ALTERED VENTILATION
AIRWAY MANAGEMENT
Part 2
AIRWAY:
- The path that air follows to get into and out of the
lungs.
- the mouth and nose are the normal entry and exit
ports for the airway. Entering air then passes
through the back of the throat(pharynx) continues
through the voice box (Larynx) down the trachea,
to finally pass through the bronchi.
Airway management:
- a set of maneuvers and medical procedures
performed to prevent and relieve airway
obstruction.
- This ensures an open pathway for gas exchange
between a patient’s lungs and atmosphere
- Adequate ventilation depends on free movement of
air through the upper and lower airways.
- In many disorders, the airways becomes narrowed
or blocked as a result of disease,
bronchoconstriction (narrowing of the airway by
contraction of muscle fibers), a foreign body or
secretions. Maintaining a patent (open) airway is
achieved through meticulous airway management,
whether in an emergency situation, such as airway
obstruction, or in long- term management.
Basic airway management
- non-invasive techniques without the need for
specialized medical equipment.
- used independently or in combination to relieve
foreign body airway obstruction.
e.g.- chest compression
- abdominal thrust
- back blows/ slaps
- Head-tilt/chin-lift - is the most reliable method of
opening the airway.
note: *If concern for c- spine injury, use jaw
thrust without head tilt
*Excessive head tilt can occlude trachea
in infants, consider padding under shoulder.
ADVANCED AIRWAY MANAGEMENT:
- is the subset of airway management that
involves advanced training, skill, and invasiveness.
- It encompasses various techniques performed to create
an open or patent airway - a clear path between a
patient’s lungs and the outside world
TYPES OF AIRWAY MANAGEMENT EQUIPMENT
FACE MASK VENTILATION:
- This intervention is appropriate when a person
shows signs of hypoxic respiratory failure, apnea, an
inability to protect the airway, or an altered mental state
caused by exertion of hypoxia.
- Proper position of the head neck, and jaw is
critical for ensuring proper oxygen delivery.
- equipment bag- based masks. A proper seal is key
to the functioning of this equipement.
SUPRAGLOTTIC AIRWAY DEVICES:
- These devices open the upper airway to allow for
unobstructed ventilation.
- this successfully provide rescue ventilation in
more than 90 percent effective of patients for whom
tracheal intubation and mask ventilation are impossible.
- increase risk: airway damage and pulmonary
aspiration. these risks may increase in severely obese
patients.
- examples are: laryngeal mask airway (LMA)
laryngeal tube
esophageal-tracheal
endotracheal tube
TRACHEAL INTUBATION:
- Uses a wide range of devices to insert a tube into
the airway through the throat.
- The TUBE often provides life- saving ventilation,
- can also be used to clear airway
- to deliver medication.
precaution: wrong technique can injure the airway or
increase the risk of aspiration.
- intubation typically requires the use of airway
clearance devices such as portable or well mounted suction
machine.
TRANSTRACHEAL ACCESS:
- accesses the trachea directly, usually via an
incision in the neck.
 - Tracheostomy is commonly used in patients with
advanced chronic obstructive pulmonary disease (COPD).
- In emergency situations, a Cricothyroidotomy -
involves an emergency incision providing airway access,
when traditional ventilation fails or is contraindicated.
- the only option for a hypoxic patient.
Airway Clearance Device
A suction machine, also known as an aspirator, is a type of
medical device that is primarily used form removing
obstructions - like mucus, saliva blood, or secretions.
Mouth-to-mask Ventilation
- In one-rescuer CPR, breaths should be supplied using
a pocket mask,
advantages:
= Eliminates direct contact
= Enables positive-pressure
= Oxygenates well if O2 attached
= Easier to perform than bag-mask ventilation
= Best for small-handed rescuers
Fingers: jaw thrust upward
Fingers: head tilt-chin lift
How to Give Mouth-to-Mask Ventilation
PROCEDURE:
1. Seal the mask against the person’s face by placing
four fingers of one hand across the top of the mask
and the thumb of the other hand along the bottom
edge of the mask
2. Using the fingers of your hand on the bottom of
the mask, open the airway using the head-tilt-chin-
lift.
*Do not use this if you suspect the person may
have a neck injury.
3. Press firmly around the edges of the mask and
ventilate while delivering a breath over one second
as you watch for chest rise.
4. Deliver a second breath.
Key - ventilation volume: “enough to produce obvious
chest rise”
1-person:
difficult, less effective
Bag-Mask Ventilation
- sometimes known by the porprietary name Ambu bag or
generically as a manual resuscitator or “self-inflating
bag”
- is handheld device commonly used to provide positive
pressure ventilation to patients who are not breathing or not
breathing adequately
Advantages:
- Provides immediate ventilation and oxygenation
- Operator gets sense of compliance and airway
resistance
- High oxygen concentrations are possible
- Can be used to assist spontaneous
Potential Complications:
- Hypoventilation
- Gastric inflation
Parts of Bag-mask
The bag: a flexible air chamber, attached to a face mask via
a shutter valve which is squeezed to expel air to
the patient.
Mask: a flexible mask to seal over the patients face.
Filter and valve: a filter & valve prevent backflow into the
bag itself (prevents patient deprivation and bag
contamination)
Oxygen Reservoir
Pressure Gauge
Oxygen Connecting tube
- Provide a volume of 6-7 mL/kg per breath
(approximately 500 mL for an average adult).
- For a patient with a perfusing rhythm, ventilate at a
rate of 10-12 breaths per minute
- Adult size: 2 liters, Pediatric size: 500 ml
Type of Bag used
1. Flow inflating Bag (Anaesthesia Bag)
- Fills only when oxygen from a compressed source
flows into it
- Depend on a compressed gas source
- Must have a tight face-mask seal to inflate
- Use a flow-control valve to regulate pressure-
inflation
2. Self-inflating bag (AMBU Bag)
- Fill spontaneously after they are squeezed, pulling
oxygen or air into the bag
- Remain inflated at all times
- Can deliver positive-pressure ventilaiton without a
compressed gas source
- Require attachment of an oxygen reservoir to
deliver 100% oxygen
The Three Pillars of Airway Management
1. Patency of Upper Airway : ( airflow integrity )
2. Protection against aspiration
3. Assurance of oxygenation and ventilation
Indication
1. Respiratory failure
- Failure of ventilation
 - Failure of oxygenation
2. Failed intubation
3. Elective ventilation in the operating room
Procedure
1. One hand to
- maintain face seal
- position head
- maintain patency
2. Other hand for ventilation
BMV Technique
- “Sniffing” position if C-spine OK
- Thumb + index finger to maintain face seal
- Middle finger under mandibular symphysis
- Ring and little finger under the angle of the
mandible
Why Sniffing position?
- Sniffing position allows for greater occipital-
atlanto-axial angulation
- No exact definition has been established
- However, 35 degrees neck flexion and 15 degrees
head extension is generally considered worldwide.
- Sniffing position prevents falling of tongue thus
preventing obstruction of the upper airway
BMW Ventilation: ASSESSMENT OF ADEQUACY
1. Observe the chest rise and fall
2. Good bilateral air entry
3. Improving color
4. Lack of air entering the stomach
5. Feeling the bag
6. Pulse oximetry (oxygen saturation)
Contraindications
- In the case of complete upper airway obstruction
- BVM ventilation is relatively contraindicated after
paralysis and induction (because of the increased
risk of aspiration)
- Caution is advised in patients with severe facial
trauma and eye injuries
- In addition, foreign material (e.g. gastric contents)
in the airway may lead to aspiration pneumonitis.
In these circumstances, alternative approaches,
including endotracheal intubation, may be
necessary.
Predictors of a Difficult Airway: BMV
- Upper airway obstruction
- Edentulous patients
- Beard
- Obese
- Elderly > 70 years
- Facial burns, dressings, scarring
- Poor lung mechanics
= resistance or compliance
Complications of BMV
Related to over-inflating or over-pressuring the patient,
which can cause:
- Hypoventilation/Hypervntilation
- Inflated air in the stomach (called gastric
insufflation)
- Lung injury from over-stretching (called
volutrauma)
- Lung injury from over-pressurization (called
barotrauma)
- Lung aspiration
- Air embolism
Mechanical Ventilator
- is a machine that helps a patient breathe(ventilate) when
they are having surgery or cannot breathe on their own
due to a critical illness
- the patient is connected to the ventilator with a hollow
tube (artificial airway) that goes in their mouth and down
into their main airway or trachea
Function of Ventilator
- a machine that blow air or air with extra oxygen into
airways and lungs.
-The airways pipes that carry oxygen into the lungs when
breathe in.
- They carry carbon dioxide (waste gas) out of your lung
when breathe out
- is a positive or negative pressure breathing device that
can maintain ventilation and oxygen delivering for a
prolonged period
Mechanical Ventilation required :
- to control the patient's respirations during surgery or
treatment
- to oxygenate the blood when the patients ventilatory
efforts are inadequate
- to rest the respiratory muscles
Indication for Mechanical Ventilation:
1. Clinical Manifestation;
- Apnea or bradypnea
- respiratory distress with confusion
- increased work of breathing not relieved by other
intervention
- confusion with need for airways protection
- circulatory shock
- controlled hyperventilation (patient with severe
head injury)
2. Laboratory Values:
- PaO2 < 55 mmHg
- PaO2 > 50 mmHg and ph < 7.32
- Vital capacity < 10 ml/kg
 - Negative respiratory force < 25 on H2O - Shift the tongue to left
- FEV < 10 ml/kg - Go in
- Press over tongue
- See epigllotis
- Lift it
ENDOTRACHEAL INTUBATION - Watch for vocal chords
- Endotracheal Intubation is the placement of a - Take the tube in right hand
special tube in trachea. - Introduce under vision
- Confirm placement by auscultation
Indication of Intubation - If tube is cuffed inflate the cuff with syringe
1. To secure airway - Connect the source tube
2. To supply oxygen - Confirmation
3. General Anesthesia by auscultation
4. Cardio Pulmonary Resucitation by chest expansion
5. Ventilatory therapy in ICU by bag movement
end-tidal CO2
Equipment: - Fix the tube with adhesive
1. Size of tube
0-1 yrs. 2.5 to 3.5 mm (plain) Connection to ventilate with:
1-3 yrs. 4 to 5 mm 1. Ambu’s bag
4-6 yrs 5 to 6 mm 2. Anesthesia machine
6 to 10 6 to 7 mm (cuffed) 3. Ventilator
adult female 7 to 8 mm
adult male 8 to 9 mm Side effects of intubation:
2. Laryngoscope 1. Tachycardia
3. Magill’s forceps 2. Rise in blood pressure
4. Stethoscope 3. Increase in secretions
5. Syringe 4. Laryngospasm
6. Source for ventilation 5. Bronchospasm
7. Suction
Complications
1. tube in esophagus
INTUBATION 2. endotracheal intubation
- is a procedure that used when patient can’t breath 3. trauma to lips tooth
on your own. 4. Bleeding
- A tube puts down to the throat and into the 5. Leak
windpipe to make it easier to get air into and out of 6. Trachities
your lungs. A machine called ventilator pumps in 7. Cough
air with extra oxygen. 8. sore throat
9. barotrauma to Lungs
Technique of Intubation
Effect of intubation
- increase in supply of O2
- to give general anaesthesia
- improve exhalaltion of C02

Failed or difficult intubation

- if the mouth opening restricted
- anterior vocal cords
- burn contracture
- one may require other options like
- fibro optic intubation
- Extension at atlanto-occipital joint - retrogate intubation
- Flexion at neck - supra epiglotic device
- Hold the layngoscope with left hand irrespective of the
dominant hand Nasotracheal intubation technique
- Open the mouth with right hand index finger with support - topical lidocaine or phenylephrine should be
of thumb applied to the nasal passages
- Introduce Laryngoscope from right angle of the mouth
 - 0.5-1.0% Neosynephrine and 4% Lidocaine, mixed significantly more difficult when secretions are
1:1 should also give satifactory results increased.
- generously lubricate the nares and endotracheal Criteria for Extubation
tube 1. Hemodynamically stable
- ET tube should be advanced through the nose - No dysrhythmias
directly backward toward the nasopharynx - Minimal inotrope requirements
- loss of resistance marks the entrance into the - Optimal fluid balance
oropharynx 2. Adequate Ventilation & Oxygenation
- laryngoscope and Magill forceps can be used to - FIO2 < 0.5
guide the endotracheal tube into the trachea under - Vital capacity of >10ml/kg
direct vision - Respiratory rate < 25 BPM
- for awake spontaneous breathing patients, the blind 3. Arterial Blood Gas
technique can be used - PCO2 < 6kPa
- PO2 > 8kPa on FIO2 of 40% & PEEP5
Confirmation of Tracheal intubation 4. Other:
- Direct visualization of the ET tube passing through - Sedating agents must be stoppped for >
the vocal cords 24hrs.
- CO2 in exhaled gases - Causative condition resolved/under
- Bilateral breath sounds control
- Absence of air movement during epigastric - Normal metabolic status. Electrolytes
auscultation balance must be normal.
- Condensation (fogging) of water vapor in the tube - Patient must be neuroligically intact.
of exhalation Awake, well motivated, follows verbal
- Refilling of reservoir bag during exhalation commands & intact gag/cough reflex.
- Maintenance of arterial oxygenation - Take into consideration aspiration risk ad
- Chest X-ray: the tip of the ET tube should be airway edema
between the carina and thoracic arc or
approximately at the level of the aortic art Complications Associated with ET & Tracheostomy tubes
- Local haemorrhage at tracheostomy site
- Air embolism
EXTUBATION - Infection
It is advisable if the cause is treated - Tracheal necrosis
 throat suction - Tracheal stenosis
 Laryngoscopy - Tracheosophaegeal fistula
 Reflexes - Failure of tracheostomy tube
 Spo2 - Obstruction of tracheostomy
- Accidental extubation
 adequate respiration
- Tube displacement
 level of consciousness
- Pneumothorax
 extubate - Swallowing dysfunction
- Extubation refers to t removal of the endotracheal Equipment
tube ( ETT ). It is the final step in liberating a 1. Suctioning equipment
patient from mechanical ventilation. 2. Personal protective equipment
- At the end of the weaning process, it may be 3. Sterile suction catheter
apparent that a patient no longer requires 4. Self-inflating manual resuscitating bag - valve
mechanical ventilation to maintain sufficient device connected to 100% O2 source
ventilation and oxygenation. 5. O2 source and tubing
- However, extubation should not be ordered until it 6. Scissors
has been determined that the patient is able to 7. Supplemental oxygen
protect the airway and the airway is patent. 8. 10ml syringe
9. A rigid pharyngeal suction tip (yankauer)
Airway Protection 10. Sterile dressing for stoma
- is the ability to guard against aspiration during 11. ET intubation supplies
spontaneous breathing. It requires sufficient cough 12. Emergency trolley
strength and an adequate level of consciousness,
each of which should be assessed prior to Preparation and Assessment
extubation because airway protection is
 1. Ensure the availability and functioning of your
oxygen therapy, suction equipment, emergency
equipment
2. Ensure the privacy of the patient
3. Assess the patients readiness for extubation:
- Cardiovascular status: BP, HR< Rythm
- Respiratory status: RR, SpO2
- Neourological status: LOC
- Stop feeds
- Make sure mechanical restraints are off
Implementation
- Wash hands put on sterile gloves
- Hyper oxygenate the patient in high fowlers
position
- Cut & remove tracheostomy tapes/plaster of ET
tube
- Deflate the cuff with 10ml syringe and instruct the
patient to breath
- Introduce suction catheter into tube
- Ask patient to cough
- Withdraw the tube and suction simultaneously
- Ask the patient to cough again ( to determine
laryngeal paralysis )
- Remove secretions from oropharynx, mouth, and
nose and give a mouthwash
- Commerce O2 therapy via face mask, keep
ventilator close for NIV CPAP
- Encourage patient to breath deeply and do PEEP
bottle exercise
- Assessment of the patients resiratory and cardiac
status
- Connect pulse oximeter
- Discard used supplies, remove personal protective
equipment and perform hand hygiene
Management of Hypoxia
- Hypoxemia or hypoxia is a medical emergency and
should be treated promptly. Failure to initiate
oxygen therapy can result in serious harm to the
patient. The essence of oxygen therapy is to
provide oxygen according to target saturation rate,
and to monitor the saturation rate to keep it within
target range. The target range (SaO2) for a normal
adult is 92 - 98%. For patients with COPD, the
target SaO2 range is 88 - 92%
- Although all medications require a prescription,
oxygen therapy may be initiated without
physician’s order in emergency situations.
Hypoxia is considered an emergency situation.
Most hospitals have protocol in place allowing
health care providers to apply oxygen in
emergency situations. The health care provider
administering oxygen is responsible for monitoring
the patient’s response and keeping the saturation
level within the target range. The most common
reasons for initiating oxygen therapy include acute
hypoxemia related to pneumonia, shock, asthma,
heart failure, pulmonary embolus, myocardial
infarction resulting to hypoxemia, post operative
states, pneumonthorax, and quantity of
hemoglobin. There are no contradictions to oxygen
therapy if indications for therapy are present.
Interventions to prevent and treat Hypoxia

Evaluation
- Assess air entry and repiratory status
- Auscultate the chest for breathing sounds and for
the presence of secretions
- Do vital observations
- Remain with the patient to determine respiratory
stability
- Obtain arterial blood gas within next hour

Record keeping
- Tidy up the procedure
- Wash hands
- Record all actions taken and chart vital signs on
observation chart

preventing oxygen desaturation

1. Etiology of oxygen desaturation:
- cause of hypoxia e.g. dyspnea, respiratory failure.
2. Evaluation of oxygen desaturation:
- identify volume overload- drugs should be
reviewed for sedative administration and dosage.
- significant hypoxia (oxygen saturation<85%)

