HHS CPO Hemodynamic Arterial Lines

Art Line Indications

Hemodynamically compromised patients with need for real time, continuous, accurate BP monitoring

• Trends and immediate responses to interventions

• Access for frequent blood sampling/ABGs

Art Line Complications

• Pain (insertion)

• Bleeding/hemorrhage

• Hematoma formation, brusing

• Infection

• Pseudo-aneurysm formation

• Neurovascular compromise

• Vasospasm

• Air embolism, particulate embolism

Art Line Sites

1. Radial → Allen’s Test

2. Femoral

3. Dorsalis pedis, Brachial auxillary (rare)

Set Up Components

• NS

• Pressure bag

• Arterial fluid line with transducer

• Sutures

• Tegaderm

• Chlorahexadine swab

• PPE

• Sterile gloves

• Sterile towels

• Dressing tray

• Tape

• Wrist board

• Needle driver

• Catheter

Radial Arterial Catheter

20 gauge, 5 cm

Femoral Arterial Catheter

20 gauge, 16 cm

Pressure Monitoring System Components

• Pigtail system for fast flush

• Transducer

Transducer

Senses a dynamic signal from vasculature and transmits signal to bedside monitor

Steps for Insertion

1. Prepare art line pressure monitoring system

2. Once catheter inserted, connect pressure monitoring system to pt and monitor

3. Level transducer and zero system

4. Once waveform and art pressure accepted, apply sterile transparent dressing - use white velcro to maintain position

5. Set alarm parameters

6. Perform a cuff (indirect) pressure and compare to art line to assess accurary → art 10-20 higher than cuff

7. Label pressure tubing with start and end date (q96h)

8. Add art line on avatar and complete documentation

9. Print waveform, scan into EPIC

Level and Zero

Position transducer at level of phelbostatic axis (R atrim, 4th intercostal space at midaxillary line)

• zero upon insertion, if there’s issues with the system, after disconnection

Arterial Waveform

Peak of wave is systole

• closure of aortic valve creates a small rebound wave → dicrotic notch

• Diastole ends and systole starts immediately after QRS

• Further from aortic valve, taller systolic peak, further dicrotic notch, lower end diastolic pressure

Damping

Natural tendency of fluid in system to extinguish motion → some necessary to absorb harmonic resonance reverberating through the system

• “shock absorber”

Square Wave Test

Ensures accuracy of hemodynamic pressure measurement

• Pull pigtail and quickly let go

Optimal Response to Square Wave Test

• Sharp upstroke

• Flat line at top

• Immediate rapid down stroke

• One undershood followed by one small overshoot

Underdamping

Waveform transmitted with magnified amplitude

• Systolic overshoot with narrow peak, non-physiologic oscillations in diastolic phase

• Overestimated SBP

• Underestimated DBP

• Widened pulse pressure

• MAP not impacted

Overdamping

Waveform loses characteristic landmarks, appears unnaturally smooth with diminished/absent dicrotic notch

• Underestimation of SBP

• Overestimation of DBP

• Narrowed pulse pressure

• MAP not impacted

Underdamping Interventions

• Remove ALL air bubbles from tubing

• Check level of transducer

• Check scale, re-zero

• use MAP

Overdamping Interventions

• Check pt status

• Ensure no kinks, loose connections, bent wrist

• Ensure no air, blood clots

• Check stopcock is in proper position

• Adequate NS fluid vol

• Pressure bag at 300 mmHg

• Catheter may be pushed against vessel wall - MD to pull back

• Check level of transducer

• Check scale, re-zero

• use MAP

Unable to Flush Interventions

• Check site

• Check for kinks

• Check stopcocks

• Check roller clamp is open, fluid in bag

• 300 mmHg pressure

• Reposition catheter

• If clot suspected, attempt to aspirate clot (3ml) with 10ml syringe (reposition wrist while doing so). If able to aspirate, remove and flush with pigtail

No Waveform Interventions

• Check pt status

• Check stopcocks

• Check for loose connections, disconnects

• Check scale

• Check zero reference and re-zero

• Check pressure bag at 300 mmHg

• Check vol in bag

• Check cable connected

Q1 Assessments and Documentation

• No air, blood, kinks, loose

• No infection or hematoma at site

• IV solution level

• Pressure at 300 mmHg

• Stopcock open to pt/transducer and off to side port

• Pain

• Limb perfusion (CSM, pulse, cap refill, temp)

Q12 Assessments and documentation

• Mount tracing

• Check correlation with cuff pressure

• Check square wave test

• Line labelled correctly on monitor

• Check alarm parameters and that they are on

Q96 Assessments and Documentation

• Change setup, label and document

• Change dressing

Arterial Line Removal - Prior to Removal

• Ensure MD order

• Check coagulation status

• Ensure IV access is patent

Arterial Line Removal - Removal Process

• Turn off alarms, stopcock off to pt, clamp flush line, deflate pressure bag

• Remove dressing, clean site with chlorahexadine

• Remove sutures/steri strips

• Place gauze over insertion site and remove catheter

• Inspect catheter to ensure completely intact

Arterial Line Removal - After Removal

Apply firm pressure with gauze for min 5 min (radial) or 10 min (femoral)

• Once min time elapsed, check site for hemostasis

• If oozing continues, hold for an additional 5 min

• Hold direct pressure for a minimum of 5 min after evidence of bleeding has stopped

• Apply transparent dressing

Femoral Line Removal

During compression of femoral site, check for pedal pulse, assess extremity for cap refill (if weak/absent, release pressure slightly)

• Keep HOB <30 for first 2 hours, then up for 45 for next 2 hrs

Femoral Site Complications

Retroperitoneal bleeding

• Abdo pain

• Back pain

• Hypotension

• Tachycardia

• Anxiety

• Diaphoresis

• Flank pain

Post Removal Site Assessment

Circulation → peripheral pulse, cap refill, sensation and movement

Bleeding:

Radial →

• q5 min x2

• q15 ×4

• q30 ×1

• q60 ×2

Femoral →

• q5 ×2

• q15 ×4

• q30 ×2

• q60 ×3