Arterial Web #1 ED5.2ppt - Vessel Health• Arterial catheter insertion and pressure monitoring began in the early 1950s. • Invasive hemodynamic monitoring is beneficial for critically

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Arterial Catheter Insertion, Care and Maintenance

Amy Bardin, MS, RRT, VA-BC

© 2012 Saxe Healthcare Communications Sponsored by Teleflex

Learning Objectives

•   Discuss insertion techniques for arterial catheter placement

•   Discuss site selection •   Describe the use of ultrasound for vessel

visualization and catheter insertion •   Review daily maintenance and bundle

strategies for arterial catheters

Continuing Education Credit (CE)

•   At the end of this webinar you can obtain 1.0 contact hour by going to www.saxetesting.com/vh

•   Complete the post-test and evaluation form. •   Upon successful submission, you will be able to print out your

certificate of completion. •   Provider (Saxe Communications) is approved by the

California Board of Registered Nursing. Provider # 14477 • This program has been approved for 1.0 contact hour of

CRCE by the AARC. •   No off-label use of products will be discussed. •   Disclosure: Ms. Amy Bardin did not disclose any conflicts of

interest in relation to this presentation.

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Background

•   Arterial catheter insertion and pressure monitoring began in the early 1950s.

•   Invasive hemodynamic monitoring is beneficial for critically ill patients: •   Continuous monitoring of blood pressure •   Serial blood sampling (gases) •   Facilitates frequent titration of drugs

•   Technology such as, ultrasound has improved insertion success and guidelines for care and maintenance are now available.

Indications for Arterial Cannulation

•   Need for/titration of inotropes or vasopressors

•   Hemodynamic instability (e.g. acute hypertension, hypertensive crisis)

•   Shock •   Multisystem trauma •   Sepsis •   Cardiac arrest •   Cardiac or general

surgery

•   Acute pulmonary embolus •   Respiratory failure •   Primary pulmonary

hypertension •   Intra-aortic balloon pump

therapy •   Mechanical ventilation •   Obstetric emergencies •   Need for arterial blood

gases

Contraindications for Arterial Cannulation

•   Lack of collateral circulation, limited circulation, or poor capillary refill to extremities

•   Negative Allen’s Test or Modified Allen’s Test

•   History of lymphedema to the extremity

•   Presence of arteriovenous fistula or graft

•   Signs of skin or other infection at or near proposed insertion site

•   History of peripheral vascular disease in extremity

•   Use caution with patients receiving thrombolytic therapies and anticoagulants – inserter must be prepared to control excess bleeding after insertion.

Davis FM, Stewart JM. Br J Anaesth. 1980;52:41-47.

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Complications

Insertion-related complications: •   Thrombosis •   Exsanguination •   Embolism (air) •   Hematoma •   Arterial spasm •   Infection •   Tissue necrosis •   Peripheral ischemia •   Peripheral nerve damage

Reducing Infection Risk

Central Line Bundle – evidence-based practices to improve patient outcomes:

•   Hand hygiene •   Maximal barrier precautions during insertion •   Use of chlorhexidine-based solution for skin

antisepsis •   Optimal catheter site selection with avoidance

of the femoral region in adults •   Daily review of line necessity with prompt

removal of unnecessary lines

Insitute for Healthcare Improvement (IHI). Implement the IHI Central Line Bundle. Available at: http://www.ihi.org/knowledge/Pages/Changes/ImplementtheCentralLineBundle.aspx.

Hand Washing

•   The cornerstone of aseptic technique •   Use soap and water or alcohol-based hand rubs. •   Performed at several points during procedure:

•   Before and after palpating insertion sites •   Before and after inserting, replacing,

accessing, repairing, or dressing an intravascular catheter

•   Do not palpate insertion site after application of antiseptic unless aseptic technique is maintained.

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Maximal Barrier Precautions

•   Non-sterile cap and mask, sterile gown, gloves, and large sheet drapes

•   Treat femoral and axillary artery catheter insertion as full surgery: •   Use maximal sterile full-body drapes •   Use special care in application of sterile gloves •   Immediately address episodes of contamination

Skin Antisepsis

•   When preparing skin, use 2% chlorhexidine gluconate (CHG) with 70% isopropyl alcohol. •   Cleanse with back and forth motion, creating friction.

Allows antiseptic to penetrate pores. •   Apply skin preparation solutions should only be applied

to clean skin. •   Prior to skin preparation, wash area with microbial

solution or soap and water. •   Cleanse catheter insertion site by applying antiseptic

solution. Apply back-and-forth motion until all applicator solution is used. Allow to air dry. Do not blot or blow dry.

