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physician to the staff will assist their ability to move patients into and
out of the laboratory to satisfy the needs of the numerous operators
and types of procedures, as well as the availability of special
equipment.
Communication at the “table” during the procedure will also
improve efficiency. The informed team can prepare the equipment,
anticipate catheter and pharmacologic needs, and shorten the time to
set up. By letting the team know where the operator is in the procedure, the next steps can be anticipated. The recording technologists
appreciate these announcements for documentation. The staff should
be “in the game,” watching and listening to be ready to get the needed
supplies without undue delay. On the other hand, communication
from the room back to the “table” improves efficiency by clearly
acknowledging requests from the operating table, reducing redundant
and unnecessary repetition of orders. Clear and open two-way communication, especially under critical portions of procedures, also
leads to improved safety through error reduction and timely performance of the catheterization. Pointers are as follows:
A. The physician, as well as the staff, sets the tone of communication
in the laboratory, like a pilot with the “right stuff”: cool, clear, and
confident.
B. Orders from the “table” should be acknowledged clearly by those
designated to carry out the order. Just as military efficiency is built
on this dictum, so should that of the well-run laboratory. It is disturbing to request medications and supplies and not know if
someone has heard the request and is attending to it.
C. Repeat orders to reduce errors.
D. When at the “table,” announce what the “table” is doing. For
example, “Left Jud going up … ,” which the recording person then
acknowledges.
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The Catheterization Laboratory 25
Optimal Staffing and Cross Training
of Personnel
Not every case of coronary angiography requires all of the previously
mentioned people to be present. In most laboratories, three assistants
are required for most catheterization procedures: One person is
scrubbed and assists the physician at the table; one is not scrubbed
and circulates in the room, providing patient care (nurse responsibilities) and procuring any supplies that are needed during the procedure;
and one performs the duties of recording technician and radiologic
technologist by selecting proper cineangiographic programs and
hemodynamic recording functions as required.
Cross training of the individuals in the catheterization laboratory
helps in maintaining the morale and confidence in each job described.
Cross training also means that each individual in the laboratory is
competent to start up the laboratory and assist in operation on an
emergency 24-hour basis when needed.
Cardiopulmonary Resuscitation
All members of the catheterization team should be fully trained in
cardiopulmonary resuscitation (CPR) and the use of defibrillators. In
some laboratories, advanced cardiovascular life support (ACLS) training and biannual renewal of certification is required. An algorithm for
CPR in the catheterization laboratory is presented in Chapter 8.
The Catheterization Lab and Code
Team Interaction
The practice of calling and running a code in the catheterization
lab varies depending on the hospital type, staff composition
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and experience, and leadership of the catheterization lab nurses and
physicians. The type of assistance brought to a code in the catheterization lab may also depend on the hospital type and staffing, hospital
policy, and whether the code occurs during weekend or off hours.
The Catheterization Laboratory
Who’s in Charge in the Catheterization Lab?
The physician performing the procedure is in charge of directing the
care of the patient at all times. Whether the patient is experiencing
ventricular tachycardia/ventricular fibrillation (VT/VF) or hypotension from tamponade, cardiogenic shock, or hypovolemia (from
bleeding or anaphylaxis), the attending catheterization lab physician
calls the shots. However, conventional critical care theory and practice state that the code leader should be responsible for nothing else
besides the resuscitation efforts. The cardiologist performing an emergency PCI on a patient in full arrest may not be the best person to
monitor and decide whether and when drugs such as lidocaine should
be given, CPR held, and so on. On the other hand, most cardiologists
would never want to be told by a “code leader” that CPR cannot be
held for a minute to obtain vascular access, or that CPR efforts should
cease. Most now agree that joint decision making is necessary.
The attending physician may recognize that the best person to
intubate his patient is an anesthesiologist or an experienced pulmonary or emergency room physician. When the situation becomes critical and the physician in charge requests more help to manage the
patient’s airway or perform chest compressions, the quickest way to
get this help may be to call a code. Alternatively, the laboratory may
have an airway emergency system that activates the anesthesiologist
on call for immediate airway help. The catheterization laboratory team
will continue to manage the patient while waiting for anesthesia or the
emergency room physicians. In the laboratory, the patient’s ventilatory
needs can temporarily be managed with bag mask ventilation. Hemodynamic support will be maintained with the administration of ACLS
medications and defibrillation as indicated. After intubation it remains
very helpful to have respiratory therapy (RT) technicians support the
airway placement and ventilator management. RT technicians are
usually key members of most code blue teams.
