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An Overview of Transradial Patient Set-up

An Overview of Transradial Patient Set-up

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  • 1. An Overview of TransradialPatient Set-upSusan R. Cooney RN, BSN, CCRNDurham VAMC Cardiac Catheterization LabDuke University School of Nursing
  • 2. Advantages of the TransradialApproach from a Nursing PerspectiveLess bleeding complications post-procedureSheath is removed by the operator immediately following theprocedureExpedites recovery time (usually 1-2 hr as opposed to 4-6 hrfor the femoral approach)Negates the need for nurse/tech to remove the sheathPatients can ambulate after the procedureReduces need for transfer assistancePatient can be taken to recovery in a wheelchair which reducesroom turn around time
  • 3. Transradial Set-upRequires very little additional time compared to femoral set-upProper set-up is essential for a successful caseFactors affecting set-up:patient size - girthability to maintain proper arm position (previous injury orprevious surgery to the arm that may affect the patient’sability to keep the arm flat or at the proper angle)
  • 4. Transradial Set-upThe first step in setting up the patient for a transradialcatheterization is performing an Allen’s testThe Allen’s test is essential to determine if the radial artery can besafely utilized during the procedureEnsure that your lab monitoring system is configured to displaythe pulse oximetry wave form as this is the most accurate way toverify the Allen’sTo eliminate confusion, classify the results of the Allen’s as normalor abnormal
  • 5. EquipmentEquipment
  • 6. EquipmentEquipment
  • 7. EquipmentEquipment
  • 8. Transradial Set-upThe “Banjo Board” is placed with the large end near the controlsThis is an extremely important step in the set-up processFailure to properly position this board could result in equipmentfalling from the tableThis could be critical during a PCIif there is a gap between the controls and the board it isdifficult to maintain a rail for device insertionbased on experience, the balloon inflation device and otherequipment can fall through the gap
  • 9. Proper board placement for right radialProper Board Placement for RightRadial
  • 10. Stabilization of the WristPlace the pediatric arm board on the dorsal side of the wristRoll the wash cloth and place it behind the wrist to slightlyhyperextend the wristSecure the arm to the board with the Co-banPlace the standard arm board beneath the upper armthis aids in keeping the arm close to the torso and addsstabilityplace towels on the board to enhance patient comfortmaintain a level surface
  • 11. Right radial set-upRight Radial Set-up
  • 12. Right radial set-upRight Radial Set-up
  • 13. Right radial set-upRight Radial Set-up
  • 14. Radial PreparationClip the hair on the radial area of the wristAlways prepare the right groin as a back up siteSaves time in the event that radial access is abortedMaintains sterilityPrepares the patient for the possibility of femoral accessCleanse the sites with Chloraprep
  • 15. Clip the siteClip the site
  • 16. Prep the sitePrep the site
  • 17. Protect the site while drapingProtect the Site While Draping
  • 18. Application of the femoral drapeApplication of the Femoral Drape
  • 19. Femoral drape modificationFemoral Drape Modification
  • 20. Application of the brachial drapeApplication of the Brachial Drape
  • 21. Drape applicationDrape Application
  • 22. Right radial set-upRight Radial Set-up
  • 23. Left Radial Set-upBasically the same as right radial set-up with modifications to thearm heightKeep in mind that the operator will remain at the right side of thepatient once access is obtainedThe height of the arm is an important factor for this reasonA stable platform is needed to support the armuse of 2 “Banjo Boards” is idealKeep the patient’s arm as close to the body as possibleLeft radial PCI cases are more challenging if the arm is notpositioned properly
  • 24. Arm board placementArm Board Placement
  • 25. Stabilization of the left armStabilization of the Left Arm
  • 26. Elevation of the left armElevation of the Left Arm
