Procedure: Arterial Line Insertion, Maintenance and Dressing Change

Procedure

Dressing Type

• The preferred dressing for arterial and central venous lines is a transparent dressing with CHG pad
• Unsutured lines require the use of a securement device; this is changed with each dressing change (e.g. PICC)
• Lines that are actively oozing or where occlusivity cannot be maintained using a transparent dressing should be dressed with a gauze dressing and tape
• All PICC lines are unsutured
• Avoid the use of bulky dressings on any vascular access device (including post removal). 
• Do not wrap dressing material or tape circumferentially around an arterial line site.

Allergies:

Check for allergies prior to doing dressing and obtain plain transparent dressing or gauze if patient has a CHG allergy.

The most common cause for contact dermatitis is inadequate dry time for CHG prep. If you suspect an allergy to CHG, apply a small test area on the inner arm to confirm/refute allergy.

Notes:

There is evidence that transparent dressings containing a CHG gel pad may reduce central line infection.

Transparent dressings allow daily visualization of the site to identify signs of potential infection.

They also protect the site from pathogens while allowing some of the moisture to be drawn away through the "breathable" membrane.

Bulky or pressure dressings will not stop bleeding from a vascular device but will delay the detection of serious bleeding.  Gauze dressings do not allow site visualization. Circumferential dressings around a wrist can compromise circulation of the hand.

Dressing Change Frequency

Transparent Dressings

• Change all TRANSPARENT arterial and central venous line dressings Q 7 days (transparent) and PRN to maintain occlusivity
• Change dressings if CHG pad feels "boggy" to touch or is significantly swollen (pad does not need to be changed if it contains blood unless the volume of fluid in the gel pad is large or lifting the dressing)

Gauze Dressings

• Change all GAUZE arterial and central venous dressings DAILY and PRN
• If using tape and gauze on central/arterial lines dressing should be changed daily.
• Change any dressing that has loosened or lost its occlusive properties.

Notes:

Daily site inspection is a standard supported by CDC and Safethealthcare Now.  If transparent dressings are not being used (which allow for site visualization), dressings should be changed daily to allow site inspection and/or to remove moist dressings.

Due to poor skin integrity, diaphoresis etc, dressing changes are done q48hr and prn to remove skin colonization. If the patient is stable with good skin condition, transparent dressings may be left in place for 7 days (per hospital policy).

There is no evidence that routine line change dates decrease infection rates; insertion of a new line poses a risk for introducing infection. Lines are changed when evidence of redness or infection is present.  The risk for central line infection due to arterial line source increases when arterial lines are in place longer than 5 days or are positional.

Assessment and Safety:

• All newly inserted arterial must be connected to pressure monitoring and waveform quality confirmed. A copy of the waveform posted to the chart. 
• Invasive pressures are always obtained from the waveform. Patency of the line and quality of the waveform determine accuracy of the numbers, as well as correct leveling and zeroing (to the phlebostatic axis).
• Arterial pressures with quality waveforms should be the most accurate blood pressure. Systolic and diastolic pressures should not be expected to be identical between invasive and NIBP readings as direct arterial measurements will typically accentuate the systolic and decrease the diastolic pressures. The mean arterial line and NIBP pressures should be within 10 mmHg. Cuff, NIBP and direct arterial line measurement are 3 different measurement methods.
• NIBP is subject to measurement errors, particularly if the cuff is applied incorrectly, the wrong size is used, the cuff is placed over clothing or rapid inflation and deflation occurs. In severe shock states, NIBP may be inaccurate.  Cuff pressure is additionally 
• When comparing a cuff/NIBP pressure to an arterial line pressure, the pressures need to be measured at the same time (observe the arterial pressure immediately before cuff inflation) and on the same limb. 
• Cuff inflation may result in a higher pressure if inflation is uncomfortable or startles the patient. Patients who require blood pressure monitoring should have an arterial line placed for comfort as well as more reliable assessment of blood pressure response.  
• Short term deferral of arterial line placement may be appropriate if the patient requires low dose norepinephrine or dopamine, has a stable response requiring minimal titration or blood pressure reassessment and the duration of administration is less than 24 hours. Arterial line deferral must be ordered and be consistent with the protocol for arterial line placement deferral during vasopressor administration. 

Safety:

Risks associated with arterial lines include hemorrhage, hematoma/arterial trauma, thrombosis, limb ischemia and infection.

Do not use pressure dressings or circumferential securement. Pressure dressings will not stop arterial bleeding, this can only be achieve by direct pressure. Bulky dressings delay detection.

