E-Mail Discussion Group

I. Monitoring of vital signs I am looking for any information or standards with regard to monitoring of vital signs with femoral sheath removal. Currently we do q5- signs till hemostasis is achieved, i.e., blood pressure and pulse ox with wave form should we also be monitoring the ECG? Ellen Ciccarillo-Clarke Email: Eciccar@harthosp.org cc: cathlabdigest@hotmail.com Response: I can’t provide standards of practice, but I can share personal experience. When I cut my teeth in the cath lab, we did no monitoring! At the time, as you know, we can only can do what we know. So we simply continued to palpate a pulse as we held pressure to watch for vagal reactions. Currently, our practice is deploying a sealing device on the table, so we have all the monitoring there. But, previously, we would do as you do, vital signs (VS) every 5 min. until hemostasis. Then, once VS are to preprocedure values, every 1 hour. In respect to ECG monitoring, I think the primary purpose would be for vagal reactions, but you have that covered with the SPO2 monitor. So in a non-acute pull, I would think your practice is safe. In an acute setting, the value of ECG would be in watching for acute closure and changes in the ECG. While I have heard of patients experiencing an acute myocardial infarction (MI) during sheath pull following a diagnostic case, this is rare and I believe other symptoms would present themselves, then warranting the patient be placed on ECG. So in short, with my experience and practice, what you are doing is safe. Hope this helped. Jon, jon@bransonheartcenter.com II. CAS Recovery I welcome your responses! My co-workers in the Recovery Room are interested in hearing from other RNs who provide post care to patients recovering from their carotid stent procedure. Their concerns lie in determining the acceptable range for the patient’s blood pressure post-procedure. Your input, and any protocol for post-carotid stent care would be greatly appreciated. Chris Reoch RCIS, St. Mary’s Hospital Richmond, VA Email: reochris2000@comcast.net cc: cathlabdigest@hotmail.com Response: A carotid artery stent (CAS) patient should have a pre-procedure, procedure, and post- procedure neurological and vital sign assessments. 1. Pre-Procedure Assessments a. Complete a neurological evaluation based on the Glasgow Coma Scale 1. Eye Opening 2. Verbal Response 3. Motor Response b. Other assessments 1. Pupil Reaction 2. Dermatome Sensory Assessment 3. Motor Strength 4. Pupil Size c. Cranial Nerve Assessment 1. Olfactory 2. Optic 3. Oculometer 4. Trochlear 5. Trigeminal 6. Abducens d. Vital Signs 1. Blood pressure 2. Pulse oximetry 3. Respiratory 2. Procedural Assessments a. Redo the assessments each time any great vessel is cannulated and angiography is performed. b. Always observe for acute bradycardia and hypotension, which can occur very rapidly since the ipsilateral baroreceptors are affected by balloon inflations and stent placements especially during post-dilation. c. Changes in blood pressure and heart rate is similar to placing digital pressure on a carotid area to break SVT. d. Have chronotropic medications such as Atropine available along with vasopressors such as dobutamine, dopamine, epinephrine, neosynephrine, or norepinephrine available for emergent care. 3. Post-procedure a. Redo the assessments each time vital signs are recorded because a change can occur anytime. b. Always observe for acute bradycardia and hypotension, which can occur several hours later. c. Notify the attending physician about any changes that occur from the baseline pre-procedural assessment. d. Have chronotropic medications such as Atropine available along with vasopressors such as dobutamine, dopamine, epinephrine, neosynephrine, or norepinephrine available for emergent care. e. Redo all assessments before the patient is discharged from the hospital. f. Contact patients daily for next 72 hours to assess their faculties and any complaints about their well-being. 4. Follow the approved standard guidelines for patient care for patients who are scheduled for enardectomies. Chuck Williams, BS, RPA, RT, RCIS, CPFT, Cardiovascular Lab C430 Emory University Hospital, Atlanta, GA rpainga@yahoo.com III. Protocols for Femoral Sheath Removal We are currently revising our protocols for femoral sheath removal: 4F, 5F, 6F, with GP2b3a inhibitors and without. I am looking for what you are doing as far as length of time of hold, time to ambulation, and time to discharge. If you use SyvekPatch® (Marine Polymer Technologies, Danvers, MA), what is the length of time of hold, time to ambulation, and time to discharge? I would appreciate any input, or actual protocols. Thank you! Mary Email: mmaliszewski@notes.cc.sunysb.edu cc: cathlabdigest@hotmail.com Responses: While I can’t provide a protocol, I will share our current practice. We use VasoSeal (Datascope Corporation, Mahwah, NJ) exclusively (5F sheaths). -Pull on table at end of case. -Hold occlusive for 1 min. -Firm, flat pressure