Cath Lab Digest Email Discussion Group: P.O. Meds and Conscious Sedation

HAVE A SUGGESTION FOR A FUTURE QUESTION? Email us at cathlabdigest@hotmail.com We frequently give aspirin and Plavix to patients after they receive conscious sedation if we are proceeding to angioplasty after an angiogram. The patients are usually only given 1 mg of Versed and 25 mcg of Fentanyl as a premed and are usually relaxed, but not really asleep. They seem to tolerate the P.O. meds well. If they cannot take the P.O. meds lying flat, we have waited to give Plavix in the recovery area after the procedure. My previous suggestions was to give aspirin and Plavix prior to a highly suspect diagnostic cath. All of our emergency cases will receive aspirin and Plavix either in the ER or prior to coming into the lab. I think any patient with known CAD or documented AMI should receive the drugs prior to coming into the lab. Kelley A. Bender fidgetrn@juno.com In our cath lab in Tampa, FL, we are all cross-trained to scrub, circulate, and record. The techs are trained to administer all cardiac drugs but only the nurses are allowed to give sedation. I am in the process of trying to change this because of the high turnover of nurses in the lab. The national trend is to train the CVTs on sedation and let them work under the direct supervision of a physician. The outcome will be better patient care, better staffing in the lab, and better services to the physicians. Drugs in the cath lab are used differently than in anywhere else in the hospital, and I feel it is appropriate to train CVTs as well as retraining the nurses from the floor. It doesn’t matter which pathway you choose to get into the cath lab, we all need training again, one way or the other. Denise Foto RCIS, RT Jimjfoto1@cs.com It is common practice to administer a Plavix loading dose and aspirin after angiography and before intervention. By not administering Plavix before the angiography, you avoid having a patient with a platelet inhibitor on board that may need to go to elective surgery. Moderate sedation should leave a patient with control of reflexes and not snow a patient so much that they can’t even swallow. As far as performing angiography without sedation, many physicians do not routinely order sedation. Lynne Jones RN, Director, Cardiology Services, Twelve Oaks Medical Center, Houston, Texas Lynne.Jones@tenethealth.com There is no contraindication to giving either drug (Plavix or aspirin) prior to intervention. All cardiacs should be taking an ASA qd unless they cannot tolerate it. Most patients are able to chew a baby ASA even moderately sedated. As for Plavix, what happened to Integrilin/Heparin/Lovenox/the others? Plavix 300mg (the loading dose) takes a while to be on-board, so we start that regime, if ordered, once the patient is back in their room post intervention. Yes, I work with one cardiologist that does not like his patients to receive Versed/Fentanyl. Since Valium IV is unavailable, Valium, Zanex & Ativan PO or Ativan IV and Benadryl IV work well for the patients and the doctor is usually okay with that too. Pamela Masterson, RN, CCRN, Cardiac Cath Lab Redding Medical Center Whitney3956@aol.com Presently, we do approximately 1200 cases a year, and about 1/3 of them are an intervention of some sort. We do give Plavix once the patient has been defined, ie: intervention or diagnostic. We do give Plavix once the patient has been defined, ie: intervention or diagnostic. We pre-med all of our patients with Valium and Benadryl P.O. and the patients are sleepy but not unconscious. All of our patients get pre meds before an angio. Usually it is Valium and Benadryl, both P.O. When the patient is brought to the lab for a procedure, if it turns into an intervention, which most often it does, we do give Plavix P.O. The patients have never had a problem with it before, as they are not unconscious, just relaxed. I certainly would not encourage holding sedation just in case of another procedure. Cynthia.Fielders@HCAHealthcare.com In our cath lab, the patients are usually given P.O. sedation, like Benadryl and Valium in the prep area after signing consents for angio and interventions. Then, in the lab, they are usually given Versed or IV Valium. Yes, we do give Plavix and ASA in the lab after the angio and prior to the intervention, with the patients flat. Usually propping them up a little and a straw work fine. We haven’t had any problems. Markscvl@aol.com We use a little conscious sedation (Valium and Versed) on all caths. And we do give P.O. meds if we turn over to intervention. It is usually about 30 minutes and most of the sedation has worn off. We do it carefully after assessing the patient’s ability to swallow and follow instructions (sip through a straw). We have had no problems. jparham@armc.org We find that most of our patients do not actually become moderately sedated from the 1-2 mg Versed/50mcg Fentanyl that is used for most of the angiograms. Whether or not we give P.O. meds while the patient is lying flat is a nursing judgement based on their level of sedation. Nurses won’t hesitate to tell a physician the patient is too sleepy to have P.O. meds/fluids. JJenisch@rcrh.org We use Versed and Fentanyl for conscious sedation in our cath lab. All of our patients are premedicated with benadryl or ASA (Plavix is allergic to aspirin). Yes, we occasionally are asked to give Plavix in the procedure room immediately post stent. If the patient is awake enough to swallow (and most are) we give the Plavix. On occasion, the patient is too sedated to safely swallow pills immediately post procedure. The patient with conscious sedation should have the swallow and gag reflex intact. In reality, most people who administer conscious sedation realize it can be a fine line between various levels of sedation. It is unfortunate that a particular MD group is withholding sedation, because it is the patient who is suffering. I believe when a patient is brought into the room and preparation is underway, this can be one of the most anxiety producing times for the patient. Hopefully your cath lab leadership and physician group can come to a consensus and have a plan that is best suited for patient care. Also, in this age of business competition, patients have more than one choice of where to have their procedure. If this isn’t a reality in your area already, it probably will be in the future. Patient comfort and quality of care is paramount. James Saine, RN, CCRN, RCIS, Education Coordinator “ Cath Lab jamessaine@mrhs.org We have more than 15 cardiologists who routinely have their patients (with PVD or known CAD) on ASA qd and Plavix 75 mg qd for days before a cath. If the patient has a cath and an intervention with stent, and they have not been on GPIIb/IIIa inhibition, we routinely start Integrilin and give a 300mg bolus dose of Plavix PO before the patient leaves the lab. In regards to conscious sedation, our patients are frequently premedicated with Benadryl 25 and Valium 5 to 10 mg P.O. This is usually given on the floors or the outpatient unit. In the lab, we titrate Versed and Fentanyl to decrease patient anxiety and increase comfort level. Our patients are not routinely sedated to the point of losing gag or cough reflexes. (We also use Perclose, Angio-Seal and VasoSeal for closing devices.) JNelson1@memorialcare.org If a patient is a straightforward PCI, most patients are given Plavix and aspirin prior to coming to the cath lab from our same day patient prep area. If the patient is a cath poss PCI, the patient is routinely given aspirin prior to arrival. If the cath poss becomes a turnover, it depends on the cardiologist if Plavix is given before the PCI session begins. I have never had an aspiration with giving a patient 7 tablets and 60 cc of water. Most physicians will give the loading dose of Plavix upon completion of the procedure. I prefer to give it this way. I will elevate the patient’s head to 15 degrees, then give the Plavix. This places the medication in the body of the stomach instead of it resting in the fundus of the stomach. Plavix tends to irritate the stomach. There have been a few cases where we have had to give 30cc of Maalox to quieten the gastric irritation. Check the literature for length of time that serum levels are reached when Plavix is given. Chuck Williams, RT(R)(CV), RCIS, Cardiac Cath Lab Emory University Hospital, Atlanta, GA codywms@msn.com Ditto that (above), but we also use paramedics. Addendum: All of our cath lab staff (Techs and RNs) are trained in conscious sedation. The patient is always assessed by our physicians prior to the administration of any sedative. We are required to ask the physician if a sedative is be used. Then we ask the patient if they feel they need the sedative. We have strict guidelines that deal with patient assessment while under medical anesthesia. We routinely give our patients ASA prior to cath. ReoPro is given to inhibit platelet aggregation. Plavix works late