  • 27. Left radial set-upLeft Radial Set-up
  • 28. Draping of the left radialDraping of the Left Radial
  • 29. Left radial set-upLeft Radial Set-up
  • 30. Right Heart Cath via Venous Accessin the Right Upper ExtremityAdvantagesAlternative to femoral vein accesssheath pulled by the operatordoes not require the patient to remain in a supine positionpost-procedureless bleeding complicationspatient can be transported via wheelchair post-procedurecan be used in conjunction with a left heart cath via the rightor left radial
  • 31. Right Heart Set-upFirst step is to evaluate the patient’s arm for a possible IV siteSite should ideally be located in the medial area of the ACIV size should be 22 Gauge to 18 GaugeA more distal site may be chosenHave your operator evaluateA site that is too distal results in the inability to obtain a wedgepressure
  • 32. Right heart cath set-upRight Heart Cath Set-up
  • 33. Right heart cath set-upRight Heart Cath Set-up
  • 34. Right heart cath set-upRight Heart Set-Up
  • 35. Right heart cath set-upRight Heart Set-Up
  • 36. Right heart cath set-upRight Heart Set-Up
  • 37. Right heart cath set-upRight Heart Set-Up
  • 38. Right heart cath set-upRight Heart Set-Up
  • 39. Right heart cath set-upRight Heart Set-Up
  • 40. Right heart cath set-upRight Heart Set-Up
  • 41. Right heart cath set-upRight Heart Cath Set-Up
  • 42. Right heart / left heart cathRight Heart Cath/Left Heart Cath
  • 43. Right heart / left heart cathRight Heart Cath/Left Heart Cath
  • 44. Right heart / left heart cathRight Heart Cath/Left Heart Cath
  • 45. Right heart / left heart cathRight Heart Cath/Left Heart Cath
  • 46. Right heart / left heart cathRight Heart Cath/Left Heart Cath
  • 47. RecoverySheath is removed by operatorCompression device is applied to the radial site as the sheath isremovedThere are several compression devices availableThe compression device shown in the following slides is the TRBand by TerumoThe TR Band utilizes an air bladder that is inflated with aprovided syringe
  • 48. TR Band application - right radialTR Band Application- RRA
  • 49. TR Band application - left radialTR Band Application- LRA
  • 50. Recovery OrdersVital signs every 15 min x 4, every 30 min x 2, then 1 hr until postsheath removallisten for bruits at the access siteAssess for sensation and briskness of capillary refill in the distalfingers and nail beds Q 15 min until the TR Band is removed
  • 51. Recovery - Air Release OrdersFor interventional proceduresAir removal can begin 90 min after sheath removalRelease 3 ml every 15 min until the air bladder is emptyIf bleeding occurs air should be injected in increments of 3 mluntil hemostasis is achieved. Once bleeding has stopped, theTR Band deflation process can recommence after 30 minOnce the TR band is empty of air it can be removed and anocclusive dressing applied to the siteIt is also recommended to keep the arm secured to thepediatric arm board until the TR Band has been removed
  • 52. Recovery - Diagnostic ProcedureAll orders the same except that air removal can begin 30 min afterthe procedure rather than 90 min
  • 53. Post TR Band RemovalPatients may be discharged/transferred after TR Band removalLimit bending of the affected wrist for 24 hrNo lifting greater than 5 pounds with the affected wrist for 24 hrNo driving for 24 hrMany facilities have same-day discharge protocols for transradialinterventional patients: reduce length of stay
  • 54. Final PointsTransradial advantagesSet-up requires very little additional time when compared tofemoral cases once a routine is establishedAllows the patient to be transported to recovery via wheelchairAllows the patient to ambulate much earlier than femoral accessFaster room turn around timesLess bleeding complicationsNo time consuming sheath pullsDecreased overall recovery time / length of stay
  • 55. Final PointsRight heart cath via right upper extremity venous accessAllows the patient to sit up immediately post-procedureSheath is removed by the operatorAllows for transfer via wheelchairLess bleeding complicationsAllows for early ambulationDecreased overall recovery time