SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE TITLE: ISSUED FOR: (crc15-nursing) (crc.02-respiratory) Nursing Respiratory Care Services DATE: REVIEWED: PAGES: 02/93 9/17 1 of 8 RESPONSIBILITY: RN, LPN II Registered Respiratory Therapists MSTs (Removal only--pacu and Cath Lab only after competency documented) PURPOSE: TO INCLUDE: To provide a procedure for the care of radial arterial lines. 1. Insertion: The act of placing a catheter into an artery. 2. Management: Care of the catheter, insertion site, dressing, tubing, flushes bag, and troubleshooting. 3. Monitoring: Waveform analysis, pressure recording. 4. Blood Sampling: Arterial blood obtained by aspirating the specimen via the indwelling catheter line. 5. Discontinuation: Removing the indwelling catheter. EXCEPTION: Neonatal Intensive Care Unit Refer to Nursing Procedures (car04) Care of Femoral Sheaths and (car11) Discontinuation of a Femoral, Venous/Arterial Sheath and Groin Management for specific care required for those sheaths. KNOWLEDGE BASE: 1. Insertion of radial arterial line catheters will be performed by a physician, trained Respiratory Therapist or Trauma PA s. 2. Insertion site will be restricted to the radial artery unless ordered as dorsalis pedis by physician. 3. A test for collateral circulation evaluating the patency of the radial and ulnar arteries (i.e., Allen Test or posterial tibial) will be performed. If inadequate, no attempt will be made and physician will be notified. 4. NOTE: Due to the temporary presence of wires and other invasive devices in the heart and vascular system, the short-term use of Heparin in the bags in the procedural/surgical departments will be practiced at the discretion of the physician.. INSERTION:
PAGE: 2 of 8 Equipment: 1. 20-gauge by 1 to 2 catheter (adult), catheter size for pediatric patient will be specified by the physician 2. Disposable hand/wrist support 3. Complete sterile infusion system including 500ml normal saline, unless otherwise ordered by physician 4. Transducer cable and holder 5. Pressure bag 6. TB syringe with 0.5ml of 1% Xylocaine (if desired) 7. Sterile gloves 8. Sterile insertion pack containing: a. Hat and mask b. Chlorhexidine/alcohol prep c. Alcohol swabs d. Sterile drape e. 4x4 gauze f. 19 and 21 gauge needles g. 48 inch pressure tubing h. Sterile dressing 9. Arterial line labels 10. Sonosite and Sterile drape (if needed) 11. Lidocaine 1% if ordered by physician Insertion Steps: 1. Verification of the physician order. 2. Perform hand hygiene and assemble infusion set. The drip chamber is to be completely fluid filled. The flush solution and infusion set should have a day/date label. Draw up lidocaine if ordered by physician. 3. Identify yourself to the patient. Identify patient per policy (01.PAT.09 Patient Identification) and explain what is to be done. Check for limb alert bands. 4. Perform Allen Test as follows.
PAGE: 3 of 8 1) Instruct the patient clench his/her fist, or if the patient is unable, you may close the hand tightly. This removes as much blood from the hand as possible. 2) Using your fingers, apply direct pressure to the radial and ulnar arteries to obstruct the arterial blood flow to the hand. 3) Have the client open his or her hand while applying occlusive pressure to both arteries. Fingers and hand should be pale and blanched which indicates lack of arterial blood flow. 4) Release the pressure over the ulnar artery. Observe color of fingers, thumbs and the hand. Fingers and hand should flush within 15 seconds. 5) Repeat steps 1) to 4) with the other hand (if necessary as blood flow inadequate). 5. If Lidocaine ordered by physician prep site with alcohol/chlorhexidine swab and inject 0.5ml intradermally). 6. Open a line pack (assemble, thoroughly flush line and transducer) Don hat, mask and perform hand hygiene. 7. Prep the patient with chlorhexidine swab using a back and forth motion over approximately a 4x4 area, for 30 seconds and allow to dry. Do not blot or fan 8. Perform hand hygiene and don sterile gloves 9.Apply sterile drape over insertion site. If Sonosite to be used during sterile procedure, drape the sonosite with sterile cover.
PAGE: 4 of 8 (Assistance would be required for this step.) 10. Use a 19-gauge needle to create a window at the insertion site, if needed. 11. Insert catheter into selected artery. 12. After successful cannulation, connect the infusion set to the hub of the catheter. 13. Check catheter for adequate blood return (when exposed to ambient pressure) and flush with Normal Saline flush bag. 14. Tear away drape and clean site of any blood. Apply dressing. 15. Remove gloves and perform hand hygiene. 16. Zero transducer line and check for a waveform. 17. Date the occlusive dressing. Apply splint and document placement in IV Flowsheet. PROCEDURE: MANAGEMENT 1. Peripheral arterial line sites will be assessed no less than every shift. Sites will be checked for oozing, edema and inflammation. 2. Transparent dressings may remain in place for up to 96 HOURS unless wet, soiled, or non-occlusive in which case they should be changed ASAP. The Respiratory Therapist will change the dressing. This will include cleaning and inspection of the site, and application of new sterile occlusive dressing. Dressings will be dated. 3. Dressings and Arterial line infusion systems will be changed and labeled Arterial on Sunday and Thursday and PRN by Respiratory Care personnel. (See Care of Femoral Arterial Sheaths (car04) and Care of Intra-Aortic Balloon Pump (crc13)). 4. The flush solution bag for the arterial line will be changed and labeled every Sunday and Thursday (or more often if flush solution runs out) by Respiratory Care personnel or nursing. 5. Zero transducer every shift and PRN.
