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Nursing guidelines

Care of the patient post cardiac catheterisation



  • Introduction

    Cardiac catheterisation involves the insertion of a catheter into a vein or artery, usually from a groin or jugular access site, which is then guided into the heart. This procedure is performed for both diagnostic and interventional purposes. Diagnostic catheters are used to assess blood flow and pressures in the chambers of the heart, valves and coronary arteries and to assist in the diagnosis and management of congenital heart defects. Interventional catheters are used as an alternative to open-heart surgery when possible and are involved in closing ventricular and atrial septal defects via catheter device closure, expansion of narrowed passages (pulmonary stenosis), stent placement, ablation of abnormal electrical pathways and widening of existing openings (balloon atrial septectomy).   

    Aim

    To provide nurses with the knowledge and skill set to competently care for a patient post cardiac catheterisation.

    Definition of Terms 

    • Arrhythmia: a general term that refers to any type of abnormal, irregular, or disorganized heartbeat.
    • Bruit: A sound heard over an artery, reflecting turbulent flow.
    • CRT: capillary refill time
    • Diaphoresis: state of perspiring profusely.
    • Ecchymosis (or bruising): The passage of blood from ruptured blood vessels into subcutaneous tissue, marked by a purple discoloration of the skin
    • Hematoma: a collection of blood outside a blood vessel. It occurs when the wall of an artery, vein or capillary, has been damaged and blood has leaked into the surrounding tissue
    • Ipsilateral: occurring on the same side of the body.
    • Pseudo aneurysm: a hematoma that forms as the result of a leaking hole in an artery.  It presents as a pulsatile mass, sometimes with a systolic bruit
    • Retroperitoneal hematoma: accumulation of blood in the retroperitoneal space.
    • Retroperitoneal Space: Region between posterior parietal peritoneum and front of lumbar vertebrae
    • Systolic bruit: an abnormal sound heard during systole.
    • Thrombus: a blood clot formed within the vascular system of the body which impedes blood flow distal to the clot.

    Assessment

    Refer to RCH Nursing Guideline: Nursing Assessment.

    History

    Include the following when taking the history of a child post cardiac catheterisation:

    • Identify if the patient has an existing cardiac condition
      • Patients with a known cyanotic or complex cardiac condition are at higher risk of complications.
    • Age of patient
      • There is a higher risk of complications in children less than 1 year of age.
    • Identify “normal” cardiac rhythm for the patient by referring to pre-procedure ECG’s
      • Sinus rhythm indicates normal cardiac conduction, but children born with extra conduction pathways or congenital cardiac defect are likely to show abnormal ECG patterns which for them is essentially their ‘norm’.
    • Identify whether the patient had a diagnostic or interventional cardiac catheter.
      • Interventional catheters have a significantly higher rate of complications compared to diagnostic cardiac catheters.
    • Identify access site (position and whether arterial or venous).
    • Check if the patient has been on anticoagulation.
      • If anticoagulants have been administered pre catheterisation the patient is at higher risk of bleedin
      • Most patients (except for patients undergoing heart biopsy) will have received a Heparin bolus during the procedure. 
    • Complete EMR review:
      • Identify if the patient had any complications during theater or in recovery. If bleeding occurred what intervention was implemented to achieve haemostasis
      • Review the findings of the catheter procedure in the theatre notes.
      • Ascertain what medications have been administered or ordered. 

    Routine Management

    On arrival to ward

    Assess and record patient observations - these should include: 

    • Observations as per the RCH Nursing Guideline: RPAO
    • Assess puncture sites, neurological and neurovascular observations with RPAO, then hourly until ambulation. Reassess site after first ambulation and then a minimum of 4 hourly prior to discharge
    • Ensure patient is continuously monitored with HR, RR and SpO2, including overnight. Monitoring can cease in the morning. 
    • The patient is required to remain on bed rest for:
      • 4 hours for a diagnostic catheterisation.
      • 6 hours for an interventional catheterisation.   
        Note: The patient is permitted to move side to side or raise bed head angle while on bed rest to increase comfort. For younger patients it may be difficult to keep them supine for a period of 4-6 hours; they can sit up in bed, sit on the parents lap or be carried, but they should not weight bare or ambulate
    • Pressure dressing should remain intact until instructed by cardiology (usually the following day prior to discharge).
    • Provide regular analgesia as ordered.
    • Maintain a strict fluid balance chart. Particularly take note of urine output; the contrast dye used in cardiac catheter can be nephrotoxic and acute kidney injury has been associated with arterial access.

