INTERDISCIPLINARY CLINICAL MANUAL Policy and Procedure

INTERDISCIPLINARY CLINICAL MANUAL Policy and Procedure TITLE: Arterial Catheter Blood Sampling/Blood NUMBER: CC 80-005 Pressure Monitoring/Catheter Removal Effective Date: October 2014 Page 1 of 11 Applies To: Holders of Interdisciplinary Clinical Manual - ICU, IMCU, OR, PACU and Emergency This is a Post-Entry Level competency for Registered Nurses that requires assessment of competency prior to performing This is an Entry Level competency for The Registered Respiratory Therapist (RRT) Arterial lines throughout Capital District Health Authority are used in ICU, IMCU, OR, PACU and Emergency. TABLE OF CONTENTS Page Policy 2 Definitions 2 Guiding Principles and Values. 2 Practice Guidelines 3 Preparing Arterial Monitoring Line... 4 Assisting With Insertion. 5 Zero Balancing And Calibration 6 Blood Sampling/Blood Gas Sampling Basic Pressure Tubing Set-up.. 6 Blood Conservation Tubing.. 8 Removal Of Arterial Catheter 9 Ongoing Maintenance And Patient Safety. 10 Related Documents 11

Monitoring/Catheter Removal (CC 80-005) Page 2 of 11 A - GENERAL POLICY 1. Arterial Catheter Blood Sampling/Blood Pressure Monitoring/Catheter Removal are post-entry level competencies for the Registered nurse and may only be performed by RNs deemed competent in the procedure. 1.1. To be deemed competent, the RN is to successfully complete the required elements of the learning module, including the self-test and demonstration of the skill according to the Proficiency Skills Checklist. 1.2. Following the initial assessment of competency, the RN is to conduct a yearly self-assessment of competency level and develop a plan to meet ongoing needs. 2. The RRT is to demonstrate ability to set-up pressure tubing for the arterial line and draw a blood gas sample from a regular arterial line set-up. 3. Only physicians, RNs with advanced practice preparation or RRTs with advanced preparation insert arterial lines. 4. Radial artery arterial lines can be removed by an RN deemed competent in the procedure. 5. Femoral arterial lines may be removed by RN s in critical care areas. In Intermediate Medical Care Units (IMCU), femoral arterial lines are to be removed by a physician or a nurse with advanced practice preparation.(nurse practitioners) DEFINITIONS (Refer to the Learning Module) GUIDING PRINCIPLES AND VALUES 1. The purpose of an arterial line is to identify changes in arterial pressure, evaluate medical therapy (i.e. titration of drugs, fluid administration) and obtain blood samples. 2. Cardiac monitors with arterial pressure monitoring capability vary from unit to unit. Refer to the manufacturer s instructions for monitor set up, zeroing and/or calibration. 3. Some units frequently utilize blood conservation arterial line tubing. 4. The least amount of blood discard is used to prevent the patient from nosocomial anemia. Discard two times the dead space volume prior to sampling. Dead space varies with the length of the line. 5. The preferred artery for arterial catheter insertion is the radial artery because it is more superficial and can be easily stabilized during insertion. The brachial or femoral arteries may also be used.

Monitoring/Catheter Removal (CC 80-005) Page 3 of 11 6. The most common complications that occur with arterial catheters are pain, vasospasm, hematoma formation, infection, hemorrhage and neurovascular compromise PRACTICE GUIDELINES 1. Adhere to the principles of aseptic technique and routine practices while performing Arterial Catheter Blood Sampling Blood Pressure Monitoring and or Catheter Removal. 2. Use normal saline unless otherwise ordered. Practice Alert: In the OR access to the radial or femoral artery catheter can be limited or impossible during surgery. This necessitates sampling at a site remote from the catheter using extension tubing. The extension tubing is 72 inches in length. In order to minimize clot formation and malfunction of the line, heparinized saline flush (1000 units of unfractionated heparin per 500 ccs of normal saline can be used in the OR or PACU at the discretion of the attending anesthesiologist. 2.1. Upon receiving a patient from the OR check the bag to see if it is heparanized saline. If so, change it to normal saline when the patient is discharged from the PACU. 3. Ensure the arterial lines are connected to a transducer and attached to a wave form monitor. 4. Obtain a written consent prior to insertion of the catheter. (Refer to CH 70-045 Consent to Treatment.) Note: In some ICU s there is a form titled ICU consent (CD0746MR)which covers various procedures that may be required as part of an ICU/OR admission to IC U 5. Do not inject or infuse any medications through an arterial line with the exception of heparinised saline flush (1000 units of unfractionated heparin per 500 ccs normal saline). (Refer to Practice Alert above). 6. Ensure that the arterial line has a pressurized, saline or heparinised saline flush line attached to it at all times; never saline lock the arterial line. 7. The inline flush device delivers approximately 3mLs per hour based on the assumption that 300mmHg pressure is applied to the flush bag at all times. 7.1. Document 5mLs as hourly intake based on the assumption that the nurse accesses the squeeze valve q1h. 8. Assess the flush system and the cannulated extremity at least every 4 hours (more frequently if warranted by patient condition) for sensation, motor function, pulse, colour, temperature and capillary refill. 9. Assess the wave forms frequently for dampening.

