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189 Cards in this Set
- Front
- Back
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How long has the concept of catheterization been around?
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>5000 years
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Hales, 1711 AD
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Performed first cardiac catheterization on horse
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Who coined the term "cardiac catheterization"?
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Claude Bernard
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Dr. Werner Forssman - 1929
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First documented cardiac catheterization on human
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Dr. Mason Sones - 1959
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- first diagnostic coronary angiogram
- accidental placement of catheter in osteum w/ successful visualization of human coronary arteries & no fibrillation - initially used "cutdown" method to access vessel |
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The brachial approach is known as the....
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"Sones" approach
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Dr. Charles Dotter & Dr. Melvin Judkins
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- first percutaneous transluminal angioplasty (PTA)
- worked together to explore PTA as a therapeutic option in lieu of surgery |
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What did the introduction of PTA (percutaneous transluminal angioplasty) lead to? (innovative techniques)
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- retrieval of intrasvascular foreign bodies
- use of tissue adhesive for therapeutic vascular occlusion - local fibronlysis & the use of intravascular coils |
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Which approach is Judkins known for?
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- FEMORAL approach
- also developed first pre-shaped catheters for angiography |
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How were catheters shaped before the Judkins catheter?
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"Cut to length" & shaped using steaming process
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Who performed the first coronary angioplasty on an awake human in 1977?
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Dr. Andreas Gruntzig
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What was used to treat lesions within coronary arteries before 1994?
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PTCA (Percutaneous Transluminal Coronary Angioplasty)
- repeat rate of angioplasties over 30% when using alone |
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What were the first 2 stents approved by the FDA?
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Gianturco-Roubin stent
Palmaz-Schatz stent |
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Judkins Catheter - Right
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- single end hole; small angled tip
- may be referred to as "JR" fr Judkins Right |
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Judkins Catheter - Left
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- single end hole; small angled tip w/ additional bend a few cm back from tip to "hook" around arch & engage tip w/ osteum of l. main coronary a.
- variety of sizes; length from bend to angled tip is different - referred to as "JL" for Judkins Left, followed by size (ex. JL 3.5) |
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Judkins Catheter - Pigtail
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- end hole w/ additional side holes; used for large boluses
- angled (preferred by some for ease of use w/ accessing l. ventrile through aortic valve) or straight |
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Cardiac Catheterization - Procedure
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- cardiologist
- involve: cardiac vasculature, great vessels & vasculature to head, abdominal vasculature, & extremity vasculature |
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Left Heart Catheterization (LHC)
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- go into left (arterial side) of heart
- measures pressure & images coronary arteries - may also measure l. ventricle & valve functions |
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Right Heart Catheterization (RHC)
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- go into right (venous side) of heart
- measures pressures on venous side - may take images (but may just use cine/fluoro) |
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Carotid Angiogram
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- aka "4 Vessel"
- looks @ aortic arch & associated arteries supplying blood to head & upper extremities |
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Aorto-Femoral Run-Off (AFR)
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- visualizes anatomy from abdominal aorta inferiorly to distal end of lower extremities
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Pacemakers
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- unit is placed under skin & conductive leads are placed within the vasculature of venous side of heart using cine/fluoro
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Percutaneous Transluminal Angioplasty (PTA)
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- aka "ballooning"
- peripheral items like iliac arteries, renal arteries, popliteal arteries, etc. |
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Percutaneous Transluminal Coronary Angioplasty (PTCA)
Percutaneous Coronary Intervention (PCI) |
- similar to PTA
- performed specifically to visualize coronary arteries |
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Carotid Stenting
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- stenting of common carotid & possibly internal carotid arteries
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Specials Lab
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- interventional radiologists
- procedures involve: non vascular anatomy, internal aspect of organs, functionality of an organ |
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Embolization
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- aneurysms in various anatomical regions are filled/occluded
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Nephrostogram
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- nephrostomy is introduced (catheter from surface of skin into renal pelvis for posterior side of patient)
- contrast media introduced & images obtained |
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Percutaneous Transhepatic Cholangiograms (PTC)
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- contrast media introduced into liver through needle to visualize liver & bile duct structures
- may place stent (known as biliary drainage & stenting) |
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Visceral Angiograms / AFR / Carotids
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Deals w/ imaging the various visceral structures of abdomen
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Vena Cava Filters
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- helps prevent pulmonary emboli
- often placed prior to surgery for help in recovery process |
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Transjugular Intrahepatic Portosystemic Shunt (TIPS)
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- shunt which creates low-resistance tract in liver btw. portal & hepatic venous systems
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Biopsies
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- removal of various portions of tissue
- used for analysis to determine etiology of tissue growth, etc. |
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For any angiographc or therapeutic procedure, ____________ _____________ is necessary to obtain.
