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Policies,Clinical,UWHC Clinical,Department Specific,Nursing Patient Care,Cardiovascular and Infusion

Arterial Catheter/Insertion, Maintenance, Blood Drawing and Discontinuation (Adult) (1.11A)

Arterial Catheter/Insertion, Maintenance, Blood Drawing and Discontinuation (Adult) (1.11A) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Cardiovascular and Infusion

1.11A

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NURSING PATIENT CARE POLICY & PROCEDURE


I. PURPOSE

To outline the procedures for assembling, assisting with insertion, measuring
pressures, troubleshooting, obtaining arterial blood, and discontinuing
arterial catheters.

II. POLICY

A. The provider is responsible for selection of the site and insertion of the catheter.
B. Use of arterial lines is limited to critical care areas, operating room, post- anesthesia care
unit, emergency department, heart vascular procedure center, and intermediate care
areas.
C. Arterial line management skills checklist completion is required.
D. Hand hygiene should be performed when indicated according to UW Health Clinical
Policy 4.1.13, Hand Hygiene.
E. Nurses who have completed checklist on removal of arterial lines can remove them
(femoral, radial/brachial).

III. PROCEDURE

A. Assembly of a Pressure Transducer and Continuous Flow Tubing System
1. Perform hand hygiene.
2. Equipment
a. Monitoring kit with disposable transducer
Pole mount: CS number 1211087
Patient mount: CS number 1211086
b. Monitor extension kit (optional) CS # 1211090
c. Appropriate sized IV bag normal saline is the preferred solution.
Heparinized solutions may be used for certain patients as ordered by
provider or D5W may be used in cases where sodium needs to be
restricted, etc.
d. Pressure infusion bag (500 mL CS # 4002398 or 1000 mL CS # 4002399)
e. IV pole with transducer holder (OR only)
f. Pressure cable (CS number 4014560) and module for monitor (if needed)
g. Monitor kit blood sampling Safeset™ CS # 4005256 (if used)
3. Set up and flush disposable pressure transducer and continuous flow tubing system
while maintaining sterility of system. Spike the bag of IV solution and place in
pressure sleeve. The sleeve should not be pressurized at this time; this can cause air






Effective Date:
December 29, 2017
☐Administrative Manual
☒Nursing Manual (Red)
☐Other _
Policy #: 1.11A
☐Original
☒Revision
Page
1
of 7
Title: Arterial Catheter/Insertion, Maintenance,
Blood Drawing and Discontinuation (Adult)

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bubbles to form in the tubing or transducer. Tighten all connections prior to
priming the tubing.
a. Prime the tubing and all stopcocks: flush the tubing and transducer by
pulling the red rubber "rattail" or by pushing the 2 clips until the flush
solution flows out through the white vented cap on the stopcock distal to
the transducer. NOTE: Rapid flushing/filling of tubing contributes to air
bubble formation. Ensure all air bubbles have been expelled. The presence
of air bubbles in the transducer or tubing may cause inaccurate pressure
measurement. A 3-inch monitor extension may be added to the distal luer
connection.
b. Replace the vented caps with dead-end caps. These are provided in the
tubing package.
c. Pressurize sleeve to 300 mm Hg. A pressure of 300 mm Hg is required for
continuous irrigation of 3-6 mL/hr. Lower pressures may result in clot
formation within the lumen of the catheter.
4. Connect cable to transducer.
B. Insertion of the Arterial Catheter
1. Equipment
a. Sterile gloves
b. ChloraPrep® applicator
c. CHG transparent dressing and dressing kit
d. Appropriate size arterial catheter
e. Suture scissors
f. Needle holder
g. Sterile disposable drape
h. Sterile 4 x 4 gauze sponges
i. Blood pressure module and cable
j. Appropriate standard precaution equipment
k. Appropriate securement device (if sutures are not used) or sutures
l. Safeset™ blood conservation system (optional)
m. 1% topical lidocaine solution (optional)
n. Lidocaine ointment (optional)
o. Tincture of benzoin (optional)
p. Arm board (optional)
q. T-connector, or high-pressure extension (optional)
2. The Allen Test for collateral blood flow should be performed by the provider if the
radial site is to be cannulated.
3. An observer insertion checklist is required only if the arterial line is inserted
through an introducer.
4. Assist the provider with limb positioning and preparation of selected site.
a. Prep skin with ChloraPrep® applicator for 1 minute and allow to dry for
30 seconds.
b. Drape the area with two sterile barriers.
c. Infiltrate skin with local anesthetic (optional).
5. Nurses will perform hand hygiene and don sterile gloves if assisting the provider in
the sterile field.
6. Assist the provider in connecting catheter to pressure tubing. Apply a StatLock® to
hold catheter in place if not sutured.
7. Apply a transparent CHG occlusive dressing or dressing with Biopatch and
transparent occlusive dressing. Record the date on the dressing.

