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Tuality Healthcare

Radial Artery Catheterization For Respiratory Therapists

Learning Module

(Entry Level Competency)

Developed By: Sasheen Pack, BSRC, RRT Date: May 2012

Radial Arterial Catheterization Learning Module

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Table of Contents Purpose……………………………………………………………………………………………………………………………………….

Certification Procedure……………………………………………………………………………………………………………….Page 2

Continuing Competency………………………………………………………………………………………………………………Page 3

Learning Objectives……………………………………………………………………………………………………………………..Page 3

Special Considerations…………………………………………………………………………………………………………………Page 7

Materials……………………………………………………………………………………………………………………………………..Page 8

Procedure…………………………………………………………………………………………………………………………………….Page 8

References…………………………………………………………………………………………………………………………………..Page 11

Test………………………………………………………………………………………………………………………………………………Page 12

Test Answers………………………………………………………………………………………………………………………………..Page 14

Competency Checklist………………………………………………………………………………………………………………….Page 15


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Purpose

To ensure a proper, consistent procedure, is performed for insertion of a percutaneous arterial catheter, by a Registered Respiratory Therapist (RRT) upon the order of the attending physician. Perquisites for the Program Must be a Registered Respiratory Therapist Certification Procedure: Arterial catheterization certification is under the direct sponsorship of Critical Care.

1. RRTs are eligible for the certification program 2. The RRTs will have a copy of Policy and Procedure which will include the Educational

Plan.

The topics covered will include, but are not limited to:

1. Purpose of the program. 2. Components of Arterial Line Setup. 3. Prerequisites of the program. 4. Site Selection. 5. Utilization of Hand held doppler 6. Procedure for Completing the Educational Program. 7. Recognition of Clinical Complications. 8. Knowledge Objectives. 9. Policy and Procedure. 10. Skill Objectives. 11. Indications for Arterial Line Insertion. 12. The RRT must perform 5 successful catheterizations under the direct supervision of a

physician with experience in arterial cannulation/ or certified RRT. 13. After completion of the training program, the Medical Director of Respiratory

Therapy has to sign off and approve the completion of this competence.


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Continuing Competency:

Competency can be maintained with the documentation of three successful arterial line insertions a year. If this cannot be achieved, then successful insertions of two arterial lines under the direct supervision of a qualified physician/ certified RRT can be done to maintain certification. Documentation of each insertion (including date, time and location) is to be done on the Respiratory Therapy Arterial Catheterization Certification Log.

Learning Objectives:

There is a patient/family information guide on Arterial Lines that should be given to the patient/families.

1. Knowledge Objectives:

On completion of the Learning Module the RRT will be able to:

1. Describe the purpose of an arterial line and pressure monitoring. 2. Perform Allen’s Test. 3. Usage of a Hand Held Doppler to assist with arterial line insertion. 4. Identify the components of the arterial line setup, and understand their purpose and

principal of operation. 5. Describe the correlation between cuff pressure and arterial line pressures. 6. Describe the clinical evaluation of radial artery site and indications for alternate site

selection. 7. Identify the potential clinical complications that may occur as a result of insertion of an

arterial catheter. 8. Identify the signs and symptoms of clinical complications. 9. Know the appropriate steps to take when there is clinical evidence of complications.

2. Skill objectives Upon completion of the Learning Module and demonstration of clinical competence for certification, the RRT will successfully insert arterial catheters according to Tuality Healthcare Policy and Procedure. The RRT is responsible for: 1. Confirming that there is a written physicians order. 2. Confirmation of lack of allergies to local anesthetics and the used antiseptic. 3. Preparation and Cleansing of site. 4. Sterile technique throughout insertions procedure. 5. Hand Held Doppler utilization and technique


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6. Placement of a # 20 gauge Arrow arterial catheter in the radial artery. 7. Confirmation of proper placement:

7.1. Pulsating blood flow 7.2. Flushing with no indication of tissue edema. 7.3. Proper wave form tracing. 7.4. Ease of arterial blood sampling.

Procedure for Completing the Education Program

1. The RRT will review the Policy Radial Arterial Catheterization and Learning Module which includes: 1.1 The rationale for arterial catheterization. 1.2 Technique for insertion. 1.3 Potential hazards and complications, including clinical recognition of such.

