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Ensure that patient and health care provider safety standards are met during this procedure including:
- Risk assessment and appropriate PPE
- 4 Moments of Hand Hygiene
- Procedural Safety Pause is performed
- Two patient identification
- Safe patient handling practices
- Biomedical waste disposal policies
- Safe Handling of Intravenous Bag and Tubing Set-up on Articulating Arms
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Set-Up Hemodynamic Circuit
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Maintain Accuracy
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Monitor Blood Pressure
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Display Waveform
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Maintain Arterial Line Alarm
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Maintain Closed System
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Obtain Blood Cultures
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Change Dressings
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Maintain Arterial Site
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Document
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Remove Arterial Lines
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INFECTION CONTROL
All vascular devices (peripheral, central venous or arterial) can be a source for blood stream infection. Strict aseptic technique should be maintained at all times during insertion, dressing changes, medication administration and when accessing all intravascular devices.
All central venous and arterial lines that are inserted without strict adherence to sterile techniques/established safety bundles should be changed as soon as possible. Lines inserted during any resuscitation (e.g., trauma resuscitation, during a crash OR or in another hospital) should be evaluated and considered for replacement. Unless there is clear documentation in the chart to confirm that insertion techniques were maintained, lines should be considered at risk and changed as soon as possible using a new site whenever possible.
All peripheral IVs should be inserted using aseptic technique. Site should not be touched unless wearing sterile gloves after prepping. Peripheral IVs should be removed if insertion technique is unknown or within 96 hours.
The insertion of all arterial and central venous lines should adhere to the Central Venous and Arterial Line Safety Checklist and Procedure Note. These forms should be completed and placed in the Progress Note of the Clinical Records. Separate insertion trays are available for arterial and central venous lines.
Arterial and central venous dressing changes are done using aseptic technique. Special dressing trays for "Arterial and Central Venous Dressing Trays" are available.
Maintain Safety Bundle Standards for Insertion, Maintenance, Dressing Changes and Removal:
Safety Bundles
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STANDARD OF NURSING CARE
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Ensure 4 moments of hand hygiene are met when performing assessments and/or managing monitoring equipment.
Perform risk assessment and select appropriate PPE based on patient diagnosis and procedure being performed.
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1.
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Set-Up Hemodynamic Circuit
RNs in CCTC are responsible for the priming, zeroing, leveling, and maintenance of hemodynamic pressure monitoring circuits and for the assessment and monitoring of hemodynamic pressures and waveforms.
RNs in CCTC may flush hemodynamic monitoring circuits as required to maintain patency.
Ensure that pressurized infusion is on a separate IV pole (not attached to the articulating arm) and at least 1 meter away from electrical outlets.
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2.
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Maintain Accuracy
At the start of every shift and PRN if arterial line becomes dampened, blood backs up or is difficult to flush:
Confirm that there is at least 250 mL of saline in the 500 mL flush bag
Confirm that the bag is pressurized to at least 300 mHg
Confirm that the pressurized bag is on an IV pole not attached to the articulating arm and at least 1 meter away from electrical outlets.
At the start of each shift and PRN for dampened waveforms or difficulty flushing/aspirating:
Relevel and rezero the transducer
Flush the transducer dome through the venting stopcock to ensure there are no small bubbles that may interfere with the pressure reading
Perform a Dynamic Response Test (DRT) to evaluate the waveform.
Reconfirm the level of the transducer before each pressure measurement and following patient repositioning, with the air-fluid interface (stopcock above transducer) leveled to the mid-axillary line.
Document level confirmation and waveform assessment in the Device Band of EHR and place a printout of the waveform in the paper-based health record.
NOTE:
Zeroing eliminates the effect of atmospheric pressure on measured hemodyamic values. Leveling eliminates the influence of hydrostatic pressure on the transducer. A transducer that is positioned below the patient's heart will produce falsely elevated pressures and a transducer positioned above the patient's heart will produce falsely low pressures.
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3.
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Monitor Blood Pressure
Continuous arterial pressure monitoring is indicated for patients requiring BP monitoring >q1h, receiving continuous IV infusion of medications that affect cardiac output/blood pressure, requiring frequent blood gas monitoring or who are hemodynamically/neurologically unstable, with intracranial pressure monitoring in place or receiving CRRT.
Prior to recording any invasive hemodynamic pressure, evaluate the quality/accuracy of the pressure waveform, assess the transducer level and ensure that sufficient flush volume and pressure is present in the system..
When comparing NIBP to arterial line pressures, Mean BP provides the most appropriate comparison. Compare cuff to NIBP pressures taken from the same limb and at the same time..
NOTE:
Cuff BP measurements become increasing less accurate when hypotension develops. Accuracy is also affected by user technique and cuff size. Insertion of an arterial line is easiest when a patient has an adequate BP. Continuous infusion of vasoactive drugs necessitates continuous BP monitoring to evaluate response to drug therapy and to identify adverse effects.
NIBP cuffs do not provide continuous pressure monitoring. Although more accurate than auscultative BP monitoring, NIBP cuffs can become inaccurate when peripheral circulation is compromised. NIBP cuffs are uncomfortable and can produce bruising in susceptible patients; they are not appropriate when >q1h BP monitoring is required. Repetitive inflation of a BP cuff can lead to falsely elevated readings.
Systolic BP readings obtained from invasive arterial catheters are often accentuated, with reduced diastolic readings. NIBP measurements utilize different technology and may produce systolic readings that do not match the arterial line systolic reading. MBP from arterial lines and NIBP circuits provide more appropriate correlation.
Patients may have differing BPs between left and right limbs, and peripheral circulation may be reduced in shock.
Arterial pressures may be falsely elevated if an artery is in spasm. This can occur following repeated insertion attempts. A warm towel wrapped around the site may help to reduce spasm.
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4.
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Display Waveforms
Invasive arterial lines and right heart catheters must be connected to a monitor that provides a continuous waveform display.
NOTE:
Waveform quality must be assessed prior to acceptance of a displayed pressure value. Pressures are derived from the detected waveform; poor quality waveforms will produce inaccurate pressure readings.
The waveform from the tip of the right heart catheter must be displayed continually to demonstrate the catheter tip location within the heart. Continuous monitoring is required to promptly detect catheter migration into the right ventricle or pulmonary wedge position.
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5.
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Maintain Arterial Line Alarms
Appropriate alarms must be on for all patients requiring continuous arterial pressure monitoring. Alarm settings should be selected based on the degree of fluctuation in the patient's BP. Upper and lower alarm limits that represent clinically important changes are selected for each individual patient.
High and low alarm settings must be assessed and documented in the Device Band to confirm that they are appropriately set. Reassess that alarms are on each hour.
Alarms may need to be disabled if an arterial line becomes positional. If an arterial line alarms is disabled, document in the Device Band the reason they are disabled and any troubleshooting efforts taken.
If an arterial line becomes positional or it can no longer be used for blood sampling, the physician should be notified and line change or removal considered. The plan for line management should be documented in the Plan of Care and communicated to the oncoming nurse.
NOTE:
Alarms provide prompt notification of both changes in the BP and accidental disconnection/opening of the circuit.
The expectation for patient
Positional arterial lines are an important potential source for intravascular infection. Catheter movement activates inflammation at the site and movement of the catheter in and out of the tract can introduce pathogens.
Catheters should be secured to prevent movement and positional arterial lines should be removed.
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6.
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Maintain Closed System
All stopcocks must have dead-end (non-vented) luer lock caps or luer lock connected infusions. This includes stopcocks located on transducers. Alcohol impregnated sampling port caps should be maintained on all sampling ports.
Hemodynamic circuits are changed with each new line and prn.
NOTE:
Accidental movement of a stopcock that does not have a dead-end luer-lock cap can result in hemorrhage. Occlusive caps are required to rp
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7.
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Obtain Blood Samples
RNs may draw blood from indwelling arterial and venous lines. Stopcocks should be turned to 45 degrees between syringe changes. Luer-lock needleless access caps should be changed before drawing a blood culture and any time the port has visible blood.
Flush thoroughly after blood sampling and maintain adequate counter pressure to prevent thrombus formation. Reconfirm waveform after flushing.
NOTE:
See Procedure for Blood Withdrawal; Blood Gases Arterial; and Blood Gases Venous.
Thrombosis poses a risk to the perfusion of the distal extremity and increases the risk for colonization of pathogens.
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8.
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Change Dressings
Arterial line dressings are changed q 7 days and PRN when using CHG transparent dressings, or Q 24 H when using gauze.
Dressings should be changed prn if occlusivity is disrupted or if the CHG pad becomes boggy.
Record any redness or abnormal findings in the AI record and report to the physician. See Procedure for Arterial and Central Line Dressings.
Dressing changes should be performed aseptically according. Arterial and Central Venous Dressing Trays are available for ease of collecting supplies.
Non-sterile cap, gown and mask with face shield plus sterile gloves are required.
NOTE:
Dressings of tape and gauze are change q 2 days and prn in critically ill patients to allow site inspection and to reduce bacterial colonization Skin condition, diaphoresis and site oozing necessitates more frequent dressing changes in critically ill patients.
It is acceptable and preferred LHSC Infection Control practice to use a Tegaderm (TM) dressing that can be changed q7days as per general hospital policy, as long as occlusivity is maintained.
The Centre for Disease Control does not recommend routine line changes.
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9.
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Monitor Arterial Site
Arterial line sites/dressing should be kept as visible as possible. Check the site q1h and prn to assess for bleeding.
Use minimal dressing material.
Assess distal extremity for evidence of compromised color, circulation or motion q1h.
Lines should be removed if there are signs of infection.
NOTE:
Bleeding can occur very rapidly from dislodged arterial catheters or opened circuits.
Bulky dressings can mask bleeding. Pressure dressings will not stop arterial bleeding.
Thrombus, catheter spasm and small vessels can lead to compromised distal circulation.
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10.
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Document
Record S/D and M BP in IView in the vital signs section of the EHR, Q1H and PRN.
Nurse creates a Dynamic Group under Devices Band for arterial line. Under Activity field, selects inserted to document the insertion date. Record.
Assess site, patency, CCM, dressing appearance and waveform quality at the start of each shift and Q1H. Document assessment at the start of each shift, Q4H and PRN in the Device Band.
Document abnormal findings in the assess/reassess section.
Print a waveform at the start of each shift and PRN to record line placement and to confirm waveform quality. Post this to the paper-based portion of the health record.
Document reasons for turning the alarms off along with troubleshooting steps attempted to maintain "alarms on".
Document dressing changes in the Device Band and record abnormal findings in the assess/reassess section.
Update "date due" for dressing changes in the Actions and Situational Awareness section in Nurse View of the EHR.
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Remove Arterial Line
RNs may remove arterial lines in CCTC, with an order from a physician. Document removal in the intravascular Device Band of the EHR.
Following removal, assess site frequently (per Procedure) for bleeding or changes to CCM.
See Procedure for Removal of Peripheral Arterial Line or Femoral Arterial Line.
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