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Intreventions 2 > Hemodynamic Monitoring > Flashcards

Hemodynamic Monitoring Flashcards

1
Q

Arterial Catheterization

Indication

A

Often noninvasive BP is all that is required.

Arterial lines are useful when

  • Patient are unstable & require minute by minuteBP measurement
  • Require frequent ABGs drawn

Refractory shock, respiratory failure

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2
Q

Arterial Catheterization

Complications

A

Bleeding, infection, thrombosis, and distal embolism

If signs of infection are present catheter should be removed

Femoral site has potential for atheroembolism during guide wire insertion

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3
Q

Pressure Transducing System

Equitment Needed

A

500 cc normal saline

550 units sodium heparin

Medication label

Pressure transducer kit

Pressure bag with manometer

Transducer cable

Monitor

Gloves

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4
Q

Pressure Transducing System

Equitment Needed

A
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5
Q

Pressure Transducing System

Insertion Procedure

A
  1. Put on gloves
  2. Inject 500 U of heparin into bag of normal saline and label appropraitely (can also use prepackaged solution of normal saline with 1 U heparin)
  3. open transducer kit packaging and ensure tightness of all connections
  4. Flush system ensuring no bubble remain
  5. replace temporary caps (white caps) with blue caps
  6. Pressuize system to 300 mmHg
  7. Level system with phlebostsic axis
  8. Connect to monitor with cable and zero system
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6
Q

When inserting Arterial Line with do you freeze the arm with

A

Freeze site with ~ 1 cc of 1% Xylocaine using the 25 gauge needle. Be sure to withdraw to check that there is no blood prior to injecting Xylocaine.

*DO NOT ACTUALLY INJECT LIDOCAINE INTO ARM!! Insert the needle and demonstrate the procedure without injecting the lidocaine.*

Wait a few minutes to allow freezing to occur.

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7
Q

Inserting Artline

A

Palpate artery again. Insert needle of the artline kit, bevel up and using a 30-45 angle. When in the artery, as shown by a flash of blood, introduce the guidewire using non-dominant hand followed by the catheter. Remove the guidewire and the needle taking care to hold the catheter in place while occluding the artery. Quickly connect the pressure monitoring system taking care to maintain aseptic technique.

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8
Q

Withdrawing Blood from Art Line

A

Insert the first 5mL syringe into port. Turn stopcock off to pressure system and open to patient. Withdraw 5 mL of blood and discard the syringe.

Insert blood gas syringe into the port and withdraw a 1 mL blood sample. Remove syringe. Cap Sample.

Turn stopcock open to the sample port and closed to the patient. Insert the second 5 mL syringe and pull the flush device while withdrawing the syringe plunger to flush the blood from the port. Turn the stopcock off to the sample port.

Using flush device flush the line until it is clear using an intermittent flush technique.

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9
Q

Blood from Pulmonary Artery

A

Sample: Mixed venous blood (balloon deflated)

Reflects: Gas exchange at tissues (O2 consumption/CO2 production)

Pressure: PAP, PCWP

Reflects: RV afterload, vascular tone, blood volume, LV preload

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10
Q

Blood from Central Vein

A

Sample: Venous blood (unmixed)

Reflects: Not useful for assessing gas exchange, can be used for some lab tests

Pressure: CVP

Reflects: Fluid volume, vascular tone, RV preload

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11
Q

Blood from Peripheral Umbilical Artery

A

Sample: Arterial Blood

Reflects: Pulmonary gas exchange (O2 uptake/CO2 removal)

Pressure: Systemic Arterial PRessure

Reflects: LV afterload, vascular tone, blood volume

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12
Q

Capillary Blood Gas Sample

A

CBG samples may be used in place of ABG to estimate pH and PaCO2.

Capillary PO2 is of little value in estimating PaO2

A small incision via lancet or similar into highly vascular area such as heel, finger, or toe.

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13
Q

CBG Warming

A

CBG samples may be used in place of ABG to estimate pH and PaCO2.

Capillary PO2 is of little value in estimating PaO2

A small incision via lancet or similar into highly vascular area such as heel, finger, or toe.

