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HELLO ALL!
I NEED A LITTLE ASSISTANCE WITH THE FOLLOWING CASE!
Clinical Indication: STEMI
Anginal Classification: IV
Access: Right Femoral, Right Radial
ASA Class: 4
1.The nature and character of the proposed treatment or procedure
2.The anticipated results
3.Possible recognized alternative methods of treatment, including non- treatment
4.Recognized serious possible risks, complication, and anticipated benefits involved in proposed and alternative treatments including non-treatment
5.Questions were answered to the patient's satisfaction
6.patient/family accepted plan for sedation Yes
PCI Patient Non-Selection Criteria
This form must be completed for ALL PCI patients.
Patient was evaluated for and does not meet the non-selection criteria; therefore PCI is indicated and will be initiated at _____ without surgical backup.
Patient was evaluated for the non-selection criteria (please check the following as appropriate to the patient’s condition) and PCI will NOT be performed at this facility).
>50% diameter stenosis of left main artery proximal to infarct-related lesion, especially if the area in jeopardy is relatively small and overall LV function is impaired.
Long, calcified, or severely angulated target lesions at high risk for PCI failure with TIMI flow grade 3 present during initial diagnostic angiography.
Lesions in areas other than the infarct artery (unless they appear to be flow limiting in patients with hemodynamic instability or ongoing symptoms).
Lesions with TIMI flow grade 3 in patients with left main or three vessel disease.
Culprit lesions in more distal branches that jeopardize only a modest amount of myocardium when there is more proximal disease that could be worsened by attempted intervention.
Chronic total occlusion.
Other comment:_____________________________________________________________________
Syntax score:
PROCEDURE
Procedure Details
The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient and/or family concurred with the proposed plan, giving informed consent. Patient was brought to the cath lab after IV hydration was begun and oral premedication was given. Patient was further sedated with fentanyl and versed. Patient was prepped and draped in the usual manner. Using the modified Seldinger access technique, a 6 French sheath was placed into the right common femoral vein and a balloontipped pacemaker was directed under fluoroscopy into the right ventricle to achieve pacing for severe bradycardia and intermittent complete heart block then a 6 French French sheath was placed in the right radial artery after getting access patient went into torsades with polymorphic ventricular tachycardia that became ventricular fibrillation requiring cardioversion this recurred twice and patient was cardioverted with 200 J each time then 300 mg of IV amiodarone was given. A left heart catheterization was done. Right and Left Coronary Angiograms were also done. Due to significant hypotension with blood pressure in the 40s and as the patient was in fulminant cardiogenic shock dopamine was started followed by Levophed and then right common femoral artery access was obtained for intra-aortic balloon pump placement that was done under fluoroscopic monitoring and patient had excellent augmentation and good response to the inotropic support as well as the balloon pump and we will continue to monitor due to her body habitus and light weight and follow was deemed high risk due to high risk of vascular complications
Interventions: Judkins right guiding catheter was inserted the wire was advanced across the 100% occluded RCA 2.0 noncompliant balloon was used to predilate the vessel then a 2.25 x 38 mm Synergy stent was deployed at 12 atm abolishing 100% lesion in the long segment of the RCA down to 0% TIMI-3 flow pre and post and no evidence of complications
After the procedure was completed, sedation was stopped and the sheaths and catheters were all removed. Hemostasis was achieved with : TR band
Findings:
DAPT Duration Brilinta for minimum of 1 year and then followed by Plavix no dual antiplatelet therapy due to anaphylaxis to aspirin
Disposition: Telemetry hemodynamically stable
Condition: stable
Treatment: guideline driven medical treatment for cardiogenic shock coronary artery disease hyperlipidemia smoking cessation, DAPT Duration no dual antiplatelet therapy due to anaphylaxis to aspirin will maintain Brilinta for minimum 1 year.
I NEED A LITTLE ASSISTANCE WITH THE FOLLOWING CASE!
Clinical Indication: STEMI
Anginal Classification: IV
Access: Right Femoral, Right Radial
ASA Class: 4
1.The nature and character of the proposed treatment or procedure
2.The anticipated results
3.Possible recognized alternative methods of treatment, including non- treatment
4.Recognized serious possible risks, complication, and anticipated benefits involved in proposed and alternative treatments including non-treatment
5.Questions were answered to the patient's satisfaction
6.patient/family accepted plan for sedation Yes
PCI Patient Non-Selection Criteria
This form must be completed for ALL PCI patients.
Patient was evaluated for and does not meet the non-selection criteria; therefore PCI is indicated and will be initiated at _____ without surgical backup.
