Percutaneous puncture of the right (or left) femoral artery under local anesthesia, coronary angiography and dilation of the lesion with a special balloon catheter, then the balloon catheter with stent was sent to the lesion, and the balloon was dilated at 8 atmospheric pressure for 30 ~ 60 seconds, and then the stent was implanted. Then use a high-pressure resistant balloon to pressurize to 12 ~ 16 atmospheric pressure, and expand for 30 ~ 60 seconds to ensure uniform expansion of the stent. The stent will be permanently embedded in the intima of the patient's coronary artery. After inserting the femoral artery sheath during the operation, heparin sodium 12 500 U was injected intravenously, and then heparin sodium was injected intravenously for every extension of 1h, with a total amount of
Postoperative care:
Stay in CCU 24 hours after operation and closely monitor ECG; Monitor the prothrombin time (PT), and closely observe whether there is angina pectoris recurrence, femoral artery wound bleeding and dorsalis pedis artery pulsation.
Prevention and monitoring of stent thrombosis
1, strict anticoagulant therapy. The most important complications of stent implantation are acute and subacute thrombosis. Pay attention to reasonable anticoagulation after operation. All stents that have not been expanded by high-pressure balloon or have been expanded by high-pressure balloon are in a hypercoagulable state, so it is necessary to closely monitor PT and strengthen anticoagulant therapy. The effective anticoagulation index is: PT should be reached at 24 h after operation and maintained at 24 s. In nursing care, patients should be given aspirin+ticlopidine+heparin and other drugs combined with anticoagulation, in which the rational use of heparin is the most critical. According to the results of PT test, we summarized two usages:
① Ordinary heparin: 7 500 U heparin calcium was injected intravenously after 6 hours without bleeding, and then 12 500 U heparin sodium was added into 500ml normal saline for intravenous drip, within 4 hours 16ml/h, after 4 hours 17ml/h, after 8 hours19 ml/h. From the 5th postoperative day to 10, 7 500U heparin calcium was injected subcutaneously into abdominal wall, once every 1 2 h. ..
② Low-molecular-weight heparin: 0.3ml or 0.4ml was injected subcutaneously into the lower abdominal wall from 6 hours after operation, every 12 hours/time for 1 week 1 0 day. After operation, the patients were instructed to take anticoagulants such as aspirin, ticlopidine or warfarin 1 ~ 3 months according to the doctor's advice, and PT was checked every week and the dosage was adjusted. Pay attention to vomiting, diarrhea and bleeding tendency of skin and mucosa.
2. Acute or subacute stent thrombosis usually occurs within 24 hours and 2 weeks after stent implantation. At this stage, the patient's emotional tension is a common cause of coronary artery spasm. Persistent severe coronary artery spasm can lead to platelet aggregation, thrombosis or stent occlusion. Therefore, attention should be paid to health education and psychological nursing before and after operation. For example, explain before the operation, broadcast videos, distribute information, and invite patients who have successfully operated to introduce their personal experiences, so that patients can understand the necessity, methods, process, precautions and safety of the operation; Tell patients that the safety of staying in CCU after operation can be guaranteed. Closely monitor angina pectoris and the changes of S-T and T ... The recurrence of angina pectoris indicates stent thrombosis or acute coronary re-occlusion, which should be paid great attention to. It is necessary to closely observe ECG monitoring and often ask patients whether they have chest tightness, chest pain, sweating, palpitations and other symptoms. Once the patient has the above symptoms or feels unwell, take necessary measures and report the condition to the doctor immediately, and carry out thrombolytic therapy if necessary, and make all preparations for emergency PTCA or coronary artery bypass grafting.
Second, the prevention and care of wound bleeding
The femoral artery sheath must be removed 1 and 1 day after operation, and heparin should be stopped 4 ~ 6 hours before extubation. It is necessary to keep the femoral artery sheath after operation, but there are risk factors such as sheath rupture and bleeding. According to previous reports, the sheath should be kept for 24 hours after operation. Nursing practice has proved that most patients can recover to a stable state within 4 ~ 6 hours after operation, that is, extubation.
2, wound dressing appropriate use "8" bandage method. After extubation, the first 36 cases in this group pressed the wound by hand for 30min to 1h, fixed it with wide adhesive tape, and pressed it with sandbags for 8h, and 9 cases showed wound infiltration, bleeding or subcutaneous hematoma. 163 cases were fixed with bandage "8" method for 24 ~ 72 hours, and 6 cases developed subcutaneous hematoma (due to premature movement). Its advantages are:
① Under full compression, platelet aggregation at the wound is enhanced, resistance to femoral artery pressure is increased, and bleeding is reduced;
② The bandage is tight and not loose;
③ The bandage roll fixed at the wound does not slip off, and the effect of pressure hemostasis is positive;
(4) Prevent skin blisters at the wound caused by allergic use of adhesive tape and epidermis peeling caused by excessive pulling of skin by adhesive tape;
⑤ Effectively prevent bleeding.
