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UWHC,UWMF,

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

Invasive and Non-invasive Hemodynamic Monitoring (Adult) (1.14)

Invasive and Non-invasive Hemodynamic Monitoring (Adult) (1.14) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Cardiovascular and Infusion

1.14

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
October 28, 2016


Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 1.14A

Original
Revision

Page
1
of 19
Title: Invasive and Non-invasive
Hemodynamic Monitoring (Adult)

I. PURPOSE

Provide a standard of care for patients receiving invasive and non-invasive hemodynamic
monitoring in the critically ill patient.

II. DEFINITION

Pulmonary Artery Catheter: The pulmonary artery catheter (PAC) is used to obtain
pressure readings including central venous pressure (CVP), pulmonary artery (PA)
pressure, pulmonary artery occlusive (PAOP) pressure commonly referred to as “wedge”,
cardiac output (CO) and mixed venous oxygenation saturation values; to monitor the
patient's hemodynamic status; and to obtain mixed venous blood samples.

III. POLICY

A. The physician is responsible for selection of the site, determining which type of PAC,
insertion of the catheter, ordering frequency of hemodynamic measurements, when to
discontinue the PAC, if the introducer is to be capped or a single lumen infusion
catheter (SLIC) inserted, and a post insertion chest-ray.
B. The use of PACs is limited to critical care areas, Operating Room (OR), and Cardiac
Cath Lab for patients age 16 and above.
C. No medications should be administered through the distal PA port of the catheter unless
written by provider.
D. For an accurate reading, the transducer needs to be placed at the phlebostatic axis
(fourth [4
th
] intercostal space, mid axillary line that is in line with the right atrial level).

IV. PROCEDURE LIST

A. Assembling, Priming and Inserting a PAC
B. Obtaining Pressure Readings from a PAC
C. Obtaining Cardiac Output from a PAC
1. Procedure for Closed Injectate System for Thermodilution
2. Continuous Cardiac Output Monitoring for Adult Patients Using Arterial Line and
FloTrac Sensor
3. Troubleshooting
D. Systemic Venous Oxygenation (SVO
2
) Monitoring
E. Drawing Mixed Venous Blood from a PAC
F. Maintenance of a PAC
G. Discontinuation of a PAC
H. Single Lumen Infusion Catheter (SLIC) Insertion


Page 2 of 19

V. ASSEMBLING, PRIMING AND INSERTING A PAC

A. Assembly of a Pressure Transducer Cardiac Output and Continuous Flow Tubing System
1. Equipment
a. 500 mL IV bag normal saline
b. Pressure infusion bag
c. Monitoring kit
i. Pole mount or patient mount
ii. Monitor extension set (optional)
iii. In-line injectate sensor
iv. Closed injectate tubing kit
v. Line change labels
vi. 500 mL D5W for CO
vii. SVO
2
monitor, computer and cable if using the oximetric PAC
2. Two Methods of Connecting Transducer (Adult): bridge or straight transducer (see
Related Resource):
B. Procedure for Priming Transducer Tubing
1. Using aseptic technique, flush the appropriate pressure transducer and continuous
flow flushing system.
a. Tighten all unbonded connections.
b. Clamp pressure tubing. Connect the normal saline solution and IV tubing to
non-pressurized portion of continuous flow tubing. Open clamp on IV tubing.
c. Insert bag of normal saline solution into pressure infusion bag. Do not inflate.
d. Position stopcock arms and pull red rubber flushing device (rattail) or push on
white clips to flush transducer tubing length and each stopcock port. Solution
will flow by gravity.
e. Check system. Remove air bubbles from system. (Bubbles prevent accurate
pressure measurement.)
f. Remove white vented caps and replace with yellow bonded caps found in the
plastic bag in the tubing kit or blue caps. (Bonded caps prevent entry of air or
bacteria into the system.)
2. Inflate bag to 300 mmHg. A pressure of 300 mmHg is required for continuous
infusion of three to six (3-6) mL/hr. Less pressure may result in a loss of line patency.
3. Attach monitoring cable to transducer. Plug cable into appropriate pressure module
on monitor.
C. Insertion of PAC
1. Equipment
a. Appropriate type of PAC (including heparin coated vs. non-heparin coated),
paceport, or oximetric PAC
b. Percutaneous sheath introducer kit with sideport
c. 2 pair sterile gloves for each physician performing procedure
d. 2 boxes of 4x4 gauze sponges
e. Chlorhexidine gluconate
f. 2 large sterile sheets and towels for maximum sterile field
g. Appropriate pressure tubing and transducer system, assembled and flushed
h. Protective precautions equipment (mask and goggle or face shield, sterile
gown, gloves) for each medical person assisting procedure.
i. Sterile 3 mL syringe


