Cardiovascular Diagnostic & Therapeutic Procedures

Chapter 28

Cardiovascular Diagnostic Procedures Purpose (4)

• Evaluate functioning of the heart by monitoring for enzymes in the blood

• Use ultrasound to visualize the heart

• Determine the heart’s response to exercise

• Use catheters to determine blood volume, perfusion, fluid status, how the heart is pumping, & degree of artery blockage.

Cardiovascular Diagnostic Procedures (5)

• Cardiac enzymes & lipid profile

• Echocardiogram

• Stress testing

• Hemodynamic monitoring

• Angiography.

Cardiovascular Therapeutic Procedures (2)

• Central vascular IV access placement

• Percutaneous coronary interventions.

Cardiac Enzymes & Lipid Profiles (2)

• Cardiac Enzymes - Released into the bloodstream when the heart muscle is injured; Specific markers in diagnosing a myocardial infarction (MI).

• Lipid Profile - Provides info regarding cholesterol levels & is used for early detection of heart disease.

Cardiac Enzymes & Lipid Profiles - Indications (4)

• Angina

• MI

• Heart disease

• Hyperlipidemia

Cardiac Enzymes & Lipid Profiles - Considerations

Preprocedure: Fasting for 12 hr is recommended prior to lipid profile sampling.

Cardiac Enzymes (4)

• Creatine Kinase MB Isoenzyme

• Troponin

• Troponin I

• Myoglobin

Creatine Kinase MB Isoenzyme (3)

• Expected Range - 0% of total CK (20-200 units/L)

• Elevated Levels First Detectable Following Myocardial Injury - 4 hrs

• Duration of Elevated Levels - 2-3 days

Troponin T (3)

• Expected Range - < 0.1 ng/mL

• Elevated Levels First Detectable Following Myocardial Injury - 2-3 hrs

• Duration of Elevated Levels - 10-14 days

Troponin I (3)

• Expected Range - < 0.03 ng/mL

• Elevated Levels First Detectable Following Myocardial Injury - 2-3 hrs

• Duration of Elevated Levels - 7-10 days

Myoglobin (3)

• Expected Range - < 90 mcg/L

• Elevated Levels First Detectable Following Myocardial Injury - 1 hr

• Duration of Elevated Levels - 24 hrs

Cardiac Tests - Expected Ranges & Purpose (4)

• Cholesterol (Total) - < 200 mg/dL, screens for heart disease

• LDL - < 130 mg/dL, bad cholesterol, transports cholesterol to the body’s cells from the liver

• HDL - Males (> 45), Females (>55), good cholesterol; Protects coronary arteries from heart disease by transporting cholesterol from the body’s cells to the liver

• Triglycerides - Males (40-160), Females (35-135 mg/dL); Evaluates risk for heart disease;

Transthoracic Echocardiography (3)

• Used to diagnose valve disorders & cardiomyopathy

• Evaluates the size, shape, & motion of the structure of the heart

• Measures the ejection fraction.

Transthoracic Echocardiography - Indications (4)

• Cardiomyopathy

• Heart failure

• Angina

• MI

Transthoracic Echocardiography - Considerations (3)

Preprocedure: Explain that this is a painless, noninvasive test.

Intraprocedure: Instruct client to lie either supine or on the left side & remain still.

Postprocedure: Provider reviews test results & plans for follow-up care

Transesophageal Echocardiography (2)

• Provides clearer ultrasonic images, than a transthoracic echocardiogram, because the waves pass through less tissue.

• A small transducer is passed through the mouth & into the esophagus to provide images of the heart.

Transesophageal Echocardiography - Indications (4)

• Heart failure

• Valvular heart disease

• Atrial or ventricular thrombi

• Monitoring during valve replacement & coronary artery bypass surgeries

Transesophageal Echocardiography - Considerations (3)

Preprocedure: Informed consent Instruct client to be NPO for 4-6 hr prior to the procedure. Obtain IV access.

Intraprocedure: Monitor client’s LOC, ECG, BP, HR, RR, & O2 status, as moderate sedation is needed for the procedure.

Postprocedure: Monitor vitals, oxygenation status, LOC, & return of gag reflex (topical anesthetics are used in the throat). 

Stress Testing (4)

• Client exercises the cardiac muscle by walking on a treadmill or pedaling a stationary bike

• Provides info regarding workload of the heart, test is discontinued once the heart rate reaches a certain rate.

• Fatigue or disability can prevent traditional exercise testing or test completion.

• Provider can prescribe test to be done as a pharmacological (chemical) stress test.

