NURSING PROCEDURE TITLE: ARTERIAL LINE PEDIATRIC Less than 30Kg a. Assisting with Insertion b. Maintenance c. Dressing Change d. Withdrawal of Blood e. Removal CATEGORY: RN - Special Nursing Procedure A. ASSISTING WITH INSERTION PURPOSE To assist with the insertion of an intra-arterial pressure monitoring system to enable continuous pressure monitoring in pediatric patients under 30Kg. Potential complications include Accidental disconnection within the system resulting in exsanguination Local and/or systemic infection Thrombus formation, emboli, distal limb ischemia If limb distal to arterial catheter ever shows signs of circulatory compromise, physician must be notified immediately and the catheter must be removed. EQUIPMENT 1. Personal protective equipment 2. Pressure module and cable 3. IV pump administration set 4. Blood conservation system Vamp Junior (Special Order item) 5. 6 inch pressure tubing SPD #313106 6. IV pump 7. 250 ml bag of Normal Saline 8. Heparin 1000U/mL 9. Patient body mount sticker 10. Towel (if transducer will not be mounted on patient) 11. Dressing set 12. #24 IV cathlon (or age appropriate size) 13. Local anesthetic 1% or 2% Xylocaine without Epinephrine 14. 3 ml syringe for anesthetic 15. #25 & #27 needles for anesthetic 16. Chlorhexidine 2% aqueous solution Approval Date: June 14, 2012 Page 1 of 11
17. 2 x 2 gauze 18. Steristrips 19. ½ & 1 tape 20. Semi transparent dressing 21. Appropriate size limb securing board 22. Disposable bed saver pad PROCEDURE A. Preparing Flush System 1. Prepare IV flush solution by adding Heparin 250Units to 250 ml Normal Saline; allows for 1unit/1mL concentration. 2. Label solution with date, time & signature. 3. Tighten all connections on IV tubing and transducer set. 4. Attach solution to IV pump administration set tubing. 5. Attach IV tubing to the open port on the transducer of the VAMP Jr. 6. Attach the 6 inch pressure tubing to the proximal (closest to the patient) end of the VAMP Jr. 7. Prime tubing, including all stopcocks. NOTE: Replace all vented caps on ports of stopcocks with non-vented caps. 8. Place IV administration set on infusion pump and set rate at 3 ml/hr. NOTE: Rate may be decreased to 1 or 2 ml/hr if fluids must be greatly restricted; order must be obtained by physician to infuse at 1 or 2mL/hr. All pediatric arterial lines are to be maintained on an infusion pump to allow for verification of hourly fluid administration. Use of a pressure bag is not optimal because many children cannot tolerate the fluid administered via a standard infusion device providing 3 ml/hr. Malfunction of the one way valve in the flow limiting infusion device may allow delivery of excessive volumes of fluid. B. Preparing The Bedside Monitor 1. Attach pressure cable to pressure port of Multimeasurement Server of the bedside monitor, or pressure module on the bridge of the bedside monitor. 2. Attach open end of cable to pressure tubing transducer. Approval Date: June 14, 2012 Page 2 of 11
3. Zero transducer: 3.1 Close stopcock to patient line. 3.2 Silence alarm. 3.3 Open stopcock to atmosphere. 3.4 Press and hold ZERO button until audible BEEP is heard. 3.5 Close stopcock to atmosphere. 3.6 Return stopcock to monitoring position. C. Insertion Insertion of an arterial line is the responsibility of a physician or respiratory therapist certified in this procedure. Common sites of arterial line insertions include the radial, brachial, femoral or pedal arteries. If any artery is used in the leg, patient must be maintained on strict bedrest. 1. Explain procedure to patient (if age appropriate) and/or parents. 2. Place disposable bed saver pad under selected insertion site. 3. Don protective equipment as indicated. 4. Open the arterial line pack or dressing set. 5. Add Chlorhexidine 2% aqueous solution to sterile bowl. 6. Add syringe to sterile field. 7. Provide #25 or #27 gauge needle as requested. 8. Provide Xylocaine solution as required. 9. Assist with positioning of selected limb as necessary Place a rolled towel under wrist if extension is required. 10. Stabilize patient s limb during insertion as required. 11. Assist with connecting arterial pressure line once catheter is insitu. Approval Date: June 14, 2012 Page 3 of 11