2. The RRT will become certified in the actual skill of arterial catheter insertion. Clinical competency will be attained by: 2.1 Observation of a physician/certified RRT performing percutaneous arterial

catheter insertion. 2.2 Performance of 5 insertions under the direct supervision of a physician /

certified RRT experienced in arterial cannulation. 2.3 Approval of completion of training by Medical Director.

Theory

1. Indications for Arterial Line Insertion: a. When continuous monitoring of arterial blood pressure is desired. b. When easy access for multiple blood sampling is required (>3 ABG sticks in a 12

hour shift).

Blood pressure measurements by cuff can differ significantly from the measurement of an arterial catheter. These differences can be aggravated in situations where the patient is hemodynamically unstable or if the patient has extreme body habitus. However, an accurately calibrated transducer with an appropriate arterial line setup (to minimize over/under damping – “flush-test”) will provide an accurate blood pressure. As an advantage, the arterial line pressure measurement allows simultaneous evaluation of the effects of drugs/arrhythmia’s on perfusion. The respiratory cycle effect (e.g. pulsus paradoxus) can also be directly observed. For these reasons critically ill or hemodymanically unstable patients (MAP ≤65 mmHg), especially those requiring inotropes or vasoactive drugs, should have an arterial line in place, with pressure monitoring.


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2. Components of Arterial Line Setup:

Most arterial catheters for adults are 20 Fr. Gauge. Larger bore catheters are not recommended, especially for smaller arteries, such as the radial artery. A catheter that is too large may occlude the artery, causing inadequate blood flow to the extremity. In the adult patient catheters smaller than 20Fr. Gauge may cause damping of the waveform and inaccurate pressure measurements. Therefore, a sterile, non-tapered #20 gauge, 5cm needle and catheter should be used.

Mechanical pressure from the artery is conducted through the fluid column in the arterial catheter and the tubing system on the transducer, and then is converted to an electrical signal, which is displayed on the monitor.

Over damping – The signal must not be dampened (false low readings). This is usually caused by air bubbles or a kink or clot in the system.

Underdamping – At the same time there must be some damping of the signal, so as not to have systolic overshoot

3. Calibration of the Transducer

The transducer should be calibrated before the line is attached to the patient and whenever there are doubtful readings. Calibration negates the pressure exerted by the atmosphere. Calibration is done to zero.

To calibrate the transducer:

1. Silence the monitor. 2. Turn the stopcock off to the patient. 3. Remove the dead ender from the sampling port, exposing the transducer to atmospheric

pressure. 4. Press the “zero” button. Watch the wave from zero. 5. Turn the stopcock off to the sampling port, the arterial waveform should reappear. 6. Replace the dead ender back onto the sampling port. 7. Ensure alarms are reset.

4. Site Selection: Ideally collateral circulation should be present. The site should be comfortable for the patient to allow mobility, and be easily accessible. It should be easy for the caregiver to visualize, keep clean, and care for. The ideal site for arterial catheterization by a RRT is the radial artery. In clinical situations whereby the radial pulse is not palpable, or there is evidence of inadequate collateral circulation, a physician must be contacted. An order for an alternative site must be obtained. Documentation of the conversation must be completed in the progress notes.


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When selecting the site for insertion of the arterial catheter. The RRT will follow this protocol: Perform a modified “Allen’s Test”: a. If positive for the presence of collateral circulation – proceed with insertion.

b. If negative for the presence of collateral circulation – perform Allen’s Test on the

other arm.

c. If both are negative notify physician. If the physician feels the need for attempting

arterial cannulation of the radial artery is warranted, proceed with attempt. An order

must be obtained and documentation of the conversation is to be completed on the

progress notes.

RRT’s must have physician approval to insert arterial lines in the brachial or dorsalis-pedis artery. Femoral artery insertion will be done by a physician only.

5. Recognition of Clinical Complications:

Clinically relevant complications are rare, but include: Artery Occlusion/thrombosis: Smaller arteries are at greater risk, especially if the cannula is too large. In the adult patient, as long as the catheter is no larger than a 20 Fr. Gauge, the artery should not be occluded. However, transient occlusion of the artery by catheter position or arteriospasm, is common. The other reason for occlusion is thrombosis. The catheter is made of Teflon (anticlotting). The extremity distal to the end of the catheter must be frequently inspected for blanching and other signs of decreased perfusion. Often, if the radial artery is cannulated and the hand is blanched, then removal of the catheter will restore blood flow. Investigate unexplained pain or other signs of inadequate blood flow, such as loss of warmth and sensation, at any site of insertion. Do NOT attempt to flush an arterial line that may be clotted. Notify a physician should any of these signs present themselves.