in the game; it is not an immediate problem to give it. If a doctor requests it, we assess and give to the patient if responsive enough to swallow. No stomach complication with administration. We have never held sedation for any reason, we use Fentanyl and Versed based on each individual patient's need. The idea of having conscious sedation relieves patients’ anxieties about the procedures and results facing them...I agree, I would want the drugs. Roberta.Sparks@advocatehealth.com We have only one MD who does not routinely conscious sedate the patient prior to angiogram (diagnostic). Our sedation policy defines light, moderate and deep sedation as set by Anesthesia Services; the majority of the patients are only lightly sedated, and have passed recovery criteria by the end of the diagnostic procedure. If an intervention is then decided upon, the patient may receive more sedation for this procedure; though again, most are only lightly sedated. If the patient’s gag reflex, swallowing ability, and orientation are appropriate (per our sedation policy) we may give P.O. chewable ASA at the beginning of the intervention, though we usually wait to the end of the intervention to administer Plavix. Most of our interventions are placed on a IIb/IIIa at the onset of intervention and are given a low-dose heparin bolus if they haven’t already had one in ER or on the unit, so Plavix can wait without consequence. We have also moved to utilizing the Hepacoat BX Velocity for most of our stents, which adds to the whole scenario. To avoid the consent issue, we developed our own consent form, which includes conscious sedation, diagnostic and interventional procedures, and consent for transfer for CABG as needed. The MDs are responsible for explaining all of this prior to the procedure, and we verify that the patient understands all of these parameters on arrival to the lab. There is then no need for additional consent if we go from diagnostic to intervention based upon findings. Pam, PAM_RAGLAND@bshsi.com We sedate our patients on the nursing units with P.O. Valium and Benadryl. When they come to the lab, we give them IV Fentanyl and IV Versed. We do give P.O. meds such as Plavix, but we usually give the Plavix at the end of the interventional procedure. The patient has already gotten ASA on the floor. If the patient seems too sleepy to take the Plavix, we take it with us to the nursing unit and let the nurse know that it still needs to be given . Annie Ruppert, RN Sharp Memorial Hospital, San Diego, CA annie.ruppert@sharp.com It is the cardiologist’s preference here at our lab. About 85% routinely give CS, but we have a few who only give it as an exception. We are a fairly large lab, 5 rooms and around 40 cardiologists. We do give PO meds (Plavix) to one of our cardiologist’s patients after angioplasty. Tina, ScogginT@methodisthealth.org At the cath lab that I work in, we regularly give conscious sedation only if needed for comfort measures. We do give Plavix after interventions, with the patient still on the cath lab table. However, if the patient is too sedated, it is held due to choking or aspiration precautions. One of our cardiologists has Plavix given 1 hour after intervention when the patient is back in their bed with the head of the bed being able to be raised 30 degrees. Alicia Wentworth awkatz2000@yahoo.com We give the Plavix after interventions with the patient lying flat or the head slightly elevated if we were able to use a closure device. If we were to give an aspirin, the patient is asked to chew it, and these are the patients that haven’t had one in the last 24 hours. Connie csgehin@yahoo.com We do give P.O. meds after sedation on occasion. Some patients are too groggy to take them, but some are not. We sedate all our patients for arteriograms; interestingly, I have visited several labs in the past year and probably half of those visited did not sedate their patients. Speaking from experience, knock me out. I prefer to wake up about an hour later. BCole@ftsm.mercy.net

OUR NEXT QUESTION FOR DISCUSSION We are revising our processes and relocating our pre and post cath patient care area. Would like some ideas on staffing, training, hours, whether or not both in and outpatients pass through there, and especially whether there are patients from any other areas such as radiology there also. Is it the same area for pre and post? Where do the families wait? Thanks. JudyTo respond, email the discussion group at: cathlabdigest@hotmail.com