Ask the Clinical Instructor

Ask the Clinical Instructor: A Q&A column for those new to the cath lab

Questions are answered by: Todd Ginapp, EMT-P, RCIS, FSICP
Questions are answered by: Todd Ginapp, EMT-P, RCIS, FSICP
Todd is the Cardiology Manager for Memorial Hermann Southeast in Houston, Texas. He also teaches an online RCIS Review course for Spokane Community College, in Spokane, Washington, and regularly presents with RCIS Review Courses. “When you have an arterial and a venous sheath in the same site, which one do you pull first and why? At what point do you pull the ‘other’ line?” – Mike Kashin, Provena Hospital, Illinois Removal of co-existing arterial and venous sheaths can be a simple process, but, at times, it does require some critical thinking skills. As with many skills, it isn’t the skill itself that is a challenge, but it is the determination of if, or when, to perform a certain skill. Hopefully we can work through this so you can use the information in the future. There can be times that two sheaths are in place at the same time. Some of those reasons can include left and right heart catheterizations, venous access through the femoral route and electrophysiology cases. If a vascular closure device cannot be utilized for the arterial sheath, a strategy must be developed to remove these sheaths. First, always follow any existing policy that your facility has in place for this process. Also, consider any specific physician orders that may have been given. If you do not have these guidelines, then you can approach it based upon the condition and circumstances of the patient. When you have two sheaths in place, you should consider removing the arterial sheath first. With any arterial sheath removal, there are complications that may occur. Some of these complications include hematomas, uncontrolled bleeding and vasovagal responses. These complications can require the administration of large amounts of IV fluids at a very rapid rate. What would be the fastest way for these to be administered: a 20-gauge IV catheter in the forearm or a venous sheath in the femoral vein? Of course, a venous sheath would allow the most rapid administration of fluids. It is a ‘central’ line. For this reason, the venous sheath would not be removed first. As a general rule, a 6Fr sheath will require at least 15 minutes of manual compression. Once the arterial sheath has been removed, and manual compression is applied, there should be continual evaluation of the puncture site and hemodynamic status of the patient. If “all is well” after 8-10 minutes of manual compression, the venous sheath could be removed (as demonstrated in Figures 4, 4a and 5). However, if staff feel that the patient would benefit from having the venous sheath left in place until the arterial manual compression is completed, that is perfectly acceptable. Remember, when removing venous sheaths, you can hold pressure right on the puncture site (compared to above the site on arterial sheath removals) and you need very little pressure because of the low pressures of the venous system. You also do not want to totally occlude the vein, which could lead to small clot formation. As with many other topics that have been presented, the ‘anticipation’ of the bad things and preparation to respond to them before they are out of control is much of the basis of what we do. Leaving the venous sheath to be removed last is one of those examples of how being prepared and thinking ahead can help the patient who is in the middle of a complication event. Acknowledgements. I would like to thank Cindy Hughes, RT, for her assistance with the photos. Ask a question at tginapp@rcis.review
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