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Preparing for the case

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Trends in the catheterization laboratory. Case Load: The CDIU. The Hospital for Sick Children 1969-2008. Understand the indications for catheterization. – PowerPoint PPT presentation

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Title: Preparing for the case


1
Preparing for the case
Lee Benson MD FSCAI The Hospital for Sick
Children, Toronto, Canada
2
No Disclosures
3
Ask yourself these questions as you prepare for
the catheterization
Why is the case being done? -pre-operative
information -hemodynamics PVRI,
LVED -morphology or intervention Is the case
elective, emergent or urgent? Is this the right
timing for the procedure? Is the child stable
enough for the procedure? if non-electiveis
transportation an issueECMO
4
Ask yourself these questions as you prepare for
the catheterization
Has the child family been prepared for the
procedure do they understand the risks and
benefits? Have you obtained consent spoken to
the family directly before the procedure? Is the
nursing staff anesthesia prepared for the
case? Is the child appropriately sedated and
stable? Have you determined the best approach
vascular access?
5
Precatheterization Conference
-reduces possibility that information will be
missed
-identifies therapeutic procedures equipment
needed
-time to review echocardiograms, CXR, prior
caths..etc
-time to develop a procedural plan
6
History Physical Examination
Intercurrent illness or recent fever depends on
how elective the case e.g. infant in CHF..may
not find a 2 week period where they are fever
free .in general avoid cath if temp
380C (likely to become bacteremic)
7
History Physical Examination
Last menstrual period or possible pregnancy must
have a very compiling reason to expose her to
radiation
Prior catheterizations or cardiac operations
particular attention to unsuccessful caths or
operations that effect vascular access
8
Physical examination right left thoracotomy
scars e.g. classical Blalock-Taussig shunts,
Glenn anastomosis, precluding access to the
heart from the arms
-vertical cut down from groin bypass vessels
usually repaired
Extensive scar tissue, makes passage of sheaths
dilators difficult often require staged
dilationsometimes with balloons
9
Abdominal, thoracic or neck vein distention
infants with prolonged ICU stays (indwelling
central lines) Mustard, Senning or Fontan
repairs can develop caval or baffle
obstruction
Peripheral arterial pulses CoA the most common
but not only arterial lesion that may limit
arterial access..e.g. subclavian artery
isolation
10
Medical psychological preparation for cardiac
catheterization
Precatheterization preparation
Preparation is individualizedno hard fast
rules
Begins when decision made to perform the
procedure
All patients beyond infancy need a general
explanation regardless of sedation/GA. Describe
that portion of the procedure that they will be
aware
Never say nothing will hurt .makes the child
more distressed uncooperative. Do not let
them think its just like an office visit
11
Medical psychological preparation for cardiac
catheterization
Precatheterization preparation
Exact details depends on the age/understanding/in
terest of the childtailored at the time of the
interview
Be truthful, not all the gruesome detailsleads
to gt anxiety
-information young children pre-procedure
tests, the inevitable needle, premeds/se
dation given
older child length of procedure, stay in
PAR, stay in hospital, any special issues IV
lines, Foleys
12
Medical psychological preparation for cardiac
catheterization
Precatheterization preparation
older patient more detail/explanation tailor
ed to patient family
Emphasize the reason for the cath, not only
technical details or risks
Full details make you medicolegally more
comfortable .but only worsens anxiety for
the child
13
Medical psychological preparation for cardiac
catheterization
Precatheterization preparation
Those in a decision making position, informed
consent should include 1- the diagnosis 2-
the nature of the procedure 3-the risks 4-the
alternatives 5-the risks of not doing the
procedure 6-the benefits
14
Medical psychological preparation for cardiac
catheterization
The risks Data from 11,073 children
catheterized (last 10 yr) looking at
complications within the first 24 h after
catheterization Complications occurred in
7.3.....1 major (stroke, perforation,
permanent arterial thrombosis, seizures) 6
minor with vascular complications (hematoma,
transient vessel occlusion) 25 children died
within 24 h (0.23 of total case
numbers) Independent risk factors young
patient age (lt6 months) male gender inpatient
status year of catheterization
15
Medical psychological preparation for cardiac
catheterization
Precatheterization preparation
No infant/most all children do not need sedation
the night before the study
Occasionally, an adolescent/ACHD-or-parent is
very apprehensive .mild sedative is reasonable
In addition to explanation psychological
preparation there are administrative issues
that must be addressed i.e., when and where to
come to the hospital, NPO etc
16
Medical psychological preparation for cardiac
catheterization
Precatheterization preparation
What are the arrangements for any pre-cath
testing?
What time to come to hospital before the
procedure
Instructions for bathingno shavingEMLA cream
1-2 hours before case at home
17
Medical psychological preparation for cardiac
catheterization
Nutritional fluid requirements
NPO after midnight not necessary 2 hours NPO
for clear fluids 4 hours for breast milk or
formula lt6 months 6 hours food or formula gt6
months
Assure that they take fluids 6 hours before the
study .but rememberin the (polycythemic)
infant .start IV to maintain hydration, as study
may be delayed ...Lactated Ringers/NS or
5dextrose/0.25NS
Remember, infants/small children empty their
stomachs faster than older children become
dehydrated/hypoglycemic
18
Medical psychological preparation for cardiac
catheterization
Immediate pre-cath preparation
EMLA cream (home) 1-2 hours before case, on all
possible access sites
Careful IV startsavoid multiple attempts
The combative child (for IV start) monitor
ECG/BP ketamine1-2 mg/kg IM midazolam..0.25m
g/kg IN Very anxious0.2 0.6 mg/kg PO (30
minutes before IV)
19
Medical psychological preparation for cardiac
catheterization
Immediate pre-cath preparation Special situations
Polycythemia (Hctgt65) increased risk of
cath effects hemodynamics
If Hgb gt200 g/l, while increases oxygen carrying
capacity ..decreased CO, leading to reduced
oxygen delivery to tissuesrisk of thrombosis
embolizationperform coagulation
studies/platelet count
Anemia decreases oxygen carrying capacity,
falsely increases CO, worsening CHFexacerbated
during the cath (blood loss/fluids) Correct any
Hgb lt80 g/l.if cant.cancel case
20
Medical psychological preparation for cardiac
catheterization
Pre-medication
Goal a calm, sleepy cooperative child, before
they enter the lab. Give medication in work up
room, PO/IN/IM/IV
When GA is not used, all children need some
sedation in addition local analgesiagood
combination is fentanyl midazolam
Fentanyl..1-3 µg/kg IV, can repeat every 30
minutesanalgesia/sedation ..anaesthetic
dose.5-10 µg/kg IV, 1-10 µg/kg/hr infusion
Midazolam.0.05-0.2 mg/kg IV, over 2 4
minutes .0.2-0.3 mg/kg IN 0.2-1 mg/kg 30
minutes prior to case PO .0.07-0.1 mg/kg
IM 30 minutes before cases

