Arterial Line - Adults
Canberra Hospital and Health ServicesClinical ProcedureArterial line - AdultsContents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc418168161 \h 1Purpose PAGEREF _Toc418168162 \h 2Scope PAGEREF _Toc418168163 \h 2Section 1 – Insertion of Arterial Line PAGEREF _Toc418168164 \h 2Section 2 – Arterial line dressing or line change PAGEREF _Toc418168165 \h 4Section 3 – Sampling from Arterial Line PAGEREF _Toc418168166 \h 5Section 4 – Removal of Arterial Line PAGEREF _Toc418168167 \h 6Section 5 – Set-up of Monitoring Equipment for PICCO and thermodilution PAGEREF _Toc418168167 \h 6Section 6 – Performing Cardiac Output (CO) Studies PAGEREF _Toc418168167 \h 6Implementation PAGEREF _Toc418168168 \h 7Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc418168169 \h 7References PAGEREF _Toc418168170 \h 7Search Terms PAGEREF _Toc418168171 \h 7PurposeThis procedure document describes the equipment required for insertion of and sampling from arterial lines, and the process of change and removal of arterial lines.The second purpose of this procedure is to outline the safe and effective management of patients with PiCCO Monitoring being cared for in the Intensive Care Unit.ScopeScope This procedure document applies to all medical staff and nursing staff who insert and/or care for arterial lines under their scope of practice. This procedure will usually only occur in critical care areas – Emergency Department, Intensive Care and Operating Theatres.Section 1 – Insertion of Arterial LineSuggested Equipment:Clean trolleyClip for hair to be removed from the proposed site if required Sterile packs containing drapes, suture equipment and gownSterile glovesMask and eyewearTape 2.5cm (may be required to immobilise wrist)Appropriately sized arterial cannula with guidewire (depends on planned site – radial, brachial or femoral)Local anaesthetic (for example 1% or 2% Lignocaine)5ml syringes 25 gauge needleDrawing up needle3/0 ethilon suture on curved needleOcclusive dressingChlorhexidine 0.5% in alcohol 70% solutionDisposable transducer monitoring kit500mls 0.9% Sodium Chloride IV fluidArm board and ElastoplastPressure bagRelevant pressure module and cable if required for areaIf required extension of the arterial line tubing, use specific not distensible tubes to assure accurate measurements Back to Table of ContentsConsider Ultrasound machine and sterile sheath covers with sterile gel in case of difficult access. Ultrasound real time guidance can reduce insertion time, failure and complications related to anatomical variation and vascular disease (i.e atheromatosis) If PICCO is inserted, prepare the insertion and thermodilution specific kits and the temperature cable to the PICCO catheter Preparation of the Transducer LineInsert appropriate pressure and / or cardiac output module into monitoring system rack if required for areaConnect transducer cablePosition transducer on pole mount and level with right atrium (fourth intercostal space, mid-axillary line), or attach to upper arm as per local practicePrepare equipment using aseptic techniqueOpen transducer kit. Connect flush bag and prepare the flush system (0.9% Sodium Chloride 500ml for intravenous infusion)Using an aseptic technique insert transducer spike into flush bag Place flush bag into the pressure cuff and pressurise solution to 300mmHg. All air bubbles must be removed to ensure accuracy of arterial pressure monitoring and prevent arterial gas embolisation Open the roller clamp and prime the flush system maintaining a sterile fieldConnect transducer cable from flush system to cable connected to pressure moduleMaintain asepsis, and be ready to hand this line to the medical officer once arterial cannula is insertedCalibrate transducer (‘zero’) to atmospheric pressurePosition patient according to the procedure requirements and comfort Back to Table of ContentsPost insertionSecure radial line with arm board and elastoplasts (note arm board may not be required for brachial line) Secure transducer and tubing.Set alarm limits and always display in the monitor the arterial pressure waveform to obtain continuous blood pressure measurements Calibrate the system by levelling to the phlebostatic axis (mid chest – mid axillary line) Performing a flush testAssess limb for: pulse, colour, temperature, movement, sensation and capillary refill and signs of bleeding. Reassessment should occur frequently.The insertion of the arterial line should be documented in the patient’s clinical record by the medical officer who performed the procedure. Note: In the ICU Clinical Information System ‘Metavision’, the interventions tab must reflect insertion of the line by entering “arterial line in situ” under the procedures buttonBack to Table of Contents At the commencement of each shift:The arterial line should be levelled and calibrated and compared with non-invasive blood pressure measurementThe flush bag solution and volume remaining should be checked and kept pressurised at 300 mmHg An assessment should be made looking for complications of the arterial line including haemorrhage, clotting, gas, kinking, limb hypoperfusion or persistent dumped waveform. Section 2 – Arterial line dressing or line changeEquipment Dressing packChlorhexidine 0.5% in Alcohol 70%Occlusive dressingClean armboard and elastoplast strapping Transducer monitoring kitPressure bag500ml bag 0.9% Normal Saline Back to Table of Contents Sterile gloves, clean gown and maskProtective sheetSterile artery forcepsProcedure Wash hands and prepare equipmentExplain procedure, ensure patient privacySuspend alarm temporarilyPrime flush line and turn off to patientPlace protective sheet under arterial insertion sitePlace Normal Saline bag into pressure cuff and pressurise cuff to 300mmHgOperator and assistant wash hands and don sterile glovesAssistant applies pressure to the artery at the cannula tipOperator cleanses hub and surrounding area with antiseptic solution. With flush system off, quickly changes and secures the prepared flush system (sterile artery forceps may be required). Turn flush system on, connect pressure cable and observe waveform.Observe site for signs of inflammation and report to medical staff any concerns.Attend cannula site dressing using aseptic technique Cleanse with antiseptic solution and allow to dry Apply clear occlusive dressing ensuring the entry site is visible.Secure transducer and flush lineZero transducer and reactivate alarms Documentation of procedure in patient’s clinical record.Note: In ICU Clinical Information System “Metavision”, the documentation of the line/ dressing change occurs in the ‘Nursing Care’ tab and in the ‘Nursing Care Plan’ tab. The location and site assessment of all arterial lines occurs in ‘Other Obs’ tab.Section 3 – Sampling from Arterial LineEquipment Pre primed Heparin arterial blood gas syringe Vacuette and appropriate vacutubes. If necessary, ‘BD –Blood Sampling accessories’ Safe arterial blood sampling accessory. Chlorhexidine Alcohol swabs.Personal Protective Equipment (gown, gloves, goggles)Back to Table of Contents Procedure Explain procedure to patient.Ensure all equipment is ready at bedside.Wash hands and don non-sterile Personal Protective EquipmentSilence monitor alarms.Turn RED tap OFF to the transducer.PULL back on the volume restricted syringe. This draws blood back past the sampling bung.Turn RED tap OFF to patient.Wipe the silicone bung with a Chlorhexidine Alcohol swab and allow to dry.If using Safedraw TM device:Insert syringe into arterial line bung and allow blood to passively fill syringe if possible.Change to vacuette and withdraw blood into vacutubes as required.Wipe the bung with a Chlorhexidine Alcohol swab. Picture: Safedraw Device and TranducerOnce specimens have been taken:Turn the RED tap OFF to the transducer.PUSH the volume restricted syringe down returning the blood into the patient lineTurn the RED tap OFF to the syringe.Manually flush to clear any blood in the line.Observe the waveform on the monitor and reactivate the alarms.Attend blood gas analysis immediately or send to biochemistry with pathology request form via the chute system (no ice required). Label Arterial Blood Gas (ABG) specimens which are sent to biochemistry with Fraction of inspired oxygen (FiO2) and patient temperature.Ensure all specimens are clearly labelled.Document actions in the patient’s clinical record.Note: On ICU Clinical Information System ‘MetaVision’, this is under ‘Nursing Care’ tab.Back to Table of Contents Section 4 – Removal of Arterial LineEquipment Dressing packChlorhexidine 0.5% in