percutaneous interventions

Percutaneous Interventions

Shannon Fogg, RN, MSNShannon Fogg, RN, MSN

Miya Purvis, RN, MSNMiya Purvis, RN, MSN

ObjectivesObjectives

Differentiate various percutaneous Differentiate various percutaneous coronary and peripheral interventions.coronary and peripheral interventions.

Describe how to assess for and Describe how to assess for and manage complications of manage complications of percutaneous interventions. percutaneous interventions.

Discuss appropriate nursing Discuss appropriate nursing interventions related to post-interventions related to post-intervention care. intervention care.

Cardiac AnatomyCardiac AnatomyReviewReview

Cardiac AnatomyCardiac AnatomyReviewReview

CAD- Coronary Artery CAD- Coronary Artery Disease Disease

CAD-Narrowing of small vessels- that CAD-Narrowing of small vessels- that supply blood to the heartsupply blood to the heart

Can be determined by:Can be determined by:– Exercise Stress TestExercise Stress Test– Nuclear ScanNuclear Scan– ECGECG– EchocardiogramEchocardiogram– Definitive test-Cardiac Cath LabDefinitive test-Cardiac Cath Lab

CAD – Coronary Artery CAD – Coronary Artery DiseaseDisease

Healthy arteryHealthy artery Heart artery with Heart artery with

healthy blood flowhealthy blood flow Heart artery – Heart artery –

plaque that plaque that restricts blood flowrestricts blood flow

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Cardiac Catheterization Cardiac Catheterization Diagnostic procedure Diagnostic procedure

Arterial Access sitesArterial Access sites

Common femoral arteryCommon femoral artery Radial arteryRadial artery Brachial arteryBrachial artery Axillary arteryAxillary artery Popliteal arteryPopliteal artery

Radiopaque Contrast Radiopaque Contrast MaterialsMaterials

Used for imagingUsed for imaging Exposes Exposes

blockages or blockages or lesionslesions

May lead to acute May lead to acute renal renal insufficiency, insufficiency, prolonged prolonged hospital stays and hospital stays and even deatheven death

Right Heart CatheterizationRight Heart Catheterization

Left Heart CatheterizationLeft Heart Catheterization

PCIPCI

POBAPOBA

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Insertion of Balloon

Inflated Balloon

Plaque against vessel wall, patent

StentStent Scaffolding Scaffolding

placed into placed into vessel vessel

Pressed into Pressed into inner wall of inner wall of arteryartery

PermanentPermanent CoatingCoating Drug-elutingDrug-eluting

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AtherectomyAtherectomy

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Other PCIsOther PCIs

BrachytherapyBrachytherapy Radiation therapyRadiation therapy Radiation source inside Radiation source inside

of or next to area of or next to area needing treatmentneeding treatment

Inhibit cell growth in Inhibit cell growth in responsible for responsible for restenosisrestenosis

Intravenous Intravenous Ultrasound Ultrasound (IVUS)(IVUS)

Technique for Technique for visualizing visualizing coronary arteries, coronary arteries, chambers, and chambers, and valvesvalves

Guided by catheterGuided by catheter May visualize May visualize

plaque that is not plaque that is not seen by seen by angiographyangiography

Peripheral Vascular DiseasePeripheral Vascular Disease

PTA – Percutaneous PTA – Percutaneous Transluminal AngioplastyTransluminal Angioplasty

Vessels of Upper and Lower Vessels of Upper and Lower extremitiesextremities– Carotid Carotid – Subclavian and BrachiocephalicSubclavian and Brachiocephalic– RenalRenal– IliacIliac– FemoropoplitealFemoropopliteal– TibioperonealTibioperoneal

Also known as PEI – Peripheral Also known as PEI – Peripheral Endovascular InterventionEndovascular Intervention

Carotid StentsCarotid Stents

Renal Artery StentsRenal Artery Stents

Valvular DiseaseValvular Disease

Valvuloplasty & Valve Valvuloplasty & Valve ReplacementReplacement

Before the Lab

Before the LabBefore the LabAssessmentsAssessments

NPO status Labs

Electrolytes Renal function

Allergies Meds

InterventionsInterventionsPreparing Your PatientPreparing Your Patient

For NurseFor Nurse Inpatients ready at Inpatients ready at

5AM5AM Notify Notify physicianphysician of of

abnormalitiesabnormalities Complete pre-Complete pre-

procedure checklistprocedure checklist On-call On-call

medicationsmedications

For PatientFor Patient Focused assessment Focused assessment

(pulses, bruit)(pulses, bruit) Baseline 12-lead Baseline 12-lead

EKG (cardiac EKG (cardiac procedures)procedures)

Informed consentInformed consent Pre-procedure Pre-procedure

verificationverification Patient educationPatient education

In the Lab

After the LabAfter the Lab

After the After the LabLab

H & PH & P Orders Orders Procedure log Procedure log

report report Cath lab Cath lab

summarysummary Cath Lab Cath Lab

nursing nursing documentationdocumentation

Where Do I Where Do I Look?Look?

