Coronary heart disease (CHD) has been identified as the single most common cause of death in the UK (Iqbal et al, 2001). Percutaneous transluminal coronary angioplasty (PTCA) is a recognised treatment for this condition and is growing in popularity (Fulton et al, 2000). In the year 2000, there was a 20% increase in the number of PTCAs performed compared with 1999, with 33 652 procedures performed throughout the UK (De Belder, 2001). However, as this does not yet achieve the targets set out in the National Service Framework for Coronary Heart Disease, an increase in the number of these procedures will inevitably occur (Department of Health, 2000).
PTCA involves the use of a balloon catheter to dilate stenosed coronary arteries. Typically, a catheter is inserted percutaneously into the femoral artery via an introducer sheath and advanced towards the area of stenosis. This sheath provides support at the puncture site and reduces potential arterial trauma as multiple catheter exchanges are required throughout the procedure (Grossman and Baim, 2000). In order to allow the heparin used to dissipate the arterial femoral sheath is not usually removed for at least two to three hours after the procedure (Iqbal et al, 2001).
As the number of PTCAs performed has increased over the past few years, nursing staff in the local interventional cardiology unit at Leeds General Infirmary found that when doctors were solely responsible for the removal of arterial femoral sheaths, delays in the procedure were common. For the patient this meant a longer period of bed rest, which increased their discomfort and the risk of developing potential problems, such as back pain and urinary retention (Schickel et a1,1999). Furthermore, delays in sheath removal could cause unnecessary demands on the use of an interventional cardiology bed. These recognised problems, alongside national efforts to decrease junior doctors’ working hours (Department of Health, 1991) provided the impetus for nurses in our unit to include the removal of femoral sheaths in their extended role. This was in accordance with the nursing belief that, by extending their role, nurses can expedite patient care and provide a more holistic approach, thus providing personal and professional satisfaction for the participating nurses (Workman, 2000).
Although stated opinion varies as to how to best use manual compression in order to achieve haemostasis following the removal of an arterial femoral sheath (Norell and Perrins, 2001), published information appears to be limited. Despite an extensive literature search, limited to English, of the Cinahl, Medline and British Nursing Index databases and the Internet via the Google search engine, dating back to 1990, only three articles were found that described removal of a femoral sheath in conjunction with manual compression. O’Brien and Recker’s (1992) article was the only one that was easily accessible. Although it was descriptive, it clearly outlined how a femoral sheath could be safely and effectively removed.
Removing a sheath from an artery is not without risk. Potential complications of the procedure are listed in Box 1.
However, many peripheral vascular complications can be limited or prevented if identified and treated early. The frequency of such complications is difficult to track, with published occurrence rates ranging from 0.5% to 15% (Simon et al, 1998). In order to reduce the risk of potential complications, the following information needs to be ascertained.
Has the heparin administered during the procedure dissipated? - It is recommended practice to administer the anticoagulant heparin during cardiac catheterisation where the procedure is expected to be longer than 20 minutes or when prior clinical indications for the use of heparin exist (Kern, 1999). Dependent on the weight, age and medical condition of the patient, it can take two to six hours for the heparin to dissipate (Lilley and Aucker, 2001). The anticoagulation time (ACT) should ideally be less than 160 seconds (Grossman and Baim, 2000). In practice, it is time consuming trying to measure the ACT. Therefore it is our local practice to remove femoral sheaths four hours after the procedure unless the cardiologist specifies otherwise.
Is a haematoma present? - Poor insertion technique, vessel laceration or excessive anticoagulation may lead to problems such as haematoma formation prior to sheath removal (Grossman and Baim, 2000). Haematomas in the soft tissue surrounding the site of the femoral sheath will feel firm and will have defined boundaries. If you are unsure whether one is present, the site of the sheath should be compared with the other side (Kern, 1999). Large haematomas can cause considerable discomfort to the patient and have the potential to develop into false aneurysms (Grossman and Baim, 2000).
Can the patient lie still? - If a patient has difficulty remaining immobile, the time to haemostasis may need to be lengthened (O’Brien and Recker, 1992; Botti et al, 2001). Activity may dislodge the forming clot from the arterial puncture site and cause bleeding (O’Brien and Recker, 1992; Botti et al, 2001). A bedpan or urinal should therefore be offered to the patient before sheath removal and the patient positioned comfortably before the procedure is begun. If the patient requires systemic analgesia, for example for backache, it is local practice to administer this at least half an hour before the removal of the femoral sheath. Pressing on the femoral artery may be painful (Wadas and Hill, 1998), so it is our local practice to administer 5-10ml of 2% lignocaine to the groin where the pressure is to be applied, dependent on the size of the patient.