Evaluation of Oxygen Desaturation
Physical examination
- Patency of the airway and strength and adequacy
of respirations should be assessed immediately.
For patients on mechanical ventilation, it is more
important to determine that the endotracheal tube
is not obstructed or dislodged. Findings are
suggestive as follows:
o Unilateral decreased breath sounds with
clear lung fields suggest pneumothorax or
right mainstem bronchus intubation; with
crackles and fever, pnemonia is more
likely
o Distended neck veins with bilateral lung
crackles suggest volume overload with
pulmonary edema, cardiogenic shock,
pericardial tamponade (often without
crackles), or acute valvular insufficeincy
o Distended neck veins with clear lungs or
History
- Very sudden onset dyspnea and hypoxia suggest
pulmonary embolus(PE) or pneumothorax (mainly
in a patient receiving positive pressure ventilation).
Fever, chills, and productive cough (or increased
secretions) suggest pneumonia. A history of
cardiopulmonary disease may indicate an
exacerbation of the disease. Symptoms and signs
of myocardial infarction may indicate acute
valvular insufficiency, pulmonary edema,
cardiogenic shock. Unilateral extremity pain
suggests deep venous thrombosis (DVT)and hence
possible PE. Preceding major trauma or sepsis
requiring significant resuscitation suggests acute
repiratorydistress syndrome. Preceding trauma
suggests pulmonary contusion.
Common Intervention to improve oxygenation:
- Incentive spirometry
- chest physical therapy
- nasa cannula
- mecanical ventilator
- endotracheal tube
- tracheostomy
- closed chest drainage
- extubation
- continuous positive airway pressure
- positive end-expiratory pressure.
Strategies to improve oxygenation
- Improving physical mobility
- Breathing and coughing exercises
- Mobilizing se cretions
- Maintaining airway patency
- Closed chest drainage
- Oxygen therapy
- Mechanical Ventilation
Non Invasive Ventilation (NIV)
- NIV - non-invasive ventilation is a broad term for
any ventilation therapy without using an invasive
artificial airway (endotracheal tube or
tracheostomy tube)
- But applied in a non-invasive way, e.g. via a mask,
nasal prongs or a helmet
- NIV, or NPPV (Non-invasive Positive Pressure
Ventilation), is also very often referred to as “mask
ventilation”
NIV benefits
Can preserve:
- normal swallowing, feeding, and speech
- Cough and physiologic air warming and
humidification
Can often eliminate:
- injury to the vocal cords or trachea
- and lower respiratory tract infections
Modes of NIV
Noninvasive positive-pressure ventilation can be given by
1. a volume ventilator
2. a pressure-controlled ventilator
3. a bilevel positive-airway-pressure (bilevel PAP)
ventilator, or
4. a continuous-positive-airwaypressure (CPAP)
device
Modes of Noninvasive positive pressure ventilation
- Volume mechanical ventilation
 Usuallybreaths of 250-500 ml (4-8ml/kg)
 Pressure vary
- Pressure mechanical ventilation
 Usually pressure support or pressure
control at 8-20cm of water
 End-expiratory pressure of 0-6 cm of
water
 Volumes Vary
- Bilevel positive airway pressure (bilevel PAP)
 Usually respiratory pressure of 6-14 cm of
water and expiratory pressure of 3-5 cm of
water
 Volume vary
 - Continuous positive airway (CPAP)
 Usually 5-12 cm of water
 Constant pressure, volumes vary
Types of noninvasive positive-pressure ventilation
1. NPPV has two major modes of supplying support: Relative contraindications
2. Bilevel positive airway pressure (BiPAP) or
3. Continuous positive airway pressure (CPAP)
Bilevel-positive airway pressure
- high-flow positive airway pressure that cycles
between high-positive pressure and low-positive
pressure.
- In the spontaneous mode, BiPAP response to the
patient’s own flow rate and cycles between high-
pressure inspiration and low-pressure exhalation
- BiPAP reliably senses the patient’s breathing
Bilevel PAP adjust setting
efforts
- When inspiration is detected the inspiratory
pressure is known as inspiratory positive airway
pressure (IPAP)
Clinical effectiveness can be determined by:
- EPAP prevents airway and alveolar collapse,
prevents atelectasis and maintains functional
residual capacity at increased level
- IPAP augments tidal volume, increases airway
pressure, decrease fatigue.
- BiPAP is similar to pressure support ventilation
- With BiPAP, supplemental oxygen is diluted by Patient monitoring
the high flow of air through the system
 Thus, patients may require higher oxygen
flows for BiPAP for nasal cannula
- Devices using a common inspiratory and expiatory
line can cause rebreathing of exhaled gases and
persistent hypercapnia
Continuous positive airway pressure
- CPAP provides continuous positive pressure
throughput the respiratory cycle
- CPAP is only effective for spontaneous breathing
- CPAP cannot provide ventilation for patients who
have apnea
- When used with a nasal mask, low ppressures (5
cm H2O) are effective in splinting the upper
airway and preventing upper airway obstruction
- During CPAP, airway pressure remains positive
during the entire respiratory cycle
- CPAP works by applying pressure though the
airways at high enough levels to keep the upper
airway patent, acting as a spint
Patients selection
1. Noninvasive positive-pressure ventilation works:
- best if the patient is relaxed
Failure of NIV
- less effective if the patient is anxious,
noninvasive ventilation techniques are not always
uncooperative, or fighting the ventilator
 Preparation of patients is critical.
Patients selection for NIV
Inclusion criteria
 cute or chronic respiratory failure
 Acute pulmonary edema
 Chronic congestive heart failure with
dleep-related breathing disorder
 Failure or prior attemps at noninvasive
ventilation
 Hemodynamic instability or life-
threatening arrhythmias
 High risk of aspiration
 Impaired mental status
 Inability to use nasal or face mask
 Life-threatening refractory hypoxemia
(PaO2 60 mmHg wh 1.0 FIO2)
- it is best to start at low pressures and gradually
increase the respiratory pressure (usually to 8 to 14
cm of water) and the end expiratory pressure
(usually 4 to 6 cm of water)
1. By palpating the sternocleidomastoid muscle to
see whether its use has decreased
2. By determining that lower thoracic expansion has
increased
3. By blood gas values have improved
- their comfort
- level of dyspnea
- respiratory rate
- oxyhemoglobin saturation
- signs of ventilator-patient asynchrony
- nasal-mask intolerance
- serious air leaks
- gastric distention
- drying of the eyes
- facial skin breakdown, especially at the bridge of
the nose
- Gastric distention is very unlikely with pressure-
support levels lower than 25 cm of water
- Eye irritation or conjunctivitis has been reported in
16 percent of patients
- Facial-skin or conjunctivitis has been reported in 2
percent to 18 percent
- Intrinsic PEEP
 is often present in patients with COPD and
can require too much respiratory effort to
trigger the ventilator
 This can be alleviated by the addition of
external PEEP
successful.
- Hemodynamic instability
- Deteriorating mental status
 - Increasing respiratory rate
- Increasing respiratory acidosis
- The inability to maintain adequate oxyhemoglobin
saturations
- Problems with respiratory secretions
- some patients are unable to tolerate or refuse to use
the selected device
In general
Noninvasive ventilation should not be used in patients:
1. Who are unable to cooperate
2. Who have impaired consciousness
3. Who have problems with retained secretions
4. Who have hemodynamic instability
Applications of noninvasive positive-pressure ventilation
- Chronic respiratory failure
- Acute respiratory failure
- Congestive heart failure
T piece
- T- Shaped tubing connected to an endotracheal
tube, connected to deliver therapy to an intubated
patient who does not require mechanical
ventilation.
- A procedure of disconnecting a patient from the
ventilator while maintaining an external oxygen
supply, commonly by using a T piece connected to
the endotracheal tube.
- Among patients receiving mechanical, readiness
for extubation from ventilatory support evaluated
with spontaneous breathing trial (SBT).
- SBT the test to determine whether the patient is
ready to assume breathing without assistance
o Daily screening of respiratory function by
SBT is associated with a shorter duration
of mechanical ventilation.
o The most common modes of SBT are T-
piece ventilation and low levels
 pressure support ventilation
(PSV), lasting between 30
minutes or 2 hours
o The simpliest form of SBT is the T-piece
trial. The patient is diconnected from the
ventilator, and the endtracheal or
tracheostomy tube is hooked to a flow-by
oxygen system, usually from the wall
oxygen outlet
Cricothyrotomy
- also known cricothyroidotomy
- is a procedure that involves placing a tube through
an incision in the cricothyroid membrane (CTM) to
establish an airway for oxygenatioin and
ventilation.
Surgical and Nonsurgical Cricothyrotomy
- Used when conventional techniques fail
- Be familiar with:
 Anatomy of the anterior aspect of the neck
 Important blood vessels in area
Open Cricothyrotomy
Involves:
- Incising the cricothyroid membrane
- Inserting an ET or tracheostomy tube directly into
the subglottic area of the trachea
Cricothyroid membrane is ideal for surgical opening into
the trachea
Several types:
- Open (surgical) cricothyrotomy
- Modified cricothyrotomy (Seldinger
technique)
- Device that functions as an introducer and
an airway
Indications
- Patent airway cannot be secured with
conventional means
 Severe foreign body obstructions
 Swelling of airway
 Maxillofacial trauma
 Inability to open mouth
Contraindications
- ability to secure a patent airway
- Inability to identify anatomic landmarks
- Crushing injuries to the larynx and
tracheal transection
- Underlying anatomic abnormalities
- Age younger than 8-year-olds
Advantages
- Can be performed quickly
- Do not need to manipulate cervical spine
Disadvantages
- Difficult to perform in children and
patients with short, muscular, or fat necks
- More difficult than needle cricothyrotomy
Complications
- Severe bleeding from laceration of the
external jugular vein
- Risks of perforating the esophagus and
damaging the laryngeal nerves
- Taking too lonwill result in hypoxia
- Subcutaneous emphysema from tube
misplacement
If commercial kit is not available, prepare:
- Scalpel
- ET or tracheostomy tube
- Commercial device (or tape) to secure
tube
- Curved hemostats
- Suction apparatus
 - Sterile gauze pads
- Bag-mask device attached to 100%
oxygen
Technique for Performing Open Cricothyrotomy
- Proceed rapidly yet cautiously
- Palpate for V notch of thyroid cartilage
- Slide index finger into depression between thyroid
and cricoid cartilage
o That is the cricothyroid membrane
- Partner prepares equipment
- Maintain aseptic technique
- Stabilize larynx; make a 1- to -cm vertical incision
over the cricothyroid membrane
- Insert a 6.0-mm cuffed ET tube or a 6.0
tracheostomy tube into trachea
- Inflate the distal cuff
- Attach the bag-mask device, and ventilate while
your partner auscultates
- Confirm proper tube placement
- Ensure bleeding has been controlled
- Secure tube and continue to ventilate
Needle Cricothyrotomy
Indications
o Inability to ventilate by less invasive
means
o Maxillofacial trauma
o Inability to open mouth
o Uncontrolled oropharyngeal bleeding
Contraindications
o Severe airway obstruction above catheter
insertion
 High-pressure ventilator leads to
barotrauma and pneumothorax
o If equipment is not immediately available
Advantages
- Easier than open cricothyrotomy
- Lower risk of damaging structures
- Allows for intubation
- No manipulation of cervical spine
Disadvantages
- Does not provide protection from aspiration
- Technique requires a specialized, high-pressure jet
ventilator
Complications
- Improper placement can cause severe
bleeding
- Excessive air leakage can cause
subcutaneous emphysema and
compression of the trachea
- Overinflation of lungs: barotrauma
- Underinflation of lungs: hypoventilation
Needle Cricothyrotomy Equipment
1. Large-bore IV catheter (14-16 gauge)
2. 10-mL syringe
3. 3 mL of sterile water or saline
4. Oxygen source (50 psi)
5. High-pressure jet ventilator device and oxygen
tubing
Technique for Performing Needle Cricothyrotomy
- Draw up approximately 3 mL of sterile water or
saline into 10-mL syringe
o Attach to IV catheter
- Place head in neutral position
- Locate the cricothyroid membrane
- Cleanse area if time permits
- Stabilize the larynx; insert the needle at 45 angle
toward the feet
o You should feel a pop as the needle
penetrates the membrane
- After a poop is felt, insert needle 1 cm farther,
aspirate with the syringe
- Advance catheter over needle until catheter hub is
flush with skin
- Withdraw the needle; dispose of properly
- Attach one end of the oxygen tubing to the
catheter; other end to the jet ventilator
- Begin ventilations by opening the release valve on
the jet ventilator
- Turn release valve off wiht chest rise
- Secure catheter and continue ventilations
Percutaneous Cricothyrotomy
- Modified Selinger techinique (using a guidewire) -
a scalpel maybe use to make a skin incision above
the cricothyroid membrane
- A needle is ued to penetrate the cricothyroid
membrane so that a guidewire may be introduced
to the trachea
Equipment for Percutaneous Cricothyrotomy
- Antiseptic solution (eg, chlorhexidine, povidone-
iodine) and sterile gauze
 - Sterile drapes Sterile gloves and gowns along with PURPOSES
eye and face protection (universal precautions) - To maintain airway patency by removing mucus
- Local anesthetic (eg, 1% or 2% lidocaine with and encrusted secretions.
epinephrine, 25-gauge needle,3-mL syringe) - To maintain cleanliness and prevent infection at
- Catheter-over-the-needle device capable of the tracheostomy site
accommodating a guidewire, attached to a 3- to 6- - To facilitate healing and prevent skin excoriation
mL syringe half-filled with saline around the tracheostomy incision
- Flexible guidewire in a plastic housing - To promote comfort
- Airway catheter (tracheal tube) that has a plastic - To prevent displacement
inflatable cuff and a removable intraluminal
curved blunt dilator (which facilitates insertion) Contraindications
#15 scalpel blade ASSESSMENT
- Suction source and suction catheter Respiratory status (ease of breathing, rate, rhythm, depth,
- Bag-valve-mask and oxygen source lung sounds, and oxygen saturation level)
- Patient monitoring equipment, including cardiac Pulse rate
monitor, pulse oximeter, blood pressure monitor Secretions from the tracheostomy site (character and
(noninvasive) amount)
- Capnometer (end-tidal carbon dioxide monitor), if Presence of drainage on tracheostomy dressing or ties
available Appearance of incision (redness, swelling, purulent
discharge, or odor)
EQUIPMENTS
TRACHEOSTOMY CARE Sterile disposable tracheostomy cleaning kit or supplies
TRACHEOSTOMY (sterile containers, sterile nylon brush or pipe cleaners,
is an opening into the trachea through the neck just below sterile applicators, gauze squares)
the larynx through which an indwelling tube is placed Sterile suction catheter kit (suction catheter and sterile
and thus an artificial airway is created. container for solution)
Sterile normal saline (Check agency protocol for soaking
solution)
TRACHEOSTOMY TUBE Sterile gloves (2 pairs)
A curved hollow tube of rubber or plastic inserted into the Clean gloves
tracheostomy stoma (the hole made in the neck and Towel or drape to protect bed linens
windpipe (Trachea)) to relieve airway obstruction, Moisture-proof bag
facilitate mechanical ventilation or the removal of Commercially available tracheostomy dressing or sterile 4-
tracheal secretions. in. x -in. gauze dressing
Cotton twill ties
Clean scissors
PARTS OF TRACHEOSTOMY TUBE EQUIPMENT

PROCEDURE

Hold faceplate in place as the assisting nurse repeats step

on the second side
Fig 1 Insert new collar on second side and secure Velcro
tab

Remove the old collar and ensure that the new collar is
securely in place .
Fig. 2 Discard soiled collar, ensure new collar is securely in
place

Remove gloves and discard disposable equipment. Label

with date and time, and store reusable supplies.
Assist client to comfortable position and offer oral hygiene.

Wash your hands.

.

SPECIAL CONSIDERATION
NURSES RESPONSIBILITY
Video tracheostomy care
https://www.youtube.com/watch?v=IqTWQzH2A2c

Introduction.....
WHAT IS SUCTIONING?
PURPOSES
INDICATION
Therapeutic:
Noisy breathing
Visible secretions in the airway
Decreased SpO2 in the pulse
oximeter & Deterioration
of arterial blood gas values
Patient’s inability to generate an
effective spontaneous cough
Presence of pulmonary atelectasis or consolidation,
presumed to be associated with secretion
retention
During special procedures like Bronchoscopy &
Endoscopy
Diagnostic:
COMPLICATIONS
TYPES OF
ASSESSMENT
ASSESSMENT….
Patient Preparation
COMMUNICATE……
EQUIPMENT ASSEMBLYING
SUCTION
SUCTION PRESSURE
IMPLEMENTATION
Continue…..
Continue…..
Continue.....
Continue…..
POST PROCEDURE CARE…
DOCUMENTATION…
CAUTION..
Video on Endotracheal
https://www.youtube.com/watch?v=8nXL4-ZEaUY

https://www.youtube.com/watch?v=ofVhnG4GARM
 Altered Ventilation Part III
DIAGNOSTIC ASSESSMENT TISSUE
PERFUSION
ELECTROCARDIOGRAM (ECG OR EKG)
a noninvasive test.
an ECG is a recording of waveforms that reflects the
electrical activity of the heart
an electrocardiogram is a graphic record of the electrical
impulses that are generated by depolarization and
repolarization
Electrodes are placed on your chest to record your heart’s
electrical signals, which cause the heart to beat.
ELECTROCARDIOGRAM: the graph on which this
electrical activity is recorded.
The 3 types of ECG:
The P wave , which represents the depolarization of the
atria.
The QRS COMPLEX, which represents the depolarization
of the ventricles
the T wave, which represents the repolarization of the
ventricles.
The electricity of the heart
The contraction of any muscle is associated with electrical
changes called “depolarization” & these changes can
be detected by electrodes attached to the surface of
the body
The wiring diagram of the heart
The normal pacemaker site of the heart is the SA node. The
conductivity of the heart normally follows an
electrical pathway from the SA node through the
interatrial pathway to the AV node to the Bundle of
his down the bundle branches to the Purkinje fibres.
Indications
Myocardial Infarction & other types of CAD such as angina
cardial dysrythmias
Cardiac enlargement
Electrolyte disturbances
Inflammatory diseases of the heart
Effects on the heart by drugs, such as antiarrythmics
Shortcomings of ECG
Fifty percent of all patients with AMI have no ECG
changes
A patient may have a normal ECG, present pain free & still
have significant risk for myocardial ischemia
Several disease processes can mimic that of an AMI,
including Left bundle-branch blocks, Ventricular
paced rhythms, and Left Ventricular Hypertrophy
ECG - A galvanometer & electrodes with six limb leads
and six chest leads. Recorded on graph paper with divisions
Electrocardiographic paper
A graph paper with each small square measuring 1mm x
1mmECG recorders & monitors are standardized at a speed
of 25 mm/sec. Time is measured on horizontal axis &
voltage on Y axis.
Each small square represents 0.04 seconds
Five small squares make up one large square representing
0.20 seconds
ECG Pattern
The baseline is the iso-electric line. It occurs when there is
no current flow.
If the current flows toward the lead, a positive deflection, is
above the baseline
If the current flows away from the lead, a negative
deflection, is below the baseline.
Left ventricle has more influence on the ECG, because of
its increased muscle mass
Lead system
A 12- lead ECG provides multiple electrical views of the
heart along a vertical & horizontal plane.
The ECG recorder compares the electrical activity detected
in different electrodes, and the electrical picture so
obtained is called “lead”. For eg. when the recorder
is set to ‘lead l’, it is comparing the electrical events
detected by the electrodes attached to right & left
arms. The ECG is made up of 12 characteristic views
of the heart, six obtained from the limb leads and six
from the chest leads.
Limbs leads-6
3 Bipolar limb leads
( Standard limb leads )- I, II, & III
3 Unipolar Augmented leads (aVR, aVL & aVF).
Obtained through 4 electrodes placed on the right
arm, right leg, left arm, & left leg.
Chest leads-6 V1, V2, V3, V4, V5, & V6
V1 - Electrode positioned in the 4th intercoastal space in
the right sternal border
V2 - 4th ICS in the left sternal border
V3 - Midwat between V2&V4
V4 - 5th ICS in the left midclavicular line
V5 - Same level as V4, anterior axillory line
V6 - Same level as V4 & V5, midaxillary line
The electrical activity of the cardiac cycle is charaterized
by five primary wave deflections, designated by letters P,
Q, R, S, T.
P WAVE
 Represents atrial contraction. Shape of the ‘P’
wave remains the same it is generated from a
different focus
QRS complex
Represents ventricular depolarization and is
composed of 3 waves, the Q, R, & S.
Q wave is the first negative deflection
R wave is the first positive deflection after the P
wave. S wave is negative deflection
following R wave. It is about 0.08 to 0.12
sec, represented by 3 small squares
PR interval
Measured from the beginning of P wave to the
beginning of QRS complex
The normal PR interval is 0.12 - 0.2 sec,
represented by 3-5 small squares. The time it
takes for the impulse to spread from atria to
ventricles
No. of small squares in one RR interval
OR
300
-------------------------------
No. of big squares
Rhythm
Whether the waves are repeated at regular interval
in consecutive beats. Usually Normal Sinus
Rhythm
P wave
One ‘p’ infront every QRS, regular, all look alike.
3mm in height & a duration of 0.04 to 0.11
sec. It is tall in RAH and broad & bifid in
LAH. It is replaced by fibrillary wave in
Atrial fibrillation & saw toothed wave in
Atrial flutter
Normal ‘p’ wave indicates the impulse is
originating in SA mode. Impulse is travelling
normally along atria. The atria are normal

ST segment PR interval
- An isoelectric line respresenting early ventricular Measured by counting the no. of small squares and
repolarisation. Normally not elevated >1mm or depressed multiplying by 0.04. Must be normal &
> 0.5. constant. It gradually lenghtens in
T wave Wenchebach phenomenon. (2nd degree heart
- Represents ventricular repolarisation. Usually block)
positive, rounded & slighty Asymmetric. 5 QRS complex
U wave Examined for:
- Result frowm slow repolarisation of ventricular Duration - 0.08 to 0.12 sec. Prolonged in
purkinje fibers. More common in lead V3. Hypokalemia ventricular hypertrophy and bundle
branch block.
Q wave - Normal V5, V6 & it is due to septal
QT interval depolarization. Q is always absent in lead
- Represent total time required for ventricular II, V1, V2. Presence of a large Q wave
depolarization & r repolarisation. From the >5mm is abnormal, usually signifies
beginning of QRS complex to the end of T wave. myocardial infarction
Normal Qt interval is 0.36 to 0.45 sec. A prolonged QT R waves & S waves - R waves are tall in V5 & V6,
interval may lead to ventricular tachycardia. but in V1 & V2, the S waves are deep.

