Management of Arterial Line

Review date: October 2011
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Management of Arterial Lines

TCP 211
GUIDELINES FOR THE MANAGEMENT OF ARTERIAL LINES

TCP 211
CROSS REFERENCE
This Strategy/ Policy should be read in
conjunction with:
TCP 113 Aseptic Non Touch Technique
(ANTT) Protocol
TCP 169 Policy for the Quality
Assessment of Blood Gas Analysers
TCP 185 Guidelines for the Management
of Transduced Central Venous Pressure
(CVP) Lines
Progress and date of approval

(Approved / Under review)
January 2009
Under review
July 2006
Manager Responsible
Principle Lead Consultant for Critical Care
Author
Critical Care Clinical Governance Lead
Date
February 2009
Policy Number
TCP 211
Previous code
N/A
Version number
Approving Committee
Trustwide Clinical Policies
Signed by Chair of the Committee

Review Date
Trustwide Clinical Policies Committee
October 2011

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TCP 211
Consultation and Ratification Schedule

Name of Committee
Trustwide Clinical Policies
Date of Committee
February 2009
Name of Person / Team
Date

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CONTENTS
1.0 Policy Statement

2.0 Key Principles
3.0 Scope
4.0 Responsibilities
5.0 Monitoring for Effectiveness
6.0 Clinical Indication and Documentation
7.0 Insertion of arterial lines
8.0 Arterial line labelling
9.0 Arterial line fluid prescription
10.0 The transducer
11.0 Setting up the transducer
12.0 Care of the line and transducer
13.0 Arterial blood gas sampling
14.0 Arterial blood gas measurements
15.0 Causes of Inaccurate Readings or Measurements
16.0 Removal of arterial lines
17.0 Bibliography
18.0 Appendix 1

TCP 211

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TCP 211
1. POLICY STATEMENT
1. 1
Recent Recommendations from the National Patient Safety Agency recommend

the development of guidelines for the management of arterial lines.
2. KEY PRINCIPLES
2.1
Arterial lines are routinely used in critical care areas for monitoring arterial blood
pressure or serial blood gas measurements. This guidance applies to all staff in
critical care, theatres and other areas such as the Emergency Department where
arterial lines are inserted and managed. Patients should not be nursed outside
these areas with arterial lines in order to avoid complications of insertion such as:
Ischaemia
Bleeding
Accidental intra-arterial administration of drugs
Nerve trauma
3. SCOPE
3.1
3.2
This policy applies to all Staff

The policy is applicable within the Trust
4. RESPONSIBILITIES
4.1
Responsibility of the Trust Board

The Trust Board delegates authority for approving this policy to the Trustwide
Clinical Policies Committee
4.2
Responsibilities of Assistant Director, Clinical Governance/Head of

Modern Matrons
To ensure the policy is reviewed
4.3
Responsibilities of Clinical Governance/Audit Lead Clinicians for Critical Care

To ensure the policy is audited annually and undertake further steps to ensure
compliance with the policy
5. MONITORING FOR EFFECTIVENESS OF POLICY

5.1
The use of the guidelines will be audited by the department of critical care.
Compliance with the guidelines will be audited annually in all critical care
areas by medical and nursing staff
This will be feedback to the relevant areas at Trust Clinical governance
meetings

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TCP 211
6. DOCUMENTATION OF CLINICAL NEED FOR INSERTION

6.1
Arterial lines and arterial blood gas sampling can be associated with morbidity
and mortality and so the clinical indication for the insertion of an arterial line
should be documented.
6.2
Indications for the insertion of arterial lines include:
6.2.1 Continuous arterial pressure monitoring:
Haemodynamically unstable patients

Patients on vasopressor or vasodilator drugs
Cardiopulmonary bypass
Major vascular, thoracic, abdominal or neurologic surgical procedures
Patients supported on an intra-aortic balloon pump (IABP)
Patients receiving intracranial pressure monitoring
6.2.2 Serial blood gas measurements:
Patients in respiratory failure

Patients being maintained on or being weaned from mechanical ventilatory
support
Patients with severe acid/base abnormalities
Where frequent blood samples are required to measure electrolyte
concentrations.
7. INSERTION OF ARTERIAL LINES

7.1
Suitable sites for the insertion of arterial lines include the radial, brachial, femoral,
dorsalis pedis and axillary arteries.
7.2
The arterial line must be inserted by a doctor or other practitioner competent in

the procedure. If the radial artery is selected the operator may perform an Allen
test to assess peripheral limb perfusion distal to the proposed arterial cannula
site prior to insertion.
Practice
1. Explain and discuss procedure with
patient
2. Doctor and assistant wash hands and
put on gloves and plastic apron. Facial
protection must be worn when there is a
risk of splashing
3. Prepare cannulation site, remove hair if
necessary. Clean skin with 2% alcoholic
chlorhexidine skin cleanser. Place
disposable pad under limb. Aseptic non-
Rationale
2. Prevents transmission of microorganisms

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touch technique must be used at all times

to prevent cross infection and
contamination of site.
4. Infiltrate cannulation site with local
anaesthetic and leave to take effect
5. Nurse may need to immobilise limb.
6. Cannula inserted
7. Apply pressure to cannulated artery
whilst transducer line is securely attached.
8. Secure cannula using Tegaderm
dressing. Secure tubing safely to limb.
9. Remove gloves, apron and if
appropriate facial protections and dispose
of as clinical waste.
10. Decontaminate hands

TCP 211
4. Minimise pain during procedure, so

facilitating patient co-operation.
5. Facilitate cannulation.
7. Prevents blood spillage
8. Allow visualisation of insertion site.

9. Prevents transmission of microorganism
8. IDENTIFICATION OF ARTERIAL LINES

8.1
An appropriate red line connection should be used to clearly indicate that the line
is arterial.
8.2
The arterial line must be clearly labelled with a red sticker.
9. ARTERIAL LINE FLUID PRESCRIPTION

9.1
Appropriate fluids must be used. Normal saline +/ - heparin. I unit heparin per ml
of fluid must be used.
9.2
Patients with a current or previous diagnosis of Heparin Induced

Thrombocytopenia should only be prescribed Normal saline as arterial line fluid.
9.3
The arterial line fluid must be prescribed on the patients drug chart or Clinical
Information System (CIS).
9.4
The fluid must be checked by two registered practitioners before it is connected

to the arterial line.
10. THE TRANSDUCER SYSTEM

The measurement of a patients blood pressure with a pressure transducer involves the
arterial cannula being connected to a pressurized line. The pressures in the cannula are
transmitted through fluid filled tubing to the transducer diaphragm.
The movement of the diaphragm is converted to a low voltage electrical signal. The
signal is amplified and converted to a real-time waveform display on the monitor. The
measurements are then digitally displayed in mmHg.

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TCP 211
11. SETTING UP THE TRANSDUCER

Practice
1. Before and after handling any
intravenous equipment the hands
should be decontaminated with soap
and water or alcoholic hand rub. Put
on gloves and apron.
2. The transducer should be removed
from its package and the Luer
connections checked for tightness.
3. The extension kits to allow blood
sampling should be as short as
possible.
4. A bag of 0.9% sodium chloride or
heparinised saline should be attached
to the transducer set.
5. The fluid bag label should be
clearly visible through the pressure
bags.
6. Label the system when set up with
date and time.
7. The drip chamber should be
squeezed gently to fill only the bottom
of the chamber.
8. To prime the set pull the small cord
on the plastic transducer.
9. When the set is primed the
pressure bag should be fitted and
inflated to 300mmHg.
Rationale
1. Significantly reduces the number of
pathogens on the hands (Larson
1995).
2. The connections can be loosely

packed.
3. Long extensions alter the pressure
reading
6. To ensure it is changed as per

protocol.
7. When the bag is pressurized the
drip chamber will fill higher.
9. At this pressure 3 to 4 mls/hr of

0.9% sodium chloride or heparinised
saline will pass through the flush
device to keep the line patent.

