Arterial Lines

• Medical or surgical condition requiring continuous monitoring of blood pressure
• Frequent access to arterial blood for arterial blood gases (e.g., ventilated patients)
• [Not a route for medication administration!]

• Understanding of procedure
• Allen's Test (radial artery)
• History of PVD, vascular grafts, AV fistula, arterial vasospasm or thrombosis, diabetes mellitus
• Allergies to iodine, tape, Latex^®, ointments

• Informed consent (principle of autonomy)
• Confirm collateral circulation to hand
• Presence of one of these medical conditions may increase the risk of arterial insufficiency distal to the insertion site.
• Guide selection of supplies to prevent allergic reaction

Steps

1. Wash hands.

2. Perform modified Allen's Test.

3. Prepare pressurized and heparinized flush solution. (See procedure under Hemodynamic Principles).

4. Flush pressurized closed transducer tubing with luer-lok connections and ports.

5. Use tubing with inline blood discard reservoir.

6. Don sterile gloves, protective gown, and mask.

7. Assist with skin preparation.

8. Facilitate immobilization of extremity.

9. Once catheter is inserted, connect pressure tubing and secure site with sterile occlusive dressing & bandage.

10. Observe waveform and perform a dynamic response test (square wave test).

11. Level the transducer with phlebostatic axis (See Hemodynamic Principles.)

12. Zero transducer to air. (See Hemodynamic Principles.)

13. Compare arterial line pressure with noninvasive cuff reading of blood pressure.

Rationales

1. Prevention of nosocomial infections.

2. Confirm collateral circulation to the hand through the ulnar artery.

3. 1-2 units heparin/mL reduces risk of catheter occlusion through thrombosis.

4. Removal of ALL air bubbles promotes better waveforms and reduces danger of air embolism.

5. Maintains closed system while obtaining blood samples.

6. Arterial line insertion is a sterile procedure

7. Reduce normoflora microbes at insertion site.

8. Facilitates access to artery during insertion.

9. Prevention of dislodgement of arterial catheter will reduce risk of hemorrhage from an artery.

10. Determines location of the catheter and degree of waveform dampness.

11. Transducer should be leveled with right atrium to provided accuracy of blood pressure readings.

12. Insures representation of the patient's BP on the monitor.

13. Validates reference point for arterial readings.

1. Check level of transducer with phlebostatic axis.
2. During first assessment of shift, zero transducer to air.
3. Assess waveform for dampness.
4. Record readings on monitor.
5. During first assessment of shift, compare reading with noninvasive cuff reading of blood pressure.

1. Insures accuracy of readings.
2. Insures representation of patient's BP on monitor.
3. Dampness may distort systolic and diastolic readings.
4. Systolic/Diastolic (Mean Arterial Pressure)
5. Verifies reference point for arterial readings.

1. Wash hands.
2. Don nonsterile gloves.
3. Prepare ABG equipment or blood specimen equipment.
4. Label all syringes or tubes with the patient's information.
5. Connect syringe or Vacutainer^® with luer-lok adaptor to port nearest patient.
6. Suspend alarms.
7. If tubing contains an inline blood discard reservoir, turn stopcock off distal to reservoir and aspirate blood from arterial line.  Turn off stopcock between reservoir and external port.
8. Turn stopcock of proximal port off to transducer (patient to external port).
9. If there is no reservoir, fill one tube or syringe of blood for discard.
10. Then collect blood specimen by Vacutainer^® or syringe for blood gases or lab work.
11. Close external port insuring tubing is open from transducer to patient.
12. If an inline blood discard reservoir exists, then eject the blood back through the arterial line into the patient.
13. Check other stopcocks to insure tubing is open between transducer and patient.
14. Flush arterial line tubing until blood is gone from tubing.
15. Assess patient's response to the procedure.
16. Send blood specimen immediately to lab (If ABG's were collected, the specimen must be sent in ice.)

