On call and cross-cover

Triage on the phone

Most overnight pages about vascular patients come down to a short list: the limb, the incision or puncture site, the blood pressure, the urine and the heparin. Your first decision is made on the phone: how fast do you need to be at the bedside? When you are unsure, go and look.

The daytime versions of the common consults (the cold leg, the foot ulcer, the incidental aneurysm, the carotid stenosis, the venous consult) are on Rounds and presenting. This page covers the calls about patients already on the service, or just back from the operating room, the angiography suite or the CTV ICU.

The questions to ask every time

• Who, and what operation. Name, room, the operation and post-operative day, or the reason for admission. “POD 1 right fem-pop bypass” already tells you what to worry about.
• Vitals now, and the trend. Heart rate and rhythm, blood pressure against the ordered target, oxygen saturation, temperature, and urine output over the last few hours.
• The limb. Color, temperature, pain, movement and sensation, and whether the pulse or Doppler signal matches the baseline marked after surgery.
• The incision or access site. Swelling, bleeding, a soaked dressing, a new lump or a pulsatile mass.
• What changed, and when. When the patient was last normal, what has been given or stopped (heparin, antihypertensives, opioids), and whether this is sudden or has been building all evening.
• “What are you worried about?” A nurse who has been in the room all shift often knows something is wrong before the numbers show it. Treat that as data.

Closed-loop orders

Every order given by phone, or at a bedside in a hurry, is a chance for error. Close the loop: say the order, have the nurse read it back, confirm it, and then enter it in PowerChart yourself as soon as you can. Give parameters, not adjectives. “Call me if the systolic is above 160 or below 100” can be acted on; “call me if anything changes” cannot.

SBAR: how to call your senior

Nurses page you in SBAR, and your senior wants the same structure from you. It forces you to commit to an assessment and to a specific request.

Situation

Who you are, which patient, and the problem in one sentence.

Background

The operation and post-operative day, the baseline exam, the anticoagulation, and anything relevant from the day.

Assessment

What you found at the bedside and what you think it is. Say it even if you are unsure: “I'm worried the graft has thrombosed.”

Recommendation

What you have done and what you need: an order, a decision, or the senior at the bedside.

Document every call

Write a short event note for every call that needed a bedside visit or changed management: when you were called and why, what you found, what you did, who you discussed it with and when, and when you will reassess. The day team learns what happened overnight, and the record protects both the patient and you. A one-line entry is enough for a routine order; a cold leg or a neck hematoma deserves a full note.

Vascular surgery cross-cover event note
Called at [time] by [RN] for: ____________
Seen at bedside at [time]
Context: POD __ s/p ____________
  Baseline exam per sign-out: [__]
S: [what the patient and nurse report; onset]
O: T __  HR __ ([rhythm])  BP __  RR __  SpO2 __
   UO __ mL/h over the last __ h
   Limb: [pulses/Doppler vs baseline, color, temp,
          cap refill, motor, sensation, compartments]
   Site: [incision/access; hematoma marked __ cm at __]
   Labs: [__]
A: ____________
P: [orders given, read back and entered]
   Discussed with [name, role] at [time]: [plan]
   Reassess at [time]; RN to call if [triggers]

A vascular sign-out

The night goes well or badly depending on what was handed over at the end of the day. A vascular sign-out uses the usual I-PASS structure and adds three things: the baseline limb exam, the anticoagulation, and an explicit plan for the bad call.

I-PASS stands for illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by the receiver. Label each patient stable, watcher or unstable. Watchers are the patients you see on your first walk-through, before anyone calls about them. For a vascular patient, the summary and the contingencies need more detail than on most services.

What must be in it

Operation and post-operative day

The exact operation, the side and the conduit: “POD 0 left fem-AT bypass with reversed great saphenous vein,” not “bypass.” Add anything unusual from the case: a difficult anastomosis, a shunt, a long clamp time, a large blood loss.

Baseline pulse and Doppler exam

What is palpable, what is present on Doppler and where those signals were marked, plus the graft pulse if there is one, with the time and who examined it: “right DP biphasic, marked with an X; PT absent at baseline.” Without this nobody can tell at 3 a.m. whether a signal is lost or was never there.

Anticoagulation

What is running and its target (a heparin drip with its aPTT or anti-Xa range, or prophylaxis only), the antiplatelets, whether protamine was given in the operating room, and anything held for a procedure with its restart time.

Blood pressure target

Specific numbers, the reason and the drug to use: a systolic ceiling after carotid surgery, a mean arterial pressure floor with a spinal drain or a fresh graft.

Drains and lines

Each drain, its location, the output so far, and how much would be too much. Arterial and central lines, and where heparin flushes are running.

CSF drain, if present

The drainage parameters from the order (the pressure threshold and the maximum volume per hour), the leveling, the frequency of neurologic checks, and who adjusts it. See New leg weakness.

Labs to follow

The timed hemoglobin, the next aPTT or anti-Xa, the potassium after reperfusion, the platelet count on heparin, and the creatinine after contrast.

Contingencies

If-then statements with a name attached: “If the graft pulse is lost, examine, make NPO, send labs and call Dr. ___ directly.” “If the neck swells, call immediately.” Plus the code status.

