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
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- Monitor ECG
- Provide Emergency Equipment
- Set-Up Hemodynamic Circuit
- Maintain Accuracy
- Display Waveforms
- Monitor PA Pressures
- Maintain Closed System
- Prevent Air Embolism
- Obtain Chest Xray
| - Select Appropriate Ports for Infusions
- Obtain Blood Samples
- Change Dressings
- Reposition PA Catheter
- Analyze CVP and PWP Waveform
- Measure Cardiac Output
- Document Placement
- Paceport (TM) Catheter
- Introducers
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Infection Control All vascular devices (peripheral, central venous or arterial) can be a source for blood stream infection and be become the nidus for a central venous infection. Strict aseptic technique should be maintained at all times during insertion, dressing changes, medication administration and accessing of 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 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 |
| STANDARD OF NURSING CARE |
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. |
1. | Monitor ECG All CCTC patients with PA catheters will have continuous ECG monitoring. See Standard for ECG Monitoring.
PA catheters can slip into the right ventricle and produce ventricular ectope. |
2. | Provide Emergency Equipment Access to ACLS equipment (e.g., defibrillator, drugs) is required for all patients with a PA catheter. If ventricular ectope/VT in a patient with a PA catheter, suspect the tip is in the RV. For ventricular ectope due to PA catheter, immediately withdraw tip until an RV tracing appears (stop all blue and white port infusions and confirm balloon is deflated first). |
3. | 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 may flush hemodynamic monitoring circuits as required to maintain patency Exception: left atrial lines and intra-aortic balloon pump lumens are maintained with pressurized heparinized saline BUT are not manually flushed by RNs. |
4. | Maintain Accuracy Hemodynamic transducers are zeroed at each initial setup, with the air-fluid interface (stopcock above transducer) leveled to the mid-axillary line. Transducer levels should be validated at the beginning of each shift, prior to each PWP or CVP measurement, following position changes, and prn to validate hemodynamic pressures. Document level confirmation in the graphic record. Documentation is required at the start of each shift and q6h, prior to each CVP and PWP measurement, and following transducer repositioning. |
5. | Display Waveforms The tip of the PA catheter must be connected to a monitor that provides a continuous waveform display. Continuous monitoring with waveform display is required during transport. Tip monitoring enables prompt identification of catheter migration to the RV or pulmonary wedge position. Right atrial waveform is displayed continuously using a separate transducer set. Continuous monitoring of the right atrial tracing facilitates prompt confirmation of a tip migration to the RV. Ensure that the right atrial (CVP) displays a Systolic-Diastolic-Mean. Set both the CVP and PA pressure modules to a defined scale (with a baseline of zero). Do not use "optimize scale". Optimize scale will auto adjust the scale to a non-zero baseline to make the waveform fill the display screen. This can delay recognition of critical PAP waveform changes (lower or damped amplitude with lower systolic PAP suggests spontaneous wedging; a sudden increase in amplitude without a systolic pressure change is suggest tip migration to the RV). Suspect that the tip is in the RV if the PA tracing suddenly changes to a taller wave with little change in the systolic pressure. Confirmation is made if the diastolic pressure at the tip of the catheter has dropped (making the waveform taller), and this lower diastolic pressure is consistent with the right atrial diastolic pressure (the right atrium and right ventricle pressures equilibrate during diastole when the tricuspid valve is open). An RV tracing will appear more symmetrical and often tombstone appearance when compared with the PAP tracing. The PAP tracing is more asymmetrical (rapid upstroke and delayed downstroke with a visible dicrotic notch similar to an arterial waveform. Print CVP and PAP tracings and post to the chart during catheter insertion/advancement and at the start of each shift and when waveform morphology changes. Baseline waveforms can provide valuable comparisons to help determine tip location. |
6. | Monitor Pulmonary Artery Pressures Monitor the pulmonary artery waveform continuously and record pressures (Pulmonary Systolic/ Diastolic/ Mean) q1H. Monitor heart rate and rhythm continuously and observe for ventricular ectope. Keep ventricular arrhythmia alarms on. During insertion, print and post the right atrial, right ventricle, pulmonary artery and pulmonary wedge pressures into the chart. These can be obtained after insertion by selecting the "full disclosure" feature of the central station. Identification of an RV tracing from the proximal injectate port (blue) suggests that the catheter has been advanced too distally (increasing the risk for pulmonary infarction or hemorrhage).
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7. | 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/needless access devices.
Hemodynamic circuits are changed with each new line and prn. Flush thoroughly after blood sampling and maintain adequate counter pressure to prevent thrombus formation. A full minute of flushing with an adequately pressurized circuit (passively flush using flush device activation) is needed to ensure blood is cleared from long narrow lumen of the PA. Do not flush aggressively by syringe as this can cause sudden increase in PAP. |
A8. | Prevent Air Embolism
Maintain luer-lock connections on all central venous devices. Clamp lumens/lines before disconnecting IVs or accessing a port. Avoid piggybacking infusions that are not running on another infusion pump into Y sites that are located below the air detection devices. Infusions pumps have air detectors up to the level of the pump. Patients with intracardiac shunts are at increased risk for venous to arterial air embolization. TPN tubing includes an air elimination filter than can be used if additional support is needed. Trendelenburg positioning and breath holding techniques are used during insertion and removal of central venous catheters to prevent air entry. If air inadvertently enters a central venous catheter, immediately aspirate from the line and place the patient left side down in a trendelenburg position. Upright positioning and hypotension increases the risk for air entry into central venous lines. During removal, catheter tract must be immediately occluded to prevent air entry into the tract. See Procedure for Removal of Central Venous Line and Removal of Pulmonary Artery Catheter. |
9. | Obtain Chest Xray Obtain chest xray upon insertion and daily or if the right heart catheter is advanced > 5 cm. To identify complications including: pneumothorax, hemothorax, hydrothorax, catheter kinking, catheter placement (e.g. right atrial placement of CVP catheters or distal placement of right heart catheter), pulmonary infarction or hemorrhage. Chest xrays do not need to be repeated for simple catheter withdrawals, unless there is ongoing concern regarding placement.
Daily and post-advancement xrays are done to assess for spontaneous catheter migration and to rule out distal placement, or to monitor for complications (e.g., hemorrhage, infarction, pneumothorax). Distal placement may be detected on xray, in the absence of a spontaneous wedge tracing. |
10. | Select Appropriate Ports for Infusions Continuous infusions that affect BP or cardiac output should not be administered via the blue proximal injectate port of the PA catheter. RECOMMENDED: Administer vasoactive drugs via the introducer. This allows urgent removal or withdrawal of the catheter if ventricular ectope develops without having to disrupt the vasoactive drug infusion.
If the proximal injectate port is the only site available for the administration of vasoactive drugs, utilize the proximal port but do not perform cardiac output measurements. Although blood products can be infused through any central line, it is preferable that the blue injection port of the right heart catheter be avoided. During cardiac output measurements, 10 ml of fluid is administered into the proximal injectate port. This would result in the administration of a bolus of vasoactive drug. While performing the cardiac output injections, the infusion would be disrupted. After completion of the cardiac output measurement, a delay would occur before the infusion would reach the patient. If the PA tip should slip into the right ventricle, withdrawal or removal is the urgent treatment. If vasoactive drugs are running into a proximal port (proximal injection - blue, venous infusion - white or Paceport(TM) - orange), the infusion may back up into the sleeve because the proximal port may be out of the blood vessel). This would cause a disruption in the administration of the vasoactive medications. If fluid or blood backs up into the sleeve, the catheter must be changed.
Administration of a vasoactive drug via a peripheral vessel places the limb at risk for injury. This risk outweighs the potential benefit associated with PA catheter monitoring.
Blood products may reduce patency of this lumen making measurement of cardiac outputs impossible. |
11. | Obtain Blood Samples
RNs may draw blood from the pulmonary artery catheter using a stopcock. See Procedure for Blood Withdrawal and Blood Gases Venous. |
12. | Dressings and Safety Bundles
Central venous 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. For IJ insertion sites, ensure dressing occlusivity is maintained and that endotracheal securement devices do not disrupt dressing integrity. Record any redness or abnormal findings in the AI record and report to the physician. Dressing changes should be performed aseptically. Arterial and Central Venous Dressing Trays are available for ease of collecting supplies. See Standard for Central Venous and Arterial Line Dressings. Non-sterile cap, gown and mask with face shield plus sterile gloves are required. |
13. | Reposition PA Catheter
RNs may not insert or advance a right heart catheter. RNs in CCTC may partially withdraw a right heart catheter from a persistent PWP or RV position without a physician's order. RNs may remove a PA catheter with a physician's order. Prior to withdrawal of a PA catheter tip from an RV to RA placement, turn off or switch proximal infusions to the introducer site. |
14. | Analyze CVP and PWP Waveform CVP and PWP measurements are obtained from a waveform printout. Waveforms are printed and analyzed to identify the right atrial pressure at end-expiration and the base of the "V" wave. ONLY NURSES WHO HAVE PREVIOUSLY BEEN APPROVED FOR PWP MEASUREMENT SHOULD PEFORM WEDGE MEASUREMENTS.
