CHHS15/098

Canberra Hospital and Health ServicesClinical ProcedureArterial line - AdultsContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Insertion of Arterial Line.........................................................................................2

Section 2 – Arterial line dressing or line change.......................................................................4

Section 3 – Sampling from Arterial Line....................................................................................5

Section 4 – Removal of Arterial Line.........................................................................................6

Section 5 – Set-up of Monitoring Equipment for PICCO and thermodilution............................6

Section 6 – Performing Cardiac Output (CO) Studies................................................................6

Implementation........................................................................................................................ 7

Related Policies, Procedures, Guidelines and Legislation.........................................................7

References................................................................................................................................ 7

Search Terms............................................................................................................................ 7

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Purpose

This procedure document describes the equipment required for insertion of and sampling from arterial lines, and the process of change and removal of arterial lines.

The second purpose of this procedure is to outline the safe and effective management of patients with PiCCO Monitoring being cared for in the Intensive Care Unit.

Scope

Scope

This procedure document applies to all medical staff and nursing staff who insert and/or care for arterial lines under their scope of practice. This procedure will usually only occur in critical care areas – Emergency Department, Intensive Care and Operating Theatres.

Section 1 – Insertion of Arterial Line

Suggested Equipment: Clean trolley Clip for hair to be removed from the proposed site if required Sterile packs containing drapes, suture equipment and gown Sterile gloves Mask and eyewear Tape 2.5cm (may be required to immobilise wrist) Appropriately sized arterial cannula with guidewire (depends on planned site – radial,

brachial or femoral) Local anaesthetic (for example 1% or 2% Lignocaine) 5ml syringes 25 gauge needle Drawing up needle 3/0 ethilon suture on curved needle Occlusive dressing Chlorhexidine 0.5% in alcohol 70% solution Disposable transducer monitoring kit 500mls 0.9% Sodium Chloride IV fluid Arm board and Elastoplast Pressure bag Relevant pressure module and cable if required for area If required extension of the arterial line tubing, use specific not distensible tubes to

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Consider Ultrasound machine and sterile sheath covers with sterile gel in case of difficult access. Ultrasound real time guidance can reduce insertion time, failure and complications related to anatomical variation and vascular disease (i.e atheromatosis)

If PICCO is inserted, prepare the insertion and thermodilution specific kits and the temperature cable to the PICCO catheter

Preparation of the Transducer Line Insert appropriate pressure and / or cardiac output module into monitoring system rack

if required for area Connect transducer cable Position transducer on pole mount and level with right atrium (fourth intercostal space,

mid-axillary line), or attach to upper arm as per local practice Prepare equipment using aseptic technique Open transducer kit. Connect flush bag and prepare the flush system (0.9% Sodium

Chloride 500ml for intravenous infusion) Using an aseptic technique insert transducer spike into flush bag Place flush bag into the pressure cuff and pressurise solution to 300mmHg. All air

bubbles must be removed to ensure accuracy of arterial pressure monitoring and prevent arterial gas embolisation

Open the roller clamp and prime the flush system maintaining a sterile field Connect transducer cable from flush system to cable connected to pressure module Maintain asepsis, and be ready to hand this line to the medical officer once arterial

cannula is inserted Calibrate transducer (‘zero’) to atmospheric pressure Position patient according to the procedure requirements and comfort

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Post insertion Secure radial line with arm board and elastoplasts (note arm board may not be required

for brachial line) Secure transducer and tubing. Set alarm limits and always display in the monitor the arterial pressure waveform to

obtain continuous blood pressure measurements Calibrate the system by levelling to the phlebostatic axis (mid chest – mid axillary line) Performing a flush test Assess limb for: pulse, colour, temperature, movement, sensation and capillary refill and

signs of bleeding. Reassessment should occur frequently. The insertion of the arterial line should be documented in the patient’s clinical record by

the medical officer who performed the procedure.

