Cath Lab Digest - October 2007 - (Page 4)

4 CLINICAL EDITOR’S CORNER OCTOBER 2007 EDITORIAL Your patient has low platelets. Think about bleeding before and after cath. MORTON KERN, MD Clinical Editor Clinical Professor of Medicine Associate Chief Cardiology University of California Irvine Orange, California LAURIE GUSTAFSON Executive Editor REBECCA KAPUR Managing Editor ELIZABETH MCTAMNEY Layout/Production Manager Y our patient is on the way to the cath lab. Your routine pre-cath check shows the chemistry and blood counts to be abnormal: • Hemoglobin is 10.6mg/dl; • White blood cell count (WBC) is 11,000 cell/mm3; • K+ (potassium) is 3.4meq/dl, platelet count of 65,000; • Blood urea nitrogen (BUN) is 28mg/dl; • Creatinine is 1.4mg/dl; • International Normalized Ratio (INR) is 1.5. HMP Communications MORTON KERN, MD Clinical Editor Clinical Professor of Medicine Associate Chief Cardiology University of California Irvine Orange, California mortonkern005@hotmail.com Should this patient continue in the lab or should you consult the physician and stop the procedure? In view of the unknown risks that these blood values portend, this patient’s procedure should wait until the physician has a clear understanding of the problems and the potential risk/benefits of performing angiography/percutaneous coronary intervention (PCI). The blood values indicate considerable caution must be used to avoid complications related to bleeding (INR, low platelets, anemia), arrhythmia (low K+), renal failure (elevated BUN/creatinine), infection (high WBCs). While most of these values are marginally abnormal (by this scenario’s intent), they should not be ignored. For this discussion, let’s focus on the low platelets and the potential for bleeding. PAUL MACKLER President/CEO PETER NORRIS Executive Vice President/General Manager JEFFREY MARTIN Vice President/Group Publisher Cardiology Division ALEX SLONIM Vice President/Associate Publisher of Cardiology CARSON MCGARRITY National Account Manager NICK OTRANTO Account Manager LUCINDA BESKA Classified Advertising Sales Manager FRED KLUMPP Manager of Information Systems KATHY MURPHY Production Director STEFANIE TULEYA RENEE OLSZEWSKI Special Projects Editors KIMBERLY B. CHESKY Production Director, Special Projects PATRICIA LEVY Director of NACCME What is a safe platelet count to perform arterial puncture? A platelet count of less than 50,000 should raise concern about significant bleeding after any puncture, arterial or venous. Platelet counts of less than 20,000 could be considered as an absolute contraindication for punctures. In some patients, especially those with renal failure, even platelet counts around 100,000 might be associated with some bleeding due to renal failure-related platelet dysfunction. We should understand the cause of low platelets before any invasive procedure. Although we may get through the cath without problems, the post-cath care may be complicated by significant bleeding, especially at the arterial puncture site. We should also be concerned about bleeding if an intervention, pacemaker insertion, intra-aortic balloon pump (IABP), or significant intracardiac catheter manipulations which might bruise or even puncture heart structures have been performed. Some maneuvers (e.g., a transseptal approach) are obviously associated with a high risk for bleeding even when coagulation functions are normal. For our patient above, in general we do not give platelets unless there is evidence of clinical bleeding or an emergency invasive procedure is required. If the procedure is urgent, the patient might then get a platelet transfusion before the procedure and if there were signs of bleeding, another afterward. Table 1. Types of HIT Type I HIT Timing Platelet count Incidence Early, transient Rarely <100K 10-20% Comment Not immune. No thrombosis. No Rx needed. 3% UFH, Immune. Complex to 0.1% LMWH PF4. Thrombosis in 30-40%. Discontinue (DC) heparins, use anti-thrombins. Type II HITT Late, prolonged Often <100K What about a new low platelet count after cath? Is it HIT? In the setting of cardiac catheterization, low platelet counts post-procedure are most commonly related to drugs or exacerbations of pre-existing clinical conditions. Exposure to certain drugs leading to destruction of circulating platelets is often associated with potential CIRCULATION: Bonnie Shannon Tel: (800) 237-7285, ext. 246 or (610) 560-0500 ext. 246 E-mail: BShannon@ hmpcommunications.com SUBSCRIPTION INFORMATION CATH LAB DIGEST is sent to all non-physician cath lab personnel working in the United States (international subscription is $60 for 1 year). If you are not receiving CATH LAB DIGEST and would like to, or have an address change, please complete the enclosed postage-paid subscription card and return to: HMP COMMUNICATIONS 83 General Warren Blvd., Suite 100 Malvern, PA 19355 POSTMASTER Send address changes to: Cath Lab Digest 83 General Warren Blvd., Suite 100 Malvern, PA 19355 PRINTED in the U.S.A. continued on page 6 Editorial Correspondence: Rebecca Kapur, Managing Editor, HMP COMMUNICATIONS Cardiology Editorial Offices, 7427 Winding Way, Brecksville, OH 44141 Tel. (800) 459-8657 Fax: (216) 393-0445 Email address: RKapur@hmpcommunications.com Circulation: Bonnie Shannon, BShannon@hmpcommunications.com, tel. (800) 237-7285, ext. 246 Advertising: Jeffrey Martin, Vice President/Group Publisher, tel. (800) 237-7285, ext. 238, Email: jmartin@hmpcommunications.com Alex Slonim, Vice President/Associate Publisher, tel. (800) 237-7285, ext. 245, Email aslonim@hmpcommunications.com Carson McBrayer, National Account Manager, tel. (800) 237-7285, ext. 234, Email: cmcbrayer@hmpcommunications.com Nick Otranto, Account Manager, tel. (800) 237-7285, ext. 270, Email: notranto@hmpcommunications.com Advertising address: HMP COMMUNICATIONS, 83 General Warren Blvd., Suite 100 Malvern, PA 19355 Tel. (800) 237-7285. Cath Lab Digest (ISSN# 1073-2667) is issued 12 times per year by HMP COMMUNICATIONS, 83 General Warren Blvd., Suite 100, Malvern, PA 19355. Periodicals postage paid at Malvern, Pennsylvania and additional mailing offices. 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Table of Contents Feed for the Digital Edition of Cath Lab Digest - October 2007

Saints Medical Center Fibromuscular Dysplasia in Children and Adolescents Cerebral Vascular Accident Following a Pulmonary Embolism: Search for the Hidden Patent Foramen Ovale Contents Clinical Editor’s Corner Meetings Calendar CEU Education Center Radiation Tracking in the Cardiac Catheterization Lab Letter to the Editor Carotid Stenting: An update Release from Stent-jail: Beneficial Snow-Plowing? Patient Management Guidelines Searching for a Cardiovascular Position? Tips for Creating a ‘Stand-Out’ Resume Long-Term Implications of Short-Term Closure Decisions – The Evolution to Vascular Access Management and the Boomerang Catalyst System The Ten-Minute Interview with… Angie Bowles, RN, CCRN CMS Issues Final FY 2008 IPPS Rule ACVP• Membership Page Experience with a New Workhorse Guidewire Ask the Clinical Instructor: Q&A for Those New to Cath Lab A Glimpse of the Future of Clinical Education: Boston Scientific’s SimSuite Bus Visits Carnegie Institute 2007 Educational Fair Held at the Washington Hospital Center Research Update: Original Contribution Abstracts from The Journal of Invasive Cardiology What Do You Think? A Virtual Cath Lab Viewer (VCL): The Development of an Online 3D C-arm Simulator and Coronary Anatomy Viewer Clinical & Industry News Cost-Effectiveness of the Radial versus Femoral Artery Approach to Diagnostic Cardiac Catheterization

Cath Lab Digest - October 2007

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