1. Arterial Line Management for the Birthing Center

2. Objectives
List reasons for Arterial Line monitoring in the OB setting.
Identify equipment needed for insertion of an arterial line.
Describe the process for Arterial Line monitoring.

3. What is Blood Pressure?
Blood pressure (BP), sometimes referred to as arterial blood pressure, is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, blood pressure varies between a maximum (systolic) and a minimum (diastolic) pressure.[1] The blood pressure in the circulation is principally due to the pumping action of the heart.[2] Differences in mean blood pressure are responsible for blood flow from one location to another in the circulation. The rate of mean blood flow depends on the resistance to flow presented by the blood vessels. Mean blood pressure decreases as the circulating blood moves away from the heart through arteries and capillaries due to viscous losses of energy. Mean blood pressure drops over the whole circulation, although most of the fall occurs along the small arteries and arterioles.[3] Gravity affects blood pressure via hydrostatic forces (e.g., during standing) and valves in veins, breathing, and pumping from contraction of skeletal muscles also influence blood pressure in veins.[2]
Other “Pressure” variables……… Resistance, tone, volume, fluids, viscosity, ………

4. History of BP Monitoring
1731 Reverend Stephen Hales cannulated a mare’s artery with a goose quill connected to a length of goose trachea. This was connected to an 8 ft. glass column manometer.
1905 Korotkoff proposed the auscultatory method.

5. Arterial Pressure Monitoring
Indications:
Continuous blood pressure evaluation
Trends in blood pressure
Efficacy of drugs, interventions
Serial blood gas samples required
Respiratory failure
Mechanically ventilated patients
Severe acid/base abnormalities

6. Why Arterial Line Monitoring?
Continuous arterial blood pressure monitoring
When there is a failure of indirect BP measurement
When there is a need for arterial waveform analysis
When there is a need for monitoring intravenous pharmacologic or mechanical cardiovascular support
Arterial blood sampling
Respiratory failure
Mechanically ventilated patients
Severe acid/base abnormalities

7. What types of patients require arterial line monitoring in the OB setting?
Patients with cardiac disease
Repaired congenital defects
Cardiomyopathy
CAD
Patients with pulmonary issues
Pulmonary Hypertension
Cystic Fibrosis
Patients with medical conditions where increase BP can result in catastrophic consequences
Marfan’s syndrome
Patients with acute changes in the OR
Post-partum hemorrhage
Sepsis

8. What Sites are used for Arterial Catheter Placement?
Radial
Brachial
Femoral
Axillary
Dorsalis pedis
The most common site used in the Birthing Center is the radial site.

9. Where will these lines be placed in the Birthing Center?
Arterial lines may be placed in the patient’s room on 5700, the OR, triage or PACU.

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11. Getting Started: What Equipment will I need?
Flush System
1000 ml bag of NS
Pressure tubing with transducer
Needless adapter
Pressure bag

12. The Transduced Flush System:
Provides a mechanism to maintain patency of invasive lines using high pressure with minimal flush delivery while transducing these lines to a monitor where intravascular and/or intracardiac pressure measurements can be taken.

13. Flush System set up
Label fluid bag with date, time, initials and phrase “No additives.”
Purge all air from the fluid bag.
Insert pressurized tubing into fluid bag. Do not inflate pressure bag yet.
Place fluid bag into pressure bag.
Open the clamp and squeeze the drip chamber to fill the chamber ½ full.

14. Flush System set up continued
6. Flush tubing under gravity flow, checking that all air bubbles have been flushed out of tubing, transducer, and stopcocks. 7. Replace vented caps with “dead end” or occlusive caps on all stopcocks and assure that all connections on tubing are tight. 8. Inflate pressure bag to 300 mmHg. 9. Attach pressure tubing to end of catheter. 10. If new invasive lines are inserted, new pressurized tubing and flush bag should be set up and used.

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16. What Equipment will be needed?
Insertion:
Arterial catheter
Chlorhexidine gluconate (CHG) swab (for CHG allergy, use 3 alcohol swabsticks and 3 povidone-iodine swabsticks)
Sterile towels
Sterile gloves
Mask and cap

17. Allen’s Test Evaluate distal circulation prior to placement
Allen’s test for radial catheter
May be incorrect in as many as 14% of patients
Requires continued evaluation of distal circulation!

18. Allen’s Test Occlude radial & ulnar artery
Ask pt. to repeatedly squeeze hand into tight fist
Ask pt. to relax hand – should be pale
Lift finger off artery not being used
Color should return within
5-10 seconds

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20. Arterial Line Insertion

21. Arterial Line Insertion
Verify that patient consent has been obtained by the physician or physician designee.
Reinforce physician’ explanation and provide reassurance to the patient during insertion.
Provide assistance to inserter as needed.
Connect pressure tubing to arterial catheter when insertion is complete, check that all connections are tight.

22. Arterial Line Insertion
Assess wave form and set monitor alarms.

23. Secure transducer level to the phlebostatic axis.
The phlebostatic axis is found at the intersection of the 4th intercostal space and the mid-axillary line.

24. Leveling and Zeroing Why zero? Possible transducer locations:
Performed to eliminate the effects of atmospheric pressure on the transducer. Should be performed after connecting the pressure system to the patient and whenever there is significant change in hemodynamic numbers.
Possible transducer locations:
Mounted on manifold on IV pole
Within the fluid line
Directly affixed to the patient

25. Zeroing the Transducer
Closed
Open
Atmospheric Pressure = 0 mmHg

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27. The Arterial Waveform Systolic Upstroke Systolic Peak Systolic Decline
Dicrotic Notch
Diastolic Runoff

28. Discrepancies w/ Cuff and A-line
Problems with the cuff
Cuff does not fit (must 20% longer than arm circumference)
Deflating too quickly (>3mmHg/second)
Regional arterial tree differences (coarctation, dissection)
Blood Pressure at extremes

29. Discrepancies w/ Cuff and A-line
Overdamping
Attenuation of the waveforms
Underestimation of blood pressure
Underdamping
Amplification of oscillations/waveforms
Overestimation of blood pressure
Overdamped
Normal
Underdamped

30. Square Wave Test Otherwise known as “dynamic response testing”
Usually performed once per shift
Done to determine if the monitoring system can accurately reproduce a patient's cardiovascular pressures
Identifies problems such as: air bubbles, kinking in the tubing, loose connections or catheter patency

31. Square Wave Test When the fast-flush is pulled - the waveform should
Have a sharp upstroke which terminates in a flat line which is followed by a rapid downstroke extending below baseline with 1 or 2 rapid oscillations
A quick return to baseline

32. Square Wave Test Problems: Troubleshooting: Overdampened
sluggish or no oscillations with a fast flush
Falsely ↓ SBP and ↑ DBP
Underdampened
undulations in the square wave with the fast flush
Falsely ↑ SBP and ↓ DBP
Troubleshooting:
Check for bubbles, blood clots, kinks, loose connections or decrease the length of tubing

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34. Assessment and Maintenance
Assess for signs of complications at least every 4 hours and prn. Any signs of complications should be reported to the physician immediately.
Change dressing when it becomes loose, moist, or soiled. Cleanse area with CHG, allow to air dry, and apply sterile dressing.
Monitor waveform and blood return to assure arterial catheter patency.
Set alarm parameters according to the patient’s current blood pressure. Keep arterial alarms on at all times since large blood volume may be lost quickly if any part of the system is loose or disconnected.

35. Complications of Arterial Lines
Pain
Infection
Hemorrhage
Hematoma
Arterial Insufficiency (<0.1%)
Arterial Embolus
Misuse and Misinterpretation

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37. Withdrawing Blood Samples
What equipment will I need?
Alcohol wipes
Saline-filled syringe
2 empty syringes
Blood transfer device (for vacutainer® tubes)
Vacutainer® tubes

38. Procedure
Scrub the needleless adapter with alcohol x 15 seconds. A 10 ml syringe to the needleless adapter.
Turn the stopcock off to the pressure tubing (on the patient).
Aspirate 5ml blood into the 10 ml syringe. Turn the stopcock off to syringe. Detach syringe and discard. Turn stopcock off to all ports.
Scrub the needleless adapter with alcohol x 15 seconds. Attach another 10 ml syringe to the needleless adapter on the stopcock. Turn the stopcock to the pressure tubing.

39. Procedure continued
Withdraw enough blood needed for blood samples. Turn stopcock off to syringe.
Scrub needleless adapter with alcohol x 15 seconds. Attach flush syringe containing 5 or 10 ml normal saline.
Attach blood transfer device to syringe with blood. Fill vacutainer® tubes with blood needed for labs.
Label blood sample(s) with patient addressograph or lab barcode label, then date, time, and initial the label.(BEFORE LEAVING THE PATIENT’S BEDSIDE)

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41. Arterial Line Removal
Patients who deem appropriate candidates for post partum recovery on 5700 will have their A-line removed.
Any patient that requires additional monitoring will be transferred to an ICU setting.

42. Arterial Line Removal
Assess the patient’s coagulation profile (PT, PTT, INR, platelets) prior to removal of the arterial catheter.
Wash hands and don gloves.
Turn pressure system off by clamping tubing or turning stopcock off to the patient.
Remove dressing and sutures (if present).
Place sterile gauze pad over site and remove catheter, immediately apply direct pressure to site.
Hold pressure until hemostatis is obtained (5-10 minutes). Longer times may be needed for anticoagulated patients.
Check for bleeding and presence of pulse 15 minutes post removal.

43. Arterial Line Removal Reportable Conditions:
Bleeding or hematoma at site.
Loss of pulse distal to insertion site.
Absence of blood return.
Signs of infection.

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45. You may now close the module.
This concludes you’re online training for A-Line Management in the Birthing Center. Please print your certificate of completion to bring to your hands-on training session.
You may now close the module.