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The Catheterization Laboratory 45
Figure 1-9 Nurse and technicians wear protective glasses, gloves, gowns,
and face masks satisfying Occupational Safety and Health Administration
(OSHA) standards. Thyroid shields should be worn by all personnel inside
the catheterization suite.
should be removed immediately and the exposed skin should be
washed with soap and water. Protective clothing worn during procedures should be removed before personnel leave the department or
hospital building.
Equipment Considerations for Protection
As awareness of the hazards of blood-borne pathogens increases, a
variety of protective equipment and instruments are being made available for use in the cardiac catheterization laboratory. Most companies
that make angiographic manifolds offer closed drainage systems. This
system incorporates a 1000-mL bag in the manifold system, which
allows aspirated blood to be flushed directly into a sealed bag. This
system reduces the potential exposure during the procedure and at
the end of the procedure during cleanup.
Another product to reduce exposure improves on the conventional waste bowl often used on the sterile back table. The closed bowl
design allows bloody, fluid-filled syringes to be emptied into the receptacle and prevents back splashing by incorporating a diaphragm slot
in which the syringe can be inserted and emptied.
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The Catheterization Laboratory
Employer Responsibility
Hepatitis B Virus Vaccination
The OSHA standard states that HBV vaccination must be made available as a prerequisite of employment to all employees with potential
for occupational exposure. If the employee declines vaccination, it is
mandatory that an HBV vaccine declination be signed.
Risk Category
The OSHA standard requires employers to inform employees of a job’s
risk category on employment. The three risk categories are
Risk Category Definition
I Employment and procedures require exposure to
II Employment and procedures may require
III Employment and procedures usually do not
Most, if not all, catheterization laboratory staff fall into category I.
The employer must provide proper training to employees regarding
blood-borne pathogens and OSHA standards. Records must be kept
documenting the dates, content, name of the person conducting the
training, and names of persons attending the session. These records
must be maintained for at least 3 years.
blood and other body fluids
exposure to blood and other body fluids
require exposure to blood and other body fluids
Eliminating Careless Practices to
Reduce Risks
Often in the cardiac catheterization laboratory employees are exposed
as a result of carelessness and lack of attention to procedures. All
incidents of employee exposure should be documented properly. A
periodic review should be conducted to determine ways to eliminate
future exposure. Careless practices that should be avoided in the
catheterization laboratory include the following:
1. Vigorous squirting of blood in syringes into the back table waste
bowl, resulting in splashing
2. Throwing of bloody gauze across the table into trash receptacles
3. Improper handling of guide wires and catheters, which may spring
out of the saline bowl and cause splashing
4. Failing to return needles properly to a needle counter or container
on the back table
Extra attention and care in such areas prevent unnecessar y exposure of staff.
Radiation Safety
The catheterization laboratory environment should be made as safe
as possible for the staff and patient. Because radiation cannot be seen,
felt, or heard, it is easy to become lackadaisical about proper protective measures. Standards for radiation protection (from the Society for
Cardiac Angiography and Intervention) include four basic principles:
1. The less exposure, the less chance there is of absorbed energy
biologic interaction.
2. No known level of ionizing radiation is a permissible dose or
absolutely safe.
3. Radiation exposure is cumulative. There is no washout
phenomenon.
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4. All participants in the cardiac catheterization laboratory have voluntarily accepted some degree of radiation exposure, but they are
obliged to minimize and reduce risks to other personnel and
themselves.
The source of radiation is the primar y x-ray beam emanating from
the under table x-ray tube upward through the patient and onto the
image intensifier. Scatter of this beam exposes all subjects to radiation
in a dose geometrically inverse to the distance from the source. Radiation scatter is increased when the angle of the tube is set obliquely. A
high degree of angulation increases the amount of radiation scatter
(see Chapter 3). Acrylic shields and table-mounted lead aprons should
be used to reduce the amount of scatter.
