Invasive catherization

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High Risk cardiac catherization What is the definition of a high risk patient?: Those that are more likely to die or have myocardial infarction or V. Fib during cardiac caths versus other pts.
High Risk cardiac catherization Name some pts that are considered high-risk:: Significant vessel disease
Left main coronary disease
Severe LV dysfunction
Diabetes
Poorly controlled hypertension
Marked abnormal excersie treamill test
Pts w/ CHF
Recent acute MI
Unstable Angina
Severe valvular heart disease, especially critical aortic stenosis
High Risk cardiac catherization Has complications in the cath lab increaed or decrease with the development of complex interventional procedures?: Increase
THe occurance of mj complications in the cath lab have increaed markedly with the development of increasingly complex interventional procedures
Incidence of complications in the High-risk pt What is the percentage of mj complication in a pt who is not high risk?: LOW 0.14%
What are the most powerful predicators of mortality during a heart cath?: Age
Pt functional class
Ejection fraction
Extent of coronary heart diseasse
What is the percentage of the ejection fraction that has a 10-fold increase in the risk of death?: An EF,30% and LM coronary stenosis
How might one try to prevent complications?: Careful attention to the pre cath pt AND recognition of potential risks decrease complications
Medications CATH RELATED RISKS: Warfarin
Diuretics
Insulin
Metformin(Glucophage)
Viagra
Warfin Contraindications/Warnings: Do not take 48-72 hours before procedure
Elective procedures INR <1.5
Diuretics Contraindications/Warnings: Do not take morning of proc
Dehydratio my decrease renal flow and increase risk of contrast nephropathy and hypotension
Insulin Contraindications/Warnings: Regular morning dose should not be taken
Long action insulin should be halved
Pt should recieve dextrose in IV fluids
Metformin(Glucophage) Contraindications/Warnings: Should not be taken the morning of the procedure, high risk 48 hours prior
Reusme 48 hour post procedure when verified renal function has not been compromised
Viagra Contraindications/Warnings: Do not use within 48 hours of elective procedure
contains nitrates-possible hypotension result
Contrast Allergy: Pts with previous reaction should be premedicated
for previous severe allergic reactions,H2 blocker should be used
Cimetidine(Tagament) Dose Rantidine (Zantac): 300mg, IV

50mg IV
What is contrast nephropathy? What percentage does this occur in of patients that undergo a cath?: A rise in serum creatinine level of 1mg/dl