Upon arrival of the code team in the laboratory, the attending
physician should identify the problem to the code team, ask for the
appropriate person to help with the problem (usually ventilation), and
continue to direct the code. If he or she cannot attend to all of these
aspects, he or she should designate a code leader while he returns to
the management of the interventional cardiac procedure. The designated code team leader and the person who will be in charge must
be announced to the laboratory team as they continue to work with
the patient still undergoing the procedure.
Patient Viewpoint
Teaching Before the Procedure
Most patients undergoing cardiac catheterization have vague and
often confused ideas of how the procedure is performed. They know
little as to what information will be provided about their cardiac status.
Procedural patient teaching is important to allay fears and to provide
optimal patient care, cooperation, and satisfaction.
The teaching should start at the time the patient enters the hospital. The nurse on the floor should provide information on what the
patient can expect while being cared for on the floor before and after
the cardiac catheterization. Topics such as diet, medications, IV
therapy, and postprocedural bed rest should be discussed.
The nurse should explain step by step how the procedure is performed, how long it will take, and what the patient should expect
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regarding sensations and discomfort associated with the procedure.
A prepared booklet (sometimes with a videotape) explaining the procedure should be given to the patient to read before the procedure.
This booklet reinforces the verbal teaching done by the nurse (e.g.,
the steps of the catheterization, breath holding, and types of equipment that the patient will see). When possible, the nurse should see
the patient first. The information given by the nurse may stimulate
questions that the patient can ask when the physician arrives to speak
to the patient. Some laboratories may not have the resources to send
a staff member to do this type of teaching. If that is the case, the floor
nurse should be well versed in catheterization laboratory techniques
to provide adequate patient teaching.
The physician’s role in patient education should focus on four
areas. First, the physician should make clear to the patient the reasons
the procedure is being performed. Second, the patient should be told
what information the cardiac catheterization will provide. Third, the
patient should be told what treatment options are available when a
diagnosis is made. Fourth, the physician should discuss the possible
risks and potential complications of the procedure. The risks, benefits,
and alternatives to cardiac catheterization should be discussed with
the patient and family. After this teaching has been done, the physician
obtains the written informed consent from the patient. The physician
has the final patient responsibility. It is not the nurse’s nor technician’s
job to obtain consent.
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The Catheterization Laboratory 27
Teaching in the Laboratory
Teaching should continue when the patient has arrived in the catheterization holding area. The team members should introduce themselves
and explain their jobs. A staff member should orient the patient to the
x-ray suite and explain briefly the function of the various pieces of
equipment. While in the laboratory, the patient should be encouraged
to communicate freely with the staff and physician. It is important that
the patient inform the staff of any pain or discomfort during the
procedure.
Patients are often overwhelmed by the mere thought of such an
invasive procedure and may have difficulty digesting all of the information that will be given. Teaching sessions should be limited to 10 to
15 minutes, with important points stressed two or three times. A wellinformed patient is less anxious, and this makes the procedure much
easier and more comfortable for the patient, the physician, and staff
members.
Team Teaching and Conferences
The educational experience of the staff and physician is enhanced by
a daily or at least a weekly cardiac catheterization conference. These
conferences emphasize to the physicians and technical staff the relationship of clinical data to the hemodynamic and angiographic data.
Review of data and discussion of various therapies (e.g., medicine,
surgery, and PCIs) provide an excellent opportunity to learn from colleagues who share cases of educational value.
Equipment in the
Catheterization Laboratory
Figures 1-5 to 1-7 show the catheterization laboratory and equipment
(also see Chapter 3, Angiography for more detail).
Fluoroscopic Imaging System
A high-resolution, image-intensifying television system with digital
cineangiographic capabilities is the “eyes” of the cardiovascular
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The Catheterization Laboratory
1
2
4
12
13
Figure 1-5 Equipment components of the cardiac catheterization labora -
tory: 1, Fluoroscope anterior-posterior (AP) tube, AP projection; 2, fluoroscope, lateral x-ray generator; 3, fluoroscope, lateral front panel image
intensifier; 4, patient table; 5, contrast media power injector; 6, display
screen, fluoroscopy, hemodynamic, intravascular ultrasound (IVUS) imaging,
and fractional flow reserve (FFR) measurement; 7, crash car t; 8, pressure
transducer holder and oximeter; 9, touch panel control for IVUS/FFR; 10,
touch panel control for x-ray system; 11, positioning control for x-ray table
and fluoroscope; 12, wedge shield under table; 13, foot pedal control for
x-ray fluoroscope.
