Section Three- Patient Care

Lab values, patient monitoring, medications and medication dosages are used as examples only. The values and dosages used are general values. Each institution will use different lab values, patient monitoring protocol, medications, and medication dosages. You should check with your institution for your protocols.

For all procedures performed in the angiography lab, informed consent must be obtained. This is a form that the patient must sign stating that the procedure has been explained to him or her. This form includes the procedure and possible complications. The patient must also be given the opportunity to have all of his or her questions answered. That is why it is called informed consent. The patient should be consented by the physician performing the procedure, and someone who is not part of the team performing the procedure should witness the consent. Consents may also be oral. Oral consents are done when the patient is unable to sign (for example, he or she is paralyzed and doesn't have use of the writing hand). Click here for an example of an Informed Consent. If the patient is unable to give consent it may be given by the next of kin or, in a medical emergency, by the chief of staff.

Prior to the exam, the physician performing the procedure reviews the patient's history and physical (H & P). The physician will also review the indications and any contraindications that the patient may have to the procedure. The patient's labs are also reviewed. Common labs are CBC, BUN, CREAT, GLUCOSE, PT/INR, and PTT.

CBC		BUN (Blood Urea Nitrogen)	8-25 mg/100ml
RBC	male 4.6-5.9 million	CREAT	male 0.6-1.5 mg/100ml
	female 4.2-5.4 million		female 0.6-1.1 mg/100ml
WBC	4300-10,800 /mm³	PT (Prothrombin Time)	11-16 seconds
HCT (hematocrit)	male 45-52%	PTT (Partial Thrombin Time)	25-38 seconds
	female 37-48%
HGB (hemoglobin)	male 13-18 g/100ml	INR (International Normalization Ratio)	0.5-1.5
	female 12-16 g/100ml
PLT	150,00-350,000 /mm³	Glucose	70-110 mg/100ml
		Potassium (K)	3.5-5 mEg/L

There are many blood tests that need to be done prior the angiogram. The CBC is the complete blood count. RBC, WBC, HCT, and HGB are some of the values. The RBC is the red blood cells. WBC is the white blood cells. When the WBC is elevated, the patient usually has some type of infection. You should check to see if the patient has a fever (another indication of infection). It is important to check WBC because, if you need to stent the patient, you don't want him or her to get an infection. The HCT is the hematocrit. This checks the percentage of red blood cells in the plasma. If you have a decreased HCT the patient has lost, or is losing, blood somewhere. You would expect to see a decreased HCT with a GI bleeder. HGB is the hemoglobin. This is composed of a pigment (heme), which has iron and a protein part (globin). We also have PLT, which are the platelets. This helps with the coagulation of blood. If you have a patient with an increased platelet count, there may be some type of malignancy. A low platelet count (or thrombocytopenia) might be seen after a viral infection, anemia or other hemolytic disorders.

BUN is the blood urea nitrogen. This test measures the amount of urea nitrogen in the blood. Urea is a waste product formed by the liver and carried through the blood to the kidneys for excretion. If the patient has an increased BUN, he or she may be dehydrated or have a diseased or damaged kidney. CREAT is the creatinine. This test tells you how well the kidney is filtering the waste (creatine phosphate). An increased creatinine is seen when the patient has kidney disease or a damaged kidney. With the increased creatinine, you will want to be careful of the contrast load the patient receives. The patient will not be able to filter the contrast as effectively as someone with a normal creatinine.

PT is the Prothrombin Time. This test is used to check how well the blood clots. If a patient has an increased PT, he or she may have been on anticoagulation therapy (heparin or coumadin). PTT is the Partial Thrombin Time. This is also used for telling how well the blood clots. If the patient has an increased PTT, he or she may be on anticoagulation therapy. If the patient is not taking any anticoagulants, he or she may have a bleeding problem. During an interventional procedure, you may be asked to do an ACT on the patient. This is the activated coagulation time. The Interventionalist uses this test (done in the procedure room) to tell how well the patient is anti-coagulated during a percutaneous angioplasty or stent placement. The INR (International Normalization ratio) is also used to determine how the patient's blood clots. Most Interventional Radiologists won't do a procedure until the patient has an INR of 1.5 or below. An increased INR may be corrected with Vitamin K or fresh frozen plasma (FFP) if the procedure is an emergency and you can’t wait for the INR to return to normal on it's own. With patients on anticoagulation therapy, the INR is found to be higher.

