59 Arterial Catheter Insertion (Assist), Care, and Removal 509

PROCEDURE Arterial Catheter Insertion 59 (Assist), Care, and Removal

Hillary Crumlett and Alex Johnson PURPOSE: Arterial catheters are used for continuous monitoring of blood pressure, assessment of cardiovascular effects of vasoactive drugs, and frequent arterial blood gas and laboratory sampling. In addition, arterial catheters provide access to blood samples that support the diagnostics related to oxygen, carbon dioxide, and bicarbonate levels (oxygenation, ventilation, and acid-base status).

PREREQUISITE NURSING aortic valve closes, marking the end of ventricular systole. KNOWLEDGE The closure of the aortic valve produces a small rebound wave that creates a notch known as the dicrotic notch. The • Knowledge of the anatomy and physiology of the vascu- descending limb of the curve (diastolic downslope) repre- lature and adjacent structures is needed. sents diastole and is characterized by a long declining • Knowledge of the principles of hemodynamic monitoring pressure wave, during which the aortic wall recoils and is necessary. propels blood into the arterial network. The diastolic pres- • Understanding of the principles of aseptic technique is sure is measured as the lowest point of the diastolic needed. downslope, which should be less than 80 mm Hg in • Conditions that warrant the use of arterial pressure moni- adults. 21 toring include patients with the following: • The difference between the systolic and diastolic pres- ❖ Frequent blood sampling: sures is the pulse pressure, with a normal value of about Respiratory conditions requiring arterial blood gas 40 mm Hg. monitoring (oxygenation, ventilation, acid-base • Arterial pressure is determined by the relationship between status) blood ﬂ ow through the vessels (cardiac output) and the Bleeding, actual or potential resistance of the vessel walls (systemic vascular resis- Electrolyte or glycemic abnormalities, actual or tance). The arterial pressure is therefore affected by any potential factors that change either cardiac output or systemic vas- Metabolic abnormalities (acid-base, tissue perfu- cular resistance. sion), actual or potential • The average arterial pressure during a cardiac cycle is Monitoring serum levels related to therapeutic inter- called the mean arterial pressure (MAP). MAP is not the ventions (renal replacement therapy, chemotherapy, average of the systolic plus the diastolic pressures because, biotherapy, apheresis therapy, etc.) during the cardiac cycle, the pressure remains closer to ❖ Continuous blood pressure monitoring: diastole than to systole for a longer period (at normal heart Hypotension or hypertension rates). The MAP is calculated automatically by most Shock: cardiogenic, septic, hypovolemic, patient monitoring systems; however, it can be calculated neurogenic with the following formula: Mechanical cardiovascular support MAP=+×()() systolic pressure diastolic pressure 2 Vasoactive medication administration • Arterial pressure represents the forcible ejection of blood 3 from the left ventricle into the aorta and out into the arte- • MAP represents the driving force (perfusion pressure) for rial system. During ventricular systole, blood is ejected blood ﬂ ow through the cardiovascular system. MAP is at into the aorta, generating a pressure wave. Because of the its highest point in the aorta. As blood travels through the intermittent pumping action of the heart, this arterial pres- arterial system away from the aorta, systolic pressure sure wave is generated in a pulsatile manner (Fig. 59-1). increases and diastolic pressure decreases, with an overall The ascending limb of the aortic pressure wave (anacrotic decline in the MAP ( Fig. 59-2 ). limb) represents an increase in pressure because of left- • The location of arterial catheter placement depends on the ventricular ejection. The peak of this ejection is the peak condition of the arterial vessels and the presence of other systolic pressure, which should be less than 120 mm Hg catheters (i.e., the presence of a dialysis shunt is a contra- in adults.21 After reaching this peak, the ventricular pres- indication for placement of an arterial catheter in the same sure declines to a level below aortic pressure and the extremity). Once inserted, the arterial catheter causes little