Air Emboli: The most crucial step that must be taken to prevent air emboli is to ensure that the tubing of the arterial line is primed before it is connected to the arterial catheter and flushed. When the arterial line is flushed it sends a fluid stream directly through the catheter. If the line is not properly primed, air in the tubing will be flushed retrograde to the arterial blood flow and can reach the cerebral arterial system, causing major complications. There have been documented cases of seizures and blindness caused by introduction or air into the cerebral arteries by flushing


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an unprimed arterial line. Avoiding prolonged arterial flushes (greater than 3 seconds) also reduces the risk. Ensuring all connections are tight will also decrease the risk of air emboli.

Infection: Infection is the most common complication. The infection can be locally at the site of insertion or present as a bacteraemia. Careful cleaning of the site with Chlorhexidene 2% solution solution prior to insertion will help eliminate normal skin flora that may cause infection. Insertion of the Arterial catheter must be performed under sterile conditions with sterile technique. The site should be inspected regularly for redness and other signs of infection. Changing the dressing occurs PRN and as per policy. Changing the setup occurs q96 hours as per policy. In conclusion, once the physician has ordered arterial line insertion, the RRT may proceed to insert the arterial catheter, according to the policy and procedure. Any difficulties or clinical complications that develop as a result must be reported to the physician immediately. All arterial catheter attempts, successful or unsuccessful, must be recorded on the Department of Respiratory Therapy, “Arterial Catheterization Sheet”, filed in the Department of Respiratory Therapy. Special Considerations/Contraindications: Contraindications are not always absolute. There are however, problems associated with blood vessel disease and blood coagulation that should be considered before attempting radial arterial catheterization. Certain clinical parameters should be evaluated. Consultation with the ordering physician is warranted in the following conditions:

1. Circulatory problems. 2. PTT greater than 50 sec., and INR of greater than1.5

Normal PT 9 to 12 seconds Normal PTT 26 to 37 seconds Normal INR 0.9 to 1.1 Note: It is the Physicians discretion to allow insertion beyond these parameters. 3. Patient receiving Warfarin/Coumadin; Note: Coumadin creates its anticoagulant effect by blocking production of the clotting factors, thus time is required for existing circulating factors to be metabolized, and therefore, a radial arterial catheterization may be safely performed within 24-48 hours after the initial dose. When available always refer to P.T./P.T.T.’s. 4. Patient receiving IV Heparin. 5. Patient receiving thrombolytic therapy; i.e. Activase rt-pa, should be considered as potential bleeding risks and should be discussed with the ordering physician. 6. Patients who do not have collateral circulation through the ulnar artery, verified by Modified Allen’s Test (radial arterial catheterization only).


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7.Patients with platelet counts 20,000mm² . 8. Are less than sixteen years of age. 9. A maximum 2 attempts per wrist will be made to place an arterial catheter. If unsuccessful, after two attempts per wrist, the RRT will consult with the physician to request their attempt for the catheter. Materials Required:

• Arterial line – flushed and calibrated (as per Nursing Policy and Procedure). • Basic or blood conservation set • Absorbent “Blue Pad”. • Towel. • Mask. • Sterile gloves • Sterile Gown • Bouffant cap • Centurion Arterial Line Tray • Arrow 20Ga Catheterization kit • Sterile Ultrasound Gel

PROCEDURE: Important Points: 1. Routine precautions require protection from blood and body fluids. Consider wearing glasses/goggles. 2. Hypotensive patients may require fluid resuscitation/inotropic/vasopressor support in order to adequately palpate and cannulate the artery.

ACTION RATIONALE Verify the physicians order, identify the patient, check for drug allergies (i.e., lidocaine) and blood work (INR, platlets, thrombolytics, warfarin)

Palpate the radial artery. Perform “Allen’s Test”

To check for the presence of collateral circulation. If Allen’s Test is negative for collateral circulation, try the other arm. If both are negative then notify the physician before proceeding.

Position the patient’s wrist by placing a rolled towel underneath. Place blue pad under the patient’s wrist.

