Re: Useful Technique for Continuous Pulse Monitoring During Sheath Removal. Cath Lab Digest, May 2005

Dear Editor, I have been a cath tech for 25 years and I must say I was blown away by some of the information in the article on sheath removal. A minimum" hold of 20 minutes?!! Somebody has got to be kidding. My usual hold time is 3-4 minutes without unusual amount of anti-coags given. I have held 10 minutes on ACT’s of 300+. A great cardiologist once told me, once it's stopped, what else are you going to do?" It does fly in the face of current medicine which insists that once you are done, try to think of something else to do. I begin by occluding the vessel for 10-15 seconds, then releasing until first sign of blood. At that point, I reapply pressure until stopped. I repeat this procedure until desired result. This usually takes no longer than 3-4 minutes, even with sheath sizes up to 10 Fr. To use the method described in the article causes the vessel to seal in a distorted manner, thereby creating an actual weakness when pressure is released. I really don’t care about a manual since most are not necessarily backed up with solid evidence, just mere empirical assumptions. Just had to write since there is so much waste in medicine and time is not a renewable resource - and in medicine, time is a lot of money. But since medical administrators and academic nurses seem to call the shots rather than those that actually work in the field, this insane practice will continue until the arrival of socialized medicine, which is destined to come unless hospital administration wakes up. The author, Philip Cenci, RN, responds: There are probably as many different techniques for pulling sheaths as there are people doing it. The question is, which is the best and safest? I think that the public both expects and deserves that. I would like to know how much pressure you are applying and what type of observation follows after you release. Does this include palpation for occult bleeding below the skin? I am all for a discussion on what is the best technique for efficiency and safety, but we need to have a standardized way to measure and evaluate the techniques. As for my twenty-minute hold, I am bound by hospital policy to hold this period of time. My initial 5 minutes as mentioned is the only period that maximum pressure is applied and is non-occlusive unless that is necessary to stop the bleeding. The next 10 minutes are not as stringent and pressure is released as needed. The last five minutes are the least pressure and serve primarily as a period of observation and palpation. The pulse oximeter serves as an aid to help me measure the amount of pressure applied. I am not accustomed to holding for as brief a period as you suggest so I cannot comment on its effectiveness. Thank you for taking the time to share your technique with me looking forward to more ideas. PhiCen@aol.com

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