Assisting with arterial catheter insertion Arterial cannulation is a common procedure in the critical care and anesthesia units that aims to continuously monitor the beat to beat (intra-arterial) blood pressure mainly. Arterial cannulation: is a procedure of inserting and securing a 16-20 Gauge size plastic tube into peripheral or central artery. Purpose: 1. Continuous monitoring of invasive blood pressure. 2. Assessment of the cardiovascular effect of vasoactive drugs 3. Frequent sampling of arterial blood samples. 4. Route of access for less common procedures (angiography, embolization, or thrombolysis). Indications: 1. Frequent blood sampling: a. Respiratory conditions requiring arterial blood gas monitoring (oxygenation, ventilation, acid-base status) b. Bleeding, actual or potential c. Electrolyte or glycemic abnormalities, actual or potential d. Metabolic abnormalities (acid-base, tissue perfusion), actual or potential e. Monitoring serum levels related to therapeutic interventions (renal replacement therapy, chemotherapy, biotherapy, apheresis therapy, etc.) 2. Continuous blood pressure monitoring: a. Hypotension or hypertension b. Shock: cardiogenic , septic , hypovolemic , or neurogenic . c. Mechanical cardiovascular support d. Vasoactive medication administration e. Burn , morbid obesity , or major surgeries. 3. Route for angiography Contraindications: Absolute Relative 1. Circulatory compromise in the extremities. 1. Recent surgery of the extremity . 2. Third degree burns in the extremity. 2. Local skin infection. 3. Raynaud’s syndrome. 3. Abnormal coagulation . 4. Thrombo-angiitis obliterans (buerger’s disease). 4. Insufficient collateral circulation. 5. First or second degree burn in the extremities. 6. Arteriosclerosis. Common sites for arterial catheters insertion 1 Choosing the arterial catheter site insertion: Equipment: • 2-inch, 20-gauge, or a 6-inch, 18-gauge nontapered Teflon guidewire (or the specific catheter for the intended insertion site) • Pressure module and cable for interface with the monitor • Pressure transducer system, including flush solution recommended according to institutional standards, a pressure bag or device, pressure tubing with transducer, and flush device • Dual-channel recorder • Nonsterile gloves, head covering, goggles, and mask • Sterile gloves and large sterile fenestrated drape • Skin antiseptic solution (e.g., 2% chlorhexidine-based preparation) • Sterile 4 × 4 gauze pads • Transparent occlusive dressing • 1% lidocaine without epinephrine, 1 to 2 mL • Sterile sodium chloride 0.9% • 3-mL syringe with 25-gauge needle 2 • Sheet protector • Bedside ultrasound machine with vascular probe • Sterile ultrasound probe cover • Sterile ultrasound gel Additional equipment: • Sterile gown and full drape • Bath towel • Small wrist board • Suture less securement device • Suture material • Chlorhexidine-impregnated sponge • Additional transparent adhesive dressing with tapes (if dressing has no tape, consider the use of 12inchSteri-Strips) • Transducer holder, intravenous (IV) pole, and laser lever for pole-mounted arterial catheter transducers Steps Rational This explanation decreases patient and Explain the procedure and the purpose of the arterial family anxiety. catheter. These symptoms may indicate infection, bleeding, or Instruct the patient to report any warmth, redness, pain, disconnection of the tubing or catheter. or wet feeling at the insertion site at any time. • Obtain the patient ’ s medical history, including history Extremities with any of these problems should of diabetes, hypertension, peripheral vascular disease, be avoided as sites for cannulation because of the vascular grafts, arterial vasospasm, thrombosis, or potential for complications. Patients with diabetes embolism. mellitus or hypertension are at higher risk for arterial •Obtain the patient ’ s history of coronary artery bypass or venous insufficiency. Previously removed radial graft surgery in which radial arteries were removed for arteries are a contraindication for ulnar artery use as conduits or presence of arteriovenous fistulas or cannulation. shunts. Review the patient ’ s current anticoagulation therapy, Anticoagulation therapy, blood dyscrasias, or history of blood dyscrasias, and pertinent laboratory alterations in coagulation studies could increase the values ( [PT], [INR], [PTT], and platelets) before the risk of hematoma formation or hemorrhage. procedure. Review the patient ’ s allergy history (e.g., allergy to decreases the risk for allergic reactions. Patients