Looking for all opinions.....

New CCU RN · Mar 11, 2004

I am really interested in your opinions on this... Our hospital recently took our low risk cath lab and expanded it. They are now doing cardiac caths, balloon pumps, temporary pacers, and stent placements on patients experiencing MI's day or night. So, now , instead of retavasing a patient and following through with that protocol, we now prep and run the patient to the cath lab as soon as the crew is ready.
My question, we do not have a cardiothoracic surgeon or an OR equipped to do open heart surgery within 50 miles, in your opinion isnt this just a little risky?? At least when we used to retavase, we would give the pt an opportunity to reperfuse before loading them on the helicopter and sending them to the heart center..
we are all just a little nervous about this. Are we overreacting?

What I would be afraid of is perforation of a coronary artery. Although it is rare that this does happen.... it does happen in the cath lab and when it does...it isn't pretty. That is the only thing (at least from what I have seen as a cardiac nurse that would necessitate emergent cardiac surgery secondary to having a cath lab procedure.)

I am at a large teaching facility and our surgeons prefer to wait and do not do CABG'ss too close timewise to the MI...... at least three or four days even with 3vd. Even if that means balloon pumping them as a bridge they will do that......it is all in the doc's school of thought.

I think patient outcome wise it will be ALOT better. As the recieving nurse of patients who rule in at an outside hospital...if for some reason they can't recieve lytics and have to wait for a transfer to a larger facility to go to the cath lab they usually arrive in some pretty bad cardiogenic shock.

Just my humble opinion....

veetach · Mar 11, 2004

the coronary artery perforation is a major fear for us too... I am sure the doc knows what he is doing, he has done quite a few in the last month but I guess that risk is always there.

I didnt know that they usually wait to do CABG's thats interesting, thanks for the info!

zambezi, BSN, RN · Mar 11, 2004

I personally wouldn't have a cath done if there wasn't a surgeon/surgical heart team available (unless I had no choice, of course)...we have a facility about two hours away that does caths without the surgical option available and every couple of months they have to transfer an "emergent" cabg/valve. etc patient to us. We also have patients in our hospital that emergently are cathed, then have emergency surgery so the problem can be fixed now rather than later (ie: high left mains, no real viable vessels). Although "the cath gone bad" doesn't happen too often- when you need it, you need it. On the opposing side of things, getting a STEMI to the cath lab and intervened on within two hours is the standard of care and has shown great results. Its a gamble. Below is a copy of the of ACCs guidelines for PCIs...

http://www.acc.org/clinical/guidelines/percutaneous/dirIndex.htm

suzanne4, RN · Mar 11, 2004

Many, many years ago in Phoenix, when the old Phoenix General was just starting up their cath lab, but no surgery available in house for hearts, they had a helicopter and crew available just outside of the door that could whisk the patient away immediately, if needed. I have been on heart teams now all over for quite some time, and no matter what city that I have been in, if they are just even considering a PTCA, we have a team available in house. Consent is even signed pre-procedure for this, just in case. In my persoanl opinion, they are just asking for trouble. All it takes is one lawsuit and?????

Good luck.................what is your hospital set up to do in a what if situation?

Do they even have a plan?

athomas91 · Mar 11, 2004

veetach..i worked at a level2 ER that did the Seaport trial...which was much the same as what you are doing...and i had the same concerns...when there is a perf...you have to wait for the helicopter....

all i can tell you is that i myself...nor a family member will have a procedure such as this done at a facility where they couldn't deal w/ an adverse outcome.....and i think patients are entitled to know that prior to agreeing...just my 2 cents

veetach · Mar 11, 2004

veetach..i worked at a level2 ER that did the Seaport trial...which was much the same as what you are doing...and i had the same concerns...when there is a perf...you have to wait for the helicopter....
all i can tell you is that i myself...nor a family member will have a procedure such as this done at a facility where they couldn't deal w/ an adverse outcome.....and i think patients are entitled to know that prior to agreeing...just my 2 cents

I TOTALLY agree with athomas, and everyone, I think the patients are not going into these procedures adequately educated. We are going to have an "inservice" about the cath lab soon (its already been over a month and a half since they started doing them). Who thinks I should ask the question about their plan for a coronary artery perf????

athomas91 · Mar 11, 2004

they don't care...they will say they will fly it to the nearest cardiac surg. location....

it is unfortunately how a facility begins a heart program...if you ask me - the wrong way...but first they start cath's...see what the demand is, entice some CT surgeons...and viola - start an open heart program...

most of us w/ some sensibility realizes this should be done the other way around...however - hospitals think w/ their purses..and they have to bring in money to prove there is the need in the area...

sooner or later (hopefully never) - a pt will suffer the consequences of a perf that can't wait to get to another facility for a repair...

i agree w/ you though that in the risks on a consent - the pt should be made aware that if that situation arises - the patient would have to be transferred because the repair could not be done at the original facility...too big of a risk if you ask me.

New CCU RN · Mar 11, 2004

At the same time, there will be a great benefit from being able to do interventional caths. The risk of perforation is extremely low...however the risk of cardiogenic shock s/p MI with failed lytics and awaiting a transfer to a larger facility is much higher.

It would be the most ideal to have cardiac surgeons onsite. I fully agree. And patients ought to be informed they will need a transfer if the cath goes bad b/c there is no cardiac surgeon... but I do think more patients will benefit from quicker balloon time compared to now where they don't have that accessibility and need to recieve lytics.

It is a catch 22 situation....however, what is a higher probability---stroking out from lytics or getting a perf in the cath lab???

Katnip, RN · Mar 11, 2004

Our hospital does caths with no open heart facilities, but we can ship someone to a hospital that does and have them there in 15-20 min. At least in theory.

50 miles is way to far to me, helicopter or no helicopter.

veetach · Mar 12, 2004

Our hospital does caths with no open heart facilities, but we can ship someone to a hospital that does and have them there in 15-20 min. At least in theory.
50 miles is way to far to me, helicopter or no helicopter.

air time to the closest cardiac facility is 26 minutes lift off to set down, I still think that is a long time.

I think I am seeing how they are rationalizing performing the caths here, it is kind of a "best of the worst" situation. Risk the possible perf from a cath (probably not happening very often) vs the possible complications from a failed round of lytics... thanks for your help everyone!

I am going to read over the consent form and look to see if the risk of perforation of the coronary artery is present on the form..

teeituptom, BSN, RN · Mar 15, 2004

It can either be good or bad

2 sides there

we get a few from outlying hosps because of it

we just do what we need to do