508 59 Arterial Catheter Insertion (Assist), Care, and Removal 509

• The radial artery is the most common site for arterial pressure monitoring. When arterial pulse waveforms are recorded from a peripheral site (compared with a central site), the waveform morphology changes. The anacrotic limb becomes more peaked and narrowed, with increased amplitude; therefore, the systolic pressure in peripheral sites is higher than the systolic pressure recorded from a more central site (see Fig. 59-2 ). In addition, the diastolic pressure decreases, the diastolic downslope may show a secondary wave, and the dicrotic notch becomes less prominent from distal sites. Figure 59-1 The generation of a pulsatile waveform. This is an aortic pressure curve. During systole, the ejected volume distends • Vasodilators and vasoconstrictors may change the appear- the aorta and aortic pressure rises. The peak pressure is known as ance of the waveforms from distal sites. Vasodilators may the aortic systolic pressure. After the peak ejection, the ventricular cause the waveform to take on a more central appearance. pressure falls; when it drops below the aortic pressure, the aortic Vasoconstrictors may cause the systolic pressure to valve closes, which is marked by the dicrotic notch, the end of the become more exaggerated because of enhanced resistance systole. During diastole, the pressure continues to decline and the in the peripheral arteries. aortic wall recoils, pushing blood toward the periphery. The trough of the pressure wave is the diastolic pressure. The difference • Several potential complications are associated with arte- between the systolic and diastolic pressure is the pulse pressure. rial pressure monitoring. Infection at the insertion site can (From Smith JJ, Kampine JP: Circulating physiology . Baltimore, develop and cause sepsis. Clot formation in the catheter 1980, Williams & Wilkins, 55.) can lead to arterial embolization. The catheter can cause a pseudoaneurysm or vessel perforation with extravasa- tion of blood and ﬂ ush solution into the surrounding tissue. Finally, the distal extremity can develop circulatory or neurovascular impairment. • Ultrasound guidance is recommended to place arterial catheters if the technology is available.8 EQUIPMENT

• 2-inch, 20-gauge, nontapered Tefl on cannula-over-needle or prepackaged kit that includes a 6-inch, 18-gauge Tefl on catheter with appropriate introducer and guidewire (or the specifi c catheter for the intended insertion site) • Pressure module and cable for interface with the monitor • Pressure transducer system, including fl ush solution recommended according to institutional standards, a pressure bag or device, pressure tubing with transducer, and fl ush device (see Procedure 75 ) • Dual-channel recorder • Nonsterile gloves, head covering, goggles, and mask • Sterile gloves and large sterile fenestrated drape • Skin antiseptic solution (e.g., 2% chlorhexidine-based preparation) • Sterile 4 × 4 gauze pads • Transparent occlusive dressing Figure 59-2 Arterial pressure from different sites in the arterial • 1% lidocaine without epinephrine, 1 to 2 mL tree. The arterial pressure waveform varies in confi guration, depend- ing on the location of the catheter. With transmission of the pressure • Sterile sodium chloride 0.9% wave into the distal aorta and large arteries, the systolic pressure • 3-mL syringe with 25-gauge needle increases and the diastolic pressure decreases; with a resulting • Sheet protector heightening of the pulse, pressure declines steadily. (From Smith JJ, • Bedside ultrasound machine with vascular probe Kampine JP: Circulating physiology. Baltimore, 1980, Williams & • Sterile ultrasound probe cover Wilkins, 57.) • Sterile ultrasound gel Additional equipment, to have available as needed, includes the following: or no discomfort to the patient and allows continuous • Sterile gown and full drape blood pressure assessment and intermittent blood sam- • Bath towel pling. If intraaortic balloon pump therapy is necessary, • Small wrist board arterial pressure may be directly monitored from the tip • Sutureless securement device of the balloon catheter in the aorta. • Suture material 510 Unit II Cardiovascular System

