Document # GAMH / CCUM

Revision # 01
Critical Unit and Edition # 01
Cath Lab; Non Invasive Procedures Date of Issue: 08/12/2024
Manual Page 1 of 39

Approval and Amendment Sheet

Amend- Release Date Page Reason for Amendment Details Remarks

ment # No. Amendment
- -

- -
 Document # GAMH / CCUM
Revision # 01
Critical Unit and Edition # 01
Cath Lab; Non Invasive Procedures Date of Issue: 08/12/2024
Manual Page 2 of 39

Prepared & Issued By: Reviewed By : Approved By:

Management Representative Medical Superintendent Executive Director
Name: Name: Name:

Signature: Signature: Signature:

Date: Date: Date:

 Document # GAMH / CCUM
Revision # 01
Critical Unit and Edition # 01
Cath Lab; Non Invasive Procedures Date of Issue: 08/12/2024
Manual Page 3 of 39

S. SOP / Policy Standard

Title Page No.
No. Reference Reference
Cover Page
Approval and Amendment Details
Table of contents
Organization, Role & Responsibity
Organization Chart
Job Descriptions
Departmental Objectives
Cath Laboratory Procedure
Admission to Cardiac catheterisation
labError: Reference source not found
In the Catheterisation laboratory
Post Procedure
Maintenance of Catheterization lab
equipment
Radiology Process
Radiology Safety Guide Lines
Radiology Guide Lines T L D Badges
Cath Lab - CAG & Other procedures’
Protocols
Diagnostic Support – Invasive & Non
invasive Cardiology, Pulmonology
Diagnostic processes
Waste Management Process
Job responsibilities for Nurses
Special Instructions - Pharmacy & Stores
indent
Critical care general and equipment cleaning
protocols

Blood Bank Requisition instructions & Safe

Transfusion practices
Sample Collection Protocol

Services of the Hospital

Registration & Admission Policy
Transfer or referral Policy
Education & making informed consents
 Document # GAMH / CCUM
Revision # 01
Critical Unit and Edition # 01
Cath Lab; Non Invasive Procedures Date of Issue: 08/12/2024
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Policy
Initial Assessment Policy
Protection of Patients & Family Rights
Patient’s Beliefs/Values in Decision Making
Patient’s Right to Information, Education. &
Expected
Quality Record Matrix
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Revision # 01
Critical Unit and Edition # 01
Cath Lab; Non Invasive Procedures Date of Issue: 08/12/2024
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Organizational Chart:

I.
Head Cardiology

Senior Consultant

Junior Consultant

Technical Incharge Nurse Manager

Technician / Jr Technician Sister-in-charge / Staff Nurse

Supportive staff

Job Descriptions:

Job Title : Circulating Nurse

Department : Nursing
Reporting to : Nursing Supervisor
Job location : Hospital Wide
Timing : As per shift

Duties and Responsibility:

 Help the patient in shifting to the table and from the table.
 Connect all I.V. lines, electrodes, syringe pumps, infusion and make sure the patency of lines.
 If infusions are about to finish, prepare a fresh one and keep.
 Make sure the patient is comfortable on the table
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Critical Unit and Edition # 01
Cath Lab; Non Invasive Procedures Date of Issue: 08/12/2024
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 Make ready availability of all the emergency drugs, additional items needed for the case.
 Deliver the required items to the doctor/scrubbed nurse
 Watch and monitor patient’s condition and act accordingly by giving O2, I.V. injections. Emergency
shock, CPR etc.
 Complete consumable register, make all entries in stock register
 Shifting out of patient and handing over to the receiving sister.

Post Procedure responsibility of scrub nurse

 Tell the patient that the procedure is over
 Clean up the area by collecting lines, connections, instruments and articles.
 Stitch sheath with sin, if needed.
 Put a sterile dressing over it
 Fix with dynaplast
 Tell the circulating nurse to stay with the patient till patient is shifted back.
 Count the instruments
 Segregate them and discard waste materials as per protocol.
 Wash, rinse, dip them inside rapid M solution
 Come back to the patient for sheath removal.
 Bring complete articles in one stretch and remove sheath
 Make sure of – no hematoma, no bleeding.

Departmental Objectives:
Lay Out
The Cardiac cauterization lab is a centralized unit with the following facilities-
 Procedure room - One
 Control room - One
 Storage area (cath lab store)
 Patient Holding Area
 Clean utility area
 Staff locker/lounge area
N.B- The procedure room and control room are adjacent to each other, with storage space as well as the
clean area located within the immediate cardiac catheterization area
Procedure Room: The catheterization laboratory procedure rooms have ample space for the equipment, in-
room storage and movement of the patient into and out of the room via stretcher or patient bed
The storage area consists of-
 In-room storage cabinetry
 Standing height counter space
Scrub sink is located immediately outside the procedure room.
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There are also adequate electrical sockets, gas and suction outlets.
Doors leading to the procedure rooms are extra wide to facilitate easy movement of stretchers/ patient’s bed.
Equipment Storage Space The equipment storage space in the procedure area shall be lined with an
electrical power strip to allow for multiple plug access to keep any battery powered/charging equipment
accessible. The equipment storage area should also be configured with cabinetry to hold catheters, guiders,
balloons, stents and guide wires
Control Room: The room is of adequate size to allow staff movement and required equipment which are
 Imaging control panels and hardware
 The window of the catheterisation lab is large
 The control room also have computer LAN connections for further installation of computer
terminals and a phone line
Patient Holding Area: Patients are kept in the cath CCU before & after procedure.
Family Waiting Area: There will also be a family waiting area that will be in close proximity to the
procedure room. This will allow the family to feel they are close to the patient and makes it easier for the
cardiologist to visit the family post procedure to explain procedure results and treatment options.
Clean area: the clean area shall store-
 Scrub area
 Lead Aprons
 Other stock items
Statutory requirements
Catheterization lab being an area affluent in radioactive emissions; guidelines laid down by AERB shall be
strictly followed and monitored
Responsibilities of the Cath Lab Technician before catheterization.
1. Boot computers, air-conditioning adequate and humidity factors normal.
2. Check all other Cath lab equipment like defibrillator, pressure monitors, transducers, IABP,
temporary pacemaker, pressure injectors, ACT monitors, etc.
3. Ensure in Cath Lab Register
– That the list of Cath lab cases booked is in order
– Call concerned consultant permission to start and the patient identity confirmed.
– Ask Cath lab sister to shift patient to Cath lab.
4. In the Cath Lab Reception area, check all investigation reports of the patient like HBsAg, HIV
status, renal parameters, and consent for procedure.
5. Send blood for cross matching if patient to undergo angioplasty.
6. Other activities
– Procurement of stocks and maintaining records in stock registers for stents, diagnostic items,
balloons
– Records for equipment maintenance
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– Maintaining Patient Data Register and preparation of monthly reports of number and type of
procedures
– Consumption reports of hardware used annually
Equipment
The cath lab is equipped with DSA (Digital Subtraction Angiography) to perform cardiac cauterization
and peripheral vascular catheterization.
The following equipments are used in the Catheterization lab
 Cardiac Digital Imaging,
 Angiogram,
 Cath Lab Diagnostic Equipment, ,
 Cath Lab Imaging System,
 Cath Lab Monitoring System,
 Cardiac Catheterization Monitor,
 Echocardiogram (on call)
 Cardiovascular Ultrasound (on call)
Other items used are- Stents and Balloons & catheters of various sizes and other hardware related with
various procedure.
Stents shall be discarded as per biomedical waste handling rules after use and balloons shall be washed and
sent to the CSSD for ETO sterilisation
Balloons used are reusable and shall be reused for a maximum of 5-6 times
Catheterisation Laboratory