Stress Testing - Indications (4)

• Angina

• Heart failure

• MI

• Dysrhythmia

Stress Testing - Considerations (Preprocedure) (3)

• Explain to client that they will be walking on a treadmill, & comfortable athletic shoes/clothing are recommended.

• Pharmacological stress testing - a medication (dipyridamole, adenosine, regadenoson, dobutamine) is given to stress the heart instead of walking on the treadmill.

• Instruct client to fast 4 hr before procedure & avoid tobacco, alcohol, & caffeine before the test.

Stress Testing - Considerations (Intraprocedure) (2)

• Apply a 12-lead ECG to monitor HR during the test. Monitor for dysrhythmias throughout the procedure.

• Instruct client to report any chest pain, SOB, or dizziness during the procedure.

Stress Testing - Considerations (Postprocedure) (3)

• Monitor the client by 12-lead ECG.

• Check BP frequently until the client is stable.

• Provider reviews findings with the client.

Hemodynamic Monitoring

Provides info about blood volume & perfusion, fluid status, & how well the heart is pumping.

Hemodynamic Monitoring - Parameters Assessed (5)

• Central venous pressure (CVP)

• Pulmonary artery pressure (PAP)

• Pulmonary artery wedge pressure (PAWP)

• Cardiac output (CO)

• Intra-arterial blood pressure

Hemodynamic Monitoring - SvO2

Indicates balance between oxygen supply & demand measured by a pulmonary artery catheter.

Hemodynamic Monitoring - Hemodynamic System (4)

• Pressure transducer

• Pressure tubing

• Monitor

• Pressure bag & flush device

Hemodynamic Monitoring - Arterial Lines (5)

• Placed in the radial (most common), brachial, or femoral artery. Not used for IV fluids

• Provide continuous info about changes in BP & permit withdrawal of samples of arterial blood. 

• Integrity of arterial waveform should be assessed to verify accuracy of BP readings.

• Monitor circulation in limb with the arterial line (cap refill, temp, color).

• Monitor for bleeding around insertion site & maintain secure connections.

Pulmonary Artery (PA) Catheters

Inserted into a large vein (internal jugular, femoral, subclavian, brachial) & threaded through the right atria & ventricle into a branch of the PA.

Multiple lumens, ports & components that allow for various hemodynamic measurements, blood sampling, & infusion of IV fluids.

Pulmonary Artery (PA) Catheters - Components (4)

• Proximal Lumen - Used to measure right atrial pressure (CVP), infuse IV fluids, & obtain venous blood samples.

• Distal Lumen - Used to measure PAPs (PA systolic, PA diastolic, mean PA pressure, & PA wedge pressure). Not used for IV fluid administration.

• Balloon Inflation Port - Intermittently used for PAWP measurements. When not in use, it should be left deflated & in the locked position.

• Thermistor - measures temp differences between the right atrium & the PA in order to determine CO.       

Pulmonary Artery (PA) Catheters - Indications (5)

• Shock (any type)

• Heart failure

• Post coronary artery bypass graft (CABG) clients

• Acute kidney injury

• Burn injury

Pulmonary Artery (PA) Catheters - Considerations (Preprocedure Line Insertion) (7)

• Assemble pressure monitoring system. Purge air from the system & maintain sterility of connections.

• Place client in supine or Trendelenburg

• Administer sedation pain medications as prescribed.

• Level transducer with phlebostatic axis (4th intercostal space, midaxillary line), which corresponds with the right atrium.

• Zero system with atmospheric pressure, because hemodynamic pressure lines must be calibrated to read zero atmospheric pressure.

• Obtain initial readings as prescribed. Compare arterial blood pressure to noninvasive blood pressure (NIBP).

• Monitor for manifestations of altered hemodynamics

Pulmonary Artery (PA) Catheters - Manifestations of Altered Hemodynamics Preload (Elevated) (6)

1. Right Heart - CVP

2. Left Heart - PAWP

3. Crackles in lungs

4. JVD

5. Hepatomegaly

6. Peripheral edema

Pulmonary Artery (PA) Catheters - Manifestations of Altered Hemodynamics Preload (Decreased) (2)

1. Poor skin turgor

2. Dry mucous membranes

Pulmonary Artery (PA) Catheters - Manifestations of Altered Hemodynamics Afterload (Elevated) (4)

• Right heart - pulmonary vascular resistance

• Left heart - systemic vascular resistance

• Cool extremities

• Weak peripheral pulses

Pulmonary Artery (PA) Catheters - Manifestations of Altered Hemodynamics Afterload (Decreased) (2)

• Warm extremities

• Bounding peripheral pulses

Pulmonary Artery (PA) Catheters - Consideration (Postprocedure) (5)

• Obtain CXR to confirm catheter placement.

