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

Arterial Catheter/Insertion, Maintenance, Blood Drawing and Discontinuation (Pediatric) (1.11P)

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

1.11P



NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
February 2, 2015

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 1.11P

Original
Revision

Page
1
of 8
Title: Arterial Catheter Set Up, Maintenance,
Blood Drawing and Discontinuation (Pediatric)

I. PURPOSE

To outline the procedures for set up, blood collection, measuring pressures,
maintenance, troubleshooting, and discontinuing arterial lines.

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, and hybrid lab cardiac cath
laboratory.
C. Arterial line competency completion is required.
D. Hand hygiene should be performed when indicated according to UWHC Hospital
Administrative Policy 13.08, Hand Hygiene.

III. PROCEDURE

A. Arterial Monitoring and Drawing of a Blood Sample Without In-line Blood
Drawing System
1. Equipment:
a. Transducer from ICU Medical™ IV monitoring Kit with 3mL squeeze
flush device with 36 inch microbore tubing and 3 way stopcock (CS#
4014445)
b. Arterial line maintenance fluid as ordered
c. Syringe pump tubing with pressure sensing disk (60 inch preferred)
(CS# 4014088) or 78 inch (CS # 4006412)
d. Needleless connector (CS # 2227087)
e. Small Bore extension set (CS # 2203480)
f. Alaris Syringe pump
g. Pressure cable for monitor
h. Central Venous Line (CVL) Access kit (CS# 4013516)
2. Set Up Arterial System Using Sterile Technique
a. Cleanse surface where the system will be set up with disinfectant wipe
Open the CVL access kit on the cleaned surface, then remove gloves
from kit and set to the side.
b. Open Transducer kit and drop contents on the drape of the CVL access
kit.
c. Open small bore extension set and drop on the drape.


Page 2 of 8

d. Open syringe tubing package; leave in package because it is not sterile.
e. Place syringe of arterial maintenance fluid near set up area, but not on
the drape.
i. Don sterile gloves.
ii. Secure the connections of the transducer system.
iii. Remove the needleless connector from the small bore
extension.
iv. Connect extension tubing to the stopcock at the distal end of
the of the 36 inch tubing.
v. Connect the syringe tubing with pressure sensing disk to the
transducer by the squeeze flush device.
vi. Connect arterial fluid syringe to needleless connector on other
end of microbore tubing set with pressure sensing disc.
3. Prime the System
a. Prime may be performed by pump or by hand. When priming gloves
are no longer sterile; maintain aseptic technique throughout procedure.
i. Begin by turning the stopcock closest to the transducer off to
the patient end of the tubing.
ii. Prime arterial fluid through the transducer by squeezing the
wings and prime until the zeroing port fills with fluid. Place a
non-vented cap on this port.
iii. Turn the stopcock off to the port and open to the patient.
iv. Continue to prime the system through to the distal stopcock
that is open to the port. Once the port is filled with fluid, place
a needless connector on the port.
v. Turn stopcock off to port, open the stopcock to the patient end
of tubing and finish priming the tubing.
ξ Connect arterial set to patient’s arterial catheter.
ξ Connect arterial monitoring cable to transducer.
ξ Start arterial fluid infusion on IV pump.
ξ Zero arterial line and begin transducing.
4. Drawing a Blood Sample From an Arterial Line
a. Verify order, print request forms and patient labels.
b. Complete patient identification, matching labels and request forms to
patient ID band according to UWHC Hospital Administrative Policy
7.31, Patient Identification.
c. Gather appropriate syringes and tubes for specimen collection, a
stopcock and a syringe for drawing waste.
d. Suspend monitor alarms.
e. Pause arterial fluids that are infusing.
i. Attach two syringes, one for blood waste and one for blood
draw to the open ports of a three way stopcock.
ii. Scrub the needless connector for 15 seconds with alcohol and
allow to dry for 15 seconds (scrub the hub).
iii. Connect the prepared three way stopcock to the needless
connector on the arterial monitoring line.


