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LPN IV Series: Central Venous Catheters and Arterial Catheters

4 Contact Hours
This peer reviewed course is applicable for the following professions:
Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN)
This course will be updated or discontinued on or before Sunday, December 18, 2022

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


This course is 1 of 8 courses available on CEUfast to meet the 24 hour written portion of the Florida LPN IV Certification requirement. The remaining 6 hours on the return demonstration of IV skills must be completed in person. To find a provider, or if you are interested in becoming a provider, refer to our Provider Information page.
Outcomes

100% will be able to operate a CVC or A-Line.

Contact hours for LPNs in any state are earned by completing this course. This course is part of a series of 24 contact hours of courses to prepare for LPN IV Certification in Florida. Florida certification participants must schedule a 6-hour live presentation and return demonstration to complete IV Certification. CEUFast.com does not provide a live presentation.

Objectives

After completing this continuing education course, the participant will be able to meet the following objectives:

  1. Identify responses to CVC complications.
  2. Discuss CVC site care.
  3. Discuss management of A-line.
  4. Identify response to A-line.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Authors:    Wesley Hunter (RN, PMT) , Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Introduction

Central venous and arterial catheters are a major component in treating critically ill patients and patients that require long-term IV treatment. It is estimated that 300 million catheters are used in the US each year. These have big risks. If you see bleeding or air in the line, clamp the line. Otherwise, do not touch unless you have been orientated.

Central Venous Catheter

Central venous catheters (CVC) are inserted into a vein in the arm, chest, or leg, and the tip ends in a large vein near the heart. These catheters may also be called a central line. The terms centrally inserted central catheter (CICC) and peripherally inserted central catheters (PICC) may be used based on the type of insertion. The term vascular access device (VAD) may also be used.

Central venous catheters (CVC) are inserted into a vein in the arm, chest, or leg, and the tip ends in a large vein near the heart. These catheters may also be called a central line. The terms centrally inserted central catheter (CICC) and peripherally inserted central catheters (PICC) may be used based on the type of insertion. The term vascular access device (VAD) may also be used. CVCs can be single, double, triple, or quadruple lumen. The different lumens have slits and a terminal hole that empty the contents of each lumen at different levels along the catheter, so the fluids infused do not mix. This device means you can infuse medications, fluids, blood, and (PN) simultaneously. The most distal opening is the most reliable for blood draws because it is less likely to be suctioned against the vein wall during aspiration (Chopra, 2018).

Catheters with antibiotic and antiseptic impregnation are available and may reduce infection rates.

The more lumens, the thicker the catheter. The more lumens, the lumen diameter decreases, the maximum infusion rate is lowered, and the rate of thrombosis increases. More lumens in a catheter increases the risk of deep vein thrombosis (DVT) and bloodstream infections (Chopra, 2018).

Indications

Indications for a central venous catheter include:

  • Lack of peripheral venous access
  • Extended treatment needs
  • Infusate is a vesicant or irritant based on pH and osmolarity (PN, Chemotherapy)
  • Fluid and nutritional support
  • Critical care
  • Hemodynamic monitoring
  • Apheresis
  • Trauma/burn resuscitation
  • High volume flow requirements

Contraindications to CVC are relative and depend upon the urgency and alternatives for venous access. Contraindications to consider are (Heffner, 2017):

  • Insertion site with anatomic distortion or other indwelling hardware (pacemaker, hemodialysis)
  • Coagulopathy or thrombocytopenia

Nontunneled catheters are easier to monitor for bleeding if a CVC is needed in patients with coagulopathy. A subclavian insertion should be avoided in these patients because the site is not easily compressed to stop bleeding (Heffner, 2017).

Non-tunneled CVCs are inserted percutaneously with the catheter exiting the skin in the area of the cannulation site. These are usually for emergency or temporary access.

