Nursing Question

Description

I am uploading few articles that can be used in my paper and presentation. also, I am uploading a policy that the paper will be talking about. The rubric and the requirements for the paper are attached as well. at first, it will talk about the policy which is (arterial puncture Blood Gas Sample Technique and Allen test) and then talk about whether the articles (studies) support the policy or not as explained in the rubric

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NURS 230 EVIDENCE-BASED PRACTICE ASSIGNMENT “POLICY REVIEW” GRADING RUBRIC
1
Evaluation
criteria
Excellent
Discussion of the
facility or
department
policy/protocol
Discusses the facility or
department policy/protocol.
Discusses the facility or
department policy/protocol.
Discusses the facility or
department policy/protocol.
Demonstrates thorough,
complete understanding.
Demonstrates minimal and
general understanding.
Demonstrates partial
understanding or
misunderstanding.
Discussion of the
evidence-based
practice to support
the facility or
department
policy/protocol
Clearly identifies evidencebased practice.
Provides incomplete description
of evidence-based practice.
Does not provide a discussion of
evidence-based practice.
Critique of the
facility or
department
policy/protocol
Discusses congruency of
existing policy/protocol and
evidence-based practice.
Does not discuss congruency of
existing policy/protocol and
evidence-based practice.
Lacks an organized approach to
analyze and critique
policy/protocol.
Demonstrates in-depth
understanding of strengths and
weaknesses of policy/protocol.
Demonstrates poor
understanding of strengths and
weaknesses of policy/protocol.
Spelling and
mechanics
The paper is consistently
grammatically correct and
without any spelling errors.
The paper is 2 pages only;
double-spaced; 12 font; 1-inch
margins.
Two EBP references published
within the last 5 years.
The paper with 2-5 grammatical
or spelling errors.
The paper is over 2 pages
Or single-spaced
Or font less than 12
Margins are not 1 inch
The paper with more than 5
grammatical or spelling errors.
The paper is over 2 pages.
Or single-spaced
Or font less than 12
Margins are not 1 inch
Oral Presentation:
Delivery
Holds attention of entire
audience with the use of direct
eye contact, seldom looking at
notes.
Consistent use of direct eye
contact with audience, but still
returns to notes.
Displays minimal or no eye
contact with audience, while
reading mostly from the notes.
Speaks with satisfactory
variation of volume and
inflection
Speaks in uneven volume with
little or no inflection
Is at ease with expected
answers to all questions,
without elaboration.
Shows little or no interest in
the topic being presented.
Oral Presentation:
Content/Organizat
ion
Average
Poor
Score
/3
/3
Presents a thorough analysis of
evidence-practice.
Speaks with fluctuation in
volume and inflection to
maintain audience interest and
emphasize key points
Demonstrates full knowledge
by answering all class questions
with explanations and
elaboration.
Provides clear purpose and
subject; pertinent examples,
facts, supports
conclusions/ideas with
evidence.
Has somewhat clear purpose
and subject; some examples,
facts that support the subject;
includes some data or evidence
that supports conclusions.
/3
/1
/3
/3
Fails to increase audience
understanding of knowledge of
topic.
2
SLO 4
Utilizes evidencebased research to
provide quality
health care, initiate
change and
improve nursing
practice by: a.
Utilizing evidence
based research in
the planning and
implementation of
basic nursing care
for medicalsurgical patients.
0 pts
Does Not Meet Expectations
0 pts
Meets Expectations
0 pts
SLO 7
Demonstrates the
importance of lifelong learning and
quality
improvement as
part of
professional
commitment to
the nursing
profession by:
a. Promoting
collaboration and
the development
of lifelong learning
skills as they begin
the role of the
professional nurse.
0 pts
Does Not Meet Expectations
0 pts
Meets Expectations
O pts
TOTAL
/16
3
The Scholarly Paper Requirements
The length of the paper is 2 pages.
The title page, running head, and any appendices are not required.
The APA format is required:
references (a minimum of two EBP references required.
margins – 1 inch
double-spaced
the font size is 12 pt
The APA format applies to all sections of the paper (reference page, citations, etc.)
The paper is graded using a grading rubric.