PAGE: 5 of 8 PROCEDURE: MONITORING 1. Arterial lines will be pressure transduced unless otherwise ordered by the physician. 2. Check pressure waveform for dampening and presence of dicrotic notch when the arterial line is pressure transduced. Set high and low pressure alarm limits on monitor specific for the individual patient. 3. Non-invasive blood pressure will be checked for correlation by manual or automatic cuff and/or return to flow every shift or PRN. If difference between noninvasive blood pressure and arterial blood pressure is greater than 20mm Hg, verify with physician which pressure to treat. 4. If dampened waveform occurs: a. Rebalance and calibrate. b. Ensure 300mm Hg pressure on bag. c. Ensure patency of infusion system (i.e., fluid in bag; no loose connections or air bubbles; no kinks in catheter or tubing; stopcock in monitoring position). d. Check non-invasive blood pressure and correlate with arterial blood pressure. PROCEDURE: BLOOD SAMPLING NOTE: The number of manipulations (entries) into the system will be minimized. NOTE: Blood cultures will not be done via pressure monitoring devices unless there are absolutely no other peripheral sites and must be accompanied by physician order. NOTE: Blood specimens, if drawn from the arterial line, will be coordinated with blood gas analysis to keep manipulations to a minimum. Equipment: 1. 3 ml syringe (1) or vacutainer and a red top tube for waste. 2. Specific tubes necessary for ordered blood test. 3. Sterile gauze 4. Non-sterile gloves 5. Sterile occlusive cap 6. Vacutainer Luer-adapter. NOTE: Stop-cocks, if used, will be covered with an occlusive cap and maintained as a sterile field. 1. Assemble materials.
PAGE: 6 of 8 Blood Sampling Steps: 2. Perform hand hygiene. 3. Positive patient identification is required. 4. Suspend monitor alarms. 5. Perform hand hygiene and don gloves. 6. Locate the stopcock closest to the arterial line insertion site and turn off to patient. 7. Remove occlusive cap of stopcock and discard it. 8. Attach a 3 ml sterile syringe or vacutainer with Luer adapter with waste tube. 9. Open stopcock to syringe/vacutainer. 10. Aspirate 3 ml of blood into the syringe/vacutainer for discard. 11. Turn stopcock off to patient. 12. Attach vacutainer to stopcock; open stopcock to syringe/vacutainer; aspirate blood sample; close stopcock to patient. 13. Open sterile gauze package and hold under stopcock; flush stopcock port into sterile gauze using intraflow device. If stopcock soiled, clean with an alcohol swab prior to applying the new sterile cap. 14. Place new sterile cap on stopcock port. Open stopcock to flow. 15. Flush until all visible blood is removed from stopcock. 16. Remove gloves and perform hand hygiene. 17. Un-suspend monitor alarms. 18. The nurse or respiratory therapist obtaining the sample will label each vial/syringe using the Final Check process (final check verification is done for each specimen by reading out loud the last 3 digits of the patients visit number and then reading out loud the last 3 digits of the patient visit number on the patient identification band) before leaving the patient s room with the following information: a. Patient label obtained from lab/rt (Lab Information system if lab-work). b. Time of collection. c. Date. d. Initials of nurse/respiratory Therapist. ALTERNATE METHOD: 1. A 3 ml syringe will be attached to the stopcock adjacent to the intraflow device. 2. Using above syringe, 3 ml of fluid will be aspirated from arterial line. 3. Using appropriate size syringe, specimen will be obtained from stopcock closest to insertion site. 4. Replace 3ml from number 2 above. 5. Flush stopcock/pressure line with intraflow device.
PAGE: 7 of 8 PROCEDURE: Equipment: DISCONTINUATION (RTs and Critical Care/PACU/Intervention RNs/ MSTs in PACU and Cath Lab only after competency documented) 1. Non-sterile gloves 2. Gauze 3. Tape or band-aids Discontinuations Steps: 1. Turn off arterial monitor. 2. Perform hand hygiene; don gloves. 3. Remove dressing. 4. Discontinue catheter. 5. Apply pressure to site a minimum of 5 minutes or until bleeding stops. 6. Nurse to evaluate distal circulation. 7. Apply band-aid/dressing. 8. Remove gloves. Perform hand hygiene. DOCUMENTATION: 1. Respiratory Care Flowsheet 2. Every shift, documentation by RN and/or Respiratory Therapist to include site condition. 3. When changing flush bag, document on EMAR time, date and solution used. 4. Document any difficulty in drawing sample from/or flushing the line. 5. Upon discontinuing catheter, document presence of hematoma, bleeding, ecchymosis, distal pulses and application of pressure dressing REFERENCES: Wiegand, D.L. McHale (2011). AACN Procedure Manual for Critical Care. Saunders: St. Louis, MO Product Information Baxter Health Corporation. Critical Care Division. Irvine, CA, 92714. Edwards SMH Policy. Patient Identification: Inpatient/Outpatient. (01.PAT.09). SMH: Author.
PAGE: 8 of 8 Shah, Harshal. et.al. Intravascular Catheter-Related Bloodstream Infection. The Neurohospitalist 3(3). 144-151. Recommended Practices for Prevention of Arterial Related Bloodstream infection, 2013. REVIEWING AUTHOR(S): Donetta Dangleis, RRT, Manager, Respiratory Therapy Benny Kruger, RN, MSN, CCRN, CNN, NPD Specialist, Critical Care/Hemo Jessica DePaulo, MSN, RN, CCRN, NPD Specialist, Critical Care APPROVAL(S): Clinical Practice Council 9/7/17