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Peter Branfield
Automated Non-invasive BP
Most common method
Oscillometry Measures blood flow induced oscillation
Cuff with dual pneumatic & sensing channels Controlled stepped deflation Blood flow causes vibrations
Sensed as pressure changes & analysed
Automated Non-invasive BP
Can be uncomfortable Pressure risk Occlusion of infusions Important to get the size right Least useful when most needed Greater frequency & accuracy needed in ICU
Multiple arterial blood samples (Lough 1987) Greater accuracy -the gold standard Visual display
What
Cannula
Flow stop (20g) Arrow PiCCO
Pressure Transducers
Turns a pressure signal into an electrical signal
Piezoresistive stain gauge
Pressure Transducers
Requires correct setting up
Continuous fluid pathway No air bubbles Non-compliant manometer tubing Zeroed to atmospheric pressure Level with the phlebostatic axis No additional tubing
Zeroing
To ensure accuracy of readings Off to patient but open to atmosphere and flush device These exert pressure on transducer This pressure is called zero Zero once per shift or if values are questionable Tip- ensure flush bag is pumped up
Phlebostatic Axis
Fourth intercostal space, midaxillar Level with right atrium Not accurate when on side Level with stopcock above transducer
Normal Waveform
Critically damped (correctly)
Return to waveform immediately after flushing
Over-Damped Waveform
Overdamped
blunted response indistinct waveform
Air bubbles Position/kinking
Under-Damped Waveform
Underdamped
exaggerated response - spiking Over estimate SBP, under estimate DBP
Anacrotic notch
Severe aortic stenosis
Complications
Cannulation can be difficult Potential complications include
Infection Occlusion Disconnection Air emboli User error
Complications (AIMS-ICU)
251 reports of 376 incidents (7525 total)
15% insertion problems 66% line use/maintenance problems 19% patient injuries
Most frequent
Inadequate line securing Accidental dislodgement Incorrect set up Distal ischaemia Infection Lack of knowledge Rule based errors Busy Lack of support /supervision
Contributing factors
CT 17.45 normal Laboratory Blood glucose 19.00 =0.1mmol/L Neuroglycopenic brain damage remained comatose Glucose put up as flush solutioncontaminated samples
Nursing Care
What do you think are the Key issues for the nursing care of a patient with an arterial catheter? 5 minutes to discuss
Place a label reading Arterial line next to the sampling three-way tap
To ensure correct identification of the arterial line
Cutaneous manisfestations
Flushing, mottling
For children under ten years of age use a syringe driver instead of the flush bag
To prevent fluid overload
In patients with ICP monitoring it is appropriate to level the transducer to the tagus of the ear
In order to correctly calculate cerebral perfusion pressure (CPP).
References
Ahrens, T (1994). Ask the Experts. Critical Care Nurse,14 (6), 98-99. Anderson, L.E. (Ed.). (1998). Mosbys medical, nursing, and allied health dictionary. (5th Ed.). St. Louis: Mosby. Campbell, B (1997). Arterial waveforms: Monitoring changes in configuration. Heart and Lung, 26 (3), 205-215. Chulay, M (1995). Ask the experts. Critical Care Nurse, 15 (2), 108. Chulay, M., & Holland, S (1996). Ask the experts. Critical Care Nurse, 16 (6), 103-107. Chulay, M., & Holland, S (1997). Ask the experts. Critical Care Nurse, 17 (3), 14-16. Gamby, A., & Bennett, J (1995). A feasibility study of the use of non-heparinised 0.9% sodium chloride for transduced arterial and venous lines. Intensive and Critical Care Nursing, 11 (3), 148 150. Daily, E., & Schroeder, J. (1995). Techniques in bedside hemodynamic monitoring. (5th ed). St Louis: Mosby. Darovic, G., Vanriper, J., & Vanriper, S. (1995). Arterial pressure monitoring. In Darovic, G. (Ed.), Hemodynamic Monitoring: Invasive and noninvasive clinical application. (pp.177-210). Philadelphia: W.B. Saunders Company. Darovic, G., & Vanriper, S. (1995). Fluid filled monitoring systems. In Darovic, G., (Ed.), Hemodynamic monitoring: Invasice and noninvasive clinical application. (pp.149-175). Philadelphia: J.B.Lippincott Company. Gavenstein, G., Paulus, J., & Paulus, D. (1987). Clinical monitoring practice. (2nd ed.). Philadelphia: J.B.Lippincott Compnay. Hudak, C. (1998). Assessment: Cardiovascular system. In Hudak, C., Gallo, B., & Benz, J. (Eds.), Critical Care Nursing: A holistic approach. (5th ed.). (pp.124-135). Philadelphia: J.B. Lippincott Company. Lough, M. (1987). Introduction to hemodynamic monitoring. The Nursing Clinics of North America. 22 (1), 89103. National Patient safety Agency Rapid Response Report Npsa/2008/Rrr06 Problems with infusions and sampling from arterial lines 28 July 2008. Sen S, Chini E N,. Brown M J (2005). Complications After Unintentional Intra-arterial Injection of Drugs: Risks, Outcomes, and Management Strategies Mayo Clinic Proceedings.;80:783-795