Sterile Field

•   Open kit in sterile manner by reaching to opposite corner and pulling wrapper toward you.

•   Avoid reaching across sterile field. •   Prepare package and gloves and set aside. •   Don cap, mask, and eye shield first. •   Avoid touching external surfaces, including skin.

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Sterile Drapes

•   Use full-body sterile drape for femoral or axillary artery catheter placement.

•   Do not move or rearrange drape once positioned.

•   Fenestrated areas should be skin-adherent to avoid contamination from un-prepped skin

•   If patient touches drape, cover the area with a sterile towel.

•   Use a small, fenestrated drape for radial and brachial site insertions.

Sterile Field Awareness

•   Always keep sterile and non-sterile items separate.

•   Avoid edges of sterile field are avoided (2-inch barrier). Place sterile items toward center.

•   Consider items or gloves dropped below waist level or behind operator as contaminated.

•   Consider items under sterile drape as contaminated.

•   Replace sterile package overwrapping with full sterile drape

Site Review

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Site Selection

•   The Centers for Disease Control and Prevention specifically address site selection based on infection risk to patients. Guidelines are now available to support insertion techniques that are site specific.

•   Radial, brachial or dorsalis pedis •   Femoral and axillary sites pose increased risk for

infection

O’Grady NP, et al. Am J Infect Control. 2011;39(4 Suppl 1):S1-34.

Most common site for arterial cannulation in the critically ill patient

•   Superficial, easily located •   Provides collateral circulation with ulnar artery •   Minimizes risk of ischemic complications should artery be occluded.

The Radial Artery

Grey H. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918. www.bartleby.com/107/

Radial Site Selection

First choice for arterial cannulation is the radial artery: •   Provides easy access and allows for patient mobility •   Collateral circulation in ulnar artery reduces risk of arterial line-associated complications

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Collateral Circulation

•   Establish collateral blood flow prior to cannulation.

•   If collateral flow is low or absent, choose another site.1,2

•   Radial thrombus in the hand with poor or absent flow may result in ischemic injury to the hand.

•   Assess collateral circulation with a Modified Allen’s Test or Doppler.

1. Venus B, Satish P. Vascular Cannulation. In: Civetta JM, et al. eds. Critical Care . 3rd ed. Philadelphia, PA: Lippincott-Raven; 1997.

2. Levy I, et al. Pediatr Infect Dis J. 2005;24:676-9.

Modified Allen’s Test

1.  Instruct the patient to clench hand into a tight fist. 2.  While hand is clenched, digitally compress both ulnar

and radial arteries. 3.  Instruct the patient to open hand partially. Hand and

fingers should appear pale. 4.  Remove pressure from ulnar artery. Entire hand

should return to normal color within 10 seconds.

Doppler Assessment

1.  Occlude ulnar and radial arteries. 2.  Place Doppler probe distal to radial artery/proximal

to thumb – confirm occlusion by absence of pulsatile sound.

3.  Release ulnar artery. 4.  If pulse restored with continued compression of the

radial artery, collateral circulation is confirmed.

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•   Larger and deeper than radial artery

•   Primary source of circulation for radial and ulnar arteries

•   Exercise caution when cannulating the brachial artery – thrombus may cause circulation problems in arm extremity.


The Brachial Artery

Brachial Site Selection

Second site of choice per CDC guidelines: •   Can be cannulated with a 20g intravascular

catheter with a 3 Fr.-sheath •   This site restricts arm movement, increasing

risk of thrombus formation and ischemia to extremity

O’Grady NP, et al. Am J Infect Control. 2011;39(4 Suppl 1):S1-34

•   Supplies greater part of the lower extremity – direct continuation of the external iliac artery.

•   Provides the truest blood pressure measurements during shock or vasoconstriction.


Femoral Artery

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Femoral Site Selection

•   Third site of choice is femoral artery: •   Highest risk of infection due to high bacterial

colonization of inguinal region •   Consider use of chlorhexidine-impregnated

sponge dressing •   Maximal sterile barriers precautions should be

used

O’Grady NP, et al. Am J Infect Control. 2011;39(4 Suppl 1):S1-34.

Insertion Techniques

Insertion Techniques

Guidewire or Seldinger Technique

•   Most common technique used today. •   Catheter/needle has guidewire, either preloaded or

added before procedure. •   Artery is accessed with needle at ~ 30° to 45° angle. •   Upon blood return, advance guidewire into artery. •   Thread catheter over the wire.