Alcohol 70%Sterile Gauze swabs Stitch cutterPersonal protective equipment (e.g. Gown, gloves, goggles)Adhesive tapeProtective sheetSterile ScissorsProcedure Explain procedure, ensure patient privacy.Suspend monitor alarms.Turn the flush system off.Place protective sheet under the site.Using aseptic technique, cleanse the cannula site and remove suture. (If a cut down was required, ascertain the date of insertion and whether the cut down suture can be removed).Remove the cannula and immediately apply firm pressure to the site.Note: This firm pressure should be applied for at least five minutes until bleeding stops. Be aware that longer periods may be required if abnormal coagulation. Leave limb exposed to allow continual observations. If the patient is to be transferred to the ward, ensure this information is handed over to relevant ward staff.Apply gauze over the site until the bleeding has stopped and discard.Radial arteries can be covered with clean gauze and tape. A Femoral artery (or other contaminated site) requires an occlusive transparent dressing removal site. Inspect cannula, ensure cannula tip is intact.Determine if a ‘tip’ culture is necessary and if so, using sterile scissors, cut tip off into yellow specimen container. Label appropriately. Document procedure in patient’s medical recordNote: In ICU Clinical Information System “MetaVision” also stop the arterial line on the Intervention tab.Back to Table of Contents Section 5 – Set-up of Monitoring Equipment for PICCO and thermodilution Equipment 2 Invasive pressure ports or modules for ABP and CVPPhilips Orange CCO module1 Pressure cable for CVPPhilips blue end thermistor cablePulsion white arterial pressure cable Philips CCO module Pulsion white arterial pressure cable Philips blue thermistor cableBack to Table of Contents Procedure to connect the equipmentConnect pressure cable to module for CVPConnect Pulsion white arterial pressure cable to port or module for ABP and to transducer flush lineConnect Philips thermistor cable to Philips CCO module and injectate temperature sensor housing to thermistor. Change screen to a ‘6, 7 or 8 Waves & PiCCO’ screen by pressing the change screen SmartKey and choosing from the drop down menuEnsure arterial pressure port is labelled ABPEnsure Cardiac Output module is activatedProcedure to set up the flushing system to measure cardiac output by thermodilution Connect 100ml bottle of 0.9% NaCl to gravity IV line and primeConnect gravity IV line to 3 way stop cockAttach Luer lock syringe to 3 way stop cockConnect 3 way stop cock to thermistorConnect thermistor to distal lumen of CVC.Aspirate 20ml of injectate by turning stop 3 way stop cock off to patientTurn 3 way stop cock off to gravity IV lineSyringe is ready for cardiac output (CO) studiesThe greater the injectate volume (15-20 ml) and the colder the temperature, the more accurate the measurement.The use of injectate with a temperature that is not at least 12°C lower than the blood temperature may cause incorrect values for the thermodilution and CCO calibration.Back to Table of ContentsSection 6 – Performing Cardiac Output (CO) StudiesProcedureZero CVPOpen C.O. procedure window by selecting the Cardiac Output SmartKey.When the “Ready for new measurement” message appears, start the measurement by selecting the Start C.O. pop-up key.When the ready tone sounds and the “Stable baseline, inject now!” message appears, inject the cooled saline from flush line into the CVP line. Another tone will then sound and “Injection detected” will appear.At the end of the measurement the thermodilution curve, cardiac output, index values, ITBV and EVLW values and any curve alerts are displayed and a “Prepare for next injection or press Stop” message will appear.When the “Stable baseline, inject now!” message appears, repeat the procedure a minimum of two more times. A maximum of 6 measurements can be performed before editing. Editing CO MeasurementsIt is important to identify and reject erroneous trials as the monitor uses all measurement trial values to calculate the average cardiac output.Review the trials. Irregular trials or trials marked with a “?” should be reviewed carefully. Consider the similarity of the values and the shape of the C.O. curve. A normal C.O. curve has one smooth peak and returns