To position the radial artery for cannulation. Do not hyperabduct the thumb, as this may obliterate the pulse. The blue pad is to protect the bed linen from soiling.

Wash hands. Routine precautions.


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Put on mask, gown, cap, and sterile gloves.

Routine precautions.

Place the 25 gauge needle onto 1ml syringe. Withdraw 0.5mL of lidocaine from single use vial.

The 25 gauge needle is only used for withdrawing and injecting the lidocaine subcutaneously.

Using chlorhexidine, cleanse the insertion site thoroughly in an top to bottom pattern for 30 seconds. Allow the solution to dry for approximately 30 to 60 seconds.

This cleanses the skin of normal flora and helps prevent infection.

Apply a sterile cover drape top the selected site.

Routine infection prevention.

Prime the #25 gauge needle with the lidocaine and infiltrate the subcutaneous tissue on both sides of the artery around the proposed site of entry, with approximately 0.5cc’s of lidocaine. (OPTIONAL)

Local freezing will allow the catheter to be inserted painlessly. The lidocaine also decreases the risk of arterial vasospasm. If the pulse is obscured following the lidocaine infiltration, massaging the area will help to restore it.

With an assistants help place Hand Held Doppler in a sterile glove. Apply coupling gel to the selected site. Slowly sweep the probe across the area to locate the artery. Determine the location of the artery when the sound generated by the Doppler is at its loudest; pulsatile multi-phatic sounds. A mark with a sterile pen can be placed. Artery should be felt where the Doppler sound was at its loudest. With your non-dominant hand hold hand held Doppler at the desired selection site. With dominant hand ensure the bevel of the needle/canal is facing up. With the needle/cannula directed against the arterial flow, puncture the skin at approximately a 30 – 60 degree angle.

Hand Held Doppler will be used to help identify the artery with pulsatile multi-phastic sounds. The correct angle of entry will facilitate insertion of the cannula.

Slowly advance the needle and canal until blood return is noted in the hub.

The tip of the needle is now intra-arterial.

Advance the needle a small distance further. This is necessary to advance the cannula into


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the artery as well. (The needle is slightly longer than the cannula.)

Bring the needle/cannula closer to the skin (about 20 degrees). Advance the guide wire into the artery – there should be no resistance when the wire leaves the needle (black mark) – if there is reposition needle and try again – do not withdrawn the guide wire back into needle once it has been advanced.

To facilitate advancement of the cannula into the artery. To facilitate easier cannula placement and prevent perforation of vessel. To avoid sheering of the guide wire.

Firmly hold the needle in place with one hand, while with the other hand, advance the catheters into the artery using a gentle rotating motion. Advance the catheter all the way up to the hub.

Do not force the catheter if there is a lot of resistance.

Remove the needle while holding the catheter in place. Observe pulsatile blood flow from the cannula.

Pulsatile blood flow from the catheter confirms that the cannula is still in the artery.

Have the assistant continuously flush the arterial line tubing as you connect it to the cannula and carefully secure it tightly. Flush the catheter to ensure patency and observe/assess the arterial waveform on the monitor.

This ensures no air bubbles are introduced into the artery. If waveform is damped or abnormal, gently reposition the catheter.

Secure catheter in place and apply clear transparent dressing.

This ensures that the catheter is held firmly in place, and helps to keep the site clean and free of infection.

Clean up the tray, carefully disposing of all sharps, needles etc. Discard all items appropriately.

Routine precautions.

Record the procedure in the progress note.

REFERENCES


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American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC). (2005). Circulation, 112(24 Supplement). Cousins, T., & O’Donnell, J. (2004). Arterial cannulation: a critical review. American Association of Nurse Anaesthetists Journal, 72(4), 267-271 Gronbeck, C., & Miller, EL. (1993). Nonphysician placement of arterial catheters. Experience with 500 insertions. Chest, 104, 1716-1717. Frezza EE, Mezghebe H. Indications and Complications of Arterial Catheter Use in Surgical and Medical Care Units: analysis of 4932 patients. Am Surg 1998; 64(2):127-131. Florida Hospital, “Arterial Cannulation Module.” 1996 Malley, W. (2004). Clinical blood gases: assessment and intervention. Philadelphia: W.B. Saunders Company. Miller, R.D. (2005). Miller’s Anesthesia, 6th Edition. Churchill Livingstone, An Imprint of Elsevier. Radial and Femeral Artery Cannulation. Clinical Best Practise Guidelines. College of Respiratory Therapists of Ontario. April 2008. Rowley DD, Mayo DF, Durbin CG Jr. initial experience with Respiratory Therapist arterial line placement services. Respiratory care 2000;45(5):482-485. South Shore Regional Hospital, “Arterial Line Insertion,” Policy and Procedure. Tegtmeyer, K., Brady, G., Lai, S., Hodo, R., & Braner, D. (2006). Placement of an arterial line. New England Journal of Medicine, 354, 15. University of Alberta Hospital, “Education Program for the Insertion of Arterial Catheters for Respiratory Therapist.” 1996.


