00:00:03.657 --> 00:00:22.

817
ARIS S. SANTOS
Was a former cardiac nurse or cardiac ICU nurse in Abu Dhabi. So I feel like to share
something today on hand. So I hope you will be learning a lot from our today's
lecture.
00:00:22.857 --> 00:00:23.097
ARIS S. SANTOS
Lecture.
00:00:26.457 --> 00:00:26.777
ARIS S. SANTOS
Start.
00:00:29.377 --> 00:00:44.697
ARIS S. SANTOS
So let's have A. little touch of history. So angina pictoris was actually introduced by
Heberden in 1772 to describe actually A. syndrome characterized by A. sensation of
strange length and anxiety in the chest.
00:00:44.697 --> 00:01:03.897
ARIS S. SANTOS
And then coronary artery bypass graft was first introduced or performed in 1960
and introduced globally in 1968. And then the percutaneous transgluminal coronary
angioplasty was first performed in September of 1977 by Andreas Brewitzig.
00:01:03.977 --> 00:01:23.257
ARIS S. SANTOS
So at the shot, so Andreas Luencing was A. German radiologist and cardiologist with
foundational interest training and research in epidemiology and angiology. He is
known for being the first to develop successful balloon angioplasty for expanding
lumen of narrowed arteries.
00:01:24.417 --> 00:01:29.137
ARIS S. SANTOS
And then the use of stents or coronary stents was first introduced in 1982.
00:01:32.017 --> 00:01:47.817
ARIS S. SANTOS
So what is interventional cardiology? So it is A. subspecialty of cardiology that uses
specialized catheter based techniques to diagnose and treat coronary artery
disease, vascular disease, the structural heart disease and congenital heart defects.
00:01:49.017 --> 00:02:04.857
ARIS S. SANTOS
It is performed by interventional cardiologist, various diagnostic tools and imaging
techniques to measure cardiovascular functions such as blood pressure and blood
flow in major arteries throughout the body and within the different chambers of the
heart.
00:02:05.977 --> 00:02:25.897
ARIS S. SANTOS
So interventional cardiologist do not perform traditional open heart surgeries. So the
use of catheters percutaneously inserted and then it goes straight to the heart and
then.
00:02:26.097 --> 00:02:41.617
ARIS S. SANTOS
diagnosis and treatment using these catheter-based techniques under fluoroscopy.
We see abiotic fluoroscopy that is through the use of guided X-rays real time.
00:02:44.737 --> 00:03:01.177
ARIS S. SANTOS
So what is A. cardiac catheterization lab? So this is A. also known as cardiac cath
lab. So it is A. special hospital group where doctors and nurses and cath lab techs
perform minimally invasive tests and procedures to diagnose and treat
cardiovascular disease.
00:03:01.657 --> 00:03:20.937
ARIS S. SANTOS
So the procedures performed in A. cardiac cath lab almost always involve tiny,
flexible tubes or catheters, which can be used instead of surgery to access the heart
and blood vessels. A Cath lab has special imaging equipment used to see the
arteries and check how well blood is flowing.
00:03:21.017 --> 00:03:23.137
ARIS S. SANTOS
To and from behind.
00:03:24.697 --> 00:03:42.497
ARIS S. SANTOS
So when I get A. background that is an actual cath lab where I used to work. So
what are the procedures that can be done in A. cath lab? So the most common is
coronary angiography, we shall be discussing later on. So that is A. diagnostic test.
00:03:42.697 --> 00:03:57.737
ARIS S. SANTOS
Used to actually visualizing my coronary arteries and then coronary angioplasty plus
stenting. So I can insert and then balloon tip catheters. That was Pinalulu wag. You
man A. stenopic blood vessels.
00:03:57.737 --> 00:04:17.217
ARIS S. SANTOS
What about pericardiosis and disease? So ethenamide is actually the removal of
excess fluid in the pericardial sac, usually for patients. OK, so X-ray diet pinion that
you insert the needle, usually because of siphoid process.
00:04:17.577 --> 00:04:23.857
ARIS S. SANTOS
And then, uh, the tip of the needle should reach the pericardial sub and then I got
aspirate go down fluids.
00:04:24.697 --> 00:04:44.057
ARIS S. SANTOS
Another thing is characterization for hemodynamic measurements. So
comprehensive hemodynamic measurements.
00:04:44.377 --> 00:04:59.697
ARIS S. SANTOS
Usually it is called smart pets catheter, usually through A. femoral approach or
regional approach.
00:05:00.297 --> 00:05:16.057
ARIS S. SANTOS
OK. And then measurement such as your cardiac output, your intra arterial VP, your
cardiac index, your pulmonary capillary wedge pressure, uh, CVP and pulmonary
artery pressure.
00:05:17.457 --> 00:05:31.457
ARIS S. SANTOS
So another procedure that is being done by Cath lab is your IABP insertion. So I
need A. manual IABP insertion. So usually this is A. balloon inserted in the aorta.
00:05:32.457 --> 00:05:48.497
ARIS S. SANTOS
So that your thigh, you know, is A. very large artery, OK, that leaves living in our
heart. Oh, so you know for the systemic circulation. So this procedure is done
through A. small cut inside your upper leg. So usually femoral approach though.
00:05:49.057 --> 00:06:07.737
ARIS S. SANTOS
And then the doctor will insert the balloon from catheter into the artery of the leg.
Then he or she will then guide it through the aorta. So from there your IAPP will start
to do its work. So the balloon is set to inflate when the heart relaxes. OK, so if you
relax your heart.
00:06:08.777 --> 00:06:25.977
ARIS S. SANTOS
He inflamed. It will actually pushes the blood going to the coronary arteries.
Remember that this IAPP actually help the heart heal.
00:06:28.217 --> 00:06:45.097
ARIS S. SANTOS
So within the heart muscles, effective pumping down heart. So as you can see ICU.
00:06:46.737 --> 00:07:06.217
ARIS S. SANTOS
So another procedure is Renal angiography plus angioplasty. So renal stenosis and
same with the peripheral angiography and angioplasty. So I continue to check that
in your blood vessels.
00:07:06.257 --> 00:07:22.177
ARIS S. SANTOS
Venous stasis, OK, or you might be instead of A. box of veins and then the
angioplasty to actually promote better blood flow to diseased arteries and veins
now.
00:07:22.377 --> 00:07:42.057
ARIS S. SANTOS
Another one is our transpheno spacing. So usually this is indicated the effective flow
of electricity within the heart. So we insert the banyan through veins.
00:07:42.057 --> 00:07:57.337
ARIS S. SANTOS
Another one is the pacemaker implantation.
00:08:01.257 --> 00:08:20.777
ARIS S. SANTOS
Uh, say some card. That's initially spacing. OK, pacemaker. OK, so your pacemaker,
that is A. that is in A. device.
00:08:21.297 --> 00:08:40.977
ARIS S. SANTOS
It will actually be the one responsible in stimulating the SA node just in case on A.
normal.
00:08:41.297 --> 00:08:42.537
ARIS S. SANTOS
Weekend repair.
00:08:44.137 --> 00:08:59.417
ARIS S. SANTOS
So next we have A. balloon mitral valvuloplasty. So this is where A. balloon is
actually placed in the stenotic bulb. So through femoral approach and then it will
inflate the balloon to actually loosen up the stiff.
00:09:19.537 --> 00:09:26.857
ARIS S. SANTOS
stenotic aortic blood, so therefore promoting better blood flow going to the aorta for
systemic circulation.
00:09:27.897 --> 00:09:47.657
ARIS S. SANTOS
Next another, sorry, another procedure being done is your ethanol septal ablation.
So procedure, usually for patients who have A. cardiomyopathy. So cardiomyopathy
is usually.
00:09:47.737 --> 00:10:04.937
ARIS S. SANTOS
Heart muscles, so heart muscles, there would be no enough space for the heart to
actually pop or compaganda space for it to pop.
00:10:05.617 --> 00:10:22.537
ARIS S. SANTOS
So the patient will actually be have a a catheter inserted, OK and then the tip of it
OK and then that alcohol.
00:10:22.977 --> 00:10:42.817
ARIS S. SANTOS
Or actually that is toxic and then it will cause the heart muscles to actually shrink.
So the last one is the your septal defect closure. So septal defect closure later. So
usually this is.
00:10:42.817 --> 00:11:00.097
ARIS S. SANTOS
Congenital anomalies know so like the your atrial septal defect, your ventricular
septal defect. So epo me it is a usually it runs category pair. So through the use
again by a long flexible catheter or tube the mesh small device would actually.
00:11:00.497 --> 00:11:20.337
ARIS S. SANTOS
It would actually be inserted the and then that hole patch. OK, so these are the
procedures that is usually done inside a card shack lab.
00:11:22.417 --> 00:11:38.977
ARIS S. SANTOS
So we can use a picture. OK, this is a cardiac cath lab. OK, so here at the patient's
table and then we have, we have here the your monitors, OK.
00:11:38.977 --> 00:11:58.657
ARIS S. SANTOS
So that these are hemodynamic monitoring monitors then would actually be used
by a picture coronary arteries. And then on this side is hemodynamic
measurements.
00:11:58.737 --> 00:12:07.217
ARIS S. SANTOS
And of course the ECG right, OK of the patient. And then we have here the
defibrillator, we have the suction machine, OK and then.
00:12:08.257 --> 00:12:15.177
ARIS S. SANTOS
We have here your pressure monitoring line, OK? And then we have your.
00:12:16.257 --> 00:12:20.577
ARIS S. SANTOS
That is our baby apparatus. We have here the uh.
00:12:24.457 --> 00:12:33.137
ARIS S. SANTOS
Your infusion pump and then your syringe pump and then this is the manual having
IAPP monitor, OK.
