POLICY: 1. Hemodynami c moni t or i ng vi a a cent r al l i ne ( cent r al venous pr essur e CVP) and/ or ar t er i al l i ne may be per f or med i n t he f ol l owi ng uni t s: I CU, PACU, Car di ac Cat h Lab, Labor & Del i ver y, CSDU, and I nt er vent i onal Radi ol ogy.
2. Hemodynami c Moni t or i ng vi a a pul monar y ar t er y ( PA) cat het er may be per f or med i n t he f ol l owi ng uni t s: I CU, PACU, Car di ac Cat h Lab.
3. Hemodynami c moni t or i ng l i nes may onl y be i nser t ed and r eposi t i oned by a t r ai ned pr act i t i oner , and must be sut ur ed or secur ed i n pl ace.
4. Radi al ar t er i al l i nes may be r emoved by an RN; Al l ot her hemodynami c moni t or i ng l i nes ar e r emoved by a t r ai ned pr act i t i oner .
5. Ar t er i al l i nes must be t r ansduced, wi t h pr essur e al ar ms on at al l t i mes.
6. I f a cont i nuous ar t er i al t hr ombol yt i c i nf usi on i s or der ed ( i . e. post - i nt er vent i onal pr ocedur e) t he ar t er i al sheat h must be t r ansduced i n or der t o have an al ar m. Moni t or al ar mmay be set t o mean pr essur e, i f a di st i nct pr essur e wave does not di spl ay.
7. Except i ons t o t r ansduci ng ar e:
a. When t he pat i ent i s i n t r anspor t , accompani ed by a RN; Deci si on whet her t o t r ansduce t he l i ne i s at t he di scr et i on of t he RN.
b. Al ar ms may onl y be t empor ar i l y suspended dur i ng bl ood dr aw f r om t he l i ne, and al ar ms must i mmedi at el y be r esumed at t he concl usi on of t he bl ood dr aw.
8. A chest X- r ay i s done post subcl avi an or j ugul ar i nser t i on of a cent r al l i ne or pul monar y ar t er y cat het er t o conf i r mpl acement ( unl ess pl aced under f l uor oscopy) and t o r ul e out a pneumot hor ax.
9. Except i n an emer gency, i nf usi on of t her apeut i c f l ui ds shoul d not be i ni t i at ed unt i l conf i r mat i on of l i ne pl acement i s pr ovi ded by t he pr act i t i oner .
10. The di st al t i p of a pul monar y ar t er y cat het er must be moni t or ed at al l t i mes, and t he l ock on t he bal l oon por t shoul d al ways be OPEN t o al l ow ai r t o escape.
DESIRED PATIENT OUTCOME:
1. Pat i ent wi l l r emai n f r ee of i nf ect i on secondar y t o i nvasi ve l i ne.
2. The pat i ent wi l l mai nt ai n hemodynami c st abi l i t y.
CLINICAL ASSESSMENTS AND CARE:
1. Hemodynami c Moni t or i ng Assessment : Al l pat i ent s wi t h hemodynami c moni t or i ng l i nes wi l l be assessed as f ol l ows:
a. Wave f or manal ysi s at t he begi nni ng of ever y shi f t , and wi t h any Clinical Protocol Page 2 of 5 Clinical Manual - Nursing Practice Manual John Dempsey Hospital Department of Nursing The University of Connecticut Health Center
change i n t he wave pat t er n. Post wavef or ms ever y shi f t .
b. Pr essur e r eadi ngs mi ni mal l y ever y 4 hour s except : Pul monar y ar t er y occl usi ve pr essur e ( PAOP) and Car di ac out put ( CO) - obt ai n ever y 4 hour s, or per pr act i t i oner s or der s.
c. Assess dr essi ng f or i nt act ness, dr yness, dr ai nage, pr esence of sut ur es, ever y 8 hour s.
d. Assess per f usi on di st al t o i nser t i on si t e ever y 4 hour s and pr n.
2. I V Fl ui ds:
a. Al l t r ansduced l i nes wi l l have a nor mal sal i ne f l ush, mai nt ai ned on a pr essur i zed bag ( set at 300mmHg) . At t hi s pr essur e, a 3- 5 ml / hr f l ush of t he syst emi s mai nt ai ned.
Except i on: t he cent r al l umen ar t er i al l i ne of an i nt r a- aor t i c bal l oon i s r out i nel y hepar i ni zed, unl ess speci f i cal l y or der ed r ef er t o I ABP pol i cy.
b. I V f l ui ds and medi cat i ons may be i nf used vi a a cent r al venous pr essur e ( CVP) l i ne, or t he pr oxi mal por t ( RA por t ) of a pul monar y ar t er y cat het er ;
I nf usi on of vasoact i ve medi cat i ons vi a t hese por t s i s not r ecommended, especi al l y i f manual car di ac out put measur ement s ar e t o be obt ai ned.
c. No I V f l ui ds ( ot her t han NS f l ush) ar e t o be i nf used vi a t he di st al por t ( PA por t ) of a pul monar y ar t er y cat het er , as t he wavef or mat t he di st al por t must be cont i nuousl y di spl ayed, i n or der t o eval uat e t hat t he cat het er i s i n cor r ect posi t i on.
d. NO I V f l ui ds ar e i nf used vi a an ar t er i al l i ne, unl ess speci f i cal l y or der ed by a pr act i t i oner ( i e. t hr ombol yt i c f or per i pher al ar t er i al occl usi on) .
3. Level i ng / Zer oi ng & Posi t i oni ng:
a. Al l ar t er i al , CVP and PA pr essur e r eadi ngs must be t aken wi t h t he t r ansducer s zer o st opcock l evel ed t o t he pat i ent ' s r i ght at r i um( phl ebost at i c axi s) t hi s i s def i ned as t he 4t h i nt er cost al space, t he AP di amet er of t he chest mi dchest ) , i f t he pat i ent i s supi ne.
b. A car pent er s l evel , or l aser l evel shoul d be used t o cor r ect l y r ef er ence t he syst emt o phl ebost at i c axi s.
c. Zer o t he t r ansducer at l east once per shi f t and any t i me t he f l ui d- ai r i nt er f ace i s i nt er r upt ed ( i . e. af t er bl ood dr aw or t ubi ng change) , as wel l as any t i me hemodynami c val ues obt ai ned ar e i n quest i on.
Clinical Protocol Page 3 of 5 Clinical Manual - Nursing Practice Manual John Dempsey Hospital Department of Nursing The University of Connecticut Health Center
To zer o t he t r ansducer : t ur n t he zer o st opcock of f t o t he pat i ent and open t he syst emt o ai r by r emovi ng t he dead- end cap. Pr ess zer o on t he moni t or . Once zer o r e- di spl ays, r epl ace t he dead- end cap. Ret ur n t he st opcock back t o moni t or i ng and r e- eval uat e t he squar e wave.
d. The head of t he bed ( HOB) may be el evat ed t o a posi t i on of comf or t f r om0 t o 60 degr ees f or ar t er i al , CVP, PA, PAOP measur ement s, wi t h t he pat i ent supi ne. When possi bl e, r eadi ngs shoul d be obt ai ned wi t h t he HOB at a consi st ent hei ght , r ecor ded on t he Nur si ng Assessment For m.
e. Car di ac out put measur ement s shoul d be obt ai ned wi t h t he pat i ent supi ne, and HOB 20- 45 degr ees.
