ARTERIAL MONITORING. Final Approval: VP Operations, Chief Nursing Officer Distribution: ICU, PACU POLICY:

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1 Policy Number: R-28 / Care of Patient 4.22 Section: Intensive Care Date Written: June 1988 Date(s) Revised: 8/98, 6/01, 11/03 Date(s) Reviewed: 4/92, 12/93, 7/95, 6/04 Reviewed/Approved by: Dept.Cmt. Date ICU Staff 3/04 OR Dir. 4/04 ICU Cmt 6/04 Final Approval: VP Operations, Chief Nursing Officer Distribution: ICU, PACU Date ARTERIAL MONITORING POLICY: An Arterial Catheter may be inserted by any Physician with arterial catheter/line privileges. Arterial monitoring is to be done in OR, PACU, and ICU by personnel trained in arterial line function. Arterial catheters are to be removed after 72 to 96 hours of use. All health care workers should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood or other body fluids of any patient is anticipated. A. Gloves should be worn for: 1. Touching blood and body fluids, mucous membranes, or non-intact skin of all patients. 2. Handling items or surfaces soiled with blood or body fluids. 3. Performing venipuncture and other vascular access procedures. 4. Gloves should be changed after each patient contact. B. Masks and protective eyewear or face shields should be worn during procedures that are likely to generate droplets or spray of blood or other body fluids to prevent exposure of mucous membranes of the mouth, nose, and eyes. C. Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or other body fluids. Gloves must be worn when working with arterial lines. When procedures are done with blood under pressure or when initiating arterial lines, gloves, mask, and goggles are to be worn. 1. Procedures for art line must be followed. 2. Hands must be washed prior to any arterial line procedure. 3. Materials for insertion will be located in the Arterial line box in ICU. Replacement box is maintained in CSS. 4. Qualified personnel are responsible for setting up the irrigation (flush) system using sterile technique cc NS with 1000 U of Heparin yielding a concentration ratio of 2:1 (heparin to NS) will be used as flush solution unless otherwise specified by the physician. Label the bag with additive used. A pressure bag inflated to 300 mm Hg. must be used to maintain patency. 6. Catheter site will be inspected and documented for signs of infiltration, infection, to ensure patency, and assess condition of extremity distal to insertion site for circulation every 2 hours and a minimum of every 4 hours. 7. Solution bag is to be changed every 72 hr. Tubing to be changed and site care done every 72 hr. and as needed. Prevention of line contamination should always be observed. 8. Trained RNs may draw arterial blood sample from the arterial line for laboratory tests ordered by the physician. 9. Calibrations and observation of wave forms visualized on the monitor to be done by personnel trained in Arterial Line function. Any changes in these wave forms should be investigated and if attempts to re-establish the wave forms are unsuccessful, the physician will be notified. Dual chamber waveforms (ECG & Art line) will be documented on set-up and every 8 hours with interpretation. 10. The printed dual-chamber waveform allows assessment of adequacy of waveform, dampening conditions, perfusion of ectopy, etc.

2 Arterial Monitoring Page Personnel trained in Arterial Line function must be aware of possible complications that could be encountered. These complications include, but are not limited to: thrombus formation, local obstruction with distal ischemia, external hemorrhage, false aneurysm, dissection, plaque dislodgment, renal shutdown (femoral artery catheter), sepsis, vasospasm, infection, and neurovascular compromise. SECTION 1: ASSEMBLY OF FLUSH SOLUTION AND TUBING (SINGLE SET) Intra-arterial pressure monitoring allows accurate measurement of systolic, diastolic, and mean pressure, and a simple access to arterial blood for arterial blood sampling. 1. Sterile technique to be used for entire procedure. 2. Materials are located on arterial line box in ICU or CSS. 500cc IV bag of Normal Saline (NS) 1000 units Heparin, TB syringe, IV additive tag Disposable transducer and system tubing Pressure bag Alcohol wipes Radial arterial cath kit Femoral arterial cath kit Wrist extension armboard RN responsible - all sections 1. Remove 500cc NS from protective bag. Inspect for leaks or defects and check expiration date. 2. Using aseptic technique, wipe Heparin port and NS bag injection port with alcohol and allow to dry. Draw up 1000 units Heparin and countercheck amount with another RN or LPN. Inject into NS bag. Complete and apply IV additive sticker to fluid bag. 1. If a defect is found, do not use. Return to CSS. 2. Use caution not to puncture bag with needle. Heparin is charged through Pyxis system. 3. Rotate bag to mix. 3. To prevent bolus of medication. 4. Remove monitoring tubing and inspect for cracks or defects. Tighten all connections and stopcocks. 5. Close roller clamp. 6. Remove cap from IV bag and from tubing puncture pin. 7. a. Twist puncture pin into port until well seated. b. Carefully remove spike from IV bag. Compress bag to remove all air in bag and replace spike snuggly into IV bag. 4. If defect is found, do not use. Return to CSS. Loose connections can cause bleed back into the tubing due to air leak. Select pressure monitoring tubing style with arterial blood collection syringe inline. 7. b. Removing all air from the IV bag is recommended for accurate pressure reading and prevention of air entering system of patient.

