Pain and discomfort in closure of femoral access coronary angiography. The CLOSuredEvices Used in everyday Practice (CLOSE-UP) pain sub study.

BACKGROUND: Pain and discomfort in relation to vascular closure are the predominant patient complaints after coronary angiography (CAG). No large-scale randomized studies have evaluated pain and discomfort after CAG with access site closure by manual compression versus a vascular closure device (VCD). AIM: To compare pain and discomfort after femoral artery closure by manual compression versus FemoSeal® VCD. METHODS: The study is a sub study to the CLOSE-UP study, a randomized, single centre comparison of FemoSeal(®) VCD versus manual compression after CAG. Pain and discomfort score was assessed immediately after the closure procedure, at time for mobilization, at discharge and after 14 days. RESULTS: 1014 patients were included and 1001 patients entered analysis. In-hospital follow-up was obtained for all patients and 14-day follow-up was completed for 96% of patients. The closure procedure lasted 1 (1-1) min in the FemoSeal(®)VCD group and 8 (6-10) min in the manual compression group. Pain and discomfort score at the procedure was significantly higher in the FemoSeal(®)VCD group. No differences in pain and discomfort were detected after leaving the catheterization laboratory. CONCLUSION: Closure of femoral access after CAG by the FemoSeal(®)VCD was associated with significantly more pain and discomfort compared with closure by manual compression. No difference in pain and discomfort was found at follow-up.

An innovative technology for safe needle disconnection after hemodialysis.

PURPOSE: Vascular access care is a key topic for hemodialysis patients. The most cost-effective and lasting vascular access for chronic hemodialysis is the native arteriovenous fistula (AVF); however, bleeding after dialysis session from puncture site is a relevant problem. Achieving hemostasis is necessary and requires hand compression by the nurse or the patient if he or she is capable and cooperative. METHODS: We assessed a new vascular closure device, VITACLIP® (Serumwerk Bernburg Vertriebs GmbH) that is an adhesive silicone seal device, which can be set onto the skin and punctured by dialysis needle. After withdrawal of the needle, VITACLIP® prevents bleeding from the punctured vessels, making hand compression unnecessary. RESULTS: We used this device in 5 chronic hemodialysis patients with native lateral-terminal AVFs. The patients' hemodialysis prescription and anticoagulants dose were not changed. This device allowed puncture of vascular access without complications such as bleeding at the end of hemodialysis; we did not observe any mechanical complications due to needle dislocation or any dermatological lesions at skin puncture site. However, the cannulation proved to be more difficult for the nurses with this device because the silicone hampers identification of the vessel for puncture for deeper AVFs. CONCLUSIONS: This device helps patient management and improves patient safety by reducing the risk of AVF bleeding at the end of dialysis, decreasing the risk of staff contact with patients' blood, and theoretically eliminating the risk of massive bleeding in the case of an inadvertent needle dislodgement going unnoticed during treatment.

Implementation of radial arterial access for cardiac interventions: a strong case for quality assurance protocols by the nursing staff.

BACKGROUND: Radial arterial access is becoming increasingly popular for coronary angiography and angioplasty. The technique is, however, more demanding than femoral arterial access, and hemostasis is not care-free. A quality assurance program was run by our nursing staff, with patient follow-up, to monitor radial arterial access implementation in our laboratory. METHOD: In 973 consecutive patients, both a hydrophilic sheath and an inflatable bandage for hemostasis were used. Bandage inflation volume and time were both reduced through subsequent data audit and protocol changes (A = 175 patients; B = 297; C = 501). RESULTS: An increase was achieved in the percentage of patients with neither loss of radial pulse nor hematoma of any size (A = 81.3%, B = 90.9%, C = 92.2%, P < 0.001), and no discomfort at all (A = 44.2%, B = 75.1%, C = 89.3%, P < 0.001). Follow-up was available for 965 patients (99%), and in 956, the access site could be re-inspected at least once. There were no vascular complications. Overall, the radial artery pulse was absent at latest follow-up in 0.6% of cases (95% confidence interval 0.21-1.05%). In 460 consecutive patients with complete assessment in protocol C, a palpable arterial pulse was absent in 5% of cases at about 20 h after hemostasis. Barbeau's test was positive in 26.5% of patients (95% confidence interval 22.5-30.6%). They had a significantly lower body weight, a lower systolic blood pressure at hemostasis, and a higher bandage inflation volume; a hematoma of any size and the report of any discomfort were also more frequent. Barbeau's test returned to normal in 30% of them 3-60 days later. CONCLUSION: Our nurse-led quality assurance program helped us in reducing minor vascular sequelae and improving patient comfort after radial access. Early occlusion of the radial artery as detected by pulse oxymeter is frequent, often reversible, and may be mostly related to trauma/occlusion of the artery during hemostasis.

