5/1/2017

1

Post Procedure Complications:

Be Prepared

Class Code:C60M251 12:15 13:15C60M351 15:15 16:15

cherrmann@frontier.comwww.cherylherrmann.com

UnityPoint Health- PeoriaHeart of IL AACN President

Speaker Disclosures AACN Speaker Bureau

Cross Country/Vyne Education

Speaker Bureau

Novartis Speaker Bureau

Handouts will be available at

www.cherylherrmann.com

Handout in My NTI

Where

in the

World is

Peoria?PEORIA

Will it Play in Peoria?

The Background

Failure Mode and Effects Analysis

Systematic way to anticipate

problems and design processes

and products to reduce risk.

FMEA

Ways to Prevent a Crisis

5/1/2017

2

Objectives

Describe complications that can occur post-procedure.

Analyze assessment data to identify post-procedure complications.

Create a plan of care to implement when a post-procedure complication occurs.

NursingGood day?? Bad day ??

Routine Procedures:Are you prepared to recognize complications?

Pacemaker insertion

Central line insertion

Thoracentesis

Chest tube insertion

Femoral artery and radial approach for peripheral or cardiac procedures

Case Study #1Pacemaker/

Central Line

Insertion

68 year old male

PMH:

COPD

Cardiomyopathy for past 7 years with EF 40%

Recent EF 30% and now has Left Bundle Branch Block

Plan: Insertion of Biventricular Pacemaker

Central Line & Pacemaker Insertion

Im not a Cardiac Nurse!

During pacemaker insertion, a central lineis inserted via the right internal jugular veinand the pacemaker leads via the leftsubclavian

5/1/2017

3

Routine Procedures?!?!?

What are potential complications from central line and/or pacemaker insertion?

What diagnostics should occur post procedure?

Potential Post Procedure Complications

Immediate

Bleeding

Arterial puncture

Arrhythmia

Air Embolism

Pneumothorax

Hemothorax

Delayed

Infection

Venous thrombosis

Pulmonary emboli

Catheter migration

Catheter embolization

Myocardial perforation

Nerve Injury

Central Line & Pacemaker Insertion

Case Progression

Post procedure vital signs started

Initial Assessment B/P 110/70, HR 80, RR 16, Sp02 99%

Clear lung sounds

Right jugular and left subclavian dressings dry and

intact

No SQ emphysema noted

Monitor shows paced rhythm

Chest Xray ordered

What are your actions?

When xray tech enters room:

Acute onset SOB and wheezing

Significant respiratory distress

Calls RN

Actions

Listen to lung sounds

Chest xray

Call MD who performed procedure

Call Rapid Response Team (RRT)

Normal CXR Pneumothorax

5/1/2017

4

Significant

pneumothorax on

right with tension

pneumothorax

component

Note shift of heart to

left

What actions do you need to do

to insert a chest tube?

Chest tube insertion cart

Insertion of Chest Tube Premedicate, please! (Chest tube insertion

reported by patients as one of the MOST painful

procedures!)

Drape patient, using sterile technique

Add prep cleansing solution

If drawing up medications used on the sterile field, follow hospital policy

Trocar Catheter Kit

Disposable kit with most generic supplies needed

Contains a trocar (chest tube) if its not the right size, you can still use the tray but order up a trocar packaged separately

All supplies are sterile: gauze sponges, needles, syringes, scalpel, sponges, generic gloves, trocar (size is listed on package)

Will have to add your cleaning solution (chloraprep or betadine) and lidocaine

Disposable Trochar Catheter Kit

Trochar

Syringes, needles

Add gloves

1. Prep site, using sterile technique

2. Drape site, using sterile technique

3. MD injects numbing medication

Used with permission from Pam Hamilton, RN

Chest Tube Insertion Steps

5/1/2017

5

4. MD will use scalpel to make

large enough opening to

insert chest tube

5. MD will use gentle PRESSURE

to insert catheter into

pleural space

6. After tube inserted, MD may clamp

BRIEFLY while hes suturing --

have drainage tubing already

there to connect-Remember:

Goal is to remove fluid/air

7. Dont leave tube clamped for

extended period of time -

Only with MD orders!

8. Assess drainage and assess for

air leak

9. Document

Chest Tube inserted

Respirations easy and regular

No respiratory distress

Another chest xray ordered

Pneumothorax resolved

Pneumothorax

Note lung re-expanded

Post chest tube insertionChest tube

And the rest of the story

RN caring for patient at lunch

Another RN responded to xray tech

Surgeon on unit --- called to pt room

CXR viewed on machine

Surgeon calls cardiologists and inserts chest tube to relieve pneumothorax

All occurred in less than 7 minutes

RN at lunch missed it all!

