Groin management 2013


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The management and prevention of groin complications post cardiac catheterization procedures. Let's get back to the BASICS.

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Groin management 2013

  1. 1. Prevention and Treatment Of Groin Complications Presented By Jacob Mason CIS
  2. 2. Anatomy
  3. 3. Angiographic anatomy The optimal puncture site for femoral artery access is 1-2 cm below the inguinal ligament.
  4. 4. The boney area is use to help achieve hemostasis by giving you a solid foundation to compress the femoral.
  5. 5. Bleeding Vascular complications are a major preventable cause of morbidity and mortality from invasive cardiac procedures.
  6. 6. Is bleeding really an issue?  Bleeding is the most common complication seen post PCI’s.  90% of bleeding occurs at the access site.  The most common access site complication is a hematoma.  Femoral access complication rates are 1.0% for diagnostic and 4% for interventional procedures
  7. 7. Bleeding type  Lower the head of the bed for better control of bleeding ( Femoral artery anatomically goes deeper. )  Sterilely apply light manual pressure approximately 5-8 minutes Uncomplicated “oozing” ( Bleeding from small capillaries or tissue ) Nuisance Treatment:
  8. 8. “Bleeding”  Manual compression must be applied to prevent further enlargement of hematoma.  Assign someone to call the physician while you hold pressure or vise versa.  Mark the boundaries of the hematoma to monitor growth and effectiveness. Controlled Pressure Bleeding type Treatment:
  9. 9. Symptoms and Causes
  10. 10.  Pain at the groin or lower back  Swelling at the insertion site ( Hematoma )  Numbness in leg of sheath insertion  Loss of pedal pulse in affected leg  Tingling odd sensation in the leg with the puncture Most common signs and symptoms
  11. 11.  Increased blood pressure Ineffective closure device  Ineffective hemostasis achieved from manual pressure  Need to urinate  Obesity  Pharmaceutical therapy  Advanced age decreasing vessel elasticity  A rapidly falling hematocrit post catherization Possible causes
  12. 12. High-Risk Patients The common risk factors and predictors for complications:  Age  Diabetes  Female gender  Morbid obesity  Uncontrolled hypertension  Large sheath size  Out patients
  13. 13. Vascular Complications
  14. 14.  Hematoma: Blood collects in soft tissue  Psendoaneurysm: A dilation of an artery with actual disruption of one or more layers of its walls.  Arteriovenous Fistula ( AV ): A direct communication forms between an artery and a vein.  Retroperitoneal Bleed ( RPH ): The hematoma extends into the retroperitoneal space, which lies deep the abdominal cavity. Powerful vigorous anticoagulation is the cornerstone of acute interventional today, While the medications prevent blood from clotting in the culprit vessel, they also promote greater risk post operatively for the development of the vascular complications. Types of groin complications
  15. 15. Loss of blood under the skin directly as a result of arterial/venous injury. What is a hematoma? A hematoma is more than just a ”bruise” in that it forms a lump which hardens.
  16. 16. When does a hematoma becoming serious?  Distal pulses become diminished  Hematoma greater than 4cm x 5cm The area around the access site become firm.  Unable to control or manage bleeding  Physical appearance becomes the obvious
  17. 17. Hematoma Loss of blood under the skin directly as a result of arterial/venous injury. Treatment A “stable” hematoma may require no more than marking the boundries An “Unstable” hematoma • Direct pressure 1-2 cm superior, or inferior to the insertion site depending on the origin of bleeding, arterial or venous • Monitor vital signs
  18. 18. Retroperitoneal hematoma ( RPH ) Bleeding into retroperitoneal cavity
  19. 19. Treatment • Stop anti-coagulation medications • Fluid replacement • Blood transfusion • Surgical repair if hemodynamically unstable • Close and constant monitoring of patient Retroperitoneal hematoma ( RPH )
  20. 20.  May or may not see hematoma at site  Flank or lower back pain  Hypotension  Tachycardia  Abnormal hematocrit/hemoglobin  Diaphoresis  Abdominal distension Retroperitoneal hematoma ( RPH )
  21. 21. This 85-year-old woman was on anticoagulation therapy for PCI. Retroperitoneal hematoma ( RPH )
  22. 22. After the inferior epigastric artery the Illiac artery takes a dive.
  23. 23. Correct Hand Position
  24. 24. Access site Apply direct pressure 1-2 cm above site Hand position
  25. 25. Good Hand Position Correct Compression Method Incorrect You will find pressing down with your finger tips is less fatiguing. On the obese patient, you will not be able to get enough force down to the arteriotomy.
  26. 26.  Closure device  Sheath size  Anticoagulant ( Heparin or Angiomax )  Closing ACT  Puncture site issues  Vital signs Factors that can affect hemostasis
