Percutaneous Interventions

Shannon Fogg, RN, MSN

Objectives
Differentiate various percutaneous coronary and peripheral interventions. Describe how to assess for and manage complications of percutaneous interventions. Discuss appropriate nursing interventions related to post-intervention care.

Cardiac Anatomy
Review

Cardiac Anatomy
Review

CAD- Coronary Artery Disease

CAD-Narrowing of small vessels- that supply blood to the heart Can be determined by:

Exercise Stress Test Nuclear Scan ECG Echocardiogram Definitive test-Cardiac Cath Lab

CAD Coronary Artery Disease

Healthy artery Heart artery with healthy blood flow Heart artery plaque that restricts blood flow

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Cardiac Catheterization
Diagnostic procedure

Arterial Access sites

Common femoral artery Radial artery Brachial artery Axillary artery Popliteal artery

Radiopaque Contrast Materials

Used for imaging Exposes blockages or lesions May lead to acute renal insufficiency, prolonged hospital stays and even death

Right Heart Catheterization

Left Heart Catheterization

PCI

POBA
Insertion of Balloon Inflated Balloon Plaque against vessel wall, patent

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Stent

Scaffolding placed into vessel Pressed into inner wall of artery Permanent Coating Drug-eluting

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Atherectomy

www.sutree.com/how-to/15755/Types-of-Atherectomy

Other PCIs
Brachytherapy
Radiation therapy Radiation source inside of or next to area needing treatment Inhibit cell growth in responsible for restenosis

Intravenous Ultrasound (IVUS)

Technique for visualizing coronary arteries, chambers, and valves Guided by catheter May visualize plaque that is not seen by angiography

Peripheral Vascular Disease

PTA Percutaneous Transluminal Angioplasty

Vessels of Upper and Lower extremities

Carotid Subclavian and Brachiocephalic Renal Iliac Femoropopliteal Tibioperoneal

Also known as PEI Peripheral Endovascular Intervention

Carotid Stents

Renal Artery Stents

Valvular Disease

Valvuloplasty & Valve Replacement

Before the Lab

Before the Lab

Assessments

NPO status Labs

Electrolytes Renal function

Allergies Meds

Preparing Your Patient

For Nurse
Inpatients ready at 5AM Notify physician of abnormalities Complete preprocedure checklist On-call medications

Interventions

For Patient

Focused assessment (pulses, bruit) Baseline 12-lead EKG (cardiac procedures) Informed consent Pre-procedure verification Patient education

In the Lab

After the Lab

After the Lab

H&P Orders Procedure log report Cath lab summary Cath Lab nursing documentation

Where Do I Look?

After the Lab

Vital signs Pulse assessment Groin assessment Telemetry/EKG Labs Pain rating and response to medications

What Do I Look For?

Interventions
Bedrest HOB 45 or less Push oral fluids (avoid citrus) IV fluids I&O Resume medications Patient Education!

Post PCI 12-Lead EKG ProB, CBC, Cardiac Enzymes 4hrs and 12 hrs post Repeat ProB if creatinine is elevated

Sheath Pulling-Manual Compression

Manual compression is the traditional method to achieve hemostasis. It is what all hemostatic devices are compared to Correct technique is essential to stop bleeding & minimize complications such as hematomas, pseudeoaneurysms, etc.

Manual Compression Technique

Distal pulses assessed prior to compression Sterile gloves should be applied Should hold two fingers above the puncture site and one finger on the top site prior to sheath/catheter removal Patient instructed to take a deep breath in & exhale slowly As the patient exhales sheath/catheter should be removed firm pressure should be applied

Sheath Pulling Interventions

ECG monitoring before and during removal Watch HR and BP every 2.5 min IV access, atropine and NS available Assess perfusion before and after pressure device in place

Post Sheath Removal Interventions

Assess puncture site & distal pulses per hospital protocol Pt should be instructed to:

Keep head down in order to avoid strain on site Hold site if pt has to cough, sneeze, or laugh Keep affected leg straight & flat Call nurse if feel anything warm & wet-have pt hold pressure at site until help arrives HOB can be no greater than 30-45 degrees

Alternatives to Manual Compression

Femostop Safe guard These devices used to assist in manual compression Placement and release of pressure of these devices These devices must be monitored during their use

Femostop
Composed of plastic arch, inflatable transparent dome, connection tubing, elastic belt, & hand held manometer Usually inflated 20 mmhg above systolic bp Over 10-15 minutes pressure is decreased 20 mmhg every 2 minutes until pressure released Pressure must be gradually released

Safeguard
Composed of latex free sterile dressing, & inflatable bulb Bulb provides constant pressure on puncture site Placed on pt once hemostasis is achieved Maximum inflation 50 ml of air Puncture site & distal pulses should be checked per hospital protocol

TR Band
Plastic bracelet w/ dual balloons used to compress radial artery Air injected via injection port to apply compression to radial artery Must be sure to keep air syringe- will need it to remove air Must assess circulation of affected hand Release of pressure-usually 2-4 hrs or as ordered by MD

Closure Devices
Angioseal-collagen plug inserted in artery, reabsorbed in body in 90 days Mynx- extravascular plug-dissipates in 30 days Perclose-suturing of artery Exoseal-Bioabsorbable plug Reduces bedrest dramatically Most patients can ambulate after 2 hrs

Complications

Bleeding

Bleeding
Manual pressure - 10 minutes (no peaking) Page CV tech Reapply dressing

GI bleeding Hematuria

Hematoma

Retroperitoneal Bleed

Vasovagal Syncope
Assessment

Interventions
Atropine 0.5mg 1mg IVP Fluid bolus (watch EF) Hold/discontinue nitrates Modified trendelenberg Check groin, H&H

Drop in HR and/or BP Feeling hot Nausea Pallor Diaphoresis

Coronary Reocclusion or MI
Assessment
Chest pain assess PQRST Bruise pain? Elevated cardiac enzymes ST elevation

Interventions

Vital Signs MONA 12-Lead EKG Possible re-cath Reassure patient

Cardiac Tamponade

Assessment

Treatment

Becks Triad Narrowing pulse pressure Tachycardia, dyspnea

O2, fluids Echocardiogram Pericardial window Pericardiocentesis

Contrast Nephrotoxicity

Contrast-induced nephrotoxic effects

increase of > 0.5mg/dL in serum creatinine within 48 hrs after contrast injection 3rd leading cause of ARF in hospitalized patients

Creatinine levels peak 4-5 days after contrast, return to baseline approximately 5 days after peak. Can last up to 3 weeks

Other Complications
Infection Groin site pain Vessel occlusion Embolization

Discharge
Patient Education Diagnoses and Procedure type, location Medications Plavix every day!! Diet and exercise Smoking cessation Site care Signs of infection Bleeding When to call 911 Follow-up appointment Contact information

References
Apple, S. & Lindsay, Jr. , J. (2000). Principles and practices of interventional cardiology. Philadelphia: LWW. Cardiovascular care made incredibly easy (2nd ed.) (2009). Philadelphia: LWW. Morton, P.G. & Fontaine, D.K. (2009). Critical care nursing: A holistic approach (9th ed.). Philadelphia: LWW.