Nursing care of client with Coronary artery disease part 2 of 2


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Nursing care of client with Coronary artery disease part 2: Management

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Nursing care of client with Coronary artery disease part 2 of 2

  2. 2. Common Nursing Diagnoses andCollaborative Interventions CLDomocmat 8/9/2012 2
  3. 3. Management Maria Carmela L.Domocmat, RN, MSN 8/9/2012 3
  4. 4. Door to needle timeDoor to balloon time CLDomocmat 8/9/2012 4
  5. 5. Goals of care1. Treat the acute attack immediately2. Determine location of myocardial infarction3. Monitor for complications Maria Carmela L.Domocmat, RN, MSN 8/9/2012 5
  6. 6. cells in ischemic area – are salvageable ifreperfusion therapies and inotropic support ispromptly instituted (Schumacher &Chernecky, 2006)within 10 min of arrival of suspected AMI –ingest aspirin and obtain baseline cardiacserum markers, 12-lead ECG Maria Carmela L.Domocmat, RN, MSN 8/9/2012 6
  7. 7. Medical management Reduce risk factors Restore blood supply Percutaneous transluminal coronary angioplasty Directional coronary atherectomy Laser ablation Transmyocardial revascularizationNursing management Reduce risk factors Restore blood supplySurgical management Cardiac surgery Open heart surgery Coronary artery bypass graftNursing management before cardiac surgery Phase I (In-hospital) Rehabilitation Programs self-care Phase 2 (Outpatient Exercise Training) Rehabilitation Programs Phase 2 (Community) Rehabilitation Programs Home exercise Rehabilitation Programs CLDomocmat 8/9/2012 7
  8. 8. Medical mgmtfirst-line and initial treatment(Schumacher & Chernecky, 2006; Smetzer, 2010) Semi folwer’s position O2 (2-4 lpm) IV access obtain 12-lead EKG VS and pulse oximetry labs (serum cardiac markers) ECG monitoring conduct hx and PE reduce pain administer meds Maria Carmela L.Domocmat, RN, MSN 8/9/2012 8
  9. 9. Medical mgmtfirst-line and initial treatment cont. admit to CCU invasive line placement (arterial line, pulmo artery cath) - to provide further data to monitor ventricular dysfunction IABP – intraaortic balloon pump for severe L ventricular dysfunction to assist ventricular ejection and promote CA perfusion anticipate emergency PTCA or CABG reperfusion procedures if thrombolytics are either CI or unsuccessful Maria Carmela L.Domocmat, RN, MSN 8/9/2012 9
  10. 10. Nursing mgmt: Goals Recognize and treat cardiac ischemia Admin thrombolytic therapy as ordered, or ready client for PTCA and observe for complications Recognize and treat potentially life- threatening dysrhythmias Maria Carmela L.Domocmat, RN, MSN 8/9/2012 10
  11. 11. Nursing mgmt: Goals Monitor for complications of reduced CO Maintain a therapeutic critical care envt Identify the psychosocial impact of AMI on client and family Educate the client in lifestyle changes and rehabilitation Maria Carmela L.Domocmat, RN, MSN 8/9/2012 11
  12. 12. Nursing Diagnoses Acute Pain Ineffective Tissue perfusion (Cardiopulmonary) Activity Intolerance Ineffective Coping Potential or dysrhythmias Potential for heart failure Potential for recurrent symptoms and extension of injury CLDomocmat 8/9/2012 12
  13. 13. Acute Painrelated to imbalance between myocardialoxygen supply and demand CLDomocmat 8/9/2012 13
  14. 14. Acute Pain1. Obtain description of chest discomfort2. Vital signs and cardiac monitoring3. Check vascular access4. Place in semi fowler’s position5. 12 lead ECG6. O2 inhalation CLDomocmat 8/9/2012 14