Page 3 of 19

j. Sterile 5 mL syringes
k. Three (3) 10 mL normal saline syringes
l. StatLock
®
or 3-0 silk or 3-0 nylon with cutting needle
m. Central line dressing kit (transparent, foam pad, transpore tape)
n. Lidocaine and atropine at bedside per provider order for insertion of PAC
o. IV Solutions with IV tubing for CVP, paceport and sideport of PAC, as
ordered by physician
p. Holder Transducer (Central Services [CS] Item Number 4010956)
D. If utilizing the oximetric PAC, calibration must be completed either prior to insertion or
in vivo (catheter is already in place). Refer to section VIII, Systemic Venous
Oxygenation (SVO2) Monitoring, for the specifics of the calibration procedure.
E. Procedure
1. Explain procedure to patient. Physician is to obtain patient consent before the
procedure.
2. Prior to the procedure, hospital policies regarding the Universal Protocol should be
followed, including: 1) Pre-procedure verification; 2) Site marking; and 3) Taking an
active "Time Out" to verify the five elements: Correct patient, procedure, site,
position and equipment. The Universal Protocol is documented on the clinical record
(refer to UWHC Hospital Administrative Policy 8.48, Operative, Invasive and Other
Procedures).
3. Place an underpad beneath the area designated for catheter insertion. Sites commonly
selected are the subclavian, internal jugular, femoral and antecubital (antecubital is
not common but could be used).
4. Assist physician with patient positioning, preparation of insertion site and
maintenance of sterile technique. Clinicians within close proximity to the sterile field
must don all four (4) components of personal protective equipment prior to insertion
of line.
5. Introducer is inserted using appropriate technique by provider and following UW
Health ClinicalPolicy 2.3.14, Insertion, Maintenance and Discontinuation of Central
Vascular Access Devices for Prevention of Central Line-Associated Bloodstream
Infection (CLABSI)
6. Physician should place a sterile sleeve over catheter to ensure ability to sterilely
reposition PAC.
7. Assist physician in connecting catheter to tubing assembly. The part of the catheter
given to the nurse is not considered sterile. For this reason, it should be kept off the
sterile field and handled by the nurse during catheter insertion. Flush appropriate
transducer and all stopcocks before connecting to the PA catheter.
a. The nurse will connect the PA port to the Luer-Lok
TM
connector on tubing
labeled "PA line," and the CVP port to tubing labeled "CVP line."
b. Pull the rattail or push clips of the intraflow device. Activate flush device on
transducer assembly to flush PA port of catheter.
c. Flush the CVP and PA port using transducer fluid to remove any air from the
catheter.
d. Connect a stopcock or needleless connector to the paceport and flush with
normal saline.
e. MicroClaves should not be attached to any port connected to a transducer.
f. Test patency of balloon with 1-1.5 mL of air by slowly inflating while
observing balloon.


Page 4 of 19

8. Zero the transducer system.
a. Consider selecting the PA Catheter mode on the bedside monitor. Select the
PA Invasive Pressure parameter window, then select catheter insertion to
optimize the PA waveform during insertion.
b. Position transducer at the phlebostatic axis.
c. Open the transducer to air. Turn stopcock arm leading to PA port to an off
position to the patient. Remove yellow cap from the stopcock and discard.
Zeroing the transducer equilibrates the system to atmospheric pressure at a
given reference point. After zeroing, replace sterile cap (with bonded cap,
either blue or white non-vented).
d. Set module to establish zero by touching PA waveform on monitor screen
then touching "zero all pressures" tab that appears on screen. Zero procedure
can also be performed by touching ”setup”, then “zero” on the appropriate
parameter window. If the system does not zero, check all stopcocks and
connections. If system still unable to zero:
i. Change cable and/or pressure module
ii. Change transducer
e. Set system to obtain pressure readings.
i. Replace yellow/blue caps on open ports, maintaining sterility.
ii. Turn stopcock nearest transducer off to air port.
9. The physician inserts the PAC through a previously inserted introducer. As catheter is
advanced, observe waveform on monitor screen. A strip recording can be printed for
documentation.
10. Assess changes in pressure waveform and record pressures as catheter is advanced
through the central venous, right atrial, right ventricular, and pulmonary arterial
compartments (Figure 3).



Figure 3. Pressure tracing as the catheter is advanced

11. During insertion, monitor and notify physician of any changes of EKG rhythm
including ectopy or any changes in vital signs.
12. Following PAC insertion and proper placement, the physician sutures the introducer
catheter or secures it with a StatLock
®
. Apply a Biopatch
®
or CHG dressing to the
insertion site, a transparent adhesive dressing (preferred over gauze), or GuardIVa or
hemcon over the oozing site).
13. Length of insertion is verified after the catheter is secured and is recorded in the
clinical record. Insertion length will be re-verified every shift and PRN. The average
insertion length is:
a. 45-55 cm from internal jugular and subclavian
b. 70-80 cm from femoral and antecubital


Page 5 of 19

14. Draw back on CVP and paceport to assure blood return. Then, flush with normal
saline to maintain patency. Secure the transducers in the holder at the phlebostatic
axis if possible.
15. Catheter placement is confirmed by provider with chest x-ray prior to infusion. A
chest x-ray is used to assure proper catheter placement and to rule out pneumothorax
or other complications.

VI. OBTAINING PRESSURE READINGS FROM A PAC

A. Position patient supine with head of bed flat or up to 45 degrees, as tolerated. Document
and maintain consistent patient position for successive pressure readings.
B. Obtain PA, CVP, and PAOP pressure readings. PA, CVP and PAOP readings should be
measured at end-expiration. You may obtain strip recording of each waveform, interpret
waveform values and document on flowsheet a minimum of every eight (8) hours or
more frequently as ordered or set forth in unit policy.
C. Wedge Readings (PAOP)
1. Select the PA Invasive Pressure parameter window, select the Setup tab, then select
Show PCWP. Balloon should be inflated for no more than 8-15 seconds with usually
less than one (1) mL being sufficient with a maximum of 1.5 mL (less for PICU
pediatric patients). Assess for proper waveform.
2. Stop inflating when proper wedge waveform is obtained. Freeze PAOP pressure
waveform on screen by touching "freeze/adjust". Immediately allow balloon to self-
deflate. Upon completion of wedge procedure, the "locking" mechanism should be
engaged with the syringe in the empty/depressed position. Also, monitor for signs of
balloon rupture which can occur with multiple inflations of the balloon.
a. Patients who are elderly and suffer from pulmonary hypertension are
especially prone to PA rupture.
b. If the balloon has ruptured, there will be no resistance during inflation and no
wedge tracing. In the case of balloon rupture: Avoid a second inflation, as
more air will be introduced into the pulmonary circuit producing a large
air embolus. Remove the balloon syringe and mark port "Do Not Use".
3. Use arrows on screen to locate point of end-expiration and place cursor at that point.
Touch "Confirm Wedge" to save value.
4. Notify provider if unable to obtain wedge waveform or if spontaneous wedge occurs.
CAUTION: A continuous wedge tracing indicates there is no blood flow distal to
catheter. This causes tissue necrosis and pulmonary infarction. Notify provider ASAP
to reposition catheter.
D. CVP Readings
1. Bridge Method:
a. Turn stopcock off to injectate syringe.
b. Turn stopcock off to any IV fluids infusing.
c. Turn stopcock off to PA transducer.
d. Obtain reading.
e. Return stopcocks to original position.
f. Once reading is obtained, IV fluids can be resumed.
2. Straight Transducer Method:
a. Turn stopcock leading to CVP open to patient and transducer if necessary to
temporarily stop medications or fluids administered through the line.


