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.
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.
III.
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
IV.
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.
D.
E.
F.
G.
V.
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).
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.
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.
Personal protective equipment (PPE). Protective glasses and gloves; scrubs due to possible
contamination.
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.
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.
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.
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.
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.
H.
I.
J.
VI.
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
and that settings are as desired.
3.
Assess:
a.
b.
c.
d.
e.
2. Position for direct visualization of
heart rate/rhythm, blood pressure
Heparin off minimum four
hours prior to sheath removal,
or ACT less than, or equal to, 150. Document ACT.
Patient’s I.V. access is patent.
Vital signs and rhythm
Drug Allergies
Groin sites for hematoma
4. Explain procedure to patient
4. Alleviates anxiety and promotes
cooperation.
5. Assess and pre-medicate patient as
ordered, or per protocol. Assure that
Atropine, Epinephrine and intravenous
fluids are immediately available.
5. Pressure on the artery/nerve can induce
a vagal response with bradycardia,
nausea, hypotension, diaphoresis.
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
Legs should be 10 – 12” apart, with
effected foot rotated outward.
circulatory changes and/or mottling of
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/
mask with eye protection .
8. The potential for contact with blood
requires appropriate protection.
9.
Gently remove dressing covering
groin, maintaining stability of sheaths(s).
9. Sheath side arms may adhere to
adhesive dressing.
10. Wipe area with 4x4s if blood present.
11. Palpate femoral pulse. (If unable to palpate,
may check with Doppler.) Clip suture, if
sheath sutured in.
11. This will be the area where
manual pressure is applied post
sheath removal.
12. Document strength of following pulses:
Dorsalis Pedal (left and right)
Post Tibial (left and right)
12. 3+
2+
1+
0+
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,
1 ½” needle.
.
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
inject 2 cc xylocaine causing
formation bleb.
e. Slowly advance needle, while
aspirating syringe, to ½ length
maintaining needle parallel to
sheaths (angle 15-30 degrees).
f. If blood not aspirated, slowly
inject 2 cc xylocaine.
g. Withdraw needle. Change needle.
h. Area Two: 2 mm lateral and
below sheath insertion site, insert
needle at 15 degree angle until tip
is under layer of skin.
i. Repeat steps d-g.
j. Withdraw needle and gently
massage area for thirty seconds.
B.
Normal
Weak
Doppled & present
Absent
b. Small needle minimizes skin
trauma during infiltration
d. If blood appears in syringe,
remove needle, change needle
and insert at alternate site.
f. Total xylocaine 6 cc per site x
two sites.
g. Changing needle with each reinsertion decreases chance of
infection.
j. Massage will disperse the xylocaine into tissue and facilitates
absorption.
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).
Follow as above, under VI.Procedures, A. Local Anesthetic, Steps 2-12
Essential Steps
1. Position gloved fingers on femoral pulse,
2-3cm above arterial sheath site, with one
finger on, or directly below, puncture site.
Key Points/Rationale
1. Pulse check ensures proper
placement of fingers before
sheath removal.
2.
Apply firm pressure with fingers and
gently remove sheath from artery, taking
care not to crush sheath.
2. Crushing sheath may strip clot
into distal artery.
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 resheath 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
and inspect site for 1-2 minutes. If bleeding
occurs, continue pressure at site until hemostasis is achieved.
6. These assessments aid in
decreasing the chances of
post hematoma/bleeding.
7.
When patient has both an arterial & venous
sheath, follow steps as outlined above for
arterial sheath removal; after ten minutes of
pressure for the arterial removal, extend finger
pressure such that it covers the femoral venous
access site and remove the sheath. Hold nonocclusive pressure ten minutes, or until
hemostasis is achieved.
7. Venous pressure is low and
does not require application
of occlusive pressure to achieve
hemostasis.
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,
all “re-bleeds”.
9.
.
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.
If no bleeding or hematoma occurs, apply anti- 9.
bacterial ointment and Bandaid following sheath
removal. Site should be left exposed for first 30
minutes whenever possible (unless family/visitors)
present). One folded gauze pad and an OpSite
may be placed 30” thereafter.
Light dressing allows easy visualization
of any oozing or bleeding at site. Heavier
dressings may block visualization of
bleed.
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
2.
Key Points/Rationale
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
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
steps as outlined above for arterial sheath removal; after ten minutes of pressure for the
arterial removal, apply firm pressure 2 mm
below venous sheath site and remove the sheath.
Hold non-occlusive pressure ten minutes, or
until hemostasis is achieved.
9.
Remove and control arterial
sheath first; then pull venous.
Venous pressure is low and
requires less pressure to
achieve hemostasis.
10. If bleeding should develop once pressure has
been released from either arterial or venous site,
a minimum of ten-twenty minutes of firm
recompression should be applied. If hemostasis
is still not obtained, notify the responsible M.D.
10. Floor nurses who receive
post cath patients should be
comfortable applying additional
pressure. If found, nurse should
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 antibacterial ointment and Bandaid, or one folded
11. Light dressing allows easy
visualization of any oozing or
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 10-20 mmHG above
above systolic blood pressure.
c. Maintain pressure at 10-20 mmHG above
c. When reducing pressure, be
systolic for 3 minutes, maximum. After
sure skin does not pull up into
three minutes, decrease dome pressure
10-20 mmHG below systolic blood pressure.
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.
the dome folds. Gently press
down on skin around the dome.
6.
After a few minutes of observation at zero
pressure, may remove system in following
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.
6. Keep at patient’s bedside, in case
further bleeding occurs.
7.
If no bleeding or hematoma occurs, apply antibacterial ointment and Bandaid, or one folded
gauze pad and OpSite.
7. Light dressing allows easy
visualization of any oozing or
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.
2.
3.
F.
Observe site for bleeding or oozing every 15 minutes x 4; every 30 minutes x 2.
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.
Report any bleeding/oozing to MD for assessment before discharge.
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.
4.
5.
6.
7.
8.
9.
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.
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.
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.
When hemostasis band has been removed, apply light dressing (Bandaid) to site.
Monitor dressing for signs of bleeding for 30 minutes.
Patient should be instructed not to lift with the arm for 24 hours. The dressing can be
removed the next day.
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
1.
2.
3.
4.
5.
6.
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.
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.)
Patient may complain of urinary urgency .
There may be neurological changes noted in the site extremity.
Patient may have a rapidly falling hematocrit post-procedure.
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
4.
5.
6.
7.
8.
9.
Sheath removal time
Amount of time pressure held
Presence of bleeding or hematoma after removal
If FemoStop used, mmHG pressures with time intervals
Patient tolerance of procedure
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)