CCU - Removal of Femoral Sheath by Registered Nurses - page 3

Policy and Procedures of Femoral Sheath Removals by Registered Nurses. If you have any information on these topics please let me know? I need to benchmark , and set up some standards for our... Read More

  1. by   SEOBowhntr
    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
  2. by   hrtprncss
    act<180 with patient's condition stable, we take out our own sheaths, though some nurses the newer one's call the fellow to take it out, though sometimes cv fellows are so busy in the er with new consults that rn's take out both venous and arterial sheaths using femstop, though i have one cardiologist who i try to beat first before he comes because he hates femstops and he manually compresses for ten minutes then tend to leave a nurse to manually compress for another twenty, i mean really i dont mind it but my fingers hurt when i do that, so femstop's the way to go, if they're not wiggly u could just sit right there and chart and watch the wound at the same time
  3. by   JustMe
    Quote from SEOBowhntr
    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!
  4. by   SEOBowhntr
    Quote from JustMe
    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
  5. by   JustMe
    Quote from SEOBowhntr
    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 ). 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.
  6. by   lee1
    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???
  7. by   teamrn
    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
  8. by   haitham abo majed
    hi iam new how can particepeat with you
  9. by   sirI
    Hello, haitham abo majed,

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

    Do you have a question/comment?
  10. by   ALCCRN
    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.
  11. by   sonshar
    Hello,
    Well, usually during the procedure you are given a concious sedation(Diamorphine, Midazolam), it does take the edge of and it is tried to keep the patient as comfortable as possible. Some patients are more sensitive than others but you are allowed to tell the staff if you are uncomfortable, well that may not even be needed as the staff present is supposed to be monitoring you closely and any sign of discomfort from you is mentioned to the Consultant and a bit more of the 'Happy stuff' is given.
    Well the sheath removal is done right in the lab obviously it depends on the type of ablation you are having or if because you had heparin and the ACT is above 150 seconds then the sheath is removed later on the ward once the ACT is about 150seconds.
    In the first instance the nurse warns you when taking the sheath off and then pulls the sheath out during which it might sting or you feel a little pain after that manual pressure is applied on yout groin by the nurse and except for the pressure you must not really feel any discomfort.
    However when the sheath is taken out later onthe ward by then the effect of the local anaesthetic wears of and so you may be given a bit of morphine before the removal of the sheath to avoid much pain and discomfort.
    I am sure you will be fine.
    I am a senior cath lab nurse.........I really do care for my patients and like keeping them as comfortable as possible.
    Sonia
  12. by   Turley007
    literature review
    add [color=#0033ff]added
    [color=#0033ff]arterial puncture site management after percutaneous transluminal procedures using a hemostatic wound dressing (clo-sur p.a.d.) versus conventional manual compression: a randomized controlled trial. (includes abstract); mlekusch w; dick p; haumer m; sabeti s; minar e; schillinger m journal of endovascular therapy, 2006 feb; 13 (1): 23-31
    add [color=#0033ff]added [color=#0033ff]bed-rest post-femoral arterial sheath removal- what is safe practice? a clinical audit. by: tagney, jenny; lackie, dawna. nursing in critical care, jul/aug2005, vol. 10 issue 4, p167-173
    add [color=#0033ff]added [color=#0033ff]comparison of the femostop device and manual pressure in reducing groin puncture site complications following coronary angioplasty and coronary stent placement. by: walker, sandra beverley; cleary, sonja; higgins, monica. international journal of nursing practice, dec2001, vol. 7 issue 6, p366-375,

    these are just a few i used for the policy i wrote. also lippencott online is a good resource. act less than 165. 20 minute manual compression and groin sites only. no brachial or illiac sheaths removed by rn staff. also we had a clause for coverage it the patient had received a thrombolytic in 24 hours the md had to remove the line.
  13. by   Kolt19
    To D/C a sheath - we use manual, c-clamp, or femostop (which requires a MD order r/t cost)

    We start checking the ACT within an hour after the patient arrives from the Cath Lab and usually pull when the ACT is less than 175 sec. We check the ACT hourly if > 175.

    We premedicate with Demerol 25 mg w/ Phenergan 12.5 mg IVP or Versed 1mg with Morphine 2mg IVP.

    Many times I start with the c-clamp or femstop, minor oozing/hematoma forms and i resort to manual pressure ... anyone else?

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