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Arterial Lines 3/8/05

1- What is an a-line?
2- What are the parts of an a-line?
3- Does it matter if the flush setup is made with saline or heparin?
4- What are a-lines used for?
5- What do I have to think about before the a-line goes in?
- What is an !llen test?
"- Where #an a-lines go besides the radial arter$?
%- Who inserts a-lines?
&- 'ow is it done?
1(- What kinds of problems #an happen during a-line pla#ement?
11- 'ow do I use an a-line to monitor blood pressure?
12- 'ow should I set the alarm limits?
13- 'ow do I draw blood samples from a-lines?
14- What order do I draw the tubes?
15- 'ow often does the transdu#er setup have to be #hanged?
1- What kind of dressing goes on an a-line site?
1"- What is the armboard for?
1%- Does the patient)s arm have to be restrained?
1&- What if m$ a-line has a good tra#ing on the s#reen* but I #an)t draw blood from it?
2(- What does +dampened, mean?
21- What if I lose the tra#e #ompletel$?
22- 'ow often should I #he#k the pulse at the a-line site?
23- 'ow do I know if the patient)s hand is at risk?
24- What do I do if the line dis#onne#ts at the hub-stop#o#k-transdu#er?
25- What do I do if the patient pulls out her a-line?
2- 'ow do I know when it)s safe to take out m$ patient)s a-line?
2"- 'ow do I remove the line?
I thought it might be interesting to get awa$ from big s#ar$ things like balloon pumps* .!-lines
and defibrillation* and to tr$ fo#using on something that we use routinel$* and tr$ to look at it in
detail/ I read on#e that pilots will sit and argue about the right wa$ to do an$thing 0 ta1iing*
turning* whatever 0 that the$ never stop tr$ing to refine their skills at both the big things and the
little ones/ 2lose attention to little things reall$ helps in the 3I24* and looking #losel$ at a tool like
an a-line might be useful in showing how details matter5as usual* please remember that this is
pre#eptor material* and not meant to be offi#ial in an$ wa$/ When $ou find mistakes* let us know
and we)ll fi1 them/ 6hanks7
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1- What is an A-line?
!-line stands for !rterial line/ 8ur teams use the same 2(-gauge straight I9 #atheters that the$
use for peripheral lines* and insert them into 0 usuall$ 0 the radial arter$ in one wrist or the other/
2- What are the parts of an a-line?
We start with a bag of heparini:ed saline; 2units of heparin per ##/ 6he bag is #onne#ted to a
standard transdu#er setup; soft tubing from the bag to the transdu#er* and stiff tubing from the
transdu#er to the patient <some of us old gu$s #all this +2obe tubing,* named after the
manufa#turer of the tubing we used ba#k in the last I#e !ge/ !n$bod$ else remember =orton
domes?> 6he stiff tubing goes from the transdu#er to a stop#o#k 0 the stop#o#k is #onne#ted to a
short length of softer tubing that we #all a +6-pie#e, <I have no idea wh$ we #all it a t-pie#e 0
doesn)t look like a ?t)/> 6he t-pie#e s#rews onto the stop#o#k at one end* and the other end plugs
into the open end of the arterial #atheter/
6he bag of flush is pumped up to 3((mm of pressure with a white pump bag 0 the transdu#er
#ontrols the forward flow of flush into the arter$* keeping it open* at a rate of <I think> 3## per hour/
If the line weren)t pressuri:ed this wa$* the arterial pressure would make the patient)s blood #limb
right ba#k up the line/
3- Does it matter if the flush setup is made with plain saline or heparinized saline?
!#tuall$ I think that it doesn)t matter in terms of keeping the vessel open 0 but it does matter if
$our patient is heparin-sensitive/ We)ve been seeing more patients turning up positive for the
heparin-indu#ed-thrombo#$topenia thing 0 latel$ when I)m making m$ own flushes for a new
patient that I know nothing about* I use saline/ If $our patient)s platelet #ount drops for no
apparent reason* $ou #an go ahead and #hange them to saline line flushes 0 apparentl$ even a
tin$ bit of heparin #an #ause this problem* whi#h seems to go awa$ after the heparin does/
- What are a-lines used for?
