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    Add as FriendCardiac Catheterization complication

    by: fuad

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    1 : Precath Preparation Dr Fuad Farooq
    2 : Preparation of the Patient Elective cardiac cath should be deferred if the patient is not prepared physiologically and physically
    3 : Consent Detailed discussion with the patient and family Should be obtained by the operator or his or her assistant Should outline the indication of procedure Explain in simple terms which procedure to take place and for what reason each step of the procedure will occur Explain the risk for routine cardiac cath Major- stroke, myocardial infarction, kidney failure, death Minor- vascular injury, allergic reaction, bleeding, hematoma, infection Possible need of emergency CABG Explain any portion of the study used for research Provide necessary information and explanation
    4 : History Including Reason of cardiac cath Precious allergies to dye, sea food Asthma, allergic rhinitis Medications esp. ASA, Clop, Metformin, anticoagulants History of kidney disease In female, if child bearing age, ask especially for pregnancy
    5 : Examination Thorough general physical examination should be done All peripheral pulses should be palpated and documented Look for arterial bruit and document it as a baseline for future reference Perform Allen’s test if radial approach Auscultate chest Look for murmurs
    6 : Metabolic Profile Renal function e.g. BUN, creatinin Electrolytes e.g., Na, K CBC Coagulation profile Any abnormality in the lab should be addressed before proceeding to LHC
    7 : Precath orders preferably written on preceding night If patient on long acting insulin dose should be reduced to half NPO at least 8 hours before procedure Shave both groins for femoral access and mostly right wrist for radial approach Avoid laceration or abrasions Apply Foley catheter or condom catheter in male
    8 : Choice of Dye Now a days mostly nonionic low osmolal dye is used Causes less nausea and emesis, LV dysfunction, bradycardia and hypotension Useful in cases of suspected LM stenosis, severe LV dysfunction, and severe aortic stenosis In patients with renal insufficiency and reported allergy to contrast dye
    9 : Contrast Media Reaction Incidence 5% 10-12% patients has history of asthma 15% patients has the history of previous reaction to the contrast media Three types Cutaneous and mucosal manifestations (angioedema, flushing, laryngeal edema, pruritis, urticaria) Smooth muscle and minor anaphylatoid reaction (bronchospasm, GI spasm, uterine contraction) Cardiovascular and major anaphylactoid reaction (arrhythmia, hypotension, vasodilatation)
    10 : More risk with the ionic contrast media than non-ionic contrast media Any patient reported previous allergy to the contrast media or history of atopy or prior anaphylactoid reaction should be premedicated with Steroid ( prednisolone 40mg PO Q6H or I.V hydrocortisone 100mg once at least 6 hours before the procedure Diphenhydramine ( Benadryl 50mg I.V once ) H2 blocker ( Clemestine 1mg I.V once) If history of life threatening dye allergy, it is prudent to admister 1ml of dye and watch for few minutes before proceeding Contrast Media Reaction..
    11 : Contrast Induced Acute Kidney Injury High risk patients are Patients with diabetes Patients with renal insufficiency (Cr >1.5) Patients who are dehydrated due to any reason Prevented by I/V hydration with 0.9% saline ( LV function should be taken into consideration for selection of rate of infusion) Dose: 1ml/kg/hr at least 2 hours before procedure and ideally Upto 6-12 hours before procedure and continue Upto 6-12 hours post procedure Alkalinization of urine prevent free radical injury to the kidney Dose: 3 ml/kg for one hour before procedure and continued as 1ml/kg/hr for 6 hours post procedure
    12 : Contrast Induced Acute Kidney Injury Acetylcysteine- has antioxidant and vasodilator properties Must be accompanied by I/V hydration and use of low or iso-osmolal contrast agent Risk reduction Upto 50% Dose: 1.2 gm P.O twice a day- starting day before the procedure and continue for two days post procedure (I/V admistration if in emergent procedure and orally cannot be given-150mg/kg prior procedure and 50mg/kg post procedure over 4 hours) Using low osmolal or iso-osmolal nonionic contrast media (use in lower dose) Avoid closely spaced studies (<48 hours apart) Avoid NSAID’s
    13 : Diabetes Mellitus Patient with diabetes on insulin therapy, overnight fast with normal dose of insulin can cause hypoglycemia Dose if insulin should be half Patient on NPH insulin has increase risk of protamine reaction Patient on Metformin, withheld it 48 hours before procedure because of risk of lactic acidosis especially in patients with renal insufficiency may resume after 48 hours only when renal function are found to be normal Hydrate the patient before during and after the procedure ( i.v saline @ 1ml/kg/hr)
    14 : Patient Education Patient should be warned that they might feel hot sensation for few seconds when contrast is injected, some patients may feel nausea Patient should specially instructed to cough when they hear anyone in the cath lab say “cough” – this will accelerates resolution of dye induced bradycardia
    15 : Equipment Before performing cath it is very essential that the monitoring equipment is fully functional Continues ECG recording, heart rate, rhythm, ST segment an automated BP and pulse oximetry are essential Resuscitation equipment should be tested and ready – defib and intubation trolley should be next to the patient