Illness severity: stable / watcher / unstable
Patient: [name], [age], room [__], code status [__]
Operation: POD __ s/p [side] [operation], conduit [__]
  Case notes: [shunt, clamp time, EBL, hard anastomosis]
Baseline exam at [time] by [who] (P palp, D Doppler, 0 none)
  R: fem __ pop __ DP __ PT __ graft __
  L: fem __ pop __ DP __ PT __ graft __
  Marked signals: [e.g. R DP and graft, X on skin]
Incision / access site: [soft, no hematoma; closure device]
Anticoagulation: [heparin gtt __ U/kg/h, target __ / ppx]
  Antiplatelet, statin: [__]   Protamine in OR: [y/n]
  Held for procedure: [__], restart at [__]
BP target: SBP __ to __ / MAP > __   PRN: [__]
Drains, lines: [type, site, output __, call if > __ mL/h]
CSF drain: [none / level __, drain if > __ mmHg, max __ mL/h]
Labs to follow: [Hb at __, K, aPTT or anti-Xa at __, plt]
Action list: [ ] ____________  [ ] ____________
If / then:
  Graft pulse or signal lost: examine, NPO, labs, call [__]
  BP outside target: [__]
  [Neck swelling / leg weakness / UO < __]: call [__]
Synthesis: receiver read back [ ]

Lost pulse or cold leg after bypass or intervention Emergency

The call you never sit on. A pulse, graft pulse or Doppler signal that was present after surgery and is now gone means the revascularization may have failed, and the window to save it is measured in hours. Go now, compare with the baseline, and call.

The page. “The foot feels cold and I can't find the pulse you marked,” or “I can't get the DP on Doppler anymore.”

Ask first. “Was that signal there at the last check, and when was that?” Then: is the leg painful, numb or weak, what are the blood pressure and rhythm, and is heparin running? Tell the nurse you are coming now, to keep the leg level and warm with blankets (no heating pads on an ischemic limb), and to give nothing by mouth until you have seen the patient.

At the bedside

1. Compare with the documented baseline. Read the sign-out and the post-op check, then examine the leg yourself. A signal that was never there is not a lost signal, and a hurried Doppler can miss one that is present. If the chart is silent and the foot is cold, assume the change is new.
2. Doppler properly, both legs. Use plenty of gel at the marked spot, angle the probe at about 45 to 60 degrees to the vessel, and check the DP, the PT, the peroneal, and the graft itself where it runs superficially. A change in character (biphasic to monophasic) matters, not just present or absent. Use the other leg as the control.
3. Look at the whole leg. Color, temperature and where it changes, capillary refill, motor function (toe and ankle movement), sensation (including the first web space), and the calf compartments: tense, tender, painful on passive stretch. Check the incisions and the graft tunnel for a hematoma. After an endovascular case, look at the access site for a hematoma, a pseudoaneurysm or loss of the femoral pulse.
4. Check the rest of the patient. Blood pressure and heart rate, the rhythm (new atrial fibrillation suggests an embolus), volume status and urine output. Send a CBC with platelets, a BMP for potassium, coagulation studies, a type and screen and a lactate, plus a CK if the leg has been ischemic for a while.
5. Call your senior from the bedside. Give the finding, the baseline and the time course. Heparin (commonly an 80 U/kg bolus, then an infusion per the nomogram) is usually started for a suspected acute occlusion, but in a fresh post-operative patient that is the senior's call, weighed against bleeding. Keep the patient NPO for a possible return to the operating room or the angiography suite.

What it might be

Graft or stent thrombosis

Abrupt loss of the graft pulse and the distal signals. Failure in the first days is usually technical: a kink, a twist, a retained valve cusp, an intimal flap, a clamp injury or poor runoff. If the patient has been on heparin and the platelets are falling, think of HIT.

Embolus

Sudden onset, often with new atrial fibrillation, or debris dislodged during the procedure. Patchy mottling of the toes with palpable pedal pulses after aortic or endovascular work is microembolization (“trash foot”).

An access-site problem

After an endovascular case: thrombosis or dissection at the puncture, a closure device that has narrowed or occluded the common femoral artery, or a hematoma compressing the vessel.

Compartment syndrome

After reperfusion of a limb that was ischemic for hours: pain out of proportion, pain on passive stretch, tense compartments and numbness. Pulses are often still present.

Low flow state

Hypotension, low cardiac output, hypovolemia, vasopressors or hypothermia soften the signals in both legs. Correct the pressure and recheck quickly, remembering that a graft with low flow can also clot. A change in one leg only is not explained by low flow.

Groin bleeding, hematoma or a new mass after access

Most endovascular complications happen at the puncture, and many of them are found overnight. Good manual pressure stops most groin bleeding. The dangerous bleed is the one you cannot see.

The page. “The groin is oozing,” “the dressing is soaked,” or “there's a lump in the groin after the angiogram.”

Ask first. “Is it bleeding right now, and is someone holding pressure?” If it is bleeding, tell the nurse to press firmly with the fingers just above the puncture until you arrive. Then ask for the vitals, which side, the procedure and the sheath size, whether a closure device was used or a sheath is still in, and what anticoagulants, antiplatelets or lytics are running.

Manual pressure, done properly

1. Find the arteriotomy, not the skin hole. The needle enters the skin and travels upward at an angle, so the hole in the artery lies above the skin puncture, typically 1 to 2 cm higher. Feel for the femoral pulse just above the skin nick and press there, over the femoral head.
2. Press with your fingers. Use the fingertips of two or three fingers, or both hands stacked, firmly enough to stop the bleeding. Once it has stopped, ease off just enough for a distal pulse or Doppler signal to return, so the leg is not ischemic for the whole hold.
3. Hold for about 15 to 20 minutes without peeking. Watch the clock; it always feels longer than it is. Hold longer if the patient is anticoagulated, the sheath was large, or the bleeding restarts.
4. Release slowly and look. Check the site, the distal pulses and the vitals. If it bleeds again, hold again and call your senior.
5. Do not rely on a sandbag. A sandbag or a pressure dressing is no substitute for direct manual pressure, and a bulky dressing can hide a growing hematoma. Some units use mechanical compression devices per local protocol.

At the bedside

• Mark the hematoma. Outline its edges with a skin marker and write the time, so the next person can tell whether it is growing.
• Check the distal pulses. Compare with the baseline. A large hematoma can compress the artery, and the puncture site can thrombose.
• Send labs. Hemoglobin (repeat it in a few hours, because the first value lags behind the bleeding), platelets, coagulation studies and a type and screen.
• Keep the patient flat with the leg straight, per the post-procedure bed rest order.
• Raise reversal with the senior. Pausing a heparin infusion, giving protamine for procedural heparin, and holding antiplatelets are the senior's decisions, weighed against thrombosis of a fresh stent or graft. Never stop dual antiplatelet therapy after a new stent on your own.
• Bleeding on a lytic infusion. If the patient is on catheter-directed thrombolysis, anything more than minor oozing at the sheath means stopping the lytic, holding pressure, sending a fibrinogen with the CBC and coagulation studies, and calling immediately. See Thrombolysis.

What it might be

Why puncture location predicts the complication, and the closure devices themselves, are covered in Endovascular: closure and complications.

After carotid surgery: blood pressure, neck swelling, new deficit

Three calls follow a carotid endarterectomy, and to a lesser degree carotid stenting or TCAR: the blood pressure is out of range, the neck is swelling, or the neurologic exam has changed. The last two are among the most time-critical calls in surgery. Whatever the page was about, look at the neck and repeat the neurologic exam.

Blood pressure out of range

The page. “BP is 184/92 after the carotid,” or “BP is 88/50 and the heart rate is 48.”

Ask first. “What is the target in the orders, and does the patient have a headache, any neurologic change, or any neck swelling?”

The surgeon sets the target, so follow the order. A common pattern is a systolic ceiling somewhere between 140 and 160 mmHg and a floor around 100, with a lower ceiling when the risk of hyperperfusion is high. Swings are common because the operation disturbs the carotid sinus baroreceptors.

• Hypertension. It drives both neck hematoma and hyperperfusion syndrome. Treat the causes first: pain, a full bladder, hypoxia or hypercarbia, anxiety, missed home antihypertensives. Then treat to target with the ordered agent, typically IV labetalol or hydralazine on the floor, or a nicardipine or clevidipine infusion in the ICU or step-down unit.
• Hypotension and bradycardia. Usually baroreceptor stimulation, more common after carotid stenting because the stent stretches the bulb. Still exclude bleeding and myocardial ischemia with an exam and an ECG. Fluids, atropine or glycopyrrolate for symptomatic bradycardia, and a vasopressor such as phenylephrine if it persists, with the senior and usually in a monitored bed. Hypotension risks stroke and myocardial ischemia, so do not ignore it.

Neck swelling Emergency

The page. “Her neck looks bigger than it did,” “he says it's hard to swallow,” or “his breathing sounds noisy.”

Ask first. “Is the patient breathing comfortably and talking normally? Any stridor?” If there is any airway concern, have the nurse call a rapid response now and sit the patient up. You are going now either way.

1. Call your senior or attending immediately. An expanding neck hematoma after carotid surgery is an airway emergency. Call for airway help early, from anesthesia or the airway team, through a rapid response if needed. Intubation can be very difficult once the larynx is pushed aside and swollen.
2. Assess the airway. Sit the patient up and give oxygen. Look for stridor, voice change, tracheal deviation, difficulty handling secretions and rising anxiety. Mark the edges of the swelling.
3. Control the blood pressure. Hypertension feeds the bleeding, but the airway comes first.
4. If the airway is compromised, open the incision at the bedside. Cut the skin sutures or remove the staples and open the layer beneath (the platysma) to let the hematoma out, which decompresses the airway. Pack gently with gauze, hold pressure, and go to the operating room. When the airway is failing, this is done by whoever is at the bedside; it is not saved for the operating room.
5. Even a stable but enlarging hematoma usually goes back to the operating room. That decision belongs to the attending, which is why the call is still immediate. After TCAR the incision is small, but it can still hide an expanding hematoma.

New neurologic deficit Emergency

The page. “He isn't moving his right hand like he was,” “her face looks droopy,” or “he's having trouble getting his words out.”

