CENTRAL IOWA HEALTHCARE Marshalltown, Iowa

Transcription

1 CENTRAL IOWA HEALTHCARE Marshalltown, Iowa INTENSIVE CARE UNIT POLICY & PROCEDURE Policy Number: R-28/4.22 Subject: Purpose: Policy: Arterial Monitoring Use of intra-arterial pressure monitoring allows accurate measurement of systolic, diastolic, and mean pressures, as well as an access to arterial blood for sampling. Arterial pressure monitoring can be done in the OR, PACU, Cath Lab, or ICU. An Arterial catheter may be inserted by any privileged physician or Anesthesia provider Universal Precautions are necessary due to possible exposure of blood by spray or droplets under pressure. Arterial catheter may be utilized and maintained up to 96 hours after which the catheter will be removed. Additional Information: 1. Materials for assembly and insertion are kept in ICU artline box, Cath Lab supplies, and Materials Department. All materials will be checked for leaks or defects before use. 2. Flush solution: a) 500ml bag of Premix Heparin Solution. b) ratio 2:1 Heparin to normal saline; 1,000 units Heparin in 500ml saline. c) components, heparin, checked with 2 RN s. d) bag contents labeled with date, time and contents. 3. Neurovascular status of extremity distal to insertion site will be checked every 2 hours; system flushed every 4 hours. 4. Dressing change over insertion site every 72 hours with tubing and fluid change. 5. Expected outcomes: a) minimal discomfort. b) minimal bloodloss; no hematoma. c) infection-free insertion site; aseptic pressure system. d) adequate circulation of extremity. e) adequate sensory and motor function of extremity. 6. Dual chamber waveform (ECG and Pressure Line) will be documented, if possible, on setup and every 8 hours to allow assessment of adequacy of waveform, dampening, perfusion of rhythm, etc. 7. Approved procedure detailed in AACN Procedure Manual for Critial Care, 6 th Edition, 2011 Elsevier, Saunders Co., Philadelphia a) preparation b) insertion c) securing arterial line (art line) d) obtaining blood specimens e) tubing and dressing change f) single and multiple pressure transducer system g) transducer calibration and flushing h) arterial catheter troubleshooting: i) Over dampened and underdampened waveform ii) Absent waverform iii) Blood back-up into tubing

2 8. See Policy CL-39 Catheter and Introducer Removal for procedure details for femoral artery catheter and introducer removal. 9. Chargeable equipment should be scanned at time of use, i.e. pressure monitoring kit, pressure infusion bag, fermoral artery cath kit, or radialortory cath kit. Section 1: Assembly Of Flush Solution And Tubing (Single Set) Equipment: Premix Heparin Solution Bag 1,000 units in 500ml fluid 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 Premix Heparin Bag from protective bag. Inspect for leaks or defects and check expiration date. 2. If no premix heparin bag available with aseptic technique, draw up 1000 units Heparin and counter-check amount with another RN or LPN. Inject into the NS bag. Complete and apply IV additive sticker to fluid bag. 1. If a defect is found, discard or return to Pharmacy. 2. Use caution not to puncture bag with needle. Heparin is charged with doctor order in electronic medical record. 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 materials department. 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. 8. Fill drip chamber with fluid. 8. Evacuate system of all air, as possible. 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. 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.

3 12. After priming all stopcock ports, allow at least 30ml 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. 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. Section II: Assembly Of Flush Solution And Tubing (Double Set) Equipment: Premix heparin Solution Bag 500ml 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. Premix Heparin Solution from protective bag. Inspect for leaks or defects and check expiration date. 4. 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. 5. Disconnect both monitoring tubings at first connection below drip chambers by unscrewing connections. 6. Remove white cap from red connector of 2- way administration set and connect to first set of monitoring system tubing at first connection. 7. Remove white cap from blue connector of 2 way administration set and connect to second set of monitoring tubing at first connection 8. 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. 10. Open roller clamp and one slide clamp and pinch infusion clamp for rapid flush to prime IV tubing. 11. Follow steps of Section I to complete the priming procedure for the first line. 12. Repeat steps 12 and 13 above to prime the second line. 3. If a defect is found, do not use. Return to CSS. 4. If defect is found, do not use. Return to materials department. Loose connections can cause bleed back into the tubing due to air leak.