Femoral artery closure after cardiac catheterization.

After diagnostic and interventional cardiac catheterization, femoral artery closure devices offer quicker time to hemostasis, ambulation, and discharge than does manual compression. Nurses should understand how femoral artery closure devices work, the potential vascular complications that may occur with their use, and the recommended time to ambulation and discharge.

The implementation of a guideline of care for patients with a Sengstaken-Blakemore tube in situ in a general intensive care unit using transitional change theory.

The use of the Sengstaken-Blakemore tube as a life-saving treatment for bleeding oesophageal varices is slowly becoming the least preferred method possibly due to the potential complications associated with its placement. Nursing practice pertaining to the care of this patient group appears ad hoc and reliant on local knowledge and experience as opposed to recognised evidence of best practice. Therefore, this paper focuses on the application of Lewin's transitional change theory used to introduce a change in nursing practice with the application of a guideline to enhance the care of patients with a Sengstaken-Blakemore tube in situ within a general intensive care unit. This method identified some of the complexities surrounding the change process including the driving and restraining forces that must be harnessed and minimised in order for the adoption of change to be successful.

Peripheral arterial sheath removal program: a performance improvement initiative.

The increasing number of endovascular procedures by both cardiologists and vascular surgeons strain available resources, such as recovery space, creating delays in the throughput of patients. The use of alternative settings, personnel, and approaches to postprocedural care has been proposed to maximize the number of procedures that can be done with existing procedure rooms. However, a key question remains about whether this can be done safely and achieve good patient outcomes. A performance improvement project was conducted to evaluate the safety and effectiveness of shifting postprocedural care and removal of intraarterial sheaths by the staff in the cardiac catheterization laboratory to specially trained acute care nurses on an inpatient vascular surgical unit. The purpose of this project was to develop a performance improvement project that included administrative, educational, and clinical components and to evaluate effects on key patient outcomes, prospectively, over 15 months.

Cateterismo cardíaco. Actuación de enfermería en una unidad de críticos / Cardiac catheterism. Nursing performance in the critical unit

En el infarto agudo de miocardio (IAM), la isquemia es aguda, intensa y mantenida, y es una de las principales causas de muerte en nuestra sociedad. El tratamiento inmediato puede reducirla considerablemente. Los objetivos marcados en este estudio fueron: verificar la evolución de los tratamientos en el IAM; comprobar la evolución en los métodos hemostáticos en pacientes sometidos a cateterismo cardíaco, y elaborar nuevos protocolos de enfermería para el cuidado pre y poscateterismo. Se realizó un estudio retrospectivo descriptivo. Desde octubre de 1999 hasta diciembre de 2002 ingresaron en nuestra unidad 1.969 pacientes, de los cuales 818 lo hicieron por patología cardíaca, de ellos se seleccionaron los que el diagnóstico fue de IAM o angina de pecho, y de entre ellos a los que se les realizó cateterismo cardíaco. Se desarrolló en una unidad de cuidados intensivos (UCI) polivalente de 12 camas, y la recogida de datos se realizó por 5 enfermeras de dicha unidad, a partir de la historia clínica y de enfermería. Se observó un incremento en la realización del cateterismo cardíaco en los últimos años, tanto diagnóstico como terapéutico, así como un incremento de la sutura intraarterial como método de hemostasia, en detrimento de la compresión mecánica. Se elaboraron nuevos protocolos de enfermería estandarizados para facilitar y mejorar el cuidado de estos pacientes e intentar reducir el tiempo de preparación para su traslado a la unidad de hemodinámica, dada la urgencia que se presentaba en la mayoría de los casos

