Death by Arterial Line?

[MarySunshine]

I was told when I was being precepted to NEVER silence the alarm on my arterial lines, no matter what, because if the line was to disconnect the patient could literally bleed to death through the line without any notice. Well, that scared me half to death so I have faithfully followed that advice.

I had a patient today who had an arterial line placed (on a previous shift) for lab draws because she was a "difficult stick." Well, It drew blood beautifully. However: 1) I could not get an accurate reading for the life of me (pitiful waveform) and neither could other nurses who tried 2) it alarmed constantly 3) she didn't require frequent labs 4) she wasn't a difficult stick!

But the night shift nurse who I gave report to was clearly frustrated with me for pulling it. She said I should have simply kept it all connected but taken it off the monitor entirely, for blood drawing purposes. Am I missing something here? She has about 8 years more experience than I do.

[Daniel4503]

I share in the frustrations of having an art line that won't pull back and won't transduce a good arterial wave form/pressure. It is hospital policy where I work that all arterial lines must be transduced on the monitor regardless of how well they work. This is a hassle sometimes because a patient may have three arterial lines (one radial for BP and blood draw, one IABP arterial line in the L fem, and maybe one arterial sheath from the cath lab in the R fem). This can make it frustrating have to deal with the alarms of 3 art lines. Getting back to your original point, yes I think it is bad to have taken the arterial line off the monitor. In any case, an arterial line that isn't working should be removed in my opinion.

[Cleveland-RN]

My experience is in Cardio-Thoracic ICU and many of our patients have gone south very quickly. Because our patients are short-stay, anyway, we usually leave a line like this in for any unexpected events to come. I would turn the audible alarm off but leave the visual alarm on and just amp up my personal monitoring of this patient. I can't tell you how many times we've d/c'd everything on a patient just to call everyone back and re-swan, re-TLC, and re-aline. I like to wait until they're stable enough to leave the unit b4 taking everything out.

[working4aBSN]

I was going to go a similiar route with you Cleveland...if the patient was respiratory issues then I would have adjusted the parameters to see if that changed the wave form and ended the alarms otherwise if is was not needed then I would have d/c'd it also..but if it was needed I would have then called the physician to place another one. It sounds as though this patient was more stable then the picture painted for you. I try never to shut any alarms off but I will sometimes adjust parameters based on what the patient has continously been running and comparing and I just try to tweek them very little..

[MarySunshine]

Thanks for replying everyone. I think that greatly widening the parameters will be in my future bag of tricks. For the record, I did ask the physician before I took the line out. The patient did not need ANY ABG's, was very stable, and was quite an easy stick for labwork.

Thanks for the good ideas and info! I did clarify with a charge nurse (without naming names) that if an aline is left off of the monitor, then that is a safety write up in our facility.

[ZASHAGALKA, RN]

My experience is in Cardio-Thoracic ICU and many of our patients have gone south very quickly. Because our patients are short-stay, anyway, we usually leave a line like this in for any unexpected events to come. I would turn the audible alarm off but leave the visual alarm on and just amp up my personal monitoring of this patient. I can't tell you how many times we've d/c'd everything on a patient just to call everyone back and re-swan, re-TLC, and re-aline. I like to wait until they're stable enough to leave the unit b4 taking everything out.

NO that's a JCAHO violation. JCAHO demands that alarms be audible - and not just audible, but audible enough to attact attn.

I'm not saying that every alarm has to be turned on, we turn off the 'irreg hr' and such alarms all the time. I've been known to turn off the spo2 alarm an awake and restless pt whose resp status isn't at issue.

But, IF YOU HAVE THE ALARM ON, you must have it audible and not just so you can hear it if you are RIGHT NEAR the monitor, but so that the alarm carries, per JCAHO.

And if you DON'T have an ABP alarm on, you are liable if your pt dies due to that negligence.

Widening the parameters is a better course of action.

~faith,

Timothy.

[Cleveland-RN]

I realize that this is a JCAHO standard, but in the pt scenario I'm speaking of, the a-line is left in only for blood draws. I'm not using it for anything else. In my unit, if we d/c an a-line then we're utilizing a non-invasive blood pressure cuff at pre-set intervals for blood pressure monitoring. This is the same thing that we're doing, just leaving the line intact.

[ZASHAGALKA, RN]

I realize that this is a JCAHO standard, but in the pt scenario I'm speaking of, the a-line is left in only for blood draws. I'm not using it for anything else. In my unit, if we d/c an a-line then we're utilizing a non-invasive blood pressure cuff at pre-set intervals for blood pressure monitoring. This is the same thing that we're doing, just leaving the line intact.

The purpose of the alarm isn't to alert you to BPs, but to a disconnect. THAT alarm must be audible. MUST.

Otherwise, when you are in the next room for 20 minutes, you might JUST be interrupted by another alarm, that ASYTOLE rhythm alarm from bleedout.

It's not the same thing. The purpose of the alarm isn't to notify you of the bad pressure reading from a dampened waveform; it's to notify you of a disconnect. Widen the parameters so it doesn't alarm for bp, but leave the alarm on and audible for the DISCONNECT alarm to blare.

Whether monitoring it for bp or not, you MUST monitor it for disconnect. And THAT alarm MUST be audible. That's a standard of care.

~faith,

Timothy.

[sunshineCCRN]

i would keep it in with wider parameters. we have VAMP attachments on our ART lines, so we draw hourly blood sugars from them, too. it saves a poke, and the "waste" is returned to the patient safely. so i guess i'm all about leaving them in....as long as you have SOME kind of a waveform/disconnect alarm!

[Pompom]

You did the right thing. That nurse with 8 years experience is an idiot and dangerous!

[ZASHAGALKA, RN]

I see this lots of times also: multiple Alines because one was 'dampened' during surgery so they put another in: normally one in the radial and one femoral.

When you get that pt, both alines are 'three-wayed' into the same transducer so that the waveform can be flipped back and forth to the most accurate line.

But, that is also a case of one line always not being monitored for disconnect. Each Aline MUST have its own transducer and its own module so that they can be separately monitored for disconnect.

Again, standard of care. No disconnect alarm means the line must be pulled or you are risking a sentinel outcome.

~faith,

Timothy.

[trixytop4]

Why would you put a A-line in a patient for blood draws and blood gases that is crazy. I would never leave a line in just for that. Monitoring hemodynamics should be the only reason you use an A-Line. I must have missed something in this forum.

[Gompers, BSN, RN]

Why would you put a A-line in a patient for blood draws and blood gases that is crazy. I would never leave a line in just for that. Monitoring hemodynamics should be the only reason you use an A-Line. I must have missed something in this forum.

What is wrong with using an A-line simply for blood draws? Yes, monitoring the BP is a great benefit of A-lines, but so is easy, painfree arterial blood sampling - especially if the labs are ordered frequently. Is it better to poke the patient every single time labs are needed? That is torture!

Just my opinion.