ST segment
Reporting an ECG ST depression ischemia & ST elevation in acute
- Description myocardial infarction
- Interpretation T wave
Positive except in aVR. Inverted T wave is found
Description includes inischemia, RVH, LVH, severe hypokalemia.
- Where depolariztion started - presence / absence Tall ‘T’ wave in moderate hyperkalemia
of ‘p’ wave. numbered, shape. QT interval
- Whether conduction occurred normally- ‘p’ Changes with variation of plasma potassium &
wave- number, shape, PR interval. calcium concentration, drugs like quindine
- An account of QRS complex, shape and duration prolongs QT interval. Normal QT interval is
Description of T waves in different leads. 0.42 seconds.
Einthoven’s triangle
1. Heart rate It is an imaginary equilateral triangle formed by connecting
- As per speed of the paper, one minute is equal to points of junctions of the right & left superior extremities &
1500 small squares or 300 big squares. the left inferior extremity.

So heart rate= 1500 We can identify the side or wall of the heart affected by
------------------------------- identifying the changes in particular leads.
Anterior wall - V2, V3, V4
Inferior wall - aVF, II, III
Lateral wall - I, aVL, V5, V6
Nursing implications
No preparation of the client is necessary for taking ECG.
Explain the procedure & reassure him that the
procedure is absolutely safe & he will not be
electrocuted.
In coronary care units, the nurses must be familiar with
ECG monitoring & must be able to detect the
development of abnormalities. Abnormal changes
should be recorded & reported immediately.
Ensure good contact between the client’s skin and the
electrodes by applying electrode jelly to the skin
where the electrode is attached.
The client should lie flat & as relaxed as possible, because
any movements or muscular twitchings recorded by
the machine may alter the tracings.
The bystanders should be kept away from the client to
prevent them touching during ECG procedure
The client should not wear ornaments during ECG. If it is
unavailable, careshould be taken that the leads
should not come in contact with the ornaments
The machine should be checked for proper standardization.
When the standardization button is pressed, there
should be a deflection of 10mm on the graph. A
spike made will be of two large squares.
The machine should be properly grounded to prevent
interference with the recording.
The nurses should ensure the correct placement of leads
while taking ECG. The improper placement of chest
leads can greatly distort the tracing and alter the
diagnosis.
No other electric equipment should work in the monitoring
area
Transport the client on trolley, to the ECG department.
The Normal ECG
The Normal ECG
Sinus rhythm (P before QRS)
Rate 50 – 100 bpm
Axis +90o to –30o
Intervals: PR .12-.20 sec
QRS <.12 sec
Sample of Abnormal ECG Tracings:
Atrial FlutterSaw tooth baselineAtrial rate 300 bpm
ECG
https://www.youtube.com/watch?
v=kwLbSx9BNbU&t=29s
CARDIAC CATHERIZATION
Cardiac catherization
It is an invasive procedure used to identify cardiac
anatomy; measure intracardiac pressure, shunt, and
oxygen saturations: and calculate systemic and
pulmonary vascular resistance. (also called cardiac
cath or coronary angiogram)
The procedure is performed in an area of the hospital called
the catheterization laboratory, or “cath lab”
Indication
To confirm or establish diagnosis
To measure cardiac output
To measure pressure and oxygen saturation
To calculate intra cardiac shunting and pulmonary and
systemic vascular resistance
To visualize coronary arteries to assess for my myocarditis
or rejection following heart transplantation
To intervene in congenital heart disease
Procedure
Catheter insertion site include femoral vein or artery,
umbilical vein or artery, brachial vein or internal
jugular vein
Under fluoroscopy, Catheter are guided through the heart
collecting pressure measurements and oxygen
saturation
Contrast dye is injected through the Catheter to visualize
blood flow patterns and structural abnormalities
Fluoroscopy
Fluoroscopy may be performed to evaluate specific areas of
the body; including the bones, muscles, and joints,as
well as solid organs such as the heart, lung, or
kidneys
Complication
Aysrthymias (usually catheter induce)
Infection
Bleeding at catheter insertion site, large hematoma
Allergic reaction to contrast material
Loss of pulse in the extremity used for cannulation
Perforation of heart or vessels
Stroke
Death
 Nursing Diagnosis
Preoperative
Fear related to surgical procedure
Deficient knowledge regarding surgical procedure
and associated nursing care
Postoperative
Risk for injury related to complications of cardiac
catherization
Pre-catherization Nursing Interventions
Provide specific instruction in nonthreatening manner
Day and time of the procedure
Nothing-by-mouth (NPO) guidelines
Sedation versus general anesthesia
Site of the planned arterial and venous puncture
nursing intervention during cardiac catheterization
Assess the patient for nausea or pain (including back pain
from lying still)
provide medication as indicated,
Assess the catheter insertion site for bleeding or hematoma
with vital signs as ordered.
Instruct him to inform you immediately if he experience
chest discomfort or other anginal symptoms
Nursing intervention after cardiac catheterization
Identify access site (position and whether arterial or venous
) The pressure in the right atrium is the CVP.
Check if the patient has been on anticoagulation.
Ascertain what medication have been administered or
ordered.
Post-catheterization interventions:
Before the patient returns to the unit, the nurse should
ensure that all equipment is available to evaluate and
maintain the patient once he arrives. These are things
such as, intravenous pole with plump, blood pressure
cuff, pulse oximetry, telemetry if ordered, and sand
bag
When the patient returns he may be placed on bed rest with
with the head of the bed no higer than 30 degrees.
The patient affected extremity must be kept straight
Insure the patient is fully awake, encourage the patient to
drink at least two liters of fluid during the first 12
hours post cardiac cath, if his condition warrants and
if it is not contraindicated
Post-catheterization interventions:
Maintain the patient on hourly intake and output
If the patient starts to bleed at the puncture site, hold
pressure above the insertion site until the bleeding is
stopped. Do not hold pressure directly on the
departure site. Notify the physician.
Explaining and providing nursing care
Obtaine baseline set of vital signs, heart rate, BP respiratory
rate, and oxygen saturation
measure and record child’s height and weight
note timeof oral intake: solids and liquids
identify known allergies
list current medication and note time last taken
help child change into hospital gown
start peripheral iv, as method
assess and mark the location of pulse (dorsalis peis,
posterior tibial)
Observe and prevent complication
Monitor and record routine vital sign, extremity
temperature, color and pulse, check with vital signs
Notify health care provider for:
Heart rate, respiratory rate, or BP
Bleeding or increasing hematoma at puncture site
Changes in oxygen saturations
Fever
Cool, pulseless extremity
Family education and health maintenance
Provide discharge information
Care of incision or puncture site
Activity restriction
Observe for and report late complications: redness,
swelling, drainage from puncture site
Follow up medical care
Cardiac catetherization
https://www.youtube.com/watch?v=z2bvwo48RAE
CENTRAL VENOUS PRESSURE
DEFINITION
Blood from the systemic veins flows into the right atrium.
A catheter is passed via; the subclavian vein or jugular vein
into the superior vena cavato determine the venous
return and intravascular volume of the right atrium.
The normal value is 5-10cm H2O
PURPOSE
To serve as a guide of fluid balance in critically ill patients
To estimate the circulating blood volume
To determine the function of the right side of the heart
To assist in monitoring circulatory failure
None of these variables are measured directly; they must be
interpreted.
ACCESS
COMPLICATIONS
Carotid Artery Puncture
Pneumothorax
Air Embolism
Arrhythmia
Perforation of SVC or R. Atrium/Ventricle
Infection
Pleural Effusion
Extravasion of Infusate
Allergic reaction to catheter material
EQUIPMENT
The equipment needed for measurement of central venous
pressure includes a sterile bag of fluids (a) with
attached fluid administration set (b), an IV extension
set (c), a manometer (d) and a stopcock (e)

The white arrows indicate the direction of fluid flow.
Initially the white knob is turned straight up towards the
manometer, allowing fluid to flow from the fluid bag
to the patient's catheter to assure the catheter is
patent (a). If fluid does not flow freely into the
patient's catheter a valid CVP reading will not be
obtained.
Then the knob is turned toward the patient (b) and fluid will
fill the manometer. The manometer should not
contain any air bubbles.
If air is present in the manometer or fluid line, let the fluids
run, overfilling the manometer until all air is purged
from the system.
Then turn the knob toward the fluids (c). The level of fluid
in the manometer will fall (the fluid is running into
the patient's catheter) until the height of the fluid
column exerts a pressure equivalent to the patient's
central venous pressure.
The top of the fluid column will slightly oscillate up and
down as the animals' heart beats and as the animal
breathes
INTERPRETATION
An increase of above normal may indicate weakening or
failure of the right side of the heart, or excessive
intravascular volume
A pressure below 5cm H2O usually reflects an
intravascular volume deficit or drug induced
excessive vasodilation
CVP measurements must not be interpreted on their own,
but viewed alongside the patient's full clinical picture
(BP, Respiratory Pattern, Colour, Temperature)
Several measurements are required to identify a trend
CVP Reading
https://youtube.com/watch?
v=MhmB52M3z80&feature=share
PULMONARY ARTERY PRESSURE
Pulmonary artery pressure (PAP)
is normally lower than systemic arterial blood pressure.
Mean PAP greater than 25mmHg, is usually
interpreted as pulmonary hypertension .
Pulmonary arterial pressure(PAH)- a high blood pressure in
the arteries that go from heart to lungs . the tiny
arteries in the lungs become narrow or blocked.
PAP
The normal mean (average) pulmonary artery pressure is
ranging 12 to 16 mmHg . which number of disease
processes affect the pulmonary circulation and
increase the pressure levels in the pulmonary arteries
and right ventricle.
PAP monitoring involves inserting a pressure sensor via
catheter in the artery that carriers blood between the
heart and lungs, this can help diagnose heart failure,
clots and other cardiovascular problems. Pulmonary
arteries are the major arteries arising from the right
ventricle of the heart.
Common cause of pulmonary hypertension
high blood pressure in the lungs arteries
due to somes types og congenital heart disease.
connective tissue disease
coronary artery disease
high blood pressure
liver disease (cirrhosis)
blood clots to the lungs
chronic lung diseases like emphysema
Pulmonary Hypertension Symptoms
2 main test used to diagnose pulmonary hypertension
echocardiogram -a scan that uses high frequency sound
waves to create an image of the heart. it’s used to
estimate the pressure inm the pulmonary arteries .
Right heart catheterisation - a thin, felxible tube (catheter)
is inserted into a vein in your neck, arm or groin, and
passed through to your pulmonary artery to confirm a
diagnosis by accurately measuring the blood pressure
in the right side of your heart and pulmonary arteries
Other tests you may include:
- electrocardiogram (ECG) - exercise tests
- chest x-ray - ventilation-perfusion
scan
- lung function tests - blood tests
Treatment of pulmonary hypertension
Therapies to eliminate the cause of the vessel damage
Oxygen to relax the blood vessels in the lung
Medications that relax and promote growth of the blood
vessels in the lungs
Anticoagulants that reduce clotting and help blood flow
Diuretics to reduce the heart failure and the amount of fluid
in the body
Medications so that the heart doesn’t have to work as hard
Intra arterial blood pressure
Invasive (intra-arterial) blood pressure (IBP) monitoring is
a commonly used technique in the Intensive Care
Unit (ICU), and is also often used in the operating
theater. The technique involves the insertion of a
catheter into suitable artery and then displaying the
measured pressure wave on a monitor.
Intra-arterial catheters ( also called arterial cannulas or A
lines) are ofter inserted for invasive blood
pressure(BP) monitoring and intravascular access for
blood sampling in high risk surgical and critical ill
patients.
USES:
Continuous monitoring of arterial pressure
-intra arterial BP monitoring is ofter employed during
the intraoperative period when major surgery is planned,
significant comorbidities are present, or difficult
intravascular access anticipated and patients are critically ill
and required titrated vasoactive medications.
Identification of abnormal arterial waveform patterns.
Evaluation of respirophasic variations in the arterial
pressure waveform to predict fluid responsiveness.
 - visual estimates or manual calculations of systolic Preferable Sites
pressure variation (SPV) Radial, femoral, dorsalis pedis
or pulse pressure variation (PPV) are possible. Cannulation
Advantage of IABP Collateral perfusion can be evaluated by modified allens
continuous beat-to-beat pressure measurement close test
monitoring of critically ill patients on vasoactive
drugs. Cannule
Pulse waveform analysis provides other important 20G INSYTE (radial)
hemodynamic parameters Single lumen 18G seldinger technique (femoral)
reduces the risk of tissue injury and neuropraxias in patients Complications
who will require prolonged blood pressure Infection
measurement Thrombosis
Aallows frequent arterial blood sampling Digital ischemia
more accurate than NIBP, especilly in the extremely Vessel damage
hypotensive or the patient with arrythmias Bleeding, Nechrosis, Haemotoma
Pulmonary artery pressure measurement
Things needed Patient Positioning
Pressure transducer Supine
Dome Head of bed 0-60
Pressure tubings (arterial extension, 3 way stopcock,
syringe) Angles 45º 30º 0º
Displaying unit Leveling
Transducer stand Eliminates effects of hydrostatic forces on the
Pressure bag with normal saline observed hemodynamic pressures
Catheter set Ensure air-fluid interface of the transducer is
leveled before zeroing and/or obtaining pressure
Pressure transducer readings
Air mineture rugged and disposable device Phlebostatic axis
Level of left atrium
These device can covert the movement of the sensing 4th ICS ½ AP diameter
diaphargm into an electrical signal Mark the chest with washable felt pen
Pressure tubings Identify Phlebostatic Axis
The catheter and stopcock are normally attached to the Intersection of the 4th ICS and ½ the
flush device and transducer by non elastic pressure anterior-posterior diameter of the chest
tubing McHale DL, Carlson KK. AACN Procedure Manual for
Critical Care 4th ed WB Saunders Philadelphia,
Continous flush device-use to fill pressure monitoring Pa 2001 (479) With permission from Elsevier
system and prevent from clotting into the catheter by Mark location chest wall with washable felt pen
continously flushing fluid through the system at the
rate of 1 to 3 ml/hr Used with permission of PACEP Collaborative
Display Level Transducer System
Pressure waveforms are visualized on a calibirated Ensure air-fluid interface of the transducer is
oscilloscope level to phelbostatic axis.
Used with permission of PACEP Collaborative
Digital displays provide a simple method for presenting Level Transducer System
quantitative data from the pressure waveform Relevel the transducer with any change in the patients
Calibration position
The accuracy of blood pressure measurement requires an Referencing the system 1 cm above the left atrium
accurate reference point that is the patient mid decreases the pressure by 0.73 mm Hg
axillary line Referencing the system 1 cm below the left atrium
Zeroing process is done by closing the patient side and increases the pressure by 0.73 mm Hg
opening the other end of the three way to the
atmosphere Angels 45º 30º 0º
Now press zero Square Wave Test
Determines the ability of the transducer to correctly reflect
ARTERIAL PRESSURE pressures
Indications Perform at the beginning of each shift
Routine measurement of systemic blood pressure in ICU Figure A Expected square wave test
Multiple blood gas analysis Figure B Over damped
Figure C Under damped
Under Damped System How to Setup an Arterial Line Transducer
Over responsive, https://youtube.com/watch?
exaggerated, artificially v=vJ_anWmQbUM&feature=share
spiked waveform
SBP erroneously high
DBP erroneously low
Causes small air
bubbles, too long of
tubing, defective
transducer
Over Damped System
Sluggish, artificially
rounded blunted
appearance
SBP erroneously low
DBP erroneously high
Causes large air
bubbles in system,
compliant tubing,
loose/open connections,
low fluid level in flush bag
PAP Documentation
Measure at end expiration
Measure pressures from a graphic tracing
Measure pulmonary capillary wedge pressure at
end-expiration using the mean of the a wave
a wave indicates atrial contraction and falls
within the P QRS interval of the
corresponding
ECG complex
Respiratory Component
Changes in intrathoracic pressure
during respiration change PAP
readings
Record and trend pressure readings at end
expiration

Used with permission of PACEP Collaborative

Respiratory Variation
Spontaneous ventilation
Mechanical ventilation
Arterial Pressure Monitoring
Arterial Pressure monitoring is a form of invasive blood
pressure monitoring and is done through the
cannulation of a peripheral artery. This form of
monitoring is commonly utilized in the management
of critically ill and perioperative patients.

