These statistics give insight into the fact that, though rare, stroke does occur in the cardiac cath lab CCL , necessitating the need for the staff to be cognizant of the signs and symptoms, along with the immediate actions to take in order to prevent suboptimal outcomes.
Patients who experience a stroke during or after diagnostic cardiac catheterization or PCI have an increased length of hospital stay by approximately four days, and experience moderate to severe disability post-discharge. Rapid recognition of a stroke and immediate intervention can significantly improve the long-term outcomes. Therefore, identifying patients at high risk, and understanding the symptoms and treatment possibilities for stroke is vital.
We believe that raising the level of awareness of the CCL staff and having clear protocols in place to address recognition and intervention regarding stroke can facilitate staff comfort and efficiency in the unlikely event of a stroke in the CCL. While the risk factors for cardiovascular disease and cerebrovascular disease are similar, invasive cardiac procedures carry additional inherent risks, which means the cath lab team must be aware of hospital protocol should a PCI patient suffer a stroke during or after their procedure.
Patients at higher periprocedural risk for stroke are those with:. Often, Corazon advocates education for cath lab staff on these and other possible risk factors. Stroke symptoms vary with the location of the infarct or hemorrhage. Common neurological deficits noted in general during stroke in the cath lab are motor weakness, aphasia, change in mental status and visual disturbances, with the most common being motor or speech deficits.
Stroke symptoms can be camouflaged by or mimic the effects of sedation, making it more difficult to identify the occurrence of a stroke. Also, certain other conditions such as seizures, hypoglycemia, and migraine can mimic stroke symptoms. The neuro exam in the CCL should be focused on assessing for these particular signs and symptoms. Rapid discovery of a stroke and prompt intervention may minimize any long-term effects of the stroke or even save the life of the patient.
Infarcts during catheterization and intervention arise from various embolic sources. The composition of the emboli also varies, from air to soft clot to calcified atheroma, or multiple compositions such as atheroma with a fibrin clot around it. Air emboli may result from large injections of air into the circulation down to gaseous microemboli that are due to microbubbles injected with contrast or saline.
Transcranial Doppler TCD studies have shown multiple cerebral microemboli released during cardiac catheterization. The exact incidence of air emboli is unknown and there are no specific neurological signs or symptoms related to air embolism. PCI involves the use of a larger guide catheter, and more and stiffer-caliber catheters than diagnostic catheterizations.
Stroke and PCI: Best Practice in the Cardiac Cath Lab | Cath Lab Digest
This raises the risk of trauma to the aorta and the dislodgement of aortic atheroma during catheter manipulation. Thrombus formed within the catheter or catheter tip during the procedure can also become a source of emboli. The transradial approach to catheterization is thought to lead to a higher number of solid emboli due to mechanical forces near the apertures of the right vertebral and common carotid arteries; plaques in those areas risk becoming dislodged and embolizing to the brain.
Deficits may be non-existent or not readily noticeable, such as some mild cognitive deficits. Since patients are not tested for these deficits, the impact on quality of life is uncertain, as are the long-term effects. Recognition of the source and type of infarct will aid in determining which type of immediate intervention will be most beneficial for the patient and in formulating overall acute care treatment and secondary stroke prevention plans. Since the brain has minimal oxygen reserves, it cannot withstand an ischemic situation for any length of time without leading to permanent deficits.
Therefore, it is imperative that interventions are instituted as soon as possible after stroke symptoms become evident. For a patient with stroke symptoms entering into the emergency department ED , treatment should be initiated within 60 minutes of entrance into the ED.
Percutaneous coronary intervention (PCI or angioplasty with stent)
In the case of the CCL, treatment should be initiated within 60 minutes of symptom discovery. Unfortunately, there are at present no established protocols for addressing a stroke specifically in the CCL. Due to the lack of established clinical or operational standards, and the lack of data to be used for benchmarking against best-practice programs, internal measures are necessary to ensure optimal care for these high-risk patients.
Corazon recommends that the CCL set up a stroke alert process Figure 1 that would ensure a rapid response to a necessary stroke intervention within the cath lab setting.
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Based on Corazon experience with diverse programs across the country, typically, the personnel to notify during a stroke alert activation are:. Once the symptoms are evident, the stroke team responders should be notified and the patient assessed more critically for deficits. The symptoms must be confirmed as the result of stroke, rather than other possible neurological events, such as seizures or brain tumor.