Waveform analysis is identified on a paper recording of each right atrial and PWP tracing. Each waveform is posted in the clinical record. The goal for right atrial pressure and PWP monitoring is to identify the pressures during end-expiration and end-diastole. Although the pre-C wave best reflects the end-diastolic pressure, it is often difficult to identify, reducing inter-rater reliability. For consistency, we measure the pressure during mid-diastole (during diastasis) because it is easy to find and reflects a pressure that is similar to the pressure at end-diastole. |
15 | Measure Cardiac Output Measure cardiac output q 6 h and prn following changes in vasoactive drugs, fluid administration or to reassess changes in the patient's hemodynamic status. Measure arterial and venous gases with each cardiac output, and enter data into the hemodynamic oxygen delivery portion of the Philips(TM) cardiac output module. Measure CVP and PAP prior to cardiac output measurement. Obtain a minimum of 3 injections, editing measurements to average 3 samples that have a variance of +/-10%. See Procedure for Measuring Cardiac Output. See Procedure for Blood Withdrawal: Blood Gases Arterial and Blood Gases Venous. |
16. | Document Open a pulmonary artery grouper and record the time of insertion. Create a separate grouper for the introducer. At the start of each shift, identify PA catheter placement and record the distance marker at the entrance point to the introducer hub in the pulmonary artery grouper. Each single black line represents 10 cm, while each thick line represents 50 cm. The markings at the insertion site represents the amount of catheter "in" the patient. Be aware that the catheter tip can migrate to a spontaneous wedge pattern or RV even when the insertion distance remains constant. Assess catheter patency and document in the intravascular devices section of the flow sheet at the start of each shift and q 4 h. May careful attention to maintain adequate volume an pressure on the hemodynamic flush system. Document catheter repositioning procedures in the EPR and record changes if indicated. Activate pulmonary artery pressures and cardiac output measurements in the vital signs section. Record PAP and CVP S/D/M every hour and PRN. Document dressing changes in the pulmonary artery catheter grouper. |
| 18 | Introducer and Pulmonary Artery Catheters Use: Introducers are used as stand-alone IVs (e.g., for rapid infusions) or to facilitate the insertion of a temporary transvenous pacemaker, pulmonary artery catheter or central venous catheter. An introducer is a central venous catheter and should be treated with the same central line insertion, maintenance and removal precautions (e.g., risk for air, central line infection, thrombosis). Pulmonary artery catheters are all inserted through an introducer that is 1F larger than the PA catheter. Vasopressors and PA Catheter: When a pulmonary artery catheter is in place, the introducer is the preferred location for the administration of vasoactive agents. The introducer is independent of the pulmonary artery catheter. If a pulmonary artery catheter is advanced or withdrawn, infusions that are being administered via the blue (proximal injectate), white (proximal infusion) or orange (right ventricle port of Paceport(TM) model) lumens must be stopped to prevent in advertent administration of fluid into the sleeve or disruption of life-supporting medication. Patency/IV Therapy: Introducers with pulmonary artery, central venous or transvenous pacing catheters require a continuous flow of IV fluid via infusion pump (5 ml per hour is sufficient). Saline lock should not be used (increased risk for thrombosis). Any patent introducer with confirmed placement can be used for the administration of medication that requires central venous access, including vasopressors. When a catheter is removed from an introducer, the introducer sheath must be immediately blocked with a sterile obturator (obturators are manufacturer specific). The introducer is independent of the pulmonary artery catheter. If a pulmonary artery catheter is advanced or withdrawn, infusions that are being administered via the blue (proximal injectate), white (proximal infusion) or orange (right ventricle port of Paceport(TM) model) lumens must be stopped to prevent inadvertent administration of fluid into the sleeve or disruption of life-supporting medication. Administration of life supporting medication via the introducer ensures uninterrupted administration during advancement, withdrawal or removal of the pulmonary artery catheter. |