for an additional 2 min. -Once patient is on cart, elevate HOB to 30 degrees. -Ambulate patient in 45 minutes (we do not use sedation either, so this would impact the ambulation time) -Discharge at 1 hour. We’ve never experienced a rebleed or complication from the ambulation. We’ve also never had a patient bleed after discharge. On the few manual pulls: -Hold occlusive for 10 min. -Supportive pressure for additional 2 min. -HOB at 15-20 degrees. -Ambulate in 90 minutes -DC in 2 hours. (As far as complication rates, they are the same as our above VasoSeal experience.) I am currently at a private free-standing lab. My prior experience was at an interventional hospital program. Any patient VasoSealed (intervention or not, heparin or not) was ambulated 1 hour post procedure (5, 6 or 7 Fr). GP IIb/IIIa patients ambulated at the end of infusion (I think this could be sooner). I should also note that venous sheaths do not change our ambulation times. They remain the same. Jon, jon@bransonheartcenter.com Protocols for femoral sheath removal without GP IIb/IIIa inhibitors: 1. 4F/5F catheters a.Use a Chito-Seal (Abbott Vascular Devices, Redwood City, CA), D-Stat (Vascular Solutions, Inc., Minneapolis, MN), STASYSPatch (St. Jude Medical Minnetonka, MN), SyvekPatch® (Marine Polymer Technologies), or a V+Pad (InterV, Gainesville, FL). b. Manual pressure should be held for a minimum of 20 minutes without occluding the artery. c. Apply a pressure bandage over the appropriately covered patch by abducting the affected extremity so when the leg is placed back into a normal AP position, the needed pressure is applied. d. If a small hematoma has occurred during the procedure, with adequate care, the collection of blood can be compressed into the muscle. e. If the artery was accessed above the inguinal ligament, a hematoma has developed and the bleeding cannot be controlled; always consider a possible retroperitoneal hemorrhage. This can be confirmed within less than 5 minutes by having an abdomino-pelvic CT done emergently. f. I personally would not consider an Angio-Seal Vascular Closure Device (St. Jude Medical) or a Perclose® (Abbott Vascular Devices) in this case, because the entry site has to be enlarged to 6F to establish hemostasis. g. If hemostasis is not readily achievable within 20 minutes, the following suggestions may be helpful: Ask the patient if their bladder is full. If it is, offer an appropriate receptacle to relieve the bladder If the patient can not relieve their bladder, then consider placing a urinary catheter. If the bladder is not distended, then consider using a FemoStop (Radi Medical Systems, Inc., Wilmington, MA) to establish hemostasis, if prolonged bleeding exists. 2. 6F catheters a. Consider any of the external patch systems. b. If the anatomical landmarks are safe for an Angio-Seal or a Perclose, then either device would be an excellent choice. c. Based on the experience of holding over 20,000 access sites, I still use a pressure bandage for a minimum of two hours. d. If hemostasis is not readily achieved within established guidelines, then follow the suggestions for distended bladders and for a FemoStop. e. Always assess the area for any signs of a local hematoma, a retroperitoneal one, and continuity of pulses proximal and distal of the puncture site. Protocols for Femoral Sheath Removal with GP IIb/IIIa inhibitors: 1. 4F/5F catheters a. Use a Chito-Seal, D-Stat, StaysisPatch, or a SyvekPatch. b. Manual pressure should be held for a minimum of 30-45 minutes without occluding the artery. c. Apply a pressure bandage over the appropriately covered patch by abducting the affected extremity so when the leg is placed back into a normal AP position, the needed pressure is applied. d. If a small hematoma has occurred during the procedure, with adequate care, the collection of blood can be compressed into the muscle. e. If the artery was accessed above the inguinal ligament, a hematoma has developed, and the bleeding cannot be controlled; always consider a possible retroperitoneal hemorrhage. This can be confirmed within less then 5 minutes by having an emergent abdomen-pelvic CT done. f. I personally would not consider an Angio-Seal or a Perclose, because the entry site has to be enlarged to 6F to establish hemostasis. g. If hemostasis is not readily achievable within 20 minutes, the following suggestions may be helpful: Ask the patient if their bladder is full. If it is, offer an appropriate receptacle to relieve the bladder If the patient can not relieve their bladder then consider placing a urinary catheter. If the bladder is not distended, then consider using a FemoStop to establish hemostasis, if prolonged bleeding exists. 4. 