Preparing for the case

1. Preparing for the case Lee Benson MD FSCAI The Hospital for Sick Children, Toronto, Canada

2. No Disclosures

3. Ask yourself these questions as you prepare for the catheterization Why is the case being done? -pre-operative information: -hemodynamics –PVRI, LVED -morphology or intervention Is the case elective, emergent or urgent? Is this the right timing for the procedure? Is the child stable enough for the procedure? if non-elective…is transportation an issue…ECMO

4. Ask yourself these questions as you prepare for the catheterization Has the child & family been prepared for the procedure… ………do they understand the risks and benefits? Have you obtained consent & spoken to the family directly before the procedure? Is the nursing staff & anesthesia prepared for the case? Is the child appropriately sedated and stable? Have you determined the best approach …vascular access?

5. Precatheterization Conference -reduces possibility that information will be missed -identifies therapeutic procedures & equipment needed -time to review echocardiograms, CXR, prior cath’s..etc -time to develop a procedural plan

6. History & Physical Examination General history & physical examination -specific questions relating to technical aspects of the case Prior history bleeding disorder allergy to drugs contrast reactions Intercurrent illness or recent fever depends on how elective the case: e.g. infant in CHF…..may not find a 2 week period where they are fever free …….in general avoid cath if temp ≥380C (likely to become bacteremic)

7. History & Physical Examination Last menstrual period or possible pregnancy must have a very compiling reason to expose her to radiation Prior catheterizations or cardiac operations particular attention to unsuccessful cath’s or operations that effect vascular access

8. Physical examination *right & left thoracotomy scars e.g. classical Blalock-Taussig shunts, Glenn anastomosis, precluding access to the heart from the arms *groin or antecubital fossa scars previous vascular cut downs may make percutaneous study difficult -saphenous vein cut down: migrates distally, enter distal to scarproximal to inguinal ligament -vertical cut down from groin bypass vessels usually repaired Extensive scar tissue, makes passage of sheaths & dilators difficult & often require staged dilation…sometimes with balloons

9. Abdominal, thoracic or neck vein distention infants with prolonged ICU stays (indwelling central lines) Mustard, Senning or Fontan repairs can develop caval or baffle obstruction Peripheral arterial pulses CoA the most common but not only arterial lesion that may limit arterial access…..e.g. subclavian artery isolation

10. Medical & psychological preparation for cardiac catheterization Precatheterization preparation *Preparation is individualized……no hard & fast rules *Begins when decision made to perform the procedure *All patients beyond infancy need a general explanation regardless of sedation/GA. Describe that portion of the procedure that they will be aware *Never say ‘nothing will hurt’ …….makes the child more distressed & uncooperative. Do not let them think it’s just like an ‘office visit’

11. Medical & psychological preparation for cardiac catheterization Precatheterization preparation *Exact details depends on the age/understanding/interest of the child…tailored at the time of the interview *Be truthful, not all the gruesome details……leads to > anxiety *-information: young children pre-procedure tests, the inevitable ‘needle’, premeds/sedation given older child length of procedure, stay in PAR, stay in hospital, any special issues: IV lines, Foley’s

12. Medical & psychological preparation for cardiac catheterization Precatheterization preparation * older patient more detail/explanation tailored to patient & family *Emphasize the reason for the cath, not only technical details or risks *Full details make you ‘medicolegally’ more comfortable…… …………….but only worsens anxiety for the child

13. Medical & psychological preparation for cardiac catheterization Precatheterization preparation Those in a decision making position, informed consent should include: 1- the diagnosis 2- the nature of the procedure 3-the risks 4-the alternatives 5-the risks of not doing the procedure 6-the benefits

14. Medical & psychological preparation for cardiac catheterization The risks: Data from 11,073 children catheterized (last 10 yr) looking at complications within the first 24 h after catheterization Complications occurred in 7.3%.....~1% major (stroke, perforation, permanent arterial thrombosis, seizures) & ~6% minor with vascular complications (hematoma, transient vessel occlusion) 25 children died within 24 h (0.23% of total case numbers) Independent risk factors: young patient age (<6 months) male gender inpatient status year of catheterization

15. Medical & psychological preparation for cardiac catheterization Precatheterization preparation *No infant/most all children do not need sedation the night before the study *Occasionally, an adolescent/ACHD-or-parent is very apprehensive …….mild sedative is reasonable *In addition to explanation & psychological preparation…… there are administrative issues that must be addressed: i.e., when and where to come to the hospital, NPO etc

16. Medical & psychological preparation for cardiac catheterization Precatheterization preparation *What are the arrangements for any pre-cath testing? *What time to come to hospital before the procedure *Instructions for bathing…no shaving…EMLA cream 1-2 hours before case at home

17. Medical & psychological preparation for cardiac catheterization Nutritional & fluid requirements *NPO after midnight not necessary 2 hours NPO for clear fluids 4 hours for breast milk or formula <6 months 6 hours food or formula >6 months Assure that they take fluids 6 hours before the study ……….but remember…in the (polycythemic) infant ….start IV to maintain hydration, as study may be delayed …..….Lactated Ringers/NS or 5%dextrose/0.25NS *Remember, infants/small children empty their stomachs faster than older children become dehydrated/hypoglycemic

