When pulling sheaths after a cath...

[qt2168]

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!

[TLCinCICU]

We pull sheaths nearly every day. Our options are a Compressar clamp, a Femostop, or manual pressure. Sheaths are not to be dc'd until the ACT is

This is basically how I pull them now: I position the patient at the side of the bed and lower the rail where I can stand over the femoral site. (We rarely get brachial sheaths.) I place something under the opposite hip, if necessary, to flatten him/her in the bed. I remove the suture, aspirate the sheath to insure patency, and pull the sheath on expiration. I LOVE using Chitoseal hemostasis pads. They are about the size of an alcohol pad and use ionic attraction to pull clotting factors to the site. Even if a Reopro/Aggrastat/Integreilin/Angiomax is used, the max hold time with a Chitoseal is 20 minutes.

[moonshadeau, ADN, BSN, MSN, RN, APN, NP, CNS]

I found that Datascope makes a really neat device called the Safeguard. It does really cut the time to hold in about half. It is a sterile dressing that looks similar to the femstop, but you can see through the dressing to assess the site. About the only problem that I have had is when there are more than one sheath to pull and then it is a little tricky. But really overall, I have to rate it an 8/10 on ease of use.

After reading some of the posts, are people still actually using sandbags? For a reminder of the patient not to move their leg and not as a pressure device, I hope.

[TLCinCICU]

Our management has passed onto us that sandbags fail to meet Joint Commission standards. They don't allow for the visual check of the site. So we simply aren't allowed to use them any longer.

[Spatialized]

Our management has passed onto us that sandbags fail to meet Joint Commission standards. They don't allow for the visual check of the site. So we simply aren't allowed to use them any longer.

Interesting. Ours simply said the distribution of weight was too uneven and not a direct enough application of weight to the site. I have occasionally used them post-pull (like 3 hours+ in the even of a stubborn re-bleed and like above, use it more as a reminder not to move the leg.

Cheers,

Tom

[TLCinCICU]

I do have a wicked little visual I use in reminding patients not to move their leg while a sheath is still in place - providing they need it. I hold up my pen and say "This is that line in your leg." I then take a paper towel and wrap it around the pen and say "And this is your artery with the line inside it." I then say "You bend and your artery bends, but the line doesn't." while making the pen rip through the paper towel. It tends to make believers out of them.:rotfl:

[BBFRN, BSN, PhD]

I do have a wicked little visual I use in reminding patients not to move their leg while a sheath is still in place - providing they need it. I hold up my pen and say "This is that line in your leg." I then take a paper towel and wrap it around the pen and say "And this is your artery with the line inside it." I then say "You bend and your artery bends, but the line doesn't." while making the pen rip through the paper towel. It tends to make believers out of them.:rotfl:

I love that- great teaching tool.

[nursecass]

All of these replies about having two people in the room are very interesting to me. Really, I was taught to have another person in the room just in case, but when I hit the real world I have found the same thing as QT-no one has the time and will actually come in and stay with me. (Although I have found that since I've been doing that voluntarily for others I now have two other nurses that will come in with me for my pulls without me asking.)

Unfortunately because of the reality of not being able to get anyone in the room with me when I pull I just try to get everything in order before I do it (full NS bag on pump, atropine at bedside, vomit bucket in reach of pt), have the call light handy and tell someone to watch for the call light in room X, because that is me and if I hit it I need help. I know it is not the best scenario, but I really don't know what else to do when people just flat refuse to come into the room with me.

As for stopping the bleeding, maybe try a device if your hospital allows. Also, for arterials remember to feel where the pulse is above the sheath and hold pressure there-not just at the site (if you are doing manual, I've found a fist usually covers both the palpable pulse area and insertion site). And just as everyone above said, getting your body positioning down so you can comfortably hold consistent pressure is key. GL!

[Nightcrawler, BSN, RN]

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!

It is sooo outside our policy to do a line pull by ourselves! You may be able to maintain hemostasis with hand pressure on your own, but what do you do if your patient vagals? You can't give atropine with your fist in their groin!

Even with two people in the room there are times when things go wrong and you end up needing a third pair of hands. For example, last night I did a pull, and when we inflated the femstop, the whole thing slipped and rotated superior to the insertion site. Unfortunately this was on someone that had a known transection of the artery, so we knew that the patient would probably develop a hematoma no matter what we did. We ended up calling a third person into the room so that the assistants could take the femstop off and reposition while I held manual pressure. Once the device was repositioned, the third person left the room.

