Cath Lab Digest - January 2008 - (Page 40)

40 ASK THE CLINICAL INSTRUCTOR JANUARY 2008 Ask the Clinical Instructor A Q&A column for those new to the cath lab Questions are answered by: Todd Ginapp, EMT-P, RCIS, FSICP Todd is the Cardiology Manager for Memorial Hermann Southeast in Houston, Texas. He also teaches an online RCIS Review course for Spokane Community College, in Spokane, Washington, and regularly presents with RCIS Review Courses. “Sometimes the cardiologists perform an ACT exam when the patient comes to the cath lab from the emergency room, and sometimes they wait and perform the test after the patient has had a heparin bolus. Why?” — CVT student, Houston, TX I ’ll take the opportunity to answer your question by explaining the Activated Clotting Time (ACT) test and how it applies to what we do in the lab. The ACT was initially developed as a screening test for patients with bleeding disorders. In the mid-70’s it began its use as a guide to the administration and reversal of heparin during coronary artery bypass grafting (CABG). The concept of “no clotting” carried over from CABG to angioplasty, since equipment is in the artery and could create clots if the blood was not “thinned.” That is why ACT is used in current coronary interventional procedures — to monitor the clotting time. There are many ‘clotting’ tests (aPTT, for example) that are more accurate, but in a percutaneous coronary intervention (PCI), the ACT is the most rapidly available test to evaluate the anticoagulation status of the blood. (Note: If you have taken the Cardiovascular Credentialing International [CCI] Registered Cardiovascular Invasive Specialist [RCIS] exam, you may recall a question concerning this point.) In a ‘normal’ patient who is not on anti-coagulation therapy, the ACT would be somewhere around 107 seconds (± 13 seconds). The desired ACT level for a patient undergoing CABG would be somewhere between 400-600 seconds. This was developed by tests that revealed that at this level, clots would not form in the heart-lung machine bypass circuits. In a PCI with heparin alone, the desired ACT level is 250-350 seconds. In a PCI where heparin and a IIb/IIIa agent is administered, the ACT is to be targeted at 200-250 seconds.1 There are two systems that seem to be more prevalent in the cath lab. One is the Hemochron (International Technidyne Corp, Edison, NJ) and the other is the Medtronic HemoTec (Medtronic HemoTec, Inc., Englewood, CO) (Figures 1-2). These systems work quite differently from one another, but their main result is the activated clotting time in seconds by analyzing how long it takes for fibrin fibers to develop. It is important to note that these systems are not interchangeable. If you are utilizing one brand on a procedure, you would not want to switch to another brand in the middle of the procedure. There is up to a 30% variance between the two.1 ACTs are generally used for one of three reasons: 1. Assessment of the patient anticoagulant status when they arrive in the cath lab after receiving a heparin bolus and/or drip; 2. Maintenance of the ACT during the PCI; 3. Optimal time for sheath removal after the procedure (generally 150 to 180 seconds). To answer your original question about why the cardiologist performed the exam on the patient arriving from the ER, I can only assume it is because the patient “The only foolish question is one left unasked.” New Staff: Your suggested topics and questions are needed! (You are welcome to remain anonymous.) Email us at: tginapp@rcisreview.com http://www.medtronic.com

Table of Contents Feed for the Digital Edition of Cath Lab Digest - January 2008

Cath Lab Digest - January 2008 Central Baptist Hospital Contrast Media Use in High-Risk Patients An Ergonomic Survey of Cath Lab Repetitive Stress Injuries Contents Clinical Editor’s Corner Takotsubo Cardiomyopathy, a.k.a., Transient Left Ventricular Apical Ballooning Syndrome: An Acute Coronary Syndrome Imposter Searching for the Key to D2B STEMI Intervention News STEMI Interventions: Commentary The Massachusetts Stent Study The Value of Educating Staff Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab SICP* Chapter Updates The Society of Invasive Cardiovascular Professionals Holds an RCIS Review Course at New Cardiovascular Horizons 18:20 To Denver — One Student’s First Clinical Experience CEU Education Center Meetings Calendar What Do You Think? Clinical & Industry News Classifieds The Ten-Minute Interview with…Heather Vardon, RN Advertisers Index

Cath Lab Digest - January 2008

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