10 Proposals for implementation With immediate effect

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1 SOUTHERN HEALTH & SOCIAL CARE TRUST 1 2 Name of Procedure/Guidelines/ Protocol Purpose of Procedure/ Guidelines/ Protocol Guideline for Insertion and management of peripheral arterial cannulas in adult patients To provide guidance on safe insertion and management of peripheral arterial catheters in adult patients 3 Replaces New 5 Name & title of author Dr. Michael.J.Morrow FRCA MEd 6 Specialty Anaesthetics and Intensive Care Medicine 7 Division ATICS 8 Equality Screened by N/A 9 Proposals for dissemination To all Southern Trust Anaesthetists/Intensivists/Acute sector nursing staff/midwives 10 Proposals for implementation With immediate effect 11 Training Implications To be included in induction manual for all Anaesthetists in training 12 Date Procedure/Guideline/ Protocol submitted June Date of next review June CG ID TAG CG0320

2 SOUTHERN HEALTH & SOCIAL CARE TRUST Purpose This Standard Operating Procedure (SOP) was designed for healthcare personnel who insert and/or care for patients with arterial catheters in theatres, critical care and high dependency units within the Southern Trust. Prerequisites for this SOP are a working knowledge of basic cardiovascular anatomy, physiology, and cardiovascular pharmacology. Procedure Statement The National Patient Safety Agency has recommended the development of guidelines for the management of arterial lines (NPSA Rapid Response report 2008). Patients may require arterial lines to monitor blood pressure (BP) trends both intra and perioperatively, titrate drug therapies and obtain blood samples for arterial blood gas analysis and laboratory studies. To ensure that a patient receives optimal treatment, it is crucial that staff are aware of factors that affect the safety and accuracy of arterial monitoring. In addition, to ensure that the opportunity for blood stream infection is minimised standard precautions must be followed. Sections 1. Indications and Documentation 2. Contraindications 3. Insertion of Arterial Line 4. Transducer Set-up 5. Arterial monitoring 6. Calibrating the system 7. Dressing 8. Blood Sampling General Principles and care Potential Complications Troubleshooting References

3 1. Documentation of Clinical Need for Insertion: Arterial lines and arterial blood gas sampling can be associated with morbidity and rarely mortality therefore the clinical indication for the insertion of an arterial line should be documented. The following situations are not exhaustive and clinical judgement should be exercised at all times. If in doubt, consult a senior colleague. Indications Situations Include Threshold for Insertion Continuous arterial pressure measurement Prolonged shock of any type Close monitoring of labile blood pressure Patients with existing or anticipated haemodynamic instability where close monitoring is required When vasoactive medications are indicated and the response to such medications requires monitoring. Patients undergoing any major vascular, thoracic, abdominal or neurologic procedures or surgery Controlled hypotensive anaesthesia Cardiac dysrhythmias (causing/with potential to cause haemodynamic instability) Patients receiving intra-aortic balloon counterpulsation Patients being transferred to other units All ASA 4 and 5 patients. Consider in ASA 3 At anaesthetist s discretion Where appropriate

4 Indications (Cont.) Indications Situations Include Minimum Thresholds Serial blood gas measurement Miscellaneous Patients with significant pulmonary system compromise requiring mechanical ventilation, or those who may have severe acid-base imbalance requiring frequent monitoring of arterial blood gases Frequent estimation of other blood chemistry Patients undergoing thrombolytic therapy for coronary, cerebral or vascular occlusions (must be inserted prior to initiation of thrombolytic therapy) to allow for continuous blood pressure monitoring and to permit blood collection for diagnostic laboratory studies without the need for venipuncture Significant obesity where noninvasive methods are unreliable or impossible

5 2. Contraindications There are few absolute contraindications to the use of arterial lines; however, there are some relative contraindications. This means that the situations listed below will increase the risk of complications when using an intra-arterial catheter. This increased risk must be examined relative to the benefit that the patient will receive in the form of more accurate assessments and interventions. Absolute contraindications include the following: Inadequate circulation to the extremity Sepsis at the proposed insertion site Thromboangitis obliterans (Buerger disease) Reynaud s phenomenon Full thickness burns at proposed insertion site Insertion sites where previous vascular surgery has been performed, or that would involve catheter placement through vascular grafts or fistulae. Relative contraindications include the following: Severe peripheral vascular disease in the selected artery Uncontrolled coagulopathy or bleeding disorders Current or recent use of fibrinolytics or anticoagulants causing an increased risk of bleeding at the insertion site

