How to do Primary PCI - bcis.org.uk€¦ · Before the cath lab.. ... In the cath lab.. • Common...

How to do Primary PCI

The basics and adjunctive pharmacology

Dr Andrew Sutton MA MD FRCP FESC

Consultant Cardiologist

The James Cook University Hospital

NO CONFLICT OF INTEREST

TO DECLARE

Before the cath lab..

• Discussion, formulation and agreement of a clear

regional protocol is key

• Essential stakeholders: ambulance services, regional

cardiologists, General Practitioners; walk-in centres;

A&E staff

Before the cath lab..

• Aim for one pre-hospital patient pathway for each

geographical region – irrespective of the day of the

week, time of day, start/end of shifts.

• Familiarity with and repetition of a single pathway

breed slickness and efficiency

• Continuous review, audit and feedback essential

Monthly median door to balloon times (minutes) JCUH October 2006 to October 2008

50

5754

49

53

50

40 41 40

34.5

30.53234

48.5

39

44.544

35

4744

52

49

69

60.5

63

0

10

20

30

40

50

60

70

80

Oct

06

Nov

06

Dec

06

Jan

07

Feb

07

Mar

07

Apr

07

May

07

Jun

07

Jul

07

Aug

07

Sep

07

Oct

07

Nov

07

Dec

07

Jan

08

Feb

08

Mar

08

Apr

08

May

08

Jun

08

Jul

08

Aug

08

Sep

08

Oct

08

Oct 06 to Oct 07=52.3 minutes

Nov 07 to Jun 08=42.4 minutes

Jun 08 to Oct 08 32.8 minutes

mean

ucl

Influence of PPCI pathway policy changes on median door to balloon times

The James Cook University Hospital October 2006 to October 2008


50

5754

49

53

50

40 41 40

34.5

30.53234

48.5

39

44.544

35

4744

52

49

69

60.5

63

0

10

20

30

40

50

60

70

80

Oct

06

Nov

06

Dec

06

Jan

07

Feb

07

Mar

07

Apr

07

May

07

Jun

07

Jul

07

Aug

07

Sep

07

Oct

07

Nov

07

Dec

07

Jan

08

Feb

08

Mar

08

Apr

08

May

08

Jun

08

Jul

08

Aug

08

Sep

08

Oct

08




mean

ucl



CCU coordinator receives call from

paramedic crew and copy of initial ECG


50

5754

49

53

50

40 41 40

34.5

30.53234

48.5

39

44.544

35

4744

52

49

69

60.5

63

0

10

20

30

40

50

60

70

80

Oct

06

Nov

06

Dec

06

Jan

07

Feb

07

Mar

07

Apr

07

May

07

Jun

07

Jul

07

Aug

07

Sep

07

Oct

07

Nov

07

Dec

07

Jan

08

Feb

08

Mar

08

Apr

08

May

08

Jun

08

Jul

08

Aug

08

Sep

08

Oct

08




mean

ucl





Patient admitted directly to

cath lab


50

5754

49

53

50

40 41 40

34.5

30.53234

48.5

39

44.544

35

4744

52

49

69

60.5

63

0

10

20

30

40

50

60

70

80

Oct

06

Nov

06

Dec

06

Jan

07

Feb

07

Mar

07

Apr

07

May

07

Jun

07

Jul

07

Aug

07

Sep

07

Oct

07

Nov

07

Dec

07

Jan

08

Feb

08

Mar

08

Apr

08

May

08

Jun

08

Jul

08

Aug

08

Sep

08

Oct

08




mean

ucl





Patient admitted directly to

cath lab

Cath lab opened by

resident member of staff

Aways room for improvement..

Help your out

of area

ambulance

colleagues...

DTB direct Q3 2009 2010

Door to Balloon (direct) October 2009 to December 2009

46

43

40

39

38

36

0

50

100

150

200

250

300

350

400

450

Oct09 Oct09 Oct09 Nov09 Nov09 Nov09 Nov09 Nov09 Dec09 Dec09 Dec09 Dec09 Dec09 Dec09

DTB median 33.5 ucl 93

In the cath lab..

• Brief assessment (history, ECG , examination)

• Exclude aortic dissection, PE

• Look for acute MR, VSD; determine access

• Previous angio available?

• Determine history of allergy

• Record usual medication (esp. anticoagulants) and

medication already administered (aspirin, opiate

analgesia)

• Obtain witnessed verbal consent

In the cath lab..

