Arterial and Venous Sheath Removal
The number of endovascular procedures performed by cardiologists and vascular surgeons has dramatically increased in the past decade. Following these procedures, arterial sheaths, venous sheaths, or both may be left in place. Removing the sheath may improve patient comfort and shorten the amount of bed rest required, which can lead to positive patient outcomes. However, sheath removal isn’t without risk, and nurses need appropriate training for the procedure.
Various methods help control bleeding following sheath removal, including manual compression (used alone or with a hemostasis pad), mechanical compression devices, collagen plug devices, or percutaneous suture-mediated closure devices. Manual compression can cause fatigue and injury, possibly leading to carpal tunnel problems for the health care worker applying the compression. Mechanical compression techniques help prevent such problems and effectively prevent hematoma formation.
Equipment
Gloves ▪ gown ▪ goggles or face shield with mask ▪ electrocardiogram (ECG) monitor ▪ blood pressure monitor ▪ permanent marker ▪ antiseptic solution (chlorhexidine-based skin preparation) ▪ sterile gauze ▪ sterile gloves ▪ suture removal kit (if the sheath is sutured in place) ▪ hypoallergenic tape ▪ linen-saver pad ▪ sterile saline solution (if using noninvasive hemostasis pad) ▪ transparent dressing (if using noninvasive hemostasis pad) ▪ Optional: mechanical compression device, noninvasive hemostasis pad.
Preparation of Equipment
Perform hand hygiene1,2,3 and bring the equipment to the patient’s bedside. Using sterile technique, open the suture removal kit and gauze packages and place them within reach. If a hemostasis pad is being used, open it using sterile technique and open the normal saline solution. (See “Sterile technique, basic,” page 671.)
Implementation
Verify the doctor’s order for sheath removal.
Confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.4
Preparing for Sheath Removal
Explain the procedure to the patient to reduce anxiety and enhance cooperation. Include activity restrictions, discomfort caused by pressure to the site, and signs and symptoms to report following the procedure.
Before sheath removal, assess for bleeding disorders and check the patient’s platelet count, prothrombin time, International Normalized Ratio, partial thromboplastin time, complete blood count, and activated clotting time to assure that hemostasis can be achieved.
Obtain vital signs, and check the ECG to establish a baseline. Check that systolic blood pressure is less than 150 mm Hg to facilitate hemostasis.
Assess neurovascular status in the extremity distal to the sheath insertion site to establish a baseline.
Mark the pulses distal to the sheath insertion site using a permanent marker to facilitate finding the pulses.
Administer an analgesic 20 to 30 minutes before the procedure to promote patient comfort.
Confirm that the patient has a patent IV catheter in case emergency fluids or medications are required.
Position the patient with the head of the bed flat to promote hemostasis.
Place the linen-saver pad underneath the affected extremity to keep the bed linen clean and to provide a place to set the sheath after removal.
If a mechanical compression device is being used, place it under the patient before sheath removal to reduce patient movement and the risk of bleeding after the sheath is removed.
If the sheath is sutured in place, open the suture removal kit using sterile technique.
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