Sheath pulls

Dinith88 · Jan 27, 2006

Jess...worst experience i had w/a sheath pull was a post-ptca lady w/alzheimers from a nursing home (why the hell the family and MD did this is beyond me...and stuff for ethical debate) . She was loaded w/plavix, on integrillin, had a ptt >200, and was so damn confused. Needless to sAy she wouldnt stay still, kept fighting to get up...at one point had her in 4-point restraints...Sedation to no avail...

Giant hematoma was result and pulled sheath early because i had no choice.

It was freakin awful. I'll leave the details to your imagination...

SEOBowhntr · Jan 31, 2006

Jess...worst experience i had w/a sheath pull was a post-ptca lady w/alzheimers from a nursing home (why the hell the family and MD did this is beyond me...and stuff for ethical debate) . She was loaded w/plavix, on integrillin, had a ptt >200, and was so damn confused. Needless to sAy she wouldnt stay still, kept fighting to get up...at one point had her in 4-point restraints...Sedation to no avail...
Giant hematoma was result and pulled sheath early because i had no choice.
It was freakin awful. I'll leave the details to your imagination...

Dinith, I feel for you. I've had half a dozen of those over the last 10 years, and they are never fun. I think my worst was actually a totally alert 55yo male who repeatedly bled and developed a huge, probably a 20cm x 20 cm x 15cm at least, and I spent the better part of 2 and a half hours holding manual pressure with BOTH hands to keep him from bleeding to death!!!!!

Not fun at all.

My second worst was probably a similar type patient who had a, Get this, (Big Word) Non-negativevasovagal response, put them together, and you'll understand why it was so bad. 50-something yo guy with his wife and son at the bedside when he starts feeling sick, and has a smallish hematoma, then suddenly his pressure is 100 systolic instead of 140, and his HR is in the 120's instead of the 70's, then within a few minutes he is 70/30's and HR is in the 160's. We thought he was bleeding to death initially, and had 2 units ready to run wide open, levophed hanging and neo on the way with 2 bags of saline going at 999cc/hr, when he suddenly started to increase his pressure ever so slightly and decrease his heart rate. The Levo never hit his vein, and the blood was never infused, as he came completely out in less than 5 minutes. But both the doc and I thought he was a dead man when it all started. We even had a beep for a vascular surgeon out when he resolved.

The patient in the first scenario was the first pt. I used a lido w/ epi injection on in the hospital I know work in. And the doc liked it so much it became part of our standard orders for repeatedly oozing groin sites.

Dinith88 · Jan 31, 2006

The patient in the first scenario was the first pt. I used a lido w/ epi injection on in the hospital I know work in. And the doc liked it so much it became part of our standard orders for repeatedly oozing groin sites.

I've Never done that. Is it a SQ injection/infiltration??? Have you done that much, or still do it?

SEOBowhntr · Jan 31, 2006

Dinith,

I use it a few times, probably once a month or so. It actually works extremely well. Similar to the way it is used in GI procedure to stop bleeds. I will infiltrate the area, not unlike you would do with regitine for a dopamine infiltration, and then massage the area I've just injected, helped the medicine start working and be distributed a little better. The end result is a local vasoconstriction which almost everytime stops small vessel bleeds. I've also used it a couple times in the past on post-op knee replacement patients after the surgeon came in and showed me how to inject a knee. The lidocaine is just a good med to put with the epinephrine because it helps get the patient a little pain relief, but it is not what I am really after, just a bonus for the patient. What I use is a 1:100,000 mix of Epinephrine in 1-2% Lidocaine, then I will use a 10cc syringe, and a 22 or 23 guage needle, and inject in a circular pattern around the site, first withdrawing making sure I am not in a vessel, then give 1ml. I use a pentagon type outline, then comeback, and inject and inverted pentagon hitting the spots between the points of my initial pentagon, injecting at anywhere from 1/2" on thinner patients to as deep at the whole 1.5" of the needle for a heavier patient. I've trained my entire unit on the procedure and gotten it approved by our cardiology department and our interventionalists, and it has been a saving grace for at least 50 or so patients who "suffered" many hours of manual pressure for small bleeds or continuous oozing vessels.

