CardiacCatheterizatio 7 n Central Venous Pressure
Definition: Cardiac catheterization (heart cath) is the insertion of a catheter into a chamber or vessel of the heart. This is done for both investigational and interventional purposes. This is a procedure to examine blood flow to the heart and test how well the heart is pumping.
Preparation: Patients should give the physician or nurse a complete list of their regular medications, including aspirin and nonsteroidal anti-inflammatory d (NSAIDs), because they can affect blood clotting. Diabetics who are taking either metformin or insulin to control their diabetes should inform the physician, as these drugs may need to have their dosages changed before the
Patients should also notify staffmembers of any allergies toshellfish containing iodine, iodineitself, or the dyes commonly usedas contrast agents before cardiaccatheterization.
Because cardiac catheterizationis considered surgery, thepatient will be instructed to fastfor at least six hours prior tothe procedure. A mild sedativemay be administered about anhour before the procedure tohelp the patient relax. If thecatheter is to be insertedthrough the groin, the areaaround the patients groin willbe shaved and cleansed with anantiseptic solution.
Goals: This technique has several goals: •confirm the presence of a suspected heart ailment •quantify the severity of the disease and its effect on the heart •seek out the cause of a symptom such as shortness of breath or signs of cardiac insufficiency •make a patient assessment prior to heart surgery
Investigative techniquesused with coronarycatheterization•to measure intracardiac andintravascular blood pressures•to take tissue samples for biopsy•to inject various agents for measuringblood flow in the heart; also to detectand quantify the presence of anintracardiac shunt•to inject contrast agents in order tostudy the shape of the heart vesselsand chambers and how they change as
Indications: Cardiac catheterization is performed to: • Diagnose or evaluate coronary artery disease • Diagnose or evaluate congenital heart defects •Diagnose or evaluate problems with the heart valves •Diagnose causes of heart failure or cardiomyopathy
The following may also be performedusing cardiac catheterization:•Repair of certain types of heart defects•Repair of a stuck (stenotic) heart valve•Opening of blocked arteries or grafts in the heart
Contraindications: o Renal insufficiency o Coagulopathy o Fever o Systemic infection o Uncontrolled arrhythmia or hypertension o Uncompensated heart failure o Radiopaque dye allergies in patients who have not been appropriately premedicated
Implementation: •The patient is placed supine on padded table and his heart rate and rhythm, respiratory status, and blood pressure are monitored throughout theprocedure. •An I.V. line is started, if not already in place, and a local anesthetic is injected at the insertion site. •A small incision is made into the artery or vein, depending on whether the test is for the left or right.
•The catheter is passed through thesheath into the vessel and guided usingfluoroscopy. •In the right-sided catheterization, the catheter is inserted into the antecubital or femoral vein and advanced through the vena cava into the right side of the heart and into the pulmonary artery.
•If left-sided heartcatheterization, the catheteris inserted into the brachialor femoral artery andadvanced retrogradethrough the aorta into thecoronary artery ostium andleft ventricle.•When the catheter is inplace, contrast medium isinjected to make visible thecardiac vessels andstructures.
•Nitroglycerin is givento eliminate catheter-induced spasm orwatch its effect on thecoronary arteries.•After the catheter isremoved, directpressure is applied tothe incision site untilbleeding stops, and asterile dressing isapplied.
Complications: •Heart attack or stroke •Abnormal heartbeat (cardiac arrhythmia) •Puncture of a blood vessel or of the heart •Bleeding, blood clot, or infection at the catheter insertion site •A blocked blood vessel in the arm or leg in which the catheter was inserted
•An allergic reaction to the X-ray dye•Ineffective endocarditis in apatient with vulvular heartdisease.•Myocardial infarction,arrhythmias, cardiactamponade, pulmonary edema,hematoma, blood loss, adversereaction to contrast media, andvasovagal response.
Because some of these problems may be life threatening, heart catheterization should always be done in a hospital that has thenecessary equipment andpersonnel to deal with any complications immediately.
Certain patients have a higher-than-average risk of complications. These include infants younger than 1 month, people older than 80 years, people with very poorheart function, and people with certain chronic illnesses, such as kidneyfailure, insulin-dependentdiabetes, and severe lung disease.
Nursing Responsibilities: •Monitor the patient’s heart rate and rhythm, respiratory and pulse rates, and blood pressure frequently. •Monitor the patient’s vital signs every 15 minutes for 2 hours after the procedure, every 30 minutes for the next 2 hours, and then every hour for 2 hours. •If no hematoma or other problems arise, begin monitoring every 4 hours. If vital signs are unstable, check every 5 minutes and notify the practitioner.