  15. 15. 7. Provide pain meds and aspirin a. Nitroglycerine – increases collateral blood flow, redistributes blood flow toward the subendocardium and causes dilation of the coronary arteries b. Morphine sulfate – relieves MI pain, decreases sympathetic stimulation which decreases O2 demand and reduces circulating catecholamines8. Assess the client’s VS and intensity of pain 5 minutes after administration of meds9. Notify physician if patients condition deteriorates CLDomocmat 8/9/2012 15
  16. 16. CLDomocmat 8/9/2012 16
  17. 17. CLDomocmat 8/9/2012 17
  18. 18. Let’s review CLDomocmat 8/9/2012 18
  19. 19. Let’s review: Acute Pain1. Obtain description of chest discomfort2. Vital signs and cardiac monitoring3. Check vascular access4. Place in semi fowler’s position5. 12 lead ECG6. O2 inhalation7. Provide pain meds and aspirin8. Assess the client’s VS and intensity of pain 5 minutes after administration of meds9. Notify physician if patients condition deteriorates CLDomocmat 8/9/2012 19
  20. 20. Ineffective Tissue perfusion (Cardiopulmonary) related to interruption of blood flow• goal : to restore perfusion to the injured area to reduce the size of the infarct and improve left ventricular function CLDomocmat 8/9/2012 20
  21. 21. Ineffective Tissue perfusion Ineffective Tissue perfusion (Cardiopulmonary)related to interruption of blood flow CLDomocmat 8/9/2012 21
  22. 22. Ineffective Tissue perfusion1. Thrombolytic therapy2. Glycoprotein IIB/IIIA Inhibitors3. Antiplatelets Aspirin Clopidogrel4. Beta blockers5. ACE Inhibitors CLDomocmat 8/9/2012 22
  23. 23. Ineffective Tissue perfusion1. Thrombolytic therapy - Tissue plasminogen activator, streptokinase, reteplase - Indicated for patients who have chest pain of greater than 30 minutes, unrelieved by nitroglycerin and transmural MI (Q wave MI) CLDomocmat 8/9/2012 23
  24. 24. CLDomocmat 8/9/2012 24
  25. 25. CLDomocmat 8/9/2012 25
  26. 26. Thrombolytic therapy dissolves thrombus and promote reperfusion the golden period is 30 minutes from “door to needle” or from onset of pain till thrombolytic therapy within 30 minutes or PTCA within 1 hour Watch out for signs of bleeding and hypersensitivity hypersensitivity reaction ( Streptokinase ) IV infusion CLDomocmat 8/9/2012 26
  27. 27. Ineffective Tissue perfusion2. Glycoprotein IIB/IIIA Inhibitors - targets the platelet component of the thrombus to prevent fibrinogen from attaching to activated platelets at the site of the thrombus - Examples: Abciximab, Eptifibatide, Abciximab, Eptifibatide, Tirofiban - Administered through IV CLDomocmat 8/9/2012 27
  28. 28. Glycoprotein IIB/IIIAInhibitors Examples: Abciximab,, Eptifibatide,, Tirofiban Abciximab Eptifibatide CLDomocmat 8/9/2012 28
  29. 29. Aspirin Swallow the tablets with a full glass of water. Taken as regular (not enteric-coated) low- enteric- low- dose aspirin. Swallow the extended-release tablets whole with a full glass of water. Do not break, crush, or chew them. Chewable aspirin tablets may be chewed, crushed, or swallowed whole. Drink a full glass of water, immediately after taking these tablets. CLDomocmat 8/9/2012 29
  30. 30. CLDomocmat 8/9/2012 30
  31. 31. Aspirin If taking aspirin on a regular basis to prevent heart attack or stroke, do not take ibuprofen (Advil, Motrin) or other NSAIDs to treat pain or fever (Ibuprofen can interfere with the anti- platelet effect of low dose aspirin) If need only a single dose of ibuprofen, take it eight hours before or 30 minutes after taking a regular (not enteric-coated) low-dose aspirin. CLDomocmat 8/9/2012 31
  32. 32. Aspirin Ask a doctor before giving aspirin to child or teenager. Aspirin may cause Reyes syndrome (a serious condition in which fat builds up on the brain, liver, and other body organs) in children and teenagers, especially if they have a virus such as chicken pox or the flu. CLDomocmat 8/9/2012 32
