Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when...
Transcript of Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when...
![Page 1: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/1.jpg)
{
Pericardial Perforation…
Preparing for Emergency
Rachael Taggart, RN,BSN,
CCRN
Cleveland Clinic
Electrophysiology Laboratory
![Page 2: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/2.jpg)
Objectives
• Discuss care of the EP patient when
complications, specifically pericardial
perforation, occur in the lab
• Describe procedural readiness for complex
ablations
• Describe case studies relevant to
pericardial perforation (pictures)
![Page 3: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/3.jpg)
There is no conflict of interest on the part of the presenter.
There is no conflict of
interest on the part of the
presenter
![Page 4: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/4.jpg)
Ablation Complications
• Vascular Access: Hematoma, AV Fistula,
retroperitoneal bleed, infection, clots
• Airway/Sedation: Emergent intubation, nasal airway
trauma
• Fluid volume overload
• Foley insertion
• Pericardial effusion/tamponade/perforation---Open
Chest
• Stroke
• Rhythm disturbance
• Pulmonary vein stenosis (PVI)
• Atrio-esophageal fistula
• Skin issues
• Pleural effusion
![Page 5: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/5.jpg)
What is it?
Accumulation of fluid or blood in the pericardial sac around
the heart. It causes the heart to become compressed and
blood flow to be restricted, leading to hemodynamic
compromise. Cardiac tamponade is life threatening and
always fatal if undetected and untreated.
Text taken from Cleveland Clinic Learning Center
Cardiac Tamponade Module, image from quizlet.com
![Page 6: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/6.jpg)
How Often Does it
Happen? In year 2013……
PVAI 811 (6, or 0.74%)
VT ablations 87 with EF greater than or equal to 50% (1, or
1.15%)
429 PPM (1, or 0.23%, initial implant)
380 ICDs (1, or 0.26%, initial implant)
From 2009-2013……
1,117 lead extractions with leads in place greater than 1 year
(1.6%, death or intrathoracic bleeding)
Taken from Cleveland Clinic Heart and Vascular
Outcomes book 2013
![Page 7: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/7.jpg)
What does it look like with our tools?
![Page 8: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/8.jpg)
![Page 9: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/9.jpg)
A Rare (but cool)
Fluoroscopy Shot
![Page 10: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/10.jpg)
Early Signs and
Symptoms
• Anxiety, restlessness
• Faintness, lightheadedness
• Fatigue/Pallor
• Feelings of impending doom
• Cool, clammy extremities Taken from Cleveland Clinic Learning Center Cardiac
Tamponade Module
![Page 11: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/11.jpg)
Classic Signs and Symptoms
Beck’s Triad
• Hypotension (defined as SBP <90)
• Increased jugular venous pressure
• Distant/muffled heart sounds
Taken from Cleveland Clinic Learning
Center Cardiac Tamponade Module
![Page 12: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/12.jpg)
Other Key Clues… • Narrowing Pulse Pressure
• Sharp/stabbing pain in the
chest
• Tachypnea/dyspnea
• Tachycardia
• Pericardial friction rub
Taken from Cleveland Clinic Learning Center Cardiac
Tamponade Module
![Page 13: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/13.jpg)
• Decreased hematocrit
• Pulsus parodoxus
• Electrical alternans
• Decreased urine output
Taken from Cleveland Clinic Learning Center
Cardiac Tamponade Module
![Page 14: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/14.jpg)
Why it Can Happen in The EP Lab
• Placement of EP catheters, use of wires, transeptal needle
• Use of radiofrequency energy and ablation catheter (steam pops)
• Anti-coagulation is unavoidable when working in the left side of the
heart
• Takes technique and experience to work on breathing person and a
beating heart with only two-dimensional aids of fluoroscopy and
mapping system
• Anatomical variations
• Patient population with other comorbidities
![Page 15: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/15.jpg)
Right atrium to left atrium Tenting the septum
Bubbles in the left atrium
![Page 16: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/16.jpg)
Ablation
catheter
Ablation
lesion
![Page 17: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/17.jpg)
So…what exactly is “ablation”???
![Page 18: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/18.jpg)
What can we do about it?
Pictures from Merit Medical
website:
http://www.merit.com/product
s/media.aspx?type=brochure
&id=185229
![Page 19: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/19.jpg)
What do we do in lab to be ready for
anything?
CBC, BMP within thirty days for outpatients, usually night before for
inpatients
Four units PRBCs on call for extractions or per physician request for
complex ablations
Stop anti-coagulation for three days (device implants), one week
(device extractions), day before with newer anticoagulants (factor Xa
inhibitors), will usually take Coumadin night before for PVIs/left
sided atrial flutters-- Not stopped because risk of stroke outweighs
risk of bleeding
Current Type and Screen for pretty much all EP procedures with
limited exceptions
BLOOD RELATED
![Page 20: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/20.jpg)
SAFETY RELATED
Vital signs with pain assessment every five minutes, more often if
needed
Two 20 gauge IVs for left-sided cases
Anesthesia team interview prior to start of case for all procedures
(exception for non-ICU pacemaker implants)
CT consult for all patients with leads in place greater than 5 years
that require extraction
Routine use of irrigated ablation catheters or cryo ablation if near
fragile structures
![Page 21: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/21.jpg)
EMERGENCY RELATED
Pericardiocentesis trays, emergency medication boxes,
echo machines in all labs
Sub-xiphoid and bilateral groins prepped ahead of time in
anticipation of need
Ventilator circuits and anesthesia machines in all room
and ready
Emergency balloon dilatation catheter on hand for SVC
tears, perforation cart from cath lab
Intra-cardiac echo at physician’s disposal for assistance
with viewing cardiac structures
![Page 22: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/22.jpg)
Two open chest carts present and stocked at all
times
Multiple red “crash carts” present and stocked at all
times in pre-designated locations
Annual open chest inservices
Experienced RN hiring
EMERGENCY RELATED CONT’D
![Page 23: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/23.jpg)
QUESTIONS???
![Page 24: Pericardial Perforation… - Cleveland Clinic · Objectives • Discuss care of the EP patient when complications, specifically pericardial perforation, occur in the lab • Describe](https://reader035.fdocuments.in/reader035/viewer/2022070617/5e0e18a56ce47d04f86649ed/html5/thumbnails/24.jpg)