•Observe the insertion site for ahematoma or blood loss.Additional compression may benecessary to control bleeding.•Check the patient’s color, skintemperature, and peripheral pulsebelow the puncture site.•Enforce bed rest for 8 hours. Ifthe femoral route was used forcatheter insertion, keep thepatient’s leg extended for 6 to 8hours.
•If medications were withheld before the test, check with the practiotner about resuming their administration. •Administer prescribed analgesics. •Make sure a posttest ECG is scheduled to check for possible myocardial damage.
Definition: Blood from systemic veins flows into the right atrium; the pressure in the right atrium is the central venous pressure (CVP). CVP is determined by the function of the right heart and the pressure of venous blood in the vena cava.
Central venous pressure is considered adirect measurement of the bloodpressure in the right atrium and venacava. It is acquired by threading acentral venous catheter (subclaviandouble lumen central line shown) intoany of several large veins. It is threadedso that the tip of the catheter rests inthe lower third of the superior venacava. The pressure monitoring assemblyis attached to the distal port of amultilumen central vein catheter.
Materials: •Sterile pack and antiseptic solution •Local anaesthetic - e.g. 5ml lignocaine 1% solution •Appropriate CV catheter for age/route/purpose •Syringes and needles •Saline or heparinised saline to prime and flush the line after insertion •Suture material - e.g. 2/0 silk on a straight needle
•Sterile dressing•Shaving equipment for the area ifvery hairy (especially the femoral)•Facility for chest X-ray if available•Additional equipment required forCVP measurement includes:manometer tubing, a 3-waystopcock, sterile saline, a fluidadministration set, a spirit leveland a scale graduated incentimeters
Preparations: Assisting with CVP placement •Adhere to institutional Policy and Procedure. •Obtain history and assess the patient. •Explain the procedure to the patient, include: local anesthetic trendelenberg positioning draping limit movement need to maintain sterile field. post procedure chest X-ray
•Obtain a sterile, flushed and pressurizedtransducer assembly•Obtain the catheter size, style and lengthordered.•Obtain supplies: Masks Sterile gloves Line insertion kit Heparin flush per policy•Position patient supine on bed capable oftrendelenberg position•Prepare for post procedure chest X-ray
Factors Affecting CVP: - Systemic vasodilatation and hypovolaemia, which leads to reduced venous return in the vena cava and reduced RAP - Right ventricular failure - Tricuspid and Pulmonary valve disease - Pulmonary hypertension - Right ventricular dysfunction and pulmonary hypertension leads to raised right atrial pressure, as does tricuspid and pulmonary stenosis.
Indications: - Systemic vasodilatation and hypovolaemia, which leads to reduced venous return in the vena cava and reduced RAP - Right ventricular failure - Tricuspid and Pulmonary valve disease - Pulmonary hypertension - Right ventricular dysfunction and pulmonary hypertension leads to raised right atrial pressure, as does tricuspid and pulmonary stenosis.
Normal CVPMeasurements: - The normal CVP is between 5 – 10 cm of H2O (it increases 3 – 5 cm H2O when patient is being ventilated) - CVP normal range: - (2-5) mmHg - (3-8)cm H2O
Increase of CVP - Over hydration - Right-sided heart failure - Cardiac tamponade - Constrictive pericarditis - Pulmonary hypertension - Tricuspid stenosis and regurgitation - Stroke volume is high
Complications(Immediate): - Hemothorax - Pneumothorax: most common, noticed after CXR, “hypoxemia and absent breath sound” requires chest tube placement - Bleeding : More common in patients with coagulopathy“easily control femoral”
Nursing Responsibility: Insertion CVL - Patient position: - Patient is moved to the side of the bed so physician would not lean over - The bed is high enough so physician would not have to stoop over - Patient should be flat without a pillow, Trendelenburg position if patient is hypovolemic - The head is turned away from the side of the procedure - Wrist restraints if necessary
The Procedure- Skin preparation:- Prepare before putting sterile gloves- Allow time for the sterilizing agent todry- Drape:- Large enough and Handed sterilely bythe assistant- Hole in the area of placement- Prepare the tray:- Prepare the equipment before starting- Anesthesia:- Use local anesthesia with lidocaine
AFTER THE INSERTION- Dispose all sharps- Place an occlusive sterile dressing- Flush lumens to maintain patency- Obtain a chest x-ray (ask for order ifphysician doesn’t mention it)- Monitor site for bleeding- Assess breath sounds- Assess circulation- Assess for hematoma- Document insertion, site, dressing andflushing