Positron Emission Tomography (PET)

Positron emission tomography (PET) is a test that uses a special type of camera and
a tracer (radioactive chemical) to look at organs in the body. The tracer usually is a
substance (such as glucose) that can be used (metabolized) by cells in the body.

During the test, the tracer liquid is put into a vein (intravenous, or IV) in your arm.
The tracer moves through your body, where much of it collects in the specific organ
or tissue. The tracer gives off tiny positively charged particles (positrons). The
camera records the positrons and turns the recording into pictures on a computer.

PET scan pictures do not show as much detail as computed tomography (CT) scans
or magnetic resonance imaging (MRI) because the pictures show only the location
of the tracer. The PET picture may be matched with those from a CT scan to get
more detailed information about where the tracer is located.

A PET scan is often used to evaluate cancer, check blood flow, or see how organs
are working.

Why It Is Done
A positron emission tomography (PET) scan is done to:
 Study the brain's blood flow and metabolic activity. A PET scan can help a doctor
find nervous system problems, such as Alzheimer's disease, Parkinson's disease,
multiple sclerosis, transient ischemic attack (TIA), amyotrophic lateral sclerosis
(ALS), Huntington's disease, stroke, and schizophrenia.
 Find changes in the brain that may cause epilepsy.
 Evaluate some cancers, especially lymphoma or cancers of the head and neck,
brain, lung, colon, or prostate. In its early stages, cancer may show up more
clearly on a PET scan than on a CT scan or an MRI.
 See how advanced a cancer is and whether it has spread to another area of the
body (metastasized). It is often necessary to do both CT and PET scans to
evaluate cancer.
 Help a doctor choose the best treatment for cancer. PET scans may also be done
to see whether surgery can be done to remove a tumor.
 Find poor blood flow to the heart, which may mean coronary artery disease.
 Find damaged heart tissue, especially after a heart attack.
 Help choose the best treatment, such as coronary artery bypass graft surgery,
for a person with heart disease.

How To Prepare
 Tell your doctor if you have diabetes. If you take medicine to control diabetes,
you may need to take less than your normal dose. Talk with your doctor about
how much medicine you should take.
 Tell your doctor about any medicines and herbal remedies you take. You may
need to stop taking some medicines or change your dose before this test.
 Do not smoke or drink caffeine or alcohol for 24 hours before this test.
 Do not eat or drink for at least 6 hours before this test.
 Tell your doctor if you are or might be pregnant or if you are breast-feeding. If
you are breast-feeding, you will need to use formula for 1 to 2 days after the PET
scan so you won't pass the tracer to your baby. This generally takes 24 hours.
 Tell your doctor if you have a fear of enclosed spaces or have ever had a panic
attack.
 You may be asked to sign a consent form for this test. Talk to your doctor about
any concerns you have regarding the need for the test, its risks, how it will be
done or what the results mean.

How It Is Done
 A positron emission tomography (PET) scan is done in a hospital nuclear
medicine department or at a special PET center by a radiologist or nuclear
medicine specialist and a technologist. You will be asked to lie on a table that is
hooked to a large scanner, camera, and computer.
 The radioactive tracer is usually given in a vein (IV). You may need to wait 30 to
60 minutes for the tracer to move through your body. During this time, you may
need to avoid moving and talking.
 The PET scanner, which is shaped like a doughnut, moves around you. The
scanned pictures are sent to a computer screen so your doctor can see them.
Many scans are done to make a series of pictures. It is very important to lie still
while each scan is being done. At some medical centers, a CT scan will be done
at the same time.
 For a PET scan of the brain, you will lie on a bed. You may be asked to read,
name letters, or tell a story, depending on whether speech, reasoning, or
memory is being tested. During the scan, you may be given earplugs and a
blindfold (if you do not need to read during the test) to wear for your comfort.
 If you are having a PET scan of your heart, electrodes for an electrocardiogram
(EKG, ECG) will be put on your body.
 During the test, you will be alone in the scanner room. The technologist will
watch you through a window and you will be able talk to him or her through a
two-way intercom at all times.
 The test takes 1 to 3 hours.
 After the test, drink lots of fluids for the next 24 hours to help flush the tracer
out of your body.

How It Feels
 You will not feel pain during the test. The table you lie on may be hard and the
room may be cool. It may be difficult to lie still during the test.
 You may feel a quick sting or pinch when the IV is put in your arm. The tracer
may make you feel warm and flushed. Some people feel sick to their stomach or
have a headache. Tell your doctor how you are feeling.
 You may feel nervous inside the PET scanner.

Risks
 There is always a slight chance of damage to cells or tissue from radiation,
including the low levels of radiation used for this test. But the chance of damage
is usually very low compared with the benefits of the test.
 Most of the tracer will be flushed from your body within 6 to 24 hours. Allergic
reactions to the tracer are very rare.
 In rare cases, some soreness or swelling may develop at the IV site where the
radioactive tracer was put in. Apply a moist, warm compress to your arm.
Results

Positron emission tomography (PET) is a test that uses a special type of camera and
a tracer (radioactive chemical) to look at organs in the body.