Ask first. “When was the last normal neurologic check?” Then the blood pressure and a fingerstick glucose. You are coming now.

1. Examine quickly and precisely. Level of consciousness, speech and language, facial symmetry, strength in both arms and legs, and vision. Record the time you found the deficit and the last known normal.
2. Call the attending immediately. A deficit after carotid surgery may mean thrombosis or a flap at the endarterectomy site, and the surgeon may want an immediate duplex or a return to the operating room for re-exploration without waiting for other imaging. If hospital policy calls for a stroke alert on any new inpatient deficit, call it too, but the vascular attending must hear about it directly and at once.
3. Protect perfusion. Keep the blood pressure in the ordered range, avoid hypotension, and correct glucose and oxygenation. Do not start heparin or any stroke treatment on your own.

What it might be

• Internal carotid thrombosis or an intimal flap at the repair, more likely when the deficit appears on waking or within the first hours.
• An embolus from the endarterectomy site.
• Hyperperfusion syndrome or intracerebral hemorrhage: headache or seizure, usually later and with high blood pressure.
• Hypoperfusion from hypotension, hypoglycemia, or residual sedation, which is a diagnosis of exclusion.

Headache or seizure: hyperperfusion syndrome

Restoring normal pressure to a hemisphere that has been underperfused for a long time can overwhelm its impaired autoregulation. The picture is an ipsilateral headache, often severe, followed by confusion, seizures, focal deficits or intracerebral hemorrhage. It usually appears in the first days to a week, most often after a very tight stenosis, with poor collateral flow or a contralateral occlusion, and with poorly controlled blood pressure. Call your senior for any severe new headache after carotid revascularization. The workup is a CT of the head to exclude hemorrhage; the treatment is strict blood pressure control to a lower target set by the attending, plus seizure management.

Cranial nerve deficits

Usually traction injuries that recover over weeks, so not emergencies, but document them and tell the team in the morning, or sooner if swallowing or the airway is affected.

Hypoglossal (XII)

The tongue deviates toward the side of the operation, with clumsy speech and swallowing.

Vagus and recurrent laryngeal (X)

Hoarseness and a weak cough, with a risk of aspiration. If the patient coughs when drinking, keep them NPO until a swallow screen. A previous operation on the other side of the neck raises the stakes, because bilateral vocal cord palsy threatens the airway.

Marginal mandibular branch (VII)

Lower-lip asymmetry on the operated side (the corner of the mouth does not pull down on smiling), from retraction near the angle of the jaw. An isolated lower-lip weakness with an otherwise normal exam is this; a facial droop with any other deficit is a stroke until proven otherwise.

Superior laryngeal

Voice fatigue and difficulty reaching high notes.

After aortic surgery: urine output, abdomen, legs

After open aortic repair the night calls are about the urine, the abdomen and the legs. After EVAR they are mostly about the groins, the limbs and a fever. Most open repairs spend the first night or two in the CTV ICU, so many of these calls come after transfer to the floor.

Low urine output

The page. “Urine output has been 15 mL an hour for the last two hours.”

Ask first. “What is the trend over the last four to six hours, what are the blood pressure and heart rate, and is the abdomen distended?” Ask the nurse to check the catheter and tubing, and to bladder scan, while you walk over.

1. Check the catheter. Kinked or clamped tubing, a full bag, a clot. Flush it or bladder scan: a full bladder with a catheter in place means the catheter is blocked. Sudden anuria with a working catheter is a vascular problem until proven otherwise.
2. Assess volume and perfusion. Heart rate, blood pressure and mean arterial pressure, capillary refill, the drain and nasogastric output, the fluid balance since surgery, and the hemoglobin. Low urine output with hypotension after an aortic operation means bleeding until proven otherwise.
3. Feel the abdomen. A tense, distended abdomen with falling urine output (and, on a ventilator, rising airway pressures) needs a bladder pressure. See abdominal compartment syndrome below.
4. Send labs. A BMP for potassium and creatinine, a CBC, a lactate, and a CK if the legs were ischemic. Dark, tea-colored urine suggests myoglobin.
5. Give fluid if the patient is dry. A crystalloid bolus (for example 250 to 500 mL) once you are sure the patient is not overloaded, with the senior's agreement in an aortic patient. Do not reach for furosemide to treat a number.
6. Think of the aorta. A suprarenal clamp, a renal artery or graft problem (including a stented renal branch after complex EVAR), embolization to the kidneys, or contrast after EVAR. Imaging of the renal arteries is the senior's call.

Abdominal compartment syndrome Emergency

Most likely after repair of a ruptured aneurysm (open or endovascular) with massive resuscitation, or with a large retroperitoneal hematoma. The signs are a tense, distended abdomen, falling urine output, hypotension, a rising lactate and, on a ventilator, rising peak airway pressures. Measure the bladder pressure: patient supine, at end-expiration, transducer zeroed where the mid-axillary line crosses the iliac crest, with no more than 25 mL of saline instilled. A pressure of 12 mmHg or more is intra-abdominal hypertension; a sustained pressure above 20 mmHg with new organ dysfunction is abdominal compartment syndrome. Call immediately. Treatment ranges from sedation, gastric and rectal decompression and limiting fluid to decompressive laparotomy, which is the senior's decision.

