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The Procedure and Procedural CareTortorici Chapter 19
Pre-procedure
* Interview patient, take Hx* Signed informed consent* 4-8 hour fast with water* Stop anticoagulant therapy* Start heparin 4 hours prior and continue 6-24 hrs. after Protomine Sulfate (coagulant) for heparin OD
Lab tests* BUN/Creatinine* Clotting factors: Prothrombin time (PT) Partial Thromboplastin time (PTT)
Pre-procedure sedation
Conscious sedation
* Valium (diazepam): a benzodiazepine
* Demerol: a synthetic opioid
* Narcan: for opioid OD
Procedure
* Establish rapport with patient
* Review chart
* Baseline vitals/neurologic tests
Vitals
Adult BP =Elderly BP =Pulse = (rate, rhythm, volume)Respiration =Temp. =
90/60 - 140/90140/92 – 170/10055-90
¼ pulse or 12-2097.6, 98.6, 99.6
Procedure
* Establish rapport with patient * Review chart* Baseline vitals/neurologic tests* Vitals/neurologic tests* Take scouts* Prep injection site* Drape* Needle puncture and catheter placement
Lumen
Arterial Anatomy
Tunica Adventitia
Tunica Media(muscular)
Elastic, fibroustissue
TunicaIntima(Endothelium)
See Chapter 10
The Judkins Technique of Catheterization Utilizing the Seldinger Technique of Arterial Puncture
Coronal MRI demonstrating the femoral artery pulse point, where arterial punctureis most commonly performed
Bladder
Uterus
Ala (wing)of ilium
Adipose ofthigh (whiteon MRI)
Thigh muscle
Cecum of colon
Original
Seldinger Needle
Cannula Stylet
Stylet, with beveled pointdown, is inserted into cannulafor puncture
Disposable needle used for femoral puncture
Cannula
Stylet
This wire has a J tip to skim over the intimal lining with minimal damage. Pushing from the other end, the solid wire core is advanced tostiffen the tip for better control.
Guide wire: Teflon wrapped wire used to introduce and manipulate catheter.
Aids insertion ofwire into hub ofcannula
Seldinger Technique of Arterial Puncture
Original method: front and back wall of the artery is punctured. to lessen the risk of introducing the guide wire into the wall and dissecting the vessel.
The risk hematoma forming from the hole in the back wall is minimal.
1. Lidocaine injection2. small incision3. spread with misquito forceps4. needle in incision, pulse felt5. 45o cephalad, 25-30 medial
Seldinger Technique of Arterial Puncture
6. The stylet is removed
7. Cannula is withdrawn,arterial return of blood
Judkins Technique of Arterial Catheterizaton
9. The cannula is removed.
Arterial bleedingstops as the puncture siteforms a seal around the guide wire
Judkins Technique of Arterial Catheterizaton
11. A sheath is inserted to protect the puncture site during catheter changes and manipulations
10. Dilate puncture site with a vessel dilator
Judkins Technique of Arterial Catheterizaton
12. The catheter is threaded through the sheath
The catheter is then advanced through the iliac arteries, up the abdominal and thoracic aorta.
Procedure
* Establish rapport with patient * Review chart* Baseline vitals/neurologic tests* Vitals/neurologic tests* Take scouts* Prep injection site* Drape* Needle puncture and catheter placement* Hook up manifold
Manifold connected to catheter forms a closed system
Contrast HeperinizedSaline flush
Strain gaugetransducer
Systolic pressuremeasured throughthe catheter in the left ventricle.
Syringe for hand injections of contrast and flushing catheter
Manifold
Waste fluid
Procedure
* Establish rapport with patient * Review chart* Baseline vitals/neurologic tests* Vitals/neurologic tests* Take scouts* Prep injection site* Drape* Needle puncture and catheter placement* Hook up manifold* Set filming and injector parameters* Position patient* Film a run
Intraprocedural Care
Monitor
* Vitals
* ECG (EKG)
* 02 (90% saturation)
Document
* Catheter in/out time
* CM volume
* Meds
* Fluoro time
* Hemodynamic pressures
* Instruments used
Postprocedural Care
* Remove catheter
* Apply pressure (direct, mechanical device, closure device)
* Final vitals/pedal pulse
If admitted Overnight bedrest Monitor vital, pressure dressing, pedal pulse Hydrate