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10. The pressure lines should be

examined for air bubbles. If found
they can be removed by
flushing or gently tapping the set.
11. All connections should be
swabbed with a 2% PDI wipe for 30
seconds then allow to dry.
12. Connect the line to the arterial
catheter using a non-touch technique.
The line is then labelled with the time
and date.
13.Needle free connectors for
example, red swanlocks are
recommended for the blood sampling
port and should be changed weekly
unless the device is changed
14. The transducer should be fitted
into its holder on the drip stand,
levelled to the patients sternal notch
or foramen magnum (neuro) and the
electrical lead connected to the
monitor by the bedside.
15. The transducer should be opened
to air and zeroed to atmospheric
pressure. Open the port on the
transducer and zero on the monitor
menu at least once per shift prior to
taking a reading
16. The pre-connected bungs on the
zero port of the transducer should be
changed for either the white bungs
provided in the set or red bungs (not
swanlocks).
17. Re-level the transducer each time
the patient changes position or the
bed is raised or lowered.
18. Check that the arterial trace is
satisfactorily displayed on the
monitor.
19.Remove gloves, apron and if
appropriate facial protections and
dispose of as clinical waste.
20. Decontaminate hands

TCP 211
10. All air must be removed to

prevent dampening of the arterial
waveform.
11. Reduces the possibility of
bacterial
contamination.
12. Reduces bacterial contamination
and protection of patient and yourself.
14. To get an accurate reference

point.
16. Air can entrain into the transducer

and alter the pressure reading and/or
water can leak from the hole in the
pre-connected bungs which are
intended for initial zeroing only.
17. To ensure a consistent zero
reference point.
18. This makes sure that the line is
patent and the readings should be
accurate.

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TCP 211
12. CARE OF THE LINE AND THE TRANSDUCER

Practice
1. Care must be taken to ensure that
the arterial line does not become
disconnected.
2. The waveform should be
continuously displayed
3. The arterial line fluid should be
checked against the prescription once
per nursing shift.
4. Every third day the transducer and
flush bag should be either changed or
taken down if no longer required (see
label for date).
5. The cannula does not need regular
flushing while on a pressure bag
system, but a flush may be required
to gain an arterial trace. The cannula
can be flushed with the manual fast
flush device.
6. The pressurized flush bag should
be maintained at a pressure of
300mmHg.
If the waveform changes check the
pressure.
7. The flush bag should be changed
with the transducer or when empty.
8. Maintain a closed system ensuring
minimal disconnection in the circuit.
9. Handwashing must be performed
and personal protective equipment
applied before cleaning the catheter
site.
10.Chloraprep or Clinnell wipes
MUST be used to clean the catheter
site during dressing changes and
allow to air dry.
11. Prior to securing the line it should
be curled in a U to prevent any
direct pull on the line
12. The site should be secured with a
sterile, moisture permeable, dressing
e.g. Tegaderm
Dressings should only be changed
when soiled or when the line is being
changed
13. If the catheter is not sutured,
Rationale
1. As the line is in an artery and not a
vein the patient can potentially
exsanguinate.
2. The arterial trace should not be
under or over damped as this will
generate inaccurate readings
3. To ensure it is visible and correct.
4. To reduce the risk of contamination

and infection.
5. Ensuring a patent line and a good

waveform will provide an accurate
arterial pressure reading. A flush can
be used to test for dampness of the
arterial trace.
6. This will ensure that 4mls/hr of
0.9% sodium chloride or heparinised
saline will be delivered through the
cannula, thereby keeping it patent
and will maintain constant pressure
within the system.
7. To avoid contamination.
9. & 10.To reduce risk of infection
11. To reduce the risk of

dislodgement of the line
13. To ensure the cannula is not

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renewal of dressings should be

preformed by 2 nurses.
14. The line should be observed for
signs of inflammation/ infection.
Changes should be reported to
medical staff.

