NTI: Post-Procedure Complications

Most of the time the patient recovers uneventfully. However, what happens when they don't? Would you know how to troubleshoot and care for the patient with complications from these commonly performed procedures? Some of the associated complications are retroperitoneal bleed, lacerated liver, perforated myocardium, and pneumothorax.

AllNurses staff recently attended NTI in Houston, Texas. Cheryl D Herrmann, RN, APN, CCRN, CCNS-CSC-CMC facilitated a session about post-procedure complications.

Cardiac Catheterization and Pacemaker Insertion

Cardiac catheterization can be done for a variety of reasons but is most performed for chest pain evaluation. Pacemaker insertion also involves multiple disease processes from sick sinus syndrome to patients post-myocardial infarction (MI) to patients with congenital heart malformations. Some of the complications that can occur include:

• Bleeding from the insertion site
• Hematoma
• Perforated myocardium
• Allergic reaction to the contrast medium
• Death

The risk of death is 0.1% per 200,000 procedures per UpToDate. The most common complication is bleeding, either acutely hemorrhagic which usually occurs in the first 12 hours or contained hemorrhage in the femoral region which might not be evident until days to weeks later.

The perforated myocardium is one of the rarer complications. The risks are increased with the use of stiff catheters, including transseptal catheterization, endomyocardial biopsy, balloon valvuloplasty, needle pericardiocentesis, and placement of a pacing catheter.

Cardiac perforation often results in bradycardia and hypotension due to stimulation of the vagus nerve. If the patient remains stable, an echo can be done. However, as these patients tend to go downhill quickly emergent pericardiocentesis should be performed via the subxiphoid approach.

Nursing Care of the Patient with a Perforated Myocardium

Most often these patients will be identified mid-procedure as once the myocardium is breached, the patient's blood pressure (BP) will fall and the patient will develop bradycardia. Nurses monitoring patients in the cath lab are on the forefront to note changes in BP and heart rate (HR). These patients will be transferred emergently to the operating room (OR) or if stable, may have echo while still in the cath lab. Nursing care will include:

• Close monitoring and documentation of baseline vitals, time of sedation, time of procedural start points as well as any concerns or issues during the procedure.
• Inform the surgeon of any discrepancies or changes in the patient's vitals or status
• If the patient is to be taken emergently to the OR, have another member of the team notify the family and move them to the appropriate waiting area.

Chest Tube Insertion and Thoracentesis

A thoracentesis can be either diagnostic - to find out what is causing the excess pleural fluid or diagnostic - to remove the excess pleural fluid. Sometimes a chest tube is inserted to drain the pleural cavity. Chest tube placement and/or thoracentesis can be done bedside, usually in an intensive care unit (ICU) or more commonly it is done in Interventional Radiology (IR) under sono-guided fluoroscopy.

These procedures are usually accomplished with local anesthetic and sedation. In the ICU environment, the patient may be on ventilatory support. When doing a thoracentesis for diagnostic purposes, common tests performed on pleural fluid include cell count, protein, lactate dehydrogenase, pH, glucose, amylase, gram stain, culture, and cytology. The pleural fluid should be immediately placed in the appropriate specimen tubes and bottles, and then sent to the laboratory for analysis

Common Complications associated with chest tube insertion or thoracentesis include:

• Pain at the puncture site
• Bleeding (eg, hematoma, hemothorax, or hemoperitoneum)
• Pneumothorax
• Empyema
• Soft tissue infection
• Spleen or liver puncture

Central Line Removal

The most serious complication that can result from central line removal is an air embolus. Key points to avoid air embolism when removing the central line:

• Place the patient in the supine position (they should not be sitting or upright)
• Instruct the patient to hold their breath and perform the Valsalva maneuver (forced expiration with the mouth closed) when the catheter is being removed If the patient is unable to cooperate with instructions, the catheter should be removed following inspiration
• Cover the insertion site immediately with sterile gauze, maintain firm manual pressure until hemostasis is achieved. Then cover the site with an air-occlusive dressing, which should remain in place for 24-72 hours.

Procedures are not without risk of complication. It is important to have all the needed emergency equipment readily available to care for your patient during and after a procedure.

References:

Diagnostic Thoracentesis

Myocardial Rupture Treatment and Management

UpToDate, Complications of Diagnostic Heart Catheterization