  33. 33. Clopidogrel Plavix when combined with aspirin , more effective in reducing death, MI or stroke when compared to aspirin alone CLDomocmat 8/9/2012 33
  34. 34. Nrg Considerations: Aspirin andPlavix teach: may bleed more if having surgery, easily or for a longer including dental time than usual while surgery, tell doctor or you are taking dentist that taking clopidogrel. Be careful aspirin or Plavix not to cut or hurt CLDomocmat 8/9/2012 34
  35. 35. Beta blockers – Metoprolol reduces myocardial O2 requirement by blocking beta receptors and slowing heart rate, prolong diastole and increase myocardial perfusion aka: beta-adrenergic blocking agents reduces myocardial O2 requirement by blocking beta receptors and slowing heart rate, prolong diastole and increase myocardial perfusion Ex: Metoprolol, Acebutolol (Sectral), Atenolol (Tenormin), Bisoprolol (Zebeta), Propranolol (Inderal LA) CLDomocmat 8/9/2012 35
  36. 36. CLDomocmat 8/9/2012 36
  37. 37. Let’s review CLDomocmat 8/9/2012 37
  38. 38. Angiotensin-converting enzyme (ACE)Inhibitors given within 48 hours of MI prevents ventricular Benazepril (Lotensin) remodeling and Captopril development of CHF Enalapril (Vasotec) help relax blood vessels Fosinopril Lisinopril (Prinivil, Zestril) Moexipril (Univasc) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik) CLDomocmat 8/9/2012 38
  39. 39. ACE Inhibitors In some people the first dose can cause a drop in blood pressure immediately. The following is advice for starting ACE inhibitors: If taking a diuretic (water tablet), may be advised not to take it for a day or so before starting an ACE inhibitor. After the very first dose, on the first day start an ACE inhibitor: Stay indoors for about four hours, as occasionally some people feel dizzy. If you do feel dizzy, sit or lie down and it will usually ease off. If you become very dizzy, contact your doctor immediately. Thereafter, there is no need to take any special precautions. CLDomocmat 8/9/2012 39
  40. 40. ACE Inhibitors CLDomocmat 8/9/2012 40
  41. 41. Let’s review:Ineffective Tissue perfusion1. Thrombolytic therapy2. Glycoprotein IIB/IIIA Inhibitors3. Antiplatelets Aspirin Clopidogrel4. Beta blockers5. ACE Inhibitors CLDomocmat 8/9/2012 41
  42. 42. Activity Intolerancerelated to imbalance between oxygensupply and demand CLDomocmat 8/9/2012 42
  43. 43. Activity Intolerance1. Bed rest with commode privilege for only 24- 24- 48 hours unless with complications.2. Explain that the purpose of CCU confinement is for continuous monitoring and safety during the early recovery period.3. Administer diazepam as ordered4. Provide psychosocial support to the patient and his family. Calmness and competency are extremely reassuring. CLDomocmat 8/9/2012 43
  44. 44. Cardiac Rehabilitation actively assisting the client in achieving and maintaining a vital and productive life while remaining within the limits of the hearts ability to respond to increases in activity and stress begins the moment a client is admitted to the hospital 3 Phases 1. From acute illness and ends with discharge from the hospital 2. After discharge and continues through convalescence at home 3. Long term conditioning CLDomocmat 8/9/2012 44
  45. 45. Program of Physical Activity1. Increase activities gradually after the first 24- 24- 48 hours2. Early mobilization after an MI. May be allowed to sit on a chair for increasing periods of time and begins ambulation on the 4th or 5th day3. Monitor V/S before activities.4. An exercise session is terminated if any one of the following occurs:cyanosis, cold sweats, occurs:cyanosis, faintness, extreme fatigue, severe dyspnea, pallor, chest pain, PR > 100, dysrhythmias, Bp > 160/90 CLDomocmat 8/9/2012 45
  46. 46. 5 Physical Activity: Sexual intercourse 4-6 weeks post MI or when a patient with uncomplicated MI is capable of walking 2 flights of stairs without difficulty nitroglycerine before sex avoid concomitant use with Sildenafil CLDomocmat 8/9/2012 46
  47. 47. Sexual intercourse Perform sexual activity in a cool, familiar environment Refrain from sexual activity during a fatiguing day, after eating a large meal, or after drinking alcohol If dyspnea, chest pain, dizziness or palpitations occur, moderation should be observed. If symptoms persist stop sexual activity. CLDomocmat 8/9/2012 47
  48. 48. Sexual intercourse assume position with less strain Ex: woman on top, side lying CLDomocmat 8/9/2012 48
  49. 49. Ineffective Coping related to effects of acute illness, major changes in lifestyle or loss of control over a body part1. Anxiolytics during the acute phase of illness2. Provide opportunity for the patient and family to explore their concerns3. Identify clients coping mechanism 1. denial, anger and depression CLDomocmat 8/9/2012 49
  50. 50. Promote Nutrition and EliminationProvide small frequent feedingsLow calorie, low cholesterol, low sodiumAvoid stimulantsAvoid taking very hot or very cold beverages andgas forming foods to prevent vasovagalstimulationUse of bedpan and straining at stool should beavoided. Avoid valsalva maneuverBedside commodeAdminister stool softeners as ordered CLDomocmat 8/9/2012 50
  51. 51. Potential for recurrent symptoms& extension of injury Goal: minimal angina while engaging in ADLs and exercise program Ix Percutaneous Transluminal coronary angioplasty (PTCA) Coronary artery Bypass graft surgery (CABG) Minimally invasive Direct coronary artery bypass (MIDCAB) Transmyocardial Laser Vascularization Of-pump Coronary Artery Bypass (OPCAB) Robotics CLDomocmat 8/9/2012 51
  52. 52. Complications of MIDysrhythmiasCardiogenic shockThromboembolismPericarditisRupture of the myocardiumVentricular aneurysmCHF CLDomocmat 8/9/2012 52
  53. 53. Potential or dysrhythmias Identify Assess hemodynamic status Monitor cardiac rhythm and CR Evaluate for discomfort CLDomocmat 8/9/2012 53
  54. 54. Dysrhythmias most common complication and most major cause of death among clients with MI When Dysrhythmias develop the cardiac nurse must: 1. Identify the Dysrhythmias 2. Assess the client’s hemodynamic status 3. Evaluate the client for chest discomfort 4. attach to cardiac monitor CLDomocmat 8/9/2012 54
  55. 55. Inferior Wall MI - bradycardia – atropine - second degree AV block – PacemakerAnterior Wall MI - 3rd degree AV block – Pacemaker - Ventricular irritability - PVC’s – the most common dysrhythmia in MI - notify physician if more than 6 PVC’s occur per minute and client is symptomatic (hypotensive, chest pain) (hypotensive, CLDomocmat 8/9/2012 55
  56. 56. Potential for heart failure Goal: regain hemodynamic stability as evidenced by: BP and PR – within client’s acceptable range and adequate for metabolic demands Adequate UO Mental alertness Clear lungs o auscultation Palpable peripheral pulses CLDomocmat 8/9/2012 56
  57. 57. Potential for heart failure (HF) Manage L ventricular failure Assess and monitor Classfication of Post MI HF (Killip I, II, III, IV) Relieve pain Decrease myocardial O2 reqt Morphine O2 Intra-aortic balloon pump Immediate reperfusion (L sided heart cath; PTCA, CABG) CLDomocmat 8/9/2012 57
  58. 58. Potential for heart failure (HF) Manage R ventricular failure Enhance R ventricular preload IFI – as much as 200 ml/hr Monitor CO Note: prevent dev L side HF : Aucultate lungs PAWP CLDomocmat 8/9/2012 58