heparin, lidocaine, antiseptic solutions, or adhesive with heparin-induced thrombocytopenia should not tape). receive heparin in the flush solution. Assess the neurovascular and peripheral vascular status help identify any neurovascular or circulatory of the extremity to be used for the arterial cannulation, impairment before cannulation to avoid potential including color, temperature, presence and fullness of complications. pulses, capillary refill, presence of bruit (in larger arteries such as the femoral artery), and motor and sensory function (compared with the opposite extremity). Note: A modified Allen ’ s test should be performed before cannulation of the radial artery place the patient supine with the head of the bed at a provides patient comfort and facilitates insertion. comfortable position. The limb into which the arterial catheter will be inserted should be resting comfortably on the bed. If the radial artery is selected, position the hand to allow This placement positions the arm and brings the for palpation of the artery (a pillow or towel may be artery closer to the surface. used to support the wrist). If the brachial artery is selected, elevate and hyperextend the patient ’ s arm and palpate the artery (a pillow or towel may be used to support the arm). If the femoral artery is selected, position the patient supine with the head of the bed at a comfortable angle. The patient ’ s leg should be straight with the femoral area easily accessible and palpate the artery (a small towel may be needed to support the hip in some cases). Hand washing Heparinized flush solutions are commonly used to Prepare the flush solution A. Use an IV solution of normal saline. minimize thrombi and fibrin deposits on catheters B. Follow institutional standards for adding heparin to the that might lead to thrombosis or bacterial IV solution, if heparin is not contraindicated. colonization of the catheter. 3 Steps Consider the use of a blood conservation arterial line system. Prime or flush the entire single-pressure transducer system Rational Reduces the risk of nosocomial anemia. Removes air bubbles. Air bubbles introduced into the patient’ s circulation can cause air embolism. Air bubbles within the tubing dampen the waveform. Each flush device delivers 1–3 mL/ hr to maintain patency of the hemodynamic system. apply and inflate the pressure bag or device to 300 mm Hg. Connect the pressure cable to the bedside monitor. Set the scale on the bedside monitor for the anticipated pressure waveform. Level the air-fluid interface (zeroing stopcock) to the phlebostatic axis Leveling ensures that the air-fluid interface of the monitoring system is level with a reference point on the body. Zero the system by turning the stopcock off to the patient, opening it to air, and zeroing the monitoring system Hand washing and wear personal protective equipment. Assist as needed with skin preparation. Assist as needed with immobilizing the extremity during catheter insertion. Connect the pressure cable from the arterial transducer to the bedside monitor. Reassess accurate leveling, and secure the transducer Zero the system again Turn the stopcock off to the top port of the stopcock. Place a sterile cap or a needleless cap on the top port of the stopcock. observe the waveform and perform a dynamic response test (square wave test) Ensures that the air-filled interface (zeroing stopcock) is maintained at the level of the phlebostatic axis. If the air-fluid interface is above the phlebostatic axis, arterial pressures are falsely low. If the air-fluid interface is below the phlebostatic axis, arterial pressures are falsely high. Ensures accuracy of the system with the established reference point. Prepares the system for monitoring and ensures a closed system. Determines whether the system is damped. This will ensure that the pressure waveform components are clearly defined. This aids in accurate measurement. The square wave test can be performed by activating and quickly releasing the fast flush. A sharp upstroke should terminate in a flat line at the maximal indicator on the monitor. This should be followed by an immediate rapid downstroke extending below the baseline with 1–2 oscillations within 0.12 second and a quick return to baseline Ensure that the provider inserting the catheter has secured the arterial catheter in place. Ensure that the provider inserting the catheter has applied an occlusive, sterile dressing to the insertion site. Apply an arm board, if necessary. 