• Chlorhexidine-impregnated sponge • Review the patient ’ s allergy history (e.g., allergy to • Additional transparent adhesive dressing with tapes heparin, lidocaine, antiseptic solutions, or adhesive tape). 1 (if dressing has no tape, consider the use of 2 -inch Rationale: This assessment decreases the risk for allergic Steri-Strips) reactions. Patients with heparin-induced thrombocytope- • Transducer holder, intravenous (IV) pole, and laser lever nia should not receive heparin in the fl ush solution. for pole-mounted arterial catheter transducers • Assess the neurovascular and peripheral vascular status of the extremity to be used for the arterial cannulation, PATIENT AND FAMILY EDUCATION including color, temperature, presence and fullness of pulses, capillary refi ll, presence of bruit (in larger arteries • Explain the procedure and the purpose of the arterial cath- such as the femoral artery), and motor and sensory func- eter. Rationale: This explanation decreases patient and tion (compared with the opposite extremity). Note: A family anxiety. modifi ed Allen ’ s test should be performed before cannula- • Explain the standard of care to the patient and family, tion of the radial artery (see Fig. 81-3). Rationale: This including insertion procedure, alarms, dressings, and assessment may help identify any neurovascular or circu- length of time the catheter is expected to be in place. latory impairment before cannulation to avoid potential Rationale: This explanation encourages the patient and complications.2,3,20 family to ask questions and voice concerns about the procedure and decreases patient and family anxiety. Patient Preparation • Explain the patient ’ s expected participation during the • Verify that the patient is the correct patient using two procedure. Rationale: Patient cooperation during inser- identifi ers. Rationale: Before performing a procedure, the tion is encouraged. nurse should ensure the correct identifi cation of the patient • Explain the importance of keeping the affected extremity for the intended intervention. immobile. Rationale: This explanation encourages patient • Ensure that the patient and family understand prepro- cooperation to prevent catheter dislodgment and main- cedural teaching. Answer questions as they arise, and tains catheter patency and function. reinforce information as needed. Rationale: Understand- • Instruct the patient to report any warmth, redness, pain, ing of previously taught information is evaluated and or wet feeling at the insertion site at any time. Rationale: reinforced. These symptoms may indicate infection, bleeding, or dis- • Ensure that informed consent is obtained. Rationale: connection of the tubing or catheter. Informed consent protects the rights of the patient and allows a competent decision to be made by the patient; however, in emergency circumstances, time may not PATIENT ASSESSMENT AND allow the form to be signed. PREPARATION • Perform a preprocedure verifi cation and time out, if non- emergent. Rationale: Ensures patient safety. Patient Assessment • Place the patient supine with the head of the bed at a • Obtain the patient ’ s medical history, including history of comfortable position. The limb into which the arterial diabetes, hypertension, peripheral vascular disease, vas- catheter will be inserted should be resting comfortably on cular grafts, arterial vasospasm, thrombosis, or embolism. the bed. Rationale: This placement provides patient Obtain the patient’ s history of coronary artery bypass graft comfort and facilitates insertion. surgery in which radial arteries were removed for use as • If the radial artery is selected, position the hand to allow conduits or presence of arteriovenous fi stulas or shunts. for palpation of the artery (a pillow or towel may be used Rationale: Extremities with any of these problems should to support the wrist). Rationale: This placement positions be avoided as sites for cannulation because of the potential the arm and brings the artery closer to the surface. for complications. Patients with diabetes mellitus or • If the brachial artery is selected, elevate and hyperextend hypertension are at higher risk for arterial or venous insuf- the patient ’ s arm and palpate the artery (a pillow or towel fi ciency. Previously removed radial arteries are a contra- may be used to support the arm). Rationale: This action indication for ulnar artery cannulation. increases accessibility of the artery. • Review the patient ’ s current anticoagulation therapy, • If the femoral artery is selected, position the patient supine history of blood dyscrasias, and pertinent laboratory with the head of the bed at a comfortable angle. The values (prothrombin time [PT], international normalized patient’ s leg should be straight with the femoral area ratio [INR], partial thromboplastin time [PTT], and plate- easily accessible and palpate the artery (a small towel may lets) before the procedure. Rationale: Anticoagulation be needed to support the hip in some cases). Rationale: therapy, blood dyscrasias, or alterations in coagulation This position is the best for localizing the femoral artery studies could increase the risk of hematoma formation or pulse. hemorrhage. 59 Arterial Catheter Insertion (Assist), Care, and Removal 511