  59. 59. Decreased Cardiac output Heart Failure is a relatively common complication after an MI results from left ventricular dysfunction, rupture of the intra-ventricular septum, intra- papillary muscle rupture with valvular dysfunction or cardiogenic shock CLDomocmat 8/9/2012 59
  60. 60. Medical Management for Killip IV Goal is to relieve pain and decrease myocardial O2 demand through preload and possibly after load reduction1. IV morphine2. O2 therapy – intubation and mechanical ventilation3. Preload reduction – nitroglycerin, nitroprusside, nitroprusside, diuretics – monitor BP constantly4. Vasopressor and Inotropes – dopamine, dobutamine – used to maintain organ perfusion but can increase O2 consumption and can worsen ischemia5. IABP CLDomocmat 8/9/2012 60
  61. 61. Intra-Intra-aortic Balloon Pump (IABP) used when clients do not respond to drug therapy invasive intervention that is used to improve myocardial perfusion during an acute MI, reduce after load and facilitate left ventricular emptying inflation of balloon during diastole increases diastolic pressure and improves coronary perfusion deflation of the balloon before diastole reduces after load at the time of systolic contraction CLDomocmat 8/9/2012 61
  62. 62. CLDomocmat 8/9/2012 62
  63. 63. ☺ Let’s watch how it works! Video animation of IABPYouTube - IABP Intraaortic Ballon Pump.flv Video of IABP in G:E CARMELA OR video downloadsvideos cardi public/documents/image/ucm064550.gif CLDomocmat 8/9/2012 63
  64. 64. IABP: IABP What precautions to take? See handout sun/news/printer.cfm?id=602 CLDomocmat 8/9/2012 64
  65. 65. PAWP CLDomocmat 8/9/2012 65
  66. 66. Thromboembolism:Thromboembolism: Pulmonary Embolismr/t phlebitis of the leg & pelvic veins CLDomocmat 8/9/2012 66
  67. 67. CLDomocmat 8/9/2012 67
  68. 68. Collaborative Management Anticoagulants Thrombolytics Move legs, avoid placing pressure under the knees, elastic stockings Early ambulation Observe for signs and symptoms indicative of pulmonary embolism Sudden onset of dyspnea Chest pain Coughing Hemoptysis Rapid weak pulse Pallor CLDomocmat 8/9/2012 68
  69. 69. Pericarditis 28% of post MI patients 2-4 days post MI inflamed areas of infarction rubs against the pericardial surface causing it to lose lubricating fluid CLDomocmat 8/9/2012 69
  70. 70. Pericarditis Dressler’s syndrome (Late Pericarditis)- 6 Pericarditis) weeks to months after MI The client presents with fever lasting 1 week or longer, pericardial chest pain, pericardial friction rub, and occasional pericardial effusion self limiting Bed rest, aspirin, prednisone, opioid analgesics CLDomocmat 8/9/2012 70
  71. 71. Rupture of the myocardiumMitral Regurgitation,VSD and VentricularAneurysm CLDomocmat 8/9/2012 71
  72. 72. Mitral Regurgitation ,VSD andVentricular Aneurysm MR due to rupture of papillary muscle of LV thinning , ballooning and hypokinesia of the left ventricular wall after a transmural MI the dysfunctional area often becomes filled with necrotic debris and clot CLDomocmat 8/9/2012 72
  73. 73. Mitral Regurgitation ,VSD andVentricular Aneurysm the aneurysm may rupture causing cardiac tamponade and death usually 7-10 days post MI 7- report presence of new murmur PVC’s- PVC’s- due to irritability of necrotic tissue CLDomocmat 8/9/2012 73
  74. 74. Management arteriolar vasodilation - to lower systemic pressure IABP surgery- surgery- 4-6 weeks post MI excise ventricular aneurysm replace mitral valve repair VSD pericardiocentesis for tamponade CLDomocmat 8/9/2012 74
  75. 75. SURGICAL TREATMENT CLDomocmat 8/9/2012 75
  76. 76. Surgical Treatment PCI or PTCA Coronary artery Bypass graft surgery Off-pump Coronary Artery Bypass Minimally invasive Direct coronary artery bypass Transmyocardial Laser revascularization Open heart surgery CLDomocmat 8/9/2012 76
  77. 77. Percutaneous CoronaryInterventions (PCI) CLDomocmat 8/9/2012 77
  78. 78. PCI AKA: Percutaneous transluminal coronary angioplasty Balloon angioplasty Laser with balloon angioplasty Stent Atherectomy Brachytherapy CLDomocmat 8/9/2012 78
  79. 79. PTCA an invasive procedure used to eliminate stenosis in the coronary arteries by insertion a catheter through the skin and moving forward through the veins. At the last stage,a balloon catheter is inserted in the coronary arterial lesion and the balloon is inflated at the level of occlusion to open the lumen CLDomocmat 8/9/2012 79
  80. 80. PTCA: types1. Percutaneous Coronary Laser Angioplasty or Laser with balloon angioplasty2. Placement of Percutaneous Coronary Stent3. Percutaneous Coronary Atherectomy4. Brachytherapy CLDomocmat 8/9/2012 80
  81. 81. CLDomocmat 8/9/2012 81
  82. 82. Angioplasty stent CLDomocmat 8/9/2012 82
  83. 83. PTCA: Lasers with balloonangioplasty creates a smoother lumen of the blood vessel Video:Lasers angioplasty CLDomocmat 8/9/2012 83
  84. 84. PTCA: Directional coronaryatherectomy G:E CARMELA Atherectomyvideo downloadsvideos cardi video CLDomocmat 8/9/2012 84
  85. 85. Nursing Management Same Preop prep Consent for procedure NPO 8 hrs Skin prep – shave bilateral groins etc CLDomocmat 8/9/2012 85
  86. 86. Nursing Management: Post-op VS, monitor for complications (AMI,Spasm) Assess for development of crackles, wheezes, tachypnea, frothy sputum, S3 heart sound Administer medications as ordered Anti-coagulation with aspirin/heparin SL Nifedipine – to prevent coronary spasm Glycoprotein IIb/IIIA – prevent restenosis CLDomocmat 8/9/2012 86
  87. 87. Nursing Management: Post-op Monitor for signs of poor organ perfusion Change in LOC Oliguria Cool, clammy extremities with decreased pulses Unusual fatigue Recurrent chest pain Monitor right atrial pressure , pulmonary artery wedge pressure (measure of preload) by using the Swan Ganz catheter if < 18mmHg do volume infusion or administer inotropes CLDomocmat 8/9/2012 87
  88. 88. Nursing Management Nursing care of client having PCI Adobe Acrobat Document CLDomocmat 8/9/2012 88
  89. 89. Coronary artery Bypass graftsurgery (CABG) CLDomocmat 8/9/2012 89
  90. 90. CABG bypass of a blockage in artery use of saphenous vein or internal mammary artery (graft of choice because it has a 90% patency rate after the procedure) reduces 80-90% of symptoms 80- indicated when clients do not respond to medical management of CAD or when disease progression is evident cardiopulmonary bypass needed CLDomocmat 8/9/2012 90
  91. 91. CABG G:E CARMELA G:E CARMELA video downloadsvideos cardi video downloadsvideos cardi Let us watch! Let us watch! Animation of Heart Bypass CABG in the OR Surgery (CABG) CLDomocmat 8/9/2012 91
  92. 92. Heart-lung bypass machine orExtracorporeal circulation (ECC) CLDomocmat 8/9/2012 92
  93. 93. Heart-lung bypass machine orExtracorporeal circulation CLDomocmat 8/9/2012 93
  94. 94. Heart-lung bypass machine orExtracorporeal circulation(ECC) CLDomocmat 8/9/2012 94
  95. 95. CLDomocmat 8/9/2012 95
  96. 96. CLDomocmat 8/9/2012 96
  97. 97. CLDomocmat 8/9/2012 97
  98. 98. Nursing care of client undergoing CABG Adobe Acrobat Document CLDomocmat 8/9/2012 98
  99. 99. Off-pump Coronary ArteryBypass (OPCAB) "beating heart" surgery CLDomocmat 8/9/2012 99
  100. 100. OPCAB CLDomocmat 8/9/2012 100
  101. 101. OPCAB CLDomocmat 8/9/2012 101
