Ask the Clinical InstructorA Q&A column for those new to the cath lab

There are a number of different ways to pull sheaths and it would be helpful for you to learn the techniques of each. The end result will be the same; the idea is to be as proficient as possible with each of the techniques. I like the techniques that require me to be there with the patient the whole time, which is just a personal preference. Some places use the C-clamp, which is fine if it is used correctly and given the patient is not squirming on the bed, table or wherever they happen to be. Some use the FemoStop which is a nice device when used correctly. As mentioned previously, I like the hand-hold techniques which require me to be at the patient's side constantly so that I can feel the area around the artery and note any changes right away. Things to note when pulling any sheath are: 1. The ACT, if any heparin was given. Be sure to follow the hospital's policy on sheath pulls and appropriate ACT before the pull. 2. Leg color and temperature before sheath pull. If the artery becomes occluded because of distal emboli, the leg will become mottled and cold. If you are unsure, you can always compare it to the unaffected leg. 3. Distal pulses. The pulses should be checked before the procedure even begins. It would be of little help to find out after the sheath pull that there was no pulse if you never checked one in the beginning. What happens then? Was there ever one? Did they have one and lose it? Do you now ask for a vascular ultrasound? 4. How high is the blood pressure? Higher blood pressure make holds more difficult and can take longer to occlude. More attention is needed to these holds. Other factors making holds more difficult: Obesity. Larger patients are harder to hold occlusive pressure on. It may be a long time before you notice that you weren't occlusive and the patient has been bleeding. Calcium on the artery. Calcium on the artery can make it more difficult to compress. Patients who move. People with back problems, restless legs, paradoxical effects to sedations and non-compliant patients in general will tend to move their legs and either move the clamp, move the position of the artery, dislodge Vaso-Seals, D-stats, etc. allowing the artery to bleed. All of that being said, check the site often. Know what it looked like beforehand and know how it is during and after. Be sure to give clear instructions about not lifting heads or moving legs. Anything warm and wet should be called to someones attention. Regardless of which way you close the artery, make sure it is done safely. Still learning about the wide variety of patients that visit the cath lab? Could your question be one that others share as well? CLD can help. Submit your question to: Jason Wilson, RCIS at hrtfixr7 (at) yahoo. com

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