Peripherally inserted central catheters (PICCs) are relatively easy to insert into peripheral veins in the upper extremity. They include Brachial and basilic veins. PICCs have a lower risk of insertion complications and are tolerated well by the patient. A PICC is inserted into a smaller vein than other PICCs.

For patients with chronic kidney disease (glomerular filtration rates <45 mL/minute; stage IIIb kidney disease or higher) requiring central venous access other than for hemodialysis, a small-bore, tunneled PICC can be used (Chopra, 2018). PICCs should be avoided in patients with chronic kidney disease. The risk of PICC-related DVT or central vein stenosis can complicate future access for hemodialysis.

Implanted catheters are meant to be semipermanent. They should only be removed due to complications or if the catheter is no longer needed. Implanted catheters can be tunneled catheters or totally implantable venous access devices.

Tunneled central venous catheters are put through a tunnel in the subcutaneous tissue between the skin insertion site and where the vein is punctured. Any catheter can be tunneled. The tunneled catheters have a lower rate of infection compared to non-tunneled catheters.

Chronic hemodialysis and apheresis catheters are specialized, tunneled, large diameter, double lumen catheters. They are used to exchange large blood volume or high flow rates. Brands are Tesio, Hickman, Quinton-Mahurkar, and MedComp.

Subcutaneously implanted venous access devices are commonly known as ports. Brands are Port-a-Cath, BardPort, PowerPort, Infuse-a-Port, passport, and Mediport. This device is a catheter that connects an implanted access device in a subcutaneous pocket to a catheter inserted into the vein. Ports are accessed with a special non-coring needle called a Huber needle. Using a regular needle causes damage to the membrane.

Huber needles come in gauges 20 and 22. Available lengths are from ½ inch to 1 ½ inch. If the needle size has not been determined for that patient, start with a 22 gauge 1 ½ inch. Ideally, the needle's hub should rest flat, as close to the skin as possible. If the Huber needle is more than ¼ inches above the insertion site, use a shorter needle next time (John Hopkins, 2008). Use an aseptic technique to access and remove the needle from the port.

Types of Catheters

Recommended type of catheter based on access needs for treatment plan (Chopra, 2018)
Access needsType of catheter
EmergencyNontunneled single-lumen
Short-term <14 daysNontunnelede CVCs or PICC
Mid-term ≥ 14 days – 3 monthsTunneled CVC or PICC
Long Term ≥ 3 monthsTunneled CVC or port

If a catheter or connection is damaged or dislodged, immediately clamp the catheter with a catheter clamp or kink and tape the line.

Use aseptic technique during the insertion and maintenance of the catheter. Use aseptic technique when the catheter lumen is opened or connected to other devices. Chlorohexidine is recommended, but Povidone-iodine can be used. Acetone and tincture of iodine may adversely affect the catheter or connectors (Bard, nd).

Closely observe the catheter after insertion for catheter damage or patient injury. A damaged catheter may cause rupture or fragmentation, leading to embolism or surgical removal.

Confirm CVC catheter tip placement by chest x-ray before initial use. Also, confirm placement if a patient is admitted with an existing PICC or undocumented CVC (Bartholomay et al., nd). To find out information about an existing CVC, you can look at chest x-rays, CT scan, interventional radiology report, operative note, discharge summary, referring doctor's notes, outside hospital transfer notes, or patient-provided documentation.

Use leur lock connections with a CVC.

Hickman, Leonard, and Broviac Central Venous Catheters are a type of central venous catheters. The catheter is inserted into a large central vein and progressed to the point that the tip is in the superior vena cava above the right atrium. The catheter is tunneled subcutaneously. The Surecuff allows tissue to grow into a cuff attached to the catheter. The cuff secures the catheter in place. The Surecuff is placed 3-5 cm below the skin exit site in the tunnel (Bard, nd).

These catheters are for long-term vascular access for the patient that lacks adequate peripheral access. The catheter can be used for IV infusion of fluids, medications, blood products, and parenteral nutrition. It can also be used to withdraw blood samples; however, small catheters will increase the chances of the sample clotting. The catheter may have single, dual, and triple lumen catheters.