-power point for presentation
SESC Poster Paper
Recognition of Laceration of an
Aberrant Superficial Ulnar Artery With
Intraoperative Allen Test and Primary
Repair
The American Surgeon
2022, Vol. 88(7) 1570–1572
© The Author(s) 2022
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/00031348221084942
journals.sagepub.com/home/asu
Collin W. Pilkington, BS1, Christian D. Simmons, MD, PhD2,
Garrett Klutts, MD3, Hanna K. Jensen, MD4, and Kyle J.
Kalkwarf, MD5
Abstract
There are variations in anatomy that may alter the vasculature of an individual. This case report demonstrates an
abnormal branching pattern of a lacerated ulnar artery and its successful surgical repair. Without proper identification,
anatomical variations can negatively impact a trauma patient.
Keywords
ulnar artery, superficial ulnar artery, trauma acute care, brief report
A 47-year-old woman presented to the emergency department as the highest level trauma activation after accidentally lacerating her right proximal, inner forearm.
This occurred after dropping a large piece of glass that she
was carrying. During transport, her blood pressure was 56/
37 mmHg prior to IV crystalloid infusion. After infusion,
upon arrival to the emergency department, it had increased
to 89/73 mmHg. The patient presented with a pressure
dressing over the wound. When the dressing was taken
down, blood was pulsating from the laceration. Despite
the superficial nature of the bleeding distal to the antecubital fossa, the trauma team speculated that she may
have lacerated an aberrant superficial ulnar artery. As
a result, perfusion of the hand was interrogated with an
Allen test. This test is performed by occluding both the
ulnar and radial arteries at the wrist until the hand becomes
pale. The other is released while compressing one of the
arteries, and color should return to the hand. This test can
also be performed using a vascular Doppler device to
check for a signal on the non-occluded artery. If there is no
signal from the non-occluded artery or the hand does not
return to its typical color, then the non-occluded artery
cannot perfuse the hand by itself. When the radial artery
was occluded at the wrist in this woman, the ulnar signal
ceased. Therefore, she was taken to the operating room for
surgical exploration of a presumed lacerated ulnar artery.
The primary arterial supply to the upper extremity
progresses from the subclavian artery to the axillary artery
and subsequently the brachial artery before bifurcating to
form the radial and ulnar arteries. The radial artery is
lateral, and the ulnar artery is medial. The ulnar artery
typically has 7 main branches: the anterior ulnar recurrent
artery, posterior ulnar recurrent artery, common interosseous artery, palmar carpal branch, dorsal carpal branch,
deep palmar branch, and the superficial palmar arch. In
most people, the ulnar artery is the dominant arterial
supply of the superficial palmar arch.3 Alternatively, the
radial artery primarily supplies the deep palmar arch.4
The ulnar artery is usually deep to the median nerve
and medial to the pronator teres, flexor carpi radialis,
palmaris longus, and flexor digitorum superficialis muscles of the proximal forearm. As it migrates through the
forearm, the ulnar artery remains deep to the flexor carpi
ulnaris muscle and lateral to the ulnar nerve. In the distal
1
College of Medicine, University of Arkansas for Medical Sciences, Little
Rock, AR, USA
2
Division of Vascular Surgery, Department of Surgery, University of
Arkansas for Medical Sciences, Little Rock AR, USA
3
Department of Surgery, University of Arkansas for Medical Sciences,
Little Rock, AR, USA
4
Departments of Surgery and Radiology, University of Arkansas for
Medical Sciences, Fayetteville, AR, USA
5
Division of Trauma & Acute Care Surgery, Department of Surgery,
University of Arkansas for Medical Sciences, Little Rock, AR, USA
Corresponding Author:
Collin W. Pilkington, BS, College of Medicine, University of Arkansas
for Medical Sciences, 4301 W Markham, Little Rock, AR 72205, USA.
Email: cwpilkington@uams.edu
Pilkington et al
forearm and wrist, the artery travels between the tendons
of the flexor digitorum superficialis and flexor carpi ulnaris. The ulnar artery enters the hand via Guyon’s canal.
