The Nurses’ Compliance in Femoral Sheath Removal Procedure in

Relation to the Incidence of Hematoma in Patients after PTCA

Jati, Christina Yuliastuti and Nisha Dharmayanti Rinarto

STIKES Hang Tuah Surabaya, East Java, Indonesia

Keywords: Hematoma, Nurses’ Compliance, PTCA, Sheath Removal.

Abstract: Femoral hematomas may occur after Percutaneous Transluminal Coronary Angioplasty (PTCA). The

objective of this study was to identify the correlation between the nurses’ compliance of femoral sheath

removal with the incidence of hematoma in patients after PTCA. This observational study enrolled 20 nurses

and 20 patients after PTCA in Intensive Care Unit, taken by simple random sampling. Data collection was

undertaken using a set of observation sheet based on Standard Operating Procedure and the presence of

hematoma. The data were analyzed with Spearman Rank test with significance level of 0,05. Results showed

that there was a significant correlation between compliance of nurses in performing the procedure of sheath

removal with the incidence of hematoma (ρ = 0.000). A properly performed compression manual on removal

of the arterial sheath, ie, for 15-20 minutes until hemostasis is reached where no bleeding through the catheter

inserts will minimize the incidence of the hematoma. Supervision, training and simulation will improve the

capacity of nurses’ knowledge and skills in performing sheath removal procedures.

1 BACKGROUND

Percutaneous Transluminal Coronary Angioplasty

(PTCA) is a procedure whereby a balloon catheter is

inserted through a wire, and then developed at the site

of stenosis to increase the lumen diameter (Philip,

2010), it is expected to improve blood flow to the

myocardium, myocardial damage is not widespread,

chest pain and symptoms of tightness can be reduced

even disappeared by the inclusion of ring or stent in

blood vessels that have blockage. Elective PTCA

within 30 days post IMA may reduce mortality and

risk of complications when compared with medical

therapy especially in patients with unstable

conditions, but in patients with stable asymptomatic

and stable hemodynamic risk the results are no better

than optimal medical therapy (Subagyo, 2012).

Klemsová and Žiaková (2014) said that both

approaches to catheterization carry the risk of

complications associated with the removal of cannula

sheath. The most common complication after cardiac

catheterization through the femoral artery is the

development of vascular complications (bleeding,

hematoma, pseudoaneurysm). From history it is

known that complications associated with the

removal of cannula (sheath) from the femoral artery

were up to 11%. Hamon et al. (2007) indicate, based

on a systematic review and meta-analysis of

randomized trials, incidence of complications in the

femoral approach in 2–5% of patients after

interventional procedures. Studies in 90 patients

undergoing cardiac interventional procedures were

randomly selected to undergo one of 3 sheath removal

methods : manual compression, mechanical

compression with Compressar, and mechanical

compression with Femostop. The results showed that

patients undergoing sheath removal manually had

fewer complications than patients who underwent

sheath removal using Compressar or Femostop

(Benson et al., 2005). Research on 413 patients with

Following Sheath Removal With Percutaneous

Coronary Intervention, as many as 60 (16.5%) had

complications. Sixty-four (15.5%) had hematoma, 6

(1.5%) had bleeding, 4 (1%) had arteriovenous fistula

and 3 (0.7%) had pseudoaneurysms. No significant

difference in complications either using manual

compression, C-Clamp or arterial vascular closure

device (Sulzbach-Hoke, Ratcliffe, Kimmel,

Kolansky, & Polomano, 2010).

Walker, Cleary, & Higgins (2001) conducted a

comparative study (FemoStop compression versus

manual compression) in order to reduce the

complications at the injection site. The results showed

Jati, ., Yuliastuti, C. and Rinarto, N.

The Nurses’ Compliance in Femoral Sheath Removal Procedure in Relation to the Incidence of Hematoma in Patients after PTCA.

DOI: 10.5220/0008329806210625

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 621-625

ISBN: 978-989-758-336-0

621

that the incidence of hematoma has a great

relationship to the method of compression used on the

femoral artery. Walker said that although using

manual pressure compression the hemostasis was

achieved faster than with FemoStop, both methods

are considered as effective to reduce complications in

the groin. However, non-compliance of nurses in the

procedure of removing the femoral sheath will lead to

hematoma, discomfort, healing period and elongated

day. Risk factors predisposing patients to these

complications are both modifiable (procedure

technique, medications, hemostasis method) and

nonmodifiable (sex, age, body mass index, blood

pressure, renal function). Patients’ risks can be

reduced by nurses who are knowledgeable about

these risk factors and identify complications before

they become problematic (Merriweather & Sulzbach-

Hoke, 2012). The objective of this study was to

identify the correlation between the nurses’

compliance of femoral sheath removal with the

incidence of hematoma in patients after PTCA.