GREAT job to the nurses!

Would you be as prepared to respond to a post procedure complication from a central line insertion?

Central Line removal

Complications can occur during insertion or removal of central lines

5/1/2017

6

Air Embolus from Central Line Removal

Symptoms

Chest pain

Dyspnea

Apprehension

Tachycardia

Syncope

If you suspect air embolus

Immediately place the patient in the left

lateral decubitus (Durant maneuver) andTrendelenburg position.

Prevents a venous air embolism fromlodging in the lungs.

The air will rise and stay in the right heartuntil it slowly absorbs.

Similarly, placing a patient in theTrendelenburg position (head down) helps

prevent arterial air embolism from travelingto the brain causing a stroke.

If CPR is required, place the patient in asupine and head-down position

Key points to avoid air embolism when removing central line:

Place the patient in supine position (they should not be sitting or

upright)

Instruct the patient to hold their breath and perform the Valsalvamaneuver (forced expiration with the mouth closed) when the

catheter is being removed

If the patient is unable to cooperate with instructions, the catheter

should be removed following inspiration

Cover the insertion site immediately with sterile gauze, maintainfirm manual pressure until hemostasis is achieved. Then cover the

site with an air-occlusive dressing, which should remain in place for24-72 hours.

Case Study #2Pacemaker/

Central Line

Insertion

A patient is several hours post pacemaker insertion at outlying hospital

c/o severe chest pain

BP drops to 80/50, HR 108, RR 22

PMH: coronary stent, MI, diabetes

On ASA and Effient

What are some potential complications ofpacemaker (or central line insertion) that youwould suspect?

Potential Post Procedure Complications

Immediate:

Bleeding

Arterial puncture

Arrhythmia

Air Embolism

Pneumothorax

Hemothorax

Delayed: Infection

Venous thrombosis

Pulmonary emboli

Catheter migration

Catheter embolization

Myocardial perforation

Nerve Injury

Central Line & Pacemaker Insertion

Myocardial Perforation

Symptoms:

Signs of tamponade

(heart is compressed from fluid)

Hypotension

Decreased urine output

Distended neck veins

Tachycardia

Dyspnea

Fluid noted around heart on CXR and/or echo

Treatment:

Fluids to maintain

hemodynamic stability

Pericardiocentesis if hemodynamically

compromised May be emergent at the bedside

May leave catheter in for drainage if unsure if perforation is resolved

Surgery for Pericardial

Window

5/1/2017

7

Normal CXR Pericardial Effusion Chest Xray Ordered

Note water bottle shape

of heart rather than the typical cardiomyopathy

size

Suspicion for pericardial effusion (fluid around

heart)

Normal Echo

Pericardial Effusion

Echocardiogram reveals

small amount of blood at

base of heart confirming

pericardial effusion from

myocardial perforationLeft Ventricle

Another Patient with

Large Pericardial Effusion

41

Pericardial Effusion

Low voltage complexes

The larger the effusion, the smaller the complex

5/1/2017

8

Pericardial Effusion Treatment

Fluids/Blood if hemodynamically unstable

Pericardiocentesis

May be emergent at bedside

May leave catheter in for drainage if unsure

if perforation is resolved

Surgery for Pericardial Window

And the rest of the story

Patient was given fluids and monitored

Effusion resolved on its own

Both pacemaker and central lines can result in myocardial perforation

Case Study #3 Pacemaker

Insertion

Patient comes to ED for syncope

Five syncopal/syncopal episodes --passed out for a few seconds

BP 123/58 mmHg

Pulse 46

Resp 22

SpO2 98%

Alert history of Alzheimer dementia

5/1/2017

9

2229

EKG in ED

Marked sinus bradycardia with junctional escape rhythm

on the monitor and had a few pauses, the longest pause

about 7 to 8 seconds long.

Atropine given in the ED

Admitted to CVICU; received atropine again for another pause.

The patient has been in sinus bradycardia overnight at

times with junctional escape beats.

The patient likely has underlying sinus node dysfunction --

No obvious clear etiology other than her age

Consent for Pacemaker

CXR post pacer

Placement of a right dual-

chamber pacemaker. No right pneumothorax

Development of a small left apical pneumothorax..