However, there is variation in the origin of the ulnar artery,
its pathway to the hand, and its size. The superficial ulnar
artery has a frequency of 2.3% and originates from the
brachial artery or the axillary artery.2 This variant passes
superficially to the flexor-pronator muscles and is commonly smaller than a typical ulnar artery.3 Due to its
superficial nature, it is also more susceptible to injury.
This woman presented to the emergency department with
signs of a lacerated superficial ulnar artery with a high
take-off.
She was taken directly to the operating room. The
laceration site was dissected until the proximal and distal
ends were identified. Bulldog vascular clamps were
placed on both ends of the transected artery. There was
suspicion that the lacerated artery was the ulnar artery
despite its unusual high take-off, superficial nature, and
small caliber. The Allen test was repeated in the operating
room, and the same results were found. This confirmed
our suspicion that it was the ulnar artery that had been
transected.
The laceration was extended, and the brachial artery
was traced to its bifurcation. A vessel loop was placed on
the proximal brachial artery to control flow, and a micropuncture kit and micro-sheath were placed in the
proximal brachial artery. An arteriogram was performed
to the right brachial artery bifurcation and the right
forearm (Figure 1). The arteriogram demonstrated
proper flow through the radial artery and the common
interosseous artery; however, there was no ulnar flow.
As a result, it was concluded that the lacerated artery
was likely the ulnar, and a primary repair was planned.
Seven thousand units of systemic unfractionated heparin
were infused. A #2 metallic vascular dilator was used to
gently dilate the artery in preparation for further manipulation. A #2 balloon embolectomy catheter was then
passed proximally and distally through the artery, and no
clot was retrieved. Each end of the lacerated artery was
spatulated to create an end-to-end anastomosis using 70 Prolene suture. The radial and ulnar Doppler signals
were then rechecked at the wrist, and the ulnar signal
was present when the radial artery was occluded. Another arteriogram was performed, but it continued to
show no ulnar flow in the forearm, suggesting a high
take-off of the ulnar artery. We used a 22-gauge butterfly
needle to inject contrast directly into the newly repaired
artery just proximal to the anastomosis to confirm that
we had repaired the ulnar artery. This arteriogram
demonstrated a brisk ulnar flow through the forearm and
confirmed a high take-off of the ulnar artery. At the
case’s conclusion, the patient had strong radial and ulnar
pulses and was admitted to the hospital for further
observation.
1571
Figure 1. Arteriogram of the right radial artery and common
interosseous artery before repair.
Overnight the patient experienced no complications
and was counseled on her surgery. We instructed her not to
allow an arterial line or a blood pressure cuff to be placed
on the right arm. Additionally, we advised her to begin
taking a daily aspirin. She was scheduled to follow up
with vascular surgery and was discharged.
It is common for trauma patients to present with arterial
bleeding. The initial goal is to identify and control
hemorrhage in the trauma bay. Typically, normal anatomy
and perfusion to the distal tissue are used to hypothesize
which vessel is bleeding and if it can be ligated or if it
needs to be repaired. Anatomical variance can make this
task difficult and potentially dangerous to the patient. As
seen in the above case, arterial bleeding from a proximal
forearm laceration can pose a challenge for surgeons in the
trauma bay. The low incidence of superficial ulnar arteries,
2.3%, can result in improper ligation in the emergency
department and potential hand ischemia.
When this woman initially presented to the emergency
department, there was a consideration of ligating the
lacerated artery. Despite the artery being superficial to
typical structures and relatively small in caliber, it was
decided that it might be the ulnar artery. This was due to
pulsatile bleeding, the vessel’s location, and the Allen test
results. In the operating room, the arteriogram demonstrated no flow through the ulnar artery to the wrist, increasing the suspicion that the lacerated artery was the
ulnar artery. The decision to repair the lacerated artery was
made to preserve as much blood supply to the hand as
possible.