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Test

1. The ideal site for arterial catheterization by a RRT is: a. Femoral artery b. Brachial artery c. Radial artery d. All of the above

2. A modified Allen’s Test should be done________any attempt at radial catheterization. a. after b. before c. during

3. Indications for arterial line catheterization are? a. Multiple blood sampling is required b. Continuous monitoring of arterial blood pressure is required c. All patients admitted to ICU d. A and B

4. The Respiratory Therapist is responsible for? a. Confirming that there is a written physicians order b. Checking for allergies to lidocaine and the chlorhexidine c. Preparation and Cleansing of the site d. Sterile technique throughout insertion procedure. e. All of the above

5. Approximately how much lidocaine is used to infiltrate the subcutaneous tissue on both sides of the artery. a. 1mL b. 2mL c. 0.5mL d. 4mL

6. The skin should be puncture at? a. 30-60 degrees b. 10-30 degrees c. 60-80 degrees d. 0-20 degrees

7. You should_______ the guide wire if there is a lot of resistance. a. Force b. Not force c. Corkscrew d. Secure

8. ____________ confirms that the catheter is in the artery. a. Damped waveform b. No pulse c. Pulsatile blood flow d. Air bubbles

9. Blood Pressure measurements by cuff__________ a. Can differ


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b. Are always the same c. Are always different d. Are incorrect

10. Document______________ in the progress notes a. Successful attempts b. Unsuccessful attempts c. All attempts d. Other people’s attempts


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Test Answers 1. C 2. B 3. D 4. E 5. C 6. A 7. B 8. C 9. A 10. C


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Competency Checklist Area Criteria Check Yes (√) or No (X) Patient Assessment Checks for order, allergies,

patient identification, and any contraindications.

Policy & Procedure

Knows the indications, contraindications, common complications their prevention and management.

Infection Control

Adheres to good hand washing and aseptic technique.

Anatomy

Demonstrates knowledge of the landmarks.

Local Anaesthetic

Uses the correct dosage and technique.

Guide wire Use

Demonstrates knowledge of equipment and the steps required for success.

Cannulation Technique

Appropriate angle of approach.

Documentation

Content documented as described in policy and signature with professional designation.

Viewed video from Arrow


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Department: Respiratory Competency Checklist For: Arterial Line Insertion Employee:______________________ Position:______________________________

Equipment/Skill C NI NC 1.Verify the physicians order, identify the patient, check for drug allergies (i.e., lidocaine) and blood work (INR, platlets, thrombolytics, warfarin)

2. Palpate the radial artery. Perform “Allen’s Test”

3.Position the patient’s wrist by placing a rolled towel underneath. Place blue pad under the patient’s wrist.

4.Wash hands 5.Put on mask, gown, cap, and sterile gloves.

6.Place the 25 gauge needle onto 1ml syringe. Withdraw 0.5mL of lidocaine from single use vial

7.Using chlorhexidine, cleanse the insertion site thoroughly in an top to bottom pattern for 30 seconds. Allow the solution to dry for approximately 60 seconds.

8.Place sterile drap to the selected site.

9.Prime the #25 gauge needle with the lidocaine and infiltrate the subcutaneous tissue on both sides of the artery around the proposed site of entry, with approximately 0.5cc’s of lidocaine. (OPTIONAL)


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10. Apply coupling gel to the wrist in location to the radial artery. Hold the probe at an angle of between 45°and 60° to the vessel under examination. Sweep the probe across to locate the artery

11..Palpate the artery; ensure the bevel of the needle/canal is facing up. With the needle/cannula directed against the arterial flow, puncture the skin at approximately a 30 – 60 degree angle.

