help with groin sheath pulls - any pointers?

CABG patch kid, BSN, RN · Jun 13, 2009

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.

mmcmarsh · Jun 14, 2009

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 spot...you'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.

kcmosue · Jun 14, 2009

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!

JF808Rn · Jun 14, 2009

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!

JustMe · Jun 16, 2009

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

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 :twocents:

anurseuk · Jun 18, 2009

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. :)

moonshadeau, ADN, BSN, MSN, RN, APN, NP, CNS · Jun 27, 2009

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.

nursej22, MSN, RN · Jun 28, 2009

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.

Buddyken · Jul 27, 2009

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.

JustMe · Jul 28, 2009

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!

TakeBack · Jul 28, 2009

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.