(22KB)DeGiovanni JV. Management
of an absent pulse following arterial catheterisation. Images
Paediatr Cardiol 2002;13:19-21
|
|
|
|
(22KB) |
DeGiovanni JV. Management
of an absent pulse following arterial catheterisation. Images
Paediatr Cardiol 2002;13:19-21
|
|
|
Consultant Paediatric Cardiologist, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK |
| Arterial Injury | Catheterisation | Anticoagulation |
| Fibrinolysis | Heart defects, congenital |
Article
Following arterial catheterisation, which is usually percutaneous and
often through the femoral vessel, clinical observations include palpation
of distal pulse, colour, temperature and capillary return of the used limb,
as well as bleeding and haematoma formation. If any of these observations
indicate reduced perfusion to the limb, remove any tight dressings, nurse
the limb exposed and at room temperature and make sure that there is no
line of demarcation as this indicates severe circulatory compromise. The
clinical observations can be confirmed by Doppler and the blood pressure
in the affected limb can be measured and compared with the contralateral
one, if unused.
Step 1: Anticoagulation
The initial treatment consists of heparin 100 U/kg as a single stat
dose, followed by an infusion of 20 U/kg/hr. If there is clinical improvement
in perfusion but the pulse remains absent after 4 hours of infusion, check
the activated partial thromboplastin time (APTT) and adjust the heparin
dose appropriately to achieve a level of around 2.5 times the control value.
Continue with heparin if improvement continues, otherwise go to the next
step i.e. thrombolysis.
Step 2: Thrombolysis
Thrombolysis should be considered if there is no clinical improvement
with heparin or if the pulse fails to return despite improvement in limb
perfusion after 4 hours of infusion and so long as there is no contraindication.
Take baseline clotting profile (repeat APTT, prothrombin time and thrombin
time) haemoglobin, fibrinogen level and cross match one unit of blood.
Ensure that patient has adequate venous access. The two commonest agents
used are streptokinase and recombinant tissue plasminogen activator (rTPA).
Streptokinase.
Initial bolus 1000 units/kg followed by an infusion of 1000 units/kg/hr.
rTPA Regime 1
Initial bolus of 0.7 mg/kg followed by an infusion of 0.2 mg/kg/hr.
rTPA Regime 2
Infusion 0.1 to 0.5 mg/kg/hr (incremental increase of 0.1 mg/kg/hr).
End Points
1. Return of pulse.
2. Bleeding at entry site.
3. Internal bleeding e.g. haematemesis, melaena, cerebral haemorrhage,
retroperitoneal bleed.
4. If no response after 6 hours or if clinical deterioration
If pulse becomes weaker after stopping lytic agent, start heparin infusion 10 units/Kg/Hr with the option of further increasing the dose. If pulse disappears after stopping lytic therapy, further thrombolysis can be carried out. Patients should not be discharged for 24 hours after stopping lytic agent to make sure that pulse patency persists and that there are no signs of bleeding. The risk of bleeding can be as high as 50%.
Step 3: Invasive measures
If the pulse or limb perfusion fail to return despite adequate thrombolysis
as assessed by thrombin time and fibrinogen levels (fibrinogen levels must
be < 1.9) or if the viability of the limb is in question, consider surgery
in infants or children. Adults may benefit from an intervention e.g. angioplasty
or stent. Surgery often consists of thrombectomy, repair of intimal flap
or repair of avulsed vessel.
Heparin alone is expected to be sufficient in around 75 – 80%. The rest will receive a lytic agent with complete restoration of the pulse in 65%, partial restoration in another 20% and the remaining 15 % will require surgery. Overall, surgery will be required in less than 5 %, and very rarely, will the limb require amputation
Further reading
 |
|
  |
 |