Patchy opacification left perihilar region consistent with atelectasis or

pneumonia.

More info. The patient is very uncooperative due to

persisting senile dementia.

Under IV sedation by anesthesiologist, we started procedure from the left subclavian approach.

Despite several attempts, not able to enter the vein and not able to do vein, actually entered the artery 4 times instead.

Hemostasis was attempted and achieved.

Venogram revealed high the level of the subclavian vein and beneath the artery, hence we terminated the approaching right and then performed from the right subclavian vein.

CXR Next Morning

What do you see?

CXR Next Morning

1. Large left pneumothorax,

significantly increased in volume since prior exam.

2. Mild rightward mediastinal shift raises concern for a

component of left tension pneumothorax.

3. Worsening left lung

atelectasis. A small left pleural effusion excluded.

Patient was

hemodynamically stable.Emergent CT inserted at

bedside

5/1/2017

10

Pneumothorax Post CT inserted

Post Line insertion Pearls

Ask if attempted more than one time and more than one site

Ask if any concerns during procedure

Rehearse/Practice what you would do for complications

Where are the emergency CT carts stored?

Case Study #4Thoracentesis

Time OutMake sure you get the right site!

Patient Safety First

And don the appropriate PPE.

82 y/o male

Thoracentesis for pleural effusion one month ago

Increasing shortness of breath and decreased activity over past few days

SOB while waiting for CXR in MD office

Direct admit

Thoracentesis

5/1/2017

11

Admission Pro BNP 666

CXR on admission showing

right pleural effusion

CXR last month post thoracentesis

Plan for bedside thoracentesis

What equipment and prep is needed for bedside thoracentesis?

What complications would you assess for post procedure?

Post Procedure Complications:

Pneumothorax

Bleeding hemothorax, hematoma, hemoperitoneum

Laceration of liver, spleen, or lung

SQ emphysema

Hypovolemia

Hypotension

Dyspnea

Re-expansion pulmonary edema

Thoracentesis

Case Progression

1800 ml drained with thoracentesis

About 20 minutes later: BP 50 systolic

HR 54

RR 16

SpO2 97%

What further assessments/diagnostics/interventions would you do?

CXR Decrease in right pleural effusion post thoracentesis

5/1/2017

12

Case Progression

250 ml Albumin hung with little response

Then Dopamine started

Moderately doppled pulse femoral

Very anxious and becoming SOB

RRT called -- transferred to CVICU

Agonal breathing, Code Blue called

Return of Spontaneous Circulation after a few minutes of CPR

Surgeon questioned if something got nicked and bleeding

Possibly liver??

MD asks for blood

Case Progression

Chest tube inserted. At least 3000 ml blood drained immediately.

Massive hemorrhage protocol implemented

13 units of blood given

CXR obtained

Massive Hemorrhage Protocol Protocol

Massive Hemorrhage Protocol

No increase in right pleural effusion post CT insertion in code

5/1/2017

13

Post Chest Tube Insertion

Bleeding stopped

Patient stabilized

Patient did not need surgery

However, patient developed multi-organ system failure and died about 5 days later. started with complication from thoracentesis

Other thoracentesis

complications

SQ emphysema

Re-expansion pulmonary edema

Reperfusion Pulmonary Edema (RPE)

Characterized by rapid onset of dyspnea and tachypnea within one hour of reexpansion of lung

Blood flow is significantly reduced with a collapsed

lung due to hypoxic pulmonary vasoconstriction

With reexpansion, pulmonary vasoconstriction

resolves and alveoli get oxygenated

Possible acute inflammatory response from hypoxic vasoconstriction

Also attributed to abrupt reduction of pleural

pressure

Rare 1% with mortality up to 20%

Reference: Alqadi, K, Fonseca-Salencia, C. et al. Reexpansion Pulmonary Edema Following Rhoracentesis.. Rhode Island Medical Jounral. Sept. 2012: 38-40

Prior to Thoracentesis

Post Thoracentesis SpO2 in the 50s

Reference: Alqadi, K, Fonseca-Salencia, C. et al. Reexpansion Pulmonary Edema Following Rhoracentesis.. Rhode Island Medical Jounral. Sept. 2012: 38-40

BiPAP, Diuretics

CXR on D/C day

Case Study #5Femoral

Cardiac

Catherization

5/1/2017

14

49 y/o comes to ED with Chest pain

Cardiac Cath done.

