Arterial lines in PACU

Presented by Autum Jacobs RN, BSN

Objectives

• How to assist with setting up arterial line tubing, pressure bag and monitoring system.

• How to interpret arterial line wave forms.

• When and how to utilize a R.O.S.E.

• Drawing blood samples from arterial line.

• How to properly discontinue an arterial line.

• Review policies for arterial lines

Goals

• Know how to assist with setting up arterial line tubing, pressure bag and monitoring system.

• Know how to interpret arterial line wave forms.• Know when and how to utilize a R.O.S.E.• Know how to draw blood samples from arterial

line.• Know how to discontinue an arterial line.• Be able to locate policies for arterial lines.

Which patients have arterial lines?

• Arterial line are used in pt’s when continuous BP monitoring is required or frequent labs are needed.

• We see them most associated with thoracotomy patients, carotid endardectomies or critically ill patients.

Arterial line locations

• Arterial lines can be place in the radial, femoral, brachial and axillary arteries.

• The most commonly used sites are either the radial or femoral arteries.

• In PACU we typically see the radial artery used.

Allen’s test

• When an arterial line is being placed, an Allen’s test MUST be completed first. If the test is negative the arterial line can not be inserted into that extremity.

Ulnar pulse check in PACU

• When the pt arrives in the PACU , an ulnar pulse must be assessed and confirmed.

• If unable to locate a pulse, you must notify the doctor.

• If ulnar pulse is not present, pt is at risk for losing that extremity.

How to set up PACU monitor

• Connect cable to monitor use port for BP-1

• Click on resume, then admit/discharge, mode select and then, add an ART.

• Set recording options by clicking menu, then manual record (set for EKG 1 and ART to view single lead EKG tracing and arterial line tracing

How to obtain accurate readings

Phlebostatic Axis(mid axillary line)

• The transducer must be place at the phlebostatic axis.

• This point reflects central blood pressure. • The phlebostatic axis is at the intersection of the

4th intercostal space and mid axillary line.• If the transducer is too high it will produce too

low values, if placed too low produces too high values.

• Placing the transducer at this point will help ensure consistency and accuracy.

Phlebostatic axis

Pressure bag

• The next step is to make sure that the fluids in the pressure bag are at 300mmHg.

• This ensures a continuous flow at 3-5ml/hr which helps prevent occlusion of the catheter.

• 0.9%NS should be used in the pressure bag.• Make sure the IV fluid bag matches the size

pressure bag (liter w/ liter pressure bag, 500ml with 500 ml pressure bag

Pressure Bag/ Priming tubing

•Arterial line tubing must be primed BEFORE it is placed to pressure.•All of the air must be removed from IV bag prior to priming/using tubing.•Only fill fluid chamber with a small amount of fluid prior to placing under pressure. The chamber will continue to fill as pressure is applied.

Zero Referencing

• Flush system• Level transducer at the phlebostatic axis• Turn stop cock off to pt.• Remove cap (all caps should be blue dead end

caps).• Press the red BP-1 square on the monitor• Press BP zero• When monitor shows complete, turn stop cock

back to the original position.• Replace blue dead end cap.

Waveforms

• The arterial line waveforms will appear red on the monitor.

• Normal arterial line waveforms look like this..(fig A)

Waveforms

• The arterial line SBP and DBP should be calculated from the waveform.

• This is simply done by marking the tallest(SBP) portion of the waveform and the lowest(DBP).

• Make sure the monitor is set to 200mmHg

Waveforms

Square wave test

Square wave test

• Helps to determine if the monitoring systems dynamic response is accurate.

• Easily done by activating the fast flush device on the transducer for 1-2 sec.

• Look at the bounce in the waveform.

Correlation• Once the arterial line has been set up

properly you want to check the correlation between the arterial line and NIBP.

• This is typically done on the same arm. (Dr. Walters will ask if the pressures were done on the same arm).

• In normal patients direct arterial pressure is usually 2-8 mmHg higher than cuff pressure.

Correlation

• If the wave form is over-dampened check the position of the wrist and arterial line arm board. Sometimes is is just positional.

• If the arterial line pressure and NIBP do not correlate, always ask the physician which pressure they would like to use.

Correlation

• If the waveform is under-dampened (has a whip) sometimes the hertz on the monitor needs to be changed.

• To change the hertz on the monitor, go to menu, parameter, BP-1, config, the choose either 8 or 6 hertz instead of 12.

R.O.S.E.

• If your NIBP and arterial lines do not correlate and there is a “whip” in the arterial line waveform, apply a resonance overshoot eliminator to the arterial line (R.O.S.E)

Drawing blood from arterial lines

• Blood samples can be obtained with or without a sampling device (vamp direct draw).

• The preferred method at YRMC is with a sampling device.

• Be sure to notify lab that you will be drawing labs from the arterial line and that you need the lab tubes.

Drawing blood from arterial line

• Silence monitor

• Release plunger and pull back to fill reservoir with 10ml solution.

• Turn stopcock off to reservoir.

• Swab site with alcohol

• Apply vamp with syringe or lab tube holder to sample site (always use site closest to pt.)

Drawing blood from arterial lines

• Draw blood sample by filling syringe or attaching lab tubes.

• Remove syringe or sampling device by pulling straight out.

• Re-swab site with alcohol.

• Return stop cock to open position

Drawing blood from arterial line

• Re-infuse blood/fluid mixture from reservoir to patient.

• Flush line to clear tubing.

• Zero and calibrate transducer.

Drawing blood from arterial lines

• See YRMC operating practice “blood sampling via arterial line”

• PRAC CC B110.10

• Step by step practice shown in hands on portion of presentation

Arterial line removal

• Any patients going not going to ICU must have their arterial lines removed prior to transfer.

• You must have a doctor’s order to remove arterial lines.

• Remove arterial lines AFTER all labs have been obtained and resulted especially ABG’s.

Arterial line removal

• Tell patient what you are going to do.

• Gather supplies(2x2’s & coban)

• Clamp fluid tubing to prevent fluid leaking, both from pressure bag and from patient.

• After tubing clamped, release pressure from pressure bag.

Arterial line removal

• Remove arterial line dressing (transparent and steri strips).

• Place folded gauze over the catheter site and gently pull catheter out. Make sure catheter intact.

• Apply direct pressure to the site for 5 minutes. (no peeking!)

Arterial line removal

• Assess extremity circulation while applying pressure. Don’t cut off all circulation

• After 5 min assess site for active bleeding. If no active bleeding noted cover site with gauze and coban.

• After removal, monitor site for re-bleeding. Be sure to give report to receiving RN about location and condition of previous site.

Policies

• Policies and operating practices can be found on the YRMC intranet.

• Operating practices used…..

• PRAC CC B110.10, (BLOOD SAMPLING VIA ARTERIAL LINES)

• PRAC CC A001.10, (ARTERIAL LINES- INSERTION, MANAGEMENT, REMOVAL)

????QUESTIONS????