Diarrhea, especially bloody: colon ischemia Emergency

The page. “He just had a loose, bloody bowel movement,” two days after an open repair.

Ask first. “What are the vitals, and is the abdomen more painful or distended?” Then go and see.

When the inferior mesenteric artery and the internal iliac supply are interrupted and the collaterals are not enough, the left colon and sigmoid can become ischemic. Bloody diarrhea after aortic surgery is colon ischemia until proven otherwise. Any early diarrhea, a rising lactate, unexplained acidosis, fever, a rising white count, or worsening abdominal pain or distension should raise the same question. It is far more common after a ruptured repair.

• Call your senior now. The diagnosis is made by bedside flexible sigmoidoscopy, arranged by the senior. A CT can miss early mucosal ischemia.
• In the meantime. NPO, IV fluids, a CBC, BMP and lactate, and broad-spectrum antibiotics if the senior agrees. Avoid hypotension.
• Why the urgency. Mucosal ischemia may settle with support; transmural necrosis needs a colectomy and is often fatal when found late. C. difficile or laxatives are diagnoses to make after ischemia has been considered, not before.

Cold, mottled or painful feet

After aortic surgery, check the feet against the baseline. Patchy mottling of the toes with palpable pulses is usually microembolization (trash foot), managed supportively. Loss of a femoral or pedal pulse that was present suggests limb thrombosis, a kinked graft limb, a dissection or a large embolus, and is handled exactly like a lost pulse after bypass: call now. A tense, painful calf after a long clamp time is compartment syndrome until proven otherwise.

Back pain or hypotension

After open repair, hypotension with a falling hemoglobin means bleeding (an anastomosis, a lumbar artery, coagulopathy or hypothermia) until proven otherwise. After EVAR, think of the access sites, a retroperitoneal bleed from an iliac injury, and, rarely, rupture from a type I or III endoleak. Myocardial infarction is the other early killer, so get an ECG and a troponin. Resuscitate, send a CBC, coagulation studies and a type and cross, and call now. The full workup is under Hypotension.

After EVAR

The access sites

Large-bore femoral punctures closed with a suture-mediated device, or groin cutdowns. Check them with the distal pulses as in Groin bleeding.

Limb occlusion

A new cold, painful leg or loss of a femoral pulse on one side, most often in the first weeks to months, and sometimes on the first night. Treat it as a lost pulse and call now.

Post-implantation syndrome

Fever, malaise and a raised white count and CRP in the first few days without infection: an inflammatory response to the graft. It is self-limited and treated with antipyretics, but it is a diagnosis of exclusion, so examine the groins, lines, lungs and urine and culture as you would for any post-operative fever.

The kidneys

Check the creatinine after the contrast load, especially with chronic kidney disease.

Spinal cord ischemia

Rare after a standard infrarenal EVAR and more common after TEVAR and fenestrated or branched repairs. Any new leg weakness is an emergency: see New leg weakness.

The operations themselves, with endoleaks, are in Open AAA repair and EVAR and endoleaks.

New leg weakness after aortic repair Emergency

Spinal cord ischemia can follow TEVAR, fenestrated or branched EVAR and open thoracoabdominal repair, and occasionally an infrarenal repair. It often appears hours to days after surgery rather than on waking, and quick action can reverse it. New weakness or numbness in the legs is an emergency until proven otherwise.

The page. “She can't lift her legs the way she could at the last check,” “he says his legs feel numb,” or “the spinal drain is alarming, leaking or draining a lot.”

Ask first. “When were the legs last normal, what is the MAP right now, and is there a spinal drain in?” You are coming now.

At the bedside

1. Call the senior and attending immediately, and the CTV ICU team if the patient is there. This is a team response that usually needs ICU-level care.
2. Examine and time it. Strength in each leg by muscle group, sensation and any sensory level, and the time of the last normal exam. Check the pulses: a cold, weak leg may be acute limb ischemia, not the spinal cord.
3. Raise the MAP. To the protocol's rescue target, commonly 90 mmHg or higher, with fluid, blood if the hemoglobin is low, and a vasopressor such as norepinephrine. Stop antihypertensives and treat any hypotension at once.
4. Drain CSF per protocol if a drain is in. Check that it is patent, leveled and zeroed, then lower the drainage threshold to the protocol's rescue setting and drain within its hourly maximum (commonly 10 to 20 mL per hour). Over-draining risks intracranial hemorrhage.
5. Optimize oxygen delivery. Hemoglobin to the protocol target, oxygenation, and cardiac output.
6. If there is no drain, discuss emergent placement. The attending and anesthesia weigh emergent lumbar drain placement against the timing of anticoagulants and antiplatelets and the platelet count, under neuraxial guidelines.
7. Repeat the exam often, at least hourly, and document each one with the time and the MAP.

What it might be

• Spinal cord ischemia from coverage or loss of the intercostal and lumbar supply, made worse by hypotension or anemia.
• A spinal epidural hematoma from the drain or an epidural catheter, especially on anticoagulation. This needs urgent MRI and neurosurgery.
• Acute limb ischemia: a cold, pulseless, weak leg.
• Motor block from an epidural infusion. Stop it and reassess with the acute pain service, but do not settle on this until the cord has been considered.
• Stroke if an arm is involved; less often hypokalemia or a peripheral nerve injury.

