cathlabnurse1972 710 Views
Joined: Jan 23, '06;
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I've been to hospitals where it is on their pre-printed post-cath orders. It is a great tool for groins like that but you have to have the order and generally a hospital policy regarding nurse administration. The epi in the lidocaine clamps down the tiny vessels in the tract. That's why dentists use lido w/ epi, less bleeding.
Sheath pulling tips:
-Blood should be withdrawn immediately before the sheath pull, not prior to other steps. The point of withdrawing the blood is to assure there are no clots in the sheath that can get "milked" out and enter circulation. You don't have to withdraw blood if your line is hooked to an adequate pressure bag. Just keep the bag inflated during the sheath pull. The whole purpose of the bag is to ensure that blood can not enter the sheath and clot.
-If your line is not hooked to a pressure bag and you are unable to aspirate blood some doctors prefer that you pull the sheath WITHOUT applying ANY pressure to the site until you get 2 to 4 "squirts" of arterial blood. This will assure that any clot in the sheath is not allowed to enter the blood stream. Most likely, the reason you can not aspirate blood is because the sheath has clotted off. However, it can also be because an obturator (solid plastic tube) placed in the cath lab was the same size as your sheath. This will completely occlude the sheath so that no blood can enter (we do it on purpose). If you know for sure your obturator is the same size as your sheath, there is most likely no reason to pull without applying pressure.
-If you are unable to feel a pulse at the femoral arterial site, try pulling the patient's leg slightly away from midline and rotating it so that the foot is also pointing away from midline. This helps bring the femoral artery to the "surface" just a little better.
-REMEMBER, and I can NOT stress this enough: The hole in the artery is NOT, NOT, NOT in the same place as the puncture site you see on the skin. This is important because if you pull a sheath or find a patient bleeding after they have had an arterial sheath pull it is IMPERATIVE that you hold pressure above the puncture site. Holding ON the site does not stop the bleeding. A good rule of thumb is to hold pressure about 1 cm above and 1 cm medial to the puncture site as long as you can feel a pulse there. If you use this as a guideline, it really does not require that much pressure. I have taken over for ex-football players who couldn't get a seal on the artery and stopped the bleeding with no difficulty (and only two fingers!) by just keeping that rule in mind.
-Check the site for firmness periodically during the sheath pull. You can have a tract that sealed without having the bleeding actually controlled. If the site is growing firmer your patient IS bleeding and you either need to change your position or ask your backup person in the room to see if they can get it under control.
-Anytime after cath/PCI your patient complains of new-onset back or flank pain on the side of an arterial stick (sometimes we have to stick both sides so keep that in mind) notify your physician IMMEDIATELY. This can mean your patient is bleeding in a spot that you have no way to detect other than with a CT scan (retroperitoneal bleed). Also notify your MD for tachycardia, hypotension, decreasing H&H (your normal signs of possible bleeding) and a decrease in platelet count. Doctors may sometimes discontinue or change certain drug orders if the platelet count gets too low. It's usually monitored every 8 hours or so with certain drug infusions. And just be aware that doctors will frequently specify what changes they want to be informed of or it may be on pre-printed orders. Don't forget to monitor those specific parameters because I assure you they are there for a reason.
-After femoral sheath pull: bedrest per MD specifications but also be sure to tell the patient to keep the affected leg straight, do not cross their legs or ankles, keep their head flat on their pillow (they can rotate it side to side), and not to raise their arms above their head. Raising the head off the pillow tightens the muscles around the femoral artery, raising the arms can stretch the area slightly. Both of these can cause the patient to bleed again.
-Besides your hospital policy for groin checks, also check the groin if your patient coughs, sneezes, or vomits and if you notice any of the actions mentioned above.
-Familiarize yourself with your hospital's policy on sheath pulling and groin checks (or radial site checks)
-Warn your patient prior to pulling the sheath that they will feel a lot of pressure where you push on the artery. Their first instinct WILL be to push against you. Let them know that if they do that, you just have to push harder to stop the bleeding. Let them know that the pressure will subside after a couple of minutes and it is important for them not to push against you or hold their breath. I find that if you tell them this BEFORE the sheath pull, they respond well when you just say, "Don't push against me" or "Don't forget to breathe". This will also drastically cut down on your vasovagal reactions!
-Pulling a sheath slowly will increase your chance of vasovagal reactions and bleeding. Remember, most of the sheath is actually in the tract not the femoral artery. If you pull the sheath slowly and don't compress until it is almost completely out of the skin, you have allowed the artery to bleed into the tissue. While this bleeding is acceptable if you feel your sheath may contain clots, it should not be done routinely.
