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Care of the patient undergoing radial approach heart catheterization: implications for medical-surgical nurses.

On average, a person dies every 39 seconds as a result of coronary vascular disease (CVD), accounting for more than 2,200 lives lost daily in the United States. As of 2008, CVD was implicated in one in every three deaths in the United States (American Heart Association, 2012). According to the U.S. Department of Health and Human Service's National Heart, Lung, and Blood Institute (NHLBI, 2011), atherosclerotic heart disease remains the number one killer of both men and women in the United States. Diagnosis of atherosclerosis is based on the patient's medical and family history, physical exam, and diagnostic test results (NHLBI, 2011).

Primary treatment focuses on therapeutic lifestyle changes, including smoking cessation, dietary changes, and exercise. However, if lifestyle alteration alone is not effective, additional medical management or even coronary intervention may be required. Angiography, specifically coronary artery angiography, is used to identify the presence of vascular plaque and determine if it is compromising arterial blood flow (NHLBI, 2011). Access to the circulatory system and into the heart is by way of a peripheral artery. According to Cosman, Arthur, and Natarajan (2011), cardiac catheterization has become the standard of care for diagnosis and treatment of coronary artery disease.

After the health care provider numbs the access area, the procedure begins with a small venipuncture made into the blood vessel. With access to the designated artery established, the cardiologist then threads a thin flexible catheter over a guide wire to the vessels of the heart (NHLBI, 2012). Radiopaque dye is injected through the catheter, allowing visualization of coronary vessel anatomy and blood flow with the assistance of x-ray technologies. Heparin is administered routinely in varying amounts to maintain anticoagulation while the catheter is in place (Durham, 2012). During the procedure, the cardiologist is able not only to diagnose heart conditions, but also to obtain blood and heart muscle samples and perform additional minor procedures (e.g., angioplasty with or without stent placement). Once all necessary tests and procedures are complete, the catheter and guide wire are removed (NHLBI, 2012).

While several approaches for catheterization have been developed, the femoral, brachial, and radial are the three most widely used techniques, with the femoral artery being the traditional, most commonly used access point (Bhimji, 2013; Durham, 2012). First described in 1989, the transradial approach for diagnostic coronary angiography has been limited to countries outside the United States (Bertrand et al., 2010). According to Adler (2014), "as recently as 2008, only 1.3% of coronary interventions in the United States were performed via the transradial approach" (para. 6). Similar usage rates outside the United States existed but now have increased as a result of research comparing complications of the two approaches (Nathan & Rao, 2012).

Nathan and Rao (2012) summarized several benefits of the transradial versus transfemoral approach, including cost savings and greater patient comfort and preference. Both mortality and ischemic events are reduced with the transradial approach due to decreased vascular access site complications, which are largely responsible for major bleeding in the patient undergoing percutaneous coronary intervention. A 73% decrease in the risk of major bleeding with radial access as compared to femoral access was reported in one study (Rao, Cohen, Kandzari, Bertrand, & Gilchrist, 2010). According to Durham (2012), bleeding complications are increased with the femoral approach due to difficulties in achieving and maintaining hemostasis, especially with intraprocedure anticoagulation use and in persons who are overweight. In addition to bleeding complications, femoral access is associated with prolonged bed rest times, increasing the potential for back pain, urinary retention, and constipation. Such complications are minimized by increased utilization of the transradial approach, resulting in shorter hospital stays and therefore decreased costs.

Statement of the Problem

Similar to most of the country, the femoral artery was the primary approach for patients undergoing cardiac catheterization at the author's facility. Despite staff familiarity with this approach, one cardiologist transitioned to the transradial approach. Informal instruction, specifically hands-on training, guided the staff learning process in caring for this new group of patients on a noncardiac ambulatory unit. A review of the literature supported the author's assumption that formal education practices were lacking on this procedure; while a wealth of information exists on the care of patients undergoing cardiac catheterization by the femoral approach, formal literature is lacking to guide nursing care of the patient undergoing transradial cardiac catheterization. Nurses in medical-surgical specialty areas need to maintain knowledge of current practices. Information to assist them in the care of the patient underdoing catheterization via the radial artery is provided.