2 METHODS

This study used observational analytic and conducted

to identify the correlation between the nurses

compliance of femoral sheath removal with the

incidence of hematoma in patients after PTCA.

Samples were taken by simple random sampling

consisting of 20 nurses and 20 patients after PTCA in

Intensive Care Unit, aged 40-60 years and take anti-

platelet drugs (Pavix, aspilet and the like), not

suffering from Diabetes mellitus and

thrombocytopenia. Data collection was undertaken

using a set of observation sheet based on Standard

Operating Procedure (SOP) and the presence of

hematoma. The applicable SOP in Intensive Care

Unit consisted of 15 steps of the procedure. Both

nurses compliance in performing sheath removal and

the incidence of hematoma were observed only one at

a time. The data were analyzed with Spearman Rank

test with significance level of 0.05.

3 RESULTS

Overall, from 20 respondents, the majority of patient

were male (60%) and The average age was 51≤60

years old (50%) and has suffered from the disease for

0-1 years (50%). Mostly get CPG as a drug therapy.

Characteristics of patients can be seen in Table 1.

While the participant nurses, mostly were female

(65%) and aged 25≤30 years old (65%). Mostly

educated diplomas (90%), not married (55%), and the

average nurse has worked >3 years in Intensive Care

Unit, as a nurse ascociate (90%) and never

participated in any specific training on sheath

removal procedures (75%). Characteristics of nurses

can be seen in Table 2.

Table 1: Patients characteristic.

Patients Characteristic

Frequency

Gender

Male

60.0%

Female

40.0%

Age

30-<40 years old

25.0%

40-<50 years old

25.0%

51-<60 years old

50.0%

Length

suffering

disease

0-1 year

50.0%

2-3 year

15.0%

3-5 year

10.0%

>5 year

25.0%

Drugs

CPG

85.0%

Plavix

15.0%

Blistra

0.0%

Table 2: Nurses characteristic.

Nurses Characteristic

Frequency

Gender

Male

35%

Female

65%

Age

20-<25 years old

30%

25-<30 years old

65%

30-35 years old

Last

Education

Diplomas

90%

Bachelor

10%

Marital

status

Not Married

55%

Married

45%

Length of

work in ICU

0-6 months

20%

6 months - 1 year

15%

1-3 years

30%

>3 years

35%

The position

of nurse

Nurse ascociate

90%

Nurse team chief

10%

Experience

in special

training

Have attended

training

25%

Never

75%

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

622

Table 3 showed that 7 (77.8%) non-adherent

nurses on the procedure of femoral sheath removal

causing hematoma in patients and 11 nurses (100%)

who adhered to the procedure did not cause

hematoma in patients after PTCA. This study found

that there was a significant correlation between

compliance of nurses in the femoral sheath removal

procedure and the incidence of hematoma (p = 0.000).

4 DISCUSSION

Percutaneous Transluminal Coronary Angioplasty

(PTCA) is a coronary angioplasty action using a

technique with balloons inserted into a stenotic

coronary vessel, after which the balloon is developed

and thus the stenosis disappears or is greatly reduced,

then the balloon is deflated and removed (Sudoyo,

2006). Percutaneous transluminal coronary

angioplasty (PTCA), formerly known as balloon

angioplasty (European Society of Cardiology, 2010).

The sheath removal procedure should be performed

carefully and in accordance with the procedure so as

not to cause vascular complications such as

hematoma. Sabo, Chlan, & Savik (2008) found that

the most frequently occurring Vascular

Complications (VCs) after sheath removal following

a percutaneous coronary intervention procedure were

ecchymosis, hematoma, and oozing. Body surface

area significantly influenced hematoma formation.

The results showed that of the 11 nurses who

adhered to Standard Operational Procedure (SOP), 6

nurses (54.5%) had worked >3 years, while from 9

non-compliant nurses to SOPs, 4 (44.4%) were new

nurses working between 0-6 months. In addition, 5

nurses who had attended the training, all complied

with SOP, while from 15 nurses who never received

special training, as many as 9 (60%) did not comply

with SOP. It can be explained that experience affects

nurse compliance in performing procedures

according to the rules, but this ability needs to be

rehearsed and repeated continuously in order to create

habits. This is in accordance with the research of

(Schiks, Verheugt, & Achterberg, 2007) about

performance evaluation of arterial femoral sheath

removal by registered nurses after PCI that was

perform in 1999 and 2005, they explained that

registered nurses achieved the norm for good

performance (80–89%) of removing arterial sheaths

according to protocol after a training programme and

this is stable in time. Since the norm for excellent

performance (≥90%) was not achieved, current

performance could be improved. e.g. by yearly

repetition of training and observation of skills.

