Letters to the Editor

Re: Streem M. Comparison of Arterial Puncture Closure Devices with Standard Manual Compression After Cardiac Catheterization at Robinson Memorial Hospital. Cath Lab Digest 2004;12(11):1-8. Dear Editor: As the physician who brought this potential problem to the attention of the cardiology group of which Mr. Streem is an employee, I have several concerns about the research methodology and the conclusions that were made. First, it appears there was no power analysis done to determine the number of patients in the sample required to detect statistical significance. If this is true, it makes any conclusions based on this data inappropriate. Second, this is a retrospective study and does not appear to make any attempt to capture delayed complications and rehospitalizations post procedure. This is particularly important for the development of thrombus and/or DVT, which are the most concerning complications of arterial puncture closure devices. Third, Mr. Streem concludes that the closure devices appear to be safer with fewer complications than manual compression. However, the data that he presents appears to support just the opposite conclusion because the incidence of thrombus, which is the most concerning complication, appears to be twice that of manual closure. At this time, the metanalysis published in JAMA 2004;291:350-357 appears to be a much more rigorous study and needs to be taken very seriously and, in fact, is somewhat confirmed by the increased incidence of thrombus formation in Mr. Streem’s study. Certainly more research needs to be done in a prospective manner with adequate sample size capturing late complications and emphasizing those complications that are more serious and potentially life-threatening or with significant long-term morbidity. Sincerely yours, David L. Weldy, MD, PhD Mantua Family Healthcare, Ravenna, Ohio Re: Marshall S. Helpful Tip from a Fellow Professional Cath Lab Digest 2004;12(11):56. Dear Editor: I just read the tip this month, and we, too, frequently give aspirin and Plavix post-procedure. I use the individually packaged straws used for filling Med-Rad barrels. Peel the package at the top, fill with water, and the curve of the straw is perfect. I’ve never had a patient cough when administering in this way. And it’s CHEAP. Alan Bauer, CVT, Products Mgr. St Joseph’s Cath Lab, Atlanta, Georgia, ABauer@sjha.org Re: Email Discussion Group: IABP Removal by Registered Nurses? Cath Lab Digest 2004;12(10):39-43. Dear Editor: When I started working cath lab, the MD would pull the balloon and hold for the first 5 minutes and then the RN would take over. Now the Cath RN pulls without MD assist. I am puzzled by the fact that ICU RNs do not pull arterial sheaths. Vicki Walston, BSN, RN, VAMC, Minneapolis, MN, walston85@msn.com Re: Rasmussen MR. Acute Myocardial Infarction Drug Management. Cath Lab Digest 2004;12(12):36-38. Dear Editor: I was reading the December issue. Great job as usual. I enjoyed the article by Mark Rasmussen, Acute Myocardial Infarction Drug management: A review, but was unable to find any mention of the use of morphine or beta blockade. I understand that this was mainly a case-specific anecdotal portrait but was also a review of MI drug management. Would it be possible to have an amendment with these two VERY IMPORTANT drugs for AMI mentioned? It would be of note particularly since dopamine, bivalirudin, lidocaine and others were mentioned and the beta adrenergic system was discussed, but neither morphine nor beta blocker medications were mentioned as ACC-indicated treatment options. Morphine is routinely underutilized in AMI and the benefits of beta blockade have been well established. I would hate for people to use this protocol based on such a prestigious facility without taking into account these very important medications. From the August 2004 ACC GUIDELINES*: CLASS I: Morphine sulfate is the analgesic of choice in pain associated with STEMI CLASS I: Oral beta blocker therapy should be administered promptly to those patients without proper contraindications, irrespective on noncomittant fibrinolytic therapy or performance of PCI CLASS IIa: It is reasonable to administer IV beta blockade to a STEMI patient without contraindication, especially if tachyarrythmia or hypertension is present. Immediate beta blocker therapy appears to reduce the magnitude of infarction and associated complications in subjects not receiving concomitant fibrinolytic therapy, the rate of reinfarction in patients receiving fibrinolytic therapy and the frequency of life-threatening ventricular arrythmias. *Source: Antman E et al. ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction Executive Summary. JACC 2004;4(3):671-719. Jason Money, RN, RCIS, Cath Lab Digest Editorial Board Member Elkins, AR, oneworld99@yahoo.com I would like to say that overall, the December article Acute MI Drug Management was very good. I understand that the article was written for patient management during the cath procedure. I also understand the points that Jason Money made (above). Although Fentanyl and Versed are drugs of choice for most of my staff physicians, there are a number of physicians that utilize morphine on a regular basis during routine caths. Morphine is still the overall drug of choice for all of our acute coronary interventions, and intravenous Lopressor is also a fairly common drug that is utilized. Since the article was titled Acute Myocardial Infarction Drug Management: A review, it does give the impression that this is an overall review of current practice. It may be a good idea, as Jason mentioned, to publish an addendum stating that Acute Myocardial Infarction Drug Management: A review was case-specific, anecdotal and an overview of the Beth Israel protocol. Ken Gorski, RN, RCIS, FSICP, Cath Lab Digest Editorial Board Member Sones Cardiac Catheterization Labs, The Cleveland Clinic Foundation Cleveland, OH, gorskik@ccf.org The December article by Mark Rasmussen, Acute MI Drug Management, is very well-written. Our standard of practice with patient management in acute MI settings is to use Versed and Fentanyl. Until five years ago, we used Dilaudid instead of Fentanyl. We very seldom use morphine sulfate. We do use beta blockers such as Lopressor or Vasotec. Since our cath lab support staff is fully trained to administer moderate sedation, we function under the administrative approved guidelines of the Department of Anesthesia, Medicine, Nursing, and Pharmacy. The Conscious Sedation Committee that is formed from members of the forementioned departments establish the policies and procedures for which medications should be used for first-line intravenous administration. Therefore, the suggestions in the article should be considered the standard policies at the author’s place of employment and should be referenced as case-specific. Chuck Williams BS, RPA, RT(R)(CV)(CI), RCIS, CPFT, CCT, Cath Lab Digest Editorial Board Member, Emory University Hospital, Atlanta, GA, codywms@msn.com Author Mark Rasmussen responds: Morphine is often given out of hospital for pain management as well as beta blockers for rate control. Morphine is not given in our cath lab. We use Fentanyl and Versed. I think the confusion for this comes from ACLS, where the acronym MONA: Morphine, Oxygen, Nitroglycerin, Aspirin greeting all patients is used. Morphine is one of many narcotics used in pain management; we do not use it in the cath lab. We often hear it from emergency room nurses that they gave it to their patients. The same is true for beta blockers. Lopressor is often given in the pre-cath setting, and on very rare occasion, in the lab. Again, not part of our routine management in the lab. The article was written for management during the procedure, and that is what it covered. I could have covered intracoronary Nitroglycerin and Nipride, and even Diltazem, but this would require more detail than the article was meant to cover. Mark R. Rasmussen, BA, BSN, RN-C, CCRN, Clinical Advisor, CCL, Beth Israel Deaconess Medical Center, Boston, MA mrasmuss@bidmc.harvard.edu

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