5%
Occurs in 20-30% of pts with baseline renal insufficiency, diabetes or both
Besides hydration what drugs can assit with renal insufficiency?: ACETHYCYSTEINE
600mg orally twice daily the day before and the day of the procedure OR
selectiv e dopamine-1 receptor agonist fenoldopam
Contrast Media Selection with high risk pts: All procedure with high risk pts should use nonionic, low-osmolar contrast
With what type of pts would you give nonionic, low-osmolar contrast?: Acute MI
CHF
ef</= 30%
Suspected LM or 3 vessel coronary artery disease
Severe aortic stenosis
Complex or multiple ventricular arrhythmias
Acute or chronic renal insufficiency
Anticipated use of large contrast agent volume
Vasovagal Reactions: Bradycardia & Hypotension
pallor
nausea
diaphoresis
With Brady what drug would you give and what dose: Atropine
0.5-1mg IV, total of 3mg
What "intervention" should be given for hypotension and brady?: Fluids and Atropine
0.5-1mg IV, total of 3mg
Hypotension Complications: Hypotension resulting from volume depletion and most other causes should be treated aggressively with NORMAL SALINE
How much NS is usually indicated for volume depletion?: Several hundred milliliters of fluid
What postition would help with hypotension?: Elevation of the pts legs to about 30 Degress increase blood return to the heart and increases effective ventricular filling, which improves cardiac output
Management of complications during cath: Be quick
determince casue and treat accordinglyCause of peripheral arterial compl should be ID'ed early
Arterial thromboembolism to other areas, such as the brain, may not immediatley treatable butrequires observatuin or prolonged heparin, it depends on neuro findings
An air embolus to the CNS may cause pts to show features of a stroke, what signs might be seen?: Agitation, confusion, aphasia
What about small air embolus: Usually resolve and do not result in permanent damage
When durin a cath can hypotension develop: Anytime
What are some causes of BEFORE causes: Hypovolemia-fasting or diuretcics (allow H2o intake)
What are some causes of During causes: Vasovagal reatction
Untreated-Can lead to irreversable shock
Uusally due to pain in the vascular access site
IN elderly may occur without brady and appear as unexplained hypotension
Hypotension that develops after Coronary arteriography of LV gram is transient and responds to IV fluids
What are some causes of After causes: Excessive contrast induced diuretics
Myocardial ischemia
Unsus[ected bleeding from the access site
Anticoagulation related retoperitoneal hematoma/bleeding
Other causes of hypotension related to cath procedures: Occult cardiac tamponade
Hemorrhage from arterial access bleeding
What can you do if hyotension is due to myocardial ischemia?: An IABP may need to be inserted before the procedure can be safetly completed
Managing hypotension from hypovolemia: Treat with IV salin infusion
elevate lower extremity > 30 degrees
Prior to proc infuse IV saline at least 500cc over
4-6 hrs prior/ post procedure
Hypotension From hemorrhage TX:: Infuse blood products
Obtain hemostasis at once in these pts
Do not cause volume overload in CHF pts
Careful measure of I&O
Unknown volume status can be determined by PCWP if needed
Hypotension from Vasovagal or Ischemic reaction TX:: Pharmalogical therapy
Atropine
IV aramine(1mg) or epinephrine bolus (1 ml of 1:10,000 U dliution) temp increase BP to normal while team access pt and other vasodilators are prepared
For prolonged can be titrated up/down
Profound Hypotension What is a cause that is usally with in 20 minutes of exposure to contrat media: Anaphylactoid reaction
What type of pts are at highest risk for hypotension caused by allergic reaction: Pts with prior anaphylaxis (16-44% of Patient)
Atopy INherited allergy twice as likely
Asthmas twice as likely
Allergic reactions-Therapy Severe: IV epinephrine with large volumes of saline
10 mcg/min until desireed BP reached wthin 1-4 mcg/min to maintain BP
Diphenhydramine 50-100 mg
Hydrocortisone
Allergic reactions-Therapy If unresponsive to initial therapy: H2 Blocker
cimetidine (50-100mg in 20 cc NS over 15 minutes
Rantidine (Zantac) 50 mg in 20cc NS IV over 15 minutes
Dopamine 2-15 mcg/kg/min IV infusion
What can cause transient ischemia and coronary artery occlusion?: Cathater induced spasm
cannulation of a severly disease coronary artery
severe osital lesion
What is a initial treatment for continued myocardial ischemia (refractory): NTG (SL,IV, IC,)
Provided that the patient is not hypotesive
What would you give a patinet that has tachcardia that is otherwise hemodynamically stable?: Give them Beta blockers such as metoprolol 5mg ic q 5 min OR a Calcium Channel Blocker such as Verapamil 2.5-5 mg q 5 min
What active measure should a person consider if ischemia is persistant after pharm intervention and/or if the patient is sig hemo unstable: Ballon Pump usually IABP
EKG_ECG monitoring during a cath proced: Continuous is essential for the safe preformance
IF faulty or fails correct immediadiatly
IV access What is the usual size needle for the peropheral access: 18-gauge
What is an alternate site to periperal?: Femoral
How large should a femoral venous access be?: Large enough to allow for a pacing wire and large amount of salin should be used Usually 6F
Conditions for which femoral access and transcutaneous pacing should be considered: Poor peripheral access
Hemodynamically instabiluty
Suspected Left main CAD
Active arrhythmias
Primary prevention of arrhythmias 3 things:: Standby transvenous pacing
Pts risk
Use of fexible,, balloon-tipped, flow-directed pacemakere wires provide the lowest risk for cardiac perforation
Risk factors for bradyarrhythmia: Preexisting RBBB during left sided heart cath
Preexisting LBBB during right sided heart cath
Heart blocker greater than fiest degree
Marked sinus bradycardia
Coronary artery angioplasty involving the dominant artery supplying the AV node, esp when rotational artherctomy or thrombus extraction devices are used

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Number of cards 52