Death by Arterial Line?

Specialties CCU

Published

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.

Specializes in Critical Care.

AACN Procedure Manual for Critical Care 5th Addition, pg 445: "Arterial catheters are used to continuously monitor blood pressure and for frequent arterial blood gas and laboratory sampling."

Page 456 - "Procedure - Set the alarm parameters according to the patient's current blood pressure. Rationale - Alarms should always be on to detect pulseless electrical activity, hypotension, hypertension, accidental disconnect, accidental removal of the catheter, or damping of the waveform." (emphasis mine)

Page 463 - "Documentation should include - Documentation of the patient alarms and their parameters."

The AACN Procedure Manual is our Gold Standard. This IS a standard of care.

~faith,

Timothy.

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When i am dealing with art lines in the PICU, the alarms are always kept on. If the wave form is dampened- then I try multiple measures to correct the problem (reposition, retape, ect.) If I am unable to correct the dampened wave, I call the MD. If the line is kept in- I adjust my alarm paramaters to compensate for the damp wave. I almost always try to keep the artline in, it is less painful to the patient than frequent labs and abgs.

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I was in Nursing clinicals several years back and I was observing in the NICU. The nurse had a pt with an artline who did not have the alarm set on the artline. I was looking at the patient and I noticed that the stopcock on the artline was opened and a large amount of blood was leaking out of the patient. :nono: I yelled for the nurse (since I could not touch the patient). Thankfully, the nurse corrected the situation. She told me that I saved the kid's life since I told her that the artline was leaking. If I did not notice that artline being disconnected and the alarm was not set--what would have happened?

Scary!

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Specializes in PICU, CVICU, IR Radiology, PICC.

I pulled one Saturday that was 3 days old. Pt POD 3 from thoracotomy. We weren't using it for anything and the wave form was damp no matter how I manipulated it. I did have to call the doc first though per policy but I agree with you. I don't know why it was put in unless maybe your night shift nurse was the one that had to get the labs and maybe that nurse wasn't a "good stick"? Regardless of experience, some people couldn't hit their butts if they had both hands on it when it comes to phlebotomy skills. Maybe someone was being lazy and did a con job to get a Aline?

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Specializes in NICU.

Just a quick little question. I'm a NICU nurse and I've seen how fast a disconnected art line will bleed back on a pt with a SBP of 40... how fast and hard will an adult art line bleed back? We talking blood spurts and puddles?

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Specializes in Critical Care.
Just a quick little question. I'm a NICU nurse and I've seen how fast a disconnected art line will bleed back on a pt with a SBP of 40... how fast and hard will an adult art line bleed back? We talking blood spurts and puddles?

Absolutely. Spurts and puddles.

You're talking about rapid exsanguination in mere minutes. IF you are in the room, you'll see the blood everywhere. If you're turning your other patient, if that abp disconnect alarm isn't set, or the art line isn't to the monitor at all, you might not notice until the asystole alarm goes off . . .

There's a phrase for that: sentinel event.

~faith,

Timothy.

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Specializes in NICU.
:uhoh3:
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Specializes in ICU.

Point #1:Invasive lines are a bold invitation for infection; Point #2: Exsanguination requiring blood product replacement is a big SENTINEL EVENT that should never happen anywhere. Point #3: Always have alarms on for art. lines in place.Use alarm parameters as Systolic,Diastolic, and the current practice,MAP.

Leaving any invasive line for the convenience of the staff is a no-no.

This patient is not on pressors,not a hard stick,etc.The line must go!

Just my 2-cents. Good day!

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Specializes in critical care, med/surg.
My first question is why on earth would you place an A-line simply for blood draws? You can't give meds through it and if you're not interested in obtaining blood gasses then it simply is the wrong choice. As far as what to do with it... I would widen the parameters assuming it had some sort of waveform. This way you solve the alarm issue, unless it becomes disconnected, in which case it should alarm. I would not have just pulled it without consulting with a midlevel. The line could be improved upon by using a longer cath placed over a wire.

My thoughts exactly...if the patient was a hard stick, why not a CVC?

I agree with the OP, if it wasn't being used for frequent ABG's or titrating pressors, why was it placed to begin with?

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Specializes in PICU, CVICU, IR Radiology, PICC.
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.

Why not a PICC? No you can't get a BP off of it but you COULD get a CVP if you needed it :) And it draws blood. Barring that, how bout a midline. For short term use, just as effective and no CXR is needed. Lower incidence of infection and no worries about blood flow to the extremity. Many times, I can place a PICC with less stress and trauma than someone placing an IV anyway. I do agree though, sticking someone for labs can be torture. New CDC guidelines recommend a PICC for anyone that will be in the hospital for up to a week now. Cool hu? Takes care of a few problems......may cause some though lol.

Oh and congrats on the motherhood.....I have teens. Better you than me! :lol2:

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Specializes in NICU.
Why not a PICC? No you can't get a BP off of it but you COULD get a CVP if you needed it :) And it draws blood. Barring that, how bout a midline. For short term use, just as effective and no CXR is needed. Lower incidence of infection and no worries about blood flow to the extremity. Many times, I can place a PICC with less stress and trauma than someone placing an IV anyway. I do agree though, sticking someone for labs can be torture. New CDC guidelines recommend a PICC for anyone that will be in the hospital for up to a week now. Cool hu? Takes care of a few problems......may cause some though lol.

Oh and congrats on the motherhood.....I have teens. Better you than me! :lol2:

Thanks for the congrats!

The problem with PICC lines is that I work in the NICU. Our PICCs are so tiny, and babies' blood pressure is so low, that drawing back isn't very easy nor is it recommended on a regular basis. The only time we ever do it is when we are drawing blood cultures off the line to r/o infection. If we have a baby with a Broviac, we'll do our blood draws off that because they're much larger and have good blood return. Another reason we prefer arterial lines is that the docs much prefer ABGs to VBGs, especially in really sick babies on high ventilator support. Also, in a very sick baby their cuff blood pressure is sometimes undetectable, and having continuous BP monitoring helps us titrate our pressors.

One more reason in the NICU - we either do capillary heelsticks or arterial punctures to get our labs. Trying to draw venous blood often "ruins" the kids' veins. So either their heels look like hamburger meat from the cap sticks, or we have to do an art stick instead. This is why we'll leave in a line that provides blood return even if the wave form is dampening.

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Specializes in Critical Care.
AACN Procedure Manual for Critical Care 5th Addition, pg 445: "Arterial catheters are used to continuously monitor blood pressure and for frequent arterial blood gas and laboratory sampling."

~faith,

Timothy.

I quoted this earlier, the AACN CC Procedure Manual uses 'frequent ABG/lab sampling' as a rationale for an arterial line.

It is a valid and recognized use for an arterial line.

~faith,

Timothy.

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