Cardiac Sheaths

We pull sheaths on adult patients in a cardiac telemetry unit. Before being brought back to the floor from the cath lab, they have an Aldrete score of 8 or equal to their preprocedure score. They have continuous cardiac monitoring, pedal pulse monitoring, and Q15 vitals, except from the time the sheath is pulled until hemostasis is acheived, then they are Q3 minutes. Our nurse to patient ratio is usually one to four, and usually we'll only have one sheath patient at a time.

Very similar to what we do also on our unit.

I pulled sheaths and it is really not a big deal. I had a few patients who vagaled on me, but you just rush fluids and adjust the bed. Your hands will be sore from applying pressure for 15 minutes and it is sometimes hard to come up with topics of conversation when you hands are on someones groin... It is actually fun to do and I think it is a great skill to have...

I work in a CCL and we typically pull sheaths on our patients prior to them going to the telemetry floor or back to an outpatient area. Thankfully, the majority of our cardiologists use closure devices such as PerClose, Angioseal or StarClose. Just as a previous responder wrote about your hands being sore from applying pressure for 15 minutes and topics of conversation, I've not seen many patients suffer complications.

Occasionally patients will be coagulated prior-to and intra-procedure and we are not able to pull the sheath before they are sent to the ICU or telemetry unit. In these circumstances, the sheath is sutured in or secured with a Tegaderm until the patients' ACT is below 170 seconds. Typically we do not see problems with their puncture site. Occasionally, additional pressure and/or a FemStop is needed. Overall, the procedure is simple and uneventful.

We routinely pull sheaths on patients who come up to our CCU with stents. Versed and fentanyl are standard meds for our patients prior to sheath pull.

We pull sheaths on my floor. I work Interventional Cardiology. The ACT has to be <175. We use the hemochron to test the ACT. Before we pull we premedicate with 5mg Valium, and one or two percocet, once the premedication meds have been given we wait about 25 min for the meds to kick in before we pull. Once the meds kick in, we make sure the pt. has voided before we pull, that can be a disaster if they haven't. We use subq lidocaine around the area where the sheath is. We place the pt's on 2L O2 NC, have a NSS 0.9 gtt setup for precaution, but check if the pt's a dialysis or CHF pt before hand. We have atropine at the bed side. We have a doppler for peda pusles. As soon as we have removed the stitch holding the sheath in place we call for another nurse to be present during the initial pull. We tell the pt. before we pull not to hold their breath, or bear down or clench their fists. We have the option of holding manual pressure or using the dreded c-clamp. I personally have always used manual pressure. I hate the c-clamp. We hold manual pressure for about 20min or more if needed, BP's are done q5min during the sheath pull. We have bedside monitors so we can see HR, BP and rhythm. After we apply a pressure dressing and a 10lb sandbag, do q 15 min BP's for the first 2 hours post sheath pull then hourly then as per floor protocol, and groin checks every 15 min for the first hour then hourly.

I can say that sometimes pt's come with ACT's in the 140's and I wish that the cath lab would have pulled it b/c now the pt's bp is elevated, very elevated and we can't pull, I have also had pt's with a baseline HR in the low 40's with a sheath that could have been puled in the cath lab and now Ihave to worry if then are going to really vasovagle on me. I have had pt's who's BP's have plummetted, hence the NSS gtt on stand by, and one time had to give atropine b/c the cath lab, or should I say PTCA factory, cranked out too many cases and were sending pt's untill 1am. A pt. had a sheath, they were too busy to pull it in the cath lab b/c they had to crank out the next case, sent the pt. to me with a ACT of 120..horrible let's give the pt. a blood clot...the HR was in the 70's, I followed sheath pulling protocol, called for my 2nd nurse to be present for the pull and well the HR went DOOOOWWWNNN to 19 when I pulled, the pt. stopped talking and the pt became diaphoretic imediatly, I grabbed the atropine I had tapped to the bed next to the IV site, gave it, NSS wideopen, pt. was fine with in a few seconds...the 2nd nurse was my help and witness.

Let's just say I called the cath lab, the interventional MD and the cardiac fellow that did the cath and gave them a piece of my mind.

But with any critical procedure, you have to be trained and know what to do.

We have had 2 nurses holding pressure to stop bleeding, we have had MD's and nurses on top of pt. to stop hematomas..we have had it all....

Hi Folks, seems to be a hot topic. I have a question about pulling sheaths: Do you fast your patients prior to sheath removal? Its a big debate in our unit at the moment do you push fliuds (and flush those kidneys) or fast due to vaso-vagal risk? I would love to hear your feedback.

They often come up with NS running by gravity. If their pressure is low or they're already renally compromised, I'll put it on a pump and keep it going at 75-100/hr until they're assisted out of bed for the first time (assuming they're not on Bicarb). While they have the sheath in, I let them have sips of water/juice or ice chips, so long as they're alert enough. If they are really starving and won't quit bugging me and I'm not worried about their swallowing, I'll let them have some jello or applesauce, but I limit those. I explain to them that sometimes people feel nauseous during a sheath pull, so I prefer to keep the tummy as empty as possible to avoid aspiration. Once the sheath is out, the bed can be tilted and they can have finger foods, or a spouse can feed them.

If they're really drowsy, I keep em NPO until they're more alert.

I work in a smaller hospital on the cardiac telemetry floor. About half of the patients that come in for a cardiac cath come to our floor to have their sheaths removed. We make sure the ACT is <180 seconds. As someone said earlier, I too like manual pressure vs. the FemStop. The FemStop may be easier on your hands, but manual pressure is so much more reliable. We hold pressure for 20 minutes or more. And if a hematoma develops, you know it right away. While I am holding pressure with one hand, and after about 5 to 10 minutes I ask the patient if he/she feels any pain in the abdomen or back. I push on the abdomen slightly and touch the back. This is basically to ensure that there is no retro bleed. I too don't really know what to talk about when holding pressure other than saying, "You're doing a good job breathing in through the nose and out through the mouth." But my second nurse always seems to bring up stuff to talk about. It is pretty rewarding once it is all over and no hematomas developed. That's what I get out of it. I've only been pulling sheaths for 2 months at this hospital. At the other hospital I worked at, there was a separate floor for chest pain/ sheaths. I worked on the Telemetry floor there too.
Best of Luck,
Rosee