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8. Document in the patient’s clinical record.
C. Obtaining Pressure Readings from an Arterial Line
1. Zero the pressure readings
a. Position transducer and a stopcock at right atrial level (4th intercostal
space, mid- axillary line), before zeroing. Which stopcock is used to zero
the transducer is immaterial, but the air-fluid interface of that stopcock
must be level with the patient's right atrium to obtain accurate pressure
readings. Use a pole or patient mount system to maintain this location of
the transducer at the phlebostatic axis.
b. Document patient’s position and head of bed level with zeroing of the
transducer.
c. Zero the transducer (zeroing the transducer equalizes the transducer to
atmospheric pressure and gives an accurate known reference point) a
minimum of every 8 hours and as needed.
d. Suspend the alarm (this will suspend the alarm for 3 minutes).
e. Open the transducer to air by turning stopcock to an off position to the
patient and removing the dead-ender cap from that stopcock.
f. To zero on monitor:
i. Option 1: On the monitor screen, push the pressure readings box and
click on the zero button.
ii. Option 2: On the monitor main screen, click on zero all pressures if
zeroing all hemodynamic pressures at once.
g. Set system to obtain pressure readings.
i. Replace caps after every zeroing and with every blood draw.
ii. Close stopcock to air. (Open stopcock to patient).
h. Verify the alarm is on before leaving the room. NEVER leave a bedside
without turning the alarms on.
2. Alarms
a. Adjust the alarm indicators to set high and low alarm units. The alarm
should be on at all times unless a procedure is being done which would
mechanically interfere with the pressure system.
D. Maintenance of an Arterial Catheter
1. At the start of each shift, assess all pressure lines for air bubbles and ensure that all
stopcocks are tight.
2. Accuracy of the system will be assessed every 8 hours and as needed by:
a. Square wave test: perform square waveform test one time per shift. Flush
the arterial catheter every shift using the transducer method system (rat tail
or clips).
b. Zero transducer.
c. Check non-invasive blood pressure using the non-invasive blood pressure
cuff.
NOTE: The square wave test is more accurate than using cuff pressure to evaluate
the accuracy of the arterial pressure value.
3. Assess insertion site for local pain and tenderness.
4. Flush solution, pressure tubing and disposable transducers are changed every 96
hours, or after the 4th full day of catheter use. New tubing should be labeled with
appropriate IV change-date labels indicating start and change days.


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5. Transparent Dressings
a. The central line dressing can utilize CHG occlusive dressing or Biopatch
transparent dressing. Change CHG dressing Biopatch every 7 days using
sterile technique.
b. Perform hand hygiene and don non-sterile gloves.
c. Remove old dressing, taking care not to dislodge catheter. (Note: arterial
catheters placed in the OR may not be sutured in place.) Sterile hub guards
may be used to secure line.
d. Perform hand hygiene and apply sterile gloves.
e. Cleanse insertion site with ChloraPrep® applicator for 1 minute and allow
to dry for 30 seconds.
f. Apply CHG sterile transparent dressing Biopatch® (blue side up)with
transparent dressing around exit site.
Note: Skin prep or benzoin may be used under transparent adhesive
dressing to protect skin and increase tape adhesion as needed.
g. Document the date the dressing and document in the patient’s clinical
record.
6. Use a blood conservation system such as SafesetTM for patients expected to have
arterial lines in place for a few days or longer. .
E. Troubleshooting an Arterial Pressure System
1. If inconsistency in readings between arterial line and cuff, consider and evaluate:
a. Different pressures in each limb.
b. Transducer not at right atrial level. The level of transducer may cause
falsely high or low-pressure reading. If possible, take cuff pressure in the
same arm as the arterial catheter if patient's condition allows and document
on flowsheet.
c. System in need of zeroing and calibration.
d. Needleless connector may affect waveform and consider removing.
2. Dampened waveform. A dampened tracing indicates poor transmission of the
waveform to the monitor. Evaluate by:
a. Remove air or blood from the pressure tubing and transducer. Air bubbles
or blood in system will dampen tracing.
b. Tighten loose connections.
c. Assess for a defect in the tubing system. Leakage of fluid from a loose
connection or defect in the system impairs the transmission of the pressure
waveform and can result in blood backup.
d. Alleviate catheter kinks. Repositioning the limb can unkink a catheter,
improving the waveform transmission.
e. If square-wave test is adequate, use mean arterial pressure (MAP) value.
Discuss with provider concerns of the dampened waveform.
f. Prevent gradual catheter occlusion by keeping the pressure in the infusion
bag at 300 mm Hg to maintain a continuous flow of IV fluid.
g. Check for catheter tip lodging against the wall of the vessel by drawing
back for a blood return. Repositioning the limb and flushing may
reposition the catheter away from the wall. In rare instances, this may be
necessary for each reading.
h. Notify provider if dampened waveform continues.
3. Absence of waveform.
a. Assess catheter and dressing.