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14
Q

CBG Indications

A

ABG indicated but arterial access not available

Non-invasive monitor readings are abnormal

Assessment of therapeutic modalities (vent)

Change in patient status

Monitoring documented disease process

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15
Q

CBG Contraindications

A
  • CBG should not be done at the following sites:
    • posterior curvature of heel (may puncture bone)
    • Heel of patient who has begun walking
    • Fingers of neonate (nerve damage)
    • On a previous puncture site
    • Inflamed, swollen, or edematous tissue
    • Cyanotic or poorly perfused tissues
    • Localized areas of infection
    • Peripheral arteries
  • On patients <24hr old due to poor peripheral circulation
  • When there is need for direct analysis of Oxygenation or Arterial blood
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16
Q

CBG Relative Contraindications

A

Peripheral vasoconstriction

Polycythemia

Hypotension

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17
Q

CBG Hazards/Complications

A
  • Infections
  • Hematoma, bruising, scarring
  • Bone calcification
  • Nerve damage
  • Pain
  • Inappropriate patient management may result from reliance on CBG PO2 values.
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18
Q

CBG Limitations

A
  • Inadequate warming of site may result in values that correlate poorly with arterial pH and PCO2
  • Undue squeezing (milking) may result in venous and lymphatic contamination of sample
  • Variability in PO2 values precludes using these samples for assessing oxygenation status
  • Sample must be anticoagulatedand obtained anaerobically
  • Cap tube should be filled completely and air bubbles expelled immediately
  • Sample should be chilled or analyzed within 10-15 minutes (watch for clots!)
  • Respassess patient at time of puncture
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19
Q

CBG Equipment

A
  • Pre-heparinized capillary tube
  • Sealant or cap
  • Lancet to make incision <2.5mm in depth
  • Gauze
  • Ice
  • PPE
  • Warm and moist cloth or commercially prepared warming pads
  • label
20
Q

CBG Document

A
  • FiO2 or prescribed O2 flow
  • Ventilator settings or O2 device used
  • Free flow of blood
  • Presence or absence of air or clot in sample
  • Patient: Temp, RR, position, level of activity, clinical appearance
  • Puncture site and appearance
  • Date, Time
  • Non-invasive data
  • Results
21
Q

CBG Frequency

A
  • Depends on clinical status of patient and indications
  • If needing frequent CBG’s may consider indwelling arterial access or non invasive monitoring techniques
  • Risk of scarring or serious laceration, should alternate sampling site

Remember go across the print of the heel

22
Q

CBG Infection Control

A
  • Universal precautions similar to ABG procurement
  • Aseptic technique, puncture site should be cleaned with anti-septic solution
  • Samples, contaminated material and lancets disposed of in appropriate containers
23
Q

Purpose of Artieral Line Sampling

A

To obtain an arterial blood sample from an indwelling catheter for the purpose of blood gas, electrolyte and metabolite analysis.

To provide technical support in troubleshooting problems with sampling from arterial indwelling catheters.

24
Q

Arterial Line Sampling Policy

A

All samples must have a physician’s order or be consistent with established ABG protocol.

All Respiratory Therapists performing this procedure must be certified for arterial line sampling.

RRTs drawing from arterial lines must follow universal blood and body fluid precautions.

25
Q

Arterial Line Sampling Point of Emphasis

A

Sample must be obtained using aseptic technique.

Ideally the patient should be in a period of homeostasis prior to obtaining sample.

Post sampling, the RRT must ensure that the line has been flushed clear of all blood, and that the arterial line continues to function properly.

Prior to leaving the patient’s room, the RRT must ensure that any alarms that were silenced have been reset.

26
Q

Arterial Line Sampling PPE

A
  1. PPE
  2. Silence monitor alarms
  3. Screw vacutainer Luer adapter to the vacutainer holder, and apply InterLink syringe cannula to vacutainer adapter
  4. While squeezing VAMP, pull back slowly over 3-5 seconds, until fully extended and the reservoir is filled with blood.
  5. Turn stopcock distal to VAMP off to VAMP (perpendicular to tubing).
  6. Clean sample port with alcohol swab. Use 30 second scrub and allow drying.
  7. Insert vacutainer into access port and collect blood tubes as required.
  8. Withdraw vacutainer and open stopcock between VAMP and patient.
  9. Depress VAMP slowly over 3-5 seconds, returning blood from reservoir to patient.
  10. Flush device until line is clear of blood (intermittent flushing technique recommended to prevent dilution of arterial blood and improves clearing of remaining blood from line due to turbulent flow).
  11. Visually inspect the area around the catheter insertion site for changes in skin appearance (i.e. blanching, redness, etc.). Report complications to the bedside RN and attending MD.
  12. Ensure return of arterial pressure waveform.
  13. Activate monitor alarms.
27
Q