Fluoroscopy generates approximately one fifth the x-ray exposure
of cineangiography. The increased use of cineangiography for complex
catheterization procedures has increased the total exposure and
should be a consideration in procedures requiring extensive intracardiac manipulation, such as angioplasty, valvuloplasty, or electrophysiology studies.
Every cardiac catheterization laboratory should have a
department-specific radiation safety policy. This policy should include
the following:
1. Routine monitoring of personnel radiation exposure
2. Continuing education programs on radiation safety for personnel
3. Program to make personnel aware of the risks associated with
radiation exposure
4. Requirement for protective equipment be worn by all personnel
5. Procedures to check safety of all equipment (x-ray dose output,
integrity of lead aprons, and thyroid shields)
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The Catheterization Laboratory 47
Lead Eyeglasses
A single x-ray exposure of 200 rad can produce cataract formation in
humans. Eyeglasses made of 0.5- to 0.75-mm lead-equivalent glass
should be worn by personnel exposed to radiation on a daily basis
(see Fig. 1-9). Glasses containing 0.5 mm of lead offer four times the
protection of regular eyeglasses. Glasses with photochromic lenses
offer two times the protection of regular eyeglasses. Plastic lenses offer
no eye protection from radiation.
Radiation-protective glasses must contain a wraparound side
shield. Glasses with proper-fitting side shields are not only effective for
radiation protection but also provide protection from blood products
splashing into the eyes.
Radiation Badges
All personnel should wear a radiation monitoring badge when in the
catheterization laboratory. To ensure accurate readings, a badge
should always remain on the person to whom it is assigned. Badges
should never be left lying on a counter or attached to a lead apron in
an area where there is potential radiation exposure. When badges are
not being used, they should be stored in an area away from any potential radiation exposure.
At the end of each month, exposed badges are collected and sent
for analysis. A monthly exposure report indicates each staff member’s
exposure for that month. This information should be posted in the
laboratory so that each staff member can monitor his or her individual
exposure. The report should be reviewed each month by the laboratory medical director and the institution’s radiation safety officer.
Radiation Dose Limitation
Although no known threshold for radiation exposure exists to define
specific risks, the National Council on Radiation Protection and
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Measurements indicates that no dose of greater than 3 roentgen equivalent in man (rem) should be allowed over a 3-month period.
The Catheterization Laboratory
Definitions of Radiation Units
1. Roentgen (R) is the measure of ionization delivered to a specific
point (exposure). One chest radiograph equals 3 to 5 mR.
2. Radiation absorbed dose (rad) is the amount of radiation energy
deposited per unit mass of tissue. The amount of absorbed dose
per given exposure depends on tissue type. For soft tissue, 1 R = 1
rad; for bone, 1 R = 4 rad (i.e., greater absorption).
3. Roentgen in man (rem) is used to express the biologic impact of a
given exposure. For x-radiation, 1 rad = 1 rem.
Methods to Limit Exposure
1. Wear leaded aprons (preferably wraparound): 0.5 mm or more
thickness provides 80% protection.
2. Limit the fluoroscopic or cineangiographic time (cineangiographic
time produces much greater exposure than fluoroscopic time).
3. Use collimators.
4. Reduce the distance between the x-ray source and the patient.
5. Maximize the distance between the x-ray source and the operator
and assistants.
6. Limit milliamperes per kilovolts as much as possible for an adequate image.
7. Use slower panning and provide good initial angiographic setup.
Angled views almost double the radiation.
8. Keep the image magnification as low as possible.
9. Use extra shielding (leaded thyroid guards, lead glasses, and protective table shields).
Radiation exposure is greater during angioplasty than during
diagnostic catheterization. If the protective shields are used carefully,
radiation exposure for single-vessel and double-vessel angioplasty
compared with diagnostic catheterization may be comparable. Radiation exposures are generally higher for these procedures, however,
especially when biplane angiography is performed.
Lead Aprons and Thyroid Shields
Lead aprons should contain 0.5-mm-thick lead lining. When properly
cared for, an apron can provide years of service. The lead lining can
crack or tear, however; this is usually caused by careless handling or
improper storage. Aprons should be placed on an appropriate hanger
or in a storage rack after use (Fig. 1-10). Repeatedly throwing an apron
over a chair or stretcher may damage the lead lining.