  102. 102. Minimally Invasive DirectCoronary Artery Bypass(MIDCAB) CLDomocmat 8/9/2012 102
  103. 103. Minimally invasive Directcoronary artery bypass(MIDCAB) indicated for clients with a lesion of the left anterior descending artery left thoracotomy incision with removal of 4th rib dissection of the left IMA and attached to the still beating heart below the level of the lesion in the LAD no cardiopulmonary bypass needed CLDomocmat 8/9/2012 103
  104. 104. CLDomocmat 8/9/2012 104
  105. 105. CLDomocmat 8/9/2012 105
  106. 106. TECAB Totally Endoscopic, Minimally Invasive Coronary Bypass Surgery : High- Precision Robotic Surgery Without any Opening of the Chest The da Vinci robots "wristed" instruments provide a greater range of motion than the human hand while eliminating physician tremor. CLDomocmat 8/9/2012 106
  107. 107. TECAB CLDomocmat 8/9/2012 107
  108. 108. TransMyocardialLaser Revascularization(TMLR) Laser ablation CLDomocmat 8/9/2012 108
  109. 109. TMLR a procedure used to relieve severe angina or chest pain in very ill patients who arent candidates for bypass surgery or angioplasty. Procedure a surgeon makes an incision on the left breast to expose the heart. Then, using a laser, the surgeon drills a series of holes from the outside of the heart into the hearts pumping chamber. From 20 to 40 mm laser channels are placed during the procedure. Bleeding from the laser channels on the outside of the heart stops after a few minutes of pressure from the surgeons finger. In some patients TMR is combined with bypass surgery. In those cases an incision through the breastbone is used. 109 CLDomocmat 8/9/2012
  110. 110. TMLR How does it work? How TMR reduces angina still isnt fully understood. The laser may stimulate new blood vessels to grow, called angiogenesis It may destroy nerve fibers to the heart, making patients unable to feel their chest pain. The heart feeds itself by taking blood from within its chambers, just like in reptiles, whose hearts have no coronary arteries. CLDomocmat 8/9/2012 110
  111. 111. Indications people who are high-risk candidates for a second bypass or angioplasty. people whose blockages are too diffuse to be treated with bypass alone. some patients with heart transplants who develop atherosclerosis after their transplant. CLDomocmat 8/9/2012 111
  112. 112. TMLR: Before CLDomocmat 8/9/2012 112
  113. 113. TMLR: After CLDomocmat 8/9/2012 113
  114. 114. TMLR CLDomocmat 8/9/2012 114
  115. 115. Transmyocardial revascularization G:E CARMELA video downloadsvideos cardiAn animation of the transmyocardialrevascularization procedure CLDomocmat 8/9/2012 115
  116. 116. Other sources Cardiac surgery/Open heart surgery Atherosclerosis =related Heart Attack e=channel Coronary Artery Angioplasty (PCI, Heart Stent Surgery) eature=related CLDomocmat 8/9/2012 116
  117. 117. ETC… CLDomocmat 8/9/2012 117
  118. 118. Cardiac tamponade is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle (myocardium) and the outer covering sac of the heart (pericardium). Cardiac tamponade is a condition involving compression of the heart caused by blood or fluid accumulation in the space between the myocardium (the muscle of the heart) and the pericardium (the outer covering sac of the heart). Blood or fluid collects within the pericardium. This prevents the ventricles from expanding fully, so they cannot adequately fill or pump blood. Cardiac tamponade is an emergency condition that requires hospitalization. CLDomocmat 8/9/2012 118
  119. 119. CLDomocmat 8/9/2012 119
  120. 120. pulsus paradoxus an abnormal inspiratory decrease in arterial blood pressure, seen in cardiac tamponade and caused by a decreased pulmonary venous return. CLDomocmat 8/9/2012 120
