1. Huber, Charlotte MSN, RN


The Pennsylvania Patient Safety Authority's reporting system is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, and birthing centers, as well as some abortion facilities, must file information on medical errors.


Safety Monitor is a column from the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit For the original article discussed in this column or for other articles on patient safety, click on "Patient Safety Advisories" and then "Advisory Library" in the left-hand navigation menu.


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Cardiac catheterization is recommended in high-risk patients with cardiac disease and unstable angina.1 But it's an invasive procedure that carries a risk of complications2; nearly half of the medical errors reported to the Pennsylvania Patient Safety Authority's reporting system between June 2004 and December 2006 were complications of cardiac catheterization. Many were vascular complications associated with the access site, including bleeding and hematoma, retroperitoneal bleeding, pseudoaneurysm, and arteriovenous fistula. The most common causes of these complications were medication errors, inconsistencies in patient assessments, unrecognized changes in a patient's condition, unintentional sheath removal, and a lack of appropriate intervention.


Some complications occurred during the transfer of patients after cardiac catheterization or because they weren't recognized as they developed, resulting in delayed or inadequately provided care. Here are two examples:


* [After a patient care unit nurse called the cardiac catheterization laboratory because of groin bleeding following cardiac catheterization,] nursing [was] told to hold pressure [at the site of catheterization] until staff from catheterization laboratory [was] available. On arrival to unit, no one was holding pressure to a hematoma of [the] right groin.


* [Following cardiac catheterization, the patient's] right groin site had [blood] oozing, and the left groin site had a hematoma. The hematoma was noted to increase in size. The heart center was called and came to the unit. During the assessment of the hematoma, the patient's blood pressure dropped to 41/25 mmHg. The patient was placed in [the] Trendelenburg [position] and was given IV fluid bolus; the blood pressure increased to 86/51 mmHg. The physician was notified, and the patient was transferred to a critical care unit for observation.



Several factors can influence the risk of developing vascular complications during or after cardiac catheterization. These include patient characteristics, the interventional cardiologist's technique, medications used during catheterization, the use of manual or mechanical compression at the access site, the use of closure devices, and the quality of nursing care.2 The following strategies may help to minimize complications after catheterization.


Identify patients at risk. Older adults, women, and patients with renal failure are at higher risk for vascular complications.3, 4 So are patients who are overly thin or morbidly obese or have "severe peripheral vascular disease, severe systolic hypertension,"2 a low baseline platelet count and hematocrit level, congestive heart failure, chronic obstructive pulmonary disease, or coagulopathy.3, 4


Use anticoagulants before and after catheterization to prevent thrombosis. Nurses administering "high-alert" (most dangerous) anticlotting medications before, during, and after cardiac catheterization should be familiar with the drugs' classification, mechanisms of action, correct dosing, and potential adverse effects. Verbal and written communication are important: make sure other team members are aware of the types of medication administered, the doses and times given, and the patients' reaction to the drugs.


Maintain hemostasis at the access site until coagulation occurs.5 This can reduce complications, increase patient safety and comfort, and shorten hospital stay. Current methods include manual compression of the site, deployment of a vascular closure device, or both.2, 6 For more information see "Strategies to Minimize Vascular Complications following a Cardiac Catheterization" in the June 2007 Patient Safety Advisory, available online at


Ensure high-quality nursing care. Administrative and nursing leaders can provide relevant educational seminars, offer patient care practice in simulation labs, and assess the competency of nurses caring for patients undergoing cardiac catheterization.7, 8 They can also consider establishing specialty units for cardiac-catheterization patients to improve their safety and care.



The frontline nurse caring for patients before, during, and after cardiac catheterization has an important role in preventing and recognizing complications. Consider incorporating the following elements into your nursing protocols and practice.


* After sheath removal, apply consistent pressure to the access site until you achieve hemostasis. This should take 20 to 30 minutes with manual compression-more time if mechanical compression devices are used.5, 7, 9


* Monitor vital signs and assess the site. Although opinions on how often to check vital signs after sheath removal vary, some sources suggest frequent initial assessments until the patient is stabilized.10, 11 During the assessment, palpate the site and assess temperature, color, pulses, and any discomfort present in the extremity used for access.


* After interventional catheterization, once hemostasis occurs ensure bed rest for two to six hours.8, 11 After diagnostic catheterization, once hemostasis is maintained ambulate patients for one hour.9


* Elevate the head of the patient's bed to 30[degrees].11


* Assess for a bruit, which indicates a condition in which vascular flow is compromised, such as pseudoaneurysm or arteriovenous fistula.7


* Document site assessment findings, including hematoma size (measured in centimeters); hematoma characteristics (such as soft or firm); skin color and temperature; and the presence of pedal pulses, bruits, or both.


* Provide both verbal and written patient education to explain the procedure, any common complications, and methods to prevent bleeding. Written materials should emphasize important actions patients can take, such as when to call the nurse for immediate assistance.



The rising number of cardiac catheterizations performed and advances in pharmaceuticals and technology mean that nurses need to be ever more vigilant in assessing for vascular complications in post-cardiac catheterization patients. Nurses can help to develop protocols and policies to ensure a consistent approach to the care of patients undergoing cardiac catheterization in their facility.




1. Scanlon PJ, et al. ACC/AHA guidelines for coronary angiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography) developed in collaboration with the Society for Cardiac Angiography and Interventions. Circulation 1999;99(17):2345-57. [Context Link]


2. Bashore TM, et al. American College of Cardiology/Society for Cardiac Angiography and InterventionsClinical Expert Consensus Document on cardiac catheterization laboratory standards. A report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2001;37(8):2170-214. [Context Link]


3. Dumont CJ, et al. Predictors of vascular complications post diagnostic cardiac catheterization and percutaneous coronary interventions. Dimens Crit Care Nurs 2006;25(3):137-42. [Context Link]


4. Kuchulakanti PK, et al. Vascular complications following coronary intervention correlate with long-term cardiac events. Catheter Cardiovasc Interv 2004;62(2):181-5. [Context Link]


5. Jones T, McCutcheon H. Effectiveness of mechanical compression devices in attaining hemostasis after femoral sheath removal. Am J Crit Care 2002;11(2):155-62. [Context Link]


6. Vaitkus PT. A meta-analysis of percutaneous vascular closure devices after diagnostic catheterization and percutaneous coronary intervention. J Invasive Cardiol 2004;16(5):243-6. [Context Link]


7. Smith TT, Labrilola R. Developing best practice in arterial sheath removal for registered nurses. J Nurs Care Qual 2001;16(1):61-7. [Context Link]


8. Tagney J, Lackie D. Bed-rest post- femoral arterial sheath removal-what is safe practice? A clinical audit. Nurs Crit Care 2005;10(4):167-73. [Context Link]


9. Doyle BJ, et al. Ambulation 1 hour after diagnostic cardiac catheterization: a prospective study of 1009 procedures. Mayo Clin Proc 2006;81(12):1537-40. [Context Link]


10. Beattie S. Cut the risks for cardiac cath patients. RN 1999;62(1):50-4. [Context Link]


11. Scheffer K. Are post-procedural nursing interventions ritualistic practice or evidence-based? Images / American Radiological Nurses Association 2003;22(3):9-12. [Context Link]