Techniques on Femoral Arterial Sheath removal?

Wedgepressure, ADN, EMT-B · Mar 20, 2021

Leverage helps, so being well above the bed using a stool is good. Depending on the French size and if they are anticoagulated will determine how long you hold pressure. The larger the sheath and the higher the ACT or aPTT the longer I hold. Also holding pressure over the insertion sight is a good rule of thumb as long as it's a retrograde stick. If it's antegrate that's a whole different ball of wax. Talk to your educator if you get those.

Getting a good groin/GU/ abdominal assessment before you pull the sheath helps to catch bleeding early. If they get hard painful swelling around or near the public symphasus or anywhere else that's a sign they may be bleeding. It's nice to have a femstop handy if you have a hostile groin and your not able to achieve hemostasis. Those are some of my tips! If I think of more I'll add them!

ambersky004, BSN, RN · Mar 20, 2021

7 hours ago, Wedgepressure said:

Leverage helps, so being well above the bed using a stool is good. Depending on the French size and if they are anticoagulated will determine how long you hold pressure. The larger the sheath and the higher the ACT or aPTT the longer I hold. Also holding pressure over the insertion sight is a good rule of thumb as long as it's a retrograde stick. If it's antegrate that's a whole different ball of wax. Talk to your educator if you get those.

Getting a good groin/GU/ abdominal assessment before you pull the sheath helps to catch bleeding early. If they get hard painful swelling around or near the public symphasus or anywhere else that's a sign they may be bleeding. It's nice to have a femstop handy if you have a hostile groin and your not able to achieve hemostasis. Those are some of my tips! If I think of more I'll add them!

Thank You wedgepressure. What is retrograde and antegrade stick? Can you describe it?

I always feel doubtful when I pull sheaths because I am small but if I do have obese patients, I let a larger nurse pulled it. We pull sheaths on our cardiac-stepdown floor when we get post cardiac cath and peripheral angio patients. It has been 3 mos I have not pulled sheaths so yesterday, my patient keeps on bleeding around the arterial and venous sheaths, ACT was 367 and she was on Aggrastat drip for interventional stent. I did not feel any hematoma or swelling around groin areas but she reported of tenderness upon palpation on her inner thigh. I did not feel any hematoma or swelling. The cardiologist came and he said she is very low in pain tolerance. I applied pressure for 5 mins and she still moderately oozes. I keep reinforcing dressings. Until her PTT came back and it is 174. I know that sheaths needs to be pulled because it keeps her bleed. But cardiologist said wait to 2 hours. We usually hold manual pressure for 20 mins. she did fine. but I keep thinking she might loose like 100 cc of blood I her. :D

Wedgepressure, ADN, EMT-B · Mar 20, 2021

Gj, it sounds like you did everything really well. Retrograde means the sheath is facing towards the aorta going against ther flow of blood. Antegrade means your going away from the aorta and with the flow of blood, this changes where the hole is in the artery and where you hold pressure.

He probably wanted to leave the sheath for 2 hours to get the ACT lower to prevent bleeding, that's a great option. He can disregard her pain all he wants but you should always have a high suspicion for bleed if they are having excessive or referred pain. Pain in the thigh may be a concern for compartment syndrome but that's usually resolved with direct pressure. Retroperitineal bleeds are the doozies. That's what you don't want. Back, flank, abdominal, pubic pain, hard, stiff painful swelling, growing hematomas these are what to look for. If after 20 minutes your still oozing I keep holding pressure.

Honestly for a 7F sheath with anticoagulation on board im probably holding for 35 minute post cath if we don't close with perclose or angioseal. Also you can set up pressure dressings with tape if your still concerned but the doc doesn't want a femstop.

Great job over all. Also talk with your cardiologist to confirm it's OK to do this, but if you have any question about the access site take the dressing off, put some sterile gloves on and hold pressure directly over the artery.

Let me know what you think and if you have any other thoughts!

ambersky004, BSN, RN · Mar 20, 2021

2 hours ago, Wedgepressure said:

Gj, it sounds like you did everything really well. Retrograde means the sheath is facing towards the aorta going against ther flow of blood. Antegrade means your going away from the aorta and with the flow of blood, this changes where the hole is in the artery and where you hold pressure.

He probably wanted to leave the sheath for 2 hours to get the ACT lower to prevent bleeding, that's a great option. He can disregard her pain all he wants but you should always have a high suspicion for bleed if they are having excessive or referred pain. Pain in the thigh may be a concern for compartment syndrome but that's usually resolved with direct pressure. Retroperitineal bleeds are the doozies. That's what you don't want. Back, flank, abdominal, pubic pain, hard, stiff painful swelling, growing hematomas these are what to look for. If after 20 minutes your still oozing I keep holding pressure.

Honestly for a 7F sheath with anticoagulation on board im probably holding for 35 minute post cath if we don't close with perclose or angioseal. Also you can set up pressure dressings with tape if your still concerned but the doc doesn't want a femstop.

Great job over all. Also talk with your cardiologist to confirm it's OK to do this, but if you have any question about the access site take the dressing off, put some sterile gloves on and hold pressure directly over the artery.

Let me know what you think and if you have any other thoughts!

Thanks for that description!

Pt was tender to the touch in her inner thigh area while she pointed the site. Do you think the venous sheath was causing it? Anyway, I pulled arterial sheath then the venous sheath after when her aPTT was about 51. The oozing stopped after both sheaths are removed. I am about 90 lbs. I usually bring my step stool and lower the bed, supine the patient and spread and rotate leg and foot away the midline. It always work for me when I locate the pulse. We usually hold pressure for 20 mins. I have learned not to occluded the pulse totally more than 3 or 5 mins because it is not good.

My other co worker on the other end who is bigger than me, her pt develop a hematoma and site kept bleeding after sheath was removed. The pt had a peripheral angio. The cardiologist came and said to put a fem stop. So nurses tried to apply it. While I was on the Pt's foot, using a doppler to hear any pulse. I told the doc, I could not feel or hear a pulse. Doc remove the pressure on the fem stop. ? it was quite a rough time during shift change. I was off the next day. So I hope my patient did well all night.