No significant occlusive coronary artery disease, mild to moderate disease of the posterior descending artery and the left anterior descending is noted

EF 25 30%

Takotsubo or a broken heart syndrome is a possibility.

Proglide for groin closure

Post Procedure

BP 143/68, HR 83, RR 18

Right groin site, clean dry, no hematoma. Pulses 2+

1545 Getting Ready for Discharge

Pt turns on light and calls out, please help me

Felt something pop in right groin

Large hematoma noted

Physician notified that patient developed large hematoma at angiogram site. Physician in route to assess patient.

What are your actions?

1545 1600 1615

BP 100/doppled 90/doppled 60/doppled

HR 110 112 60

1606 RRT called

Atropine 0.5 mg given IV

O.9 NS started, 2 liters of fluid given

02 2 liters

Pressure on groin

IVs placed in both antecubitals

Draw H/H and type/cross for packed cells

Hemoglobin dropped from 13.9 to 11.9

Sent to Interventional Radiology

Interventional Radiology Right Lower extremity angiogram for R/O

Psuedoaneurysm/AV Fistula (Right groin hematoma s/p cardiac cath)

There is no evidence of a psuedoaneurysm or A-V fistual in the right groin. The right common femoral artery is patent and demonstrates normal waveform patterns.

Monitor H/H. If Hg continues to drop may need to consider CT abdomen/pelvis.

1545 1600 1615 1653

BP 100/doppled 90/doppled 60/doppled 95/56

HR 110 112 60 96

5/1/2017

15

Other considerations

Code Blood bank?

Emergency surgery?

Retroperitoneal bleed?

Retroperitoneal (Flank) BleedBleeding in the muscle and tissues behind the abdominal wall cavity

Signs & Symptoms

Back pain

flank pain

Hypotension

Tachycardia

Blue-purple discoloration of the back

If low H/H: nausea/ chest pain, EKG changes

presents like AMI

Treatment

Can die quickly

Blood, surgery

Transradial Cardiac Catheterization

Improved patient comfort

Improved hemostasis

Reduce risk of vascular complications

Hematomas

Pseudo-aneurysms

Retroperitoneal bleeding

Data showing improved outcomes

Mortality

Radial Hemostasis

Sheath is removed and TR band applied.

Patient can sit up immediately after the procedure.

Ambulation as soon as patient is steady.

General Approach to Post-

Procedure Management

TR band on right radial artery.

Volume of air from cath lab recorded.

Oximetric probe on right thumb

Compress ulnar artery (reverse Barbeau)

Note waveform

If absent notify cath lab staff or

Remove 2 ml of air and recheck waveform

Remove 3 cc of air every 15 minutes

Repeat reverse Barbeau

Patent Hemostasis

5/1/2017

16

Patent Hemostasis

Modified Barbeau Test

Place the oximetric probe on the first digit or thumb-note the wave form

Both the radial and ulnar arteries are occluded.

Note oximetric reading and waveform

Pressure on the ulnar artery is removed while maintaining pressure on the radial artery

Note the oximetric reading and waveform

Other considerations

No BP in radial cath arm during hospital stay

Place pink name band on affected arm

Avoid lots of bending of writst (eating)

Watch for spasm

Continous Sp02 waveform monitoring for 2 hours post procedure

Case Study # 6

Femoral Cardiac

Catherization

56 y/o direct admit from rural hospital for SOB Not been feeling well for last 6 months

Dyspnea

Joint pain

Major complaint~ lower extremity swelling and SOB on exertion which he attributes to his COPD

This morning more SOB and chest discomfort Chest pressure 6/10, left sided, non radiating

Initial EKG Sinus Rhythm with Nonspecific ST changes

Troponin 0.5

Creatinine 2.5, BUN 29

5/1/2017

17

PMH CAD, stent to LAD 2

years ago

PAD, stent

Hypertension

Hyperlipidemia

Former smoker

COPD

Sleep apnea

Fractured some left ribs 6 7 months ago off work for 3 weeks

dyspnea pleural effusion thoracentesis x 3 six weeks apart =1 liter. Negative for any malignancies. Last thoracentesis 6 weeks ago

Extremity edema started around the time of last thoracentesis (6 weeks ago)

Transferred for further evaluation

ST depression V2 V 6LV hypertrophy

EKG on Admission from referring hospital

Admission CXR

Left persistent atelectasis or pneumonia or pleural effusion

Mild right basilar atelectasis noted

Cardiology consult

Acute Coronary Syndrome/NSTEMI

ST depression V 4 V6 worrisome for cardiac ischemia

2nd Troponin 5.0 (previous 0.5)

Dual antiplatelet therapy

ASA, Clopidogrel (Plavix) BetaBlocker Therapy

Stop Atenolol due to worsening kidney function

Metoprolol

Acute Kidney Injury

Stop Losartan due to kidney function.