Additionally, it is essential to pay special attention to
patients who have undergone a radial forearm flap. This is
a reconstructive procedure commonly seen in individuals
The American Surgeon 88(7)
1572
who have had head and neck cancer. A flap of the lateral
forearm is removed during the operation, and the radial
artery is ligated. If the same individual then presents to the
emergency department with pulsatile bleeding from
the proximal forearm, it is crucial to check perfusion to the
hand and make sure they do not have a superficial ulnar
artery variant. If they have this variant, the lacerated artery
must be repaired to maintain perfusion to the hand.1
Surgical intervention was necessary to identify and
repair an aberrant lacerated ulnar artery. This woman’s
vasculature was uncommon and easily could have been
mistaken for an unnecessary vessel. When an individual
presents with arterial bleeding from a medial upper extremity laceration in the trauma bay, it is important to
analyze blood flow to the hand before ligating the artery. If
there is an incomplete palmar arch, then ulnar artery
variations should be considered before ligation.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iDs
Garrett Klutts, MD  https://orcid.org/0000-0001-6313-9198
Kyle J. Kalkwarf, MD  https://orcid.org/0000-0003-16934935
References
1. Devansh. Superficial ulnar artery flap. Plast Reconstr Surg.
1996;97(2):420-426.
2. Fadel RA, Amonoo-Kuofi HS. The superficial ulnar artery:
Development and surgical significance. Clin Anat. 1996;
9(2):128-132.
3. Marques E, Bordoni B. Anatomy, shoulder and upper limb,
ulnar artery. In: StatPearls [Internet]. Treasure Island, FL:
StatPearls Publishing; 2022. PMID: 31536226
4. Zarzecki MP, Popieluszko P, Zayachkowski A, Pe˛ kala PA,
Henry BM, Tomaszewski KA. The surgical anatomy of the
superficial and deep palmar arches: A Meta-analysis. J Plast
Reconstr Aesthetic Surg. 2018;71(11):1577-1592.
Copyright of American Surgeon is the property of Sage Publications Inc. and its content may
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individual use.
Emergency Medicine Australasia (2023) 35, 142–147
doi: 10.1111/1742-6723.14148
CLINICAL PROCEDURES
Arterial line insertion
Clare ARMSTRONG
,1 Ben BUTSON1,2,3 and Paul KWA1,3
1
Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia, 2LifeFlight Retrieval Medicine, Townsville,
Queensland, Australia, and 3School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
Introduction
Arterial line insertion is a common
ED procedure with considerable clinician variation in preferred technique and equipment. This article
aims to review some of the controversies and evidence surrounding this
common ED procedure.
What are the indications?
The most common indication for
arterial line placement is for continuous blood pressure (BP) monitoring,
in settings such as shock requiring
vasoactive medications, conditions
where close BP monitoring is essential such as aortic dissection, or in
patients in whom non-invasive BP
monitoring is unreliable. Frequent
arterial blood sampling is a less common indication.
Despite being routinely used in
these settings, evidence of its benefit
on mortality and morbidity is lacking. Gershengorn et al. in a cohort
study of 60 975 patients found no
mortality benefit of arterial catheter
placement for ventilated intensive
care unit (ICU) patients.1
While both non-invasive and arterial BP measurement can be prone to
artefact and error, there appears to be
generally good correlation between
mean arterial pressure measured via
non-invasive methods and invasive
arterial methods.2,3 However, in critically ill patients, non-invasive BP
measurement is prone to underestimation of systolic BP.4
What are the
contraindications and
complications?
Commonly accepted contraindications
from more absolute to relative, are
proximal traumatic arterial injury, site
infection, deficient collateral circulation and coagulopathy.5–7
Serious complications are rare. The
risk of permanent damage from ischemia is reported as less than 0.1%,6,8
although Frezza et al. identified temporary vascular insufficiency in 3–4% of
cases.9 There is no benefit in using
heparinised saline in the transducer
bag to prevent thrombosis.10
Local infection occurs in less than
1% of patients, with the incidence of
systemic sepsis significantly lower.8,9
Infection appears more common if
aseptic technique is not followed or
a cut down technique is used.11
There may be a higher incidence of
bacterial colonisation when a line is
inserted in ED or the operating theatre compared to the ICU.12
The authors were unable to identify
any studies regarding the rate of infection in the pre-hospital environment.
We postulate this may be because prehospital insertion of arterial lines is
rarely indicated or performed.
