CARE OF ARTERIAL LINES

CLINICAL PROCEDURE
Policy # Date Introduced Supercedes Policy# Review Data due
November 2005 July 2007
Author/s: Kylie
Garnsworthy
CNS
Procedure Authorised by: Director NBICS, NB Nursing and Midwifery Council
Director of Nursing Marlene
Hinchliff
Director of Nursing Fiona Allsop
Chair – Nursing Council Sally Ingram
NB. This policy has been authorised by the above parties-a signed hardcopy is kept by the
CNC NBICS

Procedure Statement:
Critically ill patients require arterial lines to monitor blood pressure (BP) trends, titrate drug therapies and
obtain blood samples for arterial blood gases and laboratory studies. To ensure that a patient receives
optimal treatment, it is crucial that staff are aware of factors that affect the safety and accuracy of arterial
monitoring.
In addition, to ensure that the opportunity for blood stream infection is minimised standard precautions must
be followed

Relevant and Related Policies:

NSW Health Infection Control Policy Directive 2005_247
Occupational Health and Safety

Rationale:
Patients may require an arterial line for

• Haemodynamic instability where strict monitoring is required.

• When vasoactive medications are needed and the response to such medications require monitoring.
• Close monitoring of labile B.P
• Regular blood sampling.

Sections:
INSERTION OF ARTERIAL LINE
TRANSDUCER SET UP
ARTERIAL MONITORING/ ZEROING
BLOOD SAMPLING
DRESSING
GENERAL PRINCIPLES AND CARE
TROUBLESHOOTING
POTENTIAL COMPLICATIONS
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INSERTION OF ARTERIAL LINE

Equipment:
• Clean (using Viraclean) and dry dressing trolley
• Sterile dressing trolley plastic drape
• Minor procedure tray
• 5x sterile gauze packets
• Arterial Cannula
• 1% Chlorhexidine Swabs (Persist plus)
• 1% Lignocaine
• 25g needle + 5ml syringe
• 2.0 silk + needle
• 1x transparent occlusive dressing (e.g. iv 3000)
• Fenestrated drape
• Sterile gown + gloves
• Transducer, pressure bag and 500ml of Normal Saline

Preparation of Patient:
• Arteries typically cannulated for arterial pressure monitoring are Radial, Femoral, Brachial and
Dorsalis Pedis.
• Explain procedure to patient
• Verbal consent should be obtained by the medical officer performing the procedure.
• Medical officer performing procedure should do Allen’s test to ensure adequate distal blood flow if a
radial artery is being cannulated.
• Position pt in bed as comfortably as possible with area to be used exposed. (NB if a radial artery is to
be used a rolled towel may be used to hyperextend wrist to allow easier visualisation of landmarks).

From: Stillwell (2002) P. 470

Procedure:
• Performed only by a medical officer.
• A clinical handwash must be done prior to the procedure

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Documentation:

Medical officer who performed procedure needs to document in progress notes. Nursing staff need to
document on management/care plan, date of insertion site, when next dressing + line change due + date for
removal.
The arterial line can remain insitu for up to 7 days (unless signs of infection are evident eg redness,
unexplained pyrexia etc) or more. The site must be reviewed regularly and findings must be documented in
the patients progressive notes.

TRANSDUCER SET UP

Rationale:

The arterial catheter is connected to the fluid filled tubing of the monitoring system. The transducer creates
the link between the fluid filled tubing system and the electronic system converting a mechanical signal into a
waveform on the monitor. The transducer system must be set up correctly to ensure accuracy of the
monitoring system.
Transducers are to be changed every 96 hours (4 days). This change includes the transducer,
associated lines and the flush solution bag (unless empty)

Equipment:
• Hand hygiene must be performed prior to donning clean gloves (ie wash with liquid soap or use 0.5%
Chlorhexidine and alcohol hand rub)
• Gloves
• 500 ml bag Normal Saline
• Pressure bag
• Transducer giving set
• Module and cable
• Monitor

Procedure:
• Insert giving set into normal saline bag. (Keeping end sterile, ready to pass to Medical officer.)
• Ensure all roller clamps are open
• Prime line by squeezing fast flush device.
• Ensure that all air bubbles are removed from system and that all parts are primed with fluid. Air can
cause damping of the system and inaccuracy of monitoring.
• Place Saline into pressure bag and inflate to 300 mmHg.
• When M.O. is ready connect to cannula. Connect transducer to cable and watch for trace on monitor.
• Zero + calibrate system.

Documentation:
Document in the intensive care plan the date of insertion

Arterial Monitoring and Zeroing

The arterial pressure wave corresponds with the cardiac cycle.

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 From: Urden et al (2002) p. 361

Arteriole systole begins with opening of aortic valve and rapid ejection of blood into the aorta. This is the
upswing on the arterial waveform followed by a downward turn.

A notch- called dicrotic notch is visible on downward stroke which represents closure of the aortic valve
signifying the beginning of diastole.

The remainder of the downward stroke represents diastolic run off of blood flow into the arterial tree.

The QRS complex of ECG trace comes first and the arterial waveform follows.

LEVELLING AND ZEROING (Calibrating the system)

Rationale:
To ensure consistency and accuracy of the arterial blood pressure monitoring the transducer must be
positioned and calibrated regularly to an anatomically consistent site. This site is called the phlebostatic axis.

Levelling:
The phlebostatic axis is the anatomical reference point on the chest that is used as baseline for consistent
transducer site placement. This point represents the position of the atria and therefore reflects central blood
pressure. The site of the phlebostatic axis is at the intersection of the fourth intercostal space and mid
axillary line.

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 From: Urden et al (2002) p. 356

To obtain a true central blood pressure this is where the transducer should be positioned.
The transducer must always be level with phlebostatic axis.

Zeroing

Rationale:

Zeroing is the method of calibrating the monitoring system so that the effects of atmospheric and hydrostatic
pressure are eleminated. Zeroing must be carried out once per shift.

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Preparation of patient:

• Position patient on their back

• Patient may be positioned with the head of the bed elevated between 0-60°
• Flush the system
• Level transducer to phlebostatic axis (may mark this with an x on patient)
• Turn stop-cock on transducer so that it is “off” to the patient.
• Remove cap
• Press zero on the module
• Ensure that zero appears on screen replace cap and turn stop-cock so that it is open to monitoring
and patient.

NB: If patient is positioned on their side the reference point will be different. It is difficult to identify true
phlebostatic axis. There may be a discrepancy in readings. If there is a great variation when positioned on
their sides. The patient should be placed onto their back and a true reading obtained

BLOOD SAMPLING

Equipment
• 5ml syringe
• Sterile gauze
• Arterial blood gas syringe
• +/- or vacutainer + blood collection tubes
• Personal protective equipment (Gloves, googles)

Procedure

• Suspend alarm or monitor

• Hand hygiene must occur before and after the procedure
• Don personal protective equipment
• Remove cap from stopcock and attach 5ml syringe turn stop cock “off” to flush bag
• Withdraw 2-3ml of blood to clear line of saline
• Attach ABG syringe/ or vacutainer attachment and withdraw sample (if taking ABG the syringe can
passively fill)
• Once specimen has been taken, turn stopcock “off” to the patient, remove syringe/vacutainer, cover
the port with gauze and using the fast flush device, flush port.
• Replace cap
• Turn stopcock “off” to the port and flush line ensuring that all blood is cleared
• Ensure alarm is turned on

DRESSING
Rationale:
Infection at the arterial catheter site will be minimised
Dressings with modern occlusive dressings should be left intact up to 7 days
More frequent dressings should only be attended if there is a problem with kinking of line, leaking around site
or if the dressing is coming off

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Equipment
• Dressing Pack
• Sterile Gloves
• Transparent occlusive dressing (eg. IV 3000)
• Normal Saline (if visibly soiled or crustings are present)
• 2% Chlorhexidine + alcohol (Persist plus)
• Goggles

Procedure
• Wash hands (or use alcohol hand rub)
• Assemble equipment on dressing trolley
• Wash hands (alcohol hand rub may be used)
• Remove old dressing carefully
• Wash hands and don sterile gloves
• Cleanse area with normal saline (if visibly soiled or crustings are present)
• Dry site with gauze
• Apply chlorhexidine and alcohol to insertion site
• Allow to dry to air
• Apply steri-strips (if necessary) to keep cannula secure.
• Apply transparent dressing so that insertion point of cannula is in middle of dressing
NB. Transducer only needs to be changed if considered to be giving faulty readings or if time insitu is >4
days

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GENERAL PRINCIPLES AND CARE OF ARTERIAL LINE

PROCEDURE RATIONALE
Deflation of bag will result in retrograde blood flow.
Keep pressure bag inflated to 300mmHg Keeps line patent and infuses 3-5ml /hr. Prevents
dampening of trace. Prevents clots

Infection control, keep bag sterile. Ensures adequate

Flush bags of Normal Saline are changed every flushing volume.
96 hrs or PRN. All flush bags must be labelled
with time and date of commencement
Extra areas of air entrapment which can cause
Do not add extra tubing or stopcocks to system. inaccuracy of the arterial trace. Increase risk of
infection
All lines must be have rigid non-compliant tubing
Eliminates any bubbles escaping the flush solution.
Periodically flick tubing system and flush the
tubing system
Helps eliminate air bubbles. Clears the line of blood
Fast flush solution after opening the system for
blood sampling and/or zeroing
Safety measure to prevent adverse events eg.
Immobilise arm and keep sites clearly visible at haemorage or disconnection
all times. eg. On top of sheets. Do not use
bandage over arterial line site.

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TROUBLESHOOTING

PROBLEM SOLUTION
Difficulty with zeroing
Does not reach 0 waveform Check all equipment + connections between pt +
monitor
Does not reach baseline
Ensure all rollerclamps are open

Check system for air bubbles and blood clots

Recalibrate

Replace transducer, cable module, arterial line

Unable to aspirate cannula Check line for kinks

Apply traction to cannula

Gently try to flush

Replace arterial line

Falsely high readings

Incorrect placement or transducer Check position of transducer

Uncalibrated system Re zero

Kinked cannula Remove kink

Dampened Remove air bubbles/ blood clots

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POTENTIAL COMPLICATIONS

PROBLEM PREVENTION SOLUTION

Keep limb visible at all times Apply pressure to limb
HAEMORRHAGE
Ensure alarm is on so that any Assess leak
accidental disconnection can be
dealt with quickly If haemorrhage persists notify
MO
Ensure that arm is immobile with
arm board

Ensure all connections are tight

INFECTION Assess area regularly for Remove arterial Line

redness or swelling
Ensure proper hand washing
Avoid interrupting circuit as when handling arterial line or
much as possible transducer

Use gloves when touching

arterial line
Keep pressure bag inflated to Attempt to aspirate blood to
BLOCKAGE ensure 3-5ml flush remove clot

CLOTTING Attempt to aspirate blood Ensure all connections are

secure
Use fast flush device to clear
AIR EMBOLI line to prevent clot formation

Regularly check distal pulses + Notify MO and consider

INTERUPTION TO cap refill removing line
PERIPHERAL
CIRCULATION

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REFERENCES
1. Aherns T, Penick JC & Tucker MK (1995). Frequency requirements for zeroing transducers in
haemodynamic monitoring. American Journal of Critical Care; 4(6): 466-471.

2. Bridges EJ, Bond EF, Ahrens T, Daly E, Woods SL (1997) Ask the experts. Critical Care Nurse; 17(6): 1
96-97.

3. Centre for Disease Control (2002). Guidelines for the prevention of intravascular catheter-related
infections. 51 (RR10): 1-26.

4. Courtois MA, Fattal PG, Kovács SJ, Tiefenbrunn AJ & Ludbrook PA (1995). Anatomically and
physiologically based reference level for measurement of intracardiac pressures. Circulation; 92: 1Need
page numbers from Journal.

5. Hudak CM, Gallo BM & Morton PG (1998) Critical Care Nursing; A Holistic Approach. Seventh Edition.
Lippincott: New York.

6. Imperial-Perez F, McRae M (1999) Protocols for practice: Applying research at the bedside. Critical Care
Nurse; 19(2): 105-106.

7. McCann UG, Schiller HJ, Carney DE, Kilpatrick J, Gatto LA, Paskanik AM & Nieman GF (2001). Invasive
arterial monitoring in trauma and critical care. Chest; 120(4): 1322-1326.

8. McGhee BH, Bridges MEJ (2002) Monitoring arterial blood pressure: What you may not know. Critical
Care Nurse; 22(2): 50-79.

9. Stillwell SB (2002) Mosby’s Critical Care Nursing Reference. Third Edition. Mosby:St Louis.

10. Urden LD, Stacy KM, Lough ME (2002) Thelan’s Critical Care Nursing; Diagnosis and Management.
Fourth Edition. Mosby:Missouri.

11. RNSH Haemodynamic competency, July 2004

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