1.0 Introduction
Cardiac catheterization is a procedure where a small plastic catheter is placed within a large artery in
your leg and advanced to your heart. This technique is used to take pictures of the arteries of the heart
and the pump function of the left ventricle. The procedure provides the most detailed and accurate
information on the anatomy of the coronary arteries. Cardiac catheterization is necessary before a
decision can be made about bypass surgery or coronary angioplasty. On occasion, for instance, when the
arteries to the legs are blocked, the procedure is carried out through an artery in the elbow crease or
wrist.
This procedure is called an “invasive cardiac procedure” because tubes are actually placed within the
body. The procedure is, however, relatively painless. Local anaesthetic is given before insertion of the
catheters. You may feel pressure as the catheter is inserted. You may feel a warm sensation throughout
your body when the x-ray dye is injected to obtain the pictures. The procedure generally lasts for one-
half hour. After the procedure you will be asked to lie still for four hours to allow the puncture site in the
groin to heal.
There are certain risks involved in cardiac catheterization. These include an approximate 2/1000 risk of
serious complications such as heart attack or stroke
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Critical Unit and Edition # 01
Cath Lab; Non Invasive Procedures Date of Issue: 08/12/2024
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2.0 Admission for Cardiac cath

2.1 Patients needing cardiac cath care
 Taken directly as an emergency from Emergency Room
 Shifted from CCU
 Seen in Cardiac OPD and planned for cardiac catheterization after admitting in ward
2.2 In emergency the patient is rushed to cath lab and admission done in parallel
2.3 In the planned scenario, patient is admitted in the CCU (using Registration & In Patient Admission
Process ) & patient has already been scheduled in the Cardiac cath lab list, using format RH/CCU/F
2.4 Patient’s name on the cath lab list and time of call confirmed
2.5 Doctor on duty in the cardiac ward informed
2.6 Clinical bed side evaluation / investigations as per ‘pre catheterisation investigations protocol’, if not
already done, is completed. Patient is prepared as per ‘pre catheterisation patient preparation
protocol’
2.7 Call for patient from Cath lab half an hour before procedure & Patient shifted to cath lab
3.0 Pre catheterisation Investigation
For Elective Cases a variety of investigation that provide complete information of health and identify
any potential problems and avoid potential complications.
If special instructions are required before any of these tests are explains what to do before the tests.
Blood tests
The blood is sent to a lab where the following tests are performed:
 CBC
 KFT
 PT/ INT
 RBS
 HIV/HCV/ HBY
 CEA
 CMV IgM
 CRP
 Skin tests for infection
 Varicella
 Metabolic panel
 CMV IgG
 EBV
 Herpes
 Humoral immune panel
 Syphilis
 Toxoplasmosis
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 WSR
 TSH
Chest x-ray: A chest X-ray provides a picture of your heart and lungs. This X-ray provides
information about the size of heart and lungs, and the extent of lung disease.
Lung tests
Pulmonary function tests: Pulmonary function tests measure the capacity and function of your
lungs, as well as your blood’s ability to carry oxygen. During the tests, you will be asked to breathe
into a device called a spirometer.
A complete set of pulmonary function tests lasts from 1½ to 2 hours. You will have time to rest
briefly between tests.
You will need pulmonary function tests throughout your illness to:
 Evaluate how your lungs process oxygen and carbon dioxide
 Determine the severity of your lung disease
 Determine how your lung disease is advancing (This is done by comparing test results from each
pulmonary function test.)
 Decide the best treatment for your lung disease
Here are some guidelines to follow before your scheduled pulmonary function tests:
 Be sure to get plenty of sleep the night before your scheduled test.
 Plan to wear loose clothing during the test so you can give your greatest breathing effort.
 Limit your liquids and eat a light meal before the test. Drinking or eating too much before the test
might make you feel bloated and unable to breathe deeply.
Following Non Invasive Tests are performed
 2 D Echocardiography
 Stress Echocardiography
 Electrocardiogram (ECG)
 Treadmill Test (TMT)
 Trans esophageal echocardiography (TEE)
 Head up tilt test (HUTT)
 Holter Monitoring
 Pacemaker Programming
4.0 In the Catheterisation laboratory
 Patient received in Cath lab (all procedures as per cath lab operations protocol) reception area
 Entry of patient’s name and other demographic details in Cath Lab Patient Register, as well as
computer.
 Patient shifted on to cath lab table, monitors attached. Pre procedure photograph taken for record.
 Acquire patient’s angiography & all important pressures on record medium. Provide hardware
according to the procedure.
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 Cath lab procedure like coronary angiography or angioplasty done (all patient handling as per cath
lab protocols)
 Transfer the recorded angiography on CD and store as hard copy (CD given on patient’s demand
either by Billing or Cardiologist’s PA).
 Post cath orders (in printed form) attached, consisting of post cath observation and care details
 Write all pressures and hardware used during the procedure in the Cath Lab Patient Register against
patient’s name. Issued hardware entered against patient’s name in ‘Stock Register’ the same day.
 Post catheterisation procedure, the patient is evaluated clinically and wound site examined
 Billing for procedure done on computer and one copy kept in file and one copy sent to Billing
department.
Patient then shifted to ward or CCU depending on the condition of the patient.
5.0 Post Procedure
 Consultant Cardiologist issues Post catheterisation orders (in printed form), consisting of
Post catheterisation observation and Care details
 Post catheterisation procedure, the patient is evaluated clinically and wound site examined by the
senior resident/ cardiology fellow or doctor on duty.
 The catheterisation lab nurse then shifts the patient to the cath CCU/ emergeny depending on the
condition of the patient.
 Cardiology fellow/Senior resident thereafter does the Pre discharge evaluation from cath CCU. The
treating doctor advises shifting if the patient is fit for so.
 Lab is prepared for the next patient
 After the procedure all dirty linen is picked up and placed in laundry basket in the dirty linen area
and sent periodically to Laundry by the Laundry HM. Floors are cleaned.
 Catheterisation lab technician cleans the table, all opened disposables, drugs, etc. as per
catheterisation lab protocol
 Catheterisation lab instruments and any sutures, on the instrument trolley are segregated; waste
disposed off as per guidelines; instruments washed and sent to CSSD by the Cath lab nurses.
 Pre discharge evaluation done in the ward
 Patient discharged with advise for future plan of treatment (Refer Discharge related process)