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Guidewire or Seldinger Technique

Traditional Seldinger Technique

Integrated Seldinger Technique

Direct Cannulation

•   Palpate artery. •   Insert over-the-needle catheter:

•   Aim toward center of vessel at ~ 30° to 40° angle •   On appearance of free-flow arterial blood, hold

needle in position and thread cannula over-the-needle into artery.

•   Cannula should advance without resistance.

Intradermal Anesthetic

•   Inject small amount of local anesthetic prior to cannulation (e.g., lidocaine 1%).

•   Place 27- or 30-gauge needle directly between dermal layers.

•   Slowly inject 0.1-0.2 mL of anesthetic (should appear as wheal or bleb).

•   Always aspirate syringe prior to injection to ensure tip of needle is not within the vessel lumen.

•   Avoid subcutaneous injection (may result in smooth muscle relaxation of the arterial wall).

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Ultrasound Guidance

Patient Assessment and Site Selection Using Ultrasound

•   Ultrasound has become standard practice for vascular access device insertions.1,2

•   Effective visual aid •   Reduces unsuccessful insertion

attempts •   Reduces complications and patient

risk •   Allows differentiation between

arteries and veins •   Allows detection of anatomical

abnormalities

1. Shiver S, et al. Acad Emerg Med. 2006;13(12):1275-9. 2. Shiloh AL, et al. Chest. 2011;139(3):524-9.

Performing a Scan

•   Begin with the probe at a 90° angle from the area to be visualized.

•   Use plenty of gel. •   Hold probe with thumb, middle

and index fingers. Other 2 fingers form a base and rest on patient’s arm.

•   Check for screen orientation. •   Adjust screen setting for optimum

image of vessels.

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Performing a Scan

•   Make small movements •   Slide probe and adjust beam

angle (perpendicular) to achieve best transversal image of vessels

•   Vessels will appear as black circles on screen

•   Ensure probe is perpendicular to vessel walls and scan is done at 90° angle

Catheter Insertion

Radial Artery Catheter Insertion

1.  Verify you have correct patient. 2.  Perform patient education and

obtain informed consent. 3.  Perform pre-procedure

verification and time-out. 4.  Place patient in comfortable

position, supine with arms at side.

5.  Explain procedure to patient.

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6.  Gather supplies and equipment. 7.  Wash hands. 8.  Don mask. 9.  Perform pre-assessment and site

selections. Check collateral circulation using Allen’s Test.

10.  Pre-assess with ultrasound if available.

11.   Wash insertion area with antimicrobial solution or soap and water. Dry with clean towel.


12.  Place towel roll under wrist so hand is dorsiflexed and secure.

13.  Wash hands. 14.  Establish sterile field and drop

supplies onto field using caution to prevent contamination.

15.  Don sterile gloves. 16.  Prep insertion area with >0.5%

chlorhexidine gluconate (CHG) with 70% isopropyl alcohol skin preparation solution.


17. Apply small sterile drape to insertion area.

18. Place sterile probe cover on ultrasound probe.

19. Palpate artery. When using ultrasound, place probe over area and visualize the radial artery.

20. Administer local anesthetic 21. Prepare catheter and remove

protective shield.

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22. Hold catheter at a 30° to 40° angle. Puncture vessel using a continuous, controlled slow motion. Avoid transfixing both vessel walls. Blood flashback in introducer needle indicates successful entry.

23. Stabilize position of introducer needle and carefully advance spring-wire guide into vessel using actuating lever. If resistance is encountered during spring-wire guide advancement withdraw entire unit and attempt new puncture.


24.  Advance entire placement device a maximum of 1 to 2 mm further into vessel.

25.  Firmly hold introducer needle hub in position and advance catheter forward with a slight rotating motion over spring-wire guide into vessel.

26.  Hold catheter in place and remove spring-wire guide assembly. Pulsatile blood flow indicates positive arterial placement.

27.  Directly connect a 6-inch high pressure tubing with a distal stopcock.

28.  Clean site, secure catheter per facility policy 29.  Place sterile gauze and transparent, semi-permeable

dressing over catheter insertion area. 30.  Attach to pressure monitoring setup.

Brachial Artery Insertion Steps

1.  Prepping and draping 2.  When ready to insert catheter, hold catheter at a 30° to

45° angle and insert into the artery. When blood flashback is noted, lay catheter down slightly, advance wire, and then advance catheter over the wire.