• Continually monitor respiratory & cardiac status (vitals, heart rhythm, SaO₂, observe respiratory pattern & effort).

• Maintain line placement & integrity.

• Observe and document waveforms & document catheter placement each shift & prn (after movement for transport).

• Monitor & secure connections between pressure tubing, transducers, & catheter ports.

Obtaining Readings from Hemodynamic Catheter (4)

• Place client in supine prior to recording hemodynamic values. If not tolerated HOB elevated to 30°.

• Level transducer at the phlebostatic axis before readings & with all position changes.

• Zero system to atmospheric pressure.

• Compare hemodynamic findings to physical assessment & monitor trends in values over time.

Hemodynamic Monitoring - Interpretation of Findings (Expected Ranges)

CVP - 8-12 mmHg

Pulmonary artery systolic - 12-25 mmHg

Pulmonary artery diastolic - 8-15 mmHg

PAWP - 6-15 mmHg

CO - 3-6 L/min

Cl - 2.8-4.2 L/min

SvO2 - 60 - 80%

Hemodynamic Monitoring - Complications (2)

Infection/Sepsis - Occurs with lack of aseptic technique

Embolism - Plaque/clot can be dislodged during procedure

Hemodynamic Monitoring - Complications (Infection/Sepsis) Actions (6)

• Change dressings per facility protocol & as needed.

• Use surgical aseptic technique with dressing changes (mask, sterile gloves, maintain sterile field). 

• Monitor for infection (elevated WBCs or temperature).

• Perform thorough hand hygiene.

• Collect specimens (blood cultures, catheter tip cultures) & deliver to labo

• Administer antibiotic therapy, IV fluids for intravascular support & vasopressors for vasodilation secondary to sepsis.

Hemodynamic Monitoring - Complications (Embolism) Actions (3)

• Use 0.9% sodium chloride for flushing system. Flush can include heparin

• Avoid introduction of air into flushing system to prevent air embolism.

• Recognize risk of pneumothorax with insertion of the line & risk of dysrhythmias with insertion/movement of the line.

Angiography (Cardiac Catheterization)

Invasive diagnostic procedure used to evaluate presence & degree of coronary artery blockage.

Renal/Liver, Cerebral, Upper/lower Angiography

Determines blood flow & areas of possible blockage of a vessel.

Coronary Angiography (2)

• Insertion of a catheter into femoral, brachial, or radial vessel & threading it into the right or left side of the heart.

• Coronary artery narrowings &/or occlusions are identified by the injection of contrast media under fluoroscopy.

Angiography - Indications (2)

• Unstable angina & ECG changes (T wave inversion, ST segment elevation, depression).

• Confirms & determine location & extent of heart disease.

Angiography - Considerations (Preprocedure) (4)

• Maintain NPO status prior (for at least 2 hr after clear liquids or 6 hr after meal), due to risk of aspiration when lying flat

• Obtain vitals, auscultate heart & lung sounds, assess peripheral pulses.

• Contrast media (iodine) may not always be a contraindication in clients who have a shellfish allergy. Assess renal function prior to introduction of contrast media.

• If on Metformin - Withhold 24-96 hr prior to & up to 48 hr after the procedure; Can cause hypoglycemia or acidosis when receiving iodine media.

Angiography - Considerations ( Pre Client Education) (3)

• Mild sedative will be given to promote relaxation, & a local anesthetic.

• Wrist & groin are the most common sites used for the procedure; sensations of warmth/flushing might be felt when dye is injected.

• After procedure, pressure will be held on access site. If vascular closure device is not used, extremity must be kept straight to prevent bleeding

Angiography - Considerations (Intraprocedure) (4)

• Administer sedatives & analgesia as prescribed.

• Continually monitor vitals, heart rhythm, & chest pain.

• Be prepared to intervene for dysrhythmias.

• Have resuscitation equipment & emergency meds available. 

Angiography - Considerations (Postprocedure) (8)

1. Assess vitals & the affected extremity at the same intervals for bleeding/hematoma formation at the insertion site & thrombosis. (Document pedal pulse, extremity color, & temperature.)

2. Femoral Artery Access - Maintain bed rest in supine position with extremity straight for prescribed time; vascular closure device can be used to hasten hemostasis following catheter removal.

