Cardiovascular diseases (CVDs) are the leading cause of death globally. Cardiovascular disease (CVD) is a major cause of death in Australia, responsible for causing more than a quarter of all deaths. On average, 118 Australians die from CVD each day. That's equal to one person every 12 minutes.

Cardiac catheterisation is an invasive procedure indicated in  a wide  variety of  circumstances.  It is used for diagnostic and therapeutic purposes in the management of patients with cardiac diseases The procedure involves a catheter being inserted into a vein or artery and then led into the heart; usually the site of access will be from the groin, neck or throat.

Diagnostic cardiac catheters are inserted so that blood flow and pressure in the chambers of the heart can be evaluated; interventional cardiac catheters are preferred as an alternative to open heart surgery. The procedures that can be carried out when a cardiac catheter is used include (1);

• Closing septal defects; both ventricular and atrial
• Opening new passageways
• Narrow passageway expansion
• Stent placement

Cardiac catheterisation is usually carried out under a general anaesthetic and can have complications despite recent advances in operative techniques. However, statistics show that post cardiac catheterisation complications can still result in poor health and mortality in patients.

To reduce the risk of complications, it is advised that specific management and vigilant monitoring is in place for early identification of problems. Healthcare professionals, specifically nurses, are in the best position to be able to identify complications and offer prompt care to patients.

Nurses are the healthcare providers considered to be the most competent in reducing the mortality and morbidity rates for post-operative cardiac catheterisation recovering patients.

Patient assessment

The healthcare provider needs to take in many factors when caring for patients who have had cardiac catheterisation.

Firstly, patient history should be assessed. A healthcare provider should be aware of:

• Whether the patient had a diagnostic or interventional cardiac catheter inserted. This is because those who have had interventional cardiac catheter procedures will be at a higher risk of complications. The healthcare provider should also be fully aware of the findings of the procedure and whether there were any complications during theatre.
   
• Whether the patient was taking anticoagulants regularly before the procedure. Although all patients will receive heparin during the procedure, those who are take blood thinning agents beforehand have a higher risk of bleeding. The healthcare provider should also determine which medications have now been prescribed for the patient.
   
• What ‘normal’ cardiac rhythm for the patient was before the procedure took place. This can be found by referring to the pre-procedure ECG charts.
   
• The access site of the catheter, including the position and whether the catheter was arterial or venous.
   
• Age of the patient. Elderly patients and children under the age of one have a higher risk of complications.

Secondly, the healthcare provider should carry out a physical assessment of the patient in order to be aware of any potential complications. The puncture site itself should be routinely assessed to look for bleeding, haematomas, infection, and ecchymosis.

Potential complications and management of complications which can occur after a cardiac catheterisation

The risk of major complications of diagnostic cardiac catheterization procedure is usually less than 1%, and the risk and the risk of mortality of 0.05% for diagnostic procedures. For any patient, the complication rate is dependent on multiple factors and is dependent on the demographics of the patient, vascular anatomy, co-morbid conditions, clinical presentation, the procedure being performed, and the experience of the operator.

Possible complications include, but are not limited to:

Bleeding

Bleeding should be monitored from the puncture site to assess patient recovery. If the patient suffers from a violent coughing fit or vomits, immediately check for bleeding. Aim to immediately apply pressure over the puncture site with gauze to achieve haemostasis; this will typically occur within five to ten minutes. Then the patient’s pressure bandage should be reinforced and the doctor should be notified.

Haematoma

The puncture site should be assessed for any swelling, redness, or pain. A haematoma can suggest internal bleeding; therefore again manual compression should be applied to prevent further bleeding. If the patient is being given any heparin infusions, they should be immediately stopped.

The patient’s signs of intravascular volume depletion should be assessed. If any signs point towards insufficient cardiac output urgent medical help should be sought.

Identification of the bleeding source is essential for patients with continued hemodynamic deterioration. These life-threatening bleeds are more frequent when the artery is punctured above the inguinal ligament. Most patients are managed with a reversal of anticoagulation, application of manual compression and volume resuscitation, and observation.

Arrhythmia

If the arrhythmia presents as something new for the patient, then a doctor should be notified. The healthcare provider should also make sure to assess the patient’s cardiac output, however even if the arrhythmia is already known yet cardiac output is insufficient, immediate medical help should be sought. The patient should also be placed on continuous cardiac monitoring once stable.

Pseudoaneurysm

Pseudoaneurysm Is a potential cause of important femoral bleeding and must be recognized. A pseudoaneurysm develops if a connection persists between a haematoma and the arterial lumen. It presents as a pulsatile mass and the diagnosis is confirmed by ultrasound.

Small pseudoaneurysms of less than 2 to 3 cm in size may heal spontaneously and can be followed by serial Doppler examinations. Large symptomatic pseudoaneurysms can be treated by either ultrasound-guided compression of the neck of pseudoaneurysm or percutaneous injection of the thrombin using ultrasound guidance or may need surgical intervention.

Allergic reactions

Allergic reactions can be related to the use of local anesthetic, contrast agents, heparin, or other medications used during the procedure. Reactions to the contrast agents can occur in up to 1% of the patients, and people with prior reactions are pretreated with corticosteroids and antihistamines. The use of iso-osmolar agents decreases the risk compared to high osmolar agents. When severe reactions occur, they are treated similarly to anaphylaxis with intravenous (IV) epinephrine.

General patient care after the procedure

After the procedure, patients may be taken to the recovery room for observation or returned to their hospital room. They will remain flat in bed for several hours after the procedure. A nurse will monitor vital signs, the insertion site, and circulation/sensation in the affected leg or arm.

The plastic sheath which was inserted in the patient’s groin, neck, or arm will be removed soon after unless the patient requires specialised blood thinning medication.

After the recovery room, the patient should be transferred to a regular hospital or outpatient room. The length of the patient’s stay will be dependent on their condition. Some patients who have had a straightforward procedure may even be discharged on the same day, whereas others who have had an additional procedure such as an angioplasty or insertion of a stent will be required to stay overnight.

Patients should be kept lying flat for several hours after the procedure so that any serious bleeding can be avoided and that the artery can heal. It is advised that diagnostic catheterisation patients are kept on bed rest for four hours, and interventional catheterisation patients stay on bed rest for six hours.

The patient is free to move side to side for their comfort. The head of the bed should be at a maximum thirty degree tilt. The patient should be allowed to eat and drink right after the procedure if they wish to.

After the specified period of bed rest has been completed, patients may get out of bed. The nurse will assist patients the first time they get up, and will check blood pressure while lying in bed, sitting, and standing. Patients should move slowly when getting up from the bed to avoid any dizziness from the long period of bedrest.

Patients may be given pain medication for pain or discomfort related to the insertion site or having to lie flat and still for a prolonged period.

Patients will be encouraged to drink water and other fluids to help flush the contrast dye from the body. They may resume their usual diet after the procedure, unless the doctor decides otherwise.