Page 6 of 19

b. Assess for change in waveform.
c. Obtain reading.
d. Resume IV fluids and turn stopcock off to CVP pressure line.
E. Adjust the alarm limits to set high and low alarm limits for all hemodynamic parameters.
Verify alarm status on.
F. Document pressure readings in the nursing flowsheet.

VII. OBTAINING CARDIAC OUTPUT FROM A PAC

A. Procedure for Closed Injectate System for Thermodilution
1. Equipment
a. 500 mL bag of D5W or normal saline solution
b. Closed injectate tubing kit (warm or cold)
c. 10 mL syringe
d. Injectate sensor
e. Line change labels
2. Assembly of the Closed Injectate System for Thermodilution
a. Select appropriate injectate kit. Room temperature (warm) injectate and kit
may be used for all patients not requiring severely restricted fluid intake. Cold
(iced) injectate and kit is used for patients who require severely restricted
intake, are hypo or hyperthermic, are in very low output states or are febrile.
Cold injectate may improve the accuracy of the CO measurement for patients
with low or high CO.
b. Using clean technique, add in-line injectate sensor to system tubing, distal to
the 10 mL syringe.
c. Connect tubing to solution and flush system, removing all air from solution
bag, tubing, syringe and stopcock. System should be free of air to prevent air
embolism and maintain accuracy of readings.
d. Clamp tubing below solution bag. (Prevents excess fluid from flushing
through the system by gravity drainage.)
e. Connect distal stopcock to proximal (CVP) port of PAC. Injectate syringe
should be connected so that fluid will inject into catheter in a straight line.
f. Connect monitor CO cables to appropriate sensor and thermistor ports.
g. Check monitor for correct computation constant from the Setup tab in the
Cardiac Output parameter window Change settings on monitor if necessary.
For accurate readings, computation constant must correlate with catheter size,
injectate volume and temperature of injectate (room temperature or cold).
Label tubing with dated stickers according to UWHC Hospital Administrative
Policy 8.18, Vascular Access (Venous and Arterial).
3. Obtaining Cardiac Output Measurements With Room Temperature (Warm) Injectate
a. Verify the correct computation constant is in the bedside monitor. Refer to
hyperlink at the end of the policy to find it based on the pulmonary artery
catheter type. You can check the correct computation constant for the
patient’s PAC in the resource tab.
b. Select the Cardiac Output parameter window.
c. Verify the patient’s height and weight is entered in the Demographics menu
from the Measurement tab.


Page 7 of 19

d. Fill injectate syringe from 500 mL solution bag by opening clamp and
pulling back on syringe plunger to 5 or 10 mL. Exact volume of injectate must
be used for accurate readings, and must correlate to computation constant
entered in monitor. Clamp tubing below solution bag to prevent excess
injectate volume from entering syringe.
e. If infusing fluids through proximal port, temporarily stop IV fluids and open
stopcock between CVP port and CO syringe. Delivery of injectate along a
straight tubing connection allows for smooth delivery of fluid into catheter
and more accurate readings.
f. Select the Measurement tab, then “Start CO”. When monitor reads "inject
now", inject solution smoothly and quickly (less than four [4] seconds) into
catheter. CO is calculated by changes in the temperature of the blood in the
PA over time.
g. Observe the curve of the waveform produced. CO waveforms on monitor
should consistently show a smooth, rapid upstroke to be considered valid.
h. Obtain a minimum of three (3) consecutive readings for an average CO.
Allow 1-1.5 minutes between injections to stabilize the catheter baseline
temperature.
i. Press "edit average", and check the selection boxes for those trials that you
wish to include in the CO average. Eliminate values with 10% variance. Press
Confirm CO and the monitor will calculate average CO. Press "Calculations"
from the Measurement tab to obtain other hemodynamic parameters.
j. Add total amount of injectate volume (milliliters) to patient's I & O
flowsheet.
4. Obtaining Cardiac Output Measurements with Cold (Iced) Injectate
a. Assemble system as described in section “VII.A.2”. Place coiled tubing in
styrofoam cardiac output (CO)-set container and cover with ice. Periodically
refill container with ice to maintain cold solution.
b. Attach CO-set container to IV pole using holder provided.
c. Open clamp on tubing below 500 mL solution bag. Withdraw and waste 10-15
mL of D5W through stopcock distal to syringe. System must be cleared of
warm solution along length of tubing external to ice container.
d. Fill injectate syringe with 5 or 10 mL of iced solution by pulling back on
plunger. Exact volume (either 5 or 10 mL) of iced injectate must be used for
accurate sensing of temperature change in PA, and must correlate with
computation constant entered in the monitor.
e. Clamp tubing below solution bag. (Prevents excess injectate volume from
entering syringe.)
f. Inject first 5 mL of solution into patient without measuring CO. Catheter
length must be cooled before accurate sensing and measurement can be
obtained.
g. Continue with steps “c through g” in section “VII.A.3.” to obtain readings.
Document amount of fluid used.
h. Add total amount of injectate volume (milliliters) to patient's I & O flowsheet.
B. Continuous Cardiac Output Monitoring for Adult Patients Using Arterial Line and
FloTrac Sensor
1. Equipment