Monitoring/Catheter Removal (CC 80-005) Page 4 of 11 9.1. Dampened wave forms result in inaccurate readings of blood pressure. Trouble shooting of over damped and under damped wave forms is discussed in AACN Procedure Manual for Critical Care Sixth Edition p. (See Learning Module) 10. Zero the catheter at least once per shift or whenever the patient has been moved (e.g. up to the chair, transported off the unit, etc.) or when the level of the bed has changed. 11. Change the dressing and pressure tubing every 96 hours. Additionally, change the dressing whenever it becomes soiled or loose or the site needs to be inspected. 12. Check the flush bag at the beginning of each shift. for amount of fluid. 13. Inflate the pressure bag applied to the flushing solution to 300mmHg. 14. If patients have extension tubing attached to the basic arterial line either: 14.1. Discard 5mLs (standard) 14.2. Change the tubing to the standard set-up requiring the 2mL discard or 14.3. Change to the blood conservation tubing B - PREPARING ARTERIAL MONITORING LINE (Radial and Femoral) 1. Perform hand hygiene. 2. Remove pressure tubing from packaging. 3. Tighten all connections along the line. 4. Connect the tubing from the arterial line monitoring kit to the solution. Place the pressure infuser device over the IV bag and hang on the IV pole. Do not inflate. Note; Priming the tubing under pressure increases turbulence and may cause air bubbles to enter the system. 5. Prepare a label with the date, time and the RN s signature and apply to the tubing. 6. Fill the drip chamber halfway. 7. Flush the tubing including stopcock ports using the squeeze valve. 8. Change vented caps to non-vented caps using aseptic technique. 9. Inflate pressure device to 300 mmhg.

Monitoring/Catheter Removal (CC 80-005) Page 5 of 11 C - ASSISTING WITH INSERTION Equipment dressing tray Intravenous catheter of the physician s choice for radial or femoral insertion 1 - # 20 needle 1 - # 25 needle 2.0% Chlorhexidine Gluconate 70% Isopropyl Alcohol Solution or swabstiks Transparent dressing Silk suture Scalpel blade or sterile scissors Sterile gloves for physician and RN Masks for physician and assistant 1-3 ml syringe Xylocaine without epinephrine (1 or 2%) as per physician preference 1 flushed monitoring tubing 1 monitoring cable 1 transducer holder 1. Assess the patient s history for any condition that may complicate the procedure such as a coagulopathy, vascular disease or an allergy to Xylocaine. 2. Ensure the consent has been signed. 3. Explain the procedure to the patient and/or family. 4. Perform hand hygiene 5. Set up the dressing tray using sterile technique. 6. Bring the primed monitor line tubing and IV pole to the bedside. 7. Assist the physician as required. The physician performs the Allen s test. 8. After the catheter is inserted, connect the monitor line tubing to the catheter. 9. Assist the physician with suturing of the catheter. 10. Secure the catheter in place and apply a transparent occlusive dressing. 11. Level the transducer, zero the monitor and observe the wave form.(refer to Section D - Zeroing, Calibration and Waveform Analysis) 12. Dispose of supplies and perform hand hygiene. 13. Document. 14. Observe the cannulated limb for signs of bleeding, hematoma formation, pain and changes in color, size, temperature, sensation or movement.

