Alan Cheng, MD

• Assistant Professor of Medicine
• Doctor, Arrhythmia Device Service
• Johns Hopkins University School of Medicine
• Baltimore, Maryland

For patients who are sensitive or allergic to chlorhexidine or alcohol and for children younger than 2 months of age medicine for bronchitis best order for cytotec, povidone-iodine is considered an acceptable disinfectant symptoms 5 weeks pregnant cytotec 100 mcg on line. Each swab stick of povidone-iodine is applied using either a backand-forth scrubbing method or concentric circles beginning at the catheter insertion site my medicine purchase cytotec 100mcg mastercard, then moving outward treatment bipolar disorder order 200 mcg cytotec mastercard. It is important to recognize that the practice of applying antiseptics in concentric circles is based on "traditional" practice rather than research 10 medications doctors wont take generic cytotec 200 mcg online. This is certainly an area of practice that lacks evidence and needs research to validate the procedure symptoms hypoglycemia order generic cytotec from india. Povidone-iodine should not be removed with alcohol after application, but in the case of neonates, the dried povidone-iodine is removed with sterile water or 0. If the patient is not immunosuppressed and healing at the insertion site is complete, site care may be limited to daily inspection and cleansing with soap and water while the patient is bathing. Should a patient with a long-term subcutaneously tunneled catheter, managed at home without a dressing, be admitted to the hospital, organizational policies generally require a dressing because of the increased risk for infection in the inpatient setting. Dressings are always changed earlier than the scheduled 2- or 7-day interval if loosened, dislodged, or wet or if blood or drainage is present, as the risk for infection is increased due to the growth of microorganisms on the skin. The problem of failing to maintain a dry and intact dressing over central lines in hospital settings has been documented (Morrison, Raffaele, & Brennaman, 2017). Antimicrobial dressings, such as chlorhexidine-impregnated dressings, are recommended for use (Safdar et al. Chlorhexidine dressings include a small, round foam dressing that incrementally releases chlorhexidine; it is placed around the catheter at the exit site and covered with a transparent dressing. Based upon results from a large randomized controlled trial, when there were more than two dressing changes for disruption (soiled, dressing coming off), there was a more than a threefold increase in the risk of bloodstream infection (Timsit et al. With documented increases in bloodstream infection related to dressing disruption, new methods to secure the catheter dressing with additional adhesives are being explored and implemented in some organizations. A sterile cap is placed on the male end of the administration set between infusions. Flushing and Locking As discussed in Chapter 6, catheters are flushed after each intermittent infusion to clear any medication from the catheter and to prevent contact between incompatible medications or I. If not properly flushed, a precipitate can form, essentially blocking the catheter, or thrombotic occlusion can occur as a result of blood clotting within the catheter lumen. Catheters are locked with a solution left instilled in the catheter to prevent occlusion in between intermittent infusions. In a subsequently published review of the literature, the researchers found also no evidence supporting heparin locking for central lines, asserting that occlusion prevention is based on proper flushing and locking technique used with saline (Pittiruti et al. The evidence continues to emerge regarding the best locking solution as well as the frequency of locking; therefore, there remains variation in protocols between organizations. Rather than a smooth, continuous flush, current recommendations are to use a pulsatile procedure. Such solutions must be made by a compounding pharmacy because they are not available in single-dose syringes or containers. Cultural and Ethnic Considerations: Heparin Because heparin is most often obtained from porcine intestine or bovine lung, it may present a cultural issue for some patients. Hindus, Sikhs, and Muslims do not approve of some animal-derived products if there are other alternatives. Informed consent should be sought for the use of animal- or human-derived products for several religions (Eriksson, Burcharth, & Rosenberg, 2013). Heparin-induced thrombocytopenia is a rare but life- and limb-threatening immunological reaction caused by platelet activation resulting in a hypercoagulable state leading to arterial thrombosis as a result of heparin exposure. To reduce the risk of blood reflux and thus catheter occlusion, the nurse must understand proper flushing technique in relation to the type of needleless connector (refer to Chapters 5 and 6). S68) recommends the following disinfectant agents: 70% alcohol, povidone-iodine, or >0. Shorter scrub times may be acceptable based on the design of the needleless connector and the disinfectant product used. Needleless connectors are a known source for contamination via the intraluminal route, that is, through the lumen of the catheter; failure to disinfect a needleless connector for flushing or medication administration is a well-recognized problem (Moureau & Flynn, 2015). If you have a multilumen catheter, remember to change the needleless connectors on all lumens. Catheter Repair Catheter damage can occur when excessive pressure is exerted while flushing or when an accidental cut is made by scissors or the catheter clamp. Nurses as well as patients must be knowledgeable about immediate actions to take in the event of catheter damage. Patients should be provided instructions on how to immediately clamp or fold the catheter to prevent blood loss or air embolism, and they should be informed to notify the nurse. Catheter repair kits are available and are specific to the manufacturer and size of the catheter. Risks versus benefits must be considered when weighing the appropriateness of catheter removal versus catheter repair (Gorski et al. Factors to consider include risk for infection from the damaged catheter, catheter type and potential for repair, expected duration of catheter need, and patient safety. The risk of catheter-associated infection is reduced by nursing competence and use of sterile technique while performing the repair. Other options for managing a damaged or ruptured catheter include a catheter exchange procedure or insertion of a new catheter in a different site. The catheter exchange procedure involves replacing the catheter in the same site using a guidewire; this procedure is performed under the same level of aseptic technique and following the