Arterial Line Management

https://youtube.com/watch?
v=1naupO0IZOQ&feature=share

Transducers in Invasive Pressure Monitoring

https://youtube.com/watch?
v=aJmQepDWVqw&feature=share

Arterial Pressure Monitoring

https://www.youtube.com/watch?v=TjGql5HX3fY
 Medical/Surgical Procedures
Recanalization
The process of restoring flow to or reuniting an interrupted
channel of a bodily tube(as an artery or the vas
deferens)
The reestablishment of blood flow into a formerly occluded
region and may lead to significant rebleeding at the
treatment site
a complex process that initially involves adhesion of the
thrombus to the vein wall and an inflammatory
response in the vessel wall, leading to organization
and subsequent contraction of the thrombus, and to
neovascularization and spontaneous lysis of areas
inside the thrombus
Recanalization after acute deep vein thrombosis
The process of recanalization of the veins of the lower
limbs after an episode of acute deep venous
thrombosis is a part of the natural evolution of the
remodeling of the venous thrombus in patients on
anticoagulation with heparin and vitamin K
inhibitors.
A thrombus, colloquially called a blood clot, is the final
product of the blood coagulation step in hemostasis.
There are two components to a thrombus: aggregated
platelets and red blood cells that form a plug, and a
mesh of cross-linked fibrin protein. The substance
making up a thrombus is sometimes called cruor.
Symptoms of a Blood Clot
Redness
Warmth at the skin
Pain that's not caused by an injury
Swelling
A cramp-like or charley horse feeling.
Imaging tests for blood clots may include an ultrasound,
CT, or MRI scan. These tests can help doctors look
for blood clots both in blood vessels and within
tissues and organs. Doctors can generally diagnose
superficial bruises by sight , taking into account any
skin discoloration, tissue swelling, and other injuries.
INTRODUCTION
Deep vein thrombosis (DVT) of the lower extremities (LE)
is a serious and potentially fatal disease in which
there is acute thrombus formation in deep veins of
the LE that can cause partial or total obstruction of
the venous lumen. Deep vein thrombosis is currently
considered a component of the nosological entity
venous thromboembolism (VTE). Venous
thromboembolism is a wider designation that
includes both DVT and pulmonary embolism (PE).
The pathophysiologic process of thrombus formation
was described by the German pathologist Rudolf
Virchow (1821-1902) in 1856. The process itself is
known as thrombogenesis and its chief characteristic
is a loss of normal homeostasis due to an imbalance
between procoagulatory factors and natural
anticoagulants.
These factors can act independently or interdependently,
exerting varying degrees of influence on the thrombogenic
process.
For example, in cases of venous trauma the predominant
factor in development of thrombosis is endothelial
injury, whereas in spontaneous thrombosis
hypercoagulability and venous stasis are the most
important thrombogenic factors.
LOCATION :
The most common sites in which thrombi originate are the
muscular or trunk veins of the legs, according to
studies using phlebography and the labeled
fibrinogen test’
(1 ). The thrombi can propagate proximally to the popliteal,
femoral and iliac veins, resulting in the multiple types of
thrombosis that are seen in clinical practice or autopsis
(2). In the lower extremities, the deep veins most often
involved are the external iliac, the common femoral, the
deep femoral, the femoral, the popliteal, the gastrocnemius,
the soleus, the posterior tibials and the fibular
(3). Both the great and small saphenous veins can also be
affected by thrombosis, but since these veins are part of the
superficial system this condition is known as superficial
vein thrombosis (SVT).
However, the saphenous veins are connected to the deep
vein system and cases of SVT can progress to PE,
and they should not therefore be ignored when
investigating the deep vein system. In clinical
practice, DVT of LE are generally subclassified as
either proximal or distal. They are considered
proximal when they involve the iliac, femoral or
popliteal veins, with or without involvement of veins
in the legs, and are considered distal when they only
affect veins of the legs. The importance of this
differential definition is that around 46% of proximal
DVT cases can progress to PE and 4% are fatal if left
untreated
RISK FACTORS
The most common risk factors for DVT are: prolonged
immobility, traumas, postoperative period, advanced
age, pregnancy, postnatal period, obesity, malignant
neoplasms, estrogen-based female hormones,
hereditary thrombophilias (natural anticoagulant
deficiency, factor V Leiden and the G20210A
prothrombin mutation) and the acquired
thrombophilias (hyperhomocysteinemia and the
antiphospholipid antibody syndrome).
DIAGNOSIS
Patients with DVT may not exhibit specific and/or
pathognomonic signs and symptoms of the disease.
Clinical presentation is highly variable and may be
 restricted to simple localized discomfort in the
affected limb, and this can also be the case with the
much-feared PE. While pain, edema and muscle
rigidity have been identified in up to 86.7% of
patients with DVT, these signs and symptoms can
also present in other conditions, such as:
lymphangitis , cellulites, ruptured Baker's cyst,
congestive heart failure, nephrotic syndrome,
traumas, muscle hematomas, myositis and muscle
tears. In view of this, a clinical diagnosis alone is not
sufficient to confirm diagnosis in suspected cases of
DVT, . Patients who go undiagnosed and are
therefore treated inadequately can suffer chronic
venous insufficiency (CVI) and even death caused by
PE.
DIAGNOSIS
Therefore, when faced with a clinical suspicion of DVT
and a need to assess the status of a thrombosed vein
in order to treat its complications, specific
examinations or supplementary diagnostic methods
capable of directly or indirectly demonstrating the
presence and extent of the thrombus must be used.
Clinical prediction models such as those proposed by
Wells et al.(17), in combination with laboratory D-
dimer testing and imaging exams with color duplex
mapping (CDM), have made it easier to reliably
diagnose DVT
How is a Thrombos treated?
DVT treatment options include: Blood thinners. DVT is
most commonly treated with anticoagulants, also
called blood thinners. These drugs don't break up
existing blood clots, but they can prevent clots from
getting bigger and reduce your risk of developing
more clots.
How is venous thrombosis detected on ultrasound?
Sound waves are bounced off the blood within a vein.
Flowing blood changes the sound waves by the
“Doppler effect.” The ultrasound machine can detect
these changes and determine whether blood within a
vein is flowing normally. Absence of blood flow
confirms the diagnosis of DVT.
Tests use to diagnose or rule out a blood clot include:
D-dimer blood test. D dimer is a type of protein produced
by blood clots. Almost all people with severe DVT
have increased blood levels of D dimer. A normal
result on a D-dimer test often can help rule out PE.
Duplex ultrasound. This noninvasive test uses sound waves
to create pictures of how blood flows through your
veins. It's the standard test for diagnosing DVT. For
the test, a technician gently moves a small hand-held
device (transducer) on your skin over the body area
being studied. Sometimes a series of ultrasounds are
done over several days to determine whether a blood
clot is growing or to check for a new one.
Tests use to diagnose or rule out a blood clot include:
Venography. A dye is injected into a large vein in your foot
or ankle. An X-ray creates an image of the veins in
your legs and feet, to look for clots. The test is
invasive, so it's rarely performed. Other tests, such as
ultrasound, often are done first.
Magnetic resonance imaging (MRI) scan. This test may be
done to diagnose DVT in veins of the abdomen.
DVT treatment options include:
Blood thinners. DVT is most commonly treated with
anticoagulants, also called blood thinners. These drugs
don't break up existing blood clots, but they can prevent
clots from getting bigger and reduce your risk of
developing more clots.
Blood thinners may be taken by mouth or given by IV or an
injection under the skin. Heparin is typically given by IV.
The most commonly used injectable blood thinners for
DVT are enoxaparin (Lovenox) and fondaparinux (Arixtra).
After taking an injectable blood thinner for a few days,
your doctor may switch you to a pill. Examples of blood
thinners that you swallow include warfarin (Jantoven) and
dabigatran (Pradaxa).
Certain blood thinners do not need to be given first with IV
or injection. These drugs are rivaroxaban (Xarelto),
apixaban (Eliquis) or edoxaban (Savaysa). They can be
started immediately after diagnosis.
You might need to take blood thinner pills for three months
or longer. It's important to take them exactly as prescribed
to prevent serious side effects.
If you take warfarin, you'll need regular blood tests to
check how long it takes your blood to clot. Pregnant
women shouldn't take certain blood-thinning medications.
Clot busters. Also called thrombolytics, these drugs might
be prescribed if you have a more serious type of
DVT or PE, or if other medications aren't working.
These drugs are given either by IV or through a
tube (catheter) placed directly into the clot. Clot busters can
cause serious bleeding, so they're usually only used for
people with severe blood clots.
Filters. If you can't take medicines to thin your blood, you
might have a filter inserted into a large vein — the
vena cava — in your abdomen. A vena cava filter
prevents clots that break loose from lodging in your
lungs.
Compression stockings. These special knee socks reduce
the chances that your blood will pool and clot. To
help prevent swelling associated with deep vein
thrombosis, wear them on your legs from your feet to
about the level of your knees. You should wear these
stockings during the day for at least two years, if
possible.
Understanding and Diagnoisng Venous Thromboembolism
- https://youtube.com/watch?
v=pHddAMauvFk&feature=share
https://youtube.com/watch?
v=mpGD8BsYTi0&feature=share
Palliative care for End Stage Heart Failure
Palliative care is specialized medical care that focuses on
providing patients relief from pain and other
symptoms of a serious illness.
palliative care teams aims to improve the quality of life for
both patients and their families.
Roughly 5% of patients with heart failure have end -stage
disease that is refractory to medical theraphy (stage
D heart failure).
Stage D advanced heart failure be defined as the
presence of progressive and /or persistent severe signs and
symptoms of heart failure despite optimized medical,
surgical, and device theraphy.
Palliative Care
The active total care of patients whose disease is not
responsive to curative treatment. Control of pain, of
other symptoms, and of psychological, social and
spiritual problems is paramount. WHO (1990)
Palliative care, referred to as supportive care, specialized
care that focuses on improving quality of life(QOL)
through relief of stress and symptoms for patients
with serious illness.
Why involve palliative care?
The National Service Framework for Coronary Heart
Disease (DOH 2000) identifies the need to ensure
that People with unresponsive heart failure and other
malignant presentations of coronary heart disease
receive appropriate palliative care and support
The palliative needs of patients and carers should be
identified ,assessed and managed at the earliest
opportunity
Patients with heart failure and their carers should have
access to professionals with palliative care skills
within the heart failure team
The opportunity to discuss issues around uncertainty and
sudden death should be available at all stages of care
NICE Guidelines-Chronic heart failure (2003)
section 1.7
Unmet needs
There is substantial evidence for considerable unmet
palliative needs of patients with heart failure and
their informal carers The main areas of need include
symptom control, psychological and social
support,planning for the future and end of life care.
Management of chronic heart failure in adults in primary
and secondary care. (National Institute for Clinical
Excellence July 2003)
Symptoms of worsening disease
Increasing shortness of breath
Fatigue (profound weakness)
Worsening renal function
Pain (Physicalpsychologicalspiritual aspects)
Low mood
Loss of appetite (cardiac cachexia)
Incontinence
Immobility
Confusion, sleep disorders
Poor response to medication
Managing Breathlessness
Optimum palliation of symptoms of heart failure often
depends on concordance with medication especially
diuretics
Consider possible causes of breathlessness other than heart
failure such as co morbidity or psychological factors
Detailed history
Thorough assessment --?sudden onset
Chest examination/x-ray if indicated
Treat underlying cause (recent MI, arrhythmia, infection,
anaemia, pleural effusion, thyrotoxicosis,)
Diuretic adjustment
Managing Breathlessness
Trial of low dose opiates . Immediate release oral morphine
preparations e.g. oramorph 2.5 mg 4 hourly as
needed and tolerated.(Sedation and accumulation
may occur as most HF patients have a degree of renal
failure, may need reduced dose or alternative opioid
such as oxycodone 1-1.5mg) Consider prophylactic
laxative.
GTN Spray if appropriate(has this helped previously)
Sublingual lorazepam 0.5mg may provide rapid relief of
anxiety associated with breathlessness (
Avoid Diazepam long half life
Managing Breathlessness
Advise on non-pharmacological management ( see
dyspnoea management model)
Involve other experts to ensure a holistic approach
Lifestyle adjustment
Equipment e.g. fan backrest
Oxygen Therapy
Depression
Assess for depression/anxiety
Negotiate management with patient
Consider trial of antidepressants (liaise with heart failure
teams/pharmacist SSRIs may be safest )
Assess for social isolation and acknowledge impact of
disease on QOL
Refer to psychologist
Consider CBT
North Tyneside Palliative Care TeamDyspnoea
Management Model PHYSIOTHERAPIST NURSE
SPECIALIST Breathing Techniques
Anxiety Management
Pacing
Symptom Control
Provision of Walking Aids
Listening
Psychological Support
Relaxation
Energy Conservation
 Hepatomegaly or early satiety consider prokinetic before
meals
Refer to other Services Small portions
Panic Attacks May need antiemetics administered via non oral route
Managing Activities of Daily Living Cardiac Cachexia
Advise Primary Healthcare Team Cardiac cachexia is linked to raised plasma levels of
Practical Support tumour necrosis factor alpha and other inflammatory
Carer Support cytokines. The degree of body wasting is strongly
Exercise Advice correlated with neurohormonal and immune
abnormalities. The available evidence suggests that
Managing Fatigue cardiac cachexia is a multifactorial neuroendocrine
Accurate assessment and metabolic disorder with a poor prognosis. A
Treat reversible causes complex imbalance of different body systems may
Assess for depression cause the development of body wasting
Allow opportunity to express feelings about impact of Cardiac Cachexia
illness Patients may have poor appetite and lose significant
Refer to occupational therapist for equipment to reduce amounts of weight
exertion e.g.stairlift, bath lift Many patients have congestive gastrointestinal oedema
Advise on pacing (encourage gentle activity) causing impaired nutrient absorption
Cognitive Therapy Congestive hepatic enlargement may cause anorexia
CLIP ACTIVITY Sheet Cardiac Cachexia Management
Oedema Attention to detail, may be overlooked due to appearance of
Early detection important oedema
Diuretics are a palliative measure Referral to dietitian
Combination diuretic approach may be required Low sodium high calorie, high protein supplements
Salt/fluid restriction EPA Fish oils if tolerated
Positioning /elevation (not excessive do not elevate the foot Low Cholesterol levels may developstop statins if this
of the bed!) occurs
Pressure Care Discuss possibility of megestrol if severe (may affect blood
Skin care sugar)
Cough Dry Mouth
Consider possible causes of cough other than heart failure Assess for underlying Cause
e.g. infection, pulmonary oedema May be due to oxygen therapy
Do not immediately ACE inhibitors if patient has been Is patient dehydrated? Diuretics fluid restriction
taking for a long time Oral infection or oral Thrush?
If recently started on ACE inhibitor and when cough Routine mouth care
commenced discuss with Heart Failure Team Sucking ice
Simple linctus 5mls qds Sugar free gum
Is related to difficult expectoration consider nebulised Oral balance gel pilocarpine is contraindicated in severe
saline 2.5 mls prn cardiac disease
Pain Constipation
Assess pain Risk factors
Consider causes other than heart failure such as Reduced fluid intake, opioids for breathlessness, inactivity,
musculoskeletal pain, neuropathy.(Up to 70 patients dietary
report non cardiac pain) Stool softener e.g. docusate (should be commenced
Treat Cardiac pain conventionally Consider psychological, prophylactically)
spiritual and emotional aspects Co-danthramer if severe
Involve other team members as appropriate e.g. OT, Advise to avoid straining
Chaplain Extreme caution with movicol
WHO Analgesic Ladder (Caution in renal failure) Treatment agenda vs. support agenda
Extreme caution with NSAIDS ( Renal Failure/Fluid Treatment agenda up titration of drugs, exercise, daily
retention) weight, ongoing investigations
Nausea and Vomiting Support agenda adjustment to illness, coping with
Consider drug causes e.g. digoxin symptoms, uncertainty, fear of dying
Overwhelmed by amount of medication? Why do Heart Failure Patients end up dying in hospital?
Explore biochemical causes ( constant nausea due to severe Uncertainty about prognosis and whether all options
renal impairment may respond to haloperidol 1.5 exhausted
mgs) Communication death not discussed or anticipated
Carers (including GP ) exhausted
Co-morbidity
No proactive management strategies
PANIC !!! Unresolved anxiety
Palliative Care in Heart Failure
Diagnosis
Death
Heart Failure
Bereavement care
Active care
Palliative care
Cancer
Partnership
The key to a coherent joined up approach to managing End
stage Heart Failure is partnership between primary
and secondary care, and collaboration with nursing
staff, medical staff and allied health professionals.
Developing palliative care skills
Skilling up the generalists Good quality palliative care can
be delivered by many practitioners - not exclusively
by the specialist palliative care team
Sensitive honest open communication is essential
Discuss treatment options and care options on a regular
basis
End of Life Concerns (Staff)
Should we mention the chaplain?
Its a shame he has to die on an acute ward
Is he in pain or is he agitated?
Do we continue 4 hourly observations
Should the cardiac monitor be discontinued
Should we stop IV Fluids?
What do I say when his wife asks if he is dying?
The terminally ill fear the unknown more than the known,
professional disinterest more than professional
ineptitude, the process of dying more than death
itself
Derek Doyle (1986)
liverpool Care Pathway(LCP) for last 48 hours
Team decision that patient is dying andcommunicating this
to the family
Establishing a (Do-not resuscitate)DNR order
Stopping non-essential drugs
Stopping inappropriate interventions e.g. blood tests
Prescribing guidelines for managing pain, agitation, nausea,
respiratory secretions
Palliative Care - https://youtube.com/watch?
v=oAGN7cyizs0&feature=share
https://youtube.com/watch?
v=plWg6740Xo8&feature=share
Percutaneous Transluminal Angioplasty (PTA)
is a procedure that can open up the blocked blood vessels
using a small, flexible plastic tube , or catheter , with
a “balloon”at the end of it. When the tube is in place,
it inflates to open the blood vessels, or artery, so that
the normal blood flow restored.
Percutaneous Transluminal Coronary Angioplasty
Is performed to open blocked or narrowed coronary arteries
caused by coronary artery disease (CAD) and to
restorearterial blood flow to the heart tissue without
open heart surgery
Greek word ‘αγγείο’ = vesse and ‘πλαστός’ = moulded
Causes
Coronary artery disease (CAD) occurs when fatty deposits
called plaque build up inside the coronary arteries
Factors:
Smoking
High amounts of certain fats and cholesterol in the blood
High blood pressure
High amounts of sugar in the blood due to insulin
resistance or diabetes
Symptoms
Chest pain (angina pectoris) - due to lack of oxygen
Difficulty breathing or shortness of breath
Sweating or “cold sweat”
Fullness, indigestion, or choking feeling (may feel like
“heartburn”)
Nausea or vomiting
Dyspnea
Excessive fatigue
PTCA Procedure
A special catheter is inserted into the coronary artery to be
treated in the femoral artery in the groin
First a guide wire is inserted and then a catheter which
injects a dye
PTCA Procedure – Balloon
This catheter has a tiny balloon as its tip
The balloon is inflated once the catheter has been placed
into the narrowed area of the coronary artery
The inflation of the balloon compresses the fatty tissue in
the artery and makes a larger opening inside the
artery for improved blood flow
PTCA Procedure - Stent Placement
Is a procedure used in PTCA
A tiny, expandable metal coil (stent) is inserted into the
newly opened area of the artery to help keep the
artery from narrowing or closing again
PTCA Risks of the Procedure
Bleeding at the catheter insertion site (usually groin)
Blood clots or damage to the blood vessels at the insertion
site
Blood clot within the vessel treated by PTCA
Infection at the catheter insertion site
Cardiac arrhythmia
Chest pain or discomfort
Rupture of the coronary artery
PTCA Procedure monitoring
Fluoroscopy (a special type of x ray that obtains real- time
moving images) assists the physician in the location
of blockages in the coronary arteries as the contrast
dye moves through the arteries.
Nursing Intervention
After the procedure takes place, the patient will generally
require several hours for recovery.
The patient should be taken to a recovery room to wait for
the anaesthesia to wear off; typically this will take up
to one hour.
The plastic sheath which was inserted in the patient’s
groin, neck, or arm will be removed soon after unless
the patient requires specialised blood thinning
medication.
After the recovery room, the patient should be transferred
to a regular hospital or outpatient room. The length
of the patient’s stay will be dependent on their
condition. Some patients who have had a
straightforward procedure may even be discharged
on the same day, whereas others who have had an
additional procedure such as an angioplasty or
insertion of a stent will be required to stay overnight.
Nursing Intervention
Require patient puncture sites to be assessed every thirty