TCP 211
dislodged during the procedure
13. SAMPLING FROM THE ARTERIAL LINE

13.1
Staff should always ask themselves do I need to take this sample?

Indications include:
Changes in monitored respiratory variables e.g. oxygen saturation or tidal
volume
Monitoring of results of changes in ventilation
Monitoring of electrolytes
Monitoring of bleeding or coagulation tests
Monitoring acid/base abnormalities
13.2
Sampling from arterial lines should only be performed by staff competent in the
technique.
Procedure
1.Wash hands and apply gloves and
apron
2. Use non-touch technique at all times.
Clean port with 2% PDI wipe for 30
seconds; allow to dry prior to any
access. The port should have a RED
needleless valve and should also be
cleaned after use.
3. Mute alarm on monitor.
4. Connect 5 ml syringe to hub, turn port
on to artery, off to transducer. Withdraw
3 ml of blood, or until line is clear of
infusate.
5. Turn 3 way tap diagonally to close off
artery, port and transducer.
6. Connect either heparinised blood gas
syringe or vacutainer equipment and
withdraw blood slowly.
7. Turn 3 way tap off diagonally to
artery, port and transducer prior to
removing syringe/vacutainer.
8. Turn 3 way tap on to transducer and
artery and squeeze flush device
actuator to clear line completely of
blood.
9. Turn 3 way tap on to port and
Rationale
2. Reduce risk of infection
3. Prevent unnecessary noise

4. Prevent decontamination of blood
with infusate
5. Prevent back flow of blood from

artery and contamination with infusate
6. Prevent haemolysis and inaccurate
results
8. Blood is a rich culture medium and

so reduction of infection risk

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TCP 211
transducer and flush port clear of blood

into empty syringe packet, or piece of
sterile gauze.
10. Clean port with 2% PDI wipe.
11. Turn 3 way tap on to transducer and
artery.
12. Dispose of waste materials, remove
gloves and apron and wash hands
14. ARTERIAL BLOOD GAS MEASUREMENT

Blood gas analyser should only be used after or under the supervision of
someone suitably trained in its use.
14.1
Any air must be expelled immediately from the blood gas syringe as this will alter
the results
14.2
Blood gas syringes, other than those from critical care must have a clot catcher
attached attached before the blood is analysed
14.3
Results should be recorded either on the patients chart or electronic record
14.4
A brief guide to the interpretation of blood gas results is provided in Appendix 1,

but is no substitute for training and competency assessment.
14.5
Unexpected results should be discussed with the Shift leader or medical staff as
soon as possible and documented in the patients health records. The possibility
of contamination should always be considered.
15. CAUSES OF INACCURATE READINGS OR MEASUREMENTS

15.1
Pressures
System not levelled/zeroed
No fluid/ Pressure in flush bag
Wrong tubing used.
Bubbles in tubing
Limb or patient position
Cannula position
Arrhythmias
Size of cannula
15.2
Sample results
Air in syringe
Inadequate clearance of infusate
Wrong infusate and inadequate clearance
Delay in analysis
Haemolysis due to rapid withdrawal

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TCP 211
16.
REMOVAL OF ARTERIAL LINES
16.1
16.2
Arterial lines should be removed when no longer required.

As arterial pressure is greater than venous pressure a longer period of pressure
is required over the cannula site in order to prevent haematoma formation
Pressure must be applied aseptically over the site until there is no further
evidence of bleeding or tissue swelling.
16.3
17.
BIBLIOGRAPHY
Allan, D. 1984 Care of the patient with an arterial catheter. Nurs Times 1984, 80(46), 401
Bernsten AD, Soni N, Oh T E, 2003 Ohs Intensive Care Manual 5th Edition p80-81
Butterworth Heinemann
Brown J D et al. 1997 The potential for catheter microbial contamination from a
needleless connector. Journal of Hospital Infection. 36. 181-189.
Daily, E., & Schroeder, J. 1995. Techniques in bedside hemodynamic monitoring. (5th
ed). St Louis: Mosby
Darovic, G., Vanriper, J., & Vanriper, S. 1995. Arterial pressure monitoring. In Darovic,
G. (Ed.), Hemodynamic Monitoring: Invasive and noninvasive clinical application.
(pp.177-210). Philadelphia: W.B. Saunders Company
Department of Health (DoH), 2008. Clean, Safe Care Reducing Infections and Saving
Lives
EPIC (Evidence based Practice in Infection Control), 2007 National evidence-based
guidelines for preventing Healthcare-associated infections in NHS Hospitals in England,
Journal of Hospital Infection, 65s, S1-S64
Kirchhoff KT, Rebenson-Piano M, Patel MK 1984 Mean arterial pressure readings:
variations with positions and transducer level. Nurs Res. 1984 Nov-Dec; 33(6):343-5.
NPSA. 2008 Problems with infusions and sampling from arterial lines..
http://www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/arterial-lines/
Pratt, R.J et al 2007. Epic 2; National Evidence-Based Guidelines for Preventing
Healthcare-Associated Infection in NHS Hospitals in England.
http://www.epic.tvu.ac.uk/PDF%20Files/epic2/epic2-final.pdf
Slogoff S, Keats As, Arlund C. 1983 On the safety of radial artery cannulation.
Anesthesiology 1983; 59:42-7