3 Arterial Monitoring Page 3 8. Fill drip chamber 1/2 full with fluid. 9. Open roller clamp and squeeze continuous flush device at transducer slowly to prime entire system including stopcock ports. 10. Turn stopcocks off to air, direct fluid through transducer, holding transducer. 11. Continue to turn stopcocks to direct fluid through all unprimed ports. *To prime stopcocks, open to air and squeeze flush device. Then turn stopcocks off. 12. After priming all stopcock ports, allow at least 30cc of fluid to pass through the distal end of the tubing. *After priming system, replace protective cap and stopcocks caps. 13. Apply pressure bag to Heparinized IV bag and inflate to 300mg Hg. 14. Wash hands. 15. Charge for the IV solution by placing bar coded sticker on CSS charge sheet. 10. To prevent air from being trapped in the tubing and giving inaccurate readings. 11. Allows removal of air from the tubing to prevent air embolism and inaccurate reading. 12. Dead end caps are furnished with the art line tubing kits. Dead ends should be used on stopcock ports to prevent inadvertently introducing foreign matter and bacteria into the system of the patient. 15. Heparin is charged through Pyxis. SECTION II: ASSEMBLY OF FLUSH SOLUTION AND TUBING (DOUBLE SET) Intra-arterial pressure monitoring allows accurate measurement of systolic, diastolic, and mean pressures, and a simple access to arterial blood for blood sampling. A tubing double set also allows for monitoring of pulmonary artery pressures through utilization of a Swan Ganz catheter. 1. Use sterile technique for entire procedure. 2. All equipment located on Invasive Monitoring box in ICU. 500cc IV bag of Normal Saline (NS) 1000 units Heparin, TB syringe, IV additive sticker Pressure bag Monitoring system tubing with flush device (2) Two-way pressure monitoring fluid administration set 1. Assemble equipment. 2. Wash hands. 2. Prevent cross contamination. 3. Remove 500cc NS from protective bag. Inspect 3. If a defect is found, do not use. Return to CSS. for leaks or defects and check expiration date. 4. Using aseptic technique, wipe Heparin port and 4. Use caution not to puncture bag with needle. NS bag injection port with alcohol and allow to dry. Draw up 1000 units Heparin and countercheck amount with another RN or LPN. Inject into NS bag. Complete and apply IV additive sticker to fluid bag. 5. Rotate bag to mix. 5. To prevent bolus of medication.

4 Arterial Monitoring Page 4 6. Remove both sets of pressure monitoring tubing and the two-way administration set from sterile package. Inspect for cracks or defects. Tighten all connections and stopcocks. 7. Disconnect both monitoring tubings at first connection below drip chambers by unscrewing connections. 8. Remove white cap from red connector of 2-way administration set and connect to first set of monitoring system tubing at first connection. 9. Remove white cap from blue connector of 2 way administration set and connect to second set of monitoring tubing at first connection 10. To prepare tubing, see arterial monitoring setting up tubing (single set) - Section I, steps Slide both slide clamps on the monitoring system tubings to the clamped position. 12. Open roller clamp and one slide clamp and pinch infusion clamp for rapid flush to prime IV tubing. 13. Follow steps of Section I to complete the priming procedure for the first line. 14. Repeat steps 12 and 13 above to prime the second line. 15. Apply pressure bag to Heparinized IV bag and inflate to 300mm Hg. 16. Wash hands. 17. Charge for the IV solution by placing bar coded sticker on CSS charge sheet. 6. If defect is found, do not use. Return to CSS. Loose connections can cause bleed back into the tubing due to air leak. SECTION III: ARTERIAL CATHETER INSERTION *Same definition as Section 1. To have access for intra-arterial pressure monitoring and access for frequent Arterial laboratory specimens. PURPOSE: To prepare the patient and assist with the insertion of an arterial catheter. 1. Tubing to be set up and flushed prior to insertion. (See Section I - Arterial Monitoring - Assembly of Flush Solution and Tubing) 2. If femoral arterial line is placed, femoral arterial art line kit located with Art line set-up box in ICU. 3. Extremity condition distal to insertion site should be inspected for circulation and movement. Alcohol swabs/chlorhexidine prep sponges. Sterile gloves Blue curved armboard for wrist extension 1" transpore tape Radial artery catheterization kit Femoral artery catheterization kit