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b. Check that transducer is plugged in.
c. Zero - change transducer if unable to zero and/or calibrate the system.
d. Position stopcock arms into correct position.
e. Assess integrity of transducer and tubing system.
4. Artifact distorting waveform. Excessive vasoconstriction or small vessels can cause
an increase in BP in more distant vessels.
F. Drawing Blood from an Arterial Line. Order of blood draw is different from
venipuncture lab draw.
1. Equipment:
a. Print HealthLink request forms and patient labels.
b. Assemble equipment needed for blood collection:
i. PICO® syringe for blood gas collection
ii. Blood collection tubes for test(s) requested
c. Supplies for Needleless System Adapter Technique:
i. 4 mL vacutainer tube for discard: a larger discard volume may be
required if coagulation testing is requested
ii. 4 x 4 gauze
iii. Luer adapter and sterile cap(s)
d. Syringe Technique: (if necessary)
i. 2 or more sterile syringes to accommodate the amount of blood
needed and a discard
ii. Needleless adapter system
iii. Sterile 2 x 2 gauze sponges (optional)
iv. Sterile luer cap(s)
2. Complete patient identification, matching labels and request forms to patient ID
band according to UW Health Clinical Policy 3.2.1, Patient Identification.
3. Suspend monitor alarm.
4. Remove luer-lock cap closest to arterial catheter. Discard cap. Maintain sterility of
port.
5. Attach syringe or luer adapter and blood collection tube as indicated:
a. Needleless System Adapter Technique
i. Attach luer adapter and 4 mL vacutainer blood tube to stopcock port
and turn arm to open the line between the arterial catheter and the luer
adapter.
ii. Withdraw 4 mL of blood mixed with IV solution. Discard.
iii. Attach appropriate types of blood collection tubes and fill using
correct order of draw. See U-Connect: Order of Blood Collection
Tubes.
iv. Turn stopcock arm to off position in relation to the port luer adapter.
The stopcock need not be turned off in relation to the port between
blood collection tube when using the luer adapter technique.
b. Syringe Technique
i. Attach 3 mL syringe to stopcock port and turn arm to open the line
between the arterial catheter and syringe. Luer adapter and blood
collection tube technique is preferred because it reduces potential risk
of blood exposure.
ii. Turn stopcock arm to off. Aspirate about 3 mL of solution mixed with
blood. Remove 3 mL syringe and discard. Blood is not returned to
patient.

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iii. Attach appropriate size syringe. Open stopcock between port and
catheter and gently withdraw desired amount of blood. Turn stopcock
to off position in relation to the port and remove syringe.
• For ABGs expel air bubbles and cap the syringe tightly. Label
the syringe in the presence of the patient and transport to the
Core Laboratory immediately
• Fill blood collection tubes with fluid connector. Do not use
needles to transfer blood.
iv. Flush tubing
• Intermittently pull red "rattail" or push the 2 clips flushing
device for 2-3 seconds to clear blood from tubing and catheter.
• Turn stopcock off to arterial catheter and pull "rattail" flushing
device to flush port. Residual blood in a stopcock port becomes
a good culture medium and clots may form.
c. Safeset™ System Technique
i. Release the locking mechanism on the reservoir by depressing the
ridged plunger wings gently. Pull back on the plunger slowly, no
faster than 1 mL per second, to aspirate an appropriate clearing
volume.
ii. Once an appropriate discard volume has been obtained, turn the one-
way stopcock at the tip of the reservoir off by turning the handle
perpendicular to the tubing. This will ensure that the sample will not
contain any of the clearing volume.
iii. Use alcohol to cleanse the latex-free Safeset™ port from which the
sample will be drawn.
iv. Attach the Safeset™ blunt cannula to the blood collection device
(syringe or blood tube holder).
v. Insert the blunt cannula into the sampling port and aspirate the
required blood for the sample.
vi. Turn the one-way stopcock at the top of the reservoir on by turning
the handle parallel to the tubing.
vii. Reinfuse the patient's blood slowly, no faster than 1 mL per second,
by pressing the plunger back to the closed and locked position.
viii. Use disinfectant to cleanse the port the sample was drawn from.
ix. Activate the flush device until the line is clear of all blood.
6. Turn stopcock arm to off position in relation to the port and replace the stopcock
cap with a new cap.
7. Turn monitor alarms on.
8. Label blood collection tubes and PICO® syringe using patient labels in the
presence of the patient. Send specimens and lab request forms to the Core
Laboratory.
a. Request forms are marked for desired studies. Collector and time of
collection are changed if necessary. Refer to UWHC Clinical Laboratories
Policy 1502.5.06, Acceptance Policy for Specimen Identification.
b. FiO2 and presence or absence of positive end expiratory pressure (PEEP)
is marked on ABG request forms.
G. Discontinuing an Arterial Catheter
1. Check for provider’s order before discontinuing the arterial catheter.
2. Equipment:
a. Scissors

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b. 4 x 4 sponge
c. Tape
3. Perform hand hygiene and don non-sterile gloves.
4. Make sure stopcock proximal to insertion site is "off" in relation to the catheter so
there is no flow from pressure bag. Release pressure in pressure bag. Clamp tubing.
5. Loosen tape and remove suture securing the catheter. Remove catheter by pulling it
briskly in a straight line parallel to the artery.
6. Apply immediate manual pressure for 5-15 minutes. The length of time for manual
pressure varies as a result of catheter size and coagulation status.
7. If necessary, apply a pressure dressing with a 4 x 4 sponge and tape or transparent
dressing. Do not apply the pressure dressing circumferentially around the wrist.
8. Document removal of arterial catheter in the clinical record.
9. Check dressing for bleeding. Check extremity for hematoma, color, capillary refill,
numbness, and presence of pulse.
10. Clean blood and tape from cable, wipe with disinfectant solution. Store according
to unit policy. Cables are NOT disposable!

IV. UW HEALTH CROSS REFERENCES

A. Clinical Laboratories Policy 1502.5.06, Acceptance Policy for Specimen Identification
B. UW Health Clinical Policy 3.2.1, Patient Identification
C. UW Health Clinical Policy 4.1.13, Hand Hygiene
D. Laboratory Services, Order of Draw of Blood Collection Tubes (U-Connect)

V. REFERENCES

A. Alspach, J. (2006). Core Curriculum for Critical Care Nursing (6
th
ed). St. Louis,
MO: Saunders, Elsevier.
B. Infusion Nurses Society. (2011). Infusion nursing standards of practice. Journal of
Infusion Nursing: The Official Publication of the Infusion Nurses Society, 29(1
Suppl), S1-92.
C. Moser, D. K., & Riegel, B. (2008). Cardiac Nursing: A Companion to the
Braunwald’s Heart Disease. St. Louis, MO: Saunders Elsevier.

VI. REVIEWED BY

Clinical Infection Control Practitioner, Infection Control
Clinical Nurse Specialist, Cardiology
Clinical Nurse Specialist, Cardiac Surgery and Transplant
Clinical Nurse Specialist, Thoracic Surgery
Clinical Nurse Specialist, Neuroscience
Clinical Nurse Specialist, Trauma/Critical Care
Nursing Education Specialist, Critical Care
Nursing Education Specialist, Heart, Vascular and Thoracic
Nursing Patient Care Policy and Procedure Committee, December 2017

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive