American Association of Critical Care Nurses (AACN)
Recommendations Related to Hemodynamic Monitoring
Protocols
General Guidelines for Arterial and Pulmonary Artery Monitoring
 Use saline rather than dextrose flush solutions.
 Cover all stopcocks with sterile occlusive (dead-end) caps and keep in place at all times.
 Level transducer stopcock to phlebostatic axis
 On insertion
 Whenever patient position is changed
 Prior to all readings
 With patient supine, up to 45 headrest elevation
 Zero transducer at level of phlebostatic axis
 On insertion
 Whenever values significantly change
 When cable is disconnected-reconnected
 Note: Controversial to zero routinely at beginning of each shift, no studies to support and
frequent opening of the system increases chances of infection
 Assess system adequacy by performing a dynamic response test (square wave test) and mounting
strip in chart
 On insertion
 At beginning of every shift
 Whenever accuracy is questioned
 After zeroing
 Set alarm parameters according to patient status.
 Change flush bag/pressure tubing/transducer
 Every 96 hours (arterial line systems)
 Every 72 hours (PA line systems)
Note: Combined systems of arterial and PA lines are not addressed in AACN Protocols for Practice.
 Change flush bag ONLY when tubing is changed or when solution is depleted.
 Document waveform strips at the beginning of each shift or when a significant change in condition
occurs.
 Use waveform strips for pressure determination rather than the digital value on the monitor.
 Run waveform strips simultaneously with ECG, not separately.
 Do not apply anti-microbial ointment to insertion sites.
 Nurses who have demonstrated competency may remove catheters with a physician order.
Arterial Lines
 Document pulses, color, temperature, sensory function of limb distal to arterial line insertion site
every 4 hours (or more frequently if there is a problem) while the catheter is in place and for several
days after removal.
 Remove/replace catheter after 4 days.
PA Catheters
 Document all waveforms during insertion.
 Inflate the balloon with 1.5 ml of air or less for no more than 15 seconds.
 The PA diastolic pressure may be used as an indicator of PCWP except when
 There is disease causing high pulmonary vascular resistance (pulmonary hypertension)
 There is tachycardia of 130/min or >.
 Do not remove patient from the ventilator to obtain pressures.
 Notify physician immediately if waveform changes (and document with a strip) when routine
measures do not correct
 Spontaneous RV
 Spontaneous PCWP
 Development of large v waves during PCWP inflation
 Remove/replace catheter after 5 days
 Use universal precautions (gloves) when handling PA catheters.
(Continued)
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Cardiac Output Determination (Intermittent)
 Dextrose solution is preferred over saline.
 Ensure computation constant is accurate.
 Measure cardiac output with the patient backrest at 20 or <.
 Use room temperature or iced injectate.
 Use 10 ml injectate unless fluid restriction is essential, then use 5 ml
 Use 10 ml iced injectate for patients with very low CO or hyperthermia.
 Administer injectate within 4 seconds or less.
 Administer injectate at end expiatory phase of ventilatory cycle.
 Determine the CO by averaging 3 values within the middle (mean) value.
 Assess the CO curve and delete the CO value if the curve is abnormal.
 Index the CO to the body surface area (BSA) to obtain the cardiac index and document.
 Replace CO flush solution and tubing every 72 hours.
 Do not infuse vasoactive meds through proximal (right atrial) port used to do cardiac outputs.
From AACN Protocols for Practice, 1998 and AACN Procedure Manual for critical Care, 2001
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