Manual of Common Bedside Surgical Procedure CHAPTER 3 - Cardiac Procedures

8/9/2019 Manual of Common Bedside Surgical Procedure CHAPTER 3 - Cardiac Procedures

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Authors/Editors: the Halsted Residents of The Johns Hopkins

Hospital; Chen, Herbert; Sonnenday, Christopher J.; ille!oe,

"eith #.

Title: Manual of Common Bedside Surgical Procedures, 2nd

Edition

Copyright Â©2000 Lippincott Williams & Wilkins

> Table of Contents > CHAT!" # $ CA"%AC "'C!%("!)

CHAT!" #

CAR#$AC %R&CE#'RES

Sun(ay "aushal ).#., %h.#.

Jor*e #. Sala+ar ).#.

$. CAR#$AC %R&CE#'RESCar*iac proce*+res play an important role in the care of me*ical an*s+rgical patients, These proce*+res are life$sa-ing mane+-ers that sho+l*be familiar to e-ery ho+se officer, A**itionally. the s+rgical ho+se staffsho+l* be able to perform more in-asi-e techni/+es s+ch aspericar*iocentesis. p+lmonary artery catheter placement. an* intra$aorticballoon p+mp A1 placement,

A. DEFIBRILLAI!"#CARDI!$ERSI!"

3, n* icat ions4

a, 5or *efibr i llation

6entric+lar fibrillation 65

+lseless -entric+lar tachycar*ia 6T

b, Car*io-ersion

Any hemo*ynamically +nstable tachyarrhythmia other

than 65 or p+lseless 6T e,g,. atrial fibrillation. atrialfl+tter. or other s+per -entric+lar tachycar*ias

!lecti-e con-ersion in patients 7ith stabletachyarrhythmias

2, Contrain*icat ions4

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8one

#, Anesthes ia 4

f time an* the patient9s bloo* press+re permit. one may gi-e ase*ati-e e,g,. *ia:epam. mi*a:olam. ketamine

7ith or 7itho+t an analgesic agent e,g,. fentanyl. morphine, )eeAppen*i; C,


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c, )et machine to the appropriate energy le-el, The first shocksho+l* be 200 B for *efibrillation an* 0 or 300 B forelectrocon-+lsion,

*, Charge the capacitor,

e, lace electro*es on chest, There are t7o acceptableplacements4

'ne electro*e to the right of the +pper stern+m an* theother o-er the ape; of the heart to the left of the nipplein the mi*a;illary line see 5ig+re #,3

o*e Asynchrono+s )ynchrono+s

Arrhythmia 6T or 65 'ther

+nstablearrhythmias

5irst shock 200 B 0 or 300 B

)econ*shock

#00 B 200 B

Thir*shock

#?0 B #00 or #?0 B




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'ne electro*e anteriorly o-er the left precor*i+m A an*the other posteriorly beneath the left scap+la 1 see

5ig+re #,2

i*. -..

,@@

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A-oi* positioning electro*es o-er pacemakers,

f, Apply firm press+re. abo+t 2 po+n*s. to the han*$hel*pa**les, Anno+nce that *efibrillationDcar*io-ersion is abo+t toocc+r an* lo+*ly state EFGAll clearEF

g, !ns+re that no person is in contact 7ith the patient or be*,

h, %eli-er an electric shock by pressing both *ischarge b+ttonssim+ltaneo+sly,

i, f the initial rhythm persists. repeat shock at the ne;t le-el +pto a ma;im+m of #?0 B, f still no s+ccess. C" sho+l* contin+e7ith int+bation an* intra-eno+s access, The +se of

i*. -..