Prior to starting any procedure you should make sure that you have the following supplies: oxygen, oxygen tubing, suction, suction tubing, oral and nasal airways, ET kit, emergency medications, and a crash cart. The patient should be on clear liquids after midnight before the procedure. The patient should have IV access and be premedicated if he or she is allergic to contrast. After getting the patient on the angio table, the patient should then be hooked up to monitoring equipment.

One person must be assigned to monitor the patient during the procedure. This should be that person’s only job. Monitoring equipment needed is a thermometer, an EKG, a Pulse oxycemeter, and a blood pressure cuff. By connecting the patient to this monitoring equipment, you will be able to monitor temperature (a temp prior to the procedure is usually the only temp needed), EKG, Oxygen saturations, blood pressure, pulse, and respiration. If the patient is receiving blood products during the procedure, it is a good idea to check the patient’s temperature after he or she receives the first unit.

Baseline vital signs should be taken, and repeat vital signs should be taken every 10 minutes (JCAHO standard). The person monitoring the patient should also get the patient's history. It should be noted if the patient ever had an angiogram before and if there were any problems during or just after the procedure.

If the patient's systolic blood pressure gets above 180, you may need to give the patient some medications to lower it. Some institutions give the patent conscious sedation. Some give blood pressure medications, like Nifedipine, sublingually to lower the blood pressure. The patient's blood pressure might also rise if he or she needs to urinate. If the diastole blood pressure goes below 50, give the patient fluids and place the patient in Trendelenberg (head down). You also need to keep an eye on the oxygen saturations, especially during conscience sedation. If they go below 95% you should put the patient on Oxygen.

During the procedure, the patient is usually either on a 3-lead or 5-lead EKG. The leads are placed so that they are not in the area being imaged during the procedure. There are radiolucent leads available so that the leads won’t show up even if they cross the field.

As the intervention technologist, if you are monitoring the patient you should be able to recognize certain types of arrhythmias on the EKG. Many of the arrhythmias listed require some type of emergency action. Since this is a brief review, we won't be getting into the actions to take. It is best to take an ACLS class or review the EKG section of the ACLS book prior to your exam.

Medications and the dosages listed are as examples only. These dosages or medications may not be used in your angio suite. You will need to check with your department about the types of medications and dosages that should be used in your institution.

This gives an amnesic effect and helps to relax the patient. It is more potent than Valium, but Versed is shorter acting. It is usually used in combination with Fentanyl.

Versed(Midazolam)
Dose:	Adverse Effects:	Do not use:	Cautions:
IV .25-1 mg per dose give in increments, allow 2 minutes for effect. Dosage is .07-.08 mgm/kg body weight	Amnesia, headache, confusion, euphoria, muscle tremor, hypotension, PVC's, vasovagal episode, tachycardia, nodal rhythm, coughing, laryngospasm, bronchospasm, and dyspnea.	Acute narrow angle glaucoma Pregnancy	COPD Chronic Renal Failure CHF Elderly/debilitated

Valium is used to help relax patients and is much longer acting than Versed. It is not as widely used in angiography labs.

Valium (Diazepam)
Dose:	Adverse Effects:	Do not use:	Cautions:
IV .5-5 mgm per dose additional increments should be given in half the initial dose, 1-3 minutes for effect PO 2-10 mg, onset 30 to 60 minutes	Drowsiness, confusion, ataxia, hypotension, tachycardia, and cardiovascular collapse	with depressed vital signs within 14 days of a MAO inhibitor Pregnancy	Impaired liver or renal function COPD Elderly/debilitated epilepsy myasthenia gravis

The patient may be premedicated with Ativan to help calm him or her prior to the procedure.

Ativan (Lorazepam)
Dose:	Adverse Effects:	Do not use:	Cautions:
IV mgm, onset minutes IM 2-4 mgm, onset 20-30 minutes PO 2-4 mgm, onset 20-50 minutes	Drowsiness, disorientation, confusion, restlessness, nausea, vomiting, abdominal, some cardiac depression, respiratory depression, hypertension, and hypotension	Narrow angle glaucoma Pregnancy	Renal or hepatic impairment Organic brain syndrome GI disorders Myasthenia gravis Elderly/debilitated Limited pulmonary reserve

When using Versed, Valium or Ativan, (as with any IV medications), you should flush the line after giving each medication. If the patient was overmedicated with Valium, Versed or Ativan, it can be reversed using Romazicon (Flumazenil).

Flumazenil (Romazicon)
Dosage:	Adverse Reactions:
0.2 mg (2 ml) IV over 15 seconds, if the patient doesn't reach desired consciousness wait 45 seconds and give another dose of 0.2 mg every 60 seconds. The maximum total dose is 1mg (10 ml). Most patients require a dose of 0.6-1 mg.	Respiratory depression, death, convulsions, cardiac dysrhythmias, headache, sweating, nausea, vomiting, agitation, confusion, shivering, rigors, arrythmia, dysphonia, and hiccups

This is the most commonly used narcotic agent in the angiography suite. It is100 times stronger than Morphine but shorter acting.

Fentanyl (Sublimaze)
Dose:	Adverse Effects:	Do not use:	Cautions:
IV 25-50 mcg per dose, onset 1-2 minutes	Bradycardia, hypotension, respiratory depression, and chest rigidity	within 14 days of a MAO inhibitor Myasthenia gravis Pregnancy	Head injuries Increased intracranial pressure Elderly/debilitated COPD liver and kidney dysfunction Bradyarrythmias

This may be used in the angiography suite. It is not used as frequently as Fentanyl but it is longer acting.

Morphine
Dose:	Adverse Effects:	Do not use:	Cautions:
IV 2-5 mgm per dose, onset is 3 to 5 minutes dosage is .05-2 mgm/kg IM 8-10 mgm, onset 15-30 minutes	Respiratory depression, hypotension, and bronchoconstriction	Acute bronchial asthma COPD Severe liver disorder Acute alcoholism Pancreatitis Pregnancy	Psycosis Cardiac arrythmias Cardiovascular disease Severe obesity Reduced blood volume Elderly/debilitated

This may be used in the angiography suite. It is usually used when giving the patient Urokinase because it will help with the shaking that Urokinase can cause.

Demerol (Meperidine)
Dose:	Adverse Effects:	Do not use:	Cautions:
IV 10-20 mgm per dose, onset 3 to 5 minutes dosage is .5-1 mgm/kg IM 50-100 mgm, onset 10 minutes	Orthostatic hypotension, negative inotropic action, syncopal episodes, tachycardia, tremors, twitches, seizures, nausea, and vomiting	Convulsive disorders Acute abdominal condition MAO inhibitors	Head injury Increased intracranial pressure Asthma Supraventricular tachycardia Glaucoma Elderly/debilitated Impaired liver or kidney function

If the patient is overmedicated with any of the listed narcotic agents, you may reverse it with Narcan. But you must remember with the reversal agents that they do not last as long as the narcotic.

Narcan (Naloxone)
Dosage:	Adverse Effects:
IV .4-2mg, onset is 2 minutes. Dose may be repeated in 2-3 minute intervals up to a total of 10 mg	Increased blood pressure, tremors, hyperventilation, nausea, vomiting, sweating, and tachycardia

Urokinase (Abbokinase)
Dosage:	Contraindications:	Adverse Reactions:
The concentrations may vary. But a common dose is- 4,000 units/minute for the first 2 hrs and then 2,000 units/minute for the next 2 hours and then 1,000 units/hour Usually supplied unreconstituted as 250,000 units Obtained from human kidney cultures	Patients who had surgery within the last 10 days, recent CVA (within 2 months), recent intracranial or spinal surgery, cerebral tumors, and patients who are bleeding	Bleeding Fever Allergic Reaction Sepsis Embolization Death

Streptokinase (Steptase)
Dosage:	Contraindications:	Adverse Reactions:
Has been replaced by Urokinase in most institutions Doesn't work as well in lyses as Urokinase	Patients who had surgery within the last 10 days, recent CVA (within 2 months), recent intracranial or spinal surgery, cerebral tumors, and patients who are bleeding	Bleeding Fever Allergic Reaction Sepsis Embolization Death

rt-PA (Recombinant Tissue-type Plasminogen Activator)
Indications:	Characteristics:
Used to unclog coronary arteries and limit myocardia ischemia after MIs A human protein May be used when Urokinase is not available	Doesn't have the systemic effect that Urokinase and Streptokinase do

Heparin
Dosage:	Adverse Reactions:
75 units per kilogram Maximum effectiveness is 30 minutes for 1000 units and the half life is 90 minutes May be reversed with Protamine (10 mg per 1000 active units)	Hemorrhage Acute Thrombocytopenia Minor Allergic Response

Aspirin (Acetylsalicylic Acid)
Use:	Adverse Reactions:
Inhibits platelet adhesiveness Given pre and post angioplasty Patients usually take 1 baby Aspirin per day following angioplasty	Bleeding Stomach Ulcers Tinnitus (ringing in the ears)

Atropine Sulfate
Dosage:	Indications:	Adverse Reactions:
IV 0.5-1 mg	Vasovagal reactions with decreased heart rate and blood pressure, sinus bradycardia, and nausea and sweating	Tachycardia Frequent Ectopic Beats Dry Mouth Urinary Retention Blurred Vision

Epinephrine
Dosage:	Indications:	Adverse Reactions:
IV 1:10,000 Subcutaneous 1:1000	Relieves bronchospasm, laryngospasm, anaphylaxis, reverses severe hypotension, vasoconstrictor, increases heart rate, and increases ventricular contractility	Severe Headaches Hypertensive Events

Lidocaine
Dosage:	Indications:	Adverse Reactions:
IV 50-100 mg	Improves response to defibrillation, for frequent PVC, ventricular tachycardia, and fibrillation	Hypotension Bradycardia Tinnitus (ringing in the ears)

Nifedipine (Procardia)
Use:	Adverse Reactions:
Reduces blood pressure Helps prevent arterial vasospasm Dose- SL 10 mg (capsule is punctured with a needle and medication is placed under the patient's tongue)	Hypotension Bitter Taste

Nitroglycerin
Use:	Adverse Reactions:
Placed transdermally for angina and vasospasm 1 1/2" nitropaste PO for angina relief 0.4 mg Intra Arterial for artery spasm 100 micrograms	Hypotension Headache

Misc.
Priscoline (Tolazoline)	Hydralazine (Apresoline)	Papaverine
Used in the peripheral vessels, usually injected before taking arterial pressures and may be given to optimally visualize the arteries prior to arteriogram	Used to reduce blood pressure	Vasodialator and antispasmotic it's action is more pronounced with spasm in the cerebral, coronary, pulmonary, and peripheral arteries

This is used to relax the smooth muscles in the stomach, duodenum, small bowel and colon. It is usually used during Percutaneous Gastrostomy Tube placement.

Antibiotics are used for antibiotic prophylaxis. They might be used when puncturing a graft, during biliary tube placement, and during abscess drainage placement. The most common used is Cefazolin (Ancef).

During interventional procedures, the patient should be on an IV drip. You want the patient to be well hydrated prior to receiving contrast so that it is excreted easily. The IV should be running between 75 and 150 ml per hour. When you have patients with congestive heart failure (CHF) their IV should run at the low end, no more than 75 ml/hr.

Contrast agents are used in angiography to visualize the blood vessels. With contrast you are also able to visualize all different areas and organs. This is possible because the contrast media alters the density of an organ relative to its surrounding tissue. This makes the area absorb more radiation, therefore "highlighting" it, so that you may see it better. Contrast molecules have positive (cation) and negative (anion) portions.

Meglumine, sodium, or meglumine and sodium combination. Provides solubility and radiolucent.

Diatrizoate, iothalamate, or nonionic dimer. Provides solubility and radiopaque.

Types of Contrast Agents
	Ratio (contrast to osmolality particle)	Name
Ionic High-osmolar	3:2	Renografin, Conray
Ionic Low-osmolar	6:2	Hexabrix
NonIonic Low-osmolar	3:1	Isovue, Ominpaque, Optiray

Properties of Contrast Agents
Osmolality	This is determined by the number of particles in a volume of solution, most important factor for patient discomfort and vasodilation. Ionic 6 to 8 times as osmolar than blood NonIonics 2 to 3 times as osmolar than blood
Viscosity	The degree of thickness or stickiness, this gives you resistance. Agents with megulmine are more viscous than sodium. Temperature will also affect viscosity (contrast should be administered at body temperature). This will decrease patient discomfort. NonIonic is more viscous than ionic
Strength	Amount of iodine concentration, this gives you the opacity. Iodine is slightly more radiopaque than lead, the more iodine the higher the osmolity.
Toxicity	How toxic or nontoxic the contrast is. Meglumine is less toxic than sodium.
Miscibility	How solvent (miscible) the contrast is with blood. You want it to be solvent with blood to prevent embolization.

