The Procedure and Procedural Care
Tortorici Chapter 19
Pre-procedure
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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 = 90/60 - 140/90
Elderly BP = 140/92 – 170/100
Pulse
= 55-90
(rate, rhythm, volume)
Respiration = ¼ pulse or 12-20
Temp.
= 97.6, 98.6, 99.6
Procedure
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Establish rapport with patient
Review chart
Baseline vitals/neurologic tests
Vitals/neurologic tests
Take scouts
Prep injection site
Drape
Needle puncture and catheter placement
Introducing the Catheter
Arterial Anatomy
Tunica Adventitia
Tunica Media
(muscular)
See Chapter 10
Lumen
Elastic,
fibrous
tissue
Tunica
Intima
(Endothelium)
The Judkins Technique of Catheterization
Utilizing the Seldinger Technique of Arterial Puncture
Cecum of colon
Ala (wing)
of ilium
Coronal MRI demonstrating
the femoral artery pulse
point, where arterial puncture
is most commonly performed
Uterus
Thigh muscle
Bladder
Adipose of
thigh (white
on MRI)
Original
Seldinger Needle
Cannula
Stylet
Stylet, with beveled point
down, is inserted into cannula
for puncture
Cannula
Disposable needle used for femoral puncture
Stylet
Guide wire: Teflon wrapped wire used
to introduce and manipulate catheter.
Aids insertion of
wire into hub of
cannula
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 to
stiffen the tip for better control.
Seldinger Technique of Arterial Puncture
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5.
Lidocaine injection
small incision
spread with misquito forceps
needle in incision, pulse felt
45o cephalad, 25-30 medial
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.
Seldinger Technique of Arterial Puncture
6. The stylet is removed
7. Cannula is withdrawn,
arterial return of blood
Judkins Technique of Arterial Catheterizaton
Guide
Wire
8. Tilt needle, insert guide wire
Judkins Technique of Arterial Catheterizaton
9. The cannula is removed.
Arterial bleeding
stops as the puncture site
forms a seal around the
guide wire
Judkins Technique of Arterial Catheterizaton
10. Dilate puncture site
with a vessel dilator
11. A sheath is inserted to protect the puncture site
during catheter changes and manipulations
A sheath
A vessel dilator for widening the puncture hole
to accommodate a larger catheter
Guide wire
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
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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
Strain gauge
transducer
Contrast
Heperinized
Saline flush
Waste fluid
Systolic pressure
measured through
the catheter in the
left ventricle.
Manifold
Syringe for hand injections of
contrast and flushing catheter
Procedure
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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
Document
* Vitals
* Catheter in/out time
* ECG (EKG)
* CM volume
* 02 (90% saturation)
* 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
Complications
* Embolus/thrombus
* Internal hemorrhage
* Hematoma at puncture site
* Cardiac events
* Vessel dissection
* CM reaction