After the LabAfter the Lab

Vital signs Vital signs Pulse Pulse

assessmentassessment Groin Groin

assessmentassessment Telemetry/EKG Telemetry/EKG Labs Labs Pain rating Pain rating

and response and response to medicationsto medications

What Do I Look For?

InterventionsInterventions Bedrest – HOB 45° or lessBedrest – HOB 45° or less Push oral fluids (avoid citrus)Push oral fluids (avoid citrus) IV fluidsIV fluids I & OI & O Resume medicationsResume medications Patient Education!Patient Education!

Post PCIPost PCI 12-Lead EKG12-Lead EKG ProB, CBC, Cardiac Enzymes 4hrs and 12 hrs postProB, CBC, Cardiac Enzymes 4hrs and 12 hrs post Repeat ProB if creatinine is elevatedRepeat ProB if creatinine is elevated

Sheath Pulling-Manual Sheath Pulling-Manual CompressionCompression

Manual compression is the traditional Manual compression is the traditional method to achieve hemostasis.method to achieve hemostasis.

It is what all hemostatic devices are It is what all hemostatic devices are compared tocompared to

Correct technique is essential to stop Correct technique is essential to stop bleeding & minimize complications bleeding & minimize complications such as hematomas, such as hematomas, pseudeoaneurysms, etc.pseudeoaneurysms, etc.

Manual Compression Manual Compression TechniqueTechnique

Distal pulses assessed prior to compressionDistal pulses assessed prior to compression Sterile gloves should be appliedSterile gloves should be applied Should hold two fingers above the puncture Should hold two fingers above the puncture

site and one finger on the top site prior to site and one finger on the top site prior to sheath/catheter removalsheath/catheter removal

Patient instructed to take a deep breath in & Patient instructed to take a deep breath in & exhale slowlyexhale slowly

As the patient exhales sheath/catheter should As the patient exhales sheath/catheter should be removed firm pressure should be appliedbe removed firm pressure should be applied

Sheath Pulling InterventionsSheath Pulling Interventions ECG monitoring ECG monitoring

before and before and during removalduring removal

Watch HR and Watch HR and BP every 2.5 minBP every 2.5 min

IV access, IV access, atropine and NS atropine and NS availableavailable

Assess perfusion Assess perfusion before and after before and after pressure device pressure device in placein place

Post Sheath Removal Post Sheath Removal InterventionsInterventions

Assess puncture site & distal pulses per Assess puncture site & distal pulses per hospital protocolhospital protocol

Pt should be instructed to:Pt should be instructed to:– Keep head down in order to avoid strain on Keep head down in order to avoid strain on

sitesite– Hold site if pt has to cough, sneeze, or laughHold site if pt has to cough, sneeze, or laugh– Keep affected leg straight & flatKeep affected leg straight & flat– Call nurse if feel anything warm & wet-have Call nurse if feel anything warm & wet-have

pt hold pressure at site until help arrivespt hold pressure at site until help arrives– HOB can be no greater than 30-45 degreesHOB can be no greater than 30-45 degrees

Alternatives to Manual Alternatives to Manual CompressionCompression

FemostopFemostop Safe guardSafe guard These devices used to assist in These devices used to assist in

manual compressionmanual compression Placement and release of pressure of Placement and release of pressure of

these devicesthese devices These devices must be monitored These devices must be monitored

during their useduring their use

FemostopFemostop Composed of plastic arch, inflatable Composed of plastic arch, inflatable

transparent dome, connection tubing, transparent dome, connection tubing, elastic belt, & hand held manometerelastic belt, & hand held manometer

Usually inflated 20 mmhg above Usually inflated 20 mmhg above systolic bpsystolic bp

Over 10-15 minutes pressure is Over 10-15 minutes pressure is decreased 20 mmhg every 2 minutes decreased 20 mmhg every 2 minutes until pressure releaseduntil pressure released

Pressure must be gradually releasedPressure must be gradually released

SafeguardSafeguard

Composed of latex free sterile dressing, Composed of latex free sterile dressing, & inflatable bulb& inflatable bulb

Bulb provides constant pressure on Bulb provides constant pressure on puncture sitepuncture site

Placed on pt once hemostasis is Placed on pt once hemostasis is achievedachieved

Maximum inflation 50 ml of airMaximum inflation 50 ml of air Puncture site & distal pulses should be Puncture site & distal pulses should be

checked per hospital protocolchecked per hospital protocol

TR BandTR Band

Plastic “bracelet” w/ dual balloons Plastic “bracelet” w/ dual balloons used to compress radial arteryused to compress radial artery