18. Medical & psychological preparation for cardiac catheterization Immediate pre-cath preparation *EMLA cream (home) 1-2 hours before case, on all possible access sites *Careful IV starts…avoid multiple attempts *The combative child (for IV start): monitor ECG/BP ketamine………1-2 mg/kg IM midazolam…..0.25mg/kg IN Very anxious……………0.2 – 0.6 mg/kg PO (30 minutes before IV)

19. Medical & psychological preparation for cardiac catheterization Immediate pre-cath preparation Special situations *Polycythemia (Hct>65%): increased risk of cath effects hemodynamics If Hgb >200 g/l, while increases oxygen carrying capacity ..…decreased CO, leading to reduced oxygen delivery to tissues…………risk of thrombosis & embolization…perform coagulation studies/platelet count Anemia: decreases oxygen carrying capacity, falsely increases CO, worsening CHF……exacerbated during the cath (blood loss/fluids) Correct any Hgb <80 g/l……….if can’t………….cancel case

20. Medical & psychological preparation for cardiac catheterization Pre-medication *Goal: a calm, sleepy & cooperative child, before they enter the lab. Give medication in work up room, PO/IN/IM/IV When GA is not used, all children need some sedation in addition local analgesia…good combination is fentanyl & midazolam Fentanyl…..1-3 µg/kg IV, can repeat every 30 minutes…analgesia/sedation ……..anaesthetic dose….5-10 µg/kg IV, 1-10 µg/kg/hr infusion Midazolam….0.05-0.2 mg/kg IV, over 2 – 4 minutes ….0.2-0.3 mg/kg IN; 0.2-1 mg/kg 30 minutes prior to case PO ….0.07-0.1 mg/kg IM 30 minutes before cases Monitor ECG, saturation, BP

21. Medical & psychological preparation for cardiac catheterization *Under-sedation results in an uncooperative, anxious, hyperventilating, straining, moving, crying child….....both cruel to them and the staff Today GA frequently used, as most catheterizations are performed for interventional indications and a time out!

22. Medical & psychological preparation for cardiac catheterization The anaesthetists will have their own checklist…………….. ….communication with them before the case is essential Provide information so they can make an anaesthetic plan nature of the procedure cardiac anatomy recent echo functional status CHF? risk of ABE

23. Nurses role in preparation forcatheterization procedure ?

24. Nurses role in preparation forcatheterization procedure *Nursing supervises an OPD pre-catheterization clinic *Families are meet by their assigned nurse & an explanation is given to the families of the expectations for the day & administrative issues for the procedure day *Pre-ordered tests are obtained (echo, ECG, CXR within 6 months), but no routine tests (SS in appropriate populations) *Test results are reviewed & discussed by the cardiology team & communicated to the children & their family prior to discharge home

25. Nurses role in preparation forcatheterization procedure The Clinic Nurse is responsible for performing a comprehensive assessment for each child seen in pre-cath clinic, including: vital signs, height, weight, chest assessment, infectious disease & medication checklist Responsible for coordinating appropriate consultations (i.e. anesthesia consultation & thrombosis consultation) Arranging a meeting between the children/family with the cardiologist performing the procedure

26. Nurses role in preparation forcatheterization procedure The clinic nurse is responsible for educating the patient & their families on: • -the arrival time on the day of the procedure • -feeding instructions • -expectations before & after the catheterization • -provide information on research studies • -post catheterization site care upon discharge • -addressing questions & concerns of the children & their families

27. Trends in the catheterization laboratory Case Load: The CDIU The Hospital for Sick Children 1969-2008

28. Understand the indications for catheterization

29. Analyze the facts before making a decision On June 25th, 1876, General George Armstrong Custer received information that a significant number of Indians were gathering at Little Big Horn. Without analyzing the facts, he decided to ride out with 250 men to ‘surround’ almost 3000 Indians …………. this was a serious mistake.

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31. Understand the timing of the study Elective preparation for surgery, *primarily hemodynamic questions such as PAP, PVR, VEDP *anatomical questions such as pulmonary artery morphology……..complimenting MRI/echo *preoperative intervention……collateral occlusion

32. Understand the timing of the study Elective *interventional (e.g. CoA, PDA, ASD, severe but non-critical PS, AS) *EP ablation Emergent or urgent *post-operative anatomical & hemodynamic questions interventional procedures *hemodynamic (e.g. critical PS, AS, BAS, pulmonary atresia/IVS)

33. Intervention or diagnostic catheter Diagnostic catheter leading to re-operation Understand the risks *Cardiac catheterization in the immediate post-operative ICU period *Between 2004 & 2007, 49 children (~3% of cardiac surgeries), underwent 62 catheterizations before discharge from the ICU *Median age at surgery was 167 days & time to catheterization 8.5 days *Overall mortality was high (43%) *Re-operation after a non-interventional catheterization predicted worse survival (p<0.001) *Delay to catheterization, especially >2 to 3 weeks & a splinted sternum were risk factors for death

34. Understand the risks Competing risks vs. other non-invasive testing Neither cath Nor operate Operate without catheterization Mortality of catheterization (%) Catheterize Probability of disease being present% MaCartney Br Heart J 1984