what?...q 15 NIBPs with an art line???

ICUmama · Aug 28, 2009

Thanks for all the feedback. Its almost like they are new at using art lines or something, but that just cannot be the case. And i really don't want to insult anyone by inquiring. I asked one of our ICU clinical supervisors and she totally agreed with me. So I always change it to q 4 NIBP on my shift and mention it in report (along with my tirade on how ludicrous it is do check q 15), but i always, always see that it is set right back to q 15! ***!!! They are definitely all about "overkill" here. And yes, these are often pts w coagulopathies, 2-4+ edema, weeping arms, and even CALF PRESSURES! Helloooo...ever heard of peripheral nerve damage??? Yes they are sedated, but it is torture nevertheless. This really bothers me. I think i will mention it to the manager...

dorimar, BSN, RN · Aug 30, 2009

Chisca states, "Correlates? Measurement of the blood pressure by art line is the gold standard".

I only have to say that no system is fool proof. Hopefully you are not trusting your aline every time it tells you the pressure is low or high... There are many factors that affect this reading just as there many factors that can affect an NIBP reading or even a manual pressure. If you read my post above, I talk about trouble shooting when you have questionable pressure readings or questionalbe waveforms. If you have worked critical care for any lenght of time you must know this is common. Square wave test it actually the "gold standard" to determine if your aline is accurate. However, even that does not account for the postional aline dampening...

I am trying so very hard to stay positive in this profession, but I get so frustrated when cocky people want to show thier umfff and try to make themselves look better by talking down to others when it is not even necessary. We were just having a discussion trying to better our practice here....

Yes, probably over-reacting... but I am so tired of that interpersonal dynamic that seems to prevail in this profession. So tired of it.

RN1982 · Aug 30, 2009

I agree with you dorimar. If I have a positional a-line, I too use a NIBP to correlate to the A-line. Yes they will correlate if the a-line is not positional and has a lovely waveform. How can one trust an a-line if the wave form is dampened?

Chisca, RN · Aug 30, 2009

i am trying so very hard to stay positive in this profession, but i get so frustrated when cocky people want to show thier umfff and try to make themselves look better by talking down to others when it is not even necessary. we were just having a discussion trying to better our practice here....

is that what you get out of my post? i was trying to express my frustration with the practice of accepting nibp pressures over direct arterial measurements in critically ill patients. there is no evidence published to support this practice no matter how common this ritual has become. if you are aware of any studies that support this practice i would appreciate your sharing them.

dorimar, BSN, RN · Aug 31, 2009

But if a "direct arterial measurement" is either overdampened or underdampened (which happens often), then it is not accurrate. If your square wave test indicates overdampening or underdampening, then your aline is not the number to guide your treatement. Then you need to trouble shoot, and yes you should be comparing cuff to aline, especially in these situations....

I never see anyone document square wave. Every time I teach it even experienced nurses tell me they've never heard of it. Underdampened waveforms are very common. I have seen descrepencies by as much as 50 mmHG due to hyperresonnance of underdampening. Scary that we sometiems titrate nipride based on an underdampened waveform... Most people now days never even heard of a ROSE...

Chisca, RN · Aug 31, 2009

What I'm sensing is that nurses are using NIBP correalation as an independent criteria as whether or not an arterial line is accurate. Again, no published evidence to support this practice.

lucky1RN · Aug 31, 2009

Our policy is to zero the A-line and check a square wave form q shift, check the waveform with each pressure check, and level the transducer PRN. If everything checks out ok, we leave the peripheral cuff off and only check a peripheral pressure q4h. I've heard people talk about "correlating" before and I don't get it. Why even bother if your A-line is functioning properly?

Now the other day, I had a pt with an A-line that had a dampened waveform and inadequate square wave form test. I tinkered a bit with the lines/positioning/equipment, etc. but couldn't fix it. We left the line in for gases but monitored peripheral pressures. I just don't see why you would ever do both? Then your stuck trying to figure out which one to treat if they're significantly different.

I work in a 17 bed mixed ICU in a somewhat rural location so I'm always interested to hear what other people are doing...

Mrs.Rollins, ASN, RN · Sep 1, 2009

I should clarify: I don't "correlate" to see if the art line is functioning, but to see if there's a perfusion mismatch. It's also helpful, IMO, when the art line is extremely postional. Just my $0.02.

PICNICRN, BSN, RN · Sep 1, 2009

Ok, lets see if I can clarify the whole "correlation" thing. I can only speak for my self..... I was taught that, as many have already stated, your A line is your gold standard- that IS your accurate B/P- provided it zeroed appropriately, ect,ect. By "correlating" you are checking to see how close your cuff is to your A line- does it always run 10 higher, is it all over the place?? Then.... if something happens to your A-line- you kinda have some idea where you stand until you can fix your A line problem.

I guess what I am trying to say is that I think when people use the phrase "correlate" they not speaking about the accuracy of the Arterial pressure, but the accuracy of the cuff as compared to the arterial pressure.

Does that make any sense? Maybe I'm just rambling???

NtannRN · Sep 2, 2009

PICNICRN, I think you just hit the nail on the head. At my facility we "corrolate", along with zeroing,leveling,square wave tests, to make sure we are getting the most accurate numbers humanly possible for the best care possible!

chademack · Sep 2, 2009

This ought to be a no brainer. For those who say that they check BP's q 12 hrs, don't take care of me. The best practice is one that requires frequent and close attention. Many people don't even go into the room to check on people but look at a monitor. And don't say it doesn't happen, I've seen a whole lot. Why do both when your art correlates? The term is quality assurance. Art lines are positional, patients move, left arm can be different from right arm, art lines can be in the groin, aux, rad, patient have disease processes that cause vascular changes. Usually the ones crying "too much work or over kill" are those that don't know the difference in over confidence and quality of care. I am willing to bet that the reason that people have to do frequent VS checks both with an art and a cuff, is related to a sentinel event. In health, care you can NEVER....NEVER be too careful. And for the person out there ready to pounce on this, let me tell you. I have worked in all over the US, and when you see people working 2 or 3 jobs or on their 8th day in a row with 4 hrs of sleep its easy to see why those babies in Californai got the wrong heparin. That being said, a good surgeon or sharp intensivist would not give orders blindly, then want to know whats going on with their patients. If your patient is stable, pull the art line and move them to the floor if not them practice taking care of people who are sick and need that close attention. Hey, you might learn something by paying closer attention.

geekgolightly, BSN, RN · Sep 3, 2009

But if a "direct arterial measurement" is either overdampened or underdampened (which happens often), then it is not accurrate. If your square wave test indicates overdampening or underdampening, then your aline is not the number to guide your treatement. Then you need to trouble shoot, and yes you should be comparing cuff to aline, especially in these situations....
I never see anyone document square wave. Every time I teach it even experienced nurses tell me they've never heard of it. Underdampened waveforms are very common. I have seen descrepencies by as much as 50 mmHG due to hyperresonnance of underdampening. Scary that we sometiems titrate nipride based on an underdampened waveform... Most people now days never even heard of a ROSE...

I square my art line at the beginning of every shift and if I think there is a change either in the way the waveform presents, or a sudden change in pressure. But I do not know what a ROSE is. Could you tell me?

Thanks