Traffic And Visitor Control

Visitor, family and friends will not be permitted in the cath lab
Infection Control Surveillance
a. Purpose:
To minimize infection in the cath lab procedure patient; to improve outcome; to minimize disability,
morbidity and mortality; to reduce cost of hospitalization.
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b. Policy:
i. All personnel in the cath lab must provide continuous infection control surveillance measures, as out
lined in the Hospital Infection Control Policy and Procedure Manual.
ii. Defined cleaning and sterilization measures are maintained after each surgical procedure.
iii. Any personnel with an infectious or communicable disease process shall not be assigned to the cath
lab.
iv. Disposable plastic protective eye shields may be used by the cath lab nursing personnel and
cardiologist to provide maximum eye protection from patient contamination.
c. Procedure:
Barriers for isolating the operative wound from infectious contaminants are as follows:
i. Skin Barriers: Pre procedure skin preparation of the patient and cath lab team;
ii. Special cath lab attire; Sterile drapes to cover the patient and sterile field;
iii. Adherence to aseptic technique.
iv. Barriers to Nasopharyngeal Flora and Hair:
v. Wearing of masks and cap;
vi. Exclusion from the cath lab of personnel with an acute infection or skin lesion;
vii. Dust covers to be used over sterile items in storage
viii. Proper packaging of supplies and sterilization procedure
ix. Enclosed cabinets or carts for storage of sterile supplies;
x. Clean pre procedure bed linen; Barriers to Airborne Contamination:
xi. Disinfection of cath lab surface following every procedure.
xii. Maintenance of effective ventilation and air conditioning systems;
xiii. Adherence to cath lab "Traffic and Visitors Control" policy.
xiv. Protective Eye Shields: Eye shields must be worn during the direct care of reactive patients.
Cath lab Cleaning and sterilization
Cath lab Cleaning
 All equipment, cath lab tables, anaesthesia machine, etc should be cleaned with 70% alcohol.
 Daily moping with 1% Sodium hypochlorite and hospital approved detergent after each case
 clean each cath lab thoroughly with hospital approved detergent and water paying special attention
to the corner of catlab.
 Use 1% Sodium hypochlorite for terminal cleaning or Ecoshield (10%) solution.
 After disinfection with 70% alcohol place all the equipment properly in the cath lab.
 Close the cath lab and do not allow anybody to enter unless there is a procedure.
OT sterilization
 Fogging is done once a week using hospital approved sterilant (20% Ecoshield) with contact time of
1 hour. (annexure)
 Every week culture is taken on the next day of fogging from cath lab.
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 Record of sampling and their report is maintained in infection control department.

 If culture is found positive for certain pathogens then depending on the colony count (as per NABH
India, UK and WHO) the OT will be cleaned again & fogging is done before using the cath lab.
Fumigation Procedure
To sterilize the operation theatre formaldehyde gas (bactericidal & sporicidal) is used for fumigation.
Formoldehyde kills the microbes by alkylating the amino acids and sulfydral group of proteins and
purine bases.
Step1: Preparation
1. Thoroughly clean windows, doors, floor, walls and all washable equipments with soap and water.
2. Close windows and ventilators tightly. If any openings found seal it with cellophane tape or other
material.
3. Switch off all lights, A/C and other electrical & electronical items
4. Calculate the room size in cubic feet (L×B×H) and calculate the required amount of formaldehyde as
given in step 3.
Step 2: Precaution
1. Adequate care must be taken by wearing cap, mask, foot cover, spectacle etc.,
2. Formaldehyde is irritant to eye & nose; and it has been recognized as a potential carcinogen.
3. So the fumigating employee must be provided with the personal protective equipments (PPE).
Step 3: Fumigation
1. Electric Boiler Fumigation Method: For Each 1000 cu.ft 500ml of formaldehyde (40% solution)
added in 1000ml of water in an electric boiler. Switch on the boiler, leave the room and seal the
door. After 45 minutes (variable depending to volume present in the boils apparatus) switch off the
boiler without entering in to the room (Switch off the main from outside).
Step 4: Neutralization
1. After the fumigation process neutralize the formaldehyde vapor with ammonia solution. On
inspection (or Surgery) day enter the operation theatre at 7 a.m with 150 ml of 10% ammonia (for
500ml of formaldehyde used, i.e., for 1000 cu. ft).
2. Place the ammonia solution in the center of the room and leave it for 3 hours to neutralize the
formalin vapor.
Example:
Operation Theatre/ Cath lab Volume = L×B×H = 20 × 15 × 10 = 3000 cubic feet
Formaldehyde required for fumigation = 500 ml for 1000 cubic feet
= So 1500 ml of formaldehyde required
Ammonia required for neutralization = 150ml of 10% ammonia for 500 ml of formaldehyde
= So 450 ml of 10% ammonia required
Guidelines to be considered for Cath lab Sterility Check:
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1. Construction, carpentry, plumbing, electrical, cleaning and other works should be completed before
the initiation of fumigation procedure.
2. If exhaust fan is used (instead of A/C) its exterior level fins should be closed.
3. Rooms allotted for operation (as shown in the plan) should not be used for other purposes.
4. The Construction must have
a. Separate dressing room for medical officer and staff nurses
b. Patient waiting room
5. The entire block should be cleaned and fumigated.
6. Entry should be restricted to authorized persons (Label must be pasted on the main door)
7. All apparatus such as boils, suction, table, cautery, focus lights, A/C units, exhaust fans should be
cleaned completely as per the manufacturer instructions.
8. Surroundings should be clean and free from garbage, open drainage, bushes, shrubs, wastes, ect
9. Cath lab should be cleaned and fumigated once a month periodically.
Steps for infection control
The following 10 principles shall be followed to optimum aseptic condition in the cath lab-
 Only sterile items are used within the sterile field.
 Sterile persons are gowned and gloved.
 Tables are considered sterile only at table level.
 Sterile persons touch only sterile items or areas; unsterile persons only touch only unsterile items or
areas.
 Unsterile persons avoid reaching over the sterile field; sterile persons avoid leaning over unsterile
areas.
 Edges of sterile containers are not considered sterile once the package has been opened.
 Sterile field is created as close as possible to the time of use.
Proper hand washing protocols shall be followed
Gown & Gloving Technique
a. Procedure:
i. Set out enough sterile gowns, gloves and towels for all members of the scrub team.
ii. Place a sterile unfolded towel in the hand of each person.
iii. The scrub nurse will assist each person put on his/her gown as follows:
iv. Grasp the top of the gown at shoulder seams to armholes.
v. Insert gloved hands along shoulder seams to armholes.
vi. Slide gown over surgeon’s arms, avoiding touching the surgeon with gloved hands.
vii. The circulating nurse will assist the surgeon’s as follows
viii. Bring left flap of gown over so it completely covers his back.
ix. The back of the gown is now contaminated. Scrub nurse will assist surgeon’s with his/her
sterile gloves as follows:
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 Insert fingers of both hands under cuff of right glove, either keeping thumbs away from cuff
tucked under cuff. Spread glove to form a circular opening with thumb of glove facing the
surgeon.
 As surgeon inserts his hand into glove, bring the cuff up over the wrist cuff of the gown and
releases glove gently.
 The surgeon now will unhook the waist strings at the front of the gown and hands the right
string with the paper tab to either the scrub nurse lab the circulating nurse.
 The nurse will hold the paper tab while the surgeon pivots to the left. The surgeon then pulls
the string to release it from the paper tab and ties the waist string.
 The scrub nurse will give each member of the scrub team a sterile moistened towel to remove
powder residue from their hands prior to beginning the surgical procedure.
 Note: All Surgical Services Department nursing personnel must be capable of gowning and
gloving members of the surgical team.