Page 8 of 19

a. EV1000 monitor, EV1000 trifurcated pressure cable and EV1000 bedside
monitor pressure cable
b. FloTrac sensor kit (CS Item Number 4070894)
c. 500 mL normal saline
d. Pressure bag
e. Central line dressing change kit
2. Sensor Set Up and Zeroing
a. Turn on EV1000 monitor and enter patient information.
b. Open FloTrac sensor kit. Remove FloTrac sensor and prime system.
i. Spike 500 mL bag of normal saline, keeping drip chamber inverted.
ii. While keeping IV bag inverted, gently squeeze air out of bag while
pulling flush tab with the other hand until air is emptied from IV bag and
drip chamber is filled halfway.
iii. Insert IV bag into pressure bag and hang on IV pole. With gravity only
(no pressure in pressure bag), flush FloTrac sensor holding pressure
tubing in upright position until the fluid reaches the end of the tubing
and no air remains.
iv. Pressurize the pressure bag to 300 mmHg.
v. Fast-flush the FloTrac sensor and tap on tubing and stopcocks to remove
any residual bubbles.
vi. Replace all caps with non-vented caps and ensure that all connections
are tight.
c. Connect the distal end of the FloTrac sensor tubing to the arterial catheter hub
using sterile technique. Remove any pre-existing extension tubing pieces, if
possible, as different tubing diameters may impact results. If dressing is
removed, reapply a new sterile dressing according to UWHC Nursing Patient
Care Policy 1.11, Arterial Catheter/Insertion, Maintenance, Blood Drawing,
and Discontinuation (Adult & Pediatric).
d. Connect the bedside monitor’s arterial pressure cable to the white cable
connector on the FloTrac sensor.
e. Connect the green connection on the trifurcated pressure cable from the
EV1000 monitor to the green cable connector on the FloTrac sensor.
f. Level the FloTrac sensor to the phlebostatic axis and zero. NOTE: It is
important to keep the FloTrac sensor level to the phlebostatic axis at all times
to ensure accuracy of CO.
i. Open the stopcock to atmospheric air.
ii. Zero the arterial channel on the bedside monitor (refer to Nursing Patient
Care Policy 1.11).
iii. Zero the EV1000 monitor by selecting Clinical Actions (white box with
red cross icon) and select “Zero & Waveform”. Select the “-0-” icon
next to the arterial waveform. Then touch Home icon.
iv. Close stopcock to air and place new blue cap on port.
3. Hemodynamic Measurements
a. CO will be displayed in 40 seconds and automatically updated every 20
seconds.
b. CO, cardiac index (CI), and stroke volume variation (SVV) are continuously
displayed and updated every 20 seconds on the EV1000 monitor.


Page 9 of 19

c. Systemic vascular resistance (SVR) can be calculated manually or
continuously.
i. To manually derive SVR, select the Clinical Actions icon, then select
“Derived Value Calculator”. Touch “CVP” and enter current value. SVR
and SVR indexed (SVRI) will then display.
ii. To continuously display SVR, the following are required: continuous
CVP monitoring, a pressure slave cable for the EV1000 monitor and
analog-capable pressure box for the CVP module.
4. Maintenance
a. To ensure accurate values:
i. Re-zero the FloTrac each shift.
ii. Assess arterial tracing using square wave test each shift.
• Pull and release flush tab on transducer
• Observe square wave on bedside monitor
• Count oscillations
o Optimally damped: 1.5-2 oscillations before returning to
baseline.
o Underdamped: greater than two (2) oscillations. Systolic
blood pressure is overestimated and diastolic blood
pressure may be low or normal. The FloTrac results will be
falsely overestimated of CO.
o Overdamped: less than one (1) oscillation. Systolic blood
pressure falsely low and diastolic blood pressure may be
high or normal. The FloTrac results will be falsely
underestimated of CO.
b. Ensure that all arterial blood pressure alarms on the bedside monitor are
activated.
c. The sensor tubing is changed every 96 hours, according to Nursing Patient
Care Policy 1.11.
d. For monitor troubleshooting, use onscreen troubleshooting by pressing by
pressing Setting (gears) icon on main screen.
5. Discontinuation
a. When FloTrac monitoring is discontinued, disconnect the green EV1000 cable
from the transducer and turn EV1000 monitor off.
b. If continuous arterial waveform monitoring is continued, and tubing set is
within 96 hours from initiation, continue monitoring using current transducer
set up and cable.
c. If continuous arterial waveform monitoring is continued, and tubing set is due
to be changed, prime and connect new standard arterial pressure tubing,
transducer, and flush solution, according to Nursing Patient Care Policy 1.11.
If continuous arterial waveform monitoring is discontinued, remove arterial
line according to Nursing Patient Care Policy 1.11.
C. Continuous Cardiac Output Monitoring for Adult Patients Using ClearSight System
1. Equipment
a. EV1000 monitor and pump unit
b. ClearSight pressure controller cable and heart reference sensor (HRS).
c. ClearSight finger cuff (available in small, medium and large)
d. Patient monitor adapter cable and pressure cable.


Page 10 of 19

2. Sensor setup
a. Turn on EV1000 monitor and connect ClearSight pressure controller cable to
the side of the pump unit.
b. Wrap the wristband around the patient’s wrist with the finger cuff ports
facing the patient’s fingers.
c. Determine the correct finger cuff size for the patient using the sizing guide.
d. Apply the cuff to the index, middle or ring finger of the patient. Center the
finder cuff between the first two knuckles and wrap snugly ensuring the end
of the finger cuff lies inside the green zone on the inside of the finger cuff.
The air hose should be positioned underneath the patient’s finger.
e. Connect the air hose from the finger cuff into the port labeled Cuff 1. A
green LED light should illuminate when the cable is properly connected. An
orange flashing light indicates the finger cuff is expired and should be
replaced.
f. Connect the HRS to the respective port on the pressure controller. When it is
properly connected a green heart will illuminate on the pressure controller. If
it illuminates orange, the HRS should be replaced.
g. Enter the patient demographics on the patient data screen and tap the Home
button to confirm.
h. The Zero and Waveform screen should appear. To Zero the HRS hold the
finger component and the heart component at the same vertical level ensuring
the horizontal lines are aligned. Tap the align and zero HRN button.
i. When zeroing is complete, connect the finger component to the tap on the
finger cuff. Then connect the heart component to the patient at heart level.
j. To start monitoring, tap the green pump unit start/stop icon on the display. A
arterial waveform should display at the top of the screen.
k. Connect the patient monitor adapter cable to the pump unit and patient
monitor pressure cable. Connect the pressure cable to patient monitor. On the
Zero and Waveform screen move pressure output selection to the zero
position and then zero the bedside monitor. Move the pressure output
selection back to the signal position.
3. Hemodynamic Measurements
a. Continuous noninvasive blood pressure is displayed as a five beat average.
b. Additional hemodynamic parameters are displayed at a 20 second average.
c. Systemic vascular resistance (SVR) can be calculated using a CVP value.
i. To manually derive SVR, select the Clinical Actions icon, then select
“Enter CVP”. Enter current CVP value and then touch the Home button.
SVR and SVR indexed (SVRI) will then display.
ii. The CVP value must be updated as the value changes.
4. Maintenance
a. The finger cuff should be moved to a new finger every 8 hours.
Alternatively, a second finger cuff can be applied on an adjacent finger
following the steps above and connect it to the port labeled Cuff 2. The
measurements will alternate between the fingers every hour for up to 72
hours.
b. For monitor troubleshooting, use onscreen troubleshooting by pressing by
pressing Setting (gears) icon on main screen and selecting ClearSight.



Page 11 of 19

C. Troubleshooting for Pulmonary Artery Catheter

Problem Cause Prevention Treatment
Dampened
pressure tracing or
abnormally high
readings



Stopcock turned
improperly
Turn stopcock in
proper sequence
After verifying stopcocks
are turned correctly,
thoroughly flush PAC to
assess patency
Partial occlusion of tip
by clot
Use continuous drip
flush solution.
Assure pressure bag
is at 300 mmHg.
Aspirate clot with syringe,
flush with saline
Catheter tip against
vessel wall
Flush with pigtail
flush device
May need to reposition
catheter or ask patient to
cough as this may assist
in moving catheter away
from vessel wall
Air bubbles in
transducer
Flush all air from
system during
initial set-up
Check system for air
bubbles and remove
carefully to avoid air
embolism risk to patient
Inappropriate
pressure
waveform

Catheter tip in wrong
location, for example,
in RV or PA capillary
instead of PA
Notify physician ASAP,
catheter may need to be
repositioned
Movement of catheter
tip against wall of
chamber
Catheter should be
sutured or secured
with StatLock
®
in place
by physician
Negative or
inappropriately
low pressure


Transducer level
higher than mid chest
Maintain patient in
same position for
serial pressure
measurements
Re-level transducer
position to right atrium
Loose connection in
system
Use Luer-Lok
TM

stopcocks. Assess
all connections and
stopcocks every
shift.

Extreme negative
intrathoracic pressure
generated during
inspiration
Unavoidable Correlate readings with
end expiration


Page 12 of 19

No pressure
reading displayed

Transducer not open
to catheter
Follow routine,
systematic steps for
pressure
measurements
Check all system
stopcocks
Transducer plugged
into wrong outlet.
Tracing on monitor
not turned on.
Re-check system If still no reading, change
transducer
Catheter whip
(high bizarre,
peaked pressure
waveform)
Excessive catheter
movement,
particularly in
pulmonary artery
Usually
unavoidable
Place dampening device
on catheter, if still too
much whip, catheter may
need to be repositioned.
No temperature
change for CO
measurements
Environment; febrile
patient; CO over 10
Usually
unavoidable
Use iced injectate

VIII. SYSTEMIC VENOUS OXYGENATION (SVO
2
) MONITORING

A. Equipment
1. Oximetric PAC
2. SVO
2
monitor, computer and cable
3. Pressure tubing and transducer
4. Supplies for PAC line insertion (see section V.C.1.)
B. There are two options for calibration of SVO
2
: (1) in vitro (prior to insertion of PAC) and
(2) in vivo (PAC is already in place).
1. Pre-insertion
a. Prepare for oximetric PAC thermodilution catheter insertion using the same
process for all of the procedures except calibrating the PAC using an 8.5 Fr
introducer.
b. Zero pressure transducer following directions in section “V.E.8”.
c. Set up SVO
2
monitor at bedside in preparation. Turn oximetric SVO
2
monitor
on.
d. Calibrate the PAC
i. During insertion: Press “CAL” for in vitro calibration prior to insertion.
ii. Press “P” for Pre-insertion.
iii. Connect optical module to optics port of catheter. You should see a
white light on at the end of the oximetric PAC.
• For patients returning from OR with oximetric catheter in place,
follow instructions in vivo calibration.
iv. Press “Y”.
v. Wait for “CAL OK”, then remove catheter from sterile housing. Assess
for light presence at catheter tip and assist with insertion of catheter.
• If pre-insertion calibration was unsuccessful, check modules
connection, verify catheter tip in optical reference, repeat pre-
insertion calibration.



Page 13 of 19

• If second failure occurs, obtain new catheter. Handle catheter
gently. Fiber optics can be damaged if not handled properly.
2. After Insertion
a. Assure the catheter is in position, then press “CAL”.
i. Any intensity tracing of less than three (3) dots is an invalid SVO
2

value. Causes of poor intensity signal are kinks, clots, loop position, or
catheter against vessel wall.
ii. To troubleshoot, look at the waveform and assure that it is a PA
waveform, look at how far the PAC is in (number of cm), look for external
kinks, or flush the system.
iii. The physician may choose to inflate PA balloon and reposition the
catheter or obtain a CXR.
b. Press “L” for light intensity. Confirm that light intensity tracing covers a
minimum of three dots on vertical display to right of visual screen. If so, press
“Y” and proceed to in vivo calibration.
i. To check optical module, disconnect the catheter from optical module,
dim lights and place in area out of direct light.
ii. If low light message goes away, catheter is damaged and should not be
used. Notify physician.
iii. If low light persists, optical module or computer is faulty. Notify
physician.
3. Invivo calibration is necessary only when catheter becomes disconnected at optical
module, when not obtaining adequate light intensity, or with certain SVO
2
.
a. Press “CAL”.
b. Press “I” for “invivo calibration”.
c. Draw three (3) mL blood to waste from distal PA port.
d. Press “Y”, then draw one (1) mL sample and send to lab in the heparinized
syringe, marking venous and O
2
saturation on the lab sheet or rover label.
Make sure the PA port is well flushed to prevent dampening of waveform or
clot formation.
e. If venous saturation lab value is within +4 of reading on SVO
2
monitor, press
“Y”.
f. If lab value is greater than 4 press “N”. Enter the lab venous saturation < /P >
value pressing the up or the down arrow.
g. Press “Y” to confirm and complete calibration.
4. Maintenance
a. Perform CO using bedside monitor (see section VI).
b. Enter new computation constant into monitor.
i. Select “CO” on procedures menu.
ii. Select “set-up CO”.
iii. If the oximetric PAC was placed in another facility, check the
computation constant to assure it is correct.
c. Assess light intensity display for adequacy, trouble shooting as necessary.
i. Display must cover three (3) dots.
ii. Troubleshooting for high and low intensity messages is found on reference
cards at bottom of SVO
2
computer.
d. Secure optical module to upper extremity nearest insertion site. To avoid
damaging fiber optics, handle and secure catheters carefully avoiding kinking.


Page 14 of 19

e. To transport, disconnect cable at computer, not at catheter/optical connection.
Recalibration is not necessary as long as catheter is not disconnected at the
optical module. If saving data:
i. Press “logo” key.
ii. Select “SVO
2
data”.
iii. Press “S” to save SVO
2
data.

IX. DRAWING MIXED VENOUS BLOOD FROM A PAC

A. Equipment
1. Health Link lab request forms, patient or rover labels
2. Blood tubes
3. PICO
®
syringe (if needed)
4. Syringes
5. Transfer device
6. Luer-Lok
TM
caps
B. Procedure
1. Perform patient identification and match to laboratory forms and labels.
2. Validate balloon deflation. Do NOT pull back on syringe to check if balloon
completely deflated. If balloon is not deflated, open balloon syringe locking
mechanism and watch to see if balloon deflates on its own and verify PA waveform
on monitor. Mixed venous blood sample should be obtained with the PAC not in a
wedged position to prevent it from becoming partially contaminated with arterial
blood (and, therefore not being a mixed venous sample).
3. Attach a 10 mL sterile syringe to PA port stopcock.
4. Turn stopcock off to flush solution. Aspirate 3-5 mL of blood for waste to assure
purity of sample. Additional waste is required if blood is withdrawn for coagulation
studies.
5. Close stopcock halfway and remove syringe maintaining sterile technique. Discard
syringe.
6. Attach blood sample syringe to stopcock; open stopcock to syringe and PA port;
aspirate blood sample. (Utilize PICO
®
syringe to obtain mixed venous blood gas.)
Label blood gas syringe with patient's label at the patient bedside.
7. Turn stopcock to halfway position and remove blood sample. Purge air from syringe
and cap with black luer cap. If drawing venous blood gas, indicate “venous” and
FIO2 (if appropriate) on lab request form and transport to Core Laboratory
immediately.
8. Open stopcock between flush system and sampling port. Flush port until all blood is
removed. Recap port with sterile Luer-Lok
TM
caps.
9. Open stopcock to patient between flush system and PA port; flush until line is
cleared. Flush port until all blood is removed. Assess for dampened waveform. If
there is a dampened waveform, flush the system again. Reassess waveform and
pressure readings.
10. Observe monitor for return of an appropriate PA tracing.






Page 15 of 19

X. MAINTENANCE OF A PAC

A. At the start of each shift:
1. Assess the line for air bubbles.
2. Ensure all stopcocks are tight.
3. Ensure that adequate pressure (300 mmHg) is present in the pressure infusion bag.
4. Ensure that the transducer is at the phlebostatic axis.
5. Record the length of insertion of catheter and compare to previous findings.
6. If utilizing the oximetric pulmonary catheter, calibration is to be done every shift.
Refer to section VII. Systemic Venous Oxygenation (SVO
2
) Monitoring for
calibration specifics.
B. Accuracy of system will be assessed once a shift and PRN by:
1. Square wave test.
2. Zero transducer.
3. All IV tubing and flush solutions are changed every 72 hours. Refer to Nursing and
Patient Care Policy 1.56 AP, Central Vascular Access Device Use, Maintenance and
Removal (Adult & Pediatric). Tubing should be labeled with change dates. Record on
dressing date and time of dressing change and initials.
4. Dressing changes according to Hospital Administrative Policy 13.26 Insertion and
Maintenance of Central Venous Catheters for Prevention of Central Line-Associated
Bloodstream Infection (CLABSI).
C. Data collection and documentation requirements:
1. Position patient on back with the head of bed between 0-45 degrees. Document
degree of elevation for consistency.
2. All values will be obtained at end-expiration.
3. CVP, PA pressure and PAOP values every 1-4 hours, as ordered or PRN.
4. CO and derived hemodynamic parameters every four (4) hours, as ordered or PRN.
5. CVP, PA pressure and PAOP waveforms are recorded each shift.
6. If unable to wedge catheter, notify provider, and use PAD for calculation.
7. Assess for catheter complications (thrombus, infection, migration) frequently and
comply with all recommended maintenance procedures to minimize risk.

XI. DISCONTINUATION OF A PAC

A. Policy
1. The physician is responsible for ordering the removal of the PAC.
2. The physician is responsible for ordering either the removal of the introducer,
capping of the introducer, or the insertion of a SLIC.
3. RN removal of PACs is limited to the Cardiothoracic Surgery ICU, Cardiac ICU, and
TLC, and to registered nurses who have been trained in PAC removal.
4. Two RNs need to be present for the removal of the PAC and/or PAC plus introducer.
5. The PAC alone may be discontinued, leaving the introducer in place for central
intravenous access.
B. Equipment
1. For removal of PA/central venous catheter and introducer:
a. Sterile scissors
b. 4x4 gauze and tape
c. Antibiotic ointment


Page 16 of 19

d. Specimen container and extra pair of sterile scissors if culturing the tip
e. Non-sterile exam gloves
f. Central dressing kit
2. For removal of PAC only:
a. Appropriate introducer cap
i. Obturator cap (larger white cap) (CS Item Number 4006410)
ii. Obturator advanced venous access (to be used with introducer 8720249 9F
Mac kit- one OR uses for cardiac cases) (CS Item Number 4006409)
iii. Valve obturator hemostasis (blue) (CS Item Number 4006408) (to be used
with introducer CS Item Number 1203360)
b. Central line dressing kit
c. Non-sterile exam gloves
d. Chlorhexidine swab
C. Procedure
1. Obtain an order for discontinuation of the PAC and introducer, or the PAC only,
and/or SLIC insertion.
2. Explain procedure to patient.
3. Perform hand hygiene with alcohol hand gel (preferred) or soap and water according
to UWHC Hospital Administrative Policy 13.08, Hand Hygiene.
4. Close all stopcocks to patient on all ports. Plan to have new IV bags and IV tubing
primed and transferred from PAC line to other infusion sites as appropriate. Ensure
patient is stable after the transfer of drips to other sites before discontinuing PAC.
5. Place patient in a supine position, HOB flat or slight Trendelenburg with the patient’s
head turned away.
6. Ensure balloon is deflated by aligning red line on balloon port. Assess waveform and
open clamp on syringe port to assess if balloon deflates any more, then disconnect
syringe.
7. Perform hand hygiene.
8. Don non-sterile exam gloves and remove old dressing.
9. Unfasten (unscrew) the sleeve adaptor connected to the introducer sheath. Remove
non-sterile gloves. Perform hand hygiene. Don sterile gloves.
10. Instruct patient to hold breath at end of deep inspiration or while being delivered
a mechanically ventilated breath. The purpose is to prevent air embolism. You may
want to practice this before removing PAC.
11. With the PAC still transduced, using steady movement, withdraw the PAC carefully
over approximately five (5) seconds while observing the monitor for dysrhythmias
and changes in vital signs. Some dysrhythmias may be observed as the catheter tip is
pulled through the right ventricle; however, these dysrhythmias should disappear
once the catheter has been removed.
12. If any resistance or tugging is felt during removal, DISCONTINUE the procedure and
call the provider.
IMPORTANT: Resistance may indicate possible knotting or looping of the PAC
or the catheter potentially may be caught on an intracardiac structure (i.e.,
valve).
13. Ensure complete removal of the PAC by evaluating the structure of the PAC in its
entirety.


Page 17 of 19

14. After the catheter is removed, immediately insert sterile cap into introducer (if
introducer is to remain in place). If introducer remains, perform central line site care
according routine and apply Biopatch
®
or CHG transparent dressing.
15. If you are also removing introducer, verify provider order to remove catheter. Follow
steps in UWHC Nursing Patient Care Policy 1.56 AP, Central Vascular Access
Device Use, Maintenance and Removal (Adult & Pediatric)
16. If patient is on mechanical ventilator, remove catheter at the end of delivery of
inspiratory breath. During catheter removal, if resistance is met: stop and call
provider immediately.
17. Review orders to determine if culture tip needs to be cultured. If culture of tip is
ordered, see Hospital Administrative Policy 8.18. You will need two (2) people for
this procedure to prevent contamination. Do not culture tip unless ordered by provider
for suspected infection.
a. PAC only: If physician has ordered culture of PAC and/or introducer tip, have
sterile scissors and sterile specimen cup ready. As soon as catheter and/or
introducer is removed, cut off tip of catheter into sterile cup. Label specimen cup
and send to lab for culture. Avoid contamination of catheter tip with skin, gloves
and dressings. If contamination occurs, do not send for culture.
b. PAC and introducer: Follow process in 17a for PAC. For introducer removal,
follow Policy 13.26 Insertion and Maintenance of central venous catheters for
prevention of central line-associated bloodstream infection (CLABSI). You will
need a second set of sterile scissors to cut the catheter tip into a sterile specimen
cup.
18. If introducer is not discontinued, a sterile cap must be placed onto the introducer after
the PAC is removed. Perform site care as noted in section “X.C”. Introducer should
be removed within 24 hours if unused and according to provider order.

XII. SINGLE LUMEN INFUSION CATHETER (SLIC) INSERTION

A. Equipment
1. Arrow 7 Fr. 8 inch single lumen infusion catheter (SLIC) [CS # 2200262]
2. Chlorhexidine gluconate swab
3. IV set connector:
a. IV set connector and MicroClave (CS # 2203480) if no hemodynamic monitoring
will be done through SLIP port
b. IV set connector without MicroClave (CS # 1203493)
4. Saline flush (10 mL)
5. Alcohol pads
6. Sterile gloves
7. Central dressing kit
B. Procedure
1. Obtain provider order.
2. Perform hand hygiene according to Hospital Administrative Policy 13.08.
3. Discontinue PAC as described in section XI, Discontinuation of PAC. Cleanse end of
introducer with chlorhexidine gluconate swab for one (1) minute. Allow to dry (do
not blow, blot or wipe chlorhexidine away). A second person may be needed to hold
this introducer tip with sterile gloves to prevent it from becoming contaminated.