4 Maintains arterial catheter position; reduces the chance of accidental dislodgement. Reduces the risk of infection. Ensures the correct position of the extremity for an optimal waveform. Steps Set the alarm parameters according to the patient’ s current blood pressure. Remove PPE and discard used supplies in appropriate receptacles; ensure that all needles and other sharp objects are disposed of in appropriate containers. Handwashing. Compare the manual (noninvasive) blood pressure with the arterial (invasive) blood pressure. Run a waveform strip and record the patient’ s baseline arterial pressures. Observe the insertion site for signs of hemostasis after the procedure. Assess the arterial catheter insertion site and involved extremity for signs of postinsertion complications. Ensure that the catheter is clearly labeled as “arterial.” Rational Reduces the transmission of microorganisms; Standard Precautions. Safely removes sharp objects. Postinsertion bleeding can occur in any patient but is more likely to occur in patients with coagulopathies or patients undergoing anticoagulation therapy. Alerts physicians, advanced practice nurses, and other healthcare professionals that the catheter is arterial not venous. Documentation should include the following: • Patient and family education • Performance of the modified Allen ’ s test before insertion and its results (when using the radial artery) • Pre-procedure verifications and time out • Signed consent form • Arterial site accessed • Insertion of the arterial catheter (date, time, and initials marked on the dressing itself) • Size of cannula-over-needle catheter used • Any difficulties in the insertion; number of attempts • Patient tolerance of the procedure • Pain assessment, interventions, and effectiveness • Appearance of the site • Appearance of the limb, color, pulse, sensation, movement, capillary refill time, and temperature of the extremity after insertion is complete • Occurrence of unexpected outcomes • Nursing interventions taken. Complications: 1. Hemorrhage. 2. Dislodged catheter. 3. Hematoma. 4. Vascular spasm. 5. Infection (local / systematic). 6. Skin necrosis. 7. Thrombosis. 8. Proximal embolization (digital ischemia ). 9. Arterio-venous fistula. 10. Median nerve palsy. 11. Pseudoaneurysm formation. 12. Nearby structures damage. 13. Temporary arterial occlusion. 14. Compartment syndrome. 15. Air embolism. 16. Hypovolemia due to dis connected catheter 17. Cerebro-vascular accident (stroke) 5 Blood Sampling from an Arterial Catheter the blood sampling in critical care is a routine procedure , Closed blood-sampling systems like in arterial lines provide the opportunity to reinfuse blood to the patient after the laboratory sample is obtained to help reduce the risk of nosocomial anemia. EQUIPMENT • Nonsterile gloves • Sterile 4 × 4 gauze pads • Arterial blood gas kit and blood specimen tubes • Labels with the patient ’ s name and appropriate identifying data • Laboratory form and specimen labels • Goggles or fluid shield face mask • Needleless blood-sampling access device (blood-transfer device) • Extra blood-specimen tube (for discard) • Sterile injectable or noninjectable caps • Antiseptic solution (i.e., 2% chlorhexidine–based preparation) • Specimen transport bag(s) • Bag of ice • Syringes, 5 and 10 mL • Needleless cannula (for closed arterial blood-sampling system) Steps Rational • Assess the patency of the arterial catheter. ensures a functional arterial catheter. • Assess the patient’ s previous laboratory results. • Verify that the patient is the correct patient using two identifiers. •Explain the procedure to the patient • Expose the stopcock to be used for blood sampling, and prepares the site for blood position the patient ’ s extremity so that the site can easily withdrawal. be accessed. Hand washing Personal protective equipment. Temporarily suspend the arterial alarms blood Sampling With a Needleless Blood-Sampling Access Device (Blood-Transfer Device) or a Syringe 1. Arterial stopcock: A. Remove the sterile cap from the port of the three-way stopcock closest to the patient and attach the needleless blood-sampling access device (blood-transfer device) or syringe to the stopcock. Or B. Cleanse the injectable cap at the top of the stopcock closest to the patient with an antiseptic and attach the needleless blood-sampling access device (blood-transfer device) Turn the stopcock off to the flush solution The needleless blood-sampling access device (blood-transfer device) or syringe is then in direct contact with the blood in the arterial catheter. When using a needleless blood sampling access device Clears the catheter of flush solution. (blood transfer device), engage the blood specimen tube to obtain the discard volume or, if using a syringe, slowly and gently aspirate the discard volume. A. When obtaining blood for an ABG sample, discard a The discard volume includes the dead space and the blood sample that is two times the dead-space volume. blood diluted by the flush solution (e.g., dead space of 0.8 mL = 1.6 mL discard). B. When obtaining blood for coagulation studies Additional discard is needed to prevent (particularly activated partial thromboplastin time) from a contamination of the specimen with heparin in 6 Steps heparinized arterial line, use a discard volume of six times the dead-space volume Turn the stopcock off to the syringe. Remove the syringe or the blood-specimen tube and discard in the appropriate receptacle. Obtain the blood sample: If using syringes to obtain blood specimens, turn the stopcock off to the patient before changing each syringe After each new syringe is attached to the blood sampling port, turn the stopcock off to the flush solution When obtaining an ABG sample, turn the stopcock off to the patient and attach the ABG syringe directly to the top port of the stopcock or place the ABG syringe inside of the needleless access device. Turn the stopcock off to the flush solution Gently aspirate the ABG sample. Turn the stopcock off to the patient before removing the ABG syringe. Expel any air bubbles from the ABG syringe and cap the syringe. After the last specimen is obtained, turn the stopcock off to the patient. Using the fast flush device, flush the remaining blood from the top port of the stopcock onto a sterile gauze pad, into a discard syringe, or into a blood-specimen tube. Turn the stopcock off to the top port of the stopcock. Remove the needleless blood sampling access device (blood transfer device) if used. Place a new, sterile, injectable or noninjectable cap to the top port of the stopcock. Using the fast flush device, flush the remaining blood in the arterial catheter back into the patient. Remove gloves and discard used supplies in appropriate receptacles. Hand washing Turn the alarms on and ensure that the waveform returns. Label the specimens and place in a transport bag. 7 Rational order to ensure accurate laboratory results (e.g., dead space of 0.8 mL = 4.8 mL discard). This recommendation does not apply to patients undergoing systemic heparin therapy. Stops blood flow and closes the top port of the stopcock Removes and safely disposes of the discard. -if obtaining laboratory specimens in addition to an ABG and coagulation studies, obtain the routine laboratory studies first and then obtain the ABG and coagulation studies to minimize the heparin effect. -Specimen size should be the amount required for the blood test(s). -Prevents backflow of arterial blood through the open blood sampling port Opens the arterial line from the patient to the syringe. Prepares for connection of the ABG syringe. Opens the arterial line to the ABG syringe. Obtains the ABG sample while minimizing vessel trauma. Prevents the backflow of arterial blood. Ensures accuracy of the ABG results. Detaches the specimen and ensures no backflow of arterial blood from the patient. Clears blood from the system. Opens the system up for continuous arterial pressure monitoring. Maintains a closed sterile system. Promotes patency of the arterial catheter. Reduces the transmission of microorganisms; Standard Precautions. Provides accurate waveform and safe blood pressure monitoring. Properly identifies the patient and laboratory tests to be performed. Steps Rational Confirm identifying information. For ABG samples, note the time the specimen was drawn and the percentage of oxygen therapy and any other data Send the specimens for analysis Post care : Use the minimal volume of blood discard. Helps prevent nosocomial anemia. Monitor hemoglobin or hematocrit daily or as prescribed. Allows early detection of nosocomial anemia. Attempt to group blood draws together whenever Diminishes the number of times the system is possible. entered to help minimize the risk for infection. Before and after the blood withdrawal, assess and Ensures accurate arterial pressure evaluate the arterial waveform. monitoring. Turn on arterial blood pressure alarms after blood Ensures safe arterial pressure monitoring. withdrawal and review parameters. Obtain laboratory specimen results. Monitors test results. Documentation should include the following: • Date, time, and type of specimen drawn • Unexpected outcomes • Additional nursing