GCC Cardiac ICU Nursing Guide

❤ CICU Patient Types

Acute Coronary Syndromes

STEMI post-primary PCI
High-risk NSTEMI / unstable angina
Complications post-ACS (VSD, free wall rupture, papillary muscle rupture)

Cardiogenic Shock

Low cardiac output states post-MI
Acute decompensated heart failure
Myocarditis with haemodynamic compromise

Post-Cardiac Surgery

CABG, valve replacement / repair
Aortic dissection repair
Congenital cardiac surgery (adult)

Arrhythmias & Arrest

Life-threatening VT / VF requiring monitoring
High-degree AV block with pacing
Post-cardiac arrest care (TTM/targeted temperature management)

Other Cardiac Critical Illness

Massive / submassive PE with haemodynamic instability
Hypertensive emergency with end-organ damage
Acute severe aortic / mitral regurgitation

Device Patients

IABP, Impella, VA-ECMO
LVAD / destination therapy
Post-ICD / pacemaker implant observation

⚡ CICU vs General ICU

Feature	CICU	General ICU
Primary focus	Cardiac output, rhythm, coronary perfusion	Multi-organ support
Primary monitoring	Continuous 12-lead, A-line, invasive CO	Standard haemodynamics
Key interventions	PCI, IABP, ECMO, pacing	Ventilation, dialysis, vasopressors
Nurse specialisation	Cardiac rhythm, device management	Broad critical care
Staffing ratio	1:1 unstable, 1:2 stable	1:2 typical

📊 Haemodynamic Monitoring Priorities

MAP Target

65-75 mmHg

SBP Shock Threshold

<90 mmHg

ScvO2 Target

>70%

Lactate Concern

>2 mmol/L

Continuous cardiac monitoring & 12-lead ECGs on admission and prn
Arterial line for continuous BP and blood gas access
Hourly urine output — target ≥0.5 mL/kg/hr
Serial troponin, BNP/NT-proBNP, lactate
Daily weight in stable patients (fluid balance)

🎓 Cardiac Nurse Specialist Competencies

Clinical Skills

12-lead ECG acquisition & basic interpretation
Arterial & central line care
Temporary pacemaker management
Defibrillator / cardioverter operation
IABP timing & troubleshooting

Assessment Skills

Haemodynamic waveform interpretation
Cardiac output interpretation (CO, CI, SVR)
Fluid responsiveness assessment
Signs of low cardiac output state
LVAD alarm response

GCC Certifications Valued

CCRN (AACN) PCCN (AACN) CEN ACLS / BLS

European equivalent: EDIC / FCICM for advanced practice
Saudi SCFHSrecognised ICU certification

👥 CICU Staffing Ratios & Roles

1:1 Ratio — Unstable Patients

Active cardiogenic shock requiring vasopressors/inotropes
VA-ECMO / Impella patients
Post-cardiac arrest first 24 hours
Post-PCI with complications
Temporary transvenous pacing active

1:2 Ratio — Stable Patients

Uncomplicated post-PCI observation (radial access, no shock)
Stable heart failure optimisation
Post-ICD/PPM implant monitoring
Rhythm monitoring only (rate-controlled AF)

⚠GCC context: Many CICU units operate with internationally recruited nurses (Philippines, India, South Africa, UK, Egypt). Communication protocols and clear handover structures are essential. SBAR handover is standard in most GCC tertiary centres.

📈 Arterial Line Management

Zeroing & Calibration

Zero to atmospheric pressure before insertion and every 8-12 hours
Level transducer at phlebostatic axis (4th ICS, mid-axillary line)
Fast flush test (square wave test): assess dynamic response — optimal = 1-2 oscillations after flush, then return to baseline
Over-damped: rounded waveform, falsely low SBP — check for air bubbles, kinked tubing, clot
Under-damped: overshoot, falsely high SBP — resonance in long tubing