Monitoring/Catheter Removal (CC 80-005) Page 6 of 11 D - ZERO BALANCING AND CALIBRATION 1. Connect the monitoring cable to the disposable transducer and pressure (patient) monitor. 2. Level the air-fluid interface to the phlebostatic axis (4 th intercostal space, midaxillary line). 3. Close the stopcock to the patient. 4. Remove the non-vented cap from the air port of the transducer (keeping it sterile). 5. Zero balance and/or calibrate the arterial monitoring system according to the monitor s manual. 6. Replace the non-vented cap to the transducer air port. 7. Reopen the stopcock and assess the arterial waveform pattern on the monitor. 8. Set the alarms. E - BLOOD SAMPLING/BLOOD GAS SAMPLING Basic Pressure Tubing Set-up Equipment 1 10 ml syringe requisitions labels 2 x 2 sterile gauze dressing non-sterile gloves vacutainer and needleless Luer-lok adaptor blood tubes blood gas syringe ice 1. Verify the identity of the patient against the following: 1.1. checking of the armband (two patient identifiers) 1.2. blood tube labels 1.3. requisitions Refer to CH 30-040 Patient Identification and Same Name Alert. 2. Perform hand hygiene and apply clean non-sterile gloves.

Monitoring/Catheter Removal (CC 80-005) Page 7 of 11 3. Remove the dead ender and discard; cleanse the port with an alcohol swab using a juicing action. 4. Attach the syringe to the port. 5. Suspend the alarms. 6. Close the stopcock to the transducer and open the stopcock to the patient; gently aspirate 2mLs of blood and discard the sample. 7. Connect the vacutainer and blood tubes. Collect samples in the correct order as designated order of blood draw. (Refer to CC 85-079 Venipuncture for Blood Specimen/Blood Culture Collection - Blood Collection Order of Draw). 8. If a blood gas is drawn first draw back air back into the heparin syringe to 1.7mLs. Note: This amount of blood ensures the right ratio of blood to heparin in the sample. 8.1. Attach the syringe. 8.2. Allow the blood to passively fill the syringe displacing air. 8.3. Remove blood gas syringe and cap with black rubber cap. 8.4. Roll between hands and invert several times to allow for complete mixing with heparin chip. Do not shake. 8.5. Put labeled specimen in ice. 9. Turn the stopcock off to the patient to flush the system. Flush the port clear of blood using sterile 2 x 2 gauze to absorb the solution at the access port. 10. Replace the dead ender with a new sterile one.(non vented cap) 11. Open the stopcock to the patient 12. Flush the entire line using the squeeze valve for no more than 3 second intervals until the patient line is clear of any blood residue. 13. Observe for the return of the arterial wave form. 14. Turn the alarms back on. 15. Label the specimens in the presence of the patient and send to the lab. 15.1. Some units may have access to Point of care technology that allows running of some samples on their unit. Refer to POCT policies as outlined by the lab for those units. 16. Dispose of supplies and perform hand hygiene. 17. Document in the patient s health record

Monitoring/Catheter Removal (CC 80-005) Page 8 of 11 Blood Conservation Tubing Equipment requisitions labels non-sterile gloves vacutainer and needleless Luer-lok adaptor blood tubes blood gas syringe ice clear plastic puncture device for blood conservation tubing access(one or two) 1. Verify the identity of the patient against the following: : 1.1. checking of the armband(two patient identifiers) 1.2. blood tube labels 1.3. requisitions Refer to CH 30-040 Patient Identification and Same Name Alert. 2. Perform hand hygiene and apply clean non-sterile gloves. 3. Suspend the alarms. 4. Prepare the blood gas syringe and blood tubes including the vacutainer adapter attached to vacutainer. Note: Some healthcare professionals find it easier to now attach the clear plastic sampling device to the blood gas syringe and another to the vacutainer adapter. 5. Gently aspirate 10mLs of blood into the inline syringe. (Recommended rate of 1mL per second.) 6. Turn off the syringe using the stopcock 7. Attach the clear sampling device to the cleansed sampling port (unless the gas syringe and vacutainer adapter are already attached to the sampling devices.) 8. Connect the vacutainer and blood tubes. Collect samples in the correct order as designated order of blood draw. (Refer to CC 85-079 Venipuncture for Blood Specimen/Blood Culture Collection - Blood Collection Order of Draw). 9. If attaching the sampling device to the sampling port without the vacutainer/abg syringe attached, first turn the stopcock off to the patient line. If removing the vacutainer adapter/abg syringe without removing the sampling port, first turn the stopcock off to the patient line. Note: It is recommended that a separate sampling device be used for ABG sampling and another for blood tubes.