HIV/Hep B/Hep C protocol in cath lab

a. Cath lab allotment

i. Separate Pre Decided cath lab to be used for all above mentioned positive cases or post as last case
of the day.
ii. At all times all these positive cases will be posted as the last cases in any cath lab
b. Cath lab sterilization
i. Cath lab surface to be cleaned with 1% sodium hypochlorite solution
ii. Fogging to be done with Ecoshield or fumigation should be done
c. Cath lab attire
i. Reactive patient kit
ii. Double gloves,
iii. Goggles
d. Disposal of Bio medical waste
Double bag waste and dispose as per Bio medical waste policy
Infected case management
 In case of suspected or proven HIV, HCV, HBV and other infectious diseases the patient is put for
cath lab procedure as the last case of the day to enable the staff to carry out necessary disinfection
procedures after the operation.
 Information to cath lab to be given by the concerned cardiologist, when the patient is posted for cath
lab for procedure.
 The cath lab charge nurse should make all necessary arrangements for the infected cases.
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 Disposable drapes, eye protectors, shoe covers should be used by all the nurses, cardiologist &
technicians.
 Waste generated from the cath lab after the infected case is disposed according to the protocol of
waste management.
 Cath lab should be washed, cleaned, and closed for the day after spraying of 2% ecoshield
 Sharps like needles, blades, trocars and scissors and other instruments should be handled carefully.
They should be dipped in approved disinfectant immediately after the procedure and taken to CSSD
with a label ‘infected’
 Any pricks should be notified immediately to infection control nurse and treatment should start
according to the protocol.
Records Generated
 Patient case file
 Pre catheterisation investigations list
 Pre catheterisation patient preparation protocol
 Catheterisation lab patient scheduling list
 Catheterisation lab procedure protocol
 Post catheterisation patient evaluation checklist
 Catheterisation lab equipment maintenance protocol

SOP for Echocardiogram

An echocardiogram refers to an ultrasound of the heart. It makes use of high frequency sound waves to
capture images of the heart. This is a common procedure used by doctors to see your heart beating and to
observe its structures. Images captured can help doctors detect possible irregularities in your heart valves
and muscles. There are several types of echocardiograms which can be performed to provide more
information about your current state of health. Most echocardiogram procedures take approximately 30
minutes.
An echocardiogram is a non-invasive (the skin is not pierced) procedure used to assess the heart's function
and structures. During the procedure, a transducer (like a microphone) sends out ultrasonic sound waves at a
frequency too high to be heard. When the transducer is placed on the chest at certain locations and angles,
the ultrasonic sound waves move through the skin and other body tissues to the heart tissues, where the
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waves bounce or "echo" off of the heart structures. These sound waves are sent to a computer that can create
moving images of the heart walls and valves.
An echocardiogram may utilize several special types of echocardiography, as listed below:
 2-D (two-dimensional) echocardiography.
 3-D (three-dimensional) echocardiography.
 Stress echocardiography
Purpose of Procedure
Echocardiography is performed when heart disease is suspected or chest radiographs (x-rays) show that the
heart is enlarged. The echocardiogram (echo) shows the size of the heart chambers and how well the left
side of the heart is functioning. It shows whether the heart valves are normal or thickened. An echo can
detect the presence of extra fluid in the pericardial sac around the heart and sometimes the presence of
tumors in the heart that are causing the extra fluid.
Description of Technique
Echocardiography is a type of ultrasound examination. All types of ultrasounds bounce sound waves off an
object and record the returning sound waves. Special probes are placed on the patient’s chest. These probes
send and receive the sound waves or echoes. The echo machine converts these sounds waves into images of
the heart. It takes special training and months of experience to become proficient in performing
echocardiograms..
Objective
The objective of this standard operating procedure (SOP) is to describe the technique of non-invasive
echocardiography in the mouse model of Duchenne muscular dystrophy (DMD). Cardiomyopathy is an
increasingly important aspect in the treatment of DMD and cardiac evaluation must be an integral part of all
pre-clinical drug trials. These techniques provide the ability for longitudinal measurements and results are
comparable to human clinical echocardiography measurements, an important strength for helping to move
drugs into clinical trials. In brief, mice are anesthetized with inhaled isoflorane and placed on a heated
imaging platform. The temperature and heart rate of the mouse is constantly monitored to minimize
physiological variation. Mice are imaged using a high frequency echocardiography machine and a
standardized protocol is followed to systematically evaluate cardiac size and function. Once completed, the
mice are easily woken up after breathing oxygen for a short time and are returned to their cage.
The aim of this SOP is to describe the methods for high frequency echocardiography in mice and discuss
the advantages and disadvantages of the protocol.
Materials
 ECHO machine
 mouse handling platform with a Physiological Controller Unit
 Isoflurane
 Oxygen
 Anesthesia (isoflurane) blender and tubing with anesthesia scavenging system
(activated
 charcoal absorption filter
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 Optional for non-invasive BP measurement

 Depilatory cream
 Ultrasound gel
 Ophthalmic ointment
 Electrode gel
 Gauze
 Cotton tip applicators
 Tape
 Heating lamp
Procedure
 Instruct the patient to change the dress and wear the gown with the front open
 Take the patient to the Trolley/Table
 Place the mouse in an induction chamber with constant inflow of 5% isoflurane mixed with 100%
oxygen.
 Once the mouse is asleep, remove it from the induction chamber, weigh it, and place it on a heating
platform with electrocardiogram contact pads
 Place the nose into a nose cone with 1-2% isoflurane in 100% oxygen. Passively evacuate excess gases
using an activated charcoal absorption filter
 Cover the eyes with a petroleum-based ophthalmic ointment.
 Place electrode gel on the paws and tape the paws over the electrocardiogram contact pads on the
heating platform.
 Lubricate a rectal probe with gel, place it in the rectum, and tape it to the platform. Maintain the
temperature at 36.5 to 37.5 °C.
 Place a blood pressure (BP) cuff around the tail and place the tail in the sensor assembly for non-
invasive blood pressure monitoring.
 Continuously monitor the temperature, heart rate (HR), and BP during the scanning.
 Apply depilatory cream to the chest of the mouse using a cotton applicator tip and remove the cream
after 2 min with a gentle rolling motion of the cotton tips, then clean the chest with distilled water.
 Place ultrasound gel on the chest of the anesthetized mouse.
 Place the ultrasound probe in contact with the ultrasound gel and perform the scan.
 Clean skin site with spirit swab
 Electrodes application lead connection to be done
 After test remove the leads and electrodes and clean the chest
 Instruct the patient to change the clothes
 Provisional report should be given after the test and printed report to be collected on the next
working day between 3 to 5 p.m.
2. CAROTID STUDY
 Patient to change into a robe.
 Allow the patient to lie down in a flat posture
 After the test, clean the neck
 Instruct the patient to change the clothes
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 Report collected on the next day between 3 to 5 p.m.