6 3. Insertion of Arterial Line Procedure to be performed only by appropriately experienced personnel. There are two common techniques for siting arterial lines, the Seldinger technique (over guide wire) and the cannula-over-needle technique. Whatever method is chosen, the procedure should be performed in an aseptic manner. Equipment: Clean and dry dressing trolley Sterile dressing trolley drape Minor procedure tray 5x sterile gauze Arterial Cannula (usually 20g or 22g for adult patients) 2% Chlorhexidine in alcohol wipes or Chloraprep applicator 1% Lignocaine for skin infiltration 25g needle + 2ml syringe 1x adhesive dressing Fenestrated drape Sterile gloves Transducer, single-use pressure bag and 500ml of Normal Saline Arterial identification labels Preparation of Patient: 1. Explain procedure to patient. 2. Verbal consent should be obtained by the anaesthetist prior to performing the procedure. 3. Position patient in bed as comfortably as possible with area to be used exposed. (NB if a radial artery is to be used an appropriate support may be used to hyperextend wrist to allow easier insertion). 4. The wrist is extended and the radial artery palpated as it runs over the distal radius where it is most superficial. An absorbent pad should be positioned underneath the arm, particularly if the Seldinger approach is to be employed. 5. The artery is punctured through the skin, with the needle inclined at an angle of degrees to the skin. Arterial blood should be seen to come out of the needle. At this point the cannula may be advanced over the needle if using a cannula-over-needle technique, or the guidewire advanced into the artery if using the Seldinger technique. 6. The arterial line may then need to be secured with an adhesive dressing. The transfixion technique of deliberately advancing the needle/cannula through both sides of the artery and then withdrawing it again until blood flows up the cannula runs the risk of causing a false aneurysm or a haematoma around the artery and is not recommended.

7 Documentation: The anaesthetist who performs procedure must document it in the anaesthetic chart and/or medical progress notes. Nursing staff should document the procedure in the care plan, noting the date and site of insertion, when next dressing and line change are due and the planned date for removal. The arterial line can remain in-situ for up to 7 days (unless signs of infection are evident e.g. inflammation, unexplained pyrexia etc.). The site must be reviewed regularly and findings must be documented in the patient s progress notes.

8 4. Transducer Set-up Rationale: The arterial catheter is connected to the fluid filled tubing of the monitoring system. The transducer creates the link between the fluid filled tubing system and the electronic system converting a mechanical signal into a waveform on the monitor. The transducer system must be set up correctly to ensure the accuracy of the monitoring system. Transducers should be changed (minimum) every 3 days. This change includes the transducer, associated lines and the flush solution bag (unless empty) Equipment: Hand hygiene must be performed prior to donning clean gloves (i.e. wash with liquid soap or use alcohol hand rub) Gloves 500 ml bag Normal Saline Pressure bag Transducer giving set Module and cable Monitor Procedure: An appropriate red line connection should be used to clearly indicate that the line is arterial. Only 500ml bags of sterile normal saline (0.9%) should be used for the arterial line pressure transducer. Heparin should NOT be added to the saline solution. Although infusion bags will not have any additives such as heparin, they must still be labelled. Labels should clearly identify contents of infusion bags, even when pressure bags are used. Date and time of preparation and name/signature of both the person preparing and the person checking the infusion must be recorded on the label. Insert giving set into normal saline bag. (Keeping end sterile). Ensure all roller clamps are open. Prime line by squeezing fast flush device. Check all Luer connections are tightened and 3-way tap is turned off from giving port. Ensure that all air bubbles are removed from system and that all parts are primed with fluid. Air may cause damping of the system and inaccuracy of monitoring. Place saline bag into the pressure bag and inflate to 300 mmhg. When the anaesthetist is ready, connect the transducer to the cannula. Connect transducer to cable and watch for trace on monitor. The arterial line must be clearly labelled with a red sticker. Zero and calibrate system.

