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Arterial Lines

Peter Branfield

Aims & Objectives


Introduction to invasive BP monitoring Understanding of what is required Introduction to waveform analysis Understanding of potential complications Understanding of the care & safety issues of Arterial lines

Arterial Blood Pressure (BP)


Pressure exerted on arterial wall Determined by flow & resistance BP=SV X HR X SVR MAP more accurately indicates perfusion MAP = (SBP DBP)/3 + DBP

Automated Non-invasive BP
Most common method
Oscillometry Measures blood flow induced oscillation

Cuff with dual pneumatic & sensing channels Controlled stepped deflation Blood flow causes vibrations
Sensed as pressure changes & analysed

Automated Non-invasive BP
Can be uncomfortable Pressure risk Occlusion of infusions Important to get the size right Least useful when most needed Greater frequency & accuracy needed in ICU

Invasive Blood Pressure -Why?


Continuous measurement of BP
Cardiovascular instability Inotropes or vasodilators NIBP difficult or inaccurate

Multiple arterial blood samples (Lough 1987) Greater accuracy -the gold standard Visual display

What
Cannula
Flow stop (20g) Arrow PiCCO

Non-compliant manometer tubing Transducer Pressurised flush bag

Pressure Transducers
Turns a pressure signal into an electrical signal
Piezoresistive stain gauge

Single transducer costs 10:50 Safe draw 13:68

Pressure Transducers
Requires correct setting up
Continuous fluid pathway No air bubbles Non-compliant manometer tubing Zeroed to atmospheric pressure Level with the phlebostatic axis No additional tubing

Zeroing
To ensure accuracy of readings Off to patient but open to atmosphere and flush device These exert pressure on transducer This pressure is called zero Zero once per shift or if values are questionable Tip- ensure flush bag is pumped up

Phlebostatic Axis
Fourth intercostal space, midaxillar Level with right atrium Not accurate when on side Level with stopcock above transducer

HOB can be up to 60 degrees without effect

Sites for Arterial Lines


Large limb artery
Radial Brachial Axillary Doralis Pedis Femoral

Usually the radial artery

Normal Waveform
Critically damped (correctly)
Return to waveform immediately after flushing

Over-Damped Waveform
Overdamped
blunted response indistinct waveform
Air bubbles Position/kinking

Under estimate SBP, over estimate DBP

Under-Damped Waveform
Underdamped
exaggerated response - spiking Over estimate SBP, under estimate DBP

Waveform Analysis (1)


Notches
Dicrotic notch
Closing of the aortic valve Further along in hypovolaemia

Anacrotic notch
Severe aortic stenosis

Waveform Analysis (2)


Short systolic time
Hypovolaemia or high SVR

Slow systolic upstroke


Poor myocardial contractility high SVR

Waveform Analysis (3)


Marked respiratory swing
Hypovolaemia Pericardial effusion Airway obstruction

Waveforms at Different Sites


Increasing steepness & height of upstroke Changing location of the dicrotic notch

Complications
Cannulation can be difficult Potential complications include
Infection Occlusion Disconnection Air emboli User error

Complications (AIMS-ICU)
251 reports of 376 incidents (7525 total)
15% insertion problems 66% line use/maintenance problems 19% patient injuries

Most frequent
Inadequate line securing Accidental dislodgement Incorrect set up Distal ischaemia Infection Lack of knowledge Rule based errors Busy Lack of support /supervision

49% patients suffered no harm


28% minor harm 15% major harm

Contributing factors

Durie, Beckmann Gillies 2002

NPSA- RRR, 28th July 2008


82 incidents of wrong fluid
2 deaths

76 incidents related to poor sampling technique/practice


1 resulting in serious harm

Death by Arterial Line


85 yr, 3/52 ICU for MOF Suddenly unconscious @ 13.00hrs
? Stroke

CT 17.45 normal Laboratory Blood glucose 19.00 =0.1mmol/L Neuroglycopenic brain damage remained comatose Glucose put up as flush solutioncontaminated samples

Nursing Care
What do you think are the Key issues for the nursing care of a patient with an arterial catheter? 5 minutes to discuss

Nursing Care (1)


Nursing care mainly directed to preventing complications Ensure that the insertion site is visible at all times
This may not be possible with femoral-sited arterial lines To ensure early detection of disconnection or leaking from site. To maintain patients dignity

Nursing Care (2)


All connections must be secured with luer locks
To prevent accidental disconnection

Ensure that the cannula site is covered with an appropriate dressing


To maintain asepsis

Place a label reading Arterial line next to the sampling three-way tap
To ensure correct identification of the arterial line