MAP Targets in CICU

Condition	MAP Target
General post-PCI	65–75 mmHg
Post-cardiac arrest / TTM	≥65 mmHg
Cardiogenic shock	60–75 mmHg (balance)
Hypertensive emergency	Reduce by 20-25% in 1st hour
RV failure	≥65 mmHg (RV perfusion)

Waveform Interpretation

Normal Arterial Waveform Components

Anacrotic limb: rapid upstroke (systole)
Systolic peak: highest point
Dicrotic notch: aortic valve closure
Diastolic runoff: gradual decline to diastole

Pulsus Paradoxus (Cardiac Tamponade Clue)

SBP drop >10 mmHg on inspiration
Visible respiratory variation in A-line waveform
Also seen in severe asthma / COPD

Nursing Care Points

Radial artery preferred (Allen test beforehand)
Femoral A-line: check groin site q2h for haematoma, pulse checks distal
Heparinised flush solution 500 mL NS + 500 units heparin at 3 mL/hr — per local protocol
Label line clearly; never administer medications through A-line

📌 CVP Monitoring

Normal CVP

2–8 mmHg

Elevated CVP

>12 mmHg

Low CVP

<2 mmHg

CVP Waveform — Components

Wave/Descent	Represents	Abnormality
a wave	Atrial contraction	Absent in AF; giant a in heart block
c wave	Tricuspid valve closure	Often not visible
v wave	Atrial filling (passive)	Giant v wave = TR or PCWP elevation
x descent	Atrial relaxation & TV displacement	Loss in TR
y descent	Tricuspid valve opening	Steep y = constrictive pericarditis

Limitations of CVP

Poor predictor of fluid responsiveness as a single value
Trend and response to fluid challenge more useful than absolute value
Elevated CVP can reflect RV failure, tamponade, fluid overload, or high PEEP

Elevated CVP Differentials in CICU

RV infarction / failure
Cardiac tamponade (equalisation of pressures)
Pulmonary hypertension
Tension pneumothorax
Volume overload

🔧 Pulmonary Artery Catheter (Swan-Ganz)

ℹPA catheters are now less commonly used in modern CICU practice — largely replaced by less invasive cardiac output monitoring. They remain used in complex cardiogenic shock, RV failure assessment, and pre-transplant haemodynamic profiling.

Key Measurements

Parameter	Normal Range	Unit
PA systolic pressure	15–30	mmHg
PA diastolic pressure	8–15	mmHg
PCWP (wedge)	6–12	mmHg
Cardiac Output (CO)	4–8	L/min
Cardiac Index (CI)	2.2–4.0	L/min/m²
SVR	800–1200	dynes·s/cm⁵
Mixed venous O2 (SvO2)	60–75	%

Calculations

Cardiac Index

CI = CO ÷ BSA (m²) | Target CI >2.2 in shock

SVR Formula

SVR = [(MAP − CVP) ÷ CO] × 80 (dynes·s/cm⁵)

Haemodynamic Profile in Cardiogenic Shock

Low CO/CI (<2.2 L/min/m²)
Elevated PCWP (>15–18 mmHg)
High SVR (vasoconstriction)
Low SvO2 (<60% — high extraction)

👁 Less-Invasive & Non-Invasive Cardiac Output Monitoring

PiCCO System

Transpulmonary thermodilution via central venous + femoral arterial catheter
Measures: CO, ITBV (intrathoracic blood volume), EVLW (extravascular lung water)
Useful in cardiogenic shock with pulmonary oedema — guides fluid strategy
Requires calibration every 8h or after haemodynamic change

LiDCO / LiDCOplus

Lithium dilution calibration technique
Continuous beat-to-beat CO from arterial waveform
Requires periodic lithium dilution calibration
Contraindicated if patient on lithium therapy

NICOM / Bioreactance

Non-invasive — 4 electrode patches on chest
Measures phase shift of electrical current through thorax
Estimates CO, SV, SVR non-invasively
Useful in haemodynamically stable patients or post-PCI monitoring
Less accurate in arrhythmias, obesity, paced rhythms

ScvO2 Monitoring

Normal ScvO2

>70%

Borderline

60–70%

Critical

<60%

Measured via central venous catheter (superior vena cava position)
Reflects global oxygen delivery vs consumption balance
Low ScvO2: inadequate O2 delivery (anaemia, low CO, hypoxia) OR increased consumption (sepsis, shivering, fever)
High ScvO2 (>80%): distributive shock (septic), mitochondrial dysfunction, hepatic vein sampling error

Mixed Venous O2 (SvO2) vs ScvO2

SvO2: sampled from PA catheter (true mixed venous blood)
ScvO2: sampled from SVC via CVC — slightly higher (3–5%) than true SvO2
In clinical practice, ScvO2 >70% used as surrogate target (Early Goal Directed Therapy heritage)
In cardiogenic shock: low SvO2 (<60%) confirms inadequate CO

❤ Immediate Post-PCI Nursing Care

Radial Access Site (TR Band / Compression)

Radial artery preferred in modern practice — lower bleeding risk
Haemostatic band (TR Band): inflate with air per protocol, deflate incrementally over 2–4 hours
Perform Barbeau test / reverse Allen test before removal
Check hourly: swelling, haematoma, brachial pulse, capillary refill, sensation/movement of fingers
Radial artery occlusion (RAO): managed with patent haemostasis technique — ipsilateral ulnar compression during deflation

Femoral Access Site

Manual or device-assisted closure (Angioseal, Perclose)
Post-procedure bed rest 2–6 hours depending on sheath size and closure method
Hourly checks: haematoma size (mark margin), femoral/popliteal/DP pulse, sensorimotor in leg
Retroperitoneal haemorrhage: flank/back pain + haemodynamic instability — alert physician immediately

Post-PCI Complications — Nursing Vigilance

Contrast nephropathy: creatinine rise 24–48h post-procedure — monitor UO, hydration
No-reflow phenomenon: persistent ST elevation despite open artery
Stent thrombosis: sudden chest pain + ST re-elevation — emergency re-cath
Coronary perforation: haemopericardium, tamponade
Vascular access complications: see left

Post-PCI Monitoring Parameters

12-lead ECG immediately post-procedure, at 1h, and if chest pain
Serial troponin at 6h and 12h post-procedure
Continuous cardiac monitoring minimum 24h
Urine output hourly — ensure ≥125 mL/h for contrast clearance
Daily renal function for 48h (contrast nephropathy)

💊 Dual Antiplatelet Therapy (DAPT)

Standard DAPT Regimen

Loading Doses (at PCI)

Aspirin: 300 mg oral loading → 75–100 mg daily (lifelong)
Ticagrelor: 180 mg loading → 90 mg BD (preferred in STEMI) — 12 months minimum
Clopidogrel: 600 mg loading → 75 mg daily — used if ticagrelor not tolerated or on anticoagulation
Prasugrel: 60 mg loading → 10 mg daily — avoid if prior TIA/stroke, age >75, weight <60 kg

Anticoagulation Monitoring

Unfractionated heparin during PCI — ACT monitoring in cath lab (target 250–350 s)
Post-PCI: check aPTT if IV heparin continued (target 50–70 s)
Bivalirudin: shorter half-life, less bleeding at access site
NOAC use in AF + ACS: triple therapy risk — careful bleeding surveillance

⚠Ticagrelor Dyspnoea: Up to 15% of patients experience transient dyspnoea (not bronchospasm) — reassure patient, does not require cessation unless severe. Educate before discharge.

Bleeding Risk Monitoring

CRUSADE / HAS-BLED scores for bleeding risk stratification
Watch for: gingival bleeding, easy bruising, haematuria, melaena
Platelet count monitoring in GP IIb/IIIa inhibitor use — thrombocytopenia risk
Stool guaiac testing if GI symptoms

GCC-Specific: Ramadan & DAPT

Some patients stop medication during fasting — critical risk for stent thrombosis
Educate firmly: DAPT must not be discontinued
Coordinate with religious authority — medications for cardiac indications are permitted during Ramadan

🔴 Reperfusion Arrhythmias

Accelerated Idioventricular Rhythm (AIVR) — Benign

Rate 60–100 bpm, wide QRS, no P waves preceding
Occurs 1–12h after successful reperfusion
Benign reperfusion arrhythmia — sign of coronary reopening
No treatment required unless haemodynamic compromise
Differentiate from VT: rate is slower (60–100 bpm in AIVR vs >100 in VT)

Ventricular Tachycardia (VT)

Rate >100 bpm, wide QRS (>0.12s)
Sustained VT (>30s or haemodynamically unstable) — immediate treatment
Non-sustained VT (<30s, no haemodynamic compromise) — monitor, consider electrolytes
Correct K⁺ (>4.0 mEq/L) and Mg²⁺ (>0.8 mmol/L) to reduce VT burden

Other Reperfusion Arrhythmias

Sinus bradycardia: common in inferior STEMI (RCA territory) — may need atropine or transcutaneous pacing
AF: new-onset post-MI — rate control, anticoagulation consideration
Transient AV block: watch for PR prolongation progressing to complete heart block in inferior STEMI

Electrolyte Management

Electrolyte	Target (Post-MI)	Reason
Potassium (K⁺)	4.0–5.0 mEq/L	Reduces VT/VF risk
Magnesium (Mg²⁺)	>0.8 mmol/L	Membrane stabilisation
Phosphate	0.8–1.5 mmol/L	Energy metabolism

🚨 Mechanical Complications Post-MI

⚠Mechanical complications are rare (1–2% of STEMI) but carry very high mortality. They typically occur 2–7 days post-MI. Acute haemodynamic deterioration in post-MI patient must prompt immediate echo evaluation.

Ventricular Septal Defect (VSD)

Onset 3–5 days post-MI (anterior or inferior)
Presentation: new harsh pansystolic murmur + sudden deterioration
Step-up in O2 saturation from RA to PA on PA cath
Management: IABP/mechanical support, surgical repair or percutaneous closure

Papillary Muscle Rupture

Causes acute severe mitral regurgitation
Inferior MI (posteromedial PM more vulnerable — single blood supply)
Flash pulmonary oedema, new MR murmur
Cardiogenic shock despite relatively preserved LV function
Emergency surgical valve repair / replacement

Free Wall Rupture

Often catastrophic — cardiac tamponade / sudden death
Can be subacute — persistent pain, pericardial effusion on echo
Becks triad: hypotension, muffled heart sounds, JVD
Pulseless electrical activity (PEA) on arrest — consider pericardiocentesis
Emergency surgical repair required

📋 STEMI Risk Stratification — TIMI & GRACE Scores (Nursing Use)

TIMI Score (STEMI) — 0–14 Points

Age ≥75 (3 pts), 65–74 (2 pts)
DM / HTN / Angina (1 pt)
SBP <100 mmHg (3 pts)
HR >100 (2 pts)
Killip class II–IV (2 pts)
Weight <67 kg (1 pt)
Anterior ST elevation or LBBB (1 pt)
Time to treatment >4h (1 pt)
Nursing use: higher score = higher ICU nurse-to-patient vigilance needed

GRACE Score (ACS) — Nursing Implications

Parameters: age, heart rate, SBP, creatinine, Killip class, cardiac arrest, ST deviation, elevated troponin
Predicts in-hospital and 6-month mortality
High GRACE (>140) = highest risk — immediate CICU admission
Intermediate GRACE (109–140) = early invasive strategy within 24h
Nursing role: feed parameter data to medical team for score calculation; high GRACE triggers senior review

🔴 Cardiogenic Shock Definition & SCAI Classification

SBP

<90 mmHg

Cardiac Index

<2.2 L/min/m²

PCWP

>15 mmHg

Lactate

>2 mmol/L

🧮 Cardiogenic Shock Severity Calculator (SCAI Staging)

SBP (mmHg)

Heart Rate (bpm)

Urine Output (mL/hr)

Lactate (mmol/L)

Vasopressors Required?