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pharmacotherapy sho+l* be initiate* per ACL) protocol,

, Complications an* anagement4

a, na*-ertent shock to bystan*ers

(s+ally res+lts in temporary *iscomfort to the recipient.

b+t may in-ol-e serio+s b+rns,

The best treatment is pre-ention,

b, Temporary or permanent pacemaker malf+nction

After the patient is s+ccessf+lly res+scitate* an*hemo*ynamically stable. it may be necessary tointerrogate

an*Dor reset the pacemaker an* cons+lt car*iologyser-ice,

lace a transc+taneo+s pacer or insert a temporarytrans-eno+s pacer. if nee*e* see )ection C,

c , C+taneo+s b+rns

(s+ally only first$*egree b+rns. b+t may e;ten* *eeper,

Treat accor*ing to *epth of b+rn,

B. PERICARDI!CE"ESIS

3, n* icat ions4

a, To pre-ent f+rther car*iac compression *+e to car*iactampona*e. 7hich is manifeste* by increase* intracar*iacpress+res. re*+ction of -entric+lar *iastolic filling. an*Dor*ecrease in car*iac o+tp+t or stroke -ol+me

b, To establish a *iagnosis from pericar*ial fl+i*

2, Contrain*icat ions4a, Coag+lopathy platelets I 0.000. T or TT > 3,# JK control

b, ostEFcoronary bypass s+rgery beca+se of risk of inM+ry tografts

c, Ac+te tra+matic hemopericar*i+m

,@N

,N0

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*, )mall pericar*ial eff+sion. less than 200 ml

e, Absence of an anterior eff+sion or if eff+sion is loc+late*

#, Anesthes ia 4

3O li*ocaine


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c, A*minister 3O li*ocaine 7ith a 2$ga+ge nee*le into the skin

an* s+bc+taneo+s tiss+e in this area. al7ays aspirating beforeinMecting,

*, nsert the long #$inch 3?$ or 3@$ga+ge nee*le attache* to asyringe thro+gh the anestheti:e* skin 0, cm imme*iately leftof the ;iphoi* tip,

e, Attach a precor*ial l imb lea* of the !C= machine to the nee*le7ith an alligator clip for monitoring,

f, A*-ance the nee*le thro+gh the skin at a


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g, 8egati-e *eflection of the R") comple; 7ill be seen 7hencontact is ma*e 7ith the epicar*i+m of the pericar*ial sac see5ig+re #,,

i*. -.0.

i*. -.1.

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h, A*-ance the nee*le a fe7 centimeters f+rther thro+gh theepicar*i+m into the pericar*ial space, 8onclotting bloo* or

eff+sion may be enco+ntere*, )T segment ele-ation in*icatescontact 7ith the myocar*i+m, With*ra7 the nee*le into thepericar*ial space. 7here no )T segment ele-ation sho+l* beseen,

i, Aspirate al l f l+i* present,

M, 5or contin+o+s *rainage. a 3?$ga+ge soft Tef lon catheter maybe place* -ia the )el*inger techni/+e as follo7s,

k, nsert the B 7ire thro+gh the nee*le into the pericar*ial space,

l, "emo-e the nee*le. lea-ing the 7ire in place,

m, !nlarge the skin incision to abo+t 0,# cm 7ith a scalpel,

n, ass the catheter o-er the 7ire into the pericar*ial space see5ig+re #,?,

,N2

i*. -.2.




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o, "emo-e the 7ire an* attach the catheter to a close*$system

*rainage bag,p, )+t+re the catheter to the skin,

/, f pericar*iocentesis is performe* for *iagnostic p+rposes. sen*fl+i* for cell co+nt analysisS meas+rement of amylase. protein.an* gl+coseS an* c+lt+re of anaerobic or aerobic bacteria. ac i*$fast bacilli. or f+ngi,

r, onitor the patient for 2< ho+rs in an intensi-e care setting forrec+rrence of pericar*ial eff+sion,

s, 'btain an !C= for *oc+mentation of the f+nction an*appearance of the heart an* pericar*i+m,

t, )+ccess in re*+cing tampona*e is meas+re* by a *ecrease inright atrial press+res. an increase in ca r*iac o+tp+t. an* a*isappearance of p+ls+s para*o;+s,


