Management of Patients With Femoral Arterial Sheaths Following Percutaneous Coronary Intervention

Q: Do evidence-based or best practice guidelines exist for managing femoral arterial sheaths in patients who have undergone elective percutaneous coronary intervention (PCI)?A: Anna Mall, BS, RN, CCRN, replies:Estimates indicate that more than 1 million Americans will experience a new or recurrent cardiac event in 2019, and many of these patients will receive treatment in cardiac catheterization laboratories across the country.1 Cardiac catheterization is a common procedure, yet standards and protocols for caring for this patient population vary greatly among institutions, and few evidence-based standards relate to postprocedural care.2,3Although use of the radial artery to obtain vascular access has increased in the United States, the femoral artery remains a mainstay of vascular access during PCI, despite higher rates of complications, major bleeding, and transfusion.4 Few publications describe the nursing care of patients immediately after catheterization, specifically care of the femoral sheath. Nursing care and critical thinking during this period aim at preparing to remove the sheath, identifying complications at the access site early, and promoting patient comfort.5,6Monitoring and assessing these patients begin with an effective hand-off from the catheterization laboratory to the nursing unit. The handoff should include both procedural information and assessment of the access site. Common postprocedure orders include frequent monitoring of vital signs, assessment of the access site, and palpation of the distal pulses. After patient transfer, nursing staff should assess for complications including bleeding, hematoma, retroperitoneal hemorrhage, pseudoaneurysm, arteriovenous fistula, arterial occlusion, and femoral neuropathy.5Medications used during PCI may include anticoagulants to prevent acute thrombosis. If anticoagulants are administered, it may be unsafe to remove the sheath at the end of the procedure. If the sheath is not going to be removed immediately after the procedure, it should be secured (usually with a suture) to prevent dislodgment, and a sterile occlusive dressing should be placed before the patient is transferred to the nursing unit. Institutional protocols may include the use of a pressurized flush system to help maintain patency, facilitate blood draws, and aid in monitoring hemodynamic values.7 Early work by Craney et al8 and later research by Sulzbach-Hoke et al9 support capping the sheath for up to 24 hours, which resulted in no significant differences in patency or access site complications compared to sheaths with pressurized flush systems.Most femoral arterial sheaths can be safely removed between 2 and 4 hours after PCI, but removal depends on the patient’s anticoagulation status. Current evidence shows an association between longer sheath dwell times and more bleeding events.10,11 The anticoagulant used during the procedure influences the ability to safely remove the sheath. Bivalirudin and unfractionated heparin are commonly used during PCI, and understanding their pharmaco-kinetics is important when preparing to remove the sheath.The pharmacologic profile of bivalirudin is well known; the half-life is 25 minutes in patients with normal renal function (glomerular filtration rate > 90 mL/min). To mitigate the risk of bleeding, remove the sheath 2 hours after discontinuing the infusion, allowing the anticoagulant’s effects to subside. In patients with mild to severe renal impairment, monitoring the activated clotting time is recommended to ensure that the anticoagulant’s effects have subsided before the sheath is removed.12The pharmacokinetics of unfractionated heparin are not as reliable as those of bivalirudin and thus result in an unpredictable dose response. The half-life of heparin is dose dependent and varies between 30 minutes and 2 hours.13 Although rigorous evidence is lacking to support using activated clotting time to determine the appropriateness of sheath removal, it continues to be used in practice because it can be done easily.14 In the literature, the exact activated clotting time corresponding to readiness for sheath removal varies between 160 and 175 seconds, but this value is far from perfect because testing methods and devices vary.3,14,15 This target range is largely determined by institutional policies and procedures, and results outside of the range may still be interpreted as appropriate.Most institutional protocols include a period of recumbent bed rest while waiting for an anticoagulant to metabolize. With regard to head-of-bed elevation during this period, the literature lacks consensus. Pool et al6 highlight that the majority of the relevant literature supports maintaining head-of-bed elevation between 15° and 30°, which caused no increases in bleeding complications. In addition, this intervention may alleviate some patient discomfort related to back pain due to immobility. This evidence is limited, however, because these studies targeted the period after the sheath is removed and hemostasis has been achieved. More conservative approaches to patient positioning suggest keeping the head of the bed flat or elevated up to 15 °—again, this is usually guided by institutional policy and physician preference. Regardless of the angle of the head of the bed, monitoring for and assessing complications, and ensuring timely sheath removal, are vitally important in caring for this patient population.Although little current evidence relates to managing femoral artery sheaths after PCI, nursing care continues to be paramount to patient safety. Nursing care during this period is essential in recognizing complications early and providing timely interventions to reduce complications at the vascular access site. Care of the femoral sheath is within nurses’ scope of practice, and we must be aware of related institutional policies and procedures. The best practice is to apply existing knowledge and continue to review new evidence as it becomes available.