Cardiac Arrest?

💊 Inotrope & Vasopressor Infusions

Drug	Mechanism	Starting Dose	Usual Range	Nursing Notes
Dobutamine	Beta-1 agonist — positive inotropy	2.5 mcg/kg/min	2.5–20 mcg/kg/min	May cause tachycardia and hypotension (vasodilation). Monitor HR and MAP closely. Tachyarrhythmia risk >10 mcg/kg/min.
Milrinone	PDE-3 inhibitor — inodilator	0.25 mcg/kg/min	0.25–0.75 mcg/kg/min	Reduce dose in renal impairment. Causes vasodilation — may worsen hypotension. Preferred in beta-blocker toxicity.
Noradrenaline	Alpha-1 > Beta-1 — vasoconstriction	0.05 mcg/kg/min	0.05–1.0 mcg/kg/min	First-line vasopressor in cardiogenic shock alongside inotrope. Central line required. Extravasation risk — check site hourly.
Adrenaline	Alpha + Beta agonist	0.05 mcg/kg/min	0.05–0.3 mcg/kg/min	Use in refractory shock or cardiac arrest. Increases metabolic demand — monitor lactate and glucose. Second-line agent.
Vasopressin	V1 receptor — pure vasoconstriction	0.03 units/min	Fixed 0.01–0.04 units/min	Adjunct to noradrenaline — not titrated for effect. Useful to spare noradrenaline dose.
Levosimendan	Calcium sensitiser + vasodilator	0.05–0.1 mcg/kg/min	0.1–0.2 mcg/kg/min	24-hour infusion. Effects last 7–14 days. Available in GCC (Saudi, UAE, Qatar). Monitor BP closely during infusion.

⚠Titration principle: Titrate inotropes to CI >2.2 L/min/m² and ScvO2 >70%. Titrate vasopressors to MAP ≥65 mmHg. Document dose changes, haemodynamic response, and rationale every hour in active titration phase.

▶ Intra-Aortic Balloon Pump (IABP)

Principles

Counter-pulsation device: inflates in diastole (augments coronary perfusion), deflates just before systole (reduces afterload)
Inserted via femoral artery, balloon positioned in descending aorta distal to left subclavian artery
Modes: 1:1 (every beat), 1:2, 1:3 (weaning)

Timing Assessment

Problem	Waveform Sign	Action
Early inflation	Diastolic augmentation cuts into systole — V shape	Delay inflation trigger
Late inflation	Absent or reduced diastolic peak	Advance inflation timing
Early deflation	Diastolic pressure drops before systole — loss of afterload reduction	Delay deflation
Late deflation	IABP deflation into systole — increases afterload	Advance deflation timing

IABP Complications & Nursing Vigilance

Limb ischaemia: check bilateral pedal pulses, capillary refill, temperature q2h
Balloon rupture: blood in helium line — stop pump, alert physician immediately
Thrombocytopenia: monitor platelet count daily (mechanical destruction)
Haematoma / bleeding at groin: mark size, check q1h
Do not flex affected hip >30 degrees

IABP Weaning Protocol

Wean when: MAP ≥70 without vasopressors, SBP >100, CI >2.2 on minimal inotropes
Reduce to 1:2 for 2–4h, then 1:3 for 2h before removal
Do NOT leave on 1:3 longer than necessary — thrombosis risk

💡 VA-ECMO Nursing Care

⚠VA-ECMO for cardiac failure bypasses both cardiac and pulmonary function. It is the most complex device in CICU — requires 1:1 nurse-to-patient ratio and dedicated ECMO specialist/perfusionist support.