Common complications include
pain,
paraesthesia
and
minor
Correspondence: Dr Clare Armstrong, Emergency Department, Townsville University
Hospital, Townsville, QLD 4814, Australia. Email: clare.armstrong@health.qld.gov.au
Clare Armstrong, MBBS, Emergency Registrar; Ben Butson, BSc (Hons), BMBS
(Hons), GradDipRuralGP, GCertSportsMed, CCPU, FACEM, FACRRM, FRACGP,
Emergency and Retrieval Physician, Senior Lecturer; Paul Kwa, MBBS (Hons),
MPH&TM, GradCertAeroMedRet, GradCertClinEd, FACEM, Emergency Physician,
Senior Lecturer.
Accepted 19 November 2022
© 2022 Australasian College for Emergency Medicine.
bleeding.6 Temporary radial artery
spasm may occur in as many as half
of patients, however this is usually of
little clinical significance. Haematoma
is also common, occurring in 15–
50% of patients8 but again usually
clinically insignificant.
Other very rare complications
include air embolism, pseudoaneurysm,
dissection and AV fistula.6,8
What is the best site for
insertion?
The radial artery is the most common
insertion site due to accessibility, collateral blood supply and complication
rate.13 Other sites in decreasing order
of preference include the femoral,
ulnar, brachial, dorsalis pedis, axillary and posterior tibial arteries.14
Advantages of femoral arterial line
insertion are potentially lower risk of
catheter failure.15,16 In one retrospective study there was a 5% failure rate
for femoral arterial lines compared to
30% for radial lines, without an
increase in infection.15 There may also
be a lower risk of accidental dislodgement.17 Traditionally femoral has not
been the preferred site due to infection
risk from proximity to the perineum.
However, the evidence regarding
infection rates in femoral lines is conflicted, as several studies have shown
no increase in infection rates compared
to radial placement.9,15
The ulnar artery is generally not preferred due to its tortuous course but
may be a viable alternative where a
pulse is palpable.8
The brachial artery may be considered as an alternative site, although
this has not been preferred traditionally due to absence of collateral circulation. Handlogten et al. conducted a
large study in 2014 showing relatively
low risks of serious complications of
brachial artery catheterisation, which
the authors defined as complications
requiring vascular or orthopaedic surgical consultation. There was a total
incidence of vascular and neurological
complications of 0.35% at the brachial site, compared to 0.03% at the
radial site. There were no infectious
complications in this study.18 Lakhal
et al. found serious complications from
brachial artery cannulation between
0.15% and 0.8%.13
The distal radial artery may also be
accessed in the anatomical snuffbox.
Although this technique takes longer
than the standard approach and is
technically more difficult to learn, it
has been shown to be non-inferior to
traditional radial placement.19,20
The use of the Allen’s test prior to
radial artery cannulation is no longer
recommended and has been shown
to be unreliable at predicting the
presence of collateral circulation or
risk of complications.7,8,21
• 20G IV cannula, BD Insyte brand
shown (Fig. 1c).
20G IV cannulas are readily available and familiar to staff. Classic
teaching suggests that they are more
difficult to insert and are more prone
to failure than the commercial arterial
line kits.22,23 Also, venous catheters
soften somewhat at body temperature
and are prone to ‘kinking’ in deeper
vessels, more so than the stiffer propriety arterial lines. We do not recommend using these routinely,
although we cannot find literature to
prove inferiority. If using this device,
a syringe may be placed on the end
of the cannula to allow ongoing visualisation of blood flow and then be
used to obtain an arterial blood gas.
One benefit of using an integrated
self-contained
modified-Seldinger
device (Fig. 1b) is a faster time to
insertion than use of the separate kit,
however in case of failure the entire
kit must be discarded, where a
device with separate guidewire may
be reused.22
Use of the traditional Seldinger technique (Fig. 1a) takes longer to insert,
however appears to have the highest
first pass success rate of all three
methods.22,23
In a direct comparison between all
three methods of arterial line insertion, Beards et al. identified a failure
rate of 7% with a Seldinger technique,
17% with a modified Seldinger technique, and 24% with direct puncture
What equipment do I need?
Preparation – rolled towel and
adhesive tape.
Infection prevention – antiseptic,
sterile drape, sterile gloves and personal protective equipment.