a, Car*iac p+nct+re or laceration of a coronary artery

onitor -ital signs an* !C= closely,

ay re/+ire emergent thoracotomy or sternotomy

b, A ir embo l+s

Attempt to 7ith*ra7 air by aspirating thro+gh catheter,

f hemo*ynamically +nstable car*iac arrest. initiateACL) an* obtain a thoracic s+rgery cons+ltation,

f stable. position patient in left lateral *ec+bit+s an*Tren*elenb+rg position to trap air in right -entricle, C"

in this position can *emonstrate significant air entrapmentan* serial ;$rays sho+l* be obtaine* to follo7 the airembol+s, !-ent+ally. the air embol+s sho+l* *issol-e,

c, Car*iac arrhythmias

With*ra7 nee*le if hemo*ynamically significant,

ay re/+ire pharmacotherapy or electrocon-+lsion per

,N#

,N<




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ACL) protocol

*, Hemothora; or pne+mothora;

onitor 7ith serial C"s,

f significant. t+be thoracostomy see Chapter


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c, 22$ an* 2$ga+ge nee* les

*, $ml syringes t7o

e, )ho+l*er ro ll to7els

f, Appropriate catheters perc+taneo+s sheath intro*+cer kit an*

*ilatorg, 6 t+bing an* fl+sh

h, 3@$ga+ge insertion nee*le EFU@ cm long

i, 0 ,0# B 7 ire

M, )ter ile *ressings

k, )calpel

l , 2EFU0 s ilk s+t+re

m, acer catheter

n, !C= moni to r

o , A ll igator c lips

, os it ioning4

)+pine in Tren*elenb+rg position an* sho+l*er roll for s+bcla-ian-ein approach,

?, Techn i/+e4

a, nsert a @,$5r cor*is central -eno+s catheter sheath intointernal M+g+lar B -ein or s+bcla-ian -ein per Chapter 2.)ection ,

b, Attach !C= lea* 6 7ith the all igator clip to the *istal lea* ofthe pacing catheter,

c, =ently a*-ance the pacing catheter thro+gh the cor*is into theB or s+bcla-ian -ein +sing sterile techni/+e see 5ig+re #,,




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*, As the tip of the catheter enters the right atri+m. the 7a-eon the !C= monitor 7ill become -ery large,

e, As the tip of the catheter enters the right -entricle. the R")

comple; on the !C= monitor 7ill enlarge,

f, )T segment ele-ation in*icates *esire* placement of the pacingcatheter tip against the right -entric+lar 7all,

g, )ec+re the catheter in this position by s+t+ring it to the cor*isan* to the skin,

h, Attach the pacing lea*s to the p+lse generator an* set pacer to6%% mo*e,

i, 'btain a C" to confirm posit ion,


a, Lea*$electro*e catheter *isplacement

(s+ally manifeste* by loss of capt+re or sensing

'btain C",

i*. -.3.

,N?

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When *isplacement is recogni:e*. the catheter sho+l* beimme*iately repositione* or remo-e* an* a ne7 pacingcatheter inserte* if nee*e*,

b, nfec ti on

"emo-e catheter an* c+lt+re,

)tart systemic antibiotics,

f pacing is necessary. insert a ne7 catheter at a ne7site,

c , Thrombos is

"emo-e the catheter an* reinsert at a ne7 site,

*, %iaphragmatic st im+lation

ay compromise -entilation,

"eposition the catheter tip to minimi:e stim+lation,

e , ne+mothora;

f a tension pne+mothora; is s+specte*. *ecompress 7ith3?$ga+ge 6 into secon* intercostal space. mi*cla-ic+larline an* follo7e* by t+be thoracostomy,

f I 30O. 300O o;ygen an* serial


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a, 6ein thrombos is

b, Coag+lopathy T or TT > 3,# ratio. platelets I 20.000

c, (ntreate*. ongoing sepsis

*, )e-ere p+lmonary hypertension

#, Anesthes ia 4

3O li*ocaine


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b, When the insertion site is preppe* an* *rape*. the cathetersho+l* be remo-e* from its container an* teste*,

c, Test the balloon by inflating an* *eflating it 7ith theappropriate -ol+me of air +s+ally 3, ml, Look for air leakssee 5ig+re #,@,