3. Extend the bed rest time. In the past, patients were confined to bed for 24 hours after surgery. We observed that subcutaneous hematoma often occurred at the puncture site 24 hours after operation or after premature limb movement. In the future, patients are required to completely brake their limbs within 8 hours after extubation, lie on their back for 24 hours (without looking up or talking), stay in bed for 48 hours, sit by the bed for 48 hours and get out of bed for 72 hours, which effectively reduces the incidence of bleeding.
Third, the prevention and care of hypotension.
1, prevent hypovolemia and use drugs rationally. The observation of the first 32 cases in this group showed that postoperative hypotension was easy to occur. Considering that it is related to the patient's nervousness, fasting 14 ~ 18h, intraoperative blood loss, intraoperative and postoperative application of vasodilators, calcium channel blockers and magnesium polarization solution, the following measures are taken:
(1) Psychological care for patients with neurological causes;
② Fasting for 4 hours before operation;
③ Stop the infusion of vasodilators immediately after returning to the ward;
④ Eating resumed immediately after operation;
⑤ Ensure that there are at least two venous passages within ⑤24h hours, replenish blood volume in time, and then apply vasodilators.
2, preoperative hypotension can not be corrected or shock, intra-operative and postoperative aortic balloon counterpulsation.
3. Using femoral artery indwelling sheath to pressurize fluid infusion can quickly and effectively correct hypovolemia. In this group, 2 cases suddenly appeared hypovolemia 30 minutes and 80 minutes after operation. Immediately, 500 ~ 1000 ml balanced saline was injected from the femoral artery sheath under pressure and whole blood was infused for about 5 ~ 10 min, and the blood pressure of the patients returned to normal and turned to safety.
4, closely monitor blood pressure, heart rate, urine volume, observe whether there is any wound bleeding. For patients with hypertension, old age and extremely low cardiac function, we must carefully compare their basic blood pressure and pulse pressure, comprehensively analyze the overall situation, and accurately judge the early hypotension. 30 minutes to 3 hours after operation, nausea is often a precursor of hypotension or shock, and shock also occurs after urination. Unexplained hypotension should be checked for retroperitoneal bleeding (pain in the left and right lower abdomen), puncture site bleeding (such as swelling, discoloration and pulse disappearance), coronary artery rupture or perforation (pericardial tamponade), except for insufficient blood volume. When bleeding complications occur, the dosage of anticoagulant should be adjusted immediately and treated. In this group 1 case, pericardial tamponade occurred 4 hours after operation. Considering coronary artery perforation, pericardial drainage was performed immediately and he was discharged 8 days after operation.
Fourth, prevent arrhythmia, hypotension or shock and coronary artery spasm that may occur when the femoral artery sheath is removed.
After strict anticoagulant therapy, femoral artery wound is difficult to stop bleeding. Immediately after extubation, pressure should be applied to stop bleeding. However, if the force is too strong, or two wounds are pressed at the same time, the right coronary artery disease will cause vagus reflex bradycardia, which will reduce the blood returning to the heart and cause shock. Severe pain in the wound will increase the heart rate or cause coronary artery spasm. Therefore, antiarrhythmic, reinforcing, antispasmodic and vasodilating drugs should be prepared according to the condition, and urokinase should be prepared if necessary. In this group 1 case, sudden tachycardia and mild shock occurred when the sheath was pulled out to stop bleeding. ECG monitoring showed that the heart rate was 30 ~ 40 beats/min and the blood pressure was 6/0kPa. Immediately intravenous atropine 2mg, intravenous dopamine and dobutamine 40 ~ 60 mg. At the same time, the pressure of the wound was reduced, and the patient's blood pressure and heart rate quickly returned to normal, out of danger. Summing up the above experience, we improved the nursing methods:
(1) Compression and hemostasis by rupture and decompression;
② The force of pressing the wound should be based on the pulse of the dorsal artery of the foot;
(3) When bilateral femoral artery trauma occurs, extubation and pressing at the same time are strictly prohibited;
④ Patients with severe tension and wound pain must relax physically and mentally, and lidocaine 50 ~ 100 mg is injected subcutaneously at the wound. There was no abnormal change in the condition during extubation.