Page 567 - Cardiac Nursing

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C HAPTER 2 3 / Interventional Cardiology Techniques: Percutaneous Coronary Intervention 543
one-half the usual dose of insulin is given with continued surveil- transfer. Report is called to the receiving staff, including type of
lance of blood glucose before and after the procedure. Insulin procedure performed, specific artery treated, vital signs, status of
drips are used for patients with Type I diabetes mellitus, difficult the arterial sheath, and other pertinent information. (See vascular
glycemic control, ACS, or who are otherwise unstable. sheath removal under postprocedure management.)
Patients With Renal Insufficiency Postprocedure Management
Patients with pre-existing renal insufficiency and/or diabetes mel-
litus have an increased risk of contrast-induced nephropathy with The interventional patient is monitored for manifestations of my-
contrast medium used during PCI. Renal dysfunction is present ocardial ischemia, such as chest pain, electrocardiogram (ECG)
when creatinine clearance is less than 60 mL/min or serum crea- changes, arrhythmias, or hemodynamic instability. A 12-lead
tinine is 1.5 mg/dL. Creatinine clearance should be estimated ECG is obtained postprocedure to establish a baseline for com-
and medication dosage adjusted in patients with altered renal parison. Laboratory tests are drawn and should minimally include
function. Isosmolar contrast agents should be used during PCI. hematocrit, platelet count, blood urea nitrogen, and creatinine.
The major preventive strategy includes adequate hydration before All patients who have unstable angina, MI, or a complicated pro-
and after the procedure. The combination of N-acetylcysteine and cedure should have CK-MB and troponin measured. Patients may
sodium bicarbonate infusion before and after contrast administra- be relatively extracellular fluid (ECF) depleted after PCI because
tion has been reported to reduce the risk of contrast-induced of nothing-by-mouth status and radiographic contrast-induced
nephropathy in patients with renal insufficiency. 39 diuresis. Hydration is maintained by normal or half-normal saline
until oral intake is sufficient to meet patient requirements. Anti-
Intraprocedure Management coagulants, antithrombin agents, or GP IIb/IIIa receptor in-
hibitors infusions are continued as per institutional protocol or
Patient preparation is similar to the patient having a diagnostic physician orders.
cardiac catheterization (Chapter 20). Conscious sedation is given
at the discretion of the cardiologist and the patient monitored by Vascular Sheath Removal
the catheterization laboratory staff as per protocol. A sheath is Vascular sheath removal, mobilization, and ambulation protocols
placed in the femoral artery, which is the most common arterial vary according to the device protocol and hospital policies. In
access site. Alternatively, the brachial or radial artery can be used general, the sheaths are removed 4 to 6 hours after the procedure,
for arterial access. when the ACT falls below 180 seconds, by either the patient care
A bolus of heparin is given to maintain an activated clotting unit nursing staff or catheterization technician. Vascular sheaths
time (ACT) of 250 to 300 seconds. ACT below 250 seconds has are removed by manual pressure and either an adjunctive com-
been associated with thrombotic complications during PCI with pression device or a vascular closure device. Manual pressure is
multiple catheters, wires, or devices being placed in the aorta and applied for at least 20 minutes or longer, as warranted, to provide
coronary arteries. Use of low-molecular-weight heparin (LMWH) homeostasis with strict attention to the arterial site and distal cir-
or direct thrombin inhibitors can be used as an alternative to he- culation. Recognition and treatment of complications are essen-
parin (see anticoagulation options for PCI). 40,41 For patients who tial to prevent peripheral vascular injuries. The vascular site is
undergo PCI with LMWH, specific dosage regimens are available. monitored for bleeding, hematoma formation, distal circulation,
When fondaparinux (an LMWH) is used prior to intervention, and sensation, initially every 15 minutes and advancing to every
additional intravenous treatment with an anticoagulant possessing hour until stable. Manual compression remains the standard
anti-IIa activity (such as unfractionated heparin, or UFH) should method for femoral sheath removal worldwide. Passive closure
4
be used because of the risk of catheter thrombosis. Baseline an- techniques enhance manual pressure utilizing (a) external
giographic views are obtained of the coronary artery to be treated patches with prothrombotic coatings (Syvek Patch, Marine Poly-
using the standard diagnostic catheter or the guiding catheter. mer Technologies, Danvers, MA); (b) wire-stimulated tract
Coronary injections may be repeated after administration of in- thrombosis (Boomerang Wire, Cardiva Medical, Mountainview,
tracoronary nitroglycerin to exclude spasm as a significant com- CA); or (c) assisted compression devices (Femostop, RADI Med-
ponent of the target stenosis and to minimize the occurrence of ical system Inc., Wilmington MA; or Safeguard, Datascope
coronary spasm during the PCI. The appropriate guiding catheter Corp. Montvale, NJ). Pressure dressings and sand bags to groin
is positioned in the coronary ostium and a guidewire is directed sites have been found to be ineffective in controlling recurrent
across the stenotic lesion. After the wire tip is confirmed to be in or persistent bleeding and cause discomfort. 42 Minor or tract
the distal portion of the coronary artery to be treated, the angio- oozing after a compression or a vascular closure device can be
plasty balloon or other device is selected. The patient is monitored managed with light manual pressure, injection of xylocaine with
for hemodynamic stability and electrocardiographic changes dur- epinephrine, or light pressure dressing.
ing the procedure. Vasovagal reactions can occur at the time of sheath insertion or
During the procedure additional heparin or a direct thrombin removal. Common symptoms associated with a vasovagal reaction
inhibitor is given by the cardiologist to maintain an adequate include hypotension, nausea, vomiting, yawning, and diaphoresis.
ACT and anticoagulation status. A GP IIb/IIIa receptor inhibitor This syndrome is triggered by pain and anxiety, particularly in the
infusion may be selected for patients with ACS or angiographic setting of ECF deficit. 43 Treatment includes cessation of painful
thrombus. After the procedure is complete, the patient is prepared stimuli, rapid volume administration with normal saline, and
for transfer to the postinterventional ward. Vital signs are moni- atropine intravenously. If hypotension persists, additional hemo-
tored and patient placed on a portable monitor for transfer. The dynamic support with intravenous vasopressor agents may be
arterial access site is assessed for bleeding or hematoma prior to needed.