Procedure for Assisting With Insertion of an Arterial Catheter Steps Rationale Special Considerations 1 . HH 2. Prepare the fl ush solution (see Heparinized fl ush solutions are Although heparin may prevent Procedure 75 ). commonly used to minimize thombosis, 9,14,17 it has been associated A. Use an IV solution of thrombi and fi brin deposits on with thrombocytopenia and other normal saline. catheters that might lead to hematologic complications.6 Other B. Follow institutional thrombosis or bacterial factors that promote patency of the standards for adding colonization of the catheter. arterial line besides heparinized saline heparin to the IV solution, solution include male gender, longer if heparin is not arterial catheters, larger vessels contraindicated. (Level B * ) cannulated, patients receiving other anticoagulants or thrombolytics, and short-term use of the catheter.1 3. Consider the use of a blood- Reduces the risk of nosocomial conservation arterial line anemia. 5,11,16,18,19 system. (Level B * ) 4. Prime or fl ush the entire Removes air bubbles. Air bubbles Air is more easily removed from the single-pressure transducer introduced into the patient ’ s hemodynamic tubing when the system system (see Procedure 75 ). circulation can cause air is not under pressure. embolism. Air bubbles within the tubing dampen the waveform. 5. Apply and infl ate the pressure Each fl ush device delivers 1–3 mL/ bag or device to 300 mm Hg. hr to maintain patency of the hemodynamic system. 6. Connect the pressure cable to Connects the pressure transducer the bedside monitor. system to the bedside monitoring system. 7. Set the scale on the bedside Prepares the bedside monitor. monitor for the anticipated pressure waveform. 8. Level the air-fl uid interface Leveling ensures that the air-fl uid Use a pole mount or patient mount (zeroing stopcock) to the interface of the monitoring system according to institutional protocol phlebostatic axis (see Figs. is level with a reference point on (see Procedure 75 ). 75-7 and 75-9 ). the body. The phlebostatic axis The tip of the arterial catheter is not refl ects central arterial pressure.13 used as the reference point because it measures transmural pressure of a specifi c area in the arterial tree, which may be increased by hydrostatic pressure.13 9. Zero the system by turning the Prepares the monitoring system. stopcock off to the patient, opening it to air, and zeroing the monitoring system (see Procedure 75 ). 10. HH 1 1 . PE 12. Assist as needed with skin Provides help to the provider preparation. inserting the catheter.

* Level B: Well-designed, controlled studies with results that consistently support a speciﬁ c action, intervention, or treatment.

Procedure continues on following page 512 Unit II Cardiovascular System

Procedure for Assisting With Insertion of an Arterial Catheter—Continued Steps Rationale Special Considerations 13. Assist as needed with Facilitates insertion. Personal protective equipment (e.g., immobilizing the extremity head cover, mask, goggles) is needed, during catheter insertion. as well as sterile equipment. Maximal sterile barrier precautions should be used for femoral artery catheter insertion. 8,14 14. Connect the pressure cable Connects the arterial catheter to the from the arterial transducer to bedside monitoring system. the bedside monitor. 15. Reassess accurate leveling, and Ensures that the air-fi lled interface Leveling ensures accuracy. The point of secure the transducer (see (zeroing stopcock) is maintained the phlebostatic axis should be Procedure 75 ). at the level of the phlebostatic marked with an indelible marker, axis. If the air-fl uid interface is especially when the transducer is above the phlebostatic axis, secured in a pole-mount system. arterial pressures are falsely low. If the air-fl uid interface is below the phlebostatic axis, arterial pressures are falsely high. 16. Zero the system again (see Ensures accuracy of the system with Procedure 75 ). the established reference point. 17. Turn the stopcock off to the Prepares the system for monitoring top port of the stopcock. Place and ensures a closed system. a sterile cap or a needleless cap on the top port of the stopcock. 18. Observe the waveform and Determines whether the system is The square wave test can be performed perform a dynamic response damped. This will ensure that the by activating and quickly releasing test (square wave test; pressure waveform components the fast fl ush. A sharp upstroke should Fig. 59-3 ). are clearly defi ned. terminate in a fl at line at the maximal This aids in accurate measurement. indicator on the monitor. This should be followed by an immediate rapid downstroke extending below the baseline with 1–2 oscillations within 0.12 second and a quick return to baseline (see Fig. 59-3 ). 19. Ensure that the provider Maintains arterial catheter position; A sutureless securement device can be inserting the catheter has reduces the chance of accidental used. secured the arterial catheter in dislodgement. place. 20. Ensure that the provider Reduces the risk of infection. inserting the catheter has applied an occlusive, sterile dressing to the insertion site. 21. Apply an arm board, if Ensures the correct position of the necessary. extremity for an optimal waveform. 22. Set the alarm parameters Activates the bedside and central according to the patient ’ s alarm system. current blood pressure. 23. Remove PE and discard used Reduces the transmission of supplies in appropriate microorganisms; Standard receptacles; ensure that all Precautions. Safely removes sharp needles and other sharp objects objects. are disposed of in appropriate containers. 24. HH 59 Arterial Catheter Insertion (Assist), Care, and Removal 513

