5 th Asia Pacific Congenital and Structural Heart (APCASH) Intervention Symposium 2014

Transcription

1 5 th Asia Pacific Congenital and Structural Heart (APCASH) Intervention Symposium 2014 Allied Health Session What You Need to Know for Complication Management in Structural Heart Intervention (From Instrument to Procedure) Mr. LAI Kam-Wai (RN, BSN, MN, PHKAN-Cardiac) S

2 Common Structural Heart Interventions S Atrial Septal Defect (ASD) Occluder S Patent Ductus Arteriosus (PDA) Occluder S Ventricular Septal Defect (VSD) Occluder S Mitral Valve Angioplasty

3 Complicated Structural Heart Interventions S Left Atrial Appendage Occlusion (LAAO) S Trans-Aortic-Valve Implantation (TAVI) S MitraClip Implantation

4 Strategies in Complication Management SPrevention SDetection SCorrection

5 Detection of Complication ABP / NBP ECG rhythm & morphology, Limbs circulation Puncture site R/R & SpO2 Blood result Hb, WBC, PT/APTT/INR, Crea, Na, K, CPK/Troponin I CXR, GCS level Urine Output Echocardiogram Coronary Angiogram

6 Complications S Bleeding S Perforation of heart Chamber S Cardiac tamponade S Vascular complication S Acute Coronary Event S Device Dislodgement S Arrhythmia VT/VF or Heart Block S Stroke

7 Bleeding Pericardial Effusion Pseudoaneurysm Retroperitoneal Bleeding

8 Sheath Size Outer Diameter: 4.78 Outer Diameter: 4.67

9 Possible Cause of Cardiac Tamponade SDevices caused perforation S Catheter, S Wire, S Transeptal needle

10 Management of Cardiac Temponade S start CPR if developed PEA S perform echocardiogram to confirm diagnosis S stop anti-coagulation therapy as instruction S correct APTT (by IV Protamine), INR (by FFP) as instruction (if procedure continue, no need to correct anticoagulation therapy) S Preform pericardial tapping S measure volume of tapping fluid S connect the drainage catheter to BSB or low suction S Maintain low blood pressure to prevent active bleeding

11 Small ASD Occluder to Plug the Perforation Occlusion of perforation was achieved with a 10 mm AMPLATZER (AGA Medical Corporation, Plymouth, MN, USA) septal occluder and redeployment of the 12 mm ACP was successful. A pericardial drain (PD) Yu, C.-M. et al. (2013) Mechanical antithrombotic intervention by LAA occlusion in atrial fibrillation Nat. Rev. Cardiol. doi: /nrcardio

12 Instrument Preparation S Disposable Pericardial Tapping Kit S Septal Occluder < 12mm and Delivery system

13 Acute Coronary Event S Air embolism to coronary arteries S Thrombus for prolonged procedure S Obstruct coronary blood flow by device

14 Air Embolism

15 TAVI & Coronary Obstruction Valve position may obstruct the blood flow to coronary arteries

16 Ischaemia S/S:ECG with ST change and dropped in ABP

17 Instrument Preparation S Instrument for PCI Gabriel Greenberg, MD and Ran Kornowski, MDJ INVASIVE CARDIOL 2013;25(7):

18 Dislodgement of Occluder This TEE image shows the device floating freely in the left atrium (arrows). Yu, C.-M. et al. (2013) Mechanical antithrombotic intervention by LAA occlusion in atrial fibrillation Nat. Rev. Cardiol. doi: /nrcardio

19 Failed Capture of Dislodged Occluder by Goose Snare & 13Fr Sheath

20 Capture of Dislodged Occluder by Goose Snare & 14Fr Sheath

21 Capture of Dislodged Occluder by EN Snare & 14Fr Sheath

22 Holding of Dislodged Occluder by Biopsy Forcep

23 Instrument Preparation Goose Neck Snare Kit 15-25mm 14Fr 85cm Mullins Sheath

24 Instrument Preparation 5.5Fr Biposy forcep 104cm long (outer diameter 1.85mm) 7 Fr Guiding Cather 90cm long (Inner diameter 2.06mm)

25 Arrhythmia VT / VF S/S: ABP, GCS, seizure and ECG with VT /VF

26 Arrhythmia - Bradycardia S/S: dizziness, GCS ABP

27 Tachyarrhythmia S Cause by pacing stimulant Intervention S Perform DC version or defibrillation for VT/VF S Prepare antiarrhythmic agents

28 Defibrillation

29 Bradyarrhythmia Trauma by occluder MI Intervention Give medication Atropine, dopamine or adrenaline infusion Temporary Transvenous or Transcutaneous Pacing

30 Prevention of Stroke Prepare Echocardiogram for baseline and post-op assessment to rule out intra cardiac thrombus Intracardiac Echocardiogram 2D Echocardiogram 3D Echocardiogram

31 Principle of Resuscitation

32 Team Approach as Resuscitation S Team Leader S Airway S Compressor S IV/IO/Medications S Monitor /Defibrillator S Observer / Recorder

33 ACLS Algorithm Cardiac Arrest VT / VF

34 ACLS Algorithm PEA / Asystole

35 Post Cardiac Management

36 Emergency Cardiac Surgery S Stabilize the patient S insert IABP or ECMO S Arrange operation with CTSU S Inform relative and obtain consent S Arrange and collect blood product for OT S Prepare all nursing records & discharge summary S Collect all lab. result, ECG, CXR, Coro. Film, PTCA report and medication for transfer S Arrange emergency ambulance with oxygen, defibrillator and confirm location to pick up patient (CCL/ CCU) S Escort patient direct to OT S Inform CTSU that patient is on the way

37 Prevention of Complications S Availability of techniques, equipment and facilities (good stocking & good maintenance) S Staff Training S S BLS & ACLS training, CPR drill in CCL Ventilator checking S Stabilize patient s condition S S S Transvenous pacing IABP insertion ECMO insertion S Good pre-operative preparation S S Pre Op assessment S Coronary angiogram, echocardiogram, ECG,CXR, CBP, R/LFT, PT/APTT/INR Withold anticoagulation therapy

38 Proper Stocking of Consumables

39 Proper Stocking of Consumables

40 Thank You