Cardiac catheterization in Pediatrics

Cardiac catheterization is an invasive procedure in which a radio-opaque catheter is inserted through the peripheral blood vessel into the heart. It usually combined with angiography (angiocardiography) in which a radio-opaque contrast material is injected through the catheter and into the circulation.

Purposes

Cardiac catheterization provides information regarding the following:

• Oxygen saturation of blood within the chamber and great vessels
• Pressure changes within these structures
• Cardiac output or stroke volume
• Anatomical abnormalities, such as septal defects or obstruction to flow

Indications

• For diagnostic purposes
• For interventional purposes
• For electrophysiologic purposes

Types of Diagnostic Cardiac Catheterization

1. Right sided or venous catheterization: In which the catheter is introduced from a vein into the right atrium.
2. Left-sided or arterial catheterization: In which the catheter is threaded by a way of a systemic artery retrograde in the aorta and left ventricle or from a right-sided approach across the left atrium by means of a septal puncture or through an existing abnormal septal opening.

Types of Interventional Cardiac Catheterization Procedure in Children

• Balloon arterioseptostomy —transposition of great arteries (TGA)
• Balloon dilation -valvular pulmonic stenosis (PS), aortic stenosis, recurrent coarctation of aorta, etc.
• Coil occlusion-patent ductus arteriosus
  [PDA (<4 mm)]
• Transcatheter device closure —atrial septal defect (ASD)
• Amplatzer septal occluder (ASO)
• Stent placement-PS, coarctation of aorta
• Radiofrequency ablation-some tachydy-srhythmias

Equipment Needed

A sterile trolley contains:

• Sterile gowns
• Disposable sheets with center hole
• Sterile gloves of different sizes
• A sterile basin with two bowls for heparin solution to flush the catheters and needles and to pour betadine solution
• Catheters of different types and size
• Sponge holder
• Contrast material
• Sterile gauze pieces
• Plasters to seal the catheterized site after the procedure
• Xylocaine injection 1 or 2%
• Syringe and needle
• Heparin solution-injectable heparin and sterile NS
• Intravenous (IV) set—IV cannula (different sizes)
• Scissors
• Head roll to support the head
• IV stand
• Oxygen supply
• Pulse oximeter
• Electrocardiogram (ECG) monitor
• Dustbin to collect the waste to be kept at the foot end of the table

Preprocedural Care

Psychological Preparation

• Explain the procedure to the parents and child emphasizing what they will see, feel, and hear.
• Preparation materials, such as picture books or video tapes or tours of the Cath laboratory may be helpful.
• Preparation should be geared to the developmental level of the child. Additional information, such as the expected length of catheterization procedure, description of the child’s appearance after catheterization, and post procedure care, should be outlined.
• Obtain a written consent.

Physical Preparation

• A complete nursing assessment is necessary to ensure the safety of the procedure and minimize complications.
  It includes the following:
• Accurate measurement of height and weight.
• Obtain history of allergic reaction because some contrast agents used are iodine based.
• Give specific attention to signs of infection.
• Assess and mark the dorsalis pedis and posterior tibial pulse before the child goes to the Cath laboratory.
• The presence and quality of pulse in both feet are clearly documented.
• Baseline oxygen saturation with cyanosis should be recorded.
• Methods of sedation vary among institutions and may include oral or IV medications.
• Typically, the child is allowed nil by mouth (NBM) before catheterization; although polycythaemia infants and children may require IV fluids to prevent dehydration, and neonates may need dextrose solution for up to 2 hours before the procedure to prevent hypoglycaemia.
• Usually, the morning dose of all oral medication is withheld, although this is clarified beforehand with the practitioner.

Procedure for Cardiac Catheterization

• Perform surgical scrub.
• Paint the peripheral site with antiseptic swabs.
• Create a sterile field.
• The catheter is usually introduced through a percutaneous puncture into the femoral vein (the catheter is threaded over a guide wire inserted through a large bore needle)
• Rarely is a cutdown procedure needed to gain access to the vein.
• Once the vessel is entered, the catheter is guided through the heart with the aid of fluoroscopy.
• As the tubing is advanced, the child may feel pressure at the insertion site and vasospasm (fluttering) of the small vessels.
• Once the catheter is within the heart, blood samples and pressure readings are taken for analysis.
• Then contrast material may be injected and films taken of the dilution and circulation of the material.
• Note: As the contrast medium is administered, the child may experience warmth, nausea, vomiting, restlessness, or headache.

Post procedure Care

• Patients may recover from the catheterization procedure in recovery unit or in their hospital rooms. Some may require care in the intensive care unit (ICU).
• If bleeding occurs, direct pressure is applied 2.5 cm above the percutaneous site to localize pressure over the vessel punctured.
• Children are usually placed on a cardiac monitor and a pulse oximeter for the first few hours following catheterization.
• The most important nursing responsibility is observation of the following for signs of complications:
• Pulse, especially below the catheterization site, for equality and symmetry (pulse distal to the site may be weaker for the first few hours after catheterization but should gradually increase in strength).
• Temperature and color of the affected extremity, because coolness or blanching may indicate arterial obstruction.
• Vital signs, which may be taken as frequently as every 15 minutes, with special emphasis on the heart rate, which is counted for 1 full minute for evidence of dysrhythmias or bradycardia.
• BP, especially for hypotension, which may indicate hemorrhage from cardiac perforation or bleeding at the site of initial catheterization.
• Dressing for evidence of bleeding or hematoma formation in the femoral or antecubital area.
• Fluid intake, both IV and oral to ensure adequate hydration (blood preprocedural status of NBM, and diuretic actions contrast material used during the procedure put the child at risk for hypovolemia and dehydration).
• Infants are particularly at risk for hypoglycemia. They should receive dextrose containing IV fluids and blood glucose levels should be checked.
• Depending on hospital policy, the child may be kept in bed with the affected extremity maintained straight for 4-6 hours after venous cardiac catheterization and 6-8 hours for arterial cardiac catheterization to facilitate healing of the cannulated vessel.
• If younger children have difficulty complying, they can be held in parent’s lap with the leg maintained in the correct position.
• The child’s usual diet can be resumed as tolerated beginning with sips of clear fluids and advancing as the condition allows it.
• Generally, there is only slight discomfort at the percutaneous site.
• Acetaminophen, with or without codeine or ibuprofen can be given for pain.
• The catheterization site is covered with an occlusive waterproof pressure dressing (usually a foam tape dressing tightly applied) to prevent bleeding and contamination that could cause infection.
• The dressing is left on until the next day.

Home Care Management (Health Education)

• Remove the pressure dressing the day after catheterization.
• Cover site with an adhesive bandage strip for several days.
• Keep site clean and dry.
• Avoid tub bath for several days, may shower.
• Observe site for redness, swelling, drainage, and bleeding.
• Monitor for fever. Notify practitioner if it occurs.
• Avoid strenuous exercise for several days but can attend school.
• Resume regular diet without restrictions.
• Use acetaminophen or ibuprofen for pain.
• Keep follow-up appointments per practitioner’s instruction.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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