BRANDO YASANA - Sha-conferences.com

Presented by:BRANDO YASANASTAFF NURSE –CARDIAC CATH LABPRINCE SALMAN HEART CENTREKING FAHAD MEDICAL CITY

The Sheath

COMPLICATIONS RELATED TO SHEATHREMOVAL‣ Vasovagal Reaction‣ Hematoma‣ Pseudoaneurysm‣ Retroperitoneal Bleeding‣ Vessel Thrombosis‣ Groin InfectionBrando Yasana –SHA 22

VASOVAGAL REACTION‣ Occur when the “vagus” nerve is stimulated‣ Hypotension, Bradycardia, Nausea and Diaphoresis‣ Patient should be connected to:Cardiac MonitorBP Cuff and Pulse OxymeterIV fluid‣ The fluid should be running during sheath removal.Brando Yasana –SHA 22

VASOVAGAL REACTION (cont.)‣ Reaction include a 15 ‐20 mmHg drop in SBP,20 –30 BPM drop in the HR‣ Management :Trendlendburg positionOpen fluidsAtropine / anti‐emeticBrando Yasana –SHA 22

HEMATOMA‣ Anti coagulation, sheath size, poor manualsheath removal technique‣ It will start soft then it will increase in size‣ Early compression will lessen furthercomplications‣ Do good compression if hematomahappened even if there is VCDBrando Yasana –SHA 22

SHEATH REMOVAL APPROACH BEINGUTILIZED AT KFMCBrando Yasana –SHA 22

PSEUDO ANEURYSM‣ Is communicationbetween arterial lumenand an area separationwithin the arterial layers‣ Cause:inadequatecompression after sheathremoval‣ Diagnosis includepulsatile mass and systolicbruit‣ Can be treated byultrasound guidedfemostop compression

RETROPERITONEAL BLEEDS‣ Potentially fatal complication‣ May occur if femoral artery puncture isproximal to inguinal crease making effectivecompression very difficult‣ Mayoccurduetoguidewireperforationorsheath dissection.‣ The patient usually complain of acuteabdominal or back pain, tachycardia anddrop of hemoglobin.Brando Yasana –SHA 22

RETROPERITONEAL BLEEDSMANAGEMENT‣ Prolong “Femostop” compression‣ Fluid replacement‣ Blood transfusion‣ Pressure support agent‣ Surgical exploration and correction maybe necessaryBrando Yasana –SHA 22

FEMOSTOPThe Femostop device isused for controlled femoralcompression afterintravascular sheathremoval in patients whohave had routine diagnosticcardiac catheterizations,balloon angioplasty,intracoronary stentimplantation and intra-aortic balloon pumpcatheters. It is used as ahemostasis device, andsandbag replacement.

SHEATH REMOVAL APPROACH BEINGUTILIZED AT KFMC‣ .‣compressing the areaBrando Yasana –SHA 22

FACTORS PREDISPOSING TO VASCULAR ACCESSSITE BLEEDING‣ Anatomic Factors‣ Procedural Factors‣ Hemodynamic Factors‣ Hematologic Factors‣ Human Factors

ANATOMIC FACTORS• Calcified vessel• Elderly patient• Obese patient• Female patient• Patient movement

PROCEDURAL FACTOR• Back wall Puncture• High puncture(above inguinal ligament)• Low puncture (profunda or superficial i femoralartery• Multiple puncture• Large sheath size• Kinking of the sheath due to acute angulation• Prolonged procedure time

HEMODYNAMIC FACTORS> Increase pulse pressure> Severe HTN

HEMATOLOGIC FACTOR• Multiple plateletantagonists(ASA,Plavix,IIb,IIIaantagonist)• Antithrombotic agents• Thrombolytic agent• Thrombocytopenia

HUMAN FACTOR• Inexperience• Inability to gain ‘control’ of site uponsheath removal• Short duration of pressure applied toobtain homeostasis• Knowledge of the patient about theprocedure

VESSEL THROMBOSIS‣ Sheath should be removed ASAP.‣ Sheath removal should be done withoutcompressing the shaft and stripping the clotsthat may have formed within.‣ Prolonged occlusive compression should notbe done for more than 5 minutes.Brando Yasana –SHA 22

GROIN INFECTION‣ May occur or may happenspecially with the mechanicalplug homeostasis device.‣ Diabetic and immunosuppressed patient. Patientwith poor hygiene, theelderly and obese patients.‣ Prolong sheath himplantationi

Procedure Done(August - December 2010)37%CA GCA G + PCI63%CAG CAG + PCI TOTAL221 129 350

Sheath Removal Technique(August - December 2010)75%0% 10% 5%5%5%ANGIOSEALSTARCLOSEPERCLOSEFEMOSTOPMA NUA L COMPRESSIONTR BANDTechniqueTotalANGIOSEAL 34STARCLOSE 16PERCLOSE 16FEMOSTOP 16MANUAL COMPRESSION 266TR BAND 1

Percentage of Hematoma FormationAugust - December 20101%No Com plicationsHematoma Formation99%ComplicationTotalNo Complication 253Hematoma 2

CONCLUSION• small thing can become BIG. Butknowing and dealing with thesepossible complications willenable us to confidently serveeour patients and avoid fartherserious complications caused byit.

Remove catheters when theyare no longer neededThe probability of colonization and catheter‐related bloodstreaminfection increases over timeBrando Yasana –SHA 22