5 Arterial Monitoring Page 5 1. Assemble equipment. 1. Have tubing flushed and IV at hand. 2. Wash hands. 2. Prevent cross contamination. 3. Follow Procedure 1-10 Intravenous Catheter Insertion & Infusion steps #19-24 for preparation of the insertion site. 3. Consider use of chlorhexidine for skin preparation prior to insertion, depending on physician preference. 4. Depending upon physician preference, the insertion arm may be secured prior to or after the insertion of the arterial catheter. 5. When necessary to secure arm to curved blue arm board, place arm on board with the arm hyper extended over the curved portion of the board. 6. Secure by wrapping 1" silk tape around palm and forearm at the ends of armboard. Be cautious not to impair circulation. 7. Physician and nurse to apply sterile gloves. 8. Assist doctor as needed during insertion. 9. Be prepared to insert end of tubing into catheter as soon as access is established. 6. Silk tape recommended as it allows the skin to breathe. 9. Maintain sterile technique. 10. Thoroughly flush line. 10. Prevent clotting of the catheter. 11. Wash hands. 12. See Section IV Securing of Arterial Catheter and Line. 13. Document procedure on IV flowchart and/or Arterial Monitoring section of ICU flowchart in Cardiovascular section. SECTION IV: SECURING OF AN ARTERIAL CATHETER AND LINE To immobilize the arterial catheter and tubing, to maintain optimal function of the catheter, in monitoring arterial blood pressure and obtain arterial blood samples, while maintaining sterility of the catheter insertion site. PURPOSE: To ensure the integrity and sterility of the arterial line. Transparent occlusive dressing 1" & 2" silk or plastic tape Sterile gloves Tincture of Benzoine 2" Gauze wrap (optional) Blue curved armboard Alcohol wipes 1. Assemble equipment. 2. Wash hands & apply sterile gloves. 2. Prevent cross contamination.

6 Arterial Monitoring Page 6 3. Carefully re-cleanse around insertion site with alcohol & allow to dry. 4. Apply tincture of Benzoine approximately 2" around the catheter insertion site and allow to dry. 3. Keep area sterile, decrease chance of infection. 4. Promote adhesive quality. Final Securing of Winged Catheter 1. Apply transparent occlusive dressing over the catheter insertion site. 2. If physician has not previously elected to secure arm to blue curved armboard do so at this time as needed. Place arm on board. 3. Secure by wrapping 1" silk tape around palm and forearm at the ends of the arm board. Be cautious not to impair circulation. 4. Apply 2" silk or clear plastic tape over catheter site and extend around blue arm board. 5. Secure tubing to armboard close to catheter insertion site. 1. Maintain sterility of the site. 2. Best position for optimal function and accessibility. 3. Silk tape recommended as it allows the skin to breathe. 4. Silk tape preferred as it allows the skin to breathe. 5. Length of tubing should be considered to allow for transducer mounting on IV pole bracket device at the bedside. 6. Wrap hand and distal arm with 2 gauze wrap. Optional. 7. Secure the remainder of tubing as appropriate. 7. Enough tubing should be allowed for unrestricted motion of the patient s arm. 8. Flush tubing briefly with flush device. 8. Assures patency of line. 9. Wash hands. 9. Prevent cross contamination. 10. Record procedure on IV flowchart and/or ICU flowchart under Arterial Monitoring section of cardiovascular assessment. 11. Note condition of distal extremity to insertion site for circulation and mobility. SECTION V: CALIBRATING TRANSDUCER To correctly calibrate art line system to assure accurate readings. 1. Calibration to be done once every 8 hours, whenever transducer cable is removed from monitor or whenever calibration is in question. 2. To calibrate transducer all stopcocks must have port caps which will open to air. 3. If a port is covered with a cap that is sealed to air, it is to be removed and replaced with a cap that will open to air maintaining sterility of caps and ports. 4. The appropriate scale must be used for pressure monitoring. During Arterial Pressure monitoring, either Scale 200 or 100 should be utilized. The scale setting selected is normally determined by the highest pressure shown by the wave form. As the setting is lowered, SCALE becomes more sensitive, so that the wave form is magnified. If after setting up the monitor, no waveform or a very small wave form appears on the scope, you may be on the wrong SCALE setting. When the monitor is turned on, it should automatically come on at a SCALE of 100. The SCALE settings for 200 indicate a range of 0-300mm Hg and should be used for Arterial Pressure Monitoring of the Radial, Brachial, Axillary, and Umbilical (neonatal). The SCALE is adjusted by pressing and releasing the SCALE button on the Press 1 line until the appropriate setting is shown in small numbers on the left side of the screen.

