Vasovagal after sheath pull complete?

[cjblu]

Hi all...

I had a pt who was one hour post sheath pull, and she began to feel diaphoretic, nauseated, and had a large emesis, HR down to 35. Gave IV nausea meds, but the nausea returned, and another emesis. She also developed a hematoma after one of her boughts of throwing up, which resolved with pressure. I was completely worried about her, and wondering what happened, or if this has happened to others? Also, her BP was high after sheath pull, I gave hydralazine for that, and it only came down slightly 158/77...Did the hydralazine make her feel like that?

[Kristiern1]

Oh, how I hate those moments. I feel that alot of our cath patients get set up for a vasovagal response by being dry. If that situation happens again, I would consider instead of nausea meds try a fluid bolus and laying flat and with a HR of 35 and symptoms I would have given atropine IV. The nausea med probably wasnt truly indicated since if you increase the pressure and HR the Nausea will typically resolve. The hydralazine may have contributed some. My guess is she had been NPO for 8 hours or more, received IV contrast (which is further dehydrating). Next time that happens remember Flat, Fluids, Atropine!! Good luck...

[zacarias, ASN, RN]

If she was already dry and then she threw up, she probably vasovagaled again dropping her HR/BP that much more..

[SEOBowhntr]

An hour after a sheath pull is pretty rare, unless that hematoma was forming already and you just didn't know it yet. I generally try to keep post sheath pull patients BP's less than 140, even if I need to use NTG to do it, which we have standing orders for. The Vasovagal will often times only be worsened if the patients vomits because that will significantly increase vagal tone, so you should try to eliminate the cause rapidly. If the HR was 35, I'd bet the

BP was significantly lower during the worst of the event, it usually is. I've seen a couple that have vagalled to ASYSTOLE, and that is not fun at all. Atropine should have been your first liine drug, and should be readily available anytime you are pulling a sheath or caring for post-cath/PTCA patients who've had sheaths/angioseals/percloses or whatever your facility uses. Many of the Vasovagals I've seen occured during the sheath pull, rather than after, and were often times a result of an overzealous nurse pushing a clamp down a bit harder than needed. I've never once had a vasovagal while holding manual pressure which I believe is because the amount of pressure can be much more easily varied to the needs for hemostasis.