12..Slowly advance the needle and canal until blood return is noted in the hub.

13..Advance the needle a small distance further.

14..Bring the needle/cannula closer to the skin (about 20 degrees). Advance the guide wire into the artery – there should be no resistance when the wire leaves the needle (black mark) – if there is reposition needle and try again – do not withdrawn the guide wire back into needle once it has been advanced.

15..Remove the needle while holding the catheter in place. Observe pulsatile blood flow from the cannula.

16..Have the assistant continuously flush the arterial line tubing as you connect it to the cannula and carefully secure it


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tightly. Flush the catheter to ensure patency and observe/assess the arterial waveform on the monitor. 17..Secure catheter in place and apply clear transparent dressing.

18..Clean up the tray, carefully disposing of all sharps, needles etc. Discard all items appropriately.

19..Record the procedure in the progress note.

Please list other areas of safety or job performance covered and general remarks.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Respiratory Therapist conducting competency check-off:________________________________

Department Director/Manager:_____________________________________________________

I acknowledge that I have received and understand the above information and have had the opportunity to ask questions and have them answered.

Employee:__________________________ Date:____________________________

Key: C = Competent NI = Needs Improvement NC = Not Competent


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Start

Selection of site (Begin with radial artery)

Perform Modified Allen test on upper extremities

Prepare for alternate sitesite (Dorsalis pedis)

sterile technique insertion

Prepare for radial arterial site sterile technique

insertion.

Assess the risks of bleeding ( oral anticoagulants, IV Heparin, IV thrombolytics, platelet count <20,000/mm3). Obtain consent

Locate the site with hand held doppler ± palpation. Infiltrate 0.5 cc of 1 % lidocaine without epinephrine subcutaneously on

both sides of the localized site.Use chlorehxidine swab to achieve a sterile field. Using the assistance of a hand held doppler covered with a sterile cover, perform arterial catheter insertion as described in the learning module

Successful within 2 attempts

YES

Secure the catheter and connect it to a

blood conservingarterial line

tubing. Record the waveform

NO

Record the procedure in the Electronic health record’s progress note and the Respiratory therapy audit database

NEGATIVEPOSITIVE

End

Presence of MAP ≤ 65 mm Hg requiring vasopressors ± inotropes AND/OR

Arterial samples ≥ 3 in a ICU patient in a 12 hr. shift

YES

Reevaluate when clinical situation changes/Consult ICU MD if alternate choices indicated/needed ( Non invasive monitoring etc.)

Alternate sites available YES

NO

NO

Figure 1. A flowchart describing decision making in Tuality Healthcare’s RT managed arterial catheter insertion and maintenance program.


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Tuality Healthcare RT Policy

TITLE: Arterial Line Insertion Policy

Dr. Order Required: Yes

Performed by: Registered Respiratory Therapist, RRT

POLICY:

The placement of an arterial line allows continuous monitoring of the patient’s arterial blood pressure as well as to frequently sample blood for arterial blood gases and other laboratory investigations.

RESPONSIBILITY:

The Respiratory Therapist (RRT) will insert an arterial line with an order from the ICU physician. An orientation/certification program to include observation then practical demonstration is in place. The first five arterial line insertions must directly supervised by a Sr. RRT and / or physician. The therapist may then insert an arterial line without direct supervision following physician order.

When then Therapist has inserted a total of at least twenty arterial lines, he/she will then perform the next insertion for a performance/skills evaluation by a physician. Following a successful skill evaluation, the Therapist will be considered certified for arterial line insertion. All arterial line insertions must be recorded in the department log book. It must be emphasized that any arterial line insertions, whether it is new insertion or change of site, must require physician notification and approval. Please notify Sr. RRT on duty of any new or changed line as well.

PROCEDURE:

I. EQUIPMENT • Arterial line equipment tray • Clean trolley


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• Transducer set-up with normal saline solution in pressure bag • Portable IV pole • Sterile gloves x2 • Monitor cable • Alcohol or swab sticks • 2% Chlorhexidine swab • Tegaderm • Sterile 4 x 4 gauze pads • 1% Lidocaine solution without epinephrine • Sterile towels • Arm board • Mask • Hair bouffant/cap • Handheld doppler

II. PATIENT AND FAMILY EDUCATION

• Assess patient and family understanding of the reason for the arterial line insertion.