7 Arterial Monitoring Page 7 5. Turn on Alarms and set alarm limits. This will ensure close monitoring for accidental disconnection. 6. Activate dual channel recording of Art line pattern and ECG to produce documentation of information analysis. PURPOSE: To assure accurate reading for intra-arterial pressure monitoring. Alcohol wipe - If cap needs to be removed and replaced with a cap that will open to air. Disposable gloves 1. Wash hands. Wear gloves. 1. Prevent cross contamination. 2. If initiating monitoring, plug transducer cable into monitor at Pressure module site. 2. Align indentation on cord with plug in at the top and push straight in. 3. Push empty box on monitor screen, then push label select and select ART and S/D on Press 1 line. 4. Transducer must be taped or secured. See Section IV Securing of Arterial Catheter and Line. 5. Turn distal stopcock counter clockwise to be off to the patient and open to air. 6. Depress Zero button on bottom of monitor screen line for approximately two seconds and release. The numbers on the right side of the monitor screen directly across from the ART box should read or - is acceptable in either number. 7. If numbers do not read in the acceptable range, depress Zero button again as in Step If numbers still do not read in the acceptable range, Refer to Section X of this Procedure Arterial Catheter Trouble Shooting. 9. Turn the stopcock clockwise to the upright or midline position. 10. Thoroughly flush the Arterial Line. 10. Maintain patency of the line. 11. Remove gloves. Wash hands. 12. Systolic and diastolic high and low alarms can be set within guidelines determined by the physician Access to alarms on menu item Alarm Limits under Art box. 13. If a cap must be removed and replaced with a cap which opens to air, sterile technique must be maintained. The old cap is removed. The outside of the stopcock hub is wiped with alcohol and allowed to dry. Maintaining sterile technique, the new cap is secured to the port using a twisting, clockwise motion. 14. Thoroughly flush the Arterial Line. 15. Wash hands. 12. Access to alarm limits should be made in patient room. 13. Disposable gloves must be worn.

8 Arterial Monitoring Page Documentation zeroing transducer in CPSI Cardiovascular section of ICU flowchart Art line. 17. Document dual channel strip on rhythm analysis sheet. To change arterial line tubing and do site care. SECTION VI: TUBING CHANGE WITH SITE CARE *1. To be done every 72 hours and as necessary. 2. Assess condition of extremity distal to insertion site for circulation and movement. PURPOSE: To maintain proper function of the arterial monitoring system, to reduce the risk of infection, and to allow close examination of catheter insertion site. 500cc IV Bag of Normal Saline (NS) 1000 units Heparin TB syringe IV additive tag Disposable Transducer & System Tubing: Pressure tubing kit with Arterial blood collection syringe. Alcohol wipes Disposable gloves Transparent occlusive dressing 1" & 2" silk or clear plastic tape Tincture of Benzoin 1" silk tape 2" Gauze wrap - optional Sterile gloves 1. Wash hands. 2. Assemble equipment. 3. Wear gloves. 3. To prevent cross-contamination. 4. Carefully remove tape from Arterial line tubing. At this time do not remove any tape or occlusive 4. To prevent cath from dislodging during procedure. dressing being used to secure the catheter. 5. Remove gloves. Wash hands. 6. Refer to Section I of this Procedure Assembly of Flush Solution and Tubing (Single Set) for steps to prepare a new Arterial Monitoring system. Follow Steps At this point, thoroughly flush the system. 8. Release pressure from pressure bag. 9. Follow Steps 7-17 and from Section I listed above.

