REMOVAL OF FEMORAL ARTERIAL CATHETERS

Equipment Needed:

1. Sterile tray with suture removal scissors.
2. Chlorhexidine 2%.
3. 2 - 4X4 gauze squares.
4. Transparent dressing.
5. Bedside stool (if required).

	Procedure		Rationale
1.	Check ACT. If ACT is prolonged or patient has altered coagulation (e.g. received TPA), notify the physician. NOTE: Prior to removal of a femoral line sheath obtain order to remove sheath.	1.	To reduce risk of bleeding.
2.	Obtain a bedside stool if required to ensure that nurse is positioned above the femoral artery when applying pressure.	2.	Direct, downward pressure is required to compress the artery.
3.	Cleanse site with 2% chlorhexidine and remove any sutures.	3.	Chlorhexidine 2% is the recommended agent for disinfecting vascular access sites at LHSC because: it has anti-staphylococcus properties that are equal to alcohol or providine is less irritating to the skin than iodine preparations has longer residual action than alcohol
4.	Gently withdraw catheter while applying direct pressure with the sterile gauze. The nurse should be positioned directly over the femoral artery using his/her body weight to provide direct pressure. Inspect catheter for clots and ensure entire catheter has been removed. IN THE EVENT OF CATHETER FRACTURE: Apply direct pressure over the site and notify the physician immediately. If the catheter fragment is palpable, apply additional pressure distal to the catheter.	4.	Direct alignment improves body mechanics and pressure application. Clots can form on catheter tips; these can embolize to the distal extremity. Catheter fragment embolism can occlude distal extremity circulation; urgent surgical excision is required.
5.	Hold direct, manual pressure for a minimum of 10 minutes. Carefully check the site. If oozing continues, compress for 5 more minutes before checking again. Hold direct pressure for a minimum of 5 minutes after evidence of bleeding has stopped. NOTE: For femoral line sheath removal, 20 minutes or more of pressure might be required. Ensure bleeding has stopped before discontinuation of pressure.	5.	Prolonged and direct pressure is required to stop bleeding from an artery. Inadequate hemostasis can lead to retrograde bleeding. Hematomas can cause impaired circulation to the distal extremities and are painful for the patient.
6.	When bleeding has stopped, apply a 2 X 2 gauze or transparent dressing over the site.	6.	The transparent dressing protects against entry of pathogens while allowing observation of the site.
7.	Immobilize the leg. A sandbag can be used to remind the patient not to flex the hip. An ankle restraint can be used to promote immobilization.	7.	Sandbags WILL NOT stop bleeding; they are used to restrain the leg and to remind the patient not to flex the hip. Immobilizing the leg can minimize the risk for bleeding.
8.	Keep the patient flat without hip flexion for a minimum of 6 hours (longer bed restriction should be considered for patients with increased bleeding risks) (1). The patient may have a pillow under his/her head, but should not be allowed to lift their head or flex their hip. A sandbag can be applied to remind the patient not to flex the hip (but will not provide any hemostasis). Avoid the use of the mechanical vibrator during the period of bedrest. Transfers to Floor Do not transfer the patient until the bedrest period has ended.	8.	Hip flexion or abdominal straining can increase femoral artery pressure and risk for bleeding. A review of the literature and evaluation of the complication rate in patients following implementation of a 2 hour bedrest protocol post cardiac catheterization supported a reduction in the duration of bedrest from 6 hours to 2 hours (1). The potential for the mechanical vibrator to increase the risk for bleeding has not been established, however, it is reasonable to avoid activities that might theoretically increase bleeding risk. Immobilization of the leg during the bedrest period is important; transfer requires movement from one bed to another. The patient requires close monitoring of the site and distal extremity and the nurse:patient ratio on the floor may be insufficient.
9.	DO NOT APPLY A PRESSURE DRESSING.	9.	CESSATION OF ARTERIAL BLEEDING REQUIRES DIRECT PRESSURE; A PRESSURE DRESSING PROVIDES INADEQUATE COMPRESSION. PRESSURE DRESSINGS CAN INCREASE PATIENT DISCOMFORT AND DELAY THE DETECTION OF BLEEDING. (1) Pressure dressings cause increased nausea, back pain, groin pain and urinary complications in patients treated with pressure dressings versus no pressure dressing. There was no difference in bruising between groups; the group with pressure dressings had less bleeding (that required manual pressure), however, bleeding occurred later in the pressure dressing group. (2).
10.	Assess site for bleeding and evaluate distal extremity for color, circulation and motion q 5 minutes X 30 minutes, q 30 minutes X 2 then q 1 h X 4. Apply direct pressure if bleeding is detected. REPORT ANY CHANGES TO THE PHYSICIAN IMMEDIATELY and document in clinical record.	10.	Bleeding or bruising is an important complication following arterial catheter removal. Impaired circulation to the distal extremity can occur secondary to migration of a thrombus or catheter fragment, hematoma formation or vascular injury. Urgent medical intervention may be required to restore limb perfusion.
11.	Document removal in AI record (CCTC), Kardex, graphic record (flowsheet) and vascular line tracking record (UC).	11.	To communicate.

References:

1. Vlasic, W., Almond, D. (1999). Research-based practice: reducing bedrest following cardiac catheterization. Can J Cardiovasc Nurs. 10(1-2):19-22.

2. Botti, M., Williamson, B., Steen, K., McTaggart, J., and Reid, E. (1998). The effect of pressure bandaging on complications and comfort in patients undergoing coronary angiography: a multicenter randomized trial.

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