3. DOBUTAMINE STRESS ECHO
ARTICLES REQUIRED
 Tray for Intravenous Cannulation
i. IV Cannula
ii. Cotton Swab (Dry)
iii. Cotton Swab (Betadine)
iv. Tourniquet
v. Heparinised Saline
vi. Micropore
vii. Kidney Tray
 Tray for Dobutamine Infusion
i. Injection Dobutamine 250 mg
ii. Injectin Atropine 6 mg
iii. Injection Hep Saline
iv. Injection Betaloc
v. 10 cc D/S-2
vi. 05 cc D/S -1
vii. 50 cc D/S-1
viii. P.M. Lines 150cm-1
ix. Needles-2
PREPARATION OF MEDICINES
Injection Dobutamine 250 mg.
 Dobutamine 250mg dissolved in 5ml NS
 Prepared in 50ml syringe (45ml NS+5ml inj. Dobutrex)
Injection Atropine. 6mg (1ml)
 InjectionAtropine-6mg added in 5ml NS (.1mg-=1ml)
 1 ml Atropine + 5ml NS=.6 ml
Injection Betaloc
 Injection Betaloc 5mg (5ml) added in 5ml NS
 5 ml beta + 5ml NS = 10ml (2.5mg in 5 ml)
Injection Heparin 500u
PROCEDURE FOR IV CANNULATION AND DOBUTAMINE STRESS ECHO
 Confirm the patient is fasting
 Patient to change in a robe
 Pre-test evaluation (weight, height, BP)
 Instruct the patient toile down on the bed
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 Tie the BP Cuff and check the BP

 Prepare the patient & Prepare the Equipment
 Put on gloves
 Skin preparation Re-apply tourniquet
 Adopt favoured cannula grip
 Ensure cannula in panel up
 Angle 15-30 according to vein depth. Insert cannula and observe for blood in flash back
 Release tourniquet
 Apply digital pressure beyond cannula lip
 Remove stylet and dispose in sharp container
 Attach luer lock connection
 Flush the cannula
 Prepare the medication for the infusion
 Inj. Beta loc, Inj. Atropine, Heparinised saline should be kept in the tray
 Position the patient to prior to the test with ECG electrodes connected
 Test conducted by the consultant cardiologist as per standard protocol
 Dobutamine infusion to be given in dose of 10 mcg/kg/ml, 20 mcg/kg/ml, 30mcg/kl/ml and
40 mcg/kg./ml in stage dose of 3 minutes (if viability study also included starting doses should be
45mcg/kg/ml followed by 10 mcg/ml, 15 mcg/ml.
 If the THR is not achieved, inj. Atropine to be given in dose of 0.3mg intravenous every two minutes up
to a maximum of 2 mg.
 For patients who develop uncomfortable tachycardia/ Palpitation or severe ischaemia, inj. Betaloc I/V
may be given upto 5 mg slowly. Unless contra indicated isosorbide dinitrate may be used for ischaemia.
 For intractable symptoms/ischemia/ arrhythmia/ or other emergencies standard protocol to be followed
as used in the hospital.
 After stopping the dobutamine immediately check the BP
 After the test remove the cuff, leads and electrodes
 Clean the patient
 If the patient is comfortable then instruct the patient to change the clothes
 Reporting to be done by the cardiologist, collected on the next working day between 3 to 5 P.m.
 Destroy the used articles
 Change the I/V line. Used lines and throw into the red waste bag.
 Syringes cut and separated and discard into the red waste bag
 Needles burned and discard in the blue
 Electrodes in white
 Cannula cut and discard in the red
 Used gown discard in the laundry bag.
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5. TRANS ESOPHAGEAL ECHOCARDIOGRAPHY

ARTICLES REQUIRED
 Articles for Inserting the cannula
 Tray Containing
 D/S 10 ml-2
 Gauze -1
 Xylocaine spray/xylocaine viscous
 Glocves-1
 Kidney tray-1
 Suction cath-1
PROCEDURE
 Confirm the patient is fasting
 Patient to change in a robe
 Cannulate the patient
 Local anaesthesia (spray/gargle) to be given
 Patient to be positioned on the exam table with ECG electrodes
 Dentures to be removed, bite protector placed into the mouth
 Lubricate the tube with xylocaine jelly
 Exam conducted by the cardiologist
POST TEST
 Remove mouth gag & Remove the electrodes and leads
 Clean the skin
 Remove the cannula after sometime
 Change the gown
 Instruct the patient to take the food after 1 hour& to collect the reports next day between 3 to 5 p.m.

SOP for TREADMILL TEST (TMT)

TREADMILL TEST (TMT)
PRECARE
 Confirm that the patient in fasting
 Patient to change in a robe
 Pre-test (height, weight, BP) evaluation of patient to be done by nurse
 Patient chest to be shaved (if required)
 Data entry into the machine to be done by the technician
 Skin preparation, electrode application and lead connection done by the technician
PROCEDURE
 Consultant cardiologist to be informed and test to be conducted under his/her supervision.
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 Blood pressure should be checked frequently by the nurse

 Report to be collected on the next working day after 3.00 p.m.
POST CARE
 Help the patient to lie down
 Monitor the blood pressure until the parameters return to normal level
 Remove the electrodes and leads
 Change the hospital gown
 If the general condition is good, send him home with the instructions.
7. HOLTER MONITORING
 Patient to change in a robe
 Chest of the patient to be shaved by the barber (if required)
 Skin preparation, placement of electrodes and connection to the recorder to be done by the
technician
 Precautions with the recorder and the event diary for the recording of time of activities and
occurrence of symptoms to be explained to the patient by the technician. Event diary to be handed over to
the patient.
 Upon completion of the recording (after 24 hours) electrodes and recorder to be retrieved by the
technician.
 Data from the recorder to be unloaded in to the analyzer computer by the technician
 Analysis and reporting to be done by the consultant cardiologist.
8. HEAD UP TILT TEST (HUT)
PRE-TEST
 Confirm the patient is fasting
 Instruct the patient to change the dress
 Check the BP
 Cannulate the patient
 Explain the procedure to the patient
 Reassure the patient.

ARTICLES REQUIRED
 IV insertion articles
 50 cc syringe
 PM line 150 cm
 Inj. Isoprine 1 ampule
 Inj. Atropine
 Inj. Hepsaline
 10 cc D/S-1
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 5 ccD/S-1
 3 way-1
 Defibrillator
 Electrodes
 BP apparatus
 Stethoscope
 Infusion Pump
PREPARATIN OF MEDICINES
 Inj. Isoline 2 mg/ml
o Isoline 2mg/ml added in 49 ml NS
o Prepare in 50ml syringe
o Infusion started at 2 mcg/ml
 Inj. Atropine
o Inj. Atropine 1 ampule added in 5ml NS, 0.1 mg = 1ml
 Heparinised solution
PROCEDURE
 Position the patient on the tilt table
 ECG monitor connected, BP Cuff wrapped around the arm
 Inform the consultant cardiologist
 BP, HR to be monitored every 2 minutes for 20 minutes. Any symptoms to be noted. Test to be
terminated before 20 minutes if its positive.
 If the test is negative after 20 minutes of 70 degree lead up tilt then the table to be made horizontal
again and an infusion of inj. Isoproterenol to be started at dose of 2 mcg/ml. When the HR increase 20-
30% from the baseline heart rate again the table to be tilted to 70 degree.
 BP and HR monitored and recorded every 2 minutes for 20 minutes. Any symptom reported by the
patient to be noted, test to be terminated if it is positive.
 Reporting done by cardiologist.
POST CARD
 Allow the patient to lie horizontally for sometime
 Check the BP
 Remove the leads and electrodes
 Remove the cannula after sometimes
 If the patient is comfortable, allow the patient to change the dress
 Discard the used articles according to the hospital protocol.
9. ELECTROCARDIOGRAM (ECG)
 Patient to change in a robe
 Patient taken to the ECG room by the technician, ECG tracing recorded
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 ECG handed over to the patient after signature in the register

 After each use the electrodes plates should be thoroughly cleaned.

I. CORONARY ANGIOGRAPHY (CAG)

1. CAG PACKAGE (ONE DAY)
The Package includes:-
 Investigations:- CBC, RFT, PT, PTT, RBs, ABO, Rh grouping, HbsAg, Anti ACV, Anti HIV 1 st and
2nd, X-ray, Chest, ECG, Urine –R/M
 Medicines 24hrs as under, rest of the medicines are to be billed -

– Tab. Ciprobid for two days (500mg.)