    16 : Cardiac Catheterization Complication
    17 : Cath Lab Complications Death AMI Dysrhythmia Stroke Bleeding Hematoma Vascular Injury Contrast Induced Nephrotoxicity Allergic reactions/Anaphylaxis Pulmonary Edema Air/clot embolism Renal Failure (CIN) Vagal reaction
    18 : Major Complications The risk of producing a major complication (death, myocardial infarction, or major embolization) during diagnostic cardiac catheterization is generally less than 1% Risk of adverse events depends upon Demographic (age, gender) Cardiovascular anatomy (left main coronary artery disease, severe AS, diminished LV function) Clinical situation (Unstable angina, Acute MI, cardiogenic shock) Comorbids Experience of operator Peripheral arterial disease
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    21 : Mortality Rare – less then 0.1%1 High risk group Age >60 years and <1year Female NYHA IV heart failure (10 times increase risk than Class I and II Severe LMCA (20 times higher than SVCAD)2 LVEF <30% Patient with valvular heart disease, CKD, DM requiring insulin therapy, peripheral arterial disease, pul insufficiency, cerebrovascular disease Noto TJ, Johnson LW, Krone R, et al. Cardiac catheterization 1990: a report of the registry of the Society for Cardiac Angiography and Interventions. Cathet Cardiovasc Diagn 1991;24:75. Kennedy JW. Complications associated with cardiac catheterization and angiography. Cathet Cardiovasc Diagn 1982;8:5.
    22 : Myocardial infarction Periprocedural myocardial ischemia is common but risk of myocardial infarction is <0.1% Factor predispose patient for periprocedural MI are1: Extent of disease (0.17% with LM disease vs 0.06% with SVCAD vs 0.08% for 3 VCAD) Recent NSTEMI DM requiring insulin therapy 1. Johnson LW, et al. Coronary angiography 1984-1987: a report of the registry of the Society for Cardiac Angiography and Interventions, I: results and complications. Cathet Cardiovasc Diagn 1989;17:5.
    23 : Akkerhuis KM, et al. Minor Myocardial Damage and Prognosis: Are Spontaneous and Percutaneous Coronary Intervention—Related Events Different? Circulation 2002;105: 554–556).
    24 : Stroke and Transient Ischemic Attack Rare but devastating complication Incidence 0.07-0.1% but most are asymptomatic embolic event Risk factors includes: Severity of coronary artery disease Length of fluoroscopy time Diabetes Hypertension Prior stroke Renal failure Mostly caused by disruption of atheromatous plaques on the wall of aorta - other sources can be- surface of valves and cardiac chambers
    25 : Also result from injection of high osmolal contrast agent into carotids and vertebral arteries Risk is higher in patients with valvular aortic stenosis Majority of periprocedural stroke patient have poor outcome and in hospital mortality can be as high as 32% Stroke and Transient Ischemic Attack..
    26 : Stroke and Transient Ischemic Attack.. Prevented by paying careful attention to flushing and injection technique, minimize dwell time of guidewire in the aortic root of patients who are not fully anticoagulated Carefully wipe and immerse guidewires in heparinized saline before their reintroduction during left-sided heart catheterization
    27 : Local Vascular Complications Local complications at the site of insertion are most common, include Acute thrombosis Distal embolization Dissection Poorly control bleeding ( free hemorrhage, femoral hematoma, retroperitoneal hematoma Pseudoanerysm AV fistula Less frequent with radial artery access
    28 : Data obtained from the American College of Cardiology National Cardiovascular Data Registr It included information from 59 institutions and 13,878 cardiac catheterizations performed during the last quarter of 2003 Risk of Local Adverse Events following Cardiac Catheterization by Hemostasis Device Use -- Phase II Dale R. Tavris
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    31 : Hemorrhage and hematoma usually evident within 12 hours Local discomfort, hypotension, and decrease hemoglobin Conform by U/S and CT AV fistula and pseudo aneurysm may not apparent for days and weeks Local Vascular Complications..
    32 : Femoral Artery Laceration Uncontrollable free bleeding around the sheath Control by placement of upsized sheath If not control then manual pressure around the sheath until procedure is complete Then reverse anticoagulation and remove the sheath and prolong compression for 30-60 min or placement of closure device If bleeding continue the urgent vascular surgeon consult to be taken
    33 : Major Femoral Bleeding Complications After PCI Consecutive patients who underwent transfemoral PCI from 1994 to 2005 at the Mayo Clinic (n = 17,901) were studied 3 groups: Group 1 (1994 to 1995, n = 2,441) Group 2 (1996 to 1999, n = 6,207) Group 3 (2000 to 2005, n = 9,253) Incidence of major femoral bleeding complications decreased (from 8.4% to 5.3% to 3.5%; p < 0.001) Reductions in sheath size, intensity and duration of anticoagulation with heparin, and procedure time were observed (p < 0.001) multivariate analysis confirmed each as an independent predictor of complications (p < 0.001)
    34 : Adverse outcomes of major femoral bleeding prolonged hospital stay (mean 4.5 vs. 2.7 days (p < 0.0001) increased requirement for blood transfusion (39% vs. 4.7%; p < 0.0001) Major femoral bleeding and blood transfusion were both associated with decreased long-term survival, driven by a significant increase in 30-day mortality (p < 0.001) Doyle et al. J Am Coll Cardiol Intv. 2008; 1: 202-209

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