ReviewEarly ambulation after diagnostic transfemoral catheterisation: A systematic review and meta-analysis
Introduction
Femoral arterial puncture is the standard technique used to access the coronary arteries during coronary angiography, electrophysiological studies and diagnostic catheterisation of the aorta, renal, mesenteric, carotid and upper extremity arteries (Berry et al., 2004, Kato et al., 2009). In 2006, more than 1,115,000 angiogrammes were performed in the USA to diagnose and treat patients with vascular diseases (Lloyd-Jones et al., 2008). Catheterisation is normally performed by skin puncture under local anaesthesia. This procedure can lead to a variety of complications ranging from mild to severe haematoma, haemorrhage, acute thrombosis, distal embolisation, pseudoaneurysm, arteriovenous fistula, bruising, abscess, mycotic aneurysms and femoral nerve palsy. The procedure also incurs significant financial costs (Carrozza, 2012, Castillo-Sang et al., 2009). The most common complications are bleeding and haematoma, which usually appear within 12 h after the intervention, and which may lead to localised pain, hypotension and reduced haematocrit. Other problems such as arteriovenous fistula and pseudoaneurysm may not become apparent until days or weeks after the procedure (Carrozza, 2012).
Because of possible vascular events at the groin site, all patients are prescribed strict immobilisation and bed rest in the supine position (Rezaei-Adaryani et al., 2009). The involved leg is immobilised for 2–24 h after the procedure to prevent vascular complications, which occur at a rate of 1.96% (0.86–2.5%) in patients who have undergone transfemoral catheterisation (Boztosun et al., 2008, Chair et al., 2007, Lloyd-Jones et al., 2008). Bleeding and haematoma are normally formed in the soft tissue of the upper thigh and disappear a few days after catheterisation. These symptoms sometimes result in femoral nerve compression which may persist for weeks to months (Carrozza, 2012). It is therefore important to identify safe and feasible approaches to promote patient comfort without increasing the risk of vascular complications including haematoma and bleeding (Chair et al., 2007).
Different periods of bed rest are recommended after catheterisation. Boztosun et al. (2008) suggested 2 h of bed rest after angiography through the femoral artery when a 6 French catheter is used, and Bogart et al. (1999) recommended 4 h of bed rest after coronary angiography with an 8-French catheter.
It has been argued that prolonged bed rest may be associated with more discomfort, dissatisfaction, back pain, voiding problems and groin site pain (Dowling et al., 2002). Chair et al. (2007) found that earlier ambulation after angiography significantly reduced the risk of urinary discomfort. A large proportion of patients find it difficult to use the bedpan in the supine position during bed rest. Studies have also reported that back pain increases with longer duration of bed rest after catheterisation (Chair et al., 2007, Ashktorab et al., 2009). If the sandbag is removed from the insertion site and patients are given permission to change their position in bed, they experience significantly less fatigue and back pain, and their satisfaction and comfort increase (Rezaei-Adaryani et al., 2009, Wood et al., 1997). In addition, early ambulation may reduce length of the hospital stay and the cost of nursing care (Gianakos et al., 2004).
Regarding the duration of bed rest, studies have investigated a wide range of times to mobilisation after catheterisation. Some studies have considered 2 h of bed rest as early and 4 h as late ambulation. These studies have concluded that 2 h of bed rest after the procedure is safe (Baum and Gantt, 1996, Kato et al., 2009). Several studies have considered 2–4 h as early ambulation and 6 h as late ambulation (Ashktorab et al., 2009, Bogart et al., 1999). Other studies have considered 6 h as early and 12–24 h as late ambulation. Most of these studies have reported that early ambulation is safe and feasible (Keeling et al., 1994, Lau et al., 1993); however, their findings vary widely there appears to be no clear conclusion regarding the optimum duration of bed rest after transfemoral catheterisation (Bogart et al., 1999, Boztosun et al., 2008, Chair et al., 2007). This controversy among studies highlights the importance of conducting a systematic review designed to explore the effects of different durations of bed rest on the prevention of vascular complications after diagnostic transfemoral catheterisation.
Section snippets
Objective
To assess the effects of the duration of bed rest after transfemoral catheterisation on the occurrence of vascular complications and level of comfort, pain, urinary discomfort and patient satisfaction.
Search strategy
We identified relevant studies meeting the inclusion criteria by a computer-aided search of CENTRAL in the Cochrane Library (Issue 3, 2012), MEDLINE (from 1966 to February 2012), SCOPUS and CINAHL (from 1982) by using both free text and MeSH terms. We also searched Proquest Dissertations, Open SIGLE and Persian medical databases (Iranmedex, Irandoc). Studies were eligible regardless of time of publication, language of publication, or publication status. For MEDLINE search strategy see online
Description of the studies
We identified 2508 references from our electronic search, of which 42 full texts were retrieved (Fig. 1). We included 20 RCT involving a total of 4091 participants, with individual study sizes ranging between 39 and 874 participants. One study (Chair et al., 2007) was published in three reports (thesis, article and conference abstract) and another study (Bogart et al., 1999) in two reports (thesis and article). Sixty-four percent of participants were male in 16 studies. The overall mean age of
Discussion
The aim of this systematic review was to assess the effect of the duration of bed rest after transfemoral catheterisation on the occurrence of vascular complications and level of comfort, pain, urinary discomfort and patient satisfaction. A comprehensive search of the literature retrieved 20 RCT involving a total of 4019 participants.
In general the studies varied widely in how they defined early and late ambulation. These inconsistencies made comparisons between study results difficult. We
Conclusions
Early ambulation after diagnostic transfemoral catheterisation had no significant effect on the incidence of vascular complications including bleeding, haematoma, bruising, pseudoaneurysm, thrombus and arteriovenous fistula. However, early ambulation was associated with a lower level of back pain intensity and urinary discomfort compared to late ambulation. The results of this review suggest that patients can be ambulated 2–3 h after transfemoral catheterisation, and that early ambulation had no
Authors’ contributions
Mina Mohammady: Designed the review and contributed to the literature search and identification of studies for inclusion, quality appraisal, data entry into RevMan, data analysis and interpretation, and writing the review; Kazem Heidari: Developed and ran the search and contributed to study selection, quality appraisal, data extraction and write-up; Ali Akbari Sari: Contributed to the design of the review, data interpretation and write-up, and overall supervision of the study; Mitra
Acknowledgment
We thank Karen Shashok (AuthorAID in the Eastern Mediterranean) for improving the use of English in the manuscript.
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