Professional Documents
Culture Documents
DR Tarun Bhatnagar
DR Tarun Bhatnagar
Indications
Preparation & Equipments
Positioning
Insertion
Complications
Mechanism of Action
Troubleshooting
1.Continuous, beat-to-beat blood pressure
measurement.
- Hemodynamically unstable pts /ICU pts
requiring inotropic support
- Patients undergoing major surgery
2.Frequent arterial blood gas analysis
-pts with respiratory failure on ventilator
-severe acid/base disturbance.
Advantages of IBP measurement
Continuous blood pressure recording
Accurate blood pressure recording even
when patients are profoundly hypotensive vs
NIBP which is difficult or inaccurate
Real time Visual Display
Disadvantages of IBP measurement
Potential complications
Skilled technique reqd
Expensive
The radial artery has low complication
rates compared with other sites.
It is a superficial artery which aids insertion,
and also makes it compressible for haemostasis
The ulnar, brachial, axillary, dorsalis
pedis, posterial tibial, femoral arteries are
alternatives.
Allen’s test is recommended before
the insertion of a radial arterial line.
This is used to determine collateral
circulation between the ulnar and
radial arteries to the hand
If ulnar perfusion is poor and a
cannula occludes the radial
artery, blood flow to the hand
may be reduced.
The test is performed by asking the
patient to clench their hand. The
ulnar and radial arteries are
occluded with digital pressure.
The hand is unclenched and
pressure over the ulnar artery is
released. If there is good collateral
perfusion, the palm should flush in
less than 6 seconds.
Saline bag
-500 ml 0.9% saline pressurized to 300 mmHg using a pressure bag, i.e. a pressure
higher than arterial systolic pressure to prevent backflow from the cannula into the
giving set.
-The arterial set and pressurized saline bag with 2500units Heparin incorporate a
continuous slow flushing system of 3–4 ml per hour to keep the line free from clots.
-The arterial set and arterial line should be free from air bubbles.
- The line is attached to a transducer.
-Do not allow the saline bag to empty
◦ –To maintain patency of arterial cannula.
◦ –To prevent air embolism
◦ –To maintain accuracy of blood pressure reading
◦ –To maintain accuracy of fluid balance chart
◦ –To prevent backflow of blood
2. Transfixation
3. Guidewire (Seldinger)
technique
Haemorrhage may occur if there are leaks in the system.
Connections must be tightly secured and the giving set and line
closely observed..
Emboli. Air or thrombo emboli may occur.
Care should be taken to aspirate air bubbles
Accidental drug injection may cause severe, irreversible damage
to the hand.
-No drugs should be injected via an arterial line
- The line should be labelled (in red) to reduce the likelihood of this
occurring
Arterial vasospasm
Partial occlusion due to large cannula width, multiple attempts
at insertion and long duration of use
Permanent total occlusion
Sepsis or bacteraemia secondary to infected radial arterial lines is
very rare (0.13%);
-local infection is more common.
-if the area looks inflamed the line site should be changed.
–Concentration of a
drug into the tissues
served by the
cannulated artery can
result in cell death
–Skin necrosis, severe
gangrene, limb
ischemia, amputation &
permanent disabilities
Mechanism of action
A transducer is a device that
reads the fluctuations in
pressure – it doesn’t matter if it’s
arterial, or central venous, or PA
The column of saline in the arterial
set transmits the pressure changes
to the diaphragm in the transducer
The transducer reads the
changing pressure, and changes it
into an electrical signal that goes
up and down as the pressure does
which is displayed as an arterial
waveform
The transducer connects to the
bedside monitor with a cable, and
the wave shows up on the screen,
going from left to right
The transducer has to sit in a “transducer holder” – this is the
white plastic plate that screws onto the rolling pole that holds
the whole setup.
The transducer has to be levelled correctly-to make sure that it’s
at the fourth intercostal space, at the mid-axillary line
(Phlebostatic axis)
Make sure there’s no air in the line before you hook it up to
the patient – use the flusher to clear bubbles out of the tubing.
Zero the line to atmospheric pressure properly
Choose a screen scale that lets you see the waveform clearly.
To ensure accuracy of readings
Flush the device & turn it off to patient but
open to atmosphere
These exert pressure on transducer
This pressure is called zero
Zero once per shift or if values are questionable
Ensure flush bag is pumped up
Once inserted, an
arterial waveform
trace should be
displayed at all times
This confirms that
the invasive arterial
BP monitoring is
set up correctly, and
minimizes problems.
:
The highest point - systolic
pressure,
-the lowest is the diastolic.
Everybody see the little
notch on the diastolic
downslope? – there’s one in
each beat.
A little after the beginning of
diastole – the start of the
downward wave – the aortic
valve flips closed, generating
a little back-pressure bump:
called the “dicrotic notch”..
Now we know how the arterial pressure
monitoring system works, we need to be able
to decide whether or not the trace (and
BP in numerical format) is accurate.
Failure to notice this may lead to unnecessary,
or missed treatments for our patients.
There are 2 main abnormal tracing problems
that can occur once the monitor gain is set
correctly.
Dampened trace
Dampening occurs due to:
◦ air bubbles
◦ overly compliant, distensible tubing
◦ catheter kinks
◦ clots
◦ injection ports
◦ low flush bag pressure or no fluid in the flush bag
◦ Improper scaling
◦ Severe hypotension if everything else is ruled out
This type of trace Under estimate SBP, over
estimate DBP
Resonant trace
Resonance occurs due to:
◦ long tubing
◦ overly stiff, non-compliant tubing
◦ increased vascular resistance
◦ reverberations in tubing causing harmonics that
distort the trace (i.e. high systolic and low diastolic)
◦ non-fully opened stopcock valve
This type of trace
Over estimate SBP, under estimate DBP
Arterial lines measure systolic BP
approximately 5 mmHg higher and the
diastolic BP approximately 8 mmHg lower
compared to non-invasive BP (NIBP)
measurement
Troubleshooting
“It takes a year just to learn which way to
turn the stopcocks!”
This is really true: some stopcocks point to where
they’re open, and some point to where they’re closed
– it just takes some time to learn which is which.
The trick is remembering which way to turn the
stopcock, and avoiding a mess.
Don’t forget to clear the stopcock, recap, and then
flush the line.
Keep things nice and sterile.
This probably means that the artery being
monitored or gone into spasm.
You need to think about things that might make
this happen:
-Is the patient very cold?
-Are his extremities poorly perfused?
-Is he on a “shipload” of pressors, making his
arterial bed tighten up –
- Is he “dry” as well?
Sometimes arteries become unhappy with catheters
in them, and you just have to convince the team
that the patient needs a new one placed in
another site.
The first thing to think about is:
1.Is the arterial catheter still in place? Yes? Try
drawing with a 3cc syringe from the stopcock – if it draws
normally, then you’ve got a hardware problem
2.Cables become loose?
3.Did the screen scale get accidentally set to, say,
40, instead of 150 or 200mm of pressure?- you’ll only see
a flat line.