CCU - Removal of Femoral Sheath by Registered Nurses

cardiacRN2006, ADN, RN · Apr 27, 2005

jnette said:

Intersting stuff... now time for a dumb question if you all don't mind.
What exactly would meke sheath removal painful? And how do cath lab sheaths differ from ablation sheaths?

Another thing that make the sheath pulling painful is if there is already a hematoma present. When you place them on a C-clamp with a big ol hematoma, it is quite painful. We use morphine, and we allow the tech to pull them if they have passed a course and the RN must be in the room. They will also hold the pressure if it is manual pressure bing applied.

ann h · Jun 18, 2005

Hi

I an am RN in the UK and work in a cath lab.

I have just read through the was things are done in the US and am amazed.

For cardiac cath we use 4,5,6 fr check flow depending on DR

Femostops are used by all RNs once they have been taught

No IV fluids or sedation

Femstop off within 20 mins, bedrest afteer this

4fr 1 hour

5fr 2 hours

6 fr 2 1/2 hours

Out of bed walk to toilet and home. We have the odd brady one or two a week IV fluids usually does the trick.

All pataint are given after care advice and asked to rest up for 24 hours and have an adult with them overnight in case of bleeding

We do not give heparin for our angois only PCI and these patients all have angioseal an internal collegen plug.

It been great to read how it is done in the US.

SEOBowhntr · Aug 22, 2005

Howdy, I figured I'd throw my 2 pennies in here too.

I pulled my first sheath way back in Jan. 1996, and have pulled somewhere around 2000 or so since. I have seen a variety of hemostasis devices and still prefer the first I ever used which is the fingers I am typing with. I have yet to have a vasovagal (sudden drop in BP and HR, related to increase in vagal tone) while providing manual pressure. I also use c-clamps w/ Compressor discs, but really when I have time prefer the manual technique. Having performed many pulls in my 9.5yrs. of nursing, I started using a procedure about 7 yrs. ago where I would infiltrate an oozing site with lidocaine 1-2% with Epi 1:100,000 to shore up any small vessel bleeding. The technique worked quite well, resulting in a more comfortable patient and achieved hemostasis from the localized vasoconstriction. About 2yrs. ago, I authored my hospital's "Lido w/ Epi injection Policy." After getting several "ignorant" doctors on board and explaining to them how the procedure worked, and getting pharmacy approval, and getting approval of the hospital medical board, we finally got them on our Post Intervention orders last fall. If any of you guys are interested, PM me and I will forward you a copy of the policy. I have a friend and former co-worker who left my facility and took this procedure to another facility and they are currently working on a similar such protocol. This injection works wonders esp. with Perclose or Angioseal sites that have the never ending ooze. This WILL NOT be effective on an arterial bleed, but does quite well with moderate oozing sites.

Doug

hrtprncss · Aug 23, 2005

act

JustMe · Aug 23, 2005

Howdy, I figured I'd throw my 2 pennies in here too.
I pulled my first sheath way back in Jan. 1996, and have pulled somewhere around 2000 or so since. I have seen a variety of hemostasis devices and still prefer the first I ever used which is the fingers I am typing with. I have yet to have a vasovagal (sudden drop in BP and HR, related to increase in vagal tone) while providing manual pressure. I also use c-clamps w/ Compressor discs, but really when I have time prefer the manual technique. Having performed many pulls in my 9.5yrs. of nursing, I started using a procedure about 7 yrs. ago where I would infiltrate an oozing site with lidocaine 1-2% with Epi 1:100,000 to shore up any small vessel bleeding. The technique worked quite well, resulting in a more comfortable patient and achieved hemostasis from the localized vasoconstriction. About 2yrs. ago, I authored my hospital's "Lido w/ Epi injection Policy." After getting several "ignorant" doctors on board and explaining to them how the procedure worked, and getting pharmacy approval, and getting approval of the hospital medical board, we finally got them on our Post Intervention orders last fall. If any of you guys are interested, PM me and I will forward you a copy of the policy. I have a friend and former co-worker who left my facility and took this procedure to another facility and they are currently working on a similar such protocol. This injection works wonders esp. with Perclose or Angioseal sites that have the never ending ooze. This WILL NOT be effective on an arterial bleed, but does quite well with moderate oozing sites.
Doug

I agree that the good ol' fashion way of holding pressure (my hands) gives me a better idea of how the site is doing after the sheath is removed, i.e. I can FEEL the hematoma underneath my hands rather than have to guess with the clamp. Collagen plugs can't be used on all patients--weird anatomy such as a bifurcation of the vessel makes them useless. Instilling lido before sheath removal is part of our competencies, but no epi. Epi in a heart patient?? :uhoh21: Not here. But about 10cc of subq lido and wait a good 10 mins. and there is usually no problem. Plus about 2mg of MS IV and a 5 mg po Valium and they sleep through the whole thing!