• Explain to the patient and family the insertion procedure, potential need for immobility of affected extremity, and length of time catheter is expected to be in place.

• Explain the patient’s expected participation during the procedure. • Explain the importance of keeping the affected extremity immobile. • Instruct the patient to report any warmth, redness, pain, or wet feeling

at the insertion site at any time, including after catheter removal.

III. PATIENT ASSESSMENT AND PREPARATION Patient Assessment

• Obtain medical history, including diabetes, hypertension, peripheral vascular disease, vascular grafts, arterial vasospasms, thrombosis, or embolism. Obtain history of prior Coronary Artery Bypass Graph (CABG) surgery in which radial arteries were removed for use as


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conduits. Extremities with any of these problems should be avoided as sites of cannulation because of their potential for complication.

• Assess medical history for coagulopathies, use of anticoagulants, vascular abnormalities, or peripheral neuropathies to determine safety of procedure and site selection.

• Assess the patient’s allergy history (e.g., allergy to Lidocaine, antiseptic solutions, or tape).

• Assess the neurovascular and peripheral vascular status of the extremity to be used for arterial cannulation, including assessment of color, temperature, presence, and fullness of pulses, capillary refill, and monitor and sensory function as compared to the opposite extremity.

• Select cannulation site right or left radial artery is the primary site of choice.

• Check for collateral circulation by performing a modified Allen test. • Insertion in alternate sites:

! Dorsalis-pedis artery ! Brachial artery – ICU physician’s approval required ! Femoral artery – by ICU physician only

IV. PREPARE STERILE EQUIPMENT TRAY:

• Place a sterile blue drape on the clean trolley. • Using aseptic technique, add the following;

! Sterile aperture drape ! Sterile gloves ! Arrow arterial catheter ! Chlorhexidine swab ! Op-site dressing ! Bio patch ! Don : head cap, face mask, sterile gown and sterile gloves ! A nurse or RT will help add the following; ! Sterile normal saline ! Lidocaine 1% drawn into a 5 ml syringe.

• Arrange supplies on trolley using sterile technique for easy access and use.


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V. PREPARE INSERTION SITE:

• Wash hands • Perform TIME OUT procedure • Don sterile gloves, fluid shield mask, hair cap, and protective gown. • Swab the insertion site thoroughly with 2% Chlorhexidine

Gluconate and Alcohol (Chloraprep) applicators in an outward circular pattern. Repeat X 2.

• Let air dry. • Place sterile aperture drape over insertion site. • With 1% Lidocaine solution, infiltrate subcutaneous.

VI. CANNULATE THE ARTERY • Remove protective guard from catheter. • Advance and retract wire guide to ensure proper function. • Palpate the artery and slowly puncture the vessel at approximately a

30 degree angle. Ensure bevel of needle (and arrow on hub) are facing up. Observe flashback in needle chamber.

• Upon entering the artery, advance the guide wire into the artery through the needle. Ensure the flexible tip wire is used. A gentle rotating motion may aid in advancing catheter. If any resistance is met, DO NOT FORCE THE GUIDE WIRE OR CATHETER!

• Advance the catheter holding the guide wire in place, remove the needle and guide wire.

• Observe pulsatile blood flow through catheter. • Attach pressure tubing to catheter.

VII. ATTACH FLUSH/SAMPLING TUBING FROM TRANSDUCER:

• A nurse or RT will hand over normal saline-flushed tubing and continue

to flush as the therapist attaches arterial catheter, holding unsecured line very carefully. Ensure catheter flushes easily.

• Assess arterial blood pressure wave form on monitor. • Gently reposition catheter and reassess wave form if an inadequate or

dampened wave form is displayed. • Apply sterile occlusive dressing and secure arterial catheter with op-

site dressing. • Apply an armboard if necessary.


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• Carefully dispose of sharps; needles, guide wire, etc. • Discard all other items. • Level the air-fluid interface to the phlebostatic axis and zero the

transducer. • Set the alarm parameters according to the patient’s current blood

pressure. • Run a waveform strip and record baseline pressures. • Record the manual noninvasive blood pressure and compare with the

arterial (invasive) blood pressure.

VIII. DOCUMENTATION:

• Record all line insertions in Cerner for quality assurance purposes. • Record arterial line in respiratory department excel audit program

tuality healthcare radial artery catheterization for...

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