Pre-Procedure Implications

Education

While the cardiologist often has provided an explanation of the procedure to the patient during a consultation appointment, the patient may seek clarification or have additional questions the day of the procedure. The nurse caring for the patient should have at least a basic understanding of the procedure, and be able to reinforce teaching and answer questions. Additionally, because access site failure can occur, the patient should be familiar with both the femoral and radial approaches to cardiac catheterization (Durham, 2012). Other items to address at this time may include some intra-procedure and post-procedure considerations (see Table 1).

Although the catheterization laboratory team is responsible for the care of the patient during the procedure, use of intravenous (IV) sedation during the procedure should be included in pre-procedure education. Every patient undergoing a radial artery cannulation will receive some IV sedation, unless contraindicated, to minimize radial artery spasm. In contrast, with the femoral approach, IV sedation use is based upon the level of patient anxiety and often may not be administered (Durham, 2012). The patient needs to be reminded he or she will be kept for observation following the procedure due to sedation use and the need to monitor for complications.

Post-procedure monitoring includes a period of bed rest, determined by the cardiologist and based on the amount of IV sedation required during the procedure, complications or difficulties encountered, and any interventions performed. Patient education promotes patient-centered care, allowing the patient to feel less anxious as post-procedure nursing care is described (Durham, 2012). The patient should know the nurse will be monitoring him or her continuously for complications while watching the heart rate and rhythm, performing circulation checks, and assessing the access site for bruising and active bleeding (see Table 1). Nursing education in the pre-procedure period is retrospective in that future care and expectations are addressed first, followed by an explanation of how the nurse will prepare the patient for the procedure. items addressed here include assessment of circulation to the hand, access site preparation, and IV line placement.

Circulation Assessment

Presence of dual circulation in the hand is an important qualifier in being considered for a transradial cardiac catheterization. Should blood flow be impaired with damage to the radial artery during the procedure, adequate circulation to the hand can be maintained by the ulnar artery alone. However, impairment of radial artery blood flow prior to the procedure would be a contraindication for radial approach catheterization. Baseline circulation is verified using a modified Allen's test (Durham, 2012).

To perform the modified Allen's test, the nurse first should place the oximetry probe on either the thumb or first finger of the hand designated for the procedure (usually the right). Both the baseline oximetry reading and pulse strength should be recorded for post-procedure comparison. The nurse then occludes the radial and ulnar arteries until the oximetry waveform is lost. The nurse releases pressure to the ulnar artery, recording the saturation level with the radial still occluded. Finally, the nurse repeats the previous step, only this time releasing pressure over the radial artery, recording its saturation level indicated by the return of a uniform waveform. Hospital policies vary but in general the modified Allen's test is considered abnormal if the waveform does not return within a matter of seconds, or if saturation levels between the radial and ulnar arteries differ by more than a few percentage points (Durham, 2012).

Site Preparation

Access site preparation for angiography via the radial artery approach involves using a disposable clipper to remove any hair from the ventral side of the wrist. Straight razor use is prohibited due to the risk of infection. The anticipated site also should be cleansed per hospital policy, usually with Hibiclens[R] or a similar product. Because access site failure can occur, many institutions also prepare the left wrist and groin areas as alternative access sites; this minimizes time spent in the procedure if additional access sites were not prepared previously (Speiser, 2011).

IV Placement

Generally, the IV site should be in the opposite arm from that designated for the procedure. Because the right arm is used for a transradial catheterization in most cases, ideal placement of the IV would be in the left arm. In some circumstances, however, the IV must be placed in the procedural arm. In this case, IV placement must be proximal to the wrist to prevent occlusion following the procedure by the hemostasis device (Durham, 2012).