Use aseptic technique and flush lines thoroughly after blood sampling. Back flush stopcock and replace before drawing blood cultures and if blood residue is present.

Maintain adequate volume and pressure on flush system at all times to prevent thrombosis. 

Do not flush into the catheter with a syringe if line is blocked. Aspirate any clot first and flush using closed system. Flushing a clot into the system may can result in distal limb ischemia or infarction. Flushing through the stopcock increases the risk of infection.

Do not turn the stopcock off to allow clotting prior to removal of a vascular device. This will not reduce site bleeding upon removal but may results in intraluminal clotting that could be dislodged and lead to limb ischemia.

Confirm that normal saline flush is in the flush device every shift. Inadvertent use of 5% dextrose can result in alteration of glucose values (false high which could lead to incorrect insulin administration) measured from the arterial line.

Routine Assessment and Monitoring

At the start of each shift and Q4H

• Assess waveform to confirm quality and patency of catheter. Perform a Dynamic Response Test. Post waveform to the clinical record.
• Confirm solution is correct and that the saline flush volume is adequate and pressured. Decreased pressure increases the risk for clotting and will result in inaccurate pressures.  
• Ensure all stopcocks have closed (unvented) luer-lock caps.
• Inspect insertion site and surrounding area for swelling, tenderness, crepitus, redness or discharge.
• Inspect dressing integrity and palpate gel pad to assess for bogginess. Change dressing when indicated.
• Assess distal extremity for color, color, circulation, motion and swelling. Observe for blanching during flushing.
• Whenever possible, keep dressings exposed or minimize the amount of linen (e.g., a light sheet)  for prompt detection of bleeding.
• Keep arterial line alarms on to promptly detect dislodgement of catheter or hemodynamic instability.
• Troubleshoot dampened waveforms (e.g. assess flush bag/pressure, pressure tubing, catheter kinking).
• Determine any line issues (e.g. positional) and/or insertion bundle compliance concerns. Report to team and document plans for resolution.
• Review the ongoing need for arterial line during team rounds each day.
• Lines inserted during an emergency procedure where prep time may have been shortened or other breaks in aseptic technique may have occurred should be changed as soon as possible after initial resuscitation (including those inserted in the OR).

Notes:

All insertion sites must be assessed on an ongoing basis for signs of infection, bleeding, hematoma, thrombosis, interstitial placement or, catheter migration. Crepitus or air can indicate infection or air. 

Swelling or impaired circulation distal to an arterial line could indicate limb ischemia due to arterial occlusion from the catheter, from a thrombus or a hematoma.

Hemorrhage can occur from unvented caps or vented luer-locked caps if a stopcock is inadvertently bumped. Hemorrhage can be extensive and rapid from a disconnected or dislodged arterial or central venous catheter.  Significant blood loss can occur under a thick dressing or layer of blankets.

Central venous and arterial lines are indicated if ongoing resuscitation, intracranial pressure monitoring, vasoactive agent infusion or frequent ventilator changes are required.  When a patient no longer requires continuous arterial line monitoring or frequent blood gas sampling, the arterial line shoudl be removed. 

Positional arterial lines and inadequate securement is associated with blood stream infection.  Line insertion with the wrist in a neutral position with the catheter high enough to maintain securement and dressing intactness is important.

Insertion and Q Shift Vascular Device Assessment and Documentation

To identify lines at risk for infection, accurate documentation of a patient with established lines is essential. Documentation should identify where the line was inserted (e.g., in CCTC or another unit/facility), if there is documentation of compliance with the arterial/central line insertion bundle or if there were observed breaks in aseptic technique. Central line infection and blood stream infection risk may be associated with peripheral or central IVs, arterial lines or venipuncture technique.

If there is no documentation to confirm that aseptic technique was maintained or there were observed breaks in aseptic technique, the line should be flagged as having "issues for review".  This needs to be reported in the following morning rounds and the plans for the line documented.

Confirmation of line placement by blood gas and pressure monitoring upon insertion/admission is documented in the graphic record (ScvO2), by printout of the waveform and in a DAR note by the RN. The RN is also also records the name of the physician who reviewed the Chest Xray to confirm completion.

The individual who performed the insertion is required to document confirmation of central venous line placement as well as the results of the Chest Xray (for upper limb central venous lines) at the bottom of the Central Venous and Arterial Line Checklist and Procedure Record.

Communicating and Closing the Loop

The  critical care nurse is expected to identify lines that may need replacement and report issues during morning rounds (or earlier if urgent replacement is required).