6wo things mainl$; blood pressure monitoring* and for patients who need fre@uent blood draws/
!n$ patient on more than a small amount of an$ vasoa#tive drip reall$ needs to have an a-line for
proper A. management 0 if the$)re si#k enough to be put in the unit and need pressors* then
the$)re si#k enough for an a-line/ =on-invasive automati# blood pressure #uffs are useful* but if a
person is labile 0 push for an a-line/
2ertain situations absolutel$ re@uire an a-line for A. monitoring; an$ use of an$ dose of nipride*
for e1ample/ 6his is a trul$ powerful drug 0 it works ver$ @ui#kl$* and $our patient #an rapidl$ get
into all sorts of trouble unless $ou)re monitoring A. #ontinuousl$/
I)ve heard latel$ that there)s a trend towards using fewer a-lines 0 it seems sill$ <and painful> to
have $our patient get stu#k what seems like twelve times in a shift for labs and !ABs/ Cemember
that it)s alwa$s been our unit)s poli#$ for nurses to send !ABs after ever$ vent #hange* or for an$
#lini#al #hange that the patient makes/
4pdate 0 this has #hanged a little; !ABs probabl$ don)t seem to be ne#essar$ for vent #hanges
that are onl$ going to affe#t o1$genation; #hanges in Di82 or .EE.* sin#e the 82 sat will keep
$ou prett$ well informed about where $our patient)s o1$genation is at/ 2hanging something that is
going to affe#t ventilation or p' is a different matter though 0 these probabl$ still merit a blood
gas/
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5- What do ! ha"e to thin# a$out $efore the a-line %oes in?
Dirst 0 unless the patient is unresponsive* or has no pro1$ at hand 0 the team should get
informed #onsent for this pro#edure/ Fou need to remember that $ou)re putting something in one
of the two vessels that suppl$ the hand with blood/ Is the patient h$potensive 0 are $ou going to
need a doppler to find the pulse in the first pla#e? Is the patient anti#oagulated? Whi#h hand does
the patient use to write with? 0 get the team to use the other one/ Is the patient ver$ agitated* and
likel$ to pull the line out 0 does she need some sedation?
8h $es 0 have a transdu#er setup read$ to hook up to the new line/ 'ouse offi#ers do not alwa$s
think of this* espe#iall$ if the$)re Gust learning the pro#edure 0 the$)re tr$ing to do it right and not
hurt the patient/ 'ook the setup to the monitor with a #able* and :ero the transdu#er so that $ou)ll
be able to see the waveform when the line goes in/
&- What is an Allen test?
6wo main arteries/ Whi#h is the
radial* and whi#h is the ulnar?
http;--www/medi#ae1press/#om-#ardiologia-#arH(2H(1H3"-#arH(2H(1H3"/htm
6he idea here is to figure out if the ulnar arter$ will suppl$ the hand with enough blood* if the
radial arter$ is blo#ked with an a-line/ 'ere)s the wa$ I was taught; ask the patient to make a fist
and hold it/ 4se $our two thumbs to #ompress both the radial and ulnar arteries of the wrist* and
have the patient open the hand/ =ow release the ulnar arter$ - the hand should @ui#kl$ be#ome
ni#e and pink/ !llen testing should be done before an$ a-line insertion* and ma$be even before
an$ blood gas sampling/
4h* do#?5I think that was; release the ulnar arter$* to see if the hand will perfuse5but see how
well that hand pinked up? <'e)s probabl$ #he#king both5>
http;--www/visualsunlimited/#om-browse-vu12-vu123/html
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'- Where (an a-lines %o $esides the radial arter)?