Monitor ECG, saturation, BP
21
Medical psychological preparation for cardiac
catheterization
Under-sedation results in an uncooperative,
anxious, hyperventilating, straining, moving,
crying child.....both cruel to them and the staff
Today GA frequently used, as most
catheterizations are performed for interventional
indications
and a time out!
22
Medical psychological preparation for cardiac
catheterization
The anaesthetists will have their own
checklist.. .communication with them before
the case is essential
Provide information so they can make an
anaesthetic plan nature of the
procedure cardiac anatomy recent
echo functional status CHF? risk of ABE
23
Nurses role in preparation forcatheterization
procedure
?
24
Nurses role in preparation forcatheterization
procedure
Nursing supervises an OPD pre-catheterization
clinic Families are meet by their assigned
nurse an explanation is given to the families
of the expectations for the day administrative
issues for the procedure day Pre-ordered tests
are obtained (echo, ECG, CXR within 6
months), but no routine tests (SS in appropriate
populations) Test results are reviewed
discussed by the cardiology team communicated
to the children their family prior to discharge
home
25
Nurses role in preparation forcatheterization
procedure
The Clinic Nurse is responsible for performing a
comprehensive assessment for each child seen in
pre-cath clinic, including vital signs,
height, weight, chest assessment, infectious
disease medication checklist Responsible for
coordinating appropriate consultations (i.e.
anesthesia consultation thrombosis
consultation) Arranging a meeting between the
children/family with the cardiologist performing
the procedure
26
Nurses role in preparation forcatheterization
procedure
  • The clinic nurse is responsible for educating the
    patient their families on
  • -the arrival time on the day of the procedure
  • -feeding instructions
  • -expectations before after the catheterization
  • -provide information on research studies
  • -post catheterization site care upon discharge
  • -addressing questions concerns of the children
    their families

27
Trends in the catheterization laboratory
Case Load The CDIU The Hospital for Sick
Children 1969-2008
28
Understand the indications for catheterization
29
Analyze the facts before making a decision
On June 25th, 1876, General George Armstrong
Custer received information that a significant
number of Indians were gathering at Little Big
Horn. Without analyzing the facts, he decided to
ride out with 250 men to surround almost 3000
Indians . this was a serious mistake.
30
THANK YOU
31
  • Understand the timing of the study
  • Elective
  • preparation for surgery,
  • primarily hemodynamic questions such as
    PAP, PVR, VEDP
  • anatomical questions such as pulmonary
    artery morphology..complimenting MRI/echo
  • preoperative interventioncollateral
    occlusion

32
  • Understand the timing of the study
  • Elective
  • interventional (e.g. CoA, PDA, ASD, severe but
  • non-critical PS, AS)
  • EP ablation
  • Emergent or urgent
  • post-operative
  • anatomical hemodynamic questions
  • interventional procedures
  • hemodynamic (e.g. critical PS, AS, BAS,
    pulmonary atresia/IVS)

33
Understand the risks
Cardiac catheterization in the immediate
post-operative ICU period
Between 2004 2007, 49 children (3 of cardiac
surgeries), underwent 62 catheterizations before
discharge from the ICU
Median age at surgery was 167 days time to
catheterization 8.5 days
Overall mortality was high (43)
Re-operation after a non-interventional catheteri
zation predicted worse survival (plt0.001)
Delay to catheterization, especially gt2 to 3
weeks a splinted sternum were risk factors for
death
34
Understand the risks Competing risks vs. other
non-invasive testing
MaCartney Br Heart J 1984
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