The criteria for a sheath pull is whether the patient's blood can hold a clot sufficiently. This is determined by a brief lab test called the ACT, or Activated Clotting Time. If the ACT is 170 seconds or less, it is safe to remove a sheath. Anything greater, the patient's blood is too thin. During the procedure the doctor may infuse a blood thinner, such as Heparin. This medication thins the blood and raises the ACT. Therefore, if the patient comes back and has received heparin, we must test the blood for its ACT. We have a device that does this test. It's helpful we can do this test ourselves.
An alternative to heparin which the doctor may choose is Angiomax. This is a glycoprotein III inhibitor (a.k.a. blood thinner of a different kind) and the body processes it at a much more predictable rate. We wait 2 hours after the Angiomax infusion was discontinued, then it is safe to pull the sheath.
Sometimes the doctor uses no blood thinners, and we can remove the sheath immediately. Sometimes the doctor uses a closure device such as Angioseal or Starclose. Rarely a patient goes directly to surgery or has complication that sends him/her to the ICU. Even more rare, the patient dies. Since I've been working on the unit, this has happened only once.
It's interesting. The patients and their families expect us to know exactly how the day will go for the patient, like when they can eat, go to the bathroom, or go home. Honestly, we don't know a whole lot until the patient comes back from procedure and we know what medications the doctor used and whether a stent was placed. They understand once we explain it.
The Removal Process
Obviously, we only remove a sheath when the patient has one - this procedure is not done for Angioseal and Starclose patients. We love when they use a closure device.
Removing a sheath is a two-person task. One is the cardiotech, who is specifically trained in sheath removal. The other is the nurse who monitors the patient during the process. The cardiotech removes the tubing and holds pressure. The nurse is there because once the sheath is removed the cardiotech MUST NOT UNDER ANY CIRCUMSTANCES let up on the pressure. Otherwise the patient will bleed to death.
The Nurse's Role
So, the nurse is there to record vital signs (which are taken every 5 minutes), administer medications, or address any complications. The medications we typically use are morphine for pain and diazepam (valium) for anxiety. Sometimes we use fentanyl if a patient is allergic to morphine.
We watch for a few types of complications. The most common is a "vagal" which means the process of holding pressure on the groin stimulates the vagal nerve, which in turn lowers the blood pressure and heart rate. The patient may feel nauseous and throw up. The patient may break out in a cold sweat and feel light headed. We have specific protocols for how to address these things. Rarely a patient will pass out.
Because of the possibility of throwing up, the patient is not allowed to eat up until after the manual pressure procedure is completed. Patients hate that, but really, it's better than inhaling your barf and suffocating.
I have observed that if you give a patient both the Morphine and the Diazepam, they tend to vagal more frequently. These meds are depressants, anyway. I am very conservative in my administration of these medications for this reason. We have some flexibility in how much we can administer, so I always start slowly then increase. I can't un-administer!
Other complications include pain and internal bleeding.
For the entire sheath removal process, the nurse must be in the room with the patient. This means I can't care for my other patients. Most often, we help each other care for their other patients while someone's doing a sheath pull; sometimes, a nurse will do the sheath pull for another nurse. But the way things most frequently work out, you are doing a sheath pull when another of your patient arrives on the unit (a prep!), goes to procedure (give report to the lab nurse?), returns from procedure (get report from the lab nurse?), or crashes in one way or another.
You just gotta lean on the team, there's no getting around it. You also are expected to step in when another nurse is so occupied.
Holding Pressure
The tubing is removed and the pressure begins. Initially, it takes a pretty good amount of pressure and it's uncomfortable. For some people it's quite painful. I think it has to do with the patient's tolerance for pain, the location of the puncture and the patient's anatomy - how close the nerves are to the puncture, etc. Who knows this, though?
The pressure goes on for at least 20 minutes for an arterial line, at least 10 minutes for a venous line. If all goes well (as in most cases), the bleeding is stopped and the countdown begins for when the patient can eat and get up. Sometimes it takes longer for the bleeding to stop. If the ACT is too high, the bleeding won't stop any time soon...hence the reason we check ACT.
Holding pressure is a physically demanding task. It is a skill, if it is to be done well. We usually have 2 cardio techs on the unit for this task and they alternate doing the sheath pulls. However, frequently we have a bunch of sheath pulls all at the same time.
Nurses are not trained to do a sheath pull on our unit. Legally, we can be, and I would like to be so trained. I think we don't get the training for managerial reasons; that is, we are more valuable to the unit in our other role. I agree, but it would be nice to have a few back up people trained for those crazy days when we have a bazillion sheaths and only one cardiotech. When that happens, the patients must wait to get their sheaths out, and waiting is a real drag. It lengthens their bedrest period and delays everything from moving along.
If the patient tolerates the procedure well, I usually use the time to catch up on paperwork - generating the shitload of documentation I have mentioned in a previous post. It's a good time to complete the patient profile.
After Hemostatis
Hemostatis is the official term for "the patient has stopped bleeding." This is the moment when we start the countdown for sitting up, eating, and getting off bedrest. The patient must remain straight with legs immobile for the next hour. Even though the puncture is not bleeding, it is delicate. If the patient moves too much or the fragile clot lets go, the patient will bleed internally. They will usually feel it ("Hey, this puncture kind of hurts..., oh, now it really hurts") and a big bulge appears at the puncture (a hematoma). I haven't had one squirt all over the room, but that's possible too.
In this case, we hold more pressure (and it really hurts this time) for another 20 minutes or more, try to work out the blood of the hematoma, and start the countdown all over again.
After one hour post hemostatis, the patient may have the bed raised up 30 degrees and may eat. Bedrest continues and the leg(s) with the punctures must remain still for 5 hours (arterial line) or 3 hours (venous line).
This is the hardest part of the day. Most patients feel fine and want to get up to pee, or whatever. They get bored, especially after they've had some food and there's 4 hours left with nothing to do but watch daytime TV. It is too risky to get up - if they bleed again, then we start the countdown all over again.
Vital signs and Assessment
After hemostatis, we monitor vital signs every 15 minutes for the first hour, then every 30 minutes for 1 hours, then every hour for 4 hours, then every 2 hours for 4 hours, then back to our unit standard of every 4 hours. We also assess the patient's pulses in the foot of the leg with the puncture, and we check the incision for bleeding. We look at lots of groins and palpate lots of feet.
Thoughts on the Sheath Pull
As I've said before, I think the doctors don't emphasize the duration and physical demands on the patient during the post-procedure time. It can be a long time before the patient can eat - for example, if the patient's ACT does not get into the safe zone for a few hours, no eating. Patients must lie flat on their backs for a long time.
Looking back over the last year of many sheath pulls, I have the following observations:
- Skinny little old people seem to have the most difficulty with the pressure (e.g. vagals) and rebleeds. I've had several little old ladies sit up after six hours of bedrest and have their incisions open up internally. Here we go again with the pressure and bedrest. You get a nasty looking bruise if you rebleed.
- Young men are the biggest whiners for pain.
- Some old men are terrible whiners, too.
- Most people do just fine with the process and complying with the instructions.
- Some people are so fat, the nurse must raise the "apron" of fat out of the way so the cardiotech can get his or her hands in the proper position to hold pressure.
- Most people, especially old people, have lousy looking feet. Cracked skin, fungal toenails, stinky. Oh, for heaven's sake, take care of your feet, people!!
Coming soon: The workday, part 4: Afternoon and the end of the Day.
I have to work tomorrow and the next day, so it's unlikely I'll post until Thursday.
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