2. Need for serial arterial blood gas determinations. 2. Anticipation of the initiation of thrombolytic therapy

Transcription

1 I. Subject: Arterial Cannulation II. Policy: Arterial cannulation will be performed upon a physician's order by Cardiopulmonary and Respiratory Therapy personnel certified in the arterial catheterization procedure. Set-up, maintenance, and discontinuance of arterial lines should be performed by personnel who have demonstrated competency. III. Indications: 1. Cardiopulmonary instability 2. Need for serial arterial blood gas determinations 3. Need for continuous arterial pressure monitoring IV. Contraindications: A. Absolute: 1. Thrombophlebitis B. Relative: V. Rationale: 1. Hypocoagulation 2. Anticipation of the initiation of thrombolytic therapy 3. Lack of adequate collateral circulation 4. Occlusive arterial disease Indwelling catheters placed in arteries permit serial sampling of arterial blood without the need for repeated punctures. In critical periods of the patient's course of care (such as shock) the arterial line may provide the most reliable means to monitor arterial blood pressure. Collection of blood via an arterial catheter can be accomplished 1

2 without discomfort to the patient, therefore, without disturbing the patient's respiratory pattern. Patients who require titration of intravenous vasopressors or vasodilators may also have their blood pressure continuously monitored. An artery suitable for placing an indwelling catheter for continuous monitoring of intraarterial pressure should: (1) be large enough to measure pressure accurately without the catheter occluding the artery or producing thrombosis; (2) have adequate collateral circulation should occlusion occur; (3) be easy to access and in an area not prone to contamination. The radial artery meets these criteria most satisfactorily. When radial artery catheterization is not possible or is contraindicated, the brachial, femoral, or dorsalis pedis arteries may be selected. VI. Materials: A. Sterile arterial catheterization tray to include: Chloraprep applicator Fenestrated drape 1 cc tuberculin syringe-25 gauge needle 1% Xylocaine 20 gauge I.V. placement catheter (22 gauge for pediatric use) Biopatch Sterile gauze Bio-occlusive dressing Skin prep pads Adhesive tape Arm board Continuous arterial keep-open and pressure monitoring set Personal safety equipment including sterile gloves, eyewear, sterile gown and face mask. Optional- Femoral catheterization Sterile arterial catheterization tray containing: 1) 18 or 20 gauge 16cm Teflon catheter 2) flexible guide wire 3) 18 or 20 gauge needle 4) sterile drapes 2

3 5) suture with straight needle 6) Sterile 10ml normal saline syringe 7) 12 inch pressure tubing 8) 3 way stopcock VII. Procedure: A. Radial Artery Catheterization Technique: 1) Prepare hemodynamic pressure monitoring system as described in Policy and Procedure manual. 2) Explain procedure to the patient. 3) Obtain informed consent. Initiate time out procedure to assure correct patient, correct procedure, correct site, correct position, and correct equipment. 4) Perform standard Allen's test as described in the procedure for Arterial Sampling. 5) Don personal protective equipment, sterile gown and eyewear 6) Cleanse area with chlorohexadine prep and let dry. 7) Apply sterile fenestrated drape 8) Locate the radial artery by palpation. 9) Inject 0.5-1cc of 1% xylocaine intradermally and subcutaneously, raising a small skin wheal over puncture site. 10) Slowly and carefully puncture the skin and subsequently the lumen of the artery with the 20 gauge catheter over needle assembly at an angle of degrees. 11) When the needle is well within the lumen of the artery (as observed by blood flow into the catheter hub), carefully advance the Teflon catheter into the 3

4 artery while holding the needle stationary. 12) Remove the needle. Blood flow ensures intraluminal placement. 13) While holding the hub of the catheter with a sterile hand, attach the luer connector of the pressure monitoring line to the catheter hub and screw on tightly. Remove excess blood from luer connector. Flush catheter and observe pressure monitor for appropriate dynamic waveform. 14) A transparent dressing is placed over the site with a Bio-patch. 15) Prepare skin using a skin prep pad, let dry and secure cannula to skin with adhesive tape. 16) Wrap wrist loosely with gauze and secure with arterial wrist support. 17) Check for adequate circulation distal to insertion site by observing the warmth of the hand and capillary refill. Note any changes post insertion and remove catheter if significant diminished perfusion is observed. B. Brachial Arterial Catheterization Technique: Catheterization of the brachial artery is performed in a similar manner as that described for radial artery catheterization. However, bedside assessment for the adequacy of collateral flow is not practical and this site is not routinely used. C. Femoral Arterial Catheterization Technique: 1) Prepare hemodynamic pressure monitoring system as described in Policy and Procedure. 2) Explain the procedure to the patient. Obtain informed consent. Initiate time out procedure to assure correct patient, correct procedure, correct site, correct position, and correct equipment. 3) Prep site by clipping hair from the groin and cleaning with antibacterial soap. 4) Open sterile procedural tray. 4

