Prioritizing in the Cath Lab

ladyandthetiger · Feb 17, 2017

Try asking the doctors directly how they like their setups, ask intelligent questions and they will generally help

C4th L4b RN · Feb 18, 2017

Thank you for replying and I will definitely take your advice and engage the physician. Appreciate your help.

Canadavsus · Feb 19, 2017

Multitasking is a better way to say it I guess in Cath lab lingo than ccu lol. Most MD's would say it's whoever yells the loudest but just remember your patient. It all comes down to the patient. It is the same priorities as the ccu if you remember this. Yes MD's will always yell and curse at you to go get this first or do that first but the quicker you learn to think for yourself and not rely on a physicians order before you act the quicker and better you will be. Make sure you are working and learning from physicians you trust and respect and hopefully a teaching hospital. That way it's not just a nurse who trains you but the physician too. They usually want a say in making a good to excellent Cath lab nurse. And that way you know your actions will be backed up with orders. Do not let that physician leave without writing the orders you performed. You will learn to listen for the cues that tell you what is going on without looking. Or (sorry ccu nurse) forget accurate calculation for the dopamine drip and all get put at 15 but make sure you calculate prior to report and transfer out. Let it run open wide for a lousy arterial bp then put it on pump (just 5 to 10 sec) judgement call. Now this is old school Cath lab ( and I'm only in my 40's). Do as much as you can prior to the case, prime lines, grab intervention supples you may need. Forget being neat and be ok with being messy. Let that IV run wide open in a sink or the floor (clean up before you slip or defibrillated in it) to get the air out don't flick it out. Don't let that nurse get you down you will get it. It's not as easy as it looks. Identifying coronaries is always listed like its the first thing you learn but it's not. That comes with time, questions, guesses (don't be afraid to try) and hours at staring at fluoro images. And I trained at the best medical facility in Texas without the benefit of CCU experience and I survived to become a nurse that is recommended by those MD's that trained me. Good luck and feel free to ask more questions.

Canadavsus · Feb 19, 2017

Multitasking is a better way to say it I guess in Cath lab lingo than ccu Most MD's would say it's whoever yells the loudest but just remember your patient. It all comes down to the patient. It is the same priorities as the ccu if you remember this. Yes MD's will always yell and curse at you to go get this first or do that first but the quicker you learn to think for yourself and not rely on a physicians order before you act the quicker and better you will be. Make sure you are working and learning from physicians you trust and respect and hopefully a teaching hospital. That way it's not just a nurse who trains you but the physician too. They usually want a say in making a good to excellent Cath lab nurse. And that way you know your actions will be backed up with orders. Do not let that physician leave without writing the orders you performed. You will learn to listen for the cues that tell you what is going on without looking. Or (sorry ccu nurse) forget accurate calculation for the dopamine drip and all get put at 15 but make sure you calculate prior to report and transfer out. Let it run open wide for a lousy arterial bp then put it on pump (just 5 to 10 sec) judgement call. Now this is old school Cath lab ( and I'm only in my 40's). Do as much as you can prior to the case, prime lines, grab intervention supples you may need. Forget being neat and be ok with being messy. Let that IV run wide open in a sink or the floor (clean up before you slip or defibrillated in it) to get the air out don't flick it out. Don't let that nurse get you down you will get it. It's not as easy as it looks. Identifying coronaries is always listed like its the first thing you learn but it's not. That comes with time, questions, guesses (don't be afraid to try) and hours at staring at fluoro images. And I trained at the best medical facility in Texas without the benefit of CCU experience and I survived to become a nurse that is recommended by those MD's that trained me. Good luck and feel free to ask more questions.

ccheartRN · Apr 15, 2017

Hi there!

I am a long time lurker, first time poster. I realize that this post is a few months old, but the topic really resonated with me as I had the same questions (and a similar preceptor!) when I oriented to the Cath Lab. Hopefully I can be of some help. A quick note: our circulator was responsible for conscious sedation, any other medications, patient needs, and grabbing items for the scrub and MD. All labs seem to operate a little differently!

