Arterial Line Insertion Pre Reading

Transcription

1 PROCEDURE ACCREDITATION THE CANBERRA HOSPITAL EMERGENCY DEPARTMENT Arterial Line Insertion Pre Reading

2 Indications Requirement for continuous blood pressure monitoring (all patients on pressors, inotropes, HTN crises etc) Frequent sampling of ABG required (intubated patient, NIV patient etc) Patient requiring critical transport or anaesthesia where complications anticipated

3 Indications Remember patient outcome is likely to improve because an art line is in! Remember lines have complications Thus Make sure you have a good indication before inserting.. Not just because you can!

4 Consent Verbal consent if patient awake, implied consent if unable Complications Arterial injury: dissection, rupture, bleeding, haematoma Thrombosis, embolus Hand ischaemia Infection Nerve injury

5 Equipment Arterial line Femoral or radial Seldinger or cannula

6 All in one Arrow radial seldinger Femoral seldinger Old fashioned 20G cannula Long Radial seldinger

7 Equipment Arterial catheter arm board Pressure line 500mL bag N/Saline Suture kit 4/0 prolene Local anaesthetic with 27G needle Chlorhexidine prep Steristrips Tegaderm

8 Equipment Monitor capable of accepting IBP tracing

9 Set up Prior to commencing Have the arterial pressure line primed and ready nearby Have 2 steristrips nearby Have open gauze ready

10 Radial arterial line Insertion technique

11 Positioning Kylie absorbent mat under arm Dorsiflexed, supinated wrist on flat surface over 500mL fluid bag Taped into dorsiflexion Ensures: straight, superficial, stable radial artery

12 Preparation Sterile field with sterile gloves and sterile drapes. Sterile gown optional. Chlorhexidine prep to include dorsum of wrist if possible to mid palm and distal 1/3 forearm Local anaesthetic using 27 G needle over pulse and to either side for suturing. Massage anaesthetic to disperse bleb

13 Holding the patient Hold the patients wrist with your non dominant hand: thumb on dorsum; index and middle fingers palpating pulse (ensures good control of patient movement and good localisation of vessel) Use tips of fingers to localise pulse.

14 PRACTICE TIP Use the long radial seldinger in situations where difficulty is anticipated or long term use is expected. The separate needle, wire and catheter allow far greater control and adjustment The length and design allow for greater longevity and securing with sutures.

15 Seldinger technique Hold the needle in dominant hand between thumb and forefinger like a dart Place your thenar eminence on the patients thenar eminence (stability and control) Insert the needle through the skin at 45 degrees. Ensure good communication to inform the patient what you are doing, that they may feel pain and request staying still!

16 Positioning (non sterile!)

17 Seldinger technique Upon arterial puncture, flatten the needle towards the patients arm If good flow remains (pulsatile jet), insert the flexible tip of the guidewire into the needle hub and progress the guidewire

18 Seldinger technique With the guidewire passed easily, hold the proximal tip of the guidewire and remove the needle, then hold the distal end of the guidewire and remove the needle completely Pass the catheter over the guidewire,until wire is out the proximal end of the catheter Grasp the proximal end of the guidewire and insert the catheter through the skin and into the artery.

19 Troubleshooting If the guidewire does not easily pass You are in the vessel wall or You have gone out the back of the vessel Remove the guidewire Microadjust the needle in or out until good flow is obtained and pass the guidewire again If you have trouble inserting the catheter Vasospasm Wire has been removed from vessel Wire never placed correctly Severe atherosclerotic disease

20 Insertion using the ARROW TM radial kit This kit contains a needle, guidewire and cannula as an all in one Set up is unchanged Approach the artery in the same way, when flash back is achieved, flatten the cannula towards the skin Use the black tab to progress the guidewire When the guidewire is easily passed, push the cannula along the guidewire Remove the needle and guidewire Disadvantage of this kit: once flashback is achieved you have no further feedback that the needle is still in the lumen.

21 Femoral arterial line insertion The seldinger principle is identical Remember femoral triangle anatomy: Nerve Artery Vein Y-fronts! Ultrasound guidance is recommended Shave the groin to allow dressings to stick Always insert the needle below the inguinal crease to ensure compressibility of the artery if required

22 Securing the line Remove the guidewire or needle with firm pressure over the artery to prevent mess Plug in the primed line and loop it around the patients thumb Place 2 steristrips over the catheter hub and one over the line Suture in place Large tegaderm x1 or x2 Flush line Apply arm board Connect to monitor and zero

23 Arterial wave form interpretation Pressure transmitted in a closed circuit is converted into an electrical signal by a transducer MAP is derived from area under pressure curve It is important to understand the changes in ABP waveforms

24 ABP waveform Anacrotic rise, LV contraction Aortic valve closes

25 Damped trace Confirm damping: no dicrotic notch, no systolic peak Check: Pressure bag is in the green zone Flush line; a non-damped line should rebound to normal trace very quickly. Flush using the blue squeezer first and then the syringe. Unable to flush line = clotted/kinked Check: For kinks: commonly at the skin. For clots. Change: Undo the velcro straps on the splint. Pull back on the hub, and re-secure. Ensure dorsiflexed in splint and re-velcro

26 Transducer dropped Sudden hypertension should raise suspicion that the transducer is below the heart level. Sudden hypotension may be from the transducer being too high. Check the transducer Confirm with NIBP Check: clinical condition, adequate sedation

27 Hypovolaemia Pulse pressure variation with respiration Only valid in a paralysed intubated sedated patient

28 Evaluation 1. The preferred site for arterial line insertion is A. Dominant radial artery B. Non dominant brachial artery C. Non dominant radial artery D. Dominant brachial artery

29 2. The position of the wrist for radial artery cannulation is A. Volar -flexed and pronated B. Dorsi-flexed and supinated C. Volar-flexed and supinated D. Dorsi-flexed and pronated

30 3. The preferred line for difficult and/or long term use is A. 20 G cannula B. Radial seldinger kit C. All in one Arrow radial kit D. 22G cannula

31 4. Which of the following is incorrect: If you have trouble inserting the catheter; A. Vasospasm B. Venous placement C. Wire never placed correctly D. Severe atherosclerotic disease

32 5.The femoral artery should be punctured A. Above the inguinal crease B. Below the inguinal crease

33 6. Appropriate response to the following ABP tracing is A. Increase the vasopressor dose B. Give a fluid bolus C. Start CPR D. Flush the line, check the pressure in the bag, check the cannula position.