Monitoring/Catheter Removal (CC 80-005) Page 9 of 11 10. Open the stopcock to the patient and give back the blood that was in the inline sampling syringe. (Return blood at a rate of 1mL per second.) Note: The manufacturer recommends no greater than a 2 minute interval between drawing off and giving back. 11. Flush the entire line using the squeeze valve for no more than 3 second intervals until the patient line is clear of any blood residue. 12. Observe for the return of the arterial wave form. 13. Turn the alarms back on. 14. Label the specimens in the presence of the patient and send to the lab. 14.1. Some units may have access to Point of care technology that allows running of some samples on their unit. Refer to POCT policies as outlined by the lab for those units. 15. Dispose of supplies and perform hand hygiene. 16. Document in the patient s health record F - REMOVAL OF ARTERIAL CATHETER Equipment dressing tray 2%chlorhexidine and alcohol solution sterile scissors or scalpel blade 4 x 4 gauze nonsterile gloves 1. Assess the patient s coagulation status (PTT, INR, platelets). 2. Obtain a written physician s order for removal. 3. Perform hand hygiene 4. Set up a dressing tray using aseptic technique. 5. Apply gloves. 6. Discard used dressing. 7. Cleanse the site using 2.0% Chlorhexidine Gluconate 70% Isopropyl Alcohol Solution or swabstiks 8. Remove the suture (if applicable). 9. Place a 4 x 4 dressing over the insertion site. 10. Slowly and steadily remove the catheter. 11. Apply pressure to the site for at least 5 minutes.

Monitoring/Catheter Removal (CC 80-005) Page 10 of 11 12. Assess the tip of the catheter to ensure it is intact. If the tip is to be sent for C and S, use sterile scissors. 13. Apply a band-aid or 2 x 2 dressing as required. 14. Dispose of supplies, remove gloves, and perform hand hygiene. 15. Document. 16. Observe the affected limb for signs of bleeding, hematoma formation, pain and changes in color, size temperature, sensation or movement. G - ONGOING MAINTENANCE AND PATIENT SAFETY 1. Monitor the cannulated extremity immediately after insertion and every 4 hours while the arterial line is in situ for bleeding, hematoma formation, pain, infection, and change in color, size, temperature, sensation or movement. 2. Check the flush system every 4 hours assessing for pressure bag inflation (should be 300 mmhg.) and fluid in flush bag and make sure connections are tight. 3. Monitor for dampened wave forms. 4. Zero the monitor at the start of each shift and as necessary. Check fluid level in the bag at the start of the shift. Approximately 60mL of fluid is needed every 12 hour shift. Change the dressing and tubing every 96 hours. 5. Use the minimal amount of blood discard prior to taking samples to avoid nosocomial anemia. Note: At the QEII site - 3A (ICU),CCU(6.4)and 5.2 (CVICU) discard 2mL from theh standard length arterial line tubing and 5 mls from longer arterial line tubing. 6. Adhere to the Capital Health standard of using 0.9% normal saline or heparinized saline (1000 units of unfractionated heparin per 500 ccs normal saline) as the flush solution for arterial lines. Always check the bag to see that the proper solution is hanging. 6.1. On nursing units, obtain a authorized prescriber s order for heparinised saline. 7. Ensure that the alarms are on to detect any sudden hypertensive or hypotensive episode, disconnection of the catheter or pulseless electrical activity.

Monitoring/Catheter Removal (CC 80-005) Page 11 of 11 REFERENCES (Refer to Learning Module) RELATED DOCUMENTS Policies CC 85-079 CH 30-045 CH 30-040 Venipuncture for Blood Specimen/Blood Culture Collection Consent to Treatment Patient Identification and Same Name Alert Brochures IC 85-0074 Arterial Lines (http://www.cdha.nshealth.ca/patientinformation/nshealthnet/0074.pdf) Other Learning Module - Arterial Catheter Blood Sampling/Blood Pressure Monitoring/Catheter Removal * * *