Our policy says two ACLS nurses in the room, with fluid and atropine at the bedside in case of vagal. I always make sure that I am ultra prepared- everyone gets O2- fluids hung and connected to the patient- suction set up with Jankauer at hand in case of nausea. This way if the patient vagals the second set of hands opens the fluids, gives the Atropine, and you can maintain the airway with the suction in case of nausea without compromising the groin.

Ofcourse that patient last night vagaled as well. Pressure dropped from 140's systolic to low 90's and was symptomatic with nausea and lightheadedness. Pt got 900 of fluids- we were able to hold off to the atropine, but I was glad to have the suction at hand and everything set up.

My patient did fine, even with all of the drama- just a small soft residual hematoma. The best part of the whole situation was that we were able to manage the complications without overly concerning the patient. Because we were prepared we were able to implement protocols seamlessly, and treat the patient.

Please, please, please carefully review and memorize your units policies and procedures. The more sure you are about what you are going to do in any situation, the better you are able to act rather than think. If you are going to pull with hand pressure, be sure that you are able to comforably hold steady pressure.

Until you are more comfortable, maybe you can ask to observe other people in your unit pull their lines. Look at what they do-what techniques that they use. This way they will be able to see that you are working on your technique, and you will be fostering teamwork by being there to help them as much as they help you.

Good luck

[Nightcrawler, BSN, RN]

All of these replies about having two people in the room are very interesting to me. Really, I was taught to have another person in the room just in case, but when I hit the real world I have found the same thing as QT-no one has the time and will actually come in and stay with me. (Although I have found that since I've been doing that voluntarily for others I now have two other nurses that will come in with me for my pulls without me asking.)

Unfortunately because of the reality of not being able to get anyone in the room with me when I pull I just try to get everything in order before I do it (full NS bag on pump, atropine at bedside, vomit bucket in reach of pt), have the call light handy and tell someone to watch for the call light in room X, because that is me and if I hit it I need help. I know it is not the best scenario, but I really don't know what else to do when people just flat refuse to come into the room with me.

As for stopping the bleeding, maybe try a device if your hospital allows. Also, for arterials remember to feel where the pulse is above the sheath and hold pressure there-not just at the site (if you are doing manual, I've found a fist usually covers both the palpable pulse area and insertion site). And just as everyone above said, getting your body positioning down so you can comfortably hold consistent pressure is key. GL!

I know that it can be hard to find another person to spend time in the room with you, but be careful. If your policy states that there must be two nurses in the room and something goes wrong when you do it by yourself- it will be your career on the line. The hospital will not back you up, and the board doesn't care about how no one else had time.

[nursecass]

I know that it can be hard to find another person to spend time in the room with you, but be careful. If your policy states that there must be two nurses in the room and something goes wrong when you do it by yourself- it will be your career on the line. The hospital will not back you up, and the board doesn't care about how no one else had time.

I completely understand what you are saying, but in a case like this how do I go about getting a body in the room with me? I ask people outright ("I'm going into room 20 to pull a sheath, will you come in with me for the first few mintues?"), and I still get the general "Oh, I'll listen from out here, just call me if you need me." How do I go about this without sounding whiney or too pushy and demanding?

Also, I've tried to get the charge nurses to come in with me when I can't get staff, but most of them are so ADD that they will come in for about two minutes, see the sheath come out and then just walk out of the room and disappear. Any advice??? Sorry if I'm high-jacking the thread!

[Nightcrawler, BSN, RN]

I completely understand what you are saying, but in a case like this how do I go about getting a body in the room with me? I ask people outright ("I'm going into room 20 to pull a sheath, will you come in with me for the first few mintues?"), and I still get the general "Oh, I'll listen from out here, just call me if you need me." How do I go about this without sounding whiney or too pushy and demanding?

Also, I've tried to get the charge nurses to come in with me when I can't get staff, but most of them are so ADD that they will come in for about two minutes, see the sheath come out and then just walk out of the room and disappear. Any advice??? Sorry if I'm high-jacking the thread!

I don't know what to tell you. Maybe you can start by being the one to volunteer to be in the room with others for that first 10 minutes. Sometimes the only way to change the culture of a floor is to be the one to start the change.

Ofcourse everything will change immediately if there is a bad result, but that is not the way that anyone wants it to happen

[ghillbert, MSN, NP]

If your unit has a written policy about 2 people in the room, and you request someone to come in and help and they refuse? I would say "Okay, so I will just document that you are too busy to assist, since that's contrary to the protocol". It's hard to be a "troublemaker" but I agree, it's your ass on the line.