Obtaining blood specimen from art line – Syringe Method

A
  1. PPE and silence alarms
  2. Apply needleless cannula to syringe
  3. While squeezing VAMP pull back slowly over 3-5 seconds, until fully extended and the reservoir is filled with blood
  4. Turn the stopcock distal to VAMP off to VAMP (perpendicular to tubing)
  5. Clean sampl port with alcohol swab and wait 30 sec to dry
  6. Insert blood gas syringe with needleless cannula into access port and withdraw 1 mL
  7. Remove syringe and open stopcock between VAMP and patient
  8. Depress VAMP slowly over 3-5 seconds, returning blood to pt
  9. Flush device until line is clear (intermittent flushing technique recommended to prevent dilution of arterial blood and improves clearing of remaining blood from line due to turbulent flow).
  10. Visually inspect the area around the catheter insertion site for changes in skin appearance (i.e. blanching, redness, etc.).
  11. Ensure return of arterial pressure waveform.
  12. Activate monitor alarms.
28
Q

Obtaining Samples-Non-VAMP System, Vacutainer Method

Procedure

A
  1. PPE and silence alarms
  2. Screw vacutainer luer adapter to the vacutainer holder.
  3. Apply needleless syringe cannula to vacutainer adapter.
  4. Clean needleless intermittent injection cap on blood drawing port with alcohol swab (30 sec to dry)
  5. Turn stopcock off to pressure system and open to patient.
  6. Insert vacutainer into needleless intermittent injection cap.
  7. Insert 5 mL blood tube into vacutainer and press down.
  8. Remove blood tube when full and discard.
  9. Replace with blood tubes to collect blood for required lab tests.
  10. Once all required blood specimens are collected, turn stopcock off to patient and open to port.
  11. Add 5 mL flush blood tube to vacutainer.
  12. Pull flush device to fill blood tube and remove all blood from port.
  13. Remove tube from vacutainer.
  14. Remove vacutainer from port and discard flush blood tube.
  15. Turn stopcock off to port and open to patient.
  16. Flush device until line is clear of blood (intermittent flushing technique recommended to prevent dilution of arterial blood and improves clearing of remaining blood from line due to turbulent flow.
  17. Visually inspect the area around the catheter insertion site for changes in skin appearance (i.e. blanching, redness, etc.).
  18. Ensure the return of arterial pressure waveform.
  19. Activate monitor alarms.
29
Q

Obtaining blood specimen – Non-vamp System, Syringe Method

Procedure

A
  1. PPE and silence alarms
  2. Add needleless syringe cannulae to all syringes.Clean needleless intermittent injection cap on blood drawing port with alcohol swab (give 30 sec to dry)
  3. Insert 10 mL syringe into port.
  4. Turn stopcock off to pressure system and open to patient.
  5. Withdraw 5 mL of blood and discard syringe.
  6. Insert blood gas syringe with needleless cannula into port, withdraw 1 mL sample and remove syringe.
  7. Turn stopcock open to port and closed to patient.
  8. Insert syringe and pull flush device while withdrawing syringe plunger to flush all blood from port.
  9. Turn stopcock off to port and open to patient.
  10. Flush device until line is clear of blood (intermittent flushing technique recommended to prevent dilution of arterial blood and improves clearing of remaining blood from line due to turbulent flow.
  11. Visually inspect the area around the catheter insertion site for changes in skin appearance (i.e. blanching, redness, etc.).
  12. Ensure return of arterial line waveform.
  13. Activate monitor alarms.
30
Q

Arterial Line Sampling Troublehshooting

Problem: Loss of waveform post-sample drawing.

A

Reason:

  • Loose, cracked transducer.
  • Disconnected cable.
  • Stopcock in incorrect position.
  • Large leak in system.
  • Clot in the catheter or at the catheter tip.

Action:

  • Visually inspect transducer for cracks.
  • Verify that the transducer cable connections are secure and that the cable is fully
  • plugged into the monitor.
  • Ensure the stopcocks are in the correct position.
  • Gently aspirate clot, then flush the line.
31
Q

Arterial Line Sampling Troublehshooting

Problem: Dampened waveform after drawing the sample

A

Reason:

  • Air in tubing.
  • A kink or clot in the indwelling catheter.
  • Catheter positioned against vessel wall.
  • Loose or cracked transducer or air in the transducer.

