PCI What You Need to Know!
What and Where • Radial- advantages • Immediate ambulation • Easily compressible vessel • Less risk of nerve injury • Dual blood supply so decreased vascular complications • Less back pain • The sheath will be removed in cath lab and device (TR band) will be applied. • Elevate affected arm, no bending of the wrist
What and Where? • Radial Monitor site for bleeding, hematoma or ischemia Place sensor for continuous pulse oximetry of affected hand Check capillary refill q 15”x4, q 30” x2, q 1hour x 4 2 hours after diagnostics or 4 hours after intervention begin removal of TR band. Remove 5 cc of air q 15” until the device is completely deflated (15-18 cc) If bleeding occurs re-inflate until bleeding stops, wait 15-20 minutes and start deflating as above Once deflated remove band and place a protective covering
Post Radial Care • Assess perfusion of the hand (color, temperature, sensation) with vital signs • Leave the dressing intact for 24 hours • After the dressing is removed the site may be gently cleansed with soap and water • Activity and movement restrictions should be explained
Arterial and Venous Sheath Removal • Only to be performed by personnel with a demonstrated competency • If both arterial and venous sheaths are present remove arterial first (helpful if complications occur to have big femoral IV access) • Brachial sites require manual pressure ONLY to establish hemostasis
What will I need? • Medication: pre-medicate as ordered (highly recommended) • 3 tubs of 4x4 • Sterile blade • 2x2 • Tegaderm (one for each sheath being removed) • Clean and sterile gloves • Clean gown, mask and protective eyewear • Noninvasive blood pressure monitoring device (set for q 5”) • Atropine 1 mg (override from pyxis, return if not used) • Chlorahexadine solution • If order compression device
When should I question pulling a sheath? • PTT > 40 • ACT >200 • SBP >160 mmHG • Low Platelet count • Hematoma • Confusion, restlessness
Before I begin: • Assess the extremity • Mark the pulses (use a doppler as needed) • Set BP for q 5” • Have atropine, IVF bolus and oxygen available • Lay flat, HOB no >than 10 degrees • 90 degree angle to provide pressure is best! • Don protective apparel
Now What? • Wearing clean gloves, remove old dressing. Note hematoma if present and document • Turn off stopcock to patient, disconnect from transducer or IVF. Attach a syringe and aspirate 5-10 cc from catheter to pull any possible clot from the tip • Clean the site using chlorahexadine: using a circular motion from inside to outside. Open 4x4 and blade. Cut sutures.
Femoral Site • Locate pulse (1-2 cm above and medial to the puncture site) with one hand in position remove sheath during exhalation and immediately occlude artery. A femoral pulse should be felt. • Apply occlusive pressure with one hand, or femoral artery clamp for 2-3 minutes max. While holding pressure, palpate surrounding area to assess for hematoma formation. • Slowly release occlusive pressure after 2-3”. Continue manual non-occlusive pressure for a min. of 20 minutes. If removing a venous sheath remove it after approximately 10” and maintain pressure over both sites for additional 10”
Woohoo, almost done! • Slowly release and observe for hematoma or bleeding. If any bleeding noted, apply additional pressure manually or using a Femstop per manufacturer recommendations • Slowly release and observe for hematoma or bleeding. If any bleeding noted, apply additional pressure manually or using a Femstop per manufacturer recommendations • No bleeding….apply dressing
Post Removal Care • All Sites Monitor Rhythm Vital Signs q 15” x 4, q 30” x 2, q 1 hour x 2, then routine Puncture site, dressing and surrounding area Extremity for pulse, color, motion, temperature and sensation Note presence of pain (back, groin, or site pain)
You’re there! Document Procedure, VS, and patient tolerance (Also, arm circumference if brachial site) Assessment of site with completion of pressure Follow-up assessment of site and extremity Patient teaching and outcome (reminder no heavy lifting x1 week)
Policies….Our Friends • Remember to see policies for any questions Femoral compression system/Femstop No: CP30.06 Transradial Catheterization Procedures No: OPP-1 Arterial and Venous Sheath Removal No: CP30.08