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Clinical Guidelines (Nursing)

Care of the patient post cardiac catheterisation

  • Introduction

    Cardiac catheterisation involves the insertion of a catheter into a vein or artery, usually from a groin or jugular access site, which is then guided into the heart.  This procedure is performed for both diagnostic and interventional purposes.   Diagnostic catheters are used to assess blood flow and pressures in the chambers of the heart, valves and coronary arteries and to assist in the diagnosis and management of congenital heart defects.  Interventional catheters are used as an alternative to open-heart surgery when possible and are involved in closing ventricular and atrial septal defects via catheter device closure, expansion of narrowed passages (pulmonary stenosis), stent placement, ablation of abnormal electrical pathways and widening of existing openings (balloon atrial septectomy).   

    Aim

    To provide nurses with the knowledge and skill set to competently care for a patient post cardiac catheterisation.

    Definition of Terms 

    • Thrombus: a blood clot formed within the vascular system of the body which impedes blood flow   distal to the clot.
    • Retroperitoneal Space: Region between posterior parietal peritoneum and front of lumbar vertebrae
    • ECG: Electrocardiograph records the electrical activity of the heart as a visual wave-formation.
    • Arrhythmia: a general term that refers to any type of abnormal, irregular, or disorganized heartbeat.
    • Hematoma: a collection of blood outside a blood vessel. It occurs when the wall of an artery, vein or capillary, has been damaged and blood has leaked into the surrounding tissue.
    • Ecchymosis (or bruising): The passage of blood from ruptured blood vessels into subcutaneous tissue, marked by a purple discoloration of the skin.
    • Bruit: A sound heard over an artery, reflecting turbulent flow. 
    • Systolic bruit: an abnormal sound heard during systole.
    • Pseudo aneurysm: a hematoma that forms as the result of a leaking hole in an artery.  It presents as a pulsatile mass, sometimes with a systolic bruit. 
    • BP: Blood Pressure. 
    • RR: Respiratory rate.
    • HR: Heart rate.
    • GA:  General Anesthetic.
    • RPAO:  Routine Post Anesthesia Observations.
    • SpO2: Oxygen Saturations. Arterial oxygen saturation measured via pulse oximetry
    • CRT: capillary refill time.
    • Diaphoresis: state of perspiring profusely.
    • PACU: post anesthetic care unit.
    • Ipsilateral: occurring on the same side of the body.
    • Retroperitoneal hematoma: accumulation of blood in the retroperitoneal space.

    Assessment

    Refer to Nursing Assessment nursing clinical practice guideline (Link).

    History

    Include the following when taking the history of a child post cardiac catheterisation:

    • Identify if the patient has an existing cardiac condition
      Note: Patients with a known cyanotic or complex cardiac condition are at higher risk of complications
    • Age of patient
      Note: There is a higher risk of complications in children less than 1 year of age.
    • Identify “normal” cardiac rhythm for the patient by referring to pre-procedure ECG’s
      Note: Sinus rhythm indicates normal cardiac conduction, but children born with extra conduction pathways or congenital cardiac defect are likely to show abnormal ECG patterns which for them is essentially the ‘norm’
    • Identify whether the patient had a diagnostic or interventional cardiac catheter.
      Note: Interventional catheters have a significantly higher rate of complications compared to diagnostic cardiac catheters.
    • Identify access site (position and whether arterial or venous).
    • Check if the patient has been on anticoagulation.
      Note: If anticoagulants have been administered pre catheterisation the patient is at higher risk of bleeding
      Note: Most patients (except for patients undergoing heart biopsy) will have received a Heparin bolus during the procedure
    • Identify if the patient had any complications during theatre or in recovery. If bleeding occurred what intervention was implemented to achieve haemostasis
    • Enquire about the findings of the catheter procedure.
    • Ascertain what medications have been administered or ordered. 