– Injection Heparin
– Tab Brillanta
– Tab. Valium / Alprax
– Cap. Benadryl
– Tab Pantocid/ Tab Ranatac / Cap Ocid / Digene
– Cardiac Medicines
o Betaloc/ Metolar/Concor/Atenolol
o Cardace/Enam/Enapril/Listril
o Monotrate
o Nikoran/Korandil/Zynicor
o Travedon/Flavedon
o Cicpidogrel/Ceruvin/Clopigrel/Clavix / Ceruvin A/ Clopigrel AP/ Clavix AS
o Ecosprin / Loprin / Colspnn
o Storvas/ Lipicor /TG-TOR/Zosta/Simvotin/Lipicard
o Lanoxin
o Lasix / Aquazide/Lasilactone/Zytanix
o NTG/Dopamine/Dobutamine
o Amlodarone/Xylocard/Dilzem

2. PREPARATION OF PATIENT IN THE WARD FOR CAG

 Check height and Weight

 Consent for procedure to be taken by the doctor.
 Make the patient fast 10 hrs. before the procedure
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 Mark the peripheral pulses with skin pencil/marker

 Record all vital signs before sending to Cath Lab.
 Prepare the site (usually femoral) as for surgical procedure follow strict aseptic technique.
 Always keep a IV line patient in left hand
 Administer pre-medication ass ordered.
 Put the identification band
 Collect all the investigation and inform doctor on duty.
 Tell the patient to void.
 Check all the record before shifting the patient to the Cath Lab.
 Check the patient to Cath. Lab with front open gown and give the hand over to the Cath. Nurse.

3. RECEIVING OF PATIENT IN CATH LAB

 Receive the patient with time wi9sh and smile
 Patient must always accompanied by a staff.
 Orient the patient for place person and time to make them ease
 Check for
– I.V. Patency
– Size of cannula (20 G cannula)
– Other supportive lines and their patency
– Part Preparation
– Artificial dentures, undergarments etc.
– Marked pedal pulse site
 Receive file and other documents from staff nurse. Check in the file for
– Consent
– Pre cath check list
– Blood reports
– X-ray, ECG, Echo reports
– Patient diagnosis and condition
– Billing records
 Take detailed hand over from the staff accompanied
 Shift the patient to Cath lab.
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4. Pre-Cardiac Catheterisation Nursing Check list

1. Written consent obtained in the chart Yes___ No___
2. patient educated about procedure & questions answered. Yes___ No___
3. Allergies Weight:
Height:
4. NPO for 6 hours Yes___ No___
5. Current vital signs:
BP________________
Temp______________ Pulse ___________________
6. baseline ECG, Chest WX-Ray, Blood Reports Yes___ No___

7. patient voided urine on call to CAth Lab Yes___ No___

8. Check Patency fo IV line (On left arm) Yes___ No___
9. I.V. Infusio__________ at _________ ml/hr._______ Yes___ No___
10. Pre-Medications given at (time) Yes___ No___
11. Recent Lab: PT___ Hb___ ACT___ K___ Yes___ No___
12. Chart sent with patient Yes___ No___
13. Jewellery removed Yes___ No___
14. Dentures, False teeth, nail polish etc. removed Yes___ No___
15. Routine Cardiac medication taken

Comments:

Signatures of Nurse

5. ANGIOGRAPHY PROCEDURE
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 Explain the procedure before starting and make the patient comfortable.
 Explain risk involved – allergic reaction, embolus, cardiac dysrhythmias.
 Prepare sterile trolley
 Keep ready all the items need wise.
 Introduce local anesthesia 20ml.
 Puncture with puncture needle
 Insert small guide wire and straighter.
 Remove puncture needle & straighter
 Widen puncture site with blade for smooth going of sheath
 Introduce sheath
 Withdraw dilator, guide wire and straighter.
 Flush with heparinised solution (N.S.) and lock
 Push 2000 i.u. Heparin into the sheath
 Prepare the catheter by flushing the luman with hep-saline.
 Insert guide wire into the catheter and the cardiologist introduce the same to the coronaries and
visualize the position under fluoroscopy.
 Pressure is monitored in each section and recorded
 Dye is injected into coronaries right side, left side, left ventricle and to renal arteries to see the
functioning and potency of each vessel.
 When all the vessel are seen and found blockage, the cardiologist decide to go for angioplasty
immediately/ later depending upon the condition, percentage of block, ejection fraction and the
financial status of the patient after discussion with patient relative/ company etc.
 If the coronaries are normal, then he sheath is removed and send the patient back to department.
 Flush the sheath with heparinised saline after withdrawing the clots
 Discard the aspirated blood into a sterile gauze in order to see the amount of cloth and if further
aspiration is needed, do the same to avoid thrombo embolism.
 No clot seen, flush the lumen properly. Put a sterile dressing and shift the patient to post operative
room and make him comfortable.
 While shifting the patient, be careful about the leg, extremities, I.V. line supportive lines and
syringe pumps/’IABP/ ventilator etc.
 The affected leg should not be bend or moved for minimum 6 hours.
 While shifting the patient from the table, tell the patient to lift the other leg and with the support
of the same, lift/his/her back and move the trolley.
 One person should always hold the affected leg to avoid accidental bending by the patient.
 Check the pedal pulse and make sure that the flow is normal.

6. COMPLICATIONS DURING CAG

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1. Arrythmias Irritation of the conductive system or the myocardium when

catheter passes into cardiac chambers.
Transient period of anoxia of the myocardium while coronary
arteries are filled with dye.
2. Allergic Reactions Urticaria Allergic response to dye
& Anaphylactic shock
3. Embolic disorders C.V.A., Inadvertent dislodgement of fibrin or clot due to catheter
M.I., Pulm. Embolism manipulation.
Inadvertent introduction of air into cardio pulmonary system.
4. Cardiac Tamponade Perforation of heart/great blood vessel with catheter
5. Hypotension and tachycardia Vasodilatation of heart/great blood vessel with catheter
6. Pulmonary oedema Hyper osmotic effect of dye
7. Absence of distal pulse in the Occlusion of the artery in the affected extremity due to clots.
extremity
8. Nerve Damage Manipulation during procedure
9. Phlebitis in the : Post Introduction of infection Damage to the veins.
catheterization period

7. POST CHECK LIST FROM CATH LAB.

NAME OF THE PATIENT :

AGE/SEX :
DATE OF ADMISSION :
DATE OF PROCEDURE :
C.R.NO. :
DATE VITALS Medications Sheath site Handover Instruction to Sign of
& Given procedures patient receiving
TIME during staff from
procedure the
respective
place
Temp Hematoma Syringe Immobilization
Pump
BP Oozing Pressure Follow
bag doctor’s order
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RR Redness IABP
Machine
PR Aseptic Sheath
dressing
Pressure
line
Oxygen
Cylinder
Pacemaker
Pacing lead
PA catheter
Documents