Note: In the ICU Clinical Information System ‘Metavision’, the interventions tab must reflect insertion of the line by entering “arterial line in situ” under the procedures button

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At the commencement of each shift: The arterial line should be levelled and calibrated and compared with non-invasive blood

pressure measurement The flush bag solution and volume remaining should be checked and kept pressurised at

300 mmHg An assessment should be made looking for complications of the arterial line including

haemorrhage, clotting, gas, kinking, limb hypoperfusion or persistent dumped waveform.

Section 2 – Arterial line dressing or line change

Equipment Dressing pack Chlorhexidine 0.5% in Alcohol 70% Occlusive dressing Clean armboard and elastoplast strapping Transducer monitoring kit Pressure bag 500ml bag 0.9% Normal Saline

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Sterile gloves, clean gown and mask Protective sheet Sterile artery forceps

Procedure Wash hands and prepare equipment Explain procedure, ensure patient privacy Suspend alarm temporarily Prime flush line and turn off to patient Place protective sheet under arterial insertion site Place Normal Saline bag into pressure cuff and pressurise cuff to 300mmHg Operator and assistant wash hands and don sterile gloves Assistant applies pressure to the artery at the cannula tip Operator cleanses hub and surrounding area with antiseptic solution. With flush system

off, quickly changes and secures the prepared flush system (sterile artery forceps may be required). Turn flush system on, connect pressure cable and observe waveform.

Observe site for signs of inflammation and report to medical staff any concerns. Attend cannula site dressing using aseptic technique Cleanse with antiseptic solution and allow to dry Apply clear occlusive dressing ensuring the entry site is visible. Secure transducer and flush line Zero transducer and reactivate alarms Documentation of procedure in patient’s clinical record.

Note: In ICU Clinical Information System “Metavision”, the documentation of the line/ dressing change occurs in the ‘Nursing Care’ tab and in the ‘Nursing Care Plan’ tab. The location and site assessment of all arterial lines occurs in ‘Other Obs’ tab.

Section 3 – Sampling from Arterial Line

Equipment Pre primed Heparin arterial blood gas syringe Vacuette and appropriate vacutubes. If necessary, ‘BD –Blood Sampling accessories’ Safe arterial blood sampling accessory. Chlorhexidine Alcohol swabs. Personal Protective Equipment (gown, gloves, goggles)

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Procedure Explain procedure to patient. Ensure all equipment is ready at bedside. Wash hands and don non-sterile Personal Protective Equipment Silence monitor alarms.

Turn RED tap OFF to the transducer. PULL back on the volume restricted syringe. This draws blood back past the sampling

bung. Turn RED tap OFF to patient. Wipe the silicone bung with a Chlorhexidine Alcohol swab and allow to dry.

If using Safedraw TM device: Insert syringe into arterial line bung and allow blood to passively fill syringe if possible. Change to vacuette and withdraw blood into vacutubes as required. Wipe the bung with a Chlorhexidine Alcohol swab.

Picture: Safedraw Device and Tranducer

Once specimens have been taken: Turn the RED tap OFF to the transducer. PUSH the volume restricted syringe down returning the blood into the patient line Turn the RED tap OFF to the syringe. Manually flush to clear any blood in the line. Observe the waveform on the monitor and reactivate the alarms. Attend blood gas analysis immediately or send to biochemistry with pathology request

form via the chute system (no ice required). Label Arterial Blood Gas (ABG) specimens which are sent to biochemistry with Fraction of inspired oxygen (FiO2) and patient temperature.

Ensure all specimens are clearly labelled. Document actions in the patient’s clinical record.

