1. 1 TLB PowerPoint presented By Takaya L. Brown, BSN, BSN, CMSRN

2. 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 2 TLB

3. 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. 3 TLB

4. Modifiable  Procedural technique  Medications  Hemostasis method Non-modifiable  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. Since nurses are generally the ones to pull the catheters or sheaths, it is important to understand causes and predisposing risk factors of VASCs. 4 TLB

5. 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. 5 TLB

6. Table 1 Femoral puncture location and associated complications a 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 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. 6 TLB

7. 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 AntithrombinAntiplatelets 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. 7 TLB

8. 8 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.

9. 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. 9 TLB

10. 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. 10 TLB Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular access sites in PCI. Critical care nurse, 32(5): 16-29.

11. TLB 11 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.

12. TLB 12 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.

13. 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 TLB 13 Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular access sites in PCI. Critical care nurse, 32(5): 16-29.

14. TLB 14 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.

15. TLB 15 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