Children & Young People s Directorate Procedure/Guidelines/Protocol Checklist & Version Control Sheet 1 Name of Procedure/Guidelines/ Protocol: PROCEDURE FOR PERIPHERAL ARTERIAL CANNULATION 2 Purpose of Procedure/ Guidelines/ Protocol: To provide guidance on safe insertion of a peripheral arterial catheter 3 Replaces: New 4 Applicable to which staff: Neonatal and SCBU nursing staff 5 Name & title of author: Una Toland Lead Nurse Neonatal Services and ANNP team SH&SCT 6 Equality Screened by: N/A Note any issues: 7 Proposals for dissemination: Una Toland via team managers to nursing staff 8 Proposals for implementation: With immediate effect 9 Training Implications: To be included in induction training of all new nursing staff 10 Date Procedure/Guideline/ 31:03:13 Protocol submitted to Procedures Committee: 11 Outcome: Approved Comment: Approved/Minor amendments Not approved Deferred 12 Date of CYP SMT approval Comments: 13 Date of approval by Trust SMT (if required): 14 Date approved by HSCB (Social Work only): 15 Date for further review (3 year default): 16 Date added to repository:
PROCEDURE FOR PERIPHERAL ARTERIAL CANNULATION Statement: Peripheral arterial cannulation may be required when sequential arterial blood gas analysis is essential but can only be obtained from a cannula placed in a peripheral artery Indications Umbilical arterial catheterisation is not always possible Arterial access is required for blood gas analysis and invasive blood pressure monitoring Statement: Where possible an Allen s test is always performed prior to insertion of a peripheral artery cannula and the result is documented in the infant s notes. Occlude both arteries at the wrist Release the pressure on the ulnar artery Observe the circulation returning to the hand, ie it will flush pink If this does not happen, do not proceed with a radial puncture on that side It is imperative that arterial lines are labelled clearly The cannula site must be exposed and continually observed The infant with an arterial line must not be left unattended The peripheral line must be inserted using ANTT Equipment: Clean stainless steel trolley Skin cleansing agent (as per local policy) Red bionnector 2 x2ml syringes, 5ml syringe and a 50 ml syringe Arterial infusion fluids Red arterial infusion line 2 red arterial alert stickers BP transducer Clinell wipe x 1 Hepsal flush Filter needle Disposable gloves and gown Tegaderm Splint if required
ACTION Where possible inform parents of planned procedure Assess the infants NIPS prior to the procedure and treat appropriately Decontaminate hands as per local policy Prepare the trolley with requirements for the procedure, using ANTT and engage an assistant to help. Establish a sterile field Identify the vessel for cannulation by palpation Decontaminate hands and don PPE Clean the intended cannulation site and allow at least 30 seconds for drying Do not re palpitate site after cleansing Unsheath the cannula and hold it firmly so that the 2 component parts cannot be separated Gently stretch the skin over the artery If the vessel is not entered, pull back slowly as the artery may be transfixed. If so, advance after flashback of blood. If not, pull the skin back and redirect ensuring the needle does not become blocked thus preventing adequate flashback. Decrease the angle of the cannula so that it is resting on the skin and withdraw the stylet slightly. A flashback of blood will be observed up the shaft of the cannula, blood may rush back or be easily aspirated. Slowly advance the cannula over the needle with a gentle twisting movement which should secure cannulation of the artery Continue to protect the cannula, attach a 5ml syringe with flush solution connected to an extension set Apply a clear transparent dressing to the arterial cannulation site The arterial fluids which have been connected to the blood pressure transducer are now connected to the arterial line. Connect the transducer to the RATIONALE To keep parents up to date with their infants care plan and to gain their consent and cooperation To alleviate any discomfort to the infant during the procedure To reduce the risk of transmission of micro-organisms To allow adequate asepsis of skin To prevent recontamination of the site To immobilise the artery To check patency and prevent clotting To allow visibility of cannula insertion site at all times