May consider ACE I later

Plan

Invasive vs conservative NSTEMI strategy discussed in detail with patient

Conservative strategy due to acute renal injury with creatinine 2.5

Monitor renal function closely

If kidney function improves, consider coronary angiography

Diagnostic Testing

Renal Ultrasound

Bilateral renal artery stenosis

Mild renal pelvis dilation bilaterally

Echocardiogram

EF 55 %

Inferior vena cava normal collapses greater than 50% with inspiration-volume depletion

No pulmonary hypertension

5/1/2017

18

Course of Stay over next 10 days

Acute anemia --- blood transfusion

Fever and microscopic hematuria without evidence of infection

Autoimmune workup: Elevated ERS CRP and ANA, positive MPO (Myeloperoxidase) antibody

Osteoarthritis of the hands and hips and probably right elbow

Tissue biopsy Wegeners Granulomatosis

Given Cytoxan and high dose prednisone

Back to the heart.. NSTEMI Patient stabilized

BP 156 189/73-86, HR 75- 86

H/H 9.0/29

Kidney function

Creatinine 1.2, BUN 23

24 hour Intake and output = 2632/2250 with

+ 363 net

Net Intake and output since admission (11 days)

+ 1894

Scheduled for coronary angiogram

CXR day before coronary angiogram11 days post admission

You are the nurse who will be caring for the patient post cardiac cath. Based on the assessment, history, etc, you realize this patient is a higher risk. Would you expect any major complications post procedure?

1. Yes

If yes, what complications are you preparing for?

2. Probably not as you will monitor closely and treat per training as cardiac nurse

3. Unsure -- Im a float nurse!

Coronary Angiogram

Started on IV Saline last night

Minimal contrast used

No significant coronary disease

Previous stents in LAD and circumflex are patent

Flush aortography: Bilateral renal artery stenosis both greater than 80 90%.

Selective renal angiography not performed per renal service recommendation

Arrives back to unit at 0910 post procedure. Routine vital signs

Any concerns?

SpO2 = 91% on room air

5/1/2017

19

And the rest of the story. 1120 (2 hours post procedure)

Pt stable except high blood pressure. Respirations regular and easy

1140 c/o SOB, labored breathing 02 4 liters nasal cannula and then switched to non breather

mask Cardiologist paged

1145 BP 150/92, HR 108, SpO2 51%

Lasix 80 mg IV

1147 Pt having a really hard time breathing and then agonal

breathing Code blue called Intubated. No loss of pulse, no compressions needed

Transferred to CVICU

What is your interpretation of the ABGs?

time 1154 1223 1405

pH 7.02 7.13 7.29

pCO2 97 74 74

pO2 24 66 57

C02 total 29 27 29

BE 6.1 4.6 0.6

O2 sat 21 85 92

1. Respiratory Acidosis

2. Respiratory Alkalosis

3. Metabolic Acidosis

4. Metabolic Alkalosis

What is your interpretation of the ABGs?

time 1154 1223 1405

pH 7.02 7.13 7.29

pCO2 97 74 74

pO2 24 66 57

C02 total 29 27 29

BE 6.1 4.6 0.6

O2 sat 21 85 92

1. Respiratory Acidosis

2. Respiratory Alkalosis

3. Metabolic Acidosis

4. Metabolic Alkalosis

CXR after intubation

What do you think?

1. Takotsubo cardiomyopathy

2. Flash pulmonary edema

3. Pneumothorax

4. Pleural effusion

CXR after intubation

What do you think?

1. Takotsubo cardiomyopathy

2. Flash

pulmonary

edema3. Pneumothorax

4. Pleural effusion

Did you anticipate the respiratory arrest?

Previous Question

You are the nurse who will be caring for the patient post cardiac cath. Based on the assessment, history, etc, you realize this patient is a higher risk. Would you expect any major complications post procedure?

Yes If yes, what complications

are you preparing for?

Probably not as you will monitor closely and treat per training as cardiac nurse

Unsure -- Im a float nurse!