  27. 27. Safety is defined as the percentage of patients with major or minor vascular complications. Minor vascular complications are hematoma greater than 10 cm, arteriovenous fistulas, or pseudo aneurysm. Major vascular complications are death due to vascular complications, vascular repair, major vascular bleeding where hemoglobin level decreases more than 3 g/dL due to bleeding at the access site or retroperitoneal bleeding, vessel occlusion, and loss of pulse. Effectiveness is defined as the percentage of patients in whom the device was deployed successfully and the femoral artery was closed. Safety of manual compression versus closure device
  28. 28. Nick and spread technique used for deployment of the starclose
  29. 29. Angio- Seal The mechanism of closure devices Star Close
  30. 30. Assess Diagnose Intervene
  31. 31. Assess  Is the bleeding new or old?  Is it deteriorating into a more serious condition?  Are vital signs becoming compromised?  Do I need help?  Does your patient have some of the common risk factors and predictors for complications ?
  32. 32. Diagnose  Where is the bleeding originating? ( Artery VS Vein, Proximal VS Distal )  Why did the bleeding start? ( Elevated BP, need to urinate, non compliant patient )  Uncomplicated oozing? ( Is there oozing from a failed closure device, sub-que tissue bleeding  “ Frank “ bleeding “ ( Double wall stick, high grade stick, failed closure device, improper hand position )
  33. 33. Intervene  Appropriate intervention: “Uncomplicated oozing” “Frank bleeding”  Manual compression holds ( poor hand positions is one of the most common mistakes. )  Compression device ( Femstop )  Changing a saturated dressing  Vascular surgery
  34. 34. Key Points and Myths
  35. 35. Key points to remember regarding manual compression:  Firm occlusive pressure is not applied during the actual removal of the sheath to avoid dislodging any clot that may be present on the sheath.  Gradually lessening the pressure over the course of the compression time allows blood flow to distal anatomy.  If pressure is removed to evaluate the arteriotomy before the planned compression time is finished and oozing is observed, the original compression time should be extended by 50%.  If pressure is removed to evaluate the arteriotomy and pulsatile bleeding is observed, the planned compression time should start over.  A contributor to Vagel Response can also be the fear of pain, so keeping the patient calm and relaxed, and treating him/her gently, may also help.
  36. 36. Myths associated with groin management  The more pressure the better (This may cause distal embolism )  Using a step stool gives you better hemostasis ( Increase discomfort for patient as well as your wrist )  Using your fist is the best way to manage a hematoma ( It takes 50 lbs of pressure to achieve hemostasis)  More tape means more pressure (If you can’t visualize the area how do you manage it)  Patients have to lay completely flat while sheath is in place (Head can be elevated up to 35 degrees without causing complications)
  37. 37. Complications and reasons why we don’t seal every patient.
  38. 38. Profunda Bifurcation of the profunda and superficial femoral artery High Stick Sheath inserted above the inferior epigastric artery
  39. 39. Vessel size Calcium Femoral artery diameter here is less than 3 cm
  40. 40. Type A Dissection A tear in the wall of the iliacs that causes blood to flow between the layers of the wall. RFA Occluded from sheath Diseased and small right femoral artery
  41. 41. Femoral Puncture
  42. 42. Hemostat placement Femoral head Landmarks
  43. 43. Anatomical layout
  44. 44. Incorrect femoral artery puncture Entry site complications results from poorly placed femoral artery punctures. A. Too low has an increase chance of site thrombosis B. Deep femoral artery stick maybe difficult to compress C. The needle may disrupt plaque on posterior wall D. Puncture wall stick too proximal increases the chance of a retroperitoneal bleed
  45. 45. Transradial Procedure
  46. 46. Ulnar artery Is the blood vessel, with oxygenated blood, of the medial aspect of the forearm Radial artery is the main blood vessel with oxygenated blood of the lateral aspect of the forearm. Anatomic Review
  47. 47. Allen Test Is used to test blood supply to the hand. It is performed prior to cannulation
  48. 48. Allen’s test 1) The hand is elevated and the patient is asked to make a fist for about 30 seconds. 2) Pressure is applied over the ulnar and the radial arteries so as to occlude both of them. 3) Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the finger nails). 4) Ulnar pressure is released and the color should return in 7 seconds.
  49. 49. Both arteries are open Release ulnar with radial occluded Occlude both ulnar and radial
  50. 50. Diagnostic Release slowly over 60 minutes Post Cardiac Catherization Orders Intervention Release slowly over 90 minutes
  51. 51. zero tolerance Having a For bleeding
  52. 52. 4 x 6 resource flyer Cut out and laminate