Download Managing risk of complications at femoral vascular access sites

PowerPoint presented
By
Takaya L. Brown, BSN, BSN, CMSRN
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Percutaneous Coronary Intervention :
a nonsurgical procedure that is done to open narrowed coronary
arteries; performed by introducing a catheter through the skin into an
artery (groin or arm).
This procedure is performed when a patient has an
acute coronary syndrome or a non-ST elevation MI.
PCI reduces morbidity and mortality from
cardiovascular disease.
http://www.emedicinehealth.com/percutaneous_coronary_intervention_pci/art
icle_em.htm
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Because PCI requires the use of potent antithrombotic agents/Antithrombin
medications, there is an increased risk of:
•
Hematoma
•
Retroperitoneal hematoma
•
Pseudoaneurysm
•
Arterial occlusion
•
Arteriovenous fistula
•
Increased morbidity/mortality
•
Increased costs
FVACs reported during PCI are 5.5-20%.
Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular
access sites in PCI. Critical care nurse, 32(5): 16-29.
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Since nurses are generally the ones to pull the catheters or
sheaths, it is important to understand causes and predisposing
risk factors of VASCs.
Non-modifiable
Modifiable



Procedural technique
Medications
Hemostasis method




Sex
Age
BMI
Blood pressure
Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular
access sites in PCI. Critical care nurse, 32(5): 16-29.
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Many VASCs are related to punctures being made
either too high or too low below the inguinal
ligament.
Low sticks can lead to pseudoaneurysm, hematoma, or AV
fistula.
Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular
access sites in PCI. Critical care nurse, 32(5): 16-29.
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Table 1 Femoral puncture location and associated
complicationsa
Femoral puncture location: definition
•Low stick: puncture below the femoral bifurcation
•High stick: puncturing the inferior epigastric artery
•Posterior wall puncture: puncture through the back
wall of the artery
Complications
•Pseudoaneurysm
•Hematoma
•Arteriovenous fistula
•Retroperitoneal hemorrhage
•Retroperitoneal hemorrhage
a Based on data from Turi,7 Ragosta,8 Baim and Simon,15 Kamineni and
Butman,18 and Rashid and Bailey
Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular
access sites in PCI. Critical care nurse, 32(5): 16-29.
TLB
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Combinations of oral, IV antiplatelet, and antithrombin therapy are used for patients with ACS (USA
and non-STEMI).

They reduce mortality rates

They reduce adverse ischemic events, such as recurrent MI

They reduce short and long term complications of PCI
Antithrombin
Antiplatelets
Inhibits the coagulation factors that act
in the clotting cascade to form fibrin
strands
1. Unfractionated heparin (UFH)
2. Low molecular weight heparin
(LMWH): little effect on
measurements of activated clotting
time
3. Direct thrombin inhibitors (bivalrudin,
argatroban): interact directly with
thrombin without the need for
cofactor
Prevent formation of clots by allowing
platelets to be activated
1. Glycoprotein Iib/IIIa (reopro,
integrilin, aggrastat)
2. Adenosine diphosphate inhibitors
(plavix, prasugrel)
3. aspirin
Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular
access sites in PCI. Critical care nurse, 32(5): 16-29.
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These organizations support early administration of glycoprotein
IIB/IIIa inhibitors for patients at high risk for thrombotic
events related to bleeding.
Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular
access sites in PCI. Critical care nurse, 32(5): 16-29.
TLB
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There are three main techniques for obtaining
hemostasis:
1. Manual compression
2. Mechanical compression
3. Vascular closure devices
Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular
access sites in PCI. Critical care nurse, 32(5): 16-29.
TLB
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This is the gold standard for pulling sheaths and obtaining hemostasis.
•Place index and middle fingers 1-2cm above puncture site and apply
pressure for 15-20 minutes.
•This can lead to VASCs due to varying amounts of pressure being applied
as a result of hand and arm fatigue.
Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular
access sites in PCI. Critical care nurse, 32(5): 16-29.
TLB
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Applying constant pressure on the artery by use of:
C-clamp
Pneumatic device(Fem-stop)
Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular
access sites in PCI. Critical care nurse, 32(5): 16-29.
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This method was first approved in the 1990’s as a means for reducing length
of bedrest, improving hemostasis, and for patient’s comfort. Methods used:
-sutures for tying of the femoral artery
-collagenlike plugs which seals the puncture site by stimulating
platelet aggregation
-staples/clips which seal off puncture site in the artery
starclose
angioseal
perclose
Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular
access sites in PCI. Critical care nurse, 32(5): 16-29.
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Critically ill patients are at high risk for VASCs because of comorbid
conditions, such as,
-renal failure
-hypertension
-advanced age
The goal for nursing is to maintain hemostasis at the puncture site. This goal
will be attained by frequent assessment of VASCs:
-frequent vital sign checks
-frequent puncture site checks for bleeding or hematoma
-frequent pulse checks of affected limb
Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular
access sites in PCI. Critical care nurse, 32(5): 16-29.
TLB
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http://www.emedicinehealth.com/percutaneous_coronary_intervention_pci/article_em.htm
Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular
access sites in PCI. Critical care nurse, 32(5): 16-29.
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Article can be found on the AACN (C1253)
website. After completing the test, you will
receive 1.0 contact hours.
http://www.aacn.org/wd/Cetests/media/C125
3.pdf
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