The study founds 9 nurses (45%) who did not

comply with SOPs. The non-compliance was also

caused by the lack of supervision from the supervisor,

so the nurses performed the sheath removal

procedure, sometimes less cautious, because they

assumed that no one was watching during or after the

procedure. This is as stated by (Niven, 2002) that the

quality of interaction between health professionals is

an important part in determining the degree of non-

compliance due to the lack of reprimand and sanction

for nurses who have disobedient behavior in doing aff

sheath, lack of interaction between nurses because

there is no mutual reminded to be obedient to the

SOP.

Hematoma is an accumulation of external

bleeding or it can also hide inside a tissue (Ramzi S,

2004). Hematoma when evaluated in terms of extent

may be small, with only one blood point or can

become large and cause significant swelling. The

blood vessels in the body are always under constant

repair. Minor flocs occur routinely and the body is

usually able to repair damaged vessel walls by

forming fibrin patches. Sometimes the repair fails

when extensive damage and major damage lead to

continuous bleeding. Likewise, if there is great

pressure in the blood vessels, for example the main

artery, the blood will continue to leak and the

hematoma will dilate. Blood coming out of the

bloodstream is very irritating and may cause

inflammatory symptoms including pain, swelling and

redness. Symptoms of a hematoma depend on

location, size and whether it causes swelling and

edema. (Walker et al., 2001) said that the incidence

of hematoma has a great relationship to the method of

compression used on the femoral artery. This study

found that 7 (77.8%) non-adherent nurses on the

procedure of femoral sheath removal causing

hematoma in patients and 11 nurses (100%) who

Table 3: Correlation between compliance of nurses

in the femoral sheath removal procedure and the

incidence of hematoma.

Compliance

of nurses

The incidence of hematoma

hematoma

Total

Not

Obedient

77.8%

22.2%

100%

Obedient

100%

Total

100%

p = 0.000 r = 0.811

The Nurses’ Compliance in Femoral Sheath Removal Procedure in Relation to the Incidence of Hematoma in Patients after PTCA

623

adhered to the procedure did not cause hematoma in

patients after PTCA. There are several systems that

play a role in the hemostatis vascular system, platelets

and blood clotting. Prevention of blood loss, if the

blood vessels that have ruptured through several ways

between other : blood vessel constriction that is

immediately after the blood vessels cut or rupture

wall smooth muscle blood vessels contract so that the

blood flow from blood vessels that rupture will

decrease, the formation of platelet stoppers where

very small blood vessels are usually covered by small

disc-shaped platelets stacked with 1 to 4 micrometres

in bone marrow, clot freezing in ruptured vessels that

begin to form within 1 to 2 minutes and 20 minutes to

60 minutes of clot will experience retraction, this can

close the site of the wound is the formation of fibrous

tissue as a response to rupture of blood vessels occur

complex chemical structures in the blood involving

various factors of blood clotting which the end result

is the formation of a complex of activated substances

that collectively in call the prothrombin activator, the

prothrombin activator catalyzes the conversion of the

protombin to thrombin, thrombin acts as an enzyme

to convert fibrinogen into fibrin fibrils that sequence

platelets of blood cells and plasma to form clots.

(Guyton, A.C., dan Hall, 2008) The use of

thrombolytic therapy also has an effect on the

occurrence of hematoma during sheath removal.

Researchers also found that patients were still taking

thrombolytic therapy before the sheath removal that

resulted in blood thinning. Anticoagulant drugs are

used to prevent the occurrence of thrombosis, which

works to inhibit blood clotting. The mechanism of

action of anticoagulant drugs is to suppress the

synthesis of clotting factors that influence vitamin K

ie protombin, VII, IX, and X. The main work of

anticoagulant drugs is to inhibit the action of

enzymepoxide reductase. After a week of consecutive

treatment, the activity of the clotting factor will be

very low in the blood. Patients taking blood-thinning

drugs (anticoagulation) such as warfarin (coumadin),

aspirin, clopidogrel (plavix), and prasugrel. These

drugs increase the potential for spontaneous bleeding

and for widespread hematoma because the body can

not efficiently repair blood vessels and blood is

constantly out through damaged areas. Besides the

proper compression technique will reduce the

occurrence of hematoma.

This study also founds that there was a significant

correlation between compliance of nurses in the

femoral sheath removal procedure and the incidence

of hematoma (p = 0,000). Manual compression in

sheath removal is done until the hemostasis is reached

where no bleeding occurs through the catheter

insertion mark, which is 15 to 20 minutes.

Compliance of nurses in this case is assessed from the

adherence of the 15 steps based on the standard

operational procedure of femoral sheath removal

applicable in Intensive Care Unit. The researcher

gave a score of 1 if not done and score 2 when done.

