CARDIOLOGY FEMORAL SHEATH REMOVAL PROTOCOL

Transcription

1 Revised 9/10/03 CARDIOLOGY FEMORAL SHEATH REMOVAL PROTOCOL I. Outcome Goals: A. Patients having diagnostic and/or interventional cardiac procedures will: 1. Be free of significant hematoma 2. Have adequate tissue perfusion 3. Have absence of bleeding 4. Have absence of vasovagal response 5. Be free of chest pain 6. Have catheter site discomfort kept to a minimum II. III. IV. Specific Information: A. Does implementation require an M.D. order? Yes X B. Guidelines applicable to: Adult cardiology patients X Femoral Sheaths related to invasive cardiology procedures only X C. May be performed by: R.N. X Other licensed staff (special procedures technologist, registered cardiovascular technologist) X Non-licensed staff who are trained in this procedure (care partner, EKG technician, scrub technician X D. Specific education required. Successful completion of: 1. Competency based sheath removal program a. Completion of didactic training course b. Sheath removal exam with >90% score c. Removal of sheaths on ten patients (two of which should be done using a C-Clamp) under direct supervision of a cardiologist or qualified R.N., meeting critical behaviors on performance checklist. 2. The above training must be completed within a three month period of time. If this does not occur, all of the training listed in #1 will have to be repeated. 3. Competency must be maintained by removal of at least five femoral sheaths monthly. If the minimum requirement is not met for three consecutive months, supervised sheath removal must be done until competency is confirmed. 4. Annual competency performance credentialing. Equipment A. Sheath Removal Supplies to include: gauze, Betadine ointment, Op-Site, glasses (or protective other eyewear), gloves B. C-Clamp or Femostop, if need anticipated C. Medications which may be needed D. Emergency medications/equipment readily available Definitions: A. Free of significant hematoma. Significant hematoma is defined as a swelling or mass of blood (10 cm or greater) confined to an area of tissue or space, as determined by site observation and palpation. B. Adequate tissue perfusion. Adequate perfusion is defined as the presence of distal pulses as detected by palpation or Doppler examination and the presence of adequate color, motion, temperature, and sensation in the involved extremity. C. Absence of bleeding. Bleeding is defined as inadequate hemostasis after the application of pressure for at least twenty minutes.

2 D. Absence of vasovagal response. Vasovagal response is defined as the presence of two or more of the following indicators, either during sheath removal or while pressure is being applied to the site: a) decreased level of consciousness, nausea and vomiting, and cold, clammy, pale skin; b) decrease in blood pressure to less than 100mmHg systolic or greater than 15% decrease from baseline; c) decrease in heart rate to less than 60 beats per minute (or if the heart rate is less than 60 initially, a decrease of more than 15% from baseline). E. Free of chest pain. Chest pain is usually described as a discomfort, pressure, or tightness in chest, arms, or jaw. If chest pain occurs during or following sheath removal, it may be due to abrupt closure of the coronary artery and require return to cath lab. F. Minimal catheter site discomfort. Mild to moderate discomfort is expected with sheath removal. Local anesthetic and pre-procedure analgesics are given to minimize pain, when needed. G. Personal protective equipment (PPE). Protective glasses and gloves; scrubs due to possible contamination. V. Protocol A. Criteria for Sheath Removal 1. M.D. has written specific orders regarding time of sheath removal or an ACT (value <150) has shown that the sheath may be safely removed sooner. 2. Heparin must be off a minimum of four hours before sheath removal, or an ACT (value <150) has shown that the sheath may be safely removed sooner. 3. A physician familiar with potential complications and their treatment must be immediately available throughout the sheath removal procedure. After hours this physician will be the on call Harrison resident and Harrison Cardiology Fellow, who are on site, with immediate phone backup by the Interventional Cardiology Fellow on call. 4. Any problems (daytime hours) during, or after, sheath removal, RN will notify appropriate diagnostic cardiology fellow, or interventional cardiology fellow identified in post orders; after hours, the interventional fellow on call should be notified. The fellow will notify attending when needed. (Any RN who has unresolved issues may also call attending, when deemed necessary.) 5. Cardiology sheath removal personnel will only remove femoral sheaths related to invasive cardiology procedures. B. Exclusion Criteria 1. Sheaths must be removed by the M.D. with assistance of the sheath removal personnel, if available, under the following circumstances: a. Arterial sheath(s) equal to, or larger than, 9.0 French b. Sheath(s) placed through Dacron graft c. Sheath(s) with temporary transvenous pacing wire or Swan-Ganz catheter d. Expanding hematoma at sheath site e. Significant changes in circulatory status of the extremity f. Cardiology fellow will remove sheath(s) between hours of 11PM and 7AM g. Others as indicated by M.D. C. All patients will be placed on a bedside monitor for direct visualization of heart rate, rhythm and blood pressure (cycled every 5 minutes) during sheath removal. D. Local anesthetic will be administered by R.N. or M.D. only, when patient has been out of cath lab longer than one hour, or if deemed necessary. E. There will be one credentialed staff and one additional staff member at bedside during the first five minutes of removal of sheath. After this interval, the second person remains readily available to person who continues to hold pressure for the time required to obtain hemostasis. (Minimally twenty minutes for arterial stick; ten minutes for venous stick.) F. If vasovagal response occurs during or after sheath removal, the R.N. will initiate treatment as outlined in vasovagal response protocol (See VI, G). G. Role of the non-credentialed primary nurse on 7N/CCU/MICU: 1. Obtain pre-procedure medications (assess need for Lidocaine &/or Fentanyl). 2. Assure sheath removal supplies (suture removal kit, gauze tubs x 2, Betadine ointment, OpSite) are at bedside prior to sheath removal. 3. Attach patient to bedside monitor and automatic blood pressure cuff; cycle for every 5 minutes VS during sheath removal.