9 5. Arterial Monitoring The arterial pressure wave corresponds with the cardiac cycle. Arterial systole begins with opening of aortic valve and rapid ejection of blood into the aorta. This is the upswing on the arterial waveform followed by a downward turn. A notch (dicrotic notch) is visible on downward stroke, which represents closure of the aortic valve signifying the beginning of diastole. The remainder of the downward stroke represents diastolic run off of blood flow into the arterial tree. The QRS complex of ECG trace comes first and the arterial waveform follows. 6. Calibrating the system (Levelling and Zeroing) Rationale: To ensure consistency and accuracy of the arterial blood pressure monitoring the transducer must be positioned and calibrated regularly to an anatomically consistent site. This site is called the phlebostatic axis.

10 Zeroing: Zeroing is the method of calibrating the monitoring system so that the effects of atmospheric and hydrostatic pressure are eliminated. Zeroing must be carried out once per shift. Preparation of patient: 1. Position patient on their back. 2. Patient may be positioned with the head of the bed elevated between Flush the system 4. Level transducer to phlebostatic axis (may mark this with an x on patient) 5. Turn stop-cock on transducer so that it is off to the patient. 6. Remove cap 7. Press zero on the module 8. Ensure that zero appears on screen replace cap and turn stop-cock so that it is open to monitoring and patient. NB: If patient is positioned on their side the reference point will be different. It is difficult to identify true phlebostatic axis. There may be a discrepancy in readings. If there is a great variation when positioned on their sides. The patient should be placed onto their back and a true reading obtained. 7. Dressing Rationale: Infection at the arterial catheter site will be minimised. Adhesive dressings should generally be left intact for up to 7 days, however if the dressing is not transparent, then the insertion site should be carefully monitored for signs of infection. More frequent dressings should only be undertaken if there is a problem with kinking of the line, leaking around insertion site or if the dressing is peeling off. Equipment: Dressing Pack Sterile Gloves and personal protective equipment Transparent occlusive dressing Normal Saline (if visibly soiled or crustings are present) 2% Chlorhexidine Procedure: Wash hands (or use alcohol hand rub) Assemble equipment on dressing trolley Wash hands (or use alcohol hand rub) Carefully remove old dressing

11 Wash hands and don sterile gloves/ppe Cleanse area with normal saline (if visibly soiled or crustings are present) Dry site with gauze Apply chlorhexidine and alcohol to insertion site and allow to dry Apply steri-strips (if necessary) to keep cannula secure Apply transparent dressing so that insertion point of cannula is in middle of dressing NB. Transducer only needs to be changed if considered to be giving faulty readings or if time in-situ is >3 days 8. Blood Sampling Sampling from arterial lines is potentially risky and should only be carried out by appropriately trained staff. Equipment: 5ml syringe Sterile gauze Arterial blood gas sampling syringe +/- blood collection tubes Personal protective equipment (gloves, mask, goggles) Procedure: Hand hygiene must occur before and after the procedure Suspend alarm on monitor Don personal protective equipment Remove cap from stopcock and attach 5ml syringe. Turn stop cock off to flush bag Withdraw 2-3ml of blood to clear line of saline Attach ABG syringe and withdraw sample Once specimen has been taken, turn stopcock off to the patient, remove syringe, cover the port with gauze and using the fast flush device, flush port. Replace cap Turn stopcock off to the port and flush line ensuring that all blood is cleared Ensure alarm is turned on

12 General Principles and Care of Arterial Lines Procedure Keep pressure bag inflated to 300mmHg Flush bags of Normal Saline are changed every 72 hrs. or as necessary. All flush bags must be labelled with time and date of commencement Rationale Deflation of bag will result in retrograde blood flow. Keeps line patent and infuses 3-5ml /hr. Prevents dampening of trace. Prevents clots Infection control, keep bag sterile. Ensures adequate flushing volume. Infusion bags must be labelled. Labels should clearly identify contents of infusion bags, even when pressure bags are used. Date and time of preparation and name/signature of both the person preparing and the person checking the infusion must be recorded on the label. Do not add extra tubing or stopcocks to system All lines must be have rigid noncompliant tubing Periodically flick tubing system and flush the tubing system ONLY Saline 0.9% is to be used as an infusion/flush solution. This must be double checked and signed for on a label applied to the infusion bag before administration to prevent the use of unsuitable solutions. Extra areas of air entrapment, which can cause inaccuracy of the arterial trace. Increase risk of infection Eliminates any bubbles escaping the flush solution. Fast flush solution after opening the system for blood sampling and/or zeroing Helps eliminate air bubbles. Clears the line of blood Immobilise arm and keep sites clearly visible at all times e.g. On top of sheets. Do not use a bandage over arterial line site. Safety measure to prevent adverse events e.g. haemorrhage or disconnection

