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Arterial Blood Pressure Monitoring ARTERIAL BLOOD PRESSURE MONITORING A LEARNING RESOURCE FOR INTENSIVE CARE NURSING STAFF Mairi Mascarenhas Clinical Educator ICU Intensive Care Unit Raigmore Hospital Reviewed: February 2018 Indications for arterial blood pressure monitoring: Any major medical or surgical condition that compromises cardiac output, tissue perfusion or fluid volume status. Patients requiring continuous monitoring of blood pressure due to difficulties in obtaining blood pressure recordings by the cuff method. When frequent arterial blood gas sampling is required. When vasoactive/inotropic therapy is required. Insertion sites for arterial puncture/cannulation include: 1. Radial artery. 2. Axillary artery: this becomes the brachial artery at the level of the teres major muscle. 3. Brachial artery. 4. Femoral artery. 5. Dorsalis pedis artery. 1. 2. 3. 4. 5. 1. Arterial catheters: 1. Vygon leader cath 2. Baxter flow-switch An arterial catheter (line) is a sterile tube that is inserted into an artery, enabling direct access to the artery and allows connection to a fluid- filled transducer monitoring kit. 1. 2. Safety points to consider when the arterial line is inserted: No arterial line should be left in situ without attachment of a flush administration set. Always have a flush administration set prepared in advance before the arterial line is inserted. The administration set must be free from air including the dead space in the 3-way tap ports. All ports should be sealed using the appropriate bungs (rather than the dust caps that are used during priming). Ensure all connections are tight and secure. Red coloured caps should be used for arterial line port-holes thus helping prevent wrong- route errors. The transducer flush solution must be prescribed. The prescription is always 500ml 0.9% sodium chloride. The solution must be checked and signed for by 2 registered nurses. Never use any other flush solution other than 500ml 0.9% sodium chloride and always check the fluid bag against the prescription. Errors have occurred where a glucose solution has been connected resulting in blood sampling errors and patients receiving inappropriate treatments. The volume remaining in the transducer flush solution must be checked regularly and a new bag of fluid should be connected as appropriate. Special attention needs to be made where ambient lighting is reduced or during night time hours. Failure to check the volume of fluid remaining may result in a blocked arterial line. The flush administration set is changed every 96 hours. The arterial line dressing is changed every 96 hours. The arterial cannula site should be dressed with a sterile vapour permeable transparent dressing to allow insertion site inspection. The arterial line may or may not be sutured to the skin. This should be recorded in the arterial bundle documentation and should also be highlighted in the alert box on the patient’s observation chart. Never inject anything into an arterial line. The result of an accidental injection will depend on what has been injected but it has the potential to cause cardiac arrest. Where possible the cannula (limb) should be exposed and continually observed. Immediately report any blanching of the limb to medical staff. If the arterial cannula is no longer required it should be removed immediately. 2. Radial artery catheterisation: The radial artery is the preferred site for insertion because of low complication rates. Technique of radial line insertion: After cleaning the skin with chloraprep 2%, lignocaine 1% is infiltrated over the radial artery. There are 3 common insertion techniques. Whichever technique is used, the cannula should never be forced along the artery as local damage may occur. 1. Direct cannulation: insertion technique similar to that of a venous cannula. Extension of the wrist brings the artery closer to the surface. Stabilising the wrist in this position either with tape or with the aid of an assistant makes insertion easier. The radial artery is palpated. The cannula is inserted aiming to hit the middle of the artery at an angle of approximately 30° to the skin. Where there is free flow of arterial blood back into the hub of the cannula, the cannula sheath is advanced over the needle into the artery. 2. Transfixion: after obtaining a flashback, the cannula is advanced through the posterior wall of the artery. The needle is removed and a syringe attached. The cannula is slowly withdrawn while aspirating. Once free aspiration is achieved, the cannula is advanced proximally along the artery. This is a particularly useful technique in paediatric patients. 