducer sheath or dilator assembly and insertion.

a. Prepares for balloon catheter entry.

4.16 Assist with balloon catheter insertion.

a. Catheter placement is a necessary part of IAB setup.

a. Monitors arterial pressure.

b. Some manufacturers and institutions recommend hourly manual flush of central

4.20 Attach the balloon-lumen tubing to the pump console.

4.21 Follow steps for timing, troubleshooting, and patient monitoring.

a. Provides for appropriate operation of counter pulsation.

4.22 Zero the pressure transducer.

a. Ensures accurate arterial pressure measurement, timing, maintenance and functioning

b. Refer to specific manufacturer instructions.

4.23 Obtain a portable chest X-ray as soon as possible.

a. Correct IAP catheter position must be confirmed to prevent complications associated