Registered Nurse Challenges in Cardiac Catheterization
Cardiac catheterization is the process of insertion of a catheter into a chamber or blood vessel for diagnostic and interventional utility. Cardiac catheterization process includes catheterization of the coronary arteries, known as coronary catheterization and catheterization of cardiac chambers and valves.
Cardiac catheterization is a complex and arduous nurse task.
Risks and Complications
Cardiac catheterization risks include bruising, bleeding, heart attack, stroke, pseudoaneurysm, arrhythmia, allergic manifestations, tissue damages in the artery and heart, impaired respiratory function, renal damages, infection and blood clots.
A matched case-control study on the risk factors of procedural sedation and analgesia during cardiac catheterization has shown that side effects of the medications used for procedural sedation and analgesia during cardiac catheterisation can cause impaired respiratory function.
Impaired respiratory function often leads to inadequate oxygenation (Conway et.al, 2012).
Patient safety, especially after cardiac catheterization poses considerable risks. Removal of the catheter after completion of the procedures involves prevention of bleeding in the site.
Bleeding can be arrested by the application of firm pressure by manual compression or with a mechanical device.
If the femoral artery is used, the patient is required to lie flat for a few hours to prevent bleeding and hematoma. Catheterization of cardiac chambers and valves demands more post-catheterization time for the wound to clot.
Femoral artery closure devices have been shown to be better in terms of quicker time to hemostasis, ambulation, and discharge than manual compression. Understanding of the function of these femoral artery closure devices is imperative for the nurses because of the potential vascular complications involved in their use (Hamel, 2009).
The use of a StarClose device with an extraluminal design has been evaluated in patients undergoing cardiac catheterization and the device offers considerable advantages over other closure devices (Rodriguez and Katz, 2011).
The safety and efficacy of a novel vascular closure device (VCD) called the Angio-Seal Evolution (ASE) as compared to manual femoral compression (MC) has also been reported (Lupi et.al, 2011).
Pseudoaneurysm complications are a major source of morbidity after cardiac catheterization.
Studies have shown that these post-catheterization lesions occur in approximately 0.05% of treated patients after diagnostic catheterization and 1.2% patients after complex procedures.
Studies have shown that prevention of post catheterization pseudoaneurysms is possible by the use of proper puncture techniques, choosing the right place and right post interventional hemostatic compression with or without external devices (Kacila et.al, 2011).
Femoral Artery Pseudoaneurysm (FAP) is a common vascular complication after cardiac and peripheral angiographic procedures.
Injection of thrombin by ultrasound guidance is the standard procedure for the treatment of FAP.
Studies indicate a need for caution while treating FAP with thrombin due to the occurrence of severe complications after thrombin injection leading to fatality (Gabrielli et.al, 2011).
Though transradial cardiac catheterization has been shown to exhibit lower rates of arterial access site complications than transfemoral procedures, there are complications specific to the transradial procedure like that of the transient self-limiting granulomata (Zellner et.al, 2011).
Pseudoaneurysm following radial artery access is a rare complication (Collins et.al, 2012).
Some of the common complications of transradial access include asymptomatic radial artery occlusion, nonocclusive radial artery injury and radial artery spasm. Among these complications, radial artery spasm poses a serious challenge (Bhat et.al, 2012).
Arteriovenous fistula (AVF) is another potentially harmful complication of diagnostic and interventional cardiac catheterization.
Studies on the incidence and outcome of femoral vascular complications among patients undergoing cardiac catheterisation have shown that at least two percent of patients undergoing cardiac catheterisation acquire femoral AVF (Ohlow et.al, 2009).
Hemoptysis after cardiac catheterization has been frequently reported. Hemoptysis can primarily occur due to pulmonary artery pseudoaneurysms and can be treated by embolization with a vascular plug (Burrel et.al, 2010).
Tissue damage in the artery is another serious complication.
Rupture of a pulmonary artery branch, as a common complication during right heart catheterization has been recently reported (Ali et.al, 2011).
Complex regional pain syndrome (CRPS) previously referred to as reflex sympathetic dystrophy, a chronic pain condition that occurs after a surgery has been recently described following a trans- femoral catheterization-related groin pseudoaneurysm for the first time (Saad et.al, 2011).
Transcatheter Aortic Valve Implantation (TAVI) is a recent innovation developed with the goal of offering a less invasive alternative to symptomatic high-risk patients with aortic stenosis. Published literature show the need for strategies for enhancing nurses' knowledge of the risks, benefits, and potential complications of TAVI.
These strategies shall empower nurses in their role as patient advocates and educators to improve patient outcomes in TAVI (McRae and Rodger, 2012).
Prospective observational cohort studies to determine the incidence of perfusion-related complications associated with femoral artery catheters in neonates have shown that duration of catheterization and use of a catheter larger than 2.5 Fr were significant predictors of loss of pulse.