9 Arterial Monitoring Page Apply sterile gloves. Gloves and fluid-resistant gown should be considered. 11. Apply pressure at proximal end with finger or thumb. 12. Carefully remove tape and old tubing and quickly connect new tubing to hub. 13. Release pressure from end of catheter. 14. Immediately flush line. 15. Refer to Section IV of this Procedure Arterial Line Securing Site to complete the site care and securing of the site and tubing. Follow steps 3-5 and then to the appropriate area Final Securing of Winged Catheter included in Section IV to complete the procedure. 16. Wash hands. 17. Record procedure on IV flowchart and/or CPSI ICU flowchart under Arterial Line in Cardiovascular section. 10. Precautions for prevention of exposure to bloodborne pathogens need to be observed. SECTION VII: CHANGING OF FLUSH BAG SOLUTION FOR ARTERIAL CATHETER To properly change the Flush Bag Solution on a routine, every 72 hr. basis. 1. Sterile technique to be maintained during the entire procedure. 2. The procedure to be done every 72 hours. 3. When it is necessary to change the flush system tubing, every 72 hours, the flush bag is to be changed with the new system. Refer to Section VI of this procedure, Arterial line tubing change with site care for a guide to the proper technique to follow. PURPOSE: To maintain proper function of Arterial Monitoring System and reduce the risk of infection. 500cc IV bag of Normal Saline (NS) 1000 units Heparin TB syringe IV additive tag 1. Wash hands. 1. Prevent cross contamination. 2. Assemble equipment. 3. Remove 500cc NS from protective bag. Inspect for leaks or defects and check expiration date. 4. Using aseptic technique, wipe Heparin port and NS bag injection port with alcohol and allow to dry. Draw up 1000 units Heparin. Inject into NS bag. Complete and apply IV additive sticker to bag. 5. Rotate bag to mix. 4. Heparin concentration is 2:1 unless otherwise specified by the physician.

10 Arterial Monitoring Page Thoroughly flush Arterial Line System. 7. Release pressure from pressure bag and remove IV bag. 8. Remove cap from IV bag. 9. Using sterile technique remove puncture pin from present IV bag. 10. Twist puncture pin into new IV bag port until well seated. Carefully remove spike from IV bag, compress to remove all air from IV bag and replace spike snuggly into the IV bag. 11. Reapply pressure bag to Heparinized IV bag and inflate to 300 mm Hg. 12. Thoroughly flush Arterial line. 13. Wash hands. 14. a. Charge for IV bag on CSS charge sheet with bar coded label. b. Heparin is charged through Pyxis Record procedure in CPSI ICU flowchart and/or IV flowchart. 10. Be careful not to puncture bag with puncture pin. Removal of all air from the IV bag is recommended for accurate pressure reading and prevention of air entering the patient s system. SECTION VIII: OBTAINING BLOOD SPECIMENS FROM AN ARTERIAL LINE Drawing arterial blood sample from an arterial line for appropriate laboratory tests and procedures. To be done only by qualified registered nurses. Can be done by closed system technique. Can be done by open system technique. Monitor alarms should be disabled only during the time the line is closed off for the removal of the specimen. PURPOSE: To properly withdraw arterial blood specimen, using sterile technique, and maintaining patency of the Arterial Catheter. EQUIPMENT CLOSED SYSTEM: Appropriate lab blood tubes Alcohol wipes Protective needleless safety cannula cc syringes with luer loc tips Disposable gloves 1-2 needles to transfer specimen to lab blood tubes Vaccutainer with luer loc adapter needle PROCEDURE CLOSED SYSTEM: 1. Assemble equipment. Determine appropriate lab blood tubes for lab specimens ordered. 2. Wash hands. Apply glove. 2. Prevent cross contamination.