    Anticoagulation post cardiac catheterisation

    Aspirin may be ordered for device closures - be aware if the medical team has requested such medications and when it should be commenced.

    • Heparin infusion post procedure is dependent on
    • If the patient was on anticoagulation (e.g.: Warfarin) pre-procedure. A heparin infusion will commence to assist the patient returning to therapeutic coagulation levels
    • An issue has occurred during cardiac catheter that increases the risk of clots or concerns of limb compromise.

    Assessment and Management of Complications 

    In relation to the list of complications above when caring for a patient post a cardiac catheter, please escalate appropriately with either:

    • Rapid Review: Cardiology Reg #52609 OR Cardiology resident #52708 or #52709
      After hours: Speciality Reg #52183
      • The cardiac catheterisation fellow can also be contacted for review in hours on pager #5719
    • MET call:  22 22, building, floor, ward, room number, department

    Complications

    • Varying acute haemodynamic complications associated with general anaesthetic
    • Vessel damage – can ultimately compromise the growth and function of the affected limb and complicate future catheter procedure
    • Infection – assess site for heat, pain and redness. Also assess for other signs of infection including an increase in temperature, tachycardia and rigors
    • Ecchymosis – assess skin around puncture site for purple discolouration.
    Complication Assessment Management
    Haematoma Assess for discolouration, redness, swelling and pain. Mark the size with a pen if possible

    ●       If the patient has a heparin infusion, stop infusion. 

    ●       Apply manual compression over the hematoma, followed by a pressure dressing to prevent further bleeding.

    ●       Assess for signs of intravascular volume depletion- tachycardia, widening pulse pressure, hypotension, decreased peripheral perfusion, delayed CRT, agitation. 

    ●       Auscultate or palpate hematoma for presence of pulse and a systolic bruit which indicates a pseudo aneurysm.

    ●       Notify medical team
    Bleeding Check pressure dressing for any oozing or bleeding from puncture site and mark the size of bleed if possible

    ●     Lie patient supine, elevate limb and apply pressure above puncture site with gauze to achieve hemostasis. Hemostasis should occur within 5-10 minutes.

    ●     If the patient has a heparin infusion, stop infusion. 

    ●     Reinforce pressure bandage.

    ●     Notify medical team

    ●     If unable to achieve hemostasis and patient symptomatic, escalate to a MET

    Arrhythmia Assess patient’s ECG rhythm on the cardiac monitor. Ensure patient is in sinus rhythm or is in a rhythm deemed normal for the patient

    ●     Assess patient’s cardiac output- BP, peripheral perfusion, color and alertness

    ●     If insufficient cardiac output seek urgent medical assistance by calling a MET

    ●     Print rhythm strip or complete an ECG if patient is stable

    ●     Continue cardiac monitoring

    ●     Notify medical team
    Thrombus

    Assess limb for color, warmth, CRT, pulse strength, sensation, movement and pain:

    ●     Venous Clot - the affected limb will appear red and swollen, and the patient will have an increase in pain levels and delayed CRT due to blood pooling.

    ●     Arterial Clot - the affected limb will appear pale and cool and have diminished or absent pulses distal to the insertion site; additionally there may be decreased sensation and delayed CRT due to lack of supply of arterial blood.

    ●     Request rapid review or escalate to a MET if immediate concern about perfusion to limb

    ●     +/- Doppler ultrasound to confirm clot

    ●     Antithrombotic agent as ordered by the medical team. First line of treatment for an occluded vessel is a heparin infusion
    Retroperitoneal Bleeding

    Bradycardia, tachycardia, hypotension, widening pulse pressure, and decreased peripheral perfusion are signs of retroperitoneal bleeding

    Assess for abdominal pain, groin pain, back pain and diaphoresis

    ●       Retroperitoneal hematomas are ipsilateral to the puncture site so pain on the same side of the access site needs further investigation

    ●       Notify medical team

    ●       Bloods: FBE and Blood group and antibody screen. 