I)ve seen ulnar a-lines* bra#hials* a1illaries* and the o##asional one pla#ed in the dorsalis pedis 0
the foot/
6here are a#tuall$ two pulses in the foot that $ou need to know about
0 this is one of them/
http;--www/latrobe/edu/au-podiatr$-vas#ular-pulses/html
Whi#h one is this?
What would $ou do if $ou #ouldn)t find them?
http;--www/latrobe/edu/au-podiatr$-vas#ular-pulses/html
Iots of patients #ome ba#k from the #ath lab with femoral arter$ sheaths in pla#e/ Fou alwa$s
want to transdu#e an$ line that goes into an arter$ 0 what if it #ame dis#onne#ted? What #ould
happen? Wh$ would $ou want to know?
8- Who inserts a-lines?
'ouse offi#ers put these in* sometimes medi#al students under dire#t supervision/ !-lines are
tri#k$ 0 sometimes $ou ma$ have to ask the Gunior to help out an intern who)s tried a few times5
=ow and again the team is Gust not able to pla#e the line 0 the patient is ver$ h$potensive* ma$be
he)s vas#ulopathi# and Gust doesn)t perfuse too well an$whereJ or ma$be he)s ver$ +#lamped
down, 0 whi#h means that the arterial bed is ver$ tight* as in #ardiogeni# sho#k/

In tough situations* the thing to do is to have the team get in tou#h with the anesthesia resident
on #all 0 these people #an usuall$ put an a-line in a marble statue while the$)re asleep/ 6he$ are
also the folks who will use other sites than the radial arter$ 0 foot* a1illa* et#/
*- +ow is it done?
Dor the radial arter$* the most #ommon insertion* the arm is
restrained* palm up* with an armboard to hold the wrist dorsifle1ed/
! straight number 2( I9 #atheter is inserted pun#ture-wise over the
radial pulse* on something like a 3( degree angle from the skin/ If
ni#e bright red blood #omes up into the #atheter* the st$let is
removed* and the #atheter is pulled ba#k a little until the blood
reall$ starts flowing 0 this means that the tip of the #atheter is at
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the pun#ture site in the arter$/ =ow a short guide wire is fed through the #atheter* and be#ause it)s
stiff* it will slide into and along the lumen of the arter$/ 6he #atheter is slid down the wire* following
it)s path into the vessel* and the wire is removed/ !t this point the ph$si#ian will put her sterile*
gloved thumb over the end of the #atheter to stop the blood flow/ Fou want to pass the end of the
transdu#er line with the t-pie#e to the ph$si#ian* who will insert it into the #atheter hub/ En#ourage
her to pla#e it firml$ 0 it)s ver$ unpleasant if these two parts separate/ =ow take look up at the
monitor/ Bood waveform? 6he #atheter gets sutured in* and we appl$ a standard dressing/
http;--www/ispub/#om-1ml-Gournals-iGh-vol3n1-aline-fig4/Gpg
10- What #inds of pro$lems (an happen durin% a-line pla(ement?
6hink about what might happen to an$ part of the bod$ if its perfusion were disturbed; the patient
#ould develop a hematoma of one si:e or another 0 this #ould even produ#e a #ompartment
s$ndrome in the arm if not wat#hed #arefull$/ 3ake sure that $ou alwa$s keep an e$e on the sti#k
site 0 #he#k the pulse routinel$* #he#k the distal #apillar$ refill and feel the warmth of the hand
overall a #ouple of times during the shift/ !n$ time $our patient is stu#k for an arterial spe#imen 0
hold and #ompress the site for a while afterwards/ 6his reliabl$ prevents hematoma formation*
and will save $our patient a lot of grief/ <Was he anti#oagulated?>
!-lines #an sometimes be hard to pla#e/ Ine1perien#ed team members will often go through a
number of #atheters* sometimes hitting the arter$ a #ouple of times/ !rteries don)t like this ver$
mu#h* and* <Gust like the do#tors>* sometimes the$)ll go into spasm* tightening up 0 the pulse
be#omes harder to find/ En#ourage the team to tr$ the other arm if this happens* or to wait a
while to see if the spasm goes awa$/
!nother problem that +goes with the territor$, when a-lines are going into h$potensive patients is
the fa#t that the$ are* uh5h$potensive/ It)s going to be hard to find the pulse/ 6r$ turning up the
patients) pressor drip 0 often ver$ helpful/
11- +ow do ! use an a-line to monitor $lood pressure?
