CARE OF ARTERIAL LINES CLINICAL PROCEDURE Policy # Date Introduced Supercedes Policy# Review Data due November 2005 July 2007 Author/s: Kylie Garnsworthy CNS Procedure Director NBICS, NB Nursing and Midwifery Council Director of Nursing Marlene Hinchliff Director of Nursing Fiona Allsop Chair Nursing Council Sally Ingram NB. This policy has been authorised by the above parties-a signed hardcopy is kept by the CNC NBICS Procedure Statement: Critically ill patients require arterial lines to monitor blood pressure (BP) trends, titrate drug therapies and obtain blood samples for arterial blood gases and laboratory studies. To ensure that a patient receives optimal treatment, it is crucial that staff are aware of factors that affect the safety and accuracy of arterial monitoring. In addition, to ensure that the opportunity for blood stream infection is minimised standard precautions must be followed Relevant and Related Policies: NSW Health Infection Control Policy Directive 2005_247 Occupational Health and Safety Rationale: Patients may require an arterial line for Haemodynamic instability where strict monitoring is required. When vasoactive medications are needed and the response to such medications require monitoring. Close monitoring of labile B.P Regular blood sampling. Sections: INSERTION OF ARTERIAL LINE TRANSDUCER SET UP ARTERIAL MONITORING/ ZEROING BLOOD SAMPLING DRESSING GENERAL PRINCIPLES AND CARE TROUBLESHOOTING POTENTIAL COMPLICATIONS Page 1 of 11
INSERTION OF ARTERIAL LINE Equipment: Clean (using Viraclean) and dry dressing trolley Sterile dressing trolley plastic drape Minor procedure tray 5x sterile gauze packets Arterial Cannula 1% Chlorhexidine Swabs (Persist plus) 1% Lignocaine 25g needle + 5ml syringe 2.0 silk + needle 1x transparent occlusive dressing (e.g. iv 3000) Fenestrated drape Sterile gown + gloves Transducer, pressure bag and 500ml of Normal Saline Preparation of Patient: Arteries typically cannulated for arterial pressure monitoring are Radial, Femoral, Brachial and Dorsalis Pedis. Explain procedure to patient Verbal consent should be obtained by the medical officer performing the procedure. Medical officer performing procedure should do Allen s test to ensure adequate distal blood flow if a radial artery is being cannulated. Position pt in bed as comfortably as possible with area to be used exposed. (NB if a radial artery is to be used a rolled towel may be used to hyperextend wrist to allow easier visualisation of landmarks). From: Stillwell (2002) P. 470 Procedure: Performed only by a medical officer. A clinical handwash must be done prior to the procedure Page 2 of 11
ation: Medical officer who performed procedure needs to document in progress notes. Nursing staff need to document on management/care plan, date of insertion site, when next dressing + line change due + date for removal. The arterial line can remain insitu for up to 7 days (unless signs of infection are evident eg redness, unexplained pyrexia etc) or more. The site must be reviewed regularly and findings must be documented in the patients progressive notes. TRANSDUCER SET UP Rationale: The arterial catheter is connected to the fluid filled tubing of the monitoring system. The transducer creates the link between the fluid filled tubing system and the electronic system converting a mechanical signal into a waveform on the monitor. The transducer system must be set up correctly to ensure accuracy of the monitoring system. Transducers are to be changed every 96 hours (4 days). This change includes the transducer, associated lines and the flush solution bag (unless empty) Equipment: Hand hygiene must be performed prior to donning clean gloves (ie wash with liquid soap or use 0.5% Chlorhexidine and alcohol hand rub) Gloves 500 ml bag Normal Saline Pressure bag Transducer giving set Module and cable Monitor Procedure: Insert giving set into normal saline bag. (Keeping end sterile, ready to pass to Medical officer.) Ensure all roller clamps are open Prime line by squeezing fast flush device. Ensure that all air bubbles are removed from system and that all parts are primed with fluid. Air can cause damping of the system and inaccuracy of monitoring. Place Saline into pressure bag and inflate to 300 mmhg. When M.O. is ready connect to cannula. Connect transducer to cable and watch for trace on monitor. Zero + calibrate system. ation: in the intensive care plan the date of insertion Arterial Monitoring and Zeroing The arterial pressure wave corresponds with the cardiac cycle. Page 3 of 11