The procedure catheter can remain in place for the CT if there is a potential to use it for an intra-arterial lytic intervention. Also, if the sheath is still in place, a cerebral angiogram can be performed in lieu of the CT scan. An angiogram will better determine thrombus morphology, the location and degree of the occlusion, and the status of collateral circulation, when compared to CT. Selective intra-arterial treatment may be preferred if the patient has recently received antiplatelets and anticoagulants which would increase the risk of bleeding. Since there is a lesser dose of drug administered, the risk of bleeding should be decreased.
A neuro interventionalist can perform the angiogram or the intravascular interventions, if necessary. If the patient meets the criteria for intravenous t-PA, the drug should be started immediately.
The drug is mixed in sterile water and should not be shaken or sent through a pneumatic, which would destroy some of the product. Vital signs and neuro exams are performed every 15 minutes for two hours, every half hour for six hours, then every hour for the next 16 hours.
The patient should be admitted to an intensive care unit for close monitoring for neurological changes and complications due to the t-PA. Intra-arterial t-PA will be administered at a lesser dose, which will be determined by the interventionalist. If the patient is not a candidate for either intravenous or intra-arterial t-PA, mechanical extravasation of the embolus or multimodal endovascular therapy may be considered. During or shortly after cardiac catheterization, retroperitoneal bleeding and groin hematoma can also occur. If the sheath is in place during lysis, leaving it there for several hours after t-PA infusion helps to minimize the risk of bleeding.
The risk of retroperitoneal blood loss from compressible access site is lower with intra-arterial than with intravenous t-PA. If the stroke is due to an intracranial hemorrhage, anticoagulation should be reversed and a neurosurgeon consulted to determine if any surgical intervention is indicated. Stroke is an uncommon but potentially devastating complication of cardiac catheterization. Pre-procedure identification of the high-risk patient, along with measures such as having the patient well hydrated prior to the procedure, using catheter techniques to minimize trauma, and judicious use of ventriculography, can help to prevent ischemic stroke.
Just as with a cardiac emergency, having processes in place to address a stroke event can facilitate positive patient outcomes and save lives. Indeed, Corazon strongly believes in clear, well thought-out policies, procedures, and processes that activate a stroke code when needed. Initiating immediate patient assessment and intervention could minimize cerebral damage and facilitate positive long-term outcomes in the rare case of a CCL stroke event. Have any bleeding problems or are taking blood-thinning medication. Have a history of kidney problems or diabetes.
Have body piercings on your chest or abdomen. Have had any recent change in your health. Are, or may be, pregnant. Before the procedure Shortly before your procedure, you may receive a sedative to help you relax. Hair in the groin area around where the catheter will be inserted may be clipped. An intravenous IV line is inserted so, if necessary, you can be given medications quickly.
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Electrodes will be placed on your body to monitor your heart, and a small device called a pulse oximeter may be clipped on a finger or ear to track the oxygen level in your blood. During the procedure Most PCIs are conducted with the patient sedated but not asleep. You will lie on your back on a procedure table.
A local anesthetic will be injected into the skin at the site where the catheter will be inserted. Once it has taken effect, the catheter will be inserted into the blood vessels. You may feel a brief sting or pinch as the needle goes through the skin and some pressure within the artery as the catheter is moved. If you are uncomfortable, tell your doctor and if necessary additional pain medication may be given. When the catheter reaches the heart, the contrast dye will be released so the area where the blood vessel is narrowed can be identified. When the dye is released, you may feel a brief flushing sensation or feeling of warmth.
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Some people experience a salty or metallic taste in the mouth, or a brief headache. A few people may feel nauseated or even vomit, but this is rare. These effects are harmless usually last for only a few minutes. When the narrowing is located, the catheter will be advanced so the special tip can be activated. It is possible to experience some chest pain or discomfort at this point, but your doctor will monitor you carefully and the discomfort should go away quickly.
When finished, the catheter will be withdrawn and pressure put on the insertion site to stop the bleeding. Once the bleeding has stopped, a tight bandage will be applied.
watch You will need to remain lying flat during this time. If the catheter was inserted in the groin, you will have to keep your leg straight for several hours. If it was inserted in the arm, your arm will be kept elevated on pillows and kept straight with an arm board. After the procedure You will probably go to a recovery room for several hours of observation.
You will be asked to remain in bed for 2 to 6 hours, depending upon your specific condition. Pain medication may be given if you experience any discomfort.