    Routine Management

    On arrival to ward

    • Assess and record patient observations - these should include:
    • Neurological observations: Include assessment of behavior (alertness, lethargy, irritability), limb strength and range of motion, facial symmetry, Glasgow Coma Score
    • Maintain continuous cardiorespiratory monitoring to measure vital signs: HR, RR, BP, SpO2,  
    • Temperature
    • Oxygen requirements
    • Neurovascular observation
    • Continue observations as per RPAO clinical guideline (found here) Neurovascular observations should be performed with every set of observations.
    • Assess puncture site 30 minutely for 4 hours than hourly until ambulation.  Reassess site after first ambulation and then a minimum of 4 hourly prior to discharge.
      Note: the puncture site assessment commences from the time the patient enters the PACU, not when they are transferred to the inpatient unit.
    • The patient is required to remain on bed rest for:
      • 4 hours for a diagnostic catheterisation.
      • 6 hours for an interventional catheterisation.   
        Note: The patient is permitted to move side to side while on bed rest to increase comfort. For younger patients it may be difficult to keep them supine for a period of 4-6 hours; they can sit up in bed, sit on the parents lap or be carried, but they should not weight bare and ambulate
    • Do not remove dressing prematurely unless ordered to by RMO.  
    • Dressing is to be removed prior to discharge for cardiac RMO to assess. 
      Note: if a patient remains in hospital for longer than 24 hours, the dressing should be removed 24 hours post procedure.
    • Provide regular analgesia as ordered.
    • Maintain strict fluid balance chart. Particularly take note of urine output. The contrast dye used in cardiac catheter can be nephrotoxic and acute kidney injury has been associated with arterial access.

    Anticoagulation post cardiac catheterisation

    • Aspirin may be ordered for device closures - be aware if medical team has requested such medications and when it should be commenced.
    • Heparin infusion post procedure is dependent on:
      • If the patient was on anticoagulation (eg: Warfarin) pre procedure. A heparin infusion will commence to assist the patient returning to therapeutic coagulation levels.
      • An issue has occurred during cardiac catheter that increases the risk of clots or concerns of limb compromise.

    Assessment and Management of Complications 

    Complications:

    • Varying acute haemodynamic complications associated with the general anaesthetic that is required with a cardiac catheter
    • Vessel damage – can ultimately compromise the growth and function of the affected limb and complicate future catheter procedures
    • Bleeding- including hematoma 
    • Arrhythmia 
    • Retroperitoneal bleeding
    • Stroke – caused by a thrombus or hemorrhage
    • Puncture site assessment
    • Assess puncture site for: 
    • Bleeding- check pressure dressing for any oozing or bleeding from puncture site and mark the size of bleed if possible 
      Note: check for bleeding immediately after vomiting or vigorous coughing.
    • Hematoma- assess site for swelling, redness and pain and mark the size of hematoma if possible                                                                                                     
      Note: A hematoma can indicate internal bleeding into the thigh, pelvis or retroperitoneal space. 
    • Infection- assess site for heat, pain and redness.  Also assess for other signs of infection including an increase in temperature, tachycardia, and rigors
    • Ecchymosis- assess skin around site for purple discoloration

    Hematoma

    • Apply manual compression over the hematoma, followed by a pressure dressing to prevent further bleeding.  
    • If patient has a heparin infusion, stop infusion. 
    • Assess for signs of intravascular volume depletion- tachycardia, widening pulse pressure, hypotension, decreased peripheral perfusion, delayed CRT, agitation.  If insufficient cardiac output seek urgent medical assistance (MET call 777).
    • Auscultate hematoma for presence of pulse and a systolic bruit which indicates a pseudo aneurysm.
    • Notify physician
    • Bleeding at site: Lie patient supine, elevate limb and apply pressure above puncture site with gauze to achieve hemostasis.  Hemostasis should occur within 5-10 minutes.
    • If patient has a heparin infusion, stop infusion. 
    • Reinforce pressure bandage. 
    • Notify physician

    Arrhythmia

    • Assess patient’s ECG rhythm on the cardiac monitor.  Ensure patient is in sinus rhythm or is in a rhythm deemed normal for the patient
    • If an arrhythmia is present clarify if this is a new arrhythmia for the patient. If new arrhythmia notify physician. 
    • Assess patient’s cardiac output- BP, peripheral perfusion, color and alertness.  If insufficient cardiac output seek urgent medical assistance (MET call 777). Note: regardless if the arrhythmia is new or deemed a normal occurrence for the patient, if cardiac output is insufficient you
    • must seek urgent medical assistance.
    • Print rhythm strip or complete an ECG if patient is stable. 
    • Continuous cardiac monitoring. 

