NURSING PROCEDURE TITLE ARTERIAL BLOOD SAMPLING (NEONATAL) A. Umbilical Catheter Blood Collection B. Radial Arterial Line CATEGORY: RN - SNP PURPOSE To obtain blood samples for laboratory analysis NURSING ALERT: Gloves and protective eye wear must be worn when collecting blood from arterial catheters. Always draw blood gas sample prior to drawing other blood samples. Withdraw blood over 20 40 seconds from umbilical line to minimize a decrease in cerebral oxygenation in preterm infants. Laboratory requisition must include; name of patient, MRN number, date and time of collection as well as initials of nurse collecting sample. Labels attached to specimen must include patient name and MRN. Remember to fill in fields for ventilator settings, tcpo2 and tcpco2 on requisition prior to collecting blood sample. Inform physician immediately if blood does not flow freely when catheter is aspirated. Refer to NICU Lab Tests Reference list to determine minimum amount of blood required for individual tests. When multiple tests are ordered at same time, consult laboratory as amount of blood required may be less than if the tests are done separately. Analysis of blood glucose can be performed when IV solution does not contain dextrose. Potential Complications include: Loose connectors resulting in blood loss and shock Blood clots or air bubbles resulting in embolization or vascular obstruction which may result in gangrene of limbs or organs Arterial spasm (limbs or toes become pale or cyanotic) resulting in gangrene Septicemia as a result of poor aseptic technique Latrogenic anemia from frequent blood sampling Approved: December 3, 2014 Page 1 of 10
A. Umbilical Catheter Blood Collection EQUIPMENT 1. Personal protective equipment 2. Laboratory requisitions 3. Appropriate blood specimen containers 4. Alcohol swabs 5. Arterial blood gas syringe 6. Appropriate sized syringes for blood required for other tests 7. 6 ml luer lock syringe 8. Normal saline without bacteriostatic preservative 9. Shielded cannulas 10. Blood transfer device 11. Ice if blood gases to be drawn 12. Sharps container PROCEDURE 1. Don personal protective equipment. 2. Attach shielded needleless cannula to all blood sampling syringes and normal saline filled syringe. Keep insertion ends protected in sterile package. 3. Place supplies near sampling ports of transducer on infant s bed. 4. Silence alarms on monitor while blood sampling is performed. 5. Close distal shut-off valve by turning handle perpendicular to tubing. NOTE: In following steps distal refers to port furthest away from patient and proximal refers to port closest to patient. 6. Pull up on reservoir plunger, smoothly and evenly until at least 1 ml of blood has been pulled into reservoir. Approved: December 3, 2014 Page 2 of 10
NOTE: Recommended pull time is 1 ml every 10 15 seconds and slower for preterm infants (20 40 seconds). Closed system with a reservoir eliminates discarding of clearing volume and allows for reinfusion of blood, minimizing potential anemia from cumulative blood loss. 7. Close proximal shut-off valve by turning handle perpendicular to tubing. This allows access to proximal access port and prevents aspiration of blood from reservoir. 8. Swab proximal access port with an alcohol swab. 9. Push syringe with shielded cannula straight downward into proximal access port. Approved: December 3, 2014 Page 3 of 10
10. Withdraw volume of blood required into syringe slowly. Allow a little more than required. 11. Hold cannula firmly, then remove syringe/cannula from proximal access port by pulling straight upwards. 12. Repeat steps 9 11 to collect other blood samples. NURSING ALERT: Do not detach syringe from cannula while still in sampling port as blood loss will occur quickly due to access port remaining open to the arterial blood flow in the line. Syringe and cannula must be pulled out together to ensure closure of access port. Approved: December 3, 2014 Page 4 of 10
13. Reinfuse blood/fluid in reservoir by turning shut-off valve near proximal access port parallel to tubing. 14. Depress plunger of reservoir, smoothly, slowly and evenly until it is in a fully closed position. NOTE: Recommended re-infusion of the clearing volume is 1 ml every 10 15 seconds. 15. Flush line with normal saline once entire clearing volume has been re-infused. NOTE: Ensure syringe and cannula with normal saline flush solution is free of air bubbles. 15.1 Swab distal access port with an alcohol swab. 15.2 Insert syringe and cannula into distal access port by pushing straight downward. 15.3 Flush with 0.5 1ml of normal saline slowly until line is visibly cleared of blood. Approved: December 3, 2014 Page 5 of 10
15.4 Remove syringe/cannula by pulling straight upwards. 15.5 Open distal access port, by turning shut off valve parallel to tubing, thus allowing continuous infusion to commence. 16. Recheck all shut-off valves to ensure that they are parallel to tubing to allow continuous infusion to recommence. NOTE: If arterial blood pressure waveform is dampened on monitor, provide flow by pulling the Snap-Tab on disposable transducer several times. Monitor alarms should be reset and functioning. Snap tab 17. Remove all air bubbles from blood gas syringe by holding syringe vertical with open end up and gently tapping, then depress plunger till a drop of blood is squeezed out of tip. 17.1 Cap syringe 17.2 Place specimen into a small container of crushed ice. NOTE: Do not draw room air into syringe by pulling back on plunger or allow air bubbles to remain in sample as this can alter blood gas values. Approved: December 3, 2014 Page 6 of 10