Air injected via injection port to apply Air injected via injection port to apply compression to radial arterycompression to radial artery

Must be sure to keep air syringe- will Must be sure to keep air syringe- will need it to remove airneed it to remove air

Must assess circulation of affected Must assess circulation of affected handhand

Release of pressure-usually 2-4 hrs or Release of pressure-usually 2-4 hrs or as ordered by MDas ordered by MD

Closure DevicesClosure Devices

Angioseal-collagen plug inserted in Angioseal-collagen plug inserted in artery, reabsorbed in body in 90 daysartery, reabsorbed in body in 90 days

Mynx- extravascular plug-dissipates in Mynx- extravascular plug-dissipates in 30 days30 days

Perclose-suturing of arteryPerclose-suturing of artery Exoseal-Bioabsorbable plugExoseal-Bioabsorbable plug Reduces bedrest dramaticallyReduces bedrest dramatically Most patients can ambulate after 2 hrsMost patients can ambulate after 2 hrs

ComplicationsComplications

BleedingBleeding

Bleeding Bleeding – Manual pressure - 10 minutes (no Manual pressure - 10 minutes (no

peaking)peaking)– Page CV tech Page CV tech – Reapply dressingReapply dressing

GI bleedingGI bleeding HematuriaHematuria

HematomaHematoma

Retroperitoneal BleedRetroperitoneal Bleed

Vasovagal SyncopeVasovagal Syncope

AssessmentAssessment Drop in HR Drop in HR

and/or BP and/or BP Feeling hotFeeling hot

NauseaNausea PallorPallor DiaphoresisDiaphoresis

InterventionsInterventions Atropine 0.5mg – Atropine 0.5mg –

1mg IVP1mg IVP Fluid bolus Fluid bolus

(watch EF)(watch EF) Hold/discontinue Hold/discontinue

nitratesnitrates ModifiedModified

trendelenbergtrendelenberg Check groin, H&HCheck groin, H&H

Coronary Reocclusion or MICoronary Reocclusion or MI

AssessmentAssessment Chest pain – assess Chest pain – assess

PQRST PQRST Bruise pain?Bruise pain? Elevated cardiac Elevated cardiac

enzymesenzymes ST elevationST elevation

InterventionsInterventions Vital SignsVital Signs MONAMONA 12-Lead EKG12-Lead EKG Possible re-cathPossible re-cath Reassure patientReassure patient

Cardiac TamponadeCardiac Tamponade

AssessmentAssessment Beck’s TriadBeck’s Triad Narrowing Narrowing

pulse pressurepulse pressure Tachycardia, Tachycardia,

dyspneadyspnea

TreatmentTreatment O2, fluidsO2, fluids EchocardiogramEchocardiogram Pericardial Pericardial

windowwindow PericardiocentesiPericardiocentesi

ss

Contrast NephrotoxicityContrast Nephrotoxicity

Contrast-induced nephrotoxic effects Contrast-induced nephrotoxic effects – increase of > 0.5mg/dL in serum creatinine increase of > 0.5mg/dL in serum creatinine

within 48 hrs after contrast injectionwithin 48 hrs after contrast injection– 33rdrd leading cause of ARF in hospitalized leading cause of ARF in hospitalized

patientspatients Creatinine levels peak 4-5 days after Creatinine levels peak 4-5 days after

contrast, return to baseline contrast, return to baseline approximately 5 days after peak. Can approximately 5 days after peak. Can last up to 3 weekslast up to 3 weeks

Other ComplicationsOther Complications

InfectionInfection Groin site painGroin site pain Vessel occlusion Vessel occlusion EmbolizationEmbolization

DischargeDischarge

•Patient EducationPatient Education•Diagnoses and Diagnoses and Procedure type, Procedure type, locationlocation•Medications – Medications – Plavix Plavix every day!!every day!!•Diet and exerciseDiet and exercise•Smoking cessationSmoking cessation•Site careSite care

•Signs of infectionSigns of infection•BleedingBleeding

•When to call 911When to call 911•Follow-up appointmentFollow-up appointment•Contact information Contact information

ReferencesReferences

Apple, S. & Lindsay, Jr. , J. (2000). Apple, S. & Lindsay, Jr. , J. (2000). Principles and Principles and practices of interventional cardiologypractices of interventional cardiology. . Philadelphia: LWW.Philadelphia: LWW.

Cardiovascular care made incredibly easyCardiovascular care made incredibly easy (2 (2ndnd ed.) ed.) (2009). Philadelphia: LWW.(2009). Philadelphia: LWW.

Morton, P.G. & Fontaine, D.K. (2009). Morton, P.G. & Fontaine, D.K. (2009). Critical care Critical care nursing: A holistic approach nursing: A holistic approach (9(9thth ed.). ed.). Philadelphia: LWW.Philadelphia: LWW.