A Refresher on Pressure

Jon E. Jenkins, RN, RCIS

In the era of vascular closure devices, the skill of achieving hemostasis by manual compression is almost becoming a lost art. It concerns me to see cath lab personnel that do not have a good technique for manual compression. When those closure devices fail, we need to be confident in our ability to manage hemostasis. Most seem to go with the "brute force" or "monster mash" technique. While this can be effective, it presents some concerns. First, a "brute force" or "monster mash" technique is more uncomfortable for the patient. Second, it tends to cause more bruising and displaces the skin is a way that makes it difficult to assess if a hematoma is developing. Third, this technique is often not effective in our "well nourished" patients (specifically those with a tight, round belly). Finally, it is physically more demanding on the staff and often leads to the excuse "I'm just not strong enough to hold pressure," requiring calling upon your second hand to assist. I learned manual compression in the days before closure devices, when we used 8, 9, and 10 French sheaths for interventions. Not to mention the patients often received 10-15,000 units of heparin during the procedure. So 40 minutes of manual compression was not uncommon. You quickly learn how to "efficiently" pull a sheath. On top of that, I had a physician who taught by "negative or humble" reinforcement, so when I was learning and had difficulty getting control of the bleeding, he would walk over and use one finger to achieve hemostasis. For me, it was a shot to the ego, but more importantly, taught me that technique is the key, not strength. I want to briefly share a few refreshers on manual pressure. Once again, I am pushing the notion that you must think about the process. In your mind, walk through the steps and understand what you are doing. It sounds simple, and if you understand the anatomy and what is being done with the needle and sheath, it all makes sense. When something makes sense, your confidence and technique improve.

1. Consider patient size and the depth of the tissue tract between skin level and the artery. The "classic" instruction was to hold about two finger widths above the skin entry site, but as our population is getting larger, this is not adequate. Think about it. If the typical angle of entry for the access needle is 45 degrees, then the puncture site of the artery is going to vary greatly, depending on the depth of the tissue tract. In a very lean person, you could literally hold right at the skin entry, but take on a large patient and the actual puncture can be a couple of inches above the skin entry site. The thicker the tissue tract, the higher the hold site.

2. Locate the artery! I see many folks just hold "above" the sheath, but as we know, sometimes the skin entry can be well medial or lateral to the actual arterial puncture. Tip: If it is a difficult artery to palpate, apply pressure where you think the artery is and very slowly start pulling the sheath. You should be able to feel the sheath under your fingers. If you feel the sheath, it's got to be over the artery.

3. Fingertips, not all fingers or whole hand. It is much easier to compress a small amount of tissue than a large amount! If you use your whole hand (I've even seen fists used), you are trying to compress a large area of tissue. Try it on a piece of memory foam. Use a couple of fingers and compress it as deeply as you can, then try with your whole fist. You can get much deeper into the foam with your fingertips, rather than your fist. Fingertips allow you to apply very specific, directed pressure to a site. Using your whole hand is just spreading pressure over the area. Truthfully, many times you can pull a sheath and obtain hemostasis with one finger if the artery is located correctly.

4. Consider sheath size and thrombus-altering medications. The bigger the hole, the longer the hold. Heparin, clopidogrel (Plavix), eptifibatide (Integrilin), aspirin, bivalirudin (Angiomax), etc., are all going to affect when and how long you have to hold. Most facilities have protocols for hold times, so please check with yours, but we say for any patient with ACT < 170 and with bivalirudin having been off for at least two hours that you are at 3 minutes for every sheath French size. For example, a 5 French sheath is a 15-minute hold.

5. Don't move your fingers around and only switch hands if you absolutely must. This helps with patient comfort and hemostasis. It has been a very long time since I have had a patient vagal during sheath removal. One reason, I believe, is that repositioning can cause discomfort in our patients. The initial compression often does cause discomfort, but if you will hold steady, the patient will be able to relax.

6. NO PEEKING! Do not let up on the artery to see if it stopped bleeding until your hold time is complete. All your work until then can be reverted back to the beginning. If it is a 15-minute hold, then hold 15 minutes until letting up.

7. Don't let up suddenly. The sudden rush of pressure and blood to the arterial access site can open the site back up. As you begin to let off compression, do it slowly. Certainly there is more to it that this brief blog can cover. The best way to improve your technique is by pulling sheaths. If you have to pull 10-12 sheaths a day, you will develop an efficient method. We had a couple of female techs back in the day that were very petite and couldn't have weighed more that 100 lbs soaking wet.......they could pull sheaths all day. Was it strength that allowed them to do it, or a good understanding of technique? We need to focus on this in our cath labs in order to provide better care and better comfort for our patients if a manual method of hemostasis is used.

What are some tips you all have?