Clinical Guidelines (Nursing)

Care of the patient post cardiac catheterisation


  • Introduction

    Cardiac catheterisation is 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, to assist in the diagnosis and management of congenital heart defects.  Interventional catheters are used as an alternative to open-heart surgery when possible.  These procedures include closure of septal defects (ventricular septal defect device closures, atrial septal defect closure), expansion of narrowed passages (pulmonary stenosis), stent placement, ablation of abnormal electrical pathways and opening of new passages (foramen ovale).   

    In paediatrics, the procedure typically involves a general anaesthetic and is associated with varying complications.  Although the advances in catheterisation techniques have reduced the prevalence of complications post cardiac catheter, statistics show that complications remain a significant source of morbidity and mortality in these patients.  Specific management of a child post-cardiac catheterisation must utilise strategies to reduce the risk of complications.  Additionally, vigilant monitoring of the patient after cardiac catheterisation is fundamental for early identification and management of complications.  Nurses who are able to promptly identify complications are in the optimal position to prompt critical action and improve patient outcomes.  Thus, nurses that are competent in the care of a patient post cardiac catheterisation are able to minimise mortality and morbidity rates for these patients within the post-operative period. 

    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 haematoma: accumulation of blood in the retroperitoneal space.
    • Retroperitoneal Space: Region b/w 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.
    • Haematoma: a collection of blood outside a blood vessel. It occurs when the wall of a blood vessel wall, artery, vein or capillary, has been damaged and blood has leaked into the surrounding tissue.
    • Ecchymosis: 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.
    • Pseudoaneurysm: a haematoma 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 Anaesthetic.
    • RPAO:  Routine Post Anaesthesia Observations.
    • SpO2: Oxygen Saturations. Arterial oxygen saturation measured via pulse oximetry
    • CRT: capillary refill time.
    • Diaphoresis: state of perspiring profusely.
    • PACU: post anaesthetic care unit.
    • Ipsilateral: occurring on the same side of the body.

    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 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).
    • 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 (attach SR-Link here) is normal cardiac rhythm, but children born with extra conduction pathways are likely to show abnormal ECG patterns which for them is essentially the ‘norm’.
    • Is the patient on any anticoagulants?                                                                          
      Note: if anticoagulants have been administered pre catheterisation the patient is at higher risk of bleeding.  
      Note: All patients will have received heparin 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.  
    • Ask for the findings of the catheter procedure. 
    • Ascertain what medications have been administered or ordered.

    Physical

    The physical examination should include surveillance of the following:

    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.
    • Haematoma- assess site for swelling, redness and pain and mark the size of haematoma if possible                                                                                                    
      Note: A haematoma 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.

     Assessment of potential complications

    Assess for retroperitoneal bleeding

    • Assess vital signs- fluctuating BP response, bradycardia and hypotension are signs of retroperitoneal bleeding.
    • Assess for abdominal pain, groin pain and back pain. 
      Note:  Retroperitoneal haematomas are ipsilateral to the puncture site so pain on the same side of the access site needs further investigations.
    • Assess for diaphoresis.
    • Assess for signs of bleeding - tachycardia, hypotension, decreased peripheral perfusion, widening pulse pressure,  agitation, decreased haemoglobin level 

    Assess for arrhythmias

    • Assess patient’s ECG rhythm on the cardiac monitor.  Ensure patient is in sinus rhythm (Link- Sinus rhythm)or is in a rhythm deemed normal for the patient

    Assess for thrombus

    • Neurovascular observations: assess limb for colour, warmth, CRT, pulse strength, sensation, movement and pain.
    • In the presence of venous access site clot, the affected limb will appear red, swollen, the patient will have an increase in pain levels and delayed CRT due to pooling of blood. 
    • In the presence of an arterial access site clot, the affected limb will appear pale, cool, have diminished or absent pulses distal to the insertion site, have 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 on the patient’s foot. A doppler can be utilised if a pulse is not palpable. 

    Assess and document intake and output.

    Management

    Routine Management 

    On arrival to the ward assess and record patient observations - these should include:

    • Behaviour - alert, lethargic, irritable
    • HR
    • RR
    • BP
    • SpO2
    • Oxygen requirements
    • Temperature
    • Neurovascular observation
      Continue observations as per RPAO clinical guideline (Link).  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.
    • Patient is required to remain on bed rest for:
      • 4 hours for a diagnostic catheterisation.
      • 6 hours for an interventional catheterisation.   
        Note: patient is permitted to move side to side while on bed rest to increase comfort.
    • Ensure head of bed is no higher than 30 degree for duration of bed rest.  
    • 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.
    • Aspirin may be ordered for device closures - be aware if medical team has requested such medications and when it should be commenced.

    Management of Complication 

    Haematoma 

    • Apply manual compression over the haematoma 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 haematoma for presence of pulse and a systolic bruit which indicates a pseudoaneurysm.
    • Notify physician (catheterisation fellow- office hours: pager 5719, after hours: pager 5718)
    • Bleeding at site 
    • Apply pressure above insertion site with gauze to achieve haemostasis.  Haemostasis should occur within 5-10 minuets.
    • If patient has a heparin infusion, stop infusion. 
    • Reinforce pressure bandage. 
    • Notify physician (catheterisation fellow- office hours: pager 5719, after hours: pager 5718). 

    Arrhythmia

    • Assess if this is a new arrhythmia for the patient. If new Notify physician (catheterisation fellow- office hours: pager 5719, after hours: pager 5718).
    • Assess patient’s cardiac output- BP, peripheral perfusion, colour and alertness.  If insufficient cardiac output seek urgent medical assistance (MET call 777). Note: regardless if the arrhythmia is new or deemed a normal occurance 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

    • Notify physician if any changes in neurovascular observations (catheterisation fellow- office hours: pager 5719, after hours: pager 5718). 
    • +- 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

    • Notify physician if suspected (catheterisation fellow- office hours: pager 5719, after hours: pager 5718). 
    • Assess for signs of intravascular volume depletion.
    • Bloods - FBE and Blood group and antibody screen. 
    • Continuous monitoring. 
    • +- CT scan. 
    • +- Blood product transfusion. 

    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

    Evidence Table

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

    References

    • 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.
    • 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.
    • 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 Cardiovasc Interv, 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.
    • 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. (2010). Wong’s Nursing Care of Infants and Children. (9th 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.
    • 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 Annabelle Santos, Nurse Educator, Koala Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated April 2017.