f . I n t he 30 degr ee l at er al posi t i on, t he zer o r ef er ence poi nt i s t he di st ance f r omt he sur f ace of t he bed t o t he l ef t st er nal bor der , and measur ement s shoul d be obt ai ned wi t h t he HOB f l at . ( Si nce cl i ni cal l y si gni f i cant changes i n CO can occur i n t he l at er al posi t i on, af f ect i ng ot her hemodynami c par amet er s, t he hemodynami c r esponse t o t he posi t i on change shoul d be compar ed t o t he st andar d supi ne posi t i on, bef or e any deci si on i s made whet her t o t r end/ t r eat pr essur es obt ai ned when i n l at er al r ot at i on. )
4. Assessi ng/ Mai nt ai ni ng Dynami c Response
a. Check t hat t her e i s adequat e f l ui d i n t he pr essur e bag each shi f t , and mai nt ai n t he pr essur e bag at 300mmHg.
b. Ver i f y t he accur acy of t he syst em( dynami c r esponse) by per f or mi ng a squar e wave t est at i ni t i al set - up, at l east once per shi f t , af t er openi ng t he pr essur e syst em( i . e. bl ood dr aw, t ubi ng change) , and whenever pr essur e wave appear s t o be damped or di st or t ed.
c. Check t hat al l ai r i s out of t he bag & f l ush syst emand t hat al l connect i ons ar e secur e t o pr event ai r f r oment er i ng syst em. Ai r bubbl es can di st or t t he wavef or m, and al t er dynami c r esponse.
5. Bl ood Sampl i ng:
a. RNs may obt ai n bl ood sampl es f r oman ar t er i al l i ne, cent r al l i ne, or PA cat het er .
b. Bl ood may be dr awn f or l ab anal ysi s f r omt he pr oxi mal ( RA) por t of t he PA cat het er i f no ot her access i s avai l abl e.
c. A mi xed venous bl ood gas sampl e i s dr awn f r omt he di st al por t of t he PA cat het er .
6. Li ne Car e:
a. Al l por t s of t he moni t or i ng l i ne must be capped wi t h ei t her a dead- ended cap or needl el ess access devi ce. Clinical Protocol Page 4 of 5 Clinical Manual - Nursing Practice Manual John Dempsey Hospital Department of Nursing The University of Connecticut Health Center
b. Change t r ansducer f l ush syst em( t ubi ng and sol ut i on) ever y 72 hour s.
c. Ar t er i al l i ne t ubi ng shoul d be changed down t o t he st opcock cl osest t o t he pat i ent .
d. Chl or hexi di ne gl uconat e ( CHG) pr ep must be used, as per cent r al l i ne pol i cy, when accessi ng a hemodynami c moni t or i ng l i ne. Usi ng f r i ct i on, vi gor ousl y scr ub t he access por t wi t h CHG f or 15- 30 seconds.
e. Dr essi ngs must be mai nt ai ned per cent r al l i ne pol i cy.
7. Compl i cat i ons:
a. The nur se shoul d be al er t f or any of t he f ol l owi ng compl i cat i ons whi ch may be secondar y t o a hemodynami c moni t or i ng l i ne.
1) ai r embol i
2) vessel t r auma
3) dysr hyt hmi as
4) al t er ed ski n i nt egr i t y
5) phl ebi t i s
6) pul monar y embol i
7) pneumot hor ax
8) coi l ed cat het er
8. Repor t abl e Condi t i ons:
a. The f ol l owi ng condi t i ons ar e t o be r epor t ed t o t he pr act i t i oner :
1) Change i n wave f or m, dampened wave, or l oss of pr essur e wave.
2) Det er i or at i on i n pr essur e r eadi ngs i ndi cat i ng hemodynami c i nst abi l i t y.
3) Dysr hyt hmi as secondar y t o cat het er pl acement .
4) I nabi l i t y t o aspi r at e bl ood f r omcat het er .
5) I V f l ui d l eaki ng f r omcat het er .
6) Li ne not sut ur ed or secur ed.
7) Cont i nuous PAOP ( wedge) wave f or meven af t er bal l oon i s def l at ed ( t hi s i s consi der ed an emer gency, si nce per manent Clinical Protocol Page 5 of 5 Clinical Manual - Nursing Practice Manual John Dempsey Hospital Department of Nursing The University of Connecticut Health Center