The Procedure and Procedural CareTortorici Chapter 19

Pre-procedure

* Interview patient, take Hx* Signed informed consent* 4-8 hour fast with water* Stop anticoagulant therapy* Start heparin 4 hours prior and continue 6-24 hrs. after Protomine Sulfate (coagulant) for heparin OD

Lab tests* BUN/Creatinine* Clotting factors: Prothrombin time (PT) Partial Thromboplastin time (PTT)

Pre-procedure sedation

Conscious sedation

* Valium (diazepam): a benzodiazepine

* Demerol: a synthetic opioid

* Narcan: for opioid OD

Procedure

* Establish rapport with patient

* Review chart

* Baseline vitals/neurologic tests

Vitals

Adult BP =Elderly BP =Pulse = (rate, rhythm, volume)Respiration =Temp. =

90/60 - 140/90140/92 – 170/10055-90

¼ pulse or 12-2097.6, 98.6, 99.6

Procedure

* Establish rapport with patient * Review chart* Baseline vitals/neurologic tests* Vitals/neurologic tests* Take scouts* Prep injection site* Drape* Needle puncture and catheter placement

Introducing the Catheter

Lumen

Arterial Anatomy

Tunica Adventitia

Tunica Media(muscular)

Elastic, fibroustissue

TunicaIntima(Endothelium)

See Chapter 10

The Judkins Technique of Catheterization Utilizing the Seldinger Technique of Arterial Puncture

Coronal MRI demonstrating the femoral artery pulse point, where arterial punctureis most commonly performed

Bladder

Uterus

Ala (wing)of ilium

Adipose ofthigh (whiteon MRI)

Thigh muscle

Cecum of colon

Original

Seldinger Needle

Cannula Stylet

Stylet, with beveled pointdown, is inserted into cannulafor puncture

Disposable needle used for femoral puncture

Cannula

Stylet

This wire has a J tip to skim over the intimal lining with minimal damage. Pushing from the other end, the solid wire core is advanced tostiffen the tip for better control.

Guide wire: Teflon wrapped wire used to introduce and manipulate catheter.

Aids insertion ofwire into hub ofcannula

Seldinger Technique of Arterial Puncture

Original method: front and back wall of the artery is punctured. to lessen the risk of introducing the guide wire into the wall and dissecting the vessel.

The risk hematoma forming from the hole in the back wall is minimal.

1. Lidocaine injection2. small incision3. spread with misquito forceps4. needle in incision, pulse felt5. 45o cephalad, 25-30 medial

Seldinger Technique of Arterial Puncture

6. The stylet is removed

7. Cannula is withdrawn,arterial return of blood

Judkins Technique of Arterial Catheterizaton

GuideWire 8. Tilt needle, insert guide wire

Judkins Technique of Arterial Catheterizaton

9. The cannula is removed.

Arterial bleedingstops as the puncture siteforms a seal around the guide wire

Judkins Technique of Arterial Catheterizaton

11. A sheath is inserted to protect the puncture site during catheter changes and manipulations

10. Dilate puncture site with a vessel dilator

A sheath

A vessel dilator for widening the puncture holeto accommodate a larger catheter

Guide wire

Judkins Technique of Arterial Catheterizaton

12. The catheter is threaded through the sheath

The catheter is then advanced through the iliac arteries, up the abdominal and thoracic aorta.

Procedure

* Establish rapport with patient * Review chart* Baseline vitals/neurologic tests* Vitals/neurologic tests* Take scouts* Prep injection site* Drape* Needle puncture and catheter placement* Hook up manifold

Manifold connected to catheter forms a closed system

Contrast HeperinizedSaline flush

Strain gaugetransducer

Systolic pressuremeasured throughthe catheter in the left ventricle.

Syringe for hand injections of contrast and flushing catheter

Manifold

Waste fluid

Procedure

* Establish rapport with patient * Review chart* Baseline vitals/neurologic tests* Vitals/neurologic tests* Take scouts* Prep injection site* Drape* Needle puncture and catheter placement* Hook up manifold* Set filming and injector parameters* Position patient* Film a run

Intraprocedural Care

Monitor

* Vitals

* ECG (EKG)

* 02 (90% saturation)

Document

* Catheter in/out time

* CM volume

* Meds

* Fluoro time

* Hemodynamic pressures

* Instruments used

Postprocedural Care

* Remove catheter

* Apply pressure (direct, mechanical device, closure device)

* Final vitals/pedal pulse

If admitted Overnight bedrest Monitor vital, pressure dressing, pedal pulse Hydrate

Complications

* Embolus/thrombus

* Internal hemorrhage

* Hematoma at puncture site

* Cardiac events * Vessel dissection

* CM reaction