From: Urden et al (2002) p. 361 Arteriole systole begins with opening of aortic valve and rapid ejection of blood into the aorta. This is the upswing on the arterial waveform followed by a downward turn. A notch- called dicrotic notch is visible on downward stroke which represents closure of the aortic valve signifying the beginning of diastole. The remainder of the downward stroke represents diastolic run off of blood flow into the arterial tree. The QRS complex of ECG trace comes first and the arterial waveform follows. LEVELLING AND ZEROING (Calibrating the system) Rationale: To ensure consistency and accuracy of the arterial blood pressure monitoring the transducer must be positioned and calibrated regularly to an anatomically consistent site. This site is called the phlebostatic axis. Levelling: The phlebostatic axis is the anatomical reference point on the chest that is used as baseline for consistent transducer site placement. This point represents the position of the atria and therefore reflects central blood pressure. The site of the phlebostatic axis is at the intersection of the fourth intercostal space and mid axillary line. Page 4 of 11
From: Urden et al (2002) p. 356 To obtain a true central blood pressure this is where the transducer should be positioned. The transducer must always be level with phlebostatic axis. Zeroing Rationale: Zeroing is the method of calibrating the monitoring system so that the effects of atmospheric and hydrostatic pressure are eleminated. Zeroing must be carried out once per shift. Page 5 of 11
Preparation of patient: Position patient on their back Patient may be positioned with the head of the bed elevated between 0-60 Flush the system Level transducer to phlebostatic axis (may mark this with an x on patient) Turn stop-cock on transducer so that it is off to the patient. Remove cap Press zero on the module Ensure that zero appears on screen replace cap and turn stop-cock so that it is open to monitoring and patient. NB: If patient is positioned on their side the reference point will be different. It is difficult to identify true phlebostatic axis. There may be a discrepancy in readings. If there is a great variation when positioned on their sides. The patient should be placed onto their back and a true reading obtained BLOOD SAMPLING Equipment 5ml syringe Sterile gauze Arterial blood gas syringe +/- or vacutainer + blood collection tubes Personal protective equipment (Gloves, googles) Procedure Suspend alarm or monitor Hand hygiene must occur before and after the procedure Don personal protective equipment Remove cap from stopcock and attach 5ml syringe turn stop cock off to flush bag Withdraw 2-3ml of blood to clear line of saline Attach ABG syringe/ or vacutainer attachment and withdraw sample (if taking ABG the syringe can passively fill) Once specimen has been taken, turn stopcock off to the patient, remove syringe/vacutainer, cover the port with gauze and using the fast flush device, flush port. Replace cap Turn stopcock off to the port and flush line ensuring that all blood is cleared Ensure alarm is turned on DRESSING Rationale: Infection at the arterial catheter site will be minimised Dressings with modern occlusive dressings should be left intact up to 7 days More frequent dressings should only be attended if there is a problem with kinking of line, leaking around site or if the dressing is coming off Page 6 of 11
Equipment Dressing Pack Sterile Gloves Transparent occlusive dressing (eg. IV 3000) Normal Saline (if visibly soiled or crustings are present) 2% Chlorhexidine + alcohol (Persist plus) Goggles Procedure Wash hands (or use alcohol hand rub) Assemble equipment on dressing trolley Wash hands (alcohol hand rub may be used) Remove old dressing carefully Wash hands and don sterile gloves Cleanse area with normal saline (if visibly soiled or crustings are present) Dry site with gauze Apply chlorhexidine and alcohol to insertion site Allow to dry to air Apply steri-strips (if necessary) to keep cannula secure. Apply transparent dressing so that insertion point of cannula is in middle of dressing NB. Transducer only needs to be changed if considered to be giving faulty readings or if time insitu is >4 days Page 7 of 11