13 Troubleshooting Problem Difficulty with zeroing Does not reach 0 waveform Does not reach baseline Unable to aspirate cannula Possible Solution Check all equipment and connections between patient and monitor. Ensure all rollerclamps are open. Check system for air bubbles and blood clots. Recalibrate. Replace transducer, cable module, arterial line Check line for kinks Apply traction to cannula Gently try to flush Replace arterial line Falsely high readings Incorrect placement or transducer Uncalibrated system Kinked cannula Dampened Check position of transducer Re zero Remove kink Remove air bubbles/ blood clots

14 Potential Complications Problem Prevention Solution Haemorrhage Keep limb visible at all times Ensure alarms are on Ensure that arm is immobile Ensure all connections are tight Apply pressure to limb Assess leak If haemorrhage persists contact medical staff Infection Assess area regularly for redness or swelling Avoid interrupting circuit Use gloves when handling arterial line Remove arterial line Ensure proper handwashing when handling arterial line or transducer Blockage Clotting Air emboli Keep pressure bag inflated to 300mmHg Attempt to aspirate blood Use fast flush device to clear line and to prevent clot formation Attempt to aspirate blood to remove clot Ensure all connections are kept secure Interruption to peripheral circulation Regularly check distal pulses and capillary refill Notify doctor and consider removing arterial line The most common complications are temporary radial artery occlusion (20%), and hematoma (14%) followed by infection at the arterial site (<1%), hemorrhage (0.5%) or bacteremia (0.13%), and very rarely permanent ischemic damage or pseudoaneurysm (0.09% each). Local injury (e.g., intimal damage and proliferation) and scarring have been found even after short-term catheterization. Long-standing or permanent radial artery occlusion has also been described. In some

15 cases (particularly after vascular procedures) the radial artery occlusion may be delayed several days of the procedure or removal of catheter. Rare complications include paralysis of the median nerve, air embolism, compartment syndrome and carpal tunnel syndrome. Rarely, intravascular catheter fragments have occurred. Larger catheter diameter, presence of vasospasm and female sex (probably related to smaller vessel diameter) increase the risk of ischemic complications. Inadequate experience placing catheters (high number of attempts, multiple arterial sticks and hematoma formation) may also influence the complication rate.

16 REFERENCES Wilkins RG. Radial artery cannulation and ischaemic damage: a critical review. Anaesthesia (9):896-9 Webb RK, Currie M, Morgan CA, Williamson JA, Mackay P, Russell WJ, Runciman WB. The Australian Incident Monitoring Study: an analysis of 2000 incident reports. Anaesth Intensive Care Oct;21(5): Aherns T, Penick JC & Tucker MK (1995). Frequency requirements for zeroing transducers in haemodynamic monitoring. American Journal of Critical Care; 4(6): Bridges EJ, Bond EF, Ahrens T, Daly E, Woods SL (1997) Ask the experts. Critical Care Nurse; 17(6): Centre for Disease Control (2002). Guidelines for the prevention of intravascular catheter-related infections. 51 (RR10): Courtois MA, Fattal PG, Kov cs SJ, Tiefenbrunn AJ & Ludbrook PA (1995). Anatomically and physiologically based reference level for measurement of intracardiac pressures. Circulation; 92: 1. Hudak CM, Gallo BM & Morton PG (1998) Critical Care Nursing; A Holistic Approach. Seventh Edition. Lippincott: New York. Imperial-Perez F, McRae M (1999) Protocols for practice: Applying research at the bedside. Critical Care Nurse; 19(2): Scheer BV, Perel A, Pfeiffer UJ. Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Critical Care June 2002, Vol6, No3. Bernsten AD, Soni N, Oh T E, 2003 Oh s Intensive Care Manual 5th Edition p80-81 Butterworth Heinemann.