Heparin drips, bleeding and HIT

Heparin is behind a large share of overnight pages on a vascular service. Most are routine adjustments. Bleeding on heparin and a falling platelet count are not, and both need your senior.

Routine nomogram calls

• Follow the hospital nomogram. Adjust the rate to the measured aPTT or anti-Xa level exactly as the protocol says. Most hospitals monitor with one test or the other, not both. Do not freelance doses.
• Know which intensity was ordered. Targets, and whether to bolus, differ by indication: a full therapeutic nomogram with a bolus (commonly 80 U/kg, then about 18 U/kg per hour) for acute limb ischemia or venous thromboembolism, and often no bolus and a lower target soon after surgery. The order should say which.
• Know the range. A common anti-Xa target for unfractionated heparin is 0.3 to 0.7 IU/mL. aPTT ranges are calibrated by each laboratory, so use the number in the order set.
• Check that the level is real. It should be drawn about six hours after a start or a rate change, and never from the arm or line the heparin is running into. A recent dose of apixaban or rivaroxaban falsely raises the anti-Xa level, so tell the pharmacist and the senior if the patient was taking one.

Holding before procedures

Many vascular procedures are done with heparin running, so never hold it without a clear instruction: who said to hold it, from when, and when to restart. For neuraxial procedures, including placing or removing a spinal drain or an epidural, the American Society of Regional Anesthesia guidance applies: an IV heparin infusion is typically stopped 4 to 6 hours beforehand, with normal coagulation tests, and restarted no sooner than an hour afterward. Confirm the plan with anesthesia, and write the hold and restart times in the order and the sign-out.

Bleeding on heparin

1. Assess how bad it is. Where, how much, and the vitals. Apply direct pressure to anything external.
2. Stop the infusion for significant bleeding and call your senior. IV heparin has a short half-life (roughly an hour to an hour and a half at therapeutic doses), so its effect fades within a few hours of stopping. For minor oozing the senior may prefer a pause or a lower target.
3. Send labs. CBC with platelets, aPTT or anti-Xa, fibrinogen, and a type and screen or crossmatch.
4. Discuss protamine with the senior. About 1 mg reverses 100 units of heparin. For an infusion the dose covers the heparin given over roughly the last 2 to 3 hours: a drip at 1,200 units per hour has delivered about 3,000 units in the last two and a half hours, so about 30 mg. The maximum single dose is 50 mg, given slowly (no faster than about 5 mg per minute) because it can cause hypotension, bradycardia and anaphylaxis, more so with prior protamine exposure, NPH insulin use or fish allergy. It only partly reverses low-molecular-weight heparin.
5. Weigh the graft and the limb. Stopping or reversing heparin can let a fresh graft or an ischemic limb clot. That trade-off is why reversal is the senior's decision.

Falling platelets and HIT

Platelets fall after most operations from hemodilution and consumption, usually in the first few days, and then recover. Heparin-induced thrombocytopenia is different. It is an immune reaction to the complex of platelet factor 4 and heparin that typically drops the count by more than half, 5 to 10 days after heparin was started (or within a day if the patient had heparin in the past month), and it causes thrombosis, not bleeding. On a vascular service that thrombosis may be the graft. Use the 4T score to estimate the probability.

A score of 0 to 3 is low probability, and current ASH guidance is not to test and to continue heparin. A score of 4 to 5 is intermediate and 6 to 8 is high: treat as HIT while the tests are pending, with your senior.

Dialysis access calls

Fistulas and grafts generate their own calls. A clotted access can usually wait for a planned procedure, as long as the potassium and the volume status allow. Bleeding from an access and a cold, weak hand cannot wait. The operations are described in Hemodialysis access.

No thrill: a clotted fistula or graft

The page. “Dialysis says there's no thrill in his left arm graft,” or “the patient says the buzz is gone.”

Ask first. “When was it last used or felt, when is dialysis due, and what is the potassium?”

• Examine it. Feel along the access for a thrill and listen for a bruit. No pulse and no thrill means thrombosis; a strong, bounding pulse with no thrill means the outflow is blocked. Check the hand, and look for infection (redness, tenderness or drainage over a graft), which changes the plan.
• Protect the arm. No blood pressure cuffs, IVs or blood draws on that side.
• Check the potassium and volume. Send a BMP, CBC and coagulation studies. Hyperkalemia or fluid overload that cannot wait for a declot means a temporary dialysis catheter and a call to nephrology tonight.
• Plan for thrombectomy. Endovascular or open, ideally within a day or two and before the next dialysis, so the patient avoids a catheter. Keep the patient NPO after midnight if the senior plans it for the morning.

Bleeding from a fistula or graft Can be an emergency

The page. “The fistula is still bleeding after dialysis,” or “there's blood everywhere from his arm.”

Ask first. “Is someone pressing on it right now?” Tell the nurse to press firmly and directly on the bleeding point with two fingers, keep pressing, and not to use a tourniquet. Then ask for the vitals. You are coming now.