monitor and ensure settings are appropriate for arterial blood pressure monitoring (see pictorial diagram attached) Calibrate the transducer Turn the 3 way tap off to the baby Turn the 3 way tap on to the atmosphere In the set up menu select zero When you see 3 zeros turn the tap off to the atmosphere and on to the baby Observe the arterial trace on the monitor for appropriate waveform Dispose of all used equipment as per local policy Remove PPE and decontaminate hands Document procedure in infants chart Ensure arterial line and infusion pump for arterial fluids are labelled with appropriate RED ARTERIAL LINE alert sticker. Place an alert sticker close to point of cannula insertion and a second alert close to arterial infusion syringe pump. Use the designated arterial fluid pump Record arterial fluid infusion rates and VIP score hourly. Report any deviation from normal immediately to nurse in charge/doctor/annp Observe the circulation of the cannulated limb continuously for Cyanosis Decreased pulse Blanching Cool extremities/skin Sluggish cap refill time Bleeding The cannula must be removed if there is sustained blanching to the limb, distal to the cannula site See attached illustration of BP transducer set up To reduce risk of injury and ensure safe practice To prevent cross contamination To ensure adherence to NMC standards of professional record keeping To differentiate between arterial line and other access devices and ensure safe infusion practice. To ensure any complications from arterial line or fluid administration via the arterial line are promptly detected and appropriately responded to. Observe also for signs of cannula displacement Swelling Bleeding Lack of a normal waveform Fluid leakage Blanching Signs of infant pain or discomfort
Observe tissue surrounding the cannula for signs of infection pain Redness Temperature change Swelling Dampened tracing on the monitor Assess infants cardiovascular status, pulse, ECG waveform and non-invasive blood pressure Check arterial line site, all connections and infusion device flow rate Check appropriate arterial scale in use on monitor Check blood can be easily aspirated at access port Attempt to aspirate any clot using a 2ml syringe of heparinised sodium chloride syringe. Lightly bounce plunger to loosen blood clot Do not forcefully flush catheter if resistance is high Check cannula site for kinks or poor positioning and redress if necessary Reposition infant and or cannulated limb No waveform on monitor Assess infants cardiovascular status, pulse, ECG waveform and non-invasive blood pressure Check system is correctly set up and correctly attached Check appropriate scale in use on monitor Check monitor display settings are correct Try an alternative transducer Consult the MTO To ensure it is not a monitor problem and not a change in the infants clinical condition To determine if equipment is faulty To initiate repair of equipment March 2013 References: 1. MacDonald MG. (2002) Peripheral artery cannulation. CH 29. IN: MacDonald MG, Ramasethu J. Atlas of procedures in neonatology. 3 rd Ed. Lippincott Williams & Wilkins. Philadelphia. 2. RPA Newborn Care Protocol Book (2001) Management of arterial lines.www.cs.nsw.gov.au/rpa/neonatal/html/procs/artline.htm 3. Box well, G. (2005) Neonatal Intensive Care Nursing.
Illustrated Set up For Arterial BP Transducer Replace the 3 way tap on the BP transducer with the red 3 way tap on the arterial IV line. Remove the protector cap from the access point on the transducer and connect the red arterial line.
At this stage the set should look like this. Remove the white port cover from the three way tap and replace it with the arterial bionnector. Using the white bungs replace the clear bungs on the transducer.
Once all the connections are in place and the bionnectors and white bungs have been secured, the line needs primed with the heparinised solution. Pull up on the yellow tab on the transducer and push the syringe containing the heparinised solution through the giving set to prime the line. Ensure that all access points on the line have been primed by turning the three way tab to each access point ensuring that there is not air in the circuit. Connect the arterial monitor lead to the monitor in the red colour outlet. Then connect the transducer lead to the monitor lead. With the line primed and connected correctly, the transducer is ready for use and can be connected to the arterial line.
On the monitor screen you will see PA in the grey box. Press PA and the zero option appears on the bottom of the screen. Turn the 3 way tap off to the baby and on to the atmosphere. In the set up menu select zero at the bottom of the screen. When you see 3 zeros, turn the tap off to the atmosphere and on to the baby. Observe the arterial trace on the monitor for appropriate waveform.