11 Arterial Monitoring Page Thoroughly flush arterial line to establish patency of line. Inactivate alarms. 4. Locate the in-line syringe in the pressure line system; locate the red-topped blood sampling site closest to the body. 5. Locate the stopcock closest to the in-line syringe and transducer. Turn this stopcock off to the transducer. 6. Grasp the flexures of the in-line syringe and slowly withdraw over 3-5 seconds. 7. Turn the stopcock to the in-line syringe off making sure the handle is perpendicular to the tubing. 8. Cleanse the sampling port with alcohol swab. 9. Attach a 10cc luer loc syringe onto the protective safety cannula. 10. With a clock-wise twist, push the cannula through the diaphragm of the red sampling site until the device is securely on the arterial line port. 11. Allow the syringe to fill passively or apply gently pressure to the syringe plunger. 12. If more blood samples are required, remove the safety cannula and syringe in one unit. Repeat steps 9-11 if more than 10cc sample is necessary. Use counter-clockwise twist to remove unit. 13. Clean the sampling site with an alcohol swab. 14. Open the line below the in-line syringe and slowly depress the flexures of the in-line syringe to flush the system. Make sure the plunger is fully depressed. 15. Open the stopcock between the syringe and the transducer and thoroughly flush the tubing and sample-site reservoir of blood. 16. Rezero transducer as detailed in Section V. Reactivate alarms. 17. Remove gloves and wash hands. Document specimen collection in CPSI. 3. An Arterial line that is clotted should not be used for blood sampling. 5. Check that any distal stopcocks are open. 6. Barrel holds 3cc of in-line syringe. Should resistance be felt during the withdrawal, reposition the extremity and tubing. 7. Blood should not reach the point of the in-line syringe barrel. 9. Make sure the plunger is depressed to the bottom. 12. If coagulation tests are ordered, obtain blood for these tests last. 14. All the fluid and blood should be reinfused following this maneuver taking 3-5 seconds. 15. Transfer blood specimens to tubes and label with patient s identification. 16. Check the monitor for return of the arterial waveform and pressure readings. EQUIPMENT OPEN SYSTEM: Appropriate lab blood tubes Alcohol wipes Disposable gloves PPE cc syringe with Luer loc 1 5cc syringe with Luer loc 1 package sterile 4 x 4 s 1 protective needleless safety cannula 1-2 needles to transfer into lab blood tubes PROCEDURE OPEN SYSTEM: 1. Assemble equipment. Determine labs to be obtained for appropriate lab blood tubes. 2. Wash hands. Apply gloves. 2. Prevent cross contamination. Personal protective equipment may also be warranted.

12 Arterial Monitoring Page Thoroughly flush arterial line to establish patency of line. Inactive alarms. 3. If arterial line is clotted, blood sampling will not be possible. 4. Open package of sterile 4 x 4's. 4. A clean field can be provided using a clean towel on the bedside table or flat area on bed surface. 5. Remove cap from stopcock port and place on sterile 4 x 4's. 5. If in-line syringe is present on tubing, follow steps 4-7 of Closed System procedure as stated above. 6. Secure 5cc luer loc syringe on port. 6. Hold syringe in upright position to facilitate flow of blood. 7. Turn stopcock clockwise away from patient, 7. To drain IV fluid and heparin from lines for more drawing 3cc of fluid and blood into syringe. 8. Return stopcock to middle position. Remove used 3cc syringe and discard. 9. Secure appropriate specimen syringe to port, e.g. 10cc luer loc syringe. 10. Turn stopcock clockwise away from patient, drawing needed blood into syringe. 11. Turn stopcock to middle position. Remove syringe and place cover over syringe hub. 12. Wipe off stopcock port and cap with alcohol wipes and allow to dry. accurate tests times the dead-space volume of the catheter and tubing should be discarded. 12. Maintain sterile port. Should sterility be lost, apply new, sterile, dead-end caps. 13. Replace cap. 14. Thoroughly flush arterial line of all blood. 14. If in-line syringe is present and has been used to withdraw 3 cc blood into tubing, follow steps of Closed System procedure as stated above. 15. Turn stopcock counterclockwise, off to patient. 16. Place sterile 4 x 4's beneath the stopcock and thoroughly flush the hub and cap. Solution flushed to be absorbed by the 4 x 4's. 17. Return the stopcock to the midline position and reflush the line. 18. Remove gloves and wash hands. Reactivate Arterial line alarms. To discontinue an arterial catheter. 16. Clotted blood in stopcock hub can affect accuracy of pressure readings. 18. Check the monitor for return of the arterial waveform and pressure readings. SECTION IX: DISCONTINUATION OF AN ARTERIAL CATHETER 1. Maintain sterile technique during the procedure. 2. Assess condition of extremity distal to insertion site for circulation and movement after removal of the catheter, and record. 3. Examine catheter for intactness after removal and record. 4. Discontinue heparinized solution ½ to 1 hour prior to removing the catheter by clamping off the flush solution with flow caps in line. PURPOSE: To discontinue an arterial catheter that is no longer necessary or is not functioning properly.