Post-Procedure Implications

Site Assessment

Regardless of anticoagulation use during the procedure, the radial arterial sheath is removed prior to the patient's return to the recovery unit; this represents a difference from the femoral approach (Durham, 2012). A clear inflatable hemostasis band, or something similar, will be in place over the procedure site to allow the nurse to monitor the access site easily. The receiving nurse should assess immediately for any active bleeding or hematoma at the site, documenting its size and appearance. As with the pre-procedure preparation assessment, circulation should be assessed and compared to baseline values.

Circulation Assessment

The first value the nurse should note is the patient's pulse oximetry result, remembering probe placement should be on either the thumb or index finger of the affected hand. Because this reading is specific to the radial artery, it can indicate if radial circulation may have become impaired. Blood pressure is another important measure of circulation; the nurse must be careful to place the cuff on the unaffected arm so as not to cause bleeding or other circulation problems at the access site. Other methods of assessing circulation following every procedure patient are capillary refill, color and temperature, and patient reports of numbness and/or tingling in the affected hand or arm. Distal circulation must be checked frequently (generally every 5 minutes) while the hemostasis band is inflated fully, and then per hospital policy. Full band inflation times will vary from 10 minutes to 1 hour based on the amount of anticoagulant used during the procedure. This time will be specified on a hemostasis device flow sheet or other similar physician order form to guide the nurse in managing the patient's hemostasis band (Durham, 2012).

Hemostasis Device

Physician orders will include directions for removing air in increments from the inflatable hemostasis device. The nurse must document this air removal, as well as any bleeding or hematoma formation that may result. Depending on the amount of anticoagulant and if the procedure was diagnostic or interventional, pressure will be removed from the band over a period of 30 minutes to more than 4 hours in some cases. Air generally is removed in increments of 3 ml at a time, although the nurse must follow physician orders regarding pressure removal. In the event of bleeding with air removal, the nurse immediately should replace the amount of air last removed and wait the designated amount of time before trying to remove the air again (Durham, 2012). Once the hemostasis band has been deflated fully and no bleeding has occurred, the band can be removed and an occlusive dressing applied.

Activity

Activity and bed rest guidelines for femoral and radial approaches vary significantly. With the femoral approach, bed rest is longer with the patient's head of bed only slightly elevated. The patient with a radial approach typically is allowed free movement of the head of bed and generally is able to ambulate much sooner. This usually is indicated by the physician on the post-procedure orders, or may be left to the nurse's discretion based on his or her assessment that the patient can ambulate safely. Similar to the femoral approach, the arm affected by radial access should be kept straight but no pressure applied to it. Assuming the patient recovered without experiencing any post-procedure complications, he or she typically is allowed to be discharged home following a 2-4 hour observation period (Durham, 2012).

Discharge Instructions

With an occlusive dressing in place over the site, the patient is ready to be discharged to home. While the radial procedure creates less restrictions for the patient than femoral access, several important items must be addressed before the patient's departure from the hospital. The occlusive dressing typically must be left in place for 24 hours and often can be removed with the first shower following the procedure; however, physician preferences will be noted. While the site does not require any further dressing, it should be kept clean and the patient should be instructed to avoid submerging it in water to prevent infection. Signs of infection need to be reviewed with the patient, including redness or streaking, swelling, and discharge from the site. Clear instruction should be provided concerning when the patient should return for care.

In addition to monitoring for infection, the patient should know what to do in the case of bleeding. The patient should apply direct pressure over the radial site for 20 minutes and, if bleeding continues, he or she should be taken to the hospital immediately. The patient should be told to avoid lifting anything heavier than 5 pounds with the affected arm for 5 days, and especially to limit extension or flexion of the wrist for the first 24 hours (Durham, 2012). For further questions, the patient should be reminded to contact the provider or seek care as necessary.

