One of the things I wish I had better training on prior to my first Technologist position is OR procedures. Sure, most Radiography Programs give you some exposure to them, but it is unrealistic to place the expectation on a clinical rotation in your x-ray program to make you a certified guru on these procedures... and just because you can operate a majority of the features on a c-arm, it doesn't mean that you understand HOW the procedure goes, WHAT to look for, -WHEN to move the c-arm in, WHERE to center, WHO all the people are in the room and WHY they are there.
Let's break it down for a pacer insertion. Examine the pre-op film taken the day of the procedure:
You can tell that this patient has had a history of cardiac pathology. They have had a CABG - often referred to as a "cabbage" and stands for Coronary Artery Bypass Graft. This means that one of the blood vessels supplying the heart (coronary arteries) had once become occluded severely enough to block blood flow to the heart causing a heart attach (Myocardial Infarction - MI). The visual giveaway is the metal wiring that looks like twist-ties. These are placed around the sternum after open-heart surgery to mend the sternum that must be sawed through to access the mediastinum... but that's not what this post is about.
You will be asked for live fluoro during pacer insertions to assist the Cardiologist with positioning of the pacer leads. Remember the electrical conduction system in the heart? Conduction between the AV (atrioventricular) node and the SA (sinoatrial) node can sometimes fail, causing an abnormal heart rhythm, hence the need for an artificial device to assist with providing the heart with a normal "pace" for beating.
So why does the Physician need you? Without fluoro, they cannot see where the leads are being placed. It is imperative that one lead be placed in the right atrium and the other be placed in the right ventricle. Here's what you need to do:
Before the Doctor asks for fluoroscopy, you will know which side he is going to place the pacer (right or left). You will most likely come in the opposite side with the c-arm. In this occasion, the Physician inserted a pacer on the patient's left side. So when prompted, go ahead and center over the subclavian vein on the side the MD is working:
The Physician will need to insert each of the two leads separately, and there should also be a Sales Representative in the room from the device company that manufactures the pacemaker. The Physician and the Sales Rep will always be in constant communication about which lead is being inserted first because what they do requires active monitoring of heart function and good communication. Just listen to their conversation in order to find out which lead is going in first. This will have an impact on where your centering should be with the fluoroscope.
So why are we centering at the subclavian? Well, you know that the body's vasculature has many branches, and without fluoro, the Physician could take a "wrong turn" with the lead, which could potentially be life-threatening if inserted too far through the wrong vessel. This is why it is imperative to be ready to bring the c-arm in when he begins running the leads. Where could they go? Here's a picture of possible routes; green means that's where the Physician SHOULD be going, and red is where he SHOULDN'T go:
The most serious of these directions is toward the head. The blood vessels get small really fast once the lead starts travelling north. It would be easy to perforate a vessel if pushed too far. Pay attention to your image as the Cardiologist is advancing the lead. If the lead starts going up the neck, make sure to tell him because he may not be looking at the monitor in that split second that the lead turns (and you might be the only one in the room looking at it). Keep in mind that everyone in the room is multi-tasking, so don't assume that 100% of anyone's attention is on your fluoro screen.
You shouldn't really have to move the c-arm too much until the lead turns the corner to the south and heads down the IVC (inferior vena cava) and into its appropriate chamber. Anticipate this movement because the Cardiologist NEEDS to see where the lead is going. If you have let the lead go below your field of view, you are not doing your job well. This is important because as soon as the lead enters the heart, it can cause variations in sinus rhythm as it rubs the inner wall of the heart muscle. Once the first lead is anchored, or "screwed" into the heart muscle, re-center as before and follow the same procedure. Here's the final saved image from the c-arm:
Notice the outline of the heart, as well as the Atrail and Ventricular Lead positions. During live fluoro, these may blur due to the heart motion, so make sure to fluoro for at least a second when the Doctor wants to see placement. If you simply "spot" check, it might be so blurry that you can't see the tips. Here is a portable chest x-ray done after the procedure and insertion of the pacer device under the skin (but outside the ribs):
Sometimes the Physician will require an image in PACU (Post-Anesthesia Care Unit), and sometimes not. But equally important is if a 2-view chest x-ray is ordered within the next few days of the procedure. Remember how I mentioned that the leads are "screwed" into the heart muscle? The Physician will typically place a sling around the patient's neck holding the arm in place (on the side of the pacer insertion - left in this case). This is because any extreme motion of that arm may dislodge the screws in the leads. This is bad news - the surgery will have to be performed again if this happens and until it's completed, the lead may impair heart rhythm. This is why it is important to AVOID raising the arms for a lateral chest x-ray after a pacer insertion. Check with your facility's protocols to see if you are required to wait a certain number of hours or days before doing so, and encourage the patient not to raise their arms, even if they feel like they can. A 45 degree wedge sponge may be used under the patient's affected elbow to move the arm out of the way if a 2-view is absolutely required, but no lifting should occur.