minutes for four hours minimum before the patient is
allowed off of bed rest.
Patients should be kept lying flat for several hours after the
procedure so that any serious bleeding can be
avoided and that the artery can heal.
It is advised that diagnostic catheterisation patients are
kept on bed rest for four hours, and interventional
catheterisation patients stay on bed rest for six hours.
The patient is free to move side to side for their
comfort.
The head of the bed should be at a maximum thirty degree
tilt. The patient should be allowed to eat and drink
right after the procedure if they wish to
Non Cardiac Percutaneous Transluminal Angioplast -
https://youtube.com/watch?
v=_WV2UAlzao0&feature=share
Pacemakers
A pacemaker is an electronic device that provides electrical
stimuli to the heart muscle.
Pacemaker are usually used:
when a patient has a permanent or temporary
slower than normal impulse formation
when a symptomatic AV or ventricular conduction
disturbance
to control some tachydysrhythmias tha don’t
responses to medication
Pacemaker design
Pacemakers are consist of two components:
electronic pulse generator; contain the circuitry and
batteries that determine the rate (beat per minute) and
the strength or output (millamperes) of the electrical
stimulus delivered to the heart
pacemaker electrodes (leads); which carry impulsecreted by
the generator to the heart
Endocardial leads
Epicardial wires
Pacemaker design
Most pacemaker have elective replacement indicator
(ERI), a signal that indicates when the battery is
approaching depletion. The pacemaker continues to
function for several months after the appearance of ERI to
ensure that there is adequate time for a battery replacement.
Battery replacement are usually performed using a local
anesthetic, hospitalization is necessary for implantation or
battery replacement
Pacemaker Types
Temporary pacemaker
are intended for short-term use during hospitalization. Are
used to support patents until they improve or reserve
a permanent pacemakers
Epicardial wires and the endocardial may be temporary
located outside the body, and may be taped to the skin or
attached to a belt or to the patient’s bed
the temporary generator size is about the size of a small
paperback book
Permanent pacemakers
Permanent pacemakers are pacemakers that are intended for
long-term use
Endocardial leads
the generator implanted in a subcutaneous pocket
they last approximately 6 to 12 years
the permanent generator weighs less than 1 oz and is the
size of a thick credit card
Pacemaker Types
Single-Chamber System
the pacing lead is implanted in the atrium or ventricle,
depending on the chamber to be paced and sensed
Dual-Chamber Systems
have two leads one lead implanted on the atrium, One lead
implanted in the ventricle
Complication of the pacemaker use
Local infection at the entry site of the leads for temporary
pacing, or at the subcutaneous site for permanent
generator replacement
Pneumothorax and hemothorax
Bleeding and hematoma at the lead entry site for temporary
pacing, or at the subcutaneous site for permanent
generator placement
Ventricular ectopy and tachycardia from irritation of the
ventricular wall by the endocardial electrodes
Movement of dislocation of the lead placed transvenously
Complication of the pacemaker use
Phrenic nerve, diaphragmatic, or skeletal muscle
stimulation if the leads is dislocated of if the
delivered energy is set high
Cardiac perforation resulting in pericardial effusion and
rarely, cardiac tamponade, which may occur at
the time of implantation or months later
Twiddler syndrome may occur when the patient
manipulates the generator, causing lead
dislodgement or fracture of the lead
Pacemaker syndrome (hemodynamic instability caused by
ventricular pacing and loss of AV synchrony)
Nursing Implementation
Assessment and prevention of pacemaker malfunction
Prevent and treat the complications
Patient education
Assessment and prevention of pacemaker malfunction
Three primary problems can occur with a pacemaker, these
problems include failure to pace failure to capture,
and failure to sense
failure to pace occurs when the pacemaker fails to initiate
an electrical stimulus when it should fire, is noted by
absence of pacer spikes on the rhythm strip
failure to capture occur when the pacemaker generates an
electrical impulse and no depolarization is noted. On
the ECG, a pacemaker spike is noted, but is not
followed by p wave or a QRS complex
failure to sense occurs when the pacemaker doesn’t sense
the patient’s own cardiac rhythm and initiates an
electrical impulse
Assessment and prevention of pacemaker malfunction
When failure to capture occurs, nurse should addjust the
output and place the patient on his or her left side
to facilities contact of a transvenous pacing wire
with the endocardium and septum (in temporary
pacemaker)
When failure to sense occurs, nurse should turning the
patient to the left side and adjusting the sensitivity
(temporary pacemaker)
The flowing data should be noted on the patient’s record:
model of pacemaker, type of generator, date and
time of insertion, location of pulse generator,
stimulation threshold and pacer setting. This
information is important for identifying normal
pacemaker function and diagnosing pacemaker
malfunction.
Assessment and prevention of pacemaker malfunction
The battery and security of connections of temporary
pacemakers shall be checked every shift and
documented in the patient’s medical record
The ECG is monitored very carefully to detect pacemaker
malfunction
Monitor V/S especially the heart rate; because the patient
experiencing pacemaker malfunction may
develop bradycardia
Prevent and treat the complications
Prophylactic antibiotics and antibiotic irrigation of the
subcutaneous pocket prior to generator placement
has decreased the rate of infection to less tham 2%
If bleeding or hematoma occur, use of cold compresses
The sites is carefully inspected for purulent drainage,
erythema, and edema, and the patient is observed
for the signs of systemic infection
Frequent ECG monitpring to detect cardiac perforation,
because this condition can be recognized by the
change in QRS complex morphology
Assess symptoms of perforation that include pleuritic chest
pain from pericarditis, diaphragmatic or intercostal
muscle stimulation and, in the presence of
pericardial effusion, patients may develop
shortness of breath and hypotension as tamponade
develops.
Prevent and treat the complications
Assess the sign and symptoms of pneumothorax (hypoxia,
shortness of breath, pleuritic pain, and
hypotension)
Assess for dysrhytmias and treat as indicated
After implanted the pacemaker, nurses should minimizing
patint activity to prevent dislodgement of the
pacing electrode.
Permanent Pacemaker Implant surgery -
https://youtube.com/watch?
v=54taja_HveU&feature=share
Cardioversion
A procedure used to return an abnormal heartbeat to a
normal rhythm.
This procedure is used when the heart is beating very fast
or irregular. This is called arrhythmia.
Arrhythmias can cause problems such as fainting,
stroke, heart attak, and even sudden cardiac death.
Cardioversion is a synchronized administration of shock
during the R waves or QRS complex of a cardiac
cycle and restore a rapid heart beat back to normal.
Cardioversion (Elective)
Most elective or non-emergency Cardioversions are
performed:
To treat fibrillation or atrial flutter to regain heart rhythm
To treat disturbances originating in the upper chambers
(atria) of the heart
Cardioversion (Emergency)
Cardioversion is used in emrgency situations to correct a
rapid abnormal rhythm associated with faintness, low
blood pressure, chest pain, difficulty breathing, or
loss of conciousness
Types of Cardioversion
Cardioversion can be “chemical” or “electrical”
Chemical (Pharmalogical) cardioversion:
refers to the use of anti-arrhythmic medications to restore
the heart’s normal rhythm
Pharmacologic Cardioversion
If pharmalogical cardioversion is done in a hospital, your
heart rate will be regularly checked.
Cardioversion using drugs can be done outside the hospital,
but this requires close follow-up with a cardiologist
Reccomendations for Pharmacological Cardioversion of
Atrial Fibrillation
Class I
Administration of flecainide, dofetilide, propafenone, or
ibutilide is recommended for pharmacological
cardioversion of AF. (Level of Evidence: A)
Reccomendations for Pharmacological Cardioversion of
Atrial Fibrillation
Class IIa
Administration of amiodarone is areasonable option for
pharmacological cardioversion of AF. (Level of
Evidence A)
Administration of amiodarone can be beneficial on an
outpatient basis in patients with proxysmal or
persistent AF when rapid restoration of sinus
 rhythm is not deemed necessary. (Level of
Evidence: C)
Electirc Cardioversion
(Also known as “direct-current” or DC cardioversion); is a
procedure whereby a synchronized electrical shock is
delivered through the chest wall to the heart through
special electrodes or paddles that are applied to the
skin of the chest and back
Basic principles
Transient delivery of electrical current causes momentary
depolarization of most cardiac cells allowing the
sinus node to resume normal pacemaker activity
In the presence of reentrant-induced arrhythmia, such as
PSVT and VT, electrical cardioversion interrups the
self-perpetuating circuit and restores a sinus rhythm
Electrical cardioversion is much less effective in treating
arrhythmia caused by increased automaticity (eg,
digitalis-induced tachycardia, cathecholamine-
induced arrhythmia) since the mechanism of the
arrhythmia remains after the arrhythmia is terminated
and therefore is likely to recur
Indications
Based on advanced cardiac life support (ACLS) guidelines:
Any patient with narrow or wide QRS complex
tachycardia (ventricular rate > 150) who is unstable
(eg, chest pain, pulmonary edema, lightheadedness,
hypotenion, signs of shock)
Supraventicular tachycardia due to reentry
Atrial fibrillation
Atrial flutter (types I and II)
Atrial tahycardia
Monomorphic VT with pulses
Contraindications
Presence of left atrial thrombus
Digitalis toxicity or hypokalemia
Sinus tachycardia caused by various clinical conditions and
catecholamine-induced arrhuthmia
Multifocal atrial tachycardia
VF (since the cardoverter may not sense a QRS wave and
may therefore fail to deliver a shock)
Reccomendations for Direct-current Cardioversion of Atrial
Fibrillation
Class I
When a rapid ventricular response does not respond
promptly to pharmacological measures for patients
with AF with ongoing myocardial ischemia,
smptomatic hypotension, angina or hear failure,
immediate R-wave synchronized direct-current
ardioversion is recommended, (Level of Evidence:
C)
AF involving preexcitation when very rapid tachycardiaor
hemodynamic instability occurs. (Levl of evidence:
B)
Cardioversion is recommended in patients without
hempodynamic instability when symptoms of AF are
unacceptable to the patient. In case of early relapse
of AF after cardioversion, repeated cardioversion
attempts may be made following administration
antiarrhythmic medication. (Level of Evidence: C)
Recommendations for Direct-current Cardioversion of
Atrial Fibrillation
Class II a
1. Direct- current cardioversion can be useful to restore
sinus rhythm as pasr of a long term management strategy
for patients with AF.(Level of Evidence: B)
2. Patient preference is a reasonable consideration in the
selection of infrequently repeated cardioversions for the
management of symptomayic of recurrent AF. (Level of
Evidence : C )
Equipment
Defibrillator with a synchronising button.
Emergency trolley with emergency drugs; ( lignocaine,
atropine, and adrenaline).
Oxygen mask, intubation equipment, airway
Monitor and cvontinuous recording facilities (BP,. ECG.
SpO2).
Intravenous access
Suction device
Position of Paddles
Energy Requirement
Atrial Fibrillation energy requirements are as follows:
200 Joules for monophasic devices
120-200 Joules for biphasic devices
Atrial flutter energy requirement
100 Joules for monophasic devices
50- 100 Joules for biphasic devices
Ventricular tachycardia with pulse energy requirements
are follows:
200 Joules for monophasic devices
100 Joules for biphasic devices
ECG strip shows a atrial fibrillation terminated by a
synchronization shock( synchronization marks
[arrows] in the apex of the QRS complex) to normal
sinus rhythm
Preparing for a Cardioversion
Do not eat or drink for at least eight hours prior to the
procedure.
Blood thining medicines may be given with electrical
cardioversion to prevent clots from moving to the
heart.
Take your regularly scheduled medications the morning of
the procedure unless your medical practitioner has
told you otherwise.
Stop digoxin 48 hours prior to the procedure .
Bring a list of all your medications with you.
Do not apply any lotions or oinment to chest or back as
this may interferenwioth the adhesiveness of the
shocking pads.
Do not drive yourself home after receiving sedation
anesthesia.
Monophasic Vs Biphasic
Defibrillators cam deliver energy in various waveforms that
are boradly characterized as monophasic or biphasic
Monophasic defibrillation delivers a charge in onlyone
direction. Biphasic defibrillation delivers a charge on
one direction for half of the shock and in electrically
opposite direction for the second half
Newer defibrillators deliver energy in biphasic eaveforms.
Biphasic waveform defibrillatorsdeliver a more
consistent magnitude of current. They tend to
successfully terminate arrhythmias at lower
energiesthan monophasic waveform defibrillators
(Automated External defibrillator AED)
Defibrillation
is a medical technique used to counter the onset of
ventricular fibrillation, a common cause of cardiac
arrest, and pulseless ventricular tachycardia
in simple terms, the process uses an electric shock to stop
the heart arrhythmias, in the hope that the heart will
restart with rhythmic contractions
Differences with Cardioversion and Defibrillation
One major difference between cardioversion and
defibrillation with the timing of the delivery of
electrical current
Another major difference concerns the circumstance
defibrillation usually performed as an emergency
treatment .
Cardioversion is usually, but not always a planned
procedure .
Implantable Cardioversion Defibrillation
An implantable cardioverter-defibrillator (often called an
ICD) is a device that briefly passes an electric
current through the heart. It is "implanted," or put in
your body surgically. It includes a pulse generator
and one or more leads. The pulse generator
constantly watches your heartbeat.
Procedure
The most well-known type of electrode is the traditional
metal paddle with an insulated handle.
This type must be held in place on the patient's skin while a
shock or a series of shocks is delivered.
Procedure Steps:
Place paddles so that they do not touch pts clothing or bed
linens or not near direct oxygen supply.
Ensure monitor is attached to pat.
Do not charge the machine untill ready to shock.
Procedure
Exert 25 pound pressure on the paddle .
Ensure you and every body is free of the pat. Inspect skin
for burns.
Record the delivered energy.
Treatment
Shock may be delivered, but it is not regarded as the
treatment of choice.
Antiarrhthmic medications such as amiodarone, lidocaine
or magnesium are given if ventricular dysrhythmia
persists.
Special Considerations for Anticoagulation Prior to
Cardioversion
For patients with AF > 48 hours of AF, or when duration is
unknown, 3 weeks of anticoagulation are required
prior to cardioversion.
Documentation of anticoagulation adequacy is important
prior to cardioversion
Anticoagulation must be continued for at least 4 weeks post
cardioversion
TEE can be used to assess LA for thrombus as alternative
to 3-week anticoagulation (however, anti-coagulation
must continue for 4 weeks post cardioversion
Special Considerations
Cardioversion can be performed safely in pregnant women.
The fetal heart rate should be monitored during the
procedure using fetal monitoring techniques.
Cardioversion in patients with permanent pacemaker/ICD
should be performed with extra care. Improper
technique may damage the device, lead system, or
myocardial tissue, resulting in device malfunction.
The electrode paddle or patch should be at least 12
cm from the pulse generator and antero-posterior
paddle position and lowest amount of energy be
used.
Complications
Possible complications of cardioversion are uncommon but
may include:
Harmless arrhythmias, such as atrial, ventricular, and
junctional premature beats.
Serious complications include ventricular fibrillation (VF)
resulting from high amounts of electrical energy,
digitalis toxicity, severe heart disease, or improper
synchronization of the shock with the R wave
Thromboembolization is associated with cardioversion in
1-3% of patients, especially in patients with atrial
fibrillation who have not been anticoagulated prior to
cardioversion.
Bruising, burning or pain where the paddles were used.
Allergic reactions from medicines used in pharmacologic
cardioversion .
Complications
Myocardial necrosis can result from high-energy shocks.
ST segment elevation can be seen immediately and
usually lasts for 1-2 minutes. ST segment elevation
that lasts longer than 2 minutes usually indicates
myocardial injury unrelated to the shock.
Pulmonary edema is a rare complication of cardioversion. It
is probably due to transient left atrial standstill and
left ventricular systolic dysfunction.
Cardioversion - https://youtube.com/watch?
v=dC_i8zuclmQ&feature=share
 Ablation
The removal or destruction of a body part or tissue or its
function. Ablation maybe performed by surgery ,
hormones, drugs, radiofrequency, heat or other
methods.
ABLATION is a procedure to treat atrial fibrillation . It
uses small burns or freezes to cause some scarring
on the inside of the heart to help break up the
electrical signals that cause irregular heartbeats.
- a major surgery and spend a day or two in intensive
care
Cardiac ablation-- is a procedure that scars tissue in you
heart to block abnormal electrical signals. It’s used to
restore a normal heart ryhthm. Long flexible tubes
(catheters)
are threaded through blood vessels to your heart. sensors on
the tips of the catheters use heat or cold energy to
destroy (ablate) the tissue.
Catheter insertion points for cardiac ablation:
catheters may be inserted in your groin, your shoulder
or your neck. The doctor inserts the catheter through a
blood vessel into the heart. More than one catheter is ofter
used.
Types of cardiac catheter ablation
CATHETER ABLATION, also called radiofrequency or
pulmonary vein ablation -
isn’t surgery, the doctor puts a thin , flexible tube
called a catheter into a blood vessel in your leg or neck and
guides it to your heart. When reaches the area that causing
arrhythmia , it can destroy those cells. This helps get your
heartbeat regular again.
two mains kinds;
1. catheter ablation using radiofrequency (heat
cauterization)
The doctor uses catheters to send radiofrequency energy
( similar to microwave heat} that makes circular scars
around each vein or group of vein
2. catheter ablation using cryoablation (freeze
cauterization)
A single catheter send s a balloon tipped with a
material that freezes
the tissues to cause a scar
SURGICAL ABLATION -involves cutting into your chest.
There are three main kinds.
MAZE procedure the doctor will usually do this while
having open heart surgery for another problem, like bypass
or valve replacementt
They make cuts in the upper part of the heart and stitch
them togethwr to form yhe scar tissue thatn stops unusual
signals.
MINI procedure Most people with AFiB don’t need open
heart surgery. That’s where this less invasive type .The
doctor makes several small cuts between your ribs and uses
a camera to do catheter ablation.
some hospitals offer robotic assisted surgery that uses
smaller cuts and make procedure
more precise , The doctor will put a video camera or
tiny robot into the chest . It’ll guide the creation of scar
tissue that may help keep the heartbeat at the right pace.
CONVERGENT procedure. This pair catherterablation
with a mini maze . The doctor uses radiofrequency ablation
in the pulmonary vein . and a surgeon make a small cut
under the breastbone to use radiofrequency energy on the
outside of the heart.
Possible cardiac ablation risks include:
Bleeding or infection at the site where the catheter was
inserted.
blood vessel damage
New or worsening arrthythmia
Slow heart rate that could require a pacemaker to correct.
Blood clts in your leg or lungs(venous thromboembolism).
stroke or heart attack.
Narrowing of the veins that carry blood between the lungs
and heart (pulmonary vein stenosis)
Damage to your kidneys from dye usedf during the
procedure.
Death in rare cases.
Nursing consideration after an ablation
You sent Plan to have someone else drive you home after
your procedure. Some people feel a little sore after
the procedure. The soreness shouldn't last more than
a week. Most people return to normal activities
within a few days after having cardiac ablation, but
you should avoid any heavy lifting for about a week.
Nursing consideration after an ablation
Following catheter ablation, patients are seen for a 30-day
outpatient follow up visit during which a 12-lead
ECG is performed. At 3, 6, and 12 months post-
ablation, patients undergo 7-day Holter monitoring to
assess AF recurrence, burden, identification of other
arrhythmias, and correlation with any reported
symptoms.
Nursing consideration after an ablation
The ablated (or destroyed) areas of tissue inside your heart
may take up to eight weeks to heal. You may still
have arrhythmias (irregular heartbeats) during the
first few weeks after your ablation. During this time,
you may need anti-arrhythmic medications or other
treatment.
Catheter Ablation - https://youtube.com/watch?
v=_WkTQB4ARfM&feature=share
CABG
Aortocoronary bypass and coronary artery bypass grafting
A form of bypass surgery that can create new routes around
narrowed and blocked coronary arteries, permitting
increased blood flow to deliver oxygen and
nutrientsto the heart muscle. CABG surgery is one of
the most commonly performed major operations
 Purpose
Restore blood flow to the heart
Relieve chest pain & ischemia
Improves the patient’s quality of life
Enables the patient to resume a normal life cycle
Lower the risk of a heart attack
Indication
Indicartions for Corornary Artery Bypass Grafting (CABG)
depend on various factors, mainly on the individual’s
symptoms and severity of disease. Some of these
include:
Left main artery disease or equivalent
Triple vessel disease
Abnormal Left Ventricular function
Failed PTCA
Immediately after Myocardial Infarction (to help perfusion
of the viable myocardium)
Life threatening arryhthmias caused by a previous
myocardial infarction
Occlusion of grafts from previous CABG
