A BRIEF RECAP OF THE PROBLEM

Cardiac catheterisation with coronary angiography has become a common procedure performed worldwide. It is now considered a safe procedure that can be done on an outpatient basis. These procedures involving arterial puncture carry a risk of access site complications estimated to occur in 1-5% of procedures. These complications range from simple haematomas to significant bleeding events requiring transfusion, extended hospital stay and possible surgical repair. These procedures may also be associated with serious complications, even when performed in a technically flawless fashion. Major complications in cardiac catheterisations occur infrequently in approximately 3% of all procedures. These complications include death, acute myocardial infarction, emergency bypass surgery, and stroke. Minor complications occur more frequently and include vascular complications, arrhythmias, transient ischemic attack, renal insufficiency, and infection. Of these complications, vascular complications associated with the access site occur most frequently, and could include bleeding at the site, haematoma formation, retroperitoneal bleeding, pseudoaneurysm, and AV formation. Access site complications may also expose patients to further discomfort, a longer hospital stay and higher hospital costs. Several observational studies and some sub-analysis from randomised trials evaluated the possible risk factors for local, vascular complications and showed that established predictors are older age, female gender, body surface area, peripheral vascular disease, some antithrombotic regimens and access site. Some estimate that complications related to the access site results in more than 75,000 surgical procedures annually. A goal following cardiac catheterisation is to reduce vascular complications, especially haematoma formation, the most common access site complication.

ACCESS SITE CARE AND INCIDENCE OF VASCULAR COMPLICATIONS

Post cardiac catheterisation puncture site care is usually done with a tight pressure dressing in many institutions and cardiac centres due to the belief that it should prevent the bleeding. It has been used as the standard following sheath removal after percutaneous transluminal angioplasty (PTCA). This practice is cumbersome and can cause discomfort to the patient without the benefit of preventing recurrent bleeding or haematoma as patients complain about discomfort while the dressing is in place, pain when the dressing is removed after discharge, and skin complications afterwards. Also many patients have experienced skin irritation where tape has been placed. Previous studies examining pressure dressing that was applied to other types of incision, have failed to show a decrease in complication such as haematoma formation. Clinical evidence suggests that patients often experience considerable discomfort associated with the use of pressure bandaging. Therefore, there is a need to evaluate the therapeutic benefits and disadvantages of using pressure bandages in the recovery period after coronary angiography. 
The most important step to prevent the bleeding complication of the puncture site is the initial haemostasis obtained and because care of patients after cardiac catheterisation and/or percutaneous coronary intervention is largely the responsibility of nurses. Nurses have also described difficulty in assessing the sheath insertion site in the groin when a pressure dressing is in place.

RISK FACTORS AND RISK REDUCTION STRATEGIES

Factors that influence vascular complications include the following: patient characteristics, interventional cardiologist technique, medications used during the catheterisation, use of manual and/or mechanical compression at the access site, use of closure devices, and the type of dressing used after these procedures as part of the nursing care.

In addition to benefiting patient care, risk reduction strategies benefit hospitals through cost-reduction and improved catheterisation laboratory flow. Risk reduction strategies can be implemented in the cardiac catheterisation laboratory and the post interventional unit. The following strategies focus on identification of risk factors associated with complications and early implementation of methods to reduce complications:

Patient characteristics Identifying individual patient risk factors is an important aspect of care during cardiac catheterisation. The following list summarises patient characteristics that may increase the risk for development of vascular complications:

•Age (older than 70)
•Female gender
•Extremely thin or morbidly obese
•Presence of peripheral vascular disease
•Hypertension
•Renal failure
•Low platelet count and low haematocrit at baseline
•Congestive heart failure; chronic obstructive pulmonary disease
•Coagulopathies
•Interventional cardiologist technique. 

Techniques employed by the interventional cardiologist can impact vascular complications. Techniques include careful entry into the artery, use of smaller sheaths (e.g. less than 8 Fr), avoidance of venous sheath whenever possible due to adverse effects, early sheath removal, use of low-dose heparin, and minimising procedure time.
Use of medications pre- and post catheterisation
Catheterisations present a fundamental dilemma, the need to prevent thrombosis of the target vessel while promoting haemostasis of the vascular access site after the procedure. Several potent anticlotting drugs are administered before, during, and after catheterisation. Nurses administering these medications should be familiar with the drug action, correct dosing, and potential side effects. The verbal and written communication to other team members regarding the type, dose, time, and patient reaction can be instrumental in preventing errors that can lead to vascular complications.