Page 3 of 8

iv. Turn arm of attached stopcock to open the line between the
arterial monitoring line and waste syringe. Assure stopcock is
turned “off” to the blood draw syringe.
v. Aspirate 2-3 mL of solution mixed with blood (or, if drawing
coagulation labs, aspirate 3-5 mL of solution mixed with
blood).
vi. Turn the stopcock “off” to the waste syringe and withdraw
blood sample. If more than one syringe is needed, remove first
syringe and place second sterile syringe on stopcock and
withdraw sample.
vii. Once blood draw is complete, turn stopcock “off” to blood
draw syringe and reinfuse waste sample if it is a heparinized
line.
i. DO NOT reinfuse blood on non-heparinized lines due
to increased potential for clots.
ii. DO NOT return waste sample to pediatric bone marrow
transplant patients.
viii. Once waste is reinfused, turn arm of in-line stopcock “off” to
needleless connector and remove and discard attached
stopcock.
f. Flush arterial line after draw, may use 5 mL (or less as needed) sterile
heparinized normal saline or normal saline.
g. Turn monitor alarms on.
h. Restart arterial fluids.
i. Label blood collection tubes and syringes in the patient’s room using
patient labels according to UWHC Clinical Laboratories Policy
1502.5.06, Acceptance Policy for Specimen Identification.
B. Arterial Line Setup with an In-line Blood Drawing System
1. Equipment
a. In-line closed blood draw kit from ICU Medical™ (Neonate CS#
4014446, pediatric CS # 4014444)
b. Secondary tubing for neonatal set up
c. Microbore tubing SmartSite® syringe administration set
d. 500 mL bag normal saline
e. Arterial line maintenance fluids as ordered
f. Pressure cable and module for monitor
g. Alaris Syringe pump
h. Small bore extension set, if needed (CS # 2203480)
i. Central Venous Line (CVL) Access kit (CS# 4013516)
2. Set up in-line arterial blood draw system (see related document)
a. Cleanse surface where the system will be set up with disinfecting
wipe. Open the CVL access kit on the cleaned surface, then remove
gloves from kit and set to the side.
b. Open kit and drop contents of the package onto sterile drape of CVL
access kit.
c. Don sterile gloves.
d. Secure connections in kit.


Page 4 of 8

e. Attach sheathed syringe from kit to flush stopcock located at the end
of the short extension tubing that extends vertically from the main line
and transducer.
f. Attach distal end of microbore tubing set to squeeze flush device on
transducer.
g. Connect arterial fluid syringe to needleless connector on other end of
microbore tubing set with pressure sensing disc.
3. Prime the system
a. Prime may be done by hand or on the pump.
b. Position stopcocks:
i. Begin by turning the zeroing stopcock and the flushing
stopcock off to the patient end of the tubing.
ii. Turn the stopcock connected to the sheathed syringe open
to the syringe and the short extension tubing.
iii. Position the sampling stopcock to be open to the patient
end, the arterial fluid end and the sampling port. The off
arm should be positioned opposite the blue sampling port.
c. Prime arterial fluid through the transducer by squeezing the wings and
prime until the zeroing port fills with fluid. Place a non-vented cap on
this port.
d. Open the zeroing stopcock to the patient end and the arterial fluids and
continue to prime until fluid reaches the sheathed syringe.
e. Next, open the flushing stopcock to the patient end and the arterial
fluids and continue to prime to the end of the sampling stopcock. Once
primed, turn sampling stopcock off to the sampling port (it should
remain in this position while transducing).
f. Spike 500 mL bag of normal saline with secondary tubing and prime
secondary tubing.
g. Clamp secondary tubing and connect to the open port on the syringe
stopcock.
h. Turn syringe stopcock off toward the short extension tubing, and
unclamp secondary tubing connected to normal saline bag. Fill
sheathed syringe with 6 mL of normal saline from bag.
i. Once syringe is full, reclamp secondary tubing and turn the stopcock
off to the normal saline bag, open to the sheathed syringe and short
extension tubing.
j. Connect arterial set to patient’s arterial line.
k. Connect arterial monitoring cable to transducer.
l. Start arterial fluid infusion on IV pump.
m. Zero arterial line and begin transducing.
C. Blood Sampling from In-line Closed Blood Draw Kit (ICU Medical™ -see
related document for visual cues)
1. Verify order, print request forms and patient labels.
2. Complete patient identification, matching labels and request forms to patient
ID band according to UWHC Hospital Administrative Policy 7.31, Patient
Identification.
3. Gather appropriate syringes and tubes for specimen collection.,
4. Suspend monitor alarms.


Page 5 of 8

5. Draw waste blood by turning the sampling stopcock to be open to all three
ports, and turning the flushing stopcock off to the arterial fluids.
a. Gently pull back waste blood using the sheathed syringe up to the
black marking on the tubing.
6. Next, position sampling stopcock off toward arterial fluids and position flush
stopcock off toward the patient.
7. Scrub sampling stopcock for 15 seconds and allow to dry for 15 seconds, then
draw specimens.
8. Return waste blood and flush line by positioning sampling stopcock open to
all three ports and positioning flush stopcock off to arterial fluids.
9. Flush using sheathed syringe until waste blood is returned and line is cleared
(approximately 1-2 mL).
10. Position stopcocks back to monitoring positions and restart arterial fluids.
11. Turn alarms on.
12. Restart arterial fluids
13. Label blood collection tubes and syringes in the patient’s room using patient
labels according to UWHC Clinical Laboratories Policy 1502.5.06,
Acceptance Policy for Specimen Identification.
D. Refilling Flush Syringe on In-line Closed Blood Draw Kit from ICU Medical™
(see related document for visual cues)
1. To refill sheathed flush syringe with normal saline, turn the stopcock
connected to the sheathed syringe off to short extension tubing.
2. Open roller clamp on secondary tubing connected to normal saline bag.
3. Pull back on sheathed syringe and fill.
E. Arterial Pressure Monitoring and Zeroing
1. Position transducer and a stopcock at right atrial level (4th intercostal space,
mid-axillary line). The air-fluid interface of that stopcock must be level with
the patient's right atrium to obtain accurate pressure readings. Maintain the
transducer at the phlebostatic axis.
2. The stopcock closest to the transducer is used to zero the transducer.
3. Zero the transducer a minimum of every shift and as needed.
4. When zeroing the transducer, suspend monitor alarms.
5. To zero, perform the following:
a. Open the transducer to air by turning stopcock to an off position to the
patient and removing the non-vented cap from that stopcock.
b. Open the stopcock on the arterial line transducer to air and off to the
patient.
c. Touch the arterial line box on the bedside monitor.
d. Touch the “Zero” key on the opened screen on the bedside monitor.
e. When there is a “0” in the arterial line box on the bedside monitor, the
transducer is zeroed.
f. Turn the stopcock off to air and open to the patient; close the port with
a new sterile non-vented cap.
6. Once zeroing is complete, turn monitor alarms on. NEVER leave a bedside
without turning the alarms on.
7. Assess alarm limits high and low settings for appropriateness for the patient
condition.


Page 6 of 8

a. The alarms should be on at all times unless a procedure is being done
which would mechanically interfere with the pressure system.
F. Maintenance of an Arterial Line
1. At the start of each shift, assess all pressure lines for air bubbles and ensure
that all connections are tight.
2. Accuracy of the system will be assessed once a shift and as needed by:
a. Zeroing transducer.
b. Maintaining the transducer at phlebostatic axis.
c. Analyzing the waveform. The waveform should have an upright wave
with a dicrotic notch. The shape of the waveform can be affected by
the location of the arterial line and the hemodynamic status of the
patient.
d. Check blood pressure using the non-invasive blood pressure cuff one
time per shift.
3. Assess insertion site for complications which can include, erythema,
tenderness, edema, exudate, bleeding, phlebitis, infiltration, and integrity of
external catheter components (i.e., catheter hub, lumens).
4. Flush solution, pressure tubing and disposable transducers are changed every
72 hours.
a. New tubing should be labeled with appropriate IV change-date labels
indicating start and change day. Document the tubing change in the
clinical record.
5. Changing the arterial line dressing
a. Before changing an arterial line dressing in a hemodynamically
unstable patient, the risks and benefits of the dressing change should
be weighed for the patient.
b. A Biopatch® may be used if the patient is older than 2 months
corrected gestational age. If a Biopatch® is used, it is recommended
that it be changed every 7 days using sterile technique.
i. Remove old dressing, taking care not to dislodge catheter.
(Note: arterial catheters may not be sutured in place, sterile
hub guards may be used to secure the line.)
c. To change the arterial line dressing do the following:
i. Cleanse insertion site with ChloraPrep® applicator for 30-
60 seconds and allow to dry for 30 seconds.
ii. For infants less than 2 months corrected gestational age,
allow ChloraPrep to dry as outlined above, then wipe
ChloraPrep off skin using sterile sponge with saline or
sterile water, dry the skin and do not apply a Biopatch®.
iii. Apply sterile dressing. Biopatch® (blue side up) around exit
site and cover with transparent dressing. (Note: Skin prep
may be used under transparent adhesive dressing to protect
skin and increase tape adhesion as needed.)
b. Date the dressing and document in clinical record.
G. Troubleshooting an Arterial Line System
1. Dampened waveform. Evaluate by:
a. Assess for air or blood in the pressure tubing and/or transducer. Air
bubbles or blood in system will dampen tracing.


Page 7 of 8

b. Tighten loose connections.
c. Assess the length of the tubing; the length should be no more than 48
inches.
d. Alleviate catheter kinks.
e. Reposition extremity
f. Assess for arterial spasm, if suspected notify provider
g. Dislodge catheter from vessel wall; this can be accomplished by either
repositioning the extremity or flushing. In rare instances, this may be
necessary for each reading.
h. 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.
i. Notify provider if dampened waveform persists.
2. Absence of waveform.
a. Assess that the stopcock is open to the patient and the transducer.
b. Assess integrity of transducer and tubing system.
c. Check that transducer is plugged in.
d. Zero the transducer, if this does not result in a waveform, change
transducer
e. Assess the scale for invasive blood pressure on the bedside monitor.
May need to adjust the scale according to the patient’s pressure
readings.
3. Artifact distorting waveform, for example overshoot.
a. Causes may include excessive vasoconstriction or position of the
arterial line, (the more distal the higher likelihood). May need to
suspend monitor alarm.
H. Discontinuing an Arterial Line Catheter
1. Equipment:
a. Sterile iris scissors
b. Sterile 4 x 4 sponge
c. Tape
2. Check for provider order before discontinuing the arterial catheter.
3. Turn the stopcock off to the insertion site.
4. Stop the arterial fluids infusion and clamp tubing.
5. Loosen tape and remove sutures if present, securing the catheter.
6. Remove catheter by pulling it briskly in a straight line parallel to the artery.
7. 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.
8. If necessary, apply a pressure dressing with a 4 x 4 sponge . Do not apply the
pressure dressing circumferentially around the wrist.
9. Document removal of arterial catheter in the clinical record.
10. Assess site and dressing for bleeding. Check extremity for hematoma, color,
capillary refill, numbness, and presence of pulse.
11. Clean blood and tape from cable, wipe with disinfectant solution according to
UWHC Administrative Policy #13.20 Cleaning, Disinfection and Sterilization
of Patient Care Instruments and Equipment. Store according to unit policy.
Cables are NOT disposable!



Page 8 of 8

IV. UWHC CROSS REFERENCES

A. Policy 1.11P, Arterial Catheter Set Up, Maintenance, Blood Drawing and
Discontinuation (Pediatric) - Visual Guide (related reference)
B. Clinical Laboratories Policy 1502.5.06, Acceptance Policy for Specimen
Identification
C. Hospital Administrative Policy 7.31, Patient Identification
D. Hospital Administrative Policy 13.08, Hand Hygiene
E. UWHC Administrative Policy #13.20 Cleaning, Disinfection and Sterilization of
Patient Care Instruments and Equipment

V. REFERENCES

A. Amond, K (2013) Arterial Pressure Monitoring in Hazinski, M.F. Ed Nursing
Care of the Critically Ill Child (3rd Ed) St Louis MO; Elsevier Mosby
B. Lynn-McHale Wiegand, D. J., & Carlson, K. K (Eds.) (2011). AACN Procedure
Manual for Critical Care (6th Ed.). St. Louis, MO; Elsevier Saunders.
C. Slota, M. (2006) AACN Core Curriculum for Pediatric Critical Care Nursing (2nd
Ed) St. Louis MO: Elsevier Saunders.
D. Verger, J. T., & Lebet, R. M. (2008). AACN Procedure Manual for Pediatric
Acute and Critical Care. St. Louis, MO: Saunders Elsevier.
E. Verklan, T. M. & Walden, M. (2014). Core Curriculum for Neonatal Intensive
Care Nursing. St. Louis, MO: Saunders Elsevier.

VI. REVIEWED BY

Clinical Infection Control Practitioner, Infection Control
Clinical Nurse Specialist, Neonatal Intensive Care
Clinical Nurse Specialist, Pediatric Intensive Care
Nursing Patient Care Policy and Procedure Committee, January 2015

SIGNED BY

Beth Houlahan, MSN, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer