When pulling sheaths after a cath...

Spatialized · Jul 5, 2008

At our hospital we pull the sheats out that the doctors use during the heart caths. I was wondering if anyone had tips or a certain way that they do it. I seem to be having trouble stopping the blood and then I get paniced and have to call for help and this is getting to be embarrassing.
Any tips are greatly appreciated!

It really depends on your hospital policy. We use assist devices, like a C-Clamp and the Femostop for the initial pull. If that's in your facilities policy, use them. Past that, it's all up to the nurse.

When controlling bleeding, here are a couple of tips I've picked up along the way. Granted, I'm a night shifter and rarely pull sheaths myself, but have to clean up the day shift's mess.:wink2:

Really bear down on the site. Use a closed fist, get the bed height comfortable so you can put most of your weight into the pressure and hold. Hold until you're tired and then a little longer before you even check to see if the bleeding has stopped. Keep an eye on the color of the affected extremity to see if you're taking too much blood flow away and then maybe loosen up a bit. Our policy for hand pressure is 5 minutes, then re-evaluate, repeat as necessary. In more difficult cases, I've had to the put the Fem-o-stop back on to control the bleeders. On my bleeders, once I've gotten them under control I put on a new dressing so I can see if new bleeding pops up. Then it's groin checks Q1 hour and they're not allowed up for at least 4 hours past adequate hemostasis. Then it's monitor frequently

The biggest thing though is to NOT be afraid to call for an assist. It's when we as nurses don't call for help when we really need it that things tend to go south quickly.

Best of luck!

Tom

sunny_b · Jul 5, 2008

At my hospital we are to use manual pressure for the initial hold which I'm told is the gold standard for sheath pulls. We also always have another person who is plasty trained in the room throughout the hold; they check dp and pt pulses. At your facility do you do pulls alone?

I think everyone has their own way of holding; I make sure the bed is at a low height so that I can use my body weight for pressure and not be using arm muscle the whole time; make sure you position your patient close enough to the edge of the bed before you start. I find the femoral pulse near the sheath site, and do a test hold with someone checking the dp pulse just to see how hard I'll need to hold to occlude the pulse. One of the keys to a good hold, I think, is finding the right spot to hold before you start.

Then for the hold I usually hold with fingertips of one hand and knuckles of the other hand on top of the fingers; most of the pressure is from the knuckle hand because I'm leaning with my body weight and don't think my fingers would take that for long! Our policy is to hold pressure for at least 20 minutes; the dp and pt pulses should be occluded for the first 5 minutes and you release pressure slowly every five minutes then the pt must be on flat bedrest for 6 hours post(this can vary depending on the procedure they had)

Good luck, hope this helped a little bit!

UM Review RN, ASN, RN · Jul 5, 2008

I agree with Peachy, that was pretty much the way our hospital policy said to do sheath pulls, too.

Your post concerns me because it gives the impression that you're going it alone. It's safest to have the help in there before you need it.

SWEnfermera · Jul 5, 2008

SORRY EVERYONE. I WAS TYPING WITH A BABY ON MY LAP AND SHE HIT ENTER.

Anyway, as I was saying- Peachy hit on 2 key points:

- Make sure the patient is positioned close to you

- Make sure the patient is at a comfortable height, so your arms are straight over the patient, and you are using your weight to hold pressure. If your elbows are bent, you have to depend on the strength in your fingers to hold, and 20 minutes can be a long time.

I also check to make sure the patient is not rotated to the left or right; but that they are flat on their back. If the patient is rotated, you won't have pressure directly over the artery, even though you're pushing straight down. The patient's position is especially important when they have poor muscle tone and feel like a big wad of bubble gum. It has been my experience that these are the patients I have lost my position on. So I'm extra careful with them and double and triple check them for rotation.

SWEnfermera · Jul 6, 2008

Also, make sure you have someone with you at the bedside when you are pulling; especially during the first 5 minutes. This is when your patient is most likely to vagal. Your hospital should have written in their sheath-pulling policy an order for an NS bolus and Atropine IV if this should happen. Often when the patient vagals they also become nauseated. There is no way you can continue holding and give Atropine, give a bolus and give the patient an emesis basin if you are by yourself.