13 Arterial Monitoring Page 13 2 pkgs. of sterile 2 x 2's elasticon tape gloves Betadine ointment Clean towels For Specimen: Sterile collection container Sterile scissors Package 4x4 s 1. Assemble equipment. 1. Determine if tip of catheter will be cultured so contamination of specimen can be prevented. 2. Explain procedure to patient. Run a final monitor strip and obtain a manual Bp to establish a baseline. 3. Wash hands - apply gloves, apply PPE. 3. Prevent cross contamination, blood spray exposure. 4. Carefully remove tape from arterial line tubing. 5. Turn stopcock counterclockwise toward the patient. Turn off monitoring alarms. 6. Release pressure from pressure bag. 7. Remove tape and bioclusive from catheter insertion site, remove sutures, if present. 8. Place 2 x 2 over insertion site. 9. Apply pressure & remove catheter. 9. To stop blood flow to assure clotting. If catheter tip is to be cultured, place catheter on a sterile 4x4 until bleeding is controlled. 10. Continue to apply pressure to site for 5-10 minutes or until bleeding stops. 11. Apply Betadine ointment to insertion site. 12. Cover site with sterile 2 x 2 and elasticon tape for pressure dressing. 13. Check vital signs and insertion site within 30 minutes for signs of bleeding. 14. Remove gloves and wash hands. 15. Record procedure on IV flowchart and ICU flowchart under Cardiovascular section. 12. Pressure dressing should not encircle extremity. If femoral site has been used addition pressure measures may be required. 13. Check distal extremity for signs of ischenia from over-compression of arteries. If femoral site used, longer period of compression may be necessary. 15. Monitored site checks should be observed and recorded for 72 hours. SECTION X: ARTERIAL CATHETER TROUBLESHOOTING To have a systematic procedure to evaluate problems associated with arterial catheter monitoring and set guidelines to attempt to resolve or correct the problem. 1. This procedure is categorized by problems encountered with assessment and resolution steps.

14 Arterial Monitoring Page Absent or diminished Pulse distal to insertion site. a. When catheter placed in Radial artery, pulse should be checked either Ulnar or Palmar. b. Assess color, temperature, capillary refill, sensation and movement. 2. Bleed back or flashback of blood into tubing - may be observed with each pulse. a. Insufficient pressure on IV bag. Maintain 300mm Hg. pressure on IV bag. b. Loose connection reassess and tighten all connections. 3. Hemorrhage a. Due to loose connections. b. Keep all connecting sites visible and observe frequently. c. Use Luer-Lok stopcocks. 4. Local Infection a. May be due to forward movement of contaminated catheter or break in sterile technique. b. Always use aseptic technique. c. Daily inspect catheter site. d. Remove catheter after 72 to 96 hours of use. e. Change tubing every 72 hrs. Change flush solution every 72 hours. f. Carefully flush blood from tubing or stopcocks. 5. Hematoma after withdrawal of needle a. Maintain firm pressure on catheter site after withdrawal of catheter for 5-10 minutes or until all oozing stops. b. Apply elastic tape firmly over puncture site. 6. Damped pressure tracing a. May be due to occlusion in the l line. Verify that all blood has been flushed from the line and stopcock. SOURCES: Nursing Procedures, Springhouse Corp. 3 rd Edition 2000, pp AACN Procedure Manual for Critical Care, 4 th Edition, W.B. Saunders Co. Philadelphia PA, pp P:\INTCARE\icuR28r2-COP4.22.doc