*, n s+ccession. fl+sh each of the t7o ports pro;imal. *istal7ith sterile saline, )ome catheters may ha-e an a**itional portthat re/+ires fl+shing, Connect the press+re monitoring line to

the trans*+cer an* confirm the 7a-eform on the monitor bygently mo-ing the catheter tip an* 7atching for appropriate*eflections on the monitor,

e, lace a sterile plastic sheath o-er the catheter,

f, ass a catheter 7ith the balloon *eflate* into the s+bcla-ianor B -ein -ia the cor*is by +sing the nat+ral c+r-e of the

i*. -.4.




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catheter to *ictate the position,

g, When the catheter has been inserte* a *istance of 20 cmaccor*ing to the r+ler on the catheter itself. inflate theballoon 7ith 3, ml of air, %o not o-erinflate the balloon,

h, =ently a*-ance the catheter 7ith the balloon inflate* into the)6C or right atri+m, A C6 7a-eform sho+l* appear on themonitor,

i, Contin+e a*-ancing the catheter, rogression of the tip thro+ghthe "6 abo+t


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M, When the cathe te r reaches a 7e*ge* position. the 7a-e form7ill *ampen,

k, When this occ+rs. the balloon sho+l* be *eflate* an* a Atracing sho+l* appear, Lea-e the balloon *eflate* 7hen the*esire* position is achie-e*,

l, f the "6 or A tracing has not appeare* after ?0EFU0 cm.*eflate the balloon. 7ith*ra7 the catheter to 20 cm. inflate theballoon. an* attempt another insertion, Any time the catheternee*s to be 7ith*ra7n. the balloon sho+l* be *eflate*, Anytime the catheter nee*s to be a*-ance*. the balloon sho+l* beinflate*,


a, +lmonary infarction from EFGo-er7e*gingEF the catheter

)+ch a complication can be a-oi*e* by p+lling the

catheter

back 7hen the p+lmonary artery phasic press+res become*ampene* on the monitor,

%aily C"s are recommen*e* to monitor the catheter tipposition,

i*. -.6.

,NN

,300

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The balloon sho+l* not be inflate* for more than 3EFU2min+tes at a time,

)+pply o;ygenation an* -entilatory s+pport if nee*e*,

b, Arrhythmias

Arrhythmias +s+ally occ+r as the tip passes thro+gh theright -entricle,

Typically these consist of only se-eral premat+re-entric+lar contractions 6Cs or short r +ns of 6T. 7hichcease once the tip enters the A, f. ho7e-er. they persistan* are hemo*ynamically compromising. the catheter maynee* to be remo-e* an* ACL) initiate*,

Check proper position to ens+re the catheter is not c+rle*

in the right -entricle, )+pply me*ical therapy if arrhythmias *o not stop after

catheter remo-al,

c , 1al loon r+pt+re

Leakage of 0,@EFU3, ml of air into the circ+lation canocc+r if the balloon breaks, n the p+lmonary circ+lationthis can ca+se p+lmonary infarction, f the foramen o-aleis patent an* the balloon r+pt+res on insertion into theright heart. the air embol+s co+l* enter a coronary or

cerebral artery 7ith res+ltant myocar*ial infarction orstroke,

f hemo*ynamically +nstable car*iac arrest. initiateACL) an* obtain thoracic s+rgery cons+ltation,

f stable. position patient in left lateral *ec+bit+s an*Tren*elenb+rg position to trap air in right -entricle, C"in this position can sho7 significant air an* be +se* forfollo7 +p,

Air 7ill e-ent+ally *issol-e,

* , ne+mothora;

f a tension pne+mothora; is s+specte*. *ecompress 7ith3?$ga+ge 6 into secon* intercostal space. mi*cla-ic+larline follo7e* by t+be thoracostomy,

f I 30O. 300O o;ygen an* serial


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f > 30O. t+be thoracostomy

e, "+pt+re of the p+lmonary artery

+lmonary artery r+pt+re is fre/+ently fatal, t can bepre-ente* by a-oi*ing EFGo-er7e*gingEF ,