Conclusion

As the leading killer of men and women in the United States, atherosclerotic heart disease continues to require aggressive medical management in many cases. Angiography remains the standard of care in the treatment of heart disease. Unfortunately, in many centers, the choice of vascular access is often one of tradition, opinion, and expertise rather than an evidence-based decision. With the continued evolution of technology surrounding coronary intervention, however, there is a shift from mere efficacy to both efficacy and safety. Because a strong association exists between procedural complications and subsequent morbidity and mortality, an even greater push has occurred to minimize complications through use of radial access (Nathan & Rao, 2012). As an increasing number of providers implement transradial cardiac catheterization, education for nurses caring for affected patients is of great priority (Durham, 2012).

Acknowledgments: The author gratefully acknowledges the support of Susan Luparell, PhD, APRN, ACNS-BC, CNE, Associate Professor; Dale Mayer, PhD, RN, Assistant Professor; and Susan Raph, MN, RN, NEA-BC, Associate Clinical Professor and Campus Director, Montana State University College of Nursing, for their expert review of the content and format of this manuscript.

REFERENCES

Adler, D. (2014). Transradial cardiac catheterization. Retrieved from http://emed icine.medscape.com/article/2039370-overview

American Heart Association. (2012). Heart disease and stroke statistics: 2012 update. Retrieved from http://circ.aha journals.org/content/125/1/e2.extract

Bertrand, O.F., Rao, S.V., Pancholy, S., Jolly, S.S., Rodes-Cabau, J., Larose, E., ... Mann, T. (2010). Transradial approach for coronary angiography and interventions. Journal of the American College of Cardiology, Cardiovascular Interventions, 3(10), 1022-1031. doi:10.1016/j. jcin.201007.013

Bhimji, S. (2013). Vascular access in cardiac catheterization and intervention. Retrieved from http://emedicine.medscape. com/article/1894124-overview#showall

Cosman, T.L., Arthur, H.M., & Natarajan, M.K. (2011). Prevalence of bruising at the vascular access site one week after elective cardiac catheterization or percutaneous coronary intervention. Journal of Clinical Nursing, 20, 1349-1356.

Durham, K.A. (2012). Cardiac catheterization through the radial artery: An often safer alternative to a traditional procedure. American Journal of Nursing, 112(1), 4956.

Nathan, S., & Rao, S.V. (2012). Radial versus femoral access for percutaneous coronary intervention: Implications for vascular complications and bleeding. Current Cardiology Reports, 14, 502-509. doi: 10.1007/S11886-012-0287-5

Rao, S.V., Cohen, M.G., Kandzari, D.E., Bertrand, O.F., & Gilchrist, I.C. (2010). The transradial approach to percutaneous coronary intervention: Historical perspective, current concepts, and future directions. Journal of the American College of Cardiology, 55(20), 2187-2195. doi:10.1016/j/jack.2010.01.039

Speiser, B. (2011). Tips when prepping for radial procedures. Retrieved from http://www.dicardiology.com/article/tipswhen-prepping-radial-procedures

U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute (NHLBI). (2012). What is cardiac catheterization? Retrieved from http:// www.nhlbi.nih.gov/health/health-topics/ topics/cath/

U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute (NHLBI). (2011). What is atherosclerosis? Retrieved from http://www.nhlbi.nih. gov/health/health-topics/topics/athero sclerosis/

Brittany R. Gomes, MN, RN, FNP-BC, is Nurse Practitioner, The Little Clinic.
TABLE 1.

Nursing Considerations for Patients Undergoing
Transradial Cardiac Catheterization

* Patient teaching to include preparation for procedure, as well
as intra- and post-procedure considerations

* Assessment and documentation of baseline dual circulation
(Allen's test)

* Access site preparation per hospital policy

* IV line placement (preferably opposite arm)

* Access site assessment for bruising, hematoma, or active bleeding

* Assessment of circulation using pulse oximetry, blood pressure,
capillary refill,
and presence or absence of numbness and tingling

* Hemostasis device management per physician orders

* Activity restriction and bed rest guidelines

* Discharge instructions
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Title Annotation:Expert Practice
Author:Gomes, Brittany R.
Publication:MedSurg Nursing
Date:May 1, 2015
Words:2907
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