Contraindication
Left main artery disease or aortic valve insufficiency
Abdominal aortic aneurysm
Haemorrhage diseases
Valve diseases, congenital heart diseases, cardiomyopathy
Lower exgtremities edema
Severe hypertension, blood pressure higher than 70/110
Uncontrolled arrhythmias
Pregnancy
Diagnostic Evaluation
Physical Exam and Diagnostic Tests
ECG (Electrocardiogram)
MRI
Echocardiography
Coronary Angiography
Types of CABG
Traditional Coronary Artery Bypass Grafting
This is the most common type of coronary artery bypass
grafting (CABG). It’s used when at least one major
artery needs to be bypassed.
Off-pump Coronary Artery Bypass Grafting
This type of CABG is similar to traditional CABG because
the chest bone is opened to access the heart.
However, the heart isn’t stopped, and a heart-lung
bypass machine isn’t used. Off-pump CABG is
sometimes called beating heart bypass grafting
Minimally Invasive technique
Alternate methods of minimally invasive coronary artery
bypass surgery have been developed. Off-pump
coronary artery bypass (OPCAB) is a technique of
performing bypass surgery without the use of
cardiopulmonary bypass
Procedure
The patient is brought to the operating room and moved
onto the operating table
An anaesthetic or anesthesiologist places intravenous and
arterial lines and injects an analgesic, usually
fentanyl, intravenously, followed within minutes by
an induction agent (usually propofol or etomidate) to
render the patient unconscious
An endotracheal tube is inserted and secured by the
anaesthetist and mechanical ventilation is started.
General anaesthesia is maintained with an inhaled
volatile anesthetic agent such as isoflurane
The chest is opened via a median sternotomy and the heart
is examined by the surgeon
Procedure
The bypass grafts are harvested - frequent vessels are
internal thoracic arteries, radial arteries and sapenous
veins. When harvesting is done, the patient is given
heparin to inhibit blood clotting
In the case of “off-pump” surgery, the surgeon places
devices to stabilize the heart
In the case of “on-pump” surgery, the surgeon sutures
cannulae into the heart and instructs the perfusionist
to start cardiopulmonary bypass (CPB)
Procedure
Protamine is given to reverse the effects of heparin. 
Chest tubes are placed in the mediastinal and pleural space
to drain blood from around the heart and lungs. 
The sternum is wired together and the incisions are sutured
closed.
The patient is moved to an intensive care unit (ICU) or
cardiac universal bed (CUB) to recover. After
awakening and stabilizing in the ICU for 18 to 24
hours, the person is transferred to the cardiac surgery
ward..
Risks of Coronary Artery Bypass Grafting
Although complications from coronary artery bypass
grafting (CABG) are uncommon, the risks include: 
Wound infection and bleeding 
Reactions to anesthesia 
Fever 
Pain 
Stroke, heart attack, or even death
Heart Bypass Surgery - https://youtube.com/watch?
v=3Nf6Q2skGOM&feature=share
INTRA-AORTIC BALLOON PUMP (IABP)
is a type of therapeutic device. It helps the heart pump more
blood.
it’s consist of a thin, flexible tube called a catheter ,
attached to the tip of the catheter is a long balloon
“ The Intra -aortic balloon pump is a mechanical device
that increases myocardial oxygen perfusion and
indirectly increases cardiac output through afterload
reduction. It consist of a cylindrical polyurethane
balloon that sits in the aorta, approximatelyn 2
centimeters (0.79in)
from the left subclavian artery. “
It consist of two parts : a balloon inserted into the aorta ,
one of the large arteries through which blodd passes
 from the heart to the rest of the body ; and a machine
/ console outside the body.
IABP gives temporaey support for the left ventricle by
mechanically displacing blood within the aorta.
It is the most common and widely available methods of
mechanical circulatory support.
Traditionally used in surgical and non surgical patients
with cardiogenic shock.
Insertion of IABP
The device is introduced from the femoral artery and
guided into the aorta till its tip is just distal to the left
subclavian artery takeoff from the aortic arch by
using an X-ray camera to move it. 
The device is hooked up to a machine that tells the balloon
when to get bigger and when to get smaller. 
It uses helium to blow up the balloon because helium won’t
cause problems in body if it leaks.
Therefore, when properly positioned, the IABP occupies
the entire descending thoracic aorta and much of the
suprarenal abdominal aorta. 
Although fluoroscopy/echocardiography can help guide
placement, they are not absolutely necessary in
emergent situations.
Positioning
the end of the balloon should be just distal (1-2 cm) to the
takeoff of the left subclavian artery
position should be confirmed by fluoroscopy
How long can an intra aortic balloon pump stay in?
Sometimes the Intra-aortic-balloon pump(IABP) stays in
for up to one week
in rare instances, staying in for up to two weeks, therefore
increasing the risk of infection.
Indication
Cardiac failure
Refractory Unstable angina
Perioperative treatment of complications due to myocardial
infarction.
As a bridge to cardiac transplantation.
Contra Indications
Aortic Insufficiency 
Aortic aneurysm 
Aortic dissection 
Limb ischemia 
Thromboembolism
Core Principle of IABP Therapy
Synchronized counterpulsation is the core principle of
IABP therapy.
This describes inflation in diastole and deflation in systole
of a balloon situated in the descending aorta.
The overall aim is to improve myocardial function by
myocardial oxygen supply 
myocardial oxygen demand 
Input and removal of helium gas causes inflation and
deflation of the balloon. The timing of balloon
inflation and deflation is based upon the aortic
pressure waveform and the electrocardiogram.
Cont….
The balloon inflation occurs immediately after aortic valve
closure and balloon deflation just before opening of
the aortic value. 
Inflation and deflation of the balloon have two major
effects:  Inflation during diastole causes blood
displacement into the proximal aorta, resulting in
increased coronary blood flow, while Deflation
during systole reduces aortic volume and afterload
through a vacuum effect
Augmentation on a balloon pump
Balloon inflation and diastolic augmentation. As the aortic
valve closes in end-systole (this correlates with the
dicrotic notch) the IABP balloon inflation pushes
blood against the closed valve. ... Thus, as 
“the balloon inflates in diastole, it creates a peak of
pressure, which is the diastolic augmentation”
IABP counter-pulsation rapidly stabilizes patients in
cardiogenic shock. 
The greatest improvement in cardiac index and pulmonary
capillary wedge pressure occurs in patients with
mechanical defects complicating acute myocardial
infarction (MI), ie, mitral regurgitation(MR) or
ventricular septal defect(VSD)
IABP balloon waveform
The normal IABP balloon waveform 
The balloon itself has a pressure transducer, and it
generates a waveform.
ECG triggering of the IABP
The basic principles are: 
Inflation of the balloon is triggered by the the beginning of
diastole, which correlates with the middle of the T-
wave. The balloon is timed to deflate at the very end
of diastole. This correlates with the R-wave on the
ECG, and this is the most commonly used trigger for
balloon deflation. 
In atrial fibrillation, the ECG trigger is timed to deflate on
the R wave as usual, but the R-R interval (which
governs the timing of the balloon remaining inflated)
varies. The R wave timing can also be of the
"pattern" type, where normal QRS morphology is
expected, or "peak" type where - if your QRS is
monstrously misshapen - the IABP will choose the
maximum voltage peak and use that instead.
Normal Balloon Pressure Waveform
Variation in balloon pressure waveforms (Heart Rate)
Variation in balloon pressure waveforms (Rhythm)
Variation in balloon pressure wavefoms (Gas leak)
Variation in balloon pressure waveforms (Catheter
Kinking)
Balloon too large syndrome
Complications of IABP
Infection at site of insertion 
Hematoma and bleeding at insertion site 
Limb ischemia, absent pulses 
Thrombocytopenia 
Coagulation disturbances 
Aortic dissection 
Displacement of the balloon catheter obstructing left
subclavian artery or renal artery perfusion 
Vascular complications 
Balloon leak, rupture, gas loss from the balloon 
Timing issues
Limb Ischemia & Bleeding
Cause of Limb ischaemia are obstruction of a small or
diseased femoral artery by the catheter, formation of
thrombus from direct arterial injury during IABP
insertion and thromboembolism. 
Bleeding at the insertion site is due to anticoagulation
therapy or associated thrombocytopenia. 
Patients receiving IABP therapy are normally maintained
on an anticoagulation regimen to avoid thrombus
formation . 
Baseline full blood count and anticoagulation screen should
be reserved prior to and during therapy to observe for
changes such as a decrease in haemoglobin and to
monitor the effect of anticoagulation therapy
prescribed.
Weaning and Removal of IABP
Once the patient’s condition has stabilized the IABP is
considered for removal. This is preceded by a
process of weaning the pump from 1:1 to 1:2 and
finally 1:3 
Observing the patient for ischaemic chest pain or
development of heart failure symptoms such as
breathlessness, hypotension and tachycardia. Once
the patient is stable the IABP can be removed.
Nursing care For IABP patients
Post removal the patient is kept on bed rest with the leg
kept straight as per local guidelines.
Nursing care involves observing for recurrence of
symptoms as well as checking the insertion site for
haematoma formation ooze or symptoms suggestive
of retroperitoneal bleed every 15 minutes for the first
hour, half hourly for the next two hours and
thereafter hourly or as clinical acuity dictates. In
addition lower limb perfusion is assessed at these
times confirming adequate perfusion and presence of
pedal pulses.
IABP is a form of circulatory support for those presenting
with ischaemia or heart failure. Nursing care
involves care of the pump as well as assessing
patient from a cardiovascular and hemodynamic
perspective .
Purpose
To increase myocardial oxygen supply
To decrease myocardial oxygen demand
Improvement of cardiac output (CO), an increase of
coronary perfusion pressure.
IABP - https://youtube.com/watch?
v=mADxD7C8jBw&feature=share
Heart Transplantation
A heart transplant, or a cardiac transplant, is a surgical
transplant procedure performed on patients with end
heart failure or severe coronaryn artery disease when
other medical or surgical treatments have failed.
A heart transplant is an operation to replace a damaged or
failing heart with a healthy heart from a donor who’s
recently died.
Indications of Cardiac Transplantation
Patients should receive maximal medical therapy before
being considered for transplantation. They should
also be considered for alternative surgical therapies
including CABG, valve repair / replacement, cardiac
septalplasty, etc.
VO2 (oxygen carrying capacity) has been used as a
reproducible way to evaluate potential transplant
candidates and their long term risk. Generally a peak
VO2 >14ml/kg/min has been considered “too well”
for transplant as transplantation has not been shown
to improve survival over conventional medical
therapy. Peak VO2 10 to 14 ml/kg/min had some
survival benefit, and peak VO2 <10 had the greatest
survival benefit.
Evaluation of Cardiac Transplantation Recipient
Right and Left Heart Catheterization.
Cardiopulmonary testing.
Labs including BMP, CBC, LFT, UA, coags., TSH, UDS,
ETOH level, HIV, Hepatitis panel, PPD, CMV IgG,
RPR / VDRL, PRA (panel of reactive antibodies),
ABO and Rh blood type, lipids.
CXR, PFT’s including DLCO, EKG.
Substance abuse history and evidence of abstinence for at
least 6 months and enrollment in formal
rehabilitation.
Mental health evaluation including substance abuse hx and
social support.• Financial support.
Weight no more than 140% of ideal body weight.
Cardiac Donor
Brain death is necessary for any cadaveric organ donation.
This is defined as absent cerebral function and
brainstem reflexes with apnea during hypercapnea in
the absence of any central nervous system
depression.
There should be no hypothermia, hypotension, metabolic
abnormalities, or drug intoxication.
If brain death is uncertain, confirmation tests using EEG,
cerebral flow imaging, or cerebral angiography are
indicated.
Cardiac Donor – Exclusion Criteria
Age older than 55 years.
Serologic results (+) for HIV, Hepatitis B or C.
Systemic Infection.
Malignant tumors with metastatic potential (except primary
brain tumors)
Systemic comorbidity (diabetes mellitus, collagen vascular
disease)• Cardiac disease or trauma
Coronary artery disease
Allograft ischemic time estimated to be > than 4-5 hours
LVH or LV dysfunction on echocardiography
Death of carbon monoxide poisoning
IV drug abuse.
Matching Donor and Recipient
Because ischemic time during cardiac transplantation is
crucial, donor recipient matching is based primarily
not on HLA typing but on the
severity of illness
ABO blood type (match or compatible),
response to PRA
donor weight to recipient ratio (must be 75% to
125%)
geographic location relative to donor
length of time at current status.
Surgical Transplantation Techniques
Orthotopic implantation is the most common – it involves
complete explantation of the native heart.
Heterotopic implantation is an alternative technique in
which the donor heart functions in parallel with the
recipient’s heart.
Physiologic concerns of Transplant
Biatrial connection means less atrial contribution to stroke
volume.
Resting heart rate is faster (95 to 110 bpm) and acceleration
of heart rate is slower during exercise because of
denervation.
Diurnal changes in blood pressure are abolished.
Diastolic dysfunction is very common because the
myocardium is stiff from some degree of rejection
and possibly from denervation.
Postoperative Complications
Surgical
Aortic pseudoaneurysm or rupture at cannulation
site
Hemorrhagic pericardial effusion due to bleeding
or coagulopathy
Medical
Severe tricuspid regurgitation
RV failure
Pulmonary artery compression
Pulmonary hypertension
LV failure
Ischemia
Operative Injury
Acute rejection
Postoperative Complications
Rhythm disturbances
Asystole
Complete heart block.
Sinus node dysfunction with bradyarrhythmias
(25% permanent but most resolve within 1-2
weeks).
Atrial fibrillation.
Ventricular tachycardia.
Coagulopathy induced by cardiopulmonary bypass
Respiratory failure
Cardiogenic pulmonary edema.
Noncardiogenic pulmonary edema.
Infection.
Renal or hepatic insufficiency
Drugs.
CHF.
Postoperative Management
Initiation of medications, particularly immunosuppressive
agents begins on the day of the operation.
Cyclosporin
Azathioprine
Solumedrol – +/- Muromonab-CD3 (OKT3)
Postoperative Management
Pneumocystis carinii prophylaxis is started within the first
week after transplant.
If patient or donor is CMV positive then ganciclovir is
started on postop day 2.
Endomyocardial biopsy is performed on postop day 4 and
steroids can begin to be tapered if there is no
rejection greater than grade 2b.
Anticoagulation is started if heterotopic transplantation has
been performed.
Amylase and lipase are measured on day 3 to detect
pancreatitis.
ECG’s are obtained every day.
Long-term Management
Endomycardial biopsy is performed once a week for the
first month and then less frequently depending on the
presence or absence of rejection (usual regimen is qweek x
4 weeks, qmonth x 3 months, q3months in 1st year,
q4months in 2nd year, 1 to 2 times per year subsequently).
Long-term Management
Cyclosporine levels are checked periodically by individual
center protocols.
Echocardiography is useful periodically and as an adjunct
to endomyocardial biopsy.
Cardiac catheterization is performed annually for early
detection of allograft vasculopathy.
There is probably no need for routine exercise or nuclear
stress testing.
Complications - Rejection
Avoidance with preoperative therapy with cyclosporin,
corticosteroids, and azathioprine.
If rejection is suspected then workup should include:
measurement of cyclosporine level CKMB level,
echocardiography for LV function, and
endomyocardial biopsy.
Signs and symptoms of rejection only manifest in the late
stages and usually as CHF (rarely arrhythmias). Due
to close surveillance, most rejection is picked up in
asymptomatic patients.
Complications - Rejection
Hyperacute Rejection: Caused by preformed antibodies
against the donor in the recipient. It occurs within
minutes to hours and is uniformly fatal. PRA
screening is the best method in avoiding hyperacute
rejection.
Acute Cellular Rejection: Most common form and occurs
at least once in about 50% of cardiac transplant
recipients. Half of all episodes occur within the first
2 to 3 months. It is rarely observed beyond 12
 months unless immunosuppression has been
decreased.
Complications - Rejection
Vascular (Humoral) Rejection: not well defined.
Characterized by immunoglobulin and complement in the
microvasculature with little cellular infiltrate.
It is associated with positive cross match, sensitization to
OKT3, female sex, and younger recipient age.
It is more difficult to treat than acute cellular rejection, is
associated with hemodynamic instability, and carries
a worse prognosis.
Staging of Acute Rejection
If acute rejection is found, histologic review of
endomyocardial biopsy is performed to determine the
grade of rejection.
Grade 0 — no evidence of cellular rejection
Grade 1A — focal perivascular or interstitial
infiltrate without myocyte injury.
Grade 1B — multifocal or diffuse sparse infiltrate
without myocyte injury.
Grade 2 — single focus of dense infiltrate with
myocyte injury.
Grade 3A — multifocal dense infiltrates with
myocyte injury.
Grade 3B — diffuse, dense infiltrates with
myocyte injury.
Grade 4 — diffuse and extensive polymorphous
infiltrate with myocyte injury; may have
hemorrhage, edema, and microvascular
injury.
Complications - Infection
There are two peak infection periods after transplantation:
The first 30 days postoperatively: nosocomial
infections related to indwelling catheters and
wound infections.
Two to six months postoperatively: opportunistic
immunosuppresive-related infections.
There is considerable overlap, however as fungal infections
and toxoplasmosis can be seen during the first
month.
It is important to remember that immunosuppressed
transplant patients can develop severe infections in
unusual locations and remain afebrile.
Opportunistic Infections
CMV
Toxoplasma gondii
Pneumocystis carinii
Aspergillus
Complications - Malignancy
Transplant recipients have a 100-fold increase in the
prevalence of malignant tumors as compared with
age-matched controls.
Most common tumor is posttransplantation
lymphoproliferative disorder (PTLD), a type of
non-Hodgkin’s lymphoma believed to be related to
EBV.
The incidence is as high as 50% in EBV-negative
recipients of EBV-positive hearts.
Treatment involves reduction of
immunosuppressive agents, administration of
acyclovir, and chemotherapy for widespread
disease.
Skin cancer is common with azathioprine use.
Any malignant tumor present before transplantation carries
the risk for growth once immunosuppresion is
initiated because of the negative effects on the
function of T-cells.
Complications - Hypertension
As many as 75% of transplant recipients treated with
cyclosporine or corticosteroids eventual develop
hypertension.
Treatment is empiric with a diuretic added to a calcium
channel blocker, B-blocker, or Ace inhibitor.
If either diltiazem or verapamil is used, the dosage of
cyclosporin should be reduced.
Complications - Dyslipidemia
As many as 80% of transplant recipients eventually have
lipid abnormalities related to immunosuppression
medications.
These dyslipidemias have been linked to accelerated
allograft arteriopathy.
These disorders should be treated aggressively with statins
and fibrates to hopefully alleviate transplant coronary
vasculopathy.
Outcomes
The survival rate according to the United States Scientific
Registry for Organ Transplantation reports the 1-year
survival rate to be 82% and 3 year survival rate to be
74%.
The most common cause of mortality was cardiac allograft
vasculopathy.
The UNOS data suggested some group differences with 3-
year survival rate for white persons 75%, Hispanics
71%, and African Americans 68%
Similar survival rates between men and women.
Outcomes
Poor outcomes are associated with the following risk
factors:
Age less than 1 year or approaching age 65.
Ventilator use at time of transplant.
Elevated pulmonary vascular resistance.
Underlying pulmonary disease.
Diffuse atherosclerotic vascular disease.
Small body surface area.
The need for inotropic support pre-transplant.
Diabetes mellitus.
Ischemic time longer than 4 hours of transplanted
heart.
Sarcoidosis or amyloidosis as reason for transplant
(as they may occur in the transplanted heart).
Heart Transplantation - a treatment for heart failure -
https://youtube.com/watch?
v=geOAh1oZncY&feature=share
VIDEO- ASSISTED THORACOSCOPIC SURGERY
(VATS)
is a type of sugery for diagnosing and treating a variety of A single-lumen endotracheal tube with a bronchial blocker
conditions involving the chest area (thorax). It uses a is an acceptable alternative.
special video camera called a thorascope. Incision
It is a type of minimally invasive thoracic surgery that does 4 Ports.
not use a formal thoracotomy incision. Single port technique is evolving.
Advantage Incision
Avoidance of a thoracotomy incision Conversion from VATS to thoracotomy
shorter operating time Inability to achieve single-lung ventilation
less postoperative morbidity Extensive pleural adhesions
earlier return to normal activity. Uncontrolled or significant intraoperative bleeding
Indications Inability to identify a target lesion for biopsy
VATS is principally employed in the management of Technical difficulties with or primary failure of video
pulmonary, mediastinal, and pleural pathology. equipment and/or endoscopic instruments
Specific Indications Complications
Stapled lung biopsy Persistent air leak
Lobectomy or pneumonectomy Bleeding from pulmonary vessels
Resection of peripheral pulmonary nodule Intercostal nerve damage due to insertion of instruments
Evaluation of mediastinal tumors or adenopathy through the ports
Pleural biopsy Complications from single-lung ventilation, including
Bullectomy respiratory insufficiency or postoperative
Sympathectomy reexpansion pulmonary edema
Oesophagectomy Tumor implantation following VATS
Specific Indications
Treatment of recurrent pneumothorax Video Assissted Thoracoscopic Surgery -
Management of loculated empyema https://youtu.be/Uojg0rwx8X0
Pleurodesis of malignant effusions
Repair of a bronchopleural fistula
Chest trauma (mainly diaphragmatic injuries)
Pericardial window
Truncal vagotomy

