Pulling arterial sheaths

  1. In our ICU, the patients usually come down from the cath lab with the sheath still in the groin, and the RNs pull them after a few hours. Until recently, we have not had too many problems with pulling them, a small hematoma on occasion, and a couple of pseudo aneurysms, but for the last two weeks, we have had some major complications. We have had five pseudos, two that required surgical intervention. We have also had two retroperitoneal bleeds, and one woman who bled so much she went into hypovolemic shock, arrested, and had to be intubated for two days. Thankfully, she survived. There have been no apparent commonalities between these cases. The caths were done by different cardiologists, and the sheaths pulled by different nurses. The cardiac docs are kind of blowing it off, saying it's just a cluster of complications, and that it's not significant that so many happened in a short time. Our Intensivist, who is also our medical director, wants all sheaths pulled in the cath lab with the doctor present. The cardiologists of course are against this. How do you handle arterial sheaths in your unit? Who pulls them, and has anyone else had these kinds of problems?
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  2. 14 Comments

  3. by   dianah
    I work in the Cath Lab and Angio; the Radiologists pull their own and hold their own pressure. In the Cath Lab, the "Cath Tech" (a specially trained respiratory therapist, in our facility) pulls and holds or assists with deployment of Vasoseal and holds pressure after deployment. Vasoseal is not deployed for every case, for various reasons. In the past two years we too experienced a lot of what you describe (not related to Vasoseal use, just with the old pull-the-line-and-hold-pressure X15min, affected leg still for 6 hr after case), and could only relate it to the increased use of Lovenox. We now require Lovenox to be held 12 hr before the cath (or angio), in order to minimize potential bleeding after the case. The problems with bleeding you've experienced may be related to other factors as well: Pts on ASA (which our Cardiologists don't want to dc for three days pre-Cath, for obvious reasons), any homeopathic meds the pt has been taking that prolong bleeding, use of Ticlid or Plavix that may increase bleeding . . . to name a few. IMHO, in the face of your recent events, a review of suspicious factors is in order, and, I agree with your Intensivist: the Cards put 'em in, they should take responsibility for pulling them and maintaining hemostasis (just my background!! ). However, I know how hard it is to change something like this ("This is the way we've ALWAYS done it)." Also, the way you've done it in the past has worked well till now, and that seems to move suspicion away from a technique problem to the "other factors" problem.
    How are the lines handled at other facilities in your area? In your hospital is an ACT done pre-pull? Have you gone on-line to search similar problems?
    In any case, again, a review of the whole picture is in order. This may be handled by the Medical Director before you get back to work, anyway, and our discussion may be a moot point. Would be interested to know what happens. Good luck, and good advocating. -- D
  4. by   MollyMo
    I work an Interventional Cardiology unit. We do most of the pulling, unless the patient goes to CVICU as an urgent or emergent CABG case. We've had our share of problems with post bleeds. Some of it is technique. Some is the fact that even though the ACT is < 150, the patient is on Reopro or Aggrastat or Integrilin which will prolong clotting time. I cringe when I see a Vasoseal or Angioseal. I haven't seen one successfully deployed yet. Another thing could be how many times the artery was punctured. The point of insertion may not be the only hole in the artery but the docs don't always tell you that. That's why we hold pressure above, at and below the site. We use Syvek patches for most of the cases. Rarely have we had a rebleed. If we do, it's usually non-compliance with the bedrest that's the cause. We haven't had to use a Fem-Stop or a C-clamp very often. All of the RN's and the PCT's are trained to pull sheaths. We had to spend time in the cath lab before we were allowed to pull on the floor. I just had to be checked off on 2 pulls because I worked a PTCA unit in South Carolina before coming to Florida. We don't pull on anybody until the ACT is below 150. We have one cardiologist who will pull if the patient is high risk. The rest just leave it to us or send the patient to CVICU.
  5. by   jode
    I worked very recently in a VERY busy 14 interventional cardiology unit and we pulled almost all the sheaths. We keep all the interventions overnite, and although there are always the occasional hematoma or psuedo, we seldom have major complications. We do alot of research here, and very often patients are on integrelin, Reopro, Aggrastat or a combination. And our interventionalists use Plavix aggressively. Almost all of the nurses pull with a C-clamp, but depending on the intervention, and medications and patient anatomy we will use the Femostop or pull by hand. We pull for 30 minutes with an ACT less than 150. Pt compliance is essential, and our MDs order pain med and sedation to assist with this.
    Physician technique can be the cause of hematoma, as are muliple px sites. Our hospital does as many PTCA's and PTA in a day as some do in a year. So we see alot of interesting cases. Let me know if I can help you in any way.
  6. by   RNinICU
    Thanks for the suggestions. Our docs seldom use Angioseal. When they do, we have had very few problems with it. Almost all of our caths are on Integrilin or Reopro post procedure, and most of them get Plavix, too. Until now none of these meds has created a problem. One of our cardiologists always uses a Fem Stop, and he seldom has problems with bleeding, but the patients hate it. We always hold Lovenox twelve hours before caths too. ASA is a different story, it is usually only held 24 hours pre-cath. Our patients don't leave the cath lab till their ACT is 180 or less, and the cath is not pulled until it is less than 150. We have looked in to all of these things, and still found no connection. I don't think anyone thought to investigate the use of herbals or other homeopathic meds the patient might be using, but it's certianly something worth finding out about. We ask people about herbals when they are admitted, but in my experience, some people are embarrassed to admit they use them.

    I certianly don't mind if they start pulling sheaths in the cath lab. I hate being tied up for 20 minutes or more with my hand in someone's groin.
  7. by   nimbex
    Is there a nurse clinician to gather the data to determine factors?

    What does your policy state about checking clotting? We use ACT as previously mentioned, activated clotting time... 150 is the standard to clear for RN pulling.

    All these patients are on aggressive plavix, with ASA, plus reopro, integrillin, Aggristat, sometimes heparin too. If on heparin a PTT must be checked and under 70 too.

    Angioseals are done only by our MD's but nursing does the syvek patch. We hold manual pressure for 30 minutes or more until hemostasis occurs. Plus sandbag in many cases.

    nursing may NOT pull with pre-existing hematoma, ACT >150 or PTT > 70 or HIT (heparin induced thrombocytopenia, which is why we do serial labs with EDTA sensitivity.

    ANy patient who has thrombolytics cannot have sheaths pulled until the 24 hrs. is up with the above criteria.

    We have never had the complications you have stated except a RARE pseudo. and hematoma's which are due usually to poor technique.

    Let us know what your find..

    Don't worry, sheaths can safely be pulled by RN's ... You may just be having a fluke... but to rule it out, someone should investigate
  8. by   dawngloves
    When I did step down the resident, yes the resident pulled sheaths! And there was this one that I could guarentee would give you a hematoma. But we rarely had complications and hardly used a Fem stop and never a sandbag.
    The big bleeders were always on Reopro too. Hated that stuff!
  9. by   betts
    Removal of Arterial/Venous Catheter Sheaths
    by Registered Nurses

    This statement was adopted by the Board Of Nursing:
    A registered nurse may perform functions beyond the basic educational preparation, provided the
    functions are recognized by the Board as being within the legal scope of nursing practice and the nurse
    has successfully completed an organized program of study, including clinical practice.
    It is the position of the Board of Nursing that it is within the scope of practice of qualified registered
    nurses to remove arterial/venous catheter sheaths as directed by the physician in accordance with the
    following guidelines:
    1. Authorization to perform the procedure limited to RNs certifed in
    ACLS (Advanced Cardiac Life Support) or comparable course, and
    with experience and documented competency in critical care nursing.
    2. Successful completion of an organized program of study which includes
    didactic classroom instruction followed by supervised clinical practice.
    3. Continuous electrocardiographic monitoring of the patient.
    4. Physician physically present in the agency to respond to emergency
    codes.
  10. by   KateS
    I have worked in a cardiac/angiography lab for a little over one year. I have been a nurse for over 12 years and this is my first experience with pulling sheaths. I have always been a little nervous and the only instruction was from felllow RN's that have been working in the cath lab for over 15 years, so while their knowledge is great I still remain nervous. I had one bad experience when I pulled and could not get a good postion and the patient continued to ooze a lot, another nurse came behind me and attemped to take over and also could not get good control. The patient outcome was fine but it just made me more nervous. We use Angioseal quite alot and we have seen excellent results. However every time I hear it's a mannual pull (and we the RN's in the recovery area usually pull them, not the doc's) I get very nervous. I guess what I'm looking for is any guidance or instruction on pulling that would ease my nervousness.
    Thanks
  11. by   zambezi
    We pull femoral arterial sheaths in our CCU (though we are apparently training some of the nurses in our stepdown unit to pull soon...). Last dose of lovenox (if given) has to be greater than six hours. Sheath is pulled four hours after they return to the unit. Usually have aggrastat or reopro given. Patient is usually given 300-600 mg of plavix upon return to the unit as well. ACT has to be <150 (if act does not go down, we can get order to pull...) We use femstops...just got the "updated" version and I really like it. We keep the femstop on for about an hour...we check the site/pedal pulses q15min after pull. After one hour, we take femstop off palapte area then hold manual pressure or reapply femstop if arterial bleeding continues. If no arterial bleed, 10 lb sandbag is placed. q15min checks again for one hour, then q30x4, the q1hrx3. We havent had too many complicaitons or rebleeds (only one or two that I can think of). I am pretty careful with checking my sites for bleeds.
    As for angioseals, we only have one doc that uses them. When they work, they are great but ours usually have a pretty good ooze/hematoma formation so I keep a careful eye on those too.
  12. by   treecy
    I previously worked on an angioplasty unit that initially had the angioplasty fellows pull sheaths and then the RN's were trained. Our patients were admitted to us pre op and given plavix 300mg and ASA pre plasty and were on reopro, aggrestat or integrellin post plasty. We used C Clamps or manual pressure with the smaller sheaths. Femstops were available but noone used them. The Clin Spec and Nurse Mgr did trend the first 6 mos of RN pulls vs MD pulls and the RNs had fewer hematomas, pseudos and decreased discomfort of patients. Although I believe that many pseudos are caused by insertion not by removal. Maybe yoour mgr. could do some trending but it seems your unit just hit a bad row, these things happen. I wish I could find another job like the one I had.Ratio was 3-4:1, usually 3. Staff worked well together. Mgr. pitched in and was very accomodating with time off requests and because she was so accomodating we never had to use agency or pull from other floors. The unit generally closed on Saturday evening since most patients went home so we worked every other Saturday instead of everyother weekend. We all juggled our schedules to cover which rarely necessitated overtime and it worked.UNTIL......Administration decided we were only a Tele unit and increased our ratio to 5-6:1. So we would get 4 plastys and 2 caths or ICD/PM implants. Mind you we did all the admission paperwork and many times the pre procedure phlebotomy. Then we had the luxury of floating to ICU or CCU on Sundays when our unit was closed. Oh, and because we worked our Sundays we worked one less weekday so we then would get Agency or nurses pulled from other units for staffing. It became so difficult and scary I had to quit. Boy did I get off on a tangent. Sorry.
  13. by   ItalianRN
    We were recently informed that we are going to start pulling sheaths, post PTCA's, on my floor. We get 5 pts during the day (up to 6), & normally 6 pts at night (up to 7 at times). None of us, except our Manager, feels this would be safe to do. The training that only a select few are being offered, is 4 hours in ARU.

    I was told that my hospital tried this a while back, but stopped it because someone died. I guess it was so long ago that the powers that be have forgotten about it. I do not want to put my license on the line for this. Neither do my co-workers.

    We spoke to some of our CCU nurses & they think this is insane. They told us that they don't even like pulling sheaths. We'll have to do this with at least 2 nurses because the pt. usually vagals out & has to receive Atropine immediately. I think this whole idea is insane!!

    Any thoughts of what we can do to protect our jobs & our license in this upcoming situation??? Even some of the docs are against it, but most of them don't care either way. Nice, huh?? Do we have a right to refuse this? We don't even have to do the hemodynamic compentencies, but they want us to be responsible for this unstable patients. This just doesn't make sense.

    PLEASE RESPOND. THANK YOU.
  14. by   Virgo_RN
    Wow, this is an old thread!

    RNs routinely pull sheaths on my unit. Competency is verified by observing at least three sheath pulls, then performing three under supervision. Patients are continuously monitored from the time they arrive from the cath lab until the time they are assisted OOB. We have standing orders for atropine and NS in the event of a vagal response (we hardly ever see vagal responses, but they happen occasionally), and there is an interventional cardiologist on call 24/7. If hemostasis cannot be acheived within a reasonable period of time, we send them to the ICU (this is rare). We have very few complications, and I know of nobody that has ever died at our facility related to a sheath pull.

    I recall a CNA posting her a while back that CNAs at her hospital were pulling sheaths!

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