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How to do Primary PCI The basics and adjunctive pharmacology . Dr Andrew Sutton MA MD FRCP FESC Consultant Cardiologist The James Cook University Hospital. NO CONFLICT OF INTEREST TO DECLARE. Before the cath lab.. Discussion, formulation and agreement of a clear regional protocol is key
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How to do Primary PCIThe basics and adjunctive pharmacology Dr Andrew Sutton MA MD FRCP FESC Consultant Cardiologist The James Cook University Hospital
Before the cath lab.. • Discussion, formulation and agreement of a clear regional protocol is key • Essential stakeholders: ambulance services, regional cardiologists, General Practitioners; walk-in centres; A&E staff
Before the cath lab.. • Aim for one pre-hospital patient pathway for each geographical region – irrespective of the day of the week, time of day, start/end of shifts. • Familiarity with and repetition of a single pathway breed slickness and efficiency • Continuous review, audit and feedback essential
Influence of PPCI pathway policy changes on median door to balloon times The James Cook University Hospital October 2006 to October 2008
Influence of PPCI pathway policy changes on median door to balloon times The James Cook University Hospital October 2006 to October 2008 CCU coordinator receives call from paramedic crew and copy of initial ECG
Influence of PPCI pathway policy changes on median door to balloon times The James Cook University Hospital October 2006 to October 2008 Patient admitted directly to cath lab CCU coordinator receives call from paramedic crew and copy of initial ECG
Influence of PPCI pathway policy changes on median door to balloon times The James Cook University Hospital October 2006 to October 2008 Patient admitted directly to cath lab Cath lab opened by resident member of staff CCU coordinator receives call from paramedic crew and copy of initial ECG
In the cath lab.. • Brief assessment (history, ECG , examination) • Exclude aortic dissection, PE • Look for acute MR, VSD; determine access • Previous angio available? • Determine history of allergy • Record usual medication (esp. anticoagulants) and medication already administered (aspirin, opiate analgesia) • Obtain witnessed verbal consent
In the cath lab.. • Slick patient preparation (iv access; ECG monitoring; remote pads for defibrillation; monitoring of O2; removal of jewellery) • Access – “normal” route is radial (82% radial last 1000 sequential cases in JCUH) • Preferable to have easy access to femoral artery, even if not used
In the cath lab.. • Common practice to administer a “radial cocktail” (GNT/verapamil +/- UFH) after sheath insertion • Advisable to avoid verapamil for STEMI • Diagnostic angio followed by choice of guide catheter or whole procedure with Kiemeneij guide catheter
In the cath lab.. • Do the case • Use of a thrombus extraction device is normal practice • Clarify any pending non cardiac surgery prior to choice of stent • Ask yourself if the stent big enough • TR band for radial access (increasingly use of a closure device for femoral access) • Do the next case
In the cath lab – particular considerations • Inferior STEMI • Bezold-Jarisch reaction: liberal use of iv fluids, atropine; may require phenylephrine • Culprit vessel or MV PCI? • Our default strategy is culprit vessel PCI (MV PCI performed in context of cardiogenic shock and lack of haemodynamic response to culprit vessel PCI)
“A word of advice, Durk: it’s the Mesolithic, we’ve domesticated the dog, we’re using stone tools and no one’s naked anymore.” JCUH drugs Aspirin loading 300mg (paramedic). Weight adjusted UFH (60U per kg) assuming patient will also receive ReoPro (89% of last 1000 sequential cases). ReoPro is only administered in the cath lab.
“A word of advice, Durk: it’s the Mesolithic, we’ve domesticated the dog, we’re using stone tools and no one’s naked anymore.” JCUH drugs Clopidogrel loading 600mg (not by paramedics) For self-presenters to local or regional A&E, load with aspirin 300mg and clopidogrel 600mg prior to urgent transfer
“A word of advice, Durk: it’s the Mesolithic, we’ve domesticated the dog, we’re using stone tools and no one’s naked anymore.” JCUH drugs Prasugrel is used instead of clopidogrel on a patient by patient basis at operator discretion.
“A word of advice, Durk: it’s the Mesolithic, we’ve domesticated the dog, we’re using stone tools and no one’s naked anymore.” Alternatively… Aspirin loading 300mg (paramedic). Prasugrel 60mg loading dose as routine (well recognised exceptions); potential for administration by ambulance crew. Bivalirudin + bail out GpIIb/IIIa inhibitor.
In the cath lab.. escalation of care • Not all PPCI is simple
83F Inferior STEMI TIMI 2 flow Critical prox RCA
In the cath lab.. escalation of care • Not all PPCI is simple • Not all MI (or PPCI) is without complication
62M Posterolateral STEMI Severe pulmonary oedema requiring NIV and anaesthetic support
Urgent mechanical mitral valve replacement 90 minutes later Complete recovery
77F Inferior STEMI with CHB Ostial LMS disease and calcified, severe LAD and Cx disease
Vessel opened Serial balloon inflations TIMI 3 flow Delivery of kit very difficult No stent; planned urgent CABG
Vessel repeatedly re-occluded after wire removal Haemodynamic compromise IABP, TPW Cardiothoracic anaesthetic input Emergency CABG from lab
In the cath lab.. escalation of care • Not all PPCI is simple • Not all MI (or PPCI) is without complication • ...which means you get some very sick patients
In the cath lab.. escalation of care • Infrastructure for the sickest group must be in place
In the cath lab.. escalation of care • Infrastructure for the sickest group must be in place • Input from experienced cardiothoracic anaesthetists vital for some
In the cath lab.. escalation of care • Infrastructure for the sickest group must be in place • Input from experienced cardiothoracic anaesthetists vital for some • Provision for invasive ventilation • Provision for IABP General ITU do not take these patients
In the cath lab.. escalation of care • Infrastructure for the sickest group must be in place • Input from experienced cardiothoracic anaesthetists vital for some • Provision for invasive ventilation • Provision for IABP • Provision for cooling General ITU do not take these patients
In the cath lab.. escalation of care • Infrastructure for the sickest group must be in place • Input from experienced cardiothoracic anaesthetists vital for some • Provision for invasive ventilation • Provision for IABP • Provision for cooling • Provision for cardiothoracic surgical input General ITU do not take these patients
The basics.... conclusion • Agreed regional protocol for delivery of PPCI • Mechanism in place for wherever the patient presents • Mechanism of continuous monitoring, audit and feedback
The basics.... conclusion • Agreed regional protocol on drugs • Strategy for the PPCI which is not simple • Infrastructure for those patients requiring urgent anaesthetic and surgical input