Pulling Femoral Lines

hrtprncss · Jun 3, 2006

Venous first, from my experience, either from watching how the cv fellows did it, and how the cardiologist preferred when I asked before.

Kymmi · Jun 3, 2006

I always pull the arterial sheath first for two reasons. First reason that way if the patient brady's down or has any rhythm problems I still have a large venous line to push drugs through or give fluids through fast. The second reason is that the arterial line usually requires more pressure for a longer period of time so that way I can hold pressure on the arterial site and then after 10 or so minutes (depending on bleeding) I can pull the venous line and hold pressure on the venous and arterial at the same time.

hrtprncss · Jun 3, 2006

I suppose pulling the arterial sheath first makes sense as well. The reason I was taught to pull the venous sheath first before the arterial, is that once you pull the arterial sheath, then you'd have to hold pressure for a long time. One cardiologist doesn't even want us checking for hemostasis for 20 minutes, and what he does is make us put pressure for 20 minutes straight. This is manual pressure, although some cardiologist doesn't mind if we use femstop, this one is quite particular. He also does this himself, I've seen him put pressure for about 15 minutes or so, then lift up and when he saw oozing, then put pressure again for another 20 minutes, with a sour look on his face. The reason he gave me for taking out the venoush sheath first is that, if you pull the arterial sheath first then lift up and pull the venous, you will run the risk of disrupting the hemostasis you have previously achieved because you might be taking off slight pressure to d'c the venous sheath then having to apply the pressure again. Maybe he's just being picky.

Ann RN · Jun 3, 2006

I always pull the arterial sheath first for two reasons. First reason that way if the patient brady's down or has any rhythm problems I still have a large venous line to push drugs through or give fluids through fast. The second reason is that the arterial line usually requires more pressure for a longer period of time so that way I can hold pressure on the arterial site and then after 10 or so minutes (depending on bleeding) I can pull the venous line and hold pressure on the venous and arterial at the same time.

:yeahthat:

hrtprncss · Jun 3, 2006

Found something rather interesting, it's the same question discussed in a PTCA forum by cardiologists or those practicing in cardiology...Asking the same question, getting different answers, one says arterial first then some say venous first, and they list out their reasons as well http://www.ptca.org/forumtopics/topic20011121.html So now I'm confused.

Nurse-o-Matic · Jun 5, 2006

Interesting to read the way procedures are done elsewhere. When I have had mutiple lines, I have pulled them at the same time and held pressure for 20-30 minutes before peeking. A few times I've had someone come back with 3 or 4 lines in and was instructed by the cardiologist to pull them all at the same time. Now, I'm wondering if there are any potential problems that could develop doing it that way. Any thoughts?

Kymmi · Jun 5, 2006

I would think whatever hospital that you are working at would have a policy. I would never personally pull all lines at the same time though. I never pull more than one at a time because that way if for some reason the patient has any bleeding issues I only have one puncture site to deal with. Even if the hospital policy said it was ok to pull all lines at once I would still only pull one at a time. If the cardiologist insisted I pull all of them at once that would be the time I told him he'd have to pull it himself because I personally feel it is a unsafe practice. I've come to realize over the years that just because a doctor writes something or tells me to do something it doesnt always mean its the correct way.

Ann RN · Jun 7, 2006

Interesting to read the way procedures are done elsewhere. When I have had mutiple lines, I have pulled them at the same time and held pressure for 20-30 minutes before peeking. A few times I've had someone come back with 3 or 4 lines in and was instructed by the cardiologist to pull them all at the same time. Now, I'm wondering if there are any potential problems that could develop doing it that way. Any thoughts?

The pt. can have a vagal response when having femoral lines pulled. That's another reason why arterial lines should be pulled first. If the pt. is even just a little bit anxious, a small dose of versed should be given (or dilaudid). I would make sure NSS is running thru the venous line while the arterial line is being pulled. And always have atropine is at the bedside & within your reach.

twiceaslucky · Jun 21, 2006

I always pull the arterial sheath first for two reasons. First reason that way if the patient brady's down or has any rhythm problems I still have a large venous line to push drugs through or give fluids through fast. The second reason is that the arterial line usually requires more pressure for a longer period of time so that way I can hold pressure on the arterial site and then after 10 or so minutes (depending on bleeding) I can pull the venous line and hold pressure on the venous and arterial at the same time.

Yep, what she said :)

tamcan · Jul 1, 2006

I was taught by a cardiologist to not pull two sheaths at once, venous and arterial, because this could cause a fistula. I pulled the arterial first, and five min. later pulled the venous, never letting up pressure. If we used a closure pad, with manual pressure, we held 10 min. before looking, if manual with out a closure pad, a good 20 to 25 min. before letting up. never failed the venous site was the one that oozed. supeficial blood only. Before the cardiologist told me to pull one at a time, I pulled them at one time if they were close together, but now I dont anymore. We always started 2 large bore IV's before a PTCA, so we didnt need the venous sheath, the Dr's didnt like us running meds through them anyway, I have found a vagal response is in direct response to too much pressure being applied, It hurts them and the hold their breath, and next thing you know, they are going down. NS and atropine are definatly your best friend, along with a cold wash cloth, and O2, and a calm personality . Our drs sometimes order lidocaine to the sheath sites, to deaden them alittle, I can't honestly see the difference. You can hold pressure without pressing them through the matress, but it takes practice. Good luck hopes this helps.

unlucky-on-call · Jul 4, 2006

First Post

I was always taught to pull the arterial sheath first then venous, working in the cath lab means I only ever pull lines on patients that are not anti-coagulated, and therefore lines are generally in for only 20 mins, max 45.

If we proceed onto PCI or there is thrombolysis on board then the sheaths are removed in CCU/Cardiology Ward once heparin/thrombolysis has worn off.

I apply 10-15 mins manual pressure on arterial puncture site, then a further 10 or so over venous. All my colleagues in the lab use a similar approach.

As far as I am aware the staff in the unit and ward pull arterial first.

And I always have problems with oozy venous punctures no matter how long I press!!