Analgesia – lignocaine 1–2%,
appropriate syringe and needles.
Arterial line kit – commonly prepackaged kits are used which include
chosen device with or without a
guidewire, which should be prepared
on a sterile or dressing tray. A pressure
transducer should be connected to tubing primed with saline, connected to a
pressure bag at 300 mmHg.
Securing – steri-strips or sutures
may be used with a transparent
dressing. An arm board may be used
to maintain the wrist in extension.
How do the different arterial
line kits compare?
The three common options are
shown in Figure 1:
• Separate needle/wire/arterial line
Seldinger technique, Arrow brand
device shown (Fig. 1a).
• Integrated self-contained modifiedSeldinger, Arrow brand device
shown (Fig. 1b).
Figure 1. Different arterial line kits. Images taken from manufacturer websites. (a)
Seldinger device. (b) Modified Seldinger device. (c) 20G IV cannula.
© 2022 Australasian College for Emergency Medicine.
17426723, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1742-6723.14148 by Mount St. Mary’S College Charl, Wiley Online Library on [09/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
143
ARTERIAL LINE INSERTION
using a standard cannula.22 Use of a
guidewire is commonly recommended
especially in difficult cases, however
personal preference and experience
should guide choice of device.
How do I optimise patient
positioning for inserting a
radial arterial line?
The recommended positioning for
radial insertion is with the wrist
extended to 45 . Evidence to support
this however is conflicted, with moderate evidence to support positioning
at 45 in a 2012 trial, and subsequently 2016 meta-analysis.24,25
However, a more recent cadaveric
study26 and two ultrasound studies
showed no change in the location or
diameter of the radial artery with
wrist movement.27,28 Regardless,
wrist extension beyond 60 is likely
to reduce the height of the artery
and decrease success.28
Right-hand dominant operators
will prefer the patient’s right radial
artery as an insertion site due to anatomical and ergonomic alignment.
This is similar to right-hand dominant
operators preferring the patient’s right
for insertion of central venous catheters at any of internal jugular, subclavian or femoral venous sites.
The authors’ personal experience
is to extend the patient’s wrist with a
rolled-up towel (Fig. 2). If an assistant is available, they may hold the
patient’s wrist in this position. If a
single operator only then tape may
be used around the patient’s thumb/
C ARMSTRONG ET AL.
hand and bed railing to secure the
wrist in the ideal position.
When the artery is not
palpable, are any drugs
helpful?
There was no clear evidence regarding the administration of systemic
medications to improve palpation of
the radial artery prior to catheter
insertion. The authors commonly initiate vasoactive medications in
shocked patients prior to arterial line
insertion, with the improved BP
assisting in palpation of the radial
artery. A dose of ephedrine to assist
in ease of palpation of the radial
artery may be used. However, the
authors were unable to identify any
studies regarding this practice, or the
use of alternate vasoactive agents.
A 2020 study found the application
of topical nitroglycerin in children
increased the diameter of the radial
artery and improved first pass success
without any significant complications.30 However, due to delay in drug
effect, this is unlikely to be particularly
practical in the emergency setting.
What is the role of
ultrasound?
Ultrasound is being increasingly recommended to assist arterial line
insertion in newer guidelines. Unlike
for central venous catheter insertion,
ultrasound is not yet considered
standard of care for all arterial line
insertions. However, the trend is
moving that way. It is advisable as a
first line option in patients in whom
difficulty is predicted – hypotensive
patients without a palpable radial
artery, obesity, multiple previous
attempts, or when only a single suitable site is identified.31,32
Using ultrasound to only mark the
skin is less useful than real time guidance.31 The best results may be
achieved by combining a short or long
axis approach with dynamic needle
tip positioning to prevent complications and improve first pass success.32
If using the long axis technique, positioning the needle bevel down may
reduce posterior wall perforation.32
Buetti et al. conducted a large randomised controlled trial comparing
the rate of infection when ultrasound
was used in arterial line placement,
using sterile precautions, probe cover
and gel, and identified no increase in
infections.33 The use of ultrasound
may actually reduce infection risk
due to a reduction in punctures.31
Should I use local anaesthetic?
Yes, if the patient is awake. The
authors use 1–2 mL of lignocaine 1%.
Multiple studies demonstrated
overall subjective improvement in
pain where local anaesthetic is used,
taking into account the additional
pain of injection.34–36
There is no evidence that the use of
local anaesthetic causes vasospasm or
obscures the artery. Lightowler et al.
conducted a randomised controlled
trial on the use of lignocaine versus placebo during arterial puncture with
improvement in pain and no impairment in success or subjective difficulty
of the procedure.37
To suture or not to suture?
Figure 2. Optimal position. Image reference: Abide and Meissen.29
Multiple studies have shown variable
practice within and between institutions regarding the method of securing an arterial line.7,38 Despite the
use of sutures, the rate of accidental
arterial line removal is higher than
that of central lines. In a 2004 study,
6% of arterial catheters were accidentally dislodged in ICU.17
There is no specific evidence regarding the best way to secure an arterial
catheter. It is therefore reasonable to
© 2022 Australasian College for Emergency Medicine.
17426723, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1742-6723.14148 by Mount St. Mary’S College Charl, Wiley Online Library on [09/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
144
defer to your local institutional practice. The authors’ personal practice is
to use steri-strips with an adhesive
dressing combined with an extension
wrist splint. We do not recommend
routine use of sutures for arterial lines
but accept that local institutional
practice does vary.
Do I really need to be sterile?
There is conflicting evidence regarding the infection rates of arterial
lines. Some recent studies report similar infection rates to central venous
lines and therefore recommend full
sterile technique.12,31 Koh et al. identified an incidence of bacterial colonisation of 15.7 per 1000 catheter
days for arterial lines, compared to
16.3 for central venous lines. Catheter related bloodstream infection
rates were 0.92 per 100 catheter
days for arterial lines, compared to
2.23 for central venous lines.12
At a minimum sterile gloves, drape
and skin antiseptic should be used
for peripheral sites, with full barrier
precautions used in central sites.39 In
observational studies, clinicians tend
to underestimate the risk of infection
associated with arterial catheters
with generally low adherence to sterile guidelines.40,41
How do I interpret and
troubleshoot the arterial
waveform?
Care should be paid to the transducer level, which should be at the
level of the heart, approximately
5 cm below the sternum in the
supine patient. The arterial pressure will be under or overestimated
should the transducer level be accidentally changed.
Underdamping (Fig. 3 – top) of the
transducer system will overestimate
systolic, underestimate diastolic pressure and cause a narrow-peaked
waveform with a deep dichrotic
notch. Common causes are stiff tubing or a defective transducer. This can
be reduced with the use of short stiff
tubing, limiting stopcocks, avoidance
of modifying pre-packaged kits, or a
commercial device to alter damping
may be used.6
Figure 3. Arterial wave forms. Image reference: Saugel et al.6
Overdamping (Fig. 3 – bottom) is
common and results in an underestimated systolic and overestimated
diastolic with a smaller pulse pressure, slurred upstroke of the waveform and absent dichrotic notch.
Overdamping may be caused by low
bag pressure, air bubbles, clots or
kinking in the tubing or catheter, or
loose connections. To troubleshoot
overdamping modify the wrist position, ensure catheter patency, check
the tubing and connections, remove
clots or bubbles by flushing the catheter and consider changing the tubing and/or catheter.6
© 2022 Australasian College for Emergency Medicine.
The fast flush or square wave test
can differentiate between over and
under-damping, where a short saline
flush is administered, and the waveform is observed for oscillations.6,14
How long can I leave an
arterial line in for?
A 1988 study42 found the rate of
skin colonisation of arterial lines
increases significantly to 24% after
4 days, and traditional recommendations have been to change the line
after around 4 days.11,42 There is a
low infection rate for short term
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145
ARTERIAL LINE INSERTION
insertion, although with longer insertion time the rate of infection and
bacteraemia significantly increases.43,44
Newer guidelines suggest changing
the catheter only if there are signs of
infection, or at 7 days for the radial
site. Institutional guidelines should
be followed where available.
Post-removal care?
After an arterial line has been
removed, firm pressure should be
applied for 10 min, longe