!mergent car*iac s+rgeryf, Vnott ing of the catheter

The catheter may become coile* *+ring a*-ancement or7ith*ra7al, f any resistance is met *+ring positioning ofthe catheter. the attempt sho+l* be aborte* an* a C"obtaine* to -erify position,

5l+oroscopy may be nee*e* to +ncoil the catheter,

g, nfec ti on The inci*ence of infection is increase* by fre/+ent

catheter manip+lation an* lea-ing the catheter in placefor more than # *ays,

Treatment re/+ires remo-al of the catheter. c+lt+re. an*a*ministration of intra-eno+s antibiotics at times,

E. I"RA)A!RIC BALL!!" P&MP

3, n* icat ions4

a, Car*iogenic shock

b, "efractory left -entric+lar fai l+re

c, echanical complications of ac+te myocar*ial infarction -entric+lar septal *efect 6)%X. papillary m+scle *ysf+nctionor r+pt+re

*, (nstable angina refractory to me*ical management

e, schemia$in*+ce* -entric+lar arrhythmias

f, )+pport *+ring perc+taneo+s transl+minal coronary angioplastyTCA

g, Weaning from car*iop+lmonary bypass

h, 1ri*ge to transplantation

,302




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2, Contrain*icat ions4

a, rre-ersible brain *amage

b, Chronic en*$stage heart *isease

c, %issecting thoracic or aortic ane+rysm

*, Aortic ins+f ficiency

e, )e-ere peripheral -asc+lar *isease calcif ie* aortoil iac orfemoral artery

#, Anesthes ia 4

3O li*ocaine


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)+pine an* in a monitore* setting

?, Techni/+eEFnsert ion4

a, )ha-e. sterile prep. an* *rape the left or right groin area,

b, alpate the femoral p+lse at the mi*point along an imaginary

line bet7een the anterior s+perior iliac spine an* thesymphysis p+bis, alpate its co+rse 3EFU2 cm *istally see5ig+re #,33,




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c, A*minister anesthetic 7ith 2$ga+ge nee*le into the skin an*

s+bc+taneo+s area along the co+rse of the artery palpate*abo-e,

*, (sing the 3@$ga+ge insertion nee*le 7ith a $ml syringe.p+nct+re the skin at point A an* a*-ance the nee*le cranially7hile aspirating at a


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7hile aspirating, f still no ret+rn. re*irect again to7ar*palpate* p+lse,

f, f stil l no bloo* ret+rn. reassess lan*marks an* attempt access3 cm more pro;imal along the co+rse of the artery as in)ection *, f still +ns+ccessf+l. stop,

g, f -eno+s bloo* enco+ntere*. 7ith*ra7 nee*le. hol* man+alpress+re accor*ing to the complications section. an* reinsert 3cm laterally,

h, f arterial access obtaine*. remo-e the syringe 7hile keeping afinger o-er the nee*le to p re-ent e;cessi-e blee*ing,

i, ntro*+ce the B 7ire. 7ith the tip aime* to7ar* the heart.thro+gh the nee*le 7hile maintaining the nee*le in the same

location )el*inger techni/+e, The 7ire m+st pass 7ith

minimal resistance,

M, f resistance is met. remo-e the 7ire an* check nee*leplacement by 7ith*ra7ing bloo* 7ith a syringe,

k, 'nce the 7ire is passe*. remo-e the nee*le 7hile keepingcontrol of the 7ire at all times,

l, !nlarge the p+nct+re site caref+lly 7ith a sterile scalpel,

m, lace the *ilator o-er the B 7ire, A*-ance it thro+gh the skin

into the arterial l+men, "emo-e the *ilator,

n, (sing the tiss+e clamp. sprea* the s+bc+taneo+s tiss+e at theinsertion site,

o, "emo-e the A1 catheter from the kit an* l+bricate it 7ithsterile saline,

p, "emo-e the inner stylet see 5ig+re #,3#,

,30<

,30




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/, A*-ance the A1 o-er the g+i*e7ire, The proper position ofthe catheter is 7ith the balloon tip appro;imately 2 cm *istalto the take off of the left s+bcla-ian artery in the *escen*ingthoracic aorta see 5ig+re #,3