Note: On ICU Clinical Information System ‘MetaVision’, this is under ‘Nursing Care’ tab.Back to Table of Contents

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Section 4 – Removal of Arterial Line

Equipment Dressing pack Chlorhexidine 0.5% in Alcohol 70% Sterile Gauze swabs Stitch cutter Personal protective equipment (e.g. Gown, gloves, goggles) Adhesive tape Protective sheet Sterile Scissors

Procedure Explain procedure, ensure patient privacy. Suspend monitor alarms. Turn the flush system off. Place protective sheet under the site. Using aseptic technique, cleanse the cannula site and remove suture. (If a cut down was

required, ascertain the date of insertion and whether the cut down suture can be removed).

Remove the cannula and immediately apply firm pressure to the site.

Note: This firm pressure should be applied for at least five minutes until bleeding stops. Be aware that longer periods may be required if abnormal coagulation. Leave limb exposed to allow continual observations. If the patient is to be transferred to the ward, ensure this information is handed over to relevant ward staff.

Apply gauze over the site until the bleeding has stopped and discard. Radial arteries can be covered with clean gauze and tape. A Femoral artery (or other

contaminated site) requires an occlusive transparent dressing removal site. Inspect cannula, ensure cannula tip is intact. Determine if a ‘tip’ culture is necessary and if so, using sterile scissors, cut tip off into

yellow specimen container. Label appropriately. Document procedure in patient’s medical record

Note: In ICU Clinical Information System “MetaVision” also stop the arterial line on the Intervention tab.

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Section 5 – Set-up of Monitoring Equipment for PICCO and thermodilution

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Equipment 2 Invasive pressure ports or modules for ABP and CVP Philips Orange CCO module 1 Pressure cable for CVP Philips blue end thermistor cable Pulsion white arterial pressure cable

Philips CCO module Pulsion white arterial pressure cable Philips blue thermistor cable

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Procedure to connect the equipment1. Connect pressure cable to module for CVP2. Connect Pulsion white arterial pressure cable to port or module for ABP and to

transducer flush line3. Connect Philips thermistor cable to Philips CCO module and injectate temperature

sensor housing to thermistor. 4. Change screen to a ‘6, 7 or 8 Waves & PiCCO’ screen by pressing the change screen

SmartKey and choosing from the drop down menu5. Ensure arterial pressure port is labelled ABP6. Ensure Cardiac Output module is activated

Procedure to set up the flushing system to measure cardiac output by thermodilution

1. Connect 100ml bottle of 0.9% NaCl to gravity IV line and prime2. Connect gravity IV line to 3 way stop cock3. Attach Luer lock syringe to 3 way stop cock4. Connect 3 way stop cock to thermistor5. Connect thermistor to distal lumen of CVC.6. Aspirate 20ml of injectate by turning stop 3 way stop cock off to patient7. Turn 3 way stop cock off to gravity IV line8. Syringe is ready for cardiac output (CO) studies

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The greater the injectate volume (15-20 ml) and the colder the temperature, the

more accurate the measurement.

The use of injectate with a temperature that is not at least 12°C lower than the

blood temperature may cause incorrect values for the thermodilution and CCO

calibration.

CHHS15/098

Section 6 – Performing Cardiac Output (CO) Studies

Procedure Zero CVP Open C.O. procedure window by selecting the Cardiac Output SmartKey. When the “Ready for new measurement” message appears, start the measurement

by selecting the Start C.O. pop-up key. When the ready tone sounds and the “Stable baseline, inject now!” message appears,

inject the cooled saline from flush line into the CVP line. Another tone will then sound and “Injection detected” will appear.

At the end of the measurement the thermodilution curve, cardiac output, index values, ITBV and EVLW values and any curve alerts are displayed and a “Prepare for next injection or press Stop” message will appear.

When the “Stable baseline, inject now!” message appears, repeat the procedure a minimum of two more times. A maximum of 6 measurements can be performed before editing.

Editing CO MeasurementsIt is important to identify and reject erroneous trials as the monitor uses all measurement trial values to calculate the average cardiac output.

Review the trials. Irregular trials or trials marked with a “?” should be reviewed carefully. Consider the similarity of the values and the shape of the C.O. curve. A normal C.O. curve has one smooth peak and returns to the temperature baseline level after the peak.