1. Firm digital pressure on the bleeding point. Two fingers directly over the hole, firm enough to stop the bleeding while, ideally, the thrill persists. Hold for 10 to 15 minutes with the arm raised. A tourniquet can thrombose the access and is a last resort only for life-threatening bleeding that direct pressure cannot stop.
2. Look at the skin. Bleeding through thin, shiny, scabbed or ulcerated skin over an aneurysmal fistula or graft is a herald of rupture. That is an emergency even if the bleeding has stopped: call now, and keep the patient monitored until the senior has seen them.
3. Send labs and ask about heparin. CBC and coagulation studies, and find out whether heparin was given during dialysis. Protamine is the senior's decision.
4. Close the hole if pressure fails. A figure-of-eight or purse-string skin suture around a needle site, or a topical hemostatic agent, controls most needle-site bleeding. Your senior may ask you to place one.

Cold, painful or weak hand: steal and neuropathy

The page. “Her hand is cold and numb since the fistula operation,” or “it hurts during dialysis.”

Ask first. “Is it new since today's surgery, and can she move and feel her fingers?”

Compare both hands: color, temperature, capillary refill, the radial pulse or Doppler signal, and motor and sensory function. In steal, the hand improves when you compress the access.

Access-related hand ischemia steal

A cool, pale, painful hand, worse during dialysis, with a weak radial signal that improves when the access is compressed. Mild coolness with normal motor and sensory function can be documented and reviewed in the morning. Rest pain, a new motor or sensory deficit, or tissue loss needs a call now for revision or ligation.

Ischemic monomelic neuropathy

Sudden severe pain, weakness and numbness of the hand immediately after the operation, typically with a brachial artery-based access in a patient with diabetes and neuropathy, yet with a warm hand and a palpable pulse or Doppler signal. It is a surgical emergency, usually treated by ligating the access: call now.

Swollen arm after access

Some swelling after access surgery is expected and settles with elevation. A markedly swollen arm, sometimes with swelling of the face or breast and dilated veins over the chest wall, suggests central venous stenosis unmasked by the new high flow, usually from previous catheters or pacemaker leads. It is worked up with a fistulogram or venogram during the day. Check the hand perfusion and the forearm compartments, consider DVT, a hematoma or infection, and call if the hand is threatened or the arm is tense and painful.

Wounds, amputations and wound vacs

Wound calls are rarely emergencies, with three exceptions: bleeding, especially from a wound over a graft or an artery; a rapidly spreading infection; and an injured stump.

Wound vac alarms and leaks

The page. “The wound vac keeps alarming,” or “it won't hold a seal.”

Ask first. “Which alarm, how long has suction been off, and is there blood in the tubing or the canister?”

1. Look for blood first. Frank blood in the canister or tubing means stopping the suction, holding pressure over the wound and calling now, especially if the vac sits over a groin, an exposed vessel or a graft.
2. Find the leak. Listen for the hiss, smooth or patch the drape with extra film, and check for kinked tubing, a full or unseated canister, and a dead battery.
3. If you cannot restore the seal. Most manufacturers and wound teams advise that foam left without suction for more than about two hours be replaced with a moist saline gauze dressing until the vac can be reapplied. Check with the senior first if the vac covers a graft, an exposed vessel, a fasciotomy or an open abdomen.
4. Count the foam. If you remove it, record how many pieces came out against the number documented at placement.

Bleeding or injured stump

The page. “The BKA dressing is soaked through,” or “he fell trying to get to the bathroom.”

Ask first. “How much, is it still bleeding, and what are the vitals?” Then: what anticoagulants are running?

• Take the outer dressing down and look. Most bleeding is ooze from the skin edge and stops with firm direct pressure and a fresh compressive dressing.
• Brisk bleeding. Hold firm pressure and call now. For arterial bleeding that pressure cannot control, a tourniquet above the stump is a reasonable bridge to the operating room.
• A fall onto the stump. New amputees often forget the leg is gone when they get up at night. Look for dehiscence, a hematoma or bleeding, and call if the incision has opened.
• Labs. CBC, coagulation studies and a type and screen; anticoagulation decisions are made with the senior.

Dusky flap or incision edge

The page. “The skin edges on the amputation look dark,” or “the flap looks purple.”

Check that the dressing or elastic wrap is not too tight and loosen it, look for a hematoma under the flap, and check the limb perfusion against the baseline. Outline the area with a marker, note the time, and photograph it if hospital policy allows, so the morning team can judge the trend. A dusky edge is usually reviewed on rounds. Call if it is spreading quickly, if a pulse or signal has changed, or if there is crepitus, foul drainage or systemic illness.

Fever with a wound

Fever in the first 48 hours after surgery is usually inflammatory, but on a vascular service always look at every wound: take down the dressings, including the groins and the vein harvest sites. Then work through the usual sources (lines, lungs, urine, C. difficile if there is diarrhea, and DVT), with blood cultures if the patient is febrile and unwell. Some findings change the urgency.