! transdu#er is a devi#e that reads the flu#tuations in pressure 0 it doesn)t matter if it)s arterial* or
#entral venous* or .! 0 the transdu#er reads the #hanging pressure* and #hanges it into an
ele#tri#al signal that goes up and down as the pressure does/ 6he transdu#er #onne#ts to the
bedside monitor with a #able* and the wave shows up on the s#reen* going from left to right* the
wa$ EKB tra#es do/
! #ouple of things to remember;
- 6he transdu#er has to sit in a +transdu#er holder, 0 this is the white plasti# thing that s#rews
onto the rolling pole that holds the whole setup/
- 6he transdu#er has to be levelled #orre#tl$/ 4se the spirit level in the room to make sure that
it)s at the fourth inter#ostal spa#e* at the mid-a1illar$ line/
- 3ake sure there)s no air in the line before $ou hook it up to the patient 0 use the flusher to
#lear bubbles out of the tubing/
- Lero the line properl$* and #hoose a s#reen s#ale that lets $ou see the waveform #learl$/
6his #an be reall$ important in situations like balloon pumping/
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Iet)s take a se#ond to look at a <hopefull$> t$pi#al arterial waveform;
http;--www/datas#ope/#om-#a-images-millarHwaveform3/Gpg
6he highest point is the s$stoli# pressure* the lowest is the diastoli#/ Ever$bod$ see the little
not#h on the diastoli# downslope? 0 there)s one in ea#h beat/ ! little after the beginning of
diastole 0 the start of the downward wave 0 the aorti# valve flips #losed* generating a little ba#k-
pressure bump; #alled the +di#roti# not#h,/ Fou)ll need to remember that when the time #omes for
balloon pumping/
12- +ow should ! set the alarm limits?
Met them meaningfull$/ 3ake sure that the limits will tell $ou if $our patient gets into trouble/ I
alwa$s re#he#k all the alarm limits at the beginning of m$ shift/ Dor e1ample; the heart rate limits
that are built into the monitor default at 5( and 15( 0 do $ou reall$ want $our patient)s heart rate
to go to 15( before the monitor will tell $ou?
13- +ow do ! draw $lood samples from a-lines?
Menior staff nurse Nane sa$s; +It takes a $ear Gust to learn whi#h wa$ to turn the stop#o#ks7, 6his
is reall$ true; some stop#o#ks point to where the$)re open* and some point to where the$)re
#losed 0 it Gust takes some time to learn whi#h is whi#h/ Drawing samples isn)t hard 0 we use a
va#utainer* draw a red dis#ard tube of 5##* and then plug the spe#imen tubes into the va#utainer
the same wa$ $ou would if $ou were doing a peripheral vein sti#k/ 6he tri#k is remembering whi#h
wa$ to turn the stop#o#k* and avoiding a mess/ Don)t forget to #lear the stop#o#k* re#ap* and then
flush the line/ Keep things ni#e and sterile/
1- What order do ! draw the tu$es?
6he tri#k here is remembering not to #ontaminate one tube with what might be left from the one
before/ 6he main one to wat#h for is the blue .6-.66 tube 0 if it gets #ontaminated b$ heparin
from the line or the previous tube* $ou)ll get results that have nothing to do with the patient/ Draw
the blue-top spe#imen right after the red dis#ard tube/
15- +ow often does the transdu(er setup ha"e to $e (han%ed?