3. Guidewire (Seldinger) technique: a guidewire may be used if advancement of the cannula sheath over the needle proves difficult, for example in atheromatous disease. The guidewire is inserted through the cannula sheath after removal of the needle (or through needles which are provided in some arterial cannulation sets). The guidewire should advance freely along the artery. The cannula sheath is then advanced along the artery, and the guidewire is removed. The arterial line is then made secure either by using (1) suture or (2) adhesive strips. A sterile dressing is placed over the insertion site. The transducer flush is immediately connected. If the arterial cannula is not stitched in place, this must be highlighted in the alert box on the patient’s observation chart. The arterial line insertion checklist/sticker is completed and placed in the patient’s medical notes. ARTERIAL LINE INSERTION COMPLETE ALL INFORMATION Date: __________ Time: _________ Inserted by: __________ Type of cannula: ___________ Sutures in situ: Yes/No Position of cannula: ________ Blood cultures: Yes/No. Procedure: Arterial lines must be clearly identified. Correct hand hygiene: Y/N Apron and sterile gloves: Y/N Red coloured caps should be used for Chloraprep used: Y/N arterial line port-holes thus helping Sterile field maintained: Y/N Sterile technique used to apply dressing: Y/N prevent wrong- route errors. 3. Advantages of invasive BP measurement: Invasive BP measurement allows beat-to-beat blood pressure monitoring, a visible waveform, allowing a more detailed analysis of the patient’s cardiovascular system to be made. Indirect techniques can often underestimate/overestimate pressure recordings. Cuff pressures lose accuracy in the presence of shock, arrhythmias, vasoconstrictor drugs or calcified arteries. The monitoring system consists of 4 main parts: 1. The indwelling invasive catheter/cannula. 2. The transducer which receives the signal from the tubing and converts it into electrical energy. 3. The flush system which maintains catheter patency. 4. The bedside monitor which displays the waveform. Flush system/transducer set: Inflate the pressure infusor bag to 300mmHg (for adult management). An inflation pressure of 300mmHg will allow a continuous flush of 3mls/hr to keep the arterial line patent and fit for use. Inflate the pressure infusor bag to 150mmHg (for paediatric management). An inflation pressure of 150mmHg will allow a continuous flush of 1.5mls/hr to keep the arterial line patent and fit for use. The transducer must be zeroed correctly and levelled at a known reference point: The right atrium is used as a reference point for arterial catheters. The position of the right atrium is estimated at the phlebostatic axis which intersects at the midaxillary line and the 4th intercostal space. 4. Patient position: Recordings can be reliably measured at head-of-bed positions 0 to 60 °. If patients are nursed on a lateral position, it is then difficult to determine the exact/true phlebostatic axis. For this reason, measurements are not considered as accurate in lateral positions compared to those taken with a patient lying supine. Calibrating/zeroing procedure: Locate the phelbostatic axis at intersection of midaxillary line and 4th intercostal space. Turn the 3-way tap off to the patient and remove the cap from the 3-way port. Press the zero key on the monitor. Look for a display indicating that zeroing has occurred. Replace the cap on the 3-way tap and turn the stopcock on to the patient. Observe the waveform and document the blood pressure measurements including the MAP. The transducer must be calibrated: Following insertion of an arterial cannula. At the beginning of every shift. Whenever the patient’s position is changed. When the transducer set is changed. If there is any doubt concerning the displayed recordings. Note: improper damping and calibration account for a large percentage of the errors in direct arterial blood pressure monitoring. Complications of arterial lines: Rare complications: Haematoma. Site infection/abscess/sepsis. Bleeding. Thrombosis. Disconnection: haemorrhage. Ischaemia/blanching of extremity. Air emboli. Nerve injury. 5. Observe for signs of cannula displacement: Swelling. The cannula must be exposed and continually Haematoma. observed. Bleeding. This is essential for patient safety and to Lack of a normal arterial waveform. minimise blood loss if equipment becomes Fluid leakage. disconnected. Purulent discharge. Blanching or delayed capillary refill. The patient must not be left unattended. Pain, discomfort, numbness or paraesthesia. Report any of the above to medical staff. Arterial blood gas sampling: Accurate results for an arterial blood gas (ABG) depend on the proper manner of collecting, handling, and analysing the specimen. ABG measurements are particularly vulnerable to sampling errors and can produce incorrect blood results. It should be recognised that sampling is risky, prone to contamination and should only be done by appropriately trained and competent staff. Sampling errors: Presence of air in the sample. Any air bubble in the sample must be expelled as soon as possible after withdrawing the sample and before mixing with heparin or before any cooling of the sample has been done. Inadequate removal of flush solution in arterial lines prior to blood collection. Staff should be aware of the volume of system dead-space. It is recommended that a volume 3 times the dead-space should be discarded to avoid contamination.
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