Patient was evaluated for the non-selection criteria (please check the following as appropriate to the patient’s condition) and PCI will NOT be performed at this facility).
>50% diameter stenosis of left main artery proximal to infarct-related lesion, especially if the area in jeopardy is relatively small and overall LV function is impaired.
Long, calcified, or severely angulated target lesions at high risk for PCI failure with TIMI flow grade 3 present during initial diagnostic angiography.
Lesions in areas other than the infarct artery (unless they appear to be flow limiting in patients with hemodynamic instability or ongoing symptoms).
Lesions with TIMI flow grade 3 in patients with left main or three vessel disease.
Culprit lesions in more distal branches that jeopardize only a modest amount of myocardium when there is more proximal disease that could be worsened by attempted intervention.
Chronic total occlusion.
Other comment:_____________________________________________________________________
Syntax score:
PROCEDURE
- Emergent temporary pacemaker placement via right femoral vein access for complete heart block in the set up of acute myocardial infarction.
- Emergent cardiac catheterization/coronary angiography.
- Successful PCI of 100% occluded RCA/infarct-related artery
- Intra-aortic balloon pump insertion for cardiogenic shock via right common femoral vein.
- Resuscitation for cardiac arrest using CPR and cardioversion x3 for ventricular fibrillation
- ““Conscious sedation was administered by qualified nursing personnel under continuous hemodynamic monitoring, Duration 40 Min,
- A total 25mcg of fentanyl and 0.5 mg midazolam were administered.”
- Air kerma (mGy): 42
- Complications: None, patient tolerated the procedure well.
- Final ACT: 308
- Estimated Blood Loss: less than 5 mL
- Contrast: 80
- Hydration:1000
Procedure Details
The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient and/or family concurred with the proposed plan, giving informed consent. Patient was brought to the cath lab after IV hydration was begun and oral premedication was given. Patient was further sedated with fentanyl and versed. Patient was prepped and draped in the usual manner. Using the modified Seldinger access technique, a 6 French sheath was placed into the right common femoral vein and a balloontipped pacemaker was directed under fluoroscopy into the right ventricle to achieve pacing for severe bradycardia and intermittent complete heart block then a 6 French French sheath was placed in the right radial artery after getting access patient went into torsades with polymorphic ventricular tachycardia that became ventricular fibrillation requiring cardioversion this recurred twice and patient was cardioverted with 200 J each time then 300 mg of IV amiodarone was given. A left heart catheterization was done. Right and Left Coronary Angiograms were also done. Due to significant hypotension with blood pressure in the 40s and as the patient was in fulminant cardiogenic shock dopamine was started followed by Levophed and then right common femoral artery access was obtained for intra-aortic balloon pump placement that was done under fluoroscopic monitoring and patient had excellent augmentation and good response to the inotropic support as well as the balloon pump and we will continue to monitor due to her body habitus and light weight and follow was deemed high risk due to high risk of vascular complications
Interventions: Judkins right guiding catheter was inserted the wire was advanced across the 100% occluded RCA 2.0 noncompliant balloon was used to predilate the vessel then a 2.25 x 38 mm Synergy stent was deployed at 12 atm abolishing 100% lesion in the long segment of the RCA down to 0% TIMI-3 flow pre and post and no evidence of complications
After the procedure was completed, sedation was stopped and the sheaths and catheters were all removed. Hemostasis was achieved with : TR band
Findings:
| Hemodynamics | Did not cross the aortic valve due to frequent ventricular arrhythmia |
| Left Main | Patent |
| LAD | Diffuse disease in the LAD with a moderate stenosis in the proximal to mid segment diffusely diseased diagonal arteries small caliber vessels |
| RCA | 100% occluded proximally |
| Circ | Moderate disease in the midsegment but no focal lesions |
| Vessel dominance | Dominance: Right |
| Lesion type | |
| Interventions/Vessels | |
| Anticoagulants | |
| Guiding Catheter used | |
| Pre % Stenosis and TIMI flow | |
| Post % Stenosis and TIMI flow |
| Lesion Length:38 mm | ||
| Thrombus Present: yes | ACC Type: B1 | |
Stent evice | Diameter: | Length: |
Disposition: Telemetry hemodynamically stable
Condition: stable
Treatment: guideline driven medical treatment for cardiogenic shock coronary artery disease hyperlipidemia smoking cessation, DAPT Duration no dual antiplatelet therapy due to anaphylaxis to aspirin will maintain Brilinta for minimum 1 year.