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Download the Season 3, Episode 008 show notes or view them below.

Season 3 Episode 8 - Intensive Care Devices: Part 1

Intensive Care Devices: Part 1

Arterial lines, ventilators, central lines galore! Together with Acute Care Nurse Practitioner Sean Dent, Melissa and Kati discuss some tips and tricks for dealing with typical Intensive Care devices.

Introduction to Nurse Practitioner Sean Dent

  • An older “seasoned” nurse of 13+ years
  • Practiced in the ICU for his entire career except for about 3-6 months where he tried working in orthopedics
  • 7 years ago he went back to school and got his bachelor’s and master’s
  • He is now on his 5th year as an acute care nurse practitioner
  • He provides services to all of the ICUs inside the hospital

Let’s Talk Art Lines

As a brand new nurse, never dealt with art lines before, what are some big “never do,” and “always do” tips?

    • Understand why the patient is needing it – This is important because it’s not a permanent device, it’s a temporary device.
      • The sooner you can get it out the better.
      • It’s usually because their hemodynamics are compromised in some way that they need invasive monitoring.
      • An art line gives you continuous monitoring of their arterial pressure vs a cuff pressure which is intermittent and not as accurate
  • What NOT to do with an art line
      • Don’t NOT check it on a daily basis or shift basis
  • What You Should Check on Art Lines
    • Check and make sure that it is doing the job it’s supposed to do. Looking at the patient, looking at the insertion site. Looking at where it is because you can have an art line that either one of these:
      • radial art line
      • brachial art line
      • axial art line
      • Femoral art line
    • Radial art lines are the most common.
    • Look at the circulation of the limb or the site
      • This is because you just put a catheter into someone’s artery. So you have compromised the circulation of that vessel in some way.
      • You could lacerate someone’s artery if you aren’t paying attention to what you are doing.
    • The most important thing is looking at the insertion site
    • Then going from the patient to the monitor – you need to assess the function of the equipment.
      • Is it working appropriately?
      • Are all the lines, circuits and systems doing what they are supposed to be doing?
      • Is the pressure bag pumped up?
      • Is the tubing not kinked?
      • Are the 3-way stop clocks opened and closed properly?
      • If you use a vamp – is that opened or closed?
    • If things don’t look appropriate, ask for help.
    • You are trickling 3cc’s of normal saline into the artery to maintain a specific pressure, so you want to make sure you have adequate fluid and adequate pressure.
    • Look at the monitor and the quality of the waveform.
      • Do you have a whip in your wave
      • Do you have a dampened wave
      • Is it over correcting or under correcting someone’s actual blood pressure?
    • Never just treat a number. The quality of the waveform is what matters most.
    • You have to assess from wall to patient to see if something is off.
    • Is the equipment working the way it is supposed to work?
      • The way to assess that is to do the square wave test – a basic skill learned in ICU – doing a quick pressure change utilizing the pigtail on your pressure bag to see if fluid goes in and goes out quickly

Efficacy of Blood Pressure Cuffs with Art Lines

You see a number on the screen. Should you be checking that with a regular blood pressure cuff? If so, where and how often?

  • It is very patient-specific
  • Some patients that will always return inaccurate blood pressure cuff results are:
    • Patients that are third-spacing
    • Patients that are severely obese
    • Someone who is very cachectic
  • Blood pressure cuffs can be inaccurate
  • They can be used to compare
  • If you are interested in getting rid of the A-Line, you definitely need to start checking cuff pressures because you need to have some sort of correlation.
    • A-line should correlate with the cuff pressure. They usually don’t, but there should be some variance.
    • Is your A-line higher or lower than your cuff pressure?
      • You need to have this in the back of your mind so that when you get rid of the A-line you know ahead of time that the cuffer is going to be falsely elevated or going to be falsely lower.
    • When to discontinue the A-line is completely up to you and your team.
      • It should come out as soon as possible.
      • The sooner it comes out the better because it is an opportunity for infection and injury.

A-Line Tips

Follow these tips to provide excellent care for patients with A-lines

  • Make sure all the connections are tight
    • You don’t want your patient to lose blood due to loose connections
  • The A-line has to be leveled appropriately to get an accurate blood pressure
    • If the transducers are too high you aren’t going to get a good pressure
  • If you have a patient on drips and are you titrating drips off that art line, it is imperative that you make sure it is accurate
    • Quick tip: A lot of families and patients know not to bother nurses when they are giving meds, but they don’t always connect that when you are working with equipment. They don’t realize that me messing with this arterial line impacts how I give this medication and how much of it.

How to Use Different Kinds of Fluid Monitoring Devices

Tips for how to use common monitoring devices such as CVP and NICOM.

  • Know the Why – why you are doing it and how it’s working
  • You need to have a good solid foundation of anatomy and physiology and where the catheter is and what it is measuring.
  • CVP is part of a central line that is measuring fluid volume status and it is measuring central venous pressure.
    • Traditionally it sits somewhere in the SVC – just above your right atrium.
    • CVP is up from interpretation.
    • There is no normal.
    • There are trends
    • You are looking for a response to therapy.
    • Understand why you are using a CVP.
    • It is just another tool in the toolbox.
  • When you are measuring fluid volume status with various tools, it gets complicated. This is advanced stuff, you won’t have to know it on the first day.
  • CVPs can be just through a central line – they call them central venous catheters CVCs.
  • You can also measure CVPs through a Swan Ganz Catheter, or a PA Catheter
  • A PA Catheter sits in your Pulmonary Artery
  • A CVP is just a piece of a monitoring tool

Cooling Devices

How to use cooling devices correctly as you monitor patients.

  • Know how the equipment works
  • Know how to troubleshoot when alarms go off – a lot of times it has to do with connections and pressure and it depends on where the catheter is on the body.
  • Cooling devices are very specialized unless you are working in a unit where you are using it often like in a code-cool situation
    • TTP – Targeted temperature management
    • Hypothermia Protocol
  • There are different brands and types of devices
  • You can cool someone with an external device and an external device

More Resources on Intensive Care Devices:

Neonatal Intensive Care Nurse Exam Secrets Study Guide: Neonatal Nurse Test Review for the Neonatal Intensive Care Nurse ExamNeonatal Intensive Care Nurse Exam Secrets Study Guide: Neonatal Nurse Test Review for the Neonatal Intensive Care Nurse ExamNeonatal Intensive Care Nurse Exam Secrets Study Guide: Neonatal Nurse Test Review for the Neonatal Intensive Care Nurse ExamIntensive Care: The Story of a NurseIntensive Care: The Story of a NurseIntensive Care: The Story of a NurseUnisex ICU Registered Nurse Intensive Care Unit RN Staff Hoodie XL NavyUnisex ICU Registered Nurse Intensive Care Unit RN Staff Hoodie XL NavyUnisex ICU Registered Nurse Intensive Care Unit RN Staff Hoodie XL NavyCritical Care Nursing Made Incredibly Easy! (Incredibly Easy! Series®)Critical Care Nursing Made Incredibly Easy! (Incredibly Easy! Series®)Critical Care Nursing Made Incredibly Easy! (Incredibly Easy! Series®)True Stories of an Intensive Care NurseTrue Stories of an Intensive Care NurseTrue Stories of an Intensive Care Nurse