Cath Lab Digest

Because ventricular arrhythmias continue to threaten CHF patients and many anti-arrhythmic agents have not been well suited for use in these patients, a sophisticated ICD has shown encouraging results. Biventricular (BiV) pacing, also called cardiac resynchronization therapy (CRT), is used to synchronize the pumping of the heart’s ventricles with the pumping of the heart’s atria, returning the heartbeat and blood flow to normal. Heart failure causes a delay in the contractions of the ventricles, causing the left and right ventricle to pump “out of sync.” This leads to a rapid or irregular heartbeat, as well as the left ventricle not being able to pump enough blood to the body. Biventricular pacing is a new form of therapy for patients with heart failure (NYHA) class III. This combination device will now monitor the heart’s rhythm, provide protection against SCA and synchronize the contraction of the left ventricle, which improves cardiac function of the heart.

Implications for Practice: What We Need to Know

The following is more than just a disclaimer; these guidelines do not substitute for physicians’ orders or maintaining an open line of communication with the physician. To prepare your patient, written orders are required; however, in the event of no written orders, nurses must be proactive and notify the physician to obtain such needed orders to prepare the patient in a timely manner.

Perform a baseline evaluation, including past history, allergies, vital signs, and a functioning intravenous (IV) line with an 18-20 gauge heparin IV lock (heplock).

IV line and IV fluids: The IV line is preferred in the left arm when permissible, arm precautions when warranted. This IV line will serve for fluids, antibiotics, moderate “conscious” sedation and possible contrast injection (venogram) if necessary. Maintain precaution for patients with heart failure, review documented EF. As a rule of thumb we run IV fluids at the same rate as the EF, when in doubt, KVO (keep-the-vein-open) the IV line.

Informed consent: It is a process of communication between the patient or their legal surrogate and physician that results in the patient’s authorization or agreement to undergo a specific medical intervention. In Florida, the informed consent law (Florida Medical Consent Law 766.103) requires that the patient be advised of three things: 1) the nature of the procedure; 2) the substantial risks and hazards of the procedure; and 3) the reasonable alternatives to the procedure (including, when appropriate, the option of doing nothing). After learning of these things, if a patient consents to the procedure, then informed consent has taken place. Healthcare professionals who witness consents are ethically obliged to assess the patient’s understanding of the proposed treatment and to inform the physician if there is reason to believe the patient has any misunderstanding regarding the nature, purpose, inherent risks or alternatives of his or her treatment.

Medications: Patients may take their regular meds with a small amount of water the morning of the procedure, except for blood thinners (warfarin). Patients will have been asked to stop any blood thinners 5–7 days before the procedure. For inpatients on blood thinners [heparin, enoxaparin (Lovenox)], these medications will need to be stopped. Heparin requires more than six (6) hours. Always call the implanting physician for instructions or clarification.

Surgical preparation: Pre-surgical skin preps or scrubs are as per your hospital guidelines. Patients will take a shower with soap and hair clippers when warranted from neck to chest (above the nipple line) as part of the skin preparation.

NPO: Patients won’t be allowed to eat or drink anything for 8 hours, usually after midnight the day before or after breakfast for evening cases. Take precaution with diabetic patients: hold insulin and assess blood sugars.

Pre-op or on-call antibiotics: Verify patient allergies and time of procedure, and start antibiotics within one hour from actual surgical cut time of procedure. Take precaution with underlying renal failure by reviewing labs for creatinine, blood urea nitrogen (BUN) and glomerular filtration rate (GFR) that may further nephrotoxicity to our patient.
Pertinent laboratory data: Obtain CBC with platelets, a basic metabolic panel (BMP), APTT (if indicated: heparin) and PT/INR (if indicated: warfarin) for coagulation analysis. All are important. Be alert for and report elevated WBC, low hemoglobin/hematocrit and platelet count, or electrolyte imbalance (low or high K+). Review renal function: creatinine, blood urea nitrogen (BUN) and glomerular filtration rate (GFR).