1. Yes

2. No

5/1/2017

20

VentAC 24, TV 550, PEEP 12

1154 1223 1405 2116 0600

pH 7.02 7.13 7.29 7.36 7.35

pCO2 97 74 74 46 47

pO2 24 66 57 130 111

C02total

29 27 29 27 28

BE 6.1 4.6 0.6 0.4 1.6

O2 sat 21 85 92 99 98

CXR Day after code

CXR right after code

Diuresed

Afternoon after code (about 24 hours later) right renal stent placed

Extubated sent to progressive unit

Had some malignant hypertensive episodes

CXR 3 days after code7700 ml diuresis

CXR day after code

Discharged 5 days post cardiac cathLOS = 16 days

Discharge Diagnosis Malignant hypertension

likely due to RAS

NSTEMI

Bilateral renal artery stenosis (RAS); s/p renal stent

Recurrent Left pleural effusion repeat TB gold in 4 weeks

Wegeners Granulomatosis

CKD II

Chronic iron Deficiency Anemia

COPD

Discharge Medications

Albuterol neb

AmlodipineAspirin

AtenololAtorvastin

ClonidineClopidogrel

Cytoxan

Famotidine

Furosemide LasixHydralazine

IsorbideSynthroid

LisinoprilPotassium

chloridePrednisone

5/1/2017

21

What do you think caused the

flash pulmonary edema?

1. NSTEMI

2. Malignant Hypertension

3. Renal Artery Stenosis

4. Wegeners Granulomatosis

What do you think caused the

flash pulmonary edema?

1. NSTEMI

2. Malignant Hypertension

3. Renal Artery Stenosis

4. Wegeners Granulomatosis

Renal Consult

Flash Pulmonary Edema

Classic clinical finding with renal artery stenosis (RAS)

Hypertension related to RAS

Pickering Syndrome Flash pulmonary edema and bilateral

renal artery stenosis

Three mechanisms cause the flash pulmonary edema

1. Defective natriuresis

2. Increased hemodynamic burden and

exacerbation of diastolic dysfunction

3. Failure of the pulmonary capillary blood-gas

barrier

Successful revascularization of one or both renal arteries eliminates the pulmonary edema

Source: Messerli, F, Bangalore S, Makani H. Flash Pulmonary Oedema and Bilateral Renal Artery Stenosis: The Pickering Syndrome. Euroheartj. 2011

RAS activates RAAS & SNS

Source: Messerli, F, Bangalore S, Makani H. Flash Pulmonary Oedema and Bilateral Renal Artery Stenosis: The Pickering Syndrome. Euroheartj. 2011

Renin-Angiotensin-Aldosterone System (RAAS)

Low Cardiac Output/Hypotension/HypovolemiaDecreased Renal perfusion

Afferent Arteriole (baroreceptors)

Release Renin (a messenger)

Go to Liver to stimulate Angiotensin I production

Angiotensin I goes to the Lung

Angiotension Converting Enzyme (ACE) located in the pulmonary vascular membrane

Converts Angiotensin I to Angiotensin II

Angiotensin II

Growth Factor Potent Vasoconstrictor Adrenal Cortex

Increases B/P Aldosterone

Increases SVR Distal Renal Tubule

Increases H2O &

Na++ Reabsorption

Excretes K+ for Na+

5/1/2017

22

SNS ActivationRenal artery stenosis: RAAS & SNS With Unilateral RAS contralateral kidney

is functioning normally:

Compensates for the elevated BP by

Suppressing the renin secretion

Augments the sodium excretions

Pressure natriuresis occurs

With bilateral RAS this escape mechanism is defective

Thus the Development of Flash Pulmonary Edema

Pickering Syndrome Treatment

Phase 1 Stabilize patient

Treat hypertensive emergency with

antihypertensives and improve

hemodynamic unloading

Loop diuretics

Phase 2 treat the cause

Renal revascularization

Now we know..We should have been more concerned with the high blood pressure

SpO2 = 91% on room air

Flash Pulmonary Edema Warning Signs

Hypertension

Uncontrolled hypertension preprocedure

Tachycardia

Tachypnea

Decreasing Sp02

Especially in the presence of RAS or acute ischemia

In Summary

5/1/2017

23

https://www.youtube.com/watch?v=1qzzYrCTKuk

Post Procedure Complications:

Be Prepared

Class Code:C60M251 12:15 13:15C60M351 15:15 16:15

cherrmann@frontier.comwww.cherylherrmann.com

UnityPoint Health- PeoriaHeart of IL AACN President