8. SHEATH REMOVAL
 Prepare the articles for sheath removal
– Gloves
– Betadine
– Gauze packets
– Dynaplast
– Helix Spray
– Foot step to stand
 Wash hands with moderate disinfectant
 Wear gloves following aseptic technique
 Fell the pulse above the puncture site and apply pressure.
 Remove the sheath
 Allow few drops of blood to flow first to avoid cloth dislodgement if
 Present around the sheath
 Apply firm pressure by keeping sterile gauze over the artery / vein for 20 mts
 Do not remove the gauze from the site to watch bleeding before 20 mts. This gives rise to
haematoma formation and loss of blood.
9. TRANSFER OUT FROM CATH LAB
(Note: Time needed: 15 mts. For cases with sheath, 15-30 mts for cases without sheath)
 Explanation at each step in mandatory.
 Inform respective dept/’ward 15 mts. Prior shifting
 Explain the receiving end regarding things to get ready to receive the patient for e.g. syringe pumps,
flush system, ventilator etc.
 Make the patient comfortable while shifting and transporting.
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 Check before shifting

– Vital signs and general condition of patient
– IV site for swelling, redness and patency
– Haematoma at the site of insertion
– Dressing.
 Make sure that documents and file is complete before shifting the patient
 Hand over signature is to be taken from receiving end.
10. POST PROCEDURE INSTRUCTIONS IN THE WARD
 Receive the patient, make the patient lie on the bed in a comfortable position supine, head deviated
15-30o
 Continue cardiac monitor till the vital signs are stabilized.
 Ask the patient to take complete bed rest for 12 hrs. to 24 hrs.
 Watch for skin colour, temp and peripheral pulse to detect early signs of complication.
 Keep the affected extremity straight 6 to 8 hrs.
 Watch the puncture site for bleeding/ haematoma formation
 Watch for allergic reaction to the dye.
 Give liquids orally to tolerating can give advised
 Follow up the post angiography orders.
 On removal of dressing, a sterile sponge is placed and firm procedure is applied for 10-15 mts to
prevent bleeding.
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PTCA (PERCUTANEOUS TRANS LUMINAL CORONARY ANGIOPLASTY)

Angioplasty is the introduction of balloon tip catheter into the coronary artery to the Point of stenosis
to reduce or eliminate the occlusion.
Receiving of the patient is same procedure as angiography.
1. PRIMARY PTCA PACKAGE
 All Drugs in Elective PTCA and CAG Package +
 Clexane x 4 days
 Investigation extra
– CPK, CPK (MB) (3 Values)
– 6 ECGs
– Blood Gases x 4 times
– Temp. Pacemaker
– Swam Ganz
– Echo x 1
2. ELECTIVE PTCA PACKAGE
 Injection Heparin
 Injection Taxim / Monocef / Fortum / Amikacin / Gentamycin / Augmentin
 Tab Ceftum / Ciprobid / Augmentin
 All medicines in CAG packiage +
 Injection Rantac
– Injection/Panto prazole +
– Clexane / LMWH for 3 days
 Dextran
 Nebulization
 4 ECGs
 CPK-MB X 3 times.
3. POSITIONING THE PATIENTS
Drape the patient with plastic sheet and then same as angio.
4. PREPARING THE CATH LAB
Linen - Same as in Angio Pack; Extra gowns are needed.
Fluids & Consumables –
NS 1000 ml - 01 Int. needl - 01
500ml - 01 Punc. Needle - 01
Xylocaine 2% - 01 Ext. soine - 01
Surgical blade - 11 Connector - 01
- 22 Guide wire - 01
Disp syringe 20cc - 01 P.M. Line - 01
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10cc - 03 Sheath 6 for 7 F)1

……………….. - 03 Betadine solution 30ml (10%)
3 ways conn - 02 Gauze
I.V. Set - 02 Sponge Abd.
3 Core manifold - 01 Inflation device - 01
Torque 01
PTCA wire
PTCA Balloon - Guiding catheter
Contrast (for the prep of balloon)
Clexane as per the weight of the patient
NTG
Nikoran Whenever required
Aggramed
Aggribloc

CONTRAST: Ionic/Non Ionic according to patient’s blood report and allergic status.
5. PROCEDURE
 Antibiotics injections (Fortum/Amikacin) 1 hour before procedure.
 Part preparation same as CAG
 Angio procedure +
 Artery and venous both are inserted
 Introduce G.L. catheter to see pressure in different stages.
 Introduce 0.32x260cm exchange guide wire into the G.L. catheter
 Withdraw G.L. catheter and venous sheath
 Insert mullen’s sheath over the exchange wire and remove the wire.
 Insert septum puncture needle through the mullen’s sheath
 Once the septum is punctured, remove the septum puncture needle.
 Introduce ennou wire with straightner through the M.Sheath
 Remove the M. Sheath
 Dilate the site of venous sheath with an artery of ups for the easy insertion of balloon dilated which
is bigger in size.
 Insert balloon dilated via ennou wire and dilate three times
 Remove the dilator and introduce balloon over the wire with diluted contrast in a luer lock 50 ml
syringe
 Once the balloon is positioned, remove the ennou wire and stillet.
 Inflate the balloon
 Insert the combination wire/balloon stillet and ennou wire
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 Let the ennou wire be inside and remove balloon with stillet.
 Insert the 7 sheath with G.L. catheter through the ennou wire to obtain the mean pressure.
II. REQUIREMENTS FOR BALLOON VALVULOPLASTY

 Angio set, Linen pack, abdomen pack (same as angio)

 Additional articles needed for BMV then CAG
 BMV Balloon kit
– BMW balloon, Balloon stillet 1
– 50 ml. syringe 1
– 3 way stop cock 1
– Septal puncture needle 1
– Mullen sheath/dilator 1
– Gilebi wire/Ennou wire 1
– Pigtail catheter 1
– L.V. entry stillet 1
– G.L. catheter No. 06/07 1
– Venous sheath 7F 1

III. PREPARATION FOR RFA

 Injection Taxim / Fortum / Amikacin / Tab. Ciprobid/ Tab Augmentin/Tab Ceflum
 3 ECGs
 Echo
 Cardiac Medicines (as in CAG package)
 Clexane x 2 doses.
PACEMAKERS
1. PACEMAKER INSERTION
 Definition: A temporary or permanent device to initiate and maintain heart rate when patient’s
biological pacemaker is non-functioning.
 Assessment: - Assess patient conditions requiring pacemaker insertion viz. Conduction defect
following open heart surgery, Heart block (usually third degree), Tachyarrhythmias, Strokes-Adam
Syndrome, Bradycarrhythimas.
 Assess vital signs for baseline data
 Evaluate heart sounds to determine arrhythmias for baseline data.
 Assess lung sound for adventitious sounds
 Evaluate type of pacemaker to be inserted.
– External pacemaker – temporary, used in emergency situation.
o Pacing wire threaded through vein and attached to external powersource.
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o Used for heart block or bradycardia

– Demand – functions only if clients own pacaemaker fails to discharge most common.
o The pacemaker is set at a fixed rate and will discharge only if clients own rate falls below.
o Used mainly in Adam strokes or bradyanthythmias or following cardiac surgery.
– Asychronous
o Fixed rate – the pacemaker is set at a fixed rate and will fire regardless of client’s own rhythm
o Variable rate – rate can be varied.
2. NURSING CARE OF TPI PATIENTS
 Comfortable position with head up maximum 30o
 Do not allow the patient to fold the leg, or not allow it on the bed.
 Pacemaker rate should be noted and if monitor shows less than the rate adjusted it should be
informed.
 Watch for haemotoma
 Dressing of site should be changed in 24 hours, clean the site with betadine and apply new dressing.
 Pacemaker should be fixed to the patients leg properly with the tie along with it.
3. ARTICLES NEEDED FOR TPI
 Suturing set
 Slit towel
 Arterial sheath
 Puncture needle
 Guide wire
 Surgical Blade No.11
 Suture Mersilk 2-0
 Pacemaker
 Pacing bad
 Pacing lead
 pacemaker cable
 Gauze packets
 betadine solution
 Glvoes
 Hepflush
 Inj. Xylocaine 2%
 10 cc Syringes with needle
 Dynaplast
4. PERMANENT PACEMAKER IMPLANATION
 Before PPI confirm payment has been done.
 Investigations done as advised by the doctor.
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 Consent & proper explanation to be done by doctor.