Page 18 of 19

4. Using sterile technique, insert SLIC into introducer. Turn hub to lock it into place on
the introducer. Stop procedure and notify provider if any resistance is noted with
insertion.
5. Remove blue cap of SLIC and pull out obturator. Observe for immediate blood
return. Notify provider if there is no blood return and do not use SLIC for infusion.
6. Place needleless connector with IV set connector on end of SLIC.
7. Flush SLIC according to flushing guidelines.
8. If obtaining CVP pressure readings after the PAC catheter is removed, the SLIC port
is the best option. If obtaining CVP pressure readings through the SLIC port, a
needleless connector should not be used.
9. Document procedure in the patient’s clinical record.
10. Complete central line insertion checklist.

XIII. UWHC CROSS REFERENCES

A. Flushing/Locking of Venous Access Devices - Adult/Pediatric Inpatient/Ambulatory
Clinical Practice Guideline (U-Connect)
B. Hospital Administrative Policy 8.48, Operative, Invasive and Other Procedures
C. Hospital Administrative Policy 13.08, Hand Hygiene
D. Hospital Administrative Policy 13.26, Insertion and Maintenance of Central Venous
Catheters for Prevention of Central Line-Associated Bloodstream Infection (CLABSI)
E. Nursing Patient Care Policy and Procedure 1.11, Arterial Catheter/Insertion,
Maintenance, Blood Drawing, and Discontinuation (Adults and Pediatrics)
F. Nursing Patient Care Policy 1.45A, Central Venous Pressure (CVP) Monitoring (Adult)
G. Nursing Patient Care Policy 1.45P, Central Venous Pressure Monitoring (CVP)
(Pediatric)
H. Nursing and Patient Care Policy 1.56 AP, Central Vascular Access Device Use,
Maintenance and Removal (Adult & Pediatric)

XIV. Link to computation constants:
http://ht.edwards.com/resourcegallery/products/swanganz/pdfs/compconst35633.pdf

XV. REFERENCES

A. Busse, L., Davison, D. L., Junker, C., & Chawla, L. S. (2013). Hemodynamic monitoring
in the critical care environment. Advances in Chronic Kidney Disease, 20(1), 21-9.
B. Centers for Disease Control and Prevention (CDC) (2002). Guidelines for the Prevention
of Intravascular Catheter-Related Infections. MMWR, 51(RR10), 1-26.
C. DeHaan, R. J., DeNeef, M., Heijboer, H., & Van Woensel, J. B. M. (2002). The efficacy
of heparinization in prolonging patency of arterial and central venous catheters in
children: a randomized double-blind trial. Pediatric Hematology and Oncology, 19, 553-
560.
D. Druding, M. C. (2000). Integrating hemodynamic monitoring and physical assessment.
Dimensions of Critical Care Nursing, 19(4), 25-30.
E. Givertz, M. M. (2011). Hemodynamic Monitoring to Guide Treatment of Acute Heart
Failure. Journal of Cardiac Failure, 17(9), 726-8.
F. Jesurum, J. (2001). SVO
2
Monitoring. Critical Care Nurse, 21(1), 79-83.


Page 19 of 19

G. Lynn-McHale Wiegand, D. J., & Carlson, K. K. (Eds.) (2011). AACN Procedure Manual
for Critical Care (6
th
Ed.). St. Louis, MO: Elsevier Saunders Co.
H. Lazaridis, C. (2012). Advanced hemodynamic monitoring: principles and practice in
neurocritical care. Neurocritical Care, 16(1), 163-9.
I. Magder, S. (2011). Hemodynamic Monitoring in Mechanically Ventilated Patient.
Current Opinion in Critical Care, 17(1), 36-42.
J. Mims, B. C., Toto, K. H., Luecke, L. E., Roberts, M. K., Brock, J. D., & Tyner, T. E.
(2004). Critical Care Skills. A Clinical Handbook (2
nd
Ed.). St. Louis, MO: Saunders.
K. Plante, A., Ro, E., & Rowbottom, J. R. (2012). Hemodynamic and related challenges:
monitoring and regulation in the postoperative period. Anesthesiology Clinics, 30(3),
527-5.
L. Pinsky, M. R. (2007). Hemodynamic evaluation and monitoring in the ICU. CHEST,
132(6), 2020-9.
M. Polanco, P. M., & Pinsky, M. R. (2006). Practical Issues of Hemodynamic Monitoring at
the Bedside. Surgical Clinics of North America, 86(6), 1431-56.
N. Springhouse (Ed.) (2003). Best practices: a guide to excellence in nursing care.
Philadelphia, PA: Lippincott, Williams & Wilkins.
O. Wall, R. J. (2012). Update on Hemodynamic Monitoring in 2012. Critical Care Alert,
9(10), 73-7.
P. Zevola, D. R., Diosa, J., & Moggio, R. (2002). Comparison of heparinized and
nonheparinized solutions for maintaining patency of arterial and pulmonary artery
catheters. American Journal of Critical Care, 6(1), 52-55.

XVI. REVIEWED BY

Clinical Nurse Specialist, Cardiology
Clinical Nurse Specialist, Cardiac Surgery
Clinical Nurse Specialist, Critical Care
Clinical Nurse Specialist, Neurosurgery
Nursing Education Specialist, Critical Care
Nursing Patient Care Policy and Procedure Committee, October 2016

SIGNED BY

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