In acute myocardial infarction (AMI), ischemia is acute, intense and maintained, it being one of the main causes of death in our society. Immediate treatment may reduce it considerably. The objectives established in this study were the following: Verify the course of the AMI treatments Verify the evolution in hemostatic methods in patients subjected to cardiac catheterism. Elaborate new nursing protocols for pre- and post-catheterism care. A retrospective, descriptive study was done. From October 1999 to December 2002, a total of 1969 patients were admitted to our unit. Of these, 818 were admitted due to heart disease. Those whose diagnosis was AMI or Angina were selected among the latter and then those in whom cardiac catheterism was done were chosen. It was conducted in a 12 bed polyvalent ICU, the data collection being done by five nurses from that unit based on clinical and nursing history. An increase in the performance of diagnostic and therapeutic cardiac catheterism in recent years was observed, and there was also an increase in intraarterial suture as hemostasis method in detriment to mechanical compression. New standardized nursing products were elaborated to facilitate and improve the care of these patients and try to reduce preparation time for their transfer to the hemodynamics unit, given the urgency existing in most of the cases

Vascular access complications after cardiac catheterisation: a nurse-led quality assurance program.

BACKGROUND: Vascular access complications may be a cause of discomfort, prolonged hospital stay, and impaired outcomes in patients undergoing cardiac catheterisation. AIMS: To assess vascular access complication in our patients with/without the use of closure devices as a first local benchmark for subsequent quality improvement. METHODS: A nurse-led single-centre prospective survey of all vascular access complications in consecutive patients submitted to cardiac catheterisation during 4 months. RESULTS: The radial and femoral access were used in 78 (14%) and 470 (83%), respectively, of 564 procedures, and a closure device was used in 136 of the latter. A haematoma (any size) was isolated and uneventful in 9.6% of cases. More severe complications (haemoglobin loss >2 g, need for blood transfusion or vascular repair) occurred in 1.2% of cases, namely: in none of the procedures with radial access, and in 0.4% and 2.4% of femoral diagnostic and interventional coronary procedures, respectively. During complicated (n=40) vs uncomplicated (n=172) transfemoral interventions, the activated coagulation time was 309+/-83 vs 271+/-71 s (p=0.004), but the use of closure devices was similar. CONCLUSION: Severe vascular access complications in our patients were fewer than in most reports, and virtually absent in radial procedures. Vigorous anticoagulation was associated with increased complications in our patients, but closure devices were not. A new policy including both the use of the radial access whenever possible, and a less aggressive anticoagulation regimen during transfemoral interventions will be tested.

Femoral access management: comparison between two different vascular closure devices after percutaneous coronary intervention.

OBJECTIVES: Several devices have been proposed as an alternative to manual compression (MC) for femoral access management (FAME) following catheterization. Although these devices allow earlier ambulation, they have not always been shown to reduce vascular complications. As a consequence, their cost efficacy is not obvious. METHODS: During MC a special catheter deployed temporarily within the artery to achieve haemostasis (Bio-DISC) (BD) was compared with an anchor-collagen based system Angio-Seal (AS) among 463 consecutive patients undergoing PCI. We examined vascular or systemic complications, nursing time spent to puncture site management and patient's satisfaction. RESULTS: Relative contra-indications to the use of vascular closure devices were encountered in 158 patients. There were no significant differences in baseline characteristics between the patients assigned to each of the 3 treatment groups. The deployment success rate was 98% for AS and 90% for BD (p = 0.037). Vascular complications occurred in 10.8%, 4.0% and 5.8% (p: NS) of MC, AS and BD patients, respectively. The longer sheath dwell time contributed to most of the complications in MC and BD. Nursing time spent for access management was 48.9 min in MC; 28.1 min in BD and 9.9 min in AS (p < 0.0001 ). Satisfaction score above 70 was noted in 46%, 86% and 92% of patients managed by MC, BD and AS, respectively. CONCLUSION: AS use is associated with fewer complications, improved patient well being and saves 39 minutes of nursing time. The additional cost of AS is justified when used in selected patients undergoing PCI.

