How to prepare for cath lab complications
Interventional procedures can be stressful to begin with, but patient complications requiring immediate action quickly elevates that stress. And although complications can be rare, all cath lab employees need to be prepared.
The guiding principle is simple: “Be ready so you don’t have to get ready,” explained Kenzie Thompson, BSN, RCIS, a cardiovascular invasive specialist at St. Luke’s Mid-America Heart Institute, who spoke on the topic in a session at TCT 2024, the annual Transcatheter Cardiovascular Therapeutics (TCT) meeting. She urged cath lab teams to embrace a culture of readiness to manage emergencies.
“If you know you are going to have a complex case on the table, five minutes before the case even starts, go in and make sure that you have appropriate sizes for each vessel,” she said. “It’s almost like waving sage around the room, but you wave the covered stents around to get the bad juju out.”
Thompson explained that downtime in the lab should be used to anticipate rare but potentially catastrophic complications. She said cath lab teams also can run mock emergency drills and review inventory to ensure that essential equipment is available, in-date, and properly sized for the procedure at hand.
Common but critical cath lab complications
Thompson highlighted several scenarios that can escalate quickly if staff are unprepared, noting that access site bleeding following a groin puncture is the most frequent complication.
“Manual pressure is still the gold standard,” she emphasized, even when closure devices are used or are available.
Perforations, dissections, distal embolizations, loss of a device in the vessel, sedation issues and contrast allergy reactions are among some other big complications. The list also includes radiation burns, acute kidney injury, fluid overload and embolization leading to critical limb ischemia.
Perforations and dissections can dramatically increase in-hospital mortality, Thompson said. She has also seen contrast dye reactions, which can trigger unexpected cardiac instability.
She urged staff to remain vigilant for subtle warning signs and to speak up, even in high-pressure moments when physicians are focused on a procedure.
“It is your responsibility to be the patient’s advocate,” Thompson said. “We, as the nurses and technologists, have to speak up when we see something that isn’t right.”
Teamwork and training in the cath lab
While interventional cardiologists are trained extensively to manage complications, Thompson noted that cath lab nurses and technologists often encounter these events for the first time on the job. Because there is no standardized simulation program, much of the training happens in real-world scenarios.
“A lot of my pearls of wisdom come from moments when we weren’t prepared, or when mistakes were made,” Thompson said. “I like to share those experiences so others can be better prepared.”
She also stressed the importance of cross-training staff to understand different roles. Nurses who scrub and technologists who circulate should be familiar with emergency equipment and medication protocols, even if they are not the ones administering drugs.
"We've all worked together long enough that the mixture of teams really starts to bring out the strengths of certain team members and we become very, very cohesive. And we've all been in those really crummy situations and been able to see how the other person works. When we get the new person, its kind of a little rut in our little dance that we have, but we train 'em up and they dance just as beautifully as the rest of us," Thompson explained.
She also warns against assuming something will go as planned, because the team will be caught off guard if something unexpected happens.
"One of the favorite sayings across cath labs is, 'it's just a right heart.' Well, what's going to happen with that wedge catheter or that Swan-Ganz catheter? We are still in somebody's body with a foreign piece of equipment, and everything could go wrong. So you have to be prepared," she explained.
Building confidence to address complications through education
Beyond in-lab drills, Thompson encouraged peers to take advantage of educational opportunities, whether through national conferences like TCT or by working with industry clinical specialists during downtime. Cath lab nurses and technologists also like to be able to see, handle and train on equipment, devices and models outside of the lab.
At sessions on complications at interventional cardiology meetings, Thompson said it is good to hear how physicians and teams handled different emergency complications.
"You can learn so much and you learn that sometimes the physicians are just as scared as you are in those vulnerable scary moments where the patient's crashing. So I think that's really good for everybody to see.
Thompson also explained that a lot of people are scared to ask their physicians questions because they do not want to bother them, but she said that is how teams can be better prepared.
"I promise you, that physician is going to be much happier with you being well-rounded and knowledgeable ... when you're confident, when they trust you to take care of their patients, it makes life so much easier," she said.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]