Arterial line vs. cuff pressure.

[dirtyhippiegirl, BSN, RN]

Don't know if this is in the right spot or not, but:

I had a bit of a conflict with my charge nurse the other night. Had a trach'd and ventilated patient who was on sedation. His arterial line is pedal and has a long history of being positional/finicky. At one point during the night, his arterial line was reading 70s/80s systolic with a severely dampened waveform which I tried everything to fix but couldn't. His cuff pressure was reading 120s/110s systolic, however. He had strong pulses in all extremities, color was normal, and he would open his eyes to his name.

So my charge nurse comes to relieve me for lunch and I tell her what's going on. Okay. I come back about twenty minutes later and she's like "I turned off all of his sedation. His arterial line pressure is really low." I'm like "I know it's low but his waveform sucks." Well, his last cuff pressure was 100/something (MAP still well over 60). So the cuff pressure was "trending down." This is obviously where my minimal experience comes into play and I start to doubt myself. I was told to leave sedation off until his arterial pressure starts coming back up. By the time it's normal again, pt is very awake and extremely agitated. I spent the rest of the night chasing my tail trying to get him adequately sedated.

When I gave report the next morning, I explained what had happened without actually stating who had made what decisions. The oncoming nurse gave me crap. Was he hypotensive in his arterial line or his cuff? etc. etc. I wanted to tell her that it wasn't my decision to turn off sedation but didn't feel like it was my place because she was also orienting a new nurse to the unit, and I could have spoken up but I didn't.

My questions: was I appropriate in ignoring the arterial line pressure in favor of the cuff pressure? Also, are there any tips/tricks to getting a pedal line to work better? I'd changed the dressing, made sure the connections were good, tried to place a pressure dressing over the foot, re-positioned his leg...

[Perpetual Student]

If the waveform was as crappy as you said and the patient was doing as described, totally right. Treat the patient, not the monitor. Esp. when there have already been issues with the instrument giving you the reading. Believe the number that is compatible with your physical assessment.

Frankly, I wouldn't have looked like an idiot to cover for my charge. I wouldn't necessarily have named her, but I would've said someone who covered me for my break did it.

[dirtyhippiegirl, BSN, RN]

If the waveform was as crappy as you said and the patient was doing as described, totally right. Treat the patient, not the monitor. Esp. when there have already been issues with the instrument giving you the reading. Believe the number that is compatible with your physical assessment.

Frankly, I wouldn't have looked like an idiot to cover for my charge. I wouldn't necessarily have named her, but I would've said someone who covered me for my break did it.

Thanks for reassuring me! I think that while I have the knowledge base to fumble along in ICU, I tend to lack confidence which is what gets me into trouble. I felt totally confident with my decision to ignore the low arterial line readings based on all the other factors -- until the more experienced nurse came in and shut off the sedation.

Honestly, I didn't think to just say the person who covered for my break. ('tho I work on a very small unit and it might have been inferred.) Definitely something that I'll keep in mind for the future.

[iluvhrts]

One other thing you could have done was "hard flush" the art line. Take a 10 ml syringe with NS and flush it throught the port as you would if you were drawing labs out of the port. Sometimes the extra force "whips" the end of the art line back into a better position. Why were you still using a poor art line? Frequent ABG's? That and you could have asked day shift to get an order to treat NIBP instead of Aline.

[Sun0408, ASN, RN]

If after repostioning, and zeroing the A-line and I still had a crappy waveform I would have went with the cuff.. What number would you treat if you didn't have an A-line??? The cuff pressure. We will DC an A-line if the waveform becomes dampened or if it is "unreliable" for any reason..

I always, zero the A-line

Insure the pressure bag is at proper inflation

make sure the stop-cock is in the right position

Do I have blood return?

Does the line flush well?

Do I have a good waveform, is it dampened or does it have too much whip?

Of course these are not in order but it is things I check.

[Altra, BSN, RN]

I would probably agree with your assessment that the low readings were the result of the positional art line, if cuff pressure was as you stated, urine output had not dropped, peripheral pulses were palpable, etc. I've never had an a-line that I couldn't at least momentarily get a good waveform out of ... unless the line really was no good.

Other options to consider in the future:

1. If the a-line is that unreliable, it needs to be replaced. Did you consider contacting the MD to get another line put in?

2. I don't know what sedation the patient was on, but could you have contacted the MD to get it switched to another drug to ease the hypotension side effect?

3. OK, so another nurse's judgement led her to discontinue sedation r/t hypotension. Did she contact the MD for further orders? Did you? What were the parameters of the existing order and if they didn't cover hypotension ... this warrants a call to the MD, IMO. In other words ... if someone was really convinced that the patient's BP was trending down, then this should be examined in a larger context than just the sedation issue.

[dirtyhippiegirl, BSN, RN]

One other thing you could have done was "hard flush" the art line. Take a 10 ml syringe with NS and flush it throught the port as you would if you were drawing labs out of the port. Sometimes the extra force "whips" the end of the art line back into a better position. Why were you still using a poor art line? Frequent ABG's? That and you could have asked day shift to get an order to treat NIBP instead of Aline.

I was also hard flushing it.

The patient in question was a burn who couldn't have an a-line placed in the usual spots. He was on Q6H ABGs, plus PRN as he was getting weaned off the vent. Good enough for me to want to keep the line in, esp since both his radials were all burn tissue/grafts.

[dirtyhippiegirl, BSN, RN]

I've never had an a-line that I couldn't at least momentarily get a good waveform out of ... unless the line really was no good.

I could get a good waveform off the line if I pushed in the right spot. (Hence the positional description.)

Honestly, I think what freaked me out was that it did work very well when the patient was moving or agitated. Great waveform. Cuff and line pressure were the same. When the patient seemed sedated (but again -- opening eyes to name, great pulses and color) --) the waveform would overly dampen to the point where it was nearly flat. But I think that's part of having a pedal a-line, y'know?

[ckh23, BSN, RN]

With your added information. I would have just let the MD know the situation about the A line and the waveform and that you would be trending pressures by cuff. I would leave it up to them to replace the aline or not. If this patient has a pedal A line, I'm sure he has limited acess so at the very least if it was still giving you blood return you can use it for that. I always find that A lines in the lower extremeties tend to be lower than the cuff.

As for the situation with the charge nurse, you have to remember that it is your patient and not hers. When you came back from lunch you should have went back to what you were doing prior. I wouldn't fault the charge nurse for doing what she thought was right at the time you were gone, but there is no need to follow that trend when you came back. Who told you to leave the sedation off until his pressure came up anyway? The point is you know this patient better than the person who covered you for the 20 minutes you were gone.

I can understand why the oncoming nurse might have been a little peeved about the situation, but it is what it is. I would use this as a learning experience. On a positive note, kudos to you for treating the patient and not the numbers.

[wanderlust99]

I'm sure we've all had something like this happen to us in the ICU, I know I have. I've found the best way to cover yourself is just to get the doctor to look at the waveform and give you the order saying "okay to go by cuff pressure".

[Caffeine_IV]

Definitely run it by the MD in future to get an order on chart and CYA. If you did all the typical things to improve the waveform, go by the cuff pressure and patient condition.