It goes without saying that the patient's status goes first: think of your ABCs and pain control. If there is no live patient or a squirming patient in pain, there is no case!

Generally, the case is initially set up for a diagnostic heart Cath. Our lab uses a 5fr system and a mutipack of catheters with a jwire, all of which is set up in advance. As a new Cath lab nurse, my struggle began as soon as the case turned to intervention because so many things happened so quickly!

Look at your patient and their history. Have they had stents before? Are they having active chest pain? Positive troponins? Is the diagnostic portion looking lumpy and bumpy? If you suspect that some angioplasty is in your future, there are some items you can pull together to make the transition easier. I would grab a 6fr sheath (your mileage may vary, not all docs upsize), an indeflator and some conray. These are items you know will be needed. When the doc turns to you to tell you what interventional catheter, wire and stent/balloon they want, you can be opening these three things while you listen.

The first thing they will need is a bigger sheath (if they are upsizing, which most often they are). Good, you've thrown that. While the doc is trading out sheaths, the scrub person can prep their indeflator while you look all over for strangely-named wires and catheters!

Throw your interventional catheter next. Once the MD has the new sheath in place, this is the next thing they will need. Once the catheter has been advsnced, an interventional wire is needed. I used my wire as a "red flag": I did not hand the wire over until I had given (or was immediately prepared to give) heparin/aggrastat/angiomax or check an ACT if we were radial and heparin had already been given. Too many times I saw the circulator become very task focused and forget to ask about/administer a "thinner" (yes I know these are not all thinners, just generalizing here) until later in the game, when stents were hazy and appeared to be clotting. **This method may not work for you, but be sure you find a way to remember to give the "thinner" of choice. It is a soul crushing mistake to see a routine 75% lesion turn into a 100% occlusion because someone forgot to start the aggrastat! **

Finally, you'll need your stent or balloon. Around this time, it is a good idea to also be sure your scrub has enough contrast and double check your patients pain and sedation level. A patient who easily tolerated a diagnostic Cath may have some chest pain with the inflation of a stent, so a little reassurance and/or fentanyl can go a long way!

Since this is such a long post, I will make a quick summary for you:

It's time to stent!

1) bigger sheath, indeflator and conray

2) interventional catheter of choice

3) wire**ask about "thinner"

4) stent/balloon

I hope this helps you! I am now PRN in our Cath lab as I've transferred full time to critical care, but I would be happy to answer any questions you may have. Best of luck! The Cath lab is a fun place to work and gives you a really unique skill set. Happy cathing! :)

C4th L4b RN · Apr 16, 2017

Canadavsus and ccheartRN,

Thank you so much for your comments and both are extremely helpful. I appreciate all the knowledge you both have shared.

Picklebee5 · Sep 18, 2017

I work in a cath lab where nurses also scrub. This provides a better understanding of what your scrubber needs. I too get very overwhelmed at times with everything that must be done in a short period. I try to get a head start on making sure my scrubber has what he or she needs as soon as I see a lesion. I throw everything on except for the inflator, but keep it ready. Then I look at my anticoagulants/antiplatelets and have doses ready. Then by the time the MD yells for supplies I have most things ready to go. It's all about being able to anticipate what they will need before they ask for it, and that comes with time. Hope that helps.

NJ2013 · Nov 2, 2018

I work in a cath lab where nurses also scrub. This provides a better understanding of what your scrubber needs. I too get very overwhelmed at times with everything that must be done in a short period. I try to get a head start on making sure my scrubber has what he or she needs as soon as I see a lesion. I throw everything on except for the inflator, but keep it ready. Then I look at my anticoagulants/antiplatelets and have doses ready. Then by the time the MD yells for supplies I have most things ready to go. It's all about being able to anticipate what they will need before they ask for it, and that comes with time. Hope that helps.

couldn't have said any better. in addition to that, know your Doctors, and memorize their preferences. know where the supplies are, as well in keeping in mind what will they use next. For example, if they are doing a cath via radial artery, keep the exchange wire handy..