Re: help with groin sheath pulls - any pointers?

I use several 4X4 gauze pads to soak up any bleeding and just use my balled up fist at the site. I'm not a very big person so it takes a lot of my strength to hold pressure. If a hematoma is growing you can feel it--and I ask for help to hold pressure. On more than one occasion I have had another nurse help me hold pressure, but it's rare. Like my previous post, these situations are often the result of pre-procedure issues, i.e. meds the patient may be on. Our experience has been that uncontrolled bleeding and resulting pseudoaneurysms requiring repair may be due to the MD's several attempts to access the artery (too many pokes to the groin) but I have not seen this problem mentioned in the literature.

I had to laugh as I recalled one patient who had to have sheaths removed. He had a femoral gortex graft that the cardiologist used for the angiogram. I had been holding pressure for at least 30mins (with little control of the bleeding) when the MD came around and said I should let go and let him look at it. ZING!!! That fake artery shot blood clear across the room! I'd never seen anything like it before or since. I held pressure on that artery for one solid hour!

Re: help with groin sheath pulls - any pointers?

Originally Posted by Buddyken

With two fingers, I always get tired as I was pushing very hard on the artery. I wonder if I can just pressure the artery with 4X4 or 2X2 gauze. I had a patient with calcified artery once, I had very hard time to hold the artery. I got it stop bleeding with someone else help. I am very interested in the fist technique. Please give me some advices. Thank you.

Yep wad some sponges and that will broaden the surface area over which the pressure is applied. You can press it with your fist or the heel of your hand (like CPR position) so your fingers don't get cramped.

Re: help with groin sheath pulls - any pointers?

I like what Just me said; premedication and bolus with NS is a great idea. Sometimes explaing to the Pt if possilbe that your might be inflicting them with a moderate amount of discomfort can ease them into accepting some sedation. ie (versed/fentanyl) that being said, have had more successful pull when doing it myself, I have also seen people who pull get a little overzealous and not get control of the vessel; Then we go to a trendelenburg positon, atropine, NS wide open. plus we have to type and cross for the two-three units they need following a "nursing procedure". YIKES!
If you are prepared, get the pt and bed into a position that is comfortable for YOU; then you will be ready and "relaxed" when you pull. if you do things hastily then you might set yourself up for a disaster.
1, feel the pulse (femoral and distally) I mark the distal ones for yourself or another if your facility requires two for a pull.
2. cleanse area around with whatever your facility uses.
3. aspirate/don sterile gloves/O2, IV ready, emergency drugs available, set vitals for Q2-5 minutes/ locate femoral pulse site. (some of these are don simaltaneously) (spelling)
I use the index finger, middle and ring finger of the hand closest to the patient; RIght groin use left hand.
I put thos fingers about two-three fingerbredths above the actual puncture site. Seeing how the artery is entered with the modified seldinger technique will help you understand that holding on the skin puncture site=retroperitoneal bleed.
if you have your hands in the right position; pull the sheath, observe a little bleed back and then apply enough pressure til the bleeding stops. With one hand you can hold the femoral artery until hemostasis; blot the puncture site with sterile 4x4s. plus you can monitor for hematomas with your free hand.
If you were proactive and cleansed the feet with "sterile" cleansing solution you can also palpate a distal pulse to monitor how much pressure you are applying (if you are solo during sheath pulls)
I hold pressure for about 20-30 minutes though have had to hold up to 55 minutes for Femoral grafts and the like...
Some things to think about:
not fun pulling when 2b/3a inhibitors are infusing.
likewise with heparin therapy. stob both of them until hemostasis, then restart according to MD orders/ policies.
if your patient has back pain before the pull Medicate them.
Always be prepared!
your clients and family members will appreciate it
Hope that helps.

-e

Re: help with groin sheath pulls - any pointers?

I like to use my fingers rather than my fist- easier to control exactly where the pressure is. Put the bed down so you can use your body weight rather than your arm/hand, and watch for mottling in the leg. Much easier to use a fem-stop _if_ you've placed it correctly, above the insertion site for art sheath.

Most of the docs here write for fentanyl prior to pulling the sheath but if you don't have it use whatever you've got to relax the pt. Explain what you're going to do and that it's going to be uncomfortable. Also be very clear that they won't be able to bend that leg or sit up for several hours.

I _always_ let other staff know when I'm pulling a sheath so they can come running at a moment's notice, and I always have an amp of atropine handy in case they vagal down.

Once you get the hang of it it's really not that complicated, you'll be fine.