3. Conduct continuous cardiac monitoring for dysrhythmias. (Reperfusion following angioplasty can cause dysrhythmias.)

4. Administer antiplatelet or thrombolytic agents to prevent clot formation & restenosis (

5. Antiplatelets - Aspirin or Clopidogrel if having percutaneous coronary intervention [PCI] icagrelor, prasugrel, or cangrelor, Heparin, Low molecular weight heparin (enoxaparin), GP IIb/IIIa inhibitors, such as eptifibatide

6. Administer analgesics as needed.

7. Monitor urine output & give IV fluids for hydration.​​​​​​​

8. Withhold metformin for 48 hr after angiography to prevent lactic acidosis & possible AKI

Angiography - Considerations (Postprocedure Education) (5)

• Follow site care instructions regarding changing of bandage, bathing, or removal of staples/stitches.

• Immediately report bleeding from insertion site, chest pain, SOB & changes in color or temperature of extremity.

• Restrict heavy lifting, driving, manual labor, exercise, & sexual activity for prescribed period of time.

• Resume metformin as prescribed.

• STENT PLACEMENT - Take antiplatelets as prescribed, can be up to 12 months, manage weight, exercise, stop smoking

Angiography - Complications

Artery Dissection - Perforation of an artery by catheter can cause cardiac tamponade. Severe hypotension. HR changes & will require emergent pericardiocentesis & reversal of anticoagulants.

Cardiac Tamponade - Can result from fluid accumulation in pericardial sac; Hypotension, JVD, muffled heart sounds, paradoxical pulse (difference of 10 or more in SBP between inspiration & expirations)

Hematoma Formation - Blood clots can form near insertion site

Allergic Reaction RT Contrast Media - Chills, fever, rash, wheezing, tachycardia, bradycardia; Resuscitation equipment available; Administer diphenhydramine or epinephrine

External Bleeding at Insertion Site - Monitor site for bleeding or swelling, apply pressure, keep extremity straight

Embolism - plaque/clot can be dislodged; monitor for chest pain before, during & after & monitor vitals & SaO2

Restenosis of Treated Vessel - Clot reformation in coronary artery can occur immediately or several weeks after procedure.

Retroperitoneal Bleeding - Bleeding into retroperitoneal space (abdominal cavity behind peritoneum) can occur due to femoral artery puncture.

AKI - Damage to kidney can result from renal emboli, hypoperfusion, or use of contrast agent, which is nephrotoxic; Monitor urine output, BUN, & blood creatinine & electrolytes

Angiography - Complications (Cardiac Tamponade) Actions (5)

• Notify provider immediately.

• Administer IV fluids to combat hypotension.

• Obtain CXR or echocardiogram to confirm diagnosis.

• Prep client for pericardiocentesis.

• Monitor hemodynamic pressures, heart rhythm, recurrence of manifestations after procedure, dyspnea, & provide oxygen as indicated.

Angiography - Complications (Hematoma) Actions (4)

• Monitor for sensation, color, cap refill, & peripheral pulses in extremity distal to the insertion site.

• Assess groin or wrist at prescribed intervals & as needed, monitor peripheral circulation

• Hold pressure for uncontrolled oozing/bleeding.

• Notify the provider.

Angiography - Complications (Restenosis of Treated Vessel) Actions (3)

• Assess ECG patterns & for chest pain.

• Notify provider immediately & prep client for return to cardiac catheterization lab.

• Education - Notify HCP of cardiac manifestations, & take meds as prescribed.

Angiography - Complications (Retroperitoneal Bleeding) Actions (4)

• Assess for flank pain & hypotension.

• Notify provider immediately & hold firm pressure at the puncture site.

• Administer IV fluids & blood products as prescribed.

• Education - Maintain bed rest

Vascular Access (2)

• Site & type of vascular access device (VAD) is determined by characteristics of prescribed therapy (medication type, pH & osmolality, length of time

• Goal is to minimize number of catheter insertions & risk for adverse reactions.

Vascular Access - Central IV Therapy

• Used to infuse fluids due to rapid hemodilution in the superior vena cava (SVC).

• Ensure x-ray verification of tip placement prior to use.

• Inserted using sterile technique by a provider, PA, or trained nurses. Insertion occurs in the OR, client’s room, or outpatient facility.

• Tunneled & implanted catheters require surgical removal.

Central IV Catheter Types (4)

• Nontunneled percutaneous central venous catheters (CVC)

• Peripherally inserted central catheters (PICC)

• Tunneled central venous catheters (Hickman, Groshong)

• Implanted ports.