Nursing Care (3)


Never inject anything into an arterial cannula or arterial line
Concentration of a drug into the tissues served by the cannulated artery can result in cell death skin necrosis, severe gangrene, limb ischemia, amputation & permanent disabilities

Accidental Arterial Injection


Immediate discomfort (seconds)
Local irritation to intense pain

Cutaneous manisfestations
Flushing, mottling

Sensory problems (minutes)


Tinkling, burning

Altered motor function


Muscle contractures, weakness

Accidental Arterial Injection


Week later
Pluselessness Pain Cyanosis or pallor Paraesthesia paralysis

Permanent functional deficits


Chronic pain Depression Inactive lifestyle

Nursing Care (4)


Ensure that the flush bag has adequate fluid. Use only 0.9% sodium chloride Ensure that the pressure in the pressure bag is maintained at 300mmHg Do not allow the flush bag to empty
To maintain patency of arterial cannula. To prevent air embolism To maintain accuracy of blood pressure reading To maintain accuracy of fluid balance chart To prevent backflow of blood

Nursing Care (5)


Use only the manometer tubing supplied with the transducer set
Tubing is rigid and non compliant & correct length

Observe for & remove air bubbles


To ensure accuracy in measuring blood pressure. Air unlike fluid is compressible as a result the pressure waveform will be dampened

For children under ten years of age use a syringe driver instead of the flush bag
To prevent fluid overload

Nursing Care (6)


Monitor colour & temperature of limb distal to arterial line & compare to other limb
To confirm that circulation to the limb is adequate. To ensure the early detection of impaired circulation

Nursing Care (7)


Monitor and display the arterial waveform at all times
To detect cannula disconnection.

Rezero transducer once per shift


To ensure accuracy in measuring blood pressure

Explanation to patient and relatives

Nursing Care (8)


Maintain the transducer level with the patients phlebostatic axis (fourth intercostal space midaxillary line)
To ensure accuracy in measuring blood pressure.

In patients with ICP monitoring it is appropriate to level the transducer to the tagus of the ear
In order to correctly calculate cerebral perfusion pressure (CPP).

Nursing Care (9)


On removal of arterial cannula maintain pressure over puncture site for at least 5 minutes until bleeding has stopped
To prevent bleeding and haematoma formation

Send cannula tip to microbiology


Only if suspected infection To detect infection

Nursing Care (10)


Change the transducer set only when the cannula is resited
To reduce the risk of infection

References
Ahrens, T (1994). Ask the Experts. Critical Care Nurse,14 (6), 98-99. Anderson, L.E. (Ed.). (1998). Mosbys medical, nursing, and allied health dictionary. (5th Ed.). St. Louis: Mosby. Campbell, B (1997). Arterial waveforms: Monitoring changes in configuration. Heart and Lung, 26 (3), 205-215. Chulay, M (1995). Ask the experts. Critical Care Nurse, 15 (2), 108. Chulay, M., & Holland, S (1996). Ask the experts. Critical Care Nurse, 16 (6), 103-107. Chulay, M., & Holland, S (1997). Ask the experts. Critical Care Nurse, 17 (3), 14-16. Gamby, A., & Bennett, J (1995). A feasibility study of the use of non-heparinised 0.9% sodium chloride for transduced arterial and venous lines. Intensive and Critical Care Nursing, 11 (3), 148 150. 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. Darovic, G., & Vanriper, S. (1995). Fluid filled monitoring systems. In Darovic, G., (Ed.), Hemodynamic monitoring: Invasice and noninvasive clinical application. (pp.149-175). Philadelphia: J.B.Lippincott Company. Gavenstein, G., Paulus, J., & Paulus, D. (1987). Clinical monitoring practice. (2nd ed.). Philadelphia: J.B.Lippincott Compnay. Hudak, C. (1998). Assessment: Cardiovascular system. In Hudak, C., Gallo, B., & Benz, J. (Eds.), Critical Care Nursing: A holistic approach. (5th ed.). (pp.124-135). Philadelphia: J.B. Lippincott Company. Lough, M. (1987). Introduction to hemodynamic monitoring. The Nursing Clinics of North America. 22 (1), 89103. National Patient safety Agency Rapid Response Report Npsa/2008/Rrr06 Problems with infusions and sampling from arterial lines 28 July 2008. Sen S, Chini E N,. Brown M J (2005). Complications After Unintentional Intra-arterial Injection of Drugs: Risks, Outcomes, and Management Strategies Mayo Clinic Proceedings.;80:783-795