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Informed Consent
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What's required on an angiographic informed consent?
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- Patient must be advised of: technique/method, outcomes, pros/cons, alternatives to proposed procedure, pros/cons of alternatives
- signature of patient & witness (someone not directly associated w/ procedure [chaplain, ward clerk]) |
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What are the parts of an angiographic informed consent form?
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- authorization clause
- disclosure statement (risks, benefits, etc) - patient understanding - patient signatures |
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What's included on the procedure data form?
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Patient info / vital signs / staff involved / type & amt of contrast given / other meds given / images taken & fluoro time used / notes & comments about stents & catheters used
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What's an incident report used for?
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- would be made if something adverse or unexpected happens
- doesn't go into patient's chart - includes complications, treatment to rectify, follow-up steps - sent to risk management department |
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What happens if there's negligence/failure to acquire informed consent?
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- burden of proof is on PATIENT, requires "expert testimony"
- must prove: tech has duty to patient / tech breached duty / patient was injured / injured caused by breached duty |
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What happens when there's assault?
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Verbally threatening, w/ patient feeling that aggressor could immediately follow through w/ threat
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What happens when there's battery?
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Proving there has been unlawful touching; can be as simple as physician not receiving permission before touching patient in procedure
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What happens when there's false imprisonment?
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Use of restraints w/o patient permission or from an individual authorized to give consent
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Theory of "res ipsa loquitur"
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- "the thing speaks for itself"
- although there is lack of hard evidence, the nature of the incident lends support to the claim that a breach in duty has occurred - burden of proof shifts to plaintiff - vital that proper documentation be completed properly |
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Contrast Media
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Pharmaceutical agent that's administered for radiographic exam to enhance contrast of particular structure
Allows us to visualize differences in tissues of similar radiographic densities |
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Items w/ high atomic number attenuate ________ (more/ less) x-rays than those w/ a lower number
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More
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How are tissue densities measured?
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Atomic number (number of protons)
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Ingestion
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Orally drinkin the contrast media (ex. barium liquid or pill)
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Retrograde
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Against flow
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Antegrade
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With flow
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Intrathecal
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Into a sheath
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Parenteral
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Into a bloodstream (venous or arterial)
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Radiolucent
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- negative contrast media
- easily penetrated by x-rays - includes gases like O2, Co2, & even air |
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Radiopaque
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- positive contrast media
- attenuates x-rays more readily - includes barium suspensions, water-soluble iodines, & oil-based iodines - have much higher atomic #, attenuate 3x more x-rays than bone, 5x more x-rays than soft tissue |
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Agents - Suspensions (Barium Sulfate)
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- used for majority of GI studies (except where perforation or impaction is suspected)
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Agents - Oil Based (Ethiodol, Dionosil)
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- not injected IV, injected into hollow spaces (ex. uterus)
- can disperse into body & be cleansed up via urinary system |
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Bronchograms - Complications w/ Barium
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- if barium is aspirated into lungs, it's there permanently
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Agents - Water Soluble (Iodinated; Hypaque, Omnipaque, Optiray)
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- primary choice for vascular/interventional procedures
- can be used IV or IA |
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Iodine Atomic Number
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53
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Chemical Properties of Iodinated CM
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- tri-iodinated compound based on benzoic acid ring
- anions stabilize & detoxify the CM - cation increases solubility of CM |
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Why is ionic CM "ionic"?