12. Assist with catheter securement. 13. Use patient mount to secure transducer at level of phlebostatic axis. 14. Evaluate arterial waveform 14.1 Re-zero pressure line. 14.2 Adjust pressure scale as needed. 14.3 Adjust ABP alarm parameters as appropriate. 15. Document the following: Physician who performed the insertion. Location of arterial line insertion site. Site condition. Patient tolerance of procedure (any pre-medication required). Hard copy of wave form analysis. B. MAINTENANCE PURPOSE To safely carry out the invasive arterial monitoring for the duration that the catheter is insitu. For the purposes of monitoring, ensure ABP alarms remain on. PROCEDURE 1. Ensure that the infusion pump rate is set at 3 ml/hr unless otherwise ordered by the physician. 2. Ensure transducer remains secured and leveled to the phlebostatic axis. 3. Ensure all tubing connections remain tight. 4. Ensure alarm parameters are individualized for the patient on an ongoing basis. 5. Assess limb distal to insertion site for color, sensation and movement every hour and prn. 5.1 Document changes from initial assessment. 5.2 Report any abnormal findings to the physician immediately. Approval Date: June 14, 2012 Page 4 of 11
If limb distal to arterial catheter ever shows signs of circulatory compromise, physician must be notified immediately and the catheter must be removed. 6. Assess and change dressing as recommended. 7. Ensure correct position of extremity (i.e. armboard, restraint) for optimal waveform. 8. Zero transducer at beginning of each shift and after any interruption in monitoring. 9. Document a waveform strip at beginning of each shift. NOTE: Square wave test is not performed when arterial line is maintained with an IV pump. 10. Document any alterations in the waveform quality and report to physician prn. C. DRESSING CHANGE NOTE: Transparent semipermeable dressing to be changed every 7 days or PRN. Transparent dressing to be changed every 4 days or PRN. Gauze dressing to be changed every 2 days or PRN. For children with sensitivities to Chlorhexidine, alcohol followed by providone-iodine is an acceptable alternative. EQUIPMENT 1. Personal protective equipment 2. Sterile dressing set 3. Chlorhexidine 2% aqueous solution 4. Steri-strips 5. Transparent semipermeable dressing is preferred PROCEDURE 1. Explain procedure to patient if age appropriate and/or parents. 2. Don personal protective equipment. 3. Remove old dressing. 4. Observe insertion site for signs of infection. Obtain swab for C&S, if indicated. 5. Prepare dressing set. 6. Cleanse a 5 cm radius around insertion site and up the catheter with cleaning solution. Approval Date: June 14, 2012 Page 5 of 11
7. Resecure catheter with steri-strips as necessary. 8. Apply sterile occlusive dressing. 9. Document, indicating due date for next dressing change. D. WITHDRAWAL OF BLOOD PURPOSE To aseptically withdraw blood specimen from arterial line with a blood conservation device. EQUIPMENT 1. Personal protective equipment 2. Appropriate pediatric blood specimen containers 3. ABG kit (if necessary) 4. Vacutainer luer lok access device 5. Needleless shielded cannulas 6. Alcohol swab 7. Disposable bed saver pad 8. 3 ml syringe 9. Normal Saline (10 ml vial) PROCEDURE 1. Explain procedure to patient and/or parents. 2. Don personal protective equipment. 3. Draw up 2 ml of normal Saline into 3 ml syringe. Edwards Lifesciences 2003 VAMP Jr. Venous/Arterial Blood Management Protection System Package Insert Approval Date: June 14, 2012 Page 6 of 11
4. Attach needleless shielded cannula to vacutainer luer lok access device and normal saline filled syringe (ABG syringe is necessary). 5. Silence the alarms on the monitor while blood sampling is performed. 6. Close distal shut-off valve by turning the handle perpendicular to the tubing. 7. Pull up on the reservoir plunger smoothly and evenly, until the plunger stops and the reservoir has reached its full capacity. The minimum clearing volume that should be drawn into the VAMP Jr. reservoir is 1 ml. Recommended rate to pull the reservoir plunger up to the fully open position is approximately 1 ml every 10-15 seconds (approximately 30-45 seconds to fill reservoir to capacity). 8. Close the proximal shut-off valve by turning the handle perpendicular to the tubing. 9. Swab the proximal site with alcohol. 10. Attach the vacutainer access device with attached needleless shielded cannula to the proximal sampling site. Edwards Lifesciences 2003 VAMP Jr. Venous/Arterial Blood Management Protection System Package Insert 11. Fill required blood tubes, drawing coagulation last. 12. Remove vacutainer access device with attached needleless shielded cannula by pulling it straight out. 13. Procurement of ABG s: 13.1 Use syringe ABG kit and set plunger to desired sample volume of 1 ml. 13.2 Remove needle from syringe and attach Needleless Shielded Cannula. Approval Date: June 14, 2012 Page 7 of 11
