Post-op PTCA tips?

Nurse Kyles, BSN, RN · Jun 3, 2013

I work on a PCU & we get a lot of heart cath patients as well as post op open heart patients. Some common drips we run are cardizem, amiodarone, nitro, dopamine, dobutamine, esmolol,insulin, heparin, integrilin, & angiomax.

My best advice would be (if you take care of the patients before the procedure) to make sure to educate them well about what to expect after the procedure. The patients who are aware what can happen seem to do better. I have had patients swing at me while pulling their sheath. Apparently nobody told them about the strong pressure we have to hold! When pulling the sheaths always have an extra set of hands & atropine ready to go. Perhaps develop a very special prayer that the patients will come to you sealed or better yet with a TR band. Good luck!

DeeDee_RN · Jun 3, 2013

What are the steps in sheath pulling? I work on a cardiac step down unit and I haven't had to pull one yet but I'm nervous for when I do! Any tips?

Nurse Kyles, BSN, RN · Jun 4, 2013

Here is a link to a preview of the Lipincott's Nursing Procedure book.Lippincott's Nursing Procedures - Google Books

This is what we follow. The steps are on page 508-509. Basically we check the ACT (if pt is on heparin), if

Pulling sheaths is my absolute least favorite thing to do! THis is why I have my special prayer that my patients either come with an angioseal/exoseal or TR band. The best tip is to always have an extra nurse there to help. You never know when things will start going down hill. Also alert the other nurses on the unit that you are pulling a sheath so they can keep an eye on the monitor too.

RNSavingHearts · Jun 5, 2013

It is policy (where I work) that two validated nurses must be present when pulling a sheath....on that note, we actually have to go through a special validation process and have to have two successful, witnessed sheath pulls "checked off" before we can pull on our own (with another validated nurse) I would check into your facility's policy before touching a sheath cuz I know my facility is pretty strict about it.

turnforthenurse, MSN, NP · Jun 6, 2013

It is policy at my hospital to have two sheath-pulling certified RNs in the room. I don't think it's safe to have just one nurse, because things can go wrong and it's good to have an extra set of hands.

Make sure you always follow your hospital's policy. Have atropine at the bedside just in case. I like to put the pulse ox on the right toe (or whatever side you are pulling from) in addition to having the extra set of hands check for cap refill and pedal pulses. Pt should already be on a continuous cardiac monitor and I set the BP to cycle Q5min.

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cathlabnurse1972 · Jun 8, 2013

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!