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TCP 211
Traor O, Liotier J, Souweine B. 2005 Prospective study of arterial and central venous
catheter colonization and of arterial- and central venous catheter-related bacteremia in
intensive care units. Crit Care Med. 2005 Jun; 33(6):1276-80
S1134 - UpToDate - Arterial catheterization.htm
Yentis SM, Hirsch NP, Smith GB. 2003 Anaesthesia and Intensive Care A-Z 3rd edition
p44 Butterworth Heinemann

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TCP 211

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TCP 211
18.0 APPENDIX 1: QUICK GUIDE TO ARTERIAL BLOOD GAS ANALYSIS

DO NOT TAKE THE PATIENT OFF OXYGEN
Look at the Pa02 and Fi02
Note the inspired oxygen % and flow rate and document on blood gas print out.
This allows a more accurate interpretation of the patients oxygen requirements in light of their present
oxygen need. For example a low Pa02 on high flow/percentage oxygen should trigger a senior medical
review for further management.
Look at the pH
< 7.35
> 7.45
ACIDOSIS
ALKALOSIS
Look at the C02 and Bicarbonate
pCO2 >
45 mmHg
or 6.0 kPa
Respiratory Acidosis
HCO3 < 22
Metabolic Acidosis
pCO2 < 35 mmHg

or 4.6 kPa
Respiratory Alkalosis
HCO3 > 22
Metabolic Alkalosis
Look for compensation
HCO3 > 22
Metabolic
compensation
pCO2 < 35 mmHg

or 4.6 kPa
Respiratory compensation
HC03 < 22
Metabolic
compensation
pCO2 > 45 mmHg

or 6.0 kPa
Respiratory compensation
Normal values
pH
Pa02
PaC02
Standard HC03
Base Excess
Lactate
Oxygen Saturations (Sa02)
7.35 7.45
80 100 mmHg or 10.6 13.3 kPa
35 45 mmHg or 4.6 6.0 kPa
22 26 mmol/litre
+2 to -2 mmols/litre
0.5 2.0 mmols/litre
95 100%
Document the ABG and your interpretation/management plan in the patients medical notes.
Further reading
Rhodes A and Cusack R J (2000) Arterial blood gas analysis and lactate. Current Opinion in Critical Care.
6:227-231.
Williams A J (1998) Assessing and interpreting arterial blood gases and acid-base balance. BMJ. Volume
317. Downloaded from bmj.com.
Driscoll P, Brown T, Gwinnutt C & Wardle T. (1997) A Simple Guide to Blood Gas Analysis. BMJ Publishing
Group.
DH/DB Critical Care Outreach Team 08/2008

Page 16 of 16

TCP 211
Equality IMPACT ASSESSMENT FORM (EIAF) Race, Gender, Religion/Belief,

Disability, Age and Sexual Orientation
Section One:
Screening / Prioritising for Full Impact Assessment
Name of the Policy Management of Arterial Lines

Is there public
concern that the
function/
policy is being
carried out in a
discriminatory
way?
Which of the 3
parts does it
apply to (if any)
1 Eliminating
discrimination?
2 Promoting
equal
opportunities?
3 Promoting good
community
relations?
Is there
evidence
or reason
to believe
that
some
groups
could be
differently
affected?
Which
groups
are
affected
How much
evidence
do you
have?
No
No
No
No
No
No
0-2 None
or little
3-4 Some
5-6
Substantial
Priority
(add
column
s 3 & 4)
0-2 None or little

3-4 Some
5-6 Substantial
RACE
RELIGION/
BELIEF
DISABILITY
MEN/WOMEN/
TRANSGENDER
AGE
SEXUAL
ORIENTATION

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Review date: October 2011