Other Indications
Pulmonary metastesectomy.
cardiac denervation of refractory ventricular arrhythmias
and electrical storms.
Contraindications
Absolute contraindications
Markedly unstable or shocked patient
Extensive adhesions obliterating the pleural space
Prior talc pleurodesis
Contraindications
Relative contraindications
Inability to tolerate single-lung ventilation
Previous thoracotomies
Extensive pleural diseases
Coagulopathy
Prior radiation treatment for thoracic malignancy; plan to
resect
Position
The patient is turned to a full lateral decubitus position, and
the operating table is flexed to widen the rib spaces
on the operation side.
Anesthesia
General anesthesiawith selective single-lung ventilation
using a double- lumen endobronchial tube is
preferred.
Left-side intubation is usually performed unless a left
pneumonectomy is anticipated.
 SKILLS 118 (Week 8 & 9 )
DIAGNOSTIC ASSESSMENT GASTRO and
LIVER DYSFUNCTION
C O L L EC T I O N
Fecal Occult Blood Test
A fecal occult blood test (FOBT) is a noninvasive
test (nothing enters the body). This test detects
hidden (occult) blood in the stool. Such blood may
come from anywhere along the digestive tract.
Hidden blood in stool is often the first, and in
many cases the only, warning sign that a person
has colorectal disease, including colon cancer.
Fecal occult blood is a term for blood present in
the feces that is not visibly apparent.
How the Test is Performed
There are two types of FOBTs: 1) the traditional
guaiac smear test (Hemoccult, Seracult,
Coloscreen), and 2) the newer, flushable reagent
pads (EZ DetectT, ColoCARE). They are both
useful in detecting hidden blood in the stool, and
are mainly used for colorectal cancer screening.
The tests differ in the way they are performed. The
flushable reagent pads are available without a
prescription at many drugstores. In contrast, the
traditional guaiac smear test is completed and
interpreted by a medical professional, and these
tests are usually available from a laboratory or a
doctor's office.
Many consumers prefer the flushable reagent pads
because there is no stool handling and no
laboratory processing. However, health care
providers usually favor the guaiac tests because the
large studies that have shown the benefits of colon
cancer screening were done with guaiac tests.
Why the Test is Performed
This test is mainly performed for colorectal cancer
screening. It may also be performed in the
evaluation of anemia.
Advantages:
Noninvasive
Low cost
Disadvantages:
Detects blood in stool, but not its cause.
False-positive results are common with some
testing methods. This may cause unneeded anxiety
about cancer and lead to unnecessary further tests.
False-negative results are also common and may
miss disease in its early stages.
What Abnormal Results Mean
Positive test results may indicate the following:
Bleeding esophageal varices
Colon polyp or colon cancer
Esophagitis
Gastritis
GI (gastrointestinal) trauma
GI tumor
Hemorrhoids
Fissures (cracks around the anus)
Inflammatory bowel disease
Peptic ulcer
Complications of recent GI surgery
Angiodysplasia of the colon
Additional conditions under which the test may be
performed include the following:
Colon cancer screening
Evaluation of anemia
Risks
A negative test does not necessarily mean there are
no colorectal diseases present. Not all polyps
bleed, and not all polyps bleed all the time. That is
why a FOBT must be used with one of the other
more invasive screening measures (sigmoidoscopy,
colonoscopy, double barium contrast enema).
Considerations
Colonoscopy is generally recommended as the
preferred follow-up test to a positive FOBT.
Factors that can cause this test to be less accurate
include the following:
Bleeding gums following a dental procedure
Eating red meat within 3 days of the test
Eating turnips or horseradish
Drugs that can cause GI bleeding include
anticoagulants, aspirin, colchicine, iron
supplements in large doses, NSAIDs (anti-
inflammatory analgesics), and corticosteroids.
Drugs that can cause false positive measurements
include colchicine, iron, oxidizing drugs (for
example, iodine, bromides, and boric acid), and
reserpine.
Large amounts of vitamin C can cause false-
negative results on most FOBTs.
In general, avoiding food is not recommended,
with the exception of red meat as described above.
How the Test is Performed
If the test is performed in an office or hospital,
stool may be collected by a doctor during an
examination.
 If the test is performed at home, a stool sample
from three consecutive bowel movements is
collected, smeared on a card, and mailed to a
laboratory for processing. In order to ensure the
accuracy of the guaiac test, follow the
manufacturer's instructions on how to collect the
stool.
There are many ways to collect the samples. You
can catch the stool on plastic wrap that is loosely
placed over the toilet bowl and held in place by the
toilet seat. Then put the sample in a clean
container. One test kit supplies a special toilet
tissue that you use to collect the sample, then put
the sample in a clean container. Do not take stool
samples from the toilet bowl water, because this
can cause errors.
For infants and young children wearing diapers,
you can line the diaper with plastic wrap. The
plastic wrap is positioned so that it keeps the stool
from any urine. Mixing of urine and stool can spoil
a good sample.
Laboratory procedures may vary. In one type of
test, a small sample of stool is placed on a paper
card. A drop or two of testing solution is put on the
opposite side of the card. A color change indicates
the presence of blood in the stool.
“occult” meaning hidden.
Purpose: to detect pathological lesions (ex.
Carcinoma) before they produce symptoms and
while the condition is still amenable to treatment.
This testing is widely used in mass screening
programs for colorectal cancer.
A number of easy-to-use test kits for detection of
occult blood are available. Prior to such kits, the
traditional method was to expose the sample to a
sequence of solutions that included glacial acetic
acid, gum guaiac solution and hydrogen peroxide.
A blue color indicated a positive test result. The
test kits use these same principles, with some using
paper impregnated with guaiac. For these reasons,
analysis of feces for occult blood is sometimes still
referred to as “stool for guaiac.”
One of the main problems of testing stools for occult blood
is the number of false-positive results that occur.
-diet in meat
-diets high in certain vegetables (ex. horseradish, and
turnips) and in bananas.
-bleeding from the gums or nasal passages
-therapy with many drugs due to direct and indirect drug
effects on the gastrointestinal tract.
Includes:
--aspirin (300mg/day)
--iron preparations
--anticoagulant
--adrenocorticosteroids
--colchicine
--phenylbutazone
--ascorbic acid (negative)
Black stools-associated with upper G.I. bleeding when the
hemoglobin has come in contact with gastric acid
and has been converted to hematin. (5 days)
Red/maroon—liquid consistency – upper G.I. bleeding is
massive and the volume increases G.I. motility
Bright red – lower G.I. bleeding from hemorrhoids,
ulcerative colitis and carcinomas.
Occult Blood indications/purposes
-known or suspected disorder associated with
gastrointestinal bleeding
-therapy with drugs that may lead to gastrointestinal
bleeding ex. Aspirin, anticoagulants
Rectum and Anus
Hemorrhoids
usual age of occurrence: older adults
severity: usually mild; blood is bright red
other features: maybe painless or symptomatic often
associated with constipation.
Anorectal fissure
any age
usually mild; blood is bright red
nearly always painful. Crohn’s disease, anal intercourse
may predispose
In the event of a positive fecal occult blood test,
the next step in the workup is a form of
visualization of the gastrointestinal tract (ie:
endoscopy, colonoscopy, virtual colonoscopy).
guaiac-based fecal occult blood test
usually picks up a daily blood loss of about 10 ml
(about two teaspoonfuls). The sensitivity of a
single FOBT has been quoted at 30%, but if 3 tests
are done (as is standard), the sensitivity rises to
92%.
"Normally, there is only about 0.5 to 1.5 ml of
blood a day that escapes blood vessels into the
stool each day. There are more sensitive tests than
the guaiac such as a heme-porphyrin test or an
immunochemical test, but the former test is not
used much due to the high false positive rate. The
latter test is very sensitive -- it picks up as little as
 0.3 ml... It does not detect blood from the stomach
and upper small intestine so it is much more
specific for bleeding from the colon or lower
gastrointestinal tract."
PreGen-Plus
The stool-based DNA test, was capable of
detecting several stages of colorectal cancer, in
otherwise healthy adults, and most importantly in
its' early stage, the easiest and most effective to
treat, stage of colorectal cancer.
How the Test is Performed
There is no direct handling of stool with this test.
You simply note any changes on a card and then
mail the results card to your physician.
Urinate if you need to, then flush the toilet before
you defecate. After the bowel movement, place the
chemically treated tissue pad in the toilet. Watch
for a change of color on the test area of the pad
(results usually appear within two minutes). Note
the results on the card provided, then flush the pad
away. Repeat for the next two consecutive bowel
movements.
Causes for a positive test are:
2-10%: cancer (colorectal cancer, gastric cancer)
20-30% adenoma or polyps
Bleeding peptic ulcer
Angiodysplasia of the colon
EsophagogastroduodenoscopyDefinition
OGDS/ endoscopies/gastroscopy
(OGDS) is a procedure during which a small flexible
endoscope is introduced through the mouth (or
with smaller caliber endoscopes, through the nose)
and advanced through the pharynx, esophagus,
stomach, and duodenum
It considered a minimally invasive procedure.
Indication
Diagnostic evaluation for signs or symptoms suggestive of
upper GI disease (eg, dyspepsia, dysphagia,
noncardiac chest pain, recurrent emesis)
Investigation for upper GI cancer in high-risk settings
(eg, Barrett esophagus)
Indication
Biopsy for known or suggested upper GI disease
(eg, malabsorption syndromes, neoplasms,
infections)
Therapeutic intervention (eg, retrieval of foreign bodies,
control of hemorrhage, dilatation or stenting of
stricture, ablation(removal) of
neoplasms, gastrostomy placement)
Contraindication
Possible perforation, medically unstable patients, or
unwilling patients.
Relative contraindications include anticoagulation,
pharyngeal diverticulum, or head and neck
surgery.
Complication
Aspiration pneumonia
Bleeding
Perforation
Cardiopulmonary problem
Equipment
Endoscope
Stack - light source
- insufflators
- suction
Instruments - biopsy forceps
- snares
- injecting needles
Before procedure
Keep patient NBM (nil by mouth)
Obtain consent from the patient (risk for bleeding and
perforation)
Take blood for investigation - complete blood cell count,
blood cross matching, coagulation studies, BUSE,
electrocardiogram, and chest radiographs.
Take vital sign for baseline
During procedure
Placed patient in the left lateral position.
Administer topical and/or intravenous sedation to minimize
gagging and to facilitate the procedure.
Place a bite block (mouth guard) to prevent damage to the
endoscope and to ease its passage through the
mouth.
Under direct vision, the endoscope will passed through the
pharynx, esophagus, stomach and duodenum.
Liquid and particulate matter can be aspirated through the
suction channel.
The procedure and findings will be documented with
pictures or a video system. Biopsy specimens can
be obtained by passing forceps and taking small
mucosal samples for histology studies.
The procedure may last @ 5-30 minutes
After procedure
Close monitoring of vital sign for 1 – 2 hours, or until the
sedative or analgesia has worn off.
Keep patient nil by mouth until the local anesthetic has
worn off (in the throat) and the gag reflex has
returned (after two to four hours)
Patient may complaint of hoarseness and a mild sore throat
- drink cool fluids or gargle to relieve the soreness
Video Upper GI Endoscopy;EGD
https://www.youtube.com/watch?v=vW7tYgYBOFk
Rectal examination
Definition
Rectal examination consists of visual inspection of the
perianal skin, digital palpation of the rectum, and
assessment of neuromuscular function of the
perineum.
Indication
May be used to diagnosed:
Rectal tumors
Prostatic disorders and benign prostatic hyperplasia
Appendicitis
Piles
Anyabnormalities
Indication
for the estimation of the tonicity of the anal sphincter
in females, for gynecological palpations of internal organs
for examination of the hardness and color of the feces (eg.
in cases of constipation, and fecal impaction);
prior to a colonoscopy or proctoscopy.
to evaluate hemorrhoids
In newborns to exclude imperforate anus
Before the procedure
Provide privacy (is a very embarrassing examination)
Advice patient to take a deep breath during the actual
insertion of the finger into the rectum.
During the procedure
Put patient in left lateral position with the buttocks near the
edge of the bedside. Keep the right knee and hip in
slight flexion.
During the procedure
Put patient in well lit room, with total privacy.
A chaperon is needed if the patient is female
Using a gloved hand, the examiner inspects the buttocks for
fistulous tracts, the skin tags of hemorrhoids,
excoriations, blood, and rectal prolapsed.
Next, using a generous amount of lubrication, the gloved
index finger is inserted gently into the rectum.
Sigmoidoscopy, Colonoscopy And Biopsy
Definitions
Colonoscopy is the endoscopic examination of the colon
and the distal part of the small bowel
Sigmoidoscopy is the medical examination of the large
intestine from the rectum up to the sigmoid
A biopsy is a removal of tissue to determine the presence
or extent of a disease.
Indication
COLONOSCOPY:
Rectal bleeding
Iron deficiency anaemia
Cancer follow-up
Polyp follow-up
Abdominal pain
Abnormal bowel habit
SIGMOIDOSCOPY:
Symptoms that suggest anorectal pathology, including
colorectal neoplasia
Prior to anorectal procedures
To obtain biopsy of any bowel condition
To assess the true height (distance from anal verge) of
rectal cancers
Conservative treatment of sigmoid volvulus
During anterior resection of rectum to gauge the lower
resection margin
Before procedure
Stop
Aspirin and drugs for arthritis (ibuprofen, naproxen, etc.) A
week before the procedure to prevent intestinal
bleeding
Iron pills, because it may cause constipation – difficult for
colon cleansing
Barium swallow or enema, because barium can cover
intestinal mucosa thus hiding it from doctor’s
view
Anticoagulants – to prevent risk of bleeding
Insulin should not be taken during fasting
Bowel preparation
Low residue diet 2-3 days pre operatively
Administration of glycol-electrolyte solution
(Go-LYTELY) x 2 bottles / Foltran / fleet
solution @ 1 day pre op (evening).
Clear fluids only after administration of Go-
LYTELY
Bowel washout @ morning of operation day (if
necessary)
During procedure
Lie on left lateral
Sedation will be given if necessary
Doctor will administer the colonoscope through your anus
into the colon and advance it toward the end of the
colon.
If necessary, doctor will perform a biopsy, stop the
bleeding or remove the polyp.
Investigation lasts about 30-45 minutes
After procedure
Rest for 1 – 2 hours
Patient may experience some cramping or bloating (due to
inflated air during the procedure) for the next day
or 1-2 days
Biopsy results will be ready in a week
Video Colonoscopy
https://www.youtube.com/watch?v=mh90RPA-C10
Definition
Abdominal paracentesis is a bed side clinical procedure in
which needle is inserted into peritoneal cavity nd
ascitic fluid is removed.
TYPES:-
 1)diagnostic small quantity of fluid is removed for testing. In refractory ascites, removal of as much fluid as possible
2) therapeutic:>5 litres of fluid is removed to reduce with sod.restricted diet n diuretics will extend the
intraabdominal pressure and relieve the interval to next paracentesis.
asso. Symptms like dyspnoea, abdominal REMOVAL OF NEEDLE:
pain Needle is removed with one rapid smooth withdrawal
Indication motion.
For evaluation of new onset ascites. Distract the pt by asking him to cough because cough will
Testing of ascitic fluid. prevent pain sensation.
For evaluation of pt with ascitis who has signs of clinical Complication :
deterioration like fever,abd.pain,hepatic Ascetic fluid leak:
encephalopathy, decreased renal function n -improper Z track
metabolic acidosis. -using large bore needle
Paracentesis can identify unexpected diagnosis such as -large skin nick
chylous, hemorrhagic or eosinophilia ascites useful Rx: keep ostomy bag over nick.
to know etiology n antibiotic susceptibility. Bleeding:
-artery or vein
Patient preparation: In inferior epigastric bleed fig. of 8 suture is placed
Explain the procedure & Obtain Consent surrounding the needle site. Rarely laprotomy is
No fasting before Procedure needed to control bleeding in pts with renal failure
n hyper fibrinolysis.
EQUIPMENT & STAFF Bowel perforation
Clinician & Assistant Infections
Bottles should be labelled for tests prior doing paracentesis Catheter residue broken into abdominal.wall.
Bacterial culture is done in pts
BARIUM MEAL / BARIUM ENEMA DEFINITION
Choice of needle : A barium meal is a procedure in which radiographs of the
DIAGNOSTIC: 1.5 Inch, 22 Gauge needle esophagus, stomach and duodenum are taken after
For Obese :3.5 Inch, 22 Gauge spinal needle barium sulfate is ingested by a patient.
THERAPEUTIC: 15/ 16 Gauge needle to speed up the A barium enema is a procedure in which radiographs of the
removal. colon are taken after barium sulfate is infused into
KIMBERLY – CLARK QUICK TAP PARACENTESIS the colon
TRAY CONTAINS CADWELL NEEDLE which
has a sharp inner trocar & blunt outer metal INDICATION OF BARIUM MEAL
cannula with side holes to permit withdrawal of Dysphagia
fluid if end hole is occluded by bowel/ Omentum Assessment of perforated region
Esophageal reflux
Position: Carcinoma of esophagus
Mostly Supine INDICATION OF BARIUM ENEMA
Head may be elevated Changes in bowel habit
Knee elbow position for removal of minimal fluid in Colitis
dependent area Pain
Ulcerative colitis
Mass
Why left ????: Diverticulam
Abd. Wall is thinner. Neoplasm
Pool of fluid is more. Volvulus
Pt can be rolled easily to left for drainage.
WHY NOT RIGHT??? BEFORE THE PROCEDURE
Appedicectomy scar, caecum filled with gas in pts taking Bowel preparation (as in sigmoidoscopy)
lactulose. DURING THE PROCEDURE
Care must be taken not to injure inferior epigastic artery Lie on the x-ray table and preliminary x-ray is taken. Bowel
which bleeds massively & which is located near preparation (as in sigmoidoscopy)
pubic tubercle The doctor will gently insert a well-lubricant tube into the
rectum.
The tube is connected to a bag that contains the barium.
Sterilise with Iodine or Chlorhexidine The barium flows into the colon.
LA: 1% Lignocaine The doctor will monitors the flow of the barium on an x-ray
It is removal of >5 lit of fluid. fluroscope screen
Client will need to move into different position and the
table slightly tipped to get different views.
AFTER THE PROCEDURE
Give bedpan or help client to toilet, so can empty bowels
and remove as much of the barium as possible.
Advise patient to drink plenty of fluids for the next 24
hours to avoid constipation (Barium is a dense
substance, which may not be completely cleared
from toilet by normal flushing. It may be necessary
to use a toilet brush, or to flush more than once to
clear any residue from the toilet.
Endoscopic Retrograde Cholangio-pancreatography
DEFINITION
Also called ultrasound scanning or sonography, involves
exposing part of the body to high-frequency sound
waves to produce pictures of the inside of the
body.
Imaging is a noninvasive medical test that helps physicians
diagnose and treat medical conditions.
Indication
Is a useful way of examining many of the body's internal
organs e.g.
heart and blood vessels, including the
abdominal aorta and its major branches
liver
gallbladder
spleen

