Manual Compression

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Digital compression should be considered the gold standard for compressive methods. Performed properly, it can prevent bleeding and maintain distal perfusion. This procedure may be performed by a physician, nurse, or technician who has received formal training.

Before sheath removal, the distal pulses and the access site are assessed for signs of an existing hematoma. The duration of manual compression and the time of immobilization are proportional to the size of the introducer sheath and the level of anticoagulation. Although manual compression technique is

Popliteal Artery Puncture Technique
Figure 28-6. Puncture technique for the popliteal artery.

effective with smaller sheath sizes, it becomes more challenging and hazardous with increasing sheath sizes. The recommended compression time should be 10 minutes of "firm" pressure, 2 to 5 minutes of "less firm" pressure, and 2 minutes of light pressure while doing the pressure dressing. If bleeding continues, another 15 minutes of pressure should be applied.

Risk factors for prolonged bleeding include severe atherosclerosis at the puncture site and a loss of elasticity without adequate approximation of the vessel edges after removing the sheath. Other risk factors for bleeding include the sheath size, anticoagulation level at the time of sheath removal, aortic regurgitation, elevated blood pressure, obesity, and older age. The use of manual compression has the advantage of continuous observation and modulation of vascular compression. However, it has the disadvantage of requiring a staff member to be available, prolonged immobilization, and bedrest increasing patient discomfort and length of hospital stay. The Compass System (Advanced Vascular Dynamics, Vancouver, WA) is a manual compression-assist device developed to enhance comfort for patients and practitioners. It includes a handle and the detachable sterile and

Clamp Stop Bleeding

Figure 28-8. The C-clamp is a mechanical compressor system for femoral puncture sites. The disk that applies pressure rests on the vessel entry point. (Photo courtesy of Advanced Vascular Dynamics, Vancouver, WA, 2006.)

Figure 28-8. The C-clamp is a mechanical compressor system for femoral puncture sites. The disk that applies pressure rests on the vessel entry point. (Photo courtesy of Advanced Vascular Dynamics, Vancouver, WA, 2006.)

Figure 28-7. A, Compass compression assist device. B, The Compass is placed over the femoral sheath before pulling it. Then, more comfortable manual pressure is applied. (Photo courtesy of Advanced Vascular Dynamics, Vancouver, WA, 2006.)

disposable disk. Practitioners apply external pressure using the Compass in much the same way that they would apply manual pressure (Fig. 28-7).

A vascular C-clamp (Advanced Vascular Dynamics) may be substituted for manual compression (Fig. 28-8). It consists of a flat, metal base; a pivoting metal shaft attached to the base; and an adjustable arm lever to hold the desired level of pressure. Disposable plastic compression disks, which are attached to the arm, apply pressure over the desired area. This approach has the advantage of freeing up personnel for other functions. It provides pressure over a relatively small area. Its limitations include the inability to modulate pressure easily and some discomfort from the device.

The Femo-Stop (RADI Medical Systems, Reading, MA) is a pneumatic pressure device that uses a clear plastic compression bag that molds to skin contours (Fig. 28-9). The Femo-Stop is composed of a plastic arch, inflatable transparent dome, connection tubing, a stopcock, an elastic or adjustable belt, and a handheld manometer. It is held in place by straps passing around the hip. The amount of applied pressure may be modulated and observed with sphygmomanome-ter gauge. It allows visualization of the puncture site. The Femo-Stop is frequently indicated for compression to repair pseudoaneurysms.

The Safeguard (Datascope Interventional, Mahwah, NJ) is a product for post-hemostasis puncture-site management that combines a built-in inflatable bulb and a sterile dressing providing adjustable pressure to the site. The device has a clear window that allows staff to easily assess the site without removing the device. Safeguard is ideal for noncompliant patients or overweight patients (Fig. 28-10).

Compressor Arteria Femural
Figure 28-9. A, The Femo-Stop pressure system with the sphygmomanometer. B, The belt should be aligned with the puncture site equally across both hips.

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