central line insertion bundle interventions. For tunneled catheters, it is important that the subcutaneous cuff be completely removed to prevent healing delay and abscess formation (Gorski et al. Primary and secondary continuous administration sets used to administer fluids other than lipids, blood, or blood products should be changed no more frequently than every 96 hours. Blood sets and add-on filters should be changed after administration of each unit or at the end of 4 hours, whichever comes first. Any administration set that is suspected of being contaminated, or any product whose integrity is in question, should be changed. Minimum flushing volume should be equal to twice the internal volume of the catheter system. A pulsatile flushing technique of short boluses of sodium chloride followed by brief pauses. Care/Maintenance Dressings Administration Set Changes Flushing and Locking Needleless Connectors Source: Gorski et al. Replace tubing used to administer blood or blood products every 4 hours; replace tubing used to administer lipids every 12 hours. Use a noncoring needle to access implanted ports; change the needle every 7 days if running a continuous infusion via the port. Maintain a chlorhexidine dressing around the noncoring needle for access lasting beyond 4-6 hours. Condition of catheter tract (subcutaneously tunneled catheters) and surrounding tissue d. Implanted ports may be placed in children who have ongoing intermittent infusion needs, such as those with severe hemophilia requiring regular factor replacement. In infants, the umbilical vein and artery are additional routes for venous access for the first few days after birth. The umbilical vein is preferred in emergency infusions and can be used for up to 2 weeks. The catheter tip for umbilical vein catheters is located in the inferior vena cava near the junction with the right atrium (Gorski et al. The umbilical artery catheter is used for hemodynamic monitoring, arterial blood gas measurements, and obtaining blood for other laboratory work; dwell time should be limited to no more than 5 days (Gorski et al. The nurse verifies that informed consent for treatment of neonatal and pediatric patients, as well as for patients deemed emancipated minors, is documented. The nurse providing infusion therapy for neonatal and pediatric patients is knowledgeable and possesses technical expertise with respect to this population. The nurse providing infusion therapy should have knowledge and demonstrated competency in the areas of: a. Physiological characteristics and their effect on drug and nutrient selection (Gorski et al. However, chlorhexidine preparations are commonly used due to their effectiveness in skin antisepsis, and they were reported as the primary skin antiseptic agent used in neonatal intensive care units (Sharp, 2014). If povidone-iodine is used for skin antisepsis, the dried povidone-iodine is removed with sterile 0. As mentioned earlier in the chapter, the rationale is to avoid absorption of the povidone-iodine that may contribute to thyroid disorders in infants. When considering site care and dressing changes, it may or may not be appropriate to teach these procedures. If the patient has a tunneled catheter, site management is usually taught, and, as discussed earlier, regular site care and dressings may not be necessary. With implanted ports, in some cases patients will learn how to self-access the port. Although this is less common, patients who have lifelong needs for infusion therapy, such as factor replacement for hemophilia or frequent and ongoing needs for I. For the time between scheduled home-care visits, it is critical to provide patients with education addressing what symptoms to report, when and whom to report them to , and the necessary telephone numbers (Gorski, 2017). S25) Nursing Process the nursing process is a six-step process for problem-solving to guide nursing action (see Chapter 1 for details on the steps of the nursing process related to vascular access). The use of chlorhexidine dressings is associated with a decrease in risk for infection. Alternative solutions are considered for patients with a history of heparin-induced thrombocytopenia or frequent bloodstream infections. Nurse-led central venous catheter insertion: Review of 760 procedures performed across three hospitals reveals a low rate of complications. Position Statement: preservation of peripheral veins in patients with chronic kidney disease. Risk of venous thromboembolism associated with peripherally inserted central catheters: A systematic review and meta-analysis. Infusion teams in acute care hospitals: Call for a business approach: an Infusion Nurses Society white paper. Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. A randomized controlled comparison of flushing protocols in home care patients with peripherally inserted central catheters. Are antimicrobial peripherally inserted central catheters associated with reduction in central line-associated bloodstream infection Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. The role of the registered nurse in the insertion of non-tunneled central vascular access devices. Patterns and predictors of peripherally inserted central catheter occlusion: the 3P-O study. Cutting peripherally inserted central catheters may lead to increased rates of catheter-related deep vein thrombosis. The practitioner needs competency training for central venous access care and maintenance. Perform skin antisepsis at insertion site with chlorhexidine/alcohol or other acceptable skin antiseptic. Ask patient to perform Valsalva maneuver during procedure, unless contraindicated. Conducive to a successful procedure and prevents back injury to the practitioner 5. Maintain firm pressure over the exit site until bleeding stops or for a minimum of 30 seconds. Preprocedure Assess patient tolerance of procedure and evaluate for need for local anesthetic to reduce pain during needle insertion. For example, if using an anesthetic cream, it must be placed on the site approximately 60 minutes prior to access. Position the patient either in a comfortable reclining position or in a chair with a pillow behind the shoulder. Put on mask and sterile gloves; attach needleless connector to noncoring needle/ extension set and prime with 0. Perform skin antisepsis by applying chlorhexidine/alcohol solution using back-and-forth scrubbing motion for at least 30 seconds and allow to fully dry. Insert the noncoring needle perpendicular to the septum, pushing firmly through skin and septum until the needle tip contacts the back of the port. Skin antisepsis is a critical step in reducing the risk for bloodstream infection. Stabilize noncoring needle with sterile tape; place sterile gauze to support wings if needed, making sure gauze does not obscure needle site.

Calculation of the index of microcirculatory resistance without coronary wedge pressure measurement in the presence of epicardial stenosis symptoms yeast infection women order cytotec 200 mcg. Invasive assessment of the coronary microcirculation: Superior reproducibility and less hemodynamic dependence of index of microcirculatory resistance compared with coronary flow reserve treatment zygomycetes cheap cytotec online. At an average follow-up period of 3 years symptoms vaginitis cheap cytotec online american express, a primary endpoint had occurred in only two patients (3%) assigned to bypass surgery compared with 17 assigned to angioplasty (24%) and 12 assigned to medical therapy (17%) (p = symptoms 4 dpo buy cytotec 100 mcg with visa. However treatment jerawat di palembang buy cytotec from india, no patient allocated to bypass surgery needed revascularisation treatment 3 cm ovarian cyst purchase cytotec online now, compared with eight and seven patients assigned, respectively, to coronary angioplasty and medical treatment (p =. However, it is imperative to highlight that many other factors, including patient preference, comorbidities, local expertise and resources and expected completeness of revascularisation, etc. The two groups did not differ significantly in terms of death from any cause, myocardial infarction or stroke as well as their composite (8. It must be remembered that the three modes of therapy are not utilised in a mutually exclusive fashion, but in fact are complementary. The selection of revascularisation strategy for patients with complex coronary disease remains challenging and it is strongly recommended to adopt a multidisciplinary heart-team approach for decision making after careful consideration of relevant data. There are various tools available to help heart team in selecting optimal strategy. Mechanisms and prevention of restenosis: From experimental models to clinical practice. From metallic cages to transient bioresorbable scaffolds: Change in paradigm of coronary revascularization in the upcoming decade Effect of coronary artery bypass graft surgery on survival: Overview of 10-year results from randomised trials by the coronary artery bypass graft surgery trialists collaboration. Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous References 135 32. Isolated disease of the proximal left anterior descending artery comparing the effectiveness of percutaneous coronary interventions and coronary artery bypass surgery. Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis. Coronary artery bypass grafting is still the best treatment for multivessel and left main disease, but patients need to know. A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: One- to eight-year outcomes. Long-term comparison of drug-eluting stents and coronary artery bypass grafting for multivessel coronary revascularization: 5-year outcomes from the Asan medical center-multivessel revascularization registry. Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease. Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization. Randomized trial of stents versus bypass surgery for left main coronary artery disease. Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease. Percutaneous coronary intervention versus bypass surgery for left main coronary artery 136 Overview of randomised trials of percutaneous coronary intervention: Comparison with medical and surgical therapy 62. Long-term outcomes of percutaneous coronary intervention versus coronary artery bypass grafting for unprotected left main coronary bifurcation disease in the drug-eluting stent era. Nonrandomized comparison of coronary artery bypass surgery and percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease in octogenarians. As the initial ruptured plaque defect in the coronary endothelium is covered by activated platelets, this promotes further platelet recruitment and activation to the site of injury in a paracrine fashion. Indwelling interventional equipment can be intrinsically thrombogenic, either transiently (as is the case for removable equipment, such as coronary wires and balloons) or permanently (as is the case for stents). Similarly, angioplasty and stent deployment also cause platelet activation and endothelial disruption, further promoting thrombosis. Historically, early anti-thrombotic therapy following coronary stent placement included aspirin, dipyridamole, heparin and warfarin, and resulted in very high rates of bleeding complications as well as persistently high rates of stent thrombosis. Non-thienopyridine agents include ticagrelor and cangrelor, which do not require metabolic activation and lead to a reversible P2Y12 receptor inhibition, in contrast to thienopyridines. Subsequent trials examined aspirin versus aspirin plus dipyridamole and found no added benefit from the addition of dipyridamole, indicating 9. As a pro-drug, it requires conversion into its active metabolite by the hepatic cytochrome P450 9. There has only been one randomised controlled trial testing co-administration of clopidogrel and omeprazole, and it did not show an effect of omeprazole on cardiovascular outcomes. Additional populations in which special caution is advised include patients over 75 years of age and patients weighing <60 kg as increased bleeding complications were noted in these groups. Whilst these early findings are still only hypothesis generating, a number of reported clinical effects of ticagrelor. Also in contrast to the other P2Y12 agents discussed above, the use of ticagrelor is explicitly contraindicated in patients with severe hepatic dysfunction and another agent should be considered. Similar to clopidogrel and prasugrel, the use of ticagrelor in moderate liver dysfunction has not been well studied. Major advantages of cangrelor when compared with other anti-platelet agents are its rapid onset of action and rapid return of platelet function after its discontinuation. However, definite stent thrombosis was significantly reduced in the ticagrelor pre-treatment group at 24 hours, with preservation of the effect at 30 days. Anticoagulant agents specifically target the soluble coagulation cascade consisting of proteins required to form fibrin clots. These benefits were achieved without a significant increase in major bleeding and were subsequently demonstrated to remain favourable at one year follow-up. These benefits were maintained at 12 months for both the composite endpoint (32% vs. Major Bleeding: There was no difference between the groups in the 30-day incidence of major bleeding complications (6. Repeat Re-vascularisation: the need for repeat re-vascularisation procedures at 30 days was significantly less in the patients assigned to enoxaparin (27. Major Bleeding: There was no difference between the groups in the predischarge incidence of major bleeding complications (1. Major Bleeding: the incidence of major bleeding complications was higher with enoxaparin (0. Major Bleeding: the incidence of in-hospital major bleeding complications was higher with enoxaparin (9. Composite: No difference in the primary composite endpoint of in-hospital major bleeding. No coronary stenting performed in this trial, limiting its generalisability to contemporary practice. However, a subsequently published re-analysis of the trial dataset reported bivalirudin significantly reduced composite primary endpoint events at 7 days (p =. Bivalirudin was again associated with an increased risk of acute stent thrombosis (1. There was also a trend towards higher rates of re-infarction at 30 days, although the study was not adequately powered to assess this. Again noted was a greater risk of re-infarction with bivalirudin, driven by increased acute stent thrombosis (3. No differences in stent thrombosis were noted within 24 hours, at 30 days, or at 1 year. Overall, the fondaparinux treatment arm had significantly lower rates of the primary composite endpoint (9. Whilst there are multiple anti-coagulants with significant 152 Adjunctive pharmacotherapy and coronary intervention supporting evidence, unfractionated heparin has remained a durable choice and has many properties which make its use favourable. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: Randomised placebo-controlled trial. Adenosine-mediated effects of ticagrelor: Evidence and potential clinical relevance. Long-term dual antiplatelet therapy for secondary prevention of cardiovascular events in the subgroup of patients with previous myocardial infarction: A collaborative meta-analysis of randomized trials. Short- versus long-term dual antiplatelet therapy after drug-eluting stent implantation: An individual patient data pairwise and network meta-analysis. Enoxaparin versus unfractionated heparin in patients treated with tirofiban, aspirin and an early conservative initial management strategy: Results from the A phase of the A-to-Z trial. Enoxaparin versus unfractionated heparin in elective percutaneous coronary intervention. Efficacy and safety of enoxaparin versus unfractionated heparin during percutaneous coronary intervention: Systematic review and meta-analysis. Treatment with bivalirudin (Hirulog) as compared with heparin during coronary angioplasty for unstable or postinfarction angina. Bivalirudin versus unfractionated heparin during percutaneous coronary intervention. Bivalirudin versus heparin in patients planned for percutaneous coronary intervention: A meta-analysis of randomised controlled trials. This was a major breakthrough and allowed better directional control and access to distal arterial sites. Balloon catheters have similarly undergone a rapid evolution to the current ultrasophisticated models. Compliant and non-compliant balloons, scoring and cutting balloons have been added to our armamentarium. The next factor to be considered is the extent of ischemia on non-invasive testing, a predictor of clinical outcome. A type V distal perforation caused by guidewires was recently proposed by Muller et al. Type C dissection is characterised by persistence of extraluminal dye following contrast injection. Type E is a dissection with new filling defects, Type F is dissection with impaired flow rate or total occlusion. Prolonged inflation (>30 minutes) of a perfusion balloon, intended to tack up the dissection flap, has been effectively replaced by stenting in the current era. This resulted in a proximal ballooning intra-coronary haematoma which extended distally causing an external compressive occlusion of the coronary artery just beyond the distal edge of the stent (b). Intracoronary stenting has become the cornerstone of management of abrupt or threatened closure due to dissection; thrombectomy may occasionally be useful when thrombus formation is prominent. Deployment of a drug-eluting stent successfully sealed the dissection with only minimal contrast entering the aortic dissection (d). With the emergence of coronary stents, success rates have been exceptional (>95%) and restenosis is now uncommon when drug-eluting stents are used. Nonoperative dilatation of coronary-artery stenosis: Percutaneous transluminal coronary angioplasty. A comparison of balloon-expandablestent implantation with balloon angioplasty in patients with coronary artery disease. Update of clinical experience with a new catheter system for percutaneous transluminal coronary angioplasty. The balloon on a wire device: A new ultralow-profile coronary angioplasty system/concept. Randomized comparison of over-the-wire and fixed-wire balloon devices for coronary angioplasty. A randomized comparison of a sirolimuseluting stent with a standard stent for coronary revascularization. Appropriate use criteria for coronary revascularization and the learning health system: A good start. Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. Emergency coronary artery bypass surgery in the contemporary percutaneous coronary intervention era. Bedside estimation of risk from percutaneous coronary intervention: the new Mayo Clinic risk scores. A nail in the coffin of troponin measurements after percutaneous coronary intervention. Managing risk of complications at femoral vascular access sites in percutaneous coronary intervention. Coronary artery dissection and perforation complicating percutaneous coronary intervention. Frequency of abrupt vessel closure and side branch occlusion after percutaneous coronary intervention in a 6. Hence, individual operators have gained increasing experience in dealing with such disease and outcomes have been favourable in the right patient setting. This group typically consists of interventional cardiologists, non-invasive cardiologists and cardiac surgeons, who provide a balanced deliberation as to the most effective method of revascularisation on an individual patient basis. This 84-year-old male patient with a history of exertional chest discomfort was treated with implantation of a 3. These newer risk scoring systems may better guide decision-making by the Heart Team for more complex patients. Left anterior descending coronary artery pre-stenting (d) and post-stenting (e) were treated in a further procedure.

His bundle disease manifests as fractionation medicine 93 3109 generic 200 mcg cytotec visa, prolongation or splitting of the His bundle potential medicine omeprazole 20mg purchase generic cytotec pills. References 517 For induction of arrhythmias symptoms ruptured ovarian cyst order discount cytotec on line, the chamber of interest is paced at a steady rate to stabilise its refractoriness and premature impulse are inserted at progressively shorter intervals so as to induce unidirectional block and re-entry treatment using drugs is called purchase discount cytotec line. Occasional pacing at a faster rate for brief periods of time (burst pacing) can induce these arrhythmias medicine allergic reaction buy cytotec from india. These electro-anatomic mapping systems allow for three-dimensional reconstruction of heart chambers that incorporate voltage and activation-time criteria as well as non-fluoroscopic localisation of electrophysiological catheters within the heart symptoms bladder infection cheap cytotec amex. Automated multi-point acquisition with these catheters permit fast, high-resolution mapping to identify abnormal tissue that typically demonstrate low voltages, fractionation and late potentials. The judicious use of unipolar and bipolar voltage maps enable the identification of border zones and channels within scars. Cryothermal energy is another convenient form of energy source for ablation and has the advantage of reversibility of lesions if delivery is terminated early in the course of the application. Risks include those of heart catheterisation related to vascular access, trans-septal puncture, left heart catheterisation, including perforation with tamponade and thromboembolism. Of 1676 procedures at our centre over a 2-year period, rates of major complications differed between procedure types, ranging from 0. In addition, a working knowledge of electronics, signal processing and biophysics of energy sources is essential. Correlative anatomy and electrophysiology for the interventional electrophysiologist: Right atrial flutter. Vein of Marshall cannulation for the analysis of electrical activity in patients with focal atrial fibrillation. The ligament of Marshall: A structural analysis in human hearts with implications for atrial arrhythmias. Correlative anatomy for the invasive electrophysiologist: Outflow tract and supravalvar arrhythmia. London, Hackensack: Imperial College Press, World Scientific Publishing Company, 2000, p. Basic concepts in cellular cardiac electrophysiology: Part I: Ion channels, membrane currents, and the action potential. Review of contemporary antiarrhythmic drug therapy for maintenance of sinus rhythm in atrial fibrillation. Novel strategies in the ablation of typical atrial flutter: Role of intracardiac echocardiography. Cavotricuspid isthmus: Anatomy, electrophysiology, and long-term outcome of radiofrequency ablation. Efficacy and safety of cryoballoon ablation for atrial fibrillation: A systematic review of published studies. Three-dimensional visualization of the entire reentrant circuit of bundle branch reentrant tachycardia. Incidence and predictors of major complications from contemporary catheter ablation to treat cardiac arrhythmias. Focal tachycardias result from abnormal cardiac activation driven from a region of the heart not involved in generation of sinus rhythm. The clinical presentation of arrhythmias can range from chest pain, heart failure, palpitations, (pre)-syncope to rarely sudden death. Previous attendances to the emergency room for adenosine treatment, or the ability to terminate episodes with vagal manoeuvres is helpful information. Age of symptom onset in childhood would be more consistent with the presence of an accessory pathway. If one suspects ventricular arrhythmia, awareness of the presence of structural heart disease, or cardiomyopathy is important. The mean frontal axis and transition across the praecordial leads can help locate the origin further. Assessment of cardiac structure and function by echocardiography or other imaging modalities. Prior to the development of minimally invasive catheter ablation techniques, open heart surgery was the only curative option for the treatment of selected arrhythmias. The intra-cardiac catheters can be used to judge positioning of the sheath and needle, which in a right anterior oblique view should lie behind the His bundle which is adjacent to the aortic root. For confirmation of needle entry into the left atrium the pressure waveform or contrast injection can be used. The main complications that can arise are from inadvertent puncture of surrounding structures. More recently, a percutaneous approach to access the epicardial surface of the heart has been reported, initially described for the treatment of arrhythmia due to Chagas parasite infection. Coronary angiography is also necessary to ensure that potential sites of ablation are not adjacent to major epicardial vessels. Initial cardiac intervals are recorded in order to assess the cardiac conduction system at baseline. This is a normal finding and conduction will often return if isoprenaline is administered. A brief description follows but consideration of all possible manoeuvres is beyond the scope of this chapter. Historically it was used to determine effectiveness of anti-arrhythmic drug therapy in suppressing ventricular arrhythmia. Ventricular stimulation was previously thought to have a role in guiding implantable defibrillator programming, but increasingly this is being performed using empiric settings with longer detection to minimise shock therapy. A suggested regime for ajmaline provocation is a total of 1 mg/kg (up to maximum of 80 mg) administered in 10 mg doses over a minute every 2 minutes. This allows detailed activation mapping to locate the point of earliest activation. The match of the two morphologies is conventionally described as 12/12 if all 12 surface leads appear a good match. The magnetic field from each coil is detected by a sensor at the tip of a specialised mapping catheter. The strength of the magnetic field measured is inversely proportional to the distance from each magnet, allowing the catheter tip location to be triangulated in space. The voltage and impedance can be measured from multiple catheters which allows their distance from each skin patch, and therefore their location in space, to be triangulated with the help of a reference electrode. At each location, information can be collected to examine the timing of cardiac activation and also the myocardial voltage. Mapping systems allow procedures to be performed with reduced fluoroscopy and improve the speed and success of complex ablations. In a non-sustained, difficult to induce tachycardia it can be challenging to collect sufficient point data to accurately determine the origin and mechanism. Using complex mathematical processing it can generate over 3000 virtual electrograms and in theory collect the entire arrhythmia circuit in a single heartbeat. The success rates are greater than 90%, whilst complication rates are low in the region of 1%. Mapping the accessory pathway using fluoroscopic guidance and timing of intra-cardiac electrograms. On the mapping catheter the local atrial signal is earlier than any other atrial signals. Acute tissue injury and oedema can result from poor contact ablation and give the impression of success, but when tissue recovers arrhythmia will recur. Considerable variation in the contact force can be observed during cardiac and respiratory motion and also in different regions of the heart. Contrast is injected distal to the balloon to ensure a good seal against the vein ostium. The balloon is mounted on a hybrid guide wire/circular catheter that can be used to check pulmonary vein isolation. Following myocardial infarction surviving cells near the infarct zone conduct more slowly allowing a re-entry circuit to be sustained. P-wave morphology in focal atrial tachycardia: Development of an algorithm to predict the anatomic site of origin. Catheter-induced ablation of the atrioventricular junction to control refractory supraventricular arrhythmias. Catheter ablation of ventricular tachycardia in patients with structural heart disease using cooled radiofrequency energy: Results of a prospective multicenter study. Oral anticoagulant therapy for stroke prevention in patients with atrial fibrillation undergoing ablation: Results from the first European snapshot survey on procedural routines for atrial fibrillation ablation (ess-prafa). Impact of collimation on radiation exposure during interventional electrophysiology. Trans-septal catheterization in the electrophysiology laboratory: Data from a multicenter survey spanning 12 years. Programmed electrical stimulation of the heart in patients with life-threatening ventricular arrhythmias: What is the significance of induced arrhythmias and what is the correct stimulation protocol Significance of ventricular arrhythmias initiated by programmed ventricular stimulation: the importance of the type of ventricular arrhythmia induced and the number of premature stimuli required. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Differences in qrs configuration during unipolar pacing from adjacent sites: Implications for the spatial resolution of pace-mapping. Spatial resolution of atrial pace mapping as determined by unipolar atrial pacing at adjacent sites. Radiofrequency ablation of arrhythmias guided by non-fluoroscopic catheter location: A prospective randomized trial. Feasibility of a noncontact catheter for endocardial mapping of human ventricular tachycardia. Atrioventricular nodal reentrant tachycardia in patients referred for atrial fibrillation ablation: Response to ablation that incorporates slow-pathway modification. Long-term single- and multiple-procedure outcome and predictors of success after catheter ablation for persistent atrial fibrillation. Long-term follow-up of persistent atrial fibrillation ablation using termination as a procedural endpoint. Pathophysiologic basis of autonomic ganglionated plexus ablation in patients with atrial fibrillation. Prospective characterization of cathetertissue contact force at different anatomical sites during antral pulmonary vein isolation. Randomized, controlled trial of the safety and effectiveness of a contact force-sensing irrigated catheter for ablation of paroxysmal atrial fibrillation: Results of the tacticath contact force ablation catheter study for atrial fibrillation (toccastar) study. Repetitive, monomorphic ventricular tachycardia: Clinical and electrophysiologic characteristics in patients with and patients without organic heart disease. Idiopathic ventricular arrhythmias originating from the papillary muscles in the left ventricle: Prevalence, electrocardiographic and electrophysiological characteristics, and results of the radiofrequency catheter ablation. Radiofrequency ablation of frequent, idiopathic premature ventricular complexes: Comparison with a control group without intervention. Identification of reentry circuit sites during catheter mapping and radiofrequency ablation of ventricular tachycardia late after myocardial infarction. Isolated potentials during sinus rhythm and pace-mapping within scars as guides for ablation of postinfarction ventricular tachycardia. Notably, not all patients presenting with palpitations will have a clinically significant arrhythmia. The majority present with acute onset and termination of palpitations often described as a sensation of both fast and strong heartbeats. Associated symptoms might include lightheadedness, dyspnoea on exertion and chest pain. For those patients with shorter episodes, ambulatory monitoring is often necessary. Over the last few years, mobile devices have been developed that can record rhythm strips onto a cell phone. If the patient has risk factors for coronary disease, exercise or pharmacologic, stress testing might also be warranted. If the patient has known or suspected cardiac disease, the tachycardia is probably a ventricular tachycardia, and treatment for that condition should be initiated. Irregular wide-complex tachycardias are always worrisome, since they are frequently unstable. After catheters are placed, an evaluation of the underlying electrical substrate is undertaken. Some patients will have easily inducible arrhythmias, while others will require more aggressive stimulation. The first beat of the tracing represents that last beat of a drive train followed by two early extra-stimuli. The ventricular electrogram on the distal pole of the ablation catheter should precede the onset of the delta wave. Successful ablation site of a left free wall bypass tract during ventricular pacing.

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Suppurative or purulent thrombophlebitis is characterized by the presence of purulent drainage in the vein symptoms for mono generic cytotec 200mcg free shipping. This serious complication is associated with bloodstream infection and requires surgical removal of the vein shinee symptoms mp3 purchase 200mcg cytotec mastercard. All equipment should be inspected for integrity treatment guidelines generic 100 mcg cytotec fast delivery, particulate matter medicine for vertigo buy cytotec 100mcg, cloudiness medications elderly should not take cytotec 100mcg low cost, and any signs indicating a break in sterility treatment 1st metatarsal fracture cytotec 100 mcg cheap. When inspecting the venipuncture site, if the skin is noted to be visibly dirty, it should be washed with soap and water prior to skin antisepsis. If there is excess hair at the site, hair can be clipped using a scissors or disposablehead surgical clippers. The skin should not be shaved because microabrasions from shaving may increase the risk of infection. Postinfusion Phlebitis Postinfusion phlebitis is associated with inflammation of the vein that usually becomes evident within 48 hours after the cannula has been removed, so the site should be monitored for that time period. On discharge, patients should be instructed on signs and symptoms of phlebitis and on whom to contact if it occurs (Gorski et al. Host factors that may also contribute to risk of phlebitis include fragile vessels, a predisposition toward thrombosis (hypercoagulable state), high hemoglobin levels, female gender, and underlying medical disease. Catheter material Teflon (less favorable thrombogenic properties) Polyurethane (more favorable) 2. Catheter size Larger-gauge catheters take up more space in the vein and allow less blood flow around catheter 3. Infusate characteristics High dextrose concentration (>10%) High osmolarity (>900 mOsm/L) Known irritants. Host factors Fragile vessels High hemoglobin levels *Female gender Underlying medical disease (diabetes, infectious diseases, cancer, immunodeficiency, poor-quality peripheral veins) References: Dychter et al. Notably, phlebitis was the most common cause of catheter failure in this study at a rate of 17%. Irritating infusates, for osmolarity greater than 900 mOsm/L, or for dextrose concentrations in excess of 10%. Choose the smallest-gauge cannula appropriate for the infusate; in most cases, a 22- to 24-gauge catheter is selected. Ensure that the catheter is adequately stabilized in place to minimize catheter movement within the vein. Treatment Standard treatment of phlebitis is the application of warm compresses, limb elevation, and analgesics or anti-inflammatory agents as needed. If the inflammation is likely the result of bacterial phlebitis, a much more serious condition may develop if the patient is not treated. Untreated bacterial phlebitis can lead to catheter-related bloodstream infection and sepsis. Infiltration is defined as the inadvertent administration of a nonvesicant medication or solution into the surrounding tissue, whereas extravasation is the inadvertent administration of a vesicant medication into the surrounding tissue (Gorski et al. A vesicant is a medication or fluid capable of causing injury, such as necrosis or tissue damage, when it escapes from the vein. Infiltration is a common complication occurring at a rate of 14% in a prospective study (Marsh et al. Many antineoplastic (cytotoxic) drugs used in cancer treatment are classified as vesicants. This list was established based on literature reviews, case reports, and drug literature. Higherrisk infusates were classified as red; this list includes well-recognized vesicants with multiple citations and reports of tissue damage upon extravasation. Intermediate-risk infusates, classified as yellow, were associated with fewer reports of extravasation but are recognized as vesicants; published drug information and infusate characteristics indicate caution and potential for tissue damage (Gorski et al. Red List Well-recognized vesicants with multiple citations and reports of tissue damage upon extravasation Yellow List Vesicants associated with fewer published reports of extravasation; published drug information and infusate characteristics indicate caution and potential for tissue damage Acyclovir Amiodarone Arginine Dextrose concentration 10% to 12. The severity of damage is related to the type, concentration, and volume of fluid infiltrated into the interstitial tissues. Although infusion pumps do not cause infiltration, it is important to recognize that infusion pumps also do not detect infiltration. As stated earlier, medications or solutions characterized by an acidic or alkaline pH and/or high osmolarity can damage the endothelial cells of the vein, increasing the risk for venous rupture. Early recognition of infiltration/ extravasation is vital to limiting the volume of fluid and reducing the risk for tissue injury. Ulceration and possible tissue necrosis: the severity of tissue damage depends on many variables, including infusate characteristics. Ulceration is not immediately apparent; the ulcer may actually take days or weeks to develop. Compartment syndrome: Muscles, nerves, and vessels are in compartments confined in inflexible spaces bound by skin, fascia, and bone. When fluid inside a compartment increases, the venous end of the capillary bed becomes compressed. If vessels cannot carry away the excessive fluid, hydrostatic pressure rises, leading to vascular spasm, pain, and muscle necrosis inside the compartment. It is a chronic pain condition that is believed to result from dysfunction in the central or peripheral nervous system. It is characterized by dramatic changes in the color and temperature of the skin over the affected limb or body part, accompanied by intense burning pain, skin sensitivity, sweating, and swelling. Compare both arms when assessing for infiltration (note that the left arm is swollen compared with the right arm). Prevention the risk for infiltration/extravasation is reduced when risk factors are mitigated and with adequate and continuous assessment of the site. Use the smallest-gauge-size catheter to accommodate the infusion therapy and select larger veins. Any infusate administered below a previously used, and potentially damaged, vein may infiltrate into the damaged area. If placement in an area of flexion is necessary, use of a joint