The study has also shown that the loss of pedal pulse distal to small-bore monitoring femoral artery catheters in neonates and infants can be attributed to the duration of catheterization and can be controlled when 2.5-F; 5-cm polyethylene catheters are used instead of larger catheters (Dumond et.al, 2012).
Cardiac catheterization is a complex task and vascular complications are common after a cardiac catheterization.
A recent report from The Pennsylvania Patient Safety Authority shows that the cardiac catheterization complications represent the major part of the medical errors detected annually (Huber, 2009).
The National Cardiovascular Data Registry of The American College of Cardiology's has set a benchmark for vascular complications incidence and is less than one percent for diagnostic catheterizations and less than three for percutaneous coronary interventions (Cale and Constantino, 2012).
Nurse care by selection of smaller sheaths, gentle catheter manipulation, adequate anticoagulation, use of appropriate compression devices and avoiding prolonged high-pressure compression can prevent most of these complications.
Nurse’s attention for the pain symptoms, numbness and prompt diagnosis of hematoma can reduce the occurrence of cardiac catheterization complications effectively.
•Ali A, Kousha M, Soubani A. Rupture of a pulmonary artery branch during right heart catheterization. Am J Respir Crit Care Med. 2011 Apr 1; 183(7):949.
•Bhat T, Teli S, Bhat H, Akhtar M, Meghani M, Lafferty J, Gala B. Access-site complications and their management during transradial cardiac catheterization. Expert Rev Cardiovasc Ther. 2012 May; 10(5):627-34.
•Burrel M, Real MI, Barrufet M, Arguis P, Sánchez M, Berrocal L, Montañá X, Ninot S. Pulmonary artery pseudoaneurysm after Swan-Ganz catheter placement: embolization with vascular plugs. J Vasc Interv Radiol. 2010 Apr; 21(4):577-81.
•Cale L, Constantino R. Strategies for decreasing vascular complications in diagnostic cardiac catheterization patients. Dimens Crit Care Nurs. 2012 Jan-Feb; 31(1):13-7.
•Collins N, Wainstein R, Ward M, Bhagwandeen R, Dzavik V. Pseudoaneurysm after transradial cardiac catheterization: case series and review of the literature. Catheter Cardiovasc Interv. 2012 Aug 1; 80(2):283-7.
•Conway A, Page K, Rolley J, Fulbrook P. Risk factors for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory: a matched case-control study. Eur J Cardiovasc Nurs. 2012 Dec 21.
•Corley A, Barnett AG, Mullany D, Fraser JF. Nurse-determined assessment of cardiac output. Comparing a non-invasive cardiac output device and pulmonary artery catheter: a prospective observational study. Int J Nurs Stud. 2009 Oct; 46(10):1291-7.
•Dumond AA, da Cruz E, Almodovar MC, Friesen RH. Femoral artery catheterization in neonates and infants. Pediatr Crit Care Med. 2012 Jan; 13(1):39-41.
•Gabrielli R, Rosati MS, Vitale S, Millarelli M, Chiappa R, Siani A, Irace L, Caselli G. Fatal complication after thrombin injection for post-catheterization femoral pseudoaneurysm. Thorac Cardiovasc Surg. 2011 Sep; 59(6):372-5.
•Hamel WJ. Femoral artery closure after cardiac catheterization. Crit Care Nurse. 2009 Feb; 29(1):39-46; quiz 47.
•Huber C. Safety after cardiac catheterization. Am J Nurs. 2009 Aug; 109(8):57-8.
•Lupi A, Lazzero M, Plebani L, Sansa M, Bongo AS. Safety and efficacy of the new Angio-Seal Evolution™ closure device: a single-center experience. J Invasive Cardiol. 2011 Apr; 23(4):150-5.
•McRae ME, Rodger M. Transcatheter aortic valve implantation outcomes: implications for practice. J Cardiovasc Nurs. 2012 May-Jun; 27(3):270-82.
•Ohlow MA, Secknus MA, von Korn H, Neumeister A, Wagner A, Yu J, Lauer B. Incidence and outcome of femoral vascular complications among 18,165 patients undergoing cardiac catheterisation. Int J Cardiol. 2009 Jun 12; 135(1):66-71.
•Rodriguez A, Katz SG. The use of the StarClose device for obtaining femoral artery hemostasis. Vasc Endovascular Surg. 2011 Oct; 45(7):627-30.
•Saad A, Knolla R, Gupta K. Complex regional pain syndrome following transfemoral catheterization. J Invasive Cardiol. 2011 Nov; 23(11):E267-70.
•Zellner C, Yeghiazarians Y, Ports TA, Ursell P, Boyle AJ. Sterile radial artery granuloma after transradial cardiac catheterization. Cardiovasc Revasc Med. 2011
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Liz Di Bernardo