Vitacuff is an Antimicrobial cuff that may be used to help prevent central line infections. It is a concentric layer of material attached to the catheter to be placed just subcutaneously at the insertion site. The antimicrobial cuff absorbs fluids at the insertion site and works for 4-6 weeks. The antimicrobial cuff may help prevent infection at the insertion site but does not work against infection introduced into the catheter system when accessing or replacing tubing (Bard, nd).

Hickman Trifusion is a triple lumen long-term catheter. It has 3 equally sized lumens.

Groshong catheters have a closed tip. The valves are on the side of the catheter. The valve is a three-position, pressure-sensitive valve. Negative pressure opens the valve inward to allow blood draws. Positive pressure opens the valve outward to allow infusion. When not in use, the valve is closed. This valve restricts backflow, bleed back, and air emboli. This catheter reduces the need for clamping or heparinization (Bard, nd b).

Cordis catheter is a CVC with one lumen and a less flexible tube to improve ease of insertion. It is used in emergencies (Healthfully, 2018).

PowerHickman and PowerLine are catheters that allow power injections of contrast media. Otherwise, this catheter functions like other central line catheters.

Infusion pressure greater than 25 psi may damage blood vessels. Never use a syringe smaller than 10 mL for a CVC (Bard, nd).

Flushing Needs by Type of Catheter

Follow your facility's policy regarding flushing CVC. The following are recommendations for adult patients (Healthfully, 2018). Flushing should be done after the completion of infusion or blood sampling.

Flushing Needs
Type of catheterFlushing solutionFlushing frequency in not in use
Implanted ports
  • Heparin 100 units/mL. flush with 5 mL (500 u)
  • Monthly
Hickman tunneled
  • Heparin 10 units/mL flush with 5 mL (50 u)
  • 1-2 times a week
Multiple lumen nontunneled, PICCs
  • Heparin 10 units/mL flush with 5 mL (50 u)
  • Every 24 hours
Groshong, Saline only PICCs and valved catheters (Vaxcel, Bard powerPICC SOLO)
  • Preservative-free normal saline 20 mL after blood sampling or stopping PN, 10 mL after meds or routine flush
  • May use heparin
  • Every 7 days
  • Use push-pause technique when flushing with saline
Hohn
  • Heparin 10 units/mL flush with 5 mL (50 u)
  • Every 7 days

When using the push-pause technique of flushing, maintain positive pressure by clamping the line while injecting the last of the flush. Do not clamp while injecting if you are using a system that has a positive pressure feature (max-Plus). Clamp these only after removing the flushing syringe (Bartholomay et al., nd).

Withdrawing Blood Samples

Follow your hospital policy about how much blood to discard when drawing blood from a CVC.

Suggested discard amounts (Bartholomay et al., nd)
PatientBlood discard amount
Adult
  • 6 mL
Neonate
  • 1 mL max
Infant
  • 2 mL max
Child
  • 5-10 mL max
Adolescents and older children
  • 3 mL tunneled catheter
  • 3-5 mL implanted port

Insertion Site Care

Site care should be done according to your facility policy.

CDC recommends the use of Chlorhexidine gluconate 2% for site disinfection. Povidone-iodine is an alternative (Bartholomay et al., nd).

Other CDC CVC catheter site dressing recommendations are listed below (O'Grady et al., 2011). Some of these recommendations contradict each other. That is because both are correct, and the facility or provider makes a choice.