1. Prevent nosocomial infection.
2. Protect self from exposure to body fluids.
3. Preparation of equipment minimizes time during aspiration of blood in arterial line.
4. Labels beforehand insures specimen results are attributed to the correct patient.
5. Nearest port reduces how much blood needs to be discarded.
6. Reduces distressing sounds for patient.
7. This aspirates blood into reservoir instead of wasting it.
8. Now port is available for blood aspiration.
9. If using syringe, use a 5 ml syringe first to collect discarded blood.  Discarded blood is mixed with solution from pressure line, so lab values will not be accurate.
10. Here is the actual collection of the specimen.
11. Reduces risk of hemorrhage from patient.
12. Reduces blood loss associated with specimen collections.
13. Insures patency of arterial tubing system.
14. Flushing line reduces potential for thrombosis in arterial catheter.
15. Generally, this is a painless procedure due to the presence of an arterial line, but especially fragile patients may be affected by the loss of even small volumes of blood.
16. Analysis should be done as soon as possible to prevent chemical reactions or cell changes from occurring due to time delays.

    Mean Arterial Pressure (MAP) = Systolic BP + 2(Diastolic BP)

                                                                          3

• Systolic Blood Pressure:    90 – 120 mm Hg

• Diastolic Blood Pressure:    50 – 80 mm Hg

• Mean Arterial Pressure:      70 – 100 mm Hg

Problem

1. Dampened waveform

Intervention

1. Assess tubing for presence of air bubbles (most likely during initial preparation and flushing).  Remove air bubbles from nearest port.  Flush arterial line pressure tubing (dynamic response test).  Assess positioning of patient's extremity, particularly the wrist.  The patient may require a padded splint to prevent flexion of the wrist.

2. Bright red blood on patient's bedding

2. Don protective gloves.  Assess arterial tubing connections.  Inspect ports to make sure that they are "turned off" to external port ("air").  [Bright red blood is due to break in closed system allowing arterial blood to escape.]

3. Poor blanch return or perfusion in fingers distal to arterial line.

3. Assess positioning of the patient's extremity.  Assess securing dressing and bandage if it is too circumferentially tight.  Notify physician.  Arterial line may have to be discontinued if catheter is obstructing blood flow to the extremity.

4. Potential for sepsis.

4. Prevent sepsis by maintaining a closed tubing system.  Use povidine wipe on port when blood is being aspirated.  Insertion of arterial line should be treated as a sterile procedure.  Arterial catheter should be replaced every 3 days by "overwiring" to minimize risk of sepsis.  When arterial catheter is removed, the tip should be sent to lab for culture and sensitivity.

1. Assess patient's coagulation profile.
2. Wash hands.
3. Don nonsterile gloves, face shield, and protective gown.
4. Turn off monitor alarms for arterial line.
5. Remove securing dressing and tape.
6. Attach 3 ml syringe to proximal port.  Turn stopcock off to transducer and aspirate 3 ml blood.
7. Apply direct pressure 1-2 fingerwidths proximal to insertion site.
8. Remove arterial catheter covering site with a sterile 4×4 gauze.
9. Apply direct pressure over insertion site and 1-2 fingerwidths proximal to insertion site for 10 minutes.
10. Assess insertion site for bleeding or hematoma while applying pressure.
11. Assess distal circulation while applying pressure.
12. Apply a pressure dressing to the insertion site after hemostasis has occurred.

1. Determine whether direct pressure will be required for longer period of time due to reduced clotting capacity.
2. Reduce nosocomial infection risk.
3. Protect oneself from possible spurting blood during procedure.
4. Reduce anxiety provoking stimuli to patient.
5. Hold arterial line and catheter in one hand to insure that catheter does not become prematurely dislodged.
6. Aspiration of blood reduces the risk of thromboembolism from end of catheter.
7. The arterial catheter actually penetrates the artery proximal to the insertion site in the skin.
8. Sterile gauze reduces the risk of infection.
9. Arteries require more prolonged compression in order to facilitate hemostasis due to the greater arterial pressures.
10. Minimizes risk for bleeding.
11. Monitors circulation to the extremity due to the risk of thromboembolism.
12. Reduces risk for hemorrhage.