6he routine now is & hours 0 make sure that $ou label the line setup when $ou hang it/
8bviousl$* #hange the line setup if it is #ontaminated in an$ wa$/
1&- What #ind of dressin% %oes on an a-line site?
8ur routine is; s#rub the site with a sterile 414 soaked in betadine* then paint about an in#h awa$
from the site 0 all around it 0 with ben:oin/ 2ut a sterile pie#e of 414 to go on the site* and #over
with a small #lear tegaderm dressing/ 6r$ to resist the temptation to reinfor#e the site dressing
with tape 0 this #an make it reall$ hard to get the dressing off without almost losing the line/
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1'- What is the arm$oard for?
6he armboard and roll holds the wrist in a <gentl$>
dorsifle1ed position* whi#h keeps the #atheter from
kinking if the patient bends his wrist/
http;--www/dalemed/#om-images-armboard/Gpg
18- Does the patient,s arm ha"e to $e restrained?
It ought to be* if there is an$ #han#e that she might lose the line b$ moving around/ If the patient
is ver$ sedate or #hemi#all$ paral$:ed* $ou)d probabl$ be safe without a restraint/ Ae #areful
Gudging this; patients #an lose blood rapidl$ from a dis#onne#ted a-line hub/
1*- What if the a-line has a %ood tra(in% on the s(reen- $ut ! (an,t draw $lood from it?
6his probabl$ means that the arter$ being monitored has +#lamped down,* or gone into spasm/
Fou need to think about things that might make this happen; is the patient ver$ #old? !re his
e1tremities poorl$ perfused? Is he on a +shipload, of pressors* making his arterial bed tighten up
0 is he +dr$, as well? Mometimes arteries be#ome unhapp$ with #atheters in them* and $ou Gust
have to #onvin#e the team that the patient needs a new one pla#ed in another site/
20- What does .dampened/ mean?
6o me* dampening is what happens when the #atheter #an)t see the patient)s blood flow #learl$ 0
he)s bent his wrist* kinked the #atheter 0 sometimes the top of the #atheter pushes up against the
vessel wall/ 6he waveform flattens out on the s#reen 0 doesn)t look mu#h like an a-line tra#e an$
more/ 6he tri#k is to learn the differen#e between a dampened waveform and a h$potensive one7
If straightening out the patient)s wrist doesn)t help* sometimes $ou #an take the dressing down
and ba#k the #atheter out Gust a bit 0 this often works well/ <I think there)s a more te#hni#al
definiton of dampening 0 does an$bod$ know? What)s +ringing,?>
21- What if ! lose the tra(e (ompletel)?
6his #ould be a #ouple of things* and $ou need to do a little troubleshooting/ 6he first thing to
think about is; is the arterial #atheter still in pla#e? Fes? 6r$ drawing with a 3## s$ringe from the
stop#o#k 0 if it draws normall$* then $ou)ve got a hardware problem/ 2ables #ome loose? 8n#e in
a great while a transdu#er setup will fail 0 tr$ a new setup/ Did the s#reen s#ale get a##identall$
set to* sa$* 4(* instead of 15( or 2((mm of pressure?- $ou)ll onl$ see a flat line/
If the line doesn)t draw 0 is there a #lot in the hub? 6r$ taking the site dressing down 0 is the
#atheter kinked going into the patient? Mometimes art-lines Gust fail 0 the arter$ spasms and won)t
open up 0 time for a new site/
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22- +ow often should ! (he(# the pulse at the a-line site?
Mtri#tl$ speaking* ever$ hour/ In pra#ti#e* if $our patient has tolerated having the line in pla#e for
some time* this #an be loosened up a little* but tr$ to remember that a-lines are a lot more
invasive than I9)s/ ! vas#ulopathi# patient whose e1tremities ma$ be poorl$ perfused is alwa$s at
risk* even if his arteries don)t have #atheters in them/
23- +ow do ! #now if the patient,s hand is at ris#?