Action:

  • Check if there is air in the tubing.
  • Gently aspirate then flush the line to clear a clot if present in the catheter.
  • Reposition the extremity or apply gentle pressure as described above.
  • Assess if transducer is cracked or if there is air present.
32
Q

Arterial Line Sampling Troublehshooting

Problem: Unable to flush the line.

A

Reason:

  • A kink in the indwelling catheter.
  • Catheter positioned against the arterial wall.
  • A thrombosis in the catheter.
  • A stopcock in an incorrect position.
  • The flush solution bag is empty.
  • The pressure bag has lost pressure; therefore there might not be an adequate pressure gradient between the bag and the patient’s blood pressure.

Action:

  • Reposition the extremity or gently apply pressure to insertion site as outlined above.
  • Verify that the stopcocks are correctly positioned.
  • Check patency of the tubing. A common site of kinking is in the soft IV tubing between the pressure bag and the transducer, particularly where the tubing connects to the transducer.
  • Ensure that the flush solution IV bag is not empty and that the pressure bag remains at 300 mmHg.
33
Q

Arterial Line Sampling Troublehshooting

Problem: Unable to draw blood into the line.

A

Reason:

  • A clot in the catheter.
  • A kink in the indwelling catheter.
  • Catheter positioned against the arterial wall.
  • A stopcock in an incorrect position.

Action:

  • To clear a clot, gently aspirate the clot then flush the line.
  • If it is a radial arterial line, slightly extend the wrist or apply gentle pressure to the insertion site. Then attempt to draw the sample again.
  • If it is a femoral arterial line, apply gentle pressure to the insertion site or laterally rotate the leg slightly. Attempt to draw the sample.
  • Verify that the stopcocks are correctly positioned.
34
Q

It is recommended to have a systematic approach when troubleshooting. Start at the location of the most common problems:

A

Problems are frequently located within the fluid-filled portion of the system, so start by inspecting the transducer and tubing for the presence of blood, kinks, air bubble, loose connections, and stopcock position

Check that the pressure bag is >300mmHg or else there will be an increased risk for clot formation in the catheter

If there is air bubbles or blood in the tubing, gently aspirate with a syringe to remove the clotted blood or air and gently flush

If all the above does not fix the problem it could be the catheter positionReposition the limb or gently apply pressure to the insertion site. It is important not to forcibly irrigate the line, as a clot may be dislodged and cause a thromboembolism.

Last check the monitoring system by verifying that cable connections are secure. The cable or transducer may need to be replaced, however it is more time consuming, so should only be done if troubleshooting in the above sequence has not rectified the problem.

35
Q

CBG Clinical Guidelines

A

The RT is responsible for the procurement and analysis of neonatal/ped/adult CBG

There must be a physician order for a CBG

The RT should try to combine the lab and blood gas sampling when possible to minimize the number of punctures done on the pt

Previous puncture sites will not be used in CBG procurement

36
Q

What pt are CBG ideally considered for

A

CBG samples are ideally considered for the well-perfused pt

37
Q

CBG can be used in place of what

A

A capillary blood sample may be used in place of an arterial sample to assess pCO2 and pH

An arterial blood gas sample is recommended for reliable assessment of arterial oxygenation.

38
Q

The following factors may limit the ability to obtain a capillary sample

A

Peripheral vasoconstriction
• Polcythemia due to shorter clotting times

  • Clotting disorder
  • Hypotension
39
Q

Capillary samples should not be performed at or through the following sites:

A
  • Posterior curvature of the heel as the device may puncture the bone.
  • Heel of a patient who has begun walking and has callus development.
  • Posterior medial plantar surface of the heel as it may result in tibial artery laceration.
  • Previous puncture site.
  • Inflamed or edematous tissue because of potential sample contamination from the accumulated tissue fluids.
  • Cyanotic or poorly perfused tissue.
  • Localized areas of infection or bruising.
  • Fingertip of a neonate or infant < 1 year of age due to potential nerve and/or bone damage.
  • From a fingertip on the same side affected by a mastectomy due to poor lymphatic drainage and sample contamination from accumulated tissue fluids.
40
Q

Preferred Site for CBG

A

Thepreferredsiteforsamplecollectiononneonatesisthelateralormedialplantar surface of the heel.