Nontunneled Percutaneous Central Venous Catheter (CVC) (4)

• 15 to 30 cm (6-12 in) in length with 1 to 4 lumens

• Short-term use only (less than 6 weeks)

• Insertion Location - subclavian vein, jugular vein; tip in distal third of superior vena cava

• Indications - Emergent or trauma use, administration of blood, administration of chemotherapeutic agents, antibiotics, & total parenteral nutrition

Tunneled Percutaneous Central Venous Catheter (4)

• Long-term use, indicated for frequent & long-term need for vascular access.

• Insertion location - Portion of catheter lies in a subq tunnel separating point where catheter enters the vein from where it enters the skin. A cuff within the subq tissue creates a mechanical barrier to organisms & an anchoring for the catheter.

• After insertion site has healed, no dressing is needed because entrance into skin & vein are separate & tissue granulates into catheter cuff, providing a barrier.

• Groshong catheters have pressure-sensitive valves to prevent blood reflux & do not require a clamp.

Peripherally Inserted Central Catheter (PICC) (4)

• Sngle or multiple lumens

• Length of use - up to three (3) months

• Insertion location - basilic or cephalic vein.

• Indications - administration of blood, long-term administration of chemotherapeutic agents, antibiotics, & total parenteral nutrition

Vascular Access - Considerations (Preprocedure) (3)

• Cleanse site with chlorhexidine.

• Ensure sterility of equipment.

• Place a STOP sign on the door to the room to restrict entry during procedure.

Vascular Access - Considerations (Postprocedure) (6)

• Confirm placement with an x-ray.

• Assess site for redness, swelling, drainage, tenderness, & condition of dressing.

• Clean insertion port with alcohol for 15 seconds & allow to dry completely prior to accessing it. Valve disinfection caps which contain alcohol are single use

• Use transparent dressing to allow for visualization. Follow protocol for dressing changes, usually every 7 days & when wet, loose, soiled)

• Advise client not to immerse arm in water & cover dressing site to avoid water exposure.

• Educate client not to have venipuncture or BP taken in arm with PICC line.

Vascular Access - Infusion Nurses Society (INS) Practice Recommendations for Flushing (4)

• Use a 10 mL syringe for flushing PICC line. Do not apply force if resistance is met.

• Flush with 10 mL 0.9% sodium chloride before, between, & after medications.

• Flush with 10 mL 0.9% sodium chloride after drawing blood.

• Flush with 5 mL heparin (10 units/mL) when PICC is not actively in use. Frequency of flush depends on type of PICC.

Vascular Access - Implanted Port (2)

• Port is surgically implanted into chest wall pocket. Catheter is inserted into subclavian vein with tip in the SVC.

• Indications - Long-term (1 year or more) need for vascular access; commonly for chemotherapy.

Vascular Access - Implanted Port (Considerations) (4)

• When accessing port, a mask should be worn & aseptic technique used. 

• Apply topical anesthetic cream to skin if indicated. Palpate skin to locate port, hold edges of port in place with thumb & index finger to ensure proper insertion of needle.

• Access with a noncoring needle & check for blood return prior to med administration to confirm patency & placement.

• Flush with heparin 10 units/mL or 0.9% sodium chloride after every use & at least once every 3 months (INS recommendation).

Vascular Access - Complications

Phlebitis - Common complication of PICCs caused by certain drugs, bacteria, or fungus.

Occlusion - Blockage in the central IV catheter that impedes flow. Thrombosis/emboli can coagulate & cause an occlusion.

Mechanical Complication - Implanted ports can have the catheter tip and port become dislodged; Use only noncoring needle to avoid damaging mesh on implanted ports.

Vascular Access - Complications (Phlebitis) S/S (6)

• Erythema at site (usual initial indication)

• Pain or burning at site and length of vein

• Discomfort when skin over the tip is palpated

• Warmth & edema over the site

• Vein indurated (hard), red streak, &/or cordlike

• Fever

Vascular Access - Complications (Phlebitis) Preventative Measure (4)

• Hand hygiene before working with a CVC.

• Observe site for infection or infiltration with every infusion or at least daily.

• Nontunneled catheters require an intact sterile dressing (tunneled catheters do not once site is healed).

• Clean site with chlorhexidine for 30 seconds & allow to air dry prior to insertion.

Vascular Access - Complications (Occlusion) Actions (3)

• Flush the line according to INS recommendations or facility policy.

• Do not force fluid if resistance is encountered (can dislodge thrombosis).

• Use 10 mL to avoid excess pressure that could cause catheter fracture/rupture.

Vascular Access - Complications (Dislodgement) Manifestations (3)

• Dislodged Port - Swelling at port site, unrestricted movement of port, inability to access port.

• Dislodged Catheter Tip - Gurgling/swishing sounds, pain on affected side in neck or ear.

• Report findings to HCP immediately.