PreparingforthecaseLeeBensonMDFSCAITheHospitalforSickChildren,Toronto,CanadaNoDisclosuresAskyourselfthesequestionsasyouprepareforthecatheterizationWhyisthecasebeingdone? -pre-operativeinformation: -hemodynamics–PVRI,LVED -morphology orintervention

Isthecaseelective,emergentorurgent?Isthistherighttimingfortheprocedure?Isthechildstableenoughfortheprocedure? ifnon-elective…istransportationanissue…ECMOHistory&PhysicalExaminationPriorhistory bleedingdisorder allergytodrugs contrastreactionsIntercurrentillnessorrecentfever dependsonhowelectivethecase: e.g.infantinCHF…..maynotfinda2weekperiodwherethey arefeverfree…….ingeneralavoidcathiftemp≥380C (likelytobecomebacteremic)Generalhistory&physicalexamination -specificquestionsrelatingto technicalaspectsofthecase History&PhysicalExaminationLastmenstrualperiodorpossiblepregnancymusthaveaverycompilingreasontoexposehertoradiationPriorcatheterizationsorcardiacoperationsparticularattentiontounsuccessfulcath’soroperationsthateffectvascularaccessPhysicalexamination*right&leftthoracotomyscars e.g.classicalBlalock-Taussigshunts,Glennanastomosis, precludingaccesstotheheartfromthearms-verticalcutdownfromgroinbypass vesselsusuallyrepairedExtensivescartissue,makespassageofsheaths&dilatorsdifficult&oftenrequirestageddilation…sometimeswithballoons*groinorantecubitalfossascars previousvascularcutdownsmaymakepercutaneousstudy difficult -saphenousveincutdown:migratesdistally, enterdistaltoscar

proximaltoinguinal ligamentAbdominal,thoracicorneckveindistentioninfantswithprolongedICUstays(indwellingcentrallines)Mustard,SenningorFontanrepairscandevelopcavalorbaffleobstructionPeripheralarterialpulsesCoAthemostcommonbutnotonlyarteriallesionthatmaylimitarterialaccess…..e.g.subclavianarteryisolationMedical&psychologicalpreparationforcardiaccatheterizationPrecatheterizationpreparation*Preparationisindividualized……nohard&fastrules*Beginswhendecisionmadetoperformtheprocedure*Allpatientsbeyondinfancyneedageneralexplanationregardlessofsedation/GA.Describethatportionoftheprocedurethattheywillbeaware*Neversay‘nothingwillhurt’…….makesthechildmoredistressed&uncooperative.Donotletthemthinkit’sjustlikean‘officevisit’Medical&psychologicalpreparationforcardiaccatheterizationPrecatheterizationpreparation*Exactdetailsdependsontheage/understanding/interestofthechild…tailoredatthetimeoftheinterview*Betruthful,notallthegruesomedetails……leadsto>anxiety*-information: youngchildren pre-proceduretests, theinevitable‘needle’, premeds/sedationgivenolderchild lengthofprocedure, stayinPAR,stayinhospital, anyspecialissues:IVlines,Foley’sMedical&psychologicalpreparationforcardiaccatheterizationPrecatheterizationpreparation* olderpatient moredetail/explanation tailoredtopatient&family*Emphasizethereasonforthecath,notonlytechnicaldetailsorrisks*Fulldetailsmakeyou‘medicolegally’morecomfortable………………….butonlyworsensanxietyforthechildMedical&psychologicalpreparationforcardiaccatheterizationPrecatheterizationpreparationThoseinadecisionmakingposition,informedconsentshouldinclude: 1-thediagnosis 2-thenatureoftheprocedure