C Figure 59-3 Dynamic response test (square wave test) using the fast ﬂ ush system. A , Optimally damped system. B, Overdamped system. C , Underdamped system. (From Darovic GO, Zbilut JP: Fluid-ﬁ lled monitoring systems. In Hemodynamic monitoring, ed 3. Philadelphia, 2002, Saunders, 122.) 514 Unit II Cardiovascular System

Procedure for Assisting With Insertion of an Arterial Catheter—Continued Steps Rationale Special Considerations 25. Compare the manual Obtains baseline data. No direct relationship exists between (noninvasive) blood pressure noninvasive and invasive blood with the arterial (invasive) pressures because noninvasive blood pressure. techniques measure blood ﬂ ow and invasive techniques measure pressure.13 26. Run a waveform strip and Obtains baseline data. Digital values are not used because they record the patient ’ s baseline are averaged calculations. arterial pressures.

Procedure for Troubleshooting an Overdamped Waveform Steps Rationale Special Considerations 1 . HH 2 . PE 3. Identify the overdamped waveform Identiﬁ es the problem. An overdamped ( Fig. 59-4 ). waveform results in a falsely low systolic pressure and a falsely high diastolic pressure.

Figure 59-4 Overdamped arterial waveform (1 , systole; 2 , diastole). (From Daily EK, Schroeder JS: Hemodynamic waveforms . St Louis, 1990, Mosby, 110.)

4. Check the patient. A sudden hypotensive episode can look like an overdamped waveform ( Fig. 59-5 ). 59 Arterial Catheter Insertion (Assist), Care, and Removal 515

Procedure for Troubleshooting an Overdamped Waveform—Continued Steps Rationale Special Considerations

Figure 59-5 Patient developed supra- ventricular tachycardia (SVT) with a fall in arterial pressure. Note how the arterial waveform appears overdamped but is in fact reﬂ ecting a severe hypotensive episode associated with the tachycardia.

5. If the waveform is overdamped, follow these steps: A. Check the arterial line insertion Wrist movement in the radial site or leg site for catheter positioning. fl exion in the femoral site can cause catheter kinking or dislodgment, resulting in an overdamped waveform. B. Check the system for air bubbles Air bubbles can be a cause of an and eliminate them if they are overdamped system; air bubbles can found. also cause emboli. C. Check the tubing system for leaks Ensures all connections are tight. or disconnections, and correct the problem if it is found. D. Check the fl ush bag to ensure fl uid An empty fl ush bag or a pressure of less is present in the bag and that than 300 mm Hg may result in an pressure is maintained at overdamped system. 300 mm Hg. E. A catheter with an overdamped Use of the fast-fl ush device or fl ushing waveform should always be with a syringe fi rst may force a clot at aspirated before fl ushing. the catheter tip into the arterial circulation. Attempt to aspirate and fl ush the Assists with the withdrawal of air in the catheter as follows: tubing or clots that may be at the catheter tip. • Using the stopcock closest to A 5-mL syringe generates less pressure A 10-mL syringe may be the patient, remove the and may prevent arterial spasm in needed for larger nonvented cap from the blood smaller arteries (e.g., radial artery). arteries (e.g., the sampling port or cleanse the femoral artery). A needleless port and attach a needleless system can 5- or 10-mL syringe to the also be used. top port of the stopcock (see Fig. 61-1 ). • Turn the stopcock off to the Opens the system from the patient to the fl ush solution (see Fig. 61-4B ). syringe. Assesses catheter patency. • Gently attempt to aspirate; if Normally, blood should be aspirated resistance is felt, reposition the into the syringe without diffi culty. extremity and reattempt aspiration. • If resistance is still felt, stop and notify the physician or advanced practice nurse. Procedure continues on following page 516 Unit II Cardiovascular System

Procedure for Troubleshooting an Overdamped Waveform—Continued Steps Rationale Special Considerations • If blood is aspirated, remove Removes any clotted material within the All blood wastes should 3 mL, turn the stopcock off to catheter. be disposed using the patient, and discard the Standard Precautions. 3-mL sample. • Fast-ﬂ ush the remaining blood Removes blood residue from the from the stopcock onto a sterile stopcock, where it could be a gauze pad or into another reservoir for bacterial growth, and syringe and remove the syringe. prevents clotting in the blood sampling port. • Turn the stopcock off to the Maintains sterility and a closed system. blood sampling port (see Fig. 61-1 ) and place a new sterile nonvented cap (not needed if using a needleless port). • Use the fast-ﬂ ush device to Prevents the arterial line from clotting. clear the line of blood. 6. Remove PE and discard used supplies Reduces the transmission of in the appropriate receptacles. microorganisms; Standard 7 . HH Precautions.