When injecting contrast, you need to be aware of the patient's allergy history. If a patient has had a previous contrast reaction, multiple allergies, renal insufficiency, diabetes, or asthma, you should use non-ionic contrast. If performing a peripheral angiogram, you should also use non-ionic. This will decrease the pain and you will have less patient motion. With the history of previous contrast reaction, the patient should be premedicated.

Prednisone 40 mg PO 12 hours and 1 hour pre-procedure and Benadryl 50 mg PO 1 hour pre-procedure.

Contrast Reactions
Hives (urticaria)	you may give Benadryl 25-50 mg IV
Vasovagal	place the patient in Trendelenberg, give oxygen, increase IV fluids, and you may need to give Atropine 0.5-2 mg
Bronchospasm	put the patient upright or semi-upright, give oxygen, increase IV fluids, and you may need to give the patient albuterol inhalant (2 inhalations) or Epinephrine 0.01 mg IV and then 0..001-0.004 mg/min, Benadryl 25-50 mg IV
Laryngeal edema	put the patient upright or semi-upright, give oxygen, increase IV fluids, inhaled aerosol epinephrine or IV epinephrine 0.1-1 mg and Benadryl 25-50 mg IV
Hypotension	place the patient in Trendelenberg, give oxygen, increase IV fluids, and if blood pressure doesn't come up you may give IV epinephrine 0.1-1 mg and Benadryl 25-50 mg IV.
Pulmonary edema	put the patient upright or semi-upright, give oxygen, make sure you have IV access (avoid extra fluid bolus), you may give Morphine 2-4 mg IV and Benadryl 25-50 mg IV
Respiratory arrest	Start CPR and call a Code.

If you are setting the tray up for a procedure, you need to use sterile technique. Depending on the policy at your institution, you would either just put on sterile gloves or you may have to gown, mask and glove up. The best way to learn how to put on sterile gowns and gloves is to practice. When dealing with sterility, if you think that it is contaminated, then it is!

When scrubbing the access site, you need to apply the betadine in circles. You should start in small circles from the center of the field, working your way to the outer edge. You should not go over the area more than once with each sponge, and you should scrub the area at least three times.

Patient Care

Patient Prep		Monitoring
EKG		Lab Values
Medications		Contrast
Sterile Technique		IV Therapy
Hemodynamic Pressures		Post Procedural Care/Follow-up

Normal Adult Vital Signs
Blood Pressure	Systolic 100-140	Pulse	60-100 beats per minute
	Diastole 70-90	Respirations	16 to 20 per minute
Oxygen Saturations	95-99%	Temperature	98.6 degrees F Oral

	P	contraction of the atria
	PR	the time it takes from the beginning of the atrial contraction to the beginning of the ventricular contraction
	QRS	contraction of the ventricles
	T	ventricular recovery (resting of the heart)

Benedryl (Diphenhydramine)
Dose:	Use:
IV or PO 25-50 mg	Minor allergic reactions- hives and nausea

Ventricular Tachycardia
	Most dangerous. Only ventricular contraction, no normal beats.

Premature Ventricular Complex PVC)
Ventricles contract sooner than usual, tall and broad QRS. PVC's may be unifocal (1) or multifocal (more than one).

Premature Atrial Contraction (PAC)
	Atria contracts sooner than usual, longer gap between T and P wave. You might see this when performing a hickman catheter placement or a pulmonary angiogram.

Atrial Flutter
Sawtooth pattern. Result of a reentry circuit within the Atria.

Ventricular Fibrillation
	There is no pumping action of the heart (a Cardiac Arrest), this is a dire emergency.

Coumadin(Warfarin Sodium)
Use:	Adverse Reactions:
Taken PO by patients on anticoagulation therapy Must be stopped 3 days prior to arteriogram or reversed	Hemorrhage

Normal Sinus Rhythm
60-70 Beats per Minute