4 13. Apply pressure bag to Heparinized IV bag and inflate to 300mm Hg. 14. Wash hands. Section III: Arterial Catheter Insertion Purpose: To prepare the patient and assist with the insertion of an arterial catheter. Equipment: Alcohol swabs and chlorhexidine prep sponges. Sterile gloves Blue curved armboard for wrist extension 1" tape Radial artery catheterization kit Femoral artery catheterization kit 1. Assemble equipment. 1. Have tubing flushed and IV at hand. 2. Wash hands. 2. Prevent cross contamination. 3. Follow Procedure 1-10 Intravenous 3. Use chlorhexidine for skin preparation prior Catheter Insertion & Infusion steps #19-24 to insertion. for preparation of the insertion site. 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 in Electronic Medical Record (EMR) in Arterial Monitoring. Section IV: Securing Of An Arterial Catheter And Line Equipment: Transparent occlusive dressing 1" & 2" tape Sterile gloves Tincture of Benzoine Ampule 2" Gauze wrap (optional) Blue curved armboard Alcohol wipes Chlorhexidine prep

5 1. Assemble equipment. 2. Wash hands & apply sterile gloves. 2. Prevent cross contamination. 3. Carefully re-cleanse around insertion site 3. Keep area sterile, decrease chance of with Chlorhexidine prep & allow to dry. infection. 4. Apply tincture of Benzoine approximately 2" 4. Promote adhesive quality. around the catheter insertion site and allow to dry. 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. Secure the remainder of tubing as appropriate. 7. Flush tubing briefly with flush device. 8. Assures patency of line. 8. Wash hands. 9. Prevent cross contamination. 9. Record procedure in EMR Arterial Monitoring section. 10. Note condition of distal extremity to insertion site for circulation and mobility. 7. Enough tubing should be allowed for unrestricted motion of the patient s arm. Section V: Calibrating Transducer Additional Information: 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, Scale of 200 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. The SCALE settings for 200 indicate a range of 0-300mm Hg and should be used for Arterial Pressure Monitoring of the Femoral, Radial, Brachial, Axillary, and Umbilical (neonatal). 5. Turn on Alarms and set alarm limits. This will ensure close monitoring for accidental disconnection. 6. Document for analysis in EMR.

6 Equipment: 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 2. Align indentation on cord with plug in at the cable into monitor at Pressure module site. top and push straight in. 3. Push empty box on monitor screen, then push label select and select ART. 4. Transducer must be taped or secured. See 4. Align transducer with level of right atrium. 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. Touch Zero button on bottom of monitor 6. + or - is acceptable in either number. screen line. The numbers on the right side of the monitor screen to the right of ART box should read 0/0. 7. If numbers do not read in the acceptable range, touch 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. 16. Documentation zeroing transducer in EMR Art line Section. Section VI: Tubing Change With Site Care 12. Access to alarm limits should be made in patient room. 13. Disposable gloves must be worn. 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.

7 Equipment: Premix Heparin Solution Bag 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 Sterile gloves Chlorhexidine Prep 1. Wash hands. 2. Assemble equipment. 3. Wear gloves. 3. To prevent cross-contamination. 4. Carefully remove tape from Arterial line 4. To prevent cath from dislodging during tubing. At this time do not remove any tape procedure. or occlusive 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. 10. Apply sterile gloves. Gloves and fluidresistant 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 in EMR. 10. Precautions for prevention of exposure to blood-borne pathogens need to be observed. Section VII: Changing Of Flush Bag Solution For Arterial Catheter Equipment: Bag Premix Heparin Solution