13.3 Insert cannula into sampling site. 13.4 Allow syringe to fill to 1mL. 13.5 Remove syringe from sampling site. 13.6 Eject any air bubbles from ABG syringe. 13.7 Remove shielded cannula and cap syringe with rubber stopper from package. 13.8 Label specimen. 13.9 Place specimen on ice and transport specimen to lab. Edwards Lifesciences 2003 VAMP Jr. Venous/Arterial Blood Management Protection System Package Insert 14. Open proximal shut-off valve. 15. Depress reservoir plunger smoothly, slowly and evenly until it is in a fully closed position and all blood is reinfused into the line. Recommended rate to push the reservoir plunger to the closed position is approximately 1 ml every 10-15 seconds (approximately 30-45 seconds to empty a completely filled VAMP Jr. reservoir). The clearing sample should not remain in the reservoir for longer than three minutes. It is recommended that the VAMP Jr. be changed if the clearing volume remains in the reservoir for longer than three minutes. Approval Date: June 14, 2012 Page 8 of 11
16. Flushing the line. NOTE: The approximate volume required to flush the line is 1.0 1.5 ml. 16.1 Fill the 3 ml syringe with 1.5 ml of normal saline. 16.2 Attach a needleless shielded cannula to the syringe. 16.3 Insert syringe/cannula to the distal access/flush site. 16.4 Flush the tubing to clear pressure tubing of blood. 16.5 Open the distal shut-off valve. Edwards Lifesciences 2003 VAMP Jr. Venous/Arterial Blood Management Protection System Package Insert E. REMOVAL PURPOSE To remove an intra-arterial catheter in a safe and aseptic manner. EQUIPMENT 1. Sterile 2 x2 gauze 2. Elastoplast fabric tape 3. Personal protective equipment PROCEDURE 1. Verify physician s order. 2. Explain procedure to patient if age appropriate and/or parents. 3. Turn off infusion pump. Approval Date: June 14, 2012 Page 9 of 11
4. Turn stopcock off to patient. 5. Disconnect cable from transducer and remove pressure module from monitoring rack. 6. Press reset on monitor to remove pressure waveform from screen. 7. Don personal protective equipment. 8. Remove tape and dressing over arterial site carefully. 9. Inspect site and swab for C&S if signs of infection present. 10. Place 2 x2 gauze over site, apply steady pressure and gently withdraw catheter from artery. 11. Ensure that catheter is intact upon removal. 12. Maintain manual pressure to site for five minutes. 13. Apply pressure dressing to site. NOTE: Pressure dressing may be removed in 24 hours. 14. Assess for signs of bleeding. 15. Dispose of the tubing and flush system. 16. Document the following: Time removed. Condition of site. Condition of catheter (e.g. catheter removed intact). Description of dressing applied and; Patient s tolerance of procedure. Approval Date: June 14, 2012 Page 10 of 11
REFERENCES Calgary Health Region. (2002). Hemodynamic Monitoring. Child health policies and procedures H-1.0, 2-12. Calgary, AB. Curley, M. & Moloney-Harmon, P. (2001) Critical care nursing of infants and children (2 nd ed). St. Louis, MO: W.B. Saunders Company. de Neef, M., Heijboer, H., Van Woensel, J., & DeHaan, R. (2002). The efficacy of heparinization in prolonging patency of arterial and ventral venous catheters in children: A randomized double-blind trial. Pediatric hematology & oncology, 19 (8), 553-560. Edwards Lifesciences (2003). VAMP Jr. Venous/Arterial Blood Management Protection System Package Insert. Irvine, CA. Edwards Lifesciences (2003). Pressure Monitoring Kit with TruWave Disposable Pressure Transducer Package Insert. Irvine, CA. Fuhrman, B.P., Zimmerman, J.J., Carcillo, J., & Clark, R. (2011). Pediatric critical care, (4 th ed). St. Louis, MO: Elsevier Saunders. Gonce Morton, P., Fontaine, D., Hudak, C., & Gallo, B. (2005). Critical care nursing: A holistic approach (8 th ed). Philadelphia, PA: Lippincott Williams & Wilkins. Hazinski, M. (1992). Nursing care of the critically ill child (2 nd ed). Mosby Year Book. Monagle, P., Chan, A., Massicotte, P., Chalmers, E., & Michelson, A. (2004). Antithrombotic therapy in children : the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, September 2004. pp 645s-687. Verger, J. & Lebert, R. (2007). AACN procedure manual for pediatric acute & critical care. St. Louis, MO: Saunders Elsevier. Revised by: Tracy Wilson, CNE MPICU; Michele Myrah, Manager MPICU Date: June 2008 Revised by: Justin Rae, CNE MPICU; Dr. J. Soper, Medical Directory Department of Pediatrics RQHR; Michele Myrah, Manager MPICU Date: April 2012 Approved by: Date: June 14, 2012 Regina Qu Appelle Health Region Health Services Nursing Procedure Committee Approval Date: June 14, 2012 Page 11 of 11