A little long, but a little better explanation, hope that helps.

Doug

nekhismom · Feb 10, 2006

I work in the cath lab, and I pull sheaths quite often. Worst one yet occured on a floor where I was to observe and check off a new nurse. Pt was hemodynamically stable but had a GIANT hematoma, had to be at least the size of my hand. Both of us were holding that groin with all we had, and all the unit nurses kept refusing to come into the room and help us. I thought the poor lady was getting a retroperitoneal bleed because she was screaming in pain, and the hematoma got so big so fast. We held for about 45 minutes on that groin. But in the end, her leg looked really good. The hematoma was gone, but there was a big ole bruise left.

THe worst groin incidents I have ever seen come from pts who have blown their Angioseal. They all seem to be older pts who are not always very oriented to reality. And we've had several of those recently.

MarylouNP · Apr 1, 2008

I am attempting to put together a Lido/Epi injection protocol together at my hospital, and would really appreciate any existing protocols that you could forward to me. It is not that I don't know how or haven't done this--my institution's nursing education department/Nurse Practice Committee is asking for research/articles/other policies or protocols on this since they are not familiar with this. :banghead:

Thanks so much!!!:redpinkhe

Spatialized · Apr 4, 2008

My very first pull was the "worst". After trying to get the ACT to a acceptable level for hours and hours, I finally had to call the doc to get the order to pull the sheath regardless of the ACT. Mind you, this is at 0200. We get set, Femostop positioned. My pull buddy undoes the dressing so the only thing keeping the sheath in is his fingers.

Then the guy starts puking. Retching and trying to sit up/roll over. I have visions of the sheath coming out and us being showered, but not. My buddy kept the sheath in place until the guy settled down. Then we pulled.

While not "bad" it was a heckuva first time.

Tom

qt2168 · Oct 30, 2008

Ok was not my patient but I went in and helped with this. The patient was given 10 of morphine before the intial pull. There is a venous and arterial line, they start pulling the art line first and half way out the guy freaks out, yelling and coming up off the bed. They can not hold him down. Now he has put him self in tachy with a hr of 160. We quickly get6 people in there to hold legs, arms, two to hold the site and stop him from bleeding to death. This whole time the guy is A/Ox3 and does not seem to understand that we are STOPPING HIM FROM BLEEDING TO DEATH. We quickly call doc and get ativan and some other stuff and it gets much better after that. It was a very tense moment if we didnt have 6 people to hold him dowm im sure he would have bled to death.

Later on we pull a sheath in a 80 year old lady whos only complaint is her bp cuff going off so often.

Go figure.

Cathlabnurse46 · Nov 1, 2008

Years ago (almost 20... dam it was at least 20 years) when I pulled sheaths for PTCA's I would totally sedate the patients with 5 -10 of valuim and 5 or Morphine. This was way before conscious sedation laws were around. I'd set up my AMBU bag, atropine and IV fluid and give the meds. Occassionally they would be so snowed that I might have to reverse them, but they never moved. This was "back in the day" when we used "perfussion balloons", "flow through balloons" and an agioplasty balloon was inflated for 20 minutes in a vessel, not 15 seconds! The sheaths were all 7-8 french or even 9-10 french!

I always kept airways with me. I was glad when VERSED came around! Balloon pumps back then were long holds.... we still wrapped them and the sheath were 11 french.

I never had problems "years ago". I see much more complications today then I did 15-20+ years ago. IDK if it's the training or if the patients are spred out in to many different units with too many people (Nurses and Techs) with too little experence. Now we have 4F and 5F and the complication rates seem higher? A few years ago we had a pt die a few days after a PCI cath when an ICU nursed failed to recognize a retroperotenial bleed.

Complacentcy and common place is the biggest problem! Cath and pulls are viewed as "no big deal" anymore yet the Fem art can led to death if not handled properly. I think that is the problem. Complacentcy.