Bed-rest post-femoral arterial sheath removal--what is safe practice? A clinical audit.

Numbers of patients undergoing coronary angiography and angioplasty procedures have increased in England due to targets within the National Service Framework for Coronary Heart Disease. Little evidence is available regarding optimal bed-rest duration for patients post-femoral arterial sheath removal following these procedures. Through literature review and clinical benchmarking, we aimed to identify what best practice was in the UK and whether bed rest times at our centre could be reduced without increasing complications to enable increased day case procedures. An audit tool was designed to collect data regarding method of obtaining haemostasis, length of bed-rest post-sheath removal and any post-procedural complications experienced by the patient. From a convenience sample of consecutive patients, 195 complete sets of baseline data revealed an average (median) period of 6-h bed rest. This was reduced to 3h and audit repeated yielding 176 complete data sets using the same audit tool. Femoral wound site complication rates were not significantly affected by reducing bed-rest time for diagnostic or interventional procedures. These findings contributed to an important change in practice, reducing length of stay post-procedure and should be re-explored due to increased use of femoral arterial closure devices.

Determining best practice: comparison of three methods of femoral sheath removal after cardiac interventional procedures.

OBJECTIVE: To test the null hypothesis that there is no significant difference between 3 methods of sheath removal: manual compression, mechanical compression with the Compressar, and mechanical compression with the Femostop. METHODS: The research design was experimental. Ninety patients were randomly assigned using a random-numbers table to undergo one of 3 methods of sheath removal. The principal investigator (L.M.B.) requested the patients' consent to undergo randomization of the sheath removal. Post procedure, each patient was told which method of sheath removal he or she would undergo based on results of the random-numbers table assignment. RESULTS: There were no significant differences between the groups with regard to age, body mass index, sheath size, heparin utilization, antiplatelet agents, or use of IIb-IIIa inhibitors. The complications between the methodologies for sheath removal were statistically significant. Patients who underwent manual sheath removal had fewer complications compared with those who underwent sheath removal using the Compressar or Femostop (chi2 P = .04). When complications were compared with the other parameters, only the presence of postprocedure heparin infusion (chi2 P = .014) and ACT values (Student t test P = .044) proved to be statistically significant. CONCLUSIONS: Based on the results of this study, staff in the study setting are currently exploring manual sheath removal as the preferred practice. Randomized controlled studies with larger sample populations at multicenter research sites are needed to ensure generalizability of results to larger populations. When using manual pressure application in conjunction with closure pad devices, hold times can be decreased, thus resulting in cost savings through decreased equipment use, earlier discharge times, and improved bed utilization.

The Minnesota tube: its use and care in bleeding esophageal and gastric varices.

A variety of treatments are available for bleeding esophageal varices. Treatments include pharmacologic (propanolol, somatostatin, octreotide, vasopressin, and nitroglycerin), endoscopic (injection sclerotherapy and banding), vascular (transjugular intrahepatic portosystemic shunt), surgical (portovariceal disconnection and portosystemic shunts), and tamponade (via use of the Minnesota tube). This article will focus on use and care of the Minnesota tube, including numerous suggestions from the literature. Tamponade for treatment of esophageal varices may be accompanied by numerous complications, some of which are major or lethal. For this reason, extreme caution should be used when implementing this method. While hemostasis is not achievable via tamponade in 8-50% of patients and 50% of patients rebleed, use of tamponade may achieve stabilization of a patient so that sclerotherapy or surgery becomes a treatment option.