 Prepare patient as for surgical procedure. Shave chest and apply betadine paste.
 Record vitals and ECG prior to procedure
 Shift to cath lab when instructed.
5. POST PROCEDURE INSTRUCTION.
 Not to move the right upper limp
 Not to sleep in the right lateral position
 Dressing to be checked
 ECG monitoring.
6. PACEMAKER PATIENT EDUCATION
 Instruct the client about the pacemaker, including the programmed rate.
 Instruct the client in the signs of battery failure and when to notify the physicians.
 Instruct the client to repot any fever, redress, swelling or drainage from the insertion site.
 Report signs of dizziness, weakness or fatigue, swelling fo the ankles or legs, chest pains or
shortness of breath.
 Keep a pacemaker identification card with patient in the wallet.
 Instruct the client in how to take the pulse, to take the pulse daily, to maintain a diary of pulse rates,
and wear loose fitting clothes.
7. PERMANENT PACEMAKER IMPLANATION
 Prepare the patient for PPI. It is invasive sterile procedure do proper sterile technique should be used
to prevent infection.
 Batadine scrubbing should be done at least 5 minutes, then Betadine solution to clean the areas.
 Spriti with sterilium should be used for lasting claning. Cleaning area is from neck till diaphragm.
 After testing give xylocain 2% us local anesthesia.
 Then with the help of blade doctor will give insertion on Right Infra Clavicular Region. Then Doctor
will make pocket for placing pace maker.
 Puncture the subclavian vein and passing the pacing lead. Through subclavious it will go to SVC
then right atrium then right ventricular but in chamber after right atrium then right ventricular.
8. LONG TERM MAINTENANCE & CHECKING OF CARDIAC PACEMAKERS
 Identify pacemaker placement:
– Epicardial – electrodes are implanted on outside of left ventricle and they barely penetrate
myocardium. Battery pack is placaed subcutaneously in a skin pocket.
– Endocardial implanation – packing electrodes inserted through neck vein and placed near the apex
of right ventricle
a. Permanet – battery is implantaed beneath skin
b. Emporary – battery is located outside of skin
 Implantation:
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– Observe for battery failure (pacemaker not firing as set).

– Faints easily
– Hiccoughs
– Rhythm change
 Observe for hematoma at sire or insertion
 Observe for arrhythmias via cardiac monitoring
– Competition from client’s own pacemaker evidenced on rhythm strip
– Absence of pacemaker artifact on rhythm strip.
– Premature ventricular contractions (PVCs) and ventricular tachycania
 Monitor vital signs
– Hemorrhage and shock
– Cardiac tamponade
– Infection
 Provide client teaching
– Purpose for pacemaker
– Education does and side effects
– Methods of utilizing and managing
– Monitoring pulse
– Signs and symptoms of infection
 Counsel client to observe for pacemaker failure
– Decreased urine output
– Decreased blood pressure
– Cyanosis
– Shortness of breath

IV. AICD : AUTOMATIC IMPLANTABLE CARDIOVERTER DEFEBRILLATOR

The AICD is a device that detects and terminates life threatening episodes of V.F. or V.F. in patients
deemed at high risk. It is an elective procedure.
Function of AICD machine: The mechanical system consists of a pulse generation, two rates-
sensing leads and two leads through which electrical shock can be delivered directly to the
myocardium.
The AICD consists two parts
– Pacemaker
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– Battery
Pacemaker try to revert antitachia pacing, reverted AICD gives shock. There are two types of AICD
– Single chamber AICD (*) Dual Chamebr AICD single chamber, lead is placed in Rt. Ventricle. Dual
Chamber, lead are placed as Rt. Ventricle, Dual Chamber, leads are placed to Rt. Atrium and Rt.
Ventricle. Problem with single chamber device is any tachy-cardia or AF occurs, it read as V.J. and
gives shock.
– Dual chamber differentiate between V.J. and A.F. it delivers shocks when V.J. occurs.
1. INDICATION
 Sustained V.J.
 Recurrent V.J. o V..F
 Severe LF (One of the cause of V.J.)
 Patient who are unresponsive or medications or surgical ablate or irritable amyocardial tissue.
2. CONTRA INDICATIONS
 Incessant V.J. (V.J. – pertain more than 40 sec.)
 Complications:
* Haematoma * Pain
* Infection * deincisation of stitching
* Fractured leads * Prematrue battery depletion.

3. PRE-CARE
 Proper explanation of the procedure and function of the device.
 Psychological support (these patient have suicide, tendency)
 Written consent
 Part preparation from neck to umbilicus
 Apply betadine patient.
 Height and Weight to be recorded
 Dentures & ornaments are to be removed before sending the patient to Cath. Lab.
 NBM for 6-8 hours
 Make the patient to void before sending to CAth. Lab.
 Sister to accompany with the patient to CAth Lab & give proper handover to Cath Lab nurse.

4. POST CARE
 Receiving the patient and keep NBM for 2 hours then sips of water, if no vomiting can give regular
diet.
 Immobilization of the implanted limb site.
 Vitals to be recorded.
 No I.V. insertion & B.P. recording in the affected site.
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 Watch the site for oozing and haematoma.

 Do not allow the patient to lie down in affected side.
 Rise in temperature to be reported.
 Check X-ray for lead positioning.
5. PATIENT TEACHING
 Any temp. redness, swelling and heat to be reported immediately.
 Avoid tight clothing that may produce friction over the wound site.
 Avoid magnet fields such as metal detectors at security check points, MRI & microwaves. (Magnet
fields can deactivtate the ICD)
 Maintain a diary to record shocks.
 Adhere to appointments that are scheduled to test electronic performance o ICD.
 Pain remains for 10 days (normal)
 Wear medic-alert identification that includes physician is information.
Avoid frightening family or friends’ unexpected shock. Inform those close to you with event that
they are touching you, when a shock delivered they may also feel the shock.
Control………. D.M. by insulin and medicine
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hocardiography. This technique is used to "see" the actual motion of the heart structures. A 2-D echo view appears
cone-shaped on the monitor, and the real-time motion of the heart's structures can be observed. This
enables the doctor to see the various heart structures at work and evaluate them.
3-D (three-dimensional) echocardiography. 3-D echo technique captures three-dimensional views of
the heart structures with greater depth than 2-D echo. The live or "real time" images allow for a more
accurate assessment of heart function by using measurements taken while the heart is beating. 3-D echo
shows enhanced views of the heart's anatomy and can be used to determine the appropriate plan of
treatment for a person with heart disease

Quality Record Matrix:

Minimum Controlling
S.
Record Description Document No. Retention & Disposing Remarks
No.
Period Authority
<Mention Register
1.
Name>