Arterial Line Management for the
Birthing Center
Objectives
• List reasons for Arterial Line monitoring in the
OB setting.
• Identify equipment needed for insertion of an
arterial line.
• Describe the process for Arterial Line
monitoring.
What is Blood Pressure?
•
Blood pressure (BP), sometimes referred to as arterial blood pressure, is the pressure
exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital
signs. When used without further specification, "blood pressure" usually refers to the arterial
pressure of the systemic circulation. During each heartbeat, blood pressure varies between a
maximum (systolic) and a minimum (diastolic) pressure.[1] The blood pressure in the
circulation is principally due to the pumping action of the heart.[2] Differences in mean blood
pressure are responsible for blood flow from one location to another in the circulation. The
rate of mean blood flow depends on the resistance to flow presented by the blood vessels.
Mean blood pressure decreases as the circulating blood moves away from the heart through
arteries and capillaries due to viscous losses of energy. Mean blood pressure drops over the
whole circulation, although most of the fall occurs along the small arteries and arterioles.[3]
Gravity affects blood pressure via hydrostatic forces (e.g., during standing) and valves in
veins, breathing, and pumping from contraction of skeletal muscles also influence blood
pressure in veins.[2]
• Other “Pressure” variables……… Resistance,
tone, volume, fluids, viscosity, ………
History of BP Monitoring
• 1731 Reverend Stephen Hales cannulated a
mare’s artery with a goose quill connected to
a length of goose trachea. This was connected
to an 8 ft. glass column manometer.
• 1905 Korotkoff proposed the auscultatory
method.
Arterial Pressure Monitoring
Indications:
• Continuous blood pressure evaluation
• Trends in blood pressure
• Efficacy of drugs, interventions
• Serial blood gas samples required
– Respiratory failure
– Mechanically ventilated patients
– Severe acid/base abnormalities
Why Arterial Line Monitoring?
• Continuous arterial blood pressure monitoring
– When there is a failure of indirect BP measurement
– When there is a need for arterial waveform analysis
– When there is a need for monitoring intravenous
pharmacologic or mechanical cardiovascular support
• Arterial blood sampling
– Respiratory failure
– Mechanically ventilated patients
– Severe acid/base abnormalities
What types of patients require arterial line
monitoring in the OB setting?
• Patients with cardiac disease
– Repaired congenital defects
– Cardiomyopathy
– CAD
• Patients with pulmonary issues
– Pulmonary Hypertension
– Cystic Fibrosis
• Patients with medical conditions where increase BP can result in
catastrophic consequences
– Marfan’s syndrome
• Patients with acute changes in the OR
– Post-partum hemorrhage
– Sepsis
What Sites are used for Arterial Catheter
Placement?
•
•
•
•
•
Radial
Brachial
Femoral
Axillary
Dorsalis pedis
The most common site used in the Birthing
Center is the radial site.
Where will these lines be placed in the
Birthing Center?
• Arterial lines may be placed in the patient’s
room on 5700, the OR, triage or PACU.
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Getting Started:
What Equipment will I need?
• Flush System
– 1000 ml bag of NS
– Pressure tubing with
transducer
– Needless adapter
– Pressure bag
The Transduced Flush System:
• Provides a mechanism to maintain patency of
invasive lines using high pressure with
minimal flush delivery while transducing these
lines to a monitor where intravascular and/or
intracardiac pressure measurements can be
taken.
Flush System set up
1. Label fluid bag with date, time, initials and
phrase “No additives.”
2. Purge all air from the fluid bag.
3. Insert pressurized tubing into fluid bag. Do
not inflate pressure bag yet.
4. Place fluid bag into pressure bag.
5. Open the clamp and squeeze the drip
chamber to fill the chamber ½ full.
Flush System set up continued
6. Flush tubing under gravity flow, checking that all
air bubbles have been flushed out of tubing,
transducer, and stopcocks.
7. Replace vented caps with “dead end” or
occlusive caps on all stopcocks and assure that
all connections on tubing are tight.
8. Inflate pressure bag to 300 mmHg.
9. Attach pressure tubing to end of catheter.
10. If new invasive lines are inserted, new
pressurized tubing and flush bag should be set
up and used.
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What Equipment will be needed?
• Insertion:
– Arterial catheter
– Chlorhexidine gluconate
(CHG) swab (for CHG
allergy, use 3 alcohol
swabsticks and 3
povidone-iodine
swabsticks)
– Sterile towels
– Sterile gloves
– Mask and cap
Allen’s Test
• Evaluate distal circulation prior to placement
• Allen’s test for radial catheter
– May be incorrect in as many as 14% of patients
– Requires continued evaluation of distal
circulation!
Allen’s Test
1. Occlude radial & ulnar artery
2. Ask pt. to repeatedly
squeeze hand into tight fist
3. Ask pt. to relax hand –
should be pale
4. Lift finger off artery not
being used
5. Color should return within
5-10 seconds
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Arterial Line Insertion
Arterial Line Insertion
1. Verify that patient consent has been
obtained by the physician or physician
designee.
2. Reinforce physician’ explanation and provide
reassurance to the patient during insertion.
3. Provide assistance to inserter as needed.
4. Connect pressure tubing to arterial catheter
when insertion is complete, check that all
connections are tight.
Arterial Line Insertion
• Assess wave form and set monitor alarms.
Secure transducer level to the phlebostatic
axis.
• The phlebostatic axis is found at the
intersection of the 4th intercostal space and
the mid-axillary line.
Leveling and Zeroing
• Why zero?
– Performed to eliminate the effects of atmospheric
pressure on the transducer. Should be performed
after connecting the pressure system to the patient
and whenever there is significant change in
hemodynamic numbers.
• Possible transducer locations:
– Mounted on manifold on IV pole
– Within the fluid line
– Directly affixed to the patient
Zeroing the Transducer
Closed
Open
Atmospheric Pressure = 0 mmHg
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The Arterial Waveform
1. Systolic Upstroke
2. Systolic Peak
3. Systolic Decline
4. Dicrotic Notch
5. Diastolic Runoff
Discrepancies w/ Cuff and A-line
• Problems with the cuff
– Cuff does not fit (must 20% longer than arm
circumference)
– Deflating too quickly (>3mmHg/second)
– Regional arterial tree differences (coarctation, dissection)
– Blood Pressure at extremes
Discrepancies w/ Cuff and A-line
• Overdamping
– Attenuation of the
waveforms
– Underestimation of
blood pressure
Overdamped
• Underdamping
– Amplification of
oscillations/waveforms
– Overestimation of blood
pressure
Underdamped
Normal
Square Wave Test
• Otherwise known as “dynamic response
testing”
• Usually performed once per shift
• Done to determine if the monitoring system
can accurately reproduce a patient's
cardiovascular pressures
• Identifies problems such as: air bubbles,
kinking in the tubing, loose connections or
catheter patency
Square Wave Test
• When the fast-flush is pulled - the waveform should
– Have a sharp upstroke which terminates in a flat line which is followed
by a rapid downstroke extending below baseline with 1 or 2 rapid
oscillations
– A quick return to baseline
Square Wave Test
• Problems:
– Overdampened
• sluggish or no oscillations with a fast flush
• Falsely ↓ SBP and ↑ DBP
– Underdampened
• undulations in the square wave with the fast flush
• Falsely ↑ SBP and ↓ DBP
• Troubleshooting:
– Check for bubbles, blood clots, kinks, loose connections or
decrease the length of tubing
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Assessment and Maintenance
1. Assess for signs of complications at least every 4
hours and prn. Any signs of complications should be
reported to the physician immediately.
2. Change dressing when it becomes loose, moist, or
soiled. Cleanse area with CHG, allow to air dry, and
apply sterile dressing.
3. Monitor waveform and blood return to assure arterial
catheter patency.
4. Set alarm parameters according to the patient’s
current blood pressure. Keep arterial alarms on at all
times since large blood volume may be lost quickly if
any part of the system is loose or disconnected.
Complications of Arterial Lines
•
•
•
•
•
Pain
Infection
Hemorrhage
Hematoma
Arterial Insufficiency
(<0.1%)
• Arterial Embolus
• Misuse and
Misinterpretation
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Withdrawing Blood Samples
• What equipment will I
need?
–
–
–
–
Alcohol wipes
Saline-filled syringe
2 empty syringes
Blood transfer device
(for vacutainer® tubes)
– Vacutainer® tubes
Procedure
1. Scrub the needleless adapter with alcohol x 15
seconds. A 10 ml syringe to the needleless adapter.
2. Turn the stopcock off to the pressure tubing (on the
patient).
3. Aspirate 5ml blood into the 10 ml syringe. Turn the
stopcock off to syringe. Detach syringe and discard.
Turn stopcock off to all ports.
4. Scrub the needleless adapter with alcohol x 15
seconds. Attach another 10 ml syringe to the
needleless adapter on the stopcock. Turn the
stopcock to the pressure tubing.
Procedure continued
5. Withdraw enough blood needed for blood samples.
Turn stopcock off to syringe.
6. Scrub needleless adapter with alcohol x 15 seconds.
Attach flush syringe containing 5 or 10 ml normal
saline.
7. Attach blood transfer device to syringe with blood.
Fill vacutainer® tubes with blood needed for labs.
8. Label blood sample(s) with patient addressograph or
lab barcode label, then date, time, and initial the
label.(BEFORE LEAVING THE PATIENT’S BEDSIDE)
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Arterial Line Removal
• Patients who deem
appropriate candidates
for post partum
recovery on 5700 will
have their A-line
removed.
• Any patient that
requires additional
monitoring will be
transferred to an ICU
setting.
Arterial Line Removal
1. Assess the patient’s coagulation profile (PT, PTT, INR,
platelets) prior to removal of the arterial catheter.
2. Wash hands and don gloves.
3. Turn pressure system off by clamping tubing or turning
stopcock off to the patient.
4. Remove dressing and sutures (if present).
5. Place sterile gauze pad over site and remove catheter,
immediately apply direct pressure to site.
6. Hold pressure until hemostatis is obtained (5-10 minutes).
Longer times may be needed for anticoagulated patients.
7. Check for bleeding and presence of pulse 15 minutes post
removal.
Arterial Line Removal
• Reportable Conditions:
1. Bleeding or hematoma at site.
2. Loss of pulse distal to insertion site.
3. Absence of blood return.
4. Signs of infection.
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This concludes you’re online training for
A-Line Management in the Birthing
Center. Please print your certificate of
completion to bring to your hands-on
training session.
You may now close the module.