Reject unsatisfactory trials: use the Select Trial pop-up key to move between trials or select the trial using the touch screen, then select the Accept / Reject pop-up key to accept or reject. Discard conspicuously different values. The background of rejected trials is red and the background of accepted trials is green. The monitor recalculates the average values after accepting or rejecting trials.

Causes of very different thermodilution CO measurements during calibration: Haemodynamic instability (variability of HR, preload, vasoactive drugs, vascular tone) Repetition of the injection of cold saline in longer periods than 10 minutes Irregular arrhythmias Different injected saline temperature, volume , speed

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Causes of inaccurate CO measurements by transpulmonary thermodilution: Injected cold saline in a vessel in proximity to the PICCO catheter (i.e same side

central venous access and arterial line) Rapid core temperature changes Intracardiac shunts Insufficient volume or incomplete volume injected Extracorporeal circuits (i.e. ECMO, High volume dialysis Significant aortic valve diasease (stenosis, regurgitation)

Saving CO (Cardiac Output) measurements by TPTD (transpulmonary thermodilution) to calibrate the CCO (Continuous Cardiac Output) by waveform pulse contour method. When editing of the trials is finished, the results must be saved. Before the monitor can calculate CCO, the measurement must be calibrated.

In the C.O procedure window, select the Save C.O & Cal CCO pop-up key to use the averaged C.O. value to calibrate Continuous Cardiac Output (CCO).

Any significant change in the vascular tone (i.e sepsis, anaphylaxis, hyperthermia) or dose of vasoactive or vasodilatory drugs (i.e: noradrenaline, adrenaline, dobutamine, dobutamine, vasopressin, GTN, propofol) requires a new recalibration by thermodilution

Performing and Printing Calculations To enter the calculations review window, select the Hemo Calc pop-up key. Select the Resample Vitals pop-up key to use the most recent continuously

monitored values. Select the Perform Calc pop-up key to perform the displayed calculation and store

the calculation in the calculation database. Print the calculations by selecting the Print / Record pop-up key.

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PiCCO Decision Tree

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Implementation

This procedure document is a merge of four pre-existing documents – no new information presented. New staff will be oriented to the existence of this document.

Related Policies, Procedures, Guidelines and Legislation

Policies and ProceduresHealthcare Associated Infections Procedure (CHHS15/072) Aseptic Non Touch Technique (CHHS14/011)Patient Identification: Pathology Specimen Labelling (DGD12/024)Patient Identification and Procedure Matching Policy (CHHS14/051)Patient Identification and Procedure Matching Procedure (CHHS14/052)Calibration of pressure transducers (excluding Intracranial Pressure and Intra Aortic Balloon Pump Pressure monitoring), Document Number CHHS 12/146Central Venous Access Device (CVAD) Management – Children, Adolescents and Adults (NOT Neonates), Document Number CHHS 13/572Consent and Treatment SOP, Document Number DGD12-044 Hand Hygiene Standard Operating Procedure, Document Number CED11-50 Patient Identification- Correct Patient, Correct Site, Correct Procedure, Document Number CED11-27

References

Jones T DR, Rolls K, O’Reilly M, Scott J, Hoyling L, Goldie D, Armstron K. Nursing Management of Arterial Catheters for Critically Ill Patients. NSW Health Intensive Care Coordination and Monitoring Unit. 2007.

Marschall, J., et al. (2015) Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infection Control & Hospital Epidemiology 35, (07), 753-771

Philips (2008) IntelliVue Patient Monitor instruction manual. Germany

Wilson, C. (2015) Preventing central venous catheter-related bloodstream infections. Nursing Standard 29, (19), 37-43

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Search Terms

Arterial Line, Arterial Catheter, Transpulmonary thermodilution , TPTD, PICCO

Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved By28 September Addition of PiCCO information

(Section 5 & 6)CHHS Policy Committee

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