The radiologist may discuss preliminary results of the PET scan with you right after
the test. Complete results are usually available in 1 to 2 days.

Positron emission tomography (PET)

Normal: Blood flow is normal and organs are

working well. The flow and pattern of the
tracer shows normal distribution in the
body.

Abnormal: Heart: • Decreased blood flow and

increased glucose metabolism may
show that the blood vessels are
blocked. This may mean coronary
artery disease (CAD) is present.

• Decreased blood flow and glucose

metabolism may mean that heart
tissue is scarred and damaged,
such as from a heart attack.

Brain:  Areas of increased glucose

metabolism or lower oxygen use
and blood flow may mean you have
epilepsy.
 Decreased oxygen use and blood
flow may mean a stroke has
occurred.
 Decreased glucose metabolism
may mean a form of dementia.
Dementia may be caused by
Alzheimer's disease, Parkinson's
disease, Huntington's disease, or
mental illness, such as
schizophrenia.

 Patterns of blood flow and oxygen

use that are not normal may mean
a brain tumor is present.

Tumor Areas of increased glucose metabolism

detection: may mean a tumor is present.

What Affects the Test

Reasons you may not be able to have the test or why the results may not be helpful
include:
 Being pregnant. A PET scan is not usually done during pregnancy because the
radiation could harm the unborn baby (fetus).
 Using caffeine, tobacco, or alcohol in the past 24 hours.
 Not being able to lie still for the test.
 Being too anxious.
 Using sedatives.
 Taking medicines, such as insulin, that change your metabolism.

Central Venous Pressure

This is a measure of the venous pressure where the superior and inferior vena cava
join prior to entering the right auricle of the heart.

Central Venous Pressure monitoring is more accurate then blood pressure

monitoring because changes in circulating volume will be reflected in changes in
CVP. It is acquired by threading a central venous catheter (subclavian double lumen
central line shown) into any of several large veins. It is threaded so that the tip of
the catheter rests in the lower third of the superior vena cava. The pressure
monitoring assembly is attached to the distal port of a multilumen central vein
catheter.

Normal Values
Normal CVP is 2-6 mm Hg. When there is overloading of the circulatory system or
there is heart failure the CVP rises. However, when there is dehydration (e.g.
diabetes insipidus), fluid loss due to bleeding or shifting of fluids within the body
compartments (e.g. shock) then the CVP will fall.

Generally, when the CVP is rising to unhealthy levels the patient may display
difficulty with breathing. Conversely, when the CVP is falling there may be a
decrease in urinary output and the patient may complain of feeling excessively
thirsty. To correct over hydration, as illustrated by a rising CVP the physician may
choose to restrict fluids or to administer a diuretic. To deal with a falling CVP the
physician might choose to give the patient more fluids or blood as the case may be.

Procedure and Nursing Responsibilities

Prior to the insertion of a CVP line an accurate assessment of the patient must me
made. A history of the patient may be obtained from the patient, family, notes of
previous admissions and the authority who brought the patient to the Hospital.

It is important to explain the procedure to the patient to obtain his or her history.
Local anesthetic should be used where the patient does not have an allergy to it.
Placing the patient in a supine position is usually sufficient. In some cases where the
patient is hypovolumic the trendelenberg position will help dilate the veins in the
upper parts of the body and make it easier for the physician to insert the cannula.
Appropriate draping is important to maintain sterility and patient cooperation. In
some situations it may be advisable to use a mild sedative to limit pain, awareness
of the procedure and keep the patient calm.

After insertion of a CVP line it is usual to have a chest x-ray. This will confirm correct
placement of the CVP line.

The CVP catheter is an important tool used to assess right ventricular function and
systemic fluid status. The CVP catheter is also an important treatment tool which
allows for rapid infusion, infusion of hypertonic solutions and medications that could
damage veins, and serial venous blood assessment.

Heart bypass surgery

Heart bypass surgery creates a new route, called a bypass, for blood and oxygen to
reach your heart. It is done to fix problems caused by coronary artery disease
(CAD), in which the arteries that lead to your heart are partly or totally blocked.

Procedure
Before your surgery you will receive anesthesia. This will make you unconscious and
unable to feel pain. The effects of the anesthesia will last the entire procedure.

Once you are unconscious, the heart surgeon will make a 10-inch-long incision (cut)
in the middle of your chest. Then your breastbone will be separated to create an
opening that allows the surgeon to see your heart and aorta (the main blood vessel
leading from the heart to the rest of your body).

Most people who have coronary bypass surgery are connected to a heart-lung
bypass machine, or bypass pump.
 This machine does the work of your heart while your heart is stopped for the
surgery. The machine adds oxygen to your blood, and circulates your blood
through your body.
 Your heart is stopped while you are connected to this machine.

A newer method does not use the heart-lung bypass machine. The bypass is
created while your heart is still beating. This is called off-pump coronary artery
bypass, or OPCAB. This method may be used for patients who could have problems
from being on the heart-lung machine.

During this surgery, the doctor takes a vein or artery from another part of your body
and uses it to create a detour (or graft) around the blocked area in your artery.
 Your doctor may use a vein, called the saphenous vein, in your leg. To reach
this vein, an incision will be made along the inside of your leg, between your
ankle and the groin. One end of the graft will be sewn to your coronary
 artery. The other end will be sewn to an opening that will be made in your
aorta.
 The internal mammary artery (IMA), in your chest, can also be used as the
graft. One end of the IMA is already connected to your aorta, so just one end
will need to be attached. It will be sewn to your coronary artery.
 Other arteries are also now being used for grafts in bypass surgery. The most
common one is the radial artery, in your wrist.

After the graft has been created, your breastbone will be reconnected with wire,
and your incision will be sewn closed. The wire will remain inside you.

This surgery can take 4 to 6 hours. After the surgery, you will be taken to the
Intensive Care Unit.

Why the Procedure is Performed

Coronary arteries are the small blood vessels that supply your heart with oxygen
and nutrients that are carried in your blood.

When one or more of the coronary arteries becomes partly or totally blocked, your
heart does not get enough blood. This is called ischemic heart disease, or coronary
artery disease (CAD). It can cause chest pain (angina).

Coronary artery bypass surgery can be used to treat coronary artery disease. Your
doctor may have tried to treat you with medicines only. You may have also tried
cardiac rehabilitation.

CAD varies a lot from person to person, so the way it is diagnosed and treated will
also vary. Heart bypass surgery is just one treatment. It will be right for some
people, but others may have other kinds of treatment.

Risks
Risks for any surgery are:
 Blood clots in the legs that may travel to the lungs
 Breathing problems
 Infection, including in the lungs, urinary tract, and chest
 Blood loss

Possible risks from having coronary bypass surgery are:

 Heart attack or stroke
 Sternal (chest) wound infection, which is more likely to happen in people who
are obese, have diabetes, or have already had this surgery
 Post-pericardiotomy syndrome, which is a low-grade fever and chest pain. It
could last up to 6 months.
 Some people report memory loss and loss of mental clarity, or "fuzzy
thinking."
 Heart rhythm problems

Before the Procedure

Always tell your doctor or nurse what drugs you are taking, even drugs or herbs you
bought without a prescription.

During the days before your surgery:

 For the 2-week period before surgery you may be asked to stop taking drugs
that make it harder for your blood to clot. These might cause increased
bleeding during the surgery. They include aspirin, ibuprofen (such as Advil and
Motrin), naproxen (such as Aleve and Naprosyn), and other similar drugs. If
you are taking clopidogrel (Plavix), talk with your surgeon about when to stop
taking it.
 Ask your doctor which drugs you should still take on the day of the surgery.
 If you smoke, try to stop. Ask your doctor for help.
 Always let your doctor know if you have a cold, flu, fever, herpes breakout, or
any other illness.
 Prepare your home for when you are discharged from the hospital.

The day before your surgery:

 Shower and shampoo well.
 You may be asked to wash your whole body below your neck with a special
soap. Scrub your chest 2 or 3 times with this soap.
 You also may be asked to take an antibiotic, to guard against infection.

On the day of the surgery:

 You will usually be asked not to drink or eat anything after midnight the night
before your surgery. This includes chewing gum and breath mints. Rinse your
mouth with water if it feels dry, but be careful not to swallow.
 Take the drugs your doctor told you to take with a small sip of water.

After the Procedure

After the operation, you will spend 5 to 7 days in the hospital. You will spend the
first few hours in an intensive care unit (ICU).

Two to 3 tubes will be in your chest to drain fluid from around your heart. They are
usually removed 1 to 3 days after surgery.

You may have a catheter (flexible tube) in your bladder to drain urine. You may also
have intravenous (IV) lines for fluids. There will be monitors that give information
about your vital signs (pulse, temperature, and breathing). Nurses will watch your
monitors constantly.

Usually within 24 hours, you will be moved to a regular or a transitional care unit in
the hospital, and you will slowly resume some activity. You may begin a cardiac
rehabilitation program within a few days.

It takes 4 to 6 weeks to start feeling better after surgery.

Outlook (Prognosis)
Recovery from surgery takes time, and you may not see the full benefits of your
surgery for 3 to 6 months. In most people who have heart bypass surgery, the
grafts remain open and working well for many years.

But, this surgery does NOT prevent the coronary artery blockage from coming back.
You can do many things to slow it down. Not smoking, eating a heart-healthy diet,
getting regular exercise, and treating high blood pressure, high blood sugar (if you
have diabetes), and high cholesterol will all help and are very important.

You may be more likely to have problems with your blood vessels if you have kidney
disease or some other medical problems.