stabilization device. Assess the patency of the catheter before every drug administration; this includes flushing and aspirating for a blood return. If one is unable to obtain a blood return, there should be a high suspicion of infiltration. Infiltration and swelling may occur as a result of placing hands underneath the patient during turning. Occlusion or restriction of blood flow causes fluid to back up in the vessels, resulting in infiltration and dependent edema below rather than above the I. Occlusion or restriction of blood flow caused fluid to back up in the vessels, resulting in infiltration and dependent edema below rather than above the I. Instruct patient to immediately report any pain, burning, or swelling with infusion. Use sound decision making in relation to venous access, devices, and infusions: i. Avoid injured/sclerosed veins, areas of flexion, small veins, lower extremities, and extremity with altered venous return or diminished sensation. Administer vesicants through the side arm of a free-flowing infusion of a hydration solution whenever possible. In addition to visual assessment of site, verify presence of blood return before infusion and assess site frequently during the infusion. Immobilized patients and patients with muscular weakness or paralysis of an extremity may have edema of an extremity that is not related to infiltration of an I. Accurate assessment of the cannula and infusion site is the key to differentiation. Cooling promotes vasoconstriction, which limits dispersion of the drug in the tissue. Cold is recommended for extravasation of certain vesicants, contrast media, and hyperosmolar fluids. This is recommended because it promotes reabsorption of the infiltrate (Doellman et al. Assess the site regularly after an infiltration/extravasation at a frequency based on the type of infusate and individual patient needs. Instruct patient to report any worsening of signs or symptoms, such as changes in extremity mobility or sensation, or elevated temperature. This enzyme increases tissue permeability and facilitates absorption and dispersion of the drug into the tissue (Gorski et al. Provide the patient education addressing symptoms to report to the clinician, how to manage pain, and any follow-up care. Signs of infiltration included tissue blanching, decreased capillary refill time, and severely restricted active/passive range of motion of the extremity. Restricted joint movement was considered an important finding because infant "chubbiness" made swelling difficult to detect, and infants cannot express specific areas of pain or discomfort. Fasciotomies were performed on all three infants with full recovery (Talbot & Rogers, 2011). Medical record documentation is the key to understanding the events that occurred. Assessment of the site around the catheter tip is important, as is questioning the patient about discomfort at the access site. When extravasation or infiltration is suspected, discontinue the infusion immediately. An extravasation or severe infiltration should always result in immediate reporting, appropriate intervention, and completion of an unusual occurrence report. They should be removed at frequent intervals, and nurse-assisted range-of-motion exercises should be performed. Inadequate or improper use of such devices can result in pressure ulcers, circulatory constriction, infiltration, and nerve injury. Choose the catheter type, insertion site, and technique based on which pose the lowest risk of infections for the type and duration of infusion therapy. Clip hair using a scissors or disposable-head surgical clippers if there is excess hair at the site. Never shave because microabrasions from shaving may increase the risk of infection. Use a standardized checklist to ensure adherence to aseptic technique (see Chapters 2 and 8). If the site is bleeding or oozing or the patient is diaphoretic, a gauze dressing may be preferred. Use these dressings with caution in premature neonates and for those with fragile skin or complicated skin pathologies due to risk of contact dermatitis and pressure necrosis (Gorski et al. It is important to follow organizational policy when obtaining any cultures to avoid contaminated specimens. Nerve Injury Description and Etiology Because veins and nerves often lie in close proximity to each other, inadvertent injury to a nerve during venipuncture is a risk. Nerves specifically related to risk of injury with catheter placement in the arm include the radial and the median nerves. The consequences of nerve injury may be minor and self-limiting, with symptoms that resolve without intervention, or they may be major. A directpuncture nerve injury may result in formation of a neuroma, which is a mass of connective tissue and nerve fibers that prohibit regeneration of nerves at the site of injury (Gorski et al. Nerve compression injury may occur as a result of infiltration or extravasation of an infusion. The increased pressure of the fluid decreases perfusion in the area, which can lead to irreversible nerve damage and loss of function. Avoid the cephalic vein above for about 3 to 5 inches above the thumb or styloid process due to potential for nerve damage (Samarakoon et al. Reduce risk for infiltration/extravasation as discussed in the section on infiltration/extravasation. Assess swollen area for paleness and pulselessness, which indicate that tissue necrosis and nerve compression injury are developing. This type of unusual occurrence would be considered a sentinel event (see Chapter 1). Venous Spasm Description and Etiology A spasm is a sudden, involuntary contraction of a vein or artery resulting in temporary cessation of blood flow through a vessel (Alexander, Corrigan, Gorski, & Phillips, 2014). The spasm usually results from the administration of a cold infusate or an irritating solution, or from too-rapid administration of an I. Allow refrigerated medications and parenteral solutions to reach room temperature before administering them. Use a fluid warmer for rapid/large-volume transfusions in accordance with organizational policies. Apply warm compresses to warm the extremity and decrease flow rate until the spasm subsides. Systemic Complications Systemic complications are serious and can be life-threatening. With appropriate preventative interventions and ongoing monitoring, these complications are preventable. It is a serious and often fatal clinical syndrome that is characterized by organ dysfunction.