Cardiac catheterization

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1. Cardiac Catheterization Grace Frances Pedrena July 15, 2009

2. I. Introduction

3. Cardiac Catheterization -is one of the invasive procedures used to visualize the heart’s chambers, valves and great vessels in order to diagnose and treat disease related to abnormalities of the coronary arteries. The procedure involves inserting a long, flexible, radiopaque catheter into a peripheral vein peripheral artery and guiding it under fluoroscopy (x-ray observation) or angiography.

4. History Werner Forssman

5. Prevalence and Statistics

6. II. Purpose Chamber pressure Oxygen Saturation Ventricular Function Valvular Insufficiencies and stenosis Septal defects Congenital abnormalities Myocardial Function

7. Indications: The indications for cardiac catheterization are to: Confirm suspected heart disease, including coronary artery disease, myocardial disease, valvular disease and valvular dysfunction To determine the location and extent of the disease process. To assess the following: Stable, severe angina unresponsive to medical management Unstable angina pectoris Uncontrolled heart failure, ventricular dysrhythmias , or cardiogenic shock associated with acute myocardial infarction, papillary muscle dysfunction, ventricular aneurysm, or septal perforation.

8. To determine best therapeutic option ( percutaneous transluminal coronary angioplasty, stents, coronary artery bypass graft, valvulotomy versus valve replacement) To evaluate effects of medical or invasive treatment on cardiovascular function, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft patency.

9. Contraindications Allergy to the contrast medium used in the study Pregnancy, unless the benefits of performing the study greatly outweigh the risk to the fetus. It is a relative but not absolutely contraindicated. Clients who will not allow cardiac surgery to be performed to correct pathology diagnosed by the study. Medical conditions such as severe infection, irreversible brain damage, or congestive heart failure (CHF), which are considered relative to their extent emergency status, and potential benefit as opposed to the risk.

10. Coagulopathy , impaired renal function, and debilitation usually contraindicate catheterization of both sides of the heart. Unless a temporary pacemaker is inserted to counteract induced ventricular asystole , left bundle-branch block contraindicates catheterization of the right side of the heart. Digitalis toxicity, anemia and electrolyte disturbance

11. Normal Values/Normal Findings Pressures Left ventricular systolic 90-140mm Hg Left ventricular end diastolic 4-12mm Hg Central venous Pressure (CVP) 2-14cm H 2 O Left atrium 2-12mm Hg Pulmonary artery systolic/end-diastolic 17-32/4-13mm Hg Pulmonary wedge pressure 6-13 mm Hg Cardiac Output 3-6 L/min Ejection Fraction 60-70%

12. Oxygen Saturation values for the heart and its surrounding vessels Superior vena cava 70% Inferior vena cava 80% Coronary sinus 20% Right chambers 75% Pulmonary artery 75% Left chambers 95%

13. IV. Assessment Nursing assessment before the procedure measuring the client’s vital signs auscultate the heart and the lungs evaluating the peripheral pulses Asking the client about any history of allergy to iodine-based contrast agents asking if the client normally takes a digitalis preparation or diuretic

14. Assessment after the study monitoring vital signs every 15 minutes for 1 hour, every 30 minutes for the next hour and every hour if stable taking peripheral pulses. The radial pulse should be palpable and as strong as it was prior to the catheterization. assessing the skin color and temperature on both extremities of the site and comparing for circulatory alterations assess site blood leaks and apply pressure.

15. V. Procedure

16. Catheters most frequently used for right and left-heart catheterization are: Sones Judkins Amplatz

17. Coronary arteriography Pigtail Eppendorf NIH Lehman Sones Judkins Amplatz

18. Judkins Catheter Amplatz Catheter Swan- Ganz pigtail

19. Procedure The client is placed in a supine position on the x-ray table, and securely strapped into the table An infusion of D 5 W ECG leads are positioned and attached to the client as well as a cardiac monitor Blood pressure, pulse and respiration equipment is used for continuous monitoring of the heart activity and vital signs. The catheterization site is shaved if necessary, cleansed and draped to establish a sterile field. A local anesthetic is injected at the insertion or cutdown site, General anesthesia via gas or rectal suppository is administered to young children under age 12 The vein or artery is punctured with a needle and a wire inserted through the needle. The catheter is then passed over the wire and into the vessel after the needle is removed

20. Right heart catheterization femoral and antecubital vein

21. Left heart catheterization brachial or femoral artery

22. Coronary Arteriography The transseptal technique

23. 9. The site is sutured if the cutdown was performed 10. a sterile pressure dressing is applied 11. patient is returned to a recovery area for further observation

24. Cardiac catheterization involves radiation exposure for staff members as well as the patient.

25. SEE VIDEO

26. VI. Nursing Care Before the Procedure Explain to the client: That the procedure is performed in a special cardiac laboratory equipped with monitors and supplies to minimize the risk of complications. That the procedure is performed by a physician (cardiologist) and takes about 1-3 hours, depending on the test to be performed. That the food and fluids are withheld for at least 4-6 hours before the study That some medications are withheld according to physician’s instruction, especially anticoagulant therapy, which is discontinued before the study. That the site is shaved, cleansed, and anesthetized with a local anesthetic and that the catheter is inserted and that a sensation is experienced as the catheter is advanced.