to the temperature baseline level after the peak.Reject unsatisfactory trials: use the Select Trial pop-up key to move between trials or select the trial using the touch screen, then select the Accept / Reject pop-up key to accept or reject. Discard conspicuously different values. The background of rejected trials is red and the background of accepted trials is green. The monitor recalculates the average values after accepting or rejecting trials.Causes of very different thermodilution CO measurements during calibration: Haemodynamic instability (variability of HR, preload, vasoactive drugs, vascular tone) Repetition of the injection of cold saline in longer periods than 10 minutes Irregular arrhythmias Different injected saline temperature, volume , speed Back to Table of ContentsCauses of inaccurate CO measurements by transpulmonary thermodilution:Injected cold saline in a vessel in proximity to the PICCO catheter (i.e same side central venous access and arterial line) Rapid core temperature changes Intracardiac shunts Insufficient volume or incomplete volume injectedExtracorporeal circuits (i.e. ECMO, High volume dialysis Significant aortic valve diasease (stenosis, regurgitation) Saving CO (Cardiac Output) measurements by TPTD (transpulmonary thermodilution) to calibrate the CCO (Continuous Cardiac Output) by waveform pulse contour method. When editing of the trials is finished, the results must be saved. Before the monitor can calculate CCO, the measurement must be calibrated.In the C.O procedure window, select the Save C.O & Cal CCO pop-up key to use the averaged C.O. value to calibrate Continuous Cardiac Output (CCO).Any significant change in the vascular tone (i.e sepsis, anaphylaxis, hyperthermia) or dose of vasoactive or vasodilatory drugs (i.e: noradrenaline, adrenaline, dobutamine, dobutamine, vasopressin, GTN, propofol) requires a new recalibration by thermodilution Performing and Printing CalculationsTo enter the calculations review window, select the Hemo Calc pop-up key.Select the Resample Vitals pop-up key to use the most recent continuously monitored values.Select the Perform Calc pop-up key to perform the displayed calculation and store the calculation in the calculation database.Print the calculations by selecting the Print / Record pop-up key. Back to Table of Contents PiCCO Decision TreeBack to Table of Contents Implementation This procedure document is a merge of four pre-existing documents – no new information presented. New staff will be oriented to the existence of this document.Related Policies, Procedures, Guidelines and LegislationPolicies and ProceduresHealthcare Associated Infections Procedure (CHHS15/072) Aseptic Non Touch Technique (CHHS14/011)Patient Identification: Pathology Specimen Labelling (DGD12/024)Patient Identification and Procedure Matching Policy (CHHS14/051)Patient Identification and Procedure Matching Procedure (CHHS14/052)Calibration of pressure transducers (excluding Intracranial Pressure and Intra Aortic Balloon Pump Pressure monitoring), Document Number CHHS 12/146Central Venous Access Device (CVAD) Management – Children, Adolescents and Adults (NOT Neonates), Document Number CHHS 13/572Consent and Treatment SOP, Document Number DGD12-044 Hand Hygiene Standard Operating Procedure, Document Number CED11-50 Patient Identification- Correct Patient, Correct Site, Correct Procedure, Document Number CED11-27ReferencesJones T DR, Rolls K, O’Reilly M, Scott J, Hoyling L, Goldie D, Armstron K. Nursing Management of Arterial Catheters for Critically Ill Patients. NSW Health Intensive Care Coordination and Monitoring Unit. 2007.Marschall, J., et al. (2015) Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infection Control & Hospital Epidemiology 35, (07), 753-771Philips (2008) IntelliVue Patient Monitor instruction manual. GermanyWilson, C. (2015) Preventing central venous catheter-related bloodstream infections. Nursing Standard 29, (19), 37-43Back to Table of ContentsSearch Terms Arterial Line, Arterial Catheter, Transpulmonary thermodilution , TPTD, PICCO Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved By28 SeptemberAddition of PiCCO information (Section 5 & 6)CHHS Policy CommitteeBack to Table of Contents ................
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