Handling Most Challenging Patient in Difficult Situation ... Ho...Most Common cases in HKSH CCIC...
Transcript of Handling Most Challenging Patient in Difficult Situation ... Ho...Most Common cases in HKSH CCIC...
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Handling Most Challenging Patient in
Difficult Situation in Cath Lab
Ho Kit Ying Registered Nurse (Team Leader)
CCIC, HKSH
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Cath Lab & Heart Disease
Interventional cardiology is a branch of
cardiology that deals specifically with the
catheter based treatment of heart
disease
A large number of procedures can be
performed on the heart by
catheterizaton.
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Most Common cases
in HKSH CCIC
Coronary Angiogram +/- Stenting
(FFR, IVUS, OCT, Rotablation)
Electrophysiology Study +/- Ablation
(with or without 3D mapping system)
Device Implantation(Pacmaker, CRT,Micra)
Structural Heart (LAAO, TAVI, Mitraclip)
Peripheral Angiogram +/- Stenting
Minor Procedure (Tilt table,
Cardioversion, Loop Recorder)
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Type of case
Elective
Emergency
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Most Challenging Paient in
Difficult Situation in Cath Lab?
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Most Challenging Patient= Complicated ?
Most Challenging Paient in
Difficult Situation
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TAVR in an 87-year-old patient with situ-invertus and coronary artery
disease (previous stenting), bilateral carotid stenting, limited
vascular access (calcified, tortuous common iliac artery with
spontaneous dissection) , horizontal aorta…
Multi-disciplinary
approach in Hybrid OR:
• Anaesthetist
• Interventional
Cardiologists
• Cardiac Surgeon
• Vascular Surgeon
• Scrub nurses
• Cath Lab Nurses…
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Right subclavian
approach: •Vascular graft by Vascular
surgeon
•Preserve right upper limb
circulation during procedure
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SENTINEL cerebral
protection device via
left radial artery
Evolut Pro TAVR
Dextrocardia
Good pre-procedure planning,
communication and preparation
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Total Occlusion case= challenging?
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Chronic Total Occlusion (CTO): retrograde approach
Anticipation of prolonged procedure time, availability of CTO guidewires,
microcatheters, biplane, bilateral contrast injections…
Reverse CART technique
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Ideal vs Reality
Cath Lab Nurses
do the
similar work
everyday
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Unpredictable situations
Cath Lab nurses are doing similar work
everyday with many uncertainty
We need to prepare the cath lab well to handle
each case.
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M/35 yrs
Chest pain. Admitted at midnight.
ECG on admission was normal.
First Troponin was normal.
Hemodynamically stable.
Chest pain again in the morning.
ECG:
Now Troponin elevation!
What do you expect?
• Inferior STEMI (culprit: RCA or LCx)
• Primary PCI
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Poor radial pulse
Trans-femoral approach
Spontaneous RCA dissection? Primary PCI?
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Wait a minute…
Type A Aortic Dissection
Called surgeon for emergency surgery!
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No reflow after stenting
Heart block, BP drop…
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“No reflow” after post-dilation at high pressure.
TIMI 0 flow. Hypotension. AV dissociation
Managed successfully with dottering, Export
thrombectomy, IC nitroglycerin, isoptin, adenosine
via Microcatheter at distal RCA
Poor distal run-off was probably the risk factor
TIMI 3 flow was resumed. HD IVUD: no dissection.
Good stent apposition.
Uneventful when leaving cath lab. On IV abcixiamb
infusion for 12hours
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Final angiogram
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MECHANISMS FOR NO REFLOW
Niccoli G et al, JACC 2009;54:281-92
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Medical Treatment Options
Adenosine: decreases arteriolar resistance, ATP-sensitive K+ Channels, inhibit neutrophilmigation/ superoxide generation/endothelin
Nitroprusside/NTG (nitric oxide donors)
CCB: HR & BP effects, vasospasm
Glycoprotein IIb/IIIa inhibitors
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Examples of Unpredictable situations
Complications e.g. Dissection
Equipments requested, not available in
our consignment--> e.g.Peripheral stent
Machines requested not available
e.g. TEE, ICE, CARTO or Cryo machine
Uncooperative patient
--> psychological support
--> restlessness after IV sedation given
--> Anaesthetist for MAC or GA
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Prevention
Good Communication
Well preparation
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Step of Booking Elective Case
Received booking by Cath Lab Nurse or
clerk during office hour
Received booking by ICU nurse in non-
office hour
Most of the case booked by Clinic Nurse
Details needed during booking (Patient
name & ID, type of procedure,
cardiologists, or company involved)
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Problems
Most cases booked by clinic nurse
--> only got the brief information
--> the details may be ignored
--> missed the important items to prepare
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Start from Booking
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Additional Information
Duration Time
--> each session = 2 hour
--> CTO case, EP with diagnosis
Any additional equipment requested for
the procedure e.g. mapping system in EP
case, TEE or ICE for transseptal,
any equipment for CTO case
Any anaesthetist will be involved
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Based on information
Contact related companies or departments
to prepare the equipments or machine
Contact anaesthetists and prepare
equipments from OT
Prelim the time slot for individual session
--> reduce the rushing time
Arrange the appropriate lab
(Single plane or Biplane)
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Information on OT date
Transradial vs Transfemoral
Left or Right side in pacemaker implantation
Access site for CTO case
Patient's position in peripheral intervention
case
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Preparation of Patient
Physical
Psychological
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Physical Preparation—from ward
Body Weight & Body Height
Allergy History
--> Steroid Cover
Antiplatelet therapy
--> Plavix, Aspirin, Cartia, Brilinta
Informed consent
Fasting at least 6 hours
Shaving
Recent Lab result e.g. CBC, R/LFT,
Clotting profile)
Related Report (Stress test, MRI or
CT Coronary report)
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Physical Preparation – In CCIC
Identity
Valid consent form
Allergy history with steroid cover given
On call medication
Recent lab result & related report
Check peripheral pulse & Allen test
Take baseline vital sign & connect ECG
moniting +/- defibrillation pads
Puncture sites skin disinfection by
scrub nurse
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Psychological Preparation
Prelim the procedure time to patient &
relatives
Settle down the relatives in the waiting area
and give reassurance
Explain to patient before each step
Make sure patient lies in a comfort
position
Explanation of the procedure to seek
patient cooperation
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Good Partnership
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Conclusion
Effective communication & Well preparation is Critical to build
a sense of trust
& increase productivity
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Thank You
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Question 1
Which of the following is the most difficult
situation in Cath Lab?
A. CTO case
B. Complicated case
C. Emergency case
D. Unpredicated case
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Question 1
Ans : D
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Question 2
Which of the following is the best way to
prevent such situation?
A. Increase manpower
B. Well preparation
C. Increase salary
D. Increase holiday
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Question 2
Ans: B
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Question 3
What is the key component in a successful &
uneventful operation?
A. Effective communication
B. Good rapport
C. Comfortable environment
D. New generation technique
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Question 3
Ans: A
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End