00:12:34.337 --> 00:12:51.817
ARIS S. SANTOS
Of course not. This is the anesthesia machine. OK, so the patient needs to undergo.
00:12:52.897 --> 00:13:11.697
ARIS S. SANTOS
General anesthesia intubates the lab, although ideally most or actually all of the
procedures are usually through sedatives lab. So there should always be an access
for an anesthesia machine.
00:13:12.097 --> 00:13:24.257
ARIS S. SANTOS
On the other side of the table.
00:13:27.097 --> 00:13:46.257
ARIS S. SANTOS
So now so so that is me like a decade ago when I was working in a path lab. So as
you can see you are so.
00:13:46.337 --> 00:14:05.937
ARIS S. SANTOS
So from your scrubs, you need to wear a a and then sterile tapes. I'm sorry now
sterile gowns for the patient. And then also a Gath lab nurse is usually a vital part of
the Gath lab care team.
00:14:05.937 --> 00:14:21.217
ARIS S. SANTOS
Primary roles to actually assist the cardiologist during catheterization procedure. So
they examine patients before the procedure and monitor their vitals throughout the
entire process. So the responsibilities of the Cath lab nurses of Cath lab nurses
include.
00:14:21.217 --> 00:14:36.417
ARIS S. SANTOS
Ensuring consent, OK, paperwork for the patient. So it needs to be completed and
filed in the patient's chart. So usually tie in the Sisecurin of your map. But of course
the cardiologist is the one who is explaining the procedure.
00:14:36.817 --> 00:14:54.177
ARIS S. SANTOS
Especially at the risk of the condition of toxic like multiple vessels that are involved.
And then we are also the one responsible in preparing the patient for the procedure,
which can include sterilization and shading areas where the catheter will be
inserted.
00:14:54.257 --> 00:15:02.137
ARIS S. SANTOS
And then monitor exhibition levels during and after catheterizations to ensure a
patient is not experiencing an adverse reaction.
00:15:03.217 --> 00:15:21.457
ARIS S. SANTOS
And then if we are the also the one responsible in assisting in the in interventional
procedures such as balloon angioblasty, stent placement and cutting balloons. So
later on I will discuss on that. We are also the one responsible in monitoring patients
for sign of infections or side effects following the catheterization.
00:15:21.537 --> 00:15:39.657
ARIS S. SANTOS
Next is delivering discharge paperwork and instructions to patient and families. So
that includes details on medications, activities, dietary restrictions and following the
procedure. And then we are also the one responsible updating patients charge with
specific information about the.
00:15:39.937 --> 00:15:40.777
ARIS S. SANTOS
I.
00:15:43.377 --> 00:16:01.297
ARIS S. SANTOS
So to better have a better understanding of ECS of A. So we have to do first the
review of coronary circulation of the coronary arteries. So I would like you to
remember you insurance. Yeah. So I.
00:16:01.377 --> 00:16:19.537
ARIS S. SANTOS
So from here, right coronary artery and then left coronary artery. So from the left
coronary artery, so that is your left.
00:16:19.697 --> 00:16:23.857
ARIS S. SANTOS
Circumplex artery and then your left uh.
00:16:24.497 --> 00:16:27.177
ARIS S. SANTOS
Anterior descending artery, OK.
00:16:28.657 --> 00:16:47.817
ARIS S. SANTOS
So actually in the important thing to got. So we have your right coronary artery and
then from your LCA complex and your left marginal artery. OK, so you acting.
00:17:03.057 --> 00:17:19.577
ARIS S. SANTOS
Anterior representing anterior part. OK, let me just this is a coronary artery in
coronary angiogram. OK.
00:17:40.497 --> 00:17:58.257
ARIS S. SANTOS
And then this is your RCA, OK. So this has nothing to right side. So your RCA that is
your right coronary artery and then marginal arteries, OK. And then we also have
the posterior descending artery.
00:17:58.377 --> 00:18:12.697
ARIS S. SANTOS
OK. So what is important about the artery? This is the one responsible in supplying
blood to the left.
00:18:30.137 --> 00:18:40.617
ARIS S. SANTOS
And then from the.
00:18:42.657 --> 00:18:57.417
ARIS S. SANTOS
LAB diagonals and that's a LC extra man M1M20 marginal arteries, OK.
00:18:58.857 --> 00:18:58.977
ARIS S. SANTOS
OK.
00:19:02.017 --> 00:19:17.137
ARIS S. SANTOS
So the left main coronary artery is a short vessel that branches into the left anterior
descending artery or what we call LAD, so which supplies blood to the front or the
anterior wall and part of the side anterolateral wall of the left ventricle.
00:19:17.377 --> 00:19:24.257
ARIS S. SANTOS
To the top of the left ventricle and to the most of the wall between the ventricles or
your interventricular set too.
00:19:25.217 --> 00:19:42.977
ARIS S. SANTOS
The other one is your circumflex artery, which passes behind the heart between the
left ACU and left ventricle and supplies blood to the side or the lateral wall of the left
ventricle. In a small number of people, the circumflex artery supplies the lower and
back portions of the left ventricle.
00:19:44.097 --> 00:20:03.497
ARIS S. SANTOS
And then the right coronary artery, it supplies blood demand to the right ventricle
and then supplies the underside or inferior wall and backside or posterior wall of the
left ventricle. So most of the people, the posterior wall, I say left ventricle.
00:20:03.617 --> 00:20:20.377
ARIS S. SANTOS
What I would like you to think is that.
00:20:20.417 --> 00:20:39.937
ARIS S. SANTOS
So so let me just discuss this first. So part abdominance is determined by which
coronary artery branch tips of the posterior descending artery and supplies the
inferior wall and is characterized by either.
00:20:40.097 --> 00:20:59.737
ARIS S. SANTOS
Right or left or co-dominance. OK, so your part of dominance. Um, supply posterior
descending artery. Posterior descending artery. Main part coronary circulation.
00:21:00.537 --> 00:21:19.857
ARIS S. SANTOS
And left ventricle is the main pumping chamber of the heart. So for 70 to 80% of the
people, it's usually right heart dominance.
00:21:19.857 --> 00:21:39.417
ARIS S. SANTOS
To you, uh, PVA or arteries, right coronary artery. And for some people it's usually
left 5 to 10% are left heart dominance and then for 10 to 20% of the population it's
usually called dominance.
00:21:39.777 --> 00:21:48.857
ARIS S. SANTOS
Both right and left coronary arteries supply supply to the posterior descending
artery.
00:21:50.657 --> 00:22:09.697
ARIS S. SANTOS
So as you can see in the diagram from the aorta, your right coronary artery and
your left coronary artery. So left anterior descending and then circumflex. So from
left anterior descending we have your diagonal branches which supplies blood.
00:22:09.777 --> 00:22:25.217
ARIS S. SANTOS
Your septum from your LCS your complex. It will then brush out your marginal
branches that will then give blood supply to the lateral wall of the heart. And for
your diagonal branches, it usually it also supplies.
00:22:25.217 --> 00:22:39.617
ARIS S. SANTOS
Uh, blood flow to the anterior wall of the heart. And then from LCA, right or left
dominance or both.
00:22:40.697 --> 00:22:43.497
ARIS S. SANTOS
Right and left call dominance, right?
00:22:44.657 --> 00:23:02.897
ARIS S. SANTOS
So from posterior descending, OK, it usually supplies blood to the posterior wall and
then it also supplies to the inferior wall. I need that for the left ventricle. OK, so.
00:23:03.057 --> 00:23:17.977
ARIS S. SANTOS
All of them usually branch out from the posterior descending artery and then from
your right coronary artery it will then branch out your marginal branches and then it
will then if blood supply to the left to the right left again, OK.
00:23:21.857 --> 00:23:39.777
ARIS S. SANTOS
So now let's just discuss a short of the different hard walls. So from here a picture of
the green one, OK, these are the areas involved in inferior and right ventricular in
parks, OK.
00:23:40.057 --> 00:23:56.337
ARIS S. SANTOS
And then the yellow one is your the areas involved in septal import, OK. And then
the purple one is usually the areas involved in a lateral impart and then the blue
one is the areas involved in anterior imparts.
00:23:56.457 --> 00:24:09.177
ARIS S. SANTOS
OK, so I. OK, so we have to get the location, so that is usually be.
00:24:12.817 --> 00:24:30.537
ARIS S. SANTOS
Identified by the TCG depending on the leads St. elevation or through the use of
coronary angiogram. OK, so just keep in mind that the articles are important as a
diagnostic lab market.
00:24:30.777 --> 00:24:50.297
ARIS S. SANTOS
So to determine what specific part of the heart, will heart wall where in part that
tissue that due to decrease oxygen from the blood supply. So the common cause of
MI is atherosclerosis. So it refers to the build up of fats, cholesterols and other
substances in and on your artery walls or.
00:24:50.737 --> 00:25:01.297
ARIS S. SANTOS
There are plaques which can actually restrict blood flow, the plaque and burst
triggering a blood plaque. So it is usually determined that in ECGN coronary
angiograph, so I have said.
00:25:03.417 --> 00:25:23.297
ARIS S. SANTOS
So now let's proceed to acute coronary syndromes. So it is a term refers to a range
of acute myocardial ischemic states. So it usually has three types. OK, we have first
your unstable angina, your non St. segment elevation, myocardial infarction or your.
00:25:23.297 --> 00:25:36.617
ARIS S. SANTOS
And STEMI and then your SD elevation biohargial impartion or STEMI. OK, so I know
that you already so that's the.
00:25:40.057 --> 00:25:42.817
ARIS S. SANTOS
Uh, usually the uh.
00:25:44.497 --> 00:26:04.057
ARIS S. SANTOS
So troponin levels method. OK, so blood. So for the diagnostics we are we usually
use 12 with ECG. We have cardiac markers or your troponin eye, which is usually
quantitative parabasamine measure and then your exercise electrocardiography or
your stress test and then your.
00:26:04.497 --> 00:26:22.017
ARIS S. SANTOS
Coronary angiogram. So just to show that a a figure. So the classification of of
coronary syndrome. So usually chest pain. And then of course remember that we do
not sleep chest pain slightly unless we rule out maybe or heart problem.
00:26:22.537 --> 00:26:32.897
ARIS S. SANTOS
So we suspect of the coronary syndrome, if there is an St. elevation in the ECG,
definitely it is already considered standing, OK.
00:26:34.017 --> 00:26:48.697
ARIS S. SANTOS
The other St. segment or T wave changes, the positive yard. OK, usually end STEMI.
OK then the negative yard. OK, we usually.
00:26:49.137 --> 00:27:04.737
ARIS S. SANTOS
The patient is diagnosed with unstable angina.
00:27:04.817 --> 00:27:19.577
ARIS S. SANTOS
So that is and STEMI negative. It is usually unstable in China. OK, so that's how we.
00:27:20.657 --> 00:27:31.097
ARIS S. SANTOS
Guys, do you understand that diagnosed differently? Young ACS, unstable angina
and STEMI and STEMI?
00:27:33.777 --> 00:27:35.417
ARIS S. SANTOS
Can I hear a response?
00:27:38.097 --> 00:27:39.817
DELA OSA, JELINE MIGAIL P.
Yeah, well.
00:27:38.857 --> 00:27:38.977
ARIS S. SANTOS
Guys.
00:27:44.537 --> 00:27:45.377
ARIS S. SANTOS
Oh, I.
00:27:47.337 --> 00:27:50.617
ARIS S. SANTOS
Midterm exam.
00:27:51.537 --> 00:28:07.137
ARIS S. SANTOS
So you should be so ECG elevation automatic stem ECG that there is an St.
elevation.
00:28:24.617 --> 00:28:30.577
ARIS S. SANTOS
Depression usually unstable in China.
00:28:32.657 --> 00:28:40.817
ARIS S. SANTOS
Wow. OK, I'll continue. No, I didn't set up the ECS.
00:28:43.217 --> 00:28:47.977
ARIS S. SANTOS
So just to give a little, uh, pathogenesis of your ACS.
00:28:48.777 --> 00:29:04.937
ARIS S. SANTOS
But what actually happens is what is that there is actually a disruption of the
aromatous plaque and then it will then pressure or rupture the plaque and then
consequence.
00:29:05.297 --> 00:29:20.577
ARIS S. SANTOS
Exposure of core constituents like lipids, smooth muscles and bone cells. There
would come a time local generation of.
00:29:21.577 --> 00:29:36.017
ARIS S. SANTOS
And then from there there would be platelet aggregation and addition and then
formation of intracoronary trophose. So if this specific intracoronary trophose will
partially occlude a specific coronary artery.
00:29:36.017 --> 00:29:55.137
ARIS S. SANTOS
Or the partial occlusive thrombus. It will it will be resolved to unstable angina or and
STEMI. But if this intracoronary thrombus will actually become stable, OK, the
onspecific part of the coronary artery diode.
00:29:55.257 --> 00:30:02.937
ARIS S. SANTOS
OK, it will now result into steady or your SD elevation myocardial infarction.
00:30:05.257 --> 00:30:25.137
ARIS S. SANTOS
So what are the management for ACS? So pharmacologic monotayo, usually we give
oxygen therapy, so ideally 4 liters per minute by nasal glandular or face mask. But if
the patient is actually experiencing the saturation or not in the late stage or toxic
stage.
00:30:25.177 --> 00:30:43.737
ARIS S. SANTOS
The doctor will order after 10 to 15 liters per minute by a face mask. OK. And then
of course we need to advise the patient for complete bed rest. The patient is usually
on MPO, especially if we are anticipating that the patient will be undergoing a Cath
lab procedure.
00:30:43.737 --> 00:31:02.977
ARIS S. SANTOS
And then we gave opiates. OK, the opiates, usually morphine, 2 to 5 milligrams IV.
Remember that you are experiencing chest pain because of lactic acidosis, because
it is a result of anaerobic respiration.
00:31:03.337 --> 00:31:09.577
ARIS S. SANTOS
For the increasing of pain or the proportional pain. That is why we gave a strong
update, which is your more team.
00:31:10.377 --> 00:31:13.457
ARIS S. SANTOS
Next is your ISD, sorry.
00:31:20.017 --> 00:31:36.057
ARIS S. SANTOS
Next is your ISDN or your isosorbide dinitrate or the which belongs to the family of
heteroglycerin. So function of heteroglycerin as I have taught some of you in
pharmacology when you were in second year.
00:31:36.097 --> 00:31:55.777
ARIS S. SANTOS
So it is it has a vasodilatory effects of the any increase in diabeter and coronary
circulation. So it's usually given 5MG per tab sublingual. It can be done up to three
doses 15 minutes apart or chest pain.
00:31:55.977 --> 00:32:12.537
ARIS S. SANTOS
Maritime isometry ISDN. It is a 10 milligram by 10ML of fuel, so we need to plan that
together with 90CC of plain NSS, so that makes 100ML.
00:32:13.017 --> 00:32:32.657
ARIS S. SANTOS
So the usual starting order is 5 to 10 CC per hour. So what is your most important
nursing responsibility here? You have to check PP because this nitrate.
00:32:32.737 --> 00:32:48.377
ARIS S. SANTOS
Could actually cause high potential. OK, so I I.
00:32:49.617 --> 00:33:08.857
ARIS S. SANTOS
So next we have your ACS drugs. Usually it comes in a packet. We have your aspirin
or tablets, your Propidogrel or tablets. So remember that your aspirin is usually you
know, yeah, and then your Propidogrel in the end of the mouth. And then we also
give your low molecular heparin.
00:33:08.977 --> 00:33:28.177
ARIS S. SANTOS
OK, so that before heparin heparin is usually can cause breathing for instance your
low uh fractionated low molecular heparin with like your enoxaparin. So injection
subcutaneously. So it's usually .4 to point.
00:33:28.857 --> 00:33:48.617
ARIS S. SANTOS
6CC OK and then the antilipemic agents your statins. So an example if it is your
other vasitin, it could range from 40 to 80MG per tablet staff and then if
glycoprotein 2P3.
00:33:48.697 --> 00:34:08.297
ARIS S. SANTOS
A. Agents such as your Tyropipad, uh, which usually 5MG per 100ML in a premixed
vial as an infusion. OK, and then PP the time of the beta blockers or ACE inhibitors
such as your Captopril or Clonidine. OK, so they both decrease.
00:34:08.817 --> 00:34:12.577
ARIS S. SANTOS
And then another.
00:34:14.577 --> 00:34:29.377
ARIS S. SANTOS
Drugs that is usually part of the pathologic management of ACS streptokinase.
00:34:31.497 --> 00:34:51.257
ARIS S. SANTOS
OK, if you are at an emergency set up, chest pain.
00:34:51.417 --> 00:35:08.897
ARIS S. SANTOS
And your atorvastatin. OK, but for some big hospitals, your glycopropane 2B3B
agents and your tropolithics may be started depending on the doctor.
00:35:09.457 --> 00:35:09.537
ARIS S. SANTOS
Hey.
00:35:12.737 --> 00:35:31.537
ARIS S. SANTOS
So I just presented ACS medications unstable angina you expect to give aspirin
statins with a blocker or ACE inhibitors and then automatic.
00:35:31.737 --> 00:35:51.297
ARIS S. SANTOS
For N STEMI, OK, we don't consider usually PPA or your malignant and angioplasty
as an emergency. So you should ask your glycoprotein tobies.
00:35:51.737 --> 00:36:04.737
ARIS S. SANTOS
3 BF2A3B inhibitors, statins, beta blockers and your ACE inhibitors. But for Stanley,
we expect everything will be given or indicated for the patients.
00:36:10.657 --> 00:36:29.417
ARIS S. SANTOS
So remember the golden hour of ECS treatment, OK? For in some books, time of
admission to recognization should be less than 60 minutes. OK, so ideally 60
minutes. That part managed a young person there. OK, recognization means you
have to know you're paying.
00:36:29.497 --> 00:36:47.217
ARIS S. SANTOS
So for people that are people on the line sees or the use of your drop politics, that is
we we call it board to be there. OK, the goal should be less than 30 minutes. So ER
chest pain. OK, in ECG. Oops. Now he passed me, OK.
00:36:48.417 --> 00:37:03.497
ARIS S. SANTOS
So and now I'll begin with a shot of fibronilized. Uh, probably takes. OK, must start
gonna fibronilize treatment within 30 minutes. But if the hospital usually has a an
access to a path lab. OK, so.
00:37:03.857 --> 00:37:20.337
ARIS S. SANTOS
From primary coronary intervention, the goal should be less than.
00:37:20.497 --> 00:37:40.097
ARIS S. SANTOS
90 minutes. OK, maximum. Yeah. Uh, when I was working, it's usually 60 minutes.
OK, but on this 90 minutes is upon the recommendation.
00:37:40.217 --> 00:37:54.577
ARIS S. SANTOS
of the year 2021 Advanced Cardshop Life Support Guidelines. OK, so remember
door to needle is 30 minutes and then door to balloon inflation should be less than
90 minutes.
00:37:57.137 --> 00:38:16.377
ARIS S. SANTOS
So so this is actually a risk stratification system that categorizes the risk of net and
ischaic events in patients with unstable angina or non St. elevation MI and provides
a basis for therapeutic decision.
00:38:16.737 --> 00:38:36.297
ARIS S. SANTOS
So it usually includes 7 independent prognostic risk factors, assigning one point for
each risk factor. So a score of less 2 below is considered for medical and
pharmacologic management, but a score of three and above is considered for early
angiography with consideration of revascularization via primary.
00:38:36.297 --> 00:38:54.177
ARIS S. SANTOS
Coronary intervention or your CABG or your coronary artery bypass. OK, so explain
what are the seven variables for TMV score so.
00:38:55.177 --> 00:39:13.377
ARIS S. SANTOS
At age of 65 years old and above, 3 risk factors for coronary artery disease.
Example is your diabetes, meditool, hyperlipidemia, smoking or you have a family
history, OK and then even a male patient because they have a higher incidence
stuff and then 50%.
00:39:13.657 --> 00:39:33.577
ARIS S. SANTOS
Of coronary stenosis in angiography. Then there is SD segment change of 0.5mm
and then two or more vaginal episodes in the last 24 hours before presentation. And
then there is elevated cardiac markers and the use of aspirin seven days before.
00:39:33.697 --> 00:39:51.417
ARIS S. SANTOS
Presentation. So when you talk and calculate your risk now pending Mamatay or
ischemic events are presented. If you score for zero to one, that is 4.7% risk. OK, if
you just a score of two, you have 8.3 risk percent risk.
00:39:51.697 --> 00:39:52.177
ARIS S. SANTOS
OK.
00:39:53.497 --> 00:39:55.777
ARIS S. SANTOS
Then if your score of 313.2 is.
00:39:58.777 --> 00:40:17.617
ARIS S. SANTOS
And then if you score a four 19.9% risk and then if you score 526.2% risk and if you
score six to seven, at least 40.9% risk of dying or experiencing a heart attack. So if
you have cocayo at a very young age, you have this one.
00:40:18.377 --> 00:40:28.297
ARIS S. SANTOS
I mean, so I think you should consider becoming heart healthy, OK?
00:40:31.977 --> 00:40:39.857
ARIS S. SANTOS
So for the management of ACS, OK, but what do some pharmacologic management
that I discussed with Anina, we have different ways for.
00:40:41.217 --> 00:40:41.377
ARIS S. SANTOS
Or.
00:40:42.457 --> 00:41:00.457
ARIS S. SANTOS
Doing myocardial revascularization. OK, so we usually have three procedures for
assistant administration of trauma.
00:41:00.857 --> 00:41:20.217
ARIS S. SANTOS
Thrombolytics. Yeah, there is thrombolytics. So these are agents that dissolves
plots. And then we have your perfect continuous coronary intervention. This is a
combination of initial coronary angiography, coronary angiography, plus the use of
STED or prepending glomamidin atropolytics and glycoprotein 2B3A inhibitors.
00:41:20.217 --> 00:41:35.257
ARIS S. SANTOS
And then coronary, coronary artery bypass surgery. So this is just really any
gestordotomy approach, possible use of the left internal mammary artery or edema
or great sapinous vein to and that's the most in the coronary arteries.
00:41:35.337 --> 00:41:38.977
ARIS S. SANTOS
Bypassing the stenotic coronary artery, so.
00:41:40.777 --> 00:41:59.337
ARIS S. SANTOS
Before the break, you are job dominance, a part cabbage. You are job dominance
that we need to discuss the anatomy part nothing.
00:42:00.777 --> 00:42:18.337
ARIS S. SANTOS
But if if it's right or left, you can also supply those PPA. There's a posterior
descending artery. Why? A very significant surgery.
00:42:19.097 --> 00:42:36.737
ARIS S. SANTOS
You venous graft, uh uh being or your remap should actually lead to the posterior
descending artery.
00:42:37.017 --> 00:42:49.697
ARIS S. SANTOS
Ventricle to actually promote proper pumping your own heart. OK, going to the
systemic circulation, OK.
00:42:52.137 --> 00:42:55.217
ARIS S. SANTOS
OK. Do you have questions so far guys?
00:42:57.297 --> 00:42:57.337
ARIS S. SANTOS
I.
00:42:59.417 --> 00:43:01.857
ARIS S. SANTOS
Guys, do you have questions so far?
00:43:07.857 --> 00:43:10.497
ARIS S. SANTOS
Am I audible?
00:43:11.617 --> 00:43:12.217
VIROLA, NICODEMUS A.
It's.
00:43:12.697 --> 00:43:13.537
MANALAC, LAKSHA A.
Yes, Paul.
00:43:16.657 --> 00:43:17.457
ARIS S. SANTOS
OK.
00:43:23.937 --> 00:43:24.097
ARIS S. SANTOS
Hello.
00:43:24.177 --> 00:43:25.057
MANALAC, LAKSHA A.
Bro.
00:43:27.217 --> 00:43:27.337
ARIS S. SANTOS
OK.
00:43:28.617 --> 00:43:28.937
YBAÑEZ, KEZIAH NYCA R.
Well.
00:43:29.257 --> 00:43:31.817
ARIS S. SANTOS
Let me just show you uh uh YouTube.
00:43:42.457 --> 00:43:43.617
ARIS S. SANTOS
Oh, sure.
00:43:48.537 --> 00:43:49.937
ARIS S. SANTOS
Dina.
00:43:51.097 --> 00:43:53.457
ARIS S. SANTOS
Thank you, Paul. Thank you.
00:44:14.337 --> 00:44:17.057
CABAEL, JASMINE
Rahulaka Audio PO.
00:44:17.857 --> 00:44:19.137
ARIS S. SANTOS
OK.
00:44:20.697 --> 00:44:23.017
ARIS S. SANTOS
Problem but I don't wait.
00:44:25.537 --> 00:44:28.457
YBAÑEZ, KEZIAH NYCA R.
Rough me question for Palaco.
00:44:29.057 --> 00:44:32.337
ARIS S. SANTOS
Sigilam, go ahead. What's your question?
00:44:41.217 --> 00:44:44.537
ARIS S. SANTOS
OK, I was just sharing along the.
00:44:45.497 --> 00:44:46.177
ARIS S. SANTOS
It's like the weight.
00:45:02.657 --> 00:45:04.217
ARIS S. SANTOS
My sharing screen.
00:45:07.217 --> 00:45:07.897
YBAÑEZ, KEZIAH NYCA R.
Kuala Pupru.
00:45:10.377 --> 00:45:11.417
ARIS S. SANTOS
Well, my goodness.
00:45:11.177 --> 00:45:13.057
YBAÑEZ, KEZIAH NYCA R.
Meerna Boppra.
00:45:14.017 --> 00:45:14.817
ARIS S. SANTOS
Now, hey.
00:45:20.977 --> 00:45:21.657
ARIS S. SANTOS
OK.
00:45:48.057 --> 00:46:04.857
ARIS S. SANTOS
And left ventricle being the primary chamber of the heart. Blood supply, go into the
systemic circulation. How do we relate it to the cardiac dominance?
00:46:04.977 --> 00:46:24.017
ARIS S. SANTOS
Uh, dominance, left dominance, dominance. Both the right coronary artery and the
left coronary artery supplies or it is connected.
00:46:24.537 --> 00:46:44.377
ARIS S. SANTOS
to the to the cabbage. Angiography since coronary angiography is the visualization
which specific blood blood vessel supplies the PDA.
00:47:04.297 --> 00:47:14.097
ARIS S. SANTOS
I'm PDA. Kasika Param insurance. Namana Masusu playan young left ventricle to
sustain cardiac output 19.
00:47:16.457 --> 00:47:17.657
YBAÑEZ, KEZIAH NYCA R.
Yes, Oprah.
00:47:18.817 --> 00:47:20.337
ARIS S. SANTOS
OK.
00:47:30.737 --> 00:47:50.257
ARIS S. SANTOS
OK, again, I will remind you that door to needle should be 30 minutes, 30 minutes,
30 minutes or your thrombolytic agent such as your connected place, streptokinase
that should be given 30 minutes.
00:47:50.497 --> 00:48:09.697
ARIS S. SANTOS
Primary coronary intervention angioplasty that door to balloon should be less than
90 minutes. So the process of opening within the 60 minute.
00:48:10.177 --> 00:48:12.577
ARIS S. SANTOS
Golden hour easy as treatment.
00:48:15.337 --> 00:48:35.177
ARIS S. SANTOS
No coronary angiography. This is the absolute way absolutely to evaluate your
coronary artery disease. It is usually performed as part of the cardiac
categorization, which includes.
00:48:35.177 --> 00:48:54.657
ARIS S. SANTOS
The right and left ventricular angiography, hemodynamic measurements, and also it
provides a more complete evaluation of the individual's cardiac status. So it is
usually visualized by the means of fluoroscopy intracoronary.
00:48:55.017 --> 00:49:06.337
ARIS S. SANTOS
Injections and contrast medium. So the coronary angiography usually if there is
uncertain diagnosis of.
00:49:07.377 --> 00:49:22.017
ARIS S. SANTOS
And China exclude noninvasive testing such as non stress test and then assessment
and feasibility of appropriateness of various treatments.
00:49:23.457 --> 00:49:42.617
ARIS S. SANTOS
Chest pain pharmacologic management actually evaluate intervention such as your
angioplasty or.
00:49:42.697 --> 00:49:58.177
ARIS S. SANTOS
Or medical management. So the angiography also can help the doctors to classify if
it's a class one, class two, class 3 or even class 4 angina if there is unstable angina
or non Q wave MI.
00:49:59.017 --> 00:50:18.457
ARIS S. SANTOS
Angina not controlled by drug treatment. MI especially encardiogenic shock.
Encardiogenic shock. Eligible to receive the thrombolytic treatment.
00:50:18.537 --> 00:50:37.977
ARIS S. SANTOS
Aronary angiography to determine other possible options of treatment or para
malamandenko thrombolytic reperfusion, infarction. There is life-threatening
ventricular arrhythmias or angina after bypass or percutaneous intervention and
before valve surgery or corrective heart surgery.
00:50:37.977 --> 00:50:57.817
ARIS S. SANTOS
Because coronary angiography, the condition of your valves like for example, new
valve.
00:50:57.857 --> 00:51:14.777
ARIS S. SANTOS
Angiography. The capacity or. So. Coronary angiography. So percutaneous coronary
intervention or PCI.
00:51:15.377 --> 00:51:33.097
ARIS S. SANTOS
So the process of dilating A coronary stenose coronary artery stenose is using an
inflatable balloon and a metallic stent. That because if you are going to read old
books, PPCA percutaneous transluminal coronary angioplasty.
00:51:33.177 --> 00:51:52.377
ARIS S. SANTOS
That is only the insertion of a catheter and then the loboy on. So the advancement
of technology. The more appropriate term for the management is PCI or
percutaneous coronary.
00:51:52.657 --> 00:52:08.217
ARIS S. SANTOS
Or some doctors would say primary coronary intervention. So it is done through the
introduction of an arterial into the arterial circulation by a femoral, radial or brachial
artery. So the most common site is usually femoral.
00:52:09.257 --> 00:52:10.897
ARIS S. SANTOS
So uh.
00:52:13.857 --> 00:52:29.497
ARIS S. SANTOS
And it is usually under the guidance of fluoroscopy real time X-ray. So the PCI
usually began as PTCA in terms of found in the literature and now encompasses
balloon.
00:52:30.257 --> 00:52:49.817
ARIS S. SANTOS
Stents and other modifications to the catheter, including devices that can cut out
the plaque, thus open up the narrowed artery. So first is the primary angioplasty,
AKA or another term is direct angioplasty. And yeah, so it mechanically disrupts.
00:52:49.937 --> 00:53:05.417
ARIS S. SANTOS
Occlusive thrombus and compress underlying stenosis, restoring blood flow. Uh,
chest pain in ECG STEMI positive drop I. OK, the decision is to do direct angioplasty
so.
00:53:05.537 --> 00:53:21.537
ARIS S. SANTOS
To restore the blood flow that is your primary, the sequential angioplasty or AKA
adjunctive angioplasty. It is usually an angioplasty performed after thrombolysis.
00:53:22.097 --> 00:53:39.857
ARIS S. SANTOS
ER chest pain, positive drops, positive elevations, ECG and then angioplasty plan of
management is parejas.
00:53:40.177 --> 00:53:59.857
ARIS S. SANTOS
Thrombolysis plus angioplasty. Next the other one is rescue angioplasty or AKA
salvage angioplasty. It is described or defined as angioplasty perform if thrombolysis
fails to restore patency after one to two hours.
00:54:00.017 --> 00:54:14.617
ARIS S. SANTOS
So these are the three types of angioplasty understood.
00:54:18.817 --> 00:54:21.097
ARIS S. SANTOS
Understood, Buba.
00:54:21.217 --> 00:54:22.377
MANALAC, LAKSHA A.
Yes, Paul.
00:54:21.217 --> 00:54:22.297
TESTIBIA, YZABELLE SHANE C.
Yes.
00:54:21.217 --> 00:54:23.257
YBAÑEZ, KEZIAH NYCA R.
Yes, Boo, bro.
00:54:22.457 --> 00:54:22.897
VIROLA, NICODEMUS A.
Is.
00:54:24.297 --> 00:54:38.937
ARIS S. SANTOS
OK, thank you. So what are the clinical indications of PCI? So first is stable angina
and a positive stress test, unstable angina, acute MI or after MI?
00:54:39.457 --> 00:54:58.537
ARIS S. SANTOS
After cabbage, usually percutaneous intervention to the native vessels.
00:54:58.977 --> 00:55:18.457
ARIS S. SANTOS
Yeah, angioplasty, para reopen to the native vessel, original vessel, hindi hindi um
you know neck or graft. And then if of course if high risk bypass surgery and elderly
patients.
00:55:18.897 --> 00:55:35.737
ARIS S. SANTOS
Good on healing, less on hospitalization days, less costly PTCA compared to the
conventional open heart surgery by your coronary artery bypass graft.
00:55:35.857 --> 00:55:53.017
ARIS S. SANTOS
So what are the common complications and risks? So uncommon complication
arterial axis bleeding after the procedure.
00:55:53.577 --> 00:55:53.657
ARIS S. SANTOS
Uh.
00:55:55.977 --> 00:56:15.177
ARIS S. SANTOS
So that is why.
00:56:15.377 --> 00:56:35.057
ARIS S. SANTOS
Um site insertion, usually 15 minutes to ensure next. So another common
complication for arrhythmias reaction to the contrast medium and then bigger
reaction.
00:56:35.137 --> 00:56:54.497
ARIS S. SANTOS
The sheet removal and insertion. It's because you are stimulating the vagus nerve.
So what are the risks? So that one in 1400. So it's relatively safe procedure like I've
I've done it 100 times and I never had a.
00:56:54.497 --> 00:57:09.537
ARIS S. SANTOS
One casualty. So statistics about 1400 PPTCA or PPCI stroke one in 1000, coronary
artery dissection one in 1000.
00:57:09.617 --> 00:57:29.057
ARIS S. SANTOS
Arterial access complication, one in 500. Again, the arterial access complication
depending because we usually are the one who removes way back in abroad. It's
usually the nurses who removes the artery.
00:57:48.817 --> 00:58:00.737
ARIS S. SANTOS
The left main stem. The left main coronary artery is.
00:58:01.777 --> 00:58:17.897
ARIS S. SANTOS
Both LCX and LAD three major vessels, right coronary artery, LAD or the left
anterior descending artery and the left circumflex.
00:58:18.337 --> 00:58:22.137
ARIS S. SANTOS
Usually I'm not.
00:58:27.217 --> 00:58:31.177
ARIS S. SANTOS
So what are the two common problems that was post PCI?
00:58:32.297 --> 00:58:52.177
ARIS S. SANTOS
So #1 is acute vessel closure. It usually occurs 24 hours post PTCA. So 3 to 5% of
the cases may follow vessel dissection, acute thrombose formation or both. And
then restenosis. It usually occurs in the first six months after PTCA caused largely by
smooth muscle cell proliferation.
00:59:07.297 --> 00:59:26.817
ARIS S. SANTOS
So it usually has a high incidence of 25 to 50% incidence to actually decrease the
cases of stenosis. We are using stents.
00:59:27.057 --> 00:59:30.257
ARIS S. SANTOS
The Paramanga Springs. Yeah, OK.
00:59:31.217 --> 00:59:38.617
ARIS S. SANTOS
So we usually have the introducer needle and guide wire.
00:59:42.457 --> 01:00:02.097
ARIS S. SANTOS
And then Shepra, we have the patient sterile drapes. We have the macro set for
contrast line and pressure line. You contrast line. You pressure line the line. Connect
computer or the monitor to actually measure the pressures in the heart.
01:00:02.137 --> 01:00:04.017
ARIS S. SANTOS
So I'm being a uh.
01:00:20.897 --> 01:00:26.217
ARIS S. SANTOS
So from there.
01:00:28.937 --> 01:00:47.977
ARIS S. SANTOS
So manifold usually for pressure line connected again to measure the pressures in
the heart. Second is for angioplasty.
01:00:49.497 --> 01:01:05.137
ARIS S. SANTOS
And then third is for contrast. These are the examples of the balloon catheters. So
balloon.
01:01:05.177 --> 01:01:05.537
ARIS S. SANTOS
1.
01:01:08.937 --> 01:01:27.657
ARIS S. SANTOS
But the most popular is your judge skins right and then your judge skins left. If you
could see, it usually supports the.
01:01:29.937 --> 01:01:46.337
ARIS S. SANTOS
Anatomical shape of the of the coronary arteries. And then we have the angled
pigtail.
01:02:10.537 --> 01:02:17.857
ARIS S. SANTOS
You know, open like it on inflation divide, so it's young in a gamet to actually.
01:02:34.777 --> 01:02:49.057
ARIS S. SANTOS
Remember going back to this picture? I hope you.
01:02:57.457 --> 01:02:58.097
ARIS S. SANTOS
So I.
01:03:06.817 --> 01:03:25.137
ARIS S. SANTOS
So what is the most important nursing responsibility in handling the device? So you
have to follow specific pressures of the balloon catheters. It's usually measured in
millimeter mercury.
01:03:25.737 --> 01:03:43.097
ARIS S. SANTOS
Keep in mind while inflating the balloon as over-inflation may result in balloon
rupture. So guys, the balloon catheters.
01:03:44.177 --> 01:04:03.337
ARIS S. SANTOS
And maximum pressures.
01:04:03.657 --> 01:04:21.977
ARIS S. SANTOS
Artery. So it may result into the rupture of the coronary artery that may lead to
bleeding, infarction and definitely death if you cannot control the bleeding. It's
because you mishandled inflating the balloon.
01:04:22.857 --> 01:04:42.457
ARIS S. SANTOS
On the other side, you inflated less the recommended pressure, so definitely it will
poorly open or dilate the stenotic coronary artery.
01:04:42.537 --> 01:04:45.657
ARIS S. SANTOS
It's still bad for the patient.
01:04:47.897 --> 01:04:53.057
ARIS S. SANTOS
You understand that important nursing responsibility.
01:04:53.137 --> 01:04:55.137
MANALAC, LAKSHA A.
Yes, Bob Rob.
01:04:53.897 --> 01:04:55.657
HERNANDEZ, RONETTE L.
Yes, thank you.
01:04:53.937 --> 01:04:54.737
TESTIBIA, YZABELLE SHANE C.
Yes.
01:04:57.817 --> 01:05:17.377
ARIS S. SANTOS
OK, so nursing consideration. You have to ask the patient to sign an informed
consent and then you have to secure precut labs and diagnostics such as CBC,
troponin, ECG, sodium, potassium, serum creatinine and for PCI or for your primary
coronary intervention or percutaneous coronary intervention.
01:05:17.457 --> 01:05:36.417
ARIS S. SANTOS
So definitely you have to load ACS drugs like your aspirin or ASA, tropidigrel,
nitroglycerine or within the family ISDN or isosorbide dinitrate and then your
enoxaparin.
01:05:37.097 --> 01:05:56.617
ARIS S. SANTOS
MI, actually no hospital. Once not proven MI or ACS, usually the patient receives
immediately these four drugs together with your oxygen and the morphine if there
is severe chest pain or uncontrolled chest pain or unrelenting.
01:05:56.617 --> 01:06:11.417
ARIS S. SANTOS
Chest pain. You also have to equipment on standby such as your IABP machine,
ecard, defibrillator, temporary pacemaker. You have to administer IV opiates for
sedation, so fentanyl angioplasty.
01:06:11.577 --> 01:06:30.937
ARIS S. SANTOS
The patient will just feel a little, very little discomfort.
01:06:31.017 --> 01:06:47.137
ARIS S. SANTOS
And then the patient should be on NPO for six hours. Ideally pero, if it's an
emergency, the patient may be given anti-emetic drugs such as your ondansetrol or
metoclopramide. Unpopularly to Sabilipinas is your metoclopramide or your placil.
01:06:47.297 --> 01:07:02.777
ARIS S. SANTOS
And then you have to ensure that the pressure lines are connected. Hemodynamic
monitoring such as a pulmonary artery wedge pressure, atrial pressure.
01:07:04.177 --> 01:07:23.417
ARIS S. SANTOS
Intracat or during the procedure. So you have to prepare that nitroglycerin and the
heparin solution for intracoronary use. So NTG.
01:07:23.617 --> 01:07:40.177
ARIS S. SANTOS
Again, it prevents platelet aggregation.
01:07:40.377 --> 01:07:59.697
ARIS S. SANTOS
And then you have to do skin preparation at the site of insertion, macrophemoral,
maniacal, or regal and then you have to flush with NSS, all catheters, manifolds and
sheets to ensure patency and then assist with the administration of the local
anesthetic insertion of the introducer needle sheet insertion.
01:07:59.897 --> 01:08:19.737
ARIS S. SANTOS
So once the sheet is inserted, give hepsilant solution for flushing and then we
prepare for cardiac catheterization. We measure the pressure and the guide is
usually inserted first, followed by the cardiac catheter to be inserted by the doctor.
01:08:19.777 --> 01:08:39.457
ARIS S. SANTOS
So once the catheter reaches the aorta, remove the guideway smoothly.
01:08:39.657 --> 01:08:59.497
ARIS S. SANTOS
Guide wire. So angioplasty or during cardiac cadeterization, first assist a nurse
guide wire. The guide wire itself could.
01:08:59.537 --> 01:09:19.177
ARIS S. SANTOS
Actually rupture the artery. And then the doctor will flush with Epsilon and will inject
contrast. You have to assist the doctor during balloon inflation and stenting and
then.
01:09:19.377 --> 01:09:27.617
ARIS S. SANTOS
Premise circulating nurse, she or she or he will be the one to monitor the vital signs,
ECG and do the documentation of the procedure.
01:09:28.817 --> 01:09:36.857
ARIS S. SANTOS
So you have to again to monitor vital signs and ECG document no importante and.
01:09:38.537 --> 01:09:50.177
ARIS S. SANTOS
And then you have to monitor the activated clotting time. Your activated clotting
time is a young class in a blood test. Normally it is usually 70 to 120 seconds, so.
01:09:51.137 --> 01:10:08.817
ARIS S. SANTOS
ACT or the activated clotting time should be less than 150.
01:10:10.977 --> 01:10:30.257
ARIS S. SANTOS
Seconds normal 70 to 120, guys expect that the ACT would be normal in between or
during the procedure.
01:10:30.857 --> 01:10:50.457
ARIS S. SANTOS
150 seconds is reasonable or acceptable prior sheet removal. OK, so for sheet
removal you have to prepare the dressing, the elastic bandage or Luko plus and
Tegaderm and then and you have to palpate the pulse distal to the insertion site.
01:10:50.497 --> 01:11:10.377
ARIS S. SANTOS
So Ebik sabien kohalimbawang insertion site is a femoral kapain momuna yung
posterior pibial pus or the poplibial pus para ma incha.
01:11:10.417 --> 01:11:28.977
ARIS S. SANTOS
There would be enough circulation, so distal portion or in the lower extremity. You
have to check first for the distal pulse and then you have to remove the sheet, then
apply pressure for 10 to 15 minutes and then apply pressure dressing. You have to
monitor the patient in the post cap unit or coronary care unit.
01:11:29.097 --> 01:11:34.657
ARIS S. SANTOS
Encourage gradual increase in mobility and monitor for hematoma, hypotension and
ECG changes.
01:11:37.817 --> 01:11:56.457
ARIS S. SANTOS
So good candidate for angioplasty #1 if it's severe triple vessel disease, major
artery.
01:11:57.217 --> 01:12:14.577
ARIS S. SANTOS
Which is your right coronary artery left your complex and your left anterior
descending para para home my stenosis.
01:12:14.657 --> 01:12:32.817
ARIS S. SANTOS
If you couldn't see some picture, no. So the doctors would suggest bypass next.
01:12:32.857 --> 01:12:39.737
ARIS S. SANTOS
Another reason is severe left main coronary stenosis.
01:12:41.697 --> 01:13:00.737
ARIS S. SANTOS
So again, that's a good clinical indication for bypass and then occluded vessels and
suited unsuitable for angioplasty.
01:13:01.737 --> 01:13:12.617
ARIS S. SANTOS
Marginals or some diagonal diagonal vessels.
01:13:30.057 --> 01:13:39.177
ARIS S. SANTOS
So again, so just a review. Uh, this is like the algorithm map. So you have to identify
chest pain, so.
01:13:41.057 --> 01:13:55.897
ARIS S. SANTOS
ECG be begin unnecessary drugs such as your oxygen, morphine, aspirin, ISD and
beta blocker heparin or another anticoagulant that is your enoxaparin and then
Copidogrel and then.
01:13:56.457 --> 01:14:03.217
ARIS S. SANTOS
If it's an unstable angina or STEMI *** uncomplicated, angiography can be done 24
to 48 hours.
01:14:04.417 --> 01:14:20.017
ARIS S. SANTOS
Complicated. Urgent. OK, urgent angiography. Amenable to PCI coronary anatomy. If
it's yes, definitely PCI. No emergency cabbage.
01:14:20.337 --> 01:14:34.577
ARIS S. SANTOS
Is it available within 90 minutes? If yes, OK, go back here. Most probably my
angioplasty, but if it's not, if it's not available.
01:14:36.177 --> 01:14:51.817
ARIS S. SANTOS
Thrombolytic therapy. And then is there persistent ischemia? Yes. You may do repeat
thrombolytic therapy or PCI. Do PCI available if not elective PCI guys.
01:14:52.257 --> 01:15:11.977
ARIS S. SANTOS
The statistics. So number one case is Talaganatinam ischemic heart disease here in
the Philippines. This is the data of 2023. So ischemic heart disease is the number
one cause of death and sickness in the Philippines. So globally there is 20.1 million
adults who have coronary artery disease.
01:15:12.257 --> 01:15:31.897
ARIS S. SANTOS
Age 20 and above, it is the most common type of cardiovascular problem, killing
382,820 people in 2020, about two in 10 deaths about in adults. So in the
Philippines alone, coronary artery disease, which belong under ischemic heart
disease is the top.
01:15:32.177 --> 01:15:35.257
ARIS S. SANTOS
One cause of mortality in the country. Tapos.
01:15:37.137 --> 01:15:42.657
ARIS S. SANTOS
Uh, there's a sample research in the Philippines, guys. Um.
01:15:44.177 --> 01:16:02.937
ARIS S. SANTOS
As published by the Lancet Regional Health Western Pacific, so among we are
already 118 million Filipinos now. So the Philippine Heart Association recorded only
49 PCI cardio categorization lab centers in the country and among those 4924 in the
National Capital Region.
01:16:02.977 --> 01:16:22.897
ARIS S. SANTOS
There are 13 in Luzon, 7 in Besais and five in Mindanao. So imagine in MOB there is
a 9.3% mortality in patients who only receive medical management compared with
the 5.6 mortality in patients who receive primary coronary intervention. So the naka
importante cath lab.
01:16:22.897 --> 01:16:42.657
ARIS S. SANTOS
Sad to say, there are a lot of places in the country. One of the programs of of the
OHF together with the Philippine Heart Center is to designate regional heart centers.
01:16:59.257 --> 01:17:00.137
ARIS S. SANTOS
OK.
01:17:08.737 --> 01:17:13.217
ARIS S. SANTOS
Let's proceed with the intra aortic balloon pump counter pulsation.
01:17:16.057 --> 01:17:16.137
ARIS S. SANTOS
So.
01:17:17.137 --> 01:17:36.737
ARIS S. SANTOS
So this is usually introduced by clinically by Kantrowitz and Associates in 1967. This
is a standard treatment for medical and surgical patients with acute left ventricular
failure that is unresponsive to pharmacological and volume therapy.
01:17:36.817 --> 01:17:56.217
ARIS S. SANTOS
So see, this is designed to increase coronary artery perfusion, pressure and blood
flow during the diastolic phase of the cardiac cycle by inflating a balloon in the
aorta. So I want you to look at picture. So if you see OK systole during the cardiac
contraction.
01:17:57.337 --> 01:17:59.337
ARIS S. SANTOS
The map so they played in shaft.
01:18:00.297 --> 01:18:19.857
ARIS S. SANTOS
During the contraction, the relaxation of the heart.
01:18:39.457 --> 01:18:50.737
ARIS S. SANTOS
Intra aortic balloon pop actually helps distributing the blood flow to the coronaries
and distributing the blood flow going to the systemic circulation.
01:18:52.817 --> 01:19:02.497
ARIS S. SANTOS
So what are the goals of IABT Chempre to increase oxygen supply in the
myocardium, decrease the left ventricular work, and improve cardiac output?
01:19:03.577 --> 01:19:23.257
ARIS S. SANTOS
So any of the indications we have definitely treatment for cardiogenic shock after MI
Cardiogenic shock after an MIA ventricular failure after cardiac surgery.
01:19:23.417 --> 01:19:42.657
ARIS S. SANTOS
If there is severe unstable angina or short short-term bridge to cardiac
transplantation, identified donor.
01:19:43.017 --> 01:19:59.057
ARIS S. SANTOS
Transplant. So what are the contraindications? Number one, aortic insufficiency.
Aortic insufficiency. Hum blood flow.
01:19:59.497 --> 01:20:19.337
ARIS S. SANTOS
So there is a problem within your aortic valve and the anatomy of your aorta. OK,
severe peripheral vascular occlusive disease compared to the ordinary cardio
catheters for PCI.
01:20:35.617 --> 01:20:52.377
ARIS S. SANTOS
And Sempre, if you have aortic aneurysm, so Sempre, for example, this is the aorta
formations upon the insertion of the.
01:20:52.457 --> 01:20:52.977
ARIS S. SANTOS
Balloon.
01:20:55.457 --> 01:21:12.617
ARIS S. SANTOS
So before I completely end, so the cat lab nurses know the way to your heart. So the
regular nurse and tapas versus the cat lab nurse. Because cat lab nurses are like
unicorns, unique and magical.
01:21:12.817 --> 01:21:23.377
ARIS S. SANTOS
So the floor is. These are my resources, book references and online references.
01:21:27.737 --> 01:21:30.137
ARIS S. SANTOS
We have questions my guys.
01:21:38.657 --> 01:21:39.097
ARIS S. SANTOS
M.
01:21:46.377 --> 01:21:46.977
ARIS S. SANTOS
Question.
01:21:49.737 --> 01:21:52.657
ARIS S. SANTOS
Any question? Yes, Bob.
01:21:49.777 --> 01:21:50.977
ROSALES XAVIER M.
Charities.
01:21:54.577 --> 01:21:54.737
ARIS S. SANTOS
OK.
01:22:00.057 --> 01:22:01.537
ARIS S. SANTOS
I'm sorry, come again.
01:22:16.617 --> 01:22:19.537
ARIS S. SANTOS
Guys, uh, any questions from the floor?
01:22:23.977 --> 01:22:24.617
ARIS S. SANTOS
Is part of the gas.
01:22:26.017 --> 01:22:36.817
PORTUGUEZ, ANN JELLA F.
Other intervention for that.
01:22:38.377 --> 01:22:57.737
ARIS S. SANTOS
OK, I would like you to keep in mind that pacemaker are indicated for brady
arrhythmias normal heartbeat. Brady.
01:22:58.497 --> 01:23:16.857
ARIS S. SANTOS
Temporarily. Next would be the transvenous spacing. Transvenous spacing
permanent is the pacemaker implantation, which is really costly.
01:23:17.177 --> 01:23:31.737
ARIS S. SANTOS
Treatment for brady arrhythmias.
01:23:32.817 --> 01:23:49.137
ARIS S. SANTOS
I'm pacemaker or I'm pacing. It's because of the normal cardiac output to sustain
the cardiac output. So pacemaker is really the best choice.
01:23:50.097 --> 01:23:51.417
ARIS S. SANTOS
Did I answer you?
01:23:51.697 --> 01:23:53.857
PORTUGUEZ, ANN JELLA F.
Oh, sorry. Thank you for.
01:23:55.137 --> 01:23:57.577
ARIS S. SANTOS
OK, Mr. Rueda, next question.
01:24:13.177 --> 01:24:17.377
ARIS S. SANTOS
I'm sorry, complicated and uncomplicated. Uh.
01:24:19.537 --> 01:24:28.337
RUEDA, REIGNE BELINDA C.
Is a diagram for indicated and geographical if uncomplicated.
01:24:28.457 --> 01:24:48.297
ARIS S. SANTOS
OK, uncomplicated. Angiography is recommended 24 to 48 hours. Uncomplicated
vital signs.
01:24:48.377 --> 01:25:04.057
ARIS S. SANTOS
St. elevation life threatening arrhythmia urgent urgent angiography 24 to 48 hours.
So that's the difference between uncomplicated and complicated.
01:25:05.257 --> 01:25:06.817
ARIS S. SANTOS
That's a good get there.
01:25:08.057 --> 01:25:09.697
RUEDA, REIGNE BELINDA C.
Yes, Blesser. Thank you.
01:25:10.337 --> 01:25:12.057
ARIS S. SANTOS
OK. Any more questions?
01:25:22.817 --> 01:25:23.577
DY, ANDREA CASSANDRA T.
Yes, Paul.
01:25:26.057 --> 01:25:42.857
ARIS S. SANTOS
OK, so if you do not have any more questions, I won't be giving the quiz via online.
So next week, Saturday before the start of the discussion on Respy.
01:25:43.337 --> 01:26:03.097
ARIS S. SANTOS
We we will have a post test about ACS. I won't be sharing my slides because I
expected you and this is a recorded task meeting so might as well.
01:26:03.097 --> 01:26:04.417
ARIS S. SANTOS
The lecture.
01:26:05.817 --> 01:26:09.457
ARIS S. SANTOS
Any more questions and concerns before I dismiss you last?
01:26:14.937 --> 01:26:16.217
ARIS S. SANTOS
Well I know.
01:26:22.017 --> 01:26:30.297
ARIS S. SANTOS
OK, so if there are no more questions, Professor Rosales.
01:26:32.817 --> 01:26:32.937
ROSALES XAVIER M.
Um.
01:26:53.977 --> 01:27:01.537
ARIS S. SANTOS
Nevermind. Dependent, depend. It's a trip go on 10/15/20, so and 20 Siguro.
01:27:06.377 --> 01:27:07.617
LEONCIO, JASMINE ANN NICOLE A.
Thank you.
01:27:14.577 --> 01:27:18.977
SISON, TAMARA CLAUDETTE E.
Sir, last question for.
01:27:15.017 --> 01:27:15.857
ARIS S. SANTOS
Yeah.
01:27:18.017 --> 01:27:19.777
ARIS S. SANTOS
Sigilan, go ahead.
01:27:43.057 --> 01:27:46.337
SISON, TAMARA CLAUDETTE E.
Let's not, let's not.
01:27:43.617 --> 01:27:43.777
ARIS S. SANTOS
Stop.
01:27:45.657 --> 01:27:48.577
ARIS S. SANTOS
Go ahead.
01:28:04.097 --> 01:28:11.057
SISON, TAMARA CLAUDETTE E.
Mainly, um, my possible effect.
01:28:12.097 --> 01:28:23.977
ARIS S. SANTOS
Sorry, usually the 70% of the population.
01:28:48.897 --> 01:28:49.057
ARIS S. SANTOS
Cool.
01:29:00.537 --> 01:29:16.537
ARIS S. SANTOS
OK, according to the statistics, the 70 to 80%.
01:29:36.817 --> 01:29:56.257
ARIS S. SANTOS
So that is the beauty of creation. But again, while an implication or health impact
right or left, the PDA should get enough blood supply regardless of the group either
the right or left.
01:30:03.697 --> 01:30:05.457
SISON, TAMARA CLAUDETTE E.
Yes, but thank you, but.
01:30:05.337 --> 01:30:12.737
ARIS S. SANTOS
OK, Miss Leola, question. You stay on.
01:30:10.017 --> 01:30:23.377
LOYOLA, KHARLA MARIA E.
Good afternoon po. Uh, then pusa PCI po. Padipusila magreceive po nang parang
shak po or uh any yung parang sanat deafu in case of emergency.
01:30:21.377 --> 01:30:21.497
ARIS S. SANTOS
OK.
01:30:24.737 --> 01:30:39.297
ARIS S. SANTOS
Yes, oh oh. I had this once during an emergency PCI left main artery upon
angiography.
01:30:39.817 --> 01:30:59.337
ARIS S. SANTOS
Upon insertion imagining left main artery. So blood supply 70% of the left main
arteries stenotic distribution of blood for LAD and LC.
01:31:37.217 --> 01:31:56.617
ARIS S. SANTOS
Definitive treatment, defibrillation into normal sinus rhythm or you will proceed CPR
on our side.
01:31:57.617 --> 01:32:14.937
ARIS S. SANTOS
It would actually define the anatomy and how disease.
01:32:15.017 --> 01:32:18.297
ARIS S. SANTOS
The vessels are so yon, did I answer you?
01:32:19.097 --> 01:32:31.667
LOYOLA, KHARLA MARIA E.
I sir, my additional question ... ... contraindication point for Anoko for shock since .
01:32:23.137 --> 01:32:23.337
ARIS S. SANTOS
No.
01:32:24.257 --> 01:32:24.297
ARIS S. SANTOS
Uh.
01:32:30.377 --> 01:32:30.737
ARIS S. SANTOS
Wait.
01:32:31.977 --> 01:32:32.577
ARIS S. SANTOS
Voila.
01:32:34.777 --> 01:32:36.457
LOYOLA, KHARLA MARIA E.
Okay. Thank you.
01:32:36.337 --> 01:32:36.817
ARIS S. SANTOS
Mhm.
01:32:38.497 --> 01:32:40.737
ARIS S. SANTOS
Miss David question.
01:32:42.137 --> 01:32:59.617
DAVID, ALYANNA JADE S.
Good afternoon, Sir. The algorithm is not yet available, not the thrombolytic therapy
and then with continue for thrombolytic therapy if my persistent skin is patient.
01:32:45.297 --> 01:32:45.817
ARIS S. SANTOS
Mhm.
01:32:59.977 --> 01:33:06.777
DAVID, ALYANNA JADE S.
Your question is my limitations in terms of the dosage.
01:33:07.577 --> 01:33:27.457
ARIS S. SANTOS
OK, so far in my career.
01:33:27.657 --> 01:33:42.457
ARIS S. SANTOS
Problem as a clotting overdose at is a path. Hypotension. Massive bleeding that was
hypotension.
01:33:42.697 --> 01:34:02.297
ARIS S. SANTOS
The role of the hospital in the thrombolytics of the cath lab is to actually refer the
patient to a hospital who has a capability of the cath lab because that is the most
prompt decision to be done.
01:34:02.417 --> 01:34:08.817
ARIS S. SANTOS
So the patient would be needing a salvage angioplasty.
01:34:10.377 --> 01:34:10.657
ARIS S. SANTOS
Yes.
01:34:12.657 --> 01:34:13.697
DAVID, ALYANNA JADE S.
I.
01:34:15.217 --> 01:34:17.777
ARIS S. SANTOS
OK, Miss Banga, question.
01:34:17.897 --> 01:34:29.777
BANGA, RATHNAIT LORIEN C.
Good afternoon. Confirm for your aortic insufficiency. I am IABP.
01:34:29.177 --> 01:34:30.977
ARIS S. SANTOS
Yes, yes, yes.
01:34:32.177 --> 01:34:33.977
BANGA, RATHNAIT LORIEN C.
OK, but thank you, but.
01:34:37.937 --> 01:34:38.817
ARIS S. SANTOS
Any more?
01:34:41.257 --> 01:34:41.857
ARIS S. SANTOS
Uh, Mrs. Martin.
01:34:43.577 --> 01:35:02.337
MARTIN, MIKAELA ANDREA V.
Good afternoon, Cocroc. Coronary angiogram.
01:35:06.297 --> 01:35:20.017
ARIS S. SANTOS
Actually, if you're going to read old Ms. books because that most of the contrast dye
are iodine based, but the non iodine contrast.
01:35:21.377 --> 01:35:39.537
ARIS S. SANTOS
Allergies, iodine or shellfish or seafood.
01:35:40.777 --> 01:36:00.417
ARIS S. SANTOS
Most important nursing consideration is to actually check the levels of creatinine.
They would all be eliminated in the kidneys.
01:36:00.657 --> 01:36:19.737
ARIS S. SANTOS
During the procedure, usually one hour to 1 1/2 hour. So pre angiogram, pre
angioplasty, during angioplasty and postcut angiogram to actually evaluate blood
flow.
01:36:35.697 --> 01:36:36.577
ARIS S. SANTOS
So.
01:36:57.177 --> 01:37:03.137
ARIS S. SANTOS
And I said to sustain that's after 30 minutes. Any more questions?
01:37:02.977 --> 01:37:04.737
MARTIN, MIKAELA ANDREA V.
Thank you.
01:37:17.417 --> 01:37:18.297
ARIS S. SANTOS
So.
01:37:22.217 --> 01:37:41.137
ARIS S. SANTOS
According to statistics, 49 of the latest article 55 as of this year.
01:37:42.697 --> 01:38:00.017
ARIS S. SANTOS
Because you would be seeing patients that are going to improve damage or
infarcted area.
01:38:01.177 --> 01:38:11.657
ARIS S. SANTOS
It actually gives the chance in the heart.
01:38:16.137 --> 01:38:18.337
ARIS S. SANTOS
Anything to add, Sarah?
01:38:18.457 --> 01:38:33.257
ROSALES XAVIER M.
Sir, in addition, a cardiologist or interventional cardiologist before PCI.
01:38:19.497 --> 01:38:19.537
ARIS S. SANTOS
I.
01:38:39.177 --> 01:38:39.697
ARIS S. SANTOS
Yeah.
01:38:41.817 --> 01:38:44.217
ARIS S. SANTOS
Yeah, I mean.
01:38:50.177 --> 01:38:51.777
ROSALES XAVIER M.
Angioplasty.
01:38:53.017 --> 01:39:08.577
ROSALES XAVIER M.
Angiogram angiography. What is the purpose of doing angiography if you're not
willing to do angioplasty? So better.
01:38:54.857 --> 01:38:55.217
ARIS S. SANTOS
Yeah.
01:39:10.177 --> 01:39:25.857
ROSALES XAVIER M.
They require us to.
01:39:10.857 --> 01:39:14.737
ARIS S. SANTOS
Yeah, 70,00 Grammy.
01:39:26.977 --> 01:39:46.257
ROSALES XAVIER M.
Prepare half a million successful Angioplasty or Angiogram.
01:39:27.977 --> 01:39:29.617
ARIS S. SANTOS
Supermania.
01:39:40.577 --> 01:39:43.417
ARIS S. SANTOS
Oh, garbage, garbage.
01:39:46.377 --> 01:40:05.937
ROSALES XAVIER M.
Proceed. So preparing kanila na para. So kung mindi na manwilling yung patient,
ninilagagawin siyang lang ding yung para cilipin pa. Aftercare adgurang dun no
aftercare part ng nursing responsibility after PCI.
01:39:48.817 --> 01:39:49.177
ARIS S. SANTOS
H.
01:39:57.777 --> 01:39:58.057
ARIS S. SANTOS
Anna.
01:40:05.977 --> 01:40:22.737
ROSALES XAVIER M.
SA ward or SA ICU yung sa sheet nyan arterial sheet medong nakalagay jan na TR
band. Yung TR band is a bracelet na medong inflatable.
01:40:23.337 --> 01:40:38.657
ROSALES XAVIER M.
Uh, me inflatable balloon. Dona. So on pressure known is 1815 to 18 ML of air and
then.
01:40:29.817 --> 01:40:30.017
ARIS S. SANTOS
See.
01:40:38.857 --> 01:40:54.137
ROSALES XAVIER M.
Every 15 minutes 3ML of air as long as and then you have to observe for bleeding.
01:40:47.097 --> 01:40:48.617
ARIS S. SANTOS
We need welcome.
01:40:54.337 --> 01:41:01.297
ROSALES XAVIER M.
One hour, Tapas Pediman and Tangal in the Urban.
01:41:06.057 --> 01:41:07.817
ARIS S. SANTOS
Yeah, I agree.
01:41:08.297 --> 01:41:27.137
ROSALES XAVIER M.
Oral medications. We have to make sure.
01:41:27.217 --> 01:41:42.457
ROSALES XAVIER M.
So it's considered an antibody foreign body. So platelets I.
01:41:33.657 --> 01:41:35.457
ARIS S. SANTOS
Yeah, yeah.
01:41:37.697 --> 01:41:37.857
ARIS S. SANTOS
Mm.
01:41:43.377 --> 01:41:49.697
ARIS S. SANTOS
Aggregate. Aggregate.
01:42:05.657 --> 01:42:07.377
ROSALES XAVIER M.
Thank you, Paul.
01:42:08.377 --> 01:42:14.417
ARIS S. SANTOS
OK. Thank you, Sir Rosales, for the input. So any more questions?
01:42:16.217 --> 01:42:21.337
ARIS S. SANTOS
Well, Anna, before we part ways for today's class.
01:42:22.897 --> 01:42:37.817
ARIS S. SANTOS
So, Omelana, again, thank you very much for attending. We'll see you again next
week, Saturday 7:00 AM. I will be leaving a post-test regarding this one. Papos, we
will proceed with the discussion of mechanical ventilation and ADG analysis.
01:42:38.057 --> 01:42:39.737
ARIS S. SANTOS
So most probably.
01:42:41.657 --> 01:43:01.577
ARIS S. SANTOS
They face to face style, OK and then the the schedules for your ACLS return
demonstration was actually released now for both block presidents. Kindly check if
it's amenable to Inyo because there would be some groups that would be scheduled
beyond your schedule.
01:43:01.617 --> 01:43:16.617
ARIS S. SANTOS
Hours just to finish within two Saturdays. So you would have one Saturday on
September 20 to practice. OK. So concerns again, thank you very much. We'll see
you again next week, Saturday. Thank you guys.
01:43:17.337 --> 01:43:24.977
LEONCIO, JASMINE ANN NICOLE A.
Thank you, Paul. Thank you, Paul. Thank you, Paul. Thank you, Paul. Thank you,
Paul.
01:43:18.737 --> 01:43:25.377
ALIGAY, RONNEL M.
Thank you. Thank you, Sir. Thank you. Thank you. Thank you. Thank you. Thank
you.
01:43:21.457 --> 01:43:24.657
MANALO, DAPHGNE CRYSTAL MARIE S.
Thank you, Paul. Thank you, Paul.