Hemodynamic Monitoring: Setup and Insertion for Arterial Pressure and Central Venous Pressure Monitoring
CLINICAL GUIDELINES
Hemodynamic monitoring is ordered by the healthcare prescriber for the purpose of:
Early identification and diagnosis of life-threatening conditions
Evaluating immediate responses to therapies
Titration of therapy
An arterial catheter is inserted by a healthcare prescriber into an artery. These vessels include the radial (most common), dorsalis pedis, posterior tibial, umbilical, and femoral arteries.
A central venous catheter (CVC) is used to monitor CVP. The catheter is inserted by a healthcare prescriber into a venous great vessel. These vessels include the superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, iliac veins, and common femoral veins.
The use of two-dimensional (2-D) imaging (ultrasound) guidance is recommended for CVC insertion.
The registered nurse (RN) caring for the child is competent to prepare and care for hemodynamic monitoring equipment, evaluate waveforms and their data, and make clinical decisions regarding changes in the child’s therapy.
The insertion of a CVC or arterial catheter can be performed during surgical procedures or at the bedside. Optimal preparation for implementing this procedure includes ensuring aseptic techniques can be employed, using a standardized equipment set, ensuring an assistant is present to aid the healthcare prescriber and incorporating the use of a checklist or protocol for catheter placement and maintenance.
The child with hemodynamic monitoring is maintained in an intensive care setting.
Informed consent to complete this procedure is obtained. Such consent may be incorporated into the general consent for treatment in the intensive care setting.
Sedation and pain management of the child with a CVC or arterial catheter is implemented on an individual basis according to the child’s needs.
The pressure transducer is calibrated to zero at the beginning of each shift and as needed to eliminate any baseline drift.
The pressure transducer is set to the phlebostatic level (midaxillary, right atrial [4th intercostal space] level) in relation to the child at the beginning of each shift and as needed when the child position or placement in the bed changes.
EQUIPMENT
For Setup of Monitoring Equipment:
Monitoring system and equipment (i.e., monitor, connecting cable)
Disposable pressure transducer system (per institutional preference) with flush tubing. Closed system sets and nonported tubing are recommended.
250-mL bag of normal saline (with or without heparin as indicated by institutional policy or as prescribed by healthcare prescriber)
Pressure bag or infusion pump, syringe pump, or microinfusion pump (for severely fluid-restricted children)
Transducer holder on an IV pole or other holding device
Leveling device
Nonvented caps
For Insertion of Arterial or Venous Catheters:
Clean, dry bedside table
Personal protective equipment (sterile gowns, sterile gloves, nonsterile gloves, caps, masks covering mouth and nose, and full-body patient drapes)
Sterile towels
Antiseptic solution/wipes (chlorhexidine-containing solution is preferred)
Several sterile normal saline vials
Sterile syringes (assortment of sizes: 3, 5, and 10 mL, and tuberculin)
Lidocaine (xylocaine) local anesthetic (0.5% or 1%)
Sterile catheter for arterial placement or sterile single-, double-, or triple-lumen catheter for CVC placement. Prepackaged kit with catheter, introducer and guidewire recommended
Sterile 4 × 4 gauze pads
2-in tape
Suture material or sutureless securement device (per healthcare prescriber preference)
Chlorhexidine-impregnated sponge
Sterile transparent bioocclusive dressing
Surgical light (optional for healthcare prescriber)
2-D imaging equipment
For Patient Care Needs:
Sedation and pain medications (as ordered)
Armboard or limb-immobilization device (if needed)
CHILD AND FAMILY ASSESSMENT AND PREPARATION
Assess the cognitive level, readiness, and ability to process information by the child and family.
Reinforce the need for device placement, as appropriate, to both the child and family.
In collaboration with other healthcare team members, identify and discuss the risks and benefits of monitoring with the family.
Ensure that informed consent has been obtained as needed per institutional policy.
Observe child for signs and symptoms of gradual or acute hypotension/hypertension, dysrhythmias, circulatory collapse, cardiac arrest, hemorrhage, hypoxemia, metabolic acidosis/alkalosis, fluid imbalance, diminished mental status, or laboratory abnormalities.
Assess the child for history of any previous hemodynamic catheter placement (i.e., cardiac surgery or cardiac catheterization). Inform the healthcare prescriber of the location of the previous hemodynamic monitoring site and of any complications that may have occurred during any previous procedures.
CHART 45-1 How to Perform the Allen’s TestThe Allen’s test is used to determine the integrity of the blood supply to the hand.
With the hand elevated, both the ulnar and the radial arteries are occluded, which leads to blanching of the hand.
Then, one of the arteries is released; normally, the blanching disappears over the whole of the hand. Failure of the blood to diffuse into the hand when opened indicates that the artery not compressed is occluded.
This is repeated with both arteries. If the hand remains pale, the blood is often collected from another artery, usually in the groin or elbow crease.
caREminder
Allen’s test should be performed before radial artery insertion of an intra-arterial catheter (Chart 45-1).
PROCEDURESetup and Insertion for Arterial Pressure and Central Venous Pressure Monitoring
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