3 VI. 4. Primary nurse to remain at bedside as second person during first five minutes following sheath removal and to be readily available, if needed during remainder of time pressure is being held. 5. Post procedure assessments and documentation. H. Role of sheath removal R.N. (who must be certified in sheath pulling, as described in II, D) 1. Pre/intra-procedure assessment of patient 2. Documentation 3. Administration of local Xylocaine &/or I.V. Fentanyl 4. Removing, or assisting other person, removing the sheath 5. Proper application of C-Clamp, if M.D. deems necessary for prolonged pressure. 6. Proper application of FemoStop, if M.D. deems necessary for surface oozing or for prolonged pressure. 7. Report to primary nurse on floor, if other than sheath removal nurse. I. Role of sheath removal care partner or technician. (who must be certified in sheath pulling, as described in II, D) 1. Proper application of manual pressure during procedure 2. Removing, or assisting RN, in removal of femoral or neck sheath(s) 3. Proper application of C-Clamp, if M.D. deems necessary for prolonged pressure. 4. Proper application of FemoStop, if M.D. deems necessary for surface oozing or for prolonged pressure. 5. Report to primary nurse on floor, if other than sheath removal nurse. J. Patient(s) having diagnostic catheterizations only, and/or patients going to the holding room for immediate sheath removal may not require local anesthethic at groin site. This will be at discretion of credentialed personnel after assessment to patient s comfort needs. Procedures A. Local Anesthetic (to be administered by RN or MD only) Essential Steps Key Points/Rationale 1. Gather equipment a. Personal Protective Equipment (PPE) b. Pre-medications c. Atropine, Epinephrine readily available d. C-Clamp, FemoStop if ordered e. Doppler and gel, if needed f. Suture removal kit, if sheath sutured in 2. Assure patient connected to monitor 2. Position for direct visualization of and that settings are as desired. heart rate/rhythm, blood pressure 3. Assess: a. Heparin off minimum four hours prior to sheath removal, or ACT less than, or equal to, 150. Document ACT. b. Patient s I.V. access is patent. c. Vital signs and rhythm d. Drug Allergies e. Groin sites for hematoma 4. Explain procedure to patient 4. Alleviates anxiety and promotes cooperation. 5. Assess and pre-medicate patient as 5. Pressure on the artery/nerve can induce ordered, or per protocol. Assure that a vagal response with bradycardia, Atropine, Epinephrine and intravenous nausea, hypotension, diaphoresis. fluids are immediately available. 6. Position the patient flat on his/her back, 6. Allows easy access and visibility of with effected leg exposed groin to toes. femoral site; provides visibility for