27. That a sedative, analgesic, or other medication to allay anxiety and promote comfort is given 1 hour before the study. The ECG activity, pulse, and blood pressure are monitored during the procedure because a temporary increase in pulse or arrhythmias can occur during the advancement of the catheter. That the contrast medium can be injected into the heart and vessels and cause a warm feeling or metallic taste but that it lasts only a few minutes. That the client can be requested to cough or breathe deeply during the study to enhance the blood flow through the heart.

28. Prepare for the procedure: Obtain informed consent Obtain the client’s height and weight, which will be used to determine dye administration. Ensure that dietary and fluid restrictions have been followed. Ensure that routine medications are restricted or allowed per physician order and that anticoagulants have been discontinued. Provide a hospital gown without metallic closures. Allow the client to retain dentures, glasses, or hearing aids, as they do not interfere with the study. Ensure that medications to reduce allergic response to the contrast medium are administered, that is, antihistamine and corticosteroid.

29. Obtain baseline pulse, blood pressure, ECG, and peripheral pulses, and mark the sites of peripheral pulses for comparison after the study. Administer a sedative or antianxiety agent such as diazepam (Valium), or both types of medication, and an analgesic such as meperidine (Demerol) as ordered before the procedure (30 minutes to 1 hour). Initiate an intravenous (IV) line to administer fluids and medications as needed during the procedure. Have the client void before the procedure. Obtain a history of suspected or known cardiac conditions, cardiovascular status, cardiac medications, allergies to iodine, and previous tests and procedures.

30. During the procedure Place the patient in the supine position on a tilt-top table and secured by restraints. ECG leads in place for continuous monitoring. The patient may be asked to cough or deep breathe. Monitor patient’s heart rate and rhythm; respiratory and pulse rates, and blood pressure frequently during the procedure.

31. The following equipment and associated supplies be on hand when performing cardiac catheterization to treat ventricular arrhythmias or other complications: resuscitation bag oxygen Suction oximetric device endotracheal tube defibrillator monitor for pulse and blood pressure ECG external temporary pacemaker medications such as lidocaine , bretylium , epinephrine, atropine, morphine, isoproterinol

32. After the procedure Monitoring vital signs every 15 minutes for 1 hour, every 30 minutes for the next hour, and every hour if stable Taking peripheral pulses and assessing skin for color and temperature on both extremities of the site and comparing for circulatory alterations. Maintain bed rest for 4 to 6 hours, depending on the procedure Extend the extremity used and immobilize it with sand bags Encourage movement of the unaffected extremity. Schedule post procedure ECG and future suture removal from the insertion site.

33. Observe for complications of cardiac catheterization. Complaints of pain and discomfort at the insertion site, chest pain, nausea, feelings of light-headedness should be reported. Because the contrast medium acts as an osmotic diuretic, monitor urine output and ensure that the client receives sufficient oral and IV fluids for adequate excretion of the medium. Pain medication for insertion site and back discomfort may be given as prescribed. Neurologic changes such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness should also be reported ( Ignatavicius , 2006, 698).

34. For patients being discharged in the hospital on the same day as the procedure, instructions are provided for self-care: For the next 24 hours, do not bent at the waist (to lift anything), strain, or lift heavy objects. Avoid tub baths, but shower as desired. Talk with physician about when to return to work, drive or resume strenuous activities. Call physician if bleeding, swelling, bruising, pain from procedure puncture site, temperature of 38.6 C occurs. If test results showed coronary artery disease, talk with physician about treatment and rehabilitation programs. Talk with physician or nurse about lifestyle changes to reduce further or future heart problems

35. VII. Interpretations/ Significant Findings/ Complications

36. Interpretations

37. Significant Findings

38. Complications allergic reaction to contrast media dysrhythmias and bleeding from puncture site Arterial thrombosis Perforation of the heart or intratoracic great vessels Vagal reactions Myocardial infarction Pyrogen reaction Complications

39. FIN………….