interventions • Results of laboratory tests, when available Unexpected Outcomes • Inadequate blood sample • Hemolysis of specimens • Arterial spasm • Dilution of specimens that causes inaccurate laboratory results • Anemia • Clotting of the arterial catheter 8 9 Care of the arterial line catheters Steps Assess the neurovascular and peripheral vascular status of the cannulated extremity immediately after catheter insertion and every 4 hours, or more often if warranted, according to institutional standards. Check the arterial line flush system every 4 hours to ensure the following: • Pressure bag or device is inflated to 300 mm Hg. • Fluid is present in the flush solution. Perform a dynamic response test (square wave test) at the start of each shift, with a change of the waveform, or after the system is opened to air Monitor for overdamped or underdamped waveforms. An overdamped waveform is characterized by a flattened waveform, a diminished or absent dicrotic notch, or a square wave that does not fall to baseline or below baseline An underdamped waveform is characterized by catheter fling or artifacts on the waveform Zero the transducer during the initial setup, after insertion, if disconnection occurs between the transducer and the monitoring cable, if disconnection occurs between the monitoring cable and the monitor, and when the values obtained do not fit the clinical picture. Follow manufacturer recommendations for disposable systems. Recheck the level of the air-fluid interface (zeroing stopcock) to the phlebostatic axis whenever patient position changes Position the patient in the supine position with the head of the bed from 0 to 45 degrees. 10 Rational Validates adequate peripheral vascular and neurovascular integrity. Changes in sensation, motor function, pulses, color, temperature, or capillary refill may indicate ischemia, thrombosis, arterial spasm, or neurovascular compromise. Ensures that approximately 1–3 mL/hr of flush solution is delivered through the catheter, thus maintaining patency and preventing backflow of blood into the catheter and tubing. The risk of catheter occlusion related to fibrin sheath or clot formation increases if the flush solution is not continuously infusing. An optimally damped system provides an accurate waveform. -An optimally damped system provides an adequate waveform which facilitates accuracy of blood pressure monitoring. An overdamped waveform can result in inaccurate blood pressure measurement. The patient ’ s blood pressure measure may be inaccurately low. -An overdamped system can be caused by air bubbles in the system; use of compliant tubing versus stiff, loose tubing connections in the system; too many stopcocks in the system; a cracked tubing or stopcock; arterial catheter occlusion or a kink; the catheter tip being against the arterial wall; blood in the transducer; and insufficient pressure of the flush solution. -An underdamped waveform can also result in inaccurate blood pressure measurement. The patient’ s blood pressure measure may be inaccurately high. Common causes of an underdamped waveform include excessive tubing length, movement of the catheter in the artery, patient movement, and air bubbles in the system. Ensures accuracy of the hemodynamic monitoring system. Ensures accurate reference point for the left atrium and accuracy of blood pressure measurements. studies have determined that the pressure is accurate in this position. Steps Rational Use a leveling device to align the air-fluid interface with the phlebostatic axis. Place sterile injectable or noninjectable caps on all stopcocks. Replace with new sterile caps whenever the caps are removed. Continuously monitor the arterial catheter values and waveform. Observe the insertion site for signs and symptoms of infection. change the pressure transducer system (flush solution, pressure tubing, transducers, and stopcocks) every 96 hours. The flush solution may need to be changed more frequently Label the tubing: A. Arterial B. Date and time prepared Maintain the pressure bag or device at 300 mm Hg. Print a strip of the arterial pressure waveform and obtain measurement of the arterial pressures. Note if there are respiratory variations. Obtain an arterial pressure waveform strip to place on the patient ’ s chart at the start of each shift and whenever a change is found in the waveform. Monitor hemoglobin or hematocrit values daily or as prescribed. Replace gauze dressings every 2 days and transparent dressings at least every 5–7 days and more frequently as needed. Follow institutional standards for assessing pain. Administer analgesia as prescribed. Record and report abnormal findings . 11 Ensures that the air-fluid interface is level with the phlebostatic axis. Leveling to the phlebostatic axis reflects accurate central arterial pressure values. Stopcocks can be a source of contamination. Stopcocks that are part of the initial setup are packaged with vented caps. Vented caps need to be replaced with sterile injectable or noninjectable caps to maintain a closed system and reduce risk of contamination and infection. Provides for continuous waveform analysis and assessment of patient status. Infected catheters must be removed as soon as possible to prevent bacteremia. The CDC does not recommend routinely replacing peripheral arterial catheters to prevent catheter related infections. recommend that the hemodynamic flush system can be used safely for 96 hours. Identifies that the catheter is arterial and when the system needs to be changed. Maintains catheter patency. Ensures accurate blood pressure measurement. allows assessment of the adequacy of the waveform, damping, or respiratory variation. Allows assessment of nosocomial anemia: • Abnormal hemoglobin values • Abnormal hematocrit values Decreases the risk for infection at the catheter site. Identifies need for pain interventions. Arterial Catheter Dressing Change Steps Rational Gather dressing change equipment Explain the procedure to the patient Hand washing Personal protective equipment. Carefully remove and discard the arterial line dressing. Removes the previous dressing without disrupting the integrity of the catheter. inspect the catheter, insertion site, and surrounding skin. Assesses for signs of infection, catheter dislodgement, or leakage. Remove nonsterile gloves, discard dressings, and perform Reduces the transmission of microorganisms hand hygiene. Don sterile gloves Maintains aseptic and sterile technique. Cleanse the skin and catheter with 2% chlorhexidineReduces the rate of recolonization of skin flora. based preparation. Decreases the risk for bacterial growth at the insertion site. Apply a new stabilization device. Secures the catheter. Apply a chlorhexidine impregnated sponge to the site. Reduces the transmission of microorganisms. Apply a sterile air-occlusive dressing. Dressings may be a Provides a sterile environment. sterile gauze or a sterile, transparent, semipermeable dressing. Write the date and time of the dressing change on a label and tape it to the dressing. Remove gloves and discard used supplies in appropriate Reduces the transmission of microorganisms; receptacles. Standard Precautions. Hand washing Record and report abnormal findings . 12 13 Ideal arterial line after insertion and dressing 14 Removal of Arterial Catheter Steps Rational Review the patient’ s coagulation profile (PT, INR, PTT, Elevated PT, INR, PTT, and decreased platelets platelets) and anticoagulation medication profile before affect time to hemostasis. removal of the arterial catheter. -If laboratory values are abnormal, pressure needs to be applied for a longer period to achieve hemostasis. Gather dressing change equipment Explain the procedure to the patient Hand washing Personal protective equipment. Turn off the arterial monitoring alarms. Remove the dressing & the stabilizing device. Turn the stopcock off to the flush solution Apply pressure 1–2 finger widths above the insertion site. Remove the arterial catheter and place a sterile 4 × 4 gauze pad over the catheter site. Continue to hold proximal pressure and immediately apply firm pressure over the insertion site as the catheter is removed. Continue to apply pressure for a minimum of 5 minutes for the radial artery. Follow institutional standards. Longer periods of direct pressure may be needed to achieve hemostasis (e.g., patients receiving systemic heparin or thrombolytics, patients with catheters in larger arteries such as the femoral artery, or patients with abnormal coagulation values). Apply a pressure dressing to the insertion site. A pressure dressing helps prevent rebleeding. The dressing should not encircle the extremity (prevents ischemia of the extremity). Remove gloves and discard used supplies in appropriate receptacles. Hand washing Record and report abnormal findings . 15 Turns the monitoring system off to the flush solution. The arterial puncture site is above the skin puncture site because the catheter enters the skin at an angle. Prevents splashing of blood. Prevents bleeding. Achieves hemostasis. Reduces the transmission of microorganisms; Standard Precautions.