4 Legs should be apart, with circulatory changes and/or mottling of effected foot rotated outward. lower extremity; provides for proper hand/body positioning of sheath puller. Outward rotation of foot helps move ligament away from femoral artery in groin area. 7. Review physician order for sheath pull. 8. Wash hands, don gloves and glasses/ 8. The potential for contact with blood mask with eye protection. requires appropriate protection. 9. Gently remove dressing covering 9. Sheath side arms may adhere to groin, maintaining stability of sheaths(s). adhesive dressing. 10. Wipe area with 4x4s if blood present. 11. Palpate femoral pulse. (If unable to palpate, 11. This will be the area where may check with Doppler.) Clip suture, if manual pressure is applied post sheath sutured in. sheath removal. 12. Document strength of following pulses: Normal Dorsalis Pedal (left and right) 2+ Weak Post Tibial (left and right) 1+ Doppled & present 0+ Absent 13. Give pre-meds, if needed a. Local anesthetic: (2 areas) b. Draw up 12cc 1% Xylocaine using 20 ga needle. Change to 25 ga, b. Small needle minimizes skin 1 ½ needle.. trauma during infiltration c. Area One: 2 mm medial and above sheath insertion site, insert needle at 15 degree angle until tip is under layer of skin. d. Aspirate syringe, then slowly d. If blood appears in syringe, inject 2 cc xylocaine causing remove needle, change needle formation bleb. and insert at alternate site. e. Slowly advance needle, while aspirating syringe, to ½ length maintaining needle parallel to sheaths (angle degrees). f. If blood not aspirated, slowly f. Total xylocaine 6 cc per site x inject 2 cc xylocaine. two sites. g. Withdraw needle. Change needle. g. Changing needle with each reh. Area Two: 2 mm lateral and insertion decreases chance of below sheath insertion site, insert infection. needle at 15 degree angle until tip is under layer of skin. i. Repeat steps d-g. j. Withdraw needle and gently j. Massage will disperse the xylomassage area for thirty seconds. caine into tissue and facilitates absorption. B. Removal of sheath(s) using Manual Pressure (first method of choice) R.N. will assess patient and is responsible for documentation. R.N., technician or care partner will remove arterial/venous sheath(s).

5 Follow as above, under VI.Procedures, A. Local Anesthetic, Steps 2-12 Essential Steps Key Points/Rationale 1. Position gloved fingers on femoral pulse, 1. Pulse check ensures proper 2-3cm above arterial sheath site, with one placement of fingers before finger on, or directly below, puncture site. sheath removal. 2. Apply firm pressure with fingers and 2. Crushing sheath may strip clot gently remove sheath from artery, taking into distal artery. care not to crush sheath. 3. Release pressure enough to allow small 3. Purges any retained thrombi spurt of blood from artery when sheath pulled. resulting from sheath in artery. When the patient has two, or more, sheaths, Remove and control arterial Steps as outlined above for arterial sheath re- sheath first; then pull venous. moval; after ten minutes of pressure for the Venous pressure is low and arterial removal, apply firm pressure 2 mm does not require application below venous sheath site and remove the sheath. of pressure to achieve hemostasis. Hold non-occlusive pressure for additional ten minutes on both sites, or until hemostasis is achieved. 4. Note time and apply firm finger pressure to 4. Pressure controls bleeding and occlude distal pulse for five minutes. Continue promotes hemostasis. Mottling firm pressure (permitting distal pulse) for an may occur during the first five additional fifteen minutes (total of twenty minutes of pressure; should be minutes), or until hemostasis is achieved. alleviated when pressure May use gauze sponges to wipe blood from slightly reduced after first five groin area during this period, but do not minutes and distal circulation obstruct visualization of puncture site. is restored. **Note: Once sheath is removed and occlusive pressure has been initiated, sheath puller should use second hand on top of first hand to support pressure. 5. Interventional patients will require forty minutes of pressure. May use manual, C-Clamp, or combination. 6. Remove hand slowly after holding pressure 6. These assessments aid in and inspect site for 1-2 minutes. If bleeding decreasing the chances of occurs, continue pressure at site until hemo- post hematoma/bleeding. stasis is achieved. 7. When patient has both an arterial & venous 7. Venous pressure is low and sheath, follow steps as outlined above for does not require application arterial sheath removal; after ten minutes of of occlusive pressure to achieve pressure for the arterial removal, extend finger hemostasis. pressure such that it covers the femoral venous access site and remove the sheath. Hold nonocclusive pressure ten minutes, or until hemostasis is achieved. 8. If bleeding should develop once pressure has 8. Floor nurses who receive been released from either arterial or venous site, post cath patients should be a minimum of twenty minutes of recompression comfortable applying should be applied. Notify fellow for any and additional pressure. If found,

6 all re-bleeds.. nurse should immediately glove, remove dressing, apply direct pressure to site (without leaving the patient s bedside) until hemostasis obtained. Additional personnel should be asked to contact cath lab charge nurse and responsible cardiac fellow, who will assess hemostasis. Dressing should be re-applied. 9. If no bleeding or hematoma occurs, apply anti- 9. Light dressing allows easy visualization bacterial ointment and Bandaid following sheath of any oozing or bleeding at site. Heavier removal. Site should be left exposed for first 30 dressings may block visualization of minutes whenever possible (unless family/visitors) bleed. present). One folded gauze pad and an OpSite may be placed 30 thereafter. 10. Site should be visually monitored and palpated every 15 minutes x 4; every 30 minutes x 2; then, hourly for remainder of patient s down time. Distal pulses should be palpated, as above. Both site status and distal pulses should be documented at each time point. 11. Patients will remain in holding room for minimum of thirty minutes after hemostasis has been obtained. 12. Patients are generally at bedrest for generally four hours post cath sheath removal, or six hours post intervention sheath removal If admitted and patient still on down time, person transporting patient to floor via stretcher should have floor nurse receiving patient to view and confirm site status before leaving patient. This should be documented on appropriate Progress Note in an effort to decrease the chance of an unrecognized hematoma or bleed. In the event of any bleeding/oozing immediately following transfer to bed, cath lab staff will stay with patient and apply pressure; floor nurse will notify MD to formulate plan of care for patient. C. Removal of Femoral Sheath(s) using C-Clamp (CompressAR Disc System) R.N. will assess patient and is responsible for documentation. RN, or other appropriately trained personnel, will properly place C-Clamp on patient. Follow as above, under VI. Procedures, A. Local Anesthetic, Steps 2-12 Essential Steps 1. Gather equipment needed to bedside a. C-Clamp b. Sterile Disc c. Gauze d. Dressing supplies Key Points/Rationale 2. Position patient, as outlined in Manual pull, for easy access before using C-Clamp 3. Position C-clamp: Place metal base on flat surface directly under sheet below patient, or mattress, directly below hip. Place sterile disc firmly on tip of arm slide using care to keep bottom of disk

7 sterile.. 4. Assess patient s comfort and give pre-meds, if needed. 5. Locate femoral arterial pulse by manual palpation and press CompressAR arm downward, making sure puncture site is centered in the disc; fingers of disk should be pointed toward opposite shoulder of patient. (Pannus, or large abdomen may need to be retracted with 4 tape across abdomen.) 6. Clamp and disc are then pushed to within several cm above skin and the sheath(s) removed. (Hand closest to patient s head is used to compress access site, as sheath(s) are removed and C-Clamp is further depressed.) 7. Note time; C-Clamp and disc are depressed firmly 7. Pressure controls bleeding and enough to obliterate distal pulses for first 5 minutes. promotes hemostasis. Mottling After first five minutes, gently raise C-Clamp arm to may occur during the first five a 45 degree angle and depress, releasing small amount minutes of pressure; should be of pressure and permitting distal pulse. After another alleviated with reduction of five minutes, release pressure, using same technique, pressure and subsequent for second time. Five minutes later, do third release restoration of distal circulation. and maintain at this pressure for remaining compression Leg may appear darker as long time, or until hemostasis is achieved. As pressure is held, as venous circulation may be impaired during this time. 8. Gradually release pressure by slowly raising and lowering therelease Lever, located directly above the arm. Final release should occur when hemostasis is complete and pulses are palpable. When attempting to remove disk, gently slide fingers beween disk and skin to release. May support by compressing pulse point until fully released. 9. When patient has two, or more, sheaths, follow 9. Remove and control arterial steps as outlined above for arterial sheath re- sheath first; then pull venous. moval; after ten minutes of pressure for the Venous pressure is low and arterial removal, apply firm pressure 2 mm requires less pressure to below venous sheath site and remove the sheath. achieve hemostasis. Hold non-occlusive pressure ten minutes, or until hemostasis is achieved. 10. If bleeding should develop once pressure has 10. Floor nurses who receive been released from either arterial or venous site, post cath patients should be a minimum of ten-twenty minutes of firm comfortable applying additional recompression should be applied. If hemostasis pressure. If found, nurse should is still not obtained, notify the responsible M.D. immediately glove, remove dressing, apply direct pressure to site (without leaving patient s bedside) until hemostasis obtained. Re-apply dressing. 11. If no bleeding or hematoma occurs, apply anti- 11. Light dressing allows easy bacterial ointment and Bandaid, or one folded visualization of any oozing or

8 gauze pad and OpSite. bleeding at site. Heavier dressings may block visualization of bleed. 12. Clamp must be cleaned thoroughly after each use. Contraindications for C-Clamp use: 1. The inability to adequately compress due to a. marked obesity b. coexisting very large hematomas, or expanding hematomas c. excessive pain or discomfort (despite anesthetics/analgesics) 2. Femoral artery graft or vein graft due to the risk of damage 3. Patients not suitable for compression of their femoral artery due to leg edema, femoral nerve compression or arterial obstruction 4. Severe peripheral vascular disease due to risk of arterial thrombosis 5. Critical limb ischemia 6. Overlying skin necrosis and/or infection 7. Arterial injuries above or near the inguinal ligament D. Removal of Femoral Sheath(s) using FemoStop R.N. will assess patient and is responsible for documentation. RN and care partner/technician will properly place FemoStop on patient. RN will regulate mmhg pressure on FemoStop manometer. RN, technician or care partner will remove arterial/venous sheath(s). Follow as above, under VI. Procedures, A. Local Anesthetic, Steps 2-12 Essential Steps Key Points/Rationale 1. Gather equipment needed to bedside. a. FemoStop device b. FemoStop gauge c. Gauze d. 10cc syringe e. Dressing supplies 2. Position the belt under the patient s hips, making sure it is straight with no crimps 3. Assess patient s current blood pressure. 4. Remove FemoStop compression arch from sterile pouch. Position the center of the dome slightly superior and medial to the puncture site(s). 5. Thread belt through the arch by fully pressing and releasing side arm locks. Adjust belt from both sides until arch fits snugly and comfortably around patient. (Sheath hubs should be withdrawn until they are clear of dome rim.) a. Attach plastic tubing to pump and secure connections tightly. b. Inflate dome to 80 mmhg and remove b. Anticipate a small spurt arterial sheath. Continue to inflate until of blood from the artery 20 mmhg above systolic blood pressure and/or vein as the sheaths or until hemostasis is achieved. are removed. Bleeding can be expected until FemoStop pressure is mmhg above above systolic blood pressure. c. Maintain pressure at mmhg above c. When reducing pressure, be systolic for 3 minutes, maximum. After sure skin does not pull up into

9 three minutes, decrease dome pressure the dome folds. Gently press mmhg below systolic blood pressure. down on skin around the dome. Leave at this pressure for fifteen minutes, ensuring distal pulses are present. After this time, slowly release dome pressure, observing the site for bleeding and maintaining hemostasis. Continue until dome is completely deflated. **Note: Manometer should be at 60 mmhg and pedal pulses noted to be present before leaving bedside for any reason. 6. After a few minutes of observation at zero 6. Keep at patient s bedside, in case pressure, may remove system in following further bleeding occurs. manner. Carefully loosen the belt on the puncture side of the patient (without totally removing it from the arch) and gently roll the dome off the site. At same time, use a gauze pad to ensure the blood clot stays with the wound. Without completely removing the belt, move the arch so that it is clear of the area. 7. If no bleeding or hematoma occurs, apply anti- 7. Light dressing allows easy bacterial ointment and Bandaid, or one folded visualization of any oozing or gauze pad and OpSite. bleeding at site. Heavier dressings may block visualization of bleed. Contraindications for FemoStop use: 1. The inability to adequately compress due to a. marked obesity b. coexisting very large hematomas, or expanding hematomas c. excessive pain or discomfort (despite anesthetics/analgesics) 2. Femoral artery graft or vein graft due to the risk of damage 3. Patients not suitable for compression of their femoral artery due to leg edema, femoral nerve compression or arterial obstruction 4. Severe peripheral vascular disease due to risk of arterial thrombosis 5. Critical limb ischemia 6. Overlying skin necrosis and/or infection 7. Arterial injuries above or near the inguinal ligament E. Treatment Post Angio-Seal or Perclose Deployment 1. Observe site for bleeding or oozing every 15 minutes x 4; every 30 minutes x Patients may ambulate after two hours down time post diagnostic procedure; four hours down time after interventional procedure. Site should be observed for 30 minutes post ambulation before discharging patient. 3. Report any bleeding/oozing to MD for assessment before discharge. F. Treatment Post Radial Band Placement 1. No blood pressure readings, lab draws or I.V. access in the arm. 2. Evaluate access site for bleeding every 15 minutes x 4; every 30 minutes x 2 and every hour until the hemostasis device is removed, and document. If bleeding occurs, apply adequate manual pressure for hemostasis and reapply the radial band for one hour. 3. Assess the arm for ulnar pulse, color, blood return, numbness and pain.

10 4. Limit movement in the arm for 2 to 5 hours. If necessary, place the wrist on an arm board or put the arm in a sling to restrict movement. 5. Place pulse oximeter on thumb of hand used for procedure and notify MD immediately if evidence of decreased pulse, color change or pain in hand. 6. Leave the hemostasis band intact for sixty minutes after sheath is removed. Then loosen the device two notches every 15 minutes until it is loose enough to remove. (Post interventional band should be left in place for two hours, then release two notches every 30 minutes.) If bleeding occurs, apply adequate manual pressure for hemostasis and reapply the radial band for one hour. 7. When hemostasis band has been removed, apply light dressing (Bandaid) to site. Monitor dressing for signs of bleeding for 30 minutes. 8. Patient should be instructed not to lift with the arm for 24 hours. The dressing can be removed the next day. 9. Patient may experience slight tenderness at site or tingling of fingers and hand for up to three days. Patient should report any symptoms other than above to their doctor. G. Treatment of Vasovagal Response during or after Femoral Sheath Removal 1. While maintaining groin pressure, place patient in Trendelenburg position. 2. Administer 1.0 mg Atropine IV push. Note time given. 3. Infuse up to 250 cc saline bolus ( or.45% NS ) in increments of 125cc. (If patient continues to have problems, change to normal saline.) 4. Notify MD of patient s condition and response to above measures. 5. If patient is on nitroglycerin drip, turn off drip immediately. 6. Call MD for orders to DC or restart NTG drip once pressure is > 100mmHG systolic. 7. If patient remains bradycardic, repeat 1.0 mg Atropine after 5 minutes (total 2.0 mg). H. Treatment of Hematoma Pre, During or Post Sheath Removal 1. Firm manual pressure should be immediately applied to hematoma site, using consistent and continous pressure. a. If sheath still in place and hematoma is expanding, MD (appropriate fellow) is notified and the sheath should be removed as soon as possible, regardless of ACT. b. If during sheath removal reposition fingers to obtain control of bleed; call for help if needed; notify appropriate MD (fellow) if unable to get control, or if hematoma is expanding. c. If occurs after sheath removal, apply firm manual pressure over puncture site for additional twenty minutes or until hemostasis is obtained. Appropriate MD should be notified re hematoma. 2. Medicate patient, if needed, per doctor s order. 3. After hemostasis is achieved, apply firm, and not occlusive (do not occlude distal pulses), pressure to hematoma site to disseminate hematoma into tissue. Do not attempt to squeeze or express existing hematoma out of the puncture site, as this could cause unnecessary trauma to the artery. 4. Mark edges of hematoma, if able to determine these, for evaluation of further bleeding. 5. Educate patient regarding signs of expanding hematoma or bleeding. If patient admitted, or an inpatient, verify edges with receiving floor nurse. 6. Document in patient s chart. I. Risk of Retroperitoneal Hematoma Retroperitoneal hematoma or bleed is a potential complication of femoral artery puncture and is thought to result from a puncture of the external iliac artery above the level of the inguinal ligament. This site of puncture provides no bony support to help secure hemostasis during sheath removal. Retroperitoneal hematoma can occur when the sheath is still in place. It may also be associated with full anticoagulation. Other predictors include: female gender, low platelet count, anticoagulation, large sheath size, and delayed sheath removal. Clinical presentation (usually within 12 hours of the procedure) ranges from

11 1. Mild hypotension or anemia, to uncontrolled hemorrhage with severe hemodynamic instability. If the low blood pressure responds to a fluid challenge and then drops again, there is a high suspicion for a retroperitoneal bleed. 2. Patient may complain of back, flank, lower abdominal quadrant, suprainguinal, or leg pain. (Patients will frequently hold their hip in flexion to reduce traction on the nerve roots.) 3. Patient may complain of urinary urgency. 4. There may be neurological changes noted in the site extremity. 5. Patient may have a rapidly falling hematocrit post-procedure. 6. Examination reveals supra-inguinal fullness and tenderness. Immediately notify procedural MD if suspect any of above. Evaluation and treatment should include: 1. CT scan or Ultrasound of abdomen 2. Close monitoring of patient 3. If sheath in place or recently removed, consider the need to apply direct manual pressure to groin site; do not obstruct view of site with heavy dressings. 4. Discontinuation of anticoagulation. 5. IV volume replacement 6. Possible blood transfusions (usually if HCT is less than 25) 7. Rarely, but possibly vascular surgery VII. Nursing Implications to Sheath Removal Process: A. Explain procedure to patient. B. Assess puncture site(s) prior to sheath removal. C. If patient does not have a Foley or condom catheter, ask patient to void before sheath removal. D. Notify MD for any of the following: 1. Vasovagal response 2. Development of expanding hematoma (before, during or after sheath removal). 3. Inadequate hemostasis with the application of pressure, either manually or other mechanical compression device. 4. Loss of pedal pulses, changes in circulatory status of affected extremity. 5. Re-bleed of any type post compression. E. Assess and document baseline parameters pre, during compression and post compression: 1. Presence and quality of dorsalis pedis (DP) and posterior tibial (PT) pulses. 2. Temperature and sensation of extremities. 3. Vital signs. F. Monitor groin site, DP and PT pulses, level of comfort, vital signs every 5 minutes during compression; every 15 minutes x 4, every 30 minutes x 2, every 1 hour x 2 post compression time. Patient may be transported to floor 30 minutes after completion of compression. G. Primary nurse on unit who receives patient, and cath lab personnel who transports patient, should visualize site for bleeding or hematoma when transfer to bed is accomplished, and document appropriately on Progress Notes. H. Documentation should include: site status after transfer to bed from stretcher, blood pressure and pulse upon arrival to bed, and distal pulses (Scale for documentation of pedal pulses: (0) absent, (1+) present with Doppler, (2+) palpable, diminished, (3+) palpable, strong). Names of both parties should be included in documentation. I. Floor nurses will assume responsibility for patient when Cath Lab personnel have left the floor to return to Lab. Should any re-bleeding or oozing or other problems occur, floor nurse should remain at bedside, holding manual pressure and have someone immediately call appropriate MD (fellow). VIII Documentation A. Procedure note 1. Explanation of procedure to patient 2. Pre-procedure vital signs, pulse checks, level of consciousness 3. Pre-medications including local anesthetic

12 4. Sheath removal time 5. Amount of time pressure held 6. Presence of bleeding or hematoma after removal 7. If FemoStop used, mmhg pressures with time intervals 8. Patient tolerance of procedure 9. Patient teaching a. Notify nurse for bleeding, tightness, pain or pressure in groin b. Notify nurse for chest or flank pain, or other discomforts 10. Vital signs per protocol. IX Patient/Family Education A. Procedure expectations B. Purpose and function of pressure to be used C. Bedrest, with head down and affected leg straight for 2 6 hours. D. How to support groin area with pressure if cough, laugh or sneeze. E. Removal of dressing and shower the following AM F. Notify nurse for any of following: 1. Sensation change in affected extremity, i.e., cold, tingling, burning, numbness, pain 2. Warm, moist sensation in groin area that could be bleeding 3. Pressure and hardness in area of sheath (hematoma) 4. Chest discomfort, or low back or flank pain (retroperitoneal hematoma)