Cardiac Sheaths

Virgo_RN, BSN, RN · Feb 8, 2009

We pull sheaths on adult patients in a cardiac telemetry unit. Before being brought back to the floor from the cath lab, they have an Aldrete score of 8 or equal to their preprocedure score. They have continuous cardiac monitoring, pedal pulse monitoring, and Q15 vitals, except from the time the sheath is pulled until hemostasis is acheived, then they are Q3 minutes. Our nurse to patient ratio is usually one to four, and usually we'll only have one sheath patient at a time.

mamason · Feb 9, 2009

We pull sheaths on adult patients in a cardiac telemetry unit. Before being brought back to the floor from the cath lab, they have an Aldrete score of 8 or equal to their preprocedure score. They have continuous cardiac monitoring, pedal pulse monitoring, and Q15 vitals, except from the time the sheath is pulled until hemostasis is acheived, then they are Q3 minutes. Our nurse to patient ratio is usually one to four, and usually we'll only have one sheath patient at a time.

Very similar to what we do also on our unit.

jjensen · Feb 10, 2009

I pulled sheaths and it is really not a big deal. I had a few patients who vagaled on me, but you just rush fluids and adjust the bed. Your hands will be sore from applying pressure for 15 minutes and it is sometimes hard to come up with topics of conversation when you hands are on someones groin... It is actually fun to do and I think it is a great skill to have...

CrispRN · Feb 20, 2009

I work in a CCL and we typically pull sheaths on our patients prior to them going to the telemetry floor or back to an outpatient area. Thankfully, the majority of our cardiologists use closure devices such as PerClose, Angioseal or StarClose. Just as a previous responder wrote about your hands being sore from applying pressure for 15 minutes and topics of conversation, I've not seen many patients suffer complications.

Occasionally patients will be coagulated prior-to and intra-procedure and we are not able to pull the sheath before they are sent to the ICU or telemetry unit. In these circumstances, the sheath is sutured in or secured with a Tegaderm until the patients' ACT is below 170 seconds. Typically we do not see problems with their puncture site. Occasionally, additional pressure and/or a FemStop is needed. Overall, the procedure is simple and uneventful.

MatthewRN · Feb 21, 2009

We routinely pull sheaths on patients who come up to our CCU with stents. Versed and fentanyl are standard meds for our patients prior to sheath pull.

Morettia2, BSN, RN · Mar 7, 2009

We pull sheaths on my floor. I work Interventional Cardiology. The ACT has to be

I can say that sometimes pt's come with ACT's in the 140's and I wish that the cath lab would have pulled it b/c now the pt's bp is elevated, very elevated and we can't pull, I have also had pt's with a baseline HR in the low 40's with a sheath that could have been puled in the cath lab and now Ihave to worry if then are going to really vasovagle on me. I have had pt's who's BP's have plummetted, hence the NSS gtt on stand by, and one time had to give atropine b/c the cath lab, or should I say PTCA factory, cranked out too many cases and were sending pt's untill 1am. A pt. had a sheath, they were too busy to pull it in the cath lab b/c they had to crank out the next case, sent the pt. to me with a ACT of 120..horrible let's give the pt. a blood clot...the HR was in the 70's, I followed sheath pulling protocol, called for my 2nd nurse to be present for the pull and well the HR went DOOOOWWWNNN to 19 when I pulled, the pt. stopped talking and the pt became diaphoretic imediatly, I grabbed the atropine I had tapped to the bed next to the IV site, gave it, NSS wideopen, pt. was fine with in a few seconds...the 2nd nurse was my help and witness.

Let's just say I called the cath lab, the interventional MD and the cardiac fellow that did the cath and gave them a piece of my mind.

But with any critical procedure, you have to be trained and know what to do.

We have had 2 nurses holding pressure to stop bleeding, we have had MD's and nurses on top of pt. to stop hematomas..we have had it all....

CCU_NUM · Mar 10, 2009

Hi Folks, seems to be a hot topic. I have a question about pulling sheaths: Do you fast your patients prior to sheath removal? Its a big debate in our unit at the moment do you push fliuds (and flush those kidneys) or fast due to vaso-vagal risk? I would love to hear your feedback.

Virgo_RN, BSN, RN · Mar 11, 2009

They often come up with NS running by gravity. If their pressure is low or they're already renally compromised, I'll put it on a pump and keep it going at 75-100/hr until they're assisted out of bed for the first time (assuming they're not on Bicarb). While they have the sheath in, I let them have sips of water/juice or ice chips, so long as they're alert enough. If they are really starving and won't quit bugging me and I'm not worried about their swallowing, I'll let them have some jello or applesauce, but I limit those. I explain to them that sometimes people feel nauseous during a sheath pull, so I prefer to keep the tummy as empty as possible to avoid aspiration. Once the sheath is out, the bed can be tilted and they can have finger foods, or a spouse can feed them.

If they're really drowsy, I keep em NPO until they're more alert.

roseeRN · Apr 20, 2009

I work in a smaller hospital on the cardiac telemetry floor. About half of the patients that come in for a cardiac cath come to our floor to have their sheaths removed. We make sure the ACT is

Best of Luck,

Rosee

kcmosue · May 31, 2009

This is big topic to me. I have been an nurse for 30 years, and just took a job on a CVRU floor. 70% of our caths come back with closures, but the ones that don't, it appears to be my time to pull It's been years...and my hand position isn't right yet! My facility wants fingers at or above the sheath site, and want a small spurt of blood to come out before you pull. Have the time I don't even know if I've really got that femoral pulse. Some reading revealed a good way to hold is to put the index finger on the pulse point, and hold with the other two fingers........is this a good idea" Any other hand positions out there that might be easier?

Thanks!

Editorial Team / Admin · May 31, 2009

The skin puncture is below (distal to) the actual arterial puncture by 1-2 cm.

So you would want to feel for the pulse 1-2cm above the skin puncture.

Feel for the pulse.

(I'm sure you've read thru some of the other posts re:

* have pt empty bladder first

* re-anesthetize site if it's been awhile since the cath, so there's less chance of pt vagaling with the pressure/pain of the groin hold

* have enough fluids hanging that you can bolus the pt if he/she vagals

* have assist staff standing by who can help you if the pt vagals: trendelenberg, VS, opening the IV, reassuring the pt, etc

* make sure pt [hips!] is flat in bed, not sl rotated

* make sure ACT is

* have extra 4X4s ready )

After you've found the pulse, then pull as directed:

our Fellows do allow a sm spurt of blood then they apply direct, almost-occlusive pressure to the site with 2-3 strongest fingers.

Hold for the time per protocol (15-20 min).

tip: I've read/heard of nurses applying the pulse oximeter to the foot, to monitor whether they're applying occlusive pressure (don't want to occlude, just nearly so).

Perhaps you could request a refresher inservice, just to double-check the details (e.g., finger placement)?

Good luck! :)