The puncture site must be on the plantar surface medial to a line drawn posteriorly from the middle of the great toe to the heel and lateral to a line drawn posteriorly from between the 4th and 5th toes and the heel.

41
Q

CBG Puncture

A

Punctures are to be performed using a manual automated lancet device.

Heel punctures on neonate and infants must be no deeper than 2.0mm

42
Q

Other Sites than the Heelo for CBG Puncture

A

The finger tip or ear lobe may be used for sample collection in pediatric patients >1 year of age and adults.

The middle and ring finger are the preferred sample sites as the thumb has a pulse, the index finger may be more sensitive or calloused and the fifth finger may have insufficient tissue depth to prevent bone injury.

The puncture site must be on the palmar surface of the distal segment of the finger.

The side or tip of the finger should be avoided as the tissue there is about as half as thick at the tissue at the center of the finger. Fingertip punctures should occur across the fingerprints and not parallel to them

43
Q

CBG Warming

A

The need for warming the heel prior to sample collection when using an automated incision device is not universally recommended in the literature.

There is literature that reports no significant difference in analyzed values, volume of blood collected, need to repeat puncture and patient discomfort between warming and not warming for capillary sample collection.

Warming, though, may minimize the necessity to exert additional pressure to the site to obtain a sufficient sample.3

A warm, moist towel (or other warming device) at no hotter than 42 OC may be applied to the site for 3 to 5 minutes to warm prior to puncture.

44
Q

CBG and Pain

A

Heel lancing is a painful procedure.

Supportive measures such as sucrose administration, non-nutritive sucking and swaddling can be used to minimize distress. Initial pain management strategies

45
Q

Sources of potential pre-analytical error include

A
  • Failure to wipe away the first drop blood as it is rich in tissue fluid clot activators.
  • Excessive squeezing or milking of the tissue around the puncture may result in hemolysis or tissue fluid contamination.
  • Hemolysis will have a significant effect on potassium as intracellular potassium concentration is 20 times greater than the plasma concentration.
  • Sample contamination with tissue fluid will elevate the potassium level and result in lower values for other electrolytes and reported hemoglobin due to sample dilution.
  • Scooping blood along the skin as it dribbles from the puncture site may cause hemolysis and introduce micro clots into the sample.
  • Presence of a clot.
  • Introduction of air into the sample.
  • Presence of residual alcohol at the sample site (not allowing the alcohol to fully dry) may result in hemolysis.
  • Excessive or overly aggressive mixing can result in hemolysis.
  • Under mixing of the sample may result in inaccurate hemoglobin values.
46
Q

CBG Procedure

A
  1. Verify dr. order and check with RN to coordinate any punctures for lab.
  2. Ensure the pt is stable state (undistrurbed) and on proper O2/vent for 20-30 min
  3. Gather needed equitment, verify pt. give pain management and comfort strategies
  4. Wrap site with warm moist cloth, let site warm for 3-5 min the remove cloth
  5. Clean site with alcohol and allow to dry for 30 sec
  6. Position site to ensure the puncture site is below the level of the pt body
  7. Apply the lancet to the site, press down the lancet for the puncture
  8. Wipe away blood to prevent contamination
  9. Hold the capillary tube at approximately a 45-60 degree angle in the flow of blood and allow tube to fill.
  10. Collect sample from the center of the droplet of blood. Be careful not to tip the tube toward vertical allowing air bubbles to contaminate the sample.
  11. Apply gentle, circular pressure with the securing hand and squeeze slowly and rhythmically around the site to facilitate good blood flow. Release the pressure to allow for complete capillary refilling. Repeat this cycle until adequate sample is obtained. Sample should be free flowing.
  12. If the blood flow stops or becomes sluggish, briskly wipe the puncture site with gauze to remove clot formation and then continue with sample collection.
  13. Apply gauze and hold pressure to the puncture site until the site stops bleeding. Do not apply an adhesive bandage to any patient under 2 years of age.
  14. Seal both ends of capillary tube with caps. Continuously mix capillary sample on transport by end-to-end mixing
  15. Apply a patient identification label to sample and place sample and requisition in a biohazardous bag.
  16. Discard disposable items, wet linens and sharps in appropriate places.
  17. Transfer sample into another capillary tube to remove all clots and air bubbles prior to analysis.
  18. Analyze the sample within 10 minutes
  19. Document procedure in appropriate location(s) of patient’s health record. Immediately notify physician and RN of any complications/results.

Intreventions 2 (19 decks)

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