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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3855_Библиотеки_им_академика_М_И_Перельмана
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Patient Follow-Up
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the sheath at an activated clotting time of less
than 175s. Often, however, the sheath is pulled
simply on the basis of the time (e.g. 2h after
the last heparin administration).
After removal of the intra-arterial sheath,
manual compression of the puncture site
should be applied for about 5–10min, but in
any case until spontaneous bleeding from the
puncture site stops. Compression of the puncture site is strong and punctual (. Fig.6.2).
A at and not punctual compression, for
example by using the st, should be avoided,
as the pressure exerted directly on the puncture site is too low. Mechanical compression
aids, such as the FemoStop system or a compression stamp xed to the patient’s bed, can
also be used and are effective. In very obese
patients, manual compression without
mechanical aids should always be preferred
(. Fig.6.3).
After the bleeding has stopped safely
(check over several seconds!), a strong pressure bandage with a small pressure mediator
made of Styropur is applied. In order to avoid
accidental bleeding post puncture, in addition
to all the measures already mentioned, it is of
great importance to inform the patient of the
importance of not bending the leg on the
punctured side, as otherwise the pressure
would be taken off the pressure dressing and
the risk of renewed arterial bleeding from the
puncture canal would increase. In the case of
restless patients or incompliance, the use of a
closure system is recommended (. Fig.6.4).
The duration of bed rest depends on the
French sizes of the sheaths used and the
amount of anticoagulation applied. As a rule,
strict bed rest lasts between 2 and 6h. In special constellations, however, a longer period
of bed rest may be necessary. The patient
should then take it easy for two days, avoid
heavy lifting and exercise.
If arterial closure systems have been used,
the further procedure can be adapted to the
manufacturer’s instructions.
After removal of the pressure dressing and
before discharge, the puncture site should be
checked by inspection, palpation and auscultation. If abnormalities such as a ow noise, a
large hematoma or pronounced pain are
. Fig. 6.2 Punctual manual compression after pulling the sheath. (Thanks to R.Schräder)
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T. Konrad and E. Kaiser
6
. Fig. 6.3 Stopping the bleeding after punctual impression. (Thanks to R.Schräder)
. Fig. 6.4 Pressure dressing after manual compression. (Thanks to R.Schräder)
Patient Follow-Up
163
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found, immediate duplex ultrasound control
of the punctured vessel is indicated.
Particularly in the case of back or ank pain
and a relevant drop in hemoglobin, the highest level of attention is required and an immediate diagnosis of the presence of a
retroperitoneal hematoma is indicated (see
also 7 Sect. 2.1.1).
6.1.2 Access via theArm, Puncture
oftheRadial Artery
The advantage of puncturing the radial artery
over the femoral approach, namely the good
compressibility and rapid mobilization of the
patient, is immediately apparent in the postprocedural procedure. The arterial sheath is
pulled immediately after cardiac catheterization, even after previous heparin administration. The puncture site is then either manually
compressed or compressed with a mechanical
compression system, such as the TR-BandTM
(Terumo Interventional Systems Company).
The advantage of this system is the simultaneous visibility of the puncture site under compression. Alternatively, folded compresses can
be placed on the puncture site (sparing the
ulnar artery) and wrapped with an elastic
bandage. After removal of the sheath, the
hand should be monitored closely to note paresthesias of the ngers or malperfusion.
However, temporary paresthesias of ngers
I–III may also be due to local anesthesia in
the area of the puncture site. After removal of
the pressure dressing/compression system, the
puncture site should again be clinically
checked for sensitivity, perfusion and motor
function of the hand.
6.2 Monitoring After Coronary
Angiography andCoronary
Intervention
TorstenKonrad and ErhardKaiser
The necessity for post-procedural continuous
circulatory monitoring results from the
respective examination circumstances and the
procedures performed. Post-procedural monitoring always continues the monitoring
started in the cardiac catheterization laboratory, sometimes without interruption (patient
transport, patient transfer). This can be done
in the intensive care unit, the intermediate
care unit or in the normal ward with telemetry
stations.
After elective diagnostic cardiac catheterisations, bland balloon dilatations and stent
implantations, continuous ECG monitoring is
not required. Rather, a normal 12-lead resting
ECG is routinely written after about 4–6 h
and the arterial blood pressure is documented
non-invasively at regular intervals by the nursing staff. The ordering of this is the responsibility of the operator, who will order the
further procedure in his report of the cardiac
catheterization. If the arterial sheath is
removed on the normal ward, this is a moment
that requires special attention, since vasovagal
reactions with bradycardia relevant to the circulation can occasionally be observed under
the strong pressure on the femoral artery.
Because of this, intravenous volume administration or atropine administration is occasionally necessary after the arterial sheath is
pulled. The peripheral venous access cannula
should therefore only be removed after the
arterial sheath has been withdrawn.
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T. Konrad and E. Kaiser
In contrast, patients who have already had
circulatory problems in the cardiac catheterization laboratory and who may have shown
arrhythmias (short VT, atrial brillation, etc.)
require special attention. Depending on the
5 Echocardiography, duplex sonography
and TEE
5 Debrillation, cardioversion and pace-
maker therapy
5 Intensive nursing and medical care
equipment available for monitoring, continuous ECG registration with arrhythmia detection is then also carried out in the normal ward
with telemetry facilities or in the intermediate
care unit. In addition to ECG monitoring, this
group of patients also undergoes closer noninvasive blood pressure measurement in the
rst hours after the procedure and, if neces-
6
sary, additional blood samples are taken for
supplementary laboratory chemistry tests.
6.3 Outpatient Follow-Up
Examinations After Cardiac
Catheterisations
TorstenKonrad and ErhardKaiser
After cardiac catheterization and especially
after coronary interventions, outpatient noninvasive follow-up should be performed. As a
Patients Who Need to Be Monitored in
an Intensive Care Unit
5 STEMI, NSTEMI and acute coronary
syndrome
5 Condition after cardiopulmonary
resuscitation
5 Circulatory unstable patients
5 Ventilated patients
5 Patients after high-risk interventions
5 High-risk patients for bridging to sur-
gery
5 Patients with catecholamine require-
ments
5 Patients who have had procedural com-
plications, if applicable
5 Patients who have had periprocedural
complications, if applicable
Interdisciplinary intensive care units or pure
cardiac care units offer a variety of monitoring and therapy options in addition to the
rst-mentioned possibilities, so that high-risk
patients in particular are monitored and
rule, you yourself or the cardiologist who is
continuing your treatment will see your
patient again immediately and then again
after 4–6weeks post procedural in the practice/outpatient clinic in order to then carry
out a complete non-invasive follow-up.
Examinations in the Context of the First
Non-invasive Follow-Up
5 Physical examination and follow-up
history
5 Special inspection, palpation and aus-
cultation of the punctured groin/wrist
5 12-Lead resting ECG and rhythm ECG
5 Color Doppler Echocardiography
5 Possibly stress ECG (climbing level
according to Kaltenbach, ergometer,
treadmill)
5 Checking and adjusting the medication
taken
5 Determination of the further treatment
strategy and the further examination
intervals
treated post-procedurally here.
5 Continuous, non-invasive and invasive cir-
culatory monitoring
5 Continuous respiratory monitoring
6.4 Conclusion
5 Controlled and assisted ventilation
5 Controlled mild hypothermia
5 Mechanical circulatory support such as
ECMO, heart-lung machine
5 Different forms of anaesthesia
5 Complex drug therapies via syringe pumps
In addition to all medical aspects of the therapy, it is also psychologically important for
the patient to have a reliable, friendly and
knowledgeable companion in his treating cardiologist during the course of his disease.
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