    ●       Continuous monitoring

    ●       +/- CT scan

    ●       +/- Blood product transfusion
    Stroke

    Neurological observations should be performed at least 4 hourly (after RPAO) or more frequently if complicated with a thrombus post cardiac catheter

    ●       The risk of arterial ischemic stroke increases in a patient complicated with an intracardiac thrombus in the left atrium, and/or thrombus in the superior or inferior vena cava in those with single ventricle physiology

    If stroke is suspected, call a MET and follow the code stroke pathway. While waiting for assistance, prevent patient injury and aim to maintain airway.

    RCH Policies and Procedure: Code Stroke

    Investigations 

    In children who undergo diagnostic cardiac catheters no investigations are typically required unless complications are suspected.

    For interventional cardiac catheters the following investigations are required the morning prior to discharge:

    • Chest x-ray: Required for device closures prior to discharge.
    • ECHO: Required for interventional catheters prior to discharge.
    • ECG: Required for interventional catheters prior to discharge or if an arrhythmia is suspected.

    Companion Documents

    Parent Information: A parent handout will be given to parents or carers at their cardiology clinic outpatient appointment

    Further information can be found on the Cardiology webpage and intranet. 

     

    Evidence Table 

    Reference 

    Source of Evidence 

    		 Key findings and considerations 
    Chair, S., Yu, M., Choi, K., Wong, E., Sit, J., & Ip, W. (2012). Effect of early ambulation after transfemoral cardiac catheterization in Hong Kong: a single-blinded randomized controlled trial. Anadolu Kardiyoloji Dergisi: AKD = The Anatolian Journal Of Cardiology, 12(3), 222- 230. Randomized single-blinded controlled trial 
    • Ambulation at 4 hours post cardiac catheter significantly reduced patients’ back pain compared to ambulation at 12 hours. 
    • Ambulation at 4 hours post cardiac catheter significantly reduced patients’ urinary discomfort compared to ambulation at 12 hours. 
    • Ambulation at 4 hours post cardiac catheter significantly increased general well-being compared to ambulation at 12 hours. 
    • Ambulation at 4 hours post cardiac catheter had no significant difference on puncture site pain or satisfaction level of patients. 
    • Ambulation at 4 hours post cardiac catheter caused no significant increase in puncture site bleeding and therefore does not increase the risk of bleeding.   

      Wilcoxson, V. L. (2012). Early Ambulation After Diagnostic Cardiac Catheterization via Femoral Artery Access. Journal For Nurse Practitioners, 8(10), 810-815.  Pilot study
      • Early mobilization of 2-3 hours after diagnostic cardiac catheterisation via the femoral artery does not significantly increase the risk of vascular complications.  
      • Early ambulation (2-3 hours compared to 6 hours) has beneficial results on patient comfort and satisfaction and reduces hospital costs. 

      Yilmazer, M., Ustyol, A., Güven, B., Oner, T., Demirpençe, S., Doksöz, O., & ... Tavli, V. (2012). Complications of cardiac catheterization in pediatric patients: a single center experience. The Turkish Journal Of Pediatrics, 54(5), 478-485. 
      		 Retrospective study
      • The incidence of complications from all cardiac catheters was 6.2%.
      • The most common complications were arterial thrombosis and transient arrhythmias.
      • The incidence of complications post interventional cardiac catheters was higher (9.7%) when compared to diagnostic cardiac catheters (5.4%).
      • Younger age, particularly < 1 year of age, is the strongest predictor of the development of any complication (p=0.02). 
      • Among the 32 complications, arrhythmias were the most common (41%). The two major arrhythmia complications were ventricular tachycardia and complete atrioventricular block. Other arrhythmias included persistent ST elevation, supraventricular tachycardia, sinus bradycardia, and bundle branch block. 
      • The risk of complications was independently increased if the patient was <1 year of age, <5 kg or had an interventional procedure.
      • There was no significant association between gender and complications.   