    Thrombus

    • Neurovascular observations: assess limb for color, warmth, CRT, pulse strength, sensation, movement and pain. 
    • Venous vs Arterial Access Site Clot: 
    • Venous Clot - the affected limb will appear red and swollen and the patient will have an increase in pain levels and delayed CRT due to pooling of blood.
    • Arterial Clot - the affected limb will appear pale and cool and have diminished or absent pulses distal to the insertion site; additionally there may be decreased sensation and delayed CRT due to lack of supply of arterial blood.
      Note: If you notice a limb with decreased perfusion assess pressure dressing to ensure it is not too tight. 
      Note: For accurate assessment of the pulse, mark the pulse position with a pen. A Doppler ultrasound can be utilised if a pulse is not palpable. 
      Notify physician of any changes in neurovascular observations, MET or rapid review if required
    • +/- Doppler ultrasound to confirm clot
    • Antithrombotic agent as ordered by the medical team. First line of treatment for an occluded vessel is a heparin infusion.  Thrombolysis may be used in rare circumstances

    Retroperitoneal bleeding

    • Assess vital signs-  bradycardia, tachycardia, hypotension, reduced level in haemoglobin, widening pulse pressure, and decreased peripheral perfusion are signs of retroperitoneal bleeding
    • Assess for abdominal pain, groin pain and back pain
      Note:  Retroperitoneal hematomas are ipsilateral to the puncture site so pain on the same side of the access site needs further investigations
    • Assess for diaphoresis
    • Notify physician if suspected
    • Assess for signs of intravascular volume depletion
    • Bloods - FBE and Blood group and antibody screen
    • Continuous monitoring
    • +/- CT scan
    • +/- Blood product transfusion

    Stroke

    • Neurological observations should be performed each shift or more frequently if complicated with a thrombus post cardiac catheter. Note: The risk of arterial ischemic strokes increases in a patient complicated with an intracardiac thrombus in the left atrium, and/or thrombus in the superior or inferior vena cava in those with single ventricle physiology or right-to-left shunt
    • If stroke is suspected, depending on how stable the patient is, call a MET or Rapid Review. While waiting for assistance prevent patient injury and aim to maintain airway.

    Escalation of care in relation to complications associated with cardiac catheterisation

    In relation to above complications listed when caring for a patient post a cardiac catheter, see the following process of escalation of care as per protocol & following link: 
    https://www.rch.org.au/policy/policies/Medical_Emergency_ResponseProcedure/

     Rapid review
    • In hours: Cardiology registrar (#52609 pager 5437) or cardiology resident (#52709 or 52708, pager 5144 or 4023)
    • After hours: Specialties registrar #52183 or pager 4044

    MET criteria – 777, ward, department, level, building

    Catheterisation fellow - office hours: pager # 5719, after hours: pager # 4044. 

    Investigations 

    In children who undergo diagnostic cardiac catheters no investigations are typically required unless complications are suspected.

    • Chest x-ray : Required for device closures prior to discharge.
    • ECHO: Required for interventional catheters prior to discharge.
    • ECG: Required for interventional catheters prior to discharge or if an arrhythmia is suspected.

    Companion Documents

    Nursing Clinical Guidelines

    Evidence Table

    View the evidence table for the Care of the patient post cardiac catheterisation nursing guideline here

