AACN Procedure Manual For High Acuity, Progressive, and Critical

Arterial Catheter Insertion (Assist), Care, Defibrillation (Internal) Perform , 310
and Removal, 508 Donor-Site Care, 1136

Arterial Catheter Insertion (Perform) , 501 Drain Removal, 1190
Arterial Pressure–Based Cardiac Output Emergent Open Sternotomy (Perform) , 322
Monitoring, 523 Emergent Open Sternotomy (Assist), 329
Apheresis and Therapeutic Plasma Exchange Endoscopic Therapy, 989
(Assist), 1100 Endotracheal Intubation (Assist), 23
Arterial Puncture , 707 Endotracheal Intubation (Perform) , 8
Atrial Electrogram, 356 Endotracheal Tube Care and Oral Care Practices for
Atrial Overdrive Pacing (Perform) , 366 Ventilated and Non-ventilated Patients, 32
Automated External Defibrillation, 286 Epicardial Pacing Wire Removal , 373
Autotransfusion, 164 Epidural Catheters: Assisting with Insertion and Pain
Bispectral Index Monitoring, 778 Management, 929
Blood Sampling from an Arterial Catheter, 530 Esophageal Cardiac Output Monitoring: Assist, Care,
Blood Sampling from a Central Venous Catheter, 540 and Removal, 590
Blood Sampling from a Pulmonary Artery Esophageal Cardiac Output Monitoring:
Catheter, 548 Perform , 584
Bone Marrow Biopsy and Aspiration (Assist), 1119 Esophagogastric Tamponade Tube, 958
Bone Marrow Biopsy and Aspiration External Wearable Cardioverter-Defibrillator, 335
(Perform) , 1110 Extra Electrocardiographic Leads: Right Precordial
Brain Tissue Oxygen Monitoring: Insertion (Assist), and Left Posterior Leads, 477
Care, and Troubleshooting, 792 Extracorporeal Life Support (ECLS) and Extracorporeal
Burn Wound Care, 1125 Membrane Oxygenation (ECMO), 123
Calculating Doses, Flow Rates, and Administration of Extubation/Decannulation (Assist), 44
Continuous Intravenous Infusions, 1236 Extubation/Decannulation (Perform) , 40
Cardiac Monitoring and Electrocardiographic Fecal Containment Devices and Bowel Management
Leads, 467 Systems, 1193
Cardiac Output Measurement Techniques Femoral Arterial and Venous Sheath Removal, 664
(Invasive), 553 Focused Assessment with Sonography in
Cardioversion, 293 Trauma, 970
Central Venous Catheter Insertion (Assist), 731 Gastric Lavage in Hemorrhage and Overdose, 980
Central Venous Catheter Insertion (Perform) , 714 Halo Ring and Vest Care, 917
Central Venous Catheter Removal, 569 Hemodialysis, 1067
Central Venous Catheter Site Care, 574 Implantable Cardioverter-Defibrillator, 377
Central Venous/Right Atrial Pressure Monitoring, 578 Implantable Venous Access Device: Access, Deaccess,
Cerebral Blood Flow Monitoring, 811 and Care , 738
Cerebral Microdialysis, 823 Intraabdominal Pressure Monitoring, 997
Cervical Tongs or Halo Ring: Application for Use in Intraaortic Balloon Pump Management, 431
Cervical Traction (Assist), 904 Intracompartmental Pressure Monitoring , 1150
Cervical Traction Maintenance, 911 Intracranial Bolt and Fiberoptic Catheter Insertion
Chest Tube Placement (Perform) , 168 (Assist), Intracranial Pressure Monitoring, Care,
Chest Tube Placement (Assist), 178 Troubleshooting, and Removal, 829
Chest Tube Removal (Perform) , 184 Intraosseous Devices, 748
Chest Tube Removal (Assist), 190 Intraventricular Catheter with External Transducer for
Cleaning, Irrigating, Culturing, and Dressing Cerebrospinal Fluid Drainage and Intracranial
an Open Wound, 1173 Pressure Monitoring, 842
Closed Chest-Drainage System, 195 Intraventricular/Fiberoptic Catheter Insertion (Assist),
Combitube Insertion and Removal , 1 Monitoring, Nursing Care, Troubleshooting, and
Continuous End-Tidal Carbon Dioxide Removal, 835
Monitoring, 103 Invasive Mechanical Ventilation (Through an Artificial
Continuous Lateral Rotation Therapy, 111 Airway): Volume and Pressure Modes, 227
Continuous Renal Replacement Therapies, 1054 King Airway Insertion and Removal , 47
Continuous Venous Oxygen Saturation Laryngeal Mask Airway , 53
Monitoring, 116 Lumbar Puncture (Assist), 873
Débridement: Pressure Ulcers, Burns, Lumbar Puncture (Perform) , 865
and Wounds , 1183 Lumbar Subarachnoid Catheter Insertion (Assist) for
Defibrillation (External), 302 Cerebrospinal Fluid Drainage and Pressure
Defibrillation (Internal) Assist, 317 Monitoring, 856
Manual Self-Inflating Resuscitation Bag-Valve Pulmonary Artery Catheter Removal, 630
Device, 261 Pulmonary Artery Catheter and Pressure Lines,
Midline Catheters , 758 Troubleshooting, 637
Molecular Adsorbent Recirculating System Pupillometer, 880
(MARS), 1020 Radial Arterial Sheath Removal, 672
Nasogastric and Orogastric Tube Insertion, Care, and RotoRest Lateral Rotation Surface, 885
Removal, 1011 Single-Pressure and Multiple-Pressure Transducer
Nasopharyngeal and Oral Airway Insertion, 62 Systems, 653
Needle Thoracostomy (Perform) , 206 Skin-Graft Care, 1142
Negative-Pressure Wound Therapy, 1200 Small-Bore Feeding Tube Insertion and Care, 1221
Noninvasive Cardiac Output Monitoring, 596 Small-Bore Feeding Tube Insertion Using an
Noninvasive Positive Pressure Ventilation: Continuous Electromagnetic Guidance System (CORTRAK 2
Positive Airway Pressure (CPAP) and Bilevel Positive Enteral Access System EAS), 1227
Airway Pressure (BiPAP), 249 ST-Segment Monitoring (Continuous), 486
Oxygen Saturation Monitoring with Pulse Suctioning: Endotracheal or Tracheostomy Tube, 69
Oximetry, 134 Surgical Cricothyrotomy (Perform) , 79
Paracentesis (Assist), 1036 Surgical Cricothyrotomy (Assist), 85
Paracentesis (Perform) , 1030 Suture and Staple Removal, 1156
Patient-Controlled Analgesia, 941 Temporary Transcutaneous (External) Pacing, 399
Percutaneous Endoscopic Gastrostomy (PEG), Temporary Transvenous and Epicardial Pacing, 416
Gastrostomy, and Jejunostomy Tube Care, 1216 Temporary Transvenous Pacemaker Insertion
Pericardial Catheter Management, 678 (Perform) , 407
Pericardiocentesis (Assist), 349 Thermoregulation: External and Intravascular
Pericardiocentesis (Perform) , 340 Warming/Cooling Devices, 893
Peripheral Nerve Blocks: Assisting with Insertion and Thoracentesis (Perform) , 211
Pain Management, 948 Thoracentesis (Assist), 222
Peripheral Nerve Stimulators, 268 Thenar Tissue Oxygen Saturation Monitoring, 693
Peripherally Inserted Central Catheter , 766 Tracheostomy Cuff and Tube Care, 89
Peritoneal Dialysis, 1080 Transesophageal Echocardiography (Assist), 698
Peritoneal Lavage (Assist), 1048 Twelve-Lead Electrocardiogram, 494
Peritoneal Lavage (Perform) , 1041 Use of a Massive Infusion Device and a Pressure
Permanent Pacemaker (Assessing Function), 388 Infusor Bag, 1088
Pin-Site Care: Cervical Tongs and Halo Pins, 925 Ventricular Assist Devices , 450
Pronation Therapy, 142 Weaning Mechanical Ventilation, 277
Pulmonary Artery Catheter Insertion (Assist) and Wound Closure , 1162
Pressure Monitoring, 609 Wound Management with Excessive Drainage, 1210
Pulmonary Artery Catheter Insertion
(Perform) , 601
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AACN
Procedure Manual for

High Acuity, Progressive,
and Critical Care
Edited by
Debra L. Wiegand, RN, PhD, CCRN, CHPN, FAHA, FPCN, FAAN
Associate Professor
University of Maryland School of Nursing
Baltimore, Maryland;
Staff Nurse
Surgical Cardiac Care Unit
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania
7 th
EDITION
3251 Riverport Lane
St. Louis, Missouri 63043
AACN PROCEDURE MANUAL FOR HIGH ACUITY, PROGRESSIVE, ISBN: 978-0-323-37662-4

AND CRITICAL CARE, SEVENTH EDITION
Copyright © 2017 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information
or methods they should be mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any
liability for any injury and/or damage to persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the
material herein.
Previous editions copyrighted 2011, 2005, 2001, 1994, 1985.
Library of Congress Cataloging-in-Publication Data
Names: Wiegand, Debra J. Lynn-McHale, editor. | American Association of Critical-Care Nurses, issuing
body.
Title: AACN procedure for high-acuity, progressive, and critical care / edited by Debra Lynn-McHale
Wiegand.
Other titles: AACN procedure manual for critical care (Wiegand) | Procedure for high-acuity, progressive, and
critical care
Description: Seventh edition. | St. Louis, Missouri : Elsevier, [2017] | Preceded by: AACN procedure manual
for critical care / edited by Debra Lynn-McHale Wiegand. 6th ed. C2011. | Includes bibliographical
references and index.
Identifiers: LCCN 2016010545 | ISBN 9780323376624 (pbk. : alk. paper)
Subjects: | MESH: Critical Care Nursing—methods | Critical Illness—nursing | Handbooks
Classification: LCC RT120.I5 | NLM WY 49 | DDC 616/.028—dc23 LC record available at
http://lccn.loc.gov/2016010545
Executive Content Strategist: Lee Henderson

Content Development Manager: Jean Sims Fornango
Senior Content Development Specialist: Laura Selkirk
Publishing Services Manager: Jeff Patterson
Project Manager: Lisa A. P. Bushey
Designer: Ryan Cook
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Section Editors
Michael W. Day, RN, MSN, CCRN, TCRN Mary Beth Flynn Makic, RN, PhD, CNS, CCNS,
Clinical Practice Specialist CCRN-K, FAAN, FNAP
Trauma and Acute Care Surgery Associate Professor
Northeast Georgia Medical Center University of Colorado College of Nursing
Gainesville, Georgia Aurora, Colorado
Eleanor Fitzpatrick, RN, MSN, ACNP-BC, AGCNS-BC, Debra L. Wiegand, RN, PhD, CCRN, CHPN, FAHA,
CCRN FPCN, FAAN
Clinical Nurse Specialist Associate Professor
Surgical Critical Care University of Maryland School of Nursing
Thomas Jefferson University Hospital Baltimore, Maryland;
Philadelphia, Pennsylvania Staff Nurse
v
Contributors
Richard B. Arbour, MSN Kathleen Berns, MS, APRN, CNS, CFRN

Clinical Faculty, School of Nursing Clinical Nurse Specialist
LaSalle University Mayo Clinic Medical Transport
Philadelphia, Pennsylvania Mayo Clinic
Procedure 88: Bispectral Index Monitoring Rochester, Minnesota
Procedure 79: Thenar Tissue Oxygen Saturation Monitoring
Jane V. Arndt, MS, RN, CWOCN, ACNS-BC
Clinical Nurse Specialist Angela Bingham, MSN, RN
Surgical and Support Services Clinical Educator, Critical Care
Poudre Valley Hospital Providence St. Vincent Medical Center
Fort Collins, Colorado Portland, Oregon
Procedure 135: Fecal Containment Devices and Bowel Procedure 53: Ventricular Assist Devices
Management System
Cynthia Blank-Reid, RN, MSN, CEN
Sonia M. Astle, RN, MS Trauma Clinical Nurses Specialist
Clinical Nurse Specialist Department of Trauma and Surgical Critical Care
Critical Care Temple University Hospital
Inova Fairfax Medical Campus Philadelphia, Pennsylvania
Falls Church, Virginia Procedure 109: Focused Assessment with Sonography in Trauma
Procedure 119: Continuous Renal Replacement Therapies
Procedure 120: Hemodialysis Stephen Both, CRNA-MAE
Procedure 121: Peritoneal Dialysis Premiere Anesthesia
Procedure 123: Apheresis and Therapeutic Plasma Exchange Brooks Memorial Hospital
(Assist) Dunkirk, New York
Procedure 8: Laryngeal Mask Airway
John C. Bazil, RN, BSN, BSEE
Staff Nurse Joel M. Brown II, RRT, FAARC
Neurological Intensive Care Unit Director, Respiratory Care and Sleep Medicine
UT Southwestern Medical Center Nemours-Al DuPont Hospital for Children
Dallas, Texas Wilmington, Delaware
Procedure 98: Pupillometer Procedure 81: Arterial Puncture
Marcia Belcher, MSN, BBA, RN, CCRN-CSC, CCNS Shelley Burcat, RN, MSN
Clinical Nurse Specialist Clinical Nurse Specialist, Nursing
The Ohio State University Wexner Medical Center Richard M. Thomas Jefferson University
Ross Heart Hospital Philadelphia, Pennsylvania
Columbus, Ohio Procedure 141: Calculating Doses, Flow Rates, and Administration
Procedure 17: Extracorporeal Life Support (ECLS) and of Continuous Intravenous Infusions
Extracorporeal Membrane Oxygenation (ECMO)
Justin Burleson, BSN
Cameron Bell, MS, RN, CCNS, CCRN Charge Nurse, Burn ICU
Associate Nurse Manager, Burn Center University of Colorado Hospital
University of Colorado Hospital Aurora, Colorado
Aurora, Colorado Procedure 137: Wound Management with Excessive Drainage
Procedure 126: Burn Wound Care
Procedure 127: Donor-Site Care Mary G. Carey, PhD, RN
Associate Director, Clinical Nursing Research Center
Tracey M. Berlin, MSN-Ed, RN, CCRN, CNRN University of Rochester Medical Center Strong Memorial
Nursing Education Consultant Hospital
Eagleville, Pennsylvania Associate Professor, School of Nursing
Procedure 90: Cerebral Blood Flow Monitoring University of Rochester
Rochester, New York
Procedure 54: Cardiac Monitoring and Electrocardiographic Leads
Procedure 56: ST-Segment Monitoring (Continuous)
vi
Contributors vii
Roger Casey, MSN, CEN, TCRN, FAEN Janice Y. Dawson, BSN

Staff Nurse Staff Nurse Nurse, Noninvasive Cardiology
Kadlec Regional Medical Center/Freestanding Emergency Lankenau Hospital
Department Wynnewood, Pennsylvania
Kennewick, Washington Procedure 80: Transesophageal Echocardiography (Assist)
Procedure 11: Surgical Cricothyrotomy (Perform)
Procedure 12: Surgical Cricothyrotomy (Assist) Michael W. Day, RN, MSN, CCRN, TCRN
Clinical Practice Specialist
Sandy Cecil, BA, AA Nursing Trauma and Acute Care Surgery
Nurses Manager, Neuro Trauma Intensive Care Unit Northeast Georgia Medical Center
Legacy Emanuel Medical Center Gainesville, Georgia
Portland, Oregon Procedure 85: Intraosseous Devices
Procedure 91: Cerebral Microdialysis
Kate Deis, MSN, RN, CEN, ACNS-BC
Alice Chan, RN, MN, CNS, CCRN Clinical Nurse Specialist, Emergency Department
Manager, Critical Care Thomas Jefferson University Hospital
Cedars-Sinai Medical Center Philadelphia, Pennsylvania
Los Angeles, California Procedure 117: Peritoneal Lavage (Perform)
Procedure 39: Emergent Open Sternotomy (Perform) Procedure 118: Peritoneal Lavage (Assist)
Procedure 40: Emergent Open Sternotomy (Assist)
Anne Delengowski, RN, MSN, AOCN
Susan Chioffi, MSN Oncology Clinical Nurse Specialist, Nursing
Nurse Practitioner, Advanced Practice Thomas Jefferson University Hospital
Duke University Medical Center Philadelphia, Pennsylvania
Durham, North Carolina Procedure 84: Implantable Venous Access Device: Access,
Procedure 96: Lumbar Puncture (Perform) Deaccess, and Care
Procedure 97: Lumbar Puncture (Assist)
Coleen Dever, MSN, AGCNS-BC
Kathleen M. Cox, DNP, APRN, ACNP-BC, CCNS Trauma Program Coordinator
Director, Adult-Gerontologic Acute Care Nurse Practitioner Christiana Care Health System
Program Newark, Delaware
School of Nursing Graduate Studies Procedure 122: Use of a Massive Infusion Device and a Pressure
University of Texas El Paso Infusor Bag
El Paso, Texas
Procedure 42: Pericardiocentesis (Perform) Cara Diaz, RN, BSN, MS, CRNP
Procedure 43: Pericardiocentesis (Assist) Acute Care Nurse Practitioner, Trauma Neurosurgery
Procedure 62: Blood Sampling from a Central Venous Catheter R. Adams Cowley Shock Trauma Center
Procedure 63: Blood Sampling from a Pulmonary Artery Catheter Baltimore, Maryland
Procedure 78: Pericardial Catheter Management Procedure 103: Halo Ring and Vest Care
Procedure 104: Pin-Site Care: Cervical Tongs and Halo Pins
Stephanie Cox, MS
Quality Improvement Specialist Sharon Dickinson, MSN
Clinical Excellence and Patient Safety CNS, Nursing
University of Colorado Hospital University of Michigan
Aurora, Colorado Ann Arbor, Michigan
Procedure 94: Intraventricular Catheter with External Transducer Procedure 19: Pronation Therapy
for Cerebrospinal Fluid Drainage and Intracranial Pressure
Monitoring Joni L. Dirks, MSN, RN-BC, CCRN-K
Manager Clinical Educators & ICU Educator
Hillary Crumlett, BSN, MS Department of Educational Services
Clinical Director of Critical Care Providence Health Care
Northwestern Medicine-Central DuPage Hospital Spokane, Washington
Winfield, Illinois Procedure 16: Continuous Venous Oxygen Saturation Monitoring
Procedure 58: Arterial Catheter Insertion (Perform)
Procedure 59: Arterial Catheter Insertion (Assist), Care, and Julia E. Dunning, BSN, MSN
Removal Senior Nurse Practitioner, Shock Trauma Orthopedics
Procedure 61: Blood Sampling from an Arterial Catheter University of Maryland Shock Trauma Center
Procedure 68: Esophageal Cardiac Output Monitoring: Perform Baltimore, Maryland
Procedure 69: Esophageal Cardiac Output Monitoring: Assist, Procedure 129: Intracompartmental Pressure Monitoring
Care, and Removal
viii Contributors
Margaret M. Ecklund, MS, RN, CCRN-K, ACNP-BC Cindy Goodrich, RN, MSN, CCRN
Clinical Nurse Specialist, Clinical Practice Support Clinical Educator and Flight Nurse
Legacy Health Airlift Northwest
Portland, Oregon Seattle, Washington
Procedure 138: Percutaneous Endoscopic Gastrostomy (PEG), Procedure 2: Endotracheal Intubation (Perform)
Gastrostomy, and Jejunostomy Tube Care Procedure 3: Endotracheal Intubation (Assist)
Procedure 139: Small-Bore Feeding Tube Insertion and Care Procedure 26: Needle Thoracostomy (Perform)
Joanna C. Ellis, CRNP, MSN, ACNP-BC Cynthia Hambach, MSN, RN, CCRN
Trauma Nurse Practitioner Assistant Clinical Professor
Division of Traumatology, Surgical Critical Care and Emergency College of Nursing and Health Professions
Surgery Drexel University
Penn Presbyterian Medical Center Philadelphia, Pennsylvania
Philadelphia, Pennsylvania Procedure 35: Cardioversion
Procedure 131: Wound Closure Procedure 36: Defibrillation (External)
Eleanor Fitzpatrick, BSN, RN, MSN, ACNP-BC, Jillian Hamel, MS, ACNP-BC
AGCNS-BS, CCRN Nurse Practitioner, Cardiology
Clinical Nurse Specialist, Surgical Critical Care Western Washington Cardiology
Thomas Jefferson University Hospital Everett, Washington
Philadelphia, Pennsylvania Procedure 45: Atrial Overdrive Pacing (Perform)
Procedure 111: Endoscopic Therapy Procedure 65: Central Venous Catheter Removal
Procedure 115: Paracentesis (Perform) Procedure 66: Central Venous Catheter Site Care
Procedure 116: Paracentesis (Assist)
John P. Harper, MSN -BC
Susan K. Frazier, PhD, RN, FAHA Clinical Educator, Critical Care
Associate Professor, Director, PhD Program Co-Cirector RICH Nursing Education
Heart Program Corzer-Chester Medical Center
University of Kentucky, College of Nursing Upland, Pennsylvania
Lexington, Kentucky Procedure 52: Intraaortic Balloon Pump Management
Procedure 30: Noninvasive Positive Pressure Ventilation:
Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Julie Lynn Henderson, RN, MSN, ANP, FNP-BC
Airway Pressure (BiPAP) Nurse Practitioner
Procedure 33: Weaning Mechanical Ventilation Little People’s Clinic
Highlands Ranch, Colorado
John Gallagher, DNP, RN, CCNS, CCRN, RRT Procedure 133: Débridement: Pressure Ulcers, Burns, and
Trauma Program Coordinator/Clinical Nurse Specialist Wounds
Division of Trauma, Surgical Critical Care and Emergency
Surgery Kiersten Henry, RN, DNP
Penn Presbyterian Medical Center Chief Medicine Advanced Practice Provider
Philadelphia, Pennsylvania Cardiology
Procedure 29: Invasive Mechanical Ventilation (Through an MedStar Montgomery Medical Center
Artificial Airway): Volume and Pressure Modes Olney, Maryland
Procedure 34: Automated External Defibrillation
Kyle Gibson, MSN, RN, CEN, TCRN, EMT-P Procedure 41: External Wearable Cardioverter-Defibrillator
Shock Trauma Nurse, Emergency Department Procedure 47: Implantable Cardioverter-Defibrillator
Northeast Georgia Medical Center-Gainesville
Gainesville, Georgia Linda Hoke, PhD, RN, CCNS, ACNS-BC, CCRN
Procedure 1: Combitube Insertion and Removal Clinical Nurses Specialist
Procedure 7: King Airway Insertion and Removal Cardiac Intermediate Care Unit
Hospital of the University of Pennsylvania
Karen A. Gilbert, RN, MSN, CNSC, CRNP Philadelphia, Pennsylvania
Nutrition Support Clinical Nurse Specialist, Specialist Procedure 80: Transesophageal Echocardiography (Assist)
Philadelphia, Pennsylvania Nathan W. Howard, RN, BSN, CCRN
Procedure 140: Small-Bore Feeding Tube Insertion Using an Staff Nurse, Cardiac Intensive Care Unit
Electromagnetic Guidance System (CORTRAK 2 Enteral Access Providence Sacred Heart Medical Center
System EAS) Spokane, Washington
Procedure 32: Peripheral Nerve Stimulators
Contributors ix
Alexander Johnson, MSN, RN, CCNS, ACNP-BC, CCRN Rosemary Lee, DNP, ARNP, ACNP-BC,
Clinical Nurse Specialist, Critical Care CCNS, CCRN
Cadence Health—Northwestern Medicine Clinical Nurse Specialist, Critical Care
Winfield, Illinois Homestead Hospital
Procedure 58: Arterial Catheter Insertion (Perform) Homestead, Florida;
Procedure 59: Arterial Catheter Insertion (Assist), Care, and Adjunct Faculty, College of Nursing
Removal Nova Southeastern University
Procedure 61: Blood Sampling from an Arterial Catheter Palm Beach Garden, Florida
Procedure 68: Esophageal Cardiac Output Monitoring: Perform Procedure 108: Esophagogastric Tamponade Tube
Procedure 69: Esophageal Cardiac Output Monitoring: Assist, Procedure 112: Intraabdominal Pressure Monitoring
Care, and Removal
Thomas Levins, BSN, RN, CCRN, CFRN
Renee Johnson, APRN, MSN, CCRN, CCNS Clinical Coordinator, PennSTAR Flight
Critical Care Clinical Nurse Specialist, Critical Care University of Pennsylvania Health System
Gwinnett Medical Center Philadelphia, Pennsylvania
Lawrenceville, Georgia Procedure 31: Manual Self-Inflating Resuscitation Bag-Valve
Procedure 13: Tracheostomy Cuff and Tube Care Device
Maribeth Kelly, MSN, RN, PCCN Karen A. Lovett, MS, CNS, CCNS
Clinical Nurse Specialist, Medical Telemetry Director Patient Services
Thomas Jefferson University Hospital University of Colorado Hospital
Philadelphia, Pennsylvania Aurora, Colorado
Procedure 141: Calculating Doses, Flow Rates, and Administration Procedure 100: Thermoregulation: External and Intravascular
of Continuous Intravenous Infusions Warming/Cooling Devices
Peggy Kirkwood, RN, MSN, ACNCP, CHF, AACC Paul Luehrs, BSEd, BSRT, RRT, ACCS
Cardiovascular Nurse Practitioner Adult Critical Care Supervisor, Respiratory Care
Mission Hospital CoxHealth
Mission Viejo, California Springfield, Missouri
Procedure 23: Chest Tube Removal (Perform) Procedure 14: Continuous End-Tidal Carbon Dioxide Monitoring
Procedure 24: Chest Tube Removal (Assist)
Jennifer MacDermott, MS
Lisa Koser, DNP, ACNP-BC, CPNP-AC Clinical Care Specialist, Critical Care
Trauma and Acute Care Surgery Nurse Practitioner Columba, Ohio
The Ohio State University Wexner Medical Center Procedure 15: Continuous Lateral Rotation Therapy
Columbus, Ohio;
Flight Nurse Practitioner Mary Beth Flynn Makic, RN, PhD, CNS, CCNS,
The Cleveland Clinic Foundation CCRN-K, FAAN, FNAP
Cleveland, Ohio Associate Professor, College of Nursing
Procedure 5: Extubation/Decannulation (Perform) University of Colorado
Procedure 6: Extubation/Decannulation (Assist) Aurora, Colorado
Procedure 99: RotoRest Lateral Rotation Surface
Teri M. Kozik, RN, PhD, CNS, CCRN Procedure 134: Drain Removal
Clinical Nurse Specialist—Research Supervisor
Clinical Research Eileen Maloney Wilensky, MSN, ACNP-BC
St. Joseph’s Medical Center Director, Clinical Research, Quality & Safety Program
Stockton, California Neurosurgery
Procedure 54: Cardiac Monitoring and Electrocardiographic Penn Medicine
Leads, Philadelphia, Pennsylvania
Procedure 89: Brain Tissue Oxygen Monitoring: Insertion (Assist),
Thomas Lawson, MS Care, and Troubleshooting
Nurse Practitioner, Neurocritical Care
The Ohio State University Wexner Medical Center Carrie Marvill, MSN, RN, AOCNS
Columbus, Ohio Clinical Nurse Education Specialist
Procedure 17: Extracorporeal Life Support (ECLS) and Penn Medicine
Extracorporeal Membrane Oxygenation (ECMO) Philadelphia, Pennsylvania
Procedure 124: Bone Marrow Biopsy and Aspiration (Perform)
Donna Barge Lee, MSN Procedure 125: Bone Marrow Biopsy and Aspiration (Assist)
Trauma Education & Outreach Coordinator
Northeast Georgia Medical Center
Gainesville, Georgia
Procedure 18: Oxygen Saturation Monitoring with Pulse Oximetry
x Contributors
Jennifer Massetti, BSN, MS, ACNP-BC Theresa Nino, RN, MSN, CCRN
ACNP-BC, Trauma Neurosurgery Instructor, College of Nursing
R Adams Cowley Shock Trauma Center University of Colorado
University of Maryland Critical Care Trauma Nurse
Baltimore, Maryland Burn Trauma Intensive Care Unit
Procedure 101: Cervical Tongs or Halo Ring: Application for Use University of Colorado Hospital
in Cervical Traction (Assist) Aurora, Colorado
Procedure 102: Cervical Traction Maintenance Procedure 99: RotoRest Lateral Rotation Surface
Carol McGinnis, DNP, CNS, RN, CNSC DaiWai M. Olson, PhD, RN, CCRN, FNCS
Clinical Nurse Specialist Neurology & Neurotherapeutics
Sanford USD Medical Center UT Southwestern Medical Center
Sioux Falls, South Dakota Dallas, Texas
Procedure 113: Nasogastric and Orogastric Tube Insertion, Care, Procedure 98: Pupillometer
and Removal
Michele M. Pelter, RN, PhD
Kelly McGinty, BSN, MSN, FNP Assistant Professor, Director of the ECG Monitoring Research
Spokane Emergency Physicians Lab
Sacred Heart Medical Center Physiological Nursing
Spokane, Washington University of California, San Francisco
Procedure 20: Autotransfusion San Francisco, California
Procedure 54: Cardiac Monitoring and Electrocardiographic Leads
Marion E. McRae, RN, MScN, ACNP-BC, Procedure 56: ST-Segment Monitoring (Continuous)
CCRN-CSC-CMC
AACC Nurse Practitioner Glen Peterson, DNP, ACNP
Guerin Family Congenital Heart Program Assistant Professor, Clinical Director, APP Education and
Cedars-Sinai Medical Center Quality
Clinical Instructor Blood Cancer and Bone Marrow Transplant Program
David Geffen School of Medicine University of Colorado Hospital, University of Colorado Health
University of California at Los Angeles Aurora, Colorado
Los Angeles, California Procedure 124: Bone Marrow Biopsy and Aspiration (Perform)
Procedure 37: Defibrillation (Internal) Perform Procedure 125: Bone Marrow Biopsy and Aspiration (Assist)
Procedure 38: Defibrillation (Internal) Assist
Procedure 44: Atrial Electrogram Joya D. Pickett, PhD, RN, ARNP-CNS, CCNS, ACNS-
Procedure 46: Epicardial Pacing Wire Removal BC, CCRN
Critical Care Clinical Nurse Specialist, Intensive Care
Reba McVay, MSN, RN, CNS-BC, CCRN Swedish Medical Center
Director of Cardiovascular Service Line Adjunct Faculty, Biobehavioral Nursing
WellStar Atlanta Medical Center & AMC South University of Washington
Atlanta, Georgia Seattle, Washington
Procedure 67: Central Venous/Right Atrial Pressure Monitoring Procedure 25: Closed Chest-Drainage System
Procedure 72: Pulmonary Artery Catheter Insertion (Assist) and
Pressure Monitoring Ann Will Poteet, MS, RN, CNS
Procedure 74: Pulmonary Artery Catheter and Pressure Lines, Clinical Nurse Specialist, College of Nursing
Troubleshooting University of Colorado
Procedure 75: Single-Pressure and Multiple-Pressure Transducer Aurora, Colorado
Systems Procedure 110: Gastric Lavage in Hemorrhage and Overdose
Lorie Ann Meek, MSN, RN Jan Powers, PhD, RN, CCNS, CCRN, CNRN, NE-BC,
Duke Telestroke Coordinator, Network Services FCCM
Duke Health Clinical Nurse Specialist
Durham, North Carolina Indianapolis, Indiana
Procedure 106: Patient-Controlled Analgesia Procedure 19: Pronation Therapy
Megan T. Moyer, MSN Mark Puhlman, RN, MSN

Acute Care Nurse Practitioner, Neurosurgery Left Ventricular Assist Device Coordinator
Hospital of the University of Pennsylvania Center for Advanced Heart Disease
Philadelphia, Pennsylvania Providence St. Vincent Medical Center
Procedure 89: Brain Tissue Oxygen Monitoring: Insertion (Assist), Portland, Oregon
Care, and Troubleshooting Procedure 53: Ventricular Assist Devices
Contributors xi
Barbara Quinn, RN, MSN, ACNS-BC Rose B. Shaffer, RN, MSN, ACNP-BC, CCRN, FAHA
Clinical Nurse Specialist, Quality Services Cardiology Nurse Practitioner, Nursing
Sutter Medical Center Thomas Jefferson University Hospital
Sacramento, California Philadelphia, Pennsylvania
Procedure 4: Endotracheal Tube Care and Oral Care Practices for Procedure 76: Femoral Arterial and Venous Sheath Removal
Ventilated and Non-ventilated Patients Procedure 77: Radial Arterial Sheath Removal
Marylou V. Robinson, PhD, FNP-C Tess Slazinski, RN, MN, CCRN, CNRN, SCRN, CCNS
Associated Professor, College of Nursing Neuroscience/Critical Care Clinical Nurse Specialist
University of Colorado Critical Care Services
Aurora, Colorado Cedars-Sinai Medical Center
Procedure 132: Cleaning, Irrigating, Culturing, and Dressing an Pacific Palisades, California
Open Wound Procedure 92: Fiberoptic Catheter Insertion (Assist), Intracranial
Pressure Monitoring, Care, Troubleshooting, and Removal
Thomas A. Santora, RN, BSN, CCRN Procedure 93: Intraventricular/Fiberoptic Catheter Insertion
Professor of Surgery (Assist), Monitoring, Nursing Care, Troubleshooting, and
Vice Chair, Department of Surgery Removal
Temple University Hospital
Philadelphia, Pennsylvania Mary Lou Sole, PhD, RN, CCNS, FAAN, FCCM
Procedure 109: Focused Assessment With Sonography in Trauma Dean and Professor; Orlando Health Endowed Chair
College of Nursing
Brian D. Schaad, BSN, BA University of Central Florida
Charge Nurse, Burn/Trauma ICU Nurse Scientist, Center for Nursing Research
University of Colorado Hospital Orlando Health
Aurora, Colorado Orlando, Florida
Procedure 130: Suture and Staple Removal Procedure 4: Endotracheal Tube Care and Oral Care Practices for
Procedure 134: Drain Removal Ventilated and Non-ventilated Patients
Nicolle Schraeder, RN, MSN, ACNPC-AG Valerie Spotts, BSN, RN

Acute Care Nurse Practitioner, Neurosciences Educational Nurse Coordinator, Nursing-Inpatient Cardiology
Littleton Adventist Hospital University of Michigan
Littleton, Colorado Ann Arbor, Michigan
Procedure 95: Lumbar Subarachnoid Catheter Insertion (Assist) Procedure 48: Permanent Pacemaker (Assessing Function)
for Cerebrospinal Fluid Drainage and Pressure Monitoring Procedure 49: Temporary Transcutaneous (External) Pacing
Procedure 51: Temporary Transvenous and Epicardial Pacing
Susan S. Scott, MSN
Clinical Educator, MICU/SICU Jamie St. Clair, MS, RN, ACNS-BC, CCRN
Baystate Medical Center Clinical Nurse Specialist
Springfield, Massachusetts The Ohio State University Wexner Medical Center
Procedure 60: Arterial Pressure–Based Cardiac Output Monitoring Columbus, Ohio
Procedure 64: Cardiac Output Measurement Techniques (Invasive) Procedure 15: Continuous Lateral Rotation Therapy
Procedure 70: Noninvasive Cardiac Output Monitoring
Mary D. Still, BSN, MSN, APRN, ACNS
Dawn Sculco, BSN, MS Clinical Nurse Specialist Critical Care/Transplant
Clinical Nurse Specialist Nursing/Critical Care
Critical Care Unit and Emergency Department Emory Healthcare
Valley View Hospital Atlanta, Georgia
Glenwood Springs, Colorado Procedure 114: Molecular Adsorbent Recirculating System
Procedure 128: Skin-Graft Care (MARS)
Maureen A. Seckel, RN, APRN, MSN, ACNS-BC, CCNS, Nikki Taylor, MS, BSN, RN
CCRN, FCCM Clinical Nurse Level D, Cardiology
Clinical Nurse Specialist Medical Pulmonary Critical Care and University of Michigan Health System
Sepsis Coordinator Ann Arbor, Michigan
Christiana Care Health System Procedure 50: Temporary Transvenous Pacemaker Insertion
Affiliated Instructor, College of Health Sciences, School of (Perform)
Nursing Procedure 71: Pulmonary Artery Catheter Insertion (Perform)
University of Delaware Procedure 73: Pulmonary Artery Catheter Removal
Newark, Delaware
Procedure 10: Suctioning: Endotracheal or Tracheostomy Tube
xii Contributors
Kathleen Vollman, MSN, RN, CCNS, FCCM, FAAN Patricia H. Worthington, RN, MSN, CNSC
Clinical Nurse Specialist/Consultant Nutrition Support Clinical Specialist, Nursing
Advancing Nursing LLC Jefferson University Hospital
Northville, Michigan Philadelphia, Pennsylvania
Procedure 4: Endotracheal Tube Care and Oral Care Practices for Procedure 140: Small-Bore Feeding Tube Insertion Using an
Ventilated and Non-ventilated Patients Electromagnetic Guidance System (CORTRAK 2 Enteral Access
Procedure 19: Pronation Therapy System EAS),
Julie Waters, RN, MS, CCRN Kimberly Wright, MSN, RN, CEN, TCRN
Clinical Nurse Educator for Critical Care Director of Trauma Services
Providence Health Care Lawnwood Regional Medical Center & Heart Institute
Spokane, Washington Fort Pierce, Florida
Procedure 21: Chest Tube Placement (Perform) Procedure 9: Nasopharyngeal and Oral Airway Insertion
Procedure 22: Chest Tube Placement (Assist)
Shu-Fen Wung, PhD, RN, ACNP, FAAN
Debra L. Wiegand, RN, PhD, CCRN, CHPN, FAHA, Associate Professor, College of Nursing
FPCN, FAAN The University of Arizona
Associate Professor, School of Nursing Tucson, Arizona
University of Maryland Procedure 55: Extra Electrocardiographic Leads: Right Precordial
Baltimore, Maryland; and Left Posterior Leads
Staff Nurse Procedure 57: Twelve-Lead Electrocardiogram
Thomas Jefferson University Hospital Susan Yeager, MS, RN, CCRN, ACNP-BC, FNCS
Philadelphia, Pennsylvania Neurocritical Care Nurse Practitioner–Lead
Procedure 86: Midline Catheters The Ohio State University Wexner Medical Center
Procedure 87: Peripherally Inserted Central Catheter Clinical Instructor, Acute Care Nurse Practitioner Program
The Ohio State University College of Nursing
Kimberly Williams, BSN, RN-BC Columbus, Ohio
Clinical Manager, Plain Service Procedure 27: Thoracentesis (Perform)
University of Louisville Procedure 28: Thoracentesis (Assist)
Louisville, Kentucky Procedure 82: Central Venous Catheter Insertion (Perform)
Procedure 105: Epidural Catheters: Assisting with Insertion and Procedure 83: Central Venous Catheter Insertion (Assist)
Pain Management
Procedure 107: Peripheral Nerve Blocks: Assisting with Insertion
and Pain Management
Lisa Woods, MSN, BSN, BA

Wound, Ostomy, and Continence Nurse
Lutheran Medical Center
Wheat Ridge, Colorado
Procedure 136: Negative-Pressure Wound Therapy
Reviewers
Lillian Aguirre, MSN, CNS, CCRN, CCNS Kimberly Bush, MSN, RN

Clinical Nurse Specialist Staff Nurse/Clinical Nurse Educator, ISICU
Orlando Health Thomas Jefferson University Hospital
Orlando, Florida Philadelphia, Pennsylvania
Bim Akintade, PhD, MBA, MHA, ACNP-BC, CCRN Jaime Byrne, MSN, RN, CRNP, CCRN
Specialty Director, Trauma, Critical Care, ED, AGACNP/CNS Clinical Nurse Specialist, Cardiovascular Intensive Care Unit
Assistant Professor, OSAH Thomas Jefferson University Hospital
University of Maryland School of Nursing Philadelphia, Pennsylvania
College Park, Maryland
Christina M. Canfield, MSN, RN, ACNS-BC, CCRN
Anna M. Alvarez, MSN, CNS, CCNS, CWOCN Clinical Nurse Specialist
Wound Ostomy Continence Nurse Cleveland Clinic
Orlando Health Cleveland, Ohio
Orlando, Florida
Mary Centinaro, MSN, RN, CCRN
Suzanne Ashworth, CNS, MSN, CCRN, CCNS Clinical Nurse Specialist ICU/PCU
Neuroscience Clinical Nurse Specialist Thomas Jefferson University Medical Center, Methodist Campus
Orlando Health Philadelphia, Pennsylvania
Orlando, Florida
Cheryl Ciocca, RN, MS
Mary Kay Bader, RN, MSN, CCNS, CNRN, CCRN, Nurse Manager, Medical Intensive Care Unit
SCRN, FAHA, FNCS Philadelphia Veterans Affairs Medical Center
Neuro/Critical Care CNS Philadelphia, Pennsylvania
Mission Hospital
Mission Viejo, California Kathleen Colfer, MSN, RN-BC
Clinical Nurse Specialist, Manager, Staff Nurse
Tracey M. Berlin, MSN-Ed, RN, CCRN, CNRN Acute Pain Management
Nursing Education Consultant and Clinical Applications Jefferson Hospital
Specialist Philadelphia, Pennsylvania
Eagleville, Pennsylvania
James D. Colquitt, Jr., PhD, RRT, RCP
Bryan Boling, DNP, AGACNP-BC, CCRN-CSC, CEN Director of Clinical Education
Advanced Practice Provider Middle Georgia State College
Division of Critical Care, Department of Anesthesiology Macon, Georgia
University of Kentucky
Lexington, Kentucky Leigh Dangerfield, MSN, PCCN, RN-BC
Nursing Professional Development Facilitator
Lindsay Brookhart, RN, BSN, CCRN Medical University of South Carolina
General Staff RN, Adult Intensive Care Unit Charleston, South Carolina
Providence Sacred Heart Medical Center
Spokane, Washington Michele DeFilippis, MSN, RN, CCRN, CNRN
Nurse Manager
Kathy Bunzli RN, MS, ACNS-BC, CCRN, ACHPN Morristown Medical Center
St. Anthony Hospital Morristown, New Jersey
Lakewood, Colorado
Karlene Dewar, RN, MBA, CNN
Shelley Burcat, MSN, RN, AOCNS Facility Administrator
Clinical Nurse Specialist, Blood and Marrow Transplant DaVita, Inc.
Thomas Jefferson University Hospital Philadelphia, Pennsylvania
xiii
xiv Reviewers
Joni L. Dirks, RN-BC, MSN, CCRN-K Jane Guttendorf, DNP, RN, CRNP, ACNP-BC, CCRN
Manager, Clinical Educators and ICU Educator Assistant Professor, Adult-Gerontology Acute Care Nurse
Providence Health Care Practitioner Program
Spokane, Washington University of Pittsburgh, School of Nursing
Acute Care Nurse Practitioner, Department of Critical Care
Jenna Dziedzic, BSN, RN, CCRN Medicine
Educational Coordinator—Nursing (Cardiac ICU) UPMC Presbyterian
University of Michigan Health System Pittsburgh, Pennsylvania
Ann Arbor, Michigan
Linda Hale, RN, CNSC
Andrea Efre, DNP, ARNP, ANP, FNP Nurse Clinician, Nutrition Support Service
Nurse Practitioner and Consultant William Beaumont Hospital
Healthcare Education Consultants Royal Oak, Michigan
Tampa, Florida
Tonja M. Hartjes, DNP, ACNP/FNP-BE, CCRN, CSC
Nancy Eksterowicz, MSN, RNBC Clinical Associate Professor, University of Florida
Clinical Nurse Pain Specialist Adult-Gerontology Acute Care CNP Track Coordinator
University of Virginia Health System UF Health Surgical Critical Care ARNP
Charlottesville, Virginia Gainesville, Florida
Myra F. Ellis, MSN, RN, CCRN-CSC Amy Howell, CNRN

Clinical Nurse IV Staff Nurse
Duke University Hospital Providence Sacred Heart Medical Center
Durham, North Carolina Spokane, Washington
Andrea Evans-Davis, BSN, RN, CCRN Flerida Imperial-Perez, MN, RN, CNS-BC, CCNS
Staff RN, CCU Clinical Manager
Providence Sacred Heart Medical Center Children’s Hospital Los Angeles
Spokane, Washington Los Angeles, California
Kathleen Flarity, DNP, PhD, CEN, CFRN, FAEN Tina Johnson, RN-BSN, CFRN, CEN, CPEA, CMTE
Emergency CNS/Nurse Scientist Assistant Manager Critical Care Transport
University of Colorado Health, Memorial Hospital Children’s Healthcare of Atlanta
Colorado Springs, Colorado Atlanta, Georgia
John J. Gallagher, MSN, RN, CCNS, CCRN, RRT Tamara M. Kear, PhD, RN, CNN
Clinical Nurse Specialist/Trauma Program Manager Assistant Professor of Nursing
Division of Traumatology, Surgical Critical Care and Emergency Villanova University College of Nursing
Surgery Villanova, Pennsylvania
Penn Presbyterian Medical Center
Philadelphia, Pennsylvania Alyson Dare Kelleher, BSN, RN, CCRN
Chest Pain Coordinator
Dawn Gambrill, RN, CRNI Froedtert Hospital
PICC Nurse Milwaukee, Wisconsin
Philadelphia, Pennsylvania Bridget Kelly, MSN, RN-BC, CCTN
Clinical Nurse Specialist
Lisa A. Gorski, MS, RN, HHCNS-BC, CRNI, FAAN Jefferson University Hospital
Clinical Nurse Specialist Philadelphia, Pennsylvania
Wheaton Franciscan Home Health & Hospice
Milwaukee, Wisconsin Lynn A. Kelso, MSN, APRN, FCCM, FAANP
Assistant Professor; Acute Care Nurse Practitioner
Aimee D. Goss, RN, BSN, CCRN University of Kentucky
University of Michigan Health System Lexington, Kentucky
Ann Arbor, Michigan
Debra Kitchens, RN, BSN, CEN, NRP-P
Carrol Graves, RN, MSN, CCRN, CNL Trauma Program Manager
Clinical Nurse Leader Greenville Health System
Medical Intensive Care Unit Greenville, South Carolina
NF/SG Veterans Health System
Gainesville, Florida
Reviewers xv
Janet A. Kloos, RN, PhD, CCNS, CCRN CPT Mark R. Oherrick, MSN, ACNP/FNP-BC, CEN, AN
CNS, Cardiology Advanced Practice RN
University Hospitals Case Medical Center UPMC Bedford Memorial Hospital, Department of Emergency
Cleveland, Ohio Medicine, U.S. Army Reserves
Everett, Pennsylvania
Lisa K. Koser, DNP, ACNP-BC, CPNP-AC
Trauma and Acute Care Surgery Nurse Practitioner DaiWai M. Olson, PhD, RN, CCRN, FNCS
The Ohio State University Wexner Medical Center Neurology and Neurotherapeutics
Columbus, Ohio; UT Southwestern Medical Center
Flight Nurse Practitioner Dallas, Texas
The Cleveland Clinic Foundation
Cleveland, Ohio Amy Della Penna, RN, CCRN, MSN
Clinical Specialist
Sara Knippa, MS, RN, CCRN, PCCN, ACCNS-AG Thomas Jefferson University Hospital
Clinical Nurse Specialist/Educator, Cardiac ICU Philadelphia, Pennsylvania
University of Colorado Hospital
Aurora, Colorado Lynelle N. B. Pierce, MS, RN, CCRN, CCNS
Clinical Nurse Specialist, Critical Care
Cathleen Lindauer, RN, MSN, CEN University of Kansas Hospital
Clinical Outcomes Management Analyst Kansas City, Kansas
Department of Emergency Medicine
Johns Hopkins Hospital Anne Pirzadeh, RN, BSN, CWOCN
Baltimore, Maryland Certified Wound Ostomy Continence Nurse
Centura Health, Porter Adventist Hospital
Karen Lovett, RN, MS, ACNS-BC, CCNS Denver, Colorado
Clinical Nurse Specialist – Critical Care
St. Anthony Hospital Patricia Radovich, PhD, CNS, FCCM
Lakewood, Colorado Director, Nursing Research
Loma Linda University Medical Center
Patricia Marcelle, MSN, RN, CCRN-K Loma Linda, California
Nurse Educator
Monmouth Medical Center Paul C. Reid, Sr., RN, MSN
Long Branch, New Jersey Lung Transplant Nurse Coordinator
Temple University Hospital
Isagani I. Marquez, Jr., RN, BSN Philadelphia, Pennsylvania
Administrative Nurse II, Apheresis Program
University of California – San Diego Becky Reidy, ARNP, FNP, MSN
San Diego, California Providence Sacred Heart Medical Center
Spokane, Washington
Michelle A. McKay, RN, MSN, CCRN
Clinical Charge RN Lori Renaud, RN, BSN, CCRN, SCRN
Thomas Jefferson University Hospital Charge Nurse
Philadelphia, Pennsylvania Mission Hospital
Mission Viejo, California
Patricia A. McQuade, DEd, MSN, CCRN
Critical Care Nursing Educator David Ricke, RN, BSN, CCRN, CNRN, SCRN
Chilton Memorial Hospital, Atlantic Health System Permanent Charge Registered Nurse; Level IV Clinical RN
Pompton Plains, New Jersey University of Colorado Hospital
Aurora, Colorado
Kathy Meloche, BSN, RN-BC
Pain Management Coordinator Louise Rose, RN, BN, ICU Cert, Adult Ed Cert, MN,
Harper University Hospital, Hutzel Women’s Hospital PhD
Detroit, Michigan TD Nursing Professor in Critical Care Research
Sunnybrook Health Sciences Centre and the University of
Britt M. Meyer, PhD, RN, CRNI, VA-BC, NE-BC Toronto
Nurse Manager of Operations, Vascular Access Team Toronto, Ontario, Canada
Duke University Hospital
Durham, North Carolina Carol L. Ross, BSN, RN, CCRN
Staff RN
Nicole Taylor Moulder, MSN, BSN, ACNP-BC Presbyterian/St. Luke’s Medical Center
Trauma and Acute Care Surgery ACNP Denver, Colorado
Northeast Georgia Medical Center
xvi Reviewers
Erin Sarsfield, MSN, RN Jo Ann Valent, RN, BSN, BC, CWOCN, COS-C
Clinical Nurse Specialist, Adult ICUs CWOCN
Penn State Milton S. Hershey Medical Center Chilton Medical Center
Hershey, Pennsylvania Pompton Plains, New Jersey
Hildy Schell-Chaple, PhD, RN, CCRN, CCNS Jeremy Yves Vergara, MSN, RN, CNL
Clinical Nurse Specialist, Adult Critical Care Clinical Nurse Manager for the MS-ICU, CCU, and TCU
University of California, San Francisco Medical Center California Pacific Medical Center - Pacific Campus
San Francisco, California Stanford, California
Ashley Heath Seawright, DNP, ACNP-BC Brooke Wagner, RN, MSN, AGCNS-BC, CNRN
Instructor, Department of Surgery Neurosciences Clinical Nurse Specialist, Evidence Based
Division of Transplant and Hepatobiliary Surgery Practice Coordinator
University of Mississippi Medical Center Banner, University Medical Center Phoenix
Jackson, Mississippi Phoenix, Arizona
Pol-Andre Senecal, MSN, CNS, NP, CCNS, ACNP, BC David Waters, RN, BA, MA
Instructor, Pulmonary Sciences and Critical Care Medicine Senior Lecturer, Critical Care Nursing
University of Colorado School of Medicine Uxbridge Campus
Aurora, Colorado Buckinghamshire New University
Uxbridge, United Kingdom
Rose Shaffer, RN, MSN, ACNP-BC, CCRN, FAHA
Cardiology Nurse Practitioner, Nursing Whitney L. Watson, MSN, APRN, AGCNS-BC, CCRN
Thomas Jefferson University Hospital Nurse Manager
Philadelphia, Pennsylvania Medical/Transplant ICU
The University of Kansas Hospital
Tammy M. Slater, DNP, MS, ACNP Kansas City, Kansas
Johns Hopkins, School of Nursing
Baltimore, Maryland Anita J. White, MSN, APRN, ACNS-BC, CCRN
Clinical Nurse Specialist, Medical Intensive Care Unit
Michelle D. Smeltzer, MSN, RN, CEN Cleveland Clinic
Clinical Educator Cleveland, Ohio
Einstein Medical Center Montgomery
Norristown, Pennsylvania John Weisbrod, CRNA, MAE
Clinical Director, Gonzaga University/Providence
Traci B. Smith, RN, BSN Gonzaga University/Providence Sacred Heart Medical Center
Registered Nurse Master of Anesthesiology Education Program
Northeast Georgia Medical Center Spokane, Washington
Kimberly S. Wright, MSN, RN, CEN, TCRN
Susan L. Smith, DHSe, MSN, FNP, ACNP, FAANP Trauma Program Director
Senior Acute Core Nurse Practitioner Lawnwood Regional Medical Center & Heart Institute
Orlando Health Fort Pierce, Florida
Orlando, Florida
Susan Yale-Mancini, RN
Christine L. Sommers, MN, RN, CNE, CCRN Emeritus Chilton Medical Center
Executive Dean, Faculty of Nursing Pompton Plains, New Jersey
Universitas Pelita Harapan
Lippo Karawaci, Tangerang, Indonesia Susan Yeager, MS, RN, CCRN, ACNP-BC, FNCS
Neurocritical Care Nurse Practitioner–Lead
Linda Staubli, RN, BSN, CCRN The Ohio State University Wexner Medical Center;
Clinical Nurse Educator Clinical Instructor, Acute Care Nurse Practitioner Program
University of Colorado Hospital The Ohio State University College of Nursing
Aurora, Colorado Columbus, Ohio
Rosemary A. Timmerman, DNP, RN, CCNS, Amy Young, MSN, RN, ACCNS-AG
CCRN-CSC-CMC Clinical Nurse Specialist
Clinical Nurse Specialist Cleveland Clinic
Providence Alaska Medical Center Cleveland, Ohio
Anchorage, Alaska
Preface
The seventh edition of the Procedure Manual has a new title: AP icon and explanatory footnote on the first page of the
the AACN Procedure Manual for High Acuity, Progressive, procedure.
and Critical Care. The title has been changed to reflect the Because we recognize that the procedures included in this
expanding use of the procedures in diverse settings. I have manual are only a portion of the repertoire needed by today’s
worked closely with the section editors, clinical experts, and critical care practitioners to skillfully care for critically ill
key AACN and Elsevier staff members to revise and update patients, we recommend that it be used in conjunction with
this edition. We have removed procedures no longer common the AACN Core Curriculum for High Acuity, Progressive,
and added procedures for new technologies, devices, and and Critical Care Nursing, the Certification and Core Review
interventions. Although every attempt was made to capture for High Acuity and Critical Care, and AACN Advanced
current clinical practice, we recognize that high acuity, pro- Critical Care Nursing.
gressive, and critical care clinical practice is dynamic and The AACN Procedure Manual for High Acuity, Progres-
therefore that any resource to support that practice must be sive, and Critical Care is designed so that information
considered a work in progress. within each procedure can be found quickly. To provide
AACN is dedicated to the care of patients with critical high-quality care to seriously ill patients, we need resources
illness or injury and their families. AACN’s vision is of a that provide us with readily available, need-to-know infor-
healthcare system driven by the needs of patients and their mation. The book is organized into units, with most of the
families in which critical care nurses make their optimal units having several sections. All procedures are designed in
contribution. Toward that vision, our hope is that this edition the same style and begin with the following:
of the AACN Procedure Manual for High Acuity, Progres- • Purpose of the procedure
sive, and Critical Care will be a useful resource for nurses • Prerequisite Nursing Knowledge, which includes infor-
in providing quality patient care. mation the nurse needs before performing the procedure
The seventh edition of the AACN Procedure Manual for • Equipment list, which includes equipment necessary to
High Acuity, Progressive, and Critical Care will be an asset perform the procedure (some of the procedures identify
for nurses across the spectrum of acute and critical care additional equipment that may be necessary based on
practice. The manual includes a comprehensive review of individual situations)
state-of-the-art information on acute and critical care proce- • Patient and Family Education, which identifies essential
dures. The following procedures related to new and emerg- information that should be taught to patients and their
ing trends have been added: families
• King Airway Insertion and Removal (AP) • Patient Assessment and Preparation, which includes spe-
• Extracorporeal Life Support (ECLS) and Extracorporeal cific assessment criteria that should be obtained before
Membrane Oxygenation (ECMO) the procedure and describes how the patient should be
• Defibrillation (Internal) Assist prepared for the procedure
• External Wearable Cardioverter Defibrillator Each step-by-step procedure includes the following:
• Esophageal Cardiac Output Monitoring (Perform and • Steps, Rationales, and, for some steps, Special Consider-
Assist) ations
• Noninvasive Cardiac Output Monitoring • Associated research and appropriate figures and tables
• Radial Arterial Sheath Removal • Expected Outcomes, including the anticipated results of
• Thenar Tissue Oxygen Saturation Monitoring the procedure
• Midline Catheters • Unexpected Outcomes, including potential complications
• Cerebral Blood Flow Monitoring or untoward outcomes of the procedure
• Cerebral Microdialysis • Patient Monitoring, which includes information related to
• Pupilometer assessments and interventions that should be completed
• Focused Assessment with Sonography in Trauma (FAST) (the rationale for each item is described, and conditions
• Nasogastric and Orogastric Tube Insertion, Care, and that necessitate notification of an advanced practice nurse,
Removal physician, or other healthcare professional are identified)
• Molecular Adsorbents Recirculation System (MARS) • Documentation that describes what should be docu-
All procedures have been revised to reflect changes in mented after the procedure is performed
practice. As with the last edition, this edition of the AACN • References are included, and the majority of procedures
Procedure Manual for High Acuity, Progressive, and Criti- also include Additional Readings
cal Care contains not only procedures commonly performed This edition of the AACN Procedure Manual for High
by critical care nurses but also procedures performed by Acuity, Progressive, and Critical Care includes several icons
advanced practice nurses. Each advanced practice procedure that are common to many of the procedures. These icons
has an AP designation in the Table of Contents and a special include the following:
xvii
xviii Preface
A procedure with the AP icon should be performed Level D: Peer-reviewed professional and organizational stan-
only by physicians, advanced practice nurses, and other dards with the support of clinical study recommendations.
healthcare professionals (including critical care nurses) with Level E: Multiple case reports, theory-based evidence from
additional knowledge, skills, and demonstrated competence expert opinions, or peer-reviewed professional organi-
per professional licensure or institutional standard. zational standards without clinical studies to support
HH A procedure step with the HH icon designates that recommendations.
hand hygiene should be performed. This step is essential to Level M: Manufacturer’s recommendations only.
reduce the transmission of microorganisms and is part of
Standard Precautions. The references and additional readings for the seventh
PE A procedure step with the PE icon designates that edition are now provided online. To access the references
personal protective equipment should be applied. Personal and additional readings for each Procedure, simply use your
protective equipment may include gloves, protective eye- smartphone’s QR code reader and camera to scan the QR
glasses, masks, gowns, and any additional equipment needed code found at the end of the procedure. QR code reader
to protect the nurse or provider performing the procedure. apps are freely available on the Apple App Store and Google
The application of personal protective equipment reduces Play. Alternatively, you can access the references by going
the transmission of microorganisms, minimizes splash, and to http://booksite.elsevier.com/9780323376624.
is part of Standard Precautions.
This edition of the AACN Procedure Manual for High
Acuity, Progressive, and Critical Care uses AACN’s current
levels of evidence system. Therefore, whenever it is avail-
able, this research-based information is provided to indicate
the strength of recommendation for various interventions.
AACN’s level of evidence system includes:
Level A: Meta-analysis of quantitative studies or meta-

synthesis of qualitative studies with results that consis-
tently support a specific action, intervention, or treatment
(including systematic review of randomized controlled Finally, many of the included procedures use electrical
trials). equipment. This manual makes the assumption that all
Level B: Well-designed, controlled studies with results that equipment is maintained by the institution’s bioengineering
consistently support a specific action, intervention, or department according to accepted national and state regula-
treatment . tions for the individual piece of equipment.
Level C: Qualitative studies, descriptive or correlational I hope that you find this book an essential resource for
studies, integrative reviews, systematic reviews, or ran- clinical practice.
domized controlled trials with inconsistent results. Debra L. Wiegand
Acknowledgments
This edition of the AACN Procedure Manual for High two reviewers critiqued each procedure and provided impor-
Acuity, Progressive, and Critical Care could not have been tant feedback to the contributors. The reviewers’ critiques
published without the help of numerous hardworking people. improved the quality of each procedure.
I would like to thank AACN for giving me the opportunity In addition I would like to thank Paula Lusardi for helping
to edit this edition. This has been the first time I have had with this edition of the book. Paula reviewed every proce-
the opportunity to work with Michael Muscat, Publishing dure in the book and provided important feedback. I am
Director for AACN. Michael’s expertise has greatly contrib- grateful for her hard work, time, and expertise.
uted to the successful development of the book. I would like I am very grateful that I had the opportunity to work with
to thank Michael for his advice and support. the talented, hard-working, and dedicated editorial staff
I want to extend a huge thank you to each of the section at Elsevier. I want to extend a special thank you to Lee
editors: Michael Day, Eleanor Fitzpatrick, and Mary Beth Henderson, my editor. Lee provided essential leadership,
Makic. The section editors coordinated the development guidance, and support throughout the entire publication
and revision of each of the procedures within their sections. process. I also want to thank Laura Selkirk, Senior Devel-
They worked with the contributors and reviewers as each opmental Editor, for coordinating the day-to-day progress of
procedure was developed, reviewed, revised, and edited. I the book. She provided important behind-the-scenes help as
am very appreciative of their hard work and commitment to figures were drawn, permissions were obtained, and all of
a quality product. I tremendously enjoyed working with the key aspects of the book were pulled together. She worked
such an expert team. closely with Lisa Bushey, Project Manager, as individual
This book would not be possible without the hard work procedures, figures, tables, and additional key components
and commitment from the contributors. The contributors are of the book were produced. Laura and Lisa provided impor-
the staff nurses and advanced practice nurses who developed tant timelines and did their best to keep the production of
new procedures and revised existing procedures. Each con- the book moving forward. I also want to thank Scott Henson,
tributor worked very hard to ensure that each procedure Copyeditor; Ryan Cook, Designer; and Jeff Patterson, Pub-
included all of the information needed so that acute and lishing Services Manager for all of their time, hard work,
critical care nurses would have the most helpful information and dedication to the process of producing this book. The
at their fingertips. I cannot thank each of the contributors Elsevier team worked very hard to produce this quality
enough for their commitment to this book. textbook.
I also want to thank the staff nurses and advanced prac-
tice nurses who reviewed each of the procedures. At least
xix
Contents
17 Extracorporeal Life Support (ECLS) and

Unit I Pulmonary System Extracorporeal Membrane Oxygenation
SECTION ONE: Airway Management (ECMO), 123
Section Editor, Michael W. Day Thomas Lawson and Marcia Belcher
18 Oxygen Saturation Monitoring with Pulse
1 Combitube Insertion and Removal , 1 Oximetry, 134
Kyle Gibson Donna Barge Lee
2 Endotracheal Intubation (Perform) , 8 19 Pronation Therapy, 142
Cindy Goodrich Kathleen Vollman, Sharon Dickinson,
3 Endotracheal Intubation (Assist), 23 and Jan Powers
Cindy Goodrich
4 Endotracheal Tube Care and Oral Care
SECTION THREE: Thoracic Cavity Management
Practices for Ventilated and Non-ventilated
Section Editor, Michael W. Day
Patients, 32
Kathleen Vollman, Mary Lou Sole,
20 Autotransfusion, 164
and Barbara Quinn
Kelly McGinty
5 Extubation/Decannulation (Perform) , 40
21 Chest Tube Placement (Perform) , 168
Lisa Koser
Julie Waters
6 Extubation/Decannulation (Assist), 44
22 Chest Tube Placement (Assist), 178
Lisa Koser
Julie Waters
7 King Airway Insertion and Removal , 47
23 Chest Tube Removal (Perform) , 184
Kyle Gibson
Peggy Kirkwood
8 Laryngeal Mask Airway , 53
24 Chest Tube Removal (Assist), 190
Stephen Both
Peggy Kirkwood
9 Nasopharyngeal and Oral Airway
25 Closed Chest-Drainage System, 195
Insertion, 62
Joya D. Pickett
Kimberly Wright
26 Needle Thoracostomy (Perform) , 206
10 Suctioning: Endotracheal or Tracheostomy
Cindy Goodrich
Tube, 69
27 Thoracentesis (Perform) , 211
Maureen A. Seckel
Susan Yeager
11 Surgical Cricothyrotomy (Perform) , 79
28 Thoracentesis (Assist), 222
Roger Casey
Susan Yeager
12 Surgical Cricothyrotomy (Assist), 85
Roger Casey
13 Tracheostomy Cuff and Tube Care, 89 SECTION FOUR: Ventilatory Management
Renee Johnson Section Editor, Michael W. Day
29 Invasive Mechanical Ventilation (Through

SECTION TWO: Special Pulmonary Procedures
an Artificial Airway): Volume and Pressure
Section Editor, Michael W. Day
Modes, 227
John Gallagher
14 Continuous End-Tidal Carbon Dioxide
30 Noninvasive Positive Pressure Ventilation:
Monitoring, 103
Continuous Positive Airway Pressure (CPAP)
Paul Luehrs
and Bilevel Positive Airway Pressure
15 Continuous Lateral Rotation Therapy, 111
(BiPAP), 249
Jamie St. Clair and Jennifer MacDermott
Susan K. Frazier
16 Continuous Venous Oxygen Saturation
31 Manual Self-Inflating Resuscitation Bag-Valve
Monitoring, 116
Device, 261
Joni L. Dirks
Thomas Levins
xx
Contents xxi
32 Peripheral Nerve Stimulators, 268

SECTION SEVEN: Circulatory Assist Devices
Nathan W. Howard
Section Editor, Debra L. Wiegand
33 Weaning Mechanical Ventilation, 277
Susan K. Frazier
52 Intraaortic Balloon Pump Management, 431
John P. Harper
Unit II Cardiovascular System 53 Ventricular Assist Devices , 450
Mark Puhlman and Angela Bingham
SECTION FIVE: Cardiac Emergencies
SECTION EIGHT: Electrocardiographic Leads and
34 Automated External Defibrillation, 286 Cardiac Monitoring
Kiersten Henry Section Editor, Debra L. Wiegand
35 Cardioversion, 293
Cynthia Hambach 54 Cardiac Monitoring and Electrocardiographic
36 Defibrillation (External), 302 Leads, 467
Cynthia Hambach Michele M. Pelter, Teri M. Kozik,
37 Defibrillation (Internal) Perform , 310 and Mary G. Carey
Marion E. McRae 55 Extra Electrocardiographic Leads: Right
38 Defibrillation (Internal) Assist, 317 Precordial and Left Posterior Leads, 477
Marion E. McRae Shu-Fen Wung
39 Emergent Open Sternotomy 56 ST-Segment Monitoring (Continuous), 486
(Perform) , 322 Mary G. Carey and Michele M. Pelter
Alice Chan 57 Twelve-Lead Electrocardiogram, 494
40 Emergent Open Sternotomy (Assist), 329 Shu-Fen Wung
Alice Chan
41 External Wearable Cardioverter-
SECTION NINE: Hemodynamic Monitoring
Defibrillator, 335
Kiersten Henry
42 Pericardiocentesis (Perform) , 340
58 Arterial Catheter Insertion
Kathleen M. Cox
(Perform) , 501
43 Pericardiocentesis (Assist), 349
Hillary Crumlett and Alex Johnson
Kathleen M. Cox
59 Arterial Catheter Insertion (Assist), Care, and
Removal, 508
SECTION SIX: Cardiac Pacemakers Hillary Crumlett and Alex Johnson
Section Editor, Debra L. Wiegand 60 Arterial Pressure–Based Cardiac Output
Monitoring, 523
44 Atrial Electrogram, 356 Susan Scott
Marion E. McRae 61 Blood Sampling from an Arterial
45 Atrial Overdrive Pacing (Perform) , 366 Catheter, 530
Jillian Hamel Hillary Crumlett and Alex Johnson
46 Epicardial Pacing Wire Removal , 373 62 Blood Sampling from a Central Venous
Marion E. McRae Catheter, 540
47 Implantable Cardioverter-Defibrillator, 377 Kathleen M. Cox
Kiersten Henry 63 Blood Sampling from a Pulmonary Artery
48 Permanent Pacemaker (Assessing Catheter, 548
Function), 388 Kathleen M. Cox
Valerie Spotts 64 Cardiac Output Measurement Techniques
49 Temporary Transcutaneous (External) (Invasive), 553
Pacing, 399 Susan Scott
Valerie Spotts 65 Central Venous Catheter Removal, 569
50 Temporary Transvenous Pacemaker Insertion Jillian Hamel
(Perform) , 407 66 Central Venous Catheter Site Care, 574
Nikki Taylor Jillian Hamel
51 Temporary Transvenous and Epicardial 67 Central Venous/Right Atrial Pressure
Pacing, 416 Monitoring, 578
Valerie Spotts Reba McVay
xxii Contents
68 Esophageal Cardiac Output Monitoring: 86 Midline Catheters , 758

Perform , 584 Debra L. Wiegand
Alexander Johnson and Hillary Crumlett 87 Peripherally Inserted Central
69 Esophageal Cardiac Output Monitoring: Catheter , 766
Assist, Care, and Removal, 590 Debra L. Wiegand
Alexander Johnson and Hillary Crumlett
70 Noninvasive Cardiac Output Monitoring, 596
Susan Scott
Unit III Neurologic System
71 Pulmonary Artery Catheter Insertion SECTION TWELVE: Neurologic Monitoring
(Perform) , 601 Section Editor, Mary Beth Flynn Makic
Nikki Taylor
72 Pulmonary Artery Catheter Insertion (Assist) 88 Bispectral Index Monitoring, 778
and Pressure Monitoring, 609 Richard B. Arbour
Reba McVay 89 Brain Tissue Oxygen Monitoring: Insertion
73 Pulmonary Artery Catheter Removal, 630 (Assist), Care, and Troubleshooting, 792
Nikki Taylor Megan T. Moyer and Eileen Maloney Wilensky
74 Pulmonary Artery Catheter and Pressure 90 Cerebral Blood Flow Monitoring, 811
Lines, Troubleshooting, 637 Tracey M. Berlin
Reba McVay 91 Cerebral Microdialysis, 823
75 Single-Pressure and Multiple-Pressure Sandy Cecil
Transducer Systems, 653 92 Intracranial Bolt and Fiberoptic Catheter
Reba McVay Insertion (Assist), Intracranial Pressure
Monitoring, Care, Troubleshooting, and
Removal, 829
SECTION TEN: Special Cardiac Procedures
Tess Slazinski
93 Intraventricular/Fiberoptic Catheter
Insertion (Assist), Monitoring, Nursing Care,
76 Femoral Arterial and Venous Sheath
Troubleshooting, and Removal, 835
Removal, 664
Tess Slazinski
Rose B. Shaffer
94 Intraventricular Catheter with External
77 Radial Arterial Sheath Removal, 672
Transducer for Cerebrospinal Fluid Drainage
Rose B. Shaffer
and Intracranial Pressure Monitoring, 842
78 Pericardial Catheter Management, 678
Stephanie Cox
Kathleen M. Cox
95 Lumbar Subarachnoid Catheter Insertion
79 Thenar Tissue Oxygen Saturation
(Assist) for Cerebrospinal Fluid Drainage and
Monitoring, 693
Pressure Monitoring, 856
Kathleen Berns
Nicolle Schraeder
80 Transesophageal Echocardiography
(Assist), 698
Janice Y. Dawson and Linda Hoke SECTION THIRTEEN: Special Neurologic
Procedures
Section Editor, Mary Beth Flynn Makic
SECTION ELEVEN: Vascular Access
96 Lumbar Puncture (Perform) , 865
Susan Chioffi
81 Arterial Puncture , 707
97 Lumbar Puncture (Assist), 873
Joel M. Brown II
Susan Chioffi
82 Central Venous Catheter Insertion
98 Pupillometer, 880
(Perform) , 714
DaiWai M. Olson and John C. Bazil
Susan Yeager
99 RotoRest Lateral Rotation Surface, 885
83 Central Venous Catheter Insertion
Theresa Nino and Mary Beth Flynn Makic
(Assist), 731
100 Thermoregulation: External and Intravascular
Susan Yeager
Warming/Cooling Devices, 893
84 Implantable Venous Access Device: Access,
Karen A. Lovett
Deaccess, and Care , 738
Anne Delengowski
85 Intraosseous Devices, 748
Michael W. Day
Contents xxiii
117 Peritoneal Lavage (Perform) , 1041

SECTION FOURTEEN: Traction Management
Kate Deis
118 Peritoneal Lavage (Assist), 1048
Kate Deis
101 Cervical Tongs or Halo Ring: Application for
Use in Cervical Traction (Assist), 904
Jennifer Massetti Unit V Renal System
102 Cervical Traction Maintenance, 911
SECTION SEVENTEEN: Renal Replacement
Jennifer Massetti
Section Editor, Eleanor Fitzpatrick
103 Halo Ring and Vest Care, 917
Cara Diaz
119 Continuous Renal Replacement
104 Pin-Site Care: Cervical Tongs and
Therapies, 1054
Halo Pins, 925
Sonia M. Astle
Cara Diaz
120 Hemodialysis, 1067
Sonia M. Astle
SECTION FIFTEEN: Pain Management 121 Peritoneal Dialysis, 1080
Section Editor, Eleanor Fitzpatrick Sonia M. Astle
105 Epidural Catheters: Assisting with Insertion

Unit VI Hematologic System
and Pain Management, 929
Kimberly Williams SECTION EIGHTEEN: Fluid Management
106 Patient-Controlled Analgesia, 941 Section Editor, Eleanor Fitzpatrick
Lorie Ann Meek
107 Peripheral Nerve Blocks: Assisting with 122 Use of a Massive Infusion Device and a
Insertion and Pain Management, 948 Pressure Infusor Bag, 1088
Kimberly Williams Coleen Dever
Unit IV Gastrointestinal System SECTION NINETEEN: Special Hematologic

Procedures
SECTION SIXTEEN: Special Gastrointestinal
Procedures
123 Apheresis and Therapeutic Plasma Exchange
(Assist), 1100
108 Esophagogastric Tamponade Tube, 958
Sonia M. Astle
Rosemary Lee
124 Bone Marrow Biopsy and Aspiration
109 Focused Assessment with Sonography in
(Perform) , 1110
Trauma, 970
Glen Peterson and Carrie Marvill
Cynthia Blank-Reid and Thomas A. Santora
125 Bone Marrow Biopsy and Aspiration
110 Gastric Lavage in Hemorrhage and
(Assist), 1119
Overdose, 980
Glen Peterson and Carrie Marvill
Ann Will Poteet
111 Endoscopic Therapy, 989
Eleanor Fitzpatrick Unit VII Integumentary System
112 Intraabdominal Pressure Monitoring, 997
SECTION TWENTY: Burn Wound Management
Rosemary Lee
113 Nasogastric and Orogastric Tube Insertion,
Care, and Removal, 1011
126 Burn Wound Care, 1125
Carol McGinnis
Cameron Bell
114 Molecular Adsorbent Recirculating System
127 Donor-Site Care, 1136
(MARS), 1020
Cameron Bell
Mary D. Still
128 Skin-Graft Care, 1142
115 Paracentesis (Perform) , 1030
Dawn Sculco
Eleanor Fitzpatrick
116 Paracentesis (Assist), 1036
Eleanor Fitzpatrick
xxiv Contents
SECTION TWENTY-ONE: Special Integumentary Unit VIII Nutrition

Procedures Section Editor, Eleanor Fitzpatrick
138 Percutaneous Endoscopic Gastrostomy (PEG),
129 Intracompartmental Pressure Gastrostomy, and Jejunostomy Tube
Monitoring , 1150 Care, 1216
Julia E. Dunning Margaret M. Ecklund
130 Suture and Staple Removal, 1156 139 Small-Bore Feeding Tube Insertion and
Brian D. Schaad Care, 1221
131 Wound Closure , 1162 Margaret M. Ecklund
Joanna C. Ellis 140 Small-Bore Feeding Tube Insertion Using
an Electromagnetic Guidance System
(CORTRAK 2 Enteral Access System
SECTION TWENTY-TWO: Wound Management
EAS), 1227
Karen A. Gilbert and Patricia H. Worthington
132 Cleaning, Irrigating, Culturing, and Dressing
an Open Wound, 1173 Unit IX Calculating Medication Doses
Marylou V. Robinson Section Editor, Eleanor Fitzpatrick
133 Débridement: Pressure Ulcers, Burns, and
Wounds , 1183 141 Calculating Doses, Flow Rates, and
Julie Lynn Henderson Administration of Continuous Intravenous
134 Drain Removal, 1190 Infusions, 1236
Brian D. Schaad and Mary Beth Flynn Makic Shelley Burcat and Maribeth Kelly
135 Fecal Containment Devices and Bowel
Management Systems, 1193 Index, 1242
Jane V. Arndt
136 Negative-Pressure Wound Therapy, 1200
Lisa Woods
137 Wound Management with Excessive
Drainage, 1210
Justin Burleson
Unit I Pulmonary System
Section One Airway Management
PROCEDURE
1
Combitube Insertion
and Removal
Kyle Gibson
PURPOSE: A Combitube may be used to provide an emergency airway during
resuscitation of a profoundly unconscious patient who needs artificial ventilation
when endotracheal intubation is not readily available or has failed in successfully
establishing an airway.
PREREQUISITE NURSING ❖ The two black lines located on the Combitube identify
KNOWLEDGE proper depth placement when aligned with the patient’s
teeth or gum line.
• Anatomy and physiology of the upper airway should be • The correct placement of a Combitube in the airway is as
understood. follows:
• The Combitube does not require direct visualization of the ❖ Esophageal insertion (Figs. 1-2 and 1-3), in which the
airway for insertion and is inserted in a “blind” fashion, distal cuff occludes the esophagus and the proximal
as an adjunct when endotracheal intubation attempts fail balloon occludes the hypopharynx, allows ventilation
or trauma makes visualization of the airway difficult.1,10 via the blue lumen.
The Combitube (Fig. 1-1) is available in two sizes, deter- ❖ Tracheal insertion (Fig. 1-4), in which the distal cuff
mined by patient height. occludes the trachea and the proximal balloon occludes
❖ The 37F size is used for patients 48 to 66 inches tall the hypopharynx, allows ventilation through the white
(122 to 168 cm). lumen.
❖ Either size 37F or size 41F is applicable in patients 60 • Before the insertion of a Combitube, adequate ventilation
to 66 inches tall (152 to 168 cm). of an unconscious patient with a mouth-to-mask or a bag-
❖ For patients ≥66 inches (168 cm), the 41F size should valve-mask device is necessary.
be used. • In simulations, the Combitube has been successfully supe-
• The Combitube has a unique design that includes: rior in situations of trismus, tongue edema, limited mobil-
❖ A double-lumen, semirigid airway ity of the cervical spine, or a combination of the above.14
Blue lumen opening to the perforations between the • Use of the Combitube is contraindicated for airway man-
cuffs agement10 in the following cases:
White lumen opening distal to the distal cuff ❖ Patients with an intact gag reflex
Each lumen fitted with a 15-mm male adapter ❖ Patients with known esophageal disease
❖ Two cuffs for occlusion ❖ Patients who have ingested caustic substances
Proximal cuff (85 mL or 100 mL, depending on ❖ Patients with a known or suspected foreign body in the
tube size) to occlude the hypopharynx hypopharynx
Distal cuff (12 mL or 15 mL, depending on tube • The Combitube contains latex and may cause an allergic
size) to occlude either the esophagus or the trachea reaction in patients or in personnel who handle the device
Each cuff connected to a pilot balloon and valve: with sensitivity to latex.
blue for proximal (No. 1), white for distal (No. 2) • The Combitube is supplied either in a complete kit (with
all of the necessary components for insertion), in soft or
rigid packaging, or as a single individual device (without
any of the necessary components for insertion). If the
This procedure should be performed only by physicians, advanced
single individual device is used, additional components
practice nurses, and other healthcare professionals (including critical care are necessary for insertion. See equipment list below.
nurses) with additional knowledge, skills, and demonstrated competence per • Initial and ongoing training is needed to maximize inser-
professional licensure or institutional standard. tion success and minimize complications.8
1
2 Unit I Pulmonary System
Figure 1-4 Combitube in tracheal position.
• Medications delivered via endotracheal tube cannot be

Figure 1-1 Components of the combitube. used with a Combitube in the esophageal position. Medi-
cations may not reach the alveolar surfaces of the lung for
absorption.
• The Combitube is intended for use up to 8 hours only.
EQUIPMENT
• Gloves, mask, gown, and eye protection
• Suction equipment (suction canister with control head,
tracheal suction catheters, Yankauer suction tip)
• Combitube, of the appropriate size for the patient’s height
• Large (100-mL) Luer-tip syringe
• Small (20-mL) Luer-tip syringe
• Water-soluble lubricant
• Oxygen source and tubing
• Mouth-to-mask or self-inflating manual resuscitation bag-
valve-mask device and mask attached to a high-flow
oxygen source
• Fluid deflector elbow
• Colormetric carbon dioxide (CO2) device or end-tidal CO2
detector with waveform capnography if available
PATIENT AND FAMILY EDUCATION

Figure 1-2 Esophageal insertion of a combitube.
• If time allows, provide the family with information about
the Combitube and the reason for insertion. Rationale:
This information assists the family in understanding why
the procedure is necessary and decreases their anxiety.
PATIENT ASSESSMENT AND

PREPARATION
Patient Assessment
• Assess level of consciousness and responsiveness. Ratio-
nale: In an emergency situation, the Combitube should
be inserted only into a patient who is profoundly uncon-
scious, unresponsive, and unable to maintain adequate
ventilation. Administration of neuromuscular blocking
agents and sedation may be needed to ensure that the
patient’s gag reflex does not return while the Combitube
Figure 1-3 Combitube in esophageal position. is in place.11
1 Combitube Insertion and Removal 3
• Assess history and patient information for possibility of the correct identification of the patient for the intended
esophageal disease or caustic substance ingestion. Ratio- intervention.
nale: A Combitube is contraindicated in patients with • Ensure adequate ventilation and oxygenation with either
these conditions.10 a mouth-to-mask or a self-inflating manual resuscitation
• Assess patient’s height. Rationale: This assessment allows bag-valve-mask device. Rationale: The patient is nonre-
the selection of an appropriately sized Combitube. sponsive and unable to maintain adequate ventilation
• Assess risk for hypertensive bleeding and take precautions without assisted ventilation before the Combitube
if increased catecholamine stress response is likely. Ratio- insertion.
nale: Combitube insertion may cause pronounced cate- • Ensure that the suction equipment is assembled and in
cholamine response.6,12 working order. Rationale: The patient may regurgitate
during insertion or while the Combitube is in place and
Patient Preparation need oropharyngeal or tracheal suctioning or both.
• Verify correct patient with two identifiers. Rationale: • Perform a preprocedure verification and time out, if non-
Prior to performing a procedure, the nurse should ensure emergent. Rationale: Ensures patient safety.
Procedure for Combitube Insertion

Steps Rationale Special Considerations
1. HH
2. PE
3. Open the package and test the Ensures that the device is not defective
integrity of both cuffs. (Level M*) and will work as indicated.
A. Pull the plunger back on the Readies the syringe for inflating the Use 85-mL volume for the 37F
large syringe to the appropriate cuff. size and 100-mL volume for
volume for the size of the tube the 41F size.
and attach it to the proximal
(blue) valve, marked “No. 1.”
B. Inflate the proximal cuff with Ensures that the device is not defective If a leak is found, discard the
the appropriate volume and and will work as indicated. device and secure another.
assess for leaks.
C. Actively deflate the proximal Provides for smoother insertion and
cuff, leaving the syringe readies the syringe for inflation after
attached to the valve. insertion.
D. Pull the plunger back on the Readies the syringe for inflating the Use 12-mL volume for the 37F
small syringe to the appropriate cuff. size and 15-mL volume for
volume for the size of the tube the 41F size.
and attach it to the distal
(white) valve, marked “No. 2.”
E. Inflate the distal cuff with the Ensures that the device is not defective If a leak is found, discard the
appropriate volume and assess and will work as indicated. device and secure another.
for leaks.
F. Actively deflate the distal cuff, Provides for smoother insertion and
leaving the syringe attached to readies the syringe for inflation after
the valve. insertion.
4. Lubricate the device with water- Facilitates and eases insertion.
soluble lubricant. (Level M)
5. Attach a fluid deflector to the clear Diverts any fluid that may be A fluid deflector is included in
lumen marked “No. 2.” (Level M) regurgitated through the tube during the kits but not in the single
insertion away from the person individual devices.
inserting the device.
*Level M: Manufacturer’s recommendations only.
Procedure continues on following page

Procedure for Combitube Insertion—Continued

6. Grasp the patient’s jaw with one Pulls the tongue forward and away With facial trauma, assess for
hand and pull up (or forward if the from the hypopharynx. the presence of broken teeth
patient is in a sitting position), (real or artificial) and remove
maintaining the head in a neutral loose fragments.
position (see Fig. 1-4).11 Maintain cervical spine
(Level M*) precautions with suspected or
known spine trauma.
A Combitube used during
airway management causes
cervical spine movement less
or equal to conventional
laryngoscopes.9
Use extreme caution to avoid
puncturing the balloons
during insertion.
7. Grasp the Combitube in the other Places the Combitube in the
hand so that it curves toward the appropriate position for insertion.
patient’s feet. (Level M)
8. Insert the tip of the Combitube Allows the Combitube to follow the Do not force the Combitube.
into the patient’s mouth and patient’s hypopharynx until it is in If it does not easily advance,
advance it in a downward curving the correct position. attempt to redirect or remove
motion, maintaining a midline and reinsert.
position, until the teeth or gum
line is between the two black
marks on the device. (Level M)
9. Inflate the proximal cuff with the Inflates and seats the proximal cuff Use 85-mL volume for the 37F
appropriate volume, using the blue into the posterior hypopharynx and size and 100-mL volume for
valve, marked “No. 1.” (Level M) seals it. the 41F size.
Significant resistance is felt as
the cuff is inflated. Keep the
syringe plunger depressed
while removing it from the
valve to prevent air escaping
from the cuff.4
If an air leak develops, add
10 mL of air at a time until
the leak seals. Volumes of
150 mL may be needed for
some individuals.4
10. Inflate the distal cuff with the Inflates the distal cuff and seals the Use 12-mL volume for the 37F
appropriate volume, using the esophagus (or trachea) depending on size and 15-mL volume for
white valve, marked “No. 2.” location. Both locations allow the the 41F size.
(Level M) establishment of an effective airway.
11. Connect the self-inflating manual Most of the time, the distal balloon is
resuscitation bag-valve device to in the esophagus.2 With both cuffs
the 15-mm adapter on the blue inflated, the only place the
lumen, marked “No. 1,” and ventilation can go is into the trachea.
ventilate. (Level M)


12. Assess for tube placement. Determines placement of the tube and
(Level M*) which lumen should be used to
ventilate.
A. Assess for gurgling over the If the distal cuff is in the esophagus, Listening over the epigastrium
epigastrium, chest rise and fall, no gurgling is heard over the initially provides rapid
and breath sounds in the lung epigastrium and the ventilation determination that the
fields with each ventilation. expands the lungs, causing the chest ventilation is going into the
to rise and fall and breath sounds to esophagus.1
be heard over the lung fields. Go to When assessing for the presence
Step 13. of breath sounds, always
If the distal cuff is in the trachea, consider the possibility of a
gurgling is heard over the pneumothorax. This condition
epigastrium and no rise and fall of can change the breath sounds
the chest is seen or breath sounds presentation and lead the
heard over the lung fields. Go to inserter to believe that the
Step 12B. Combitube is misplaced.
If no gurgling or breath sounds are
noted with ventilation, the
Combitube may have been advanced
too far into the esophagus, blocking
the perforations from the blue
lumen. Go to Step 12C.
B. Immediately switch the If the distal cuff is in the trachea, no Listening over the epigastrium
self-inflating manual gurgling is heard over the initially provides rapid
resuscitation bag-valve device epigastrium and the ventilation determination that the
to the clear lumen, marked expands the lungs, causing the chest ventilation is going into the
“No. 2,” and attempt to to rise and fall and breath sounds to esophagus.1
ventilate, assessing for gurgling be heard over the lung fields. Go to When assessing for the presence
over the epigastrium, chest rise Step 13. of breath sounds, always
and fall, and breath sounds in consider the possibility of a
the lung fields with ventilation. pneumothorax. This condition
can change the breath sounds
presentation and lead the
inserter to believe that the
Combitube is misplaced.
C. Deflate the proximal cuff, Allows for the repositioning of the If repositioning of the
using a syringe on the blue Combitube so that the soft tissue of Combitube does not establish
valve, marked “No. 1,” esophagus no longer occludes the an effective airway, remove
withdraw the Combitube blue lumen perforations. Return to the device and establish an
approximately 2 to 3 cm, and Step 9. airway with alternative
reinflate the “No. 1” cuff. means.
13. Secure the Combitube with either Prevents the possibility of
tape or a manufactured tube holder dislodgement.3
(see Fig. 2-10).
14. Further assess device placement Confirms proper placement with two
with an end-tidal carbon dioxide additional methods.4,5
device,2,13 or an esophageal
detector device.2,13 (Level E*)
15. Continue ventilation through Adequate ventilation can be achieved
whichever lumen provides the with the distal cuff of the Combitube
airway. (Level M) in either the esophagus or the
trachea.
*Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to
support recommendations.


16. Remove and discard PE .
17. HH
18. Document the procedure in the
patient’s record.
Procedure for Combitube Removal

1. HH
2. PE
3. To remove the Combitube: Removal is indicated within 8 A fiber-optic scope may be used to
hours of insertion or when replace a Combitube with an
skilled personnel can manage the endotracheal tube.
patient’s airway. If the Combitube has been placed in
the trachea, cricoid pressure should
be established and maintained until
the new airway is established.
A. Decompress the stomach. Removes any contents from the If the Combitube is placed in the
stomach, which makes esophagus, a small suction catheter
regurgitation less likely with may be inserted through the white
removal of the device. “No. 2” lumen to decompress the
stomach.
B. Attach a 100-mL syringe to the Deflates the proximal cuff and
blue valve, marked “No. 1,” allows suctioning of the
and deflate the cuff. hypopharynx.
C. Suction the hypopharynx. Removes secretions that may have
accumulated in the hypopharynx.
D. Attach a 20-mL syringe to the Deflates the distal cuff and allows
white valve, marked “No. 2,” the Combitube to be withdrawn.
and deflate the cuff.
E. Withdraw the Combitube from Allows the patient to breathe on
the airway, and administer his or her own and supplies
supplemental oxygen. supplemental oxygen to counter
any hypoxia.
4. Remove and discard PE .
5. HH
patient’s record.
Expected Outcomes Unexpected Outcomes

• Establishment of an effective airway in an emergency • Complications from use of the Combitube related to
situation insertion technique or excessive cuff pressures
• Maintenance of adequate ventilation and oxygenation • Sore throat7
• Recovery of spontaneous ventilation • Dysphagia7
• Bleeding15
• Pharyngeal perforation15
• Esophageal lacerations15
• Esophageal rupture15
• Improper placement, resulting in hypoventilation
Patient Monitoring and Care

Steps Rationale Reportable Conditions
These conditions should be reported
if they persist despite nursing
interventions.
1. Monitor ventilation effectiveness Determines that the Combitube is • Increased difficulty in ventilation
while the Combitube is in place functioning correctly and providing • Unexplained decreases in oxygen
by monitoring: adequate ventilation and saturation (Spo2) or end-tidal
A. Difficulty of ventilation. oxygenation. carbon dioxide (Petco2) levels
B. Spo2.
C. Petco2.
2. Monitor for return of May indicate need either to remove the
spontaneous attempts at device or use medications (sedatives
breathing. or nondepolarizing neuromuscular
blockade) to prevent the gag reflex.7
Documentation
Documentation should include the following:
• Assessment findings that indicate the need to insert a • Assessment findings after insertion of the Combitube
Combitube that indicate which lumen ventilates the patient
• Confirmation of adequacy of ventilation, with • Secondary confirmation of adequacy of ventilation,
auscultation of gastric area and lung fields with Petco2 or an esophageal detection device, in conjunction
• Any difficulties with placement of the Combitube with Spo2 levels with ventilation
• Petco2 levels • Ongoing monitoring of difficulty or ease of
• Need for sedation or neuromuscular blockade or both ventilation
• Assessment findings on removal of the Combitube, • Spo2 levels
including work of breathing, breath sounds, and Spo2 • Assessment findings that indicate the need to remove
levels the Combitube or replace it with an endotracheal tube
References and Additional Readings

For a complete list of references and additional readings for
this procedure, scan this QR code with any freely available
smartphone code reader app, or visit
http://booksite.elsevier.com/9780323376624.
1 Combitube Insertion and Removal 7.e1
References 10. Lavery G, McCloskey B: The difficult airway in adult

1. American Heart Association: ACLS resource text (ACLS), critical care. Crit Care Med 39:2163–2173, 2008.
Dallas, 2008, AHA. 11. Mace SE: Challenges and advantages in intubation:
2. Calkins T, Miller K, Langdorf MI: Success and Rapid sequence intubation. Emerg Med Clin North Am
complication rates with prehospital placement of an 26:1043–1068, 2008.
esophageal-tracheal Combitube as a rescue airway. 12. Oczenski W, et al: Hemodynamic and catecholamine
Prehosp Disaster Med 21(Suppl 2):97–100, 2006. stress responses to insertion of the Combitube, laryngeal
3. Carlson J, Mayrose J, Wang H: How much force is mask airway, and tracheal intubation. Anesth Analg
required to dislodge an alternate airway? Prehosp Emerg 88:1389–1394, 1999.
Care 14:31–35, 2010. 13. Rich J, Thierbach A, Frass M: The Combitube, self-
4. Frass M: Combitube. Internet J Anesthesiol 5(2):2001. inflating bulb, and colorimetric carbon dioxide detector to
Text available at: <http://ispub.com/IJA/5/2/7924> advance airway management in the first echelon of the
(Accessed 22.06.09). battlefield. Mil Med 171:389–395, 2006.
5. Frass M, et al: Evaluation of esophageal Combitube in 14. Robak O, et al: Feasibility and speed of insertion of seven
cardiopulmonary resuscitation. Crit Care Med 15:609– supraglottic airway devices under simulated airway
611, 1987. conditions. Can J Emerg Med 14:330–334, 2012.
6. Kayhan D, et al: Which is responsible for hemodynamic 15. Vézina MC, et al: Complications associated with
response due to laryngoscopy and endotracheal esophageal-tracheal Combitube in the pre-hospital setting.
intubation? Catecholamines, vasopression or angiotensin? Can J Anaesth 54:124–128, 2007.
Eur J Anaesthesiol 22:780–785, 2005.
7. Keller C, et al: The influence of cuff volume and Additional Readings
anatomic location on pharyngeal, esophageal, and Foley LJ, Ochroch EA: Bridges to establish an emergency
tracheal mucosal pressures with the esophageal airway and alternate intubating techniques. Crit Care Clin
tracheal Combitube. Anesthesiology 96:1074–1077, 16:429–444, 2000.
2002. Gaitini LA, Vaida SJ, Agro F: The esophageal-tracheal
8. Kory P, et al: Initial airway management skills of senior Combitube. Anesthesiol Clin North Am 20:893–906, 2002.
residents: Simulation training compared with traditional Idris AH, Gabrielli A: Advances in airway management.
training. Chest 132:1927–1931, 2007. Emerg Med Clin North Am 20:843–857, 2002.
9. Kılıç T, et al: Upper cervical spine movement during Ostermayer DG, Gausche-Hill M: Supraglottic airways: The
intubation with different airway devices. Am J Emerg Med history and current state of prehospital airway adjuncts.
31:1034–1036, 2013. Prehosp Emerg Care 18:106–115, 2014.
PROCEDURE
2
Endotracheal Intubation
(Perform)
Cindy Goodrich
PURPOSE: Endotracheal intubation is performed to establish and maintain a
patent airway, facilitate oxygenation and ventilation, reduce the risk of aspiration,
and assist with the clearance of secretions.
PREREQUISITE NURSING • Videolaryngoscopy is gaining increased popularity as a

KNOWLEDGE method for oral intubation. This involves using fiberoptics
or a micro video camera encased in the laryngoscope that
• Anatomy and physiology of the pulmonary system should provides a wide-angle view of the glottic opening while
be understood. attempting oral intubation. Emerging literature supports
• Indications for endotracheal intubation include the this highly effective tool as a method to increase first-
following15,20: pass success by providing a superior view of the glottis
❖ Inadequate oxygenation and ventilation compared with traditional direct laryngoscopy.5,7,16 This
❖ Altered mental status (e.g., head injury, drug overdose) method also requires minimal lifting force, resulting in
for airway protection less movement of the cervical spine during intubation.13
❖ Anticipated airway obstruction (e.g., facial burns, epi- • Endotracheal tube size reflects the size of the internal
glottitis, major facial or oral trauma) diameter of the tube. Tubes range in size from 2 mm for
❖ Upper airway obstruction (e.g., from swelling, trauma, neonates to 9 mm for large adults. Endotracheal tubes that
tumor, bleeding) range in size from 7 to 7.5 mm are used for average-sized
❖ Apnea adult women, whereas endotracheal tubes that range in
❖ Ineffective clearance of secretions (i.e., inability to size from 8 to 9 mm are used for average-sized adult men
maintain or protect airway adequately) (Fig. 2-1).9,10,20 The tube with the largest clinically accept-
❖ High risk of aspiration able internal diameter should be used to minimize airway
❖ Respiratory distress, respiratory failure resistance and assist in suctioning.
• Pulse oximetry should be used during intubation so that • Double-lumen endotracheal tubes are used for indepen-
oxygen desaturation can be quickly detected and treated dent lung ventilation in situations with bleeding of one
(see Procedure 18).3,14 lung or a large air leak that would impair ventilation of
• Proper positioning of the patient is critical for successful the good lung.
intubation. • The patient’s airway should be assessed before intubation.
• Two types of laryngoscope blades exist: straight and The LEMON© mnemonic can be used to determine
curved. The straight (Miller) blade is designed so that the whether a difficult intubation is anticipated.3
tip extends below the epiglottis, to lift and expose the ❖ L = Look Externally: look for features associated with
glottic opening. The straight blade is recommended for a difficult intubation such as a short neck, prominent
use in obese patients, pediatric patients, and patients with incisors, broken teeth, a large protruding tongue, a
short necks because their tracheas may be located more narrow or abnormally shaped face, a receding jaw, or
anteriorly. When a curved (Macintosh) blade is used, the a prominent overbite.3
tip is advanced into the vallecula (the space between the ❖ E = Evaluate using the 3-3-2 rule: These three rules
epiglottis and the base of the tongue), to expose the glottic help to determine whether there will be alignment of
opening. the pharyngeal, laryngeal, and oral axes.3
• Laryngoscope blades are available with bulbs or with a Three fingers: distance between upper and lower
fiberoptic light delivery system. Fiberoptic light delivery incisors in the mouth opening
systems provide a brighter light. Bulbs are prone to Three fingers: distance between tip of chin and chin-
becoming scratched or covered with secretions. neck junction (hyoid bone)
Two fingers: distance between thyroid cartilage and
mandible
❖ M = Mallampati Grade: This scoring system provides
practice nurses, and other healthcare professionals (including critical care an estimate of the space available for oral intubation
nurses) with additional knowledge, skills, and demonstrated competence per using direct laryngoscopy. It relates the amount of
professional licensure or institutional standard. mouth opening to the size of the tongue. Classes1 and
8
2 Endotracheal Intubation (Perform) 9
Figure 2-1 Parts of the endotracheal tube (Soft-Cuffed Tube by Smiths Industries Medical
Systems, Co, Valencia, CA). (From Kersten LD: Comprehensive respiratory nursing, Philadelphia,
1989, Saunders, 637.)
2 predict a routine laryngoscopy, class 3 predicts dif-

ficulty, and class 4 predicts extreme difficulty. The
patient is asked to open his or her mouth as wide as
possible, sticking the tongue out. Look into the mouth
using a light to assess the amount of hypopharynx that
is visible.3
❖ O = Obstruction: Look for causes that might interfere
with intubation, such as tonsillar abscess, epiglottitis,
trauma, tumors, swollen tongue, and obesity.3
❖ N = Neck Mobility: Look for conditions that might
limit neck range of motion such as a hard cervical
collar (trauma), ankylosing spondylitis, previous neck
surgery, and rheumatoid arthritis. If trauma is not sus-
pected, ask the patient to touch his or her chin to his
or her chest and extend the neck to the ceiling.3
• Visualization of the vocal cords can be aided by using
laryngeal manipulation. This is accomplished by applying Figure 2-2 Cricoid pressure. Firm downward pressure on the
cricoid ring pushes the vocal cords downward toward the field of
backward, upward, and rightward pressure (BURP) on the vision while sealing the esophagus against the vertebral column.
thyroid cartilage to move the larynx to the right while the
tongue is displaced to the left by the laryngoscope blade.3
• Application of cricoid pressure (Sellick maneuver) may patients with facial fractures or suspected fractures at the
increase the success of the intubation as long as it does base of the skull, and after cranial surgeries, such as trans-
not interfere with ventilation or placement of the endotra- nasal hypophysectomy.3
cheal tube. This procedure is accomplished by applying • Improper intubation technique may result in trauma to the
firm downward pressure on the cricoid ring, pushing the teeth, soft tissues of the mouth or nose, vocal cords, and
vocal cords downward so that they are visualized more posterior pharynx.
easily (Fig. 2-2).When applied correctly it may protect • In trauma patients with suspected spinal cord injuries and
against insufflation of the stomach and aspiration of the those not completely evaluated, manual in-line cervical
lungs. If applied incorrectly it may interfere with ventila- immobilization of the head must be maintained during
tion and make laryngoscopy intubation more difficult. endotracheal intubation to keep the head in a neutral posi-
Once begun, cricoid pressure must be maintained until tion. An assistant should be directed to manually immo-
intubation is completed unless there is difficulty intubat- bilize the head and neck by placing his or her hands on
ing or ventilating the patient. The routine use of cricoid either side of the patient’s head, with thumbs along the
pressure is not recommended during cardiac arrest.14 mandible and fingers behind the head on the occipital
• Endotracheal intubation can be done via nasal or oral ridge. Gentle but firm stabilization should be maintained
routes. The route selected will depend on the skill of the throughout the procedure.3,10
practitioner performing the intubation and the patient’s • Confirmation of endotracheal tube placement should be
clinical condition. done immediately after intubation to protect against unrec-
• Nasal intubation requires a patient who is breathing spon- ognized esophageal intubation. This includes using both
taneously and is relatively contraindicated in trauma clinical findings and end-tidal carbon dioxide(CO2).3,4,14
❖ Clinical findings consistent with tracheal placement • This procedure should be performed only by physicians,
include visualization of the tube passing through the advanced practice nurses, and other healthcare profession-
vocal cords, absence of gurgling over the epigastric area, als (including critical care nurses) with additional knowl-
auscultation of bilateral breath sounds, bilateral chest edge, skills, and demonstrated competence per professional
rise and fall during ventilation, and mist in the tube.14,15 licensure and institutional standard.
❖ End-tidal CO2 detectors assist in confirming proper
placement of the endotracheal tube into the trachea (see EQUIPMENT
Procedure 14). The presence of CO2 in the expired air
indicates that the airway has been successfully intu- • Personal protective equipment, including eye protection
bated, but does not ensure the correct position of the • Endotracheal tube with intact cuff and 15-mm connector
endotracheal tube. (women, 7-mm to 7.5-mm tube; men, 8-mm to 9-mm tube)
❖ Disposable end-tidal CO2 detectors are chemically • Laryngoscope handle with fresh batteries
treated with a nontoxic indicator that changes color in • Laryngoscope blades (straight and curved)
the presence of CO2. • Spare bulb for laryngoscope blades
❖ Continuous end-tidal CO2 (capnography) assists in • Flexible stylet
confirming proper placement of the endotracheal tube • Magill forceps (to remove foreign bodies obstructing the
into the trachea as well as allowing for detection of airway if present)
future tube dislodgment. • Self-inflating manual resuscitation bag-valve-mask device
❖ During cardiac arrest (nonperfusing rhythms), low with tight fitting face mask connected to supplemental
pulmonary blood flow may cause insufficient expired oxygen (15 L/min)
CO2.22 If CO2 is not detected, use of an esophageal • Oxygen source
detector device is recommended for confirmation of • Luer-tip 10-mL syringe for cuff inflation
proper placement into the trachea.2,3,14,18,23 • Water-soluble lubricant
❖ At least five to six exhalations with a consistent CO2 • Rigid pharyngeal suction-tip (Yankauer) catheter
level must be assessed to confirm endotracheal tube • Suction apparatus (portable or wall)
placement in the trachea because the esophagus may • Suction catheters
yield a small but detectable amount of CO2 during the • Bite-block or oropharyngeal airway
first few breaths.15 • Endotracheal tube–securing apparatus or appropriate tape
❖ Esophageal detector devices work by creating suction ❖ Commercially available endotracheal tube holder
at the end of the endotracheal tube by compressing a ❖ Adhesive tape (6 to 8 inches long)
flexible bulb or pulling back on a syringe plunger. • Stethoscope
When the tube is placed correctly in the trachea, air • Monitoring equipment: cardiac monitor, pulse oximetry,
allows for reexpansion of the bulb or movement of the and sphygmomanometer
syringe plunger. If the tube is located in the esophagus, • Disposable end-tidal CO2 detector, continuous end-tidal
no movement of the syringe plunger or reexpansion of CO2 monitoring device, and esophageal detection device
the bulb is seen. These devices may be misleading in • Drugs for intubation as indicated (induction agent, seda-
patients who are morbidly obese, in status asthmaticus, tion, paralyzing agents, lidocaine, atropine)
late in pregnancy, or in patients with large amounts of • Assortment of oropharyngeal airways and nasopharyngeal
tracheal secretions.14 airways
• Endotracheal tube cuff pressure should be checked after • Rescue airways such as LMA, King LT, or Combitube
verifying correct endotracheal tube position. The cuff • Failed airway equipment: gum elastic bougie, videolaryn-
pressure recommended for assistance in preventing both goscope, optical stylet fiberoptic scope, and cricothyroid-
microaspiration and tracheal damage is 20 to 30 cm otomy kit
H2O.11,17,19 Additional equipment, to have available as needed, includes
• Intubation attempts should take no longer than 15 to 20 the following:
seconds. If more than one intubation attempt is necessary, • Anesthetic spray (nasal approach)
ventilation with 100% oxygen using a self-inflating • Local anesthetic jelly (nasal approach)
manual resuscitation bag device with a tight-fitting face • Ventilator
mask should be performed for 3 to 5 minutes before each
attempt. If intubation is not successful after three attempts, PATIENT AND FAMILY EDUCATION
consider using another airway adjunct, such as a laryngeal
mask airway (LMA), Combitube, or King LT Airway (see • If time permits, assess the patient’s and the family’s level
Procedures 1, 7, and 8). of understanding about the condition and rationale for
• It is important to have a clearly defined difficult/failed endotracheal intubation. Rationale: This assessment iden-
airway plan and alternative airway equipment available at tifies the patient’s and the family’s knowledge deficits
the bedside in case of unsuccessful intubation. This may concerning the patient’s condition, the procedure, the
consist of a gum elastic bougie, LMA, and videolaryngo- expected benefits, and the potential risks. It also allows
scope. Surgical airway equipment such as that needed for time for questions to clarify information and voice con-
a cricothyroidotomy should be available at the bedside in cerns. Explanations decrease patient anxiety and enhance
case of a failed airway.15 cooperation.
• Explain the procedure and the reason for intubation, if the

clinical situation permits. If not, explain the procedure and Patient Preparation
reason for the intubation after it is completed. Rationale: • Perform a preprocedure verification and time out. Ratio-
This explanation enhances patient and family understand- nal: Ensures patient safety.
ing and decreases anxiety. • Ensure that the patient understands preprocedural teach-
• If indicated and the clinical situation permits, explain the ing, if appropriate. Answer questions as they arise, and
patient’s role in assisting with insertion of the endotra- reinforce information as needed. Rationale: Understand-
cheal tube. Rationale: This explanation elicits the patient’s ing of previously taught information is evaluated and
cooperation, which assists with insertion. reinforced.
• Explain that the patient will be unable to speak while the • Before intubation, initiate intravenous or intraosseous
endotracheal tube is in place but that other means of com- access. Rationale: Readily available intravenous or
munication will be provided. Rationale: This information intraosseous access may be necessary if the patient
enhances patient and family understanding and decreases needs to be sedated or paralyzed or needs other medica-
anxiety. tions because of a negative response to the intubation
• Explain that the patient’s hands are often immobilized to procedure.
prevent accidental dislodgment of the tube. Rationale: • Position the patient appropriately.
This information enhances patient and family understand- ❖ Positioning of the nontrauma patient is as follows:
ing and decreases anxiety. place the patient supine with the head in the sniffing
position, in which the head is extended and the neck is
flexed. Placement of a small towel under the occiput
PATIENT ASSESSMENT AND elevates it several inches, allowing for proper flexion
PREPARATION of the neck (Fig. 2-3). Rationale: Placement of the
head in the sniffing position allows for better visualiza-
Patient Assessment tion of the larynx and vocal cords by aligning the axes
• Verify correct patient with two identifiers. Rationale: of the mouth, pharynx, and trachea.
Prior to performing a procedure, the nurse should ensure ❖ Positioning of the trauma patient is as follows: manual
the correct identification of the patient for the intended in-line cervical spinal immobilization must be main-
intervention. tained during the entire process of intubation. Ratio-
• Assess for recent history of trauma with suspected spinal nale: Because cervical spinal cord injury must be
cord injury or cranial surgery. Rationale: Knowledge of suspected in all trauma patients until proved otherwise,
pertinent patient history allows for selection of the most this position helps prevent secondary injury should a
appropriate method for intubation, which helps reduce the cervical spine injury be present.
risk of secondary injury. • Premedicate as indicated. Rationale: Appropriate pre-
• Assess nothing-by-mouth status, the use of a self-inflating medication allows for more controlled intubation, reduc-
manual resuscitation bag-valve device with mask before ing the incidence of insertion trauma, aspiration,
intubation, and for signs of gastric distention. Rationale: laryngospasm, and improper tube placement.
Increased risk of aspiration and vomiting occurs with • As appropriate, notify the respiratory therapy department
accumulation of air (from the use of a self-inflating of impending intubation so that a ventilator can be set up.
manual resuscitation bag-valve-mask device), food, or Rationale: The ventilator is set up before intubation.
secretions.
• Assess level of consciousness, level of anxiety, and respi-
ratory difficulty. Rationale: This assessment determines
the need for sedation or the use of paralytic agents and the
patient’s ability to lie flat and supine for intubation.
• Assess oral cavity for presence of dentures, loose teeth,
or other possible obstructions and remove if appropriate.
Rationale: Ensures that the airway is free from any
obstructions.
• Assess vital signs and assess for the following: tachypnea,
dyspnea, shallow respirations, cyanosis, apnea, altered
level of consciousness, tachycardia, cardiac dysrhythmias,
hypertension, and headache. Rationale: Any of these con-
ditions may indicate a problem with oxygenation or ven-
tilation or both.
• Assess patency of nares (for nasal intubation). Rationale:
Selection of the most appropriate naris facilitates insertion
and may improve patient tolerance of the tube. Figure 2-3 Neck hyperextension in the sniffing position aligns
• Assess need for premedication. Rationale: Various medi- the axis of the mouth, pharynx, and trachea before endotracheal
cations provide sedation or paralysis of the patient as intubation. (From Kersten LD: Comprehensive respiratory nursing,
needed. Philadelphia, 1989, Saunders, 642.)
Procedure for Performing Endotracheal Intubation

General Setup
1. HH
2. PE
3. Establish intravenous or Provides access to deliver indicated
intraosseous access if not present. medications.
4. Attach patient to monitoring Provides continuous patient
equipment including cardiac and monitoring during intubation.
blood pressure monitor and pulse
oximeter.
5. Set up suction apparatus, and Prepares for oropharyngeal
connect rigid suction-tip catheter suctioning as needed.
to tubing.
6. Check equipment.
A. Choose appropriate-sized Appropriate-sized endotracheal Generally a 7–7.5-mm internal
endotracheal tube. tubes facilitate both intubation diameter tube is used for adult
and ventilation. females and an 8–9-mm internal
diameter for adult males.9,10,14,20
B. Use 10-mL syringe to inflate Verifies that equipment is functional Once the endotracheal tube cuff has
cuff on tube, assessing for and that tube cuff is patent been checked for leaks and it is
leaks. Completely deflate cuff. without leaks; prepares tube for completely deflated, place back into
insertion. its packaging to avoid
contamination.
C. Insert the stylet into the Provides structural support for the Stylet must be recessed by at least 0.5
endotracheal tube, ensuring flexible endotracheal tube during inch from the distal end of the tube
that the tip of the stylet does insertion. Maintaining the tip of so that it does not protrude beyond
not extend past the end of the the stylet within the lumen of the the end of the tube.
endotracheal tube. endotracheal tube prevents
damage to the vocal cords and
trachea.
D. Connect the laryngoscope Verifies that the equipment is Check the bulb for brightness.
blade to the handle, and functional. Replace bulb if dull or burnt out.
ensure the blade’s bulb is
securely seated.
7. Assess patient’s airway to Use of LEMON© mnemonic can
determine whether a difficult assist in determination of difficult
intubation is anticipated. intubation.3
(Level D*)
8. Position the patient’s head by Allows for visualization of the The ear (external auditory meatus) and
flexing the neck forward and vocal cords with alignment of the sternal notch should be aligned when
extending the head, in sniffing mouth, pharynx, and trachea. patient is examined from the side.
position (only if neck trauma is This allows for flexion of the
not suspected; see Fig. 2-3). If cervical spine.15 Placement of a
spinal trauma is suspected, small towel under the occiput
request that an assistant maintain elevates it, allowing for proper neck
the head in a neutral position flexion. Do not flex or extend neck
with in-line spinal of patient with suspected spinal cord
immobilization. injury; the head must be maintained
in a neutral position with manual
in-line cervical spine
immobilization.3
9. Check the mouth for dentures and Dentures should be removed before
remove if present. oral intubation is attempted but
may remain in place for nasal
intubation.
*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.
Procedure for Performing Endotracheal Intubation—Continued

10. Suction the mouth and pharynx Provides for a clear view of the
as needed if copious secretions posterior pharynx and larynx.
are visualized.
11. Insert oropharyngeal airway if Assists in maintenance of upper Use only in unconscious patients with
indicated (see Procedure 9). airway patency. Helps to improve an absent gag reflex.
ability to ventilate during
bag-valve-mask ventilation.
12. Preoxygenate for 3–5 minutes, Helps prevent hypoxemia. Gentle Bag-valve-mask ventilation may not be
with 100% oxygen via a breaths reduce incidence of air needed in the spontaneous breathing
nonrebreather mask if ventilations entering stomach (leading to patient. Avoid aggressive positive-
are adequate or via a self-inflating gastric distention, aspiration), pressure ventilation with a self-
manual resuscitation bag-valve- decrease airway turbulence, and inflating manual resuscitation bag
mask device (see Procedure 31) if distribute ventilation more evenly because this may increase the risk
ventilations are inadequate. within the lungs. for gastric vomiting.
(Level D*) Preoxygenation ensures that
nitrogen is washed out of the
lungs and will extend the
allowable apneic time until the
oxygen in the lungs is used up.4,15
13. Premedicate patient as indicated. Sedates and relaxes the patient,
allowing easier intubation.
14. Remove oropharyngeal airway if Clears the airway for advancement
present. of the laryngoscope blade and
For nasotracheal intubation, proceed endotracheal tube.
to Step 35
Orotracheal Intubation
15. Grasp laryngoscope (with blade Prepares for efficient blade Grasp handle as low as possible and
in place and illuminated light on) placement. keep wrist rigid to prevent using
in left hand. upper teeth as a fulcrum.
16. Use fingers of right hand to open Provides access to oral cavity. Use a scissor-like motion with thumb
the mouth. and second finger of right hand to
gently open the mouth. Hold the tips
of the thumb and middle finger of
the right hand together. Insert them
between the upper and lower
incisors. Using a scissor-like motion
move fingers past one another by
flexing each finger.15
17. Using a controlled motion, slowly Displaces the tongue to the left, Avoid pressure on the teeth and lips.
insert the blade into the right side increasing visualization of the Inserting the blade smoothly and
of the patient’s mouth, using it to glottic opening (Fig. 2-5). quickly obtaining an optimal view of
push the tongue to the left (Fig. the glottis opening will help to
2-4). Advance the blade inward increase first-pass success.15 If the
and toward midline past the base patient’s chest is obstructing
of the tongue. placement of the laryngoscope
handle, consider placing blankets or
towels under the head and upper
back to elevate the head relative to
the chest. Do not do this if cervical
spine injury is suspected.15 In trauma
victims, consider turning the handle
90 degrees to insert the blade into
the mouth and rotate to midline as
the blade is advanced.


Figure 2-4 Technique of orotracheal intubation. The laryngoscope

blade is inserted into the oral cavity from the right, pushing the tongue to
the left as it is introduced.
Figure 2-5 The blade is advanced into the oropharynx, and the laryn-
goscope is lifted to expose the epiglottis.
18. Visually identify the epiglottis Identification of anatomical External laryngeal manipulation
and vocal cords. landmarks provides landmarks for (BURP) may assist with
successful intubation visualization of the vocal cords.3
Apply BURP on the thyroid cartilage
to move the larynx to the right while
the tongue is displaced to the left by
the laryngoscope blade.3 This may
be done by the intubator or by an
assistant.
Cricoid pressure (Sellick maneuver)
may provide increased visualization
of the vocal cords by moving the
trachea posteriorly. This is
accomplished by applying firm
downward pressure on the cricoid
ring, pushing the vocal cords
downward so that they are visualized
more easily (see Fig. 2-1). Once
cricoid pressure is applied, it must
be maintained until the intubation is
completed. The routine use of
cricoid pressure is not recommended
during cardiac arrest.14

19. Carefully advance the blade Identification of the epiglottis is key
toward the epiglottis in a well- for successful direct laryngoscopy
controlled manner. intubation.
A. With a curved blade, advance Exposes the glottic opening. Keep left arm and back straight when
tip into vallecula (area This lifting motion elevates the pulling upward, allowing for use of
between the base of the epiglottis, keeping the tongue out shoulders when lifting patient’s head
tongue and the epiglottis) and of the way, allowing for maximal to the bed (Fig. 2-6). Levering back
exert outward and upward exposure of the glottis. on the laryngoscope handle will
gentle traction at a 45-degree impair the view and may damage the
angle (decreases the risk of teeth. Touching the teeth indicates
teeth inadvertently being used excessive levering or ineffective
as a fulcrum). Lift the lift.15
laryngoscope in the direction
of the handle to lift the tongue
and posterior pharyngeal
structures out of the way,
allowing for exposure of the
glottis opening. Do not allow
the handle to lever back,
causing the blade to hit the
teeth.
Figure 2-6 The tip of the blade is placed in the vallecula, and the
laryngoscope is lifted further to expose the glottis. The tube is inserted
through the right side of the mouth.
B. With a straight blade, advance Exposes the glottic opening. Keep left arm and back straight when
tip just beneath the epiglottis Using the paraglossal technique pulling upward, allowing for use of
and exert gentle traction allows for a better view by shoulders when lifting patient’s head
outward and upward at a displacing the tongue with (decreases use of teeth as a fulcrum).
45-degree angle to the bed. minimal effort.15 Using a straight blade may provide a
Blade may be inserted to the better view when the larynx is more
right of the tongue into the anterior or in those with a receding
natural gutter between the chin.15 Midline insertion of the blade
lower molars (paraglossal often results in difficulty in
technique) or midline.15 Do controlling the tongue which may
not allow the handle to lever obscure the view, particularly in
back, causing the blade to hit unconscious adults.
the teeth.
20. Lift the laryngoscope handle up Allows for correct placement of Do not use the blade as a pry bar; this
and away from the operator (at a tube into trachea (Fig. 2-7). may result in damage to the teeth or
45- to 55-degree angle from the mouth.15
trachea) until the vocal cords are BURP may assist with visualization of
visualized. the vocal cords.3

Figure 2-7 The endotracheal

tube is passed through the vocal
cords. (From Flynn JM, Bruce NP:
Introduction to critical care skills,
St Louis, 1993, Mosby, 56.)
21. Hold end of tube in right hand Tube is placed with the right hand.
with curved portion downward.
22. With use of direct vision, gently Tube must be seen passing through The front teeth or gums should be
insert tube from right corner of the vocal cords to ensure proper aligned between the 19-cm and
mouth through the vocal cords placement. Advance tube 1.25– 23-cm depth markings on the tube to
(Fig. 2-8) until the cuff is no 2.5 cm farther into the trachea. ensure the tip of the tube is above
longer visible and has passed When correctly positioned, the tip the carina.4 Common tube placement
through the vocal cords (Fig. of the tube should be halfway at the teeth or gums is 20–21 cm for
2-9). Do not apply pressure on between the vocal cords and the women and 22–23 cm for men.10,15
the teeth or oral tissues. carina.4,14 If intubation is unsuccessful within 30
seconds, or the patient’s oxygen
saturations falls below 90% during
the attempt, remove the tube.15
Ventilate with 100% oxygen with a
bag-valve-mask device before
another intubation attempt is made
(repeat Steps 13 through 20).
Before reattempting intubation, correct
problems related to positioning,
procedure, or equipment.

Figure 2-8 The tube is advanced through the vocal cords into the
trachea.
Figure 2-9 The tube is positioned so that the cuff is below the vocal
cords, and the laryngoscope is removed.
23. When the tube is correctly Firmly holding tube at the lips An assistant may remove the stylet
placed, continue to hold it provides stabilization and while the intubator firmly holds the
securely in place at the lips with prevents inadvertent extubation. endotracheal tube in place,
right hand while first withdrawing preventing dislodgement of the tube.
the laryngoscope blade and then
the stylet with left hand.
24. Inflate cuff with 5–10 mL of air Inflation volumes vary depending In adults, decreased mucosal capillary
depending on the manufacturer’s on manufacturer and size of tube. blood flow (ischemia) results when
recommendation. Do not Keep cuff pressure between 20 pressure is greater than 40 mm
overinflate the cuff. (Level M*) and 30 mm Hg to decrease risk of Hg.4,14
aspiration and prevent ischemia Consider using manometer to measure
and decreased blood flow.11,14 cuff pressure and increase or
decrease pressure as indicated to
achieve cuff pressure of 20–30 mm
Hg.11,14
25. Confirm endotracheal tube Ensures correct placement of
placement while manually endotracheal tube.
bagging with 100% oxygen.
A. Auscultate over epigastrium. Allows for identification of If air movement or gurgling is heard,
(Level D*) esophageal intubation.4,14 esophageal intubation has occurred.
The tube must be removed and
intubation reattempted. Improper
insertion may result in hypoxemia,
gastric distention, vomiting, and
aspiration.


B. Auscultate lung bases and Assists in verification of correct
apices for bilateral breath tube placement into the trachea. A
sounds. (Level D) right main-stem bronchus
intubation results in diminished
left-sided breath sounds.3,4
C. Observe for symmetrical chest Assists in verification of correct Absence may indicate right main stem
wall movement. (Level D) tube placement.3,4,14 or esophageal intubation.
D. Attach disposable end-tidal Disposable CO2 detectors may be CO2 detectors usually are placed
CO2 detector. Watch for color used to assist with identification between the self-inflating manual
change, which indicates the of proper tube placement.6,9,18,21 resuscitation bag-valve mask device
presence of CO2. (Level B*) Detection of CO2 confirms proper and the endotracheal tube. CO2
endotracheal tube placement into detectors should be used in
the trachea.3,4,14 conjunction with physical
assessment findings. At least five to
six exhalations with a consistent
CO2 level must be assessed to
confirm endotracheal tube placement
in the trachea because the esophagus
may yield a small but detectable
amounts of CO2 during the first few
breaths.15
or
Attach continuous end-tidal CO2 Continuous end-tidal CO2 is a At least five to six exhalations with a
monitor and watch for detection of reliable indicator of proper tube consistent CO2 level must be
CO2 (see Procedure 14). (Level B) placement and also allows for assessed to confirm endotracheal
detection of future tube tube placement in the trachea since
dislodgment.14 the esophagus may yield small but
detectable amounts of CO2 during
the first few breaths.15
or
Consider use of esophageal detection During cardiac arrest (nonperfusing
device in cardiac arrest. (Level B) rhythms), low pulmonary blood
flow may cause insufficient
expired CO2.22
If CO2 is not detected, use of an
esophageal detector device is
recommended.2,8,12,18,23
E. Evaluate oxygen saturation Spo2 decreases if the esophagus has Spo2 findings should be used in
(Spo2) with noninvasive pulse been inadvertently intubated. The conjunction with physical
oximetry. (see Procedure 18). value may or may not change in a assessment findings.
(Level D) right main-stem bronchus
intubation.4,14
26. If CO2 detection, assessment Esophageal intubation results in gas
findings, or Spo2 reveals that the flow diversion and hypoxemia.4,14
tube is not correctly positioned,
deflate cuff and remove tube
immediately. Ventilate and
hyperoxygenate with 100%
oxygen for 3–5 minutes, then
reattempt intubation, beginning
with Step 13.
*Level B: Well-designed, controlled studies with results that consistently support a specific action, intervention, or treatment.

27. If breath sounds are absent on the Absence of breath sounds on the When correctly positioned, the tube tip
left, deflate the cuff and withdraw left may indicate right main-stem should be halfway between the vocal
tube 1-2 cm. Reevaluate for intubation, which is common cords and the carina.
correct tube placement (Step 25). because of the anatomical
position of the right main-stem
bronchi.2
28. Connect endotracheal tube to Reduces motion on tube and mouth
oxygen source via self-inflating or nares.
manual resuscitation bag-valve
device, or mechanical ventilator,
using swivel adapter.
29. Insert a bite-block or Prevents the patient from biting The bite-block should be secured
oropharyngeal airway (to act as a down on the endotracheal tube. separately from the tube to prevent
bite-block) along the endotracheal dislodgment of the tube.
tube, with oral intubation if
indicated.
30. Secure the endotracheal tube in Prevents inadvertent dislodgment of Commercial tube holder or tape should
place (according to institutional tube.1,4,9,14 not cause compression on sides or
standard). (Level B*) front of the neck, which may result
in impaired venous return to the
brain.14
Consider manually holding the
endotracheal tube when moving the
patient to prevent inadvertent
dislodgement of the tube.
Use of Commercially Available Endotracheal Tube Holder
A. Apply according to Allows for secure stabilization of Commercially available tube holders
manufacturer’s directions. the tube, decreasing the are often more comfortable for
(Level M*) likelihood of inadvertent patients and easier to manage if the
extubation. endotracheal tube is manipulated.15
Use of Adhesive Tape
A. Prepare tape as shown in Fig. Use of a hydrocolloid membrane on
2-10. the patient’s cheeks helps protect
the skin.
Second piece of adhesive
Adhesive tape stuck to first piece Figure 2-10 Methods of securing adhesive tape. Example
(sticky side) (nonsticky) protocol for securing the endotracheal tube with adhesive
Tear in end tape. 1. Clean the patient’s skin with mild soap and water. 2.
of tape Remove oil from the skin with alcohol and allow to dry. 3.
Apply a skin adhesive product to enhance tape adherence.
(When the tape is removed, an adhesive remover is neces-
sary.) 4. Place a hydrocolloid membrane over the cheeks to
protect friable skin. 5. Secure with adhesive tape as shown.
(From Henneman E, Ellstrom K, St John RE: AACN protocols
for practice: Care of the mechanically ventilated patient
series, Aliso Viejo, CA, 1999, American Association of
Critical-Care Nurses, 56.)


B. Secure tube by wrapping Secures the endotracheal tube in Tape should not cause compression on
double-sided tape around place. sides or front of the neck, which
patient’s head and torn tape may impair venous return to the
edges around endotracheal brain.14
tube.
31. Reevaluate for correct tube Verifies that the tube was not
placement (Step 25). inadvertently displaced during the
securing of the tube.
32. Note position of tube at teeth or Establishes a baseline for future Common tube placement at the teeth
gums (use centimeter markings assessment of possible or gums is 20–21 cm for women and
on tube). endotracheal tube migration, in or 22–23 cm for men.10,15
out.
33. Hyperoxygenate and suction Removes secretions that may
endotracheal tube and pharynx obstruct tube or accumulate on
(see Procedure 10) as needed. the top of the cuff.
34. Confirmation of correct tube Chest radiograph documents actual Because a chest radiograph is not
position should be verified with a tube location (distance from the immediately available, it should not
chest radiograph. (Level D*) carina). be used as the primary method of
tube assessment.3,10,14
Nasotracheal Intubation
35. Follow Steps 1 through 14. Steps necessary to initiate nasal Dentures may be left in place for
intubation. nasotracheal intubation.
36. Spray nasal passage with Anesthetizes and vasoconstricts
anesthetic and vasoconstrictor, as nasal mucosa to decrease
indicated or ordered. incidence of trauma and bleeding.
37. Lubricate tube with local Allows for smooth passage of tube.
anesthetic jelly.
38. Slowly insert tube into selected Tube is introduced into airway
naris, and guide tube up from the channel.
nostril, then backward and down
into the nasopharynx.
39. Gently advance the tube until Tube is located at opening of Breath sounds become maximal just
maximal sound of moving air is trachea. before entering the glottis.
heard through the tube.
40. While listening, continue to Facilitates movement of tube Magill forceps may assist with
advance tube during inspiration. through glottic opening. advancement of tube.
41. When endotracheal tube is A properly inflated cuff will
placed, inflate cuff. (See Step 24) minimize secretion aspiration and
facilitate stabilization in the
trachea.
42. Follow Steps 25-28 and 30-34 to For nasotracheal intubation note
evaluate tube placement and position of tube at nare.
secure tube in place.
43. Remove PE . Reduces transmission of
microorganisms and body
secretions; Standard Precautions.
44. HH

• Placement of patent artificial airway • Intubation of esophagus or right main-stem bronchus
• Properly positioned and secured airway (improper tube placement)
• Improved oxygenation and ventilation • Accidental extubation
• Facilitation of secretion clearance • Cardiac dysrhythmias because of hypoxemia and
vagal stimulation
• Broken or dislodged teeth
• Leaking of air from endotracheal tube cuff
• Oral or nasal trauma with bleeding
• Tracheal injury at tip of tube or at cuff site
• Laryngeal edema
• Vocal cord trauma
• Suctioning of gastric contents or food from
endotracheal tube (aspiration)
• Obstruction of endotracheal tube

interventions.
1. Auscultate breath sounds on Allows for detection of tube • Absent, decreased, or unequal
insertion, with every manipulation movement or dislodgment. breath sounds
of the endotracheal tube and every
2–4 hours and as needed.
2. Maintain tube stability, with use of Reduces risk of movement and • Unplanned extubation
specially manufactured holder, twill dislodgment of tube.
tape, or adhesive tape.
3. Monitor and record position of tube Provides for identification of • Tube movement from original
at teeth, gums, or nose (in reference tube migration. position
to centimeter markings on tube).
4. Maintain endotracheal tube cuff Provides adequate inflation to • Cuff pressure less than 20 or
pressure of 20–30 mm Hg.11,14 decrease aspiration risk and higher than 30 mm Hg that
prevents overinflation of cuff persists despite nursing
to avoid tracheal damage.11,14 interventions.
5. Hyperoxygenate and suction Prevents obstruction of tube • Inability to pass a suction catheter
endotracheal tube, as needed (see and resulting hypoxemia. • Copious, frothy, or bloody
Procedure 10). secretions
• Significant change in amount or
character of secretions
6. Assess for pain and inadequate Allows identification of pain • Pain not controlled by medications
sedation. and/or discomfort related to or nursing interventions
the intubation. • Observed ventilator dyssynchrony
7. Inspect nares or oral cavity once Allows for the detection of • Redness, necrosis, skin breakdown
per shift while patient is intubated. skin breakdown and necrosis.
Documentation
• Patient and family education • Clinical confirmation of tube placement including
• Vital signs before, during, and after intubation, assessment of breath sounds
including oxygen saturation and end-tidal CO2. • Measurement of cuff pressure
• Size of endotracheal tube • Number of intubation attempts
• Type of intubation: oral or nasal • Use of any medications
• Type and size of blade used • Patient response to procedure
• Depth of endotracheal tube insertion in centimeters at • Occurrence of unexpected outcomes
teeth, gums, or naris • Pain assessment, interventions, and effectiveness
• Confirmation of tube placement, including chest
radiograph, end-tidal CO2 detector, and capnography
(method of placement confirmation)

2 Endotracheal Intubation (Perform) 22.e1
References 13. Kill C, et al: Videolaryngoscopy with glidescope reduces

1. Barnason S, et al: Comparison of two endotracheal tube cervical spine movement in patients with unsecured
securement techniques on unplanned extubation, oral cervical spine. J Emerg Med 44:750–755, 2013.
mucosa, and facial skin integrity. Heart Lung 27:409–417, 14. Neumar RW, et al: Part 8: Adult advanced cardiovascular
1998. life support: 2010 American Heart Association guidelines
2. Bozeman WP, et al: Esophageal detector device versus for cardiopulmonary resuscitation and emergency
detection of end-tidal carbon dioxide level in emergency cardiovascular care. Circulation 122(Suppl 3):S729–S767,
intubation. Ann Emerg Med 27:595–599, 1996. 2010.
3. Committee on Trauma: American College of Surgeons: 15. Orebaugh S, James VS: Direct laryngoscopy and tracheal
Advanced trauma life support manual: Airway and intubation in adults. In UpToDate, Wolfson AB, editor:
ventilator management, ed 9, Chicago, 2012, American UpToDate, Waltham, MA: <http://www.uptodate.com/
College of Surgeons. contents/direct-laryngoscopy-and-tracheal-intubation-in
4. Airway, airway adjuncts, oxygenation, and ventilation. In -adults>. (Accessed November 2014).
Cummins RO, editor: ACLS: principles and practice, 16. Kory P, et al: The impact of video laryngoscopy use
Dallas, 2003, American Heart Association, pp 135–180. during urgent endotracheal intubation in the critically ill.
5. De Jong A, et al: Video laryngoscopy versus direct Anesth Analg 117:144–149, 2013.
laryngoscopy for orotracheal intubation in the intensive 17. Rello J, et al: Pneumonia in intubated patients: Role of
care unit: A systematic review and meta-analysis. respiratory airway care. Am J Respir Crit Care Med
Intensive Care Med 40:629–639, 2014. 154:111–115, 1996.
6. Goldberg JS, et al: Colorimetric end-tidal carbon dioxide 18. Schaller RJ, Huff JS, Zahn A: Comparison of a
monitoring for tracheal intubation. Anesth Analg 70: colorimetric end-tidal CO2 detector and an esophageal
191–194, 1990. aspiration device for verifying endotracheal tube
7. Griesdale DE, et al: Glidescope® video-laryngoscopy placement in the prehospital setting: A six-month
versus direct laryngoscopy for endotracheal intubation: experience. Prehosp Disaster Med 12:57–63, 1997.
A systematic review and meta-analysis. Can J Anaesth 19. Sole ML, et al: Evaluation of an intervention to maintain
59:41–52, 2012. endotracheal tube cuff pressure within therapeutic range.
8. Hendey GW, et al: The esophageal detector bulb in the Am J Crit Care 20:109–118, 2011.
aeromedical setting. J Emerg Med 23:51–55, 2002. 20. Stewart C: Tracheal intubation. In Stewart C, editor:
9. Henneman E, Ellstrom E, St John RE: Airway Advanced airway management, New Jersey, 2002,
management. In AACN protocols for practice: Care of the Prentice Hall, pp 76–113.
mechanical ventilated patient series, Aliso Viejo, CA, 21. Takeda T, et al: The assessment of three methods to verify
1999, American Association of Critical-Care Nurses. tracheal tube placement in the emergency setting.
10. Holleran RS: ASTNA patent transport: Principles and Resuscitation 56:153–157, 2003.
practice, ed 4, St Louis, 2010, Mosby. 22. Varon AJ, Morrina J, Civetta JM: Clinical utility of a
11. Jailette E, et al: Optimal care and design of the tracheal colorimetric end-tidal CO2 detector in cardiopulmonary
cuff in the critically ill patients. Ann Intensive Care 4:7, resuscitation and emergency intubation. J Clin Monit
2014. 7:289–293, 1991.
12. Kasper CL, Deem S: The self-inflating bulb to detect 23. Zaleski L, Abello D, Gold MI: The esophageal detector
esophageal intubation during emergency airway device. Does it work? Anesthesiology 79:244–247,
management. Anesthesiology 88:898–902, 1998. 1993.
PROCEDURE
3
Endotracheal Intubation (Assist)
Cindy Goodrich
PURPOSE: Endotracheal intubation is performed to establish and maintain a
patent airway, facilitate oxygenation and ventilation, reduce the risk of aspiration,
and assist with the clearance of secretions.
PREREQUISITE NURSING success by providing a superior view of the glottis, com-

KNOWLEDGE pared with traditional direct laryngoscopy.5,7,16 This
method also requires minimal lifting force, resulting in
• Anatomy and physiology of the pulmonary system should less movement of the cervical spine during intubation.13
be understood. • Endotracheal tube size reflects the size of the internal
• Indications for endotracheal intubation include the diameter of the tube. Tubes range in size from 2 mm for
following15,20: neonates to 9 mm for large adults. Endotracheal tubes that
❖ Inadequate oxygenation and ventilation range in size from 7 to 7.5 mm are used for average-sized
❖ Altered mental status (e.g., head injury, drug overdose) adult women, whereas endotracheal tubes that range in
for airway protection size from 8 to 9 mm are used for average-sized adult men
❖ Anticipated airway obstruction (e.g., facial burns, epi- (see Fig. 2-2).9,10,20 The tube with the largest clinically
glottitis, major facial or oral trauma) acceptable internal diameter should be used to minimize
❖ Upper airway obstruction (e.g., from swelling, trauma, airway resistance and assist in suctioning.
tumor, bleeding) • Double-lumen endotracheal tubes are used for indepen-
❖ Apnea dent lung ventilation in situations with bleeding of one
❖ Ineffective clearance of secretions (i.e., inability to lung or a large air leak that would impair ventilation of
maintain or protect airway adequately) the good lung.
❖ High risk of aspiration • Visualization of the vocal cords can be aided by using
❖ Respiratory distress, respiratory failure laryngeal manipulation. This is accomplished by applying
• Pulse oximetry should be used during intubation so that backward, upward, and rightward pressure (BURP) on
oxygen desaturation can be quickly detected and treated the thyroid cartilage to move the larynx to the right while
(see Procedure 18).3,14 the tongue is displaced to the left by the laryngoscope
• Proper positioning of the patient is critical for successful blade.3
intubation. • Application of cricoid pressure (Sellick maneuver) may
• Two types of laryngoscope blades exist: straight and increase the success of the intubation as long as it does
curved. The straight (Miller) blade is designed so that the not interfere with ventilation or placement of the endotra-
tip extends below the epiglottis to lift and expose the cheal tube. This procedure is accomplished by applying
glottic opening. The straight blade is recommended for firm downward pressure on the cricoid ring, pushing the
use in obese patients, pediatric patients, and patients with vocal cords downward so that they are visualized more
short necks because their tracheas may be located more easily (see Fig. 2-1).When applied correctly it may protect
anteriorly. When a curved (Macintosh) blade is used, the against insufflation of the stomach and aspiration of the
tip is advanced into the vallecula (the space between the lungs. If applied incorrectly it may interfere with ventila-
epiglottis and the base of the tongue) to expose the glottic tion and make laryngoscopy intubation more difficult.
opening. Once begun, cricoid pressure must be maintained until
• Laryngoscope blades are available with bulbs or with a intubation is completed unless there is difficulty intubat-
fiberoptic light delivery system. Fiberoptic light delivery ing or ventilating the patient. The routine use of cricoid
systems provide a brighter light. Bulbs are prone to pressure is not recommended during cardiac arrest.14
becoming scratched or covered with secretions. • Endotracheal intubation can be done via nasal or oral
• Video laryngoscopy is gaining increased popularity as a routes. The route selected will depend on the skill of the
method for oral intubation. This involves using fiberoptics practitioner performing the intubation and the patient’s
or a micro video camera encased in the laryngoscope that clinical condition.
provides a wide-angle view of the glottic opening while • Nasal intubation requires a patient who is breathing spon-
attempting oral intubation. Emerging literature supports taneously and is relatively contraindicated in trauma
this highly effective tool as a method to increase first-pass patients with facial fractures or suspected fractures at the
23
base of the skull and after cranial surgeries, such as trans- • Endotracheal tube cuff pressure should be checked after
nasal hypophysectomy.3 verifying correct endotracheal tube position. The cuff
• Improper intubation technique may result in trauma to the pressure recommended for assistance in preventing both
teeth, soft tissues of the mouth or nose, vocal cords, and microaspiration and tracheal damage is 20 to 30 cm
posterior pharynx. H2O.11,17,19
• In trauma patients with suspected spinal cord injuries and • Intubation attempts should take no longer than 15 to 20
those not completely evaluated, manual in-line cervical seconds. If more than one intubation attempt is necessary,
immobilization of the head must be maintained during ventilation with 100% oxygen using a self-inflating
endotracheal intubation to keep the head in a neutral posi- manual resuscitation bag device with a tight-fitting face
tion. An assistant should be directed to manually immo- mask should be performed for 3 to 5 minutes before each
bilize the head and neck by placing his or her hands on attempt. If intubation is not successful after three attempts,
either side of the patient’s head, with thumbs along the consider using another airway adjunct, such as a laryngeal
mandible and fingers behind the head on the occipital mask airway (LMA), Combitube, or King LT Airway (see
ridge. Gentle, but firm stabilization should be maintained Procedures 1, 7, and 8).
throughout the procedure.3,10 • It is important to have a clearly defined difficult/failed
• Confirmation of endotracheal tube placement should be airway plan and alternative airway equipment available at
done immediately after intubation to protect against the bedside in case of unsuccessful intubation. This may
unrecognized esophageal intubation. This includes using consist of a gum elastic bougie, LMA, and video laryngo-
both clinical findings and end-tidal carbon dioxide scope. Surgical airway equipment such as that needed for
(CO2).3,4,14 a cricothyroidotomy should be available at the bedside in
❖ Clinical findings consistent with tracheal placement case of a failed airway.15
include visualization of the tube passing through the • Those assisting with intubation should have additional
vocal cords, absence of gurgling over the epigastric knowledge, skills, and demonstrated competence per pro-
area, auscultation of bilateral breath sounds, bilateral fessional licensure and institutional standard.
chest rise and fall during ventilation, and mist in the
tube.14,15 EQUIPMENT
❖ End-tidal CO2 detectors assist in confirming proper
placement of the endotracheal tube into the trachea (see • Personal protective equipment, including eye protection
procedure 14). The presence of CO2 in the expired air • Endotracheal tube with intact cuff and 15-mm connector
indicates that the airway has been successfully intu- (women, 7-mm to 7.5-mm tube; men, 8-mm to 9-mm
bated, but does not ensure the correct position of the tube)
endotracheal tube. • Laryngoscope handle with fresh batteries
❖ Disposable end-tidal CO2 detectors are chemically • Laryngoscope blades (straight and curved)
treated with a nontoxic indicator that changes color in • Spare bulb for laryngoscope blades
the presence of CO2. • Flexible stylet
❖ Continuous end-tidal CO2 (capnography) assists in • Magill forceps (to remove foreign bodies obstructing the
confirming proper placement of the endotracheal tube airway if present)
into the trachea as well as allowing for detection of • Self-inflating manual resuscitation bag-valve-mask device
future tube dislodgment. with tight fitting face mask connected to supplemental
❖ During cardiac arrest (nonperfusing rhythms), low pul- oxygen (15 L/min)
monary blood flow may cause insufficient expired • Oxygen source
CO2.22 If CO2 is not detected, use of an esophageal • Luer-tip 10-mL syringe for cuff inflation
detector device is recommended for confirmation of • Water-soluble lubricant
proper placement into the trachea.2,3,14,18,23 • Rigid pharyngeal suction-tip (Yankauer) catheter
❖ At least five to six exhalations with a consistent CO2 • Suction apparatus (portable or wall)
level must be assessed to confirm endotracheal tube • Suction catheters
placement in the trachea because the esophagus may • Bite-block or oropharyngeal airway
yield a small but detectable amount of CO2 during the • Endotracheal tube–securing apparatus or appropriate tape
first few breaths.15 ❖ Commercially available endotracheal tube holder
❖ Esophageal detector devices work by creating suction ❖ Adhesive tape (6 to 8 inches long)
at the end of the endotracheal tube by compressing a • Stethoscope
flexible bulb or pulling back on a syringe plunger. • Monitoring equipment: cardiac monitor, pulse oximetry,
When the tube is placed correctly in the trachea, air and sphygmomanometer
allows for reexpansion of the bulb or movement of the • Disposable end-tidal CO2 detector, continuous end-tidal
syringe plunger. If the tube is located in the esophagus, CO2 monitoring device, and esophageal detection device
no movement of the syringe plunger or reexpansion of • Drugs for intubation as indicated (induction agent, seda-
the bulb is seen. These devices may be misleading in tion, paralyzing agents, lidocaine, atropine)
patients who are morbidly obese, in status asthmaticus, • Assortment of oropharyngeal airways and nasopharyngeal
late in pregnancy, or in patients with large amounts of airways
tracheal secretions.14 • Rescue airways such as LMA, King LT, or Combitube
3 Endotracheal Intubation (Assist) 25
• Failed airway equipment: gum elastic bougie, video laryn- • Assess level of consciousness, level of anxiety, and
goscope, optical stylet fiberoptic scope, and cricothyroid- respiratory difficulty. Rationale: This assessment deter-
otomy kit mines the need for sedation or the use of paralytic agents
Additional equipment, to have available as needed, includes and the patient’s ability to lie flat and supine for
the following: intubation.
• Anesthetic spray (nasal approach) • Assess oral cavity for presence of dentures, loose teeth,
• Local anesthetic jelly (nasal approach) or other possible obstructions and remove if appropriate.
• Ventilator Rationale: Ensures that the airway is free from any
obstructions.
PATIENT AND FAMILY EDUCATION • Assess vital signs and assess for the following: tachypnea,
dyspnea, shallow respirations, cyanosis, apnea, altered
• If time permits, assess the patient’s and the family’s level of consciousness, tachycardia, cardiac dysrhythmias,
level of understanding about the condition and rationale hypertension, and headache. Rationale: Any of these
for endotracheal intubation. Rationale: This assessment conditions may indicate a problem with oxygenation or
identifies the patient’s and the family’s knowledge deficits ventilation or both.
concerning the patient’s condition, the procedure, the • Assess patency of nares (for nasal intubation). Rationale:
expected benefits, and the potential risks. It also allows Selection of the most appropriate naris facilitates insertion
time for questions to clarify information and voice con- and may improve patient tolerance of the tube.
cerns. Explanations decrease patient anxiety and enhance • Assess need for premedication. Rationale: Various medi-
cooperation. cations provide sedation or paralysis of the patient as
• Explain the procedure and the reason for intubation, if the needed.
clinical situation permits. If not, explain the procedure and
reason for the intubation after it is completed. Rationale: Patient Preparation
This explanation enhances patient and family understand- • Perform a preprocedure verification and time out. Ratio-
ing and decreases anxiety. nal: Ensures patient safety.
• If indicated and the clinical situation permits, explain the • Ensure that the patient understands preprocedural teach-
patient’s role in assisting with insertion of the endotra- ing, if appropriate. Answer questions as they arise, and
cheal tube. Rationale: This explanation elicits the patient’s reinforce information as needed. Rationale: Understand-
cooperation, which assists with insertion. ing of previously taught information is evaluated and
• Explain that the patient will be unable to speak while the reinforced.
endotracheal tube is in place but that other means of com- • Before intubation, initiate intravenous or intraosseous
munication will be provided. Rationale: This information access. Rationale: Readily available intravenous or
enhances patient and family understanding and decreases intraosseous access may be necessary if the patient needs
anxiety. to be sedated or paralyzed or needs other medications
• Explain that the patient’s hands are often immobilized to because of a negative response to the intubation
prevent accidental dislodgment of the tube. Rationale: procedure.
This information enhances patient and family understand- • Position the patient appropriately.
ing and decreases anxiety. ❖ Positioning of the nontrauma patient is as follows:
Place the patient supine with the head in the sniffing
position, in which the head is extended and the neck is
PATIENT ASSESSMENT AND flexed. Placement of a small towel under the occiput
PREPARATION elevates it several inches, allowing for proper flexion
of the neck (see Fig. 2-3). Rationale: Placement of the
Patient Assessment head in the sniffing position allows for better visualiza-
• Verify correct patient with two identifiers. Rationale: tion of the larynx and vocal cords by aligning the axes
Prior to performing a procedure, the nurse should ensure of the mouth, pharynx, and trachea.
the correct identification of the patient for the intended ❖ Positioning of the trauma patient is as follows: Manual
intervention. in-line cervical spinal immobilization must be main-
• Assess for recent history of trauma with suspected spinal tained during the entire process of intubation. Ratio-
cord injury or cranial surgery. Rationale: Knowledge of nale: Because cervical spinal cord injury must be
pertinent patient history allows for selection of the most suspected in all trauma patients until proved otherwise,
appropriate method for intubation, which helps reduce the this position helps prevent secondary injury should a
risk of secondary injury. cervical spine injury be present.
• Assess nothing-by-mouth status, the use of a self-inflating • Premedicate as indicated. Rationale: Appropriate pre-
manual resuscitation bag-valve device with mask before medication allows for more controlled intubation, reduc-
intubation, and for signs of gastric distention. Rationale: ing the incidence of insertion trauma, aspiration,
Increased risk of aspiration and vomiting occurs with laryngospasm, and improper tube placement.
accumulation of air (from the use of a self-inflating • As appropriate, notify the respiratory therapy department
manual resuscitation bag-valve-mask device), food, or of impending intubation so that a ventilator can be set up.
secretions. Rationale: The ventilator is set up before intubation.
Procedure for Performing Endotracheal Intubation

General Setup
1. HH Reduces the transmission of Protective eyewear should be worn by
microorganisms and body all individuals involved in the
secretions. Standard Precautions. intubation, including those who are
assisting, to avoid exposure to
secretions.
2. PE
3. Establish intravenous or Provides access to deliver
intraosseous access if not present. indicated medications.
4. Attach patient to monitoring Provides continuous patient
equipment, including cardiac and monitoring during intubation.
blood pressure monitor and pulse
oximeter.
5. Set up suction apparatus, and Prepares for oropharyngeal
connect rigid suction-tip catheter to suctioning as needed.
tubing.
6. Check equipment as directed by
individual performing the intubation.
A. Gather appropriate-sized Appropriate-sized endotracheal Generally a 7–7.5-mm internal
endotracheal tube. tubes facilitate both intubation diameter tube is used for adult
and ventilation. females and an 8–9-mm internal
diameter for adult males.9,10,14,20
B. Use 10-mL syringe to inflate cuff Verifies that equipment is Once the endotracheal tube cuff has
on tube, assessing for leaks. functional and that tube cuff is been checked for leak and it is
Completely deflate cuff. patent without leaks; prepares completely deflated, place back into
tube for insertion. its packaging to avoid
contamination.
C. Insert the stylet into the Provides structural support for the Stylet must be recessed by at least 0.5
endotracheal tube, ensuring that flexible endotracheal tube during inch from the distal end of the tube
the tip of the stylet does not insertion. Maintaining the tip of so that it does not protrude beyond
extend past the end of the the stylet within the lumen of the end of the tube.
endotracheal tube. the endotracheal tube prevents
damage to the vocal cords and
trachea.
D. Connect the laryngoscope blade Verifies that the equipment is Check the bulb for brightness.
to the handle, and ensure the functional. Replace bulb if dull or burnt out.
blade’s bulb is securely seated.
7. Assist in positioning the patient’s Allows for visualization of the The ear (external auditory meatus) and
head by flexing the neck forward vocal cords with alignment of sternal notch should be aligned
and extending the head, into the the mouth, pharynx, and trachea. when patient is examined from the
sniffing position (only if neck side. This allows for flexion of the
trauma is not suspected; see Fig. cervical spine.15 Placement of a
2-3). If spinal trauma is suspected, small towel under the occiput
assist in maintaining the head in a elevates it, allowing for proper neck
neutral position with in-line spinal flexion. Do not flex or extend neck
immobilization. This is performed of patient with suspected spinal cord
by manually immobilizing the head injury; the head must be maintained
and neck by placing your hands on in a neutral position with manual
either side of the patient’s head, in-line cervical spine
with thumbs along the mandible and immobilization.3
fingers behind the head on the
occipital ridge. Use gentle but firm
stabilization throughout the
procedure.3,10 (Level D*)

8. Check the mouth for dentures and Dentures should be removed
remove if present. before oral intubation is
attempted but may remain in
place for nasal intubation.
9. Suction the mouth and pharynx as Provides for a clear view of the
needed if copious secretions are posterior pharynx and larynx.
visualized.
10. Insert oropharyngeal airway if Assists in maintenance of upper Use only in unconscious patients with
indicated (see Procedure 9). airway patency. Helps to an absent gag reflex.
improve ability to ventilate
during bag-valve-mask
ventilation.
11. Preoxygenate for 3–5 minutes, with Helps prevent hypoxemia. Gentle Bag-valve-mask ventilation may not
100% oxygen via a nonrebreather breaths reduce incidence of air be needed in the spontaneous
mask if ventilations are adequate or entering stomach (leading to breathing patient. Avoid aggressive
via a self-inflating manual gastric distention, aspiration), positive-pressure ventilation with a
resuscitation bag-valve-mask device decrease airway turbulence, and self-inflating manual resuscitation
(see Procedure 31) if ventilations distribute ventilation more bag because this may increase the
are inadequate. (Level D*) evenly within the lungs. risk for gastric vomiting.
Preoxygenation ensures that
nitrogen is washed out of the
lungs and will extend the
allowable apneic time until the
oxygen in the lungs is used
up.4,15
12. Premedicate patient as directed by Sedates and relaxes the patient, This may require a second assistant
the practitioner intubating the allowing easier intubation. to administer and document
patient. medications given before, during,
and after intubation.
13. Remove oropharyngeal airway if Clears the airway for advancement
present. of the laryngoscope blade and
endotracheal tube.
14. Have self-inflating manual Intubation attempts should not If intubation is unsuccessful within 30
resuscitation bag-valve-mask device take longer than 30 seconds. seconds, or the patient’s oxygen
connected to 100% oxygen source Patients need to be saturations falls below 90% during
and face mask ready for hyperoxygenated and ventilated the attempt, remove the tube.15
hyperoxygenation and manual between intubation attempts.3,4 Ventilate with 100% oxygen with a
ventilation. bag-valve-mask device before
another intubation attempt is made.
Before reattempting intubation,
correct problems related to
positioning, procedure, or equipment
15. Apply external laryngeal External laryngeal manipulation In some cases, the intubator may
manipulation (BURP) and/or cricoid (BURP) may assist with perform BURP manipulation by
pressure ONLY as directed by the visualization of the vocal cords.3 him- or herself to initially visualize
practitioner performing the Apply BURP on the thyroid the vocal cords. The assistant should
intubation. cartilage to move the larynx to be prepared to take over for the
the right while the tongue is intubator once the cords are
displaced to the left by the visualized. Once cricoid pressure
laryngoscope blade.3 Cricoid (Sellick maneuver) is applied, it
pressure moves the trachea must be maintained until the
toward the posterior, which may intubation is completed. The
provide better visualization of intubator may request the assistant to
the vocal cords by the retract the corner of the patient’s
practitioner. right lip to increase the field of view.


16. Once the tube has been correctly Inflation volumes vary depending In adults, decreased mucosal capillary
placed, assist with cuff inflation as on manufacturer and size of blood flow (ischemia) results when
directed. Inflate cuff with 5–10 mL tube. Keep cuff pressure pressure is greater than
of air depending on the between 20 and 30 mm Hg to 40 mm Hg.4,14 Consider using a
manufacturer’s recommendations. decrease risk of aspiration and manometer to measure cuff pressure
Do not overinflate the cuff. prevent ischemia and decreased and increase or decrease pressure as
blood flow.11,14 indicated to achieve cuff pressure of
20–30 mm Hg.
17. Once endotracheal tube has been Ensures correct placement of If requested, hold the endotracheal
placed, assist with confirmation of endotracheal tube into trachea. tube securely at the lip, making note
tube placement as directed by the of how far tube has been placed into
intubator. Continue ventilating with trachea by noting markings on
100% O2 self-inflating manual endotracheal tube. Avoid
resuscitation bag. hyperventilation; gently ventilate
with 10–12 breaths per minute
watching for visible chest rise.4,14
A. Auscultate over epigastrium. Allows for identification of If air movement or gurgling is heard,
(Level D*) esophageal intubation.4,14 esophageal intubation has occurred.
The tube must be removed and
intubation reattempted. Improper
insertion may result in hypoxemia,
gastric distention, vomiting, and
aspiration.
B. Auscultate lung bases and apices Assists in verification of correct
for bilateral breath sounds. tube placement into the trachea.
(Level D) A right main-stem bronchus
intubation results in diminished
left-sided breath sounds.3,4
C. Observe for symmetrical chest Assists in verification of correct Absence may indicate right main-stem
wall movement. (Level D) tube placement.3,4,14 or esophageal intubation.
D. Attach disposable end-tidal CO2 Disposable CO2 detectors may be CO2 detectors usually are placed
detector. Watch for color change, used to assist with identification between the self-inflating manual
which indicates the presence of of proper tube placement.6,9,18,21 resuscitation bag-valve device and
CO2. (Level B*) Detection of CO2 confirms the endotracheal tube. CO2 detectors
proper endotracheal tube should be used in conjunction with
placement into the trachea.3,4,14 physical assessment findings. At
least five to six exhalations with a
consistent CO2 level must be
assessed to confirm endotracheal
tube placement in the trachea
because the esophagus may yield
small but detectable amounts of CO2
during the first few breaths.15
or
Attach continuous end-tidal CO2 monitor Continuous end-tidal CO2 is a At least five to six exhalations with a
and watch for detection of CO2 (see reliable indicator of proper tube consistent CO2 level must be
Procedure 14). (Level B) placement and also allows for assessed to confirm endotracheal
detection of future tube tube placement in the trachea
dislodgment.14 because the esophagus may yield
small but detectable amounts of CO2
during the first few breaths.15

Or
Consider use of esophageal detection During cardiac arrest
device in cardiac arrest. (Level B*) (nonperfusing rhythms), low
pulmonary blood flow may
cause insufficient expired CO2.22
If CO2 is not detected, use of an
esophageal detector device is
recommended.2,8,12,18,23
E. Evaluate oxygen saturation Spo2 decreases if the esophagus Spo2 findings should be used in
(Spo2) with noninvasive pulse has been inadvertently intubated. conjunction with physical
oximetry (see Procedure 18). The value may or may not assessment findings.
(Level D*) change in a right main-stem
bronchus intubation.4,14
18. If CO2 detection, assessment Esophageal intubation results in
findings, or Spo2 reveals that the gas flow diversion and
tube is not correctly positioned, hypoxemia.4,11
deflate cuff and assist with tube
removal as directed by the intubator.
Ventilate and hyperoxygenate with
100% oxygen for 3–5 minutes, then
assist with reattempt at intubation,
beginning with Step 11.
19. If breath sounds are absent on the Absence of breath sounds on the When correctly positioned, the tube tip
left, cuff should be deflated and left may indicate right main- should be halfway between the
withdrawn by 1–2 cm. Reevaluate stem intubation, which is vocal cords and the carina.2
for correct tube placement (Step 17) common because of the
as directed by the intubator. anatomical position of the right
main-stem bronchi.
20. Connect endotracheal tube to Reduces motion on tube and
oxygen source via self-inflating mouth or nares.
manual resuscitation bag-valve
device, or mechanical ventilator,
using swivel adapter.
21. Insert a bite-block or oropharyngeal Prevents the patient from biting The bite-block should be secured
airway (to act as a bite-block) along down on the endotracheal tube. separately from the tube to prevent
the endotracheal tube, with oral dislodgment of the tube.
intubation if indicated.
22. Secure the endotracheal tube in Prevents inadvertent dislodgment Commercial tube holder or tape
place as directed (according to of tube.1,4,9,14 should not cause compression on
institutional standard). (Level B) sides or front of the neck, which
may impair venous return to the
brain.14 Consider manually holding
the endotracheal tube when moving
the patient to prevent inadvertent
dislodgement of the tube.
Use of Commercially Available Endotracheal Tube Holder
A. Apply according to Allows for secure stabilization of Commercially available tube holders
manufacturer’s directions. the tube, decreasing the are often more comfortable for
(Level M*) likelihood of inadvertent patients and easier to manage if the
extubation. endotracheal tube is manipulated.15


Use of Adhesive Tape
A. Prepare tape as shown in Use of a hydrocolloid membrane
Fig. 2-10. on the patient’s cheeks helps
protect the skin.
B. Secure tube by wrapping Secures the endotracheal tube in Tape should not cause compression on
double-sided tape around place. sides or front of the neck, which
patient’s head and torn tape may impair venous return to the
edges around endotracheal tube. brain.14
23. Reevaluate for correct tube Verifies that the tube was not
placement (Step 17). inadvertently displaced during
the securing of the tube.
24. Note position of tube at teeth or Establishes a baseline for future Common tube placement at the teeth
gums (use centimeter markings on assessment of possible or gums is 20–21 cm for women
tube). endotracheal tube migration, in and 22–23 cm for men.10,15
or out.
25. Hyperoxygenate and suction Removes secretions that may
endotracheal tube and pharynx (see obstruct tube or accumulate on
Procedure 10) as needed. the top of the cuff.
26. Confirmation of correct tube Chest radiograph documents actual
position should be verified with a tube location (distance from the
chest radiograph. (Level D*) carina). Because a chest
radiograph is not immediately
available, it should not be used
as the primary method of tube
assessment.3,10,14
27. Remove PE . Reduces transmission of
microorganisms and body
28. HH

• Placement of patent artificial airway • Intubation of esophagus or right main-stem bronchus
• Properly positioned and secured airway (improper tube placement)
• Improved oxygenation and ventilation • Accidental extubation
• Facilitation of secretion clearance • Cardiac dysrhythmias because of hypoxemia and
vagal stimulation
• Broken or dislodged teeth
• Leaking of air from endotracheal tube cuff
• Oral or nasal trauma with bleeding
• Tracheal injury at tip of tube or at cuff site
• Laryngeal edema
• Vocal cord trauma
• Suctioning of gastric contents or food from
endotracheal tube (aspiration)
• Obstruction of endotracheal tube

interventions.
1. Auscultate breath sounds on Allows for detection of tube • Absent, decreased, or unequal
insertion, with every movement or dislodgment. breath sounds
manipulation of the endotracheal
tube and every 2–4 hours.
2. Maintain tube stability, with use Reduces risk of movement and • Unplanned extubation
of specially manufactured holder, dislodgment of tube.
twill tape, or adhesive tape.
3. Monitor and record position of Provides for identification of • Tube movement from original
tube at teeth, gums, or nose (in tube migration. position
reference to centimeter markings
on tube).
4. Maintain endotracheal tube cuff Provides adequate inflation to • Cuff pressure less than 20 or
pressure of 20–30 mm Hg.11,14 decrease aspiration risk and higher than 30 mm Hg that
prevents overinflation of cuff persists despite nursing
to avoid tracheal damage.11,14 interventions.
5. Hyperoxygenate and suction Prevents obstruction of tube • Inability to pass a suction catheter
endotracheal tube, as needed (see and resulting hypoxemia. • Copious, frothy, or bloody
Procedure 10). secretions
• Significant change in amount or
character of secretions
6. Assess for pain and inadequate Allows identification of pain • Pain not controlled by medications
sedation. and/or discomfort related to or nursing interventions
the intubation. • Observed ventilator dyssynchrony
7. Inspect nares or oral cavity once Allows for the detection of skin • Redness, necrosis, skin breakdown
per shift while patient is breakdown and necrosis.
intubated.
Documentation
• Patient and family education • Clinical confirmation of tube placement including
• Vital signs before, during, and after intubation, assessment of breath sounds
including oxygen saturation and end-tidal CO2 • Measurement of cuff pressure
• Size of endotracheal tube • Number of intubation attempts
• Type of intubation: oral or nasal • Use of any medications
• Type and size of blade used • Patient response to procedure
• Depth of endotracheal tube insertion centimeters at • Occurrence of unexpected outcomes
teeth, gums, or naris • Pain assessment, interventions, and effectiveness
• Confirmation of tube placement, including chest
radiograph, end-tidal CO2 detector, capnography
(method of placement confirmation)

3 Endotracheal Intubation (Assist) 31.e1
References 13. Kill C, et al: Videolaryngoscopy with glidescope reduces

1. Barnason S, et al: Comparison of two endotracheal tube cervical spine movement in patients with unsecured
securement techniques on unplanned extubation, oral cervical spine. J Emerg Med 44(4):750–755, 2013.
mucosa, and facial skin integrity. Heart Lung 27:409–417, 14. Neumar RW, et al: Part 8: Adult advanced cardiovascular
1998. life support: 2010 American Heart Association guidelines
2. Bozeman WP, et al: Esophageal detector device versus for cardiopulmonary resuscitation and emergency
detection of end-tidal carbon dioxide level in emergency cardiovascular care. Circulation 122(Suppl 3):S729–S767,
intubation. Ann Emerg Med 27:595–599, 1996. 2010.
3. Committee on Trauma: American College of Surgeons: 15. Orebaugh S, James VS: Direct laryngoscopy and tracheal
Advanced trauma life support manual: Airway and intubation in adults. In UpToDate, Wolfson AB, editors:
ventilator management, ed 9, Chicago, 2012, American UpToDate, Waltham, MA, 2016. <http://www.uptodate
College of Surgeons. .com/contents/direct-laryngoscopy-and-tracheal-intubation
4. Cummins RO, editor: Airway, airway adjuncts, -in-adults>. (Accessed 11.14).
oxygenation, and ventilation. In ACLS: principles and 16. Kory P, et al: The impact of video laryngoscopy use
practice, Dallas, 2003, American Heart Association, during urgent endotracheal intubation in the critically ill.
pp 135–180. Anesth Analg 117:144–149, 2013.
5. De Jong A, et al: Video laryngoscopy versus direct 17. Rello J, et al: Pneumonia in intubated patients: Role of
laryngoscopy for orotracheal intubation in the intensive respiratory airway care. Am J Respir Crit Care Med
care unit: A systematic review and meta-analysis. 154:111–115, 1996.
Intensive Care Med 40:629–639, 2014. 18. Schaller RJ, Huff JS, Zahn A: Comparison of a
6. Goldberg JS, et al: Colorimetric end-tidal carbon dioxide colorimetric end-tidal CO2 detector and an esophageal
monitoring for tracheal intubation. Anesth Analg 70: aspiration device for verifying endotracheal tube
191–194, 1990. placement in the prehospital setting: A six-month
7. Griesdale DE, et al: Glidescope® video-laryngoscopy experience. Prehosp Disaster Med 12:57–63, 1997.
versus direct laryngoscopy for endotracheal intubation: 19. Sole ML, et al: Evaluation of an intervention to maintain
A systematic review and meta-analysis. Can J Anaesth endotracheal tube cuff pressure within therapeutic range.
59(1):41–52, 2012. Am J Crit Care 20(2):109–118, 2011.
8. Hendey GW, et al: The esophageal detector bulb in the 20. Stewart C: Tracheal intubation. In Stewart C, editor:
aeromedical setting. J Emerg Med 23:51–55, 2002. Advanced airway management, New Jersey, 2002,
9. Henneman E, Ellstrom E, St John RE: Airway Prentice Hall, pp 76–113.
management. In AACN protocols for practice: Care of the 21. Takeda T, et al: The assessment of three methods to verify
mechanical ventilated patient series, Aliso Viejo, CA, tracheal tube placement in the emergency setting.
1999, American Association of Critical-Care Nurses. Resuscitation 56:153–157, 2003.
10. Holleran RS: ASTNA patent transport: Principles and 22. Varon AJ, Morrina J, Civetta JM: Clinical utility of a
practice, ed 4, St Louis, 2010, Mosby. colorimetric end-tidal CO2 detector in cardiopulmonary
11. Jailette E, et al: Optimal care and design of the tracheal resuscitation and emergency intubation. J Clin Monit
cuff in the critically ill patients. Ann Intensive Care 4:7, 7:289–293, 1991.
2014. 23. Zaleski L, Abello D, Gold MI: The esophageal detector
12. Kasper CL, Deem S: The self-inflating bulb to detect device. Does it work? Anesthesiology 79:244–247, 1993.
esophageal intubation during emergency airway
management. Anesthesiology 88:898–902, 1998.
PROCEDURE
4
Endotracheal Tube Care
and Oral Care Practices
for Ventilated and
Non-ventilated Patients
Kathleen Vollman, Mary Lou Sole, and Barbara Quinn
PURPOSE: Endotracheal tube (ETT) management and oral care are performed to
prevent buccal, oropharyngeal, and tracheal trauma from the tube and cuff; to
provide oral hygiene; to promote ventilation; and to decrease the risk of ventilator-
associated pneumonia (VAP) and hospital-acquired pneumonia.
PREREQUISITE NURSING • VAP and HAP increase not only ventilator and intensive
KNOWLEDGE care unit (ICU) days and hospital length of stay, but also
overall morbidity and mortality of the patient.3,10,31,39,64
• Anatomy and physiology of the pulmonary system should • Oral hygiene:
be understood. ❖ Anatomy and physiology of the oral cavity and the
• ETTs are used to maintain a patent airway or to facilitate importance of evidence-based oral hygiene procedures
mechanical ventilation. The presence of artificial airways, on a regular basis should be understood.4,17,18,20,34,53,60
especially ETTs, prevents effective coughing and secre- ❖ The oral cavity is a significant source of bacterial
tion removal, necessitating periodic removal of pulmo- colonization. Within 48 hours of admission to the
nary secretions with suctioning; serves as a direct portal hospital, the normal oral flora changes to include
for microorganisms; and significantly increases the risk respiratory pathogens not normally found in healthy
for pneumonia. They also increase the risk for the devel- individuals.24
opment of VAP.22,31,56 ❖ Salivary flow is a natural host defense in facilitating
• Suctioning of airways should be performed only for the removal of plaque and microorganisms. The major
clinical indications and not as a routine fixed-schedule immune factor in saliva is immunoglobulin A (IgA).
treatment (see Procedure 10). In acute-care situations, Its role is to protect the upper airway by limiting the
suctioning is performed as a sterile procedure to prevent absorption and penetration of microorganisms.18
healthcare-acquired pneumonia.55 ❖ Mechanical ventilation often promotes dry mouth or
• Adequate systemic hydration and supplemental humidifi- reduced salivary flow, contributing to plaque accumu-
cation of inspired gases assist in thinning secretions for lation and decreased production of salivary immune
easier aspiration from airways.31,57 The oropharynx and factors.11
the upper gastrointestinal tract are the main reservoirs for ❖ Certain medications as well as withholding food and
pathogens associated with VAP and hospital-acquired oral fluids may also contribute to dry mouth in all
pneumonia (HAP). Micro aspiration of this oral bacteria patients, including those not on a ventilator.
can result in VAP and HAP.16,18,19,31,42 ❖ The equipment used to remove oral secretions as well
• Appropriate cuff management (see Procedure 13) helps as suctioning of the ETT may contribute to the coloni-
prevent major aspirations of pulmonary secretions, pre- zation of the oral cavity.5,52
pares for tracheal extubation, and decreases the risk of • Oral care practices for ventilator patients:
iatrogenic infections.31 ❖ Tooth brushing is an essential component of an effec-
• Constant pressure from the ETT on the mouth or nose can tive oral care program; however, evidence related to
cause skin breakdown. prevention of VAP is not conclusive.1
• If the patient is anxious or uncooperative, use of two ❖ Foam swabs are limited in their ability to remove
caregivers for retaping and/or repositioning the ETTs may plaque from sheltered areas or between teeth. Brushing
help prevent accidental dislodgment of the tube. is able to clean the proximal sites and crevices.43
32
4 Endotracheal Tube Care and Oral Care Practices for Ventilated and Non-ventilated Patients 33
Mouthwashes while having beneficial antibacterial

❖ • Two sources of suction or a bifurcated connection device
properties, frequently contain alcohol which can dry attached to a single suction source
the oral tissues.18 • Connecting tube(s) (4 to 6 feet)
❖ Use of chlorhexidine oral rinse (CHG) twice daily • Nonsterile gloves
should be part of a comprehensive oral care program • Stethoscope
for ventilated patients to reduce the incidence of
VAP.33,50 PATIENT AND FAMILY EDUCATION
❖ Effect of povidone-iodine as an oral cleanser to reduce
VAP remains unclear.33 • Explain the procedure to the patient and family, including
❖ Oral care given every 2 to 4 hours appears to provide the purpose of ETT care and the importance of compre-
a greater improvement in oral health. If oral care is not hensive oral care in prevention of infection in both intu-
provided for 4 to 6 hours, previous benefits are thought bated and non-intubated patients.1 Rationale: This step
to be lost.13 identifies patient and family knowledge deficits concern-
• Oral care practices for non-ventilated patients: ing patient condition, procedure, expected benefits, and
❖ Patients not on a ventilator are still at risk for pneumo- potential risks and allows time for questions to clarify
nia, and studies indicate that oral care can reduce this information and voice concerns. Explanations decrease
risk. Currently, non-ventilator HAP occurs more often patient anxiety and enhance cooperation.
than VAP, with similar mortality rates, costing more • If indicated, explain the patient’s role in assisting with
lives and dollars than VAP.10 ETT care. Rationale: Eliciting the patient’s cooperation
❖ Brushing teeth after each meal and a weekly review by assists with care.
a dentist or hygienist can reduce the incidence of pneu- • Explain that the patient will be unable to speak while the
monia in elderly patients, resulting in fewer days with ETT is in place but that other means of communication
fever and lower mortality rates.63 will be provided. Rationale: This information enhances
❖ Not only can enhanced oral care reduce pneumonia in patient and family understanding and decreases anxiety.
nursing home residents, it may also improve swallow • Explain that the patient’s hands may be immobilized to
and cough reflex sensitivities, factors that could also prevent accidental dislodgment of the tube. Rationale:
help to prevent pneumonia.62 This information enhances patient and family understand-
❖ Increased frequency of oral care for non-ventilated ing and decreases anxiety.
adult patients in an acute-care hospital reduced non-
ventilated HAP by 37% over 12 months.45
❖ There are no documented studies that show the optimal PATIENT ASSESSMENT AND
frequency of oral care for non-ventilated patients. For PREPARATION
the general public, the American Dental Association
recommends brushing twice daily with a soft-bristled Patient Assessment
toothbrush using therapeutic toothpaste, and rinsing • Verify correct patient with two identifiers. Rationale:
with an antiseptic rinse.2 Prior to performing a procedure, the nurse should ensure
❖ If a non-ventilated patient cannot manage oral secre- the correct identification of the patient for the intended
tions and is at high risk for aspiration, the caregiver intervention.
may consider using a suction toothbrush, similar to • Assess for signs and symptoms that indicate that oral
those used in the ventilated-patient setting.46 cavity and ETT care is necessary. Rationale: Assessment
provides for early recognition that oral or ETT care is
EQUIPMENT needed.
❖ Excessive secretions (oral or tracheal)
• Goggles or glasses and mask ❖ Dry oral mucosa
• Bite-block or oral airway if needed ❖ Debris in the oral cavity
• Adhesive or twill tape; commercial ETT holder (design ❖ Plaque buildup on teeth
must ensure ability to provide oral care and suctioning) ❖ Soiled tape or ties or commercial device
• 2 × 2 gauze or cotton swab for cleaning around the ❖ Patient biting or kinking tube
nares ❖ Pressure areas on nares, corner of mouth, or tongue
• Normal saline solution ❖ ETT moving in and out of mouth
• Soft pediatric/adult toothbrush or suction toothbrush ❖ Patient able to verbalize or audible air leak around ETT
• Foam oral swab or oral suction swab • Assess level of consciousness and level of anxiety. Ratio-
• Oral cleansing solution (e.g., 1.5% H2O2,7,18,28,38,49,51 nale: This assessment determines the need for pain medi-
chlorhexidine,7,12,21,26,27,30,32,33,50,58,59 cetylpyridinium chlo- cation or sedation during ETT care and the number of care
ride,7,37,48,56 toothpaste13,29,32,43) providers needed to perform the activities.
Additional equipment, to have available as needed, includes
the following: Patient Preparation
• Suction catheter for oral and nasal suctioning (single-use • Ensure that the patient understands preprocedural teach-
Yankauer, covered Yankauer, disposable oral saliva ings. Answer questions as they arise and reinforce infor-
ejector) mation as needed. Rationale: This process evaluates
and reinforces understanding of previously taught (≥60 degrees) position or the most comfortable position
information. for both the patient and nurse before performing the care.
• Maintain the patient in a semi-Fowler’s (≥30 degrees) Rationale: This position promotes comfort and reduces
position during mechanical ventilation to reduce the risk physical strain and maintains head of bed elevation to
of aspiration.15,31,59 Assist the patient to a high Fowler’s reduce risk of aspiration.15,31,59
Procedure for Endotracheal Tube and Oral Care for Ventilated Patients
1. HH
2. PE
3. Ensure that ETT is connected to Decreases pressure exerted by
the ventilator with a swivel ventilator tubing on the ETT,
adapter. thereby minimizing risk of pressure
ulceration.
4. Support the ETT and tubing as Prevents inadvertent displacement or If the patient is at risk for
needed. dislodgement of the tube. inadvertent or sudden
movements, obtain an assistant
to manually support the ETT
and tubing.
5. If suctioning is clinically Removes secretions that may obstruct Suctioning of airways should be
indicated,55 hyperoxygenate via tube. performed only for a clinical
the ventilator before ETT suction indication and not as a routine
and between attempts (see fixed-schedule treatment.55
Procedure 10).
6. If patient is nasally intubated, Removes secretions that could cause The Society for Healthcare
clean around ETT with saline pressure and subsequent skin Epidemiology of America
solution–soaked gauze or cotton breakdown. (SHEA) compendium and The
swabs. Centers for Disease Control and
Prevention (CDC) guidelines for
prevention of VAP recommend
that patients intubated nasally be
reintubated orally as soon as
possible to reduce the risk of
VAP.31,57
7. If patient is intubated orally, The bite-block or oropharyngeal The bite-block should be secured
remove bite-block or airway prevents the patient from separately from the tube to
oropharyngeal airway (acting as biting down on the ETT and prevent dislodgment of the ETT.
bite-block) before proceeding occluding airflow. The bite-block or ETT securing
with oral hygiene. mechanism may be a barrier to
providing good oral care.
8. Initiate oral hygiene with a Mechanical cleansing and oral hygiene Pediatric or soft-bristle
pediatric or adult (soft) reduce oropharyngeal colonization toothbrushes may be easier to
toothbrush, at least twice a day. and dental plaque, which is use in adult intubated
Gently brush patient’s teeth to associated with VAP.16,35,36,43,45,47,48 patients.39,45,60
clean and remove plaque from Toothpaste or cleansing solution
teeth. Suction oropharyngeal should contain additives that assist
secretions after brushing. Use in the breakdown of mucus in the
toothpaste or a cleansing solution mouth. Sodium bicarbonate assists
that assists in the breakdown of in removal of debris accumulation
debris (Level C*).4,9,23,25,28,35,45,54,58 on oral tissue and teeth.18
*Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results.
Procedure for Endotracheal Tube and Oral Care for Ventilated Patients—Continued
9. In addition to brushing twice Oral cleansing, suctioning, and Foam swabs are effective in
daily, use oral swabs with a 1.5% moisturizing every 2–4 hours is a stimulating mucosal tissue but
hydrogen peroxide solution to part of comprehensive oral care that less effective in plaque
clean mouth every 2–4 hours. has shown to improve oral health removal.13,43
and reduce the risk of healthcare-
acquired pneumonia.13,18,45,49,51,54,58,60
Studies support the safety and
efficacy of greater than 1% and less
than 3% H2O2 as a cleanser for
plaque removal and maintaining
overall gingival health.20,42,43
10. Suction oropharyngeal secretions Saliva serves a protective function. Implementation of a
after cleansing. After each Mechanical ventilation causes comprehensive oral care
cleansing, apply a mouth drying of the oral mucosa, affecting program is recommended by the
moisturizer to the oral mucosa salivary flow and contributing to CDC, SHEA, and the Institute
and lips to keep tissue moist. mucositis and regions for bacterial for Health Care Improvement to
(Level C*) deposits and growth.18,39,44 reduce VAP.27,31,57
Use of mouthwash as a cleansing
agent is not recommended.18
11. Suction oral cavity and pharynx Removes secretions that may Oral suction equipment and
at a minimal frequency of every accumulate on top of the cuff and suction tubing should be
4 hours.54(Level C) cause microaspiration.8,49,54 changed every 24 hours.
(Continuous subglottic Continuous subglottic suctioning with Nondisposable, noncovered oral
suctioning: Level A*) a specially designed ETT has been suction apparatus has been
(Intermittent suctioning: shown to reduce VAP.31,41,60 shown to be colonized with
Level C) Intermittent deep oral cleansing with a microorganisms present in the
disposable or covered catheter as a oral cavity.52 Nondisposable oral
part of a comprehensive oral care suction apparatus should be
program has been shown to reduce rinsed with sterile isotonic
VAP in a quality-improvement sodium chloride solution after
project.18,28,49 each use and placed on a paper
towel if not disposable or
covered.18,49,52,63 Covered oral
suction apparatus should be
rinsed with sterile or distilled
water and cover put back in
place.18,28,49,52 Placement of tonsil
suction back into the package is
associated with greater
colonization.18,39,52 Disconnection
of a closed suction system to
provide oral suctioning may
contribute to increased bacterial
colonization at the point of the
disconnection.18,39,52
*Level A: Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a specific action, intervention, or
treatment (including systematic review of randomized controlled trials).

Procedure for Endotracheal Tube and Oral Care for Ventilated Patients—Continued
12. Application of antiseptic oral Twice a day application of 2% and More frequent use of antiseptics
rinses (chlorhexidine, 0.12% chlorhexidine gluconate to than recommended may result in
cetylpyridinium chloride, added the oral cavity within a 2-hour time greater discoloration of the
after brushing or done in period from brushing has reduced teeth.18,37,47
conjunction with comprehensive VAP rates.7,12,21,26,27,50,58
oral care, can help reduce Cetylpyridinium chloride has been
VAP.33,50,58 (Level B*) shown to be an effective solution in
the removal of plaque and
prevention of gingivitis.7,37,48,55
Povidone-iodine effectiveness as a
rinse to reduce VAP remains
unclear.33
13. Move oral tube to the other side Prevents or minimizes pressure areas
of the mouth. Replace bite-block on lips, tongue, and oral cavity.
or oropharyngeal airway (to act Deep oral suctioning above the cuff
as bite-block) along the ETT if before deflation or position change
necessary to prevent biting. If can reduce the risk of colonized oral
deflation of the cuff is necessary secretions being aspirated.8,54
to move from one side of the
mouth to the other, deep oral
suctioning should be performed
before deflation. (Level C*)
14. After oral hygiene is completed, The securing mechanism should be If the method to secure the ETT
change the ETT securing changed if using tape and/or moved obstructs the ability to provide
mechanism with new tape, ties, at least once daily to provide an effective oral care, consider
or commercial device, as needed, opportunity for assessment and changing the securement
according to institutional repositioning of the ETT to reduce method.
standard (see Fig. 2-10). the risk of a pressure skin injury. If
(Level C) the securing mechanism loosens,
more frequent change may be
necessary.44,53When tape was
compared with commercially
available devices, tape was superior
to three of four devices in
withstanding high external forces
and was the most cost effective.6,40
15. Ensure proper cuff inflation (see Helps in preventing air leaks during
Procedure 13). ventilation and aspiration.
16. Reconfirm tube placement (see Common tube placement at the teeth
Procedure 2), and note position is 21 cm for women and 23 cm for
of tube at teeth, gumline, or men.
nares.
17. Remove PE and discard supplies.
18. HH
Procedure for Oral Care: Non-ventilated Patients

Independent Self-Care
1. Instruct patient to brush gently for 1–2 Promotes good oral Consider using the following tools:
minutes and swish with oral rinse. hygiene. soft-bristled toothbrush, therapeutic
Moisturize lips and mouth as needed for toothpaste, alcohol-free antiseptic oral
dryness. rinse, and non–petroleum-based
moisturizer.45,46
2. Encourage brushing four times a day Promotes good oral
(i.e., after each meal and before hygiene.
bedtime).45,46(Level C*)
Dependent, Unable to Manage Own Oral Care or Secretions Safely
1. HH
2. PE
3. Brush with a suction toothbrush and Promotes good oral Consider using the following tools: suction
toothpaste or gel for 1–2 minutes, hygiene. toothbrush, therapeutic toothpaste or gel,
suctioning frequently. alcohol-free antiseptic oral rinse, and
non–petroleum-based moisturizer.
5. HH
Edentulate Patients, Dentures
1. HH
2. PE
3. If no teeth or dentures, gently brush Promotes good oral Consider using the following tools:
gums, tongue four times a day (i.e., after hygiene. soft-bristled toothbrush, therapeutic
each meal and before bedtime). If patient toothpaste/gel, alcohol-free antiseptic
is allowed nothing by mouth or is on oral rinse, and non–petroleum-based
tube feedings, oral care can be performed moisturizer.45,46
every 6 hours. Apply antiseptic oral rinse
with moistened swab and suction. Apply
moisturizer with swab.45,46(Level C)
4. If patient is wearing dentures, soak at Promotes good oral
night in denture cleanser. During the hygiene.
daytime, rinse/swab with antiseptic rinse
after each meal and apply moisturizer,
prn.45,46 (Level C)
6. HH

• Patent airway • Dislodged ETT
• Secured ETT • Occluded ETT
• Removal of oral secretions • ETT cuff leak
• Intact oral and nasal mucous membranes • Pressure ulcers in mouth or on the lip or nares
• Reduced oral colonization • VAP
• Moist pink oral cavity

These conditions should be
reported if they persist despite
nursing interventions.
1. Keep head of bed elevated at least Maintaining the head of the bed in an
30 degrees, unless elevated position decreases the risk
contraindicated.8,15,31,59,60 of aspiration. Contraindications
(Level C*) include hemodynamic instability,
decreased cerebral perfusion pressure,
and patient in the prone position.
2. Suction ETT if clinically Maintains patent airway. • Inability to pass suction
indicated. catheter
3. Monitor amount, type, and color Monitors for signs of infection. • Change in quantity or
of secretions. characteristics of secretions
4. If patient is nasally intubated, Nasal intubation is associated with an • Purulent drainage from the
recommend reintubation in the increased risk for sinusitis and the nares or present in the back
oral cavity. (Level C) potential development of VAP.31 of the throat
5. Assess oral cavity and lips every 2 If oral care is omitted for an extended • Breakdown of lip, tongue, or
hours, and perform oral care (as period, previous benefits are oral cavity
outlined in Steps 7–12) every 2–4 lost.13,18,28,49,61 Early recognition of • Presence of mouth sores
hours and as needed. (Level C) pressure or drainage allows for • Bleeding of the gums during
6. For non-vented patients, assess prompt intervention. Promotes good brushing
oral cavity and lips every 2 hours oral hygiene.
and perform oral care outlined in
Steps 1–4 based on patient type.
(Level C)
7. With oral care, assess for buildup Assessment and removal of plaque • Continued plaque buildup on
of plaque on teeth or potential decreases bacteria in the mouth. teeth, presence of an abscess
infection related to oral abscess.
8. Avoid reusing devices unless Apparatuses exposed to the oral cavity
covered or protected (i.e., in-line or secretions in the lungs when left
suction or covered Yankauer). unprotected within the environment
have been shown to be colonized
with bacteria in the oral cavity.52
9. Reconfirm tube placement (see Ensures secured tube. • Tube movement in and out
Procedure 2), and note position of of mouth
tube at teeth or nares.
10. Retape or secure ETT every 24
hours and as needed for soiled or
loose securing devices.
11. With subglottic secretion drainage Damage to the tracheal mucosa was • Clogged subglottic suction
ETT in place, if tube becomes noted with the use of subglottic port
clogged irrigate with air per secretion drainage. In one study in
manufacturer’s instructions but do patients whose ETT was clogged,
not increase suction pressure patients were reintubated and their
beyond what is recommended by clogged tubes were examined. In 17
the manufacturer. (Level M*) of 19 subglottic suction ports, the
clogging was caused by tracheal
mucosa versus secretions.14 Consider
routine irrigation with air to prevent
clogging.
Documentation
• Patient and family education • Condition of lips, mouth, and tongue
• Patient tolerance to suctioning • Absence of a cuff leak
• Aspirate amount, type, and color • Pressure in the cuff (2–30 mm Hg)
• Presence of nasal drainage • Centimeter mark on ETT and placement position in
• Repositioning of ETT and new position the oral cavity
• Retaping of ETT • Which naris ETT is in
• Oral care, moisturization, and oral suctioning

4 Endotracheal Tube Care and Oral Care Practices for Ventilated and Non-ventilated Patients 39.e1
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PROCEDURE
5
Extubation/Decannulation
(Perform)
Lisa Koser
PURPOSE: To remove the artificial airway, allowing the patient to breathe
through the upper airway.
PREREQUISITE NURSING EQUIPMENT

KNOWLEDGE
• Personal protective equipment (including eye protection)
• Extubation refers to removal of a translaryngeal endotra- • Self-inflating manual resuscitation bag-valve device con-
cheal tube, whereas decannulation refers to removal of a nected to 100% oxygen source
tracheostomy tube. • Oxygen delivery device (i.e., face mask) connected to
• Indications for extubation and decannulation include the humidified oxygen
following1,3: • Suctioning equipment with sterile suction catheter or kit
❖ The underlying condition that led to the need for an • Rigid pharyngeal suction-tip (Yankauer) catheter
artificial airway is reversed or improved. • Scissors (for tape or ties)
❖ Hemodynamic stability is achieved, with no new • 10-mL syringe (if cuff present)
reasons for continued artificial airway support. • Sterile dressing for tracheal stoma
❖ The patient is able to effectively clear pulmonary • Endotracheal intubation supplies and emergency cart
secretions.
❖ Adequate muscle strength is achieved. PATIENT AND FAMILY EDUCATION
❖ The ability to protect airway and minimal risk for aspi-
ration exist. • Explain the purpose of and procedure for removing the
❖ Mechanical ventilatory support is no longer needed endotracheal or tracheostomy tube. Rationale: Identifies
(i.e., adequate spontaneous ventilation and oxygen- knowledge deficits of the patient and family concerning
ation is achieved, or palliative extubation is planned). the patient’s condition, the procedure, and the expected
• Most extubations and decannulations are planned. Plan- benefits. This step also allows time for questions to clarify
ning allows for preparation of the patient physically and information and voice concerns. Explanations decrease
emotionally, decreasing the likelihood of reintubation* patient anxiety and enhance cooperation.
and hypoxic sequelae. Unintentional or unplanned extuba- • Explain the suctioning process and the importance of
tion complicates a patient’s overall recovery and increases coughing and deep breathing after the tube is removed.
risk of inpatient death.2 Rationale: Understanding therapy encourages coopera-
• Extubation may occur in a rapid fashion when the previ- tion with the follow-up procedures necessary to maintain
ous indications are met, whereas decannulation generally a patent airway.
occurs in a stepwise fashion. The patient with a tracheos- • Explain that the patient’s voice may be hoarse after extu-
tomy tube may be weaned gradually from the tracheos- bation or decannulation. Following the removal of the
tomy tube, including downsizing the tube diameter, using tracheostomy tube, occlusion of the stoma may be neces-
fenestrated tubes and inner cannulas, and capping the tra- sary to facilitate normal speech and coughing. Rationale:
cheostomy tube. The tracheostomy tube is removed when Knowledge minimizes the patient’s and family’s fear and
the patient is able to breathe comfortably, maintain ade- anxiety.
quate ventilation and oxygenation, and manage secretions • Explain that the patient may need continued oxygen or
through the normal anatomical airway. humidification support. Rationale: Many patients con-
tinue to need supplemental oxygen for some time after
extubation. Continued humidification often helps decrease
hoarseness and liquefies secretions.
• Explain that reinsertion of the endotracheal tube or cannula
*This procedure should be performed only by physicians,
may be necessary if the patient develops respiratory
advanced practice nurses, and other healthcare professionals (including criti- failure. Rationale: Patients may require mechanical ven-
cal care nurses) with additional knowledge, skills, and demonstrated com- tilation if respiratory failure develops after extubation or
petence per professional licensure or institutional standard. decannulation.
40
5 Extubation/Decannulation (Perform) 41
• After extubation, a swallow evaluation is often necessary. Positive end-expiratory pressure <8 cm H2O
❖
Rationale: Assess the ability to swallow and prevent aspi- Hemodynamic stability and absence of serious cardiac
❖
ration with oral intake. dysrhythmias
• Assess the patient’s ability to cough. Rationale: The
ability to cough and clear secretions is important for suc-
PATIENT ASSESSMENT AND cessful airway management after extubation.
PREPARATION Patient Preparation
Patient Assessment • Verify correct patient with two identifiers. Rationale:
• Rationale: Assesses patient’s readiness for extubation. Prior to performing a procedure, the nurse should ensure
Desired level of consciousness has been achieved (most the correct identification of the patient for the intended
patients are awake and able to follow commands).2 intervention.
• Assess the stability of the patient’s respiratory status.2,4 • Ensure that the patient and family understand preproce-
❖ Rationale: Assesses patient’s readiness for extubation. dural teachings. Answer questions as they arise and rein-
Absence of respiratory distress and no other indication force information as needed. Rationale: This process
for intubation evaluates and reinforces understanding of previously
❖ Negative inspiratory pressure less than or equal to taught information.
−20 cm H2O • Place the patient in the high Fowler’s (>60 degrees)
❖ Positive expiratory pressure greater than or equal to or semi-Fowler’s (>30 degrees) position if not contra-
+30 cm H2O indicated and does not contribute to restriction of breath-
❖ Spontaneous tidal volume greater than or equal to ing (i.e., obesity). Rationale: Respiratory muscles are
5 mL/kg ideal body weight more effective in an upright position versus a supine
❖ Fraction of inspired oxygen (Fio2) less than or equal or prone position. This position facilitates coughing
to 50% and minimizes the risk of vomiting and consequent
❖ Normal or baseline Paco2 aspiration.
Procedure for Performing Extubation and Decannulation

1. HH
2. PE
3. Hyperoxygenate and suction Removes secretions in artificial
endotracheal tube or tracheostomy airway and oral cavity.
(see Procedure 10).
4. Cut twill tape or remove tape or Frees the tube for removal.
securement device to free tube.
5. Insert syringe into one-way valve Prepares for cuff deflation.
of pilot balloon.
6. Suction the oral cavity. Removes secretions that may be Alternative methods to facilitate
aspirated upon extubation. removal of secretions while an
endotracheal tube is removed include
application of positive pressure while
the cuff is deflated, insertion of
suction catheter 1–2 inches (5 cm)
below distal end of tube, and
application of suction while cuff is
deflated and tube removed.2
7. Deflate the tube cuff (if it is Readies the tube for removal.
inflated).
8. Ask the patient to take a deep Promotes hyperinflation. Vocal A self-inflating manual resuscitation
breath and remove the tube on cords are maximally abducted bag-valve device can assist in
inspiration, while monitoring and at peak inspiration. Assists in a hyperinflation (see Procedure 31).
supporting the patient. smooth, quick, less traumatic
removal. Vocal cords are
maximally abducted at peak
inspiration. In addition, initial
cough response expected after
extubation should be more
forceful if started from maximal
inspiration versus expiration.
Procedure for Performing Extubation and Decannulation—Continued

9. Encourage the patient to cough Promotes hyperinflation; helps
and breathe deeply. remove secretions.
10. Suction the oral pharynx. Removes secretions.
11. Apply supplemental oxygen and Promotes moisture and prevents Cool humidification is usually
aerosol, as appropriate. oxygen desaturation. preferred after extubation to help
minimize upper airway swelling.4
12. Decannulation ONLY: place a dry, Contains secretions that may leak Tracheostomy stoma closure usually
sterile, 4 × 4 dressing over stoma out of stoma. occurs within a few days but may
when tracheostomy tube is take longer with a long-term
removed. tracheostomy.
13. Discard used supplies and remove
PE .
14. HH

• Smooth atraumatic extubation or decannulation • Fatigue and respiratory failure
• Stable respiratory status • Persistent hoarseness
• Stable hemodynamics • Tracheal stoma narrowing
• Stable neurological status • Aspiration
• Laryngospasm
• Trauma to soft tissue
• Upper airway obstruction
• Neurological decline

These conditions should be reported if
they persist despite nursing
interventions.
1. Monitor vital signs, respiratory Change in vital signs and • Tachycardia
status, oxygenation, neurological oxygenation after extubation • Tachypnea
status, and phonation immediately or decannulation may indicate • Blood pressure significantly greater
after extubation, within 1 hour, respiratory compromise, than baseline
and per institutional standard. which necessitates • Oxygen saturation (Spo2) less than or
reintubation. equal to 90% (unless otherwise
ordered)
• Stridor
• Breathing difficulty
• Respiratory dyssynchrony
2. Provide supplemental oxygen as Decreases incidence of oxygen • Spo2 less than or equal to 90%
needed. desaturation immediately (unless otherwise ordered)
after extubation. • Decreased level of consciousness
(high Paco2)
• Inability to auscultate adequate air
exchange
3. Monitor for aspiration related to Failure to suction or ineffective • Inability to handle secretions
pooled secretions. suctioning of the pharynx
allows accumulated secretions
to advance farther into the
trachea on cuff deflation.
4. Encourage frequent coughing and Prevents atelectasis and • Ineffective cough
deep breathing and use of an secretion accumulation.
incentive spirometer.
5 Extubation/Decannulation (Perform) 43
Patient Monitoring and Care —Continued

5. Frequent oral care (see Maintains oral mucosa and
Procedure 4). keeps oral cavity clear of
dried secretions.
6. Assess swallowing ability. Presence of tube over extended • Inability to handle secretions
Facilitate swallow study as periods may result in • Inability to swallow without coughing
indicated by institutional standard. impaired swallowing ability.
7. Follow institution standard for Identifies need for pain • Continued pain despite pain
assessing pain. Administer interventions. interventions
analgesia as prescribed.
Documentation
• Patient and family education • Patient response to procedure
• Respiratory and vital signs assessment before and after • Unexpected outcomes and complications
procedure • Nursing interventions taken
• Date and time when procedure is performed • Pain assessment, interventions, and effectiveness
• Breath sounds and upper airway sounds • Ability to phonate
• Neurological status

5 Extubation/Decannulation (Perform) 43.e1
References Burns SM: Weaning from mechanical ventilation. In Burns

1. Artime C, Hagberg C: Tracheal extubation. Respir Care SM, editor: AACN protocols for practice: care of mechani-
59:991–1005, 2014. cally ventilated patients, ed 2, Sudbury, MA, 2007, Jones
2. Gupta P, et al: The effect of a mechanical ventilation and Bartlett, pp 97–160.
discontinuation protocol in patients with simple and Hess D, et al: Respiratory care: Principles and practice,
difficult weaning: Impact on clinical outcomes. Respir Sudbury, MA, 2012, Jones and Bartlett.
Care 59:170–177, 2014. Morris LL, McIntosh E, Whitmer A: The importance of
3. Howie WO, Dutton RP: Implementation of an evidence- tracheostomy progression in the intensive care unit. Crit
based extubation checklist to reduce extubation failure in Care Nurse 34:40–50, 2014.
patients with trauma: A pilot study. AANA J 80:179–184, O’Conner H, White A: Tracheostomy decannulation. Respir
2012. Care 55:1076–1081, 2010.
4. Pandian V, et al: Utilization of a standardized Ortega R, et al: Endotracheal extubation. N Engl J Med
tracheostomy capping and decannulation protocol to 370:1272, 2014.
improve patient safety. Laryngoscope 124:1794–1800, Perren A, et al: Patients’ prediction of extubation success.
2014. Intensive Care Med 36:2045–2052, 2010.
Additional Readings
American Association for Respiratory Care: Clinical practice
guideline: removal of the endotracheal tube. Respir Care
52:81–93, 2007.
PROCEDURE
6
Extubation/Decannulation
(Assist)
Lisa Koser
PURPOSE: To remove the artificial airway, allowing the patient to breathe
through the upper airway.
PREREQUISITE NURSING • Oxygen delivery device (i.e., face mask) connected to

KNOWLEDGE humidified oxygen
• Suctioning equipment with sterile suction catheter or kit
• Extubation refers to removal of a translaryngeal endotra- • Rigid pharyngeal suction-tip (Yankauer) catheter
cheal tube, whereas decannulation refers to removal of a • Scissors (for tape or ties)
tracheostomy tube. • 10-mL syringe (if cuff present)
• Indications for extubation and decannulation include the • Sterile dressing for tracheal stoma
following1,4: • Endotracheal intubation supplies and emergency cart
❖ The underlying condition that led to the need for an
artificial airway is reversed or improved. PATIENT AND FAMILY EDUCATION
❖ Hemodynamic stability is achieved, with no new
reasons for continued artificial airway support. • Explain the purpose of and procedure for removing the
❖ The patient is able to effectively clear pulmonary endotracheal tube or tracheostomy. Rationale: This step
secretions. identifies knowledge deficits of the patient and family
❖ Adequate muscle strength is achieved. concerning the patient’s condition, the procedure, and the
❖ The ability to protect the airway and minimal risk for expected benefits. This step also allows time for questions
aspiration exist. to clarify information and voice concerns. Explanations
❖ Mechanical ventilatory support is no longer needed decrease patient anxiety and enhance cooperation.
(i.e., adequate spontaneous ventilation and oxygen- • Explain the suctioning process and the importance of
ation are achieved or palliative extubation is planned). coughing and deep breathing after the tube is removed.
• Most extubations and decannulations are planned. Plan- Rationale: Understanding therapy encourages coopera-
ning allows for preparation of the patient physically and tion with the follow-up procedures necessary to maintain
emotionally, decreasing the likelihood of reintubation and a patent airway.
hypoxic sequelae. Unintentional or unplanned extubation • Explain that the patient’s voice may be hoarse after extu-
complicates a patient’s overall recovery and increases risk bation or decannulation. Following the removal of the
of inpatient death.2,3 tracheostomy tube, occlusion of the stoma may be neces-
• Extubation may occur in a rapid fashion when the previ- sary to facilitate normal speech and coughing. Rationale:
ous indications are met, whereas decannulation generally Knowledge minimizes the patient’s and family’s fear and
occurs in a stepwise fashion. The patient with a tracheos- anxiety.
tomy tube may be weaned gradually from the tracheos- • Explain that the patient may need continued oxygen or
tomy tube, including downsizing the tube diameter, using humidification support. Rationale: Many patients con-
fenestrated tubes and inner cannulas, and capping the tra- tinue to need supplemental oxygen for some time after
cheostomy tube. The tracheostomy tube is removed when extubation or decannulation. Continued humidification
the patient is able to breathe comfortably, maintain ade- often helps decrease hoarseness and liquefies secretions.
quate ventilation and oxygenation, and manage secretions • Explain that reinsertion of the endotracheal tube or
through the normal anatomical airway. cannula may be necessary if the patient develops respira-
tory failure. Rationale: Patients may require mechanical
EQUIPMENT ventilation if respiratory failure develops after extubation
or decannulation.
• Personal protective equipment (including eye protection) • After extubation, a swallow evaluation is often necessary.
• Self-inflating manual resuscitation bag-valve device con- Rationale: Assess the ability to swallow and prevent aspi-
nected to 100% oxygen source ration with oral intake.
44
6 Extubation/Decannulation (Assist) 45
PATIENT ASSESSMENT AND • Assess the patient’s ability to cough. Rationale: The
PREPARATION ability to cough and clear secretions is important for suc-
cessful airway management after extubation.
Patient Assessment
• Rationale: Assesses patient’s readiness for extubation.
Desired level of consciousness has been achieved (most Patient Preparation
patients are awake and able to follow commands).2 • Verify correct patient with two identifiers. Rationale:
• Assess the stability of the patient’s respiratory status. Prior to performing a procedure, the nurse should ensure
Rationale: Assesses patient’s readiness for extubation.2,5 the correct identification of the patient for the intended
❖ Absence of respiratory distress intervention.
❖ Negative inspiratory pressure less than or equal to • Ensure that the patient and family understand preproce-
−20 cm H2O dural teachings. Answer questions as they arise and rein-
❖ Positive expiratory pressure greater than or equal to force information as needed. Rationale: This process
+30 cm H2O evaluates and reinforces understanding of previously
❖ Spontaneous tidal volume greater than or equal to taught information.
5 mL/kg ideal body weight • Place the patient in the high Fowler’s (>60 degrees) or
❖ Fraction of inspired oxygen (Fio2) less than or equal to semi-Fowler’s (>30 degrees) position if not contraindi-
50% cated and does not contribute to restriction of breathing
❖ Normal or baseline Paco2 (i.e., obesity). Rationale: Respiratory muscles are more
❖ Positive end-expiratory pressure <8 cm H2O effective in an upright position versus a supine or prone
❖ Hemodynamic stability and absence of serious cardiac position. This position facilitates coughing and minimizes
dysrhythmias the risk of vomiting and consequent aspiration
Procedure for Assisting with Extubation and Decannulation

1. HH
2. PE
3. Assist with hyperoxygenating and Removes secretions in artificial
suctioning the tube (see Procedure 10). airway and oral cavity.
4. Manually stabilize the tube until the Prevents inadvertent removal or
other healthcare provider is ready to dislodgement of the tube.
remove it from the patient.
5. Encourage the patient to cough and Promotes hyperinflation; helps
breathe deeply. remove secretions.
6. Suction the oral pharynx. Removes secretions.
7. Apply supplemental oxygen and Promotes moisture and prevents Cool humidification is usually
aerosol, as appropriate. oxygen desaturation. preferred after extubation to help
minimize upper airway swelling.5
8. Decannulation ONLY: place a dry, Contains secretions that may Tracheostomy stoma closure
sterile, 4 × 4 dressing over stoma leak out of stoma. usually occurs within a few days
when tracheostomy tube is removed. but may take longer with a
long-term tracheostomy.
9. Discard used supplies and remove PE .
10. HH

• Smooth atraumatic extubation or decannulation • Fatigue and respiratory failure
• Stable respiratory status • Persistent hoarseness
• Stable hemodynamics • Tracheal stoma narrowing
• Stable neurological status • Aspiration
• Laryngospasm
• Trauma to soft tissue
• Upper airway obstruction
• Neurological decline

1. Monitor vital signs, respiratory Change in vital signs and • Tachycardia
status, oxygenation, neurological oxygenation after extubation • Tachypnea
status, and phonation immediately or decannulation may indicate • Blood pressure significantly
after extubation, within 1 hour, respiratory compromise, greater than baseline
and per institutional standard. which necessitates • Oxygen saturation (Spo2) less
reintubation. than or equal to 90% (unless
otherwise ordered)
• Stridor
• Breathing difficulty
• Respiratory dyssynchrony
2. Provide supplemental oxygen as Decreases incidence of oxygen • Spo2 less than or equal to 90%
needed. desaturation immediately (unless otherwise ordered)
after extubation. • Decreased level of
consciousness (high Paco2)
• Inability to auscultate
adequate air exchange
3. Monitor for aspiration related to Failure to suction or ineffective • Inability to handle secretions
pooled secretions. suctioning of the pharynx
allows accumulated secretions
to advance farther into the
trachea on cuff deflation.
4. Encourage frequent coughing and Prevents atelectasis and • Ineffective cough
deep breathing, and use of an secretion accumulation.
incentive spirometer.
5. Frequent oral care (see Maintains oral mucosa and
Procedure 4). keeps oral cavity clear of
dried secretions.
6. Assess swallowing ability. Presence of tube over extended • Inability to handle secretions
Facilitate swallow study as periods may result in • Inability to swallow without
indicated by institutional standard. impaired swallowing ability. coughing
Documentation
• Patient and family education • Patient response to procedure
• Respiratory and vital signs assessment before and after • Unexpected outcomes and complications—listed
procedure previously
• Date and time when procedure is performed • Nursing interventions taken
• Breath sounds and upper airway sounds • Pain assessment, interventions, and effectiveness
• Neurological status • Ability to phonate

6 Extubation/Decannulation (Assist) 46.e1
References Burns SM: Weaning from mechanical ventilation. In Burns

1. Artime C, Hagberg C: Tracheal extubation. Respir Care SM, editor: AACN protocols for practice: care of
59(6):991–1005, 2014. mechanically ventilated patients, ed 2, Sudbury, MA,
2. Gupta P, et al: The effect of a mechanical ventilation 2007, Jones and Bartlett, pp 97–160.
discontinuation protocol in patients with simple and Hess D, et al: Respiratory care: Principles and practice,
difficult weaning: Impact on clinical outcomes. Respir Sudbury, MA, 2012, Jones and Bartlett.
Care 59(2):170–177, 2014. Morris LL, McIntosh E, Whitmer A: The importance of
3. Hagberg C: Benumof and Hagberg’s airway management, tracheostomy progression in the intensive care unit.
Philadelphia, PA, 2012, Elsevier Saunders. Crit Care Nurse 34(1):40–50, 2014.
4. Howie WO, Dutton RP: Implementation of an O’Conner H, White A: Tracheostomy decannulation. Respir
evidence-based extubation checklist to reduce extubation Care 55(8):1076–1081, 2010.
failure in patients with trauma: A pilot study. AANA J Ortega R, et al: Endotracheal extubation. N Engl J Med
80(3):179–184, 2012. 370(3):1272, 2014.
5. Pandian V, et al: Utilization of a standardized Perren A, et al: Patients’ prediction of extubation success.
tracheostomy capping and decannulation protocol to Intensive Care Med 36:2045–2052, 2010.
improve patient safety. Laryngoscope 124(8):1794–1800,
2014.
Additional Readings
American Association for Respiratory Care: Clinical practice
guideline: removal of the endotracheal tube. Respir Care
52(1):81–93, 2007.
PROCEDURE
7
King Airway Insertion
and Removal
Kyle Gibson
PURPOSE: A King Airway, a type of supraglottic airway, can provide an
emergency airway during resuscitation without the need for direct laryngoscopy.
The King Airway may be used for a patient who is unconscious without a gag reflex
and needs artificial ventilation when a definitive or alternative airway is not
available or has failed.
PREREQUISITE NURSING vidual device. If the individual device is used, additional

KNOWLEDGE components are necessary for insertion.
• The latex-free King Airway has a unique design that
• Anatomy and physiology of the upper airway should be includes the following:
well understood. ❖ A proximal and distal cuff that is inflated through a
• The King Airway does not require direct laryngoscopy single inflation port with a pilot balloon
and may be inserted blindly.3 ❖ A 15-mm connector color coded for easy sizing iden-
• The King Airway may act as an airway bridge when tification and able to connect to bag-valve devices and
definitive airway control is not available or has failed.7 ventilator circuits
• The King Airway LT-D (Fig. 7-1) is manufactured in five ❖ A blue orientation line on the lumen to allow correct
sizes based on height or weight4: handling and placement of the King Airway
❖ Size 2 is used for patients 35 to 45 inches tall (90 to ❖ Black lines on the lumen indicating the position
115 cm) or 12 to 25 kg and has a green connector for of the patient’s teeth or gumline for tube-depth
identification. identification
❖ Size 2.5 is used for patients 41 to 51 inches tall (105 ❖ Two cuffs for occlusion (cuff volume is 25 to 90 mL
to 130 cm) or 25 to 35 kg and has an orange connector with a goal cuff pressure of 60 mm H2O)
for identification. Proximal cuff stabilizes the tube and occludes the
❖ Size 3 is used for patients 4 to 5 feet tall (122 oropharynx
to 155 cm) and has a yellow connector for Distal cuff occludes the esophagus and decreases
identification. gastric ventilation
❖ Size 4 is used for patients 5 to 6 feet tall (155 to ❖ Two ventilation outlets laying in between the two cuffs,
180 cm) and has a red connector for identification. allowing passage of a fiberoptic bronchoscope or a
❖ Size 5 is used for patients greater than 6 feet tube-exchange device (gum elastic bougie) for both
tall (>180 cm) and has a purple connector for LTD and LTS-D models
identification. • Upon insertion, the distal tip of the King Airway occludes
• The King Airway LTS-D (Fig. 7-2) is manufactured to the esophagus (Fig. 7-3).
include a second lumen, allowing gastric access for a • Before insertion of the King Airway, adequate ventilation
suction catheter up to 18 Fr. The King Airway LTS-D is and oxygenation needs to be performed by either mouth-
not available in sizes 2 or 2.5. to-mask or bag-valve mask connected to high-flow
• The King Airway allows for positive pressure ventilation oxygen.
over 30 mm H2O.4 • The King Airway is contraindicated in the following
• The King Airway is supplied in either a complete kit (with cases5:
all the necessary equipment for insertion) or as an indi- ❖ Patients with an intact gag reflex
❖ Patients with a known esophageal disease, such as
esophageal varices or esophageal trauma
❖ Patients who have ingested caustic substances
❖ Patients with a foreign body in the trachea
practice nurses, and other healthcare professionals (including critical care ❖ Patients with a tracheostomy or stoma
nurses) with additional knowledge, skills, and demonstrated competence per • Medications delivered via endotracheal tube cannot be
professional licensure or institutional standard. used with the King Airway. Medications may not reach
47
• Appropriate syringe for inflation of cuffs: this may be a

60- to 80-mL syringe for adult patients or a small 20-mL
syringe for pediatric patients
• Water-soluble lubricant
• Colorimetric carbon dioxide (CO2) device or end-tidal
CO2 device with monitor
• Appropriate-size gastric tube if using LTS-D model
the following:
Figure 7-1 King Airway LT-D • Laryngoscope or a tongue depressor

• If time permits, provide the family or guardian with infor-
mation about the King Airway and the reason for inser-
tion. Rationale: Educating the family or guardian with
information about the King Airway and the need for inser-
tion is necessary. It may alleviate anxiety.
Figure 7-2 King Airway LTS-D PATIENT ASSESSMENT AND

PREPARATION
Patient Assessment
• Assess the level of consciousness of the patient. Ratio-
nale: The King Airway should only be inserted into a
patient who is unconscious, unresponsive without a gag
reflex, and unable to maintain adequate ventilation.
Administration of paralytics and/or sedation may be
needed to ensure the patient’s gag reflex does not return
after the King Airway is in place.
• Assess the patient for any type of esophageal injury, such
as a clothesline injury. Rationale: The King Airway is
contraindicated in esophageal trauma.
• Assess history and patient information from bystanders,
if available, for possibility of esophageal disease or caustic
substance ingestion. Rationale: A King Airway is contra-
indicated in patients with these conditions.
• Assess the patient’s height or weight. Rationale: The
Figure 7-3 Properly placed King Airway, with the proximal cuff King Airway is sized based on the patient’s height for the
stabilizing the tube and occluded the oropharynx and the distal tip
adult population and based on height or weight for the
occluding the esophagus.
pediatric population.
the alveolar surfaces of the lung for absorption due to the Patient Preparation
distal end of the King Airway being in the esophagus. • Verify correct patient with two identifiers. Rationale:
• Initial and continued education on and practice with inser- Prior to performing a procedure, the nurse should ensure
tion of the King Airway is essential to maximize insertion the correct identification of the patient for the intended
success and minimize complications.6 intervention.
• Ensure that suction equipment is assembled and readily
EQUIPMENT available. Rationale: The patient may regurgitate during
insertion or while the King Airway is in place and will
• Personal protectant equipment ultimately need suctioning to prevent aspiration.
• Suction equipment including regulator, canister, tubing, • Perform preprocedure verification and time out, if not
and suctioning device emergent. Rationale: Ensures patient safety.
• Mouth-to-mask or self-inflating resuscitation bag-valve • Ensure adequate ventilation and oxygenation are being
mask connected to high-flow oxygen performed before insertion of the King Airway via a
• King Airway of the appropriate size based on height for mouth-to-mask or a self-inflating bag-valve-mask device.
adult patients and either height or weight for pediatric Rationale: The patient is usually unresponsive and cannot
patients adequately maintain ventilation without assistance.
7 King Airway Insertion and Removal 49
Procedure for King Airway Insertion

1. HH
2. PE
3. Using the information provided, The King Airway LTS-D is only
choose the correct King Airway manufactured for sizes 3–5.
size, based on patient height or
weight.
4. Open the package and test the Ensures that the device is not If a leak is found, discard the
integrity of both cuffs. (Level M*) defective and will work as device and secure another.
A. Pull the plunger back on the manufactured.
syringe to the appropriate Readies the syringe for inflating
volume for the size of the the cuffs upon insertion.
King Airway and attach it to
the inflation port.
B. Inflate the proximal and distal
cuffs and assess for leaks.
C. Deflate the cuffs, leaving the
syringe attached.
5. Lubricate the King Airway with Provides for smoother insertion. Make sure that the ventilation holes
water-soluble lubricant. are not covered with lubricant.
(Level M)
6. Have a spare King Airway ready This allows no delay in initiating
and prepared for immediate use if an airway if the first King
failure or damage occurs with the Airway fails or becomes
first one. damaged while inserting.
7. Preoxygenate the patient when Prevents hypoxia. Provider must be aware of
possible. preventing anoxia during the
procedure, especially if multiple
attempts are made.
8. If no spinal injury is suspected, Pulls the tongue forward, away Maintain manual cervical spinal
extend the neck and position the from the posterior pharynx. immobilization with suspected or
head in a “sniffing position.” known spine trauma.
9. Hold the King Airway at the Readies the King Airway for With facial trauma, assess for the
connector with dominant hand. insertion and opens the airway presence of broken teeth and
With nondominant hand, hold for insertion. remove loose fragments.
mouth open and apply chin lift.
(Level M)
10. With the King Airway rotated Allows the King Airway to A laryngoscope or a tongue
laterally such that the blue follow the patient’s pharynx depressor can be used to lift the
orientation line is touching the until it is in the correct tongue anteriorly to allow easy
corner of the mouth, introduce tip position. advancement.3
of the King Airway into mouth
and advance behind base of the
tongue. (Level M)
11. As the King Airway passes under Proper placement of the King Do not force the King Airway. If it
the tongue, rotate tube back to the Airway occurs when distal tip does not easily advance, attempt
midline so that blue orientation of the lumen is in the to redirect or remove and reinsert.
line faces the chin. (Level M) esophagus. Tracheal intubation
does not occur.8
12. Without exerting excessive force, Places the King Airway in the Depth of insertion is key to
advance tube until base of correct anatomical location for providing a patent airway.
connector is aligned with teeth or ventilation.
gums. (Level M)

Procedure for King Airway Insertion—Continued

13. Using the syringe provided, inflate Inflates and seals the proximal The King Airway may rise out of
the cuffs of the King Airway with and distal cuffs. This stabilizes the mouth during inflation of
the appropriate predetermined the tube and reduces the cuffs so that the teeth or gums are
volume. possibility of gastric return. between the black lines on the
lumen of the tube.
14. Attach bag-valve device to the With successful placement, the
15-mm color-coded connector. distal balloon is in the
While gently bagging the patient esophagus. With both cuffs
to assess ventilation, inflated, the only place
simultaneously withdraw the King artificial ventilation can flow
Airway until ventilation is easy is into the trachea.
and free flowing. (Level M*)
15. Depth markings are provided at Determines placement of the During spontaneous ventilation, the
the proximal end of the King King Airway. epiglottis or other tissue can be
Airway lumen that refer to the drawn into the distal ventilatory
distance from the distal opening, resulting in obstruction.3
ventilatory opening. Advancing the King Airway
1–2 cm, or initiating deeper
placement, normally eliminates
this obstruction.
16. Confirm proper position by Confirms proper placement of When assessing for the presence of
auscultation. the King Airway. breath sounds, always consider
A. Assess for gurgling over the the possibility of a pneumothorax,
epigastrium, equal chest rise especially in the trauma patient.
and fall, and bilateral breath Absent breath sounds may lead
sounds. the provider to believe that the
B. If available, use colorimetric King Airway is misplaced.
CO2 detector or end-tidal CO2
(capnography).
17. Readjust cuff inflation to just seal Cuffs are inflated with minimum
volume and prevent air leaks. volume necessary to seal the
(Level M) airway at the peak ventilatory
pressure employed.
18. Secure the King Airway to the Reduces the chance of A bite-block may also be used, if
patient using either tape or a dislodgment. desired, to provide greater tube
premanufactured tube holder. security.
19. If using the King Airway LTS-D May reduce gastric distention
and a gastric tube is indicated, and may increase the ease of
lubricate before insertion into ventilation.
gastric lumen.
20. Discard supplies and remove PE .
21. HH
patient’s record.

7 King Airway Insertion and Removal 51
Procedure for King Airway Removal

1. HH
2. PE
3. Have suction readily available. Allows suctioning of the airway
preprocedure and postprocedure.
4. Remove the King Airway. Removal is indicated when airway A fiberoptic scope or manufactured
can be managed by skilled intubation catheter1 or gum elastic
personnel. bougie may be used to replace the King
Airway with an endotracheal tube.
A. If King LTS-D is in place, Removes any content in the Regurgitation is always a possibility upon
decompress the stomach by stomach, which makes removal of a King Airway.
inserting a gastric tube through regurgitation less likely upon
the gastric access lumen. removal.
B. Attach appropriate syringe to Deflates both proximal and distal
the pilot balloon and deflate cuffs and allows suctioning of
the cuffs. pharynx to occur.
C. Suction the pharynx. Removes secretions from pharynx. Suction no more than 10 seconds at a time.
D. Withdraw the King Airway Allows the patient to breathe on
from the airway. his or her own.
5. Apply supplemental oxygen. Reduces hypoxia postremoval.
7. HH
patient’s record.

• Establishment of an effective airway in an emergent • Laryngospasm3
situation or a failed nonemergent situation • Coughing3
• Maintains adequate ventilation and oxygenation • Sore throat2,3
• Recovery of spontaneous ventilation • Dysphagia3
• Dysphonia3
• Gagging
• Vomiting

interventions.
1. Monitor ventilations and Determines that the King Airway • Increase difficulty in ventilation.
oxygenation while the King Airway is functioning correctly and • Decrease oxygen saturation.
is in place. providing adequate ventilation • Increase end-tidal carbon dioxide.
A. Difficulty of ventilation. and oxygenation. • Absent breath sound[s].
B. Oxygen saturation (Spo2).
C. End-tidal carbon dioxide (ETco2).
2. Monitor for return of spontaneous May indicate the need either to • High-pressure alarms.
attempts at breathing. remove the device or • High minute volume.
chemically sedate the patient
using sedatives or
neuromuscular blockade to
prevent the gag reflex.
Documentation
• Assessment findings that indicate the need to insert a • Assessment findings after the insertion of the King
King Airway Airway
• Size of the King Airway used • Ongoing monitoring of difficulty or ease of
• Confirmation of adequacy of ventilation, with ventilation
auscultation of gastric area and lung fields • Spo2 levels
• Any difficulties with placement of the King Airway • If insertion of gastric tube, chart output of gastric
• Number of attempts it took to place the King Airway contents.
• What marking the King Airway is at via teeth or lips • Assessment findings that indicate the need to remove
• End-tidal CO2 levels the King Airway or replace it with an endotracheal
• Need for sedation or neuromuscular blockade tube

7 King Airway Insertion and Removal 52.e1
References 6. Nelson J, et al: Evaluation of the Storz CMAC,

1. Budde A, et al: Comparison of 2 techniques of laryngeal Glidescope, GVL, AirTraq, King LTS-D, and direct
tube exchange in a randomized controlled simulation laryngoscopy in a simulated difficult airway. Am J Emerg
study. Am J Emerg Med 33(2):173–176, 2015. Med 31:589–592, 2013.
2. Gaitini L, et al: An evaluation of the laryngeal tube during 7. Russi C, Hartley M, Buresh C: A pilot study of the King
general anesthesia using mechanical ventilation. Anesth LT supralaryngeal airway use in a rural Iowa EMS
Analg 96:1750–1755, 2003. System. Int J Emerg Med 135–138, 2008.
3. Hagberg C, et al: An evaluation of the insertion and 8. Russi C, Wilcox C, House H: The laryngeal tube device:
function of a new supraglottic airway device, the King LT, A simple and timely adjunct to airway management. Am J
during spontaneous ventilation. Anesth Analg 102: Emerg Med 25:263–267, 2007.
621–625, 2006. Additional Reading
4. King Systems: King LTS-D Quick Guide, Noblesville, IN,
2013. <http://www.kingsystems.com/wp-content/uploads/ Ostermayer DG, Gausche-Hill M: Supraglottic airways: The
2010/09/Lit-109-KingLTS-D-0213.pdf>. (Accessed history and current state of prehospital airway adjuncts.
06.01.15. Prehosp Emerg Care 18(1):106–115, 2014.
5. King Systems: King LTS-D Instructions for Use,
Noblesville, IN, 2009. <http://www.kingsystems.com/
wp-content/uploads/2010/09/INFM-63-KLTSS.pdf>.
(Accessed 06.10.15).
PROCEDURE
8
Laryngeal Mask Airway
Stephen Both
PURPOSE: Despite the wide adoption and use of the laryngeal mask airway
(LMA) for routine surgery, this procedure focuses on this device’s utility as an
emergency airway device involving a lost or compromised airway in the
unconscious patient when endotracheal intubation is not readily available or has
failed (e.g., cardiac arrest, prehospital airway management, failed intubation/
difficult airway, conduit for intubation). Although second-generation LMAs offer
better protection against aspiration, it should be understood that the LMA is not a
definitive airway.1,2,4,7
PREREQUISITE NURSING before fasting. However, in all these clinical sce-

narios, the LMA Supreme (second-generation supra
KNOWLEDGE glottic device) is ideally suited to serve as an “airway
• The requirements for rapid airway management in an rescue device” in preference to the LMA Classic or
unconscious patient should be understood. the LMA Unique (first-generation supraglottic
• The anatomy and physiology of the upper airway should device).3,5
be understood. ❖ LMA Supreme is contraindicated in the following:
• The design of the LMA available should be understood Patients with fixed decreased pulmonary compli-
(Figs. 8-1 and 8-2): ance, such as in pulmonary fibrosis due to inade-
❖ An airway tube connects the mask and the 15-mm male quate seal around the larynx5
adapter. Adult patients who have had radiotherapy to the
❖ The mask’s cuff, when inflated, conforms to the con- neck involving the hypopharynx (risk of trauma,
tours of the hypopharynx, with the opening of the air failure to seal effectively)5
tube positioned directly over the laryngeal opening. Patients with a mouth opening inadequate to permit
❖ A cuff inflation line with a valve and a pilot balloon insertion8
leads to the mask’s cuff. Patients with suspected acute intestinal obstruction
• Benefits of second-generation LMAs over first generation or ileus or patients having been injured shortly after
LMAs should be understood (Table 8-1). ingesting a substantial meal8
• The final placement of an LMA in the airway should be Patients who have ingested caustic substances5
understood (Fig. 8-3). ❖ LMA Supreme usage precautions include the follow-
• The ability to ventilate an unconscious patient adequately ing:
5
with a mouth-to-mask or bag-valve-mask device is ❖ The LMA Supreme is a single use–only device.
necessary. Due to oropharyngeal tissue being specifically
• The underlying risks of the LMA should be understood. prone to swelling and bleeding with mild to moder-
❖ Due to the potential risk of regurgitation and aspiration, ate traumatic forces (potentially resulting in dire
do not use the LMA as a “first-choice airway” in the consequences), excessive force should not be used
following elective or difficult airway patients on a non- at any time during insertion of the LMA Supreme
emergency pathway9: or insertion of a gastric tube through the drain tube
Patients who have not fasted, including patients of the LMA Supreme.5
whose fasting cannot be confirmed.5 Never overinflate the cuff after insertion. An appro-
Patients who are morbidly obese, who are more than priate intracuff pressure is 60 cm H2O. Excessive
14 weeks pregnant, who have multiple or massive intracuff pressure can result in malposition and sore
injury or acute abdominal or thoracic injury, who throat, dysphagia, or nerve injury.5,6,8
have any condition associated with delayed gastric If airway problems persist or ventilation is inade-
emptying, or who have used opiate medication quate, the LMA Supreme should be removed and an
airway established by some other means.9
The LMA Supreme is made of medical grade poly-
vinyl chloride that can be torn or perforated. Avoid
practice nurses, and other healthcare professionals (including critical care contact with sharp or pointed objects at all times. Do
nurses) with additional knowledge, skills, and demonstrated competence per not insert the device unless the cuff is fully deflated
professional licensure or institutional standard. as described in the instructions for insertion.5
53
Cuff
Aperture bar Valve
Inflation indicator balloon
Inflation line Soft palate

Airway Uvula Posterior
connector third of tongue
Epiglottis
Aryepiglottic
Mask fold
Laryngeal
Airway tube inlet
Pyriform
Figure 8-1 Components of the first-generation laryngeal mask Interarytenoid fossa
airway (LMA; LMA Classic pictured). (From the Laryngeal Mask notch
Mucous
Company Limited: Instruction manual: LMA-Classic. San Diego, membrane
2005, Laryngeal Mask Company Limited.) Thyroid gland covering
cricoid cartilage
Airway tube Esophagus Upper
Drain (15-mm connector) esophageal
tube sphincter
LMA Supreme Figure 8-3 Dorsal view of the laryngeal mask airway (LMA)
Fixation manifold showing position in relation to pharyngeal anatomy(LMA Classic
tab pictured.) (From The Laryngeal Mask Company Limited: Instruc-
Integrated tion manual: LMA-Classic. San Diego, 2005, Laryngeal Mask
bite block Company Limited.)
Elliptical
airway tube TABLE 8-1 Improvements to Second-
Modified cuff Generation Supraglottic
Airway Devices Compared
With First Generation
Drain tube
opening Design
Pilot
balloon Improvements Rationale
Figure 8-2 Components of a second-generation laryngeal mask Improved Controlled ventilation at higher airway
airway (LMA; LMA Supreme pictured): Manifold with an integral pharyngeal seal pressures (and hence in a wider range
bite block, an anatomically shaped airway tube enclosing a drain
of patients and clinical situations)
tube, a modified cuff through which a cuff inflation line with pilot
tube. (From Hagberg C: Benumof and Hagberg’s Airway Manage- Increased Lessens the likelihood of regurgitant
ment, ed 3, Philadelphia, 2013, Elsevier.) esophageal fluids entering the pharynx and
seal leading to aspiration
Gloves should be worn during preparation and Integrated bite Impedes patient’s ability to bite and
insertion to minimize contamination of the airway.5 block potentially occlude the airway, risking
Store device in a dark, cool environment, avoiding hypoxia and negative pressure
direct sunlight or extremes of temperature.5,9 pulmonary edema
• The LMA may provide a more viable means of ventilation Gastric port May be used to confirm correct device
than a bag-valve-mask device in patients with a beard or positioning, enable access to the
without teeth.3 stomach, alert the user to the
• Initial and ongoing training is necessary to maximize presence of regurgitation, and enable
insertion success and minimize complications.3–5,7 gastric contents to safely bypass the
• This procedure refers specifically to the LMA Supreme, a oropharynx and exit the patient (e.g.,
second-generation LMA. Other types of second-generation Laryngeal Mask Airway [LMA]
LMA devices are available and provide additional fea- Supreme and LMA Proseal)
tures, such as use as a conduit for endotracheal intubation From Cook T, Woodall N, Frerk C: Major complications of airway management in
through the LMA (e.g., LMA Fastrach). the UK: The Fourth National Audit Project of the Royal College of Anaesthetists,
• An understanding of the different models now available 2011, available at www.rcoa.ac.uk/nap4.
will aid in LMA selection (Table 8-2).
• Understand the advantages and disadvantages of LMAs
compared with facemask ventilation and endotracheal
tube intubation (Table 8-3).
8 Laryngeal Mask Airway 55
TABLE 8-2 Type of Laryngeal Mask Airway (LMA) With Corresponding Generation
and Features
Type of Supraglottic
Device (LMA) Generation LMA Features
LMA Classic 1st Early prototype nondisposable LMA
LMA Unique 1st Disposable standard LMA
LMA Proseal 2nd Inflatable cuff with improved pharyngeal seal = ventilation tolerances, gastric port, and
LMA Supreme 2nd an integrated bite block
I-Gel LMA 2nd Noninflatable gel cuff rather than inflatable cuff for pharyngeal seal, gastric channel,
and integrated bite block
Air-Q LMA 2nd Designed to facilitate endotracheal intubation through the LMA device; no gastric port
AMBU Aura-I LMA 2nd
LMA Fastrach 2nd
LMA CTrach 2nd Incorporates a camera to facilitate passage of an endotracheal tube; no gastric port
From Hagberg C: Benumof and Hagberg’s Airway Management, ed 3, Philadelphia, 2013, Elsevier; Butterworth J, Mackey DC, Wasnick J: Morgan & Mikhail’s Clinical
Anesthesiology, ed 5, New York, 2013, McGraw Hill; Nagelhout JJ, Plaus KL: Nurse anesthesia, ed 5, St. Louis, 2014, Elsevier.
TABLE 8-3 Advantages and Disadvantages of the Laryngeal Mask Airway (LMA) Compared
With Facemask Ventilation and Tracheal Intubation
Advantages Disadvantages
LMA compared • Hands-free operation • More invasive
with facemask • Better seal in bearded patients • More risk of airway trauma
• Often easier to maintain airway • Requires new skill
• Protects against airway secretions • Multiple contraindications
• Less facial nerve and eye trauma
LMA compared • Less invasive • Increased risk of gastrointestinal aspiration
with tracheal • Very useful in difficult intubations • Limits maximum positive pressure ventilation
intubation • Less tooth and laryngeal trauma • Less secure airway
• Less laryngospasm and bronchospasm • Can cause gastric distention
• Does not require neck mobility • Not designed for prolonged use; maximum time period of
• No risk of esophageal or endobronchial intubation 10–24 hours has been studied without adverse effects4
From Butterworth J, Mackey DC, Wasnick J: Morgan & Mikhail’s Clinical Anesthesiology, ed 5, New York, 2013, McGraw-Hill.
TABLE 8-4 Laryngeal Mask Airways (LMA) Supreme Selection Guide

Maximum Size Recommended Maximum Optimum Intra-Cuff
Airway Size Patient Weight Nasogastric Tube Inflation Volume Pressure (Do Not Exceed)
1 <5 kg 6 Fr 5 mL 60 cm H2O
1.5 5–10 kg 6 Fr 8 mL
2 10–20 kg 10 Fr 12 mL
2.5 20–30 kg 10 Fr 20 mL
3 30–50 kg 14 Fr 30 mL
4 50–70 kg 14 Fr 45 mL
5 70–100 kg 14 Fr 45 mL
From Teleflex Medical Incorporated, Morrisville, NC.
EQUIPMENT • Suction equipment (suction canister with control head,

tracheal suction catheters, Yankauer suction tip)
• LMA Supreme size selection (Table 8-4) • Mouth-to-mask or bag-valve-mask device attached to a
5
❖ For normal adults, use the size 4 device as a first choice. high-flow oxygen source
• Water-soluble lubricant • Tape
• Gloves, mask, and eye protection • 60-cm3 syringe
Additional equipment, to have available as needed, includes ventilate a patient with decreased pulmonary compliance
the following: may override the occlusive pressure of the LMA.5
• Nasogastric (NG) tube (for sizing see Table 8-4). The • Assess predictors of difficult LMA insertion.10 Consider
drain port of the LMA Supreme can facilitate the passage the mnemonic “RODS”:
of an appropriately sized NG tube after correct positioning ❖ R = restricted mouth opening
of an LMA Supreme. ❖ O = obstruction/obesity
❖ D = disrupted or distorted airway
PATIENT AND FAMILY EDUCATION ❖ S = stiff, as in asthma, pulmonary fibrosis, or pulmo-

nary edema10
• If time allows, provide the family with information regard-
ing the LMA and the reason for insertion. Rationale: This Patient Preparation
information assists the family in understanding why the • If time permits, assess the patient’s and family’s level of
procedure is necessary and decreases family anxiety. understanding about the condition and rationale for use of
the LMA. Rationale: This assessment identifies the
patient’s and family’s knowledge deficits concerning the
PATIENT ASSESSMENT AND patient’s condition.
PREPARATION • Ensure adequate ventilation and oxygenation with either a
mouth-to-mask or bag-valve-mask device (see Procedure
Patient Assessment 31). Rationale: The patient is nonresponsive and apneic
• Assess the level of consciousness and responsiveness. without assisted ventilation before the LMA insertion.5
Rationale: In an emergency situation, the LMA should be • Ensure that the suction equipment is assembled and in
inserted only into a patient who is profoundly unconscious working order. Rationale: The patient may regurgitate
and unresponsive.5 Laryngospasm and/or vomiting may during the insertion or while the LMA is in place and may
result, causing the inability to ventilate if an LMA is require oropharyngeal or tracheal suctioning.5
introduced into a conscious or semiconscious patient. • Anything that is not permanently affixed in the patient’s
• Assess history and patient information for the possibility mouth (e.g., dentures, partials, jewelry) should be removed.
of delayed gastric emptying (e.g., hiatal hernia, recent Rationale: Inadvertent dislodgment and aspiration might
food ingestion, poorly controlled diabetes). Rationale: In occur with the placement of the LMA.5 Significant time
a patient with delayed gastric emptying, the benefits of should not be wasted in removing such oral appliances if
LMA insertion must be weighed against the possibility of significant hypoxia is being experienced.
regurgitation.5 • Placement is most successful with the patient positioned
• Assess history and patient information for possibility of supine with the head in the neutral or sniffing position.5
decreased pulmonary compliance (i.e., pulmonary fibro- Rationale: Proper head positioning facilitates successful
sis, obesity). Rationale: The high pressures needed to placement of an LMA.
Procedures for Laryngeal Mask Airway (LMA Supreme) Insertion

1. HH
2. PE
3. Ensure that a spare LMA of the Provides for a “backup” device
same type is immediately should the initial device fail.
available. (Level M*)
4. Remove the LMA from the Ensures that the device is not
package and inspect. (Level M) defective and will work as
indicated.
A. Inspect the exterior of the Ensures that the exterior surface of
mask for any cuts, tears, or the device has not been damaged in
scratches. any way.
B. Inspect the interior of the Particles in the airway tube may be Discard the device if any evidence of
airway tube for any particles inhaled when the device is used. damage is found and open the
backup device
C. Examine the 15-mm male The 15-mm male connector is Discard the device if any particles
connector at the end of the essential for ventilation with a cannot be removed from the tube
airway tube and ensure that it bag-valve device or ventilator. and open the backup device
fits tightly into the tube.

Procedures for Laryngeal Mask Airway (LMA Supreme) Insertion—Continued

5. Perform the deflation and
inflation tests. (Level M*)
A. Expel the air from the 60-mL Ensures that the device is not
syringe and connect it to the defective and will work as
pilot balloon valve. indicated.
B. Pull back the syringe plunger The appropriate-size syringe is Discard the device if the connector
to deflate the cuff fully. needed to inflate the cuff to the does not fit tightly into the airway
proper test level. tube and open the backup device.5
C. Examine the cuff to ensure Full deflation of the cuff helps ensure Discard the device if the cuff does not
that it remains fully deflated its patency. remain fully deflated and open the
(Fig. 8-4). backup device.5
D. Obtain a 60-ml syringe and Ensures that the device is not Discard the device if the cuff does not
pull back on the syringe to the defective and will work as remain fully deflated and open the
volume required for each indicated. backup device.5
LMA size, reattach to the
valve, and inflate the cuff with
the appropriate volume for the
size (see Table 8-4).
E. Examine the inflated cuff to Ensure that the device is not defective Discard the device if the cuff bulges
ensure that it is symmetrical and will work as indicated. asymmetrically and open the
without bulges. backup device.5
F. Examine the pilot balloon to Ensures that the device is not Discard the device if the pilot balloon
ensure that its inflated shape defective and will work as is spherical or bulges and open the
is elliptical. indicated. backup device.5
Insertion Technique
(If possible, preoxygenate patients Facilitates replacing nitrogen with Conditions that increase oxygen
with 100% oxygen for several oxygen in the lungs. Increases the demand (e.g., sepsis, pregnancy)
minutes before the insertion of any duration of apnea without and decrease functional residual
advanced airway adjunct desaturation, which facilitates more capacity (e.g., morbid obesity,
intervention) (Level E*).4,6,7 time to place airway adjunct and pregnancy) reduce the apnea period
improves patient safety before desaturation ensues.6
Figure 8-4 Laryngeal Mask Airway (LMA) Supreme deflation technique. After
firmly connecting a syringe of at least 50 mL to the inflation port, hold the syringe
and the LMA Supreme exactly as shown. Compress the distal end of the device in
between the index finger and thumb while withdrawing air until a vacuum has been
obtained. While deflating, hold the device so that the distal end is curled slightly
anteriorly. Deflate the device until the tension in the syringe indicates that a vacuum
has been created in the mask. Keep the syringe under tension while rapidly discon-
necting it from the inflation port. (From Teleflex Medical Incorporated, Morrisville,
NC.)


6. Fully deflate the cuff by holding Facilitates smooth insertion and
the device so that the distal end is avoids deflection of the epiglottis.
curled slightly anteriorly, as
shown in Fig. 8-4. Attach a
syringe. Compress the distal tip
of the mask with thumb and
index finger. (Level M*)
7. Lubricate the posterior surface of Facilitates smooth insertion. Avoid excessive lubrication on the
the cuff and airway tube with a anterior portion (aperture side) of
small amount of water-soluble the cuff because it may be aspirated
lubricant (Fig. 8-5, Step 2). or occlude lumen.
(Level M) Do not use lidocaine lubricants
because they may delay the return
of protective reflects and may cause
an allergic reaction.9
8. Stand behind or besides the Facilitates proper body position for The patient’s head may be left in a
patient’s head. Place the patient’s the person inserting the device and neutral position if cervical spine
head in the neutral or sniffing the patient’s head during insertion. injury is possible.5 If cervical
position (see Fig. 8-5, Step 3). instability is suspected, manual
(Level E*) stabilization should be maintained
by the assistant during the
placement procedure.
9. Hold the device exactly as shown in Facilitates smooth insertion.
Fig. 8-5. Press the distal tip against
the inner aspect of the upper teeth
or gums (see Fig. 8-5, Step 3).
10. Slide inwards using a slightly Assists in maneuvering the LMA into Do not use force. If the LMA does not
diagonal approach (direct the tip the proper position advance, remove, reventilate, and
away from the midline). Continue reinsert.9 The mask must be pressed
to slide inwards, rotating the hand up against the hard palate to be
in a circular motion so that the inserted correctly.9 If the cuff becomes
device follows the curvature behind obstructed by the tonsils, a diagonal
the tongue (see Fig. 8-5, Step 4). maneuver is often successful.5,9
11. Resistance should be felt when Continues moving the LMA into the
the distal end of the device proper final position.
meets the upper esophageal
sphincter. The device is now fully
inserted (see Fig. 8-5, Step 5).
12. Inflate with the minimal amount of The recommended intracuff pressure
air needed to achieve an effective should not exceed 60 cm H2O.
seal. For further details on a
successful insertion, see Box 8-1.
Securing the LMA (Fixation)5
13. Use a piece of adhesive tape Facilitates the approximate length
30–40 cm long, holding it necessary to secure the LMA.
horizontally by both ends
14. Press the adhesive tape The fixation tab is located above the Fixation tab should be located 1–2 cm
transversely across the fixation bite block on LMA Supreme. Other above the lips if placement and
tab (if present) or an area 2–3 cm first- and second-generation devices sizing is appropriate. Fixation tab
above the lips on the LMA do not possess fixation tabs. should not be applied with
airway tube. downward pressure to lips/teeth nor
be located >3 cm above the lips
(may indicate improper sizing or
improper placement of LMA).
BOX 8-1 Successful Insertion of a

Laryngeal Mask Airway Depends
Upon Attention to Several
Details
1. Choose the appropriate size (see Table 8-4) and check for leaks
A B before insertion.
2. The leading edge of the deflated cuff should be wrinkle free and
face away from the aperture.
3. Lubricate the back side of the cuff.
4. The patient must be vastly unresponsive and relaxed before
attempting insertion.
5. Place the patient’s head in sniffing position (see Fig. 8-5).
6. Correct positioning can be aided by using your index finger to
guide the cuff along the hard palate and down into the
C D hypopharynx until an increased resistance is felt.
Figure 8-5 Insertion of second-generation Laryngeal Mask 7. Inflate with the correct amount of air (see Table 8-4).
Airway (LMA) Supreme. (From Teleflex Medical Incorporated, 8. Obstruction after insertion is usually due to a down-folded
Morrisville, NC.) epiglottis or transient laryngospasm.
9. Avoid pharyngeal suction, cuff deflation, or laryngeal mask
removal until the patient is awake (e.g., opening mouth on
command) unless removing to facilitate a more secure airway.
From Butterworth J, Mackey DC, Wasnick J: Morgan & Mikhail’s Clinical

Anesthesiology, ed 5, New York, 2013, McGraw-Hill.

15. Continue to press downward so Secures the LMA with slight inward Without securing the LMA in place,
that the ends of the tape adhere to pressure. This assists in maintaining displacement or migration of device
each of the patient’s cheeks and LMA seal. from airway is probable.
the device itself is gently pressed
inwards by the tape.
16. Bite block may be considered if The patient may bite down on a Second-generation LMAs incorporate
utilizing a first-generation LMA. first-generation LMA airway, bite blocks within the device.
collapsing the tube and thus
compromising airway.
17. Dispose of supplies.
18. HH
Procedures for Laryngeal Mask Airway (LMA Supreme) Correct Position

1. Correct placement should produce Maintenance of low ventilator If sounds are heard in the epigastrium
a leak-free seal against the glottis, pressures prevents overriding the on auscultation, remove the device
with the mask tip at the upper pressure in the cuff, creating a and manually ventilate the patient
esophageal sphincter leak, or forcing air into the with a bag-valve mask.
2. The bite-block portion of the stomach. Limit tidal volumes to <8 mL/kg.
LMA Supreme should lie between Helps confirm correct depth with Observe a slight up-down meniscus
the teeth. primary assessment. movement of the lubricant following
3. A drop of water-soluble lubricant Confirms proper placement with tip the application and release of gentle
(1–2 mL) can be placed on the of LMA sealed in esophagus. pressure on the suprasternal notch,5
proximal end of the gastric Indicates that the distal end of the aka “suprasternal notch test.”5 This is
drainage tube port. drain tube is correctly placed so more important if the rescuer plans to
4. Observe a slight up-down that it seals around the upper pass an NG tube of appropriate size
meniscus movement of the esophageal sphincter down the LMA for gastric
lubricant following the decompression purposes. Increased
application and release of gentle risk of laryngospasm and airway
pressure on the suprasternal notch occlusion can result if the LMA is
mal-positioned, resulting in NG
placement down the bronchi.
Procedures for Laryngeal Mask Airway (LMA Supreme) Removal

1. HH Removal may prevent agitation, Removal of the LMA is often to
2. PE regurgitation, and laryngeal spasm. facilitate the placement of a more
3. Remove the LMA as follows: Prevents excess ventilator pressures. secure and definitive airway such as
A. Gently assist with ventilations Indicates a return of some protective an endotracheal tube. This is
when the patient begins reflexes. usually accomplished by personnel
spontaneously breathing. If the LMA is removed before specifically trained in airway
B. Observe for signs of effective swallowing and coughing, emergencies (e.g., anesthesiologists
swallowing. When the patient secretions may enter the larynx, and certified registered nurse
can open his or her mouth on causing bronchospasm. anesthetists).
command, deflate the cuff and Maintains monitoring of the airway Tape or tube-securing device may be
remove the LMA.5 and the patient’s ability to breathe removed at this time.
C. Continue to assess for airway on his or her own. Unless overt secretions are noted after
and breathing effectiveness: LMA removal, avoid suctioning
i. Establishment of an effective because it may cause laryngeal
airway in an emergency spasm. The cuff should remove
situation excess secretions when removed
ii. Maintenance of adequate and prevent aspiration.5
ventilation Potential complications related to the
iii. Recovery of spontaneous use of the LMA appear inversely
ventilation proportional to the experience and
4. Dispose of supplies. skill level of the operator and
5. HH patient-related factors (e.g.,
placement in semiconscious
individual, patients with full
stomachs, etc.).4,8
• Regurgitation
• Aspiration
• Laryngospasm
• Gagging
• Retching
• Trauma to tissues
• Damage to various nerves
• Sore or dry mouth
• Hoarseness, stridor
Expected Outcome Unexpected Outcomes

• Placement of patent artificial Airway • Aspiration of gastric contents
• Properly positioned and secured airway • Trauma to oral and pharyngeal tissue potentially
• Improved oxygenation and ventilation leading to worsening ventilation, nerve damage, and
aspiration of blood
• Inability to ventilate lungs effectively secondary to:
1. Improper sizing or position of LMA
2. High airway and thoracic pressures (e.g.: Obese and
Asthmatic patients)
3. Obstruction: secretion or foreign body
4. Pt semi-conscious
5. Poor seal of LMA cuff (over or under inflated)
6. Anatomical mismatch of patient and device (uncom-
mon anatomical airway variants can result in a poor
seal and fit of the LMA)4,6,7

interventions.
1. Monitor the patient and LMA Ensures proper ventilation and airway • Inability to ventilate patient
during ventilation for potential management. • Decreased oxygen levels despite
problems. Pressure-controlled and volume- adequate oxygen delivery
A. Attach a pulse oximeter and controlled ventilation may be used • Indications of an air leak,
monitor for trends. but should be minimized or avoided especially with a prolonged
B. Watch for air leaks around the because LMAs are not designed for expiratory phase or lack of normal
cuff that may be caused by long-term airway management. smooth oval swelling around the
malposition. If suspected, assess Pressure-controlled ventilation may cricothyroid membrane4,5
for normal smooth oval require lower peak airway • The LMA’s cuff pressures may
swelling around cricothyroid pressures.4,5,9 Efforts should be need to be adjusted during ascent
membrane. If absent, in made to secure a definitive airway and descent portions of air
conjunction with prolonged (endotracheal intubation) as soon as transport for unpressurized cabins
expiratory phase, remove the possible. With mechanical • Monitor for signs of excessive or
LMA, reventilate, and reinsert.9 ventilation, tidal volume, deficient LMA cuff pressures,
C. If regurgitation occurs, as respiratory rate, and inspiratory-to- namely, ventilation difficulties and
indicated by fluid in the airway expiratory ratios need to be excessive air leaks
tube, immediately tilt the adjusted to prevent high peak • Airway problems, difficulty with
patient’s head down and turn airway pressures.4,5,9 ventilation, or regurgitation
the patient’s body to one side, Monitors adequate oxygenation.
remove bag-valve device, and May indicate problems with the LMA
suction through the airway tube. position.
Do not add more air to the cuff
because it may force the soft cuff
off the larynx.5,9
Allows drainage and clearance of
fluid from the airway tube.
If airway problems, difficulty with
ventilation, or regurgitation
continue, remove the LMA and
establish an airway by other
means.9
Documentation
• Initial patient assessment that indicates a need for • Preoxygenation and ventilation before LMA insertion
LMA insertion • Insertion technique
• Performance of visual inspection, inflation and • Initial cuff inflation pressure
deflation tests • Signs of correct placement and cuff inflation
• After insertion, assessment of end-tidal carbon dioxide • Securing of the LMA
and chest rise and fall • After removal, patency of airway, effectiveness of
• Before removal, presence of swallowing and ability to breathing, pulse oximetry and vital sign readings,
open mouth patient symptoms, or signs of complications
• Any complications while the LMA is in place (e.g.,
regurgitation or air leaks)

8 Laryngeal Mask Airway 61.e1
References 7. Nagelhout J, Plaus K: Nurse Anesthesia, St. Louis, MO,

1. Neumar RW, et al: American Heart Association guidelines 2014, Elsevier.
for cardiopulmonary resuscitation and emergency 8. The Laryngeal Mask Company Limited: Instructions for
cardiovascular care science. Part 8: Adult advanced use—LMA Supreme, Victoria, Mahe, Seychelles, 2013, Le
cardiovascular life support. Circulation 122:S729–S767, Rocher.
2010. 9. The Laryngeal Mask Company Limited: LMA instruction
2. Apfelbaum J, et al: Practice guidelines for management of manual, San Diego, 2005, the Laryngeal Mask Company
the difficult airway. Anesthesiology 118(2):1–20, 2013. Limited.
3. Cook T, Woodall N, Frerk C: NAP4: 4th National audit 10. Walls RM, Murphy MF: Manual of emergency airway
project of the Royal College of Anaesthetists and the management, ed 4, Philadelphia, 2012, Lippincott
difficult airway society. March, 2011. Williams and Wilkens.
4. Hagberg C: Benumof and Hagberg’s Airway Management,
Philadelphia, 2013, Elsevier Saunders. Additional Readings
5. LMA Supreme Instruction Manual. The Laryngeal Mask Bosson N, Byrd R: Laryngeal mask airway. Medscape
Company Limited, 2010. 2014.
6. Morgan & Mikhail’s Clinical Anesthesiology. New York, Cattano D: Don’t forget the LMA! Anesthesia Patient Safety
2013, McGraw-Hill/Lange. Foundation Newsletter, Summer 2008.
PROCEDURE
9
Nasopharyngeal and Oral
Airway Insertion
Kimberly Wright
PURPOSE: Nasopharyngeal and oral airways are used to provide short-term
airway maintenance and to facilitate the removal of tracheobronchial secretions.
PREREQUISITE NURSING ❖ Patients with obstructed nasal passageways5

❖ Patients with suspected basilar skull or cribriform plate
KNOWLEDGE
fracture5
Nasopharyngeal Airway ❖ Patients with facial trauma that prevents the safe inser-
• Nasopharyngeal airways are inserted into a single naris tion or use of the airway3,5
and passed into the posterior oropharynx to the base of
the tongue (Fig. 9-1).2 Oropharyngeal Airway
• The nasopharyngeal airway has three parts: the flange, • Oropharyngeal airways are typically disposable, curved,
cannula, and bevel or tip. The flange is the wide trumpet- plastic or hard rubber devices with an opening or channel
like end that prevents further slippage into the airway. The to facilitate suctioning.1
hollow shaft of the cannula permits airflow into the hypo- • The oropharyngeal airway is placed over the tongue. The
pharynx. The bevel or tip is the opening at the distal end curvature or body of the airway displaces the tongue
of the tube. When the correct size is properly inserted, the forward from the posterior pharyngeal wall, a common
flange will rest against the patient’s naris3 and the tip can site of airway obstruction.
be seen resting posterior to the base of the tongue. • An oropharyngeal airway has four parts: the flange, body,
• The external diameter of the nasopharyngeal airway tip, and channel (Fig. 9-3). The flange rests against the
should be slightly smaller than the patient’s external nares lips. This design protects against aspiration into the
opening. The length of the nasopharyngeal airway is airway. The body of the airway curves over the tongue.
determined by measuring the distance between the tip The tip is the distal-most part of the airway toward the
of the patient’s nose and the tip of the patient’s earlobe base of the tongue.
(Fig. 9-2).3 Improperly sized nasopharyngeal airways may • Oral airways are manufactured in a variety of sizes for
result in increased airway resistance, limited airflow (if adults, children, and infants. Sizing depends on the age
the airway is too small), kinking, mucosal trauma, gagging, and size of the patient (Table 9-1). An alternative method
vomiting, and gastric distention (if the airway is too used to select the size of an oral airway is to place the
large).5 oropharyngeal airway on the space between the patient’s
• The advantages of the nasopharyngeal airway include ear lobe and the corner of the patient’s mouth (Fig. 9-4).3
ease and rapidity of insertion, increased comfort and toler- • Improperly sized airways can cause airway obstruction (if
ance in a conscious patient, decreased incidence of gag they are too small) and tongue displacement against the
reflex stimulation, minimal incidence of mucosal trauma oropharynx (if they are too large).3
during frequent suctioning, and the ability to be inserted • Oropharyngeal airways are contraindicated in a conscious
when the patient’s teeth are clenched.1,5 patient as they may stimulate a gag reflex and further put
• In selected patient situations, a nasopharyngeal airway the airway at risk for compromise due to vomiting.2
may be used to facilitate the passage of a fiberoptic bron- • An oropharyngeal airway may be used in conjunction with
choscope and to tamponade small bleeding blood vessels an oral endotracheal tube to facilitate artificial ventilation,
in the nasal mucosa. acting as a bite-block and preventing damage to the endo-
• Most available nasopharyngeal airways are designed to be tracheal tube, tongue, and soft tissues of the mouth.
placed into the right naris. Therefore, when inserted in the • Oropharyngeal airway placement should never be
left naris, the airway adjunct must be rotated until the attempted in a patient who is actively demonstrating
bevel is facing the nasal septum.3 seizure activity.
• Contraindications to the use of a nasopharyngeal airway
are as follows: EQUIPMENT
❖ Patients undergoing anticoagulation or antiplatelet
therapy5 • Appropriately sized nasal or oral airway
❖ Patients prone to epistaxis • Nonsterile gloves
62
9 Nasopharyngeal and Oral Airway Insertion 63
Flange Lips
Cannula Measure
jaw angle
Bevel
A
Flange
Cannula
Figure 9-4 Alternative Method for Selecting the Size of an Oro-

pharyngeal Airway. (From Eubanks DH, Bone RC: Comprehensive
respiratory care: A learning system, St. Louis, 1990, Mosby, 552.)
B Tip
Figure 9-1 Nasopharyngeal Airway. A, Airway parts. B, Proper
placement. (From Eubanks DH, Bone RC: Comprehensive respira-
tory care: A learning system, St. Louis, 1990, Mosby, 518.)
Measure to
tragus of ear
Flange secured
with safety pin
and tape
Airway tip
B
Figure 9-2 A, Estimating nasopharyngeal airway size. B, Nasopharyngeal position after insertion.
(From Eubanks DH, Bone RC: Comprehensive respiratory care: A learning system, St. Louis, 1990,
Mosby, 552.)
Flange Body Oropharyngeal

tube in place
Tip
A
Channel
Flange
Body
Channel
B Tip C
Figure 9-3 Oropharyngeal Airways. A, Guedel airway. B, Berman airway. C, Properly inserted
oropharyngeal tube. (From Eubanks DH, Bone RC: Comprehensive respiratory care: A learning
system, St. Louis, 1990, Mosby, 518.)
airways are generally used for temporary airway

TABLE 9-1 Oral Airway Sizes
maintenance.2
Diameter of Oral Size of Oral • Assess neurological status and assess for the presence of
Size of Patient Airway (mm) Airway (Guedel) the gag reflex. Rationale: Evaluation of the patient’s neu-
rological status assists in determining the need for an
Large adult 100 5
artificial airway. Presence or absence of the gag reflex can
Medium adult 90 4 help the nurse select the most appropriate airway adjunct.
Small adult 80 3 • Assess cardiopulmonary status. Rationale: Evaluation of
the patient’s cardiopulmonary status assists in determining
From Cummins RO, editor: Airway, airway adjuncts, oxygenation, and ventilation.
In ACLS: principles and practice, Dallas, 2003, American Heart Association, 145. the need for an artificial airway.
• For nasal insertion, assess the nasal passageway for any
apparent obstruction or deformity.3 With finger pressure,
occlude one nostril; feel for air movement under the open
nostril. Patency also can be assessed with inspection of
• Tongue depressor each naris with a flashlight. Rationale: Assessment of
• Water-soluble lubricant (nasopharyngeal airway) patency promotes smooth, quick, unobstructed airway
• Tape (nasopharyngeal airway) insertion, and reduces the risk for injury or bleeding.
Additional equipment, to have available as needed, includes • For nasal insertion, consider contacting the practitioner
the following: for an order to apply a topical anesthetic to coat the nasal
• Goggles, glasses, or face mask passageway. Rationale: Topical anesthetics with a vaso-
• Suction equipment constrictor help shrink nasal mucosa and decrease the
incidence of trauma and bleeding.
PATIENT AND FAMILY EDUCATION • For oral insertion, assess the condition of the oral mucosa,
dentition, and gums. Rationale: Preprocedural assessment
• Explain the purpose of the airway and the procedure to provides baseline information for later comparison.
conscious patients or to the family of an unconscious • For oral insertion, remove loose-fitting dentures and any
patient, if the patient’s condition and time allow. Ratio- foreign objects (including partial plates, tongue studs, lip
nale: This process identifies family knowledge deficits rings) from the mouth. Rationale: Removal ensures that
about the patient’s condition, the procedure, its expected objects do not advance further into the airway during
benefits, and its potential risks and allows time for ques- insertion.
tions to clarify information and voice concerns. Commu-
nication and explanation regarding therapy are cited as Patient Preparation
important needs of patients and families to relieve anxiety • Verify correct patient with two identifiers. Rationale:
and encourage communication. Prior to performing a procedure, the nurse should ensure
• Discuss the sensory experiences associated with airway the correct identification of the patient for the intended
insertion, including the presence of an airway in the nose intervention.
(nasal), the inability to clench teeth together (oral), and • Select the appropriate size of the airway adjunct by mea-
possible gagging. Rationale: Knowledge of anticipated suring as outlined previously in the Prerequisite Nursing
sensory experiences reduces anxiety and distress. Knowledge section. Rationale: Airway adjuncts must be
of the appropriate length and diameter to achieve airway
patency.
PATIENT ASSESSMENT AND • Position the patient. For nasal insertion, unless contrain-
PREPARATION dicated, a supine or high Fowler’s position is acceptable.
For oral insertion, the supine position is preferred. Ratio-
Patient Assessment nale: This positioning promotes patient and nurse comfort
• Assess the patient’s need for long-term airway mainte- and provides easy access to the external nares or oral
nance. Rationale: Nasopharyngeal and oropharyngeal cavity.
Procedure for Nasopharyngeal Airway Insertion

1. HH
2. PE To reduce the risk of exposure to
exhaled or coughed secretions,
consider donning protective
eyewear and face mask.
3. Assess the airway for the need to Facilitates visualization of nasal Suction should always be available to
suction blood or secretions. structures and potential obstacles clear the airway of any visible
to insertion. secretions or foreign bodies.6
(Level D*)
4. Generously lubricate the tip Facilitates passage of the device
and outer cannula of the airway into the correct position while
with water-soluble lubricant.2–4 reducing friction-related trauma.
(Level D)
5. Elevate the tip of the nose and Following the natural contour of If resistance is encountered, rotate the
gently slide airway into nostril. the nasal passage decreases the tube and continue gentle forward
Guide it posteriorly and toward incidence of trauma. pressure. Do not force the tube. If
the ear, along the nasal passage resistance continues, withdraw the
until the flange rests against the tube and try the other nostril.
nostril.2 (Level D) During tube insertion, if the patient
has increasing dyspnea or
respiratory distress, consider
removing the tube.
6. Visualize the oropharynx and tip Verifying the location of the airway
of the nasopharyngeal airway to in the pharynx confirms proper
ensure effective positioning has airway positioning and allows for
been achieved (see Fig. 9-2). inspection of posterior pharynx
for excessive bleeding or mucus.
7. Reassess airway patency.3 Feel Optimal airway positioning allows
for air movement over the flange. for forward airflow, removal of
Listen for snoring or other secretions, and possible
sounds concerning for upper prevention of airway occlusion.
airway obstruction. (Level D)
8. Suction secretions as needed. Maintains patent airway. Recheck flange for proper position.
9. Consider the need for bag-mask If respiratory effort is insufficient Nasopharyngeal airways are intended
ventilation or the need for or copious secretions threaten for short-term use to temporarily
placement of a definitive airway.3 airway patency, additional facilitate ventilation.
(Level D) measures are required to
maintain adequate ventilation.
10. Follow institution standard for Identifies need for pain Continued pain despite pain
assessing pain. Administer interventions. interventions.
11. Discard used supplies and
equipment.
12. Remove gloves and perform
hand hygiene

Procedure for Oropharyngeal Airway Insertion

1. HH
2. PE Protective eyewear or face masks
should be worn in the presence of
copious secretions.
3. Suction the mouth and pharynx Clears airway of secretions, blood,
with a rigid pharyngeal suction tip and vomit so that they do not
(Yankauer) catheter, if blood or enter the airway with airway
secretions are present. insertion.6 (Level D*)
4. Open the patient’s mouth with the Provides access to oral cavity.
chin-lift maneuver crossed-finger
technique (Fig. 9-5).3 (Level D)
Figure 9-5 Crossed-Finger Technique for Opening the Mouth. (From

Eubanks DH, Bone RC: Comprehensive respiratory care: A learning
system, St. Louis, 1990, Mosby, 631.)
5. Remove poorly fitted or broken Poorly fitted or broken dentures can Consider leaving well-fitted dentures
dentures, if present. hinder the insertion of the airway in place to maintain structure and
adjunct and can pose additional support for the oropharyngeal
risk for airway obstruction. airway.
6. Insert oral airway with curved end Prevents posterior tongue Remove the airway immediately if the
up (Fig. 9-6A), or lateral to displacement. patient gags, gasps for air, or begins
tongue.4 A tongue depressor may breathing irregularly. The airway
assist in tongue control during should never be inserted end-up in
insertion. (Level D) children, as this poses increased
risk for damage to the soft palate.
Airway tip
points up Figure 9-6 Insertion of an Oro-
pharyngeal Airway. A, Advance
airway with curved end up.
Airway rotated B, Rotate airway 180 degrees.
180 degrees (From Eubanks DH, Bone RC:
Comprehensive respiratory care:
A learning system, St. Louis,
1990, Mosby, 551.)
A B
Procedure for Oropharyngeal Airway Insertion—Continued

7. Advance oral airway over the base Prevents posterior tongue
of the tongue until the flange is displacement.
parallel with the patient’s nose.
8. Gently rotate the tip to point down Positions the airway adjunct to hold When the oral airway is properly
(see Fig. 9-6B); the flange should the tongue in the normal sized, the flange should rest against
rest against the patient’s lips. anatomical position.3 (Level D*) the patient’s lips (see Fig. 9-4).
9. Verify airway patency by Proper placement and size are
ventilating the patient with a essential for securing and
bag-mask device and carefully maintaining a patent airway.2,3
assessing for resistance or (Level D)
obstruction.
10. Suction pharynx as needed. Maintains patent airway; pooled
secretions provide a medium for
bacterial growth.
11. Reassess the patient’s respiratory Validates the effectiveness of the
status. oral airway.
12. Consider the need for placement If respiratory effort is insufficient Oropharyngeal airways are intended
of a definitive airway.3 (Level D) or copious secretions threaten for short-term use to temporarily
airway patency, additional facilitate ventilation in the
measures are required to unconscious patient.3
maintain adequate ventilation.
equipment.
14. Remove PE and perform hand
hygiene.

• Airway patency maintained • Pulmonary aspiration
• Effective removal of tracheobronchial secretions • Inability to insert airway due to patient condition
• Effective positioning of airway and displacement of • Airway obstruction
tongue away from hypopharynx • Nasal or oral mucosal trauma or ulceration
• Epistaxis

interventions.
1. In the rare event the adjunct must Allows for more complete • Redness
remain in place for a prolonged inspection of the mucosa, • Swelling
period of time, assess skin and cavity, and surrounding tissues; • Drainage
mucosa in contact with airway enables complete hygiene. • Bleeding
adjunct every 8–12 hours. • Skin breakdown
2. Consider removing and reinserting
a new nasal airway in the opposite
naris each assessment to prevent
skin breakdown.

3. Provide meticulous oral care Decreases secretions, • Lacerations
every 2–4 hours and as needed. encrustations, oral infections, • Ulcerations
and airway port occlusions. • Areas of necrosis
• Drainage
4. Oxygenate and suction as Retained secretions increase the • Change in character or amount
necessary, per assessment. potential for airway obstruction of secretions
and pulmonary infections.
5. Monitor respiratory status every Change in respiratory status may • Change in respiratory status not
2–4 hours. indicate displacement of corrected with repositioning of
airway or worsening airway or suctioning
respiratory condition. • Stridor
• Crowing
• Gasping respirations
• Snoring
Documentation
• Patient and/or family education • Verification of proper placement
• Insertion of nasopharyngeal or oropharyngeal airway • Method of adjunct securement, if any
• Size of airway adjunct inserted • Appearance and character of airway secretions, if
• Any difficulties with insertion or unexpected outcomes present
• Use of lubrication and/or topical anesthetics • Tissue integrity around airway adjunct
• Patient tolerance, including respiration, vital signs, and
pain assessments before and after procedure

9 Nasopharyngeal and Oral Airway Insertion 68.e1
References Additional Readings

1. Feliciano D, Mattox K, Moore E, editors: Trauma, ed 7, Harless J, Ramaiah R, Bhananker SM: Pediatric airway
New York, 2012, McGraw-Hill. management. Int J Crit Illn Inj Sci 4:65–70, 2014.
2. American College of Surgeons, Committee on Trauma: Kim SH, et al: An assessment of oropharyngeal airway
Advanced trauma life support student course manual, position using a fibreoptic bronchoscope. Anaesthesia
ed 9, Chicago, IL, 2012, American College of Surgeons. 69:53–57, 2014.
3. Gurney D: Airway and ventilation. Trauma nursing core Roberts K, Whalley H, Bleetman A: The nasopharyngeal
course provider manual, ed 7, Des Plaines, IL, 2014, airway: dispelling myths and establishing the facts.
Emergency Nurses Association, pp 55–62. J Emerg Med 22:394–396, 2005.
4. Higginson R, Jones B, Davies K: Emergency and intensive St. John RE, Seckel MA: Airway management. In Burns SM,
care: assessing and managing the airway. Br J Nurs editor: AACN protocols for practice: care of the
16:970–977, 2011. mechanically ventilated patient, ed 2, Sudbury, MA, 2007,
5. Kundra P, Parida S: Awake airway control in patients with Jones and Bartlett Publishers.
anticipated difficult mask ventilation. Indian J Anaesth St John R, Seckel M: Airway management. In Burns SM,
58:206–208, 2014. editor: Care of mechanically ventilated patients, ed 2,
6. Bullard D, et al: Contraindications to nasopharyngeal Sudbury, MA, 2007, Jones and Bartlett.
airway insertion. Nursing 42(10):66–67, 2012.
PROCEDURE
10
Suctioning: Endotracheal or
Tracheostomy Tube
Maureen A. Seckel
PURPOSE: Endotracheal or tracheostomy tube suctioning is performed to
maintain the patency of the artificial airway and to improve gas exchange, decrease
airway resistance, and reduce infection risk by removing secretions from the
trachea and main-stem bronchi. Suctioning also may be performed to obtain
samples of tracheal secretions for laboratory analysis.
PREREQUISITE NURSING ❖ Auscultation of adventitious lung sounds (rhonchi)

KNOWLEDGE over the trachea or main-stem bronchi or both
❖ Increase in peak airway pressures when the patient is
• Endotracheal and tracheostomy tubes are used to maintain on mechanical ventilation
a patent airway and to facilitate mechanical ventilation. ❖ Increase in respiratory rate or frequent coughing or
The presence of these artificial airways, especially endo- both
tracheal tubes, prevents effective coughing and secretion ❖ Gradual or sudden decrease in arterial blood oxygen
removal, necessitating periodic removal of pulmonary (Pao2), arterial blood oxygen saturation (Sao2), or arte-
secretions with suctioning. In acute-care settings, suction- rial saturation via pulse oximetry (Spo2) levels
ing is always performed as a sterile procedure to prevent ❖ Sudden onset of respiratory distress, when airway
hospital-acquired infections. patency is questioned
• Suctioning is performed with one of two basic methods. • Suctioning of airways should be performed only for a
In the open-suction technique, after disconnection of the clinical indication and not as a routine fixed-schedule
endotracheal or tracheostomy tube from any ventilatory treatment.28,29
tubing or oxygen sources, a single-use suction catheter is • Hyperoxygenation should always be provided before and
inserted into the open end of the tube. In the closed- after each pass of the suction catheter into the endotra-
suction technique, also referred to as in-line suctioning, a cheal tube, whether with the open- or closed-suctioning
multiple-use suction catheter inside a sterile plastic sleeve method. Use of the ventilator to hyperoxygenate is pre-
is inserted through a special diaphragm attached to the end ferred over manual ventilation to hyperoxygenate and is
of the endotracheal or tracheostomy tube (Fig. 10-1). The more effective at delivering a fraction of inspired oxygen
closed-suction technique allows for the maintenance of (Fio2) of 1.0.28,29 Note: Much of the research and guide-
oxygenation and ventilation support, which may be ben- lines regarding suctioning has been done with endotra-
eficial in patients with moderate to severe pulmonary cheal or tracheostomy patients on mechanical ventilation.
insufficiency. In addition, the closed-suction technique For tracheostomy patients who are not on mechanical
decreases the risk for aerosolization of tracheal secretions ventilation, the need to preoxygenate or hyperventilate
during suction-induced coughing and may reduce some should be based on institutional protocol and individual-
hand and equipment cross contamination. Use of the ized patient assessment including level of consciousness,
closed-suction technique is preferred in patients who ability to cough and manage secretions, Spo2, and Fio2.
experience cardiopulmonary instability during suctioning • Suctioning is a necessary procedure for patients with arti-
with the open technique, who have high levels of positive ficial airways. When clinical indicators of the need for
end-expiratory pressure (PEEP; >10 cm H2O) or inspired suctioning exist, there is no absolute contraindication to
oxygen (>80%),who are at risk for derecruitment, who suctioning. In situations in which suctioning would be
have grossly bloody pulmonary secretions, or in whom poorly tolerated by the patient, strong evidence of a clini-
airborne transmission of disease with risk to the health- cal need for suctioning should exist and a specific plan for
care worker, such as active pulmonary tuberculosis, is suctioning, developed with the healthcare team, should be
suspected. implemented.
• Indications for suctioning include the following: • Complications associated with suctioning of artificial
❖ Secretions in the artificial airway airways include the following:
❖ Suspected aspiration of gastric or upper-airway ❖ Hypoxemia
secretions ❖ Respiratory arrest
69
❖ Cardiac arrest fibrosis, bronchiectasis) but has not been shown in the
❖ Cardiac dysrhythmias (premature contractions, tachy- literature to be effective for routine use in all patients.34
cardias, bradycardias, heart blocks) • Adequate systemic hydration and supplemental humidifi-
❖ Hypertension or hypotension cation of inspired gases assist in thinning secretions for
❖ Decreases in mixed venous oxygen saturation (Svo2) easier aspiration from airways. Instillation of a bolus of
❖ Increased intracranial pressure normal saline solution does not thin secretions, may cause
❖ Bronchospasm decreases in arterial and mixed venous oxygenation, and
❖ Pulmonary hemorrhage or bleeding may contribute to lower-airway contamination from the
❖ Pain and anxiety mechanical dislodgment of bacteria within the artificial
• Tracheal mucosal damage (epithelial denudement, hyper- airway or from contamination of saline solution during
emia, loss of cilia, edema) occurs during suctioning when instillation.28,29
tissue is pulled into the catheter tip holes. These areas of • The suction catheter should not be any larger than half of
damage increase the risk of infection and bleeding. Use the internal diameter of the endotracheal or tracheostomy
of special-tipped catheters, low levels of suction pressure, tube (Table 10-1).
or intermittent suction pressure has not been shown to
decrease tracheal mucosal damage with suctioning. EQUIPMENT
• Postural drainage and percussion may improve secretion
mobilization from small to large airways in chronic respi- • Open technique
ratory diseases with large mucus production (e.g., cystic ❖ Suction catheter of appropriate size (see Table 10-1)
❖ Sterile saline or sterile water solution
❖ Sterile gloves
❖ Sterile solution container
❖ Source of suction (wall mounted or portable)
❖ Connecting tube, generally 4 to 6 ft.
❖ Goggles and mask, or mask with eye shield
the following:
❖ Manual self-inflating manual resuscitation bag-
valve device connected to an oxygen flow meter, set at
15 L/min (not recommended for patients on mechani-
cal ventilation as a routine method to deliver hyperoxy-
genation breaths)
❖ Positive end expiratory pressure (PEEP) valve (for
patients on >5 cm H2O PEEP and who must be hyper-
oxygenated with a self-inflating manual resuscitation
bag)
• Closed technique
❖ Closed-suction setup with a catheter of appropriate size
(see Table 10-1)
❖ Sterile saline solution lavage containers (5 to 10 mL)
❖ Obtain (individually packaged) suction catheters for
oral care.
❖ Source of suction (wall mounted or portable)
Figure 10-1 Closed-suction technique. (From Sills JR: The com- ❖ Connecting tube, generally 4 to 6 ft
prehensive respiratory therapist exam review: Entry and advanced ❖ Nonsterile gloves
levels, St. Louis, 2010, Elsevier, Mosby.) ❖ Goggles and mask, or mask with eye shield
TABLE 10-1 Guideline for Catheter Size for Endotracheal and Tracheostomy Tube
Suctioning*
Endotracheal Tube Size Tracheostomy Tube Size
Patient Age (mm) (mm, Inner Diameter) Suction Catheter Size
Small child (2–5 years) 4.0–5.0 3.0–5.5 6F to 8F
School-age child (6–12 years) 5.0–6.0 4.0–6.5 8F to 10F
Adolescent to adult 7.0–9.0 5.0–9.0 10F to 16F
*This guide should be used as an estimate only. Actual sizes depend on the size and individual needs of the patient. Always follow manufacturer’s guidelines.
Adapted from St John RE, Seckel M: Airway management. In AACN protocols for practice: care of the mechanically ventilated patient series, Sudbury, MA, 2007, Jones
and Bartlett Publishers, 41.
10 Suctioning: Endotracheal or Tracheostomy Tube 71
PATIENT AND FAMILY EDUCATION potential secretions in the airway, increasing resistance to
gas flow.
• Explain the procedure for endotracheal or tracheostomy • Evaluate Spo2 and Sao2 levels. Rationale: These values
tube suctioning to the patient and family. Rationale: indicate potential secretions in the airway, impaired gas
The explanation reduces anxiety and allows for exchange.
family members to step out if uncomfortable with the • Assess signs and symptoms of inadequate breathing pat-
procedure. terns, including dyspnea, shallow respirations, intercostal
• Explain that suctioning may be uncomfortable and could and suprasternal retractions, frequent triggering of venti-
cause the patient to experience shortness of breath. Ratio- lator alarms, and increased respiratory rate. Rationale:
nale: This information reduces anxiety and elicits patient Respiratory distress is a late sign of lower-airway
cooperation. obstruction.
• Explain the patient’s role in assisting with secretion
removal by coughing during the procedure. Rationale: Patient Preparation
This information encourages cooperation and facilitates • Verify correct patient with two identifiers. Rationale:
removal of secretions. Prior to performing a procedure, the nurse should ensure
the correct identification of the patient for the intended
intervention.
PATIENT ASSESSMENT AND • Ensure that the patient understands preprocedural teach-
PREPARATION ings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication
Patient Assessment evaluates and reinforces understanding of previously
• Assess for signs and symptoms of airway obstruction, taught information.
including secretions in the airway, inspiratory wheezes, • Assist the patient in achieving a position that is comfort-
expiratory crackles, restlessness, ineffective coughing, able for the patient and nurse, generally semi-Fowler’s or
decreased level of consciousness, decreased breath Fowler’s, with the bed elevated to the nurse’s waist level.
sounds, tachypnea, tachycardia or bradycardia, cyanosis, Rationale: This positioning promotes comfort, oxygen-
hypertension or hypotension, and shallow respirations. ation, and ventilation, and reduces strain.
Rationale: Physical signs and symptoms result from • Secure additional personnel to assist with the self-inflating
inadequate gas exchange associated with airway manual resuscitation bag-valve device to provide hyper-
obstruction. oxygenation (open-suction technique only) if utilized.
• Note increased peak inspiratory pressures during volume Rationale: Two hands are necessary to inflate the self-
ventilation or decreased tidal volume during pressure ven- inflating manual resuscitation bag-valve device for adult
tilation. Rationale: These pressure changes may indicate tidal volume levels (>600 mL).
Procedure for Endotracheal or Tracheostomy Tube Suctioning

1. HH
2. PE
3. Turn on suction apparatus and The amount of suction applied Follow manufacturer’s directions for
set vacuum regulator to should be only enough to remove suction pressure levels with
80–120 mm Hg. (Level D*) secretions effectively. High closed-suction catheter systems.
negative-pressure settings may (Level M*)
increase tracheal mucosal
damage.1,13,15,29,37
4. Secure one end of the connecting Prepares suction apparatus.
tube to the suction source and
place the other end in a
convenient location within reach.

Procedure for Endotracheal or Tracheostomy Tube Suctioning—Continued

5. Monitor the patient’s Observes for signs and symptoms of Development of cardiopulmonary
cardiopulmonary status before, complications: decreased arterial instability, particularly cardiac
during, and after the suctioning and mixed venous oxygen dysrhythmias or arterial
period. (Level B*) saturation, cardiac dysrhythmias, desaturation, necessitates immediate
bronchospasm, respiratory termination of the suctioning
distress, derecruitment, cyanosis, procedure.
increased blood pressure or
intracranial pressure, anxiety, pain,
agitation, or changes in mental
status.1,6,8,9,13–17,23–25,28,29,34,37–39
6a. Open-suction technique only.
A. Open sterile catheter package Prepares catheter and prevents
on a clean surface, with the transmission of microorganisms.
inside of the wrapping used
as a sterile field.
B. Depending on manufacturer, Prepares catheter flush solution.
set up the sterile solution
container or sterile field. Use
prefilled solution container or
open empty container, taking
care not to touch the inside
of the container. Fill with
approximately 100 mL of
sterile normal saline solution
or sterile water.
C. Don sterile gloves. Prevents contamination of the open In the event that one sterile glove and
sterile suction catheter. one nonsterile glove are used, apply
the nonsterile glove to the
nondominant hand and the sterile
glove to the dominant hand.Handle
all nonsterile items with the
nondominant (nonsterile) hand.
D. Pick up suction catheter, with Maintains catheter sterility. The dominant (sterile) hand should
care to avoid touching Connects the suction catheter and not come into contact with the
nonsterile surfaces. With the connecting tubing. connecting tubing. Wrapping the
nondominant hand, pick up suction catheter around the sterile
the connecting tubing. Secure dominant hand helps prevent
the suction catheter to the inadvertent contamination of the
connecting tubing. catheter.
E. Check equipment for proper Ensures equipment function.
functioning by suctioning a
small amount of sterile
solution from the container.
Proceed to Step 7
6b. Closed-suction technique only.
A. Connect the suction tubing to Readies the suction setup for
the closed system suction suctioning.
port or unlock the thumb
valve according to
manufacturer’s guidelines.

7. Hyperoxygenate the patient for Hyperoxygenation with 100% Use of the ventilator to deliver the
at least 30 seconds with one of oxygen is used to prevent a hyperoxygenation may be more
the following three methods. decrease in arterial oxygen levels effective in increasing arterial
(Level B*) during the suctioning oxygen levels.1,28,29
procedure.1,13,15,27–29,32,33
A. Press the suction Hyperoxygenation with 100%
hyperoxygenation button on oxygen is used to prevent a
the ventilator with the decrease in arterial oxygen levels
nondominant hand. during the suctioning
procedure.1,13,15,27–29,33(Level B)
or
B. Increase the baseline Fio2 Hyperoxygenation with 100% With this method, caution must be
level on the mechanical oxygen is used to prevent a used to return the Fio2 to baseline
ventilator. decrease in arterial oxygen levels levels after completion of
during the suctioning suctioning.
procedure.1,13,15,27–29,33(Level B)
or
C. Disconnect the ventilator or Attach a PEEP valve to the self- Use of a second person to deliver
gas-delivery tubing from the inflating manual resuscitation hyperoxygenation breaths with the
end of the endotracheal or bag-valvedevice for patients on self-inflating manual resuscitation
tracheostomy tube, attach the greater than 5 cm H2O PEEP. bag-valvedevice significantly
self-inflating manual Verify 100% oxygen delivery increases tidal volume
resuscitation bag-valvedevice capabilities of manual delivery.10–12,29
to the tube with the resuscitation bag-valve device by One-handed bagging rarely achieves
nondominant hand, and checking manufacturer’s adult tidal volume breaths
administer five to six breaths guidelines or with direct (>500 mL).
over 30 seconds. measurement with an in-line
oxygen analyzer when baseline
ventilator oxygen delivery to the
patient is greater than 60%. Some
models of self-inflating manual
resuscitation bag-valve device
entrain room air and deliver less
than 100% oxygen.


8. Remove the ventilator circuit or Suction should be applied only as Directional catheters are available for
self-inflating manual needed to remove secretions and selective right or left mainstem
resuscitation bag-valve device for as short a time as possible to bronchus placement. Straight
with the nondominant hand. minimize decreases in arterial catheters usually enter the right
With the control vent of the oxygen levels. mainstem bronchus.18,20,33
suction catheter open to air, Saline solution should not be instilled
gently but quickly insert the into the artificial airway before
catheter with the dominant hand suctioning.1,3,8,13,15,27,32–34 (Level B*)
into the artificial airway until In adult patients, there is no
resistance is met, then pull back conclusive evidence to support the
1–2 cm before applying practice of minimally invasive
suction.9,13,15,28–34 (Level E*) suctioning versus deep suctioning
due to inconsistencies in the
definitions. There are several
definitions of minimally invasive or
shallow suctioning in the literature,
including the following examples:
the combination of suctioning
without hyperoxygenation or
hyperinflation, without normal
saline instillation, and without the
suction catheter passing beyond the
end of the endotracheal tube,22,28 the
insertion of the suctioning catheter
to a predetermined length of the
airway and connector,1 or insertion
of the suctioning catheter 2 cm
beyond the endotracheal tube.15
Deep suctioning has been defined as
insertion of the suctioning catheter
until resistance is felt1,15 or the
catheter is beyond the endotracheal
tip.9
9. Place the nondominant thumb Tracheal damage from suctioning is
over the control vent of the similar with intermittent or
suction catheter to apply continuous suction.6,19,21,26,28,33
continuous or intermittent (Level C*)
suction. Place and maintain the Decreases in arterial oxygen levels
catheter between the dominant during suctioning can be kept to a
thumb and forefinger as you minimum with brief suction
completely withdraw the catheter periods.1,7,15,29,32,33 (Level B)
for less than or equal to 10
seconds into the sterile catheter
sleeve (closed-suction technique)
or out of the open airway
(open-suction technique).

10. Hyperoxygenate for 30 seconds Hyperoxygenation with 100%
as described in Step 7. oxygen is used to prevent a
decrease in arterial oxygen levels
during the suctioning
procedure.1,13,15,27–29,33 (Level B*)
11. One or two more passes of the The number of suction passes should Consider allowing the patient rest and
suction catheter, as delineated in be based on the amount of hemodynamic recovery time after
Steps 8 and 9, may be secretions and the patient’s several suction catheter passes.
performed if secretions remain in clinical assessment due to the risk Discuss with the team the treatment
the airway and the patient is of complications including pain plan for excessive secretions.
tolerating the procedure. Provide and discomfort.1,27–31,33 (Level E*)
30 seconds of hyperoxygenation Hyperoxygenation with 100%
before and after each pass of the oxygen is used to prevent a
suction catheter. See Step 7. decrease in arterial oxygen levels
procedure.1,13,15,21,27–29 (Level B)
12. If the patient does not tolerate Use of a different suctioning
suctioning despite technique may be physiologically
hyperoxygenation, try the less demanding.33 (Level E)
following steps:
A. Ensure that 100% oxygen is Hyperoxygenation with 100%
being delivered. oxygen is used to prevent a
decrease in arterial oxygen levels
procedure.1,13,15,27–29,33 (Level B)
B. Maintain PEEP during Maintenance of PEEP prevents
suctioning. Check that the collapse of alveoli during
PEEP valve is attached suctioning.
properly to the self-inflating
manual resuscitation bag-
valve device with use of that
method for
hyperoxygenation.
C. Switch to another method of Other methods of suctioning may be
suctioning (e.g., closed- more effective and safer for the
suctioning technique). patient.
D. Allow longer recovery Allows the patient to regain prior
intervals between suction oxygenation levels.
passes.
E. Hyperventilation may be Due to the possibility of barotrauma, Hyperinflation should be delivered by
used in situations in which hyperventilation should be used the ventilator to control pressures
the patient does not tolerate only if the patient does not and avoid disconnection.1,28,29
suctioning with tolerate suctioning with
hyperoxygenation alone, with hyperoxygenation alone.
either the self-inflating
manual resuscitation bag-
valve device or the ventilator.


13. When the airway has been Suctioning of the oropharyngeal area Care should be taken to avoid
cleared adequately of secretions, if secretions are present may oropharyngeal tissue trauma and
perform oropharyngeal enhance patient comfort and gagging during suctioning.
suctioning. (Level D*) should be part of an oral hygiene
A separate suction catheter program.2,5,35,36 After
must be opened for this step oropharyngeal suctioning, the
with the closed-suction suction catheter is contaminated
technique. with bacteria present in the oral
cavity, potentially gram-negative
bacilli, and should not be used for
lower-airway suctioning.1,5,13,15,35,36
(Level D)
14. Rinse the catheter and Removes buildup of secretions in
connecting tubing with sterile the connecting tubing and, with
saline or sterile water solution the closed-suction catheter system,
until clear. in the in-line suction catheter.
Open-suction technique: suction
the unused sterile solution
until tubing is clear.
Closed-suction technique: instill
sterile saline or water solution
into side port of in-line
suction catheter, taking care
not to lavage down
endotracheal tube, while
applying continuous suction
until catheter is clear.
15. Open-suction technique only: on Reduces transmission of
completion of upper-airway microorganisms.
suctioning, wrap the catheter
around the dominant hand. Pull
glove off inside out. Catheter
remains in glove. Pull off other
glove in same fashion, and
discard. Turn off suction device.
16. Suction collection tubing and Solutions and catheters that come in Check institutional standards on the
canisters may remain in use for direct contact with the lower discarding of multiuse sterile
multiple suctioning episodes. airways during suctioning must be solution containers and equipment
sterile to decrease the risks for removal.
hospital-acquired pneumonia.
Devices that are not in direct
contact with the lower airways
have not been shown to increase
infection risk.5 (Level D)
17. Remove PE and discard used
supplies.
18. HH

• Removal of secretions from the large airways • Cardiac dysrhythmias (premature atrial or ventricular
• Improved gas exchange contractions, tachycardias, bradycardias, heart blocks,
• Airway patency asystole)
• Amelioration of clinical signs or symptoms of need for • Hypoxemia
suctioning (e.g., adventitious breath sounds, coughing, • Bronchospasm
high airway pressures) • Excessive increases in arterial blood pressure or
• Sample for laboratory analysis intracranial pressure
• Hospital-acquired infections
• Cardiopulmonary distress
• Decreased level of consciousness
• Airway obstruction
• Pain or discomfort

interventions.
1. Monitor the patient’s Observes for signs and symptoms of • Decreased arterial or mixed
cardiopulmonary status complications.1,4,14,16,17,19,25,27,28,33,34,37,38,43,44 venous oxygen saturation
before, during, and after the • Cardiac dysrhythmias
suctioning period. (Level B*) • Bronchospasm
• Respiratory distress
• Cyanosis
• Increased blood pressure or
intracranial pressure
• Anxiety, agitation, pain, or
changes in mental status
• Diminished breath sounds
• Decreased oxygenation
• Increased peak airway pressures
• Coughing
• Increased work of breathing
2. Reassess the patient for signs Assesses effectiveness of intervention and
of suctioning effectiveness. the possible indications for further
suctioning.
3. Follow institution standard for Identifies need for pain interventions. • Continued pain despite pain
assessing pain. Administer interventions.
Documentation
• Patient and family education • Volume, color, consistency, and odor of secretions
• Presuctioning assessment, including clinical indication obtained
for suctioning • Any difficulties during catheter insertion or
• Suctioning of endotracheal or tracheostomy tube hyperoxygenation
• Size of endotracheal or tracheostomy tube and suction • Tolerance of suctioning procedure, including
catheter development of any unexpected outcomes during or
• Type of hyperoxygenation method used after the procedure
• Pain assessment, interventions, and effectiveness • Nursing interventions
• Postsuctioning assessment

10 Suctioning: Endotracheal or Tracheostomy Tube 78.e1
References suction catheter insertion techniques. Heart Lung 17:

1. American Association for Respiratory Care: AARC 10–14, 1988.
Clinical Practice Guideline: Endotracheal suctioning of 20. Kubota Y, et al: Is a straight catheter necessary for
mechanically ventilated patients with artificial airways selective bronchial suctioning in the adult? Crit Care Med
2010. Respir Care 55:758–764, 2010. 14:755–756, 1986.
2. AACN Practice Alert: Oral care for patients at risk for 21. Kuzenski B: Effect of negative pressure on
ventilator-associated pneumonia (VAP).<http://www.aacn tracheobronchial trauma. Nurs Res 27:260–263, 1978.
.org/wd/practice/docs/practicealerts/oral-care-patients-at 22. Luer JP, et al: Endotracheal suctioning versus minimally
-risk-vap.pdf>. (Accessed 21.11.14.). invasive airway suctioning in intubated patients: A
3. Caparros AC: Mechanical ventilation and the role prospective randomized controlled trial. Intensive Care
of saline instillation in suctioning adult intensive Med 29:426–432, 2003.
care unit patients. Dimens Crit Care Nurs 33:246–253, 23. Maggiore SM, et al: Decreasing the adverse effects of
2014. endotracheal suctioning during mechanical ventilation by
4. Cerqueria N, et al: Acute effects of physiotherapeutic changing practice. Respir Care 58:1588–1597, 2013.
respiratory maneuvers in critically ill patients with 24. McCauley C, Boller L: Bradycardiac responses to
craniocerebral trauma. Clinics 68:1210–1214, 2013. endotracheal suctioning. Crit Care Med 16:1165–1166,
5. Coffin SE, et al: Strategies to prevent ventilator-associated 1988.
pneumonia in acute care hospitals. Infect Control Hosp 25. Morris LL: Tracheostomy care and complications in the
Epidemiol 20:S31–S40, 2008. intensive care unit. Crit Care Nurse 33:19–30, 2013.
6. Czarnik R, et al: Differential effects of continuous versus 26. Ogburn-Russell L: The effect of continuous and
intermittent suction on tracheal tissue. Heart Lung intermittent suctioning on the tracheal mucosa of dogs.
20:144–151, 1991. Heart Lung 16:297, 1987.
7. Ellstrom K: The pulmonary system. In Alspach J, editor: 27. Oh H, Seo W: A meta-analysis of the effects of various
Core curriculum for critical care nursing, ed 6, St. Louis, interventions in preventing endotracheal suctioning
2006, Elsevier, pp 45–183. induced hypoxemia. J Clin Nurs 12:912–924, 2003.
8. Favretto DO, et al: Endotracheal suction in intubated 28. Overend TJ, et al: Updating the evidence base for
critically ill adult patients undergoing mechanical suctioning adult patients: A systematic review. Can Respir
ventilation: A systematic review. Rev Lat Am Enfermagem J 16:e6–e17, 2009.
5:997–1007, 2012. 29. Pedersen CM, et al: Endotracheal suctioning of the adult
9. Gillies D, Spence K: Deep versus shallow suction of intubated patient—What is the evidence? Intensive Crit
endotracheal tubes in ventilated neonates and young Care Nurs 25:21–30, 2009.
infants. Cochrane Database Syst Rev (6):CD003309, 30. Puntillo KA, et al: Patients’ perceptions and responses to
2013. procedural pain: Results from the Thunder Project II. Am
10. Glass C, et al: Nurses’ ability to achieve hyperinflation J Crit Care 10:238–251, 2001.
and hyperoxygenation with a manual resuscitation bag 31. Russian CJ, Gonzales JF, Henry NR: Suction catheter
during endotracheal suctioning. Heart Lung 22:158–165, size: An assessment and comparison of 3 different
1993. calculation methods. Respir Care 59:3–38, 2014.
11. Grap MJ, et al: Endotracheal suctioning: Ventilator versus 32. St John RE, Seckel MA: Airway and ventilator
manual delivery of hyperoxygenation breaths. Am J Crit management. In Burns S, editor: AACN essentials of
Care 5:192–197, 1996. critical care nursing, ed 3, New York, 2014, McGraw-Hill
12. Hess D, Goff G: The effects of two-hand versus one-hand Publishing, pp 119–157.
ventilation on volumes delivered during bag-valve 33. St John RE, Seckel MA: Airway management. In Burns
ventilation at various resistances and compliances. Respir SM, editor: AACN protocol for practice: Care of
Care 32:1025–1028, 1987. mechanically ventilated patients, ed 2, Sudbury, MA,
13. Joanna Briggs Institute: Artificial airway: suctioning, 2006, Jones and Bartlett Publishers, pp 1–57.
Recommended Practice JB12335, 2013. 34. Seckel MA: Ask the experts: Normal saline and mucous
14. Joanna Briggs Institute: Tracheostomy: suctioning, plugging. Crit Care Nurse 32:66–68, 2012.
Recommended Practices JB12491, 2013. 35. Shi Z, et al: Oral hygiene care for critically ill patients to
15. Joanna Briggs Institute: Endotracheal suctioning, prevent ventilator-associated pneumonia. Cochrane
Evidence Summaries JB11357, 2014. Database Syst Rev (8):CD008367, 2013.
16. Jongerden IP, et al: Changes in heart rate, mean arterial 36. Sole ML, et al: Oropharyngeal secretion volume in
pressure, and oxygen saturation after open and closed intubated patients: The importance of oral suctioning.
endotracheal suctioning: a prospective observational study. Am J Crit Care 20:141–145, 2011.
J Crit Care 27:647–654, 2012. 37. Subirana M, Solà I, Benito S: Closed tracheal suction
17. Kaiser JR, Gauss CH, Williams DK: The effects of closed systems versus open tracheal systems for mechanically
tracheal suctioning plus volume guarantee on cerebral ventilated adult patients. Cochrane Database Syst Rev
hemodynamics. J Perinatol 31:671–676, 2011. (7):CD004581, 2010.
18. Kirimili B, King J, Pfaeffle H: Evaluation of tracheal 38. Tingay DG, et al: The effect of endotracheal suction on
bronchial suction techniques. J Cardiovasc Surg 59: regional tidal ventilation and end-expiratory lung volume.
340–344, 1970. Intensive Care Med 36:888–896, 2010.
19. Kleiber C, Krutzfield N, Rose E: Acute histologic changes 39. Ugras GA, Aksoy G: The effects of open and closed
in the tracheobronchial tree associated with different endotracheal suctioning on intracranial pressure and
cerebral perfusion pressure: A crossover, single-blind MacIntyre CR, et al: Quantifying the risk of respiratory
clinical trial. J Neurosic Nurs 44:e1–e8, 2012. infection in healthcare workers performing high-risk
procedures. Epidemiol Infect 142:1802–1808, 2014.
Additional Readings Sole M, Bennett M: Comparison of airway management
Kjonegaard R, Fields W, King ML: Current practice in airway practices between registered nurses and respiratory care
management: A descriptive evaluation. Am J Crit Care practitioners. Am J Crit Care 23:191–199, 2014.
19:168–173, 2010.
PROCEDURE
11
Surgical Cricothyrotomy
(Perform)
Roger Casey
PURPOSE: Surgical cricothyrotomy is an emergent procedure that creates an
opening in the cricothyroid membrane to facilitate placement of an endotracheal or
tracheostomy tube to provide effective oxygenation and ventilation.
PREREQUISITE NURSING • Complete transection of trachea

KNOWLEDGE • Laryngotracheal disruption with retraction of distal
trachea
• Surgical cricothyrotomy is used only when the airway
cannot be obtained or maintained by standard means such Relative
as bag-valve-mask device ventilation, the use of airway • Anterior neck hematoma5—preexisting pathology of
adjuncts (oropharyngeal or nasopharyngeal airways), larynx or trachea including hematoma, infection, tumor,
endotracheal intubation, or rescue airways (King Airway, or abscess occurring at or near incision site6
Combitube, or laryngeal mask airway [LMA]; Procedures • Coagulopathies
1, 7, and 8, respectively).3 • Fractured larynx with inability to identify anatomical
• Surgical cricothyrotomy may be needed in patients with landmarks3
facial or neck trauma. Maintenance of the airway may be • Lacerations of the structures of the neck3
difficult in these patients because the injuries often disrupt • Massive neck swelling3
the lower facial structures and may make an adequate seal • Children less than 12 years of age5
with a bag-valve device difficult to obtain. The airway
may also be obstructed or disrupted, making endotracheal EQUIPMENT
intubation difficult or ineffective.
• Difficulty in obtaining or maintaining an airway may • Personal protective equipment (mask, eye protection, gown)
result from upper airway obstruction as a result of trauma, • Sterile surgical gloves
allergic reactions with swelling and angioedema, foreign • Sterile surgical drape
bodies, anatomical variations, tumors, and bleeding.2 • Topical antiseptic solution
• The need for emergent surgical cricothyrotomy must be • No. 10 or 11 blade scalpel
determined quickly. This intervention is potentially life- • 4 × 4 gauze sponges
saving, and implementation cannot be delayed. • Suction and suction catheter
• Surgical cricothyrotomy requires specialized training and • Curved hemostats
should be performed only by highly skilled medical pro- • Tracheal hook
viders2 or nursing providers.2 • Tracheal (Trousseau) dilator or nasal speculum
• Commercially prepared kits, such as the Melker Emer- • 5- to 6-mm cuffed endotracheal tube or No. 4 (Shiley)
gency Cricothyrotomy Catheter (Cook Medical, Inc, tracheostomy tube
Bloomington, Ind; www.cookmedical.com), are available • 10-mL syringe
and use a specially designed airway and a modified Seld- • Cloth tracheostomy ties
inger (or percutaneous cricothyrotomy) technique for • Bag-valve-mask device with oxygen source
insertion. • Stethoscope
Contraindications the following:
Absolute • Commercially prepared kit which uses a specially designed
• Airway can be managed effectively with bag-valve-mask airway and a modified Seldinger (or percutaneous crico-
device, intubation, or rescue airway (King Airway, Com- thyrotomy) technique for insertion.
bitube, or LMA)
practice nurses, and other healthcare professionals (including critical care • If time permits, assess the patient’s and family’s level
nurses) with additional knowledge, skills, and demonstrated competence per of understanding about the condition and rationale for
professional licensure or institutional standard. the procedure. Rationale: This assessment identifies the
79
patient’s and family’s knowledge deficits concerning the promise. Rationale: If the patient has the ability to
patient’s condition, the procedure, the expected benefits, maintain an airway, allowing the patient to remain
and the potential risks. It also allows time for questions to in an upright position, with suction provided if nec-
clarify information and voice concerns. Explanations essary, assists the patient in maintaining the airway.
decrease patient anxiety and enhance cooperation. If the patient is placed in a supine position for pack-
• Family members should be provided with a quick and aging or transport, this may cause significant airway
concise explanation of the emergent need to obtain an compromise.
airway. This information is often best explained by another • Assess respiratory effort.
member of the healthcare team rather than the provider ❖ Assess rate, depth of respirations, accessory muscle
performing the procedure to prevent delay in establishing use, chest wall motion, and breath sounds. Rationale:
the airway. If possible, obtain consent for the procedure This process is to identify inadequate respiratory efforts
from the family member. Rationale: This explanation quickly and determine the optimal method for oxygen-
enhances patient and family understanding and decreases ation and ventilation.
anxiety. ❖ Monitor oxygen saturation and end tidal carbon dioxide
• A patient who needs emergency surgical cricothyrotomy (ETco2). Rationale: This process is to identify inade-
is likely unresponsive from the inability to maintain the quate respiratory efforts quickly and determine the
airway and adequate oxygenation and ventilation; there- optimal method for oxygenation and ventilation.
fore, patient education may not be possible. If the patient ❖ If respiratory efforts are inadequate, attempt ventilation
is responsive, the airway and ventilatory efforts are ade- with a bag-valve-mask device and supplemental
quate and surgical cricothyrotomy is not indicated. Ratio- oxygen. If an airway cannot be maintained or oxygen-
nale: The emergency nature of the procedure precludes ation and ventilation with a bag-valve-mask device are
patient education. inadequate, prepare for endotracheal intubation. Ratio-
nale: This process is to identify inadequate respiratory
efforts quickly and determine the optimal method for
PATIENT ASSESSMENT AND oxygenation and ventilation.
❖ If intubation is not possible, prepare for emergent sur-
PREPARATION
gical cricothyrotomy. Rationale: This process is to
Patient Assessment identify inadequate respiratory efforts quickly and
• Assess airway patency. determine the optimal method for oxygenation and
❖ Open the airway with a jaw-thrust or chin-lift maneu- ventilation.
ver. If traumatic injury is suspected, maintain cervical
stabilization. Rationale: Allows for visualization of the
airway for any foreign bodies, secretions, or other Patient Preparation
obstructions. • Verify correct patient with two identifiers. Rationale:
❖ Assess for presence of foreign bodies, secretions, or Prior to performing a procedure, the nurse should ensure
other obstructions. Use suction, basic life support the correct identification of the patient for the intended
(BLS) maneuvers, or Magill forceps to clear and main- intervention.
tain the airway. Rationale: Often airway patency can • Perform a preprocedure verification and time out, if non-
be achieved and maintained with simple maneuvers emergent. Rationale: Ensures patient safety.
such as patient positioning, use of an airway maneuver, • Position the patient supine and maintain cervical spine
suction, or insertion of an oral or nasal pharyngeal stabilization if indicated. Rationale: Patients who need
airway. If the patient has potential for airway compro- emergent surgical cricothyrotomy often have traumatic
mise (i.e., bleeding, swelling, or traumatic injuries) injuries that necessitate cervical spine stabilization.
and is alert and able to maintain the airway, allow the • Continue attempts to ventilate and oxygenate the patient
patient to maintain a position of comfort and suction with a bag-valve-mask device by any means possible if
to maintain a patent airway. the patient is apneic or respiratory efforts are inadequate.
❖ Do not attempt to place the patient in a supine posi- Rationale: This action can prevent further hypoxia and
tion because this may cause significant airway com- hypercarbia.
Procedure for Surgical Cricothyrotomy

1. HH
2. PE Use of face mask and eye protection
is recommended because of the
increased risk of airborne blood or
body fluids during this procedure.
3. Place the patient in a supine Position the patient to expose the Maintain manual cervical spine
position, with head and neck neck and larynx. stabilization for patients with
in neutral position. suspected cervical spine injury.
11 Surgical Cricothyrotomy (Perform) 81
Procedure for Surgical Cricothyrotomy—Continued

4. Identify the cricothyroid Identifies the correct location for The incision is just inferior to the
membrane (Fig. 11-1). First, incision and endotracheal tube vocal cords and superior to the
identify the thyroid placement. The cricothyroid thyroid gland.
prominence, or Adam’s apple. membrane is preferred over the
The cricothyroid membrane is trachea because it is more
palpated at the midline, anterior than the lower trachea
approximately one and less thyroid and soft tissue
fingerbreadth below the are found between the membrane
thyroid prominence. and the skin. Additionally, there
is less vascularity, leading to less
significant chance of bleeding.
Superior thyroid notch
Hyoid bone
Thyrohyoid ligament
Thyroid cartilage
Cricothyroid Figure 11-1 Anatomy of Neck and

membrane Location of Cricothyroid Membrane.
Cricoid cartilage (Adapted from Patton KT, Thibodeau GA:
Mosby’s handbook of anatomy and physi-
ology, ed. 2 St. Louis, 2014, Elsevier.)
Thyroid gland
Trachea
Tracheal
cartilage
5. Prepare the skin with a topical Decreases potential for wound

antiseptic solution. infection.
6. Immobilize the larynx by Allows for ease in creating an Throughout the procedure the larynx
stretching the skin with the incision in the skin, and keeps must be immobilized.
thumb and middle finger of the larynx from shifting.
the nondominant hand to make
it taut and stabilize the larynx.
7. Take the scalpel in the Overly deep or long incisions risk Avoid directing the scalpel toward
dominant hand and make a damage to the larynx, cricoid the head, as this may cause
2-cm vertical midline incision cartilage, and trachea. laceration of the vocal cords.3
through the dermis, over the Some references recommend a
cricothyroid membrane. horizontal skin incision.1,2
8. Dab the wound with sterile Use a dabbing technique to Use an assistant, if available, to
gauze to control any bleeding minimize further tissue trauma control bleeding and minimize
from the incision. and bleeding. interruptions in the procedure.

9. Identify the cricothyroid Blunt dissection is preferred over The index finger can be placed on
membrane. Palpate the sharp dissection to minimize the inferior aspect of the thyroid
cricothyroid membrane further tissue trauma and cartilage to identify the superior
through the skin incision with bleeding. border of the cricothyroid
the index finger. If necessary, membrane.
use the curved hemostats to
bluntly dissect through the
skin to locate and visualize the
cricothyroid membrane.
10. Make a horizontal incision in Incising the lower half of the The incision should be approximately
the lower half of the membrane is preferred to avoid 1–1.5 cm in length. Do not attempt
cricothyroid membrane with the superior cricothyroid artery to puncture the cricothyroid
the scalpel (Fig. 11-2). and vein. The opening needs to membrane. Use the scalpel to
be large enough to accommodate gently incise only the membrane.
a 5–6 mm cuffed endotracheal or
No. 4 (Shiley) tracheostomy tube.
A puncturing motion may also
puncture the posterior wall of the
trachea and lacerate the
esophagus, and could lacerate or
damage the vocal cords.
Thyroid
cartilage Figure 11-2 Surgical Cricothyrotomy.
(From Black JM, Hawks JH: Medical-
Cricoid surgical nursing: Clinical management for
cartilage positive outcomes, ed 8, St. Louis, 2009,
Elsevier.)
Thyroid Sternal
gland notch
11. Dab the wound with sterile Use a dabbing technique to Use an assistant, if available, to
gauze to control any bleeding minimize further tissue trauma control bleeding and minimize
from the incision. and bleeding. interruptions in the procedure.
12. Insert tracheal dilator or nasal Avoids further trauma to the
speculum into the opening in cricothyroid membrane or vocal
the cricothyroid membrane. cords and guides the tube into the
Direct the tip of the speculum airway.
toward the patient’s feet.
13. Carefully spread the dilator or The dilator or speculum enlarges The tube should advance easily into
speculum vertically and the opening vertically, but use the tracheal opening.
advance the tube into the caution to avoid further trauma to
opening. If resistance is met, the cricothyroid membrane or
do not force the tube into the vocal cords. Consider utilizing
opening. the tracheal hook to maintain
the opening. Care must be
undertaken to ensure there is an
instrument in the airway at all
times so as not to allow the
cricothyroid incision to close.
11 Surgical Cricothyrotomy (Perform) 83

14. Carefully remove the tracheal Use caution to avoid inadvertent
dilator or nasal speculum once removal of the tube along with
the tube has been placed in the the dilator or speculum.
trachea.
15. Inflate the tube cuff with the Prevents an air leak and optimizes A cuffed tube is preferred over an
syringe to a minimal occlusive oxygenation and ventilation. uncuffed tube to prevent an air
pressure. leak and reduce the risk of
aspiration.
16. Attach the bag-valve device to
the tube and oxygenate and
ventilate the patient.
17. Auscultate for the presence of Tube position may be confirmed Primary confirmation relies on
equal breath sounds and the with the same methods as oral or physical examination techniques to
absence of epigastric sounds nasal endotracheal tube confirm correct tube placement.2
with a stethoscope. Observe placement.
chest rise and fall.
18. Confirm correct placement Tube position may be confirmed Secondary confirmation verifies
with secondary means such as with the same methods as oral or correct tube placement.2
an exhaled CO2 detector or nasal endotracheal tube
monitoring device. Obtain placement.
chest radiography.
19. Secure the tube with Prevents dislodgment or movement Use a square knot to secure the
tracheostomy ties. of tube. tracheostomy ties.
21. HH
Expected Outcomes Unexpected Outcomes1,2,5

• Establishment of emergent surgical airway access • Blood loss or hemorrhage
• Adequate oxygenation and ventilation • Aspiration or asphyxia
• Improved or stabilized patient condition • False passage of the endotracheal tube into
subcutaneous tissue4
• Tracheal perforation
• Esophageal perforation
• Subcutaneous emphysema
• Mediastinal emphysema
• Vocal cord injury or paralysis
• Tracheal stenosis (delayed)

1. Monitor breath sounds, adequacy Monitors effectiveness of airway, • Inability to ventilate
of oxygenation and ventilation, and oxygenation, and ventilation. • Decreased or absent breath sounds
oxygen saturation (Spo2). Consider • Decrease in Spo2
continuous capnography. • Loss of ETco2
2. Monitor endotracheal tube position. Prevents movement or • Inadvertent dislodgment or
dislodgment of tube. removal of tube
3. Observe insertion site for bleeding, Identifies displacement of tube • Excessive bleeding from the site
swelling, or subcutaneous air. or significant air leak. • Swelling or subcutaneous air at
the insertion site
Documentation
• Assessment findings to support the need for an • Pain assessment, interventions, and effectiveness
emergent surgical airway • Inability to obtain or maintain airway and provide
• Size and type of endotracheal/tracheostomy tube oxygenation and ventilation by any other means
inserted and centimeter mark at skin opening • Documentation of the procedure, to include date and
• Confirmation of proper tube placement with both time
primary and secondary means • Any difficulties encountered during the procedure

11 Surgical Cricothyrotomy (Perform) 84.e1
References operations manual, Spokane, WA, 2013, Northwest

1. American College of Surgeons: Airway and ventilatory MedStar.
management: Advanced trauma life support, ed 9, 4. Proehl JA: Emergency nursing procedures, ed 4, St. Louis,
Chicago, 2012, ACS. 2009, Saunders.
2. American Heart Association: Airway, airway adjuncts, 5. Tintinalli JE, Kelen GD, Stapczynski JS: Emergency
oxygenation and ventilation: Advanced cardiac life medicine: A comprehensive study guide, ed 7, New York,
support: Principles and practice, Dallas, 2011, 2010, McGraw-Hill.
AHA. 6. Walls RM, Murphy MF: Manual of emergency airway
3. Northwest MedStar, Critical Care Air Medical Transport management, 4 ed, Philadelphia, 2012, Lippencott
Service: Cricothyrotomy, surgical: Adult/Peds: program Williams and Wilkens.
PROCEDURE
12
Surgical Cricothyrotomy (Assist)
Roger Casey
PURPOSE: Surgical cricothyrotomy is an emergent procedure that creates an
opening in the cricothyroid membrane to facilitate placement of an endotracheal or
tracheostomy tube to provide effective oxygenation and ventilation.
PREREQUISITE NURSING Relative

KNOWLEDGE • Anterior neck hematoma5—preexisting pathology of
larynx or trachea including hematoma, infection, tumor,
• Surgical cricothyrotomy is used only when the airway or abscess occurring at or near incision site6
cannot be obtained or maintained by standard means such • Coagulopathies
as bag-valve-mask device ventilation, the use of airway • Fractured larynx with inability to identify anatomical
adjuncts (oropharyngeal or nasopharyngeal airways), landmarks3
endotracheal intubation, or rescue airways (King Airway, • Lacerations of the structures of the neck3
Combitube, or laryngeal mask airway [LMA]; Procedures • Massive neck swelling3
1, 7, and 8, respectively).3 • Children less than 12 years of age5
• Surgical cricothyrotomy may be needed in patients with
facial or neck trauma. Maintenance of the airway may be EQUIPMENT
difficult in these patients because the injuries often disrupt
the lower facial structures and may make an adequate seal • Personal protective equipment (mask, eye protection, gown)
with a bag-valve device difficult to obtain. The airway • Sterile surgical gloves
may also be obstructed or disrupted, making endotracheal • Sterile surgical drape
intubation difficult or ineffective. • Topical antiseptic solution
• Difficulty in obtaining or maintaining an airway may • No. 10 or 11 blade scalpel
result from upper airway obstruction as a result of trauma, • 4 × 4 gauze sponges
allergic reactions with swelling and angioedema, foreign • Suction device and suction catheter
bodies, anatomical variations, tumors, and bleeding.2 • Curved hemostats
• The need for emergent surgical cricothyrotomy must be • Tracheal hook
determined quickly. This intervention is potentially life- • Tracheal (Trousseau) dilator or nasal speculum
saving, and implementation cannot be delayed. • 5- to 6-mm cuffed endotracheal tube or No. 4 (Shiley)
• Surgical cricothyrotomy requires specialized training and tracheostomy tube4
should be performed only by highly skilled medical pro- • 10-mL syringe
viders or nursing providers.2 • Cloth tracheostomy ties
• Commercially prepared cricothyrotomy kits are available • Self-inflating manual resuscitation bag-valve-mask device
and often use a modified Seldinger technique with a with oxygen source
guidewire or dilator system. • Oxygen source and tubing
• This procedure should be performed only by physicians, • Stethoscope
advanced practice nurses, and other healthcare profes- • Commercially prepared kits and use a specially designed
sionals (including critical care nurses and trained trans- airway and a modified Seldinger (or percutaneous crico-
port personnel) with additional knowledge, skills, and thyrotomy) technique for insertion
demonstrated competence per professional licensure or
institutional/organizational standards. PATIENT AND FAMILY EDUCATION
Contraindications • If time permits, assess the patient’s and family’s level
Absolute of understanding about the condition and rationale for
• Airway can be managed effectively with bag-valve-mask the procedure. Rationale: This assessment identifies the
device, intubation, or rescue airway (King Airway, Com- patient’s and family’s knowledge deficits concerning the
bitube, or LMA) patient’s condition, the procedure, the expected benefits,
• Complete transection of trachea and the potential risks. It also allows time for questions to
• Laryngotracheal disruption with retraction of distal clarify information and voice concerns. Explanations
trachea decrease patient anxiety and enhance cooperation.
85
• Family members should be provided with a quick and patient in maintaining the airway. If the patient is
concise explanation of the emergent need to obtain an placed in a supine position for packaging or transport,
airway. This information is often best explained by another this move may cause significant airway compromise.
member of the healthcare team rather than the provider • Assess respiratory effort.
performing the procedure to prevent delay in establishing ❖ Assess rate, depth of respirations, accessory muscle
the airway. If possible, obtain consent for the procedure use, chest wall motion, and breath sounds. Rationale:
from the family member. Rationale: This explanation This process is to identify inadequate respiratory efforts
enhances patient and family understanding and decreases quickly and determine the optimal method for provid-
anxiety. ing oxygenation and ventilation.
• A patient who needs emergency surgical cricothyrotomy ❖ If equipment is available, monitor oxygen saturation
is likely unresponsive from the inability to maintain the and end tidal carbon dioxide (ETco2). Rationale: This
airway and adequate oxygenation and ventilation; there- process is to identify inadequate respiratory efforts
fore, patient education may not be possible. If the patient quickly and determine the optimal method for provid-
is responsive, the airway and ventilatory efforts are ade- ing oxygenation and ventilation.
quate and surgical cricothyrotomy is not indicated. Ratio- ❖ If respiratory efforts are inadequate, attempt ventilation
nale: The emergency nature of the procedure precludes with a self-inflating manual resuscitation bag-valve-
patient education. mask device and supplemental oxygen. If an airway
cannot be maintained or oxygenation and ventilation
are adequate with a self-inflating manual resuscitation
PATIENT ASSESSMENT AND bag-valve-mask device, prepare for endotracheal intu-
PREPARATION bation. Rationale: This process is to identify inade-
quate respiratory efforts quickly and determine the
Patient Assessment optimal method for providing oxygenation and
• Assess airway patency. ventilation.
❖ Open the airway with a jaw-thrust or chin-lift maneu- ❖ If intubation is not possible, prepare for emergent sur-
ver. If traumatic injury is suspected, maintain cervical gical cricothyrotomy. Rationale: This process is to
stabilization. Rationale: Allows for visualization of the identify inadequate respiratory efforts quickly and
airway for any foreign bodies, secretions, or other determine the optimal method for providing oxygen-
obstructions. ation and ventilation.
❖ Assess for presence of foreign bodies, secretions, or
other obstructions. Use suction, basic life support Patient Preparation
(BLS) maneuvers, or Magill forceps to clear and main- • Verify correct patient with two identifiers. Rationale:
tain the airway. Rationale: Often airway patency can Prior to performing a procedure, the nurse should ensure
be achieved and maintained with simple maneuvers the correct identification of the patient for the intended
such as patient positioning, use of an airway maneuver, intervention.
suction, or insertion of an oral or nasal pharyngeal • Perform a preprocedure verification and time out, if non-
airway. If the patient has potential for airway compro- emergent. Rationale: Ensures patient safety.
mise (i.e., bleeding, swelling, or traumatic injuries) and • Position the patient supine and maintain cervical spine
is alert and able to maintain the airway, allow the stabilization if indicated. Rationale: Patients who need
patient to maintain a position of comfort and suction emergent surgical cricothyrotomy often have traumatic
to maintain a patent airway. injuries that require cervical spine stabilization.
❖ Do not attempt to place the patient in a supine position • Continue attempts to ventilate and oxygenate the patient
because this may cause significant airway compromise. with a self-inflating manual resuscitation bag-valve-mask
Rationale: If the patient has the ability to maintain an device if the patient is apneic or respiratory efforts are
airway, allowing the patient to remain in an upright inadequate. Rationale: This action can prevent further
position, with suction provided if necessary, assists the hypoxia and hypercarbia.
Procedure for Assisting with Surgical Cricothyrotomy

1. HH
2. PE Use of face mask and eye
protection is recommended
because of the increased risk
of airborne blood or body
fluids during this procedure.
3. Place the patient in a supine Position the patient to expose the Maintain cervical spine
position, with head and neck in neck and larynx. stabilization for patients with
neutral position. suspected cervical spine injury.
12 Surgical Cricothyrotomy (Assist) 87
Procedure for Assisting with Surgical Cricothyrotomy—Continued

4. If one assistant (assistant A) is Prevents further hypoxia and Maintain sterile field and
available, continue attempts to hypercarbia. anticipate the needs of the
oxygenate and ventilate the patient Use of an assistant minimizes person performing the
with a bag-valve-mask device. interruptions in the procedure. procedure. Use caution when
5. If a second assistant (assistant B) is handling equipment to prevent
available, assist the person contamination or inadvertent
performing the procedure. injury.
6. The person performing the Identifies the correct location for The incision is just inferior to
procedure locates the cricothyroid incision and tube placement. the vocal cords and superior to
membrane (see Fig. 11-1), prepares The cricothyroid membrane is the thyroid gland.
the skin with a topical antiseptic preferred over the trachea
solution, and makes an incision because it is more anterior than
through the skin. the lower trachea and less thyroid
and soft tissue are found between
the membrane and the skin.
7. Assistant B uses gauze sponges and A dabbing technique minimizes If a second assistant is not
a dabbing technique to control any further tissue trauma and available, the primary assistant
bleeding from the incision, when bleeding. Only assist with blood should continue to attempt to
asked by the person performing the loss control when asked to avoid ventilate the patient.
procedure. contact with the scalpel.
8. The person performing the Discontinuing ventilations Assistant A stops ventilations
procedure incises the cricothyroid minimizes airborne just before the incision is
membrane with the scalpel (see Fig. contamination when the being made.
11-2). Assistant B prepares the cricothyroid membrane is
curved hemostats that may be incised. Blunt dissection is
needed to bluntly dissect the skin to preferred over sharp dissection to
locate and visualize the cricothyroid minimize further tissue trauma
membrane. and bleeding.
9. Assistant B prepares the Enlarging the opening in the Assistant A continues to hold
endotracheal or tracheostomy tube cricothyroid membrane allows ventilation attempts until the
and tracheal dilator or nasal passage of the tube. tube is placed.
speculum for the person performing
the procedure.
10. Assistant B uses the syringe to Prevents an air leak and optimizes A cuffed tube is preferred over
inflate the tube cuff to a minimal oxygenation and ventilation. an uncuffed tube to prevent an
occlusive pressure once the tube is air leak and reduce the risk of
placed. aspiration.
11. Assistant A attaches the bag-valve Prevents inadvertent movement or
device to the tube and oxygenates displacement of tube.
and ventilates the patient. Assistant
B manually stabilizes the tube.
12. Auscultate for the presence of equal Tube position may be confirmed Primary confirmation relies on
breath sounds and the absence of with the same methods as oral or physical examination
epigastric sounds with a stethoscope. nasal endotracheal tube techniques to confirm correct
Observe chest rise and fall. placement. tube placement.2
13. Confirm correct placement with Tube position may be confirmed Secondary confirmation verifies
secondary means such as an exhaled with the same methods as oral or correct tube placement.2
CO2 detector or monitoring device. nasal endotracheal tube
Obtain chest radiography. placement.
14. Secure the tube with tracheostomy Prevent dislodgment or movement Use a square knot to secure the
ties. Dress the site with gauze and of tube. tracheostomy ties.
tape.
16. HH
Expected Outcomes Unexpected Outcomes1,2,5

• Establishment of emergent surgical airway access • Blood loss or hemorrhage
• Provision of adequate oxygenation and ventilation • Aspiration or asphyxia
• Improved or stabilized patient condition • False passage of the endotracheal tube into
subcutaneous tissue4
• Tracheal perforation
• Esophageal perforation
• Mediastinal emphysema
• Vocal cord injury or paralysis
• Tracheal stenosis (delayed)

interventions.
1. Monitor breath sounds, adequacy Monitors effectiveness of airway, • Inability to ventilate
of oxygenation and ventilation, and oxygenation, and ventilation. • Decreased or absent breath sounds
oxygen saturation (Spo2). Consider • Decrease in Spo2
continuous capnography. • Loss of ETco2
2. Monitor endotracheal tube position. Prevents movement or • Inadvertent dislodgment or
dislodgment of tube. removal of tube
3. Observe insertion site for bleeding, Identifies displacement of tube • Excessive bleeding from the site
swelling, or subcutaneous air. or significant air leak. • Swelling or subcutaneous air at
the insertion site
Documentation
• Assessment findings to support the need for an • Pain assessment, interventions, and effectiveness
emergent surgical airway • Inability to obtain or maintain airway and provide
• Size and type of endotracheal/tracheostomy tube oxygenation and ventilation by other means
inserted and centimeter mark at skin opening • Documentation of the procedure, to include date and
• Confirmation of proper tube placement by both time
primary and secondary means • Any difficulties encountered during the procedure

12 Surgical Cricothyrotomy (Assist) 88.e1
References operations manual, Spokane, WA, 2013, Northwest

1. American College of Surgeons: Airway and ventilatory MedStar.
management: advanced trauma life support, ed 9, 4. Proehl JA: Emergency nursing procedures, ed 4, St. Louis,
Chicago, 2012, ACS. 2009, Saunders.
2. American Heart Association: Airway, airway adjuncts, 5. Tintinalli JE, Kelen GD, Stapczynski JS: Emergency
oxygenation and ventilation: advanced cardiac life medicine: a comprehensive study guide, ed 7, New York,
support: Principles and practice, Dallas, 2011, 2010, McGraw-Hill.
AHA. 6. Walls RM, Murphy MF: Manual of emergency airway
3. Northwest MedStar, Critical Care Air Medical Transport management, ed 4, Philadelphia, 2012, Lippencott
Service: Cricothyrotomy, surgical: Adult/Peds: program Williams and Wilkens.
PROCEDURE
13
Tracheostomy Cuff and
Tube Care
Renee Johnson
PURPOSE: Tracheostomy tube care includes care of the tracheal tube cuff, the
inner and outer cannulas of the tracheal tube, and the tracheal dressing and ties.
Proper care of the tracheostomy tube maintains an adequate airway seal and
tracheal tube patency. Proper cuff inflation may decrease the risk of aspiration of
some particles. The tracheal dressing and ties are changed to maintain skin
integrity and decrease the risk of infection. Additionally, the tracheal ties help
maintain stability of the tracheal tube and prevent tube dislodgement.
PREREQUISITE NURSING identified by the surgeon, and an incision is made below

the cricoid cartilage. The isthmus of the thyroid gland is
KNOWLEDGE exposed, cross-clamped, and ligated. A Bjork flap may be
• Tracheotomy refers to the surgical procedure in which an created. The flap is created when a small portion of the
incision is made below the cricoid cartilage through the tracheal cartilage is pulled down and sutured to the skin.
second to fourth tracheal rings (Fig. 13-1). Tracheostomy The flap helps facilitate reinsertion of the tracheostomy
refers to the opening, or the stoma, made by the incision. tube if it is dislodged, especially in patients who may be
The tracheostomy tube is the artificial airway inserted into obese or have difficult anatomy.14 Percutaneous tracheot-
the trachea during the tracheotomy (Fig. 13-2). omy has been proven to be a safe alternative to surgical
• A tracheotomy is performed as either an elective or emer- tracheostomy on mechanically ventilated patients.8,13
gent procedure for a variety of reasons (Box 13-1). There Unlike surgical tracheotomy, percutaneous tracheotomy
is no standard time when a tracheotomy should be per- can be performed without direct visualization of the
formed. The decision is based on the projected length of trachea.14 A bronchoscope may or may not be used to
time that mechanical ventilation or an artificial airway is assist with visualization during the procedure. A needle is
required to remain in place. A tracheostomy tube is the passed into the trachea. A J-tipped guidewire is placed into
preferred method of airway maintenance in patients who the trachea, the incision is then the dilated, and the trache-
may require mechanical ventilation for more than 14 to ostomy tube is placed.
21 days.4-6,20,23,25 Further studies need to be done to help • Tracheostomies are not without complications. Common
predict which mechanically ventilated patients may benefit complications include infection, bleeding, tracheomala-
from early tracheostomy.2,3,11-13 cia, skin breakdown, and transesophageal fistula. Common
• Compared with endotracheal tubes, tracheostomy tubes postoperative tracheostomy emergencies are hemorrhage,
provide added benefits to patients, including the follow- tube obstruction, and dislodgement. Hemorrhage can
ing: prevention of further laryngeal injury from the trans- occur at the stoma site or into the trachea. A small amount
laryngeal tube; improved patient comfort, acceptance, and of bleeding is expected postprocedure and is limited to a
tolerance; ease of oral care; decreased work of breathing short period of time. Bleeding that continues or is moder-
due to decreased airflow resistance; facilitation of weaning ate to large in volume could be due to a bleeding vessel
from mechanical ventilation; decreased requirements or a tracheoinnominate artery fistula. Bleeding vessels
for sedation; provision of a speech mechanism which may need to be ligated by a physician.
enhances communication; increased patient mobility; • Tracheoinnominate artery fistula is a rare complication
facilitation of removal of secretions; and reduced risk for with high mortality indices. In this complication the
unintentional airway loss. innominate artery has eroded into the trachea, which can
• Elective tracheotomy is generally performed in the operat- result in exsanguination and is more common when a
ing room but may be performed at the bedside; percutane- tracheostomy tube is subject to traction to one side or the
ous tracheotomy is commonly performed at the bedside other, away from the midline. Any concerns over bleeding
on ventilated patients. Emergent surgical cricothyrotomy should be reported to the physician immediately. Tube
may occur before the patient arrives in the critical care obstruction can occur from occlusion due to secretions or
unit or at the bedside (for additional information on from the tracheostomy tube being displaced into the ante-
cricothyrotomy refer to Procedure 11). rior portion of the trachea within a false passage. If the
• Surgical placement is performed under general anesthesia. tube is obstructed from secretions, it should be suctioned.
Using an open surgical technique, a stoma is created. The If the tube is felt to be dislodged into a false passage,
trachea is visualized by the surgeon. Landmarks are treatment depends on how mature the stoma is. If the
89
Thyroid stoma is mature the tube should be replaced. If the stoma

cartilage is immature—that is, the stoma is less than a week old—
mask ventilation should be employed with the cuff deflated
Cricothyroid and an orotracheal tube should be inserted. Once the
Cricothyroi- membrane airway is secure the tracheostomy can be revised.14 The
dotomy
physician should be notified if the tube becomes obstructed
Cricoid and aggressive measures other than routine suctioning are
cartilage needed to clear the cannula or secretions of debris.
• An initial tracheotomy tube change varies depending
Percutaneous Subcricoid on whether the trach was placed via standard surgical
dilational space
procedure or via percutaneous approach. Currently there
tracheostomy
is no evidence to justify when the initial or subsequent
First tracheal
cartilage
tracheotomy tubes should be changed; it typically occurs
by physician preference. The first tube change most
Standard
lracheoslomy Second tracheal commonly occurs around day 5 postoperatively. Some
sile cartilage reports state that for a percutaneous tracheotomy the
initial change should not occur until postoperative day 10
to allow the stoma to mature. After the initial change, the
tracheotomy should be changed approximately every 14
days thereafter. The first change is usually done by the
Figure 13-1 Sites for tracheostomy insertion. (From Serra A:
physician.12,14
Tracheostomy care, Nurs Stand 14:42,45–52, 2000.)
• In all instances, caution should be used to ensure that the
tracheostomy tube is not accidentally dislodged or decan-
nulated. The stoma takes approximately 1 week to heal
posttracheotomy. Dislodgment of the tube in the first week
is considered an emergency; the tissue may collapse, and
it may not be possible to replace the tracheal tube. Predis-
Oral pharynx posing factors to tube dislodgement or decannulation
include an underinflated cuff, loose ties, neck or airway
edema, excessive coughing, agitation or undersedation,
Epiglottis morbid obesity, downward traction caused by the weight
of the ventilator circuit, and an improperly sized trache-
Larynx ostomy tube. Trach ties should be secure. Weight or trac-
Vocal cords tion from the ventilator circuit should be minimized; when
Thyroid cartilage
transporting or mobilizing the patient the tube should
Trachea
Cricothyroid membrane remain in a neutral midline position. Tube position should
be noted before and after the patient is moved to ensure
Cricoid cartilage Esophagus safety. Individual institutions usually use protocols to
manage new tracheostomy tubes and accidental dislodg-
ment to ensure patient safety.7,12,14,17,31,33
• A tracheostomy tube is shorter than but similar in diameter
to an endotracheal tube. Some tracheostomy tubes have
both outer and inner cannulas. The outer cannula forms
the body of the tracheostomy tube with a cuff. The neck
Figure 13-2 A tracheostomy (sometimes called a tracheotomy) flange, attached to the outer cannula, assists in stabilizing
is created surgically by making an opening through the skin of the the tube in the trachea and provides the small holes neces-
neck into the trachea. (From Serra A: Tracheostomy care, Nurs sary for properly securing the tube. Some tracheostomy
Stand 14:42,45–52, 2000.)
tubes have an inner cannula inserted into the outer cannula.
The inner cannula is removable for easy cleaning without
airway compromise and may be disposable. The tracheal
tube cuff is an inflatable balloon that surrounds the shaft
BOX 13-1 Indications for Tracheostomy of the tracheal tube near its distal end. When inflated, the
• Bypass acute upper airway obstruction cuff presses against the tracheal wall to prevent air leakage
• Prolonged need for artificial airway and pressure loss from the lungs during positive pressure
• Prophylaxis for anticipated airway problems ventilation. The tracheal tube cuff is inflated by injecting
• Reduction of anatomical dead space air through a pilot balloon with a one-way inflation valve.
• Prevention of pulmonary aspiration The air in the pilot balloon is used to assess of the amount
• Retained tracheobronchial secretions of pressure in the tracheal tube cuff (Fig. 13-3).
• Chronic upper airway obstruction • Tracheostomy tubes are available in various materials,
sizes, and styles from several manufacturers. It is important
13 Tracheostomy Cuff and Tube Care 91
the inner cannula is removed, the cuff deflated, and the

Outer cannula tracheostomy tube occluded with the plastic plug, the
patient can breathe through the fenestration(s) and around
Cotton tape
the tube, using the normal anatomical airway. When a
Flange
fenestrated tracheostomy tube is occluded in this manner,
Outer the patient can speak, as air is allowed to pass over the
Pilot cannula vocal cords. Additional oxygen can be provided to the
balloon Cuff patent via nasal cannula if needed.8
Inflation • Uncuffed tubes are commonly used in children, in patients
One-way tube with laryngectomies, and during weaning from the trache-
inflation X-ray
valve indicator ostomy. Uncuffed tubes may also be used in long-term
Inner cannula mechanically ventilated patients who have adequate pul-
15 mm
adapter
monary compliance and sufficient oropharanygeal muscle
strength for functional swallowing and articulation and
Rounded laryngeal strength to achieve glottis closure.8
tip • Cuffed tubes are generally used in patients requiring
Obturator mechanical ventilation. Cuffed tubes allow for airway
Figure 13-3 Parts of a tracheostomy tube. (From Eubanks DH, clearance, and the cuff limits aspiration of oral and gastric
Bone RC: Comprehensive respiratory care, ed 2. St Louis, 1990, secretions in ventilated patients. Cuffed tubes include
Mosby, p. 570.) high-volume, low-pressure cuffs; low-volume, high-
pressure cuffs; and foam cuffs (Fig. 13-4). High-volume,
low-pressure cuffs are the most desirable. These tubes
for the clinician to understand the differences between the allow a large surface area to come into contact with the
various tracheostomy tubes to ensure appropriate feature, tracheal wall, distributing the pressure over a much greater
fit, and size for the patient. The tube should be selected with area. This cuff has a relatively larger inflation volume that
the goal of minimizing damage to the tracheal wall, allow- requires lower filling pressure to obtain a seal (<25 mm Hg
ing adequate ventilation, and when possible promoting or 34 cm H2O). The older cuff design (low-volume, high-
translaryngeal airflow for communication to assist with pressure) may require 40 mm Hg (54.4 cm H2O) to obtain
future rehabilitation and therapy. The American Thoracic an effective seal and is undesirable.
Society has published guidelines to guide users in selecting • It is generally accepted that cuff pressure should be 20 to
the appropriate tube and size.12,16 Routine patient care and 25 mm Hg to minimize the risk of tracheal wall injury and
tube maintenance may be affected based on the tube size, decrease the risk of microaspiration for most tracheos-
style, and construction. tomy tubes.8,26 The amount of pressure and volume neces-
• Tracheostomy tubes can be constructed of metal (silver or sary to obtain a seal and prevent mucosal damage depends
stainless steel) or plastic (polyvinyl chloride or silicone). on tube size and design, cuff configuration, mode of ven-
Metal tubes are rarely used due to cost, rigid construction, tilation, and the patient’s arterial blood pressure (tracheal
lack of cuff, the possibility of damage by cleaning with capillary perfusion pressure is 25 to 35 mm Hg for nor-
hydrogen peroxide or enzymatic cleaners, and lack of a motensive patients). Lower cuff pressures are associated
15-mm connector needed to attach the tracheostomy tube with less mucosal damage but are also associated with
to a ventilator or bag-valve mask.8,14 Polyvinyl chloride silent aspiration, which has been shown when the cuff
softens with the patient’s body temperature, which helps pressures are less than 20 mm Hg.8,22,30
the tube conform to the patient’s anatomy and assists in • Appropriate cuff care helps prevent major pulmonary
centering the distal tip in the trachea. Silicone tubes are aspirations; prepares for tracheal extubation; decreases the
naturally soft and are not affected by the patient’s body risk of inadvertent decannulation; provides a patent airway
temperature.8 for oxygenation, ventilation, and removal of secretions;
• Tracheostomy tubes may be angled or curved, and come and decreases the risk of hospital-acquired infections.
in standard or extra length, fenestrated, and cuffed or • A variety of techniques or devices is available to measure
uncuffed. Angled tubes have a straight portion and a cuff pressures, including bedside pressure manometers.
curved portion, whereas curved tubes have a uniform Two techniques, minimal leak technique and minimal
angle of curvature. Extra length on the tracheostomy tube occlusion volume (MOV), had historically been listed
may refer to additional length that is proximal (horizontal in the literature as effective methods to assess proper
length) or distal (vertical length). Extra proximal length cuff inflation. Both of these methods have fallen out
may facilitate tracheostomy tube placement in patients of favor due to the risk of aspiration when the cuff is
with large necks (for example, obese patients); extra distal deflated, increasing the incidence of ventilator-associated
length may facilitate placement in patients with tracheal pneumonia for some patients. Little research has been
anomalies or tracheal malacia.8 conducted regarding the best practices with cuff pressure
• Fenestrated tracheostomy tubes are similar to standard assessments.10,15
tracheostomy tubes with an added opening located in the ❖ Measurement of tracheal tube cuff pressures can be
posterior portion of the tube above the cuff. Fenestrated achieved through the use of a commercial pressure
tubes come with an inner cannula and a plastic plug. When gauge by assembling equipment to assess pressure via
Figure 13-4 Cross-sectional view in D-shaped trachea. Effects of soft and hard cuff inflation
on the tracheal wall. (From Kersten LD: Comprehensive respiratory nursing. Philadelphia 1989,
Saunders, p. 648.)
bedside manometer. An advantage to direct cuff pres- mechanisms are mainly responsible for airway damage:
sure monitoring is that there is no need to deflate then tube movement and pressure. Duration of intubation
reinflate the cuff, thus decreasing the potential risk for also plays a significant role.16,28
aspiration. Disadvantages are that these devices are ❖ Routine cuff deflation is unnecessary and is no longer
designed for high-volume, low-pressure cuffs that recommended.17
are air filled. Saline-filled cuffs would damage the • Consideration should be given to obtaining assistance
device.24 with tracheostomy care, especially when tracheal ties are
❖ The MOV consists of injection of air into the cuff until changed or when the patient is agitated. An assistant can
no leak is heard, then withdrawal of the air until a minimize risk for accidental dislodgement.
small leak is heard on inspiration, and then addition of
more air until no leak is heard on inspiration.1,10,17,25,30 EQUIPMENT
The main advantages of this method are that it is
easy to perform and that there is little additional equip- • Specially designed manometer to measure cuff pressures
ment needed to perform the MOV. The main disadvan- • Stethoscope
tage is that by withdrawing air from the cuff, a leak is • Self-inflating manual resuscitation bag-valve device
created, thus increasing the patient’s potential risk for • Oxygen source and tubing
aspiration. • Suction supplies (see Procedure 12)
❖ Although rare since the use of high-volume, low- • Personal protective equipment
pressure devices became common, the adverse effects • Sterile normal saline solution or sterile water
of tracheal tube cuff inflation include tracheal stenosis, • Two to three sterile containers to place supplies (cotton
necrosis, tracheoesophageal fistulas, and tracheomala- swabs, normal saline)
cia. These complications may be more likely to occur • Sterile cotton balls and/or cotton-tipped applicators
in conditions that adversely affect tissue response to • Sterile nylon brush
mucosal injury, such as hypotension. Two major • Sterile 4 × 4 gauze
• Commercial tracheostomy tube holder patient with mechanical ventilation. Rationale: An ade-
• Sterile precut tracheostomy dressing or dressing used by quate seal of the cuff to the tracheal wall does not permit
institutional preference air to flow past the cuff.
• If inner cannula is disposable, new sterile disposable inner • Assess signs and symptoms of inadequate ventilation,
cannula of the same size including rising arterial carbon dioxide tension, chest-
• Extra sterile tracheostomy kit at bedside and obturator abdominal dyssynchrony, patient-ventilator dyssynchrony,
Additional equipment, to have available as needed, includes dyspnea, headache, restlessness, confusion, lethargy,
the following: increasing (early sign) or decreasing (late sign) arterial
• Scissors blood pressure, and activation of expiratory or inspiratory
• 10-mL syringe volume alarms on mechanical ventilator. Rationale: This
• Three-way stopcock guides needed interventions.
• Padded hemostats • Assess the amount of air or pressure currently or previously
• Short 18-gauge or 23-gauge blunt needle used to inflate the cuff. Rationale: The amount of air previ-
• Tongue depressor ously used to inflate the cuff can be used as a guideline to
• Tape (1 inch wide) determine changes in volume or pressure or both.
• Reintubation equipment, in case of accidental extubation • Assess the size of the tracheal tube and the size of the
patient. Rationale: The volume and pressure of air needed
PATIENT AND FAMILY EDUCATION to seal the airway depends on the relationship between the
tracheal tube and the diameter of the trachea.
• Explain the procedure and the reason for tracheal tube cuff • Assess the amount of secretions. Rationale: This may
care, tracheal tube care, and/or tracheostomy dressing increase the frequency of suctioning and tube care.
change. Rationale: This communication identifies patient • Assess for the presence of cutaneous tracheal sutures.
and family knowledge deficits concerning the patient’s Rationale: After 7 days (when the trach is mature),
condition, procedure, expected benefits, and potential the sutures may no longer be required. If they remain
risks, and allows time for questions to clarify information in place, notify the physician and query for removal.
and voice concerns. Explanations decrease patient anxiety The sutures increase the risk of decanulation due to
and enhance cooperation. difficulty with maneuvering to care for the site and dress-
• Explain the patient’s role in assisting cuff care. Rationale: ing. Prolonged suture retention may also promote skin
This information elicits patient cooperation. breakdown.
• Explain that the procedure may cause the patient to cough.
Rationale: This explanation prepares the patient for what Patient Preparation
to expect. • Ensure that the patient and family understand preprocedural
teachings. Answer questions as they arise, and reinforce
PATIENT ASSESSMENT AND evaluates and reinforces understanding of previously taught
PREPARATION information.
• Verify that the patient is the correct patient using two
Patient Assessment identifiers. Rationale: Before performing a procedure, the
• Assess the presence of bilateral breath sounds. Rationale: nurse should ensure the correct identification of the patient
This assessment provides baseline data. for the intended intervention.
• Assess signs and symptoms of cuff leakage, including • Consider placing the patient in semi-Fowler’s position.
audible or auscultated inspiratory leak over larynx, audible Rationale: This positioning promotes general relaxation,
patient vocalizations, inflation (pilot) valve balloon defla- oxygenation, and ventilation. It also reduces stimulation
tion, and loss of inspiratory and expiratory volume on of the gag reflex and risk of aspiration.
Procedure for Tracheostomy Cuff and Tube Care

Measurement of Cuff Pressure
1. HH
2. PE
3. Hyperoxygenate and suction Clears secretions above the trach If an open suction system is used, a
tracheobronchial tree and pharynx cuff and in the lower airway and fresh sterile catheter is needed for
before cuff deflation. Special care decreases incidence of suctioning the tracheobronchial
should be untaken with subglottic aspiration. tree. When suctioning of the
suctioning16 (see Procedure 12). tracheobronchial tree is complete,
(Level D*) the same catheter may be used to
suction the pharynx. If a closed
suction system is used in suctioning
the tracheobronchial tree, a fresh
sterile catheter is needed for
suctioning the pharynx.
4. Attach a commercial pressure gauge Allows for measurement of the
to the tracheal cuff.18 cuff pressure.
5. Read the measurement. Intracuff pressure measurement Most cuffs are sufficiently inflated
provides an approximation of with <10 mL of air.
cuff-to-tracheal wall pressure.17
6. If the cuff pressure is >25 cm H2O, Provides optimal pressure to seal Hazards of cuff inflation include cuff
press the pressure-release button on the cuff without causing overinflation, distention, and
the pressure gauge until the pressure excessive tracheal pressure. rupture. The patient who is alert and
reaches 20–25 cm H2O. If the cooperative may be asked to speak.
pressure is <20 cm H2O, add air by If the trachea is sealed, vocalization
squeezing the bulb to increase is not possible.
pressure.8,28 (Level D)
7. If unable to maintain appropriate Elevated cuff pressures have been
pressures, notify the physician or associated with tracheal stenosis
advance practice nurse. and necrosis. Inadequate cuff
pressures may lead to impaired
ability to provide ventilation and
increase the risk for aspiration.28
8. Dispose of used supplies and
equipment and remove PE .
9. HH
Troubleshooting Tracheal Cuff Problems
Faulty Inflation Valve
1. HH
2. PE
3. Identify the faulty inflation valve by Determines need for repair. If the inflation valve becomes faulty
determining that the cuff continually and reintubation is undesirable,
deflates, despite the addition of air to consider instituting an emergency
the cuff (Fig. 13-5). cuff-inflation technique. There are
commercial cuff inflation-valve
repair kits available. Follow
institutional standards regarding
who is responsible for repairing a
faculty inflation valve.
4. Clamp the inflation tube with the Prevents further air loss through
padded hemostat. the faulty inflation valve.
5. Insert a three-way stopcock into the Provides access to the cuff.
inflation valve.
6. Inflate the cuff with the MOV Allows for cuff inflation; restores
technique. tracheal wall and cuff seal.
Figure 13-5 Attachments for emergency cuff inflation for a faulty inflation line.
(From Sills J: An emergency cuff inflation technique, Respir Care 31:200, 1986.)
Procedure for Tracheostomy Cuff and Tube Care—Continued

7. Turn the stopcock off to the inflation Temporarily maintains cuff
valve and leave it in place; remove pressure.
the hemostat.
8. Discard used supplies and remove PE.
9. HH
Faulty Inflation Tube
1. HH
2. PE
3. Identify malfunctioning of the Determines need for and method There are commercial inflation tube
inflation tube by determining that an of repair. repair kits available.
air leak is present in the tube (see Follow institutional standards
Fig. 13-5). regarding who is responsible for
repairing a faculty inflation tube.
Collaborate with respiratory therapy,
the advanced practice nurse, and the
physician.
4. Clamp the inflation tube, below the Prevents further air loss through The placement of the padded hemostat
leak with the padded hemostat. the faulty inflation line. should allow adequate inflation tube
length to accept the blunt needle.
5. Cut the inflation line above the Allows introduction of the blunt
padded hemostat but below the needle for repair.
identified leak.
6. Insert a short 18-gauge to 23-gauge Provides inflation access. Maintain care to avoid puncture or
blunt needle into the inflation tube. severing of inflation line or
clinician’s skin.
7. Attach a three-way stopcock to a Provides control of airflow in and
blunt needle, “Off” to the inflation out of the inflation tube.
tube.
8. With a 10-mL syringe, inflate the Allows cuff inflation; restores
cuff with air using the MOV tracheal wall and cuff seal.
technique.
9. Turn the stopcock off to the Provides for temporary use of the
inflation tube. tracheal tube while maintaining
cuff pressure.
10. Secure the assembled device with Provides for stabilization and
tape to a tongue depressor. protection.
11. Assemble equipment for tracheal Prepares for tracheal tube Make plans to change the tube as a
tube replacement. replacement. more permanent solution.
12. Discard used supplies and remove Reduces transmission of
PE . microorganisms and body
13. HH

Tracheostomy Tube Care
1. HH
2. PE Protective eyewear or a face mask
should be worn.22
3. Hyperoxygenate and suction the Reduces the risk of hypoxemia and Saline solution flushes to assist with
trachea and pharynx as needed (see arrhythmias; removes secretions secretion removal are not
Procedure 12). and diminishes the patient’s need recommended. These flushes do not
to cough during the procedure. loosen secretions, but they
potentiate infections. (Level D*)
4. Remove and discard soiled Provides access and visibility of
tracheostomy dressing and PE . the tracheostomy site.
5. HH
6. For disposable inner cannula: Replaces the inner cannula.
A. Open prepackaged inner
cannula.
B. Apply clean gloves.
C. Remove soiled inner cannula.
D. Replace with prepackaged
cannula.
7. For nondisposable inner cannula Prepares for cleaning the Only sterile normal saline should be
(open prepackaged commercial tracheostomy. used for cleaning tracheostomy
tracheostomy care kit): tubes. Hydrogen peroxide may
A. Prepare sterile saline or sterile cause pitting of metal inner
water on a sterile field.22,31,32 cannula.25
B. Apply sterile gloves.
C. Remove oxygen source and then
inner cannula, placing it in
sterile saline or sterile water.
8. Place tracheostomy collar, T tube, or Maintains oxygen supply. If the patient cannot tolerate
ventilator oxygen source over or disconnection from a ventilator for
near the outer cannula. the time needed to clean the inner
cannula, replace the existing inner
cannula with a clean one and
reattach the ventilator. Then, clean
the cannula just removed from the
patient and store it in a sterile
container for the next inner cannula
change.29
9. Clean the inner cannula with a small Assists in the removal of debris
brush. and thick secretions.
10. Rinse inner cannula by pouring Removes any remaining debris
normal saline over the cannula. from the cannula. Excess
Remove excess solution by tapping solution left on the inside of the
on the inside edge of the sterile inner cannula may lead to
container. Do not dry the outside aspiration. Solution on the
portion of the inner cannula. outside portion of the inner
cannula may help act as a
lubricant for insertion.29
11. Remove the oxygen source from Allows access to the opening of
over the outer cannula. the outer cannula.
12. Insert the inner cannula and lock it Secures the inner cannula.
into place.
13. Reapply the oxygen source to the Reestablishes oxygen supply.
inner cannula hub.

14. Moisten 4 × 4 gauze pads with Removes debris and secretions
sterile normal saline or sterile water from the stoma area.
and clean the stoma site, outer
cannula, and neck plate surface by
wiping with cotton-tipped swabs
and 4 × 4 gauze.
15. Dry the skin around the stoma by Decreases the likelihood of
gently patting it dry. microorganism growth and skin
breakdown.
16. If needed, prepare to attach a new Ties may need to be replaced if Review individual institutional polices
tracheostomy tube holder or twill they are soiled. regarding the use of twill tape or
tape tie. commercial trach tie devices.
Institutions may prohibit
tracheostomy tube holders from
being changed for up to 72 hours
after tracheostomy tube placement
due to the risk of dislodgement.
Have an assistant hold the neck plate
securely if this procedure is
performed.
17. Remove the current tracheostomy Prepares for replacement. Make certain an assistant securely
tube holder or twill tape. holds the tracheostomy in place.
18. Tracheostomy tube holder: Connect Removes soiled holder or tape. A variety of commercial tracheostomy
one side of the neck plate to the tube holders is available. In some
new tracheostomy tube holder, then instances a newly placed
connect the other side of the neck tracheostomy tube may be sutured
plate and tighten the tube holder, into place and no holder or ties are
allowing one finger under the holder used (i.e. for patients with a new
to ensure it is secure. laryngectomy and flap). If this
Twill tape: Cut a length long enough to occurs, the physician should write
encircle the patient’s neck two clear orders if a tracheostomy
times. Cut ends diagonally. Insert holder or twill tape should not be
one end through the faceplate eyelet used.
and pull the ends even. Pass both
ends of the tie around the patient’s
neck and insert one end through the
faceplate’s second eyelet. Pull
snugly to allow space for one finger
between tie and the patient’s neck
and tie the ends securely with a
double square knot so that the knot
rests on the side of the patient’s
neck (Fig. 13-6).
19. Apply a clean, precut tracheostomy Provides a dressing between the Any precut surgical gauze is
dressing under the neck plate. tracheostomy and the neck plate. sufficient. Never cut a 4 × 4 gauze
pad because cut edges fray and
provide a potential source for
infection.22,25 (Level D*)
20. Provide oral care (see Procedure 4). Increases patient comfort.
PE .
22. HH

A B
C
Figure 13-6 Placement of tracheostomy twill tape. A, Faceplate with threading of twill tape
(for prevention of decannulation, an additional person needs to stabilize faceplate). B, Advancing
of the twill tape around the back of the neck and looping through the other side of the faceplate.
C, Doubling of the twill tape and securing it in a knot.

• Tracheal tube remains in correct position • Decannulation or tube dislodgment
• Cuff pressure is kept at a level to maintain a seal • Tracheal mucosal ischemia from cuff overinflation
between cuff and tracheal wall (usually between 20 • Faulty inflation valve or tube
and 25 mm Hg) • Cuff overinflation and distention over the end of the
• Cuff remains intact tube
• Airway remains patent • Cuff rupture
• Stoma site is infection free • Prolonger apnea, increasing hypoxemia, or
cardiopulmonary arrest
• Hemorrhage
• Interstitial air: subcutaneous emphysema,
pneumothorax, pneumopericardium,
pneumomediastinum
• Thyroid gland injury
• Cardiac dysrhythmias
• Tube tip erosion into the innominate artery
• Skin breakdown, pressure areas, stomatitis
• Signs of stoma infection
• Bronchopulmonary infection
• Displacement or dislodgement out of trachea
• Excessive cuff pressure
• Leaking airway cuff
• Airway obstruction from misalignment, cuff
overinflation, or dried or excessive secretion
• Tracheal stenosis, malacia, or tracheoesophageal
fistula

1. Assess respiratory status Inadequate interface between tracheal cuff and • Rising arterial carbon dioxide
for optimal ventilation. tracheobronchial mucosa decreases inspiratory tension
flow. • Chest-abdominal dyssynchrony
• Patient-ventilator dyssynchrony
• Dyspnea
• Headache
• Restlessness
• Confusion
• Lethargy
• Increasing (early sign) or
decreasing (late sign) arterial
blood pressure
• Activation of expiratory or
inspiratory volume alarms on
the mechanical ventilator
2. Measure cuff pressure Prevents tracheal injury and aspiration. Excessive • Cuff pressure <20 mm Hg or
every 8 hours, cuff pressure is cited as the most frequent >25 mm Hg
or per institutional problem of tracheal intubation and the best • Inability to maintain cuff
requirements, predictor of tracheolaryngeal injury.8,10 pressure
maintaining cuff If the volume (milliliters) needed to seal the airway
pressure between increases, evaluate the patient for tracheal
20 and 25 mm Hg.31 dilation with chest radiography of cuff diameter/
(Level D*) tracheal diameter ratio. Increasing volumes also
may indicate a leak in the cuff, inflation valve, or
tube.
3. Maintain tracheal tube Manipulation of the tracheal tube increases the • Inability to maintain cuff
cuff integrity. likelihood of cuff disruption. Cuff leak or rupture inflation
is evident when the pressure on the manometer • Audible air through the
continues to decrease. patient’s nose or mouth
• Low-pressure or low-volume
alarm sounds on the
mechanical ventilator
• Audible or auscultated
inspiratory leak over larynx
• Patient able to vocalize audibly
• Pilot balloon deflation
• Loss of inspiratory and
expiratory volume on patients
with mechanical ventilation
4. Hyperoxygenate and Removal of secretions reduces chance for partial or
suction patient based on complete airway obstruction.
assessment (see
Procedure 12).


5. Compare patient’s Identifies the effects of tracheal tube cuff care on • Decreased arterial oxygen
cardiopulmonary status the cardiovascular system. saturation
before and after tracheal • Cardiac dysrhythmias
tube cuff care. • Bronchospasm
• Cyanosis
• Increased blood pressure or
intracranial pressure
• Anxiety, agitation, or changes
in level of consciousness
6. Reassess cuff pressure Changes in altitude may change the volume of gas
and volume when in the cuff; volume and pressure need to be
transporting the patient reevaluated during and after transport.
from one altitude to
another (i.e., air
transport) or during
hyperbaric therapy
without environmental
pressurization.
7. Provide continuous Artificial airways bypass the nose and mouth,
humidified air or preventing normal warming, humidification, and
oxygen. Warm or cool filtering.4,22
as appropriate.21,25,29
(Level D*)
8. Maintain the Traction on the tracheostomy from ventilator • Sutures that prevent adequate
tracheostomy tube in a circuits, oxygen, or suction tubing may cause the stoma care
neutral position, midline tip of the tracheostomy tube to erode through the
with the patient’s body. trachea and, potentially, into the innominate
artery.
9. Auscultate lung sounds Improper placement may lead to inadequate • Decreased chest wall motion
to check proper ventilation and complications. An extra sterile • Unilateral breath sounds
placement of tracheostomy kit should be kept at the bedside at • Audible expiratory wheeze
tracheostomy tube and all times. Displacement into the subcutaneous • Bilateral decreased breath
ensure tracheostomy tissue can occur. How emergent the situation is sounds
tube is securely in depends on whether the upper airway is • Oxygen desaturation
place. obstructed. Decannulation inadvertently occurs • Dyspnea and respiratory
from lack of tracheotomy securement. If distress
decannulation occurs and if retention sutures are • Stridor
present, pull them apart to lift the trachea up and • Ventilator alarms
hold the tracheal stoma open. Do not cross
tracheal sutures because this action will close the
airway. When help arrives, a second person
should reinsert the tracheostomy tube as per
individual facility policy.23 If the patient does not
have retention sutures, open a new tracheostomy
tube set, remove the inner cannula, insert the
obturator into the outer cannula, and slide it into
place.14
10. Inspect and palpate for Air may escape into the incision, causing • Subcutaneous emphysema
air under the skin. subcutaneous emphysema. Special note:
Subcutaneous emphysema does not injure the
patient with an artificial airway in place.
However, puffiness of the soft tissue may result
and, if significant, can change the patient’s
appearance, alarming the patient and family.

11. Assess for bleeding or a Surgical procedures increase the risk of potential • Frank bleeding or constant
constant ooze of blood. injury to adjacent tissue or structures. Stoma oozing of blood
placement below the second and third
cartilaginous rings results in an increased
incidence of innominate artery erosion.
12. Gently palpate the tube Pulsation felt on the tracheal tube is suggestive of • Pulsation of the tracheal tube
for pulsation. potential erosion of major blood vessels.
13. Follow institutional Identifies pain and need for appropriate • Continued pain despite
standards for assessing interventions. interventions
pain and administering
14. Tracheostomy care Keeps tube free of secretions, mucus, and plugs • Frequent plugs
should be performed that may impede airway patency. • Copious drainage
every 4–8 hours and as • Change in color, odor, or
needed or per tenacity of secretions
institutional policy
depending on the type
and volume of
secretions
produced.13,19,20,23,27
(Level E*)
15. Assess stoma for signs Skin irritation or breakdown may occur from the • Elevated temperature
of infection, neck plate, tracheostomy tube holder, or sutures, • Swelling
inflammation, or if present. • Excoriated or open areas
pressure from tension • Redness
by trach ties or
equipment.
16. Monitor secretions for Change in secretion characteristic may indicate • Purulent drainage
color, consistency, odor, infection or inadequate hydration. • Excessively thick secretions
and amount. • Copious or purulent secretions
17. Maintain the head of the Promotes oropharyngeal and nasopharyngeal
bed at 30–45 degrees drainage and minimizes the risk of aspiration.
and during enteral Prevents ventilator-associated or hospital-
feedings.24 (Level D*) acquired pneumonia.9 Withholding enteral
feedings when gastric residuals are high is also
important in the prevention if regurgitation and
pulmonary aspiration.
18. Perform oral care every Prevents bacterial overgrowth and promotes patient
2–4 hours (see comfort.
Procedure 4).
19. Tracheostomy tube care Prevents bacterial overgrowth and promotes patient
should be completed comfort.
every 4–8 hours and as
needed, or as
institutional policy
dictates.21,25,29 (Level D)
20. Promote effective The patient cannot talk, which may result in fear
patient-provider and anxiety. Patients need an established
communication (paper communication mechanism.
and pencil, letter or A speaking valve may be used to facilitate speech.
word boards, one-way
speaking valves, if
appropriate).

Documentation
• Patient and family education and comprehension • Cuff inflation volume and cuff pressure
• Vital signs assessed before and after the procedure • Patient’s tolerance of the procedure.
• Date, time, and frequency of tracheostomy care • Condition of stoma, including inflammation and
• Type and size of tracheostomy tube, changing of inner secretions
cannula, replacement of tracheostomy tube holder, and • Expected and unexpected outcomes
general condition of stoma and surrounding skin • Type and amount of secretions, frequency of
• Nursing interventions in response to assessed suctioning
complications • Performance of oral care
• Patient and family education • Pain-assessment interventions, and effectiveness
• Cardiopulmonary and vital sign assessment before and • Evidence that the securing device is adequate without
after procedure being excessively tight (2-finger technique)
• Method of cuff inflation

13 Tracheostomy Cuff and Tube Care 102.e1
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11. Masoudifar M, Aghadavoudi O, Nasrollahi L: Correlation annulas&a=false&ad=false>.
between timing of tracheostomy and duration of 30. Urden L, et al: Thelan’s critical care nursing: Diagnosis
mechanical ventilation in patients with potentially normal and management, St Louis, 2005, Mosby.
lungs admitted to the intensive care unit. Adv Biomed Res 31. White A, Sucharita K, O’Connor H: When to change a
1:25, 2012. tracheostomy tube. Respir Care 55(8):1069–1075, 2010.
12. Mitchell R, et al: Clinical consensus statement: 32. Winn M, Right K: Tracheostomy: A guide to nursing care.
Tracheostomy care. Otolaryngol Head Neck Surg Austr Nurs 13(5):1–4, 2005.
148(1):6–20, 2013. 33. Zhu H, et al: Improving the quality of tracheostomy care.
13. Mittendorf EA, et al: Early and late outcome of bedside Breathe 10(4):287–294, 2014.
percutaneous tracheostomy in the intensive care unit. Am
Surg 68:342–346, 2002. Additional Reading
14. Morris L, Whitmer A, McIntosh E: Tracheostomy care 1. Blot S, Rello J, Vogelaers D: What is new in the prevention
and complications in the intensive care unit. Crit Care of ventilator-associated pneumonia? Cur Opin Pulm Med
Nurse 22(5):18–31, 2013. 17(3):155–159, 2011.
15. Morris L, et al: Monitoring tracheal tube cuff pressures 2. MacIntyre N, Branson R: Mechanical ventilation, ed 2,
in the intensive care unit: A comparison of digital Philadelphia, 2009, Saunders.
palpation and manometry. Ann Otol Rhinol Laryngol 3. McCloskey J, Bulechek G: Nursing interventions
116(9):639–642, 2007. classification, ed 6, St Louis, 2012, Mosby.
Section Two Special Pulmonary Procedures
PROCEDURE
14
Continuous End-Tidal Carbon
Dioxide Monitoring
Paul Luehrs
PURPOSE: End-tidal carbon dioxide, also referred to as PetCO2, provides a
noninvasive continuous measurement of exhaled carbon dioxide (CO2) concentration
commonly referred to as capnometry. A capnograph is a graphic depiction of a
waveform tracing of each respiratory cycle. The partial pressure of end-tidal CO2 is
representative of alveolar CO2 (PaCO2), which under normal ventilation/perfusion
matching in the lungs closely parallels arterial levels of CO2 (PaCO2)
PREREQUISITE NURSING the vascular system to the lungs, where it is eliminated

KNOWLEDGE through exhalation. CO2 elimination can also be evalu-
ated with a blood gas machine or capnometer.
• There are three broad categories of indications for • In intubated patients, Petco2 can be monitored through a
capnography/capnometry: verification of artificial airway sensor that is placed directly into the ventilator circuit.
placement; assessment of pulmonary circulation and • In nonintubated patients capnography can be performed
respiratory status; and optimization of mechanical with a specialized nasal cannula that delivers supplemen-
ventilation.2,9 tal oxygen and measures Petco2 and respiratory rate.
• Capnography provides the clinician with a calculation of Placing the capnography cannula is the same as initiating
airway respiratory rate (RR), and the combination of both a nasal cannula for supplemental oxygen. Breath samples
Petco2 and RR can provide clinicians with one of the are obtained through both nostrils, and oxygen is deliv-
earliest indications that ventilation is hindered. In fact ered through the nasal prongs (design depends on manu-
capnography can detect respiratory depression before facturer). For patients who breathe either partially or fully
changes in pulse oximetry occur. Petco2 monitoring through their mouths, a specially designed nasal cannula
allows clinicians to actively monitor patients for clinical can be used that allows for exhaled gas to be captured for
changes and rapidly correct abnormal ventilatory con- analysis.
cerns, such as airway obstruction, congestive heart failure, • The Petco2 monitor may be a stand-alone system or a
pulmonary embolism, asthma, and chronic obstructive module incorporated into the patient’s bedside physiologi-
pulmonary disease (COPD).6,7,11 cal monitor or the mechanical ventilator. An infrared cap-
• The principles of arterial blood gas sampling (see Proce- nometer passes light through an expiratory gas sample
dure 61) and interpretation should be understood. and, with a photodetector, measures absorption of that
• Ventilation is the bulk movement of gases into and out of light by the gas. The capnograph determines the amount
the lung during the respiratory cycle and is composed of of CO2 in the gas sample based on the absorption proper-
two distinct processes: inspiration and expiration. ties of CO2. The capnograph provides a display called a
❖ During inspiration, gas is drawn into the alveoli, at capnogram or Petco2 waveform.
which time it participates in gas exchange. Oxygen- • The capnograph samples exhaled CO2 by one of two
ation occurs when the oxygen diffuses across the alve- methods: aspiration (side stream) or nonaspiration (main-
olar membrane into the capillary bed. CO2 exchange stream) sampling. In the side-stream method, a sample of
occurs during this time as it diffuses across the alveolar gas is transported via small-bore tubing to the bedside
membrane into the alveoli. Oxygenated blood is then monitor for analysis. In the mainstream system, analysis
distributed to and metabolized by the cells of the body. occurs directly at the patient-ventilator circuit.
Oxygen saturation can be evaluated with a blood gas • Normal Petco2 concentration in a patient with healthy
machine (oxygen saturation [Sao2]) or pulse oximetry lungs and airway conditions is 30 to 43 mm Hg. As the
(Spo2). patient breathes, a characteristic waveform is created that
❖ During expiration, alveolar gas is exhaled, which can be divided into two segments: inspiration and expira-
results in the elimination of CO2. Cells produce CO2 as tion.11 Paco2 (partial pressure of arterial carbon dioxide)—
a byproduct of metabolism; this CO2 is transported by Petco2 gradient is the difference between the Paco2
103
CO2 ❖ A ramping waveform is an indication of airway obstruc-

D tion such as is seen in COPD and asthma.
38
C
EQUIPMENT
• Personal protective equipment
E
• Capnometer
A B • Airway adapter or Petco2 nasal cannula
0
Time
Figure 14-1 Essentials of the normal capnographic waveform. PATIENT AND FAMILY EDUCATION
(Reprinted by permission of Nellcor Puritan Bennett LLC, Boulder,
CO, part of Covidien.) • Discuss the reason for implementation of capnography.
Rationale: Discussion reduces anxiety for the patient and
family associated with an additional monitor, related
obtained from an arterial blood gas and the Petco2 measure interventions, and unfamiliar procedures.
by the capnometer. A normal gradient is 2 to 5 mm Hg • If the patient is alert, explain the procedure to the patient;
with the Paco2 always higher. A widened gradient can if the patient is not alert, explain the procedure to the
result from increasing dead space ventilation such as is family. Rationale: This communication informs the
seen in COPD and pulmonary embolism. Additionally a patient and/or the family of the purpose of monitoring,
widened gradient can result from low perfusion disease improves cooperation with interventions, and reduces
states. anxiety.
• The normal capnographic waveform has the following
characteristics (Fig. 14-1):
❖ The zero baseline is seen during inspiration of fresh PATIENT ASSESSMENT AND
gas and the beginning of exhalation as CO2-free gas PREPARATION
from anatomical dead space is expelled. This gas
comes from the artificial airway (if present) and the Patient Assessment
large airways, oropharynx, and nasopharynx (see Fig. • Assess for indications for Petco2 monitoring, including
14-1A and B). general anesthesia,9 monitored anesthesia care, procedural
❖ A rapid sharp upstroke occurs as the gas from the sedation and analgesia,3 confirmation of endotracheal tube
intermediate airways, containing a mixture of fresh gas placement,9–11 adequacy of chest compressions in cardio-
and CO2-rich gas, begins to be expelled from the lungs pulmonary arrest,8 analysis/monitoring of ventilation in
(see Fig. 14-1B and C). mechanical ventilation,9 obstructive sleep apnea,1 and
❖ A nearly flat alveolar plateau occurs as exhaled flow neuromuscular disease. Additional indications (actual or
velocity slows and mixed gas is displaced by alveolar potential) include acute airway obstruction or apnea, dead
gas (Fig. 14-1C and D). Alveolar exhalation of CO2 is space ventilation, and incomplete alveolar emptying.
nearing completion. Rationale: Assessment for initiation of Petco2 monitoring
❖ A distinct end-tidal point most closely reflects the ensures that patients at risk for inadequate ventilation
maximal concentration of exhaled CO2 and the end of and gas exchange receive monitoring for such occur-
exhalation (Fig. 14-1D). rences, allowing for early institution of appropriate
❖ A rapid down stroke occurs as the patient begins the interventions.
inspiration of fresh gas that is essentially devoid of CO2
(see Fig. 14-1D and E). Patient Preparation
❖ The orientation of the capnogram is commonly con- • Verify correct patient with two identifiers. Rationale:
fused because the positive aspect of the waveform Prior to performing a procedure, the nurse should ensure
occurs with exhalation, whereas the negatively the correct identification of the patient for the intended
deflected limb occurs with inhalation. This is opposite intervention.
from other respiratory waveforms, including the respi- • Ensure that the patient understands preprocedural teach-
rogram, spirogram, and flow-volume loop. The capno- ing. Answer questions as they arise, and reinforce infor-
gram deviates from normal whenever physiological or mation as needed. Rationale: Understanding of previously
mechanical disruption of the breath occurs. taught information is evaluated and reinforced.
14 Continuous End-Tidal Carbon Dioxide Monitoring 105
Procedure for Continuous End-Tidal Carbon Dioxide Monitoring

1. HH
2. PE
3. Obtain order or follow Order provides guideline for
institutional protocol for duration of monitoring,
continuous Petco2 monitoring acceptable parameters for results,
with capnography. and appropriate interventions for
abnormal results.
4. Assess for proper functioning of Ensures reliability of Petco2 values
capnograph, including electronic and waveforms obtained.
equipment, self-start,
autocalibration, airway adapter,
sensor, and display monitor; and
secure connections. (Level M*)
5. Connect capnograph into Decreases incidence of electrical Check capnograph’s battery capacity
grounded wall outlet, connect interference. and charging time, if applicable.
the appropriate patient cable
into display monitor, and turn
on instrument. (Level M)
6. Perform calibration routine. Accurate measurement for devices All monitors have some type of
Calibration procedure should depends on proper calibration. calibration procedure; see
occur daily or more often when Improper calibration may lead to operator’s manual for exact steps.
instrument is in clinical use.4 erroneous Petco2 values.
(Level M)
7. If the patient is not intubated,
apply Petco2 nasal cannula and
connect to capnograph.
8. For intubated patients, assemble Decreases incidence of improper Sampling errors and gas leaks in the
airway adapter, sensor, and gas sampling. system are major causes of
display monitor; connect to the inaccurate readings. Placing the
patient’s circuit as close as sensor or sampling port as close as
possible to the patient’s possible to the patient’s airway
ventilation connection. decreases response time to detect a
change in CO2.
9. Ensure that the light source is Decreases condensation and
on top of the circuit so that secretion accumulation on CO2
condensation and secretions do port where gas is drawn for
not pool and obstruct the light sampling.
transmission in mainstream
sensor. (Level M)
10. Set appropriate alarms. Alarm Alerts the nurse to potentially The Petco2 alarm is set 5% above and
limits should include respiratory life-threatening problems. below acceptable parameter or per
rate, apnea default, high and institutional standard. If monitor is
low Petco2, and minimal levels interfaced with other equipment
of inspiratory CO2. (Level M) (electrocardiogram monitor,
mechanical ventilator, pulse
oximeter), ensure alarms are set
consistently among all monitors.
11. Discard supplies
12. HH


• Significant changes in ventilatory status are detected • Inaccurate measurements of Petco2 are displayed
• Alterations in the alveolar-arterial carbon dioxide • Inaccurate measurements from calibration drift or
gradient are identified contamination of optics with moisture or secretions
are displayed
• Equipment malfunction occurs
• Inadvertent extubation from weight of sensor

interventions.
1. HH
2. PE
3. Observe artificial airway for The airway adapter often adds weight to • Endotracheal or tracheal tube
patency.9 the airway and increases the risk of dislodgment
dislodgment or kinking. If kinking
occurs, support the airway with an
artificial support or towel.
4. If the patient is not intubated, Poor placement or occlusion of nasal
check nasal cannula or cannula or mouthpiece interferes with
mouthpiece for proper accurate Petco2 monitoring.
placement and ensure that it is
clear of secretions.5
5. Observe waveform for quality. If waveform is of poor quality, the • Poor-quality waveform
(Level M*) numerical Petco2 value should not be • Questionable Petco2 reading
accepted. If the Petco2 waveform is
acceptable and the Petco2 numerical
reading is questionable, obtain arterial
blood gas measurement to confirm
changes in Petco2.
6. Observe waveform for Increasing Petco2 occurs from • Petco2 increase of greater than
gradually increasing Petco2 absorption of CO2 from exogenous 10% of baseline
(Fig. 14-2).5,8 sources and increased CO2 production.
Clinical conditions in which
increasing Petco2 is found include
increased metabolism, hyperthermia
(usually indicated by a rapid rise in
Petco2), sepsis, hypoventilation or
inadequate minute ventilation,
neuromuscular blockade, decreased
alveolar ventilation, partial obstruction
of the airway, use of respiratory
depressant drugs, and conditions that
cause metabolic alkalosis.


CO2 WAVEFORM
76
38
0 Figure 14-2 Gradually increasing Petco2. (Reprinted by permission of

76
CO2 TREND Nellcor Puritan Bennett LLC, Boulder, CO, part of Covidien.)
38
7. Observe for a gradual increase Reflects rebreathing of previously • Malfunction of the ventilator
in both baseline CO2 and exhaled gas. Clinical conditions in
Petco2 values (Fig. 14-3).5,8 which a gradual increase in both
baseline CO2 and Petco2 levels is
found include defective exhalation
valve on mechanical ventilator and
excessive mechanical dead space in
ventilator circuit.
76 CO2 WAVEFORM
38
0 Figure 14-3 Gradual increase in baseline and Petco2. (Reprinted

by permission of Nellcor Puritan Bennett LLC, Boulder, CO, part of
CO2 TREND
76 Covidien.)
38
8. Observe for an exponential fall Indicates a sudden increase in dead • Petco2 decreased by more than
in Petco2 (Fig. 14-4).5,8 space ventilation seen in clinical 10% of baseline
conditions such as hypoventilation,
cardiopulmonary bypass, pulmonary
embolism, and severe pulmonary
hypoperfusion.10

76
CO2 WAVEFORM
38
0 Figure 14-4 Exponential fall in Petco2. (Reprinted by permission of

76 CO2 TREND Nellcor Puritan Bennett LLC, Boulder, CO, part of Covidien.)
38
9. Observe for decreased Petco2 Gradual decreases indicate a decrease in • Petco2 decreased by more than
(with a normal waveform; perfusion or a decrease in production 10% of baseline
Fig. 14-5).5,8 of CO2 and may be seen in patients
with high minute volumes,
hypothermia, metabolic acidosis,
decreased cardiac output, and
hypovolemia.
76
CO2 WAVEFORM
38
0 Figure 14-5 Decreased Petco2. (Reprinted by permission of Nellcor

76 CO2 TREND Puritan Bennett LLC, Boulder, CO, part of Covidien.)
38
10. Observe for a sudden decrease Incomplete sampling or full exhalation • Petco2 decreased by more
in Petco2 to low values is not detected in the system. This than10% of baseline
(Fig. 14-6).5,8 may be seen in patients with a leak in
the airway system, partial airway
obstruction, mechanical ventilator
malfunction, malpositioning/
dislodgement of the airway, or partial
disconnection of a ventilator circuit.
76
CO2 WAVEFORM
38
0 Figure 14-6 Sudden decrease in Petco2 values. (Reprinted by

permission of Nellcor Puritan Bennett LLC, Boulder, CO, part of
76 CO2 TREND
Covidien.)
38
0

11. Observe for a sudden decrease Drop in waveform to baseline or near • Dislodged endotracheal tube
in Petco2 to near zero baseline (baseline equals zero) implies • Complete airway obstruction
(Fig. 14-7).5,8 that no respirations are present. Such • Mechanical ventilator
a drop in waveform may also occur malfunction
within the case of significant • Airway disconnection
ventilation/perfusion changes such as • Esophageal intubation
pulmonary emboli. • Apnea
76
CO2 WAVEFORM
38
0 Figure 14-7 Sudden decrease in Petco2 to near zero. (Reprinted

by permission of Nellcor Puritan Bennett LLC, Boulder, CO, part of
76 CO2 TREND
Covidien.)
38
12. Observe for a sustained low Sustained low Petco2 values are • Complete airway obstruction that
Petco2 without alveolar plateau indicative of incomplete alveolar necessitates reintubation
(Fig. 14-8).5,8 emptying, such as in partially kinked • Petco2 decreased greater than
endotracheal tube, bronchospasm, 10% of baseline
mucous plugging, improper exhaled
gas sampling, or insufficient
expiratory time on the ventilator.
CO2 WAVEFORM
76
38
0 Figure 14-8 Low Petco2, without alveolar plateau. (Reprinted by per-

mission of Nellcor Puritan Bennett LLC, Boulder, CO, part of
76 CO2 TREND Covidien.)
38
13. Routinely monitor the airway If the adapter or the port becomes • Obstruction in the airway
adapter or sampling port for obstructed, the quality of the adapter or sampling port
signs of obstruction.5,8,9 capnographic waveform is poor and
(Level M*) Petco2 is not reliable.


14. Evaluate the patient’s response The impact of activities (e.g., • Petco2 values increased or
to activities that may positively suctioning, repositioning, change in decreased by more than 10% of
or negatively affect ventilation mechanical support, nutritional baseline
(e.g., sedation, analgesia, supplementation, cardiopulmonary
suctioning, repositioning, resuscitation, neuromuscular blockade,
change in mechanical support, verification of endotracheal tube
nutritional supplementation, placement) on ventilation can be
cardiopulmonary resuscitation, evaluated with Petco2 monitoring.
neuromuscular blockade,
verification of endotracheal
tube placement,).9 (Level B*)
15. Discard supplies
16. HH
Documentation
• Patient and family education • Medications that may affect respiratory system (e.g.,
• Mechanical ventilator settings neuromuscular blockers, sedatives, or
• Petco2 value and capnogram bronchodilators)
• Paco2 (partial pressure of arterial carbon dioxide)— • Respiratory assessment (e.g., respiratory rate,
Petco2 gradient (special attention should be given to breathing patterns, adventitious sounds)
this gradient as an indication of dead space ventilation) • Unexpected outcomes
• Arterial blood gases • Nursing interventions
• Times of calibration • Patient teaching
• Respiratory therapies

14 Continuous End-Tidal Carbon Dioxide Monitoring 110.e1
References sedation and analgesia on room air. CJEM 12:397–404,

1. American Society of Anesthesiologists Task Force on 2010.
Perioperative Management of Patients with Obstructive 7. Thompson JE, Jaffe MB: Capnographic waveforms in the
Sleep Apnea: Practice guidelines for the perioperative mechanically ventilated patient. Respir Care 50:100–108,
management of patients with obstructive sleep apnea: 2005.
an updated report by the American Society of 8. Touma O: The prognostic value of end tidal carbon
Anesthesiologists Task Force on Perioperative dioxide during cardiac arrest: a systematic review.
Management of Patients with Obstructive Sleep Apnea. Resuscitation 84:1470–1479, 2013.
Anesthesiology 120:268–286, 2014. 9. Walsh BK, Crotwell DN, Restrepo RD: Capnography/
2. Beitz A, et al: Capnographic monitoring reduces the capnometry during mechanical ventilation: 2011. Respir
incidence of arterial oxygen desaturation and hypoxemia Care 56:503–509, 2011.
during propofol sedation for colonoscopy: a randomized, 10. Waugh JB, Epps CA, Khodneva YA: Capnography
controlled study (ColoCap Study). Am J Gastroenterol enhances surveillance of respiratory events during
107:1205–1212, 2012. procedural sedation: a meta-analysis. Clin Anesth 23:
3. Godwin SA, et al: Clinical policy: procedural sedation 189–196, 2011.
and analgesia in the emergency department. Ann Emerg 11. Zwerneman K: End-tidal carbon dioxide monitoring:
Med 63:247–258, 2014. AVITAL sign worth watching. Crit Care Nurs Clin North
4. Manifold CA, et al: Capnography for the nonintubated Am 18:217–225, 2006.
patient in the emergency setting. J Emerg Med 45:
626–632, 2013. Additional Readings
5. Nagler J, Krauss B: Capnography: a valuable tool for Huttmann SE, Windisch W, Storre JH: Techniques for the
airway management. Emerg Med Clin North Am measurement and monitoring of carbon dioxide in the
26(4):881–897, 2008. blood. Ann Am Thorac Soc 11:645–652, 2014.
6. Sivilotti ML, et al: A comparative evaluation of Kodali BS: Capnography outside the operating rooms.
capnometry versus pulse oximetry during procedural Anesthesiology 118:192–201, 2013.
PROCEDURE
15
Continuous Lateral Rotation
Therapy
Jamie St. Clair and Jennifer MacDermott
PURPOSE: Continuous lateral rotation therapy (CLRT) or kinetic therapy involves
the use of dynamic rotation of a support surface delivered via a specialized overlay
or bed to continuously rotate the patient laterally from side to side. Early
mobilization is crucial in minimizing the deleterious effects of prolonged immobility
but is difficult to achieve in critically ill patients. The purpose of CLRT therapy is to
assist in reducing ventilator-associated pneumonia incidence by providing a form of
early mobility.2,3,6,9–13,15,16 There is conflicting evidence as to the effects of CLRT on
resolution of atelectasis and reduction in mortality, length of mechanical ventilation,
length of intensive care unit and hospital stay, and cost.2,3,6,10,12,13,15,16
PREREQUISITE NURSING ❖ Long bone fractures and/or traction18

18
❖ Unstable intracranial pressure (>20 mm Hg)
KNOWLEDGE
• It must be understood when CLRT should be used cau-
• Knowledge is needed regarding the physiological effects tiously, including
18
of immobility on body systems. Potential complications ❖ Extreme agitation and/or motion sickness
in the critically ill patient include the following8: ❖ Immediate postoperative period following open-heart
❖ Pulmonary—pneumonia, atelectasis, pulmonary surgery18
16,18
embolism ❖ Multiple rib fractures
18
❖ Cardiovascular—deep vein thrombosis ❖ Bronchospasm
18
❖ Integumentary—pressure ulcers ❖ Uncontrollable diarrhea
❖ Gastrointestinal—constipation, fecal impaction • Due to the lack of evidence for specific therapy parame-
❖ Metabolic—glucose intolerance ters,8 the degree of rotation and time interval should be
❖ Musculoskeletal—muscle atrophy set by the clinician or per institution policy. The degree of
• Principles of prevention of ventilator-acquired pneumonia rotation is set individually on each side; it may be inter-
should be understood.1,4,5,14 CLRT is an adjunct treatment mittent or constant, or provide unilateral or bilateral rota-
and should not be the sole therapy instituted to prevent tion, depending on patient condition. For example, if a
ventilator-associated pneumonia.1,8 patient does not tolerate turning to his left side, the surface
• Indications for CLRT include critically ill patients who may be programmed for a shorter time interval or lesser
are at a higher risk of pulmonary complications, such as degree of rotation on that side.
the following: • Components necessary for maximal patient benefit include
❖ Patients at risk for ventilator-associated pneumonia initiation of therapy within 48 hours of intubation and
❖ Patients with increasing ventilator support require- continuous rotation for more than 18 hours per day.17,20
ments refractory to standard treatment interventions • Knowledge of potential physiological changes that occur
Fraction of inspired oxygen (Fio2) >50% for 1 hour during CLRT is required. Changes in patient’s hemody-
or more7,18 namics or oxygen saturation during rotation are often the
Positive end-expiratory pressure (PEEP) >818 result of the patient’s underlying disease process.17,20 If
❖ Patients who have clinical indications for acute lung hemodynamic and/or oxygenation changes occur, the
injury or adult respiratory distress syndrome3: patient’s oxygenation, respiratory rate, ventilator settings,
Partial pressure of arterial oxygen (Pao2/Fio2 ratio arterial blood gas levels, adequacy of volume resuscita-
<3007,15,18 tion, cardiac performance, vascular tone, and other appro-
Presence of fluffy infiltrates via chest priate parameters should be assessed and the need for
radiograph8,17 additional intervention should be evaluated.17,20
Presence of atelectasis via chest radiograph8,17 • Knowledge of potential complications associated with
• Knowledge is needed of contraindications for CLRT, CLRT is required. Documented complications include
such as disconnection of intravascular catheters, intolerance to
❖ Unstable spine or pelvic injury until the injury is rotation, adverse effects on intracranial pressure, and
stabilized18 arrhythmias.8,17
111
• Several support surfaces are available for CLRT. Identify arterial blood gas, chest radiograph, and mental status.17
the type of continuous lateral rotational therapy used at Rationale: Initial and ongoing evaluation of effectiveness
the individual institution, whether a framed surface or of CLRT on body systems.
added overlay, following manufacturer’s guidelines. Refer • Assessment of the patient’s skin, including evidence
to institutional policy for types of support surfaces that of pressure ulcer formation or other alterations.11,13,17
may be used. Rationale: Baseline and ongoing skin status data are
• Manufacturer-specific guidelines for implementing CLRT provided.
should be reviewed before the patient is placed on the • Assessment of the patient’s vascular system, including
support surface/bed frame. hemodynamic stability, presence of lower extremity
• Daily evaluation of the patient’s response to CLRT and edema, and deep vein thrombosis. Rationale: Baseline
assessment of continued need for CLRT are required.17,20 and ongoing vascular status data are provided.
Criteria for discontinuation may include resolution of • Discuss goals for pressure redistribution and CLRT with
indications for therapy.17,20 prescribing provider. Rationale: The properties of the
CLRT support surface are evaluated to match patient
EQUIPMENT factors.
• Nonsterile gloves Patient Preparation

• Sheet, slide board, or other transitioning device to assist • Ensure the patient and family understand pre-procedural
with moving a patient onto a surface teachings. Answer questions as they arise and reinforce
• Appropriate CLRT surface information as needed. Rationale: Understanding previ-
ously taught clinical information and rationale is evalu-
PATIENT AND FAMILY EDUCATION ated and reinforced.
• Evaluate the properties of the support surface to meet
• Explain to the patient and family the adverse effects of pulmonary needs. Rationale: Support surface selection
pulmonary complications and complications of immobil- should match clinical indication for patient therapy.
ity. Rationale: Explanation encourages understanding • Verify correct patient with two identifiers. Rationale:
when a different bed surface is needed based on the risk Prior to performing a procedure, the nurse should ensure
assessment of the patient. The patient and family are able the correct identification of the patient for the intended
to ask questions. intervention.
• Explain the purpose of CLRT, properties of the support • Ensure adequate personnel are available to assist when
surface, and possible risks involved with treatment. Ratio- moving the patient to the new surface. Place the patient
nale: Understanding and cooperation are increased when in the supine position with the head of the bed elevated to
patients and families understand purpose of therapy. 30 degrees (if not medically contraindicated) in prepara-
tion for a move to a specialty surface. Rationale: Transfer
of the patient from one bed to another is potentiated.
PREPARATION
Patient Assessment
• Assessment of the patient’s respiratory status, including
breath sounds, respiratory rate, cough, oxygen saturation,
Procedure Continuous Lateral Rotational Therapy

1. HH
2. PE
3. Ensure the bed is locked in the Ensures patient and staff safety. Align both surfaces side by side at a
horizontal position and that the height comfortable for staff to move
drive is disengaged and the brake the patient to new surface, assuring
is on. both surfaces are locked and will
not move on patient transfer.
4. With use of a draw sheet or other Shearing of patient skin and/or Do not leave the patient unattended at
transfer device, move the patient patient or staff injury may be any time during the patient transfer.
to the center of the surface while avoided.
maintaining body alignment.
15 Continuous Lateral Rotation Therapy 113
Procedure Continuous Lateral Rotational Therapy—Continued

5. Transfer the patient to the center Assures proper positioning of If using a specialty mattress overlay,
of the bed, aligning the patient the patient for rotation. it is recommended to place the
using guides on surface or per mattress on the bed frame, then
manufacturer’s instructions. transfer the patient to the new
(Level M*) surface.
6. Utilize all securement straps and Prevents unexpected outcomes
supports to ensure the patient is and promotes patient safety.
held safely in place and prevent
shearing over potential areas of
friction. (Level M)
7. Assure all invasive tubing and Assessment leads to early
lines are free from obstruction or intervention if necessary.13
risk of dislodgement.17 (Level D*) (Level D)
8. Initiate therapy per prescriber Begins therapy.
order or institutional policy.17
(Level D)
9. Monitor the patient through an Ensures that the patient tolerates, Consider longer time intervals, or a
entire rotational cycle to assess and is safe during, rotation. decreased angle initially, to allow
for ventilation or hemodynamic the patient to increase tolerance to
changes. Assure invasive tubing motion.17 (Level D)
and lines remain free from
obstruction or risk of
dislodgement.17 (Level D)
10. Discard any used supplies and
remove PE .
11. HH

• Improved pulmonary function • Desaturation with rotation
• Absence of development of ventilator-associated • Hemodynamic instability with rotation
pneumonia • Dislodgement of invasive lines
• Intact skin integrity • Development of worsening pulmonary status
• Wound healing • Development of urinary tract infection
• Absence of friction and shearing • Friction, shearing, motion sickness, agitation,
• Absence of excessive skin moisture or dryness disorientation, and falls from lateral movement of
• Improved peripheral circulation table if the patient is not strapped in properly
• Improved urinary elimination • Pressure ulcer formation or further deterioration of
existing pressure ulcers

interventions.
1. Cardiopulmonary resuscitation A flat, firm surface is needed for • Need for CPR
(CPR): Identify CPR valve or effective CPR.
deflate surface to bed frame.
If foam base, place backboard under
the patient. Begin CPR.

2. Assess the patient’s pulmonary Lateral rotational movement provides • Adventitious breath sounds
function.17,19 (Level D*) continuous postural drainage and • Decreased respiratory rate and
mobilization of secretions.19 depth
(Level D) • Cough
• Cyanosis
• Dyspnea
• Nasal flaring
• Decreased oxygen saturation
• Abnormal blood gases
• Decreased mental acuity
• Restlessness
• Abnormal chest radiograph results
3. Assess patient skin for evidence The patient continues to be at risk • Development of pressure ulcers or
of breakdown, by manually for skin breakdown and pressure skin breakdown, or worsening of
repositioning the patient at least ulcer development. Ensure that wounds.
every 2 hours. Closely monitor routine skin assessments continue
pressure point areas (occiput, throughout rotational therapy.
sacrum, and heels) or areas that
may rub against support surfaces
with rotation (axilla, groin/inner
thighs, face/ears, and/or feet) per
hospital policy. Consider applying
protective dressing to areas prone
to shearing.11,13,19 (Level D)
4. Assess the patient’s vascular Lateral rotation movement • Edema, decreased or absent
circulation.17 (Level D) discourages venous stasis. pulses, discoloration, and/or pain
5. Assess the patient for urinary Lateral rotational movement • Decreased urine output
retention. decreases urinary stasis. • Bladder distention
6. Monitor the patient’s tolerance Lateral rotational movement may • Intolerance to device
and hemodynamic goals.17 alter hemodynamics because of the • Vital signs consistently below or
(Level D) degree of rotation and changes in above desired goals/parameters
transducer positioning.17 (Level D)
7. Follow institutional standard for Identifies need for pain interventions. • Continued pain despite pain
assessing pain. Administer interventions
8. Maintain in motion for 18 out of Provides proper rotation and • Inability to tolerate rotational
24 hours.17 (Level D) adequate mobility. therapy angle and time frame
9. Determine when therapy should Lateral rotation therapy is no longer
be discontinued. Reassess need required.
every 24 hours.17 (Level D)
Documentation
• Patient and family education • The patient’s response to therapy
• Date and time therapy instituted • Any unexpected outcomes and interventions taken
• Rationale for use of lateral rotation therapy surface • Phone number and name of company representative;
• Number of hours the patient is in rotation mode per 24 keep in easily accessible area of chart, in the event
hours and the degree of rotation achieved the bed malfunctions
• Complete a full skin assessment per institutional policy • Pain assessment and management according to
and as needed institutional policy
• Status of wound healing if applicable
15 Continuous Lateral Rotation Therapy 115

15 Continuous Lateral Rotation Therapy 115.e1
References 13. Makic MB, et al: Examining the evidence to guide

1. American Association of Critical Care Nurses: AACN practice: challenging practice habits. Crit Care Nurse
practice alert: ventilator-associated pneumonia. Crit Care 34:28–45, 2014.
Nurse 28:83–85, 2008. 14. Muscedere J, et al: Comprehensive evidence-based
2. Ahrens R, et al: Effect of kinetic therapy on pulmonary clinical practice guidelines for ventilator-associated
complications. Am J Crit Care 13:376–382, 2004. pneumonia: prevention. J Crit Care 23:126–137, 2008.
3. Choi S, Nelson L: Kinetic therapy in critically ill patients: 15. Simonis G, et al: A prospective, randomized trial of
combined results based on meta-analysis. J Crit Care continuous lateral rotation (“kinetic therapy”) in patients
7:57–62, 1992. with cardiogenic shock. Clin Res Cardiol 101:955–962,
4. Coffin S, et al: Strategies to prevent ventilator-associated 2012.
pneumonia in acute care hospitals. Infect Control Hosp 16. Staudinger T, et al: Continuous lateral rotation therapy to
Epidemiol 29:S31–S40, 2008. prevent ventilator-associated pneumonia. Crit Care Med
5. deBoisblanc B, et al: Effect of air-supported, continuous, 38:486–490, 2010.
postural oscillation on the risk of early ICU pneumonia in 17. Swadener-Culpepper L: Continuous lateral rotation
nontraumatic critical illness. Chest 103:1543–1547, 1993. therapy. Crit Care Nurse 30:S5–S7, 2010.
6. Delaney A, et al: Kinetic bed therapy to prevent 18. Swadener-Culpepper L, Skaggs R, Van Gilder A: The
nosocomial pneumonia in mechanically ventilated impact of continuous lateral rotation therapy in overall
patients: A systematic review and meta-analysis, 2006. clinical and financial outcomes of critically ill patients.
<http://ccforum.com/content/10/3/R70>. (Accessed Crit Care Nurse 31:270–279, 2008.
16.11.14.) 19. Wanless S, Aldridge M: Continuous lateral rotation
7. Fleegler B, et al: Continuous lateral rotation therapy for therapy: a review. Nurs Crit Care 17:28–35, 2011.
acute hypoxemic respiratory failure: the effect of timing. 20. Washington G, Macnee C: Evaluation of outcomes: the
Dimens Crit Care Nurs 28:283–287, 2009. effects of continuous lateral rotational therapy. J Nurs
8. Goldhill D, et al: Rotational bed therapy to prevent and Care Qual 20:273–282, 2005.
treat respiratory complications: a review and meta- Additional Readings
analysis. Am J Crit Care 16:50–61, 2007.
9. Hanneman SG: Manual vs automated lateral rotation to National Guideline Clearinghouse: Prevention of ventilator-
reduce preventable pulmonary complications in ventilator associated pneumonia. Health Care Protocol. <http://
patients. Am J Crit Care 24:24–32, 2015. www.guideline.gov/content.aspx?id=36063>. (Accessed
10. Hess D: Patient positioning and ventilator-associated 29.11.14.)
pneumonia. Respir Care 50:892–899, 2005. Rauen C, et al: Seven evidence-based practice habits: Putting
11. Jankowski I: Tips for protecting critically ill patients from some sacred cows out to pasture. Crit Care Nurse
pressure ulcers. Crit Care Nurse 30:S7–S9, 2010. 28:98–124, 2008.
12. Klompas MB: Strategies to prevent ventilator-associated
pneumonia in acute care hospitals: 2014 update. Infect
Control Hosp Epidemiol 35:915–936, 2014.
PROCEDURE
16
Continuous Venous Oxygen
Saturation Monitoring
Joni L. Dirks
PURPOSE: Venous oxygen saturation monitoring is performed to measure the
oxygen saturation of hemoglobin in the venous blood. The value can be obtained
either from the pulmonary artery (PA; mixed venous oxygen saturation—SvO2) or
from the superior vena cava (central venous oxygen saturation—ScvO2).
Measurement can be performed intermittently with individual blood samples or
continuously with a specialized fiberoptic catheter/probe and an associated
computer or module. Assessment of venous oxygen saturation provides an
indication of the balance between a patient’s oxygen delivery and oxygen
consumption.
PREREQUISITE NURSING must be viewed in the light of these changing determi-

KNOWLEDGE nants and considered an index of oxygen balance.5,10,12,17
• A normal Svo2 generally is considered to be 60% to 80%,
• Anatomy and physiology of the cardiopulmonary system and a clinically significant change in Svo2 (5% to 10%)
should be understood. can be an early indicator of physiological instability.12,16
• Physiological principles related to invasive hemodynamic Svo2 values of less than 60% may result from either inad-
monitoring should be understood. equate oxygen delivery or excessive oxygen consumption.
• Technical aspects of central venous catheter (CVC) place- It should be noted that in late stages of sepsis a patient
ment and pressure monitoring (see Procedure 67) should may have a normal or high Svo2 value, which may indi-
be understood. cate impaired cellular function or severe arteriovenous
• Technical aspects of pulmonary artery catheter (PAC) shunting.13 It is always important to consider the clinical
placement (see Procedures 71 and 72) and pressure moni- picture along with Svo2 values.
toring (see Procedure 74) should be understood. • The percent of venous oxygen saturation as measured in
• Physiological concepts of oxygen delivery, oxygen the PA (Svo2) is flow weighted and represents a true
demand, and tissue oxygen consumption should be under- mixing of all venous blood in the body: inferior vena cava
stood. (IVC), superior vena cava (SVC), and coronary sinus.
• Clinically, venous oxygen saturation provides an index of • PACs are being used less frequently in critically ill
overall oxygen balance because it is a reflection of the patients, so the use of CVCs to measure venous saturation
dynamic relationship between the patient’s oxygen deliv- has emerged as an alternative.12,16 The percent of venous
ery and oxygen consumption. Early detection of oxygen oxygen saturation as measured in the SVC (Scvo2) reflects
imbalance can facilitate implementation of goal-directed the mixing of venous blood from the superior half of the
treatment protocols for sepsis, shock, high-risk surgery, body. It does not include blood from the IVC and coronary
and trauma.1,11,16 sinus.
• Whenever the demand for oxygen exceeds supply, the • Scvo2 and Svo2 do not correlate absolutely, but trend
body’s primary compensatory mechanisms are to increase together in a variety of hemodynamic states.16 In normal
oxygen delivery by increasing cardiac output or to increase conditions, Scvo2 is slightly lower than Svo2. In periods
oxygen extraction at the tissue level. of hemodynamic instability, Scvo2 is higher than Svo2,
• In a critically ill patient with limited cardiac output, with a difference that ranges from 5% to 7% and up to
increased extraction occurs to meet the demand for oxygen 18% in severe shock.17 This difference is in part because
at the tissue level. The result is a decreased level of oxygen of a redistribution of blood flow caused by the various
returning to the heart and a lower Svo2 measurement. pathophysiologies.5,10,17 Therefore Scvo2 overestimates
Many factors can affect the requirements for oxygen and Svo2 in shock conditions; a low Scvo2 likely indicates an
subsequently Svo2 (Box 16-1).5,10,12,17 even lower Svo2.13
• Svo2 does not correlate directly with any of the determi- • Continuous venous saturation monitoring is performed
nants of oxygen delivery (i.e., cardiac output, hemoglobin, with a three-component system (Fig. 16-1):2–4,7,8
and arterial oxygen saturation) or oxygen consumption. ❖ A fiberoptic central venous or PA catheter contains
Because a critically ill patient is in a dynamic state, Svo2 two or three optical filaments that exit at the distal
116
16 Continuous Venous Oxygen Saturation Monitoring 117
BOX 16-1 Common Conditions and

Activities That Affect Venous
Oxygen Saturation Values
FIBEROPTIC FILAMENTS
DECREASED CENTRAL AND MIXED VENOUS
OXIMETER MONITOR
OXYGEN SATURATION RECEIVING FIBER
Decreased Oxygen Delivery VENOUS
OXYGEN
• Heart failure SATURATION
(SvO2/ScvO2)
• Hypovolemia
• Anemia
SENDING
• Hemorrhage FIBER
• Hypoxemia BLOOD
FLOW
Increased Oxygen Consumption PHOTO DETECTOR
• Fever
• Pain OPTICS MODULE PULMONARY
ARTERY
• Agitation
LIGHT EMMITING DIODES
• Shivering
• Seizures Figure 16-1 Oximetry system with reflectance spectrophotom-
• Increased work of breathing etry. (From McGee WT, Headley J, Frazier JA, editors: Quick guide
• Infection to cardiopulmonary care. Irvine, CA, 2014, Edwards Lifesciences
• Burns Corporation.)
• Head injury
• Numerous nursing procedures (e.g., dressing changes, nected from the patient’s catheter. If the need to dis
suctioning, turning, and chest physiotherapy) connect is unavoidable, refer to the manufacturer’s
INCREASED CENTRAL AND MIXED VENOUS instructions for a disconnection procedure that does not
OXYGEN SATURATION result in memory loss.
Increased Oxygen Delivery ❖ An oximeter computer, either a stand-alone unit or a
• Fluid resuscitation module for a bedside monitoring system, has a micro-
• Inotropic medications processor that converts the light information from the
• Blood transfusion optic module into an electrical display. This display is
• Oxygen therapy updated every few seconds for continuous monitoring.
Decreased Oxygen Consumption This information may be displayed as a continuous
• Hypothermia graphic trend, a numeric display, or both, depending on
• Analgesia the manufacturer.
• Sedation • Proper calibration of the monitor and catheter ensures
• Pharmacological paralysis accuracy of venous saturation values. The two types of
• Anesthesia calibration are in vitro, in which the catheter and optics
• Cellular dysfunction (shunting, sepsis) module are calibrated before insertion; and in vivo, where
• Mechanical ventilation
the venous saturation value from the system is compared
• Decreased musculoskeletal activity
with a laboratory cooximeter value from a blood sample
drawn from the catheter tip. Follow manufacturer recom-
mendations for performing calibration procedures. Daily
in vivo calibrations are recommended by some manufac-
lumen. One filament serves as a sending fiber for the turers. In addition, proper blood sampling techniques from
emission of light; the other serves as a receiving fiber the distal port of the PAC or CVC catheter are necessary
for the light reflected back from the blood in the vessel for ensuring accurate values for calibration.2–4,7,8
(Fig. 16-2).
❖ The optic module houses the light-emitting diodes EQUIPMENT
(LEDs), which transmit various wavelengths of light,
and a photodetector, which receives light. The light • Fiberoptic PAC for Svo2 (various sizes, 4 to 8 Fr; various
wavelengths are shone through a blood sample as it lumens; various lengths, 25 to 110 cm)
travels between the LED and the photodetector. Desat- • Fiberoptic CVC for Scvo2 (various sizes for pediatric to
urated hemoglobin, saturated hemoglobin (oxyhemo- adult use, 4.5 to 8.5 Fr; various lengths, 5 to 20 cm;
globin), and dyshemoglobin (carboxyhemoglobin, single, double, or triple lumen)
methemoglobin) have different light-absorption char- • Fiberoptic probe for Scvo2 (2.2 Fr, 37-cm length inserted
acteristics. The ratio of hemoglobin to oxyhemoglobin through a port in an existing CVC)
is determined and reported as a percentage value.2–4,7,8 • Optic module
All patient data, including calibration of saturation • Oximeter computer or bedside monitoring system module
values and patient identification information, are stored • Equipment required for central venous monitoring or PA
in this component. This module should not be discon- catheterization and pressure monitoring
Optical Module
Connector
Proximal Lumen
Sheath
Distal Lumen Suture Ring

Suture Wings
A
Proximal Lumen
Optical Module Sheath

Distal Lumen
Connector
Suture Ring
Suture Wings
B Medial Lumen
Thermistor Thermal
@4 cm Filament
Thermistor
Thermal Connector
Filament Balloon
Connector Balloon Inflation Valve
PA Distal
Lumen
VIP Port @30 cm

Proximal Injectate Proximal Injectate
Lumen Hub Port @26 cm
Optical Module
Connector VIP Lumen Hub
PA Distal
C Lumen Hub
Figure 16-2 Oximetry catheters. A, Central venous catheter B, Small French size for pediatric
applications C, Pulmonary artery catheter. (From McGee WT, Headley J, Frazier JA, editors: Quick
guide to cardiopulmonary care. Irvine, CA, 2014, Edwards Lifesciences Corporation.)
Additional equipment, to have available as needed, includes ate fears and concerns. Additional monitors may produce
the following: increased anxiety in the patient and family.
• Printer (optional)
PATIENT AND FAMILY EDUCATION PATIENT ASSESSMENT AND

PREPARATION
• Assess patient and family understanding of the clinical
benefits of venous oximetry monitoring. Rationale: For Patient Assessment
information to be the most appropriate, assessment of the • Indications for use of Scvo2/Svo2 monitoring include the
level of patient and family understanding of the need for following:1,11,15,16,18
Scvo2 or Svo2 monitoring is important. By explaining the ❖ High-risk cardiovascular and vascular surgery
usefulness of Svo2 monitoring in language that nonmedi- ❖ Heart failure
cal personnel can understand, the patient and family are ❖ Shock
able to ask appropriate questions, and understand more ❖ Respiratory failure
clearly the clinical presentation of the patient and implica- ❖ Severe burns
tions for further treatment therapies. ❖ Sepsis (as a component of early goal-directed therapy)
• Explain the continuous nature of this monitoring system ❖ Multisystem organ dysfunction
and the significance of the alarms. Rationale: Explanation ❖ Head injury
of the procedure to the patient and family helps to allevi- ❖ Trauma
❖ Acute respiratory distress syndrome the correct identification of the patient for the intended
❖ Mechanical ventilation (adjustment of settings, intervention.
weaning) • Answer patient questions as they arise, and reinforce
Patient Preparation evaluates and reinforces understanding of previously
• Verify correct patient with two identifiers. Rationale: taught information.
Prior to performing a procedure, the nurse should ensure
Procedure for Continuous Mixed Venous Oxygen Saturation Monitoring

1. HH
2. PE
3. Assemble necessary equipment Ensures equipment is ready and
and supplies for continuous available for the procedure.9
monitoring. (Level D*)
4. Connect power cord to Allows electronics to warm up; Some monitors allow toggling
computer, turn on, and observe confirms component function.2–4,7,8 between Svo2, Scvo2, or So2.
system check on the computer Ensure the proper label is used.2–4,7,8
screen. (Level M*)
5. Connect optics module to LEDs are housed in optics module. Warm-up times may vary by
computer. (Level M) Approximately 5–20 minutes are manufacturer and temperature of
needed to warm light source location of monitoring.
sufficiently.3,4,7,8
6. Remove outer wrap of catheter Provides access to inner package; Catheter packaging may vary
package and aseptically peel isolates connector from catheter tip according to manufacturer. Follow
back the inner wrap portion that to maintain sterility during in vitro manufacturer’s directions for use to
covers the optic connector of the calibration.2–4,7,8 ensure proper handling.
catheter. (Level M)
7. Firmly connect the optic Ensures connections are tight and
connector to the optic module. properly aligned for light
(Level M) transmission.2–4,7,8
8. Perform in vitro calibration or Standardizes or calibrates the light Catheter lumens must be dry.
standardization. (Level M) source to the catheter. Calibration Do not flush catheter before
is performed before catheter performing this step or in vitro
insertion. Catheter tip should be calibration is invalid.
left in the calibration cup or
container in the package during in
vitro calibration.2–4,7,8
9. Pull back remaining wrap Prepares catheter for insertion.2–4,7,8
covering catheter package with
aseptic technique. (Level M)
10. Carefully remove catheter from Prevents the transmission of Fiberoptics in the catheter and PA
tray with sterile technique. Pull microorganisms; prevents damage catheter balloon are fragile and
catheter tip up and out of the to the balloon of the PA may be damaged if not handled
calibration cup. (Level M) catheter.2–4,7,8 properly.
11. Attach pressure tubing, and Enables monitoring of chamber Refer to institutional standards for
prime lumens with flush solution pressures during PAC insertion; use of heparinized flush solution.12
(see Procedure 75). maintains patency of lumens.
12. Perform a preprocedure Ensures patient safety.
verification and time out if
nonemergent.

Procedure for Continuous Mixed Venous Oxygen Saturation Monitoring—Continued

13. Assist physician or advanced Provides assistance to physician or In some cases, a separate fiberoptic
practice nurse with CVC or PAC advanced practice nurse while probe for Scvo2 monitoring may be
site preparation and catheter catheter is inserted. inserted through an existing CVC.
insertion.
14. Observe PA waveforms during Central PAC tip placement is A light intensity or signal indicator
insertion. necessary for optimal light verifies adequate reflection of the
reflection.2–4,7–9 light signals after the catheter tip is
placed correctly.2–4,7,8
15. Note amount of air required for Inflation volume of 1.25–1.5 mL is Ensure passive deflation of balloon
inflation of PAC balloon to recommended for proper catheter before proceeding.
obtain a wedge tracing. tip placement.4,8 Less than optimal inflation volume to
(Level M*) obtain a wedge tracing may
indicate distal catheter migration. A
change in the intensity or signal
indicator also may alert the
clinician to this condition.
16. Set high and low alarm limits Individualizes alarm settings
and activate alarms. (Level D*) according to patient baseline.
Audible alarms notify the clinician
of significant changes in Scvo2/
Svo2 values and trends.9
17. Apply a sterile dressing to Reduces transmission of Use institutional standard for central
insertion site. (Level D) microorganisms.14 venous catheter dressings.
18. Firmly secure the optic module Excessive tension on catheter or
near the patient. (Level M) optic module may break the optic
fibers.2–4,7,8
19. Input patient height and weight Allows for calculation of derived This may be done before placement.
data as per institutional standard. hemodynamic parameters.4,8,9
20. After calibration and insertion of Provides baseline information for
catheter, obtain baseline set of comparison with patient’s response
hemodynamic and oxygenation to interventions.
indices.
21. Continuously monitor PA Spontaneous catheter migration may Tip position may influence signal
pressure tracings and Svo2/Scvo2 occur after insertion. quality if the catheter is positioned
values. (Level D) against a vessel wall.
Signal quality may be compromised
by clotting at the tip of the catheter,
pulsatility, or hemodilution.4 If the
catheter becomes wedged the
readings may reflect postcapillary
arterialized blood and the Svo2
value may increase.9,12
22. Obtain catheter-placement Provides confirmation of proper
confirmation per institution catheter.
standard (i.e., chest radiograph).
Venous Blood Sampling Skill/In Vivo Calibration
23. HH (if independent from catheter
placement).
24. PE (if independent from catheter
placement).
Procedure for Continuous Mixed Venous Oxygen Saturation Monitoring—Continued

25. Draw venous blood sample from In vivo calibration may be necessary Mixed venous samples should be
distal port of catheter for in vivo to verify the accuracy of the drawn from the distal port of the
calibration (see Procedure 63 for computer and value displayed PAC.9 Central venous samples
mixed venous blood sampling or after insertion of the fiberoptic should be drawn from the distal
Procedure 62 for CVC blood catheter. Ideally, the patient’s port of the CVC.6
sampling). hemodynamic and oxygenation
status should be stable for
optimal calibration.2–4,7,8
26. Perform a verification or in vivo In vivo calibration verifies the Follow specific recommendations
calibration per manufacturer’s accuracy of the Scvo2/Svo2 from the manufacturer about the
instructions or institutional being displayed.2–4,7–9 In vivo frequency of calibration and
standard. (Level D*) calibration is required if the specific steps to implement the
catheter was inserted without process.
performing preinsertion
calibration or if the catheter is
disconnected from the optical
module. In vivo calibration may
also be performed on a routine
basis (typically every 24 hours)
or whenever the displayed value
is in question.
27. Ensure measurement is Cooximetry measures direct
performed with a laboratory fractional oxyhemoglobin
cooximeter. (Level D) saturation; blood gas analyzers
calculate oxygen saturation from
measured partial pressure values.
A calculated saturation value from a
gas analyzer may not correlate
with the actual patient value
and, if used for calibration, may
produce erroneous results. 2–4,7–9
28. Observe bedside monitor display Reconfirms catheter tip placement in Proper positioning of the catheter is
for return of PA/central venous the PA/SVC/right atrium9,12 important for accurate
pressure waveform and resume measurement of venous oxygen
Svo2/Scvo2 monitoring. saturation and to prevent possible
(Level D) complications.12
equipment.
30. Remove personal protective Reduces the transmission of
equipment. PE microorganisms and body
31. HH

• Svo2 values and trends within normal range • Svo2 values less than 60% or greater than 80%
(60%–80%)9,12,16 • Svo2 value trends greater than 10% from baseline
• Scvo2 values and trends greater than 70%1,17 • Scvo2 value trends less than 65%–70%1,17
• Scvo2/Svo2 trends not fluctuating greater than 5%–10% • Infection from presence of an indwelling PAC or
of baseline value12,16 CVC
• Hemodynamic and oxygenation parameters optimal for • PA occlusion, infarction, or rupture
patient condition

interventions.
1. Ensure that no kinks or Fiberoptics are fragile and can break if not • Change in PA waveform or Svo2
bends are found in the handled carefully. value that does not correlate to
catheter. (Level D*) Overtightening of the introducer connector can patient condition
cause crimping and breakage of the • Changes in RA waveforms or
fiberoptics.4,8 Subclavian or internal jugular Scvo2 value that do not correlate
approaches for insertion may cause kinking to patient condition
in the vessel if the vessel is tortuous. Sending
and receiving wavelengths may show either a
change in light signal or values that do not
reflect the patient’s status.
2. Monitor PA waveforms Migration of the catheter tip may reflect • Permanent wedge waveform
continuously. (Level D) postcapillary arterialized blood causing an
elevation in the Svo2 value. Uncorrected
catheter migration places the patient at risk
for PA infarction or rupture.9,12
3. Observe Svo2 value and Normal Svo2 values range from 60% to • Svo2 values greater than 80% or
trends. (Level B*) 80%12,16; values outside this range may less than 60%
indicate an imbalance between oxygen
delivery and consumption. A value change of
greater than 5%–10% may signify a clinically
significant change.9,12
A target value of greater than 65% in severe
sepsis and septic shock is recommended.1 If
the patient’s clinical presentation differs from
the observed Svo2 value or trends, recheck
the accuracy of the monitoring system.
4. Observe Scvo2 value Scvo2 values trend with Svo2. A target value of • Scvo2 values less than 70%
and trends. (Level B) greater than 70% in severe sepsis and septic
shock is recommended.1
Documentation
• Patient and family education relationship of the event with the continuous trend,
• Scvo2/Svo2 whenever the hemodynamic profile is especially if the event produces a marked change in
recorded the value
• Additional oxygenation indices as indicated • Hard copy printout (as available)
• Specific nursing activities (e.g., suctioning, turning the • Unexpected outcomes
patient, or titrating a vasoactive drug) and the • Nursing interventions

16 Continuous Venous Oxygen Saturation Monitoring 122.e1
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12. Lough ME, Thompson C: Cardiovascular diagnostic Mohseni-Bod H, et al: Evaluation of a new pediatric
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in septic shock using central venous and mixed venous (2):CD003408, 2013.
oxygen saturation. Crit Care Clin 26:323–333, 2010. Spenceley N, et al: Evaluation of a pediatric central venous
14. O’Grady P, et al: Guidelines for prevention of oximetry catheter in critically ill children. Pediatr Crit
intravascular catheter-related infections. Am J Infect Care Med 11:26–30, 2010.
Control 39:S1–S34, 2011.
15. Teixeira C, et al: Central venous saturation is a predictor
of reintubation in difficult-to-wean patients. Crit Care
Med 38:491–496, 2010.
PROCEDURE
17
Extracorporeal Life Support
(ECLS) and Extracorporeal
Membrane Oxygenation (ECMO)
Thomas Lawson and Marcia Belcher
PURPOSE: There are multiple indications for extracorporeal life support (ECLS)
and extracorporeal membrane oxygenation (ECMO) in adults with acute severe
heart and/or lung failure with high mortality risk despite optimal conventional
therapy.
PREREQUISITE NURSING hours), hypercarbic respiratory failure refractory to tra-

ditional mechanical ventilator support, severe air leak
KNOWLEDGE syndromes (such as from a bronchopleural fistula after
• Advanced cardiac life support knowledge and skills are a pulmonary resection), bridge to lung transplantation,
needed. or immediate respiratory collapse (pulmonary emboli,
• A thorough knowledge of central venous and arterial blocked airway)3
anatomy, cardiac anatomy and physiology, arterial and ❖ Cardiogenic shock as a bridge to ventricular assist
venous blood gas interpretation, and ventilator manage- device or recovery due to inadequate tissue perfusion
ment is important. from low cardiac output despite adequate volume
• Clinical and technical competence with use of the ECLS/ resuscitation, refractory to inotropes, vasopressors, and
ECMO equipment is essential. intraaortic balloon pump counterpulsation. This typi-
• An understanding of the possible causes of cardiac and/or cally occurs secondary to acute myocardial infarction,
respiratory failure is needed. myocarditis, peripartum cardiomyopathy, decompen-
• ECLS/ECMO physiology differs significantly based on sated chronic heart failure, or post cardiotomy shock.3
cannula location, even though the circuit configuration ❖ Extracorporeal cardiopulmonary resuscitation; wit-
that delivers oxygenated blood under pressure remains the nessed arrest with refractory pulselessness despite
same. Venous to venous (VV) provides gas exchange and advanced cardiac life support and continuous CPR with
is used exclusively for respiratory failure whereas venous an easily reversible etiology3
to arterial (VA) also provides mechanical circulatory • Absolute Contraindications3:
support by introducing the oxygenated blood under pres- ❖ Irreversible central nervous system damage
sure into the arterial system (Fig. 17-1). ❖ Multiple organ dysfunction syndrome
• Deoxygenated blood is mechanically pumped out of the ❖ Unrecoverable native heart in a patient who is not a
vena cava(s) via a drainage cannula placed in the femoral, candidate for ventricular assist device (VAD), total
internal jugular, or subclavian vein into an exchanger artificial heart or cardiac transplant
where blood is oxygenated and carbon dioxide is removed. ❖ Chronic organ dysfunction (i.e., liver failure, renal
The oxygenated blood is then pumped back via the return failure requiring dialysis)
cannula into either the right atrium (VV) or the aorta ❖ Prolonged CPR greater than 30 minutes without ade-
(VA). A single dual-lumen bicaval cannula for VV can- quate tissue perfusion
nulation is also available. An alternative to peripheral ❖ Terminal malignancy
cannulation is cannulation of the central vessels via ster- ❖ Mechanical ventilation greater than 10 days or with
notomy during cardiothoracic surgery. Cannula place- high airway pressures and/or high levels of Fio2 greater
ment includes right atrium to pulmonary artery (VV) or than 7 days1,3
right atrium to aorta (VA). • Relative Contraindications3:
• Indications: ❖ Contraindication to anticoagulation
❖ Respiratory failure, including acute hypoxic respira- ❖ Advanced age; there is no specific maximum age, but
tory failure of any etiology when the risk of mortality risk increases with age
is greater than 50% (Pao2/Fio2 <150 on Fio2 >90%) or ❖ Obesity; there is no specific maximum weight or body
when the risk of mortality is greater than 80% (Pao2/ mass index
Fio2 <100 on Fio2 >90% despite optimal care for >6 ❖ Pharmacological immunosuppression
123
Figure 17-2 Dual lumen cannula. (From Maquet Getinge Group.

Photo of Avalon Elite Bi-Caval Dual Lumen Catheter. Accessed at
http://www.maquet.com/int/products/avalon-elite/.)
• Sutures
• Horizontal tube attachment devices
Figure 17-1 Venous to arterial (VA) and venous to venous (VV) • Cannulas
cannulation. (From Lindstrom SJ, Pellegrino, VA, Butt WW: Extra- ❖ VV: either large dual lumen cannula (Fig. 17-2) or two
corporeal membrane oxygenation, Med J Austral 191[3]:178-182, large venous cannulas
2009.) ❖ VA: large venous drainage and arterial return cannulas.
Also may need a small catheter for antegrade distal
femoral artery perfusion to prevent lower extremity
ischemia. The distal perfusion cannula returns a small
portion of the oxygenated arterial return blood to the
❖ Recent or expanding central nervous system lower extremity, beyond the large arterial cannula.
hemorrhage • Equipment needed:
• VV cannulation reduces the risk of arterial thrombus and ❖ Pump
limb ischemia, but the patient must have adequate circula- ❖ Oxygenator
tory function (may be supported with vasoactive medica- ❖ Heat exchanger
tions and inotropes).1,3 ❖ Pump controller
• In a VV configuration, mixed venous oxygenation sat Additional equipment, to have available as needed, includes
uration measurements are elevated, reflecting that the the following:
venous return blood is fully saturated from the exterior • Emergency cart (defibrillator, respiratory equipment,
oxygenator.1,3 cardiac medications)
• Cannula placement should be assessed upon initial place- • Ultrasound equipment
ment with echocardiography, radiographs, or fluoroscopy, • Fluoroscopy equipment
and serially by measuring and documenting the length • Echocardiogram equipment
from the skin puncture to the end of the cannula.
• Changes in clinical condition including but not limited to PATIENT AND FAMILY EDUCATION
decrease in oxygenation, decrease in pump flow, presence
of tube chatter, decreased mentation, or hypotension • Explain the procedure and the reason for ECLS/ECMO
warrant reevaluating cannula position. therapy. Rationale: Explanation may decrease patient and
family anxiety.
EQUIPMENT • Explain the environment and plan of care to the patient
and family on an ongoing basis, including but not limited
• Nonsterile gloves, masks, and caps to the frequency of assessment, sounds and function of
• Sterile gloves, gowns, and drapes equipment, placement of the cannulas, explanation of
• Central venous catheter insertion supplies (see Proce- alarms, dressings, and additional therapies. Rationale:
dure 82) This communication provides information to the patient
• Arterial catheter insertion supplies (see Procedure 58) and family, normalizing foreign devices such as an ECLS/
• Normal saline intravenous solutions ECMO circuit and may alleviate some of the apprehension
• Tape a patient and family may experience.
17 Extracorporeal Life Support (ECLS) and Extracorporeal Membrane Oxygenation (ECMO) 125
PATIENT ASSESSMENT AND contraindication to anticoagulation and thus is problem-

PREPARATION atic for patients requiring ECLS/ECMO.
Patient Assessment Patient Preparation
• Assess the patient’s medical history, including cardiac, • Verify that the patient is the correct patient using two
pulmonary, renal, and other chronic and acute illnesses. identifiers. Rationale: Before performing a procedure, the
Rationale: Provides important baseline data. physician, advanced practice nurse, or other healthcare
• If the patient required cardiopulmonary resuscitation, note professional should ensure the correct identification of the
the length of time CPR was performed and the reported patient for the intended intervention.
adequacy of compressions. Rationale: Provides important • Ensure that the patient and/or family understands prepro-
data that may aid in determining the indication or contra- cedural information. Answer questions as they arise, and
indication to ECLS/ECMO therapy. reinforce information as needed. Rationale: Understand-
• Perform a hemodynamic, cardiovascular, peripheral vas- ing of previously taught information is evaluated and
cular, pulmonary, and neurological assessment. Ratio- reinforced.
nale: Provides baseline data that may aid in the • Obtain informed consent. Rationale: Informed consent
determination of which configuration (VV vs. VA) to use. protects the rights of a patient and makes a competent
• Assess the current laboratory profile specifically including decision possible for the patient.
complete blood count (CBC), chemistry panel, partial • Perform a preprocedure verification and time out. Ratio-
thromboplastin time (PTT), international normalization nale: Ensures patient safety.
ratio (INR), liver function panel, arterial blood gas, and • Administer prescribed sedation or analgesics as needed.
central or mixed venous oxygen saturation if access is Rationale: Sedation and analgesics minimize anxiety and
available. Rationale: Provides baseline data. discomfort.
• Assess for active bleeding. Rationale: The inner surface • Ensure that an echocardiogram has been performed as
of the cannulas, the tubing, and the oxygenator are throm- prescribed. Rationale: This study documents the nature
bogenic, and the patient will require anticoagulation and severity of heart failure.
to prevent thrombus formation. Severe bleeding is a
Procedure for Extracorporeal Life Support and Extracorporeal Membrane Oxygenation

Assisting With Initial Cannulation (if not already cannulated)
1. Gather equipment; type of VV vs. VA configurations require Intraoperatively placed central cannulas
equipment will depend on the different types of cannulas. may require a subclavian graft.
type of cannulas to be placed
(Fig. 17-3).
2. Prime the ECLS/ECMO circuit The circuit should be free of air to
with sterile saline. prevent air embolism.
3. HH
4. PE
Figure 17-3 Complete extracorporeal

membrane oxygenation (ECMO) circuit.
(From Lindstrom SJ, Pellegrino, VA, Butt
WW: Extracorporeal membrane oxygen-
ation, Med J Austral 191[3]:178-182,
2009.)

Procedure for Extracorporeal Life Support and Extracorporeal Membrane

Oxygenation—Continued
5. Assist as needed with preparing Limits the introduction of potentially
the skin with an antiseptic infectious skin flora into the
solution (e.g., 2% chlorhexidine- vessel during the puncture.
based preparation).
6. Discard used supplies, perform Reduces the transmission of Cap and mask are required for
hand hygiene, and apply sterile microorganisms and prepares for everyone in the room once a sterile
gown and gloves. the procedure. field is established as in an operating
room.
Sterile gown and gloves are required
for those performing or directly
assisting with the cannulation.
7. Assist as needed with placing Prepares sterile field.
sterile drapes.
8. If ultrasound is to be used, assist Maintenance of sterile technique is Ultrasound will not provide useable
as needed with the equipment and essential to prevent bacteremia images without adequate conduction
ensure the probe is covered with and device colonization. gel. Sterile ultrasound gel must be
a sterile sheath. inside and outside the sheath.
9. Assist with cannulation when the Provides needed assistance. Ensure that sterility is maintained
physician needs help. throughout the procedure.
10. Anticipate the need for large Normal saline solutions are used to
volumes of normal saline flush air from the cannulas once
solutions when the cannulas are placed.
placed.
11. When the cannulas are connected Note the following terminology:
to the ECLS/ECMO circuit in: Drainage cannula (deoxygenated blood
A. VA configuration: Assess for to the ECMO circuit)
dark venous blood draining Return cannula (oxygenated blood
from the patient’s venous returning to the patient).
cannula and return of bright In a VA configuration, there will be
red oxygenated blood to the retrograde blood flow to part of the
arterial cannula. native arterial system.
B. VV configuration: Assess that Some VA configurations may require a
the oxygenated blood second, smaller return line to provide
returning to the patient is distal antegrade perfusion because
flowing into the cannula the large arterial cannula often blocks
nearest the right atrium. flow. This may be placed during the
initial cannulation or at a later date.
Label the ends of the cannulas as
drainage and return.
12. Assist as needed with applying Decreases the risk of infection.
sterile dressings.
13. Assist the insertion team as Aids in determining proper
radiographs, fluoroscopy or positioning of the cannulas.
bedside echocardiography are
obtained.
14. Measure the distance from the Ensures that the system is secure; Consider also utilizing a horizontal
exterior end of each of the maintains safety. tube attachment device.
cannulas to the skin, document,
and secure tightly with both tape
and sutures.
15. Plug the pump controller into Provides the power supply.
electrical outlet.
16. Remove PE and sterile equipment
and discard used supplies.
17. HH

Troubleshooting
1. HH
2. PE
3. Assess for chatter/chugging of the Relative or absolute volume Decreasing the flow rate is a temporary
ECLS/ECMO circuit tubing. depletion will require solution; correcting the underlying
A. Assess patient’s volume administration of fluids or blood. fluid deficiency needs to be
status. Chatter can lead to hemolysis.3 addressed.
i. Decreasing the flow rate (if A malpositioned cannula may be When the drainage cannula sucks up
hemodynamically creating turbulent staccato flow against the venous wall turbulent
appropriate) can leading to chatter. staccato flow through the circuit may
temporarily reduce chatter, cause the tubes to shake.
but the flow setting should
be returned to previous
settings when possible.
ii. Flow should be noted
before and after decreasing
support.
B. Reassess cannula position by
comparing with the baseline
cannula position
measurement. Radiographic
confirmation may also be
necessary.
4. Assess for clots or fibrin deposits Deposits on the oxygenator can Turbulent swirling of the blood near
within the circuit tubing and decrease its efficiency and lead to clots or fibrin deposits may be seen
oxygenator (clots typically have a decreased gas exchange. Deposits through the tubing.
dark maroon appearance and distal to the oxygenator in the Clots may require exchange of the
fibrin deposits are white) and return cannula may embolize affected part of the circuit. Notify
notify the physician if they are causing pulmonary embolus, perfusion or ECLS/ECMO specialist
found. stroke, or organ damage from if clot is noted.3
ischemia. Large deposits may Ensure anticoagulation is therapeutic
cause hemodynamically (patient-specific PTT goal).
significant alterations in flow rate, Therapeutic anticoagulation reduces the
turbulent flow and hemolysis. risk of developing these deposits.
Typically heparin but alternatively a
direct thrombin inhibitor such as
argatroban or bivalirudin may be
used if heparin-induced
thrombocytopenia is suspected.
5. Assess for high pressure alarms The high pressure alarm indicates
(>300–400 mm Hg) if these increased pressures on the
alarms are available on the pump (arterial) return side of the
controller. If present: oxygenator.
A. Check the circuit distal to the Small air bubbles caught in the
pump for kinks or occlusions. oxygen exchanger may impede
B. Check the patient’s blood blood flow resulting in a high
pressure. pressure alarm.
C. Notify the physician if unable In a VA configuration, this alarm
to resolve high pressure may result from an elevated blood
alarms. pressure.

6. Power outage ECMO machines typically have a Some pumps may not have a hand
A. Ensure pump switches to short battery life. cranking backup feature.
battery power. Switching off less essential Summon assistance as this will be
B. Switch off the water bath/ components such as the heater can fatiguing if done for an extended
heater. conserve power (if both the period of time.
C. If the battery loses power, controller and heater are receiving Be aware of the expected battery
hand crank the pump: power from the same source). duration at your institution and take
i. Remove the pump from its Hand cranking the pump can this into consideration when planning
electronic power source. prevent a low-flow thrombosis to move the patient (e.g., for CT
ii. Attach the manufacturer- and continue to provide some scanning)
supplied hand crank to the support until power is restored.
back of the pump and turn.
D. Notify the physician.
7. Assess for hyperthermia. If the Permissive hyperthermia may be Fevers can be controlled by utilizing an
patient’s temperature is higher indicated in some circumstances, ice bath within the circuit to cool the
than the target: but if allowing a fever is not blood as it passes through.
A. Use the ice bath. warranted, it can easily be If the patient’s condition warrants,
B. Use the heater and adjust the corrected. workup for infection should be
temperature knob to the completed and empiric antibiotics
desired temperature. initiated.
8. Assess for hypothermia. Due to the large volume of blood The ECLS/ECMO circuit will have a
circulating outside the body, temperature exchanger with heater
patients are susceptible to heat and ice bath and desired temperature
loss. may be adjusted with a dial and the
utilization of an ice bath.
The ECLS/ECMO circuit may be
utilized to maintain normothermia in
hypothermic patients.
The ECLS/ECMO circuit may be
utilized to induce and maintain
hypothermia/targeted temperature
management (i.e., post cardiac
arrest).
9. Assess for inadequate Due to the altered cardiopulmonary Increasing oxygen flow to the
oxygenation. physiology in ECLS/ECMO oxygenator is a quick fix for hypoxia,
A. If the outlet saturation patients, oxygenation can provide but further evaluation is typically
(determined by drawing a clues to device malfunction or the warranted.
blood gas from the return need to titrate oxygen delivery. Address patient conditions contributing
cannula of the circuit, Suggests failure of the oxygenator to increased oxygen consumption.
postoxygenator) is <95%, itself, as opposed to a problem Exchange of components in the ECLS/
with a venous saturation with the patient. ECMO circuit is typically performed
(before the oxygenator) of by a perfusionist or ECLS/ECMO
≥70–75% and the patient’s specialist.
Hgb is ≥12, the oxygenator
may need to be exchanged.
B. Check for water in the gas
phase.
C. Assess hematocrit. It should be Optimizing the hematocrit improves Hematocrit targets may vary by center;
>40% for VV ECMO and oxygen-carrying capacity of the follow institutional standards.
>30% for VA ECMO. blood.
10. Assess for hypercarbia (Pco2 Normalized Pco2 contributes to Increasing the airflow through the
>70). acid-base balance and cerebral “sweep” part of the oxygenator
perfusion. Elevated Pco2 typically removes more CO2 from the blood.
requires adjustment to ECLS If the initial systemic Pco2 is >70 it
settings. may take several hours to normalize,
so avoid making adjustments too
rapidly.3

11. Assess for any air bubbles in If air is allowed to enter the Exercise caution with all venous lines
circuit. pulmonary artery or aorta, it may and catheters and central line sites to
A. If air is found in the circuit, obstruct blood flow causing organ avoid accidental entrainment of air
immediately clamp the lines. ischemia. into the circuit.
B. Support the patient by
increasing ventilator support
and vasoactive support as
prescribed.
C. Check the circuit proximal to
the pump for an open
stopcock, leaky connection,
tubing compromise, dislodged
cannula, or decannulation.
Correct the problem identified
and notify the physician.
D. Check the IV lines for air in
line and remove the air if
found.
12. Assess extremities: A common complication in the leg The presence of distal pulses does not
A. Check pulses, skin ipsilateral to the femoral arterial rule out compartment syndrome.
temperature, sensation, cannulation is ischemic injury. Consider obtaining an arterial blood
movement, and capillary refill. Ischemia from embolus or gas (ABG) from the right upper
B. Evaluate for compartment mechanical occlusion of the artery extremity and oxygen saturation in
syndrome of the extremity at the cannulation site may cause either the right upper extremity or
(pain, particularly with compartment syndrome of the the right ear lobe and compare with
passive muscle stretch of the extremity distal to arterial the left lower extremity or the lower
affected compartment, cannulation. extremities.
tautness of a muscular Regional oxygenation saturation
compartment). Consider sensors may be helpful in detecting
consulting the appropriate unilateral decreases in oxygenation.
service to obtain quantitative
compartment pressures.
C. Consider placement of a distal A distal perfusion catheter is a
perfusion catheter off the second, smaller, return cannula
return side of the circuit. usually placed in the femoral
artery distal to the location of the
primary return cannula enters the
artery.
D. Evaluate for harlequin Harlequin syndrome can occur due The presence of harlequin syndrome
syndrome (flow competition to flow competition in the aorta can signal circulatory recovery.
in the aorta due to left between the native left ventricle Change to VV if lung failure persists
ventricular recovery with output and the ECLS/ECMO as prescribed.
upper body hypoxia).4 return cannula output, leading to
poorly oxygenated blood from the
left ventricle entering the
brachiocephalic and coronary
arteries and well-oxygenated
blood from the ECLS/ECMO
circuit only going to the more
distal arteries.

13. Assess for hemolysis. Hemolysis may be a sign of device Plasma free hemoglobin >10 indicates
A. Check plasma-free malfunction requiring flow hemolysis.
hemoglobin and lactate adjustment or cannula position Pink-tinged urine may be due to
dehydrogenase (LD). adjustment. hemolysis.
B. Assess urine color. Inlet suction >300 mm Hg can cause
C. Check the inlet suction. hemolysis.
D. Check for clots in the pump Turbulent blood flow, from rapidly
chamber. flowing through a small opening, can
E. Notify physician. cause hemolysis.
supplies.
15. HH

• Rapid increase in oxygenation and gas exchange • Related to initial cannulation: Perforation/rupture/
• Circulatory stabilization but with lower pulse pressure, tear/dissection of femoral vein/vena cava/femoral
of ≥15 mm Hg artery, aorta. Retroperitoneal hemorrhage. Cannula
malposition. Inability to cannulate.
• Secondary: Distal limb ischemia (VA only),
coagulopathy, hemorrhage (anticoagulation), organ
failure, anoxic brain injury, hemolysis,
thromboembolism (VA), increased left ventricular
wall tension (VA), maldistribution of oxygenated
blood (VA), cannula dislodgement, bleeding, sepsis,
air embolism, disseminated intravascular coagulation,
skin breakdown, renal failure, heparin-induced
thrombocytopenia (HIT)5
• Equipment failure
• Hemolysis (membrane failure, turbulence in cannula
or pump from hypovolemia)

interventions.
1. Assess level of consciousness. Monitors for cerebral perfusion. • Change in level of consciousness
Thrombi may develop and dislodge • Increased agitation or confusion
during ECLS/ECMO therapy. • Change in saturation levels (per
Sudden neurological changes may device instructions for use) if
be an indication of intracerebral utilizing cerebral oxygenation
hemorrhage. monitors
2. Assess sensory and motor Monitors sensory and motor function. • Change in assessment findings
function using a scale (e.g.,
Glasgow Coma Scale).
3. Perform pupil checks every 2–4 Assess for adequacy of cerebral • Change in pupil size and reactivity
hours (more often if perfusion.
administering neuromuscular
blockade).1,3,6

4. Elevate head of bed.1,3,6 Prevent Elevation and maintaining patient’s • Change in venous return as
pressure on the groin if using head in midline position encourages evidence by change in flow rates
femoral cannulation. In order to venous return.
elevate the head of bed in this
paitent population use the reverse
Trendelenburg position.
5. Provide periods of stimulation Clustering of care, intermittent • Lack of response to therapy
and quiet time, provide means of periods of darkness and promoting
distraction, provide a comforting, prolonged periods of rest can
restful environment.1 promote neurological recovery.
6. Follow institutional standard for Identifies need for pain interventions • Continued pain despite pain
assessing pain.7,9 Administer interventions
analgesia as needed.
7. Assess agitation and sedation and Identifies need for medications and • Continued anxiety despite anxiety
administer anxiolytics as support interventions
prescribed.
8. Assess vital signs and pulmonary Demonstrates the effectiveness of • Unstable vital signs
artery pressures every 15–30 ECLS/ECMO therapy. • Abnormal pulmonary artery
minutes to every hour as patient’s pressures
status dictates. Follow
institutional standards.
9. Assess circulation to the Demonstrates adequate peripheral • Capillary refill >3 seconds
extremities at least every 2 perfusion. Changes may indicate • Diminished or absent pulses
hours.1,3,6 thrombotic or embolic obstruction (pulses may be absent on VA
Follow institutional standard. of perfusion to extremity support at high flow rates)
• Pale color, mottled or cyanotic
• Diminished or absent sensation
• Pain
• Diminished or absent movement
• Cold or cool to touch
10. Assess presence or absence of Edema of extremities may indicate • Change in skin integrity
edema (position patient to poor perfusion and may promote • Presence of edema
promote optimal perfusion of lack of skin integrity.
extremities and minimize
dependent edema).1,3,6
11. Measure urine output hourly. Demonstrates adequate perfusion to • Urine output <0.5 mL/kg/hr
the kidneys.
12. Assess respiratory status by Demonstrates adequacy of respiratory/ • Abnormal ABG results
auscultating breath sounds, ventilator support (gas exchange is • Abnormal pulse oximetry values
evaluating respiratory rate and controlled primarily by the • Abnormal breath sounds and
effort, arterial blood gases and membrane oxygenator). pulmonary assessment
peak inspiratory pressure if
ventilated.
13. Monitor platelet count, Care should be taken to prevent over • Abnormal laboratory values
hematocrit, activated clotting anticoagulation. Anticoagulation
time (ACT), CBC count, increases risk of intracranial
prothrombin time (PT), PTT, and hemorrhage and excessive bleeding.
INR as prescribed.
14. Monitor for systemic evidence of Hematologic and coagulation profiles • Bleeding from ECLS/ECMO
bleeding or coagulation may be altered as a result of blood insertion site
disorders.1,3,6 loss during ECLS/ECMO insertion, • Bleeding from incisions or mucous
anticoagulation therapy, platelet membranes
dysfunction, and hemolysis. • Petechiae/ecchymosis
• Guaiac-positive nasogastric
aspirate or stool
• Hematuria
• Decreased hemoglobin/hematocrit

15. Maintain nasogastric/orogastric Monitors gastrointestinal status. • Changes in gastric tube drainage
tube for feeding and/or • Abnormal bowel sounds
decompression as prescribed. • Abdominal distention and
tenderness
• Changes in bowel activity
16. Obtain daily weights if possible. Daily weights may assist in • Change in weight of more than
assessment of fluid balance. 2 kg/day
17. Frequent repositioning with close Promotes comfort and skin integrity. • Skin breakdown
examination of back of head, • Inability of patient to tolerate
heels, sacrum (consider utilization movement and repositioning
of specialty bed with low air loss
and continuous lateral rotation,
also consider utilizing products to
decrease risk of friction injuries
such as a turning and positioning
glide sheet).1–3,6,10
18. Assess ECLS/ECMO circuit at Demonstrates adequate ECLS/ECMO • Abnormal ECLS/ECMO circuit
least every hour. Follow therapy, such as blood flow, pump findings, such as air in line, clots
institutional standard. speed, Fio2, sweep gas flow. in oxygenator
19. Maintain sterile dressings on all Decreases incidence of infection and • Signs and symptoms of infection
invasive lines and cannula sites. allows for site assessment.
Change ECMO dressing every 24
hours and as needed.1
20. Logroll patient every 2 hours Promotes comfort and skin integrity. • Disruption of skin integrity
until hemodynamic stability is
obtained.1–3,6,10
21. When patient is hemodynamically Prevents hazards of immobility and • Postural hypotension
stable and condition allows, begins rehabilitation. • Decrease in flow with position
ambulate progressively. Use of a Ensures all lines are secure when change
multidisciplinary team is patient is ambulating. • Unrelieved dizziness
essential.1,8 Follow institutional • Prolonged deconditioning
standards.
22. Evaluate family’s coping Promotes family involvement in care • Family’s inability to cope
mechanism, strengths, and needs and decision-making.
on a continual basis.1
23. Consult pastoral care, palliative Team assists with meeting family and • Family’s inability to cope
care, or bereavement specialists.1 patient needs.
24. Ensure safe transport of patient Ensures entire team, including nurses, • Patient’s inability to be transported
and equipment to tests and physicians, respiratory therapists, such as unstable vital signs or
procedures.1,8 and perfusion or ECLS/ECMO instability of ECLS/ECMO circuit
specialist, is prepared for transport.
Documentation
• Patient and family education • Additional interventions
• Plan of care • ECLS/ECMO parameters (pump flow, Fio2, and
• Universal protocol requirements, sterile procedure/ sweep flow)
protocol • Cannula site and cannula measurements
• Informed consent • Securement of cannulas
• Patient response to ECLS/ECMO • Dressing changes and site assessment
• Confirmation of placement • Skin integrity
• Hemodynamic status • Patient tolerance
• Pain assessment, interventions and effectiveness • Unexpected outcomes
• Activity level

17 Extracorporeal Life Support (ECLS) and Extracorporeal Membrane Oxygenation (ECMO) 133.e1
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Extracorporeal support for severe acute respiratory failure. Williams KE: Extracorporeal membrane oxygenation for acute
Semin Respir Crit Care Med 35(4):519–527, 2014. respiratory distress syndrome in adults. AACN Adv Crit
6. Gay SE, et al: Critical care challenges in the adult ECMO Care 24(2):149–158, 2013.
patient. Dimens Crit Care Nurs 24(4):157–162, 2005.
7. Rose L, et al: Behavioral pain assessment tool for
critically ill adults unable to self-report pain. Am J Crit
Care 22(3):246–255, 2013.
PROCEDURE
18
Oxygen Saturation Monitoring
with Pulse Oximetry
Donna Barge Lee
PURPOSE: Pulse oximetry is a noninvasive monitoring technique used to
estimate the measurement of arterial oxygen saturation of hemoglobin. Pulse
oximetry is indicated in patients at risk for hypoxemia, such as during conscious
sedation procedures, transport, and adjustment of fraction of inspired oxygen (FiO2).
PREREQUISITE NURSING ❖ When hemoglobin has greater affinity for oxygen,

KNOWLEDGE less is available to the tissues (increased oxygen affin-
ity). Conditions such as increased pH (alkalosis),
• Oxygen saturation is an indicator of the percentage of decreased temperature, decreased Paco2, and decreased
hemoglobin saturated with oxygen at the time of the mea- 2,3-diphosphoglycerate (as found in stored blood prod-
surement. The reading, obtained with standard pulse ucts) increase oxygen binding to the hemoglobin and
oximetry, uses a light sensor that contains two sources of limit its release to the tissue.
light (red and infrared) absorbed by hemoglobin and trans- • Anemic patients will have normal oxygen saturation
mitted through tissues to a photodetector. The infrared levels but may be hypoxic because the total oxygen
light is absorbed by the oxyhemoglobin, and the red light content of the arterial blood is decreased.
is absorbed by the reduced hemoglobin. The amount and • Oxygen saturation values may vary with the amount of
type of light transmitted through the tissue is converted to oxygen usage or uptake by the tissues. In some patients,
a digital value that represents the percentage of hemoglo- a difference is seen in Spo2 values at rest compared with
bin saturated with oxygen (Fig. 18-1). values during activity, such as ambulation, motion, or
• Oxygen saturation values obtained with pulse oximetry positioning.19
(Spo2) represent one part of a complete assessment of a • Oxygen saturation does not directly reflect the patient’s
patient’s oxygenation status and are not a substitute for ability to ventilate. The true measure of ventilation is
measurement of arterial saturation of oxygen (Sao2) or of determination of the Paco2 in arterial blood. Use of Spo2
ventilation (as measured with arterial partial pressure of in a patient with obstructive pulmonary disease may result
carbon dioxide [Paco2]). in erroneous clinical assessments of a condition. As the
• A complete assessment of oxygenation includes evalua- degree of lung disease increases, the patient’s drive to
tion of oxygen content and delivery, which includes the breathe may shift from an increased carbon dioxide stimu-
following parameters: arterial partial pressure of oxygen lus to a hypoxic stimulus. Enhancing the patient’s oxygen-
(Pao2), Sao2 hemoglobin, cardiac output, and, when avail- ation and increasing the Spo2 may limit the ability to
able, mixed venous oxygen saturation. ventilate. The normal baseline Spo2 for a patient with
• Normal oxygen saturation values are approximately 97% known severe restrictive disease and more definitive
to 99% in a healthy individual breathing room air. An methods of determination of the effectiveness of ventila-
oxygen saturation value of 95% is clinically accepted in tion must be assessed before consideration of interven-
a patient with a normal hemoglobin level. With a normal tions that enhance oxygenation.
blood pH and body temperature, an oxygen saturation • The accuracy of Spo2 measurements may be influenced
value of 90% is generally equated with a Pao2 of by physiological variables, including the following:
60 mm Hg. ❖ Hemoglobin level
• Tissue oxygenation is not reflected by arterial or oxygen ❖ Presence of dyshemoglobinemias (i.e., carboxyhemo-
saturation obtained with pulse oximetry. globinemia after carbon monoxide exposure)
• The affinity of hemoglobin with oxygen may impair or ❖ Arterial blood flow to the vascular bed
enhance oxygen release at the tissue level. ❖ Temperature of the digit or the area where the oximetry
❖ Oxygen is more readily released to the tissues when pH sensor is located
is decreased (acidosis), body temperature is increased, ❖ Vasoconstriction
Paco2 is increased, and 2,3-diphosphoglycerate levels ❖ Venous congestion
(a byproduct of glucose metabolism that facilitates ❖ Fraction of inspired oxygen (percentage of inspired
the dissociation of oxygen from the hemoglobin oxygen)
molecule to tissue) are increased (decreased oxygen ❖ Degree of ventilation-perfusion mismatch
affinity). ❖ Venous return at the sensor location
134
18 Oxygen Saturation Monitoring with Pulse Oximetry 135
if a carbon monoxide (CO) oximeter is available, measure-

ment of carboxyhemoglobin and methemoglobin.3
• Dark skin has been suggested to possibly affect the ability
of the pulse oximeter to accurately monitor arterial oxygen
saturation by interfering with the transmission of light and
thus the accuracy of the readings. One study found more
frequent differences between the Spo2 and Sao2 in dark-
skinned patients compared with lighter-skinned patients.11
• Certain dyes used intravenously may interfere with
the accuracy of measurements, although as a result
of rapid clearance the impact is limited. Dyes include
methylene blue, indigo carmine, indocyanine green, and
fluorescein.8
Figure 18-1 A sensor device that contains a light source and a • A pulse oximeter should not be used as a predictive
photodetector is placed around a pulsating arteriolar bed, such as indicator of the actual arterial blood gas saturation;
the finger, great toe, nose, or earlobe. Red and infrared wavelengths however, the pulse oximetry does provide information
of light are used to determine arterial saturation. (Reprinted by about changes in the patient’s oxygenation and an early
permission of Nellcor Puritan Bennett LLC, Boulder, CO, part of warning sign of hypoxemia. Continuous pulse oximetry
Covidien.) monitoring in critical care settings can allow clinicians to
recognize early signs of deterioration and provide early
• The accuracy of Spo2 measurements may be influenced interventions that may prevent rescue events such as
by environmental variables, including the following: cardiac arrests or respiratory arrests.22
❖ Nail polish • Low-perfusion states such as hypotension, vasoconstric-
❖ Pigmentation tion, hypothermia, or administration of vasoconstrictive
❖ Dyes agents limit the ability of the oximeter to distinguish the
❖ Ambient light sources true pulsatile waveform from background noise.
❖ Motion • The mean oxygen saturation value from the finger of an
• Discoloration of the nail bed or obstruction of the nail bed arm that has been physically restrained has been shown
(i.e., blood under the fingernail) can potentially affect the to be significantly different from the finger of an unre-
transmission of light through the digit. Dark nail polish, strained arm. Therefore if physical restraints are being
such as blue, green, brown, or black,4 has been reported used, it is recommended that the pulse oximetry sensor
to limit the transmission of light and thus affect the Spo2, not be placed on the finger of a restrained arm.2
although a recent study showed that fingernail polish does • A pulse oximeter should never be used during a cardiac
not cause a clinically significant change in the pulse oxim- arrest situation because of the extreme limitations of blood
eter readings in healthy individuals.17,18 If the nail polish flow during cardiopulmonary resuscitation and the phar-
cannot be removed and is believed to be affecting the macological action of vasoactive agents administered
accuracy of the reading, the sensor can be placed in a during the resuscitation effort.9
lateral side-to-side position on the finger to obtain read- • In vasoconstrictive states, oxygen saturation may be mea-
ings if no other method of sampling the arterial bed is sured with a finger probe, but in patients with significant
available.5,18 Bruising under the nail can limit the trans- shifts in hemodynamic stability the ear or forehead has
mission of light and result in an artificially decreased Spo2 been shown to be reasonably resistant to the vasoconstric-
value. Pulse oximetry has not been shown to be affected tive effects of the sympathetic nervous system.1,15,21
by the presence of an elevated bilirubin.2 The presence of • Forehead sensors use reflectance and are more accurate in
acrylic fingernails may impair the accuracy of the pulse low-flow states but may be affected by venous congestion.
oximetry reading, and removal of the nail covering may Forehead sensors used in patients placed in Trendelen-
be necessary to ensure accurate measurement, although burg’s position may require up to 20 mm Hg of external
unpolished acrylic nails have been proven not to affect pressure to achieve accurate readings, which may be
pulse oximetry readings.16,23 accomplished with an appropriately applied headband.1
• Standard pulse oximeters use two wavelengths and are Disposable pulse oximeters intended for use on fingers
unable to differentiate between oxygen and carbon mon- should not be used on the forehead, as they are often
oxide bound to hemoglobin and falsely elevated Spo2 inaccurate.20
measurements. Standard pulse oximetry equipment should
never be used in suspected cases of carbon monoxide EQUIPMENT
exposure. However, recent technology advancements in
pulse oximetry have included the introduction of a monitor • Oxygen saturation monitor
system that uses up to 12 wavelengths with a digit-based • Oxygen saturation cable and sensor, which may be dispos-
pulse oximeter sensor and that allows for measurement able or nondisposable
estimates of certain dyshemoglobinemias (i.e., carboxyhe- • Manufacturer’s recommended germicidal agent for clean-
moglobinemia).12 An arterial blood gas always should be ing the nondisposable sensor (used for cleaning between
obtained to determine the accurate oxygen saturation and, patients)

PREPARATION
• Explain the need for determination of oxygen saturation
with a pulse oximeter. Rationale: This explanation Patient Assessment
informs the patient of the purpose of monitoring, enhances • Signs and symptoms of decreased oxygenation, including
patient cooperation, and decreases patient anxiety. cyanosis, dyspnea, tachypnea, decreased level of con-
• Explain that the values displayed may vary with patient sciousness, increased work of breathing, agitation,
movement, amount of environmental light, patient level confusion, disorientation, and tachycardia/bradycardia.
of consciousness (awake or asleep), and position of the Rationale: Patient assessment determines the need for
sensor. Rationale: This explanation decreases patient and continuous pulse oximetry monitoring. Anticipation of
family anxiety over the constant variability of the values. conditions in which hypoxia could be present allows
• Explain that the use of pulse oximetry is part of a much earlier intervention before unfavorable outcomes occur.
larger assessment of respiratory status. Rationale: This • Assess the extremity (digit) or area where the sensor will
explanation prepares the patient and family for other pos- be placed, including decreased peripheral pulses, periph-
sible diagnostic tests of oxygenation (e.g., arterial blood eral cyanosis, decreased body temperature, decreased
gas). blood pressure, exposure to excessive environmental light
• Explain the equipment to the patient. Rationale: This sources (e.g., examination lights), excessive movement or
information facilitates patient cooperation in maintaining tremor in the digit, presence of dark nail polish or bruising
sensor placement. under the nail, presence of artificial nails, clubbing of the
• Explain the need for an audible alarm system for alerting digit tips, and blood under the fingernails. Rationale:
clinicians of oxygen saturation values below a set accept- Assessment of factors that may inhibit accuracy of the
able limit, as determined by the clinician. Demonstrate the measurement of oxygenation before attempting to obtain
alarm system, alerting the patient and family to the pos- the Spo2 reading enhances the validity of the measurement
sibility of alarms, including causes of false alarms. Ratio- and allows for correction of factors as is possible.
nale: Provision of an understanding of the use of an alarm
system and its importance in the overall management of Patient Preparation
the patient’s condition and of circumstances in which a • Verify that the patient is the correct patient using two
false alarm may occur assists in understanding of the Spo2 identifiers. Rationale: Before performing a procedure, the
values seen at the bedside. nurse should ensure the correct identification of the patient
• Explain the need to move or remove the sensor on a for the intended intervention.
routine basis to prevent complications related to the type • Ensure that the patient understands preprocedural teach-
of sensor used and monitoring site (i.e., digit, forehead, ings. Answer questions as they arise, and reinforce
ear). Rationale: An understanding of the need to move the information as needed. Rationale: This communication
sensor routinely assists in patient understanding of the evaluates and reinforces understanding of previously
frequency of sensor movement. taught information.
Procedure for Oxygen Saturation Monitoring with Pulse Oximetry

1. HH
2. PE
3. Select desired sensor site. If digits are Adequate arterial pulse Avoid sites distal to indwelling
chosen, assess for warmth and strength is necessary for arterial catheters, blood pressure
capillary refill. Confirm the presence obtaining accurate Spo2 cuffs, or venous engorgement (e.g.,
of arterial blood flow to the area measurements. arteriovenous fistulas, blood
monitored. transfusions).
Procedure for Oxygen Saturation Monitoring with Pulse Oximetry—Continued

4. Select the appropriate pulse oximeter The correct sensor optimizes Several different types of sensors are
sensor for the area with the best signal capture and available, including disposable and
pulsatile vascular bed to be sampled minimizes artifact-related nondisposable sensors, which may
(Fig. 18-2). The digits are the most difficulties.5,6,13,14 be applied over a variety of
common site because of ease of vascular beds, including the digit,
application of the sensor. earlobe, nasal bridge or septum,
Consideration of other sites may and forehead. The latter requires an
produce more accurate results in appropriately placed headband.
conditions of extreme peripheral Do not use one manufacturer’s
vasoconstriction or decreased sensors with another manufacturer’s
perfusion.1,21 (Level C*) pulse oximeter unless compatibility
has been verified.
Figure 18-2 Sensor types and

sensor sites for pulse oximetry
monitoring. Use “wrap” or “clip”
style sensors on the fingers
(including thumb), great toe, and
nose. The windows for the light
source and photodetector must be
placed directly opposite each
other on each side of the arteriolar
bed to ensure accuracy of Spo2
measurements. Choice of the
correct size of the sensor helps
decrease the incidence of excess
ambient light interference and
optical shunting. “Clip” style
sensors are appropriate for fingers
(except the thumb) and the
earlobe. Ensuring that the arterio-
lar bed is well within the clip with
the windows directly opposite
each other decreases the possibil-
ity of excess ambient light inter-
ference and optical shunting.
(Reprinted by permission of
Nellcor Puritan Bennett LLC,
Boulder, CO, part of Covidien.)


5. Plug oximeter power cord into With use of electrical outlets, Portable systems have rechargeable
grounded wall outlet if the unit is not grounded outlets decrease batteries and depend on sufficient
portable. If the unit is portable, ensure the occurrence of electrical time plugged into an electrical
sufficient battery charge by turning it interference. outlet to maintain the proper level
on before use. Plug patient cable into of battery charge. When system is
monitor. used in the portable mode, always
check battery capacity.
6. Apply the sensor in a manner that To determine a pulse oximetry
allows the light source (LEDs) to be: value properly, the light
A. Directly opposite the light detector sensors must be in opposing
(photodetector). (Level C*) positions directly over the
area of the sample.6,7,21
B. Shielded from excessive Light from sources such as If the oximeter sensor fails to detect a
environmental light. (Level C*) examination lights or pulse when perfusion seems
overhead lights can cause adequate, excessive environmental
falsely elevated oximetry light (overhead examination lights,
values.10,14,21 phototherapy lights, infrared
warmers) may be blinding the light
sensor. Troubleshoot by reapplying
the sensor or shielding the sensor
with a towel or blanket or moving
the sensor to a different monitoring
site.
C. Positioned so that all sensor- If the light from the sensor’s Known as optical shunting, the light
emitted light comes into contact LEDs bypasses the tissue bypasses the vascular bed;
with perfused tissue beds and is bed and is detected at the shielding the sensor does not
not seen by the other side of the photodetector, the result is eliminate this if the sensor is too
sensor or without coming into either a falsely high reading large or not properly positioned.
contact with the area to be read. or no reading.
7. Gently position the sensor so that it The pulse oximeter is unable Restriction of arterial blood flow can
does not cause restriction to arterial to distinguish between true cause a falsely low value and lead
flow or venous return. (Level C*) arterial pulsations and fluid to vascular compromise, causing
waves (e.g., venous potential loss of viable tissues.
engorgement or fluid Edema from restriction of venous
accumulation).5,6,13 return can cause venous pulsation.
Elevation of the site above the
level of the heart reduces the
possibility of venous pulsation.
Moving the sensor to another site
on a routine schedule also reduces
tissue compromise. Never place the
sensor on an extremity that has
decreased or absent sensation
because the patient may not be able
to identify discomfort or the signs
and symptoms of loss of circulation
or tissue compromise.
8. Plug sensor into oximeter patient Connects the sensor to the
cable. oximeter, which allows
Spo2 measurement and
analysis of waveforms.

9. Turn instrument power switch on. Applies power to the device. Allow adequate time for self-testing
procedures and for detection and
analysis of waveforms before
values are displayed. The time
required to perform the self-test
and adequately warm depends on
specific manufacturer.
10. Determine accuracy of detected If arterial blood flow through This problem occurs particularly with
waveform by comparing the numeric the sensor is insufficient, the use of the fingers and the toes
heart rate value with that of a the heart rate values may in conditions of low blood flow.
monitored heart rate or an apical vary significantly. If the Consider moving the sensor to
heart rate or both. (Level M*) pulse rate detected with another site, such as the earlobe or
oximeter does not correlate the forehead (be sure the sensor
with the patient’s heart rate, type is appropriate for the
the oximeter is not monitoring site).Rotate the site of a
detecting sufficient arterial reusable sensor every 4 hours;
blood flow for accurate replace an adhesive disposable
values. sensor every 24 hours.13
11. Set appropriate alarm limits. Alarm limits should be set Oxygen saturation limits should be
appropriate to the patient’s 5% less than the patient’s
condition. acceptable baseline. Heart rate
alarms should be consistent with
the cardiac monitoring limits (if
monitored).
13. Cleanse nondisposable sensor, if used, Reduces transmission of
between patients with manufacturer’s microorganisms to other
recommended germicidal agent. patients.
12. Discard used supplies and remove PE
13. HH

• All changes in oxygen saturation are detected • Accurate pulse oximetry is not obtainable because of
• The number of oxygen desaturation events is reduced movement artifact
• The need for invasive techniques for monitoring • Low-perfusion states or excessive edema prevents
oxygenation is reduced accurate pulse oximetry measurements
• False-positive pulse oximeter alarms are reduced • Disagreements occur in Sao2 and oximeter Spo2

interventions.
1. Evaluate laboratory data along Spo2 values are one segment of a • Inability to maintain oxygen
with the patient for evidence of complete evaluation of the patient’s saturation levels as desired
reduced arterial oxygen oxygenation status and supplemental
saturation or hypoxemia. oxygen therapy. Data should be
integrated into a complete
assessment to determine the overall
status of the patient. If Spo2 is used
as an indicator of Sao2, an arterial
blood gas with CO oximetry should
be done to determine whether the
values correlate consistently.
2. Evaluate sensor site every 2–4 Assessment of the skin and tissues • Change in skin color
hours (if a disposable sensor is under the sensor identifies skin • Loss of warmth of tissue
used) or every 2 hours (if a breakdown or loss of vascular flow, unrelated to vasoconstriction
reusable or nondisposable sensor allowing appropriate interventions to • Loss of blood flow to the digit
is used). Rotate the site of a be initiated. Application of • Evidence of skin breakdown
reusable sensor every 4 hours; additional tape may constrict blood from the sensor
replace an adhesive disposable flow at the monitoring site and result • Change in color of the nail bed,
sensor every 24 hours13 or per in both inaccurate monitor readings which indicates compromised
manufacturer’s recommendations and further compromised local skin circulation to the nail
if the securing mechanism is perfusion.
compromised or soiled. Never
apply additional adhesive tape to
secure a sensor. (Level M*)
3. Monitor the sensor site for Excessive movement at the monitoring • Inability to obtain pulse oxygen
excessive movement, which site may result in unreliable saturation levels
results in motion artifact. saturation values.
Moving the sensor to a less physically
active site may reduce the risk of
motion artifact; use of an adhesive
versus reusable sensor may also help
as a result of better fit. If the digits
are used, ask the patient to rest the
hand on a flat or secure surface.
4. Compare and monitor the actual The two numeric heart rate values • Inability to correlate actual heart
heart rate with the pulse rate should correlate closely. rate and pulse rate from oximeter
value from the pulse oximeter to A difference in pulse rate values
determine accuracy of values. reported with pulse oximeter may be
from excessive movement, poor
peripheral perfusion at the
monitoring site, or loss of pulsatile
flow detection.
Documentation
Patient and family education Simultaneous arterial blood gases (if available)
Indications for use of pulse oximetry Recent hemoglobin measurement (if available)
Patient’s pulse rate with Spo2 measurements Skin assessment at sensor site
Fio2 delivered (if patient is receiving oxygen) Pulse oximeter monitor alarm settings
Patient clinical assessment at the time of the saturation Events precipitating acute desaturation
measurement Unexpected outcomes
Sensor site Nursing interventions

18 Oxygen Saturation Monitoring with Pulse Oximetry 141.e1
References and finger transmission sensors. Intensive Care Med

1. Agashe GS, Coakley J, Mannheimer PD: Forehead pulse 38:1718–1722, 2012.
oximetry. Anesthesiology 105:1111–1115, 2006. 16. Peters SM: The effect of acrylic nails on the measurement
2. Akin Korhan EA, Yont GH, Khorshid L: Comparison of of oxygen saturation as determined by pulse oximetry.
oxygen saturation values obtained from fingers on AANA J 65:361–363, 1997.
physically restrained or unrestrained sides of the body. 17. Rodden AM, et al: Does fingernail polish affect pulse
Clin Nurse Spec 25(2):71–74, 2011. oximeter readings? Intensive Crit Care Nurs 23:51–55,
3. Barker SJ, et al: Measurement of carboxyhemoglobin and 2007.
methemoglobin by pulse oximetry. Anesthesiology 18. Schallom L: Comparison of forehead and digit oximetry
105:892–897, 2006. in surgical/trauma patients at risk of decreased peripheral
4. Chan MM: What is the effect of fingernail polish on pulse perfusion. Heart Lung 36:188–194, 2007.
oximetry? Chest 123:2163–2164, 2003. 19. Shah N, et al: Performance of three new-generation pulse
5. Cheatham S, Kolber MJ, Ernst MP: Concurrent validity of oximeters during motion and low perfusion in volunteers.
arterial blood oxygen saturation measurements: A J Clin Anesth 24:385–391, 2012.
preliminary analysis of an iPad pulse oximeter and 20. Smithline HA, et al: Pulse oximetry using a disposable
traditional pulse oximeter using bluetooth. Int J Athletic finger sensor placed on the forehead in hypoxic patients.
Therapy Training 19(3):37–42, 2014. J Emerg Med 39:121–125, 2010.
6. Grap MJ: Pulse oximetry. Crit Care Nurse 18:94–99, 21. Szaflarski NL, Cohen NH: Use of pulse oximetry in
1998. critically ill adults. Heart Lung 18:444–453, 1989.
7. Grap MJ: Pulse oximetry. In AACN protocols for practice: 22. Taenzer AH, et al: Impact of pulse oximetry surveillance
Technology series, Aliso Viejo, CA, 2005, American on rescue events and intensive care unit transfers, a
Association of Critical-Care Nurses. before-and-after concurrence study. Anesthesiology
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pulse oximeters. Anesthesiology 67:864–865, 1987. 23. Villaflor CR, et al: Research in brief—Effect of an acrylic
9. Hedges J, et al: Pulse oximetry. In Roberts JR, editor: gel nail art on pulse oximetry readings. Singapore Nurs J
Clinical procedures in emergency medicine, ed 4, 40(4):38–41, 2013.
Philadelphia, 2004, Saunders, pp 32–36. Additional Readings
10. Hinkelbein J, et al: Artificial acrylic finger nails may alter
pulse oximetry measurement. Resuscitation 74:75–82, Bianchi J, et al: Pulse oximetry index: A simple arterial
2006. assessment for patients with venous disease. J Wound Care
11. Jubran A: Reliability of pulse oximetry in titrating 17:253–260, 2008.
supplemental oxygen therapy in ventilator-dependent Clark AP: Legal lessons: “But his O2 sat was normal!”. Clin
patients. Chest 97:1420–1425, 1990. Nurse Spec 16:162–163, 2002.
12. Kelleher JF: Pulse oximetry. J Clin Monit 5:37–62, 1989. Giuliano KK, Higgins TL: New-generation pulse oximetry in
13. Masimo: Rainbow SET Pulse CO-Oximetry, 2008. the care of critically ill patients. Am J Crit Care 14:26–39,
<http://www.masimo.com/Rainbow/about.htm>. 2005.
(Accessed 21.03.09.) Witting MD, Scharf SM: Diagnostic room-air pulse oximetry:
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99:11–17, 1999. 26:131–136, 2008.
15. Nesseler N, et al: Pulse oximetry and high-dose
vasopressors, a comparison between forehead reflectance
PROCEDURE
19
Pronation Therapy
Kathleen Vollman, Sharon Dickinson, and Jan Powers
PURPOSE: The prone position may be indicated in patients diagnosed with acute
respiratory distress syndrome demonstrating severe hypoxemia, defined as a partial
pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio of
<150 mm Hg with an FiO2 of at least 60% and positive end-expiratory pressure
(PEEP) of at least 5 cm H2O and a tidal volume close to 6 mL/kg of predicted body
weight. The prone position is used in an attempt to improve oxygenation and
reduce ventilator-induced lung injury in patients with acute respiratory distress
syndrome (ARDS). The position also may be used for mobilization of secretions as a
postural drainage technique, posterior wound management that allows excellent
visualization and management of the site, relief of pressure in the sacral region,
positioning for operative or diagnostic procedures, and therapeutic sleep for
critically ill patients who normally sleep on the abdomen at home.
PREREQUISITE NURSING One meta-analysis showed significant reduction in the

KNOWLEDGE incidence of ventilator-associated pneumonia (VAP) in
the prone position33; another showed a trend toward
• Prone positioning is used as an adjunct short-term sup- significance in VAP reduction of 23% (P = 0.09)1; and
portive therapy in an attempt to recruit alveoli to improve the third showed no difference in VAP rates between
gas exchange and reduce ventilator injury in critically ill the two positions.3 The fourth meta-analysis did not
patients with ARDS with severe hypoxemia. evaluate the effect on VAP.21
❖ On the basis of numerous studies and three older and ❖ Part of the variability in outcomes between the analy-
one recent meta-analyses, and the latest prospective ses has to do with the inclusion criteria used to choose
randomized controlled trial (RCT), patients with ARDS the studies incorporated in the meta-analysis. The anal-
and severe hypoxemia placed in the prone position ysis by Alsaghir and Martian3 resulted in five trials that
significantly increase Pao2/Fio2 ratio compared with in met inclusion criteria out of 63 with a total of 1316
the supine position. The greatest effect was seen within patients. The meta-analysis performed by Abroung and
the first few days, with continuing benefit up to 8 group1 included 5 trials out of 72 with a total of 1372
days.1–6,10,13,16,17,21,23,29,33,35,37 Guerin and colleagues patients, and the analysis by Sud and colleagues33
studied a total of 466 ARDS patients with severe included 13 trials out of 1676 studies with analysis
hypoxemia, with 237 in the prone group and 229 in the being performed on 1559 patients. Lee et al. analyzed
supine group. Patients were randomly assigned to 11 trials totaling 2246 patients. They excluded RCTs
undergo prone or supine positioning. After eligibility conducted on pediatric patients and randomized cross
was determined, a stabilization period of 12 to 24 hours over trials that assigned patients to both groups.21
took place before randomization. Those in the prone ❖ The last major outcomes to be examined in the meta-
group were turned within 1 hour of randomization and analyses were the presence of significant complications
spent at least 16 consecutive hours in the prone posi- when the prone position was compared with the supine
tion per day. The 28-day mortality was significantly position. Three of the four analyses reported on com-
reduced in the prone group. The mortality of the prone plications. Two analyses showed a statistically signifi-
group was 16% compared with the supine group at cant higher risk for the development of pressure ulcers
32.8%. This benefit held out to 90 days.17 However, the in the prone position,21,33 and Abroung and group1
other two of the four meta-analyses showed no improve- showed no significant difference in major airway com-
ment in mortality with the use of the prone position.1,33 plications in the prone position; however, Lee and
The other two meta-analyses showed significant colleagues demonstrated that prone positioning was
improvement in mortality in patients with severe- significantly associated with major airway complica-
hypoxemia ARDS.3,21 Lee and colleagues also found tions.21 Guerin and colleagues in their recent prospec-
that >10 hours a day in the prone position was associ- tive RCT showed that the incidence of complications
ated with a reduction in mortality.21 did not differ between groups except with cardiac
❖ No significant difference was seen in number of days arrests. The supine group had a significantly higher rate
on mechanical ventilation with the prone position.1,3,33 of cardiac arrest than the prone group.17
142
19 Pronation Therapy 143
• To enhance an understanding of how prone positioning diseased lung. The ARDS lung weight is increased
may affect gas exchange, understanding the factors that twofold to threefold from normal. The increased weight
influence the distribution of ventilation and perfusion is from edema and the resulting hydrostatic forces. The
within the lung is important. result is a progressive squeezing of gas along the
❖ Distribution of ventilation: Regional pleural pressures vertical-dorsal axis. This decrease of regional inflation
and local lung compliance jointly determine the volume along the vertical axis results in dependent or dorsal
of air distributed regionally throughout the lungs. lung collapse. In the prone position, these densities
Three major factors—gravity and weight of the lung, shift. The pattern almost completely reverts toward
compliance, and heterogeneously diseased lungs— normal. The inflation gradient is less steep, and the
influence regional distribution. In an upright individ- difference results in a more homogeneous regional
ual, the pleural pressure next to the diaphragm is less inflation. This inflation may be related to a redistribu-
negative than at the pleural apices. The weight of the tion of gas because of the change in hydrostatic forces
lung and the effect of gravity on the lung and its sup- caused by differences in pleural pressure, as described
porting structures in the upright position create this previously.12,14,29
difference in regional pleural pressures. This relation- • Distribution of perfusion: Similar to ventilation, regional
ship results in a higher functional residual capacity distribution of perfusion is influenced by three factors:
(FRC) in the nondependent zone or the apices, redirect- cardiac output, pulmonary vascular resistance, and gravity
ing ventilation to the dependent zone.11,19,41 When body or body position.
position changes, changes occur in regional pleural ❖ In an upright individual, blood flow decreases as it
pressures, compliance, and volume distribution. In the moves from base to apex with virtually no flow at the
supine position, distribution becomes more uniform apex. This decrease is caused by the influence of gravity
from apex to base. The ventilation of dependent lung on pulmonary vascular pressures within the lung
units exceeds that of nondependent lung units, however, ❖ In zone 1, near the apex, alveolar pressure exceeds
and a reduction in FRC is seen.11,41 The two factors that arterial pressure, creating little or no flow.
contribute to the reduction in FRC seen in moving from ❖ In zone 2, the pulmonary artery pressure exceeds alve-
the upright to the supine position include the pressure olar pressure, which exceeds the venous pressure.
of the abdominal contents on the diaphragm and the Blood flow in this area occurs based on the differences
position of the heart and the relationship of the sup- in pressure between the arterial and alveolar bed.
porting structures to the lung and its influence on ❖ In zone 3, the arterial pressure is greater than the
pleural pressure gradients.11,12,22 venous pressure, which is greater than the alveolar
❖ The first factor to influence pleural pressure, regional pressure. In this zone, the influence of the alveolar
volumes, and FRC is the effect of the abdominal con- pressure on blood flow is reduced, resulting in freedom
tents on the function of the diaphragm. In spontane- of flow in this region.41,42
ously breathing individuals in the supine position, the • In supine and lateral positions, apical region blood flow
diaphragm acts as a shield against the pressure exerted changes. No real change is seen in basilar units, but a
by the abdominal contents, preventing the contents greater dependent versus nondependent blood flow occurs.
from interfering with dependent lung-volume distribu- In the prone position, a marked reduction occurs, however,
tion. When patients are mechanically ventilated with in the gravitational perfusion gradient, which suggests no
positive-pressure breaths, sedated, or paralyzed, the gravity-dependent benefit to flow in the prone position.26
active muscle tension in the diaphragm is lost, which • On the basis of the current available data as outlined here,
results in a cephalad displacement of the diaphragm changes in oxygenation seem to be related to differences
and allows abdominal pressures to decrease dependent in the regional inflation/ventilation of the lung while prone
lung-volume inflation and FRC.11,19 The only way to and are not related to a redistribution of blood flow.7,22,28
modify this influence is to change the posture to a In a recent examination of the Guerin et al. trial data, it
prone position with the abdomen unsupported.11,29 appears that the improvement in gas exchange did not
❖ The second factor to influence pleural pressure, regional predict survival. It was suggested that improved survival
volumes, FRC, and compliance is the position of the occurred by reducing ventilator-induced lung injury as it
heart and supporting structures. The heart and the dia- was first discussed in 1997. Prone positioning creates a
phragm extend farther dorsally and rest against a rigid more uniform distribution of end-expiratory lung volume
spine in the supine position, squeezing the lungs or FRC and a more uniform tidal volume.2
beneath them. This pressure on the lungs generates • Suggested criteria for use of the prone position include
more positive pleural pressures, which results in a the following:
greater propensity of the alveoli at end expiration to ❖ Consider early use of the prone position for patients
collapse. In the prone position, the heart and upper with ARDS with severe hypoxemia defined as a Pao2/
abdomen rest against the sternum, exerting less weight Fio2 ratio <150 mm Hg, with a Fio2 >60% with at least
on the lung tissue. Less effect on pleural pressure 5 cm of PEEP.17
occurs, which leaves the pleural pressures more nega- • Precautions to manual pronation therapy include the
tive, maintaining open alveoli.22,26,29 following4,10,28,31,36,37:
❖ A third factor that contributes to the distribution of ❖ Patient unable to tolerate a head-down position
volume is heterogeneously or unevenly distributed ❖ Increased intracranial pressure
❖ Unstable spine (unless Stryker Frame [Stryker EQUIPMENT

Medical], Kalamazoo, MI)
❖ Patient with hemodynamically unstable condition • Pillows, gel or foam blocks, flat sheet
(as defined by a systolic blood pressure <90 mm Hg) • Four or five staff members
with fluid and vasoactive support in place • Resuscitation bag and mask, connected to an oxygen
❖ Weight 160 kg or greater (weigh the risk/benefit ratio source
for the patient and staff) • Lift sheets (Figs. 19-1 and 19-2)
❖ Extracorporeal membrane oxygenator cannula place- or
ment problems • RotoProne Therapy System for use in all patient popula-
❖ With use of a support frame, patient weight >135 kg tions (Fig. 19-3): weight limit per manufacturer’s recom-
(300 lbs) mendations, 88 to 350 lbs (40 to 159 kg); height limit per
❖ Open chest or unstable chest wall manufacturer’s recommendations, 54 to 78 inches (140 to
❖ Bronchopleural fistula 200 cm)
❖ Unstable pelvis or
❖ Facial trauma • Lateral rotation therapy bed with or without prone acces-
❖ Grossly distended abdomen or ischemic bowel sory kit
❖ Pregnancy or
❖ Bifurcated endotracheal tube (ETT) • Vollman Prone Positioner (VPP; Hill-Rom, Inc, Bates-
• Absolute contraindications for use of Automated Prone ville, IN; Fig. 19-4): weight limit per manufacturer’s rec-
Positioning RotoProne Therapy System (Arjohuntleigh, ommendation, 300 lbs (no longer manufactured but may
Sweden) include the following: have been purchased in the past)
❖ Unstable cervical, thoracic, lumbar, pelvic, skull, or • Three staff members (with VPP)
facial fractures • Stryker Frame for use in patients with unstable spines,
❖ Cervical or skeletal traction if available: weight limit per manufacturer’s
❖ Uncontrolled intracranial pressure recommendations
❖ Patient weight <40 kg (88 lbs) Additional equipment, to have available as needed, includes
❖ Patient weight >159 kg (350 lbs) the following:
❖ Patient height >6 ft 6 inches • Capnography monitor
• The use of the prone position is discontinued when
the patient no longer shows a positive response to the PATIENT AND FAMILY EDUCATION
position change or mechanical ventilation support has
been optimized. In the Guerin et al protocol, prone • Explain to the patient and family the patient’s lung/
positioning was stopped when the following criteria oxygenation problem and the reason for the use of the
were met17: prone position. Rationale: This explanation decreases
❖ Improvement in oxygenation, defined as Pao2/Fio2 patient and family anxiety by providing information and
ratio <150 mm Hg, with an Fio2 >60% with ≤10 cm of clarification.
PEEP (these criteria had to be met in the supine posi- • Explain the care procedure to the patient and family,
tion at least 4 hours after the end of the last prone including positioning procedure, perceived benefit, fre-
session) quency of assessments, expected response, and parame-
❖ A Pao2/Fio2 ratio of more than 20% relative to the ratio ters for discontinuation of the positioning technique and
in the supine position before two consecutive prone equipment (if special bed or frame is initiated). Rationale:
sessions This communication provides an opportunity for the
❖ Complications occurring during a prone session leading patient and family to verbalize concerns or ask questions
to its immediate interruption, including nonscheduled about the procedure.
extubation, main stem bronchus intubation, ETT
obstruction, hemoptysis, oxygen saturation <85% for
greater than 10 minutes or a Pao2 of <55 mm Hg for PATIENT ASSESSMENT AND
more than 5 minutes. When the Fio2 was at 100%, PREPARATION
cardiac arrest, a heart rate of <30 bpm for more than 1
minute, systolic blood pressure of <60 mm Hg for Patient Assessment
more than 5 minutes, and any other life-threatening • Assess time interval from initial diagnosis to position
reason change. Rationale: Prone positioning should be per-
• With use of the RotoProne Therapy System Surface, formed within the first 24 hours of the diagnosis of severe-
weaning from the prone position is recommended. Increase hypoxemia ARDS. Prone positioning should occur for at
supine time while decreasing time in the prone position least 16 hours in a 24-hour period.
until the patient is able to tolerate 12 to 24 hours in • Assess the hemodynamic status of the patient to identify
the supine position with no decrease in oxygenation the ability to tolerate a position change.31,39 Most critically
response. The patient can then be taken off the RotoProne ill patients take 5 to 10 minutes to equilibrate to a position
and placed on an appropriate surface to achieve patient change. Allow for this time period before determining
goals. lack of ability to tolerate the prone position.39 Rationale:
A B
C D
E
Figure 19-1 The five-step method to prone a patient using a regular bed, flat sheet, and four staff.
A, Using a flat sheet, pull the patient to one side of the bed using four staff members. B, Place the
flat sheet around the arm that will pull through (the side you are turning toward). C, A second flat
sheet is placed on the bed and tucked under the patient. This sheet will pull through as you are
turning the patient. D, Using the sheet, turn the patient over and position the patient prone. The arm
and sheet will pull across the bed. E, Pull and center the patient. Discard the sheet that was used to
supine the patient. Straighten lines and tubes. (From University of Michigan Surgical Intensive Care
Technique.)
Imbalances between oxygen supply and demand must be are narrow, which makes completion of the turn difficult
addressed before the pronation procedure to offset any on patients who weigh more than 160 kg. The team must
increases in oxygen demand that may be created by the consider the potential for injury to the healthcare workers
physical turning. The final decision to place a patient with when making the decision to turn morbidly obese patients
a hemodynamically unstable condition in a prone position prone. With use of a special bed made specifically for
rests with the physician or advanced practice nurse who prone positioning, follow the weight and height limita-
must weigh the risks against the potential benefits of the tions recommended by the manufacturer.
prone position. • Evaluate patient for any history of contraindications for
• Assess mental status before use of the prone position. particular arm positions while manually proned. Ratio-
Rationale: Agitation, whether caused by delirium, anxiety, nale: Identifies patients with arm or shoulder injuries that
or pain, can have a negative effect with the prone position. may preclude proning.
Nevertheless, agitation is not a contraindication for use of
the prone position. The healthcare team should strive to Patient Preparation
manage the agitation effectively to provide a safe environ- • Verify that the patient is the correct patient using two
ment for the use of the prone position. identifiers. Rationale: Before performing a procedure, the
• Assess size and weight load to determine the ability to nurse should ensure the correct identification of the patient
turn within the narrow critical care bed frame and to for the intended intervention.
weigh the potential risk of injury to the healthcare worker. • Ensure that the patient and family understand prepro-
Rationale: When manually turning a patient prone in a cedural teachings. Answer questions as they arise and
hospital bed, with or without a frame, one must determine reinforce information as needed. Rationale: This com-
whether a 180-degree turn can be accomplished within the munication evaluates and reinforces understanding of pre-
confines of the space available. Critical care bed frames viously taught information.
A B
C D
E F
Figure 19-2 The five-step method to supine a patient using a flat sheet and four staff. A, Using
a flat sheet, pull the patient to one side of the bed. B, Place the flat sheet around the arm that will
pull through (the side you are turning toward). C, A second flat sheet is placed on the bed and tucked
under the patient. This sheet will pull through as you are turning the patient. D, Using the sheet turn
the patient over and position the patient prone. The arm and sheet will pull across the bed. E, Discard
the sheet that was used to supine patient. F, Straighten lines and tubes. (From University of Michigan
Surgical Intensive Care Technique.)
Figure 19-3 The Rotoprone therapy system. (Courtesy KCI Figure 19-4 Diagram of the Vollman Prone Positioner. (From
Licensing, Inc, 2008.) Hill-Rom, Inc, San Antonio, TX.)
• Assess patient’s mental condition. Rationale: Assessment the teeth digging into the tongue. Other bite blocks may
of pain, anxiety/agitation and delirium using a reliable and be used, but do not use bite blocks that fit over the
valid scale and providing appropriate management before, tongue as this will cause undue pressure and increase
during, and after the turn are key to accomplishing a safe risk of tongue breakdown.
procedure. ❖ Ensure the tape or ties of the ETT or tracheotomy tube
• If using gastric feedings, turn off the tube feeding 1 hour are secure. Changing of the ties may be necessary on
before the prone position turn. Rationale: This action return to the supine position if they are not secure. If
assists with gastric emptying and reduces the risk of aspi- adhesive tape is used to secure the ETT, consider
ration during the turning procedure.38 Enteral feeding can double taping or wrapping completely around the head
be continued during prone position34; use of prokinetic because increased salivary drainage occurs in the prone
agents or transpyloric feedings is recommended to prevent position and may loosen the adhesive.31,37 Commercial
complications associated with vomiting.30 ETT securement devices are not recommended for use
• Before positioning the patient prone, the following care during prone positioning because of the possibility of
activities should be performed. Rationale: These activi- increased skin breakdown and breakdown of adhesive
ties prevent areas of pressure and potential skin break- from increased salivary drainage.20
down; avoid complications related to injury or accidental ❖ Central and arterial lines should be sutured into place.
extubation; and promote the delivery of comprehensive ❖ If a wound dressing on the anterior body is due to be
care before, during, and after the pronation therapy.31,36,37,40 changed during the prone-position sequence, perform
❖ Order prone positioning. the dressing change before the turn. If saturated on
❖ Remove electrocardiogram (ECG) leads from the ante- return from the prone position, the dressing needs to
rior chest wall. be changed.
❖ Perform eye care, including lubrication and taping of ❖ Empty ileostomy/colostomy bags before positioning.
the eyelids closed in a horizontal fashion (or per insti- Placement of the drainage bag to gravity drainage and
tutional policy). padding around the stoma to prevent pressure directly
❖ Ensure the tongue is inside the patient’s mouth. If the on stoma are recommended.
tongue is swollen or protruding, insert a dental mouth- ❖ Capnography monitoring is suggested to help ensure
prop. The dental mouth-prop fits between the teeth proper positioning of the ETT during the turning pro-
(upper and lower) holding the mouth open to prevent cedure and in the prone position.
Procedure for Preparation for Manual Prone Therapy

1. HH
2. PE
3. Two staff members are Four to five individuals are needed to The RT at the head of the bed is
positioned on each side of the position a patient safely prone responsible for monitoring the ETT,
bed, with another staff member without a frame. Additional ventilator tubing. The nurse
(often a respiratory therapist stability and position of the adjacent to the RT monitors the
[RT]) positioned at the head of personnel may be necessary, based intravenous (IV) lines located by
the bed. (Level D*) Ideally, on the size of the patient.8,9,31,36,37,40 the patient’s head. For increased
some of the staff should be airway security, the RT or nurse
experienced with proning and should hold the ETT during the
moving the patient back to turn.31,37
supine in case of an emergency.
4. Correctly position all tubes and All IV tubing and invasive lines are If the patient is in skeletal traction,
invasive lines. Remove ECG adjusted to prevent kinking, one individual needs to apply
patches from the chest. disconnection, or contact with the traction to the leg while the lines
body during the turning procedure and weights are removed for the
and while the patient remains in turn. If a skeletal pin comes into
the prone position. ECG patches contact with the bed, a pillow
can be a source of pressure when needs to be placed in the correct
the patient is proned.8,9 position to alleviate pressure points.

Procedure for Preparation for Manual Prone Therapy—Continued

5. Lines inserted in the upper Disconnecting IV lines before the
torso are aligned with either turn may help to prevent
shoulder, and the excess tubing dislodgement but places the patient
is placed at the head of the bed. at an increased risk for infection.
The only exception is for the
chest tubes or other large-bore
tubes (e.g., tubes used for
extracorporeal membrane
oxygenation). (Level D*)
6. Chest tubes and lines or tubes Consider addition of an extension
placed in the lower torso are tube to lines that are too short to be
aligned with either leg and placed at the head of bed or the
extend off the end of the bed. end of the bed.
(Level D)
7. If the patient has an open Open abdomens are not a
abdomen, cover with a contraindication for use of the
synthetic material or vacuum prone position. A cover with a
dressing before positioning. synthetic material such as a Wound
Identify a positioning strategy Vac, or support such as an
that allows the abdomen to be abdominal binder, may be used
free of restriction. effectively to secure the abdomen.25
8. Assess to make sure you have Maximally inflating the air surface Consider the use of a bariatric bed for
enough bed width to safely turn firms up the mattress, making the patients >300–350 lbs.
the patient 180 degrees. If on a turn easier to perform.
low air-loss surface, maximally
inflate.36,40 (Level E*)
9. Preoxygenate the patient with a Maximize oxygenation before
Fio2 of 100% for 30 minutes turning.
before prone or supine
positioning.8 (Level E)
remove PE
11. HH
Procedure for Manual Pronation Therapy: The Five-Step Method to Prone the Patient8,9
(see Fig. 19-1)
1. Start with flat sheet that is under the The person on the side of the bed
patient and pull the patient while still closest to the patient maintains
supine to the side of the bed away body contact with the bed at all
from the ventilator. Turn the patient in times to serve as a side rail and
the direction of the mechanical prevent a fall. (Level C*)
ventilator.
(see Fig. 19-1)—Continued
2. The flat sheet is placed around the This maneuver protects the arm
arm that is located in the middle of and allows it to be pulled
the bed (encircle the arm, that will from under the patient after
pull through) side you are turning completing the turn.
toward.
3. A second flat sheet is placed on the Both sheets will pull through after
bed and tucked under the patient and turning the patient.
the covered arm. The patient is rolled
as far as possible to the side of the
bed to allow placement of the second
sheet as far under the patient as
possible. This sheet will pull through
as you are turning the patient.
4. Under direction of the person at the The first flat sheet is pulled through Chest and/or pelvic support can be
head of the bed, with a count of three, and away from the ventilator, done by placing a pillow at the
the patient is carefully turned back pulling the arm with it. This abdomen before completing the
over by pulling the first sheet from sheet can be recycled and the turn.
the side of the bed back toward the second flat sheet pulled through
middle of the bed. The wrapped arm away from the ventilator. Placing
is gently pulled from under the the new sheet (second sheet)
patient using the original sheet while under the patient allows you to
pulling the second sheet under the be ready to return the patient to
patient. The original flat sheet is the supine position at any time.
discarded. (Level E*) It also allows the patient to lay
on a clean, absorbent surface.
5. The patient is now prone. Pull and Every attempt is made to prevent Patients may have range-of-motion
center the patient. Straighten and pressure areas to the face, around limitations to the shoulder area that
reconnect lines and tubes. Position lines and tubes, and over bony may make keeping the arms in a
the head to prevent pressure areas. prominences. The head should flexed position difficult.
Place the patient in the reverse lie directly on the bed in a The patient should be repositioned
Trendelenburg position if not side lying position. Arms are every 2 hours, the same as a patient
contraindicated. Place feet on pillows. positioned for comfort by either in the supine position. The head
(Level E) placing them aligned with the should also be rotated every 2
body or in a swimmers position, hours from side to side.
one up and one down.
Preparation for Returning a Patient to Supine Position
1. Repeat procedure steps 3–9 under Procedure for Preparation for Manual Prone Therapy above.
The Five-Step Method for Returning to the Supine Position From the Prone Position8,9 (see Fig. 19-2)
1. Start with a flat sheet that is under the The person on the side of the bed The RT at the head of the bed is
patient and pull the patient while still closest to the patient maintains responsible for monitoring the ETT,
prone to the side of the bed, away body contact with the bed at all ventilator tubing. The nurse
from the ventilator. Turn the patient in times to serve as a side rail and adjacent to the RT monitors the
the direction of the mechanical prevent a fall. (Level C*) intravenous lines located by the
ventilator. patient’s head. For increased airway
security, the RT or nurse should
hold the ETT during the turn.31,37

(see Fig. 19-1)—Continued
2. The flat sheet is placed around the This maneuver protects the arm
arm that is located in the middle of and allows it to be pulled from
the bed (encircle the arm that will under the patient after
pull through) while you are turning completing the turn.
toward.
3. A second flat sheet is placed on the Both sheets will pull through after
bed and tucked under the patient and turning the patient.
the covered arm. The patient is rolled
as far as possible to the side of the
bed to allow placement of the second
sheet as far under the patient as
possible. This sheet will pull through
as the patient is turned.
4. Under direction of the person at the The first flat sheet is pulled through Offloading of bony prominences can
head of the bed, with a count of three, and away from the ventilator, be accomplished by placing pillows
the patient is carefully turned back pulling the arm with it. This under the back and buttocks.
over by pulling the first sheet from sheet can be recycled and the
the side of the bed back toward the second flat sheet is pulled
middle of the bed. The wrapped arm through away from the ventilator.
is gently pulled from under the Placing the new sheet (second
patient using the original sheet while sheet) under the patient allows
pulling the second sheet under the you to be ready to prone at any
patient. The original flat sheet is time. It also allows the patient to
discarded. (Level E*) lay on a clean, absorbent surface.
5. The patient is now supine. Pull and Every attempt is made to prevent Position the head to prevent pressure
center the patient. Straighten and pressure areas around lines, areas. Elevate the head of the bed,
reconnect lines and tubes. tubes, and boney prominences. 30–45 degrees to prevent a
ventilator-associated event, if not
contraindicated. Place legs on
pillows to free float the heels and
reduce edema. Place arms on
pillows to reduce edema and
prevent pressure. Place head on a
pillow, if not contraindicated.
Provide range of motion.
The patient should be repositioned
every 2 hours unless
contraindicated.
Procedure for Automated Pronation Therapy (Using the RotoProne Therapy System;
see Fig. 19-3)
1. HH
2. PE
3. After removing all pieces from The patient needs to be placed on the
the RotoProne Therapy System, RotoProne surface to use this
move the patient from the device for proning.
intensive care unit bed to the
RotoProne Therapy System.
4. Position the patient in the center To appropriately place packs on the Ears should be visible through the ear
of the surface with head patient for the prone procedure, he holes on the headpiece.
positioned in the attached head or she must be centered on the
support. surface with his or her head in the
head support.
5. Position all tubes and invasive
lines:
A. Lines inserted in the upper All intravenous tubing and invasive
torso are aligned with either lines are adjusted to prevent
shoulder and positioned at kinking, disconnection, or contact
the head of the bed in the with the body during the turning
tube-management system.8,9 procedure and while the patient
(Level C*) remains in the prone position.8,9
B. Chest tubes and lines or tubes The addition of extension tubing to
placed in the lower torso are lines that are too short to be placed
aligned with either leg and at the head of the bed or the end of
extend through the center hole the bed may be necessary.
at the foot of the surface.
C. If the patient has an open Open abdominal wounds are not a
abdomen, it should be contraindication for use of the
supported with some type prone position. A cover with a
of supportive dressing. synthetic material and a support
(Level E*) such as an abdominal binder or
vacuum dressing may be used
effectively to secure the abdomen.25
6. Follow manufacturer’s For safe operation of the product,
recommendations for securing manufacturer’s recommendations
patient on therapy surface. should be followed.
(Level M*)
A. Place leg piece and side packs Ensure the patient is snugly secured
on surface. Tighten side packs within side packs. If the side packs
by using the crank at the are not secured tightly before the
midpoint of the bed. The turn, the patient may have shear or
packs should fit snugly friction injuries develop during the
against the patient’s sides. turning process. This can also cause
the bed to alarm.
B. Place abdominal support mesh Provides abdominal support when
over the patient’s abdomen. patient is in the prone position.
C. Position additional pads on All packs need to be positioned to
patient for support if needed. prevent undue pressure on the
Place chest pad on chest so patient’s surfaces and to avoid
the top is level with the malposition of joints (avoid
patient’s shoulders. hyperextension of knees and hips in
prone position).
*Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results

see Fig. 19-3)—Continued
D. Tighten the headpiece snugly The patient’s head needs to be
around the patient’s head. secured during the turning
procedure to prevent patient injury
and tube dislodgement.
E. Position all packs snugly over This action prevents direct pressure
the patient (lower leg below over bony prominences and
knees, upper leg above knees, provides sufficient distance between
pelvic pack over iliac crest, the chest and pelvis to allow the
and chest pack over chest/ abdomen to be free of restriction,
shoulder area) and buckle. and prevents bowing of the back.
The chest pack may need to be
tightened over the patient last
because constriction of the chest
may restrict the patient’s ventilatory
effort and increase peak airway
pressures.
F. Place the face pack on the Face pads should be resting on the
patient’s face and attach to the face; do not tighten because this
head piece by inserting black will create undue pressure.
locking straps on both sides.
Ensure the top pad is above
the eyebrows and the side
pieces frame the mouth.
7. On the screen at the foot of the These maneuvers are performed to
bed, set therapy on RotoProne prevent disconnection of the
Therapy System to prone toward ventilator tubing or kinking of the
the direction of the ventilator. ETT during the turning
procedure.31,36,37,40
PE .
9. HH
Turning Prone With the RotoProne Therapy System
All steps listed below are performed Use the touch screen buttons on
on the touch screen at the foot of screen at the foot of the surface,
the surface. following manufacturer’s
instructions for turning the patient
to the prone position.
1. “Check tubing,” “Check airway,” These safety checks are important to
“Check head support” (push each prevent complications during the
button on the screen after turning procedure.
checking).
2. Push the “Rotate” button. Must start rotation before turning
prone.
3. Push the “Prone” button. This will begin instructions for
automated prone positioning of the
patient.
4. Push the “Rotate and lower” Surface must be in flat and low
button. Press and hold button position before prone position can
until screen changes. be achieved
5. “Check tubing,” “Check airway,” These safety checks are important to
“Check head support,” “Check prevent complications during the
abdominal support,” “Check arm turning procedure.
slings” (push each button on the
screen after checking).
6. Reconfirm the face pack and push Final safety check to assure the face Important note: The face pack is
the button on the touch screen. pack is secure before positioning the only piece without a safety
prone to prevent any patient injury. sensor.
7. Press “Prone.” Press and hold the This begins the automated prone Release the button if need arises to
button during the entire turning positioning process. stop the turning procedure because
procedure. (This step can also be of kinking or pulling on tubes.
accomplished with pushing the It may be helpful to have an
“Prone/supine” button on the additional person present during the
hand control.) (Level M*) actual turning procedure to monitor
invasive lines and ventilator tubing
to ensure all lines are positioned
correctly. In the absence of an
additional person, use of the
handset at the head of the bed is
recommended for turning the
patient so all invasive lines and
tubes are visible during turning.
8. After the patient is in the prone It is important to perform safety
position, the screen shows checks after the patient is in prone
additional buttons to “Check position to assure patient safety.
tubing,” “Check airway,” “Check
head support” (push each button
after checking).
9. Press “Rotate.” Patient should rotate 62 degrees to Degree of rotation and pause times on
each side while in the prone each side can be adjusted based on
position as tolerated. individual patient response to
therapy.
10. Push the “Surface position” This button allows changes in surface
button on screen. height and position.
11. Place the patient in the reverse The reverse Trendelenburg position is
Trendelenburg position by recommended to keep the head of
pressing the button on screen the bed up to decrease edema and
(push and hold until 11–12 prevent complications associated
degrees). (Level M*) with feeding or potential aspiration.
12. Open back hatches in the prone All hatches can be opened to allow
position. for full chest expansion. The foot
hatch should be opened and
propped open to prevent undue
pressure on the heels.

13. Leave patient in the prone Recommended time to remain in the The healthcare team may decide to
position for 3 hours 15 minutes prone position is 3 hours 15 vary the recommended schedule
with 62-degree rotation to each minutes, alternating with 45 based on individual patient-care
side. (Level C*) minutes supine to achieve a total of needs. Adjustment of time intervals
19.5 hours prone time in a 24-hour and rotation times based on the
period.32 After prone time is patient’s response to therapy may
completed, position the patient be necessary. Changes to degree of
supine for 45 minutes as tolerated. rotation or pause times can be made
The positioning schedule is based by pushing the “therapy settings”
on whether the patient is able to button. If the need arises to quickly
sustain improvements in Pao2 made return the patient to the supine
while in the prone or supine position, “CPR buttons” are located
position. on the touch screen and below the
screen at the foot of the bed.
15. HH
Turning Supine With the RotoProne Therapy System
1. HH
2. PE
3. Close any open hatches. All hatches must be closed before Make sure all hatches are closed
moving to the supine position to before returning the patient to the
prevent patient injury. The system supine position.
will not operate until the hatches
are closed.
4. Push the “Supine” button. Prepares the system to begin the
supine function of the surface.
5. Push the “Rotate and lower” Surface must be in the flat and low
button and hold until screen position before the turning
changes. procedure can be achieved
6. “Check tubing,” “Check airway,” It is important to perform safety
“Check head support” (push each checks to assure patient safety
button after checking).
7. Press “Supine” and hold the This begins the automated turning Release the button if need arises to
button during the entire turning process to return the patient to the stop the turning procedure because
procedure. (This step can also be supine position. of kinking or pulling on tubes.
accomplished by pushing the It may be helpful to have an
“Prone/supine” button on the additional person present during the
hand control.) (Level M*) actual turning procedure to monitor
invasive lines and ventilator tubing
to ensure all lines are positioned
correctly. In the absence of an
additional person, use of the
handset at the head of the bed is
recommended for turning the
patient so all invasive lines and
tubes are visible during turning.
8. Insert the locking pin after the Inserting the locking pin will secure
patient assumes the supine the system in one position and the
position. bed will not alarm when packs are
removed from patient.
Procedure for Automated Pronation Therapy (Using the RotoProne Therapy System; see
Fig. 19-3)—Continued
9. Open packs over the patient as Allows for easy access to all areas on
needed for patient care. patient, prevents pressure, and
allows for any skin care measures
to be provided.
10. Carefully remove the face pack. Face pack should be removed in the Care must be taken to prevent
supine position to prevent undue dislodging of any tubes positioned
pressure on the face; this also within or on the face pack.
allows for eye care, oral care, and
skin care to be provided as needed.
11. Rotate the patient supine as Placement of the bottom foot pack While the patient is supine, complete
tolerated up to 45 minutes or an and either the chest or the pelvic all assessments and procedures
hour. To rotate patient supine, the pack is necessary for supine scheduled. After completion, the
bottom pack closest to the foot of rotation. Rotation helps provide patient may be rotated in supine
the bed, and either the chest or continued mobilization for position. Placement of the bottom
the pelvic pack must be secured oxygenation and reduction of foot pack and either the chest or the
over the patient. pressure areas pelvic pack is necessary for supine
rotation. With automated prone
positioning, if the patient is unable
to maintain the improvement in gas
exchange seen with the prone
position when returned to a supine
position, the patient can be returned
to the prone position. If the patient
tolerates the supine position, the
patient should optimally remain in
the supine/lateral position for only
45 minutes to 1 hour before being
repositioned prone.
12. Place in reverse Trendelenburg The reverse Trendelenburg position is For increased facial edema, ice packs
position to get the head of the recommended to keep the head of can also be used. These can be
bed elevated to maximum 11–12 the bed up to decrease edema and placed over the eyes or lips while
degrees by pushing the “Surface prevent complications associated in the supine position as needed.
position” button then “Reverse with feeding or potential aspiration.
Trendelenburg.” (Level M*)
PE .
14. HH
Procedure for Manual Pronation Therapy With the Vollman Prone Positioner (VPP)
(the device is no longer manufactured; see Fig. 19-4)
1. HH
2. PE
3. Bring the VPP to the bedside. Readies the device for application With use of the frame, ensure it has
been cleaned with an appropriate
hospital-approved disinfectant.
4. Ensure that emergency equipment In the event of an emergency
is available. (i.e., accidental extubation or
hemodynamic instability),
availability of equipment allows
for rapid patient stabilization.

(the device is no longer manufactured; see Fig. 19-4)—Continued
5. Place a lift sheet under the patient A lift sheet allows for the use of A lift sheet is unnecessary if the
to assist with turning. correct body alignment during patient is on a low air-loss surface
the turning procedure.31,37 and a support frame is used.
6. One staff member is positioned on Three staff members are needed The individual at the head of the bed
either side of the bed, with another for the turn: two perform the is responsible for monitoring the
staff member positioned at the actual lifting and turning, and ETT, ventilator tubing, and
head of the bed.36,37,40 (Level C*) the third is positioned at the monitoring/intravenous lines
head of the bed.36,37,40 located by the patient’s head.
For increased airway security, the
individual at the head of the bed
should hold the ETT during the
turn.31,37
7. Correctly position all tubes and All intravenous tubing and If the patient is in skeletal traction,
invasive lines. invasive lines are adjusted to one individual needs to apply
prevent kinking, disconnection, traction to the leg while the lines
or contact with the body during and weights are removed for the
the turning procedure and while turn. If a skeletal pin comes into
the patient remains in the prone contact with the bed, a pillow
position. needs to be placed in the correct
position to alleviate pressure points.
A. Lines inserted in the upper Disconnecting lines before the
torso are aligned with either turn may help to prevent
shoulder, and the excess tubing dislodgment but places the
is placed at the head of the bed. patient at an increased risk for
The only exception to this rule infection.
is for chest tubes or other
large-bore tubes (e.g., tubes
used for extracorporeal
membrane oxygenation).
B. Chest tubes and lines or tubes Consider addition of an extension
placed in the lower torso are tube to lines that are too short to
aligned with either leg and be placed at the head of the bed
extend off the end of the bed. or the end of the bed.
C. If the patient has an open Open abdomens are not a
abdomen, cover with a contraindication for use of the
synthetic material or vacuum prone position. A cover with a
dressing before positioning and synthetic material and a support
identify a positioning strategy such as an abdominal binder
that allows the abdomen to be may be used effectively to
free of restriction. secure the abdomen.25
8. If on a low air-loss surface, Maximally inflating the air surface
maximally inflate. firms up the mattress, making
the turn easier to perform.
9. Always turn the patient in the Helps to maximize the length of
direction of the mechanical the tubing and prevents pulling,
ventilator. which may dislodge the position
of the ETT.
A. Turn the patient’s head so that Helps to maximize the length of
it faces away from the the tubing and prevents pulling
ventilator. Without which may dislodge the position
disconnecting the ventilator of the ETT.
tubing from the ETT, place the
portion of the tubing that
extends out from the ETT on
the side of the patient’s face
that is turned away from the
ventilator.
B. Loop the remaining ventilator Helps to maximize the length of
tubing above the patient’s the tubing and prevents pulling,
head.36,37,40 (Level C*) which may dislodge the position
of the ETT.
10. The straps that secure the Prepares the patient for placement
positioner to the body are placed of the VPP to minimize the
under the patient’s head, chest amount of time during which
(axillary area), and pelvic region at the device is on top of the
this time. patient.
Placing the Vollman Prone Positioner
1. Attach the frame to the patient The chest piece is the only
while the patient is in the supine nonmovable part and serves as
position. Lay the frame gently on the marker piece for proper
top of the patient. Align the chest placement and alignment of the
piece to rest between the clavicle device.36,40
and sixth rib.36,37,40 (Level C)
2. Adjust the pelvic piece to rest This placement prevents direct
one-half inch above the iliac pressure over bony prominences
crest.36,37,40 (Level C) and provides sufficient distance
between the chest and pelvis to
allow the abdomen to be free of
restriction and prevents bowing
of the back.36,40
3. Adjust the forehead and chin Allows for correct support without If the patient has limited neck range
pieces to provide full facial support interfering with the clinician’s of motion or a short neck, the
in a face-down or a side-lying ability to access the ETT. face-down position is optimal.
position without interfering with Because readjusting the head to
the ETT. relieve pressure points is difficult,
moving both headpieces up to the
top of the frame is recommended.
Only the head cushion supports the
forehead, and the chin is suspended
to reduce the risk of skin
breakdown from pressure.

4. Fasten the positioner to the patient If the device is not secured tightly When the device is secured correctly,
with the soft adjustable straps. before the turn, the patient may it appears uncomfortable and
As the straps are tightened, the have shear or friction injuries possibly painful. As a result, the
cushions compress. When fastened, develop on the chest and pelvic practitioner has a tendency not to
lift the positioner to assess whether area during the turning process. fasten the device as tightly as is
a secure fit has been obtained. needed to prevent injury.
Readjust as necessary. (Level M*) When secured correctly, the device
creates a feeling of pressure and a
sense of security for the patient
during the turning process.
Turning Prone With the Half-Step Technique
1. With a draw sheet, move the Provides sufficient room to rotate
patient to the edge of the bed the body safely 180 degrees
farthest away from the ventilator in within the confines of a narrow
preparation for the prone turn. The critical care bed.36,37,40
individual closest to the patient
maintains body contact with the
bed at all times, serving as a side
rail to ensure a safe environment.
(Level C*)
2. Turning with the VPP:
A. Tuck the straps on the bar Helps with forward motion when
located between the chest and the turning process begins.36,37,40
pelvic piece underneath the
patient. (Level C)
B. Tuck the patient’s arm and Helps with forward motion when
hand that now rest in the center the turning process begins.36,37,40
of the bed under the buttocks,
after position alignment with
the edge of the mattress is
achieved. (Level C)
C. Cross the leg closest to the Helps with forward motion when
edge of the bed over the the turning process begins.36,37,40
36,37,40
opposite leg at the ankle.
(Level C)
3. Turn the patient to a 45-degree Use of a wide base of support is
angle toward the ventilator. extremely important to improve
balance and prevent self-injury
during the turning procedure.36,40
A. The staff member on the Positions staff to be ready for the
ventilator side of the bed grips turn.
the upper steel bar.
B. The staff member on the Positions staff to be ready for the
opposite side of the bed grasps turn.
the straps attached to the lower
steel bar.
C. With a three count, lift the Count of three provides
patient by the frame into a coordination of effort among the
prone position. team members.
D. During the turning procedure, Provides an extra measure of
the staff member at the head of safety for the ETTs and invasive
the bed ensures that all tubes lines.
and lines are secure and
patent.36,37 (Level C*)
4. Loosen the straps at this time. If The procedure for returning to the
the patient is unstable, keeping supine position takes less than 1
the straps fastened securely is minute if the straps are fastened
recommended to facilitate a safe and a support frame is used.
quick return to the supine position
in the event of an emergency.
5. Gently rotate the arms parallel to To prevent damage to the brachial Many patients have range-of-motion
the body, then flex them into a plexus. limitations to the shoulder area that
position of comfort so that they are may make keeping the arms in a
lying adjacent to the head. Minor flexed position difficult. Many
adjustments of the patient’s body ways can be used to position the
may be necessary to obtain correct arms for comfort. The arms can be
alignment when in the prone left in a side-lying position, aligned
position. with the body, or positioned one
up and one down, similar to a
swimmer position.31
6. If on a low air-loss surface, release A return to normal pressures on If on a standard hospital mattress,
the maximal inflation. the surface helps to alleviate the thigh-knee-calf area must be
pressure at various bony supported to minimize the risk of
prominences in the prone pressure injury and prevent
position. discomfort.31,36,37,40
7. Place a support or other pillow A support in this area allows for If the patient is tall enough, dangling
under the ankle area. correct body alignment and the feet over the edge of the
prevents tension on the tendons mattress may be a sufficient
in the foot and ankle region. alternative to support the ankles
and feet in correct alignment.
PE .
9. HH
Returning to the Supine Position
1. HH
2. PE
3. Align the patient with the edge of Provides sufficient room to rotate The patient turns toward the center of
the mattress closest to the the body safely 180 degrees the mattress, away from the
ventilator. within the confines of a narrow ventilator.
critical care bed.36,40
4. Arrange the ventilator tubing to The staff member at the head of
provide sufficient mobility and the bed is responsible for
length to prevent pulling during the monitoring placement of the
turning procedure. ventilator tubing, monitoring
wires, and invasive lines.
5. Straighten the patient’s arms from To prevent damage to the brachial
a flexed position and bring them to plexus area and ready the
rest on either side of the head. patient for return to the supine
Remove leg and ankle pillow position.
supports. If on a low air-loss
surface, maximally inflate.

6. Cross the leg closest to the edge of Prepares the patient for turning.
the bed over the opposite leg at the
ankle.
7. Stretch the arms parallel to the The process is used to prevent any
body and bring them into a brachial plexus injury.
downward position.
8. With the VPP: fasten the straps If the device is not secured tightly
tightly before repositioning. before the turn, the patient may
have shear or friction injuries
develop on the chest and pelvic
area during the turning process.
9. Turn the patient to a 45-degree The steel bars on the positioning
angle with the steel bars, then roll frame allow lifting as the patient
the patient onto his or her back. is realigned into the center of
the bed.
10. Unfasten the positioner and remove The device comes with two sets of
from the patient. The straps may straps. The straps were designed
be left under the patient in to be left underneath the patient
preparation for the next turn. to allow for ease of the next
prone positioning cycle.
PE .
12. HH

• Increased oxygenation • Agitation
• Improved secretion clearance • Disconnection or dislodgment of tubes and lines
• Improved compliance of the lungs and alveolar • Peripheral arm nerve injury
recruitment • Periorbital and conjunctival edema
• Improved mortality • Skin injuries or pressure ulcers
• Eye pressure or injury

interventions.
1. Assess the patient’s tolerance to Oxygen saturation is not used as a • Failure of the respiratory rate,
the turning procedure: measure of intolerance to the turning respiratory effort, heart rate,
• Respiratory rate and effort procedure because patients often have and blood pressure to return to
• Heart rate and blood pressure desaturation with a deep lateral turn; normal 5–10 minutes after the
however, if the patient responds to the turn39
prone position, the condition stabilizes
quickly when settled into the prone
position. The lateral-turn decrease in
oxygen saturation may deter the
healthcare team from trying the prone
position.
If respiratory rate and effort, heart rate,
and blood pressure do not return to
normal within 10 minutes of the turn,
the patient may be displaying initial
signs of intolerance.37,39,43

2. Assess the patient’s response to Of all patients with acute lung injury • Decrease from baseline in the
the prone position: turned prone, more than 70% had Spo2 or failure of the Svo2 or
• Pulse oximetry (Spo2) improvement in oxygenat Scvo2 to return to baseline after
• Mixed venous oxygenation ion.4,5,10,13,17,23–25,27,28,35,40 A response is 5–10 minutes
saturation (Svo2) or central defined by a Pao2/Fio2 ratio greater
mixed venous oxygen than 20% or a Pao2 greater than
saturation (Scvo2) and 10 mm Hg.29 The time response varies
hemodynamics among patients. Some patients
• Arterial blood gases 30 immediately respond, whereas others
minutes after position change may take a longer time to show
• Pao2/Fio2 ratio maximal response to the position
change.
Hemodynamic measurements are
accurate in the prone position
compared with supine as long as the
zero reference point is calibrated at the
phlebostatic axis.38
3. With manual proning, reposition The face and ears have minimal • Skin breakdown
the patient’s head on an hourly structural padding to reduce the risk of
basis in the prone position to skin breakdown. Patients with short
prevent facial breakdown. While necks or limited neck range of motion
one staff member lifts the have difficulty assuming a head
patient’s head, a second staff side-lying position. These patients are
member moves the headpieces to more likely to have facial breakdown
provide support for the head in a develop, making turning the patient
different position. (Level D*) more frequently or use of the previous
Not necessary with automated technique necessary to prevent
proning. Arms should be breakdown.18,31,37
positioned for comfort by either
placing them aligned with the
body or in a swimmer’s position,
one up and one down.
4. Assess skin frequently for areas Greater than 2 hours on a standard • Nonblanchable redness
of nonblanchable redness or surface without changing position • Shearing and friction injuries
breakdown. Place a hydrocolloid increases a patient’s risk for
dressing or 5-layer silicone breakdown. If the patient is on a
dressing over areas where pressure-reduction surface, the time
shearing and friction injuries are remaining in a stationary position can
likely to occur (i.e., chest, pelvis, be lengthened.18
elbows, and knees). (Level M*) The use of a hydrocolloid or a 5-layer
silicone dressing may serve as a
protective barrier, reducing the risk of
pressure, shearing, and friction
injuries.18,31,37 If VPP is used and a
skin injury occurs on the chest or
pelvis, reassess tightness of the device
before the prone position turn. The
injury is most often related to a
loose-fitting apparatus and is likely a
shear injury versus pressure.


5. Provide frequent oral care and The prone position promotes postural • Drainage from the nares
suctioning of the airway as drainage through the natural use of • Change in amount or character
needed. gravity. Drainage from the nares may of secretions
be a clinical sign of an undetected
sinus infection.
6. Maintain eye care to prevent It is important to maintain lubrication via • Changes in the conditions of the
corneal abrasions. institutional standard protocol to prevent eyes
dryness leading to cornel abrasions.
7. Maintain tube feeding as The risk for aspiration is minimal in the • Evidence of tube feeding
tolerated. (Level D*)33 prone position because the patient is material when suctioning
(Level C*)25 already in a head-down, side-lying
position that maximizes the use of
gravity to move vomited matter safely.
A reverse Trendelenburg position
changes that relationship. It may
reduce the risk of microaspiration
and may increase the risk of a large
emesis occurring.38 Use of prokinetic
agents or transpyloric feedings is
recommended to prevent complications
associated with vomiting.
Studies have shown increased risk of
complications in the prone position in
patients receiving gastric feedings.
These studies recommend use of
promotility agents or postpyloric
feedings to reduce the risk of
complications such as vomiting and
enhance gastric emptying.30
8. Scheduling frequency: the Although the literature demonstrates that • Clinically significant decreases
positioning schedule is based on longer times in the prone position in oxygenation (>10 mm Hg) or
the most recent RCT, which within a 24-hour period is better, it oxygen saturation (<88%)
suggests at least 16 hours of remains important that the healthcare
prone positioning a day.17 team weigh other physiological factors
A. Time spent in the supine when a patient remains in any
position is based on the length stationary position for an extended
of time the patient is able to period. Following the principles of
sustain or maintain the pressure relief used when positioning
improvement in gas exchange patients laterally or supine can
that occurred while prone. minimize the potential for skin injury
This time may be consecutive and edema formation. Longer time
or sequential depending on spent in a single position necessitates
the type of apparatus used and that the support surface provides
the risk of skin injury and greater pressure reduction or relief
hemodynamic instability than a standard hospital mattress.31,37
experienced.4,5,13,17,23,27,35,37 (Level C)
(Level C)
B. For automated proning with
the RotoProne Therapy
System, the suggested time in
the prone position is 3 hours
15 minutes prone alternating
with 45 minutes as tolerated
in the supine position.

9. Manual prone positioning should Use of lateral rotation therapy in • Complications occurring during
be discontinued if the following conjunction with prone positioning is a prone session leading to its
criteria have been met: suggested so that when the patient is immediate interruption,
• Improvement in oxygenation returned to a supine position, he or including nonscheduled
defined as Pao2/Fio2 ratio she is laterally rotated. The use of extubation, main-stem bronchus
<150 mm Hg, with an Fio2 continuous lateral rotation therapy has intubation, ETT obstruction,
<60% with ≤10 cm of PEEP been associated with a reduction in hemoptysis, oxygen saturation of
(these criteria had to be met pulmonary complications.15,24,31,37 <85% for >10 minutes or a Pao2
in the supine position at least of <55 mm Hg for more than 5
4 hours after the end of the minutes. When the Fio2 was at
last prone session). 100%, cardiac arrest, a heart rate
• Pao2/Fio2 ratio of more than of <30 bpm for more than 1
20% relative to the ratio in minute, systolic blood pressure
the supine position before of less than 60 for more than 5
two consecutive prone minutes, and any other life-
sessions. threatening reason.17 (Level B*)
10. With automated prone
positioning, if the patient is
unable to maintain the
improvement in gas exchange
seen with the prone position
when returned to a supine
position, the patient can be
returned to the prone position.
If the patient tolerates supine
position, the patient should
optimally remain in the supine/
lateral position for only 45
minutes to 1 hour before being
repositioned prone.
Documentation
• Patient and family education • Complications noted during or after the procedure
• Ability to tolerate the turning procedure • Use of continuous lateral rotation therapy or other
• Length of time in the prone position devices
• Maximal oxygenation response in the prone position • Amount and type of secretions
• Oxygenation response when returned to the supine • Unexpected outcomes
position • Nursing interventions
• Positioning schedule used

19 Pronation Therapy 163.e1
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the recommendations related to hemodynamic monitoring 41. West JB: Respiratory physiology: the essentials, ed 3,
and tube feeding? Crit Care Nurse 21:84–86, 2001. Baltimore, 1985, Williams & Wilkins.
39. Vollman KM: Understanding critically ill patients’ 42. West JB, Dollery CT, Naimark A: Distribution of blood
hemodynamic response to mobilization using the evidence flow in isolated lung: relation to vascular and alveolar
to make it safe and feasible. Crit Care Nurs Q 36(1): pressures. J Appl Physiol 19:713–724, 1964.
17–27, 2013. 43. Winslow EH, et al: Effects of a lateral turn on mixed
40. Vollman KM, Bander JJ: Improved oxygenation utilizing venous oxygen saturation and heart rate in critically ill
a prone positioner in patients with acute respiratory adults. Heart Lung 19:555–561, 1990.
Section Three Thoracic Cavity Management
PROCEDURE
20
Autotransfusion
Kelly McGinty
PURPOSE: Autotransfusion is the collection of the patient’s own blood from an
active bleeding source within the thoracic cavity, due to trauma or surgery, which is
then reinfused to maintain the patient’s blood volume.
PREREQUISITE NURSING • Patient (or surrogate) consent should always be obtained

KNOWLEDGE before any blood infusion in a nonemergent setting.
Patients have the right to know risks and benefits of
• Understanding of infusion therapy and fluid balance is receiving transfusions of any kind. Emergent transfusions
necessary.8 will usually include allogeneic blood transfusions and
• Autotransfusion is commonly used for trauma victims should be administered per institutional protocol.1,7
and for patients undergoing cardiothoracic procedures, • Patients (or their surrogate) may decline autotransfusions
reducing the need for bank blood transfusions and the due to religious beliefs. Jehovah’s Witnesses may be open
associated risks of transfusion reactions and disease to receiving salvaged blood as long as it is not processed
transmission.4,11 and remains attached to their person throughout the col-
• Indications for autotransfusion include patients that are lection process. However, consent for transfusion in this
losing more than 100 mL of blood an hour or collecting population should be strongly considered given their reli-
more than 300 mL in a collection system.5,6,11–14 gious views regarding transfusions.7
• A variety of autotransfusion devices are available.
Autotransfusion may be a component of a standard EQUIPMENT
water-seal or dry-chest-drainage system (see Fig. 25-1)
or a separate system and may be continuous or • Personal protection equipment (i.e., gloves, mask,
intermittent. eyeshield)
❖ Continuous systems have an intravenous line con- • Chest-drainage unit
nected directly to the patient from the chest-drainage • Autotransfusion collection system
collection unit, via an intravenous pump. • Blood administration set
❖ Intermittent systems have an autotransfusion bag that • 40-µm microemboli filter
collects the blood either in-line or directly from the • Normal saline
chest-drainage collection unit. The autotransfusion bag • Wall suction and regulator
is disconnected from the chest-drainage collection unit
connected to a saline primed blood administration infu- PATIENT AND FAMILY EDUCATION
sion set for delivery to the patient.
• Nurses should be familiar with their institution’s auto- • If time permits, assess the patient’s and family’s level
transfusion system, policies, and procedures. of understanding about the condition and rationale for
• Contraindications to autotransfusion include the the procedure. Rationale: This assessment identifies the
following:4,8,10 patient’s and family’s knowledge deficits concerning the
❖ Septicemia patient’s condition, the procedure, the expected benefits,
❖ Malignant cells in the blood shed and the potential risks. It also allows time for questions
❖ Renal or hepatic insufficiency to clarify information and voice concerns. Explanations
❖ Coagulopathies decrease patient anxiety and enhance cooperation.
❖ Blood that has been in the collection system for longer • Explain the procedure and the reason for the procedure, if
than institutional standards allow the clinical situation permits. If not, explain the procedure
❖ Any of these contraindications may be overruled if the and reason for the intubation after it is completed. Ratio-
patient is exsanguinating and there is not an adequate nale: This explanation enhances patient and family under-
supply of banked blood available.4 standing and decreases anxiety.
164
20 Autotransfusion 165
PATIENT ASSESSMENT AND Rationale: Significant blood loss, related systemic hypo-
PREPARATION perfusion, and the associated decrease in oxygen-carrying
capacity, with its effect on hypoxemia, often require the
Patient Assessment replacement of blood with whole blood or packed red
• Patient should be assessed for signs and symptoms of blood cells. In appropriate patient populations (trauma or
hypovolemia and shock, which include the following:4,5,11–14 cardiovascular), autotransfusion should be considered as
❖ Pale, cool, clammy skin the need to replace blood becomes apparent.4,5,11–14
❖ Dyspnea
❖ Tachycardia
Patient Preparation
❖ Hypotension • Ensure the patient (or his or her surrogate) understands
❖ Decreased cardiac output or index the procedural education. Answer questions as they arise,
❖ Oliguria and reinforce information as needed. Rationale: This
❖ Decreased hemoglobin and/or hematocrit communication evaluates and reinforces understanding of
❖ Decreased central venous pressure, pulmonary artery previously provided education.
pressure, or pulmonary wedge pressure.
Procedure for Autotransfusion

1. HH
2. PE
3. Assemble collection system. Prepares the equipment. Wall suction will be required to
facilitate drainage into chest-
drainage system.
4. Addition of anticoagulant into the There are various anticoagulants Follow institutional protocol.
autotransfusion bag before collecting that can be used during this
the blood may be considered, transfusion. Citrate phosphate
depending on the institution’s dextrose 2 (CPD2) is
protocol or manufactures’ commonly used (1 mL per
instructions. (Level E*) 7 mL blood).1,3,7,9
5. Connect the patient’s drainage Allows for collection of shed
system or chest tube to the blood.
collection bag directly or via a
water-seal system.
6. Before disconnecting the filled Prevents infection by keeping
collection bag for infusion, prepare transfusion system closed and
new collecting bag. sterile.
7. Close clamp or clamp tubes on the Prevents air from entering the
new collection bag. system.
8. Close the clamp on the chest- Stops drainage while changing If the collection bag is part of the
drainage system. tubing and adding new water-seal system, close the
collection bag, again clamps to the water-seal drainage
decreasing chance for infection unit. Prepares system for changing
and exposure to blood-borne of collection bags and prevents
pathogens. infection or air entering system.
9. Disconnect the filled bag from the Prepares the filled bag for
patient system, maintaining sterility administration of the shed
at all times. blood to the patient.
10. Take the previously prepared new Prepares the chest-drainage
collection bag; attach it to the system for the collection of
water-seal unit or to the patient’s further shed blood, if
chest tube or drainage tube. necessary.

Procedure for Autotransfusion—Continued

11. Confirm that all connections are Ensures integrity of the system.
secured; open clamps on the
autotransfusion bag and patient
drainage tubing.
12. Prime the blood-administration Prepares the blood-administration Do not apply pressure or use with
tubing with normal saline. set for shed blood infusion. pressure device during transfusion.
13. Add the microfilter to the blood side Prevents microembolization from A 40-mcg filter is always used when
of the tubing and connect filled the shed blood. transfusing salvaged blood to
collection bag.1,3,4,9,14 (Level E*) prevent microembolization.
14. Initiate infusion of the shed blood. Restores blood volume. Reinfuse blood within 6 hours of
(Level D*) collection and ensure it is
complete within 4 hours of
starting the infusion.1–3
15. Repeat this procedure as needed Restores blood volume.
based on reassessment of patient
following initial transfusion.
16. Discard supplies and equipment and
remove PE .
17. HH

• Patient infused with own blood in a timely manner • Blood transfusion reaction
• Improved hemoglobin and hematocrit • Fluid overload
• Improved oxygenation • Infection; septicemia
• Hemodynamic stability

interventions.
1. Assess cardiopulmonary status Provides baseline and ongoing • Tachycardia
and vital signs every 15 minutes, assessment of the patient’s • Hypoxia or hypoxemia
until 1 hour after transfusion is condition. • Jugular vein distention
completed. • Hypotension
• Dysrhythmias
• Fever
2. Evaluate and maintain chest tube Obstruction of the drainage • Inability to establish patency
patency every 2 hours. interferes with drainage of
blood from the chest.
20 Autotransfusion 167

3. Monitor the amount of blood Volume loss can cause patients to • Blood accumulation of >200 mL/hr
accumulation in the chest- become hypovolemic. • New onset of clots
drainage unit and mark the • Sudden decrease or absence of
drainage on the outside of the drainage
unit in hourly or shift increments,
as necessary.
4. Monitor for blood-transfusion A patient receiving autotransfusion • Fever >101°F (38.5°C)
reaction. is unlikely to experience a • Chills
blood-transfusion reaction. • Tachycardia
• Abdominal or back pain
• Hypotension
• Hematuria
Documentation
• Patient and surrogate education • Patient response, including vital signs
• Amount of drainage • Nursing interventions
• Amount of transfusion volume • Unexpected outcomes
• Date and start time of collection and when it was
infused

20 Autotransfusion 167.e1
References 8. Konig G, Waters JH: Washing and filtering of cell-

1. American Association of Blood Banks: Guidelines for salvaged blood—Does it make autotransfusion safer?
blood recovery and reinfusion in surgery and trauma, Transfus Altern Transfus Med 12(3–4):78–87, 2012.
Bethesda, MD, 1997, American Association of Blood 9. Oeltjen AM, Santrach PJ: Autologous transfusion
Banks. techniques. J Intraven Nurs 20:305–310, 1997.
2. American Association of Blood Banks: Technical manual, 10. Perseghin P, et al: Effectiveness of leukocyte filters in
ed 16, Bethesda, MD, 2008, American Association of reducing tumor cell contamination after interoperative
Blood Banks. blood salvage in lung cancer patients. Vox Sang 72:221,
3. American Associated of Blood Banks: Guidance for 1997.
standards for perioperative autologous blood collection 11. Purcell TB: Autotransfusion. In Roberts JR, Hedges JR,
and administration, Bethesda, MD, 2002, American editors: Clinical procedures in emergency medicine, ed 4,
Association of Blood Banks. Philadelphia, 2004, Saunders, pp 410–426.
4. Brown CV, et al: Autologous blood transfusion during 12. Avidan M, Silvergleid AJ, Heath M: Surgical blood
emergency trauma operations. Arch Surg 146:690–694, conservation: intraoperative and postoperative blood
2010. salvage. <http://www.uptodate.com/contents/surgical
5. Carless PA, et al: Cell salvage for minimising -blood-conservation-intraoperative-and-postoperative
perioperative allogeneic blood transfusion. Cochrane -blood-salvage>. (Accessed 13.12.14.)
Database Syst Rev CD001888, 2010. 13. Warner C: The use of the orthopedic perioperative
6. Esper SA, Waters JH: Intra-operative cell salvage: a fresh autotransfusion system in total joint replacement surgery.
look at the indication and contraindications. Blood Tranfus Orthop Nurs 20:29, 2001.
9:139–147, 2011. 14. Weltert L, et al: Reduction of allogeneic red blood cell
7. Hughes DB, Ullery BW, Barie PS: The contemporary usage during cardiac surgery by an integrated intra- and
approach to the care of Jehovah’s witnesses. J Trauma postoperative blood salvage strategy: results of a
65:237–247, 2008. randomized comparison. Transfusion 53:790–797, 2013.
PROCEDURE
21
Chest Tube Placement (Perform)
Julie Waters
PURPOSE: Chest tubes are placed for the removal or drainage of air, blood, or
fluid from the intrapleural space. They also are used to introduce sclerosing agents
into the pleural space to prevent a reaccumulation of fluid.
PREREQUISITE NURSING • A pneumothorax may be classified as an open, closed, or

KNOWLEDGE tension pneumothorax.
❖ Open pneumothorax: The chest wall and the pleural
• The thoracic cavity is a closed airspace in normal condi- space are penetrated, which allows air to enter the
tions. Any disruption results in the loss of negative pres- pleural space, as in a penetrating injury or trauma; a
sure within the intrapleural space. Air or fluid that enters surgical incision in the thoracic cavity (i.e., thoracot-
the space competes with the lung, resulting in collapse of omy); or a complication of surgical treatment (e.g.,
the lung. Associated conditions are the result of disease, unintentional puncture during invasive procedures,
injury, surgery, or iatrogenic causes. such as thoracentesis or central venous catheter
• Chest tubes are sterile flexible polyvinyl chloride (PVC) insertion).
or silicone nonthrombogenic catheters approximately 20 ❖ Closed pneumothorax: The pleural space is penetrated,
inches (51 cm) long, varying in size from 8 to 40 Fr. The but the chest wall is intact, which allows air to enter
size of the tube placed is determined by the indication and the pleural space from within the lung, as in spontane-
viscosity of the drainage.6 The side of the chest tube ous pneumothorax. A closed pneumothorax occurs
usually has a radiopaque strip down the side to assist in without apparent injury and often is seen in individuals
visualization on chest radiographs. with chronic lung disorders (e.g., emphysema, cystic
• Indications for chest tube insertion include the fibrosis, tuberculosis, necrotizing pneumonia) and in
following: young, tall men who have a greater than normal height-
❖ Pneumothorax (collection of air in the pleural space) to-width chest ratio; after blunt traumatic injury; or
❖ Hemothorax (collection of blood) iatrogenically, occurring as a complication of medical
❖ Hemopneumothorax (accumulation of air and blood in treatment (e.g., intermittent positive-pressure breath-
the pleural space) ing, mechanical ventilation with positive end-expiratory
❖ Thoracotomy (e.g., open heart surgery, pressure).
pneumonectomy) ❖ Tension pneumothorax: Air leaks into the pleural space
❖ Pyothorax or empyema (collection of pus) through a tear in the lung and has no means to escape
❖ Chylothorax (collection of chyle from the thoracic from the pleural cavity, creating a one-way valve
duct) effect. With each breath the patient takes, air accumu-
❖ Cholothorax (collection of fluid containing bile) lates and pressure within the pleural space increases,
❖ Hydrothorax (collection of noninflammatory serous and the lung collapses. This condition causes the medi-
fluid) astinal structures (i.e., heart, great vessels, and trachea)
❖ Pleural effusion to be compressed and shift to the opposite or unaffected
❖ Pleurodesis (instillation of anesthetic solutions and side of the chest. Venous return and cardiac output are
sclerosing agents) impeded, and collapse of the unaffected lung is pos-
• Chest tubes inserted for traumatic hemopneumothorax or sible. This life-threatening emergency requires prompt
hemothorax (blood) should be large (36 to 40 Fr). Medium recognition and intervention.
tubes (24 to 36 Fr) should be used for fluid accumulation • Absolute Contraindications: A lung that is densely adher-
(pleural effusions). Tubes inserted for pneumothorax (air) ent to the chest wall throughout the hemithorax is an
should be small (≤24 Fr).2,6 absolute contraindication to chest tube therapy.5
• Relative Contraindications: Use of chest tubes in patients
with multiple adhesions, giant blebs, or coagulopathies
should be carefully considered; however, these relative
contraindications are superseded by the need to reexpand
practice nurses, and other healthcare professionals (including critical care the lung. When possible, any coagulopathy or platelet
nurses) with additional knowledge, skills, and demonstrated competence per defect should be corrected before chest tube insertion.
professional licensure or institutional standard. The differential diagnosis between a pneumothorax
168
21 Chest Tube Placement (Perform) 169
Figure 21-2 Occlusive chest tube dressing. (From Kersten

LD: Comprehensive respiratory nursing, Philadelphia, 1989,
Saunders.)
Figure 21-1 Standard sites for tube thoracostomy. A, The second

intercostal space, midclavicular line. B, The fourth or fifth intercos-
tal space, midaxillary line. Most clinicians prefer midaxillary line
placement for all chest tubes, regardless of pathology. Placement of
the tube too far posteriorly does not allow the patient to lie down
comfortably. (From Roberts JR, Hedges JR, editors: Clinicals in
emergency medicine, ed 4, Philadelphia, 2004, Saunders.) A
and bullous disease necessitates careful radiological

assessment.5
• Ultrasound guidance for chest tube placement is strongly
recommended because it can localize fluid accumulation
and decrease the risk of complications.3 B
• Chest tubes should be inserted into the “triangle of safety.” Parham-Martin band
This is an area bordered inferiorly by a horizontal line at Figure 21-3 The securing of connection points. A, Tape.
the level of the fifth intercostal space, anteriorly by the B, Parham-Martin bands. (From Kersten LD: Comprehensive respi-
ratory nursing, Philadelphia, 1989, Saunders.)
lateral border of the pectoralis major, and posteriorly by
the lateral border of the latissimus dorsi.3
• The tube size and insertion site selected for the chest tube
are determined by the indication.5,6 If draining air, the tube
is placed near the apex of the lung (second intercostal EQUIPMENT
space); if draining fluid, the tube is placed near the base
of the lung (fourth or fifth intercostal space; Fig. 21-1). • Caps, masks, sterile gloves, gowns, drapes
❖ Once the tube is in place, it should be sutured to the • Protective eyewear (goggles)
skin to prevent displacement, and an occlusive dressing • Antiseptic solution: 2% chlorhexidine or povidone-
applied (Fig. 21-2). The chest tube also is connected to iodine
a chest drainage system (see Procedure 25) to remove • Local anesthetic: 1% or 2% lidocaine solution (with or
air and fluid from the pleural space, which facilitates without epinephrine)
reexpansion of the collapsed lung. All connection • 10-mL syringe with 20-gauge 1 1 2 -inch needle
points are secured with tape or zip ties (Parham Martin • 5-mL syringe with 25-gauge 1-inch needle
bands) to ensure that the system remains airtight • Tube thoracostomy insertion tray
(Fig. 21-3). ❖ Sterile towels, 4 × 4 sterile gauze
❖ The water-seal chamber should bubble gently immedi- ❖ Scalpel with No. 10 or 11 blade
ately on insertion of the chest tube during expiration ❖ Two Kelly clamps
and with coughing. Continuous bubbling in this ❖ Needle holder
chamber indicates a leak within the patient or in the ❖ Monofilament or silk suture material (No. 0 or 1-0)
chest-drainage system. Fluctuations in the water level ❖ Sterile basin or medicine cup
in the water-seal chamber of 5 to 10 cm, rising during ❖ Suture scissors
inhalation and falling during expiration, should be ❖ Two hemostats
observed with spontaneous respirations. If the patient • Thoracostomy tubes (8 to 40 Fr, as appropriate)
is on mechanical ventilation, the pattern of fluctuation • Closed chest-drainage system
is just the opposite. Any suction applied must be dis- • Suction source
connected temporarily to assess correctly for fluctua- • Suction connector and connecting tubing (usually 6 feet
tions in the water-seal chamber. for each tube)
• 1-inch adhesive tape or zip ties (Parham-Martin bands) the chest. Rationale: This activity facilitates gravity
• Occlusive dressing materials: drainage and prevents backflow and potential infectious
❖ 4 × 4 gauze pads or slit drain sponges contamination into the pleural space.
❖ Petrolatum gauze • Instruct the patient about the availability of prescribed
❖ Tape or a commercial securing device analgesic medication and other pain-relief strategies.
• Additional equipment, to have available as needed, Rationale: Pain relief ensures comfort and facilitates
includes the following: coughing, deep breathing, positioning, range of motion,
❖ Ultrasound machine and ultrasound gel and recuperation.

• If time permits, assess the patient’s and family’s level PREPARATION
of understanding about the condition and rationale for
the procedure. Rationale: This assessment identifies the Patient Assessment
patient’s and family’s knowledge deficits concerning the • Assess for significant medical history or injury, including
patient’s condition, the procedure, the expected benefits, chronic lung disease, spontaneous pneumothorax, hemo-
and the potential risks. It also allows time for questions to thorax, pulmonary disease, therapeutic procedures, and
clarify information and voice concerns. Explanations mechanism of injury. Rationale: Medical history or
decrease patient anxiety and enhance cooperation. injury may provide the etiological basis for the occur-
• Explain the procedure and the reason for the procedure, if rence of pneumothorax, empyema, pleural effusion, or
the clinical situation permits. If not, explain the procedure chylothorax.
and reason for the intubation after it is completed. Ratio- • Evaluate diagnostic test results (if patient’s condition does
nale: This explanation enhances patient and family under- not necessitate immediate intervention), including chest
standing and decreases anxiety. radiograph and arterial blood gases. Rationale: Diagnos-
• Explain that the patient’s participation during the proce- tic testing confirms the presence of air or fluid in the
dure is to remain as immobile as possible and maintain pleural space, a collapsed lung, hypoxemia, and respira-
relaxed breathing. Rationale: This explanation facilitates tory compromise.
insertion of the chest tube and prevents complications • Assess baseline cardiopulmonary status for signs and
during insertion. symptoms that necessitate chest tube insertion.4 Ratio-
• After the procedure, instruct the patient to sit in a semi- nale: Accurate assessment of signs and symptoms allows
Fowler’s position (unless contraindicated). Rationale: for prompt recognition and treatment. Baseline assess-
This position facilitates drainage, if present, from the ment provides comparison data for evaluation of changes
pleural space by allowing air to rise and fluid to settle to and outcomes of treatment.
be removed via the chest tube. This position also makes ❖ Tachypnea
breathing easier. ❖ Decreased or absent breath sounds on affected side
• Instruct the patient to turn and change position every 2 ❖ Crackles adjacent to the affected area
hours. The patient may lie on the side with the chest tube ❖ Shortness of breath, dyspnea
but should keep the tubing free of kinks. Rationale: ❖ Asymmetrical chest excursion with respirations
Turning and changing position may prevent complications ❖ Cyanosis
related to immobility and retained pulmonary secretions. ❖ Decreased oxygen saturation
Keeping the tube free of kinks maintains patency of the ❖ Hyperresonance in the affected side (pneumothorax)
tube, facilitates drainage, and prevents the accumulation ❖ Subcutaneous emphysema (pneumothorax)
of pressure within the pleural space that interferes with ❖ Dullness or flatness in the affected side (hemothorax,
lung reexpansion. pleural effusion, empyema, chylothorax)
• Instruct the patient to cough and deep breathe, with splint- ❖ Sudden, sharp chest pain
ing of the affected side. Rationale: Coughing and deep ❖ Anxiety, restlessness, apprehension
breathing increase pressure within the pleural space, facil- ❖ Tachycardia
itating drainage, promoting lung reexpansion, and pre- ❖ Hypotension
venting respiratory complications associated with retained ❖ Dysrhythmias
secretions. The application of firm pressure over the chest ❖ Tracheal deviation to the unaffected side (tension
tube insertion site (i.e., splinting) may decrease pain and pneumothorax)
discomfort. ❖ Neck vein distention (tension pneumothorax)
• Encourage active or passive range-of-motion exercises of ❖ Muffled heart sounds (tension pneumothorax)
the arm on the affected side. Rationale: The patient may
limit movement of the arm on the affected side to decrease Patient Preparation
the discomfort at the insertion site, which may result in • Verify that the patient is the correct patient using two
joint discomfort and potential joint contractures. identifiers. Rationale: Before performing a procedure, the
• Instruct the patient and family about activity as prescribed nurse should ensure the correct identification of the patient
while maintaining the drainage system below the level of for the intended intervention.
• Ensure that the patient understands preprocedural teach- • Determine the size of chest tube needed. Rationale: Evac-
ings. Answer questions as they arise, and reinforce uation of air necessitates a smaller tube; evacuation of
information as needed. Rationale: This communication fluid necessitates a larger tube.
evaluates and reinforces understanding of previously • Assist the patient to a supine position with the ipsilateral
taught information. arm abducted and flex the elbow so that the patient’s hand
• Obtain informed consent if circumstances allow. Ratio- is comfortably positioned above his or her head.2,8 Ratio-
nale: Invasive procedures, unless performed with implied nale: This positioning enhances accessibility to the inser-
consent in a life-threatening situation, require written tion site for positioning of the chest tube.
consent of the patient or significant other. • Administer prescribed analgesics or sedatives as needed;
• Ensure patient has a patent intravenous access. Rationale: follow institutional policy for moderate or procedural
This access provides a route for analgesic, sedation, and sedation. Rationale: Analgesics and sedatives reduce the
emergency medications. discomfort and anxiety experienced and facilitate patient
• Determine the insertion site and mark the skin with an cooperation.
indelible marker. Rationale: The insertion site is deter- • Administer supplemental oxygen as needed. Monitor
mined by the indication for the chest tube and diagnostic pulse oximeter and/or end-tidal carbon dioxide level.
images. For a pneumothorax, the tube may be directed Rationale: Real-time assessment of patient’s respiratory
anterior and apical. For fluid drainage, it may be aimed status during the procedure is provided.
posterior and basilar.6
Procedure for Performing Pleural Chest Tube Placement

1. HH
2. PE
3. Don sterile gloves, sterile gown, mask, Chest tube insertion is a sterile
eye protection, and head covering. procedure and requires full
surgical attire, unless
performed in a life-
threatening situation.
4. Have an assistant open the outer Reduces transmission of
wrapper of the tube thoracotomy microorganisms.
insertion tray, remove the tray from
wrapper, and open it with sterile
technique.
5. Prepare equipment. Facilitates insertion of the tube.
A. Check that all equipment is present.
B. Have an assistant pour antiseptic
solution into the sterile cup or basin
with aseptic technique (or open the
swab packet and stand by).
C. Have an assistant open the chest
tube package and empty it onto the
open tray.
D. Grasp suture needle with needle
holder.
E. Remove the trocar from the chest
tube and grasp the proximal end of
the chest tube with a large Kelly
clamp (Fig. 21-4).
F. Prepare the syringe with lidocaine
solution.
Procedure for Performing Pleural Chest Tube Placement—Continued

Figure 21-4 The tube is grasped with the curved clamp, with the tube
tip protruding from the jaws. (From Roberts JR, Hedges JR, editors:
Clinicals in emergency medicine, ed 4, Philadelphia, 2004, Saunders.)
6. Identify the insertion site and have an Assists in preparation of area Insertion site for air removal is right
assistant position the patient. for insertion and proper or left second intercostal space.
(Level E*) placement of tube.8 Insertion site for fluid removal is
right or left fifth or sixth intercostal
space, midaxillary line. Incision
site is one rib below insertion site.
7. Perform a preprocedure verification Ensures patient safety.
and time out, if nonemergent.
8. Surgically prepare the skin with Inhibits growth of bacteria at Prepare the area from the clavicle to
antiseptic solution, and drape the insertion site; maintains the umbilicus, midchest to anterior
area surrounding the insertion site. sterility.2,8 axillary line.
(Level E)
9. Anesthetize the skin, subcutaneous Results in loss of sensation and When infiltrating with lidocaine,
tissue, muscle, and periosteum one decreased pain during aspirate repeatedly as the needle is
intercostal space below the intercostal insertion.2,8 inserted to identify the presence of
space that will be used to place the air or fluid; 30–40 mL of lidocaine
tube with lidocaine solution. may be needed for anesthesia.
A. With a 5-mL syringe (25-gauge
needle), inject a subcutaneous
wheal of lidocaine at the insertion
site.
B. With a 10-mL syringe (20-gauge,
1 1 2–inch needle), advance the
needle/syringe, aspirating as you
go, until air or pleural fluid is
confirmed.
C. Inject the lidocaine deeper, and
slowly withdraw the syringe,
generously anesthetizing rib
periosteum, subcutaneous tissue,
and pleura (Fig. 21-5). (Level E)

Figure 21-5 Insertion of a chest tube can be relatively painless with

proper infiltration of the skin and pleura with local anesthetic. The liberal
use of buffered 1% lidocaine without epinephrine (maximal lidocaine
dose, 5 mg/kg) is recommended. (From Roberts JR, editor: Roberts and
Hedges’ clinical procedures in emergency medicine, ed 6, Philadelphia,
2014, Saunders.)
10. An incision should be made, similar to Allows for the diameter of the When making the incision, incise
the diameter of the tube being inserted, chest tube.2,8 down through the subcutaneous
directly over the inferior aspect of the tissue; the space should be large
anesthetized rib below the insertion enough to admit a finger.
site (Fig. 21-6). (Level E*)
Figure 21-6 Transverse skin incision is made directly over the inferior
aspect of the anesthetized rib down to the subcutaneous tissue. (From
Dumire SM, Paris PM: Atlas of emergency procedures, Philadelphia,
1994, Saunders.)
11. Introduce the Kelly clamp through the Facilitates insertion of the tube. Additional lidocaine is infiltrated as
incision, with the tips down, creating a Blunt dissection minimizes needed. The direction of the tunnel
tunnel through the subcutaneous tissue trauma to the neurovascular created through the subcutaneous
and muscle; use an opening and bundle.2,8 tissue and muscle determines the
spreading maneuver; aim toward the direction the chest tube takes after
superior aspect of the rib until the insertion. Be sure the clamp stays
pleural space is reached (Fig. 21-7). close to the ribs to avoid injury to
(Level E) the neurovascular bundle.


5
5th ICS
6
6th ICS
Figure 21-7 Blunt dissection is accomplished with forcing a closed
clamp through the incision and using an opening-and-spreading maneuver
to create a tunnel to the pleura. ICS, intercostal space.
12. When the clamp is just over the Ensures opening is large enough This maneuver necessitates more
superior portion of the rib, close the for the chest tube. pressure than might be anticipated.
clamp and push it with steady pressure Steady, even, controlled A lunging motion or use of the
through the parietal pleura and into the pressure provides control of trocar, however, may cause a hole
pleural space, then widen the hole in the clamp once the pleura is in lung or injury to the liver or
the pleural space by spreading the perforated.2,8 spleen.
clamp (Fig. 21-8). (Level E*)
Figure 21-8 Just over the superior portion of the rib, close the clamp
and push with steady pressure into the pleura. (From Dumire SM, Paris
PM: Atlas of emergency procedures, Philadelphia, 1994, Saunders.)

13. Insert the index finger to dilate the Relieves air or fluid when Feel for lung tissue (lung should
tract and hole in the pleura. penetration of the space is expand and meet finger on
made and ensures entry into inspiration), diaphragm, or
the pleural space and not into adhesions. Manually break up any
a space inadvertently created clot, if found.
between the parietal pleura If significant adhesions are
and chest wall.8 unexpectedly encountered, abandon
that site and select another one.
14. Insert the chest tube into the chest The Kelly clamp provides To drain air, aim the tube posteriorly
cavity with a curved Kelly clamp, stiffness to the chest tube, and superiorly toward the apex of
holding the proximal end to guide the allowing for more control as the lung; to drain fluid, aim the
tip into the pleural space. Remove the it is inserted into the pleural tube inferiorly and posteriorly. Do
clamp and guide the tube, in a rotating space. not allow any side holes of the
motion, through the tract and into the tube to remain outside the thoracic
space. The tube is advanced until the cavity.
last hole is in the pleural space.
Condensation of air or fluid in the tube
should be noted.
15. Connect the chest tube to the closed Ensures the tube is properly
chest-drainage system (see Procedure positioned.
25) and check for rise and fall
(tidaling) of the H2O column. Assistant
applies ordered amount of suction.
16. Suture the tube to the chest wall. Wrap Secures the position of the Type of stitch used depends on the
the free ends of the suture around the tube.4 Sutures should be snug preference of the physician; the
tube (similar to lacing a shoe). Tie the to prevent free air from goal is to prevent displacement of
ends of the suture snugly around the passing into the subcutaneous the chest tube.
top of the tube (Fig. 21-9). tissue.
Securely tied
initial “stay” suture
Figure 21-9 A “stay” suture is placed first next to the tube to close the
Long ends skin incision. A, The knot is tied securely, and the ends, which subse-
wrapped around quently are wrapped around the chest tube, are left long. B, The ends of
Left long tube and
tightly tied
the suture are wound twice about the tube, tightly enough to indent the
tube slightly, and are tied securely. (From Roberts JR, editor: Roberts and
Hedges’ clinical procedures in emergency medicine, ed 6, Philadelphia,
Left long 2014, Saunders.)
A B
17. Apply occlusive dressing. Provides cover for the wound,

A. Slit drain sponges or 4 × 4 gauze secures the dressing to the
are applied under and over top of wound, and creates an airtight
the chest tube insertion site. dressing.
Petrolatum gauze is used around
the chest tube, or follow
institutional standards.7
B. Secure with a tape dressing.
18. Tape all connection points to the Creates an airtight system. Check that all tube drainage holes are
drainage system or secure with zip ties Airtight connections prevent air in the pleural space.
(Parham-Martin bands). (Level E*) leaks into the pleural space.1,4


19. Secure the tube below the dressing to Functions as a strain relief to
the patient’s skin with a commercial prevent tube and dressing
securing device or tape. dislodgment.
20. Obtain a chest radiograph. (Level E*) Chest radiograph confirms Ensure that the distal drainage hole is
placement of tube, expansion within the pleural space. Document
of lung, and removal of fluid.8 result of chest radiograph in the
patient’s record.
21. Dispose of equipment and remove PE .
22. HH

• Removal of air, fluid, or blood from the pleural space • Hemorrhage or shock
• Relief of respiratory distress • Increasing respiratory distress
• Reexpansion of the lung (validated with chest • Infection
radiograph) • Damage to intercostal nerve that results in
• Restoration of negative pressure within the pleural neuropathy or neuritis
space • Incorrect tube placement
• Chest tube kinking, clogging, or dislodgment from
chest wall
• Reexpansion pulmonary edema

interventions.
1. Assess cardiopulmonary and vital Provides baseline and ongoing • Tachypnea
signs every 1–4 hours and as assessment of patient’s condition. • Decreased or absent breath sounds
needed. Abnormalities can indicate • Hypoxemia
recurrence of the condition that • Tracheal deviation
necessitated chest tube insertion. • Subcutaneous emphysema
On the basis of the patient’s • Neck vein distention
clinical condition or physician • Muffled heart tones
orders, vital signs may need to be • Tachycardia
checked more frequently. • Hypotension
• Dysrhythmias
• Fever
2. Monitor chest tube output every Provides data for diagnosis. Higher • Bloody drainage greater than or
1–4 hours, and record amount and drainage amounts require more equal to 200 mL/hr
color. frequent assessment. On the basis • Sudden cessation of drainage
of the patient’s clinical condition or • Change in character of drainage
physician orders, output may need
to be checked more frequently.
3. Assess for pain at the insertion Pain interferes with adequate deep • Continued pain despite pain
site or for chest discomfort. breathing. Pain at insertion site, interventions
particularly with inspiration, may
indicate improper tube placement.

4. Evaluate the chest drainage Water level normally rises and falls • Absence of tidaling in water-seal
system for rise and fall (tidaling) with respiration until lung is chamber
in water-seal chamber. Check expanded. Bubbling immediately • Persistent bubbling
connections.4 (Level E*) after insertion signifies that air is
being removed from the pleural
space; bubbling with exhalation
and coughing is normal. Persistent
bubbling indicates an air leak
either in the patient’s lung or in the
chest drainage system.
5. Assess insertion site and Skin integrity is altered during • Fever
surrounding skin with daily insertion, which can lead to • Redness around insertion site
dressing change for presence of infection. • Purulent drainage
subcutaneous emphysema and • Subcutaneous emphysema
signs of infection or inflammation.
Documentation
• Patient and family education • Presence of fluctuation and bubbling
• Reason for chest tube insertion • Amount of suction
• Respiratory and vital sign assessment before and after • Patient’s tolerance to procedure
insertion • Postinsertion chest radiograph results
• Description of procedure, including tube size, date and • Unexpected outcomes
time of insertion, insertion site, and any complications • Nursing interventions
associated with procedure • Pain assessment, interventions, and effectiveness
• Type and amount of drainage

21 Chest Tube Placement (Perform) 177.e1

1. Buchman TG, et al: Thoracic trauma. In Tininalli JE, Argall J: Seldinger technique chest drains and complication
Kelen DG, Stapczynski JS, editors: Emergency medicine: rate. Emerg Med J 20:169–170, 2003.
a comprehensive guide, ed 6, New York, 2004, McGraw- Bauman M, Handley C: Chest-tube care: the more you know,
Hill, pp 1595–1612. the easier it gets, Am Nurs Today 6(9), 2011.
2. Dev SP, et al: Chest-tube insertion. N Engl J Med 357:e15, Briggs D: Nursing care and management of patients with
2007. intrapleural drains. Nurs Stand 24(21):47–55, 2010.
3. Havelock T, et al: Pleural procedures and thoracic Durai R, Hoque H, Davies TW: Managing a chest tube and
ultrasound: British Thoracic Society pleural disease drainage system. AORN J 91(2):275–280, 2010.
guideline 2010. Thorax 65(Suppl 2):ii61–ii76, 2010. Inaba K, et al: Does size matter? A prospective analysis of
4. Irwin RS, Rippe JM: Intensive care medicine, 28-32 versus 36-40 French chest tube size in trauma.
Philadelphia, 2008, Wolters Kluwer/Lippincott & Williams J Trauma Acute Care Surg 72(2):422–427, 2012.
& Wilkins. Jeffries M, et al: Chest tube dressings: Outcomes of taking
5. Laws D, Neville E, Duffy J: BTS guidelines for insertion petroleum-based dressings out of the equation on air leak
of a chest drain. Thorax 58(Suppl II):ii53–ii59, 2003. and infection rates. Poster presentation; National Teaching
6. Mahmood K, Wahidi MM: Straightening out chest tubes: Institute Boston, MA, 2013, American Association of
what size, what type, and when. Clin Chest Med 34: Critical-Care Nurses.
63–71, 2013. Agency for Healthcare Research and Quality: Problems and
7. Muffly TM, et al: Effect of petroleum gauze packing on prevention: chest tube insertion. <http://www.ahrq.gov/
the mechanical properties of suture materials. J Surg Educ research/findings/factsheets/errors-safety/chesttubes/index
69(1):37–40, 2012. .html>. Accessed 24.11.14.
8. Roberts J: Clinical procedures in emergency medicine, Woodrow P: Intrapleural chest drainage. Nurs Stand 27(40):
ed 6, Philadelphia, 2014, Saunders. 49–56, 2013.
PROCEDURE
22
Chest Tube Placement (Assist)
Julie Waters
PURPOSE: Chest tubes are placed for the removal or drainage of air, blood, or
fluid from the intrapleural space. They also are used to introduce sclerosing agents
into the pleural space to prevent a reaccumulation of fluid.
PREREQUISITE NURSING unintentional puncture during invasive procedures,

KNOWLEDGE such as thoracentesis or central venous catheter
insertion).
• The thoracic cavity is a closed airspace in normal condi- ❖ Closed pneumothorax: The pleural space is penetrated
tions. Any disruption results in the loss of negative pres- but the chest wall is intact, which allows air to enter
sure within the intrapleural space. Air or fluid that enters the pleural space from within the lung, as in spontane-
the space competes with the lung, resulting in collapse of ous pneumothorax. A closed pneumothorax occurs
the lung. Associated conditions are the result of disease, without apparent injury and often is seen in individuals
injury, surgery, or iatrogenic causes. with chronic lung disorders (e.g., emphysema, cystic
• Chest tubes are sterile flexible polyvinyl chloride (PVC) fibrosis, tuberculosis, necrotizing pneumonia) and in
or silicone nonthrombogenic catheters approximately young tall men who have a greater than normal height-
20 inches (51 cm) long, varying in size from 8F to 40F. to-width chest ratio; after blunt traumatic injury; or
The size of the tube placed is determined by the indication iatrogenically, occurring as a complication of medical
and viscosity of the drainage.6 The side of the chest tube treatment (e.g., intermittent positive-pressure breath-
usually has a radiopaque strip down the side to assist in ing, mechanical ventilation with positive end-expiratory
visualization on chest radiographs. pressure).
• Indications for chest tube insertion include the ❖ Tension pneumothorax: Air leaks into the pleural space
following: through a tear in the lung and has no means to escape
❖ Pneumothorax (collection of air in the pleural space) from the pleural cavity, creating a one-way valve
❖ Hemothorax (collection of blood) effect. With each breath the patient takes, air accumu-
❖ Hemopneumothorax (accumulation of air and blood in lates and pressure within the pleural space increases,
the pleural space) and the lung collapses. This condition causes the medi-
❖ Thoracotomy (e.g., open heart surgery, astinal structures (i.e., heart, great vessels, and trachea)
pneumonectomy) to be compressed and shift to the opposite or unaffected
❖ Pyothorax or empyema (collection of pus) side of the chest. Venous return and cardiac output are
❖ Chylothorax (collection of chyle from the thoracic impeded, and collapse of the unaffected lung is pos-
duct) sible. This life-threatening emergency requires prompt
❖ Cholothorax (collection of fluid containing bile) recognition and intervention.
❖ Hydrothorax (collection of noninflammatory serous • Absolute contraindications: Lung that is densely adherent
fluid) to the chest wall throughout the hemithorax is an absolute
❖ Pleural effusion contraindication to chest tube therapy.5
❖ Pleurodesis (instillation of anesthetic solutions and • Relative contraindications: Use of chest tubes in patients
sclerosing agents) with multiple adhesions, giant blebs, or coagulopathies
• Chest tubes inserted for traumatic hemopneumothorax or should be carefully considered; however, these relative
hemothorax (blood) should be large (36F to 40F). Medium contraindications are superseded by the need to reexpand
tubes (24F to 36F) should be used for fluid accumulation the lung. When possible, any coagulopathy or platelet
(pleural effusions). Tubes inserted for pneumothorax (air) defect should be corrected before chest tube insertion.
should be small (12F to 24F).2,6 The differential diagnosis between a pneumothorax
• A pneumothorax may be classified as an open, closed, or and bullous disease necessitates careful radiological
tension pneumothorax. assessment.5
❖ Open pneumothorax: The chest wall and the pleural • The tube size and insertion site selected for the chest tube
space are penetrated, which allows air to enter the are determined by the indication.5,6 If draining air, the tube
pleural space, as in a penetrating injury or trauma; a is placed near the apex of the lung (second intercostal
surgical incision in the thoracic cavity (i.e., thoracot- space); if draining fluid, the tube is placed near the base
omy); or a complication of surgical treatment (e.g., of the lung (fifth or sixth intercostal space; see Fig. 21-1).
178
22 Chest Tube Placement (Assist) 179
• Once the tube is in place, it should be sutured to the skin patient’s condition, the procedure, the expected benefits,
to prevent displacement and an occlusive dressing should and the potential risks. It also allows time for questions
be applied (see Fig. 21-2). The chest tube also is con- to clarify information and voice concerns. Explanations
nected to a chest-drainage system (see Procedure 25) to decrease patient anxiety and enhance cooperation.
remove air and fluid from the pleural space, which facili- • Explain the procedure and the reason for the procedure, if
tates reexpansion of the collapsed lung. All connection the clinical situation permits. If not, explain the procedure
points are secured with tape or zip ties (Parham-Martin and reason for the intubation after it is completed. Ratio-
bands) to ensure that the system remains airtight (see nale: This explanation enhances patient and family under-
Fig. 21-3). standing and decreases anxiety.
• The water-seal chamber should bubble gently immedi- • Explain that the patient’s participation during the proce-
ately on insertion of the chest tube and during expiration dure is to remain as immobile as possible and to do relaxed
and with coughing. Continuous bubbling in this chamber breathing. Rationale: This explanation facilitates inser-
indicates a leak within the patient or in the chest-drainage tion of the chest tube and prevents complications during
system. Fluctuations in the water level in the water-seal insertion.
chamber of 5 to 10 cm, rising during inhalation and falling • After the procedure, instruct the patient to sit in a semi-
during expiration, should be observed with spontaneous Fowler’s position (unless contraindicated). Rationale:
respirations. If the patient is on mechanical ventilation, This position facilitates drainage, if present, from the
the pattern of fluctuation is just the opposite. Any suction pleural space by allowing air to rise and fluid to settle to
applied must be disconnected temporarily to assess cor- be removed via the chest tube. This position also makes
rectly for fluctuations in the water-seal chamber. breathing easier.
• Instruct the patient to turn and change position every 2
EQUIPMENT hours. The patient may lie on the side with the chest tube
but should keep the tubing free of kinks. Rationale:
• Caps, masks, sterile gloves, gowns, drapes Turning and changing position prevent complications
• Protective eyewear (goggles) related to immobility and retained pulmonary secretions.
• Antiseptic solution: 2% chlorhexidine or povidone- Keeping the tube free of kinks maintains patency of the
iodine tube, facilitates drainage, and prevents the accumulation
• Local anesthetic: 1% or 2% lidocaine solution (with or of pressure within the pleural space that interferes with
without epinephrine) lung reexpansion.
❖ 10-mL syringe with 20-gauge, 1 1 2 -inch needle • Instruct the patient to cough and deep breathe, with splint-
❖ 5-mL syringe with 25-gauge, 1-inch needle ing of the affected side. Rationale: Coughing and deep
• Tube thoracostomy tray breathing increase pressure within the pleural space, facil-
❖ Sterile towels, 4 × 4 sterile gauze itating drainage, promoting lung reexpansion, and pre-
❖ Scalpel with No. 10 or 11 blade venting respiratory complications associated with retained
❖ Two Kelly clamps secretions. The application of firm pressure over the chest
❖ Needle holder tube insertion site (i.e., splinting) may decrease pain and
❖ Monofilament or silk suture material (No. 0 or 1-0) discomfort.
❖ Sterile basin or medicine cup • Encourage active or passive range-of-motion exercises of
❖ Suture scissors the arm on the affected side. Rationale: The patient may
❖ Two hemostats limit movement of the arm on the affected side to decrease
• Thoracotomy tubes (8 to 40Fr, as appropriate) the discomfort at the insertion site, which may result in
• Closed chest-drainage system joint discomfort and potential joint contractures.
• Suction source • Instruct the patient and family about activity as prescribed
• Suction connector and connecting tubing (usually 6 feet while maintaining the drainage system below the level of
for each tube) the chest. Rationale: This activity facilitates gravity
• 1-inch adhesive tape or zip ties (Parham-Martin bands) drainage and prevents backflow and potential infectious
• Occlusive dressing materials contamination into the pleural space.
❖ 4 × 4 gauze pads or slit drain sponges • Instruct the patient about the availability of prescribed
❖ Petrolatum gauze analgesic medication and other pain-relief strategies.
❖ Tape or a commercial securing device Rationale: Pain relief ensures comfort and facilitates
Additional equipment, to have available as needed, includes coughing, deep breathing, positioning, range of motion,
the following: and recuperation.
• Ultrasound machine and ultrasound gel
PATIENT AND FAMILY EDUCATION PREPARATION
• If time permits, assess the patient’s and family’s level Patient Assessment
of understanding about the condition and rationale for • Assess significant medical history or injury, including
the procedure. Rationale: This assessment identifies the chronic lung disease, spontaneous pneumothorax, hemo-
patient’s and family’s knowledge deficits concerning the thorax, pulmonary disease, therapeutic procedures, and
mechanism of injury. Rationale: Medical history or injury

may provide the etiological basis for the occurrence Patient Preparation
of pneumothorax, empyema, pleural effusion, or • Verify correct patient with two identifiers. Rationale:
chylothorax. Prior to performing a procedure, the nurse should ensure
• Evaluate diagnostic test results (if patient’s condition does the correct identification of the patient for the intended
not necessitate immediate intervention), including chest intervention.
radiograph and arterial blood gases. Rationale: Diagnos- • Ensure that the patient understands preprocedural teach-
tic testing confirms the presence of air or fluid in the ings. Answer questions as they arise, and reinforce
pleural space, a collapsed lung, hypoxemia, and respira- information as needed. Rationale: This communication
tory compromise. evaluates and reinforces understanding of previously
• Assess baseline cardiopulmonary status for the following taught information.
signs and symptoms that necessitate chest tube insertion.4 • Obtain consent if circumstances allow. Rationale: Inva-
Rationale: Accurate assessment of signs and symptoms sive procedures, unless performed with implied consent
allows for prompt recognition and treatment. Baseline in a life-threatening situation, require written consent of
assessment provides comparison data for evaluation of the patient or significant other.
changes and outcomes of treatment. • Ensure patient has a patent intravenous access. Rationale:
❖ Tachypnea This access provides a route for analgesics, sedation, and
❖ Decreased or absent breath sounds on affected side emergency medications.
❖ Crackles adjacent to the affected area • Consult with the practitioner for the appropriate-size chest
❖ Shortness of breath, dyspnea tube to be inserted. Rationale: Evacuation of air neces-
❖ Asymmetrical chest excursion with respirations sitates a smaller tube; evacuation of fluid necessitates a
❖ Cyanosis larger tube.
❖ Decreased oxygen saturation • Assist the patient to a supine position with the ipsilateral
❖ Hyperresonance in the affected side (pneumothorax) arm abducted and flex the elbow so that the patient’s hand
❖ Subcutaneous emphysema (pneumothorax) is comfortably positioned above his or her head.2,8 Ratio-
❖ Dullness or flatness in the affected side (hemothorax, nale: This positioning enhances accessibility to the inser-
pleural effusion, empyema, chylothorax) tion site for positioning of the chest tube.
❖ Sudden, sharp chest pain • Administer prescribed analgesics or sedatives as needed;
❖ Anxiety, restlessness, apprehension follow institutional policy for moderate or procedural
❖ Tachycardia sedation. Rationale: Analgesics and sedatives reduce the
❖ Hypotension discomfort and anxiety experienced and facilitate patient
❖ Dysrhythmias cooperation.
❖ Tracheal deviation to the unaffected side (tension • Administer supplemental oxygen as needed. Monitor
pneumothorax) pulse oximeter or end-tidal carbon dioxide level. Ratio-
❖ Neck vein distention (tension pneumothorax) nale: Real-time assessment of patient’s respiratory status
❖ Muffled heart sounds (tension pneumothorax) during the procedure is provided.
Procedure for Assisting with Pleural Chest Tube Placement

1. HH
2. PE
3. Open the chest tube insertion tray Reduces transmission of
using sterile technique. microorganisms.
4. Assist with preparation of the Facilitates insertion of the tube.
equipment.
A. Check that all equipment is
present.
B. Pour antiseptic solution into basin
or medicine cup with aseptic
technique or open antiseptic swab
packet and stand by.
C. Open the chest tube package and
empty it onto the open sterile tray.
D. Assist to prepare a syringe with
lidocaine.
Procedure for Assisting with Pleural Chest Tube Placement—Continued

5. Assist the physician or advanced Assists in preparation of area for Insertion site for air removal is right
practice nurse with preparation of the insertion and proper placement or left second intercostal space.
insertion site. of tube.8 Insertion site for fluid removal is
right or left fifth or sixth
intercostal space, midaxillary line.
Incision site is one rib below
insertion site (see Fig. 21-1).
7. After tube insertion, connect the chest Ensures the tube is properly
tube to the closed chest-drainage positioned.3
system and check for rise and fall
(tidaling) of the H2O column. Apply
ordered amount of suction.
8. Assist with suturing of the tube to the Secures the position of the tube.4 Type of stitch used depends on the
chest wall. Sutures should be snug to individual; the goal is to prevent
prevent free air from passing displacement of the chest tube.
into the subcutaneous tissue.
9. Apply occlusive dressing (see Provides cover for the wound
Fig. 21-2). with the least damage to the
A. May use slit drain sponge or surrounding skin.
4 × 4 gauze under and over top
of the chest tube insertion site.
Petrolatum gauze is used around
the chest tube, or follow
B. Secure with tape dressing.
10. Tape all connection points to the Creates an airtight system. Check that all tube drainage holes
drainage system or secure with Airtight connections prevent air are in the pleural space.
zip ties (Parham-Martin bands). leaks into the pleural space.1,4
(Level E*)
11. Secure the tube below the dressing to Functions as a strain relief to
the patient’s skin with a commercial prevent tube and dressing
securing device or tape. dislodgement.
12. Confirm tube placement with chest Chest radiograph confirms Ensure that the distal drainage hole
radiography. (Level E) placement of tube, expansion is within the pleural space.
of lung, and removal of fluid.8 Document result of chest
radiograph in the patient’s record.
13. Dispose of used supplies and remove
PE .
14. HH


• Removal of air, fluid, or blood from the pleural space • Hemorrhage or shock
• Relief of respiratory distress • Increasing respiratory distress
• Reexpansion of the lung (validated with chest • Infection
radiograph) • Damage to intercostal nerve that results in
• Restoration of negative pressure within the pleural neuropathy or neuritis
space • Incorrect tube placement
• Chest tube kinking, clogging, or dislodgment from
chest wall

interventions.
1. Assess cardiopulmonary and vital Provides baseline and ongoing • Tachypnea
signs every 1–4 hours and as assessment of patient’s condition. • Decreased or absent breath sounds
needed. Abnormalities can indicate • Hypoxemia
reoccurrence of the condition that • Tracheal deviation
necessitated chest tube insertion. • Subcutaneous emphysema
On the basis of the patient’s • Neck vein distention
clinical condition or physician • Muffled heart tones
orders, vital signs may need to be • Tachycardia
checked more frequently. • Hypotension
• Dysrhythmias
• Fever
2. Monitor chest tube output every Provides data for diagnosis. Higher • Bloody drainage greater than or
1–4 hours and record amount and drainage amounts require more equal to 200 mL/hr
color. frequent assessment. On the basis • Sudden cessation of drainage
of the patient’s clinical condition or • Change in character of drainage
physician orders, output may need
to be checked more frequently.
3. Assess for pain at the insertion Pain interferes with adequate deep • Continued pain despite pain
site or for chest discomfort. breathing. Pain at insertion site, interventions
particularly with inspiration, may
indicate improper tube placement.
4. Evaluate the chest-drainage Water level normally rises and falls • Absence of tidaling in water-seal
system for rise and fall (tidaling) with respiration until lung is chamber
or bubbling in water-seal chamber. expanded. • Persistent bubbling
Check connections. Bubbling immediately after insertion
signifies that air is being removed
from the pleural space; bubbling
with exhalation and coughing is
normal. Persistent bubbling
indicates an air leak either in the
patient’s lung or in the chest-
drainage system.3
5. Assess insertion site and Skin integrity is altered during • Fever
surrounding skin with daily insertion, which can lead to • Redness around insertion site
dressing change for presence of infection.3 • Purulent drainage
subcutaneous emphysema and • Subcutaneous emphysema
signs of infection or inflammation.
Documentation
• Patient and family education • Presence of tidaling and bubbling
• Reason for chest tube insertion • Amount of suction
• Respiratory and vital sign assessment before and after • Patient’s tolerance of procedure
insertion • Postinsertion chest radiograph results
• Description of procedure, including tube size, date and • Unexpected outcomes
time of insertion, insertion site, and any complications • Nursing interventions
associated with the procedure • Pain assessment, interventions, and effectiveness
• Type and amount of drainage

22 Chest Tube Placement (Assist) 183.e1

1. Buchman TG, et al: Thoracic trauma. In Tininalli JE, Agency for Healthcare Research and Quality: Problems and
Kelen DG, Stapczynski JS, editors: Emergency medicine: prevention: chest tube insertion. <http://www.ahrq.gov/
a comprehensive guide, ed 6, New York, 2004, research/findings/factsheets/errors-safety/chesttubes/
McGraw-Hill, pp 1595–1612. index.html>, (Accessed: 24.11.14.)
2. Dev SP, et al: Chest-tube insertion. N Engl J Med 357:e15, Argall J: Seldinger technique chest drains and complication
2007. rate. Emerg Med J 20:169–170, 2003.
3. Havelock T, et al: Pleural procedures and thoracic Bauman M, Handley C: Chest-tube care: the more you know,
ultrasound: British Thoracic Society pleural disease the easier it gets. Am Nurs Today 6(9):2011.
guideline 2010. Thorax 65(Suppl 2):ii61–ii76, 2010. Briggs D: Nursing care and management of patients with
4. Irwin RS, Rippe JM: Intensive care medicine, intrapleural drains. Nurs Stand 24(21):47–55, 2010.
Philadelphia, 2008, Wolters Kluwer/Lippincott & Williams Durai R, Hoque H, Davies TW: Managing a chest tube and
& Wilkins. drainage system. AORN J 91:275–280, 2010.
5. Laws D, Neville E, Duffy J: BTS guidelines for insertion Inaba K, et al: Does size matter? A prospective analysis of
of a chest drain. Thorax 58(Suppl II):ii53–ii59, 2003. 28-32 versus 36-40 French chest tube size in trauma.
6. Mahmood K, Wahidi MM: Straightening out chest tubes: J Trauma Acute Care Surg 72:422–427, 2012.
what size, what type, and when. Clin Chest Med 34: Jeffries M, et al: Chest tube dressings: Outcomes of taking
63–71, 2013. petroleum-based dressings out of the equation on air leak
7. Muffly TM, et al: Effect of petroleum gauze packing on and infection rates. Poster presentation; National Teaching
the mechanical properties of suture materials. J Surg Educ Institute, Boston, MA, 2013, American Association of
69:37–40, 2012. Critical-Care Nurses.
8. Roberts J: Clinical procedures in emergency medicine, Woodrow P: Intrapleural chest drainage. Nurs Stand
ed 6, Philadelphia, 2014, Saunders. 27(40):s49–s56, 2013.
PROCEDURE
23
Chest Tube Removal (Perform)
Peggy Kirkwood
PURPOSE: Chest tube removal is performed to discontinue a chest tube when it
is no longer needed for the removal or drainage of air, blood, or fluid from the
intrapleural or mediastinal space.
PREREQUISITE NURSING type is the horizontal mattress or purse-string suture,

KNOWLEDGE which is threaded around and through the wound edges in
a U shape with the ends left unknotted until the chest tube
• Chest tubes are placed in the pleural or mediastinal space is removed. Usually one or two anchor stitches accom-
to evacuate an abnormal collection of air or fluid or both. pany the purse-string suture (Fig. 23-1).
• For interpleural chest tubes, the air leak detector should • A primary goal of chest tube removal is removal of tubes
bubble gently immediately on insertion of the chest tube without introduction of air or contaminants into the pleural
during expiration and with coughing. Continuous bub- space.
bling in the air leak detector indicates a leak in the patient • Available data indicate there is no consensus as to the rate
or the chest-drainage system. Fluctuations in the water of drainage that should be used as a threshold for tube
level (also known as tidaling) in the water-seal chamber removal and no evidence to suggest that it is unsafe to
of 5 to 10 cm, rising during inhalation and falling during remove tubes that still have a relatively high rate of fluid
expiration, should be observed with spontaneous respira- drainage.5,20 Research has shown that, depending on the
tions. If the patient is on mechanical ventilation, the reason for the chest tube, volumes of 200 to 450 mL/day
pattern of fluctuation is just the opposite. Any suction do not adversely affect length of stay or overall costs
applied must be disconnected temporarily to assess cor- compared with lower threshold volumes, nor does the risk
rectly for fluctuations in the water-seal chamber. of pleural fluid reaccumulation increase.5,22 However,
• Flexible Silastic (Blake; Ethicon, Inc., Somerville, NJ) some suggested guidelines include the following:
drains may be used in place of large-bore chest tubes in ❖ Drainage has decreased to 50 to 200 mL in the prior
the mediastinal and pleural spaces after cardiac surgery. 24 hours if tube was placed for hemothorax, empyema,
These tubes provide more efficient drainage and improved or pleural effusion.
patient mobility with minimized tissue trauma and pain ❖ If tube was placed after cardiac surgery, drainage has
with removal.3,16 changed from bloody to serosanguineous, no air leak
• Chest radiographs are done periodically to determine is present, and amount is less than 100 mL in the past
whether the lung has reexpanded. Daily chest radiographs 8 hours.1,10
have been found not to be necessary while the tube is in ❖ Pleural tubes are placed after cardiac surgery if the
place.5,7,16,19,21 Reexpanded lungs, along with respiratory pleural cavity has been entered. They typically are
assessments that show improvement in the patient’s respi- removed within 24 to 48 hours after surgery.1,10
ratory status, are the basis for the decision to remove the ❖ Mediastinal chest tubes most often are removed 24 to
chest tube. 36 hours after cardiac surgery.1
• While the tubes are in place, patients may have related ❖ Lungs are reexpanded (as shown on chest radiographic
discomfort. Prompt removal of chest tubes encourages results).
patients to increase ambulation and respiratory measures ❖ Respiratory status has improved (i.e., nonlabored res-
to improve lung expansion after surgery (e.g., coughing, pirations, equal bilateral breath sounds, absence of
deep breathing). However, removal of the chest tube may shortness of breath, decreased use of accessory muscles,
also be a painful procedure for the patient.4,9,12–14 symmetrical respiratory excursion, and respiratory rate
• The types of sutures used to secure chest tubes vary less than 24 breaths/min).
according to the preference of the physician, the physician ❖ Fluctuations are minimal or absent in the water-seal
assistant, or the advanced practice nurse. One common chamber of the collection device, and the level of solu-
tion rises in the chamber.
❖ For interpleural chest tubes, air leaks have resolved for

at least 24 hours (the absence of continuous bubbling
practice nurses, and other healthcare professionals (including critical care in the water-seal chamber or absence of air bubbles
nurses) with additional knowledge, skills, and demonstrated competence per from right to left in the air leak detector), and lung is
professional licensure or institutional standard. fully reinflated on chest radiographic results.
184
23 Chest Tube Removal (Perform) 185
maneuver on the count of three. Have the patient practice

the maneuver before the procedure. Rationale: This
explanation elicits patient cooperation and facilitates
removal.
• Instruct the patient to turn and reposition every 2 hours
after the chest tube has been removed. Rationale: This
action prevents complications related to immobility and
retained secretions.
• Instruct the patient to cough and breathe deeply after the
chest tube has been removed, with splinting of the affected
side or sternum (with mediastinal tubes). Rationale: This
action prevents respiratory complications associated with
retained secretions. The application of firm pressure over
A B the insertion site (i.e., splinting) decreases pain and
Figure 23-1 Purse-string suture. Removing the chest tube. discomfort.
A, First throw of a knot in the mattress suture. B, Removal of the • Instruct the patient about the availability of prescribed
chest tube and tying of purse-string suture. (From Leonar S, analgesic medication after the chest tube is removed.
Nikaidoh H: Thoracentesis and chest tube insertion. In Levin D, Rationale: Analgesics alleviate pain and facilitate cough-
Morriss F, editors. Essentials of pediatric intensive care, St Louis,
1990, Quality Medical Publishing.)
ing, deep breathing, and repositioning.9,13,19
• Instruct the patient and family to report signs and symp-
toms of respiratory distress or infection immediately.
Rationale: Immediate reporting facilitates prompt inter-
EQUIPMENT vention to relieve a recurrent pneumothorax or to treat an
infection.
• Suture-removal set
• Antiseptic swabs (povidone-iodine, chlorhexidine gluco-
nate with alcohol, etc.) PATIENT ASSESSMENT AND
• Petrolatum gauze, as per hospital protocol PREPARATION
• Rubber-tipped Kelly clamps or disposable umbilical
clamps Patient Assessment
• Wide occlusive tape (2 inches) • Assess respiratory status. Rationale: Assessment of respi-
• Elastic closure device, such as Steri-Strips (3M, St. Paul, ratory status verifies the patient’s readiness for chest tube
MN) removal.
• Dry 4 × 4 gauze sponges (two to four) ❖ Oxygen saturation within normal limits
• Waterproof pad ❖ Nonlabored respirations
• Personal protective equipment (goggles, sterile and non- ❖ Absence of shortness of breath
sterile gloves, mask, gown) ❖ Decreased use of accessory muscles
Additional equipment, to have available as needed, includes ❖ Respiratory rate of less than 24 breaths/min
the following: ❖ Equal bilateral breath sounds
• Specimen collection cup (if catheter tip is to be sent to the • Assess chest tube drainage (less than 200 mL in 24 hours
laboratory for analysis) or less than 100 mL in 8 hours after cardiac surgery).1,5,10
• Scissors Rationale: Assessment of drainage verifies patient readi-
ness for chest tube removal.
PATIENT AND FAMILY EDUCATION • For interpleural chest tubes, assess for minimal or no air
leak in the air leak detector zone or indicator with pleural
• Assess the patient’s and family’s level of understanding tubes. Rationale: This assessment indicates whether the
about the condition and rationale for the procedure. Ratio- lung is reexpanded and whether air leak is present.
nale: This assessment identifies the patient’s and family’s • Evaluate chest radiographic results. Rationale: Lung
knowledge deficits concerning the patient’s condition, the reexpansion indicates that need for chest tube is resolved.
procedure, the expected benefits, and the potential risks. • Assess vital signs and (optional) arterial blood gases.
It also allows time for questions to clarify information and Rationale: Vital sign assessment indicates whether the
voice concerns. Explanations decrease patient anxiety and patient can tolerate chest tube removal.
enhance cooperation. • Assess laboratory results for clotting capability and medi-
• Explain the procedure, reason for removal, and sensations cations that may affect clotting. Rationale: Low platelet
to be expected.15,19 The most commonly reported sensa- levels or thrombolytic medications may precipitate exces-
tions are pulling, pain or hurting, and burning.14 Rationale: sive bleeding.17
This explanation decreases patient anxiety and enhances
cooperation. Patient Preparation
• Explain the patient’s role in assisting with removal. • Verify correct patient with two identifiers. Rationale:
Explain that the patient should perform the Valsalva Prior to performing a procedure, the nurse should ensure
the correct identification of the patient for the intended minutes before or 30-mg ketorolac 60 minutes before the
intervention. procedure have been shown to produce substantial relief
• Ensure that the patient understands preprocedural teach- of pain without excessive analgesia.13 Pain medication,
ings. Answer questions as they arise, and reinforce relaxation exercises, and application of cold reduces the
information as needed. Rationale: This communication discomfort and anxiety experienced, which facilitates
evaluates and reinforces understanding of previously patient cooperation.8,9,12,13
taught information. Anticipatory preparation may prepare • Time the removal procedure to occur at peak analgesic
patients for a better experience.12,18 effect. Rationale: This timing increases patient coopera-
• Administer premedication of adequate analgesics at least tion and decreases anxiety.13
20 minutes before the procedure. Alternatively, subfascial • Place the patient in the semi-Fowler’s position. Alterna-
lidocaine may be injected into the chest tube tract. In tively, place the patient on the unaffected side with the
addition to opioids, adjunct methods shown to decrease waterproof pad underneath the site. Rationale: This posi-
pain during chest tube removal include slow deep- tion enhances accessibility to the insertion site of the chest
breathing relaxation exercises and application of cold tube and protects the bed from drainage.
packs.8,9 Rationale: Intravenous 4-mg morphine 20
Procedure for Performing Chest Tube Removal

1. HH
2. PE
3. Open the sterile suture removal Aseptic technique is maintained to
set and prepare petrolatum gauze prevent contamination of the
dressing and two to four 4 × 4 wound.
gauze sponges, as per hospital
protocol.
verification and time out, if
nonemergent.
5. Discontinue suction from Bubbling in the air leak detector is If an air leak is present, the tube
chest-drainage system and check associated with an air leak. When should not be removed. Consult
for air leakage in air leak an air leak is present, removal of with the physician, physician
detector zone or indicator. the chest tube may cause assistant, or advanced practice
Observe the air leak detector development of a pneumothorax. nurse to determine appropriate
zone or indicator while the Ensures a recurrent action.
patient coughs. pneumothorax has not occurred.
6. Remove existing tape, and clean Allows access to the chest tube at Antiseptic swabs remove a broad
area around tubes with antiseptic the skin level and prepares the spectrum of microbes quickly and
solution or swab. Determine type sutures for removal. provide high-level antimicrobial
of suture that secures each chest action for up to 6 hours after use.6
tube. Clip appropriately. If a
purse-string suture is present,
leave the long suture ends intact.
(Level D*)
7. Confirm that the tube is free Allows ease of removal and avoids
from the suture and the tape. tearing the skin.
8. Cover pleural insertion sites with Avoids the influx of air.
petrolatum gauze dressing and
mediastinal insertion site with 4
× 4 gauze pads, as per hospital
protocol.
Procedure for Performing Chest Tube Removal—Continued

9. Clamp each tube to be removed Possibly prevents air from being
with two Kelly clamps or introduced into the pleural space,
umbilical clamps.11 (Level E*) although controversy is found in
the literature.11
10. Instruct the patient to perform a Valsalva maneuver is needed to
Valsalva maneuver at either end provide positive pressure in the
inspiration or end expiration.2 pleural cavity and decrease the
(Level E) incidence of an involuntary gasp
by the patient when the tube is
removed.2
A. End inspiration: Instruct
patient to take a deep breath
and hold it while performing
the Valsalva maneuver for
each tube removed. If the
patient is receiving ventilator
support and is unable to
follow instructions, remove
the tube during peak
inspiration.
B. End expiration: Instruct
patient to forcibly exhale and
perform the Valsalva
maneuver at end expiration.
C. If possible, patients may need
to hold their breath until
sutures are tied.
11. Remove chest tubes rapidly, Prevents accidental entrance of air Some resistance is expected; however,
smoothly, and individually while into the pleural space. Removal if strong resistance is encountered
patient is performing Valsalva of pleural chest tubes should be and rapid removal of the tube is
maneuver or during peak accomplished rapidly with the not possible, stop the procedure
inspiration if the patient is on a simultaneous application of an and consult with the physician,
mechanical ventilator. occlusive dressing or closure physician’s assistant, or advanced
with purse-string sutures to practice nurse immediately.
decrease possibility of air from Resistance may indicate that the
entering the pleural space. tube was inadvertently sutured
during surgery or sternal closure.
A. Hold sutures in hand closer to
head of patient, and apply
mild pressure over exit site
with folded 4 × 4 gauze pad.
B. If tube was “Y” connected to
another tube, cut the removed
tube below the clamp to
allow for easier manipulation
when removing the remaining
chest tubes.
12. If a purse-string suture is present, Creates a firm closure of the chest Avoid pulling the suture too tight to
tie it off with a square knot (see tube site. prevent tissue necrosis at the site
Fig. 23-1). If no purse-string was and to facilitate easier removal
used, the site may be closed with later.
adhesive skin closure strips.

Procedure for Performing Chest Tube Removal—Continued

13. Secure dressing with tape. Creates a firm closure of the chest This action is easier with a second
tube site. person to place the tape while
holding pressure over the site.
14. Examine each chest tube to If portion of tube is not removed, Consult with physician, physician
verify that the entire tube has surgical removal is necessary to assistant, or advanced practice
been removed. remove it. nurse immediately if a portion of
the tube remains in the patient.
15. Assess the patient’s condition Ensures stable respiratory status Increased work of breathing,
after the procedure and compare after the procedure. decreased oxygen saturation,
the results with the preprocedure increased restlessness, symptoms of
assessment, as described chest discomfort, and diminished
previously. breath sounds on the affected side
are warning signs to be observed.
16. Obtain a chest radiograph Assesses that the lung has remained Low incidence of complication.
(generally 1–4 hours after expanded. Recommended to perform chest
removal) only as clinically radiograph only if patient is
indicated.7,16,19,21 (Level B*) clinically deteriorating.7,16,19,21
18. HH

• Patient is comfortable and has no respiratory distress • Pneumothorax
• Lung remains expanded after chest tube removal • Bleeding
• Site remains free of infection • Skin necrosis
• Retained chest tube
• Infected chest tube insertion site

interventions.
1. Assess respiratory status, Diminished respiratory status could • Decreased oxygen saturation on
including oxygen saturation, work indicate a pneumothorax. pulse oximetry
of breathing, breath sounds, and Pneumothorax could be from • Increased work of breathing
symptoms of chest discomfort. removal of the chest tube before • Diminished breath sounds on
Obtain chest radiograph if all the air, fluid, or blood in the affected side
significant changes are found. pleural space had been drained, • Increased restlessness and
or it may recur after removal of symptoms of chest discomfort
the chest tube if air is introduced
accidentally into the pleural space
through the chest tube tract.
2. Monitor insertion site for bleeding. Persistent bleeding from insertion • Persistent bleeding
If bleeding is found, apply site could mean chest tube was
pressure and place a tight against a vein or artery of chest
occlusive dressing over site, which wall before removal.
may be removed after 48 hours.

3. Monitor purse-string suture site If purse-string suture was pulled too • Dark or inflamed skin with
for signs of skin necrosis. tightly closed when chest tube necrotic areas visible
was removed, skin necrosis may
be seen.
4. Monitor site for signs of infection. Prolonged insertion of a chest tube • Purulent drainage
increases the risk that the tract • Increased body temperature
created by the chest tube may • Inflammation
become infected, or infection may • Tenderness
occur after removal of the chest • Warmth at site
tube if the opening created by the
removal becomes contaminated.
5. Monitor insertion area for Air may leak into the surrounding • Crepitus
development of subcutaneous tissues and cause crepitus.
emphysema.
6. Monitor for signs and symptoms Removal of chest tubes may cause • Distant heart tones
of pericardial effusion or cardiac increased bleeding into • Decreased blood pressure,
tamponade. pericardium. Pericardial bleeding tachycardia
may continue after chest tubes are • Pulsus paradoxus
removed. • Narrowed pulse pressure
• Equalized pulmonary artery
pressures
Documentation
• Patient and family education • Patient’s tolerance of the procedure
• Respiratory and vital signs assessments before and • Completion and results of chest radiograph
after procedure • Specimens sent to laboratory (if applicable)
• Date and time of procedure and who performed the • Unexpected outcomes
procedure • Nursing interventions
• Amount, color, and consistency of any drainage • Pain assessment, interventions, and effectiveness
• Application of a sterile occlusive dressing
• Type of suture in place and what was done to it (cut
and removed or tied)

23 Chest Tube Removal (Perform) 189.e1
References 12. Puntillo K, et al: Patients’ perceptions and responses to

1. Abramov D, et al: Timing of chest tube removal after procedural pain: results from Thunder Project II. Am J
coronary artery bypass surgery. J Card Surg 20:142–146, Crit Care 10:238–251, 2001.
2005. 13. Puntillo K, Ley SJ: Appropriately timed analgesics
2. Bell RL, et al: Chest tube removal: end-inspiration or control pain due to chest tube removal. Am J Crit Care
end-expiration? J Trauma 50:674–677, 2001. 13:292–304, 2004.
3. Bjessmo S, et al: Comparison of three different chest 14. Refai M, et al: The impact of chest tube removal on pain
drainages after coronary artery bypass surgery: a and pulmonary function after pulmonary resection. Eur J
randomised trial in 150 patients. Eur J Cardiothorac Surg Cardiothorac Surg 41:820–823, 2012.
31:372–375, 2007. 15. Sakopoulos AG, et al: Efficacy of Blake drains for
4. Bruce EA, Howard RF, Franck LS: Chest drain removal mediastinal and pleural drainage following cardiac
pain and its management: a literature review. J Clin Nurs operations. J Card Surg 20(6):574–577, 2005.
15:145–154, 2008. 16. Sepehripour AH, Shakil F, Shah R: Is routine chest
5. Cerfolio RJ, Bryant AS: Results of a prospective radiography indicated following chest drain removal after
algorithm to remove chest tubes after pulmonary resection cardiothoracic surgery? Interact Cardiovasc Thorac Surg
with high output. J Thorac Cardiovasc Surg 135:269–273, 4:834–838, 2012.
2008. 17. Sullivan B: Nursing management of patients with a chest
6. Digison MB: A review of antiseptic agents for pre- drain. Br J Nurs 17:388–393, 2008.
operative skin preparation. Plast Surg Nurs 27:185–189, 18. Summer GH, Puntillo K: Management of surgical and
2007. procedural pain in a critical care setting. Crit Care Nurs
7. Eisenberg RL, Khabbaz KR: Are chest radiographs Clin North Am 13:233–242, 2001.
routinely indicated after chest tube removal following 19. Tolsma M, et al: The clinical value of routine chest
cardiac surgery? AJR Am J Roentgenol 197:122–124, radiographs in the first 24 hours after cardiac surgery.
2011. Anesth Analg 112:139–142, 2011.
8. Ertug N, Ulker S: The effect of cold application on pain 20. Utter GH: The rate of pleural fluid drainage as a criterion
due to chest tube removal. J Clin Nurs 21:784–790, 2012. for the timing of chest tube removal: theoretical and
9. Friesner SA, Curry DM, Moddeman GR: Comparison of practical considerations. Ann Thorac Surg 96:2262–2267,
two pain-management strategies during chest tube 2013.
removal: relaxation exercise with opioids and opioids 21. Whitehouse MR, Patel A, Morgan JA: The necessity of
alone. Heart Lung 35:269–276, 2006. routine post-thoracostomy tube chest radiographs in
10. Gercekoglu H, et al: Effect of timing of chest tube post-operative thoracic surgery patients. Surgeon 7:79–81,
removal on development of pericardial effusion following 2009.
cardiac surgery. J Card Surg 18:217–224, 2003. 22. Younes RN, et al: When to remove a chest tube?
11. Laws D, Neville E, Duffy J: British Thoracic Society A randomized study with subsequent prospective
guidelines for the insertion of a chest drain. Thorax consecutive validation. J Am Coll Surg 195:658–662,
58(Suppl II):ii53–ii59, 2003. 2002.
PROCEDURE
24
Chest Tube Removal (Assist)
Peggy Kirkwood
PURPOSE: Chest tube removal is performed to discontinue a chest tube when it
is no longer needed for the removal or drainage of air, blood, or fluid from the
intrapleural or mediastinal space.
PREREQUISITE NURSING a U shape with the ends left unknotted until the chest tube
KNOWLEDGE is removed. Usually, one or two anchor stitches accom-
pany the purse-string suture (Fig. 23-1).
• Chest tubes are placed in the pleural or mediastinal space • A primary goal of chest tube removal is removal of tubes
to evacuate an abnormal collection of air or fluid or both. without introduction of air or contaminants into the pleural
• For interpleural chest tubes, the air leak detector should space.
bubble gently immediately on insertion of the chest tube • Available data indicate there is no consensus as to the rate
during expiration and with coughing. Continuous bub- of drainage that should be used as a threshold for tube
bling in the air leak detector indicates a leak in the patient removal and no evidence to suggest that it is unsafe to
or the chest-drainage system. Fluctuations in the water remove tubes that still have a relatively high rate of fluid
level (also known as tidaling) in the water-seal chamber drainage.5,20 Research has shown that, depending on the
of 5 to 10 cm, rising during inhalation and falling during reason for the chest tube, volumes of 200 to 450 mL/day
expiration, should be observed with spontaneous respira- do not adversely affect length of stay or overall costs
tions. If the patient is on mechanical ventilation, the compared with lower threshold volumes, nor does the risk
pattern of fluctuation is just the opposite. Any suction of pleural fluid reaccumulation increase.5,22 However,
applied must be disconnected temporarily to assess cor- some suggested guidelines include the following:
rectly for fluctuations in the water-seal chamber. ❖ Drainage has decreased to 50 to 200 mL in the prior
• Flexible Silastic (Blake; Ethicon, Inc, Somerville, NJ) 24 hours if tube was placed for hemothorax, empyema,
drains may be used in place of large-bore chest tubes in or pleural effusion.
the mediastinal and pleural spaces after cardiac surgery. ❖ If tube was placed after cardiac surgery, drainage has
These tubes provide more efficient drainage and improved changed from bloody to serosanguineous, no air leak
patient mobility with minimized tissue trauma and pain is present, and amount is less than 100 mL in the past
with removal.3,16 8 hours.1,10
• Chest radiographs are done periodically to determine ❖ Pleural tubes are placed after cardiac surgery if the
whether the lung has reexpanded. Daily chest radiographs pleural cavity has been entered. They typically are
have been found to be unnecessary while the tube is in removed within 24 to 48 hours after surgery.1,10
place.5,7,16,19,21 Reexpanded lungs, along with respiratory ❖ Mediastinal chest tubes most often are removed 24 to
assessments that show improvement in the patient’s respi- 36 hours after cardiac surgery.1
ratory status, are the basis for the decision to remove the ❖ Lungs are reexpanded (as shown on chest radiographic
chest tube. results).
• While the tubes are in place, patients may have related ❖ Respiratory status has improved (i.e., nonlabored res-
discomfort. Prompt removal of chest tubes encourages pirations, equal bilateral breath sounds, absence of
patients to increase ambulation and respiratory measures shortness of breath, decreased use of accessory muscles,
to improve lung expansion after surgery (e.g., coughing, symmetrical respiratory excursion, and respiratory rate
deep breathing). However, removal of the chest tube may less than 24 breaths/min).
also be a painful procedure for the patient.4,9,12–14 ❖ Fluctuations are minimal or absent in the water-seal
• The types of sutures used to secure chest tubes vary chamber of the collection device, and the level of solu-
according to the preference of the physician, the physician tion rises in the chamber.
assistant, or the advanced practice nurse. One common ❖ For interpleural chest tubes, air leaks have resolved for
type is the horizontal mattress or purse-string suture, at least 24 hours (the absence of continuous bubbling
which is threaded around and through the wound edges in in the water-seal chamber or absence of air bubbles
190
24 Chest Tube Removal (Assist) 191
from right to left in the air leak detector), and the lung • Instruct the patient and family to report signs and symp-
is fully reinflated on chest radiographic results. toms of respiratory distress or infection immediately.
Rationale: Immediate reporting facilitates prompt inter-
EQUIPMENT vention to relieve a recurrent pneumothorax or to treat an
infection.
• Suture-removal set
• Antiseptic swabs (povidone-iodine, chlorhexidine gluco- PATIENT ASSESSMENT AND
nate with alcohol, etc.) PREPARATION
• Petrolatum gauze, as per hospital protocol
• Rubber-tipped Kelly clamps or disposable umbilical Patient Assessment
clamps • Assess respiratory status. Rationale: Assessment of respi-
• Wide occlusive tape (2 inches) ratory status verifies the patient’s readiness for chest tube
• Elastic closure device, such as Steri-Strips (3M, St. Paul, removal.
MN) ❖ Oxygen saturation within normal limits
• Dry 4 × 4 gauze sponges (two to four) ❖ Nonlabored respirations
• Waterproof pad ❖ Absence of shortness of breath
• Personal protective equipment (goggles, sterile and non- ❖ Decreased use of accessory muscles
sterile gloves, mask, gown) ❖ Respiratory rate of less than 24 breaths/min
Additional equipment, to have available as needed, includes ❖ Equal bilateral breath sounds
the following: • Assess chest tube drainage (less than 200 mL in 24 hours
• Specimen collection cup (if catheter tip is to be sent to the or less than 100 mL in 8 hours after cardiac surgery).1,5,10
laboratory for analysis) Rationale: Assessment of drainage verifies patient readi-
• Scissors ness for chest tube removal.
• For interpleural chest tubes, assess for minimal or no air
PATIENT AND FAMILY EDUCATION leak in the air leak detector zone or indicator. Rationale:
This assessment indicates whether the lung is reexpanded
• Assess the patient’s and family’s level of understanding and whether or not air leak is present.
about the condition and rationale for the procedure. Ratio- • Obtain chest radiographic results. Rationale: Lung reex-
nale: This assessment identifies the patient’s and family’s pansion indicates that need for chest tube is resolved.
knowledge deficits concerning the patient’s condition, the • Assess vital signs. Rationale: Vital sign assessment
procedure, the expected benefits, and the potential risks. indicates whether the patient can tolerate chest tube
It also allows time for questions to clarify information and removal.
voice concerns. Explanations decrease patient anxiety and • Assess laboratory results for clotting capability and medi-
enhance cooperation. cations that may affect clotting. Rationale: Low platelet
• Explain the procedure, reason for removal, and sensations levels or thrombolytic medications may precipitate exces-
to be expected.15,19 The most commonly reported sensa- sive bleeding.17
tions are pulling, pain or hurting, and burning.14 Ratio-
nale: This explanation prepares the patient and enhances
cooperation. Patient Preparation
• Explain the patient’s role in assisting with removal. • Verify correct patient with two identifiers. Rationale:
Explain that the patient should perform the Valsalva Prior to performing a procedure, the nurse should ensure
maneuver on the count of three. Have the patient practice the correct identification of the patient for the intended
the maneuver before the procedure. Rationale: This intervention.
explanation elicits patient cooperation and facilitates • Ensure that the patient understands preprocedural teach-
removal. ings. Answer questions as they arise, and reinforce
• Instruct the patient to turn and reposition every 2 hours information as needed. Rationale: This communication
after the chest tube has been removed. Rationale: This evaluates and reinforces understanding of previously
action prevents complications related to immobility and taught information. Anticipatory preparation may prepare
retained secretions. patients for a better experience.12,18
• Instruct the patient to cough and breathe deeply after the • Administer premedication of adequate analgesics at least
chest tube has been removed, with splinting of the affected 20 minutes before the procedure. Alternatively, subfascial
side or sternum (with mediastinal tubes). Rationale: This lidocaine may be injected into the chest tube tract. In
action prevents respiratory complications associated with addition to opioids, adjunct methods shown to decrease
retained secretions. The application of firm pressure over pain during chest tube removal include slow deep-
the insertion site (i.e., splinting) decreases pain and breathing relaxation exercises and application of cold
discomfort. packs.8,9 Rationale: Intravenous 4-mg morphine 20
• Instruct the patient about the availability of prescribed minutes before or 30-mg ketorolac 60 minutes before the
analgesic medication after the chest tube is removed. procedure have been shown to have substantial relief of
Rationale: Analgesics alleviate pain and facilitate cough- pain without excessive analgesia.12 Pain medication,
ing, deep breathing, and repositioning.9,13,19 relaxation exercises, and application of cold reduces the
discomfort and anxiety experienced, which facilitates • Place the patient in the semi-Fowler’s position. Alterna-
patient cooperation.8,9,12,13 tively, place the patient on the unaffected side with the
• Time the removal procedure to occur at peak analgesic waterproof pad underneath the site. Rationale: This posi-
effect. Rationale: This timing increases patient cooperation enhances accessibility to the insertion site of the chest
tion and decreases anxiety.13 tube and protects the bed from drainage.
Procedure for Assisting with Chest Tube Removal

1. HH
2. PE
3. Assist with opening the sterile suture Aseptic technique is maintained to
removal set and preparing petrolatum prevent contamination of the
gauze dressing and two to four 4 × 4 wound.
gauze sponges, as per hospital
protocol.
5. Assist with discontinuing suction Bubbling in the air leak detector is If an air leak is present, the tube
from chest-drainage system and associated with an air leak. When should not be removed. Consult
check for air leakage in air leak an air leak is present, removal of with the physician, physician
detector zone or indicator. Observe the chest tube may cause assistant, or advanced practice
the air leak detector zone or indicator development of a pneumothorax. nurse to determine appropriate
while the patient coughs. Ensures a recurrent action.
pneumothorax has not occurred.
6. Assist with removing existing tape, Allows access to the chest tube at Antiseptic swabs remove a broad
and clean area around tubes with the skin level and prepares the spectrum of microbes quickly and
antiseptic swab. (Level D*) sutures for removal. provide high-level antimicrobial
action for up to 6 hours after use.6
7. Assist with covering the pleural Avoids the influx of air.
insertion sites with petrolatum gauze
dressing and mediastinal insertion
site with 4 × 4 gauze pads, as per
hospital protocol.
8. Assist with clamping each tube to be Possibly prevents air from being
removed with two Kelly clamps or introduced into the pleural space,
umbilical clamps.11 (Level E*) although controversy is found in
the literature.11
9. The tube is removed while the Valsalva maneuver is needed to
patient is performing a Valsalva provide positive pressure in the
maneuver at either end inspiration or pleural cavity and decrease the
end expiration.2 (Level E) incidence of an involuntary gasp
by the patient when the tube is
removed.2
A. End inspiration: Instruct patient Removal of pleural chest tubes
to take a deep breath and hold it should be accomplished rapidly
while performing the Valsalva with the simultaneous application
maneuver for each tube removed. of an occlusive dressing or
If the patient is receiving closure with purse-string sutures
ventilator support and is unable to decrease possibility of air from
to follow instructions, remove the entering the pleural space.
tube during peak inspiration.
24 Chest Tube Removal (Assist) 193
Procedure for Assisting with Chest Tube Removal—Continued

B. End expiration: Instruct patient to
forcibly exhale and perform the
Valsalva maneuver at end
expiration.
C. If possible, patients may need to
hold their breath until sutures are
tied.
10. Assist with securing the dressing Creates a firm closure of the chest This action is easier with a second
with tape. tube site. person to place the tape while
holding pressure over the site.
11. Assess the patient’s condition after Ensures stable respiratory status Increased work of breathing,
the procedure, and compare the after the procedure. decreased oxygen saturation,
results with preprocedure assessment increased restlessness, symptoms
as noted previously. of chest discomfort, and
diminished breath sounds on the
affected side are warning signs to
be observed.
12. Ensure a chest radiograph is Assesses that the lung has remained Low incidence of complication.
obtained, if ordered (generally 1–24 expanded. Recommended to perform chest
hours after removal) only as radiograph only if patient is
clinically indicated.7,16,19,21 (Level B*) clinically deteriorating.7,16,19,21
14. HH

• Patient is comfortable and has no respiratory distress • Pneumothorax
• Lung remains expanded after chest tube removal • Bleeding
• Site remains free of infection • Skin necrosis
• Retained chest tube
• Infected chest tube insertion site

interventions.
1. Assess respiratory status, Diminished respiratory status could • Decreased oxygen saturation on
including oxygen saturation, work indicate a pneumothorax. pulse oximetry
of breathing, breath sounds, and Pneumothorax could be from • Increased work of breathing
symptoms of chest discomfort. removal of the chest tube before • Diminished breath sounds on
Obtain chest radiograph if all the air, fluid, or blood in the affected side
significant changes are found. pleural space had been drained, • Increased restlessness and
or it may recur after removal of symptoms of chest discomfort
the chest tube if air is introduced
accidentally into the pleural space
through the chest tube tract.

2. Monitor insertion site for bleeding. Persistent bleeding from insertion • Persistent bleeding
If bleeding is found, apply site could mean chest tube was
pressure and place a tight against a vein or artery of chest
occlusive dressing over site, which wall before removal.
may be removed after 48 hours.
3. Monitor purse-string suture site If purse-string suture was pulled too • Dark or inflamed skin with
for signs of skin necrosis. tightly closed when chest tube necrotic areas visible
was removed, skin necrosis may
be seen.
4. Monitor site for signs of infection. Prolonged insertion of a chest tube • Purulent drainage
increases the risk that the tract • Increased body temperature
created by the chest tube may • Inflammation
become infected, or infection may • Tenderness
occur after removal of the chest • Warmth at site
tube if the opening created by the
removal becomes contaminated.
5. Monitor insertion area for Air may leak into the surrounding • Crepitus
development of subcutaneous tissues and cause crepitus.
emphysema.
6. Monitor for signs and symptoms Removal of chest tubes may cause • Distant heart tones
of pericardial effusion or cardiac increased bleeding into • Decreased blood pressure,
tamponade. pericardium. tachycardia
Pericardial bleeding may continue • Pulsus paradoxus
after chest tubes are removed. • Narrowed pulse pressure
• Equalized pulmonary artery
pressures
Documentation
• Patient and family education • Patient’s tolerance of the procedure
• Respiratory and vital signs assessments before and • Completion and results of chest radiograph
after procedure • Specimens sent to laboratory (if applicable)
• Date and time of procedure and who performed the • Unexpected outcomes
procedure • Nursing interventions
• Amount, color, and consistency of any drainage • Pain assessment, interventions, and effectiveness
• Application of a sterile occlusive dressing

24 Chest Tube Removal (Assist) 194.e1
References 12. Puntillo K, et al: Patients’ perceptions and responses to

1. Abramov D, et al: Timing of chest tube removal after procedural pain: results from Thunder Project II. Am J
coronary artery bypass surgery. J Card Surg 20:142–146, Crit Care 10:238–251, 2001.
2005. 13. Puntillo K, Ley SJ: Appropriately timed analgesics
2. Bell RL, et al: Chest tube removal: end-inspiration or control pain due to chest tube removal. Am J Crit Care
end-expiration? J Trauma 50:674–677, 2001. 13:292–304, 2004.
3. Bjessmo S, et al: Comparison of three different chest 14. Refai M, et al: The impact of chest tube removal on pain
drainages after coronary artery bypass surgery: a and pulmonary function after pulmonary resection. Eur J
randomised trial in 150 patients. Eur J Cardiothorac Surg Cardiothorac Surg 41:820–823, 2012.
31:372–375, 2007. 15. Sakopoulos AG, et al: Efficacy of Blake drains for
4. Bruce EA, Howard RF, Franck LS: Chest drain removal mediastinal and pleural drainage following cardiac
pain and its management: a literature review. J Clin Nurs operations. J Card Surg 20:574–577, 2005.
15:145–154, 2008. 16. Sepehripour, AH, Shakil F, Shah R: Is routine chest
5. Cerfolio RJ, Bryant AS: Results of a prospective radiography indicated following chest drain removal after
algorithm to remove chest tubes after pulmonary resection cardiothoracic surgery? Interact Cardiovasc Thorac Surg
with high output. J Thorac Cardiovasc Surg 135:269–273, 4:834–838, 2012.
2008. 17. Sullivan B: Nursing management of patients with a chest
6. Digison MB: A review of antiseptic agents for drain. Br J Nurs 17:388–393, 2008.
preoperative skin preparation. Plast Surg Nurs 27: 18. Summer GH, Puntillo K: Management of surgical and
185–189, 2007. procedural pain in a critical care setting. Crit Care Nurs
7. Eisenberg RL, Khabbaz KR: Are chest radiographs Clin North Am 13:233–242, 2001.
routinely indicated after chest tube removal following 19. Tolsma M, et al: The clinical value of routine chest
cardiac surgery? Am J Roentgenol 197:122–124, 2011. radiographs in the first 24 hours after cardiac surgery.
8. Ertug N, Ulker S: The effect of cold application on Anesth Analg 112:139–142, 2011.
pain due to chest tube removal. J Clin Nurs 21:784–790, 20. Utter GH: The rate of pleural fluid drainage as a criterion
2012. for the timing of chest tube removal: theoretical and
9. Friesner SA, Curry DM, Moddeman GR: Comparison of practical considerations. Ann Thorac Surg 96:2262–2267,
two pain-management strategies during chest tube 2013.
removal: relaxation exercise with opioids and opioids 21. Whitehouse MR, Patel A, Morgan JA: The necessity of
alone. Heart Lung 35:269–276, 2006. routine post-thoracostomy tube chest radiographs in
10. Gercekoglu H, et al: Effect of timing of chest tube post-operative thoracic surgery patients. Surgeon 7:79–81,
removal on development of pericardial effusion following 2009.
cardiac surgery. J Card Surg 18:217–224, 2003. 22. Younes RN, et al: When to remove a chest tube?
11. Laws D, Neville E, Duffy J: British Thoracic Society A randomized study with subsequent prospective
guidelines for the insertion of a chest drain. Thorax consecutive validation. J Am Coll Surg 195:658–662,
58(Suppl II):ii53–ii59, 2003. 2002.
PROCEDURE
25
Closed Chest-Drainage System
Joya D. Pickett
PURPOSE: Closed chest-drainage systems are used to facilitate the evacuation
of fluid, blood, and air from the pleural space, the mediastinum, or both; to restore
negative pressure to the pleural space; and to promote reexpansion of a collapsed
lung.
PREREQUISITE NURSING Although water is added to the water-seal chamber, water

KNOWLEDGE does not need to be added to the suction chamber. Instead,
the suction source (usually a wall regulator) is increased
• The clinical need for chest drainage arises whenever the until an indicator appears.
negative pressure in the pleural cavity is disrupted by the • Some CDSs are waterless, referred to as dry-dry drains,
presence of air and/or fluid, resulting in pulmonary com- and have a one-way valve, which eliminates the need to
promise. The purpose of a chest-drainage system (CDS) fill any chambers (except an air-leak indicator zone, as
is to evacuate the air and/or fluid from the chest cavity to needed). A valve opens on expiration and allows patient
reestablish normal intrathoracic pressure. air to exit, then closes to prevent atmospheric air from
• Closed CDSs are integrated disposable systems (also entering during inspiration. This one-way valve feature
known as chest-drainage units) that are modeled after the allows the system to be used in the vertical or horizontal
classic three-bottle CDS. position without loss of the seal. These systems are safe
• Normal anatomy and physiology of the thorax: if accidentally tipped. The amount of suction delivered is
❖ Under usual conditions, normal intrapleural pressures regulated with an adjustable dial.
measure approximately −4 cm H2O during expiration, ❖ Advantages of dry suction are ease of setup; ease of
whereas at end inspiration, pressure decreases to −8 cm application if higher, more precise levels of suction are
H2O.15 needed; and a quiet system.
❖ The mediastinum is within the musculoskeletal cage of • CDSs may have some of the following components:
the thorax and contains three subdivisions. The two ❖ Tubing, which may or may not be latex free. See manu-
lateral subdivisions hold the lungs. Between the lungs facturer guidelines for specific information
is the mediastinum, which contains the heart, the great ❖ Collection chambers, which may be replaceable,
vessels, parts of the trachea and esophagus, and other allowing them to be removed when filled and replaced
structures. with a new collection chamber without changing the
❖ The lungs consist of the trachea and the bronchi, which entire unit
divide into smaller branches until they reach the alveoli, ❖ Fluid-collection ports, which may be self-sealing ports
known as the air sacs. or collection tubes for aspiration of drainage samples
• Thoracic pathophysiology requiring a chest tube and and removal of excess chamber fluid levels
CDS, which may occur spontaneously or as the result of ❖ A one-way mechanism created by a water-seal that
trauma and/or surgery: permits air and fluid to be removed and prevents back-
❖ Pneumothoraces (e.g., open, closed, and tension) flow into the chest20
❖ Hemothorax ❖ Accessories that may be used to convert systems to
❖ Pleural effusions autotransfusion units
❖ Chylothorax • Examples of CDSs include the Pleur-Evac, Thora-Klex,
❖ Empyema Argyle, and Atrium systems.
❖ Pericardial effusions, including cardiac tamponade • CDSs contain the following chambers (Fig. 25-1):
• CDSs include the following types: ❖ The collection chamber, the largest of the three cham-
❖ Dry suction with a traditional water-seal, dry suction bers, generally on the far-right side of the CDS, is the
with a one-way valve, and wet suction with a tradi- drainage reservoir. This is where drainage from the
tional water-seal pleural space accumulates. A window with calibrated
❖ Those that implement the use of gravity, suction, markings is located on the exterior of the drainage col-
or both to restore negative pressure and remove lection for observation of the color, amount, and con-
air, fluid, and blood from the pleural space or the sistency of fluid.
mediastinum ❖ The suction-control chamber, generally on the far-left
• Some CDSs use dry suction with a traditional water-seal side of the CDS, is the suction chamber that regulates
and either a regulator or a restricted orifice mechanism. the amount of negative pressure applied to the system.
195
TABLE 25-1 Pressure Conversion Chart*

cm H2O mm Hg
20 15
25 18
30 22
35 26
40 30
45 33
50 37
60 44
*Approximate values.
Reprinted with permission of Atrium Medical Corporation, Hudson, NH.
❖ The most common amount of suction pressure ranges

from −10 to −20 cm H2O.1,3,8,14 High suction levels
may cause persistent pleural air leaks, air stealing,
lung tissue entrapment, and reexpansion pulmonary
edema.14,17
❖ There are differences in flow rates and in accuracy of
delivered negative pressures noted in CDSs; however,
they are not likely to be clinically important.6,7
❖ Some systems contain an exit vent from the water-seal
chamber that ensures the drainage unit remains vented
when the suction device is off. Do not close or occlude
the exit vent.21,29 When using CDSs without an exit
vent, the drainage systems should be disconnected
from suction before they are turned off.21,29
❖ Some wall-mounted suction devices need control and
pressure gauges to regulate and monitor for potential
surges in suction levels.15,22,25
❖ If clinically appropriate, some wet suction with tradi-
tional water-seal drainage systems can provide suction
Figure 25-1 Disposable system correlates with three-bottle
levels greater than −25 cm H2O. The suction-chamber
system. (From Luce JM, Tyler ML, Pierson DJ: Intensive respira-
tory care, Philadelphia, 1984, Saunders.) vent holes can be occluded with nonporous tape or by
replacing them with the manufacturer’s special pronged
vent plug and connecting directly to wall regulator
❖ The water-seal chamber, in traditional water-seal CDSs suction. Suction levels must be converted from pre-
(wet systems), is usually the middle chamber and scribed levels of cm H2O suction to mm Hg of wall
provides a one-way relief valve between the atmo- suction (Table 25-1).
spheric pressure and the patient’s negative intrapleural • General guidelines in the proper care of the CDC include
pressure. the following:
❖ Positive-pressure relief valves are used to prevent a ❖ Greater pressure within the chest than within the
tension pneumothorax if the suction tubing becomes system is needed to maintain proper functioning of the
accidentally occluded or if the suction source fails. closed system; this requirement is accomplished by
In addition, automatic and manual pressure relief keeping the drainage unit at least 1 foot below the chest
valves vent excessive negative pressure, such as may tube insertion site and the tubing free of dependent
occur during deep inspiration or with milking of the loops and obstructions,1,11,13,25,27 which prevents siphon-
chest tube. ing of the contents back into the pleural cavity.25
• Suction guidelines include the following: ❖ Except for the exit vent, an airtight system is required
❖ When clinically indicted, the addition of a suction to assist in maintaining negative pressure in the pleura
source can enhance drainage when large volumes of air and to prevent air entrapment in the pleural space.
or fluid must be evacuated. ❖ Tidaling, fluctuations that occur with inspiration and
❖ Currently guidelines recommend that a water-seal expiration, provides a continuous manometer of the
alone is safe for most patients with a pneumothorax or pressure changes in the pleural space and indicates
small air leak.2–5,8,9,21 However, if the pneumothorax overall respiratory effort. Absence of fluctuations sug-
or air leak is large, expanding, or persistent, suction is gests obstruction of the drainage system from clots,
recommended.5,8,9 contact with lung tissue, kinks, loss of subatmospheric
25 Closed Chest-Drainage System 197
pressure from fluid-filled dependent loops, or complete limit the movement of the arm on the affected side to
reexpansion of the lung.1,10,19 decrease the discomfort at the insertion site, which
❖ In general, clamping of chest tubes is contraindicated. may result in joint discomfort and potential joint
Clamping a chest tube in a patient with a pleural air complications.
leak may cause a tension pneumothorax. The few • Instruct the patient and family about activity as prescribed
situations in which chest tubes may be clamped briefly while maintaining the drainage system below the level
(i.e., less than a minute) include locating the source of of the chest. Rationale: The drainage system is main-
an air leak, replacing the CDS, determining whether a tained below the level of the chest to facilitate gravity
patient is ready to have the chest tube removed, and drainage and to prevent backflow into the pleural space
during chest tube removal.1,14,15,21,29 and potential infectious contamination into the pleural
space.
EQUIPMENT • Instruct the patient and family about the availability of
prescribed analgesic medication and other pain-relief
Disposable Setup (Wet and Dry Systems) strategies. Rationale: Pain relief ensures comfort and
• Disposable chest-drainage unit facilitates coughing, deep breathing, positioning, and
• Gloves range-of-motion exercises, and promotes healing.
• Suction source and regulator
• Connecting tubing
• 1-L bottle of sterile water or normal saline (for systems PATIENT ASSESSMENT AND
that use water) PREPARATION
• 50-mL irrigation syringe (if not supplied with unit) for
systems that use water Patient Assessment
• Tape (1 inch), one roll, or zip ties (e.g., Parham-Martin • Assess significant medical history or injury, including
bands) chronic lung disease, spontaneous pneumothorax, pulmo-
nary disease, therapeutic procedures, and mechanism of
PATIENT AND FAMILY EDUCATION injury. Rationale: Medical history or injury may provide
the etiological basis for the occurrence of pneumothorax,
• Explain the procedure, the indication for the chest tube hemothorax, empyema, pleural effusion, or chylothorax.
insertion, and how the closed CDS works. Rationale: This • Assess patient’s baseline cardiopulmonary status (if
communication identifies patient and family knowledge patient’s condition does not necessitate immediate inter-
deficits about the patient’s condition, procedure, expected vention). Rationale: Provides reference points for future
benefits, and potential risks and allows time for questions assessments upon completion of the procedure.
to clarify information and to voice concerns. Explanations • Assess baseline cardiopulmonary status, as follows:
decrease patient anxiety and enhance cooperation. ❖ Vital signs (blood pressure, heart rate, respiratory rate)
• After chest tube insertion, instruct the patient to sit in a ❖ Shortness of breath or dyspnea
semi-Fowler’s position (unless contraindicated). Ratio- ❖ Anxiety, restlessness, or apprehension
nale: Proper positioning facilitates drainage from the lung ❖ Cyanosis
by allowing air to rise and fluid to settle, enhancing ❖ Decreased oxygen saturation (e.g., pulse oximetry
removal via the chest tube. This position also makes [Spo2])
breathing easier. ❖ Decreased or absent breath sounds on the affected side
• Instruct the patient to turn and reposition every 2 hours to ❖ Crackles adjacent to the affected area
facilitate drainage. The patient may lie on the side with ❖ Asymmetrical chest excursion with respirations
the chest tube but should keep the tubing free of kinks. ❖ Hyperresonance with percussion on the affected side
Rationale: Turning and positioning prevents complica- (pneumothorax)
tions related to immobility and retained secretions. ❖ Dullness or flatness with percussion on the affected
Keeping the tubing free of kinks maintains patency of the side (hemothorax, pleural effusion, empyema, or
tube, facilitates drainage, and prevents the accumulation chylothorax)
of pressure within the pleural space, which interferes with ❖ Subcutaneous emphysema or crepitus (pneumothorax)
lung reexpansion. ❖ Sudden sharp focal chest pain
• Instruct the patient to cough and deep breathe, with splint- ❖ Tracheal deviation to the unaffected side (tension
ing of the affected side or sternum (if mediastinal tube pneumothorax)
is in place). Rationale: Coughing and deep breathing ❖ Neck vein distention (tension pneumothorax, cardiac
increase pressure within the pleural space, facilitating tamponade)
drainage, promoting lung reexpansion, and preventing ❖ Muffled heart sounds (cardiac tamponade)
respiratory complications associated with retained secre- Rationale: Provides reference points for future tests
tions. The application of firm pressure over the chest upon completion of the procedure.
tube insertion site (e.g., splinting) may decrease pain and • Assess diagnostic tests (if patient’s condition does not
discomfort. necessitate immediate intervention):
• Encourage active or passive range-of-motion exercises of ❖ Chest radiograph
the arm on the affected side. Rationale: The patient may ❖ Arterial blood gases
nurse should ensure the correct identification of the patient

Patient Preparation for the intended intervention.
• Ensure the patient understands preprocedural teachings. • Administer prescribed analgesics or sedatives as needed.
Answer questions as they arise, and reinforce informa- Rationale: Analgesics and sedatives reduce the discom-
tion as needed. Rationale: This communication evaluates fort and anxiety experienced, facilitating patient coopera-
and reinforces understanding of previously presented tion and improving outcomes.
information.
identifiers. Rationale: Before performing a procedure, the
Procedure for Dry Suction Closed Chest-Drainage Systems

1. HH
2. PE
3. Open sterile packages. Maintains aseptic technique whenever
changes are made to the system.
4. Stabilize the unit. Some systems Keeping the clamp visible helps Clamping of chest tubes can cause air
have a floor stand. For systems prevent inadvertent clamping. trapped in the pleural space to
with an in-line connector, move accumulate and may cause tension
the patient tube clamp down pneumothorax.
next to the in-line connector.
5. Dry suction with a traditional Depth of solution required to establish Water-seal levels greater than 2 cm
water-seal: Remove the a water-seal; the water-seal permits increase the work of breathing;
connector cap from the short air and fluid to be removed from levels less than 2 cm can expose
tubing of the water-seal the patient and prevents the the water-seal to air and increase
chamber and use the funnel backflow of air into the chest.1,19 the risk for pneumothorax.19
provided or a 50-mL syringe to
add sterile water or normal
saline to the 2-cm level. Some
systems provide prefilled sterile
water containers.
Dry suction with a one-way valve:
Fill air-leak monitor zone.
6. Hang drainage unit from bed Drainage unit must be kept below the Avoid hanging drainage unit from
frame or set it on a floor stand. level of the chest to promote bed rails or other movable
(Level E*) gravity drainage and to prevent structures.
backflow of drainage into the
pleural space, which interferes with
lung expansion.1,25
7. Connect the long tubing from Creates the closed CDS; avoid Avoid dependent or fluid-filled loops,
the drainage collection chamber dependent or fluid-filled loops.13,24 which may create back pressure
to the chest tube. (Level C*) and decrease the effectiveness of
suction.13,24
8. For gravity drainage, leave the Creates the exit vent for the escape of Clamping of chest tubes can cause
suction-control chamber open to air. air trapped in the pleural space to
air. (Level M*) accumulate and may cause tension
pneumothorax.
Procedure for Dry Suction Closed Chest-Drainage Systems—Continued

9. To initiate suction, connect the Activates suction. Apply suction as per manufacturer’s
CDS to the suction source and guidelines. For example, to apply
dial in the prescribed amount of −20 cm H2O suction, use a
suction (usually −10 to −20 cm minimum vacuum pressure of
H2O), and then increase suction −80 mm Hg. Suction source
source until indicator mark vacuum should be > −80 mm Hg
appears according to when multiple chest drains are
manufacturer’s guidelines. used. For a suction level <−20 cm
H2O, any observed bellows
expansion across the monitor
window confirms adequate suction
operation. To decrease suction, set
the dial, confirm patient on suction,
then depress the high-negativity
vent, venting to the newer lower
amount.
10. Tape all connection points in Except for the exit vent, a secure and Zip ties (Parham-Martin bands) may
the CDS (see Fig. 21-2). airtight system is required to avoid be used to secure connections
A. One-inch tape is placed inadvertent disconnection that could instead of tape.
horizontally, extending over cause air entrapment in the pleural
the connections (a portion of space and decreased pleural
the connector may be left negative pressure.
unobstructed by the tape). This technique secures the
connections but allows visualization
of drainage in the connector.
B. Reinforce the horizontal
tape with tape placed
vertically so that it encircles
both ends of the connector.
11. Dispose of soiled equipment
and supplies and remove PE .
12. HH
Procedure for Wet Suction Closed Chest-Drainage Systems

1. HH
2. PE
3. Open sterile packages. Maintains aseptic technique
whenever changes are made to
the system.
4. Stabilize the unit. Some systems Keeping the clamp visible helps Clamping of chest tubes can cause
have a floor stand. For systems with prevent inadvertent clamping. air trapped in the pleural space to
an in-line connector, move the accumulate and may cause tension
patient tube clamp down next to the pneumothorax.
in-line connector.
5. Remove the connector cap from the Depth of solution required to Water-seal levels >2 cm increase the
short tubing of the water-seal establish a water-seal; the work of breathing; levels <2 cm
chamber and use the funnel water-seal permits air and fluid can expose the water-seal to air
provided or a 50-mL syringe to add to be removed from the chest and increase the risk for
sterile water or normal saline to the and prevents backflow of air.1,19 pneumothorax.19
2-cm level.
6. For gravity drainage, leave the short Creates the exit vent for the Clamping or occlusion of the exit
tubing from the suction control escape of air. vent can cause air to remain
chamber open to air by turning trapped in the pleural space, which
stopcock to “open” or “on” position. may cause tension pneumothorax.
Procedure for Wet Suction Closed Chest-Drainage Systems—Continued

7. For suction drainage, fill the Suction is regulated by the height Refill the solution level as necessary
suction-control chamber with sterile of the solution level in this to the prescribed amount to
water or normal saline to the chamber. replace solution lost through
prescribed level (usually −10 to evaporation.
−20 cm H2O suction). Connect the Remove excess fluid as necessary
short tubing from the suction-control via self-sealing grommet.
chamber to the suction source.
8. Hang chest-drainage unit from bed Drainage unit must be kept below Avoid hanging drainage unit from
frame, or set it on a floor stand. the level of the chest to promote bed rails or other movable
(Level E*) gravity drainage and to prevent structure.
backflow of drainage into the
pleural space, which interferes
with lung expansion.1,25
9. Connect the long tubing from the Creates the drainage-collection Dependent or fluid-filled loops may
drainage collection chamber to the system; avoid dependent or create back pressure and decrease
chest tube. (Level C*) fluid-filled loops.13,24 the effectiveness of suction.13,24
10. Turn on the suction source, if Activates suction. Some systems have a suction-control
prescribed, to elicit gentle constant feature to maintain the desired
bubbling. Leave stopcock between suction level automatically despite
CDS and suction source fully open fluctuations in the suction source.
and adjust force of bubbling at The stopcock should be kept fully
suction source to decrease risk for in “open” or “on” position and
pneumothorax. force of bubbling should be
adjusted at suction source.
11. Tape all connection points in the Except for the exit vent, a secure Zip ties (Parham-Martin bands) may
CDS (see Fig. 21-2).15 and airtight system is required be used to secure connections
A. One inch tape is placed to avoid inadvertent instead of tape.
horizontally extending over the disconnection that could cause
connections (a portion of the air entrapment in the pleural
connector may be left space and decreased pleural
unobstructed by the tape). negative pressure.
B. Reinforce the horizontal tape This technique secures the
with tape placed vertically so connections but allows
that it encircles both ends of the visualization of drainage in the
connector. connector.
12. Dispose of soiled equipment and
supplies and remove PE .
13. HH

• Removal of air, fluid, or blood from the thoracic cavity • Tension pneumothorax
• Fluctuation or tidaling noted in the water-seal chamber • Hemorrhagic shock
(until lung reexpanded) • Absence of drainage and fluctuation or tidaling, or
• Relief of respiratory distress continuous bubbling in the water-seal chamber with
• Reexpansion of the collapsed lung as validated with continued respiratory distress
chest radiograph • No evidence of reexpansion of lung
• Fever, purulent drainage, and redness around the
insertion site or purulent drainage in the chest tube

reported if they persist
despite nursing interventions.
1. Assess every 1–2 hours and with Provides baseline and ongoing assessment • Tachypnea
any change in patient condition or of patient’s condition. • Decreased or absent breath
according to institution protocol. sounds
• Hypoxemia
• Tachycardia
• Dysrhythmias
• Hypotension
• Muffled heart tones
(crepitus)
• Neck vein distention
• Tracheal deviation
• Fever
• Absence of fluctuations in
water-seal chamber with
respiratory distress
2. Monitor the amount and type of Marking container provides reference point • Drainage >100 mL/hr1 or
drainage by marking the drainage for future measurements. according to practitioner
level on the outside of the Volume loss can cause patients to become order
drainage-collection chamber in hypovolemic or can signal • Sudden decrease or absence
hourly or shift increments intrapulmonary bleeding. of drainage
(depending on the amount of Drainage should decrease gradually and • Change in characteristics of
drainage) or in time increments change from bloody to pink to straw drainage, such as
established by institution policy or colored. Sudden flow of dark bloody unexpectedly bloody,
per practitioner orders. Monitor drainage that occurs with position cloudy, or milky
amount and type of drainage. change is often old blood. • New onset of clots
Decreased or absent drainage associated
with respiratory distress may indicate
obstruction; decreased or absent
drainage without respiratory distress
may indicate lung reexpansion.
Autotransfusion: if chest-drainage
transfusion (autotransfusion) is being
considered, please see Autotransfusion
(Procedure 20).

3. Assess patient and CDS for an air Assessing for an air leak is one way to • New or increasing air leaks
leak. If a suction source has been determine whether the patient is in the chest or around the
added, momentarily turn suction experiencing a pneumothorax. Bubbling chest tube insertion site
off or pinch suction tubing to when suction is initially turned on • Chest tube drainage from a
accurately assess.1 An air leak is occurs with air displaced by fluid mediastinal tube does not
present if air bubbles are observed drainage in the collection chamber, loose normally cause bubbling in
in the water-seal chamber or going connections in the system, or an air leak the water-seal chamber; if
from right-to-left in the leak in the pleural space.10 With a minor air noted, it may indicate
detector zone. leak, bubbling may occur only with communication with the
When assessing the air-leak chamber, coughing when airway pressures reach pleural space; notify
ask the patient to take deep breaths their peak.8,29 An airtight system is physician
in and out. If you do not note an required to help reestablish negative • Notify physician of system
air leak, ask the patient to cough.8 pressure in the pleural space. If bubbling knock over and changing of
When the patient’s pleural space is in the water-seal chamber stops when the CDS (e.g., chest
leaking air, intermittent bubbling is the chest tube is occluded at the dressing radiograph may be
seen corresponding to respirations. site, the air leak is inside the patient’s ordered).29
If bubbling is continuous, suspect chest or under the dressing. If a new-
an air leak in the system. To locate onset air leak, reinforce the dressing and
the source, intermittently pinch the notify the physician. If the bubbling
chest tube or drainage tubing for a stops when the drainage tubing is
moment (i.e., less than a minute), occluded along its length, the air leak is
beginning at the insertion site and between the occlusion and the patient’s
progressing to the chest-drainage chest; check to ensure all connections
unit.1 are airtight.1,8 If bubbling does not stop
with occlusion, replace the CDS.
4. Assess chest tube and CDS patency Obstruction of drainage from the chest • Inability to establish patency
on insertion, every 1–2 hours, and tube interferes with lung reexpansion or • Excessive drainage
with a change in patient condition. may cause cardiac tamponade. • Signs and/or symptoms of
Routine chest tube stripping or Stripping the entire length of the chest increasing:
milking is not recommended. Upon tube is contraindicated because it results • Pneumothorax
identification of a visible clot or in transient high negative pressures in • Cardiac tamponade
other obstructing drainage, gently the pleural space that could lead to lung • Hemothorax
milk (manual squeezing and entrapment.11
releasing of small segments of No significant differences are reported in
tubing, or fan-folding and the amount of drainage when the tubing
compressing small segments is milked as opposed to stripped.12
of tubing13) between the Milking can cause excessive negativity.
fingers.10–12,16,18,22,23,26, 28-30 Use the high negativity relief value to
(Level C*) restore negativity to prescribed levels
Ensure there are no clamps on the (see Step 8). Milking with a clamp on
chest tubes during milking. can result in the build-up of excessive
thoracic pressure.
5. Maintain drainage tubing free of Drainage that accumulates in dependent • Loops or kinks that cannot
dependent loops (i.e., place the loops obstructs chest drainage into the be removed
tube horizontally on the bed and collecting system and increases pressure
down into the collection chamber, within the lung.10,12,13,15,22,24 Allow
coiling the tubing on the bed). If a enough length for patient movement.
dependent loop cannot be avoided,
lift and drain the tubing every 15
minutes.13,14,24 (Level C)

6. Monitor fluid levels in the CDS To maintain prescribed water-seal and • Inability to maintain a
chambers by briefly turning off the suction levels and to prevent water-seal or to keep suction
suction and refill (usually every 8 complications. Water-seal levels >2 cm at prescribed level
hours for suction chamber and increase the work of breathing; levels
every 24 hours for water-seal) or <2 cm expose the water-seal to air and
remove solution levels as necessary increase the risk for pneumothorax.1,19
to the prescribed amount.
7. Assess for CDS patency: note Tidaling, fluid fluctuation up and down or • Absence of fluctuations or
fluctuations or tidaling of fluid back and forth, indicates effective tidaling
level in the water-seal chamber communication between the pleural
(disposable CDS) or the long straw space and drainage system and provides
of the water-seal bottle (bottle an indication of lung expansion.
CDS) with respirations.1,19 Fluctuations or tidaling stops when the
If a suction source has been added, lung is reexpanded or when the tubing is
momentarily turn suction off or obstructed by a kink, a fluid-filled loop,
pinch suction tubing to accurately the patient lying on the tubing, or a clot
assess for fluctuations or tidaling. or tissue at the distal end.1,10,19 Suction
must be turned off to accurately assess
for tidaling.
8. Assess CDS equipped with a float Changes in the patient’s intrathoracic • Sustained increases in
valve for increases in the patient’s pressure are reflected by the height of negative pressures
negative intrathoracic pressure. the water in the water-seal column. Do
Inspect water-seal chamber for not lower water-seal column when
increased levels (e.g., after milking suction is not operating or when patient
of chest tube or when decreasing is on gravity drainage. Resume suction
the amount of suction). Ensure the while performing this operation. If
CDS is operating on suction. suction is not operative, or operating on
Second, temporarily depress the gravity drainage, depressing the high-
filtered manual vent until the float negative relief valve can reduce negative
valve releases and the water pressure within the collection chamber
column lowers. to zero (atmosphere), possibly resulting
in a pneumothorax.
9. Assess insertion site and Crepitus may indicate chest tube • New or increasing
surrounding skin for the presence obstruction or improper tube position. subcutaneous emphysema
of subcutaneous emphysema Skin integrity is altered during insertion (crepitus)
(crepitus) and signs of infection or and can lead to infection. Petroleum • Fever
inflammation daily and with each gauze dressing has been noted to cause • Redness around insertion
dressing change. Dressings should skin maceration, potentiating the risk of site
be changed when soiled, per infection.15 • Purulent drainage
institution protocol, or when
ordered by practitioner. Routine
petroleum dressings are not
recommended.15 (Level E*)


10. Monitor collection chamber for When the patient has an air leak or • Respiratory distress noted
total amount of fluid. Change CDS pneumothorax, clamping of the chest during or after procedure
when approaching full or if system tube may precipitate a tension • Changes in breath sounds
integrity is interrupted (i.e., pneumothorax because the air has no after procedure
cracked). Assess cardiopulmonary escape route and may accumulate in the • Nonfunctioning CDS
status and vital signs (including pleural space.1,15,17 Clamping of the chest
Spo2) before and after procedure. tube should be as brief as possible.
Prepare new CDS according to
manufacturer’s instructions. Then,
briefly (i.e., for less than a minute)
cross clamp the chest tube close to
the patient’s chest. Attach the new
system, unclamp the chest tube,
check connections, and assess
function of drainage system.
11. During gravity drainage, The suction control stopcock should • Notify physician of
ambulation, or transport with always remain in the “on” or “open” inadvertent clamping or
gravity drainage, ensure CDS is position. Do not clamp or cap the capping of the suction line
upright, below the chest tube suction line. Leaving the port open
insertion site, and maintain the allows air to exit and minimizes the
suction control stopcock in the possibility of tension pneumothorax.
“on” or “open” position. Do not
clamp chest tube during
transport.1,25 (Level E*)
assessing pain. Administer interventions.
13. Obtain a drainage specimen from Provides a specimen for analysis. • Inability to obtain specimen
some disposable CDSs. Cleanse the
site with antiseptic solution and use
a syringe with a smaller (e.g.,
20-gauge) needle to withdraw the
specimen from the self-sealing
diaphragm, or self-sealing drainage
tubing, as available. Momentarily
forming a dependent loop in the
fluid collection tubing may be
necessary to obtain a specimen.
Documentation
• Patient and family education • Respiratory, thoracic, and vital sign assessment at
• Pain assessment, interventions, and effectiveness baseline and with changes in therapy
• Cardiopulmonary and vital sign assessment • Completion and results of the postinsertion chest
• Type of drainage system used radiograph and any other ordered diagnostic tests
• Amount of suction, fluctuation or tidaling, type and • Unexpected outcomes
amount of drainage • Nursing interventions
• Air leak: absence, presence, severity, and resolution • Patient’s tolerance of the therapy

25 Closed Chest-Drainage System 205.e1
References 19. Jablonski S, et al: Efficacy assessment of the drainage

1. Allibone L: Nursing management of chest drains. Nurs with permanent airflow measurement in the treatment of
Stand 17:45–56, 2003. pneumothorax with air leak. Thorac Cardiovasc Surg
2. Alphonso N, et al: A prospective randomized controlled 62:509–515, 2014.
trial of suction versus non-suction to the under-water seal 20. Kane CJ, York NL, Minton LA: Chest tubes in the
drains following lung resection. Eur J Cardiothorac Surg critically ill patient. Dimens of Crit Care Nurs 32(3):
27:391–394, 2005. 111–117, 2013.
3. Ayed AK: Suction versus water seal after thoracoscopy 21. Kam AC, O’Brien M, Kam PCA: Pleural drainage
for primary spontaneous pneumothorax: Prospective systems. Anaesthesia 48:154–161, 1993.
randomized study. Ann Thorac Surg 75:1593–1596, 22. Kelly AM: Review of management of primary
2003. spontaneous pneumothorax: is the best evidence clearer
4. Baumann MH: Management of spontaneous 15 years on? Emerg Med Aust 19:303–308, 2007.
pneumothorax. Clin Chest Med 27:369–381, 2006. 23. Lehwaldt D, Timmins F: Nurses’ knowledge of chest
5. Baumann MH: Management of spontaneous drain care: an exploratory descriptive survey. Nurs Crit
pneumothorax: An American College of Chest Physicians Care 10(4):192–200, 2005.
Delphi consensus statement. Chest 119:590–602, 2001. 24. Lim-Levy F, et al: Is milking and stripping chest tubes
6. Baumann MH: What size chest tube? What drainage really necessary? Ann Thorac Surg 42:77–80, 1986.
system is ideal? And other chest tube management 25. Pierce J, Piazza D, Naftel DC: Effects of two chest tube
questions. Curr Opin Pulm Med 9:276–281, 2003. clearance protocols on drainage in patients after
7. Baumann MH, et al: Comparison of function of myocardial revascularization surgery. Heart Lung
commercially available pleural drainage units and 20:125–130, 1991.
catheters. Chest 123:1878–1886, 2003. 26. Remerand F, et al: Incidence of chest tube malposition in
8. Cerfolio RJ: Recent advances in the treatment of air leaks. the critically ill. A prospective computed tomography
Curr Opin Pulm Med 11:319–323, 2005. study. Anesthesiology 106(6):1112–1119, 2011.
9. Cerfolio RJ, et al: The management of chest tubes in 27. Schmelz JO, et al: Effects of position of chest drainage
patients with a pneumothorax and an air leak after tube on volume drained and pressure. Am J Crit Care
pulmonary resection. Chest 128:816–820, 2005. 8:319–323, 1999.
10. Deshpande KS, Tortolandi AJ, Kvetan V: Troubleshooting 28. Shalli S, et al: Chest tube selection in cardiac and thoracic
chest tube complications: how to prevent—or quickly surgery: a survey of chest tube-related complications and
correct—the major problems. J Crit Ill 18(6):275–280, their management. J Card Surg 24:503–509, 2009.
2003. 29. Tang AT, Velissaris TJ, Weeden DF: An evidence-based
11. Duncan C, Erickson R: Pressures associated with chest approach to drainage of the pleural cavity: evaluation of
tube stripping. Heart Lung 11:166–171, 1982. best practice. J Eval Clin Pract 8:333–340, 2002.
12. Duncan C, Erickson R, Wiegel RM: Effect of chest tube 30. Wallen M, et al: Mediastinal chest drain clearance for
management on drainage after cardiac surgery. Heart cardiac surgery. Cochrane Database Syst Rev
Lung 16:1–9, 1987. (4):CD003042, 2004.
13. Gordon PA, et al: Positioning of chest tubes: Effects on
pressure and drainage. Am J Crit Care 6:33–38, 1997. Additional Readings
14. Gordon PA, Norton JM, Merrell R: Redefining chest tube Atrium: Managing chest drainage, Hudson, NH, 2007, Atrium
management: analysis of the state of practice. Dimens Crit Medical Corporation.
Care Nurs 14:6–13, 1995. Atrium: Managing dry suction chest drainage, Hudson, NH,
15. Gross SB: Current challenges, concepts and controversies 2007, Atrium Medical Corporation.
in chest tube management. AACN Clin Issues Crit Care Brunelli A, et al: Digital measurements of air leak flow and
Nurs 4:260–275, 1993. intrapleural pressures in the immediate postoperative
16. Halm MA: To strip or not to strip? Physiological effects period predict risk of prolonged air leak after pulmonary
of chest tube manipulation. Am J Crit Care 16(6): lobectomy. Cardiothorac Surg 39:584–588, 2011.
609–612, 2007. Cerfolio RJ, Varela G, Brunelli A: Digital and smart chest
17. Henry M, Arnold T, Harvey J: British Thoracic Society drainage systems to monitor air leaks: the birth of a new
guidelines for the management of spontaneous era? Thorac Surg Clin 20:413–420, 2010.
pneumothorax. Thorax 58:39–52, 2003. Pompili C, et al: Multicenter international randomized
18. Isaacson JJ, George IT, Brewer MJ: The effect of chest comparison of objective and subjective outcomes between
tube manipulation on mediastinal drainage. Heart Lung electronic and traditional chest drainage systems. Ann
15(6):601–605, 1986. Thorac Surg 98:490–497, 2014.
PROCEDURE
26
Needle Thoracostomy (Perform)
Cindy Goodrich
PURPOSE: Needle thoracostomy is performed to reduce a tension pneumothorax
to a simple pneumothorax in a patient with a rapidly deteriorating condition. This
temporary measure is followed quickly by the insertion of a chest tube for more
definitive management.
PREREQUISITE NURSING ❖ Dysrhythmias

KNOWLEDGE ❖ Cyanosis
❖ Decreased pulse oximetry readings
• Anatomy and physiology of the pulmonary system should ❖ Pulseless electrical activity
be understood. • Needle thoracostomy is performed by placing a needle
• The thoracic cavity, in normal conditions, is a closed air into the pleural space to remove air and reestablish nega-
space. Any disruption results in the loss of negative pres- tive pressure in patients who are rapidly deteriorating
sure within the intrapleural space. Air or fluid that enters from a life-threatening tension pneumothorax (Fig. 26-1).
the space competes with the lung, which results in col- Definitive treatment requires the insertion of a chest tube
lapse of the lung. Associated conditions are the result of as soon as possible after this temporary measure.1
disease, injury, surgery, or iatrogenic causes. • Needle decompression success is influenced by the chest
• A pneumothorax is classified as an open, closed, or tension wall thickness. Current evidence suggests that an 8-cm
pneumothorax. In patients with tension pneumothorax, air needle will reach the pleural space more than 90% of the
leaks into the pleural space through a tear in the lung and, time, whereas a 5-cm length needle will only reach the
with no means to escape from the pleural cavity, creates pleural space more than 50% of the time.1
a one-way valve effect. With each breath the patient
takes, air accumulates, pressure within the pleural space EQUIPMENT
increases, and the lung collapses. As a result, the medias-
tinal structures (i.e., heart, great vessels, and trachea) shift • Personal protective equipment including eye protection
to the opposite or unaffected side of the chest. Venous • 14- to 16-gauge hollow needle or catheter at least 5 cm in
return and cardiac output are impeded, and the possibility length
of collapse of the unaffected lung exists.1 • Antiseptic solution
• Tension pneumothorax is a medical emergency that neces- • 4 × 4 gauze dressing
sitates immediate intervention. Accurate assessment of the • Tape
following signs and symptoms allows for prompt recogni- • Oxygen
tion and treatment: • Self-inflating manual resuscitation bag-valve-mask device
❖ Tracheal deviation to the unaffected side • Oxygen source and tubing
❖ Jugular vein distention • Commercially available (Heimlich) flutter valve to attach
❖ Sudden, sharp chest pain to the needle or catheter, or, as an emergency alternative,
❖ Decreased or absent breath sounds on the affected side a one-way valve may be created by using the following:
❖ Asymmetrical chest excursion with respirations ❖ Scissors
❖ Tachypnea, shortness of breath, dyspnea, increased ❖ Sterile glove (powder-free)
work of breathing ❖ Small rubber band
❖ Decreased oxygen saturation ❖ Cut a finger off the glove, cut the very tip of the glove
❖ Subcutaneous emphysema finger off, and attach it to the needle with the rubber
❖ Anxiety, restlessness, apprehension band.1
❖ Tachycardia
❖ Hypotension PATIENT AND FAMILY EDUCATION
• If time permits, assess the patient’s and family’s level
practice nurses, and other healthcare professionals (including critical care of understanding about the condition and rationale for
nurses) with additional knowledge, skills, and demonstrated competence per the procedure. Rationale: This assessment identifies the
professional licensure or institutional standard. patient’s and family’s knowledge deficits concerning the
206
26 Needle Thoracostomy (Perform) 207
Figure 26-1 Use of a needle and a sterile finger cot or a finger from a sterile glove to fashion a
one-way (flutter) valve for emergency evacuation of a tension pneumothorax. A small opening is
made in the free end of the glove finger to allow air to escape during expiration. (From Cosrniff JH:
An atlas of diagnostic and therapeutic procedures for emergency personnel, Philadelphia, 1978,
J.B. Lippincott.)
patient’s condition, the procedure, the expected benefits, outcomes of treatment. Tension pneumothorax is a medical
and the potential risks. It also allows time for questions emergency that necessitates immediate intervention.
to clarify information and voice concerns. Explanations • If the situation allows, assess vital signs, including pulse
decrease patient anxiety and enhance cooperation. oximetry. Rationale: Baseline assessment data provide
• Explain the procedure and the reason for the procedure, if information about the patient’s condition and allows for
the clinical situation permits. If not, explain the procedure comparison during and after the procedure.
and reason for its implementation after it is completed.
Rationale: This explanation enhances patient and family Patient Preparation
understanding and decreases anxiety. • Verify correct patient with two identifiers. Rationale:
• If indicated, explain the patient’s role in assisting with Prior to performing a procedure, the nurse should ensure
needle thoracostomy. Rationale: Eliciting the patient’s the correct identification of the patient for the intended
cooperation assists with insertion of a needle and flutter intervention.
valve. • Ensure that the patient and family understand the emer-
gency nature of the procedure and preprocedural teach-
ings, if appropriate. Answer questions as they arise, and
PATIENT ASSESSMENT AND reinforce information as needed. Rationale: This com-
PREPARATION munication evaluates and reinforces understanding of pre-
viously taught information.
Patient Assessment • Position the patient in supine position with the head of the
• Assess whether signs and symptoms are consistent with bed flat. Rationale: This positioning allows for identifica-
tension pneumothorax, as noted previously. Rationale: tion of landmarks for proper placement of needle and
Accurate assessment of signs and symptoms allows for flutter valve.
prompt recognition and treatment. Baseline assessment • Perform a preprocedure verification and time out, if non-
provides comparison data for evaluation of changes and emergent. Rationale: Ensures patient safety.
Procedure for Performing Needle Thoracostomy

1. HH
2. PE Protective eyewear prevents exposure
to secretions that may be expelled
as the needle penetrates the
pressurized pleural space.
3. Administer high-flow oxygen Allows for oxygenation and
and ventilate as needed. ventilation before needle insertion.
4. Locate the second intercostal Identification of landmarks for
space at the midclavicular line needle thoracostomy.
on the side of the suspected
tension pneumothorax.
5. Prepare the skin with antiseptic Cleanses area before needle
solution using a circular motion. insertion.
6. Locate the upper margin of the Allows the proper placement of the
third rib with several fingers. needle into the pleural space.
Insert needle into the second Inserting the needle above third rib
intercostal space at the avoids damaging the nerve, artery,
midclavicular line, pointing the and vein that lie just beneath each
needle posterior but slightly rib.
upward and sliding it over the
top of the third rib.1–4 (Level D*)
7. Puncture the parietal pleural Although an audible rush of air This procedure may not be successful
space. Listen for an audible indicates that needle due to chest wall thickness,
escape of air as the needle enters decompression has been anatomical complications, or
the pleural space. If a catheter successful, a dramatic kinking of the catheter.1 May need
over needle device is used, improvement in the patient’s to repeat procedure with a longer
remove the needle.1–4 (Level D) clinical condition is the best catheter to puncture the parietal
indicator of successful pleura in patients with large, thick
intervention. chests. Verify catheter is not kinked
and that it is has been inserted into
the proper anatomical location.
8. Attach a flutter valve to the Allows air to escape the pleural Needle and flutter valve act as a
needle or catheter, if not already space and prevents air from one-way valve, preventing reentry
attached.1–4 (Level D) entering. of air into pleural space but
allowing for escape of air during
expiration (see Fig. 26-1).
9. Apply a small dressing around Allows for temporary stabilization
the needle or catheter and secure, of needle or catheter until a chest
or suture, it in place. tube can be inserted.
10. Prepare for immediate chest tube Definitive treatment of tension
insertion (see Procedures 21 and pneumothorax.
22).
remove PE .
12. HH
26 Needle Thoracostomy (Perform) 209

• Removal of air from pleural space • Resultant pneumothorax in patient without tension
• Reestablishment of negative intrapleural pressure pneumothorax
• Tension pneumothorax conversion to simple • Damage to nerves, veins, or arteries because of
pneumothorax improper flutter-valve placement
• Improved oxygenation and ventilation • Local hematoma or cellulitis
• Pleural infection
• Unsuccessful placement of needle due to chest wall
thickness, anatomical complications, or kinking of
catheter

interventions.
1. Assess vital signs. Provides information regarding • Significant changes in the patient’s
the patient’s condition. vital signs
2. Stabilize the needle or Prevents movement and • Dislodged needle or catheter
catheter with dressing until dislodgment of needle or
chest tube is inserted. catheter. A chest tube should be
inserted as soon as practical.
3. Continuously monitor for Determines whether chest • Tracheal deviation to the unaffected
signs and symptoms of decompression has been side
tension pneumothorax.1–4 successful and allows for early • Jugular vein distention
(Level D*) identification of new • Sudden, sharp chest pain
pneumothorax until chest tube • Decreased or absent breath sounds
has been placed. on the affected side
• Asymmetrical chest excursion with
respirations
• Tachypnea, shortness of breath,
dyspnea, increased work of breathing
• Anxiety, restlessness, apprehension
• Tachycardia
• Hypotension
• Dysrhythmias
• Cyanosis
4. Continuously monitor for Determines need for repeated • Return of signs and symptoms of
catheter/needle occlusion due needle decompression and tension pneumothorax as listed
to clot formation at the rapid insertion of a chest tube. previously
catheter/needle tip.
5. Follow institution standard Identifies need for pain • Continued pain despite pain
for assessing pain. Administer interventions. interventions

Documentation
• Vital signs before and after insertion of needle or • Occurrence of unexpected outcomes
catheter, including pain, as appropriate • Nursing interventions
• Location of needle or catheter • Patient and family education
• Size and length of needle or catheter used • Pain assessment, interventions, and effectiveness
• Response after needle or catheter placement

26 Needle Thoracostomy (Perform) 210.e1
References 3. Holleran RS: ASTNA patent transport: principles and

1. American College of Surgeons, Committee on Trauma: practice, ed 4, St Louis, 2010, Mosby.
Advanced trauma life support (ATLS) student course 4. Roberts JR, Hedges JR, editors: Clinical procedures in
manual: thoracic trauma, ed 9, Chicago, 2012, American emergency medicine, ed 6, Philadelphia, 2014, Saunders.
College of Surgeons.
2. Emergency Nurses Association: Trauma nursing core
course: provider manual, ed 7, Des Plaines, IL, 2014,
Emergency Nurses Association.
PROCEDURE
27
Thoracentesis (Perform)
Susan Yeager
PURPOSE: Thoracentesis is performed to assist in the diagnosis and therapeutic
management of patients with pleural effusions.
PREREQUISITE NURSING do not establish a diagnosis; instead the laboratory results

KNOWLEDGE must be correlated with the clinical findings and serum
laboratory results.
• Thoracentesis is performed with insertion of a needle or • Light’s criteria should be used to distinguish between a
a catheter into the pleural space, which allows for removal pleural fluid exudate and transudate. In order to apply
of pleural fluid. Light’s criteria, the total protein and lactate dehydroge-
• Pleural effusions are defined as the accumulation of nase (LDH) should be measured in both blood and pleural
fluid in the pleural space that exceeds 10 mL and results fluid (Box 27-1).2,3
from the overproduction of fluid or disruption in fluid • Exudative effusions indicate a local etiology (e.g., pulmo-
reabsorption.1 nary embolus, infection), whereas transudative effusions
• Thoracentesis is not used to verify the presence of pleural usually are associated with systemic etiologies (e.g., heart
effusion. Diagnosis of pleural effusion is made via clinical failure).3
examination, patient symptoms, and diagnostic tech- • Exudative pleural effusions meet one of the following
niques. A number of techniques can demonstrate pleural criteria:
effusion with varying levels of sensitivity. Percussion ❖ Pleural fluid LDH/serum LDH ratio is greater than 0.6
requires a minimum of 300 to 400 mL for identification international units/mL.
of a pleural effusion, whereas a standard chest radiogra- ❖ Pleural fluid LDH is more than two thirds of the upper
phy requires 200 to 300 mL. Lateral decubitus radio- limit of normal for serum LDH.
graphs can be used to recognize smaller fluid amounts and ❖ Pleural fluid protein/serum protein ratio is greater than
highlight whether present fluid is free flowing. Ultrasound 0.5 g/dL.3
scan, computed tomography (CT) scan, and magnetic • Relative contraindications for thoracentesis include the
resonance imaging (MRI) technology can detect 100 mL following:
of fluid with 100% sensitivity.1 Therefore, initial diagnosis ❖ Patient anatomy that hinders the practitioner from
of pleural effusion may be optimized via imaging tech- clearly identifying the appropriate landmarks
niques such as chest radiographs, ultrasound scans, CT ❖ Patients actively undergoing anticoagulation therapy or
scans, or MRI combined with patient symptoms and clini- with an uncorrectable coagulation disorder
cal examination findings. ❖ Patients receiving positive end-expiratory pressure
• Diagnostic thoracentesis is indicated for differential diag- therapy
nosis for patients with pleural effusion of unknown etiol- ❖ Patients with splenomegaly, elevated left hemidia-
ogy. A diagnostic thoracentesis may be repeated if initial phragm, or left-sided pleural effusion
results fail to yield a diagnosis. ❖ Patients with only one lung as a result of a previous
• Therapeutic thoracentesis is indicated to relieve the symp- pneumonectomy
toms (e.g., dyspnea, cough, hypoxemia, or chest pain) ❖ Patients with known lung disease
caused by a pleural effusion. ❖ Patients with active skin infection at the point of needle
• Pleural effusions are classified as either transudative or insertion4
exudative effusions. • Ultrasound scan–guided thoracentesis is thought to reduce
• Samples of pleural fluid are analyzed and assist in distin- complications.
guishing between exudative and transudative etiologies of • Complications commonly associated with thoracentesis
effusion. Results of laboratory tests on pleural fluid alone include pneumothorax, hemopneumothorax, hemorrhage,
hypotension, cough, pain, visceral injury, and reexpansion
pulmonary edema.4–6
• The most common complications from pleural aspiration
are pneumothorax, pain, hemorrhage, and procedure
practice nurses, and other healthcare professionals (including critical care failure. The most serious complication is visceral injury.5
nurses) with additional knowledge, skills, and demonstrated competence per • Hypotension can occur as part of the vasovagal reaction,
professional licensure or institutional standard. causing bradycardia, during or hours after the procedure.
211
• Three-way stopcock
BOX 27-1 Light’s Criteria for Exudative
• Sterile 20-mL syringe
Pleural Effusions (Applies If • Sterile 50-mL syringe
One or More Criteria Are Met) • Two chemistry blood tubes
EXUDATIVE CRITERIA • Hemostat or Kelly clamp
Ratio of pleural fluid protein to serum protein is >0.5 • Pulse oximetry equipment
Ratio of pleural fluid lactate dehydrogenase (LDH) to serum LDH • Side table
is >0.6 • Pillow or blanket to be placed on side table
Pleural fluid LDH level is > 2 3 of the upper limit of normal for • 14-gauge needle
serum LDH • 16-gauge catheter
• Vacutainers or evacuated bottles (1 to 2 L) with pressure
Modified from Porcel J, Light R: Diagnostic approach to pleural effusion in tubing
adults, Am Fam Physician 73(7):1211–1220, 2006. Additional equipment, to have available as needed, includes
the following:
• Atropine, oxygen, thoracostomy supplies, advanced
cardiac life-support equipment
If it occurs during the procedure, cessation of the proce- • Ultrasound-scan equipment as available and with a cre-
dure and intravenous (IV) atropine may be necessary. If dentialed provider
hypotension occurs after the procedure, it is likely the • Two complete blood count tubes
result of fluid shifting from pleural effusion reaccumula- • One anaerobic and one aerobic media bottle for culture
tion. In this situation, the patient is likely to respond to and sensitivity
fluid resuscitation.7 • Sterile tubes for fungal and tuberculosis cultures specimen
• Development of cough generally initiates toward the tubes
end of the procedure and should result in procedure • Commercially prepackaged thoracentesis kits, which are
cessation. available in some institutions
• Reexpansion pulmonary edema is thought to occur from
overdraining of fluid too quickly. The incidence is less PATIENT AND FAMILY EDUCATION
than 1% but asymptomatic radiologically apparent reper-
fusion pulmonary edema may be slightly more frequent.5 • Assess patient’s and family’s level of understanding about
The maximum volume of fluid that can be safely removed the condition and rationale for the procedure. Rationale:
is uncertain because the volume removed does not clearly This assessment identifies the patient’s and family’s
correlate with the onset of symptoms. Traditionally, to knowledge deficits concerning the patient’s condition, the
avoid this complication, discontinuation of fluid removal procedure, the expected benefits, and the potential risks.
occurs with the onset of symptoms or when the total fluid It also allows time for questions to clarify information and
removed reaches 1000 to 1500 mL.5,6 voice concerns. Explanations decrease patient anxiety and
• If using continuous positive airway pressure, caution enhance cooperation.
should be taken to avoid potential pneumothorax follow- • Explain the procedure and the reason for the procedure, if
ing aspiration if there is no pleural drain in place.5 Patients the clinical situation permits. If not, explain the procedure
receiving positive airway pressure can undergo thoracen- and reason for the intubation after it is completed. Ratio-
tesis with an ultrasound-guided incidence of less than 7% nale: This explanation enhances patient and family under-
pneumothorax noted.4,8 standing and decreases anxiety.
• Baseline diagnostic study results (i.e., lateral decubitus • Explain the patient’s role in thoracentesis. Rationale:
chest radiograph, ultrasound imaging, CT scan, or MRI) This explanation increases patient compliance, facilitates
should be reviewed before the procedure to identify the needle and catheter insertion, and enhances fluid removal.
location and extent of pleural fluid accumulation.
EQUIPMENT PATIENT ASSESSMENT AND

PREPARATION
• Indelible marker
• Sterile gloves Patient Assessment
• Sterile drapes • Assess medical history of symptoms, occupational expo-
• Sterile towels sure, pleuritic chest pain, malignancy disease, heart
• Adhesive bandage or adhesive strip failure, and medication usage. Rationale: Medical history
• Antiseptic solution may provide valuable clues to the cause of a patient’s
• Sterile 4 × 4 gauze pads pleural effusion or presence of hypercoagulable states
• Intervention medications (opioid, sedative, or hypnotic as a result of medications. Knowledge of medication
agents, local anesthetic 1% or 2% lidocaine) usage can indicate the need for anticoagulation reversal.
• One small needle (25-gauge, 5 8 -inch long) In addition, an increasing number of medications are
• 5-mL syringe for local anesthetic noted to contribute to exudative effusions. See http://
• Three large needles (20- to 22-gauge, 1 1 2 to 2 inches long) www.pneumotox.com.9
27 Thoracentesis (Perform) 213
• Assess for signs and symptoms of pleural effusion. or if initial tube drainage is unsuccessful and surgery is to
Rationale: Physical findings may suggest a pleural be considered.2
effusion. • Assess baseline vital signs, including pulse oximetry.
❖ Trachea deviated away from the affected side Rationale: Baseline assessment data provide information
❖ Affected side dull to flat with percussion about patient status and allow for comparison during and
❖ Absent or decreased breath sounds after the procedure.
❖ Tactile fremitus • Assess recent serum laboratory results, including the fol-
❖ Pleuritic chest pain lowing. Rationale: These studies help determine whether
❖ Hypoxemia the patient is at risk for bleeding. Although thoracentesis is
❖ Tachypnea considered to have a low risk of bleeding, an international
❖ Dyspnea normalized ratio of 1.5 or less is acceptable for invasive
❖ Cough, weight loss, night sweats, anorexia, and malaise procedures.5,11 Platelet transfusion is recommended for
may also occur with pleural infection or malignancy counts less than 50,000. No consensus/recommendations
disease exist for partial thromboplastin time and hematocrit thresh-
• Assess chest radiograph or other imaging findings. olds. There is no evidence to support the use of bleeding
Posterior-anterior chest radiographs should be performed times before minimally invasive procedures.11
in the assessment of all suspected pleural effusions.2 ❖ Hematocrit
Rationale: If at least half the hemidiaphragm is obliter- ❖ Platelet count
ated on erect anterior-posterior radiograph results, suffi- ❖ Prothrombin time/international normalized ratio
cient fluid is in the pleural space for a thoracentesis. ❖ Partial thromboplastin time
Greater than 200 mL of fluid is considered abnormal in • Assess timing of day that the procedure is to occur. Unless
erect chest radiograph results. it is a patient emergency, pleural procedures should not
• If a small amount of loculated fluid is noted, a lateral take place out of hours.5 Rationale: Avoiding out-of-hour
decubitus radiograph should be obtained. Rationale: procedures when possible increases the likelihood of
Lateral decubitus radiographs assist with distinguishing having additional staff and resources available to support
between free-moving fluid and pleural thickening. Lateral potential untoward sequelae.
radiographs show blunting of the costophrenic angle with
50 mL. If the pleural effusion is measured to be greater Patient Preparation
than 10 mm deep on a lateral decubitus radiograph, a • Verify that the patient is the correct patient using two
diagnostic thoracentesis can be performed.10 identifiers. Rationale: Before performing a procedure, the
• Anterior-posterior chest radiographs completed in the nurse should ensure the correct identification of the patient
intensive-care setting are typically completed in the supine for the intended intervention.
position and are less sensitive in the identification of • Ensure that the patient understands preprocedural teach-
pleural effusions. In this setting, hazy opacification of one ings. Answer questions as they arise and reinforce
lung field or minor fissure thickening may be the only information. Rationale: This communication evaluates
clues to the presence of a pleural effusion.10 Rationale: In and reinforces understanding of previously taught
the supine position, pleural effusions tend to spread out information.
across the posterior thoracic surface and are less evident • Obtain written informed consent for the procedure. Ratio-
on supine radiographs. nale: Invasive procedures, unless performed with implied
• Thoracic ultrasound guidance is strongly recommended consent in a life-threatening situation, require written
for all pleural procedures for pleural fluid acquisition.5 consent of the patient or significant other.
Marking of the site using thoracic ultrasound for subse- • Consider medications for pain, sedation, or chemical
quent remote aspiration is not recommended except for paralysis, as indicated by the patient’s condition. Ratio-
large pleural effusions.5 Rationale: Ultrasound-guided nale: Pain and sedation medications or chemical paralysis
pleural aspiration has been shown to increase the yield may be necessary to maximize positioning. If utilizing
and reduce the risks of complications, particularly pneu- sedation or paralysis, ensure that airway adjuncts or defin-
mothoraces and inadvertent organ puncture. Ultrasound itive airways are secured before induction.
detects pleural fluid septations with greater sensitivity • Have atropine available. Rationale: Bradycardia, from a
than computed tomography.2 However, it should be vasovagal reflex, can occur during thoracentesis.
noted that ultrasound may not impact the incidence of • Initiate pulse oximetry monitoring. Rationale: Pulse
intercostal vessel laceration as vessels are not visualized oximetry provides a noninvasive means for monitoring
on ultrasound.5 oxygenation and heart rate at the bedside, which allows
• CT scans with contrast should be performed for pleural for prompt recognition and intervention should problems
enhancement before complete drainage of the fluid. Ratio- develop.
nale: CT scans are useful in distinguishing malignant • Ensure patent intravenous access. Rationale: Provides IV
from benign pleural thickening. CT scan results may also access for both procedural and emergency medications, as
be helpful when complicated pleural infection is present necessary
Procedure for Diagnostic and Therapeutic Thoracentesis

Diagnostic Thoracentesis
1. HH
2. PE
3. Assemble equipment and review Ensures proper equipment is Ultrasound guidance reduces
of available imaging. readily available throughout complications associated with
procedure and in emergency pleural procedures in the critical
situations. Review of imaging care setting and its routine use is
ensures the proper side has been recommended.5 (Level C*)
selected and provides anatomical
guidance to the practitioner.6
4. Position patient for procedure with Positioning enhances ease of
assistant standing in front of withdrawal of pleural fluid.
patient. Assuring patient is comfortable
If the patient is alert and able, increases the chance that the
position the patient on the edge of procedure will be successfully
the bed with feet supported on a completed. Having the assistant
stool and arms resting on a pillow in front of the patient ensures
on an elevated bedside table (Fig. visualization of facial cues and
27-1A). The patient may sit on a enables the cessation of
chair backward and rest arms on a inadvertent patient movements
pillow on the back of the chair. If that might interfere with the
the patient is unable to sit, position procedure.
the patient in the lateral recumbent
position on the unaffected side,
with the back near the edge of the
bed and the arm on the affected
side above the head. Elevate the
head of the bed to 30 or 45
degrees, as tolerated.
Figure 27-1 Thoracentesis. A, Ideal patient position for thoracentesis.
Procedure for Diagnostic and Therapeutic Thoracentesis—Continued

5. If not utilizing ultrasound, the Identifies the superior border of the Use the posterior axillary line as the
following physical examination pleural effusion and identifies insertion point to avoid the spinal
utilizing landmarks should be and validates the planned site for cord.
completed. Percuss the affected thoracentesis. Palpation midway If the space identified for insertion is
side posteriorly to determine the between the spine and posterior below the eighth intercostal space
highest point of the pleural axillary line is a location where (area is approximated at the
effusion. Effusion is generally the ribs can generally be posterior edge of scapula),
noted using the following: one to palpated. Accessing above the ultrasound scan should be done to
two interspaces below the level at ninth rib minimizes potential mark the fluid level and its
which breath sounds disappear on injury to solid organs. Accessing relationship to the diaphragm,
auscultation or become decreased, 9–10 cm lateral to the spine which helps identify a safe point of
percussion becomes dull, or below the eighth rib was noted entry to avoid solid-organ damage.
fremitus disappears. Identify the to be associated with decreased When able, ultrasound guidance
intercostal space below this point canulation of tortuous vessels should be utilized to identify
but above the ninth rib. Once the and has been deemed the “safe effusion location.2,5 (Level D*)
level is noted, a mark should be zone.”2,4,5
made 9–10 cm lateral to the spine
moving toward the posterior
axillary line.
6. Apply sterile personal protective Reduces the transmission of
equipment, while an assistant microorganisms and body
opens the necessary equipment secretions during an invasive
onto a sterile field or opens the procedure.
appropriate sterile tray with the
equipment.
7. Have an assistant provide Premedication with opioid,
preprocedural medications. antianxiolytic, sedative, or
hypnotic assures patient comfort
throughout procedure.
verification and time out, if
nonemergent.
9. Sterilize a wide area surrounding Although the pleural space is
the insertion site using 0.05% efficient in clearing bacteria,
chlorhexidine or 10% povidone- aseptic technique minimizes skin
iodine solution. Use concentric contaminants, which reduces the
circles from insertion site mark risk of infection.4
outward, and drape area with
sterile drape.
10. Anesthetize the skin with 1%–2% Increases comfort for patient by
lidocaine (25-gauge, 5 8 -inch anesthetizing the skin.
needle) in the typical wheal
fashion around the insertion site.


11. With lidocaine, insert a 20–22- Anesthetizes the work area for Always aspirate before injecting to
gauge, 1 1 2–2-inch needle through optimal patient comfort. prevent lidocaine from entering a
the wheal. Advance the needle Insertion above the rib minimizes blood vessel or the pleural space.
toward the rib, injecting the manipulation or laceration of the A longer needle may be needed in
lidocaine into the deep tissue. vascular bundle located beneath extremely obese patients.
“Walk” the needle over the the rib and the intercostal arteries
superior edge of the rib and (Fig. 27-1B).4,6 (Level C*)
periosteum of the underlying rib
superiorly and laterally. The exact
puncture site should be
immediately above the superior
aspect of a rib and, when possible,
8–10 cm lateral from the spine.6
Figure 27-1, cont’d B, Ideal placement of needle insertion.
12. After anesthetizing the periosteum In addition to anesthetizing the

of the underlying rib, gently parietal pleura, utilizing this
advance the needle and alternately technique the pleural space is
aspirate and inject lidocaine until identified by pleural fluid
pleural fluid is obtained in the aspirate in the syringe.4,12 If air
syringe. bubbles are noted, the lung tissue
may have been violated or air
may have been introduced by the
thoracentesis system. Withdraw
syringe to tissue and redirect.
Withdrawal of needle minimizes
manipulation of lung tissue.
13. When pleural fluid is obtained, Approximates the length of
place a sterile gloved finger on the insertion for the thoracentesis
needle at the point where the needle or catheter.
needle exits the skin. Withdraw
the needle and syringe. For
therapeutic thoracentesis, proceed
to step 21.
14. Attach a three-way stopcock and The open stopcock valve allows for Longer needles may be necessary in
50-mL syringe to a 20–22-gauge, aspiration of pleural fluid during the obese patient.
1 1 2 - or 2-inch needle. Open the needle insertion and minimizes
stopcock valve between the atmospheric air introduction.
syringe and the needle.

15. Insert the selected needle via the Inserting the needle superior to the It is possible that no fluid is accessed
anesthetized tract, superior to the rib avoids disruption of the (dry tap). If a dry tap occurs, the
rib, and continually aspirate until vascular and lymph systems (Fig. needle may be withdrawn and
pleural fluid is obtained, filling the 27-1B). The pleural fluid is used reinserted in a slightly different
50-mL syringe. Fluid should be for laboratory testing for the angle if the patient tolerated the
separated into three sterile differential diagnosis. A sample initial “dry tap.” A second tap
containers for microbiology, of 35–50 mL is needed for a warrants reevaluation with an
biochemistry, and cytology diagnostic analysis of fluid. A ultrasound if not initially
analysis. change in patient position can be employed.4 A larger gauge needle
attempted to facilitate fluid may be needed for thick or
drainage. loculated fluid, or the needle may
have been inserted above or below
the pleural fluid. When pleural
fluid is aspirated, the needle may
be stabilized with placing a
hemostat or clamp on the needle at
the skin site to keep the needle
from advancing farther into the
pleural space, preventing lung
puncture. Note the appearance of
the aspirated fluid because this
may provide clues to the
underlying etiology of effusion.
Straw-colored fluid is common and
typical of transudates. Blood-
stained fluid is suggestive of
hemothorax, malignancy disease,
pulmonary infarction, trauma, or
postcoronary artery bypass surgery.
Fluid turbidity suggests empyema
or chylothorax, and food particles
indicates esophageal rupture.
16. Fill the specimen tubes from the Analysis may aid in determining an To interpret pleural fluid laboratory
pleural fluid–filled syringe by etiology of the pleural effusion. values utilizing Light’s criteria,
turning the stopcock “off” to the serum and pleural fluid chemistry
patient and allowing the tubes to laboratory values must be obtained
fill passively by vacuum or by (e.g., total protein and LDH).
depressing the syringe plunger Initial laboratory testing may also
(Fig. 27-1C). Send the specimen include cytology, gram stain,
tubes to the laboratory for culture, amylase, and glucose.4
appropriate analysis.
Figure 27-1, cont’d C, Attach catheter

to three-way stopcock syringe and vacu-
tainer. Barton ED: Thoracentesis. In Rosen
P, Chan TC, Vilke M, Sternbach G, editors:
Atlas of emergency procedures, St. Louis,
Mosby, 2001. pp. 36–37.
C

17. Evaluate patient response Monitoring patient heart rate, pulse
throughout procedure. oximetry, and clinical response
throughout the procedure enables
prompt intervention or cessation
of procedure should
complications arise.
18. On completion of diagnostic If the patient is nonventilated and If air is aspirated during the
thoracentesis, withdraw the needle. asymptomatic, only 1% of procedure, multiple needle passes
Apply pressure to the puncture site patients were noted to have a are required, or the patient
for a few minutes, then apply an pneumothorax on a develops signs of a pneumothorax,
adhesive strip or adhesive bandage postthoracentesis chest imaging should be ordered.
over the puncture site. Without radiograph.4 Postthoracentesis chest radiograph
concrete clinical indications, (i.e., in mechanically ventilated patients
withdraw of air, multiple needle remains controversial.4
passes, or clinical changes), a
chest radiograph is not necessary
after a routine thoracentesis.2,4,6
(Level C*)
PE .
20. HH
Therapeutic Thoracentesis
21. Insert a 14-gauge needle attached The 14-gauge needle is selected
to a 20-mL syringe, bevel down, because it allows for insertion
into the anesthetized tract until and passage of a 16-gauge
pleural fluid is returned. catheter; a smaller-sized catheter
may be unstable and fold or kink
on itself.
22. When pleural fluid is obtained, Occluding the needle helps prevent
remove the syringe from the the possible occurrence of a
needle, occluding the needle with pneumothorax.
an index finger.
23. Insert the 16-gauge catheter Advancing the catheter toward the In therapeutic thoracentesis, a
through the 14-gauge needle. costodiaphragm allows for catheter is preferred over a needle
Advance the catheter slowly optimal drainage of pleural fluid. because the lung is expected to
through the needle, angling the reexpand.
catheter in a downward fashion A needle could puncture the lung
toward the costodiaphragm until during reexpansion and cause a
the catheter moves freely in the pneumothorax.
pleural space.
24. While advancing the catheter Never pull the catheter back
beyond the needle tip, remove the through the needle because the
needle and leave the catheter in catheter may be cut or sheared
the pleural space. Attach a by the needle tip.
three-way stopcock with a 50-mL
syringe to the end of the catheter.

25. Fill the 50-mL syringe with When changing syringes, be certain To interpret pleural fluid chemistry
pleural fluid. Fill the specimen the stopcock is positioned such laboratory values, serum chemistry
tubes from the pleural fluid–filled that air does not enter the pleural laboratory values also must be
syringe by turning the stopcock space. Analysis may aid in obtained (see Diagnostic
“Off” to the patient and allowing determining an etiology of the Thoracentesis section). Local
the tubes to fill passively by pleural effusion. anesthetics (i.e., lidocaine) are
vacuum or by depressing the acidic; therefore, care should be
syringe plunger (Fig. 27-1C). Send taken during pleural sampling to
the specimen tubes to the avoid contamination of sample.4
laboratory for appropriate analysis.
26. Attach the vacutainer or evacuated The vacutainer or evacuated bottles The maximum volume of fluid that
bottles with tubing to the three- use negative pressure to can be safely reviewed is uncertain
way stopcock. Open the valve to withdraw pleural fluid from the because the volume removed does
the vacutainer and fill the pleural space, providing not clearly correlate with the onset
vacutainer. therapeutic relief. Reposition of symptoms. Traditionally, to
catheter or patient, or both, if avoid this complication,
drainage stops to determine discontinuation of fluid removal
whether fluid is still present. occurs with the onset of symptoms
or when the total fluid removed
reaches 1000–1500 mL.5,6
(Level E*)
The patient may feel the need to
cough as the lung reexpands.
27. On completion of thoracentesis, If the patient is nonventilated and If air is aspirated during the
remove the catheter. Apply asymptomatic, only 1% of procedure, multiple needle passes
pressure to the puncture site for a patients were noted to have a are required, or if the patient
few minutes, then apply an pneumothorax on a develops signs of a pneumothorax,
adhesive strip or adhesive bandage postthoracentesis chest imaging should be ordered.
over the puncture site. (Level C*) radiograph.4 Postthoracentesis chest radiograph
in mechanically ventilated patients
remains controversial.4
28. Reposition the patient to optimize Patient may desire to lie down after
comfort. procedure. Head of bed
placement may vary if dyspnea,
hypotension, or other symptoms
re-present during procedure.
29. Dispose of equipment and remove
PE .
30. HH

• Patient is comfortable and has decreased respiratory • Pneumothorax
distress • Vasovagal response
• Lung reexpansion occurs • Dyspnea
• Site remains infection free • Hypovolemia
• Procedure aids in diagnosis of etiology of pleural • Hematoma
effusion • Hemothorax
• Liver or splenic laceration

interventions.
1. Monitor vital signs and Any change in vital signs may alert • Tachypnea
cardiopulmonary status before the practitioner of possible • Decreased or absent breath sounds
and after thoracentesis and as unexpected outcomes. Use of on the affected side
needed. supplemental oxygen may be • Shortness of breath, dyspnea
necessary. • Asymmetrical chest excursion
with respirations
• Sudden sharp chest pain
• Tachycardia
• Hypotension
• Dysrhythmias
• Tracheal deviation to the
unaffected side
• Muffled heart sounds
2. If indicated, obtain a A chest radiograph is used to evaluate • Pneumothorax
postthoracentesis expiratory for lung reexpansion and evidence • Expanding pleural effusion
chest radiograph.10 (Level D*) of a possible pneumothorax or • Catheter migration
hemothorax. If a pneumothorax or
hemothorax is present, a chest tube
may be necessary. Without concrete
clinical indications, chest
radiograph is not necessary after a
routine thoracentesis
Documentation
• Patient and family teaching • Total amount of pleural fluid aspirated
• Consent for procedure • Site assessment
• Adherence to Universal Protocol • Intact catheter on withdrawal
• Patient positioning and monitoring devices • Occurrence of unexpected outcomes
• Medication administration and patient response • Postthoracentesis radiograph acquisition and results,
• Patient tolerance, including procedural pain and as needed/available
instillation and response to pain medications • Laboratory test ordered and results as available
• Insertion of catheter or needle • Interpretation of laboratory results
• Catheter or needle size used • Nursing interventions
• Any difficulties in insertion • Pain assessment, interventions, and effectiveness
• Pleural fluid aspirate characteristics

27 Thoracentesis (Perform) 221.e1
References 10. Parsons P, Tu Y: Thoracentesis and percutaneous pleural

1. Barton E: Thoracentesis. In Rosen P, et al, editors: Atlas biopsy. In Parsons P, Heffner J, editors: Pulmonary
of emergency procedures, St Louis, 2001, Mosby. respiratory therapy secrets, Philadelphia, 2006, Mosby.
2. Hooper C, Lee YC, Maskell N: BTS Pleural Guideline 11. Malloy PC, et al: Consensus guidelines for periprocedural
Group: Investigation of a unilateral pleural effusion in management of coagulation status and hemostasis risk in
adults: British Thoracic Society Pleural Disease Guideline percutaneous image-guided interventions. J Vasc Interv
2010. Thorax 65(Suppl 2):ii4–ii17, 2010. Radiol 20(7 Suppl):S240–S249, 2009.
3. Light RW: Clinical practice. Pleural effusion. N Engl J 12. Thomsen TW, DeLaPena J, Setnik GS: Videos in
Med 346(25):1971–1977, 2002. clinical medicine. Thoracentesis. N Engl J Med 355:e16,
4. Heffner JE: Diagnostic thoracentesis. UpToDate Oct 17, 2006.
2013. <http://www.uptodate.com/contents/diagnostic
-thoracentesis?source=see_link&anchor=H4>. Accessed Additional Readings
20.11.14. Antunes G, et al: BTS guidelines for the management of
5. Havelock T, et al: Pleural procedures and thoracic malignant pleural effusions. Thorax 58(Suppl 2):ii29–ii38,
ultrasound: British Thoracic Society pleural disease 2003.
guideline 2010. Thorax 65(Suppl 2):ii61–ii76, 2010. Davies CWH, Gleeson FV, Davies RJO: BTS guidelines for
6. Huggins JT, Doelken P: Large volume thoaracentesis. the management of pleural infection. Thorax 58:ii18,
UpToDate Mar 25, 2014. <http://www.uptodate.com/ 2003.
contents/large-volume-thoracentesis?source=search_result Dietrich C, et al: Ultrasound of pleurae and lungs. Ultrasound
&search=large+volume+thoracentesis&selectedTitle Med Biol 41(2):351–365, 2015.
=1%7E16>. Loddenkemper R: Pleural effusions. In Albert R, Spiro S, Jett
7. Wilson M, Irwin R: Thoracentesis. Procedures and J, editors: Clinical respiratory medicine, Philadelphia,
techniques in intensive care medicine, Philadelphia, 2012, 2004, Mosby.
Lippincot & Williams & Wilkins. Mayo PH, et al: Safety of ultrasound-guided thoracentesis in
8. Goligher EC, et al: Utility and safety of draining pleural patients receiving mechanical ventilation. Chest
effusions in mechanically ventilated patients: A systematic 125(3):1059–1062, 2004.
review and meta-analysis. Crit Care 15:R46, 2011. Thomsen TW, DelaPena J, Stenik GS: Thoracentesis, videos
9. Camus P: Pneumotox: The drug induced respiratory in clinical medicine 355/e16(15). <http://content.nejm.org/
disease website. <http://www.pneumotox.com>. Accessed cgi/content/video_preview/355/15/e16>. Accessed
12.11.14. 14.09.08.
PROCEDURE
28
Thoracentesis (Assist)
Susan Yeager
PURPOSE: Thoracentesis is performed to assist in the diagnosis and therapeutic
management of patients with pleural effusions.
PREREQUISITE NURSING hypotension, cough, pain, visceral injury, and reexpansion

KNOWLEDGE pulmonary edema.4–6
• The most common complications from pleural aspiration
• Thoracentesis is performed with insertion of a needle or are pneumothorax, pain, hemorrhage, and procedure
a catheter into the pleural space, which allows for removal failure. The most serious complication is visceral injury.5
of pleural fluid. • Hypotension can occur as part of the vasovagal reaction,
• Pleural effusions are defined as the accumulation of fluid causing bradycardia, during or hours after the procedure.
in the pleural space that exceeds 10 mL and results from If it occurs during the procedure, cessation of the proce-
the overproduction of fluid or disruption in fluid dure and intravenous (IV) atropine may be necessary. If
reabsorption.1 hypotension occurs after the procedure, it is likely the
• Diagnostic thoracentesis is indicated for differential diag- result of fluid shifting from pleural effusion reaccumula-
nosis for patients with pleural effusion of unknown etiol- tion. In this situation, the patient is likely to respond to
ogy. A diagnostic thoracentesis may be repeated if initial fluid resuscitation.7
results fail to yield a diagnosis. • Development of cough generally initiates toward the
• Therapeutic thoracentesis is indicated to relieve the symp- end of the procedure and should result in procedure
toms (e.g., dyspnea, cough, hypoxemia, or chest pain) cessation.
caused by a pleural effusion. • Reexpansion pulmonary edema is thought to occur from
• Samples of pleural fluid are analyzed and assist in distin- overdraining of fluid too quickly. The incidence is less
guishing between exudative and transudative etiologies of than 1%, but asymptomatic radiological pulmonary edema
effusion. Results of laboratory tests on pleural fluid alone may be slightly more frequent.5 The maximum volume of
do not establish a diagnosis; instead the laboratory results fluid that can be safely removed is uncertain because the
must be correlated with the clinical findings and serum volume removed does not clearly correlate with the onset
laboratory results. of symptoms. Traditionally, to avoid this complication,
• Exudative effusions indicate a local etiology (e.g., pulmo- discontinuation of fluid removal occurs with the onset of
nary embolus, infection), whereas transudative effusions symptoms or when the total fluid removed reaches 1000
usually are associated with systemic etiologies (e.g., heart to 1500 mL.5,6
failure). • If using continuous positive airway pressure, caution
• Relative contraindications for thoracentesis include the should be taken to avoid potential pneumothorax follow-
following: ing aspiration if there is no pleural drain in place.5 Patients
❖ Patient anatomy that hinders the practitioner from receiving positive airway pressure can undergo thoracen-
clearly identifying the appropriate landmarks tesis with an ultrasound-guided incidence of less than 7%
❖ Patients actively undergoing anticoagulation therapy or pneumothorax noted.4,8
with an uncorrectable coagulation disorder
❖ Patients receiving positive end-expiratory pressure EQUIPMENT
therapy
❖ Patients with splenomegaly, elevated left hemidia- • Indelible marker
phragm, or left-sided pleural effusion • Sterile gloves
❖ Patients with only one lung as a result of a previous • Sterile drapes
pneumonectomy • Sterile towels
❖ Patients with known lung disease • Adhesive bandage or adhesive strip
❖ Patients with active skin infection at the point of needle • Antiseptic solution
insertion4 • Sterile 4 × 4 gauze pads
• Ultrasound scan–guided thoracentesis is thought to reduce • Intervention medications (opioid, sedative, or hypnotic
complications. agents, local anesthetic 1% or 2% lidocaine)
• Complications commonly associated with thoracentesis • One small needle (25-gauge, 5 8 -inch long)
include: pneumothorax, hemopneumothorax, hemorrhage, • 5-mL syringe for local anesthetic
222
28 Thoracentesis (Assist) 223
• Three large needles (20- to 22-gauge, 1 1 2 to 2 inches long) • Assess for signs and symptoms of pleural effusion. Ratio-
• Three-way stopcock nale: Physical findings may suggest a pleural effusion.
• Sterile 20-mL syringe ❖ Trachea deviated away from the affected side
• Sterile 50-mL syringe ❖ Affected side dull to flat with percussion
• Two chemistry blood tubes ❖ Absent or decreased breath sounds
• Hemostat or Kelly clamp ❖ Tactile fremitus
• Pulse oximetry equipment ❖ Pleuritic chest pain
• Side table ❖ Hypoxemia
• Pillow or blanket to be placed on side table ❖ Tachypnea
• 14-gauge needle ❖ Dyspnea
• 16-gauge catheter ❖ Cough, weight loss, night sweats, anorexia, and malaise
• Vacutainers or evacuated bottles (1 to 2 L) with pressure may also occur with pleural infection or malignancy
tubing disease
Additional equipment, to have available as needed, includes • Anterior-posterior chest radiographs completed in the
the following: intensive-care setting are typically completed in the supine
• Atropine, oxygen, thoracostomy supplies, advanced position and are less sensitive in the identification of
cardiac life-support equipment pleural effusions. In this setting, hazy opacification of one
• Ultrasound-scan equipment as available and with a cre- lung field or minor fissure thickening may be the only
dentialed provider clues to the presence of a pleural effusion.10 Rationale: In
• Two complete blood count tubes the supine position, pleural effusions tend to spread out
• One anaerobic and one aerobic media bottle for culture across the posterior thoracic surface and are less evident
and sensitivity on supine radiographs.
• Sterile tubes for fungal and tuberculosis cultures specimen • Assess baseline vital signs, including pulse oximetry.
tubes Rationale: Baseline assessment data provide information
• Commercially prepackaged thoracentesis kits which are about patient status and allow for comparison during and
available in some institutions after the procedure.
• Assess recent serum laboratory results, including the fol-
PATIENT AND FAMILY EDUCATION lowing. Rationale: These studies help determine whether
the patient is at risk for bleeding. Although thoracentesis is
• Assess patient’s and family’s level of understanding about considered to have a low risk of bleeding, an international
the condition and rationale for the procedure. Rationale: normalized ratio of 1.5 or less is acceptable for invasive
This assessment identifies the patient’s and family’s procedures.5,11 Platelet transfusion is recommended for
knowledge deficits concerning the patient’s condition, the counts < 50,000. No consensus/recommendations exist for
procedure, the expected benefits, and the potential risks. partial thromboplastin time and hematocrit thresholds.
It also allows time for questions to clarify information and There is no evidence to support the use of bleeding times
voice concerns. Explanations decrease patient anxiety and before minimally invasive procedures.11
enhance cooperation. ❖ Hematocrit
• Explain the procedure and the reason for the procedure, if ❖ Platelet count
the clinical situation permits. If not, explain the procedure ❖ Prothrombin time/international normalized ratio
and reason for the intubation after it is completed. Ratio- ❖ Partial thromboplastin time
nale: This explanation enhances patient and family under-
standing and decreases anxiety. Patient Preparation
• Explain the patient’s role in thoracentesis. Rationale: • Verify that the patient is the correct patient using two
This explanation increases patient compliance, facilitates identifiers. Rationale: Before performing a procedure,
needle and catheter insertion, and enhances fluid removal. the nurse should ensure a timeout was completed to verify
intervention.
PATIENT ASSESSMENT AND • Ensure that the patient understands preprocedural teach-
PREPARATION ings. Answer questions as they arise and reinforce infor-
mation. Rationale: This communication evaluates and
Patient Assessment reinforces understanding of previously taught information.
• Assess medical history of symptoms, occupational expo- • Ensure written informed consent for the procedure has
sure, pleuritic chest pain, malignancy disease, heart failure, been completed. Rationale: Invasive procedures, unless
and medication usage. Rationale: Medical history may performed with implied consent in a life-threatening situ-
provide valuable clues to the cause of a patient’s pleural ation, require written consent of the patient or significant
effusion or presence of hypercoagulable states as a result other.
of medications. Knowledge of medication usage can indi- • Assist with patient positioning. Several alternative posi-
cate the need for anticoagulation reversal. In addition, an tions may be used, as follows. Rationale: Positioning
increasing number of medications are noted to contribute enhances patient comfort and ease of pleural fluid
to exudative effusions. See http://www.pneumotox.com.9 withdraw.
❖ On the edge of the bed with legs supported and arms • Inquire about the need for sedation or paralysis. Ratio-
resting on a pillow on the elevated bedside table (see nale: Sedation or paralysis may be necessary to maximize
Fig. 27-1). positioning.
❖ Backwards on a chair with arms resting on a pillow • Have atropine available. Rationale: Bradycardia, from a
over the chair back. vasovagal reflex, is not uncommon during thoracentesis.
• If the patient is unable to sit, position the patient on the • Initiate pulse oximetry monitoring. Rationale: Pulse
unaffected side, with his or her back near the edge of the oximetry provides a noninvasive means for monitoring
bed and the arm on the affected side above the head. oxygenation and heart rate at the bedside, which allows
Elevate the head of the bed to 30 or 45 degrees, as toler- for prompt recognition and intervention should problems
ated. Position yourself or another member of the health- develop.
care team in front of the patient. Rationale: This • Ensure patent IV access. Rationale: Provides IV access
positioning enables visualization of facial cues and a close for both procedural and emergency medications, as
proximity to reassure or comfort the patient. necessary
Procedure for Assisting with Diagnostic and Therapeutic Thoracentesis

1. HH
2. PE
3. Assemble equipment and Ensures proper equipment is readily
procedure tray. available throughout procedure and
in emergency situations.
4. Assist with patient positioning. Positioning that optimizes patient
comfort aids in patient cooperation
and completion of the procedure.
5. Assume a position in front of Positioning in front of the patient
the patient and provide physical ensures visualization of facial cues
support for positioning, as and enables the cessation of
necessary. inadvertent patient movements that
might interfere with the procedure.
6. As directed by physician or Premedication with opioid,
advanced practice provider, antianxiolytic, sedative, or
administer procedural hypnotic ensures patient comfort
medications. throughout procedure.
7. Throughout procedure, assist The physician or advanced practice
with providing continuous provider is focused on the
monitoring of patient vital signs technique required to obtain the
and response to the procedure fluid and may be delayed in
and interventions. noticing patient changes.
8. As directed by physician or Analysis may aid in determining an To interpret pleural fluid laboratory
advanced practice provider, etiology of the pleural effusion. values, serum chemistry laboratory
assist with filling of the values must be obtained (e.g., pH,
specimen tubes from the pleural total protein, glucose, and lactate
fluid–filled syringe. Label dehydrogenase).
appropriately and send the
specimen tubes to the laboratory
for appropriate analysis.
9. As directed by physician or The vacutainer or evacuated bottles Evacuating more than 1000–1500 mL
advanced practice provider, use negative pressure to withdraw of pleural fluid at one time may
assist with attaching the pleural fluid from the pleural cause hypovolemia, hypoxemia, or
vacutainer or evacuated bottles space, providing therapeutic relief. reexpansion pulmonary edema.
with tubing to the three-way Assist in repositioning the patient The patient may feel the need to
stopcock. if drainage stops, as directed. cough as the lung reexpands.
28 Thoracentesis (Assist) 225
Procedure for Assisting with Diagnostic and Therapeutic Thoracentesis—Continued

10. On completion of thoracentesis, Without concrete clinical indications,
the physician or advanced chest radiograph is not necessary
practice provider may apply after a routine thoracentesis.
pressure to the puncture site for
a few minutes. After pressure
application has been completed,
apply an adhesive bandage over
the puncture site.
11. Reposition patient to optimize Patient may desire to lie down after
comfort. procedure completion. Head-of-bed
placement may vary if dyspnea,
hypotension, or other symptoms
are present during procedure.
12. Dispose of soiled supplies and
remove personal PE .
13. HH

• Patient is comfortable and has decreased respiratory • Pneumothorax
distress • Vasovagal response
• Lung reexpansion occurs • Dyspnea
• Site remains infection free • Hypovolemia
• Procedure aids in diagnosing of etiology of pleural • Hematoma
effusion • Hemothorax
• Liver or splenic laceration

interventions.
1. Monitor vital signs and Any change in vital signs may • Tachypnea
cardiopulmonary status before, alert the practitioner of possible • Decreased or absent breath sounds
during, and after thoracentesis. unexpected outcomes. Use of on the affected side
supplemental oxygen may be • Shortness of breath, dyspnea
necessary. • Asymmetrical chest excursion
with respirations
• Sudden sharp chest pain
• Tachycardia
• Hypotension
• Dysrhythmias
• Tracheal deviation to the
unaffected side
• Muffled heart sounds

2. If indicated, obtain a A chest radiograph is used to • Pneumothorax
postthoracentesis expiratory evaluate for lung reexpansion • Catheter migration
chest radiograph. (Level C*) and evidence of a possible • Expanding pleural effusion
pneumothorax or hemothorax.
If a pneumothorax or hemothorax
is present, a chest tube may be
necessary. Without concrete
clinical indications, chest
radiograph is not necessary
after a routine thoracentesis.2,3,5
Documentation
• Patient and family teaching • Total amount of pleural fluid aspirated
• Presence of completed consent for procedure • Site assessment
• Adherence to Universal Protocol • Occurrence of unexpected outcomes
• Patient positioning and monitoring devices • Postthoracentesis radiograph acquisition and results,
• Medication administration and patient response as needed/available
• Patient tolerance, including procedural pain and • Laboratory test ordered and results, as available
instillation and response to pain medications • Nursing interventions
• Pleural fluid aspirate characteristics • Pain assessment, interventions, and effectiveness

28 Thoracentesis (Assist) 226.e1
References 11. Malloy PC, et al: Consensus guidelines for periprocedural

1. Barton E: Thoracentesis. In Rosen P, et al, editors: Atlas management of coagulation status and hemostasis risk in
of emergency procedures, St Louis, 2001, Mosby. percutaneous image-guided interventions. J Vasc Interv
2. Hooper C, Lee YC, Maskell N, BTS Pleural Guideline Radiol 20(7 Suppl):S240–S249, 2009.
Group: Investigation of a unilateral pleural effusion in Additional Readings
adults: British Thoracic Society Pleural Disease Guideline
2010. Thorax 65(Suppl 2):ii4–ii17, 2010. Antunes G, et al: BTS guidelines for the management of
3. Light RW: Clinical practice. Pleural effusion. N Engl J malignant pleural effusions. Thorax 58(Suppl 2):ii29–ii38,
Med 346(25):1971–1977, 2002. 2003.
4. Heffner JE: Diagnostic thoracentesis. UpToDate Oct 17, Davies CWH, Gleeson FV, Davies RJO: BTS guidelines for
2013. <http://www.uptodate.com/contents/diagnostic the management of pleural infection. Thorax 58:ii18,
-thoracentesis?source=see_link&anchor=H4>. Accessed 2003.
20.11.14. Dietrich C, et al: Ultrasound of pleurae and lungs. Ultrasound
5. Havelock T, et al: Pleural procedures and thoracic Med Biol 41(2):351–365, 2015.
ultrasound: British Thoracic Society pleural disease Doyle JJ, et al: Necessity of routine chest roentgenography
guideline 2010. Thorax 65(Suppl 2):ii61–ii76, 2010. after thoracentesis. Ann Intern Med 124:816–820, 1996.
6. Huggins JT, Doelken P: Large volume thoaracentesis. Loddenkemper R: Pleural effusions. In Albert R, Spiro S,
UpToDate Mar 25, 2014. <http://www.uptodate.com/ Jett J, editors: Clinical respiratory medicine, Philadelphia,
contents/large-volume-thoracentesis?source=search_result 2004, Mosby.
&search=large+volume+thoracentesis&selectedTitle=1 Maskell NA, Butland RJA: BTS guidelines for the
%7E16>. investigation of a unilateral pleural effusion in adults.
7. Wilson M, Irwin R: Thoracentesis. Procedures and Thorax 58:ii8, 2003.
techniques in intensive care medicine, Philadelphia, 2012, Mayo PH, et al: Safety of ultrasound-guided thoracentesis in
Lippincott & Williams & Wilkins. patients receiving mechanical ventilation. Chest
8. Goligher EC, et al: Utility and safety of draining 125(3):1059–1062, 2004.
pleural effusions in mechanically ventilated patients: Thomsen TW, DelaPena J, Stenik GS: Thoracentesis, videos
A systematic review and meta-analysis. Crit Care 15:R46, in clinical medicine 355/e16(15). <http://content.nejm.org/
2011. cgi/content/video_preview/355/15/e16>. Accessed
9. Camus P: Pneumotox: The drug induced respiratory 14.09.08.
disease website. <http://www.pneumotox.com>. Accessed
12.11.14.
10. Parsons P, Tu Y: Thoracentesis and percutaneous pleural
biopsy. In Parsons P, Heffner J, editors: Pulmonary
respiratory therapy secrets, Philadelphia, 2006, Mosby.
Section Four Ventilatory Management
PROCEDURE
29
Invasive Mechanical Ventilation
(Through an Artificial Airway):
Volume and Pressure Modes
John Gallagher
PURPOSE: Initiation and maintenance of positive-pressure ventilation through an
artificial airway are accomplished to maintain or improve oxygenation and
ventilation and to provide respiratory muscle rest. Selection of volume or pressure
modes is dependent on the available evidence, clinical goals, availability of modes,
and practitioner preference.
PREREQUISITE NURSING so that mitochondrial energy stores can be repleted.8,24

KNOWLEDGE Respiratory work and rest vary with different modes
and the application of the same. In general, when
• Indications for the initiation of mechanical ventilation hypercarbia is present, mechanical ventilation is neces-
include the following: sary to relieve the work of breathing. Muscle unloading
❖ Apnea (e.g., neuromuscular or cardiopulmonary is accomplished differently and depends on patient-
collapse) ventilator interaction and the mode.13,14,63,67
❖ Acute ventilatory failure, which is generally defined as • Ventilators are categorized as either negative or positive
a pH of less than or equal to 7.25 with an arterial partial pressure. Although negative-pressure ventilation (i.e., the
pressure of carbon dioxide (Paco2) greater than or iron lung) was used extensively in the 1940s, introduction
equal to 50 mm Hg of the cuffed endotracheal tube resulted in the dominance
❖ Impending ventilatory failure (serial decrement of arte- of positive-pressure ventilation (PPV) in clinical practice
rial blood gas values or progressive increase in signs during the second half of the 20th century. Although spo-
and symptoms of increased work of breathing) radic interest in negative-pressure ventilation continues,
❖ Severe hypoxemia: an arterial partial pressure of the cumbersome nature of the ventilators and the lack
oxygen (Pao2) of less than or equal to 50 mm Hg on of airway protection associated with this form of ventila-
room air indicates a critical level of oxygen in the tion preclude a serious resurgence of this mode of
blood. Although oxygen-delivery devices may be used ventilation.11,21
before intubation, the refractory nature of shunt (perfu- ❖ Positive-pressure ventilation: positive-pressure modes
sion without ventilation) may necessitate that positive of ventilation have traditionally been categorized into
pressure be applied to reexpand closed alveoli. Resto- volume and pressure. However, with the advent of
ration of functional residual capacity (FRC; lung microprocessor technology, sophisticated iterations of
volume that remains at the end of a passive exhalation) traditional volume and pressure modes of ventilation
is the goal. have evolved.11,25 Many of the modes have names that
❖ Respiratory muscle fatigue: the muscles of respiration are different from traditional volume and pressure
can become fatigued if they are made to contract repet- modes, but they are similar in many characteristics.
itively at high workloads.86 Fatigue occurs when Little data exist to show that the newer modes improve
muscle-energy stores become depleted. Weakness, outcomes.11,17,25,57 A wide variety of modes described in
hypermetabolic states, and chronic lung disease are this procedure are actually a combination of volume
examples of conditions in which patients are especially and pressure but for ease of learning are classified into
prone to fatigue. When fatigue occurs, the muscles no specific categories.
longer contract optimally and hypercarbia results.8,24 ❖ Volume ventilation has traditionally been the most
Twelve to 24 hours of rest are typically needed to rest popular form of PPV, largely because tidal volume (Vt)
the muscles. Respiratory muscle rest requires that the and minute ventilation (MV) are ensured, which is an
workload of the muscles (or muscle loading) be offset essential goal in the patient with acute illness. With
227
volume ventilation, a predetermined Vt is delivered mortality rate has been noted, although positive trends
with each breath regardless of resistance and compli- have been demonstrated in some variables of interest
ance. Vt is stable from breath to breath, but airway such as oxygenation.17,28,31,39,46,47,69,83,84
pressure may vary. The gas flow-rate pattern of volume • Summary descriptions of modes, mode parameters, and
ventilation is generally constant from the beginning to ventilator alarms are provided within this procedure and
the end of the breath (square wave). In modern ventila- in Boxes 29-1 and 29-2, and Table 29-1.
tors, this can be changed to accelerating, decelerating,
or even sine patterns. To rest the respiratory muscles
with volume ventilation, the ventilator rate must be BOX 29-1 Traditional Modes of
increased until spontaneous respiratory effort ceases. Mechanical Ventilation
When spontaneous effort is present, such as with initia- (On All Ventilators)
tion of an assist/control (A/C) breath, respiratory
muscle work continues throughout the breath.67,96 VOLUME MODES
❖ With traditional pressure ventilation, the practitioner Control Ventilation (CV) or Controlled Mandatory
Ventilation (CMV)
selects the desired pressure level and the Vt is deter-
Description: With this mode, the ventilator provides all of the
mined by the selected pressure level, airway resistance,
patient’s minute ventilation. The clinician sets the rate, Vt,
and lung compliance. This characteristic is impor-
inspiratory time, and PEEP. Generally, this term is used to describe
tant to note in caring for a patient with an unstable situations in which the patient is chemically relaxed or is paralyzed
condition on a pressure mode of ventilation. Careful from a spinal cord or neuromuscular disease and is unable to
attention to Vt is necessary to prevent inadvertent initiate spontaneous breaths. This mode does not exist as a
hyperventilation or hypoventilation. To ensure respira- standard mode on modern ventilators. Patients on assist/control
tory muscle rest on pressure-support ventilation (PSV), (A/C) mode who are unable to trigger the machine are essentially in
workload must be offset with the appropriate adjust- CMV.
ment of the pressure-support level. To accomplish this Assist/Control (A/C) Ventilation
adjustment, the pressure-support level is increased to Description: This option requires that a rate, Vt, inspiratory time,
lower the spontaneous respiratory rate to less than or and PEEP be set for the patient. The ventilator sensitivity also is set,
equal to 20 breaths/min and to attain a Vt of 6 to and when the patient initiates a spontaneous breath, a full-volume
10 mL/kg of predicted body weight (PBW).13,14,17,61 breath is delivered.
❖ Pressure ventilation provides for an augmented inspira-
Synchronized Intermittent Mandatory Ventilation (SIMV)
tion (pressure is maintained throughout inspiration). Description: This mode requires that rate, Vt, inspiratory time,
The flow pattern (speed of the gas) is described as sensitivity, and PEEP are set by the clinician. In between mandatory
decelerating; that is, gas-flow delivery is high at the breaths, patients can spontaneously breathe at their own rates and
beginning of the breath and tapers off toward the end Vt. With SIMV, the ventilator synchronizes the mandatory breaths
of the breath. This pattern is in contrast to volume with the patient’s own breaths.
ventilation, in which the flow rate is typically more
PRESSURE MODES
consistent during inspiration (i.e., the same at the Pressure Support Ventilation (PSV)
beginning of the breath as at the end of the breath). The Description: This mode provides augmented inspiration to a patient
decelerating flow pattern associated with pressure ven- who is spontaneously breathing. With pressure support (PS), the
tilation is thought to provide better gas distribution and clinician selects an inspiratory pressure level, PEEP, and sensitivity.
more efficient ventilation.61,63,87 When the patient initiates a breath, a high flow of gas is delivered
❖ Increasingly, sophisticated ventilator technology has to the preselected pressure level, and pressure is maintained
resulted in the development of volume-assured pres- throughout inspiration. The patient determines the parameters of Vt,
sure modes of ventilation. Ventilator manufacturers rate, and inspiratory time.
have responded rapidly to the request of practitioners Pressure-Controlled (PC) and Pressure-Controlled
that pressure modes of ventilation be designed in such Inverse Ratio Ventilation (PC/IRV)
a way that the minimum desired tidal volume be can Description: This mode may provide pressure-limited ventilation (PC)
be achieved on a breath-to-breath basis. These are alone, or combined with an inverse ratio of inspiration to expiration
called adaptive pressure control or dual control pres- (PC/IRV). The clinician selects the pressure level, rate, inspiratory
sure modes. The potential value of such modes is time (1 : 1, 2 : 1, 3 : 1, 4 : 1), and PEEP level. With prolonged
obvious. The more desirable decelerating flow pattern inspiratory times, auto-PEEP may result. The auto-PEEP may be a
may be provided and plateau pressures controlled, with desirable outcome of the inverse ratios. In PC without IRV,
more consistent Vt and MV. conventional inspiratory times are used, and rate, pressure level,
❖ Additional modes of ventilation have been promoted and PEEP are selected.
for use in patients with acute respiratory distress syn- Positive End-Expiratory Pressure (PEEP) and Continuous
drome (ARDS), including high-frequency oscillation, Positive Airway Pressure (CPAP)
airway pressure-release ventilation (APRV), and other Description: This ventilatory option creates positive pressure at end
ventilator-specific modes, such as biphasic, adaptive exhalation. PEEP restores functional residual capacity. The term
support, and proportional assist ventilation. Although PEEP is used when end-expiratory pressure is provided during
some data exist that suggest the modes may be benefi- ventilator positive pressure breaths.
cial in patients with ARDS, to date no change in
29 Invasive Mechanical Ventilation (Through an Artificial Airway): Volume and Pressure Modes 229
lung injury. The lung injury was described as a loss of

BOX 29-2 Ventilator Alarms
alveolar integrity (i.e., alveolar fractures) and move-
DISCONNECT ALARMS (LOW-PRESSURE OR ment of fluids and proteins into the alveolar space
LOW-VOLUME ALARMS) (sometimes called non-ARDS-ARDS).33,34,43,52 Plateau
When disconnection occurs, the clinician must be immediately pressures of 30 cm H2O or more for greater than 48 to
notified. Generally, this alarm is a continuous one and is triggered 72 hours were associated with the injury.34,49,52
when a preselected inspiratory pressure level or minute ventilation ❖ Studies in humans followed the recognition that large
is not sensed. With circuit leaks, this same alarm may be activated Vts may be associated with lung injury.1 The ARDS
even though the patient may still be receiving a portion of the Network conducted a randomized controlled trial of
preset breath. Physical assessment, digital displays, and adult patients with ARDS that compared low lung-
manometers are helpful in troubleshooting the cause of the alarms. volume ventilation (6 mL/kg) with more traditional
PRESSURE ALARMS volumes (i.e., 12 mL/kg). The results showed that the
High-pressure alarms are set to ensure notification of pressures lower-volume ventilation resulted in a lower mortality
that exceed the selected threshold. These alarms are usually set rate.1 As a result, current recommendations are to limit
10–15 cm H2O above the usual peak inspiratory pressure (PIP). volumes (and lower pressures) in patients with stiff
Some causes for alarm activation (generally an intermittent alarm) lungs. With pressure ventilation, pressure is limited by
include secretions, condensate in the tubing, biting on the definition; however, until additional evidence emerges
endotracheal tubing, increased resistance (i.e., bronchospasm), on the efficacy of controlling pressures versus volumes
decreased compliance (e.g., pulmonary edema, pneumothorax), and in ARDS, a goal should be to ensure a Vt in the 6 mL/
tubing compression. When this alarm is triggered, the breath kg range. Another lung-protective strategy is that of
delivery is halted and the remaining tidal volume to be delivered by “recruitment” and the prevention of “derecruitment.”
the machine is not delivered. This will then often result in the Investigators showed that stiff noncompliant lungs
occurrence of a low-volume alarm.
were at risk of trauma from the repetitive opening
Low-pressure alarms are used to sense disconnection, circuit
associated with tidal breaths. The application of higher
leaks, and changing compliance and resistance. They are generally
levels of positive end-expiratory pressure (PEEP) was
set 5–10 cm H2O below the usual PIP or 1–2 cm H2O below the
PEEP level or both.
associated with better recruitment and resulted in
Minute ventilation alarms may be used to sense disconnection or improved mortality rates.3,4,18,44,85
❖ The extent of hemodynamic changes associated with
changes in breathing pattern (rate and volume). Generally,
low-minute ventilation and high-minute ventilation alarms are set PPV depends on the level of applied positive pressure,
(usually 5–10 L/min above and below usual minute ventilation). the duration of positive pressure during different phases
When stand-alone pressure support ventilation (PSV) is in use, this of the breathing cycle, the amount of pressure transmit-
alarm may be the only audible alarm available on some ventilators. ted to the vascular structures, the patient’s intravascular
FiO2 alarms are provided on most new ventilators and are set volume, and the adequacy of hemodynamic compensa-
5–10 mm Hg above and below the selected FiO2 level. tory mechanisms. PPV can reduce venous return, shift
Alarm silence or pause options are built in by ventilator the intraventricular septum to the left, and increase
manufacturers so that clinicians can temporarily silence alarms for right-ventricular afterload as a result of increased pul-
short periods (i.e., 20 seconds) because alarms must stay activated monary vascular resistance.22,38,53,54 The hemodynamic
at all times. The ventilators reset the alarms automatically. effects of PPV may be prevented or corrected by opti-
Alarms provide important protection for patients on ventilation. mizing filling pressures to accommodate the PPV-
However, inappropriate threshold settings decrease usefulness. induced changes in intrathoracic pressures; by
When threshold gradients are set too narrowly, alarms occur minimizing the peak pressure, plateau pressure, and
needlessly and frequently. Conversely, alarms that are set too PEEP; and by optimizing the inspiratory-to-expiratory
loosely (wide gradients) do not allow for accurate and timely (I : E) ratio.
assessments. ❖ Pulmonary barotrauma (i.e., air-leak disease) is damage
to the lung from extrapulmonary air that may result
From Burns SM: Mechanical ventilation and weaning. In Kinney MR, et al, from changes in intrathoracic pressures during PPV.
editors: AACN clinical reference for critical care nursing, ed 4. St Louis, 1998,
Barotrauma is manifested by pneumothorax, pneumo-
Mosby.
mediastinum, pneumopericardium, pneumoperito-
neum, and subcutaneous emphysema. The risk of
barotrauma in a patient receiving PPV is increased with
preexisting lung lesions (e.g., localized infections,
• Complications of PPV include volume-pressure trauma, blebs), high inflation pressures (i.e., large Vt, PEEP,
hemodynamic changes, and pulmonary barotrauma. main-stem bronchus intubation, patient-ventilator
❖ Volume-pressure trauma, in contrast to barotrauma (or asynchrony), and invasive thoracic procedures (e.g.,
air-leak disease), was first described in animals with subclavian catheter insertion, bronchoscopy, thoracen-
stiff noncompliant lungs who were ventilated with tra- tesis). Barotrauma from PPV may be prevented by
ditional lung volumes (range, 10 to 12 mL/kg PBW). controlling peak and plateau pressures, optimizing
The investigators noted that the large volumes trans- PEEP, preventing auto-PEEP, ensuring patient-
lated into high plateau pressures (also known as static, ventilator synchrony, and ensuring proper artificial
distending, or alveolar pressure) and subsequent acute airway position.
TABLE 29-1 Volume and Pressure Modes and Corresponding Ventilator Parameters
Mode Name and Description Main Parameters Comments
Assist Control (A/C) Vt Generally considered a support mode. Must switch to another
Rate mode or method for weaning.
Inspiratory time (Ti)
Sensitivity
FiO2
PEEP
Synchronized Mandatory Ventilation Vt Originally used as a weaning mode; however, work of
(SIMV) Rate breathing is high at low SIMV rates. Often used in
Ti conjunction with PSV.
Sensitivity
FiO2
PEEP
Pressure Support Ventilation (PSV) PS level Often pressure is arbitrarily selected (e.g., 10–20 cm H2O) then
Sensitivity adjusted up or down to attain the desired tidal volume.
FiO2 Some use the plateau pressure if transitioning from volume
PEEP ventilation as a starting point.
Pressure-Controlled Ventilation (PCV) Inspiratory pressure limit (IPL) Variants of PCV include Volume-Assured Pressure Options and
Rate some other modes such as Airway Pressure Release
Ti Ventilation and Bilevel Ventilation.
Sensitivity
FiO2
PEEP
Pressure Controlled–Inverse Ratio As for PCV, but an inverse Some ventilators allow for the I : E ratio to be selected.
Ventilation inspiratory : expiratory (I : E)
ratio is attained by lengthening
the Ti. Inverse ratios include
1 : 1, 2 : 1, 3 : 1, and 4 : 1.
Bilevel Positive Airway Pressure PressureHIGH (PHIGH) Similar in many ways to PC in that an inspiratory pressure
(Bilevel or BiPAP) PressureLOW(PLOW) (PressureHIGH)
THIGH(Similar to I Time in PC) and PEEP (PressureLOW) are set. However, unlike PC, the patient
TLOW (Similar to E time in PC) may take spontaneous breaths as well. If additional support
Or set ratio THIGH/TLOW ratio is desired for patient-initiated breathing, pressure support in
Rate bilevel mode (Psupp) may be selected as well. Attention to
FIO2 Vt is important because the patient can augment Vt
significantly with supported spontaneous breaths.
Airway Pressure Release Ventilation Pressure high (PHIGH): high CPAP APRV is a form of biphasic ventilation with a very short
(APRV) level. expiratory time. Generally, the CPAP level is adjusted to
Pressure low (PLOW) is generally ensure adequate oxygenation while the rate of the releases
0–5 cm H2O. are increased or decreased to meet ventilation goals. Vt is
Time high (THIGH). variably dependent on the CPAP level, compliance and
Time low (TLOW). resistance of the patient, and patient spontaneous effort.
FiO2
Dual Control or Volume-Assured These modes provide pressure These modes are ventilator specific. Although the similarities
Pressure Modes (1–5 listed here) breaths with a minimum tidal are greater than the differences, they are called different
volume assurance. names. Often the names suggest that the mode is a volume
mode, yet a decelerating flow pattern (associated with
pressure ventilation) is always provided.
1. Volume Support (VS) Vt The pressure level is automatically adjusted to attain the
Sensitivity desired Vt. If control of pressure is desired, it must be
FiO2 carefully monitored.
PEEP
2. Pressure-Regulated Control Rate and Ti set in addition to As with VS. The difference is that this is a control mode.
(PRVC) those set for VS. Spontaneous breaths, however, may also occur.
TABLE 29-1 Volume and Pressure Modes and Corresponding Ventilator Parameters—cont’d
Mode Name and Description Main Parameters Comments
3. Volume Control Plus (VC+) Rate and Ti are set in addition to This is a mode option listed in the category called Volume
those set for VS. Ventilation Plus. To access this mode, the user selects the
SIMV or A/C (both control modes) then selects VC+. For
some clinicians, this is confusing because it appears that
the patient is on two different modes versus VC+.
4. Adaptive Support Ventilation Body weight Once basic settings are selected, ASV is started and %MinVol
(ASV) %MinVol (minute volume), high is adjusted if indicated. Spontaneous breathing is
pressure limit automatically encouraged, and when the inspiratory
pressure (Pinsp) is consistently 0 and rate is 0, extubation
may be considered.
5. Proportional Assist Ventilation Proportional Pressure Support Depending on the ventilator, the amount of assist that is
(PAV) (PPS): PEEP, FiO2, percent provided is determined by the clinician and different
volume assist and flow assist parameters are selected to do so. Default percent support
Proportional Assist Plus: PAV+: numbers are recommended, but the clinician must
PEEP, FiO2, percent support determine the timing of reductions of same.
6. Automatic Tube Compensation Endotracheal tube internal This is not a mode but rather a pressure option to offset the
(ATC) diameter work associated with tube resistance. It can be combined
Percent compensation with other modes or used alone as in a CPAP weaning trial.
Adapted with permission from Burns S: Pressure modes of mechanical ventilation: The good, bad and the ugly, AACN Adv Crit Care 19:399–411, 2008.
Auto-PEEP is a common complication of mechanical

❖ the lungs), use of continuous-aspiration subglottic suc-
ventilation and can result in hemodynamic compro- tioning (CASS) tubes, decreased ventilator tubing
mise and even death. Because increased intrathoracic changes, use of heat and moisture exchangers (HMEs),
pressures are transmitted to the adjacent capillaries, stringent hand washing, backrest elevation (BRE) of
venous return is decreased and the effect can be pro- greater than 30 degrees, and when possible the use of
found. Auto-PEEP and dynamic hyperinflation should noninvasive ventilation (especially in patients with
be assumed in the patient on ventilation with acute immunocompromise).23,74,75,82
severe asthma whose condition is hemodynamically ❖ Other interventions with a lower level of evidence sup-
compromised, and a brief cessation of mechanical ven- porting their use include oral care techniques such as
tilation or decrease in rate and shortening of inspiratory mouth care and oral decontamination with agents such
time should be accomplished.16,59,65,79 Auto-PEEP is as chlorhexidine or oral antibiotics.45 Of interest,
caused by inadequate expiratory time relative to the gastric residual volumes have not been found to be
patient’s lung condition. Auto-PEEP is often seen in consistently associated with VAP.73 Box 29-3 lists the
patients with prolonged inspiratory times, short expira- top recommendations of authoritative professional
tory times, high minute ventilation requirements, bron- organizations for the prevention of VAP.
chospasm, low elastic recoil, mucus hypersecretion,
increased wall thickness, airway closure or collapse, EQUIPMENT
and mechanical factors (e.g., water in the ventilator
circuit, pinched ventilator tubing).16,59,65,79 Correcting • Endotracheal or tracheostomy tube
these factors reduces auto-PEEP. In some cases where • Electrocardiogram and pulse oximetry
auto-PEEP cannot be eliminated, adding set PEEP to • Supplemental oxygen source
the level of auto-PEEP results in reduction of the inspi- • Manual self-inflating resuscitation bag-valve device (with
ratory trigger threshold and thus improvement of PEEP adjusted to patient baseline level or with a PEEP
patient triggering.16,59,62,79 valve)
• Complications of PPV include ventilator-associated pneu- • Appropriately sized resuscitation face mask
monia (VAP). • Ventilator
❖ VAP occurs after 3 to 5 days of mechanical ventilation • Suction equipment
and accounts for one third of all healthcare-associated
infections and between 50% and 83% of infections in PATIENT AND FAMILY EDUCATION
the patient with MV.23,74,75,82
❖ Modifiable risk factors to the aspiration of colonized • Explain the procedure and the reasons for PPV to the patient
organisms in the patient on ventilation include inter- and family. Rationale: Communication and explanations
ventions such as proper endotracheal tube cuff inflation for therapy are important needs of patients and families.
(secretions that collect above the cuff of the endotra- • Discuss the potential sensations the patient will experi-
cheal or tracheostomy tube and leak past the cuff into ence, such as relief of dyspnea, lung inflations, noise of
BOX 29-3 Top Modifiable VAP Prevention

Interventions: Guidelines by
Authoritative Professional PREPARATION
Organizations* Patient Assessment
• Back rest elevation (>30–45 degrees) • Assess for signs and symptoms of acute ventilatory failure
• Continuous aspiration of subglottic secretions tubes and fatigue. Rationale: Ventilatory failure indicates the
• Limit/interrupt sedation (spontaneous awakening trial) need for initiation of PPV. While PPV is being considered
• Spontaneous breathing trial/assess readiness to extubate daily. and assembled, support ventilation via a self-inflating
• Noninvasive ventilation when possible manual resuscitation bag-valve-mask (BVM), if
• Early Mobility necessary.
• No routine ventilator circuit change ❖ Rising arterial carbon dioxide tension
• Hand washing and aseptic technique ❖ Chest-abdominal dyssynchrony
❖ Shallow or irregular respirations
*Professional Associations: ❖ Tachypnea, bradypnea, or dyspnea
• AHRQ, Prevention of Ventilator Associated Pneumonia (2011). http:// ❖ Decreased mental status
www.guideline.gov/content.aspx?id=36063. Accessed January 27, 2016. ❖ Restlessness, confusion, or lethargy
• Association for Professionals in Infection Control (APIC) (2009). Guideline to
❖ Increasing or decreasing arterial blood pressure
Eliminating Ventilator Associated Pneumonia. http://www.apic.org/Resource
❖ Tachycardia
_/EliminationGuideForm/18e326ad-b484-471c-9c35-6822a53ee4a2/File/
VAP_09.pdf: Accessed: January 27, 2016. ❖ Atrial or ventricular dysrhythmias
• Institute for Clinical Systems Improvement (2011). https://www.icsi. • Determine arterial pH and carbon dioxide tension. Ratio-
org/_asset/y24ruh/VAP.pdf. Accessed: January 27 2016. nale: Acute ventilatory failure is confirmed by an uncom-
• Society for Healthcare Epidemiology in America (SHEA) (2014). Strategies to pensated respiratory acidosis. Ventilatory failure is an
Prevent Ventilator Associated Pneumonia in Acute Care Hospitals. indication for PPV.
• Assess for signs and symptoms of inadequate oxygen-
ation. Rationale: Hypoxemia may indicate the need for
ventilator operation, and alarm sounds. Rationale: Knowl- PPV. While PPV is being considered and assembled,
edge of anticipated sensory experiences reduces anxiety provide 100% oxygen via manual resuscitation bag and
and distress. mask or via an oxygen delivery device, such as a nonre-
• Encourage the patient to relax. Rationale: This encour- breather mask.
agement promotes general relaxation, oxygenation, and ❖ Decreasing arterial oxygen tension
ventilation. ❖ Tachypnea
• Explain that the patient will be unable to speak. Establish ❖ Dyspnea
a method of communication in conjunction with the ❖ Central cyanosis
patient and family before initiating mechanical ventila- ❖ Alterations in level of consciousness
tion, if necessary. Rationale: Ensuring the patient’s ability ❖ Restlessness
to communicate is important to alleviate anxiety. ❖ Confusion
• Teach the family how to perform desired and appropriate ❖ Agitation
activities of direct patient care, such as pharyngeal suction ❖ Tachycardia
with the tonsil-tip suction device, range-of-motion exer- ❖ Bradycardia
cises, and reconnection to ventilator if inadvertent discon- ❖ Dysrhythmias
nection occurs. Demonstrate use of the call bell. Rationale: ❖ Intercostal and suprasternal retractions
Family members have identified the need and desire to ❖ Increasing or decreasing arterial blood pressure
help in the patient’s care. ❖ Adventitious breath sounds
• Explain to the patient and family the importance of not ❖ Decreasing urine output
touching the ventilator controls, including silencing and ❖ Metabolic acidosis
resetting alarms. Rationale: Families may become famil- • Determine Pao2 or arterial oxygen saturation (Sao2). Ratio-
iar with the ventilator over time and, in a desire to help, nale: Hypoxemia is confirmed by Pao2 of <60 mm Hg or
reset or silence an alarm without an understanding of the Sao2 of less than 90% on supplemental oxygen. Hypoxemia
cause/underlying problem. may indicate the need for PPV.
• Provide the patient and family with information on the • Assess for signs and symptoms of inadequate breathing
critical nature of the patient’s dependence on PPV. Ratio- patterns. Rationale: Respiratory distress is an indication
nale: Knowledge of the prognosis, probable outcome, or for PPV.
chance for recovery is cited as an important need of ❖ Dyspnea
patients and families. ❖ Chest-abdominal dyssynchrony
• Offer the opportunity for the patient and family to ask ❖ Rapid-shallow breathing pattern
questions about PPV. Rationale: Asking questions and ❖ Irregular respirations
having questions answered honestly are cited consistently ❖ Intercostal or suprasternal retractions
as the most important need of patients and families. ❖ Inability to say a whole sentence
This communication evaluates and reinforces understand-

Patient Preparation ing of previously taught information.
• Verify that the patient is the correct patient using two • Premedicate as needed. Rationale: Administration of
identifiers. Rationale: Before performing a procedure, the sedatives, narcotics, or muscle relaxants may be necessary
nurse should ensure the correct identification of the patient to provide adequate oxygenation and ventilation in some
for the intended intervention. patients.
• Perform a preprocedure verification and time out, if non- • Ensure patient is positioned properly for optimum ventila-
emergent. Rationale: Ensures patient safety. tion. Rationale: Placement of the patient in a head-of-bed
• If patient is not in distress ensure that the patient under- elevation of at least 30 degrees enhances diaphragmatic
stands preprocedural teachings. Answer questions as they excursion, decreases intrathoracic pressure, and helps
arise, and reinforce information as needed. Rationale: prevent aspiration and VAP.
Procedure for Invasive Mechanical Ventilation (Through an Artificial Airway):

Volume and Pressure Modes
1. HH
2. PE
Volume-Control Modes
3. Select mode (see Box 29-1 and Table Mode selection varies depending SIMV is often used in conjunction
29-1). The three traditional volume on the clinical goal and clinician with PSV (to overcome circuit
modes and mode settings are control preference. resistance and to decrease the
mechanical ventilation (CMV), assist/ Traditional volume modes that work of breathing associated
control (A/C), and synchronized may provide total ventilatory with spontaneous effort).
intermittent mandatory ventilation support include control, SIMV, The use of SIMV plus PSV has
(SIMV). and A/C. With SIMV and A/C been associated with prolonged
A. CMV: The intent of control the ventilator rate must be high weaning times. If respiratory
ventilation is to have volume and enough or the patient sedated so muscle rest is the goal with
rate ensured. As with all modes of that spontaneous effort is not SIMV plus PSV, the level of
ventilation, the patient is never present. Other modes may also PSV should be high enough to
completely “locked out” and can provide complete support provide a Vt of 6–12 mL/kg and
breathe between the control breaths, depending on the settings. to maintain a total rate (IMV
which is ensured by setting the Remember that the goal is to plus PSV breaths) of ≤20
sensitivity or flow triggers (see Step offset the patient’s work of breaths/min.13,14,36,37,41,67,68,86
8). However, should control over breathing. See subsequent
ventilation be desired, sedation and description of other modes and
often paralytic agents are provided their application.
to ensure the goal.
B. A/C: Ventilation ensures that a
control rate and volume are set.
Patient-initiated breaths are
delivered at the predetermined
volume selected for the control
breaths.
C. SIMV: With this mode, a rate (fx)
and Vt are set and are delivered in
synchrony with the patient’s
respiratory effort. Between
mandatory breaths, the patient may
initiate breaths at a patient-
determined volume and rate.

Volume and Pressure Modes—Continued
4. Set Vt <10 mL/kg PBW. In patients Vt is selected in conjunction with When lower Vt values are used in
with ARDS, Vt should be set at fx to attain an MV 5–10 L/min an attempt to reduce lung injury,
4–6 mL/kg PBW. (Level B*) with a Paco2 35–45 mm Hg. patients may need sedation and
Large Vt values (12 mL/kg) have potentially muscle relaxants if
been associated with lung injury they are dyssynchronous with the
in patients with ARDS.3,4,18,44,85 ventilator. Hypercarbia is an
expected outcome of low Vt
values.7,26,27,78 Permissive
hypercarbia is generally well
tolerated in patients if the pH is
reduced gradually (over 24–48
hours); pH around 7.2 is cited as
an end point if tolerated.77
Occasionally, bicarbonate infusions
are used to keep the pH within
an acceptable range. However,
this temporizing maneuver may
result in a higher Paco2 because
bicarbonate is metabolized into
CO2 and H2O.
Permissive hypercarbia should not
be attempted in patients with
elevated intracranial pressure or
patients with myocardial
ischemia, myocardial injury, or
dysrhythmias. Patients who are
allowed to become hypercarbic
may need sedation and often
muscle relaxants (paralytic
agents) to control ventilation.
5. Select respiratory rate (frequency) Vt and rate are selected to When low Vts are used, as in
between 10 and 20 breaths/min. maintain an acceptable Paco2 ARDS, a higher rate may be
with an MV between 5 and necessary to maintain pH and
10 L/min. Generally, once Vt is Paco2 at acceptable levels
selected, rate is the parameter because smaller Vt provides
adjusted to attain a desired less-efficient ventilation; the
Paco2; the rate selected depends result is higher CO2 and lower
on whether or not the clinical pH.27,33,34,78
goal is to rest or work the
respiratory muscles.

6. For I : E times, select inspiratory time Inspiratory flow refers to the speed Generally, flow rates of
(this parameter name is different, with which Vt is delivered approximately 50 L/min are used
depending on the ventilator). Examples during inspiration. initially and adjusted to provide
of parameter names include percent Increasing the flow rate shortens an inspiratory time that
inspiratory time, inspiratory time, flow the inspiratory time. Conversely, synchronizes with patient effort.
rate, and peak flow. slowing the flow rate lengthens Short inspiratory times and long
I : E ratios are usually 1 : 2 or 1 : 3. the inspiratory time. expiratory times are necessary in
A typical inspiratory time for an adult patients with obstructive lung
is in the range of 0.75–1.2 second. diseases (e.g., emphysema,
asthma). In contrast, patients
with restrictive diseases, such
as ARDS, have noncompliant
lungs. Longer inspiratory times
enhance recruitment and prevent
derecruitment.1,3,16,59,65,79
7. Adjust flow as necessary to attain Achieves the desired I : E ratio and
patient ventilator synchrony. comfortable breathing patterns.
8. Set the sensitivity (trigger sensitivity). The more negative the number, the When auto-PEEP is present, the
Most ventilators have pressure-sensing less sensitive the ventilator is to patient has to generate a negative
sensitivity mechanisms that trigger patient effort, which increases pressure equal to the set
flow, which means that the patient must the patient respiratory workload sensitivity plus the level of
generate a decrease in the system and may lead to dyssynchrony. auto-PEEP. Auto-PEEP is
pressure with an inspiratory effort. common in patients with asthma,
When the ventilator senses the drop in chronic obstructive pulmonary
pressure, flow (or a breath) is delivered. disease, and high respiratory
If a pressure trigger is used, sensitivity rates and minute ventilation. This
is set between −1 and −2 cm H2O additional work may fatigue the
pressure. patient. Patient ventilator
dyssynchrony is likely.6,62,65
9. If the ventilator has a flow-triggering Flow triggering has been
option, select the flow trigger in L/min. associated with faster ventilator
The smaller the number, the more response times and less work of
sensitive the ventilator. Flow triggering breathing than pressure sensing.6
is set in conjunction with a base flow
(flow in L/min that is provided between
ventilator breaths). Flow rate is
monitored in the expiratory limb of the
ventilator. When flow is disrupted
during a spontaneous breath, a decrease
in flow downstream is sensed;
additional flow or a breath is delivered.
10. Set Fio2 to 0.60–1.0 (60%–100%), if Initiation of PPV with maximal The goal is an Fio2 ≤0.5; high
Pao2 is unknown. oxygen concentration avoids levels of Fio2 result in increased
A. Adjust Fio2 downward as tolerated hypoxemia while optimal risk of oxygen toxicity,
by monitoring Sao2 and arterial ventilator settings are being absorption atelectasis, and
blood gas values. determined and evaluated. In reduction of surfactant
addition, it permits measurement synthesis.30,42,48
of the percentage of venous
admixture (shunt), which
provides an estimate of the
severity of the gas-exchange
abnormality.

11. Select PEEP or continuous positive A PEEP level of 5 cm H2O is High levels of PEEP ≥10 cm H2O
airway pressure (CPAP) level. Initial considered physiological rarely should be interrupted
setting is often 5 cm H2O. (essentially the amount of because reestablishment of FRC
A. PEEP may be adjusted as needed pressure at end exhalation (and Pao2) may take hours.
after evaluation of tolerance (e.g., normally provided by the Prevention of this derecruitment
Sao2, Pao2, physical assessment). glottis). Higher levels of PEEP in the patient with ARDS is
PEEP levels are increased to restore may be used to prevent alveolar especially important. Super-
FRC and allow for reduction of Fio2 collapse during the expiratory PEEP levels (i.e., ≥20 cm H2O)
to safe levels (i.e., ≤0.5) to decrease phase of the ventilator breath in may be necessary in patients
the risk of oxygen toxicity. atelectasis or ARDS. with noncompliant lungs (e.g.,
patients with ARDS) to prevent
lung injury. The repetitive
opening and closing of stiff
alveoli is thought to result in
alveolar damage; to that end, the
use of high PEEP levels to
maintain alveolar distention and
to prevent injury during PPV is
considered a protective lung
strategy.3–5,12,33,34,44 In general,
when high PEEP levels are used,
Vt values are lower than normal
and subsequent hypercarbia may
be anticipated.
Use of muscle relaxants, sedatives,
and narcotics is often necessary
to prevent patient spontaneous
breathing.
B. CPAP is often referred to as PEEP Patients who are spontaneously Generally, the pressure levels of
without the positive pressure breathing may not require CPAP are relatively low but vary
breaths. CPAP is a spontaneous delivery of ventilator breaths, with individual patient
breathing mode that provides but positive pressure applied to conditions. A traditional
continuous pressure throughout the the airways and alveoli to application of CPAP is for
ventilator cycle. It is commonly prevent collapse or obstruction obstructive sleep apnea (OSA)
used as a mode for spontaneous- during exhalation. through a noninvasive mask or
breathing weaning trials. prongs. When used for OSA, the
mode provides a pneumatic
splint to the airways to prevent
obstruction during sleep.
Pressure Modes (Invasive)
1. Select mode: PSV, pressure-controlled/ Mode selection depends on Many new modes that use
inverse ratio ventilation (PC/IRV), clinical goals, mode availability microprocessor technology are
volume-assured pressure support option, (these vary widely with different available on specific ventilators.
APRV, adaptive support ventilation, ventilators), and clinician Although many are similar to
proportional assist ventilation (PAV), preference. To date, no mode traditional modes, others are not.
automatic tube compensation (ATC), or has emerged as superior.17,81,89 Parameter names also vary. Refer
high-frequency oscillation (HFO). Modes include those designed to specific ventilator operating
for spontaneous breathing and manuals and websites for details
those for control or partial not contained in this procedure.
control of ventilation.

2. PSV augments spontaneous respirations Pressure level in conjunction with PSV sometimes is used between
with a clinician-selected pressure level. compliance and resistance IMV breaths to offset the work
Adjust the PSV level to attain a Vt determines delivered Vt. of breathing associated with
<10 mL/kg PBW with a spontaneous artificial airways and circuits
respiratory rate (RR) ≤20 breaths/min during spontaneous breathing.
(if respiratory muscle rest is desired; PSV generally is considered a
this is called PSVmax). Decrease PSV weaning mode of ventilation,
level during weaning trials as tolerated which necessitates stability of
by patient. Tolerance criteria for trials patient condition. PSV may be
may be predetermined by protocols or used in patients with less stable
on an individual basis. Often during conditions provided that close
trials, Vt values are allowed to be lower attention is given to changes in
(i.e., 5–8 mL/kg) and RR higher (i.e., Vt and RR. High levels of PSV
25–30 breaths/min) than when rest is may provide respiratory muscle
the goal. However, these parameters are unloading.
always evaluated in conjunction with
other signs and symptoms of fatigue
and intolerance.13,14,41,61,63,95 (Level B*)
A. Set sensitivity (as with volume The more negative the number, the
ventilation). less sensitive the ventilator is to
patient effort, which increases
the patient respiratory workload
and may lead to dyssynchrony.
B. Set Fio2 (as with volume Initiation of PPV with maximal
ventilation). oxygen concentration avoids
hypoxemia while optimal
ventilator settings are being
determined and evaluated. In
addition, it permits measurement
abnormality.
C. Set PEEP (as with volume A PEEP level of 5 cm H2O is
ventilation). considered physiological
(essentially the amount of
pressure at end exhalation
normally provided by the
glottis). Higher levels of PEEP
may be used to prevent alveolar
collapse during the expiratory
phase of the ventilator breath in
atelectasis or ARDS.

3. PC/IRV are both control modes of Absolute pressure level is the sum If the clinical goal is to ensure a
ventilation. With these modes, a of the inspiratory pressure level plateau pressure of ≤30 cm H2O,
pressure level is selected; the rate and (IPL) and PEEP. the pressure level may be
inspiratory time are selected as well. lowered gradually over 24–48
They were originally used to manage hours to prevent sudden changes
patients with ARDS in whom the goal in Paco2 and pH.50,76,78
was to limit the pressure level. In
addition, the decelerating flow pattern
of the modes was considered desirable.
PC/IRV was used to enhance lung
recruitment by prolonging inspiration.
Expiration was shortened, thereby
decreasing the potential for
derecruitment.
A. Select IPL. With this pressure mode, Rate and IPL determine MV.
the level of pressure support is often
identified as IPL versus PSV.
B. Select rate. Vt and rate are selected to When low Vts are used, as in
maintain an acceptable Paco2 ARDS, a higher rate may be
with an MV between 5 and necessary to maintain pH and
10 L/min. Generally, once Vt is Paco2 at acceptable levels
selected, rate is the parameter because smaller Vts provide
adjusted to attain a desired less-efficient ventilation; the
Paco2; the rate selected depends result is higher CO2 and lower
on whether or not the clinical pH.27,33,34,79
goal is to rest or work the
respiratory muscles.
C. Select inspiratory time or inverse I : E ratios are set at 1 : 1, 2 : 1, 3 : 1, Generally, clinicians start with 1 : 1
I : E ratio (ventilators vary). or 4 : 1 by selecting the ratios and increase as necessary
appropriate inspiratory time. to improve oxygenation.
Ratios are adjusted upward to A limiting factor related to
improve shunt and oxygenation. prolonged inspiratory times is
Blood pressure may be adversely hemodynamic compromise and
affected. Rate is usually hypotension, which is generally
relatively high (e.g., 20–25 why the use of ratios >2 : 1 rarely
breaths/min). is seen clinically.
Auto-PEEP is common and may be
a desired outcome of PC/IRV.66,76
D. Select PEEP level. When Because IRV may result in Auto-PEEP generated by IRV is
transitioning from volume auto-PEEP, evaluation of the expected and helpful in
ventilation to PC/IRV, the PEEP total amount of PEEP present is expanding collapsed alveoli.
initially is maintained at the level important. This can be measured
used previously until the effect of through the performance of an
the IRV is assessed. (Level C*) expiratory hold maneuver on the
ventilator.

E. Set Fio2 to 0.60–1.0 (60%–100%) if Initiation of PPV with maximal The goal is an Fio2 ≤0.5; high
Pao2 is unknown. oxygen concentration avoids levels of Fio2 result in increased
Adjust Fio2 downward as tolerated hypoxemia while optimal risk of oxygen toxicity,
by monitoring Sao2 and arterial ventilator settings are being absorption atelectasis, and
blood gas values. determined and evaluated. In reduction of surfactant
addition, it permits measurement synthesis.30,42,48
abnormality.
F. Set sensitivity (as with volume The goal of PC/IRV is to improve If controlled ventilation is the goal,
ventilation). (Level B*) oxygenation and allow for chemical relaxation may be
reduction of Fio2 to ≤0.5.17,50,76,87 necessary in conjunction with
This is done in conjunction with sedatives and narcotics.
the addition of PEEP. Always Patient tolerance of IRV (i.e., the
set sensitivity so that the patient prolonged inspiratory times) is
can get a breath if needed. unlikely without such
interventions. Remember that
IRV may result in auto-PEEP
(which may be a desirable
outcome of the mode).
Regardless, auto-PEEP should be
anticipated and measured
regularly.
4. Dual-control pressure mode options are Specific names vary depending on Few studies have been
pressure modes that assure a minimum ventilator manufacturer. accomplished that show the
set tidal volume. The breath delivery Examples include Pressure superiority of these modes. In
varies with the specific mode. For dual Augmentation (Carefusion, San addition, many modes are
control pressure support options, Diego, CA) and Volume Support available only on specific
parameter selection (i.e., pressure, and Pressure Regulated Volume ventilators. These modes are
volume, rate) is specific to the Control (Maquet, Wayne, NJ); complex; concurrent use of
ventilator; however, selection of desired similar modes are available on pressure, flow, and volume
(or guaranteed) Vt is required. Some other manufacturers’ ventilators. waveform displays may be
ventilators also require selection of the necessary to assess the modes
pressure level. Spontaneous breathing accurately. Refer to specific
modes and controlled modes are ventilator operating manuals or
available.2,11,15,17, 58,87,90 (Level C*) websites for additional
A. For volume-guaranteed pressure information.
options, please see specific See Table 29-1 parameters for
ventilator manual for parameter volume-guaranteed pressure
setting. (Level M*) options.
B. PEEP, Fio2 and sensitivity are set as
per volume ventilation, as are rate
and inspiratory time if the mode is a
control mode. However, the desired
Vt must be selected as well.17


5. Biphasic and APRV ventilation are Although the modes appear to be Few studies have been
relatively new modes that appear on safe and effective, randomized accomplished that show the
selected ventilators. Used most controlled trials are not superiority of these modes. In
commonly for patients with ARDS, the available. Regardless, one big addition, many modes are
modes use relatively high levels of advantage to these modes is that available on specific ventilators.
pressure to recruit the lung (restore they do not require that the These ventilatory modes require a
FRC). APRV is a type of biphasic patient be heavily sedated or steep learning curve on the part
ventilation with a very short expiratory paralyzed. Spontaneous of physician, advanced practice
(release) time.56,69,71,80,81,88, 89,97 breathing is expected. Generally, nurse, and other healthcare
(Level C*) the patient’s breathing pattern is professionals who care for the
rapid. patients; as with most new forms
of ventilation, education of staff
should occur before the mode is
used. Although the appeal of
APRV and biphasic ventilation is
in part because the patient may
breath spontaneously, it is
unclear whether the associated
workload is advantageous.72
A. With APRV, a high level of CPAP is The high level of CPAP helps On some machines, the formal
selected, and brief expiratory “recruit” the lung. Alveolar mode name APRV may not be
“releases” are provided at set filling and emptying time used. It may be incorporated
intervals (similar to setting a RR); constants in the ARDS lung under biphasic ventilation.
the releases are very brief (≤1.5 vary; the brief expiratory
seconds). releases provided with APRV
allow for more uniform
emptying throughout the lung
and ultimately improved gas
distribution. An additional
benefit of periodic airway
pressure releases is that they
may decrease the potential
negative effect of the high
CPAP level on venous return. At
the high CPAP level, the patient
may take spontaneous breaths at
the rate that they require.47,56,70,84
B. With the biphasic mode, two The theoretical advantage of this APRV mode as described
different levels of PEEP are selected mode over traditional PC/IRV is previously may be achieved in
and are called high-PEEP and that the mode may fully support ventilators with biphasic modes.
low-PEEP. This is really an lung recruitment while still Biphasic modes have many trade
interaction of traditional PC allowing for spontaneous names (BiVent, BiLevel, BiPAP,
ventilation. A rate is set, and the breathing at the two pressure DuoPap). The APRV settings are
cycles look similar to PC or PC/IRV levels.17,56,81 achieved on each type of
ventilation (depending on the I : E In contrast to traditional PC/IRV, ventilator in a slightly different
ratio). The major difference is that the patient receives additional manner. Refer to the specific
flow is available to the patient for flow adequate to meet ventilator manual for parameter
spontaneous breathing at both inspiratory demands throughout settings.
pressure levels. In addition, Pressure the ventilatory cycle.
Support (PS) may be added to assist Deterioration with spontaneous
in decreasing the work associated effort is less likely; as a result,
with spontaneous breathing.17,56,81 heavy sedation and paralytics
(Level E*) may be avoided.

C. For APRV and biphasic mode Manufacturers have different
options, please see specific names for parameters settings.
ventilator manual for parameter Although there are similarities
settings. (Level M*) among the ventilator models, it
is important to be familiar with
the ventilators used in your
practice area.
D. Specific APRV settings: The combination of the inspiratory Patients on APRV should be
i. Pressure high (PHIGH), which is pressure (Phigh) and inspiratory transported on the ventilator to
the high-PEEP level. May be set time (Thigh) determine the avoid alveolar derecruitment
at the measured plateau pressure machine-delivered tidal volume. associated with disconnection
to start. The expiratory time (Tlow) from the ventilator circuit. This
ii. Pressure low (PLOW), which is determines the duration of can occur when the patient is
the low-PEEP level, is generally exhalation. In APRV, the transitioned to a bag-valve mask
set at 0 cm H2O. expiratory time is very short for transport. If the patient must
iii. Time high (THIGH): 4–6 seconds. (usually <1.0 second). be disconnect from the ventilator,
iv. Time low (TLOW): 0.4–0.8 Therefore, the Plow is set at the endotracheal tube may be
seconds (keep <1.5 seconds). 0 cm H20, because there is clamped during the inspiratory
Rate is determined by the insufficient time for the alveoli phase before circuit
combined inspiratory (THIGH) to collapse before the next disconnection to reduce the
expiratory time (TLOW). breath. chance of alveolar derecruitment.
E. Specific biphasic settings: The combination of the inspiratory
i. Pressure high (PHIGH) pressure (Phigh) and inspiratory
Set to achieve the desired tidal time (Thigh) determines the
volume for the patient machine-delivered tidal volume.
ii. Pressure low (PLOW). Set to The expiratory time (Tlow)
attain best PEEP determines the duration of
iii. Rate: 8–10 exhalation. In biphasic (non-
iv. Inspiratory time (THIGH): 1.5 APRV), the I : E ratio is usually
seconds or set THIGH/TLOW ratio set at conventional ratios (1 : 2
(I : E ratio) or 1 : 3).
v. Fio2.
F. Fio2 and sensitivity are set as See Steps 8 and 9.
outlined in Steps 8 and 9 above
under Volume Control Modes.


6. Adaptive support ventilation: The mode The working concept with this The higher the %MinVol, the
is referred to by the ventilator mode is that the patient will higher the level of support
manufacturer as “intelligent ventilation” breathe at fx and Vt that provided to the patient.
and is designed to assess lung minimize elastic and resistive
mechanics on a breath-to-breath basis loads. In all modes, the
(controlled loop ventilation) for opportunity for spontaneous
spontaneous and control settings. It breathing is promoted (the user
achieves an optimal Vt by automatically does not have to switch back
adjusting mandatory respiratory fx and and forth from one mode to
inspiratory pressure. Built into the another to encourage
mode are algorithms that are “lung spontaneous breathing because
protective.” The protective strategies this is automatically done). Thus
are designed to minimize auto-PEEP the interactions required by the
and prevent apnea, tachypnea, excessive clinician are few.
dead space, and excessively large
breaths.2,15,19,25,58,90 (Level C*)
Parameters to set include predicted body
weight, minute volume (%MinVol), and
high pressure limit in addition to Fio2.
(Level M*)
7. PAV: The concept with this pressure PAV may provide a more Few studies have been
mode is to prevent fatiguing workloads physiological breathing accomplished that show the
although still allowing the patient to pattern.10,17,25,45,60,94 The modes superiority of this mode. In
breathe spontaneously. Current PAV recognize that patient effort addition, many modes are
modes take measurements throughout reflects work and demand, and available on specific ventilators.
the inspiratory cycle and automatically base the adjustments
adjust the pressure, flow, and volume accordingly. The percent of
proportionally to offset the resistance assist is adjusted to a higher
and elastance of the system with each percent if less work is desired
inspiration (patient and circuit). and a lower percent if more
Different names for the modes are work is necessary.
provided by specific manufacturers, and
parameters that require adjustment vary
somewhat between the ventilators.
(Level M)
Parameter settings include PEEP, Fio2,
percent volume assist, and percent flow
assist.
8. ATC is a ventilatory adjunct rather than ATC adjusts the pressure ATC is increased during inspiration
a mode and is available on many (proportional to tube resistance) and lowered during expiration,
current ventilators. It is designed to needed to provide a variable fast thus decreasing the work of
overcome the work of breathing inspiratory flow during breathing as a result of tube
imposed by the artificial airway. spontaneous breathing. resistance. In some patients, the
Parameters include internal diameter use of ATC has resulted in
size of the endotracheal tube and the auto-PEEP.35,93
desired percent of compensation.17, 35,93
(Level C)

9. High-frequency oscillation ventilation The method achieves oscillation of Studies to date have not shown the
(HFOV) differs significantly from the lung around a constant superiority of this mode over
conventional ventilator modes or mode airway pressure (essentially traditional modes in adults with
options. HFOV does not require bulk opening the lung and keeping it ARDS. The mode is safe if
movement of volume in and out of the open).31,32,39,83 appropriately applied by those
lungs; rather, a bias flow of gases is with experience in its use;
provided, and an oscillator disperses the however, it is not easily
gases throughout the lung in what has understood by clinicians.
been called augmented dispersion at Especially of concern is the fact
high frequencies.31,32,39,83 (Level C*) that patients on the mode often
The parameters for HFOV are different need sedation and neuromuscular
from conventional ventilation and are blockade.
outlined in the following.
A. Bias flow: flow in L/min (usual The bias flow combined with the
range, 40–50 L/min). oscillatory activity (extremely
rapid pulses in a back and forth
motion) results in the constant
infusion of fresh gases and
evacuation of old gases.
B. Oscillatory frequency (fx): In Hz Increases in frequency in HFOV 1 Hz is equivalent to 60 breaths.
(usual range, 3–6 Hz).20,39,40 actually reduces CO2
elimination because there is less
time for CO2 to be removed
from the lungs between the
oscillatory breaths. This is
different from conventional
ventilation, with which an
increase in rate may reduce
CO2.20,39,40
C. Mean airway pressure: generally
slightly greater than conventional
ventilation initially.
D. ΔP: The change in pressure or ΔP and fx are adjusted to achieve
pressure amplitude (generally Paco2 within a target range.
adjusted to achieve chest wall
vibration).
E. Fio2 level and PEEP level: as in
conventional ventilation (generally
PEEP is >10).
F. Percent inspiratory time: controls
the percentage of time the oscillator
spends in the inspiratory phase. A
starting place is 33%.
11. HH
Humidity
1. Humidity is essential to prevent the Inspired gases may be humidified HMEs are popular because they
drying effect of the gases provided by with the use of standard cascade decrease the risk of infection and
the ventilator. or high-volume humidifiers. are inexpensive.
Many institutions use disposable
HMEs in place of conventional
humidifiers.


2. For conventional humidifiers, ensure Gases generally are humidified Cool circuits may be tolerated well
that the humidifier has adequate fluid before entering the artificial in patients without secretions.
(sterile distilled water) and that the airway. Temperature is measured In patients with thick or tenacious
thermostat setting is adjusted according at the patient’s airway; secretions, attention to inspired
to manufacturer’s recommendations. temperatures between 35°C and temperature is important to
(Level M*) 37°C (95°F and 98°F) are prevent mucus plugging; circuit
considered optimal.72 temperatures may need to be
closer to body temperature (37°C
versus 35°C) in these cases.
3. HMEs are placed between the airway The moisture in warmed exhaled
and the ventilator circuit. gases passes through the vast
surface area of the HME and
condenses. With inspiration, dry
gases pass through the HME
and become humidified. The use
of HMEs has been associated
with decreased incidence of
ventilator-associated
pneumonias in patients on
ventilation.9,29,51,91,92 (Level B*)
A. Change HMEs per manufacturer’s The longer the HME is in line, the In patients undergoing weaning,
instructions. (Level M*) more efficient the the additional resistive load
humidification; however, added by these humidifiers may
inspiratory resistance increases preclude their use.51,55,64,77
over time. HMEs are often
changed every 2–3 days (refer
to manufacturer’s instructions).
B. Do not use if secretions are copious Obstruction is possible, and HMEs
or bloody. are not indicated in these
conditions.
5. HH

• Maintenance of adequate pH and Paco2 • Abnormal pH, Paco2, and Pao2
• Maintenance of adequate Pao2 • Hemodynamic instability
• Maintenance of adequate breathing pattern • Pulmonary barotrauma
• Respiratory muscle rest • Inadvertent extubation
• Malpositioned endotracheal tube
• Nosocomial lung infection
• Acid-base disturbance
• Respiratory muscle fatigue

interventions.
1. Ensure activation of all alarms Ensures patient safety. • Continued activation of alarms
each shift (see Box 29-2).
2. Check for secure stabilization Reduces risk of inadvertent • Unplanned extubation or
and maintenance of endotracheal extubation or decannulation. decannulation,
or tracheostomy tube. • Dislodgment of airway
3. Monitor in-line thermometer to Reduces risk of thermal injury from • Temperature <35°C or >37°C
maintain inspired gas overheated inspired gas and risk of
temperature (in the range poor humidity from underheated
35–37°C [95–98°F]). inspired gas.
4. Keep ventilator tubing clear of Reduces risk of respiratory infection • Continued condensation
condensation. Drain any by decreasing inhalation of
condensation in the ventilator contaminated water droplets.
tubing toward condensation-
collection reservoirs on the
expiratory limb of the circuit
(clean to dirty). Avoid draining
condensation back toward the
patient. (dirty to clean).
5. Ensure availability of self- Provides capability for immediate • Inability to oxygenate or ventilate
inflating manual resuscitation delivering of ventilation and
bag-valve device attached to oxygenation to relieve acute
supplemental oxygen at the head respiratory distress caused by
of the bed. Attach or adjust hypoxemia or acidosis.
PEEP valve if the patient is on
>5 cm H2O.
6. Check ventilator for baseline Ensures that prescribed ventilator • Fio2, PIP, Vt, or fx settings different
Fio2, peak inspiratory pressure parameters are used (e.g., 100% from prescribed
(PIP), Vt, fx, and alarm oxygen used for suctioning is not
activation with initial inadvertently delivered after
assessment and after removal of suctioning procedure), provides
ventilator from patient for diagnostic data to evaluate
suctioning, bagging, or draining interventions (e.g., PIP is reduced
ventilator tubing. after suctioning or bagging), and
ensures that the monitoring and
warning functions of the ventilator
are functional (i.e., alarms).
7. Explore any changes in peak Acute changes in PIP or Vt may • Unexplained high-pressure alarms
inspiratory pressure >4 cm H2O indicate mechanical malfunction,
or decreased (sustained) Vt on such as tubing disconnection, cuff
PSV. Immediately explore the or connector leaks, tubing or
cause of high-pressure alarms. airway kinks, or changes in
resistance and compliance. Always
consider possibility of tension
pneumothorax.
8. Place bite-block between the An oral airway serves the same • Biting on tube
teeth if the patient is biting on purpose but may not be tolerated as
the oral endotracheal tube. well as the bite-block because it
may induce gagging.

9. Evaluate patient-ventilator By taking the patient off the • Patient-ventilator dyssynchrony
dyssynchrony by manually ventilator for manual ventilation,
ventilating the patient with a synchrony may be accomplished
self-inflating manual more quickly than on the ventilator.
resuscitation bag-valve device. This intervention may reduce risk
of barotrauma and cardiovascular
depression. If patient breathes in
synchrony with bagging, consider
changes in ventilatory parameters.
If patient does not breathe
synchronously with bagging,
explore differential diagnoses of
problems distal to the airway.
Respiratory care practitioner, nurse
practitioner, or physician
consultation may be necessary.
10. Assess for signs of atelectasis. May occur as a result of • Localized changes in auscultation
hypoventilation as well as mucous (increased or bronchial breath
plugging of bronchioles. Early sounds)
detection of atelectasis indicates the • Localized dullness to percussion
need for alteration to promote • Increased breathing effort
resolution (tidal volume • Tracheal deviation toward the side
adjustment, recruitment maneuver, of abnormal findings
PEEP adjustment). • Increased peak and plateau pressures
• Decreased compliance
• Decreased Pao2 or Sao2 (with
constant ventilator parameters)
• Localized consolidation (“whiteout,”
opacity) on chest radiograph
11. Assess for signs and symptoms Early detection of pneumothorax is • Acute, increasing, or severe dyspnea
of pulmonary barotrauma (i.e., essential to minimize progression • Restlessness
pneumothorax). to cardiac tamponade and death. • Agitation
Tension pneumothorax requires • Localized changes in auscultation
immediate emergency (decreased or absent breath sounds)
decompression with a large-bore on the affected side
needle (i.e., 14-gauge) into the • Localized hyperresonance or
second or third intercostal space, tympany to percussion on the
midclavicular line on the affected affected side
side, followed by immediate chest • Elevated chest on the affected side
tube placement. • Increased breathing effort
• Tracheal deviation away from the
side of abnormal findings
• Increased peak and plateau pressures
• Decreased Pao2 or Sao2
• Localized increased lucency with
absent lung markings on chest
radiograph.
• Hypotension

12. Assess for signs of volume- Volume-pressure trauma is assumed if • Acute, increasing, or severe dyspnea
pressure trauma that are the patient has the last three criteria • Restlessness
consistent with ARDS. noted. Ventilatory management • Agitation
should focus on ensuring that • Generalized crackles, especially in
lung-protective strategies are in the dependent portions of the lung
place so that additional injury does • Refractory hypoxemia
not ensue. Some examples include • Increased peak and plateau pressures
Vt of 6 mL/kg and lung recruitment • Decreased compliance
with PEEP. In general, these • Decreased Pao2 or Sao2
strategies result in hypercarbia • Bilateral diffuse lung opacity on
because ventilation is not efficient. chest radiograph or computer axial
tomography (CAT) scan of the chest
• Pao2:Fio2 of <200
• A noncardiac etiology for the “wet”
lung
13. Monitor for signs and symptoms Respiratory distress indicates the • Chest-abdominal dyssynchrony
of acute respiratory distress, need for changes in PPV. • Shallow or irregular respirations
hypoxemia, hypercarbia, and While troubleshooting the difficulties, • Tachypnea, bradypnea, or dyspnea
fatigue. support ventilation via a manual • Decreased mental status
self-inflating resuscitation bag if • Restlessness, confusion, lethargy
necessary. • Increasing or decreasing arterial
blood pressure
• Tachycardia
• Atrial or ventricular dysrhythmias
• Significant changes in arterial pH,
Pao2, Paco2, or Sao2
14. Assess for signs and symptoms Early detection and correction of a • Dyspnea
of a malpositioned endotracheal malpositioned endotracheal tube • Restlessness or agitation
tube. can prevent inadvertent extubation, • Unilateral decreased or absent
atelectasis, barotrauma, and breath sounds
problems with gas exchange. • Unilateral dullness to percussion
• Increased breathing effort
• Asymmetrical chest expansion
• Increased PIP
• Changes in endotracheal tube depth
• Radiographic evidence of
malposition.
• Decreased Sao2
15. Assess for signs and symptoms Inadvertent extubation is sometimes • Vocalization
of inadvertent extubation. obvious (e.g., the endotracheal tube • Activated ventilator alarms
is in the patient’s hand). Often, the • Low pressure
tip of the endotracheal tube is in • Low minute ventilation
the hypopharynx or in the • Inability to deliver preset pressure
esophagus; however, an inadvertent • Decreased or absent breath sounds
extubation may not be immediately • Gastric distention
apparent. Reintubation may be • Changes in endotracheal tube depth
necessary, although some patients • Signs and symptoms of inadequate
may not need reintubation. If ventilation, oxygenation, and
reintubation is necessary, breathing pattern
ventilation and oxygenation are
assisted with a manual self-inflating
resuscitation bag-valve device and
face mask.

16. Evaluate the patient’s need for This evaluation allows the nurse to • Spontaneous breathing trial failure
long-term mechanical anticipate patient and family needs • Inability to wean from the ventilator
ventilation. for the patient’s discharge to an
extended-care facility, rehabilitation
center, or home on PPV.
17. Observe for hemodynamic PPV can cause decreased venous • Decreased blood pressure
changes associated with return and afterload because of the • Change in heart rate (increase or
increased Vt, PEEP/CPAP, or increase in intrathoracic pressure. decrease of >10% of baseline)
recruitment maneuver. This mechanism often manifests • Weak peripheral pulses, pulsus
immediately after initiation of paradoxus, or decreased pulse
mechanical ventilation and with pressure
large Vt, increases in PEEP or • Decreased cardiac output
CPAP levels and manual • Decreased mixed venous oxygen
hyperinflation techniques. tension
Cardiovascular depression • Increased arterial-venous oxygen
associated with manual or periodic difference
ventilator hyperinflation is
immediately reversible with
cessation of hyperinflation.
Decreases in blood pressure with
PPV also may be seen with
hypovolemia.
Always consider potential for
pneumothorax with acute changes.
Documentation
• Patient and family education • Patient responses to PPV (including the patient’s
• Date and time ventilatory assistance was instituted indication of level of comfort and respiratory
• Ventilator settings, including the following: Fio2, mode symptoms)
of ventilation, Vt, respiratory frequency (total and • Depth of endotracheal tube at the teeth or gum
mandatory), PEEP level, I : E ratio or inspiratory time, • Hemodynamic values
PIP, dynamic compliance, and static compliance • Vital signs
• Arterial blood gas results • Respiratory assessment findings
• Sao2 readings • Unexpected outcomes
• Reason for initiation of PPV • Nursing interventions
• Assessment of pain, interventions and response to • Degree of backrest elevation
intervention • Humidifier change maintenance

29 Invasive Mechanical Ventilation (Through an Artificial Airway): Volume and Pressure Modes 248.e1
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PROCEDURE
30
Noninvasive Positive Pressure
Ventilation: Continuous
Positive Airway Pressure (CPAP)
and Bilevel Positive
Airway Pressure (BiPAP)
Susan K. Frazier
PURPOSE: Noninvasive positive pressure ventilation is delivery of ventilatory
support without the placement of an artificial airway (an oral or nasal endotracheal
tube or tracheostomy); ventilatory support is provided through a nasal mask, nasal
pillows, full face mask, or helmet mask. Noninvasive positive pressure ventilation is
used to prevent airway obstruction during sleep, to maintain or improve ventilation
and/or oxygenation, and to provide respiratory muscle rest in patients in whom
invasive mechanical ventilation is not possible, acceptable, or desired. Continuous
positive airway pressure (CPAP) is the provision of continuous positive airway
pressure throughout inspiration and expiration; bilevel positive airway pressure is
the administration of two levels of airway pressure, one during inspiration and
another during expiration. Bilevel positive airway pressure (BiPAP) is a proprietary
name of Respironics Inc., but for the purposes of this procedure, the acronym
BiPAP indicates bilevel positive airway pressure.
PREREQUISITE NURSING postextubation respiratory failure, a 35% decrease in the

KNOWLEDGE likelihood of reintubation, and a reduction in the likeli-
hood of intensive care unit (ICU) and hospital mortality
• Although invasive mechanical ventilation delivered by 41% and 59% respectively, compared with standard
through an artificial airway has been the principal support therapy. Chandra and colleagues10 reported a 400%
strategy for patients with impaired ventilation and oxy- increase in the use of noninvasive ventilation for patients
genation in critical care since the early 1970s, Sullivan with an acute exacerbation of COPD over the decade from
and colleagues39 introduced the use of CPAP delivered 1998 to 2008, and a subsequent reduction in invasive
through a nasal mask to patients with obstructive sleep ventilation of 42%.
apnea in 1981, and in 1987 to patients with acquired • The use of noninvasive ventilation maintains upper-airway
muscle weakness and muscular dystrophy.12 protective reflexes and the ability to speak and swallow
• The use of noninvasive positive pressure ventilation has and avoids complications associated with intubation and
become common, and often a first-line support. Recently invasive ventilation such as airway trauma, barotrauma,
Ugurlu and colleagues40 determined that nearly 40% of ventilation-induced acute lung injury, and hospital-acquired
patients who required ventilator support initially received ventilator-associated pneumonia.26 Carron and colleagues8
noninvasive ventilation; most common diagnoses managed reviewed the prevalence of complications associated with
with noninvasive ventilation were acute exacerbation of noninvasive ventilation from a meta-analysis. Airway
chronic obstructive pulmonary disease (COPD) and car- dryness was reported in 10% to 20% of patients, nasal
diogenic pulmonary edema. Nearly three quarters of these congestion in 20% to 50%, gastric insufflation in 10% to
patients were successful users of noninvasive ventilation, 50%, facial erythema in 20% to 32%, nasal/sinus/ear pain
and the mortality rate of those who received noninvasive in 10% to 30%, minor air leaks in 80% to 100%, major air
ventilation was nearly half that of patients ventilated leaks in 18% to 68%, claustrophobia in 5% to 20%, carbon
invasively. dioxide (CO2) rebreathing in 50% to 100%, nasal skin in
• Lin and colleagues21 demonstrated that noninvasive ven- lesions in 10% to 50%, and general discomfort in 30% to
tilation was effective in the prevention of postextubation 50% of patients.
respiratory failure in a meta-analysis of 10 clinical trials; • Patient predictors of potential failure of noninvasive ven-
they identified a 25% reduction in the likelihood of tilation before application of noninvasive ventilation
249
include established severe acute respiratory distress syn- cough, high severity of illness (APACHE II >19), and
drome, reduced level of consciousness, shock of any etiol- malnutrition as indicated by total protein less than 5.8 mg;
ogy, Glasgow coma score less than 11, Acute Physiology those with one, two, or three of these risk factors increased
and Chronic Health Evaluation (APACHE) II severity of their risk of failure by 4.7, 13.6, and 21.6 times,
illness score higher than 29, profuse secretions, tachypnea respectively.14
(>35 breaths/minute), pH less than 7.25, hypotension • Acute cardiogenic pulmonary edema. CPAP was demon-
(systolic blood pressure <90 mm Hg), age over 40 years, strated to reduce the need for intubation by 56% and
edentulism, severe agitation, and asynchronous breath- mortality by 36% in patients with acute cardiogenic pul-
ing.17,26 Predictors observed after initiation of noninvasive monary edema, particularly those with edema subsequent
ventilation include major air leaks, poor tolerance, and to myocardial ischemia or infarction. Bilevel noninvasive
ventilatory asynchrony. After 1 hour of ventilation, con- ventilation reduced the risk for intubation by 46% but had
tinued tachypnea, lack of improvement in oxygenation, no effect on mortality in a meta-analysis.44 The use of
hypercarbia, acidosis, and evident fatigue predict failure noninvasive ventilation in this patient population before
of noninvasive ventilation.17 arrival in the emergency department has also been studied,
but trials have been small with methodological issues.
Indications for Noninvasive Positive A systematic review of these trials provided minimal
Pressure Ventilation evidence that the need for intubation was reduced, but
• Obstructive sleep apnea. Obstructive sleep apnea (OSA) mortality was unchanged with prehospital initiation of
is characterized by repeated episodes of upper-airway col- noninvasive ventilation in acute cardiogenic pulmonary
lapse during sleep with subsequent oxyhemoglobin desat- edema.4 In a recent well-designed trial, investigators com-
uration, hypoxemia, and recurrent sleep arousal. OSA pared CPAP and bilevel noninvasive ventilation in patients
produces fragmented sleep; daytime sleepiness; exagger- with cardiogenic pulmonary edema; bilevel ventilation
ated fluctuation in intrathoracic pressure, blood pressure, use was associated with more rapid improvement in oxy-
and cardiac rhythm; systemic inflammation; sympathetic genation, reduction in dyspnea, and a significantly lower
activation; and endothelial dysfunction.3 Long-term con- need for intensive care admission compared with CPAP.23
sequences of OSA include hypertension,47 atherosclero- There were no differences in need for intubation, mortal-
sis and cardiovascular disease,7 cognitive dysfunction, ity, or acute myocardial infarction between these two
decreased quality of life, depression,1 and premature all- strategies.
cause mortality.25,28 Additionally, individuals with OSA • Asthma. There is theoretical support for the use of nonin-
are two and a half times more likely to have a motor vasive positive pressure ventilation in the management of
vehicle accident, particularly those who are 65 years of acute asthma; however, there currently are few data to
age and older.19 Recently, investigators estimated the prev- support its use. Small trials have described improvements
alence of moderate to severe OSA at 10% for 30- to in dyspnea, respiratory rate, and airflow, which were
49-year-old men, 3% for 30- to 49-year-old women, 17% attributed to the use of positive airway pressure and
for 50- to 70-year-old men, and 9% for 50- to 70-year-old improved dispersal of inhaled bronchodilators.33
women; these findings represented a 14% to 55% increase • Pneumonia. The use of noninvasive ventilation in the
in prevalence of OSA over the past 2 decades.34 Although management of community-acquired pneumonia was
CPAP is highly effective as a pneumatic split to the upper associated with significantly shorter length of ventilation,
airway, investigators have reported poor adherence, with shorter length of intensive care stay, fewer hospital days,
nonadherence rates of 46% to 83%.31,43 Predictors of and lower mortality compared with intubated patients in
adherence include the initial 1-month experience and a large trial of more than 500 patients.27 In a large cohort
adverse effects attributed to CPAP therapy9 and variability of elderly, immunocompromised patients with pneumo-
of more than 75 minutes in bedtime.37 A systematic evalu- nia, noninvasive ventilation was associated with a 34%
ation of interventions to improve adherence to nocturnal reduction in mortality.18 However, in a recent trial the
CPAP found that ongoing supportive interventions, edu- failure rate for noninvasive ventilation was 76%; mortal-
cational interventions, and behavioral therapy increased ity was not different from patients ventilated invasively.30
CPAP use by 50, 35, and 90 minutes/night, respectively; Thus there are equivocal data to support the effective
however, these studies were generally of low quality.46 use of noninvasive ventilation for community-acquired
• Acute exacerbation of COPD. The use of noninvasive pneumonia.
ventilation to manage patients with acute exacerbation of • Postextubation respiratory failure. The use of noninvasive
COPD has been associated with a 36% reduction in mor- positive pressure ventilation after planned tracheal extu-
tality, a 35% reduction in hospital-acquired pneumonia, bation reduced reintubation rate by 35%, ICU mortality
an 18% reduction in hospital length of stay, a 30% reduc- by 59%, and hospital mortality by 41%.21 However, when
tion in costs, and 78%, 55%, and 29% reductions in mor- respiratory failure after tracheal extubation was estab-
tality in patients with low, moderate, and high comorbidity lished, there was no improvement in outcomes, and some
burdens compared with patients managed with invasive evidence suggested that mortality was increased because
ventilation.24 Noninvasive ventilation is the established of delayed reintubation.13 The efficacy of noninvasive
standard of care for acute exacerbations of COPD with ventilation after extubation is dependent on patient risk
concomitant administration of appropriate antibiotics, for failure and the reason for invasive ventilation, the
corticosteroids, and bronchodilators.36 Predictors of those timing of application, patient motivation, and the skill and
patients who failed noninvasive ventilation included weak experience of clinicians.15 Those patients at high risk of
30 Noninvasive Positive Pressure Ventilation 251
extubation failure, postoperative patients, immediate • Facial interfaces are the most common in critical care
application of noninvasive ventilation after extubation, clinical practice and include oronasal masks, face masks,
and an experienced and skilled cohort of clinicians may and full face masks.26 These interfaces vary in size and
reduce morbidity and mortality, particularly in carefully the area of the face covered and are particularly useful for
selected postoperative patients.2 patients who are mouth breathers. An oronasal and tradi-
• Thoracic trauma. There is evidence to support the effec- tional face mask covers the mouth and nose, whereas a
tive use of noninvasive ventilation in the thoracic trauma total face mask covers the mouth, nose, and eyes. These
population. Pooled data from 10 studies demonstrated a interfaces are associated with nasal congestion, skin
74% reduced risk of mortality; as well as a 68% reduced breakdown, nasal and mouth dryness, and claustrophobia
risk for intubation, a reduction of intensive care stay by and are less useful in patients who are vomiting.26 Total
nearly 2.5 days, improved oxygenation, and reduced face masks may be better tolerated and induce fewer
respiratory rate.11 However, the optimal type of noninva- adverse effects, but their superiority for outcomes such as
sive ventilation has not been determined. mortality has not been demonstrated.22
• Palliative care and neuromuscular disorders. The use • The helmet interface is the least frequently used; this
of noninvasive ventilation with neuromuscular disorders interface covers the entire head and part of the neck. The
such as Duchenne muscular dystrophy and amyotrophic helmet allows maximal interaction with the surrounding
lateral sclerosis increased minute ventilation, reduced environment and is not associated with skin breakdown;
respiratory rate, reduced hypoxemia time, decreased however, it cannot be used with traditional ventilator as
energy expenditure, and prolonged survival.29,42 There a high gas flow is required to prevent rebreathing, and
was also a demonstrated reduction in dyspnea and need the associated noise with a helmet use may reduce
for morphine, with subsequent improvement in quality tolerance.32,41
of life for end-stage patients with COPD, cancer, and neu-
romuscular disorders.16,31 Thus noninvasive ventilation Modes of Noninvasive Positive
may be a useful strategy for symptom palliation at end of Pressure Ventilation
life. • CPAP does not provide inspiratory support but maintains
positive airway pressure at end-expiration. Thus collapsed
alveoli are recruited, functional residual capacity is
Contraindications for Use of Noninvasive increased, ventilation perfusion match is improved, lung
Positive Pressure Ventilation compliance is optimized, and the work of breathing is
Absolute Contraindications lessened.26
• Respiratory arrest, apnea • Noninvasive bilevel positive pressure provides two levels
• Uncontrolled vomiting of pressure, an inspiratory positive airway pressure (IPAP),
• Absence of upper-airway reflexes which may also be referred to as pressure support, and an
• Pneumothorax (untreated) expiratory positive airway pressure (EPAP). The use of
• Acute, copious upper-gastrointestinal bleeding regular intensive-care ventilators permits the addition of
• Recent gastric, laryngeal, or esophageal surgery intermittent mandatory ventilation.48 Bilevel ventilation is
• Facial and/or airway trauma commonly used in acute-care patients.26
• Total airway obstruction • Other modes of noninvasive ventilation include assist-
control, where a preset rate is used; proportional assist,
Relative Contraindications where the degree of inspiratory support is determined by
• Medically unstable—hypotension, cardiac dysrhythmias, the patient effort; neurally adjusted, where ventilatory
need for vasopressors support is triggered by electrical activity in the dia-
• Agitated or uncooperative phragm;5,35,38 and adaptive pressure control or volume-
• Excessive secretions assured pressure support, where the ventilator titrates the
• Impaired swallow reflex degree of pressure based on inspiratory effort and tidal
• Cardiac ischemia volume.26 These modes are typically used in complex
• Cardiac dysrhythmias patient situations, and none have been demonstrated to be
superior.
Noninvasive Positive Pressure
Ventilation Interfaces EQUIPMENT
An interface is the device that connects the positive pressure
source (ventilator) to the patient airway. Interfaces can be • Noninvasive interface (see Fig. 30-1)
categorized as nasal, face, or helmet (Fig. 30-1).17,26 • CPAP or BiPAP ventilator
• Nasal interfaces are the most commonly used in patients • Electrocardiographic monitor
with chronic conditions such as OSA.26 Nasal interfaces • Pulse oximeter—stand alone or monitor module
include nasal pillows and nasal masks. Nasal interfaces • Self-inflating manual resuscitation bag-valve-mask device
permit speech and feeding; unfortunately, these interfaces • Oxygen source and tubing
are also associated with greater resistance to gas flow and • Suction equipment
the potential for considerable leak of gas from the mouth.45 • Intubation equipment and endotracheal tubes
Thus nasal interfaces are of minimal use during critical • Equipment for needle thoracostomy or tube
illness. thoracostomy
A B C
Figure 30-1 Noninvasive patient interfaces. A, Nasal mask. B, Nasal pillow. C, Full face mask.
(Images used with permission of Philips Respironics, Inc, Murrysville, PA.)
• Personal protective equipment (gloves, mask, goggles, explanations will reduce anxiety, fear, and distress and
gown, as appropriate) may improve patient tolerance.
• Humidification equipment as required • Promote relaxation in the patient. Techniques such as dis-
Additional equipment (to have available depending on patient traction may be useful. Rationale: Relaxation and coop-
need) includes the following: eration promote optimal delivery of positive pressure gas
• Medications, as indicated flow, improve ventilation and oxygenation, and reduce the
work of breathing.
PATIENT AND FAMILY EDUCATION • Establish a method of communication in conjunction with
patient and family before initiation of ventilation. Explain
• If time permits, assess patient and family level of under- that the patient will be able to speak, but this should be
standing about the condition and rationale for the proce- minimalized to optimize the therapy. Rationale: The
dure. Rationale: This assessment identifies knowledge ability to communicate needs, symptoms, and feelings
deficits about the patient’s condition, the procedure, the is vital to effective patient care and will reduce anxiety
expected benefits, and the potential risks. The nurse should and fear.
provide sufficient time for questions to clarify information • Instruct the patient and family about how to use the call
and for patient and family to voice concerns. Explanations system to obtain assistance and how to perform selected
decrease patient anxiety and enhance cooperation. activities to improve patient comfort. This includes how
• Explain the procedure and the reason for the procedure to remove the mask if nausea and vomiting occur. Ratio-
before and during the institution of noninvasive ventila- nale: This supports autonomy of patient and family;
tion. Reinforce the information as required by the patient’s includes family in caregiving, which is an identified need;
condition. Rationale: This explanation enhances patient and reduces anxiety of patient and family members. Air
and family understanding, decreases anxiety, and increases insufflation may produce gastric distension, nausea, and
cooperation. vomiting with potential for pulmonary aspiration.
• Provide details about the potential sensations associated • Explain that the patient will not be permitted oral intake
with noninvasive ventilation (dyspnea, claustrophobia, during noninvasive ventilation. Rationale: Reduces the
lung inflation, noise, alarms). Rationale: Clear, complete risk for pulmonary aspiration.
• Offer information about the goals of noninvasive ven- dyspnea, central cyanosis, restlessness, confusion, decreased
tilation for the patient and frequent reports about pro- level of consciousness, agitation, tachycardia, bradycardia,
gress. Rationale: Information about care, goals, and cardiac dysrhythmias, intercostal and suprasternal retrac-
probable outcome is a stated need of patients and family tions, alteration in arterial blood pressure (increased or
members. decreased), adventitious breath sounds, reduced urine
• Provide the opportunity for questions during noninvasive output, and acidosis. Rationale: Early detection of hypox-
ventilation. Rationale: Family members state that the emia permits the clinician to intervene and institute addi-
ability to ask questions and receive honest understandable tional supports to maintain adequate tissue oxygenation.
answers is their most important need. • Evaluate ventilation with measurement of Paco2 and pH.
Hypercarbia and respiratory acidosis indicate inadequate
ventilation. Rationale: Paco2 is the best indicator of ade-
PATIENT ASSESSMENT AND quacy of ventilation. Early detection of inadequate venti-
PREPARATION lation permits the clinician to intervene and improve
ventilation with the noninvasive method or rapidly insti-
Patient Assessment tute intubation and invasive mechanical ventilation.
• Evaluate for the signs and symptoms of respiratory muscle
fatigue and impending acute ventilatory failure. These Patient Preparation
include rising arterial partial pressure of carbon dioxide • Verify that the patient is the correct patient by two inde-
(Paco2) and end-tidal CO2, chest wall-abdominal dyssyn- pendent clinicians. Rationale: Ensures correct identifica-
chrony, shallow or irregular respirations, tachypnea, brad- tion of the appropriate patient for the procedure.
ypnea, dyspnea, reduced level of consciousness, confusion, • Evaluate patient understanding of the information pro-
lethargy, restlessness, change in arterial blood pressure vided. Answer questions and reinforce information as
(increase or decrease), tachycardia, and cardiac dysrhyth- needed. Rationale: Determines patient understanding,
mias. Rationale: Early detection of inadequate ventilation reinforces information, and reduces anxiety of patient and
permits the clinician to intervene and improve ventilation family.
with the noninvasive method or rapidly institute intuba- • Premedicate the patient as needed. Rationale: Cautious
tion and invasive mechanical ventilation. use of low-dose narcotics, sedatives, or anxiolytics may
• Evaluate patient for signs and symptoms of inadequate be required to improve patient tolerance, reduce anxiety,
oxygenation. These include decreased oxygen saturation and promote optimal ventilation. Medication should not
by pulse oximetry (SpO2), PaO2 ≤60 mm Hg, tachypnea, reduce level of consciousness or central ventilatory drive.
Procedure for Noninvasive Ventilation (CPAP and Bilevel Ventilation)

1. HH
2. PE
3. Assemble and prepare equipment. Readies equipment for the
procedure.
4. Select noninvasive interface for use Interface device fit is Not all interfaces may be available.
with noninvasive ventilation (see essential to efficacy. The The presence of a nasal or oral gastric
Fig. 30-1).20,21,41,45 (Level C*) interface should be tube does not preclude noninvasive
carefully selected with ventilation. Most of the ventilators
attention to patient have leak compensation built into the
preference, face and nose system. However, a large leak may
size, facial deformities, make patient-initiated cycling more
skin integrity, presence of difficult. Obtunded patients and
nasal or oral gastric tubes, patients with excessive secretions are
and availability. not good choices.26 (Level E*)
Helmet and full face mask ventilation
should be used cautiously. The
patient should be able to remove the
interface quickly if nausea and
vomiting are imminent; otherwise the
potential for aspiration is high.

Procedure for Noninvasive Ventilation (CPAP and Bilevel Ventilation)—Continued

5. A chin strap may be used with a Optimal mask fit is vital, so
nasal mask to prevent excessive the patient receives
leaks through the mouth. adequate support.
CPAP
1. Select mode: CPAP.3,6,11,20,21,24,46 Prepares the ventilator to This mode may be labeled CPAP or
(Level A*) deliver CPAP. another vendor-specific name.
Refer to specific ventilator
manufacturer information for specific
names of the mode.
2. Select desired CPAP level. Establishes the initial Selection of a CPAP level of 3–5 cm/
pressures settings, which H2O or less is adequate to initiate.26
may be adjusted as need. (Level D*) Increase as needed to
attain goal (e.g., relief of dyspnea,
improved oxygenation, and
comfortable breathing pattern).
Begin by holding the mask in place,
initiate with 1 cm/H2O pressure, and
increase slowly to improve tolerance.
3. Select desired Fio2 level. Establishes the initial There are limitations to the absolute
oxygen setting, which amount of oxygen that may be bled
may be adjusted as into the system. Follow manufacturer
needed. directions.
A majority of ventilators that deliver
CPAP provide a full range of Fio2
from room air to 1.0. Oxygen may
also be delivered by an oxygen flow
meter in L/min, whereby oxygen is
bled into the ventilator at the patient
interface, or into the patient circuit.
Begin with current patient Fio2 and
increase as indicated. Monitoring of
arterial oxygen saturation allows for
adjustment as needed. If adequate
oxygenation is not attained by
adjusting oxygen to manufacturer
specifications, a traditional ventilator
may be used to supply CPAP using a
noninvasive interface.26 (Level D)
PE .
5. HH

BiPAP or Bilevel
1. Select levels of support. Bilevel Establishes inspiratory and Selections of the levels of support are
provides two levels of support: IPAP expiratory pressure levels arbitrary, but in general start low and
and EPAP.6,11,20,21,24 (Level A*) of support. adjust upward. The concepts related
Depending on the ventilator, the two to use of pressure support and PEEP
levels may have different names. are described in Procedure 29 for
For example, one vendor refers to invasive mechanical ventilation.
pressure support ventilation as IPAP Refer to specific ventilator
and positive end-expiratory pressure manufacturer information for specific
(PEEP) as EPAP. names of the modes. Initiation at low
levels is reasonable (i.e., pressure
support of 5 cm H2O and PEEP of
3 cm H2O); slowly increase levels as
tolerated to attain a comfortable
respiratory rate and pattern and
acceptable arterial blood gas values.
2. Select the bilevel options (dependent Establishes desired bilevel The selection of the specific BiPAP
on ventilator manufacturer), which modes. option is dependent on the patient
include the following: condition and the goals of therapy.
A. A spontaneous mode, whereby If leaks around the interface prevent
the patient initiates all breaths patient cycling, consider a
(similar to “stand-alone” mode). spontaneous timed option or a
B. A spontaneous-timed option, control option. Settings on specific
which is similar to pressure ventilators vary. However, concepts
support with a backup rate (some related to the settings are the same as
vendors call this assist-control). with invasive ventilation. (See
C. Control mode. In contrast to the Procedure 29.)
spontaneous and spontaneous-
timed modes, the control mode
requires that a control rate and
inspiratory time be selected.


3. Adjust Fio2 by means of an oxygen Establishes desired Fio2 Each ventilator has specifications that
source (oxygen tubing connected to level. dictate the maximal flows allowed.
a flow meter) that is connected into Ventilator function may be adversely
the mask or in the inspiratory line at affected if the manufacturer
the junction of the ventilator and recommendations are not followed.
ventilator interface. Delivery of high levels of Fio2 is not
possible. For patients with high Fio2
requirement, BiPAP may not be a
good option, because the degree of
intrapulmonary shunt may require
high inspiratory and expiratory
pressures that will not be
tolerated.17,20,26,40 (Level C*)
Consider the use of a traditional
ventilator for noninvasive
ventilation.26 With use of a traditional
ventilator, pressure support may not
be the best mode to use, because
cycling may be impeded by mask
leaks. The assist-control mode or a
volume guaranteed-pressure mode
may be used as an alternative26
(exceptions exist and are ventilator
specific). (Refer to Procedure 29.)
PE .
5. HH

• Maintenance of pH (7.35–7.45) and Paco2 • Failure of the noninvasive ventilation to improve pH,
(35–45 mm Hg); goal arterial blood gases should be Paco2, and PaO2
individualized, particularly for those patients with • Hemodynamic instability
chronic hypercapnia and some degree of hypoxemia • Pulmonary barotrauma
with obstructive lung disease • Respiratory muscle fatigue
• Maintenance of adequate Pao2 (80–100 mm Hg); • Skin breakdown under mask
individualize goal for those with COPD • Aspiration
• Regular ventilation with adequate minute volume • Claustrophobia and panic
• Respiratory muscle rest
• Intact skin under interface

interventions.
1. Activate available alarms with Alerts clinicians of monitored values • Continued activation of alarms in
reasonable high and low limits. outside of high and low limits. spite of interventions to improve
Use reasonable alarm values Limits should be individualized and ventilation, intolerance,
(high pressure at 10 cm H2O determined based on the ventilator inadequate airway clearance, and
above patient peak, low settings and patient condition. excessive work of breathing
exhaled volume/flow least 2 Ensures patient safety.
Liters/min, low rate 8–10
breaths/min.6,20 (Level C*)
2. Evaluate regularly for Ensures delivery of adequate positive • Inability to rapidly stabilize
stabilization and maintenance pressure flow with minimal to no interface and maintain adequate
of the interface.3,11 (Level A*) leaks. Reduces risk of inadvertent ventilation
mask removal and subsequent • Uncontrolled agitation and panic
inadequate ventilation. that results in poor stabilization of
interface
3. Monitor in-line thermometer to Reduces risk of thermal inhalation • Inspired gas temperature <35°C or
maintain inspired gas injury from overheated inspired gas >37°C
temperature when and risk of poor humidity from
humidification is added to the underheated inspired gas.
circuit (in the range 35°C–37°C
[95°F–98°F]; only applies to
some ventilators).17,26,46
(Level E*, M*)
4. Keep interface and circuit clear Reduces risk of respiratory infection • Excessive secretions
of secretions and condensation by decreasing inhalation of
when humidification is contaminated water droplets and
used.17,26 (Level M) secretions.
5. Ensure availability of manual Ensures that there will be immediate
self-inflating resuscitation bag delivery of ventilation and
with supplemental oxygen at oxygenation to relieve acute
the head of the bed. Attach or respiratory distress caused by
adjust PEEP valve if the hypoxemia or acidosis if needed.
patient is receiving more than
5 cm H2O CPAP.
6. Regularly monitor ventilator Ensures that prescribed ventilator • Settings different from those
for baseline settings and alarm settings are delivered. prescribed
activation with initial
assessment and after removal
and reapplication of
noninvasive ventilation.

7. Evaluate alarms to determine Multiple reasons for alarms exist and • Unexplained high or low pressure,
cause and correct issues. When may indicate mask or tubing exhaled volume, and rate alarms
capability is available, alarms disconnection, kinks in the tubing,
should be integrated into the or serious changes in the patient
central system. condition. Always consider the
possibility of tension pneumothorax.
Maintain equipment for emergency
needle decompression of tension
pneumothorax near patient.
8. Change patient position as Frequent position changes are
often as possible but at least indicated to reduce the potential for
every 2 hours. Rotating beds atelectasis and pneumonia caused by
may be helpful. Elevated head secretion stasis. Promotes airway
of bed may improve functional clearance.
residual capacity.
9. Evaluate patient-ventilator There may be asynchrony of the • Dyspnea
synchrony. trigger, flow, or cycle.26 (Level C*) • Chest-abdominal asynchrony
Trigger asynchrony is demonstrated by • Rapid-shallow breathing pattern
ineffective ventilatory efforts and • Irregular, ineffective ventilation
auto-triggering; adjustment of • Intercostal or suprasternal
pressure support and reduction of retractions
leaks should rectify. Flow
asynchrony is demonstrated by
inadequate flow time for patient
demand; adjustment to a higher flow
cycle will address this. Cycle
asynchrony is demonstrated by
asynchrony of the ventilator and the
patient inspiratory time; alteration of
cycle time should address this issue.
Notify physician and respiratory-care
practitioner and assess patient
frequently with any changes in
settings to assure resolution of
synchrony.
10. Observe for hemodynamic Hemodynamic changes may indicate • Hypotension
changes associated with functional changes in circulating • Heart rate increase or decrease of
increased inspiratory and volume caused by positive >10% of baseline value with
expiratory pressures. intrathoracic pressure. Always worsening hemodynamic state
consider potential for pneumothorax • Decreased cardiac output
with acute changes. Equipment used • Decreased mixed venous oxygen
for rapid release of tension tension
pneumothorax should be in close • Increased arterial-venous oxygen
proximity (i.e., 14-gauge needle; see difference
Procedure 26). Chest tube insertion
equipment should be readily
available.

11. Monitor for signs and Respiratory distress indicates the need • Hypercarbia
symptoms of acute respiratory for changes in ventilator settings or • Chest-abdominal asynchrony
distress, hypoxemia, need for intubation and invasive • Shallow or irregular ventilation
hypercarbia, and respiratory ventilation. • Tachypnea, bradypnea, or dyspnea
muscle fatigue. While troubleshooting, support • Reduced level of consciousness
ventilation via a self-inflating • Restlessness, confusion, lethargy
manual resuscitation bag-valve- • Increase in pulmonary artery
mask-device, if indicated. occlusion pressure
• Decreased mixed venous oxygen
saturation
• Tachycardia
• Atrial or ventricular dysrhythmias
• Acidosis, hypoxemia, hypercarbia
12. Evaluate patient regularly for Early detection of pneumothorax is • Acute, increasing, or severe
signs and symptoms of essential to minimize progression dyspnea
pulmonary barotrauma (i.e., and adverse effects. Tension • Restlessness
pneumothorax). pneumothorax requires immediate • Agitation
emergency decompression with a • Decreased or absent breath sounds
large-bore needle (i.e., 14-gauge) on the affected side
into the second intercostal space or • Localized hyperresonance or
midclavicular line on the affected tympany to percussion on the
side (see Procedure 26) or affected side
immediate chest tube placement • Elevated chest on the affected side
(see Procedure 21). • Increased breathing effort
• Tracheal deviation away from the
side of abnormal findings
• Increased peak and plateau airway
pressures
• Decreased Pao2 and Sao2
• Localized increased lucency with
absent lung markings on chest
radiograph
13. Assess skin under mask every The pressure of the tightly fitting • Skin breakdown under the
1–2 hours for skin interface may cause skin breakdown. interface
breakdown.26 (Level E*)
Documentation
• Patient and family education • Patient responses to noninvasive ventilation including
• Date and time ventilatory assistance was instituted the patient report of level of comfort, and respiratory
• Ventilator settings, including the following: type of symptoms
interface used, Fio2, mode of ventilation, pressure • Hemodynamic values that are available
levels (inspiratory and expiratory), respiratory • Standard vital signs
frequency (total and mandatory if set) • Respiratory assessments
• Arterial blood gas results • Unexpected outcomes
• Spo2 measures • Nursing interventions
• Reason for initiating noninvasive ventilation

30 Noninvasive Positive Pressure Ventilation 260.e1
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PROCEDURE
31
Manual Self-Inflating
Resuscitation Bag-Valve Device
Thomas Levins
PURPOSE: The use of a manual self-inflating resuscitation bag, otherwise known
as “bagging,” is an essential skill for all levels of providers. It is also one of the
most difficult to perform. It is used to provide ventilation when spontaneous
respirations are inadequate or absent.
PREREQUISITE NURSING additional ventilator breath before completion of the

KNOWLEDGE preceding ventilator-delivered breath. Hyperinfla-
tion occurs when exhalation time is inadequate,
• Bagging is an essential skill utilized in many emergency which results in auto–positive end-expiratory pressure
situations: (PEEP).
❖ Cardiac arrest ❖ Dynamic hyperinflation is most commonly associated
❖ General anesthesia/neuromuscular blockade with bronchospasm and chronic obstructive pulmonary
❖ Altered level of consciousness disease.2 A high index of suspicion is necessary for the
❖ To assess the patency of airway devices such as an presence of dynamic hyperinflation if hemodynamic
endotracheal tube instability or worsening respiratory distress occurs
❖ To assist patients in respiratory distress with bagging.
❖ To provide oxygenation and ventilation before and ❖ Auto-PEEP increases intrathoracic pressures and may
after airway suctioning decrease venous return, which may result in hypoten-
❖ To provide oxygenation and ventilation during patient sion. It may also result in significant barotrauma and
transport the possibility of pneumothorax or tension pneumotho-
❖ To evaluate the interaction of the patient and rax. A rapid solution to auto-PEEP with hemodynamic
ventilator or respiratory compromise is a brief disconnection
• Bagging should result in chest movement and auscultatory from the bag to allow passive deflation and a decrease
evidence of bilateral air entry. in intrathoracic pressures. This should result in
• In patients without an artificial airway in place, effective improved hemodynamics. With resumption of bagging,
bagging requires an unobstructed airway, slight head and providing a longer exhalation time (smaller tidal
neck extension (i.e., the same technique used for mouth- volumes with a lower respiratory rate) will help to
to-mouth ventilation), and firm placement of the face minimize auto-PEEP.
mask over the nose and mouth (Fig. 31-1). An exception
to this technique is with known or suspected cervical spine EQUIPMENT
injury, in which the patient’s airway is opened with the
jaw thrust (without neck hyperextension). Effective • Manual self-inflating resuscitation bag and mask of appro-
bagging is best accomplished with two people: one to priate size (Fig. 31-2)
secure the mask and ensure head and neck placement and • Appropriately sized airway adjuncts in the nonintubated
one to bag.1 In patients with artificial airways, such as patient
endotracheal or nasotracheal tubes or tracheostomies, the ❖ Oral pharyngeal airway
nurse must understand the components of artificial airways ❖ Nasopharyngeal airway
and their relationship to the upper-airway anatomy. • Oxygen source and regulator
• When signs and symptoms of respiratory distress are • Large-bore suction
noted in a patient on mechanical ventilation and trouble- • McGill forceps of various sizes
shooting the ventilator does not immediately resolve the • Personal protective equipment
issue, the patient should be bagged on 100% oxygen. ❖ Eye protection
• Monitor the rate and depth of bagged breaths. ❖ Face mask/shield
❖ Large bagged breaths or rapid rates during bagging ❖ Gloves
may result in dynamic hyperinflation and resultant ❖ Gown
hypotension.2 Additional equipment, to have available as needed, includes
❖ Dynamic hyperinflation may also occur in ventilated the following:
patients who “breath stack,” which is initiating an • PEEP valve, if required
261
PATIENT AND FAMILY EDUCATION and alleviate the cause of respiratory distress puts the
patient at risk for further decompensation.
• If time permits, assess the patient’s and family’s level • Discuss the sensory experience associated with bagging.
of understanding about the condition and rationale for Rationale: Knowledge of anticipated sensory experiences
the procedure. Rationale: This assessment identifies the decreases anxiety and distress.
patient’s and family’s knowledge deficits concerning the • Instruct the patient to communicate discomfort with
patient’s condition, the procedure, the expected benefits, breathing during bagging, if possible. Rationale: The
and the potential risks. It also allows time for questions to bagging technique can be altered to produce a more com-
clarify information and voice concerns. Explanations fortable breathing pattern by working with the patient’s
decrease patient anxiety and enhance cooperation. spontaneous respiratory efforts.
• Explain the procedure and the reason for the procedure, if • Offer the opportunity for the patient if possible and the
the clinical situation permits. If not, explain the procedure family to ask questions about bagging. Rationale: The
and reason for the intubation after it is completed. Ratio- ability to ask questions and have questions answered hon-
nale: This explanation enhances patient and family under- estly is cited consistently as the most important need of
standing and decreases anxiety. patients and families.
• If the patient is currently on a ventilator, inform the patient
if possible and the family if present that the patient will PATIENT ASSESSMENT AND
be disconnected from the ventilator and bagging will be PREPARATION
performed. Describe the reason (e.g., ventilator malfunc-
tion, suctioning, patient comfort, the need for patient Patient Assessment
transport) for bagging. Explain that if the patient is in • Verify that the patient is the correct patient using two
respiratory distress, bagging must be done immediately. identifiers if possible. Rationale: Before performing a
Rationale: Information about the patient’s therapy is an procedure, the nurse should ensure the correct identifica-
important need of the patient and family members. tion of the patient for the intended intervention, though
Dyspnea is uncomfortable and frightening. It leads to completing this in patients in severe distress should not
anxiety, fear, and distrust. Failure to diagnose promptly delay intervention.
• Assess for signs of respiratory distress, including mental
status changes; respiratory rate, rhythm, and quality;
breath sounds; heart rhythm and rate; hypoxemia or
hypoxia; hypertension or hypotension; or diaphoresis.
Rationale: Any acute change in patient status may indi-
cate that bagging is necessary.
• If present, assess for sudden increase or decrease in end-
tidal carbon dioxide (Etco2) readings. Rationale: Any
acute change in patient status may indicate that bagging
is necessary.
• Assess the patency of the patient’s airway. Rationale:
Establishes if there are any obstructions of the patient’s
airway and the patency of the patient’s ability to maintain
an open airway. Suction as necessary with a large-bore
Figure 31-1 Proper technique of ventilation with manual self-
suction device or utilize McGill forceps to remove larger
inflating resuscitation bag-valve device and face mask. (From foreign bodies. If no protective airway reflexes are present,
Wilkins RL, Stoller JK, Kacmarek RM: Egan’s fundamentals of consider inserting an oropharyngeal airway or nasopha-
respiratory care, ed 8, St Louis, 2008, Mosby.) ryngeal airway.
Figure 31-2 Manual self-inflating bags: bag-valve assembly with and without reservoir.
31 Manual Self-Inflating Resuscitation Bag-Valve Device 263
• Use ventilator alarms if patient is receiving mechanical

ventilation, including low- or high-pressure or apnea Patient Preparation
alarms. Rationale: Any acute change in patient status may • Ensure that the patient understands preprocedural teach-
indicate that bagging is necessary. Rapid response with ings if possible. Answer questions as they arise and
100% fraction of inspired oxygen (Fio2) protects the reinforce information as needed. Rationale: This com-
patient and allows for rapid evaluation of airway resis- munication evaluates and reinforces understanding of
tance, placement, and function of the artificial airway if previously taught information.
one is in place.
• If present, ensure proper placement and function of any
artificial airway. Rationale: The positioning and patency
of the airway must be ensured.
Procedure for Manual Self-Inflating Resuscitation Bag

Using the Manual Self-Inflating Bag Device without an Advanced Airway
1. HH
2. PE
3. Attach the bag to an oxygen A minimum amount of oxygen is If a reservoir bag is present, it must
source and open the oxygen required to provide a high Fio2, be fully inflated to provide a high
source to a minimum of 15 L/min. usually >15 L/min flow. concentration of oxygen.
4. If the patient is spontaneously Working with the patient's Use thumb and index fingers to
breathing, place mask over the spontaneous respirations will provide downward pressure on
patient‘s face and attempt to assist minimize patient discomfort. mask while using the 3rd, 4th, and
spontaneous respirations 5th fingers to lift mandible toward
mask (see Fig. 31-1). Avoid placing
the 3rd, 4th, and 5th fingers
beneath the mandible on the soft
tissue because this may worsen
airway obstruction. Fingers/
pressure should be placed on the
mandible itself.
5. If the patient is not breathing Opening the airway allows the Jaw thrust if cervical spine trauma is
spontaneously, open the airway patient either to attempt self- suspected. If the patient is unable
using either the head tilt/chin lift ventilation or to be bagged. to maintain his or her own airway,
or jaw thrust maneuvers. consider inserting an oropharyngeal
airway or nasopharyngeal airway.
6. After obtaining an adequate seal Compressing the bag too fast may If adequate mask seal cannot be
with mask, slowly compress the result in gastric insufflation, obtained and ventilations are
bag over 1 second, at emesis, and the possibility of inadequate with a single provider,
approximately 10–12 breaths/min breath stacking (dynamic utilize a two-person technique with
(1 breath every 5–6 seconds).3 hyperinflation). one provider maintaining a mask
seal while the other ventilates the
patient by compressing the bag-
valve mask.4
Obtaining an adequate mask seal with
a single provider is frequently
difficult. If bagging the patient is
difficult, look for causes of high
airway resistance (e.g., obstructed
airway) or low lung compliance
(e.g., bronchospasm, mucus
plugging, pulmonary edema,
pneumonia, acute lung injury, or
pneumothorax).
Procedure for Manual Self-Inflating Resuscitation Bag—Continued

7. Assess chest rise and fall and Confirm the effectiveness of the If ventilations are not effective, be
bilateral breath sounds with each bagging. prepared to intervene by assessing
bag compression. Is the chest the mask size and seal and/or
rising? Do you still have an adjusting hand placement to obtain
adequate seal with the mask? a better seal. Call for assistance and
prepare for intubation or other
rescue airway-device placement.
8. When assistance arrives, discard
used supplies and PE .
9. HH
Using the Manual Self-Inflating Bag-Valve Device in a Patient with an Advanced Airway (i.e., Endotracheal Tube,
Tracheostomy, Laryngeal Mask Airway, or King Airway)
1. HH
2. PE
3. Attach the bag to an oxygen A minimum amount of oxygen is Attach a PEEP valve, if the patient is
source and open the oxygen required to provide a high Fio2, on a ventilator with a PEEP of
source to a minimum of 15 L/min. usually >15 L/min flow. 5 cm H2O or more, and adjust the
bag’s PEEP level to that of the
ventilator settings.
4. Silence the ventilator alarms. Eliminates the ventilator alarms
when the circuit is disconnected.
5. Disconnect patient from the Allows for attachment of the
ventilator. bag-valve device.
6. Connect bag to artificial airway. Allows for manual ventilation.
7. Slowly compress the bag over 1 Compressing the bag too fast may If bagging the patient is difficult, look
second, at approximately 10–12 result in breath stacking (dynamic for causes of high airway resistance
breaths/min (1 breath every 5–6 hyperinflation). (e.g., obstructed airway, misplaced
seconds).3 artificial airway) or low lung
compliance (e.g., bronchospasm,
mucus plugging, pulmonary edema,
pneumothorax).
8. Observe patient’s breathing Helps patient gain control over A higher manual rate may be required
pattern and rate and attempt to breathing by ensuring ventilation initially because larger breaths are
synchronize manual breaths with and adequate oxygenation.1 more difficult to provide with
the patient’s spontaneous effort. manual ventilation compared with
(Level C*) breaths provided by the ventilator.
9. If the patient is awake and alert, Provides synchrony between patient
encourage the patient to relax and breaths and manual breaths.
breathe with the manual breaths
that are provided.
10. Gradually adjust the rate of Reestablishes synchrony. A return to higher ventilator support
manual breaths to a rate that settings may be necessary after
meets the patient’s demand. bagging.
11. Ascertain whether the patient is Promotes comfort.
comfortable with the manual
breaths.
12. Assess the ease or difficulty with Difficulty in bag compression may
which the bag is compressed. identify presence of a
pneumothorax or pulmonary
emboli.
13. If signs and symptoms of distress Indicates that respiratory distress is Reassess the patient once placed back
are resolved, reconnect the patient relieved. on ventilator.
to the ventilator.

14. If the patient’s distress is not Indicates respiratory distress cannot In some situations, such as pulmonary
eliminated with bagging, consider be relieved with bagging. Further embolus, no distinct physical
the following steps: assessment is needed. assessment findings may be
A. Hyperoxygenate and suction. Suctioning provides information immediately evident.
B. Assess for the presence of related to the presence of Support the patient until appropriate
bilateral breath sounds and secretions or airway obstruction. interventions are accomplished.
symmetrical chest expansion. By auscultating the lungs during The use of anxiolytics or analgesics
C. Assess the ease (or difficulty) bagging, essential information or both may be appropriate to
with which the bag can be related to tube placement (e.g., decrease anxiety and pain.
compressed. migration to right mainstem or However, a thorough evaluation of
D. Assess anxiety and discomfort displaced) or patient status (e.g., the cause of distress must be
as potential causes of dyspnea. bronchospasm, pulmonary edema) undertaken both before and after
may be obtained. Asymmetrical administration.
chest expansion may be the result
of a displaced artificial airway,
pneumothorax, or obstruction.
A change in ease of bag compression
provides gross data about
increasing (improved) or
decreasing (deteriorating) lung
compliance.
Although psychological reasons for
respiratory distress are possible,
rule out physiological causes first.
15. Return patient to ventilator when Returns the patient to his or her
respiratory distress is relieved. baseline.
16. Reactivate and check ventilator Safety precautions. Ensures the
alarms and settings. nurse is alerted to actual or
potential life-threatening problems.
17. Observe breathing pattern, patient
ventilator synchrony, peak
inspiratory pressure (volume
ventilation), and tidal volume and
respiratory frequency (patient
initiated).
18. Check that call system is within
patient’s reach, if appropriate.
PE .
20. HH
Maintenance Ventilation, with an Advanced Airway, during Patient Transport
Portable ventilators are highly recommended for use during transport instead of manual bagging. If a transport
ventilator is not available, bagging may be required. Procedures may vary depending on institutional standards.
1. HH
2. PE
3. Obtain an appropriate-sized bag Ensures that appropriate equipment An appropriately sized mask must
and mask. is available during the transport. accompany the patient in the event
of inadvertent removal of the
invasive airway.

4. Attach the bag to an oxygen A minimum amount of oxygen is Attach a PEEP valve if the patient is
source and open the oxygen required to provide a high Fio2, on a ventilator with a PEEP of
source to a minimum of 15 L/min. usually >15 L/min flow. 5 cm H2O or more and adjust the
bag’s PEEP level to that of the
ventilator settings.
5. Confirm airway placement and the Establishes patency of the airway
patient’s tolerance to ventilator and ventilator’s settings.
and settings.
6. Silence the ventilator alarms. Eliminates the ventilator alarm when
the circuit is disconnected.
7. Disconnect patient from Allows for attachment of the
ventilator. spirometer and bag-valve device.
8. Connect the bag-valve device and Maintains ventilation pattern similar 1.0 Fio2 is typically used during
bag patient with Fio2 of 1.0, at an to that being provided by the patient transports. Adjust liter flow
approximate rate depth and ventilator. of oxygen to maintain the patient’s
pattern as ventilator breaths. arterial blood oxygen saturation
(Sao2) at the desired level. If
bagging the patient is difficult, look
for causes of high airway resistance
(e.g., obstructed airway, misplaced
artificial airway) or low lung
compliance (e.g., bronchospasm,
mucus plugging, pulmonary edema,
pneumothorax).
9. Attach continuous Etco2 monitor. Etco2 monitoring continuously Etco2 monitoring is a vital part of
monitors airway placement and monitoring during patient transport
the adequacy of ventilations. to ensure continued airway patency
and adequate ventilations.5
(Level E*)
10. Frequently reassess the patient to Promotes patient comfort. Frequent reassessment is vital to
ensure that the patient is patient comfort and safety.
comfortable with the bagging Adjustments may be needed to
technique. maintain patient comfort with
manual ventilation.
11. Reattach the patient’s advanced Reestablishes mechanical ventilation.
airway to the ventilator when the
transport is completed.
PE .
13. HH

• Maintenance of adequate oxygenation and ventilation • Hemodynamic instability from dynamic
• Resolution of respiratory distress if present hyperinflation
• Pulmonary barotrauma (e.g., pneumothorax)
• Inability to restore adequate ventilation and
oxygenation with bagging
• Inadvertent extubation during bagging
• Equipment failure and inability to bag

interventions.
1. Evaluate trends or sudden Impairment of the patient’s lung • Difficulty bagging (stiff)
changes in lung compliance, function or airway may be • No observable chest wall movement
airway resistance, or the identified by changes in the • Agitation
patient’s condition. patient’s condition or the ability • Diaphoresis
to bag the patient. • Hyper- or hypotension
• Tachy- or bradycardia
2. Observe for signs and Proper technique results in a • Dyssynchronous breathing
symptoms of synchrony comfortable synchronous
with the bagging, including breathing pattern.
adequate chest rise and fall.
3. Monitor Spo2 and Etco2 Spo2 and Etco2 provide information • Decrease in Spo2 >10%
values and trends. regarding the adequacy of • Increase in Etco2 >10%
oxygenation and ventilation.
Documentation
• Patient and family education • Patient’s response to the procedure
• Reason for bagging (e.g., to transport, suction, etc.) • Unexpected outcomes
• Frequency • Nursing interventions

31 Manual Self-Inflating Resuscitation Bag-Valve Device 267.e1
References 5. Frakes MA: Measuring end-tidal carbon dioxide: Clinical

1. Walls RM, Murphy MF: Manual of emergency airway applications and usefulness. Crit Care Nurse 21(5):23–37,
management, ed 4, Philadelphia, 2012, Lippincott 2001.
Williams and Wilkins. Additional Reading
2. Blanch L, Bernabe F, Lucangelo U: Measurement of air
trapping, intrinsic positive end expiratory pressure and American Academy of Orthopaedic Surgeons, American
dynamic hyperinflation in mechanically ventilated patients. College of Emergency Physicians: Critical Care Trans-
Respir Care 1(50):110–124, 2005. port.(6) Respiratory Emergencies and Airway Manage-
3. American Heart Association: Advanced cardiac life ment, Sudbury, MA, 2011, Jones and Bartlett Publishers.,
support provider manual. Part 5. 2011, American Heart pp 126–185.
Association. pp 35–36.
4. American Heart Association: Advanced cardiac life
support provider manual. Part 5. 2011, American Heart
Association. pp 38–40.
PROCEDURE
32
Peripheral Nerve Stimulators
Nathan W. Howard
PURPOSE: Peripheral nerve stimulators (PNSs) are used in association with the
administration of neuromuscular-blocking medication agents to assess nerve-
impulse transmission at the neuromuscular junction of select skeletal muscles.
PREREQUISITE NURSING receptors are blocked. Three twitches correspond to

KNOWLEDGE approximately 75% blockade, and two to one twitches in
response to four stimulating currents correlate with
• PNSs are used in association with the administration of approximately 80% to 90% blockade of the neuromuscu-
neuromuscular-blocking drugs (NMBDs) to block skeletal lar junction receptors.9 One to two twitches is the recom-
muscle activity. mended level of block, although the appropriate level has
• NMBDs are given in the intensive care unit, along with not yet been determined through research in the critically
sedatives and opioids, most commonly to coordinate con- ill population.5 Absence of twitches may indicate that
temporary modes of mechanical ventilation with breathing 100% of receptors are blocked, which exceeds the desired
in patients with severe lung injury. Neuromuscular-blocking level of blockade (Table 32-1).
agents are also used to assist with the management of • The stimulating current is measured in milliamperes
increased intracranial pressure after a head injury; for (mA). The usual range of milliamperes required to stimu-
severe muscle spasms associated with seizures, tetanus, and late a peripheral nerve and elicit a muscle twitch is 20 to
drug overdose; to reduce intraabdominal hypertension1; in 50 mA, although increasing the current to 70 or 80 mA
hypothermia protocols for cardiac arrest6; and for preserva- may be necessary, especially in the obese patient.9
tion of delicate reconstructive surgery. • Some stimulators do not indicate the milliamperes.
• NMBDs do not affect sensation or level of consciousness. Instead, digital or dialed numbers ranging from 1 to 10
Because NMBDs lack amnesic, sedative, and analgesic represent the range of milliamperes from 20 to 80 mA.
properties, sedatives and analgesics should always be With use of these instruments, the usual setting is 2 to 5,
given concurrently to minimize the patient’s awareness of although a setting of 10 is sometimes necessary. Other
blocked muscle activity and discomfort. Sedatives and stimulators (with and without digital displays) automati-
analgesics should be initiated before NMBDs because cally adjust the voltage output relative to resistance and
neuromuscular blockade hinders the assessment of anxiety deliver the current accordingly.10
and pain.5 • The ulnar nerve in the wrist is recommended for testing,
• Numerous medications, such as aminoglycosides and although the facial and the posterior tibial nerves may also
other antibiotics, beta blockers, calcium channel blockers, be used.
corticosteroids, and anesthetics, and conditions, such as • Peripheral nerve monitoring is used in conjunction with
acidosis and various electrolyte imbalances, potentiate the the assessment of clinical goals, and clinical decisions
effects of neuromuscular-blocking agents. Thus the level should never be made solely on the basis of the twitch
of blockade is subject to variation, which necessitates response.
vigilant monitoring with a PNS and titration of the • Titration of the drugs according to clinical assessment and
NMBD.6 muscle twitch response may help provide a sufficient level
• The muscle twitch response to a small electrical stimulus of blockade without overshooting the goal. Overshooting
delivered by the PNS corresponds to an estimated number the level of blockade with use of excessive doses of
of nerve receptors blocked by the NMBDs and assists NMBDs is of special concern in the critically ill patient
the clinician in the assessment and titration of the medi- because it may predispose the patient to prolonged paraly-
cation dosage. The level of blockade is estimated by sis and muscle weakness, reported in the literature.6 Moni-
observing the muscle twitch after stimulating the appro- toring with a PNS during the administration of NMBDs
priate nerve with a small electrical current delivered by results in the use of less medication, hastens recovery of
the PNS. spontaneous ventilation, and accelerates restoration of
• The train-of-four (TOF) method of stimulation is most neuromuscular transmission (NMT),2 which is necessary
commonly used for ongoing monitoring of NMBD use. for resumption of muscle activity. Although some patients
After delivery of four successive stimulating currents to a have severe muscle weakness after neuromuscular block-
select peripheral nerve with the PNS, in the absence of ade, peripheral nerve monitoring during NMBD therapy
significant neuromuscular blockade, four muscle twitches facilitates prompt recovery of NMT when therapy is
follow. The four twitches signify that 70% or fewer of the terminated.2
268
32 Peripheral Nerve Stimulators 269
• Explain that the electrodes require periodic changing,

TABLE 32-1 Train-of-Four (TOF)
which feels like removing an adhesive-backed bandage.
Stimulation as a Correlation Rationale: This explanation may elicit decreased anxiety.
of Blocked Nerve Receptors
TOF (No. of Percent of Receptors Blocked
Twitches) (Approximately)7 PATIENT ASSESSMENT AND
0
4 100 PREPARATION
1
4 90 Patient Assessment
2
4 80
3 • Verify that the patient is the correct patient using two
4 75
4 identifiers. Rationale: Before performing a procedure, the
4 <70
Adapted from Figure 4, p. e5, Train-of-four suppression in Wilson J, Collins AS, for the intended intervention.
Rowan BO: Residual neuromuscular blockade in critical care, Crit Care Nurse • Assess the patient for the best location for electrode place-
32(3):e1–e10, 2012. ment. Consider criteria such as edema, fat, hair, diapho-
resis, wounds, dressings, and arterial and venous catheters.
Rationale: This assessment improves conduction of stim-
ulating current through dermal tissue.
EQUIPMENT • Assess the patient for history or presence of hemiplegia,
hemiparesis, or peripheral neuropathy. Rationale: Motor
• Peripheral nerve stimulator response to nerve stimulation of the affected limb may be
• Two pregelled electrode pads (the same as is used for diminished; receptors may be resistant to NMBDs and
electrocardiography monitoring) lead to excess doses.9
• Two lead wires packaged with the peripheral nerve • Assess whether burns are present or whether topical oint-
stimulator ments are being used. Rationale: In patients with burns
• Alcohol pads for skin degreasing and cleansing or topical ointments, for whom electrode adherence is
Additional equipment, to have available as needed, includes difficult, a bipolar touch probe may be more effective than
the following: the electrode pads and lead wires. Poor electrode adher-
• A bipolar touch stimulator probe may be substituted for ence interferes with the conduction of the stimulating
the pregelled electrodes and lead wires current.
• Scissors or clippers if hair removal is necessary
Patient Preparation
PATIENT AND FAMILY EDUCATION • Ensure that the patient and family understand pre
procedural teachings. Answer questions as they arise
• If time permits, assess the patient’s and family’s level and reinforce information as needed. Rationale: Evalu-
of understanding about the condition and rationale for ates and reinforces understanding of previously taught
the procedure. Rationale: This assessment identifies the information.
patient’s and family’s knowledge deficits concerning the • Clip hair at the electrode placement sites if necessary.
patient’s condition, the procedure, the expected benefits, Rationale: This action improves electrode contact, which
and the potential risks. It also allows time for questions to facilitates current flow to the nerve.
clarify information and voice concerns. Explanations • Cleanse skin and degrease with alcohol. Rationale:
decrease patient anxiety and enhance cooperation. Cleansing improves electrode contact, which facilitates
• Explain the procedure and the reason for the procedure, if current flow to the nerve.
the clinical situation permits. If not, explain the procedure • Apply the electrodes and test the TOF response to deter-
and reason for the intubation after it is completed. Ratio- mine the adequacy of the location before initiating admin-
nale: This explanation enhances patient and family under- istration of an NMBD. In an emergent situation, testing
standing and decreases anxiety. the TOF response before the administration of an NMBD
• Describe the equipment to be used. Rationale: This may not be possible. Rationale: Testing improves the
description may decrease anxiety. reliability of the interpretation of the TOF response.
• Reassure the patient and family that medications for seda- • Whenever possible, determine the supramaximal stimula-
tion and analgesia are provided throughout this therapy so tion (SMS) level before initiating NMBDs. The SMS is
the patient is comfortable while paralyzed. Rationale: the level at which additional stimulating current elicits no
Reassurance that the patient’s pain and anxiety will be further increase in the intensity of the four twitches. In an
treated during therapy is provided. emergent situation, determination of the SMS level before
• Describe the experience of the stimuli as a slight prickly the administration of an NMBD may not be possible.
sensation. Rationale: The use of sensation descriptors Rationale: This determination helps establish adequate
may reduce anxiety. stimulating current and improves reliability of testing.
Procedures for Peripheral Nerve Stimulators

Testing the Ulnar Nerve
1. HH
2. PE
3. Extend the arm, palm up, in a The ulnar nerve is superficial and
relaxed position; cleanse with easy to locate; degreasing
alcohol pad (Fig. 32-1). increases conduction.
Figure 32-1 Placement of electrodes

along the ulnar nerve.
Proximal
electrode
Distal
electrode
4. Apply two pregelled electrodes Enables stimulation of the ulnar Ensure that the patient’s wrist is clean
over the path of the ulnar nerve nerve. Skin resistance causes the and dry.
(see Fig. 32-1). Place the distal greatest impediment to current
electrode on the skin at the flow, which can be reduced
flexor crease on the ulnar through clean dry skin and secure
surface of the wrist, as close to electrodes. The electrode gel
the nerve as possible. Place the enhances conduction. Maintaining
second electrode approximately the electrodes as close as possible
1–2 cm proximal to the first, in alignment with the nerve
parallel to the flexor carpi minimizes artifact from direct
ulnaris tendon. (Level E*) muscle stimulation.9
5. Use caution in selecting the site Direct muscle stimulation elicits a In patients with hemiplegia, place the
of the electrode placement to response similar to the TOF, electrodes on the unaffected limb
avoid direct stimulation of the which makes evaluation of because resistance to NMBDs on
muscle rather than the nerve. blocked nerve-impulse the affected side may lead to excess
(Level E*) transmission difficult. doses.9 In patients with limbs
immobilized from orthopedic casts,
use the unaffected limb because
possible resistance to some NMBDs
on the affected limb may lead to
excess doses.4
Procedures for Peripheral Nerve Stimulators—Continued

6. Plug the lead wires into the Necessary for the conduction of
nerve stimulator, matching the electrical current.
negative (black) and positive
(red) leads to the black and red
connection sites.
7. Attach the lead wires to the Prepares the equipment.
electrodes. Connect the negative
(black) lead to the distal
electrode over the crease in the
palmar aspect of the wrist.
Connect the positive (red) lead
to the proximal electrode.
8. Turn on the PNS and select the Excessive current results in Patients with diabetes mellitus may
current determined by the SMS overstimulation and can cause need higher stimulating current than
or, if not performed, a low repetitive nerve firing. patients without diabetes because of
current (10–20 mA is typical). impaired motor nerve fibers and
nerve endings.8
9. Depress the TOF key; through Finger movements result from Placing the operator’s hand over the
tactile assessment, determine direct muscle stimulation. The fingers helps reduce interpretation
twitching of the thumb and quality of the twitches may be of artifactual movement. Use the
count the number of twitches. subtle and decrease in amplitude dominant hand for tactile
Do not count finger movements, with increasing edema; detection assessment because it may more
only the thumb. with tactile methods increases accurately detect the TOF response.
sensitivity and accuracy.
10. Maintain a consistent current Increases reliability and validity in
with each stimulation. the quality of the twitch response.
remove PE .
12. HH
Testing the Facial Nerve
1. HH
2. PE
3. Place one electrode on the face Stimulates the facial nerve. Ensure that the patient’s face is clean
at the outer canthus of the eye Maintaining the electrodes as and dry. When wounds, edema,
and the second electrode close as possible in alignment invasive lines, and other factors
approximately 2 cm below, with the nerve minimizes artifact interfere with ulnar nerve testing,
parallel with the tragus of the from direct muscle stimulation.9 the facial or posterior tibial nerves
ear (Fig. 32-2). may be substituted. The risk for
direct muscle stimulation is greater,
however, with resulting
underestimation of blockade. Also,
the alternate nerves correlate less
well with blockade of the
diaphragm.7 (Level C*)


Figure 32-2 Placement of electrodes along the facial nerve.
4. Plug the lead wires into the Necessary for conduction of the
black and red leads to the black
and red connection sites.
electrode at the tragus of the
ear. Connect the positive (red)
lead to the proximal electrode
at the outer canthus of the eye.
6. Turn on the PNS and select the Excessive current results in
current determined by the SMS overstimulation and can cause
or, if not performed, a low repetitive nerve firing.
current (10–20 mA is typical).
7. Depress the TOF key; through Determines the neuromuscular
tactile assessment, determine blockade at the junction between
twitching of the muscle above a branch of the facial nerve and
the eyebrow and count the orbicularis muscle.
number of twitches.
remove PE .
9. HH
Testing the Posterior Tibial Nerve
1. HH
2. PE
3. Place one electrode Stimulates the posterior tibial nerve. Ensure that the patient’s skin is clean
approximately 2 cm posterior to Maintaining the electrodes as and dry.
the medial malleolus (Fig. close as possible in alignment
32-3). (Level E*) with the nerve minimizes artifact
from direct muscle stimulation.9

Figure 32-3 Placement of electrodes along the posterior tibial nerve.
4. Place the second electrode Maintaining the electrodes as close

approximately 2 cm above the as possible in alignment with the
first (see Fig. 32-3). nerve minimizes artifact from
direct muscle stimulation.9
5. Plug the lead wires into the Necessary for conduction of the
black and red leads to the black
and red connection sites.
electrode 2 cm posterior to the
medial malleolus. Connect the
positive (red) lead to the
proximal electrode 2 cm above
the medial malleolus.
7. Turn on the PNS and select the Excessive current results in
current determined by the SMS overstimulation and can cause
or, if not performed, a low repetitive nerve firing.
current (10–20 mA is typical).
8. Depress the TOF key; through Determines the neuromuscular
tactile assessment of plantar blockade at the junction between
flexion of the great toe, count the posterior tibial nerve and the
the number of twitches. flexor hallucis brevis muscle.
remove PE .
10. HH
Determining the Supramaximal Stimulation
1. HH
2. PE
3. Beginning at 5 mA, increase the Uses the lowest level necessary to
milliamperes in increments of elicit the twitches.
5 mA until four twitches are
observed.
4. Note the amount of current (in If no increase in intensity of the For example, if a strong response is
milliamperes) that corresponds muscle twitch is found when the observed at 30 mA, raise the
to four vigorous twitches. milliamperes are increased, the current to 35 mA. If no increase is
Administer one to two more SMS is the level at which four seen in intensity of the twitch, the
TOF stimuli to confirm the vigorous twitches were observed. SMS is 30 mA. If an increase is
response. This current level is seen, raise the milliamperes to
then used in TOF testing for 40 mA. If an additional increase is
that site. seen in twitch intensity, raise it to
45 mA. If the intensity shows no
further increase, the SMS is 40 mA.

Determining the Train-of-Four Response during Neuromuscular-Blocking Drug Infusion
1. HH
2. PE
3. Retest the TOF 10–15 minutes Evaluates the level of blockade Always assess electrode condition and
after a bolus dose or when provided. placement before testing.
continuous infusion of NMBD
is given/initiated/changed.
4. If more than one or two Signifies that less than 85–90% of
twitches occur and receptors are blocked.
neuromuscular blockade is
unsatisfactory for clinical goals,
increase the infusion rate as
prescribed or according to
hospital protocol and retest in
10–15 minutes.
5. Retest every 4–8 hours after a Evaluates the level of blockade and
clinically stable and satisfactory avoids underestimation and
level of blockade is achieved. overestimation of blockade.
6. Discard supplies and remove
PE .
7. HH
Troubleshooting with Zero Twitches
1. HH
2. PE
3. Change the electrodes and Drying of the gel or poor contact
ensure that the patient’s skin is from moisture or soiling
clean and dry. (Level E*) compromises conduction.10
4. Check the lead connections and One of the most common causes of
the PNS for mechanical failure PNS malfunction is low battery
and change the battery if voltage.9
needed. (Level E*)
5. Increase the stimulating current. The current may be inadequate to
(Level E*) stimulate the nerve, especially for
increasingly edematous patients.9
6. Retest another nerve (the other Avoids overestimating the level of
ulnar nerve or facial or blockade with false zero twitch
posterior tibial nerves). responses.
7. If no other explanations are Excessive neuromuscular blockade
found for a zero response, produces absence of a twitch
check the NMBD infusion for response and, if allowed to
the rate, dose, and persist, may contribute to
concentration. Reduce the prolonged paralysis or severe
infusion rate of the NMBD as weakness.6 Peripheral
prescribed or according to hypothermia causes a decrease in
hospital protocol. (Level E) twitch response and may require
a decrease in NMBD by 80%.9
8. Discard supplies and remove
PE .
9. HH

• Slight discomfort during the TOF test • Moderate to severe discomfort from the TOF test
• The muscles of the thumb twitch, rather than the • Impaired skin integrity when the electrodes are
fingers, when the ulnar nerve is stimulated removed
• The twitch response approximates the number of • The fingers twitch when the ulnar nerve is stimulated
blocked peripheral nerve receptors; for example, four as a result of artifact; if the thumb does not twitch,
twitches before initiating the NMBD infusion and one this signifies direct muscle rather than ulnar nerve
to two twitches when a desired level of blockade is stimulation
achieved • Resumption of four twitches does not occur within 2
• The NMBD dosage is titrated according to the TOF hours of discontinuation of NMBD7
test and clinical goals
• Resumption of four twitches occurs within 2 hours
when the NMBD is discontinued7

interventions.
1. Cleanse and thoroughly dry the Improves the electrode
skin before applying electrodes. adherence.
2. Change the electrodes every 24 Optimizes conduction of the • Skin breakdown
hours or whenever they are loose stimulating current. This action
or when the gel becomes dry. also assists with decreasing the
risk for skin breakdown from
the adhesive on the electrodes.
Use caution when removing
the old electrodes so as not to
disrupt skin integrity.
3. Select the most accessible site with Facilitates ease in testing,
the smallest degree of edema and electrode adherence, and the
hair and with no wounds, catheters, conduction of current.
or dressings that impede accurate
electrode placement over the
selected nerve.
4. Never use the Single Twitch, These methods are designed for
Tetany, or Double Burst settings, if profound neuromuscular
available on the PNS. (Level E*) blockade and may cause
extreme discomfort.10
5. Assess the patient’s oxygenation The patient may have subtle • Excessive patient movement
and ventilation, neurological movement of the extremities despite acceptable TOF
function, and tissue perfusion with an acceptable TOF • Change in vital signs
before increasing the rate of the response. Clinical decisions • Decreased oxygenation (e.g.,
NMBD infusion. should never be made solely measured via arterial blood gas
on the TOF test results. or pulse oximetry)
• Change in neurological function
6. Extreme caution must be exercised Direct electrical current can be • Cardiac dysrhythmias or change
to prevent the PNS lead wires from conducted from the PNS in patient condition
contacting an external pacing through the pacing wires to the
catheter or pacing lead wires. heart.


7. Perform the TOF testing every 4–8 Determines an effective dose of • Abnormal TOF results
hours during NMBD infusion after NMBD.
the patient’s condition is clinically
stable and a satisfactory level of
neuromuscular blockade is
achieved, or per institution policy.
8. Consider objective methods of Muscle paralysis during therapy
sedation monitoring, such as with NMBDs hinders sedation
bispectral index monitoring (see assessment with subjective
Procedure 88) or evoked potentials, instruments.
during NMBD therapy.3 (Level E*)
9. Remove the electrodes, lead wires, Metal objects are attracted to the
and PNS from the patient for magnetic field.
magnetic resonance imaging or
exposure to any magnetic field.
Documentation
• Patient and family education • Assessment data (e.g., neurological, pulmonary,
• The time, baseline SMS milliamperes, most recent cardiovascular)
milliamperes, TOF twitch response, and nerve site • Unexpected outcomes
tested • Troubleshooting attempts
• The TOF response as 0 4, 1 4, 2 4, 3 4, or 4 4 • Additional interventions
• Dosage of NMBD • Pain assessment, interventions, and effectiveness

32 Peripheral Nerve Stimulators 276.e1
References 6. Murray MJ, Brull SJ, Bolton CF: Brief review:

1. De Laet I, et al: The effect of neuromuscular blockers in Nondepolarizing neuromuscular blocking drugs and
patients with intra-abdominal hypertension. Intensive Care critical illness myopathy. Can J Anaesth 53(11):
Med 33(10):1811–1814, 2007. 1148–1156, 2006.
2. Foster J, Clark AP: Functional recovery after 7. Nagelhout JJ, Naglaniczny KL: Nurse anesthesia, ed 3,
neuromuscular blockade in mechanically ventilated Philadelphia, 2004, Saunders.
critically ill patients. Heart Lung 35(3):178–189, 2006. 8. Saenz AD: Peripheral nerve stimulator—Train of four
3. Jacobi J, et al: Clinical practice guidelines for the monitoring. Medscape. <http://emedicine.medscape.com/
sustained use of sedatives and analgesics in the critically article/2009530-overview>. (Accessed 14.12.14.).
ill adult. Crit Care Med 30:119–140, 2002. 9. Saitoh Y, et al: Monitoring of neuromuscular block after
4. Kim KS, et al: The duration of immobilization causes the administration of vecuronium in patients with diabetes
changing pharmacodynamics of mivacurium and mellitus. Br J Anaesth 90:480–486, 2003.
rocuronium in rabbits. Anesth Analg 96:438–442, 2003. 10. Thompson C: Monitoring the neuromuscular junction.
5. Murray M, et al: Clinical practice guidelines for sustained <http://www.anaesthesia.med.usyd.edu.au/resources/
neuromuscular blockade in the adult critically ill patient. lectures/nmj_monitoring_clt/nmjonitoring.html>.
Crit Care Med 30:142–156, 2002. (Accessed 01.02.16.).
PROCEDURE
33
Weaning Mechanical Ventilation
Susan K. Frazier
PURPOSE: Weaning from mechanical ventilation is a process whereby the work
of breathing is transferred from the mechanical ventilator to the individual, who is
liberated from mechanical support; satisfactory spontaneous ventilation is indicated
by optimal oxygenation and carbon dioxide removal for 30 to 120 minutes.
PREREQUISITE NURSING levels of continuous positive airway pressure (CPAP),

KNOWLEDGE pressure support (PS), or automatic tube compensation
(ATC), a strategy whereby the degree of pressure needed
• Scientists classify successful weaning as adequate oxy- to overcome the resistance imposed by the endotracheal
genation and carbon dioxide removal for 24 to 48 hours tube for the measured flow is applied in patients capable
after cessation of mechanical ventilation support, regard- of spontaneous ventilation.22 These supports are intended
less of when extubation occurs.41,47,48 to reduce work of breathing imposed by the endotracheal
• Positive pressure mechanical ventilation use is associated tube; however, work of breathing is highly variable due
with the need for sedation and the possibility for excess to the nonlinear, flow-dependent nature of the pressure
sedation, potential exposure to high airway pressures with decrease across the airway.56 PS adequate to overcome the
subsequent barotrauma, disruption of upper-airway pro- work produced by the endotracheal tube can range from
tective mechanisms, and increased risk for lower respira- 5 to 22 cm H2O pressure.24 ATC uses a continuous mea-
tory infection or ventilator-associated pneumonia.48 surement of flow to calculate the inspiratory pressure
• To date, none of the predictors of readiness to wean are needed to compensate for the flow-dependent work. ATC
sufficiently sensitive and specific in all populations; thus assumes a constant lumen and normal shaped endotra-
the use of mechanical ventilation may continue even when cheal tube; however, Oto and colleagues56 found that
the patient has the ability to ventilate independently.59 deformations in the tube and secretion buildup in the
After the requirement for ventilatory support is adequately lumen after 48 hours of placement increased the imposed
addressed, ventilator discontinuation should be initiated. resistance and reduced the efficacy of ATC. A superior
However, premature ventilator removal is also linked with technique for spontaneous breathing trials has not been
potential for airway obstruction, hypoxemia, pulmonary identified.44
aspiration, respiratory muscle failure, respiratory arrest, • Typically, a majority of patients (55% to 81%) required
and mortality.48 Thus clinicians seek the ideal point in the simple ventilator weaning; difficult weaning was required
clinical course to initiate ventilator discontinuation. The by 16% to 39% and prolonged weaning by less than 1%
transition from mechanical to spontaneous ventilation, to 6%.26,29 Difficult and prolonged weaning were associ-
known as weaning, is a process that requires as much as ated with a greater comorbid burden, higher severity of
40% of total ventilator time in adults who require ventila- illness, longer intensive care and hospital stay, and higher
tory support.6,19 mortality.29 Clinical factors associated with weaning
• Annually in the United States, approximately 300,000 success included normal respiratory rate, optimal cardio-
patients require invasive ventilation for more than 4 days; vascular function, adequate nutrition, sufficient hemoglo-
scientists estimate that by 2020, 600,000 individuals bin, electrolyte homeostasis, adequate respiratory muscle
annually will require mechanical ventilation.73,74 These strength, psychological and neurological stability, ade-
patients may be classified as those who require simple, quate oxygenation, normal bowel function, fluid homeo-
difficult, or prolonged ventilator weaning.48,57 Patients stasis, and normal blood pH.8,28,30,41
who require simple weaning are those who are successful • The use of weaning protocols directed by registered
on the initial attempt; difficult weaning requires at least nurses,14,61 respiratory therapists,29,62 or computer-driven
three spontaneous breathing trials and as long as 7 days protocols49 has demonstrated significant reductions in
to achieve a successful transition. Those who require pro- ventilator hours,29,61 intensive care days, and hospital
longed weaning need more than three spontaneous breath- length of stay compared with usual care.5,14,29,62
ing trials and longer than 7 days to achieve successful • Well-established evidence-based guidelines support the
independent ventilation. use of a daily spontaneous breathing trial for 30 to 120
• Trials of spontaneous ventilation consist of cessation of minutes to evaluate individual ability to sustain indepen-
mechanical ventilation and administration of supplemen- dent spontaneous ventilation.25,49 Respiratory pattern, arte-
tal humidified oxygen, most often accompanied by varied rial blood gas concentrations for adequacy of ventilation
277
TABLE 33-1 Weaning Criteria Identified as Potential Predictors by McMaster Review

Variable Threshold Values Criterion Evaluated Likelihood Ratios*
VE in L/min 10–15 Respiratory muscle endurance 0.8–2.37
NIF in cm H2O −20 to −30 Effort-independent inspiratory respiratory 0.23–3.01
muscle strength
Pimax in cm H2O −15 to −30 Respiratory muscle function 0.98–3.01
P0.1/Pimax 0.30 Respiratory drive and inspiratory muscle 2.14–25.3
strength
CROP index 13 Compliance, ventilatory drive, oxygenation, 1.05–19.74
respiratory muscle function
Respiratory rate in breaths/min 30–38 Ventilatory drive and pattern 1.00–3.89
Vt in mL 325–408 or 4–6 mL/kg Respiratory muscle endurance 0.71–3.83
ideal body weight
f/Vt 60–105 Ventilatory pattern and drive 0.84–4.67
*A likelihood ratio of <1 indicates a reduced likelihood of successful weaning; a ratio of 0.5 to 2.0 indicates a small, clinically unimportant likelihood; ratios of <0.1 or
>10 indicate a high likelihood of failure or success; VE = minute ventilation; NIF = negative inspiratory force; Pimax = maximal inspiratory pressure; P0.1/Pimax = ratio of
inspiratory pressure at 0.1 second and maximal inspiratory pressure; CROP index = index of compliance, respiratory rate, oxygenation, and airway pressures; Vt = tidal
volume; f/Vt = rapid shallow breathing index.
From Cook D, Meade M, Guyatt G, et al: Evidence report on criteria for weaning from mechanical ventilation. Rockville, MD: Agency for Health Care Policy and
Research, 1999, (classic reference); MacIntyre NR, Cook DJ, Ely EW, et al: Evidence-based guidelines for weaning and discontinuing ventilatory support: A collective
task force facilitated by the American College of Chest Physicians, the American Association for Respiratory Care, and the American College of Critical Care Medicine,
Chest 120(6 suppl):375S–395S, 2001.
and oxygenation, hemodynamic stability, and patient evaluated in as many as 24 studies, there have been no
comfort are used as indicators of tolerance. Failure of consistently robust predictors of weaning success in all
the spontaneous breathing trial is identified by tachypnea, patient populations.48,49 Over the past decade, investiga-
a rapid shallow breathing pattern, partial pressure of O2 in tors have failed to identify effective predictors of ventila-
arterial blood (Pao2) <60 mm Hg with a fraction of tor weaning success; thus, success predictors are not
inspired oxygen (Fio2) of 0.40, oxygen saturation values consistently used in clinical practice (Table 33-1).32,48
(Spo2) obtained with pulse oximetry, heart rate and/or
blood pressure increase or decrease of >20% of baseline Other Criteria That May Be Used for
values, increase in work of breathing as indicated by Evaluation of Weaning Readiness
respiratory accessory muscle effort, intercostal retrac- • Vital capacity (VC) or forced vital capacity (FVC) is the
tions, nasal flaring, and/or asynchronous thoracic cavity- maximal volume exhaled after a maximal inspiration or
abdominal movement, diaphoresis, agitation, and the volume forcibly exhaled during a forced expiratory
alteration in level of consciousness.58 volume maneuver. The normal VC is double to triple the
• In 1999 the Agency for Health Care Policy Research tidal volume, or 10 to 15 mL/kg ideal body weight in a
funded a comprehensive review of published studies normal adult. VC is the sum of the inspiratory and expira-
intended to identify predictors of the likelihood of suc- tory reserve volumes and the tidal volume. VC and FVC
cessful ventilator weaning.13 Sixty six potential predictors are used as indicators of ventilatory and respiratory muscle
were identified; the investigators calculated the odds reserve, adequacy, and function. These measures may be
that each measure would accurately predict successful particularly useful in evaluation of patients with neuro-
weaning. Only eight of these measures demonstrated sta- muscular disorders who require mechanical ventilation,
tistically significant predictive ability; however, the likeli- but are more often used to determine the need for ventila-
hood of accurate prediction by these was generally poor tion in that patient population.11,36,55,60
and highly variable. These measures included minute ven- • B-type natriuretic peptide (BNP) is a hormone produced
tilation (VE), negative inspiratory force (NIF), maximal and secreted by cardiac myocytes in response to stretch-
inspiratory pressure (Pimax), and the ratio of pressure at ing, which occurs with increased preload associated with
0.1 second to maximal inspiratory pressure (P0.1/Pimax) fluid overload. BNP concentration is an independent
all measured during mechanical ventilation; measures predictor of ventilator weaning failure due to cardiac
made during a 1- to 2-minute spontaneous breathing dysfunction.72 BNP-guided fluid management that con-
trial included an index score that was comprised of com- sisted of furosemide administration and fluid restric-
pliance, respiratory rate, oxygenation, pressure (CROP tion when BNP concentration was ≥200 pg/mL was
index), respiratory rate, tidal volume (Vt), and the respira- associated with an average reduction of 26 hours in time
tory frequency to tidal volume ratio (f/Vt) or the rapid to successful extubation and an increase of nearly 3
shallow breathing index. Although these criteria are ventilator-free days compared with usual care during ven-
included in evidence-based guidelines49 and were tilator weaning.51
33 Weaning Mechanical Ventilation 279
• Diaphragm thickening fraction/diaphragm electromyog- • Other clinical indicators of weaning readiness that have
raphy derived indices are recently evaluated predictors of been tested included hemoglobin concentration,41 ineffec-
ventilator weaning ability.16,17,21,53 The diaphragm is the tive cough,32 heart rate less than 105 beats/minute, and
primary ventilatory muscle. During ultrasound measure- Paco2 <54 mm Hg at the end of a 30-minute spontaneous
ment of diaphragm thickening with spontaneous ventila- breathing trial,65 presence of depressive disorder,35 main-
tion, diaphragm thickness was calculated as thickness at tenance of central venous oxygen saturation during a
end-inspiration minus thickness at end-expiration divided spontaneous breathing trial,70 and knee tissue oxygen satu-
by thickness at end-expiration. A value greater than 36% ration (Sto2) and skin mottling score change during a
predicted successful weaning with sensitivity 0.82, speci- spontaneous breathing trial.50 Burns and colleagues devel-
ficity 0.88, positive predictive value 0.92, and negative oped the Burns Weaning Assessment Program (BWAP),
predictive value 0.75.21 Diaphragm electrical activity has an instrument that contained 26 clinical factors for evalu-
also been evaluated using a neurally adjusted ventilatory ation before ventilator weaning. In a recent evaluation of
assist catheter (NAVA), a nasogastric catheter with multi- the BWAP, 20 of these factors were significantly associ-
ple electrodes placed in the distal esophagus, that captured ated with weaning success in a variety of specialty inten-
real-time electrical activity of the diaphragm.17 When sive care unit patients.8 Another investigative group found
diaphragm electrically derived values were compared that a modified BWAP using a cut-off point of 60 provided
between those patients who were successfully weaned and a sensitivity of 81% and a specificity of 82%, which was
those who failed weaning, patients who failed had signifi- superior to traditional measures like the rapid shallow
cantly higher derived values compared with the successful breathing index and Pimax.34 Although numerous investiga-
patients; these values occurred early in a spontaneous tors have identified multiple independent predictors of
breathing trial and persisted throughout the trial. Investiga- weaning success and failure, the lack of consistent predic-
tors have proposed that these derived values provided an tive power in heterogeneous patient populations limits
evaluation of the balance between ventilatory drive and their clinical utility and significantly reduces their utility
the sustainability of the demand for ventilation.53 in clinical care.
• Heart rate variability (HRV) is an indicator of the balance
between sympathetic and parasympathetic stimulation Methods of Ventilator Weaning
to the heart; measurement of the interval between succes- • Standardized weaning protocol use is associated with sig-
sive cardiac electrical stimulations producing contraction nificantly increased weaning success and reduced ventila-
is used to calculate measures of HRV. Time domain mea- tor days, along with reduced ICU and hospital lengths
sures use statistical analysis of these time intervals. Fre- of stay.5,38,39 For example, implementation of a standard-
quency domain measures are determined by separating ized protocol for ventilator weaning was demonstrated to
electrical activity into different frequency ranges and cal- increase the use of spontaneous breathing trials by 26%
culating the total power within a given time period.66 and subsequently reduce the occurrence of ventilator-
There are four primary frequency bands produced in this associated conditions by 37%, infection-related ventilator-
analysis, high frequency, low frequency, very low fre- associated conditions by 65%, and probable pneumonia
quency, and ultralow frequency bands. The high frequency by 49%.39 In addition, these investigators found that stan-
band (0.15 to 0.4 Hz) is a reflection of parasympathetic dardized weaning reduced ventilator time by 2.4 days, ICU
activity; this band may be referred to as the respiratory length of stay by 3 days, and hospital length of stay by
band because of its association with heart rate variation 6.3 days. However, investigators also reported difficulty
produced with respiration. The low frequency band (0.04 with protocol adherence and lack of any change in ventila-
to 0.15 Hz) reflects baroreceptor activity during rest and tor time after protocol implementation, probably due to
during 24-hour recordings has been demonstrated to nonadherence to the specific protocol components.37 To
respond to increased sympathetic innervation. The very date, the use of a standardized protocol for ventilator
low frequency (0.0033 to 0.04 Hz) is generated by sensory weaning has been demonstrated to be superior to usual
neurons in the heart and is an intrinsic cardiac rhythm care, regardless of the specific method used for weaning.
that is essential to health; reductions in very low fre- • T-piece spontaneous breathing trial with administration
quency power are associated with all-cause mortality, of supplemental oxygen by T-piece is recommended for
sudden cardiac death, and systemic inflammation. The discontinuation of mechanical ventilation.49,59 Spontane-
ultralow frequency (<0.0033 Hz) reflects 24-hour cardiac ous breathing trials with T-piece were associated with
oscillations associated with circadian rhythm, as well as superior arterial and central venous oxygenation com-
temperature regulation, metabolic rate, and the renin- pared with CPAP with PS and CPAP with automatic tube
angiotensin-aldosterone system. Investigators have identi- compensation during spontaneous breathing trials.45
fied significantly reduced total power in those patients However, other investigators found no difference in
who failed the transition to spontaneous ventilation; those weaning success, hemodynamic values, and arterial blood
who were successfully weaned increased low frequency gas values between T-piece and CPAP weaning.10 Cur-
and total power in response to a spontaneous breathing rently, spontaneous breathing trials are widely recom-
trial.31 Other investigators developed nonlinear analysis mended because they are safe, effective, and efficient
techniques of heart rate variability during weaning to strategies to evaluate tolerance of independent ventilation,
identify differences between patients who were success- and they may be accompanied by supplemental oxygen
fully weaned and those who failed.1 via T-piece, PS, CPAP, or automatic tube compensation.
However, none of these methods has demonstrated supe- support for comprehensive superior outcomes with this
riority in all patient populations. weaning strategy.7,62
• Pressure support (PS) permits the patient to trigger inspi-
ration and control respiratory rate, depth, length, and flow EQUIPMENT
during each spontaneous breath. Inspiration is supported
by a preset inspiratory pressure; the tidal volume achieved • Standardized weaning protocol approved for your facility
with each breath is determined by individual effort, pul- • Personal protective equipment (i.e., gloves, mask, goggles,
monary compliance, airway and endotracheal tube resis- gown)
tance, and the set level of PS. Several investigators have • Force meter/aneroid pressure manometer—typically a
concluded that PS weaning was associated with greater component of the mechanical ventilator
weaning success compared with T-piece weaning, particu- • Spirometer to measure volumes—typically a component
larly in patients who required simple weaning.20,40 of the mechanical ventilator
However, with conventional PS, the level of support is • Equipment for endotracheal suctioning
constant and ventilatory variability is reduced; breathing Additional equipment, to have available as needed, includes
variability reductions have been previously associated the following:
with weaning failure.71 The use of variable PS, also known • Self-inflating manual resuscitation bag-valve device con-
as noisy PS, improved tidal volume variability and was nected to oxygen source as needed
significantly associated with improved patient ventilator • Oxygen flow meter connected to oxygen source with
synchrony.68 In an experimental model of acute lung heated aerosol humidifier with in-line thermometer and
injury, variable PS was superior to conventional PS in water trap for T-piece weaning or tracheostomy collar as
improvement of gas exchange, reduction of work of appropriate for those using this method of weaning
breathing, alveolar edema, and inflammatory infiltrates.67
Variable pressure support for ventilator weaning is cur- PATIENT AND FAMILY EDUCATION
rently in clinical trials to evaluate its efficacy as a weaning
mode for adult patients. • Assess patient and family level of understanding about the
• Continuous positive airway pressure (CPAP) consists of condition and rationale for the procedure. Rationale:
adding positive airway pressure throughout the ventilatory Assessment identifies the patient and family knowledge
cycle during spontaneous breathing. Positive pressure at deficits about the patient’s condition, the procedure, the
end-expiration in particular increases functional residual expected benefits, and the potential risks. The clinician
capacity and redistributes extravascular lung water to the should permit time for questions to clarify information
interstitial space, which improves pulmonary compliance, and voice concerns. Explanations decrease patient anxiety
oxygenation, and ventilation-perfusion match.27,46 Com- and enhance cooperation.
parison of ventilator weaning with CPAP to T-piece pro- • Explain the procedure and the reason for the procedure
vided evidence that CPAP was superior, because 16% before and during the procedure. Reinforce information
more patients in the CPAP group were weaned;52 however, frequently. Rationale: Explanation enhances patient and
other investigators have found no significant difference in family understanding and decreases anxiety.
weaning outcome when CPAP was compared with the • Maintain the clear and frequent transmission of informa-
application of automatic tube compensation23 and worse tion about patient progress, change in status, and prognosis
outcomes when CPAP combined with PS was compared with the patient and family members. Rationale: Estab-
with T-piece.45 Thus there is equivocal evidence to support lishes an open trusting relationship and encourages real-
the superiority of CPAP to other methods of ventilator istic perception of the situation and patient prognosis.
weaning. • Describe the potential sensations (dyspnea, increased
• Automated weaning systems with the use of computer- airway resistance, increased ventilatory effort, palpita-
driven automated systems to support earlier removal of tions) that the patient may experience during evaluation
mechanical ventilation have been tested over the past and spontaneous breathing trials, and explain the impor-
decade. An automated ventilator system monitors and tance of cooperation and maximal effort. Explain that
interprets clinical data that include end-tidal CO2 concen- prolonged ventilation may require muscle conditioning
tration, respiratory rate, and tidal volume and adapts the and produce more sensations associated with distress.
level of PS in 2- to 4-cm H2O increments based on these Rationale: A clear understanding of expected sensa-
values. A minimal level of PS is the goal, and the system tions reduces anxiety and improves understanding and
can automatically initiate a spontaneous breathing trial cooperation.
with automatic tube compensation or PS. Early investiga- • Provide reassurance during the procedure; ensure continu-
tors reported significant reductions in weaning time, venous presence of qualified, experienced clinician(s). Ratio-
tilator days, and intensive care length of stay,42 and more nale: May reduce anxiety, promote patient cooperation,
recent studies supported these findings.43 However, and improve and enhance effort.
recently investigators found no improvement in weaning • Explain how the patient will be monitored and evaluated
outcomes of surgical patients with the computer-automated for tolerance of spontaneous breathing and ensure patient
strategy,64 and scientists in two recent systematic reviews and family that mechanical ventilation will be reinstituted
concluded that evidence to date did not provide definitive should the patient demonstrate intolerance. Rationale:
Provides assurance to the patient and family that clinicians medications, absence of evidence of myocardial ischemia,
will protect the patient from harm during the procedure. adequacy of hemoglobin concentration for oxygen trans-
port, electrolyte and acid-base homeostasis, adequate
PATIENT ASSESSMENT AND nutritional status, fluid volume state, lack of localized or
PREPARATION systemic infection, and adequacy of respiratory muscle
function (muscle fatigue or lack of endurance). These
Patient Assessment factors should be effectively managed before the initiation
• Evaluate the patient for objective and subjective measures of weaning. Rationale: Adequate attention to all factors
of adequacy of ventilation and oxygenation. Objective that influence ability to ventilate spontaneously improves
measures include oxygenation (Pao2, Spo2), carbon the likelihood of successful weaning from ventilation.
dioxide removal (Paco2, end-tidal CO2), arterial pH, respi-
ratory rate (tachypnea, bradypnea, apnea), synchrony of Patient Preparation
chest and abdominal movements, level of consciousness, • Verify patient identity for the prescribed procedure to
agitation, arterial blood pressure and heart rate within ensure the correct patient will receive the appropriate
normal limits or less than 20% change from values normal treatment. Rationale: Ensures correct identification of the
for the individual, new cardiac dysrhythmias, and volume appropriate patient for the procedure.
and characteristics of secretions. Subjective indicators • Review the procedure and expected sensations with the
include self-reported dyspnea, sensation of excessive patient and family; answer questions as they arise. Rein-
work of breathing, anxiety, and fatigue. Rationale: Early force the importance of patient relaxation, cooperation,
detection of inadequate ventilation and oxygenation and maximal effort. Rationale: Determines patient under-
permits the clinician to quickly intervene and return the standing, reinforces information, and reduces anxiety of
patient to the prior ventilator settings. patient and family.
• Evaluate the level of patient responsiveness and degree • Position the patient for comfort and physiological support
of sedation for those patients receiving intermittent or of ventilation; consider the use of a position elevated 45
continuous sedation infusion using a reliable and valid degrees, as this supported optimal respiratory muscle
instrument like the Richmond Agitation-Sedation Scale.4,63 function.15 Rationale: Investigators found that a 45-degree
Assess the patient for delirium with a reliable and valid elevation reduced work of breathing and intrinsic positive
instrument like the Confusion Assessment Method for the end-expiratory pressure level, compared with supine and
Intensive Care Unit (CAM-ICU)4,18 because the presence sitting positions.15
of delirium has previously been hypothesized to be associ- • Initiate titration/reduction or cessation of sedation (seda-
ated with the use of sedation and mechanical ventilation, tion interruption, sedation vacation) following hospital
and this combination may trigger weaning failure.3,12 protocol. Some prior investigations have demonstrated
Rationale: Adequate cognitive function supports the that sedation interruption is safe and reduced length of
ability of the patient to cooperate and participate in the ventilation.2,33 However, recently other investigators found
procedure and increases the likelihood of success. no difference in ventilator time, length of stay, medication
• Evaluate the patient for factors that induced the need for use, or mortality with this strategy, but unplanned extuba-
mechanical ventilation in the individual, particularly those tion rate was increased with daily sedation interrup-
that are reversible, and address those before weaning tion.9,54,69 However, the patient should be relaxed, able to
trials. These factors include correction of the underlying cooperate, and free from pain/discomfort during this expe-
cause of the respiratory failure, neurological function and rience. Rationale: Minimal sedation optimizes the ability
adequate ventilatory drive in particular, cardiovascular of the patient to understand the procedure, the sensations
stability demonstrated by heart rate and blood pressure detected during weaning, and to cooperate, thereby
within normal limits without the use of vasoactive increasing the likelihood of success.
Procedure for Ventilator Weaning

Evaluation of Readiness
1. HH
2. PE
3. Assemble and prepare equipment Prepares equipment for procedure.
and supplies.
4. Use the spirometer as indicated in Spirometer in the ventilator may Ensure that there is minimal leak
the facility protocol to evaluate be used to measure spontaneous around the endotracheal tube cuff
specific indicators if they are to Vt and VE and VC. because this will give inaccurate
be measured before weaning trial. measures of volumes measured
through the tube.
Provide patient with rest periods on
the ventilator between
measurements.
5. Request the patient breathe Ventilator may measure the VE, the Evaluate patient status and discontinue
normally for 1 minute; the total volume exhaled in 1 evaluation if intolerance detected
spirometer in the ventilator may minute. Spontaneous Vt is also (Spo2 < 90%, tachypnea, bradypnea,
be used to determine values measured breath to breath or agitation, diaphoresis, tachycardia,
required by your facility protocol. determined by dividing the etc.)
1-minute total exhaled volume
by the measured respiratory rate.
6. Measure the rapid shallow Threshold values for weaning are
breathing index (f/Vt), divide the 60–105.
measured spontaneous Vt by the
respiratory rate if required in your
facility protocol.
7. Measure the VC and/or FVC if VC and FVC measures require Most often used with patients who
these are a component of your patient cooperation and effort. have a neuromuscular disorder.
facility protocol. For a VC These measures are typically
measure, instruct the patient to repeated at least three times and
exhale then inhale as deeply as the average value used.
possible (maximal inspiration),
followed by an exhalation of all
the gas possible (maximal
expiration). For the FVC measure,
the patient is instructed to
maximally inhale and then
forcibly exhale the maximal
amount as quickly as possible.
8. When indicated by your facility This measure is typically repeated There are ventilators that will permit
protocol, measure the negative at least three times and either the this measure to be made while the
inspiratory force. Instruct the best effort achieved or the patient is connected to the
patient to maximally inhale. average value used. This ventilator.
Determine the maximal pressure measure can be effort The patient will be unable to ventilate
generated during the inspiratory independent in patients who are normally during this measure and
effort over a 20-sec period. unable to cooperate. may become anxious. Prior
Threshold −20 to −30 cm H2O explanation should reduce this
pressure (a greater negative anxiety. Abort the measure with
value is desirable). signs of excessive anxiety and
intolerance.
9. Evaluate patient condition; return Patient measures that indicate Spontaneous breathing trial in those
to mechanical ventilation using adequate ventilatory drive, deemed ready to wean may be
previous settings or initiate respiratory muscle strength, and supported with PS, CPAP, ATC to
spontaneous breathing trial based endurance lead to initiating a reduce the effect of the endotracheal
on facility weaning protocol. spontaneous breathing trial in tube on flow.
most protocols.
Procedure for Ventilator Weaning—Continued

PE .
11. HH
Spontaneous Breathing Trial with T-Piece or Tracheostomy Collar
1. HH
2. PE
3. Position patient for optimal Head of the bed elevated 45
respiratory muscle function and degrees provides optimal support
comfort. of respiratory muscle function.15
4. Remove patient from the Endotracheal tube or tracheostomy Monitor respiratory frequency,
ventilator and connect the removes the upper-airway breathing pattern, heart rate, cardiac
endotracheal tube or tracheostomy mechanisms that warm and rhythm, Sao2, and general
to a humidified, heated oxygen humidify inhaled gas. appearance of patient continuously
source with the same Fio2 as during the trial. General appearance
patient received via the ventilator includes skin color and temperature,
unless otherwise prescribed. presence of mottling or cyanosis,
Recommended time for perceived anxiety, degree of
spontaneous breathing trials is subjective work of breathing, and
30–120 minutes, driven by patient patient report of tolerance.
tolerance.25,49 (Level B*)
5. Stay with the patient during the Patient and family require frequent Abort the trial if patient intolerance
trial. Provide coaching, accurate information about status develops. This type of weaning may
encouragement, and information and care. Frequent require repeated conditioning of
to the patient and family during encouragement and reminders respiratory muscles with
the trial. Celebrate successes, and that spontaneous breathing will subsequently longer trial periods, as
provide encouragement for those have different sensation from muscles become trained.59
who are not tolerant of the trial. mechanical ventilation may
increase tolerance of the trial.
6. At the end of the trial time, return Report the measures obtained As many as 80–90% of patients
patient to the mechanical before the trial, the length and require simple weaning most
ventilator at the prior settings. tolerance of the trial to the care commonly with spontaneous
team. breathing trials, and can be
extubated after the initial weaning
trial. For those who require difficult
or prolonged weaning, gradual
reduction of support strategies like
PS or CPAP are more common.58
PE .
8. HH
Spontaneous Breathing Trial and Gradual Reduction of Support with CPAP or PS
1. HH
2. PE
3. Position patient for optimal Head of the bed elevated 45
respiratory muscle function and degrees provides optimal support
comfort. of respiratory muscle function.15

Procedure for Ventilator Weaning—Continued

4. Set the ventilator to the prescribed Patient will remain connected to Monitor respiratory frequency,
level of CPAP or PS and the ventilator, but all ventilation breathing pattern, heart rate, cardiac
spontaneous ventilation. Typical will be patient-initiated/ rhythm, Sao2, and general
levels of CPAP are 5–8 cm H2O; spontaneous. CPAP will maintain appearance of patient during the
PS may begin with higher levels a positive pressure throughout trial.
of support and be titrated the ventilatory cycle; PS will Use caution with high levels of PS,
downward according to patient provide inspiratory gas with the because patients who have
tolerance. set level of inspiratory support. obstructive lung disease may
The initial PS level should be develop alveolar overdistension and
that which attains a spontaneous air trapping.
respiratory rate of ≤20 breaths/
min with the absence of
accessory muscle use, and a Vt
of 6–10 mL/kg ideal body
weight.
5. Stay with the patient during the Patient and family require frequent Abort the trial if patient intolerance
trial. Provide coaching, accurate information about status develops. This type of weaning
encouragement, and information and care. Frequent increases endurance of respiratory
to the patient and family during encouragement and reminders muscles as levels of support are
the trial. Celebrate successes and that spontaneous breathing with decreased. Full ventilatory support
provide encouragement for those these modes will have different should be provided at night to
who do not tolerate the trial. sensations from mechanical promote rest, especially early in the
ventilation may increase weaning process.
tolerance of the trial. If the endotracheal or tracheostomy
cuff is insufficiently inflated, the PS
cycle-off mechanism may not
activate (i.e., the ventilator cycles
off when it senses that flow is one
fourth the original flow). If this
decrement of flow is not recognized,
the result is an inappropriately long
inspiratory time.
6. Depending on the facility Report the measures obtained As many as 80–90% of patients
protocol, CPAP or PS level may before the trial, the length and require simple weaning, most
be titrated downward until a lower tolerance of the trial, and the commonly with spontaneous
limit is reached and tolerated by titration of CPAP or PS to the breathing trials, and can be
the patient. In patients who have care team. extubated after the initial weaning
difficult or require prolonged trial (see Procedures 5 and 6). For
weaning, gradual reduction in those who have difficult or require
support may be performed with an prolonged weaning, gradual
automatic ventilator system or reduction of support strategies like
with use of a nurse, physician, or pressure support or CPAP are more
respiratory therapist-driven common.58
protocol. (Level A*)5
PE .
8. HH

• Identification of the appropriate time for ventilator • Cardiac or respiratory distress or arrest during trial
weaning • Cardiac dysrhythmias that influence hemodynamic
• Effective transition from mechanical to spontaneous state during weaning
independent ventilation without complication • Pulmonary aspiration
• Ability to sustain adequate independent ventilation for • Ventilator-associated pneumonia
more than 48 hours • Respiratory muscle fatigue/failure
• Hypoxemia and/or hypercapnia with acidosis
• Dyspnea, anxiety and agitation
• Unsuccessful, demoralizing weaning trials

interventions.
1. Evaluate patient responses to Premature spontaneous breathing Abort trial with signs of intolerance
ventilation and weaning trials are associated with worse to prevent complications and
systematically. Be vigilant for patient outcomes.48 subsequently worse outcomes.
deviations from a homeostatic These signs and symptoms include
condition. development of anxiety, agitation,
tachypnea or bradypnea, thoracic
abdominal asynchrony, worsening
dyspnea, altered level of
consciousness, reduction in Pao2,
Spo2, and Sao2, increase in
end-tidal CO2 or Paco2,
tachycardia or bradycardia,
cardiac dysrhythmias, and/or
change in blood pressure or heart
rate more than 20% from baseline.
Documentation
• Patient and family education provided before and • Duration of trial and measured criteria per protocol at
during ventilator weaning the end of trial time
• Individualized goals set by multidisciplinary team and • Titration of support level, decreases in support level
patient for weaning timing, and tolerance of titration
• Method and procedures used for weaning • Complications and unexpected outcomes
• Preweaning measures of readiness for spontaneous • Notification of multidisciplinary team
breathing trial per facility protocol • Extubation and subsequent status
• Patient physiological and psychological responses to
weaning trial

33 Weaning Mechanical Ventilation 285.e1
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Additional Readings
1. Damuth E, et al: Long-term survival of critically ill
patients treated with prolonged mechanical ventilation:
Unit II Cardiovascular System
Section Five Cardiac Emergencies
PROCEDURE
34
Automated External
Defibrillation
Kiersten Henry
PURPOSE: An automated external defibrillator (AED) is a defibrillator that, by
using a computerized detection system, analyzes cardiac rhythms, distinguishes
between rhythms that require defibrillation and rhythms that do not, and delivers a
series of preprogrammed electrical shocks. The automated external defibrillator is
designed to allow early defibrillation by physicians, advanced practice nurses, and
other healthcare professionals who have minimal or no training in rhythm
recognition or manual defibrillation.
PREREQUISITE NURSING normal rhythm. The longer the heart goes without circula-
KNOWLEDGE tion, the more depleted its energy stores. In a heart with
depleted energy stores, defibrillation is more likely to
• Defibrillation is the therapeutic use of an electrical shock result in asystole because no fuel remains to support spon-
that temporarily stops or stuns an irregularly beating heart taneous depolarization or myocardial contraction. Effec-
and allows the spontaneously repolarizing pacemaking tive CPR can supply the needed oxygen and energy
cells within the heart to recover and resume more normal substrates to the heart cells and allow them to return to a
electrical activity. Ventricular fibrillation (VF) and ven- perfusing rhythm.1,6
tricular tachycardia (VT) are the only two rhythms recog- • Three stages of VF are seen in cardiac arrest. The first
nized as shockable by an automated external defibrillator phase is the electrical phase. During this phase, which is
(AED; Fig. 34-1). considered the first 4 to 5 minutes of VF, defibrillation is
• Time is the major determining factor in the success rates most likely to be effective, and the sooner the shock can
of defibrillation. In out-of-hospital cardiac arrests, for be delivered the more likely it is to work. During the next
every minute defibrillation is delayed the chance of 5 to 10 minutes after VF occurs, the hemodynamic or
success decreases by 7% to 10%. When used in conjunc- circulatory phase, a brief period of CPR may “prime the
tion with effective CPR, the decrease in the likelihood of pump” and provide oxygen to the myocardial cells,
success is more gradual and averages 3% to 4% per improving the effectiveness of the defibrillation. The met-
minute. Effective CPR increases the amount of time in abolic phase starts 10 minutes after VF. During this phase,
which defibrillation may be effective.1,10 the cardiac cells have experienced global ischemia and
• Although defibrillation is the definitive treatment for VF energy depletion if no CPR has been initiated. CPR before
and pulseless VT, the use of the AED is not a stand-alone defibrillation is more likely to be successful and needs to
skill; it is used in conjunction with CPR. CPR should be be used in conjunction with advanced cardiac life support
started as soon as the patient is found to be pulseless and (ACLS) therapies.1,6
not stopped until the AED has been turned on, the pads • The AED is attached to the patient with adhesive electrode
have been attached, and the machine is prompting the pads. Through these pads, the rhythm is analyzed and a
provider to “stand clear” or “don’t touch the patient.”1,2 shock delivered, if indicated. If the AED recognizes VF
Immediate postshock CPR starting with compressions has or VT, visual and/or verbal prompts guide the operator to
been documented to lead to increased return of spontane- deliver a shock to the patient. The AED, not the operator,
ous circulation and increased cerebral survival,1,9 which is makes the decision about whether the rhythm is appropri-
why time is not taken to check for a rhythm or pulse after ate for defibrillation.
defibrillation. • The chance of the AED shocking inappropriately is
• Ventricular fibrillation depletes the cardiac energy stores minimal. There is a higher incidence of inappropriate
of adenosine triphosphate (ATP) more rapidly than a shocks with manual defibrillation than AED.8 The AED
286
34 Automated External Defibrillation 287
Figure 34-1 Automated external defibrillator

device. (Courtesy Philips Medical Systems.)
should be applied only to unresponsive, nonbreathing, quality CPR and rapid initiation of ACLS should remain
pulseless patients. To keep artifact interference to a a focus for in-hospital cardiac arrest.
minimum, the patient should not be touched or moved • Many manual defibrillators have analysis capability that
during the analysis time. allows a tiered response (i.e., individuals with different
• The mnemonic “PAAD” makes it easy for the rescuer to skill levels can use the same defibrillator).
remember the steps of operation of the AED: “P” for • Most AEDs in use in emergency response systems (EMS)
Power on, “A” for Attach the pads, “A” for clear to or in the hospital have a method of recording the event in
Analyze, and “D” for clear to Defibrillate. the form of rhythm strip printouts, audio and event record-
• Although AEDs are simple to use, healthcare personnel ing devices, data cards, or computer chips that can print
should be familiar with and technically competent in use an event summary.
of AEDs. • AEDs may or may not have monitor screens. AEDs
• The AED is recommended for use in children ages 1 with screens may allow the provider with rhythm
through 8 years if the child shows no signs of circulation. recognition skills to override the AED’s analysis and
Approximately 15% of children in arrest have initial VT recommendations.
or VF.5 Primary VF in children rapidly changes to asys- • An important safety issue an AED operator must address
tole; rhythm detection and rapid defibrillation in children is the possibility of inadvertently shocking a bystander or
is most effective. It is best if the defibrillator has a pedi- other provider at the scene. The operator must clear the
atric switch or pediatric pads, which have an attenuator in patient verbally and visibly by looking at the patient from
the cord that decreases the amount of energy delivered. If head to toe before and during the discharge of the energy
pediatric pads are not available, adult pads should be to the patient.
used.3–5 With use of adult pads, ensure that they do not • All defibrillation programs need to include training for the
touch each other because this may cause electrical arcing potential operators. Training should include psychomotor
and skin burns and divert defibrillation energy. The pads skills, troubleshooting, equipment maintenance, and inter-
should be at least 1 inch apart. If the pads cannot be fit on facing with ACLS providers. Physicians, advanced prac-
the child’s chest in a lead-II position, an anterior-posterior tice nurses, and other healthcare professionals have the
pad placement should be used.3 Never use pediatric pads responsibility to be familiar with the machine they will
on an adult or large child because the reduced energy use.
levels delivered by these electrodes may not be effective • When a resuscitation team (e.g., 911 responders, code
for treatment of VF. team, ACLS providers) arrives, the team assumes respon-
• The use of AEDs in prehospital settings has increased the sibility for monitoring and treating the patient.
success of defibrillation. The goal in the hospital should
be to have the ability to defibrillate any person in cardiac EQUIPMENT
arrest within 3 minutes or less of discovery. Placement of
AED units in nonmonitored patient units and in public use • AED
areas of a hospital decreases the time to defibrillation. The • Nonsterile gloves
largest study of in-hospital cardiac arrest found overall • Barrier device or airway management equipment (bag-
survival to discharge to be 15%.2,10 AEDs are also needed valve device with mask and oxygen)
in freestanding or ambulatory care settings. The majority • Hand towel
of in-hospital cardiac arrests do not involve VT/VF and • At least two sets of adult defibrillation pads and poten-
therefore are not indications for defibrillation.5,10 High tially one set of child defibrillation pads
288 Unit II Cardiovascular System
Additional equipment, to have available as needed, includes PATIENT ASSESSMENT AND

the following: PREPARATION
• Trauma shears (with ability to cut through clothing)
• Clippers or scissors Patient Assessment
• Extra electrocardiographic (ECG) paper • Establish that the patient is unresponsive, has absent
• Cardiac board or abnormal breathing, and is pulseless. Rationale:
AEDs are indicated for the treatment of patients in cardiac
PATIENT AND FAMILY EDUCATION arrest.
• Ensure that patient does not have a Do Not Resuscitate
• AEDs are used in emergency situations with limited or (DNR) order indicating CPR and defibrillation should
no time to educate the family about the equipment or not be performed. Gathering this information should not
the procedure. If family is present in the room during the delay delivery of care. Rationale: Honors previously
arrest, a staff member should be assigned to keep the determined patient wishes.
family informed of the procedures taking place and to
offer support. Rationale: Information provides education Patient Preparation
and support. • Remove clothing from the patient’s chest and ensure that
• After a sudden cardiac event, a patient may be discharged the skin is dry where the AED electrodes will be placed.
from an institution with an implanted cardioverter defi- Rationale: This action prepares the patient for placement
brillator or a wearable cardioverter defibrillator. In these of the AED electrodes and minimizes the risk of electrical
situations, patient and family education is essential and burns.
should include information regarding performing CPR. • Call for or obtain the AED; activate emergency response
Rationale: Education prepares the family for potential procedures for your setting. Rationale: Ensures the avail-
future procedures and emergencies. ability of the AED and additional emergency personnel.
Procedure for Automated External Defibrillation

1. HH
2. PE
3. Assess patient. Perform CPR until CPR helps keep the patient in a Place a backboard under the patient
the AED is available, turned on, shockable rhythm longer, who is in bed.
attached to the patient, and increasing the chance that
prompts you to clear the patient. defibrillation will be effective.
(If another provider is not nearby,
it is reasonable for the healthcare
provider to leave the patient and
quickly obtain the AED.)
4. The person in charge of the AED When the AED is on, the prompts Some AEDs automatically turn on
should: tell you what to do. when they are opened.
A. Open the AED. CPR should continue during the
B. Press the “on” button. next few steps.
C. Proceed with the next steps as
instructed by the AED.
5. Attach the electrode pads to the Moisture under the pads can decrease Patients ages 1–8 may use pediatric
patient’s bare, dry chest: the effectiveness of the contact of or adult pads, adult patients must
the electrode pads. Ensure the use adult-sized pads.2
appropriate-sized pads are used.
Procedure for Automated External Defibrillation—Continued

A. Place one pad below the right This placement ensures that the heart Placing an electrode pad on the
clavicle to the right of the is between the two electrode pads, sternum decreases effectiveness.
sternum and the other to the maximizing the current flow Bone blocks some of the energy.
left of the left nipple or through the heart. Even with proper placement, only
slightly lower than the nipple 4–25% of the delivered current
line with the center of the actually passes through the heart,
electrode pad on the so proper pad placement is
midaxillary line. The electrode crucial.1
pads have pictures that Polarity of the electrode pads is
indicate where to place them interchangeable for defibrillation
(see Fig. 34–1). purposes. However, if ECG
monitoring is being done, the
QRS complex is inverted if the
positive and negative pads are
reversed.
B. An alternative electrode pad This placement also ensures that the Ensure that the electrode pads are
position is anterior-posterior heart is between the two electrode directly above and below each
placement, where one pad is pads. other.
anterior over the left apex and
the other is posterior behind
the heart in the infrascapular
location.
6. Connect the cables from the Prepares equipment.
electrode pads to the AED.
7. Place the electrode pads firmly to The AED uses the electrode pads to
eliminate air pockets and to form monitor and to shock.
a complete seal. Good contact must be ensured to
defibrillate most effectively; air
pockets under the electrode can
cause electrical sparks and skin
burns.
A. Do not place the electrode Defibrillating over medication
pads over any medication or patches can cause burns and block
monitoring patches. Remove the transfer of energy from the
any medication pads from the electrode pad to the heart.
chest and wipe the chest clean.
B. For the patient with an Placement of electrode pads directly Some manufacturers recommend
implantable cardioverter over an implanted device can placing electrode pads 6 inches
defibrillator (ICD) or divert energy away from the heart away from the device generators
pacemaker, keep the electrode and can damage the device. if possible.
pads 3 inches from the device The ICD or pacemaker should be
generator. When possible for checked for possible damage to
these patients, anterior- the device after defibrillation.
posterior placement is Try to place the pads without
preferred. Other acceptable interrupting CPR. Pad placement
placement options are on the should not delay defibrillation.1,2
lateral chest wall on the right
and left sides (biaxillary) or
placement of the left pad in
the standard apical position
and the other pad on the right
or left upper back.

8. Once the electrode pads are in The machine needs to analyze the CPR must be stopped at this point.
place and plugged in, most AEDs rhythm to determine whether No one should be touching the
sense an electrical pattern and tell defibrillation is needed, and patient when the AED is
the operator to make sure no one touching the patient or doing CPR analyzing.
is touching the patient (“stand may give the machine a false
clear” or “don’t touch the message or delay the ability of the
patient”). AED to analyze the rhythm.
9. Wait for the AED to analyze the
patient’s rhythm:
A. If a shock is advised, clear the The AED has determined that the Use a mnemonic such as “I’m clear,
patient visually and verbally. rhythm is either VF or VT; you’re clear, we’re all clear,” and
defibrillation is needed. look at the patient while talking
Maintain safety for everyone around to ensure that no one is touching
the patient. Anyone touching the the patient.
patient or any conductive apparatus Another mnemonic is “Shocking on
that is in contact with the patient three. One, I am clear. Two, you
(e.g., stretcher frame, intubation are clear. Three, we are all clear.
stylet) when the energy is Shocking now.”
discharged receives some of that
shock.
B. If no shock is advised, restart If the patient is not in a shockable
CPR. rhythm and was pulseless, the only
treatment is CPR until the ACLS
team arrives.
10. Push the shock button or buttons, Delivering the shock quickly is the The energy levels for AEDs are
as prompted while looking at the best way to convert the fatal preset to an energy level
patient. rhythm. Most AEDs discharge the recommended by the
energy into the machine if the manufacturer. Some AEDs are
shock button is not pushed within fully automatic and deliver a
a preset time frame, usually about shock if needed without user
10–15 seconds. interaction. In this case the AED
warns the user to stand clear
before delivering the shock.
11. Immediately restart CPR, Providing immediate postshock Change compressors every 2
beginning with compressions. compressions increases the minutes to ensure effectiveness of
Continue CPR for 2 minutes, probability of return of CPR. Performing chest
approximately five cycles of 30 spontaneous circulation.1,2,9 compressions is tiring, and
compressions to two breaths. If an effectiveness decreases after 2
advanced airway has been minutes.1
achieved, an asynchronous breath
should be delivered 10 times/
min.9 (Level D*)
12. After 2 minutes, the AED prompts Checks to see whether the initial Ensure that no one touches the
the physicians, advanced practice shock was effective or whether the patient during the analysis. A
nurses, and other healthcare patient needs to be defibrillated good time to change compressors
professionals “stand clear” or again. is during the analysis pause.
“don’t touch the patient” to allow
it to analyze the rhythm,
determining whether the rhythm
remains shockable.
13. Repeat steps 8-11 if prompted to If the patient remains in a shockable Be sure to clear the patient for
shock again. rhythm, CPR and defibrillation are analysis and shocking.
most likely to be effective in return
of spontaneous circulation.

14. If you receive a “no shock Continues emergency intervention. If a change occurs in the patient’s
advised” message, resume CPR condition, check a pulse. If a
until the ACLS team arrives and pulse is found, check for adequate
the rhythm can be checked, or the breathing. If adequate breathing is
patient begins to move.7 not found and the patient has a
pulse, provide rescue breaths at a
rate of one every 5–6 seconds
with a bag-valve device with
mask and oxygen if available.
15. Once the patient has a pulse, Determines the patient’s response to
obtain vital signs and assess level CPR and use of the AED.
of consciousness.
16. Transfer the patient to a critical Continues assessment and medical
care unit. intervention.
17. Ensure that AED is cleaned and Prepares emergency equipment for
electrodes are replaced. future use.
18. Discard PE and used supplies in Reduces the transmission of
appropriate receptacle. microorganisms; Standard
Precautions.
19. HH

• Restoration of perfusing rhythm • Operator or bystander shocked
• Restoration of spontaneous respirations • Skin burns
• Transfer to a critical care unit for postresuscitation • Pain
care • Unsuccessful resuscitation; death

interventions.
1. Monitor vital signs at least every Determines hemodynamic stability. • Abnormal vital signs
15 minutes until stable. • Dysrhythmias
2. Monitor ECG rate and rhythm. A patient with VF or VT is at risk • Dysrhythmias
for additional dysrhythmias.
3. Administer antidysrhythmic and Antidysrhythmic medications may • Dysrhythmias
vasopressor medications as prevent the risk of additional • Hypotension
prescribed. dysrhythmias. Vasopressors may
be required to maintain adequate
blood pressure in patients who
are hypotensive postarrest.
5. Initiate induced hypothermia Reduces the incidence of hypoxic
postarrest if prescribed. brain injury after cardiac arrest.
Documentation
• Type of arrest (witnessed or not witnessed) • Preshock and postshock rhythms
• Time from patient collapse to first shock (only if • Any complications
witnessed) • Assessment after resuscitation (if applicable)
• CPR information (including start and stop times) • Pain assessment, interventions, and effectiveness
• CPR performed before AED application: yes/no • Unexpected outcomes
• Time of application of AED • Nursing interventions
• Time of first shock • Patient and family education
• Number of times patient was defibrillated

34 Automated External Defibrillation 292.e1
References 7. Kleinman ME, et al: 2015 American Heart Association

1. American Heart Association: ACLS resource text: For guideline update for cardiopulmonary resuscitation and
instructors and experienced providers, Dallas, 2011, emergency cardiovascular care: Part 5: Adult basic life
American Heart Association. support and cardiopulmonary resuscitation quality.
2. American Heart Association: BLS for healthcare Circulation 132(s2):s414–s435, 2015.
providers, Dallas, 2011, American Heart Association. 8. Kramer-Johnson J, et al: Pauses in chest compression and
3. American Heart Association: Pediatric advanced life inappropriate shocks: A comparison of manual and
support: provider manual, Dallas, 2011, American Heart semi-automatic defibrillation attempts. Resuscitation
Association. 73(2):212–220, 2007.
4. Atkins DL, et al: 2015 American Heart Association 9. Link MS, et al: 2015 American Heart Association
guideline update for cardiopulmonary resuscitation and guideline update for cardiopulmonary resuscitation
emergency cardiovascular care: Part 11: Pediatric Basic and emergency cardiovascular care: Part 7: Adult
Life Support and Cardiopulmonary Resuscitation Quality. Advanced Cardiovascular Life Support. Circulation
Circulation 132(s2):s519–s525, 2015. 132(s2):s444–s464, 2015.
5. Chan PS, et al: Automated external defibrillators and 10. Morrison LJ, et al: Strategies for improving survival
survival after in-hospital cardiac arrest. JAMA after in-hospital cardiac arrest in the United States:
304(19):2129–2136, 2010. 2013 consensus recommendations: A consensus statement
6. Ewy GA: Cardiocerebral resuscitation, defibrillation, and from the American Heart Association. Circulation
cardioversion. In Jeremias A, Brown DL, editors: Cardiac 127:1538–1563, 2013.
intensive care, Philadelphia, 2010, Elsevier.
PROCEDURE
35
Cardioversion
Cynthia Hambach
PURPOSE: Cardioversion is the therapy of choice for terminating
hemodynamically unstable tachydysrhythmias. It also may be used to convert
hemodynamically stable atrial fibrillation or atrial flutter into normal sinus rhythm.
PREREQUISITE NURSING placed on an anticoagulant, and the cardioversion is per-

KNOWLEDGE formed once anticoagulation is achieved. Anticoagulation
therapy should be continued for 4 weeks after cardiover-
• Understanding the anatomy and physiology of the cardio- sion because of the possibility of delayed embolism.2
vascular system, principles of cardiac conduction, basic • Elective cardioversion also may be used in patients with
dysrhythmia interpretation, and electrical safety is needed. hemodynamically stable ventricular or supraventricular
• Basic and advanced cardiac life support knowledge and tachydysrhythmias unresponsive to medication therapy.3
skills are essential. • If time and clinical condition permit, the patient should
• Clinical and technical competence in the use of the defi- be given a combination of analgesia and sedation to mini-
brillator is important. mize discomfort.4,8,9
• Synchronized cardioversion is recommended for termina- • Defibrillators deliver energy or current in waveform pat-
tion of those dysrhythmias that result from a reentrant terns. Delivered energy levels may differ among the
circuit, which include unstable supraventricular tachycar- various defibrillators and waveforms. Various types of
dia, atrial fibrillation, atrial flutter, and unstable monomor- monophasic waveforms are used in older defibrillators.
phic ventricular tachycardia with a pulse.3,4,8 Biphasic waveforms have been designed more recently
• The electrical current delivered with cardioversion depo- and are used currently in implantable cardioverter defibril-
larizes the myocardial tissue involved in the reentrant lators (ICDs), automated external defibrillators, and
circuit. This depolarization renders the tissue refractory; manual defibrillators sold at the present time.
thus, it is no longer able to initiate or sustain reentry. A ❖ Monophasic waveforms deliver energy in one direc-
countershock synchronized to the QRS complex allows tion. The energy travels through the heart from one pad
for the electrical current to be delivered outside the heart’s or paddle to the other.3
vulnerable period in which a shock can precipitate ven- ❖ Biphasic waveforms deliver energy in two directions.
tricular fibrillation. This synchronization occurs a few The energy travels through the heart in a positive direc-
milliseconds after the highest part of the R wave but tion and then reverses itself and flows back through the
before the vulnerable period associated with the T wave.3,4,8 heart in a negative direction.3
• Cardioversion may be implemented in the patient with an ❖ Due to their increased success in terminating dysrhyth-
emergent condition. The aforementioned dysrhythmias mias, defibrillators with biphasic waveforms are pre-
are converted with synchronized cardioversion when the ferred for the treatment of atrial and ventricular
patient develops symptoms from the rapid ventricular dysrhythmias.6
response. Symptoms may include hypotension, acutely • When performing synchronized cardioversion, use energy
altered mental status, signs of shock, ischemic chest pres- recommendations as specified by the American Heart
sure, and acute heart failure.4,8 Association (Table 35-1).3,8
• Elective cardioversion may be used to convert hemody-
namically stable atrial fibrillation or atrial flutter into EQUIPMENT
normal sinus rhythm. When used to convert atrial fibril-
lation or atrial flutter, anticoagulation therapy is consid- • Defibrillator/monitor with electrocardiogram (ECG) oscil-
ered for 3 weeks before cardioversion to decrease the risk loscope/recorder capable of delivering a synchronized
of thromboembolism. Anticoagulation therapy may not be shock
necessary if atrial fibrillation or atrial flutter has been • ECG cable
present for less than 48 hours, depending on thromboem- • Self-adhesive defibrillation pads connected directly to the
bolic risk. A physician, advanced practice nurse, or other defibrillator or conductive gel, paste, or prepackaged
healthcare professional may choose to perform a trans- gelled conduction pads to be used with defibrillator
esophageal echocardiogram to exclude the possibility of paddles
an atrial thrombus before cardioversion for patients at • Intravenous sedative and/or analgesic pharmacological
high risk for thromboembolism. The patient is immediately agents as prescribed
293
TABLE 35-1 American Heart Association PATIENT ASSESSMENT AND

Energy Level PREPARATION
Recommendations for Patient Assessment
Treatment of • Assess the patient’s ECG results for tachydysrhythmias,
Tachydysrhythmias including paroxysmal supraventricular tachycardia, atrial
Tachydysrhythmia Initial Dose fibrillation, atrial flutter, and monomorphic ventricular
tachycardia with a pulse, which could require synchro-
Unstable atrial fibrillation 200 J (monophasic) nized cardioversion. Rationale: Tachydysrhythmias may
120–200 J (biphasic) precipitate deterioration of hemodynamic stability.4,8
Unstable monomorphic 100 J (monophasic or • Assess the patient’s vital signs and any associated symp-
ventricular tachycardia biphasic) toms of hemodynamic compromise with each significant
Other unstable supraventricular 50–100 J (monophasic or change in ECG rate and rhythm. Rationale: Deterioration
tachycardia or atrial flutter biphasic) of vital signs or the presence of associated symptoms
Unstable polymorphic Treat as ventricular fibrillation indicates hemodynamic compromise that could become
ventricular tachycardia with high-energy shock life threatening.4,8
(irregular form and rate) (defibrillation doses) • Assess for the presence or absence of peripheral pulses
and the patient’s level of consciousness. Rationale:
Note: Escalate subsequent doses as needed.
This baseline determination assists in the detection of
(From Sinz, E. et al, editors: Advanced cardiac life support provider manual.
Dallas, 2011, American Heart Association.)
cardioversion-induced peripheral embolization.1
• Obtain the patient’s serum potassium, magnesium, digi-
• Bag-valve device with mask and oxygen delivery talis levels (if taking this medication), and arterial blood
• Flow meter for oxygen administration, oxygen source gas results. Rationale: Electrolyte imbalances, acid-base
• Emergency suction and intubation equipment disturbances, and digitalis toxicity contribute significantly
• Blood pressure monitoring equipment to electrical instability and may potentiate postconversion
• Pulse oximeter dysrhythmias.1 Hypokalemia should be corrected to
• Intravenous infusion pumps prevent postconversion dysrhythmias. Although cardio-
Additional equipment, to have available as needed, includes version is considered a safe practice in patients taking
the following: digitalis glycosides, the medication is generally discontin-
• Cardiac board ued on the day of cardioversion.
• Emergency medications
• Emergency transcutaneous pacing equipment Patient Preparation
• Verify correct patient with two identifiers. Rationale:
PATIENT AND FAMILY EDUCATION Before performing a procedure, the nurse should ensure
• Assess patient and family understanding of the etiology intervention.
of the dysrhythmia. Rationale: This assessment deter- • Ensure that the patient and family understand prepro-
mines the patient and family understanding of the condi- cedural teaching. Answer questions as they arise, and
tion and additional educational needs. reinforce information as needed. Rationale: This com-
• Explain the procedure to the patient and family. Ratio- munication evaluates and reinforces understanding of
nale: This explanation decreases anxiety and promotes previously taught information.
patient cooperation. • Ensure that informed consent is obtained. Rationale:
• Discuss the use of sedative and analgesic pharmacology Informed consent protects the rights of the patient and
agents. Rationale: This discussion will help alleviate the makes competent decision making possible for the patient;
patient’s fear and anxiety about receiving an electrical however, in emergency circumstances, time may not
shock. allow the consent form to be signed.
• Explain the signs and symptoms of hemodynamic com- • Perform a preprocedure verification and time out if non-
promise associated with the preexisting cardiac dysrhyth- emergent. Rationale: Ensures patient safety.
mias to the patient and family. Rationale: This explanation • Obtain 12-lead ECG. Rationale: Provides baseline data.
enables the patient and family to recognize when the • Give the patient nothing by mouth per institution policy.
patient needs to notify the nurse or physician. Rationale: Decreases the risk of aspiration.
• Evaluate and discuss with the patient the need for • Establish a patent intravenous access. Rationale: Medica-
long-term pharmacological support. Rationale: This dis- tion administration may be necessary.3,4,8
cussion allows the nurse to anticipate educational needs • Assist the patient to a supine position. Rationale: Supine
of the patient and family regarding specific discharge positioning provides the best access for procedure initia-
medications. tion, intervention, and management of possible adverse
• Assess and discuss with the patient the need for lifestyle effects.
changes. Rationale: The underlying pathophysiology may • Remove all metallic objects from the patient. Rationale:
necessitate alterations in the patient’s current lifestyle and Metallic objects are excellent conductors of electrical
require a plan for behavioral changes. current and could result in burns.
35 Cardioversion 295
• Remove transdermal medication patches from the remove hair. Hair may also be clipped if time is available.
patient’s chest and wipe area clean or ensure the defibril- Rationale: This action allows the electrodes to adhere to
lator pad or paddle does not touch the patch. Rationale: the chest.3,8
Transdermal medication patches may block the transfer • Remove loose-fitting dentures, partial plates, or other
of energy from the pad or paddle to the patient and mouth prostheses. Rationale: Removal decreases the risk
produce a chest burn when the pad or paddle is placed of airway obstruction during the procedure. Evaluate each
over it.3,8 individual situation (e.g., dentures may facilitate a tighter
• Ensure that the patient is in a dry environment and dry the seal for airway management).
patient’s chest if it is wet. Rationale: Water is a conductor • Preoxygenate the patient as prescribed and appropriate to
of electricity. If the patient and rescuer are in contact with the condition. Rationale: This will optimize oxygen deliv-
water, the rescuer may receive a shock or the patient ery until the patient is stabilized.4,8
may receive a skin burn. Also, if the patient’s chest is wet, • If time allows, consider administration of sedation and
the current may travel from one paddle across the water analgesia as prescribed. Rationale: These medications
to the other, resulting in a decreased amount of energy to provide amnesia and decrease anxiety and pain during the
the myocardium.8 procedure.4,8,9
• If the patient has a hairy chest, self-adhesive defibrillation • Maintain a patent airway with oxygenation throughout
pads may stick to the patient’s hair instead of the skin. the procedure. Rationale: Respiratory depression and
Apply pressure to pads to ensure contact. If this is not hypoventilation can occur after administration of seda-
working and it is an emergency, remove pads briskly to tives and analgesics.9
Procedure for Cardioversion

1. HH
2. PE
3. Connect the patient to the The R wave must be sensed by the
monitoring lead wires on the defibrillator to achieve
defibrillator. synchronization for
cardioversion.3,4,8
4. Select a monitor lead that displays Synchronized cardioversion must If a combination defibrillator/monitor
an R wave of sufficient amplitude sense the R wave to deliver the is not being used, a converter cable
to activate the synchronization current outside the heart’s must connect the monitor to the
mode of the defibrillator. In most vulnerable period.3,4,8 defibrillator to achieve
models, synchronization is achieved Lead II generally produces a large synchronization.
when the monitoring lead produces R wave.
a tall R wave. (Level M*)
5. Place the defibrillator in the Synchronization prevents the
synchronization mode. Ensure that random delivery of an electrical
the patient’s QRS complexes appear charge, which may cause
with a marker to signify correct ventricular fibrillation.3,4,8
synchronization of the defibrillator
with the patient’s ECG rhythm (Fig.
35-1). To confirm that the
synchronization has been achieved,
observe for visual flashing on the
screen or listen for auditory beeps.
If necessary, adjust the R wave gain
until the synchronization marker
appears on each R wave. (Level D*)

Figure 35-1 R-wave synchronization. Note the synchronization marker above each R wave.
(Courtesy Drexel University Center for Interdisciplinary Clinical Simulation and Practice.)
Procedure for Cardioversion—Continued

6. If the defibrillator is unable to Avoids a delay or failure of shock
distinguish between the peak of the delivery in the synchronized
QRS complex and the peak of the T mode.3,4,8
wave, as in polymorphic ventricular
tachycardia, proceed with
unsynchronized defibrillation (see
Procedure 36).
7. Apply self-adhesive defibrillation Reduces transthoracic resistance, Self-adhesive defibrillation pads
pads or prepare defibrillation enhancing electrical conduction connected directly to the
paddles with proper conductive through subcutaneous tissue.3,8 defibrillator have been found to be
agent. (Level D*) Minimizes erythema from the as effective as paddles.8
electrical current. Advantages of hands-free
cardioversion are safety and
convenience of use. These devices
can be used for monitoring, and
they allow for rapid delivery of a
shock if necessary. For that reason,
they are recommended for routine
use instead of standard paddles.8
Prepackaged gelled conductive pads
are available for placement in the
area of each paddle.3,8
Gel pads should be replaced if they
appear to be drying out or as per
manufacturer recommendations.
Conductive gel should be evenly
dispersed on the defibrillator
paddles and should adequately
cover the surface.
Be careful not to smear gel between
paddles because current may follow
an alternate pathway over the chest
wall and avoid the heart. It may
also cause a potential for a spark,
causing a fire hazard. For that
reason, gel pads are preferred.3

8. Follow these steps for pad or
paddle placement:
A. Place one pad or paddle at the Cardioversion is achieved by Most pads or paddles are 8–12 cm in
heart’s apex, just to the left of passing an electrical current diameter.3
the nipple at the midaxillary through the cardiac muscle mass Avoid placing pads or paddles over
line. Place the other pad or to restore a single source of lead wires or implanted devices
paddle just below the right impulse generation; this pathway (ports, pacemakers, ICD).3,8
clavicle to the right of the maximizes current flow through
sternum (Fig. 35-2). the myocardium.3,8
A Figure 35-2 Paddle placement and current flow in A, monophasic

defibrillation and B, biphasic defibrillation. (From Lewis SL, et al:
Medical-surgical nursing: Assessment and management of clinical prob-
lems, ed 9, St Louis, 2014, Mosby.)
B. In women, the apex pad or Placement over a woman’s breast

paddle is placed at the fifth to should be avoided to reduce
sixth intercostal space with the transthoracic resistance.
center of the pad or paddle at
the midaxillary line.

C. Anterior-posterior placement All methods of pad or paddle
also may be used. placement are effective.3,8
i. Self-adhesive defibrillation
pads are used for this
approach.
ii. The anterior pad is placed in
the anterior left precordial
area, and the posterior pad is
placed posteriorly behind the
heart in the right or left
infrascapular area (Fig. 35-3).
iii. An alternative approach is to
place the anterior pad in the
right infraclavicular area and
the posterior pad in the left
infrascapular position.
Figure 35-3 Anterior-posterior place-

ment of self-adhesive defibrillation pads.
A, Anterior pad placed over the left precor-
dium. B, Posterior pad placed under the
right scapula.
A B
D. In a patient with a permanent Cardioversion over an implanted Do not place the pad or paddle over
pacemaker, do not place pads or pacemaker may impair passage of the pulse generator and lead wire.3,8
paddles directly over the pulse current to the patient and may Anterior-posterior placement is also
generator. cause the device to malfunction suggested.3
or become damaged.3,8 The pacemaker should be assessed
after any electrical countershock.
Standby emergency pacing equipment
should be available should
pacemaker failure occur.
E. Pad or paddle placement in the Cardioversion over an ICD may Do not place the pad or paddle over
patient with an ICD is the same impair passage of current to the the pulse generator and lead wire.3,8
as standard paddle placement patient and cause the device to Anterior-posterior placement is also
for cardioversion (see Fig. malfunction or become suggested.3
35-2). Pads or paddles should damaged.3,8 The ICD should be checked after
not be placed over the device. external countershock.
(Level D*) If the ICD is delivering shocks to the
patient, wait 30–60 seconds before
defibrillating the patient with the
manual defibrillator.3, 8
9. Ensure that the defibrillator cables Allows cardioversion to occur
are positioned to allow for adequate without excessive tension on the
access to the patient. cables.

10. Turn on the ECG recorder for a Establishes a visual recording of the
continuous printout. patient’s current ECG status and
response to intervention. Provides
a permanent record of the
patient’s response to intervention.
11. Charge the defibrillator as The defibrillator is charged with the
prescribed or in accordance with lowest energy level necessary to
the recommendations of the convert the tachydysrhythmia.3,8
American Heart Association (see
Table 35-1). (Level D*)
12. Disconnect the oxygen source Decreases the risk of combustion in Arcing of electrical current in the
during actual cardioversion. the presence of electrical current.3 presence of oxygen could
precipitate an explosion and
subsequent fire hazard.3
13. State “all clear” or similar wording Maintains safety to caregivers Use a mnemonic such as “I’m clear,
three times, and visually verify that because electrical current can be you’re clear, we’re all clear” and
everyone is clear of contact with conducted from the patient to look at the patient while talking to
the patient, bed, and equipment. another individual if contact ensure that no one is touching or is
occurs. in contact with the patient.
When using hands-free cardioversion,
take special care to clear other
personnel from patient contact
because they do not have the visual
cue of the paddles being placed on
the patient’s chest.
14. Verify that the defibrillator is in the Synchronization prevents the
synchronization mode and that the random delivery of an electrical
patient’s QRS complexes appear charge, which may potentiate
with a marker to signify correct ventricular fibrillation.3,8
synchronization of the defibrillator
with the patient’s ECG rhythm (see
Fig. 35-1). (Level D*)
15. When using self-adhesive hands- Depolarizes the cardiac muscle.8
free defibrillation pads, depress the
discharge button on the defibrillator
to deliver the charge. In the
synchronized mode, a delay occurs
before the charge is released, which
allows the sensing mechanism to
detect the QRS complex.
16. If using handheld paddles, apply Firm paddle pressure decreases This application of pressure is not
pressure to each paddle against the transthoracic resistance, thus necessary for defibrillator models
chest wall and depress both buttons improving the flow of electrical with hands-free and automatic
on the paddles simultaneously and current across the axis of the transthoracic impedance sensing/
hold until the defibrillator fires. heart.3 correction options built in.


17. Observe the monitor for conversion Simultaneous depolarization of the If unsuccessful in converting the
of the tachydysrhythmia, and assess myocardial muscle cells should rhythm, proceed with repeated
the patient’s carotid pulse. If a pulse reestablish a single source of energy recommendations (see
is palpated, assess the patient’s vital impulse generation.8 Table 35-1).
signs and level of consciousness. Ensure that the defibrillator is still in
the synchronization mode; many
defibrillators revert back to the
unsynchronized mode after
cardioversion.
Ventricular fibrillation may develop
after cardioversion. If so, deactivate
the synchronizer and follow the
procedure for defibrillation (see
Procedure 36).3,8
18. Clean the defibrillator, and remove Conductive gel accumulated on the
any gel from the paddles. defibrillator paddles impedes
surface contact and increases
transthoracic resistance.
19. If self-adhesive defibrillation pads Self-adhesive defibrillation pads Loss of adhesive integrity in self-
were used, evaluate the placement may crimp, crack, or fold with adhesive defibrillation pads may
and integrity of pads. loss of adhesiveness. occur in restless or diaphoretic
patients.
20. Remove PE and discard used Reduces the transmission of
supplies in appropriate receptacle. microorganisms; standard
precautions.
21. HH

• Reestablishment of a single source of impulse • Continued tachydysrhythmias
generation for the cardiac muscle • Ventricular fibrillation that progresses to
• Hemodynamic stability cardiopulmonary arrest
• Bradycardia
• Asystole
• Pulmonary edema
• Systemic embolization
• Respiratory complications
• Hypotension
• Pacemaker or ICD dysfunction
• Skin burns
• Pain

interventions.
1. Evaluate neurological status An altered level of consciousness may • Change in level of consciousness
before and after cardioversion. occur after hemodynamically unstable • Sensory or motor changes
Reorient as needed to person, dysrhythmias.5,8 Cerebral emboli may
place, and time. develop as a postprocedural
complication.1,2
2. Monitor pulmonary status Hemodynamically unstable • Dyspnea
before and after cardioversion. tachydysrhythmias may cause • Crackles
respiratory complications.4,8 • Rhonchi
Respiratory depression and hypoventilation • Slow shallow respirations
can occur after administration of • Decrease in oxygen saturation as
sedatives and analgesics.9 measured with pulse oximetry
3. Monitor cardiovascular status Dysrhythmias may develop after • Hypotension
(blood pressure, heart rate, cardioversion.5,7,8 • Supraventricular dysrhythmias
and rhythm) before and after • Ventricular dysrhythmias
cardioversion. • Bradycardia
• Asystole
4. Prepare for administration of Dysrhythmias may develop after • Supraventricular dysrhythmias
intravenous antidysrhythmic cardioversion.5,7,8 • Ventricular dysrhythmias
medications as prescribed. • Bradycardia
• Asystole
5. Assess for burns. Erythema at electrode sites may be seen • Skin burns
from local hyperemia in the current
pathway.
Skin burns may be minimized with use of
gel pads or placement of appropriate
paste or gel on the paddles.
Local cold application to electrode site
after cardioversion may decrease the
incidence and severity of burns and pain
at site.10
Documentation
• Patient and family education • Pain assessment, interventions, and effectiveness
• Signed informed consent • Printout of the ECG tracing depicting the cardiac
• Universal Protocol requirements, if nonemergent rhythm before and after cardioversion (before and
• Neurological, pulmonary, and cardiovascular after each attempt if more than one attempt is used)
assessment before and after cardioversion • Condition of the skin of the chest wall
• Interventions to prepare the patient for cardioversion • Unexpected outcomes and nursing interventions
• The joules used and the number of cardioversion • Serum electrolytes, digoxin level, and coagulation
attempts made laboratory results

35 Cardioversion 301.e1
References cardiovascular care, part 8: Adult advanced cardiovascular

1. American College of Cardiology/American Heart life support. Circulation 122(Suppl III):S729–S767, 2010.
Association Task Force on Practice Guidelines and the 5. American Heart Association: 2010 Guidelines for
European Society of Cardiology Committee for Practice cardiopulmonary resuscitation and emergency
Guidelines: American College of Cardiology/American cardiovascular care, part 9: Post-cardiac arrest care.
Heart Association/European Society of Cardiology 2006 Circulation 122(Suppl III):S768–S786, 2010.
guidelines for the management of atrial fibrillation. 6. American Heart Association: 2015 Guidelines update for
Circulation 114:e257–e354, 2006. cardiopulmonary resuscitation and emergency
2. American College of Cardiology/American Heart cardiovascular care, part 7: Adult advanced cardiovascular
Association Task Force on Practice Guidelines and the life support. Circulation 132(Suppl II):S444–S464, 2015.
Heart Rhythm Society: American Heart Association/ 7. Gronberg T, et al: Arrhythmic complications after
American College of Cardiology/Heart Rhythm Society electrical cardioversion of acute atrial fibrillation: The
2014 guidelines for the management of patients with atrial FinCV study. Europace 15:1432–1435, 2013.
fibrillation. JACC 64:2246–2280, 2014. 8. Sinz E, et al, editors: Advanced cardiac life support
3. American Heart Association: 2010 Guidelines for provider manual, Dallas, 2011, American Heart
cardiopulmonary resuscitation and emergency Association.
cardiovascular care, part 6: Electrical therapies: 9. Thomas SP, et al: Sedation for electrophysiological
Automated external defibrillators, defibrillation, procedures. Pacing Clin Electrophysiol 37:781–790,
cardioversion, and pacing. Circulation 122(Suppl 2014.
III):S706–S719, 2010. 10. Yava A, et al: Effectiveness of local cold application on
4. American Heart Association: 2010 Guidelines for skin burns and pain after transthoracic cardioversion.
cardiopulmonary resuscitation and emergency Emerg Med J 29:544–549, 2012.
PROCEDURE
36
Defibrillation (External)
Cynthia Hambach
PURPOSE: External defibrillation is performed to eradicate life-threatening
ventricular fibrillation or pulseless ventricular tachycardia. The goal for defibrillation
is to restore coordinated cardiac electrical and mechanical pumping action,
resulting in restored cardiac output, tissue perfusion, and oxygenation.
PREREQUISITE NURSING specific recommendation for the optimal energy level for
KNOWLEDGE biphasic waveform defibrillation. Biphasic energy recom-
mendations are device specific, using a variety of wave-
• Understanding the anatomy and physiology of the cardio- forms that are effective in terminating fatal dysrhythmias.
vascular system, principles of cardiac conduction, basic When using biphasic defibrillators, the American Heart
dysrhythmia interpretation, and electrical safety is needed. Association (AHA) recommends using the amount of
• Basic and advanced cardiac life support (ACLS) knowl- energy specified by the manufacturer (120–200 J). If oper-
edge and skills are necessary. ators are unaware of the effective biphasic dose, they
• Clinical and technical competence in the use of the defi- should use the maximal amount specified on the defibril-
brillator is needed. lator for the first shock, followed by escalating doses for
• Ventricular fibrillation and pulseless ventricular tachycar- subsequent shocks.4
dia (VT) are lethal dysrhythmias. Early emergent defibril- • A wearable cardioverter defibrillator (WCD) has been
lation is the treatment of choice to restore normal electrical developed for patients at high risk for sudden cardiac
activity and coordinated contractile activity within the arrest. Patient populations may include those who do not
heart.1,7 meet the current guidelines for an immediate ICD implan-
• The electrical current delivered with defibrillation depo- tation but who are at risk, those who may need protection
larizes the myocardium, terminating all electrical activity when ICD therapy is interrupted because of infection or
and allowing the heart’s normal pacemaker to resume lead malfunction, patients with nonischemic cardiomy-
electrical activity within the heart.7 Defibrillator pads or opathy, and those patients at high risk who are in need
paddles placed over the patient’s chest wall surface in the of a ventricular assist device or cardiac transplant. It
anterior-apex or anterior-posterior position maximize the may also be used to protect patients with syncope until a
current flow through the myocardium.1,7 definitive diagnosis is found. The WCD has the ability to
• Defibrillators deliver energy or current in waveform pat- detect and treat life-threatening tachydysrhythmias without
terns. Delivered energy levels may differ among different bystander support and allows the patient to ambulate freely.
defibrillators and waveforms. Various types of monopha- Results have shown that the WCD is a safe and effective
sic waveforms are used in older defibrillators. Biphasic method to terminate life-threatening dysrhythmias in this
waveforms have been designed more recently and are high-risk patient population.6 (See Procedure 41.)
used currently in implantable cardioverter defibrillators
(ICDs), automated external defibrillators, and manual EQUIPMENT
defibrillators sold at the present time.
• Monophasic waveforms deliver energy in one direction. • Defibrillator with electrocardiogram (ECG) oscilloscope/
The energy travels through the heart from one pad or recorder
paddle to the other.1 • ECG cable
• Biphasic waveforms deliver energy in two directions. The • Self-adhesive defibrillation pads connected directly to the
energy travels through the heart in a positive direction and defibrillator or conductive gel, paste, or prepackaged
then reverses itself and flows back through the heart in a gelled conduction pads to be used with defibrillator
negative direction. Investigators in both in-hospital and paddles
out-of-hospital studies concluded that lower energy bipha- • Bag-valve device with mask and oxygen delivery
sic waveform shocks had equal or higher success rates for • Flow meter for oxygen administration, oxygen source
eradicating ventricular fibrillation than monophasic defi- • Emergency suction and intubation equipment
brillators.1 Due to their increased success in terminating • Blood pressure monitoring equipment
dysrhythmias, defibrillators with biphasic waveforms are • Pulse oximeter
preferred for the treatment of atrial and ventricular dys- • End-tidal carbon dioxide (ETco2) monitoring equipment
rhythmias.4 More research is needed to determine a • Intravenous infusion pumps
302
36 Defibrillation (External) 303
Additional equipment, to have available as needed, includes • Assess vital signs. Rationale: Blood pressure and pulse
the following: are absent in the presence of ventricular fibrillation
• Cardiac board because of the loss of cardiac output.7
• Emergency transcutaneous pacing equipment Patient Preparation
• Verify correct patient with two identifiers. Rationale:
PATIENT AND FAMILY EDUCATION Before performing a procedure, the nurse should ensure
• Teaching may need to be performed after the procedure. intervention.
Rationale: If emergent defibrillation is performed in the • If family is present during the procedure, a staff member
face of hemodynamic collapse, education may be impos- should be assigned, if possible, to provide support and
sible until after the procedure has been performed. keep family informed. Rationale: By relaying informa-
• Assess patient and family understanding of the etiology tion and answering questions, a staff member may provide
of the dysrhythmia. Rationale: This assessment deter- support to ease family members’ anxiety during the
mines the patient and family understanding of the condi- procedure.
tion and guides additional educational needs. • If possible, ask a member of pastoral care or another
• Explain the procedure to the patient and the family. Ratio- designated healthcare provider to provide support for
nale: This explanation decreases anxiety and promotes family members during the procedure. Rationale:
understanding. Pastoral care team members or other members of the
• Explain to the patient and the family the signs and symp- healthcare team should be available to provide family
toms of hemodynamic compromise associated with pre- support.
existing cardiac dysrhythmias. Rationale: This explanation • Remove all metallic objects from the patient. Rationale:
enables the patient and the family to recognize when to Metallic objects are excellent conductors of electrical
contact the nurse or physician. current and could result in burns.
• Evaluate and discuss with the patient the need for long- • Remove transdermal medication patches from the patient’s
term pharmacological support. Rationale: This evaluation chest and wipe area clean or ensure the defibrillator pad
and discussion allows the nurse to anticipate educational or paddle does not touch the patch. Rationale: Transder-
needs of the patient and family regarding specific dis- mal medication patches may block the transfer of energy
charge medications. from the pad or paddle to the patient and produce a chest
• Assess and discuss with the patient the need for lifestyle burn when the pad or paddle is placed over it.1,7
changes. Rationale: Underlying pathophysiology may • Ensure that the patient is in a dry environment and dry the
necessitate alterations in the patient’s current lifestyle and patient’s chest if it is wet. Rationale: Water is a conductor
require a plan for behavioral changes. of electricity. If the patient and rescuer are in contact with
• Assess and discuss with the patient the need as applicable water, the rescuer may receive a shock or the patient
for an ICD. Rationale: Life-threatening dysrhythmias may receive a skin burn. Also, if the patient’s chest is wet,
may persist after initial defibrillation and pharmacological the current may travel from one paddle across the water
interventions.2 to the other, resulting in a decreased amount of energy to
• Assess and discuss with the patient the need as applicable the myocardium.7
for an emergency communication system. Rationale: • If the patient has a hairy chest, self-adhesive defibrilla-
People with recurrent life-threatening dysrhythmias are at tion pads may stick to the patient’s hair instead of the
risk for cardiac arrest.2 skin. Apply pressure to pads to ensure contact. If this
is not working, remove pads briskly to remove hair.
Rationale: This action allows the electrodes to adhere to
PATIENT ASSESSMENT AND the chest.1,7
PREPARATION • Initiate basic life support (BLS) if immediate defibrilla-
tion is not available. Rationale: Basic life support main-
Patient Assessment tains cardiac output to diminish irreversible organ and
• Assess the ECG monitor for tachydysrhythmias, includ- tissue damage.2,7
ing paroxysmal supraventricular tachycardia, atrial fibril- • Oxygenate the patient with a bag-valve device with mask
lation, atrial flutter, atrial tachycardia, and ventricular and 100% oxygen. Rationale: This will optimize oxygen
tachycardia. Rationale: Tachydysrhythmias often precede delivery until the patient is stabilized.2,4,7 Use of bag-mask
ventricular fibrillation, can be life-threatening, and can ventilation is more effective with two rescuers.2
precipitate deterioration of hemodynamic stability.7 • Place the defibrillator in the defibrillation mode. Ratio-
• Assess the ECG monitor for ventricular fibrillation. Ratio- nale: The defibrillation mode must be set to disperse the
nale: Ventricular fibrillation is life-threatening; if not ter- electrical charge randomly because the synchronization
minated immediately, death ensues.7 mode does not fire in the absence of a QRS complex.1,7
Procedure for Defibrillation (External)

1. HH
2. PE
3. Apply self-adhesive defibrillation Reduces transthoracic resistance, Self-adhesive defibrillation pads
pads or prepare defibrillation thus enhancing electrical connected directly to the
paddles with proper conductive conduction through defibrillator have been found to be
agent. (Level D*) subcutaneous tissue.1,7 as effective as paddles. Advantages
Minimizes erythema from the of hands-free defibrillation are
electrical current. safety and convenience of use.7
Self-adhesive defibrillation pads
decrease the risk of arcing, they can
be used for monitoring, and they
allow for fast delivery of a shock if
necessary. For that reason, the pads
are recommended for routine use
instead of standard paddles.7
Prepackaged gelled conductive pads
are available for placement in the
area of the defibrillation paddles.1,7
Gel pads should be replaced if they
appear to be drying out or as per
manufacturer recommendations.
Conductive gel should be evenly
dispersed on the defibrillator
paddles and should adequately
cover the surface.
Be careful not to smear gel between
paddles because current may follow
an alternate pathway over the chest
wall and avoid the heart. It may
also cause a potential for a spark,
causing a fire hazard. For that
reason, gel pads are preferred.1
4. Ensure that the defibrillator cables Allows defibrillation to occur
are positioned to allow for without excessive tension on
adequate access to the patient. cables.
5. Turn on the ECG recorder for Establishes a visual recording of
continuous printout. the patient’s current ECG,
verifies response to intervention,
and provides a permanent record
of the response to defibrillation.
6. Follow these steps for pad or
paddle placement:
A. Place one pad or paddle at the Defibrillation is achieved by Most pads or paddles range from
heart’s apex, just to the left of passing an electrical current 8–12 cm in diameter and are
the nipple at the midaxillary through the cardiac muscle mass effective.1
line. Place the other pad or to restore a single source of Avoid placing pads or paddles over
paddle below the right clavicle impulse generation. This lead wires or implanted devices
to the right of the sternum (see pathway maximizes current flow (ports, pacemakers, ICD).1,7
Fig. 35-2). through the myocardium.1,7
Procedure for Defibrillation (External)—Continued

B. In women, the apex pad or Placement over a woman’s breast
paddle is placed at the fifth to should be avoided to reduce
sixth intercostal space with the transthoracic resistance.
center of the pad or paddle at
the midaxillary line.
C. Anterior-posterior placement All methods of pad placement are
may also be used. effective.1,7
i. Self-adhesive defibrillation
pads are used for this
approach.
ii. The anterior pad is placed in
the anterior left precordial
area, and the posterior pad
is placed posteriorly behind
the heart in the right or left
infrascapular area (see
Fig. 35-3).
iii. An alternative approach is
to place the anterior pad in
the right infraclavicular area
and the posterior pad in the
left infrascapular position.
D. If the patient has a permanent Defibrillation over an implanted Do not place the pad or paddle over
pacemaker, do not place pads pacemaker may impair passage the pulse generator and lead wire.1,7
or paddles directly over the of current to the patient and Anterior-posterior placement is also
pulse generator. may cause the device to suggested.1
malfunction or become The pacemaker should be assessed
damaged.1,7 after any electrical countershock.
Standby emergency pacing equipment
should be available in case the
patient’s permanent pacemaker does
not function appropriately.
E. Pad or paddle placement in the Defibrillation over an implanted Do not place the pad or paddle over
patient with an ICD is the same ICD may impair passage of the pulse generator and lead wire.1,7
as standard placement for current to the patient and cause Anterior-posterior placement is also
defibrillation (see Fig. 35-2). the device to malfunction or suggested.1
Pads or paddles should not be become damaged.1,7 The ICD should be checked after
placed over the device. external countershock.
(Level D*) If the ICD is delivering shocks to the
patient, wait 30–60 seconds before
defibrillating the patient with the
manual defibrillator.1,7
7. Charge the defibrillator as The defibrillator is charged with AHA monophasic energy
prescribed or in accordance the lowest energy level needed recommendations for adults are for
with AHA recommendations. to convert ventricular fibrillation a 360-J shock.1,7
(Level D*) or pulseless ventricular When using biphasic defibrillators,
tachycardia.1,7 AHA recommends using the
amount of energy specified by the
manufacturer (120–200 J). If
operators are unaware of the
effective biphasic dose, they should
use the maximal amount specified
on the defibrillator for the first
shock, followed by escalating doses
for subsequent shocks.4


8. Disconnect the oxygen source Decreases the risk of combustion Arcing of electrical current in the
during actual defibrillation. in the presence of electrical presence of oxygen could
current.1 precipitate an explosion and
subsequent fire hazard.1
9. State “all clear” or similar wording Maximizes safety to self and Use a mnemonic such as “I’m clear,
three times and visually verify that caregivers because electrical you’re clear, we’re all clear,” and
all personnel are clear of contact current can be conducted from look at the patient while talking to
with the patient, bed, and the patient to another person if ensure that no one is touching or is
equipment. contact occurs. in contact with the patient.
With use of a hands-free
defibrillation, take special care to
clear other personnel from patient
contact because they do not have
the visual cue of the paddles being
placed on the patient’s chest.
10. Verify that the patient is still in Ensures that defibrillation is
ventricular fibrillation or pulseless necessary.
ventricular tachycardia.
11. When using self-adhesive hands- Depolarizes the cardiac muscle.7
free defibrillation pads, depress the
discharge button on the
defibrillator to deliver the charge.
In the defibrillation mode, an
immediate release of the electrical
charge occurs.
12. If using handheld paddles, apply Firm paddle pressure decreases This application of pressure is not
pressure to each paddle against the transthoracic resistance, thus necessary for defibrillator models
chest wall and depress both improving the flow of electrical with hands-free and automatic
buttons on the paddles current across the axis of the transthoracic impedance sensing/
simultaneously and hold until the heart.1 correction options built in.
defibrillator fires.
13. Administer 2 minutes CPR is needed for 2 minutes to
(approximately five cycles) of provide some coronary and
CPR. (Level D*) cerebral perfusion until adequate
heart function resumes.1,7
14. Observe the monitor for Simultaneous depolarization of the If using ETco2 monitoring, observe
conversion of the dysrhythmia. If a myocardial muscle cells should for capnography waveform that
stable rhythm is noted, assess for reestablish a single source of indicates return of spontaneous
the presence of a carotid pulse. If a impulse generation.7 circulation (ROSC).2
pulse is palpated, assess vital signs
and level of consciousness.
15. If the patient is still in ventricular Immediate action increases the A vasopressive medication such as
fibrillation or pulseless VT, chance of successful subsequent epinephrine may be given during
continue CPR and immediately depolarization of cardiac CPR to improve cardiac output and
charge the paddles to 360 J muscle.1,7 blood pressure.4 It has been proven
(monophasic) or device-specific to assist with initial resuscitation
value (escalating; biphasic) and although there is no evidence that it
repeat Steps 8–14. (Level D*) improves the rate of survival to
hospital discharge.2,7

16. If the second attempt is Immediate action increases the An antidysrhythmic medication such
unsuccessful, continue CPR and chance of successful subsequent as amiodarone or lidocaine may be
immediately charge the paddles to depolarization of cardiac given during CPR to assist in
360 J (monophasic) or device- muscle.1,7 terminating the dysrhythmia. There
specific value (escalating; is no evidence that the use of an
biphasic) and repeat Steps 8–14. antidysrhythmic medication will
(Level D*) increase long-term survival or
survival with a positive neurologic
outcome after cardiac arrest.4
17. If the third attempt is unsuccessful, Actions necessary to maintain the BLS must be continued throughout
continue with ACLS. (Level D*) delivery of oxygenated blood to resuscitation.2,7
vital organs.2,7
18. Obtain vital signs and assess level Determines patient response to
of consciousness. defibrillation.
19. Transfer patient to a critical care Continues assessment and medical
unit (if not there already). intervention.7
20. After the emergency has ended, Prepares emergency equipment for
clean the defibrillator and remove future use.
the gel.
21. If the self-adhesive defibrillation Self-adhesive defibrillation pads Loss of adhesive integrity in self-
pads were used, evaluate the may crimp, crack, or fold with adhesive defibrillator pads can
placement and integrity of the loss of adhesiveness. occur in restless or diaphoretic
pads. patients.
22. Remove PE and discard used Reduces transmission of
supplies in appropriate receptacle. microorganisms; standard
precautions.
23. HH

• Reestablishment of a single source of impulse • Continued ventricular fibrillation
generation for the cardiac muscle • Continued cardiopulmonary arrest
• Hemodynamic stability • Asystole
• Myocardial infarction (MI)
• Respiratory complications
• Cerebral anoxia and brain death
• Systemic embolization
• Hypotension
• Pacemaker or ICD dysfunction
• Skin burns
• Pain

interventions.
1. Evaluate neurological status Altered level of consciousness may • Change in level of consciousness
before and after defibrillation. occur after cardiac arrest.3,7
Reorient as necessary to person,
place, and time.
2. If patient’s neurological status is Therapeutic hypothermia has been • Core temperature >32–36°C
decreased (unable to follow shown to improve neurological during treatment protocol
verbal commands), prepare for recovery for patients post cardiac
procedures to achieve targeted arrest.3,5,7
temperature management.
Maintain patient’s temperature
between 32°C to 36°C for 24
hours. Follow institution
standards.
3. Monitor the patient’s airway and Goal is to support cardiac and • Change in respirations
pulmonary status after pulmonary function to optimize • Change in breath sounds
defibrillation. tissue perfusion to vital organs, • Decreased oxygen saturation as
especially the brain.3,7 measured with pulse oximetry
• Abnormal arterial blood gas results
4. Prepare for insertion of an Hyperventilation of the patient should • Abnormal Paco2 results
advanced airway if patient be avoided as it may cause adverse • Abnormal ETco2 results
remains unconscious or hemodynamic effects secondary to
unresponsive and administer increased thoracic pressure. It may
10–12 breaths/min to achieve a also decrease Paco2 leading to
Paco2 of 35–45 mm Hg or an decreased cerebral blood flow.3,7
ETco2 of 30–40 mm Hg.
Mechanical ventilatory support
may be necessary.
5. Administer sedation and Intubation and mechanical ventilation • Continued pain or anxiety despite
analgesia in mechanically can cause the patient pain and interventions
ventilated patients as prescribed. anxiety.3
6. Administer oxygen therapy as Goal is to administer enough oxygen • Sao2 <94%
prescribed. to maintain oxygen saturation
(Sao2) ≥94% and to avoid oxygen
toxicity.3,7
7. Monitor vital signs immediately Vital signs should stabilize after • Hypotension
after defibrillation and at least achieving a normal heart rate and • Hypertension
every 15 minutes until stable. rhythm. • Tachycardia
• Bradycardia
8. Administer intravenous fluids or Goal is a systolic blood pressure • Hypotension
vasopressive medications to ≥90 mm Hg or mean arterial • Hypertension
support cardiac output and pressure ≥65 mm Hg.3,5,7
maintain normal blood pressure
as prescribed.
9. Continue to monitor the ECG Postdefibrillation dysrhythmias may • Dysrhythmias
after defibrillation. occur. Administration of
antidysrhythmic medications may
be prescribed.2,4,7
10. Monitor electrolyte levels. Abnormal electrolyte levels may have • Abnormal electrolyte results
contributed to the development of
ventricular dysrhythmias.
11. Obtain a 12-lead ECG and Cardiac arrest may be caused by • ECG changes
prepare for emergent coronary acute coronary syndrome.3,5
angiography if warranted.

12. Assess for burns. Erythema at electrode sites may be • Skin burns
seen from local hyperemia in the
current pathway.
Skin burns may be minimized with
use of gel pads or placement of
appropriate paste or gel on the
paddles.
Local cold application to electrode
site after defibrillation may
decrease the incidence and severity
of burns and pain at the site.8
13. Consider other possible causes Interventions may be aimed at
for ventricular fibrillation or correcting underlying
pulseless ventricular pathophysiology and preventing the
tachycardia. recurrence of lethal dysrhythmias.3,7
14. Closely monitor neurological The goal is to return patients to their • Changes in level of consciousness
status. precardiac arrest neurological • Changes in neurological
function.3,7 examination
Documentation
• Neurological, pulmonary, and cardiovascular • Pain assessment, interventions, and effectiveness
assessments before and after defibrillation • Patient response to defibrillation
• Interventions to prepare the patient for defibrillation • Condition of skin of the chest wall
• The joules (J) used and the number of defibrillation • Unexpected outcomes and nursing interventions
attempts made • Patient and family education
• Printout of ECG tracings that depict the cardiac
rhythm before and after defibrillation

36 Defibrillation (External) 309.e1
References cardiovascular care, part 7:adult advanced cardiovascular

1. American Heart Association: 2010 Guidelines for life support. Circulation 132(Suppl II):S444–S464, 2015.
cardiopulmonary resuscitation and emergency 5. American Heart Association: 2015 Guidelines update for
cardiovascular care, part 6: electrical therapies: automated cardiopulmonary resuscitation and emergency
external defibrillators, defibrillation, cardioversion, and cardiovascular care, part 8:post-cardiac arrest care.
pacing. Circulation 122(Suppl III):S706–S719, 2010. Circulation 132(Suppl I):S465–S482, 2015.
2. American Heart Association: 2010 Guidelines for 6. Klein HU, et al: Risk stratification for implantable
cardiopulmonary resuscitation and emergency cardioverter defibrillator therapy: The role of the wearable
cardiovascular care, part 8:adult advanced cardiovascular cardioverter-defibrillator. Eur Heart J 34:2230–2242,
life support. Circulation 122(Suppl III):S729–S767, 2010. 2013.
3. American Heart Association: 2010 Guidelines for 7. Sinz E, et al, editors: Advanced cardiac life support
cardiopulmonary resuscitation and emergency provider manual, Dallas, 2011, American Heart
cardiovascular care, part 9:post-cardiac arrest care. Association.
Circulation 122(Suppl III):S768–S786, 2010. 8. Yava A, et al: Effectiveness of local cold application on
4. American Heart Association: 2015 Guidelines update for skin burns and pain after transthoracic cardioversion.
cardiopulmonary resuscitation and emergency Emerg Med J 29:544–549, 2012.
PROCEDURE
37
Defibrillation (Internal) Perform
Marion E. McRae
PURPOSE: The purpose of internal defibrillation is to deliver electrical current
directly to the epicardial surface of the heart via sterile internal defibrillation paddles
when a shockable rhythm is present.
PREREQUISITE NURSING • Large sterile suction catheter (Yankauer), sterile tubing,

KNOWLEDGE suction canisters, suction regulator, and suction source
• Sterile internal paddles (ensure compatibility with the
• Cardiac arrest after cardiac surgery, which occurs in about defibrillator). Adult internal paddles are usually 5 to
0.7% to 2.9% of patients, is the most common scenario in 7.5 cm in diameter.
which internal defibrillation is needed.3,11 • Defibrillator
• Understanding is needed of cardiovascular anatomy and Additional equipment, to have available as needed, includes
physiology, principles of cardiac conduction, dysrhythmia the following:
interpretation, and electrical safety. • Intubation equipment
• Advanced cardiac life support knowledge and skills are • Flow meter for oxygen administration
needed. • Bag-valve device with mask capable of delivering 100%
• If open-chest resuscitation with internal defibrillation oxygen and at least 500-mL volumes
is attempted in cardiac arrest, it should be performed • Intravenous (IV) fluids (e.g., 500 mL of normal saline)
within the first 5 minutes after cardiac arrest for the best • Emergency medications
outcomes.11 • Temporary pacemaker equipment
• Clinical and technical competence in the use of the defi- • Antiseptic skin prep solution (e.g., 2% chlorhexidene-
brillator is needed. based preparation)
• Knowledge of aseptic and sterile technique is necessary.
• Emergent sternotomy or thoracotomy precedes internal PATIENT AND FAMILY EDUCATION
defibrillation (see Procedure 39).
• Knowledge of internal paddle placement and energy • Teaching may need to be performed after the procedure.
requirements for internal defibrillation is needed. Rationale: Internal defibrillation usually is performed in
• Internal paddle placement should ensure that the axis of the face of sudden hemodynamic collapse.
the heart is situated between the sources of current. • Explain to the family the need for internal defibrillation.
• Energy requirements for internal defibrillation usually Rationale: This information keeps the family informed.
range from 5 to 20 J for biphasic shocks and 10 to 40 J
for monophasic shocks.11 It has been suggested that bipha-
sic shocks for ventricular fibrillation and pulseless ven- PATIENT ASSESSMENT AND
tricular tachycardia should start at 10 to 20 J10 or at 20 J.1 PREPARATION
Biphasic shocks are more effective than monophasic
shocks at the same energy level in internal defibrilla- Patient Assessment
tion.10,12 The amount of myocardial damage from internal • Assess for dysrhythmias, especially ventricular ectopy.
defibrillation does not differ between monophasic and Rationale: Ventricular dysrhythmias may precede ven-
biphasic shocks.12 tricular tachycardia and ventricular fibrillation.
• Assess vital signs when dysrhythmias occur. Rationale:
EQUIPMENT This assessment provides data about the patient’s response
to dysrhythmias.
• Surgical head covers, masks, eye protection, sterile gowns, • Assess for pulseless ventricular tachycardia or ventricular
sterile gloves, large sterile drape fibrillation. Rationale: Assessment determines the need
• Open sternotomy or thoracotomy tray for resuscitation, which includes internal cardiac defibril-
lation. If immediate intervention is not initiated, return of
circulation may not be possible.
This procedure should be performed only by physicians, advanced Patient Preparation
practice nurses, and other healthcare professionals (including critical care
nurses) with additional knowledge, skills, and demonstrated competence per • Verify correct patient with two identifiers. Rationale:
professional licensure or institutional standard. Before performing a procedure, the nurse should ensure
310
37 Defibrillation (Internal) Perform 311
the correct identification of the patient for the intended • Prepare for this procedure by opening the chest and
intervention. draping the patient in a sterile fashion (refer to Procedure
• Ensure the patient has a patent airway and ventilation 39). Rationale: Allows the internal paddles to be inserted
before the initiation of the procedure. Assign responsibil- into the patient’s chest.
ity to this task to another qualified provider. Rationale: • Remove all metallic objects from the patient’s skin. Ratio-
The patient’s airway is protected and maintained, and a nale: Metallic objects are conductors of electrical current
means for adequate ventilation and oxygenation is and may cause burns.
provided. • Order sedation and analgesia as needed. Rationale: Pro-
• Place the patient in a flat supine position. Rationale: This motes patient comfort.
position provides the best access during the procedure and
during intervention for management of adverse effects.
Procedure for Internal Defibrillation

1. HH
2. PE
3. Confirm that the patient is in Reconfirms that defibrillation is External defibrillation should be
ventricular fibrillation or pulseless needed. attempted first whenever possible (see
ventricular tachycardia. Procedure 36) unless the chest is
already open and there is rapid access
for internal defibrillation. Follow
institution’s standard.
4. Initiate basic and advanced cardiac Life-saving interventions are It is controversial whether external
life support.11 (Level D*) necessary. cardiac compressions (because of
potential damage to the postoperative
cardiac patient) should be started if
rapid defibrillation can be
accomplished.2,8
External cardiac compressions should be
delivered while awaiting a
defibrillator.6 The American Heart
Association’s 2010 advanced
cardiovascular life support guidelines
recommend external chest
compressions if emergency
resternotomy is not immediately
available.11
Deformation of transcatheter aortic
valves with external chest
compressions has been reported.5,9
Left hemithorax compressions may be
safer with transcatheter than
compressions over the sternum.9
Follow institution’s standards regarding
initiation of external cardiac
compressions.

Procedure for Internal Defibrillation—Continued

5. Don sterile equipment. Prepares for sterile procedure. The physician, advanced practice nurse,
or other healthcare professional(s)
performing the procedure should
perform hand antisepsis and hand
scrub if possible.1,4 However, if a
closed sleeve technique for gowning
and gloving technique is used,
handwashing is not necessary in
cardiac arrest as it delays
resuscitation. Increased time to
defibrillation decreases the likelihood
of successful resuscitation.1
6. If there is blood/fluid in the Fluid/blood may need to be
mediastinum, connect a sterile evacuated from the
Yankauer suction to a sterile mediastinum before
suction tubing and suction the defibrillation.
mediastinum before defibrillation.
7. Ask for internal paddles (Fig. Prepares the equipment.
37-1) to be opened and placed on
the sterile field and hand off the
connection cable for the
defibrillator to an unsterile
assistant to connect to the
defibrillator.
Figure 37-1 Internal paddles. (Courtesy

Marion E. McRae.)
8. If the internal paddles are two-part Prepares the equipment.

paddles, connect the defibrillation
paddles to the handles (usually via
screw mechanism).
9. Identify the number of joules the The lowest energy level that Biphasic shocks of 5–20 J usually are
defibrillator is to be charged to will convert the rhythm and sufficient to convert pulseless
(usually 5–20 J for biphasic minimize damage to the rhythms.10–12
shocks, 10–40 J for monophasic myocardium is used. Refer to the defibrillator manufacturer’s
shocks).11,12 (Level D*) operation guidelines for specific
recommendations and follow
institution guidelines.

10. Position one paddle over the right This will aid in depolarizing the
atrium or right ventricle; the other entire myocardium.
paddle is placed over the apex of
the heart (Fig. 37-2).
Figure 37-2 Paddle placement for internal defibrillation. (From Kinkade

S, Lohrman JE: Critical care nursing procedures: a team approach, Phila-
delphia, 1990, BC Decker.)
11. State “all clear” three times and Electrical current can be Use a mnemonic such as “I’m clear,
visually verify that all personnel conducted from the patient to you’re clear, we’re all clear,” and look
are clear of contact with the another person if contact at the patient while talking to ensure
patient, bed, and equipment. occurs. that no one is touching or is in contact
with the patient.
12. Simultaneously depress and hold In the defibrillation mode, an Follow manufacturer’s
the buttons on each paddle until immediate release of the recommendations.
the defibrillator discharges if the electrical charge depolarizes
paddles are equipped with cardiac muscle.
defibrillation buttons. If the Simultaneous depolarization of
paddles are not equipped with the myocardial muscle cells
defibrillation buttons, ask for the may result in simultaneous
defibrillation button on the repolarization of enough
defibrillator to be activated. myocardial cells to reestablish
(Level M*) a single cardiac impulse.
13. Assess the patient’s response to Determines whether additional
defibrillation (heart rate and interventions may be needed.
rhythm, blood pressure, level of
consciousness).
*Level M: Manufacturer’s recommendations only


A. If the first defibrillation is not Continues emergency treatment.
successful, perform additional
defibrillations as needed.11
(Level D*)
B. Open chest cardiac Open-chest cardiac compression Do not press your fingers into the
compressions may be initiated may be initiated if internal epicardial surface as tears can occur in
if needed: defibrillation is not thinner or weak areas of tissue.
i. Place one hand around the successful. Do not lift the apex of the heart as
surface of the apex of the Internal cardiac massage is posterior ventricular rupture can
heart toward the posterior superior to external cardiac occur,4 especially if there are
aspect of the heart with the massage.4 prosthetic atrioventricular valve
palm up and fingers straight. prostheses in situ.
ii. Avoid lifting the apex of the
heart.
iii. Avoid any grafts or other
structures on the heart such
as epicardial pacemaker
leads.
iv. Place the palm of the other
hand on the anterior surface
of the heart keeping the
fingers straight.
v. Squeeze the heart between
your two hands at 100/min.4
(Level E*)
C. If defibrillation is successful, Aids in determining whether Provide additional supportive therapies
obtain vital signs and assess additional interventions are as needed. Epicardial pacing and
the patient. needed. vasoactive agents may be needed.
14. Prepare the patient for transfer to Prepares for chest closure. Follow institution standard for closing
the operating room to close the the chest in the unit or in the
chest; cover the patient’s chest operating room.
with a sterile drape or sterile The chest may be left open with a sterile
occlusive dressing before occlusive dressing in place particularly
transporting the patient to the if the patient remains unstable.
operating room.
15. Remove sharps from the open Reduces risk for injury.
chest tray and discard in a sharp
container.
16. Place the internal paddles in the Prepares for sterilization of Follow manufacturer and institutional
appropriate bag or container and equipment. guidelines for cleansing the
ensure that it is sent for defibrillator and internal paddles.
decontamination, disinfection, and Discard disposable internal paddles if
sterilization. used.
17. Remove PE and sterile equipment Reduces the transmission of
and discard used supplies in microorganisms; Standard
appropriate receptacles. Precautions.
18. HH
19. Request that sterile internal Prepares for another emergency.
paddles and an open chest tray are
immediately restocked.

• Reestablishment of a single origin of the cardiac • Inability to resuscitate; death
impulse • Cerebral anoxia, brain impairment
• Hemodynamic stability • Infection
• Myocardial injury (e.g., from hypoxia, defibrillation,
sternotomy/thoracotomy, internal compressions)
• Pain

interventions.
1. Continue to monitor the Dysrhythmias may develop. • Dysrhythmias
patient’s cardiac rate and
rhythm after defibrillation.
2. Assess the patient’s Determines patient’s neurological • Change in level of consciousness
neurological status after status after arrest and defibrillation.
defibrillation. Order the The benefit of therapeutic
frequency of neurological hypothermia in cardiac arrest after
assessments. If resuscitation is cardiac surgery is unknown.
successful but the patient However, due to the strength of
remains unresponsive after the evidence in other populations it
resuscitation, consideration should be considered. Hypothermia
should be given to therapeutic can impair coagulation which is a
hypothermia at 32–34°C for at concern if a patient is bleeding.
least 12–24 hours.7 (Level E*
in this population)
3. Order arterial blood gases and Determines oxygenation and acid- • Abnormal respirations
ventilator settings for ongoing base balance after arrest and • Abnormal oxygen saturation
patient care. defibrillation and provides for • Abnormal arterial blood gas results
ongoing respiratory support.
4. Order vital sign monitoring Determines the patient’s • Abnormal vital signs
immediately after hemodynamic stability.
defibrillation and at least
every 15 minutes until stable.
5. Prescribe intravenous Antidysrhythmic medications may be • Dysrhythmias
antidysrhythmic medications prescribed to prevent or control
as needed. dysrhythmias.
6. Order hemoglobin/hematocrit Ensures sufficient hemoglobin for • Abnormal hemoglobin and
levels if blood loss occurred oxygen transport. hematocrit results
during the procedure.
7. Order blood replacement Replaces blood loss that occurred
products if needed. during the procedure.
8. Order electrolyte levels and Abnormal electrolyte levels may • Abnormal electrolyte results
replace electrolytes if low. contribute to the development of
ventricular dysrhythmias.
9. Order and interpret a 12-lead Assesses for myocardial ischemia. • ECG abnormalities
electrocardiogram (ECG).
10. Order analgesia and sedation Ensures patient comfort. • Continued pain or agitation despite
as needed. pain and sedation interventions
support recommendations

Documentation
• Orders given during the resuscitation • Any unexpected outcomes and interventions taken
• A procedure note describing the procedure performed, • Amount of chest drainage/blood loss
the sequential events occurring, patient assessment • Time chest was covered with a sterile occlusive
before and after defibrillation, and complications of the dressing or when the chest was closed.
procedure • Laboratory values obtained immediately before and
• Printout of ECG tracings with cardiac events before, after defibrillation.
during, and after each defibrillation • Family notification of the event.
• Patient response to defibrillation • Patient (if applicable) and family education about the
• Pain assessment, interventions, and effectiveness event
• Medications and IV fluids given during the
resuscitation

37 Defibrillation (Internal) Perform 316.e1
References 7. Peberdy MA, et al: Part 9: Post-cardiac arrest care: 2010

1. Dunning J, et al: Guideline for resuscitation in cardiac American Heart Association guidelines for
arrest after cardiac surgery. Eur J Cardiothorac Surg cardiopulmonary resuscitation and emergency
36:3–28, 2009. cardiovascular care. Circulation 122(Suppl):S768–S786,
2. Gosev I, Nikolic I, Aranki S: Resuscitation practices 2010.
in cardiac surgery. J Thorac Cardiovasc Surg 148: 8. Pulido JN: Unique aspects of resuscitation practices
1152–1156, 2014. in postoperative cardiac surgical care: A call to action.
3. Jones B: Postoperative complications of cardiac surgery J Thorac Cardiovasc Surg 148:1156–1157, 2014.
and nursing interventions. In Hardin SR, Kaplow R, 9. Scherner M, et al: Transapical valve implantation and
editors: Cardiac surgery essentials for critical care resuscitation: Risk of valve destruction. Ann Thorac Surg
nursing, Sudbury MA, 2010, Jones & Bartlett. 92:1909–1910, 2011.
4. Kirmani B, et al: The cardiac surgery advanced life 10. Schwarz B, et al: Biphasic shocks compared with
support course, ed 2, Middlesbrough, UK, 2012, Author. monophasic damped sine wave shocks for direct
(published by author). ventricular defibrillation during open heart surgery.
5. Kirov HM, et al: Deformation of a transapical aortic Anesthesiology 98:1063–1069, 2003.
valve after cardiopulmonary resuscitation: A potential 11. Soar J, et al: European Resuscitation Council guidelines
risk of stainless steel stents. J Am Coll Cardiol 60:1838, for resuscitation 2010 section 8: Cardiac arrest in special
2012. circumstances. Resuscitation 81:1400–1433, 2010.
6. Neumar RW, et al: Part 8: Adult advanced cardiovascular 12. Winterhalter M, et al: Effectiveness and safety of internal
life support: 2010 American Heart Association Guidelines rectilinear biphasic versus monophasic defibrillation in
for Cardiopulmonary Resuscitation and Emergency patients undergoing cardiac surgery. J Cardiothorac Vasc
Cardiovascular Care. Circulation 122:S729–S767, 2010. Anesth 19(6):739–745, 2005.
PROCEDURE
38
Defibrillation (Internal) Assist
Marion E. McRae
PURPOSE: The purpose of internal defibrillation is to deliver electrical current
directly to the epicardial surface of the heart when a shockable rhythm is present.
PREREQUISITE NURSING Additional equipment, to have available as needed, includes

KNOWLEDGE the following:
• Intubation equipment
• Cardiac arrest after cardiac surgery, which occurs in about • Flow meter for oxygen administration
0.7% to 2.9% of patients, is the most common scenario in • Bag-valve device with mask capable of delivering 100%
which internal defibrillation is needed.6 About 25% to oxygen and at least 500-mL volumes
50% of cardiac arrest after cardiac surgery results from • Intravenous (IV) fluids (e.g., 500 mL of normal saline)
ventricular fibrillation.1 • Emergency medications
• Understanding is needed of cardiovascular anatomy and • Temporary pacemaker equipment
physiology, principles of cardiac conduction, dysrhythmia • Antiseptic skin prep solution (e.g., 2% chlorhexidine-
interpretation, and electrical safety. based preparation)
• Advanced cardiac life support knowledge and skills are
needed. PATIENT AND FAMILY EDUCATION
• If open-chest resuscitation with internal defibrillation
is attempted in cardiac arrest, it should be performed • Teaching may need to be performed after the procedure.
within the first 5 minutes after cardiac arrest for the best Rationale: Internal defibrillation usually is performed in
outcome.2,6 the face of sudden hemodynamic collapse.
• Clinical competence in the use of the defibrillator is • Explain to the family the need for internal defibrillation.
needed. Rationale: This information keeps the family informed.
• Emergent open sternotomy or thoracotomy precedes inter-
nal defibrillation (see Procedures 39 and 40). PATIENT ASSESSMENT AND
• Energy requirements for internal defibrillation usually PREPARATION
range from 5 to 20 J for biphasic (electrical current goes
from one paddle to the other and then back to the first Patient Assessment
paddle) shocks and 10 to 40 J for monophasic (electrical • Assess for dysrhythmias, especially ventricular ectopy.
current travels from one paddle to the other) shocks.6 It Rationale: Ventricular dysrhythmias may precede ven-
has been suggested that biphasic shocks for ventricular tricular tachycardia and ventricular fibrillation.
fibrillation or pulseless ventricular tachycardia should • Assess vital signs when dysrhythmias occur. Rationale:
start at 10 to 20 J3 or 20 J.1 Biphasic shocks are more This assessment provides data about the patient’s response
effective than monophasic shocks at the same energy level to dysrhythmias.
in internal defibrillation.5,7 The amount of myocardial • Assess for pulseless ventricular tachycardia or ventricular
damage from internal defibrillation does not differ between fibrillation. Rationale: Assessment determines the need
monophasic and biphasic shocks.7 for resuscitation, which may include internal cardiac defi-
brillation. If immediate intervention is not initiated, return
EQUIPMENT of circulation may not be possible.
• Surgical head covers, masks, eye protection, sterile gowns, Patient Preparation
sterile gloves, large sterile drape • Verify correct patient with two identifiers. Rationale:
• Open sternotomy or thoracotomy tray Before performing a procedure, the nurse should ensure
• Large sterile suction catheter (Yankauer), sterile tubing, the correct identification of the patient for the intended
suction canisters, suction regulator, and suction source intervention.
• Sterile internal paddles (ensure compatibility with the • Ensure the patient has a patent airway and ventilation
defibrillator). Adult internal paddles are usually 5 to before the initiation of the procedure. Rationale: The
7.5 cm in diameter. patient’s airway is protected and maintained, and a means
• Defibrillator for adequate ventilation and oxygenation is provided.
317
• Place the patient in a flat supine position. Rationale: This • Establish or ensure patency of IV access. Rationale: Med-
position provides the best access during the procedure and ication administration may be necessary.
during intervention for management of adverse effects. • Administer sedation and analgesia as prescribed. Ratio-
• Remove all metallic objects from the patient’s skin. Ratio- nale: Promotes patient comfort.
nale: Metallic objects are conductors of electrical current
and may cause burns.
Procedure for Defibrillation Internal

1. HH
2. PE
3. Confirm that the patient is in Reconfirms that defibrillation is External defibrillation should be
ventricular fibrillation or pulseless needed. attempted first whenever possible
ventricular tachycardia. (see Procedure 36) unless the chest
is already open and there is rapid
access for internal defibrillation.
4. Initiate basic and advanced cardiac Life-saving interventions are Follow institution standards
life support.3,6 (Level D*) necessary. regarding initiating external
cardiac compressions.
5. Assist the physician, advanced Prepares for sterile procedure. The provider performing the
practice nurse, or other healthcare procedure should perform hand
provider performing the procedure antisepsis and hand scrub if
with applying personal protective possible.1,3 However, if a closed
and sterile equipment. sleeve technique for gowning and
gloving is used, handwashing is
not necessary in cardiac arrest as it
delays resuscitation. Increased
time to defibrillation decreases the
likelihood of successful
resuscitation.1
6. As needed, place a sterile Yankauer Fluid/blood may need to be
and suction tubing onto the sterile evacuated from the mediastinum
field. before defibrillation.
7. As needed, have the provider Prepares equipment.
performing the procedure hand one
end of the suction tubing back to
you to connect to the suction
source.
8. Ensure that the defibrillator is Facilitates access to the The defibrillator cannot touch the
positioned within reach of the defibrillator. patient, field, or healthcare
defibrillator cables with the screen providers but must be close
facing toward the provider enough to treat the patient.
performing the procedure if
possible.
9. When requested open the package Prepares equipment.
with the internal paddles and place
them on the sterile field.
10. Connect the internal paddle cable Prepares the equipment. Maintain asepsis by not touching the
to the defibrillator when the healthcare provider handing off the
healthcare provider performing the paddle cable.
procedure hands the cable off the Use caution when pulling the
sterile field to you. connector to the defibrillator so
that objects on the sterile field are
not dislodged or entangled.
38 Defibrillation (Internal) Assist 319
Procedure for Defibrillation Internal—Continued

11. Charge the defibrillator when The defibrillator is charged with Biphasic shocks of 5–20 J usually
requested to the prescribed energy the lowest energy level are sufficient to convert ventricular
level (usually 5–20 J for biphasic necessary to convert the rhythm tachycardia or ventricular
shocks, 10–40 J for monophasic and minimize damage to the fibrillation.5-7
shocks).6,7 (Level D*) myocardium. Refer to the defibrillator
manufacturer’s operation
guidelines for specific
recommendations and to your
institutional policy.
12. Ensure that the healthcare provider Electrical current can be
delivering the shock states “all conducted from the patient to
clear” three times and visually another person if contact occurs.
verifies that all personnel are clear
of contact with the patient, bed,
and equipment.
13. If the internal paddles being used In the defibrillation mode, an Follow manufacturer’s
can only be discharged by immediate release of the recommendations.
depressing the defibrillation button electrical charge depolarizes
on the defibrillator, press the button cardiac muscle.
when all personnel are clear. (Some Simultaneous depolarization of
internal paddles are equipped with the myocardial muscle cells
a defibrillation button that the may result in simultaneous
provider can activate on the repolarization of enough
paddles). (Level M*) myocardial cells to reestablish a
single cardiac impulse.
14. Assess the patient’s response to Determines whether additional
defibrillation (heart rate and interventions may be needed.
rhythm, blood pressure, level of
consciousness):
A. If the first defibrillation is not Continues emergency treatment.
successful, assist the team with
additional defibrillations as
needed.
B. If defibrillation is successful, Aids in determining whether Provide additional supportive
obtain vital signs and assess the additional interventions are therapies as needed. Epicardial
patient. needed. pacing and vasoactive agents may
be prescribed.
15. Assist with transferring the patient Prepares for chest closure. Follow institution standard for
to the operating room. closing the chest in the unit or in
the operating room.
The chest may be left open with a
sterile occlusive dressing in
place particularly if the patient
remains unstable.
16. Assist as needed with placing the Prepares for sterilization of
internal paddles in the appropriate equipment.
bag or container and ensure that it
is sent for decontamination,
disinfection, and sterilization.