The plan for this line should be documented in the AI record under "Plan of Care".  If the plan is not completed on the current shift, it is important to communicate this information to the oncoming shift and to document in the AI record the plan status. If the line change is deferred to the following day, the issue should be presented during morning rounds.

If decisions are made to leave a line in place, there should be physician documentation in the progress note to support the decision. .

Refer to the Nursing Documentation Standards for line tracking information.

Dressing Change Procedure

Non-sterile gown, cap and mask with eye shield is required by anyone within one meter of field.

The dressing should be performed using aseptic technique.  This includes preparing the tray using the transfer forceps to add sterile supplies.

A sterile field should be created using drapes provided in the tray. 

Sterile gloves are worn following removal of the dressing and must be worn during any touching of the catheter site. Caution should be taken to prevent glove contamination.

Prior to starting, perform a bedside assessment to determine if the patient requires sedation or if an extra pair of hands will be needed to maintain patient positioning and prevent contamination of the sterile field.

The patient should be positioned so that the full area under the dressing is visible and the patient can remain still during the prep time.

Hair should be clipped during the dressing change to enhance adhesion, Shaving is contraindicated.

Prepare Tray

1. Perform hand hygiene
2. Open tray at bedside
3. Don cap, gown, face mask with eye shield
4. Open sterile tray. Maintain aseptic technique and use the overwrap to create a sterile field.
5. Open sterile supplies and add to the tray using transfer forceps (don't open and drop them onto the field):
   • Dressing
   • Securement device
   • CHG swab (2 are included with Central Venous and Arterial Line Dressing Tray)
   • If patient has a lot of drainage, add sterile normal saline for a sterile field
6. Open the top of the no-sting barrier film and loosen the package. Expose approximately 2 inches of stick, leaving moist swab stick in the package. Lean the no-sting barrier film toward the edge of your sterile field where you can later remove it without contaminating your field (the swab will dry out if you place it on your tray in advance)

Remove Old Dressing

1. Don non-sterile gloves (included in dressing change tray)
2. Secure the dressing with one hand while gently removing existing dressing starting with the securement device
3. If line a sutureless securement device is being used, remove the dressing over the securement device first.
4. Remove the securement device using a shoveling movement with the CHG swab.
5. Once removed, tape the ends of the catheter lumen to the patient maintaining catheter alignment, with tape placed well beyond the area where the new dressing will be located.
6. Remove remaining dressing
7. If hair removal is required, clip using the sterile clipper head prior to skin cleansing.
8. Remove gloves and perform hand hygiene

Cleanse site:

1. Don sterile gloves
2. If site is visibly soiled, cleanse area with saline soaked gauze using metal forcept
3. Dry saline (if use) with a gauze square before prepping with CHG
4. Scrub the entire area using 2 - CHG 2% and alcohol 70% swabsticks:

Swab 1:

Use an up and down motion while moving from left to right. Turn the swabstick over and scrub the same area using a side to side movement.

Swab 2:

Lift the catheter and cleanse the skin underneath using an up and down motion.  With the unused side of swab to cleanse the undersurface of the tubing.

5. Ensure a minimum of 2 minutes
6. Apply no-sting barrier film to area that will be covered by dressing (excluding the area under the CHG)
7. Allow the full 1 minute dry time
8. Ensure that the catheter is well secured.

Notes:

The friction produces during scrubbing loosens epithelial cells and improves skin exposure to antiseptic solution.

All surfaces of skin and catheter should be cleaned.

The most common cause of skin burns and redness is the application of the dressing before the prep has adequately dried.

Longer than 2 minutes may be required if more than 2 swabs have been used or the skin is visibly wet.

No-sting barrier film enhances dressing adherence and protects the skin.

Application of no-sting under the CHG pad can cause skin burns.

Apply Dressing:

1. Apply securement device and ensure catheter will not move. 
2. Press and smooth edges of device completely
3. Position the dressing so that the CHG pad is over the insertion site and the dressing extends to cover the securement device and/or catheter hub.
4. Gently press the dressing and press toward the edges.  DO NOT STRETCH during application.
5. Remove the dressing border. 
6. Remove the anchor strip (still attached to the border) and position it over the bottom of the dressing so that it is half on the skin and half on the actual dressing.
7. The smooth side of the border paper can be rubbed over the dressing toward the edges enhance adherence.
8. Date the dressing and update the Kardex.

Notes:

Stretching during application can lead to skin burns.

Smoothing the paper over the dressing after dressing application produces heat and friction which improves dressing adherence

Successful dressing application takes time, but results in prolonged adherence with less frequent changes and site exposure over time.

Document

Document the dressing change and report any abnormal findings to the physician.

Document the plan for abnormal findings.