Procedure for Troubleshooting an Underdamped Waveform Steps Rationale Special Considerations 1 . HH 2 . PE 3. Identify the underdamped waveform. Identiﬁ es the problem. An underdamped waveform results in a falsely high systolic pressure and a falsely low diastolic pressure. 4. Check the system for air bubbles Air bubbles can contribute to and eliminate them if they are found. underdamping; air bubbles can also cause emboli. 5. Check the length of the tubing of the Ensures that the tubing length is pressure transducer system. minimized. 6. Observe the waveform and perform Determines whether the system is a dynamic response test (square damped. This will ensure that wave test; Fig. 59-3 ). the pressure waveform components are clearly deﬁ ned. This aids in accurate measurement. 7. Remove PE and discard used Reduces the transmission of supplies in appropriate receptacles. microorganisms; Standard Precautions. 8 . HH 59 Arterial Catheter Insertion (Assist), Care, and Removal 517

Procedure for Arterial Catheter Dressing Change Steps Rationale Special Considerations 1 . HH 2 . PE 3. Carefully remove and Removes the previous dressing without If present, remove the securement discard the arterial line disrupting the integrity of the device. dressing. catheter. 4. Inspect the catheter, insertion Assesses for signs of infection, site, and surrounding skin. catheter dislodgement, or leakage. 5. Remove nonsterile gloves, Reduces the transmission of discard dressings, and microorganisms perform hand hygiene. 6. Don sterile gloves Maintains aseptic and sterile technique. 7. Cleanse the skin and catheter Reduces the rate of recolonization of Allow time for the solution to air dry. with 2% chlorhexidine-based skin ﬂ ora. Decreases the risk for preparation.14 bacterial growth at the insertion site. 8. Apply a new stabilization Secures the catheter. device. 9. Apply a chlorhexidine- Reduces the transmission of Follow institutional standards. impregnated sponge to the microorganisms. A chlorhexidine-impregnated sponge site.12,14 (Level D * ) dressing is recommended if an institution ’ s central line–associated bloodstream infection rate is not decreasing despite adherence to basic prevention measures, including education and training, appropriate use of chlorhexidine for skin antisepsis, and maximum sterile barrier.8,12,14 Use with caution in patients predisposed to local skin necrosis, such as burn patients or patients with Stevens- Johnson syndrome.22 10. Apply a sterile air-occlusive Provides a sterile environment. Write the date and time of the dressing dressing. Dressings may be a change on a label and tape it to the sterile gauze or a sterile, dressing. transparent, semipermeable dressing. 14 11. Remove gloves and discard Reduces the transmission of used supplies in appropriate microorganisms; Standard receptacles. Precautions. 12. HH

* Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommen dations.

Procedure continues on following page 518 Unit II Cardiovascular System

Procedure for Removal of the Arterial Catheter Steps Rationale Special Considerations 1. Review the patient ’ s coagulation Elevated PT, INR, PTT, and If laboratory values are abnormal, profi le (PT, INR, PTT, platelets) decreased platelets affect time to pressure needs to be applied for a and anticoagulation medication hemostasis. longer period to achieve profi le before removal of the hemostasis. arterial catheter. 2 . HH 3 . PE 4. Turn off the arterial monitoring The alarm system is no longer alarms. needed. 5. Remove the dressing. Prepares for catheter removal. 6. Remove the stabilizing device. Prepares for catheter removal. 7. Turn the stopcock off to the Turns the monitoring system off to fl ush solution (see Fig. 61-4B ). the fl ush solution. 8. Apply pressure 1–2 fi nger The arterial puncture site is above widths above the insertion site. the skin puncture site because the catheter enters the skin at an angle. 9. Remove the arterial catheter and Prevents splashing of blood. place a sterile 4 × 4 gauze pad over the catheter site. 10. Continue to hold proximal Prevents bleeding. pressure and immediately apply fi rm pressure over the insertion site as the catheter is removed. 11. Continue to apply pressure for a Achieves hemostasis. Follow institutional standards. minimum of 5 minutes for the Longer periods of direct pressure radial artery. may be needed to achieve hemostasis (e.g., patients receiving systemic heparin or thrombolytics, patients with catheters in larger arteries such as the femoral artery, or patients with abnormal coagulation values). 12. Apply a pressure dressing to the A pressure dressing helps prevent The dressing should not encircle the insertion site. rebleeding. extremity (prevents ischemia of the extremity). 13. Remove PE and discard used Reduces the transmission of supplies in appropriate microorganisms; Standard receptacles. Precautions. 14. HH