9
3
5
8
11
6
7
10
Figure 1-6 View of the catheterization laboratory from control room: Mul-
tiple monitoring screens for hemodynamic recording, intravascular ultrasound (IVUS) imaging, fractional flow reserve (FFR), and procedure
documentation are in front of the nurse and technician.
laboratory. The fluoroscopic image comes from a C-arm, which is a
semicircular support with the x-ray tube at one end and the image
intensifier at the other. Rotation of the C-arm allows viewing over a
wide range of different angles. The patient is placed in the center of
the semicircle that can be moved 180 degrees around the patient as
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Figure 1-7 View of contrast power injector monitor screen.
needed to visualize the heart. Two C-arms, side by side, are called
biplane and with a double monitoring system can provide visualization of the heart from two different angles at the same time. The fluoroscopic and physiologic recorders have sets of display television
monitors.
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The Catheterization Laboratory 29
X-Ray Table
The patient is positioned on a special table that is easily panned under
the fluoroscopes during angiography. The tables have bearings and
brakes activated by hand controls at the end or side of the table. The
table extends out from its base to permit the under table tube to cover
a large area of the patient during the imaging examination. Patient
weight limits for cardiac catheterization laboratories are set to prevent
damage to the table machinery that has free-floating tabletop bearings
permitting translation in the horizontal, vertical, and tilting directions.
For cardiac catheterization laboratories in the United States, weight
limits for minimum, mean, and maximum patient weights have been
reported to be 160 kg, 198.9 kg, and 250 kg (350 lbs, 437.5 lbs, and
550 lbs, respectively). At least three to five patients per hospital per
year are rejected for being over their laboratory’s weight limit.
Physiologic Hemodynamic Recorder
In addition to observation and recording of images of the heart during
catheterization, it is necessar y to observe and record the ECG and
various blood pressures within the cardiovascular system. A reliable
ECG and pressure monitoring system is essential for the safety of the
patient and collection of hemodynamic information (described in
detail in Chapter 4).
Contrast Power Injector
A high-pressure contrast media injector is needed to administer a large
bolus of contrast media into the left ventricle (10 to 20 mL/sec), pulmonary arteries (10 to 25 mL/sec), or aortic arch (40 to 60 mL/sec).
When properly set and flushed, the power injector can be used to
inject contrast media into the coronar y arteries (3 to 8 mL/sec). Some
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injector systems also incorporate a pressure transducer and have
replaced traditional manifolds with stopcocks (see Chapter 4).
The Catheterization Laboratory
Crash Cart and Defibrillator
Every cardiovascular laboratory is equipped with an emergency “crash cart” near the x-ray table. The crash cart contains
emergen cy drugs, oxygen, airways, suction apparatus, and other emergency equipment.
A defibrillator should be charged and ready for use during a
procedure. The defibrillator must be tested daily and must be kept at
close range for prompt use. Electrode gel, temporary pacemakers, and
new electrode patches should be on every cart.
Sterile Equipment and Supplies
The angiographer works from a sterile pack or tray that contains the
various supplies needed to perform the procedure. The pack contains
syringes and needles, local anesthetic, basins for flushing solutions,
small drapes and towels, clamps, scalpels, pressure manifolds, and
connecting tubing (Fig. 1-8). These trays may be made up at the hospital or prepackaged by various suppliers.
Figure 1-8 Back table with sterile supplies.
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Most laboratories send reusable items to a central hospital supply
area for sterile processing. The three main methods of sterilization are
steam, chemical gas, and liquid chemical sterilization. Check with the
central processing laboratory before submitting catheters, pacemakers, or special devices for sterilization and reuse.
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The Catheterization Laboratory 31
Training Requirements
Cardiovascular Technologist Training
Requirements in Cardiac Catheterization
Cardiovascular technology is a field recognized by the American
Medical Association. The cardiovascular technologist specializing in
invasive cardiovascular technology is a health care professional who,
through the use of specific high-technology equipment and at the
direction of a qualified physician, performs procedures on patients
leading to the diagnosis and treatment of congenital and acquired
heart disease and peripheral vascular disease. The technologist is
proficient in the use of physiologic analytical equipment during diagnostic and therapeutic procedures. The cardiovascular technologist is
trained in advanced life support techniques because the patient population under study is often at increased risk for cardiopulmonary
arrest. The technologist, through established methodology of diagnostic examinations, creates a database from which a correct anatomic
and physiologic diagnosis may be developed for each patient. The
invasive cardiovascular technologist is a highly specialized diagnostician of the various presentations of cardiovascular disease. A list of
procedures performed in the catheterization laboratory is provided in
Appendix A.