To assess the integrity of the lead, aprons should be examined
under fluoroscopy at least once each year. Documentation should be
kept regarding the integrity of each apron. To do this, each apron
should contain some sort of identification (e.g., number, color, or
name).
Because of the nature of work in the catheterization laboratory,
personnel are not always able to maintain a frontal position to the x-ray
beam. Wraparound lead aprons should be considered. Aprons should
be long enough to cover the long bones (femur) and should extend to
the knee or just below the knee. Because proper fit is important, many
companies take measurements to ensure a proper fit. A hanging rack
for the lead aprons should be used to prevent cracking resulting from
excessive folding of aprons left lying over chairs or benches.
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Figure 1-10 One proper storage method to prevent lead aprons from
developing cracks, reducing radiation protection. All aprons should be hung
when not in use.
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The Catheterization Laboratory 49
Because the thyroid gland is particularly sensitive to ionizing
radiation, a lead thyroid shield should be worn in the presence of ionizing radiation. Similar to aprons, thyroid shields should be stored
properly and the lead periodically checked radiographically.
Physician Training Requirements in
Cardiac Catheterization
Diagnostic Catheterization in Adults
Training in Diagnostic and Interventional Cardiac Catheterization published by the American College of Cardiology (ACC) and endorsed
by the Society for Cardiovascular Angiography and Interventions
(COCATS Training Recommendations) provides guidance as to the
trainee’s overall professional goals and further determines the requisite knowledge and skill set to be acquired in the training fellowship
program. In general, trainees may be divided into three broad groups
with differing training requirements:
•
Level 1—Trainees who will practice noninvasive cardiology and
whose invasive activities will be confined to critical care unit procedures. However, this level also provides cognitive training in the
indications, risks, and outcomes for the procedures and in the
accurate interpretation of data obtained in the catheterization
laboratory.
•
Level 2—Trainees who will practice diagnostic but not interven-
tional cardiac catheterization.
•
Level 3—Trainees who will practice diagnostic and interventional
cardiac catheterization.
Each level has specific goals for training that build on one another
and are detailed in the following text. All cardiologists should have
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The Catheterization Laboratory
level 1 knowledge and skills. Jacobs, et al in the Task Force 3 recommendations outline requisites for program accreditation, goals, structure, activity level and patient mix, training program curriculum, and
need for conferences.
The following are the proposed physician requirements for certification in the performance of cardiac catheterization. The physician
should spend a minimum of 12 months in the cardiac catheterization
laboratory. The trainee acquires a clear understanding of the indications, limitations, complications, and medical and surgical implications of the findings of cardiac catheterization and angiography. This
background includes an understanding of the pathophysiology and
the ability to interpret a wide variety of hemodynamic and angiographic data in adults. (Pediatric catheterization requires a special
training track.) All trainees receive basic instruction in radiation
safety, use of fluoroscopy, and radiologic anatomy.
The trainee learns to perform catheterization of the right and
left sides of the heart by the various percutaneous routes. Routine
ventriculography and coronary angiography are taught. Temporary
RV pacing, endomyocardial biopsy, and pericardiocentesis are part
of the training experience, if available. A working knowledge of
catheterization laboratory equipment, including physiologic recorders, pressure transducers, blood gas analyzers, image intensifiers and
other x-ray equipment, and angiographic image management is
emphasized for trainees seeking advanced catheterization laboratory
experience.
Trainees should be exposed to adult patients with valvular, congenital, cardiomyopathic, ischemic heart disease as well as peripheral
vascular and structural heart disease. Studies of acutely ill patients
(cardiogenic shock, acute myocardial infarction, or unstable angina)
are currently a routine part of invasive cardiology. At the end of
the cardiac catheterization training period, for level 2 training, a
trainee should have performed at least 300 catheterization procedures; in 150 of them, the trainee should have been the primary
operator. The number of cases to meet the training levels are shown
in Table 1-12.
