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