Complications of Interventional Catheterization Complications of cardiac catheterization span from common, self-limited events such as ectopy, atrial arrhythmias, and hematoma formation, to more consequential events such as air embolism, device embolization, cardiac arrest, or neurologic injury and death Adverse events appear to be particularly common in small patients, particularly neonates, and in patients with complex, singleventricle heart disease As the scope of transcatheter interventions continues to expand, the ability of the operator to anticipate, abate, and treat complications becomes increasingly important Whenever possible, the presence of a dedicated pediatric cardiac anesthesiologist may enhance patient stability during procedures, provide greater access to intensive resuscitation, and optimize respiratory and circulatory status A detailed compendium of the variety of complications that could occur is beyond the scope of this text; however, preparation before any catheterization procedure—interventional or diagnostic—is a critical element in alerting the operator and the catheterization team to a vulnerable patient Such preparation should include planning for an eventual adverse event such as airway compromise, bleeding from an angioplasty site, vascular access difficulty, or the resuscitation approach if cardiac arrest should occur Making such meetings a regular occurrence before any and every catheterization procedure enhances safety for all patients Troubleshooting for unanticipated but well-described complications should be part of the training of an interventional cardiologist As the incidence of complications in well-established procedures is decreasing over time due to technical advances in catheter and technology, younger interventional cardiologists are less exposed to problem-solving on their feet Prevention of complications still remains the best way of staying out of trouble during interventional catheterization Surgical backup should be strongly considered when embarking on a complex intervention or even a routine procedure in the particularly vulnerable child Postprocedural Considerations Postprocedure care begins with hemostasis at the accessed vessel sites Pediatric patients are often limited to manual compression to achieve hemostasis, whereas adult patients may receive closure devices to seal puncture sites Thus in pediatric patients the importance of supine postprocedural positioning, to prevent bleeding from accessed vessels, cannot be overstated Supine duration varies but typically ranges from 2 to 6 hours after achievement of hemostasis Patient monitoring during recovery may include continuous pulse oximetry, cardiac telemetry, and focused assessments The assessments should occur frequently immediately after procedure and continue to space out as the patient recovers The focused assessment includes vital signs, direct visualization of access site (remove diaper and blankets), perfusion distal to the access site, telemetry review and auscultation of heart and lung sounds Immediate action should follow the identification of hypotension, muffled heart sounds, decreasing oxygenation, arrhythmias, or change of a murmur post procedure, such as return of a murmur that had ceased following device implant These red flags could indicate retroperitoneal bleeding, cardiac tamponade, or embolization of an occlusion device Additional complications that can occur include access site hematomas, pseudoaneurysm, or arterial thrombus If perfusion distal to the catheter insertion site is in question, as evidenced by change in color, temperature, or decreased pulse, further assessment should be undertaken Patients less than 5 kg have an increased risk of arterial thrombus.38 The provider should rule out an ischemic extremity, which would be cold to touch and white An ischemic leg requires emergent anticoagulation or lytic therapy and vascular surgical consultation should be obtained A lower extremity with an arterial thrombus may feel cool with no pulse palpable distal to the catheter insertion site but is rarely ischemic A suspected arterial thrombus should be treated quickly with enoxaparin, if no contraindications are present Contraindications include cerebral hemorrhage A limited ultrasound of the affected extremity can confirm thrombus, but palpation of the distal pulse (posterior tibial or dorsalis pedis) is more sensitive because a normal early ultrasound may frequently be a false negative Therapy should only be discontinued if a normal pulse returns Prior to discharge from the hospital, patients should undergo all imaging ordered by the interventional cardiologist Patients should achieve discharge criteria prior to discharge Criteria includes ambulating without bleeding from the access site, a resumed feeding regimen, urination, and pain control In addition, patients and families require extensive discharge teaching and anticipatory guidance Discharge teaching should include site care Patients should not submerge in water until 3 days after the procedure Site examination and monitoring should occur daily for the first few postcatheterization days, for signs of infection such as erythema, swelling, warmth, and purulent discharge Physical activity restrictions include no straddle activities, typically for 7 days Additional restrictions may be placed for patients returning to a job with a lifting requirement Families should be provided with contact information if they have questions or concerns after discharge Scheduled follow-up with the primary cardiologist should be arranged and is determined based on the procedure performed However, a specific postcatheterization follow-up visit is not always necessary It is suggested to contact the family by telephone to answer questions and identify complications a day or two following discharge Patients receiving an implanted device may start new antiplatelet or anticoagulation therapy post intervention This should be anticipated if at all possible preprocedure, such that counseling and teaching may begin early Follow-up may need to be arranged, including laboratory monitoring Involvement of a pharmacist may facilitate easy transition to an outpatient anticoagulation service Subacute bacterial endocarditis prophylaxis may be necessary for patients following certain device implants, and counseling should discuss this Provide anticipatory guidance to patients after pulmonary valve implants about the signs and symptoms of endocarditis because there is an increased risk after implant ...Postprocedure care begins with hemostasis at the accessed vessel sites Pediatric patients are often limited to manual compression to achieve hemostasis, whereas adult patients may receive closure devices to seal puncture sites Thus in pediatric patients the importance of supine postprocedural positioning, to prevent