Procedure for Defibrillation Internal—Continued

supplies in appropriate receptacles. microorganisms; Standard
Precautions.
18. HH
19. Obtain sterile internal paddles to Prepares for another emergency.
restock emergency supplies.

• Reestablishment of a single origin of the cardiac • Inability to resuscitate; death
impulse • Cerebral anoxia, brain impairment
• Hemodynamic stability • Infection
• Myocardial injury (e.g., from hypoxia, defibrillation,
sternotomy/thoracotomy, internal compressions)
• Pain

interventions.
1. Continue to monitor the patient’s Dysrhythmias may develop. • Dysrhythmias
cardiac rate and rhythm after
defibrillation.
2. Assess the patient’s neurological Determines patient’s • Change in level of consciousness
status after defibrillation. neurological status after arrest
Initiate therapeutic hypothermia if and defibrillation.
prescribed. (Level E* in this
population)1,3,4
3. Monitor the patient’s vital signs Determines the patient’s • Abnormal vital signs
immediately after defibrillation and hemodynamic stability.
at least every 15 minutes until stable.
4. Initiate intravenous antidysrhythmic Antidysrhythmic medications • Dysrhythmias
medications as prescribed. may be prescribed to prevent
or control dysrhythmias.
5. Obtain blood samples for laboratory Abnormal electrolyte levels may • Abnormal electrolyte results
analysis as prescribed (e.g., contribute to the development
electrolyte levels). of ventricular dysrhythmias
(specifically low potassium
and magnesium levels).
6. After successful internal defibrillation Assesses for myocardial • ECG abnormalities
obtain a 12-lead electrocardiogram ischemia.
(ECG) if prescribed.
7. Administer analgesia and sedation as Ensures patient comfort. • Continued pain or agitation despite
prescribed. pain and sedation interventions
38 Defibrillation (Internal) Assist 321
Documentation
• Cardiovascular, respiratory, and neurological • Any unexpected outcomes and interventions taken
assessments before and after defibrillation • Amount of chest drainage
• Each defibrillation and joules used • Any unexpected outcomes and interventions taken
• Printout of ECG tracings with cardiac events before, • Laboratory values obtained immediately before,
during, and after each defibrillation during, and after defibrillation
• Patient response to defibrillation • Family notification of the event
• Pain assessment, interventions and effectiveness • Patient (if applicable) and family education about the
• Medications and IV fluids given during the event
resuscitation

38 Defibrillation (Internal) Assist 321.e1
References cardiovascular care. Circulation 122(Suppl):S768–S786,

1. Dunning J, et al: Guideline for resuscitation in cardiac 2010.
arrest after cardiac surgery. Eur J Cardiothorac Surg 5. Schwarz B, et al: Biphasic shocks compared with
36:3–28, 2009. monophasic damped sine wave shocks for direct
2. Kirmani B, et al: The cardiac surgery advanced life ventricular defibrillation during open heart surgery.
support course, ed 2, Middlesbrough, UK, 2012, Author. Anesthesiology 98:1063–1069, 2003.
(published by author). 6. Soar J, et al: European Resuscitation Council guidelines
3. Neumar RW, et al: Part 8: Adult advanced cardiovascular for resuscitation 2010 section 8: Cardiac arrest in special
life support: 2010 American Heart Association Guidelines circumstances. Resuscitation 81:1400–1433, 2010.
for Cardiopulmonary Resuscitation and Emergency 7. Winterhalter M, et al: Effectiveness and safety of internal
Cardiovascular Care. Circulation 122:S729–S767, 2010. rectilinear biphasic versus monophasic defibrillation in
4. Peberdy MA, et al: Part 9: Post-Cardiac Arrest Care: patients undergoing cardiac surgery. J Cardiothorac Vasc
2010 American Heart Association guidelines for Anesth 19(6):739–745, 2005.
cardiopulmonary resuscitation and emergency
PROCEDURE
39
Emergent Open Sternotomy
(Perform)
Alice Chan
PURPOSE: Emergent open sternotomy for a patient after cardiac surgery is
performed to identify and eliminate areas of persistent hemorrhage, relieve
pericardial tamponade, and provide access for open cardiac massage and internal
defibrillation.

KNOWLEDGE
• Antiseptic solution (e.g., 2% chlorhexidine gluconate skin
• Knowledge of anatomy and physiology of the cardiovas- preparation)
cular system is necessary. • Head cover, masks, eye protection, sterile gown, sterile
• Advanced cardiac life support knowledge and skills are gloves, sterile drapes
needed. • Sterile thoracic pack and sternotomy tray
• Understanding of the signs and symptoms of cardiac tam- ❖ Wire cutter
ponade is necessary. ❖ Rib spreader
• Emergent open sternotomy is performed for patients who ❖ Kelly clamps and skin snaps
have undergone a median sternotomy. ❖ Knife handle
• Emergent open sternotomy is indicated for exsanguinating ❖ Scissors
hemorrhage or cardiac tamponade with imminent cardiac • Electrocautery equipment: generator, cautery, electrical
arrest.4,7 dispersing pad (e.g., grounding pad)
❖ The goal of mediastinal exploration for persistent hem- • Large sterile suction catheter (e.g., Yankauer)
orrhage is to stop the bleeding and retain circulating • Suction containers, tubing, regulator, and suction source
blood volume. The requirement for homologous blood • Radiopaque gauze or other surgical sponge materials
transfusion and incidence of wound infection associ- • Polypropylene (Prolene) suture (cutting needle) and other
ated with an undrained mediastinal hematoma may be suture material according to preference
decreased.2 • Clip applicator and clips
❖ The goal of mediastinal exploration for cardiac tam- • Syringes: 3 mL, 5 mL, 10 mL, and 20 mL
ponade is to relieve the pressure on the ventricles • Knife blades: Nos. 10, 11, 15
during diastole. The decreased pressure allows the ven- • Sternal wires or bands
tricles to fill during diastole, which should increase • Sterile stapler or sutures
contractility, stroke volume, and cardiac output to • Sterile dressing supplies
improve systemic perfusion. • Emergency medication and resuscitation equipment, includ-
• Knowledge and skills related to aseptic and sterile tech- ing internal defibrillation paddles and external defibrillation
nique, surgical instrumentation, sternal opening, sternal pads or paddles
exploration, sternal closure, and suturing are needed.1,4–6 • Prescribed analgesia or sedation
• Paralytic agents may be a necessary adjunct to sedation Additional equipment, to have available as needed, includes
and analgesia to improve oxygenation, diminish muscle the following:
activity, and enhance visualization. • Prescribed blood products and intravenous solutions
• Internal defibrillation may be necessary if life-threatening • Warm saline solution with or without an antibiotic, as
dysrhythmias occur (see Procedure 37). prescribed
• Chest tubes and chest tube drainage system
• Epicardial wires
• Intraaortic balloon catheter and pump console or other
mechanical assist device
practice nurses, and other healthcare professionals (including critical care • Peripheral nerve stimulator (used if paralytic agents are
nurses) with additional knowledge, skills, and demonstrated competence per administered)
professional licensure or institutional standard. • Sterile staple remover
322
39 Emergent Open Sternotomy (Perform) 323
PATIENT AND FAMILY EDUCATION ❖ Distended neck veins

❖ Distant heart sounds
• Teaching may not be provided until after the procedure. ❖ Equalization of intracardiac pressures, including right
Rationale: When an emergent sternotomy is performed atrial, pulmonary artery diastolic, and pulmonary artery
for rapid hemodynamic collapse, education of the patient occlusion pressures
and family may not be possible before the procedure. ❖ Decreased cardiac output and cardiac index
• Explain the reason that the open sternotomy procedure • Pulsus paradoxus
was performed and its outcome or anticipated outcome. • Assess for excessive chest tube drainage. Rationale:
Rationale: This explanation provides information and Severity of bleeding assists with the determination of
encourages the patient and family to ask questions and the need for emergent mediastinal exploration. Follow
clarify details about the patient and procedure. the institution’s guidelines regarding determination of the
timing of mediastinal exploration. One recommendation
for timing the procedure is when chest tube drainage con-
PATIENT ASSESSMENT AND tinues at equal to or greater than 3 mL/kg/hr for at least 3
PREPARATION hours.3
Patient Assessment Patient Preparation
• Assess hemodynamic and neurological status. Rationale: • Verify that the patient is the correct patient using two
This assessment identifies baseline data that may indicate identifiers. Rationale: Before performing a procedure, the
the need for emergent open sternotomy and provides com- nurse should ensure the correct identification of the patient
parison data. for the intended intervention.
• Assess the patient’s medical history, specifically for coag- • Ensure that the patient and family understand procedural
ulation disorders, renal disease with coexistent uremia, teaching (if time is available). Answer questions as they
and functional status of the right and left ventricle. Ratio- arise and reinforce information as needed. Rationale:
nale: Baseline data are obtained. Understanding of the information provided is evaluated
• Assess current laboratory data, specifically complete and reinforced.
blood cell count, platelet count, international normalized • Obtain informed consent (may not be possible if the pro-
ratio, activated partial thromboplastin time, and fibrino- cedure is an emergency). Rationale: Informed consent
gen. Rationale: Near-normal baseline coagulation study protects the rights of the patient and ensures a competent
results decrease the likelihood of coagulopathy as a pos- decision for the patient and the family.
sible cause for ongoing hemorrhage. • Perform a preprocedure verification and time out, if non-
• Assess for signs and symptoms of cardiac tamponade. emergent. Rationale: Ensures patient safety.
Rationale: The presence of some or all of these signs and • Ensure the patient’s airway is protected and that supple-
symptoms help the physician, advanced practice nurse, or mental oxygen is delivered. Rationale: The probability
other healthcare professional determine whether the emer- that the patient’s ventilatory needs will be met is enhanced.
gent open sternotomy is indicated: • Position the patient in the supine position with the head
❖ Sudden decrease or cessation in chest tube drainage of the bed flat. Rationale: This position ensures visualiza-
❖ Hypotension (mean arterial blood pressure, <60 mm Hg) tion of the chest and enhances hemodynamic stability.
❖ Altered mental status • Prescribe and ensure that an analgesic and/or sedative are
❖ Apical heart rate greater than 110 beats/min administered. Rationale: Promotes patient comfort.
❖ Narrowing of pulse pressure
Procedure for Performing Emergent Open Sternotomy

1. Call the physician and operative The physician can assess the need for Follow the institution’s standard.
team. further surgical intervention.
The operative team may be needed to
assist at the bedside or to prepare
the operating room if further
exploration is needed.
2. HH
3. PE
4. Prepare the electrocautery device Electrocautery is used to terminate Grounding is essential to avoid
for possible use: Apply the capillary oozing or bleeding. burning the patient and possible
electrical dispersing pad (i.e., electrical shock to the healthcare
grounding pad) to the patient’s providers.
dry skin over a large well Electrocautery may not be
perfused muscle mass and attach immediately available in the critical
the grounding cable to the care setting; follow institution
device.1 (Level D*) standard.
5. Ensure that a new sterile suction Suction within the mediastinum is
system is set up. necessary during the procedure.
6. Remove the sternal dressing and Inhibits microorganism transmission. Prepare the skin beginning at the
cleanse the chest with an incision line, extending outward to
antiseptic solution (e.g., 2% include the area from the chin to
chlorhexidine gluconate the midabdomen (caudal to the
solution). Remove gloves when umbilicus) and to include the area
cleansing is completed and wash outward to one anterior axillary
hands. line and then outward to the
opposite anterior axillary line.
Minimize solution from running off
the surgical site, dripping, pooling,
and soaking fabric and the patient’s
hair.
Ensure alcohol-based preparation
agents have not wet the patient’s
hair or bedding nor pooled in
skin-folds or the umbilicus because
the risk of fire is increased
(nonflammable preparations
eliminate the risk of fire).1
7. Don personal protective Removes debris and transient All personnel in the room must don
equipment and sterile microorganisms.1 caps and masks.
equipment: Inhibits rebound microorganism
A. Surgical head cover, mask, growth.1
and eye protection.
B. Perform hand antisepsis/hand
scrub.
C. Sterile gown and sterile
gloves.
8. Ask the critical care nurse or Prepares equipment. The critical care nurse or person
person assisting to open the assisting with the procedure can
sternotomy tray and to hand it to help by opening sterile packs and
the person performing the the instrument tray.
procedure.
Procedure for Performing Emergent Open Sternotomy—Continued

9. Fully drape the patient with A large sterile field minimizes the Allows good view of the incision.
exposure of only the surgical risk of infection and provides
site.1,3,5 (Level D*) space to maintain asepsis of
instruments and supplies during
the procedure.
10. Hand off the distal end of the Cautery is used to stop bleeding from The cautery control is not sterile. The
electrocautery cable (active small vessels. connection must be handed off of
electrode) to the critical care the sterile field without the
nurse or assisting healthcare healthcare provider performing the
provider. procedure and the assisting
personnel touching each other.
11. Open the incision down to the Ensures visualization of the sternal Remove staples with a staple
sternum with the staple remover wires or bands. remover; cut sutures and tissue
or scalpel, exposing the sternal with a scalpel.
wires or bands.
12. Cut the sternal wires (or bands) Provides access to the mediastinum. Use care when removing the sternal
from the top to the bottom with The sternal wires fatigue and break wires to minimize damage to the
the wire cutter or untwist the when untwisted with the heavy heart, underlying equipment (e.g.,
wires with the heavy needle needle holders. epicardial pacing wires, chest
holder. tubes), and coronary artery bypass
grafts and injury to the healthcare
provider.
13. With your hands, gently separate Caution must be taken to separate the
the sternum. sternum gently because the heart,
bypass grafts, and pacing wires
rest just under the sternal bone.
14. Place the sternal retractor under Exposes the heart and mediastinum. Sternal retractor blades can trap and
the sternal bone. Slowly crank it tear bypass grafts and pacing wires
open while feeling along the if caught and pulled apart when the
edge of the retractor blades and retractor is cranked open.
observing the mediastinal cavity
and heart for anything caught in
the retractor.
15. For bleeding, apply pressure Pressure on the bleeding site may Resuscitate with intravenous fluids,
with a finger over any bleeding minimize blood loss. inotropic medications, and blood
site and suction the remainder of products as necessary.
the chest, evacuating any clots.
16. Control and ligate bleeding sites, May eliminate the need for further The physician determines whether the
enhance the sternal retraction, exploration and assists with better patient needs to be transferred to
and provide suctioning and visualization of the surgical field. the operating room for further
electrocautery as needed. surgical intervention.
17. If pulseless ventricular Emergency intervention is needed. The critical care nurse or additional
tachycardia or ventricular assistive personal can help to
fibrillation occurs, internal obtain the defibrillator and the
defibrillation is needed (see internal defibrillation paddles.
Procedure 37).
18. Insert or assist with insertion of Chest tubes and epicardial pacing
chest tubes or epicardial pacing wires can be displaced during
wires as needed. sternal retraction or mediastinal
exploration.
19. Warm saline solution with or May decrease the incidence of Determine whether additional
without an antibiotic may be infection. antibiotic coverage is needed.
used to flush the chest cavity
before closing the incision.

Procedure for Performing Emergent Open Sternotomy—Continued

20. Assist with the placement of Cardiac tamponade may conceal
mechanical assist devices if right or left ventricular
needed. dysfunction; mechanical assistance
may be necessary to improve
cardiac output.
21. Assist with patient transport to The patient may need further Ensure that the patient’s chest is
the operating room if necessary. exploration; surgical repair of covered with sterile drapes or with
coronary artery bypass grafts, a dressing during transportation.
cardiac valves, or the myocardium;
or insertion of an assist device
(e.g., intraaortic balloon pump,
ventricular assist device).
22. If the patient does not need to Ensures sternal closure. Caution must be taken not to
return to the operating room, penetrate the heart, pericostal
assist the physician with vessels, lungs, or bypass grafts with
reinsertion of sternal wires as the sternal wires.
follows: Multiple wiring techniques can be
A. Grasp the sternal wire with used for sternal wound closure;
the needle holder. the advanced practice nurse or
B. From under the sternum, physician performing the procedure
push one end of the wire up may use an alternate method or use
between two ribs at the sternal bands to close the sternum.
sternal border.
C. Repeat step B with the other
end of the wire on the
opposite side of the sternum
(same intercostal space).
D. Pull the sternum together
with the wire and twist the
edges of the wires together
with the needle holder.
E. Cut off the excess wire and
bend the twisted edges flat
against the sternum.
F. Repeat with additional wires
every two to three ribs until
the sternum is closed.
23. Assist the physician with tissue Promotes wound healing. The patient’s chest may be left open
and skin closure according to and covered with a sterile occlusive
preference (staples or sutures). dressing if severe tissue swelling or
ventricular dysfunction exists.
24. Apply an occlusive dressing to Dressings provide a physical barrier
the sternal incision, epicardial to external sources of
pacing wires, and chest tube contamination and cushion from
sites. physical contact and trauma; they
absorb drainage, maintain a moist
environment at body temperature
to enhance wound healing, and are
used for aesthetics.
25. Dispose of sharps per facility Minimizes risk of sharps injury. A chest radiograph may be prescribed
standard.1,5 to rule out the presence of any
retained surgical sponges, needles,
or instruments.

26. Discard used supplies in Reduces the transmission of
appropriate receptacles, and microorganisms and body
remove and discard PE . secretions; Standard Precautions.
27. HH
28. Remove and package Prepares for another emergency.
instruments for sterilization.

• Resolution of the condition that necessitated the • Severe right or left ventricular dysfunction
emergent open sternotomy • Continued dysrhythmias, bleeding, or coagulation
• Increased cardiac output disorders
• Increased tissue perfusion, including cerebral, renal, • Myocardial, aortic, coronary artery, or coronary
and peripheral perfusion artery bypass graft perforation
• Minimal chest tube drainage • Cardiac arrest
• Decreased need for blood transfusions • Pneumothorax
• Intracardiac infarction
• Atrial and ventricular dysrhythmias
• Pain
• Surgical infection
• Death

interventions.
1. Perform cardiovascular, Determines hemodynamic stability • Mean arterial blood pressure
hemodynamic, and peripheral and volume status; recurrent <60 mm Hg
vascular assessments every tamponade or dysrhythmias may • Abnormal changes in heart rate
15–30 minutes as patient develop during and after • Decrease in cardiac index
status requires (including sternotomy. • Abnormal pulmonary artery
vital signs, pulmonary artery Determines the adequacy of cerebral pressures
pressures, cardiac index, perfusion; hemodynamic instability • Urine output <0.5 mL/kg/hr
level of consciousness, and can lead to cerebral anoxia. • Equalizing pulmonary artery
urine output). Determines adequate perfusion to the pressures
kidneys. • Change in level of consciousness
2. Assess heart and lung sounds Abnormal heart and lung sounds • Distant heart sounds
every 2 hours and as needed. may indicate the need for • Abnormal lung sounds
additional treatment.
3. Monitor coagulation, Coagulation and hematologic profiles • Abnormal hemoglobin and
hematologic, and electrolyte provide data that indicate the risk hematocrit, activated partial
laboratory blood study of bleeding and indicate the need thromboplastin time,
results. for additional treatment. international normalized ratio,
Electrolyte studies provide data platelets, fibrinogen, calcium,
regarding the risk for dysrhythmias magnesium, or potassium
and decreased contractility.
4. Closely monitor chest tube Determines functioning of the chest • Cessation of chest tube drainage
drainage. tube drainage system and the • Increased chest tube drainage
amount of chest drainage. • Clots in the chest tube drainage
system
5. Assess pain and prescribe Identifies need for pain interventions. • Continued pain despite pain
analgesia as needed. interventions
Documentation
• Patient and family education • Patient therapies and response, including
• Signed informed consent, if nonemergent hemodynamic parameters, inotropic or vasopressor
• Universal Protocol requirement, if nonemergent agents, analgesia, sedation, ventilation, and
• Pain assessment, interventions and effectiveness neurological status
• Indications for the procedure and the procedure • Additional interventions
performed • Unexpected outcomes
• Amount of blood collected from chest suctioning;
estimated blood loss

39 Emergent Open Sternotomy (Perform) 328.e1

1. AORN (Association of periOperative Registered Nurses): Foroughi M, Hernadez C: Cardiovascular complication and
Perioperative standards and recommended practices, management after cardiac surgery. In Dabbagh A,
Denver, 2014, AORN. Esmailian F, Aranki SF, editors: Postoperative critical care
2. Bojar R: Manual of perioperative care in adult cardiac for cardiac surgical patients, New York, 2014, Springer.
surgery, ed 5, UK, 2011, John Wiley & Sons. Lemmer JH, Vlahakes GJ: Handbook of patient care in
3. Hardin S, Kaplow R: Cardiac surgery essentials for cardiac surgery, ed 7, Philadelphia, 2010, Lippincott
critical care nursing, Canada, 2010, Jones and Bartlett. Williams & Wilkins.
4. Hodge T: Fast facts for the cardiac surgery nurse: Macaroni MR, et al: Managing cardiac arrest after cardiac
Everything you need to know in a nutshell, New York, surgery: The impact of a five year evolving re-sternotomy
2011, Springer. policy and a review of the literature. Analg Resusc S1:1–7,
5. Phillips N: Berry & Kohn’s operating room technique, 2013.
ed 12, St Louis, 2012, Mosby. Polonen PE, et al: A prospective, randomized study of
6. Rothrock JC: Alexander’s care of the patient in surgery, goal-oriented hemodynamic therapy in cardiac surgical
ed 14, St Louis, 2010, Mosby. patients. Anesth Analg 90:1052–1059, 2000.
7. Soar J, et al: European Resuscitation Council guidelines Roekaerts PM, Heijmans JH: Early postoperative care after
for resuscitation 2010 section 8: Cardiac arrest in special cardiac surgery. In Narin C, editor: Perioperative
circumstances, 1–221. considerations in cardiac surgery, Croatia, 2012, In Tech.
PROCEDURE
40
Emergent Open Sternotomy
(Assist)
Alice Chan
PURPOSE: Emergent open sternotomy for a patient after cardiac surgery is
performed to identify and eliminate areas of persistent hemorrhage, relieve
pericardial tamponade, and provide access for open cardiac massage and internal
defibrillation.
PREREQUISITE NURSING ❖ Kelly clamps and skin snaps

KNOWLEDGE ❖ Knife handle
❖ Scissors
• Knowledge of the anatomy and physiology of the cardio- • Electrocautery equipment: generator, cautery, electrical
vascular system is necessary. dispersing pad (e.g., grounding pad)
• Advanced cardiac life support knowledge and skills are • Large sterile suction catheter (e.g., Yankauer)
needed. • Suction containers, tubing, regulator, and suction source
• Understanding of signs and symptoms of cardiac tampon- • Radiopaque gauze or other surgical sponge materials
ade is necessary. • Polypropylene (Prolene) suture (cutting needle), other
• Emergency open sternotomy is performed for patients suture material as requested
who have undergone a median sternotomy. • Clip applicator and clips
• Emergent open sternotomy is indicated for exsanguinating • Syringes: 3 mL, 5 mL, 10 mL, and 20 mL
hemorrhage or cardiac tamponade with imminent cardiac • Knife blades: Nos. 10, 11, 15
arrest.3,6 • Sternal wires or bands
❖ The goal of mediastinal exploration for persistent hem- • Sterile stapler or sutures
orrhage is to stop the bleeding and retain circulating • Sterile dressing supplies
blood volume. The requirement for homologous blood • Emergency medication and resuscitation equipment
transfusion and incidence of wound infection associ- Additional equipment, to have available as needed, includes
ated with an undrained mediastinal hematoma may be the following:
decreased.3 • Prescribed analgesia and sedation
❖ The goal of mediastinal exploration for cardiac tam- • Blood products and intravenous solutions as prescribed
ponade is to relieve the pressure on the ventricles • Warm saline solution with or without an antibiotic, as
during diastole. The decreased pressure allows the ven- prescribed
tricles to fill during diastole, which should increase • Chest tubes and chest tube drainage system
contractility, stroke volume, and cardiac output to • Epicardial wires
improve systemic perfusion. • Intraaortic balloon catheter and pump console or other
• Knowledge and skills related to aseptic and sterile tech- mechanical assist device
nique are needed. • Peripheral nerve stimulator (used if paralytic agents are
• Paralytic agents may be a necessary adjunct to sedation administered)
and analgesia to improve oxygenation, diminish muscle • Sterile staple remover
activity, and enhance visualization.
• Internal defibrillation may be necessary if life-threatening
dysrhythmias occur (see Procedures 37 and 38). PATIENT AND FAMILY EDUCATION
EQUIPMENT • Teaching may not be provided until after the procedure.
Rationale: When an emergent sternotomy is performed
• Antiseptic solution (e.g., 2% chlorhexidine gluconate skin for rapid hemodynamic collapse, education of the patient
preparation) and family may not be possible before the procedure.
• Head cover, masks, eye protection, sterile gown, sterile • Explain the reason that the open sternotomy procedure
gloves, sterile drapes was performed. Rationale: This explanation provides
• Sterile thoracic pack and sternotomy tray information and encourages the patient and family to
❖ Wire cutter ask questions and clarify details about the patient and
❖ Rib spreader procedure.
329
PATIENT ASSESSMENT AND for mediastinal exploration. Follow the institution’s guide-
PREPARATION lines regarding determination of the timing of mediastinal
exploration. One recommendation for timing the proce-
Patient Assessment dure is when chest tube drainage continues at equal to or
• Assess hemodynamic and neurological status. Rationale: greater than 3 mL/kg/hr for at least 3 hours.2
This assessment identifies baseline data that may indicate
the need for emergent open sternotomy and provides com- Patient Preparation
parison data. • Verify that the patient is the correct patient using two
• Assess current laboratory data, specifically complete identifiers. Rationale: Before performing a procedure, the
blood cell count, platelet count, international normalized nurse should ensure the correct identification of the patient
ratio, activated partial thromboplastin time, and fibrino- for the intended intervention.
gen. Rationale: Near-normal baseline coagulation study • Ensure that the patient and family understand procedural
results decrease the likelihood of coagulopathy as a pos- teachings (if time available). Answer questions as they
sible cause for ongoing hemorrhage. arise, and reinforce information as needed. Rationale:
• Assess for signs and symptoms of cardiac tamponade. Understanding of the information provided is evaluated
Rationale: The presence of some or all of these signs and and reinforced.
symptoms assists the healthcare team to decide whether • Ensure that informed consent was obtained (may not be
an emergent open sternotomy is necessary: possible if the procedure is an emergency). Rationale:
❖ Sudden decrease or cessation in chest tube drainage Informed consent protects the rights of the patient and
❖ Hypotension (mean arterial blood pressure, <60 mm Hg) ensures a competent decision for the patient and the
❖ Altered mental status family.
❖ Apical heart rate greater than 110 beats/min • Perform a preprocedure verification and time out, if non-
❖ Narrowing of pulse pressure emergent. Rationale: Ensures patient safety.
❖ Distended neck veins • Ensure the patient’s airway is protected and that supple-
❖ Distant heart sounds mental oxygen is delivered. Rationale: Ensures adequate
❖ Equalization of intracardiac pressures, including right ventilation and oxygenation.
atrial, pulmonary artery diastolic, and pulmonary artery • Position the patient in the supine position with the
occlusion pressures head of the bed flat. Rationale: This position ensures
❖ Decreased cardiac output and cardiac index visualization of the chest and enhances hemodynamic
❖ Pulsus paradoxus stability.
• Assess for excessive chest tube drainage. Rationale: Pres- • Administer analgesia and sedation as prescribed. Ratio-
ence of bleeding assists with the determination of the need nale: Promotes patient comfort.
Procedure for Assisting with Emergent Open Sternotomy

1. Assist as needed with calling the The physician can reassess the need Follow the institution’s standard.
patient’s physician and operative for further surgical intervention.
team. The operative team may be needed to
assist at the bedside or to prepare
the operating room if further
exploration is needed.
2. HH
3. PE
4. Assist with preparation of the Electrocautery may be used to Grounding is essential to avoid
electrocautery device for possible terminate capillary oozing or burning the patient and possible
use: bleeding. electrical shock to the healthcare
A. Apply the electrical dispersing providers.
pad (i.e., grounding pad) to Electrocautery may not be
the patient’s dry skin over a immediately available in the
large well perfused muscle. critical care setting; follow
B. Attach the grounding cable to institution standard.
the electrocautery device.1
(Level D*)
*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations
40 Emergent Open Sternotomy (Assist) 331
Procedure for Assisting with Emergent Open Sternotomy—Continued

5. Set up a new sterile suction Suction within the mediastinum is
system. necessary during the procedure.
6. Assist if needed with removing Prepares for the procedure.
the sternal dressing.
7. Assist if needed with cleansing Inhibits microorganism transmission. The skin is cleansed beginning at the
the patient’s chest with an incision line, extending outward to
antiseptic solution (e.g., 2% include the area from the chin to
chlorhexidine gluconate solution). the midabdomen (caudal to the
umbilicus) and to include the area
outward to one anterior axillary
line and then outward to the
opposite anterior axillary line.
Minimize solution from running off
of the surgical site, dripping,
pooling, and soaking fabric and
the patient’s hair.
Ensure alcohol-based preparation
agents have not wet the patient’s
hair or bedding nor pooled in
skin-folds or the umbilicus
because the risk of fire is
increased (nonflammable
preparations eliminate the risk
of fire).1
8. If needed, assist the physician, Inhibits rebound microorganism All personnel in the room must don
advanced practice nurse, or other growth.1 head covers and masks.
healthcare provider performing
the procedure with:
A. Donning surgical head cover,
mask, and eye protection.
B. Donning sterile gown and
sterile gloves.
9. Assist as needed, with opening Prepares equipment.
the sternotomy tray on a clean
dry surface.
10. Assist as needed with fully A large sterile field minimizes the Allows good view of the incision.
draping the patient with exposure risk of infection and provides space
of only the surgical site.1,4,5 to maintain asepsis of instruments
(Level D*) and supplies during the procedure.
11. Assist as needed with setting up Cautery is used to stop bleeding from The cautery control is not sterile.
the electrocautery system (e.g., small vessels. The connection must be handed
adjusting the controls). off of the sterile field without the
healthcare provider performing the
procedure and the assisting
personnel touching each other.
12. Assist as needed with providing Assists with procedure and ensures
supplies and with removing sharp that removed wires are safely
objects (e.g., cut wires) from the discarded.
surgical field.
13. Assist with suctioning as needed. Clears blood from the field.

Procedure for Assisting with Emergent Open Sternotomy—Continued

14. If pulseless ventricular Provides emergent intervention.
tachycardia or ventricular
fibrillation occurs, assist with
obtaining equipment for internal
defibrillation (see Procedures 37
and 38).
15. Prepare chest drainage system Epicardial pacing wires and chest
and pacemaker to be connected tubes can be displaced during
after placement of chest tubes or sternal retraction.
epicardial pacing wires.
16. Assist as needed with obtaining May decrease the incidence of
or preparing warm saline solution infection.
with or without an antibiotic for
flushing chest cavity.
17. Prepare equipment for placement Cardiac tamponade can conceal right
of mechanical assist devices if or left ventricular dysfunction;
needed. mechanical assistance may be
necessary to improve cardiac
output.
18. Assist with transporting the The patient may need further Ensure that the patient’s chest is
patient to the operating room if exploration or surgical repair of covered with sterile drapes or with
necessary. coronary artery bypass grafts, a dressing during transportation.
cardiac valves, the myocardium, or
placement of an assist device (e.g.,
intraaortic balloon pump,
ventricular assist device).
19. If the patient does not return to Ensures sternal closure.
the operating room, assist the
healthcare provider performing
the procedure by providing
supplies for reinsertion of the
sternal wires.
20. Provide supplies for tissue and Ensures closure of the sternal
skin closure. incision.
21. Assist or apply an occlusive Dressings provide a physical barrier The patient’s chest may be left
dressing to the sternal incision, to external sources of open and covered with a sterile
epicardial pacing wires, and chest contamination and cushion from occlusive surgical dressing if
tube sites after the procedure is physical contact and trauma; they severe ventricular dysfunction
completed. absorb drainage, maintain a moist exists.
environment at body temperature
to enhance wound healing, and are
used for aesthetics.
22. Discard used supplies, and Reduces the transmission of A chest radiograph may be ordered
remove and discard PE . microorganisms and body to rule out the presence of any
secretions; Standard Precautions. retained surgical sponges, needles,
or instruments.
23. Assist if needed with packaging Prepares equipment for future use.
used instruments for sterilization.
24. HH
40 Emergent Open Sternotomy (Assist) 333

• Resolution of the condition that necessitated the • Severe right or left ventricular dysfunction
emergent open sternotomy • Continued dysrhythmias, bleeding, or coagulation
• Increased cardiac output disorders
• Increased tissue perfusion, including cerebral, renal, • Myocardial, aortic, coronary artery, or coronary
and peripheral perfusion artery bypass graft perforation
• Minimal chest tube drainage • Cardiac arrest
• Decreased need for blood transfusions • Pneumothorax
• Intracardiac infarction
• Atrial and ventricular dysrhythmias
• Pain
• Surgical site infection
• Death

interventions.
1. Perform cardiovascular, Determines hemodynamic stability • Mean arterial blood pressures
hemodynamic, and peripheral and volume status; recurrent <60 mm Hg
vascular assessments every tamponade or dysrhythmias may • Abnormal changes in heart rate
15–30 minutes as patient develop during and after • Decrease in cardiac index
status requires (including sternotomy. • Abnormal pulmonary artery pressures
vital signs, pulmonary artery Determines the adequacy of cerebral • Urine output <0.5 mL/kg/hr
pressures, cardiac index, level perfusion; hemodynamic instability • Equalizing pulmonary artery
of consciousness, and urine can lead to cerebral anoxia. pressures
output). Determines perfusion to the kidneys. • Change in levels of consciousness
2. Assess heart and lung sounds Abnormal heart and lung sounds • Distant heart sounds
every 2 hours and as needed. may indicate the need for • Abnormal lung sounds
additional treatment.
3. Monitor coagulation, Coagulation and hematologic profiles • Abnormal hemoglobin and
hematologic, and electrolyte provide data that indicate the risk hematocrit, activated partial
laboratory blood study results of bleeding and indicate the need thromboplastin time, international
as prescribed. for additional treatment. normalized ratio, platelets,
Electrolyte studies provide data fibrinogen, calcium, magnesium, or
regarding the risk for dysrhythmias potassium levels
and decreased contractility.
4. Monitor chest tube drainage. Determines functioning of the chest • Cessation of chest tube drainage
tube drainage system and the • Increased chest tube drainage
amount of chest drainage. • Clots in chest tube drainage system
5. Follow institution standard Identifies need for pain interventions. • Continued pain despite pain
for assessing pain. Administer interventions
Documentation
• Patient and family education • Patient therapies and response, including
• Signed informed consent, if nonemergent hemodynamic values, inotropic or vasopressor
• Universal Protocol requirement, if nonemergent agents, ventilation, and neurological status
• Indications for procedure and the procedure performed • Additional interventions
• Amount of blood collected from chest suctioning; • Unexpected outcomes
estimated blood loss • Pain assessment, interventions and effectiveness

40 Emergent Open Sternotomy (Assist) 334.e1
References Additional Reading

1. AORN (Association of periOperative Registered Nurses): Bojar R: Manual of perioperative care in adult cardiac
Perioperative standards and recommended practices, surgery, ed 5, UK, 2011, John Wiley & Sons.
Denver, 2014, AORN. Foroughi M, Hernadez C: Cardiovascular complication and
2. Chikwe J, Cooke D, Weiss A: Cardiothoracic surgery, management after cardiac surgery. In Dabbagh A,
New York, 2013, Oxford University Press Inc. Esmailian F, Aranki SF, editors: Postoperative critical care
3. Hardin S, Kaplow R: Cardiac surgery essentials for cardiac surgical patients, New York, 2014, Springer.
for critical care nursing, Canada, 2010, Jones and Lemmer JH, Vlahakes GJ: Handbook of patient care in
Bartlett. cardiac surgery, ed 7, Philadelphia, 2010, Lippincott
4. Hodge T: Fast facts for the cardiac surgery nurse: Williams & Wilkins.
Everything you need to know in a nutshell, New York, Macaroni MR, et al: Managing cardiac arrest after cardiac
2011, Springer. surgery: The impact of a five year evolving re-sternotomy
5. Phillips N: Berry & Kohn’s operating room technique, policy and a review of the literature. Analg Resusc Cur
ed 12, St Louis, 2012, Mosby. S1:1–7, 2013.
6. Soar J, et al: European Resuscitation Council Guidelines Polonen PE, et al: A prospective, randomized study of
for Resuscitation 2010 Section 8. Cardiac arrest in special goal-oriented hemodynamic therapy in cardiac surgical
circumstances: Electrolyte abnormalities, poisoning, patients. Anest Analg 90:1052–1059, 2000.
drowning, accidental hypothermia, hyperthermia, asthma, Roekaerts PM, Heijmans JH: Early postoperative care after
anaphylaxis, cardiac surgery, trauma, pregnancy, cardiac surgery. In Narin C, editor: Perioperative
electrocution. Resuscitation 81:1400–1433, 2010. considerations in cardiac surgery, Croatia, 2012, In Tech.
PROCEDURE
41
External Wearable
Cardioverter-Defibrillator
Kiersten Henry
PURPOSE: The external wearable cardioverter-defibrillator (WCD) is a temporary
device that is used to prevent sudden cardiac death from malignant ventricular
dysrhythmias. The WCD continuously monitors a patient’s heart rate and rhythm
and attempts to convert ventricular tachycardia or ventricular fibrillation via
defibrillation.
PREREQUISITE NURSING continue for at least 25 seconds, allowing the patient to

KNOWLEDGE deactivate the device if the detected arrhythmia is actually
interference due to electronic devices or motion artifact.
• Knowledge of the anatomy and physiology of the cardio- The patient can deactivate the WCD by pushing a button
vascular system, principles of cardiac conduction, and located on the battery pack. If defibrillation is indicated,
basic dysrhythmia interpretation is needed. the device will audibly warn bystanders to stand clear.2,3
• Knowledge of basic functioning of the WCDs and patient • Audible alerts with the Zoll LifeVest8:
response to WCD therapy is needed. ❖ Gong followed by “Contact your physician” or “Treat-
• Knowledge of principles of defibrillation threshold, anti- ment has been given, call your doctor.” This indicates
dysrhythmia medications, alteration in electrolytes, and that therapy has been given and the patient is being
effect on the defibrillation threshold is necessary. monitored.
• Basic life support (BLS) and advanced cardiac life support ❖ Two-tone alarm followed by “If patient is not respon-
(ACLS) knowledge and skills are needed. sive, call for help, perform CPR,” or “Device disabled,
• The WCD may be utilized as a bridge therapy to the call ambulance.” These mean that the Zoll LifeVest is
implantable cardioverter-defibrillator (ICD). not sensing a shockable rhythm, has delivered the
• The WCD is different from an automated external defibril- maximum number of therapies, or cannot detect the
lator because it requires no bystander assistance. electrocardiogram (ECG).
• The WCD currently commercially available in the United ❖ Two-tone alarm accompanied by “Electrical shock
States is the Zoll LifeVest. The LifeVest is worn by the possible, do not touch patient. Bystanders do not inter-
patient underneath his or her clothes. The purpose of the fere.” A shock will be delivered within 25 to 60 seconds
vest is to sense malignant ventricular arrhythmias and unless the patient deactivates the device. Bystanders
defibrillate as appropriate.1 should stand clear until defibrillation is completed, as
• The vest contains four nonadhesive electrodes that con- they can be shocked if the patient is touched during
tinuously monitor the cardiac rhythm. Three defibrillator defibrillation.
pads release gel just before defibrillation to protect the ❖ The presence of blue gel on the patient’s chest indicates
skin from burns.1 that a defibrillation has likely been delivered.
• The WCD monitor and batteries are worn in a holster • The WCD monitors patient rhythm and stores data about
around the waist (Fig. 41-1). vest utilization. This information is transmitted electroni-
• Patients are advised to change the rechargeable battery cally to the manufacturing company, which provides clini-
daily. Batteries need approximately 1 to 2 hours to recharge cal information to the prescribing provider.
on the charging unit. • Indications for the WCD include any situation in which a
• If the WCD senses ventricular fibrillation or ventricular patient is at risk for sudden cardiac death but is not eligible
tachycardia, it can deliver a series of up to five defibrilla- for an ICD. Delays in ICD eligibility are related to the
tions. The energy delivered is selected by the provider fact that a patient may regain left ventricular function
when the device is ordered. The LifeVest can deliver up with optimal medical therapy, reducing the patient’s risk
to 150 joules per defibrillation. The heart rate threshold of sudden cardiac death.7
for defibrillation is also determined by the ordering • Explanation of an ICD due to infection:8
provider.2,3 ❖ Patients who may require ICD implantation but are
• When a shockable ventricular rhythm is detected, the within the mandated waiting period:4,6
est begins a series of audible warnings and physical vibra- Patients within 40 days of a myocardial infarction
tions to alert the patient and bystanders. The warnings who did not undergo coronary intervention
335
EQUIPMENT
• LifeVest garment
• Sensing electrodes
• Defibrillator pads
• Battery pack with waist holster
• Extra battery pack
• Charging/transmission station
• Cardiac monitor
• Nonsterile gloves
the following:
• Cardiac board
• Resuscitation equipment

• Assess learning needs, readiness to learn, and factors that
influence learning. Rationale: This assessment allows the
nurse to individualize teaching in a meaningful manner.
• Assess patient and family understanding of WCD therapy
and the reason for its use. Rationale: This assessment
provides information regarding knowledge level and
necessity of additional teaching.
• Provide information about the normal conduction system,
Figure 41-1 LifeVest wearable cardioverter-defibrillator. (From such as the structure of the conduction system, the source
ZOLL, Pittsburgh, PA.)
of the heartbeat, the normal and abnormal heart rhythms,
the symptoms of abnormal heart rhythms, and the poten-
Patients within 90 days of a myocardial infarction tially life-threatening nature of VT and VF. Rationale:
who underwent percutaneous coronary intervention Understanding the conduction system and dangerous dys-
or coronary artery bypass grafting rhythmias assists the patient and family in recognizing the
Patients with cardiomyopathy who have not been on seriousness of the patient’s condition and the need for
optimal medical therapy for at least 90 days WCD therapy.
Patients awaiting cardiac transplantation • Provide information about WCD therapy, including the
Patients with ICD indications when the patient’s reason for the WCD, device operation, location of the
condition prohibits ICD implantation device, types of therapy given by the device, risks and
• A clinical trial of the WCD in patients after myocardial benefits of the device, and follow-up. This will occur
infarction who were not eligible for ICD implantation due in conjunction with the provider who ordered the device
to mandatory waiting periods found a survival rate of 91% and the WCD company representative, who provides
in patients wearing the WCD who had ventricular tachy- fitting of the device and patient education. Rationale:
cardia or ventricular fibrillation arrest. The greatest benefit Understanding WCD functioning assists the patient and
was seen in the first 30 days after hospital discharge.4 family in developing realistic perceptions of WCD
• Studies of WCD patients show that 24.5% of sudden therapy.
cardiac deaths were due to respiratory arrest, asystole, or • Reinforce with the patient and family members the impor-
sudden cardiac death. In patients with ventricular tachy- tance of wearing the vest at all times (including during
cardia or ventricular fibrillation arrest while wearing the sleep), except when showering or bathing. Another
WCD, survival was 90%. This trial also showed a 90% responsible adult should be present during showering or
compliance rate in the majority of patients utilizing the bathing to obtain help in the event of a life-threatening
LifeVest WCD.2 dysrhythmia. The device is not waterproof, but should be
• If a patient meets eligibility criteria for an ICD, the ICD worn at all other times. Rationale: Understanding the
is preferable to the WCD.2 importance of compliance with wearing the vest will help
• Research on use of the WCD in children is limited.5 decrease the risk of death from sudden cardiac death.
• For patients presenting to the hospital wearing a WCD, • Reinforce with the patient and family members that only
refer to facility-specific protocols regarding management the patient should press the button to cancel defibrillation
of the device, including communication to all team if the device begins alert. If the patient is not coherent to
members regarding safety precautions with WCD use. abort the defibrillation, it is likely indicated. Family
Some facilities require the device be removed during hos- members should be educated to stand clear of the patient
pitalization, whereas others encourage patients to wear it if defibrillation occurs, and immediately call 911. Ratio-
at all times. nale: Understanding that the device is likely functioning
41 External Wearable Cardioverter-Defibrillator 337
appropriately if defibrillating an unconscious patient will WCD patient and early diagnosis of lethal arrhythmias
help limit the likelihood of inappropriate deactivation by during hospitalization.
bystanders or risk of the bystander injury due to an electri-
cal shock. Patient Preparation
PATIENT ASSESSMENT identifiers. Rationale: Before performing a procedure, the
AND PREPARATION nurse should ensure the correct identification of the patient
for the intended intervention.
Patient Assessment • Ensure that the patient and family understand prepro-
• In conjunction with the physician, advanced practice cedural teaching. Answer questions as they arise, and
nurse, and other healthcare professionals, assess the patient reinforce information as needed. Rationale: Understand-
for orientation and mental capacity to manage the WCD. ing of previously taught information is evaluated and
Rationale: Patients who cannot exercise compliance with reinforced.
the WCD, or deactivate the device before inappropriate • Consent for monitoring and using the device is obtained
defibrillation, are not candidates for WCD therapy.1 from the patient by the WCD product representative.
• Monitor and document the cardiac rhythm per unit proto- Rationale: Placement of the WCD is not an invasive pro-
col during hospitalization. Rationale: This will allow real- cedure. The patient is consenting to the company monitor-
time assessment of any arrhythmias that occur in the ing vest utilization and therapy.
Procedure for External Wearable Cardioverter-Defibrillator

1. HH
2. PE
3. Assist the WCD product There are different vest sizes.
representative as needed in Utilization of the appropriate-
determining the appropriate vest size vest will increase
size for the patient. compliance as well as increase
cardiac monitoring accuracy.
4. Assist if needed with placing the Provides assistance and begins
WCD on the patient. therapy.
5. The patient should wear the This provides an opportunity for The patient should demonstrate an
device as prescribed. the patient to get comfortable understanding of WCD placement, the
with the fit of the device and rationale for wearing the device, and
how it operates. appropriate utilization of the device.
6. Continue cardiac monitoring Monitors for changes in heart The WCD does not protect against
even though the patient is rate and rhythm. arrest from pulseless electrical
wearing the WCD. activity/asystole.
7. If the device indicates that
defibrillation is indicated:9
A. Assess and stay with the A bystander can be shocked
patient. Do not touch the during defibrillation with the
patient. WCD.
B. Wait for the device to The audible alerts will indicate Observe the heart rate and rhythm on
function. The device may which phase of the process the the cardiac monitor.
deliver up to 5 shocks. WCD is in, monitoring or
(Level M*) preparing to defibrillate.
C. If the device successfully Determines the patient’s
converts a life-threatening response to the therapy.
dysrhythmia:
i. Assess the patient’s level
of consciousness.
ii. Assess the patient’s vital
signs and heart rhythm.

Procedure for External Wearable Cardioverter-Defibrillator—Continued

D. If the device is not successful CPR can be interpreted by the device as
in converting a life- ventricular arrhythmia.
threatening dysrhythmia:
i. Remove the WCD battery Disconnecting the battery will The battery should be removed or
and/or vest after deactivate the defibrillator. disconnected before initiation of CPR
defibrillation attempts are If anterior/posterior placement to avoid inappropriate defibrillation.
complete. of defibrillator pads is When removing the WCD, if cutting the
required, the vest should be cloth vest off is required, make every
removed. attempt to avoid cutting through the
ECG leads.
This allows the device to be utilized by
the patient at a later time.
ii. Initiate BLS and ACLS. Provides emergency Patients may progress to pulseless
interventions. electrical activity/asystole, which the
device will not treat.
8. After successful or unsuccessful The device download can be The device will store pre- and
treatment, contact the WCD helpful in determining rhythm posttherapy ECG strips. This
product representative to type (if not captured on a information can also be obtained from
download the device information. hospital-based monitor). the cardiac monitoring system.
9. Discard used supplies and Reduces the transmission of
personal protective equipment in microorganisms and body
appropriate receptacles. secretions; Standard
Precautions.
10. HH
11. Obtain an additional WCD vest Provides equipment needed for
and defibrillator pads from the ongoing therapy.
company representative.

• WCD detects life-threatening VT or VF • WCD delivers inappropriate defibrillation
• WCD delivers appropriate defibrillation • Failure of the WCD to detect VF/VT
• Patient deactivates the WCD if audible/physical • Patient is noncompliant with wearing of the WCD
warnings begin and the patient is conscious • Staff/bystander injury
• Emergency treatment is provided

interventions.
1. Continuous cardiac monitoring. Detects dysrhythmias. • Abnormal heart rate
• Dysrhythmias
2. Assess the patient’s response to WCD Determines patient status after • Anxiety
defibrillation, including anxiety, defibrillation. • Abnormal heart rate
cardiac rate and rhythm, level of • Dysrhythmias
consciousness, and vital signs. • Hypotension
• WCD therapy
• Defibrillation
• WCD malfunction
• Hemodynamic instability
• Neurological changes
assessing pain. Administer analgesia interventions. interventions
as prescribed.
41 External Wearable Cardioverter-Defibrillator 339
Documentation
• WCD settings • Pain
• Patient and family education • Patient response to WCD therapy
• Patient’s return demonstration of device placement and • Anxiety assessment, interventions, and effectiveness
utilization • Occurrence of any unexpected outcomes
• All rhythm-strip recordings • Additional interventions

41 External Wearable Cardioverter-Defibrillator 339.e1
References 6. Heart Rhythm Society 2013: Review of Buxton AE,

1. Adler A, Halkin A, Viskin S: Wearable cardioverter- Lee KL, Fisher JD, Josephson ME, Prystowsky EN,
defibrillators. Circulation 127:854–860, 2013. Hafley G. A randomized study of the prevention of sudden
2. Chung M, et al: Aggregate national experience with the death in patients with coronary artery disease. Multicenter
wearable cardioverter defibrillator: event rates, compliance, unsustained tachycardia trial investigators. N Engl J Med
and survival. J Am Coll Cardiol 56(3):194–203, 2010. 341(25):1882–1890, 1999.
3. Dillon K, Szymkiewicz S, Kaib T: Evaluation of the 7. Klein H, et al: Bridging a temporary high risk of sudden
effectiveness of a wearable cardioverter defibrillator arrhythmic death: experience with the wearable
detection algorithm. J Electrocardiol 43:63–67, 2010. cardioverter defibrillator (WCD). Pacing Clin
4. Epstein A, et al: Wearable cardioverter-defibrillator use in Electrophysiol 33:353–367, 2009.
patients perceived to be at high risk early post-myocardial 8. Mulpuru S, Pretorius V, Birgersdotter-Green U: Device
infarction. J Am Coll Cardiol 62(21):2001–2007, 2013. infections: management and indications for lead
5. Everitt M, Saarel E: Use of the wearable external cardiac extraction. Circulation 128:1031–1038, 2013.
defibrillator in children. Pacing Clin Electrophysiol 9. Zoll Medical Corporation: LifeVest® wearable defibrillator
33(6):742–746, 2010. patient management (poster), 2013.
PROCEDURE
42
Pericardiocentesis (Perform)
Kathleen M. Cox
PURPOSE: Pericardiocentesis is the removal of excess fluid from the pericardial
sac for identification of the etiology of pericardial effusion by fluid analysis
(diagnostic pericardiocentesis) and/or prevention or treatment of cardiac tamponade
(therapeutic pericardiocentesis).
result of trauma, myocardial infarction, or iatrogenic

PREREQUISITE NURSING injury, whereas chronic effusions can result from condi-
tions such as bacterial or viral pericarditis, cancer, autoim-
KNOWLEDGE mune disorders, uremia, etc.2 With a decrease in cardiac
• Advanced cardiac life support (ACLS) knowledge and output, the patient often develops chest pain, dyspnea,
skills are required. tachycardia, tachypnea, pallor, cyanosis, impaired cere-
• Knowledge and skills related to sterile technique are bral and renal function, diaphoresis, hypotension, neck
needed. vein distention, distant or faint heart sounds, and pulsus
• Clinical and technical competence in the performance of paradoxus.4
pericardiocentesis is required. • The amount of fluid in the pericardium is evaluated
• Knowledge of cardiovascular anatomy and physiology is through chest radiograph, two-dimensional echocardio-
needed. gram, electrocardiography (ECG), and clinical findings.
• The pericardial space normally contains 20–50 mL of Chest x-rays may not be diagnostically significant in
fluid. patients with acute traumatic tamponade.6
• Pericardial fluid has electrolyte and protein profiles similar • Pericardiocentesis to remove fluid from the pericardial
to plasma. sac is performed therapeutically to relieve tamponade or
• Pericardial effusion is generally defined as the accumula- to diagnose the etiology of the effusion. An acute tampon-
tion of fluid within the pericardial sac that exceeds the ade resulting in hemodynamic instability necessitates an
stretch capacity of the pericardium, generally more than emergency procedure. Blind pericardiocentesis should be
50 to 100 mL.7 performed only in extreme emergency situations.7
• The space within the pericardial sac is finite; however, • Pericardiocentesis is usually performed via a subxiphoid
initially large increases in intrapericardial volume result approach.
in relatively small changes in intrapericardial pressure. If • Two-dimensional echocardiography or ultrasound to
fluid continues to accumulate and increases intrapericar- assist in guiding the needle during pericardiocentesis is
dial pressures above the filling pressures of the right heart, strongly recommended.2,6,7
right–ventricular diastolic filling is compromised, result- • This procedure may also be performed with fluoroscopy
ing in cardiac tamponade.5 in a cardiac catheterization or interventional radiology
• Intrapericardial fluid accumulation can be acute or chronic suite.
and therefore varies in presentation of symptoms. Acute • Urgent or emergent chest exploration is necessary in the
effusions are usually a rapid collection of fluid occurring face of cardiac injury, rapid reaccumulation of pericardial
over minutes to hours and may result in hemodynamic fluid, or ineffective drainage of the pericardium.
compromise with volumes of less than 250 mL.6 Chroni- • There are no absolute contraindications to pericardio-
cally developing effusions occurring over days to weeks centesis in the setting of life-threatening hemodynamic
allow for hypertrophy and distention of the fibrous instability. Relative contraindications include coagulopa-
pericardial membrane. Patients with chronic effusions thy, prior thoracic surgery or pacemaker placement, arti-
may accumulate greater than or equal to 2000 mL of ficial heart valves or other cardiac devices, or inability to
fluid before exhibiting symptoms of hemodynamic directly visualize the effusion using ultrasound during
compromise.6 procedure.6
• Symptoms of cardiac tamponade are nonspecific so the • Cardiac output is generally improved after
diagnosis relies on clinical suspicion and associated signs pericardiocentesis.
and symptoms. Acute pericardial effusions are usually a
EQUIPMENT
practice nurses, and other healthcare professionals (including critical care • Pericardiocentesis tray (or thoracentesis tray)
nurses) with additional knowledge, skills, and demonstrated competence per • 16-gauge or 18-gauge, 3-inch cardiac needle or catheter
professional licensure or institutional standard. over the needle
340
42 Pericardiocentesis (Perform) 341
• Antiseptic skin preparation solution (e.g., 2% is necessary to determine the patient’s baseline health
chlorhexidine-based preparation) status and to identify potential risk factors. The nurse-
• Two packs of 4 × 4 gauze sponges patient interaction provides an opportunity for the nurse
• No. 11 knife blade with handle (scalpel) to establish a therapeutic relationship focused on the
• Sterile 50-mL to 60-mL, 10-mL, 5-mL, and 3-mL syringes patient.2
• Sterile drapes and towels • Assess the patient’s neurological status, heart rate, cardiac
• Masks, goggles or face shields, surgical head covers, rhythm, heart sounds (S1, S2, rubs, murmurs), pulmonary
sterile gowns, and gloves artery pressures, central venous pressure (noninvasive or
• Two three-way stopcocks invasive), blood pressure, mean arterial pressure (MAP),
• 1% lidocaine (injectable) oxygen saturation via pulse oximetry (Spo2), and respira-
• 10 mL syringe with 25-gauge needle tory status. Rationale: Provides baseline data.
• Culture bottles and specimen tubes for fluid analysis • Evaluate current laboratory values to include a complete
• 2-inch and 3-inch tape blood cell count, electrolytes, and coagulation profile.
Additional equipment, to have available as needed, includes Rationale: Review of these data is essential to identify
the following: the potential risk of cardiac dysrhythmias or abnormal
• Emergency cart (defibrillator, emergency respiratory bleeding. If the international normalized ratio or partial
equipment, emergency cardiac medications, and tempo- thromboplastin time or both are elevated, reversing the
rary pacemaker) level of anticoagulation therapy should be considered
• Two-dimensional echocardiography equipment before performing the procedure. It may be prudent to
• 12-lead ECG machine defer the procedure until the blood levels indicate a reduc-
• Sterile marker tion in bleeding risk.6
• Echocardiogram contrast medium
• Suture supplies Patient Preparation
• Scissors • Confirm that the patient and family understand preproce-
• If continuous drainage is necessary: dural teaching by having them verbalize understanding.
❖ J guidewire, 0.035 diameter Clarify key points by reinforcing important information
❖ Vessel dilator, 7 Fr and answer all questions. Rationale: Preprocedure com-
❖ Pigtail catheter, 7 Fr munication provides a framework of patient expectations,
❖ Tubing and drainage bag or bottle enhances cooperation, and reduces anxiety.2
❖ Three-way stopcock and nonvented caps • Verify that the patient is the correct patient using two
identifiers. Rationale: The nurse should always ensure the
PATIENT AND FAMILY EDUCATION correct identification of the patient for the intended inter-
vention for patient safety.
• Explain to the patient and family the reason necessitating • Obtain informed consent by providing specific and rele-
the pericardiocentesis (e.g., relief of pressure on the heart); vant information about the procedure. Implied consent
describe the procedure in detail, to include risks, benefits, may be assumed if emergent life-saving intervention is
alternatives, expected outcomes, and potential complica- necessary. Rationale: Informed consent is based on the
tions. Rationale: Communication of pertinent information autonomous right of the patient and facilitates a competent
helps the patient and family to understand the procedure decision for the patient and the family.2
and the potential risks and benefits, subsequently reducing • Perform a preprocedure verification and time out, if non-
anxiety and apprehension.1 emergent. Rationale: Ensures patient safety.
• Teach the patient and family about the signs and symp- • Coordinate the procedure with the echocardiogram techni-
toms of pericardial effusion (e.g., dyspnea, dull ache or cian or ultrasonographer to assist with the two-dimensional
pressure within the chest, dysphagia, cough, tachypnea, echocardiogram or ultrasound if this approach is being
hoarseness, hiccups, or nausea).4,5 Rationale: Early rec- used. Rationale: Echocardiogram- or ultrasound-directed
ognition of signs and symptoms of recurrent pericardial pericardiocentesis allows for more precise localization of
effusion may prompt detection of a potentially life- the effusion and is associated with higher success rates
threatening problem. and lower complication rates.5–7
• If nonemergent, prescribe and ensure that an analgesic
PATIENT ASSESSMENT AND and/or sedative is administered. Rationale: Analgesia
PREPARATION and sedation reduce anxiety and promote comfort and
cooperation.
Patient Assessment • Apply the limb leads and connect the leads to the cardiac
• Elicit the patient’s history of the present illness and mech- bedside monitoring system or to the 12-lead ECG
anism of injury (if applicable), past medical history, and machine. Rationale: The ECG is monitored during and
current medications and/or medical therapies from the after the procedure for changes that may indicate cardiac
patient or reliable source. Rationale: A thorough history injury.
Procedure for Performing Pericardiocentesis

1. HH
2. PE Consider putting a mask on the
patient during the actual procedure
if the patient is not intubated (in a
contained system), especially if the
patient has methicillin-resistant
Staphylococcus aureus (MRSA)–
positive results on nasal swab or
known colonization.
3. Prepare the pericardiocentesis Reduces the potential for infection.
tray and supplies with aseptic
technique.
4. Position patient in the supine Facilitates patient comfort, decreases
position with the head of the bed work of breathing, and aids
elevated 30–45 degrees as the adequate aspiration of fluid.
patient’s condition allows.
5. Cleanse the skin with antiseptic Minimizes the potential for infection. Clipping the hair may be necessary
solution (e.g., 2% chlorhexidine- before applying antiseptic solution.
based preparation) and perform
HH.
6. If two-dimensional
echocardiogram or ultrasound is
being used, skip to step 14.
7. Using maximal barrier Minimizes the risk of infection;
precautions, fully drape the maintains aseptic and sterile
patient with exposure of only the precautions.
surgical site and apply mask,
goggles or face shield, surgical
cap, sterile gown, and sterile
gloves.2
8. Attach a three-way stopcock to a Provides the mechanism to aspirate
3-inch cardiac needle, and attach fluid.
to a 50-mL or 60-mL syringe.
9. If time and patient condition Reduces patient discomfort. Local infiltration of analgesia reduces
permit, inject access site with patient discomfort.
2–3 mL 1% lidocaine using a Alternatively, as the needle is
10-mL syringe and a 25-gauge introduced, the physician, advanced
needle, raising a wheal. If unable practice nurse, or other healthcare
to perform this step, attach a professional may insert a small
syringe with 1% lidocaine to one amount of 1% lidocaine to add
side of the stopcock to inject analgesic effect.
analgesia during the access
procedure.
10. Continuously monitor the bedside Determines patient response during A 12-lead ECG machine can also be
ECG, vital signs, Spo2, and the procedure. used for cardiac monitoring.
venous pressure during needle
aspiration and fluid
withdrawal.2,4,5
Procedure for Performing Pericardiocentesis—Continued

11. Subxiphoid approach to Minimizes the risk of cardiac injury; The movement of the heart usually
pericardiocentesis (Fig. 42-1): angles >45 degrees may lacerate the defibrinates blood in the pericardial
A. A 16- or 18-gauge needle is liver or stomach. space so that it cannot clot.8
slowly inserted into the left Clotting usually indicates penetration
xiphocostal angle of the heart chamber and blood
perpendicular to the skin obtained from within a ventricle or
3–4 mm below the left costal atrium.5
margin. Slowly advance the If clotting occurs with the fluid
needle under the xiphoid obtained, withdraw the needle.
toward the left shoulder while If no fluid is aspirated, withdraw the
maintaining negative pressure needle completely and redirect it
on the syringe (aspirating). working from the patient’s left to
B. After the needle is advanced right.
to the inner aspect of the rib
cage, the needle’s hub is
depressed while the needle
points toward the patient’s left
shoulder. The needle is slowly
advanced 5–10 mm until fluid
is aspirated. You may feel a
distinct “give” when the
needle penetrates the
pericardium. Successful
removal of fluid confirms
needle position.
12. When the needle position is Removes the pericardial fluid for Usual tests include body fluid
confirmed, obtain the fluid analysis. cytology, cell count, electrolytes,
samples and remove the needle. routine aerobic and anaerobic
No more than 50–150 mL of cultures, acid-fast bacilli cultures,
pericardial fluid should be and other tests as indicated.
removed at one time.5,6
(Level E*)
If continuous drainage is
needed, go to step 19.
13. Label the specimen and send the Prepares the sample for analysis.
specimen to the laboratory.
When Two-Dimensional Echocardiogram or Ultrasound Is Used
14. Perform a two-dimensional Two-dimensional echocardiogram or
echocardiogram or ultrasound to ultrasound can help to identify the
determine the location and size of location and size of the pericardial
the effusion. effusion.
15. Determine the ideal entry site and The ideal entry site is the point where A straight trajectory that best avoids
needle trajectory for the the effusion is closest to the vital structures, including the liver,
pericardiocentesis. transducer and fluid accumulation is myocardium, and lung, should be
maximal.4,6,7 chosen.
The internal mammary artery also
should be avoided.6–8
16. Mark the skin with a sterile May aid with the procedure.
marker.
17. Return to Step 7 and follow the
procedural steps.

B
E
Figure 42-1 Subxiphoid approach to catheter placement into pericor-

dial space. A, A short needle (16 gauge or 18 gauge) is inserted into the
left xiphocostal angle perpendicular to the skin and 3 to 4 mm below the
left costal margin. B, After the needle is advanced to the inner aspect of
the rib cage, the needle’s hub is depressed so that the needle points
toward the patient’s left shoulder. The needle is then cautiously advanced
about 5 to 10 mm until fluid is reached. The fingers may sense a distinct
“give” when the needle penetrates the parietal pericardium. Successful
removal of fluid confirms the needle’s position. C, The syringe is then
disconnected from the needle, and the flexible tip of the guidewire is
advanced into the pericardial space. The needle is withdrawn and
replaced with a soft multihole pigtail catheter (6 Fr to 8 Fr) with use of
the Seldinger technique. D, After dilation of the needle tract, the catheter
is advanced over the guidewire into the pericardial space. E, Once the
catheter is properly positioned, aspiration of fluid should result in rapid
improvement in blood pressure and cardiac output, a decrease in atrial
and pericardial pressures, and a decrease in the degree of any paradoxical
pulse. Electrical alternans, if present, also decreases or disappears. (From
C Guidewire Spodick DH: The technique of pericardiocentesis, J Crit Ill 2:91, 1987.)

18. If bloody fluid is aspirated, a few If the contrast material appears in the Two-dimensional echocardiogram or
milliliters of echo contrast pericardial space, the procedure can ultrasound assists in determining
medium can be infused to be continued. the position of the needle.
confirm position.6,7 If the contrast material disappears, the Echo contrast is agitated saline
A. Echocardiogenic saline can be needle may be in one of the heart solution that is injected via the side
prepared by using two 5-mL chambers and must be withdrawn port of the stopcock.6
syringes attached to a three- and repositioned.
way stopcock, one filled with
sterile normal saline and one
with air.
B. Agitate the saline between the
two syringes and inject into
the sheath. The agitated saline
should appear as an echogenic
stream.7
C. When the fluid is determined
to be pericardial, return to
Step 12.
When Continuous Drainage Is Desired
19. When the needle tip position is A soft guidewire minimizes the risk
confirmed to be within the of cardiac injury and allows for the
pericardial space, insert the passage of the guidewire and
flexible tip of the guidewire placement within the pericardial
through the needle into the space.
pericardial space and then remove
the needle, leaving the guidewire
in place. The guidewire is passed
so that it wraps around the heart
within the pericardial space.6,7
20. A multiholed pigtail or straight A flexible-tipped soft catheter with Either a pigtail catheter or a straight
soft catheter is passed over the multiple holes in the tip is used to catheter with multiple holes can be
guidewire using the Seldinger facilitate drainage of the effusion. used for better drainage.
technique5 (see Fig. 42-1). Use of a soft-tipped catheter reduces
the chances of causing myocardial
injury and dysrhythmias during the
procedure.1
21. Remove the guidewire and Maintains asepsis; allows for If the effusion is small, when fluid is
connect the end of the catheter to continual drainage of the effusion. drained remove the catheter.
the three-way stopcock and the
drainage collection bag.5–7
22. If an indwelling catheter is placed Facilitates fluid drainage; minimizes
to continuously drain a large the potential for infection.
pericardial effusion, attach the
catheter to the sterile bag or
bottle using aseptic technique
(see Procedure 78).
23. If an indwelling catheter is to Prevents dislodging or accidental
remain in place, secure the removal.
catheter by suturing the catheter
securely to the patient’s chest
wall.
24. Cleanse the area around the May reduce the risk of infection.
catheter with an antiseptic
solution and apply an occlusive
sterile dressing.3

25. Continue bedside ECG Allows monitoring of cardiac rate and
monitoring, and discontinue rhythm.
12-lead ECG if used.
26. Dispose of PE , sharps, and used
supplies in appropriate
receptacles.
27. HH
28. If an indwelling catheter is May reduce the risk of infection.
placed, consider prescribing
antibiotics.

• Fluid removed from the pericardial sac • Decrease in blood pressure, increase in venous
• Relief of pain, discomfort, or other symptoms that pressure, cardiac dysrhythmias, or excessive bleeding
indicated the need for the procedure • Hemodynamic instability
• Improved cardiac output • ST-segment depression
• Patient’s blood pressure, venous pressure, heart • PR-segment elevation
sounds, pulse pressure, and cardiac rhythm within • Cardiac tamponade
normal limits • Pain

interventions.
1. Continuously monitor ECG; A change in these signs may indicate • Increasing venous pressure
assess pulmonary artery (PA) cardiac tamponade, cardiac injury, • Decreasing arterial pressure
pressures, venous pressure, blood or hemodynamic instability. • Change in level of consciousness
pressure, Spo2, and neurological • Pulsus paradoxus
status during and every 15 • Equalizing PA pressures
minutes after the procedure until • Decreased cardiac index
stable (if available, continuously • Abnormal systemic vascular
monitor cardiac index and resistance
systemic vascular resistance).
2. Treat dysrhythmias if they occur. Dysrhythmias may lead to cardiac • Persistent dysrhythmias despite
decompensation. appropriate intervention
3. Auscultate heart and lung sounds Evaluates potential pericardial fluid • Asymmetrical breath sounds
immediately after the procedure. reaccumulation or puncture of the • Dyspnea
lung. • Tachypnea
• Decreased Spo2
• Distant or faint heart sounds
4. Obtain a portable chest Assesses for pneumothorax and • Pneumothorax
radiograph immediately after the hemothorax. • Hemothorax
procedure.
5. Obtain a two-dimensional Determines the effectiveness of the • Pericardial effusion
echocardiogram within several pericardial drainage.
hours after the procedure.

6. Monitor the pericardiocentesis Assesses for post-procedural • Bleeding or hematoma at site
site for bleeding every 15 hemostasis and possible drainage.
minutes after the procedure is
completed until the patient’s
condition is stable, then every 4
hours for 24 hours. If an
indwelling catheter is present,
continue to monitor the site every
4 hours until the catheter is
removed.
7. Monitor hemoglobin, hematocrit, Assesses for potential of effusion • Bleeding or hematoma at site
and coagulation studies every 8 recurrence or bleeding at the site. • Decrease in hemoglobin or
hours after the procedure for 24 hematocrit values
hours or as indicated. • Changes in coagulation study
results
8. Assess pericardiocentesis site Determines the presence of infection. • Erythema
every day. • Edema
• Purulent drainage
• Foul odor
• Temperature >100.5°F (>38°C)
9. Prescribe site care:
A. Cleanse the area surrounding May reduce infection. The Centers for
the pericardial catheter with Disease Control and Prevention
an antiseptic solution (e.g., (CDC) do not have a specific
2% chlorhexidine-based recommendation for care of
preparation). pericardial catheters or site care.
B. Apply a dry sterile gauze or The CDC recommends replacing
transparent dressing with the intravascular catheter dressings
date and time of the dressing when the dressing becomes damp,
change. loosened, or soiled or when
inspection of the site is necessary.3
10. Evaluate the size of the effusion Records how effective drainage was • Increased size of the effusion
within 24 hours of the indwelling and whether the need for the
catheter placement with the use indwelling catheter continues to
of a two-dimensional exist.
echocardiogram.
11. Remove the indwelling catheter Minimizes the potential for infection.
using aseptic technique when no
longer needed.
12. Be prepared for emergent chest Deterioration may indicate • Decreased blood pressure
exploration if sudden reaccumulation of cardiac • Presence of dysrhythmias
deterioration in the patient’s tamponade or cardiac damage. • Increased venous pressure
condition occurs. • Change in mental or respiratory
status
• Diaphoresis
• Distant heart sounds
13. Provide emotional support to the Minimizes apprehension and anxiety.
patient throughout the procedure.
14. Keep the patient and family The unknown increases the anxiety
informed about the patient’s and apprehension of the patient and
condition. Be available to answer family.
patient’s and family’s questions
and facilitate meeting their needs
as appropriate.
15. Assess pain and prescribe Identifies need for pain interventions. • Continued pain despite pain
analgesia as needed. interventions
Documentation
• Specific preprocedure instruction and patient’s and • Placement of indwelling catheter (if used) to include
family’s satisfactory understanding total length, diameter, and length from skin to hub
• Universal Protocol requirement, if nonemergent • Removal of indwelling catheter, if used
• Legally signed consent form • Assessment of pericardiocentesis fluid
• Pre- and postprocedure level of consciousness; blood • Amount and consistency of postprocedure drainage
pressure; venous pressures; pulmonary arterial • Occurrence of unexpected outcomes
pressures; cardiac index, cardiac output, systemic • Pain assessment, interventions and effectiveness
vascular resistance, if available; heart sounds and • Pre- and postprocedural evaluation and location of
cardiac rhythm; respiratory status and pulse oximetry effusion with two-dimensional echocardiogram, if
reading used
• Pre- and postprocedure hemoglobin, hematocrit, and • ECG rhythm strips
coagulation results, if performed • Emergency interventions performed if necessary
• Medications administered with dosage and times noted • Specimens sent to the laboratory

42 Pericardiocentesis (Perform) 348.e1
References 6. Mallemat HA, Tewelde SZ: Pericardiocentesis. In Roberts

1. Bailey L: Strategies for decreasing patient anxiety in the JR, editor: Roberts & Hedges clinical procedures in
perioperative setting. AORN J 92(4):445–457, 2010. emergency medicine, ed 6, Philadelphia, 2014, Elsevier
2. Burlew CC, Moore EE: Emergency department thoracotomy. Saunders, pp 298–318.
In Mattox KL, Moore EE, Feliciano DV, editors: Trauma, ed 7. Synovitz CK, Brown EJ: Pericardiocentesis. In Tintinalli
7, New York, 2013, McGraw-Hill Medical, pp 236–239. JE, editor: Tintinelli’s emergency medicine: A
3. Centers for Disease Control and Prevention: Guidelines comprehensive study guide, ed 7, New York, 2011,
for the prevention of vascular catheter-related infections McGraw-Hill Medical, pp 250–257.
(DHHS publication), Washington, DC, 2011, US 8. Wall MJ, Tsai P, Mattox K: Heart and thoracic vascular
Government Printing Office. injuries. In Mattox KL, Moore EE, Feliciano DV, editors:
4. Gucalp R, Dutcher JP: Oncologic emergencies. In Loscalzo Trauma, ed 7, New York, 2013, McGraw-Hill Medical,
J, editor: Harrison’s pulmonary and critical care medicine, pp 485–488.
New York, 2010, McGraw-Hill Medical, pp 476–478.
5. Jneid H, Maree AO, Palacios IF: Pericardial tamponade: Additional Reading
Clinical presentation, diagnosis, and catheter-based Labovitz AJ, et al: Focused cardiac ultrasound in the emergent
therapies. In Parrillo JE, Dellinger RP, editors: Critical setting: A consensus statement of the American Society of
care medicine, ed 4, Philadelphia, 2014, Elsevier Saunders, Echocardiography and American College of Emergency
pp 82–85. Physicians. J Am Soc Echocardiogr 23:1225–1230, 2010.
PROCEDURE
43
Pericardiocentesis (Assist)
Kathleen M. Cox
PURPOSE: Pericardiocentesis is the removal of excess fluid from the pericardial
sac for identification of the etiology of pericardial effusion by fluid analysis
(diagnostic pericardiocentesis) and/or prevention or treatment of cardiac tamponade
(therapeutic pericardiocentesis).
PREREQUISITE NURSING vein distention, distant or faint heart sounds, and pulsus
KNOWLEDGE paradoxus.4
• The amount of fluid in the pericardium is evaluated
• Advanced cardiac life support (ACLS) knowledge and through chest radiograph, two-dimensional echocardio-
skills are required. gram, electrocardiography (ECG), and clinical findings.
• Knowledge and skills related to aseptic technique are Chest x-rays may not be diagnostically significant in
necessary. patients with acute traumatic tamponade.6
• Knowledge of cardiovascular anatomy and physiology is • Pericardiocentesis to remove fluid from the pericardial
needed. sac is performed therapeutically to relieve tamponade or
• The pericardial space normally contains 20–50 mL of to diagnose the etiology of the effusion. An acute tampon-
fluid. ade resulting in hemodynamic instability necessitates an
• Pericardial fluid has electrolyte and protein profiles similar emergency procedure. Blind pericardiocentesis should be
to plasma. performed in emergency situations.7
• Pericardial effusion is generally defined as the accumula- • Pericardiocentesis is usually performed via a subxiphoid
tion of fluid within the pericardial sac that exceeds the approach.
stretch capacity of the pericardium, generally more than • Two-dimensional echocardiography or ultrasound to
50 to 100 mL.7 assist in guiding the needle during pericardiocentesis is
• The space within the pericardial sac is finite; however, strongly recommended.2,6,8
initially large increases in intrapericardial volume result • This procedure may also be performed with fluoroscopy
in relatively small changes in intrapericardial pressure. If in a cardiac catheterization or interventional radiology
fluid continues to accumulate and increases intrapericar- suite.
dial pressures above the filling pressures of the right heart, • Urgent or emergent chest exploration is necessary in the
right-ventricular diastolic filling is compromised, result- face of cardiac injury, rapid reaccumulation of pericardial
ing in cardiac tamponade.5 fluid, or ineffective drainage of the pericardium.
• Intrapericardial fluid accumulation can be acute or • There are no absolute contraindications to pericardiocen-
chronic and therefore varies in presentation of symptoms. tesis in the setting of life-threatening hemodynamic insta-
Acute effusions are usually a rapid collection of fluid bility. Relative contraindications include coagulopathy,
occurring over minutes to hours and may result in hemo- prior thoracic surgery or pacemaker placement, artificial
dynamic compromise with volumes of less than 250 mL.6 heart valves or other cardiac devices, or inability to
Chronically developing effusions occurring over days directly visualize the effusion using ultrasound during the
to weeks allow for hypertrophy and distention of the procedure.6
fibrous pericardial membrane. Patients with chronic effu- • Cardiac output is generally improved after
sions may accumulate greater than or equal to 2000 mL pericardiocentesis.
of fluid before exhibiting symptoms of hemodynamic
compromise.6 EQUIPMENT
• Symptoms of cardiac tamponade are nonspecific so the
diagnosis relies on clinical suspicion and associated signs • Pericardiocentesis tray (or thoracentesis tray)
and symptoms. Acute pericardial effusions are usually a • 16-gauge or 18-gauge, 3-inch cardiac needle or catheter
result of trauma, myocardial infarction, or iatrogenic over the needle
injury, whereas chronic effusions can result from condi- • Antiseptic skin preparation solution (e.g., 2%
tions such as bacterial or viral pericarditis, cancer, autoim- chlorhexidine-based preparation)
mune disorders, uremia, etc.2 With a decrease in cardiac • Two packs of 4 × 4 gauze sponges
output, the patient often develops chest pain, dyspnea, • No. 11 knife blade with handle (scalpel)
tachycardia, tachypnea, pallor, cyanosis, impaired cere- • Sterile 50-mL to 60-mL, 10-mL, 5-mL, and 3-mL syringes
bral and renal function, diaphoresis, hypotension, neck • Sterile drapes and towels
349
• Masks, goggles or face shields, surgical head covers, interaction provides an opportunity for the nurse to estab-
sterile gowns, and gloves lish a therapeutic relationship focused on the patient.2
• Two three-way stopcocks • Assess the patient’s neurological status, heart rate, cardiac
• 1% lidocaine (injectable) rhythm, heart sounds (S1, S2, rubs, murmurs), pulmonary
• 10-mL syringe with 25-gauge needle artery pressures, central venous pressure (noninvasive or
• Culture bottles and specimen tubes for fluid analysis invasive), blood pressure, mean arterial pressure, oxygen
• 2-inch and 3-inch tape saturation via pulse oximetry (Spo2), and respiratory
Additional equipment, to have available as needed, includes status. Rationale: Provides baseline data.
the following: • Evaluate current laboratory values to include a complete
• Emergency cart (defibrillator, emergency respiratory blood cell count, electrolytes, and coagulation profile.
equipment, emergency cardiac medications, and tempo- Rationale: Review of these data is essential to identify
rary pacemaker) the potential risk of cardiac dysrhythmias or abnormal
• Two-dimensional echocardiography equipment bleeding. If the international normalized ratio or partial
• 12-lead ECG machine thromboplastin time or both are elevated, reversing the
• Sterile marker level of anticoagulation therapy should be considered
• Echocardiogram contrast medium before performing the procedure. It may be prudent to
• Suture supplies defer the procedure until the blood levels indicate a reduc-
• Scissors tion in bleeding risk.6
• If continuous drainage is necessary:
❖ J guidewire, 0.035 diameter
Patient Preparation
❖ Vessel dilator, 7 Fr • Confirm that the patient and family understand preproce-
❖ Pigtail catheter, 7 Fr dural teaching by having them verbalize understanding.
❖ Tubing and drainage bag or bottle Clarify key points by reinforcing important information
❖ Three-way stopcock and nonvented caps and answer all questions. Rationale: Preprocedure com-
munication provides a framework of patient expectations,
PATIENT AND FAMILY EDUCATION enhances cooperation, and reduces anxiety.2
• Explain to the patient and family the reason necessitating identifiers. Rationale: The nurse should always ensure the
the pericardiocentesis (e.g., relief of pressure on the heart). correct identification of the patient for the intended inter-
Rationale: Communication of pertinent information helps vention for patient safety.
the patient and family to understand the procedure and • Ensure that informed consent is obtained. Implied consent
may reduce anxiety and apprehension.1 may be assumed if emergent life-saving intervention is
• Teach the patient and family about the signs and symp- necessary. Rationale: Informed consent is based on the
toms of pericardial effusion (e.g., dyspnea, dull ache or autonomous right of the patient and facilitates a competent
pressure within the chest, dysphagia, cough, tachypnea, decision for the patient and the family.2
hoarseness, hiccups, or nausea).4,5 Rationale: Early rec- • Assist as needed with a preprocedure verification and time
ognition of signs and symptoms of recurrent pericardial out, if nonemergent. Rationale: Ensures patient safety.
effusion may prompt detection of a potentially life- • Assist with coordinating the procedure with the echocar-
threatening problem. diogram technician or ultrasonographer to assist with the
two-dimensional echocardiogram or ultrasound if this
PATIENT ASSESSMENT AND approach is being used. Rationale: Echocardiogram- or
PREPARATION ultrasound-directed pericardiocentesis allows for more
precise localization of the effusion and is associated with
Patient Assessment higher success rates and lower complication rates.5–7
• Elicit complete history of present illness and mechanism • Administer analgesics or sedatives as prescribed. Ratio-
of injury (if applicable), past medical history, and current nale: Analgesia and sedation reduce anxiety and promote
medications and/or medical therapies from the patient or comfort and cooperation.
reliable source. Rationale: A thorough history is neces- • Continue cardiac monitoring or initiate bedside cardiac mon-
sary to determine the patient’s baseline health status itoring. Rationale: The ECG is monitored during and after
and to identify potential risk factors. The nurse-patient the procedure for changes that may indicate cardiac injury.
43 Pericardiocentesis (Assist) 351
Procedure for Assisting With Pericardiocentesis

1. HH
patient during the actual
procedure if the patient is not
intubated (in a contained
system), especially if the patient
has methicillin-resistant
Staphylococcus aureus
(MRSA)–positive results on
nasal swab or known
colonization.
3. Using aseptic technique, assist as needed Prepares for procedure.
with opening the pericardiocentesis tray
and supplies.
4. If tolerated, ensure that the patient is Facilitates patient comfort,
positioned in the supine position with the decreases work of breathing,
head of the bed elevated 30–45 degrees. and aids adequate aspiration of
fluid.
5. Assist the physician, advance practice Minimizes the potential for Clipping hair from the area may
nurse, or healthcare provider performing infection. be necessary before applying
the procedure with cleansing the patient’s the antiseptic solution.
skin with antiseptic solution (e.g., 2%
chlorhexidine-based preparation) and
perform HH.
6. If two-dimensional echocardiogram or
ultrasound is being used, skip to Step
14.
7. Assist as needed with applying personal Protects provider and maintains
protective, and sterile equipment (e.g., aseptic and sterile technique.
masks, head covers, sterile gowns, and
sterile gloves) and if needed assist with
fully draping the patient with exposure
of only the surgical site.
8. Assist if needed with providing a Provides needed supplies.
three-way stopcock, 3-inch cardiac
needle, and 50-mL or 60-mL syringe.
9. Assist if needed with preparing for a Reduces patient’s discomfort. As the needle is introduced, the
local injection (e.g., 10-mL syringe with physician, advanced practice
1% lidocaine and a 25-guge needle). nurse, or other healthcare
professional may insert a small
amount of 1% lidocaine to add
analgesic effect.
10. Continuously monitor the bedside ECG, Determines the patient’s response
vital signs, Spo2, pulmonary artery during the procedure.
pressures, and venous pressure during
needle aspiration and fluid
withdrawal.2,4,5
11. Continuously monitor the patient as the Continues to determine patient The movement of the heart
physician, advanced practice nurse, or response during the procedure. usually defibrinates blood in the
other healthcare professional slowly pericardial space so that it
inserts the needle. cannot clot.
Clotting usually indicates
penetration of the heart
chamber and blood obtained
from within a ventricle or
atrium.1,3
Procedure for Assisting With Pericardiocentesis—Continued

12. Assist if needed with obtaining Provides diagnosis of the organism Usual tests include body fluid
pericardial fluid samples. If continuous involved in pericardial effusion. cytology, cell count,
drainage is used, go to step 17. electrolytes, routine aerobic and
anaerobic cultures, acid-fast
bacilli cultures, and other tests
as indicated.
13. Assist if needed with labeling the Prepares the samples for analysis.
specimens and send the specimens to the
laboratory.
When Two-Dimensional Echocardiogram or Ultrasound Is Used
14. Assist the physician, advanced practice Provides assistance. Assist if needed with marking the
nurse, or other healthcare professional skin with a sterile marker.
and the echocardiogram/ultrasound
technician as needed.
15. Return to Step 7 and proceed.
16. If bloody fluid is aspirated, be prepared Provides assistance.
to assist the physician, advanced practice
nurse, or other healthcare professional in
infusing a few milliliters of echo contrast
medium into the space where the needle
is to confirm position.6,7
If requested, prepare echocardiogenic
saline with aseptic technique by:
A. Attaching two 5-mL syringes to a
three-way stopcock, one filled with
air and one with 5 mL sterile normal
saline.
B. Hand the syringes attached to the
stopcock using aseptic technique to
the physician, advanced practice
nurse, or other healthcare
professional performing the
procedure.
When this is determined to be pericardial
fluid, return to step 12.
When Continuous Drainage Is Desired
17. Assist the physician, advanced practice Provides assistance.
nurse, or other healthcare professional if
needed as he or she removes the steel
needle and inserts a soft floppy-tipped
guidewire through the needle. The
guidewire is passed so that it wraps
around the heart within the pericardial
space.6,7
18. Assist the physician, advanced practice Maintains asepsis; allows for
nurse, or other healthcare professional continual drainage of the
with removing the guidewire and effusion.1
connecting the end of the catheter to the
three-way stopcock and the drainage
collection bag.5–7
19. If an indwelling catheter is placed to Facilitates fluid drainage;
continuously drain a large pericardial minimizes the potential for
effusion, assist the physician, advanced infection.
practice nurse, or other healthcare
professional with attaching the sterile
bag or bottle with aseptic technique (see
Procedure 78).
Procedure for Assisting With Pericardiocentesis—Continued

20. If an indwelling catheter is in place, Prevents dislodging or accidental
assist the physician, advanced practice discontinuation of the drainage.
nurse, or other healthcare professional if
needed by providing suture supplies.
21. Assist if needed with cleansing the area May reduce the risk of infection.
around the catheter with antiseptic
solution and apply an occlusive sterile
dressing.3
22. Continue bedside ECG monitoring and Allows monitoring of cardiac rate
discontinue the 12-lead ECG if used. and rhythm.
23. Dispose of PE and used supplies in Reduces the transmission of
appropriate receptacles. microorganisms; Standard
Precautions.
24. HH
25. Administer antibiotics as prescribed. May reduce the risk of infection.

• Fluid removed from the pericardial sac • Decrease in blood pressure, rise in pulmonary artery
• Relief of pain, discomfort, or other symptoms that pressures, venous pressure, cardiac dysrhythmias, or
indicated the need for the procedure excessive bleeding
• Improved cardiac output • Hemodynamic instability
• Patient’s blood pressure, venous pressure, heart • ST-segment depression
sounds, pulse artery pressures, and cardiac rhythm • PR-segment elevation
within normal limits • Cardiac tamponade
• Pain

interventions.
1. Continuously monitor the patient’s A change in these signs may • Increasing venous pressure
ECG; assess pulmonary artery (PA) indicate cardiac tamponade, • Decreasing arterial pressure
pressures, venous pressure, blood cardiac injury, or hemodynamic • Decrease in intensity of heart
pressure, Spo2, and neurological instability. sounds
status during and every 15 minutes • Change in level of consciousness
after the procedure until stable (if • Pulsus paradoxus
available, continuously monitor • Equalizing PA pressures
cardiac index and systemic • Decreased cardiac index
vascular resistance). • Decreased systemic vascular
resistance
2. Treat dysrhythmias as prescribed. Dysrhythmias may lead to cardiac • Persistent dysrhythmias despite
decompensation. appropriate intervention
3. Auscultate heart and lung sounds Evaluates potential fluid • Asymmetrical breath sounds
immediately before and after the reaccumulation or puncture of the • Dyspnea
procedure. lung. • Tachypnea
• Decreased Spo2
4. Ensure a portable chest radiograph Assesses for pneumothorax and • Pneumothorax
is obtained immediately after the hemothorax. • Hemothorax
procedure as prescribed.

5. Ensure a two-dimensional Shows the effectiveness of the • Pericardial effusion
echocardiogram is obtained within pericardial drainage.
several hours after the procedure as
prescribed.
6. Monitor the pericardiocentesis site Assesses for postprocedural • Bleeding or hematoma at the site
for bleeding every 15 minutes after hemostasis and possible drainage. • Drainage at the insertion site
the procedure is completed until
the patient’s condition is stable,
then every 4 hours for 24 hours.
If an indwelling catheter is present,
continue to monitor the site every
4 hours until the catheter has been
removed.
7. Monitor hemoglobin, hematocrit, Assesses for the potential of effusion • Bleeding or hematoma at site
and coagulation levels as recurrence or bleeding at the site. • Decrease in hemoglobin or
prescribed (e.g., every 8 hours after hematocrit
the procedure for 24 hours and • Changes in coagulation study
then as indicated). results
8. Assess the pericardiocentesis site Determines the presence of • Erythema
every day. infection. • Edema
• Purulent drainage
• Foul odor
• Temperature >100.5°F (>38°C)
• Signs and symptoms of infection
9. Perform site care as prescribed or Reduces infection. The Centers for
according to institutional standards: Disease Control and Prevention
A. Cleanse the area surrounding (CDC) do not have a specific
the pericardial catheter with an recommendation for care of
antiseptic solution (e.g., 2% pericardial catheters or site care.
chlorhexidine-based
preparation).
B. Apply a dry sterile gauze or The CDC recommends replacing
transparent dressing with the intravascular catheter dressings
date and time of the dressing when the dressing becomes damp,
change. Follow institutional loosened, or soiled or when
standards. (Level E*) inspection of the site is necessary.3
10. Be prepared for chest exploration Deterioration in the patient’s • Decreased blood pressure
if the patient’s status deteriorates. hemodynamic status may indicate • Dysrhythmias
an increasing effusion and the • Increased venous pressure
need for immediate surgical • Change in mental or respiratory status
intervention. • Diaphoresis
11. Provide emotional support to the Minimizes apprehension and
patient throughout and after the anxiety.
procedure.
12. Keep the patient and family The unknown increases the anxiety
informed about the patient’s and apprehension of the patient
condition. Be available to answer and family.
patient’s and family’s questions
and facilitate meeting their needs
as appropriate.
13. Follow institutional standards for Identifies need for pain • Continued pain despite pain
* Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to
Documentation
• Specific preprocedure instruction and patient’s and • Preprocedure and postprocedure hemoglobin,
family’s satisfactory understanding hematocrit, and coagulation results, if performed
• Legally signed informed consent • Medications administered
• Universal Protocol requirement, if nonemergent • Assessment of pericardiocentesis fluid
• Pre- and postprocedure level of consciousness; blood • Amount and consistency of postprocedure drainage
pressure; venous pressures; pulmonary arterial • Occurrence of unexpected outcomes
pressures; cardiac index, cardiac output, and systemic • Pain assessment, interventions, and effectiveness
vascular resistance, if available; heart sounds and • ECG rhythm strips
cardiac rhythm; respiratory status and pulse oximetry • Emergency interventions necessary
reading. • Specimens sent to the laboratory

43 Pericardiocentesis (Assist) 355.e1

2. Burlew CC, Moore EE: Emergency department Saunders, pp 298–318.
thoracotomy. In Mattox KL, Moore EE, Feliciano DV, 7. Synovitz CK, Brown EJ: Pericardiocentesis. In Tintinalli
editors: Trauma, ed 7, New York, 2013, McGraw-Hill JE, editor: Tintinelli’s emergency medicine: A
Medical, pp 236–239. comprehensive study guide, ed 7, New York, 2011,
3. Centers for Disease Control and Prevention: Guidelines for McGraw-Hill Medical, pp 250–257.
the prevention of vascular catheter-related infections 8. Wall MJ, Tsai P, Mattox K: Heart and thoracic vascular
(DHHS publication), Washington, DC, 2011, US injuries. In Mattox KL, Moore EE, Feliciano DV, editors:
Government Printing Office. Trauma, ed 7, New York, 2013, McGraw-Hill Medical,
4. Gucalp R, Dutcher JP: Oncologic emergencies. In Loscalzo pp 485–488.
J, editor: Harrison’s pulmonary and critical care medicine,
New York, 2010, McGraw-Hill Medical, pp 476–478. Additional Reading
5. Jneid H, Maree AO, Palacios IF: Pericardial tamponade: Labovitz AJ, et al: Focused cardiac ultrasound in the
Clinical presentation, diagnosis, and catheter-based emergent setting: A consensus statement of the American
therapies. In Parrillo JE, Dellinger RP, editors: Critical Society of Echocardiography and American College of
care medicine, ed 4, Philadelphia, 2014, Elsevier Saunders, Emergency Physicians. J Am Soc Echocardiogr 23:1225–
pp 82–85. 1230, 2010.
Section Six Cardiac Pacemakers
PROCEDURE
44
Atrial Electrogram
Marion E. McRae
PURPOSE: An atrial electrogram (AEG) is obtained to determine the presence of
atrial activity in a dysrhythmia or to identify the relationship between atrial and
ventricular depolarizations.
PREREQUISITE NURSING paroxysmal supraventricular tachycardia, atrial flutter,

KNOWLEDGE atrial fibrillation with relatively regular ventricular rate
intervals, or junctional tachycardia)
• Understanding of the anatomy and physiology of the car- • AEGs can be performed with multichannel telemetry or a
diovascular system, principles of cardiac conduction, and bedside ECG monitor that allows for simultaneous display
basic dysrhythmia interpretation is necessary. of the AEG along with the surface ECG.4–6 A 12-lead ECG
• Principles of general electrical safety apply with use of machine also can be used to obtain an AEG.
epicardial pacing wires. Gloves should always be worn • Accurate identification of the epicardial atrial pacing wire
when handling pacing electrodes to prevent microshock or wires is important.
because even small amounts of electrical current can cause • The two types of AEGs that can be obtained from epicar-
serious dysrhythmias if transmitted to the heart.1,9–11 dial pacing wires are unipolar and bipolar.
• Advanced cardiac life support knowledge and skills are ❖ A unipolar electrogram measures electrical activity
needed. between one atrial epicardial wire and a surface ECG
• AEG is a method of recording electrical activity that origi- electrode. The unipolar AEG detects atrial and ven-
nates from the atria with use of temporary atrial epicardial tricular activity.
wires placed during cardiac surgery. Standard electrocar- ❖ A bipolar electrogram detects electrical activity be-
diogram (ECG) monitoring records electrical events from tween the two atrial epicardial wires. The bipolar AEG
the heart with electrodes located on the surface of the predominantly detects atrial activity because both
patient’s body, which is a considerable distance from the electrodes are attached to the atria.
myocardium. One limitation of ECG monitoring may be • Atrial electrograms increase the accuracy of nurses’ diag-
its inability to detect P waves effectively.3 noses of cardiac arrhythmias.5,8 However, they remain
• AEGs detect electrical events directly from the atria, underused in clinical practice.6,10
which provides a greatly enhanced tracing of atrial activ- • An AEG cannot be performed if the patient is dependent
ity. This enhanced tracing allows for determination of the on atrial pacing for hemodynamic stability since at least
presence of atrial activity, comparison of atrial events with one atrial pacing wire must be disconnected from the
ventricular events and determination of the relationship pacemaker to perform the AEG, resulting in a loss of atrial
between the two. pacing.
• The American Heart Association Practice Standards for
Electrocardiographic Monitoring in Hospital Settings EQUIPMENT
recommend recording an AEG whenever tachycardia
of unknown origin develops in a patient after cardiac • Nonsterile gloves
surgery.2 • Temporary atrial epicardial pacing wires placed during
• Indications for AEG are as follows:2 cardiac surgery
❖ When atrial activity is not clearly detected on ECG • Multichannel ECG monitor and recorder or 12-lead ECG
monitoring machine (ensure that biomedical safety standards are met
❖ For determining the relationship between atrial and and the machine is safe for use with epicardial wires)
ventricular activity • Sterile dressings and materials needed for site care includ-
❖ For differentiating wide-complex rhythms (i.e., ven- ing antiseptic solution
tricular tachycardia and supraventricular tachycardia Additional equipment, to have available as needed, includes
with aberrant ventricular conduction) the following:
❖ For differentiating narrow-complex supraventricular • ECG electrodes
tachycardias (i.e., sinus tachycardia, atrial tachycardia, • Lead wire with alligator clips
356
44 Atrial Electrogram 357
• Insulating material for epicardial pacing wires (e.g., finger ment determines the presence or absence of P waves and
cots, needle caps, glove, ear plug) the potential need for an AEG.
• Assess the patient’s cardiac rhythm for the relationship
PATIENT AND FAMILY EDUCATION between atrial and ventricular activity. Rationale: This
assessment determines the relationship between P waves
• Provide information about the normal conduction system, and QRS complexes and the potential need for an AEG.
normal and abnormal heart rhythms, and symptoms of • Assess for dysrhythmias. Rationale: This assessment
abnormal heart rhythms. Rationale: This information determines the patient’s baseline cardiac rhythm.
helps the patient and family to understand the patient’s • Assess the patient’s hemodynamic status (e.g., systolic,
condition and encourages the patient and family to ask diastolic, and mean arterial pressure; level of conscious-
questions. ness; dizziness; dyspnea; nausea; vomiting; cool or
• Provide information about the AEG and the reason for the clammy skin; and chest pain). Rationale: The patient’s
AEG and explanation of the equipment. Rationale: This hemodynamic status and need for immediate intervention
communication may decrease patient anxiety and help the are determined.
patient and family to understand the procedure, why it is
needed, and how it will help the patient. Patient Preparation
• Explain the patient’s expected participation during the • Verify that the patient is the correct patient using two
procedure. Rationale: This explanation encourages patient identifiers. Rationale: Before performing a procedure, the
assistance. nurse should ensure the correct identification of the patient
• Ensure that the patient understands preprocedure teach-
PATIENT ASSESSMENT AND ing. Answer questions as they arise, and reinforce in
PREPARATION formation as needed. Rationale: This communication
evaluates and reinforces understanding of previously
Patient Assessment taught information.
• Assess the patient’s cardiac rhythm for the presence of • Expose the patient’s chest and identify the epicardial
atrial activity in more than one lead from the multichannel pacing wires. Rationale: This action provides access to
ECG monitor or 12-lead ECG. Rationale: This assess- the atrial pacing wires.
Procedure for Atrial Electrogram

1. HH
2. PE Epicardial wires are a direct source
of electrical conduction to the
myocardium. Use of gloves
prevents microshocks with
handling of epicardial wires that
could cause arrhythmias.2,9–11
3. Touch a large metal object such as This prevents microshock that can Any static electricity is discharged
the patient’s bed before touching cause arrythmias.8 before touching the pacing wires.
the wires.9 (Level E*)
4. Expose and identify the atrial Differentiation of the atrial from the Typically the atrial wires exit the
epicardial pacing wires. ventricular wires is important to chest to the right of the patient’s
ensure that the appropriate sternum and the ventricular wires
epicardial wires are used. exit to the left of the patient’s
sternum (Fig. 44-1).
5. Ensure that you are not using a Using a ground wire will record only
ground wire (only one sutured to a surface ECG not an AEG.
the chest wall).5

Figure 44-1 Atrial wires exit the chest to the right of the patient’s Figure 44-2 Tip of atrial epicardial wire in direct contact with
sternum. Ventricular wires exit the chest to the left of the patient’s the metal on the end of the V lead wire. (Drawing by Paul
sternum. (Drawing by Todd Sargood.) W. Schiffmacher, Thomas Jefferson University, Philadelphia.)
Procedure for Atrial Electrogram—Continued

Obtaining a Unipolar AEG with Multichannel Telemetry or Bedside ECG Monitor: Lead V
1. Detach the V lead wire from the Prepares equipment. Determine that the ECG monitoring
electrode on the patient’s chest. system meets all safety
requirements.
2. Place the tip of one of the atrial Electrical activity is transmitted from A lead wire with alligator clips at
epicardial wires in direct contact the epicardial wire to the ECG both ends also can be used to
with: monitoring system. connect the epicardial pacing wire
A. The metal on the end of the to the monitor.
V lead wire (Fig. 44-2).2
(Level D*)
or
B. The conductive gel on the Electrical activity is transmitted from The electrode can be wrapped
adhesive side of the electrode the epicardial wire to the ECG around the atrial wire if continuous
attached to the V lead wire monitoring system. monitoring of the AEG is indicated
(Fig. 44-3).4–6 to diagnose an unknown
intermittent rhythm (Fig. 44-4).4
3. Select lead V on the ECG monitor Use of the precordial lead allows for
and a surface ECG lead (I, II, III, detection of atrial electrical activity
augmented vector foot, augmented between the lead V and an
vector right, or augmented vector indifferent limb lead in a unipolar
left). configuration.
4. Record a dual-channel strip. Displays the AEG simultaneously Label lead V on the ECG strip as the
with a surface ECG lead. AEG.
Figure 44-4 An electrode wrapped around the tip of the atrial

epicardial wires. (Kern LS, McRae ME, Funk M: ECG monitoring
Figure 44-3 The tip of the atrial epicardial wire in direct contact after cardiac surgery: Postoperative atrial fibrillation and the atrial
with the conductive gel on the adhesive side of the electrode. (Kern electrogram, AACN Adv Crit Care 18[3]:299, 2007.)
LS, McRae ME, Funk M: ECG monitoring after cardiac surgery:
Postoperative atrial fibrillation and the atrial electrogram, AACN
Adv Crit Care 18[3]:298, 2007.)

5. Analyze the AEG strip and Identifies P waves and QRS Multiple atrial spikes will exist
compare the surface ECG with the complexes and determines the between ventricular spikes if the
AEG: relationship between the P waves atrial rate is greater than the
A. Vertically line up the QRS and the QRS complexes. ventricular rate (e.g., atrial flutter,
complexes on the ECG strip atrial fibrillation, second or third
with the ventricular deflections degree atrioventricular block).
on the AEG.
B. All other spikes should be atrial
activity either being initiated in
the atrium or being conducted
retrograde to the atrium
(Fig. 44-5).
Obtaining a Unipolar AEG with Multichannel Telemetry or Bedside ECG Monitor: Lead I
1. Detach the right arm (RA) lead Prepares equipment. Determine that the ECG bedside
wire from the electrode on the monitoring system meets all safety
patient’s chest. requirements.
2. Place the tip of one of the atrial Electrical activity is transmitted from A lead wire with alligator clips at
epicardial wires in direct contact the epicardial wire to the ECG both ends also can be used to
with: monitoring system. connect the epicardial pacing wire
A. The metal on the end of the RA to the monitor.
lead wire.2 (Level D*)
or
B. The conductive gel on the Electrical activity is transmitted from The electrode can be wrapped
adhesive side of the electrode the epicardial wire to the ECG around the atrial wire if continued
attached to the RA lead wire monitoring system. monitoring is indicated to diagnose
(see Fig. 44-3).4 an unknown intermittent rhythm
(see Fig. 44-4).4

Figure 44-5 Unipolar AEG strip from lead V. The surface ECG was obtained in lead II. On the
basis of the surface ECG, the rhythm appears to be junctional with no evidence of P waves or atrial
activity. The unipolar AEG shows retrograde P waves that follow the QRS complex, confirming the
junctional rhythm interpretation.
Figure 44-6 Unipolar AEG strip from lead I. The surface ECG was obtained in lead V. The
unipolar AEG was obtained in lead I. The atrial activity is magnified in lead I.

3. Select lead I and a surface ECG Lead I detects electrical activity Label lead I on the ECG strip as the
lead on the ECG monitor. between the RA limb lead and the AEG.
left arm (LA) limb lead. Because
the atrial pacing wire is in contact
with the RA lead, lead I detects the
electrical activity between the atrial
wire and the surface LA limb lead.
4. Record a dual-channel strip. Displays the AEG simultaneously A dual-channel recorder permits the
with a surface ECG lead. comparison of the surface ECG
with the AEG.
5. Analyze the AEG strip and Identifies P waves and QRS
compare the surface ECG with the complexes and determines the
AEG (Fig. 44-6). relationship between the P waves
A. Vertically line up the QRS and the QRS complexes.
complexes on the ECG strip
with the ventricular deflections
on the AEG.
B. All other spikes should be atrial
activity either being initiated in
the atrium or being conducted
retrograde to the atrium (see
Fig. 44-6).

Obtaining a Unipolar AEG with a 12-Lead ECG Machine
1. Connect the patient to the 12-lead Provides another method of obtaining Determine that the 12-lead ECG
ECG machine (see Procedure 57). an AEG. machine meets all safety
requirements.
2. Attach one atrial epicardial pacing Prepares for the AEG.
wire to the clip of the RA lead
wire of the 12-lead ECG machine
(Fig. 44-7).
3. Run a 12-lead ECG. Lead I measures the electrical activity
between the RA and LA. Because
the atrial pacing wire is connected
to the RA lead, lead I detects the
electrical activity between the atrial
wire and surface LA limb lead.
Lead II measures the electrical
activity between the RA and left
leg (LL) leads. Because the atrial
pacing wire is connected to the RA
lead, lead II detects the electrical
activity between the atrial wire and
the surface LL lead.
4. Analyze leads I and II. Identifies P waves and QRS
complexes and determines the
relationship between the P waves
and the QRS complexes.
Obtaining a Bipolar AEG with Multichannel Telemetry or Bedside ECG Monitor
1. Detach the RA and LA lead wires Two atrial pacing wires are used Determine that the ECG monitoring
from the electrodes on the when obtaining a bipolar AEG. system meets all safety
patient’s chest. requirements.
Figure 44-7 Attach 12-lead ECG per procedure except that the RA lead wire connects to one of
the atrial epicardial pacing wires. (Drawing by Todd Sargood.)
Figure 44-8 Bipolar AEG strip from lead I. The surface ECG was obtained in lead V. The bipolar
AEG was obtained in lead I. The atrial activity is magnified in lead I. Also note how small the
ventricular activity is in lead I.

2. Atrial pacing wires:
A. Place the tip of one atrial Connection to the limb leads of the A lead wire with alligator clips at
epicardial pacing wire to the ECG monitor allows for the both ends also can be used to
metal on the end of the RA lead detection and recording of atrial connect the epicardial pacing wires
wire and limb lead and place electrical activity. to the monitor leads.
the tip of the other atrial
epicardial pacing wire to the
metal on the end of the LA lead
wire and limb lead.
or
B. Place the tip of one atrial Electrical activity is transmitted from The electrodes can be wrapped
epicardial pacing wire to the the epicardial wire to the ECG around the atrial wires if continued
conductive gel on the adhesive monitoring system. monitoring is indicated to diagnose
side of the electrode attached to an unknown intermittent rhythm
the RA lead wire and place the (see Fig. 44-4).4
tip of the other atrial epicardial
pacing wire to the conductive
gel on the adhesive side of the
electrode attached to the LA
lead wire (see Fig. 44-3).
3. Select lead I on the bedside ECG Lead I detects electrical activity Bipolar tracings magnify atrial
monitor. between the RA limb lead and the activity and minimize ventricular
LA limb lead. Because the atrial activity.
pacing wires are in contact with the
RA lead and the LA lead, lead I
detects the electrical activity
between the two atrial wires and
therefore records an AEG.
4. Record a dual-channel strip of Displays the AEG simultaneously Label lead I on the ECG strip as the
lead I and another surface lead. with a surface ECG. bipolar AEG.
5. Analyze the AEG strip (Fig. 44-8). Identifies P waves and QRS
complexes; determines the
relationship between the P waves
and the QRS complexes.

Obtaining a Bipolar AEG with a 12-Lead ECG Machine
1. Connect the patient to the 12-lead Provides another method of obtaining Determine that the ECG monitoring
ECG machine (see Procedure 57). an AEG. system meets all safety
requirements.
2. Attach one atrial epicardial pacing Connection to the limb leads of the
wire to the RA limb lead and the ECG machine allows for the
other atrial epicardial pacing wire detection and recording of atrial
to the LA limb lead of the 12-lead electrical activity.
ECG machine.
3. Run a 12-lead ECG. Lead I measures the electrical activity
between the RA and LA limb leads,
which sense atrial activity from
both epicardial wires, to provide a
bipolar AEG tracing.
4. Analyze lead I (Fig. 44-9). Displays the bipolar AEG for Bipolar tracings magnify atrial
analysis. Identifies P waves and activity and minimize ventricular
QRS complexes and determines the activity. With this method,
relationship between the P waves unipolar AEGs also are obtained in
and the QRS complexes. lead II and lead III.
Figure 44-9 A 12-lead ECG obtained with two atrial pacing wires connected to the RA and LA
lead wires. Lead I shows a bipolar AEG. The P swave is greater in size than the QRS complex.
Leads II and III show unipolar AEGs. In leads II and III, atrial activity is enhanced. Atrial activity
is enhanced throughout the 12-lead ECG.

After AEG Is Obtained
1. Disconnect the atrial epicardial Disconnects the wires from the
wires. bedside monitoring system or the
12-lead ECG machine.
2. Reconnect or ensure that the ECG Establishes continuous ECG
lead wire(s) are connected to the monitoring.
electrode(s) on the patient’s chest.
3. Apply a dry sterile dressing to the Reduces the transmission of Follow institution’s guidelines for
epicardial wire exit sites if this microorganisms; Standard site care.
was removed to access the atrial Precautions.
epicardial wires.
4. Place the uninsulated portion of Prevents microshock.
the epicardial wires in an insulated
material (e.g., finger cot, needle
cap, needle barrel, glove, ear
plug).9–11 (Level E*)
5. Remove gloves and discard used Reduces the transmission of
supplies in appropriate receptacle. microorganisms; Standard
Precautions.
6. HH

• Atrial activity is identified • Hemodynamically significant dysrhythmias
• The relationship between atrial and ventricular activity • Dysrhythmias in which atrial activity is unclear or
is determined the relationship between atrial and ventricular activity
is unclear
• Microshocks that cause dysrhythmias

interventions.
1. Evaluate the AEG for the presence AEG determines the presence or • Inability to identify atrial activity
of atrial activity and its relationship absence of atrial activity. • Inability to determine the
to ventricular activity. Compare with relationship between the atrial
the surface ECG for interpretation. and ventricular activity
2. Monitor the ECG rhythm for The underlying dysrhythmia may • Altered hemodynamic status
changes. change during the AEG. caused by change in ECG rhythm
3. Monitor vital signs and level of Ensures adequate tissue perfusion. • Hemodynamic instability
consciousness during the AEG and • Change in level of consciousness
as needed.
4. Assess and treat dysrhythmias Identifies dysrhythmias that need • Return of rhythm stability
identified by the AEG and ECG. AEG intervention. • Change in cardiac rate or rhythm
can increase diagnostic accuracy of
arrhythmias.5,8 (Level C*)

5. Site care should be as follows:
A. Cleanse the area surrounding the May reduce infection. There are no • Any signs or symptoms of
epicardial pacing wires with an specific recommendations for infection
antiseptic solution (e.g., 2% epicardial pacing wire site care.7
chlorhexidine-based preparation).
(Level D*)
B. Apply a dry sterile dressing with There are no specific
the date and time of the dressing recommendations for epicardial
change. Institutional standard pacing wire dressing care. The
should be followed for frequency Centers for Disease Control and
and type of dressing. (Level D*) Prevention recommends replacing
gauze dressings every 2 days and
transparent dressings at least
every 7 days.7 Dressings should
be replaced when they become
damp, loosened, or soiled or when
Wet materials increase the likelihood
of microshock as electrical current
travels more effectively through
fluid.
C. Protect the exposed uninsulated Prevents microshocks and • Dysrhythmias
portion of the epicardial pacing potentially lethal dysrhythmias. • Hemodynamic instability
wires in an insulated environment • Microshocks
according to institutional
standards (e.g., finger cot, glove,
plastic needle cap, needle barrel,
ear plug).9–11 (Level E*)
Documentation
• Patient and family education • Hemodynamic status and level of consciousness
• AEG tracing with interpretation • Patient tolerance of the procedure
• Treatment undertaken for arrhythmias present • Occurrence of unexpected outcome

44 Atrial Electrogram 365.e1
References 8. Preston J, Currey J, Considine J: Atrial electrogram

1. Batra AS, Balaji S: Postoperative temporary epicardial diagnostic accuracy improves after an innovative
pacing: When, how and why? Ann Pediatr Cardiol education program. Aust J Crit Care 26:86–87, 2013.
1(2):120–125, 2008. 9. Reade MC: Temporary epicardial pacing after cardiac
2. Drew BJ, et al: Practice standards for electrocardiographic surgery: a practical review. Part 1: General considerations
monitoring in hospital settings: An American Heart in the management of epicardial pacing. Anesthesia
Association Scientific Statement from the Councils on 62:264–271, 2007.
Cardiovascular Nursing, Clinical Cardiology, and 10. Timothy PR, Rodeman BJ: Temporary pacemakers in
Cardiovascular Disease in the Young. Circulation critically ill patients: Assessment and management
110:2721–2746, 2004. strategies. AACN Clin Issues 15(3):305–325, 2004.
3. Humes RA, et al: Utility of temporary atrial epicardial 11. Woods SL, et al: Pacemakers and implantable
electrodes in postoperative pediatric cardiac patients. defibrillators. In Cardiac nursing, ed 6, Philadelphia,
Mayo Clin Proc 64:516–521, 1989. 2009, Lippincott, Williams and Wilkins.
4. Kern LS, McRae ME, Funk M: ECG monitoring after Additional Reading
cardiac surgery: Postoperative atrial fibrillation and the
atrial electrogram. AACN Adv Crit Care 18:294–304, Reade MC: Temporary epicardial pacing after cardiac surgery:
2007. a practical review: part 2: selection of epicardial pacing
5. McRae ME, Chan A, Imperial-Perez F: Cardiac surgical modes and troubleshooting. Anaesthesia 62:364–373,
nurses’ use of atrial electrograms to improve arrhythmia 2007.
diagnoses. Am J Crit Care 19:124–134, 2010. Vitello-Cicciu JM, et al: Profile of patients requiring the use of
6. Miller JN, Drew BJ: Atrial electrograms after cardiac epicardial wires after coronary artery bypass surgery.
surgery: Survey of clinical practice. Am J Crit Care Heart Lung 16(3):301–305, 1987.
16:350–359, 2007.
7. O’Grady NP, et al: Guidelines for the prevention of
intravascular catheter-related infections. Am J Infect
Control 39(4):S1–S34, 2011.
PROCEDURE
45
Atrial Overdrive Pacing
(Perform)
Jillian Hamel
PURPOSE: The purpose of atrial overdrive pacing is to attempt to restore sinus
rhythm in the setting of reentrant atrial dysrhythmias, especially atrial flutter, by
intermittently pacing at a rate faster than the tachycardia. Sinus rhythm enhances
cardiac output by allowing atrial contraction to contribute to ventricular filling.
PREREQUISITE NURSING wires placed during cardiac surgery. A transvenous atrial

KNOWLEDGE pacing lead with an active fixation tip to help keep the
lead in the atrium also can be used.
• Knowledge of the anatomy and physiology of the car- • Overdrive atrial pacing involves the delivery of short
diovascular system, principles of cardiac conduction, bursts of rapid pacing stimuli through an epicardial atrial
and basic and advanced dysrhythmia interpretation is pacing wire or a transvenous lead in the atrium. The physi-
necessary. cian or advanced practice nurse determines the duration
• Supraventricular dysrhythmias (e.g., atrial flutter, reen- and rate of the burst.
trant atrial tachycardia, atrioventricular [AV] nodal reentry ❖ One approach to overdrive pacing is to atrial pace the
tachycardia, reentrant tachycardias that use an accessory heart with 20 milliampere (mA) at a rate 20% to 30%
pathway, such as Wolff-Parkinson-White [WPW] syn- faster than the intrinsic atrial rate for 30 seconds, then
drome) sometimes can be terminated by overdrive atrial abruptly stop pacing. An alternate approach is to initi-
pacing.1,2 ate atrial pacing at a rate 20 beats/min faster than the
• Atrial fibrillation occasionally terminates with overdrive intrinsic atrial rate; if 1:1 capture does not occur after
atrial pacing, but this is not a reliable therapy for atrial 30 seconds, the paced rate can be increased by 20
fibrillation. Many contemporary permanent pacemakers beats/min; repeat every 30 seconds until 1:1 capture is
have arrhythmia response algorithms that include antit- achieved. Continue pacing until the heart rate decreases
achycardia pacing, but research has not yet shown that from AV block (e.g., 2:1, 3:1) or 1 to 2 minutes of 1:1
continuous atrial overdrive pacing prevents the progres- pacing have occurred, then stop pacing.6
sion to permanent atrial fibrillation or reduces other major ❖ Successive bursts usually are performed at gradually
adverse cardiac events.3,4 increasing rates (maximal capability of the pulse gen-
• Knowledge of pacemaker function and patient response erator for overdrive atrial pacing is 800 pulses/min)
to pacemaker therapy is needed. and may be delivered for up to 2 minutes.7
• Principles of general electrical safety need to be applied • The atrial pacing wire or atrial pacing lead needs to be
with use of temporary invasive pacing. accurately identified with initiation of overdrive pacing
• Gloves always should be worn when handling pacemaker because pacing the ventricle at rapid rates may induce
electrodes to prevent microshock because even small ventricular tachycardia or ventricular fibrillation.
amounts of electrical current can cause serious dysrhyth- • Rapid atrial pacing may result in degeneration of the
mias if they are transmitted to the heart.5,9–12 atrial rhythm to atrial fibrillation with a rapid ventricu-
• Clinical and technical competence related to the use of a lar response. This pacemaker-induced atrial fibrillation
temporary atrial pacemaker pulse generator and the rapid usually does not sustain itself for more than a few minutes
atrial pacing feature is needed (Fig. 45-1). before it converts to normal sinus rhythm.6
• Advanced cardiac life support knowledge and skills are • If an accessory pathway is present, rapid atrial pacing can
necessary. result in conduction to the ventricles over the accessory
• In the acute care setting, overdrive atrial pacing is per- pathway, leading to ventricular fibrillation.
formed most commonly with epicardial atrial pacing • Overdrive suppression of the sinus node may result
in periods of bradycardia, asystole, junctional or
ventricular escape rhythms, or polymorphic ventricular
tachycardia.
practice nurses, and other healthcare professionals (including critical care • Conversion of an atrial tachydysrhythmia can result in
nurses) with additional knowledge, skills, and demonstrated competence per dislodgment of atrial thrombus and embolization of clots
professional licensure or institutional standard. to the pulmonary or systemic circulation.
366
45 Atrial Overdrive Pacing (Perform) 367
and family anxiety and promote cooperation with the

procedure.
• Reassure the patient that atrial pacing usually cannot be
felt and that any sensation most likely will be a “flutter-
ing” feeling in the chest. Rationale: This reassurance pre-
pares the patient and may decrease the patient’s anxiety.

PREPARATION
Patient Assessment
• Assess the patient’s ECG rhythm and intervals, verifying
atrial and ventricular rates. Rationale: This assessment
determines baseline cardiac conduction.
• Assess the patient’s vital signs and hemodynamic param-
eters. Rationale: This assessment determines baseline
cardiovascular function.
• Assess for signs and symptoms that might be caused by
the dysrhythmia (e.g., shortness of breath, dizziness,
A B nausea, chest pain, signs of poor peripheral perfusion).
Figure 45-1 A, Temporary dual-chamber pulse generator with
Rationale: The patient’s response to the dysrhythmia is
overdrive atrial pacing capability. B, Enlargement of lower screen determined.
on the pacemaker showing rapid atrial pacing controls. (Courtesy • Assess the patency of the intravenous access. Rationale:
Medtronic, Inc.) Intravenous access is needed for possible administration
of fluids and medications.
• Note any medications that might have an effect on
the patient’s cardiac rhythm or hemodynamic param-
EQUIPMENT eters (e.g., beta blockers, calcium channel blockers,
antidysrhythmics, and digoxin). Rationale: Knowledge
• Nonsterile gloves of medication therapy can alert the healthcare provid-
• External pulse generator capable of rapid atrial pacing ers to potential cardiac rhythms (e.g., bradycardia or
• Connecting cable (between the pulse generator and the atrioventricular block) after termination of the atrial
patient’s pacemaker leads) dysrhythmia.
• Cardiac monitor and recorder • Verify the patient’s coagulation study results. Rationale:
• Electrocardiogram (ECG) electrodes Therapeutic coagulation levels may decrease the risk of
• Double alligator clip or wire with connector pins (if embolization.2,6–8
needed to create a ground wire)
• Materials for epicardial pacing wire site care: Patient Preparation
❖ Antiseptic pads or swab sticks (e.g., 2% chlorhexidine- • Verify that the patient is the correct patient using two
based preparation) identifiers. Rationale: Before performing a procedure, the
❖ Gauze pads nurse should ensure the correct identification of the patient
❖ Tape for the intended intervention.
• Insulating material for epicardial pacing wires or transve- • Obtain informed consent (may not be possible in an emer-
nous pacing electrode connector pins (e.g., finger cot, gency). Rationale: Informed consent protects the rights
needle cap, needle barrel, glove, ear plug) of the patient and makes a competent decision possible
• Blood pressure monitoring system for the patient.
Additional equipment, to have available as needed, includes • Ensure that the patient and family understand pre-
the following: procedural teaching. Answer questions as they arise and
• Defibrillator reinforce information as needed. Rationale: This com-
• Emergency medications munication evaluates and reinforces understanding of pre-
• Airway management equipment viously taught information.
• Standard pulse generator or transcutaneous pacemaker • Perform a preprocedure verification and time out, if non-
and equipment emergent. Rationale: Ensures patient safety.
• Subcutaneous needle for a ground wire • Initiate continuous bedside cardiac monitoring (if not
already in place). Rationale: The patient’s cardiac rate
PATIENT AND FAMILY EDUCATION and rhythm must be visible at the bedside during the pro-
cedure to determine atrial capture during pacing and to
• Explain the procedure and its purpose to the patient and evaluate the response of the patient’s cardiac rate and
family. Rationale: This explanation may decrease patient rhythm after pacing.
• Obtain a 12-lead ECG as needed. Rationale: The ECG • Place a blood pressure cuff on the patient’s arm and obtain
may aid in determining the patient’s baseline cardiac the patient’s blood pressure or obtain the patient’s blood
rhythm. pressure from the arterial catheter. Rationale: This aids in
• Assist the patient to a supine position. Rationale: This assessment of the patient’s baseline blood pressure and
position facilitates access to the epicardial pacemaker hemodynamic response to rapid atrial pacing.
wires or the transvenous atrial pacing lead wire.
Procedure for Performing Atrial Overdrive Pacing

1. HH
2. PE Gloves protect the patient from
microshock while pacemaker wires
are being handled.5,9-12
3. Attach the connecting cable to The connecting cable provides
the external pulse generator, extra length so that the pulse
making sure that the positive (+) generator does not have to be
pole of the cable is connected to placed on the patient’s chest or
the (+) terminal of the pulse abdomen.
generator and the negative (−)
pole of the cable is connected to
the (−) terminal.
4. For epicardial atrial pacing:
A. Expose the atrial epicardial The atrial epicardial wires usually The atrial epicardial pacing wires can
pacing wires. exit the chest to the right of the be verified by performing an atrial
patient’s sternum (see Fig. 44-1). electrogram (see Procedure 44).
B. Connect an atrial epicardial The pacing current is delivered
pacing wire to the negative through the negative terminal of
terminal of the connecting the pulse generator; an
cable. epicardial pacing wire on the
atrium must be connected to the
negative terminal for the atrium
to receive pacing impulses.
C. Connect a second epicardial The pacing circuit is completed as If only one atrial pacing wire is
pacing wire or a ground wire energy reaches the positive present, additional options for a
to the positive terminal of the electrode. ground wire include an ECG
connecting cable. monitoring electrode on the chest
near the epicardial pacing wire exit
site or a subcutaneous needle in
the tissue on the chest.
The positive terminal of the
connecting cable is connected to
the metal snap of the monitoring
electrode or the subcutaneous
needle hub with a double alligator
clip.
5. For transvenous atrial pacing: The pacing stimulus travels from
A. Identify the proximal and the the pulse generator to the
distal electrode connector pins negative terminal and energy
on the external portion of the returns to the pulse generator via
atrial pacing lead. the positive terminal.
B. Connect the distal (negative) Energy from the pulse generator is
electrode connector pin to the directed to the distal electrode in
negative terminal of the contact with the atrium.
connecting cable.
Figure 45-2 The top trace shows ECG lead II recorded during an episode of paroxysmal atrial tachycardia at a rate of 150 beats/min.
Beginning with the eighth beat in this trace (black dot), rapid atrial pacing at a rate of 165 beats/min was initiated. In the middle trace,
which begins 12 seconds after the top trace, atrial capture is shown clearly. In the bottom trace, which is continuous with the middle trace,
sinus rhythm appears when atrial pacing is terminated abruptly (open circle). Paper recording speed was 25 mm/sec. S, Stimulus artifact.
(From Cooper TB, MacLean WAH, Waldo AL: Overdrive pacing for supraventricular tachycardia: A review of theoretical implications and
therapeutic techniques, Pacing Clin Electrophysiol 1:200, 1978.)
Figure 45-3 Rhythm strip shows

rapid atrial pacing in an attempt to
terminate atrial flutter.
Procedure for Performing Atrial Overdrive Pacing—Continued

C. Connect the proximal The pacing circuit is completed as
(positive) electrode connecting energy reaches the positive
pin to the positive terminal of electrode.
the connecting cable.
6. Set the rate and the milliampere The settings are based on the
(mA/output) controls on the pulse characteristics of the patient’s
generator. dysrhythmia and the threshold
needed for atrial capture.
7. Initiate atrial overdrive pacing. Short bursts of pacing stimuli at a Bursts can be repeated at faster rates
Pace the atrium for a brief period rapid rate are intended to create and for longer intervals until the
of 30 seconds to 2 minutes, refractory tissue in the atrium dysrhythmia terminates or changes.
then abruptly terminate pacing and interrupt the reentry circuit
(Figs. 45-2 and 45-3). responsible for the
tachydysrhythmia.
A. Pace the heart with 20 mA at Refer to the pulse generator’s
a rate 20–30% faster than the technical manual for instructions
intrinsic atrial rate for 30 on how to initiate rapid atrial
seconds, then stop pacing. pacing.
Procedure for Performing Atrial Overdrive Pacing—Continued

B. An alternate approach is to On termination of the dysrhythmia,
initiate atrial pacing at a rate the sinus node may be suppressed
20 beats/min faster than the for a period, resulting in
intrinsic atrial rate; if 1:1 bradycardia, asystole, junctional or
capture does not occur after ventricular escape rhythms, or
30 seconds, increase the paced ventricular tachycardia.
rate by 20 beats/min; repeat Initiation of temporary atrial,
every 30 seconds until 1:1 ventricular, or transcutaneous
capture is achieved. Continue pacing may be necessary until
pacing until the heart rate normal sinus function returns.
decreases from AV block
(e.g., 2:1, 3:1) or 1–2 minutes
of 1:1 pacing have occurred,
then stop pacing.6 (Level E*)
8. When atrial pacing is completed, Removes the rapid atrial Standard pacemaker therapy can be
disconnect the connecting cable pacemaker. initiated if necessary.
from the epicardial pacing wires
or from the transvenous pacing
electrode connector pins.
9. Apply a sterile occlusive dressing May reduce the incidence of
to the pacemaker site if not infection.
already in place.
10. Protect the exposed pacemaker Prevents microshock, which can
electrode connector pins or result in symptomatic
epicardial pacemaker wires with dysrhythmias.
an insulating material (e.g., finger
cot, needle cap, needle barrel,
glove, ear plug).9–12 (Level E)
11. Secure the pacing wires or Prevents accidental dislodgment.
connector pins.
12. Label each epicardial pacemaker Aids identification of the
wire or dressing to identify atrial epicardial pacemaker wires.
and ventricular pacing wires.
supplies in appropriate microorganisms; Standard
receptacles. Precautions.
14. HH

• Return to normal sinus rhythm • Continuation of the tachydysrhythmia
• Stable or improved hemodynamic status • Conversion to atrial fibrillation
• Prolonged period of bradycardia or asystole after
termination of the tachydysrhythmia
• Rapid conduction of atrial paced impulses to the
ventricle through an accessory pathway, resulting in
ventricular tachycardia or ventricular fibrillation
• Emergence of a slow junctional or ventricular escape
rhythm or ventricular tachycardia after termination of
the tachydysrhythmia
• Microshock that results in ventricular tachycardia or
fibrillation
• Pain

interventions.
1. Monitor the patient’s cardiac Allows for immediate recognition of • Heart rate or rhythm changes
rhythm continuously at the bedside rhythm changes or return of the • Return of initial tachydysrhythmia
during the procedure and after the initial tachydysrhythmia. • Any significant or
procedure. hemodynamically unstable
dysrhythmia
• Need for additional temporary
pacing to maintain adequate heart
rate after conversion of the
tachydysrhythmia
2. Monitor the patient’s vital signs Changes in vital signs may indicate • Abnormal heart rate or rhythm
before initiating overdrive pacing, significant change in the patient’s • Hypotension
every 5–10 minutes during condition.
attempts to overdrive pace, with Blood pressure often improves with
any significant heart rate or rhythm cessation of the tachydysrhythmia
change during the procedure, and or restoration of normal sinus
on termination of the procedure. If rhythm; blood pressure may
the patient’s condition is not deteriorate if the ventricular rate
hemodynamically stable after the accelerates because of overdrive
procedure, monitor vital signs pacing.
every 5–10 minutes until stable. If the patient is receiving
Monitor vital signs per unit antidysrhythmic medications,
standard if the patient’s condition changes in vital signs may indicate
is stable after the procedure. an adverse medication reaction.
3. Replace gauze dressings every 2 Although guidelines specific to • Redness or exudate around site
days and transparent dressings at epicardial wires and transvenous • Increased white blood cell count,
least every 7 days.13 Cleanse the pacemaker sites do not exist, the increased band neutrophil values
site with an antiseptic solution Centers for Disease Control and • Elevated temperature
(e.g., 2% chlorhexidine-based Prevention (CDC) recommend
solution). Follow institution replacing dressings on
standard. (Level D*) intravascular catheters when the
dressing becomes damp, loosened,
or soiled or when inspection of the
site is necessary.13
4. Monitor the patient’s response to Antidysrhythmic medications may • Prolongation of QT interval
antidysrhythmic medications. be necessary to prevent recurrence • Rhythm changes
of the initial tachydysrhythmia or
to control the ventricular rate.

Documentation
• Signed informed consent, if nonemergent • Number of pacing attempts
• Universal Protocol requirements, if nonemergent • Patient’s response to the procedure (e.g., anxiety,
• Patient and family education provided and an pain)
evaluation of their understanding of the procedure • Pain assessment, interventions and effectiveness
• Rhythm strip documenting initial cardiac rate and • Post procedure rhythm strip
rhythm • Post procedure vital signs
• Initial vital signs • Any medications given during procedure
• Pacemaker settings for each attempt of overdrive • Any unexpected outcomes
pacing: rate, mA, duration • Additional interventions
• Rhythm strip documenting each overdrive pacing burst

45 Atrial Overdrive Pacing (Perform) 372.e1
References 6. Palazzo MO: Atrial fibrillation and the postoperative

1. Batra AS, Balaji S: Post operative temporary epicardial cardiac surgery patient. Crit Care Nurs Clin North Am
pacing: When, how and why? Ann Pediatr Cardiol 19:395–402, 2007.
1(2):120–125, 2008. 7. Smith W, Hood M: Arrhythmias. In Sidebotham D, et al,
2. Blomström-Lundqvist C, et al: ACC/AHA/ESC guidelines editors: Cardiothoracic critical care, Philadelphia, 2007,
for the management of patients with supraventricular Butterworth-Heinemann.
arrhythmias: Executive summary: A report of the 8. Oligin JE, Zipes DP: Specific arrhythmias: Diagnosis and
American College of Cardiology/American Heart treatment. In Libby P, et al, editors: Braunwald’s heart
Association Task Force on Practice Guidelines and the disease: A textbook of cardiovascular medicine, ed 9,
European Society of Cardiology Committee for Practice Philadelphia, 2011, Saunders/Elsevier.
Guidelines (Writing Committee to Develop Guidelines for 9. Overbay D, Criddle L: Mastering temporary invasive
the Management of Patients With Supraventricular cardiac pacing. Crit Care Nurse 24(3):25–32, 2004.
Arrhythmias). J Am Coll Cardiol 42:1493–1531, 2003. 10. Reade MC: Temporary epicardial pacing after cardiac
3. Brignole M, et al: 2013 ESC Guidelines on cardiac pacing surgery: A practical review: Part 1: General considerations
and cardiac resynchronization therapy: The Task Force on in the management of epicardial pacing. Anaesthesia
cardiac pacing and resynchronization therapy of the 62:264–271, 2007.
European Society of Cardiology (ESC). Developed in 11. Timothy PR, Rodeman BJ: Temporary pacemakers in
collaboration with the European Heart Rhythm critically ill patients: Assessment and management
Association (EHRA). Eur Heart J 34(29):2281–2329, strategies. AACN Clin Issues 15:305–325, 2004.
2013. 12. Woods SL, Froelicher ES, et al, editors: Pacemakers and
4. Boriani G, et al: Atrial antitachycardia pacing and implantable defibrillators. In Cardiac nursing, ed 5,
managed ventricular pacing in bradycardia patients with Philadelphia, 2005, Lippincott Williams and Wilkins.
paroxysmal or persistent atrial tachyarrhythmias: The 13. O’Grady NP, et al: Guidelines for the prevention of
MINERVA randomized multicentre international trial. intravascular catheter-related infections. Am J Infect
Eur Heart J 35(35):2352–2362, 2014. Control 39(4):S1–S34, 2011.
5. Drew B: Practice standards for electrocardiographic Additional Reading
monitoring in hospital settings: An American Heart
Association scientific statement from the Councils on Neumar RW, Shuster M, et al: Part 1: Executive Summary:
Cardiovascular Nursing, Clinical Cardiology, and 2015 American Heart Association Guidelines Update
Cardiovascular Disease in the Young: endorsed by the for Cardiopulmonary Resuscitation and Emergency
International Society of Computerized Electrocardiology Cardiovascular Care. Circulation 132(18 suppl 2), 2015.
and the American Association of Critical-Care Nurses.
Circulation 110:2721–2746, 2004.
PROCEDURE
46
Epicardial Pacing Wire Removal
Marion E. McRae
PURPOSE: Temporary epicardial pacing wires are inserted into the epicardium
during cardiac surgery and are removed when pacing therapy is no longer needed.
PREREQUISITE NURSING about this, what warning signs to look for, and to identify
KNOWLEDGE that the wires are in situ before magnetic resonance image
(MRI) scanning, although MRI scanning with retained
• Knowledge of the cardiovascular anatomy and physiology epicardial wires is considered safe at 1.5 Tesla. 6,7,12,18
is necessary.
• Knowledge of placement and function of epicardial pacing EQUIPMENT
wires is necessary.
• Advanced cardiac life support knowledge and skills are • Nonsterile gloves
needed. • Antiseptic solution (e.g., 2% chlorhexidine-based
• Knowledge of where atrial, ventricular, and ground wires solution)
are placed on the chest is necessary. • Suture removal kit
• Principles of general electrical safety need to be applied • Sterile gauze
with use of temporary epicardial pacemaker wires.10 • Tape
• Gloves always should be worn when handling epicardial Additional equipment, to have available as needed, includes
pacemaker electrodes to prevent microshock because even the following:
small amounts of electrical current can cause serious dys- • Emergency equipment including resuscitation cart and
rhythmias if they are transmitted to the heart.1,13 sternotomy tray
• Knowledge of cardiac dysrhythmias and treatment of life- • Temporary transcutaneous or transvenous pacing
threatening dysrhythmias is necessary. equipment
• Relative contraindications to epicardial pacing wire
removal include, abnormal coagulation study results (ele- PATIENT AND FAMILY EDUCATION
vated international normalized ratio [INR], partial throm-
boplastin time [PTT], heparin level, or heparin anti-Xa • Assess patient and family readiness to learn, and identify
level), very low platelet counts, presence of dysrhythmias factors that affect learning. Rationale: This assessment
that necessitate pacing, and compromised hemodynamic allows the nurse to individualize teaching.
status.4,10 Acceptable levels for INR, PTT, heparin level, • Provide information about the epicardial pacing wires, the
or anti-Xa level are determined by institutional policy. reason for their removal, and an explanation of the proce-
• Knowledge of signs and symptoms of cardiac tamponade dure. Rationale: This information helps the patient and
is needed (e.g., hemodynamic instability, dyspnea, muffled family to understand the procedure and why it is needed
heart sounds, diaphoresis, equalizing pulmonary artery and may decrease anxiety.
pressures, jugular venous distention, pulsus paradoxus, • Explain the patient’s expected participation during and
narrowed pulse pressure, orthopnea, altered level of after the procedure. Rationale: Encourages patient par-
consciousness).2,9,15 ticipation in the treatment plan and may decrease anxiety.
• Epicardial pacing wires should not be cut but should be • Explain that the patient may feel mild pain and a burning
removed. Retained epicardial pacing wires can cause or pulling sensation during the procedure.11,14 Rationale:
long-term problems. The wires can eventually protrude This explanation prepares the patient for the procedure.
through the skin, cause local infection or infective endo-
carditis, and they can migrate, causing serious tissue and
organ injury.16,18 PATIENT ASSESSMENT AND
• Although it is not recommended, if cut epicardial pace- PREPARATION
maker wires are left in situ, the patient must be educated
Patient Assessment
• Assess the patient’s baseline cardiovascular, hemody-
namic, and peripheral vascular status. Rationale: This
practice nurses, and other healthcare professionals (including critical care assessment provides data that can be used for comparison
nurses) with additional knowledge, skills, and demonstrated competence per with postremoval assessment data and hemodynamic
professional licensure or institutional standard. values.
373
• Assess the patient’s current laboratory data, including nurse should ensure the correct identification of the patient
electrolyte and coagulation study results. Rationale: This for the intended intervention.
assessment identifies laboratory abnormalities. Baseline • Ensure that the patient and family understand prepro-
coagulation studies (INR [if on warfarin], PTT or heparin cedural teaching. Answer questions as they arise, and
levels [if on heparin], anti-Xa levels [if on low molecu- reinforce information as needed. Rationale: Evaluates
lar weight heparin]) and platelet counts are helpful in and reinforces understanding of previously taught
determining the patient’s risk for bleeding.4 Electrolyte information.
abnormalities such as hypokalemia, hyperkalemia, or • Remove epicardial pacing wires at least the day before
hypomagnesemia may increase cardiac irritability. discharge (approximately 24 hours or longer).10 Ratio-
• Ensure that the patient is not fully anticoagulated and/or nale: Removal at this time provides time for observation
that the platelet count is not very low. Based on the half- for potential complications.
life of heparin,8 stop a heparin infusion 2 hours before • Administer prescribed analgesic medication before
pacemaker wire removal and start the heparin infusion 1 removing the epicardial pacing wires.11,14 Rationale:
hour after pacemaker removal.4,8 Remove pacemaker Analgesics may minimize discomfort during epicardial
wires at the nadir of low molecular weight heparin doses pacing wire removal. Patients report mild pain and a
or hold for several hours when the next dose is due. burning or pulling sensation during the procedure.11,14
Ensure that the INR is less than 1.5 to 2 before removing • Determine the patency of an intravenous (IV) catheter.
pacemaker wires if the patient is on warfarin.4,10 Ensure Rationale: A patent IV is necessary should emergency
the platelet count is greater than 50,000. Rationale: fluids or medications be needed.
Bleeding is more likely to occur if the patient is antico- • Ensure that patient has electrocardiographic (ECG) moni-
agulated or the platelet count is low. toring. Rationale: ECG monitoring provides assessment
for the presence of potential dysrhythmias during epicar-
Patient Preparation dial wire removal.2
Procedure for Epicardial Pacing Wire Removal

1. HH
2. PE Gloves minimize the possibility of
microshock when in contact with
the epicardial pacing wires.1,13
3. Assist the patient into the supine This position provides the best Epicardial pacing wires are removed
position with head of bed (HOB) access during the procedure. with the patient lying in bed.
up 30 degrees.
4. Touch a large metal object such as Static electricity could be
the patient bed before touching the conducted to the pacemaker
wires to ensure any static electricity wires resulting in microshock.
is discharged.13 (Level E*)
5. Remove the dressing and tape over Exposes the epicardial wire exit
the epicardial wires. sites.
6. Cleanse each of the epicardial May reduce the risk of infection. Cleanse at least a 3-inch area around
pacing wire exit sites with an each of the exit sites.
antiseptic solution (e.g., 2%
chlorhexidine solution).
7. Untie or cut the suture knot of each Prepares for epicardial pacing wire
of the epicardial pacing wires at the removal.
skin.
8. Obtain an ECG strip and observe Dysrhythmias may occur during
the patient’s ECG monitor while epicardial wire removal,
removing epicardial wires. particularly ventricular ectopy.2
46 Epicardial Pacing Wire Removal 375
Procedure for Epicardial Pacing Wire Removal—Continued

9. Remove each epicardial atrial Steady, slow, gentle tension Follow institution standard.
pacing wire and then right uncoils the pacing lead from the If slow, steady, gentle tension does
ventricular epicardial pacing wires epicardial surface of the heart. not remove the wires, stop the
by pulling with a steady, slow, Removing the atrial wires first procedure and notify the surgeon.
gentle tension. There may also be allows ventricular pacing if Wires can become trapped in
epicardial wires on the left ventricle hemodynamic instability occurs. adhesions.
for right atrial-left ventricular or
biventricular pacing that require
removal.5 Ground pacing wires are
anchored only in the skin and are
removed similar to skin sutures.
10. Inspect each epicardial pacing wire Ensures that each epicardial wire If bleeding occurs at the epicardial
to ensure that each wire is intact extracted is completely intact. pacing wire site, apply direct
and to assess for the presence of pressure until bleeding stops.
tissue.3,19 (Level E*) If tissue is noted on the epicardial
wire(s) observe the patient for
hemodynamic instability.
Notify the physician if tissue is
noted on the epicardial wire(s) and
if bleeding or oozing continues.
11. Apply a sterile dressing over the Decreases the risk of infection
epicardial exit sites. until the exit sites heal. Contains
drainage from the site.
supplies in appropriate receptacle. microorganisms and body
13. HH

• Removal of the epicardial pacing wires • Dysrhythmias
• Stable cardiac rate and rhythm • Hemodynamic instability
• Stable vital signs • Pain
• Hemorrhage
• Cardiac tamponade
• Hematoma
• Infection

interventions.
1. Ask the patient to let you know if These signs and symptoms have • Dyspnea
any pain, changes in breathing, been found to correlate with • Bleeding
sweating, or lightheadedness occur. cardiac tamponade after • Palpitations
(Level C*) pacemaker wire removal.9 • Diaphoresis
Dyspnea has a sensitivity of • Chest pressure
87–89% for cardiac tamponade.15 • Presyncope


2. After the epicardial wires are Determines the patient’s • Abnormal vital signs
removed, monitor vital signs hemodynamic status.
frequently for at least 2 hours. Abrupt hypotension can occur
Follow institution standard. within 2 hours of pacemaker
(Level C*) wire removal.9
3. Continue ECG monitoring for at Provides assessment of possible • Dysrhythmias
least 24 hours after removal of dysrhythmias. • ECG changes
epicardial pacing wires.10 (Level E*)
4. Follow institution standard There is little evidence that activity
regarding activity limitations after limitation after removal of
epicardial pacing wire removal. pacemaker wires prevents
complications.17
5. When obtaining vital signs, assess Early detection is important • Hypotension and tachycardia
for signs and symptoms of cardiac because cardiac tamponade is a • Pulsus paradoxus
tamponade. potentially fatal complication. • Beck’s triad (jugular venous
distention, hypotension, and
muffled heart sounds)
• Presyncope
• Altered level of consciousness
• Orthopnea
6. Follow the institution’s standard Identifies need for pain • Continued pain despite pain
Documentation
• Patient and family education • Site assessment
• Removal of epicardial pacing wires • Vital signs and ECG strip
• Patient tolerance of the procedure • Occurrence of unexpected outcomes and
• Pain assessment, interventions, and effectiveness interventions

46 Epicardial Pacing Wire Removal 376.e1
References 10. McClurken JB: Minimizing complications from temporary

1. Batra AS, Balaji S: Postoperative temporary epicardial epicardial pacing wires after cardiac surgery. PA–PSRS
pacing: When, how and why? Ann Pediatr Card 1(2): Patient Safety Advisory 3(1):8–12, 2006.
120–125, 2008. 11. Mullin MH, et al: Sensations during removal of epidural
2. Carroll KC, et al: Risks associated with removal of pacing wires after coronary artery bypass graft surgery.
ventricular epicardial pacing wires after cardiac surgery. Heart Lung 38(5):377–381, 2009.
Am J Crit Care 7(6):444–449, 1998. 12. Prasad SK, Pennell DJ: Safety of cardiovascular magnetic
3. Clark L: Bedside nurses removing epicardial pacer wires: resonance in patients with cardiovascular implants and
From concept to practice. Can J Cardiovasc Nurs devices. Heart 90:1241–1244, 2004.
17(1):27–30, 2007. 13. Reade MC: Temporary epicardial pacing after cardiac
4. Conte JV, et al: The Johns Hopkins manual of cardiac surgery: A practical review. Part 1: General considerations
surgical care, ed 2, Philadelphia, 2008, Mosby. in the management of epicardial pacing. Anaesthesia
5. Garcia-Bengochea JB, et al: Temporary epicardial left 62:264–271, 2007.
ventricular and biventricular pacing improves cardiac 14. Roschkov S, Jensen L: Coronary artery bypass graft
output after cardiopulmonary bypass. J Cardiothorac Surg patients’ pain perception during epicardial pacing wire
7:113–120, 2012. removal. Can J Cardiovasc Nurs 14:32–38, 2004.
6. Hartnell GG, et al: Safety of MR imaging in patients who 15. Roy CL, et al: Does this patient with a pericardial
have retained metallic materials after cardiac surgery. AJR effusion have cardiac tamponade? JAMA 297(16):1810–
AM J Roentgenol 168:1157–1159, 1997. 1818, 2007.
7. Levine GN, et al: Safety of magnetic resonance imaging 16. Salami MA, Coleman RJ, Buchan KG: Colonic injury
in patients with cardiovascular devices: An American from temporary epicardial pacing wires. Ann Thorac Surg
Heart Association scientific statement from the Committee 93:1309–1311, 2012.
on Diagnostic and Interventional Cardiac Catheterization, 17. Schofield J: Activity restriction after temporary epicardial
Council on Clinical Cardiology, and the Council on pacing wire removal: Does it matter? Am J Crit Care
Cardiovascular Radiology and Intervention: Endorsed by 19(3):e17, 2010.
the American College of Cardiology Foundation, the 18. Shaikhrezai K, et al: Is it safe to cut pacing wires flush
North American Society for Cardiac Imaging, and the with the skin instead of removing them? Interact
Society for Cardiovascular Magnetic Resonance. Cardiovasc Thorac Surg 15:1047–1051, 2012.
Circulation 116:2878–2891, 2007. 19. Wollan DL: Removal of epicardial pacing wires: An
8. Lexi-Comp, Inc (Lexi-Drugs). Lexi-Comp, Inc, October expanded role for nurses. Prog Cardiovasc Nurs
16, 2014. 10(4):21–26, 1995.
9. Mahon L, et al: Cardiac tamponade after removal of
temporary pacer wires. Am J Crit Care 21:432–440, 2012.
PROCEDURE
47
Implantable
Cardioverter-Defibrillator
Kiersten Henry
PURPOSE: The implantable cardioverter-defibrillator (ICD) is a device that is used
to prevent sudden cardiac death from malignant ventricular dysrhythmias. The ICD
continuously monitors a patient’s rhythm and attempts to convert ventricular
tachycardia or ventricular fibrillation via antitachycardia pacing, cardioversion,
defibrillation, or some combination of these. The ICD has the capability for backup
bradycardia pacing.
PREREQUISITE NURSING ❖ Class IIa: Reasonable for:

KNOWLEDGE Patients with unexplained syncope, significant left
ventricular (LV) dysfunction, nonischemic dilated
• Knowledge of the anatomy and physiology of the cardio- cardiomyopathy
vascular system, principles of cardiac conduction, and Patients with sustained VT with normal or near-
basic dysrhythmia interpretation is needed. normal ventricular function
• Knowledge of basic functioning of ICDs and patient Patients with hypertrophic cardiomyopathy (HCM)
response to ICD therapy is needed. or arrhythmogenic right ventricular dysplasia
• Knowledge of principles of defibrillation threshold, anti- (ARVD) and with one or more major risk factors for
dysrhythmia medications, alteration in electrolytes, and sudden cardiac death (SCD)
effect on the defibrillation threshold is necessary. Patients with long QT syndrome who are having
• Advanced cardiac life support (ACLS) knowledge and syncope or VT while receiving beta blockers
skills are needed. Patients who are not hospitalized and are waiting
• Clinical and technical competence related to use of the transplantation
external defibrillator is necessary. Patients with Brugada syndrome, with either syncope
• Indications for ICD implantation, based on the 2012 or with documented VT that has not resulted in
Update of the American College of Cardiology (ACC)/ cardiac arrest
American Heart Association (AHA)/Heart Rhythm Patients with catecholaminergic polymorphic VT
Society (HRS) guidelines8: with syncope or documented sustained VT on beta
❖ Class I: Indicated in: blocker therapy
Survivors of cardiac arrest as a result of ventricular Patients with cardiac sarcoidosis, giant cell myocar-
fibrillation (VF) or sustained unstable ventricular ditis, or Chagas’ disease
tachycardia (VT) ❖ Class IIb: May be considered in:
Patients with structural heart disease and sustained Patients with nonischemic cardiomyopathy with
VT (hemodynamically stable or unstable) LVEF less than or equal to 35%, NYHA functional
Patients with syncope of undetermined origin with class I
hemodynamically significant VT or VF at electro- Patients with long QT syndrome and risk factors for
physiology study (EPS) SCD
Patients with nonischemic dilated cardiomyopathy Patients with syncope and advanced structural heart
(DCM) with left ventricular ejection fraction (LVEF) disease in whom thorough invasive and noninvasive
less than or equal to 35%, New York Heart Associa- investigations have failed to define a cause
tion (NYHA) functional class II or III Patients with familial cardiomyopathy associated
Patients with LVEF less than 35% as a result of prior with SCD
myocardial infarction (MI; more than 40 days after Patients with LV noncompaction
MI), NYHA class II or III; or LVEF less than 30%, ❖ Class III: Not indicated in:
NYHA functional class I Patients without a clinical expectation of survival
Patients with nonsustained VT as a result of prior for at least 1 year (with reasonable functional status),
MI, LVEF less than 40%, with inducible VF or even if other implantation criteria are met
sustained VT at EPS Patients with refractory VT or VF
377
Figure 47-1 ICD and lead system (including superior vena cava
lead, right ventricular lead, and coronary sinus lead). (Courtesy
Boston Scientific Corporation, Natick, MA.)
Patients with significant psychiatric illness that may

be impacted by device implantation, or may impact
patient’s ability to follow up
Patients with NYHA Class IV heart failure, refrac-
tory to drug therapy, who are not candidates for
transplantation or cardiac resynchronization therapy
Patients with syncope of undetermined cause, and
no evidence of inducible ventricular tachyarrhyth-
mias or structural heart disease Figure 47-2 Top, ICD patch that is placed on the right ventricle.
Bottom, Superior vena cava lead. (Courtesy Boston Scientific Cor-
Patients with VF/VT that can be treated with cath- poration, Natick, MA.)
eter or surgical ablation
Patients with ventricular dysrhythmias due to a
reversible disorder (such as electrolyte imbalance or
medications) without evidence of structural heart or bipolar, and active or passive fixation. The lead systems
disease may be single, double, or multiple.
• A specific time period of guideline-driven medical therapy • Leads may be attached to the heart via active or passive
must be initiated before implantation of an ICD. The indi- fixation. Active fixation leads use a screw, barb, or hook
cation for implantation determines the necessary waiting at the tip that is embedded into the myocardium to ensure
period: stability of the lead. Passive fixation leads use tines or fins
❖ Patients with any cardiomyopathy not on optimal at the tip that allow the lead to attach to trabeculae of the
medical therapy must be reassessed for eligibility after myocardium.
3 months. • Most leads are endocardial (transvenous) leads and are
❖ Patients who are post-MI or ischemic cardiomyopathy inserted transvenously through the subclavian, cephalic,
and are revascularized with percutaneous coronary or axillary veins.
intervention or coronary artery bypass must be reas- • Epicardial leads are less common but are used in special
sessed for eligibility after 3 months. circumstances. Epicardial pacing leads may be placed on
❖ Patients who are post-MI without revascularization the outside of the left ventricle to provide biventricular
must be reassessed for eligibility after 40 days. pacing when coronary sinus placement of the LV lead has
❖ Patients with any cardiomyopathy who have been on been unsuccessful. Epicardial patches may be placed on
guideline-directed medical therapy for the required the outside of the heart, both anteriorly and posteriorly.
interval can be referred for ICD implantation.12 Epicardial patches provide a greater surface area for defi-
• The ICD system is composed of a pulse generator and a brillation (see Fig. 47-2).
lead system. The pulse generator is titanium and contains • All leads have a cathode (negative pole) and an anode
the capacitors, circuitry, and a lithium battery (Fig. 47-1). (positive pole). A unipolar lead uses one conductor wire,
• Battery longevity may be greater than 5 years, depending with a distal electrode as cathode and the metal can as the
on the number of times therapies are delivered and the anode. This configuration produces a large electrical
frequency of pacing.15,16 The pulse generator is typically circuit and a large pacing artifact on electrocardiography
located in a pectoral subcutaneous pocket. (ECG). Because of the large area covered, this configura-
• The leads are insulated wires that sense the patient’s tion is susceptible to stimulation of chest muscles and also
intrinsic rhythm and can pace or deliver therapies (Fig. to electromagnetic interference. A bipolar lead uses two
47-2). Leads are classified as atrial or ventricular, endo- electrodes on the distal end of the lead to form the circuit.
cardial (transvenous) or epicardial (myocardial), unipolar The cathode is located at the distal tip, and the anode
47 Implantable Cardioverter-Defibrillator 379
several millimeters proximal to the tip. Because of the ❖ Class III: Not indicated in:
closer circuitry, a smaller pacing artifact is seen on ECG. Patients with a non-LBBB pattern and QRS dura-
• All ICDs function as pacemakers. Some ICDs are tion less than 150 ms who have NYHA class I/II
also biventricular pacemakers. Cardiac resynchroniza- symptoms
tion therapy (CRT) paces the right and left ventricles Patients whose expected survival with good func-
together to establish synchrony in an effort to improve LV tional capacity is less than 1 year
function.11 Biventricular pacing must be as close to 100% • The ICD detects tachydysrhythmias, delivers antitachy-
as possible for the greatest benefit. Biventricular pacing cardia pacing (ATP) or electrical therapy (shock), and
leads are placed in the right atrium, the right ventricle, provides bradycardia pacing. ATP attempts to convert
and an epicardial vein on the surface of the left ventricle monomorphic VT by pacing at a rate faster than the VT
accessed through the coronary sinus. Patients must be rate, thereby terminating the dysrhythmia. ATP is a pain-
on guideline-based medical therapy before placement of less way of treating VT, sometimes avoiding shock therapy
a device for CRT. Indications for biventricular pacing, altogether. The PainFree II trial demonstrated that com-
based on the 2012 Update of the American College of pared with shocks, empirical ATP for fast VT was highly
Cardiology (ACC)/American Heart Association (AHA)/ effective, equally safe, and improved quality of life.19
Heart Rhythm Society (HRS) guidelines8: Cardioversion is generally referred to as synchronized
❖ Class I: Indicated in: electrical therapy. Defibrillation is not synchronized and
Patients with LVEF less than or equal to 35%, left is generally used to convert ventricular dysrhythmias.6
bundle branch block (LBBB) with a QRS duration • The ICD therapies may be programmed from one to
greater than or equal to 150 ms, NYHA class II-IV three zones. In the first zone (e.g., rates 182 to 200
symptoms, and sinus rhythm beats per minute), the device may be programmed to
❖ Class IIa: May be useful in: differentiate between supraventricular tachycardia (SVT)
Patients with LVEF less than or equal to 35%, and VF/VT. A delay of 30 to 40 beats allows the device
LBBB with a QRS duration 120 to 149 ms or non- to differentiate between rhythms and initiate appropri-
LBBB pattern with QRS duration greater than or ate therapy. Additional zones based on heart rates (201
equal to 150 ms, NYHA class II-IV symptoms, and to 250 and >250) allow for more aggressive manage-
sinus rhythm ment of tachyarrythmias. Zones may be programmed
Patients with ejection fraction less than or equal to for sequential therapies of ATP followed by electrical
35% who require ventricular pacing for other reasons defibrillation if ATP is unsuccessful. Programming of
Patients with ejection fraction less than or equal to multiple zones helps to reduce inappropriate defibrillator
35% who are undergoing new or replacement device shocks.10,14,18,23
placement and are expected to have ventricular • A defibrillator code was developed in 1993 by the North
pacing greater than 40% of the time American Society of Pacing and Electrophysiology and
❖ Class IIb: May be considered in: the British Pacing and Electrophysiology Group to
Patients with ischemic cardiomyopathy, LVEF less describe the capabilities and operation of ICDs. The
than or equal to 30%, LBBB with a QRS greater defibrillator code is patterned after the pacemaker code;
than or equal to 150 ms, NYHA class I symptoms, however, it has some important differences (Table 47-1).3
and sinus rhythm The defibrillator code offers less information about the
Patients with LVEF of less than or equal to 35%, a ICD’s antibradycardia pacing function but more specific
non-LBBB pattern with QRS 120 to 149 ms, NYHA information about the shock functions.
class III/IV symptoms, and sinus rhythm • A magnet applied over an ICD disables the device thera-
Patients with LVEF of less than or equal to 35%, a pies of ATP and electrical cardioversion/defibrillation but
non-LBBB pattern with QRS greater than or equal does not affect pacemaker function. The magnet is used
to 150 ms, NYHA class II symptoms, and sinus during procedures that may cause electromagnetic inter-
rhythm ference (EMI). EMI from cautery devices, for example,
TABLE 47-1 NASPE/BPEG Defibrillator Code

Position I Position II Position III Position IV
Antitachycardia Tachycardia Antibradycardia
Shock Chamber Pacing Chamber Detection Pacing Chamber
O = none O = none E = electrogram O = none
A = atrium A = atrium H = hemodynamic A = atrium
V = ventricle V = ventricle V = ventricle
D = dual (A + V) D = dual (A + V) D = dual (A + V)
NASPE/BPEG, North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group.
From Bernstein AD, et al. The NASPE/BPEG defibrillator code (NBD code). Pacing Clin Electrophysiol, 16, 1776, 1993.
may be improperly sensed as a tachydysrhythmia, causing • Provide information about ICD therapy, including the
inappropriate device shock. In most models, removal of reason for the ICD, device operation, location of the
the magnet restores normal ICD function. Some models, device, types of therapy given by the device, risks
however, do not resume previous settings once the magnet and benefits of the device, and follow-up. Rationale:
is removed.17 Checking with the manufacturer before Understanding of ICD functioning assists the patient
magnet use is best to determine the specific recommenda- and family in developing realistic perceptions of ICD
tions for each ICD. If a device programmer and trained therapy.
personnel are available, device tachydysrhythmia detec- • Discuss postimplant incision care, including inspection of
tion and therapies can be disabled through the program- the incision and pocket. The incision is kept dry for several
mer for the duration of the procedure. days after the procedure. Rationale: The nurse or physi-
• Emotional adjustments vary with each patient and family. cian needs to know whether any of the following signs or
Patients may experience depression, anxiety, fear, and symptoms of infection appear: redness, edema, warmth,
anger. Some patients view the device as an activity restric- drainage, and/or fever.
tion, and others see it as a life-saving device that allows • Discuss postoperative activity. For the first 4 to 6 weeks
normal life to resume. Preimplantation psychological after implant: (1) no lifting of the arm on the side of the
variables, such as degree of optimism or pessimism, and ICD above the shoulder or extending the arm to back
an anxious personality style may place patients at a higher (including activities such as swimming, golfing, and
level of risk for difficulty adjusting to the ICD.17 Support bowling); (2) no lifting of items heavier than 10 lb; and
groups may serve a vital role for ICD recipients who are (3) no excessive pushing, pulling, or twisting. Rationale:
anxious and for patients who may need additional support. The activity restrictions help to prevent new leads from
Education interventions with patients and family members dislodgment.
help to reduce psychosocial distress. Delivery of shock is • Provide patients with an identification card (temporary
shown to increase the risk of posttraumatic stress disorder cards are usually given to patients at the time of implant,
in patients with ICDs.7 and permanent cards are sent to patients by the manufac-
• The option of ICD deactivation should be discussed before turer several weeks later). Encourage the patient to wear
the device is implanted.21 Early discussions of device Medic Alert identification and to carry the identification
deactivation facilitate later discussions and are an impor- card at all times. Rationale: This identification ensures
tant part of the informed consent process.13,22 that appropriate information is available to anyone caring
for the patient.
EQUIPMENT • If patients are prescribed antidysrhythmic medication,
stress the importance of continuing the medication. Ratio-
• ECG monitor and recorder nale: Antidysrhythmic medications suppress dysrhyth-
• ECG electrodes mias and may limit potential ICD shocks.
Additional equipment, to have available as needed, includes • Discuss the need for patients to keep a current list of
the following: medications in their wallets. Rationale: The patient or
• ICD programmer (commonly obtained from the electro- other family members should be prepared to provide nec-
physiology department or specific manufacturer) essary information to healthcare providers in an emer-
• Magnet (doughnut or bar type) gency situation.
• 12-lead ECG machine • Encourage family members to learn community CPR.
• Analgesia and sedation as prescribed Rationale: Family members may be more prepared for an
• Emergency medications and resuscitation equipment emergency situation (e.g., if the ICD does not convert a
• Antidysrhythmia medications as prescribed life-threatening rhythm or the ICD malfunctions).
• Educate patients and families about what to do for a
PATIENT AND FAMILY EDUCATION device shock. The shock varies in intensity from mild to
severe pain. If patients have received an isolated shock
• Assess learning needs, readiness to learn, and factors that and are asymptomatic afterward, they should call their
influence learning. Rationale: This assessment allows the healthcare provider to determine further action (usually an
nurse to individualize teaching in a meaningful manner. appointment for device interrogation). If patients have
• Assess patient and family understanding of ICD therapy received multiple shocks in a short period of time (within
and the reason for its use. Rationale: This assessment minutes to hours), or if they have had one shock and do
provides information regarding knowledge level and not feel well, they should activate the emergency medical
necessity of additional teaching. services (EMS) system by calling 911 to seek emergency
• Provide information about the normal conduction system, evaluation at an emergency room.4 Rationale: Repeated
such as structure of the conduction system, source of the shocks may indicate conditions that necessitate prompt
heartbeat, normal and abnormal heart rhythms, symptoms treatment, such as electrolyte imbalance or ischemia.
of abnormal heart rhythms, and the potentially life- They may also indicate malfunction of the device sensing,
threatening nature of VT and VF. Rationale: Understand- which may occur with lead fracture.
ing of the conduction system and dangerous dysrhythmias • Inform patients to call their healthcare provider if they
assists the patient and family in recognizing the serious- hear an audible tone emitted from the device. An audible
ness of the patient’s condition and the need for ICD therapy. tone may indicate battery depletion or signal device
parameter alerts (such as lead impedance out of normal PATIENT ASSESSMENT AND
range). Some devices use vibratory alerts in place of PREPARATION
audible tones to signal an alert condition. Rationale: The
ICD should be interrogated to determine the reason for Patient Assessment
the tone and to ensure safe device function. • Assess the patient’s cardiac rate and rhythm. Rationale:
• Inform patients and families that family members are not This assessment establishes baseline data.
harmed if they touch the patient when a shock is delivered. • Presurgical instructions usually include maintaining
Rationale: This information prepares the patient and nothing by mouth (NPO) for at least 8 hours before the
family and may decrease anxiety. procedure and obtaining complete blood cell count (CBC),
• Driving restrictions vary from state to state and among chemistries, prothrombin time (PT), and partial thrombo-
physicians. Each patient should discuss plans for long plastin time (PTT) for baseline data. Rationale: All these
trips and driving restrictions with the physician. Current actions ensure patient safety to prevent complications
guidelines prohibit anyone with an ICD from obtaining a such as excessive bleeding and aspiration.
commercial driver’s license.9 Rationale: These restric- • For patients prescribed oral anticoagulation, review with
tions are intended to prevent motor vehicle accidents from the physician who will be implanting the device whether
sudden loss of consciousness while driving. the anticoagulation medication should be continued or
• Educate patients and families that the terms “elective bridged with a short acting anticoagulant such as heparin.
replacement indicated” (ERI) and “end of life” (EOL) are Rationale: Historically, warfarin has been held for several
used to describe the status of the battery. At ERI, the days before the implant procedure with heparin as a bridge
battery is able to function for approximately another 2 to to surgery. Recent research shows a lower incidence with
3 months. A generator change is done as soon as possible continuation of warfarin rather than bridging with heparin.5
during that time period. At EOL, the generator must be • Assess the patency of the patient’s intravenous access.
changed promptly. Rationale: This teaching prepares Rationale: Intravenous access should be ensured for
patients and families for generator changes, alleviates administration of prescribed medications.
misunderstanding, and may decrease anxiety. • Administer antibiotics as prescribed. Rationale: Antibiot-
• Inform patients and family members about follow-up ics are administered to reduce infection from skin micro-
device checks or “interrogations.” Stress the importance organisms such as Staphylococcus aureus (cause of early
of keeping these appointments. Devices are checked every infection) and Staphylococcus epidermidis (cause of later
3 to 6 months (but may be more frequent if any issues infection).2
arise that necessitate monitoring). Many follow-up checks • Identify the manufacturer of the ICD and how it is pro-
are now done remotely, through Internet-based systems. grammed. Rationale: Interrogation of the device provides
A transmitter device is mailed to the patient from the important information: battery voltage and impedance,
device manufacturer.15 Rationale: Routine interrogation charge time, dysrhythmias detected by device (logbook)
maintains optimal functioning of the ICD and alerts pro- and any therapies given (ATP or shock), pacing and
viders of dysrhythmias. sensing thresholds, and impedances for all leads, percent
• Inform the patient and family of potential sources of of pacing and sensing in each chamber, and review of
EMI to the ICD. In the hospital, EMI include magnetic programmed parameters.20,21 Interrogation usually also
resonance imaging, diathermy, computed tomography, reveals device and lead information (models and serial
lithotripsy, electrocautery, radiation therapy, and nerve numbers), implant date, and implanting physician infor-
stimulators. Outside the hospital, these include handheld mation. See Figure 47-3 for an example of an ICD inter-
wands used by airport security, arc welders, large trans- rogation report.
formers or motors, antitheft devices at stores or libraries,
cellular phones less than 6 inches away from the pulse Patient Preparation
generator, the antenna of an operating citizens’ band or • Verify that the patient is the correct patient using two
ham radio, improperly grounded electrical equipment, and identifiers. Rationale: Before performing a procedure, the
handheld tools less than 12 inches away from the pulse nurse should ensure the correct identification of the patient
generator. Cellular phones should be positioned on the for the intended intervention.
opposite side of device.1 Rationale: EMI can deactivate • Ensure that the patient and family understand preproce-
ICD therapies. dural teaching. Answer questions as they arise, and rein-
• Explore the patient’s feelings about having an ICD. force information as needed. Rationale: Understanding of
Provide education to the patient and family members previously taught information is evaluated and reinforced.
about the device implantation. Rationale: Acknowledging • Ensure that informed consent has been obtained (before
these stressors may alleviate the most common psycho- ICD insertion). Rationale: Informed consent protects the
logical disturbances after ICD implantation, which include rights of the patient and makes a competent decision pos-
stress, anxiety, depression, and fear.17 sible for the patient.
• Inform patients to notify their physicians if the device • Perform a preprocedure verification and time out (before
begins to wear through the skin or the device site becomes ICD insertion). Rationale: Ensures patient safety.
reddened, warm, painful, or has discharge. Rationale: • Provide analgesia or sedatives as prescribed and needed.
These signs and symptoms identify problems (e.g., infec- Rationale: Analgesia and sedatives promote comfort and
tion) that need additional medical care. may decrease anxiety.
9 Quick Look
Device: En Trust Serial Number: Date of Interrogation: -Feb-2007 16:08:52

Patient: Physician:
1 Device Status (Implanted: 13-Jun-2006) Measured on:

Battery Voltage (ERI=2.61 V) 3.17 V 24-Feb-2007
Last Full Energy Charge 7.9 sec 13-Dec-2006
2 Atrial(5076) RV
Pacing Impedance 488 ohms 504 ohms 24-Feb-2007
Defibrillation Impedance RV=76 ohms 24-Feb-2007
Programmed Amplitude/Pulse Width 3 V / 0.4 ms 3 V / 0.4 ms
3 Measured P/R Wave 3 mV 20 mV 24-Feb-2007
Programmed Sensitivity 0.3 mV 0.45 mV
4 Parameter Summary
Mode AAI<=>DDD Lower Rate 60 bpm Paced AV 180 ms
Mode Switch 171 bpm Upper Track 130 bpm Sensed AV 150 ms
Upper Sensor 130 bpm
5 Detection Rates Therapies
AT/AF Monitor >171 bpm All Rx Off
VF On >200 bpm ATP During Charging, 25J, 35J × 5
FVT OFF All Rx Off
VT On 171-200 bpm Burst(3), Ramp(3), 20J, 35J × 3
Enhancements On: AF/All, Sinus Tach
Clinical Status Since 24-Oct-2006 Cardiac Compass Trends (Jun-2006 to Feb-2007)
6 Treated P l l
VF 0 Treated >5
4
FVT (Off) VT/VF 3
VT 1 (#/day) 2
1
AT/AF (Monitor) 0
7 Monitored AT/AF 6
VT (Off) (hr/day) 5
4
VT-NS (>4 beats, >171 bpm) 3 3
SVT: VT/VF Rx Withheld 0 2
AT/AF 1 1
0
4
Time in AT/AF <0.1 hr/day (<0.1%) Patient
3
Longest AT/AF 2 hours Activity
(hr/day) 2
Functional Last Week 1
Patient Activity 0.9 hr/day 0
Jul-06 Sep-06 Nov-06 Jan-07 Mar-07 May-07 Jul-07
9 Therapy Summary VT/VF AT/AF Pacing (% of Time Since 24-Oct-2006) 8

Pace-Terminated Episodes 1 of 1 0 AS-VS 44.5%
Shock-Terminated Episodes 0 0 AS-VP <0.1%
Total Shocks 0 0 AP-VS 55.4%
Aborted Charges 0 0 AP-VP <0.1%
MVP On
10 OBSERVATIONS (1)
Patient Activity less than 2 hr/day for 17 weeks.
Medtronic CareLink Network Confidential Patient Information 02-May-2007 16:27:07

A Copyright © 2001-2005 Medtronic, Inc Page 1
Figure 47-3 A, Printout from an ICD interrogation.
1 Are the battery voltage and charge time OK?
2 How are the leads performing?
3 Is sensing OK?
Are the sensitivity settings appropriate?
4 What are the pacing parameters?

Do they look appropriate for the patient?
5 What are the detection and therapy parameters?

Do they look appropriate for the patient?
6 Has the device treated any VT/VF episodes?
7 Has the device detected any AT/AF, SVT, or nonsustained

episodes?
8 Have you minimized unnecessary right ventricular pacing?
9 Were therapies successful? Assess any episodes using EGMs,

Interval Plots, and Episode Texts.
10 Are there any observations?

B
Figure 47-3, cont’d B, Questions to consider during ICD interrogation. Healthcare providers
trained at interpretation of results can gather this type of information from an ICD device check.
Procedure for Implantable Cardioverter-Defibrillator

1. HH
2. PE
3. Cleanse the skin for application of Proper skin preparation is essential Clipping of chest hair may be
the ECG electrodes with cleansing to maintain appropriate skin-to- necessary to ensure good skin
pads or soap and water. electrode contact. contact with the electrodes.
4. Attach the ECG leads to the Assesses cardiac rhythm.
electrodes, place the electrodes on
the patient’s chest, and record the
ECG.
Procedure for Implantable Cardioverter-Defibrillator—Continued

5. If the patient experiences VT or
VF:
A. Assess and stay with the Ensures patient safety and provides Run a continuous ECG strip of the
patient. an opportunity to assess the dysrhythmia from the bedside
patient’s response to the monitor if possible; record a 12-lead
dysrhythmia. ECG if possible.
B. Wait for the device to function: The ICD requires a brief period Note: The device may not detect VT/
antitachycardia pacing or shock (8–30 seconds) to assess the VT VF if the rate of the VT is below the
therapy. or VF and to initiate therapy. programmed detection rate.23
C. If the dysrhythmia continues, The ICD reassesses the cardiac
wait for the ICD to recharge rhythm, recharges, and shocks
and shock again if indicated. again as preprogrammed.
D. If the ICD has been functioning Provides emergency care. Assess the patient’s response to VT;
as preprogrammed and still the patient’s condition may be
does not convert the hemodynamically stable or unstable.
dysrhythmia, initiate BLS and Notify the physician or advanced
ACLS. practice nurse immediately and
prepare emergency equipment.
E. Apply defibrillation electrodes
(patches) or paddles in one of
the two following ways:
i. Place one electrode or The electrical current passes Defibrillator paddles and defibrillation
paddle at the heart’s apex through the cardiac muscle. electrodes should not be placed over
just to the left of the nipple medication patches or the ICD
in the midaxillary line (at generator.
fifth to sixth intercostal The paddles and electrodes should be a
space) and place the other minimum of 2 inches away from the
electrode or paddle just generator when external shocks are
below the right clavicle to delivered.
the right of the sternum.
or
ii. Apply anterior-posterior The electrical current passes
defibrillation electrodes or through the cardiac muscle.
paddles. The anterior
electrode or paddle is placed
in the anterior left precordial
area, and the posterior
electrode or paddle is placed
posteriorly behind the heart
in the left infrascapular area.
F. If the ICD does not convert Provides emergency treatment. ICDs have preprogrammed pacing
VT/VF and the patient’s capability; cardiac pacing is initiated
condition is hemodynamically by the ICD if the result of
unstable, externally defibrillate defibrillation is bradycardia or
the patient according to ACLS asystole.
guidelines (see Procedure 36). If external defibrillation is needed, the
ICD should be interrogated to assess
for potential damage to the device.

ICD Deactivation
1. Prepare for deactivation of the The ICD may need to be If the device is functioning
ICD: deactivated if it is defibrillating a inappropriately, deactivation may be
A. Review the physician cardiac rhythm that is not VT or necessary to prevent harm to the
prescription. VF, such as atrial fibrillation patient.
B. Obtain supplies. with a rapid ventricular response. The following circumstances may
The device also can be temporarily necessitate ICD deactivation: lead
deactivated during surgical dislodgment, lead migration, lead
procedures where EMI may fracture, inappropriate identification
interfere with appropriate device of the rhythm, and inappropriate
function. defibrillation threshold.
The ICD may be deactivated if Consider connecting the patient to an
therapy is no longer effective or external defibrillator as indicated and
needed or is not desired.15,21 desired.
2. HH
3. PE
4. Determine who will deactivate the The ICD may be deprogrammed by Follow institution standards regarding
ICD. This may include a physician, personnel trained in use of the personnel who can deactivate the
nurse, advance practice nurse, or ICD programmer. ICD with use of the programmer.
other healthcare professional. Ensures that the device is
deprogrammed as prescribed.
5. If the ICD programmer is Deactivation response to a magnet Follow the institution’s standards
unavailable, a magnet may be varies among manufacturers. regarding personnel who can
used to deactivate the device: Some ICDs are deactivated when deactivate the ICD with a magnet.
A. Place a bar or doughnut the magnet is placed on the skin A magnet applied over an ICD disables
magnet over the ICD generator. above the generator, and then the the device therapies of ATP and
B. Follow the manufacturer’s magnet can be removed. electrical cardioversion/defibrillation,
guidelines regarding removing Other ICDs are deactivated only but it does not turn off pacemaker
the magnet or taping the when the magnet remains on the function. The magnet may initiate
magnet in place. (Level M*) skin over the generator. asynchronous pacing.
If information about a patient’s ICD
model and magnet features is
unknown or is not clear, contact the
personnel responsible for ICDs in
your institution or contact the
manufacturer to determine this
information.
Some ICDs emit a synchronous tone
that occurs with each R wave when
the device is activated and a constant
tone when the ICD is deactivated.
Knowledge of which manufacturers
have this ability and whether the
feature is turned on is important; not
all devices emit a synchronous tone.
6. Remove gloves, discard used Reduces the transmission of
supplies, and ensure equipment is microorganisms; Standard
cleaned. Precautions.
7. HH


ICD Reactivation
1. HH
2. PE
3. Determine who will reactivate the The ICD may be reprogrammed by Follow the institution’s standards
ICD. This may include a physician, personnel trained in use of the regarding personnel who can
nurse, advance practice nurse, or ICD programmer. reactivate the ICD with use of the
other healthcare professional. Ensures that the device is programmer.
reprogrammed as prescribed.
4. If the ICD programmer is not When the magnet is removed, most Follow the manufacturer’s
available: ICDs automatically reactivate. recommendations regarding magnet
A. If a bar or doughnut magnet is features.
over the ICD generator, remove Some ICDs emit a synchronous tone
the magnet. that occurs with each R wave when
B. If a bar or doughnut magnet is the device is activated and a constant
not over the ICD generator, tone when the ICD is deactivated.
place one there and then Knowledge of which manufacturers
remove the magnet. (Level M*) have this ability and whether the
feature is turned on is important; not
all devices emit a synchronous tone.
5. Remove gloves, discard used Reduces the transmission of
supplies, and ensure equipment is microorganisms; Standard
cleaned. Precautions.
6. HH

• ICD detects life-threatening VT or VF • Failure of the ICD to detect VT or VF
• ICD delivers appropriate therapy, including • Failure of the ICD to convert life-threatening
antitachycardia pacing and defibrillation as necessary dysrhythmia despite appropriate therapy and
• Cardiac rhythm is converted to a hemodynamically defibrillation attempts
stable rhythm • Failure of the backup pacing system to pace if
• ICD provides bradycardia pacing as needed bradycardia or asystole is the result of defibrillation
• Inappropriate defibrillation
• Infection at the ICD pulse generator site, leads, or
myocardium
• Lead fracture or migration
• Pulse generator migration
• Pulse generator pocket hematoma
• Loosened set screw in device header (this screw
holds the lead circuitry in place in the device header);
loose set screws usually manifest as improper device
function and occur generally immediately after
implant
• Air embolism
• Venous thrombosis
• Skin erosion
• Pneumothorax
• Frozen shoulder on operative side
• Twiddler’s syndrome (manipulation of the device in
the device pocket by a patient, either intentionally or
unintentionally, which may lead to dislodgement)

interventions.
1. Monitor the ECG continuously. Detects dysrhythmias. • Dysrhythmias
2. Monitor the ICD for Detects functioning of the ICD. • Ventricular dysrhythmias
antitachycardia pacing, • ICD therapy
cardioversion, and defibrillation. • Defibrillation
• ICD malfunction
3. Assess the patient’s response to Determines patient status and • Cardiac rate and rhythm before
ICD defibrillation, including necessity for additional and after defibrillation
cardiac rate and rhythm, level of treatment. • Level of consciousness
consciousness, and vital signs. • Vital signs
5. Monitor for signs and symptoms Placement of an invasive device • Redness
of infection. may result in infection. • Edema
• Drainage
• Increased white blood cell count
• Increased temperature
6. Monitor for signs of bleeding and Placement of an invasive device • Bleeding at incision
hematoma at ICD insertion site. may result in untoward bleeding. • Edema around ICD site
Documentation
• Device interrogation information: battery voltage and • All rhythm strip recordings
charge time, dysrhythmias detected by device and any • Patient response to ICD therapy
therapies given, status of leads, programmed • Pain assessment, interventions, and effectiveness
parameters (see Figs. 47-3, A and 47-3, B) • Anxiety assessment, interventions, and effectiveness
• Patient and family education • Occurrence of any unexpected outcomes
• Adjustment to device • Additional interventions

47 Implantable Cardioverter-Defibrillator 387.e1
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Med 335:1933–1940, 1996. 28(2):84–96, 2008.
Poole JE, et al: Complication rates associate with pacemaker
or implantable cardioverter-defibrillator generator
PROCEDURE
48
Permanent Pacemaker
(Assessing Function)
Valerie Spotts
PURPOSE: The purpose of permanent pacing is to electrically stimulate
myocardial contraction and to restore and maintain an appropriate heart rate or
ventricular synchrony when a chronic conduction or impulse-formation disturbance
exists in the cardiac conduction system. Assessment of the permanent pacemaker
is important in maintaining proper function.
PREREQUISITE NURSING pacing. A transvenous pacing lead may be positioned in

KNOWLEDGE the right atrium, the right ventricle, or a cardiac vein sup-
plying the left ventricle (or a combination of these),
• Knowledge of the normal anatomy and physiology of the depending on the type of pacing needed.
cardiovascular system, cardiac conduction, and basic dys- • Unipolar pacing involves a relatively large electrical
rhythmia interpretation is necessary. circuit. The distal tip of the pacing lead is the negative
• Knowledge of pacemaker function and patient response electrode and is in contact with the myocardium. The
to pacemaker therapy is needed. positive electrode encompasses the metallic pacemaker
• Advanced cardiac life support (ACLS) knowledge and case, located in the soft tissue. Energy is delivered from
skills are needed. the negative electrode to the positive electrode, causing
• Permanent pacing is indicated for the following clinical myocardial depolarization. The electrocardiogram (ECG)
conditions5: tracing shows a large, easily visible spike.
❖ Symptomatic sinus node dysfunction • Bipolar pacing uses a smaller electrical circuit in which
❖ Acquired atrioventricular (AV) block in adults the distal tip of the pacing lead is the negative electrode
❖ Chronic bifascicular and trifascicular block in contact with the myocardium. The pacing lead has
❖ AV block associated with acute myocardial infarction a second positive electrode that is located within 1 cm
❖ Hypersensitive carotid sinus and neurocardiogenic of the negative electrode. Energy is delivered from
syncope the negative electrode to the positive electrode, causing
❖ Specific conditions related to cardiac transplantation, myocardial depolarization. The ECG tracing may show
neuromuscular diseases, sleep apnea syndromes, or small spikes, or the spikes may not be visible on a
infiltrative and inflammatory diseases such as cardiac surface ECG.
sarcoidosis • Basic principles of cardiac pacing include sensing, pulse
❖ Prevention and termination of supraventricular tachy- generation, capture, and impedance (Table 48-1 lists
cardia via pacing definitions).6
❖ Hypertrophic cardiomyopathy with sinus node dys- • Depending on the type of pacemaker, the pacemaker lead
function or AV block may be placed in the atrium, the right ventricle, or the left
❖ Certain congenital heart defects ventricle. A standard code exists to describe pacemakers
❖ Certain cases of left-ventricular dysfunction, to restore (Table 48-2).2 The nurse must know the programmed
ventricular synchrony (cardiac resynchronization mode with the pacemaker code to determine whether the
therapy [CRT])1,3,11 device is functioning appropriately. Refer to Table 48-3 to
• Relative contraindications to permanent pacemakers review different programmed modes for pacemakers.
include the following: • Dual-chamber pacemakers contain pacing leads that are
❖ Active infection (e.g., endocarditis, positive blood located in the atrium and the ventricle. Pacing and sensing
culture results) occur in both chambers when programmed in DDD or
❖ Bleeding with abnormal coagulation laboratory results DDI modes. Pacing is inhibited by sensed atrial or ven-
• Components of the pacemaker are the pulse generator and tricular activity. Sensed or paced atrial activity triggers a
the leads. The pulse generator weighs less than 1 oz and ventricular paced response in the absence of intrinsic ven-
is typically implanted subcutaneously in a pectoral pocket. tricular activity within a programmed AV interval.4
The outer casing is made of titanium and contains the • Biventricular pacemakers (CRT) contain leads in the right
electronic components and the battery (Fig. 48-1). Typical atrium and the right ventricle and on the surface of the left
battery life is 5 to 10 years and is dependent on variables ventricle and simultaneously pace the right and left ven-
such as output values, impedance, and the percentage of tricles (Fig. 48-2).
388
48 Permanent Pacemaker (Assessing Function) 389
• Some pacemaker systems also include an implantable

cardioverter-defibrillator (see Procedure 47).
• Some pacemakers can be programmed to switch modes
(e.g., DDD mode to DDI mode) to avoid pacing at
the upper rate in patients who experience intermittent
atrial dysrhythmias in which rapid atrial rates are
generated.
• Certain pacemakers can be programmed with pacing ther-
apies for atrial dysrhythmias. This programming is called
antitachycardia pacing, in which the device paces faster
Pacemaker
Left
Atrial lead ventricular
lead
Right
ventricular
lead
Figure 48-1 Permanent pacemaker pulse generator. (Reproduced Figure 48-2 Biventricular pacemaker (cardiac resynchronization
with permission of Medtronic, Inc.) therapy). (Courtesy Medtronic, Inc, Minneapolis, MN.)
TABLE 48-1 Pertinent Definitions Related to Pacemakers

Sensing Ability of the pacemaker to detect intrinsic myocardial electrical activity. The pacemaker is either inhibited from
delivering a stimulus or initiates an electrical impulse based on the programmed response.
Pulse generation Occurs when the pacemaker produces a programmed electrical current for a programmed duration. This energy
travels through the transvenous lead wires to the myocardium. The electrical impulse is seen as a line or
spike on the ECG recording (pacemaker spikes are shown in Fig. 48-4).
Capture Successful stimulation of the myocardium by the pacemaker impulse that results in depolarization. Two settings
are used to ensure capture: amplitude and pulse width. Evidenced on the ECG by a pacemaker spike/stimulus
followed by either an atrial or ventricular complex, depending on the chambers being paced (see Fig. 48-4).
Lead impedance Opposition to flow of electrical current by the leads, electrodes, the electrode-myocardial interface, and body
tissues.6 Measured in ohms, normally between 200 and 1200 ohms. A lead insulation break can cause
impedance to fall below 200 ohms. A lead fracture can cause impedance to exceed 2000 ohms.
Failure of pulse generation The pacemaker does not discharge a pacing stimulus to the myocardium at its programmed time. Evidenced by
the absence of a pacemaker spike on the ECG where expected (see Fig. 48-5).
Failure to sense The pacemaker has either detected extraneous signals that mimic intrinsic cardiac activity (oversensing) or has
not accurately identified intrinsic activity (undersensing).
Oversensing is recognized on the ECG by pauses where paced beats were expected and prolongation of the
interval between paced beats (see Fig. 48-6). Oversensing leads to underpacing.
Undersensing is recognized on the ECG by inappropriate pacemaker spikes relative to the intrinsic electrical
activity (pacemaker spikes occurring where they are not needed) and shortened distances between paced
beats (see Fig. 48-7). Undersensing leads to overpacing. Spikes may appear during the QRS complex as part
of normal pacemaker function seen with fusion and pseudofusion beats.
Failure to capture Pacemaker has delivered a pacing stimulus that was unable to initiate depolarization and contraction of the
myocardium. Evidenced on the ECG by pacemaker spikes that are not followed by a P wave for atrial pacing
or spikes not followed by a QRS complex for ventricular pacing (see Fig. 48-8).
TABLE 48-2 Revised NASPE/BPEG Generic Code for Antibradycardia Pacing

I II III IV V
Chambers Paced Chambers Sensed Response to Sensing Rate Modulation Multisite Pacing
O = None O = None O = None O = None O = None
A = Atrium A = Atrium T = Triggered R = Rate modulation A = Atrium
V = Ventricle V = Ventricle I = Inhibited V = Ventricle
D = Dual (A + V) D = Dual (A + V) D = Dual (T + I) D = Dual (A + V)
S = Single (A or V)* S + Single (A or V)*
*Manufacturer’s designation only. NASPE, North American Society of Pacing and Electrophysiology; BPEG, British Pacing and Electrophysiology Group.
(From Bernstein AD, Daubert JC, Fletcher RD, et al: The revised NASPE/BPEG generic code for antibradycardia, adaptive-rate, and multisite pacing, Pacing Clin
Electrophysiol 25:261, 2002.)
TABLE 48-3 Programmed Pacing Modes

Pacemaker Code Pacemaker Response
AOO Atrial pacing; no sensing; asynchronous mode → paces atria at fixed, preprogrammed rate.
AAI Atrial pacing, atrial sensing and inhibition; intrinsic P waves inhibit atrial pacing; if no sensed atrial events → paces
in atria at preprogrammed rate.
AAIR Atrial pacing; atrial sensing; intrinsic P waves inhibit atrial pacing; if no sensed atrial events → paces in atria; rate
response to patient’s activity.
VOO Ventricular pacing; no sensing; asynchronous mode → paces ventricle at fixed, preprogrammed rate.
VVI Ventricular pacing: ventricular sensing; intrinsic QRS inhibits ventricular pacing; if no sensed events → paces in
ventricle at preprogrammed rate.
VVIR Ventricular pacing: ventricular sensing; intrinsic QRS inhibits ventricular pacing; if no sensed events → paces in
ventricle; rate response to patient’s activity.
DOO Atrial and ventricular pacing: no sensing; asynchronous mode → paces atria and ventricles at fixed,
preprogrammed rate.
DDI Atrial and ventricular pacing; atria and ventricular sensing; no tracking of atria: sensed atrial events inhibit atrial
pacing/do not trigger a ventricular pacing pulse; sensed atrial events with absent ventricular event inhibit atrial
pacing but do pace ventricle at preprogrammed rate; if both atrial and ventricular events absent → AV sequential
pacing results at preprogrammed rate.
DDIR Atrial and ventricular pacing; atrial and ventricular sensing; no tracking of atria (as described previously in DDI); AV
sequential rate modulation.
DDD Atrial and ventricular pacing; atrial and ventricular sensing; intrinsic P wave and intrinsic QRS can inhibit pacing;
intrinsic P wave can trigger a paced QRS (tracks the atrium).
May see four possible combinations in DDD mode: 1, atrial sensed/ventricular sensed; 2, atrial sensed/ventricular
paced; 3, atrial paced/ventricular sensed; 4, atrial paced/ventricular paced.
DDDR Atrial and ventricular pacing; atrial and ventricular sensing; tracks the atrium: intrinsic P wave and intrinsic QRS
can inhibit pacing, intrinsic P wave can trigger a paced QRS; AV sequential rate modulation.
than a patient’s heart rate in an attempt to convert the • Electromagnetic interference (EMI) may interfere with
rhythm. pacemaker function and includes electrocautery, cardio-
• Rate-responsive pacemakers include a sensor and are version and defibrillation, magnetic resonance imaging
designed to mimic normal changes in heart rate based on (which is relatively contraindicated for patients with pace-
physiological needs. Most commonly, the sensor reacts to makers),7 diathermy, and transcutaneous nerve stimula-
motion and vibration or respirations and initiates an tors. Magnetic resonance imaging–conditional pacemakers
appropriate change in the pacing rate, depending on meta- and leads have recently become available. Other outside
bolic activity. These patients have a set pacemaker rate causes of EMI include welding equipment less than 24
range. inches from the device, electrical motors, chain saws,
• Inappropriate pacemaker function includes failure of battery-powered cordless power tools and drills less
pulse generation, failure to sense, and failure to capture than 12 inches from the device, magnetic mattresses and
(see Table 48-1 for definitions).6 chairs, and airport wands for security checks. Household
appliances such as microwave ovens rarely cause EMI. ing minimum frequency of routine device checks: within
Cell phones may cause EMI and should be used on the 72 hours of device implant (in person) then 2 to 12 weeks
ear opposite the device. The cell phone should be carried after implantation (in person), followed by every 3 to 12
on the opposite side of the body, with at least 6 inches months (in person or remote), annually, and then every 1
maintained between the cell phone and the device.12 to 3 months at signs of battery depletion (in person or
Patients who are pacemaker-dependent may experience remote). Devices may be checked more frequently as
dizziness, lightheadedness, near syncope, or syncope if needed (e.g., if a change occurs in antidysrhythmia medi-
EMI inhibits proper sensing and therefore inhibits pacing. cations or heart failure therapies).
• A pacemaker programmer appropriate for the pacemaker • Instruct patients to carry their identification cards at all
make and model is required for a device check or “inter- times. Patients receive identification cards from the manu-
rogation.” Note that some situations may require notifica- facturer at the time of implant. These cards identify the
tion of the device manufacturer to obtain the proper model of pacemaker used. Also encourage patients to
interrogation equipment (the device programmer). Manu- wear Medic Alert information. Rationale: This instruction
facturer information can be found on the patient’s pace- ensures that appropriate identifying information is avail-
maker identification card and via chest radiography. able to other healthcare providers, if needed.
EQUIPMENT
PATIENT ASSESSMENT
• ECG monitor and recorder with paper AND PREPARATION
• ECG cable and electrodes
Additional equipment, to have available as needed, includes Patient Assessment
the following: • Identify the manufacturer of the pacemaker. This informa-
• Pacemaker magnet tion may be found on the patient’s identification card.
• Pacemaker programmer appropriate for the pacemaker If no card is available, the make of the device may
manufacturer and model be identified on chest radiography. Rationale: Identifica-
tion of the manufacturer ensures that the correct pro-
PATIENT AND FAMILY EDUCATION grammer is used to review the programmed pacemaker
parameters.
• Assess learning needs, readiness to learn, and factors • Identify the programmed mode of the pacemaker. Ratio-
that influence learning. Rationale: This assessment nale: Knowledge of how the pacemaker is intended to
allows the nurse to individualize teaching in a meaningful respond is necessary to detect appropriate and inappropri-
manner. ate function.
• Provide information about the normal conduction system, • Identify the reason for permanent pacemaker support.
such as structure of the conduction system, source of Rationale: Knowledge of the clinical indication (e.g.,
heartbeat, normal and abnormal heart rhythms, and symp- complete heart block) provides the nurse with baseline
toms of abnormal heart rhythms. Patients with cardiomy- data, such as pacemaker dependency, when evaluating
opathy and heart failure need further information about pacemaker function and patient response.
ventricular dyssynchrony. Rationale: Understanding of • Determine the patient’s pacemaker history: date of inser-
the normal conduction system and pumping function tion; last battery change; most recent pacemaker check;
assists the patient and family in recognizing the need for any problems with the pacemaker or pacemaker site; and
permanent pacemaker therapy. any unexpected symptoms such as dizziness, chest pain,
• Provide information about permanent pacing, including shortness of breath, palpitations, or activity intolerance.
the reason for pacing; explanation of the equipment; what Rationale: The pacemaker history provides information
to expect during permanent pacing; precautions and useful for determining any problems that may occur.
restrictions in activities of daily living; signs and symp- • Assess the patient’s ECG for appropriate pacemaker func-
toms of complications; instructions on when to call the tion. Rationale: Evidence of inappropriate function deter-
physician, advanced practice nurse, or pacemaker clinic; mines the need for further testing.
and information on expected follow-up. Rationale: • Assess the patient’s hemodynamic response to the paced
Understanding of pacemaker functioning and expecta- rhythm. Rationale: The patient’s hemodynamic response
tions after discharge assists the patient and family in indicates how effective the pacemaker is in maintaining
developing realistic perceptions of permanent pacing an adequate cardiac output in response to the patient’s
therapy. Information may improve compliance with physiological needs. Evidence of inadequate cardiac
restrictions and promote effective lifestyle management output may be exhibited as decreased level of conscious-
after discharge. ness, fatigue, dizziness, shortness of breath, pallor, dia-
• Provide information about required device follow-up, phoresis, chest pain, or hypotension.
including in-clinic evaluation, transtelephonic monitor- • Patients with new biventricular pacemakers should also
ing, or remote monitoring. Rationale: Periodic pacemaker be assessed for signs and symptoms of dehydration.
checks are essential for routine device monitoring and Rationale: Patients on long-term diuretics may have over-
evaluation of changes in patient condition related to the diuresis after pacemaker implantation as a result of
pacemaker. Current guidelines11 recommend the follow- improved circulation and hemodynamics9.
Patient Preparation as needed. Rationale: This communication evaluates

• Verify the correct patient with two patient identifiers. and reinforces understanding of previously taught
Rationale: Before performing a procedure, the nurse information.
should ensure the correct identification of the patient for • Pacemaker interrogation may be performed with the
the intended intervention. patient either sitting or in the supine position. Rationale:
• Ensure that the patient and family understand teaching. This position prepares the patient for pacemaker
Answer questions as they arise, and reinforce information interrogation.
Procedure for Assessing Function of Permanent Pacemaker

1. HH
2. PE
3. Prepare skin with cleansing pads Proper skin preparation is essential
or soap and water for the to maintain appropriate skin-to-
application of ECG electrodes. electrode contact.
4. Attach the ECG leads to the Attaching the leads to the electrodes
electrodes, and place the first and then placing the
electrodes on the patient’s chest electrodes on the chest produces
(see Procedure 54). less discomfort.
5. Record an ECG rhythm strip. Allows for evaluation of the patient’s
intrinsic rhythm and aids in
assessment of pacemaker function.
6. Follow institutional standards for
recording a rhythm strip with a
magnet placed over the
pacemaker (Level M*):
A. Place the pacemaker magnet A magnet placed over the pacemaker Follow institutional standards to
on top of the pacemaker causes the pacemaker to pace at ensure that a nurse can use the
generator. the preprogrammed parameters. pacemaker magnet.
B. Record the ECG rhythm strip. This is needed to assess the rhythm
and for documentation.
C. Remove the magnet. After the magnet is removed, the ECG
rhythm represents the patient’s
current status (intrinsic rhythm,
paced rhythm, or a combination).
D. Assess the ECG rhythm. Determines the patient’s inherent
rhythm.
7. Inspect the ECG rhythm strip for Determines whether the pacemaker Depending on the type of lead and
pacemaker spikes, and evaluate is functioning adequately and programming, pacemaker spikes
for evidence of failure to sense or assesses electrical activity of the may be difficult to detect on the
failure to capture (Figs. 48-3 atria and ventricles. surface ECG.
through 48-8).
A. Identify atrial activity. Is the Determines the presence of atrial Different AV intervals may be
pacemaker programmed to activity in response to the programmed for sensed and paced
detect atrial activity? Was the pacemaker settings. events.
atrial activity sensed? What is
the pacemaker programmed to
do when atrial activity is
sensed? If the pacemaker is
programmed to trigger
ventricular pacing with sensed
atrial activity, is a ventricular-
paced complex seen at the
programmed AV interval? If
not, did an intrinsic QRS
complex occur before the
programmed AV interval?

Spike Ventricular paced beat
Figure 48-3 DDD pacing, normal operation: atrial activity sensed, ventricle paced.
Figure 48-4 Dual-chamber

DDD pacing, normal operation:
atrial paced, ventricle paced.
Failure to fire
Figure 48-5 Failure of pulse generation.
Figure 48-6 Ventricular over-

sensing and possibly ventricular
pulse-generation failure. Ventricu-
lar spike expected at 150 ms. Ven-
tricular spike and corresponding
ventricular depolarization did not
occur at points A and B. Also, atrial
timing reset by oversensed ven-
tricular activity resulted in erratic
atrial pacing (suspicious for frac-
ture of ventricular lead).
Figure 48-7 Ventricular undersensing. Pacemaker appears to be firing

asynchronously. The third and sixth ventricular complexes represent con-
current intrinsic ventricular depolarization overlaid by inappropriate
pacemaker fire.
Figure 48-8 DDD system with

failure to capture or sense ven-
tricular activity. All ventricular
spikes show absence of corre-
sponding ventricular depolariza-
tion. No timing circuit reset by
intrinsic ventricular complexes.
Procedure for Assessing Function of Permanent Pacemaker—Continued

B. If no intrinsic atrial activity is If a pacemaker spike is present but
present, determine whether evidence of atrial capture is not
the pacemaker is programmed present, attempt to assess the
to pace the atrium. If atrial presence of atrial contraction by the
pacing should be occurring, following:
determine the lower rate limit 1. Looking for the “a” wave in the
at which the pacemaker central venous pressure (or
stimulates atrial activity. right-atrial pressure) waveform
Evaluate whether the (if available).
pacemaker is firing at this 2. Changing the ECG lead.
rate. 3. Listening to the heart sounds (S1
becomes softer in the absence of
atrial contraction because
left-ventricular contractility
affects the loudness of S1).3
4. Examine a 12-lead ECG tracing,
which may show pacemaker
spikes not seen on a monitor
strip.
C. Identify ventricular activity. Is Determines the presence of Failure of ventricular capture can be
the pacemaker programmed to ventricular activity in response to a life-threatening situation.
detect intrinsic activity? Is it the pacemaker settings. With biventricular pacing, the loss of
sensed appropriately? What is capture in one ventricle may be
the pacemaker programmed to seen only by a change in the
do when ventricular activity is patient’s condition or a change in
sensed? Does inhibition of the QRS width or appearance.8
ventricular pacing occur?
D. If no intrinsic ventricular Determines the presence of If ventricular activity is not present as
activity is found, determine ventricular activity in response to expected, determine whether other
whether the pacemaker is the pacemaker settings. pacemaker features are enabled,
programmed to pace the such as programming to minimize
ventricles. If pacing should ventricular pacing or hysteresis.
occur, identify the lower rate
limit and determine whether
ventricular pacing spikes are
occurring at this rate. If
occurring at intervals that are
longer than the lower rate
limit, evaluate for oversensing
of unwanted signals. If
occurring at intervals that are
shorter than the lower rate
limit, is the pacemaker in a
rate-responsive mode? Is
hidden atrial activity
triggering a ventricular
output? Is atrial oversensing
found? Determine whether
each ventricular pacing spike
is followed by a QRS
complex. If the pacemaker has
an upper rate limit, determine
whether the patient is being
paced appropriately when that
limit has been reached.

E. If antitachycardia pacing is Determines appropriate pacemaker
programmed, determine function.
whether the tachycardia
detection criterion has been
met and whether the
pacemaker intervened
appropriately.
F. If the patient has a The purpose of biventricular pacing Detailed interrogation of function is
biventricular pacemaker, is to pace both ventricles needed because a surface ECG
verify that the ventricles are simultaneously to restore rhythm strip does not provide
consistently paced.8,10 ventricular synchrony. If the enough information to assess
patient is not consistently being proper function adequately. Fig.
paced in the ventricles, the system 48-9 illustrates various aspects of
is not working properly. biventricular pacing.
A B
C D
Figure 48-9 Biventricular pacing. A, Intrinsic ventricular activation (left bundle branch block).
B, Right-ventricular pacing. C, Left-ventricular pacing. D, Biventricular pacing. (Ellenbogen KA,
Wood MA: Cardiac pacing & ICDs, ed 5, Oxford, 2008, Blackwell Publishing, 1095. Used with
permission.)

8. Perform a check of the Determines appropriate pacemaker Follow institutional standards
pacemaker using the function. regarding training required before
manufacturer’s programmer (only The wand retrieves and transmits the use of the pacemaker programmer.
done by trained personnel), when programmed information. Some devices have a wireless
available and as prescribed: Allows for determination of connection to the programmer and
A. Place the wand attached to the pacemaker function, programmed a wand is not used.
programmer over the patient’s parameters, dysrhythmias, and Pacemaker device check with the
pacemaker. alerts. programmer provides the following
B. Perform testing of sensing, information13,14:
capture thresholds, and lead • Battery voltage (and impedance)
impedances. • Magnet rate (varies by
manufacturer)
• Pacing and sensing thresholds for
atrium and right ventricle, and
pacing threshold for left ventricle
• Pacing lead impedance for all
leads
• Dysrhythmias detected by the
device (e.g., mode switches, high
ventricular rate episodes)
• Percentage of pacing in each
chamber
• Review of programmed parameters
• Review of any “safety” or
automatic device alerts
• Review of hemodynamic
measurements or recordings of any
other programmed parameters
(e.g., heart rate variability, activity
level), depending on the type of
device
C. Determine whether the Ensures proper programming.
pacemaker needs to be
reprogrammed.
9. Assess the patient’s vital signs The patient may have the electrical
and hemodynamic response. activity of pacing without the
associated mechanical activity of
cardiac contraction (e.g., pulseless
electrical activity).
10. If inappropriate pacemaker Inappropriate pacemaker function
function is detected, notify the may compromise cardiac output
physician or advanced practice and necessitate immediate
nurse immediately and implement adjustment of settings or
basic life support and advanced replacement of malfunctioning
cardiac life support as needed. components.
supplies in appropriate receptacle. microorganisms; Standard
Precautions.
12. HH

• Appropriate pacemaker functioning based on • Failure to sense (e.g., oversensing, undersensing) or
programmed parameters failure to capture; failure to sense or capture in the
• Adequate systemic tissue perfusion and cardiac output immediate postimplant period may indicate lead
as evidenced by patient being alert, oriented, and dislodgment
normotensive, with no dizziness, shortness of breath, • Lead perforation of the myocardium may occur
chest discomfort, or lightheadedness within the first 24 hours of implant; signs and
• Minimal discomfort with new implant, no discomfort symptoms may include intermittent failure of pacing
with preexisting implant or sensing, distant heart sounds, pericardial rub, and
• No signs or symptoms of fluid or infection at the in extreme cases hemodynamic instability
incision • Diaphragmatic stimulation may occur if high-voltage
outputs are needed to pace the ventricles
• Hematoma
• Wound infection
• Venous thrombus

interventions.
1. Monitor the ECG continuously. Determines whether the patient’s • Failure of the pacemaker to
cardiac rate and rhythm are perform as programmed
consistent with the programmed • Oversensing
pacemaker parameters. • Undersensing
• Failure to capture
2. Monitor the patient’s vital signs Determines the patient’s response • Abnormal vital signs
and hemodynamic status. to pacemaker therapy. • Hemodynamic instability
3. Assess the pacemaker pocket in Determines healing and the • Bleeding at incision
the acute postimplant phase. presence of fluid. • Edema around pacemaker site
• Increased pain at incision site
4. Assess for signs and symptoms Identifies infection. • Redness
of infection. • Edema
• Drainage
• Elevated white blood cell count
• Elevated temperature
• Increased pain or tenderness at
the pacemaker site
5. Follow institutional standards Identifies need for pain • Continued pain despite pain
Documentation
• Device indications and device type • Physical assessment, including vital signs and
• Patient education and evaluation of patient and family hemodynamic response
understanding • Unexpected outcomes
• Programmed parameters • Interventions needed and evaluation of interventions
• ECG rhythm strip recordings • Pain assessment, interventions, and effectiveness
• Evaluation of pacemaker function

48 Permanent Pacemaker (Assessing Function) 398.e1
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Riegel B, editors: Cardiac nursing: A companion to Sauer WH, Bristow MR: The comparison of medical therapy,
Braunwald’s heart disease, St Louis, 2008, Elsevier. pacing, and defibrillation in heart failure (COMPANION)
13. Wilkoff BL: Pacemaker remote follow-up evaluation and trial in perspective. J Interv Card Electrophysiol 21(1):
review: Results of the PREFER trial: Late-breaking 3–11, 2008.
PROCEDURE
49
Temporary Transcutaneous
(External) Pacing
Valerie Spotts
PURPOSE: Transcutaneous or external pacing stimulates myocardial
depolarization through the chest wall. External pacing is used as a temporary
measure when normal cardiac conduction fails to produce myocardial contraction
and the patient experiences hemodynamic instability.
PREREQUISITE NURSING • In the nondemand or asynchronous mode, pacing occurs

KNOWLEDGE at the set rate regardless of the patient’s intrinsic rate. In
the demand or synchronous mode, the pacemaker senses
• Knowledge of cardiac anatomy and physiology is needed. intrinsic myocardial activity and paces when the intrinsic
• Knowledge of cardiac monitoring is necessary. cardiac rate is lower than the set rate on the external pulse
• The ability to interpret dysrhythmias is needed. generator.
• Knowledge of temporary pacemaker function and expected • Pacing occurs when the external pulse generator delivers
patient responses to pacemaker therapy is necessary. enough energy through the pacing electrodes to the myo-
• Clinical and technical competence in the use of the exter- cardium, which is known as pacemaker firing and is repre-
nal pacing equipment (Fig. 49-1) is needed. sented as a spike on the electrocardiograph (ECG) tracing.
• Indications for transcutaneous pacing are as follows:1–3 • Electrical capture occurs when the pacemaker delivers
❖ Symptomatic bradycardia unresponsive to medications enough energy to the myocardium so that depolarization
❖ In standby mode for the following rhythms in the acute occurs. Capture is seen on the ECG with a pacemaker
myocardial infarction setting:3,4 spike followed by a ventricular complex. The ventricular
Symptomatic sinus node dysfunction complex occurs after the pacemaker spike, and the QRS
Mobitz type II second-degree heart block is wide (greater than 0.11 seconds), with the initial and
Third-degree heart block terminal deflections in opposite directions. In Figure 49-5,
Newly acquired left, right, or alternating bundle- complexes 2 and 3 begin with a downward (negative)
branch block or bifascicular block deflection and end with an upward (positive) direction.
• Temporary transvenous pacing is indicated when pro- Mechanical capture occurs when a paced QRS complex
longed pacing is needed. results in a palpable pulse.
• Contraindications for transcutaneous pacing are as follows:2,7 • Standby pacing is when the pacing electrodes are applied
❖ Severe hypothermia in anticipation of possible use but pacing is not needed at
❖ Asystole (as presenting rhythm) the time.
• Pacing is contraindicated in severe hypothermia because
cold ventricles are more prone to ventricular fibrillation EQUIPMENT
and are more resistant to defibrillation.7
• External cardiac pacing is a temporary method of stimu- • Nonsterile gloves
lating ventricular myocardial depolarization through the • Blood pressure monitoring equipment
chest wall via two large pacing electrodes (patches). The • External pulse generator
electrodes are placed on the anterior and posterior chest • Pacing cable
wall (Figs. 49-2 and 49-3) or anterior and lateral chest • Pacemaker electrodes (patches)
wall (Fig. 49-4) and are attached by a cable to an external • ECG electrodes
pulse generator. The external pulse generator delivers • ECG monitor
energy (milliamps) to the myocardium based on the set • ECG cable
pacing rate, output, and sensitivity. Some models of exter- Additional equipment, to have available as needed, includes
nal pulse generators are combined with an external defi- the following:
brillator, and the electrodes of these models may be used • Emergency cart
for pacing and defibrillation. • Medications including sedatives and analgesics
• Sensitivity refers to the ability of the pacemaker to detect • Scissors
intrinsic myocardial activity. • Transvenous pacing equipment
399
Figure 49-1 Provides defibrillation, monitoring, and external

pacing. (Reproduced with permission of Medtronic Inc.) Figure 49-3 Location of the anterior (front) pacing electrode.
(Aehlert B: ACLS study guide, ed 3, St Louis, 2007, Mosby, 229.)
need further instruction about possible lifestyle modifica-

tions and follow-up visits, and information about the pace-
maker to be implanted.

PREPARATION
Patient Assessment
• Assess the patient’s cardiac rate and rhythm for the pres-
ence of dysrhythmias that indicate the need for external
cardiac pacing. Rationale: Recognition of a dysrhythmia
is the first step in determining the need for external cardiac
pacing or placing the external pacemaker on standby.
• Determine the patient’s hemodynamic response to the
dysrhythmia, such as the presence or absence of a pulse;
Figure 49-2 Location of the posterior (back) pacing electrode. presence of hypotension; altered level of consciousness;
(Aehlert B: ACLS study guide, ed 3, St Louis, 2007, Mosby, 229.) dizziness; shortness of breath; nausea and vomiting; cool,
clammy, diaphoretic skin; or the development of chest
PATIENT AND FAMILY EDUCATION pain. Rationale: The decision to initiate pacing depends
on the effect of the dysrhythmia on the patient’s cardiac
• Assess learning needs, readiness to learn, and factors that output.
influence learning. Rationale: This assessment reveals the
patient’s and family’s knowledge so that teaching can be Patient Preparation
individualized to be meaningful to the patient and family. • Verify that the patient is the correct patient using two
• Discuss basic facts about the normal conduction system, identifiers. Rationale: Before performing a procedure, the
the reason external cardiac pacing is indicated, and what nurse should ensure the correct identification of the patient
happens to the patient when pacing occurs. Rationale: for the intended intervention.
This discussion assists the patient and family in recogniz- • Ensure that the patient and family understand prepro-
ing the need for external pacing and what to expect when cedural teaching. Answer questions as they arise, and
pacing occurs. reinforce information as needed. Rationale: This com-
• Discuss interventions to alleviate discomfort. Rationale: munication evaluates and reinforces understanding of
This discussion provides the patient with an opportunity previously taught information.
to validate perceptions. It gives the patient and family • Maintain bedside ECG monitoring. Rationale: External
knowledge that interventions are used to minimize the pacing units do not provide central monitoring or dys-
level of discomfort. rhythmia detection.
• If indicated, inform the patient and family of the possibil- • Establish or ensure patency of intravenous access. Ratio-
ity of the need for transvenous or permanent pacing nale: Medication administration may be necessary.
support. Rationale: This information prepares the patient • Assist the patient to the supine position and expose the
and family for the possibility of additional therapy. If patient’s torso while maintaining modesty. Rationale: This
permanent pacing is necessary, the patient and family positioning prepares for electrode (patch) placement.
49 Temporary Transcutaneous (External) Pacing 401
Figure 49-5 Electrocardiograph tracing of external pacing.

(From Zoll Medical Corporation, Burlington, MA.)
Figure 49-4 Location of anterior-lateral pacing electrodes.

(Aehlert B: ACLS study guide, ed 3, St Louis, 2007, Mosby, 229.)
Procedure for Temporary Transcutaneous (External) Pacing

1. HH
2. PE
3. Administer sedative or analgesic Decreases discomfort associated Not indicated for patients who are
medications as prescribed. with external cardiac pacing.6,7 unconscious with hemodynamically
unstable conditions. Not indicated
for standby because pacing may
not be needed.
4. Turn on the pulse generator and Provides the power source. Many devices work on battery or
monitor. alternating current (AC) power.
5. Prepare the skin on the patient’s Removal of skin oils, lotion, and Optional step in an emergency.
chest and back by washing with moisture improves electrode Dry thoroughly.
nonemollient soap and water. adherence and maximizes Trim body hair with scissors, if
delivery of energy through the necessary.
chest wall. Avoid use of flammable liquids to
prepare the skin (e.g., alcohol,
benzoin) because of the increased
potential for burns.7 Avoid shaving
the chest hair because the presence
of nicks in the skin under the
pacing electrodes can increase
patient discomfort.
Remove any medication patches
applied to the chest area.
6. Apply the ECG electrodes to the Prepares the equipment.
ECG leads.
Procedure for Temporary Transcutaneous (External) Pacing—Continued

7. Connect the ECG cable to the Prepares the equipment. Follow the manufacturer’s
monitor inlet of the pulse recommendations.
generator. (Level M*) Attachment of the ECG electrodes to
the ECG leads and the ECG cable
to the pacemaker monitor is
optional for some manufacturers in
an emergency. If the ECG leads are
not placed, the pacemaker may
function in the asynchronous mode.
The pacemaker may not function
unless both the ECG monitoring
connection and the pacing
electrode connection are both
connected to the pacemaker.
8. Apply the ECG electrodes to the Displays the patient’s intrinsic
patient (see Procedure 54). rhythm on the monitor.
9. Adjust the ECG lead and size to Detection of the intrinsic rhythm is Lead II usually provides the most
the maximum R wave size. Look necessary for the demand mode prominent R wave.
for an indicator that the pacemaker of pacing.
is sensing the QRS complexes on
the intrinsic rhythm, usually seen
as a marker above each native
QRS complex.
10. Apply the back (posterior, +) Placement of the pacing electrodes Avoid placing the pacing electrodes
pacing electrode between the spine in the recommended anatomical over bone because this increases
and left scapula at the level of the location enhances the potential the level of energy needed to pace,
heart (see Fig. 49-2). for successful pacing. increases patient discomfort, and
increases the possibility of
noncapture.
11. Apply the front (anterior, −) pacing Placement of the pacing electrodes For women, adjust the position of the
electrode at the left, fourth in the recommended anatomical pacing electrode below and lateral
intercostal space, midclavicular locations enhance the potential to breast tissue to ensure optimal
line (see Fig. 49-3). (Level M*) for successful pacing. adherence.
Avoid placement of the pacing
electrodes over the bedside monitor
ECG electrodes and permanently
placed devices, such as implantable
cardioverter-defibrillators or
permanent pacemakers.
12. If the patient’s condition is Facilitates ease of electrode Pacing may be less effective with this
hemodynamically unstable, the placement for emergent pacing. method of electrode placement.7,8
back (posterior) electrode may be
placed over the patient’s right
sternal area at the second or third
intercostal space. The front
(anterior) electrode is maintained
at the apex (fourth or fifth
intercostal space, midclavicular
line; see Fig. 49-4).
13. Connect the pacing electrodes to Necessary for the delivery of
the pacemaker cable and connect electrical energy.
the pacemaker cable to the external
pulse generator. (Level M*)


14. Set the pacemaker rate, level of Each patient needs different Follow institutional standards
energy (output, mA) (Fig. 49-6). pacemaker settings to provide regarding who can initiate external
safe and effective external cardiac pacing.
pacing. The demand mode is used as long as
the ECG leads are attached to the
pacemaker monitor.
A. Set the demand or the The demand mode is used to In the asynchronous mode, the
synchronous mode. prevent competition from the pacemaker fires regardless of the
patient’s intrinsic rhythm. intrinsic rhythm and rate.
B. Set the rate. Pacing should be at a rate that The pacemaker may have a default
maintains adequate cardiac output setting (e.g., 80 bpm) that can be
but does not induce ischemia. adjusted as needed.
C. Set the mA. Use the lowest amount of energy The pacemaker may have a default
i. Slowly increase the mA that consistently results in setting that can be adjusted as
setting (output) until capture myocardial capture and needed, or the pacemaker may turn
is present. contraction to minimize on at 0 mA and will need to be
ii. Set the mA slightly higher discomfort.1 increased for pacing to occur.
than the capture threshold The average adult usually can be
(an additional 2 mA).1,7 paced with a current of 40–70 mA.
Figure 49-6 Controls for external pacemaker settings.


15. When the pacemaker fires, observe Identifies appropriate functioning of If a pacemaker spike occurs and is
that each pacemaker spike is the pacemaker. not followed by a ventricular
followed by a wide ventricular complex, slowly increase the
complex and a T wave in the energy (mA) level.
opposite deflection of the QRS Artifact from skeletal muscle
(see Fig. 49-5). twitching may make an ECG
tracing difficult to interpret.
Skeletal muscle twitching occurs at
lower mA settings, before capture
of the myocardium.1,7
Confirm mechanical capture by
assessing pulse.
16. Palpate the patient’s pulse (e.g., Ensures adequate blood flow with The carotid pulses usually are not
femoral pulse, right brachial pulse, paced complexes. palpated because the electrical
radial pulse). stimulation from the pacemaker
may mimic a pulse.1,2
17. Evaluate the patient’s vital signs The patient’s hemodynamic If symptoms do not improve with
and hemodynamic response to response should improve with pacing, assess for other causes
pacing. pacing if symptoms were related such as electrolyte abnormalities.
to bradycardia.1,3
Precautions.
19. HH

• Adequate systemic tissue perfusion and cardiac output • Failure of the pacemaker to sense the patient’s
as evidenced by blood pressure greater than 90 mm Hg underlying rhythm with the possibility of R-on-T
systolic (or resolution of hypotension), return to phenomenon (initiation of ventricular
baseline mental status, absence of dizziness or tachydysrhythmias as a result of an improperly timed
syncope, absence of shortness of breath, absence of spike on the T wave)
nausea and vomiting, and absence of ischemic chest • Failure of the pacemaker to capture the myocardium
pain • Failure of the pacemaker to pace
• Stable cardiac rate and rhythm • Discomfort, including skin burns from the delivery of
• Appropriate sensing, pacing, and capture present high levels of energy through the chest wall, painful
sensations, and skeletal muscle twitching

interventions.
1. Monitor vital signs every 15 Ensures adequate tissue perfusion with • Change in vital signs
minutes until stable, then hourly paced beats. Adjustments in the • Hemodynamic instability
or more frequently as needed. pacing rate may need to be made
based on vital signs.
Continuous assessment is needed
because pacing thresholds may
change and response to the pacemaker
settings can change over time.

2. Continue to monitor the patient’s Provides an alarm system. Of note, if • Changes in capture or sensing
cardiac rate and rhythm through ECG leads are disconnected from the • Dysrhythmias
the central monitoring system. pacemaker monitor, pacing reverts to
The pacing spike may obscure or asynchronous, which could compete
mimic the QRS complex, making with the native rhythm.
ventricular capture difficult to
see.5 Select a lead that minimizes
the size of the pacing spike and
maximizes the QRS complex.5 Set
the pacemaker option on the
central monitoring system.
3. Monitor level of comfort and The external delivery of energy through • Continued pain despite
sedation level: the chest wall may cause varying interventions to alleviate pain
A. Assess the patient’s level of degrees of discomfort.1,2,7,8 • Patient intolerance of the
comfort and sedation level prescribed medications (e.g.,
following institution standard. nausea, hypotension, decreased
B. Administer prescribed respirations)
analgesic and sedative
medications as needed.
C. Adjust the level of energy to
the lowest level for capture.
D. Evaluate the patient’s response
to interventions.
4. Obtain an ECG recording strip to Documents cardiac rate, rhythm, and • Dysrhythmias
document pacing function on pacemaker activity. • Failure to capture
initiation of pacing, every 4–8 • Failure to pace
hours, and as needed or according
to institutional standards.
5. Obtain blood samples for Acidosis and electrolyte abnormalities • Electrolyte abnormalities
laboratory analysis as prescribed. need to be corrected for an effective • Acidosis
response to pacing.
6. Evaluate pacemaker function Ensures continued functioning of the • Inability to maintain appropriate
(capturing and sensing) with any pacemaker. sensing and capture
change in patient condition or • Changes in patient condition that
vital signs. affect appropriate pacemaker
function
7. Monitor the patient’s cardiac rate Determines whether the dysrhythmia • Worsening of the baseline
and rhythm for resolution of the has subsided. cardiac rate and rhythm (e.g.,
dysrhythmia that necessitates change from symptomatic
pacemaker intervention. second-degree heart block to
A. This monitoring may complete heart block)
necessitate turning the
pacemaker off, if prescribed, to
assess the patient’s underlying
rate and rhythm. Do not turn
the pacemaker off if the patient
is 100% paced.
B. When assessing the patient’s A sudden cessation of pacing can lead
intrinsic rate and rhythm, to asystole because the intrinsic rate
reduce the pacing rate slowly. and rhythm may be suppressed by
continuous pacing.7

8. Check the adherence of the pacing Changes in skin integrity caused by • Changes in skin integrity
electrodes to the skin at least burns or skin breaks significantly alter • Burns
every 4 hours. If pacing is not the patient’s level of comfort and
occurring, assess the skin integrity exposes the patient to possible
under the pacing electrodes. infection.
9. Change the electrodes at least Pacing electrodes should not be used
every 24 hours or after 8 hours of once they have been out of the
continuous pacing.8 (Level M*) package for 24 hours.7
Documentation
• Patient and family education • Medications administered
• Patient preparation • Pacing rate, mode, mA
• Date and time external cardiac pacing is initiated • Percentage of the time the patient is paced if in the
• Description of events that warranted intervention demand mode
• Vital signs and physical assessment before and after • Status of skin integrity when the pacing electrodes
external cardiac pacing are changed
• ECG recordings before and after pacing • Unexpected outcomes
• Pain assessment, interventions, and effectiveness • Additional interventions

49 Temporary Transcutaneous (External) Pacing 406.e1
References Association scientific statement from the Councils on

1. Aehlert B: ACLS study guide, ed 4, St Louis, 2012, Cardiovascular Nursing, Clinical Cardiology, and
Mosby. Cardiovascular Disease in the Young: Endorsed by the
2. Neumar RW, et al: Part 1: Executive Summary: 2015 International Society of Computerized Electrocardiology
American Heart Association guidelines update for and the American Association of Critical-Care Nurses.
cardiopulmonary resuscitation and emergency Circulation 110(17):2721–2746, 2004.
cardiovascular care. Circulation 132(18 Suppl 2): 6. Gibson T: A practical guide to external cardiac pacing.
S315–S367, 2015. Nurs Stand 22(20):45–48, 2008.
3. Amsterdam EA, et al: 2014 AHA/ACC guideline for the 7. Medtronic Physio-Control Corp: LIFEPAK 20e
management of patients with non-ST-elevation acute defibrillator/monitor operating instructions, Redmond,
coronary syndromes. Circulation 130(25):2354–2394, WA, 2013, Physio-Control, Inc.
2014. 8. Zoll P: Noninvasive temporary cardiac pacing.
4. Antman EM, et al: ACC/AHA guidelines for management J Electrophys 1(2):156–161, 1987.
of patients with ST-elevation myocardial infarction:
A report of the American College of Cardiology/American Additional Reading
Heart Association Task Force on Practice Guidelines. Jacobson C, Marzlin K, Webner C: Chapter 17. In Electrical
Circulation 110:e82–e292, 2004. management of arrhythmias in cardiovascular nursing
5. Drew B, et al: Practice standards for electrocardiographic practice, Burien, WA, 2007, Cardiovascular Nursing
monitoring in hospital settings: An American Heart Education Associates.
PROCEDURE
50
Temporary Transvenous
Pacemaker Insertion (Perform)
Nikki Taylor
PURPOSE: The purpose of temporary cardiac pacing is to ensure or restore an
adequate heart rate and rhythm. A transvenous pacemaker is inserted as a
temporary measure when the normal conduction system of the heart fails to
produce or conduct an electrical impulse, resulting in hemodynamic compromise or
other debilitating symptoms.
PREREQUISITE NURSING ❖ Reduce the possibility of ventricular dysrhythmias in

KNOWLEDGE the presence of bradycardia
❖ Supplement an inadequate rhythm, such as when tran-
• Knowledge of the normal anatomy and physiology of the sient decreases in heart rate occur (e.g., chronotropic
cardiovascular system, principles of cardiac conduction, incompetence in shock)
and basic and advanced dysrhythmia interpretation is ❖ Allow the administration of medications that may
needed. cause a rhythm or conduction abnormalities (e.g., beta
• Knowledge of temporary pacemaker function and expected blockers).
patient responses to pacemaker therapy is necessary. • Temporary transvenous pacing is indicated for the follow-
• Clinical and technical competence in central line insertion, ing:
temporary transvenous pacemaker insertion, and suturing ❖ Third-degree atrioventricular (AV) block
is needed. ❖ Type II AV block
• Knowledge of the principles of sterile technique is ❖ Dysrhythmias that may occur in the setting of an acute
essential. myocardial infarction (e.g., symptomatic bradycardia,
• Clinical and technical competence related to the use of complete heart block, new bundle-branch block with tran-
temporary pacemakers is necessary. sient complete heart block, alternating bundle-branch
• Competence in chest radiograph interpretation is needed. block)
• Advanced cardiac life support (ACLS) knowledge and ❖ Sinus node dysfunction (e.g., symptomatic bradydys-
skills are needed. rhythmias, treatment of bradycardia-tachycardia syn-
• Principles of general electrical safety apply with use of dromes, sick sinus syndrome)
temporary invasive pacing. ❖ Ventricular standstill or cardiac arrest
• Gloves always should be worn when handling pacemaker ❖ Long QT syndrome with ventricular dysrhythmias
electrodes to prevent microshock because even small ❖ Drug toxicity
amounts of electrical current can cause serious dysrhyth- ❖ Postoperative cardiac surgery
mias if they are transmitted to the heart.2,7,9,10 ❖ Prophylaxis with cardiac diagnostic or interventional
• Knowledge of the care of the patient with central venous procedures
catheters (see Procedures 67 and 82). ❖ Chronotropic incompetence in the setting of cardiogenic
• The insertion of a temporary transvenous pacemaker is shock
performed in emergency and elective clinical situations. ❖ Malfunction/infection of permanent cardiac pacemaker
Temporary transvenous pacing may be used for the • When temporary transvenous pacing is used, the pulse
following: generator is attached externally to one or more pacing
❖ Stimulate the myocardium to contract in the absence leads that are inserted through a vein into the right atrium
of an intrinsic rhythm and/or right ventricle.
❖ Establish adequate cardiac output and blood pressure • Veins used for the insertion of a transvenous pacing lead
❖ Ensure tissue perfusion to vital organs wire include the subclavian, femoral, brachial, internal
jugular, or external jugular.
• Single-chamber ventricular pacing is the most appropriate
method in an emergency because the goal is to establish
practice nurses, and other healthcare professionals (including critical care a heart rate as quickly as possible.
nurses) with additional knowledge, skills, and demonstrated competence per • The transvenous pacing lead is an insulated wire with one
professional licensure or institutional standard. or two electrodes at the tip of the wire (Fig. 50-1).
407
Figure 50-1 Bipolar lead wire.
• The pacing lead can be a hard-tipped or a balloon-tipped ❖ Pacing rate adjusts the number of pacing stimuli deliv-
pacing catheter that is placed in direct contact with the ered per minute.
endocardium. Most temporary leads are bipolar with the ❖ Pacing output determines the amount of energy deliv-
distal tip electrode (seen as a metal ring) separated from ered to the endocardium in milliamperes (mA). Dual-
the proximal electrode by 1 to 2 cm of pacing catheter chamber pacing requires that mA are set for both the
(also seen as a metal ring; see Figs. 50-1 and 51-1). atria and the ventricle.
• Basic principles of cardiac pacing include sensing, pacing, ❖ AV interval on a dual-chamber pacemaker controls the
and capture. amount of time between atrial and ventricular stimula-
• Sensing refers to the ability of the pacemaker device to tion (electronic PR interval).
detect intrinsic myocardial electrical activity. Sensing ❖ Sensitivity determines the size of the intrinsic activity in
occurs if the pulse generator is in the synchronous or millivolts (mv) that will be detected by the generator.
demand mode. The pacemaker either is inhibited from • The ability of the pacemaker to detect the patient’s intrin-
delivering a stimulus or initiates an electrical impulse in sic rhythm is determined by the pacing mode. In an asyn-
response to a sensed event. chronous mode, the pacemaker functions as a fixed-rate
• Pacing occurs when the temporary pulse generator is acti- pacemaker and is not able to sense any of the patient’s
vated and the programmed level of energy travels from inherent cardiac electrical activity. In a synchronous
the pulse generator through the temporary pacing lead mode, the pacemaker is able to sense the patient’s inherent
wire to the endocardium. This is known as pacemaker cardiac electrical activity.
firing and is exhibited as a vertical line or spike on the • The ability of the pacemaker to depolarize the myocar-
electrocardiogram (ECG) recording. dium depends on many variables: position of the electrode
• Capture refers to the successful conduction of the pace- and degree of contact with viable endocardial tissue; level
maker impulse through the myocardium, resulting in of energy delivered through the pacing wire; presence
depolarization. Capture is evidenced on the ECG by a of hypoxia, acidosis, or electrolyte imbalances; fibrosis
pacemaker spike followed by either an atrial or a ventricu- around the tip of the catheter; and concomitant medication
lar complex, depending on the chamber being paced. The therapy.3,5
healthcare provider can assess whether the electrical • All electrical equipment in the patient’s room must be prop-
depolarization resulted in mechanical activity by observ- erly grounded to prevent interference from occurring.
ing pressure waveforms for evidence of contraction (right • Exposed pacing leads should be insulated when not in use
or left atrial, pulmonary artery, or arterial) or by palpating to prevent microshock.2,7,9,10
a pulse.
• Pulse generators can be used for single-chamber pacing EQUIPMENT
with one set of terminals at the top of the pulse generator,
into which the pacing wires are inserted (via a connecting • Antiseptic skin preparation solution (e.g., 2% chlorhexidine-
cable). A dual-chamber pacemaker requires two sets of based solution)
terminals, one each for the atrial and ventricular wires. • Sterile drapes, gloves and gowns, and towels
• The temporary pulse generator houses the controls and the • Masks, head cover, goggles, or face shields
energy source for pacing. Different models of pacemakers • Balloon-tipped pacing catheter and insertion tray
use either dials or touch pads to adjust the following • Pacing lead wire
settings: • Pulse generator
50 Temporary Transvenous Pacemaker Insertion (Perform) 409
• 9-V battery for pulse generator cardiac pacing. Rationale: This assessment determines
• Connecting cables the need for invasive cardiac pacing.
• Alligator clips or wires with connecting pins • Assess the patient’s hemodynamic response to the dys-
• ECG monitor and recorder rhythmia. Rhythm disturbances may reduce cardiac output
• Supplies for dressing at insertion site significantly, with detrimental effects on perfusion of
Additional equipment, to have available as needed, includes vital organs. Rationale: This assessment determines the
the following: urgency of the procedure. It may indicate the need for
• Local anesthetic temporizing measures (e.g., vasopressors or transcutane-
• Percutaneous introducer needle or 14-gauge needle ous pacing).
• Introducer sheath with dilator • Review current medications. Rationale: Medications may
• Guidewire (per physician or advanced practice nurse choice) be implicated as a cause of the dysrhythmia that led to the
• Suture, syringes, needles, and scalpel need for pacemaker therapy, or medications may need to
• Emergency equipment (i.e., automated external defibrilla- be held as a result of concomitant effect. Other medica-
tor [AED], defibrillator) tions, such as antidysrhythmics, may alter the pacing
• Portable ultrasound scan equipment threshold. Review of medications could also determine
• Fluoroscopy whether reversal agents could be used as an alternative to
• Lead aprons or shields pacemaker therapy.
• 12-lead ECG machine • Review the patient’s current laboratory study results,
including chemistry, electrolyte profile, arterial blood gases,
PATIENT AND FAMILY EDUCATION coagulation profile, platelet count, and cardioactive medi-
cation levels. Rationale: This review assists in determining
• Assess learning needs, readiness to learn, and factors that whether inserting the pacemaker was precipitated by meta-
influence learning. Rationale: This assessment enables bolic disturbances or medication toxicity and establishes
teaching to be individualized in a manner that is meaning- the pacing milieu. The review provides the healthcare pro-
ful to the patient and the family. vider with information regarding the risk for abnormal
• Discuss basic facts about the normal conduction system, bleeding during or after the procedure is performed.
such as structure and function of the conduction system,
normal and abnormal heart rhythms, and symptoms and Patient Preparation
significance of abnormal heart rhythms. Rationale: The • Verify that the patient is the correct patient using two
patient and family should understand the conduction identifiers. Rationale: Before performing a procedure, the
system, why the procedure is necessary, and what poten- nurse should ensure the correct identification of the patient
tial risks and benefits are associated with this invasive for the intended intervention.
procedure. • Ensure that the patient and family understand preprocedural
• Provide a basic description of the temporary transvenous teaching. Answer questions as they arise and reinforce
pacemaker insertion procedure. Rationale: The patient information as needed. Rationale: Evaluates and reinforces
and family should be informed of the invasive nature of understanding of previously taught information.
the procedure and any risks associated with the procedure. • Obtain informed consent. Rationale: Informed consent
An understanding of the procedure may reduce anxiety protects the rights of the patient and makes a competent
associated with the procedure. decision possible for the patient; however, in emergency
• Describe the precautions and restrictions required while circumstances, time may not allow a consent form to be
the temporary pacemaker is in place, such as limitation of signed.
movement, avoiding handling the pacemaker or touching • Perform a preprocedure verification and time out, if non-
exposed portions of the electrodes, and situations in which emergent. Rationale: Ensures patient safety.
the nurse should be notified (e.g., if the dressing becomes • Connect the patient to a 5-lead monitoring system or to a
damp, if the patient experiences dizziness). Rationale: 12-lead ECG machine. Rationale: This monitoring facili-
Understanding potential limitations may improve the tates the placement of the balloon-tipped catheter by indi-
patient’s cooperation with restrictions and precautions. cating the position of the catheter during its placement.
Also, it allows for monitoring of the patient’s cardiac
PATIENT ASSESSMENT AND rhythm during the procedure.
PREPARATION • Prescribe and ensure that pain medication and/or sedation
is administered. Rationale: Medication may be indicated
Patient Assessment depending on the patient’s level of anxiety and pain. Seda-
• Assess the patient’s cardiac rhythm for the presence of the tion or pain medication may not be possible if the patient’s
dysrhythmia that necessitates the initiation of temporary condition is hemodynamically unstable.
Procedure for Performing Temporary Transvenous Pacemaker Insertion

1. HH
2. PE
3. Connect the patient to the bedside Monitors the patient’s intrinsic If the monitoring system is not a
monitoring system, and monitor the heart rate and rhythm during 5-lead system, also connect the
ECG continuously (see Procedure 54). and after the procedure to patient to the 12-lead ECG
evaluate for adequate rate and machine (see Procedure 57).
pacemaker function.
4. Dispose of used supplies and wash Minimizes the risk of infection.
hands.
5. Check the placement of the central Central venous access is needed If central venous access is needed,
venous access with chest radiography as the transvenous pacing refer to Procedure 82.
before starting the procedure. catheter is passed through the
central venous system.
6. Assess functioning of the temporary Ensures a functional pacemaker Different ways to assess battery
pacemaker, and insert a new battery pulse generator. function depend on the model and
into the pulse generator before manufacturer; check
beginning therapy. (Level M*) manufacturer’s recommendations
for specific instructions.
7. Attach the connecting cable to the Prepares the pacing system; the Some lead wires are labeled distal
pulse generator, connecting the pacing stimulus travels from and proximal; distal connects to
“positive” on the cable to the the pulse generator to the negative, and proximal connects
“positive” on the pulse generator and negative terminal, and energy to positive.
the “negative” on the cable to the returns to the pulse generator Some lead wires may not have
“negative” on the pulse generator. via the positive terminal. negative and positive marked on
them.
Polarity is established when the
wires are placed in the connecting
cable.
Two connecting cables are needed
with both atrial and ventricular
pacing.
8. All personnel performing and assisting Minimizes the risk of infection Gloves should be worn whenever
with the procedure should wash hands and maintains standard and the pacing electrodes are handled
and apply PE and sterile equipment sterile precautions. to prevent microshock.2,7,9,10
(e.g., masks, head covers, goggles or
face shields, sterile gowns, and gloves).
9. Cleanse the site with antiseptic solution Minimizes the risk of infection.
(e.g., 2% chlorhexidine-based
preparation).
10. Drape the site with the sterile drapes. Provides a sterile field and
reduces the transmission of
microorganisms.
11. Insert the balloon-tipped pacing The transvenous pacing catheter For transvenous, ventricular pacing,
catheter through the introducer, and is threaded through the central the negative pacing electrode is
slowly advance the pacing lead, using venous system, using one of positioned in the endocardium (at
one of the following insertion four methods to confirm the apex) of the right ventricle.
techniques: proper placement.
A. Blind technique: This technique can be used to If premature ventricular contractions
i. Continue advancing the pacing quickly achieve pacing in or runs of ventricular tachycardia
lead. unstable patients. occur, deflate the balloon and
withdraw the catheter a little.
ii. The balloon can be inflated The balloon allows blood flow to Once capture is identified on ECG,
when the tip of the pacing lead is facilitate catheter mechanical contraction should be
in the vena cava, approximately advancement. confirmed with palpation of a
at the 20 cm marking. pulse.
*Level M: Manufacturer’s recommendations only

Procedure for Performing Temporary Transvenous Pacemaker Insertion—Continued

B. Ultrasound guided technique Transcutaneous ultrasound scan
(Level E*): visualization of the pacing lead
i. Obtain ultrasound equipment. as it is being passed through
ii. Continue advancing the pacing the central venous system may
lead. ensure a quicker and more
iii. The balloon can be inflated when accurate placement of the
the tip of the pacing lead can be pacing electrode within the
visualized in the vena cava. endocardium of the right
iv. Advance the pacing lead to the ventricle.1,4,6
desired intracardiac position
guided by ultrasound.
C. Fluoroscopy guided technique: Fluoroscopy may be needed to If fluoroscopy is used, all personnel
i. Obtain fluoroscopy equipment. permit direct visualization of must be shielded from the
ii. Continue advancing the pacing the pacing electrode. radiation with lead aprons or be
lead. positioned behind lead shields. A
iii. The balloon can be inflated when lead sheet or apron should also be
the tip of the pacing lead can be placed below the patient’s waist.
visualized in the vena cava.
iv. Advance the pacing catheter to
the desired intracardiac position
guided by fluoroscopy.
D. ECG-guided technique: When an ECG is obtained As a result of the temporary pacing
i. The V lead of a 5-lead system directly from the pacing catheter transmission of impulses
or a 12-lead ECG machine can electrode, proper position of from within the right ventricle,
be used. the catheter tip is verified by conduction of the impulse
ii. Connect the patient to the limb visualization of the throughout the ventricles occurs
leads of the 12-lead ECG ST-segment elevation via cellular conduction of the
machine if this method is used. indicating catheter contact impulse rather than transmission
iii. Attach the V lead of the ECG with the endocardium. down the bundle branches.
monitoring system or the
12-lead ECG machine to the
negative electrode connector
pin (distal pin) of the pacing
lead wire.
iv. An alligator clip or a wire with
connector pins can be used if
needed (see Fig. 50-2).
v. Set the monitoring system to
record the V lead continuously.
vi. Continue advancing the pacing
lead.
vii. The balloon can be inflated
when the tip of the pacing lead is
in the vena cava, approximately
at the 20 cm marking.
viii. Advance the pacing lead and
observe the ECG for ST
segment elevation in the V lead
(see Fig. 50-3).
ix. Observe for left bundle-branch
block pattern and left-axis
deviation that usually can be
identified.

Figure 50-2 Alligator clips. ECG, electrocardiogram.
Procedure for Performing Temporary Transvenous Pacemaker Insertion—Continued

12. After the electrodes are properly Energy from the pulse generator A bridging connecting cable is
positioned: is directed to the negative recommended for use between
A. Deflate the balloon. electrode in contact with the the pacing lead and the pulse
B. Connect the pacing lead external ventricle. generator.
electrode pins to the pulse generator The pacing circuit is completed
via the connecting cables. as energy reaches the positive
C. Ensure that the positive and electrode.
negative electrodes are connected to The lead wires must be
the respective positive and negative connected securely to the
terminals on the pulse generator via pacemaker to ensure
the connecting cables. appropriate sensing and
capture and to prevent
inadvertent disconnection.
13. Set the pacemaker settings and initiate Initiates pacemaker therapy.
pacing (refer to Procedure 51).
14. Suture the pacing lead in place. Minimizes the risk of
dislodgment.
15. Apply a sterile occlusive dressing over Minimizes the risk of infection.
the site.
16. Secure the pacemaker equipment such The pulse generator should be Pinning the generator to the
as strapping the pulse generator to the protected from falling or patient’s sheets or pillow is not
patient’s torso or securing the pulse becoming inadvertently recommended because if the
generator in a carrying device. detached by patient movement. patient moves, sits up, or gets out
Disconnection or tension on the of bed, the pacing lead may be
pacing electrodes may lead to inadvertently disconnected.
pacemaker malfunction.
17. Remove PE and discard used supplies Reduces the transmission of
in appropriate receptacles. microorganisms; Standard
Precautions.
18. HH
19. Obtain a chest radiograph. In the absence of fluoroscopy, a
chest radiograph is essential to
detect potential complications
associated with insertion and
to visualize lead position.
Figure 50-3 Electrocardiogram rhythm recorded in the right ventricle; elevated ST segments
when the pacing electrode is wedged against the endocardial wall of the right ventricle. (From
Meltzer LE, Pinneo R, Kitchell JR: Intensive coronary care, ed 4, Bowie, MD, 1983, Robert J. Brady
Co.)

• Paced rhythm on ECG consistent with parameters set • Inability to achieve proper placement of the pacing
on the pacemaker, as evidenced by appropriate heart catheter
rate, proper sensing, and proper capture • Failure of the pacemaker to sense, causing
• Patient exhibits hemodynamic stability, as evidenced competition between the pacemaker-initiated
by systolic blood pressure greater than 90 mm Hg, impulses and the patient’s intrinsic cardiac rhythm
mean arterial blood pressure greater than 60 mm Hg, • Failure of the pacemaker to capture the myocardium
alert and oriented condition, and no syncope or • Pacemaker oversensing that causes the pacemaker to
ischemia be inappropriately inhibited
• Pacemaker leads securely connected to the pulse • Stimulation of the diaphragm that causes hiccupping,
generator possibly related to pacing the phrenic nerve,
perforation, wire dislodgment, or excessively high
pacemaker mA setting
• Phlebitis, thrombosis, embolism, or bacteremia
• Ventricular dysrhythmias
• Arterial puncture, pneumothorax, hemothorax,
pneumomediastinum, or the development of
subcutaneous emphysema from the insertion
procedure3,5
• Myocardial perforation, cardiac tamponade, or
postpericardiotomy syndrome from the insertion
procedure and electrode placement
• Air embolism
• Lead dislodgment
• Pain

interventions.
1. Monitor vital signs and The goal of cardiac pacing is to • Change in vital signs associated
hemodynamic response to improve cardiac output by with signs and symptoms of
pacing following institutional increasing heart rate or by hemodynamic deterioration
standards and as often as the overriding life-threatening
patient’s condition warrants. dysrhythmias.
2. Evaluate the ECG for the Proper pacemaker functioning is • Dysrhythmias
presence of the paced rhythm or assessed by observing the ECG for • Inability to obtain capture
resolution of the initiating pacemaker activity consistent with • Oversensing
dysrhythmia. the parameters set. • Undersensing

3. Follow institutional standards Promotes comfort. • Continual hiccups (may indicate
for assessing pain. Prescribe wire perforation or phrenic nerve
analgesia. stimulation)
• Continued pain despite pain
interventions
4. Check and document sensitivity Ensures proper pacemaker • Problems with sensitivity or
and threshold at least every 24 functioning. threshold
hours.
Threshold may be checked by Prevents unnecessarily high levels of
physicians or advance practice energy delivery to the myocardium.
nurses in patients at high risk
(e.g., if pacemaker dependent).
Follow institutional standards. Threshold may be checked more
frequently if the patient’s condition
changes or pacemaker function is
questioned.
5. Replace gauze dressings every 2 Although guidelines specific to pacing • Increased temperature
days and transparent dressings at leads do not exist, the Centers for • Increased white blood cell count
least every 7 days.8 Cleanse the Disease Control and Prevention • Purulent drainage at the insertion
site with an antiseptic solution (CDC) recommend replacing site
(e.g., 2% chlorhexidine-based dressings on intravascular catheters • Warmth, redness, discoloration,
preparation). Follow institutional when the dressing becomes damp, or pain at the site
standards. (Level D*) loosened, or soiled, or when
6. Monitor for other complications. Early recognition leads to prompt • Embolus
treatment. • Thrombosis
• Perforation of the myocardium
• Pneumothorax
• Hemothorax
• Phlebitis
7. Monitor electrolyte levels. Electrolyte imbalances may • Abnormal electrolyte values
precipitate dysrhythmias.
8. Ensure that all pacemaker Maintenance of tight connections is • Inability to maintain tight
connections are secure. necessary to ensure proper sensing, connections with available
to ensure impulse conduction, and equipment, jeopardizing pacing
to minimize the risk of microshock therapy
conduction to the heart.
Documentation
• Description of the events that warranted intervention • Vital signs and hemodynamic parameters before,
• Patient and family education and response to education during, and after the procedure
• Signed informed consent form • Proper placement confirmed with chest radiography
• Universal Protocol requirements, if nonemergent • Patient response to procedure
• Date and time of insertion • Complications and interventions
• Date and time of initiation of pacing • Occurrence of unexpected outcomes and
• Type of pacing wire inserted and location of insertion interventions taken
• Pacemaker settings: mode, rate, output, sensitivity • Pain assessment, interventions, and patient response
setting, threshold measurements, and whether to medication
pacemaker is on or off • Date and time pacing was discontinued
• ECG monitoring strip recording before and after • Adjustment to monitoring system to ensure detection
pacemaker insertion, with interpretation of paced rhythms

50 Temporary Transvenous Pacemaker Insertion (Perform) 415.e1
References 7. Norman EM: Critical care extra: Critical questions:

1. Dahlberg ST: Temporary cardiac pacing. In Irwin RS, Avoiding electrical hazards, temporary pacing wires. Am J
et al, editors: Procedures and techniques in intensive care Nurs 98:16GG–HH, 1998.
medicine, ed 6, Philadelphia, 2008, Lippincott Williams & 8. O’Grady N, et al: Guidelines for the prevention of
Wilkins. intravascular catheter-related infections. Am J Infect
2. Drew B: Practice standards for electrocardiographic Control 39(4):S1–S34, 2011.
monitoring in hospital settings: An American Heart 9. Timothy PR, Rodeman BJ: Temporary pacemakers in
Association scientific statement from the Councils on critically ill patients: Assessment and management
Cardiovascular Nursing, Clinical Cardiology, and strategies. AACN Clin Issues 15:305–325, 2004.
Cardiovascular Disease in the Young: Endorsed by the 10. Woods SL, et al, editors: Pacemakers and implantable
International Society of Computerized Electrocardiology defibrillators. In Cardiac nursing, ed 5, Philadelphia,
and the American Association of Critical-Care Nurses. 2005, Lippincott Williams and Wilkins.
Circulation 110:2721–2746, 2004.
3. Espiritu JD, Keller CA: Pneumomediastinum and Additional Readings
subcutaneous emphysema from pacemaker placement. Komberger A, et al: Bridge to recovery or permanent system
Pacing Clin Electrophysiol 24:1041–1042, 2001. implantation: An 8-year single-center experience in
4. Harrigan RA, et al: Temporary transvenous pacemaker transvenous semipermanent pacing. Pacing Clin
placement in the emergency department. J Emerg Med Electrophysiol 36(9):1096–1103, 2013.
32:105–111, 2007. Neumar RW, et al: Part 1: Executive Summary: 2015 American
5. Huysmans W, Budts W: Late free atrial wall rupture after Heart Association guidelines update for cardiopulmonary
percutaneous atrial septal defect closure and transvenous resuscitation and emergency cardiovascular care.
pacemaker implantation. Catheter Cardiovasc Interv Circulation 132(18 Suppl 2):S315–S367, 2015.
72:286–288, 2008. Sovari AA: Transvenous Cardiac Pacing, Medscape, updated
6. Macedo W, Jr, et al: Ultrasonographic guidance of March 5, 2014.
transvenous pacemaker insertion in the emergency Yaqub Y, et al: Temporary transvenous cardiac pacing in
department: A report of three cases. J Emerg Med patients with acute myocardial infarction predicts
17:491–496, 1999. increased mortality. Cardiol Res 3(1):1–7, 2012.
PROCEDURE
51
Temporary Transvenous and
Epicardial Pacing
Valerie Spotts
PURPOSE: The purpose of temporary cardiac pacing is to ensure or restore an
adequate heart rate and rhythm. Transvenous and epicardial pacing are initiated as
temporary measures when a failure of the normal conduction system of the heart to
produce an electrical impulse results in hemodynamic compromise.
PREREQUISITE NURSING • Temporary invasive pacing is indicated for the follow-

KNOWLEDGE ing:7,8,10
❖ Symptomatic third-degree atrioventricular (AV) block
• Knowledge of the normal anatomy and physiology of the ❖ Symptomatic second-degree heart block
cardiovascular system, principles of cardiac conduction, ❖ Dysrhythmias that complicate acute myocardial infarc-
and basic dysrhythmia interpretation is needed. tion
• Understanding of temporary pacemakers is needed to ❖ Symptomatic bradycardia or bradydysrhythmias
evaluate pacemaker function and the patient’s response to ❖ New bundle-branch block with transient complete heart
pacemaker therapy. block
• Clinical and technical competence related to use of tem- ❖ Alternating bundle-branch block
porary pacemakers is needed. ❖ Symptomatic sinus node dysfunction
• Advanced cardiac life support (ACLS) knowledge and ❖ Treatment of bradycardia-tachycardia syndrome (sick
skills are necessary. sinus syndrome)
• Basic principles of hemodynamic monitoring are essential in ❖ Ventricular standstill or cardiac arrest
the assessment of the efficacy of temporary pacing therapy. ❖ Long QT syndrome with ventricular dysrhythmia
• Knowledge of the pulmonary artery (PA) catheter function ❖ Medication toxicity or adverse effects of a medication
and its use relative to hemodynamic monitoring with ❖ Postoperative cardiac surgery
use of a PA catheter with pacing function is necessary (see ❖ Low cardiac output states
Procedure 72). ❖ Prophylaxis with cardiac diagnostic, interventional, or
• Knowledge of the care of patients with central venous surgical procedures
catheters (see Procedure 66) is needed. ❖ Chronotropic incompetence in the setting of cardio-
• Principles of general electrical safety apply, with the use genic shock
of temporary invasive pacing methods, must be under- • The three primary methods of invasive temporary pacing
stood. Gloves always should be worn when handling elec- are transvenous endocardial pacing, pacing via a PA cath-
trodes to prevent microshock. In addition, the exposed eter, and epicardial pacing.
proximal ends of the pacing wires should be insulated • Transvenous pacing:
when not in use to prevent microshock.3,11–13 ❖ In temporary transvenous pacing, the pulse generator
• The insertion of a temporary pacemaker is performed in is externally attached to a pacing lead that is inserted
emergent and elective clinical situations. through a vein into the right atrium or ventricle.
• Temporary pacing may be used to stimulate the myocar- ❖ Veins used for insertion of the pacing lead are the
dium to contract in the absence of an intrinsic rhythm, subclavian, femoral, brachial, internal jugular, or exter-
establish an adequate cardiac output and blood pressure nal jugular veins.
to ensure tissue perfusion to vital organs, reduce the pos- ❖ Single-chamber ventricular pacing is the most common
sibility of ventricular dysrhythmias in the presence of method used in an emergency because the goal is to
bradycardia, supplement an inadequate rhythm with tran- establish a heart rate as quickly as possible.
sient decreases in heart rate (e.g., chronotropic incompe- ❖ Temporary atrial or dual-chamber pacing can be initi-
tence in shock), or allow the administration of medications ated if the patient needs atrial contraction for improve-
(e.g., beta blockers) to treat ischemia or tachydysrhyth- ment in hemodynamics.
mias in the presence of conduction system dysfunction or ❖ The pacing lead is an insulated wire with one or two
bradycardia. electrodes at the tip of the wire (Fig. 50-1).
416
51 Temporary Transvenous and Epicardial Pacing 417
Figure 51-2 Pulmonary artery catheter with atrial and ventricu-

Figure 51-1 Balloon-tipped bipolar lead wire for transvenous
lar pacing lumens.
pacing.
The pacing lead can be a hard-tipped or balloon-tipped

❖
pacing catheter that is placed in direct contact with the
endocardium (Fig. 51-1). Most temporary leads are
bipolar, with the distal tip electrode separated from the
proximal ring by 1 to 2 cm (see Fig. 50-1).
❖ An external temporary pulse generator is connected to
the transvenous pacing wire via a bridging or connect-
ing cable.
• Pacing via a PA catheter:
❖ Temporary atrial or ventricular pacing via a thermodi-
lution PA catheter can be done with combination cath-
eters that are specifically designed for temporary Figure 51-3 Epicardial wires.
pacing.
❖ PA pacing catheters feature atrial and ventricular
ports for the introduction of the pacing lead wires Bipolar is more common. With bipolar placement,
(Fig. 51-2). both leads are connected to the myocardium and
❖ Use of a PA catheter combines the capabilities of PA both are able to function as negative poles.
pressure monitoring, thermodilution cardiac output Unipolar placement has one lead on the myocar-
measurement, fluid infusion, mixed venous oxygen dium (negative) and another lead placed on the
sampling, and temporary pacing. chest wall (positive). This positive lead is some-
❖ One limitation of these multifunction catheters is that times referred to as a ground or skin lead.
the simultaneous measurement of pulmonary artery ❖ Typically, the atrial wires are located on the right of
occlusion pressure (PAOP) and pacing is usually not the sternum, and the ventricular wires exit to the left
possible. Balloon inflation can cause repositioning of of the sternum (Figs. 44-1 and 51-4).
the pacing electrode with catheter movement; measure- ❖ If a minimally invasive surgery was performed the
ment of the PAOP may cause pacing to become pacing wires may be in different locations; discuss and
intermittent.10 label the pacing wires so that it is clear which wires
• Temporary epicardial pacing: are apical and which are ventricular.
❖ Temporary epicardial pacing is a method of stimulating ❖ An external temporary pulse generator (Figs. 51-5,
the myocardium through the use of polytetrafluoroeth- 51-6, and 51-7) is connected to the epicardial pacing
ylene (PTFE)–coated, unipolar or bipolar stainless wires via a bridging or connecting cable (Fig. 51-8).
steel wires that are sutured loosely to the epicardium ❖ Atrial and ventricular thresholds for epicardial wires
after cardiac surgery (Fig. 51-3). increase by the fourth postoperative day.4
❖ The epicardial wires may be attached to the right • Basic principles of cardiac pacing include sensing, pacing,
atrium for atrial pacing, the right ventricle for ventricu- and capture.
lar pacing, or both for AV pacing. ❖ Sensing refers to the ability of the pacemaker device
❖ Each pacing wire is brought through the chest wall to detect intrinsic myocardial electrical activity. Sensing
before the chest is closed. occurs if the pulse generator is in the synchronous or
❖ Epicardial wires can be placed in a unipolar or bipolar demand mode. The pacemaker either is inhibited from
configuration. delivering a stimulus or initiates an electrical impulse.
LED light display pacing

and sensing functions
Lock/Unlock key safeguards

against unintentional para-
meter changes
Pacing rate dial
Atrial output dial
Ventricular output dial
High-resolution LCD screen

with backlighting
Menu dial for fine-tuning

parameters
Emergency dual chamber

asynchronous pacing key
Two atrial wires Two ventricular wires
Figure 51-4 Location of atrial and ventricular epicardial lead Pause key for suspending
wires. pacing and sensing
On/Off keys
RAP (Rapid Push button battery drawer
CAUTION:
Atrial Pacing) ATRIAL USE ONLY allows easy access
controls
Figure 51-6 Dual-chamber temporary pulse generator, model
Green pace Orange sense
5388. LED, light-emitting diode; LCD, liquid crystal display.
Rate dial
(Reproduced with permission of Medtronic, Inc.)
Low battery
Output dial spike, depending on the chamber being paced. Mechan-

ical capture is evidenced by generation of a pulse.
Sensitivity dial
• Temporary pulse generator:
❖ The temporary pulse generator houses the controls and
energy source for pacing.
OFF button ON button ❖ Some pulse generators are for single-chamber pacing
only and have one set of terminals at the top of the
pulse generator into which the pacing wires are inserted
(via connecting cable; see Fig. 51-5).
Battery
compartment • A dual-chamber pacemaker requires two sets of terminals
for the atrial and ventricular wires (see Figs. 51-6, 51-7,
and 51-9). A dual-chamber pacemaker can be used for
Figure 51-5 Single-chamber temporary pulse generator. (Repro- single-chamber pacing, but settings for the chamber not
duced with permission of Medtronic, Inc.)
being paced should be programmed to off to avoid any
signal interference.8
❖ Pacing occurs when the temporary pulse generator is • Different models of pacemakers use either dials or touch
activated and the requisite level of energy travels from pads to change the settings.
the pulse generator through the temporary wires to the ❖ The pacing rate is determined by the rate dial or touch
myocardium, which is known as pacemaker firing and pad.
is represented as a line or spike on the electrocardio- ❖ The AV interval dial or pad on a dual-chamber pace-
gram (ECG) recording. maker controls the amount of time between atrial and
❖ Electrical capture refers to the successful stimulation ventricular stimulation (electronic PR interval).
of the myocardium by the pacemaker, resulting in ❖ The energy delivered to the myocardium is determined
depolarization. Capture is evidenced on the ECG as an by setting the output (milliampere [mA]) dial or pad
atrial or ventricular complex following the pacemaker on the pulse generator.
Figure 51-9 Pulse generator terminals to connect cables from

atrial and ventricular leads.
EQUIPMENT
• Antiseptic solution (e.g., 2% chlorhexidine-based prepa-
ration)
• Pacing lead wires
• Pulse generator
• Battery/batteries for pulse generator (usually 9 V or AA)
• Connecting cables
• ECG monitoring equipment
• Dressing supplies
the following:
Figure 51-7 Dual-chamber temporary pulse generator, model
5392. (Reproduced with permission of Medtronic, Inc.)
• Central venous catheter insertion supplies (see Procedure
82)
• Alligator clips or wire with connector pins
• Suture, needles, syringes
• Emergency equipment
• Fluoroscopy
• Lead aprons or shields
• Multiple-pressure transducer system, with use of PA cath-
eter (see Procedure 75)
• 12-lead ECG machine
• Local anesthetic
• Sterile drapes, towels, masks, goggles or face shields,
gowns, caps
• Insulating material for epicardial wires (e.g., finger cots,
glove, needle caps, ear plugs)
Figure 51-8 Connecting cables. (Reproduced with permission of
Medtronic, Inc.)
• Assess learning needs, readiness to learn, and factors that
❖ Dual-chamber pacing requires that mA be set for the influence learning. Rationale: This assessment enables
atria and the ventricle. teaching to be individualized in a manner that is meaning-
• The ability of the pacemaker to detect the patient’s intrin- ful to the patient and family.
sic rhythm is determined by the pacing mode and sensitiv- • Discuss basic information about the normal conduction
ity setting. In the asynchronous mode, the pacemaker system, such as structure and function of the conduction
functions as a fixed-rate pacemaker and is not able to system, normal and abnormal heart rhythms, signs, symp-
sense any of the patient’s inherent cardiac activity. In the toms, and the significance of abnormal heart rhythms.
synchronous mode, the pacemaker is able to sense the Rationale: The patient and family should understand the
patient’s inherent cardiac activity. conduction system and why the procedure is necessary.
• The ability of the pacemaker to depolarize the myocar- • Provide a basic description of the temporary pacemaker
dium depends on many variables: the position of the elec- insertion procedure. Rationale: The patient and family
trodes and degree of contact with viable myocardial tissue; should be informed of the invasive nature of the procedure
the level of energy delivered through the pacing wire; the and any risks associated with it. An understanding of the
presence of hypoxia, acidosis, or electrolyte imbalances; procedure may reduce anxiety.
fibrosis around the tip of the catheter; and concomitant • Describe the precautions and restrictions required while
medication therapy.10,12 the temporary pacemaker is in place, such as limitation of
movement, avoidance of handling the pacemaker or need to be held because of concomitant effect. Other
touching exposed portions of the electrodes, and when medications, such as antidysrhythmics, may alter the
to notify the nurse (e.g., if the dressing becomes wet, if pacing threshold.
the patient experiences dizziness). Rationale: Under- • Review the patient’s current laboratory study results,
standing limitations may improve patient cooperation including chemistry or electrolyte profile, arterial blood
with restrictions and precautions. The patient and family gases, and/or cardioactive medication levels. Rationale:
also will alert nurses to potential problems. This review assists in determining whether the need for
pacing was precipitated by metabolic disturbances or
medication toxicity and establishes the pacing milieu.
Patient Preparation
PREPARATION
• Assess the patient’s baseline cardiac rhythm for the pres- nurse should ensure the correct identification of the patient
ence of the dysrhythmia that necessitates temporary for the intended intervention.
cardiac pacing. Rationale: This assessment determines • Ensure that the patient and family understand pre
the need for invasive cardiac pacing. procedural teaching. Answer questions as they arise, and
• Assess the patient’s hemodynamic response to the dys- reinforce information as needed. Rationale: This com-
rhythmia. Rhythm disturbances may reduce cardiac output munication evaluates and reinforces understanding of pre-
significantly with detrimental effects on perfusion to viously taught information.
vital organs. Rationale: This assessment determines the • Confirm that informed consent has been obtained. Ratio-
urgency of the procedure. It may indicate the need for nale: Informed consent protects the rights of the patient
temporizing measures, such as vasopressors or transcuta- and makes a competent decision possible for the patient;
neous pacing. however, in emergency circumstances, time may not
• Review the patient’s current medications. Rationale: allow the consent form to be signed.
Medications may be a cause of the dysrhythmia that led • Perform a preprocedure verification and time out, if non-
to the need for pacemaker therapy, or medications may emergent. Rationale: Ensures patient safety.
Procedure for Temporary Transvenous and Epicardial Pacing

Initiating Temporary Pacing
1. HH
2. PE
3. Connect the patient to the bedside Monitors the patient’s intrinsic Skin preparations may be needed to
monitoring system and monitor the rhythm and the patient’s remove oils to improve impulse
ECG continuously (see Procedure rhythm during and after the transmission.2
54). procedure to evaluate for
adequate pacemaker function.
4. Assess pacemaker functioning and Ensures a functional pacemaker Different ways to assess battery function
insert a new battery into the pulse pulse generator. depend on the model and manufacturer;
generator before beginning therapy. check the manufacturer’s
(Level M*) recommendations for specific
instructions.
5. Prepare the pacing system: Prepares equipment; the pacing Connecting cables are specific to either
A. Ensure that the pulse generator stimulus travels from the transvenous or epicardial wires.
is turned off. pulse generator to the Some lead wires are labeled distal and
B. Attach the connecting cable to negative terminal, and energy proximal; distal connects to negative, and
the pulse generator. returns to the pulse generator proximal connects to positive.
C. The atrial cable connects into via the positive terminal. Some lead wires may not have negative
the socket labeled “A.” and positive marked on them.
D. The ventricular cable connects Polarity is established when the wires are
into the socket labeled “V.” placed in the connecting cable.
Two connecting cables are needed with
both atrial and ventricular pacing.

Procedure for Temporary Transvenous and Epicardial Pacing—Continued

Assisting With Initiation of Temporary Transvenous Pacing
1. Follow Steps 1 through 5 in
Initiating Temporary Pacing.
2. If a central venous catheter is A central line is needed for An introducer sheath is used that fits the
not in place, assist as needed transvenous pacing. pacemaker wire that is being inserted.
with catheter insertion (see
Procedures 82 and 83).
3. Assist as needed with insertion of Provides needed assistance.
the transvenous pacing lead wire.
4. All personnel performing and Minimizes the risk of infection,
assisting with the procedure maintains sterility, and
should apply PE and sterile maintains standard and sterile
equipment (e.g., masks, head precautions.
covers, goggles or face shields,
sterile gowns, and sterile gloves).9
5. Assist as needed with cleansing Minimizes the risk of infection. Gloves should be worn whenever handling
the insertion site with antiseptic the pacing electrodes to prevent
solution (e.g., 2% chlorhexidine- microshock.3,11–13
based preparation).
6. Assist as needed with draping the Provides a sterile field and
insertion site. reduces the transmission of
microorganisms.
7. Assist as needed as the pacing Facilitates the insertion process. If a balloon-tipped pacing lead is used,
lead is passed through the balloon inflation occurs when the tip of
introducer. the pacing lead is in the vena cava. The
air-filled balloon allows the blood flow to
carry the catheter tip into the desired
position in the right ventricle.
8. Assist with verifying the position For transvenous, ventricular
of the transvenous pacing lead pacing, the negative pacing
wire: electrode is positioned in the
endocardium (at the apex) of
the right ventricle.
A. Ultrasound scan Transcutaneous ultrasound may
be used to assist with
insertion of the pacing
electrode.
B. Fluoroscopy Fluoroscopy may be used to If fluoroscopy is used, all personnel must
assist with visualization of be shielded from the radiation with lead
the pacing electrode. aprons or be positioned behind lead
shields.
C. Chest radiography X-ray may be used to confirm
the placement of the pacing
electrode.

D. Bedside monitoring system or The ECG is derived directly Determine that the ECG monitoring system
12-lead ECG machine from the pacing electrode, meets all safety requirements.
i. Connect the patient to the and the position of the As a result of the temporary pacing
limb leads. catheter tip is verified by the catheter transmission of impulses from
ii. Attach the V lead of the internal electrical recording, within the right ventricle, conduction of
ECG monitoring system or which shows ST-segment the impulse throughout the ventricles
the 12-lead ECG machine to elevation when in contact occurs via cellular conduction of the
the negative electrode with the myocardium. impulse rather than transmission down
connector pin (distal pin) of the bundle branches.
the pacing lead wire (an
alligator clip or wire with
connector pins may be
needed; see Fig. 50-2).
iii. Set the monitoring system
to record the V lead
continuously.
iv. Observe the ECG for
ST-segment elevation in the
V lead recording (see Fig.
50-3).
v. Observe for left bundle-
branch block pattern and
left-axis deviation that
usually can be identified.
9. After the pacing lead wire is Energy from the pulse A connecting cable is recommended for use
properly positioned: generator is directed to the between the pacing wires and the pulse
A. Connect the external electrode negative electrode in contact generator.
pins to the pulse generator via with the ventricle. Some lead wires are labeled distal and
the connecting cables. The pacing circuit is completed proximal; distal connects to negative, and
B. Ensure that the positive and as energy reaches the positive proximal connects to positive.
negative electrode connector electrode. Some lead wires may not have negative
pins are connected to the The lead wires must be and positive marked on them.
respective positive and connected securely to the Polarity is established when the wires are
negative terminals on the pulse pacemaker to ensure placed in the connecting cable.
generator (see Fig. 51-9) via appropriate sensing and
the connecting cables (Fig. capture and to prevent
51-10). inadvertent disconnection.
C. Ensure all connections are
secure.
Figure 51-10 Transvenous cable that

connects to transvenous pacemaker leads
with shrouded pins. (Reproduced with per-
mission of Medtronic, Inc.)

10. For AV demand pacing, when an Ensures that the atrial Transvenous temporary atrial leads may be
atrial lead is placed in addition to electrodes are connected placed short term for procedures and
a ventricular lead: correctly to the pulse then removed.
A. Connect the atrial electrodes to generator.
the atrial terminals via the Ensures that the ventricular
connecting cable. electrodes are connected
B. Connect the ventricular correctly to the pulse
electrodes to the ventricular generator.
terminals via the connecting The pacing stimulus travels
cable. from the pulse generator to
C. The connecting cable(s) should the negative terminal, and
already be connected to the energy returns to the pulse
pulse generator for each generator via the positive
chamber that is being paced terminal.
(see Fig. 51-9).
Assisting With Initiating Temporary Pacing via a Pulmonary Artery Catheter
1. Follow Steps 1 through 5 in Prepares equipment.
2. Assist the physician, advanced Provides assistance as needed. Pacing electrodes may be inserted at the
practice nurse, or other provider time of PA catheter insertion, or they
with insertion of the PA catheter may be inserted at a later time, when
(see Procedure 72). temporary pacing is needed because of a
change in the patient’s condition.
3. Obtain the appropriate pacing lead Only probes specifically Continuous monitoring of the right-
for insertion. manufactured for use with ventricular pressure waveform via the
the PA catheter should be pacing lumen is recommended before
used; check specific insertion of the electrode to ensure
manufacturer’s correct placement of the right ventricular
recommendations. port 1–2 cm distal to the tricuspid valve.
4. Assist as needed with insertion of Close monitoring of the ECG Follow specific manufacturer’s instructions
the pacing lead wire. during insertion of the pacing regarding pacing lead insertion and
lead is necessary to detect securing the pacing lead in place within
dysrhythmias. the catheter lumen.
5. After the pacing lead wire is Energy from the pulse Gloves should be worn whenever handling
properly positioned: generator is directed to the the pacing electrodes to prevent
A. Connect the positive and negative electrode. microshock.3,11–13
negative electrode connector The pacing circuit is completed
pins to the pulse generator via as energy reaches the positive
the connecting cable. electrode.
B. Ensure that the positive and The pacing electrode needs to
negative electrodes are be securely connected to the
connected to the respective pulse generator to ensure
positive and negative terminals appropriate sensing and
on the pulse generator via the capture and to prevent
connecting cables. inadvertent disconnection.
C. Ensure all connections are
secure.
6. Check institutional policy or obtain Intermittent capture has been Usually, the PA catheter is not wedged
specific provider prescription noted during the wedging during pacing therapy.6
regarding not wedging the PA procedure as a result of
catheter. movement of the electrode
with catheter migration into
the wedge position.6

Epicardial Pacing
1. Follow Steps 1 through 5 in
2. Expose the epicardial pacing wires Identifies the correct chamber Gloves should be worn whenever handling
(Fig. 51-3) and identify the chamber for pacing. the epicardial wires to prevent
of origin (see Figs. 44-1 and 51-4). microshock.3,11–13
A. Epicardial wires that exit to the
right of the sternum are atrial
in origin.
B. Epicardial wires that exit to the
left of the sternum are
ventricular in origin.
3. Set-up the system: Energy from the pulse
A. Connect the epicardial wires to generator is directed to the
the pulse generator via the negative electrode in contact
connecting cables (See step 4 with the myocardium.
below). The pacing circuit is completed
B. Ensure that the positive and as energy reaches the positive
negative electrodes are electrode.
connected to the respective The epicardial wires must be
positive and negative terminals connected securely to the
on the pulse generator via the pacemaker to ensure
connecting cables. appropriate sensing and
C. Ensure all connections are capture and to prevent
secure. inadvertent disconnection.
4. Determine what type of pacing will In a unipolar pacing system, With unipolar pacing (one electrode in
be initiated: only one epicardial pacing contact with the heart), the epicardial
A. Unipolar pacing electrode is in contact with wire must be the negative electrode, and
B. Bipolar pacing the chamber being paced (the the ECG patch, skin wire, or
negative electrode). The subcutaneous needle is the positive
positive, or indifferent electrode.
(ground), electrode may be With AV demand pacing, both atrial
an ECG electrode patch, may epicardial wires are connected to the
be an epicardial wire sewn to atrium (via the connecting cable) and the
the subcutaneous tissue of ventricular epicardial wires are connected
the chest wall, or may be a to the terminal labeled ventricle (via the
subcutaneous needle inserted connecting cable).
into the chest wall.
In a bipolar pacing system, two
epicardial pacing electrodes
are in direct contact with the
myocardial tissue of the
chamber being paced.
All Methods of Temporary Pacing
1. Determine the mode of pacing The pacing mode chosen Asynchronous pacing in the presence of an
desired. should be the one that best intrinsic rhythm may result in R-on-T
achieves the goal of pacing phenomenon, leading to a lethal
therapy. dysrhythmia, and should be used only in
Possibilities include atrial, the absence of an intrinsic rhythm.6,8,10
ventricular, or AV
asynchronous (fixed rate)
pacing or atrial, ventricular,
or AV synchronous (demand)
pacing.

2. Set the pacemaker mode, Prepares pacemaker equipment. Follow institutional standards regarding
pacemaker rate, and level of whether critical care nurses can set the
energy (output or mA) as pacemaker mode and energy level, and
prescribed or as determined by test the sensitivity and stimulation
sensitivity and stimulation threshold levels.
threshold testing (see subsequent The demand or the synchronous mode is
Steps 3, 4, and 5). recommended to avoid competition
between the pacemaker-initiated beats
and the patient’s intrinsic rhythm.
Output is set to ensure capture of the
myocardium.
In AV pacing, separate output settings are
used to ensure capture of the atrium and
the ventricle.
3. Depending on the pulse generator, Prepares the equipment. Follow the manufacturer’s
turn all settings to the lowest level, recommendations.
then turn on the pulse generator. Settings cannot be adjusted on some pulse
(Level M*) generators until after the pulse generator
is turned on.
Other pulse generators turn on at default
settings, after a self-test, and the settings
can be adjusted at that time.
4. Determine the sensitivity threshold Sensitivity threshold is the This step is omitted if the patient has no
(for each chamber as appropriate). level at which intrinsic intrinsic rhythm.
Set the rate for 10 beats/min myocardial activity is In determining a sensitivity threshold, the
below the patient’s intrinsic recognized by the sensing mA should be turned to the lowest level
rate.1,7,8 electrodes. to avoid the possibility of a pacemaker
(Level M*) Setting the pacemaker rate stimulus falling on the T wave (R-on-T
lower than the intrinsic rate phenomenon) and inducing a potentially
avoids competition between lethal dysrhythmia.5
the pacemaker and the
patient’s intrinsic rhythm.
For demand pacing, the
sensitivity must be measured
and set.
A. Gradually turn the sensitivity After the sensitivity threshold is
dial counterclockwise (or to a determined, some physicians and
higher numeric setting) and advanced practice nurses prefer to set the
observe the sense indicator sensitivity settings all the way to the
light for flashing. The sense demand mode (most sensitive),
indicator light stops flashing regardless of the sensitivity threshold.
when the device is unable to Follow institutional standards.
sense the patient’s intrinsic
rhythm.
B. Slowly turn the sensitivity dial If the sensitivity is set to the most
clockwise (or to a lower sensitive, the pacemaker may be
numeric setting) until the sense inappropriately inhibited because it may
indicator light flashes with detect and interpret extramyocardial
each complex and the pace activity (e.g., muscle movement, artifact)
indicator light stops. This value as actual myocardial activity.
is the sensing threshold.


C. Set the sensitivity dial to the
number that was half the
sensing threshold to provide a
2 : 1 safety margin.1,7,8
5. Determine the stimulation The output dial regulates the This step should be performed by a
threshold (for each chamber as amount of electrical current physician or advanced practice nurse in a
necessary).1,7,8 (mA) that is delivered to the patient who is pacemaker dependent for
Follow institution standard. myocardium to initiate bradydysrhythmia.
depolarization. Individual institutional policies govern
The output (mA) is set at least when threshold determination should be
two times above the done and whether a nurse may test the
stimulation threshold to allow stimulation threshold; thresholds may not
for increases in the be determined if sensitivity is poor or
stimulation threshold without if the patient’s inherent heart rate is
loss of capture.1,7,8 >90 beats/min.
The output (mA) is Threshold may increase or decrease within
recommended to be ≤15 mA hours of electrode placement as a result
to prevent fibrosis at the lead/ of fibrosis at the tip of the catheter,
myocardium interface.2 medication administration (e.g., some
antidysrhythmics), alteration of position,
or underlying pathology.1,5,7,8,10
In the case of dual-chamber pacing, the
threshold for each chamber is assessed.
Pacing rates vary depending on the
indication for pacing.
A. Set the pacing rate
approximately 10 beats/min
above the patient’s intrinsic
rate.
B. Gradually decrease the output
from 20 mA until capture is
lost.
C. Gradually increase the mA
until 1 : 1 capture is established.
This is the stimulation
threshold. The pace light will
be flashing.
D. Set the mA at least two times The output (mA) is This output setting is sometimes referred to
higher than the stimulation recommended to be ≤15 mA as the maintenance threshold.
threshold.1,7,8,13 to prevent fibrosis at the lead/
myocardium interface.2
6. Set the prescribed pacemaker rate. Ensures adequate cardiac
output.
7. Assess the cardiac rate and rhythm The ECG tracing should reflect
for appropriate pacemaker appropriate response to the
function: pacemaker settings if
functioning properly.
A. Capture: is there a QRS Sometimes atrial activity may
complex for every ventricular not be visible because of
pacing stimulus? Is there also a low-voltage amplitude. If the
P wave for every atrial pacing patient is paced solely via
stimulus (Fig. 51-11)? atrial pacing, ventricular
tracking and response should
follow the atrial rate setting.
Figure 51-11 Pacemaker electrocardiogram (ECG) strip of atrioventricular pacing. Note the atrial
pacing spike before each P wave and the ventricular pacing spike before each QRS complex.

B. Rate: is the rate at or above the
pacemaker rate if in the
demand mode?
C. Sensing: does the sense light
indicate that every QRS
complex is sensed?
8. After the settings are adjusted for Pacemaker settings may be The patient may need to be reminded not
optimal patient response, place the inadvertently altered by to touch the pulse generator.
protective plastic cover over the patient movement or
pacemaker controls, or place the handling if the controls are
controls in the locked position. not covered or locked.
9. Assess the patient’s response to Pacemaker settings are
pacing, including blood pressure, determined by patient
level of consciousness, heart response.
rhythm, and other hemodynamic
parameters.
10. Apply a sterile occlusive dressing Prevents infection. The epicardial electrodes and the insertion
over the insertion site. sites may be covered with a 4 × 4–inch
dressing and taped to the chest.5,13 The
wires may be placed over the dressing
and covered with gauze.
11. Secure the necessary equipment to The pulse generator should be Exposed wires should be secured in an
provide some stability for the protected from falling or insulated material (e.g., finger cots,
pacemaker, such as hanging the becoming inadvertently glove, plastic needle cap, ear plugs).11–13
pulse generator on an intravenous detached by patient Care must be taken to avoid bending or
pole, strapping the pulse generator movement. kinking the wires because this can lead
to the patient’s torso, hanging the to fractured wires.
pulse generator around the
patient’s neck, or securing the
pulse generator under a draw
sheet.
Precautions.
13. HH
14. Obtain a chest radiograph as In the absence of fluoroscopy, a Not necessary for epicardial pacing.
prescribed. radiograph is essential to
detect potential complications
associated with insertion and
to visualize lead position.
15. Selectively restrict patient mobility Prevents electrode dislodgment. Follow institutional policy regarding
depending on the insertion site. ambulation for the patient with a
temporary pacemaker.

• Paced rhythm on ECG consistent with parameters set • Failure of the pacemaker to sense, causing
on the pacemaker, as evidenced by appropriate heart competition between the pacemaker-initiated
rate, sensing, and capture impulses and the patient’s intrinsic cardiac rhythm
• Patient exhibits hemodynamic stability, as evidenced • Failure of the pacemaker to capture the myocardium
by a systolic blood pressure >90 mm Hg, a mean • Pacemaker oversensing that causes the pacemaker to
arterial blood pressure >60 mm Hg, baseline mental be inappropriately inhibited
status, and no syncope or ischemia • Stimulation of the diaphragm that causes hiccupping,
• All pacemaker wires are securely connected to the which may be related to pacing the phrenic nerve,
pulse generator perforation, wire dislodgment, or an excessively high
pacemaker mA setting
• Phlebitis, thrombosis, embolism, or bacteremia
• Ventricular dysrhythmias
• Pneumothorax or hemothorax
• Myocardial perforation and cardiac tamponade
• Air embolism
• Lead dislodgment
• Pacemaker syndrome as a result of loss of AV
synchrony
• Continual hiccups (may indicate wire perforation)
• Pain

interventions.
1. Monitor vital signs and The goal of cardiac pacing is to • Abnormal vital signs associated
hemodynamic response to pacing improve cardiac output by with signs and symptoms of
following institution standard and increasing heart rate or by hemodynamic deterioration
as often as the patient condition overriding life-threatening
warrants. dysrhythmias.
2. Evaluate the ECG for the presence Proper pacemaker functioning is • Inability to obtain a paced rhythm
of the paced rhythm or resolution assessed by observing the ECG for (loss of capture or failure to
of the initiating dysrhythmia. pacemaker activity consistent with capture)
the parameters set. • Oversensing
• Undersensing
3. Follow institutional standards for Identifies need for pain interventions. • Continued pain despite pain
analgesia as prescribed. • Continual hiccups
4. Check and document sensitivity Ensures proper pacemaker functioning • Problems or significant changes
and stimulation threshold and prevents high levels of energy with sensitivity or threshold
according to institutional standards delivery to the myocardium. The
(e.g., usually at least every 24 threshold may be checked more
hours).10,11 The threshold may be frequently if the patient’s condition
checked by physicians and/or changes or pacemaker function is
advanced practice nurses in questioned.
patients at high risk (e.g., if
pacemaker dependent).

5. Replace gauze dressings every 2 Although guidelines specific to • Increased temperature
days and transparent dressings at epicardial wires and transvenous • Increased white blood cell count
least every 7 days.9 Cleanse the pacemaker sites do not exist, the • Drainage at the insertion site
site with an antiseptic solution Centers for Disease Control and • Warmth or pain at the insertion site
(e.g., 2% chlorhexidine-based Prevention (CDC) recommend
preparation). Follow institutional replacing dressings on intravascular
standards. (Level D*) catheters when the dressings
become damp, loosened, or soiled
or when inspection of the site is
necessary.9
6. Monitor for other complications. Early recognition leads to prompt • Embolus
treatment. • Thrombosis
• Perforation of the myocardium
• Pneumothorax
• Hemothorax
• Phlebitis
7. Monitor electrolyte levels as Electrolyte imbalances may • Abnormal electrolyte values
prescribed. precipitate dysrhythmias or change
stimulation thresholds.
8. Ensure that all connections are Maintenance of tight connections is • Inability to maintain tight
secure and the low-battery necessary to ensure proper connections with available
indicator is not present. pacemaker functioning. Battery life equipment, jeopardizing pacing
varies with the amount of pacing therapy
energy needed. Follow institutional
guidelines for assessing the
low-battery indicator.
9. If the pulse generator is no longer Microshocks can lead to lethal • Microshocks
needed for a patient with epicardial dysrhythmias. Epicardial wires are
pacing wires, isolate and contain often left in place after pacing is no
the tips to avoid microshocks (e.g., longer needed (generator is
finger cot, needle cap, needle disconnected).
barrel, glove, ear plug).11–13
Documentation
• Patient and family education • Presence of underlying rhythm
• Signed informed consent form • Patient response to the procedure
• Universal Protocol requirements • Complications and interventions
• Date and time of initiation of pacing • Medications administered and patient response to the
• Description of events that warranted intervention medications
• Vital signs and hemodynamic parameters before, • Pain assessment, interventions, and patient response
during, and after the procedure • Date and time of battery-status assessments
• ECG monitoring strip recording before and after • Date and time pacing was discontinued
pacemaker insertion • Adjustment to monitoring system settings to ensure
• Type of pacemaker wire inserted and location detection of paced rhythms
• Pacemaker settings: mode, rate, output, sensitivity,
threshold measurements, and whether the pacemaker is
on or off

51 Temporary Transvenous and Epicardial Pacing 430.e1
References in the management of epicardial pacing. Anaesthesia

1. Abate E, Kusumoto FM, Goldschlager NF: Techniques for 62:264–271, 2007.
temporary pacing. In Kusumoto FM, Goldschlager NF, 12. Timothy PR, Rodeman BJ: Temporary pacemakers in
editors: Cardiac pacing for the clinician, ed 2, New York, critically ill patients: Assessment and management
2007, Springer-Verlag. strategies. AACN Clin Issues 15:305–325, 2004.
2. Chua J, Schwarzenberger J, Mahajan A: Optimization of 13. Jacobson C, Gerity D: Pacemakers and implantable
pacing after cardiopulmonary bypass. J Cardiothorac Vasc defibrillators. In Woods SL, et al, editors: Cardiac
Anesth 26(2):291–301, 2012. nursing, ed 5, Philadelphia, 2005, Lippincott Williams and
3. Drew B: Practice standards for electrocardiographic Wilkins.
Association scientific statement from the Councils on Additional Readings
Cardiovascular Nursing, Clinical Cardiology, and Batra AS, Balaji S: Post operative temporary epicardial
Cardiovascular Disease in the Young: Endorsed by the pacing: When, how and why? Ann Pediatr Cardiol
International Society of Computerized Electrocardiology 1(2):120–125, 2008.
and the American Association of Critical-Care Nurses. Conover M: Electrical stimulation therapies. In Understanding
Circulation 110:2721–2746, 2004. Electrocardiography, ed 8, St Louis, 2003, Mosby,
4. Elmi F, Tullo NG, Khalighi K: Natural history and Chapter 33.
predictors of temporary epicardial pacemaker wire Conover M: Pacemaker therapies for bradyarrhythmias. In
function in patients after open heart surgery. Cardiology Understanding Electrocardiography, ed 8, St Louis, 2003,
98:175–180, 2002. Mosby, Chapter 34.
5. Finkelmeier BA: Temporary pacing and defibrillation in Cottrell DB, Welch E: Caring for a patient with a temporary
cardiothoracic surgical nursing, Philadelphia, 2000, pacemaker. LPN 5(1):36–42, 2009.
Lippincott. Dwyer D, Bauer K: Take the lead on safety with temporary
6. Gammage MD: Temporary cardiac pacing. Heart 83:715– cardiac pacing. Nursing 3:63–64, 2010.
720, 2000. Gibson JA: Keeping pace: Understanding temporary
7. Medtronic Corp: Model 5388 dual chamber temporary transvenous cardiac pacing. Nursing Crit Care 9(5):20–27,
pacemaker technical manual, Minneapolis, 2007, 2014.
Medtronic. Hongo RH, Goldschlager NF: Cardiac pacing in the critical
8. Medtronic Corp: Medtronic 5392 dual chamber temporary care setting. In Kusumoto FM, Goldschlager NF, editors:
external pacemaker technical manual, Minneapolis, 2013, Cardiac pacing for the clinician, ed 2, New York, 2007,
Medtronic. Springer-Verlag.
9. O’Grady NP, et al: Guidelines for the prevention of Pinneri F, et al: Echocardiography-guided versus fluoroscopy-
intravascular catheter-related infections. Am J Infect guided temporary pacing in the emergency setting: An
Control 39(4):S1–S34, 2011. observational study. J Cardiovasc Med 14:20–27, 2013.
10. Overbay D, Criddle L: Mastering temporary invasive Reade MC: Temporary epicardial pacing after cardiac surgery:
cardiac pacing. Crit Care Nurse 24(3):25–32, 2004. A practical review: Part 2: Selection of epicardial pacing
11. Reade MC: Temporary epicardial pacing after cardiac modes and troubleshooting. Anaesthesia 62:364–373,
surgery: A practical review: Part 1: General considerations 2007.
Section Seven Circulatory Assist Devices
PROCEDURE
52
Intraaortic Balloon Pump
Management
John P. Harper
PURPOSE: Intraaortic balloon pump therapy is designed to increase coronary
artery perfusion, which increases myocardial oxygen supply, and decrease afterload
and myocardial workload, which decreases myocardial oxygen demand.
PREREQUISITE NURSING • IABP therapy is an acute short-term therapy for patients

with reversible left-ventricular failure or an adjunct to
KNOWLEDGE other therapies for irreversible heart failure. Cardiac assis-
• Knowledge of the anatomy and physiology of the cardio- tance with the IABP is performed to improve myocardial
vascular system is needed. oxygen supply and reduce myocardial workload. Intraaor-
• Understanding of the principles of hemodynamic monitor- tic balloon (IAB) pumping is based on the principles of
ing, electrophysiology, dysrhythmias, and coagulation is counterpulsation (Fig. 52-1).
necessary. • The events of the cardiac cycle provide the stimulus for
• Clinical and technical competence related to the use of the balloon function, and the movement of helium gas between
intraaortic balloon pump (IABP) is needed. the balloon and the control console gas source produces
• Advanced cardiac life support knowledge and skills are inflation and deflation of the balloon.
necessary. • Recognition of the R wave or the QRS complex on the
• Indications for IABP therapy are as follows: electrocardiogram (ECG) is the most commonly used
❖ Cardiogenic shock trigger source.
❖ Refractory unstable angina • Inflation occurs during ventricular diastole and causes an
❖ Acute myocardial infarction (MI) complicated by left- increase in aortic pressure. This increased pressure dis-
ventricular failure3,13,28,30 places blood proximally to the coronary arteries and dis-
❖ Recurrent ventricular dysrhythmias as a result of tally to the rest of the body. The result is an increase in
ischemia18 myocardial oxygen supply and subsequent improvement
❖ Support before, during, and after coronary artery in cardiac output.
bypass graft surgery2,31 • Deflation occurs just before ventricular systole or ejection,
❖ Support before, during, and after coronary artery which decreases the pressure within the aortic root, reduc-
angioplasty or additional interventional cardiology ing afterload and myocardial workload.
procedures for patients at high risk4,11 • Insertion and placement verification:
❖ Mechanical complications of acute MI, including ❖ The IAB catheter is commonly placed in the femoral
aortic stenosis, mitral stenosis, mitral valvuloplasty, artery via percutaneous puncture or arteriotomy.
mitral insufficiency, ventricular septal defect, and left- ❖ The IAB catheter can also be placed in the left-axillary
ventricular aneurysm artery.16,17
14,20
❖ Intractable ventricular dysrhythmias ❖ The IAB catheter lies approximately 2 cm inferior to
❖ Bridge to cardiac transplantation, ventricular-assist the left subclavian artery and superior to the renal
devices, or total artificial hearts arteries. This position allows for maximum balloon
❖ Cardiac injury, including contusion and coronary artery effect without occlusion of other arterial supplies (Fig.
tears 52-2).
❖ Septic shock ❖ The IAB should not fully occlude the aorta during
20,31
❖ Patient at high risk undergoing noncardiac surgery inflation. It should be 85% to 90% occlusive.
• Contraindications to IABP therapy are as follows: ❖ Fluoroscopy is recommended to aid in IAB catheter
❖ Moderate to severe aortic insufficiency positioning, especially for patients with a tortuous
❖ Thoracic and abdominal aortic aneurysms aorta.
• The relative value of IABP therapy in the presence of ❖ Correct catheter position is verified via radiography if
severe aortoiliac disease, major coagulopathies, and ter- fluoroscopy is not used during catheter insertion. The
minal disease should be evaluated individually. visibility of the IAB catheter tip may be enhanced
431
• IAB catheter (size range, 7 to 10 Fr for adults; balloon

catheters vary in balloon volumes, 25 to 50 mL)
• IAB catheter insertion kit
• Antiseptic solution (e.g., 2% chlorhexidine-based
preparation)
• Caps, goggles or face shields, masks, sterile gowns,
gloves, and drapes
• Sterile dressing supplies
• O-silk suture on a cutting needle or a sutureless secure-
ment device
• No. 11 scalpel, used for skin entry
• 1% lidocaine without epinephrine, one 30-mL vial
• Stopcocks, one two-way and one three-way
• One Luer-Lok plug
• 500 mL of normal saline flush solution (add heparin if
prescribed or according to institutional standards)
• Single-pressure transducer system (see Procedure 75)
Figure 52-1 Counterpulsation. (Courtesy Datascope Corp, the following:
Montvale, NJ.) • Analgesics and sedatives as prescribed
• Lead apron/collar and radiation dosimeter badge (needed
when the IABP is temporarily placed on standby if procedure is performed with fluoroscopy)
(follow manufacturer’s guidelines).
❖ The central lumen of many IAB catheters provides a
means for monitoring aortic pressure.
❖ Some IAB catheters use fiberoptic technology. These
catheters have a fiberoptic sensor located at the tip of
the IAB catheter. The sensor transmits the pressure
signal to the IAB console where it is displayed as an
aortic pressure waveform.33
• Timing methods of IABP therapy vary slightly from man-
ufacturer to manufacturer. With the traditional or conven-
tional method, the IAB deflates at the QRS complex,
before isovolumetric contraction. The IAB also deflates at
the QRS complex with the real-time method. An impor-
tant principle of real timing is the duration of the balloon
deflation during cardiac systole. During real timing, the
IAB is timed to deflate at the onset of each QRS complex
and to remain deflated throughout systole. A constant dia-
stolic interval is not necessary for real timing.5,6,21,24
• The development of fiberoptic catheters and changes in
the design of the IABP console has produced timing algo-
rithms that automatically adjust timing. The algorithms
identify markers, including the initial trigger event, the
dicrotic notch, and end-diastolic pressure. The timing
algorithms are updated on a continual basis, allowing for
optimal inflation and deflation. Timing adapts to changes
in both heart rate and ECG rhythm on a beat-to-beat
basis.12,33
• The mechanics of the IABP control console vary from
manufacturer to manufacturer.
• Specific information concerning controls, alarms, trouble-
shooting, and safety features is available from each manu-
facturer and should be read thoroughly by the nurse before
use of the equipment.
EQUIPMENT Figure 52-2 Intraaortic balloon positioned in the descending tho-

racic aorta, just below the left subclavian artery but above the renal
• IABP, helium gas supply artery. (From Quaal SJ: Comprehensive intraaortic balloon coun-
• ECG and arterial pressure monitoring supplies terpulsation, ed 2, St Louis, 1993, Mosby.)
52 Intraaortic Balloon Pump Management 433
• Intravenous (IV) solutions as prescribed ❖ Divide the ankle systolic pressure by the brachial sys-
• Emergency medications and resuscitation equipment tolic pressure to determine the ankle/arm index (normal
• Vasopressors as prescribed range, 0.8 to 1.2).
• Antibiotics as prescribed • Assess the patient’s current laboratory profile, including
• Heparin infusion or dextran if prescribed complete blood count, platelet count, prothrombin time,
international normalized ratio, partial thromboplastin
PATIENT AND FAMILY EDUCATION time, and bleeding time. Rationale: Provides baseline
data. Baseline coagulation studies are helpful in determin-
• Assess patient and family understanding of IABP therapy ing the risk for bleeding. Platelet function may be affected
and the reason for its use. Rationale: Clarification or by the mechanical trauma from balloon inflation and
reinforcement of information is an expressed family need. deflation.
• Explain the standard care to the patient and family, includ- • Assess for signs and symptoms of heart failure that neces-
ing the insertion procedure, IABP sounds, frequency of sitate IABP therapy, including the following. Rationale:
assessment, alarms, dressings, need for immobility of the Physical signs and symptoms result from the heart’s
affected extremity, expected length of therapy, and param- inability to adequately contract and from inadequate coro-
eters for discontinuation of therapy. Rationale: This nary or systemic perfusion.
4
explanation encourages the patient and family to ask ques- ❖ Unstable angina
tions and prepares the patient and family for what to ❖ Altered mental status
expect. ❖ Heart rate greater than 110 beats/min
• After catheter removal, instruct the patient to report any ❖ Dysrhythmias
warm or wet feeling on the leg and any dizziness or light- ❖ Systolic blood pressure less than 90 mm Hg
headedness. Rationale: These feelings may be indicative ❖ Mean arterial pressure (MAP) less than 70 mm Hg with
of bleeding at the insertion site. vasopressor support
3
❖ Cardiac index less than 2.4
PATIENT ASSESSMENT AND ❖ Pulmonary artery occlusion pressure (pulmonary capil-
PREPARATION lary wedge pressure) greater than 18 mm Hg

❖ Decreased mixed venous oxygen saturation (Svo2)
Patient Assessment ❖ Inadequate peripheral perfusion
• Assess the patient’s medical history, specifically related to ❖ Urine output less than 0.5 mL/kg/hr
competency of the aortic valve, aortic disease, or periph-
eral vascular disease. Rationale: This assessment pro- Patient Preparation
vides baseline data regarding cardiac functioning and • Verify that the patient is the correct patient using two
identifies contraindications to IABP therapy. identifiers. Rationale: Before performing a procedure, the
• Assess the patient’s cardiovascular, hemodynamic, periph- nurse should ensure the correct identification of the patient
eral vascular, and neurovascular status. Rationale: This for the intended intervention.
assessment provides baseline data. • Ensure that the patient and family understand prepro-
• Assess the extremity for the intended IAB catheter place- cedural teaching. Answer questions as they arise, and
ment for the quality and strength of the femoral, popliteal, reinforce information as needed. Rationale: Understand-
dorsalis pedal, and posterior tibial pulses.7,29 ing of previously taught information can be evaluated and
• Assess the ankle/arm index as follows. Rationale: The reinforced.
IAB catheter is inserted into the vasculature of the extrem- • Validate that the informed consent form has been signed.
ity that exhibits the best perfusion. Also, this assessment Rationale: Informed consent protects the rights of the
provides baseline data related to peripheral blood flow, patient and makes a competent decision possible for the
which may be compromised by the IAB. patient; however, in emergency circumstances, time may
❖ Record the brachial systolic pressure with a Doppler not allow the form to be signed.
scan signal. • Perform a preprocedure verification and final time out.
❖ Locate the posterior tibial or dorsalis pedal pulse with Rationale: Ensures patient safety.
a Doppler scan signal. • Validate the patency of central and peripheral intravenous
❖ Apply the blood pressure cuff around the ankle, above access. Rationale: Central access is needed for vasopres-
the malleolus. sor administration; peripheral access is needed for fluid
❖ Inflate the cuff to 20 mm Hg above the brachial systolic administration.
pressure. • Assist the patient to a supine position. Rationale: Posi-
❖ Note the reappearance of the Doppler scan signal as tions the patient for IAB insertion.
the cuff deflates.
Procedure for Assisting with IAB Catheter Insertion

1. HH
2. PE
3. Turn on the IABP console and Provides power source and Follow the manufacturer’s
the helium gas. activates the gas that drives the recommendations.
IABP.
4. Sedate the patient as prescribed Movement of the lower extremity A knee immobilizer or a sheet placed
and as needed; the affected may inhibit insertion of the over the affected leg and tucked in
extremity may need to be catheter or contribute to catheter may minimize movement of the
restrained. kinking once the IAB is in place. affected leg.
5. Establish ECG input to the The R wave is the preferred trigger Usually, one set of ECG electrodes
IABP console and obtain an signal from which the IABP can connects to the bedside monitoring
ECG configuration with reference systole and diastole system and the second set of ECG
optimal R wave amplitude and and therefore establish inflation electrodes connects to the IABP
absence of artifact. Indirect and deflation points. console.
ECG input can be obtained via With use of a slave signal, refer to the
a “slave” of the bedside ECG bedside monitor manufacturer
to the IABP console. instructions for optimizing the ECG
and pacemaker recognition.
6. Assist with placement of Hemodynamic monitoring aids in A radial arterial catheter is commonly
hemodynamic monitoring the assessment and management inserted.27
catheters if they are not already of the patient who needs IABP
present (refer to Procedure 72). therapy.
7. Complete the IABP console Ensures adequate functioning of Models of the pump console vary.
preparation. Refer to the the IABP device. Review of manufacturer instructions is
instruction manual. (Level M*) recommended.
8. All personnel performing and Minimizes the risk of infection and
assisting with the procedure maintains standard and sterile
should apply personal and precautions.
protective sterile equipment
(e.g., masks, head covers,
goggles or face shields, sterile
gowns, and gloves).
9. Wear lead apron/collar and Lead apron/collar minimizes
radiation dosimeter badge if radiation exposure. Radiation
inserted under fluoroscopy. dosimeter badges track radiation
exposure.
10. Assist if needed with prepping Provides a sterile field and reduces
and draping the intended the transmission of
insertion site with the sterile microorganisms.
drapes.
11. Assist as needed with Makes supplies available and Catheters vary in balloon volumes.
removing the IAB catheter maintains sterility. An adequate volume is necessary to
from the sterile packing and achieve optimal hemodynamic effects
place the catheter and insertion from IABP therapy.
tray on the sterile field. Patient height may be used as a guideline
for selection of balloon volume.
Clinical judgment and patient factors,
such as patient torso length, are
considered.11

Procedure for Assisting with IAB Catheter Insertion—Continued

12. Administer a heparin bolus Anticoagulation therapy may Systemic anticoagulation therapy may
before arterial puncture, if decrease the incidence of not be used in all patients.32
clinically indicated and thromboemboli related to the
prescribed. indwelling IAB catheter.
13. Attach the supplied one-way Creates a device for removing air
valve to the Luer-tip of the from the balloon catheter.
distal end of the balloon
helium lumen.
14. Pull back slowly on the syringe Removes air from the balloon, Maintains the wrap of the balloon for
until all the air is aspirated. creating a vacuum. insertion.
15. Disconnect the syringe only, Prevents air entry back into the
leaving the one-way valve in balloon.
place.
16. Follow the manufacturer May decrease the drag on the Not all IAB catheters need lubrication.
recommendations for catheter during insertion. Review manufacturer instructions.
lubricating the catheter before
insertion. (Level M*)
17. Flush the inner lumen of the Removes air from the central If the catheter is not flushed before
IAB catheter before insertion. lumen. insertion, allow the backflow of arterial
blood before connection to the flush
system.25
Follow institutional policy or physician
or advanced practice nurse prescription
regarding the use of heparinized
normal saline solution.
18. Assist as needed with the Prepares for balloon catheter entry. Some IABs are inserted without a sheath.
introducer sheath or dilator If the IAB is inserted via the sheathless
assembly and insertion. method, only the vessel dilator is
used.9,10
19. Assist with balloon catheter Catheter placement is a necessary Some fiberoptic IABP catheters need to
insertion. part of IAB setup. be calibrated before insertion. Follow
20. Assist with removal of the Releases the vacuum and readies
one-way valve according to the the balloon for counterpulsation.
manufacturer’s
recommendations.
21. If the inner lumen of a double- Monitors the arterial pressure. Follow institutional policy or physician
lumen catheter is used to or advanced practice nurse prescription
monitor arterial pressure, attach regarding the use of heparinized
a three-way stopcock with a normal saline solution.
single-pressure transducer The inner lumen, if used, must be
system (see Procedure 75) attached to an alarm system because
connected to the monitor and undetected disconnection could result
set the alarms. in life-threatening hemorrhage.
The proximal tip of the inner lumen used
for arterial pressure monitoring is at
the level of the left subclavian artery,
not at the aortic arch; therefore, this
location is not the same as a central
line placed at the aortic root.25,26

Procedure for Assisting with IAB Catheter Insertion—Continued

22. Avoid fast flush and blood Air may enter the system during Some manufacturers and institutions
sampling from the central fast flush and also during blood recommend hourly fast flush of central
aortic lumen. sampling, resulting in air emboli. lumen lines. If fast flush is required
and prescribed, ensure that the IABP is
on standby (not pumping) during the
flush. However, the risk of air embolus
entry or dislodging a thrombus at the
lumen tip is a major concern. Refer to
institutional policy in regard to fast
flush of central lumen catheters.
23. Attach the helium tubing to the Attachment is necessary to initiate The helium tubing is packaged with the
balloon helium lumen and therapy. IAB.
connect the helium tubing to
the IABP console.
24. Follow the steps for timing, Provides for appropriate operation Many IABP consoles have features for
troubleshooting, and patient of counterpulsation. automatic timing. Refer to specific
monitoring. manufacturer’s instructions.
25. Conventional IAB:
A. Level the air-fluid interface Ensures accurate arterial pressure
of the stopcock. measurement.
B. Zero the hemodynamic Negates the effects of atmospheric
monitoring system. pressure.
26. Fiberoptic IAB:
A. Calibrate the system. Prepares the equipment.
B. Follow the manufacturer’s Prepares the equipment. Refer to specific manufacturer’s
instructions for instructions for fiberoptic IAB
calibration.23,27 catheters.
Some fiberoptic IAB catheters perform
automatic in vivo calibration.
27. Ensure that a portable chest Correct IAB catheter position must If fluoroscopy is used for insertion of the
radiograph is obtained. be confirmed to prevent catheter, a radiograph immediately
complications associated with after placement is not necessary.
Note: Temporarily place the the interference of the arterial Some patients may have hemodynamic
IABP on standby while blood supply. instability when the IABP is on
obtaining the chest radiograph. Placing the IABP on standby standby for more than a few seconds;
enhances the visibility of the assess each patient’s hemodynamic
balloon on the radiograph. response to IABP therapy.
Some IAB catheters have
radiopaque markers at the tip
and base of the IAB membrane
to identify the position of the
catheter.
28. Ensure that the IAB is secured Maintains optimal position and The IAB catheter may be sutured or a
to the patient’s skin. reduces the risk of IAB catheter sutureless securement device may be
migration. used to secure the catheter.
29. Assist as needed with applying Minimizes the risk of infection. The IAB catheter may have a sleeve to
a sterile dressing to the allow for repositioning of the IAB
catheter-insertion site. catheter under aseptic conditions.
30. Ensure sharps are discarded in Reduces the risk of injury and the
a sharp container; remove PE transmission of microorganisms;
and sterile equipment and Standard Precautions.
discard used supplies in
appropriate receptacles.
31. HH
Procedure for Timing of the IABP

1. Select an ECG lead that optimizes The R wave of the ECG is the Refer to manufacturer instructions for
the R wave. (Level M*) preferred trigger source for trigger options.
identifying the cardiac cycle.
2. Assess the timing of the IABP The arterial waveform assists in Refer to specific manufacturer’s
with the arterial waveform. identifying accurate IAB instructions for automatic timing.
inflation and deflation.23,25,26
3. Set the IABP to auto mode. The IABP console automatically Some IABP consoles have this feature.
adjusts timing of inflation and Fiberoptic catheters have a sensor at
deflation. the tip of the IAB catheter that
transmits the pressure signal back to
the IABP console, producing an
aortic pressure waveform.
Timing algorithms adjust inflation and
deflation automatically.33
4. Timing can be checked by setting Comparison can be made between
the IABP frequency to the every- the assisted and unassisted
other-beat setting (1:2 or 50%; arterial waveforms.
Fig. 52-3).
mm
Hg Diastolic
augmentation
140
Unassisted systole Assisted
systole
120
Figure 52-3 Intraaortic balloon pump frequency of 1:2. (Courtesy
Datascope Corp, Fairfield, NJ.)
100
80 Unassisted aortic
end diastolic Assisted aortic
pressure end diastolic
pressure
5. Inflation: The dicrotic notch represents

closure of the aortic valve.
A. Identify the dicrotic notch of
the assisted systolic waveform
(see Fig. 52-3).
B. Adjust inflation later to expose Identifies the landmark for accurate
the dicrotic notch. inflation.
C. Slowly adjust inflation earlier Balloon augmentation should occur A sharp V wave may not be seen in
until the dicrotic notch after the aortic valve closes.5,12,24 patients with low systemic vascular
disappears and a sharp V wave resistance.
forms (see Fig. 52-3).
D. Compare the augmented Balloon augmentation ideally is If balloon augmentation is less than the
pressure with the patient’s equal to or greater than the patient’s systolic pressure, consider
unassisted systolic pressure. patient’s unassisted systolic the possibility that the patient is
blood pressure.11 hypovolemic or tachycardic, the
balloon is positioned too low, or the
balloon volume is set too low.27
Low volume may also be the result of
an inadequate fill volume or an IAB
catheter that is too small for the
patient.

Figure 52-4 Intraaortic balloon pump inflation. A, Radial. B, Femoral.

C, Central aortic.
Procedure for Timing of the IABP—Continued

E. Adjust inflation if needed. Necessary to achieve optimal Timing of inflation varies slightly
diastolic augmentation. depending on the location of the
arterial catheter and resulting
physiological delays.24,26
Radial: Inflate 40–50 ms before the
dicrotic notch.
Femoral: Inflate 120 ms before the
dicrotic notch (Fig. 52-4).
The radial artery is recommended for
use for pressure monitoring for IABP
timing.24,26
6. Deflation:
A. Identify the assisted and These landmarks are important in IABP frequency is set at 1:2 (50%).
unassisted aortic end-diastolic determination of accurate IAB
pressures and the assisted and deflation.
unassisted systolic pressures
(see Fig. 52-3).5,6
B. Set the balloon to deflate so The assisted systolic pressure is Reduction of afterload decreases the
that the assisted aortic end- less than the unassisted systolic energy required by the heart during
diastolic pressure is as low as pressure as a result of a decrease systole.
possible (lower than the in afterload, thus reducing the Afterload reduction without
patient’s unassisted diastolic myocardial workload.12,24 diminishment of diastolic
pressure) while still maintaining augmentation is important to
optimal diastolic augmentation achieve.
and not impeding the next
systole (the assisted systole).
1:1 IABP Frequency
mm
Hg
Diastolic
140
augmentation
Assisted
systole Assisted
120 systole
100
80 Assisted
aortic end-diastolic Figure 52-5 Correct intraaortic balloon pump timing (1:1). (Courtesy Data-
pressure scope Corp, Fairfield, NJ.)
Procedure for Timing of the IABP—Continued

7. Set the IABP frequency to 1:1 Ensures that each heartbeat is
(100%; Fig. 52-5). assisted.
8. Assess timing every hour, Inappropriate timing prevents Many IABP models use algorithms to
whenever the heart rate changes effective IABP therapy. automatically adjust timing for
by more than 10 beats/min, and changes in heart rate and rhythm.
when the rhythm changes. Refer to the specific manufacturer
guidelines for a description of
automatic timing modes and their
specific features.
9. Assess and intervene to correct Ensures accurate timing and
inappropriate timing. optimal functioning of the IABP.
A. Problem: early inflation (Fig. Inflation occurs before closure of Early inflation is the worst timing
52-6). Intervention: move the aortic valve, leading to error, reducing left-ventricular
inflation later. premature aortic valve closure, performance and IABP efficiency.12
increased left-ventricular volume,
and decreased stroke volume.12
B. Problem: late inflation (Fig. A delay in inflation leads to a
52-7). Intervention: adjust decrease in coronary artery
inflation earlier. perfusion.
C. Problem: early deflation (Fig. Deflation occurs before the aortic Note the sharp diastolic wave after
52-8). Intervention: adjust valve opens, leading to decreased augmentation and the increase in the
deflation later. balloon augmentation and less or assisted systolic pressure.
no afterload reduction; coronary
artery perfusion may also be
decreased.
D. Problem: late deflation (Fig. Deflation occurs after the aortic Note the delayed diastolic wave after
52-9). Intervention: adjust valve has opened, leading to an augmentation and the diminished
deflation earlier. increase in the aortic end- assisted systole.
diastolic pressure and an increase Late deflation is identified by a
in afterload. diminished assisted systolic pressure,
an increase in heart rate, an increase
in filling pressures, a decrease in
cardiac output and cardiac index, and
an increased afterload. Maintaining a
reliable trigger minimizes the risk of
late deflation.5,6,11,23
Timing Errors
Early Inflation
Diastolic
Inflation of the IAB prior augmentation
Unassisted
to aortic valve closure systole
Assisted
Waveform Characteristics: systole
• Inflation of IAB prior to
dicrotic notch
• Diastolic augmentation
encroaches onto systole
(may be unable to
distinguish)
Assisted
Physiologic Effects: aortic end diastolic
• Potential premature pressure
closure of aortic valve
• Potential increased in LVEDV and
LVEDP or PCWP
• Increased left ventricular wall stress
or afterload
• Aortic regurgitation
• Increased MVO2 demand Figure 52-6 Early inflation. (Courtesy Datascope Corp, Fairfield, NJ.)
Timing Errors
Late Inflation
Unassisted
Inflation of the IAB markedly systole Diastolic Assisted
after closure of the aortic valve augmentation
systole
Waveform Characteristics:
• Inflation of the IAB after
the dicrotic notch Dicrotic
• Absence of sharp V notch
• Suboptimal diastolic
augmentation Assisted
aortic end-
Physiologic Effects: diastolic
• Suboptimal coronary artery pressure
perfusion Figure 52-7 Late inflation. (Courtesy Datascope Corp, Fairfield, NJ.)
Timing Errors
Early Deflation
Premature deflation of the IAB Diastolic

during the diastolic phase augmentation
Assisted
Waveform Characteristics: systole
• Deflation of IAB is seen as a
sharp drop following diastolic
augmentation
• Suboptimal diastolic
augmentation
• Assisted aortic end diastolic
pressure may be equal to Unassisted
Assisted
or less than the unassisted aortic end-
aortic end-
aortic end diastolic pressure diastolic
diastolic
• Assisted systolic pressure pressure
pressure
may rise
Physiologic Effects:
• Suboptimal coronary perfusion
• Potential for retrograde coronary
and carotid blood flow
• Angina may occur as a result of retrograde
coronary blood flow
• Suboptimal afterload reduction Figure 52-8 Early deflation. (Courtesy Datascope Corp, Fairfield,
• Increased MVO2 demand NJ.)
Timing Errors
Late Deflation
Deflation of the IAB late in

diastolic phase as aortic valve
is beginning to open
Diastolic
Waveform Characteristics: augmentation
• Assisted aortic end-diastolic Unassisted
pressure may be equal to systole
Prolonged rate
or greater than the
of rise of
unassisted aortic end
assisted systole
diastolic pressure
• Rate of rise of assisted Widened
systole is prolonged appearance
• Diastolic augmentation
may appear widened Assisted
aortic end-
Physiologic Effects: diastolic
• Afterload reduction is essentially pressure
absent
• Increased MVO2 consumption due
to the left ventricle ejecting against
a greater resistance and a prolonged
isovolumetric contraction phase
• IAB may impede left ventricular
ejection and increase the afterload Figure 52-9 Late deflation. (Courtesy Datascope Corp, Fairfield, NJ.)
Procedure for Balloon-Pressure Waveform

1. Determine whether the IABP Helium is shuttled in and out of the IAB Refer to the specific manufacturer’s
console has a balloon-pressure catheter, and the balloon-pressure instructions regarding the
waveform. waveform represents this movement. balloon-pressure waveform.
2. Assess the balloon-pressure Reflects pressure that is in the IAB.
waveform.
3. Determine whether the balloon A normal balloon-pressure waveform
pressure waveform is normal reflects that the IAB is inflating and
(Fig. 52-10). A normal balloon deflating properly.22
pressure waveform:
A. Has a fill pressure (baseline Reflects pressure in the tubing between
pressure) slightly above the IAB and the IABP driving
zero. mechanism.
B. Has a sharp upstroke. Occurs as helium inflates the IAB
catheter.
C. Has peak inflation artifact. This overshoot pressure artifact is
caused by helium gas pressure in the
pneumatic line.1
D. Has a pressure plateau. This plateau is created as the IAB The plateau indicates the length of
remains inflated during diastole. time of inflation and whether full
inflation (volume) has been
delivered to the IAB. If no
plateau pressure is found, the
IAB may not be fully inflated.
E. Has a rapid deflation. Helium is quickly shuttled from the
IAB.
Figure 52-10 Normal balloon gas waveform. 1, zero baseline; 2, fill

pressure; 3, rapid inflation; 4, peak inflation artifact; 5, plateau pressure
or inflation plateau pressure; 6, rapid deflation; 7, peak deflation pressure
and return to fill pressure. (Courtesy Arrow International.)

100 10:10 HR 102 BPM

ECG Pattern Trigger
DEC PSP 71 mM
250
08 PDP 86 MM
0
EDP 39 MM
0
MAP 49 MM
B
Figure 52-11 A, Balloon-pressure waveform superimposed on the arterial pressure waveform.
B, Actual recording of an arterial pressure waveform (top) and balloon gas waveform (bottom) from
a patient with balloon pump. (Courtesy Arrow International.)
Procedure for Balloon-Pressure Waveform—Continued

F. Has a negative deflection Helium returns to the IABP console and
below baseline and then then stabilizes within the system.
returns to baseline.
4. Compare the balloon-pressure Demonstrates the relationship between Note the similarity in the width of
waveform with the arterial the balloon-pressure waveform and the balloon-pressure waveform
pressure waveform (Fig. 52-11). the arterial waveform. Reflects the and the augmented arterial
effect of the balloon on the waveform.18
augmented arterial pressure.
5. Determine whether the balloon Abnormal balloon-pressure waveforms Refer to the specific manufacturer’s
pressure waveform meets the may indicate restriction to helium instructions regarding
previous description. shuttle. troubleshooting abnormal
balloon-pressure waveforms.
Procedure for Troubleshooting

1. Atrial fibrillation:
A. Assess and treat the underlying The underlying cause of the
cause. dysrhythmia should be treated.
B. Set the IABP to inflate and Inflation of the IAB should correspond
deflate most of the patient’s to the diastolic interval of each
beats. cardiac cycle.
The IAB automatically deflates on the
R wave.
C. Refer to manufacturer’s Select a mode on the IABP console The real-time method of timing may
instructions for the appropriate for optimal R wave tracking. track dysrhythmias better than
IABP console settings for traditional or conventional IABP
atrial fibrillation (e.g., the timing.22
atrial fibrillation trigger mode).
Procedure for Troubleshooting—Continued

2. Tachycardia: Because diastole is shortened during
A. Assess and treat the underlying The underlying cause of the tachycardia, the IAB inflation time
cause. tachycardia should be treated. also is shortened.
B. Set the timing and the IAB timing and frequency should be The IABP may need to be changed to a
frequency of the IABP to set to optimize coronary perfusion 1:2 frequency.
optimize hemodynamic and afterload reduction. Pumping every other beat may improve
response. the patient’s hemodynamic status.
Some IABPs with automatic timing
can track rates as high as
220 beats/min.
3. Asystole:
A. Switch the trigger to arterial This trigger can be used if an Follow advanced cardiac life support
pressure. arterial pressure is generated from (ACLS) standards for emergency
chest compressions. care.
B. If the IABP console is not in Sets the IABP timing. Refer to the manufacturer’s manual.
the auto-operation mode: Preliminary research suggests that
i. Set inflation to provide when used during cardiopulmonary
diastolic augmentation. resuscitation, IAB counterpulsation
ii. Set deflation to occur increases cerebral and coronary
before the upstroke of the perfusion.2,11
next systole.
C. If chest compressions do not Refer to manufacturer’s guidelines for
provide an adequate trigger: recommendations for minimal
i. Turn or push the control to The internal trigger keeps the IAB balloon volume.
internal trigger. catheter moving so that clot
formation is minimized.22
ii. Set the rate at Maintains consistent movement of
60–80 beats/min. IAB catheter.
iii. Set the IABP frequency to A 1:2 frequency is adequate to
1:2. prevent thrombus formation on
the IAB catheter.
iv. Turn the balloon Slight inflation and deflation of the
augmentation down to 50%. IAB catheter prevents clot
formation.
D. If the IABP console is in the Sets the IABP timing and maintains
auto-timing mode, the console consistent movement of the IAB
automatically attempts to catheter.
self-time if an arterial pressure
is generated, or switches to an
internal trigger.
4. Ventricular tachycardia or
ventricular fibrillation:
A. Assess and treat the underlying The underlying cause of the
cause. tachycardia should be treated.
B. Cardiovert or defibrillate as Attempts to convert the Follow ACLS standards for emergency
necessary (see Procedures 35 dysrhythmia. care.
and 36). Ensure that personnel are cleared from
the patient and equipment before
cardioversion or defibrillation.
The IABP console is electrically
isolated.
5. Loss of vacuum or IABP failure:
A. Check and tighten the A loose connection may contribute
connections on the pneumatic to a loss of vacuum.
tubing.
Procedure for Troubleshooting—Continued

B. Check the compressor power Ensures that power is available to
source. drive the helium.
C. Hand inflate and deflate the Prevents clot formation along the Refer to specific manufacturer’s
balloon every 5 minutes if dormant balloon. guidelines for manually inflating and
necessary. (Level M*) deflating the IAB.
Ensure that the correct syringe is kept
with the IABP console for this
emergency; check manufacturer’s
guidelines for frequency of hand
inflation.
D. Change the IAB console. Establishes a power source and
(Level M*) effective IABP therapy.
6. Suspected balloon perforation:
A. Observe for loss of Helium may be gradually leaking Set the alarm limits so the alarms
augmentation. from the balloon catheter. sound with a decrease of 10 mm Hg
in diastolic augmentation.
B. Check for blood in the balloon Blood or any discoloration in the It is possible for a balloon leak to be
lumen tubing. helium tubing indicates that the self-sealing as a result of the surface
balloon has perforated and that tension between the inside and the
arterial blood is present. outside of the IAB membrane. This
may be evidenced by the presence of
dried blood in the balloon lumen
tubing. The dried blood may appear
as a brownish, coffee-ground–like
substance.
C. Assess for changes or lack of a The balloon-pressure waveform may
normal balloon-pressure be absent if the balloon is unable
waveform. to retain helium, or the pressure
plateau may gradually decrease if
the IAB is leaking helium.
7. Balloon perforation:
A. Place the IABP on standby. Prevents further IAB pumping and Some IABP consoles automatically
continued helium exchange. shut off if a leak is detected. The
IAB catheter should be removed
within 15–30 minutes.8
B. Clamp the IAB catheter. Prevents arterial blood backup.
C. Disconnect the IAB catheter Prevents blood from backing up into
from the IABP console. the IABP console.
D. Notify the physician or The IAB catheter needs to be If the IAB leak has sealed itself off,
advanced practice nurse. removed or replaced immediately. this may result in entrapment of the
IAB in the vasculature. Surgical
removal may be necessary.
E. Prepare for IAB catheter The IAB catheter should not lie Do not manually inflate and deflate the
removal or replacement. dormant for longer than 30 IAB if balloon perforation is
minutes. suspected. Perforation of a balloon
membrane may indicate that the
patient’s vascular condition may
induce abrasion or perforation in
subsequent balloon membranes.
F. Discontinue anticoagulation Clotting occurs more readily if
therapy as prescribed. anticoagulation therapy is stopped
(necessary if removing the
catheter).

Procedure for Weaning and IAB Catheter Removal

1. HH
2. PE
3. Assess clinical readiness for Optimal clinical and Patient hemodynamic status should be
weaning. hemodynamic parameters optimal before weaning from IABP
validate readiness for weaning. therapy.
Signs of clinical readiness include the
following: no angina, heart rate <110
beats/min, absence of unstable
dysrhythmias, MAP >70 mm Hg with
minimal or no vasopressor support,
pulmonary artery occlusion pressure
<18 mm Hg, cardiac index >2.4 mixed
venous oxygen saturation between
60% and 80%, capillary
refill <2 seconds, and urine output
>0.5 mL/kg/hr.
4. Change the assist ratio to 1:2 The length of time required to Follow physician or advanced practice
(50%), and monitor the patient’s wean from IABP therapy nurse prescription or institutional
response for 1–6 hours, as depends on the hemodynamic policy on IABP weaning.
prescribed, or per the response of the patient and the
institution’s protocol. length of time the patient has
received IABP therapy.13,29
5. If hemodynamic parameters IABP consoles vary in assist Follow physician or advanced practice
remain stable, further change the ratios. nurse prescription or institutional
ratio (depending on the patient policy on IABP weaning.
and the balloon-console assist
frequencies, or as prescribed).
6. Discontinue heparin or dextran Decreases the likelihood of
4–6 hours before IAB catheter bleeding after balloon removal.
removal, or reverse heparin with
protamine (as prescribed) just
before catheter removal.
7. Turn the IABP to standby or off Ensures deflation of the IAB The patient’s arterial pressure collapses
and disconnect the IAB from the catheter. the balloon membrane in preparation
console. for withdrawal.
8. Assist with removing sutures or Prepares for IAB removal.
the sutureless securement device.
9. Assist the physician or advanced Facilitates removal. The IAB catheter is not withdrawn into
practice nurse with removal of the sheath but removed as an entire
the percutaneous catheter. unit to avoid shearing the balloon.
10. Ensure that pressure is held on Ensures that hemostasis is A femoral compression system can be
the insertion site for 30–45 obtained and decreases the used to achieve hemostasis (see
minutes after the IAB catheter is incidence of bleeding and Procedure 76).
withdrawn. hematoma formation. Pressure may be needed for a longer
period of time if the patient has been
receiving anticoagulant therapy or if
coagulation study results are abnormal.
11. Assess the insertion site for Assists in the detection of
signs of bleeding or hematoma bleeding.
formation before application of a
sterile pressure dressing.
12. Apply a pressure dressing to the Minimizes bleeding from the
insertion site for 2–4 hours or as insertion site.
prescribed.
Procedure for Weaning and IAB Catheter Removal—Continued

13. Obtain vital signs and Determines patient stability or
hemodynamic parameters every instability.
15 minutes × 4, every 30
minutes × 2, then every hour as
the patient’s condition warrants,
or as prescribed.
14. Assess the quality of perfusion Removal of the IAB catheter may
to the decannulated extremity dislodge thrombi on the
immediately after removal and catheter and lead to arterial
every 1 hour × 2, then every 2 occlusion.
hours, or as prescribed.
15. Maintain immobility of the Promotes healing and decreases
decannulated extremity and stress at the insertion site.
maintain bed rest with the head
of the bed no greater than 30
degrees for 8 hours, as
institutional protocol.
supplies in appropriate microorganisms and body
receptacle. secretions; Standard
Precautions.
17. HH

• Increased myocardial oxygen supply • Impaired perfusion to the extremity with the IAB
• Decreased myocardial oxygen demand catheter in place
• Increased cardiac output • Balloon perforation
• Increased tissue perfusion, including cerebral, renal, • Inappropriate IAB placement
and peripheral circulation • Pain
• Bleeding or coagulation disorders
• Aortic dissection
• Infection

interventions.
1. Perform systematic
cardiovascular, peripheral
vascular, and hemodynamic
assessments every 15–60
minutes as patient status requires
or as prescribed.
A. Level of consciousness Assesses for adequate cerebral • Change in level of consciousness
perfusion; thrombi may develop
and dislodge during IABP therapy;
the IAB may migrate, decreasing
blood flow to the carotid arteries.
B. Vital signs and pulmonary Demonstrates effectiveness of IABP • Unstable vital signs
artery pressures therapy. • Significant changes in
hemodynamic pressures
• Lack of response to IABP therapy

C. Arterial and balloon pressures Ensures effectiveness of IABP timing • Difficulty achieving effective IABP
and therapy. therapy
D. Cardiac output, cardiac Demonstrates effectiveness of IABP • Abnormal cardiac output, cardiac
index, and systemic vascular therapy. index, and systemic vascular-
resistance values resistance values
E. Circulation to extremities Determines peripheral perfusion. If • Capillary refill >2 seconds
reportable conditions are found, • Diminished or absent pulses (e.g.,
they may indicate catheter or antecubital, radial, femoral,
embolus obstruction of perfusion to popliteal, tibial, pedal)
the extremity. Specifically, • Color pale, mottled, or cyanotic
decreased perfusion to the left arm • Diminished or absent sensation
may indicate misplacement of the • Pain
IAB catheter.2,8,15,29 • Diminished or absent movement
• Cool or cold to the touch
F. Urine output Determines perfusion to the kidneys. • Urine output <0.5 mL/kg/hr
2. Assess heart and lung sounds Abnormal heart and lung sounds may • Abnormal heart and lung sounds
every 4 hours and as needed. indicate the need for additional
treatment.
Special note: When the patient’s
condition permits, place the IABP
on standby to accurately auscultate
heart and lung sounds because
IABP therapy creates extraneous
sounds and impairs heart and lung
sound assessment.
3. Maintain the head of the bed at Prevents kinking of the IAB catheter
less than 45 degrees. and migration of the catheter.
4. Monitor for signs of balloon In the event of balloon perforation, a • Blood or brown flecks in the tubing
perforation by assessing the very small amount of helium could • Loss of IABP augmentation
balloon tubing on a regular basis be released into the aorta, • Control-console alarm activation
for evidence of discoloration or potentially causing an embolic (e.g., gas loss)
blood in the tubing. event. Because of pressure
gradients in the aorta, blood is
more likely to enter the balloon
membrane and be dehydrated by
the helium.
5. Maintain accurate IABP timing. If timing is not accurate, cardiac • Signs and symptoms of
output may decrease rather than hemodynamic instability
increase.
6. Log-roll the patient every 2 Promotes comfort and skin integrity
hours. Prop up pillows to and prevents kinking of the IAB
support the patient and to catheter. Special note: log-rolling
maintain alignment. Consider may not be tolerated in patients
use of pressure-relief devices. with severe hemodynamic
(Level E*) compromise; low-pressure beds are
necessary for these patients.
Low-pressure beds can decrease
the occurrence of pressure ulcers in
patients who need IABP therapy.4,25


7. Immobilize the cannulated Prevents dislodgment and migration • Alteration in skin integrity
extremity with a draw sheet of the IAB catheter. • Alteration in peripheral perfusion
tucked under the mattress or Special note: assess skin integrity and
with a soft ankle restraint or a perfusion distal to the restraint
knee immobilizer as prescribed. every hour.
8. Initiate passive and active Prevents venous stasis and muscle
range-of-motion exercises every atrophy.
2 hours to extremities that can
be mobilized.
9. Assess the area around the IAB IAB catheter inflation and deflation • Bleeding at insertion site
catheter insertion site every 2 traumatizes red blood cells and • Hematoma at insertion site
hours and as needed for evidence platelets.
of hematoma or bleeding.
10. Maintain anticoagulation therapy Prophylactic anticoagulation therapy • Abnormal coagulation study results
as prescribed; monitor may be used to prevent thrombi • Abnormal hemoglobin and
coagulation studies. and emboli development. hematocrit study results
Anticoagulation therapy may alter
hemoglobin, hematocrit, and
coagulation values.32
11. Monitor patient for systemic Hematologic and coagulation profiles • Bleeding from IAB insertion site
evidence of bleeding or may be altered as a result of blood • Bleeding from incisions or mucous
coagulation disorders. loss during balloon insertion, membranes
anticoagulation, and platelet • Petechiae or ecchymosis
dysfunction as a result of • Guaiac-positive nasogastric aspirate
mechanical trauma by balloon or stool
inflation and deflation.32 • Hematuria
• Decreased hemoglobin or
hematocrit
• Decreased filling pressures
• Increased heart rate
• Retroperitoneal hematoma
• Pain in the lower abdomen, flank,
thigh, or lower extremity
12. Follow institutional standards for Promotes comfort. • Continued pain despite pain
13. Replace gauze dressings at the Decreases the incidence of infection • Signs or symptoms of infection
IAB catheter site every 2 days and allows an opportunity for site
and transparent dressings at least assessment. Although guidelines do
every 7 days. Cleanse the site not exist specifically for IAB site
with an antiseptic solution (e.g., dressings, the Centers for Disease
2% chlorhexidine solution). Control and Prevention (CDC)19
(Level D*) recommend replacing invasive line
dressings when the dressing
becomes damp, loosened, or soiled,
necessary.

14. Assess for balloon migration. The IAB should be positioned 2 cm • Signs of possible subclavian artery
below the left subclavian artery occlusion: unequal or absent radial
and just above the renal arteries. If pulse and dampening or loss of the
the IAB migrates proximally, it arterial pressure waveform in the
may occlude the subclavian or ipsilateral radial artery (radial
carotid arteries. If the IAB migrates artery on the same side as the IAB
too low, it could occlude the renal catheter)
or mesenteric arteries. • Signs of possible carotid artery
occlusion include change in level
of consciousness and orientation or
unilateral neurological deficit
• Signs of renal artery occlusion:
oliguria or anuria, back or flank
pain, nausea, and anorexia
• Signs of mesenteric artery
occlusion: abdominal pain,
diarrhea, nausea, and decreased
bowel sounds
15. Identify parameters that Close observation of the patient’s • No angina
demonstrate clinical readiness to tolerance to weaning procedures is • Heart rate <110 beats/min
wean from IABP therapy. necessary to ensure that the body’s • Absence of unstable dysrhythmias
oxygen demands can be met. The • MAP >70 mm Hg with little or no
presence of these reportable vasopressor support
conditions indicates that • Pulmonary artery occlusion
consideration should be given to pressure <18 mm Hg
weaning the patient from the IABP. • Cardiac index >2.4
• Svo2 between 60% and 80%
• Capillary refill <2 seconds
• Urine output >0.5 mL/kg/hr
Documentation
• Patient and family education • Assessment of pain, interventions, and response to
• Informed consent interventions
• Universal protocol requirements • Confirmation of placement (e.g., chest radiograph)
• Insertion of the IAB catheter (including size of • Insertion site assessment
catheter used and balloon volume) • Hemodynamic status
• Peripheral pulses and neurovascular assessment of the • IABP pressures (unassisted end-diastolic pressure,
affected extremity unassisted systolic pressure, balloon-augmented
• Any difficulties with insertion pressure, assisted systolic pressure, assisted end-
• IABP frequency diastolic pressure, and MAP)
• Patient response to the procedure and to IABP • Occurrence of unexpected outcomes
therapy • Additional nursing interventions taken

52 Intraaortic Balloon Pump Management 449.e1
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PROCEDURE
53
Ventricular Assist Devices
Mark Puhlman and Angela Bingham
PURPOSE: Ventricular assist devices, depending on the device, can be used for
cardiogenic shock and postcardiotomy support to allow for myocardial recovery, for
bridge to cardiac transplantation, or for destination therapy (permanent implantation
in those patients who are not transplant candidates). Temporary devices are used
as a bridge from one device to another, as a bridge to a decision for cardiac
transplant, or as a bridge to recovery. Patients should be in New York Heart
Association class IIIB or IV heart failure, have a left ventricular ejection fraction of
25% or less, an oxygen treadmill test of 14 or less, or be inotrope-dependent for 14
days or intraaortic balloon pump–dependent for 7 days.1–4,10,14–17,25,27,28
PREREQUISITE NURSING demonstrated competence in testing coagulability and

KNOWLEDGE titrating medication to maintain optimal anticoagulation
according to institutional standards is required.
• Understanding of the normal anatomy and physiology of • Indications for VAD therapy include the following:5
the cardiovascular, peripheral vascular, and pulmonary ❖ Inability to wean from cardiopulmonary bypass
systems is important. ❖ Bridge to cardiac transplant
• Understanding of the management of heart failure is ❖ Destination therapy: New York Heart Association class
essential. IIIB or IV status in a patient whose condition does not
• Knowledge of the principles of hemodynamic monitoring, respond to optimal medical therapy and who is not a
cardiopulmonary bypass, electrophysiology and dysrhyth- transplant candidate18,19
mias, and coagulation is needed. ❖ Bridge to myocardial recovery after cardiogenic shock
• Clinical and technical competence related to use of ven- • Relative contraindications of VAD therapy include the
tricular assist devices (VADs) is necessary. following4,25:
2
• Advanced cardiac life support knowledge and skills are ❖ Body surface area (BSA) less than 1.2 m (HeartMate
needed. II left ventricular assist device [LVAD; St. Jude/
• Knowledge is necessary of the complications of VAD Thoratec Corporation, Pleasanton, CA])23
2
therapy, including, but not limited to, bleeding, cardiac ❖ BSA less than 1.2 m (HeartWare left ventricular
tamponade, right ventricular failure, myocardial infarc- assist device, HeartWare Corporation, Framingham,
tion, cardiac arrhythmias, hepatic dysfunction, pulmonary MA)6
4,25
dysfunction, renal dysfunction, infection, neurological ❖ Patients with irreversible end-stage organ damage
dysfunction, thrombosis, and VAD malfunction.1,2,8,9 ❖ Unrepairable ventricular septal defect or free wall rupture
• Knowledge of the effect of preload, afterload, right ven- with those receiving an LVAD alone4,25
tricular failure, cardiac tamponade, and cardiac dysrhyth- ❖ Comorbidity that limits life expectancy to less than 3
mias on the function of the device is necessary. years (cancer, liver disease, etc.)4,25
• Knowledge of the interaction between the patient and the ❖ Active infection (valvular endocarditis, implantable
device is needed. cardioverter defibrillator [ICD] infection with bactere-
• Specific information concerning controls, alarms, trouble- mia)4,25
shooting, and safety features is available from each manu- ❖ Diabetes-related proliferative retinopathy, very poor
facturer and should be read thoroughly by the nurse before glycemic control, or severe nephropathy, vasculopathy,
use of the equipment. Please refer to the operator’s instruc- or peripheral neuropathy4,25
4,25
tions for use (IFU), which are available for each system, ❖ Active pregnancy
for more details. ❖ Active psychiatric illness that requires long-term insti-
• Knowledge and understanding of anticoagulation needs tutionalization or a patient’s inability to care for or
specific to the VAD that is being used are necessary, and maintain the device4,25
❖ Neuromuscular disease that severely compromises a

patient’s ability to use and care for the external system
practice nurses, and other healthcare professionals (including critical care components or to ambulate or exercise4,25
nurses) with additional knowledge, skills, and demonstrated competence per ❖ Psychosocial and cognitive conditions may limit the
professional licensure or institutional standard. use of a VAD except in bridge to recovery because the
450
53 Ventricular Assist Devices 451
patient needs to have the cognitive skills to manage lower housing communicates with the controller and
the VAD4,25 contains a continuous flow of saline to decrease the risk
4,25
❖ Significant caregiver burden or lack of any caregiver of thrombus formation and provide lubrication.21
4,25
❖ Active substance abusers ❖ Using the ProtekDuo RA-PA catheter, percutaneous
❖ Medical noncompliance right ventricular support can be achieved.
• Impella (temporary):11–13 • The HeartMate II Left Ventricular Assist System (LVAS)
❖ The Impella systems are nonpulsatile microaxial flow (Thoratec/St Jude Corporation, Pleasanton, CA):23
20
devices that deliver 2.5 L (Impella LP 2.5), 3.5 L (Impella ❖ The HeartMate II LVAS is a continuous axial flow
CP), or 5.0 L (Impella LP 5.0) of blood flow.2 pump and is approved as a bridge to transplant and
❖ The pumps are implanted percutaneously or via destination therapy in patients with advanced heart
sternotomy. failure.
❖ The Impella 5.0 is implanted directly via a sternotomy ❖ The LVAD is implanted just below the diaphragm in
or via a surgical cut down to expose the femoral artery. the abdomen.
❖ Once in position, the Impella sits across the aortic ❖ The HeartMate II is made of titanium and weighs
valve, with the inlet area in the left ventricle and the approximately 160 g. Blood flows from the left ven-
outlet area in the ascending aorta. tricle through the pump and back to the patient’s cir-
❖ Transthoracic echocardiography is used to confirm culation via the outflow graft.
proper placement. ❖ Continuous flow is generated by a small rotor inside
❖ The console continuously monitors pump placement the pump. The speed of the pump is set by the LVAD
and alerts the physician, advanced practice nurses, and team and does not change in response to preload.
other healthcare professionals to issues with catheter ❖ A driveline is passed underneath the skin and exits the
displacement and other alarm states. right or left upper quadrant of the abdomen. The drive-
❖ The Impella RP has been approved in the United States line connects the LVAD to a controller and a power
as a humanitarian device exception (HDE) for right- source (batteries or power module).
sided support. • The HeartWare LVAS (HeartWare Corporation, Framing-
• The CentriMag Ventricular Assist Device (St. Jude/ ham, MA):6
Thoratec Corp., Pleasanton, CA) (temporary)24,26: ❖ The HeartWare Left Ventricular Assist System consists
❖ The CentriMag VAD is a continuous centrifugal flow of a continuous flow centrifugal force blood pump
device that delivers up to 10 L of blood flow.24 with an integrated, partially centered inflow cannula; a
❖ The pump is placed via catheters by a thoracotomy 10-mm diameter gel-impregnated polyester outflow
approach.24 graft; and a percutaneous driveline.
❖ The CentriMag operates via an electromagnetic rotor ❖ The pump has one moving part, an impeller, which
that operates at a range of 0 to 5500 rpm.24 spins blood to generate up to 10 L/min of flow.
24
❖ The pump is driven by a primary console. Intraopera- ❖ A short integrated inflow cannula is inserted into the
tive cannulation can be accomplished via left atrial left ventricle, and the outflow graft connects the pump
or left ventricular cannulation (inflow) to the aorta to the aorta.
(outflow), accomplishing left ventricular support for ❖ The device is implanted in the thoracic cavity.
short-term use.24 ❖ The controller is a microprocessor unit that controls
❖ Intraoperative cannulation can also be accomplished and manages the HeartWare System operation. The
via right atria (inflow) to pulmonary artery (outflow), controller sends power and operating signals to the
accomplishing right ventricular support for short-term blood pump and collects information from the pump.
use.24 ❖ The device is approved as a bridge to transplant in
❖ Using two devices, biventricular support can be patients with advanced heart failure listed for a cardiac
accomplished.24 transplant. This device is under study for permanent
• The Tandem Heart (TandemLife Corp., Pittsburgh, PA) implantation (destination therapy).
(temporary):21,22
❖ The Tandem Heart is a continuous centrifugal flow EQUIPMENT
device that delivers up to 5 L of blood flow at
7500 rpm.21 This device is a left-atrial-to-femoral • VAD drive console/unit or monitor
bypass system for short-term use. • Connection cables (specific to device)
21
❖ The pump is implanted via a percutaneous approach. • Backup drive console/unit/monitor, batteries, and controller
❖ A 21-Fr cannula is inserted from the right atrium via a • Device-specific equipment
transseptal cannulation to the left atrium. Blood is • Impella Percutaneous Ventricular Assist Device
drawn into the centrifugal pump and returned to the ❖ Impella Device
femoral artery.21 ❖ Automated Impella controller
❖ The Tandem Heart operates via an electromagnetic ❖ Impella purge cassette
rotor that operates at a range of 3000 to 7500 rpm.21 ❖ Purge fluid (dextrose/heparin solution prepared by phar
21
❖ The pump is driven by a microprocessor controller. macy)
❖ The Tandem Heart has a dual-chamber pump. The ❖ Normal saline 500 mL infusion bag
upper housing allows for the movement of blood. The ❖ Straight IV tubing (nonpump tubing)
❖ Pressure bag
❖ Knee immobilizer (if Impella is placed femorally) PATIENT AND FAMILY EDUCATION
❖ Sterile gauze
❖ Straight IV tubing in the cage of the Impella controller • Assess patient and family understanding of VAD therapy
❖ Connector cable and the reason for its use. Rationale: Clarification or
❖ Impella “instructions for use” with alarm explanation reinforcement of information is an expressed patient and
• Centrimag Ventricular Assist Device family need during times of stress and anxiety.
❖ CentriMag device • Explain the environment and planned care to the patient
❖ Automated CentriMag dontroller and family, including the frequency of assessment, sounds
❖ Backup CentriMag controller and function of equipment, placement of the device,
❖ Two chest tube clamps explanation of alarms, dressings and therapy, anticoagula-
❖ CentriMag “instructions for use” with alarm explanation needs, decreased or assisted mobility, and parameters
tion for discontinuation of therapy. Rationale: This communi-
• TandemHeart Ventricular Assist Device cation provides information and encourages the patient
❖ TandemHeart device and family to ask questions or voice concerns or fears
❖ TandemHeart controller related to the therapy.
❖ Backup TandemHeart controller • Before surgery, a meeting with another patient on a VAD
❖ 1000-mL bag of normal saline (NS) solution may be helpful for the patient and family, if both patients
❖ TandemHeart infusion tubing agree. Rationale: Meeting with another patient with a
❖ Two chest tube clamps VAD provides social support.
❖ Kelly clamp • If appropriate, begin discharge teaching to include opera-
❖ TandemHeart “instructions for use” with alarm expla- tion of the VAD, dressing changes, battery changes, place-
nation ment of self on and off of the battery and the power module,
• Heartmate II and Heartware changing of the controller, and appropriate bathing tech-
❖ Power base unit (power module) with cable niques with use of shower equipment (when approved
❖ Battery charger by the VAD team). It is recommended that patients and
❖ System monitor their families be provided with comprehensive education
❖ Display monitor regarding the care and maintenance of their VAD with the
❖ Controller expectation they will be able to perform a return demon-
❖ Controller cell stration of these key components. Rationale: This teach-
❖ Large batteries ing provides information and ensures that the patient will
❖ Battery clips be safe at home. It also allows the patient and family to
Additional equipment, to have available as needed, includes ask questions as needed.
the following:
• Emergency equipment and medications
• Knee immobilizer PATIENT ASSESSMENT AND
• Sterile dressing supplies for acute dressing change: PREPARATION
❖ Preslit 4 × 4 sterile gauze pads (alternatively, round
preslit island dressing) Patient Assessment
❖ Sterile 2 × 2 sterile gauze • Assess the patient’s medical history, history of heart
❖ Chrorprep applicator, 3 mL in size failure, competency of the aortic/pulmonic valves, com-
❖ Tape, 1-inch and 2-inch petency of the mitral/tricuspid valves, pulmonary hyper-
❖ Sterile gloves tension, right ventricular function, left ventricular function,
❖ Head covers (until driveline ingrowth occurs) and peripheral vascular disease. Rationale: This assess-
❖ Masks (until driveline ingrowth occurs) ment provides baseline data regarding cardiac functioning
❖ Sterile gowns (until driveline ingrowth occurs) and facilitates decision making regarding insertion of the
❖ Sterile drapes appropriate device and postoperative management.
❖ Driveline fixation device • Perform a cardiovascular, hemodynamic, peripheral vas-
❖ Suture removal kit to remove circumferential suture cular, neurovascular, and psychosocial assessment and
postop assessment of body mass index (height, weight, BSA).
• Sterile dressing supplies for chronic dressing change: Rationale: These assessments provide baseline data and
❖ Prepackaged driveline management system consisting help with determination of the type of device to use.
of: • Assess the current laboratory profile, including the com-
Sterile 4 × 4 sterile gauze plete blood cell count, platelet count, prothrombin time,
Chlorprep 3-mL applicator partial thromboplastin time (PTT), international normal-
Sterile gloves ized ratio (INR), blood chemistry, liver profile, protein,
Masks and albumin levels. Rationale: This assessment provides
Driveline fixation device baseline data and may indicate end-organ dysfunction
Biopatch related to low-flow state. It also may be used to predict
Clear Tegaderm dressing shield the patient’s risk of bleeding.
Patient Preparation • Ensure that an informed consent form has been signed (if
• Verify that the patient is the correct patient with two iden- it is known before surgery that the VAD will be placed).
tifiers. Rationale: Before performing a procedure, the Rationale: Informed consent protects the rights of the
nurse should ensure the correct identification of the patient patient and makes a competent decision possible for the
for the intended intervention. patient and family.
• Ensure that the patient and family understand preoperative • Perform a preprocedure verification and time out. Ratio-
teaching. Answer questions as they arise, and reinforce nale: This ensures patient safety.
information as needed. Rationale: This communication • Provide emotional support to the patient and family.
evaluates and reinforces understanding of previously Rationale: The patient and family are under an extreme
taught information. amount of stress.
Procedure for Ventricular Assist Devices (Temporary/Short Term)

Impella Percutaneous LVAD (Abiomed Corporation)
1. Verify the presence of the backup In the event of device failure, support
motor and console. can rapidly be reestablished.
2. HH
3. PE
4. Once the patient is stable after Prepares the system.
admission to the critical care unit,
transition from initial setup to
standard configuration on the
Impella controller:
A. Attach normal saline (NS)
with straight tubing to the red
side arm of the Impella CP
catheter.
B. Pressurize the normal saline
with the pressure bag to
300 mm Hg (do not use
pressure tubing).
C. Press “PURGE SYSTEM” on
the Impella CP controller then
select “Transfer to Standard
Configuration.”
D. Create a slow drip from the
pressurized NS to flood the
Luer-Lok connector of the red
pressure side arm and make a
wet-to-wet connection.
E. Fully open the roller clamp
once connected.
F. Select OK to confirm transfer.
5. Change the purge fluid as Heparin and dextrose are specific to The rate will be preset by the
prescribed or based on institution the function of the Impella device Automatic Impella Controller (AIC)
standard (e.g., heparin 25,000 and longevity of the catheter. flow rate.
units/D5W 500 mL). Change purge cassette, pressurized
NS bag, and tubing every 96 hours;
follow institutional standards.
6. Check the ACT as prescribed Determines whether the desired level Additional heparin may be needed in
(e.g., 2 hours after the purge of anticoagulation is achieved. the purge fluid to achieve the
solution is initiated). desired ACT range.
The range will be determined by the
physician or advanced practice
nurse.
Procedure for Ventricular Assist Devices (Temporary/Short Term)—Continued

7. Ensure the Impella device is in
the proper position.
A. Ensure that a transthoracic Determines whether the device is
echocardiogram is obtained as across the aortic valve.
prescribed.
B. Ensure the Tuohy-Borst valve Maintains the position of the device May need to remove the initial
is locked. across the aortic valve. dressing to assess whether the valve
is locked. Follow institutional
standards.
Document the centimeter marker on
the Impella CP catheter closest to
the sheath.
C. Apply the knee immobilizer Prevents catheter migration.
(for femoral insertion).
D. Assess Impella position using Ensures the catheter has not migrated.
the “Placement Signal” as
displayed by the Automatic
Impella.
8. Confirm the mode of operation is Ensures equipment is set as Verify the prescribed P-level.
P-level mode. prescribed.
9. If the P-level needs to be
changed, push the menu button
and choose P-level mode.
10. Ensure the white introducer side Accessing the introducer could
arm is capped off and marked compromise the position of the
“DO NOT USE.” Impella.
11. Troubleshooting:
A. Resuscitation:
i. For CPR, decrease the
performance level to P2.
ii. Defibrillate as needed. No need to stop or disconnect the
device.
iii. Compressions may be Compressions may dislodge Provide compressions only if
contraindicated. cannulation, causing loss of support prescribed by the physician or
and/or bleeding. advanced practice nurse. Follow
iv. If the patient survives the
resuscitation:
a. Verify the position of Determines whether the position of
the device with the device is correct.
echocardiogram as
prescribed.
b. Resume P-level as Continues treatment as prescribed.
prescribed.
B. Respond to device alarms: Corrects the alarm condition. Refer to the IFU for specific
i. Rapidly assess the alarm interventions needed for each
condition. alarm.
ii. Respond to each alarm. For technical support, call Abiomed
iii. Notify the physician or Clinical Support Center (1-800-
advanced practice nurse if 422-8666)
assistance is needed.

12. Weaning and removal: Discontinue anticoagulation as
prescribed.
A. Follow the weaning process
as prescribed. Follow
insitutional standards.
B. Decrease the performance
level by 2 P-levels every 3
hours, or as prescribed, until
at P2.
C. Maintain the Impella at P2 for This is typically at least 2 hours.
the prescribed amount of time.
D. Assess the patient’s response
to P2.
E. Assist as needed with device The patient must demonstrate
removal. ventricular recovery before
removal.
F. Assist as needed as pressure is Manual pressure may be maintained
maintained at the insertion at the insertion site for a minimum
site. of 20 minutes or until hemostasis is
achieved.
Follow institutional standards.
G. Compression devices may be
utilized after manual
compression.
H. Monitor for hematoma
formation or overt bleeding at
the site.
I. Assess for retroperitoneal
bleeding (HCT dropping,
abdominal/flank pain) or
hemodynamic compromise.
supplies. microorganisms; Standard
Precautions.
14. HH
CentriMag Ventricular Assist Device (Left, Right, or Biventricular Device) (St Jude/Thoratec Corporation)
1. Verify the presences of the In the event of device failure, support
backup motor, console, and chest can rapidly be established.
tube clamps.
2. HH
3. PE
4. Assess pump function. Ensures the device is functioning
appropriately.
5. Assess the pump insertion site. Determines whether bleeding or
hematoma is present.
6. Assess for VAD chatter. VAD chatter indicates that the device Assess for volume, VAD rate, right
is running too fast for the amount ventricular function, arrhythmia,
of blood being delivered to it. and position of the cannula.
7. Adjust the flow probe 1 cm every The flow probe can contribute to
8 hours, ensuring that the arrows thrombus formation if left in place
on the probe point in the too long.
direction of blood flow.
8. Anticoagulation:
A. Administer anticoagulation as Maintains the patency of the device
prescribed (e.g., heparin and decreases thrombus formation.
25,000 units/500 mL D5W).

B. Check the ACT as prescribed Determines whether the desired level
(e.g., hourly). of anticoagulation is achieved.
C. Additional anticoagulation The ACT range will be determined by
may be needed as prescribed. the physician or advanced practice
nurse.
9. Troubleshooting:
A. CPR: Compressions may be Compressions may dislodge the Only provide compressions if
contraindicated. cannula(ae). prescribed by the physician or
advanced practice nurse. Follow
B. Defibrillate as necessary. No need to stop or disconnect the
device.
C. Respond to device alarms:
i. Rapidly assess the alarm If the device is stopped for longer Refer to the IFU for specific
condition. than 5 minutes, it may not be safe interventions needed for each
to restart. alarm.
For technical support, call Thoratec
HeartLine at 800-456-1477.
ii. Respond to each alarm.
iii. Notify the physician or
advanced practice nurse if
iv. If an equipment change is Prevents backflow of the device.
necessary, clamp the return
tubing before switching to
the backup equipment.
v. Always unclamp the tubing
after restarting the device.
prescribed.
A. Follow physician or advanced
practice nurse prescription for
weaning.
B. Decrease the device rate as
prescribed.
C. Assess the patient’s response The patient needs to demonstrate
to the decrease in the device ventricular recovery before
rate. removal.
D. The device will be removed in
the operating room.
E. Assess for bleeding, Determines patient stability.
hematoma, and hemodynamic
status after return from the
operating room.
Precautions.
12. HH
Tandem Ventricular Assist System (Left, Right, or Biventricular Device) (TandemLife Corporation)
1. Verify the presence of the backup In the event of device failure,
console and tubing clamps. support can be rapidly
reestablished.
2. HH
3. PE
4. Assess pump function. Ensures the device is functioning
appropriately.
5. Assess the pump insertion site. Determines whether bleeding or
hematoma is present.

6. Assess the VAD for chatter. VAD chatter indicates that the device Assess for volume, VAD rate, right
is running too fast for the amount ventricular function, arrhythmia,
of blood being delivered to it. and malposition of cannula
7. Assess the insertion depth. Determines the position of the
cannula(ae).
8. Immobilize the affected limb. Prevents catheter migration.
9. Anticoagulation:
A. Administer anticoagulation as Maintains the patency of the device A heparin infusion is prescribed along
prescribed (e.g., heparin and decreases thrombus formation. with the TandemHeart infusate.
25,000 units/500 mL D5W).
B. Check the activated clotting Determines whether the desired level
time as prescribed (e.g., of anticoagulation is achieved.
hourly).
C. Additional anticoagulation The ACT range will be determined by
may be needed as prescribed. the physician or advanced practice
nurse.
D. Heparin may also be used as Maintains the patency of the device Do not use heparin in D5W through
an infusate through the and decreases thrombus formation. the device.
device.
10. Troubleshooting:
A. CPR: Compressions may be Compressions may dislodge the Only provide compressions if
contraindicated. cannula(ae). prescribed by the physician or
advanced practice nurse. Follow
institution standard.
B. Defibrillate as necessary. No need to stop or disconnect the
device.
C. Respond to device alarms:
i. Rapidly assess the alarm If the device is stopped for longer Refer to the IFU for specific
condition. than 5 minutes, it may not be safe interventions needed for each
to restart. alarm.
For technical support, call
CardiacAssist/Technical Support at
1-800-373-1607.
ii. Respond to each alarm.
iii. Notify the physician or
advanced practice nurse if
iv. If an equipment change is Prevents backflow of blood into the
necessary, clamp the return device.
tubing before switching to
the backup equipment.
v. Always unclamp the tubing
after restarting the device.
prescribed.
A. Follow the weaning process
as prescribed. Follow
B. Decrease the device rate as
prescribed.
C. Assess the patient’s response The patient must demonstrate
to the decrease in device rate. ventricular recovery before
removal.
D. Assist as needed with device
removal.

E. Assist as needed as pressure is Manual pressure may be maintained
maintained at the insertion at the insertion site for a minimum
site. of 20 minutes or until hemostasis is
achieved.
F. Compression devices may be
utilized after manual
compression.
G. Monitor for hematoma
formation or overt bleeding at
site.
H. Assess for retroperitoneal
bleeding (HCT decreasing,
abdominal/flank pain) or
hemodynamic compromise.
Precautions.
13. HH
Procedure for (Durable/Long Term)

HeartMate II LVAS (St Jude/Thoratec Corporation)
1. HH
2. PE
3. Changing from the power module
to batteries:
A. Check the battery life by Ensures that the battery is charged. Batteries are fully charged when four
pushing down the alarm green lights appear.
silence button. Batteries are changed when one green
light is lit.
B. Place a battery into each Allows patient ambulation.
battery clip by lining up the
arrow on the large battery and
battery clip and inserting until
the battery clicks securely into
the holder.
C. Disconnect the white An alarm sounds once per second, Do not disconnect both power sources
controller cable from the and a yellow crescent flashes, at the same time.
power module cable by indicating disconnection from the
loosening the white nut and power module.
then pulling them apart.
D. Connect the white controller The alarm is resolved.
cable to the battery clip.
E. Disconnect the black An alarm sounds once per second,
controller cable from the and the yellow crescent flashes,
power module cable by indicating disconnection from the
loosening the black nut and power module.
then pulling them apart. The alarm resolves after the cable is
connected properly.
Procedure for (Durable/Long Term)—Continued

4. Changing from batteries to the
power module:
A. Disconnect the white An alarm sounds once per second, Do not disconnect both cables at the
controller cable from the and the yellow crescent flashes, same time because power failure
battery clip. indicating disconnection from the may occur, resulting in the need to
battery. use the emergency backup battery.
B. Connect the white controller The alarm is resolved.
cable to the white power
module cable connection.
C. Disconnect the black An alarm sounds once per second,
controller cable from the and the yellow crescent flashes,
battery clip. indicating disconnection from the
power module.
D. Connect the black controller Returns the power connection to the The alarm is resolved.
cable to the black power power module cable to allow power
module cable connection. to be obtained from an AC source.
E. Remove the batteries from the Allows the batteries to recharge.
clips and place the batteries
back into the universal battery
charger.
5. Troubleshooting (general):
A. Power module alarm: AC fail: The external power to the power The power module emits a steady
module is off. tone.
The internal battery of the power
module powers the pump for 30
minutes.
i. Change the power source.
ii. Switch from the power
module to the batteries.
iii. Ensure that the power
module is plugged into an
outlet with emergency
power backup.
B. Power module alarm: Low The power module internal battery is This alarm is a steady tone.
battery: almost depleted.
i. Change the power source.
ii. Switch from the power
module to batteries.
C. Power module alarm: Alarm Used to silence the power module fail If the patient is connected to the
reset: alarm. power module, all alarms sound at
the power module and controller;
both need to be silenced.
i. Press the alarm reset
switch.
ii. The AC fail alarm is
silenced and does not come
back on.
6. Troubleshooting (HeartMate II Always check the patient, then check
controller alarms): connections from the patient to the
controller, and then check
connetions from the controller to
the patient. If the patient is on the
monitor, the alarm is visible on the
monitor.
A. Alarm: Red heart: The VAD may not be functioning Emits a steady tone.
adequately. Call physician and LVAD team.

i. Check whether the LVAD If the VAD is not functioning “RED HEART: GREEN POWER
is still pumping by adequately, emergency interventions LIGHT ON” can occur if the
listening for a VAD hum may be needed. LVAD flow is <2.5 L/min.
with a stethoscope and If the pump is running, administer IV
look for the green power fluids and treat arrhythmias and
light on the controller. hypertension as prescribed.
If the pump is not running, change
the controller per the IFU
procedure.
If the pump is not running and the
patient is in cardiovascular arrest,
begin basic life support (BLS) and
advanced cardiac life support
(ACLS). (Do not start
compressions without a specific
order.)
ii. Check that the controller is
connected securely to the
driveline.
iii. Change the power source:
change batteries or, if on
the power module, switch
to battery source.
B. Alarm: Red battery: Fewer than 5 minutes of battery Emits a steady tone.
power remain.
After the batteries are depleted, the Batteries should not be permitted to
emergency battery will give an get this low.
additional 15 minutes of power.
i. Immediately replace the
batteries.
Or
ii. Change to an alternate
power source.
C. Alarm: Yellow diamond: Fewer than 15 minutes of battery Emits 1 beep per second.
power remain.
i. Change batteries.
Or
ii. Change to power module.
D. Alarm: Yellow wrench: Assess for interruption of the Refer to the IFU for specific
driveline (driveline fault), interventions.
emergency battery not installed or
expired, or controller not
synchronized with monitor time.
i. Read the LCD screen and
follow instructions.
ii. Consult your hospital
contact or Thoratec
representative.
7. Self-test:
A. Place the patient on the power A self-test is done each day to check
module, then hold down the the function of the pump, controller,
battery button until all the and the emergency backup battery.
lights on the controller light
and a loud alarm sounds.

B. All lights should go off except
for the power light, and all
alarms should silence if the
controller passes the test.
8. Changing the controller: Refer to the IFU for specific
interventions.
A. Lay out the new controller Eases the changing of the controllers. The patient should be in a sitting or
next to the old controller. lying position.
B. Open the latch on the back of Allows for the controller change. The device will stop when you
the controller. Push the red disconnect the patient from the
button down and pull the controller.
driveline out of the controller Monitor the patient closely.
at the same time.
C. Connect the driveline to the Allows the power to be restored. The controller will have the backup
new controller by lining up the battery powering the controller but
“black triangles or black lines” must have both batteries replaced to
and pushing to engage. Close continue safely.
the controller lock to ensure The controller starts the pump at the
the driveline stays engaged. preset rate.
D. Connect the batteries to the Restores power.
new controller.
E. The original controller must This silences the alarms on the The controller will stop alarming.
be placed in standby mode by disconnected controller.
pushing and holding the
battery button for a count of
five after both power cables
have been disconnected.
Precautions.
10. HH
HeartWare LVAS (HeartWare Corporation)
1. PE
2. HH
3. Changing from the AC power to
batteries:
A. Assure that the battery to Ensures that the backup battery will Batteries are fully charged when four
which you are connecting is power the LVAD during disconnect green lights appear.
fully charged by pressing the from the AC source. Make certain that the backup battery
battery button. is available and is fully charged.
B. Remove the AC power cable
from the controller by turning
the connector toward the
arrow and pulling straight out.
C. Connect the new battery to The patient is now on total battery There will be an audible click when
the controller by grasping the power. the battery is engaged.
connector of the battery,
lining up the arrows, and
pushing straight in.
4. Changing from batteries to AC
power:
A. Connect the power cable to Ensures safety.
the AC outlet (be sure that it
is grounded).
B. Remove one of the batteries
from the controller by turning
the connector toward the
arrow and pulling straight out.

C. Connect the AC power cable Connects the VAD to AC power. There will be an audible click when
to the controller by grasping the battery is engaged.
at the connector of the battery, One battery will remain connected to
lining up the arrows, and the controller as a backup.
pushing straight in.
5. Troubleshooting HeartWare
Alarms:
A. VAD Stopped Assess the patient and implement
emergency care if needed.
B. Look at the LED screen. If the driveline disconnects, the
The LED screen displays device will stop.
“connect driveline” and the
red alarm indicator will be
flashing red.
C. Check connections.
D. Reconnect the driveline to the Continues VAD function.
controller
E. If the LED screen displays,
“change controller” or
“controller failure.
F. Immediately change the Replaces equipment. Notify the VAD coordinator.
controller.
6. Battery alarms:
A. If the alarm is “Critical Ensures that the battery is fully
Battery 1 or 2,” change the charged.
battery that is depleted.
B. If there is a continuous All power has been lost, necessitating This will result in the VAD stopping.
high-pitched alarm with no a new power source. Assess the patient and implement
LED message, replace the emergency care if needed.
power immediately.
7. Changing the controller: Refer to the IFU.
A. Place the new controller next Eases the transition when connecting The patient should lie or sit down
to the old controller. the new controller. because the patient will lose
support momentarily as the
controller is changed.
B. Connect the backup power Provides power to the new controller. The power-disconnect alarm and the
source to the new controller. VAD-stopped alarm will sound
until the controller is connected to
the driveline.
C. Pull back the white driveline Exposes the driveline connector to the
cover on the old controller’s controller.
silver connector.
D. Grasp the driveline connector The device will stop when the
and pull straight out to driveline is disconnected from the
disconnect the patient from controller.
the controller. Monitor the patient closely.
E. Align the black dot on the The device will restart.
driveline connector with the
black dot on the new
controller driveline port and
push in until a click is heard.
F. Replace the second battery on
the new controller.
G. Replace the white driveline
cover over the silver
connector.

H. Place the red adapter into the The controller should stop alarming.
old controller and remove all
power.
I. If no red alarm adapter is
available, press both the alarm
silence and the scroll buttons
together for 5 seconds.
Precautions.
9. HH
Procedure for Acute Driveline Dressing4

1. Gather supplies and protective Prepares for the procedure.
equipment for dressing change.
2. HH
3. PE
4. Create a sterile field with the
sterile drape.
5. Drop sterile dressing supplies
onto the sterile drape.
6. Place a mask on the patient Decreases contamination of the Everyone in the room should apply a
unless the patient is intubated. wound. mask.
This is required until tissue ingrowth
occurs.
7. Apply a cap. Prepares for the procedure. This is required until tissue ingrowth
occurs.
8. Remove gloves, wash hands, and Prepares for the procedure.
apply clean gloves
9. Carefully remove the old
dressing.
10. Assess the driveline site for Determines early signs of infection.
drainage and redness.
11. Remove clean gloves and wash
hands.
12. Apply sterile gloves Prepares for sterile procedure.
13. Gently clean around the exit site Deceases the risk of infection.
from the center out with
14. Allow the antiseptic solution to Increases the effectiveness of the
dry. antiseptic.
15. Never use Betadine ointment, These products can cause damage to
skin prep, Uni-Solve, or acetone the driveline.
around the driveline.
16. Place a folded 2 × 2 gauze pad This relieves pressure at the edge of
under the driveline. the exit site under the driveline
preventing erosion.
17. Apply a preslit 4 × 4 gauze pad Decreases strikethrough.
(for excessive drainage) or preslit
island dressing (for normal
drainage).
Procedure for Acute Driveline Dressing—Continued

18. Use breathable tape to secure the Decreases strikethrough.
4 × 4 or to close the preslit island
dressing.
19. Secure the driveline with a An immobilized driveline allows for
driveline fixation device or an faster tissue ingrowth and decreases
abdominal binder. the risk of infection.
Precautions.
21. HH
Procedure for Chronic Driveline Dressing4

1. Gather supplies and protective Use the acute dressing if any drainage
equipment for dressing change. or redness appears.
2. HH
3. PE
4. Open the dressing kit.
5. Place a mask on the patient Decreases contamination of the Everyone in the room should apply a
unless the patient is intubated. wound. mask.
6. Remove gloves, wash hands, and
apply clean gloves.
7. Remove the old dressing.
8. Assess the driveline site for Determines whether signs of infection
drainage and redness. are present.
9. Remove clean gloves, wash Prepares for the procedure.
hands, and apply sterile gloves.
10. Gently clean around the exit site Decreases the risk of infection.
from the center out with
11. Allow the antiseptic solution to Increases the effectiveness of the
dry. antiseptic.
12. Never use Betadine ointment, These products can cause damage to
skin prep, Uni-Solve, or acetone the driveline.
around the driveline.
13. Place a Biopatch around May decrease the risk of infection. Placing the Biopatch on damp skin
driveline. can cause irritation. The stie must
Follow institution standard. be dry.
14. Place a clear dressing (e.g.,
Tegaderm) over the driveline exit
site.
15. Secure the driveline with a
driveline fixation device or
abdominal binder.
Precautions.
17. HH

• Increased myocardial oxygen supply and decreased • Device failure
myocardial oxygen demand • VAD infection
• Increased cardiac output and index • Neurological dysfunction
• Increased tissue perfusion • Bleeding and coagulation disorders
• Safe bridge to heart transplant • Multisystem organ failure
• Improved activity tolerance and quality of life • Thrombotic event
• Pain

interventions.
1. Perform systematic cardiovascular,
respiratory, peripheral vascular,
and hemodynamic assessments as
patient status necessitates. Follow
A. Level of consciousness. Assesses for the adequacy of cerebral • Decreased level of consciousness
perfusion; thrombi may develop • Agitation
and dislodge during VAD therapy. • Confusion
B. Vital signs and pulmonary Demonstrates the effectiveness of • Unstable vital signs
artery pressures. VAD therapy and evaluates • Hemodynamic instability
ventricular function.
C. VAD flow and mixed venous Demonstrates the effectiveness of • Abnormal values
oxygen saturation. VAD therapy.
D. Circulation to the extremities. Demonstrates adequate • Extremities: Cool or cold to the
peripheral perfusion. touch
If reportable conditions are found, • Capillary refill >2 seconds
they may indicate thrombotic or • Diminished or absent pulses
embolic obstruction of perfusion to (radial, popliteal, tibial, pedal)
an extremity. • Color pale, mottled, or cyanotic
Nonpalpable pulses may be a normal • Diminished or absent sensation
finding in the continuous flow • Pain
devices. Doppler should be used in • Diminished or absent movement
these cases to verify continuous
flow. May only have “wind tunnel”
pulses if continuous flow pump
(e.g., Impella).
E. Urine output. Demonstrates adequate perfusion to • Urine output <0.5 mL/kg/hr.
the kidneys.
2. Assess VAD, heart, and lung Abnormal VAD, heart, and lung • Abnormal VAD sounds, such as
sounds every 4 hours and as sounds may indicate the need for grinding or sputtering
needed. Follow institutional additional treatment. • Diastolic murmur
standards. • Crackles or rhonchi
3. Monitor for signs and symptoms of Adequate VAD function depends on • Inadequate VAD output
inadequate preload. an appropriate volume status. • Abnormal hemodynamic data
4. Logroll the patient every 2 hours Promotes comfort and skin integrity • Disruption of skin integrity
until hemodynamic stability is and prevents kinking of the VAD
obtained, and then advance activity drivelines.
as prescribed and tolerated.
Prop pillows or positioning wedge
to support the patient and to
maintain alignment.
Consider specialty beds as needed.

5. Initiate passive and active range- Prevents venous stasis and muscle • Mobility concerns
of-motion exercises every 2 hours. atrophy. • Developing contractures
6. Assess the area around the VAD Anticoagulation therapy increases the • Bleeding from the driveline exit
cannulae/drivelines exit site(s) for risk of bleeding. site
evidence of bleeding. Ensure that • Any signs of cracking or wear in
each driveline is positioned the driveline
properly and secured. Use of a
VAD driveline securement device
or stabilizer belt may help. Follow
7. Assess prothrombin time, PTT, Monitors for coagulation problems • Bleeding from cannulation sites,
INR, CBC, platelet, haptoglobin, and hemolysis. All VADs require mucus membranes, or wounds
and plasma-free hemoglobin as prophylactic anticoagulation • Abnormal laboratory values and
prescribed. therapy to prevent thrombi and coagulation levels outside of goal
emboli development. range
• Signs and symptoms of emboli
8. Change the VAD site dressing per Decreases the incidence of infection • Signs and symptoms of infection
institutional standards. Do not use and allows an opportunity for site • Alterations in wound healing
prophylactic topical agents because assessment.
they may increase maceration and Special note: Most manufacturers do
increase the risk of resistant not recommend the use of
microorganisms.4,7,21 povidone-iodine because of
degradation of the drivelines. In
addition, no acetone should be in
the patient’s room. Patients with an
open sternotomy may need a
physician or an advanced practice
nurse at the bedside during dressing
changes.
9. Follow institutional standards for Identifies the need for pain • Continued pain despite pain
assessing pain. Administer interventions. interventions.
Documentation
• Patient and family education • Unexpected outcomes
• Universal protocol requirements • Additional interventions
• Informed consent • Assessment of driveline site
• VAD parameters (e.g., flow, pump speed) • Backup equipment (e.g., drive console, controllers)
• VAD power source • Dressing changes
• Patient response to the VAD • Skin integrity
• Confirmation of placement • Device-specific documentation:
• Hemodynamic status • HeartMate II: pump speed, flow, motor power, and
• Pain assessment, interventions, and effectiveness pulse index
• Activity level • HeartWare: pump speed, flow, and motor power

53 Ventricular Assist Devices 466.e1
References 19. Rose EA, et al: The REMATCH trial: Rationale,

1. Abiomed: 2013. “Impella 2.5 with the automated Impella design, and endpoints. Ann Thoracic Surg 67:723–730,
controller: Circulatory support system instructions for 1999.
use” [Online]. Accessed March 2016 via the Web at 20. Slaughter M, et al: Advanced heart failure treated with
<http://www.abiomed.com/assets/AIC_2-5_IFU_Rev_G continuous-flow left ventricular assist device. N Engl J
.pdf>. Med 361:23, 2009.
2. Birati E, Rame E: Left ventricular assist device 21. Strueber M, et al: Multicenter evaluation of an
management and complications. Crit Care Clin 30:607– intrapericardial left ventricular assist system. J Am Coll
627, 2014. Cardiol 57(12):1375–1382, 2011.
3. Cowger J, et al: Left ventricular assist device management 22. TandemLife: 2016. TandemLife: Instructions for use.
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failure. Curr Opinion Cardiol 26:149–154, 2011. 23. Thiele H, et al: Reversal of cardiogenic shock by
4. Drews T, et al: Differences in pulsatile and non-pulsatile percutaneous left atrial-to-femoral atrial bypass assistance.
mechanical circulatory support in long-term use. J Heart Circulation 104:2917–2922, 2001.
Lung Transplant 27:1096–1101, 2008. 24. Thoratec: 2nd Generation CentriMag System Operating
5. Feldman D, et al: The 2013 International Society for Manual (US), Thoratec-Document No PL-0047
Heart and Lung Transplantation guidelines for mechanical (September 2013). Retreived from: <http://www.thoratec
circulatory support: Executive Summary. J Heart Lung .com/medical-professionals/resource-library/ifus-manuals/
Transplant 32(2):157–187, 2013. thoratec-centrimag.aspx#>.
6. Frazier OH: Prologue: Ventricular assist devices and 25. Thoratec: HeartMate II Instructions for use. Retrieved
total artificial hearts: A historical perspective. Cardiol from <http://www.thoratec.com/medical-professionals/
Clin 21:1–13, 2003. resource-library/ifus-manuals/heartmate-ll-lvad.aspx>,
7. HeartWare: HeartWare Ventricular Assist System: 2014.
Instructions for Use. Miami Lakes, FL,2014, HeartWare. 26. Thoratec: 2nd Generation CentriMag System Operating
8. Hravnak M, George E, Kormos RL: Management of Manual (US). Retrieved from <http://www.thoratec.com/
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insertion sites. J Heart Lung Transplant 12(5):856–863, thoratec-centrimag.aspx#.6:1–114>, 2013.
1993. 27. Yancy CW, et al: ACCF/AHA Guideline for the
9. Kirklin JK, et al: Sixth INTERMACS annual report: Management of Heart Failure: Executive Summary:
A 10,000-patient database. J Heart Lung Transplant A Report of the American College of Cardiology
33(6):555–564, 2014. Foundation/American Heart Association Task Force
10. Konstam MA, et al: Continuous aortic flow augmentation: on Practice Guidelines. Circulation 128:1810–1852,
A pilot study of hemodynamic and renal responses to a 2013.
novel percutaneous intervention in decompensated heart 28. Willey JZ, et al: Cardiovascular disease in the era of left
failure. Circulation 112:3107, 2002. ventricular assist devices with continuous flow, risk
11. Kukuy EL, et al: Devices as destination therapy. Cardiol factors, diagnosis, and treatment. J Heart Lung Transplant
Clin 21:67–73, 2003. 33(9):878–887, 2014.
12. LaRocca GM, et al: The Impella Recover LP 5.0 left
ventricular assist device: A bridge to coronary artery Additional Readings
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Echocardiogr 19:468.e5–468.e7, 2006. ventricular assist device. Ann Thorac Surg 66:2119–2120,
13. Lee MS, Makkar RR: Percutaneous left ventricular assist 1998.
devices. Cardiol Clin 24:265–275, 2006. Bond AE, et al: The left ventricular assist device. Am J Nurs
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ventricular assistance to support high-risk percutaneous DeRose J, et al: Implantable left ventricular assist devices
coronary interventions. Am J Cardiol 91:479–481, provide an excellent outpatient bridge to transplantation
2003. and recovery. J Am Coll Cardiol 30:1773–1777, 1997.
15. Long J, et al: Improving outcomes with long-term Goldstein DJ, Oz MC: Cardiac assist devices, New York,
destination therapy using left ventricular assist 2000, Futura Publishing.
devices. John R, et al: Low thromboembolic risk for patients with the
J Thorac Cardiovasc Surg 135:1353–1361, 2008. HeartMate II left ventricular assist device. J Thorac
16. Park S, et al: Outcomes in advanced heart failure with Cardiovasc Surg 136:1318–1323, 2008.
left ventricular assist devices for destination therapy. Livinston E, et al: Increased activation of the coagulation and
Circulation 2012. doi: 10.1161/ fibrinolytic systems leads to hemorrhagic complications
circheartfailure.111.963991. during left ventricular assist implantation. Circulation
17. Rogers JG, et al: Chronic mechanical circulatory support 94(Suppl II):II227–II234, 1996.
in inotrope-dependent heart failure patients who are not McCarthy P, et al: One hundred patients with the HeartMate
transplant candidates. Results of the INTrEPID trial. J Am left ventricular assist device: Evolving concepts and
Col Cardiol 50(8):741–747, 2007. technology. J Thorac Cardiovasc Surg 115:904–912, 1998.
18. Rose EA, et al: Long-term mechanical left ventricular McGee E, McCarthy P, Moazami N: Temporary mechanical
assistance for end stage heart failure. N Engl J Med circulatory support. In Cohn L, editor: Cardiac surgery in
345:1435–1443, 2001. the adult, New York, 2008, McGraw-Hill.
Miller L, et al: Use of a continuous-flow device in patients Slaughter MS, et al; HeartMate II, I.: Advanced heart failure
awaiting heart transplantation. N Engl J Med 357:885– treated with continuous-flow left ventricular assist device.
896, 2007. N Engl J Med 361(23):2241–2251, 2009.
Park SJ, et al; HeartMate II Clinical, I.: Outcomes in advanced Wiegand DL, Kalowes PG: Withdrawal of cardiac medications
heart failure patients with left ventricular assist devices for and devices. AACN Adv Crit Care 18(4):415–425, 2007.
destination therapy. Circ Heart Fail 5(2):241–248, 2012. Windecker S: Percutaneous left ventricular assist devices for
Pitsis AA, Visouli AN: Update on ventricular assist device treatment of patients with cardiogenic shock. Curr Opin
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578, 2008.
Schakenbach LH: Care of the patient with a ventricular assist
device. In Protocols for practice, Aliso Viejo, CA, 2002,
American Association of Critical Care Nurses.
Section Eight Electrocardiographic Leads and
Cardiac Monitoring
PROCEDURE
54
Cardiac Monitoring and
Electrocardiographic Leads
Michele M. Pelter, Teri M. Kozik, and Mary G. Carey
PURPOSE: Continuous physiological monitoring is performed routinely for
patients with acute and critical illnesses. A key component of physiological
monitoring is electrocardiographic or ECG monitoring. The electrocardiogram
provides a graphic picture of cardiac electrical activity, and can be used
continuously to assess dynamic changes. The electrocardiogram is used for
diagnostic purposes and to guide treatment.
PREREQUISITE NURSING • Telemetry ECG monitoring systems also use skin elec-
KNOWLEDGE trodes and leads wires, but are designed to transmit the ECG
waveforms, via telemetry, to a central monitoring system
• Knowledge of the anatomy and physiology of the cardio- for analysis (Figs. 54-2 and 54-3). This wireless system
vascular system, principles of cardiac conduction, prin- allows patients to ambulate freely. Some telemetry systems
ciples of electrophysiology, electrocardiographic lead can monitor patients’ ECGs during transport to other hos-
placement, basic dysrhythmia interpretation, and electri- pital units such as radiology, the cardiac catheterization
cal safety is necessary. Knowledge of cardiac pathophysi- laboratory, and other diagnostic areas of the hospital.
ology is also required. • With both hardwire and telemetry monitoring systems it
• Electrocardiographic monitoring is indicated for patients is important to appreciate that ECG waveforms can be
in critical care units and for those in select acute-care set- altered from body-position changes and artifact, which
tings, including progressive care, medical surgical units, can cause false alarms.4,7 Because of this, careful human
postanesthesia care units, operating rooms, and emer- oversight is required.
gency departments to list a few. Electrocardiographic • Electrocardiographic leads are placed at specific locations
monitoring may also be used during patient transport in on the torso to “view” different aspects of the heart. The
the acute-care setting. number of ECG leads available varies by manufacturer
• Electrocardiographic monitoring is designed to provide and age of the ECG system; there are 3-, 5-, 6- or even
clinicians with a graphic display of the electrical activity 12-lead systems. Some ECG monitoring systems “derive”
of the heart and is generated by depolarization and repo- more views of the heart using a reduced number of lead
larization of cardiac tissue. Cardiac depolarization and wires, and then mathematically generate additional views
repolarization is the result of electrolytes shifting in and of the heart. One example is the EASI lead configuration,
out of the myocardial cells, which is captured on the body which uses five lead wires to generate a “derived” 12-lead
surface in the form of an ECG. Both normal and abnormal ECG (Phillips Healthcare, Andover, MA). EASI derived
cardiac activity can be assessed with the ECG. 12-lead ECGs and their measurements are approximations
• Hardwire ECG monitors display the ECG using skin elec- to standard 12-lead ECGs and should not be used for
trodes that are placed on the patient’s torso and lead wires diagnostic interpretations; instead, a standard 12-lead
that are attached to the skin electrodes. This type of moni- ECG that applies electrodes on the wrist and ankles should
toring system means patients cannot exceed the length of be obtained.
the lead wires; consequently patients are tethered to the • Accurate ECG interpretation is based on precise place-
monitoring system, which may be bedside or portable ment of skin electrodes on the torso; hence, correct and
(Fig. 54-1). ECG abnormalities generate an audible alarm consistent placement of skin electrodes during ECG moni-
and are transmitted and stored in a central monitoring toring is critical. Incorrect placement of skin electrodes
system, which may or may not be assessed by a dedicated can distort the appearance of the ECG waveform enough
monitor observer. Alarms can and should be adjusted for that misdiagnosis and therefore inappropriate treatment
each patient from either the bedside monitor or central can occur. Fig. 54-4 illustrates the location of skin elec-
monitoring station to minimize false alarms.5 trodes for three- and five-lead ECG systems, which are
467
B
Figure 54-1 A, Bedside monitoring system. B, Networked patient monitor with portal technology
for critical and intermediate care. (Courtesy Philips Medical System, Andover, MA.)
shown because these two lead systems are commonly used • Electrocardiographic waveforms are described as either
in the hospital setting. positive (i.e., upward direction) or negative (i.e., down-
• Correct attachment of the lead wires to the skin electrodes ward direction). The factors that determine the direction
is of critical importance as well. Lead wires are labeled of the ECG waveforms are (1) lead location, (2) lead
by the manufacturer to assist with placement. Labels typi- polarity (positive or negative), and (3) the direction of the
cally used are RA (right arm), RL (right leg), LA (left cardiac impulse generated by the heart. Normal cardiac
arm), LL (left leg), and V or C (V or precordial vector and conduction proceeds from the atria (superior part of the
C or chest lead) in systems that provide this lead(s). Lead heart) to the ventricles (inferior part of the heart). When
wires may also be color coded, but these can vary by cardiac conduction flows toward a positive electrode, an
manufacturer. Figures 54-5 and 54-6 show lead wires for upright QRS complex, or positive, waveform is produced
three- and five-lead systems. (Fig. 54-7A).
54 Cardiac Monitoring and Electrocardiographic Leads 469
Figure 54-3 Central station. (Courtesy Philips Medical Systems,

Andover, MA.)
Figure 54-2 Telemetry monitoring system. (Courtesy Philips

Medical Systems, Andover, MA.)
Figure 54-5 Three-lead wire system. (Courtesy Philips Medical
Systems, Andover, MA.)
A B
Figure 54-4 A, B, Three- and five-lead system lead locations on
the torso. A
B
Figure 54-7 Shows positive and negative waveforms.
Figure 54-6 Five-lead wire system. (Courtesy Philips Medical

Systems, Andover, MA.)
• The number of ECG leads displayed visually on the • Reassure the patient and family that ECG monitoring is
bedside or central monitor varies by clinician preference, continuous and that the patient’s heart rate and rhythm
manufacturer, or lead system type (i.e., hardwire versus will be monitored and treated as indicated. Rationale: The
telemetry). It is important to note that the ECG monitoring patient and family are reassured that immediate care is
system may analyze more leads than are visible on the available.
monitoring screen, thus providing clinicians with more • Teach the patient and family about the ability to move and
ECG information. Variations among cardiac monitors or ambulate based on activity prescriptions and the moni-
should be communicated in the unit’s educational program toring type (i.e., hardwire versus telemetry). Rationale:
and included in each unit’s policies and procedures. This emphasis encourages mobility on the part of the
Optimal ECG lead selection for analysis and display is patient and allays fears about disruption of the monitoring
based on the goals of monitoring for each patient’s clinical system.
situation (i.e., heart rate, rhythm changes, ischemia, • Explain the importance of reporting any symptoms, such
etc.).3,5,7,8 as pain, dizziness, palpitations, chest discomfort, etc.
Rationale: Reporting of symptoms ensures appropriate
EQUIPMENT and timely assessment and intervention if indicated.
• ECG monitor (i.e., hardwire or telemetry), which may also

include transport ECG monitor PATIENT ASSESSMENT AND
• ECG lead wires, which may or may not be disposable PREPARATION
• Skin electrodes, pregelled and disposable
• Nonsterile gloves Patient Assessment
• Skin-preparation supplies, which vary based on the hos- • Assess whether the patient has a history of, or is at risk
pital protocol, to include for, cardiac dysrhythmias or cardiac problems. Rationale:
❖ Dry gauze pads The history provides baseline data and may guide selec-
❖ Terrycloth with soap and water tion of monitoring leads.
Additional equipment, to have available as needed, includes • Assess landmarks on the torso for identification of
the following: correct placement of skin electrodes. Rationale: This
• Pouch or pocket gown to hold telemetry device assessment ensures accurate ECG data will be obtained
• Clippers or scissors, used with caution in patients on anti- for interpretation.
coagulants, to clip hair from the chest as needed to ensure
adequate adhesion of skin electrodes. Patient Preparation
• Black indelible marker to mark precordial sites where skin • Verify that the patient is the correct patient using two
electrodes are placed, to ensure electrodes are replaced in identifiers. Rationale: Before performing a procedure,
the correct location and thus maintain consistent lead clinicians should ensure the correct identification of the
locations. patient for the intended procedure.
• ECG calipers for measuring waveforms, which may be • Ensure that the patient and family understand prepro-
available electronically via the central monitor. cedural teaching. Answer questions as they arise, and
• Telemetry batteries reinforce information as needed. Rationale: This com-
munication evaluates and reinforces the understanding of
PATIENT AND FAMILY EDUCATION previously taught information.
• Assist the patient to the supine position. Rationale: This
• Assess the readiness of the patient and family to learn. position enables easy access to the chest for electrode
Rationale: Anxiety and concerns of the patient and family placement.
may inhibit the ability to learn. • Assist the patient in removing clothing that covers the
• Provide explanation to the patient and family regarding chest and limbs, but provide for the patient’s privacy.
ECG equipment, the purpose of ECG monitoring, and the Rationale: Clothing removal provides a clear view of
possibility of alarms. Rationale: These explanations assist the chest and allows for identification of landmarks and
in making the patient and family feel more comfortable proper placement of leads as the patient’s privacy is
with monitoring and may reduce anxiety. maintained.
Procedure for Cardiac Monitoring: Hardwire and Telemetry

1. HH
2. Verify that the central monitor When activated, the central When an alarm is generated, the
system is on, if applicable. monitoring system will turn on nurse must assess the patient to
ECG software that will sound an confirm findings, verify patterns,
alarm when ECG parameters are and carefully evaluate computer
exceeded. software interpretations for
accuracy.
3. For telemetry monitoring, insert a Batteries can fail if left sitting for Refer to manufacturer
battery (or batteries) into the long periods of time in the unit. recommendations regarding battery
telemetry device. storage and replacement.
4. Check the cable and lead wires for Detects conditions that may Safety must be maintained; if
fraying, broken wires or interfere with the ECG signal. equipment is damaged, obtain
discoloration. alternative equipment and notify
the biomedical engineer for repair.
Disposable lead wires systems are
available.
5. Plug the patient cable into the Assists with determining placement Optimal lead selection should be
monitor. Identify the number of of skin electrodes and the number based on the type of lead system
lead wires available for the system of lead wires available for available and the goals of
being used. monitoring. monitoring for each patient’s
clinical situation (i.e., heart rate,
arrhythmia, ischemia, QT-interval
monitoring).3,5,7,8
A. Three-lead systems use the Assists with determining placement The three-lead system is the simplest
following lead wires; RA, LA, of skin electrodes and lead wires ECG monitoring lead system. With
and LL (Figs. 54-4A and 54-5). available. this lead configuration, leads I, II,
or III can be displayed. This
system is often used for portable
monitor defibrillators.
B. Five-lead systems use the Assists with determining placement This lead system provides the
following lead wires; RA, LA, of skin electrodes and lead wires following leads; the six limb leads
RL, LL, and a chest lead available. I, II, III, aVR (augmented unipolar
labeled “C” or “V” (Figs. [vector] right arm), aVL
54-4B and 54-6). (augmented unipolar [vector] left
arm), aVF (augmented unipolar
[vector] foot [i.e., left leg]), and
one precordial or chest lead labeled
V unipolar [vector] or C (chest).
Select the V or chest lead based on
goals of ECG monitoring.3,7,8
6. If lead wires are designed with a Prepares monitoring. Pushing the snap type lead wires onto
“snap” connection, connect the the skin electrodes already placed
lead wires to the each electrode on the torso can be uncomfortable
before placing the skin electrode for the patient.
on the patient’s torso.
7. HH
8. PE
Procedure for Cardiac Monitoring: Hardwire and Telemetry—Continued

9. Identify skin electrode locations Removes dead skin cells, promoting Clipping hair should be done with
(Fig. 54-4A and B), then clean and impulse transmission. Moist skin caution in patients at risk for
slightly abrade the skin where the is not conducive to electrode bleeding.
electrodes will be applied. adherence. Failure to properly Quality improvement projects have
A. Wash the skin with soap and prepare the skin may cause shown that changing skin
water. artifacts and interfere with electrodes daily can reduce
B. Abrade the skin with a gauze interpretation.1,3 artifacts,1,2 but considerations for
pad. skin breakdown should be made.
C. Ensure that the skin is dry
before skin electrodes are
applied.
D. Clipping of chest hair may be
necessary to ensure that
adequate skin contact with
the skin electrodes is made.
(Level C*)
10. If possible, mark any precordial Ensures that skin electrodes are
location with a black indelible replaced to the correct location to
marker. maintain consistent lead locations.
11. Remove the backing from the The gel should be moist to allow Skin electrodes should be stored in a
pregelled electrodes and assess the for maximal impulse dry area and not exposed to direct
center of the pads for moistness. transmission. sunlight because this can dry out
the conductive gel.
12. Apply electrodes to the correct Electrodes must be applied firmly to Electrode failure due to loss of
location on the torso. Ensure the the skin to prevent external contact with the skin or dried-out
skin electrodes are completely influences from affecting the gel can results in excessive false
adhering to the skin. ECG. alarms.1,2,5
13. Place electrodes as follows: Proper positioning is essential to Lead selection for display and
A. Three-lead system (Figs. ensure accurate waveforms are analysis by the central monitoring
54-4A, 54-5): generated for analysis.3,4,7,8 station is based on the aims of
• Apply RA electrode just cardiac monitoring and chest wall
below the clavicle close to constraints (i.e., wounds, dressings,
the junction of the right arm etc.).3,4,7,8
and torso.
• Apply LA electrode just
below the clavicle close to
the junction of the left arm
and torso.
• Apply LL electrode below
the level of the umbilicus, on
the left abdominal region.
(Level C*)
*Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results.

B. Five-lead system Arm electrodes that are not placed Many hospitals set the default
(Figs. 54-4B, 54-6): on the outer chest and under the precordial lead to V1. If another
• Apply RA electrode just clavicle or leg electrodes that are chest lead is selected, the central
below the clavicle close to placed above the umbilicus can monitoring station should be edited
the junction of the right arm alter the ECG waveforms and to reflect the correct chest lead
and torso. result in inaccurate recordings.7,8 being monitored because the V
• Apply LA electrode just In five-lead systems only one lead selected will be printed on any
below the clavicle close to precordial lead can be selected. rhythm strips printed or stored.
the junction of the left arm The central monitoring station
and torso. should be programed to indicate
• Apply RL electrode below the chest (precordial) lead
the level of the umbilicus, on selected.
the right abdominal region.
• Apply LL electrode below
the level of the umbilicus, on
the left abdominal region.
• Apply the chest (precordial)
lead electrode to the selected
site based on the goals of
monitoring:
Lead V1 is the single best
chest, or precordial lead
for arrhythmia monitoring.1
This lead is located in the
4th intercostal space on the
right sternal border. Lead
V6 can be substituted when
V1 cannot be applied (e.g.,
dressings, wounds, etc.).
Lead V6 is located at the
midaxillary in the 5th
intercostal space.
Lead V3 is the single best
precordial lead for
detection of transient
myocardial ischemia.3
On the central monitoring
station, ensure that the
chest lead placed on the
patient is correctly
identified on the monitor.
(Level D*)
14. Reduce tension on the lead wires Decreased tension on the lead wires Software analysis will cease when
and cables. will minimize the leads becoming the lead wires are not connected, or
disconnected. This will also the skin electrodes are not in
minimize pulling on the contact with the torso.
electrodes, which can be
uncomfortable for the patient.
15. For telemetry monitoring, secure The recorder must be secure so that
the recorder in a pouch or pocket it is not dropped or damaged, and
in the patient’s gown. to minimize pulling on the
electrodes.


16. Examine the ECG tracing on the The QRS complex should be Most calibration is set to default
monitor for quality waveforms. approximately twice the height of settings by each facility’s
the other waveforms (e.g., P biomedical department. Typically,
wave, T wave, etc.) to ensure calibration of the ECG should be
proper detection of heart rate by set to 10 mm/mV; at this
the ECG software. If the T wave calibration, 1 mV is expected to
is nearly equal to the R wave, produce a rectangle of 10 mm
each complex may be double height and 5 mm width. Calibration
counted, resulting in false heart for ECG time (speed of paper
rate alarms. recording) is typically set to 25
mm/sec. Some cardiac monitors
have size adjustments that can be
used to increase or decrease the
size (gain) of complexes, and speed
adjustments to slow or speed up
the rate of the paper recording of
the ECG. Alteration of these
settings can affect waveform
analysis; it should be done with
careful consideration and noted in
the medical record.
17. Obtain a baseline ECG strip and Review the normal conduction
interpret for rhythm, heart rate, sequence and identify
presence of P waves, length of PR abnormalities that may necessitate
interval, width of QRS complexes, further evaluation or treatment.
ST-segment deviation, presence of
T waves, and length of QT
interval.
18. Set alarm parameters. Upper and For hard-wire monitoring systems, Monitoring systems allow for setting
lower alarm limits are set on the alarms can be adjusted at the and adjusting alarms at the bedside
basis of the patient’s current bedside or at the central or the central console. The types of
clinical status and heart rate. monitoring station. For telemetry alarms may include heart rate (i.e.,
monitoring systems, alarm high or low), abnormal rhythms or
parameters are typically adjusted waveforms, pacemaker recognition,
at the central monitoring station. and others, depending on the
manufacturer.
Caution: alarms should not be
disabled except in specific
circumstances (i.e., anticipated end
of life). To reduce alarm burden
(false alarms), alarms should be
adjusted according to the known
clinical status of the patient to
minimize false alarms.3,5
19. Set ST-segment parameters if Transient myocardial ischemia can ST-segment monitoring should not be
indicated (see Procedure 56). be assessed with ST-segment used in patients with left bundle
software in select patients when branch block, or ventricular pacing
indicated. because a high number of false
alarms are likely to occur.3
Precautions.
21. HH

• Properly applied skin electrodes and lead wires • Altered skin integrity
• A clear ECG tracing displayed (Fig. 54-8) • Alternating current interference, also called 60-cycle
• Alarms are adjusted to the patient’s current clinical interference (Fig. 54-9)
status • Wandering baseline (Fig. 54-10)
• Prompt identification of heart rate changes, • Artifact (Fig. 54-11)
arrhythmias, ischemia, and lengthening of the
QT-interval based on the goals of monitoring
• False alarms that require human overreading
Figure 54-8 Monitor strip of clear ECG pattern.
Figure 54-9 Monitor strip with 60-cycle interference.
Figure 54-10 Monitor strip with wandering baseline.
Figure 54-11 Monitor strip with motion artifact.


1. Evaluate the ECG routinely for the Continuous evaluation of ECG • Abnormal ECG waveforms,
presence of P waves, QRS waveforms and following any heart rate changes from a
complexes, clear interpretable changes can promptly identify patient’s baseline level, and
baseline, and absence of artifact or alterations in a patient’s condition rhythm changes
distortion. Obtain and analyze so treatment can be initiated if
visually a rhythm strip on admission, indicated.3,6-8
every shift (as per institution
protocol), and following any
changes from the patient’s baseline.
2. Evaluate the ECG pattern Changes in the ECG pattern may • Abnormal cardiac rate and
continually for arrhythmias, assess indicate significant problems for rhythm
patient clinical tolerance following the patient and may necessitate • Hemodynamic instability
any changes, and provide prompt immediate intervention or
nursing intervention. additional diagnostic tests, such as
a 12-lead ECG, or laboratory tests.
3. Evaluate skin integrity around the Skin integrity must be maintained in • Alteration in skin integrity
electrodes on a daily basis, and patients while ensuring that ECG
change the electrodes according to quality is high. Replace electrodes
institutional standards. quickly so that continuous
monitoring is ensured. Skin
electrodes may require slight
relocation if skin integrity is
compromised. Place the skin
electrode as close to the correct
site as possible, and note this in
the medical record.
4. Verify accurate electrode placement Accurate interpretation of
and that lead wires are correctly waveforms and arrhythmias
attached every shift or when leads depends on proper placement of
are removed (i.e., following the electrodes and knowledge of
transport to another department, leads being viewed.
shower, etc.).
Documentation
• Patient and family education there is a change in lead placement, when there are
• An initial or baseline ECG strip changes in electrolytes, or following administration
• Routine ECG strips according to institutional protocol of medications that can affect the QT interval.2
• An ECG strip should be printed and placed in the • Unexpected outcomes
medical record following changes in heart rate or
rhythm, when the patient experiences symptoms, when

54 Cardiac Monitoring and Electrocardiographic Leads 476.e1
References 8. Rautaharju PM, et al: Recommendations for the

1. Cvach MM, et al: Daily electrode change and effect on standardization and interpretation of the electrocardiogram:
cardiac monitor alarms: An evidence-based practice A scientific statement from the American Heart
approach. J Nurs Care Qual 28:265–271, 2013. Association Electrocardiography and Arrhythmias
2. Dandoy CE, et al: A team-based approach to reducing Committee, Council on Clinical Cardiology; the American
cardiac monitor alarms. Pediatrics 134(6):e1686–e1694, College of Cardiology Foundation; and the Heart Rhythm
2014. Society. J Am Coll Cardiol 53:982–991, 2009.
3. Drew BJ, et al: Practice standards for electrocardiographic Additional Readings
Association scientific statement from the Councils on ECG Puzzler Features located in the American Journal of
Cardiovascular Nursing, Clinical Cardiology, and Critical Care (AJCC), 2001 to the present.
Cardiovascular Disease in the Young: endorsed by the Burns S: AACN essentials of critical care nursing, New York,
International Society of Computerized Electrocardiology 2014, The McGraw-Hill Companies, Inc.
and the American Association of Critical Care Nurses. Donnely MP, et al: Lead selection: Old and new methods
Circulation 110(17):2721–2746, 2004. for locating the most electrocardiogram information.
4. Drew BJ, et al: Bedside diagnosis of myocardial ischemia J Electrocardiol 41:257–263, 2008.
with ST-segment monitoring technology: Measurement Drew BJ, Kingfield P: Standardizing electrocardiographic
issues for real-time clinical decision making and trial leads: Introduction to a symposium. J Electrocardiol
designs. J Electrocardiol 30(Suppl):157–165, 1998. 41:187–189, 2008.
5. Drew BJ, et al: Insights into the problem of alarm fatigue Drew BJ: Putting it all together: Case studies on ECG
with physiologic monitor devices: A comprehensive monitoring. AACN Adv Crit Care 18:305–317, 2007.
observational study of consecutive intensive care unit Drew BJ: Pitfalls and artifacts in electrocardiography. Cardiol
patients. PLoS ONE 9(10):e110274, 2014. Clin 24:309–315, 2006.
6. Drew BKJ, et al: Prevention of torsade de pointes Drew BJ, Funk M: Practice standards for ECG monitoring
in hospital settings: A scientific statement from the in hospital settings: Executive summary and guide for
American Heart Association and the American College of implementation. Crit Care Nurs Clin North Am 18:
Cardiology Foundation. J Am Coll Cardiol 55(9):934–947, 157–168, 2006.
2010. Lancia L, et al: A comparison between EASI system 12-lead
7. Kligfield P, et al: Recommendations for the standardization ECGs and standard 12-lead ECGs for improved clinical
and interpretation of the electrocardiogram: Part 1: The nursing practice. J Clin Nurs 17:370–377, 2008.
electrocardiogram and its technology: A scientific Sole M, Klein D, Moseley M: Introduction to critical care
statement from the American Heart Association nursing, ed 6, St. Louis, 2013, Elsevier Saunders.
Electrocardiography and Arrhythmias Committee, Council Sendelbach S, Funk M: Alarm fatigue: A patient safety
on Clinical Cardiology: The American College of concern. AACN Adv Crit Care 24(4):378–386, 2013.
Cardiology Foundation; and the Heart Rhythm Society.
Circulation 115:1306–1324, 2007.
PROCEDURE
55
Extra Electrocardiographic
Leads: Right Precordial and Left
Posterior Leads
Shu-Fen Wung
PURPOSE: Extra electrocardiographic (ECG) leads are used in conjunction with
the standard 12-lead ECG to provide additional diagnostic information.
PREREQUISITE NURSING Patients with RV infarction are prone to hypotension and

KNOWLEDGE shock that responds to treatment with fluid resuscitation.
• Indications for recording a right-precordial ECG are as
• Understanding of the anatomy and physiology of the car- follows:
diovascular system, principles of electrophysiology, ECG ❖ Evaluation and treatment of suspected acute MI, espe-
lead placement, basic rhythm interpretation, and electrical cially patients with inferior-wall MI (ST-segment
safety is necessary. elevation in leads II, III, and augmented vector foot
• Advanced cardiac life support (ACLS) knowledge and [aVF])
skills are needed. ❖ Evaluation of the risk for AV node conduction distur-
• The right ventricular (RV) leads V1R through V6R and left bances and anticipation of treatment plans
posterior leads V7 through V9 are unipolar leads in which ❖ Prediction of the site of coronary artery occlusion (RV
the chest electrode serves as the “exploring” electrode or infarction occurs with proximal right coronary artery
positive pole of the lead. These precordial leads view the [RCA] occlusion)2
heart from the vantage point of their electrode positions ❖ Determination of the risk of “volume-responsive” shock,
on the chest, similar to the standard precordial leads V1 in which case fluid resuscitation is warranted and vaso-
through V6. dilators (e.g., nitroglycerin) are contraindicated
• For recordings of RV or left posterior leads, the three limb • Indications for recording a left-posterior ECG are as
electrodes (right arm [RA], left arm [LA], left leg [LL]) follows:
also are required to create a central terminal (negative ❖ Evaluation and treatment of acute or suspected MI,
pole); the one limb electrode (right leg [RL]) serves as the especially patients with isolated ST-segment depres-
ground lead and is used to stabilize the ECG recording. sion in the precordial leads V1 through V3 and patients
• Accurate identification of electrode positions for the stan- with a nondiagnostic ECG
dard 12-lead ECG is needed because the same anatomical ❖ Presence of chest pain or anginal-equivalent symptoms
landmarks are used to locate the RV and left posterior (e.g., jaw, left shoulder or arm discomfort, or shortness
leads. of breath) or ST-segment depression in the left precor-
• Right precordial leads are useful in diagnosing an RV dial leads V1 through V3 after percutaneous coronary
myocardial infarction (MI). These RV leads are important interventions of the left circumflex artery
because they enable clinicians to identify patients with an ❖ Any of these ECG characteristics are indicative of pos-
acute MI who are at high risk of atrioventricular (AV) terior MI (inferobasal MI) in lead V1: R waves ≥ 6 mm
conduction disturbances, to predict the site of coronary in height, R wave ≥ 40 ms in duration, R/S ratio (R
artery occlusion, and to guide appropriate hemodynamic wave amplitude in mm over S wave amplitude in mm)
monitoring and interventions. ≥ 1, or S wave ≤ 3 mm. In lead V2, R wave ≥ 15 mm
• Left posterior leads are used to aid in the detection in height, R wave ≥ 50 ms in duration, R/S ratio ≥ 1.5,
of posterior wall MI and to facilitate timely reperfusion or S wave ≤ 4 mm.3
treatment. Recording of left posterior leads also can help ❖ Differentiation of true posterior MI from other condi-
in the differential diagnosis of tall R waves in leads V1 tions that can cause tall R waves in lead V1, such as
and V2.1 RV hypertrophy, right bundle-branch block, Wolff-
• Patients with an acute inferior MI and RV involvement, Parkinson-White syndrome, and ventricular septal
determined by ST-segment elevation in the right precor- hypertrophy
dial leads, are at high risk for high-degree AV block. • In patients with RV infarction who exhibit shock, volume
Nurses should monitor patients closely for conduction expansion is used to provide adequate RV and left ven-
disturbances and anticipate the need for temporary pacing. tricular filling pressures and to restore arterial pressure
477
and peripheral blood flow. Positive inotropic agents also ECG tracing, such as relaxing, avoiding conversation and
may be indicated to augment the residual contractile force body movement, and breathing normally. Rationale: This
of the damaged RV. Use of vasodilators (e.g., nitroglyc- explanation ensures the patient’s cooperation to improve
erin) should generally be avoided because they cause the quality of the tracing and avoids unnecessary repeating
venous dilation and reduced preload. Use of diuretics of the ECG because of muscle artifacts.
(e.g., furosemide) should be avoided because they reduce
preload and left ventricular filling.4
EQUIPMENT PREPARATION
• 12-lead ECG machine with patient cable and lead wires Patient Assessment
• ECG electrodes • Assess for the presence of anginal symptoms, such as
Additional equipment, to have available as needed, includes chest pain, pressure, tightness, heaviness, fullness, or
the following: squeezing sensation; radiated pain; shortness of breath;
• Gauze pads or terrycloth washcloth nausea; and extreme fatigue. Rationale: This evaluation
• Cleansing pads or nonemollient soap and water correlates ECG changes with patient symptoms.
• Skin preparation solution (e.g., skin barrier wipe or tinc- • Assess the patient’s history of cardiac conditions and
ture of benzoin) medications. Rationale: Knowledge about the patient’s
• Indelible marker cardiac history and medications can help in interpretation
• Clippers or scissors to clip hair from chest if needed of ECG recordings. For example, digitalis therapy causes
chronic ST-segment depression that does not indicate
PATIENT AND FAMILY EDUCATION acute myocardial ischemia. A normal-looking isoelectric
ST segment in a patient on digitalis therapy may indicate
• Describe the procedure and reasons for obtaining extra acute myocardial ischemia (Fig. 55-1).
ECG leads. Reassure the patient that the procedure is • Interpret the patient’s standard 12-lead ECG for any signs
painless. Rationale: This communication clarifies infor- of myocardial ischemia or MI and dysrhythmias. Ratio-
mation, reduces anxiety, and gains cooperation from the nale: Nurses should be able to evaluate the standard
patient. 12-lead ECG for the location of myocardial ischemia or
• Explain the patient’s role in assisting with the ECG record- infarction and assess the possibility of RV and posterior
ing and emphasize actions that improve the quality of the involvement (Fig. 55-2).
Figure 55-1 Baseline ST-segment deviation as a result of left bundle-branch block before percu-
taneous coronary intervention (left panel, before angioplasty). During angioplasty balloon inflation
of the proximal left circumflex (LCX) coronary artery (right panel, LCX occlusion), the patient
developed myocardial ischemia with chest pain radiating to the left arm. ST segments in the left
posterior leads (V7, V8, and V9) became elevated compared with the baseline preangioplasty tracing
to produce a normal-looking, isoelectric ST segment. This pseudonormalization of the ST segment
during ischemia can be misinterpreted as normal without assessment of the baseline ECG.
55 Extra Electrocardiographic Leads: Right Precordial and Left Posterior Leads 479
Figure 55-2 Initial ECG in a patient admitted to the emergency department with an acute inferior
MI (elevated ST segments and Q waves in leads II, III, and aVF) with apical involvement (elevated
ST segment in leads V4, V5, and V6). ST-segment depression in leads V1, V2, and V3 suggests pos-
terior involvement. Left posterior and right precordial leads should be recorded to assess posterior
and RV involvement.
munication evaluates and reinforces the understanding of

Patient Preparation previously taught information.
• Verify that the patient is the correct patient using two • Assist the patient to the supine position and expose the
identifiers. Rationale: Before performing a procedure, the patient’s torso while maintaining the patient’s modesty.
nurse should ensure the correct identification of the patient Rationale: This position enables the recording of the ECG
for the intended intervention. and allows comparison of serial ECGs and comparison
• Ensure that the patient and family understand prepro- with standard waveforms. Body positional changes, such
cedural teaching. Answer questions as they arise, and as elevation and rotation, can change recorded amplitudes
reinforce information as needed. Rationale: This com- and axes.
Procedure for Extra Electrocardiographic Leads

1. HH
2. Check cables and lead wires for Detects faulty equipment. If the equipment is damaged, obtain
fraying or broken wires. alternative equipment and notify a
biomedical engineer for repair.
3. Check the lead wires for accurate Obtains accurate ECG recordings
labels. and proper placement of leads.
4. Plug the ECG machine into a Maintains electrical safety. Follow manufacturer’s
grounded alternating current (AC) recommendations and institutional
wall outlet or ensure functioning if protocol on electrical safety per
battery operated. the biomedical department.
5. Turn the ECG machine on and Equipment may require self-test and Manufacturers provide a calibration
program the ECG machine: paper warm-up time. Verify equipment check in the machine to identify
speed, 25 mm/sec; calibration, setting in accordance with clinical the sensitivity setting. Most
10 mm/mV; filter settings, practice and recommendation by machines have automatic settings.
0.05–100 Hz. (Level E*) the American Heart Association
(AHA).5 Multichannel machines
may require input of information
(e.g., data about the patient) to
store the ECG appropriately.
6. PE

Procedure for Extra Electrocardiographic Leads—Continued

7. Place the patient in a supine Provides adequate support for limbs ECGs should be recorded in the
position. (Level B*) so that muscle activity is minimal. same body position to ensure
Body-position changes can cause ECG changes are not caused by a
ST-segment deviation and QRS change in body position.
waveform alteration.6-9 If another position is clinically
necessary, note the altered
position on the ECG recording.
8. Expose only the necessary body Provides privacy and warmth, which Ensuring privacy may reduce
parts of the patient (legs, arms, and reduces shivering. anxiety. Shivering may interfere
chest) for electrode placement. with the quality of recording.
9. Identify the electrode locations. Ensures the accuracy of the lead
placement.
Limb Leads (Fig. 57-4)
• RA: inside right forearm Accurate electrode placement is Limb leads should be placed in
• LA: inside left forearm. essential for obtaining valid and fleshy areas; bony prominences
• RL: anywhere on the body; by reliable data for ECG recordings. should be avoided. The limb leads
convention, usually on the right The RL electrode is a ground need to be placed equidistant
ankle or inner aspect of the calf electrode that does not contribute from the heart and should be
• LL: left ankle or inner aspect of the to the ECG tracings. positioned in approximately the
calf same place on each limb.
Right Precordial Leads (Fig. 55-3)
• V1R: fourth intercostal space (ICS) at All patients with an acute inferior These right precordial leads are
the left sternal border (same as V2) wall MI should have right placed across the right precordium
• V2R: fourth ICS at the right sternal precordial leads recorded in with the same landmarks that are
border (same as V1) addition to precordial leads V1 used for the precordial leads V1
• V3R: halfway between V2R and V4R through V6. through V6.10
*Level B: Well-designed controlled studies with results that consistently support a specific action, intervention, or treatment.
Figure 55-3 Electrode locations for recording a right precordial ECG. (From Drew BJ, Ide B:
Right ventricular infarction, Prog Cardiovasc Nurs 10:46, 1995.)
Figure 55-4 ST-segment elevation in leads II, III, and aVF indicates acute inferior wall MI. These
characteristics on the standard 12-lead electrocardiogram (ECG) (left panel) suggest RV infarction:
diagnosis of an inferior MI; ST-segment elevation in lead III exceeding that of lead II; ST-segment
elevation confined to V1 without elevation in the remaining precordial leads; and ST depression in
lead aVL.15 Definitive diagnosis of RV infarction is made by observing ST-segment elevation greater
than or equal to 1 mm in one or more of the right precordial leads. In the right panel, ST-segment
elevation is seen in V2R (V1) through V6R. (From Drew BJ, Ide B: Right ventricular infarction, Prog
Cardiovasc Nurs 10:46, 1995.)

• V4R: right midclavicular line in the Slight alterations in the position of V1R is at the same location as V2,
fifth ICS one precordial electrode may and V2R is at the same location as
• V5R: right anterior axillary line at the distort significantly the appearance V1 in the standard 12-lead ECG
same horizontal level as V4R of the cardiac waveforms and can (see Fig. 55-4). The redundancy
• V6R: right midaxillary line at the have a significant impact on the of V1 (or V2R) and V2 (or V1R) can
same horizontal level as V4R diagnosis.11,12 be used to ensure that the ECGs
are recorded accurately. Identify
the sternal notch and move
downward to locate the angle of
Louis; the second ICS is located
right below the angle of Louis.
Left Posterior Leads (Fig. 55-5)
• V7: posterior axillary line at the Left posterior leads are placed to Help the patient turn to the right
same level as V4 through V6 view the posterior wall of the left side to expose the left side of the
• V8: halfway between V7 and V9 ventricle. Left posterior leads back. Ensure the patient is safely
• V9: left paraspinal line at the same should be recorded in patients turned. Leads V4 through V6 are
level as V4 through V6 admitted with a suspected located at the midclavicular line
posterior MI or known to have in the fifth ICS; leads V7 through
left circumflex artery disease. V9 are at the same horizontal
level as V4 through V6.
Figure 55-5 Electrode locations for recording a left posterior electrocardiogram.

10. Clean and slightly abrade the skin Removes dead skin cells, promoting Failure to properly prepare the skin
where the electrodes will be impulse transmission.13-15 Moist may cause artifact.
applied. skin is not conducive to electrode
A. Wash the skin with soap and adherence.
water if needed.
B. Abrade the skin with a gauze
pad or abrader.
applied.
the skin electrodes is made.
(Level C*)
11. Identify the electrode sites and Minimizes ECG changes caused by After accurate identification of the
mark with an indelible marker. altered electrode placement.16 locations, an indelible marker
should be used to mark the
electrode sites if serial ECGs are
anticipated.
12. For pregelled electrodes, remove Allows for appropriate conduction Gel must be moist. If pregelled
the backing and test for moistness. of impulses. electrodes are not moist or
For adhesive electrodes, remove adhesive electrodes are not sticky,
the backing and check each replace the electrodes.
adhesive pad, as each should be
sticky or moist.
13. Apply the electrodes securely and Electrodes must be secure to prevent If limb plate electrodes are used, do
place the electrodes on the marked external influences from affecting not overtighten to minimize
locations. the ECG. Secure the electrodes to discomfort.
obtain quality ECG recordings.

14. Identify the number of available Newer multiple-channel machines If the ECG machine can record only
ECG channels for simultaneous can record 16 leads at a time, 12 leads, record three separate
recording in the ECG machine. which allows simultaneous ECGs: (1) standard 12-lead with
recording of a standard 12-lead precordial leads, (2) RV leads,
ECG and four channels of RV and (3) left posterior leads. Some
leads V3R through V6R or three newer-generation ECG machines
channels of left posterior leads V7 may allow recording more than
through V9. 12 leads. If the machine can
record 16 leads, you can record
two ECGs: (1) standard 12-lead
plus RV leads (V3R through V6R),
then (2) standard 12-lead plus left
posterior leads (V7 through V9).
Follow institutional protocol for
recording these extra leads so that
a consistent method is used to
avoid confusion.
15. Connect the lead wires to the Identifies RV and posterior leads. Make a notation on the ECG tracing
electrodes and record the ECG. that these are RV leads or
Correctly label the ECG tracings, posterior leads. Labels on
with the extra leads noted. the ECG printout depend on
the connected lead wire and the
location of the electrode.
A. For recording RV leads with a When the unipolar precordial lead Change the labels on the ECG
12-lead ECG machine, connect wires V1 through V6 are connected printouts from V1 to V1R, V2 to
as follows: to the RV or left posterior V2R, V3 to V3R, V4 to V4R, V5 to
• V1 wire to electrode V1R electrodes, the ECG machine V5R, and V6 to V6R.
• V2 wire to electrode V2R records signals from where the
• V3 wire to electrode V3R electrodes are placed.
• V4 wire to electrode V4R
B. For recording of left posterior Make a notation of “left posterior
leads with a 12-lead ECG leads” and relabel appropriately
machine, connect as follows: on the printouts: change V4 to V7,
• V4 wire to electrode V7 V5 to V8, and V6 to V9.
• V5 wire to electrode V8
• V6 wire to electrode V9
16. Assess the quality of the tracing. Ensures a clear tracing is obtained
and no lead is off.
17. Disconnect the equipment; clean Reduces the transmission of Some pregelled electrodes can be
the gel off the patient (if microorganisms; Standard left in place for repeat ECGs.
necessary), remove PE , discard Precautions. Follow the manufacturer’s directions
used supplies, and prepare the and hospital policy for electrode
equipment for future use. use and removal in these cases.
18. HH

• Clear and accurate recording of ECG tracings that • Inaccurate lead placement: electrode misplacement or
allows clinicians to diagnose dysrhythmias and incorrect lead connection
ischemia • Failure to identify the recordings as either RV or left
• Institutional protocol developed for recording the extra posterior ECGs and to change the ECG leads to their
posterior and RV leads according to the availability correct labels; this could lead to misdiagnosis
and type of ECG machine so that the recording method • Poor ECG tracing caused by electrical artifacts from
is consistent external or internal sources
• External artifact introduced by line current (60-cycle
interference), which may be minimized by
disconnecting nearby electrical devices, unplugging
the ECG machine and operating on battery,
improving grounding, or replacing lead wires
• Internal artifact may result from body movement,
shivering, muscle tremors, and hiccups

interventions.
1. Evaluate the ECG recordings for Promptly initiates appropriate • Abnormal ST-segment deviation
acute RV or posterior myocardial interventions, such as reperfusion (elevation or depression) may
ischemia or infarction (Fig. 55-6). treatment or vasodilators. A indicate acute myocardial
Record whether the patient has criterion of 0.5 mm ST elevation in ischemia, injury, or infarction
chest pain on the ECG tracing. V7–9 may suggest acute myocardial
Use a 0–10 score to quantify pain ischemia in the posterior wall of
severity (e.g., 8/10 chest pain). the left ventricle.10
Figure 55-6 An electrocardiogram (ECG) recorded in a 76-year-old patient with diabetes during
occlusion of the left circumflex artery. ST-segment depression is observed in precordial leads V1 to
V4, which suggests a posterior MI (left panel). Left posterior leads V7 to V9 are helpful in recording
ST-segment elevation that confirms posterior myocardial ischemia (right panel). Observing
ST-segment elevation in the contiguous posterior leads allows patients with an acute MI to benefit
from thrombolytic therapy, which would be denied based on analysis of the standard 12-lead ECG
alone.

2. Assess the presence of chest pain Ischemia caused by decreased • Angina
or anginal equivalent symptoms coronary blood flow or increased
(e.g., jaw, left shoulder or arm myocardial oxygen demand may
discomfort, or shortness of breath). produce anginal symptoms.
3. Evaluate the patient’s ECG for The RCA supplies blood to the AV • Patients with an acute MI with
signs of AV node conduction node in 90% of patients. Occlusion RV involvement, as evidenced by
disturbances in patients with RV of the RCA proximal to the RV a QRS pattern or ST-segment
infarction (e.g., second-degree or branch decreases the blood supply elevation greater than or equal to
third-degree AV block). to the AV nodal artery. 1 mm in the right precordial
leads.17
The incidence rate of high-degree AV
block in patients with inferior MI
with RV involvement is
significantly higher (48%) than in
patients without RV MI (13%).18
4. Assess the patient’s hemodynamic Hypotension and reduced cardiac • Cardiovascular and hemodynamic
status. output in patients with RV changes associated with RV
infarction could be attributed to ischemia, injury, or infarction
inadequate left ventricular filling.4 (e.g., elevated mean atrial
pressure, reduced cardiac output,
hypotension, and prominent
venous engorgement).
Documentation
• Patient and family education • Interventions as indicated from the recorded ECG
• The reason the extra leads are recorded (e.g., suspected • Occurrence of unexpected outcomes
RV infarction, posterior MI) • Assessment of pain, interventions, and response to
• Description of associated symptoms interventions
• Interpretation of the ECGs recorded • Additional interventions

55 Extra Electrocardiographic Leads: Right Precordial and Left Posterior Leads 485.e1
References based on ST-segment amplitude and vector orientation—

1. Casas RE, Marriott HJ, Glancy DL: Value of leads V7-V9 preliminary results. Can J Cardiol 19(9):1023–1029,
in diagnosing posterior wall acute myocardial infarction 2003.
and other causes of tall R waves in V1-V2. Am J Cardiol 10. Wung SF, Drew BJ: New electrocardiographic criteria for
80(4):508–509, 1997. posterior wall acute myocardial ischemia validated by a
2. Wung SF: Discriminating between right coronary artery percutaneous transluminal coronary angioplasty model of
and circumflex artery occlusion by using a noninvasive acute myocardial infarction. Am J Cardiol 87(8):970–974,
18-lead electrocardiogram. Am J Crit Care 16(1):63–71, A974, 2001.
2007. 11. Drew BJ: Pitfalls and artifacts in electrocardiography.
3. Haisty WK, Jr, et al: Performance of the automated Cardiol Clin 24(3):309–315, vii, 2006.
complete Selvester QRS scoring system in normal 12. Wung SF: Computer-assisted continuous ST-segment
subjects and patients with single and multiple myocardial analysis for clinical research: Methodological issues.
infarctions. J Am Coll Cardiol 19(2):341–346, 1992. Biol Res Nurs 3(2):65–77, 2001.
4. Cohn JN, et al: Right ventricular infarction. Clinical and 13. Klingler DR, et al: A comparison of gel-to-gel and skin
hemodynamic features. Am J Cardiol 33(2):209–214, 1974. measurements of electrode impedance. Med Instrum
5. Kligfield P, et al: Recommendations for the 13(5):266–268, 1979.
standardization and interpretation of the 14. Clochesy JM, Cifani L, Howe K: Electrode site
electrocardiogram: Part I: The electrocardiogram and its preparation techniques: A follow-up study. Heart Lung
technology: A scientific statement from the American 20(1):27–30, 1991.
Heart Association Electrocardiography and Arrhythmias 15. Tam HW, Webster JG: Minimizing electrode motion
Committee, Council on Clinical Cardiology; the American artifact by skin abrasion. IEEE Trans Biomed Eng
College of Cardiology Foundation; and the Heart Rhythm 24(2):134–139, 1977.
Society: endorsed by the International Society for 16. Drew BJ: Pseudo myocardial injury patterns because of
Computerized Electrocardiology. Circulation nonstandard electrocardiogram electrode placement.
115(10):1306–1324, 2007. J Electrocardiol 41(3):202–204, 2008.
6. Adams MG, Drew BJ: Body position effects on the ECG: 17. Braat SH, et al: Value of lead V4R for recognition of the
implication for ischemia monitoring. J Electrocardiol infarct coronary artery in acute inferior myocardial
30(4):285–291, 1997. infarction. Am J Cardiol 53(11):1538–1541, 1984.
7. Baevsky RH, et al: Supine vs semirecumbent and upright 18. Braat SH, et al: Right ventricular involvement with acute
12-lead electrocardiogram: Does change in body position inferior wall myocardial infarction identifies high risk of
alter the electrocardiographic interpretation for ischemia? developing atrioventricular nodal conduction disturbances.
Am J Emerg Med 25(7):753–756, 2007. Am Heart J 107(6):1183–1187, 1984.
8. Nelwan SP, et al: Correction of ECG variations caused by
body position changes and electrode placement during Additional Reading
ST-T monitoring. J Electrocardiol 34(Suppl):213–216, Burns S: AACN essentials of critical care nursing, New York,
2001. 2014, The McGraw-Hill Companies, Inc.
9. Pharand C, et al: Distinction between myocardial ischemia Sole M, Klein D: Introduction to critical care nursing, ed 6,
and postural changes in continuous ECG monitoring St. Louis, 2013, Elsevier Saunders.
PROCEDURE
56
ST-Segment Monitoring
(Continuous)
Mary G. Carey and Michele M. Pelter
PURPOSE: Bedside ST-segment monitoring provides ongoing surveillance for
detection of transient myocardial ischemia. This technology should be applied to
patients who are being evaluated or are diagnosed with acute coronary syndrome
(ACS), including acute myocardial infarction and unstable angina. For these patients,
continuous ST-segment monitoring is valuable in detecting recurrent or transient
ischemia and in determining the success of thrombolytic therapy and percutaneous
coronary intervention.
PREREQUISITE NURSING brought on by disruption of an atherosclerotic plaque fol-

KNOWLEDGE lowed by cycles of plaque rupture, coronary vasospasm,
platelet stimulation, and thrombus formation with resul-
• Understanding of the anatomy and physiology of the tant loss of blood flow.5,7,15 Because this type of ischemia
cardiovascular system, coronary arteries and associated threatens the entire thickness (transmural) part of the myo-
location of the heart perfused by the coronary arteries, cardium, immediate treatment to reestablish blood flow to
principles of cardiac conduction, electrocardiogram the heart is essential. The typical ECG manifestation of
(ECG) lead placement, basic dysrhythmia interpretation, total supply-related ischemia is ST-segment elevation
ECG leads and location of each lead or lead views, and visible in the ECG leads that lie directly over the ischemic
electrical safety is needed. myocardial zone.
• Understanding of ACS and associated terms is necessary: • Occlusion of the right coronary artery typically produces
(1) ST-elevation myocardial infarction (STEMI), (2) non- ST-segment elevation in leads II, III, and aVF (Fig. 56-2).
STEMI, and (3) unstable angina. Occlusion of the left anterior descending coronary artery
• Advanced cardiac life support (ACLS) knowledge and typically produces ST-segment elevation in leads V2, V3,
skills are needed. and V4 (Fig. 56-3). Diagnosis of total coronary occlusion
• Continuous monitoring of the ECG for ischemic of the left circumflex coronary artery (LCX) is more
ST-segment changes is more reliable than patient symp- complex because placement of the standard ECG elec-
toms because more than three quarters of ECG-detected trodes is on the anterior chest, opposite the wall that this
ischemic events are clinically silent.2,9,14,15,18 Patients who coronary artery supplies. Occlusion of the LCX may
have transient ischemia detected with continuous produce ST-segment depression in leads V1, V2, or V3,
ST-segment monitoring are more likely to have unfavor- which reflects the reciprocal, or mirror image, ST-segment
able outcomes, including myocardial infarction (MI) elevation occurring in the posterior wall of the left ven-
and death, compared with patients without such tricle. In some patients ST-segment changes may also be
events.2,3,9,11,12,14,15,18 seen in leads I and aVL.21
• Given the dynamic, unpredictable, and silent nature of • A second type of ischemia for which patients with ACS
myocardial ischemia, continuous ECG monitoring of or stable angina are at risk is demand-related ischemia.
patients for ischemia is essential.16 Clinicians should This type of ischemia occurs when the demand for oxygen
monitor over time the trend of the ST segments and the (i.e., exercise, tachycardia, or stress) exceeds the flow
part of the ECG that changes during acute ischemia and capabilities of a coronary artery. Patients with this type of
evaluate any ST-segment changes (elevation or depres- ischemia are likely to have a stable atherosclerotic plaque.
sion) for possible myocardial ischemia19 (Fig. 56-1). The ST-segment pattern of demand-related ischemia is
• Nonischemic ST-segment changes can occur and should ST-segment depression, often appearing in several ECG
be considered when evaluating ST-segment trend changes, leads (Fig. 56-4).
and they include movement of the skin electrodes, dys- • Ideally, diagnosis of myocardial ischemia should be done
rhythmias, intermittent bundle-branch block pattern, body with continuous monitoring of all 12 ECG leads because
position changes, and ventricular paced rhythms.1,9,13 the mechanism of ischemia may vary (i.e., supply- [occlu-
• One type of myocardial ischemia seen in patients with sion] versus demand-related ischemia), resulting in dis-
ACS is supply-related ischemia, which results from com- tinctly different ST-segment patterns (e.g., elevation or
plete coronary artery occlusion. Coronary occlusion is depression) in specific ECG leads. If only two ECG leads
486
56 ST-Segment Monitoring (Continuous) 487
#3
6 Ischemic events
4 #1
#2
ST level 2
millimeter
(mm)
0
–2
V6 V5
V4 V3
V2 V1 15
III aVF 12
II 9
12 ECG leads –aVR I 6
aVL 0 3
15-hour time period
Figure 56-1 The importance of assessing the trend of the ST segments over time. The three-
dimensional image illustrates ST-segment deviation in millimeters (Y-axis) in all 12 electrocardio-
graph leads (X-axis) over a 15-hour period (Z-axis). Illustrated are three separate ischemic events,
characterized by ST-segment elevation, in leads V3 to V5. (Adapted from Pelter MM, Adams MG,
Drew BJ: Transient myocardial ischemia is an independent predictor of adverse in-hospital
outcomes in patients with acute coronary syndromes treated in the telemetry unit, Heart Lung
32:71–78, 2003.)
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Figure 56-2 The typical ST-segment pattern of supply-related ischemia in the inferior wall. The
right coronary artery is likely occluded, resulting in ST-segment elevation in leads II, III, and aVF.
are available, however, the best two for ischemia detection biomarkers of injury may be a cost-effective way to
are leads III and V3.9 Patient-specific monitoring also may triage patients who arrive at the emergency department
be done if a prior 12-lead ECG was obtained during acute with chest pain.
ischemia (i.e., STEMI, percutaneous coronary interven- ❖ After nonurgent PCI procedures with suboptimal
tion [PCI], or treadmill test). In this scenario, the ECG results, monitoring should be initiated immediately
lead(s) showing maximal ST-segment deviation should be postprocedure and continue for 24 hours or longer if
selected for continuous monitoring to detect recurrent arrhythmias or ST-segment–deviation events occur.
ischemia. ❖ Variant angina resulting from coronary vasospasm
• According to current consensus statements,9,10 multilead • According to these same guidelines,9,10 ST-segment moni-
ST-segment monitoring is indicated in most patients with toring may be of benefit for the following cases:
the following diagnoses: ❖ Postacute MI
❖ Early phase of acute MI (STEMI, non-ST STEMI, ❖ After nonurgent uncomplicated PCI
“rule-out”): patients should be monitored for a ❖ With high risk for ischemia after cardiac or noncardiac
minimum of 24 hours until they remain event-free for surgery
12 to 24 hours. • ST-segment monitoring may not be appropriate for certain
❖ Chest pain (or anginal equivalent) that prompts a visit patient groups because current software cannot reliably
to the emergency department: ST-segment monitoring interpret ST-segment changes resulting from myocardial
for 8 to 12 hours in combination with testing serum ischemia and leads to false-positive alarms, contributing
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Figure 56-3 The typical ST-segment pattern of supply-related ischemia in the anterior wall.
The left anterior descending artery is likely occluded, resulting in ST-segment elevation in leads V2
to V4.
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Figure 56-4 The typical ST-segment pattern of demand-related ischemia. Note the ST-segment
depression appearing in nearly every ECG lead, with the exception of V1 and aVR. Note also that
this patient is experiencing tachycardia, a common cause of demand-related ischemia.
to alarm fatigue.9,10,15 Specifically, it may not be suitable Additional equipment, to have available as needed, includes
to monitor patients with the following: the following:
❖ Left bundle-branch block • Clippers or scissors, used with caution in patients on anti-
❖ Ventricular paced rhythm coagulants, to clip hair from the chest as needed to ensure
❖ Confounding dysrhythmias that obscure the ST segment adequate adhesion of skin electrodes
❖ Agitation causing excessive artifact • Black indelible marker to mark precordial sites where skin
• A variety of bedside and telemetry cardiac monitors are electrodes are placed to maintain consistent lead loca-
currently available for use in clinical practice. Not all tions by ensuring electrodes are replaced to the correct
monitoring systems are equipped with ST-segment moni- locations.
toring software, however. Clinicians must determine • ECG calipers for measuring waveforms (may be available
whether their cardiac monitoring system has ST-segment electronically via the central monitor)
monitoring capabilities.
EQUIPMENT
• Explain the purpose of ST-segment monitoring. Ratio-
• ECG monitor with ST-segment monitoring capacity nale: This explanation decreases patient and family
• ECG lead wires, which may or may not be disposable anxiety.
• Skin electrodes, pregelled and disposable • Encourage the patient to report any symptoms of chest
• Nonsterile gloves pain or anginal equivalent (e.g., arm pain, jaw pain, short-
• Skin-preparation supplies, which vary based on the hos- ness of breath, or nausea). Rationale: This education
pital protocol; these may include a wash cloth, soap and heightens the patient’s awareness of cardiac sensations
water, or gauze pads and encourages communication of anginal symptoms.
PATIENT ASSESSMENT AND Patient Preparation

PREPARATION • Verify that the patient is the correct patient using two
Patient Assessment nurse should ensure the correct identification of the patient
• Assess if the patient is at high risk for ischemia. Ratio- for the intended intervention.
nale: Patients at risk for myocardial ischemia need to be • Ensure that the patient and family understand prepro-
identified. cedural teaching. Answer questions as they arise, and
• Assess the patient’s cardiac rhythm. Rationale: This reinforce information as needed. Rationale: This com-
assessment provides baseline data and ensures the munication evaluates and reinforces understanding of pre-
patient has a cardiac rhythm suitable for ST-segment viously taught information.
monitoring. • Place the patient in a resting supine position in bed, and
• Identify the patient’s baseline ST-segment levels before expose the patient’s torso while maintaining modesty.
initiating ST-segment monitoring. Rationale: The patient’s Rationale: This preparation provides access to the
baseline ST-segment level is identified for comparison patient’s chest for electrode placement and ensures that an
with subsequent changes. artifact-free ECG is obtained.
Procedure for Continuous ST-Segment Monitoring

1. HH
2. PE
3. Identify accurate electrode Ensures accurate ECG data. Electrodes (V3 to V5) should be
placement (Fig. 56-5). placed immediately below a
pendulous breast so that the breast
lies on top of the electrode,
preventing motion artifact.
Figure 56-5 Correct lead placement for 12-lead ST-segment monitor-

ing. Limb electrodes must be located as close as possible to the junction
of the limb and the torso. To ensure an inferior view of the myocardium,
the left leg (LL) electrode must be placed well below the level of the
umbilicus. For V1, the electrode is located at the fourth intercostal space
to the right of the sternum. V2 is in the same fourth intercostal space just
to the left of the sternum, and V4 is in the fifth intercostal space on the
midclavicular line. Placement of lead V3 is halfway on a straight line
between leads V2 and V4. Leads V5 and V6 are positioned on a straight
line from V4, with V5 in the anterior axillary line and V6 in the midaxillary
line. RA, right arm; LA, left arm; RL, right leg.

Procedure for Continuous ST-Segment Monitoring—Continued

4. Clean and slightly abrade the Removes dead skin cells, promoting Clipping hair should be done with
skin where the electrodes will impulse transmission. Moist skin is caution in patients at risk for
be applied. not conducive to electrode bleeding. Quality improvement
A. Wash the skin with soap adherence. Failure to properly projects have shown that changing
and water. prepare the skin may cause skin electrodes daily can reduce
B. Abrade the skin with a artifacts and interfere with artifacts.4,6
gauze pad. interpretation.4,9, 17
applied.
D. Clipping chest hair may be
the skin electrodes is
made. (Level C*)
5. If possible, mark any Ensures that skin electrodes are Continuous ST-segment monitoring
precordial locations with a replaced to the correct location to trends depend on stable electrode
black indelible marker. maintain consistent lead locations. placement.
Sudden changes in ST-segment trends
often indicate electrode movement.
6. Remove the backing from the Gel should be moist to allow for Skin electrodes should be stored in a
pregelled electrodes and maximal impulse transmission. dry area and not exposed to direct
assess the center of the pads sunlight because this can dry out
for moistness. the conductive gel.
7. Connect the ECG leads to the Prepares the monitoring system and
electrodes before placing the prevents unnecessary pressure on
electrodes on the patient. the patient’s chest when connecting
the lead wires to the electrodes.
8. Select the monitoring leads. Although any ECG lead can be used If continuous 12-lead ECG
for ST-segment monitoring, monitoring is unavailable, lead-
monitoring of all 12 ECG leads or specific ischemia monitoring is
the selection of a lead or leads encouraged. Lead III is sensitive to
based on the myocardial zone at inferior ischemia, and V3 is
risk is desirable (e.g., inferior or sensitive to anterior or posterior
anterior).9 ischemia.9,10
9. If required by the bedside Prepares the monitoring system and Refer to manufacturer’s
monitor manufacturer, identify ensures accurate monitoring. recommendations.
the ECG complex landmarks
and select the J point + 60-ms
landmark.9,10 (Level M*)
10. Set the ST-segment alarm. Maximizes the sensitivity and For bedside cardiac monitoring, the
specificity of ST-segment alarm threshold should be set
monitoring and may reduce 1–2 mm above and below the
unnecessary false alarms. patient’s baseline ST-segment level
(Fig. 56-6).9,10 Recently, a wider
threshold of 2 mm for triggering an
alarm has been used to reduce false
positives and alarm fatigue.
Establishing a patient-specific
ST-segment level, rather than an
isoelectric ST-segment level, is
important because the patient’s
baseline ST-segment level is rarely
isoelectric.9,10,13
R 1 mm
60 ms
P-R S-T
}
seg. segment
T P T 4 mm
J point 4 mm
Q
}
60 ms
A B C
Figure 56-6 A, Normal electrocardiograph complex. Measurement points used in ST-segment
analysis are indicated. The PR segment is used to identify the isoelectric line. The ST segment begins
at the J point, which is the end of the QRS complex. The ST-segment measurement point can be
measured at 60 or 80 ms past the J point. B, ST-segment elevation. The ST segment shown measures
+4 mm. C, ST-segment depression. The ST segment shown measures −4 mm. (Adapted from Tisdale
LA, Drew BJ: ST segment monitoring for myocardial ischemia, AACN Clin Issues Crit Care Nurs
4:36, 1993.)
Procedure for Continuous ST-Segment Monitoring—Continued

11. Print the baseline ECG tracing Ensures a quality baseline ECG for Verify that lead wires are not
to evaluate the quality of the comparing subsequent changes reversed, especially the limb leads.
signal and secure for future because ST-segment monitoring is
reference. based on continuous trending.
12. If possible, obtain an ECG Comparison of side-lying ECGs with
with the patient in right- and ECGs from subsequent alarms may
left-side–lying positions and prevent interpreting as ischemia
secure these for future false-positive ST-segment
reference. deviations caused by changes in
body position.1,8,18
14. HH

• Accurate ECG monitoring that allows clinicians to • Altered skin integrity
detect and interpret ST-segment changes • Alternating current (AC) interference, also called
• Timely detection of myocardial ischemia 60-cycle interference (see Fig. 54-9)
• An increase in the number of bedside alarms when the • Wandering baseline (see Fig. 54-10)
ST-segment software is initiated which may be caused • Artifacts (see Fig. 54-11)
by actual ischemia, body-position changes, transient • Inappropriate diagnosis of ischemia in nonischemic
dysrhythmias, heart rate changes, artifacts, or lead conditions (i.e., bundle-branch block, early
misplacement13 repolarization)20
• Inappropriate intervention based on a false
ST-segment alarm8

interventions.
1. Check electrode placement every Enhances the quality of ST-segment
shift. There is inadequate data on monitoring.
disposable electrodes and how
often they should be changed to
prevent false alarms due to
electrode failure.
2. Evaluate ST-segment trends Ensures that no significant • ST-segment trend changes more
routinely while obtaining vital deviations in the ST-segment trend than 1 mm ST amplitude change
signs. occur. Requiring the ST change to lasting at least 1 minute8
last at least 1 minute and to be
present in two contiguous leads
may drastically reduce the number
of false ST-segment monitor
alarms. Contiguous (side-by-side)
leads in the limb leads, should be
defined using the following
sequence: aVL, I, minus aVR, II,
aVF, III. ST changes in two of
these side-by-side leads would
meet the criteria for ischemia.
3. Interpret all ST-segment alarms Ensures accurate interpretation. A • ST-segment changes
and determine the cause. If actual 12-lead resting ECG assists with • Onset of symptoms or anginal
ischemia is noted, assess the determining ischemia location and equivalent
patient for signs and symptoms type (i.e., supply versus demand).
that suggest acute ischemia, Determines the patient’s response
anginal equivalents, hemodynamic to ischemia.
changes, or dysrhythmias, and
then obtain a 12-lead ECG.
4. Assess the patient for signs and Determines the presence of • ST-segment changes
symptoms that suggest acute ischemia. Because ischemia can • Onset of symptoms or anginal
ischemia, even if no new be clinically silent, a 12-lead ECG equivalent
ST-segment changes are assists with determining ischemia
identified, and obtain a 12-lead location and type (i.e., supply
ECG as needed. versus demand).
analgesia and nitrates as
prescribed.
Documentation
• Patient and family education • Presence and intensity of chest pain or anginal
• Initiation of ST-segment bedside monitoring equivalent, interventions, and effectiveness
• Initial ECG strip with baseline ST segment • Additional interventions taken
• Any ST-segment changes or any symptoms that • Unexpected outcomes
suggest acute ischemia

56 ST-Segment Monitoring (Continuous) 493.e1
References trials involving 12-lead ST-segment monitoring.

1. Adams MG, Drew BJ: Body position effects on the ECG: J Electrocardiol 38(4 Suppl):180–185, 2005.
Implication for ischemia monitoring. J Electrocardiol 13. Drew BJ, et al: Bedside diagnosis of myocardial ischemia
30(4):285–291, 1997. with ST-segment monitoring technology: Measurement
2. Adams MG, et al: Frequency of silent myocardial issues for real-time clinical decision making and trial
ischemia with 12-lead ST segment monitoring in the designs. J Electrocardiol 30(Suppl):157–165, 1998.
coronary care unit: Are there sex-related differences? 14. Drew BJ, et al: Insights into the problem of alarm fatigue
Heart Lung 28(2):81–86, 1999. with physiologic monitor devices: A comprehensive
3. Akkerhuis KM, et al: Recurrent ischaemia during observational study of consecutive intensive care unit
continuous multilead ST-segment monitoring identifies patients. PLoS ONE 9(10):e110274, 2014.
patients with acute coronary syndromes at high risk of 15. Gottlieb SO, et al: Silent ischemia as a marker for early
adverse cardiac events: Meta-analysis of three studies unfavorable outcomes in patients with unstable angina.
involving 995 patients. Eur Heart J 22(21):1997–2006, N Engl J Med 314(19):1214–1219, 1986.
2001. 16. Krucoff MW, et al: Continuously updated 12-lead
4. Cvach MM, et al: Daily electrode change and effect on ST-segment recovery analysis for myocardial infarct
cardiac monitor alarms: An evidence-based practice artery patency assessment and its correlation with multiple
approach. J Nurs Care Qual 28:265–271, 2013. simultaneous early angiographic observations. Am J
5. Cura FA, et al: Protection of distal embolization in Cardiol 71(2):145–151, 1993.
high-risk patients with acute ST-segment elevation 17. Medina V, Clochesy JM, Omery A: Comparison of
myocardial infarction (PREMIAR). Am J Cardiol electrode site preparation techniques. Heart Lung
99(3):357–363, 2007. 18(5):456–460, 1989.
6. Dandoy CE, et al: A team-based approach to reducing 18. Pelter MM, Adams MG, Drew BJ: Transient myocardial
cardiac monitor alarms. Pediatrics 134(6):e1686–e1694, ischemia is an independent predictor of adverse
2014. in-hospital outcomes in patients with acute coronary
7. DeWood MA, et al: Prevalence of total coronary syndromes treated in the telemetry unit. Heart Lung
occlusion during the early hours of transmural myocardial 32(2):71–78, 2003.
infarction. N Engl J Med 303(16):897–902, 1980. 19. Pelter MM, et al: A research method for detecting
8. Drew BJ, Adams MG: Clinical consequences of transient myocardial ischemia in patients with suspected
ST-segment changes caused by body position mimicking acute coronary syndrome using continuous ST-segment
transient myocardial ischemia: Hazards of ST-segment analysis. J Vis Exp (70):2012.
monitoring? J Electrocardiol 34(3):261–264, 2001. 20. Shusterman V, et al: Dynamic tracking of ischemia in the
9. Drew BJ, et al: AHA scientific statement: Practice surface electrocardiogram. J Electrocardiol 40(Suppl 6):
standards for electrocardiographic monitoring in hospital S179–S186, 2007.
settings: An American Heart Association Scientific 21. Stephens KE, et al: Interpreting 12-lead
Statement from the Councils on Cardiovascular Nursing, electrocardiograms for acute ST-elevation myocardial
Clinical Cardiology, and Cardiovascular Disease in the infarction: what nurses know. J Cardiovasc Nurs
Young: endorsed by the International Society of 22(3):186–193, 2007.
Computerized electrocardiology and the American
Association of Critical-Care Nurses. J Cardiovasc Nurs Additional Readings
20(2):76–106, 2005. ECG Puzzler Features located in the American Journal of
10. Drew BJ, Krucoff MW: Multilead ST-segment monitoring Critical Care (AJCC), 2001 to present.
in patients with acute coronary syndromes: A consensus Adams MG, Pelter MM: In hospital cardiac monitoring. In
statement for healthcare professionals: ST-Segment Conover M, editor: Understanding electrocardiography,
Monitoring Practice Guideline International Working ed 8, St Louis, 2003, Mosby, pp 431–443.
Group. Am J Crit Care 8(6):372–388, 1999. Pelter MM, et al: Among Unstable Angina and Non-ST-
11. Drew BJ, Pelter MM, Adams MG: Frequency, Elevation Myocardial Infarction Patients, Transient
characteristics, and clinical significance of transient ST Myocardial Ischemia and Early Invasive Treatment Are
segment elevation in patients with acute coronary Predictors of Major In-hospital Complications.
syndromes. Eur Heart J 23(12):941–947, 2002. J Cardiovasc Nurs 2015. [Epub ahead of print].
12. Drew BJ, et al: Designing prehospital ECG systems for Wagner GS: Marriott’s practical electrocardiology, ed 11,
acute coronary syndromes: Lessons learned from clinical Philadelphia, 2008, Lippincott Williams & Wilkins.
PROCEDURE
57
Twelve-Lead Electrocardiogram
Shu-Fen Wung
PURPOSE: A 12-lead electrocardiogram (ECG) provides information about the
electrical activity of the heart from 12 different views or leads. The ECG is the most
commonly performed cardiovascular diagnostic procedure.1 Common uses of a
12-lead ECG include diagnosis of acute coronary syndromes, identification of
arrhythmias, and determination of the effects of medications, electrolytes, or
structural abnormalities on the electrical system of the heart.
PREREQUISITE NURSING • Nurses should be able to operate the 12-lead ECG machine.
KNOWLEDGE Calibration of 1 mV equals 10 mm and paper speed of
25 mm/sec are standards used in clinical practice. For
• Understanding of the anatomy and physiology of the car- ST-segment analysis, filter settings of 0.05 to 100 Hz are
diovascular system, principles of electrophysiology, ECG recommended by the American Heart Association.5 Any
lead placement, basic rhythm interpretation, and electrical variation used for particular clinical purposes should be
safety is necessary. noted on the tracing. Specific information regarding con-
• Advanced cardiac life support (ACLS) knowledge and figuring the ECG machine, troubleshooting, and safety
skills are needed. features is available from the manufacturer and should be
• A 12-lead ECG provides different views or leads of the read before use of the equipment.
electrical activity of the heart. The 12 standard leads • Nurses should be able to interpret recorded ECGs for the
include six limb leads (I, II, III, augmented vector right presence or absence of myocardial ischemia/infarction and
[aVR], augmented vector foot [aVF], and augmented arrhythmias so that patients can be treated appropriately.
vector left [aVL]), and six chest leads (V1 to V6). • Advances in technology have allowed for online or wire-
• The limb leads view the heart from the frontal or vertical less transmission, networking capabilities, and computer-
plane (Fig. 57-1), and the chest leads view the heart from ized interpretation of the 12-lead ECG (Fig. 57-3). The
the horizontal plane (Fig. 57-2). 12-lead ECG cable is attached to a processing device that
• The basic ECG waveforms are labeled with P, Q, R, S, digitizes the 12-lead ECG recording and transfers the
and T waves, which represent electrical activity within the information to the wireless device, which transmits the
heart. information to the medical record. This increases access
• Accuracy in identification of anatomical landmarks for to the 12-lead ECG for review and can assist with rapid
location of electrode sites and knowledge of the impor- interpretation and treatment of the patient.
tance of accurate electrode placement are needed. Accu-
rate ECG interpretation is possible only when the recording EQUIPMENT
electrodes are placed in the proper positions. Slight altera-
tions of the electrode positions may distort significantly • 12-lead ECG machine with patient cable and lead wires
the appearance of the ECG waveforms and can lead to • ECG electrodes
misdiagnosis.2 Reliable comparison of serial (more than Additional equipment, to have available as needed, includes
two ECGs recorded at different times) ECG recordings the following:
relies on accurate and consistent electrode placement. An • Gauze pads or terrycloth washcloth
indelible marker is recommended for clear identification • Cleansing pads or nonemollient soap and water
of the electrode locations to ensure that the same electrode • Skin preparation solution (e.g., skin barrier wipe or tinc-
locations are selected when serial ECGs are recorded. ture of benzoin)
• Nurses should be aware of body-positional changes that • Indelible marker
can alter ECG recordings. Serial ECGs should be recorded • Clippers or scissors to clip hair from the patient’s chest if
with the patient in a supine position to ensure that all needed
recordings are done in a consistent manner. Side-lying
positions and elevation of the torso may change the posi- PATIENT AND FAMILY EDUCATION
tion of the heart within the chest and can change the
waveforms on the ECG recording.3,4 If a position other • Describe the procedure and reasons for obtaining the
than supine is clinically necessary, notation of the altered 12-lead electrocardiogram. Reassure the patient that the
position should be made on the tracing. procedure is painless. Rationale: This communication
494
57 Twelve-Lead Electrocardiogram 495
Figure 57-1 Vertical plane leads: I, II, III, aVR, aVL, aVF.
Figure 57-3 Example of a wireless electrocardiograph (ECG)
device. The 12-lead cable is attached to a processing device that can
then be transmitted to the medical record.
recordings can help clinicians determine whether a change

is acute or chronic.
• Assess for the presence of anginal symptoms, such as
chest pain, pressure, tightness, heaviness, fullness, or
squeezing sensation; radiated pain; or shortness of breath,
nausea, and extreme fatigue. Rationale: This evaluation
correlates ECG changes with patient symptoms.
• Assess the patient’s history of cardiac conditions and
review medication history. Rationale: Knowledge about
Figure 57-2 Horizontal plane leads: V1 to V6. the patient’s cardiac history and medications can help in
interpretation of ECG recordings.
clarifies information, reduces anxiety, and gains coopera- Patient Preparation

tion from the patient. • Verify that the patient is the correct patient using two
• Explain the patient’s role in assisting with the ECG record- identifiers. Rationale: Before performing a procedure, the
ing and emphasize actions that improve the quality of the nurse should ensure the correct identification of the patient
ECG tracing, such as relaxing, avoiding conversation and for the intended intervention.
body movement, and breathing normally. Rationale: This • Ensure that the patient and family understand prepro-
explanation ensures the patient’s cooperation to improve cedural teaching. Answer questions as they arise, and
the quality of the tracing and avoids unnecessary repeating reinforce information as needed. Rationale: This com-
of the ECG because of muscle artifact. munication evaluates and reinforces the understanding of
previously taught information.
• Assist the patient to the supine position and expose the
PATIENT ASSESSMENT AND patient’s torso while maintaining the patient’s modesty.
PREPARATION Rationale: This position enables the recording of a
standard 12-lead ECG and allows comparison of serial
Patient Assessment ECGs and comparison with standard waveforms. Body-
• Interpret previously recorded ECGs. Rationale: Each positional changes, such as elevation and rotation, can
patient has an individual baseline ECG. Previous ECG change recorded amplitudes and axes.
Procedure for 12-Lead Electrocardiogram

1. HH
2. Check cables and lead wires for Detects faulty equipment. If the equipment is damaged, obtain
fraying or broken wires. alternative equipment and notify
a biomedical engineer for repair.
3. Check the lead wires for accurate Obtains accurate ECG recordings
labels. and proper placement of leads.
4. Plug the ECG machine into a Maintains electrical safety. Follow manufacturer’s
grounded alternating current (AC) recommendations and institutional
wall outlet or ensure functioning if protocol on electrical safety per
battery operated. the biomedical department.
5. Turn the ECG machine on and Equipment may require self-test Manufacturers provide a calibration
program the ECG machine: paper and warm-up time. Verify check in the machine to identify
speed, 25 mm/sec; calibration, equipment settings in the sensitivity setting. Most
10 mm/mV; filter settings, 0.05– accordance with clinical practice machines have automatic settings.
100 Hz. (Level E*) and recommendations by the
American Heart Association
(AHA).5 Multichannel machines
may require input of information
(e.g., data about the patient) to
store the ECG appropriately.
6. PE
7. Place the patient in a supine Provides adequate support for ECGs should be recorded in the
position. (Level B*) limbs so that muscle activity is same body position to ensure
minimal. Body-position changes ECG changes are not caused by a
can cause ST-segment deviation change in body position. If
and QRS waveform another position is clinically
alteration.3,4,6 necessary, note the altered
position on the ECG recording.
8. Expose only the necessary body Provides privacy and warmth, Ensuring privacy may reduce
parts of the patient (legs, arms, and which reduces shivering. anxiety.
chest) for electrode placement. Shivering may interfere with the
quality of recording.
9. Identify skin electrode locations. Ensures the accuracy of the lead
placement.
A. Limb leads (Fig. 57-4).
Figure 57-4 Limb lead placement in 12-lead ECG.
Procedure for 12-Lead Electrocardiogram—Continued

• Right arm (RA): inside right Accurate electrode placement is Limb leads should be placed in
forearm essential for obtaining valid and fleshy areas; bony prominences
• Left arm (LA): inside left reliable data for ECG should be avoided. The limb
forearm recordings. The RL electrode is leads need to be placed
• Right leg (RL): anywhere on a ground electrode that does not equidistant from the heart and
the body; by convention, contribute to the ECG tracings. should be positioned in
usually on the right ankle or approximately the same place on
inner aspect of the calf each limb.
• Left leg (LL): left ankle or
inner aspect of the calf
B. Precordial Leads (Fig. 57-5)
• Identify the sternal notch. The angle of Louis assists with Variations in precordial lead
Slide fingers down the center identifying the second rib for placement of as little as 2 cm can
of the sternum to the obvious correct placement of precordial result in important diagnostic
bony prominence, angle of leads in the appropriate ICS. errors, particularly in anteroseptal
Louis, which identifies the Slight alterations in the position of infarction and ventricular
second rib and provides a any of the precordial leads may hypertrophy.6
landmark for noting the second alter the ECG significantly and If precordial leads cannot be
intercostal space (ICS). can affect diagnosis and accurately placed because of
❖ V1: fourth ICS at right treatment.2,7,8 chest wounds, placement of
sternal border defibrillator pads, or other
❖ V2: fourth ICS at left sternal reasons, the alternative site
border should be clearly documented on
❖ V4: fifth ICS at the ECG.9
midclavicular line It is recommended that electrodes
❖ V3: halfway between V2 and be placed under the breast in
V4 women until additional studies
❖ V5: horizontal level to V4 at are available.5
the anterior axillary line
❖ V6: horizontal level to V4 at
the midaxillary line
Figure 57-5 Precordial or chest lead placement.
10. Clean and slightly abrade the skin Removes dead skin cells, Failure to properly prepare the skin
where the electrodes will be applied. promoting impulse may cause artifacts and interfere
A. Wash the skin with soap and transmission.10-12 Moist skin is with interpretation.
water, if needed. not conducive to electrode
B. Abrade the skin with a gauze adherence.
pad or abrader.
C. Ensure that the skin is dry before
skin electrodes are applied.
necessary to ensure that adequate
skin contact with the skin
electrodes is made. (Level C*)

11. Identify the electrode sites and mark Minimizes ECG changes caused After accurate identification of the
them with an indelible marker. by altered electrode placement.2,6 locations, an indelible marker
should be used to mark the
electrode sites if serial ECGs are
anticipated.
12. For pregelled electrodes, remove the Allows for appropriate conduction Gel must be moist. If pregelled
backing and test for moistness. For of impulses. electrodes are not moist or
adhesive electrodes, remove the adhesive electrodes are not sticky,
backing and check each adhesive replace the electrodes.
pad, as each should be sticky or
moist.
13. Apply the electrodes securely and Electrodes must be secure to If limb plate electrodes are used, do
place the electrodes on the marked prevent external influences from not overtighten to minimize
locations. affecting the ECG. Secure the discomfort.
electrodes to obtain quality ECG
recordings.
14. Fasten the lead wires to the limb Provides for correct lead-to-limb
electrodes, avoiding bending or connection.
strain on the wires, and use the
correct lead-to-electrode connection.
15. Identify the multiple-channel Multiple-channel machines run
machine recording setting several leads simultaneously and
(Fig. 57-6). can be set to run leads in
different configurations.
Figure 57-6 Multiple-channel ECG machine. (Courtesy Philips

Medical Systems, Andover, MA.)

16. Obtain a 12-lead ECG recording. Three to six seconds are all that is A multiple-channel machine runs
Most systems record each lead for needed for a permanent record; the limb and chest leads
3–6 seconds and automatically mark a longer strip may be obtained if simultaneously.
the correct lead. a rhythm strip is needed.
17. Examine the quality of the 12-lead While the patient is still connected Reviews the normal conduction
ECG tracing. to the machine, the nurse should sequence and identifies
examine the ECG to see whether abnormalities that may necessitate
any leads need to be repeated. further evaluation or treatment.
18. Disconnect the equipment; clean the Increases patient comfort. Some pregelled electrodes can be
gel off the patient (if necessary), Reduces the transmission of left in place for repeat ECGs.
remove PE , discard used supplies, microorganisms; Standard Follow the manufacturer’s
and prepare the equipment for Precautions. directions and hospital policy for
future use. electrode use and removal in
these cases.
19. HH

• A clear and accurate 12-lead ECG recording that • Altered skin integrity
allows clinicians to diagnose dysrhythmias and • Inaccurate lead placement or connection (Fig. 57-8)
ischemia (Fig. 57-7) • AC interference, also called 60-cycle interference
• Prompt identification of abnormalities (see Fig. 54-9)
• Wandering baseline (see Fig. 54-10)
• Artifact or waveform interference (see Fig. 54-11)
Figure 57-7 Clear 12-lead ECG recording.

B
Figure 57-8 Limb lead reversal on 12-lead electrocardiograph (ECG) in lead I. A, Correct place-
ment. B, Incorrect placement.

interventions.
1. Obtain a 12-lead ECG as Provides determination of • Angina
prescribed and as needed (e.g., for myocardial ischemia, injury, • Arrhythmias
angina or arrhythmias). and infarction. Aids in • Abnormal 12-lead ECG
diagnosis of arrhythmias.
2. Compare the 12-lead ECG with the Determines normal and • Any abnormal changes in the
previous 12-lead ECGs. abnormal findings. 12-lead ECG
3. Follow institutional standards for Promotes comfort. • Continued pain despite pain
analgesia and nitrates as prescribed.
Documentation
• Patient and family education • Pain assessment, interventions, and patient response
• The fact that a 12-lead ECG was obtained to interventions
• The reason for the 12-lead ECG • Follow-up to the 12-lead ECG as indicated
• Any altered lead placement and reason • Unexpected outcomes
• Symptoms that the patient experienced (e.g., chest • Additional interventions
pain, syncope, dizziness, or palpitations)

57 Twelve-Lead Electrocardiogram 500.e1
References Hancock EW, et al: AHA/ACCF/HRS recommendations for

1. Kligfield P: The centennial of the Einthoven the standardization and interpretation of the
electrocardiogram. J Electrocardiol 35(Suppl):123–129, electrocardiogram: Part V: Electrocardiogram changes
2002. associated with cardiac chamber hypertrophy: A scientific
2. Drew BJ: Pseudo myocardial injury patterns because of statement from the American Heart Association
nonstandard electrocardiogram electrode placement. Electrocardiography and Arrhythmias Committee, Council
J Electrocardiol 41(3):202–204, 2008. on Clinical Cardiology; the American College of
3. Adams MG, Drew BJ: Body position effects on the ECG: Cardiology Foundation; and the Heart Rhythm Society.
Implication for ischemia monitoring. J Electrocardiol Endorsed by the International Society for Computerized
30(4):285–291, 1997. Electrocardiology. J Am Coll Cardiol 53(11):992–1002,
4. Nelwan SP, et al: Correction of ECG variations caused by 2009.
body position changes and electrode placement during Macfarlane PW: Age, sex, and the ST amplitude in health and
ST-T monitoring. J Electrocardiol 34(Suppl):213–216, disease. J Electrocardiol 34(Suppl):235–241, 2001.
2001. Mason JW, et al: Recommendations for the standardization
5. Kligfield P, et al: Recommendations for the and interpretation of the electrocardiogram: Part II:
standardization and interpretation of the Electrocardiography diagnostic statement list a scientific
electrocardiogram: Part I: the electrocardiogram and its statement from the American Heart Association
technology: A scientific statement from the American Electrocardiography and Arrhythmias Committee, Council
Heart Association Electrocardiography and Arrhythmias on Clinical Cardiology; the American College of
Committee, Council on Clinical Cardiology; the American Cardiology Foundation; and the Heart Rhythm Society
College of Cardiology Foundation; and the Heart Rhythm Endorsed by the International Society for Computerized
Society: endorsed by the International Society for Electrocardiology. J Am Coll Cardiol 49(10):1128–1135,
Computerized Electrocardiology. Circulation 2007.
115(10):1306–1324, 2007. Rautaharju PM, et al: AHA/ACCF/HRS recommendations for
6. Baevsky RH, et al: Supine vs semirecumbent and upright the standardization and interpretation of the
12-lead electrocardiogram: Does change in body position electrocardiogram: Part IV: The ST segment, T and U
alter the electrocardiographic interpretation for ischemia? waves, and the QT interval: A scientific statement from the
Am J Emerg Med 25(7):753–756, 2007. American Heart Association Electrocardiography and
7. Drew BJ: Pitfalls and artifacts in electrocardiography. Arrhythmias Committee, Council on Clinical Cardiology;
Cardiol Clin 24(3):309–315, 2006. the American College of Cardiology Foundation; and the
8. Wung SF: Computer-assisted continuous ST-segment Heart Rhythm Society. Endorsed by the International
analysis for clinical research: Methodological issues. Society for Computerized Electrocardiology. J Am Coll
Biol Res Nurs 3(2):65–77, 2001. Cardiol 53(11):982–991, 2009.
9. Drew BJ, et al: Practice standards for Sole M, Klein D, Moseley M: Introduction to critical care
electrocardiographic monitoring in hospital settings: nursing, ed 6, St. Louis, 2013, Elsevier Saunders.
An American Heart Association scientific statement Surawicz B, et al: AHA/ACCF/HRS recommendations for the
from the Councils on Cardiovascular Nursing, Clinical standardization and interpretation of the electrocardiogram:
Cardiology, and Cardiovascular Disease in the Young: Part III: Intraventricular conduction disturbances: A
endorsed by the International Society of Computerized scientific statement from the American Heart Association
Electrocardiology and the American Association of Electrocardiography and Arrhythmias Committee, Council
Critical-Care Nurses. Circulation 110(17):2721–2746, on Clinical Cardiology; the American College of
2004. Cardiology Foundation; and the Heart Rhythm Society.
10. Clochesy JM, Cifani L, Howe K: Electrode site Endorsed by the International Society for Computerized
preparation techniques: A follow-up study. Heart Lung Electrocardiology. J Am Coll Cardiol 53(11):976–981,
20(1):27–30, 1991. 2009.
11. Tam HW, Webster JG: Minimizing electrode motion Wagner GS, et al: AHA/ACCF/HRS recommendations for the
artifact by skin abrasion. IEEE Trans Biomed Eng standardization and interpretation of the electrocardiogram:
24(2):134–139, 1977. Part VI: Acute ischemia/infarction: A scientific statement
12. Lawler JC, Davis MJ, Griffith EC: Electrical from the American Heart Association Electrocardiography
characteristics of the skin. The impedance of the surface and Arrhythmias Committee, Council on Clinical
sheath and deep tissues. J Invest Dermatol 34:301–308, Cardiology; the American College of Cardiology
1960. Foundation; and the Heart Rhythm Society: endorsed by
the International Society for Computerized
Additional Readings Electrocardiology. Circulation 119(10):e262–e270, 2009.
Burns S: AACN essentials of critical care nursing, New York,
2014, McGraw-Hill Companies.
Section Nine Hemodynamic Monitoring
PROCEDURE
58
Arterial Catheter Insertion
(Perform)
PURPOSE: Arterial catheters are used for continuous monitoring of blood
pressure, assessment of cardiovascular effects of vasoactive drugs, and frequent
arterial blood gas and laboratory sampling. In addition, arterial catheters provide
access to blood samples that support the diagnostics related to oxygen, carbon
dioxide, and bicarbonate levels (oxygenation, ventilation, and acid-base status).
PREREQUISITE NURSING Mechanical cardiovascular support

KNOWLEDGE Vasoactive medication administration
• Noninvasive indirect blood pressure measurements deter-
• Knowledge of anatomy and physiology of the vasculature mined with auscultation of Korotkoff sounds distal to
and adjacent structures is needed. an occluding cuff consistently average 10 to 20 mm Hg
• Nurses must be adequately prepared to insert arterial cath- lower than simultaneous direct measurement.11
eters. This preparation should include specific educational • Arterial waveform inspection can help with rapid diagno-
content about arterial catheter insertion and opportunities sis of the presence of valvular disorders, and determine
to demonstrate clinical competency. the effects of dysrhythmias on perfusion, the effects of
• Knowledge of the principles of sterile technique is essen- the respiratory cycle on blood pressure, and the effects
tial. of intraaortic balloon pump therapy or ventricular assist
• Understanding the principles of hemodynamic monitoring device therapy on blood pressure.
is necessary. • The most common complications associated with arterial
• Clinical competence in suturing is needed. puncture include pain, vasospasm (artery spasm), hema-
• Conditions that warrant the use of arterial pressure moni- toma formation, thrombosis, embolism, infection, hemor-
toring include patients with the following: rhage, vascular insufficiency, ischemia, direct nerve
❖ Frequent blood sampling: trauma, and fistula formation.3 It has been found that
Respiratory conditions requiring arterial blood gas major complications occurred in less than 1% of patients
monitoring (oxygenation, ventilation, acid-base with arterial catheters, regardless of site selection.17 Arte-
status) rial catheter sites are a source of bloodstream infections,
Bleeding, actual or potential with the femoral site being more heavily associated with
Electrolyte or glycemic abnormalities, actual or colonization compared with other sites. The infective
potential potential of the arterial catheter is equivalent to the short-
Metabolic abnormalities (acid-base, tissue perfu- term central venous device regarding colonization and
sion), actual or potential bloodstream infections, and should be assessed together
Monitoring serum levels related to therapeutic inter- for signs and symptoms of infection.8
ventions (renal replacement therapy, chemotherapy, • Causes of failure to cannulate the artery include a tangen-
biotherapy, apheresis therapy, etc.) tial approach to the artery, tortuosity of the artery, arterial
❖ Continuous blood pressure monitoring: spasm, and impingement of the needle tip on the posterior
Hypotension or hypertension wall.18
Shock: cardiogenic, septic, hypovolemic, neurogenic • Site selection should include the following
considerations:
❖ The preferred artery for arterial catheter insertion is the

radial artery.12 Although this artery is smaller than the
practice nurses, and other healthcare professionals (including critical care ulnar artery, it is more superficial and can be more
nurses) with additional knowledge, skills, and demonstrated competence per easily stabilized during the procedure.8 Conduct a mod-
professional licensure or institutional standard. ified Allen’s test before performing an arterial puncture
501
on the radial artery (see Fig. 81-3). Normal palmar • Nonsterile gloves, head covering, goggles, and mask
blushing is complete before 7 seconds, indicating a • Sterile gloves and large sterile fenestrated drape
positive result; 8 to 14 seconds is considered equivocal; • Skin antiseptic solution (e.g., 2% chlorhexidine-based prep-
and 15 or more seconds indicates a negative test result. aration)
Doppler flow studies or plethysmography can also be • Sterile 4 × 4 gauze pads
performed to ensure the presence of collateral flow. • Transparent occlusive dressing
Research shows these studies to be more reliable than • 1% lidocaine without epinephrine, 1 to 2 mL
the modified Allen’s test.1,18 Thrombosis of the arterial • Sterile sodium chloride 0.9%
cannula is a possible complication. Ensuring collateral • 3-mL syringe with 25-gauge needle
flow distal to the puncture site is important for preven- • Sheet protector
tion of ischemia. Puncture of both the radial and ulnar • Bedside ultrasound machine with vascular probe
arteries on the same hand is never recommended, to • Sterile ultrasound probe cover
prevent compromising blood supply to the hand.4,13 • Sterile ultrasound gel
❖ The brachial artery is a potential insertion site. Before Additional equipment, to have available as needed, includes
use of this site consider that the brachial artery is the the following:
main artery supplying the arm; it branches into the • Sterile gown and full drape
radial and ulnar arteries, and it has no collateral circula- • Bath towel
tion.16 Hemostasis after arterial cannulation is enhanced • Small wrist board
by its proximity to the bone if the entry point is approx- • Sutureless securement device
imately 1.5 inches above the antecubital fossa. • Chlorhexidine-impregnated sponge
❖ Use the femoral artery in the case of cardiopulmonary • Additional transparent adhesive dressing with tapes (if dress
arrest or altered perfusion to the upper extremities. The ing has no tape, consider the use of 1 2-inch Steri-Strips)
femoral artery is a large superficial artery located in the • Transducer holder, intravenous pole, and laser lever for
groin. It is easily palpated and punctured; however, risk pole-mounted arterial catheter transducers
is associated with accessing the arterial vessel due to • Suture material
the proximity of the femoral artery to the femoral vein
(see Fig. 81-2). Complications related to femoral artery PATIENT AND FAMILY EDUCATION
puncture include hemorrhage and hematoma formation
(because bleeding can be difficult to control), inadver- • Explain the procedure and the purpose of the arterial cath-
tent puncture of the femoral vein (because of its close eter. Rationale: This explanation decreases patient and
proximity to the artery), infection (because aseptic family anxiety.
techniques are difficult to maintain in the groin area), • Explain to the patient that the procedure may be uncom-
and limb ischemia (if the femoral artery is damaged). fortable but that a local anesthetic will be used first to
❖ The dorsalis pedis and posterior tibial arteries are typi- alleviate most of the discomfort. Rationale: Patient coop-
cally avoided when selecting an arterial catheter site; eration is elicited, and insertion is facilitated.
however, they may be considered because they are • Explain the patient’s role in assisting with catheter inser-
supported by collateral circulation, which can prevent tion. Rationale: This explanation elicits patient coopera-
an ischemic injury.9 The dorsalis pedis is typically tion and facilitates insertion.
avoided due to the risk of dislodgement and inability
to secure the catheter well. The posterior tibial artery PATIENT ASSESSMENT AND
has been associated with ischemic injuries that have PREPARATION
resulted in amputation.16
• In adults, the use of the radial, brachial, or dorsalis pedis Patient Assessment
sites is preferred over the femoral or axillary sites of inser- • Obtain the patient’s medical history, including history of
tion to reduce the risk of infection.12,15 diabetes, hypertension, peripheral vascular disease, vas-
• Ultrasound guidance is recommended to place arterial cular grafts, arterial vasospasm, thrombosis, or embolism.
catheters if the technology is available.12 Obtain the patient’s history of coronary artery bypass graft
surgery in which radial arteries were removed for use as
EQUIPMENT conduits or presence of arteriovenous fistulas or shunts.
Rationale: Extremities with any of these problems should
• 2-inch, 20-gauge, nontapered Teflon cannula-over-needle be avoided as sites for cannulation because of the potential
or prepackaged kit that includes a 6-inch, 18-gauge Teflon for complications. Patients with diabetes mellitus or
catheter with appropriate introducer and guidewire (or the hypertension are at higher risk for arterial or venous insuf-
specific catheter for the intended insertion site) ficiency. Previously removed radial arteries are a contra-
• Pressure module and cable for interface with the monitor indication for ulnar artery cannulation.
• Pressure transducer system, including flush solution rec- • Assess the patient’s medical history of coagulopathies, use
ommended according to institutional standards, a pressure of anticoagulant therapy, vascular abnormalities, or periph-
bag or device, pressure tubing with transducer, and flush eral neuropathies. Rationale: This assessment assists in
device (see Procedure 75) determining the safety of the procedure and aids in site
• Dual-channel recorder selection.
58 Arterial Catheter Insertion (Perform) 503
• Assess the patient’s allergy history (e.g., allergy to lido- nurse should ensure the correct identification of the patient
caine, topical anesthetic cream, antiseptic solutions, or for the intended intervention.
tape). Rationale: This assessment decreases the risk for • Perform a preprocedure verification and time out, if non-
allergic reactions. emergent. Rationale: Ensures patient safety.
• Assess the patient’s current anticoagulation therapy, known • Ensure that the patient and family understand prepro-
blood dyscrasias, and pertinent laboratory values (e.g., cedural teaching. Answer questions as they arise and
platelet levels, partial thromboplastin time, prothrombin reinforce information as needed. Rationale: Understand-
time, and international normalized ratio) before the proce- ing of previously taught information is evaluated and
dure. Rationale: Anticoagulation therapy, blood dyscra- reinforced.
sias, or alterations in coagulation studies could increase • Obtain informed consent. Rationale: Informed consent
the risk for hematoma formation or hemorrhage. protects the rights of the patient and makes a competent
• Assess the intended insertion site for the presence of a decision possible for the patient; however, in emergency
strong pulse. Rationale: Identification and localization of circumstances, time may not allow the form to be signed.
the pulse increases the chance of a successful arterial • Place the patient supine with the head of the bed at a com-
cannulation. fortable position. The limb into which the arterial catheter
• Presence of collateral flow to the area distal to the arterial will be inserted should be resting comfortably on the bed.
catheter should be evaluated before the artery is cannu- Rationale: This placement provides patient comfort and
lated. For radial arterial lines, a modified Allen’s test facilitates insertion.
should be performed. Rationale: This assessment deter- • If the radial artery is selected, position the hand to allow
mines the presence of collateral flow to the hand to reduce for palpation of the artery (a pillow or towel may be used
vascular complications including ischemia. to support the wrist). Rationale: This placement positions
• If available, assess the intended artery with a Doppler the arm and brings the artery closer to the surface.
ultrasound scan. Rationale: This assessment aids in deter- • If the brachial artery is selected, elevate and hyperextend
mination of the patency of the artery and blood flow.1,2 the patient’s arm and palpate the artery (a pillow or towel
Identification and localization of the artery to be cannu- may be used to support the arm). Rationale: This action
lated increases the chance of a successful cannulization increases accessibility of the artery.
and reduces the complication rate and need for multiple • If the femoral artery is selected, position the patient supine
attempts at placement.14 with the head of the bed at a comfortable angle. The patient’s
leg should be straight with the femoral area easily acces-
Patient Preparation sible and palpate the artery (a small towel may be needed to
• Verify that the patient is the correct patient using two support the hip in some cases). Rationale: This position is
identifiers. Rationale: Before performing a procedure, the the best for localizing the femoral artery pulse.
Procedure for Performing Arterial Catheter Insertion

1. Obtain ultrasound equipment. Prepares equipment. Assistance may be needed from
radiology.
2. Ensure that a single-pressure Prepares equipment.
transducer system is prepared
(see Procedure 75).
3. HH
4. PE
5. Place a waterproof pad under the Avoids soiling of bed linens.
selected site.
6. Determine the anatomy of the Helps ensure proper placement of the
artery. (Level E*) arterial catheter and guides the area
to be prepped.12

Procedure for Performing Arterial Catheter Insertion—Continued

7. If the radial artery is to be used, Although evidence is found in The modified Allen’s test does not
the modified Allen’s test should support of and against the use of always ensure adequate flow
be performed before arterial the modified Allen’s test, the test through the ulnar artery.
catheter insertion (see Fig. 81-3). can be performed before a radial A Doppler ultrasound flow indicator
(Level C*) artery puncture in an attempt to can also be used to further verify
assess the patency of the ulnar blood flow.1,5
artery and to assess for an intact
superficial palmar arch.3–5,7,13,14
A. With the patient’s hand held Forces the blood from the hand.
overhead, instruct the patient
to open and close the hand
several times.
B. With the patient’s fist Obstructs the flow of blood to the If the patient is unconscious or
clenched, apply direct hand. unable to perform the procedure,
pressure on both the radial clench the fist passively for the
and the ulnar arteries. patient.
C. Instruct the patient to lower Allows observation for pallor. Performed passively if the patient is
and open the hand. unconscious or unable to assist.
D. While maintaining pressure Return of color within 7 seconds If the test results are abnormal, the
on the radial artery, release indicates patency of the ulnar artery modified Allen’s test should be
the pressure over the ulnar and an intact superficial palmar performed on the opposite hand. If
artery and observe the hand arch; this is interpreted as normal results for both hands are
for the return of color. Allen’s test results. If color returns abnormal, consider use of a site
between 8 and 14 seconds, the test other than the radial arteries.
is considered equivocal and the
healthcare provider must consider
the risk and benefits of continuing
with performing this procedure. If
15 or more seconds are needed for
color to return, test results are
considered abnormal and another
site should be considered.
8. HH
9. PE Reduces the transmission of
microorganisms.
10. Prepare the site with the Limits the introduction of potentially
antiseptic solution (e.g., 2% infectious skin flora into the vessel
chlorhexidine-based preparation). during the puncture.
A. Cleanse the site with a
back-and-forth motion while
applying friction for 30
seconds.
B. Allow the antiseptic solution
to dry.
11. Remove gloves and perform HH
12. Open the arterial cannula Prepares for the procedure.
insertion kit.
13. Apply sterile gloves. Arterial catheter insertion is a sterile Personnel protective equipment (e.g.,
procedure. head cover, mask, goggles) is
needed as well as sterile
equipment. If the arterial catheter
will be placed in a femoral artery,
a sterile gown should be worn.15

14. Drape the area around the site Provides a sterile field and minimizes A large sterile fenestrated drape
with sterile drapes. the transmission of organisms. should be used during peripheral
arterial catheter insertion.12,15
Maximal sterile barrier precautions
should be used for femoral artery
catheter insertion.12,15
15. Locally anesthetize the puncture Provides local anesthesia for the Most patients experience pain during
site.4,7,9,10,13 (Level C*) arterial puncture. arterial puncture.6,7
A. Use a 1-mL syringe with a Minimizes vessel trauma. Absence of Medications such as lidocaine
25-gauge needle to draw up epinephrine decreases the risk for ointment, amethocaine gel, and
0.5 mL of 1% lidocaine peripheral vasoconstriction. EMLA cream may reduce
without epinephrine. pain.8,11,13,19
If these medications are used,
manufacturer’s recommendations
should be followed.
B. Aspirate before injecting the Determines whether or not a blood
local anesthetic. vessel has been inadvertently
entered.
C. Inject intradermally and then Decreases the incidence of localized
with full infiltration around pain during injection of all skin
the intended arterial insertion layers. Patients report reduced pain
site. Use approximately when a local intradermal anesthetic
0.2–0.3 mL for an adult. agent is used before arterial
puncture.
16. Perform the percutaneous Use of ultrasound scan technology
puncture of the selected artery. may be used to assist with catheter
insertion.
A. Palpate and stabilize the Increases the likelihood of correctly
artery with the index and locating the artery and decreases
middle fingers of the the chance of the vessel rolling.
nondominant hand.
B. With the needle bevel up and A slow, gradual thrust promotes entry
the syringe at a 30-degree to into the artery without inadvertently
60-degree angle to the radial passing through the posterior wall.
or brachial artery, puncture
the skin slowly. Adjust the
angle to a 60-degree to
90-degree angle to the
femoral artery.
17. Advance the needle and the Advancing the cannula farther
cannula until a blood return is ensures that the entire cannula is in
noted in the hub, then slowly the artery and not just the tip of the
advance the catheter about 1 4– 1 2 stylet.
inch farther to ensure that the
cannula is in the artery.
18. If, on initial insertion, a blood Some arteries may vasospasm as a
return is not noted, a 3-mL result of sudden insertion of the
syringe may be placed at the end catheter. Taking the time to place a
of the cannula. While advancing syringe on the catheter and
the catheter, gentle withdrawing withdrawing slightly during
of the syringe plunger may be insertion may allow the artery to
performed in an effort to relax and help to determine
determine proper placement in whether proper placement within
the artery. the artery has been achieved.


19. Level the catheter to the skin; The rotary action helps to advance If an over the wire catheter is used,
then continue to advance the the catheter through the skin. advance the wire completely to
cannula to its hub with a steady the hub and then advance the
rotary action. catheter over the wire.
20. Once positioning is confirmed, Maintains catheter patency and Arterial blood is pulsatile.
remove the stylet and connect the prepares the system for arterial
catheter to the single-pressure blood pressure monitoring.
transducer system and flush the
system.
21. Observe the arterial waveform. Confirms arterial catheter placement.
22. Secure the arterial catheter in Maintains arterial catheter The catheter may be sutured in place,
place. positioning; reduces the chance of or a sutureless securement device
accidental dislodgment. may be used to secure the catheter.
23. Apply an occlusive, sterile Reduces the risk for infection. Follow institutional standards for
dressing to the insertion site. application of a chlorhexidine-
impregnated sponge.
24. Level the air-fluid interface Prepares the monitoring system.
(zeroing stopcock) to the
phlebostatic axis, zero the
monitoring system, verify the
arterial waveform through a
square wave test, and activate the
alarm system (see Procedure 59).
receptacles; dispose of needles Precautions. Safely removes sharp
and other sharp objects in objects.
appropriate containers.
26. HH

• Successful cannulation of the artery • Pain
• Ability to obtain blood samples from the arterial • Complications of puncture or vasospasm
catheter • Complications after the procedure, such as change in
• Peripheral vascular and neurovascular systems intact color, temperature, sensation, or movement of the
• Alterations in blood pressure stability identified and extremity cannulated; hematoma, hemorrhage,
treated accordingly infection, or thrombus at the insertion site
• Inability to cannulate the artery

interventions.
1. Observe the insertion site for Postinsertion bleeding can occur in • Bleeding
signs of hemostasis after the any patient but is more likely to • Hematoma
procedure. occur in patients with • Changes in vital signs
coagulopathies or patients
undergoing anticoagulation therapy.
2. Assess the arterial catheter Arterial catheter insertion can result • Changes in pulse, color, size,
insertion site and involved in peripheral vascular and temperature, sensation, or
extremity for signs of neurovascular compromise of the movement in the extremity used
postinsertion complications.13 extremity distal to the puncture site. for the arterial catheter insertion

3. Ensure that the catheter is Alerts physicians, advanced practice
clearly labeled as “arterial.” nurses, and other healthcare
professionals that the catheter is
arterial not venous.
4. Assess the arterial catheter Determines necessity for catheter • Erythema, warmth, hardness,
insertion site for signs or removal and further treatment. tenderness, or pain at the arterial
symptoms of infection. line insertion site
• Presence of purulent drainage
from the arterial line insertion site
5. Follow institutional standards Identifies need for pain interventions. • Continued pain despite pain
Documentation
• Patient and family education • Any difficulties in the insertion; number of attempts
• Performance of the modified Allen’s test before • Patient tolerance of the procedure
insertion and its results (when using the radial artery) • Pain assessment, interventions, and effectiveness
• Preprocedure verifications and time out • Appearance of the site
• Signed consent form • Appearance of the limb, color, pulse, sensation,
• Arterial site accessed movement, capillary refill time, and temperature of
• Insertion of the arterial catheter (date, time, and initials the extremity after insertion is complete
marked on the dressing itself) • Occurrence of unexpected outcomes
• Size of cannula-over-needle catheter used • Nursing interventions taken

58 Arterial Catheter Insertion (Perform) 507.e1
References monitoring, Aliso Viejo, CA, 1998, American Association

1. Abu-Omar Y, et al: Duplex ultrasonography predicts of Critical-Care Nurses.
safety of radial artery harvest in the presence of an 12. Infusion Nurses Society: Infusion therapy standards of
abnormal Allen test. Ann Thorac Surg 77:116–119, 2004. practice. J Infus Nurs 39(1S):S1–S159, 2016.
2. Barone JE, Madlinger RV: Should an Allen test be 13. National Committee for Clinical Laboratory Standards:
performed before artery cannulation? J Trauma 61: Procedures for the collection of arterial blood specimens:
468–470, 2006. approved standards H11-A4, ed 4, Wayne, PA, 2004,
3. Buffington S: Specimen collection and testing. In Nattina National Committee for Clinical Laboratory Standards.
Sandra M, editor: Lippincott’s nursing procedures, ed 2, 14. Oettlé AC, et al: Evaluation of Allen’s test in both arms
Springhouse, PA, 1996, Springhouse Corp, pp 145–147. and arteries of left and right-handed people. Surg Radiol
4. Celenski SA, Seneff MG: Arterial line placement and Anat 28:3–6, 2006.
care. In Irwin RS, et al, editors: Procedures and 15. O’Grady NP, et al: Guidelines for the prevention of
techniques in intensive care medicine, ed 6, Philadelphia, intravascular catheter-related infections, Atlanta, 2011,
2008, Lippincott Williams & Wilkins, pp 38–46. Centers for Disease Control and Prevention.
5. Chernecky CC, Berger BJ, editors: Laboratory tests and 16. Schales K: Arterial catheters: Indications, insertion and
diagnostic procedures, ed 5, St Louis, 2008, Saunders use in critical care. Br J Nurs 19(19):S16–S21, 2010.
Elsevier. 17. Scheer BV, Perel A, Pfeiffer UJ: Clinical review:
6. Clarke S: Arterial lines: An analysis of good practice. complications and risk factors of peripheral arterial
J Child Health Care 3:22–27, 1999. catheters used for haemodynamic monitoring in
7. Giner J, et al: Pain during arterial puncture. Chest anaesthesia and intensive care medicine. Crit Care
110:1443–1445, 1996. 6:198–204, 2002.
8. Gowardmen JR, Lipman J, Rickard CM: Assessment 18. Shiver S, Blaivas M, Lyon M: A prospective comparison
of peripheral arterial catheters as a source of sepsis in of ultrasound-guided and blindly placed radial arterial
the critically ill: A narrative review. J Hosp Infect catheters. Acad Emerg Med 13:1275–1279, 2006.
75(1):12–18, 2010. 19. Tran NQ, Pretto JJ, Worsnop CJ: A randomized controlled
9. Hudson TL, Dukes SF, Reilly K: Use of local anesthesia trial of the effectiveness of topical amethocaine in
for arterial punctures. Am J Crit Care 15:595–599, 2006. reducing pain during arterial puncture. Chest 122:
10. Hussey VM, Poulin MV, Fain JA: Effectiveness of 1357–1360, 2002.
lidocaine hydrochloride on venipuncture sites. AORN J
66:472–475, 1997. Additional Readings
11. Imperial-Perez F, McRae M: Protocols for practice: Lough M: Hemodynamic monitoring: Evolving technologies
Hemodynamic monitoring series. arterial pressure and clinical practice, St. Louis, MO, 2016, Elsevier Mosby.
PROCEDURE
59
Arterial Catheter Insertion
(Assist), Care, and Removal
PURPOSE: Arterial catheters are used for continuous monitoring of blood
pressure, assessment of cardiovascular effects of vasoactive drugs, and frequent
arterial blood gas and laboratory sampling. In addition, arterial catheters provide
access to blood samples that support the diagnostics related to oxygen, carbon
dioxide, and bicarbonate levels (oxygenation, ventilation, and acid-base status).
PREREQUISITE NURSING aortic valve closes, marking the end of ventricular systole.
KNOWLEDGE The closure of the aortic valve produces a small rebound
wave that creates a notch known as the dicrotic notch. The
• Knowledge of the anatomy and physiology of the vascu- descending limb of the curve (diastolic downslope) repre-
lature and adjacent structures is needed. sents diastole and is characterized by a long declining
• Knowledge of the principles of hemodynamic monitoring pressure wave, during which the aortic wall recoils and
is necessary. propels blood into the arterial network. The diastolic pres-
• Understanding of the principles of aseptic technique is sure is measured as the lowest point of the diastolic
needed. downslope, which should be less than 80 mm Hg in
• Conditions that warrant the use of arterial pressure moni- adults.21
toring include patients with the following: • The difference between the systolic and diastolic pres-
❖ Frequent blood sampling: sures is the pulse pressure, with a normal value of about
Respiratory conditions requiring arterial blood gas 40 mm Hg.
monitoring (oxygenation, ventilation, acid-base • Arterial pressure is determined by the relationship between
status) blood flow through the vessels (cardiac output) and the
Bleeding, actual or potential resistance of the vessel walls (systemic vascular resis-
Electrolyte or glycemic abnormalities, actual or tance). The arterial pressure is therefore affected by any
potential factors that change either cardiac output or systemic vas-
Metabolic abnormalities (acid-base, tissue perfu- cular resistance.
sion), actual or potential • The average arterial pressure during a cardiac cycle is
Monitoring serum levels related to therapeutic inter- called the mean arterial pressure (MAP). MAP is not the
ventions (renal replacement therapy, chemotherapy, average of the systolic plus the diastolic pressures because,
biotherapy, apheresis therapy, etc.) during the cardiac cycle, the pressure remains closer to
❖ Continuous blood pressure monitoring: diastole than to systole for a longer period (at normal heart
Hypotension or hypertension rates). The MAP is calculated automatically by most
Shock: cardiogenic, septic, hypovolemic, patient monitoring systems; however, it can be calculated
neurogenic with the following formula:
Mechanical cardiovascular support MAP = (systolic pressure) + (diastolic pressure × 2)
Vasoactive medication administration
• Arterial pressure represents the forcible ejection of blood 3
from the left ventricle into the aorta and out into the arte- • MAP represents the driving force (perfusion pressure) for
rial system. During ventricular systole, blood is ejected blood flow through the cardiovascular system. MAP is at
into the aorta, generating a pressure wave. Because of the its highest point in the aorta. As blood travels through the
intermittent pumping action of the heart, this arterial pres- arterial system away from the aorta, systolic pressure
sure wave is generated in a pulsatile manner (Fig. 59-1). increases and diastolic pressure decreases, with an overall
The ascending limb of the aortic pressure wave (anacrotic decline in the MAP (Fig. 59-2).
limb) represents an increase in pressure because of left- • The location of arterial catheter placement depends on the
ventricular ejection. The peak of this ejection is the peak condition of the arterial vessels and the presence of other
systolic pressure, which should be less than 120 mm Hg catheters (i.e., the presence of a dialysis shunt is a contra-
in adults.21 After reaching this peak, the ventricular pres- indication for placement of an arterial catheter in the same
sure declines to a level below aortic pressure and the extremity). Once inserted, the arterial catheter causes little
508
59 Arterial Catheter Insertion (Assist), Care, and Removal 509
• The radial artery is the most common site for arterial pres-
sure monitoring. When arterial pulse waveforms are
recorded from a peripheral site (compared with a central
site), the waveform morphology changes. The anacrotic
limb becomes more peaked and narrowed, with increased
amplitude; therefore, the systolic pressure in peripheral
sites is higher than the systolic pressure recorded from a
more central site (see Fig. 59-2). In addition, the diastolic
pressure decreases, the diastolic downslope may show a
secondary wave, and the dicrotic notch becomes less
prominent from distal sites.
Figure 59-1 The generation of a pulsatile waveform. This is an
aortic pressure curve. During systole, the ejected volume distends • Vasodilators and vasoconstrictors may change the appear-
the aorta and aortic pressure rises. The peak pressure is known as ance of the waveforms from distal sites. Vasodilators may
the aortic systolic pressure. After the peak ejection, the ventricular cause the waveform to take on a more central appearance.
pressure falls; when it drops below the aortic pressure, the aortic Vasoconstrictors may cause the systolic pressure to
valve closes, which is marked by the dicrotic notch, the end of the become more exaggerated because of enhanced resistance
systole. During diastole, the pressure continues to decline and the in the peripheral arteries.
aortic wall recoils, pushing blood toward the periphery. The trough
of the pressure wave is the diastolic pressure. The difference
• Several potential complications are associated with arte-
between the systolic and diastolic pressure is the pulse pressure. rial pressure monitoring. Infection at the insertion site can
(From Smith JJ, Kampine JP: Circulating physiology. Baltimore, develop and cause sepsis. Clot formation in the catheter
1980, Williams & Wilkins, 55.) can lead to arterial embolization. The catheter can cause
a pseudoaneurysm or vessel perforation with extravasa-
tion of blood and flush solution into the surrounding
tissue. Finally, the distal extremity can develop circulatory
or neurovascular impairment.
• Ultrasound guidance is recommended to place arterial
catheters if the technology is available.8
EQUIPMENT
• 2-inch, 20-gauge, nontapered Teflon cannula-over-needle
or prepackaged kit that includes a 6-inch, 18-gauge Teflon
catheter with appropriate introducer and guidewire (or the
specific catheter for the intended insertion site)
• Pressure module and cable for interface with the monitor
• Pressure transducer system, including flush solution rec-
ommended according to institutional standards, a pressure
bag or device, pressure tubing with transducer, and flush
device (see Procedure 75)
• Dual-channel recorder
• Nonsterile gloves, head covering, goggles, and mask
• Sterile gloves and large sterile fenestrated drape
• Skin antiseptic solution (e.g., 2% chlorhexidine-based
preparation)
• Sterile 4 × 4 gauze pads
• Transparent occlusive dressing
Figure 59-2 Arterial pressure from different sites in the arterial
• 1% lidocaine without epinephrine, 1 to 2 mL
tree. The arterial pressure waveform varies in configuration, depend-
ing on the location of the catheter. With transmission of the pressure • Sterile sodium chloride 0.9%
wave into the distal aorta and large arteries, the systolic pressure • 3-mL syringe with 25-gauge needle
increases and the diastolic pressure decreases; with a resulting • Sheet protector
heightening of the pulse, pressure declines steadily. (From Smith JJ, • Bedside ultrasound machine with vascular probe
Kampine JP: Circulating physiology. Baltimore, 1980, Williams & • Sterile ultrasound probe cover
Wilkins, 57.) • Sterile ultrasound gel
the following:
or no discomfort to the patient and allows continuous • Sterile gown and full drape
blood pressure assessment and intermittent blood sam- • Bath towel
pling. If intraaortic balloon pump therapy is necessary, • Small wrist board
arterial pressure may be directly monitored from the tip • Sutureless securement device
of the balloon catheter in the aorta. • Suture material
• Chlorhexidine-impregnated sponge • Review the patient’s allergy history (e.g., allergy to

• Additional transparent adhesive dressing with tapes heparin, lidocaine, antiseptic solutions, or adhesive tape).
(if dressing has no tape, consider the use of 1 2 -inch Rationale: This assessment decreases the risk for allergic
Steri-Strips) reactions. Patients with heparin-induced thrombocytope-
• Transducer holder, intravenous (IV) pole, and laser lever nia should not receive heparin in the flush solution.
for pole-mounted arterial catheter transducers • Assess the neurovascular and peripheral vascular status of
the extremity to be used for the arterial cannulation,
PATIENT AND FAMILY EDUCATION including color, temperature, presence and fullness of
pulses, capillary refill, presence of bruit (in larger arteries
• Explain the procedure and the purpose of the arterial cath- such as the femoral artery), and motor and sensory func-
eter. Rationale: This explanation decreases patient and tion (compared with the opposite extremity). Note: A
family anxiety. modified Allen’s test should be performed before cannula-
• Explain the standard of care to the patient and family, tion of the radial artery (see Fig. 81-3). Rationale: This
including insertion procedure, alarms, dressings, and assessment may help identify any neurovascular or circu-
length of time the catheter is expected to be in place. latory impairment before cannulation to avoid potential
Rationale: This explanation encourages the patient and complications.2,3,20
family to ask questions and voice concerns about the
procedure and decreases patient and family anxiety. Patient Preparation
• Explain the patient’s expected participation during the • Verify that the patient is the correct patient using two
procedure. Rationale: Patient cooperation during inser- identifiers. Rationale: Before performing a procedure, the
tion is encouraged. nurse should ensure the correct identification of the patient
• Explain the importance of keeping the affected extremity for the intended intervention.
immobile. Rationale: This explanation encourages patient • Ensure that the patient and family understand prepro-
cooperation to prevent catheter dislodgment and main- cedural teaching. Answer questions as they arise, and
tains catheter patency and function. reinforce information as needed. Rationale: Understand-
• Instruct the patient to report any warmth, redness, pain, ing of previously taught information is evaluated and
or wet feeling at the insertion site at any time. Rationale: reinforced.
These symptoms may indicate infection, bleeding, or dis- • Ensure that informed consent is obtained. Rationale:
connection of the tubing or catheter. Informed consent protects the rights of the patient and
allows a competent decision to be made by the patient;
however, in emergency circumstances, time may not
PATIENT ASSESSMENT AND allow the form to be signed.
PREPARATION • Perform a preprocedure verification and time out, if non-
emergent. Rationale: Ensures patient safety.
Patient Assessment • Place the patient supine with the head of the bed at a
• Obtain the patient’s medical history, including history of comfortable position. The limb into which the arterial
diabetes, hypertension, peripheral vascular disease, vas- catheter will be inserted should be resting comfortably on
cular grafts, arterial vasospasm, thrombosis, or embolism. the bed. Rationale: This placement provides patient
Obtain the patient’s history of coronary artery bypass graft comfort and facilitates insertion.
surgery in which radial arteries were removed for use as • If the radial artery is selected, position the hand to allow
conduits or presence of arteriovenous fistulas or shunts. for palpation of the artery (a pillow or towel may be used
Rationale: Extremities with any of these problems should to support the wrist). Rationale: This placement positions
be avoided as sites for cannulation because of the potential the arm and brings the artery closer to the surface.
for complications. Patients with diabetes mellitus or • If the brachial artery is selected, elevate and hyperextend
hypertension are at higher risk for arterial or venous insuf- the patient’s arm and palpate the artery (a pillow or towel
ficiency. Previously removed radial arteries are a contra- may be used to support the arm). Rationale: This action
indication for ulnar artery cannulation. increases accessibility of the artery.
• Review the patient’s current anticoagulation therapy, • If the femoral artery is selected, position the patient supine
history of blood dyscrasias, and pertinent laboratory with the head of the bed at a comfortable angle. The
values (prothrombin time [PT], international normalized patient’s leg should be straight with the femoral area
ratio [INR], partial thromboplastin time [PTT], and plate- easily accessible and palpate the artery (a small towel may
lets) before the procedure. Rationale: Anticoagulation be needed to support the hip in some cases). Rationale:
therapy, blood dyscrasias, or alterations in coagulation This position is the best for localizing the femoral artery
studies could increase the risk of hematoma formation or pulse.
hemorrhage.
Procedure for Assisting With Insertion of an Arterial Catheter

1. HH
2. Prepare the flush solution (see Heparinized flush solutions are Although heparin may prevent
Procedure 75). commonly used to minimize thombosis,9,14,17 it has been associated
A. Use an IV solution of thrombi and fibrin deposits on with thrombocytopenia and other
normal saline. catheters that might lead to hematologic complications.6 Other
B. Follow institutional thrombosis or bacterial factors that promote patency of the
standards for adding colonization of the catheter. arterial line besides heparinized saline
heparin to the IV solution, solution include male gender, longer
if heparin is not arterial catheters, larger vessels
contraindicated. (Level B*) cannulated, patients receiving other
anticoagulants or thrombolytics, and
short-term use of the catheter.1
3. Consider the use of a blood- Reduces the risk of nosocomial
conservation arterial line anemia.5,11,16,18,19
system. (Level B*)
4. Prime or flush the entire Removes air bubbles. Air bubbles Air is more easily removed from the
single-pressure transducer introduced into the patient’s hemodynamic tubing when the system
system (see Procedure 75). circulation can cause air is not under pressure.
embolism. Air bubbles within the
tubing dampen the waveform.
5. Apply and inflate the pressure Each flush device delivers 1–3 mL/
bag or device to 300 mm Hg. hr to maintain patency of the
hemodynamic system.
6. Connect the pressure cable to Connects the pressure transducer
the bedside monitor. system to the bedside monitoring
system.
7. Set the scale on the bedside Prepares the bedside monitor.
monitor for the anticipated
pressure waveform.
8. Level the air-fluid interface Leveling ensures that the air-fluid Use a pole mount or patient mount
(zeroing stopcock) to the interface of the monitoring system according to institutional protocol
phlebostatic axis (see Figs. is level with a reference point on (see Procedure 75).
75-7 and 75-9). the body. The phlebostatic axis The tip of the arterial catheter is not
reflects central arterial pressure.13 used as the reference point because it
measures transmural pressure of a
specific area in the arterial tree, which
may be increased by hydrostatic
pressure.13
9. Zero the system by turning the Prepares the monitoring system.
stopcock off to the patient,
opening it to air, and zeroing
the monitoring system (see
Procedure 75).
10. HH
11. PE
12. Assist as needed with skin Provides help to the provider
preparation. inserting the catheter.

Procedure for Assisting With Insertion of an Arterial Catheter—Continued

13. Assist as needed with Facilitates insertion. Personal protective equipment (e.g.,
immobilizing the extremity head cover, mask, goggles) is needed,
during catheter insertion. as well as sterile equipment. Maximal
sterile barrier precautions should be
used for femoral artery catheter
insertion.8,14
14. Connect the pressure cable Connects the arterial catheter to the
from the arterial transducer to bedside monitoring system.
the bedside monitor.
15. Reassess accurate leveling, and Ensures that the air-filled interface Leveling ensures accuracy. The point of
secure the transducer (see (zeroing stopcock) is maintained the phlebostatic axis should be
Procedure 75). at the level of the phlebostatic marked with an indelible marker,
axis. If the air-fluid interface is especially when the transducer is
above the phlebostatic axis, secured in a pole-mount system.
arterial pressures are falsely low.
If the air-fluid interface is below
the phlebostatic axis, arterial
pressures are falsely high.
16. Zero the system again (see Ensures accuracy of the system with
Procedure 75). the established reference point.
17. Turn the stopcock off to the Prepares the system for monitoring
top port of the stopcock. Place and ensures a closed system.
a sterile cap or a needleless cap
on the top port of the stopcock.
18. Observe the waveform and Determines whether the system is The square wave test can be performed
perform a dynamic response damped. This will ensure that the by activating and quickly releasing
test (square wave test; pressure waveform components the fast flush. A sharp upstroke should
Fig. 59-3). are clearly defined. terminate in a flat line at the maximal
This aids in accurate measurement. indicator on the monitor. This should
be followed by an immediate rapid
downstroke extending below the
baseline with 1–2 oscillations within
0.12 second and a quick return to
baseline (see Fig. 59-3).
19. Ensure that the provider Maintains arterial catheter position; A sutureless securement device can be
inserting the catheter has reduces the chance of accidental used.
secured the arterial catheter in dislodgement.
place.
20. Ensure that the provider Reduces the risk of infection.
inserting the catheter has
applied an occlusive, sterile
dressing to the insertion site.
21. Apply an arm board, if Ensures the correct position of the
necessary. extremity for an optimal
waveform.
22. Set the alarm parameters Activates the bedside and central
according to the patient’s alarm system.
current blood pressure.
receptacles; ensure that all Precautions. Safely removes sharp
needles and other sharp objects objects.
are disposed of in appropriate
containers.
24. HH
C
Figure 59-3 Dynamic response test (square wave test) using the fast flush system. A, Optimally
damped system. B, Overdamped system. C, Underdamped system. (From Darovic GO, Zbilut JP:
Fluid-filled monitoring systems. In Hemodynamic monitoring, ed 3. Philadelphia, 2002, Saunders,
122.)
Procedure for Assisting With Insertion of an Arterial Catheter—Continued

25. Compare the manual Obtains baseline data. No direct relationship exists between
(noninvasive) blood pressure noninvasive and invasive blood
with the arterial (invasive) pressures because noninvasive
blood pressure. techniques measure blood flow and
invasive techniques measure
pressure.13
26. Run a waveform strip and Obtains baseline data. Digital values are not used because they
record the patient’s baseline are averaged calculations.
arterial pressures.
Procedure for Troubleshooting an Overdamped Waveform

1. HH
2. PE
3. Identify the overdamped waveform Identifies the problem. An overdamped
(Fig. 59-4). waveform results in a
falsely low systolic
pressure and a falsely
high diastolic pressure.
Figure 59-4 Overdamped arterial wave-

form (1, systole; 2, diastole). (From Daily
EK, Schroeder JS: Hemodynamic wave-
forms. St Louis, 1990, Mosby, 110.)
4. Check the patient. A sudden hypotensive episode can

look like an overdamped waveform
(Fig. 59-5).
Procedure for Troubleshooting an Overdamped Waveform—Continued

Figure 59-5 Patient developed supra-

ventricular tachycardia (SVT) with a fall
in arterial pressure. Note how the arterial
waveform appears overdamped but is in
fact reflecting a severe hypotensive episode
associated with the tachycardia.
5. If the waveform is overdamped,

follow these steps:
A. Check the arterial line insertion Wrist movement in the radial site or leg
site for catheter positioning. flexion in the femoral site can cause
catheter kinking or dislodgment,
resulting in an overdamped waveform.
B. Check the system for air bubbles Air bubbles can be a cause of an
and eliminate them if they are overdamped system; air bubbles can
found. also cause emboli.
C. Check the tubing system for leaks Ensures all connections are tight.
or disconnections, and correct the
problem if it is found.
D. Check the flush bag to ensure fluid An empty flush bag or a pressure of less
is present in the bag and that than 300 mm Hg may result in an
pressure is maintained at overdamped system.
300 mm Hg.
E. A catheter with an overdamped Use of the fast-flush device or flushing
waveform should always be with a syringe first may force a clot at
aspirated before flushing. the catheter tip into the arterial
circulation.
Attempt to aspirate and flush the Assists with the withdrawal of air in the
catheter as follows: tubing or clots that may be at the
catheter tip.
• Using the stopcock closest to A 5-mL syringe generates less pressure A 10-mL syringe may be
the patient, remove the and may prevent arterial spasm in needed for larger
nonvented cap from the blood smaller arteries (e.g., radial artery). arteries (e.g., the
sampling port or cleanse the femoral artery). A
needleless port and attach a needleless system can
5- or 10-mL syringe to the also be used.
top port of the stopcock (see
Fig. 61-1).
• Turn the stopcock off to the Opens the system from the patient to the
flush solution (see Fig. 61-4B). syringe. Assesses catheter patency.
• Gently attempt to aspirate; if Normally, blood should be aspirated
resistance is felt, reposition the into the syringe without difficulty.
extremity and reattempt
aspiration.
• If resistance is still felt, stop
and notify the physician or
advanced practice nurse.
Procedure for Troubleshooting an Overdamped Waveform—Continued

• If blood is aspirated, remove Removes any clotted material within the All blood wastes should
3 mL, turn the stopcock off to catheter. be disposed using
the patient, and discard the Standard Precautions.
3-mL sample.
• Fast-flush the remaining blood Removes blood residue from the
from the stopcock onto a sterile stopcock, where it could be a
gauze pad or into another reservoir for bacterial growth, and
syringe and remove the syringe. prevents clotting in the blood
sampling port.
• Turn the stopcock off to the Maintains sterility and a closed system.
blood sampling port (see Fig.
61-1) and place a new sterile
nonvented cap (not needed if
using a needleless port).
• Use the fast-flush device to Prevents the arterial line from clotting.
clear the line of blood.
6. Remove PE and discard used supplies Reduces the transmission of
in the appropriate receptacles. microorganisms; Standard
7. HH Precautions.
Procedure for Troubleshooting an Underdamped Waveform

1. HH
2. PE
3. Identify the underdamped waveform. Identifies the problem. An underdamped waveform results in
a falsely high systolic pressure and
a falsely low diastolic pressure.
4. Check the system for air bubbles Air bubbles can contribute to
and eliminate them if they are found. underdamping; air bubbles can
also cause emboli.
5. Check the length of the tubing of the Ensures that the tubing length is
pressure transducer system. minimized.
6. Observe the waveform and perform Determines whether the system is
a dynamic response test (square damped. This will ensure that
wave test; Fig. 59-3). the pressure waveform
components are clearly defined.
This aids in accurate measurement.
Precautions.
8. HH
Procedure for Arterial Catheter Dressing Change

1. HH
2. PE
3. Carefully remove and Removes the previous dressing without If present, remove the securement
discard the arterial line disrupting the integrity of the device.
dressing. catheter.
4. Inspect the catheter, insertion Assesses for signs of infection,
site, and surrounding skin. catheter dislodgement, or leakage.
5. Remove nonsterile gloves, Reduces the transmission of
discard dressings, and microorganisms
perform hand hygiene.
6. Don sterile gloves Maintains aseptic and sterile technique.
7. Cleanse the skin and catheter Reduces the rate of recolonization of Allow time for the solution to air dry.
with 2% chlorhexidine-based skin flora. Decreases the risk for
preparation.14 bacterial growth at the insertion site.
8. Apply a new stabilization Secures the catheter.
device.
9. Apply a chlorhexidine- Reduces the transmission of Follow institutional standards.
impregnated sponge to the microorganisms. A chlorhexidine-impregnated sponge
site.12,14 (Level D*) dressing is recommended if an
institution’s central line–associated
bloodstream infection rate is not
decreasing despite adherence to basic
prevention measures, including
education and training, appropriate use
of chlorhexidine for skin antisepsis,
and maximum sterile barrier.8,12,14
Use with caution in patients predisposed
to local skin necrosis, such as burn
patients or patients with Stevens-
Johnson syndrome.22
10. Apply a sterile air-occlusive Provides a sterile environment. Write the date and time of the dressing
dressing. Dressings may be a change on a label and tape it to the
sterile gauze or a sterile, dressing.
transparent, semipermeable
dressing.14
11. Remove gloves and discard Reduces the transmission of
used supplies in appropriate microorganisms; Standard
12. HH

Procedure for Removal of the Arterial Catheter

1. Review the patient’s coagulation Elevated PT, INR, PTT, and If laboratory values are abnormal,
profile (PT, INR, PTT, platelets) decreased platelets affect time to pressure needs to be applied for a
and anticoagulation medication hemostasis. longer period to achieve
profile before removal of the hemostasis.
arterial catheter.
2. HH
3. PE
4. Turn off the arterial monitoring The alarm system is no longer
alarms. needed.
5. Remove the dressing. Prepares for catheter removal.
6. Remove the stabilizing device. Prepares for catheter removal.
7. Turn the stopcock off to the Turns the monitoring system off to
flush solution (see Fig. 61-4B). the flush solution.
8. Apply pressure 1–2 finger The arterial puncture site is above
widths above the insertion site. the skin puncture site because the
catheter enters the skin at an angle.
9. Remove the arterial catheter and Prevents splashing of blood.
place a sterile 4 × 4 gauze pad
over the catheter site.
10. Continue to hold proximal Prevents bleeding.
pressure and immediately apply
firm pressure over the insertion
site as the catheter is removed.
11. Continue to apply pressure for a Achieves hemostasis. Follow institutional standards.
minimum of 5 minutes for the Longer periods of direct pressure
radial artery. may be needed to achieve
hemostasis (e.g., patients receiving
systemic heparin or thrombolytics,
patients with catheters in larger
arteries such as the femoral artery,
or patients with abnormal
coagulation values).
12. Apply a pressure dressing to the A pressure dressing helps prevent The dressing should not encircle the
insertion site. rebleeding. extremity (prevents ischemia of the
extremity).
14. HH

• Successful cannulation of the artery • Pain
• Peripheral vascular and neurovascular systems intact • Insertion complications
• Alterations in blood pressure identified and treated • Inability to cannulate the artery
• Able to continuously monitor blood pressure • Change in color, temperature, sensation; movement
• Maintenance of baseline hemoglobin and hematocrit of the extremity used for insertion
levels • Hematoma, hemorrhage, infection, or thrombosis at
• Adequate circulation to the involved extremity the insertion site
• Adequate sensory and motor function to the involved • Decreased hemoglobin and hematocrit values
extremity • Catheter disconnection with significant blood loss
• Maintenance of catheter site without infection • Presence of a new bruit
• Removal of catheter when no longer needed • Impaired sensory or motor function of the extremity
• Elevated temperature or elevated white blood cell
count
• Redness, warmth, edema, or drainage at or from the
insertion site

interventions.
1. Assess the neurovascular and Validates adequate peripheral vascular • Diminished or absent pulses
peripheral vascular status of the and neurovascular integrity. Changes • Pale, mottled, or cyanotic
cannulated extremity in sensation, motor function, pulses, appearance of the distal extremity
immediately after catheter color, temperature, or capillary refill • Extremity that is cool or cold to
insertion and every 4 hours, or may indicate ischemia, thrombosis, the touch
more often if warranted, arterial spasm, or neurovascular • Capillary refill time of greater
according to institutional compromise. than 2 seconds
standards. • Diminished or absent sensation or
pain at the site or distal extremity
• Diminished or absent motor
function
2. Check the arterial line flush Ensures that approximately 1–3 mL/hr
system every 4 hours to ensure of flush solution is delivered through
the following: the catheter, thus maintaining patency
• Pressure bag or device is and preventing backflow of blood into
inflated to 300 mm Hg. the catheter and tubing.
• Fluid is present in the flush The risk of catheter occlusion related to
solution. fibrin sheath or clot formation
increases if the flush solution is not
continuously infusing.
3. Perform a dynamic response An optimally damped system provides • Overdamped or underdamped
test (square wave test) at the an accurate waveform. waveforms that cannot be
start of each shift, with a corrected with troubleshooting
change of the waveform, or procedures
after the system is opened to
air (see Fig. 59-3).
4. Monitor for overdamped or An optimally damped system provides • Overdamped or underdamped
underdamped waveforms. an adequate waveform which waveforms that cannot be
An overdamped waveform is facilitates accuracy of blood pressure corrected with troubleshooting
characterized by a flattened monitoring. procedures
waveform, a diminished or An overdamped waveform can result in
absent dicrotic notch, or a inaccurate blood pressure
square wave that does not measurement. The patient’s blood
fall to baseline or below pressure measure may be inaccurately
baseline (see Fig. 59-4). low.
An underdamped waveform is An overdamped system can be caused by
characterized by catheter air bubbles in the system; use of
fling or artifacts on the compliant tubing versus stiff, loose
waveform (see Fig. 59-3,C). tubing connections in the system; too
many stopcocks in the system; a cracked
tubing or stopcock; arterial catheter
occlusion or a kink; the catheter tip
being against the arterial wall; blood in
the transducer; and insufficient pressure
of the flush solution.
An underdamped waveform can also
result in inaccurate blood pressure
measurement. The patient’s blood
pressure measure may be inaccurately
high.
Common causes of an underdamped
waveform include excessive tubing
length, movement of the catheter in
the artery, patient movement, and air
bubbles in the system.

5. Zero the transducer during the Ensures accuracy of the hemodynamic
initial setup, after insertion, if monitoring system.
disconnection occurs between
the transducer and the
monitoring cable, if
disconnection occurs between
the monitoring cable and the
monitor, and when the values
obtained do not fit the clinical
picture. Follow manufacturer
recommendations for
disposable systems.
6. Recheck the level of the Ensures accurate reference point for the
air-fluid interface (zeroing left atrium and accuracy of blood
stopcock) to the phlebostatic pressure measurements.
axis whenever patient position
changes (see Procedure 75).
7. Place sterile injectable or Stopcocks can be a source of
noninjectable caps on all contamination. Stopcocks that are part
stopcocks. Replace with new of the initial setup are packaged with
sterile caps whenever the caps vented caps. Vented caps need to be
are removed. replaced with sterile injectable or
noninjectable caps to maintain a
closed system and reduce risk of
contamination and infection.
8. Continuously monitor the Provides for continuous waveform
arterial catheter values and analysis and assessment of patient
waveform. status.
9. Observe the insertion site for Infected catheters must be removed as • Redness at the site
signs and symptoms of soon as possible to prevent • Purulent drainage
infection. bacteremia. • Tenderness or pain at the
The CDC does not recommend routinely insertion site
replacing peripheral arterial catheters • Elevated temperature
to prevent catheter-related infections.14 • Elevated white blood cell count
10. Change the pressure transducer The CDC14 and the Infusion Nurses
system (flush solution, pressure Society8 and research findings10,15
tubing, transducers, and recommend that the hemodynamic
stopcocks) every 96 hours. flush system can be used safely for 96
(Level B*) hours. This recommendation is based
The flush solution may need to on research conducted with disposable
be changed more frequently. pressure monitoring systems used for
peripheral and central lines.
11. Label the tubing: Identifies that the catheter is arterial and
A. Arterial when the system needs to be changed.
B. Date and time prepared
12. Maintain the pressure bag or Maintains catheter patency.
device at 300 mm Hg.

13. Print a strip of the arterial Ensures accurate blood pressure
pressure waveform and obtain measurement.
measurement of the arterial
pressures. Note if there are
respiratory variations.
14. Obtain an arterial pressure The printed waveform allows assessment
waveform strip to place on the of the adequacy of the waveform,
patient’s chart at the start of damping, or respiratory variation.
each shift and whenever a
change is found in the
waveform.
15. Monitor hemoglobin or Allows assessment of nosocomial • Abnormal hemoglobin values
hematocrit values daily or as anemia. • Abnormal hematocrit values
prescribed.
16. Replace gauze dressings every Decreases the risk for infection at the
2 days and transparent catheter site. The CDC14 and the
dressings at least every 5–7 Infusion Nurses Society7,8
days and more frequently as recommends replacing the dressing
needed.7,8,14,22 (Level D*) when it becomes damp, loosened, or
soiled or when inspection of the site is
necessary.
17. Print a strip of the arterial The printed waveform allows assessment
waveform to place on the of the adequacy of the waveform and
patient’s chart at the start of the presence of damping.
each shift and whenever a
change in the waveform occurs.
18. Assess the need for the arterial The CDC14 does not recommend routine • Signs and symptoms of infection
catheter daily. (Level D*) replacement of arterial catheters. at the arterial catheter insertion
Catheters should be removed when no site
longer needed and should be replaced
when there is a clinical indication.
19. Follow institutional standards Identifies need for pain interventions. • Pain at the catheter site.
for assessing pain. Administer
Documentation
• Patient and family education • Site assessment
• Completion of informed consent • Arterial site dressing change
• Preprocedure verifications and time out • Intake of flush solution volume
• Performance of the modified Allen’s test before • Printed strip of the arterial pressure waveform
insertion and its results (when using the radial artery) • Appearance of the limb, color, pulse, sensation,
• Insertion of the arterial catheter movement, capillary refill time, and temperature of
• Size of the arterial catheter inserted the extremity after insertion is complete
• Number of insertion attempts • Arterial pressures
• Date and time of arterial catheter site care and dressing • Waveforms
change • Occurrence of unexpected outcomes and
• Pain assessment, interventions, and effectiveness interventions

59 Arterial Catheter Insertion (Assist), Care, and Removal 522.e1
References 20. Slogoff S, Keats AS, Arlund C: On the safety of radial

1. American Association of Critical-Care Nurses: Evaluation artery cannulation. Anesthesiology 59:42–47, 1983.
of the effects of heparinized and nonheparinized flush 21. US Department of Health and Human Services, National
solutions on the patency of arterial pressure monitoring Institutes of Health, National Heart, Lung, and Blood
lines: the AACN Thunder Project. Am J Crit Care 2:3–15, Institute, National High Blood Pressure Education
1993. Program: The seventh report of the joint national
2. Barone J, Madlinger RV: Should an Allen test be committee on prevention, detection, evaluation and
performed before radial artery cannulation? J Trauma treatment of high blood pressure. Publication No. 04-5230
6:468–470, 2006. 2004, retrieved July 27, 2009 from <www.nhlbi.nih.gov/
3. Wilson SR, et al: Ultrasound-guided radial artery guidelines/hypertension/jnc7full.pdf>.
catheterization and the modified Allen’s test. J Emerg Med 22. Timsit J, et al: Chlorhexidine-impregnated sponges
38:354–358, 2010. and less frequent dressing changes for prevention of
4. Crowther M, et al: Heparin-induce thrombocytopenia in catheter-related infections in critically ill adults. JAMA
the critically ill: Interpreting the 4Ts test in a randomized 310:1231–1241, 2009.
trial. J Crit Care 29:470.e7–470.e15, 2014.
5. McEvoy MT, Shander A: Anemia, bleeding, and blood Additional Readings
transfusion in the intensive care unit: Causes, risks, Barbeito A, Mark JB: Arterial and central venous pressure
costs and new strategies. Am J Crit Care 22(6):eS1–eS13, monitoring. Anesthesiol Clin 24:717–735, 2006.
2013. Bridges EJ, et al: Ask the experts. Crit Care Nurse 17:96–97,
6. Greenwood MJ, et al: Vascular communications of the 101–102, 1997.
hand in patients being considered for transradial coronary Chulay M, Holland S: Ask the experts: where should the
angiography: Is the Allen’s test accurate? J Am Coll transducer be leveled for radial or femoral arterial pressure
Cardiol 46:2013–2017, 2005. monitoring? Crit Care Nurse 16:103–107, 1996.
7. Infusion Nurses Society: Policies and procedures for Darovic GO: Arterial pressure monitoring. In Hemodynamic
infusion nursing, ed 5, 2016, Infusion Nursing Society. monitoring: Invasive and noninvasive clinical application,
8. Infusion Nurses Society: Infusion therapy standards of ed 3, Philadelphia, 2002, Saunders.
practice. J Infus Nurs 39(1S):S1–S159, 2016. Foster B: Continuing discussion on transducer placement. Ask
9. Kordzadeh A, Austin T, Panayiolopoulos Y: Efficacy of the experts column of the December 1996 issue. Zero
normal saline in the maintenance of the arterial lines in referencing arterial lines. Crit Care Nurse 17:18, 1997.
comparison to heparin flush: A comprehensive review of Gorny DA: Arterial blood pressure measurement
the literature. J Vasc Access 15(2):123–127, 2014. technique. AACN Clin Issues Crit Care Nurs 4:66–80,
10. Luskin RL, et al: Extended use of disposable pressure 1993.
transducers: A bacteriologic evaluation. JAMA 255:916– Halm MS: Flushing hemodynamic catheters: What does the
920, 1986. science tell us? Am J Crit Care 17:73–76, 2008.
11. MacIsaac CM, et al: The influence of a blood conserving Imperial-Perez F, McRae M: Protocols for practice:
device on anemia in intensive care patients. Anaesth hemodynamic monitoring series: Arterial pressure
Intensive Care 31:653–657, 2003. monitoring, Aliso Viejo, CA, 1998, American Association
12. Maki DG, et al: Prospective, randomized, investigator- of Critical-Care Nurses.
masked trial of novel chlorhexidine-impregnated disk Imperial-Perez F, McRae M: Protocols for practice: Applying
(Biopatch) on central venous and arterial catheters (abstr). research at the bedside: Arterial pressure monitoring.
Infect Control Hosp Epidemiol 21:96, 2000. Crit Care Nurse 22:70–72, 2002.
13. McGhee BH, Bridges MEJ: Monitoring arterial blood Lapum JL: Patency of arterial catheters with heparinized
pressure: What you may not know. Crit Care Nurse solutions versus non-heparinized solutions: A review of
22:60–79, 2002. the literature. Can J Cardiovasc Nurs 16:64–67, 2006.
14. O’Grady NP, et al: Summary of recommendations: Leeper B: Ask the experts: What is the standard regarding
guidelines for the prevention of intravascular catheter- isotonic sodium chloride solution versus heparin in
related infections. Clin Infect Dis 52:1087–1099, 2011. pressure monitoring systems? Crit Care Nurse 26:
15. O’Malley MK, et al: Value of routine pressure monitoring 137–138, 2006.
system changes after 72 hours of continuous use. Crit Lough M: Hemodynamic monitoring: Evolving technologies
Care Med 22:1424–1430, 1994. and clinical practice, St. Louis, MO, 2016, Elsevier
16. Peruzzi WT, et al: A clinical evaluation of a blood Mosby.
conservation device in medical intensive care unit McLean B: Comparing blood pressure measures: Does one
patients. Crit Care Med 21:501–506, 1993. measure equal another. Crit Care Nurse 35(1):75–81,
17. Randolph AG, et al: Benefit of heparin in peripheral 2015.
venous and arterial catheters: Systematic review and Shaffer C: Diagnostic blood loss in mechanically ventilated
meta-analysis of randomized controlled trials. BMJ patients. Heart Lung 36:217–222, 2007.
316:969–975, 1998. Tuncali BE, et al: A comparison of the efficacy of heparinized
18. Silver MJ, et al: Evaluation of a new blood-conserving and nonheparinized solutions for maintenance of
arterial line system for patients in intensive care units. perioperative radial arterial catheter patency and
Crit Care Med 21:507–511, 1993. subsequent occlusion. Anesth Analg 100:1117–1121, 2005.
19. Silver MJ, et al: Reduction of blood loss from diagnostic Zevola DR, Dioso J, Moggio R: Comparison of heparinized
sampling in critically ill patients using a blood-conserving solutions for maintaining patency of arterial and
arterial line system. Chest 104:1711–1715, 1993. pulmonary artery catheters. Am J Crit Care 6:52–55, 1997.
PROCEDURE
60
Arterial Pressure–Based Cardiac
Output Monitoring
Susan Scott
PURPOSE: Arterial pressure–based cardiac output monitoring is a minimally
invasive technology that can be used to obtain hemodynamic data on a continuous
basis.
PREREQUISITE NURSING • The difference between the systolic and diastolic pressures
KNOWLEDGE is called the pulse pressure, with a normal value of 40 mm Hg.
• Arterial pressure is determined by the relationship between
• Knowledge of the anatomy and physiology of the cardio- blood flow through the vessels (cardiac output), the com-
vascular system is necessary. pliance of the aorta and larger vessels, and the resistance
• Knowledge of the anatomy and physiology of the vascu- of the more peripheral vessel walls (systemic vascular
lature and adjacent structures is needed. resistance). The arterial pressure is therefore affected by
• Understanding of the pathophysiologic changes that occur any factors that change either cardiac output, compliance,
in heart disease and affect flow dynamics is necessary. or systemic vascular resistance.
• Understanding of aseptic technique is needed. • The average arterial pressure during a cardiac cycle is
• Understanding of the hemodynamic effects of vasoactive called the mean arterial pressure (MAP). It is not the
medications and fluid resuscitation is needed. average of the systolic plus the diastolic pressures, because
• Understanding of the principles involved in hemodynamic at normal heart rates systole accounts for 1 3 of the cardiac
monitoring is necessary. cycle and diastole accounts for 2 3 of the cardiac cycle.
• Knowledge of invasive cardiac output monitoring is needed. The MAP is calculated automatically by most patient
• Knowledge of arterial waveform interpretation is needed. monitoring systems; however, it can be calculated manu-
• Knowledge of definitions and norms for cardiac output, ally using the following formula:
cardiac index, systemic vascular resistance, stroke volume,
stroke index, preload, afterload, and contractility and stroke Systolic pressure + (diastolic pressure × 2)
volume variation is necessary. 3
• Arterial pressure represents the forcible ejection of blood
from the left ventricle into the aorta and out into the arte- • MAP represents the driving force (perfusion pressure) for
rial system. During ventricular systole, blood is ejected blood flow through the cardiovascular system. MAP is at
into the aorta, generating a pressure wave. Because of its highest point in the aorta. As blood travels through the
the intermittent pumping action of the heart, this arterial circulatory system, systolic pressure increases and dia-
pressure wave is generated in a pulsatile manner (see stolic pressure decreases, with an overall decline in the
Fig. 59-1). The ascending limb of the aortic pressure wave MAP (see Fig. 59-2).
(anacrotic limb) represents an increase in pressure because • Arterial pressure–based cardiac output (APCO) is obtained
of left-ventricular ejection. The peak of this ejection is from an arterial catheter.10–12
the peak systolic pressure, which is normally 100 to • APCO technology measures the rate of flow (cardiac out-
140 mm Hg in adults. After reaching this peak, the ven- put).10–12
tricular pressure declines to a level below aortic pressure • Stroke volume and heart rate are key determinants of cardiac
and the aortic valve closes, marking the end of ventricular output.
systole. The closure of the aortic valve produces a • Although systemic vascular resistance affects cardiac out-
small rebound wave that creates a notch known as the put, the location of that effect is global and not limited
dicrotic notch. The descending limb of the curve by location of that measurement because cardiac output is
(diastolic down slope) represents diastole and is character- measured as flow per minute throughout the body. Man-
ized by a long declining pressure wave, during which the ufacturers of the arterial pressure–based cardiac output
aortic wall recoils and propels blood into the arterial systems have factored in variance for both radial artery
network. The diastolic pressure is measured at the lowest catheters and femoral artery catheters.9
point of the diastolic down slope and is normally 60 to • Ultrasound guidance is recommended to place arterial
80 mm Hg. catheters if the technology is available.7
523
EQUIPMENT PATIENT ASSESSMENT AND

PREPARATION
• Invasive arterial catheter and insertion kit
• Specialized sterile transducer and sensor kit (manufac- Patient Assessment
turer specific) • Obtain the patient’s medical history, including a history
• Intravenous (IV) pole and transducer holder (manufac- of peripheral vascular disease, diabetes, and hypertension.
turer specific) Rationale: These conditions increase the patient’s risk for
• Pressure-transducer system, including flush solution rec- arterial or venous insufficiency.
ommended according to institutional standards, a pressure • Obtain the patient’s medical history for peripheral vascu-
bag or device, pressure tubing with transducer, and flush lar disease, vascular grafts, arteriovenous fistulas or
device shunts, arterial vasospasm, thrombosis, or embolism. In
• Pressure module and cable for interface with the monitor addition, obtain the patient’s history of coronary artery
• Normal saline-flush solution bypass graft surgery in which radial arteries were removed
• Monitoring system (central and bedside monitor) for use as conduits. Rationale: Extremities with any of
• Special monitor to interface with the bedside monitor for these problems should be avoided as sites for cannulation
trending and display of hemodynamic values (manufac- because of the potential for complications.
turer specific) • Assess the neurovascular and peripheral vascular status of
• Dual-channel recorder the extremity to be used for the arterial cannulation,
• Indelible marker including color, temperature, presence and fullness of
• Nonvented (noninjectable) caps pulses, capillary refill, presence of bruit, and motor and
• Leveling device (low-intensity laser or carpenter level) sensory function (compared with the opposite extremity).
• Sterile and nonsterile gloves Note: A modified Allen’s test may be performed before
Additional equipment, to have available as needed, includes cannulation of the radial artery (see Fig. 81-3). Rationale:
the following: This assessment may identify neurovascular or circulatory
• Heparin if prescribed impairment, so potential complications related to radial
• 3-mL syringe artery cannulation may be avoided.
• Dressing supplies • Assess the patient’s vital signs and compliance factors
• Tape (e.g., age, gender, height, weight). Rationale: This assess-
• Sterile ultrasound probe cover ment provides baseline data. The compliance factors
• Sterile ultrasound gel allow for the individual variables that ultimately dictate
pulse pressure and its relevance (proportionality) to stroke
PATIENT AND FAMILY EDUCATION volume.
• Explain the rationale for arterial line insertion, including Patient Preparation
how the arterial pressure is displayed on the bedside • Verify that the patient is the correct patient using two
monitor. Rationale: This explanation may decrease patient identifiers. Rationale: Before performing a procedure, the
and family anxiety and increase understanding. nurse should ensure the correct identification of the patient
• Explain the standard of care to the patient and family, for the intended intervention.
including insertion procedure, alarms, dressings, and • Ensure that the patient and family understand preproce-
length of time the catheter is expected to be in place. dural teaching. Answer questions as they arise, and rein-
Rationale: This explanation encourages the patient and force information as needed. Rationale: Understanding
family to ask questions and voice concerns about the of previously taught information is evaluated and
procedure and may decrease patient and family anxiety. reinforced.
• Explain the patient’s expected participation during the • Ensure that informed consent has been obtained. Ratio-
procedure. Rationale: Patients will know how they can nale: Informed consent protects the rights of the patient
help with the procedure. and makes a competent decision possible for the patient.
• Explain the importance of keeping the affected extremity • Perform a preprocedure verification and time out, if non-
immobile. Rationale: This explanation encourages patient emergent. Rationale: Ensures patient safety.
cooperation to prevent catheter dislodgment and ensures • Validate the patency of IV access. Rationale: Access may
a more accurate waveform. be needed for administration of emergency medications
• Instruct the patient to report any warmth, redness, pain, or fluids.
numbness, or wet feeling at the insertion site at any time, • Place the patient’s extremity in the appropriate position
including after catheter removal. Rationale: These symp- with adequate lighting of the insertion site. Rationale:
toms may indicate infection, bleeding, or disconnection of This placement prepares the site for cannulation and facil-
the tubing or catheter. itates an accurate insertion.
60 Arterial Pressure–Based Cardiac Output Monitoring 525
Procedure for Arterial Pressure–Based Cardiac Output Monitoring

Initiating the Procedure
1. HH
2. PE
3. If the radial artery is to be used, The modified Allen’s test has been The modified Allen’s test does not
perform the modified Allen’s test recommended before a radial artery always ensure adequate flow
before the puncture (see Fig. puncture to assess the patency of through the ulnar artery.
81-3). (Level C*) the ulnar artery and an intact A Doppler ultrasound flow indicator
superficial palmar arch.3,14 can also be used to further verify
blood flow.1,2,4,7
4. Prepare the flush solution (see Heparinized flush solutions are Although heparin may prevent
Procedure 75). commonly used to minimize thrombosis,8,13,15 it has been
A. Use an IV solution of normal thrombi and fibrin deposits on associated with thrombocytopenia
saline. catheters that might lead to and other hematologic
B. Follow institutional standards thrombosis or bacterial colonization complications.5
for adding heparin to the IV of the catheter. Other factors that promote patency of
solution, if heparin is not the arterial line besides heparinized
contraindicated. (Level B*) saline solution include male gender,
longer arterial catheters, larger
vessels cannulated, patients
receiving other anticoagulants or
thrombolytics, and short-term use
of the catheter.1
5. Gather the equipment needed for Prepares supplies. Refer to the specific manufacturer for
obtaining an arterial pressure– additional required equipment for
based cardiac output. setup and maintenance.
Some technologies require additional
calibration procedures and
equipment.10
6. Obtain the patient’s baseline This information may be needed to Follow manufacturer guidelines.
compliance factors (e.g., allow for the individual variables Some manufacturers require
age, gender, height, weight). that ultimately dictate pulse calibration.
(Level M*) pressure and its relevance Manufacturers that do not require
(proportionality) to stroke volume. calibration use age, gender, height,
and weight to determine vascular
compliance.
An accurate height and weight
reflecting perfused tissue is important
in the determination of body surface
area (BSA) and cardiac index.
Fluid weight gain often is discounted
because it is not perfused tissue.
Medications are generally based on
perfused weight in the case of
morbidly obese patients.
Because adipose tissue is highly
vascular, actual weight and height
are necessary to determine BSA.
BSA is needed for calculating indexed
values.
Precautions.
8. HH

Procedure for Arterial Pressure–Based Cardiac Output Monitoring—Continued

Setting Up the Arterial Pressure–Based Cardiac Output (APCO) System
1. HH
2. PE
3. Open the APCO sensor kit. Prepares equipment. Follow manufacturer
recommendations.
4. Secure all connections. Tight connections ensure the integrity Vented caps are standard with
of the system. transducer sets and kits, and allow
for initial priming of the system.
5. Insert the APCO sensor into the Stabilizes the sensor.
transducer holder that is secured
on the IV pole next to the patient.
6. Level the vent port near the The reference point is the phlebostatic
sensor to the phlebostatic axis. axis because it accurately reflects
central arterial pressure.
7. Prime or flush the entire APCO Removes air bubbles. Prime the system using gravity to
system: minimize small bubbles.
A. Activate the flush device to Removes air from the system.
deliver the flush solution
through the sensor and out
through the vent port.
B. Close the vent port by turning
the stopcock to the neutral
position.
C. Place a sterile nonvented Maintains a closed sterile system.
(noninjectable) cap on the top
of the stopcock.
D. Purge air from the remaining Prepares the monitoring system.
part of the tubing.
8. Inflate the pressure bag or device Inflating the pressure bag to
to 300 mm Hg. 300 mm Hg allows approximately
1–3 mL/hr of flush solution to be
delivered through the catheter, thus
maintaining catheter patency and
minimizing clot formation.
9. Assist as needed with insertion of Provides needed assistance.
the arterial catheter (See
Procedures 58 & 59).
10. Connect the bedside monitor Information can then be transferred Follow manufacturer guidelines.
cable to the APCO sensor from the sensor to the monitor. Some cables are color coded.
(Fig. 60-1).
11. Enter the patient’s gender, age, This information is needed to allow Follow manufacturer guidelines.
height, and weight. (Level M*) for the individual variables that Some manufacturers require
ultimately dictate pulse pressure calibration.
and its relevance (proportionality)
to stroke volume.
The result is stroke volume
variability.
12. Set up the monitor. Prepares equipment. Follow the manufacturer’s guidelines
as the setup may vary.
13. Observe the cardiac output (CO) Provides assessment data. The cardiac output value is updated
display. regularly based on the
manufacturer.

Figure 60-1 FloTrac sensor and Vigileo monitor. (Courtesy of Edwards Lifesciences, LLC, 2009.)
Procedure for Arterial Pressure–Based Cardiac Output Monitoring—Continued

14. Set the alarm parameters Activates the bedside and central Follow manufacturer guidelines.
according to the patient’s current alarm system.
blood pressure.
15. Remove PE and discard used Reduces the transmission of Ensure sharps are safely disposed.
16. HH

• Accurate measurement of cardic output (CO) • Poor-quality arterial pressure wave leading to the
• Maintenance of catheter patency inability to obtain an accurate CO
• Minimal discomfort from the arterial catheter • Infection
• Maintenance of baseline hemoglobin and hematocrit • Impaired peripheral tissue perfusion (e.g., edema,
levels coolness, pain, paleness, or slow capillary refill of the
• Adequate circulation to the involved extremity fingers of the cannulated extremity)
• Adequate sensory and motor function of the extremity • Perforated or lacerated artery
• Maintenance of the catheter site without infection • Hematoma at the insertion site
• Pain or discomfort from the arterial catheter insertion
site
• Decreased hemoglobin and hematocrit values
• Catheter disconnection with significant blood loss

interventions.
1. Assess the neurovascular and Determines peripheral vascular and • Diminished or absent pulses
peripheral vascular status of the neurovascular integrity. Changes in • Pale, mottled, or cyanotic
cannulated extremity immediately sensation, motor function, pulses, appearance of the extremity
after catheter insertion and every 4 color, temperature, or capillary refill • Extremity that is cool or cold to
hours, or more often if needed. may indicate ischemia, arterial the touch
Follow institutional standards. spasm, or neurovascular • Capillary refill time of more than 2
compromise. seconds (or longer than patient’s
baseline)
• Diminished or absent sensation
• Diminished or absent motor
function
2. Assess the arterial catheter Identifies the possibility of site • Redness at the site
insertion site for signs and infection. • Purulent drainage
symptoms of infection. • Tenderness or pain at the insertion
site
3. Continuously monitor heart rate, Provides assessment of patient status. • Abnormal vital signs
blood pressure, and cardiac • Abnormal cardiac output
indices. • Abnormal cardiac index
5. Assess the patient’s response to The hemodynamic management of the • Abnormal cardiac output
prescribed interventions. patient requires close monitoring • Abnormal cardiac index
and interventions based on the • Abnormal vital signs
parameters obtained from the
APCO data.
6. Replace gauze dressings every 2 Decreases the risk for infection at the
days and transparent dressings at catheter site. The Centers for
least every 5–7 days and more Disease Control and Prevention
frequently as needed.6,7,13,16 (CDC)13 and the Infusion Nurses
(Level D*) Society6,7 recommend replacing the
dressing when the dressing
becomes damp, loosened, or soiled,
necessary.
Documentation
• Patient and family education • Type of flush used
• Informed consent • Amount of flush solution on intake and output record
• Preprocedure verification and time out • Vital signs, cardiac output, cardiac index, and other
• Patient tolerance of the procedure hemodynamic parameters
• Peripheral vascular and neurovascular assessment • Positive flow by modified Allen’s test if the radial
before and after the procedure artery is used
• Assessment of the insertion site • Site assessment
• Patient response to the insertion procedure • Unexpected outcomes
• Pain assessment, interventions, and effectiveness • Additional nursing interventions

60 Arterial Pressure–Based Cardiac Output Monitoring 529.e1
References 15. Randolph AG, et al: Benefit of heparin in peripheral

1. Abu-Omar Y, et al: Duplex ultrasonography predicts venous and arterial catheters: Systematic review and
safety of radial artery harvest in the presence of an meta-analysis of randomized controlled trials. BMJ
abnormal Allen test. Ann Thorac Surg 77:116–119, 2004. 316:969–975, 1998.
2. American Association of Critical-Care Nurses: Evaluation 16. Timsit J, et al: Chlorhexidine-impregnated sponges and
of the effects of heparinized and nonheparinized flush less frequent dressing changes for prevention of catheter-
solutions on the patency of arterial pressure monitoring related infections in critically ill adults. JAMA 310:1231–
lines: the AACN Thunder Project. Am J Crit Care 2:3–15, 1241, 2009.
1993. Additional Readings
3. Barone J, Madlinger RV: Should an Allen test be
performed before radial artery cannulation? J Trauma Button D, et al: Clinical evaluation of the FloTrac/Vigileo
6:468–470, 2006. system and two established continuous cardiac output
4. Bobbia X, et al: Ultrasound guidance for radial arterial monitoring devices in patients undergoing cardiac surgery.
puncture: A randomized controlled trial. Am J Emerg Med Br J Anaesth 99(3):329–336, 2007.
31:810–815, 2013. Chakravarthy M, et al: Comparison of simultaneous estimation
5. Greenwood MJ, et al: Vascular communications of the of cardiac output by four techniques in patients undergoing
hand in patients being considered for transradial coronary off-pump coronary artery bypass surgery: A prospective
angiography: Is the Allen’s test accurate? J Am Coll observational study. Ann Card Anaesth 10(2):121–126,
Cardiol 46:2013–2017, 2005. 2007.
6. Infusion Nurses Society: Infusion Nursing Standards of de Waal E, et al: Validation of a new arterial pulse contour-
Practice. J Infus Nurs 34(1S):S6–S110, 2016. based cardiac output device. Crit Care Med 35(8):1904–
7. Infusion Nurses Society: Policies and Procedures 1909, 2007.
for Infusion Nursing, ed 5, 2016, Infusion Nurses deWilde R, et al: Performance of three minimally invasive
Society. cardiac output monitoring systems. Anaesthesia 64:762–
8. Kordzadeh A, Austin T, Panayiolopoulos Y: Efficacy of 769, 2009.
normal saline in the maintenance of the arterial lines in Lough M: Hemodynamic monitoring: Evolving technologies
comparison to heparin flush: A comprehensive review of and clinical practice, St. Louis, 2015, Elsevier.
the literature. J Vasc Access 15(2):123–127, 2014. Prasser C, et al: Evaluation of a new arterial pressure-based
9. Lee G, Gowthami A: Diagnosis and management of cardiac output device requiring no external calibration.
heparin-induced thrombocytopenia. Hematol Oncol Clin BMC Anesthesiol 7(9):9, 2007.
North Am 27(3):541–563, 2013. Peyton P, Chong S: Minimally invasive measurement of
10. Hadian M, et al: Cross comparison of cardiac output cardiac output during surgery and critical care: A meta-
trending accuracy of LiDCO, PICCO, FloTrac and analysis of accuracy and precision. Anesthesiology
pulmonary artery catheters. Crit Care 14:1–10, 2010. 113(5):1220–1235, 2010.
11. Metzelder S, et al: Performance of cardiac output Randolph AG, et al: Benefit of heparin in peripheral venous
measurement derived from arterial pressure waveform and arterial catheters: Systematic review and meta-analysis
analysis in patients requiring high-dose vasopressor of randomized controlled trials. BMJ 316:969–975, 1998.
therapy. Br J Anaesth 106:776–784, 2011. Robertson-Malt S, et al: Heparin versus normal saline for
12. Mora B, et al: Validation of cardiac output measurement patency of arterial lines. Cochrane Database Syst Rev
with the LiDCO pulse contour system in patients with (5):CD007364, 2014.
impaired left ventricular function after cardiac surgery. Schloglhofer T, Schima H: Semi-invasive measurement of
Anaesthesia 66:675–681, 2011. cardiac output based on pulse contour: A review and
13. O’Grady NP, et al: Guidelines for the prevention of analysis. Can J Anaesth 61:452–479, 2014.
intravascular catheter-related infections. Am J Infect Valgimigli M, et al: Transradial coronary catheterization and
Control 39(4 Suppl 1):S1–S34, 2011. intervention across the whole spectrum of Allen’s tests
14. Oettlé AC, et al: Evaluation of Allen’s test in both arms results. J Am Coll Cardiol 63:1833–1841, 2013.
and arteries of left and right-handed people. Surg Radiol
Anat 28:3–6, 2006.
PROCEDURE
61
Blood Sampling from an
Arterial Catheter
PURPOSE: Blood sampling from an arterial catheter is performed to obtain blood
specimens for arterial blood gas analysis or other laboratory testing.
PREREQUISITE NURSING • Syringes, 5 and 10 mL

KNOWLEDGE • Needleless cannula (for closed arterial blood-sampling sys-
tem)
• Knowledge of the vascular anatomy and physiology is needed. PATIENT AND FAMILY EDUCATION
• Understanding of gas exchange and acid-base balance is
necessary. • Explain the procedure to the patient and family. Ratio-
• Technique for specimen collection and labeling should be nale: Teaching provides information and may reduce
understood. anxiety and fear.
• Principles of hemodynamic monitoring are necessary. • Explain the importance of keeping the affected extremity
• Knowledge about the care of patients with arterial cath- immobile. Rationale: This explanation encourages patient
eters (see Procedure 59) and stopcock manipulation (see cooperation during blood withdrawal.
Procedure 75) is needed. • Explain the patient’s expected participation during the
• Understanding of the closed arterial line blood sampling procedure. Rationale: Patient cooperation during inser-
system is necessary. tion is encouraged.
• Closed blood-sampling systems provide the opportunity
to reinfuse blood to the patient after the laboratory
sample is obtained to help reduce the risk of nosocomial PATIENT ASSESSMENT AND
anemia.3,7,10,14,15 PREPARATION
Patient Assessment
EQUIPMENT
• Assess the patency of the arterial catheter. Rationale: This
• Nonsterile gloves ensures a functional arterial catheter.
• Sterile 4 × 4 gauze pads • Assess the patient’s previous laboratory results. Ratio-
• Arterial blood gas kit and blood specimen tubes nale: This assessment provides data for comparison.
• Labels with the patient’s name and appropriate identifying
data Patient Preparation
• Laboratory form and specimen labels • Verify that the patient is the correct patient using two
• Goggles or fluid shield face mask identifiers. Rationale: Before performing a procedure, the
• Needleless blood-sampling access device (blood-transfer nurse should ensure the correct identification of the patient
device) for the intended intervention.
• Extra blood-specimen tube (for discard) • Ensure that the patient and family understand prepro-
• Sterile injectable or noninjectable caps cedural teaching. Answer questions as they arise, and rein-
• Antiseptic solution (i.e., 2% chlorhexidine–based prepara- force information as needed. Rationale: Understanding of
tion) previously taught information is evaluated and reinforced.
• Specimen transport bag(s) • Expose the stopcock to be used for blood sampling, and
Additional equipment, to have available as needed, includes position the patient’s extremity so that the site can easily
the following: be accessed. Rationale: This prepares the site for blood
• Bag of ice withdrawal.
530
61 Blood Sampling from an Arterial Catheter 531
Procedure for Blood Sampling From an Arterial Catheter

1. HH
2. PE
3. When obtaining an ABG sample, Prepares the ABG syringe. Heparin is usually in powdered form.
open the ABG kit and use the If prepackaged ABG kits are not
plunger to rid the excess heparin available, draw 0.5 mL of a 1 : 1000
and air from the syringe. dilution of heparin in a 3-mL
syringe. Pull back on the plunger to
coat the inside of the syringe and
the needle. Rid the excess heparin
and air from the syringe.2
4. Temporarily suspend the arterial Prevents the alarm from sounding as
alarms. the pressure waveform is lost
during the blood draw.
Blood Sampling With a Needleless Blood-Sampling Access Device (Blood-Transfer Device) or a Syringe
1. Arterial stopcock:
A. Remove the sterile cap from Prepares for blood sampling.
the port of the three-way
stopcock closest to the patient
and attach the needleless
blood-sampling access device
(blood-transfer device)
(Fig. 61-1, A) or syringe (Fig.
61-1, B) to the stopcock.
Or
B. Cleanse the injectable cap at
the top of the stopcock closest
to the patient with an
antiseptic solution1,9
(Level B*)
and attach the needleless
(blood-transfer device)
(Fig. 61-2).
2. Turn the stopcock off to the flush The needleless blood-sampling access
solution (Fig. 61-3). device (blood-transfer device) or
syringe is then in direct contact
with the blood in the arterial
catheter.
3. When using a needleless blood- Clears the catheter of flush solution.
sampling access device (blood-
transfer device), engage the blood
specimen tube to obtain the
discard volume or, if using a
syringe, slowly and gently
aspirate the discard volume.
A. When obtaining blood for an The discard volume includes the dead The dead space is the space between
ABG sample, discard a blood space and the blood diluted by the the tip of the arterial catheter to the
sample that is two times the flush solution (e.g., dead space of top port of the stopcock.
dead-space volume. 0.8 mL = 1.6 mL discard).11,12
(Level B*)
B
Figure 61-1 A, The needleless blood-sampling access device (blood-transfer device) attached to
the port of the three-way stopcock. The stopcock is turned “off” to the port of the stopcock. B, A
syringe attached to the port of the three-way stopcock. The stopcock is turned “off” to the port of
the stopcock). (Drawing by Paul W. Schiffmacher, Thomas Jefferson University Hospital, Philadel-
phia, PA.)
Figure 61-2 Needleless blood-sampling access device (blood-

transfer device). (Drawing by Paul W. Schiffmacher, Thomas Jef-
ferson University Hospital, Philadelphia, PA.)
Figure 61-3 The needleless blood-sampling access device (blood-transfer device) attached to the
port of the three-way stopcock. The stopcock is turned “off” to the flush solution. (Drawing by Paul
W. Schiffmacher, Thomas Jefferson University Hospital, Philadelphia, PA.)
Procedure for Blood Sampling From an Arterial Catheter—Continued

B. When obtaining blood for Additional discard is needed to This recommendation does not apply
coagulation studies prevent contamination of the to patients undergoing systemic
(particularly activated partial specimen with heparin in order to heparin therapy.
thromboplastin time) from a ensure accurate laboratory results More research is needed with this
heparinized arterial line, use a (e.g., dead space of 0.8 mL = patient population.
discard volume of six times 4.8 mL discard).4–6,8,13
the dead-space volume.
(Level B*)
4. Turn the stopcock off to the Stops blood flow and closes the top Not necessary if using a needleless
syringe. port of the stopcock. blood-sampling device.
5. Remove the syringe or the Removes and safely disposes of the If unable to dispose of the discard
blood-specimen tube and discard discard. specimen immediately, place it
in the appropriate receptacle. away from the field so it is not
mistaken for the actual blood
specimen(s) for laboratory analysis.
6. Obtain the blood sample: Obtains the appropriate blood If obtaining laboratory specimens in
specimens. addition to an ABG and coagulation
studies, obtain the routine
laboratory studies first and then
obtain the ABG and coagulation
studies to minimize the heparin
effect.
Specimen size should be the amount
required for the blood test(s).
A. If using the needleless system, The needleless blood-sampling access
the stopcock should remain device (blood-transfer device) is a
off to the flush solution as nonvented system, so no backflow
each blood specimen tube is of arterial blood from the patient
engaged. occurs.


B. If using syringes to obtain Prevents backflow of arterial blood Transfer the specimen to the
blood specimens, turn the through the open blood sampling appropriate laboratory tubes or
stopcock off to the patient port. specimen collection containers.
before changing each syringe
(Fig. 61-4, A).
After each new syringe is Opens the arterial line from the
attached to the blood- patient to the syringe.
sampling port, turn the
stopcock off to the flush
solution (Fig. 61-4, B).
B
Figure 61-4 A, A syringe attached to the port of the three-way stopcock. The stopcock is turned
“off” to the patient. B, A syringe attached to the top of the three-way stopcock. The stopcock is
turned “off” to the flush solution. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University
Hospital, Philadelphia, PA.)

C. When obtaining an ABG Prepares for connection of the ABG
sample, turn the stopcock off syringe.
to the patient and attach the
ABG syringe directly to the
top port of the stopcock or
place the ABG syringe inside
of the needleless access
device.
D. Turn the stopcock off to the Opens the arterial line to the ABG
flush solution. syringe.
E. Gently aspirate the ABG Obtains the ABG sample while
sample. minimizing vessel trauma.
F. Turn the stopcock off to the Prevents the backflow of arterial
patient before removing the blood.
ABG syringe.
G. Expel any air bubbles from Ensures accuracy of the ABG results.
the ABG syringe and cap the
syringe.
7. After the last specimen is Detaches the specimen and ensures no
obtained, turn the stopcock off to backflow of arterial blood from the
the patient. patient.
8. Using the fast flush device, flush Clears blood from the system. Follow institution standard.
the remaining blood from the top
port of the stopcock onto a sterile
gauze pad, into a discard syringe,
or into a blood-specimen tube.
9. Turn the stopcock off to the top Opens the system up for continuous Remove the needleless blood-
port of the stopcock. arterial pressure monitoring. sampling access device (blood-
transfer device) if used.
10. Place a new, sterile, injectable or Maintains a closed sterile system.
noninjectable cap to the top port
of the stopcock.
11. Using the fast flush device, flush Promotes patency of the arterial
the remaining blood in the catheter.
arterial catheter back into the
patient.
Blood Sampling With a Closed Arterial Blood-Sampling System
1. Slowly and gently pull back on Withdraws and stores blood from the Temporarily silence the arterial alarm.
the blood-withdrawal reservoir patient until it is ready to be
plunger until it fills to full reinfused after blood sampling is
capacity (Fig. 61-5). complete.
2. Close the stopcock by turning it Closes the system.
perpendicular to the tubing (Fig.
61-6).
3. Attach a needleless cannula (Fig. Prepares for blood sampling.
61-7) to the needleless blood-
sampling access device (blood-
transfer device) (Fig. 61-8, A) or
a syringe (Fig. 61-8, B).
4. Cleanse the blood-sampling port Prepares for blood sampling and Follow institutional standards.
with an antiseptic solution.1,9 reduces the risk for infection.
(Level B*)

Figure 61-6 The stopcock of the closed blood-sampling system

in the open and closed position. (Drawing by Paul W. Schiffmacher,
Thomas Jefferson University Hospital, Philadelphia, PA.)
Figure 61-5 Closed blood-sampling system. (Drawing by Paul

W. Schiffmacher, Thomas Jefferson University Hospital, Philadel-
phia, PA.)
Figure 61-7 The needleless cannula for the closed blood-

sampling system. (Drawing by Paul W. Schiffmacher, Thomas Jef-
ferson University Hospital, Philadelphia, PA.)
A B
Figure 61-8 A, The needleless cannula attached to a needleless
blood-sampling access device. B, The needleless cannula attached
to a syringe. (Drawing by Paul W. Schiffmacher, Thomas Jefferson
University Hospital, Philadelphia, PA.)
Figure 61-9 Attachment of the needleless cannula into the blood-

sampling port of the closed blood-sampling system. (Drawing by Figure 61-10 Removal of the needleless cannula from the blood-
Paul W. Schiffmacher, Thomas Jefferson University Hospital, Phila- sampling port of the closed blood-sampling system. (Drawing by
delphia, PA.) Paul W. Schiffmacher, Thomas Jefferson University Hospital, Phila-
delphia, PA.)

5. While holding the base of the Prepares for blood sampling.
blood sampling port, engage
(push) the needleless cannula
(with the attached needleless
blood-sampling access device or
syringe) into the blood-sampling
port (Fig. 61-9).
6. Engage each blood tube into the Obtains the sample. If obtaining both blood samples and
needleless blood-sampling access an ABG sample, remove the entire
device (blood-transfer device) or unit (needleless cannula with the
obtain an ABG sample. needleless blood-sampling access
device) before engaging the
needleless cannula with the ABG
syringe.
7. After the blood samples are Removes the needleless cannula.
obtained, hold the base of the
blood-sampling port and remove
the needleless cannula (with
attached needleless blood-
sampling access device or ABG
syringe) from the sampling port
by pulling it straight out (Fig.
61-10).
8. Open the stopcock by turning it Opens the system to prepare for
to the open position (parallel to reinfusion of the stored withdrawn
the tubing) (see Fig. 61-6). blood sample.
9. Slowly and smoothly reinfuse the Returns blood to the patient to help
discard volume.3,7,10,14,15 reduce the risk of nosocomial
(Level B*) anemia.
10. Swab the blood-sampling port Removes excess blood and fluid from
with antiseptic solution. the sampling port to prevent
bacterial growth.
11. Flush the system with the fast Promotes the patency of the arterial
flush device. catheter.


After Blood Specimens Are Obtained
2. HH
3. Turn the alarms on and ensure Provides accurate waveform and safe
that the waveform returns. blood pressure monitoring.
4. Label the specimens and place in Properly identifies the patient and Confirm identifying information. For
a transport bag. Complete the laboratory tests to be performed. ABG samples, note the time the
laboratory form per institutional specimen was drawn and the
protocol. percentage of oxygen therapy and
any other data required by
institutional protocol.
5. Send the specimens for analysis. Allows the laboratory to conduct the Follow institutional standards
analysis. regarding the use of ice for ABG
samples.

• Adequate blood sample with minimal blood loss • Inadequate blood sample
• No hemolysis of specimens • Hemolysis of specimens
• No arterial spasm • Arterial spasm
• Arterial line patency maintained • Dilution of specimens that causes inaccurate
laboratory results
• Anemia
• Clotting of the arterial catheter

interventions.
1. Use the minimal volume of blood Helps prevent nosocomial anemia. • Decrease in hemoglobin or
discard. hematocrit levels
2. Monitor hemoglobin or hematocrit Allows early detection of nosocomial • Decrease in hemoglobin or
daily or as prescribed. anemia. hematocrit levels
3. Attempt to group blood draws Diminishes the number of times the • Signs of catheter-related infection
together whenever possible. system is entered to help minimize
the risk for infection.
4. Before and after the blood Ensures accurate arterial pressure
withdrawal, assess and evaluate the monitoring.
arterial waveform.
5. Turn on arterial blood pressure Ensures safe arterial pressure
alarms after blood withdrawal and monitoring.
review parameters.
6. Obtain laboratory specimen results. Monitors test results. • Abnormal specimen results
Documentation
• Patient and family education • Additional nursing interventions
• Date, time, and type of specimen drawn • Results of laboratory tests, when available
• Unexpected outcomes

61 Blood Sampling from an Arterial Catheter 539.e1
References 11. Preusser BA, Lash J, et al: Quantifying the minimum

1. Casey AL, Worthington T, et al: A randomized, discard sample required for accurate arterial blood gases.
prospective clinical trial to assess the potential infection Nurs Res 38:276–279, 1989.
risk associated with the PosiFlow needleless connector. 12. Rickard CM, Couchman BA, et al: A discard volume of
J Hosp Infect 54:288–293, 2003. twice the deadspace ensures clinically accurate arterial
2. Darovic GO: Arterial pressure monitoring. In blood gases and electrolytes and prevents unnecessary
Hemodynamic monitoring: Invasive and noninvasive blood loss. Crit Care Med 31:1654–1658, 2003.
clinical application, ed 3, Philadelphia, 2002, Saunders. 13. Rudisill PT, Moore LA: Relationship between arterial and
3. Gleason E, Grossman S, Campbell C: Minimizing venous activated partial thromboplastin time values in
diagnostic blood loss in critically ill patients. Am J Crit patients after percutaneous transluminal coronary
Care 1:85–90, 1992. angioplasty. Heart Lung 18:514–519, 1989.
4. Gregersen RA, Underhill SL, et al: Accurate coagulation 14. Silver MJ, Jubran H, et al: Evaluation of a new blood-
studies from heparinized radial artery catheters. Heart conserving arterial line system for patients in intensive
Lung 16(6):686–692, 1987. care units. Crit Care Med 21:507–511, 1993.
5. Harper J: Use of intraarterial lines to obtain coagulation 15. Silver MJ, Li YH, et al: Reduction of blood loss from
samples. Focus Crit Care 15:51–55, 1988. diagnostic sampling in critically ill patients using a
6. Laxson CJ, Titler MG: Drawing coagulation studies from blood-conserving arterial line system. Chest 104:
arterial lines: An integrative literature review. Am J Crit 1711–1715, 1993.
Care 3:16–24, 1994. Additional Readings
7. MacIsaac CM, Presneill JJ, et al: The influence of a blood
conserving device on anaemia in intensive care patients. Imperial-Perez F, McRae M: Protocols for practice:
Anaesth Intensive Care 31:653–657, 2003. hemodynamic monitoring series: Arterial pressure
8. Molyneaux RD, Papciak B, Rorem DA: Coagulation monitoring, Aliso Viejo, CA, 1998, American Association
studies and the indwelling heparinized catheter. Heart of Critical-Care Nurses.
Lung 16:20–23, 1987. Lough M: Hemodynamic monitoring: Evolving technologies
9. O’Grady NP, Alexander M, et al: Summary of and clinical practice, 2015, Elsevier.
recommendations: Guidelines for the prevention of Vincent JL: Arterial, central venous, and pulmonary artery
intravascular catheter-related infections. Clin Infect Dis catheters. In Parrillo JE, Dellinger RP, editors: Critical
52(9):1087–1099, 2011. care medicine: Principles of diagnosis and management in
10. Peruzzi WT, Parker MA, et al: A clinical evaluation of a the adult, Philadelphia, 2014, Elsevier Saunders, pp
blood conservation device in medical intensive care unit 48–50.
patients. Crit Care Med 21:501–506, 1993.
PROCEDURE
62
Blood Sampling from a Central
Venous Catheter
Kathleen M. Cox
PURPOSE: To obtain blood from the central venous catheter for laboratory
analysis.
PREREQUISITE NURSING • Extra blood-specimen tube for discard

KNOWLEDGE • Laboratory form and patient identification specimen labels
• 2 × 2 and 4 × 4 gauze pads
• Knowledge of anatomy and physiology of the cardiovas- • Needleless caps (injectable caps)
cular system is needed. • Specimen transport bag(s)
• Understanding principles and performance of sterile and Additional equipment, to have available as needed, includes
aseptic technique and infection control is necessary. the following:
• Understanding the technique for specimen collection and • Additional syringes
labeling is required.
• Knowledge and significance of signs and symptoms of PATIENT AND FAMILY EDUCATION
catheter-related infection and sepsis is necessary.
• Central line–associated bloodstream infection (CLABSI) • Explain the purpose for blood sampling to the patient and
is linked to increased mortality of up to 25% and greater family. Rationale: Provision of information helps the
than $1 billion in associated costs.5,6,10 patient and family make informed decisions, reduces
• Knowledge of strategies to prevent catheter-related infec- anxiety, and facilitates cooperation.
tions is essential. • Explain the patient’s expected participation during the
• Skill and knowledge of caring for patients with central procedure. Rationale: Discussion of the patient’s partici-
venous catheters (CVCs) is needed (see Procedure 83). pation supports patient autonomy and sense of control,
• Understanding of the principles of hemodynamic monitor- and increases patient cooperation.1
ing is necessary.
• Awareness of the effect of heparin and hemolysis on PATIENT ASSESSMENT AND
various blood tests and understanding of the need for PREPARATION
appropriate discard volumes are required.
• Alternate routes of blood withdrawal such as venipuncture Patient Assessment
or arterial catheters should be considered to minimize the • Assess the patency of the CVC. Rationale: Ensures func-
risk of CLABSI.3,6,10 tion of the CVC catheter.
• Ideally a needleless system should be used for capping and • Evaluate previous laboratory results. Rationale: These
accessing CVC ports. Needleless systems reduce needle- results provide baseline data for comparison.
stick injuries and risk of blood-borne infection transmission • Determine whether intravenous solutions or medications
to physicians, advanced practice nurses, and other health- are infusing through the CVC. Rationale: Intravenous
care professionals and may also reduce CLABSI.10 solutions and medication must be temporarily discontin-
ued before blood sampling to reduce interference with the
EQUIPMENT laboratory analysis.14 Critical infusions (i.e., vasoactive
medications) may not be able to be stopped; additional
• Nonsterile gloves blood access sites need to be considered.
• Goggles or fluid shield face mask
• Antiseptic solution (e.g., 2% chlorhexidine–based solu- Patient Preparation
tion) • Verify that the patient is the correct patient using two
• Needleless blood-sampling access device (blood-transfer identifiers. Rationale: Before performing a procedure, the
device) nurse should ensure the correct identification of the patient
• Blood specimen tubes for the intended intervention.
• 10-mL syringe • Confirm that the patient and family understand preproce-
• Sterile normal saline solution for injection dural teaching by having them verbalize understanding.
540
62 Blood Sampling from a Central Venous Catheter 541
Clarify key points by reinforcing important information • Position the patient so that the intended blood sampling
and answer all questions. Rationale: Preprocedure com- port is exposed. Rationale: Optimal positioning improves
munication provides a framework of patient expectations, the ease of obtaining the blood sample and reduces poten-
enhances cooperation, and reduces anxiety.1 tial contamination of the port.
Procedure for Blood Sampling from Central Venous Catheters

1. HH
2. PE
Blood Sampling From the CVC Hemodynamic Monitoring System
1. Cleanse the needleless cap Reduces the risk for infection. Follow institutional standards.
(injectable cap) on the
hemodynamic monitoring system
stopcock with an antiseptic
solution and allow to dry.3,8,10,12,13
(Level B*)
2. Attach the needleless blood Prepares for blood sampling.
sampling device (blood transfer
device) to the stopcock of the
hemodynamic monitoring system
(Fig. 62-1).
3. Temporarily suspend the right- Prevents the alarm from sounding
atrial pressure/central venous because the RAP/CVP waveform is
pressure (RAP/CVP) monitoring lost during the blood sampling.
alarm.
Figure 62-1 Needleless blood-sampling device (blood-transfer device) attached to the needleless
(injectable) capped stopcock of the hemodynamic monitoring system. The stopcock is open to the
transducer system. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia,
PA.)
Procedure for Blood Sampling from Central Venous Catheters—Continued

4. Turn the stopcock off to the The needleless blood sampling device
monitoring system and flush is now in contact with the central
solution (Fig. 62-2). venous blood.
5. Insert a blood-specimen tube into Clears the catheter of flush solution. Dead-space information for a catheter
the blood-sampling device The discard volume includes the dead is usually listed in the information
(blood-transfer device) to obtain space (from the tip of the lumen to that comes with the catheter.
the discard volume.3,13 (Level B*) the top port of the needleless
capped stopcock) and the blood
diluted by the flush solution (e.g.,
3.5 mL).2–4,11,14
6. Remove the discard blood- Removes discard safely.
specimen tube and discard in the
appropriate receptacle.
7. Insert the blood-specimen tube Obtains the blood specimen.
into the blood-sampling device to
obtain the specimen.
8. After obtaining the specimen, Removes and safely discards The blood in the needleless cap can
detach the blood-sampling device equipment. be cleared by fast flushing the
from the capped stopcock and blood into a blood-specimen tube
discard it in appropriate or syringe (Fig. 62-3).
receptacle.
Figure 62-2 Needleless blood-sampling device (blood-transfer device) attached to the needleless
(injectable) capped stopcock of the hemodynamic monitoring system. The stopcock is turned “off”
to the monitoring system and flush solution. (Drawing by Paul W. Schiffmacher, Thomas Jefferson
University, Philadelphia, PA.)
Figure 62-3 A syringe attached to the port of the three-way stopcock. The stopcock is turned
“off” to the patient. The system is open between the flush solution and the syringe attached to the
needleless cap. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)

9. Cleanse the needleless cap at the Reduces the risk for infection. Follow institutional standards.
top of the stopcock with an
antiseptic solution and allow to
dry.3,8,10,12,13
(Level B*)
10. Attach a 10-mL syringe filled Prepares flush solution.
with sterile normal saline solution
to the needleless (injectable)
capped stopcock.
11. Gently flush the normal saline Clears blood from the needleless cap
solution into the needleless and the stopcock.
(injectable) cap (Fig. 62-4).
12. Turn the stopcock off to the This opens the system for continuous
blood-sampling device (blood- RAP/CVP pressure monitoring.
transfer device).7
13. Fast flush the remaining blood in Promotes patency of the CVC.
the CVC back into the patient.
14. Observe the monitor for return of Ensures continuous monitoring of the
the RAP/CVP waveform. waveform.
16. HH
17. Turn the alarms back on. Activates the alarm system.

“off” to the monitoring system and flush solution. The system is open between the patient and the
syringe attached to the needleless (injectable) cap. (Drawing by Paul W. Schiffmacher, Thomas Jef-
ferson University, Philadelphia, PA.)

18. Label the specimen and place in a Properly identifies the patient and Confirm identifying information.
transport bag. Complete the laboratory tests to be performed.
laboratory form.
19. Send the specimen for analysis. Ensures analysis.
Blood Sampling From a Single CVC Port That Is Not Monitored
1. HH
2. PE
3. Temporarily discontinue Minimizes the risk of diluting the If the blood sample is obtained from a
intravenous solutions and blood specimen, which may affect multiple-lumen catheter (e.g., triple
medications before blood the accuracy of the laboratory lumen), stop intravenous and
sampling. results.14 medication infusions from all of the
CVC ports, and ensure that
temporarily stopping intravenous
medications does not affect
hemodynamic stability.
Obtain the blood sample from the
distal lumen.
4. Remove and cap the intravenous Prepares equipment and maintains
solution infusing through the asepsis of the intravenous system.
intended blood-sampling port.

(injectable cap) at the end of the
CVC sampling port with an
antiseptic solution and allow to
dry.3,8,10,12,13
(Level B*)
6. Attach the needleless blood- Prepares for blood sampling.
sampling device (blood-transfer
device) to the needleless cap
(injectable cap) of the CVC port
(Fig. 62-5).
7. Insert a blood-specimen tube into Clears the catheter of flush solution. Dead-space information for a catheter
the blood-sampling device to The discard volume includes the is usually listed in the information
obtain the discard volume. dead space (from the tip of the that comes with the catheter.
lumen to the top port of the
needleless capped stopcock) and the
blood diluted by the flush solution
(e.g., 3.5 mL).3,14
8. Remove the discard blood- Removes discard safely.
specimen tube and discard in the
9. Insert the blood-specimen tube Obtains the blood specimen. Obtain additional specimens as
into the blood-sampling device to prescribed.
obtain the specimen. Specimen size should be the amount
required for the blood test(s).
10. After obtaining the specimen, Removes and safely discards
detach the blood-sampling device equipment.
from the capped stopcock and
discard it in the appropriate
receptacle.
with an antiseptic solution and
allow to dry.3,8,10,12,13
(Level B*)
12. Attach a 10-mL syringe filled Prepares flush solution.
with sterile normal saline solution
to the needleless cap (injectable
cap) of the CVC port.
Figure 62-5 The needleless blood-sampling device (blood-transfer device) attached to the needle-
less (injectable) cap of the central venous catheter (CVC) port. (Drawing by Paul W. Schiffmacher,
Thomas Jefferson University, Philadelphia, PA.)

13. Gently flush the normal saline Clears blood from the needleless cap
solution into the needleless cap (injectable cap) and the CVC port.
(injectable cap).
14. Remove the normal saline Removes and safely discards
solution syringe and discard it in equipment.
the appropriate receptacle.
with an antiseptic
solution.3,8,10,12,13 (Level B*)
16. Reattach and resume the Continues treatment.
intravenous solution or
medication infusion.
18. HH
transport bag. Complete the laboratory tests to be performed.
laboratory form.
20. Send the specimen for analysis. Allows the laboratory to conduct the
analysis.

• Catheter remains patent with good waveform if • Clotting of the CVC
monitoring system is used • Catheter-related infection
• Catheter site remains free from infection • Inability to obtain blood sample
• Adequate blood sample with minimal blood loss • Hemolysis of specimens
• No hemolysis of the specimen • Dilution of specimens that causes inaccurate
laboratory results

interventions.
1. Use the minimal volume of blood Helps prevent nosocomial anemia. • Decreased hemoglobin level and
discard.14 hematocrit level
2. Monitor hemoglobin and Allows early detection of nosocomial • Decreased hemoglobin level and
hematocrit values if frequent anemia. hematocrit level
blood sampling is needed.
3. Attempt to obtain all blood Diminishes the number of times the • Signs of catheter-related sepsis
samples at one time when system is entered to help minimize
possible.9 the risk of infection.
4. Before and after the blood Ensures accurate RAP/CVP • Abnormal RAP/CVP waveforms
withdrawal, assess and evaluate monitoring.
the RAP/CVP waveform if
monitored.
5. Obtain laboratory specimen Assesses patient condition. • Abnormal specimen results
results.
Documentation
• Patient and family education • Unexpected outcomes
• Time and type of specimen drawn • Inability to obtain sample
• Results of laboratory tests when available

62 Blood Sampling from a Central Venous Catheter 547.e1
References 10. O’Grady NP, et al: Guidelines for the prevention of

1. Bailey L: Strategies for decreasing patient anxiety in the intravascular catheter-related infections. Clin Infect Dis
perioperative setting. AORN J 92:445–457, 2010. 52(9):1087–1099, 2011.
2. Carlson KK, et al: Obtaining reliable plasma sodium and 11. Palermo LM, Andrews RW, Ellison N: Avoidance of
glucose determinations from pulmonary artery catheters. heparin contamination in coagulation studies drawn from
Heart Lung 19:613–619, 1990. indwelling lines. Anesth Analg 59:222–224, 1980.
3. Camp-Sorrell D: Access device guidelines: 12. Simmons S, Bryson C, Porter S: “Scrub the hub”:
recommendations for nursing practice and education, ed Cleaning duration and reduction in bacterial load in
3, Pittsburgh, 2011, Oncology Nursing Society. central venous catheters. Crit Care Nurs Q 34(1):31–35,
4. Krueger KE, et al: The reliability of laboratory data from 2011.
blood samples collected through pulmonary artery 13. Vincent JL: Arterial, central venous, and pulmonary artery
catheters. Arch Pathol Lab Med 105:343–344, 1981. catheters. In Parrillo JE, Dellinger RP, editors: Critical
5. Malpiedi PJ, et al: National and state healthcare associated care medicine: principles of diagnosis and management in
infection standardized infection ratio report. In Centers the adult, Philadelphia, 2014, Elsevier Saunders, pp
for Disease Control and Prevention publications, 48–50.
Washington, D.C., 2013, US Government Printing Office. 14. Wyant S, Crickman R: Determining the minimum discard
6. McKenny M, Fitzgerald M, Scully M: How do I diagnose volume for central venous catheter blood draws. Clin J
& manage catheter-related blood stream infections? In Oncol Nurs 16(5):454–458, 2012.
Deutschman CS, Neligan PJ, editors: Evidence-based Additional Readings
practice of critical care, Philadelphia, 2010, Saunders
Elsevier, pp 263–276. 1. Halm M, Hickson T, Stein D: Blood cultures and central
7. McNeil CR, Rezaie SR, Adams BD: Central venous catheters: Is the “easiest way” best practice? Am J Crit
catheterization and central venous pressure monitoring. In Care 20(4):335–338, 2011.
Roberts JR, editor: Robert’s & Hedges clinical procedures 2. Infusion Nurses Society: Policies and procedures for
in emergency medicine, ed 6, Philadelphia, 2014, Elsevier infusion nursing, ed 4, 2016, Infusion Nurses Society.
Saunders, pp 397–431. 3. Infusion Nurses Society: Infusion nursing standards of
8. Mimoz O, Villeminey S, Ragot S: Chlorhexidine-based practice. J Infusion Nurs 34(1S):S6–S110, 2016.
antiseptic solution vs alcohol-based povidone-iodine for 4. McLaws ML, Burrell AR: Zero risk for central-line
central venous catheter care. Arch Intern Med associated bloodstream infection: Are we there yet? Crit
167(19):2066–2072, 2007. Care Med 40(2):388–393, 2012.
9. Morton PG: Patient assessment: Cardiovascular system. In 5. Weber DJ, Rutala WA: Central-line associated bloodstream
Morton PG, Fontaine DK, editors: Critical care nursing: infections: Prevention and management. Infect Dis Clin
A holistic approach, ed 10, Philadelphia, 2012, Lippincott North Am 25(1):77–102, 2011.
Williams & Wilkins, pp 272–275.
PROCEDURE
63
Blood Sampling from a
Pulmonary Artery Catheter
Kathleen M. Cox
PURPOSE: To obtain blood from the pulmonary artery (PA) catheter for
determination of mixed venous oxygen saturation.
PREREQUISITE NURSING PATIENT AND FAMILY EDUCATION

KNOWLEDGE
• Explain the purpose for blood sampling to the patient and
• Knowledge of anatomy and physiology of the pulmonary family. Rationale: Provision of information helps the patient
and cardiovascular system is needed. and family make informed decisions, reduces anxiety, and
• Understanding principles and performance of sterile and facilitates cooperation.
aseptic technique and infection control is necessary. • Explain the patient’s expected participation during the
• Physiological gas exchange and acid-base balance should procedure. Rationale: Discussion of the patient’s partici-
be understood. pation supports patient autonomy and sense of control and
• Technique for specimen collection and labeling should be increases patient cooperation.1
known.
• Principles of hemodynamic monitoring need to be under-
stood. PATIENT ASSESSMENT AND
• Knowledge about the care of patients with PA catheters PREPARATION
(see Procedure 72) and stopcock manipulation (see Pro-
cedure 75) is needed. Patient Assessment
• The most frequent blood specimen obtained from the PA • Assess the patient’s cardiopulmonary and hemodynamic
is one for mixed venous oxygen saturation (Svo2) analy- status, including abnormal lung sounds, respiratory dis-
sis.9,10 tress, dysrhythmias, decreased mentation, agitation, and
• Svo2 measures the oxygen saturation of the venous blood skin color changes. Rationale: These signs and symptoms
in the PA (see Procedure 16). could necessitate blood sampling for venous oxygenation.
• Svo2 samples may be obtained to calibrate the equipment • Assess for a decrease in cardiac output related to changes
when continuously monitoring Svo2 values. in preload, afterload, or contractility. Rationale: Mixed
• Routine blood sampling from the PA catheter is not rec- venous blood samples are used to evaluate changes in
ommended because entry into the sterile system may cardiopulmonary function.
increase the incidence of catheter-related infection.2,6,7 • Assess the hemodynamic waveforms. Rationale: Deter-
mines that the PA catheter is in the proper position.
EQUIPMENT • Assess for a decrease in cardiac output related to changes
in preload, afterload, or contractility. Rationale: Mixed
• Nonsterile gloves venous blood samples are used to evaluate changes in
• Goggles or fluid shield face mask cardiopulmonary function.
• Antiseptic solution (e.g., 2% chlorhexidine-based solution)
• Needleless blood sampling access device (blood-transfer Patient Preparation
device) • Verify that the patient is the correct patient using two
• Two 10-mL syringes identifiers. Rationale: Before performing a procedure, the
• Blood-specimen tubes nurse should ensure the correct identification of the patient
• Blood gas sampling syringe for the intended intervention.
• Needleless cap (injectable cap) or nonvented cap (nonin- • Confirm that the patient and family understand preproce-
jectable cap) dural teaching by having them verbalize understanding.
• Laboratory form and specimen label Clarify key points by reinforcing important information
• Specimen transport bag(s) and answer all questions. Rationale: Understanding of
Additional equipment, to have available as needed, includes previously taught information is evaluated and reinforced.
the following: • Position the patient so that the intended blood sampling
• Additional syringes port is exposed. Rationale: Optimal positioning improves
• Bag of ice the ease of obtaining the blood sample and reduces poten-
• Sterile 4 × 4 gauze pad tial contamination of the port.
548
63 Blood Sampling from a Pulmonary Artery Catheter 549
Procedure for Blood Sampling from a Pulmonary Artery Catheter

1. HH
2. PE
3. When drawing a mixed venous Prepares the ABG syringe. Heparin is usually in powdered form.
oxygen (Svo2) sample, open the
arterial blood gas (ABG) kit and
expel the excess air and heparin
from the syringe.
4. Temporarily suspend the PA Prevents the alarm from sounding
alarms. because the PA waveform is lost
during the blood draw.
5. PA distal stopcock:
A. Remove the nonvented cap Prepares the line for blood sampling.
(noninjectable cap) from the
stopcock of the distal lumen
of the PA catheter.
or
B. Cleanse the needleless cap Prepares the line for blood sampling Follow institutional standards.
(injectable cap) at the top of and reduces the risk for infection.
the stopcock of the distal
lumen of the PA catheter with
an antiseptic solution and
allow to dry.2,4,7,8 (Level B*)
6. Place a sterile syringe or a Prepares for blood sampling.
needleless blood sampling access
device (blood-transfer device)
into the top port of the stopcock
of the distal lumen of the PA
catheter (see Figs. 62-1 and
63-1).
O
F
F
To
patient To flush
solution
“off” to the port of the stopcock. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University,
Philadelphia, PA.)
Procedure for Blood Sampling from a Pulmonary Artery Catheter—Continued

7. Turn the stopcock off to the flush The syringe or needleless blood-
solution (see Figs. 62-2 and sampling access device is then in
63-2). direct contact with the blood in the
PA.
8. With a syringe, slowly and gently Clears the catheter of flush solution. If additional laboratory studies are
aspirate the discard volume or, if The discard volume includes the dead needed, larger discard volumes may
using a needleless blood- space (from the tip of the distal be necessary for accurate results.12
sampling access device, engage lumen to the top port of the
the blood specimen tube to stopcock) and the blood diluted by
obtain the discard volume. the flush solution (e.g.,
(Level B*) 3.5 mL).2,3,5,10–12
9. Turn the stopcock off to the Stops blood flow and closes the top
syringe or the needleless blood- port of the stopcock.
sampling access device (see Figs.
62-1 and 63-1).
10. Remove the syringe or the blood Removes and safely disposes of the
specimen tube and discard in the discard.
11. Insert an ABG syringe into the Prepares for removal of a blood
stopcock or insert the ABG sample.
syringe into the needleless
blood-sampling access device.
12. Turn the stopcock off to the flush Prepares for blood sampling.
system (see Figs. 62-2 and 63-2).
To
To flush
O
F
F
patient
solution
“off” to flush solution. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadel-
phia, PA.)
63 Blood Sampling from a Pulmonary Artery Catheter 551
Procedure for Blood Sampling from a Pulmonary Artery Catheter—Continued

13. Slowly aspirate the Svo2 sample Slow aspiration is important to
(e.g., 1 mL). prevent contamination of the mixed
venous sample with arterial blood
from the pulmonary capillaries,
which will falsely elevate the Svo2
value.11
14. Turn the stopcock off to the Prevents bleeding.
syringe or the needleless blood
sampling access device (see Figs.
62-1 and 63-1).
15. Remove the ABG syringe. Detaches the specimen.
16. Expel any air bubbles from the Ensures the accuracy of the Svo2
ABG syringe and cap the syringe. results.
17. Turn the stopcock off to the Prepares the system.
patient.
18. Fast flush the remaining blood Clears blood from the system.
from the top port of the stopcock:
A. Remove the nonvented or
noninjectable cap.
B. Flush the blood onto a sterile
gauze pad, into a discard
syringe, or into a blood
specimen tube.
19. Turn the stopcock off to the top Opens the system up for continuous Remove the needleless blood-
port of the stopcock (see Figs. PA pressure monitoring. sampling access device if used.
62-1 and 63-1).
20. Attach a new sterile nonvented Maintains a closed sterile system.
cap (noninjectable cap) or cleanse
the needleless cap (injectable cap)
with antiseptic solution.
21. Flush the remaining blood in the Promotes patency of the PA catheter.
PA catheter back into the patient.
22. Observe the monitor for return of Ensures continuous monitoring of the
the PA waveform. PA waveform.
Precautions.
24. HH
25. Turn the alarms back on. Activates the alarm system.
transport bag. Complete the laboratory tests to be performed. Label the blood-gas laboratory slip
laboratory form. as a mixed venous sample.
27. Send the specimen for analysis. Needed for ABG analysis. Follow institutional policy regarding
use of ice for ABG samples.

• Adequate blood sample with minimal blood loss • Inability to obtain Svo2 sample
• PA catheter patency maintained • Clotting of the PA catheter
• Svo2 value and trends within normal range (60–80%) • Arterial sample obtained as a result of rapid
withdrawal of blood from the pulmonary capillaries
instead of mixed venous oxygen sample for blood-
gas analysis

interventions.
1. Before and after the blood Ensures that the PA catheter is • Abnormal PA waveforms or values
withdrawal, assess and evaluate the properly positioned.
PA waveform.
2. Correlate the Svo2 results with the Changes in the Svo2 indicate changes • Abnormal mixed venous oxygen
measured cardiac output. in cardiac output and hemodynamic saturation, preload, afterload,
status. cardiac output, and cardiac index
3. Correlate the Svo2 results with the Svo2 decreases with: • Fever
clinical assessment data.2,10 • Increased oxygen consumption • Shivering
• Decreased oxygen delivery • Seizures
Svo2 increases with: • Agitation
• Decreased tissue oxygen • Pain
consumption • Decreased cardiac output
• Increased oxygen delivery • Decreased hemoglobin
• Decreased arterial oxygen
saturation
• Hypothermia
Documentation
• Patient and family education • Any difficulties with PA catheter blood sampling
• Time and date of the Svo2 sample • Nursing interventions performed
• Svo2 results • Unexpected outcomes

63 Blood Sampling from a Pulmonary Artery Catheter 552.e1
References central venous catheter care. Arch Intern Med

1. Bailey L: Strategies for decreasing patient anxiety in the 167(19):2066–2072, 2007.
perioperative setting. AORN J 92(4):445–457, 2010. 9. Morton PG: Patient assessment: Cardiovascular system.
2. Camp-Sorrell D: Access device guidelines: In Morton PG, Fontaine DK, editors: Critical care
Recommendations for nursing practice and education, ed nursing: A holistic approach, ed 10, Philadelphia, 2012,
3, Pittsburgh, 2011, Oncology Nursing Society. Lippincott Williams & Wilkins, pp 272–275.
3. Carlson KK, et al: Obtaining reliable plasma sodium and 10. Palermo LM, Andrews RW, Ellison N: Avoidance of
glucose determinations from pulmonary artery catheters. heparin contamination in coagulation studies drawn from
Heart Lung 19(6):613–619, 1990. indwelling lines. Anesth Analg 59:222–224, 1980.
4. O’Grady NP, et al: Summary of recommendations: 11. Vincent JL: Arterial, central venous, and pulmonary artery
guidelines for the prevention of intravascular catheter- catheters. In Parrillo JE, Dellinger RP, editors: Critical
related infections. Clin Infect Dis 52(9):1087–1099, 2011. care medicine: Principles of diagnosis and management
5. Krueger KE, et al: The reliability of laboratory data from in the adult, Philadelphia, 2014, Elsevier Saunders, pp
blood samples collected through pulmonary artery 48–50.
catheters. Arch Pathol Lab Med 105:343–344, 1981. 12. Wyant S, Crickman R: Determining the minimum discard
6. Malpiedi PJ, et al: National and state healthcare associated volume for central venous catheter blood draws. Clin J
infection standardized infection ratio report. In Centers Oncol Nurs 16(5):454–458, 2012.
for Disease Control and Prevention publications,
Washington, D.C., 2013, US Government Printing Office. Additional Readings
7. McKenny M, Fitzgerald M, Scully M: How do I diagnose Caille V, Squara P: Oxygen uptake to delivery relationship:
& manage catheter-related blood stream infections? In a way to assess adequate flow. Crit Care 10(S3):1–7,
Deutschman CS, Neligan PJ, editors: Evidence-based 2006.
practice of critical care, Philadelphia, 2010, Saunders Infusion Nurses Society: Policies and procedures for infusion
Elsevier, pp 263–276. nursing, ed 4, 2016, Infusion Nurses Society.
8. Mimoz O, Villeminey S, Ragot S: Chlorhexidine-based Infusion Nurses Society: Infusion nursing standards of
antiseptic solution vs alcohol-based povidone-iodine for practice. J Infus Nurs 34(1S):S6–S110, 2016.
PROCEDURE
64
Cardiac Output Measurement
Techniques (Invasive)
Susan Scott
PURPOSE: Cardiac output (CO) measurements are used to assess and monitor
cardiovascular status. CO monitoring can be used in the evaluation of patient
responses to various therapies, including fluid management interventions,
vasoactive and inotropic medication administration, and mechanical assist devices.
CO measurements can be obtained either continuously or intermittently via a
pulmonary artery (PA) catheter. CO measurements provide data that may be useful
in directing and/or improving the care for critically ill patients with hemodynamic
instability.
PREREQUISITE NURSING • Stroke volume is the amount of blood volume ejected

KNOWLEDGE from either ventricle per contraction. Left ventricular
stroke volume is the difference between left ventricular
• Understanding of normal anatomy and physiology of the end-diastolic volume and left ventricular end-systolic
cardiovascular system and pulmonary system is neces- volume. Left ventricular stroke volume is normally 60 to
sary. 100 mL/contraction. Major factors that influence stroke
• Understanding of basic dysrhythmia recognition and treat- volume are preload, afterload, and contractility.
ment of life-threatening dysrhythmias is needed. • Right heart preload refers to the pressure in the right
• Pathophysiologic changes associated with structural heart ventricle (RV) at the end of diastole and is measured by
disease (e.g., ventricular dysfunction from myocardial the RAP or CVP. Elevations in left heart filling pressures
infarction, diastolic or systolic changes, and valve dys- may be accompanied by parallel changes in RAP, espe-
function) should be understood. cially in patients with left systolic ventricular dysfunction.
• Understanding of the principles of aseptic technique is nec- Other factors that affect RAP are venous return, intravas-
essary. cular volume, vascular capacity, and pulmonary pressure.
• Understanding of the PA catheter (see Fig. 72-1), lumens Right heart preload is increased in right heart failure, right
and ports, and the location of the PA catheter in the heart ventricular infarction, tricuspid regurgitation, pulmonary
and PA (see Fig. 72-2) is needed. hypertension, and fluid overload. Right heart preload is
• Pressure transducer systems (see Procedure 75) should be decreased in hypovolemic states.
understood. • Left heart preload refers to the pressure in the LV at the
• Competence in the use and clinical application of hemo- end of diastole and is measured by the PAOP. When LV
dynamic waveforms and values obtained with a PA cath- preload or end-diastolic volume increases, the muscle
eter including assessing normal and abnormal waveforms fibers are stretched. The increased tension or force of
and values for right atrial pressure (RAP), pulmonary contraction that accompanies an increase in diastolic
artery pressure (PAP), and pulmonary artery occlusion filling is called the Frank-Starling law. According to the
pressure (PAOP) is needed. PAOP may also be termed Frank-Starling law the heart adjusts its pumping ability
pulmonary artery wedge pressure (PAWP). to accommodate various levels of venous return. Note:
• Knowledge of vasoactive and inotropic medications and In patients with advanced chronic LV dysfunction and
their effects on cardiac function, ventricular function, coro- remodeled hearts (spherical or globular shaped LV instead
nary vessels, and vascular smooth muscles is needed. of the normal elliptical-shaped LV), the Frank-Starling
• CO is defined as the amount of blood ejected by the left law does not apply. In these patients, muscle fibers of the
ventricle (LV) per minute and is the product of stroke heart are already maximally lengthened; as a result, the
volume (SV) and heart rate (HR). It is measured in liters heart cannot respond significantly to increased filling or
per minute. stretch with increased force of contraction.
• Afterload refers to the force the ventricular myocardial
CO = SV × HR
fibers must overcome to shorten or contract. It is the force
• Normal CO is 4 to 8 L/min. The four physiological factors that resists contraction. The amount of force the LV must
that affect CO are preload, afterload, contractility, and overcome influences the amount of blood ejected into the
heart rate. systemic circulation. Afterload is influenced by peripheral
553
Figure 64-1 Systematic assessment of the determinants of cardiac output may assist the clinician
in defining the etiological factors of cardiac output alteration more precisely. (From Whalen DA,
Keller R: Cardiovascular patient assessment. In Kinney MR, et al, editors: AACN clinical reference
for critical care nurse, ed 4, St. Louis, 1998, Mosby, 227-319)
vascular resistance (the force opposing blood flow within sympathetic neural stimulation, or decreased body tem-
the vessels), systolic blood pressure, systolic stress, and perature. Increased heart rate can be triggered by factors
systolic impedance. Peripheral resistance is affected by that cause catecholamine release, such as hypoxia, hypo-
the length and radius of the blood vessel, arterial blood tension, pain, or anxiety. The more rapid the heart rate,
pressure, and venous constriction or dilation. The systolic the less time is available for adequate diastolic filling,
force of the heart is increased in conditions that cause which can result in a decreased CO. Because multiple
vasoconstriction (increased afterload), including aortic factors regulate cardiac performance and affect CO, these
stenosis, hypertension, or hyperviscosity of blood (e.g., factors must be assessed (Fig. 64-1).
polycythemia). The systolic force of the heart is decreased • Cardiac index adjusts the CO to an individual’s body size
in conditions that cause vasodilation or decrease the (square meter of body surface area), making it a more
viscosity of blood (e.g., anemia). Right ventricular after- precise measurement than CO.
load is calculated as pulmonary vascular resistance. Left • Refer to Table 64-1 for normal hemodynamic values and
ventricular afterload is calculated as systemic vascular calculations.
resistance. • At the bedside, CO measurements are obtained through a
• Contractility is defined as the ability of the myocardium PA catheter via the intermittent bolus CO method or the
to contract and eject blood into the pulmonary or systemic continuous CO method.
vasculature. Contractility is increased by sympathetic • Thermodilution CO measures right ventricular outflow;
neural stimulation, and the release of calcium and norepi- therefore, intracardiac right-to-left shunts, as well as tri-
nephrine is decreased by parasympathetic neural stimula- cuspid and pulmonic valve insufficiency, can result in
tion, acidosis, and hyperkalemia. Contractility and heart inaccurate measurements.3,38
rate can be influenced by neural, humoral, and pharmaco- • The thermodilution cardiac output (TDCO) method: an
logical factors. injectate solution of a known volume (10 mL) and tem-
• In addition to stroke volume, CO is affected by heart rate. perature (room or cold temperature) is injected into the
Normally, nerves of the parasympathetic and sympathetic right atrium (RA) through the proximal port of the PA
nervous system regulate heart rate through specialized catheter. The injectate exits the catheter into the RA,
cardiac electrical cells. Heart rate and rhythm are influ- where it mixes with blood and flows through the RV to
enced by neural humoral, and pharmacological factors. the PA. A thermistor located at the tip of the PA catheter
Decreased heart rate can be the result of factors such as detects the change in blood temperature as the blood
increased parasympathetic neural stimulation, decreased passes the tip of the catheter in the PA. The CO is
64 Cardiac Output Measurement Techniques (Invasive) 555
TABLE 64-1 Hemodynamic Parameters

Parameters Calculations Normal Value
Body surface area (BSA) Weight (kg) × height (cm) × 0.007184 Varies with size (range = 0.58–2.9 m2)
CO HR × SV 4–8 L/min
Stroke volume (SV) CO × 1000 / HR 60–100 mL/beat
Stroke volume index (SVI) SV / BSA 30–65 mL/beat/m2
Cardiac index (CI) CO / BSA 2.5–4.5 L/min/m2
Heart rate (HR) 60–100 beats/min
Preload
Central venous pressure (CVP) or RAP 2–6 mm Hg
Left atrial pressure (LAP) 4–12 mm Hg
Pulmonary artery diastolic pressure (PADP) 5–15 mm Hg
PAOP 4–12 mm Hg
RVEDP 0–8 mm Hg
LVEDP 4–10 mm Hg
Afterload
Systemic vascular resistance (SVR) MAP − CVP/RAP × 80 / CO 900–1400 dynes/s/cm−5
SVR index (SVRI) MAP − CVP/RAP × 80 / CI 2000–2400 dynes/s/cm−5/m2
Pulmonary vascular resistance (PVR) PAMP − PAOP × 80 / CO 100–250 dynes/s/cm−5
PVR index (PVRI) PAMP − PAOP × 80 / CI 255–315 dynes/s/cm−5/m2
Systolic blood pressure 100–130 mm Hg
Contractility
Ejection fraction (EF):
Left LVEDV × 100 / SV 60–75%
Right RVEDV × 100 / SV 45–50%
Stroke work index:
Left SVI (MAP − PAOP) × 0.0136 50–62 g-m/m2/beat
Right SVI (MAP − CVP) × 0.0136 5–10 g-m/m2/beat
Pressures:
MAP DBP + 1
3 (SBP − DBP) 70–105 mm Hg
PAMP PADP + 1
3 (PASP − PADP) 9–16 mm Hg
CO, Cardiac output; DBP, diastolic blood pressure; MAP, mean arterial pressure; LVEDP, left ventricular end-diastolic pressure; RVEDP, right ventricular end-diastolic
pressure; PAMP, pulmonary artery mean pressure; PAOP, pulmonary artery occlusion pressure; LVEDV, left ventricular end-diastolic volume; RVEDV, right ventricular
end-diastolic volume; PASP, pulmonary artery systolic pressure; PADP, pulmonary artery diastolic pressure; SBP, systolic blood pressure.
Adapted from Tuggle D: Optimizing hemodynamics: Strategies for fluid and medication titration in shock. In Carlson K, editor: AACN advanced critical care nursing, St
Louis, 2009, Saunders, 1106; and Ahrens T: Hemodynamic monitoring, Crit Care Nurs Clin N Am 11:19-31, 1999.
calculated as the difference in temperatures on a time the second thermistor improved accuracy compared
versus temperature curve. with Fick CO measurements and also improved preci-
• CO can be calculated from PA catheters with two types of sion or repeatability of CO measurements in both cold
thermistors: and room temperature.4,26 In one study, cold injectate
❖ A single thermistor has one inline temperature sensor had excellent precision with the standard single-
near the tip of the catheter that lies in the PA when in thermistor PA catheter. Researchers concluded that
proper position. the dual-thermistor PA catheter provided the greatest
❖ A dual thermistor has two inline temperature sensors, benefit in decreasing measurement variability when
one in the right atrium/superior caval vein (immediately room temperature injections were used to measure CO.4
above the injectate port opening) and one near the tip of • The change in temperature over time is plotted as a curve
the catheter (same position as single thermistor). and displayed on the bedside monitor screen. CO is math-
Because a temperature sensor is located in the right ematically calculated from the area under the curve and is
atrium, there is no need to enter a “correction factor” or displayed digitally and graphically on the monitor screen
“computation constant” into the computer to account (Fig. 64-2). The area under the curve is inversely propor-
for the loss in thermal indicator (heat) from the hub of tional to the rate of blood flow. Thus a high CO is associ-
the RA injectate port to the RA. Investigators found that ated with a small area under the curve, whereas a low CO
Figure 64-2 A, Examining cardiac output curves to establish reliability of

values. B, Normal cardiac output curve with rapid upstroke and smooth progres-
A sive decrease in temperature sensing. (B: From Ahrens T: Hemodynamic monitor-
ing, Crit Care Nurs Clin North Am 11[1]:28, 1999.)
is associated with a large area under the curve (Fig. 64-3, proximal lumen port). When a PA catheter is properly
A). placed, the thermal filament section of the catheter is
• The thermistor near the distal tip of the catheter detects located in the RV. This filament emits a pulsed low heat
the temperature change and sends a signal to the CO energy signal in a 30- to 60-second pseudorandom
computer and bedside monitor. The computer calculates binary (on/off) sequence, which allows blood to be
the CO with the modified Stewart-Hamilton equation, and heated and the heat signal adequately processed over
the CO number is displayed on the monitor screen. The time as blood passes through the ventricle. A bedside
average result of three to five measurements is used to computer constructs thermodilution curves detected
determine CO. from the pseudorandom heat impulses and measures
• Accuracy of TDCO is dependent on adequate mixing of CO automatically. The computer screen displays
blood and injectate, forward blood flow, steady baseline digital readings updated every 30 to 60 seconds that
temperature in the PA, and appropriate procedural tech- reflect the average CO of the preceding 3 to 6 minutes.
nique.3,19 In addition, loss of thermal indicator (heat), The CCO eliminates the need for fluid boluses, reduces
respiratory artifact, and hemodynamic instability can contamination risk, and provides a continuous CO
cause variability from one injection to another.19,29,32 trend.1,2,32
• Traditionally cardiac output measurements have been rec- ❖ Because the CCO computer constantly displays and
ommended to be performed at end-expiration, though frequently updates the CO, treatment decisions can be
there is research suggesting that this is not necessary.20,24 expedited. Derived hemodynamic calculations (e.g.,
Additional research is needed. cardiac index and systemic vascular resistance) can be
• Commercially available closed-system delivery sets (CO- obtained with greater frequency, thereby providing up-
Set, Edwards Lifesciences, LLC, Irvine, CA) can be used to-time information in assessment of response to thera-
with both cold and room temperature injectate (Figs. 64-4 pies that affect hemodynamics.1
and 64-5). • CCO has been compared with TDCO, transesophageal
• The Continuous Cardiac Output (CCO) method proceeds Doppler scan technique, and aortic transpulmonary tech-
as follows: nique to determine its precision. Study results all show
❖ Continuous measurement of CO can be performed small bias, limits of agreement, and 95% confidence
without the need for injected fluid. The CO can be limits, reflecting that CCO provides accurate measure-
obtained with a heat-exchange CO catheter. This cath- ment of CO and is a reliable method.1,2,6,22,32,39,50
eter has a membrane that allows for heat to exchange • Adequate mixing of blood and indicator (heat) is neces-
with blood in the right atrium. sary for accurate CCO measurements. Conditions that
❖ The PA catheter with CCO capability contains a 10-cm prevent appropriate mixing or directional flow of the indi-
thermal filament located close to the injection port cator or blood include intracardiac shunts or tricuspid
(15 to 25 cm from the tip of the catheter, near the regurgitation.
Figure 64-3 A, Variations in the normal cardiac output curve seen in certain clinical conditions.
B, Abnormal cardiac output curves that produce an erroneous cardiac output value. (From Urden
LD, Stacy KM, Lough ME: Critical care nursing: Diagnosis and management, ed,7, St Louis, 2014,
Mosby.)
• The CCO method is based on the same physiological prin- measurements are available, but large infusions of fluid
ciple as the TDCO method (indicator-dilution technique). are discouraged.8,15
• The TDCO method uses a bolus of injectate as the indica- • Because bolus injections are not needed with the CCO
tor for measurement of CO. The CCO method uses heat method, the prevalence of user error is theoretically reduced.14
signals produced by the thermal filament as the indicator. • The CCO catheter can be used to obtain both CCO and
The CCO computer provides a time-averaged rather than TDCO measurements.
instantaneous CO reading. CCO values are influenced by • The CCO does not reflect acute changes in CO values
the same principles as TDCO. because the updated value on the monitor display is an
• The heated thermal filament has a temperature limit to a average of 3 to 6 minutes of data. A delay of approxi-
maximum of 44 °C (111.2 °F). When calibrated by the mately 10 or more minutes to detect a change of 1 L/min
manufacturer, CCO computers produce reliable calcula- in CO may occur. When monitoring a patient with an
tions within a temperature range of 30 to 40 °C (86 to unstable condition that is being aggressively treated with
104 °F) or 31 to 43 °C (87.8 to 109.4 °F). An error message medication or other therapies, one should be aware of the
appears if the temperature in the PA is out of range. Follow delay in data displayed.
• Infusions through proximal lumens should be limited EQUIPMENT
to maintenance of patency of the lumen. Concomitant
infusions through the proximal lumen can theoretically • Nonsterile gloves
affect CCO measurements by altering the PA temperature. • Cardiac monitor
Studies have shown that such infusions can cause varia- • Hemodynamic monitoring system (see Procedure 75)
tions in TDCO measurements.19,47 • PA catheter (in place)
• To date, no published data describing the effect of concur- • CO computer or module
rent central line infusions on the accuracy of CCO • Connecting cables
Vigilance II monitor
Sterile injectate
solution
(user supplied)
Edwards Lifesciences Lid

Swan-Ganz thermodilution
catheter
Thermistor
Distal Mounting Model
Balloon EDSL
lumen tab
70CC2 container
Non-vented supplied
cable IV spike
Thermistor Snap clamp Inline placed
connector To IV/pressure Flow through cooling tube
monitoring housing Injectate delivery
tubing Cooling
Tubing coils
coil
10 cc syringe
Check valve Thermal tubing

Proximal
Balloon injectate
inflation hub User supplied Temperature Model 93-521 cooling
valve 3-way stopcock & probe container mounting bracket
continuous flush device (supplied separately)
Figure 64-4 Closed injectate delivery system. Cold temperature injectate. (From Edwards Life-
sciences, LLC, Irvine, CA.)
Additional equipment, to have available as needed, includes ception of cold solution and may decrease anxiety associ-
the following: ated with the procedure.
• Bolus thermodilution
❖ Injectate temperature probe
❖ Injectate solution PATIENT ASSESSMENT AND
❖ 10-mL prefilled syringes
PREPARATION
❖ Injectate solution bag with intravenous (IV) tubing and
three-way Luer-Lok stopcock Patient Assessment
❖ Closed CO injectate system • Assess the patient’s history of medication therapy, includ-
❖ Ice (for cold injectate only) ing medication allergies, recent bolus therapies, and current
❖ Nonvented caps for stopcocks medications. Rationale: Medications can influence CO
• Setup for CCO measurements.
• Syringe holder or automatic injector device • Assess the patient’s medical history for the presence of
• Printer coronary artery disease, valvular heart disease, and left or
• Dispensing port right ventricular dysfunction. Rationale: Medical history
provides baseline information regarding cardiovascular
PATIENT AND FAMILY EDUCATION performance.
• Assess current intracardiac waveforms (e.g., PAP, RAP,
• Explain the procedure for CO and the reason for its mea- PAOP). Rationale: This assessment ensures the PA cath-
surement. Include expectations related to sensations during eter is positioned properly.
the procedure. (The patient should not experience pain or • Assess the patient’s vital signs, fluid balance, heart and lung
discomfort.) Rationale: Explanation decreases patient sounds, skin color, temperature, level of consciousness,
and family anxiety. Preparatory information of sensations peripheral pulses, cardiac rate and rhythm, and hemody-
decreases patient fear of the impending procedure. namic values. In patients with advanced systolic heart
• Explain the monitoring equipment involved, the frequency failure, assess for pulsus alternans (alternating strong and
of measurements, and the goals of therapy. Rationale: weak pulses). Rationale: Clinical information provides
Explanation encourages the patient and family to ask ques- data regarding blood flow and tissue perfusion. Abnormali-
tions and voice specific concerns about the procedure. ties can influence the variability of CO measurements.
• Explain any potential variations in temperature the patient • Ensure that no medication is being infused via the proxi-
may or may not experience if a cold injectate is used. mal port. Rationale: Medications infused via this port will
Rationale: This explanation acknowledges the varying be bolused into the patient if the bolus CO method is
physical responses to the injectate and the possible per- utilized. This is not an issue with the CCO method.
Vigilance II monitor
Sterile injectate
solution
(user supplied)
Edwards Lifesciences
Swan-Ganz thermodilution
Thermistor catheter
Non-vented
Distal IV spike
Balloon lumen
70CC2 cable Snap clamp
Thermistor
connector Flow through
To IV/pressure
housing
monitoring
10 cc syringe
Injectate delivery
tubing
Check valve
Balloon
inflation User supplied
Temperature
valve 3-way stopcock &
probe
continuous flush device
Figure 64-5 Closed injectate delivery system. Room temperature injectate. (From Edwards Life-
sciences, LLC, Irvine, CA.)
• Ensure that the patient and family understand preprocedural
Patient Preparation information. Answer questions as they arise, and reinforce
• Verify that the patient is the correct patient using two information as needed. Rationale: Understanding of previ-
identifiers. Rationale: Before performing a procedure, the ously taught information is evaluated and reinforced.
nurse should ensure the correct identification of the patient • Assist the patient to the supine position. Rationale: CO
for the intended intervention. measurements are most accurate in the supine position.
Procedure for Measurement of Cardiac Output With the Closed or Open

Thermodilution Method
1. HH
2. PE
3. Select the injectate delivery Both systems are reliable.32,37,40 A closed system may eliminate cost
system: open or closed method. and time expenditures of individual
(Level B*) syringe preparation.
The closed system has infection
control benefits because of
reduction of multiple entries into
the system.34
4. Select cold or room temperature Room temperature injectate may be The acceptable temperature range for
injectate. used for most patients. Research on cold and room temperature injectate
(Level B*) room temperature versus cold varies by system (manufacturer).
injectate supports the accuracy of Generally, room temperature is
either method.7,9,12,23,41,42,45,48 18–25 °C, and cold is 0–12 °C.
Cold injectate may improve the
accuracy of CO measurement for
patients with low or high CO.45

Procedure for Measurement of Cardiac Output With the Closed or Open Thermodilution
Method—Continued
5. Select the injectate bolus amount An injectate of 10 mL may be used Volumes of 5 mL may necessitate
(generally 10 mL). (Level B*) for most patients.12,31,36 additional injections because of
greater variability of individual
measurements.31
6. Connect the CO cable to the PA Prepares the system.
catheter.
7. Select the computation constant The computation constant is a Carefully select the correct
consistent with the type and size correction factor determined by the computation constant for the type
of the PA catheter, injectate catheter manufacturer that corrects and catheter size, injectate volume,
volume, and injectate for the gain of indicator (heat) that and cold or room temperature
temperature. Confirm the injectate occurs as the injectate moves injectate.
delivery system. through the catheter from the hub Confirm the setting on the CO
of the injectate port to the injection computer/monitor.
port opening in the RA. Recheck the computation constant
The catheter manufacturer provides a before each series of CO
table to determine the correct measurements.
computation constant. Follow the manufacturer guidelines.
The computation constant must be
accurate for valid and reliable CO
measurements.
8. Connect the CO computer to the Supplies the energy source.
power source if it is a stand-alone
device or turn on the CO
computer or module.
9. Note the temperature of the The injectate temperature should be at Follow manufacturer’s
injectate (on the computer or least 10 °C less than the patient’s recommendations.
monitor screen). core temperature.27
10. Position the patient supine, with Studies of patients in the supine CCO values may be accurate with the
the head of the bed elevated no position with the head of bed flat or patient’s head of the bed elevated to
more than 20 degrees. elevated up to 20 degrees have not 45 degrees.11,17
(Level B*) shown significant differences in The patient’s medical condition and
TDCO measurements.18,21,25,50 level of instability may determine
Consistency in patient position may positioning.
increase stability in consecutive CO Position should be documented and
readings. communicated.
Consistent positioning when obtaining
CO measurements over time
decreases measurement variability.
Cautiously use CO values obtained
from lateral positions.
The lateral recumbent position
increases variability in CO
measurements.10,51
11. Verify the position of the PA Proper positioning of the PA catheter Improper positioning of the PA
catheter by assessing both the RA ensures that the distal thermistor is catheter tip may result in false
and PA waveforms for proper located in the PA. values.14,15,22,28
waveform contours. The distal thermistor sensor calculates
the time-temperature data.
Excessive coiling of the PA catheter
in the RA or RV can result in poor
positioning of the distal thermistor
in relation to the injectate port.22
Procedure for Measurement of Cardiac Output With the Closed or Open Thermodilution
Method—Continued
12. Observe the patient’s cardiac rate A rapid heart rate or dysrhythmias
and rhythm. may decrease CO and lead to
variability in CO measurements.
13. If possible, consider restricting TDCO measurements obtained during
infusions delivered through the administration of other infusions
introducer or other central lines. can cause variability in CO
(Level C*) measurements (by as much as 40%
higher).19,50
Precautions.
15. HH
Procedure for Closed-Method of Syringe Preparation and Cardiac Output Determination

Follow Steps 1–13 of the Procedure for Measurement of CO
1. HH
2. PE
3. Obtain the injectate solution
4. Aseptically connect the IV tubing Prepares the system.
to the injectate solution.
5. Hang the IV injectate solution on Eliminates air from the tubing.
an IV pole; prime the tubing.
6. Remove the sterile cap from the Prepares for the injectate connection.
proximal lumen of the PA
catheter.
7. Connect the injectate tubing to Connects the injectate solution to the
the proximal lumen of the PA PA catheter.
catheter via a three-way Luer-Lok
stopcock (see Figs. 64-4 and
64-5).
8. Connect the injectate syringe to The syringe is used for solution Connect the system so that the CO
the three-way stopcock (see Figs. injection. syringe is in a straight line with the
64-4 and 64-5). PA catheter to decrease resistance
with injection of solution.
To ensure accurate readings, when
using a multiport PA catheter the
proximal port should be used rather
than the venous infusion port.38
9. Connect the inline temperature Measures the injectate temperature. Verify temperature.
probe (see Figs. 64-4 and 64-5).
10. If using cold injectate, set up the If using cold injectate, cool the Refer to manufacturer’s
cold injectate system (e.g., injectate solution to 0–12 °C recommendations.
CO-Set closed injectate system; (32–53 °F). Cold injectate may be proarrhythmic
see Fig. 64-4). in some patients.35,46
11. Turn the stopcock so that it is Prepares for injection.
open to the injectate solution
(closed to the patient) and
withdraw 10 mL of the injectate
solution into the syringe.
Procedure for Closed-Method of Syringe Preparation and Cardiac Output

Determination—Continued
12. Turn the stopcock so that it is Minimal handling (<30 seconds) of Syringe holders or automatic injector
closed to the injectate solution the syringe is recommended to devices are available and can be
and open to the patient. Support avoid thermal indicator variation used.
the stopcock with the palm of the that may introduce error into the
nondominant hand to aid in CO calculation.5,8,28
injectate administration.
13. Activate the CO computer, and The CO computer or module needs to Follow manufacturer’s guidelines.
wait for the “ready” message. be ready before injection of
solution.
14. Before administering the bolus An abnormal baseline may increase Patients with advanced systolic heart
injectate, observe for a steady variability in CO measurements and failure (low ejection fraction) are
baseline temperature (e.g., the introduce error.1 more susceptible to a wavering
line before the CO curve begins initial baseline from unstable PA
should be flat without blood temperature.
undulations) on the monitor
screen (see Figs. 64-2B and
64-3A).
15. Observe the patient’s respiratory End expiration is defined as the phase Follow institution standard.
pattern. Prepare to begin of the respiratory cycle preceding
administering the injectate at end the start of inspiration.
expiration to decrease variance in Significant variations in transthoracic
CO measurements from the pressure during respiration can
respiratory cycle affect CO by altering venous
(Level C*) return.20,40,44,45
16. Administer the bolus injectate Prolonged injection time may result A prolonged injection time interferes
rapidly and smoothly in 4 in false low CO. with time and temperature
seconds or less. Rates of 2–4 seconds for injection of calculations.
5–10 mL of injectate yield accurate One respiratory cycle is generally <4
results.5,13,43 seconds.
One ventilation cycle on a ventilator
is generally 4 seconds.
17. Assess the CO curve and value The CO curve must be a normal Normal CO is 4–8 L/min.
on the monitor screen (see Figs. curve. Abnormal CO curves may also
64-2 and 64-3). A normal curve starts at baseline provide information about the
(baseline must be a straight, flat, patient’s clinical condition, such as
nonwavering line) with a smooth tricuspid valve regurgitation.
upstroke and a gradual downstroke.
If the CO curve is not normal, the CO
measurement obtained from the
injection should be discarded.
Abnormal contours of the curve may
indicate improper catheter position.
An abnormal CO curve may represent
technical error.
18. Repeat Steps 3 through 17 (up to Discard all CO measurements that do Allow 60 seconds between each CO
three times total for cold injectate not have normal CO curves or have measurement to ensure consistency
and up to five times total for wandering baselines. and accuracy.
room temperature injectate).
Procedure for Closed-Method of Syringe Preparation and Cardiac Output

19. Determine the CO measurement Determines accurate CO value.49
by calculating the average of
three measurements within 10%
of a middle (median) value.
(Level E*)
20. Return the proximal stopcock at Resumes RA monitoring.
the RA lumen to the original
position.
21. Continue infusions delivered Continues therapy.
through the introducer or other
central lines.
22. Observe the PA and RA Continues hemodynamic monitoring.
waveforms on the monitor.
24. HH
25. Determine the hemodynamic Assesses cardiac performance and Compare the values with prior values
calculations. hemodynamic status. and determine whether the plan of
care requires alterations.
Procedure for Open Method of Syringe Preparation and Cardiac Output Determination
Follow Steps 1–13 of the Procedure for Measurement of Cardiac Output
1. HH
2. PE
3. Prepare syringes or obtain Prepares the injectate for CO Prefilled syringes may decrease
manufactured prefilled syringes measurements. variability related to injectate
for CO determination. volume.
A. Clean the injectate port of the Manufactured prefilled syringes may
D5W IV bag with an alcohol be stored per manufacturer’s
wipe. recommendations.
B. Apply a dispensing port to the Solutions drawn up should be used
bag’s injectate port immediately for CO measurements.
C. Aseptically withdraw the Solution drawn up in the clinical area
injectate solution from the IV (as opposed to under a laminar flow
bag into three to five 10-mL area) that has no preservative,
syringes and cap securely. should not be stored for later use.
A dispensing port negates the use of
needles and reduces the incidence
of accidental needlesticks.
4. Cold injectate: Cool the syringes Iced slush is used to cool syringes. Place syringes in a bag in the
in ice. container, not directly into the
slush.
Handling of a cold syringe causes
warming and hampers validity of
CO measurements.5,8,28
Cold injectate may be
proarrhythmic.35,46
Procedure for Open Method of Syringe Preparation and Cardiac Output

5. Remove the nonvented cap from Prepares the stopcock.
the proximal lumen stopcock of
the PA catheter.
6. Aseptically connect one of the Reduces the risk of introducing
sterile CO injectate syringes onto microorganisms into the system.
the proximal lumen stopcock of
the PA catheter.
7. Turn the stopcock so that it is Prepares the system for injectate Minimize handling (<30 seconds)
closed to the flush solution and administration.
open between the injectate
syringe and the patient. Support
the stopcock with the palm of the
nondominant hand.
8. Connect the inline temperature Measures the injectate temperature.
probe (see Figs. 64-4 and 64-5).
9. Activate the CO computer, and The CO computer or module needs to Follow manufacturer’s guidelines.
wait for the “ready” message. be ready before injection of
solution.
10. Before administering the bolus An abnormal baseline may increase Patients with advanced systolic heart
injectate, observe for a steady variability in CO measurements and failure (low ejection fraction) are
baseline temperature (e.g., the introduce error.1 more prone to a wavering initial
line before the CO curve begins baseline from unstable PA blood
should be flat without temperature.
undulations) on the monitor
screen (see Figs. 64-2B and
64-3A).
11. Observe the patient’s respiratory End expiration is defined as the phase Follow institution standard.
pattern. Prepare to begin of the respiratory cycle preceding
administering the injectate at end the start of inspiration.
expiration to decrease variance in Significant variations in transthoracic
CO measurements from the pressure during respiration can
respiratory cycle affect CO by altering venous
(Level C*) return.20,40,44,45
12. Administer the bolus injectate Prolonged injection time may result A prolonged injection time interferes
rapidly and smoothly in 4 in false low CO. with time and temperature
seconds or less. Rates of 2–4 seconds for injection of calculations.
5–10 mL of injectate yield accurate One respiratory cycle is generally <4
results.5,13,43 seconds.
One ventilation cycle on a ventilator
is generally 4 seconds.
13. Assess the CO curve and value The CO curve must be a normal Normal CO is 4–8 L/min.
on the monitor screen (see Figs. curve. Abnormal CO curves may also
64-2 and 64-3). A normal curve starts at baseline provide information about the
(baseline must be a straight, flat, patient’s clinical condition, such as
nonwavering line) with a smooth tricuspid valve regurgitation.
upstroke and a gradual downstroke.
If the CO curve is not normal, the
reading should be discarded.
Abnormal contours of the curve may
indicate improper catheter position.
An abnormal CO curve may represent
technical error.
Procedure for Open Method of Syringe Preparation and Cardiac Output

14. Repeat Steps 6 through 13 (up to Obtains CO measurements. Discard Allow 60 seconds between each CO
three times total for cold injectate all CO measurements that do not measurement to ensure consistency
and up to five times total for have normal CO curves or have and accuracy.
room temperature injectate). wandering baselines. Asepsis is essential as the stopcock is
turned and syringes are exchanged
between CO measurements.
15. Determine the CO measurement Determines accurate CO value.49
by calculating the average of
three measurements within 10%
of a middle (median) value.
(Level E*)
16. After the last injectate is Closes the system; maintains the
completed: sterility of the system.
A. Turn the right atrial lumen
stopcock of the PA catheter so
that the system is open between
the patient and the transducer.
B. Aseptically remove the last
injectate syringe.
C. Place a new, sterile,
nonvented cap on the
stopcock port.
17. Observe the PA and RA Continues hemodynamic monitoring.
waveforms on the monitor.
18. Remove PE and discard used Removes and safely discards used
supplies in appropriate supplies.
receptacles.
19. HH
20. Determine hemodynamic Assesses cardiac performance and Compare values with prior values and
calculations. hemodynamic status. determine whether the plan of care
requires alterations.
Procedure for Measurement of Cardiac Output With Continuous Cardiac Output Method
1. HH
2. PE
3. Turn on the CO computer or Provides energy.
module.
4. Connect the CO cable to the PA Prepares equipment.
catheter.
5. Observe PA waveforms (e.g., RA, Determines whether the PA catheter is The thermal filament should float
PA). in the correct position. freely in the RV to prevent the loss
of indicator (heat) into the cardiac
tissue.
If the loss of indicator occurs, the CO
value is overestimated, giving
erroneous readings.
Follow manufacturer’s guidelines.
The device may not measure CO if
the PA catheter is malpositioned.
Procedure for Measurement of Cardiac Output With Continuous Cardiac Output

Method—Continued
6. Position the patient supine with CCO measurements are most accurate Additional studies are needed to
the head of the bed elevated up to in a supine position, but head-of- determine the effect of patient body
45 degrees. (Level C*) bed angle can be varied for position on CCO measurements.
comfort, between 0 and 45 Document body position at the time
degrees.16 of hemodynamic data collection.
7. Check the heat signal indicator CCO systems assess the quality of CCO monitors provide messages for
on the CO computer or module the measured thermal signal. troubleshooting signal-to-noise ratio
per manufacturer’s Relationships are in response to interferences.
recommendations. thermal noise or signal-to-noise Refer to manufacturer
ratio. recommendations.
Technologic advances suppress the
effects of blood thermal noise.52
8. Note that the CCO values reflect CCO measurements are averaged over CCO values are updated every 30–60
an average of the preceding 3–6 the preceding 3–6 minutes and are seconds. Continuous data collection
minutes of data collection. not individual measurements. reflects phasic changes in the
respiratory cycle.
CCO measurements are not timed to
the respiratory cycle.
9. When documenting CCO values, Provides data regarding hemodynamic
also document other status.
hemodynamic findings.
10. Compare the CCO value with the CCO is a global assessment parameter The CCO method eliminates many of
patient’s current clinical status and must be appreciated as part of the potential user-related and
and hemodynamic findings. the patient’s total hemodynamic technique-related errors associated
profile at a given time. with the intermittent bolus CO
method.
Research shows clinically acceptable
correlation between the TDCO
technique and the CCO method in
the steady state.1,6,30,32,33
Future studies are needed to
determine efficacy in patients in
various phases of acute
hemodynamic instability and in
specific patient populations.
Also, the effects of changes in
positioning need to be studied
further, especially in patients with
structural or functional heart
damage.
11. Note: The CCO catheter system
can be used to obtain TDCO by
following Steps 1–13 of the
Procedure for Measurement of
Cardiac Output with the Closed
or Open Thermodilution Method
CO and then follow the steps for
either the Closed or Open
Method of Syringe Preparation
and Cardiac Output
Determination.
supplies in appropriate receptacles. supplies.
13. HH

• Accurate CO measurement are obtained • Inability to accurately measure CO
• Hemodynamic profile and derived parameters are • Erroneous readings because of technical, equipment,
obtained with accuracy, whether through the or operator error
continuous or intermittent method • Contamination of the system
• Sterility and patency of the PA catheter is maintained • Occlusion of the proximal PA lumen

interventions.
1. Maintain patency of the PA PA catheter patency is essential for • Inability to maintain PA catheter
catheter. accurate monitoring. patency
2. Monitor RA and PA waveforms for Proper placement determines accurate • Abnormal RA or PA waveforms or
confirmation of proper catheter hemodynamic and CO values
position. measurement.
3. Maintain the sterility of the PA Reduces the risk for catheter-related • Fever, site redness, drainage, or
catheter. infections. symptoms consistent with infection
4. Calculate cardiac index, systemic Determines cardiac performance and • Abnormal cardiac index, systemic
vascular resistance, and other current hemodynamic status. vascular resistance, or other
parameters as prescribed or hemodynamic values
indicated.
5. Monitor vital signs and respiratory Changes in vital signs or respiratory • Changes in vital signs
status hourly and as indicated. status may indicate hemodynamic • Changes in respiratory status
compromise.
6. Include the fluid volume used in Additional volume given • Signs or symptoms of fluid
the TDCO in the patient’s total intermittently should be included in overload (e.g., respiratory distress,
fluid volume intake. the total intake for accurate fluid crackles, increased PADP or PAOP,
volume assessment. elevated jugular venous pressure,
new or worsening S3 gallop,
worsening edema)
7. Assess the patient’s response to Hemodynamic monitoring may • Significant worsening or
therapies. expedite treatment decisions. improvement in CO and
hemodynamic parameters.
• Pulmonary vascular resistance
(PVR) and systemic vascular
resistance (SVR)
8. If using a closed system delivery Reduces the incidence of infection.
set (CO set), change the system
components (tubing, syringe,
stopcocks, and IV solution) every
96 hours with the hemodynamic
monitoring system (see Procedure
75).
Documentation
• Patient and family education nitroprusside, nicardipine, or nesiritide]), and
• CO, cardiac index, SVR, volume indicators (PAOP and intravascular volume (e.g., diuretics)
RAP) • Significant medical therapies or nursing interventions
• CO curves that affect CO (e.g., intraaortic balloon pump or
• Baseline PA blood temperature ventricular assist device therapies, volume expanders,
• Continuous or intermittent bolus method position changes), vascular resistance, or
• Volume and temperature of injectate intravascular volume (e.g., sedation, blood/blood
• Concurrent headrest elevation, vital signs, and products, headrest elevation, fluid restriction, sodium
hemodynamic measurements restriction)
• Titration or administration of medications that affect • Unexpected outcomes
contractility (e.g., dobutamine, milrinone, dopamine, • Additional interventions, including psychosocial or
epinephrine), vascular resistance (e.g., intravenous emotional/psychiatric interventions that might
nitrates or arterial vasodilator therapy [e.g., influence hemodynamic trends

64 Cardiac Output Measurement Techniques (Invasive) 568.e1
References through the venous infusion port of the pulmonary artery

1. Albert NM, Spear B, Hammell J: Agreement and clinical catheter. J Cardiothorac Vasc Anesth 11:437–439, 1997.
utility of two techniques for measuring cardiac output in 20. Groeneveld AB, et al: Effect of mechanical ventilator
patients with low cardiac output. Am J Crit Care 8:464– cycle on thermodilution right ventricular volumes and
474, 1999. cardiac output. J Appl Physiol 89:89–96, 2000.
2. Baillard C, et al: Haemodynamic measurements 21. Grose BL, Wood SL, Laurent DJ: Effect of backrest
(continuous cardiac output and systemic vascular position on cardiac output measured by the thermodilution
resistance) in critically ill patients: Transesophageal method in acutely ill patients. Heart Lung 10:661–665,
Doppler versus continuous thermodilution. Anaesth 1981.
Intensive Care 27:33–37, 1999. 22. Kalassian KG, Raffi TA: The technique of thermodilution
3. Balik M, Pachl J, Hendl J: Effect of the degree of cardiac output measurements. J Crit Illness 11:249–256,
tricuspid regurgitation on cardiac output measurements 1996.
by thermodilution. Intensive Care Med 28:1117–1121, 23. Kiely M, Byers LA, Greenwood R: Thermodilution
2002. measurement of cardiac output in patients with low
4. Berthelsen PG, et al: Thermodilution cardiac output: Cold output: room temperature versus iced injectate. Am J Crit
vs. room temperature injectate and the importance of Care 7:436–438, 1998.
measuring the injectate temperature in the right atrium. 24. Kjetsa E, et al: Synchronizing thermodilution cardiac
Acta Anaesthesiol Scand 46:1103–1110, 2002. output measurements with spontaneous breathing does not
5. Bilfinger TV, Lin CY, Anagnostopoulos CE: In vitro improve precision. Acta Anesthesiol Scand 60:354–359,
determination of accuracy of cardiac output measurement 2016.
by thermal dilution. J Surg Res 33:409–414, 1982. 25. Kleven M: Effect of backrest position on thermodilution
6. Boldt J, et al: Is continuous cardiac output measurement cardiac output in critically ill patients receiving
using thermodilution reliable in the critically ill patient? mechanical ventilation with positive end-expiratory
Crit Care Med 22:1913–1918, 1994. pressure. Heart Lung 13:303–304, 1984.
7. Bourdillon PDV, Fineberg N: Comparison of iced and 26. Lehmann KG, Platt MS: Improved accuracy and precision
room-temperature injectate for thermodilution cardiac of thermodilution cardiac output measurement using
output. Cathet Cardiovasc Diagn 17:116–120, 1989. a dual thermistor catheter system. J Am Coll Cardiol
8. Bridges EJ: Hemodynamic monitoring. In Woods SL, 33:883–891, 1999.
et al, editors: Cardiac nursing, ed 5, Philadelphia, 2005, 27. Levett JM, Replogle RL: Thermodilution cardiac output:
JB Lippincott Williams & Wilkins, pp 478–526. A critical analysis and review of the literature. J Surg Res
9. Daily EK, Mersch J: Thermodilution cardiac outputs using 27:392–404, 1979.
room and ice temperature injectate: Comparison with the 28. Loveys BJ, Woods SL: Current recommendations for
FICK method. Heart Lung 16:294–300, 1987. thermodilution cardiac output measurement. Prog
10. Doering L, Dracup K: Comparisons of cardiac output Cardiovasc Nurs 1:24–32, 1986.
in supine and lateral positions. Nurs Res 37:114–118, 29. Magden S: Invasive hemodynamic monitoring. Crit Care
1988. Clin 31:67–87, 2015.
11. Driscoll A, et al: The effect of patient position on the 30. Marcum J, et al: A comparison of varying injectate
reproducibility of cardiac output measurements. Heart volumes in determining thermodilution cardiac output in
Lung 24:38–44, 1995. critically ill postsurgical patients. Am J Crit Care 2:262,
12. Elkayam U, et al: Cardiac output by thermodilution 1995.
technique: Effect of injectate’s volume and temperature on 31. McCloy K, Leung S, Beldon J: Effects of injectate
accuracy and reproducibility in the critically ill. Chest volume on thermodilution measurements of cardiac output
84:418–422, 1983. in patients with low ventricular ejection fraction. Am J
13. Enghof E, Sjogren S: Thermal dilution for measurement Crit Care 8:86–92, 1999.
of cardiac output in the pulmonary artery catheter in man 32. Medin DL, et al: Validation of continuous thermodilution
in relation to choice of indicator volume and injection cardiac output in critically ill patients with analysis of
time. Ups J Med Sci 78:33–37, 1973. systematic errors. J Crit Care 13:184–189, 1998.
14. Frazier SK: Hemodynamic monitoring. In Moser D, 33. Mihaljevic T, et al: Continuous versus bolus
Reigel B, editors: Cardiac nursing: A companion to thermodilution cardiac output measurement:
Braunwald’s heart disease, Philadelphia, 2008, Saunders. A comparative study. Crit Care Med 23:944–949, 1995.
15. Gawlinski A: Protocols for practice: Hemodynamic 34. Nelson LD, Martinez OV, Anderson HB: Incidence of
monitoring series: cardiac output monitoring, Aliso Viejo, microbial colonization in open versus closed delivery
CA, 1998, American Association of Critical Care Nurses. systems for thermodilution injectate. Crit Care Med
16. Gidwar UM, Mohanty B, Chatterjee K: The pulmonary 14:291–293, 1986.
artery catheter a critical appraisal. Cardiol Clin 31:545– 35. Nishikawa R, Dohi S: Slowing of heart rate during
565, 2013. cardiac output measurement by thermodilution.
17. Giuliano KK, et al: Backrest angle and cardiac output Anesthesiology 57:538–539, 1982.
measurement in critically ill patients. Nurs Res 52:242– 36. Pearl RG, et al: Effect of injectate volume and
248, 2003. temperature on thermodilution cardiac output
18. Grap MJ, et al: Use of backrest elevation in critical care: determination. Anesthesiology 64:798–801, 1986.
A pilot study. Am J Crit Care 8:495–496, 1999. 37. Plachetka JR, et al: Comparison of two closed systems for
19. Griffin K, et al: Thermodilution cardiac output thermodilution cardiac output. Crit Care Med 9:487–489,
measurements during simultaneous volume infusion 1981.
38. Renner L, Meyer L: Injectate port selection affects 49. Weil MH: Measurement of cardiac output. Crit Care
accuracy and reproducibility of cardiac output Med 5:117–119, 1977.
measurements with multiport thermodilution pulmonary 50. Wetzel RC, Latson TW: Major errors in thermodilution
artery catheter. Am J Crit Care 3:55–59, 1994. cardiac output measurement during rapid volume infusion.
39. Reuter D, et al: Cardiac output monitoring using Anesthesiology 62:684–687, 1985.
indicator-dilution techniques: Basics, limits and 51. Whitman GR, Howaniak DL, Verga TS: Comparison of
perspectives. Anesth Analg 110:799–811, 2010. cardiac output measurements in 20-degree right- and
40. Riedinger MS, Shellock FG, Swan HJ: Reading left-lateral recumbent positions. Heart Lung 11:256–257,
pulmonary artery and pulmonary capillary wedge pressure 1982.
waveforms with respiratory variations. Heart Lung 52. Wilson AE, et al: Effect of backrest position on
10:675–678, 1981. hemodynamic and right ventricular measurements in
41. Rocca GD, et al: Continuous and intermittent cardiac critically ill adults. Am J Crit Care 5:264–270, 1996.
output measurement: Pulmonary artery catheter versus
aortic transpulmonary technique. Br J Anaesth 88:350– Additional Readings
356, 2002. AACN Practice Alert: Pulmonary artery/central venous
42. Shellock FG, Riedinger MS: Reproducibility and accuracy pressure monitoring in adults. Crit Care Nurse 36(4):
of using room-temperature vs ice-temperature injectate for e2–e18, 2016.
thermodilution cardiac output determination. Heart Lung Ahrens T: Hemodynamic monitoring. Crit Care Nurs Clin
12:175–176, 1983. North Am 11:19–31, 1999.
43. Shellock FG, et al: Thermodilution cardiac output Burchell SA, et al: Evaluation of a continuous cardiac
determination in hypothermic postcardiac surgery patients: output and mixed venous oxygen saturation catheter in
Room vs. ice temperature injectate. Crit Care Med critically ill surgical patients. Crit Care Med 25:388–391,
11:668–670, 1983. 1997.
44. Snyder JV, Powner DJ: Effects of mechanical ventilation Giraud R, Bendjelid K: Hemodynamic monitoring in the ICU,
on the measurement of cardiac output by thermodilution. Switzerland, 2016, Springer.
Crit Care Med 10:677–682, 1982. Headley JM: Strategies to optimize the cardiorespiratory
45. Stevens JH, et al: Thermodilution cardiac output status of the critically ill. AACN Clin Issues 6:121–134,
measurement: Effects of the respiratory cycle on its 1995.
reproducibility. JAMA 253:2440–2442, 1985. Jansen JR, et al: Mean cardiac output by thermodilution with
46. Todd MM: Atrial fibrillation induced by right atrial a single controlled injection. Crit Care Med 29:1868–
injection of cold fluid during thermodilution cardiac 1873, 2001.
output determination: A case report. Anesthesiology Lough M: Hemodynamic monitoring: Evolving technologies
59:253–255, 1983. and clinical practice, St Louis Missouri, 2015, Elsevier.
47. Wallace DC, Winslow EH: Effects of iced and room Sandham JD, et al: A randomized, controlled trial of the use
temperature injectate on cardiac output measurements of pulmonary-artery catheters in high-risk surgical
in critically ill patients with low and high cardiac outputs. patients. N Engl J Med 348:5–14, 2003.
Heart Lung 22:55–63, 1993. Suess EM, Pinsky MR: Hemodynamic monitoring for the
48. Walsh E, et al: Iced vs room-temperature injectates for evaluation and treatment of shock: What is the current
cardiac index measurement during hypothermia and state of the art? Semin Respir Crit Care Med 36(06):890–
normothermia. Am J Crit Care 19(4):365–372, 2010. 898, 2015.
PROCEDURE
65
Central Venous Catheter
Removal
Jillian Hamel
PURPOSE: Central venous catheters are removed when therapy is completed,
when complications occur, or when the patient has a catheter-related infection.
PREREQUISITE NURSING • Sterile specimen container (needed if a culture of the

KNOWLEDGE catheter tip will be obtained)
• Suture removal kit
• Knowledge of the normal anatomy and physiology of the • Emergency equipment
vasculature and cardiovascular system is necessary.
• Knowledge of normal coagulation values is needed. PATIENT AND FAMILY EDUCATION
• Principles of aseptic technique should be known.
• Advanced cardiac life support (ACLS) knowledge and skills • Explain the procedure to the patient and family and the
are necessary. reason for catheter removal. Rationale: This explanation
• Clinical and technical competence in central venous cath- provides information and decreases anxiety.
eter (CVC) removal is necessary. • Explain the importance of patient participation during the
• Knowledge of the state nurse practice act is important catheter removal. Rationale: This explanation ensures
because some states do not allow this intervention to be patient cooperation and facilitates safe removal of the
performed by a registered nurse. catheter.
• Knowledge of potential complications associated with the • Instruct the patient and family to report any signs and
removal of the CVC is needed. symptoms of shortness of breath, bleeding, or discomfort
• An air embolism can occur during or after the removal of at the site of catheter removal. Rationale: Identifies patient
the catheter as a result of air drawn in along the subcutane- discomfort and early recognition of complications.
ous tract and into the vein. During inspiration, negative
intrathoracic pressure is transmitted to the central veins.
Any opening external to the body to one of these veins PATIENT ASSESSMENT AND
may result in aspiration of air into the central venous PREPARATION
system. The pathological effects depend on the volume
and rate of air aspirated. Signs and symptoms include: Patient Assessment
respiratory distress, agitation, cyanosis, gasp reflex, • Assess vital signs and the neurovascular status of the
sucking sound, hypotension, petechiae, cardiac dysrhyth- extremity distal to the catheter insertion site. Rationale:
mias, altered mental status, and cardiac arrest. This assessment provides baseline data.
• Assess the patient’s current coagulation values. Ratio-
EQUIPMENT nale: If the patient has abnormal coagulation study results,
hemostasis may be difficult to obtain. Abnormal coagula-
• Fluid-shield face mask or goggles tion results should be discussed with the physician or
• Gowns, nonsterile gloves advance practice nurse before catheter removal.
• Antiseptic solution (e.g., 2% chlorhexidine-based prepa- • Assess the catheter site for redness, warmth, tenderness,
ration) or presence of drainage. Rationale: Determines whether
• 4 × 4 gauze pads signs or symptoms of infection are present.
• Petroleum-based ointment
• One roll of 2-inch tape Patient Preparation
• Two moisture-proof absorbent pads • In collaboration with the physician or advance practice
Additional equipment, to have available as needed, includes nurse, determine when the CVC should be removed.
the following: Rationale: The invasive catheter is removed when it is no
• Additional dressing supplies (e.g., semipermeable trans- longer indicated.
parent dressing) • In collaboration with the physician or advance practice
• Sterile scissors nurse, determine whether the tip of the catheter will be
569
cultured. Rationale: This discussion determines addi- delenburg’s position is contraindicated or not tolerated by
tional supplies that may be needed. the patient). Rationale: The patient should be positioned
• Verify that the patient is the correct patient using two so that the catheter exit site is at or below the level of the
identifiers. Rationale: Before performing a procedure, the heart.5,6 A normal pressure gradient exists between atmo-
nurse should ensure the correct identification of the patient spheric air and the central venous compartment that pro-
for the intended intervention. motes air entry if the compartment is open. The lower the
• Ensure that the patient and family understand prepro- site of entry below the heart, the lower the pressure gradi-
cedural teaching. Answer questions as they arise, and ent, thus minimizing the risk of air being drawn in and
reinforce information as needed. Rationale: Understand- thus a venous air embolism.
ing of previously taught information is evaluated and • Start a new peripheral intravenous (IV) line or ensure that
reinforced. an existing peripheral IV line is patent. Rationale: IV
• Place the patient in a supine position with the head of the access is established for fluids or medications.
bed in a slight Trendelenburg’s position (or flat if Tren-
Procedure for Central Venous Catheter Removal

1. HH
2. PE All physicians, advanced practice nurses,
and other healthcare professionals in
the room should wear personal
protective equipment including a face
mask.
3. Transfer or discontinue the IV Prepares the catheter for
solution. removal and ensures IV fluids
are infusing in another site.
4. Open the sterile scissors or Prepares supplies for use.
suture removal kit and sterile
gauze pads.
5. Place a moisture-proof Collects blood and body fluids
absorbent pad under the associated with removal;
patient’s upper torso and another serves as a receptacle for the
close to the catheter site. contaminated catheter.
6. Place the patient supine in slight Minimizes the risk for venous Place the patient flat if Trendelenburg’s
Trendelenburg’s air embolus by increasing the position is contraindicated or not
position.1,3,4,7–10,13,16 (Level E*) pressure in the large veins tolerated by the patient or a femoral
above atmospheric pressure, CVC will be removed.
thus reducing the risk of air If the CVC is in the femoral vein, extend
aspiration. The patient should the patient’s leg and ensure the groin
be positioned so that the area is adequately exposed.
catheter exit site is at or below Cases have been reported of venous air
the level of the heart.5,6 embolus occurring after removal of
CVCs when patients were not in a
supine slight Trendelenburg position.
7. Have the patient turn his or her Decreases the risk for This step is not needed if a femoral
head away from the catheter site contamination. catheter is removed.
(if removing an internal jugular
or subclavian catheter).
8. Remove the catheter dressing Prepares for removal.
and discard.
9. Remove the nonsterile gloves, Decreases the risk for
perform hand hygiene, and contamination.
apply a pair of sterile gloves.
10. Remove the securing device or, Allows for removal of the Ensure that the entire suture is removed.
if present, cut sutures and gently catheter. Retained sutures can form epithelialized
pull the sutures through the skin. tracts that can lead to infection.
65 Central Venous Catheter Removal 571
Procedure for Central Venous Catheter Removal—Continued

11. Ask the patient to take a deep Minimizes the risk for venous If the patient is receiving positive
breath in and hold it if removing air embolus. pressure ventilation, withdraw the
an internal jugular or subclavian catheter during the inspiratory phase of
catheter.12,14,16,17 (Level E*) the respiratory cycle or when a breath
is delivered via a bag-valve device.
12. Withdraw the catheter, pulling Minimizes trauma. If resistance is met, do not continue to
parallel to the skin and using a remove the catheter. Notify the
steady motion. advanced practice nurse or physician
immediately.
13. As the catheter exits the site, Minimizes the risk for venous The distal end of a multilumen catheter
apply pressure with a gauze pad. air embolus and promotes should be removed quickly because the
hemostasis. exposed proximal and medial openings
could permit the entry of air.
14. Instruct the patient to exhale Once the catheter is removed the
after the catheter is removed. patient can breathe normally.
15. Lay the catheter on the Ensures the removal of the If the introducer tip will be cultured,
moisture-proof absorbent pad. entire catheter. have another provider assist with
Check to be sure that all of the cutting the tip with sterile scissors and
catheter was removed. placing it in a sterile specimen
container before placing the catheter
on the moisture-proof absorbent pad.
Routine culturing of tips upon removal
is not recommended.6
16. Continue applying firm, direct Ensures hemostasis. Because CVCs are placed in large veins,
pressure over the insertion site hemostasis may take up to 10 minutes
with the gauze pad until to occur.
bleeding has stopped. Pressure may be needed for a longer
coagulation studies are abnormal.
17. Apply an occlusive dressing, Decreases the risk for infection Label the dressing with the date, time,
consisting of sterile petroleum- at the insertion site and and your initials.
based ointment, sterile gauze, minimizes the risk for venous
and cover with tape or a air embolus.
transparent semipermeable
membrane dressing.1,2,5,6,8,10,13
(Level E*)
18. Maintain the patient in the May decrease the risk of a
supine position for 30 minutes postprocedure venous air
after catheter removal.5 embolism.
receptacles Precautions.
20. HH


• The catheter is removed intact • Inability to remove the catheter
• Hemostasis is achieved at the catheter site • Catheter not removed intact
• Venous air emboli
• Persistent bleeding
• Hematoma
• Infection
• Broken catheter/fragmentation
• Pain

interventions.
1. Assess the patient’s vital signs, Provides baseline data and data that • Abnormal vital signs
pulse oximetry, and level of identify changes in patient • Shortness of breath or tachypnea
consciousness before and after condition. • Cyanosis or decreased oxygen
the CVC is removed. saturation
• Changes in mental status
2. If signs and symptoms of venous Venous air embolus is a potentially • Respiratory distress
air embolus are present, life-threatening complication. The • Dyspnea
immediately place the patient in left lateral Trendelenburg’s position • Coughing
the left lateral Trendelenburg’s prevents air from passing into the • Tachypnea
position. left side of the heart and traveling • Altered mental status (agitation,
into the arterial circulation. restlessness)
• Cyanosis
• Gasp reflex
• Sucking sound near the site of the
catheter insertion/air entrainment
• Petechiae
• Chest pain
• Hypotension
3. After removal of the CVC, assess Bleeding or a hematoma can develop • Bleeding
the site for signs of bleeding if there is still bleeding from the • Hematoma development
every 15 minutes × 2, every 30 vessel.
minutes × 2, and then 1 hour
later.
4. Remove the dressing and assess Verifies healing and closure of the • Abnormal healing
for site closure 24 hours after site.
CVC removal.
65 Central Venous Catheter Removal 573

5. Daily assess the need for the The Centers for Disease Control and • Signs and symptoms of infection
CVC. If long-term use of the Prevention (CDC)11 do not have at the CVC catheter insertion site
CVC is needed, frequently specific recommendations regarding • Signs and symptoms of sepsis
reassess the necessity of the line. routine replacement of CVCs.
(Level C*) Researchers conducting one study
recommend that CVCs do not need
to be changed more frequently than
every 7 days.2 There are no specific
recommendations regarding routine
replacement of CVCs that need to
be in place for >7 days.2,15
Guidewire exchanges should not be
used routinely. A guidewire
exchange should only be used to
replace a catheter that is
malfunctioning.11
Documentation
• Patient and family education • Application of air occlusive dressing
• Date and time of catheter removal • Patient tolerance of the procedure
• Site assessment • Unexpected outcomes and interventions
• Pain assessment, interventions, and effectiveness

65 Central Venous Catheter Removal 573.e1
References 12. Oztekin DS, et al: Comparison of complications and

1. Ely EW, et al: Venous air embolism from central venous procedural activities of pulmonary artery catheter removal
catheterization: A need for increased physician awareness. by critical care nurses versus medical doctors. Nurs Crit
Crit Care Med 27:2113–2117, 1999. Care 13:105–115, 2008.
2. Eyer S, et al: Catheter-related sepsis: Prospective, 13. Pronovost PJ, Wu AW, Sexton JB: Acute decompensation
randomized study of three methods of long-term catheter after removing a central line: Practical approaches to
maintenance. Crit Care Med 18:1073–1079, 1990. increasing safety in the intensive care unit. Ann Intern
3. Hamilton H: Complications associated with venous access Med 140:1025–1033, 2004.
devices: Part one. Nurs Stand 20(26):43–50, 2006. 14. Rountree WD: Removal of pulmonary artery catheters by
4. Hsiung GR, Swanson PD: Cerebral air embolism after registered nurses: A study in safety and complications.
central venous catheter removal. Neurology 55: Focus Crit Care 18:313–318, 1991.
1063–1064, 2000. 15. Safdar N, Maki DG: The pathogenesis of catheter-related
5. Infusion Nurses Society: Policies and procedures for blood stream infections with noncuffed short-term central
infusion nursing, ed 5, 2016, Infusion Nurses Society. venous catheters. Intens Care Med 30:62–67, 2004.
6. Infusion Nurses Society: Infusion nursing standards of 16. Turnage WS, Harper JV: Venous air embolism occurring
practice. J Infus Nurs 34(1S):S6–S110, 2011. after removal of a central venous catheter. Anesth Analg
7. Khan H, Zaida A: Paradoxical air embolism following 72:559–560, 1991.
CVC removal. BMJ Case Rep Sep 26, 2013. 17. Wadas TM: Pulmonary artery catheter removal. Crit Care
8. Kim DK, et al: The CVC removal distress syndrome: Nurse 14:62–72, 1994.
An unappreciated complication of central venous catheter Additional Readings
removal. Am Surgeon 64:344–347, 1998.
9. McCarthy PM, et al: Air embolism in single-lung Deceuninck O, et al: Massive air embolism after central
transplant patients after central venous catheter removal. venous catheter removal. Circulation 116:e516–e518,
Chest 107:1178–1179, 1995. 2007.
10. Mennim P, Cormac FC, Taylor JD: Venous air embolism Lough M: Hemodynamic Monitoring: Evolving Technologies
associated with removal of central venous catheter. BMJ and Clinical Practice, 2015, Elsevier.
305:171–172, 1992.
11. O’Grady NP, et al: Summary of recommendations:
Guidelines for the prevention of intravascular catheter-
related infections. Clin Infect Dis 52(9):1087–1099, 2011.
PROCEDURE
66
Site Care
Jillian Hamel
PURPOSE: Site care of the central venous catheter allows for assessment and
care of the catheter-insertion site.
PREREQUISITE NURSING • Explain the importance of patient positioning during

KNOWLEDGE the dressing change. Rationale: Patient cooperation is
increased; the potential for contamination is decreased.
• Understanding of the principles of aseptic technique is needed.
• Knowledge of the signs and symptoms of catheter-related
infection and sepsis is necessary. PATIENT ASSESSMENT AND
• Most serious catheter-related infections are associated PREPARATION
with central venous catheters (CVCs), especially those
that are placed in the intensive-care setting.6 Patient Assessment
• Bloodstream infections related to the use of CVCs are an • Assess the patient’s arm, shoulder, neck, and chest on
important cause of patient morbidity, mortality, and the same side as the catheter insertion site for signs
increased healthcare costs.2 of pain, swelling, or tenderness. Assess the patient’s
• Topical antibiotic ointment or creams are not recom- leg size and assess for signs of pain, swelling, or ten-
mended on the catheter insertion site. The use of antibiotic derness on the same side as the catheter insertion site
ointment or cream can potentially promote fungal infec- if the CVC is placed in the femoral vein. Rationale:
tions and antimicrobial resistance.6 Assessment evaluates for thrombophlebitis or venous
• CVCs do not need to be routinely replaced to prevent thrombosis.
catheter-related infections.6 Clinical judgment should be • Assess for signs and symptoms of infection. Signs and
used to determine the appropriateness of removing the symptoms may include redness, swelling, and drainage at
catheter.6 the catheter site or fever, chills, and positive blood cul-
tures. Rationale: Infection is a potential complication of
EQUIPMENT any invasive catheter.
• Assess the patient’s history for sensitivity to antiseptic
• Nonsterile gloves solutions. Rationale: Assessment decreases the risk for
• Prepackaged sterile dressing kit or separate supplies as allergic reactions.
listed below
• Sterile gloves Patient Preparation
• Face mask • Verify that the patient is the correct patient using two
• Transparent semipermeable dressing or sterile 4 × 4 gauze identifiers. Rationale: Before performing a procedure, the
• Roll of 2-inch tape nurse should ensure the correct identification of the patient
• Antiseptic solution (e.g., 2% chlorhexidine-based prepa- for the intended intervention.
ration) • Ensure that the patient and family understand prepro-
Additional equipment, to have available as needed, includes cedural teaching. Answer questions as they arise, and
the following: reinforce information as needed. Rationale: Understand-
• Securement device (used with nonsutured central venous ing of previously taught information is evaluated and
catheters) reinforced.
• Chlorhexidine gluconate–impregnated sponge • If the patient is on ventilatory support, assess the patient’s
need for suctioning before beginning the procedure.
PATIENT AND FAMILY EDUCATION Femoral catheter sites need to be inspected for potential
contamination with urine or stool. Rationale: The risk for
• Explain the dressing change procedure. Rationale: Expla- catheter site contamination by secretions or excretions is
nation prepares the patient and decreases patient anxiety. minimized.
574
66 Central Venous Catheter Site Care 575
Procedure for Central Venous Catheter Site Care

1. HH
2. PE
3. Prepare supplies. Prepares equipment.
4. Position the patient so that the Prepares for dressing change. If the CVC is in the femoral vein,
CVC site is easily accessible. extend the patient’s leg and ensure
the groin area is adequately
exposed while maintaining patient
privacy and comfort.
5. Have the patient turn his or her Decreases the risk for site
head away from the catheter contamination.
insertion site (if performing site
care on an internal jugular or
subclavian catheter).
6. Apply a face mask. Reduces the transmission of
microorganisms.
7. Remove and discard the CVC Exposes the catheter site for
dressing. inspection and site care.
8. Remove the securement device if it The securement device should
is present. be changed with each
dressing change.3
9. Inspect the catheter, insertion site, Assesses for signs of infection,
and surrounding skin. catheter dislodgment,
leakage, or loose sutures.
10. Remove and discard gloves in the Removes and safely discards
appropriate receptacle. used supplies.
11. HH
12. Apply sterile gloves. Maintains aseptic and sterile
technique.
13. Cleanse the skin, catheter, and Reduces the rate of Allow the solution to dry.
stabilizing device with 2% recolonization of skin flora. When cleansing, a back-and-forth
chlorhexidine-based motion should be used for at least
preparation.1–4,6,7 (Level A*) 30 seconds.3
14. Apply a new stabilization device. Secures the catheter.
15. Apply a chlorhexidine-impregnated Reduces the transmission of Follow institutional standards.
sponge to the site.4,6 (Level D*) microorganisms. A chlorhexidine-impregnated sponge
dressing is recommend if an
institution’s central line–associated
bloodstream infection rate is not
decreasing despite adherence to
basic prevention measures,
including education and training,
appropriate use of chlorhexidine
for skin antisepsis and MSB.4,5
Use with caution in patients
predisposed to local skin necrosis,
such as burn patients or patients
with Stevens-Johnson syndrome.8

Procedure for Central Venous Catheter Site Care—Continued

16. Apply a sterile air occlusive Provides a sterile environment. If the patient is diaphoretic or if the
dressing. Dressings may be a sterile site is bleeding or oozing, a gauze
gauze or a sterile, transparent, dressing is preferred.4,6
semipermeable dressing.6 Topical antibiotic ointment and
creams should be avoided.6
Precautions.
18. Document date and time of changes Indicates when the dressing
of the external dressing. was changed.
19. HH

• Dressing remains dry, sterile, and intact • Catheter-associated bloodstream infection
• Catheter site remains free of infection • Infection at the catheter site
• Catheter remains in place without dislodgment • Accidental removal or dislodgement of the catheter
• Impaired integrity of the skin under the dressing

interventions.
1. Assess the catheter site daily If there is tenderness at the insertion • Signs and symptoms of infection
and as needed by palpation site, fever without obvious source, at the catheter insertion site
through an intact dressing. or other signs and symptoms of a • Signs and symptoms of sepsis
local or bloodstream infection, the
dressing should be removed to allow
thorough examination of the site.4,6
2. Replace gauze dressings Decreases the risk for infection at the
every 2 days and transparent catheter site. The Centers for
dressings at least every 5–7 Disease Control and Prevention
days and more frequently as (CDC) and the Infusion Nurses
needed.3,4,6,7 (Level D*) Society recommend replacing the
dressing when it becomes damp,
loosened, or soiled, or when
inspection of the site is necessary.3,4,6
*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations
Documentation
• Patient and family education • Date and time of dressing change
• Date and time of the procedure • Unexpected outcomes
• Assessment of the catheter site • Additional interventions
• Type of dressing applied • Pain assessment, interventions, and effectiveness
66 Central Venous Catheter Site Care 577

66 Central Venous Catheter Site Care 577.e1
References 7. Timsit JF, et al: Chlorhexidine-impregnated sponges and

1. Balamongkhon B, Thamlikitkul V: Implementation of less frequent dressing changes for prevention of catheter-
chlorhexidine gluconate for central venous catheter site related infections in critically ill adults: A randomized
care at Siriraj Hospital, Bangkok, Thailand. Am J Infect controlled trial. JAMA 301(12):1231–1241, 2009.
Control 35:585–588, 2007. 8. Wall JB, Divito SJ, Talbot SG: Chlorhexidine gluconate-
2. Chaiyakunapruk N, et al: Chlorhexidine compared with impregnated central line dressings and necrosis in
povidone-iodine solution for vascular catheter-site care: complicated skin disorder patients. J Crit Care 29(6):1130
A meta-analysis. Ann Intern Med 136:792–807, 2002. e1–1130 e4, 2014.
3. Infusion Nurses Society: Policies and Procedures for
Infusion Nursing, ed 4, Norwood, MA, 2016, Infusion Additional Readings
Nurses Society. Alexander M, Corrigan A, Gorski L, editors: Infusion Nurses
4. Infusion Nurses Society: Infusion nursing standards of Society Infusion Nursing: An Evidence-Based Approach,
practice. J Infus Nurs 34(1S):S6–S110, 2016. ed 3, St. Louis, MO, 2010, Saunders.
5. Maki DG, et al: Prospective, randomized, investigator- Maki DG, Kluger DM, Crnich CJ: The risk of bloodstream
masked trial of novel chlorhexidine-impregnated disk infection in adults with different intravascular devices:
(Biopatch) on central venous and arterial catheters (abstr). A system review of 200 published prospective studies.
Infect Control Hosp Epidemiol 21:96, 2000. May Clin Proc 81:1159–1171, 2006.
6. O’Grady NP, et al: Summary of recommendations: Marshall J, et al: Strategies to prevent central line-associated
guidelines for the prevention of intravascular catheter- bloodstream infections in acute care hospitals: 2014
related infections. Clin Infect Dis 52(9):1087–1099, update. Inject Control Hosp Epidemiol 35(7):753–771,
2011. 2014.
PROCEDURE
67
Central Venous/Right Atrial
Pressure Monitoring
Reba McVay
PURPOSE: Central venous/right-atrial pressure monitoring provides information
about the patient’s intravascular volume status and right-ventricular preload. The
central venous pressure (CVP) or the right atrial pressure (RAP) allows for evaluation
of right-sided heart hemodynamics and evaluation of patient response to therapy.
CVP and right-atrial pressure are used interchangeably.

KNOWLEDGE
• Pressure transducer system, including flush solution rec-
• Knowledge of the normal anatomy and physiology of the ommended according to institutional standards, a pressure
cardiovascular system is needed. bag or device, pressure tubing with transducer, and flush
• Knowledge of the principles of aseptic technique and device (see Procedure 75)
infection control is necessary. • Pressure module and cable for interface with the monitor
• Knowledge is needed of the principles of hemodynamic • Dual-channel recorder
monitoring. • Leveling device (low-intensity laser or carpenter level)
• The CVP/RAP represents right-sided heart preload or the • Nonsterile gloves
volume of blood found in the right ventricle at the end of • Sterile injectable or noninjectable caps
diastole. Additional equipment (to have available depending on patient
• CVP/RAP influences and is influenced by venous return need) includes the following:
and cardiac function. Although the CVP/RAP is used as a • Indelible marker
measure of changes in the right ventricle, the relationship
is not linear because the right ventricle has the ability to PATIENT AND FAMILY EDUCATION
expand and alter its compliance, changes in volume can
occur with little change in pressure. • Discuss the purpose of the central venous catheter and
• The CVP/RAP normally ranges from 2 to 6 mm Hg in the monitoring with both the patient and family. Rationale:
adult. This discussion reduces anxiety and includes the patient
• The central venous catheter is inserted in a central vein and family in the plan of care.
with the tip of the catheter placed in the proximal superior • Explain the patient’s expected participation during the
vena cava. procedure. Rationale: The explanation encourages patient
• Knowledge is needed of the setup, leveling, and zeroing assistance.
of the hemodynamic monitoring system (see Procedure
75).
• Interpretation of RA/CVP waveforms including identifi- PATIENT ASSESSMENT AND
cation of a, c, and v waves is important. The a wave PREPARATION
reflects right-atrial contraction. The c wave reflects closure
of the tricuspid valve. The v wave reflects passive filling Patient Assessment
of the atria during right-ventricular systole. The CVP/RAP • Determine hemodynamic, cardiovascular, and peripheral
measurement is the mean of the a wave. vascular status. Rationale: This assessment provides
• CVP/RAP values are useful in evaluating volume status, baseline data.
effect of medication therapy (especially medication that • Determine the patient’s baseline pulmonary status. If
decreases preload), and cardiac function (Box 67-1). the patient is mechanically ventilated, note the type of
• Monitoring parameters from the femoral catheter is not support, ventilator mode, and presence or absence of
recommended. The catheter is too distant from the right positive end-expiratory pressure (PEEP) or continuous
atrium to produce reliable data. positive airway pressure (CPAP). Rationale: The pres-
578
67 Central Venous/Right Atrial Pressure Monitoring 579
cardia, and dry mucous membranes. Rationale: Assess-

BOX 67-1 Central Venous Pressure (CVP)
ment data should correlate with a decreased CVP/RAP
CONDITIONS CAUSING INCREASED CVP value.
Elevated intravascular volume • Assess for signs and symptoms of fluid volume excess.
Depressed right-sided cardiac function (RV infarct, RV failure) Signs and symptoms may include dyspnea, abnormal
Cardiac tamponade breath sounds (i.e., crackles), S3 heart sound, peripheral
Constrictive pericarditis edema, tachycardia, and jugular vein distention. Ratio-
Pulmonary hypertension nale: Assessment data should correlate with an increased
Chronic left-ventricular failure CVP/RAP value.
CONDITIONS CAUSING DECREASED CVP
Reduced intravascular volume*
Patient Preparation
Decreased mean arterial pressure • Verify that the patient is the correct patient using two
Venodilation identifiers. Rationale: Before performing a procedure, the
*Although the measured CVP is low, cardiac function may be depressed, normal, for the intended intervention.
or hyperdynamic when there is reduced vascular volume. • Ensure that the patient and family understand teaching.
RV, Right ventricular. Answer questions as they arise, and reinforce information
as needed. Rationale: Understanding of previously taught
information is evaluated and reinforced.
ence of mechanical ventilation alters hemodynamic wave- • Place the patient in the supine position with the head
forms and pressures. of the bed flat or elevated up to 45 degrees. Rationale:
• Assess for signs and symptoms of fluid volume deficit. This positioning prepares the patient for hemodynamic
Signs and symptoms may include thirst, oliguria, tachy- monitoring.
Procedure for Central Venous/Right-Atrial Pressure Monitoring

1. HH
2. PE
3. Position the patient in the supine Studies have determined that the CVP/RAP may be accurate for
position with the head of the bed CVP/RAP is accurate in this patients in the supine position with
at 0–45 degrees. (Level B*) position.3–5,7,12,14,16,27,28 the head of the bed elevated up to
60 degrees,5,16 but additional studies
are needed to support this.
Only one study13 supports the
accuracy of hemodynamic values
for patients in the lateral positions;
other studies do not.3,9,12,20,26
The majority of studies support the
accuracy of hemodynamic
monitoring for patients in the prone
position.1,2,8,11,15,21,25
Two studies demonstrated that prone
positioning caused an increase in
hemodynamic values.22,24
4. Level the air-fluid interface of The phlebostatic axis is at Mark the location of the phlebostatic
the monitoring system to the approximately the level of the axis if not already identified.
phlebostatic axis (see Procedure atria and should be used as the
75 and Figs. 75-7 and 75-9). reference point for the air-fluid
interface.
5. Zero the transducer (see Allows the monitor to use
Procedure 75). atmospheric pressure as a
reference for zero.

Procedure for Central Venous/Right-Atrial Pressure Monitoring—Continued

6. Observe the waveform and Determines whether the system is The square wave test can be
perform a dynamic response test damped. This will ensure that performed by activating and
(square wave test). the pressure waveform quickly releasing the fast flush.
components are clearly defined. A sharp upstroke should terminate in
This aids in accurate measurement. a flat line at the maximal indicator
on the monitor.
This should be followed by an
immediate rapid downstroke
extending below baseline with 1–2
oscillations within 0.12 second and
a quick return to baseline (see Fig.
59-3).
7. Run a dual-channel strip of the Right-atrial pressures should be Some monitors have the capability of
electrocardiogram (ECG) and determined from the graphic “freeze framing” waveforms. A
CVP/RAP waveform (Fig. 67-1). recording so that end expiration cursor can be used to determine
can be properly identified. pressure measurements.
8. Measure the CVP/RAP at end Measurement is most accurate as
expiration. the effects of intrathoracic
pressure changes are minimized.
9. With the dual-channel recorded Compares electrical activity with At times, the c wave is not present.
strip, draw a vertical line from mechanical activity. Usually,
the beginning of the P wave of three waves are present on the
one of the ECG complexes down CVP/RAP waveform.
to the CVP/RAP waveform.
Repeat this with the next ECG
complex (see Fig. 72-7).
10. Align the PR interval with The a wave correlates with this
the CVP/RAP waveform (see interval.
Fig. 72-7).
Figure 67-1 Central venous pressure (CVP) waveform with a, c, and v waves present. The a
wave is usually seen just after the p wave of the electrocardiogram (ECG). The c wave appears at
the time of the RST junction on the ECG. The v wave is seen in the TP interval.
Procedure for Central Venous/Right-Atrial Pressure Monitoring—Continued

11. Identify the a wave (see Fig. The a wave is seen approximately The a wave reflects atrial contraction.
67-1). 80–100 ms after the P wave. The The c wave reflects closure of the
c wave follows the a wave, and tricuspid valve. The v wave reflects
the v wave follows the c wave. passive filling of the right atrium.
12. Identify the scale of the CVP/ Aids in determining the pressure The RAP scale commonly is set at
RAP tracing (see Figs. 67-1 and measurement. 20 mm Hg. Scale settings may vary
67-2). based on monitoring equipment.
13. Measure the mean of the a wave The a wave represents atrial
to obtain the RAP (see Fig. 67-2 contraction and reflects
and Fig. 72-8). ventricular filling at end diastole.
15. HH

• Accurate CVP/RAP measurements • Inaccurate readings
• Adequate and appropriate waveforms • CVP/RAP readings that do not correlate with
• CVP/RAP readings that correlate with physical physical findings
findings • Infection
• Evaluation of information obtained to guide • Sepsis
therapeutic interventions • Occluded catheter
Figure 67-2 Reading the right-atrial pressure (RAP) from paper printout at end expiration in a
spontaneously breathing patient. While observing the patient, identify inspiration. The point just
before inspiration is end expiration. The arrow indicates the point of end expiration. Reading is
taken as a mean value. The RAP value for this patient is 16 mm Hg.

interventions.
1. Recheck leveling whenever the Ensures an accurate reference point
patient position changes. at the phlebostatic axis.
2. Zero the transducer during initial Ensures the accuracy of the
setup or before insertion, if hemodynamic monitoring system;
disconnection occurs between the minimizes the risk for
transducer and the monitoring cable, contamination of the system.
if disconnection occurs between the
monitoring cable and the monitor, at
least once per shift, and when the
values obtained do not fit the clinical
picture. Follow manufacturer’s
zeroing of the system.
3. Monitor the pressure transducer Air emboli are potentially fatal.
system (pressure tubing, transducer,
stopcocks, etc.) for air and eliminate
air from the system.
4. Assess central venous catheter Ensures catheter patency. • Occluded catheter
patency every 8 hours and administer
thrombolytics as prescribed if the
catheter is occluded.6,23 (Level B*)
5. Continuously monitor the CVP/RAP Provides for continuous waveform • Abnormal CVP/RAP values or
waveform; obtain the hemodynamic analysis and assessment of patient waveforms
value hourly and as necessary with status.
changes in patient condition. Follow
6. Change the hemodynamic The Centers for Disease Control and
monitoring system (flush solution, Prevention (CDC),18 the Infusion
pressure tubing, transducer, Nurses Society,10 and research
and stopcocks) every 96 hours. findings17,19 recommend that the
(Level B*) hemodynamic flush system can be
The flush solution may need to be used safely for 96 hours.
changed more frequently if the This recommendation is based on
volume of solution is decreased. research conducted with disposable
pressure monitoring systems used
for peripheral and central lines.
7. Perform a dynamic response test An optimally damped system • Overdamped or underdamped
(square wave test) at the start of each provides an accurate waveform. waveforms that cannot be
shift, with a change of the waveform, corrected with troubleshooting
or when the system is opened to air procedures
(see Fig. 59-3).
8. Maintain the pressure bag or device At 300 mm Hg, each flush device
at 300 mm Hg. delivers approximately 1–3 mL/hr
to maintain patency of the system.
9. Obtain a CVP/RAP waveform strip Allows assessment of the waveform
to place on the patient’s chart at the and the CVP/RAP measurement.
start of each shift and whenever
there is a change in the waveform or
patient condition.
Documentation
• Patient and family education • Occurrence of unexpected outcomes and
• CVP/RAP pressures and waveform interventions
• Site assessment

67 Central Venous/Right Atrial Pressure Monitoring 583.e1
References 19. O’Malley MK, et al: Value of routine pressure monitoring

1. Blanch L, et al: Short-term effect of prone position in system changes after 72 hours of use. Crit Care Med
critically ill patients with acute respiratory distress 22:1424–1430, 1994.
syndrome. Intensive Care Med 23:1003–1039, 1997. 20. Osida C: Measurement of pulmonary artery pressures:
2. Brussel T, et al: Mechanical ventilation in the prone Supine verses side-lying head elevated positions.
position for acute respiratory failure after cardiac surgery. Heart Lung 18:298–299, 1989.
J Cardiothorac Vasc Anesth 7:541–546, 1993. 21. Pappert D, et al: Influence of positioning on ventilation-
3. Cason CL, et al: Effects of backrest elevation and position perfusion relationships in severe adult respiratory distress
on pulmonary artery pressures. Cardiovasc Nurs 26:1–5, syndrome. Chest 106:1511–1516, 1994.
1990. 22. Pelosi P, et al: Effects of the prone position on respiratory
4. Chulay M, Miller T: The effect of backrest elevation on mechanics and gas exchange during acute lung injury.
pulmonary artery and pulmonary capillary wedge Am J Respir Crit Care Med 157:387–393, 1998.
pressures in patients after cardiac surgery. Heart Lung 23. Ponec D, et al: Recombinant tissue plasminogen activator
13:138–140, 1984. (Alteplase) for restoration of flow in occluded central
5. Clochesy J, Hinshaw AD, Otto CW: Effects of change of venous access devices: A double-blind placebo-controlled
position on pulmonary artery and pulmonary capillary trial: The cardiovascular thrombolytic to open occluded
wedge pressure in mechanically ventilated patients. NITA lines (COOL) efficacy trial. J Vasc Interv Radiol 12:
7:223–225, 1984. 951–955, 2001.
6. Deitcher SR, et al: Safety and efficacy of alteplase for 24. Voggenreiter G, et al: Intermittent prone positioning in the
restoring function in occluded central venous catheters: treatment of severe and moderate posttraumatic lung
Results of the cardiovascular thrombolytic to open injury. Crit Care Med 27:2375–2382, 1999.
occluded lines trial. J Clin Oncol 20:317–324, 2002. 25. Vollman KM, Bander JJ: Improved oxygenation utilizing
7. Dobbin K, et al: Pulmonary artery pressure measurement a prone positioner in patients with acute respiratory
in patients with elevated pressures: Effect of backrest distress syndrome. Intensive Care Med 22:1105–1111,
elevation and method of measurement. Am J Crit Care 1996.
1:61–69, 1992. 26. Wild L: Effect of lateral recumbent positions on
8. Fridrich P, et al: The effects of long-term prone measurement of pulmonary artery and pulmonary artery
positioning in patients with trauma-induced adult wedge pressures in critically ill adults. Heart Lung
respiratory distress syndrome. Anesth Analg 83: 13:305, 1984.
1206–1211, 1996. 27. Wilson AE, et al: Effect of backrest position on
9. Groom L, Frisch SR, Elliot M: Reproducibility and hemodynamic and right ventricular measurements in
accuracy of pulmonary artery pressure measurement in critically ill adults. Am J Crit Care 5:264–270, 1996.
supine and lateral positions. Heart Lung 19:147–151, 28. Woods SL, Mansfield LW: Effect of body position upon
1990. pulmonary artery and pulmonary capillary wedge
10. Infusion Nurses Society: Infusion nursing standards of pressures in noncritically ill patients. Heart Lung 5:83–90,
practice. J Infus Nurs 39(1S):S6–S1159, 2016. 1976.
11. Jolliet P, Bulpa P, Chevrolet JC: Effects of prone position
on gas exchange and hemodynamics in severe acute Additional Readings
respiratory distress syndrome. Crit Care Med 26: AACN Practice Alert: Pulmonary artery/central venous
1977–1985, 1998. pressure monitoring in adults. Crit Care Nurse 36(4):
12. Keating D, et al: Effect of sidelying positions on e2–e18, 2016.
pulmonary artery pressures. Heart Lung 15:605–610, Bridges E: Pulmonary artery/central venous pressure
1986. measurement, AACN Practice Alert, revised 2009.
13. Kennedy GT, Bryant A, Crawford MH: The effects of Bridges EJ: Pulmonary artery pressure monitoring: When,
lateral body positioning on measurements of pulmonary how, and what else to use. AACN Adv Crit Care 17:286–
artery and pulmonary wedge pressures. Heart Lung 305, 2006.
13:155–158, 1984. Burns S: AACN essentials of critical care nursing, ed 3,
14. Lambert CW, Cason CL: Backrest elevation and New York, 2014, McGraw-Hill Education/Medicine.
pulmonary artery pressures: research analysis. Dimens Darovic GO: Hemodynamic monitoring: Invasive and
Crit Care Nurs 9:327–335, 1990. noninvasive clinical application, ed 3, Philadelphia, 2002,
15. Langer M, et al: The prone position in ARDS patients. Saunders.
Chest 94:103–107, 1982. Keckeisen M: Protocols for practice: Hemodynamic
16. Laulive JL: Pulmonary artery pressures and position monitoring series: Pulmonary artery pressure monitoring,
changes in the critically ill adult. Dimens Crit Care Nurs Aliso Viejo, CA, 1997, American Association of Critical-
1:28–34, 1982. Care Nurses.
17. Luskin RL, et al: Extended use of disposable pressure Lough M: Hemodynamic monitoring: Evolving technologies
transducers: A bacteriologic evaluation. JAMA 255: and clinical practice, St. Louis, 2016, Elsevier.
916–920, 1986. Magder S: Invasive intravascular hemodynamic monitoring:
18. O’Grady NP, et al: Summary of recommendations: Technical issues. Crit Care Clin 23:401–414, 2007.
Guidelines for the prevention of intravascular catheter- Pinsky M: Advances in hemodynamic monitoring, an issue for
related infections. Clin Infect Dis 52(9):1087–1099, critical care clinics, ed 1, Pittsburg, 2015, Critical Care
2011. Medicine.
PROCEDURE
68
Esophageal Cardiac Output
Monitoring: Perform
PURPOSE: Insertion of an esophageal probe for monitoring aortic blood flow is
used to assess the hemodynamic condition of critically ill patients. Esophageal
cardiac output monitoring or esophageal Doppler monitoring (EDM) uses Doppler
ultrasound technology to provide information regarding left ventricular performance
and patient fluid status.
PREREQUISITE NURSING • A widened waveform base with increased FTc may indi-
cate euvolemia.
KNOWLEDGE • A reduced waveform height with low PV may indicate left
• Knowledge of cardiovascular anatomy and physiology is ventricular failure.
needed. • An increased waveform height with increased PV may
• Understanding of the anatomy of the upper gastrointesti- indicate a hyperdynamic state.
nal tract is essential. • A reduced waveform height with a narrow waveform base
• It is important to understand the appropriateness, criteria, may indicate elevation in systemic vascular resistance
and contraindications of the insertion of an esophageal (SVR).
probe for monitoring aortic blood flow. • Indications for the EDM are as follows:
• The ability to recognize the EDM aortic waveforms by ❖ Potential status of hypoperfusion (e.g., hypovolemia,
visual display and auditory pitch is necessary. cardiogenic shock, hemorrhagic shock, septic shock)
• An understanding of normal and associated values of ❖ Hemodynamic monitoring and evaluation of patients
aortic waveforms is important (Fig. 68-1 and Table 69-1). with major organ dysfunction (e.g., renal failure, respi-
• An understanding of additional waveforms that guide ratory failure, liver failure)
esophageal probe insertion is needed (Fig. 69-1). ❖ Differential diagnosis of hypotensive states
• Clinical and technical competence in esophageal probe ❖ Aid in the diagnosis of heart failure, cardiogenic
insertion and esophageal monitoring is essential. shock, papillary muscle rupture, mitral regurgitation,
• Clinical and technical competence in understanding the ventricular septal rupture, or cardiac rupture with
esophageal Doppler monitor functions and options are tamponade
needed. ❖ Management of high-risk cardiac patients undergoing
• Corrected flow time (FTc), peak velocity (PV), and stroke surgical procedures during preoperative, intraopera-
distance (SD) come directly from the Doppler velocity tive, and postoperative periods
measurements; stroke volume (SV) and cardiac output • Contraindications to EDM include oral or upper gastroin-
(CO) are derived using an algorithm generated from the testinal tract anomalies, coagulopathies, coarctation of the
patient nomogram information (see Table 69-1). aorta, and intraaortic balloon pump therapy.
• The base of the waveform is used as a marker of left • Proper positioning of the esophageal probe is essential for
ventricular preload and displayed as FTc. accurate data collection and waveform monitoring.
• The waveform height is used as a marker of contractility • EDM technology utilizes a thin silicone probe, approxi-
and is displayed as PV. mately 6 mm in diameter and 90 cm in length.
• Minute distance (MD) is the distance (cm) moved by the • Once the patient’s age, height, and weight are entered into
column of blood through the aorta in 1 minute. the monitor, they are burned into a memory chip within
• SD is the distance (cm) moved by the column of blood the probe. EDM nomogram limits are:
through the aorta in one systolic period. ❖ Age: 16 to 99 years
• A narrowed waveform base with decreased FTc may indi- ❖ Weight: 66 to 330 pounds
cate hypovolemia. ❖ Height: 59 to 83 inches
• When nomogram limits are surpassed, calculated data
such as SVR, SV, stroke volume index (SVI), CO, and
practice nurses, and other healthcare professionals (including critical care cardiac index (CI) are not obtainable. Velocity data such
nurses) with additional knowledge, skills, and demonstrated competence per as FTc, PV, SD, and MD will still be measured. Refer to
professional licensure or institutional standard. specific manufacturer’s nomogram limits.
584
68 Esophageal Cardiac Output Monitoring: Perform 585
Here you go
Mean acceleration
Peak velocity
(cm/sec2)
(cm/sec)
Stroke distance
(cm)
Velocity
Flow time (msec)
Time
Figure 68-1 The EDM/EDM + waveform. (From the EDM quick reference guide, with kind
permission of Deltex Medical, Greenville, SC.)
EQUIPMENT
assessment provides baseline data that can be used for
• EDM monitor, patient interface cable, power cord comparison with postinsertion data.
• EDM probe • Assess the patient’s respiratory status. If the patient is
• Water-soluble lubricant mechanically ventilated, note the type of support: ventilator-
• Nonsterile gloves assisted breathing and/or continuous positive airway breath-
• Sedative or analgesic ing. Rationale: Determines the patient’s baseline pulmonary
Additional equipment, to have available as needed, includes status.
the following: • If the patient currently has respiratory compromise or could
• Topical lidocaine develop respiratory compromise with the adjunct of con-
• Tongue blade scious sedation, consider mechanical ventilation. Ratio-
• Supportive equipment if conscious sedation is necessary nale: Protects airway and provides oxygenation. Sedation
(e.g., oxygen, Ambu bag, suction, oral airway) and/or local anesthesia may be needed for probe insertion
• Gown, mask, and goggles or face shield and tolerance.
• Assess the patient’s current laboratory profile, including
PATIENT AND FAMILY EDUCATION electrolyte and coagulation studies. Rationale: Baseline
coagulation studies are helpful in determining the risk for
• Explain the procedure and the reason for the EDM moni- bleeding. Electrolyte abnormalities may contribute to
toring. Rationale: This explanation increases patient cardiac irritability.
understanding and may decrease patient anxiety.
• Explain that the procedure may stimulate gagging and that Patient Preparation
sedation may be given to promote comfort. Rationale: • Verify that the patient is correct patient using two identi-
This explanation prepares the patient and may decrease fiers. Rationale: Before performing a procedure, the nurse
his or her anxiety. should ensure the correct identification of the patient for
• Inform the patient of the risks and anticipated benefits of the intended intervention.
the esophageal monitoring probe. Rationale: This allows • Ensure that the patient and/or family understand the pre-
the patient to make an informed decision. procedural information. Answer questions as they arise
and reinforce information as needed. Rationale: This
PATIENT ASSESSMENT AND process evaluates and reinforces the understanding of pre-
PREPARATION viously taught information.
• Obtain informed consent. Rationale: Informed consent
Patient Assessment protects the rights of the patient and ensures that he or she
• Obtain the patient’s medical history specifically related to can make a competent decision.
oral or upper gastrointestinal anomalies (e.g., esophageal • Perform a preprocedure verification and time out. Ratio-
strictures, varices, oral surgery, trauma, ulcers). Ratio- nale: This ensures patient safety.
nale: This assesses for contraindications to insertion. • Consider administration of sedation or analgesics. Ratio-
• Assess the patient’s hemodynamic, cardiovascular, periph- nale: This decreases the anxiety and gagging that occurs
eral vascular, and neurovascular status. Rationale: This with enhanced probe tolerance.
Procedure for Esophageal Cardiac Output Monitoring: Perform

1. HH
2. Plug the esophageal Doppler Provides the energy source.
monitor into the wall outlet and
turn it on.
3. Connect the interface cable to the Prepares the equipment.
esophageal Doppler monitor.
4. Connect the esophageal probe to Prepares the equipment.
the interface cable.
5. When prompted, enter the Prepares the monitor. Data must be in these ranges:
patient’s age, weight, and height The monitor will confirm data entry Age: 16–99 years
into the esophageal Doppler and change to the probe focus Weight: 66–330 pounds
monitor. mode. Height: 59–83 inches
A. Turn the control knob to If a patient’s data are outside the
change the values. nomogram limits, estimated values
B. Press the control knob to enter cannot be obtained but velocity
the selected values. data are available.
C. Push the keypad under the Refer to the manufacturer’s
words “accept data.” recommendations for nomograms.
D. If any data are incorrect, press
“change data” to return to the
nomogram screen and change
any data that have been
incorrectly entered; then
repress the “accept data” key
pad.
If the probe has been used
previously, the patient
information will appear on the
screen. Probes are reusable by the
same patient.
6. Wash hands and don nonsterile
gloves.
7. Administer sedation if necessary. Promotes patient comfort and ability The esophageal probe may cause
to tolerate the esophageal probe gagging.
insertion. Topical lidocaine may be used to
reduce gagging.
8. Apply a water-based lubricant on Minimizes mucosal injury and It is important that only water-soluble
6–10 cm of the distal end of the irritation during insertion; facilitates lubricant be used in probe
esophageal probe. insertion and aids in signal placement.
acquisition. Oil-soluble lubricant cannot be
absorbed through the pulmonary
mucosa and may cause respiratory
complications should the probe be
inadvertently placed in the lungs.
9. Insert the probe orally with the Begins the insertion process. Nasal insertion may also be
bevel edge toward the hard appropriate in select patients if oral
palate. insertion is contraindicated.
Insertion should never be forced.
Forceful insertion can cause mucosal
damage to the posterior pharynx or
the esophagus.
10. Utilize the depth markings on the Aids in proper probe depth Proper probe depth is essential to
esophageal probe to facilitate adjustment. obtain optimal aortic signal.
positioning. Generally the patient’s incisors should
be between the 35-cm and the
40-cm length markings.
Procedure for Esophageal Cardiac Output Monitoring: Perform—Continued

11. Observe the esophageal Doppler Enhances the accuracy of the probe The ideal waveform has a black
monitor and listen for an auditory insertion. center outlined with red and yellow.
signal to establish the optimal The sound pitch should be clear and
descending aortic waveform should correspond with the aortic
while rotating, inserting, and flow pattern noted on the monitor
withdrawing the probe until the screen.
ideal waveform appears and is
heard as the sharpest audible
pitch (see Figs. 68-1 and 69-1).
If unable to obtain an aortic
waveform, consider that the
probe may be in the trachea. If
this occurs, remove the probe and
attempt reinsertion.
12. Observe the peak velocity display The highest peak velocity is usually Use specific manufacturer’s
(PVD) on the monitor to assess associated with the best visual and recommendation for PVD (e.g.,
for the greatest peak velocity auditory signal. sharp upstroke with moderately
achieved. crisp peak to the waveform).
(Level M*)
13. Press the filter button to activate Eliminates visual and auditory low Use specific manufacturer’s
the signal artifacts filter when frequency signals (usually due to recommendations for noise filters.
appropriate. excess heart valve or wall motion
(Level M*) noise).
14. Press the auto gain button for Optimizes amplification of the Use specific manufacturer’s
optimal amplification of the waveform. recommendations for optimal
signal. waveform management.
(Level M*)
15. Press the scale button to change Aids in visualization of the waveform Use specific manufacturer’s
the waveform scale. display. recommendations for optimal
(Level M*) waveform visualization.
16. If activation of auto gain does not Indicates initiation of monitoring. A white arrow depicts the beginning
provide parameter display, press and end of systole and the peak
“run” after an optimal signal is velocity of each cycle.
obtained. A green line called the Use manufacturer’s recommendations
follower should hug the contour for beginning the monitoring
of the waveform. process.
(Level M*)
17. Record the displayed data from SD, PV, and FTc are direct Use specific manufacturer’s
the top of the EDM screen. measurements. recommendations for obtaining and
(Level M*) All other data are calculated from recording data.
these three measurements along
with body surface area.
Precautions.
19. HH
20. Compare SD, FTc, and PV values Determines hemodynamic status.
with normal values (see Table
69-1).


• Accurate placement of the esophageal probe • Oral, pharyngeal, or esophageal mucosal tears;
• Adequate and appropriate waveforms ulceration; or infections
• Ability to obtain accurate information regarding • Hematoma
hemodynamic parameters • Hemoptysis
• Evaluation of information obtained to guide • Hemorrhage
therapeutic interventions • Probe placed into the trachea or bronchus
• Vagal response during insertion or from gagging
• Vomiting or aspiration
• Esophageal-tracheal fistula formation
• Pain

interventions.
1. Perform systematic cardiovascular Obtains baseline data and assesses • Changes in level of consciousness
and neurological assessments patient status. Assesses for signs of • Changes in vital signs
before, during, and after the adequate perfusion. Evaluates • Abnormal hemodynamic
insertion of the probe. patient response to the procedure parameters
and medications administered.
2. Monitor the patient’s mouth for Identifies skin breakdown. • Redness, ulceration
signs of trauma from the probe • Swelling, drainage
insertion. • Foul odor
• Bleeding
• Skin breakdown
3. Perform oral care every 2 hours Oral tubes tend to cause mouth • Patient unable to tolerate
and as needed while the probe is in dryness and increase the potential esophageal probe placement (e.g.,
place. for mucosal breakdown. inability to relieve gagging,
The esophageal probe may be left anxiety)
in place if tolerated; the probe
usually does not require taping to
maintain placement.
4. Follow institutional standards for Identifies need for pain interventions. • Unrelieved patient discomfort
assessing pain. Administer Promotes patient comfort.
5. Monitor aortic waveforms while Ensures proper probe placement. • Abnormal waveforms
the esophageal probe is in place.
Waveforms should be assessed
when data collection is needed,
such as every hour.
Documentation
• Patient and family education • Patient tolerance of the procedure
• Signed informed consent • Hemodynamic data obtained
• Appearance of waveforms • Occurrence of unexpected outcomes
• Sedatives or analgesia administered • Nursing interventions taken

68 Esophageal Cardiac Output Monitoring: Perform 589.e1
Additional Readings Marik P: Techniques for assessment of intravascular volume in

Agency for Healthcare Research and Quality: Esophageal critically ill patients. Intensive Care Med 24(5):329–337,
Doppler ultrasound-based cardiac output monitoring 2009.
for real-time therapeutic management of hospitalized Mowatt G, et al: Systematic review of the clinical
patients – a review, 2007. <http://www.cms.hhs.gov/ effectiveness and cost-effectiveness of oesophageal
determinationprocess/downloads/id45TA.pdf>. (Accessed Doppler monitoring in critically ill and high-risk surgical
14.02.10.) patients. Health Technol Assess 13(7):1–134, 2009.
Ahrens T: Hemodynamics in sepsis. AACN Adv Crit Care Prentice D, Sona C: Esophageal Doppler monitoring for
17(4):435–445, 2006. hemodynamic assessment. Crit Care Nurs Clin North Am
Ahrens T: Stroke volume optimization vs central venous 18:189–193, 2006.
pressure in fluid management. Crit Care Nurse 30(2):71– Roche A, Miller T, Gan T: Goal-directed fluid management
73, 2010. with trans-oesophageal Doppler. Best Pract Res Clin
Deltex Medical: Cardiac function and fluid status monitoring Anaesthesiol 23:327–334, 2009.
system. In Deltex medical operating handbook, Greenville, Schober P, Loer S, Schwarte L: Perioperative hemodynamic
SC, 2012, Deltex Medical. monitoring with transesophageal Doppler technology.
Johnson A, Mohajer-Esfahani M: Exploring hemodynamics. Anesth Analg 109:340–353, 2009.
A review of current and emerging noninvasive monitoring Turner M: Doppler-based hemodynamic monitoring.
techniques. Crit Care Nurs Clin North Am 26:357–375, A minimally invasive alternative. AACN Clin Issues
2014. 14(2):220–231, 2003.
Lough M: Hemodynamic monitoring: Evolving technologies
and clinical practice, St. Louis, MO, 2015, Elsevier.
PROCEDURE
69
Esophageal Cardiac Output
Monitoring: Assist, Care,
and Removal
PURPOSE: Esophageal Doppler monitoring of aortic blood flow is used to assess
the hemodynamic condition of critically ill patients. Esophageal cardiac output or
esophageal Doppler monitoring (EDM) uses Doppler ultrasound technology to
provide information regarding left ventricular performance and patient fluid status.
PREREQUISITE NURSING • A reduced waveform height with a narrow waveform base

KNOWLEDGE may indicate elevation in systemic vascular resistance
(SVR).
• Knowledge of cardiovascular anatomy and physiology is • Optimal positioning of the probe is essential for accurate
needed. data collection (refer to Procedure 68)
• Understanding of the anatomy of the upper gastrointesti- • EDM technology uses a thin silicone probe, approxi-
nal tract is essential. mately 6 mm in diameter and 90 cm in length.
• The ability to recognize the EDM aortic waveforms by • Once the patient’s age, height, and weight are entered into
visual display and auditory pitch is necessary. the monitor, they are burned into a memory chip within
• An understanding of normal and associated values aortic the probe. EDM nomogram limits are:
waveforms is important (Table 69-1 and Fig. 68-1). ❖ Age: 16 to 99 years
• An understanding of additional waveforms that guide ❖ Weight: 66 to 330 pounds
esophageal probe insertion is needed (Fig. 69-1). ❖ Height: 59 to 83 inches
• Understanding of the technique and importance of obtain- • When nomogram limits are surpassed, calculated data
ing an optimal signal is needed. such as SVR, SV, stroke volume index (SVI), CO, and
• Clinical and technical competence in understanding the cardiac index (CI) are not obtainable. Velocity data such
esophageal Doppler monitor functions and options is as FTc, PV, SD, and MD will still be measured. Refer to
needed. specific manufacturer’s nomogram limits.
• Corrected flow time (FTc), peak velocity (PV), and stroke
distance (SD) come directly from the Doppler velocity EQUIPMENT
measurements; stroke volume (SV) and cardiac output
(CO) are derived using an algorithm generated from the • EDM monitor, patient interface cable, power cord
patient nomogram information (see Table 69-1). • EDM probe
• The base of the waveform is used as a marker of left • Water-soluble lubricant
ventricular preload and displayed as FTc. • Nonsterile gloves
• The waveform height is used as a marker of contractility Additional equipment, to have available as needed, includes
and is displayed as PV. the following:
• Minute distance (MD) is the distance (cm) moved by the ❖ Topical lidocaine
column of blood through the aorta in 1 minute. ❖ Tongue blade
• SD is the distance (cm) moved by the column of blood ❖ Supportive equipment if conscious sedation is neces-
through the aorta in one systolic period. sary (e.g., oxygen, Ambu bag, suction, oral airway)
• A narrowed waveform base with decreased FTc may indi- ❖ Gown, mask, and goggles or face shield
cate hypovolemia. ❖ Sedatives or analgesics as necessary
• A widened waveform base with increased FTc may indi-
cate euvolemia. PATIENT AND FAMILY EDUCATION
• A reduced waveform height with low PV may indicate left
ventricular failure. • Explain the procedure and the reason for the EDM moni-
• An increased waveform height with increased PV may toring. Rationale: This explanation increases patient
indicate a hyperdynamic state. understanding and may decrease patient anxiety.
590
69 Esophageal Cardiac Output Monitoring: Assist, Care, and Removal 591
• Explain that the procedure may stimulate gagging and that

TABLE 69-1 Normal Ranges for Measured
sedation may be given to promote comfort. Rationale:
Parameters Obtained From
This explanation prepares the patient and may decrease
Esophageal Doppler his or her anxiety.
Monitoring* • Explain the monitoring and troubleshooting procedures to
Corrected Flow Peak Velocity the patient and family. Rationale: This explanation keeps
Time (FTc) Age (PV)1,2 the patient and family informed and reduces their anxiety.
• Instruct the patient about signs and symptoms to report to
330–360 milliseconds 20 years 90–120 cm/sec the critical care nurse and staff, including oral bleeding,
30 years 85–115 cm/sec sore throat, and displacement of the probe. Rationale: This
40 years 80–110 cm/sec encourages the patient to report changes and problems.
50 years 70–100 cm/sec
60 years 60–90 cm/sec PATIENT ASSESSMENT AND
70 years 50–80 cm/sec PREPARATION
80 years 40–70 cm/sec Patient Assessment
90 years 30–60 cm/sec • Assess the patient’s hemodynamic, cardiovascular, periph-
*Note: Normal ranges should not be confused with a physiological target. eral vascular, and neurovascular status. Rationale: This
1
Singer, M (1993). Esophageal Doppler monitoring of aortic blood flow: assessment provides baseline data that can be used for
Beat-by-beat cardiac output monitoring. Inter Anaesthesia Clin 31; 99–125. comparison with postinsertion data.
Normal range values appear in bold. • Assess the patient’s current laboratory profile, including
2
Gardin, J.M., Davidson, D.M., Rohan, M.K., et al. Relationship between age, electrolyte and coagulation studies. Rationale: Baseline
body size, gender, and blood pressure and Doppler flow measurements in the
coagulation studies are helpful in determining the risk for
aorta and pulmonary artery. Am Heart J 113; 101–109. Extrapolated values do
not appear in bold. bleeding. Electrolyte abnormalities may contribute to
cardiac irritability.
C
Figure 69-1 Additional waveforms that guide esophageal probe insertion. A, Celiac axis: Probe
too low. B, Intracardiac: Rotate probe. Adjust depth as necessary. C, Azygos vein: Correct depth or
slightly low. Rotate and/or withdraw probe slightly. (From the EDM Quick Reference Guide, with
kind permission of Deltex Medical, Greenville, SC.)
Patient Preparation process evaluates and reinforces understanding of previ-

• Verify that the patient is the correct patient using two ously taught information.
identifiers. Rationale: Before performing a procedure, the • Ensure that informed consent was obtained. Rationale:
nurse should ensure the correct identification of the patient Informed consent protects the rights of the patient and
for the intended intervention. ensures that he or she can make a competent decision.
• Ensure that the patient and/or family understand the pre- • Administer sedation, analgesia, and local anesthetics as
procedural information. Answer questions as they arise prescribed. Rationale: This may decrease the pain, anxiety
and reinforce information as needed. Rationale: This and gagging that occurs with probe manipulation.
Procedure for Esophageal Cardiac Output Monitoring: Assist, Care, and Removal
1. HH
2. Ensure that the esophageal Provides the energy source.
Doppler monitor is plugged into
the wall outlet and is turned on.
3. Ensure that the interface cable is Prepares the equipment.
connected to the esophageal
Doppler monitor and that the
esophageal probe is connected to
the interface cable.
4. If needed, assist with entering Prepares the monitor. The monitor Data must be in these ranges:
patient information into the will confirm data entry and change Age: 16–99 years
esophageal Doppler (i.e., patient’s to the probe focus mode. Weight: 66–330 pounds
age, weight, and height). Height: 59–83 inches
If the probe has been used If a patient’s data are outside the
previously, the patient nomogram limits, estimated values
information will appear on the cannot be obtained but velocity data
screen. Probes are reusable by the are available.
same patient.
A. Turn the control knob to Refer to the manufacturer’s
change the values. recommendations for nomograms.
B. Press the control knob to
enter the selected values.
C. Push the keypad under the
words “accept data.”
If any data are incorrect, press
“change data” to return to the
nomogram screen and change any
data that have been incorrectly
entered; then repress the “accept
data” key pad.
5. Wash hands and don nonsterile
gloves.
6. Administer sedation, analgesia, Decreases the patient’s anxiety, The esophageal probe may cause
and topical anesthetics as promotes patient comfort and the gagging.
prescribed and as needed. ability to tolerate the esophageal Topical lidocaine may be used to
probe insertion. reduce gagging.
7. Assist, if needed, with probe Provides needed assistance.
insertion.
8. Monitor the patient’s response to Ensures that the patient is able to
probe insertion. tolerate the procedure.
Procedure for Esophageal Cardiac Output Monitoring: Assist, Care, and

Removal—Continued
9. Assist as needed with comparing Increases and decreases in SD, PV, or Follow manufacturer’s
the EDM values to normal values FTc depict specific hemodynamic recommendations for normal values
and the patient’s baseline values. physiology. and interpretation.
Normal values should not be confused
with physiological targets (see
Table 69-1).
10. Administer IV fluids and/or Provides interventions to improve
vasoactive agents as prescribed. cardiac output.
11. Validate the effectiveness of Values may show the need for therapy It is important that the probe is
medical therapy by obtaining adjustments. refocused before each patient
values again after the prescribed assessment, ensuring an optimal
therapy has been completed. signal.
12. If prescribed and tolerated by the Continues monitoring. A physician, advanced practice nurse,
patient, leave the probe in place or other healthcare professional
throughout therapy adjustments. may need to adjust the position of
the esophageal probe.
The probe can also be removed and
replaced as needed.
Follow institution standard.
Precautions.
14. HH
Finding the Maximum Flow
1. HH
2. PE
3. Adjust the volume control knob Auditory signals are necessary for
on the esophageal Doppler accurate probe placement.
monitor.
4. Grasp the probe gently in one Manipulates the position of the
hand. esophageal probe.
5. Rotate left and right and then Facilitates locating the appropriate A physician, advanced practice nurse,
slowly pull back and insert the aortic signal. or other healthcare professional
probe while listening for the may need to adjust the position of
sharpest audible pitch associated the esophageal probe.
with the highest peak velocity. Follow institution standard.
The esophageal probe should be
adjusted until the sharpest aortic
waveform possible is obtained, in
terms of both visual display and
audible pitch.
Precautions.
7. HH
Troubleshooting the Absence of the Aortic Waveform
1. HH
2. PE
3. Locate the depth markings to An optimal waveform is obtained
check that the probe has not been when the distance to aortic flow is
dislodged. closest.
4. Ensure the monitor, cable, and Loose connections will distort values.
probe are all connected
appropriately.
Procedure for Esophageal Cardiac Output Monitoring: Assist, Care, and

Removal—Continued
5. Readjust the esophageal probe as Ensures accurate positioning. A physician, advanced practice nurse,
needed according to the or other healthcare professional
insertional procedure. may need to adjust the position of
the esophageal probe.
Precautions.
7. HH
Removal of the Esophageal Probe
1. HH Reduces transmission of A physician, advanced practice nurse,
microorganisms; Standard or other healthcare professional
Precautions may need to remove the esophageal
probe.
2. PE
3. Gently pull the esophageal probe Careful removal decreases the
from the esophagus and mouth. possibility of causing mucosal tears.
4. Place the probe in a clean Probes may be used on an intermittent
container or wrap it for future basis.
reuse.
Precautions.
6. HH

• Accurate placement of the esophageal probe • Oral, pharyngeal, or esophageal mucosal tears;
• Adequate and appropriate waveforms ulceration; or infections
• Ability to obtain accurate information regarding • Hematoma
hemodynamic parameters • Hemoptysis
• Evaluation of information obtained to guide • Hemorrhage
therapeutic interventions • Probe placed into the trachea or bronchus
• Vagal response during insertion or from gagging
• Vomiting or aspiration
• Esophageal-tracheal fistula formation
• Pain

interventions.
1. Perform systematic cardiovascular Obtains baseline data and assesses • Changes in level of consciousness
and neurological assessments patient status. Assesses for signs of • Changes in vital signs
before, during, and after the adequate perfusion. Evaluates • Abnormal hemodynamic
insertion of the probe. patient response to the procedure parameters
and medications administered.
2. Monitor the EDM waveforms Provides assessment of proper • Abnormal waveforms
while the esophageal probe is in placement of the probe; normal and
place. abnormal waveforms.