• Necrotizing soft tissue infection. Pain out of proportion, rapidly spreading erythema, bullae, crepitus, thin gray drainage and systemic toxicity. Call now: it needs operative debridement.
• An infected groin over a graft. Purulent drainage, a groin wound that opens down toward a graft, or any bleeding from an infected groin, which can herald anastomotic disruption. Call now.
• Wet gangrene or a foot abscess. Sepsis from the foot needs source control, sometimes a guillotine amputation. Send cultures, start antibiotics and call. See The diabetic foot.

Chest pain, new AF, hypotension

The vascular patient is a cardiac patient. Myocardial infarction is the leading cause of death after open aortic surgery and a major cause after other vascular operations, and most perioperative myocardial injury is silent. Take every cardiac call seriously, and think about the limbs and grafts at the same time.

Chest pain

The page. “He's complaining of chest pressure.”

Ask first. “What are the vitals and the rhythm? Please get a 12-lead ECG now.” Then go.

1. ECG within 10 minutes, compared with the old one. ST elevation means activating the cardiology or cath lab pathway per local protocol and calling your senior at the same time, because anticoagulation and antiplatelets after fresh surgery are a joint decision.
2. Examine. Vitals, lungs, volume status, the incisions and the limbs. Consider the other causes: pulmonary embolism, aortic dissection (especially with known aortic disease), pneumonia, reflux and musculoskeletal pain.
3. Send labs. A troponin, repeated per the hospital's high-sensitivity protocol, with a CBC, BMP and magnesium.
4. Treat the cause. Much perioperative ischemia is a supply and demand mismatch from anemia, tachycardia, hypotension, hypertension or pain. Continue the home aspirin, statin and beta-blocker unless the patient is hypotensive or bleeding, and do not give nitroglycerin to a hypotensive patient.
5. Call your senior and involve medicine or cardiology per the service's usual pattern for a troponin rise.

New atrial fibrillation

The page. “Heart rate is 140 and irregular. That's new.”

Ask first. “What's the blood pressure, and is the patient short of breath, confused or having chest pain?” Ask for an ECG.

1. Decide whether it is unstable. Rapid AF with hypotension, ischemia, pulmonary edema or altered mental status calls for a rapid response and synchronized cardioversion.
2. Look for the trigger. Pain, bleeding or hypovolemia, hypoxia, sepsis, pulmonary embolism, ischemia, a missed home beta-blocker, and electrolytes. Replace potassium to about 4 and magnesium to about 2.
3. Control the rate. IV metoprolol or diltiazem if the blood pressure allows, or amiodarone if the pressure is borderline or the ejection fraction is low, with the senior. Restart home rate control.
4. Think embolism. New AF is an embolic source, so check the feet, the grafts and the neurologic exam. Anticoagulation for new post-operative AF balances bleeding against stroke and limb risk, and it is rarely started overnight without discussion with the senior.

Hypotension

The page. “Blood pressure is 82/45.”

Ask first. “What was it before, what's the heart rate, is the patient awake and making urine, and is there new pain, bleeding or drain output?”

1. Bleeding first. Look at every incision, both groins, the drains and the abdomen, and ask about back or flank pain. Send a CBC (the first hemoglobin can be normal in acute bleeding), coagulation studies and a type and cross, and place two large-bore IVs.
2. Resuscitate while you think. A fluid bolus if there is no sign of overload, and blood if the patient is bleeding, with the senior.
3. Work through the rest. Cardiac causes (an ECG for ischemia or arrhythmia), sepsis, medications (antihypertensives, opioids, and an epidural infusion, a common and easily missed cause), baroreceptor effects after carotid surgery, pulmonary embolism, and adrenal insufficiency in patients on chronic steroids.
4. Check the limbs and grafts. Low flow can clot a fresh graft. Recheck the signals once the pressure is restored.

When to wake your senior or attending

On a vascular service the rule is simple: if you are wondering whether to call, call. No one is ever criticized for calling about the situations below. A senior woken for a false alarm is far better than a graft or a limb lost to a call put off until morning.

Always call, right away

• Any loss of a previously present pulse, graft pulse or Doppler signal, or a cold, pale, mottled, numb or weak limb after revascularization.
• Any new neurologic deficit, including new leg weakness after aortic repair and any change after carotid surgery.
• Neck swelling after carotid surgery, or any trouble breathing or swallowing.
• Suspected rupture or retroperitoneal bleeding: hypotension with back, flank or abdominal pain, a falling hemoglobin, or bleeding that pressure does not control.
• Suspected compartment syndrome, in a limb or in the abdomen.
• Bloody diarrhea after aortic surgery, or any early diarrhea after aortic repair.
• Bleeding from the skin over a fistula or graft, or significant bleeding on a lytic infusion.
• Suspected HIT (a 4T score of 4 or more) or a new thrombosis on heparin.
• A spinal drain problem, or headache or drowsiness in a patient with a drain.
• A rapid response, a code, an unplanned ICU transfer, a STEMI or an unstable arrhythmia in a vascular patient.
• Any patient you are worried about, or whom the nurse is worried about, even if you cannot yet say why.

Making the call count

Call from the bedside or with the chart open, use SBAR, and end with a specific question. Have the vitals, your exam compared with the baseline, the relevant labs, and what you have already done. But never delay a come-now call to collect data. “I'm at the bedside, the graft pulse is gone, I'll call back with the labs” is the right first call.