What is the patient’s blood pressure? - If a patient is hypertensive (that is, has a systolic pressure greater than 150mmHg), the pressure within the arteries is high. This means that greater pressure is exerted at the arterial puncture site, impeding the clot’s ability to adhere and seal off the puncture wound (O’Brien and Recker, 1992). Therefore, as prolonged pressure (greater than 30 minutes) will probably be required, the application of a mechanical pressure device such as a FemoStop should be considered (Grossman and Baim, 2000). In addition, consideration should be given to administering the patient’s antihypertensive medications at an appropriate time to ensure maximum effect, when required for this procedure.
If a patient is hypotensive, that is with a systolic pressure of less than 100mmHg, the patient is at risk of acute myocardial ischaemia (Kern, 1999). In acute cases of hypotension, patients will often respond to the elevation of the lower extremities (>30 degrees) as this increases venous return (Kern, 1999). The cause of the hypotension should also be treated, as it may be caused by preprocedural medications, hypovolaemia induced by the fasting state, and/or excessive contrast-induced diuresis and/or vasovagal reaction (Kern, 1999).
In the case of drug-induced hypotension, treatment is directed towards discontinuation or reversal of the offending medication. This may mean stopping or decreasing the intravenous vasodilators, such as nitroglycerine, or administering naloxone if narcotics are found to be the cause of the drop in blood pressure (Kern, 1999).
Potential vasovagal reactions - Pressure on a large artery and pain can stimulate the vagus nerve, which will respond by slowing the heart rate and lowering blood pressure (Kern, 1999). Anxiety and tissue injury can also result in a vasovagal reaction (Wadas and Hill, 1998). Early signs include pallor, nausea and/or yawning, which often present with a slowing of the heart rate before a drop in blood pressure. Vasovagal reactions may lead to irreversible shock if untreated. However, they respond dramatically to intravenous atropine (usual dose 0.6 to 1.0mg). Elevation of the legs, infusion of gelatin (Gelofusine) and administering oxygen are helpful adjuncts (Kern, 1999; Grossman and Baim, 2000).
As vasovagal reactions may occur while pressing on the groin during sheath removal, it is advisable to have another person present who can administer treatment while pressure on the site is maintained.
What is the patient’s heart rate? - Iodinated contrast medium and/or a vasovagal response contribute to slowing the heart rate (Kern, 1999). Therefore in order to avoid a life-threatening bradyarrhythmia, it is local practice to administer 600 micrograms of atropine to a symptomatic patient (one whose pulse is less than 50 beats per minute and whose systolic blood pressure is less than 100mmHg). Medical staff are informed if the patient remains bradycardic after two doses of atropine have been administered.
When assessing whether to administer atropine, it is important to note how symptomatic the patient is (Kern, 1999). Drugs that may cause bradycardia include betablockers, calcium channel blockers, digoxin, amiodorone, methyldopa, and clomidine (Lilley and Aucker, 2001).
Does the patient have a venous sheath in situ? - Occasionally during a PTCA, an additional sheath will be inserted into the femoral vein to allow for a temporary pacing wire or venous access if peripheral venous access is a problem (Kern, 1999). When this does occur, the arterial sheath should be removed first (Box 2) to reduce the risk of atrioventricular fistulas, haematoma formation and blood loss. The venous sheath can then be removed according to local protocol (Kern, 1999) (Box 4).
Nursing care following femoral sheath removal - Based on current available research, once haemostasis has been achieved either by manual compression or using a FemoStop it is local practice for patients to remain supine for two hours. They can then sit up for two hours and, in the absence of bleeding or haematoma formation, they are able to gently mobilise around the ward (Keeling et al, 2000). While the patient is on bedrest, the nurse maintains half-hourly observations on the patient, checking the following:
- The pulse and blood pressure for signs of hypovolaemic shock
- The affected groin to ensure no recurrence of bleeding or haematoma formation
- Pedal pulses, skin colour and warmth on the affected leg’s foot to ensure no distal ischaemia has occurred (Botti et al, 2001).
Patients are advised to:
- Keep the affected leg straight for the first two hours
- Press on the groin site when coughing or sneezing
- Call for nurse assistance if there is a recurrence of bleeding
- Inform the nurse if they experience chest pain
- Drink plenty of fluids in order to prevent hypotension.
It has been shown through research that, although most institutions use care plans to standardise care following an angioplasty, due to the absence of clinical trials, these plans are based on historical practices and not on the results of research studies (Peet et al, 1995; Juran et al, 1999). Despite the emphasis that clinical governance has placed on evidence-based practice, there have been no studies in the UK to examine the practices here. Therefore, in Leeds we have had to rely on our own experience as well as research from overseas when updating our protocol in removing femoral sheaths. However, unpublished research carried out by nurses in the unit found that, by following the devised protocol, nurses are as efficient in removing femoral sheaths as their medical colleagues.
Further local research has found that the nurses participating in this role have a positive attitude towards this task, because they believe that it improves the care that they provide for their patients, and that it increases their nursing autonomy. It is accepted, however, that both these local studies have their limitations and that further research is needed in this area.
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