SEOBowhntr · Aug 24, 2005

I agree that the good ol' fashion way of holding pressure (my hands) gives me a better idea of how the site is doing after the sheath is removed, i.e. I can FEEL the hematoma underneath my hands rather than have to guess with the clamp. Collagen plugs can't be used on all patients--weird anatomy such as a bifurcation of the vessel makes them useless. Instilling lido before sheath removal is part of our competencies, but no epi. Epi in a heart patient?? :uhoh21: Not here. But about 10cc of subq lido and wait a good 10 mins. and there is usually no problem. Plus about 2mg of MS IV and a 5 mg po Valium and they sleep through the whole thing!

Just me,

The Lidocaine w/ Epinephrine is injected SQ/IM to create a localized vasoconstriction, it is not IV, and has no effect on HR or BP. The Epinephrine does two great things, it shores up the oozing, and makes the Lidocaine last a lot longer, because it decreases the rate it is metabolized when it vasoconstricts the local area. I don't use this technique to "numb" the site up, I use it to stop the bleeding, the numbing effect is just a bonus. This is the same trick you see ER doc's use when they suture up a messy cut, the Lido w/ Epi gives them a "clean" area to work in so they can see what they are doing a little better. Also a trick used in anesthesia for nerve blocks, spinal, etc.

Doug

JustMe · Aug 25, 2005

Just me,
The Lidocaine w/ Epinephrine is injected SQ/IM to create a localized vasoconstriction, it is not IV, and has no effect on HR or BP. The Epinephrine does two great things, it shores up the oozing, and makes the Lidocaine last a lot longer, because it decreases the rate it is metabolized when it vasoconstricts the local area. I don't use this technique to "numb" the site up, I use it to stop the bleeding, the numbing effect is just a bonus. This is the same trick you see ER doc's use when they suture up a messy cut, the Lido w/ Epi gives them a "clean" area to work in so they can see what they are doing a little better. Also a trick used in anesthesia for nerve blocks, spinal, etc.
Doug

Yeah, I know what the epi is added for, but there could still be systemic effect from it. Ever notice your heart pounding when the dentist gives you novocaine? I asked my dentist and he admitted that there's epi in it (besides the fact that you just got shot in the mouth :rotfl: ). Is there any research even out there about using Lido alone or Lido with epi? I read one study that claimed you only need the IV MS for patient comfort while pulling sheaths. I've found that the Lido (plus allowing enough time for proper numbing) is more than adequate for patient comfort. Most of their complaints are back pain from having to lay flat.

lee1 · Aug 26, 2005

Using the C-Clamp seems to be the easiest. we usaully premedicate the patients with MSO4 and Phenergan.

Do you stay WITH the patient while the C clamp is on at all times. How far in advance is the medication given prior to removal???

teamrn · Sep 12, 2006

I'm a newbie, so please be gentle! What is the difference between a femoral sheath and femoral line? Thought the sheath was an anatomical entity NOT to be removed. Or is the reference to removing a femoral sheath, actually the removal of the plastic sheath of the cannula in the femoral vein?

Something to do w/ IABP?

Isn't a femoral line, a central one; though not to be relied on for PCWP

Isn'a a femoral sheath, part of a patient's anatomy?

I'm stumped and need this info; can someone explain in BABY TERMS and gently?

Thanks in advance and where can I go for procedure? It's kind of obvious I don't work in ICU, but am intrigued. Can someone help out a fellow RN?

team

haitham abo majed · Sep 13, 2006

hi iam new how can particepeat with you

Editorial Team / Admin · Sep 13, 2006

Hello, haitham abo majed,

You are participating everytime you make a response to a thread. We are glad to have you.

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ALCCRN · Sep 19, 2006

A femoral line usually refers to an arterial line placed in the femoral artery. You can have arterial lines in other places, radial, brachial, axillary, etc. These are very small lines, just a little bigger than an IV. Femoral Sheaths are used in the cath lab. The sheaths come in different sizes, but are much bigger than an IV. Sheaths are also placed in the artery. So the sheath is actually the plastic that is placed into the artery by the MD. He uses this sheath to feed the catheters to place stents, etc. Sheaths can also be placed into veins as well. The previous posts were referring to devices that can be used to hold pressure on the artery after pulling the sheath. There are many different kinds, manual pressure, C-clamp, Femo-stop,etc. And some procedures that the physician can do, like Perclose, that helps with hemostasis.