Management of haemostasis
Haemostasis at the access site after cardiac catheterisation is important to reduce complications, increase patient comfort and safety, and decrease hospital stay. Management of the arterial access site after diagnostic and or interventional catheterisation continues to evolve. The methods currently used to obtain haemostasis post-catheterisation include manual or mechanical compression of the site and/or deployment of a vascular closure device (VCD).

1. Manual versus mechanical compression: Traditionally, manual or mechanical compression for 20-30 minutes has been the standard of practice following sheath removal. Mechanical compression is as effective as manual compression for femoral artery haemostasis after cardiac catheterisation. Vascular complications at the puncture site did not differ significantly when either a mechanical compression device or manual compression was applied. Manual compression and mechanical devices have their limitations, including patient discomfort and prolonged bed rest.

2. VCDs: An alternative to manual or mechanical compression is a VCD. Studies have concluded that VCDs are safe and offer advantages that include early ambulation and patient comfort.

Nursing role
Although there are no consistent standards of care in literature, nursing care activities are essential to preventing vascular complications. Nurses play a critical role in the management of patients after cardiac catheterisation. Early detection and management of vascular complications is key to minimising complications. Moreover, providing comprehensive education and training for nurses who care for cardiac catheterisation patients lays the foundation for safe, quality care. Facilities should consider the following:

•Provide seminars or educational modules for care of cardiac catheterisation patients
•Facilitate simulation labs to observe and demonstrate interventions, including sheath removal, palpation of access sites, manual compression, and application of mechanical compression devices
•Develop a competency skills list that is validated by an experienced practitioner
•Perform annual competency skills assessment.
Facilities should develop protocols and policies to ensure a consistent approach to the care of catheterisation patients in their facility by incorporating the following nursing care elements into nursing protocols and practice:

•Ensure compression time of 20-30 minutes after sheath removal with either manual or mechanical compression devices
•Assess vital signs and site every 15 minutes for 1 hour after sheath removal and then every hour until the patient is allowed to walk (i.e. 3-6 hours)
•During site assessment, palpate site and assess temperature, colour, and pulses present in the extremity used for access
•Assess for patient discomfort at the site
•Ensure bed rest for 2-6 hours for interventional catheterisation after haemostasis. Ambulate patients one hour after diagnostic catheterisation if haemostasis is maintained
•Ensure head of bed is not elevated more than 30 degrees
•Assess for a bruit that indicates compromised vascular flow indicative of pseudoaneurysm or AV fistula
•Include the following in documentation about the access site: haematoma measurement in centimetres, skin colour and temperature, haematoma character (e.g., soft or firm), and the presence of pedal pulses and/or bruit
•Provide patient education.

EVIDENCE-BASED PRACTICE TO REDUCE INCIDENCE OF ACCESS SITE COMPLICATIONS

New techniques have been developed and used to decrease incidence of such complication. One of these techniques is the application of transparent film dressing (TFD) at the puncture site after cardiac catheterisation, which approved and rated better with regard to comfort, ease-of-use, ease of dressing removal, less pain, decreased haematoma formation. Better cosmetic appearance and greater patient acceptance were also noted with the use of TFD. Furthermore, this type of dressing will facilitate nurses assessment of the puncture site and enhance early detection of any complication might be encountered since nurses will have the ability to visually assess ongoing bleeding in the subcutaneous tissue immediately post cardiac catheterisation.

SAFETY AND EFFECTIVENESS OF TRANSPARENT FILM DRESSING

A transparent film dressing is made of a thin and flexible polyurethane film coated with a skin-friendly polyacrylate adhesive. The dressing can be permeable to both water vapour and oxygen, but impermeable to micro-organisms. It can provide moist wound healing for superficial wounds. Because the dressing is waterproof and aids in the prevention of bacterial contamination, Opsite reduces the risk of infection from airborne bacteria. They are appropriate for superficial wounds with little drainage to reduce friction and for a stage 1 pressure ulcer or to help autolytic debridement of a dry escharic wound. Another factor to consider when selecting a transparent film dressing for wounds is the method of application. The easiest dressings to apply are those that use a frame or window delivery system, such as Bioclusive and Tegaderm. TFD can be used safely and comfortably after achieving haemostasis.

SUMMARY

Nurses on the frontline caring for patients before, during and after cardiac catheterisation play a key role in the prevention of complications. With the increasing number of cardiac catheterisations performed, evolving technology, and advances in pharmaceutical therapy comes an increase risk of vascular complications. The strategies described in this article can be incorporated into the daily practice of cardiologists and nurses caring for these patients.