Expected Outcomes Unexpected Outcomes • Successful cannulation of the artery • Pain • Peripheral vascular and neurovascular systems intact • Insertion complications • Alterations in blood pressure identiﬁ ed and treated • Inability to cannulate the artery • Able to continuously monitor blood pressure • Change in color, temperature, sensation; movement • Maintenance of baseline hemoglobin and hematocrit of the extremity used for insertion levels • Hematoma, hemorrhage, infection, or thrombosis at • Adequate circulation to the involved extremity the insertion site • Adequate sensory and motor function to the involved • Decreased hemoglobin and hematocrit values extremity • Catheter disconnection with signiﬁ cant blood loss • Maintenance of catheter site without infection • Presence of a new bruit • Removal of catheter when no longer needed • Impaired sensory or motor function of the extremity • Elevated temperature or elevated white blood cell count • Redness, warmth, edema, or drainage at or from the insertion site 59 Arterial Catheter Insertion (Assist), Care, and Removal 519

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions should be reported if they persist despite nursing interventions. 1. Assess the neurovascular and Validates adequate peripheral vascular • Diminished or absent pulses peripheral vascular status of the and neurovascular integrity. Changes • Pale, mottled, or cyanotic cannulated extremity in sensation, motor function, pulses, appearance of the distal extremity immediately after catheter color, temperature, or capillary refi ll • Extremity that is cool or cold to insertion and every 4 hours, or may indicate ischemia, thrombosis, the touch more often if warranted, arterial spasm, or neurovascular • Capillary refi ll time of greater according to institutional compromise. than 2 seconds standards. • Diminished or absent sensation or pain at the site or distal extremity • Diminished or absent motor function 2. Check the arterial line fl ush Ensures that approximately 1–3 mL/hr system every 4 hours to ensure of fl ush solution is delivered through the following: the catheter, thus maintaining patency • Pressure bag or device is and preventing backfl ow of blood into infl ated to 300 mm Hg. the catheter and tubing. • Fluid is present in the fl ush The risk of catheter occlusion related to solution. fi brin sheath or clot formation increases if the fl ush solution is not continuously infusing. 3. Perform a dynamic response An optimally damped system provides • Overdamped or underdamped test (square wave test) at the an accurate waveform. waveforms that cannot be start of each shift, with a corrected with troubleshooting change of the waveform, or procedures after the system is opened to air (see Fig. 59-3 ). 4. Monitor for overdamped or An optimally damped system provides • Overdamped or underdamped underdamped waveforms. an adequate waveform which waveforms that cannot be An overdamped waveform is facilitates accuracy of blood pressure corrected with troubleshooting characterized by a fl attened monitoring. procedures waveform, a diminished or An overdamped waveform can result in absent dicrotic notch, or a inaccurate blood pressure square wave that does not measurement. The patient ’ s blood fall to baseline or below pressure measure may be inaccurately baseline (see Fig. 59-4 ). low. An underdamped waveform is An overdamped system can be caused by characterized by catheter air bubbles in the system; use of fl ing or artifacts on the compliant tubing versus stiff, loose waveform (see Fig. 59-3,C ). tubing connections in the system; too many stopcocks in the system; a cracked tubing or stopcock; arterial catheter occlusion or a kink; the catheter tip being against the arterial wall; blood in the transducer; and insuffi cient pressure of the fl ush solution. An underdamped waveform can also result in inaccurate blood pressure measurement. The patient ’ s blood pressure measure may be inaccurately high. Common causes of an underdamped waveform include excessive tubing length, movement of the catheter in the artery, patient movement, and air bubbles in the system. Procedure continues on following page 520 Unit II Cardiovascular System