-Always make sure your patient's blood pressure is not too high to pull an arterial sheath. If the blood pressure is too high it is very difficult to achieve hemostasis. Your hospital or doctor should have parameters for this.
-If you have an arterial and venous sheath, do not pull both at the same time. This can lead to the formation of an AV fistula. Most frequently, the arterial sheath is pulled prior to the venous sheath. While some people say it doesn't matter which comes first, most nurses like the venous sheath in place in case a medical emergency occurs during the arterial sheath pull (this is rare, don't worry). This leaves a central line in place just in case. Most nurses would rather be prepared and "ward off evil spirits". Just wait until you have hemostasis of the arterial before pulling the venous. I usually pull arterial, and then three quarters of the way into manual pressure I pull the venous. Again, check your hospital policy.
-If you are holding pressure and your patient suddenly becomes nauseated (with or without a decrease in heart rate/BP), try easing up on your pressure just a little. Patients will often become nauseated before you see an actual drop in their heart rate or BP. What you are likely seeing is the prequel to a vasovagal reaction. The reaction can often be stopped just by easing up a little. A lot of people have a tendency at first to hold way more pressure than is actually needed. The same can be true of a gradually developing bradycardia that develops several minutes into arterial pressure. Just try easing up a little. Remember though, you must frequently assess for signs of bleeding just to be sure. Of course, if this doesn't work or you are unable to release any pressure, consider atropine and fluids per MD order or hospital policy. (This does not apply to symptomatic bradycardia that occurs immediately after a sheath pull. Though this rarely happens, atropine and fluid bolus should be considered at that point.)
-If you are caring for a post-sheath patient and you note a pulsatile mass at the puncture site, notify the MD (possible pseudoaneurysm)
-These are just a few tips I've gathered over the years. If they do not fall in line with your MD orders and/or hospital policy, please do NOT use them. Best of luck, I'm sure you will do great!
I wouldn't be concerned so much with how quickly the BP and BG were lowered as I would with how much they were lowered, especially the BP. I don't think a period of 5 hours is too quickly for either of these. Unfortunately, there are pieces to this puzzle missing. A. Was her previous CVA embolic or hemorrhagic? (I'm assuming embolic because the CT showed an old infarct. Patients and families can rarely tell you this information, you can usually only find if you have access to old medical records.) B. Any known carotid artery disease (especially in presence of previous embolic CVA)? C. What were her BP and BG at the time of her complaints? D. What is the patient's age?
I think you are right that the BG level can make a patient who is accustomed to a higher level feel "strange". What may concern me more is that she may not be adequately perfusing her brain if she has carotid stenosis. Those patients require a much higher pressure for adequate cerebral perfusion. When I worked neuro ICU we would frequently use vasopressors in order to keep patients pressures above 140-150.
Hypoperfusion and/or hypoglycemia both need to be considered especially with the "clammy" skin. Perfusion is not dependent on heart rate, it is dependent on blood pressure. You can have a heart rate of 35 but a blood pressure of 150/75. Conversely, you can have a heart rate of 70 but a blood pressure of 60/30. Clearly, the patient with the heart rate of 35 is perfusing better than the patient with the heart rate of 70 in this case.
Also, if the patient is elderly the confusion after hydromorphone would not be that uncommon. What is most concerning though is the sudden headache, especially in the setting you described. While the CT can rule out acute bleeding in the brain, it cannot rule out ischemia. Also, I do not think it can rule out brain stem infarcts/bleeding. For that, you do need MRI if I remember correctly (It has been several years since I worked neuro). Also, bear in mind that ischemic injury does not show immediately on a CT scan. This can take up to 48 hours to show. The first CT after neuro changes is generally only used to rule out bleeding.
Anyway, enough useless trivia from me. In short (too late for that, ha) I don't think the time span you described is unreasonable. Also, I do think you were definitely thinking along the right lines in trying to pinpoint the cause of her symptoms and I think you did everything right. Your assessment and re-assessment of the patient is very impressive!
1. There is a different concentration of parenteral nutrition which can be given peripherally. This is PPN. It is different from TPN. TPN can only be administered via a central IV line.
2. You do not have to stop TPN to draw blood peripherally. TPN should not be stopped abruptly as this can cause hypoglycemic reactions. Labs should never be drawn from a central line through which TPN has been infusing.
3. Elevated serum glucose levels may need to be treated by adding insulin to the TPN, using SQ insuling and supplementing with an insulin gtt if needed. If you are using an insulin gtt, you can piggyback the gtt in at the port below the filter that is in your TPN line and run it on a separate pump.
4. There are some medications that are compatible with TPN, insulin, lipids, and some antibiotics--I just always call pharmacy first and make sure that I piggyback everything below the filter.
Hope this helps
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