Let's break it down for a pacer insertion. Examine the pre-op film taken the day of the procedure:
You can tell that this patient has had a history of cardiac pathology. They have had a CABG - often referred to as a "cabbage" and stands for Coronary Artery Bypass Graft. This means that one of the blood vessels supplying the heart (coronary arteries) had once become occluded severely enough to block blood flow to the heart causing a heart attach (Myocardial Infarction - MI). The visual giveaway is the metal wiring that looks like twist-ties. These are placed around the sternum after open-heart surgery to mend the sternum that must be sawed through to access the mediastinum... but that's not what this post is about.
You will be asked for live fluoro during pacer insertions to assist the Cardiologist with positioning of the pacer leads. Remember the electrical conduction system in the heart? Conduction between the AV (atrioventricular) node and the SA (sinoatrial) node can sometimes fail, causing an abnormal heart rhythm, hence the need for an artificial device to assist with providing the heart with a normal "pace" for beating.
So why does the Physician need you? Without fluoro, they cannot see where the leads are being placed. It is imperative that one lead be placed in the right atrium and the other be placed in the right ventricle. Here's what you need to do:
Before the Doctor asks for fluoroscopy, you will know which side he is going to place the pacer (right or left). You will most likely come in the opposite side with the c-arm. In this occasion, the Physician inserted a pacer on the patient's left side. So when prompted, go ahead and center over the subclavian vein on the side the MD is working:
The Physician will need to insert each of the two leads separately, and there should also be a Sales Representative in the room from the device company that manufactures the pacemaker. The Physician and the Sales Rep will always be in constant communication about which lead is being inserted first because what they do requires active monitoring of heart function and good communication. Just listen to their conversation in order to find out which lead is going in first. This will have an impact on where your centering should be with the fluoroscope.
So why are we centering at the subclavian? Well, you know that the body's vasculature has many branches, and without fluoro, the Physician could take a "wrong turn" with the lead, which could potentially be life-threatening if inserted too far through the wrong vessel. This is why it is imperative to be ready to bring the c-arm in when he begins running the leads. Where could they go? Here's a picture of possible routes; green means that's where the Physician SHOULD be going, and red is where he SHOULDN'T go:
The most serious of these directions is toward the head. The blood vessels get small really fast once the lead starts travelling north. It would be easy to perforate a vessel if pushed too far. Pay attention to your image as the Cardiologist is advancing the lead. If the lead starts going up the neck, make sure to tell him because he may not be looking at the monitor in that split second that the lead turns (and you might be the only one in the room looking at it). Keep in mind that everyone in the room is multi-tasking, so don't assume that 100% of anyone's attention is on your fluoro screen.
You shouldn't really have to move the c-arm too much until the lead turns the corner to the south and heads down the IVC (inferior vena cava) and into its appropriate chamber. Anticipate this movement because the Cardiologist NEEDS to see where the lead is going. If you have let the lead go below your field of view, you are not doing your job well. This is important because as soon as the lead enters the heart, it can cause variations in sinus rhythm as it rubs the inner wall of the heart muscle. Once the first lead is anchored, or "screwed" into the heart muscle, re-center as before and follow the same procedure. Here's the final saved image from the c-arm:
Notice the outline of the heart, as well as the Atrail and Ventricular Lead positions. During live fluoro, these may blur due to the heart motion, so make sure to fluoro for at least a second when the Doctor wants to see placement. If you simply "spot" check, it might be so blurry that you can't see the tips. Here is a portable chest x-ray done after the procedure and insertion of the pacer device under the skin (but outside the ribs):
Sometimes the Physician will require an image in PACU (Post-Anesthesia Care Unit), and sometimes not. But equally important is if a 2-view chest x-ray is ordered within the next few days of the procedure. Remember how I mentioned that the leads are "screwed" into the heart muscle? The Physician will typically place a sling around the patient's neck holding the arm in place (on the side of the pacer insertion - left in this case). This is because any extreme motion of that arm may dislodge the screws in the leads. This is bad news - the surgery will have to be performed again if this happens and until it's completed, the lead may impair heart rhythm. This is why it is important to AVOID raising the arms for a lateral chest x-ray after a pacer insertion. Check with your facility's protocols to see if you are required to wait a certain number of hours or days before doing so, and encourage the patient not to raise their arms, even if they feel like they can. A 45 degree wedge sponge may be used under the patient's affected elbow to move the arm out of the way if a 2-view is absolutely required, but no lifting should occur.
No comments:
Post a Comment