Ana Finnegan, an RN in the cardiac cath lab at University of Miami Hospital, is a passionate advocate for the transradial approach that provides access through the wrist for diagnostic and interventional cardiac caths.
"My background taught me the transradial approach was the last resort, something we'd set up for if the femoral approach didn't work, so it was a hassle and inconvenience," she acknowledged. "But I became an immediate convert after caring for these patients. After a transradial procedure, the patients don't have to lie flat for 6 hours, and that's huge for our elderly population with back problems and hip surgeries."
Cath lab nurses provide psychosocial support and education. "There's often a knowledge deficit because patients don't understand how we can get the catheter up the arm and into the heart," Finnegan said. "It's easier for them to grasp how to get from the femoral artery to the heart."
Lynn Hanley, RN, clinical coordinator of the cardiac cath lab at WellStar Kennestone Hospital, Marietta, GA, understands her patients are anxious about the procedure.
"The first question I usually hear is, 'Am I going to have pain?'" she said. "The second is a concern about what the doctor will find during the procedure, and the third is if the patient will be able to tolerate the bed rest during and immediately after the procedure."
Cardiac cath nurses make sure the IV is patent and check lab results before the procedure.
"We look closely at renal function because contrast media can be hard on the kidneys," Hanley said. "If the patient doesn't have normal renal function, we may use a bicarbonate drip or Mucomyst to protect his kidneys. We also check the INR (International Normalized Ratio) to identify any abnormal bleeding risk. Due to the low bleeding risk, one benefit of the transradial approach is that it can be performed safely in the setting of an elevated INR."
The nurses in the pre-procedure bay also perform an Allen's test to evaluate arterial flow to the hand. This assessment involves checking the radial and ulnar pulses using a pulse oximeter with a probe attached to the index finger on the side of the body that will be used for the catheter insertion - usually the right. The nurse watches for a wave form on the pulse oximeter.
After viewing the baseline wave form, the nurse compresses the radial and ulnar arteries at the same time until the wave form flattens, then releases the radial artery and watches to be sure the wave form returns to baseline. Finally, the nurse compresses both arteries again until the wave form flattens, releases pressure on the ulnar artery and watches for the wave form to return to baseline.
"If the wave form doesn't return to baseline, we call this finding a negative Allen's test," Hanley said. "Most physicians will change from a transradial to a femoral approach if the patient has a negative Allen's test. However, there's some new thinking that a negative Allen's test does not necessarily preclude a transradial procedure."
Once the patient is prepped and draped for the procedure, nurses participate in a time-out to ensure it's the right procedure and the right patient.
"The physician will then ask me to push Versed and fentanyl for conscious sedation, and within 1-2 minutes the patient feels the effect," Finnegan described. "We want to take the edge off, but not put the patient out completely because we may need him to take a deep breath or to cough at various times during the procedure."
After numbing the access site, the physician gives a transradial cocktail of Verapamil and heparinized saline (and sometimes nitroglycerine) to prevent arterial spasm.
Transradial caths at WellStar Kennestone are performed with the patient under moderate sedation. "During the procedure, the nurse's primary responsibility is patient observation, making sure his blood pressure isn't dropping and his oxygen saturation stays adequate," Hanley said. "We use bedside electronic documentation to record any medications we administer, and scan in the equipment used during the procedure as well."
Hanley and her colleagues perform a post-sedation evaluation to determine when the patient is ready to be discharged or transferred to an inpatient bed.
"Most of our patients are awake and alert very quickly, and able to move themselves from the procedure table to the stretcher," she said. "Our outpatients go back to the admit/recovery area and stay on bed rest for an hour or so. If the patient has had a diagnostic procedure, he can go home 2-4 hours after the procedure. Those who have had interventions such as angioplasties are admitted for an overnight stay."
Finnegan described the transradial band used to prevent bleeding after the procedure. "[It] applies pressure to the radial artery, and we follow a protocol to deflate its balloon 3-5 cc at a time, starting 2 hours after the procedure," she said. "We'll monitor for any bleeding or compartment syndrome during that time. In the meanwhile, the patient can go to the bathroom, sit up and eat, and be much more comfortable than if he were lying flat."
Transradial bands have made a big difference at Wellstone as well. "[They] reduce the bed rest time to approximately 1 hour, increase bed availability in the post-procedure areas and decrease nursing hours per patient," Hanley said.
Discharge teaching is aimed at reducing bleeding and other complications.
"For the transradial approach, the most important instruction is hand rest," Hanley said. "That means no flexing, no rotation, no pushing up from a sitting or lying position, no pushing or pulling, and no heavy lifting for 3 days. I can recall only two incidents of hematoma formation since we started doing these procedures, so our patients are doing a good job of following those instructions."
Finnegan hopes to see more cardiac diagnostic and interventional procedures done via the transradial approach. "[It's] wonderful for almost any patient, but it's especially beneficial for obese patients, cachectic patients with pressure ulcers, and individuals who have breathing problems or significant edema," she said.
Sandy Keefe is a frequent contributor to ADVANCE.