8 1. Wash hands. 1. Prevent cross contamination. 2. Assemble equipment. 3. Inspect for leaks or defects and check expiration date of Heparin premix. 4. If premix Heparin unavailable, using aseptic technique, wipe Heparin port and NS bag injection port with alcohol and allow to dry. Draw up 1000 units Heparin. Inject into the NS bag. Complete and apply IV additive sticker to bag. 5. Rotate bag to mix. 6. 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. Charge all items at time of use. 15. Record procedure in EMR. 4. Heparin concentration is 2:1 unless otherwise specified by the physician with bag volume 500ml. 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 by Closed System Technique and Open System Technique. Equipment Closed System: Appropriate lab blood tubes Alcohol wipes Protective needleless safety cannula ml 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 gloves. 2. Prevent cross contamination. Use Sterile Technique 3. Thoroughly flush arterial line to establish 3. An Arterial line that is clotted should not be patency of line. Inactivate alarms. used for blood sampling.

9 4. Locate the in-line syringe in the pressure line system; locate the in-line blood sampling site closest to the body. 5. Locate the stopcock closest to the in-line syringe and transducer. Turn stopcock off between in-line syringe and 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 10ml luer loc syringe onto the sampling adaptor. 10. With a clock-wise twist, push the cannula through the diaphragm of the 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. 5. Check that any distal stopcocks are open. 6. Barrel holds 3ml 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 of luerloc syringe is depressed to the bottom to ensure absence of air. 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 ml syringe with Luer loc 1 5ml 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

10 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. 3. Thoroughly flush arterial line to establish 3. If arterial line is clotted, blood sampling will patency of line. 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 5. If in-line syringe is present on tubing, follow sterile 4 x 4's. 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 drawing 3ml of fluid and blood into syringe. 8. Return stopcock to middle position. Remove used 3ml syringe and discard. 9. Secure appropriate specimen syringe to port, e.g. 10ml 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. more 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 3ml 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. Section IX: Discontinuation Of 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. Additional Information: Removal of femoral catheter and introducer is detailed in Policy CL-39 Catheter and Introducer Removal.

11 Equipment: 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. Withdraw in-line syringe to draw blood back into tubing 4. Withdrawing blood into tubing will pull any clots at tip of catheter into tubing right before removal to prevent embolization. 5. Carefully remove tape from arterial line tubing. 6. Turn stopcock counterclockwise toward the patient. Turn off monitoring alarms. 7. Release pressure from pressure bag. 8. Remove tape and bioclusive from catheter insertion site, remove sutures, if present. 9. Place 2 x 2 over insertion site. 10. Apply pressure & remove catheter. 10. To stop blood flow to assure clotting. If catheter tip is to be cultured, place catheter on a sterile 4x4 until bleeding is controlled. 11. Continue to apply pressure to site for a minimum of 20 minutes or until bleeding stops. 12. Cover site with sterile gauze and elasticon tape for pressure dressing. 13. Check vital signs and insertion site every 15 minutes time 4; for signs of bleeding. 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 ischemia from over-compression of arteries. If femoral site used, longer period of compression may be necessary. 14. Remove gloves and wash hands. 15. Record procedure in EMR artline section. 15. Monitored site checks should be observed and recorded for 72 hours.

12 Section X: Arterial Catheter Troubleshooting 1. Absent or diminished Pulse distal to insertion site. a. Assess color, temperature, capillary refill, sensation and movement. b. Notify physician immediately. 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 lose 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 a minimum of 20 minutes or until all oozing stops. b. Apply elastic tape firmly over puncture site. c. Encourage patient to keep extremity still. 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. Section XI: Documentation 1. Electronic Medical Record: Sections Artline/CVP 2. Care Plan 3. Education of patient and family

13 Originated by: Intensive Care Effective date: June 1988 Authorized by: ICU Staff 3/16 OR Dir 3/16 Authorized by: Chief Nursing Officer Date Revision date: 8/98, 6/01, 11/03, 8/09, 1/14, 3/16 Review date: 4/92, 12/93, 7/95, 6/04 Distribution: ICU, PACU, Cath Lab Sources: Nursing Procedures, Springhouse Corp. 5 th Edition 2009 AACN Procedure Manual for Critical Care, 6 th Edition, Elservier - W.B. Saunders Co. Philadelphia 2011 P:\INTCARE\icuR28r2-COP4.22r4crk.doc