Arterial lines in PACU

Presented by Autum Jacobs RN, BSN

Objectives
How to assist with setting up arterial line tubing, pressure bag and monitoring system. How to interpret arterial line wave forms. When and how to utilize a R.O.S.E. Drawing blood samples from arterial line. How to properly discontinue an arterial line. Review policies for arterial lines

Goals
Know how to assist with setting up arterial line tubing, pressure bag and monitoring system. Know how to interpret arterial line wave forms. Know when and how to utilize a R.O.S.E. Know how to draw blood samples from arterial line. Know how to discontinue an arterial line. Be able to locate policies for arterial lines.

Which patients have arterial lines?

Arterial line are used in pts when continuous BP monitoring is required or frequent labs are needed. We see them most associated with thoracotomy patients, carotid endardectomies or critically ill patients.

Arterial line locations

Arterial lines can be place in the radial, femoral, brachial and axillary arteries. The most commonly used sites are either the radial or femoral arteries. In PACU we typically see the radial artery used.

Allens test
When an arterial line is being placed, an Allens test MUST be completed first. If the test is negative the arterial line can not be inserted into that extremity.

Ulnar pulse check in PACU

When the pt arrives in the PACU , an ulnar pulse must be assessed and confirmed. If unable to locate a pulse, you must notify the doctor. If ulnar pulse is not present, pt is at risk for losing that extremity.

How to set up PACU monitor

Connect cable to monitor use port for BP-1 Click on resume, then admit/discharge, mode select and then, add an ART. Set recording options by clicking menu, then manual record (set for EKG 1 and ART to view single lead EKG tracing and arterial line tracing

How to obtain accurate readings

Phlebostatic Axis(mid axillary line)

The transducer must be place at the phlebostatic axis. This point reflects central blood pressure. The phlebostatic axis is at the intersection of the 4th intercostal space and mid axillary line. If the transducer is too high it will produce too low values, if placed too low produces too high values. Placing the transducer at this point will help ensure consistency and accuracy.

Phlebostatic axis

Pressure bag
The next step is to make sure that the fluids in the pressure bag are at 300mmHg. This ensures a continuous flow at 3-5ml/hr which helps prevent occlusion of the catheter. 0.9%NS should be used in the pressure bag. Make sure the IV fluid bag matches the size pressure bag (liter w/ liter pressure bag, 500ml with 500 ml pressure bag

Pressure Bag/ Priming tubing

Arterial line tubing must be primed BEFORE it is placed to pressure. All of the air must be removed from IV bag prior to priming/using tubing. Only fill fluid chamber with a small amount of fluid prior to placing under pressure. The chamber will continue to fill as pressure is applied.

Zero Referencing

Flush system Level transducer at the phlebostatic axis Turn stop cock off to pt. Remove cap (all caps should be blue dead end caps). Press the red BP-1 square on the monitor Press BP zero When monitor shows complete, turn stop cock back to the original position. Replace blue dead end cap.

Waveforms
The arterial line waveforms will appear red on the monitor. Normal arterial line waveforms look like this..(fig A)

Waveforms
The arterial line SBP and DBP should be calculated from the waveform. This is simply done by marking the tallest(SBP) portion of the waveform and the lowest(DBP). Make sure the monitor is set to 200mmHg

Waveforms

Square wave test

Square wave test

Helps to determine if the monitoring systems dynamic response is accurate. Easily done by activating the fast flush device on the transducer for 1-2 sec. Look at the bounce in the waveform.

Correlation
Once the arterial line has been set up properly you want to check the correlation between the arterial line and NIBP. This is typically done on the same arm. (Dr. Walters will ask if the pressures were done on the same arm). In normal patients direct arterial pressure is usually 2-8 mmHg higher than cuff pressure.

Correlation
If the wave form is over-dampened check the position of the wrist and arterial line arm board. Sometimes is is just positional. If the arterial line pressure and NIBP do not correlate, always ask the physician which pressure they would like to use.

Correlation
If the waveform is under-dampened (has a whip) sometimes the hertz on the monitor needs to be changed. To change the hertz on the monitor, go to menu, parameter, BP-1, config, the choose either 8 or 6 hertz instead of 12.

R.O.S.E.
If your NIBP and arterial lines do not correlate and there is a whip in the arterial line waveform, apply a resonance overshoot eliminator to the arterial line (R.O.S.E)

Drawing blood from arterial lines

Blood samples can be obtained with or without a sampling device (vamp direct draw). The preferred method at YRMC is with a sampling device. Be sure to notify lab that you will be drawing labs from the arterial line and that you need the lab tubes.

Drawing blood from arterial line

Silence monitor Release plunger and pull back to fill reservoir with 10ml solution. Turn stopcock off to reservoir. Swab site with alcohol Apply vamp with syringe or lab tube holder to sample site (always use site closest to pt.)

Drawing blood from arterial lines

Draw blood sample by filling syringe or attaching lab tubes. Remove syringe or sampling device by pulling straight out. Re-swab site with alcohol. Return stop cock to open position

Drawing blood from arterial line

Re-infuse blood/fluid mixture from reservoir to patient. Flush line to clear tubing. Zero and calibrate transducer.

Drawing blood from arterial lines

See YRMC operating practice blood sampling via arterial line PRAC CC B110.10 Step by step practice shown in hands on portion of presentation

Arterial line removal

Any patients going not going to ICU must have their arterial lines removed prior to transfer. You must have a doctors order to remove arterial lines. Remove arterial lines AFTER all labs have been obtained and resulted especially ABGs.

Arterial line removal

Tell patient what you are going to do. Gather supplies(2x2s & coban) Clamp fluid tubing to prevent fluid leaking, both from pressure bag and from patient. After tubing clamped, release pressure from pressure bag.

Arterial line removal

Remove arterial line dressing (transparent and steri strips). Place folded gauze over the catheter site and gently pull catheter out. Make sure catheter intact. Apply direct pressure to the site for 5 minutes. (no peeking!)

Arterial line removal

Assess extremity circulation while applying pressure. Dont cut off all circulation After 5 min assess site for active bleeding. If no active bleeding noted cover site with gauze and coban. After removal, monitor site for re-bleeding. Be sure to give report to receiving RN about location and condition of previous site.

Policies
Policies and operating practices can be found on the YRMC intranet. Operating practices used.. PRAC CC B110.10, (BLOOD SAMPLING VIA ARTERIAL LINES) PRAC CC A001.10, (ARTERIAL LINESINSERTION, MANAGEMENT, REMOVAL)

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