3.  If a single lumen sheath is used, hold introducer needle at a 30° to 45° angle and insert into the artery. When free flow blood is obtained, advance the guidewire into the needle, remove needle, place sheath over the wire, remove wire.

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Brachial Artery Insertion Steps

4.  Directly connect a 6-inch sterile high pressure tubing with a distal, one-way stopcock.

5.  Clean site and secure catheter per facility policy. 6.  Place sterile gauze and transparent, semi-permeable

dressing over the catheter insertion area. 7.  Attach pressure monitoring setup.

Femoral Site Insertion Steps

1.  Prep and drape using maximum barrier precautions. 2.  When ready to insert catheter, hold catheter at a 30° to

45° angle and insert into the artery. Once blood flashback is noted, lay catheter down slightly, advance wire and then advance catheter over the wire.

3.  If a single-lumen sheath is used, hold introducer needle at a 30° to 45° angle and insert into the artery. Once free flow blood is obtained, advance the guidewire into the needle, remove needle, place sheath over the wire, remove wire.

Femoral Site Insertion Steps

4.  Directly connect a 6-inch sterile high pressure tubing with a distal, one-way stopcock.

5.  Clean site and secure catheter per facility policy. 6.  Place chlorhexidine-impregnated sponge around

catheter at insertion site. 7.  Place semi-permeable dressing over the catheter

insertion area. 8.  Attach pressure monitoring setup.

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Femoral Artery Insertion Considerations

•   Use maximum barrier precautions

•   Use ultrasound to reduce total number of insertion attempts

•   Check distal pedal pulse •   Justify site selection

O’Grady NP, et al. Am J Infect Control.2011;39(4Suppl 1):S1-34.

Steps that matter…RISK reduction

Practice Considerations

•   Use mobile cart and preassembled kits. •   Femoral artery not a recommended insertion

site for adults due to greater risk of infection. •   Daily assess the need for catheter use to

avoid increased infection risk. Promptly remove unnecessary lines.

•   Do NOT routinely change catheter sites to prevent infection.

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Daily Maintenance

•   Inspect insertion site, extremity temperature, condition and distal pulses, skin color above and below insertion site.

•   Note presence of ecchymosis or edema, leaking or drainage from insertion site.

•   Inspect pressure monitoring system to ensure adequate waveform and accuracy.

•   Verify integrity of dressing.

Daily Maintenance

•   Resolve difficulties with catheter performance.

•   Replace femoral site when able. •   Verify continued need for catheter. Remove

when not clinically warranted.

Catheter Removal

1.  Explain procedure to patient. 2.  Wash hands and don gloves. 3.  Remove dressing. (Precaution: To avoid cutting catheter, do not use scissors.) 4. As catheter exits the site, apply pressure with a dressing

containing petroleum gauze until hemostasis occurs. 5.  Apply a pressure dressing to the site. Bleeding risk is higher

with femoral arteries, so femoral pressure devices may be used to minimize risk.

6.  Inspect catheter upon removal to ensure entire length was withdrawn.

7.  Document removal procedure.

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•   Flushing: •   Follow facility’s policies and procedures and manufacturer’s

recommendations for transducer/flush device. •   Follow hospital policy and procedure with regard to

heparinized solution or use of normal saline or flush solution. •   Dressing changes:

•   Generally, dressings are changed every 96 hours with pressure monitoring system.

•   Use of chlorhexidine-impregnated sponge dressing may decrease need for dressing changes more than every 7 days.


•   Securement: •   Secured lines are less likely to

become infected. •   Consider using steri-strips and

other sutureless securement devices.

•   Pressure Transducers: •   Replace at 96-hour intervals at

one way stopcock. •   Pressure tubing and distal

stopcock.

Continuing Education Credit (CE)

•   To obtain 1.0 contact hour, go to www.saxetesting.com/vh •   Complete the post-test and evaluation form. •   Certificate of completion will be issued immediately. •   Provider approved by the California Board of Registered

Nursing. Provider # 14477. •   This program has been approved for 1.0 contact hour of

CRCE by the AARC.

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Questions ?

Thank you for your attention This session has been recorded and will be archived on

www.vesselhealth.org

Documents

Arterial Web #1 ED5.2ppt - Vessel Health• Arterial catheter insertion and pressure monitoring began in the early 1950s. • Invasive hemodynamic monitoring is beneficial for critically