Scope of Practice
The invasive cardiovascular technologist performs diagnostic procedures involving patients in the invasive cardiovascular laboratory (and
coronary care and medical-surgical intensive care environments, if
needed). The technologist may also assist a qualified physician in the
performance of procedures in specialized clinics. The duties of the
technicians and nurses in the laboratory often cross over but all should
review the particular scope of their practice (i.e., what they can and
cannot do alone and under the direction of a physician) within the
specific hospital and laboratory. Nurses, unlike technologists, are
the only ones who are responsible for administration of medications
and patient monitoring unless specific provisions are made to the
contrary.
The scope of practice in any laboratory can also be divided into
tasks performed by the nurse/technician without direct physician
supervision, tasks performed with remote physician supervision (e.g.,
VCD), tasks with direct supervision (e.g., critical procedures, such as
seating an angiographic catheter), and tasks that should be performed
only by physicians (e.g., PCI and use of complex devices). For catheterization laboratories, there is no “gold standard” of practice patterns
across the nation. Local practice establishes catheterization laboratory standards. The scope of what can be done in the catheterization
laboratory comes from several important interacting competencies
and laws:
1. Nurse/technician individual competence
2. Physician competence
3. Hospital policies
4. Health care regulatory laws, the most important of which is that
it is illegal to practice medicine without a license
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within the three stages of the catheterization experience:
1. Preprocedure duties: These consist of checking clinically important
2. Critical procedures: The physician is responsible for everything that
The Catheterization Laboratory
Nurse/technician duty requirements can be viewed as tasks
1. Preprocedure setup and preparation
2. Critical procedures (the angiogram, hemodynamic study, and
percutaneous intervention)
3. Postprocedure care (including access site management)
aspects related to the patient entering into the laboratory (consent,
laboratory tests, indications, complicating conditions such as drug
or food allergies, pulses and records of prior procedures with their
associated problems, or access or contrast reaction). The nurse/
technician should be knowledgeable, able to communicate clearly
and sympathetically, and compulsive enough to collect this information to protect the patient from medical misadventure.
Once in the room and on the table, nurse/technician duties
include IV access, groin preparation, ECG monitoring, and hemodynamic setups. Preprocedural and intraprocedural medication
knowledge and administration are critical. All personnel in the
laboratory should be familiar with the scope of these activities.
Critical procedures begin with the arterial puncture.
happens during the critical procedures, so his or her competence
is always on the line. The physician’s trust in the laboratory personnel also is part of this competence. The transfer of critical procedures to competent technicians requires time, effort, education,
and physician trust. The variations on these components form the
standard of practice in the laboratory for that particular case.
a. Noncritical tasks of critical procedures: (A noncritical task
during a critical procedure means that the task is not required
to be done by a physician and generally is not life threatening.
But recall that anything done wrong or poorly in the laboratory
can potentially be life threatening.) These tasks include performing angiography, contrast injection during angiography, and
hemodynamic studies (pulling back catheters during hemodynamic recording is a noncritical task of a critical procedure). For
PCI, passing angioplasty guide wires falls into the task category
of critical procedure (needing direct physician supervision).
Angioplasty balloon inflation is a noncritical task performed by
an assistant or the operator. For special devices such as intraaortic balloon pumps, rotoblators, AngioJets, thrombus aspiration
systems, cutting balloons, filter wires, and so forth, concentrated
expertise is required. These device tasks are critical procedures
and fall to the physician. However, in some laboratories, physician experience (and selected device competence) with an
infrequently used device may be less than that of the nurses/
technicians working with the numerous other physicians on a
daily basis.
b. What should be the scope of practice in this situation? The physi-
cian selecting the device is still responsible for all aspects of its
use and complications. The nurse/technician and laboratory
itself will be at risk should they take on the placement and use
of a specialty device with which the physician is not entirely
competent, comfortable, and certified. These activities fall
outside the scope of nurse/technician practice. Assistance with
these critical procedures is needed, but solo or direct performance by a trained technician, even with direct supervision, is
questionable, mainly for the reasons that this is part of the practice of cardiovascular medicine and the ethically difficult explanation of complications should they occur.
A physician who is not comfortable with a special technique
or procedure required in the course of a catheterization should not
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be performing a critical procedure that may require this technique.
For example, if a physician is not comfortable with a filter wire and
has not achieved competence in the device use, he or she should
not have a filter wire placed by a technician that requires that individual to perform the critical placement and recovery. If a complication occurs, who takes the responsibility?
3. Postprocedure duties: For vascular closure, the physician is respon-
sible for arterial closure either by compression or a closure device.