18. Use blood transfer device to transfer appropriate amount of blood for each test into corresponding tubes. 18.1 Invert tubes gently, several times, to mix blood and anticoagulant to prevent clotting. 18.2 Label specimens using requisition stickers or writing patient name, hospital identification number and date of birth on a sticker and attach to specimen tube. 18.3 Transport to laboratory as soon as possible. 19. Remove gloves and wash hands. 20. Examine feet, toes and gluteal region for cyanosis and pallor. NURSING ALERT: Cyanosis or pallor can indicate arterial spasm. Wrap opposite extremity in a warm, moist cloth diaper when arterial spasm is suspected. Warmth applied to one extremity may improve circulation to opposite limb due to sympathetic nervous stimulation. Circulation should improve within 15 minutes after application of moist heat. Notify physician if colour of limb does not improve within 15 minutes. NOTE: In absence of an umbilical arterial catheter, a physician may request blood collection from umbilical venous catheter. Collect samples using same procedure. Caution must be taken not to interrupt flow of inotropes or other critical medications which may be infusing via the umbilical venous line. B. Radial Arterial Line NOTE: Radial arterial lines will not have a reservoir transducer system with access ports for blood sampling. Blood samples are collected from needleless port on extension tubing attached to insertion site. Clearing volume must be discarded. Flushing with normal saline is not recommended as severe blanching at site can occur. EQUIPMENT 1. Personal protective equipment 2. Laboratory requisitions 3. Appropriate blood specimen containers 4. Alcohol swabs 5. Arterial Blood Gas Syringe 6. Appropriate sized syringes for amount of blood required for other tests 7. Normal saline without bacteriostatic preservative 8. Blood transfer device 9. Sharps container Approved: December 3, 2014 Page 7 of 10
PROCEDURE 1. Don PPE. 2. Attach needleless caps to syringes for blood samples and normal saline flush. 3. Place supplies in infant s bed, near arm with radial line in situ. 4. Silence alarms on monitor while blood sampling is performed. 5. Clamp IV tubing on t-connector extension set closest to luer lock needleless port. 6. Swab needleless luer lock cap with an alcohol swab. 7. Attach an empty sterile syringe to luer lock cap and gently withdraw plunger of syringe until arterial blood fills extension set completely and enters syringe (approximately 0.5 1ml ). NOTE: Be sure to stabilize insertion site while withdrawing blood sample. Detach syringe with clearing volume and discard. 8. Attach heparinized syringe to luer lock end and withdraw amount of blood needed for gas analysis first and then attach additional syringes to withdraw amount of blood required for additional tests ordered. 9. Unclamp tubing on extension set and allow continuous IV infusion to commence. NOTE: If arterial blood pressure waveform is dampened on cardio respiratory monitor, provide flow by pulling Snap-Tab on disposable transducer several times. Monitor alarms should be reset and functioning. Snap Tab 10. Recheck that line is patent and continuous infusion has recommenced. NOTE: A small amount of normal saline (< 0.5mls) can be gently flushed through extension if needed to clear extension set, but is generally not recommended. Pushing rapidly will cause blanching at insertion site and should be avoided. 11. Reset monitor alarms. Approved: December 3, 2014 Page 8 of 10
12. Remove all bubbles from blood gas syringe by gently tapping to top and depressing plunger till a drop of blood is squeezed out of tip. 12.1 Cap syringe. 12.2 Place specimen into a small container of crushed ice. NOTE: Do not draw room air into syringe by pulling back on plunger or allow air bubbles to remain in sample as this can alter blood gas values. 13. Use transfer device to transfer appropriate amount of blood for each test ordered into corresponding tubes. 13.1 Invert tubes gently to mix blood and anticoagulant to prevent clotting. 13.2 Label specimens using requisition stickers or writing patient s name, hospital identification number and date of birth on a sticker and attach to specimen tube. 13.3 Transport to laboratory as soon as possible. 14. Remove gloves and wash hands. Approved: December 3, 2014 Page 9 of 10
REFERENCES Edwards Lifesciences Canada Inc. (2000). Inservice poster for venous arterial blood management protection system. Gomella, T.L., Cunningham, D., Eyal, F.G., & Zenk, K.E. (1999). Neonatology management, procedures, on-call problems, diseases and drugs. (4 th ed.). Appleton & Lange. Green, C., & Yohann, D.M. (1994). Umbilical arterial and venous catheters: placement, use and complications. Neonatal Network 17(6): 23-27. Schulz, G., Keller, E., Haensse, D., Arlettaz, R., Bucher, H.U., & Fauchere, J.C. (2003). Slow blood sampling from an umbilical artery catheter prevents a decrease in cerebral oxygenation in the preterm newborn. Pedatrics 111: e73-e76. Revised by: Moni Snell, CDE, NICU Date: August, 2007 Revised by: Tamara Dickin, CNE, NICU Date: October 2014 Approved by Date: Dec. 3, 2014 Regina Qu Appelle Health Region Health Services Nursing Procedure Committee Approved: December 3, 2014 Page 10 of 10