5 5) Put on personal protective equipment and sterile gloves. 6) Connect saline syringe to stopcock and 12 inch tubing and flush. 7) Cleanse area with chlorohexadine solution. 8) Cover the patient with full body sterile drape. The sterile field should be large enough to allow manipulation of the guide wire and catheter without risk of contamination. 9) Place the index, middle and fourth fingers of one hand along the course of the femoral artery beyond the inguinal ligament. If the index finger is spread away from the middle and ring fingers, which are held together, the insertion site is between the index and the middle fingers. 10) Infiltrate the overlying skin with 1% lidocaine without epinephrine. 11) Enter the skin and subsequently the lumen of the artery at about a 45 degree angle. As soon as a free flow of blood is evidenced from the end of the needle, insert the guide wire through the needle well into the artery, then remove the needle. The wire must pass without resistance. 12) Insert the catheter over the wire into the lumen of the artery. Remove the guide wire. 13) Attach the leur connector from the 12 inch pressure monitoring line to the end of the catheter. Remove excess blood from the luer connector. Flush catheter. 14) Suture the catheter in place. 15) A transparent dressing is placed over the site with a Bio-patch. 16) Check for adequate circulation distal to the insertion site by observing warmth of limb, pulse, and capillary refill. Note any changes post insertion and remove catheter if significant disturbance in perfusion is observed. 5

6 D. Maintenance: 1) The insertion site should remain sterile. A transparent dressing covers the site. The Biopatch should be changed if the integrity of the dressing is compromised. 2) Inspect the site every 4 hours. Site care and dressing change using aseptic technique with a chlorahexadine solution is performed every performed every 7 days. 3) Routine replacement of peripheral arterial catheters is not recommended to prevent catheter-related infections. The insertion site should be changed if signs of infection, significant hematoma, or significant oozing of fluid or blood occur. The physician will be notified of expiration or complications and an order requested for discontinuance/ re-insertion. 4) The arterial line should be immobilized at all times, securely anchored with tape or sutures. 5) The normal saline fluid bag for the transducer system should be changed every 24 hours. The pressure transducer system and tubing should be changed every 96 hours. The pressure on the fluid bag should be maintained at 300 mmhg. E. Pressure Monitoring: 1) The arterial blood pressure monitoring transducer should be zero referenced at the site of insertion. Typically, however, the transducer is referenced with the pulmonary artery catheter at the phlebostatic axis which introduces negligible error in the measurement of systemic blood pressure. The transducer should be leveled and zeroed at set-up and every 4 hours subsequently. 2) The pressure components of the normal arterial wave form include the systolic pressure, the diastolic pressure, the pulse pressure, the mean arterial pressure, the pulse pressure, the mean arterial pressure, and the diachrotic notch. The systolic pressure corresponds to the waveform peak, and the 6

7 diastolic pressure the low point. The pulse pressure represents the difference between the systolic and diastolic pressures. The mean pressure is the average pressure throughout the cardiac cycle and may be calculated by integration of the arterial pressure waveform signal over time, or estimated by the following formula: MAP= SP + (DP x 2) 3 The diastolic notch represents closure of the aortic valve. 3) Normal values for arterial blood pressure in the adult are as follows: Systolic Diastolic Mean mmhg mmhg mmhg 4) Overshoot of the pressure signal can occur from artifactually increased frequency response of the pressure monitoring system. Use of the noncompliant pressure tubing of the shortest length possible can help reduce this effect. Additionally, newer pressure monitors will filter out excessive frequency response. Attachment of a special overshoot eliminating device in the transducer pickup system may be necessary to obtain the proper waveform and accurate readings. F. Discontinuance: 1) Arterial lines will be discontinued when ordered by the physician, if non- functional, if any signs of infection exist, or significant bleeding at the site occurs. 2) Hold pressure on the site after removing the catheter until all signs of bleeding have ceased. Dress with sterile gauze. 7

8 VIII. Hazards/Complications: 1) Arterial Thrombosis 2) Thromboembolism 3) Catheter Embolism 4) Air Embolism 5) Hemorrhage 6) Hematoma 7) Local Infection 8) Systemic Infection 9) Ischemia and necrosis caused by thrombosis or embolism 10) Vaso-vagal reaction 11) Neuropathy 12) Arterial venous fistula (femoral) 13) Aneurysm 14) Arterial spasm 15) Clinical mismanagement from incorrect data IX. Documentation: Document arterial cannulation in the medical record, recording the date, time, insertion site, technique of insertion, catheter type, and dressing procedure. Also document Allen's test result and pre and post insertion perfusion. Document systolic and diastolic blood pressure at insertion. Document any complications along with time physician notified of the 8

9 problem. Document the condition of site, dressing change and waveform quality every 4 hours. 9