Manual/mechanical access site compression is usually delegated
to the staff with indirect physician supervision (indirect supervision
indicates that the physician is in the area but not immediately in
the room). However, in some laboratories, the nurses/technicians
are trained on VCD, certified (and trusted) by the physician and
hospital policy, and permitted to close the artery alone, often with
the physician in the control room (i.e., they are indirectly
supervised).
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The Catheterization Laboratory 33
Emergency Life Support
The cardiovascular technologist is proficient in basic life support techniques as recommended by the American Heart Association as follows:
1. Techniques of CPR, cardioversion, or defibrillation
2. Management of the airway, including orotracheal and nasotracheal
intubation and bag-mask ventilation
3. Proficiency in the preparation and delivery of emergency medica-
tions by means of IV line placement and IV infusion, including
cardioactive medications at the request of a qualified physician
Preparation, Inventory, Maintenance, and
Sterile Techniques
The invasive cardiovascular technologist is proficient in the preparation of the patient for all procedures and for the maintenance, inventory, stocking, and sterile preparation of all equipment, parts, catheter
devices, and room preparations for each procedure as follows:
1. Information and support to the patient before, during, and after
each procedure, including sterile preparation of the patient
2. Cleaning, packaging, and sterilization of all sundry catheterization
trays and ancillary area equipment
3. Maintenance of the sterile field during such procedures
4. Preparation, recording, interpretation, and filing of all procedural
protocols and reports
5. Ordering of all disposable supplies necessary for each procedure
6. Retrieval of data regarding individual patients and disease entities
for clinical and research purposes
Equipment Used in the Invasive
Cardiovascular Laboratory
The invasive cardiovascular technologist is proficient in the operation
and maintenance of all diagnostic and therapeutic equipment used
for procedures, including electrical safety for each piece of equipment. The equipment listed is neither all inclusive nor exclusive to the
various types and brands of equipment used in the cardiovascular
laboratory areas.
1. Physiologic equipment
a. ECG/pressure recorder/analyzer (with computer interfaces)
b. Pressure transducers
c. Electrocardiographic interfaces
d. Cardiac output thermodilution computer
e. Blood gas and oxygen content and saturation analyzer
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2. Angiographic equipment
3. Temporary pacemakers
4. Left ventricular support devices
5. Emergency (code) cart equipment
The Catheterization Laboratory
a. Cineangiography operations
b. Digital imaging interfaces
c. Contrast media pressure injector
a. External and transvenous pacemakers
b. Connecting cables
a. Intraaortic balloon pumps
b. LV catheter support pumps (e.g., Impella)
c. Cardiopulmonary bypass systems (e.g., Tandem Heart)
d. Consoles
a. Medications
b. Defibrillator
Medications Used in
Coronary Angiography
This section describes common medications used in the cardiac catheterization laboratory. It is not intended to be all inclusive, and the
reader is recommended to review the doses, indications, contraindications, and side effects in more detail. A list of the medications commonly used is provided in Box 1-6.
Anticoagulation and Antiplatelet
Agents for Cardiac Catheterization
Heparin
The appropriate doses of heparin and measurement of satisfactory
anticoagulation for catheterization are dependent on the clinical
needs. For routine diagnostic procedures from the radial approach,
some suggest 40 to 70 U/kg. Heparin is satisfactory for patients in
whom a prolonged (>20 minute arterial time) catheterization proce-
dure is anticipated or in whom prior clinical indications for use of
heparin exist (e.g., acute coronary syndromes [ACSs] with patients on
glycoprotein [GP] IIb/IIIa blockers, thrombotic tendency, known
severe peripheral vascular disease, and/or embolic phenomenon on
previous study). For most femoral procedures, additional heparin
(beyond that included in heparinized flush solutions) is omitted from
routine left-sided heart catheterization when the procedure is performed in a timely manner.
Heparin reversal with protamine sulfate should be reserved for
patients without fish allergy or previous use of NPH insulin. Lowmolecular-weight heparin has replaced unfractionated heparin in
some circumstances and is partially reversible with protamine.
Warfarin
While warfarin is not given in the catheterization laboratory, the
management of patients receiving warfarin undergoing cardiac catheterization is a common problem because of the increased risk of
procedure-related bleeding. In a patient with an elevated international
normalized ratio (INR), femoral access is potentially associated with
an increased risk of bleeding and access site complications, especially
after PCI. This issue is not as great a concern when using radial artery
access.
In general, cardiac catheterization should not proceed until the
INR is <1.8. The cessation of warfarin and potential clotting problems
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