    References

    • Altiok, M., Yurtsever, S., & Kuyurtar, F. (2007). Review of the methods to prevent femoral arteriotomy complications and contrast nephropathy in patients undergoing cardiac catheterization: cardiac catheterization and care approaches in Turkey. Journal of Cardiovascular Nursing, 22(6), 452-458.
    • Amoozgar, H; Naghshzan, A; Edraki, M.R; Jafari, H; Ajami, G.H; Mohammadi, H; Mehdizadegan, N; Borzouee, M & Kambiz, K (2019). Arterial and Venous Complications Early after Cardiac Catheterization in Children and Adolescents: A Prospective Study. Iran Journal of Pediatrics, 29(5); 1-9.
    • Applegate, R., Sacrinty, M., Kutcher, M., Kahl, F., Gandhi, S., Santos, R., & Little, W. (2008). Trends in vascular complications after diagnostic cardiac catheterization and percutaneous coronary intervention via the femoral artery, 1998 to 2007. JACC. Cardiovascular Interventions, 1(3), 317-326.
    • Brotschi, B; Hug, M.I; Kretschmar, O; Rizzi, M & Albisetti, M. (2015). Incidence and predictors of cardiac catheterisation-related arterial thrombosis in children. Heart, 101: 948-953.
    • Chair, S., Yu, M., Choi, K., Wong, E., Sit, J., & Ip, W. (2012). Effect of early ambulation after transfemoral cardiac catheterization in Hong Kong: a single-blinded randomized controlled trial. Anadolu Kardiyoloji Dergisi: AKD. The Anatolian Journal of Cardiology, 12(3), 222-230.
    • Ellis, S., Bhatt, D., Kapadia, S., Lee, D., Yen, M., & Whitlow, P. (2006). Correlates and outcomes of retroperitoneal hemorrhage complicating percutaneous coronary intervention. Catheter Cardiovascular Intern, 67, 541–545.
    • Farouque, H., Tremmel, J., & Shabari et al. (2005). Risk factors for the development of retroperitoneal hematoma after percutaneous coronary intervention in the era of glycoprotein IIb/IIIa inhibitors and vascular closure devices. J Am Coll Cardiol, 45 (1), 363–368.
    • Harrar, D.B; Salussolia, C.L; Vittner, P; Danehy, A; Sen, S; Whitehill, R; Chao, J.H; Bernson-Leung, M.E & Rivkin, M.J (2019). Stroke after Cardiac Catheterization in Children. Pediatric Neurology, 100, 42-48.
    • Harper, J. (2007). Post-diagnostic cardiac catheterization: development and evaluation of an evidence-based standard of care. Journal for Nurses in Staff Development: JNSD: Official Journal Of The National Nursing Staff Development Organization, 23(6), 271-276.
    • Hockenberry, M., & Wilson, D. (2018). Wong’s Nursing Care of Infants and Children. (11th ed.). St. Louis: Mosby
    • Karen, U. (2001). Therapeutic cardiac catheterization for congenital heart disease- a new era in pediatric care.  Journal of Pediatric Nursing, 16 (5), 300-307.
    • Krasemann, T. (2015). Complications of cardiac catheterisation in children. Heart, 101: 915
    • Marques, J.S & Goncalves, C (2014). Post-catherisation arterial thrombosis in children – pathophysiology, prevention and treatment. Cardiology in the Young, 24: 767-773.
    • Medical Dictionary. (2013). Retrieved from http://medical-dictionary.thefreedictionary.com/. 
    • Pennsylvania Patient Safety Authority. (2007). Strategies to minimize vascular complications following a cardiac catheterization. PA-PSRS Patient Safety Advisory, 4(2), 1-6
    • Rezaei-Adaryani, M., Ahmadi, F., & Asghari-Jafarabadi, M. (2009). The effect of changing position and early ambulation after cardiac catheterization on patients' outcomes: a single-blind randomized controlled trial. International Journal of Nursing Studies, 46(8), 1047-1053.
    • Wilcoxson, V. L. (2012). Early Ambulation after Diagnostic Cardiac Catheterization via Femoral Artery Access. Journal For Nurse Practitioners, 8(10), 810-815
    • Yilmazer, M., Ustyol, A., Güven, B., Oner, T., Demirpençe, S., Doksöz, O., & ... Tavli, V. (2012). Complications of cardiac catheterization in pediatric patients: a single center experience. The Turkish Journal of Pediatrics, 54(5), 478-485.

     

    Please remember to read the disclaimer.

     

    The development of this nursing guideline was coordinated by Charmaine Cini, Nurse Educator, Koala Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2020..