        Amoozgar, H; Naghshzan, A; Edraki, M.R; Jafari, H; Ajami, G.H; Mohammadi, H; Mehdizadegan, N; Borzouee, M & Kambiz, K (2019). Arterial and Venous Complications Early after Cardiac Catheterization in Children and Adolescents: A Prospective Study. Iran Journal of Pediatrics, 29(5); 1-9. Prospective study
        • Of the total 179 vascular access performed 70% of cases were interventional procedures.  
        • 17 arterial and 16 venous events occurred, 4% and 5% of them respectively, were more serious. 
        • The more serious arterial complications were dissection, pseudo-aneurysm and fistula, whereas in venous access they were pseudo-aneurysm and thrombosis. 
        • The incidence of more serious complications was highest among patients younger than 1 year of age.
        Brotschi, B; Hug, M.I; Kretschmar, O; Rizzi, M & Albisetti, M. (2015). Incidence and predictors of cardiac catheterisation-related arterial thrombosis in children. Heart, 101: 948-953. Observational study
        • Arterial thrombosis occurred in 14 children; 12 of the cases were in infants less than 12 months and 2 in older children.  
        • Overall younger age (p<0.01) and low body weight (p<0.004) were significantly associated with an increased risk of arterial thrombosis. 
        • Cyanotic cardiac disease (p-0.07) showed a trend towards increased thrombotic risk.
        • When decreased limb perfusion was suspected, doppler ultrasound was utilised
        Harrar, D.B; Salussolia, C.L; Vittner, P; Danehy, A; Sen, S; Whitehill, R; Chao, J.H; Bernson-Leung, M.E & Rivkin, M.J (2019). Stroke after Cardiac Catheterization in Children. Pediatric Neurology, 100, 42-48. Retrospective review
        • 20 children, with a median age of 1 year, had a new clinically-apparent post-catheterization arterial ischemic stroke.
        • Stroke commonly occurred after balloon dilation for pulmonary vein stenosis and systemic pulmonary collateral closure.
        • Most common presenting symptoms were weakness and seizure.
        Krasemann, T. (2015). Complications of cardiac catheterisation in children. Heart, 101: 915 Editorial
        • Interventional cardiac catheterisation seems to have higher complication rate than diagnostic procedures
        • Severe complications include death, cerebral infarction, and cardiac injury.
          Minor events include transient rhythm disturbance requiring no intervention.
          Most frequently adverse events are vascular, mainly arterial thrombosis.
        • Youngest patients have the highest risk of complications.  
        • Guidelines for the diagnosis of post procedural arterial thrombosis should be established  
        Marques, J.S & Goncalves, C (2014). Post-catheterisation arterial thrombosis in children – pathophysiology, prevention and treatment. Cardiology in the Young, 24: 767-773. Narrative review
        • Arterial thrombus with a decreased or absent pulse was the most common vascular complication, effecting 165 patients (out of 4952)
        • Most were treated with heparin
        • Interventional catheterisation and lower age were considered independent risk factors for this complication
        • Physical examination alone was not enough to diagnose, using doppler ultrasound and MRI
        Gündeş, E., Aday, U., Bulut, M., Çiyiltepe, H., Çetin, D. A., Gülmez, S., ... & Duman, M. (2017). Factors affecting treatment, management and mortality in cases of retroperitoneal hematoma after cardiac catheterization: a single-center experience. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 13(3), 218-224.
        		 Retrospective observational study

        • Retroperitoneal hemorrhage (RPH) occurring in patients after cardiac catheter is a rare complication of the procedure.
        • RPH can accompany subclinical bleeding symptoms, such as pain in the lower abdominal quadrant, femoral neuropathy, hypotension, nausea, and inguinal sensitivity or fullness
        • The retroperitoneal space can contain a large volume of blood until hypovolemic symptoms appea
        • In this study, of the 124,064 patients, RPH occurred in 0.054% of the
        • In cases where the femoral site is used, complications included hemorrhage, ecchymosis, hematoma, RPH, pseudoaneurysm, emboli, thrombosis, infection and ischaemia 
        Quinn, B. P., Yeh, M., Gauvreau, K., Ali, F., Balzer, D., Barry, O., ... & Bergersen, L. (2022). Procedural risk in congenital cardiac catheterization (PREDIC3T). Journal of the American Heart Association, 11(1), e022832.

        		   Audit
        • All data collected from hospitals participating in the ‘Congenital Cardiac Catheterisation Project on Outcomes
        • Of all catheters performed, 46% were interventional and 31% were diagnostic (remaining cases were biopsies
        • Interventional catheters had the highest severity of complications
        • Most common complications were vascular access related ie. thrombosis or vessel injury, atrial arrhythmia, hypotension, device or stent issues, respiratory or anesthesia related events
        Parkinson, J., Vidal, J. A. M., & Kline-Rogers, E. (2019). Nursing care of the cardiac catheterisation patient. Interventional Cardiology and Cardiac Catheterisation: The Essential Guide, 89. Textbook chapter 
        • Discussion of nursing care post cardiac catheterisation
        • Neurovascular observations should be completed with every set of observations and should be assessed against the opposite limb 
        • Puncture sites should be assessed visually and manually palpated watching for signs of haematoma, bleeding, pseudoaneurysm and RPH
        • If signs of bleeding, manual compression is gold standard and should be applied 1cm superior to the site
        Naseri Salahshour, V., Sabzali Gol, M., Basaampour, S. S., Varaei, S., Sajadi, M., & Mehran, A. (2017). The effect of body position and early ambulation on comfort, bleeding, and ecchymosis after diagnostic cardiac catheterization. Journal of Client-Centered Nursing Care, 3(1), 19-26. Quasi-experimental 
        • Early ambulation (6hrs) had no effect on bleeding post diagnostic cardiac catherisation compared to the control group
        • Intervention group able to move side to side which saw no difference in ecchymosis or bleeding risk
        • Moving side to side, elevation of bedhead to 30 degrees and early ambulation also improved patient comfort
        Odegard, K. C., Bergersen, L., Thiagarajan, R., Clark, L., Shukla, A., Wypij, D., & Laussen, P. C. (2014). The frequency of cardiac arrests in patients with congenital heart disease undergoing cardiac catheterization. Anesthesia & Analgesia, 118(1), 175-182.   Systematic review
        • Over the study period (7289 procedures), there were 38 events of sudden cardiac arrhythmia leading to cardiac arrest
        • Children undergoing a ventricular septal defect device closure are more prone to arrhythmia
        • Stenting open the semilunar valves and the atrioventricular valves can lead to a low cardiac output stat
        • Children undergoing balloon dilation for valve stenosis are at risk of arrhythmias and decreased cardiac output as the balloon inflates
        Luceri, M. J., Tala, J. A., Weismann, C. G., Silva, C. T., & Faustino, E. V. S. (2015). Prevalence of post‐thrombotic syndrome after cardiac catheterization. Pediatric blood & cancer, 62(7), 1222-1227. Cross-sectional study 
        • Prevalence of post thrombolytic syndrome was 64.5%, most of them mild
        • None of the findings were seen as abnormalities on ultrasound
        • Children who were perceived at higher risk of DVT due to cardiac disease were more likely to be prescribed heparin or aspirin
         Wybraniec, M. T., Mizia-Stec, K., & Więcek, A. (2015). Contrast-induced acute kidney injury: the dark side of cardiac catheterization. Pol Arch Med Wewn, 125(12), 938-49.   Review article 
        • Following cardiac catheterisation, worsening renal function can be expected
        • Contrast induced acute kidney injury is the third most common type of acquire hospital AKI
        • Careful consideration of pre existing kidney disease and fluid status/hydration is needed pre and post cardiac catheterisation  


          Please remember to read the disclaimer.

           

          The development of this nursing guideline was coordinated by Ruby Budge, RN, Koala Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated August 2024.