Cannula Care

Venous cannula (drainage): typically femoral vein — large bore (21–25 Fr)
Arterial cannula (return): femoral artery — 15–19 Fr
Inspect insertion sites q2h: bleeding, haematoma, cannula migration
Secure all circuit connections — accidental decannulation is catastrophic
Do not move patient without ECMO specialist present

Flow Monitoring

Target ECMO flow: 2.2–2.5 L/min/m² to unload native heart
Suction events (flow chattering): volume depletion, positional, tamponade — check filling, reposition, alert physician
Monitor circuit for clots: dark speckling in oxygenator
Daily ACT or aPTT: heparin infusion to maintain circuit anticoagulation (ACT 160–200 s, aPTT 50–80 s — per protocol)

Limb Perfusion — DLEG Critical

Arterial cannula in femoral artery compromises distal limb perfusion
Distal perfusion catheter (DPC): small catheter in SFA — MUST be patent
Check limb hourly: temperature, colour, capillary refill, Doppler signal
Signs of limb ischaemia: pallor, mottling, pain, absent Doppler — emergent action

North-South Syndrome

In VA-ECMO: oxygenated blood from ECMO competes with hypoxic blood from native cardiac output
Upper body (arms, head) may receive de-saturated blood from failing lungs
Monitor SpO2 on right hand (pre-ductal) and ABG — if upper body hypoxic, requires conversion to VV-ECMO or hybrid configuration

⚡ Impella Device Nursing

Impella Overview

Percutaneous microaxial flow pump — inserted via femoral or axillary artery
Catheter crosses aortic valve into LV — actively pumps blood from LV to aorta
Models: Impella CP (3.7L/min), Impella 5.0 (5L/min)
Unloads the LV — reduces wall stress, allows myocardial recovery

Nursing Priorities

Motor current monitoring: detects position changes (suction = too deep in LV; aortic = too shallow)
Purge system: glucose/heparin solution — check flow rate, refill q24h
Position signal: must remain on "optimal" — alert if changes
Femoral site care: leg immobilisation, hourly pulse checks
Haemolysis monitoring: daily LDH, plasma-free haemoglobin, urine colour

💡 LVAD Nursing (Left Ventricular Assist Device)

Driveline Care

Driveline exits through abdominal wall — high infection risk
Dressing change: sterile technique, typically every 7 days or if soiled
Immobilise driveline with securement device — prevent traction and trauma
Inspect for signs of infection: erythema, induration, purulent discharge
Driveline infection is life-threatening — earliest detection critical

Anticoagulation

Warfarin target INR: 2.0–3.0 (per device protocol)
Plus aspirin 100 mg daily
Daily INR monitoring during hospital stay; weekly as outpatient
Risk: stroke (thromboembolism) and pump thrombosis if under-anticoagulated

Critical LVAD Alarms

Alarm	Likely Cause	Action
Low flow	Hypovolaemia, RV failure, arrhythmia, tamponade	Assess volume, rhythm, BP — call team
Suction alarm	Volume depletion, RV failure	IV fluids cautiously — assess RV
Low speed	Thrombosis, system error	Alert LVAD coordinator urgently
Controller battery low	Power issue	Connect to mains immediately

⚠LVAD patients have no palpable pulse and no standard SpO2 reading from pulse oximetry — use mean arterial pressure via Doppler for BP assessment. NIBP cuff is unreliable.

📐 Cardiac Rhythm Recognition

Rhythm	Rate (bpm)	QRS	P Waves	Haemodynamic Risk	Initial Action
VF	Chaotic	No QRS — chaotic	None	Cardiac arrest	Immediate defibrillation 200J biphasic + CPR
Pulseless VT	>100	Wide (>0.12s)	Dissociated	Cardiac arrest	Defibrillation 200J + CPR
Monomorphic VT (pulse)	100–250	Wide, regular	Dissociated	High if SBP <90	Cardioversion if unstable; amiodarone if stable
Torsades de Pointes	150–250	Wide, twisting	None	High — degenerates to VF	Mag sulphate 2g IV; stop QT-prolonging drugs
AF (rapid)	100–180	Narrow (usually)	Absent — fibrillatory baseline	Moderate (high if WPW)	Rate control (metoprolol, digoxin); anticoagulation; consider cardioversion
SVT (AVNRT)	150–250	Narrow	Absent / in QRS	Low-moderate	Valsalva; adenosine 6mg IV rapid push
3rd Degree AV Block	Atrial: normal; Ventricular: 20–60	Wide (escape)	No relationship to QRS	High — syncope / arrest	Transcutaneous pacing; prepare transvenous pacing
2nd Degree Mobitz II	Variable	Narrow / normal	P waves without QRS	Moderate-high	Pacing on standby; cardiology review

