Cardiac Sheaths

This is big topic to me. I have been an nurse for 30 years, and just took a job on a CVRU floor. 70% of our caths come back with closures, but the ones that don't, it appears to be my time to pull It's been years...and my hand position isn't right yet! My facility wants fingers at or above the sheath site, and want a small spurt of blood to come out before you pull. Have the time I don't even know if I've really got that femoral pulse. Some reading revealed a good way to hold is to put the index finger on the pulse point, and hold with the other two fingers........is this a good idea" Any other hand positions out there that might be easier?
Thanks!

The skin puncture is below (distal to) the actual arterial puncture by 1-2 cm.
So you would want to feel for the pulse 1-2cm above the skin puncture.
Feel for the pulse.

(I'm sure you've read thru some of the other posts re:
* have pt empty bladder first
* re-anesthetize site if it's been awhile since the cath, so there's less chance of pt vagaling with the pressure/pain of the groin hold
* have enough fluids hanging that you can bolus the pt if he/she vagals
* have assist staff standing by who can help you if the pt vagals: trendelenberg, VS, opening the IV, reassuring the pt, etc
* make sure pt [hips!] is flat in bed, not sl rotated
* make sure ACT is <170 [or whatever your facility's protocol directs]
* have extra 4X4s ready )

After you've found the pulse, then pull as directed:
our Fellows do allow a sm spurt of blood then they apply direct, almost-occlusive pressure to the site with 2-3 strongest fingers.
Hold for the time per protocol (15-20 min).
tip: I've read/heard of nurses applying the pulse oximeter to the foot, to monitor whether they're applying occlusive pressure (don't want to occlude, just nearly so).

Perhaps you could request a refresher inservice, just to double-check the details (e.g., finger placement)?

Good luck!

Sometimes I have had up to 6 pt's with one of them being a sheath pt... And when I do have 4 pt's with one of them being a sheath pt, the LPN's throw a fit because the have a higher pt ratio than the RN's with sheath pt's. I have had pt's vagal, hematomas, I had a pt throw a clot in the opposite leg than what was stented and go for an emegent fem-pop bypass at 0300. I had a pt with undiagnosed clotting disorder almost bleedout on me, I've had who was HIV+ try to pull the sheath out himself so he could go AMA. There is a reason for a lower nurse to patient ratio with sheath pt's.

Horror stories aside, 99% of the time when I pull a sheath everything goes fine. If the pt was on angiomax, then the MD orders a specific time for the sheath pull. If the pt was on heparin and a glycoprotein IIb/IIIa inhibitor, then we do serial ptt's until the ptt<70. IV valium and morphine usually for sedation, O2 per protocol, pt on cardiac monitoring, spO2 monitoring. We normally use syvak or syvak NT to aid in hemostasis, and hold manual pressure 15-20 minutes. Then femostop x 1 hour, bedrest 3-4 hours. Extra bags of normal saline and atropine at the bedside.

Now when we are pulling the sheath, the charge nurse is supposed to take our phone and cover our pt's until the pt is stable.

If you use Femostops, have the Radi rep give some inservices.

Wow! How generous!

Our pts get an amp of atropine on thier belly and a one liner about how this is gonna feel weird.

I also put the Pox on thier toe...

we pull sheaths on unsedated adult pts on the cardiac pcu that i work on. I hate it!

Our cath lab lets you have a day or two pulling sheaths to prepare yourself for it. Maybe ask your cath lab if you can spend a day pulling? I do not pull sheaths, although I'm on a unit where it can be done. We have a team for that.

I work on a universal bed telemetry/ CVICU floor. We often get pts back from cath lab with sheaths sutured into place. We remove sheaths when our ACTs are less than 175, hold manual pressure x20min, and apply a femostop only if we are still having problems with bleeding after that. Our pts diet is typically as tolerated after a cath, but we usually are pretty careful with letting them eat prior to sheath removal. It is NO fun when you have a pt vomiting while you are holding pressure on their groin site!