Endoscopic retrograde cholangiopancreatography (ERCP)

is a technique that combines the use of endoscopy
and fluoroscopy to diagnose and treat certain
problems of the biliary or pancreatic ductal
systems Pancreas
INDICATION Kidneys
Gallstones Bladder
Blockage of the bile duct Uterus, ovaries, and unborn child (fetus) in pregnant
Jaundice patients
Undiagnosed upper-abdominal pain Eyes
Cancer of the bile ducts or pancreas Thyroid and parathyroid glands
Pancreatitis Scrotum (testicles)

BEFORE THE PROCEDURE Example image’s

NPO for 8 hours before procedure Ultrasound is also used to:
Inform doctor if known allergy to any drug / food Guide procedures e.g. needle biopsies
Stop anticoagulant 1 week prior to procedure Image the breasts and to guide biopsy of breast cancer.
Remove the eyeglasses and dentures. Diagnose a variety of heart conditions and to assess damage
Obtain the consent after a heart attack or diagnose for valvular heart
disease.
PROCEDURE
Put patient in left lateral Ultra sound machine
The throat is anesthetized with a spray or solution, and the
patient is usually mildly sedated.
The endoscope is then gently inserted into the upper
esophagus to the main bile duct entering the
duodenum.
Dye is then injected into this bile duct and/or the pancreatic
duct and x-ray films are taken Ultra Sonography
PROCEDURE of the gallbladder provides a noninvasive means
If a gallstone is found, steps may be taken to remove it. of studying the gallbladder and the
If the duct has become narrowed, an incision can be made biliary ducts
using electrocautery to relieve the blockage / Advantages:
placement of stents No ionizing radiation
The procedure takes from 20 to 40 minutes Detection of small calculi
No contrast medium
Less patient preparation
AFTER THE PROCEDURE
Close monitoring for 1-2 hours Before the procedure
Do not drive or operate machinery for at least eight hours. Client should wear comfortable, loose-fitting clothing for
Video ERCP the ultrasound exam.
https://www.youtube.com/watch?v=5VgoDJ31V_0 Client may need to remove clothing and jewelry in the area
Ultrasound / SONOGRAPHYDefinition to be examined.
They may be asked to wear a gown during the procedure. Traction device or setup, including weights
Other preparation depends on the type of examination that Manual manometer or sphygmomanometer
the client will have. Y-tube connector (if not already built into the tamponade
balloon ports)
Before the procedure Vacuum suction device, tubing, and connectors
For some scans the doctor may instruct not to eat or drink Soft restraints
for 12 hours before appointment. Topical anesthetic (spray and jelly) and water-soluble
For others client may be asked to drink up to six glasses of lubricating jelly
water two hours prior to exam and avoid urinating
so that bladder is full when the scan begins. 3 or 4 tube clamps
How the procedure performed Large (e.g., 50 mL) catheter tip irrigating syringe
In an ultrasound examination, a transducer both sends the Surgical scissors for emergency balloon decompression
sound waves and records the echoing waves. Standard NG tube (may not be required if GEBT has a
When the transducer is pressed against the skin, it directs built-in gastric aspiration port)
small pulses of impossible to hear, high-frequency
sound waves into the body.
As the sound waves bounce off of internal organs, fluids
and tissues, the sensitive microphone in the PROCEDURE
transducer records tiny changes in the sound's pitch
and direction.
Cont:-
These signature waves are instantly measured and
displayed by a computer, which in turn creates a
real-time picture on the monitor.
One or more frames of the moving pictures are typically
captured as still images. Consider endotracheal intubation prior to GEBT placement.

During the procedure

A clear gel is applied to the area to be examined to augment
the ultrasound transmission and reception.
The sound waves produced by the transducer cannot
penetrate air, so the gel helps to eliminate air
pockets between the transducer and the skin.
If used, the NG tube should secured 3 cm proximal to the
Client will be asked to lie still and hold the breath from esophageal balloon.
time-to-time to assist in acquisition of the best
images.
Sometimes patients need to roll to different positions
Most ultrasound examinations are completed within 30
minutes to an hour.

After the procedure

Wiped off the gel from skin. Clamp the inflation tube after inflation.
After an ultrasound exam, client should be able to resume
the normal activities immediately.
Oesophageal Ballon Tamponade DEFINITION
Balloon tamponade usually refers to the use of balloons
inserted into the esophagus or stomach, and inflated to stop
refractory bleeding from vascular structures including
esophageal varices and gastric varices in the upper
gastrointestinal tract.
INDICATION
A balloon tamponade tube is used when the bleeding from Use of the sponge-rubber cuff to secure the tube.
oesophageal varices is dangerous and the tube is
usually inserted during an endoscopy.

EQUIPMENT:
GEBT tube

Monitor the inflation pressure of the esophageal balloon
with a manometer.
POST-PROCEDURE
After bleeding has been controlled for several hours,
reduce the pressure in the esophageal balloon by 5
mm Hg every 3 hours, until an intraesophageal
balloon pressure of 25 mm Hg is achieved without
ongoing bleeding.
If bleeding can be controlled with an intraesophageal
balloon pressure of 25 mm Hg, maintain this
pressure for the next 12 to 24 hours.
Once satisfactory positioning of the GEBT tube has been
confirmed, do not disturb the tube for 20 to 24
hours, unless necessary because of complications.
Provide the patient with analgesics and sedation.
Apply soft restraints to the patient’s arms.
If the bleeding does not remain controlled, other therapeutic
interventions must be considered.
COMPLICATIONS
Aspiration pneumonitis
Asphyxia due to airway obstruction. Keep scissors at the
bedside so that the tube can be cut and quickly
removed if this complication occurs.
Esophageal perforation or rupture
Uncommon major complications include duodenal rupture,
tracheobronchial rupture, and periesophageal
abscess formation.
Common minor complications include pain, discomfort,
local pressure effects of gastric or esophageal
erosions or mucosal ulcers, regurgitation, chest
discomfort, back pain, and pressure necrosis of the
nose or lip.
Choleangiogram:
Radiographic examination of the biliary ducts
special x-ray procedure that is done with contrast media to
visualize the bile ducts after the a cholecystectomy
(removal of the gallbladder). The bile ducts drain
bile from the liver into the duodenum (first part of
the small bowel).
Video : Oesophageal Ballon Tamponade
https://www.youtube.com/watch?v=NHelCd5Jtp4
Computed tomography
is an imaging procedure that uses special x-ray equipment
to create detailed pictures, or scans, of areas inside
the body.
It is also called computerized
tomography and computerizedaxial tomography
(CAT)
CholecystographyDefinition
Is a procedure that helps to diagnose gallstones.
In the test, a special dye, called a contrast medium, is
either injected into patient body or is taken as
special pills (oral cholecystography).
This contrast medium shows up the structure of the
gallbladder and bile duct on x-ray.
Before the procedure
Explain the procedure to patient.
Sign a consent form that gives permission to do the
procedure.
Fasting prior to the procedure.
Notify the radiologic technologist if patient are pregnant or
suspect patient may be pregnant.
During the procedure
Remove any clothing or jewelry that may interfere with the
exposure of the body area to be examined.
Patient may be given an enema prior to the procedure to
clear the intestines of gas or feces that may
interfere with imaging of the gallbladder.
Cont..
Body parts not being imaged may be covered with a lead
apron (shield) to avoid exposure to the x-rays.
Several x-rays will be taken while patient are in various
positions.
If testing of the gallbladder’s ability to contract is
requested, patient will be given some type of fatty
intake to stimulate gallbladder contraction.
After procedure
Generally, there is no special care following
cholecystography.
Because the contrast dye is excreted from the body through
the kidneys, sometime patient may feel some slight
discomfort with urination for a day or so.
Liver biopsyDefinition
Liver biopsy is the biopsy (removal of a small sample
of tissue) from the liver. It is a medical test that is
done to aid diagnosis of liver disease, to assess the
severity of known liver disease, and to monitor the
progress of treatment.
Type of liver biopsy
Percutaneous Liver Biopsy
via a needle through the skin
Transvenous Liver Biopsy
through the blood vessels
Laparoscopic Liver Biopsy
technique that avoids making a large incision by instead
making one or a few small incisions.
Percutaneous Liver Biopsy
 Laparoscopic Liver Biopsy The patient can resume eating a normal diet.
Indication Complications
Liver biopsy: Diagnostic purposes
Alcoholic liver disease Prolonged internal bleeding
Elevated liver enzymes of unknown cause Patient with liver cancer will develop a fatal hemorrhage
Biliary tract obstruction/jaundice from a percutaneous biopsy.
Fatty liver disease Leakage of bile
Hemochromatosis Infection
Wilson disease Fractional test meal
Autoimmune liver disease Gastric analysis
Alpha1-antitrypsin deficiency Gastric acid stimulation test
pH monitoring
Possible injury due to drug therapies
Hepatitis B For zollinger-Ellison syndrome (tumor at pancreas/
Hepatitis C duodenum)/ actropic gastritis
Hepatomegaly (liver enlargement) of undetermined cause Preparation
Cancers that originate in the liver NPO for 8 -12 h
Cancers that spread (metastasize) to the liver from other Withhold medication that effect gastric secretion 24-48h
sites Positioning in a semi fowlers
Noncancerous tumors or abnormalities in the liver NGT insertion around 21’, laying along the greater curve
Gastric sample are aspirate and collected every 15m for
next 1 hour.
Liver biopsy: Monitoring therapy Liver Transplantation
The Liver
Chronic viral hepatitis The largest single organ in the human body.
HIV/AIDS In an adult, it weighs about 1.5 Kg and is roughly the size
Liver transplantation (to rule out rejection or infection) of a football.
Located in the upper right-hand part of the abdomen,
behind the lower ribs.
Before procedure Gross Anatomy
NPO by mouth for 4 – 8 hours before the biopsy. The liver is divided) into four lobes: the right (the largest
Sign a consent form lobe), left, quadrate and caudate lobes.
Ask patient maybe have a allergy for medication.
Asked to empty the bladder so that he or she will be more Supplied with blood via the protal vein and hepatic artery.
comfortable during the procedure.
Check patient vital sign to identify any physical problem Blood carried away by the hepatic vein.
During procedure
Patients lie on their back with their right hand resting above
their head. It is connected to the diaphragm and abdomainal walls by
A local anesthetic is applied to the area where the biopsy five ligaments.
needle will be inserted. If needed, an IV tube is
used to give sedatives and pain medication.
The doctor makes a small incision in the abdomen, either Gall Bladder
toward the bottom of the rib cage or just below it, Muscular bag for the storage, concentration,
and inserts the biopsy needle. acidification and delivery of bile to small
intestine
Patients will be asked to exhale and hold their breath while
the needle is inserted and a liver sample is quickly The liver is the only human organ that has the remarkable
withdrawn. property of self-regeneration. If a part of the liver
Several samples may be collected, requiring multiple is removed, the remaining parts can grow back to
needle insertions. its original size and shape.

Microscopic Anatomy

After procedure LIVER FUNCTION TESTS

lie on their right sides for 1-4 hours ALT
Monitor patient's vital signs. AST (SGOT)
Bed rest for a day is recommended, followed by a week of ALKALINE PHOSPHATASE
avoiding heavy work or strenuous exercise. BILIRUBIN
PROTHROMBIN TIME/INR HE- LT remains the only permanent Rx
ALBUMIN 3. Refractory ascites-
carries a mortality of >50% at 2 yrs.
More prone for variceal bleed, HRS, SBP.
Annual incidence of HRS in cirrhotics with ascites is 8%
with median survival of 2 wks in Type I and 6
Cirrhosis Of Liver months in Type II.
Liver Transplantation LT should be considered as soon as HRS is diagnosed.
Liver transplantation (LT) is now established as the only
definitive treatment for end stage liver disease
(ESLD) Main indications for LTx: complications of ESLD
Starzl et al carried out 1st human liver transplant in 1963 4. HPS- [4-47% prevalence] LT is the only curative Rx for
Survival following liver transplant HPS
1 year survival: 87 – 93% 5. PPHTN- 2-8%, associated with higher post
3 year survival: > 75% transplantation mortality

Individual etiologies – viral hepatitis, ALD, NAFLD, HPB

.....(http://www.ustransplant.org The 2009 malignancy, AIH, Cholestatic disorders, ALF, HCC.
Annual Report of the OPTN and SRTR: Transplant Contraindication for LT
Data 1999-2008).

Liver Transplantation
Issues
Whether patient needs LT?
When to refer or consider for LT?
Is patient suitable for LT?

Liver Transplantation
Living Donor Liver Transplant
Goals of Liver Transplantation
Provides maximum benefit to patients with liver failure
who have no other medical or surgical alternative for
survival
Likely prolongs life at least 5 years
Restores patient to normal or near normal functional status
Scoring systems

Model for End-Stage Liver Disease (MELD)

MELD score = 0.957 x Loge (creatinine mg/dl) + 0.378 x
Loge (bilirubin mg/dl) + 1.12 x Loge (INR) + 0.643
Multiply the score by 10 and round to the nearest
whole number
Established in Feb 2002
Numerical scale, from 6 (less ill) to 40 (gravely ill)
This ‘score’ tells us how urgently LT is required within
next 3 months
Most patients on LT waiting list have MELD score between
11 and 20

Indications for Liver Transplantation

Indications for Liver Transplantation
Main indications for LTx: complications of ESLD

GE variceal bleed- each episode of bleeding carries a 20%

mortaliity rate. LT is the best way to decompress
the portal system if other therapies have failed. –
De Francis et al, Baveno V, J Hepatology, 2010]