SHEATH PULL PROTOCOL 9.10.03 cath lab - …

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. Specific Information: A. Does implementation require an 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: 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.)

2 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 , 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.

3 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. 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).

4 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. 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.

5 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 with assistance of the SHEATH removal personnel, if available, under the following circumstances: a. Arterial SHEATH (s) equal to, or larger than, French b. SHEATH (s) placed through Dacron graft c.

6 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 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 or 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.)

7 F. If vasovagal response occurs during or after SHEATH removal, the 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. H. Role of SHEATH removal (who must be certified in SHEATH pulling, as described in II, D) 1. Pre/intra-procedure assessment of patient 2.

8 Documentation 3. Administration of local Xylocaine &/or Fentanyl 4. Removing, or assisting other person, removing the SHEATH 5. Proper application of C-Clamp, if deems necessary for prolonged pressure. 6. Proper application of FemoStop, if 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 deems necessary for prolonged pressure. 4. Proper application of FemoStop, if 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.

9 This will be at discretion of credentialed personnel after assessment to patient s comfort needs. 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 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 access is patent. c. Vital signs and rhythm d. Drug Allergies e. Groin sites for hematoma 4.

10 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 Legs should be 10 12 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.