4suall$ this will be prett$ obvious; the pulse will diminish* or go awa$ altogether/ 6he hand ma$
look dusk$* or be #old* or lose some sensation 0 remember to assess for #oloring* sensation*
motion* and #apillar$ refill/ If $ou think that the a-line is threatening the patient)s hand* let the
team know right awa$* and be read$ to set up for another insertion somewhere else if the line is
still ne#essar$/
2- What do ! do if the line dis(onne(ts at the hu$/stop(o(#/transdu(er?
6his is what alarms are for 0 the monitor should flash +line dis#onne#t,/ Fou reall$ want to get
down to the room right awa$ 0 the patient is definitel$ at risk for losing some blood in this
situation/
If the #atheter hub has #ome apart from the t-pie#e* the thing to do is to s#rew a s$ringe onto it*
keeping it sealed and #lean while $ou atta#h a #lean t-pie#e <the$)re in sterile pa#kages> to the
stop#o#k/ Bet someone to hold the arter$ pro1imal to the #atheter <north along the wrist* above
the insertion site> while $ou remove the s$ringe and repla#e it with the new t-pie#e end/ <Dlush the
line #lear first7>
If the t-pie#e #omes loose from the stop#o#k* tr$ to see if the parts are still sterile 0 usuall$ in this
situation the$ haven)t been tightened enough/ Nust s#rew the parts together to make a tight seal
and flush the line/
If the stiff transdu#er tubing #omes loose at the transdu#er itself* blood will ba#k up @ui#kl$ along
the line/ If the loose end is hanging* turn the site stop#o#k off to the patient to stop the blood flow*
and put together a new transdu#er setup right awa$/ !lwa$s make sure that $our setups are
s#rewed together tightl$7
25- What do ! do if the patient pulls out her a-line?
2ompress the site with a sterile 414 for several minutes* longer if the patient is anti#oagulated/
!ssess the perfusion of the hand/ 6r$ to see if the patient has ripped out her sutures or not5
make sure $ou put the patient on the non-invasive #uff at meaningful intervals while $ou talk to
the team about repla#ing the line/
2&- +ow do ! #now when it,s safe to ta#e out m) patient,s a-line?
6his is usuall$ prett$ obvious 0 the patient is hemod$nami#all$ stable* needs onl$ one or two
blood draws in a da$* no more need for !ABs 0 $ou know all that stuff/
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2&- +ow do ! remo"e the line?
Fou)ll want to dis#onne#t the #able from the monitor before $ou do this* whi#h will automati#all$
turn off the alarms/ What I do is #lamp the t-pie#e* whi#h has a little line #lamp on it like the ones
on the lumens of a triple-port #vp line 0 that leaves a minimum of hardware #onne#ted to the
patient while $ou work on removing the #atheter/ 6ake out the sutures in the usual wa$ with a
fresh sterile kit/ 'ave a 414 read$* pull the #atheter* and manuall$ #ompress the site for at least 3
to 5 minutes/ 3ake sure the patient)s hand is still perfused/ 2he#k for hematoma or bleeding* put
a #ompression dressing on the site <not too tight7>* whi#h $ou #an then take off after about an
hour/ Ce#he#k the site hourl$ for a few hours afterwards 0 a hematoma #ould still form* and sin#e
there isn)t a whole lot of room in a wrist* $ou)d definitel$ want to know7
0uiz 0uestions
6rue or Dalse;
1- !n$ patient* on an$ dose of an$ pressor* should have an arterial line/
2- !n$ patient on an$ dose of nipride should have an arterial line/
3- !llen tests are for sissies/
4- It)s perfe#tl$ safe for a patient to have an arterial line/
5- !rterial line site dressings don)t have to be sterile/
- !-line blood pressures are more a##urate than #uff blood pressures/
"- Cadial a-line pressures are more a##urate than ulnar ones/ .edal ones/ Demoral ones/
%- Cestraining an a-lined arm is for sissies/
&- 6he author of these @uestions is prett$ darned flip7
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