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3/23/12
1
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.
Grey H. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918. www.bartleby.com/107/
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.
Grey H. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918. www.bartleby.com/107/
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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Radial Artery Catheter Insertion
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.
Radial Artery Catheter Insertion
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.
Radial Artery Catheter Insertion
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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Radial Artery Catheter Insertion
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.
Radial Artery Catheter Insertion
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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Practice Considerations
• 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.
Practice Considerations
• 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.
3/23/12
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Questions ?
Thank you for your attention This session has been recorded and will be archived on
www.vesselhealth.org