📞 12-Lead ECG — Nursing Role in CICU

Acquire 12-lead ECG within 10 minutes of chest pain onset / symptom change (STEMI target: Door-to-ECG <10 min)
Accurate electrode placement: limb leads (LA, RA, LL, RL) and V1–V6 precordial leads
V1: 4th ICS right sternal border; V2: 4th ICS left sternal border; V3: between V2 and V4; V4: 5th ICS mid-clavicular; V5: anterior axillary line; V6: mid-axillary line
Posterior leads (V7, V8, V9): posterior STEMI — place at same level as V4–V6 on posterior chest wall
Right-sided leads (V3R, V4R): right ventricular infarction in inferior STEMI

ST Elevation Criteria (STEMI)

≥1 mm in ≥2 contiguous limb leads
≥2 mm in ≥2 contiguous precordial leads (men)
≥1.5 mm in V2–V3 (women)
New LBBB with ischaemic symptoms = STEMI equivalent
Nursing action: immediate physician notification, activate cath lab if STEMI criteria met

⚡ Temporary Transvenous Pacing (TVP)

Settings & Parameters

Parameter	Initial Setting	Target
Rate	60–80 bpm	Above intrinsic rate
Output (mA)	Set at 2× capture threshold	Minimum for 100% capture
Sensitivity (mV)	1–3 mV initially	Detects intrinsic R waves >5 mV

Capture Threshold

Set output at 20 mA, gradually reduce until capture lost — this is the threshold
Set output at 2× threshold (safety margin) — e.g., if threshold = 3 mA, set to 6 mA
Normal threshold: 0.5–2 mA — check daily (rises with fibrosis, electrolyte imbalance)

Troubleshooting TVP Problems

Problem	Signs	Action
Failure to capture	Pacing spike without wide QRS	Increase output; check connections; reposition lead
Failure to sense	Pacing during intrinsic rhythm (competitive)	Increase sensitivity (lower mV value); reposition lead
Oversensing	Pauses — T waves/noise inhibiting pacemaker	Decrease sensitivity (higher mV)
Lead displacement	Loss of capture + ECG change	CXR; reposition under fluoro guidance

TVP Nursing Care

Secure pacing catheter firmly — prevent inadvertent displacement
Protect external generator from drops/damage
Dressing change q48–72h with sterile technique
Bed rest if femoral insertion; limited movement if subclavian/internal jugular
Monitor for RV perforation: sudden change in capture, hypotension, pericardial rub

🔙 PPM & ICD Post-Implant Nursing Care

Permanent Pacemaker (PPM) — 24–48h Post-Implant

Arm restriction: ipsilateral arm — no raising above shoulder for 4–6 weeks (lead displacement risk)
Wound care: inspect for haematoma, infection, erosion
CXR post-implant: confirm lead position, exclude pneumothorax
Device check before discharge: sensing and pacing thresholds, impedance
Patient education: avoid MRI (unless MRI-conditional device), no prolonged pressure over device

ICD Post-Implant Nursing

Same wound and arm care as PPM
Inappropriate shock counselling: most common ICD complication — caused by AF with rapid ventricular rate, oversensing, lead fracture
Document all shocks: date, time, activity, associated symptoms — transmit to EP team
Magnet use: placing device magnet over ICD inhibits therapy (tachycardia detection/therapy suspended) — used in end-of-life care or inappropriate shocks
CPR: chest compressions safe with ICD in place — maintain standard BLS protocol

⚡ Cardioversion & Defibrillation — Nursing Role

Unsynchronised Defibrillation (Emergency)

Indications: VF, pulseless VT, Torsades
Energy: 200J biphasic (initial), 200–360J subsequent
No synchronisation — deliver immediately
Nursing role: clear call ("I'm clear, you're clear, everyone clear"), apply gel/pads, confirm rhythm, deliver shock, resume CPR immediately

Synchronised Cardioversion (Elective/Urgent)

Indications: AF, AFL, SVT, haemodynamically unstable VT with pulse
Sync mode ON — shock delivered on R wave (avoids T wave → VF)
AF: start 120–200J biphasic; AFL/SVT: 50–100J
For elective cardioversion: sedation/anaesthesia required, NPO 4–6h, anticoagulation check (AF >48h needs 3 weeks anticoagulation or TOE to exclude thrombus)
Pre-procedure: IV access, O2, emergency drugs ready, anaesthesia support

ℹPost-cardioversion: obtain 12-lead ECG immediately. Monitor rhythm continuously for 1 hour minimum. Transient ST changes are common and do not require intervention unless associated with haemodynamic compromise.

Cardiac ICU (CICU) Nursing Guide Critical CareGCC Edition

❤ CICU Patient Types

Acute Coronary Syndromes

Cardiogenic Shock

Post-Cardiac Surgery

Arrhythmias & Arrest

Other Cardiac Critical Illness

Device Patients

⚡ CICU vs General ICU

📊 Haemodynamic Monitoring Priorities

🎓 Cardiac Nurse Specialist Competencies

Clinical Skills

Assessment Skills

GCC Certifications Valued

👥 CICU Staffing Ratios & Roles

1:1 Ratio — Unstable Patients

1:2 Ratio — Stable Patients

📈 Arterial Line Management

Zeroing & Calibration

MAP Targets in CICU

Waveform Interpretation

Normal Arterial Waveform Components

Pulsus Paradoxus (Cardiac Tamponade Clue)

Nursing Care Points

📌 CVP Monitoring

CVP Waveform — Components

Limitations of CVP

Elevated CVP Differentials in CICU

🔧 Pulmonary Artery Catheter (Swan-Ganz)

Key Measurements

Calculations

Cardiac Index

SVR Formula

Haemodynamic Profile in Cardiogenic Shock

👁 Less-Invasive & Non-Invasive Cardiac Output Monitoring

PiCCO System

LiDCO / LiDCOplus

NICOM / Bioreactance

ScvO2 Monitoring

Mixed Venous O2 (SvO2) vs ScvO2

❤ Immediate Post-PCI Nursing Care

Radial Access Site (TR Band / Compression)

Femoral Access Site

Post-PCI Complications — Nursing Vigilance

Post-PCI Monitoring Parameters

💊 Dual Antiplatelet Therapy (DAPT)

Standard DAPT Regimen

Loading Doses (at PCI)

Anticoagulation Monitoring

Bleeding Risk Monitoring

GCC-Specific: Ramadan & DAPT

🔴 Reperfusion Arrhythmias

Accelerated Idioventricular Rhythm (AIVR) — Benign

Ventricular Tachycardia (VT)

Other Reperfusion Arrhythmias

Electrolyte Management

🚨 Mechanical Complications Post-MI

Ventricular Septal Defect (VSD)

Papillary Muscle Rupture

Free Wall Rupture

📋 STEMI Risk Stratification — TIMI & GRACE Scores (Nursing Use)

TIMI Score (STEMI) — 0–14 Points

GRACE Score (ACS) — Nursing Implications

🔴 Cardiogenic Shock Definition & SCAI Classification

🧮 Cardiogenic Shock Severity Calculator (SCAI Staging)

💊 Inotrope & Vasopressor Infusions

▶ Intra-Aortic Balloon Pump (IABP)

Principles

Timing Assessment

IABP Complications & Nursing Vigilance

IABP Weaning Protocol

💡 VA-ECMO Nursing Care

Cannula Care

Flow Monitoring

Limb Perfusion — DLEG Critical

North-South Syndrome

⚡ Impella Device Nursing

Impella Overview

Nursing Priorities

💡 LVAD Nursing (Left Ventricular Assist Device)