• Slick patient preparation (iv access; ECG

monitoring; remote pads for defibrillation;

monitoring of O2; removal of jewellery)

• Access – “normal” route is radial (82% radial

last 1000 sequential cases in JCUH)

• Preferable to have easy access to femoral

artery, even if not used

In the cath lab..

• Common practice to administer a “radial

cocktail” (GNT/verapamil +/- UFH) after

sheath insertion

• Advisable to avoid verapamil for STEMI

• Diagnostic angio followed by choice of guide

catheter or whole procedure with Kiemeneij

guide catheter

In the cath lab..

• Do the case

• Use of a thrombus extraction device is normal

practice

• Clarify any pending non cardiac surgery prior to

choice of stent

• Ask yourself if the stent big enough

• TR band for radial access (increasingly use of a

closure device for femoral access)

• Do the next case

In the cath lab – particular considerations

• Inferior STEMI

– Bezold-Jarisch reaction: liberal use of iv fluids,

atropine; may require phenylephrine

• Culprit vessel or MV PCI?

– Our default strategy is culprit vessel PCI (MV PCI

performed in context of cardiogenic shock and

lack of haemodynamic response to culprit vessel

PCI)

“A word of advice, Durk: it’s the Mesolithic, we’ve domesticated the dog, we’re using stone tools and no one’s naked anymore.”

JCUH drugs

Aspirin loading 300mg

(paramedic).

Weight adjusted UFH

(60U per kg) assuming

patient will also receive

ReoPro (89% of last

1000 sequential cases).

ReoPro is only

administered in the cath

lab.


JCUH drugs

Clopidogrel loading 600mg

(not by paramedics)

For self-presenters to local

or regional A&E, load with

aspirin 300mg and

clopidogrel 600mg prior to

urgent transfer


JCUH drugs

Prasugrel is used instead of

clopidogrel on a patient by

patient basis at operator

discretion.


Alternatively…

Aspirin loading 300mg

(paramedic).

Prasugrel 60mg loading

dose as routine (well

recognised exceptions);

potential for

administration by

ambulance crew.

Bivalirudin + bail out

GpIIb/IIIa inhibitor.

In the cath lab.. escalation of care

• Not all PPCI is simple

83F

Inferior

STEMI

TIMI 2 flow

Critical prox

RCA

Lesion

uncrossable

with whole

range of

CTO

balloons

Lesion

successfully

crossed

with 2.1F

Tornus

device

Subsequent

rotablation

and stenting

Final result



• Not all MI (or PPCI) is without complication

62M

Posterolateral

STEMI

Severe

pulmonary

oedema

requiring NIV

and

anaesthetic

support

Severe MR

noted pre-

lab

Sub-total

occlusion of

Cx

Cx ballooned

for ongoing

pain

IABP

Urgent

mechanical

mitral valve

replacement

90 minutes

later

Complete

recovery

77F

Inferior

STEMI with

CHB

Ostial LMS

disease and

calcified,

severe LAD

and Cx

disease

Occluded

RCA in

calcified

vessel

Vessel

opened

Serial balloon

inflations

TIMI 3 flow

Delivery of kit

very difficult

No stent;

planned

urgent CABG

Vessel

repeatedly

re-occluded

after wire

removal

Haemodynamic

compromise

IABP, TPW

Cardiothoracic

anaesthetic

input

Emergency

CABG from lab



• Not all MI (or PPCI) is without complication

• ...which means you get some very sick patients


• Infrastructure for the sickest group must be in

place



place

– Input from experienced cardiothoracic

anaesthetists vital for some



place



– Provision for invasive ventilation

– Provision for IABP

General ITU

do not take

these patients



place





– Provision for cooling

General ITU

do not take

these patients



place





– Provision for cooling

– Provision for cardiothoracic surgical input

General ITU

do not take

these patients

The basics.... conclusion

Agreed regional protocol for delivery of

PPCI

Mechanism in place for wherever the

patient presents

Mechanism of continuous monitoring,

audit and feedback

The basics.... conclusion

Agreed regional protocol on drugs

Strategy for the PPCI which is not simple

Infrastructure for those patients

requiring urgent anaesthetic and surgical

input

How to do Primary PCI - bcis.org.uk€¦ · Before the cath lab.. ... In the cath lab.. • Common...

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