6F catheters a. Consider any of the external patch systems. b. If the anatomical access landmarks are safe for an Angio-Seal or a Perclose, then either device would be an excellent choice. c. Based on the experience of holding over 20,000 access sites, I would still use a pressure bandage for a minimum of three hours. d. If hemostasis is not readily achieved within established guidelines, then follow the suggestions for distended bladders and for a FemoStop. e. Always assess the area for any signs of a local hematoma, a retroperitoneal hematoma, and continuity of pulses proximal and distal of the puncture site, before a pressure bandage is applied. Chuck Williams, BS, RPA, RT, RCIS, CPFT, Cardiovascular Lab C430, Emory University Hospital, Atlanta, GA, rpainga@yahoo.com IV. DES: Broadening Patient Selection Anyone have evidence-based reports to support the need to broaden the patient selection criteria for DES? The IFU says de novo lesions, single vessel and no acute MIs. We are currently adhering to the IFU until we can come up with defined evidence that it is OK to broaden our selection criteria. Patti Coblentz Email: PatriciaACoblentz@ProvenaHealth.com cc: cathlabdigest@hotmail.com Response: We have placed drug-eluting stents in the artery that caused an AMI. All clinical indications have to be met. If the patient has other severe occlusions of the other major arteries and major branches, the physicians usually schedules the patient for another procedure to address these sites a few days later. If stents are used, they make their decisions accordingly. Chuck Williams, BS, RPA, RT, RCIS, CPFT, Cardiovascular Lab C430, Emory University Hospital, Atlanta, GA, rpainga@yahoo.com More upcoming questions for the Cath Lab Digest Email Discussion Group (and readers!) Would you be able to help your fellow professionals with the following questions? Ok to hire surgical/scrub techs? I am opening a new cath lab in Wisconsin and am wondering if there are any legal guidelines we need to follow in hiring Surgical/Scrub techs (STs) in the cath lab. Where I came from, we had a couple STs that were not certified because they had been in the field before the ST programs were around. I wanted all RTRs and RNs, but we are having trouble finding those people. Can we hire staff that does not have the ST certification (EMTs, GI Techs, LPNs etc) to fill a surgical tech role if our job description is clear on what they can and can not do? And what roles should these people be limited to in your opinion, can they cover the CV role if they get on-the-job training? Thank you! Shelly Gluege, RT(R) Supervisor of Cardiac Cath/Interventional Vascular Labs, Diagnostic and Treatment Center, Schofield, WI Email: gluegema@dxandtx.com cc: cathlabdigest@hotmail.com Share your door-to-balloon timing? We are looking at our door-to-balloon time, so I thought I would try to see what other labs are doing. 1. What is your door to balloon time? 2. Do you track all AMIs? 3. Do you still have an in-house RN for sheath pulling and acutes? 4. How many are on the call team? 5. What is their expected response time? Julie Baran, RN, BSN, Clinical Manager Adult and Pediatric Invasive Cardiology Memorial Hermann Hospital Email: julie_baran@mhhs.org Cc: cathlabdigest@hotmail.com Techs: Central access & closure devices? In order for our techs to establish central access and utilize closure devices, they must be credentialed and have those items be within their scope of practice. If your techs perform these skills, what credentialing did they obtain, and how did you reflect these skills within their scope of practice? What education and/or competency assessments were required in order to complete the training process? Thank you! Anonymous by request Email: cathlabdigest@hotmail.com Use of pressurized normal saline? How many cath labs use pressurized normal saline instead of heparin art line flush bags (2 USP heparin units/ML) when connecting to a sheath/IABP/Swan? Brian Crosby RCIS, RN, BSN HealthPark Medical Center Email: brian.crosby@leememorial.org Cc: cathlabdigest@hotmail.com Non-physician vascular closure Consideration for making the switch from physician-based closure (Perclose, AngioSeal) to RN/CVT closure is being explored in our lab. The thought is still in its infancy and I would like to make a comparison of other labs that have dealt with the pitfalls that I am encountering. Here are some of the questions I would like to pose: 1. First, how are your RNs/CVTs covered for malpractice upon performing the closure? 2. Is an Operations Medical Director established, much like the field-based Emergency Medical Services serviced by paramedics? 3. Do you have any hard data to support the positive aspects of non-physician closure? 4. Is there any data to provide an example of what happens when the non-physician closure goes wrong? 5. How do you make the hard sell to physicians that non-physician closure is beneficial for both the patient and the lab? Additionally, I would like to ascertain the thoughts of both physicians and lab personnel regarding non-physician closure, in respect to time management and patient care aspects. Mica Bodenheimer, NREMTP/CVT Fax: 804.287.7527 (Tel.) 804-281-8193 Cc: Cath Lab Digest @ 800.459.8657

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