Pulling Femoral Lines

[Nurse-o-Matic]

If you have a patient with a venous and arterial line do you pull them one at a time or both together? Thanks!

[Critical LPN]

While faced a few years ago with this problem, as the policy then became mine to write up, the standard to leave the venous sheath in was considered for I.V. fluid patency. However the point came up that if you were maintaing enough pressure to occlude arterial pressure as needed to stop bleeding either manual or with the femstop, you would be shuting off flow as well as occluding the venous line. We found that making sure you had another line (either central or peripherally), would be a better choice because if the patient were to vagel or bleed out from arterial pull, that they could do the same with the venous sheath pull and then you had no line to give fluids or meds. Also to consider, all that pressure on the venous line from holding the arterial site next to it, could allow for a clot to form in the venous line that could be forced into the system and cause embolus to pass when the fluids are cranked up in I.V. Of course, it was learned by trial and error that this worked best for our patients who tended to be also compromised due to long term aspirin therapy, coumadin and sometime underlying alcohol/drug problems. We were to pull when certain PTT or ACT

levels were reached as that was the doctors orders, however many patients had perfect ACT levels I found but they had so many underlying problems that doctors did not take in account individually and record on order list for the staff nurse to watch for (such as the afor mentioned substance use, long term coumadin/aspirin use). Also as a nurse who keeps up on natural meds and supplements, I saw that people who took daily doses of Vit. E,large dose Vit. C and ginko bilboa as well as others were prone to require longer hold times and perhaps note possible rebleed even after they appear perfectly fine for a couple of hours. The ACT or Ptt only measures a certain part of the clotting chain and thus not totally reliable. The best bet is to always have another large bore as possible line for fluids as in a crisis situation, another nurse can be giving fluids and monitoring V/S and patient condition while you are pulling either/both sheats. As anyone who has done it can tell you that trying to hold even direct firm pressure or getting the femstop(does not work well with some bodytypes) just right while the patient is starting to vagel or crash is a bad time to hope that the venous line you are also probably putting some pressure on as next to the arterial line being pulled, does not work.

There are always those out there who will take the short path of quick decision and do only as their policy says, and no more. I guess that through the years, I have found and tried to mentor others that "LOOK AND KNOW YOUR PATIENT" . Policies are guidelines to follow and it is the for us as trained professionals to always strive to do more if needed and it is our duty to try and do the best thing for our patients. Their are no textbook patients out there in the world. Most always, bleeding and hematomas as well as psuedoanyuesms could be prevented if the patient history and supplements (that sometimes do not get noted on chart) would be asked of the patient prior to the pulling of any major lines. It only takes a few seconds to ask and I have found that if you tell a patient that certain alcohol, meds or supplements could interfere with his clotting time and you are just trying to prevent any problems , they will tell you everything if done in a professional and discrete way. Could spare them complications and also you as well as the institution you work in, legal compications.

[pinecone]

We are having difficulty with this policy at our hospital regarding which to pull first. I was always taught to pull arterial first for those same reasons listed. We pull using the femstop and obtain hemostasis over an hour with fem pressure. Since the vein is relatively close to the artery the vein is no longer open ( it becomes occluded with femstop pressure). i have also learned that pulling the arterial first and then the venous or both at once increases the risk for AV fistula formation. This is stated in the femstop insert. Although if anyone knows of any recent case studies regarding the issue please let me know.

[CCURN]

In my experience, just as long as you can apply enough pressure over the femoral artery, then you can pull it first before the venous sheath. Either or, it doesnt matter, just as long as you can maintain pressure...I never pull them together though