This study found that of the 20 nurse respondents, the

highest total score was 40 at the fourth, fitfh, sixth and

eightth steps, this means that all nurses performed

observation/ monitoring of vital signs during the

procedure, palpated the dorsalis pedis pulsation,

placed 2 fingers 2-3 cm above the sheath for touch

pulsation of the femoral artery and perform manual

compression properly until the blood does not come

out. The compression is done by reducing the strength

25% after ± 15 minutes while the patient is observed,

if blood is still out then back to the beginning until no

blood came out, 5 minutes later strength of pressure

minus 50%. When it is stop to came out, then give a

band aid and do a compression bandage. The

researcher assumes that all steps in Standard

Operational Procedure (SOP) must be done properly

and carefully to minimize the complication of femoral

sheath removal (hematoma).

5 CONCLUSIONS

Percutaneous Transluminal Coronary Angliplasty

(PTCA), or Coronary Angioplasty, is a non-surgical

procedure with minimal incisions used to open

narrowed blood vessels. This procedure uses a

flexible catheter with a balloon at the end, which is

inflated at high pressure inside the narrowed artery

wall. This action will plaque plaque in the blood

vessels and improve blood flow to the heart muscle.

This procedure can eliminate some of the symptoms

of artery blockage, such as chest pain or shortness of

breath. Nurses compliance in the femoral sheath

removal procedure in patients after PTCA is

associated with the incidence of hematoma, The

compression should be performed carefully and in

accordance with the standard operational procedure

to prevent the occurrence of vascular complications,

one of which is a hematoma. Yearly repetition of

training and observation of skills (supervision) will

improve the capacity of nurses’ knowledge and skills

in performing sheath removal procedures.

Limitations of the study were in terms of confounding

variables that can not be controlled by the researchers,

such as body surface, bleeding and blood clotting

period, which may affect the occurrence of

hematoma.

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

624

ACKNOWLEGEMENTS

Our deepest appreciation goes to our beloved families

for the endless love, pray, and support to keep going

and never giving up. we gratefully thank to the

principal of Stikes Hang Tuah Surabaya (Hang Tuah

Surabaya, Health Sciences Institute) for allowing us

to move forward and develop ourselves. Our gratitude

also goes to all the respondents.

REFERENCES

Benson, L. M., Wunderly, D., Perry, B., Kbboord, J.,

Wenk, T., Birdsall, B., & Nyirenda, T. (2005).

Determining best practice: comparison of three

methods of femoral sheath removal after cardiac

interventional procedures. Heart & Lung: The

Journal of Acute and Critical Care, 34(2), 115–

121.

European Society of Cardiology. (2010). Guidelines

for Myocardial Revascularisation.

Guyton, A.C., dan Hall, J. . (2008). Buku Ajar

Fisiologi Kedokteran (11th ed.). Jakarta: EGC.

Klemsová and Žiaková. (2014). Standardization of

the Possibility of Specialised Nursing Care After

Cardiac Catetrization, 7.

Merriweather, N., & Sulzbach-Hoke, L. M. (2012).

Managing risk of complications at femoral

vascular access sites in percutaneous coronary

intervention. Critical Care Nurse, 32(5), 16–29.

Niven, N. (2002). Psikologi Kesehatan Pengantar

Untuk Perawat Profesional Kesehatan lain.

Jakarta: EGC.

Ramzi S, dkk. (2004). Buku Ajar Patologi (7th ed.).

Jakarta: EGC.

Sabo, J., Chlan, L. L., & Savik, K. (2008).

Relationships among patient characteristics,

comorbidities, and vascular complications post-

percutaneous coronary intervention. Heart &

Lung: The Journal of Acute and Critical Care,

37(3), 190–195.

Schiks, S., Verheugt, A., & Achterberg. (2007).

Performance evaluation of arterial femoral sheath

removal by registered nurses after PCI. European.

Journal of Cardiovascular Nursing, 6(3), 172–

177.

Subagyo. (2012). Basic Clinical Approach In

Cardiovasculer Management. Surabaya: RSUD

Dr. Soetomo.

Sudoyo, A. (2006). Buku Ajar Ilmu Penyakit Dalam.

Jakarta: Fakultas Kedokteran Universitas

Indonesia.

Sulzbach-Hoke, L. M., Ratcliffe, S. J., Kimmel, S. E.,

Kolansky, D. M., & Polomano, R. (2010).

Predictors of complications following sheath

removal with percutaneous coronary intervention.

Journal of Cardiovascular Nursing, 25(3).

Walker, S. B., Cleary, S., & Higgins, M. (2001).

Comparison of the FemoStop device and manual

pressure in reducing groin puncture site

complications following coronary angioplasty

and coronary stent placement. International

Journal of Nursing Practice, 7(6), 366–375.

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