Because the potential for harm is greater with interventional
techniques, only physicians highly skilled and thoroughly trained in
the fundamentals of diagnostic catheterization should undertake
the additional year of training that is needed for competency in interventional cardiology (percutaneous coronar y and peripheral vascular interventions, and interventions for structural heart disease [e.g.,
transaortic valve replacement {TAVR}, mitral clip, balloon valvulo-
Table 1-12
Summary of Training Requirements in Diagnostic and
Interventional Cardiac Catheterization
Task
Force Area Level
3 Diagnostic
catheterization
Interventional
catheterization
From Jacobs AK, Babb JD, Hirshfeld JW, et al: Task Force 3: training in diagnostic
and interventional cardiac catheterization. Endorsed by the Society for
Cardiovascular Angiography and Inter ventions. J Am C oll Cardiol 51(3):355–361,
2008.
Minimal
Number of
Procedures
1 100 4 100
2 200 8 300
3 250 20 550
Cumulative
Duration of
Training
(Months)
Minimal
Cumulative
Number of
Cases
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The Catheterization Laboratory 51
plasty, septal defect closures, left atrial appendage closure; see
Chapter 10]).
Integrity in the Catheterization Lab
Admiral Sizemore describes principles of “Operational Excellence in
Navy Aviation,” and I saw immediate parallels of principles to our work
in the catheterization laboratory from his experience with naval aviation and how it related to the practice of medicine. How does experience in naval aviation apply to the catheterization lab, and how do the
lessons from training and experience help naval aviators support their
missions? On review of Table 1-13, one can see that the training and
experience of the catheterization lab team parallels the critical principles that support our mission.
The Navy provides safety and protection for all of us in our great
country. It is a never-ending mission. Although of considerably
smaller scope than that of the U.S. Navy, the mission is same for the
catheterization laboratory. Patients who come into the catheterization laboratory expect safety and protection that we endeavor to
achieve with excellence as they undergo their procedures. The high
level of task performance by naval aviators is required to maintain
readiness within the extraordinary stressful environment of working
on aircraft carriers patrolling the oceans of the world. In a similar
manner, working in the catheterization laboratory, at times a stressful
environment, also requires flexibility and rapid responses. Admiral
Sizemore notes that “aviation is extraordinarily complex and requires
enormous commitment both in materials and in the individuals” with
highly specialized training backgrounds. One could easily substitute
“medicine” for “aviation” in the preceding sentence without changing
the meaning.
Just as is done in naval aviation, so too should the requirements
to maintain proficiency in the catheterization lab be a part of everyday
life. In the catheterization laboratory with the near-continuous
introduction of new devices and procedures, becoming proficient and
maintaining proficiency is necessary to assure safety and quality.
Hopefully the materials in this book help our catheterization labs
succeed in their mission to our patients.
Table 1-13
Principles of Operational Excellence in Navy Aviation*
(and the Catheterization Lab)
Principle Metric
1. Integrity Do the right thing; adhere to the high
2. Procedural knowledge Know your job and procedures; never stop
3. Procedural compliance By the book procedure; no shor t cuts; fight
4. Formal
communications
5. Question attitudes Speak up, ask, and investigative when you
6. Forceful backups Speak up, ask, and act when you know
7. Risk management Identif y, understand, mitigate, and manage
*From Sizemore WG 2nd: U.S. Naval air t raining and operational excellence. Tex
Hear t Inst J 4 0(5):562- 563, 2013.
standards at all times.
learning.
complacency.
Use clearly stated and standardized
language that minimizes
misunderstanding.
are unsure of when you sense or know
something is not right.
something is wrong.
risks.
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The Catheterization Laboratory
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The Catheterization Laboratory 53
To view Video 1-1, please activate your book on
www.ExpertConsult.Inkling.com using the pincode
on the inside front cover.
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For more information, see Video 1-1.
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The Catheterization Laboratory 53.e1
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