3-therisks 4-thealternatives 5-therisksofnotdoingtheprocedure 6-thebenefitsMedical&psychologicalpreparationforcardiaccatheterizationTherisks:Datafrom11,073childrencatheterized(last10yr)lookingatcomplicationswithinthefirst24haftercatheterizationComplicationsoccurredin7.3%.....~1%major(stroke,perforation,permanentarterialthrombosis,seizures)&~6%minorwithvascularcomplications(hematoma,transientvesselocclusion)25childrendiedwithin24h(0.23%oftotalcasenumbers)Independentriskfactors: youngpatientage(<6months) malegender inpatientstatus yearofcatheterizationMedical&psychologicalpreparationforcardiaccatheterizationPrecatheterizationpreparation*Noinfant/mostallchildrendonotneedsedationthenightbeforethestudy*Occasionally,anadolescent/ACHD-or-parentisveryapprehensive…….mildsedativeisreasonable*Inadditiontoexplanation&psychologicalpreparation……thereareadministrativeissuesthatmustbeaddressed:i.e.,whenandwheretocometothehospital,NPOetcMedical&psychologicalpreparationforcardiaccatheterizationPrecatheterizationpreparation*Whatarethearrangementsforanypre-cathtesting?*Instructionsforbathing…noshaving…EMLAcream1-2hoursbeforecaseathome*WhattimetocometohospitalbeforetheprocedureMedical&psychologicalpreparationforcardiaccatheterizationNutritional&fluidrequirements*NPOaftermidnightnotnecessary 2hoursNPOforclearfluids 4hoursforbreastmilkorformula<6months 6hoursfoodorformula>6monthsAssurethattheytakefluids6hoursbeforethestudy……….butremember…inthe(polycythemic)infant….startIVtomaintainhydration,asstudymaybedelayed…..….LactatedRingers/NSor5%dextrose/0.25NS*Remember,infants/smallchildrenemptytheirstomachsfasterthanolderchildrenbecomedehydrated/hypoglycemicMedical&psychologicalpreparationforcardiaccatheterizationImmediatepre-cathpreparation*EMLAcream(home)1-2hoursbeforecase,onallpossibleaccesssites*CarefulIVstarts…avoidmultipleattempts*Thecombativechild(forIVstart):monitorECG/BP ketamine………1-2mg/kgIM midazolam…..0.25mg/kgINVeryanxious……………0.2–0.6mg/kgPO(30minutesbeforeIV)Medical&psychologicalpreparationforcardiaccatheterizationImmediatepre-cathpreparationSpecialsituations*Polycythemia(Hct>65%): increasedriskofcath effectshemodynamicsIfHgb>200g/l,whileincreasesoxygencarryingcapacity..…decreasedCO,leadingtoreducedoxygendeliverytotissues…………riskofthrombosis&embolization…performcoagulationstudies/plateletcountAnemia: decreasesoxygencarryingcapacity,falselyincreasesCO,worseningCHF……exacerbatedduringthecath(bloodloss/fluids)CorrectanyHgb<80g/l……….ifcan’t………….cancelcaseMedical&psychologicalpreparationforcardiaccatheterizationPre-medication*Goal:acalm,sleepy&cooperativechild,beforetheyenterthelab.Givemedicationinworkuproom,PO/IN/IM/IVWhenGAisnotused,allchildrenneedsomesedationinadditionlocalanalgesia…goodcombinationisfentanyl&midazolamFentanyl…..1-3μg/kgIV,canrepeatevery30minutes…analgesia/sedation ……..anaestheticdose….5-10μg/kgIV,1-10μg/kg/hrinfusionMidazolam….0.05-0.2mg/kgIV,over2–4minutes ….0.2-0.3mg/kgIN;0.2-1mg/kg30minutespriortocasePO ….0.07-0.1mg/kgIM30minutesbeforecasesMonitorECG,saturation,BPMedical&psychologicalpreparationforcardiaccatheterization*Under-sedationresultsinanuncooperative,anxious,hyperventilating,straining,moving,cryingchild….....bothcrueltothemandthestaffTodayGAfrequentlyused,asmostcatheterizationsareperformedforinterventionalindicationsandatimeout!Medical&psychologicalpreparationforcardiaccatheterizationTheanaesthetistswillhavetheirownchecklist……………..….communicationwiththembeforethecaseisessentialProvideinformationsotheycanmakeananaestheticplan natureoftheprocedure cardiacanatomy recentecho functionalstatus CHF? riskofABENursesroleinpreparationfor

catheterizationprocedure?Nursesroleinpreparationfor

catheterizationprocedure*NursingsupervisesanOPDpre-catheterizationclinic*Familiesaremeetbytheirassignednurse&anexplanationisgiventothefamiliesoftheexpectationsfortheday&administrativeissuesfortheprocedureday*Pre-orderedtestsareobtained(echo,ECG,CXRwithin6months),butnoroutinetests(SSinappropriatepopulations)*Testresultsarereviewed&discussedbythecardiologyteam&communicatedtothechildren&theirfamilypriortodischargehomeNursesroleinpreparationfor

catheterizationprocedureTheClinicNurseisresponsibleforperformingacomprehensiveassessmentforeachchildseeninpre-cathclinic,including: vitalsigns,height,weight,chestassessment,infectious disease&medicationchecklistResponsibleforcoordinatingappropriateconsultations(i.e.anesthesiaconsultation&thrombosisconsultation)Arrangingameetingbetweenthechildren/familywiththecardiologistperformingtheprocedureNursesroleinpreparationfor

catheterizationprocedureTheclinicnurseisresponsibleforeducatingthepatient&theirfamilieson:

-thearrivaltimeonthedayoftheprocedure-feedinginstructions-expectationsbefore&afterthecatheterization-provideinformationonresearchstudies-postcatheterizationsitecareupondischarge-addressingquestions&concernsofthechildren&theirfamiliesTrendsinthecatheterizationlaboratoryCaseLoad:TheCDIUTheHospitalforSickChildren1969-2008UnderstandtheindicationsforcatheterizationOnJune25th,1876,GeneralGeorgeArmstrongCusterreceivedinformationthatasignificantnumberofIndiansweregatheringatLittleBigHorn.Withoutanalyzingthefacts,hedecidedtorideoutwith250mento‘surround’almost3000Indians………….thiswasaseriousmistake.AnalyzethefactsbeforemakingadecisionTHANKYOUUnderstandthetimingofthestudy Elective preparationforsurgery, *primarilyhemodynamicquestionssuchas PAP,PVR,VEDP *anatomicalquestionssuchaspulmonary arterymorphology……..complimentingMRI/echo *preoperativeintervention……collateral occlusionUnderstandthetimingof