  121. 121. inotropic agent any of a class of agents affecting the force of muscle contraction, particularly a drug affecting the force of cardiac contraction; positive inotropic agents increase, and negative inotropic agents decrease the force of cardiac muscle contraction. CLDomocmat 8/9/2012 121
  122. 122. Drugs affect the function of the heart in three main ways. They can affect the force of contraction of the heart muscle (inotropic effects); they can affect the frequency of the heartbeat, or heart rate (chronotropic effects); or they can affect the regularity of the heartbeat (rhythmic effects). CLDomocmat 8/9/2012 122
  123. 123. Inotropic agentsA drug may be classified by the chemical type of the active ingredient orby the way it is used to treat a particular condition. Each drug can beclassified into one or more drug classes.Inotropic agents affect the contraction of the heart muscle. Positiveinotropes stimulate and increase the strength of heart musclecontraction causing the heart rate to increase. Negative inotropicagents weaken the force of muscular contractions.Inotropic state depends on the amount of calcium in the cytoplasm ofthe heart muscle wall, as contractility of the heart depends on control ofintracellular calcium i.e. control of calcium entry into the cell membraneand calcium storage in the sarcoplasmic reticulum. The main factorscontrolling calcium entry are activity of voltage gated calcium channelsand sodium ions, which affects calcium/sodium ion exchange.Positive inotropes usually increase the level of intracellular calcium andnegative inotropes decrease it. CLDomocmat 8/9/2012 123
  124. 124. Inotropic agents Digoxin Dobutamine Milrinone CLDomocmat 8/9/2012 124
  125. 125. pulsus paradoxus also paradoxic pulse or paradoxical pulse, is defined as an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg or 10 torr. When the drop is more than 10mm Hg, it is referred to as pulsus paradoxus. has nothing to do with pulse rate or heart rate. The normal variation of blood pressure during breathing/respiration is a decline in blood pressure during inhalation/inspiration and an increase during exhalation/expiration. is a sign that is indicative of several conditions, including cardiac tamponade, pericarditis, chronic sleep apnea, croup, and obstructive lung disease (e.g. asthma, COPD). CLDomocmat 8/9/2012 125
  126. 126. CTT CLDomocmat 8/9/2012 126
  127. 127. CLDomocmat 8/9/2012 127
  128. 128. CLDomocmat 8/9/2012 128
  129. 129. Pleur-evacⓇAdult/Pediatric ChestDrainage Model A-6000. The Pleur-evacChest DrainageSystems have been theworlds most popularunits since theirinception in 1967.(Courtesy of Deknatel,Inc., Fall River, MA.) CLDomocmat 8/9/2012 129
  130. 130. 1. Standard percutaneous access to thevenous system is performed. CLDomocmat 8/9/2012 130
  131. 131. 2. The Trellis catheter is advanced throughthe clot over a standard 0.035" guidewire. CLDomocmat 8/9/2012 131
  132. 132. 3. The distal occluding balloon is inflated. CLDomocmat 8/9/2012 132
  133. 133. 4. After the proximal occluding balloon isinflated, delivery of the thrombolytic agentbegins. CLDomocmat 8/9/2012 133
  134. 134. 5. The Trellis dispersion wire is activated withthe motor drive unit. CLDomocmat 8/9/2012 134
  135. 135. 6. Clot dispersion continues. CLDomocmat 8/9/2012 135
  136. 136. 7. After clot is dispersed, remaining materialis aspirated through the Trellis catheter. CLDomocmat 8/9/2012 136
  137. 137. 8. The Trellis catheter and guidewire arewithdrawn when treatment is complete. CLDomocmat 8/9/2012 137
  138. 138. CLDomocmat 8/9/2012 138