Cardiac catheterization involves inserting catheters into arteries and veins to obtain images and measure pressures in the heart. There are several pre, intra, and post procedural practices to ensure safety. Pre-procedurally, consent is obtained, labs are checked, and the patient is prepared. Intra-procedurally, a time out is conducted and infection control measures are followed. Post-procedurally, the patient is monitored for complications like bleeding, given discharge instructions, and scheduled for follow up to check renal function and access sites. The goal is to perform the procedure safely and ensure proper follow up care.
2. • Cardiac catheterization is the insertion and
passage of small plastic tubes (catheters) into
arteries and veins to the heart to obtain x-ray
pictures (angiography) of coronary arteries and
cardiac chambers and to measure pressures in
the heart (hemodynamic).
3. Patient selection
• Its physician responsibility to decide indication
and rule out contraindications of the cardiac
catheterization.
5. Pre-procedural practices
• Detailed history and examination
• Consent for the Procedure
• Sedation, Anesthesia and Analgesia Evaluation
• Labs and Other Studies
• Preparations for special conditions
• To confirm regarding Ayushman/ HIM CARE/
payement status of pt
6. Consent for the Procedure-
• Consent may be obtained by the operator or his/her
assistant or physician.
• The person obtaining consent should :
1. Explain in simple terms what procedure will take place,
for what reason each step of the procedure will occur, the
roles of the team performing the procedure, and what is
expected to be learned from the test.
2. Explain the risks for routine cardiac catheterization.,
hematoma.
7. 2. If PCI is anticipated, consent for this should be
obtained as well discussing options for medical
therapy, stenting, or coronary bypass surgery in
advance of the procedure.
3. Provide the necessary information and
explanation but do not overwhelm the patient. It
is good practice to include the family when
explaining what will happen and possible
outcomes you expect.
8. Sedation, Anesthesia and Analgesia
Evaluation
• conscious sedation
• ASA and/or Mallampati classification should be
established by the physician
• NPO for 2 hrs (clear liquids) and 6 hours (solids)
9. Medications
• Initiate antiplatelet therapy prior to the procedure
when PCI is possible/likely
• Discontinue warfarin with goal INR
• Discontinue novel oral anticoagulants 1-2 days prior
to procedure
• Adjust insulin dosing for NPO status
• Hold Metformin on day of procedure and restart a
minimum of 48 hrs after procedure
10. Labs and Other Studies
• hemoglobin, platelet count, electrolytes including
blood urea nitrogen, creatinine.
• PT/INR is not required unless there is warfarin use,
severe anemia, or liver disease
• Obtain baseline ECG
• Check B-HCG for women of childbearing age.
• Viral markers HIV,HBV,HCV
12. Contrast media reaction
• Pretesting-no value in determining who will
have an adverse reaction.
• 60 mg of prednisone the night before and 60 mg
of prednisone the morning of the procedure,
along with 50 mg of oral Benadryl
(diphenhydramine)
• Pretreatment with corticosteroids to decrease all
types of reactions
13. Contrast induced nephropathy
• transient rise in serum creatinine (0.5 mg/dL or
a relative increase of 25%) following cardiac
angiography, defined as CIN.
• It may occur in 15% of the general cath
population, or 50% of patients who have risk
factors including
14.
15. Prevention of CIN
• limitation of total contrast volume to 3 mL/kg .
• Hydrate patients at risk of CIN with Normal
Saline e.g. 1-1.5ml/kg/hr for 3-12 hrs before
procedure and 6-24 hrs after
• Use of iso-osmolar agent iodixanol (Visipaque)
16. Intra-operative preparations and time
out
• Review medical records and check-list
• Time out
• Infection control
• Reverse time out
• Radiation expoure
17. Review medical records and check-list
• On the patient’s arrival in the laboratory, a staff member
should review a brief checklist to ensure that all
preprocedural requirements have been met
Check the patient’s ID band and known allergies
Check laboratory results (key tests: hemoglobin, electrolytes including blood urea
nitrogen, creatinine)
Check blood pressure, all pulses (arms and legs), and baseline ECG
Anticoagulant status: Check the international normalized ratio (INR)
Recheck childbearing potential (patient may need β-human chorionic
gonadotropin level)
Verify that the proper paperwork has been copied, filled out for the procedure, and
confirm that the consent form is signed
18. Assess the patient’s understanding of the procedure and answer
the patient’s questions
Check that the oral airway forms for the procedure are signed and in the chart.
If not, make arrangements for their completion before the procedure.
Check that the intravenous (IV) line is secure and patent.
Check that the patient has ingested nothing solid by mouth before the
procedure.
Check whether premedications were given as ordered.
Start documentation of the precatheterization condition and note any physical
deficits (abnormal neurologic examination, bruising or bleeding sites
19. The Time Out
• a preprocedure safety
review
the team verifies
the right patient is in
the room
the right procedure is
going to be performed
the right operative site
will be used
the patient has renal
failure, allergies, or is
being treated with
anticoagulants
20. Infection control
• Use electric clippers to shave/prep the access site
• Scrub access sites with anti-microbial and chlorine
based preps
• Use either traditional surgical scrub with water/soap
or chlorhexidine/ethyl alcohol hand antiseptic
solutions
• Wear hats/masks for every procedure involving
device insertion
• Consider antibiotics during insertion of vascular
closure devices in high-risk patients (i.e. diabetics)
21. The Reverse Time Out or “I Need 2
Minutes”
• needed when the case goes too fast.
• catheterization laboratory attending physicians who sometimes
want to work so fast that they outstrip the ability of the
catheterization laboratory team to keep up with their demands or
become confused by conflicting or changing orders from the
operators.
• anyone working in the laboratory can call a time out, which is stated
out loud as “I need 2 minutes.”
• The operators should stop and take a breath.
• This gives the person (and the team) who called time out a couple of
minutes of uninterrupted time for him or her to get everything
caught up and correct.
22. the called time out would not be appropriate if
there was a critical situation occurring in which
the patient could not wait for an emergency drug
or other life-sustaining intervention (e.g., left
ventricular [LV] support device or an intraaortic
balloon pump [IABP] insertion).
23. Radiation Exposure
• ◦Goal: ALARA (As Low as Reasonably
Achievable)
• All: Wear lead aprons, thyroid shields, radiation
badges, lead glasses (when close to radiation
source)
• radiation exposue more than 5 Ro over 3
months is not acceptable.
25. Monitoring
• Check vital signs q15 min for the first 2 hours
• Urine output should be >30 mL/hr.
• Tachycardia with low blood pressure indicates
blood loss until proven otherwise.
26. Vascular access site management
• Check vascular site for bleeding or hematoma.
• Remove sheath when ACT < 180 seconds (for
heparin), after 2 hours (for bivalirudin)
• Restrict ambulation for 2-6 hours after manual
compression
27. Discharge Instructions and Patient
Information
• Stress DAPT duration and adherence
• Provide stent card with device information and
location
• Counsel on physical activity limitations, diet and
cessation of smoking.
29. Appropriate Follow-up Evaluation
• serum Cr check up within 3-5 days for those at risk
of CIN
• Provide clinic follow-up within 4 weeks of discharge
or earlier if presence of baseline renal insufficiency,
anemia, or procedural complications
• Document evaluation of
access site
Re-assess medication list and compliance
Address lifestyle modifications including need for
cardiac rehab/smoking cessation