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions 5. Zero the transducer during the Ensures accuracy of the hemodynamic initial setup, after insertion, if monitoring system. disconnection occurs between the transducer and the monitoring cable, if disconnection occurs between the monitoring cable and the monitor, and when the values obtained do not fi t the clinical picture. Follow manufacturer recommendations for disposable systems. 6. Recheck the level of the Ensures accurate reference point for the air-fl uid interface (zeroing left atrium and accuracy of blood stopcock) to the phlebostatic pressure measurements. axis whenever patient position changes (see Procedure 75 ). 7. Place sterile injectable or Stopcocks can be a source of noninjectable caps on all contamination. Stopcocks that are part stopcocks. Replace with new of the initial setup are packaged with sterile caps whenever the caps vented caps. Vented caps need to be are removed. replaced with sterile injectable or noninjectable caps to maintain a closed system and reduce risk of contamination and infection. 8. Continuously monitor the Provides for continuous waveform arterial catheter values and analysis and assessment of patient waveform. status. 9. Observe the insertion site for Infected catheters must be removed as • Redness at the site signs and symptoms of soon as possible to prevent • Purulent drainage infection. bacteremia. • Tenderness or pain at the The CDC does not recommend routinely insertion site replacing peripheral arterial catheters • Elevated temperature to prevent catheter-related infections. 14 • Elevated white blood cell count 10. Change the pressure transducer The CDC 14 and the Infusion Nurses system (fl ush solution, pressure Society 8 and research fi ndings10,15 tubing, transducers, and recommend that the hemodynamic stopcocks) every 96 hours. fl ush system can be used safely for 96 (Level B * ) hours. This recommendation is based The fl ush solution may need to on research conducted with disposable be changed more frequently. pressure monitoring systems used for peripheral and central lines. 11. Label the tubing: Identifi es that the catheter is arterial and A. Arterial when the system needs to be changed. B. Date and time prepared 12. Maintain the pressure bag or Maintains catheter patency. device at 300 mm Hg.

* Level B: Well-designed, controlled studies with results that consistently support a speciﬁ c action, intervention, or treatment. 59 Arterial Catheter Insertion (Assist), Care, and Removal 521

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions 13. Print a strip of the arterial Ensures accurate blood pressure pressure waveform and obtain measurement. measurement of the arterial pressures. Note if there are respiratory variations. 14. Obtain an arterial pressure The printed waveform allows assessment waveform strip to place on the of the adequacy of the waveform, patient ’ s chart at the start of damping, or respiratory variation. each shift and whenever a change is found in the waveform. 15. Monitor hemoglobin or Allows assessment of nosocomial • Abnormal hemoglobin values hematocrit values daily or as anemia. • Abnormal hematocrit values prescribed. 16. Replace gauze dressings every Decreases the risk for infection at the 2 days and transparent catheter site. The CDC 14 and the dressings at least every 5–7 Infusion Nurses Society 7,8 days and more frequently as recommends replacing the dressing needed. 7,8,14,22 (Level D * ) when it becomes damp, loosened, or soiled or when inspection of the site is necessary. 17. Print a strip of the arterial The printed waveform allows assessment waveform to place on the of the adequacy of the waveform and patient ’ s chart at the start of the presence of damping. each shift and whenever a change in the waveform occurs. 18. Assess the need for the arterial The CDC 14 does not recommend routine • Signs and symptoms of infection catheter daily. (Level D * ) replacement of arterial catheters. at the arterial catheter insertion Catheters should be removed when no site longer needed and should be replaced when there is a clinical indication. 19. Follow institutional standards Identiﬁ es need for pain interventions. • Pain at the catheter site. for assessing pain. Administer analgesia as prescribed.

* Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommen dations.

Documentation Documentation should include the following: • Patient and family education • Site assessment • Completion of informed consent • Arterial site dressing change • Preprocedure verifi cations and time out • Intake of fl ush solution volume • Performance of the modifi ed Allen ’ s test before • Printed strip of the arterial pressure waveform insertion and its results (when using the radial artery) • Appearance of the limb, color, pulse, sensation, • Insertion of the arterial catheter movement, capillary refi ll time, and temperature of • Size of the arterial catheter inserted the extremity after insertion is complete • Number of insertion attempts • Arterial pressures • Date and time of arterial catheter site care and dressing • Waveforms change • Occurrence of unexpected outcomes and • Pain assessment, interventions, and effectiveness interventions 522 Unit II Cardiovascular System

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .