arterial sheath puling post cath

Published

Specializes in icu, cardiac, respiratory.

hello!! i searched through other threads and found some great information, but i need more.

hoping someone can help.......

i am employed in a pre-post cardaic cath area. we have begun to train to pull sheaths.

my questions are.....

is there a standard policy for sheath pulling in north carolina?

is anyone willing to share their hospital policies with me?

in your hospital do you pull femoral, brachial, radial?

is it just diagnostic sheaths or do you pull with anticoagulants present?

how many staff members in a room during a sheath pull?

is it a rn-rn or a rn-lpn or a rn-nursing assistant or rn- tech or do you pull alone?

we want to be standard with other hospitals across north carolina and the USA

thank you in advance for any insight you are willing to give me.

Up Vote Up Vote ×
Specializes in Cardiac Telemetry, ED.

Not in NC, but yes our facility has a standard of care. Cath prep and recovery pulls some, but many patients go to the inpatient unit to have their sheaths pulled by staff RNs on the floor.

We pull mostly femoral, sometimes brachial, and radials usually come from the cath prep and recovery area with a pressure device in place. The RNs on the floor loosen and remove the device.

We pull diagnostic and post intervention sheaths, with heparin or Angiomax on board. With heparin, we have to get an ACT

I pulled many sheaths alone, though it's nice to have a CNA present to write down the frequent VS or have an extra set of hands. Typically our aides were too busy to spend a half hour in the room, so I pulled alone most of the time. Just made sure that my phone was handy, and that my charge nurse and break buddy both knew I was in there pulling.

Up Vote Up Vote ×

you pull femoral sheaths alone??? That is unheard of. That is unsafe practice. How do you call your charge nurse or break buddy when you have you have both your hands on a femoral artery, potentially bleeding due to multiple reasons, or the patient begins to vagal, or bradycardic.

There should always be 2 RN's pulling, or a Cath lab tech holding pressure and a RN present to do pulse checks and vital sign monitoring, available to push atropine or bolus saline.

I am amazed that your hospital policy allows only one person in the room with such a potentially dangerous procedure.

Up Vote Up Vote ×
Specializes in Cardiac Telemetry, ED.
How do you call your charge nurse or break buddy when you have you have both your hands on a femoral artery, potentially bleeding due to multiple reasons, or the patient begins to vagal, or bradycardic.

There should always be 2 RN's pulling, or a Cath lab tech holding pressure and a RN present to do pulse checks and vital sign monitoring, available to push atropine or bolus saline.

I don't work on that unit anymore, but:

Our signal for emergency was to yank the call bell out of the wall. This sets off an alarm and people will come running. For less emergent situations, like maybe just a second set of eyes or hands, I kept my phone sitting within easy reach on the bedside table. We also kept our charge nurse, break buddy, and CNA informed of when we were going to be in the room pulling, and they would poke their heads in periodically and check to see if everything was okay. While I was in the room alone, I was hardly "alone" in a true sense, because my coworkers all knew when I was in a room with a sheath and would be ready to come running if I needed help, and I likewise returned the courtesy when any of my coworkers was pulling.

We used C-clamps for holding pressure (lidocaine infiltration of groin site prior to applying C-clamp), bedside cardiac monitoring with Q5 minute VS, and doppler for distal pulse monitoring, keeping the RN's hands free to give medications, document VS, bolus fluids, etc.

Atropine was kept at the bedside within easy reach, along with saline flushes and anything else (like pain meds) that might be needed during the pull. Every post PTCA/PCI patient came from the cath lab with a liter of NS hanging, either infusing at a rate ordered by the cardiologist for renal protection, or at a TKO rate.

Since all of our post cath patients were on telemetry in addition to a bedside monitor, any rhythm changes would be detected by the monitor tech (who was also kept informed of all sheath removals), who would alert the charge nurse to the rhythm change, prompting the charge nurse to come to the room to check it out.

If you don't know how to handle a bleed or a vagal, you have no business pulling sheaths, alone or otherwise. The training process should cover all of the "what ifs", and the first few pulls should be supervised by an experienced RN. :redbeathe

Up Vote Up Vote ×

i appreciate your response, however I still feel at least for the first 5-10 minutes, there should be a second RN available just in case.

However, you didn't mention that you use c clamps (we use femstops), and I do know that after about 10-15 minutes, with PT/dp establishment, and everything looks good, the second RN does walk away and is available if needed....

so with that said, thanks for not taking what I said as a personal attack...

Up Vote Up Vote ×
Specializes in CVICU.

I'm not sure if you can get to this site without logging into AACN's site first, but here's the article from Bold Voices regarding who should pull sheaths: http://www.nxtbook.com/nxtbooks/aacn/boldvoices_200909/?startid=0#/8

Up Vote Up Vote ×

you need to log in first!!!

Up Vote Up Vote ×
Specializes in Cardiac.
Not in NC, but yes our facility has a standard of care. Cath prep and recovery pulls some, but many patients go to the inpatient unit to have their sheaths pulled by staff RNs on the floor.

We pull mostly femoral, sometimes brachial, and radials usually come from the cath prep and recovery area with a pressure device in place. The RNs on the floor loosen and remove the device.

We pull diagnostic and post intervention sheaths, with heparin or Angiomax on board. With heparin, we have to get an ACT

I pulled many sheaths alone, though it's nice to have a CNA present to write down the frequent VS or have an extra set of hands. Typically our aides were too busy to spend a half hour in the room, so I pulled alone most of the time. Just made sure that my phone was handy, and that my charge nurse and break buddy both knew I was in there pulling.

This sounds exactly like my unit too. Only we use femstops. The other staff nurses are off pulling their owns lines or just too busy too help out for a half hour. We let our Charge and any nearby RN know we are pulling a line and take atropine,fluids in with us. It doesn't usually take 2 hands to hold pressure unless you really have a bleeder or an obese belly.Everyone seems to do just fine and we have been doing this for years.

Up Vote Up Vote ×

i;'m trying to figure out how you are able pump up a femstop and pull the sheath concurrently, monitor the groin, and make sure you have pulses to the lower extremity...alone. As well as monitoring the heart rate, blood pressure, etc. At least for the first 5 minutes there should be 2 hands. I think it is unsafe practice otherwise.

Up Vote Up Vote ×
Specializes in Cardiac step-down, PICC/Midline insertion.

OMG. I can't believe so many places have just 1 RN in the room....and you guys don't use your hands. I realize with most hospitals you just don't have the staff, so it seems they have found ways to get around it with femstops and C-clamps. I work at Oklahoma Heart and we have very strict sheath pulling policies. Two RN's in the room during the pull. You have to have a Dr's order for a femstop and we rarely use them. According to what I was taught, research shows the "best" method is to simply use your fingers to put pressure 1 inch above the insertion site and then directly over the insertion site.

We pull with drugs on board all the time. We wait 30 minutes to pull if angiomax is given, 2 hours if lovenox is used (which is RARE) and if they use heparin the ACT must be less than 250. I usually wait until the ACT is less than 200 myself. We use a special patch (Syvek Excel) that's coated with some kind of enzyme from seaweed that causes the blood to clot faster. The 2nd nurse uses a doppler to find the distal pulse and the other nurse pulls the sheath and holds occlusive pressure for 10 minutes, then 5 minutes of non-occlusive pressure. We keep atropine at the bedside in case the pt vagals. I have probably pulled about 40-50 sheaths (new nurse obviously) and I've only had 2 problems with bleeds, but got it under control.

We also have a handle that we can use to hold pressure, but even though it hurts like the dickens, I still prefer my fingers. You can tell almost immediately when there is bleed because you can feel the hematoma and express it. Plus your fingers put pinpoint pressure on the area instead of just generalized pressure that a femstop or C-clamp does. This is of course the procedure for groin sites.....our cath lab only does brachials if they can't get in through the groin. But anyway that's just how we do it at the Heart Hospital. I didn't realize there were so many other methods used, so it's been interesting reading through these.

I tend to agree with bradlyrn1 though....I think it's not very safe to only have 1 nurse in the room, even if your using a femstop/c-clamp. If that device fails, all you have is your hands, then you're tied to the patient and have to rely on a 2nd set of hands to push drugs, get vitals, and whatever else you might need.

Up Vote Up Vote ×
Specializes in Cardiac Telemetry, ED.

My facility has had a cath lab since 1969. Our cardiac floor nurses have been pulling sheaths for many years, and our safety record is excellent.

Up Vote Up Vote ×
Specializes in Cardiac.

We do not need a Dr. order for a femstop. We pull 1 hour after angiomax and only if ACT is

Up Vote Up Vote ×
+ Join the Discussion