Appendix G: Indwelling Arterial Sheath Management

Key Principles

- Leave sheath in place during:
  - Ongoing resuscitation
  - Concern for re-bleeding
  - Prior to transport
- Premature removal risks:
  - Loss of access
  - Hemorrhage
  - Inability to re-establish aortic occlusion

Patency Maintenance

- Continuous flow is mandatory
  - Preferred: Pressure bag + arterial line transduction
  - Alternative: Continuous or intermittent (via manual flush) saline or heparinized saline infusion
- Suggested heparinized infusion:
  - ~500 units/hour (if not contraindicated)
- If not transduced:
  - Flush at least hourly
- No-flow and stagnant blood in sheath = rapid thrombosis

Monitoring

- Continuous arterial waveform monitoring (if transduced)
  - Watch for dampening or loss of waveform
  - Neurovascular checks minimum: hourly
- Assess:
  - Pulses / Doppler signals
  - Skin color and temperature
  - Motor and sensory function

Positioning & Transport

- Keep patient:
  - Supine or reverse Trendelenburg
- If movement required:
  - Keep flat
  - Log roll only
- Avoid hip flexion
- Secure sheath prior to transport (suturing in place ideal)
- Maintain continuous pressure or low rate infusion during transport

Pre-Removal Evaluation

- Confirm access site and sheath position:
  - Physical exam (inguinal ligament landmarks)
  - X-ray (relative to femoral head to hold pressure over bony landmark)
  - CT (± contrast) if available or already obtained
  - Angiography (if available)

Sheath Removal

- Only after:
  - Definitive hemorrhage control
  - In appropriate setting (Role 3/4 capable of vascular management)
- Do NOT remove immediately prior to transport
- Removal considerations:
  - Manual pressure ≥30 minutes
  - Large sheath / coagulopathy / difficulty → consider surgical cutdown
- If operative repair is anticipated:
  - Leave sheath in place until controlled exposure achieved

Indwelling Arterial Sheath Management Algorithm