arterial sheath pulling post catheterizations

[anurse4life]

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.

[nurse171]

I am not a nurse in NC, but an RN in another state. I work in a unit that preps and recovers for Cath and EP labs. During sheath pulls, we work in pairs, one RN and one Cardio Tech. The tech actually pulls all femoral (by FAR the largest percentage) and holds pressure while I monitor and document and manage any problems that occur during the pull. Brachials and Radials are pulled by a NP or a Fellow. IJ's are pulled by RN's. This is the same for non-anticoagulated sheath pulls or interventional (PCI's, RFA's etc.) where a form of anticoagulation was used. If Heprin was used, protamine is administered in the lab prior to the patient being returned to us for sheath pull. However, we still check the ACT to make sure their blood is clotting at the protocol rate prior to pull. We have set protocols for venous and arterial pulls. A standard order set is provided for meds that the RN may administer etc., frequency groin site checks post hemostasis etc. so it's pretty cookie cutter. I hope this helps.

[mpccrn, BSN, RN]

our hospital is just starting a cardiac cath program and i wrote most of the policies and procedures regarding it. After extensive research I found it recommended that highly trained limited personell (cath techs) be the only ones to pull sheaths. It was found that these people are the most trained and qualified people to do it and keep their competency current through repetition. I also wrote that the techs document the pulling in the progress notes. I saw no reason for the RN to play secretary for them.

[EmilyCCRN]

our hospital is just starting a cardiac cath program and i wrote most of the policies and procedures regarding it. After extensive research I found it recommended that highly trained limited personell (cath techs) be the only ones to pull sheaths. It was found that these people are the most trained and qualified people to do it and keep their competency current through repetition. I also wrote that the techs document the pulling in the progress notes. I saw no reason for the RN to play secretary for them.

I agree that only "highly-trained" personnel should be pulling sheaths, and cath lab techs (radiology techs and UAPs such as CVTs) generally have extensive experience in this arena. It is important to note, however, that an RN must be on hand during the sheath pull to monitor for complications such as vasovagal reactions. If I'm the only RN around, I am NOT the one pulling the sheath. My tech will pull while I monitor the patient. If I have a second (critical care/cath lab) RN, I get to pull the sheath.

I am quite experienced at pulling sheaths, which are mostly CFA (common femoral artery) access sites. My cath lab performs both cardiac and peripheral interventions, so it's not uncommon to see antegrade CFA access. These are a little trickier to pull, IMO. We do a ton of radial approaches here, but the MD always pulls these (whether diagnostic or interventional) at the end of the case, as we use a form of mechanical compression for radial access sites. We rarely use a brachial approach anymore, but I have pulled these sheaths, as well.

If a procedure was diagnostic only, heparin should not have been given during the case, which means that the sheath can be pulled right away. If anticoagulants were given and the MD is unable to use a closure device (Starcose, Perclose, Angio-Seal, Mynx, etc.), we generally wait until the ACT is less than 180 before pulling (unless Angiomax was used--it's a direct thrombin inhibitor that cannot be measured by ACT--the protocol is to pull the sheath 2 hours after Angiomax was dc'd).

Cath Lab digest is a free periodical that is an excellent resource for arterial sheath management, among other things cath lab-related.

Oh, and not that you asked, but I must throw in my regarding the pulling of arterial and venous sheaths. ALWAYS pull the arterial sheath first and NEVER pull them at the same time!!!!!