GENERAL PRINCIPLES AND CARE OF ARTERIAL LINE PROCEDURE Keep pressure bag inflated to 300mmHg Flush bags of Normal Saline are changed every 96 hrs or PRN. All flush bags must be labelled with time and date of commencement Do not add extra tubing or stopcocks to system. All lines must be have rigid non-compliant tubing Periodically flick tubing system and flush the tubing system Fast flush solution after opening the system for blood sampling and/or zeroing Immobilise arm and keep sites clearly visible at all times. eg. On top of sheets. Do not use bandage over arterial line site. RATIONALE Deflation of bag will result in retrograde blood flow. Keeps line patent and infuses 3-5ml /hr. Prevents dampening of trace. Prevents clots Infection control, keep bag sterile. Ensures adequate flushing volume. Extra areas of air entrapment which can cause inaccuracy of the arterial trace. Increase risk of infection Eliminates any bubbles escaping the flush solution. Helps eliminate air bubbles. Clears the line of blood Safety measure to prevent adverse events eg. haemorage or disconnection Page 8 of 11
TROUBLESHOOTING PROBLEM Difficulty with zeroing Does not reach 0 waveform Does not reach baseline SOLUTION Check all equipment + connections between pt + monitor Ensure all rollerclamps are open Check system for air bubbles and blood clots Recalibrate Replace transducer, cable module, arterial line Unable to aspirate cannula Check line for kinks Apply traction to cannula Gently try to flush Replace arterial line Falsely high readings Incorrect placement or transducer Uncalibrated system Kinked cannula Dampened Check position of transducer Re zero Remove kink Remove air bubbles/ blood clots Page 9 of 11
POTENTIAL COMPLICATIONS PROBLEM PREVENTION SOLUTION HAEMORRHAGE Keep limb visible at all times Ensure alarm is on so that any accidental disconnection can be dealt with quickly Ensure that arm is immobile with arm board Ensure all connections are tight Apply pressure to limb Assess leak If haemorrhage persists notify MO INFECTION BLOCKAGE CLOTTING AIR EMBOLI INTERUPTION TO PERIPHERAL CIRCULATION Assess area regularly for redness or swelling Avoid interrupting circuit as much as possible Use gloves when touching arterial line Keep pressure bag inflated to ensure 3-5ml flush Attempt to aspirate blood Use fast flush device to clear line to prevent clot formation Regularly check distal pulses + cap refill Remove arterial Line Ensure proper hand washing when handling arterial line or transducer Attempt to aspirate blood to remove clot Ensure all connections are secure Notify MO and consider removing line Page 10 of 11
REFERENCES 1. Aherns T, Penick JC & Tucker MK (1995). Frequency requirements for zeroing transducers in haemodynamic monitoring. American Journal of Critical Care; 4(6): 466-471. 2. Bridges EJ, Bond EF, Ahrens T, Daly E, Woods SL (1997) Ask the experts. Critical Care Nurse; 17(6): 1 96-97. 3. Centre for Disease Control (2002). Guidelines for the prevention of intravascular catheter-related infections. 51 (RR10): 1-26. 4. Courtois MA, Fattal PG, Kovács SJ, Tiefenbrunn AJ & Ludbrook PA (1995). Anatomically and physiologically based reference level for measurement of intracardiac pressures. Circulation; 92: 1Need page numbers from Journal. 5. Hudak CM, Gallo BM & Morton PG (1998) Critical Care Nursing; A Holistic Approach. Seventh Edition. Lippincott: New York. 6. Imperial-Perez F, McRae M (1999) Protocols for practice: Applying research at the bedside. Critical Care Nurse; 19(2): 105-106. 7. McCann UG, Schiller HJ, Carney DE, Kilpatrick J, Gatto LA, Paskanik AM & Nieman GF (2001). Invasive arterial monitoring in trauma and critical care. Chest; 120(4): 1322-1326. 8. McGhee BH, Bridges MEJ (2002) Monitoring arterial blood pressure: What you may not know. Critical Care Nurse; 22(2): 50-79. 9. Stillwell SB (2002) Mosby s Critical Care Nursing Reference. Third Edition. Mosby:St Louis. 10. Urden LD, Stacy KM, Lough ME (2002) Thelan s Critical Care Nursing; Diagnosis and Management. Fourth Edition. Mosby:Missouri. 11. RNSH Haemodynamic competency, July 2004 Page 11 of 11