Page 570 - Cardiac Nursing

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546 PA R T I V / Pathophysiology and Management of Heart Disease
chest pain and hypotension, and is most commonly seen in the undergoing PCI is 0.8% to 5.5%, and has decreased significantly
catheterization laboratory. Treatment includes nitroglycerin or a from earlier experiences. Decreased incidence of complications
low-pressure balloon. If spasm is significant, the patient may be has been seen with the decrease in sheath size and the current
maintained on nitroglycerin and intravenous fluids overnight. standard drug regimen for stent management.
Hematoma formation or ecchymosis is frequent and self-limiting.
Arrhythmias and Conduction It usually requires no intervention other than comfort measures.
Disturbances Retroperitoneal bleeding caused by large hematomas dissecting
into the retroperitoneum are life threatening and need prompt at-
Ischemia during treatment can cause ECG changes, including tention by the nursing and medical staff. Inadvertent puncture of
transient heart block, atrial arrhythmias, or ventricular arrhyth- the artery proximal to the inguinal ligament (i.e., the external il-
mias. Significant arrhythmias occur in approximately 1% of PCI, iac artery) while placing the arterial sheath is frequently the cause.
usually as a result of prolonged ischemia during balloon inflation There is less supporting tissue in this area, and it is more difficult
or luminal occlusion with devices. 57 to compress the puncture site. Retroperitoneal bleeding is charac-
terized by lumbar or groin pain, a significant drop in hematocrit,
hypotension, and possible bradycardia or tachycardia. Diagnosis is
Contrast Medium-Related confirmed by a computed tomography scan. Treatment involves
Complications transfusion and fluid resuscitation to maintain adequate blood
pressure, reversal of anticoagulation and occasionally surgical re-
Hypersensitivity reactions to radiocontrast medium are independ-
ent of amount or rate of infusion. This reaction can occur imme- pair of the artery.
diately (within 1 hour) or delayed (from 1 hour to 1 week). Signs Arterial thrombosis at the puncture site may lead to occlusion
and symptoms include pruritus, urticaria, angioedema, laryn- of the artery or distal thrombosis into the extremity. Preexisting
gospasm, bronchospasm, hypotension with loss of consciousness, peripheral vascular disease increases the risk of a thromboembolic
and rarely hypovolemic shock and death. Risks of hypersensitivity event. Surveillance of distal circulation and sensory checks should
reactions are previous anaphylactoid reaction to contrast, asthma, be continued after sheath removal. Signs of loss of pulse, color
a history of allergic rhinitis, or drug or food allergies. Strategies to changes, decreased sensation, decreased temperature, or decreased
prevent recurrent reactions include use of low osmolar contrast motor function are potential indicators of thrombosis.
and a prednisone regimen (premedicate with prednisone 13 hours Pseudoaneurysm is an extra-luminal cavity in communication
before the procedure, administer a second dose at 7 hours before the with an adjacent artery, usually the femoral artery. Inadvertent
procedure, and administer a third dose 1 hour before the proce- puncture of the superficial femoral or profunda femoris artery in-
dure), an H1 antihistamine (diphenhydramine) 1 hour before the creases the incidence of arterial complications. Contributing fac-
procedure, and possibly an H2 blocker (cimetidine or ranitidine), tors include inadequate compression of the puncture site, heparin
which has shown conflicting benefit prior to the procedure. For use, intramural arterial calcifications, and hypertension. On phys-
emergency procedures, an intravenous steroid (hydrocortisone) ical examination, the patient may have a pulsatile mass, systolic
should be given immediately and every 4 hours until completion of bruit, normal distal arterial pulses, and pain in the groin. Doppler
procedure and diphenhydramine 1 hour before the procedure. 38 ultrasound and color flow imaging are used to confirm the diag-
Contrast-induced nephropathy can cause temporary or permanent nosis and delineate the location and size of the pseudoaneurysm.
renal dysfunction. Patients with diabetes or preexisting renal insuffi- Although most small pseudoaneurysms spontaneously close in 4
ciency, and older adults are at highest risk. Limiting volume of con- to 8 weeks without sequelae, they may enlarge or hemorrhage, es-
trast and hydration prior to PCI remains the best preventive strategy. pecially in patients with prolonged anticoagulation. Treatment in-
Volume overload (ECF, water, or both; Chapter 7) can be due cludes ultrasound-guided compression, thrombin injection with
61
to hypertonic contrast agents, myocardial depression secondary to ultrasound guidance, or surgical closure.
ischemia, poor baseline ventricular function, routine diuretics and Arteriovenous (AV) fistula is a communication between an artery
other medication held prior to PCI, and excessive volume pre- and vein. The mechanism of injury involves a puncture through
loading. Prevention involves continued monitoring of ECF and both the femoral artery and vein, which results in a false communi-
water status before and after the procedure, particularly in patients cation. On physical examination, the patient may have a pulsatile
with LV dysfunction, and reinstituting routine medications. Ad- mass in the groin and a continuous systolic–diastolic bruit; over
ditional diuretics may be needed. time, temperature of the extremity decreases due to high flow
through the fistula and ischemia of the extremity; a thrill may be
present at the site; and heart failure may result if the fistula is per-
Cerebrovascular Complications
sistent. Doppler ultrasound and color flow imaging confirm diag-
Transient ischemic attacks or cerebral vascular accidents secondary nosis. Surgical treatment may be necessary for closure and repair of
to plaque disruption may occur from manipulation of catheters and the peripheral vasculature.
devices during intervention in patients with diffuse atherosclerotic Septic endarteritis is rare and has been implicated in chronic in-
disease. 58 A rare complication is spontaneous intracerebral hemor- timal damage and stasis due to flow turbulence in the region of a
rhage with aggressive anticoagulation and antiplatelet agents. pseudoaneurysm or AV fistula, multiple procedures through the
same access site, obesity, or sheaths left in place for over 24 hours.
Groin Complications In high-risk patients, antibiotics are given postprocedure and may
be continued postdischarge if warranted. 62
Bleeding post-PCI is an independent predictor for short- and VCD complications include infection, femoral artery compro-
long-term clinical events with increased mortality and morbid- mise, arterial laceration, uncontrolled bleeding, pseudoaneurysm,
ity. 59,60 The incidence of vascular complications among patients AV fistula, as well as device embolism and limb ischemia. These