suanna · Jul 6, 2008

Our protocal is a little tougher. Manual presure x30 min followed by sandbag x 4 hrs. Your arm gets mighty tired after 30 min. Put the bed at a comfortable height. Don't use your finger tips- fist or nuckles bent apply more consistant presure with less fatigue. Use only a small gauze pad at the site when applying pressure- we used to use a stack of gauze but found the site often bleed under the pad and the gauze spread the pressure out too far to be effective. Turn on the TV and try to get comfortable. Have back up avail if you get too tired of need to leave for some other reason. NO PEEKING!!!! consistant pressure for at least 20 min without peeking. Apply pressure just above the insertion site- remember when you are trying to stop arterial bleeding the flow is from the proximal to distal- if you hold pressure too distal you will promote a bleed rather than stop one. Is the patient hypertensive- ask to have a med avail to treat this before you pull (Cardene, NTG, Nipride, beta blocker). You may not need it but if the pressure is painful for the patient of they are anxious you will have a hard time holding pressure against a SBP>180. Have atropine at bedside- some patients get vagal when sheaths are pulled. Make sure your IV is good- if something blows you don't want to try a new site in an emergency. Keep an eye on the distal limb- you shouldn't see much color change. Pulse may diminish but should still be palpable( be careful checking pulses- don't change the pressure at the site when checking. When 20-30min are up GRADUALLY ease up on the pressure over 5-10 min.

Virgo_RN, BSN, RN · Jul 6, 2008

I wrote a paper on evidence based practice when in NS, and one of the research articles I used stated that there is no difference in outcome between using a C clamp and holding manual pressure.

At my facility, we use a C clamp and a doppler. I've seen a few manual holds, in instances where the patient's anatomy makes it difficult to place the clamp, or when there is a problem with achieving hemostasis.

qt2168 · Jul 6, 2008

I try to get someone to go in with me but usually they are busy with something and I can just not find someone. So I tell them that I am pulling a sheath and to please listen out. Thats pretty much how everyone does it here. I do get very nervous just as I am about to pull the sheath, almost sick with nerves, but that is how everyone does it. Its not like I can force someone to come in. And if I even could I would be the only one who did it like that so it must be somthing that I am doing wrong since nobody else needs help very often. I think my problem is that I am leeaving the bed to high because my arms are usually bent and it does get hard to hold pressure for 30 min. I will try lowering the bed and pulling the patient closer to me to help with my technique. Hope that works! Thank you for all the advice!

allnurses Guide · Jul 6, 2008

Look for your hospital's written protocol. Just because others haven't had problems YET doesn't mean you are wrong to ask for help. As explained, if something happens, it's too late to ask for help then.

Spatialized · Jul 6, 2008

I almost forgot, take a double with you! We have to have an ACLS trained nurse with us when we pull sheaths (granted, we're all ACLS trained...) to have an extra set of hands if things go south.

Also I found having the patient void prior to pulling helps reduce the incidence of vagal episodes, but I can't really back it up with any research.

Tom

MissAnthrope · Jul 7, 2008

A few tips I personally use, take them as you will...

1. Remember that the sheath site is the femoral, and holding proximal to the site means that the artery is "slanted" (from where it branches off the distal aorta). I tend to position my hand a little sideways above the insertion site. And being above the puncture site gives you a clearer view so you don't have to peek (see number 9).

2. Aspirate a couple mLs of blood from the sheath before pulling in case there are any clots on the tip.

3. Take Atropine in with you. Don't forget to set the vitals for every 5 mins.

4. If you have a second nurse available, definitely have them with you the first couple minutes. Even a seasoned CNA can help you apply pressure or hold an emesis basin if noone else is available.

5. Definitely ask the pt if they need to void before the pull. 20-30 mins is a long time when they've got fluids running at 150 an hour.

6. Put the bed low and pull them all the way over to your side. Save your back and your aching hands!

7. I never fail to explain exactly what will happen to the pt, that it will hurt for a bit until their body acclimates to the pressure, and that they should not tense their body, which only pushes the abdominal muscles out and pushes my hand off the insertion site, in which case I'll have to push even harder. Fear of the unknown can make it a lot worse on the poor pt.

8. In keeping with that, remind them they should not hold their breath at all. With the pain and pressure, pts tend to hold their breath and tense up, and increases the likelihood they could vagal. I don't know if there's scientific proof for that, but I've never had a vagal in my career yet. (Knocking on wood as I type that.)

9. Don't dare move your hands or even your pinky for the first five minutes or so. "Peeking" or "readjusting" is what most often causes that early hematoma formation while the body is still trying to form a clot. After ten-15 mins or so, I find I can often free one of my hands to manually express any firm areas that might have popped up.

10. If they're hypertensive, get the BP down if you can. Pulling a femoral sheath when the systolic is 180 and up is no fun on your poor arm muscles. Morphine works well as well as being nice to the pt in anticipation of pain, or even putting that nitropaste on a little early.

11. Remember that even a bit of bradycardia will make it a little harder to find the femoral pulse, take your time.

Just my :twocents: . Hope its useful for someone.