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Sheath Pulls

One of the unique procedures we do on our unit is the removal of arterial and venous sheaths.  A sheath is a large bore (7-11 French) tube inserted into the vein or artery, usually the femorals, that allows the insertion of a variety of instruments to perform procedures like stenting, diagnostics and ablabtion.  It used to be the docs would pull the sheaths in the cath lab, or in post-procedure.  Since we split our unit, the step-down side is set with a 3:1 ratio and any intact sheath goes there.  Consequently we’ve been getting a lot more.

Many times, the day shift pulls these, but as the docs are adding more procedures and they’re taking longer, the night shift is getting more to pull.  Lately I’ve been drawing a lot of ablation pulls.  In other words, many holes to plug. They need so much access to thread the multiple tools into the heart.  In this particular view you can see 4 tools inside.  4 tools equals 4 sheaths, if not more.

The other night I had a doozy: 6 to pull.  3 in the right femoral vein and 1 in the right femoral artery, 1 in the internal jugular vein and a giant honkin’ 11 French in the left femoral vein.  The pic below is a visual representation of the size of the typical catheters.  French sizing is basically sized in milimeters, so an 11 French is 11 milimeters in diameter.  Not exactly small.  Luckily it was venous.  I shudder to think of one that size in an artery.

The nice thing with venous sheaths is that it’s just hand pressure for 10 minutes and you’re good.  It was just the sheer number that is daunting at times.  The IJ came out good, like pulling a CVC.  Just have to rememeber not to put too much pressure on the neck.  Wouldn’t want to stop any blood or air flow!

By the time we moved to the left venous, we had literally gathered a crowd. There was me, my second, my preceptee adn my second’s preceptee.  We always have another nurse in with us when we pull just to have another sets of hands in case things go south.  And this night, both of us had preceptess with us.  Since we don’t have sheaths all that frequently, and rarely in this number, I like to make sure any new folks to the floor can at least watch the prceedings.  It all goes with the mantra: see one, do one, teach one.  Besides the 4 of us, my charge nurse popped in as well.  I think we had it covered if things went to shit.

Out the sheath came and there was a gasp of amazement.  Think about the blue BIC pens so ubiquitous to any office.  Yes, it was the size of the end of one of those pens.

“We don’t see many of this size very often.” my charge said.

I bite my tongue thinking, “Yeah, I get that a lot!”

Finally we’re down to the arterial sheath.  Being an artery, it’s a little different.  I tend to use a Femostop pressure device that exerts direct pressure on the puncture site to achieve hemostasis.

Usually it takes me an hour from when I pull the sheath until the Femostop is off.  Now some nurses on the floor take less time, but I have my reasons.  I’m conservative, but *knocking on wood* I have yet to have a re-bleed or hematoma when I pull a sheath.  It’s not like we’re just hanging out.  We’re grabbing vital signs every 5 minutes, checking distal pulses, sensation and color to the foot and generally distracting the patient from the large amount of pressure being exerted on their groin.

The best thing about our new unit is that we can take the time needed to do this.  Now, I’ve done this ncredibly time-consuming procedure with 4 other patients.  It ain’t pretty, but can be done.  Now though, I can take the time I need.  Besides the cath lab, we’re the only ones to do this in our hospital.  Granted, now that the sheaths are out, we have to bug the patient every hour to make sure there is no hematoma or bleeding and they still have good distal circulation.  I always joke, “You’re going to be sick of me by the end of this.  And not get any sleep at all.” And it’s true, they’re sick of me, and I’m sick of doing it.  But it’s the job.  And I love my job.

Categories: The Journey Tags: ,
  1. September 13, 2008 at 2:12 pm

    You just made it to my great “blog list.”

    Wait, is that really an honor? Hmmm . . .

    Great Blog! Keep it coming.

  2. October 7, 2008 at 2:52 pm

    Glad to hear you have the opportunity and time on your floor to do the sheath pulls.
    I remember the days of pulling the sheaths.. with no one around. In fact when the patient started cirlin’ the drain you had to scream for help.
    That’s why we always hung a liter of fluid on a pressure bag before we even started our pull.
    Just in case.. *wink* *wink*

  3. Kay RT(R)(M)(CI)
    April 25, 2009 at 2:06 pm

    I’ve been pulling sheaths for 22 years now. Never had the priveledge to work where a DR pulled the sheath. Now I not only pull on adults but on pediatrics from a few hours old and up and usually with acts above 200. What fun.

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