When patients have received Plavix® (clopidogrel, Bristol-Meyers Squibb, New York, NY), Integrilin® (eptifibatide, Millenium Pharmaceuticals, Cambridge, MA) or Reopro® (abciximab, Eli Lilly and Co., Indianapolis, IN), the patient is closely observed for the need for additional holding time to prevent bruising and or hematoma. In cases of prolonged bleeding (>30 minutes), a FemoStop® (Radi Medical Systems, Inc., Wilmington, MA) or C-clamp is applied at a non-occlusive pressure for an additional prescribed time until hemostasis has been achieved.

The difficulty that arises when applying these techniques is how do you quantify 75%, 50%, or even 25%? When using two hands, it is difficult to monitor distal pulses unless you lift one hand and change the applied pressure to palpate the dorsalis pedal pulse or have a second nurse on hand to monitor the pulse manually or by Doppler. The problem with the two-nurse technique is that the nurse monitoring the pulse has no idea how much pressure is being applied by you and a miscommunication can decrease accuracy. To apply these principles in manual sheath removal cases, I have been using the bedside pulse oximeter on the distal ipsilateral limb (Figure 1; Note: Unlike the photo shown, the toe used should be clean and free of nail polish.) Applying the probe to the first or second toe serves two functions. First, pulse oximetry is required during conscious sedation recovery. Second, our pulse oximeters give us two visual scales to monitor pulse strength, a wave sweeping across the monitor screen that decreases in amplitude with increases in applied pressure on the artery and a three asterisk (*useful2.jpguseful3.jpguseful4.jpguseful5.jpguseful6.jpg**