  • Use either sterile gauze or a sterile transparent dressing to cover the site
  • If the patient is diaphoretic or the site is bleeding or oozing, use gauze dressing
  • Use chlorhexidine-impregnated dressing with an FDA cleared label that specifies indication for reducing catheter-related bloodstream infections for short-term, non-tunneled catheters in adults
  • Do not use chlorhexidine-impregnated dressings in premature neonates
  • CDC has no recommendation regarding the use of chlorhexidine-impregnated dressing in patients less than 18 and in non-premature neonates
  • Replace dressing if it becomes damp, loose, or visibly soiled
  • Do not use topical antibiotics except for dialysis catheters
  • Do not submerge the catheter or insertion site in water
  • Replace gauze dressings every 2 days for short-term catheters
  • Replace transparent dressings every 7 days for short-term catheters
  • The risk of dislodging the catheter may outweigh the benefit of changing the dressing in pediatric patients
  • Monitor the insertion site visually when changing the dressing or under a transparent dressing
  • Monitor the insertion site by palpation if a gauze dressing is used
  • For catheters expected to be in place for 5 days or more, use chlorhexidine/silver sulfadiazine or minocycline/rifampin-impregnated catheter

The following is a recommended procedure:

  1. Clean the work surface
  2. Wash your hands
  3. Open dressing kit and supplies
  4. Remove the old dressing, starting from the top and working down
    1. Do not use scissors or sharp-edged instruments because they could damage the catheter
  5. Wash your hands again
  6. Assess the insertion site for signs and symptoms of infection or dislodgement
  7. Assess the external length of the catheter to determine if migration of the catheter has occurred
  8. Put on gloves
  9. Clean the insertion site with chlorhexidine preparation with alcohol. A sterile cotton-tipped applicator soaked in hydrogen peroxide to glean gross contamination. Start at the insertion site and circle outward with cleaning implements. Never go back to the center of the insertion site with a used implement
  10. Repeat cleaning two more times
  11. Antiseptics should be allowed to dry according to the manufacturer's recommendations
  12. Gently clean the outside of the catheter with the inside surface of an alcohol wipe starting from the insertion site and moving up the catheter
  13. Replace the dressing

It is very important to use the correct catheter clamp. The wrong clamp can damage the catheter. The clamp should be smooth. Clamp the catheter over the reinforced clamping sleeve or tape tab. Never clamp over the reinforced segment directly adjacent to the connector.

Clamp the catheter whenever:

  1. it is not being used
  2. it is open to the air, such as catheter cap changes or connecting tubing

Complications

CVCs have an advantage for the patient because there are fewer needle sticks during treatment, but a CVC can change the patient's body image. In addition, the patient must be able to comply with the care and handling of CVC. The best complication prevention is to remove the catheter as soon as it is not needed.

Complications (O'Grady et al., 2011)
InfiltrationInfiltration is caused by dislodgement of the catheter from the vein with unintentional infusion into the surrounding tissue
PreventionSigns and symptomsIntervention
  • Select the best catheter and insertion site
  • Secure catheter and tubing
  • Splint site
  • Assess catheter for patency prior to use
  • Discomfort or pain
  • Swelling
  • Blanching
  • Coolness of surrounding tissue
  • Slows or quits flowing
  • Absence of blood backflow
  • Stop infusion
  • Disconnect tubing
  • Remove catheter
  • If severe, apply warm compress and elevate site
Vesicant ExtravasationExtravasation is the infiltration of vesicant solutions into the surrounding tissue. Vesicants include chemotherapy, hyperosmolar solutions, parenteral nutrition, and KCL
PreventionSigns and symptomsIntervention
  • Same as infiltration
  • Same as infiltration
  • Infusing a vesicant solution
  • Stop infusion
  • Disconnect tubing
  • Do not remove the catheter
  • Apply dry cold compress
  • Contact provider
PhlebitisCaused by
  • Injury to the vein during venipuncture or prolonged catheter use
  • Catheter too large for the vein
  • Poor aseptic technique
  • Irritation to the vein because of rapid infusion or irritating solutions (smaller veins are more susceptible)
  • Clot formation at the end of the catheter due to slow infusion rates or inadequate hemodilution of infused medication or solutions
  • More commonly seen with synthetic polyurethane catheters then silicone catheters
PreventionSigns and symptomsIntervention
  • Secure catheter and tubing
  • Splint site
  • Assess catheter for patency prior to use
  • Use large vein for irritating infusion
  • Adequately dilute irritating medications
  • Discomfort and pain that will progress along the path of the catheter and vein
  • Redness, swelling, warmth, induration
  • Purulence
  • Red streak above site
  • Palpable venous cord
  • Apply warm compress
  • Elevate site
  • Consider removing the catheter
  • Consider pharmacological interventions (analgesic, anti-inflammatory, corticosteroids)
Catheter-associated bloodstream infectionCaused by
  • Underlying thrombophlebitis
  • Contaminated equipment or solutions
  • Prolonged placement of the IV catheter, tubing or solution container
  • Lack of aseptic technique in insertion or dressing changes
  • Cross-contamination from other infected areas of the body
  • Critically ill or immunosuppressed
PreventionSigns and symptomsIntervention
  • Adhere to hand hygiene
  • Use aseptic technique, maximum sterile barrier precautions during insertion, mask, cap, sterile gown and sterile gloves
  • Clean site appropriately Chlorhexidine use instead of povidone-iodine
  • Change tubing as recommended
  • Maintain integrity of the administration system
  • Use dressing that allows visualization of the site
  • Avoid insertion into the femoral vein
  • Use best practices checklists for insertion and maintenance
  • Remove unnecessary CVC
  • Antibiotic-impregnated catheters
  • Vigilant catheter care
  • Signs of local infection
  • Fever, chills
  • Nausea, vomiting
  • Elevated WBC
  • Malaise, tachycardia
  • Backache, headache
  • May progress to septic shock with profound hypotension
  • Stop infusion
  • Consider removing the catheter
  • Get a sample of any exudate for possible culture
  • When removing catheter, cut off the tip of with sterile scissors and place in sterile dry container for possible culture
  • Start appropriate antibiotic therapy
Circulatory overloadFluid overload is caused by the infusion of excessive IV fluids. The elderly, infants and patients with cardiac or renal failure are at greater risk.
PreventionSigns and symptomsIntervention
  • Assess for cardiac or kidney conditions
  • Be vigilant in high-risk patients
  • Monitor infusion rate
  • Use electronic infusion device in high-risk patients
  • Keep accurate intake and output
  • Splint the site if the flow rate fluctuates too widely with movement
  • Increased BP and pulse
  • Increased CVP, venous distention, engorged jugular veins
  • Headache
  • Anxiety
  • Shortness of breath, tachypnea, coughing
  • Pulmonary crackles
  • Chest pain
  • Notify the provider
  • Sit the patient up to ease breathing
  • Reduce IV infusion rate
  • Monitor for worsening condition
Air Embolism
  • Caused when air enters catheter during tubing change or catheter removal of central venous line (negative intrathoracic pressure sucks in air during inspiration)
  • Air in tubing deliver by IV push or infusion
PreventionSigns and symptomsIntervention
  • Clear all air from tubing before infusion
  • Change solution containers before they run empty
  • Ensure all connections are secure
  • Use Luer-lock connections or administration sets with air-eliminating filters unless contraindicated
  • Use correct technique when removing central venous access devices
  • When removing central venous device, place the patient in supine or Trendelenburg, unless contraindicated, so the insertion site is at or below the level of the heart
  • Instruct the patient to bear down (Valsalva maneuver) during catheter removal
  • Sudden onset of dyspnea, breathlessness, and tachypnea
  • Chest pain, hypotension tachycardia
  • Altered mental status, altered speech
  • Change in facial appearance, paralysis
  • Immediately prevent additional air from entering the bloodstream by closing, kinking, clamping, or covering the existing device or insertion site with an air occlusive dressing
  • Immediately turn the patient on the left side and lower the head of the bed. This will trap air in the right side of the heart
  • Notify the provider immediately
  • Administer oxygen as needed
Occlusion or sluggish flowCaused by:
  • Malposition of the catheter against the side of a vein or valve
  • Clot at the end of the catheter
  • External mechanical causes (kinking of tubing, clogged filter, needless connector)
  • Compression of the catheter between the clavicle and first rib, leading to occlusion, damage, or breakage
PreventionSigns and symptomsIntervention
  • Assess the functionality of the vascular access device routinely
  • Use appropriate flushing procedures
  • Secure the IV with tape and armboard if needed
  • Unable to withdraw blood or sluggish blood return
  • Sluggish flow or frequent occlusion alarms
  • Signs of infiltration or extravasation
  • Assess for mechanical causes of occlusion
  • Reposition the catheter by pulling back slightly on the cannula in case the cannula is against a wall or valve
  • Lower the solution container below the patient heart and observe for blood backflow
  • Assess the functionality of the electronic infusion device
  • Consider removing the device
Venous thrombosisCaused by:
  • Infusion of irritating solutions
  • Infection along catheter
  • Fibrin sheath formation around the catheter with eventual clot formation
  • Patient factors
    • Hypercoagulable state (cancer diabetes, end state renal failure)
    • History of deep vein thrombosis
    • Surgical or trauma patients
    • Critical care patients
    • Extreme age
PreventionSigns and symptomsIntervention
  • Select appropriate vascular access device and site location
  • Ensure proper dilution of irritating substances
  • Ensure proper placement of vascular access device
  • Institute nonpharmacological strategies for thrombosis prevention if possible (early mobility, adequate hydration)
  • Anticoagulant prophylaxis if ordered
  • Swelling and pain around the IV or in the extremity proximal to the insertion site
  • Slowing of IV infusion or inability to draw blood from the central line
  • Palpable lump in the cannulated vessel
  • Notify provider
  • Anticipate therapeutic anticoagulant dose
Insertion or migration injury
  • Brachial plexus injury
  • Cardiac arrhythmia
  • Cardiac tamponade
  • Catheter tip malposition or retraction
  • Catheter or cuff erosion through the skin
  • Insertion site necrosis
  • Hemothorax
  • Hydrothorax
  • Pneumothorax
  • Thoracic duct injury
  • Laceration or perforation of vessels or viscus
  • Myocardial erosion
  • Vessel erosion
  • Venous stenosis
PreventionSigns and symptomsIntervention
  • Experienced operator
  • Ultrasound-guided insertion
  • Specific to the injury
  • Specific to injury and symptoms
  • Notify the practitioner

CVCs are the most frequent cause of healthcare-associated bloodstream infections (TJC, 2012). Central line-associated bloodstream infections (CLABSI) are a major concern identified by the Joint Commission (JC). An estimated 80,000 CLABSIs occur in US ICUs every year. There are an estimated 250,000 CLABSIs per year when other treatment areas are counted. The mortality rate due to CLABSIs is 12.3%. These infections are mostly preventable. That means the nurse has a major impact on preventing CLABSIs (TJC, 2012).

Prophylactic antibiotics are not recommended (Heffner, 2017).

Do not routinely replace PICCs and PICCs. Do not remove PICCs and PICCs based on fever alone (O'Grady et al., 2011).

Removal

The tissue will grow into the Surecuff within 2-3 weeks (Bard, nd). Use the method of removal determined by the physician and your facility. This method may include traction of the catheter to surgical removal.

Traction removal procedure (Bard, nd).:

  • Remove the dressing and any sutures.
  • Pull the external catheter downward in a straight line away from the insertion site in a series of gentle tugs. There will be a break-away feeling when the tissue separates from the cuff. If a catheter does not dislodge, stop pulling the catheter. The tissue may be dissected using local anesthesia if the cuff does not separate.
  • Once tissue ingrowth into a cuff is dislodged, there should be no resistance to removing the catheter. Resistance may indicate that the catheter is pinched between the clavicle and first rib. Stop pulling on the catheter if you have resistance. Continuing to pull on the catheter may cause breakage and embolism. You can try repositioning the patient to relieve the pinched catheter.
  • Apply pressure to the insertion site when needed to control bleeding.

Arterial Catheters

Arterial catheters are also called intra-arterial catheters or A-lines. These catheter tips are positioned into the pulmonary artery. If in doubt, do not touch.

A-lines are used in critical care to obtain arterial blood for laboratory testing and directly measure blood pressure and cardiac output. When central venous lines are not available, the A-line can be used to obtain blood samples.

A-lines are indicated when (Healthfully, 2018):

  • frequent blood gases are needed to manage respiratory failure
  • close monitoring of Blood pressure
  • continuous monitoring of cardiac output and stroke volume

Close blood pressure monitoring is needed when the pressure is acute and labile can occur with shock, major surgery, hypertensive emergency, or vasopressor therapy.

A-line blood pressure monitoring is the gold standard. The mean arterial pressure generally correlates will with sphygmomanometry in healthy patients. The sphygmomanometry is not as accurate when the patient has calcified arteries, shock, cardiac arrhythmias, or is on vasoconstrictor drugs. Noninvasive finger artery blood pressure correlates well with radial artery blood pressure monitoring in ambulatory patients but is unreliable when the patient is hemodynamically unstable (Theodore & Clermont, 2018).

Technical problems with the pressure transducer make the measurements invalid. Follow hospital policy and manufacturer directions in use and checking of the transducer position. Calibrating the monitor and transducer is no longer necessary because current disposable transducers are standardized (Theodore & Clermont, 2018). Be thankful. Frequent calibrating used to drive me crazy.

Other errors due to dynamic response can be checked by testing at the bedside using a rapid-flush test. Problems may be caused in an under-damped system by excessive tubing length, connecting with stopcocks, or patient factors (tachycardia, high output states). Over-damped systems are usually air bubbles in the connecting tubing (Theodore & Clermont, 2018).

The collateral flow should be assessed prior to insertion in the smaller arteries when considering an insertion site. Inadequate collateral flow can cause ischemic complications leading to necrosis (Healthfully, 2018). Data support no particular A-line insertion site, but the following are arteries are common sites (Theodore & Clermont, 2018):

  • Radial
  • Femoral
  • Brachial
  • Dorsalis pedis
  • Axillary

In pediatric patients, the temporal and umbilical arteries can also be used.

Insertion of an arterial line is done under sterile conditions.

Ultrasound should be used to identify and guide catheter placement for patients in whom vessel palpation is difficult (e.g., small vessels, obesity) (Theodore & Clermont, 2018).

Transducers, tubing, flush solutions, and flush devices should be replaced every 96 hours.

Complications

Arterial catheters have all the complications of venous catheters plus (Theodore & Clermont, 2018):

  • Vascular or adjacent structure injury during insertion
    • Radial artery insertion is associated with peripheral neuropathy
    • Femoral artery insertion with retroperitoneal hematoma
    • Axillary artery insertion with brachial plexopathy or median nerve damage
  • Vasospasm
  • Pseudoaneurysm
  • Arteriovenous fistula
  • Distal ischemia and necrosis
  • A-lines hemorrhage more blood faster than a CVC

Catheter functionality is improved, and the incidence of thrombosis with A-lines can be reduced by using a heparin flush instead of normal saline (Healthfully, 2018). If heparin is contraindicated, sodium citrate may be used as an alternative flushing agent.

A-line air embolism causes more ischemic damage to end organs than central line air embolisms. Air introduced into a central venous line travels to the capillaries and can be filtered out. A-lines deliver the air directly into an organ.

A-line infections increase with lines in place for over four days, but routinely changing A-line sites is not recommended (Theodore & Clermont, 2018). Instead, a strict aseptic technique is required.
Arterial catheters should be discontinued as soon as they are not critical to patient care. Femoral catheters should not be in for more than 5 days. A-lines at other sites should not be in for more than 7 days.

Keep all components of the pressure monitoring system sterile. Minimize the number of manipulations and entries into the monitoring system. Use a closed flush system rather than an open system (syringe and stopcock) (O'Grady et al., 2011).

Do not administer dextrose-containing solution or PN through the pressure monitoring system.

Iatrogenic blood loss due to blood withdrawal can be minimized using intra-arterial ABG monitoring. This technique uses a fluorescent optode to measure arterial pH, PaCO2, and PaO2 measurements as needed without removing blood from the patient. Fiber optic continuous sensor systems (e.g., Paratrend 7+; Philips Medical Systems) are also available, which may offer an advantage if monitoring is needed over a prolonged period of time (Theodore & Clermont, 2018).

Removal

Hospital policies guide the removal of an A-line. In general, physicians or physician extenders are authorized to remove catheters in patients with coagulopathies, thrombocytopenia, or platelet dysfunction (Healthfully, 2018).

Before removing an A-line, international normalized ratio (INR), PTT, and platelet counts should be checked, and medications that affect coagulation and platelet function noted. If any of these are abnormal, or if the patient is on antiplatelet therapy, extended compression times will be needed (Healthfully, 2018).

Aseptic technique is used during the removal of arterial catheters. After hand washing, put on nonsterile gloves, a protective gown, and a face mask with a shield regardless of catheter location. The catheter should be flushed prior to removal, or blood can be drawn back into the catheter to prepare it for removal (Theodore & Clermont, 2018).

Because of the angle of entry, the arterial puncture site is usually 1 to 2 cm proximal to the skin puncture site for radial arterial lines and 2 to 3 cm proximal to femoral lines. To remove the catheter, clean the catheter site according to hospital policy. Place dressing and apply pressure over the arterial puncture site, then slowly pull the catheter out, maintaining pressure at the artery and skin puncture sites (Theodore & Clermont, 2018). The catheter should be inspected to ensure it is intact.

NOTE: If the catheter has fragmented, pressure should be applied distal to the catheter. Embolization of the catheter fragment can occlude the distal extremity circulation, and urgent surgical referral should be obtained (Theodore & Clermont, 2018).

After catheter removal, hold pressure on the site for at least 5 minutes over the radial artery and 10 minutes over a femoral artery. If the site continues to bleed, apply pressure and recheck every 5 minutes. Larger diameter catheters will require more time. If the patient has coagulation problems, increase the pressure time by 50-100% (Theodore & Clermont, 2018). Watch your patient closely after removal. Seeing an arterial removal site break open is one of those situations that make you realize how few times you have truly been afraid.

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References

  • Bard Access Systems, Hickman, Leonard, and Broviac Central Venous Catheter, Instructions for use. n.d.
  • BARD. Nursing Procedure Manual, Groshong. n.d.b.
  • Bartholomay, M. Dreher, D. Evans, T. Finn, S. Guthrie, D. Lyons, H. Mulligan, J. and Tyksienski, C. Nursing Management of Venous Access Devices: An Overview of Central Venous Access Devices. n.d.
  • Chopra, V. Central Venous Access Devices and Approach to Selection in Adults. UpToDate. May 30, 2018.
  • Healthfully. Types of Central Venous Catheters. November 6, 2018. Retrieved 12/6/18 (Visit Source).
  • Heffner, A. Androes, M. Overview of central venous access. UpToDate. October 24, 2017.
  • John Hopkins. Interdisciplinary Practice Manual. Infection Control. VAD policy. March 1, 2008. Retrieved 12/8/19 (Visit Source).
  • O'Grady, N. Alexander, M. Burns, L. Dellinger, P. Garland, J. CDC Guideline for the Prevention of Intravascular Catheter Related Infections, 2011. Last update October 2017.
  • The Joint Commission. Preventing Central-Line Associated Bloodstream Infections. 2012.
  • Theodore, A. Clermont, G. Arterial Catherization Techniques for Invasive Monitoring. UpToDate. May 15, 2018