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2 anions that cause negative charge (compared to only 1 positive cation)
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Composition of Nonionic CM
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- has 1 of anion portions of benzoic ring replaced w/ non-ionizing side chain
- creates structure w/ only 1 cation & 1 anion, canceling out ionic nature of CM - reduces osmolality (reduces patient rxns) - lower neurotoxicity |
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Hydrophilicity
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- determines how well patient will tolerate CM
- more hydrophilic, fewer side effects it will tend to produce - number & spatial distribution of side chain hydroxyl group determines hydrophilicity |
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Concentration of CM
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- measured as an expression of weight per volume; displayed mg/ml
- most of today's labs - 300 - 370 mg/ml - pertains to amount of salt in solution - concentration will be listed on label of bottle |
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Viscosity
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- deals w/ "thickness" or "thinness" of fluid
- determined by size & thickness of molecules in solution - temp is inversely proportional |
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Warming the CM allows for a ____________ (more/less) viscous solution, which is easier to administer
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Less
Causes less adverse reactions (approx. temp of 98 F, 37 C) |
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Osmolality
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- deal w/ # of dissolved ions (both cations & anions) in a liter of solution
- has been made closer & closer to osmolality of human blood (smaller the difference, closer to homeostasis blood will remain) |
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___________ is a Prime factor that causes pain/warmth sensations that patient may feel
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Osmlality
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Chemotoxic Adverse Reaction
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- related to various hemodynamic changes that may occur
- rxns deal w/ properties of the medium, amt injected, & speed at which it was injected (rate) |
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Idiosyncratic Adverse Reactions
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- all other non-hemodynamic events
- not really involved w/ medium properties, rate, or amount injected |
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"At-risk" individuals include...
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- high BUN/Creatinine levels
- asthmatic / hay fever - urtricaria (hives) - food allergies - iodine sensitivity / previous reactions to CM contrast |
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Most common type of reaction is ________, occuring in approx. ______ of patients (ex. warming, metallic taste, slight pain)
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Minor: 5%
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Severe reactions (life-threatening) occur at a rate of....
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0.1%
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Most severe reactions occur within the first ___________ of CM administration
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5 minutes
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95% of all reactions occur within first.......
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20 minutes
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Some adverse reactions can occur upwards of _______ post-injection, so closely regulated recovery periods are vital
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1 hour
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Cutaneous Reactions
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- feeling flushed, sweating, urtricaria
- mostly classified as minor - most require no treatment - diphenhydramine used to help lessen itching/size of hives |
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Neurologic Reactions
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- headache, altered LOC
- severity of rxn is directly related to concentration of CM (proportional) |
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Respiratory Reactions
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- coughing, dyspnea, respiratory distress
- classification is dependent on patient's immune response |
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Cardiovascular Reactions
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- depressed ST segment, T inversion, PVCs, sinus arrhythmias
- most occur after injection into cerebral or coronary arteries |
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Gastrointestinal Reactions
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- nausea, vomiting, metallic taste (like pennies) in mouth
- usually minor |
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Ways to Prevent Adverse Reactions
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Patient History / Premedication / Selecting Appropriate CM / Emergency Equipment
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When was the automatic injector introduced?
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1950s
Delivered large quantities of CM in seconds |
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Disadvantages of first automatic injectors
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- time needed to achieve desired pressure
- personnel proximity - diastole initiation difficulties - dissection (vessel rupture) |
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Electromechanical Flow Rate Injector
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- developed as remedy to 1st auto-injectors
- components: arm(s) / syringe / console / safety features / |
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Flow Rate
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- delivers a given amount over a period of time (mL/sec)
- to increase flow rate: increase diameter of catheter / increase total pressure / decrease length of catheter / decrease viscosity of CM |
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What is pressure measured in?
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Psi (pounds per square inch)
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For saftey, set pressure limit 100 psi _________ (above/below) the max pressure limit of hardware
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Below
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Injection Delay
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- starts filming or acquiring images, THEN begins injecting CM (often used for digital subtraction imaging [DSA])
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X-ray Delay
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- opposite of injection delay; allows for injection of contrast prior to imaging
- can be useful for DSA image of distal lower extremity w/ catheter tip in proximal common iliac a. |
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Injection Duration
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- figured by volume used & the rate of injection
- divided total volume by rate; result is given in sec (s) |
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Safety Features - Pressure
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- machines have range of 100-1000 psi
- coronary: 400-650 psi - ventricle/aorta: 900 psi |
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Safety Features - Rate/Rise Control Mechanism
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- minimizes catheter whipping
- prevents sudden bursts that might rupture smaller or diseased vessels - allows small time gap btw. 0 psi & desired psi |
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Safety Features - Mechanical Stop
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- prevents "runaway" injector
- usually set for 2-3 mL greater than volume desire |
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Safety Features - Jacket
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- high pressure plastic jacket surrounds syringe
- prevents metal contact w/ CM (eliminates possibilities of electrical shock) |
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Required Items for an Infection to Occur
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- pathogen
- environment (where microbes live & multiply) - portal of exit (ex. nose, mouth, urinary tract, intestines) - means of transmission |
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Direct Contact
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Touching an infected person; touching body fluids/blood of that person
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Indirect Contact
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- usually facilitated through fomites (inorganic items)
- potential host touches something that infected person previously touched |
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Droplet Precautions
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- contact w/ infectious secretions from conjunctiva / nose / mouth of infected person
- droplets can travel 3-5 feet; shouldn't be confused w/ airborne |
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Vehicle Precautions
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- organic items
- ex. food, water, etc contaminated w/ microorganisms |
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Vector Precautions
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- insect or animal carriers
- deposit disease by stinging or biting host (like a tick) |
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Airborne Precautions
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- involves residue from evaporated droplets (particles) of diseased microorganisms; suspended in air for long periods of time
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What kingdom do microorganisms belong to?
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Protista Kingdom (not planet or animal kingdom)
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Resident Flora
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- ex. staphylococci on superficial layers of skin [completely harmless there, if it enters lungs, different stroy]]
- require firm friction & effective soap & quantities of water to remove from skin |
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Transient Flora
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- for infection to propagate, microorganism must be able to survive then multiply within body
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Does a bacteria cell have a "true" nucleus?
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No; very simple cell structure
Prokaryotes |
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Shape - Spherical
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Cocci
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Shape - Oblong
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Bacilli
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Shape - Spiral
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Spirilla
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Groups - Diplo
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Groups of 2
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Groups - Strepto
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Grouped in chains
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Groups - Staphylo
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Grouped in grapelike bunches
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What does a bacteria form when conditions are bad for survival?
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- "spore" protective coat
- "endospores" much harder to kill than vegetating bacteria |
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Fungi - Classification
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- has true nucleus
- Eukaryote |
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Fungi - Yeasts
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- one-ceed forms
- reproduce through budding |
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Fungi - Molds
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- form multicellular colonies
- reproduce by spore formation |
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What's the primary source of material for the production of antibiotic drugs?
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Fungi (both yeasts & molds)
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Virus - Classification
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- Eukaryote
- Has true nucleus - smallest of microorganisms - cannot be seen w/ normal microscope |
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How do viruses survive & reproduce?
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By invading host cells
- must attach to cell @ specific receptor sites |
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Lysis
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As new viruses leave host cell, they destroy it (host cell) through rapid release
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Can a virus be in a cell without showing any symptoms?
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Yes; new virus lies dormant in host cell (very much alive & destructive within the cell)
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Viruses Invading Nerve Ganglia
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- leaves genetic material in latent phase after acute infection period
- Virus lies dormant until patient experiences high stress situation that "wakes" it; spreads to surrounding cells to produce more cells |
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What's an example of a Virus Invading the Nerve Ganglia?
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Herpes simplex (fever blister on lips)
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Protozoa - Classification
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Eukaryote
- more complex than bacteria or fungi - Has true nucleus - parasitic; move from place by pseudopod formation / flagellar action / by cilia |
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Flagella
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- whiplike tails; use swift movements
Cilia: smaller, more delicate, hairlike projections |
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Body's First Line of Defense
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- non-specific, non-selective
- ex. skin, hair, ciliated mucous membranes in upper respiratory tract, acidic mucoid linings of body organs - react to any foreign substance or microbe to prevent infection from beginning |
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Body's Second Line of Defense
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- inflammatory response (begins @ site of injury); fever if invasion becomes systemic
- chemicals secreted, serum proteins activated, phagocytosis begins |
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Body's Third Line of Defense
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- involves antigens / antibodies
- antigens: foreign organic substances; cause body to produce antibodies - antibodies: react against specific antigen in an effort to kill them |
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Process of Infection - Incubation Stage
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- pathogen enters body
- may lie dormant for short period - begins to produce nonspecific symptoms of disease |
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Process of Infection - Prodromal Stage
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- more specific symptoms of particular diseases are exhibited
- increase in microorganisms - becomes highly infectious |
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Process of Infection - Full Disease Stage
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- reaches its fullest extent
- may only produce subclinical symptoms (while continuing to be highly infectious) |
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Process of Infection - Convalescent Stage
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- symptoms diminish, eventually disappear
- some microbes go into latent phase (instead of disappear) |
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What are some examples of microbes that go into a latent phase during the convalescent stage?
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Malaria, TB, herpes infections
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Autoclaves
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Steam sterilizers
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Chemical Sterilization
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- cold sterilization
- used for items that cannot withstand heat - aqueous gluteraldehyde is often used |
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Gas Ethylene Oxide Sterlization
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- used for items that cannot withstand heat & moisture
- must be cleaned & DRIED (water forms ethylene glycol [toxic]) |
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Gas Plasma Sterlization
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- highly ionized gas (made w/ vaporized hydrogen peroxide)
- provides nontoxic, dry, low-temp, time-efficient means of sterilization |
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When in doubt, consider an item ____________
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Unsterile
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The table height is sterile line: ___________ (above/below) is sterile, ____________ (above/below) is not
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Above / Below
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Sterile persons should pass one another.....
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Back-to-Back
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Ampules
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- single dose medication containers
- break neck away from body (gauze covering neck of ampule) |
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Vials
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- multi-dose medication containers
- contents in vacuum so must insert air before withdrawing anything - must insert same amt. of air as amt. of drug desired |
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When is MEDICAL ASEPSIS used
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- between patients
- everyday handwashing |
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What direction does sterile handwashing go on the arm?
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From fingertips to elbows
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Medical Asepsis
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Microorganisms have been eliminated through use of soap, water, friction, & various chemial disinectants
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Surgical Asepsis
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Microorganisms & their spores have been completely destroyed by means of heat or by a chemical process
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Angiographic Team
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1) Physician
2) Scrub Tech (can be RN) 3) Circulator (RT in charge of equipment) 4) Nurse 5) Recorder (can be RT or RN) |
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What 3 heart-related medications are important to watch for when obtaining patient history?
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Heparin (anticoagulant)
Warfarin Sodium (Coumadin) Aspirin |
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Normal BUN Levels
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10-22 mg/dl
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Normal Creatinine Levels
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0.6-1.5 mg/dl
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Normal Hemoglobin Levels
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12-18 g/L
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Normal PT (Prothrombin Time)
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10-13 seconds
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Normal PTT (Partial Thrombolastin Time)
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22-35 seconds
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High Risk Factors for Angiographic Procedures
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- anuria
- history of previous heart attack - blood dyscrasia - cerebrovascular accident (CVA) - previous rxns to contrast |
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Assessment of Patient - Mental
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- assess LOC, possible confusion, comprehension of procedure, current stress level
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Assessment of Patient - Physical
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- baseline stats (needed so any changes during the procedure can be noted)
- notice changes in skin color & feeling |
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Which 2 arteries in the legs are assessed before & after procedures?
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Posterior Tibial (PT) A.
Dorsalis Pedis (DP) A. |
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Pre-Procedure Meds - Atropine
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Prevents against vaso-vagal reaction
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Pre-Procedure Meds - Demerol/Fentanyl
|
- narcotic analgesic (helps w/ pain)
- another possibility --> morphine |
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Pre-Procedure Meds - Valium/Versed
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Antiemetics used to control nausea
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Pre-Procedure Meds - Diet
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Most meds require NPO 4-8 hrs prior to procedure
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Essential Monitoring - Continuous EKG
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- baselines taken before admin. of drugs
- can realize when changes occur |
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Essential Monitoring - Continuous Pulse Ox
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- evaluates oxygen saturation of blood
- "finger probe" on finger or toe - if room is very cold, can produce false readings |
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Essential Monitoring - Blood Pressure (Invasive/Noninvasive)
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- BP cuff = noninvasive
- invasive --> utilizes catheter inserted into patient during procedure (fluid in catheter "pushes back" on diaphragm in catheter / turned into electrical signal, can be read as hemodynamic waveform) |
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Essential Monitoring - Respiratory Rate, LOC
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- evaluated for alterations due to: pharmacologic agents / pathologies (ex. TIA)
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Essential Monitoring - Continuous IV Access
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- necessary to provide meds
- extravasation/infiltration = bad |
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Seldinger Technique
|
- 1950s by Sven Seldinger
- needle inserted through skin / double-wall puncture / pulls back on needle until pulsatile blood flow occurs / wire inserted into needle / pressure on proximal wire, needle removed / dilator, sheath introduced / sheath flushed to ensure patency |
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Modified Seldinger Technique
|
- most often used in today's setting
- same steps as Seldinger, EXCEPT only single-wall stick |
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Why is a single-wall stick better than a double-wall stick?
|
Less trauma to patient @ puncture site
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Cutdown Approach
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- any artery, typically = brachial
- AC prepped & draped, 1" transverse incision made - sutures tied around vessel, another transverse incision made into vessel; dilators used until big enough for catheter - sutures tightened around catheter (prevents bleeding) - vessel & incision are sutured, removed a few days later after proper care |
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Percutaneous Approach - Femoral
|
- JUDKINS approach
- access in middle to lower 1/3 of femoral head to facilitate proper compression post-procedure - puncture site = 1 cm below inguinal ligament - used for problems in: lower ext, pelvis, abdominal & thoracic aorta/branches, brachiocephalic vessels, coronary a, l. ventricle |
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Contraindications to using Judkins Method
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- occlusive disease in distal aorta, iliac a., common femoral a. / tortuosity of iliacs / femoral artery grafts / aneurysm of femoral a.
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Percutaneous Approach - Brachial
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- SONES approach
- humerus is utilized for localization of artery and for holding pressure post-procedure |
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Percutaneous Approach - Radial
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- only done if brachial isn't palpated well
- French size on catheter should be kept as small as possible (ex. 4 Fr. Max) - used to help problems in/when: femoral approach unsuccessful / path. of upper ext. / cerebral atherosclerosis / internal mammary grafts |
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Contraindications for using Sones Approach
|
- occlusive disease
- certain distal anatomy b/c of inability to reach w/ catheter tip |
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Axillary Approach
|
- least desirable b/c of brachial plexus proximity to incision site
- used to help problems in/when: divided into left axillary & right axillary |
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Left Axillary
|
Descending Thoracic Aorta
Abdominal Aorta Pelvis Lower Extremities |
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Right Axillary
|
Ascending Aorta
Left Ventricle Selective Coronary A. 4 Vessel Study of Cerebral A. |
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Contraindications of Axillary Approach
|
Nerve proximity / Occlusive disease / Aneurysm / Graft of subclavian a.
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Translumbar Approach (TLA)
|
- T12 (high) or L2 (low) approach
- pts. must lie prone 1-2 hours - useful for: aortic injections / less useful for: selective angiography of coronary a. - spot localized several cm below 12th rib / midway btw. T12 & lateral flank - no compression required for TLA after procedure |
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T12 (High) TLA Approach
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- preferred for typical TLA patient
- probability of infra-renal aortic occlusion - carries risk of puncturing lung |
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Common Symptoms after TLA Approach
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- mild backache (due to retroperitoneal hematoma)
- usually asymptomatic |
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Contraindications of TLA Approach
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Uncontrolled Hypertension / known Supraceliac Aortic Aneurysm / Severe Scoliosis / Dense Aortic Calcification / Aortic graft
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What's the major complication associated with instruments used in cath lab?
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Blood clots
Use systemic heparinization to help reduce clots / solution of heparinized saline is usually made (45 u heparin for every kg BW) |
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Where do most complications occur in angiography?
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At puncture site
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How is a hematoma caused?
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Inadequate manual compression while trying to obtain hemostasis
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Vitals & Time Periods
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Every 15 min - 1st hour
Every 30 minutes - 2nd hour Every hour - next 4 hours |
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Complications @ Puncture Site
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- may be multiple lumen sticks (allows for more complications)
- solution --> proper pressure holding to adequate hemostasis |
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Greatest Areas of Risk of CM Complications
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Brain / Kidneys / Heart
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Renal arteries __________ (vasoconstrict/vasodilate) upon injection of CM
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Vasoconstrict (most vessels do opposite)
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