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r, "emo-e the g+i*e7ire an* confirm intra$arterial placement byaspirating bloo*,

s, Attach catheter female L+er to a stan*ar* arterial press+re

monitoring system,

t, Attach catheter male L+er to A1 system,

+, )+t+re the catheter in place, )ec+re an* co-er 7ith clearsterile tape,

i*. -.0.

,30?

,30




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-, 'btain portable C" to confirm position,

7, nitially. proper a+gmentation is accomplishe* 7ith the A1synchroni:e* 342 7ith the patient9s arterial press+re an* thens7itche* to a 343 a+gmentation,

, Techni/+eEF"emo-al4

a, T+rn o ff A1,

b, Aspirate air from balloon to ens+re *eflation,

c, C+t sec+ring s+t+res an* remo-e A1 catheter 7ith a singles7ift p+ll,

*, mme*iately place press+re o-er the insertion site 7ith ga+:epa*s in each han*, 'ne han* is place* pro;imal to the entrysite. an* one *istal,

e, "elease press+re from the *istal han* to allo7 a little back$blee*ing from the *istal -essel to *islo*ge any clot presentsee 5ig+re #,3,

f, Apply press+re 7ith the *istal han* an* then release press+re

,30@

i*. -.1.

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from the pro;imal han* for 3EFU2 secon*s. allo7ing for7ar*blee*ing to *islo*ge clots see 5ig+re #,3?,

g, Hol* man+al press+re for a minim+m of #0 min+tes see 5ig+re#,3,

i*. -.2.

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h, The patient sho+l* remain s+pine 7ith legs e;ten*e* for ?ho+rs 7ith a press+re bag in place,

i, 0ake fre/+ent checks of the groin area for hematoma

formation,

M, oni to r *ista l p+l ses reg+la rly,

@, Complications an* anagement4

a, Limb ischemia of lo7er e;tremities

anifeste* by *ecrease* or absent peripheral p+lses. apale or bl+e skin *iscoloration. a relati-e *ecrease in skintemperat+re of the affecte* e;tremity. e;tremity pain. or

paresthesias,

%oc+ment preinsertion an* postinsertion pe*al p+lses,Assess the risk$benefit ratio of remo-ing the A1 -ers+sloss of limb, 5+rther management may re/+ire femoralartery e;ploration an*Dor thrombectomy,

b, Aortic * issect ion

i*. -.3.

,30N




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Ca+se* by an intimal tear an* flap ma*e in the aorta*+ring balloon insertion,

anifeste* by a poor a+gmentation tracing. fail+re of theballoon to +n7rap. hypotension. or back pain,

mme*iately remo-e the A1 an* initiate appropriates+rgical treatment,

c , "enal i nM+ry

"es+lts either from thromboembolic e-ents or secon*aryto occl+sion of the orifice of the renal artery by theballoon,

Thrombectomy or proper repositioning of the balloon,

*, Thromboembolism

ay lea* to limb or organ ischemia an* may be pre-ente*7ith anticoag+lation,

!mbolectomy is sometimes s+ccessf+l,

e, 1l ee*ing

(s+ally occ+rs at the insertion site. partic+larly if thepatient is anticoag+late* or has a coag+lopathy,

'ften rea*ily controlle* 7ith local press+re,

f, nfec ti on

"emo-e A1,

1egin systemic antibiotics,

ootnoteYcontaine* in most A1 insertion kits

,330


Manual of Common Bedside Surgical Procedure CHAPTER 3 - Cardiac Procedures

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