help with groin sheath pulls - any pointers?

  1. I recently took a job in a Cardiovascular recovery unit, partly because of the hours and partly because it is so close to home that I can get to work in <10 without driving on the highway..a real perk in the winter. We have 7 beds. Our cath lab isn't all that busy yet, so we don't see more than 3 - 4 caths returning to us on any good day, and usually far less. At least 70% have closure devices, which is lovely...but on those 20-30 percent that require a sheath pull, I am having a heck of a time. I've been an RN a long time, but my experience with sheath pulls can be counted on one hand prior to this job.

    I am inconsistent with my control, and I think I am having trouble knowing where to place my fingertips. I feel for a femoral pulse, but either because of nerves or age (I'm 52) I don't REALLY know if I'm feeling it or not sometimes...especially when the pt is female and has a fat pad there. I attempt to place my fingers above (maybe 1 fingerbreath) and medial to the groin site...but today I had a lot of trouble getting control, had to use 2 hands quickly and then covered the site and repositioned my hands with felt like an eternity to me, but was probably less than a minute.

    My biggest problem is the educator. She is much younger than me (most are), and seems to think that sheath pulls should be my favorite thing to do. As I have not been checked off on all my required, she, or someone, has to be there when I pull. I'm not shirking my responsibilities, but if I live a million years and never see another groin sheath it won't bother me. Am I the only nurse out there that feels this way?

    ANyway, any pointers would be appreciated. I've thought about doppling the pulse to get a better idea of placement, but then I'd have to wipe off the gel and it IS a sterile area, so.....
  2. Visit kcmosue profile page

    About kcmosue

    Joined: May '08; Posts: 5


  3. by   CABG patch kid
    You mentioned placing your fingers and I'm wondering exactly how you hold the site after you pull, meaning, do you use your fist? For example, picture the pt has a sheath in the right groin. I would stand on the right side of the bed, check for the femoral pulse, then place my left FIST lightly where the pulse is, just above the actual puncture site, ready to place pressure. Then with my right hand, begin pulling the sheath. As soon as the sheath leaves the skin, push down pressure with my left fist, using my right hand to stablize my fist, usually around the wrist (so you are using both hands). Then I have my other nursing buddy in the room lower the bed for me, so I can lean my body weight down on the pt (my first sheath pull was a bleeder who squirted across the room, so now I'm paranoid). If you use your body weight rather than just pushing with your arms and shoulders, you will feel less fatigue.

    This method has seemed to work well for me. You may have to adjust your fist a bit if you see some oozing you may not quite be in the right spot. Generally I don't like to move around too much, I don't switch off between hands, I just take the pain as a sacrifice to keep my patient from bleeding to death. No, sheath pulls are not fun! They are time consuming and my hands do fall asleep, but it is a satisfying feeling when you are done.
  4. by   mmcmarsh
    I guess everyone has their own method. When I pull a sheath, I first feel for a femoral pulse. Then, while the sheath is still in, I have someone dopple a pedal pulse and I apply a small amount of pressure to where I think I'm going to hold and listen. If you are in the right'll hear it. When I pull, I hold my hand in a c position. My thumb rests on the iliac crest and my 3 fingers across the femoral artery. It is kind of hard to explain without a visual. This is the way our cardiologists and cath lab staff have taught us. Really, if you have your hand in the right place...2 or 3 fingers should be enough.
  5. by   kcmosue
    That is absoultely the best advice I think I've heard! I essentially do have my hand in a "c" position, but I like the doppler idea. I think that would help me verify that I do have my finger on the femoral pulse and the right pressure point.
    Since i"m not "checked off" to do this, I always have someone "monitoring" my attempts, usually the critical care educator...who, by the way, isn't much of a help, she has not given me any pointers but expects me to complete 7 pulls and then be skilled enough to do it...I think if I used this doppler method, my confidence level would go up, and I wouldn't feel like I was "guessing" every time I pull. I'm not sure that I want to do the fist technique, I think the educator would have a cow. although I'm sure it would be easier on my arm/hand.
    Thanks for the tip!
  6. by   JF808Rn
    I have tried that "Hand Clamp" technique and using the fist technique also and I have to say that I like the fist technique much better! But I assess for a fem pulse first, then position myself to the side of the sheath, apply slight pressure above the art. sheath or below for a ven. sheath. then simultaneously pull and press with body weight. Hope this helps!
  7. by   JustMe
    Like CABG Patch Kid I use my fist. I note where the sheath is inserted and place my fist above the site, then pull. There are other considerations before pulling a sheath tho. I won't pull a sheath if the patient's BP is too high--i.e. >140 systolic. In our facility we wait until the ACT is <150. I also premedicate and give a fluid bolus before pulling the sheath. I hold firm pressure for about 10mins (depending on the ACT), then start peeking at the site to confirm control. I usually have to hold the site for about 20mins if everything else is in place.

    I've been pulling sheaths for over 20 years and it's just a matter of confidence in your skills and having a resource available to you. Just so you don't feel alone out there, the literature indicates a variety of issues regarding sheath pulling. It seems that complications are more in line with pre-existing conditions rather than the method used to pull the sheath.

    Just my
  8. by   anurseuk
    I don't work in a cath lab but have taken large femoral lines out. When removing IABPs we use a femstop device (which works a treat). Our surgeons tend to be a bit messy but we had a cardiology pt so the cardiologist came up to remove IABP, put the femstop on half inflated just above puncture site and removed, quickly inflated. NO BLOOD!
    When I've recieved emergencies from cathlabs who have had radial catheters they quite often come up with a cuff inflated which works the same as a fem stop.
  9. by   moonshadeau
    Technique comes with time. My best advice has always been to make sure that either you or the patient has the call light in reach- just in case.
  10. by   nursej22
    I have trouble occluding the femoral artery with just 2 fingers--my nails with dig into the patient and I just don't have enough strength or flexibility in my wrists to do the hand clamp method anymore. Instead I place 2 fingers of my left hand on the artery and apply more pressure on top with my right hand knuckles, for about 2 minutes total occlusion (sat monitor pleth on pt's great toe works well), and then gradually back off. On a chubby person, I will fold up a 4x4 to a 2x 1/2 inch pad and use it to keep my fingers from digging in.
    Those hard calcified arteries are the worst! They feel like a piece of steel wire under your fingers and will slip out from under your fingers.
  11. 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.
  12. by   JustMe
    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!
  13. by   TakeBack
    Quote from 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.
  14. by   earache77
    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.