3. Monitor hemodynamic status as Guides therapy • Changes in hemodynamic
frequently as prescribed and as monitoring values
needed (e.g., SV, CO, CI, SVR,
FTc, PV). Follow institution
standard.
4. Assess EDM waveforms and Identifies that troubleshooting has • Unsuccessful troubleshooting
values before and after been successful. attempts
troubleshooting.
Assess waveforms when data
collection is needed, such as every
hour. Follow institution standard.
5. Perform oral care every 2 hours Oral tubes tend to cause mouth • Patient unable to tolerate
and as needed while the probe is in dryness, which increases the esophageal probe placement (e.g.,
place. potential for mucosal breakdown. inability to relieve gagging,
The esophageal probe may be left anxiety)
in place if tolerated; the probe
usually does not require taping to
maintain placement.
6. Follow institutional standards for Identifies need for pain interventions. • Unrelieved patient discomfort
assessing pain. Administer Promotes patient comfort.
Documentation
• Patient and family education • Pain
• Appearance of waveforms • Site assessment
• Sedatives or analgesia administered • Occurrences of unexpected outcomes and
• Hemodynamic data obtained interventions
• Patient tolerance

69 Esophageal Cardiac Output Monitoring: Assist, Care, and Removal 595.e1
Additional Readings Marik P: Techniques for assessment of intravascular volume in

Agency for Healthcare Research and Quality: Esophageal critically ill patients. Intensive Care Med 24(5):329–337,
Doppler ultrasound-based cardiac output monitoring for 2009.
real-time therapeutic management of hospitalized patients Mowatt G, et al: Systematic review of the clinical
– a review, 2007. <http://www.cms.hhs.gov/ effectiveness and cost-effectiveness of oesophageal
determinationprocess/downloads/id45TA.pdf> (Accessed Doppler monitoring in critically ill and high-risk surgical
14.02.10.) patients. Health Technol Assess 13(7):1–134, 2009.
Ahrens T: Hemodynamics in sepsis. AACN Adv Crit Care Prentice D, Sona C: Esophageal Doppler monitoring for
17(4):435–445, 2006. hemodynamic assessment. Crit Care Nurs Clin North Am
Ahrens T: Stroke volume optimization vs central venous 18:189–193, 2006.
pressure in fluid management. Crit Care Nurse 30(2):71– Roche A, Miller T, Gan T: Goal-directed fluid management
73, 2010. with trans-oesophageal Doppler. Best Pract Res Clin
Deltex Medical: Cardiac function and fluid status monitoring Anaesthesiol 23:327–334, 2009.
system. In Deltex medical operating handbook, Greenville, Schober P, Loer S, Schwarte L: Perioperative hemodynamic
SC, 2012, Deltex Medical. monitoring with transesophageal Doppler technology.
Johnson A, Mohajer-Esfahani M: Exploring hemodynamics. Anesth Analg 109:340–353, 2009.
A review of current and emerging noninvasive monitoring Turner M: Doppler-based hemodynamic monitoring.
techniques. Crit Care Nurs Clin North Am 26:357–375, A minimally invasive alternative. AACN Clin Issues
2014. 14(2):220–231, 2003.
Lough M: Hemodynamic monitoring: Evolving technologies
and clinical practice, St. Louis, MO., 2015, Elsevier.
PROCEDURE
70
Noninvasive Cardiac
Output Monitoring
Susan Scott
PURPOSE: Noninvasive cardiac output monitoring is a technology that can be
used to obtain hemodynamic data on a continuous basis without the use of an
invasive procedure.
PREREQUISITE NURSING has been validated in postcardiac surgery patients,10 care

KNOWLEDGE must be taken when interpreting data via this method with
other patient populations because researchers have reported
• Knowledge of the anatomy and physiology of the cardio- conflicting results.4,7,8,11,16
vascular system is necessary. • Bioreactance, another method, estimates cardiac output
• Knowledge of the anatomy and physiology of the vascu- noninvasively by analysis of the frequency spectra varia-
lature and adjacent structures is needed. tions of a delivered oscillating current.
• Understanding of the pathophysiologic changes that occur • Signal stability of both bioimpedance and bioreactance
in heart disease and affect flow dynamics is necessary. may fail after 24 hours.15
• Understanding of the hemodynamic effects of vasoactive • Another method, ultrasonic cardiac output monitoring,
medications and fluid resuscitation is needed. uses a continuous wave Doppler monitor using a probe
• Understanding of the principles involved in hemodynamic applied to the chest. The cardiac output is calculated from
monitoring is necessary.3 the cross-sectional area of either the aortic or pulmonic
• Understanding of the appropriateness, criteria, and contra- valve using a software nomogram. A report of a meta-
indications of the use of noninvasive cardiac output is analysis of this method revealed results comparable to that
important. of thoracic bioimpedance in the perioperative and critical
• Knowledge of the principles of noninvasive cardiac output care settings.5
monitoring is essential.3 • A fourth type of noninvasive cardiac output device obtains
• Knowledge of definitions and norms for cardiac output, a cardiac output based on arterial pressure pulse contour
cardiac index, systemic vascular resistance, stroke volume, analysis. It works via an inflatable cuff wrapped around a
stroke index, preload, afterload, and contractility is finger, along with a device that measures the diameter of
necessary. the arteries in the finger. With each systole, the device
• Arterial pressure represents the forcible ejection of blood senses the increase in diameter of the arteries and inflates
from the left ventricle into the aorta and out into the arte- the cuff to keep the diameter of the arteries constant. The
rial system. accuracy of this method has been validated during and
• Noninvasive cardiac output methods are easy to use and after cardiac surgery.1,4,5,11 Its reliability for tracking the
there is little if any risk associated with their application. effects of a fluid challenge has been questioned,14 and
• Noninvasive cardiac output methods are typically com- although it is not interchangeable with transpulmonary
pared with the thermodilution method because this is con- thermodilution cardiac output, trending the values corre-
sidered the “gold standard” for determining cardiac lates well with it.2,6,7,11,13
output.12
• One noninvasive cardiac output method is bioimpedance EQUIPMENT
cardiography. This involves the application of electrodes
placed on the skin or the endotracheal tube.12 Bioimpedance • Electrocardiographic (ECG) monitor (i.e., hardwire or
cardiography is based on measurements of the resistance telemetry); may also include transport ECG monitor
to the transmission of electrical currents.1,9,10,12,15 In the • ECG lead wires, which may or may not be disposable
body, blood and plasma are channels of low resistance to • Skin electrodes, pregelled and disposable
electrical current, whereas heart muscle, lungs, and fat • Noninvasive cardiac output monitor
have higher resistance.1 When the current is applied, if • Noninvasive cardiac output cables
blood is being ejected from the heart, the impedance to • Noninvasive electrodes and probes
flow decreases. During diastole, when the heart is filling, Additional equipment, to have available as needed, includes
impedance returns to baseline. Some bioimpedance devices the following:
involve obtaining whole body bioimpedance, whereas • Emergency equipment and medications
others use thoracic bioimpedance. Although this method • Arm board
596
70 Noninvasive Cardiac Output Monitoring 597

PREPARATION
• Explain the rationale for noninvasive cardiac output moni-
toring, including how the reading is displayed at the Patient Assessment
bedside. Rationale: This explanation may decrease patient • Obtain the patient’s medical history, including any perfu-
and family anxiety. sion problems to the upper extremities. Rationale: This
• Explain the standard of care to the patient and family, provides baseline information and may aid in selecting the
including application of the monitoring device, alarms, extremity for monitoring. Decreased perfusion may impair
and length of time the technology is expected to be uti- the signal to the selected extremity.
lized. Rationale: This explanation encourages the patient • Assess the patient’s vital signs and compliance factors
and family to ask questions and voice concerns about the (e.g., age, gender, height, weight). Rationale: This assess-
procedure and decreases patient and family anxiety. ment provides baseline data and information that needs to
• Explain the patient’s expected participation during the be entered into the noninvasive cardiac output monitor.
procedure. Rationale: Patient cooperation during use of
the device is encouraged. Patient Preparation
• Explain the importance of keeping the affected extremity • Ensure that the patient and family understand preprocedural
immobile based on the technology utilized. Rationale: This teachings. Answer questions as they arise, and reinforce
explanation helps the patient to understand the importance information as needed. Rationale: Understanding of previ-
of the device and ensures an accurate waveform. ously taught information is evaluated and reinforced.
• Instruct the patient to report any discomfort related to the • Verify that the patient is the correct patient using two
device. Rationale: There should be no to minimal discom- identifiers. Rationale: Before performing a procedure, the
fort associated with this technology. nurse should ensure the correct identification of the patient
Procedure for Noninvasive Cardiac Output Monitoring

Noninvasive Cardiac Output Monitoring Using the Bioimpedence or Bioreactance Method
1. HH
2. PE
3. Apply the electrodes to the Proper electrode placement is needed Follow the manufacturer’s guidelines
patient’s chest, endotracheal tube for acquisition of accurate regarding the exact locations for
if using endotracheal hemodynamic data. electrode placement.
bioimpedance cardiography, and
neck based on the manufacturer’s
instructions. (Level M*)
4. Turn on the noninvasive cardiac Prepares the equipment.
output monitor.
5. Input the specific patient data as The data are used to calculate
required by the noninvasive hemodynamic parameters.
cardiac output monitor.
(Level M*)
6. Observe the waveforms and data Accurate hemodynamic calculations Follow manufacturer’s guidelines.
displayed on the monitor. are dependent on quality input.
(Level M*)
Precautions.
8. HH

Procedure for Noninvasive Cardiac Output Monitoring—Continued

Noninvasive Cardiac Output Monitoring Using the Arterial Pressure Contour Analysis Method
1. HH
2. PE
3. Determine the correct finger cuff Proper application of the pressure cuff
size and apply the cuff to the is needed for acquisition of accurate
middle phalanx of either the hemodynamic data.
index, middle, or ring finger.
A. Apply the finger cuff snugly
enough so that the cuff does
not move.
B. The image of the finger on the
cuff should be just proximal
to the fingernail.
(Level M*)
4. Lead the cuff cable and the Positions the cable and the hose to
pneumatic hose around the finger facilitate connection to the wrist
to the dorsum of the hand. unit.
5. Apply the wrist unit and attach Secures the equipment. The wrist unit can be applied to an
the connectors. arm board alongside the wrist.
Avoid overtightening the arm board to
the wrist.
6. Attach the pneumatic hose and Prepares the equipment.
the electronic connector to the
wrist unit.
7. Connect the heart reference Prepares the equipment.
sensor to its port on the wrist
unit.
8. Put the finger strap of the heart Prepares the equipment.
reference sensor on the index
finger.
9. Turn on the noninvasive cardiac Prepares the equipment.
output monitor.
10. Enter the specific patient data as These data are used to calculate Press the measurement button to enter
required by the noninvasive hemodynamic data. the data.
cardiac output monitor (i.e.,
gender, height, weight, and age).
(Level M*)
11. Zero the sensor: Prepares the system.
A. Place the heart end of the Keep the heart reference sensor next
heart reference sensor next to to the other end of the sensor that is
the finger end of the sensor. on the patient’s finger.
B. Press the hand icon on the
screen.
C. Press the “zero HRS” key on
the lower left-hand corner of
the screen and press the
“next” key, which appears in
the dialogue box on the
screen. Then press the “zero”
button. Once zeroing is
complete, press the “finish”
button.

70 Noninvasive Cardiac Output Monitoring 599
Procedure for Noninvasive Cardiac Output Monitoring—Continued

12. Attach the heart reference sensor Prepares the system. The sensor may also be attached to a
to the patient at the level of the stationary object at the level of the
heart. heart.
13. Press the “start” key at the lower It takes 20 seconds for the Data are upgraded over five cardiac
right-hand corner of the screen noninvasive cardiac output heartbeats and are updated every
and, after approximately 20 monitoring device to provide two cardiac heartbeats.
seconds, data will be displayed. accurate hemodynamic calculations.
14. Set alarms. Alerts the nurse to important
hemodynamic changes.
15. Tap on the display screen over a This permits the nurse to see each
given parameter. parameter value.
16. Press “stop” to discontinue Stops all noninvasive cardiac output Do not remove the finger cuff before
monitoring. monitoring. stopping the system. Removal
while the system is still on can
result in damage to the cuff.
Precautions.
18. HH

• Generation of reliable, continuous hemodynamic data, • Inability to accurately monitor hemodynamic
including cardiac output, cardiac index, and systemic parameters
vascular resistance. • Hemodynamic data do not reflect clinical
• Hemodynamic data are incorporated into patient presentation
assessment, diagnosis, and therapeutic interventions

interventions.
1. Continuously monitor heart rate Provides assessment of patient status. • Abnormal heart rate
and rhythm. • Dysrhythmias
2. Obtain vital signs per institutional Provides assessment of patient status. • Abnormal heart rate
standards and as needed. • Abnormal blood pressure
• Abnormal respirations
3. Obtain cardiac indices as Provides assessment of patient’s • Abnormal cardiac output and
prescribed or per institutional hemodynamic status. cardiac index
standards. • Abnormal systemic vascular
resistance
Documentation
• Patient and family education • Vital signs, cardiac output, cardiac index, and other
• Peripheral vascular and neurovascular assessment hemodynamic parameters
• Pain assessment, interventions, and effectiveness • Unexpected outcomes
• Additional nursing interventions

70 Noninvasive Cardiac Output Monitoring 600.e1
References 9. Engoren M, Barbee D: Comparison of cardiac output

1. Albert N: Bioimpedence cardiography measurements of determined by bioimpedance, thermodilution and
cardiac output and other cardiovascular parameters. Crit the Fick method. Am J Crit Care 14(1):40–45, 2005.
Care Nurs Clin North Am 18:195–202, 2006. 10. Gujjar A, et al: Noninvasive cardiac output by
2. Ameloot K, VanDeVijver K, Broch O: Nexfin noninvasive transthoracic electrical bioimpedance in post-cardiac
continuous hemodynamic monitoring: Validation against surgery patients: Comparison with thermodilution method.
continuous pulse contour and intermittent transpulmonary J Clin Monit Comput 22(3):175–180, 2008.
thermodilution derived cardiac output on critically ill 11. Hofhuizen C, et al: Validation of noninvasive pulse
patients. ScientificWorldJournal 11:519080, 2013. contour cardiac output using finger arterial pressure in
3. Alhashemi J, Cecconi M, Hofer C: Cardiac output cardiac surgery patients requiring fluid therapy. J Crit
monitoring: An integrative perspective. Crit Care Care 1(29):161–165, 2014.
15(2):214, 2011. 12. Lee A, Hochman Chon J, Ranasinghe J: Cardiac output
4. Ball T, et al: Comparison of the endotracheal cardiac assessed by invasive and minimally invasive techniques.
output monitor to thermodilution in cardiac surgery Anesthesiol Res Pract 1–17, 2011.
patients. J Cardiothorac Vasc Anesth 24:762–766, 2010. 13. Martina JR, et al: Noninvasive continuous arterial blood
5. Bendjelid K, et al: Performance of a new pulse contour pressure monitoring with Nexfin. Anesthesiology
method for continuous cardiac output monitoring: 116(5):1092–1103, 2012.
Validation in critically ill patients. Br J Anaesth 14. Monnet X, et al: The estimation of cardiac output by the
111(4):573–579, 2013. Nexfin device is of poor reliability for tracking the effects
6. Broch O, et al: A comparison of the Nexfin® and of a fluid challenge. Crit Care 16(5):R212, 2012.
transcardiopulmonary thermodilution to estimate cardiac 15. Porhomayon J, El-Solh A, Papadakos P: Cardiac output
output during coronary artery surgery. Anaesthesia monitoring devices: An analytic review. Intern Emerg
67(4):377–383, 2012. Med 7(2):163–171, 2012.
7. Chen G, Meng L, Alexander B: Comparison of 16. Trinkman F, et al: Is arterial pulse contour analysis using
noninvasive cardiac output measurements using Nexfin Nexfin a new option in the noninvasive measurement of
monitoring device and esophageal Doppler. J Clin Anesth cardiac output? A pilot study 27(2):283–287, 2013.
24:275–283, 2012.
8. Chong S, Peyton P: A meta-analysis of the accuracy and
precision of the ultrasonic cardiac output monitor.
Anaesthesia 67:1266–1271, 2012.
PROCEDURE
71
Insertion (Perform)
Nikki Taylor
PURPOSE: Pulmonary artery (PA) catheters are used to determine hemodynamic
status in critically ill patients. PA catheters provide information about right-sided
and left-sided intracardiac pressures and cardiac output. Additional functions
available are fiberoptic monitoring of mixed venous oxygen saturation (SvO2),
intracardiac pacing, and assessment of right-ventricular volumes and ejection
fraction.
PREREQUISITE NURSING (CO), cardiac index (CI), systemic vascular resistance

KNOWLEDGE (SVR), pulmonary vascular resistance (PVR), stroke
volume/stroke index), Svo2, right-heart pressures (pulmo-
• Knowledge of the normal anatomy and physiology of the nary artery pressure [PAP] and RAP), and PAOP, a reflec-
cardiovascular and pulmonary systems is needed. tion of left-ventricular end-diastolic pressure and volume.
• Knowledge of the normal anatomy and physiology of Also, information regarding right-ventricular ejection
the vasculature and adjacent structures of the neck is fraction and end-diastolic volume can be determined with
necessary. specific PA catheters.
• Knowledge of the principles of sterile technique is essen- • CO, CI, and Svo2 can be measured intermittently or
tial. continuously.
• Clinical and technical competence in central line insertion • There are several types of PA catheters with different
and suturing is important. functions (e.g., pacing, Svo2 monitoring, continuous CO,
• Clinical and technical competence in PA catheter insertion or right-ventricular volume monitoring). Catheter selec-
is essential. Competence in chest radiograph interpretation is based on patient need.
tion is needed. • The PA catheter contains a proximal lumen port, a distal
• Basic dysrhythmia recognition and treatment of life- lumen port, a thermistor connector, and a balloon inflation
threatening dysrhythmias should be understood. lumen port (see Fig. 72-1). Some catheters also have addi-
• Advanced cardiac life support (ACLS) knowledge and tional infusion ports that can be used for the infusion of
skills are needed. medications and intravenous fluids.
• Understanding of PA pressure monitoring (see Procedure • The distal lumen port is connected to a transducer system
72) is required. to monitor systolic, diastolic, and mean PA pressures, and
• Hemodynamic information obtained with a PA catheter is can be accessed to obtain mixed venous blood samples for
routinely used to guide therapeutic interventions, includ- analysis or calibration of Svo2 for continuous monitoring.
ing administration of fluids and diuretics, and titration of The proximal lumen (or injectate lumen) port is connected
vasoactive and inotropic medications.1–3,12,13 to a transducer system to monitor the right-atrial pressure
• Interpretation of right-atrial pressure (RAP)/central and is accessed to inject solution when measuring thermo-
venous pressure and pulmonary arterial occlusion pres- dilution cardiac outputs. The balloon inflation lumen port
sure (PAOP) waveforms including identification of a, c, is accessed to inflate the balloon with air to advance (float)
and v waves is needed. The a wave reflects atrial contrac- the catheter tip to occlude forward flow through the PA
tion. The c wave reflects closure of the atrioventricular and measure PAOP or pulmonary artery wedge pressure.
valves. The v wave reflects passive filling of the atria • The standard 7.5 Fr PA catheter is 110 cm long, and has
during ventricular systole. black markings at 10-cm increments and wide black mark-
• Directly measured or calculated hemodynamic data ings at 50-cm increments to facilitate insertion and posi-
obtained from the PA catheter include cardiac output tioning (see Fig. 72-1). The catheter should reach the PA
after advancing 40 to 55 cm from the internal jugular vein,
35 to 50 cm from the subclavian vein, 60 cm from the
femoral vein, 70 cm from the right antecubital fossa, and
practice nurses, and other healthcare professionals (including critical care 80 cm from the left antecubital fossa.
nurses) with additional knowledge, skills, and demonstrated competence per • Central venous access for PA catheter insertion may be
professional licensure or institutional standard. obtained at a variety of sites (see Procedure 82).
601
• The right subclavian vein is a more direct route than the ❖ Anesthesia in cardiac surgery with any of the following:
left subclavian vein for placement of a PA catheter because Evidence of previous MI
the catheter does not cross the midline of the thorax.1,2,9,15 Resection of ventricular aneurysm
• Use of an internal jugular vein minimizes the risk for a Coronary artery bypass graft (reoperation)
pneumothorax. The preferred site for catheter insertion is Coronary artery bypass graft (left main or complex
the right internal jugular vein. The right internal jugular coronary disease)
vein is a “straight shot” to the right atrium.15 Complex cardiac surgery (multivalvular surgery)
• Knowledge of West’s lung zones helps identify optimal High-risk surgery (e.g., pulmonary hypertension)
physiological zones to obtain data from the PA catheter ❖ General surgery:
(Fig. 71-1). The PA catheter tip should be positioned in Vascular procedures (abdominal aneurysm repair,
lung zone 3, below the level of the left atrium in the aortobifemoral bypass)
dependent portion of the lung.19 In lung zone 3, both pul- Patients at high risk1,15,17
monary arterial and venous pressures exceed alveolar Hypotensive anesthesia1
pressure, resulting in the PAOP reflecting left-atrial pres- ❖ Cardiac disorders:
sures rather than alveolar pressures.19 Unstable angina that necessitates vasodilator therapy
• Common indications for insertion of a PA catheter include Heart failure unresponsive to conventional therapy
the following:1,2,7,8,10,11,14,16,18 (cardiomyopathy)1,2,18
❖ Acute coronary syndrome or myocardial infarction Management of heart failure
(MI) complicated by hemodynamic instability, heart Cardiogenic shock
failure, cardiogenic shock, mitral regurgitation, ventral Potentially reversible systolic heart failure, such as
septal rupture, subacute cardiac rupture with tampon- fulminant myocarditis and peripartum cardiomy-
ade, postinfarction ischemia, papillary muscle rupture, opathy
or severe heart failure (e.g., cardiomyopathy, constric- Pulmonary hypertension during acute medication ther-
tive pericarditis) apy
❖ Hypotension unresponsive to fluid replacement or with Distinguishing cardiogenic from noncardiogenic pul-
heart failure monary edema
❖ Cardiac tamponade, significant dysrhythmias, right- Constrictive pericarditis or cardiac tamponade
ventricular infarct, acute pulmonary embolism, and Evaluation of pulmonary hypertension for a precar-
tricuspid insufficiency diac transplant workup
Apex
Alveolus Zone 1
(minimal
perfusion)
Capillary
Zone 2
(intermittent
Pulmonary perfusion)
artery
Pulmonary Pulmonary
artery vein
(unoxygenated (oxygenated
blood) blood)
Pulmonary Zone 3
vein (continuous
perfusion)
Base
Figure 71-1 West’s lung zones. Schema of the heart and lungs demonstrating the relationship
between the cardiac chambers and the blood vessels and the physiological zones of the lungs. Zone
1 (PA > Pa > Pv): Absence of blood flow. Zone 2 (Pa > PA > Pv): Intermittent blood flow. Zone 3
(Pa > Pv > PA): Continuous blood flow, resulting in an open channel between the pulmonary artery
catheter and the left atrium. PA, pulmonary artery; Pa, pressure arterial; Pv, pressure venous. (From
Copstead LC, Banasik JL: Pathophysiology, ed 5. Philadelphia, 2014, Saunders.)
71 Pulmonary Artery Catheter Insertion (Perform) 603
Patients who need intraaortic balloon pump therapy

❖ • Transducer holder and intravenous pole
Pulmonary disorders:
❖ • Heparin
Acute respiratory failure with chronic obstructive • 3-mL syringe
pulmonary diseases • Chlorhexidine-impregnated sponge
Cor pulmonale with pneumonia
Optimization of positive end-expiratory pressure PATIENT AND FAMILY EDUCATION
and volume therapy in patients with acute respira-
tory distress syndrome1 • Explain the procedure and the reason for the PA catheter
❖ Critically ill pregnant patients (e.g., severe preeclamp- insertion. Rationale: Explanation may decrease patient
sia with unresponsive hypertension, pulmonary edema, and family anxiety.
persistent oliguria) • Explain the need for sterile technique and explain that the
❖ Severe shock states patient’s face may be covered. Rationale: The explanation
❖ Major trauma or burn decreases patient anxiety and elicits cooperation.
❖ Systemic inflammatory response syndrome • Inform the patient of expected benefits and potential risks.
• Relative contraindications to PA catheter insertion include Rationale: The patient is given information to make an
the following: informed decision.
❖ Preexisting left bundle-branch block • Explain the patient’s expected participation during the
❖ Presence of fever (>101°F [38°C]) procedure. Rationale: Patient assistance is encouraged.
❖ Mechanical tricuspid valve
❖ Severe coagulopathy
❖ Presence of an endocardial pacemaker PATIENT ASSESSMENT AND
❖ History of heparin-induced thrombocytopenia if only
PREPARATION
heparin-coated PA catheters are available
Patient Assessment
EQUIPMENT • Determine the patient’s medical history of cervical disk
disease or difficulty with vascular access. Rationale:
• Percutaneous sheath introducer kit and sterile catheter Baseline data are provided.
sleeve • Determine the patient’s medical history of pneumothorax
• PA catheter (non–heparin-coated catheters and latex-free or emphysema. Rationale: Patients with emphysematous
PA catheters are available) lungs may be at higher risk for puncture and pneumotho-
• Bedside hemodynamic monitoring system with pressure rax depending on the approach.
and cardiac output monitoring capability • Determine the patient’s medical history of anomalous
• Pressure modules and cables for interface with the monitor veins. Rationale: Patients may have a history of dextro-
• Cardiac output cable with a thermistor/injectate sensor cardia or transposition of the great vessels, which leads to
• Pressure transducer system, including flush solution rec- greater difficulty in catheter placement.
ommended according to institutional standards, a pressure • Assess the intended insertion site. Rationale: Scar tissue
bag or device, pressure tubing with transducers, and flush may impede placement of the catheter.
device (see Procedure 75) • Assess the patient’s cardiac and pulmonary status. Ratio-
• Dual-channel recorder nale: Some patients may not tolerate the supine position
• Sterile normal saline intravenous fluid for flushing the or Trendelenburg’s position for extended periods.
introducer and catheter-infusion ports • Assess vital signs and pulse oximetry. Rationale: Baseline
• Antiseptic solution (e.g., 2% chlorhexidine–based prepa- data are provided.
ration) • Assess for electrolyte imbalances (potassium, magne-
• Head covering, fluid-shield masks, sterile gowns, sterile sium, and calcium). Rationale: Electrolyte imbalances
gloves, nonsterile gloves, and full sterile drapes may increase cardiac irritability.
• 1% lidocaine without epinephrine • Assess the electrocardiogram (ECG) for left bundle-
• Sterile basin or cup branch block. Rationale: Right bundle-branch block has
• Sterile water or normal saline solution for checking been associated with PA catheter insertion. Caution should
balloon integrity be used because complete heart block may ensue.9,17
• Sterile dressing supplies • Assess for heparin and latex sensitivity or allergy. Ratio-
• Stopcocks (may be included with the pressure tubing nale: PA catheters are heparin bonded and contain latex.
systems) If the patient has a heparin allergy or a history of heparin-
• Sterile caps (injectable or noninjectable) induced thrombocytopenia, consider the use of a non–
• Leveling device (low-intensity laser or carpenter level) heparin-coated catheter.17,19 If the patient has a latex
Additional equipment, to have available as needed, includes allergy, use a latex-free PA catheter.
the following: • Assess for a coagulopathic state and determine whether
• Fluoroscope the patient has recently received anticoagulant or throm-
• Emergency equipment bolytic therapy. Rationale: These patients are more likely
• Temporary pacing equipment to have complications related to bleeding and may need
• Indelible marker interventions before insertion of the PA catheter.
• Perform a preprocedure verification and time out. Ratio-

Patient Preparation nale: Ensures patient safety.
• Verify that the patient is the correct patient using two • Prescribe sedation or analgesics as needed. Rationale:
identifiers. Rationale: Before performing a procedure, the Sedation and analgesics minimize anxiety and discomfort.
inserting provider should ensure the correct identification Movement of the patient may inhibit insertion of the PA
of the patient for the intended intervention. catheter.
• Ensure that the patient understands preprocedural teach- • If the patient is obese or muscular and the preferred site
ing. Answer questions as they arise, and reinforce infor- is the internal jugular vein or subclavian vein, place a
mation as needed. Rationale: Understanding of previously towel posteriorly between the shoulder blades. Rationale:
taught information is evaluated and reinforced. This action helps extend the neck and provide better
• Obtain informed consent. Rationale: Informed consent access to the subclavian and internal jugular veins.
protects the rights of a patient and makes a competent
decision possible for the patient.
Procedure for Performing Pulmonary Artery Catheter Insertion

1. HH
2. PE
3. Place the patient in the supine The site access is prepared for Ensure that the patient is in the
position and prepare the area with PA catheter insertion. Trendelenburg position (see Procedure
the antiseptic solution (e.g., 2% 82).
chlorhexidine–based
preparation).15,17
4. Perform hand hygiene and apply Minimizes the risk of infection All healthcare personnel involved in the
sterile gown and gloves. and maintains standard and procedure need to apply head
sterile precautions. coverings, fluid-shield masks, sterile
gowns, and gloves.
5. Place sterile drapes over the Prepares the sterile field. Fully drape the patient with exposure of
prepared area. only the insertion site.
6. With assistance, open the sterile Prepares the equipment.
kits.
7. Obtain central venous access with The PA catheter is inserted into
an introducer (see Procedure 82). a central vein.
8. Hand off the ports of the PA Connects the ports to the flush
catheter to the critical care nurse system; connects the
assisting with connection to the transducer systems to the
hemodynamic monitoring system bedside monitor.
(see Procedure 72).
9. Flush all open lumens with Removes air from the PA
normal saline and attach sterile catheter.
injectable or noninjectable caps to
retain the flush.
10. Insert the PA catheter through the Maintains sterility of the PA
sterile catheter sleeve. (Level B*) catheter to allow repositioning
of the catheter.4–6
11. Insert the recommended amount Checks for integrity of the If an air leak is present, air bubbles are
of air (1.5 mL) into the balloon balloon. noted.
port and immerse the inflated
balloon in the sterile bowl with
water or normal saline solution.
12. Remove the balloon syringe and Prepares for insertion.
let the balloon passively deflate;
empty the syringe and reattach
the syringe to the balloon port.
Procedure for Performing Pulmonary Artery Catheter Insertion—Continued

13. If a PA catheter with the ability to Calibrates the system. Calibrate the catheter according to
monitor Svo2 is being inserted, manufacturer’s guidelines.
the fiberoptics are calibrated
before removal from the package
(see Procedure 16). (Level M*)
14. Ensure that the critical care nurse Prepares the monitoring system
has leveled and zeroed the so that right-heart pressures
hemodynamic monitoring system and PA pressures can be
(see Procedure 75). visualized and measured
during catheter insertion.
15. Wiggle the PA catheter and Ensures the ability to see the
observe the monitor. Wiggling waveform during insertion
(sometimes called whipping) the and ensures that there are no
PA catheter will produce artifacts connection issues or catheter
on the monitor screen. defects before insertion.
16. While observing the monitor and Waveforms and pressure values If there is any resistance when inflating
the markings on the PA catheter change while moving from the balloon, allow the balloon to
(Fig. 71-2), follow these steps: the superior vena cava to the deflate, advance the catheter another
A. Advance the catheter through right atrium to the right centimeter, and attempt to inflate the
the introducer to the superior ventricle to the pulmonary balloon again.
vena cava into the right artery and into the wedge The catheter should reach the PA after
atrium. position. advancing 40–55 cm from the
B. Slowly inflate the balloon with internal jugular vein, 35–55 cm from
1.5 mL of air after verifying a the subclavian vein, 60 cm from the
right-atrial waveform. femoral vein, 70 cm from the right
C. Advance the catheter through antecubital fossa, and 80 cm from
the tricuspid valve, into the the left antecubital fossa.
right ventricle. Assess for the When inserting the PA catheter into the
right-ventricular waveform. subclavian vein, have the patient
D. Continue to advance the bring his or her ear to the shoulder
catheter from the right on the side of the insertion site. This
ventricle through the pulmonic creates a sharp angle between the
valve into the PA and assess jugular and subclavian veins and
for the PA waveform. may help prevent misdirection of the
E. Advance the catheter until a catheter into the internal jugular vein.
PAOP waveform (a, c, v During insertion, monitor the ECG
waves) is visualized to obtain tracing for dysrhythmias. Run a
a PAOP. graphic strip of the insertion
F. Passively allow the balloon to waveforms.
deflate. The balloon should only be inflated
G. Observe the waveform change when advancing the catheter and
from the PAOP waveform to should always be deflated when the
the PA waveform. catheter is withdrawn.11
17. Ensure proper placement by Ensures proper placement and
wedging the PA catheter again accurate readings.
and print a graphic strip of the
waveforms.

Figure 71-2 Pulmonary artery catheter advancing through

the heart with appropriate waveforms. (Adapted from Bucher
L, Melander S: Critical care nursing. Philadelphia, 1999,
Saunders.)
Procedure for Performing Pulmonary Artery Catheter Insertion—Continued

18. Extend the sterile catheter sleeve Maintains sterility of the PA The duration of catheter sterility in the
over the catheter and secure in catheter to allow repositioning sleeve is unknown. One team of
place. of the catheter.4–6 researchers found that the catheter
was thought to be sterile up to 4
days.5
Another team of researchers also
studied catheter sterility using the
sleeve; they recommend that the PA
catheter should not be repositioned
after 4 hours.6
19. Apply an occlusive, sterile Reduces the incidence of Dressings may be a sterile gauze or a
dressing and secure the catheter. infection and prevents sterile, transparent, semipermeable
dislodgement. dressing.15,17
Follow institutional standards for
application of a chlorhexidine-
impregnated sponge (see
Procedure 66).
20. Note the centimeter marking at Aids in ensuring placement and The tip of the PAC may migrate.
the introducer site. troubleshooting.
21. Obtain a chest radiograph. Confirms the catheter tip is
positioned in the PA.
22. Remove sterile and PE and Reduces the transmission of
discard used supplies in microorganisms; Standard
23. HH

• Accurate placement of the pulmonary artery catheter • Pneumothorax or hemothorax
• Adequate and appropriate waveforms • Infection or sepsis
• Ability to obtain accurate information about cardiac • Ventricular dysrhythmias
pressures • Misplacement (e.g., hepatic vein)
• Evaluation of information to guide diagnosis and/or • Valvular damage
therapeutic interventions • Vessel wall erosion
• Hemorrhage
• Hematoma
• Pericardial or ventricular rupture
• Venous air embolism
• Pulmonary artery infarction
• Pseudoaneurysms
• Catheter-site infection
• Air embolism
• PA rupture
• PA dissection
• PA catheter balloon rupture
• PA catheter knotting
• Heparin-induced thrombocytopenia or thrombosis
• Thromboembolism
• Pain
• Balloon rupture

interventions.
1. Perform systematic cardiovascular,
peripheral vascular, and
hemodynamic assessments before
and immediately after insertion:
A. Assess level of consciousness. Assesses for signs of adequate • Change in level of consciousness
perfusion; air embolism may
present with restlessness; patient
may present with decreased level
of consciousness if the catheter is
advanced into the carotid artery.
B. Assess vital signs. Demonstrates response to the • Abnormal vital signs
procedure and effectiveness of
therapies performed.
C. Assess postinsertion hemodynamic Obtains baseline data and assesses • Abnormal hemodynamic
values: PA systolic pressure, PA patient status. pressures or cardiac parameters
diastolic pressure (PADP), RAP,
PAOP, CO, CI, SVR, and other
parameters as needed.
2. Assess the central line insertion site If coagulopathies are present, a • Bleeding that does not stop
for hematoma or hemorrhage. pressure dressing may be needed. • Hematoma
3. Assess heart and lung sounds after Abnormal heart or lung sounds • Diminished or muffled heart
PA catheter insertion. may indicate cardiac tamponade, sounds
pneumothorax, or hemothorax. • Absent or diminished breath
sounds unilaterally

4. Assess the results of the chest Ensures adequate placement in lung • Abnormal chest radiograph
radiograph. zone 3 below the level of the left results
atrium.
5. Monitor for signs and symptoms of Identifies complications. • Signs or symptoms of cardiac
cardiac tamponade and air embolism. tamponade or air embolism
6. Monitor the centimeter marking at Aids in determining if the position • Changes in the external
the introducer site. of the catheter has moved. centimeter marking
• Abnormal PA waveforms
assessing pain. Administer analgesia interventions. interventions
as prescribed.
Documentation
• Patient and family education • Centimeter mark at the edge of the introducer
• Completion of informed consent • Any difficulties encountered during placement (e.g.,
• Universal Protocol requirements ventricular ectopy, new bundle-branch blocks)
• Insertion of PA catheter and sheath introducer • Patient tolerance
• Type and size of catheter placed • Confirmation of placement (e.g., chest radiograph)
• Size of introducer sheath • Initial values after placement of the catheter (PAPs,
• PA pressure values on insertion (RAP, right-ventricular PAOP, RAP, CO, CI, SVR, PVR, Svo2)
systolic and diastolic pressures, PA systolic pressure, • Occurrence of unexpected outcomes
PADP, PAOP) • Additional interventions
• Graphic strip of insertion • Pain assessment, interventions, and effectiveness
• Insertion site of the PA catheter

71 Pulmonary Artery Catheter Insertion (Perform) 608.e1

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catheters. Crit Care 9:R631–R635, 2005. 2006.
16. Morris AH, Chapman RH: Wedge pressure confirmation Harvey S, et al: Assessment of the clinical effectiveness of
by aspiration of pulmonary capillary blood. Crit Care pulmonary artery catheters in management of patients in
Med 13:756–759, 1985. intensive care (PAC-Man): A randomized controlled trial.
17. O’Grady N, et al: Guidelines for the prevention of Lancet 366(9484):472–477, 2005.
intravascular catheter-related infections. Am J Infect Harvey S, et al: Pulmonary artery catheters for adult
Control 39(4):S1–S34, 2011. patients in intensive care. Cochrane Database Syst Rev
18. Pulmonary Artery Consensus Conference Participants: (3):CD003408; 2006.
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consensus statement. Crit Care Med 25:910–925, monitoring series: pulmonary artery pressure monitoring,
1997. Aliso Viejo, CA, 1997, American Association of
19. Silver D, Kapsch DN, Tsoi EK: Heparin-induced Critical-Care Nurses.
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Lough M: Hemodynamic monitoring: Evolving technologies The American Society of Anesthesiologists’ Task Force on
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Conference: Consensus statement. Crit Care Med 25: et al: Pulmonary artery vs central venous catheter to guide
910–925, 1997. treatment of acute lung injury. N Engl J Med
Rapoprot LJ, Teres D, Steingrub J: Patient characteristics 354(21):2213–2224, 2006.
and ICU organizational factors that influence frequency Tuggle D: Optimizing hemodynamics: strategies for fluid and
of pulmonary artery catheterization. JAMA 283:2555, medication titration in shock, AACN advanced critical
2000. care nursing, Philadelphia, 2009, Elsevier, pp 1099–1133.
Swan JHC: What role today for hemodynamic monitoring. Wiener R, Welch H: Trends in the use of the pulmonary artery
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in a man with the use of a flow-directed balloon-tipped
catheter. N Engl J Med 280:447, 1970.
PROCEDURE
72
Insertion (Assist) and
Pressure Monitoring
Reba McVay
PURPOSE: Pulmonary artery (PA) catheters are used to determine hemodynamic
status in critically ill patients. PA catheters provide information about right-sided
and left-sided intracardiac pressures and cardiac output. Additional functions
available are fiberoptic monitoring of mixed venous oxygen saturation, intracardiac
pacing, and assessment of right-ventricular volumes and ejection fraction.
Hemodynamic information obtained with a PA catheter is used to aid diagnosis and
guide therapeutic intervention, including administration of fluids and diuretics and
titration of vasoactive and inotropic medications.
Usually, the PAOP is approximately 1 to 4 mm Hg less

PREREQUISITE NURSING than the pulmonary artery diastolic pressure (PADP).
KNOWLEDGE Because these two pressures are similar, the PADP is
commonly followed, which minimizes the frequency of
• Knowledge of the normal cardiovascular and pulmonary balloon inflation, thus decreasing the potential of balloon
anatomy and physiology is needed. rupture and PA trauma.
• Knowledge of principles of aseptic technique is essential. • Differences between the PADP and the PAOP may exist
• Basic dysrhythmia recognition and treatment of life- for patients with pulmonary hypertension, chronic obstruc-
threatening dysrhythmias should be understood. tive lung disease, acute respiratory distress syndrome,
• Advanced cardiac life support (ACLS) knowledge and pulmonary embolus, and tachycardia.
skills are needed. • See Procedure 71 for common indications for insertion of
• Knowledge of the components of the PA catheter (Fig. a PA catheter.
72-1) and the location of the PA catheter in the heart and • Hemodynamic monitoring with a PA catheter has no abso-
PA (Fig. 72-2) is necessary. lute contraindications, but an assessment of risk versus
• Knowledge of the setup of the hemodynamic monitoring benefit to the patient should be considered. Relative con-
system (see Procedure 75) is needed. traindications to PA catheter insertion include presence of
• Understanding of normal hemodynamic values (see Table fever, presence of a mechanical tricuspid valve, presence
64-1) is essential. of an endocardial pacemaker, and a coagulopathic state.
• The PA catheter contains a proximal injectate lumen port, A patient with left bundle-branch block may have a right
a PA distal lumen port, a thermistor connector, and a bundle-branch block develop during PA catheter insertion,
balloon-inflation port with valve. Some catheters also resulting in complete heart block. In these patients, a
have two infusion ports, right atrial (RA) and right ven- temporary pacemaker should be readily available.
tricular (RV) lumens that can be used for infusion of • PA pressures may be elevated as a result of PA hyperten-
medications and intravenous fluids. sion, pulmonary disease, mitral valve disease, LV failure,
• The PA distal lumen is used to monitor systolic, diastolic, atrial or ventricular left-to-right shunt, pulmonary emboli,
and mean pressures in the PA. This lumen also allows for or hypervolemia.
sampling of mixed venous blood. The proximal injectate • PA pressures may be low due to hypovolemia or low
lumen is used to monitor the RA pressure and inject the pulmonary vascular resistance (e.g., vasodilation).
solution used to obtain cardiac output (CO). The balloon- • Transduced waveforms that are viewable during insertion
inflation port is used to advance the PA catheter tip to the include RA, RV, PA, and PA occlusion (PAO; Figs. 71-2
wedge position and measure the pulmonary artery occlu- and 72-3).
sion pressure (PAOP). • The RA and PAO waveforms have a, c, and v waves:
• PAOP may be referred to as pulmonary artery wedge pres- ❖ The a wave reflects atrial contraction, the c wave
sure or the pulmonary capillary wedge pressure. reflects closure of the atrioventricular valve, and the v
• The PA diastolic pressure and the PAOP are indirect wave reflects passive filling of the atria during ven-
measures of left ventricular (LV) end-diastolic pressure. tricular systole (Figs. 72-4 and 72-5).
609
Figure 72-1 Anatomy of the pulmonary artery (PA) catheter. The standard 7.5-Fr thermodilution
PA catheter is 110 cm in length and contains four lumens. It is constructed of radiopaque polyvinyl
chloride. Black markings are on the catheter in 10-cm increments beginning at the distal end. At the
distal end of the catheter is a latex rubber balloon of 1.5-mL capacity, which, when inflated, extends
slightly beyond the tip of the catheter without obstructing it. Balloon inflation cushions the tip of
the catheter and prevents contact with the right-ventricular wall during insertion. The balloon also
acts to float the catheter into position and allows measurement of the pulmonary artery occlusion
pressure. The narrow black bands represent 10-cm lengths, and the wide black bands indicate 50-cm
lengths. (From Visalli F, Evans P: The Swan-Ganz catheter: A program for teaching safe effective
use, Nursing 81[11]:1, 1981.)
Figure 72-2 Pulmonary artery (PA) catheter location within the heart. Pulmonary artery occlusion
pressure (PAOP) is an indirect measure of left-atrial (LA) and left-ventricular (LV) end-diastolic
pressure. Pulmonary artery occlusion pressure (PAOP) is also referred to as pulmonary artery wedge
pressure (PAWP). (From Kersten LD: Comprehensive respiratory nursing, Philadelphia, 1989,
Saunders.)
72 Pulmonary Artery Catheter Insertion (Assist) and Pressure Monitoring 611
Figure 72-3 Schematic of waveform progression as a pulmonary artery (PA) catheter is inserted
through the various cardiac chambers. (From Abbott Critical Care Systems, Mountain View, CA.)
Figure 72-4 Identification of a, c, and v waves in the waveform for right-atrial and central venous
pressure. Atrial waveforms are characterized by three components: a, c, and v waves. The a wave
reflects atrial contraction, the c wave reflects closure of the tricuspid valve, and the v wave reflects
passive filling of the atria. (From Ahrens TS, Taylor LK: Hemodynamic waveform analysis, Phila-
delphia, 1992, Saunders.)
❖ The a wave reflects ventricular filling at end diastole. Elevated a waves in the PAOP waveform may occur in
❖
The mean of the a wave is determined by averag patients with mitral valve stenosis, acute LV ischemia
ing the top and bottom values of the a wave. or infarction, LV failure, and AV dissociation.
❖ Elevated a and v waves may be evident in right atrial ❖ Elevated v waves in the RAP/CVP waveform may
pressure (RAP/central venous pressure [CVP]) and in occur in patients with tricuspid valve insufficiency.
PAOP waveforms. These elevations may occur in ❖ Elevated v waves in the PAOP waveform may occur in
patients with cardiac tamponade, constrictive pericar- patients with mitral valve insufficiency or a ruptured
dial disease, and hypervolemia. papillary muscle.
❖ Elevated a waves in the RAP/CVP waveform may • Insertion and placement verification should occur as fol-
occur in patients with pulmonic or tricuspid valve ste- lows:
nosis, RV ischemia or infarction, RV failure, PA hyper- ❖ The PA catheter is typically inserted through the sub-
tension, and atrioventricular (AV) dissociation. clavian, internal jugular, or femoral veins.
Figure 72-5 Normal pulmonary artery occlusion pressure (PAOP) waveform. Note the delay in
the a, c, and v waves because of the time needed for the mechanical events to show a pressure
change. This waveform is from a spontaneously breathing patient. The arrow indicates end expira-
tion, where the mean of a wave pressure is measured. Pulmonary artery occlusion pressure (PAOP)
is also referred to as pulmonary artery wedge pressure (PAWP).
❖ The standard 7.5 Fr PA catheter is 110 cm long and has • Antiseptic solution (e.g., 2% chlorhexidine–based prepa-
black markings at 10-cm increments and wide black ration)
markings at 50-cm increments (see Fig. 72-1). The • Head covers, fluid-shield masks, sterile gowns, sterile
catheter should reach the PA after being advanced gloves, nonsterile gloves, and full sterile drapes
approximately 40 to 55 cm from the internal jugular • 1% lidocaine without epinephrine
vein, 35 to 50 cm from the subclavian vein, and 60 cm • Sterile basin or cup
from the femoral vein. • Sterile water or normal saline solution
❖ Verification of PA catheter position is validated with • Sterile dressing supplies
waveform analysis. Correct catheter position shows a • Stopcocks (may be included in some pressure-tubing sys-
PAO waveform when the balloon is inflated and a PA tems)
waveform when the balloon is deflated. • Sterile injectable or noninjectable caps
❖ Confirmation of the PA catheter position is also verified • Leveling device (low-intensity laser or carpenter level)
with chest radiography. Additional equipment, to have available as needed, includes
❖ The PA catheter balloon contains latex, which may the following:
cause allergic reactions. Latex-free catheters are avail- • Fluoroscope or ultrasound machine
able. • Emergency resuscitation equipment
• Temporary pacing equipment
EQUIPMENT • Indelible marker
• Transducer holder and IV pole
• PA catheter (non–heparin-coated PA catheters and latex- • Heparin
free PA catheters are available) • 3-mL syringe, slip tip and Luer-Lock
• Percutaneous sheath introducer kit and sterile catheter • Chlorhexidine-impregnated sponge
sleeve
• Pressure modules and cables for interface with the monitor PATIENT AND FAMILY EDUCATION
• Cardiac output cable with a thermistor/injectate sensor
and/or continuous CO monitor • Provide the patient and family with information about the PA
• Pressure-transducer system, including flush solution rec- catheter, the reason for the PA catheter, and an explanation
ommended according to institutional standards, a pressure of the equipment. Rationale: The patient and family will
bag or device, pressure tubing with transducers, and flush understand the procedure, why it is needed, and how it will
device (see Procedure 75) help manage care. Patient and family anxiety may decrease.
• Dual-channel recorder • Explain the patient’s expected participation during the
• Sterile normal saline intravenous (IV) solution for flush- procedure. Rationale: This explanation will encourage
ing of the introducer and catheter infusion ports patient assistance.
PATIENT ASSESSMENT AND Patient Preparation

PREPARATION
• Determine baseline hemodynamic, cardiovascular, periph- nurse should ensure the correct identification of the patient
eral vascular, and neurovascular status. Rationale: Assess- for the intended intervention.
ment provides data that can be used for comparison with • Ensure that the patient and family understand preproce-
postinsertion assessment data and hemodynamic values. dural teaching. Answer questions as they arise, and rein-
• Determine the patient’s baseline pulmonary status. If the force information as needed. Rationale: Understanding of
patient is mechanically ventilated, note the type of support, previously taught information is evaluated and reinforced.
ventilator mode, and presence or absence of positive end- • Ensure that informed consent has been obtained. Ratio-
expiratory pressure (PEEP) or continuous positive airway nale: Informed consent protects the rights of the patient
pressure. Rationale: The presence of positive pressure and makes a competent decision possible for the patient.
mechanical ventilation alters hemodynamic waveforms • Perform a preprocedure verification and time out. Ratio-
and pressures. nale: Ensures patient safety.
• Assess the patient’s medical history specifically related to • Validate the patency of the alternate central or peripheral
problems with venous access sites, cardiac anatomy, and IV access catheter. Rationale: Access may be needed for
pulmonary anatomy. Rationale: Identification of obstruc- administration of emergency medications or fluids.
tions or disease should be made before the insertion • Assist the patient to the supine position. Rationale: This
attempt. position prepares the patient for skin preparation, catheter
• Assess the patient’s current laboratory profile, including insertion, and setup of the sterile field.
electrolyte, coagulation, and arterial blood gas results. • Sedate the patient and/or give analgesics as prescribed and
Rationale: Laboratory abnormalities are identified. Base- needed. Rationale: Movement of the patient may inhibit
line coagulation studies are helpful in determination of the insertion of the PA catheter.
risk for bleeding. Electrolyte and arterial blood gas imbal-
ances may increase cardiac irritability.
Procedure for Assisting With Pulmonary Artery Catheter Insertion and

Pressure Monitoring
Assisting With PA Catheter Insertion
1. HH
2. Prepare the flush solution for the Heparinized flush solutions are Although heparin may prevent
pressure-transducer systems (see commonly used to minimize thrombosis,24,29 it has been
Procedure 75). thrombi and fibrin deposits on associated with thrombocytopenia
A. Use an IV bag of normal catheters that might lead to and other hematologic
saline. thrombosis or bacterial colonization complications.5
B. Follow institutional standards of the catheter. Further research is needed regarding
for adding heparin to the IV use of heparin versus normal saline
bag, if heparin is prescribed to maintain PA catheter patency.
and not contraindicated.
(Level B*)
3. Prime or flush the pressure- Removes air bubbles. Air is more easily removed from the
transducer systems (see Air bubbles introduced into the hemodynamic tubing when the
Procedure 75). patient’s circulation can cause air system is not under pressure.
embolism.
Air bubbles within the tubing dampen
the waveform.
4. Apply and inflate the pressure Each flush device delivers 1–3 mL/hr
bag or device to 300 mm Hg. to maintain patency of the
hemodynamic system.
5. Connect the pressure cables (RA Connects the pressure-transducer
and PA) to the bedside monitor systems to the bedside monitoring
(see Fig. 75-2). system.

Pressure Monitoring—Continued
6. Set the scales on the bedside Prepares the bedside monitor. The scale for the RA/CVP pressure
monitor for each anticipated commonly is set at 20 mm Hg, and
pressure waveform. the PA scale commonly is set at
40 mm Hg.
Scale settings may vary based on
monitoring equipment.
The scales can be adjusted if needed
after the PA catheter is inserted
based on patient pressures.
7. Level the RA (proximal) air-fluid The phlebostatic axis approximates The reference point for the atria
interface (zeroing stopcock) and the level of the atria and is the changes when a patient is in the
the PA (distal) air-fluid interface reference point for patients in the lateral position (see Fig. 75-8).
(zeroing stopcock) to the supine position.
phlebostatic axis (see Figs. 75-7
and 75-9).
8. Zero the system connected to the Prepares each monitoring system so
PA (distal) lumen and to the RA that pressures can be obtained
(proximal) lumen of the PA during catheter insertion.
catheter by turning the stopcock
of each system off to the patient,
opening it to air, and zeroing the
monitoring system (see Procedure
75).
9. HH
10. PE All healthcare personnel involved in
the procedure need to apply head
coverings, fluid-shield masks, and
sterile gowns.
11. Assist the physician or advanced Aids in preparing for the procedure. The patient will be fully draped with
practice nurse as needed with exposure of only the insertion site.
opening the packaging of sterile
drapes, and opening the PA
catheter and introducer kits.
12. When the sheath introducer is in Maintains the patency of the sheath
place, connect a normal saline IV introducer infusion port.
solution to the infusion port.
13. Connect the pressure-transducer Provides assistance in preparing the
system to the PA distal and catheter.
proximal ports of the PA catheter
when the physician, advanced
professional inserting the PA
catheter hands them off to the
critical care nurse.
14. Flush the air from the catheter. Removes air from the pulmonary Flush additional infusion ports and
artery catheter. attach sterile injectable or
noninjectable caps.
15. If inserting a PA catheter with the Calibrates the system before insertion. Follow manufacturer guidelines for
ability to monitor mixed venous catheter calibration.
oxygenation, the fiberoptics are
calibrated before removal from
the package (see Procedure 16).
16. Observe as the physician or The movement of the catheter will be
advanced practice nurse wiggles seen on the monitor.
the PA catheter (sometimes called This ensures that there are no
“whipping”). connection issues or catheter
defects before insertion.

17. The physician or advanced Maintains sterility of the PA catheter Additional research is needed to
practice nurse will insert the PA to allow repositioning of the determine how long the sleeve
catheter through a sterile catheter catheter.8 remains sterile.
sleeve (see Procedure 71).
18. As insertion begins, continuously Provides documentation of RA, RV, A dual-channel recorder is preferred
monitor and print the and PA pressures during insertion so the ECG and the PA waveform
electrocardiogram (ECG) and PA and dysrhythmia occurrence during can be simultaneously recorded.
distal pressure waveform strip. insertion.
19. After the tip of the PA catheter is The inflated balloon helps to advance The presence of the tip of the catheter
in the right atrium, inflate the the PA catheter through the right in the right atrium is determined by
balloon with no more than side of the heart and into the PA, observing the waveform (for RA/
1.25–1.5 mL of air and close minimizing the chance of CVP waveform with a, c, v waves)
the gate valve or the stopcock endocardial damage. from the catheter’s distal lumen
(Fig. 72-6). Closing the gate valve or the stopcock during insertion (see Fig. 72-3).
holds air in the balloon during Use the syringe from the PA insertion
insertion. kit. It will not allow more than
1.5 mL of air to be used.
Clearly communicate with the
physician, advanced practice nurse,
or other healthcare professional
inserting the catheter:
A. If the provider requests, “Inflate
the balloon.”
B. The critical care nurse should
respond, “Inflating the balloon”
and “Balloon inflated and locked.”
20. Observe for RA, RV, PA, and Placement in the PA is validated with Monitor the ECG tracing as the PA
then PAO waveforms (see Fig. waveform analysis. catheter is inserted because
72-3). ventricular dysrhythmias may result
from RV irritability.
RV pressures are obtained only during
insertion.
21. Verify that the PA catheter tip is When the balloon is inflated, the The catheter usually reaches the
in the proper position. catheter floats from the PA to a PA after being advanced
A. When the balloon is deflated, smaller pulmonary arteriole. approximately 40–55 cm from the
the PA waveform is displayed internal jugular vein, 35–50 cm
on the monitor. from the subclavian vein, and
B. When the balloon is inflated, 60 cm from the femoral vein.
the PAO waveform is Placement may vary depending on
displayed on the monitor. patient size.
A chest radiograph is obtained to
verify catheter position.
Sliding gate Arrow aligned indicates

valve “open” position
Catheter
CLOSED
Arrow offset indicates

“closed” position OPEN
Gate Valve Operation

Figure 72-6 Pulmonary artery catheter gate valve. Top left: Gate valve in the open position.
Bottom left: Gate valve in the closed position. (From Baxter Edwards Corporation.)

22. After the PA catheter is in place: The gate valve or stopcock is closed Air is expelled from the syringe, and
A. Open the balloon inflation during insertion to retain air in the the empty syringe is reconnected to
gate valve or stopcock. balloon. the balloon inflation valve port.
B. Remove the balloon syringe. The air is then passively released so Clearly communicate with the
that continuous monitoring of the physician, advanced practice nurse,
PA waveform can be performed. or other healthcare professional
inserting the catheter:
A. If the physician, advanced practice
professional requests, “Deflate the
balloon.”
B. The critical care nurse should
respond, “Deflating the balloon”
and “Balloon deflated.”
23. Reassess accurate leveling and Ensures that the air-filled interface Leveling ensures accuracy.
secure the pressure transducer (zeroing stopcock) is maintained at The point of the phlebostatic axis
system (see Procedure 75). the level of the phlebostatic axis. should be marked with an indelible
If the air-fluid interface is above the marker, especially with use of a
phlebostatic axis, PA pressures are pole-mount setup.
falsely low.
If the air-fluid interface is below the
phlebostatic axis, PA pressures are
falsely high.
24. Zero both the RA and PA Allows the monitor to use
pressure transducer systems (see atmospheric pressure as a reference
Procedure 75). for zero.
25. Observe the waveform and Determines whether the system is The square wave test can be
perform a dynamic response test damped. performed by activating and
(square wave test; see Fig. 59-3). This will ensure that the pressure quickly releasing the fast flush.
waveform components are clearly A sharp upstroke should terminate in
defined and aids in accurate a flat line at the maximal indicator
measurement. on the monitor.
a quick return to baseline.
26. Assist if needed with applying an Reduces the risk for infection. Follow institutional standards for
occlusive, sterile dressing to the application of a chlorhexidine-
insertion site (see Procedure 66). impregnated sponge (see Procedure
66).
27. Connect the thermistor connector Allows the core temperature to be
of the PA catheter to the CO monitored and is needed for CO
monitor or module (see Procedure measurement.
64).
28. Document the external centimeter Identifies the length of the PA catheter If the centimeter marking is not
marking of the PA catheter at the inserted and allows for evaluation visible at the exit site, measure the
introducer exit site. of PA catheter movement. distance from the introducer exit
site to the nearest visible marking.
29. Set the monitor alarms. Activates the bedside and central Upper and lower alarm limits are set
alarm system. on the basis of the patient’s current
clinical status and hemodynamic
values.
30. Remove PE and sterile equipment Removes and safely discards used
and discard used supplies in supplies.

31. HH
32. Ensure chest radiograph is Verifies PA catheter positioning.
completed.
Obtaining PA Pressure Measurements
RA/CVP
1. Position the patient in the supine Studies have determined that the RA RA and PA pressures may be accurate
position with the head of the bed and PA pressures are accurate in for patients in the supine position
from 0 to 45 degrees. (Level B*) this position.3,6,7,10,18,20,22,34,35 with the head of the bed elevated
up to 60 degrees,7,22 but additional
studies are needed to support this.
position.1,2,12,17,21,27,32
2. Run a dual-channel strip of RA pressures should be measured The digital monitor data can be used
the ECG and RA waveform from the graphic strip because the to measure RA pressure if
(Fig. 72-7). effect of ventilation can be ventilation does not cause
identified. respiratory variation of the RA
pressure waveform.
Some monitors have the capability of
“freeze framing” waveforms.
A cursor can be used to measure
pressure measurements.
3. Measure RA pressure at end The effects of intrathoracic pressure
expiration. on the RAP is minimized at the
end-expiration phase of the
respiratory cycle.
Figure 72-7 Note vertical lines drawn from the beginning of the P wave of two of the electro-
cardiogram complexes down to the right atrial (RA) waveform. The first positive deflection of the
RA waveform is the a wave; the second positive deflection is the v wave. The c wave, which would
lie between the a wave and the v wave, is not evident in this strip. CVP, central venous pressure.

4. With the dual-channel recorded Compares electrical activity with At times, the c wave is not present.
strip, draw a vertical line from mechanical activity. Usually three
the beginning of the P wave of waves are present on the RA
one of the ECG complexes down waveform.
to the RA waveform.
Repeat this with the next ECG
complex (see Fig. 72-7).
5. Align the PR interval with the The a wave correlates with this
RA waveform. interval.
6. Identify the a wave. The a wave is seen approximately The a wave reflects atrial contraction.
80–100 ms after the P wave. The c wave reflects closure of the
The c wave follows the a wave, and tricuspid valve. The v wave reflects
the v wave follows the c wave. passive filling of the atria.
7. Identify the scale setting of the Optimizes the view of the waveform The RAP scale commonly is set at
RA waveform on the monitor and aids in measurement of the 20 mm Hg and may be adjusted to
(Fig. 72-8). pressure. the patient’s RAP to optimize the
view of the waveform.
8. Measure the mean of the a wave The a wave represents atrial
to obtain the RAP (see Fig. 72-8). contraction and reflects right
ventricular filling at end diastole.
Figure 72-8 Obtaining measurements of right-atrial and central venous pressures (RA/CVP).
Aligning the a wave on the RA/CVP waveform with the PR interval on the electrocardiogram
facilitates accurate measurement of RA/CVP at end diastole. (From Ahrens TS, Taylor LK: Hemo-
dynamic waveform analysis, Philadelphia, 1992, Saunders.)

PA Systolic and Diastolic Pressures
other studies3,13,18,26,33 do not.
The majority of the studies1,2,12,17,21,27,32
support the accuracy of
hemodynamic monitoring for
patients in the prone position, yet
two studies showed that prone
2. Print a dual-channel strip of PA pressures are measured from the Some monitors have the capability of
the ECG and PA waveform graphic strip when respiratory “freeze framing” waveforms.
(Fig. 72-9). variation of the waveform is noted A cursor can be used to measure
because the effect of ventilation can pressures.
be identified.
Figure 72-9 Obtaining measurements of pressure in the pulmonary artery (PA). For systolic
pressure, align the peak of the systolic waveform with the QT interval on the electrocardiogram.
For PA diastolic pressure, use the end of the QRS as a marker to detect the PA diastolic phase. Obtain
the reading just before the upstroke of the systolic waveform. (From Ahrens TS, Taylor LK: Hemo-
dynamic waveform analysis, Philadelphia, 1992, Saunders.)

3. Measure the PA pressure at end The effects of intrathoracic pressure
expiration. on the PAP is minimized at the
end-expiration phase of the
respiratory cycle.
4. Identify the QT interval on the Represents ventricular depolarization.
ECG strip.
5. Align the QT interval with the PA Allows comparison of cardiac
waveform. electrical activity with mechanical
activity.
6. Identify the scale setting of the Optimizes the view of the waveform The PAP scale commonly is set at
PA waveform on the monitor. and aids in measurement of the 40 mm Hg and may be adjusted to
pressure. the patient’s PAP to optimize the
view of the waveform.
7. Measure the PA systolic pressure Reflects the highest PA systolic
at the peak of the systolic pressure.
waveform on the PA waveform
(see Fig. 72-9).
8. Align the end of the QRS Compares electrical activity with
complex with the PA waveform mechanical activity.
(see Fig. 72-9). The end of the QRS complex
correlates with ventricular end-
diastolic pressure.
9. Measure the PA diastolic pressure This point occurs just before the
at the point of the intersection of upstroke of the systolic pressure.
this line (see Fig. 72-9).
PAOP
other studies3,13,18,26,33 do not.
The majority of the studies1,2,12,17,21,27,32
support the accuracy of
hemodynamic monitoring for
patients in the prone position, but
two studies demonstrated that prone
2. Fill the PA balloon syringe with More than 1.5 mL of air may rupture
1.5 mL of air. the PA balloon and the pulmonary
arteriole.
3. Connect the PA balloon syringe This port is designed for balloon air
to the gate valve or stopcock of inflation.
the balloon port of the PA
catheter (see Fig. 72-6).

4. Print a dual-channel strip of the The PAO pressures are measured Some monitors have the capability of
ECG and PA waveform. from the graphic strip because the “freeze framing” waveforms.
effect of ventilation can be A cursor can be used to measure
identified. pressures.
5. Slowly inflate the balloon with A slight resistance is usually felt Avoid overinflation of the balloon
air until the PA waveform during inflation of the balloon. because it can cause pulmonary
changes to a PAO waveform Only enough air needed to convert arteriole infarction or rupture,
(Fig. 72-10). the PA waveform to a PAO resulting in potentially life-
waveform should be instilled. threatening hemorrhage.14
Thus the entire amount of 1.5 mL of
air is not necessarily needed.
6. Inflate the balloon for no more Prolonged inflation of the balloon can
than 8–15 seconds (2–4 cause pulmonary arteriole infarction
respiratory cycles). and/or rupture, with potentially
life-threatening hemorrhage.14
7. Disconnect the syringe from the Allows air to passively escape from Active withdrawal of air from the
balloon-inflation port to passively the balloon. balloon can weaken the balloon,
deflate the balloon. (Level M*) pull the balloon structure into the
inflation lumen, and possibly cause
balloon rupture.
8. Observe the monitor to verify the Ensures adequate balloon deflation
PAO waveform changes back to and safe positioning of the PA
the PA waveform. catheter for continuous monitoring.
9. Expel air from the balloon The syringe should remain empty
syringe. when reconnected so that accidental
balloon inflation does not occur.
Figure 72-10 Change in pulmonary artery pressure (PAP) waveform to pulmonary artery occlu-
sion pressure waveform with balloon inflation. The balloon is inflated while the bedside monitor is
observed for change in the waveform. Balloon inflation (arrow) in patient with normal pulmonary
artery occlusion pressure. Pulmonary artery occlusion pressure (PAOP) is also referred to as pulmo-
nary artery wedge pressure (PAWP).

10. Reconnect the empty balloon The syringe that is manufactured for
syringe to the balloon-inflation the PA catheter should be connected
port. to the PA balloon port to avoid loss
of the custom designed syringe.
This syringe can be filled with only
1.5 mL of air, thus serving as a
safety feature to minimize the
chance of balloon overinflation.
11. Follow institutional standard The most important considerations are
regarding keeping the gate valve that the balloon syringe is attached
or the stopcock open. to the balloon-inflation port, the
syringe is empty, and the PA distal
waveform reflects a pulmonary
artery waveform.
12. With the dual-channel recorded Compares cardiac electrical activity The c waves commonly are not
strip, draw a vertical line from with mechanical activity. present on PAO waveforms because
the beginning of the P wave of Two waves (a and v) to three waves of the distance the pressure needs
one of the ECG complexes down (a, c, and v waves) will be present to travel back to the transducer.
to the PAO waveform. Repeat on the PAO waveform.
this with the next ECG complex.
13. Align the end of a QRS complex Aligns relationship of cardiac
of the ECG strip with the PAO electrical activity with mechanical
waveform (Fig. 72-11). activity
Figure 72-11 Obtaining measurement of the pulmonary artery occlusion pressure (PAOP). For
accurate readings, align the a wave from the PAO waveform with the end of the QRS on the elec-
trocardiogram at end diastole. Pulmonary artery occlusion pressure (PAOP) is also referred to as
pulmonary artery wedge pressure (PAWP). (From Ahrens TS, Taylor LK: Hemodynamic waveform
analysis, Philadelphia, 1992, Saunders.)

14. Identify the a wave (see Fig. The a wave correlates with the end of If only two waves are present, the
72-11). the QRS complex. first wave is the a wave and the
The c wave follows the a wave, and second wave is the v wave.
the v wave follows the c wave.
15. Identify the scale of the PAO Aids in determination of pressure The PA scale commonly is set at
tracing. measurement. 40 mm Hg.
16. Measure the mean of the a wave The a wave represents atrial If PEEP is being used and the PEEP
to obtain the PAOP (see contraction and reflects LV filling at is more than 10 cm H2O,
Fig. 72-5). end diastole. adjustments in determination of the
pressures may be necessary.
17. Compare the PADP with the The PAOP is commonly 1–4 mm Hg Significant differences between PADP
PAOP. less than the PADP. and PAOP may exist for patients
PADPs that correlate with PAOPs with pulmonary hypertension,
represent LV filling pressures. chronic obstructive lung disease,
acute respiratory distress syndrome,
pulmonary embolus, and
tachycardia.
18. Follow PADP if a close Considered an accurate measurement Minimizes the number of times the
correlation is found between of LV filling pressures. PA balloon is inflated.
PADP and PAOP.
19. Follow the PAOP if >4 mm Hg of Ensures the accuracy of
difference is found between measurements.
PAOP and PADP.
Measurement of Hemodynamic Pressures at End Expiration
1. Measure all hemodynamic Atmospheric and alveolar pressures
pressures at end expiration to are approximately equal at end
ensure accuracy. expiration. Intrathoracic pressure is
closest to zero at end expiration.
Measurement of hemodynamic
pressures is most accurate at end
expiration because pulmonary
pressures have minimal effect on
intracardiac pressures.
2. Determine end expiration by Aids in the determination of the end
observing the rise and fall of the expiratory phase of ventilation.
chest during breathing and use of
printed graphics of hemodynamic,
respiratory, capnography, or
continuous airway pressure
waveforms.
Determining End Expiration for the Patient Breathing Spontaneously
1. Record a strip of the PA A labeled recording aids in In patients who are breathing
waveform. determination of accurate spontaneously, the normal
hemodynamic pressure values. inspiratory : expiratory ratio is
approximately 1 : 2.
2. Note that the pressure waveform Intrapleural pressure decreases during
dips down during the inspiratory spontaneous inspiration, and this
phase of spontaneous breathing decrease is reflected by a fall in
(Fig. 72-12). cardiac pressures.
3. Note that the pressure waveform At end-expiration atmospheric and
elevates during the expiratory intrathoracic pressures (pleural and
phase of breathing (see Fig. alveolar) are equalized; thus cardiac
72-12). pressures are most accurately
reflected.
Figure 72-12 Respiratory fluctuations of pulmonary artery pressure (PAP) waveform in a spon-
taneously breathing patient. The location of inspiration (I) is marked on the waveform. The points
just before inspiration are end expiration, where readings are taken.

4. Measure the pressure at the end Ensures accurate and consistent
of the expiratory phase (see Fig. pressure measurements.
72-12).
Determining End Expiration for the Patient Receiving Positive Pressure Mechanical Ventilation
1. Record a strip of the PA A labeled recording aids in
waveform. determination of accurate
hemodynamic pressure values.
2. Note that the pressure waveform As the ventilator delivers a positive
elevates as a breath is delivered pressure breath to the lungs, an
by the ventilator (Fig. 72-13). increase in intrathoracic pressure
results.
This increase in intrathoracic pressure
causes an increase in cardiac
pressures.
3. Note that the pressure waveform As the mechanical breath is exhaled,
dips down as the breath is intrathoracic pressures decrease and
exhaled (see Fig. 72-13). cardiac pressures are most
accurately and consistently
measured.
Determining End Expiration for the Patient Receiving Intermittent Mandatory Mechanical Ventilation
1. Record a strip of the PA A labeled recording aids in
waveform. determination of accurate
hemodynamic pressure monitoring.
2. If the patient is receiving Aids in accuracy of pressure
intermittent mandatory measurements.
ventilation, measure the pressure
during the end expiration.
3. Note that the pressure waveform As the ventilator delivers a breath to
elevates as a breath is delivered the lungs, an increase in
by the ventilator (Fig. 72-14). intrathoracic pressure results.
This increase in pressure causes an
increase in cardiac pressures.
Figure 72-13 Patient on mechanical ventilation (on pressure support–type ventilator) who had
no spontaneous respiration because of neuromuscular-blocking agent (vecuronium). The point of
end expiration is located just before the ventilator artifact. Pulmonary artery occlusion pressure
(PAOP) is also referred to as pulmonary artery wedge pressure (PAWP).
Figure 72-14 Intermittent mandatory ventilation mode of ventilation and the effect on the pul-
monary artery waveform. (From Ahrens TS, Taylor LK: Hemodynamic waveform analysis, Phila-
delphia, 1992, Saunders.)

4. Note that the pressure waveform As the mechanical breath is exhaled,
dips down as the breath is intrathoracic pressure decreases and
exhaled (see Fig. 72-14). cardiac pressures are more
accurately reflected.
5. Identify the patient’s spontaneous This breath may occur just before
breath (see Fig. 72-14). triggered ventilator breaths.
6. Determine end expiration. Ensures accuracy of measurements. Airway pressure waveforms can be
used to facilitate identification of
end expiration.

• Accurate placement of the PA catheter • Pneumothorax or hemothorax
• Adequate and appropriate waveforms • Infection/sepsis
• Ability to obtain accurate cardiac pressure • Ventricular dysrhythmias
measurements and associated hemodynamic data • Heart block
• Evaluation of information obtained to guide diagnostic • Misplacement
and therapeutic interventions • Hemorrhage
• Hematoma
• Pericardial or ventricular rupture
• PA infarction
• PA rupture
• PA catheter balloon rupture
• PA catheter knotting
• Pseudoaneurysm formation
• Heparin-induced thrombocytopenia
• Thrombosis
• Valvular damage
• Pain

interventions.
1. Recheck transducer leveling Ensures accurate reference point for
whenever patient position the left atrium.
changes.
2. Zero the transducer during initial Ensures accuracy of the hemodynamic
setup or before insertion if monitoring system.
disconnection occurs between the
transducer and the monitoring
cable, if disconnection occurs
between the monitoring cable and
the monitor, and when the values
picture.

3. Place sterile injectable or Stopcocks can be a source of
noninjectable caps on all contamination.
stopcocks. Replace with new Stopcocks that are part of the initial
sterile caps whenever the caps are setup are packaged with vented
removed. caps.
Vented caps need to be replaced with
sterile injectable or noninjectable
caps to maintain a closed system
and reduce the risk of
contamination and infection.
4. Monitor the pressure-transducer Air in the transducer system affects • Suspected air emboli
system (pressure tubing, the accuracy of pressure
transducer, stopcocks, etc.) for air measurements.
and eliminate air from the Air emboli are also potentially fatal.
system.
5. Continuously monitor Provides for continuous waveform • Abnormal hemodynamic
hemodynamic waveforms and analysis and assessment of patient waveforms or pressures
obtain hemodynamic values status.
(pulmonary artery systolic
pressure, PADP, RAP) hourly and
as necessary with condition
changes and to evaluate therapy
interventions. Follow institutional
standards for obtaining
hemodynamic values.
6. Obtain CO, cardiac index, and Monitors patient status and response • Abnormal hemodynamic
systemic vascular resistance and to therapeutic interventions. parameters or significant changes
additional parameters after in hemodynamic parameters
catheter insertion and as
necessary per patient condition
and interventions.
pressure tubing, transducers, and Nurses Society,16 and research
stopcocks) every 96 hours. findings23,25 recommend that the
changed more frequently if near This recommendation is based on
empty of solution. research conducted with disposable
pressure-monitoring systems used
8. Perform a dynamic response test An optimally damped system • Overdamped or underdamped
(square wave test) at the start of provides an accurate waveform. waveforms that cannot be
each shift, with a change of the corrected with troubleshooting
waveform, or after the system is procedures
opened to air (see Fig. 59-3).
9. Label the tubing with the date Identifies when the system needs to
and time the system was be changed.
prepared.
10. Maintain the pressure bag or At 300 mm Hg, each flush device
device at 300 mm Hg. delivers approximately 1–3 mL/hr
to maintain patency of the system.


11. Do not fast flush the distal lumen PA rupture may occur with prolonged • Hemoptysis
of the PA catheter for longer than flushing of high-pressure fluid.
2 seconds.9
12. Never flush the distal lumen of Excessive PA pressure may cause PA • Hemoptysis
the PA catheter when the balloon damage or rupture.
is wedged in the pulmonary
artery.
13. Use aseptic technique when Prevents contamination of the system
withdrawing from or flushing the and related infection.
PA catheter.
14. Clear the system, including Blood can become a medium for
stopcocks, of all traces of blood bacterial growth.24
after blood withdrawal. Clots also may be flushed into the
catheter if all blood is not
eliminated.
15. Maintain sterility and integrity of Any tear in the sleeve breaks the • Defects in the integrity of the
the plastic sleeve covering the PA sterile barrier, making catheter plastic sleeve
catheter. repositioning no longer possible.
16. Blood products and albumin Viscous blood may occlude the
should never be infused through catheter.
the PA catheter. The accuracy of the PA monitoring
system may be adversely affected.
17. IV fluids are never infused via PA monitoring is not possible, and a
the distal lumen of the PA life-threatening situation can occur
catheter and are sometimes (e.g., undetected wedged PA
infused via the proximal lumen of catheter).
the PA catheter when IV access is
necessary.
18. Replace gauze dressings every 2 Decreases the risk for infection at the • Signs or symptoms of infection
days and transparent dressings at catheter site.
least every 5–7 days and more The Centers for Disease Control and
frequently as needed.15,16,24,30 Prevention (CDC) and the Infusion
(Level D*) Nurses Society recommend
replacing the dressing when it
becomes damp, loosened, or soiled
necessary.15,16,24
19. Perform central venous catheter Ensures consistency of dressing
site care (see Procedure 66). change and indicates when the next
change will occur.
20. Print PA waveform strips to place The printed waveform allows
on the patient’s chart at the start assessment of the adequacy of the
of each shift and whenever a waveform, the presence of
change in the waveform occurs. damping, and if respiratory
variation is present.

21. Assess the need for the PA The Centers for Disease Control and • Signs and symptoms of infection at
catheter daily. If long-term use of Prevention (CDC)24 and research the PA catheter insertion site
the PA catheter is needed, findings4,11 recommend that PA • Signs and symptoms of sepsis
consider changing the PA catheter catheters do not need to be changed
every 7 days. more frequently than every 7 days.
(Level B*) There are no specific
replacement of PA catheters that
need to be in place for >7 days.11,24
malfunctioning.24
Documentation
• Patient and family education • Pain assessment, interventions, and effectiveness
• Completion of informed consent • Cardiac rhythm during PA catheter insertion and
• Universal protocol requirements monitoring
• Insertion of the PA catheter • Site assessment
• External centimeter marking of PA catheter noted at • PA pressures (RA/CVP, RV, PA systolic, diastolic,
exit site mean, and PAOP)
• Patient tolerance of procedure • Waveforms (RA/CVP, RV, pulmonary artery pressure,
• Confirmation of PA catheter placement (e.g., PAOP)
waveforms, chest radiograph) • CO/CI and systemic vascular resistance
• Date and time of PA catheter site care and dressing • Occurrence of unexpected outcomes and
change interventions

72 Pulmonary Artery Catheter Insertion (Assist) and Pressure Monitoring 629.e1
References 20. Lambert CW, Cason CL: Backrest elevation and

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Bridges EJ: Pulmonary artery pressure monitoring: When, Nurs 15:41–55, 2001.
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Liu C, Webb C: From the Food and Drug Administration:
pulmonary artery rupture: Serious complication associated
PROCEDURE
73
Removal
Nikki Taylor
PURPOSE: The pulmonary artery catheter is removed when hemodynamic
monitoring is no longer clinically indicated, when complications occur (e.g.,
dysrhythmias, pseudoaneurysms), or when there is risk for infection associated with
the prolonged use of intravascular catheters.
PREREQUISITE NURSING ❖ The PA catheter is knotted (observed on chest radio-

KNOWLEDGE graph).
❖ A permanent pacemaker, temporary transvenous pace-
• Knowledge of the normal cardiovascular anatomy and maker, or implantable cardioverter defibrillator (ICD)
physiology is necessary. is present (catheter should be removed by an advanced
• Knowledge of normal values for intracardiac pressures is practice nurse or a physician).
important.
• Knowledge of normal coagulation values is needed. EQUIPMENT
• Knowledge of normal waveform configurations for right-
atrial pressure, right-ventricular pressure, pulmonary • 1.5-mL syringe
artery pressure, and pulmonary arterial occlusive pressure • Sterile and nonsterile gloves
is necessary. • Gown
• Venous access routes should be known. • Fluid-shield face mask or goggles
• Principles of aseptic technique should be known. • 4 × 4 sterile gauze pads
• Advanced cardiac life support knowledge and skills are • Central line dressing kit
needed. • Two moisture-proof absorbent pads
• Potential complications associated with removal of the • One roll of 2-inch tape
pulmonary artery (PA) catheter should be understood. Additional equipment, to have available as needed, includes
• Clinical and technical competence in PA catheter removal the following:
is necessary. • Obturator/cap for introducer catheter port with hemostasis
• Knowledge of the state nurse practice act is important to valve
ensure that removal of a PA catheter is not prohibited. • Additional dressing supplies (e.g., transparent dressing)
• Air embolism can occur during the removal of the cath- • Petroleum-based ointment
eter. Air embolism after the removal of the catheter is • Suture removal kit
the result of air drawn in along the subcutaneous tract and • Scissors
into the vein. During inspiration, negative intrathoracic • Sterile specimen container
pressure is transmitted to the central veins. Any opening • Emergency equipment
external to the body to one of these veins may result
in aspiration of air into the central venous system. The PATIENT AND FAMILY EDUCATION
pathological effects depend on the volume and rate of air
aspirated. • Explain the procedure and the reason for removal of the
• Indications for the removal of the PA catheter include the catheter. Rationale: This explanation provides informa-
following: tion and decreases anxiety.
❖ The patient’s condition no longer necessitates hemody- • Explain the importance of patient participation during the
namic monitoring. removal of the catheter. Rationale: The explanation
❖ Complications occur because of the presence of the PA ensures patient cooperation and facilitates safe removal
catheter. of the catheter.
❖ The patient shows evidence of a catheter-related infec- • Instruct the patient and family to report any shortness of
tion that may be associated with the PA catheter. breath, bleeding, or discomfort at the insertion site after
• Contraindications to percutaneous removal of the PA cath- removal of the catheter. Rationale: Identifies patient dis-
eter include the following: comfort and early recognition of complications.
630
73 Pulmonary Artery Catheter Removal 631

Patient Preparation
PREPARATION
• In collaboration with the physician and/or advance prac-
Patient Assessment tice nurse, determine when the PA catheter should be
• Assess the electrocardiogram (ECG), vital signs, and neu- removed. Rationale: The invasive catheter is removed
rovascular status of the extremity distal to the catheter when it is no longer indicated.
insertion site. Rationale: This assessment serves as base- • Verify that the patient is the correct patient using two
line data. identifiers. Rationale: Before performing a procedure, the
• If the introducer will also be removed, assess the current nurse or the provider removing the PA catheter should
coagulation values of the patient. Rationale: If the patient ensure the correct identification of the patient for the
has abnormal coagulation study results, hemostasis may intended intervention.
be difficult to obtain after the introducer catheter is • Ensure that the patient and family understand prepro-
removed. cedural teaching. Answer questions as they arise, and
• Verify catheter position with waveform analysis or chest reinforce information as needed. Rationale: Understand-
radiograph. Rationale: Accuracy of catheter position is ing of previously taught information is evaluated and
ensured. reinforced.
• Determine whether the patient has a permanent pace- • Place the patient in a supine position with the head of the
maker, temporary transvenous pacemaker, or ICD. Ratio- bed in a slight Trendelenburg’s position (or flat if Tren-
nale: PA catheter removal by a critical care nurse is delenburg’s position is contraindicated or not tolerated by
contraindicated in the presence of a permanent pacemaker, the patient). Rationale: The patient should be positioned
temporary transvenous pacemaker, or ICD. Entanglement so that the catheter exit site is at or below the level of the
of the PA catheter and the pacemaker electrodes can occur. heart.5,6 A normal pressure gradient exists between atmo-
• Assess the integrity of the PA catheter. Rationale: The PA spheric air and the central venous compartment that pro-
catheter should be removed by an advanced practice nurse motes air entry if the compartment is open. The lower the
or physician if the integrity of the PA catheter or intro- site of entry below the heart, the lower the pressure gradi-
ducer is compromised (e.g., visible cracks are noted). ent, thus minimizing the risk of air being drawn in and
• Assess the catheter insertion site for redness, warmth, thus a venous air embolism.
tenderness, or presence of drainage. Rationale: Signs and
symptoms of infection are assessed.
Procedure for Pulmonary Artery Catheter Removal

1. HH
and other healthcare professionals in
the room should wear personal
protective equipment including a face
mask.
3. Transfer or discontinue Prepares the catheter for removal. Make sure the patient has the proper
intravenous (IV) solution and alternative IV access to transfer
flush solutions. solutions/medications that were
administered through the PA catheter
before removal.
4. Place a moisture-proof absorbent Collects blood and body fluids
pad under the patient’s upper associated with removal; serves
torso and another under the PA as a receptacle for the
catheter. contaminated catheter.
5. Place the patient supine in a Minimizes the risk for venous air Place the patient flat if Trendelenburg’s
slight Trendelenburg’s embolus. The patient should be position is contraindicated, not
position.3,7–9,14 (Level E*) positioned so that the catheter tolerated by the patient, or a femoral
exit site is at or below the level PA catheter will be removed.
of the heart.5,6 If the PA catheter is in the femoral vein,
extend the patient’s leg and ensure the
groin area is adequately exposed.

Procedure for Pulmonary Artery Catheter Removal—Continued

6. Have the patient turn his or her Decreases the risk for This step is not needed if a femoral PA
head away from the PA catheter contamination. catheter.
and insertion site.
7. Open supplies. Prepares for removal.
8. Remove the syringe from the Allows air to passively escape Myocardial or valvular tissues can be
balloon inflation port, ensure that from the balloon and ensures damaged if the PA catheter is removed
the gate valve or stopcock is in adequate balloon deflation. with the balloon inflated.
the open position, and observe
the PA waveform (see Fig. 72-6).
9. Turn off all stopcocks to the Prepares for removal.
patient.
10. Remove the old dressing. Prepares for removal. Signs of local or systemic infection may
determine the need to send a culture
of the catheter tip.
11. Unlock the sheath from the Prepares for removal.
introducer catheter.
12. Discard nonsterile gloves in Removes and safely discards used
appropriate receptacle, perform supplies. Reduces the
hand hygiene, and apply sterile transmission of microorganisms;
gloves. Standard Precautions.
13. If present, clip the sutures Frees the PA catheter for removal.
securing the PA catheter.
14. Ask the patient to take a deep Minimizes the risk for venous air If the patient is receiving positive
breath in and hold it.11–15 embolus. pressure ventilation, withdraw the
(Level E*) catheter during the inspiratory phase of
the respiratory cycle or while a breath
is delivered via a bag-valve device.
15. While stabilizing the introducer Ensures the removal of an intact Observe the ECG tracing rhythm and the
catheter, gently withdraw the PA catheter. waveforms from the distal lumen
catheter with a constant, steady during removal. Dysrhythmias may
motion (Fig. 73-1). occur during removal but are usually
self-limiting.1,11,13 If resistance is met,
do not continue to remove the
catheter; notify the advanced practice
nurse or physician immediately.
Resistance may be caused by catheter
knotting, kinking, or wedging.
Figure 73-1 While stabilizing the intro-

ducer, gently withdraw the pulmonary
artery catheter using a constant, steady
motion. (From Wadas TM: Pulmonary
artery catheter removal, Crit Care Nurse
14:63, 1994.)

16. Temporarily cover the The hemostasis valve must be The introducer may remain in place to
hemostasis valve with a sterile- occluded to minimize the risk provide central venous access.
gloved finger until the sterile for air embolus and blood loss.
obturator/cap is attached.
17. Instruct the patient to exhale as Once the catheter is removed the
soon as the PA catheter is patient can breathe normally.
removed.
18. Place the PA catheter on the Allows for assessment of the If the catheter tip will be cultured, have
moisture-proof absorbent pad catheter. another provider assist with cutting
and inspect it to ensure that the the tip with sterile scissors and placing
entire catheter was removed. it in a sterile specimen container
before placing the PA catheter on the
moisture-proof absorbent pad.
19. If the introducer remains in Decreases the risk for infection at
place, perform site care and the insertion site.
apply a sterile dressing to the
site per institutional standards.
20. If the introducer is to be Frees the introducer for removal.
removed, clip the sutures or
remove the securing device.
21. Ensure that the patient is still Minimizes the risk for venous air Cases have been reported of venous air
supine in a slight embolus. The patient should be embolus occurring after removal of
Trendelenburg’s position.3,7–9,14 positioned so that the catheter central venous catheters when patients
(Level E*) exit site is at or below the level were not in a supine slight
of the heart.5,6 Trendelenburg position.
22. Ask the patient to take a deep Minimizes the risk for venous air If the patient is receiving positive
breath in and hold it.9,11–13 embolus. pressure ventilation, withdraw the
(Level E*) catheter during the inspiratory phase
of the respiratory cycle or while a
breath is delivered via a bag-valve
device.
If the introducer is in the femoral vein,
extend the patient’s leg and ensure the
groin area is adequately exposed.
23. Withdraw the introducer, pulling Minimizes trauma. If resistance is met, do not continue to
parallel to the skin and using a remove the introducer. Notify the
steady motion. advanced practice nurse or physician
immediately.
24. As the introducer exits the site, Minimizes the risk for venous air
apply pressure with a gauze pad. embolus and promotes
hemostasis.
25. Instruct the patient to exhale as Once the catheter is removed, the
soon as the introducer is patient can breathe normally.
removed.
26. Lay the introducer on the Ensures the removal of the entire If the introducer tip will be cultured,
moisture-proof absorbent pad. introducer. have another provider assist with
Check to be sure that all of the cutting the tip with sterile scissors and
introducer was removed. placing it in a sterile specimen
container before placing the introducer
on the moisture-proof absorbent pad.
Routine culturing of tips upon removal
is not recommended.6


27. Continue applying firm, direct Ensures hemostasis. Because central venous catheters are
pressure over the insertion site placed in large veins, 10 minutes may
with the gauze pad until bleeding be needed for hemostasis to occur.
has stopped. Pressure may be needed for a longer
coagulation study results are
abnormal.
28. Apply an occlusive dressing, Decreases the risk for infection at Mark the dressing with the date, time,
consisting of sterile petroleum- the insertion site and minimizes and your initials. Indicates when the
based ointment and sterile gauze, the risk for venous air embolus. dressing was placed.
and cover with tape or a
membrane dressing.3,5–7,9,11
(Level E*)
29. Maintain the patient in the May decrease the risk of a
supine position for 30 minutes postprocedure venous air
after catheter removal.5 embolism.
31. HH

• The PA catheter is removed • Dysrhythmias
• The introducer may or may not be removed • Valvular damage
• PA rupture
• Thrombosis
• Venous air emboli
• Uncontrolled bleeding
• Infection
• Inability to percutaneously remove the PA catheter
because of knotting or kinking
• Pain
• Broken catheter/fragmentation

interventions.
1. Assess the need for the PA catheter The Centers for Disease Control and • Signs and symptoms of infection
daily. If long-term use of the PA Prevention (CDC)10 and research at the PA catheter insertion site
catheter is needed; consider findings2,4 recommend that PA • Signs and symptoms of sepsis
changing the PA catheter every 7 catheters do not need to be
days. (Level B*) changed more frequently than
every 7 days. There are no specific
replacement of PA catheters that
need to be in place for >7 days.4,10
malfunctioning.8
2. Monitor the patient’s vital signs, Provides baseline data and data that • Abnormal vital signs
pulse oximetry, and level of identify changes in patient • Persistent shortness of breath or
consciousness before and after the condition. tachypnea
PA catheter and/or introducer • Cyanosis or decreased oxygen
removal. saturation
• Changes in mental status
• Signs of acute cardiac ischemia
(chest pain, ECG changes, etc.)
3. Monitor the patient’s cardiac rate Ventricular dysrhythmias may occur • Ventricular dysrhythmias that
and rhythm during PA catheter as the PA catheter passes through occur after the PA catheter is
withdrawal. the right ventricle. removed
4. Monitor for signs and symptoms of Venous air embolus is a potentially • Respiratory distress
venous air embolus and, if present, life-threatening complication. The • Dyspnea
immediately place the patient in left lateral Trendelenburg’s position • Coughing
the left lateral Trendelenburg’s prevents air from passing into the • Tachypnea
position. left side of the heart and traveling • Altered mental status (agitation,
into the arterial circulation. restlessness)
• Cyanosis
• Gasp reflex
• Sucking sound near site of
• Petechiae
• Chest pain
• Hypotension
5. After removal of the introducer, Bleeding or a hematoma can develop • Bleeding
assess the site for signs of bleeding if there is still bleeding from the • Hematoma development
every 15 minutes × 2, every 30 vessel.
minutes × 2, and then 1 hour later.
6. Remove the dressing and assess Verifies healing and closure of the • Abnormal healing
for site closure 24 hours after site.
introducer removal.

Documentation
• Patient and family education • Date and time of removal
• Patient assessment before and after removal of the PA • Occurrence of unexpected outcomes
catheter • Nursing interventions taken
• Patient’s response to the procedure • Application of an air-occlusive dressing
• Pain assessment, interventions, and effectiveness • Site assessment

73 Pulmonary Artery Catheter Removal 636.e1
References 11. Oztekin DS, et al: Comparison of complications and

1. Baldwin IC, Heland M: Incidence of cardiac dysrhythmias procedural activities of pulmonary artery catheter removal
in patients during pulmonary artery catheter removal after by critical care nurses versus medical doctors. Nurs Crit
cardiac surgery. Heart Lung 29:155–160, 2000. Care 13:105–115, 2008.
2. Chen Y, et al: Comparison between replacement at 4 days 12. Peter DA, Saxman C: Preventing air embolism
and 7 days on the infection rate for pulmonary artery when removing CVCs: An evidence-based approach
catheters in an intensive care unit. Crit Care Med to changing practice. Medsurg Nurs 12:223–229,
31:1353–1358, 2003. 2003.
3. Ely EW, et al: Venous air embolism from central venous 13. Rountree WD: Removal of pulmonary artery catheters by
catheterization: A need for increased physician awareness. registered nurses: A study in safety and complications.
Crit Care Med 27:2113–2117, 1999. Focus Crit Care 18:313–318, 1991.
4. Eyer S, et al: Catheter-related sepsis: Prospective, 14. Turnage WS, Harper JV: Venous air embolism occurring
randomized study of three methods of long-term catheter after removal of a central venous catheter. Anesth Analg
maintenance. Crit Care Med 18:1073–1079, 1990. 72:559–560, 1991.
5. Infusion Nurses Society: Policies and procedures for
infusion nursing, ed 5, 2016, Infusion Nurses Society. Additional Readings
6. Infusion Nurses Society: Infusion nursing standards of Arnaout S, et al: Rupture of the chordae of the tricuspid valve
practice. J Infus Nurs 39(1S):S11–S159, 2016. after knotting of the pulmonary artery catheter. Chest
7. Kim DK, et al: The CVC removal distress syndrome: An 120:1742–1744, 2001.
unappreciated complication of central venous catheter Darovic GO: Hemodynamic monitoring: Invasive and
removal. Am Surg 64:344–347, 1998. noninvasive clinical application, ed 3, Philadelphia, 2002,
8. McCarthy PM, et al: Air embolism in single-lung Saunders.
transplant patients after central venous catheter removal. Lough M: Hemodynamic monitoring: Evolving technologies
Chest 107:1178–1179, 1995. and clinical practice, St. Louis, 2015, Elsevier.
9. Mennim P, Cormac FC, Taylor JD: Venous air embolism Mirski MA, et al: Diagnosis and treatment of vascular air
associated with removal of central venous catheter. BMJ embolism. Anesthesiology 106:164–177, 2007.
305:171–172, 1992. Wadas TM: Pulmonary artery catheter removal. Crit Care
10. O’Grady N, et al: Guidelines for the prevention of Nurse 14:62–72, 1994.
intravascular catheter-related infections. Am J Infect Woodrow P: Central venous catheters and central venous
Control 39(4):S1–S34, 2011. pressure. Nurs Stand 16:45–52, 54, 2002.
PROCEDURE
74
Pulmonary Artery Catheter and
Pressure Lines, Troubleshooting
Reba McVay
PURPOSE: Troubleshooting of the pulmonary artery (PA) catheter is important to
maintain catheter patency, to ensure that data from the PA catheter are accurate,
and to prevent the development of catheter-related and patient-related
complications.
• The waveforms that occur during insertion should be

PREREQUISITE NURSING recognized, including right atrial (RA), right ventricular
KNOWLEDGE (RV), PA, and PA occlusion (PAO; see Fig. 72-3).
• The a wave reflects atrial contraction. The c wave reflects
• Knowledge of cardiovascular and pulmonary anatomy closure of the atrioventricular valves. The v wave reflects
and physiology is needed. passive filling of the atria during ventricular systole (see
• An understanding of basic dysrhythmia recognition and Figs. 72-4 and 72-5).
treatment of life-threatening dysrhythmias is important. • Knowledge of normal hemodynamic values (see Table
• Advanced cardiac life support (ACLS) knowledge and 64-1) is needed.
skills are needed. • Elevated a and v waves may be evident in RA or central
• Knowledge of principles of aseptic technique is venous pressure (CVP) and in PAO waveforms. These
necessary. elevations may occur in patients with cardiac tamponade,
• Understanding of the setup of the hemodynamic monitor- constrictive pericardial disease, and hypervolemia.
ing system (see Procedure 75) is needed. • Elevated a waves in the RA or CVP waveform may occur
• An understanding of the PA catheter (see Fig. 72-1) and in patients with pulmonic or tricuspid stenosis, right-
the location of the PA catheter in the heart and pulmonary ventricular ischemia or infarction, right-ventricular failure,
artery (see Fig. 72-2) is needed. PA hypertension, and atrioventricular dissociation.
• Pulmonary artery occlusion pressure (PAOP) may be • Elevated a waves in the PAO waveform may occur in
referred to as PA wedge pressure. patients with mitral stenosis, acute left ventricular isch-
• After wedging of the PA catheter, air is passively removed emia or infarction, left ventricular failure, and atrioven-
by disconnecting the syringe from the balloon-inflation tricular dissociation.
port. Active withdrawal of air from the balloon is avoided • Elevated v waves in the RA or CVP waveform may occur
because it can weaken the balloon, pull the balloon struc- in patients with tricuspid insufficiency.
ture into the inflation lumen, and possibly cause balloon • Elevated v waves in the PAO waveform may occur in
rupture. patients with mitral insufficiency or ruptured papillary
• The pulmonary artery diastolic pressure (PADP) and the muscle.
PAOP are indirect measures of left-ventricular end-
diastolic pressure. Usually, the PAOP is approximately 1 EQUIPMENT
to 4 mm Hg less than the PADP. Because these two pres-
sures are similar, the PADP is commonly followed, which • Nonsterile gloves
minimizes the frequency of balloon inflation, thus decreas- • Syringes (5 or 10 mL)
ing the potential of balloon rupture. • Sterile injectable or noninjectable caps
• Differences between the PADP and the PAOP may exist • Sterile 4 × 4 gauze
for patients with pulmonary hypertension, chronic obstruc- • Stopcocks
tive lung disease, adult respiratory distress syndrome, • Needleless blood-sampling access device
pulmonary embolus, and tachycardia. • Pressure monitoring cables
• Pulmonary artery pressures (PAPs) may be elevated • Pressure transducer system, including flush solution rec-
because of PA hypertension, pulmonary disease, mitral ommended according to institutional standards, a pressure
valve disease, left ventricular failure, atrial or ventricular bag or device, pressure tubing with transducers, and flush
left-to-right shunt, pulmonary emboli, or hypervolemia. device
• PAPs may be decreased because of hypovolemia or low • Dual-channel recorder
pulmonary vascular resistance (e.g., vasodilation). • Leveling device (low-intensity laser or carpenter level)
637
Additional equipment (to have available depending on patient move back into the right ventricle, or may become dis-
need) includes the following: lodged with the catheter tip malpositioned in the RA or
• Indelible marker central vein.
• Emergency equipment • Assess the configuration of the PA catheter waveforms.
• Blood-specimen tubes Rationale: Thrombus formation at the tip of the catheter
lumen may be evidenced by an overdamped waveform.
PATIENT AND FAMILY EDUCATION • Assess the patient’s hemodynamic and cardiovascular
status. Rationale: The patient’s clinical assessment should
• Explain the troubleshooting procedures to the patient and correlate with the PA catheter derived hemodynamic data.
family. Rationale: The patient and family are kept • Assess the patient and the PA catheter site for signs of
informed, and anxiety is reduced. infection. Rationale: Infection can develop because of the
• Explain the patient’s expected participation during the invasive nature of the PA catheter.
procedure. Rationale: This explanation will encourage
patient assistance. Patient Preparation
• Inform the patient and family of signs and symptoms to • Verify that the patient is the correct patient using two
report to the critical care nurse, including chest pain, pal- identifiers. Rationale: Before performing a procedure, the
pitations, new cough, tenderness at the catheter-insertion nurse should ensure the correct identification of the patient
site, and chills. Rationale: The patient is encouraged to for the intended intervention.
report signs of discomfort and potential PA catheter • Ensure that the patient understands preprocedural teach-
complications. ing. Answer questions as they arise, and reinforce infor-
mation as needed. Rationale: Understanding of previously
PATIENT ASSESSMENT AND taught information is evaluated and reinforced.
PREPARATION • Determine the patency of the patient’s intravenous cath-
eters. Rationale: Access may be needed for administra-
Patient Assessment tion of emergency medication or fluids.
• Monitor PA waveforms continuously. Rationale: The PA
catheter may migrate forward into a wedged position, may
Procedure for Pulmonary Artery Catheter and Pressure Lines, Troubleshooting

1. HH
2. PE
Troubleshooting an Overwedged PA Catheter Balloon
1. Identify an overwedged PA The overwedged PA catheter balloon Overinflation of the balloon can cause
catheter balloon from the PA occurs when the PA catheter pulmonary arteriole infarction or
waveform analysis (Fig. 74-1). balloon is overinflated. rupture, resulting in life-threatening
hemorrhage.
2. Remove the syringe from the gate Facilitates passive removal of air Ensure that the gate valve or stopcock
valve or the stopcock of the PA from the PA catheter balloon. is in the open position (see Fig.
balloon inflation port. 72-6).
3. Note the change in the PA As the balloon deflates the PA
waveform from the overwedged waveform returns.
waveform to the PA waveform.
4. Fill the syringe with 1.5 mL of Determines the amount of air needed
air and connect the syringe to the to convert the PA waveform to a
gate valve or stopcock of the PAO waveform.
balloon port of the PA catheter.
Slowly inflate the balloon with
air until the PA waveform
changes to a PAO waveform (see
Fig. 72-10) and note the amount
of air used.
5. Disconnect the syringe from the Allows air to passively escape from Active withdrawal of air from the
balloon-inflation port to deflate the balloon. balloon can weaken the balloon,
the balloon and verify that the pull the balloon structure into the
PAO waveform changes back to inflation lumen, and possibly cause
the PA waveform. (Level M*) balloon rupture.

74 Pulmonary Artery Catheter and Pressure Lines, Troubleshooting 639
Figure 74-1 Balloon inflation (arrow). Overwedging of balloon (balloon has been overinflated).
The danger of overinflating the balloon is that the pulmonary artery vessel may rupture from the
pressure of the balloon. ECG, electrocardiogram; PAP, Pulmonary artery pressure.
Procedure for Pulmonary Artery Catheter and Pressure Lines,

Troubleshooting—Continued
6. Expel air from the balloon The syringe should remain empty The syringe that is manufactured for
syringe and reconnect the empty when reconnected so that accidental the PA catheter should be connected
balloon syringe to the balloon- balloon inflation does not occur. to the PA balloon port to avoid loss
inflation port. of the custom-designed syringe.
7. Follow institutional standards The most important considerations are
waveform reflects a PA waveform.
8. Note the external centimeter Identifies whether the PA catheter has The advanced practice nurse or the
marking of the PA catheter at the migrated forward from the physician may need to reposition
introducer exit site. previously documented the catheter.
measurement.
9. Note and record the amount of air Prevents overinflation of the PA
needed to wedge the PA catheter. catheter balloon.
Preventing an Overwedged PA Catheter
1. Fill the syringe with 1.5 mL of Instilling more than 1.5 mL of air
air. may rupture the PA balloon and the
pulmonary arteriole.
2. Connect the PA balloon syringe This port is designed for PA balloon The PA balloon syringe is designed so
to the gate valve or stopcock of inflation. it will not hold more than 1.5 mL
the balloon-inflation port of the of air.
PA catheter.
3. Slowly inflate the balloon with Only instill enough air needed to
air until the PA waveform convert the PA waveform to a PAO
changes to a PAO waveform (see waveform.
Fig. 72-10).
4. Inflate the PA balloon for no Avoids prolonged pressure on the
more than 8–15 seconds (2–4 pulmonary arteriole.
respiratory cycles).

5. Disconnect the PA balloon Allows air to passively exit from the
syringe from the balloon-inflation balloon.
port for passive deflation of the
balloon.
6. Observe the monitor as the PAO Ensures adequate balloon deflation.
waveform changes back to the PA
waveform.
7. Expel air from the PA syringe. The syringe should remain empty
when reconnected so that accidental
balloon inflation does not occur.
8. Reconnect the empty PA balloon Retains the safety syringe.
syringe to the balloon inflation
port.
9. Follow institutional standards The most important considerations are
waveform reflects a PA waveform.
Troubleshooting an Absent Waveform
1. Check to see whether there is a Kinks may inhibit waveform
kink in the PA catheter. transmission.
2. Ensure that all connections are Loose connections allow air into the
tight. system and can overdamp or
eliminate the waveform.
3. Ensure that the stopcock is open Stopcocks open to the transducer
to the transducer (Fig. 74-2). system allow waveform
transmission from the
cardiovascular system to the
monitor; stopcocks closed to the
transducer prevent waveform
transmission to the monitor and
oscilloscope.
4. Check that the cables are in the Necessary for signal transmission.
appropriate pressure modules.
5. Ensure that the pressure cables No waveform is transmitted without
are securely plugged into the proper connection.
monitor.
6. Ensure that the appropriate Necessary for specific parameter
monitor parameters are turned on. monitoring.
7. Ensure the appropriate scale has A larger scale (e.g., 100 mm Hg)
been chosen for pressure being causes the waveform to be smaller
monitored (e.g., 40 mm Hg scale and possibly not to be visible on
is used for PA monitoring). the oscilloscope.
8. Level and zero the monitoring Ensures accurate setup and function
system (see Procedure 75). of the monitoring system.
9. Ensure that there is fluid in the Low pressure may result in a clotted A square waveform test should not be
flush bag and that the pressure on catheter, resulting in loss of the done. A clotted catheter under
the flush bag or device is waveform. pressure of flush may dislodge
delivering 300 mm Hg. clots.
10. Aspirate through the stopcock Ensures patency of the PA catheter. A clotted/obstructed catheter has no
that is closest to the catheter to waveform and no blood return
check for blood return (see when aspirated.
Fig. 63-2).
Figure 74-2 The stopcock is open to the transducer. (From Ahrens TS, Taylor LK: Hemodynamic
waveform recognition, Philadelphia, 1993, Saunders.)

11. Replace the monitoring cable. A faulty cable can result in an absent If the cable is changed, zero the
waveform. monitoring system.
12. Replace the pressure transducer A faulty transducer can result in an If the pressure transducer system is
system. absent waveform. changed, zero the new monitoring
system.
13. Notify the advanced practice The catheter may need to be removed
nurse or the physician if or replaced.
troubleshooting is unsuccessful.
Troubleshooting an Overdamped Waveform
1. Obtain a monitor strip of The waveform can be compared with
the overdamped waveform the previous waveforms.
(Fig. 74-3).
2. Ensure that all connections are Loose connections allow air into the
tight. system or loss of pressure from the
system and can overdamp the
waveform.
3. Ensure that there is fluid in the Low counterpressure from the flush
flush bag and that the pressure on solution bag results in an
the flush bag or device is set at overdamped waveform.
300 mm Hg.
C
Figure 74-3 Effects of overdamping on pulmonary artery pressure (PAP) and right-atrial pressure
(RAP) waveforms. A, Normal waveform with elevated pulmonary artery pressures (1, systole;
2, dicrotic notch; 3, diastole). B, Overdamped PAP waveform. C, Overdamping of RAP wave
form. Overdamping of the waveform may result from clots at the catheter tip, catheter against
vessel or heart wall, air in lines, stopcock partially closed, or deflated pressure bag. ECG,
electrocardiogram.

4. Check all tubing for air bubbles. Removes air from the system, Check that the IV flush bag and
If air exists within the transducer, prevents the air from entering the pressure tubing drip chamber
follow these steps: patient, and ensures accurate contain fluid.
A. Remove the noninjectable cap monitoring of waveforms.
at the top port of the stopcock
or cleanse the top of the
injectable cap with an
antiseptic solution.
B. Insert a sterile syringe or a
into the top port of the
stopcock or the top of the
injectable cap of the stopcock
(see Figs. 62-1 and 63-1).
C. Turn the stopcock off to the
patient (see Figs. 62-3).
D. Fast flush the air from the
transducer and system into the
syringe or insert a blood-
specimen tube into the
E. Open the system to the
transducer (see Figs. 62-1 and
63-1).
F. Remove the syringe or the
from the stopcock.
G. Zero the hemodynamic
monitoring system (see
Procedure 75).
H. If not using an injectable cap,
place a new noninjectable cap
on the top port of the
stopcock.
I. Evaluate and then monitor the
waveform.
5. If air exists between the pressure Removes air from the system,
bag and a stopcock, follow these prevents the air from entering the
steps: patient, and prevents overdamping
of the system to ensure accurate
monitoring.
A. Remove the noninjectable cap
(see Figs. 62-1 and 63-1).

patient (see Fig. 62-3).
D. Fast flush the air from the
transducer and system into the
E. Open the system to the
transducer (see Fig. 62-1 and
63-1).
F. Remove the syringe or the
from the stopcock.
G. If not using an injectable cap,
place a new sterile
noninjectable cap on the top
port of the stopcock.
H. Evaluate and monitor the PA
waveform.
6. If the air is between the patient Removes air from the system,
and a stopcock (Fig. 74-4), prevents the air from entering the
follow these steps: patient, and ensures accurate
monitoring of waveforms.
(see Figs. 62-1 and 63-1).
flush solution (see Figs. 62-2,
62-4, and 63-2.
D. Gently pull the air back into
the syringe or insert a
blood-specimen tube into the
injectable system.
Figure 74-4 Air between the patient and stopcock. (Courtesy Edwards Lifesciences, Irvine, CA.)

E. When all the air is removed,
turn the stopcock off to the
F. Fast flush the blood from the Clears the tubing of blood.
top port of the stopcock.
G. Open the system to the
63-1).
H. Remove the syringe or
from the stopcock.
I. Zero the hemodynamic
Procedure 75).
J. If not using an injectable cap,
place a new sterile
K. Evaluate and then monitor the
pressure waveform.
7. Aspirate through the stopcock of Ensures that blood flows easily within
the catheter to check for adequate the catheter and assesses for the
blood return. presence of clots.
B. Connect a 5–10-mL syringe to
the stopcock or to the
injectable cap.
flush solution (see Figs. 62-2,
62-4 and 63-2).
D. Gently aspirate until blood
enters the syringe.
E. Turn the stopcock open to the
63-1).
F. Fast flush the blood in the
tubing back into the patient.
G. Turn the stopcock off to the
patient (see Fig. 62-3) and
fast flush the blood from the
top port of the stopcock or the
injectable cap into the syringe.
H. Open the stopcock to the
63-1).
I. Remove the syringe from the
top port of the stopcock or the
injectable cap.
J. Zero the hemodynamic
Procedure 75).

K. If not using an injectable cap,
place a new sterile
of the stopcock.
L. Evaluate and then monitor the
waveform.
8. Check the transducer for the Ensures accurate monitoring of The pressure-transducer system may
presence of blood. If blood is waveforms. need to be replaced.
present, follow these steps:
B. Turn the stopcock off to the
C. Connect a 5–10-mL syringe to
the stopcock or to the
injectable cap or insert a
D. Fast flush the blood from the
transducer tubing into the
injectable access device.
E. Remove the syringe or the
blood-access device.
F. Turn the stopcock open to the
transducer (see Fig. 75-5).
G. Zero the hemodynamic
Procedure 75).
H. If not using an injectable cap,
place a new sterile
I. Evaluate and monitor the
waveform.
9. Observe the waveform and Determines whether the system is The square-wave test can be
(square-wave test). This will ensure that the pressure quickly releasing the fast flush.
defined. a flat line at the maximal indicator
This aids in accurate measurement. on the monitor.
extending below the baseline with
1–2 oscillations within 0.12 second
and a quick return to baseline. (See
Fig. 59-3).
10. Notify the advanced practice The catheter needs to be removed or
nurse or physician if replaced.
troubleshooting is unsuccessful.

Troubleshooting a Continuously Wedged Waveform
1. Identify the wedged waveform Confirms the need for Continuous monitoring of the PA
(see Fig. 72-5). troubleshooting. waveform is necessary to assess for
the presence of the PA waveform.
PA catheters should be wedged for
no longer than 8–15 seconds (2–4
respiratory cycles) when obtaining
a PAOP measurement.
2. Remove the PA balloon inflation Ensures that air is not trapped within
syringe and ensure that the gate the PA balloon.
valve (see Fig. 72-6) or stopcock
is open.
3. Assist the patient in changing May help the catheter float out of the Monitor the PA waveform for a
position, or if possible ask the wedge position. change from a PAO waveform to a
patient to cough. PA waveform.
4. If troubleshooting is unsuccessful,
Immediate repositioning of the The critical care nurse may withdraw
notify the advanced practice catheter is necessary because the PA catheter according to
nurse or physician. prolonged wedging can lead to PA institutional policy.
infarction.
5. Never flush a wedged PA Flushing the catheter in the wedged
catheter. position may lead to PA rupture and
hemorrhage.
Troubleshooting a Catheter in the Right Ventricle
1. Identify the RV waveform (Fig. The RV waveform resembles the PA Note the external centimeter marking
74-5). waveform. on the PA catheter.
The RV waveform, however, does not
have a dicrotic notch.
In addition, the diastolic pressure of
the RV waveform is lower than the
PADP.
The normal PADP is 8–15 mm Hg;
the normal RV diastolic pressure is
0–8 mm Hg.
2. Inflate the PA balloon with The inflated PA balloon may readily
1.5 mL of air. float into position in the PA.
3. Observe for a change in the Waveform analysis aids in The catheter may not advance to the
waveform from RV to PA to PAO identification of PA catheter PA or PAO waveforms.
(see Fig. 72-3). position.
4. Remove the syringe from the PA Air passively is released from the PA Expel the air from the PA balloon
balloon inflation port. balloon. syringe, and then reconnect the
empty syringe to the balloon
inflation port.
5. Observe the PA waveform. The waveform should change from
the PAO waveform to a PA
waveform.
6. If the RV pressure waveform is An inflated PA balloon cushions the The PA catheter tip may cause
still present, inflate the PA balloon catheter tip and prevents ventricular dysrhythmias.
inflation port with 1.5 mL of air. endocardial irritation. If the PA balloon is inflated, the
ventricular dysrhythmias may
decrease because the inflated
balloon may cause less irritation of
the endocardium.
Figure 74-5 Right ventricular pressure (RVP) waveform. This waveform was seen coming from
the pulmonary artery (PA; distal) lumen of a PA catheter. The catheter was coiled in the right ventricle
(RV). ECG, electrocardiogram.

7. Assist the patient with a change The inflated PA catheter may float
of position. into the PA after a position change.
8. Observe for change in waveform Waveform analysis aids identification
from RV to PA to PAO (see Fig. of the PA catheter position.
72-3).
9. Remove the balloon syringe from Deflates the PA balloon. Expel air from the syringe.
the balloon port.
10. If troubleshooting is unsuccessful, The PA catheter cannot remain in the If ventricular dysrhythmias are
notify the advanced practice right ventricle because it may present, consider temporarily
nurse or physician. trigger life-threatening ventricular leaving the balloon inflated until
dysrhythmias. the catheter is repositioned in the
Immediate repositioning is necessary. PA.
If the balloon remains inflated,
continuous visual monitoring is
necessary in case the catheter floats
into the wedge position.
The critical care nurse may advance
or remove the PA catheter
according to institutional policy.
Troubleshooting an Inability to Wedge the PA Catheter
1. Note the external centimeter Determines whether the catheter has The advanced practice nurse or
marking of the PA catheter at the moved from its previous location. physician may need to reposition
introducer exit site and compare Most PA catheters are in the correct the catheter.
this with the most recent position if the external markings of
documented marking. the catheter are between 45 and
55 cm.
The PA catheter tip may not be distal
enough in the PA to float into the
wedge position.

2. Ensure that the PA balloon is The full 1.5 mL of air may be Repositioning the patient may aid in
inflated with the maximum necessary to wedge some PA changing the position of the
1.5 mL of air. catheters. catheter and may facilitate
successful wedging of the PA
catheter.
3. Resistance should be felt when Resistance is present when the PA The balloon may rupture because of
inflating the PA balloon. balloon is intact. overinflation, frequent inflations, or
repeated aspiration of air from the
balloon rather than allowing it to
passively deflate.
4. If no resistance is felt or if blood If the balloon is ruptured, no
flows back from the balloon resistance is felt during an inflation
lumen, follow these steps: attempt.
Blood may also come back through
the balloon lumen.
A. Immediately discontinue
balloon inflation attempts.
B. Remove the syringe.
C. Close the gate valve or
stopcock.
D. Tape the balloon inflation port
closed and label the tape that
the balloon should not be
used.
5. If the balloon is ruptured or The PA catheter may be removed and/ If the PA catheter remains in place,
troubleshooting is unsuccessful, or replaced. the PADP can be followed if the
notify the advanced practice PADP correlated with the PAOP.
nurse or physician.
Troubleshooting Unexpected Changes in PAP
1. Ensure that the patient is in the Studies have determined that the RA RA and PA pressures may be accurate
supine position with the head of and the PA pressures are accurate in for patients in the supine position
the bed from 0 to 45 degrees. this position.3–6,10,12,14,22,23 with the head of the bed elevated
(Level B*) up to 60 degrees,5,14 but additional
for patients in lateral positions;
position.1,2,7,9,13,17,20
2. Ensure that the air-fluid interface Ensures accurate pressure
(zeroing stopcock) is level with the measurements.
phlebostatic axis (see Procedure If the air-fluid interface is above the
75). phlebostatic axis, PA pressures are
falsely low.
If the air-fluid interface is below the
phlebostatic axis, PA pressures are
falsely high.


3. Zero the transducer-monitoring Ensures the accuracy of the
system (see Procedure 75). monitoring system.
4. Check for air bubbles in the Air contributes to an overdamped
pressure-monitoring system and pressure transducer system,
eliminate bubbles if present. resulting in falsely low pressure
measurements.
5. Assess the patient’s hemodynamic Hemodynamic data and assessment If the hemodynamic data and
parameters and compare with data should correlate. assessment data do not correlate,
assessment data. review hemodynamic measurement
steps for potential sources of
inaccuracy.
6. If the PAP changes and Hemodynamic data guide therapeutic
hemodynamic parameters are interventions.
accurate, administer/titrate fluids
or vasoactive agents as prescribed
and/or notify the advanced
practice nurse or physician.
Troubleshooting Blood Backup into a PA Catheter or Pressure-Transducer System
1. Turn the stopcock off to the Prevents blood from going into the If blood reaches the transducer, it may
patient (see Fig. 75-4). transducer. have to be replaced.
2. Ensure that the transducer system Loose connections or open stopcocks A crack in the system necessitates
is closed and that all connections cause a decrease in pressure within replacing the entire monitoring
are tight and that all stopcocks the fluid-filled system, and blood system.
are closed to air and have may exert a back pressure into the
noninjectable or injectable caps. pressure tubing.
3. Ensure that there is fluid in the Low pressure from the bag results in
flush solution bag and that the blood backup.
pressure on the flush bag or
device is delivering 300 mm Hg.
4. Once the source of the problem is Prevents clot formation within the
located and corrected, flush the monitoring system.
entire line to remove blood from Blood can become a medium for
the system. bacterial growth.15
5. Zero the hemodynamic Ensures accuracy of the monitoring
monitoring system (see Procedure system.
75).
oscillations within 0.12 seconds and
a quick return to baseline (see Fig.
59-3).
7. Evaluate and monitor the PA Ensures presence of the correct
waveform. waveform, location of PA catheter,
and system functioning.

Troubleshooting When the Patient Develops Hemoptysis or Bloody Secretions from the Endotracheal Tube
During PA Catheter Monitoring
1. Notify the physician/advanced PA perforation with hemorrhage is a
practice nurse immediately. potentially lethal complication of a
PA catheter.
2. Maintain patency of the airway. Prevents alterations in ventilation and Prepare for intubation if the patient is
oxygenation. not already intubated.
3. Remain with the patient for Reduces anxiety and fear; provides
monitoring and reassurance. essential assessment.
4. Be prepared to follow these steps: Blood loss from the PA can be fatal.
A. Send blood specimens to Immediate surgical or interventional
assess coagulation status and radiology repair of the PA may be
to prepare for blood-product necessary.
transfusions.
B. Assist if needed with calling
for a chest radiograph.
C. Prepare the patient for
transport to the procedural
area/operating room as
requested.
After All Troubleshooting Interventions:
supplies.
2. HH

• Normal pulmonary tissue perfusion • PA balloon rupture
• Absence of PA catheter–related dysrhythmias and other • Pulmonary infarction and rupture
complications • PA catheter–related infection
• Absence of signs of PA catheter–related infection • Discomfort at the PA catheter insertion site
• Absence of discomfort associated with PA catheter • Ventricular tachycardia unresponsive to
• Accurate PA waveform, pressure monitoring, and data antidysrhythmic medications

interventions.
1. The PA waveform should be Provides assessment of proper • Abnormal waveforms (e.g.,
continuously monitored. placement of the PA catheter and continued PAO waveform and RV
abnormal waveforms such as PAO waveforms)
or RV waveforms.
2. Pressure alarms should be set and Alerts the critical care nurse to • Abnormal hemodynamic values
remain on at all times. pressure changes and to
disconnections in the pressure-
monitoring system.
3. Evaluate the hemodynamic Ensures that the system is intact and • Abnormal waveforms
monitoring system and waveform functioning appropriately.
configurations.

4. Monitor hemodynamic status (PA, Guides diagnosis, appropriate • Abnormal hemodynamic
PAO, RA, cardiac output, cardiac therapeutic interventions, and monitoring values
index, systemic vascular resistance, evaluation of therapies.
etc.).
5. Assess the hemodynamic Identifies that troubleshooting has • Unsuccessful troubleshooting
waveforms and pressure values been successful. attempts
before and after troubleshooting.
Documentation
• Patient and family education • Patient tolerance of procedure
• Troubleshooting intervention and outcome • Site assessment
• Occurrence of unexpected outcomes and interventions • External centimeter marking of PA catheter noted at
• Pain assessment, interventions, and effectiveness exit site

74 Pulmonary Artery Catheter and Pressure Lines, Troubleshooting 652.e1
References related infections. Clin Infect Dis 52(9):1087–1099,

1. Blanch L, et al: Short term effects of prone position in 2011.
critically ill patients with acute respiratory distress 16. Osika C: Measurement of pulmonary artery pressures:
syndrome. Intensive Care Med 23:1033–1039, 1997. Supine verses side-lying head-elevated positions. Heart
2. Brussel T, et al: Mechanical ventilation in the prone Lung 18:298–299, 1989.
position for acute respiratory failure after cardiac surgery. 17. Pappert D, et al: Influence of positioning on ventilation-
J Cardiothorac Vasc Anesth 7:541–546, 1993. perfusion relationships in severe adult respiratory distress
3. Cason CL, et al: Effects of backrest elevation and position syndrome. Chest 106:1994, 1511–1516.
on pulmonary artery pressures. Cardiovasc Nurs 26:1–5, 18. Pelosi P, et al: Effects of the prone position on respiratory
1990. mechanics and gas exchange during acute lung injury. Am
4. Chulay M, Miller T: The effect of backrest elevation on J Respir Crit Care Med 157:387–393, 1998.
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13:138–140, 1984. injury. Crit Care Med 27:2375–2382, 1999.
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elevation and method of measurement. Am J Crit Care wedge pressures in critically ill adults. Heart Lung
1:61–69, 1992. 13:305, 1984.
7. Fridrich P, et al: The effects of long-term prone 22. Wilson AE, et al: Effect of backrest position on
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respiratory distress syndrome. Anesth Analg 83:1206– critically ill adults. Am J Crit Care 5:264–270, 1996.
1211, 1996. 23. Woods SL, Mansfield LW: Effect of body position upon
8. Groom L, Frisch SR, Elliot M: Reproducibility and pulmonary artery and pulmonary capillary wedge
accuracy of pulmonary artery pressure measurement in pressures in noncritically ill patients. Heart Lung 5:83–90,
supine and lateral positions. Heart Lung 19:147–151, 1976.
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9. Jolliet P, Bulpa P, Chevrolet JC: Effects of prone position on Additional Readings
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10. Keating D, et al: Effect of sidelying positions on pulmonary e18, 2016.
artery pressures. Heart Lung 15:605–610, 1986. Bridges EJ: Pulmonary artery pressure monitoring: When,
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lateral body positioning on measurements of pulmonary 305, 2006.
artery and pulmonary wedge pressures. Heart Lung Darovic GO: Hemodynamic monitoring: Invasive and
13:155–158, 1984. noninvasive clinical application, ed 3, Philadelphia, 2002,
12. Lambert CW, Cason CL: Backrest elevation and Saunders.
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Crit Care Nurs 9:327–335, 1990. monitoring series: Pulmonary artery pressure monitoring,
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Chest 94:103–107, 1988. Care Nurses.
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Guidelines for the prevention of intravascular catheter- Care Nurse 29:46–59, 2009.
PROCEDURE
75
Single-Pressure and Multiple-
Pressure Transducer Systems
Reba McVay
PURPOSE: Single-pressure and multiple-pressure transducer systems provide a
catheter-to-monitor interface so that intravascular and intracardiac pressures can
be measured. The transducer detects a biophysical event and converts it to an
electronic signal.
EQUIPMENT
PREREQUISITE NURSING
KNOWLEDGE • Invasive catheter (e.g., arterial, PA)
• Pressure modules and cables for interface with the monitor
• Knowledge of the anatomy and physiology of the cardio- • Cardiac output cable with a thermistor/injectate sensor for
vascular system is needed. use with the PA catheter
• Knowledge of principles of aseptic technique is necessary. • Pressure transducer system, including flush solution rec-
• Fluid-filled pressure-monitoring systems used for bedside ommended according to institutional standards, a pressure
hemodynamic pressure monitoring are based on the prin- bag or device, pressure tubing with transducers, and flush
ciple that a change in pressure at any point in an unob- device
structed system results in similar pressure changes at all • Monitoring system (central and bedside monitor)
other points of the system. • Dual-channel recorder
• Pressure transducers detect the pressure waveform gener- • Sterile injectable or noninjectable caps
ated by ventricular ejection and converts that pressure • Indelible marker
wave into an electrical signal, which is transmitted to the • Leveling device (low-intensity laser or carpenter level)
monitoring equipment for representation as a waveform Additional equipment (to have available depending on patient
on the oscilloscope. need) includes the following:
• Invasive measurement of intravascular (arterial) pressure • Heparin
requires insertion of a catheter into an artery. • 3-mL syringe
• Invasive measurement of intracardiac (right atrial [RA] • Stopcocks
and pulmonary artery [PA]) pressures requires insertion • 4 × 4 gauze pads or hydrocolloid gel pad
of a catheter into the PA. • Tape
• Invasive measurement of central venous pressure/RA • Nonsterile gloves
pressure can be monitored by insertion of a catheter into • Transducer holder and intravenous (IV) pole
the internal jugular vein or subclavian vein or via a port
of a PA catheter. PATIENT AND FAMILY EDUCATION
• A single-pressure transducer system is used to measure
pressure from a single catheter (e.g., arterial catheter, • Assess patient and family understanding of hemodynamic
central venous; Fig. 75-1). monitoring and the reason for its use. Rationale: Clarifi-
• A double-pressure transducer system is used to measure cation or reinforcement of information is an expressed
pressure from two catheters (e.g., arterial and central patient and family need.
venous) or two ports (e.g., PA and RA) from a single • Explain the procedure for hemodynamic monitoring.
catheter (e.g., PA catheter; Fig. 75-2). Rationale: This information prepares the patient and the
• A triple-pressure transducer system is commonly used to family for what to expect and may decrease anxiety.
measure pressures from the arterial and PA catheters. With
this system, arterial pressures, PA pressures, and RA pres- PATIENT ASSESSMENT AND
sures can be obtained (Fig. 75-3). PREPARATION
• For accuracy of the hemodynamic values obtained from
any transducer system, leveling and zeroing are Patient Assessment
essential. • Assess the patient for conditions that may warrant the
• All hemodynamic values (PA, RA, and arterial) are refer- use of a hemodynamic monitoring system, including
enced to the level of the atria. The external reference point hypotension or hypertension, cardiac failure, cardiogenic
of the atria is the phlebostatic axis. shock, cardiac arrest, hemorrhage, respiratory failure,
653
fluid imbalances, oliguria, anuria, and sepsis. Rationale:

To arterial Assessment provides data regarding signs and symptoms
or central
Normal saline venous catheter of hemodynamic instability.
solution in • Obtain the patient’s medical history of coagulopathies, use
pressure bag of anticoagulants, vascular abnormalities, cardiac valvular
disease, pulmonary hypertension, and peripheral neuropa-
thies. Rationale: The medical history assists in determin-
Air-fluid ing the safety of the procedure and aids in site selection.
interface
(zeroing Patient Preparation
stopcock)
• Verify the patient is the correct patient using two identi-
pressure
300
mm Hg OFF
fiers. Rationale: Before performing a procedure, the nurse

Transducer
should ensure the correct identification of the patient for
Monitoring
cable the intended intervention.
• Ensure that the patient and the family understand prepro-
cedural teaching. Answer questions as they arise, and
reinforce information as needed. Rationale: Understand-
OFF
ing of previously taught information is evaluated and

reinforced.
• Position the patient in the supine position with the head
of the bed flat or elevated up to 45 degrees. Rationale:
This positioning prepares the patient for hemodynamic
monitoring.
Figure 75-1 Single-pressure transducer system. (Drawing by

Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia,
PA.)
PA distal Right atrial

lumen port lumen port
Normal saline
solution in
pressure bag
ECG ART PA RA CO
300 pressure Air-fluid
mm Hg interface
(zeroing
stopcock)
OFF OFF
Transducer
Transducer holder
OFF
PA pressure RA pressure
monitoring monitoring
cable cable
Figure 75-2 Double-pressure transducer system. ART, arterial; CO, cardiac output, ECG, elec-
trocardiogram; PA, pulmonary artery; RA, right atrial. (Drawing by Paul W. Schiffmacher, Thomas
Jefferson University, Philadelphia, PA.)
75 Single-Pressure and Multiple-Pressure Transducer Systems 655
Balloon Right Pulmonary Right

To patient's inflation ventricular artery atrial
arterial valve and infusion catheter infusion
catheter syringe for IV fluid for IV fluid
0
Normal saline 1
solution in 2
pressure bag 3
PA distal Right atrial

lumen port lumen port
pressure
300 ECG ART PA RA CO
mm Hg Air-fluid
interface
(zeroing
stopcock)
OFF OFF OFF
Transducer
Transducer holder
OFF
Pressure
tubing
Figure 75-3 Triple-pressure transducer system. ART, arterial; CO, cardiac output, ECG, electro-
cardiogram; PA, pulmonary artery; RA, right atrial. (Drawing by Paul W. Schiffmacher, Thomas
Procedure for Single-Pressure and Multiple-Pressure Transducer Systems

Disposable Pressure Transducer System Setup
1. HH
2. Use an IV bag of normal saline Normal saline solution is preferred.
solution. Solutions containing dextrose
(Level B*) increase the incidence of infection
and should not be used.7,15,26,28,38
3. Follow institutional standards for Heparinized flush solutions are used Although heparin may prevent
adding heparin to the flush to minimize thrombi and fibrin thrombosis,28,35 it has been
solution. deposits on catheters that might associated with thrombocytopenia
(Level B*) lead to thrombosis or bacterial and other hematologic
colonization of the catheter. complications.9
Arterial catheters flushed with
heparinized saline solution are more
likely than those flushed with
nonheparinized saline solution to
remain patent for up to 72 hours.1,21
Further research is needed regarding
use of heparin versus normal saline
solution to maintain PA line patency.

Procedure for Single-Pressure and Multiple-Pressure Transducer Systems—Continued

4. Label the IV bag, indicating the Identifies the contents of the IV flush
date and time the solution was bag and identifies when the IV bag
hung, the dose of heparin needs to be changed.
(if used), and your initials.
5. Open the prepackaged pressure Provides the correct pressure tubing. Assemble the pressure transducers,
transducer kit with aseptic pressure tubing, and stopcocks if
technique. not preassembled by the
A. A single-pressure tubing kit manufacturer.
can be used for RA or arterial Use the minimal number of stopcocks
monitoring (see Fig. 75-1). and tubing length to avoid
B. A double-pressure tubing kit underdamped waveforms.
can be used for PA and RA
monitoring (see Fig. 75-2).
C. A triple-pressure tubing kit
can be used for arterial, PA,
and RA monitoring (see
Fig. 75-3).
6. Tighten all connections. Prepares the system. Tightening the
connections prevents air from
entering the system and fluid leaks.
7. Spike the outlet port of the IV Allows access to the IV flush Separate flush systems are needed if
solution with the pressure tubing. solution. invasive catheters are inserted at
different times.
8. Open the roller clamp and Primes the drip chamber. Filling the drip chamber at least
squeeze the drip chamber to fill halfway is important to prevent air
the chamber half full. bubbles from entering the tubing
and allows the nurse to see that the
solution is flowing when
performing a manual flush of the
invasive line.
9. Insert the IV bag into the Priming the tubing under pressure Air should never be allowed to
pressure bag or device on the IV increases turbulence and may cause develop in a hemodynamic system.
pole. Do not inflate the pressure air bubbles to enter the tubing. Micro or macro air emboli can
bag. migrate to major organs and present
a potentially life-threatening
complication.
10. Flush the entire system, including Eliminates air from the system. Vented caps are placed by the
transducer, stopcock, and pressure manufacturer and permit
tubing with the flush solution. sterilization of the entire system.
A. With the flush device, flush These vented caps need to be
solution from the IV bag replaced with sterile injectable or
through to the tip of the noninjectable caps to prevent
pressure tubing. bacteria and air from entering the
B. Turn the stopcock off to system.
the patient end of the tubing
(Fig. 75-4).
C. With the flush device, flush
solution from the IV bag
through the stopcock.
D. Replace the vented cap on the
stopcock with an injectable or
noninjectable cap.
E. Open the stopcock to the
transducer (Fig. 75-5).
11. With use of double-pressure or Eliminates air from the systems.
triple-pressure transducer systems,
repeat Step 10 with each of the
pressure transducer systems.
To To flush
O
F
F
patient solution
Figure 75-4 Stopcock off to the patient. (Drawing by Paul W. Schiffmacher, Thomas Jefferson
University, Philadelphia, PA.)
Flush device
O
F
F
To
patient To flush
solution
Transducer
Figure 75-5 Stopcock open to the transducer. (Drawing by Paul W. Schiffmacher, Thomas Jef-

12. Inflate the pressure bag or device Inflating the pressure bag to 300 mm
to 300 mm Hg. Hg allows approximately 1–3 mL/
hr of flush solution to be delivered
through the catheter, thus
maintaining catheter patency and
minimizing clot formation.
13. With use of a pole mount, insert Secures each transducer. Place each of the transducers into the
the transducer into the pole- space with the correct label (i.e.,
mount holder (sometimes called a PA, RA/central venous, or arterial)
transducer plate) (Fig. 75-6). (see Fig. 75-6).
14. With sterile technique, connect Allows for monitoring of pressures. Before assisting with connections,
the end of each transducer tubing protective equipment needs to be
to the appropriate catheter port applied.
(e.g., PA, RA, arterial).
supplies.
16. HH
17. Label the pressure tubing, Identifies when the pressure tubing
indicating the date, time, and needs to be changed.
your initials.
Monitor Setup
1. Turn on the bedside monitor. Prepares the monitor.
2. Plug the pressure cables into Necessary for signal transmission to Some monitors are preprogrammed to
the appropriate pressure modules the monitor. display the waveform that
in the bedside monitor (see corresponds to the module for cable
Fig. 75-3). insertion (e.g., first position,
arterial; second position, pulmonary
artery; third position, right atrial).
Figure 75-6 Transducers in pole mount. (Courtesy Edwards Lifesciences, Irvine, CA.)

3. Turn the parameters on (e.g., PA, Visualizes the correct waveforms.
RA, arterial).
4. Set the appropriate scale for the Necessary for visualization of the The scale for RA pressure is
pressure being measured. complete waveform and to obtain commonly set at 20 mm Hg.
accurate readings. The scale for PA pressure is
Waveforms vary in amplitude commonly set at 40 mm Hg.
depending on the pressure within The scale for arterial blood pressure
the system. is commonly set at 180 mm Hg.
Scales may vary based on monitoring
equipment. Scales can be adjusted
based on patient pressures.
Leveling the Transducer
1. HH
2. PE
position with the head of the bed and the PA pressures are accurate in for patients in the supine position
from 0 to 45 degrees. (Level B*) this position.8,10–12,17,22,24,42,43 with the head of the bed elevated
for patients in lateral positions;
other studies do not.4,8,14,17,30,37,41
position.3,6,13,16,23,32,40

4. Locate the phlebostatic axis for The phlebostatic axis is at The reference point for the left-lateral
the supine position (Fig. 75-7). approximately the level of the atria decubitus position is the fourth
and should be used as the reference intercostal space (ICS) at the left
point for the air-fluid interface. parasternal border (Fig. 75-8).18,31
The reference point for the right-
lateral decubitus position is the
fourth ICS at the midsternum (see
Fig. 75-8).18,31
A. Identify the fourth ICS on the
edge of the sternum.
B. Draw an imaginary line along
the fourth ICS laterally, along
the chest wall.
C. Draw a second imaginary line
from the axilla downward,
midway between the anterior
and posterior chest walls.
D. The point at which these two
lines cross is the level of the
phlebostatic axis.
E. Mark the point of the
phlebostatic axis with an
indelible marker.
5. Use a leveling device (low- Ensures that the air-fluid interface is
intensity laser or carpenter’s level with the phlebostatic axis.
level) to align the air-fluid Leveling to the phlebostatic axis
interface with the phlebostatic reflects accurate central arterial
axis. pressure values.
Figure 75-7 Phlebostatic axis in the supine position.
A B
Figure 75-8 Reference points for the hemodynamic monitoring system for patients in lateral
positions. A, For the right-lateral position, the reference point is the intersection of the fourth inter-
costal space and the midsternum. B, For the left-lateral position, the reference point is the intersection
of the fourth intercostal space and the left-parasternal border. (From Keckelsen M: Protocols for
practice: Hemodynamic monitoring series: Pulmonary artery monitoring, Aliso Viejo, CA, 1997,
American Association of Critical-Care Nurses.)

Pole mount2,36:
Low-intensity laser:
A. Place the low-intensity laser Ensures that the air-fluid interface is
leveling device next to the level with the phlebostatic axis.
air-fluid interface (zeroing Leveling to the phlebostatic axis
stopcock). reflects accurate central arterial
B. Point the laser light at the pressure values.
phlebostatic axis.
C. Move the pole mount holder
up or down until the interface
is level with the phlebostatic
axis.
Carpenter level:
A. Place one end of the carpenter Ensures that the air-fluid interface is
level next to the air-fluid level with the phlebostatic axis.
interface (zeroing stopcock). Leveling to the phlebostatic axis
B. Place the other end of the reflects accurate central arterial
carpenter level at the pressure values.
phlebostatic axis.
C. Move the pole-mount holder
up or down until the interface
is level with the phlebostatic
axis (Fig. 75-9).
6. With patient mount:
A. Place the pulmonary artery Ensures that the air-fluid interface is
distal/PA air-fluid interface level with the phlebostatic axis.
(zeroing stopcock) at the Leveling to the phlebostatic axis
phlebostatic axis. reflects accurate central arterial
pressure values.
B. Place the PA proximal (RA) Leveling the arterial interface to the
and arterial air-fluid interfaces tip of an arterial catheter reflects
(zeroing stopcocks) directly the transmural pressure of a
next to the pulmonary artery particular point in the arterial tree
distal/PA air-fluid interface. (e.g., radial artery) and not central
arterial pressure.5,20,27,33
C. Place a 4 × 4 gauze or May prevent skin breakdown.
hydrocolloid gel pad between
each of the transducers and
the patient’s skin.
D. Secure each of the systems in
place with tape.
7. Remove PE and discard.
8. HH
Figure 75-9 Air-fluid interface (zeroing stopcock) is level with the phlebostatic axis using a
carpenter level. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)

Zeroing the Transducer
1. HH
2. PE
3. Turn the stopcock off to the Prepares the system for the zeroing
patient end of the tubing (see procedure.
Fig. 75-4).
4. Remove the nonvented cap from Allows the monitor to use
the stopcock, opening the atmospheric pressure as a reference
stopcock to air. for zero.
5. Push and release the zeroing The monitor automatically adjusts Some monitors require that the zero
button on the bedside monitor. itself to zero. be turned and adjusted manually.
Observe the digital reading until Zeroing negates the effects of Some systems also may require
it displays a value of zero. atmospheric pressure. calibration.
Refer to manufacturer’s guidelines for
specific information.
6. Place a new, sterile injectable or Maintains sterility.
noninjectable cap on the
stopcock.
7. Turn the stopcock so that it Permits pressure monitoring and
is open to the transducer (see maintains catheter patency.
Fig. 75-5).
a quick return to baseline (see
Fig. 59-3).
10. HH

• The pressure-monitoring system is prepared aseptically • Loose connections within the hemodynamic
• The hemodynamic monitoring system remains intact monitoring system
with secure connections • Stopcocks left open to air without an injectable or
• The phlebostatic axis is accurately identified noninjectable cap
• The air-fluid interface of the transducer is leveled to • Air bubbles within the system
the phlebostatic axis • Pressure bag inflated to <300 mm Hg
• The pressure-monitoring system is zeroed

interventions.
1. Check the IV flush bag every 4 Ensures that the IV flush bag contains
hours and as needed. solution to maintain catheter
patency.
2. Check that the IV flush bag is Maintains catheter patency.
maintained at 300 mm Hg every 4
hours and as needed.
pressure tubing, transducers, and Nurses Society15 and research
stopcocks) every 96 hours. findings25,29 recommend that the
changed more frequently if near This recommendation is based on
empty of solution. research conducted with disposable
pressure monitoring systems used
4. If a nonvented cap is removed Reduces the risk of infection.
from a stopcock it should be
replaced with a new sterile
injectable or noninjectable cap.
5. Zero the hemodynamic monitoring Ensures the accuracy of the
system during initial setup or hemodynamic monitoring system.
before insertion, after insertion, if
disconnection occurs between the
cable, if disconnection occurs
between the monitoring cable and
the monitor, and when the values
picture.
Follow manufacturer’s
recommendations for disposable
systems.
6. Perform a dynamic response test An optimally damped system Overdamped or underdamped
(square-wave test) at the start of provides an accurate waveform. waveforms that cannot be corrected
each shift, with a change of the with troubleshooting procedures.
waveform, or when the system is
opened to air (see Fig. 59-3).
7. Check the hemodynamic Ensures that all connections are
monitoring system every 4 hours tightly secured and that there are no
and as needed. cracks in the system.
Ensures that the system is closed with
nonvented caps on all stopcocks.
Ensures that the system is free of air
bubbles.
8. Set the hemodynamic monitoring Provides immediate alarm for high
system alarms. and low pressures.
Documentation
• Patient and family education • Type of flush solution
• Date and time of hemodynamic monitoring system • Unexpected outcomes
preparation • Additional nursing interventions
• Hemodynamic monitoring system leveling and zeroing

75 Single-Pressure and Multiple-Pressure Transducer Systems 663.e1
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1993. readings: Variations with positions and transducer level.
2. Bisnaire D, Robinson L: Accuracy of leveling Nurs Res 33:343–345, 1984.
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4. Bridges EJ, et al: Effect of 30 degree lateral recumbent Crit Care Nurs 9:327–335, 1990.
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Am J Crit Care 9:262–275, 2000. 24. Laulive JL: Pulmonary artery pressures and position
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7. Buxton AE, et al: Failure of disposable domes to prevent caused by contaminated infusion products: IV: Growth of
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9. Chong BH: Heparin-induced thrombocytopenia. Br J 28. O’Grady NP, et al: Summary of recommendations:
Haematol 89:431–439, 1995. guidelines for the prevention of intravascular catheter-
10. Chulay M, Miller T: The effect of backrest elevation on related infections. Clin Infect Dis 52(9):1087–1099, 2011.
pulmonary artery and pulmonary capillary wedge 29. O’Malley MK, et al: Value of routine pressure monitoring
pressures in patients after cardiac surgery. Heart Lung system changes after 72 hours of use. Crit Care Med
13:138–140, 1984. 22:1424–1430, 1994.
11. Clochesy J, Hinshaw AD, Otto CW: Effects of change of 30. Osika C: Measurement of pulmonary artery pressures:
position on pulmonary artery and pulmonary capillary Supine versus side-lying head-elevated positions. Heart
wedge pressure in mechanically ventilated patients. NITA Lung 18:298–299, 1989.
7:223–225, 1984. 31. Paolella LP, et al: Topographic location of the left atrium
12. Dobbin K, et al: Pulmonary artery pressure measurement by computed tomography: Reducing pulmonary artery
in patients with elevated pressures: Effect of backrest catheter calibration error. Crit Care Med 16:1154–1156,
elevation and method of measurement. Am J Crit Care 1988.
1:61–69, 1992. 32. Pappert D, et al: Influence of positioning on ventilation-
13. Fridrich P, et al: The effects of long-term prone perfusion relationships in severe adult respiratory distress
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respiratory distress syndrome. Anesth Analg 83:1206– 33. Pauca AL, et al: Does radial artery pressure accurately
1211, 1996. reflect aortic pressure? Chest 102:1193–1198, 1992.
14. Groom L, Frisch SR, Elliot M: Reproducibility and 34. Pelosi P, et al: Effects of the prone position on respiratory
accuracy of pulmonary artery pressure measurement in mechanics and gas exchange during acute lung injury.
supine and lateral positions. Heart Lung 19:147–151, Am J Respir Crit Care Med 157:387–393, 1998.
1990. 35. Randolph AG, et al: Benefit of heparin in central venous
15. Infusion Nurses Society: Infusion therapy standards of and pulmonary artery catheters. Chest 113:165–171, 1998.
practice. J Infusion Nurs 39(1S):S85, 2016. 36. Rice WP, et al: A comparison of hydrostatic leveling
16. Jolliet P, Bulpa P, Chevrolet JC: Effects of prone position methods in invasive pressure monitoring. Crit Care Nurse
on gas exchange and hemodynamics in severe acute 20(20):22–30, 2000.
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pulmonary artery pressures. Heart Lung 15:605–610, 38. Solomon SL, et al: Nosocomial fungemia in neonates
1986. associated with intravascular pressure-monitoring devices.
18. Keckeisen M: Protocols for practice: Hemodynamic Pediatr Infect Dis 5:680–685, 1986.
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Aliso Viejo, CA, 1997, American Association of Critical- treatment of severe and moderate posttraumatic lung
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40. Vollman KM, Bander JJ: Improved oxygenation utilizing monitoring, Aliso Viejo, CA, 1998, American Association
a prone positioner in patients with acute respiratory of Critical-Care Nurses.
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1996. reference levels in supine and lateral positions. Am J Crit
41. Wild L: Effect of lateral recumbent positions on Care 2:72–80, 1993.
measurement of pulmonary artery and pulmonary artery Lough M: Hemodynamic monitoring: Evolving technologies
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hemodynamic and right ventricular measurements in Infect Control Hosp Epidemiol 10:47–53, 1989.
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e2–e18, 2016. artery pressure measurements. Int J Nurs Studies 36:
Darovic GO: Hemodynamic monitoring: Invasive and 497–505, 1999.
noninvasive clinical application, ed 3, Philadelphia, 2002, Vollman KM: What are the practice guidelines for prone
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Section Ten Special Cardiac Procedures
PROCEDURE
76
Femoral Arterial and Venous
Sheath Removal
Rose B. Shaffer
PURPOSE: Arterial and venous sheaths are placed for cardiac catheterizations
and interventional procedures. Achieving and maintaining hemostasis after their
removal is essential to prevent access site complications.
PREREQUISITE NURSING ❖ Percutaneous suture-mediated closure devices (e.g.,

Perclose [Abbott Vascular Devices, Santa Clara, CA])
KNOWLEDGE ❖ Percutaneous staple/clip closure devices (e.g., Star-
• Knowledge of the femoral artery and vein anatomy is Close [Abbott Vascular Devices, Santa Clara, CA])
important. • Collagen plug devices, percutaneous suture-mediated
• The technique for the percutaneous approach to the closure devices, and percutaneous staple/clip closure
insertion of the arterial and venous sheaths should be devices are deployed into the artery by the physician at
understood. the end of the diagnostic catheterization or interventional
• Technical and clinical competence in removal of arterial procedure.
and venous sheaths is needed. • Sheath removal can be associated with many complica-
• Knowledge about anticoagulation and antiplatelet therapy tions, including the following:
used during interventional procedures is essential. ❖ External bleeding at the site
• Understanding the technology (i.e., activated clotting time ❖ Internal bleeding (e.g., localized hematoma or retro-
[ACT] machine) used to determine the timing of arterial peritoneal bleed)
sheath removal and knowledge of the institution’s stan- ❖ Vascular complications (e.g., pseudoaneurysm, arterio-
dards regarding the appropriate ACT level before arterial venous fistula, dissection, thrombus, or embolus)
sheath removal is important. ❖ Neurovascular complications (sensory or motor
• The importance of peripheral vascular and neurovascular changes in the affected extremity)
assessment of the affected extremity (e.g., assessment of ❖ Vasovagal complications
the quality and strength of the pulse to be accessed and
the pulses distal to the access site, assessment for a bruit) EQUIPMENT
should be understood.
• Knowledge about the variety of hemostasis options avail- • Cardiac monitoring system
able should include the following: • Blood pressure monitoring system
❖ Manual compression alone or in combination with non- • Antiseptic solution (e.g., 2% chlorhexidine-based prepa-
invasive hemostasis pads (e.g., Syvek Patch [Marine ration)
Polymer Technologies, Inc., Danvers, MA]; D-Stat Dry • Nonsterile gloves
[Vascular Solutions, Minneapolis, MN]) • Sterile gloves
❖ Mechanical compression devices (e.g., FemoStop [St. • Protective eyewear
Jude Medical, St. Paul, MN; Fig. 76-1]; CompressAR • Dressing supplies
C-clamp [Advanced Vascular Dynamics, Milwaukie, • 10-mL syringe
OR]). Additional equipment, to have available as needed, includes
❖ Collagen plug devices (e.g., Angio-Seal [St. Jude the following:
Medical, St Paul, MN]) • Selected hemostasis option (mechanical compression
device or noninvasive hemostasis pad)
• Alcohol pads
practice nurses, and other healthcare professionals (including critical care • Indelible marker
nurses) with additional knowledge, skills, and demonstrated competence per • Selected analgesic and/or sedative as prescribed
professional licensure or institutional standard. • Portable Doppler ultrasound machine
664
76 Femoral Arterial and Venous Sheath Removal 665
• Assess the patient’s platelet count, prothrombin time, with

international normalized ratio, and partial thromboplastin
time before sheath removal. Rationale: Laboratory results
should be within acceptable limits (per institutional stan-
dards) to decrease the risk for bleeding after sheath
removal.
• Assess the patient’s complete blood count (CBC). Ratio-
nale: Assessment determines baseline data.
• Assess the patient’s ACT before sheath removal. Ratio-
nale: Results should be within acceptable limits (per insti-
tutional standards) to decrease the risk for bleeding after
sheath removal.
• Assess the patient’s electrocardiographic rhythm and vital
signs. Rationale: Baseline data are established. Collabo-
rate with the physician or advanced practice nurse if the
patient’s blood pressure is elevated; elevated blood pres-
sure may need to be treated before sheath removal to
Figure 76-1 FemoStop in the correct position. (From Barbiere achieve and maintain hemostasis.
C: A new device for control of bleeding after transfemoral catheter- • Review the documented baseline assessment of the access
ization, Crit Care Nurse 15[1]:52, 1995.) site before vascular access, including assessment for pres-
ence or absence of bruit. Rationale: Baseline assessment
• Suture removal kit data are established.
• ACT machine • Assess the extremity distal to the sheath for quality and
• Readily available emergency medications (e.g., atropine), strength of pulses, color, temperature, sensation, and
additional IV fluids, and resuscitation equipment movement. Rationale: Baseline assessment data are
established before sheath removal.
PATIENT AND FAMILY EDUCATION • Assess for patency of the intravenous (IV) access and
ensure that more than 500 mL of IV fluid remains in the
• Explain the procedure to the patient and the family. Ratio- IV bag or is readily available. Rationale: This assessment
nale: This explanation provides information and may allows for emergency medication or fluids to be adminis-
help decrease anxiety and fear. This also encourages the tered if necessary (e.g., vasovagal reaction).
patient to ask questions and voice concerns about the
procedure. Patient Preparation
• Explain the importance of bed rest, of not lifting the head • Verify that the patient is the correct patient using two
off the pillow, of maintaining the head of the bed at no identifiers. Rationale: Before performing a procedure, the
higher than 30 degrees, and of keeping the affected nurse should ensure the correct identification of the patient
extremity straight after the procedure. Rationale: The for the intended intervention.
patient is prepared for what to expect after the procedure, • Ensure that the patient and the family understand prepro-
and patient cooperation is elicited to decrease the risk for cedural teaching. Answer questions as they arise, and
bleeding, hematoma, and other vascular complications. reinforce information as needed. Rationale: Understand-
• Explain that the procedure may produce discomfort and ing of previously taught information is evaluated and
that pressure will be felt at the site until hemostasis is reinforced.
achieved. Encourage the patient to report discomfort, and • Verify that the physician, advanced practice nurse, or
reassure the patient that analgesia and or sedation will be other healthcare professional has placed an order stating
provided. Rationale: Explanation prepares the patient for when the femoral sheath can be removed. Rationale:
what to expect and allays fears. Before performing a procedure, the nurse should deter-
• After sheath removal, instruct the patient to report any mine the timing of removal of the femoral sheath.
warm, wet feeling, numbness, or pain at the puncture site. • Mark the distal pulses with an indelible marker. Ratio-
Also, instruct the patient to report any sensory or motor nale: Marking facilitates the ability to locate pulses after
changes in the affected extremity. Rationale: This aids in the procedure.
the early recognition of complications and identifies the • If a mechanical device is used to maintain pressure, posi-
need for additional pain interventions. tion the device under the patient. Rationale: The device
is positioned before sheath removal because patient move-
PATIENT ASSESSMENT AND ment must be minimized after sheath removal.
PREPARATION
Patient Assessment
• Assess the patient’s medical history for bleeding disor-
ders. Rationale: Bleeding disorders may increase the risk
for bleeding or vascular complications.
Procedure for Arterial and Venous Sheath Removal

1. HH
2. PE
3. Place a blood pressure cuff on the Establishes a baseline blood pressure Monitor the patient’s blood pressure
patient’s arm and obtain the before sheath removal. every 5 minutes during arterial
patient’s blood pressure. sheath removal until hemostasis is
achieved.
If possible, place the blood pressure
cuff on the opposite arm of the IV
to allow for uninterrupted flow of
IV fluids.
4. Place the head of the patient’s Prepares the patient for the procedure
bed in the flat position. and improves the ability to achieve
hemostasis.
5. Administer analgesia or sedation Analgesia and sedation have been The routine use of subcutaneous
as prescribed. (Level B*) shown to reduce the discomfort lidocaine infiltrated around the
associated with sheath catheter site has not been proven to
removal.15,31,34 reduce the discomfort associated
with sheath removal.8,15,31,34
6. Turn off the arterial catheter Monitoring is no longer needed;
alarm. prevents the alarm from sounding.
7. Open the suture-removal kit if the Prepares for sheath removal.
sheaths are sutured in place.
8. If using a noninvasive hemostasis Prepares for sheath removal and
pad in conjunction with manual ensures sterility.
compression, open the pad using
sterile technique.
9. Remove the arterial and venous Prepares for sheath removal.
sheath dressing.
10. Clean the arterial and venous Decreases the risk for infection.22 Follow institutional standards.
sites with an antiseptic solution
(e.g., 2% chlorhexidine solution).
11. Attach a 10-mL syringe to the Ensures there is no clot in the sheath. Notify the physician or advanced
blood-sampling port of the practice nurse if unable to withdraw
stopcock, turn the stopcock off to blood.
the flush bag, and gently draw
back 5–10 mL of blood into the
syringe.
12. Remove and discard the Removes and safely discards used
nonsterile gloves and used supplies.
supplies in the appropriate
receptacle.
13. HH
14. Apply sterile gloves. Maintains asepsis.
15. Remove sutures, if present. Prepares for sheath removal. Additional stabilizing devices may be
used and removed.
16. Palpate the femoral pulse. Allows for more accurate positioning
of the hemostasis option (manual or
mechanical).
Procedure for Arterial and Venous Sheath Removal—Continued

17. Determine the method that will Both manual and mechanical Collagen plug devices, percutaneous
be used to achieve hemostasis. compression devices are effective suture-mediated closure devices,
(Level B*) in achieving hemostasis and and percutaneous staple/clip closure
reducing the risk of groin devices are deployed into the artery
complications.5,7,13,23,24,27,33 by the physician at the end of the
Studies comparing arterial closure catheterization or interventional
devices to either manual or procedure.
mechanical compression are
inconclusive regarding the
optimal method of arterial
closure in terms of vascular
complications.1,6,12,16,21,25,27,29
18. Position the hemostasis option The arterial puncture site If the patient is obese or has a large
(manual or mechanical) 1–2 cm (arteriotomy) is superior and medial abdomen, a second person may be
above the site where the arterial to the skin puncture site because needed to assist with sheath
sheath enters the skin. (If using a the arterial sheath is inserted at a removal.
noninvasive hemostasis pad in 45-degree angle.
conjunction with manual Body weight is used to apply firm Adjust the bed height for the comfort
pressure, see Step 21.) pressure. of the person holding manual
With manual pressure, ensure pressure.
positioning with the arms straight
down, directly over the femoral
artery.
19. Simultaneously depress the Prevents bleeding. Removing the Never withdraw the sheath if
hemostasis option (manual or arterial sheath during the exhalation resistance is met. Notify the
mechanical) and gently remove phase of the respiratory cycle may physician or advanced practice
the arterial sheath from the prevent the patient from “bearing nurse.
femoral artery during exhalation. down” during arterial sheath
removal.
20. Continue to apply firm pressure. Firm pressure is needed to achieve The distal pulse may decrease during
hemostasis. application of full pressure but
should not be completely
obliterated. If manual compression
is being performed, another person
is needed to assess distal perfusion.
A. Maintain manual pressure The length of time needed to achieve Follow institution standard.
above the arterial puncture hemostasis depends on several
site for approximately 20 factors, including the size of the
minutes. sheath used; the type of procedure;
the use of bivalirudin, heparin, or
antiplatelet medications during
the procedure; the ACT level at the
time of sheath removal; and the
patient’s anatomy at the femoral
insertion site.
Patients who are hypertensive or
obese may need a longer
application of pressure.


B. Maintain the mechanical Prevents bleeding. With use of a mechanical device, set
compression device. the pressure of the device according
(Level M*) to manufacturer’s recommendation
and institutional standards. Tissue
damage may occur if prolonged
pressure is maintained (i.e., longer
than 2–3 hours).3 During
mechanical compression,
monitoring of the arterial puncture
site and distal pulses is essential.
21. With use of a noninvasive Follow manufacturer’s guidelines.
hemostasis pad in conjunction
with manual compression:
A. Apply manual pressure The arterial puncture site
1–2 cm proximal to the skin (arteriotomy) is superior and medial
insertion site (see Step 18). to the skin puncture site because
the arterial sheath is inserted at a
45-degree angle.
B. Place the noninvasive Prevents bleeding
hemostasis pad directly over
the puncture site before
removing the sheath.
C. Remove the sheath. Removes unneeded catheter.
D. Reduce the proximal pressure Noninvasive hemostasis pads must be
to allow a small amount of moistened to activate the
blood from the arterial hemostatic mechanism.
puncture site to moisten the
noninvasive hemostasis pad;
then quickly reapply the
proximal manual pressure.
(Level M*)
E. Hold firm manual pressure The arterial puncture site
proximal to the skin insertion (arteriotomy) is superior and medial
site and over the noninvasive to the skin puncture site because
hemostasis pad at the puncture the arterial sheath is inserted at a
site. 45-degree angle.
F. Gradually release the Ensures hemostasis. The total time of compression
proximal pressure after 3–4 depends on the same factors listed
minutes; however, pressure for manual compression (see Step
should be maintained over the 20 A).
puncture site for at least 10
minutes.
G. Place a new sterile gauze over Maintains asepsis. The noninvasive hemostasis pad is
the hemostasis pad and cover left in place for 24 hours.
with a sterile dressing.
22. While achieving hemostasis, Verifies adequate circulation while The pulse may decrease during
assess the circulation of the hemostasis is achieved. application of full pressure but
extremity distal to the site of the should not be completely
arterial sheath removal. obliterated. If manual compression
is being performed, another person
is needed to assess distal perfusion.


23. With use of manual compression Pressure is no longer needed. With use of a mechanical device,
or mechanical compression, follow manufacturer’s
discontinue pressure once recommendations, institutional
hemostasis is achieved. standards, or physician prescription
regarding the gradual reduction of
pressure from the device. Notify the
nurse if unable to achieve
hemostasis.
24. When a venous sheath is in place, Achieves both arterial and venous Follow manufacturer’s guidelines and
remove the venous sheath hemostasis. The arterial sheath is institutional standards. For example,
approximately 5–10 minutes after removed first because pressure if the FemoStop device is used, the
removal of the arterial sheath and needs to be applied to the arterial venous sheath is removed first to
maintain manual pressure over site longer than the venous site to reduce the risk of arteriovenous
both sites for approximately 10 achieve hemostasis. In addition, the fistula formation.
additional minutes or until venous line may be used to give Collagen plug devices, percutaneous
hemostasis is achieved.2,18 additional IV fluids or medications, suture-mediated devices, and
if needed (e.g., vasovagal reaction). percutaneous staple/clip closure
devices are not used for venous
punctures.
If a collagen plug device, a
percutaneous suture-mediated or a
staple/clip closure device is
deployed in the arteriotomy
immediately after the procedure,
the venous sheath must still be
removed with manual pressure
applied for at least 10 minutes.
Noninvasive hemostasis pads may be
used in conjunction with manual
pressure to achieve hemostasis for
venous punctures.
25. After hemostasis is achieved, Determines whether bleeding or a If bleeding or a hematoma is noted
palpate the area around the hematoma has occurred around the around the arterial site after
arterial site. arterial site. hemostasis is achieved, apply
manual pressure and notify the
nurse.
26. Apply a sterile dressing to the Maintains asepsis. Follow institutional standards for type
arterial and/or venous sites. of sterile dressing to be applied
(transparent vs. pressure dressing).
A sterile transparent dressing allows
for easier assessment of the
puncture site for bleeding or
hematoma formation.2,19
27. Remove PE and sterile equipment Reduces the transmission of
and discard used supplies in microorganisms; Standard
28. HH

• Arterial and venous sheaths removed with hemostasis • Inability to remove the arterial or venous sheaths
achieved • Inability to achieve hemostasis
• Adequate peripheral vascular and neurovascular • Impaired perfusion to the extremity distal to the site
integrity of the extremity distal to the site of sheath of sheath removal
removal (positive sensation, movement, capillary refill, • Impaired motor/sensory status of the extremity distal
color, temperature, pulse) to the site of sheath removal
• No evidence of peripheral vascular or neurovascular • Loss of arterial pulses distal to the site of sheath removal.
complications • Development of a hematoma or new bruit
• Cardiovascular and hemodynamic stability • Development of a retroperitoneal bleed
• Development of a pseudoaneurysm or arteriovenous
fistula
• Vasovagal response during the removal of the arterial
sheath
• Hemodynamic instability
• Angina or shortness of breath
• Decrease in hemoglobin >2 g compared with
preprocedure values
• Unrelieved pain

interventions.
1. Assess the peripheral vascular and A thrombus, embolus, or dissection • Change in strength of pulses in the
neurovascular status of the affected may precipitate changes in affected extremity (diminished or
extremity after arterial sheath peripheral vascular or neurovascular absent)
removal: every 15 minutes × 4, status, necessitating early • Coldness or coolness of the distal
every 30 minutes × 2, and then intervention. extremity
every 60 minutes × 4. • Paresthesia in the affected extremity
• Pallor, cyanosis of the affected
extremity
• Pain in the affected extremity
• Decrease in mobility of the
affected extremity
2. Obtain vital signs after removal of Changes in vital signs may occur • Abnormal vital signs
the arterial sheath every 15 because of a vasovagal response or
minutes × 4, every 30 minutes × 2, blood loss.
and then every 60 minutes × 4.
3. Assess the puncture site every 15 Detects presence of bleeding, • Bleeding at arterial or venous sites
minutes × 4, every 30 minutes × 2, hematoma, or bruit. • Hematoma development
and then every 60 minutes × 4, • New bruit
including assessment of presence • Pain at the access site
or absence of bruit.
4. Monitor the electrocardiographic Detects the presence of dysrhythmias. • Dysrhythmias
data during and after sheath Bradydysrhythmias are common
removal. with vasovagal reactions.
5. After hemostasis is achieved, the Minimizes back discomfort and does • Occurrence of bleeding
head of the patient’s bed can be not increase vascular • Hematoma development
elevated up to 30 degrees. complications.9,26 • Abnormal vital signs
(Level B*) • New bruit
• Changes in peripheral vascular or
neurovascular status
• Back pain not relieved with
position changes or analgesics

6. Maintain bed rest for 1–6 hours Minimizes back discomfort, • Occurrence of bleeding
after hemostasis obtained when minimizes complications of • Hematoma development
manual or mechanical pressure is prolonged bed rest, and • Abnormal vital signs
used. (Level B*) does not increase vascular • New bruit
With collagen plug devices, complications.4,10,11,14,17,20,28,30,32,35 • Changes in peripheral vascular or
percutaneous suture-mediated Bed rest times vary depending on neurovascular status
closure devices, percutaneous the size of sheath used; the type of • Back pain not relieved with
staple/clip closure devices, and procedure; the use of bivalirudin, position changes or analgesics
noninvasive hemostasis pads, heparin, or antiplatelet medications
the bed rest time is decreased during the procedure; and
to between 1 and 4 hours, institutional standards.
depending on the manufacturer’s
recommendations; follow
Maintain bed rest for 1–4 hours Patients with venous punctures need
after venous sheath removal. less time in bed than with arterial
Follow institutional standards. punctures because the venous
system is a lower-pressure system,
so the incidence of vascular
complications is decreased.
analgesia as prescribed and
reassess per institutional standards.
Documentation
• Patient and family education • Method of hemostasis
• Date and time of sheath removal • Site assessment after hemostasis is obtained,
• Site of arterial and venous sheath removal including presence or absence of a bruit
• Quality of arterial and venous sheaths removed (e.g., • Heart rate and rhythm, blood pressure, and
intact, cracked) respiratory rate
• Any difficulties with removal • Peripheral vascular and neurovascular checks to the
• Patient tolerance of the procedure affected extremity
• Pain assessment, interventions, and effectiveness • Occurrence of unexpected outcomes
• Any medications administered • Nursing interventions
• Time hemostasis is obtained • Evaluation of any nursing intervention

76 Femoral Arterial and Venous Sheath Removal 671.e1
References 18. Martinez CA, Moscucci M: Percutaneous approach

1. Arora N, et al: A propensity analysis of the risk of including trans-septal and apical puncture. In Moscucci
vascular complications after cardiac catheterization M, editor: Grossman and Baims’ cardiac catheterization,
procedures with the use of vascular closure devices. angiography, and intervention, ed 8, Philadelphia, 2014,
Am Heart J 153:606–611, 2007. Lippincott Williams & Wilkins, pp 138–169.
2. Bangalore S, Bhatt DL: Femoral arterial access and 19. McIe S, et al: Transparent film dressing vs pressure
closure. Circulation 124:e147–e156, 2011. dressing after percutaneous transluminal coronary
3. Barbiere CC: A new device for control of bleeding after angiography. Am J Crit Care 18:14–20, 2009.
transfemoral catheterization: The FemoStop system. Crit 20. Mohammady M, et al: Early ambulation after diagnostic
Care Nurse 15:51–53, 1995. transfemoral catheterization: A systematic review and
4. Bashore TM, et al: 2012 American College of Cardiology meta-analysis. Int J Nurs Stud 51:39–50, 2014.
Foundation/Society for Cardiovascular Angiography and 21. Nikolsky E, et al: Vascular complications associated with
Interventions expert consensus document on cardiac arteriotomy closure devices in patients undergoing
catheterization laboratory standards update. J Am Coll percutaneous coronary procedures. J Am Coll Cardiol
Cardiol 59:2221–2305, 2012. 44:1200–1209, 2004.
5. Benson LM, et al: Determining best practice: Comparison 22. O’Grady NP, et al: Guidelines for the prevention of
of three methods of femoral sheath removal after cardiac intravascular catheter-related infections. Am J Infect
interventional procedures. Heart Lung J Acute Crit Care Control 39(4 Suppl 1):S1–S34, 2011.
34:115–121, 2005. 23. Rudisill PT, et al: Study of mechanical versus manual-
6. Bincari F, et al: Meta-analysis of randomized trials on the mechanical compression following various interventional
efficacy of vascular closure devices after diagnostic cardiology procedures. J Cardiovasc Nurs 11:15–21,
angiography and angioplasty. Am Heart J 159:518–531, 1997.
2010. 24. Simon A, et al: Manual versus mechanical compression
7. Bogart MA: Time to hemostasis: A comparison of manual for femoral artery hemostasis after cardiac catheterization.
versus mechanical compression of the femoral artery. Am Am J Crit Care 7:308–313, 1998.
J Crit Care 4:149–156, 1995. 25. Smilowitz NR, et al: Practices and complications in
8. Bowden SM: Worrey JA: Assessing patient comfort: vascular closure devices and manual compression in
Local infiltration of lidocaine during femoral sheath patients undergoing elective transfemoral coronary
removal. Am J Crit Care 4:368–369, 1995. procedures. Am J Cardiol 110:177–182, 2012.
9. Coyne C, et al: Controlled trial of backrest elevation 26. Sulzbach LM, Munro BH, Hirshfeld JW: A randomized
after coronary angiography. Am J Crit Care 3:282–288, clinical trial of the effect of bed position after PTCA. Am
1994. J Crit Care 4:221–226, 1995.
10. Doyle BJ, et al: Ambulation 1 hour after diagnostic 27. Sulzbach-Hoke LM, et al: Predictors of complications
cardiac catheterization: A prospective study of 1009 following sheath removal with percutaneous coronary
procedures. Mayo Clin Proc 81:1537–1540, 2006. intervention. J Cardiovasc Nurs 25:E1–E8, 2010.
11. Fowlow B, Price P, Fung T: Ambulation after sheath 28. Tagney J, Lackie D: Bed-rest post-femoral arterial sheath
removal: A comparison of 6 and 8 hours of bedrest after removal: What is safe practice? A clinical audit. Nurs Crit
sheath removal in patients following a PTCA procedure. Care 10:167–173, 2005.
Heart Lung J Acute Crit Care 24:28–37, 1995. 29. Tavris DR, et al: Bleeding and vascular complications at
12. Gurm HS, et al: Comparative safety of vascular closure the femoral access site following percutaneous coronary
devices and manual closure among patients having intervention (PCI): An evaluation of hemostasis strategies.
percutaneous coronary intervention. Ann Intern Med J Invasive Cardiol 24:2–8, 2012.
159:660–666, 2013. 30. Vlasic W, Almond D, Massel D: Reducing bedrest
13. Jones T, McCutcheon H: Effectiveness of mechanical following arterial puncture for coronary interventional
compression devices in attaining hemostasis after femoral procedures—impact on vascular complications: the BAC
sheath removal. Am J Crit Care 11:155–162, 2002. Trial. J Invasive Cardiol 13:788–792, 2001.
14. Keeling AW, et al: Reducing time in bed after 31. Wadas TM, Hill J: Is lidocaine infiltration during femoral
percutaneous transluminal coronary angioplasty (TIBS sheath removal really necessary? Heart Lung 27:31–36,
III). Am J Crit Care 9:185–187, 2000. 1998.
15. Kiat Ang C, et al: Effect of local anesthesia and 32. Walker S, et al: Comparison of complications in
intravenous sedation on pain perception and vasovagal percutaneous coronary intervention patients mobilized at
reactions during femoral arterial sheath removal after 3, 4 and 6 hours after femoral arterial sheath removal.
percutaneous coronary intervention. Int J Cardiol J Cardiovasc Nurs 23:407–413, 2008.
116:321–326, 2005. 33. Walker SB, Cleary SR, Higgins M: Comparison of the
16. Koreny M, et al: Arterial puncture closing devices FemoStop device and manual pressure in reducing groin
compared with manual compression after cardiac puncture site complications following coronary
catheterization: Systematic review and meta-analysis. angioplasty and coronary stent placement. Int J Nurs
JAMA 291:350–357, 2004. Pract 7:366–375, 2001.
17. Logemann T, et al: Two versus six hours of bed rest 34. Wensley C, et al: Pain relief for the removal of femoral
following left-sided cardiac catheterization and a meta- sheath after percutaneous coronary intervention (2014
analysis of early ambulation trials. Am J Cardiol 84: review). Cochrane Database Syst Rev (4):CD006043,
486–488, 1999. 2008.
35. Wilcoxson VL: Early ambulation after diagnostic cardiac Galli A, Palatnik A: Ask the experts: What is the proper
catheterization via femoral artery access. JNP 8:810–815, activated clotting time (ACT) at which to remove a
2012. femoral sheath after PCI? What are the best “protocols”
for sheath removal? Crit Care Nurse 25:88–95, 2005.
Additional Readings Juergens CP, et al: Vaso-vagal reactions during femoral arterial
Chlan LL, Sabo J, Savik K: Effects of three groin compression sheath removal after percutaneous coronary intervention
methods on patient discomfort, distress, and vascular and impact on cardiac events. Int J Cardiol 127:252–254,
complications following a percutaneous coronary 2007.
intervention procedure. Nurs Res 54:391–398, 2005. Kim M: Vascular closure devices. Cardiol Clin 24:277–286,
Christensen BV, et al: Vascular complications after 2006.
angiography with and without the use of sandbags. Nurs McConnell MKT, et al: Comparison of different methods for
Res 47:51–53, 1998. achieving hemostasis after arterial sheath removal.
Cura FA, et al: Safety of femoral closure devices after J Cardiovasc Nurs 27:E1–E5, 2012.
percutaneous coronary interventions in the era of Merriweather N, Sulzbach-Hoke LM: Managing risk of
glycoprotein IIb/IIIa platelet blockade. Am J Cardiol complications at femoral vascular access sites in
86:780–782, 2000. percutaneous coronary intervention. Crit Care Nurse
Dressler DK, Dressler KK: Caring for patients with femoral 32:16–30, 2012.
sheaths: After percutaneous coronary intervention, sheath Patel MR, et al: Arteriotomy closure devices for
removal and site monitoring are the nurse’s responsibility. cardiovascular procedures: A scientific statement from the
AJN 106:64A–64H, 2006. American Heart Association. Circulation 122:1882–1893,
Dueling JHH, et al: Closure of the femoral artery after cardiac 2010.
catheterization: A comparison of Angio-Seal, StarClose, Sabo J, Chlan LL, Savik K: Relationships among patient
and manual compression. Cathet Cardiovasc Interv characteristics, comorbidities, and vascular complications
71:518–523, 2008. post-percutaneous coronary intervention. Heart Lung
Dumont CJP, et al: Predictors of vascular complications post 37:190–195, 2008.
diagnostic cardiac catheterization and percutaneous Shoulders-Odom B: Management of patients after
coronary intervention. Dimens Crit Care Nurs 25: percutaneous coronary interventions. Crit Care Nurse
137–142, 2006. 28:26–42, 2008.
PROCEDURE
77
Radial Arterial Sheath Removal
Rose B. Shaffer
PURPOSE: Radial arterial sheaths are placed for cardiac catheterizations and
interventional procedures. Achieving and maintaining hemostasis after their removal
is essential to prevent access-site complications.

KNOWLEDGE
• Cardiac monitoring system
• Knowledge of the radial and ulnar artery anatomy is impor- • Blood pressure monitoring system
tant. • Pulse oximeter sensor with monitor
• Knowledge and skill regarding how to perform and inter- • Antiseptic solution (e.g., 2% chlorhexidine-based prepa-
pret a modified Allen’s test using plethysmography and ration)
oximetry is needed. • Nonsterile gloves
• The technique for the percutaneous insertion of the radial • Protective eyewear
artery sheath should be understood. • Dressing supplies
• The importance of peripheral vascular and neurovascular • Commercially available inflatable bladder-based radial
assessment of the affected extremity should be understood. compression device
• Knowledge that the radial artery access is sometimes asso- • 10-mL syringe or syringe supplied with the radial com-
ciated with procedure failure (i.e., inability to access the pression device
radial artery or advance catheters) so that the femoral site Additional equipment, to have available as needed, includes
may also be prepared for possible access. the following:
• Knowledge that the radial artery sheath is removed with • Alcohol pads
the use of a radial compression device at the end of the • Selected analgesia and/or sedative as prescribed
diagnostic or interventional procedure. • Portable Doppler ultrasound machine
• Knowledge of the concept of patent hemostasis. • Armboard
• Commercially available radial compression devices are
available to assist achieving hemostasis. One device is the PATIENT AND FAMILY EDUCATION
TR Band™, Radial Compression Device (Terumo Medical
Corporation, Somerset, NJ) (Fig. 77-1). • Explain the procedure to the patient and the family. Ratio-
• Technical and clinical competence in removal of the radial nale: This explanation provides information and may help
compression device is needed. decrease anxiety and fear. This also encourages the patient
• Conditions that may influence the choice for radial access and family to ask questions and voice concerns about the
include the presence of bleeding disorders, current antico- procedure.
agulant use, morbid obesity, and severe peripheral arterial • Explain the importance of keeping the radial compression
disease. device on the affected wrist after the procedure for the
• Contraindications to a radial approach include abnormal prescribed timeframe to maintain hemostasis after the pro-
modified Allen’s test (Barbeau test), absence of a radial cedure. Rationale: The patient is prepared for what to
pulse, the presence of a dialysis fistula, planned intraaortic expect after the procedure, and patient cooperation is elic-
balloon pump insertion, and severe vasospastic disease ited to decrease the risk for bleeding, hematoma, and other
such as Raynaud’s disease. vascular complications.
• Complications of radial artery sheath removal include the • Explain that the procedure may produce discomfort and
following: that pressure will be felt at the site until hemostasis is
❖ External bleeding at the site achieved. Encourage the patient to report discomfort, and
❖ Internal bleeding (e.g., localized hematoma) reassure the patient that analgesia will be provided if
❖ Vascular complications (e.g., radial artery occlusion needed. Rationale: Explanation prepares the patient for
from thrombus, embolus, dissection, or spasm; pseudoa- what to expect and allays fears.
neurysm; arteriovenous fistula; radial artery perforation) • After radial arterial sheath removal, instruct the patient to
❖ Neurovascular complications (sensory or motor changes report any warm, wet feeling or pain at the puncture site.
in the affected extremity) Also, instruct the patient to report any sensory or motor
❖ Compartment syndrome changes in the affected extremity. Rationale: This aids in
672
77 Radial Arterial Sheath Removal 673
and partial thromboplastin time. Rationale: Laboratory

results should be within acceptable limits (per institutional
standard) to decrease the risk for bleeding after sheath
removal.
• Assess the patient’s electrocardiographic rhythm and vital
signs. Rationale: Baseline data are established and deter-
mine hemodynamic stability.
• Review the documented baseline assessment of the
extremity distal to the sheath for color, temperature, sen-
sation, movement, and pulse oximetry waveform. Ratio-
nale: Baseline assessment data are established.
Patient Preparation
Figure 77-1 TR Band radial compression device. (Courtesy for the intended intervention.
Terumo Medical Corporation, Somerset, NJ.) • Ensure that the patient and the family understand prepro-
cedural teaching. Answer questions as they arise, and
the early recognition of complications and identifies the reinforce information as needed. Rationale: Understand-
need for additional pain interventions. ing of previously taught information is evaluated and
reinforced.
PATIENT ASSESSMENT AND • Ensure that the physician, advanced practice nurse, or
PREPARATION other healthcare professional has placed an order stating
when to begin removing air from the radial compression
Patient Assessment device. Rationale: Before performing a procedure, the
• Assess the patient’s complete blood count, platelet count, nurse should determine when to begin removing air from
prothrombin time, with international normalized ratio, the radial compression device.
Procedure for Radial Arterial Sheath Removal

1. HH
2. PE
3. At the completion of both Early discontinuation of the radial There is no need to obtain an
diagnostic and interventional sheath can help reduce the risk of activated clotting time because the
procedures, the radial artery complications such as ischemia or radial artery is more superficial and
compression device is placed thrombosis, which can lead to easier to compress than the femoral
around the wrist per radial artery occlusion.1 artery.1,3,4
manufacturer’s recommendation
(see Fig. 77-1).
4. Using a syringe, a prescribed Enough pressure is applied over the Some radial compression devices
amount of air is injected into the radial arteriotomy site to achieve come with a special syringe only
port to inflate the bladder (per patent hemostasis. used for that specific device. Each
physician preference and compression device has a maximum
manufacturer guidelines), as the amount of air that can be injected
radial sheath is removed. Once into the bladder. Do not exceed
the sheath is out, air is slowly manufacturer guidelines for
removed using the syringe until a inflation.
flash of blood is seen at the radial The patient will leave the procedure
insertion site. Then another room with the compression device
1–2 cm3 of air is reinjected into in place and the bladder inflated.
the port. An arm board may be used to prevent
hyperflexion and hyperextension of
the wrist.
Procedure for Radial Arterial Sheath Removal—Continued

5. Place a blood pressure cuff on the Avoids an increase in pressure on the
opposite extremity to obtain the affected radial artery.
patient’s blood pressure.
6. Place a pulse oximeter sensor on Aids in determining adequate
the thumb or index finger of the perfusion to the distal digits.
affected extremity and observe
the waveform on the monitor.
7. Determine whether an adequate Patent (nonocclusive) hemostasis Complete occlusive pressure over the
pulse oximetry waveform is allows enough radial artery arteriotomy site (e.g., a tight elastic
present. (Level B*) compression to result in hemostasis pressure bandage) leads to higher
as well as maintain forward radial rates of radial artery occlusion and
artery flow, to help reduce the risk may impede venous return to the
of radial artery occlusion.1,5–8 hand, leading to swelling and
discoloration of the hand and/or
fingers.2,3,8
If the waveform is dampened or
absent, release air from the bladder
using the syringe, per institutional
standards or manufacturer
guideline, until the waveform
returns.
If bleeding occurs during this time,
reinflate the bladder to achieve
hemostasis and immediately notify
the physician or the advanced
practice nurse.
8. Compress the ulnar artery of the Absence of the waveform with ulnar If the waveform is lost with ulnar
affected extremity. If the artery compression confirms artery compression, immediately
waveform continues, blood flow diminished or absent blood flow in notify the physician or the
in the radial artery is confirmed. the radial artery. advanced practice nurse.
9. Determine the time the bladder of Establishes baseline information and A flow sheet may be used as a
the radial compression device provides hand-off communication communication tool.
was inflated in the procedure to the next physician, advanced Air (pressure) is released from the
room and the amount of air that practice nurse, or other healthcare bladder at specific time increments.
was placed in the bladder. professional for when to begin
releasing the air (pressure) from the
bladder.
10. Maintain the initial bladder Maintains initial hemostasis. Follow institutional standard and
compression for the prescribed manufacturer guidelines for how
time. (Level M*) long to maintain the initial bladder
compression before beginning to
release air from the bladder. The
initial bladder compression may be
longer for interventional procedures
than for diagnostic procedures
based on factors such as the amount
of anticoagulation used and the
sheath size. Initial bladder
compression time may vary from
30 minutes to 2 hours.
Procedure for Radial Arterial Sheath Removal—Continued

11. If no bleeding is noted, using the Gradually decreases pressure and Follow institutional standards and
syringe, release the prescribed assesses the progress of hemostasis. manufacturer guidelines for time
amount of air from the bladder at intervals and the amount of air to
the specified intervals (i.e., be released. When attaching the
remove 3 cm3 of air every 15 syringe to the connector, keep a
minutes) until all of the air is finger on the plunger so that all the
removed. (Level M) air does not escape at once. Some
devices have a safety mechanism to
prevent this from occurring.
12. If bleeding occurs at any point Maintains hemostasis. Follow manufacturer guideline and
during the release of air from the institutional standards.
bladder, reinject the specified
amount of air (i.e., 3 cm3) for the
specified time period (i.e., 15
minutes) and reassess hemostasis.
If there is no bleeding after
reinflation (i.e., 15 minutes),
resume releasing air from the
bladder (i.e., 3 cm3 of air every
15 minutes) according to
institutional protocol or
manufacturer guideline until all
of the air is removed from the
bladder.
13. When all the air is removed from Determines that hemostasis is If bleeding recurs, the bladder can be
the bladder and hemostasis is maintained. reinflated with the prescribed
obtained, monitor the site for amount of air to achieve
another 5 minutes with the hemostasis.
compression device in place.
14. Carefully remove the radial Removes equipment.
compression device.
15. Clean the area with antiseptic Maintains asepsis. Follow institutional standards.
solution and apply a dry sterile
dressing.
16. The dressing should not encircle Avoids impaired arterial circulation
the entire wrist. and impaired venous return.
17. Assess the area. Determines whether there is any If bleeding or hematoma is noted
bleeding or hematoma. around the arterial site, apply
manual pressure and notify the
or physician assistant.
supplies in the appropriate microorganisms; Standard
19. HH

• Arterial sheath removed with hemostasis achieved • Inability to achieve hemostasis during deflation of the
before the patient leaves the procedure room and radial compression device’s air bladder
during deflation of the radial compression device’s air • Impaired perfusion to the digits distal to the site of
bladder sheath removal
• Adequate peripheral vascular and neurovascular • Impaired motor/sensory status of the extremity distal
integrity of the digits distal to the site of sheath to the site of sheath removal
removal (positive sensation, movement, capillary refill, • Loss of the radial or ulnar pulse
color, temperature, radial and ulnar pulse, good pulse • Development of a hematoma or new bruit
oximeter waveform with sensor on the thumb or index • Development of a pseudoaneurysm or arteriovenous
finger of the affected extremity) fistula
• No evidence of peripheral vascular or neurovascular • Development of a dampened or absent pulse oximeter
complications waveform
• Cardiovascular and hemodynamic stability • Hemodynamic instability
• Unrelieved pain

interventions.
1. Assess the peripheral vascular and Changes in peripheral vascular or • Change in strength of radial or
neurovascular status of the affected neurovascular status may indicate ulnar pulse in the affected
extremity every 15 minutes while radial artery occlusion or other extremity (diminished or absent)
the compression device is in place. complications. • Coldness or coolness of the distal
After the compression device is extremity
removed, assess every 15 minutes • Sluggish capillary refill
× 4, every 30 minutes × 2, and • Paresthesia in the affected
then every 60 minutes × 4. extremity
• Pallor, cyanosis of the affected
extremity
• Pain in the affected extremity
• Decreased mobility of the affected
extremity
• Loss of the pulse oximetry
waveform
2. Obtain vital signs after removal of Determines hemodynamic stability or • Abnormal vital signs
the arterial sheath every 15 instability.
minutes × 4, every 30 minutes × 2,
and then every 60 minutes × 4
(follow institutional protocol).
3. Assess the puncture site every 15 Detects presence of bleeding, • Bleeding at arterial site
minutes while the radial hematoma, or bruit. • Hematoma development
compression device is in place. • New bruit
Once it is removed, assess every
15 minutes × 4, every 30 minutes
× 2, and then every 60 minutes
× 4, including assessment of
presence or absence of bruit
(follow institutional protocol).

4. Monitor the pulse oximeter Dampening or loss of the waveform • Dampening or loss of the pulse
waveform (with the sensor on the may indicate radial artery oximeter waveform
thumb or forefinger of the affected occlusion.
extremity) after removal of the
sheath every 15 minutes × 4, every
30 minutes × 2, and then every 60
minutes × 4 (follow institutional
protocol).
5. Monitor the electrocardiographic Detects the presence of dysrhythmias. • Dysrhythmias
data during and after sheath
removal.
6. The patient may raise the head of Radial artery access does not require • Occurrence of bleeding
the bed to the desired level and prolonged bed rest; therefore the • Hematoma development
may get out of bed with assistance. head of the bed can be raised to a • Abnormal vital signs
level of comfort and early mobility • New bruit
can be facilitated. • Changes in peripheral vascular or
neurovascular status
8. Avoid obtaining blood for Avoids unnecessary pressure on the
laboratory tests and avoid taking affected radial artery to promote
the patient’s blood pressure in the healing and to prevent
affected extremity for 24 hours. complications.
Documentation
• Date and time of sheath removal and initial hemostasis • Evidence of patent hemostasis
in the procedure room • Site assessment after hemostasis obtained and radial
• Quality of arterial sheath removed (e.g., intact, device removed, including presence or absence of a
cracked) bruit
• Any difficulties with sheath removal • Heart rate and rhythm, blood pressure, and
• Patient and family education respiratory rate
• Patient tolerance of the procedure • Peripheral vascular and neurovascular checks to the
• Pain assessment, interventions, and effectiveness affected extremity
• Any medications administered • Occurrence of unexpected outcomes
• Any issues during radial compression device deflation • Nursing interventions
(e.g. uncontrolled bleeding) • Evaluation of any nursing intervention
• Date and time radial compression device is removed

77 Radial Arterial Sheath Removal 677.e1
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Barbeau GR, et al: Evaluation of the ulnopalmar arches with 2010.
pulse oximetry and plethysmography: Comparison with Rao SV, et al: Radial versus femoral access. J Am Coll
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randomized clinical trial. J Am Coll Cardiol 63:964–972, Valgimigli M, et al: Transradial coronary catheterization and
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PROCEDURE
78
Pericardial Catheter Management
Kathleen M. Cox
PURPOSE: Placement of an indwelling pericardial catheter allows for the slow
and/or intermittent evacuation of fluid from the pericardial space. An indwelling
pericardial catheter also allows for the infusion of medications (e.g., antibiotics or
chemotherapeutic agents) into the pericardial space.
PREREQUISITE NURSING • The pericardial catheter may be connected to a closed

KNOWLEDGE drainage system (Fig. 78-1).
• The pericardial catheter may also be left in place to facili-
• Knowledge of anatomy and physiology of the cardiovas- tate the infusion of medications (e.g., antibiotics, chemo-
cular system, to include understanding of the principles of therapeutic agents) depending on the patient’s clinical
cardiac conduction, electrocardiogram (ECG) lead place- manifestations.
ment, and dysrhythmia interpretation. • An indwelling catheter should usually be removed within
• Knowledge and skills related to aseptic technique is 48 to 72 hours after placement to avoid risk of infection
necessary. or iatrogenic pericarditis.4 Depending on the patient’s
• Advanced cardiac life support (ACLS) knowledge and underlying condition, the catheter may be left in place for
skills. longer periods to facilitate resolution of pericardial effu-
• The pericardial space normally contains 20 to 50 mL of sion, cardiac tamponade, or infusion of medication.8 Peri-
fluid. cardial catheters should be removed immediately for any
• Pericardial fluid has electrolyte and protein profiles similar signs of infection or an abrupt rise in white blood cell
to plasma. count.9
• Pericardial effusion is generally defined as the accumula- • Pericardial catheters are generally removed when the peri-
tion of fluid within the pericardial sac that exceeds the cardial drainage decreases to less than 25 to 30 mL for the
stretch capacity of the pericardium, generally more than preceding 24-hour period.6
50 to 100 mL.12 • Extended catheter drainage is associated with a reduction
• Intrapericardial fluid accumulation can be acute or chronic of the reoccurrence of cardiac tamponade compared with
and therefore it varies in presentation of symptoms. Acute a single pericardiocentesis in patients with pericardial
effusions are usually a rapid collection of fluid occurring effusion related to malignancy.10
over minutes to hours and may result in hemodynamic
compromise with volumes less than 250 mL.8 Chronically EQUIPMENT
developing effusions occurring over days to weeks allow
for hypertrophy and distention of the fibrous pericardial • Pericardial catheter
membrane. Patients with chronic effusions may accumu- • Sterile drapes: 4 small drapes and a full-body drape
late greater than or equal to 2000 mL of fluid before • Sterile and nonsterile gloves, gowns, masks, protective
exhibiting symptoms of hemodynamic compromise.8 eyewear
• Symptoms of cardiac tamponade are nonspecific, so the • Sterile 0.9% normal saline (NS) solution for irrigation and
diagnosis relies on clinical suspicion and associated signs sterile basin
and symptoms. Acute pericardial effusions are usually a • Sterile syringes: 3-, 5-, 30-, or 60-mL Luer-Lok
result of trauma, myocardial infarction, or iatrogenic injury, • Sterile 1000-mL vacuum bottle available for the initial
whereas chronic effusions can result from conditions such procedure
as bacterial or viral pericarditis, cancer, autoimmune dis- • Antiseptic solution (e.g., 2% chlorhexidine-based
orders, uremia, etc.2 With a decrease in cardiac output, the preparation)
patient often develops chest pain, dyspnea, tachycardia, • Sterile 4 × 4 gauze
tachypnea, pallor, cyanosis, impaired cerebral and renal • Sterile transparent occlusive dressing
function, diaphoresis, hypotension, neck vein distention, • Adhesive tape
distant or faint heart sounds, and pulsus paradoxus.6 • Sterile three-way Luer-Lok stopcock with nonvented caps
• Pericardiocentesis is an effective treatment for pericardial and replacement caps
effusion (see Procedures 42 and 43). For chronic or rapidly • Drainage tubing
accumulating effusions, an indwelling pericardial catheter • Pericardial drainage bag
may be placed for continuous or intermittent drainage of Additional equipment, to have available as needed, includes
excess fluid. the following:
678
78 Pericardial Catheter Management 679
Pericardial signs and symptoms (e.g., dyspnea, dull ache or pressure

catheter To chest within the chest, dysphagia, cough, tachypnea, hoarse-
ness, hiccups, or nausea).5,6 Rationale: Early recognition
3-way of signs and symptoms of recurrent pericardial effusion
Infusion stopcock may prompt detection of a potentially life-threatening
port problem.
Drainage
tubing
PREPARATION
Patient Assessment
Drainage • Assess the patient’s neurological, cardiovascular, and
bag hemodynamic status including heart rate, cardiac rhythm,
heart sounds (S1, S2, rubs, murmurs), blood pressure
(BP), mean arterial pressure, peripheral pulses, oxygen
saturation via pulse oximetry, respiratory status, and
if available, pulmonary artery pressures, pulmonary
Emptying
artery occlusion pressure (PAOP), right-atrial pressure
port (RAP), cardiac output (CO) and cardiac index (CI),
and systemic vascular resistance. Rationale: Provides
Figure 78-1 Indwelling pericardial catheter system. (From baseline data.
Hammel WJ: Care of patients with an indwelling pericardial • Assess the patient for dyspnea, tachypnea, tachycardia,
catheter; Crit Care Nurs 18[5]:40–45, 1998.) muffled heart sounds, precordial dullness to percussion,
or impaired consciousness; hypotension (systolic BP
• Anticoagulant flush available for dwell if prescribed (i.e., <100 mm Hg or decreased from patient’s baseline);
heparin) increased jugular venous pressure/jugular distention;
• Cytotoxic disposal receptacle (when chemotherapeutic or pulsus paradoxus (inspiratory decrease in systolic BP
cytotoxic agents are prescribed; also used to avoid aero- amplitude) greater than 12 to 15 mm Hg; equalization of
solization of the medication once disconnected from the RAP, PAOP, and pulmonary artery diastolic pressure; and
patient) decreased CO/CI.2 Rationale: Assessment of these signs
• Emergency cart (defibrillator, emergency respiratory and symptoms of possible cardiac tamponade is essential
equipment, emergency cardiac medications) for identification of potential complications and catheter
patency.
PATIENT AND FAMILY EDUCATION • Determine the patient’s allergy history (e.g., heparin, anti-
septic solutions). Rationale: This assessment decreases
• Explain to the patient and family the reason necessitating the risk for allergic reactions by avoiding known aller-
the indwelling pericardial catheter (e.g., relief of pressure genic products.
on the heart). Rationale: Communication of pertinent
information helps the patient and family to understand the Patient Preparation
procedure and the potential risks and benefits, subse- • Confirm that the patient and family understand preproce-
quently reducing anxiety and apprehension.1 dural teaching by having them verbalize understanding.
• Discuss potential discomfort the catheter may cause with Clarify key points by reinforcing important information
inspiration and the insertion site. Reassure patient and and answer all questions. Rationale: Preprocedure com-
family that pain medication will be prescribed and admin- munication provides a framework of patient expectations,
istered as necessary. Rationale: This explanation prepares enhances cooperation, and reduces anxiety.1
and informs the patient of the pain-management plan and • Verify that the patient is the correct patient using two
reassures the patient that pain management is a priority. patient-specific identifiers. Rationale: The nurse should
• Instruct the patient and family about the patient’s risk for always ensure the correct identification of the patient for
recurrent pericardial effusion, describing the potential the intended intervention for patient safety.
Procedure for Pericardial Catheter Management

Steps Rationale Considerations
General Management of the Patient With a Pericardial Catheter Without a Drainage System
1. HH
patient during the actual procedure
if the patient is not intubated (in a
contained system), especially if the
patient has methicillin-resistant
Staphylococcus aureus (MRSA)–
positive results on nasal swab or
known colonization.
3. Assist the physician or advanced Provides assistance as needed. The pericardial catheter may be
practice nurse with the inserted in the operating room, in a
pericardiocentesis procedure (see special procedure environment
Procedures 42 and 43). (e.g., cardiac catheterization
laboratory or interventional
laboratory), or at the bedside.
4. Determine that the connections Ensures that the integrity of the At the completion of the pericardial
between the pericardial catheter system is intact. tap, the stopcock is turned off to
and the stopcock are tight. the patient and a sterile nonvented
cap is placed on the stopcock port.
5. Observe the drainage of pericardial Ensures pericardial catheter patency. Pericardial fluid is commonly
fluid for color, amount, and The presence of fibrin matrix in the straw-colored, serous drainage. A
consistency. drainage can result in obstruction of two-dimensional (2D) or Doppler
the catheter and be problematic for echocardiogram can be performed
future manual taps. after the pericardiocentesis to assess
for reaccumulation of pericardial
fluid.8
6. Perform catheter site care. Prevents infection.
A. HH
B. PE
C. Remove the dressing and Allows for site assessment and
discard it in an appropriate prepares for site care.
receptacle.
D. Assess the skin surrounding the Assesses for signs and symptoms of
catheter-insertion site. infection.
E. Remove and discard the Maintains aseptic technique.
nonsterile gloves in an
F. HH
G. Apply sterile gloves. Prepares for the procedure.
H. Cleanse the skin around the Reduces the rate of recolonization of
pericardial catheter-insertion skin microflora. The Centers for
site using a back and forth Disease Control and Prevention
motion while applying friction (CDC) do not have a specific
for 30 seconds with an recommendation for care of
chlorhexidine-based solution)3,4
and allow time to dry.
(Level D*)
I. Ensure that the catheter and Reduces the possibility of
stopcock are securely anchored displacement.
to the chest.
Procedure for Pericardial Catheter Management—Continued

J. Apply a sterile, occlusive Provides a sterile environment.
dressing over the catheter Identifies the last dressing change.
insertion site. Label the
dressing with the date, time,
and initials of the person
performing the dressing
change.
K. Remove PE and discard used
receptacles.
L. HH
7. If pericardial fluid removal is Removes excess pericardial fluid and Follow institutional standards
desired, aspirate pericardial fluid relieves symptoms of cardiac regarding personnel permitted to
every 4–6 hours as prescribed or as tamponade; ensures catheter aspirate and flush pericardial
often as is clinically indicated patency. catheters (e.g., registered nurses,
through the three-way stopcock advanced practice nurses,
using sterile technique.8 physicians).
Consider placing a mask on the
patient during the procedure if the
patient is not intubated. Pericardial
fluid samples may be collected for
select diagnostic tests (e.g., protein,
glucose, hematocrit, white blood
cell count, bacterial or fungal
cultures).
A. HH
B. PE
C. Ensure the stopcock is turned Prepares for fluid removal.
off to the patient and then
remove the nonvented cap from
the infusion port of the
three-way stopcock.
D. Cleanse the infusion port cap at Decreases the risk for infection.
the top of the stopcock with an
antiseptic solution for 15
seconds and allow to dry.3,4,9,11
E. Attach a sterile, 60-mL Prepares for fluid removal.
Luer-Lok syringe to the
three-way stopcock.
F. Turn the stopcock open to the Permits aspiration of fluid.
syringe and patient.
G. Gently aspirate pericardial fluid Gentle removal is necessary to avoid
while monitoring patient pericardial or myocardial injury.
response.
H. After completion of the fluid Stops pericardial drainage.
withdrawal, turn the stopcock
off to the patient.
I. Disconnect the specimen Removes the specimen.
syringe from the stopcock.
J. Connect the flush syringe to the Prepares the equipment for flushing.
stopcock.
K. Turn the stopcock open to the Clears the pericardial catheter and Monitor vital signs and ECG tracing
syringe and patient and gently promotes catheter patency. while flushing the pericardial
flush the pericardial catheter catheter to assess patient response
with 2–5 mL of sterile NS to the procedure; follow institution
solution or heparinized saline standard for administration of dwell
solution as prescribed. solution.

L. Turn the stopcock off to the Removes equipment.
patient and disconnect the flush
syringe
M. Carefully place a new sterile Maintains sterile, closed system and
nonvented cap on the stopcock. reduces risk of infection.
N. Measure the amount of Records amount of drainage.
drainage.
O. Remove PE and discard used
receptacles.
P. HH
8. If the pericardial catheter is Follow institutional standards
blocked or obstructed to flow: regarding personnel permitted to
aspirate and flush pericardial
catheters (e.g., registered nurses,
advanced practice nurses,
physicians).
A. HH
B. PE
C. Examine the catheter to Relieves mechanical obstruction to
determine whether there is an flow.
external mechanical cause of
the pericardial catheter
blockage, and correct if
present. Consider the
following:
i. Kinks in tubing.
ii. Tubing may be compressed
underneath patient.
iii. Turn or reposition patient
to facilitate flow.
D. Assess for loose tubing Ensures intact drainage system.
connections and, if loosened,
tighten connections.
E. Determine correct positioning Facilitates unobstructed fluid
of the stopcock. If needed, drainage.
correct the stopcock position.
F. If the previous steps do not Attempts to relieve the obstruction.
correct the obstruction to flow,
do the following:
i. Turn the stopcock off to Prepares the equipment.
the patient and remove the
cap from the infusion port
of the stopcock.
ii. Clean the infusion port of Decreases the risk of infection.
the stopcock with an
alcohol swab for 15
seconds and allow to
dry.3,4,9,11
iii. Attach the syringe for the Prepares the equipment.
flush and turn the stopcock
open to the patient.

iv. Turn the stopcock open to Attempts to improve pericardial Monitor vital signs and ECG tracing
the syringe and patient and catheter patency. Heparinized saline to determine patient response while
gently flush the pericardial solution may be used for a dwell if flushing the pericardial catheter.
catheter with 2–5 mL of the drainage tends to be serous or Follow institutional standard for
sterile NS solution or fibrous in consistency.7 administration of dwell solution, if
heparinized saline solution prescribed.
as prescribed (use NS if
the patient is sensitive to
heparin).
v. Gently attempt to aspirate Allows for aspiration of flush solution Deduct the volume of flush solution
flush solution. and pericardial fluid. from the total volume for accurate
measurement of pericardial fluid.
vi. Determine whether the Assesses the proper functioning of the Monitor vital signs and ECG.
pericardial catheter is system.
patent and fluid is draining.
vii. If the above measures do Additional interventions are indicated.
not remove the catheter
blockage, notify the
physician or advanced
practice nurse immediately.
9. If medications are prescribed for Follow institutional standards for PE
infusion into the pericardium: when administering cytotoxic or
antineoplastic medications.
Follow institutional standards
regarding personnel permitted to
instill medications into the
pericardial sac.
A. HH
B. PE
C. Review the prescribed Ensures the accuracy of medication
medication, dose, method of administration and prepares the
delivery, amount, and time for equipment.
dwell. Assemble the
medication, tubing, pump or
syringe and two flush syringes
of 0.9% NS (2–5 mL each).3,7
D. Ensure that the stopcock is off Prepares for the procedure.
to the patient and remove the
cap from the infusion port.
E. Clean the infusion port of the Reduces the risk of infection.
stopcock with an alcohol swab
for 15 seconds and allow to
dry.3,4,9,11
F. Attach a flush syringe and turn Ensures catheter patency.
the stopcock open to the
patient. Establish patency of
the catheter by gentle infusion
and withdrawal of 0.9% NS.
G. Turn the stopcock off to the Prepares the equipment.
patient and disconnect the flush
syringe.

H. Attach the prescribed Administers the medication as Infusion of the medication may
medication (either infusion or prescribed. activate signs and symptoms of
syringe). With the use of a cardiac tamponade.11
syringe for delivery, gently Monitor vital signs and ECG tracing
instill the medication. If using while infusing the medication to
an infusion pump, set the assess response of the patient.
appropriate medication infusion If the patient has any abnormal signs
rate. or symptoms, stop the infusion and
notify the advanced practice nurse
or the physician.
I. Turn the stopcock off to the Stops the medication administration.
patient when the medication
delivery is complete.
J. Disconnect the tubing or Removes the equipment.
syringe.
K. Attach a flush syringe of 0.9% Prepares the equipment.
NS.
L. Turn the stopcock open to the Ensures the medication is completely
patient and gently flush the in the pericardium and none
catheter. remains in the catheter.
M. Turn the stopcock off to the Closes and maintains the integrity of
patient and apply a sterile the system.
nonvented cap to the infusion
port.
N. Allow the medication to dwell Allows time for the medication to act.
for the prescribed time.
O. When the dwell time is Prepares the equipment.
complete, remove the infusion
port cap and attach a syringe
large enough to retrieve the
medication plus the pericardial
fluid accumulation.
P. Gently withdraw the Removes the medication. Volume of the retrieved fluid should
medication and pericardial be equivalent to the volume of
drainage. medication that was instilled, plus
the flush solution and additional
pericardial fluid that accumulated
during the dwell time.
Q. Turn the stopcock off to the Removes the equipment.
patient and disconnect the
syringe.
R. Attach a flush syringe of Prepares the equipment.
2–5 mL of 0.9% NS with or
without heparin as prescribed.3,8
S. Turn the stopcock open to the Clears the pericardial catheter.
patient and instill the 0.9% NS
or heparin flush.
T. Turn the stopcock off to the Closes the pericardial catheter system
patient, remove the flush and maintains the integrity of the
syringe, and apply a sterile closed system.
nonvented cap to the infusion
port.

U. Remove PE and discard used Discard any antineoplastic or
supplies in the appropriate cytotoxic agent, tubing, and flush
receptacles. syringes in the designated
biohazard receptacle.
V. HH
General Management of the Patient With a Pericardial Catheter Closed Drainage System
1. HH
2. PE
3. Assist the physician or advanced Provides assistance as needed. The pericardial catheter may be
practice nurse with the inserted in the operating room, in a
pericardiocentesis (see Procedures special procedure environment
42 and 43). (e.g., cardiac catheterization
laboratory or interventional
laboratory), or at the bedside.
4. Determine that the connections Ensures the integrity of the system. At the completion of the pericardial
between the pericardial catheter tap, a nonvented sterile cap is
and the stopcock are tight. placed on the stopcock port and the
stopcock is turned off to the patient
or open to drainage as prescribed.
5. Position the drainage-collection Ensures pericardial catheter patency. Pericardial fluid is commonly
receptacle lower than the catheter- The presence of fibrin matrix in the straw-colored, serous drainage.
insertion point to facilitate drainage can result in obstruction of A 2D or Doppler echocardiogram can
drainage, and observe the fluid for the catheter and be problematic for be performed after the
color, amount, and consistency. future manual taps. pericardiocentesis to assess for
reaccumulation of pericardial fluid.8
6. Perform catheter-site care. Helps prevent infection. Observe the site for any evidence of
drainage and notify the physician or
advanced practice nurse of this
finding.
A. HH
B. PE
C. Remove the dressing and Allows for site assessment and
discard it in an appropriate prepares for site care.
receptacle.
D. Assess the catheter and Assesses for signs and symptoms of
insertion site. infection.
E. Remove and discard the Maintains aseptic technique.
nonsterile gloves in an
F. HH
G. Apply sterile gloves and
establish a sterile field.
H. Cleanse the skin around the Reduces the rate of colonization of
pericardial catheter-insertion skin microflora. The Centers for
site using a back and forth Disease Control and Prevention
motion while applying friction (CDC) do not have a specific
for 30 seconds with an recommendation for care of
chlorhexidine-based solution).3,4
Allow the antiseptic to remain
on the insertion site and to air
dry completely.9,11 (Level D*)


I. Determine whether the catheter Ensures a secure system.
and stopcock are securely
anchored to the chest.
J. Apply a sterile, occlusive Provides a sterile environment.
dressing over the catheter- Identifies the last dressing change.
insertion site. Label the
dressing with the date, time
and initials of the person
performing the dressing
change.
K. Remove PE and discard used
receptacle.
L. HH
7. If pericardial fluid removal is Removes pericardial fluid. Follow institutional standards
desired: intermittently or regarding personnel permitted to
continuously drain the pericardial aspirate and flush pericardial
fluid as prescribed by turning the catheters (e.g., registered nurses,
stopcock off to the infusion port advanced practice nurses,
and open between the patient and physicians).
the drainage bag (see Fig. 78-1).
A. Intermittent drainage: If
intermittent drainage is
prescribed, the stopcock is
usually off to the patient and
opened every 4–6 hours to
drainage or as clinically
indicated with Doppler scan or
2D echocardiogram and patient
presentation until the
accumulation of fluid is
resolved (follow the prescribed
regimen).
B. Continuous drainage:
If continuous drainage is
prescribed, the stopcock
remains open between the
patient and the drainage bag
and off to the infusion port
(follow the prescribed
regimen).
C. Empty the pericardial drainage Reduces the possibility of Pericardial fluid samples may be
bag every 8 hours or sooner if colonization in the bag and the collected for selected diagnostic
prescribed. potential reflux of fluid to the tests.
patient.
i. HH
ii. PE
iii. Turn the stopcock off to Reduces risk of pneumopericardium.
the patient.
iv. Open the emptying port of Discard drainage.
the drainage bag and drain
the pericardial fluid into a
receptacle for measurement
and waste disposal.

v. Close the port and secure Closes and maintains integrity of the
the drainage bag. system.
vi. Resume the prescribed Continues prescribed treatment.
drainage mode.
D. After completion of Prepares for the procedure.
intermittent fluid drainage,
temporarily turn the stopcock
off to the patient for the flush
procedure.
i. HH
ii. PE
iii. Remove the infusion port Reduces risk of infection.
cap and cleanse the
infusion port at the top of
dry.3,4,9,11
iv. Connect the flush syringe, Clears the pericardial catheter and
turn the stopcock open to maintains catheter patency.
the syringe and patient, and
gently flush the pericardial
catheter with 2–5 mL of
sterile NS solution or
heparinized saline solution
heparin).
v. Turn the three-way Maintains integrity of the closed
stopcock off to the patient system and minimizes risk of
and disconnect the flush pneumopericardium.
syringe.
vi. Place a new sterile Maintains asepsis.
nonvented cap on the
infusion port.
vii. Remove PE and discard
used supplies in
viii. HH
8. If the pericardial catheter is Follow institutional standards
blocked or obstructed to flow: regarding personnel permitted to
aspirate and flush pericardial
catheters (e.g., registered nurses,
advanced practice nurses,
physicians).
A. HH
B. PE
C. Determine whether the Facilitates drainage by gravity.
drainage system is lower than
the insertion point and
reposition if needed.

D. Examine the catheter to Relieves mechanical obstruction to
determine whether there is an flow.
external mechanical cause of
the pericardial catheter
blockage, and correct if
present. Consider the
following:
i. Kinks in tubing.
ii. Tubing may be compressed
underneath patient.
iii. Turn or reposition patient
to facilitate flow.
E. Assess for loose tubing Ensures intact drainage system.
connections and, if loosened,
tighten connections.
F. Determine correct positioning Facilitates unobstructed fluid
of the stopcock. If needed, drainage.
correct the stopcock position.
G. If the previous steps do not
correct the obstruction to flow,
do the following:
i. Remove the infusion port Decreases the risk of infection.
cap and cleanse the
infusion port at the top of
dry.3,4,9,11
ii. Connect the flush syringe, Attempts to improve pericardial Monitor vital signs and ECG tracing
turn the stopcock open to catheter patency. Heparinized saline while flushing the pericardial
the syringe and patient, and solution may be used for a dwell if catheter to assess patient response.
gently flush the pericardial the drainage tends to be serous or Follow institutional standards for
catheter with 2–5 mL of fibrous in consistency.7 administration of dwell solution, if
sterile NS solution or prescribed.
heparinized saline solution
patient is sensitive to
heparin).
iii. Turn the stopcock off to Allows drainage of flush solution and Volume of the drained fluid should be
the infusion port and allow pericardial fluid. equivalent to the volume of the
the fluid to passively drain flush solution and additional
or turn the stopcock off to accumulated pericardial fluid;
the drainage bag and gently deduct the amount of flush used to
attempt to aspirate the flush accurately measure output.
solution through the
attached syringe.
iv. Determine whether the Assesses patency of the system.
pericardial catheter is
draining and patent.
v. If the previous measures Ensures integrity of the system and Ensure the stopcock is off to the
are ineffective for drainage may facilitate drainage. patient at the time of the change.
but the catheter itself is
patent, consider changing
the tubing and the
drainage-bag system.

vi. After the tubing/bag Determines whether the system is
change, assess the patency functioning.
of the system.
vii. If these measures do not Additional interventions are Accumulation of fluid in the
remove the catheter necessary. pericardium without the possibility
blockage, notify the of drainage may result in
physician or advanced tamponade.
practice nurse immediately.
viii. Remove PE and discard
used supplies in
ix. HH
9. If medications are prescribed for Follow institutional standards for PE
infusion into the pericardium: when administering cytotoxic or
antineoplastic medications. Follow
institutional standards regarding
personnel permitted to instill
medications into the pericardial sac.
A. HH
B. PE
C. Review the prescribed Ensures the accuracy of medication
medication, dose, method of administration.
delivery, amount, and time for
dwell. Assemble the
medication, tubing, pump or
syringe, and two flush syringes
of 0.9% NS (2–5 mL each).3,7
D. Turn the stopcock off to the Reduces risk of infection.
patient, remove the infusion
port cap, and cleanse the
infusion port at the top of the
stopcock with an antiseptic
solution for 15 seconds and
allow to dry.3,4,9,11
E. Turn the stopcock off to the Prevents inadvertent instillation of
drainage bag. Attach the medication into the drainage bag.
prescribed medication (either
infusion or syringe).
F. With the use of a syringe for Administers the medication. Infusion of the medication may
delivery, gently instill the activate signs and symptoms of
medication as prescribed. cardiac tamponade.11
If using an infusion pump, set Monitor vital signs and ECG tracing
the appropriate medication- while infusing the medication to
infusion rate. (Patency of the assess patient response.
catheter is established by virtue If the patient has abnormal signs and
of evident drainage. symptoms, stop the infusion and
If there is a question about notify the advanced practice nurse
catheter patency, follow the or the physician.
flush procedure listed in the
medication infusion section of
General Management of the
Patient with a Pericardial
Catheter without a Drainage
System.)

G. If the medication is to dwell in
the pericardial space before
reestablishment of pericardial
drainage:
i. Turn the stopcock off
to the patient at the
completion of the infusion.
ii. Disconnect the medication
syringe or tubing.
iii. Attach a syringe with
2–5 mL of 0.9% NS flush
and turn the stopcock off to
the drainage bag.
iv. Gently flush the catheter Ensures that the medication is
and turn the stopcock off instilled in the pericardial space and
to the patient for the does not lie in the catheter.
completion of the dwell
time as prescribed.
v. Disconnect the syringe and
close system with a sterile
nonvented cap.
vi. After the dwell time is Allows pericardial drainage to The drain time should allow for all of
complete, turn the stopcock resume. the medication to exit the
off to the infusion port and pericardium.
open to drainage.
vii. Measure the amount of the Volume of the drained fluid should be
solution infused and the equivalent to the volume of the
drainage collected. medication instilled, the flush
solution, and additional
accumulated pericardial fluid;
deduct the amount of medication
infused and flush used to accurately
measure output.
viii. Resume the prescribed
drainage mode: continuous
or intermittent. If
intermittent, follow the
prescription for the drain
time after infusion.
a. Once the drain time is Reduces the risk for infection.
completed, clean the
infusion port of the
stopcock with an alcohol
swab for 15
seconds.3,4,9,11
b. Connect the flush Helps to maintain the pericardial
syringe, turn the catheter patency.
stopcock open to the
syringe and patient, and
gently flush the
pericardial catheter with
2–5 mL of sterile NS
solution or heparinized
saline solution as
prescribed (use NS if
heparin).

c. Turn the stopcock off to Maintains integrity of the system.
the patient until the next
time the patient is due
for intermittent drainage.
d. Remove PE and discard
used supplies in
e. HH

• Patent pericardial drainage system • Infection
• Resolution of pericardial effusion • Pain
• Hemodynamic stability • Catheter obstruction
• Patient free of infection • Reaccumulation of pericardial fluid
• Patient free of pain and anxiety • Cardiac tamponade and hemodynamic instability
• Medications administered as prescribed • Dysrhythmias
• Cardiac arrest

These conditions must be reported if
interventions
1. Perform cardiovascular and Assesses for signs of cardiac • Signs of cardiac tamponade:
hemodynamic assessments at least tamponade and determines dyspnea, tachypnea, tachycardia,
every 60 minutes and as patient hemodynamic stability. hypotension, increased jugular
condition necessitates, or as venous pressure, pulsus paradoxus,
prescribed muffled heart sounds, precordial
dullness to percussion, altered
level of consciousness.
• Equalization of RAP, PAOP
• CI <2.5 L/min/m2
• Dysrhythmias
2. Assess the patency of the Pericardial catheter blockage may • Inability to obtain pericardial
pericardial catheter: predispose the patient to excessive drainage or cessation of pericardial
A. Without a closed drainage accumulation of pericardial fluid drainage
system, every 4–6 hours, and that may lead to cardiac tamponade • Signs and symptoms of cardiac
as needed or as prescribed. and/or hemodynamic instability. tamponade or hemodynamic
B. With a closed drainage system, instability
every hour, and as needed or as • Evidence of accumulation of
prescribed. pericardial fluid on Doppler or 2D
echocardiography
3. Assess the amount and type of Provides information regarding the • Change in the amount, color, or
fluid draining from the pericardial continued need for the catheter and consistency of pericardial drainage
catheter. potential problems. from patient’s baseline
4. Change the pericardial catheter Provides an opportunity to assess for
dressing every 24 hours.4 signs and symptoms of infection. • Elevated white blood cell counts
Infective pericarditis is associated • Elevated temperature
with increased mortality and • Signs and symptoms of infection at
morbidity rates.10 the insertion site (e.g., pain,
The CDC recommends replacing erythema, drainage, etc.)
dressings on intravascular catheters
when the dressing becomes damp,
loosened, or soiled or when

5. If in use, change the pericardial Reduces the risk of infection.
tubing and drainage bag every 72
hours.3,8
6. Follow institutional standards for Identifies need for pain interventions. • Continued pain despite
assessing pain and administer The patient may experience chest interventions
analgesia as prescribed. pain or pleuritic type pain while the
pericardial catheter is in place.
7. Identify parameters that Facilitates early removal of the • Pericardial drainage <25–30 mL
demonstrate clinical readiness for pericardial catheter and reduces the over the previous 24 hours12
removal of the indwelling risk of infection. • Hemodynamic stability as
pericardial catheter.8,13 evidenced by systolic BP
>100 mm Hg, CI >2.5 L/min/m2,
absence of pulsus paradoxus, no
equalization of RAP, PA diastolic
pressure, and PAOP
• Absence of pericardial effusion on
Doppler or 2D echocardiography13
8. Identify situations in which the Additional interventions may be • Hemodynamic instability
pericardial effusion cannot be needed. • Continued pericardial effusion
resolved with use of pericardial
drainage via tap or closed system.10
Documentation
• Patient and family education • Volumes of injectate or aspirate
• Universal Protocol requirements • Characteristics of the pericardial drainage: color,
• Patient tolerance of the indwelling pericardial catheter consistency, and/or changes
• Dressing, tubing, and drainage bag changes • Hemodynamic status
• Amount of pericardial drainage each shift, including • Pain assessment, interventions, and effectiveness
net volumes when catheter is flushed or medications • Occurrence of unexpected outcomes/treatments
are infused • Nursing interventions

78 Pericardial Catheter Management 692.e1

2. Burlew CC, Moore EE: Mattox KL, Moore EE, Feliciano Saunders, pp 298–318.
DV, editors: Trauma, ed 7, New York, 2013, McGraw-Hill 9. O’Grady NP, et al: Guidelines for the prevention of
Medical, pp 236–239. intravascular catheter-related infections. Clin Infect Dis
3. Camp-Sorrell D: Access device guidelines: 52(a):1087–1099, 2011.
Recommendations for nursing practice and education, ed 10. Saltzman AJ, Paz YE, Rene AG: Comparison of surgical
3, Pittsburgh, 2011, Oncology Nursing Society. pericardial drainage with percutaneous catheter drainage
4. Centers for Disease Control: Guidelines for the prevention for pericardial effusion. J Invasive Cardiol 24(11):590–
of vascular catheter-related infections, Washington, DC, 593, 2012.
2011, Department of Health and Human Services. 11. Simmons S, Bryson C, Porter S: “Scrub the hub”:
5. Gucalp R, Dutcher JP: Loscalzo J, editor: Harrison’s Cleaning duration and reduction in bacterial load in central
Pulmonary and Critical Care Medicine, New York, 2010, venous catheters. Crit Care Nurs Q 34(1):31–35, 2011.
McGraw-Hill Medical, pp 476–478. 12. Synovitz CK, Brown EJ: Pericardiocentesis. In Tintinalli
6. Jneid H, Maree AO, Palacios IF: Parrillo JE, Dellinger JE, editor: Tintinelli’s emergency medicine: A
RP, editors: Critical Care Medicine, ed 4, Philadelphia, comprehensive study guide, ed 7, New York, 2011,
2014, Elsevier Saunders, pp 82–85. McGraw-Hill Medical, pp 250–257.
7. Johnson KK, Soundarraj D, Patel P: Tenecteplase for 13. Wall MJ, Tsai P, Mattox KL: Mattox KL, Moore EE,
malignant pericardial effusion. Pharmacotherapy Feliciano DV, editors: Trauma, ed 7, New York, 2013,
27(2):303–305, 2007. McGraw-Hill Medical, pp 485–488.
PROCEDURE
79
Thenar Tissue Oxygen
Saturation Monitoring
Kathleen Berns
PURPOSE: Thenar tissue oxygen saturation monitoring is a noninvasive
technique to measure an approximated value of percent hemoglobin oxygen
saturation in the tissue and is a measure of tissue perfusion status.
❖ Patients undergoing resuscitation and who are requir-

PREREQUISITE NURSING ing active treatment.11
KNOWLEDGE ❖ Patients being assessed in the prehospital environment
where laboratory tests may not be available.7,12
• Tissue oxygen saturation (Sto2) is the measure of hemo- • Sto2 monitoring should not be used in the presence of
globin oxygen saturation of the microcirculation. ionizing radiation such as computed tomography (CT) or
• Oxygen saturation of arterial blood Sao2 measures and x-ray. Exposure to ionized radiation will cause cumulative
Spo2 estimates O2 saturation in the arteries. damage to the device resulting in inaccurately low read-
• Central venous oxygen saturation (Scvo2) measures O2 ings. Also, remove the sensor from the patient before
saturation in the superior vena cava. magnetic resonance imaging (MRI).
• Mixed venous oxygen saturation (Svo2) measures O2 satu-
ration in the pulmonary artery. EQUIPMENT
• Tissue oxygenation (Sto2) measures O2 saturation in the
microcirculation, where O2 diffuses into tissue cells. It is • Tissue oxygenation monitor
a direct measure of tissue oxygenation and a sensitive • Tissue oxygen disposable sensor or nondisposable clip
indicator of tissue perfusion status (Fig. 79-1). • Soap and water or antiseptic solution to cleanse the thenar
• Sto2 is measured at the thenar muscle, which is a periph- eminence
eral muscle. During shock, blood flow to peripheral • Nonsterile gloves
muscles and core organs (liver, gut, and kidneys) is Additional equipment, to have available as needed, includes
reduced in order to preserve brain and heart oxygenation. the following:
Sto2 measured at the thenar eminence allows noninvasive • Batteries
monitoring of early changes in perfusion status during
shock and resuscitation. PATIENT AND FAMILY EDUCATION
• The thenar site is minimally affected by age, gender,
edema, and adipose and is not confounded by hypother- • Assess patient and family readiness to learn and identify
mia.1–3 factors that affect learning. Rationale: This assessment
• Low Sto2 is associated with poor outcomes such as organ allows the nurse to individualize teaching.
dysfunction and mortality; thus further assessment data • Provide information about Sto2 monitoring. Rationale:
should be obtained.4–8 This information helps the patient and family to under-
• Monitoring the Sto2 trend may guide fluid resuscitation stand the procedure and why it is needed and may decrease
(Fig. 79-2). anxiety.
• Low Sto2 readings can be present even when vital signs • Explain the displayed values and possible alarms of the
are stable.8,9 monitor. Explain that values may change depending on
• Patients who may benefit from the use of Sto2 include the the sensor positioning and light that may affect the sensor.
following: Rationale: This information will help the patient and
❖ High-acuity elderly such as those over 65 years old family know what to expect.
with shortness of breath, chest pain, abdominal pain,
weakness, or syncope.9 PATIENT ASSESSMENT AND
❖ Trauma patients of any age in which the mechanism of
PREPARATION
injury puts them at risk for bleeding.8,9
❖ Trauma patients who require massive blood Patient Assessment
transfusion.10 • Assess the patient for signs and symptoms of hypo-
❖ All patients who are at risk for bleeding or are sus- perfusion, including cyanosis, tachypnea, tachycardia,
pected of having internal bleeding.8,9 altered level of consciousness, hypotension, decreased
693
Figure 79-1 Tissue oxygen saturation is measured in the microcirculation where oxygen is
exchanged with tissue. (From Hutchinson Technology pamphlet, What is InSpectra Sto2, 2008.)
urine output, mottling of the lower extremities Rationale: nurse should ensure the correct identification of the patient
Sto2 monitoring is useful in the early detection of hypo- for the intended intervention.
perfusion and can lead to earlier treatment. • Ensure the patient and family understand preprocedural
• Assess the thenar eminence. Rationale: Determines skin teaching. Answer questions as they arise and reinforce
integrity. information as needed. Rationale: This communication
evaluates and reinforces understanding of previously
Patient Preparation taught information.
Figure 79-2 It is important to watch the tissue oxygen saturation trend when assessing and treat-
ing the patient. (From Hutchinson Technology website, Education Resources, 2008.)
79 Thenar Tissue Oxygen Saturation Monitoring 695
Procedure for Thenar Tissue Oxygenation (Sto2) Monitoring

1. HH
2. PE
3. Determine whether continuous A single measurement can be used to The spot-check device has a clip-type
tissue monitoring will be quickly assess tissue perfusion. cable that is not disposable.
performed or if a single Continuous Sto2 monitoring is useful The continuous monitor has a sensor
measurement will be obtained. in guiding treatments. cable that attaches firmly to the
thenar eminence and is for single
patient use.
Follow prescribed order for tissue
monitoring or institutional standard.
4. Clean and dry the palm and The thenar eminence needs to be Avoid placing the sensor over a
thenar eminence. clean and dry in order for the hematoma and skin obscured by ink
sensor to adhere to the skin. such as tattoos, markers, or pens.
The sensors also need a clean area so
that monitoring is accurate.
5. Plug the monitor into a grounded Prepares the equipment.
wall outlet or ensure that a fully
charged battery is installed.
6. Attach the optical cable to the Prepares the equipment. Carefully align the pins when
Sto2 monitor. connecting the optical cable to the
monitor to avoid bending the pins.
7. Press the power button on the Prepares the equipment. The equipment does not need to be
monitor. The start-up time is approximately 30 calibrated.
seconds.
8. Apply the continuous monitoring Ensure the sensor is attached to the Approximately 20 seconds is needed
sensor or clip the nondisposable patient to avoid high ambient light before determining a value.
sensor to the palm and thenar conditions that may result in the
eminence (Fig. 79-3). device not being able to take a
measurement or provide inaccurate
measurements.
9. Observe the tissue hemoglobin The THI is an indicator of signal Patient movement can cause changes
index (THI) signal strength on strength based on the measure of in measurement values.
the monitor display. the total amount of hemoglobin
present in the monitored tissue.
Figure 79-3 Tissue oxygen monitor with nondisposable clip placed on the palm and thenar emi-
nence. (Photo courtesy of Mayo Clinic.)
Procedure for Thenar Tissue Oxygenation (Sto2) Monitoring—Continued

10. If the THI signal is greater than A THI greater than five indicates
five, observe the Sto2. sufficient hemoglobin to obtain an
adequate Sto2 signal in most
circumstances.
11. Remove PE and discard used Reduces the transmission of If using the nondisposable sensor
supplies in appropriate receptacle. microorganisms and body cleanse it with a manufacturer’s
secretions; Standard Precautions. recommended agent.
12. HH

• Accurate Sto2 values are obtained. • Accurate tissue oxygenation is not obtained because
• Changes in tissue oxygenation are detected and treated. of movement or ambient light.
• The need for invasive techniques for monitoring • Sto2 is not able to be used due to a tattoo on the
oxygenation and tissue perfusion is reduced. thenar skin.

interventions.
1. Evaluate the patient’s vital signs, Monitoring Sto2 is one method for • Trends demonstrating decreasing
level of consciousness, and evaluating the patient. Sto2 values
laboratory values along with the A complete assessment of the patient • Sto2 values <75%
Sto2 values for evidence of should be done, and reliance on a • Cyanosis
reduced tissue oxygenation and single measurement should be • Tachypnea
hypoperfusion. avoided. • Tachycardia
• Altered level of consciousness
• Hypotension
• Decreased urine output
• Mottling of the lower extremities
• Increased lactate level
2. Evaluate the sensor site every 15 Assessment of the skin and tissues • Change in skin color
minutes if a reusable sensor is used under the sensor identifies skin • Loss of warmth of tissue
or every 24 hours or per breakdown or loss of vascular flow. • Loss of blood flow to the digits
manufacturer’s recommendations if • Evidence of skin breakdown from
a nonreusable sensor is used. the sensor
• Change in color of the nailbeds
3. Ensure that ambient light does not If light gets under the sensor, the • Inability to obtain Sto2 values
affect the sensor. values may be inaccurate.
• Have the patient rest his or her
hand, palm side down, on a flat
surface.
• A towel or blanket can be
placed over the patient’s hand/
sensor to block out light.
79 Thenar Tissue Oxygen Saturation Monitoring 697
Documentation
• Patient and family education • Other laboratory results such as hemoglobin, lactate,
• Indication for use of the Sto2 monitor and arterial blood gas
• Patient assessment at the time of the Sto2 measurement • Skin assessment at sensor site
• THI level • Nursing intervention and treatments provided
• Sto2 level • Patient response to treatment
• Unexpected outcomes

79 Thenar Tissue Oxygen Saturation Monitoring 697.e1
References 8. Veening A, Ince C, Bakker J: Incidence of a low tissue

1. Crookes B, et al: Can near-infrared spectroscopy identify oxygen saturation in a mixed population of critically ill
the severity of shock in trauma patients? J Trauma patients. Crit Care 14(Suppl 1):151, 2010.
58:806–816, 2005. 9. Ardolic B, Menendez B, Mihata R: The incidence of
2. Poeze M: Tissue-oxygenation assessment using near- hypoperfusion in patients waiting for a medical floor bed.
infrared spectroscopy during severe sepsis: Confounding Ann Emerg Med 56(Suppl):S131–S132, 2010.
effects of tissue edema on StO2 values. Intensive Care 10. Moore F, et al: Massive transfusion in trauma patients:
Med 32:788–789, 2006. Tissue hemoglobin oxygen saturation predicts poor
3. Beilman G, et al: Early hypothermia in severely injured outcome. J Trauma 64:1010–1023, 2008.
trauma patients is a significant risk factor for multiple 11. Santora R, Moore R: Monitoring trauma and intensive
organ dysfunction syndrome but not mortality. Ann Surg care unit resuscitation with tissue hemoglobin oxygen
249:845–850, 2009. saturation. Crit Care 13(Suppl 5):S10, 2009.
4. Cohn J, et al: Tissue oxygen saturation predicts the 12. Guyette FX, et al: Prehospital dynamic tissue oxygen
development of organ dysfunction during traumatic shock saturation response predicts in-hospital lifesaving
resuscitation. J Trauma 62:44–55, 2007. interventions in trauma patients. J Trauma 72:930–935,
5. Lima A, et al: Low tissue oxygen saturation at the 2012.
end of early goal-directed therapy is associated with Additional Reading
worse outcome in critically ill patients. Crit Care 13
(Suppl 5):S13, 2009. Mitchell C: Tissue oxygenation monitoring as a guide for
6. Leone M, et al: Oxygen tissue saturation is lower in trauma resuscitation. Crit Care Nurse 36(3):12–19, 70,
nonsurvivors than in survivors after early resuscitation of 2016.
septic shock. Anesthesiology 111:366–371, 2009.
7. Sagraves J, et al: Tissue oxygenation monitoring in the
field: a new EMS vital sign. J Trauma 67:441, 2009.
PROCEDURE
80
Transesophageal
Echocardiography (Assist)
Janice Y. Dawson and Linda Hoke
PURPOSE: Transesophageal echocardiography (TEE) offers an alternative
approach for obtaining high-quality images of the heart structure that are not well
visualized with a conventional transthoracic echocardiography (TTE) approach. A
TEE obtains images of the heart from a transducer inside the esophagus. The
esophagus lies immediately behind the heart, and with this technology clear images
of the heart can be obtained.
PREREQUISITE NURSING structures. These images represent “slices” of the heart

KNOWLEDGE in motion.
❖ Three-dimensional (3D) echocardiography provides
• Knowledge of cardiovascular anatomy and physiology is added dimensions to the 2D echocardiogram. It pro-
necessary. vides detailed anatomical assessment of cardiac pathol-
• Knowledge of basic arrhythmia recognition and treatment ogy, chamber volume measurement, and views of heart
of life-threatening arrhythmias is needed. valves, enabling a better appreciation of the severity
• Advanced cardiac life support (ACLS) knowledge and and mechanisms of valve diseases.
skills are needed. ❖ Doppler echocardiography: This assesses the flow of
• A topical anesthetic is used in the oropharyngeal area; blood through the heart. The signals that represent
thus, the patient’s gag reflex may be diminished or absent, blood flow are displayed as a series of black-and-white
putting the patient at risk for aspiration.4 tracings or color images on the screen.
• It is essential to know the institution’s conscious sedation • A TEE is considered a safe and relatively noninvasive diag-
guidelines. nostic technique. However, severe, even life-threatening
• Sedation can put the patient at risk for respiratory complications have been reported.5
depression.9 • General indications for TEE are as follows1,2,4:
• A fiberoptic probe with an ultrasound transducer is inserted ❖ Evaluation of cardiac and aortic structures and function
through the mouth into the esophagus just behind the heart with inadequate TTE images or in whom diagnostic
(Fig. 80-1). The transducer located at the tip of the probe information is not obtainable by TTE
sends high-frequency sound waves toward the heart, ❖ Rule out clot prechemical and/or electrical
which returns as echoes. The echoes are converted, by cardioversion
computer, into moving images of the heart. The image is ❖ Suspected acute thoracic aortic pathology including
displayed on a screen and can be recorded on videotape but not limited to dissection/transection
or compact disk (CD), printed on paper, or sent electroni- ❖ Evaluation of valvular (mitral) structure and function
cally to a picture-archiving communication system. This to assess appropriateness for, and to assist with plan-
test is used to visualize structures of the heart and aorta ning of, an intervention
that may not be seen with a standard TTE and to clarify ❖ Diagnosis of infective endocarditis with a high pretest
structures that may be otherwise poorly seen. The test may probability (e.g., staphylococcus bacteremia, funge-
be performed as an outpatient or inpatient procedure or in mia, prosthetic heart valve, or intracardiac device)
the operating room.4 ❖ Evaluation for cardiovascular source of embolus with
• Various modes of echocardiography are used to examine no identifiable noncardiac source
the heart, blood vessels, valve function, and blood flow. ❖ Intraoperative cardiac monitoring
The three techniques include: ❖ Guiding the management of catheter-based intracar-
❖ Motion-mode (M-mode) echocardiography: This is a diac procedures such as septal defect closure or
one-dimensional echocardiogram that visualizes time, atrial appendage obliteration and transcatheter valve
depth, and intensity. It looks like a tracing instead of a procedures
picture of the heart and is used to measure the exact ❖ Prosthetic valve disorders
size of the heart chambers. • Contraindications to TEE can be divided into absolute
❖ Two-dimensional (2D) echocardiography: This shows and relative. Gastrointestinal (GI) evaluation and clear-
the actual shape and motion of the different heart ance should be considered before the procedure.
698
80 Transesophageal Echocardiography (Assist) 699
Transesophageal Echocardiogram (TEE)
Esophagus
Transesophageal
echocardiography
(TEE) probe in Heart
esophagus Echocardiogram monitor
(probe can also
be placed in Atrium
the stomach)
Ventricle
Sound waves
create pictures
of the heart
Stomach
Figure 80-1 Transesophageal echocardiography (TEE) probe inserted through the mouth and into
the esophagus just behind the heart.
• Absolute contraindications are as follows2,5: EQUIPMENT

❖ Diseases of the throat/esophagus/stomach including,
but not limited to, known obstructive esophageal • Transesophageal ultrasound probe
disease, obstruction, stenosis, tumors, fistulae, or varices • Echocardiography machine (compatible with the probe)
❖ Esophageal perforation, laceration • Constant low wall suction with connecting tubing and
❖ A history of esophageal radiation or unresolved esoph- rigid pharyngeal suction tip catheter
ageal dilation • Protective mask, goggles, nonsterile gloves, and barrier
❖ Perforated viscus gowns
❖ Dysphagia and odynophagia • Water-soluble lubricant
❖ Active upper GI bleeding • Oxygen, with both nasal prongs and mask available
❖ Patients who ate within 6 to 8 hours of the study, unless • Topical anesthetic such as lidocaine solution with an
emergent as in aortic dissection or trauma administration device (i.e., mucosal atomization device),
❖ Unwilling patients viscous lidocaine, or benzocaine spray (as prescribed)
❖ Inability to obtain intravenous access • Premedication for sedation and appropriate reversal agents
• Relative contraindications are2,5: (as prescribed)
❖ Upper GI surgery • Syringes, blunt needles, and labels for medications
❖ Recent upper GI bleed • Antiseptic agents for IV connection cleansing such as
❖ History of radiation to neck and mediastinum alcohol prep pads
❖ Barrett’s esophagus • IV insertion kit (if adequate IV access is not in place)
❖ History of dysphagia • IV tubing
❖ Restriction of cervical mobility from severe cervical • One bag (500 mL or 1000 mL) of 0.9% normal saline IV
arthritis solution
❖ Esophageal varices • Syringes of proper size for aspirating and flushing IV
❖ Coagulopathy, thrombocytopenia access if needed
❖ Active esophagitis • Tongue depressor
❖ Active peptic ulcer disease • Emesis basin
❖ Loose teeth • Flashlight (to assess the oropharyngeal area, especially in
• A TEE does not pose a risk for infection. Patients with the case of trauma)
prosthetic values do not need antibiotics prescribed before • Disposable bite guard (may use the type with or without
the procedure.7 a strap to hold it in place)
• Thermometer
• Continuous electrocardiographic monitor PATIENT ASSESSMENT AND
• Continuous pulse oximetry monitor and equipment PREPARATION
• Continuous capnography monitor and tubing (organiza-
tion specific) Patient Assessment
• Automatic blood pressure machine and cuff (with manual • Verify the correct patient using two identifiers. Rationale:
blood pressure cuff available for backup use) Before performing a procedure, the nurse should ensure
• Two pillows, one supporting the neck and one supporting the correct identification of the patient for the intended
the back, to maintain the side-lying position procedure.
• Bags with respective labels for carrying probe to and from • Assist the physician, advanced practice nurse, or other
procedure (institution specific) healthcare professional with assessing the patient’s medical
• ACLS cart, airway equipment, and medications history for absolute and relative contraindications for the
Additional equipment, to have available as needed, includes TEE procedure. Rationale: Screening for absolute and
the following: relative contraindications for the TEE procedure prevents
• Denture cup with patient identification adverse outcomes.
• Tonsillar forceps and cotton balls with radiopaque string • Assess the patient’s baseline cardiac rhythm. Rationale:
attached (institution specific) The patient’s rhythm may have converted if the indica-
• Methylene blue, if benzocaine spray is used tion for the procedure was an arrhythmia. Passage of a
• Ultrasound gel large-bore tube may cause vagal stimulation and brady
• Three-way stopcock and syringes, at least two 10-mL arrhythmias.
syringes with normal saline flush solution and one 10-mL • Assess the patient’s history of medication allergies. Ratio-
empty syringe, for the administration of the saline contrast nale: Identifying allergies may avoid an adverse medica-
agent if used tion reaction.
• Confirm the patient was NPO for the prescribed length of
PATIENT AND FAMILY EDUCATION time. Rationale: NPO status for an appropriate period of
time before the procedure allows for gastric emptying and
• Assess the patient and family’s understanding of the pro- decreases the likelihood of aspiration.
cedure and the indication for therapy. Rationale: Informa- • Assess the patient’s medication history.1 Rationale: Fre-
tion about the procedure increases patient cooperation and quent use of certain medications (e.g., analgesics and anx-
decreases patient and family anxiety and apprehension. iolytics) or illicit drugs and alcohol may affect the patient’s
• Verify that the patient understands the preparation for the response to moderate sedation and the medications.
procedure, which includes not having food or nonclear • Confirm medications the patient has taken within the
liquids for at least 6 hours and nothing by mouth (NPO) last 4 hours. Rationale: Recent sedative, analgesic, and
for 2 to 3 hours before the procedure as prescribed.4,8 vasoactive medications may affect the patient’s toler-
Before the test, the patient may take daily medications, ance and response to the medications given during the
with a sip of water, as prescribed or according to institu- procedure.
tion standards. Rationale: Undigested material in the • Assess the patient’s height, weight, baseline respiratory,
stomach increases the risk for aspiration. Prescribed medi- hemodynamic, and neurological status before anesthetiz-
cations may be needed. ing the posterior pharynx and administering any sedative
• Explain that the local anesthetic may make the patient’s agents. Rationale: Baseline assessment data provide
tongue and throat feel swollen and that he or she may feel information to use as a comparison for further assessment
unable to swallow. The gag reflex will be inhibited by the once medications have been administered.
local anesthetic and may last approximately 1 hour after • Assess the patient’s baseline vital signs, oxygen satura-
administration. They may experience gagging or retching tion, and if applicable capnography reading. Rationale:
during the numbing process and during the initial passage Close monitoring of vital signs and oxygenation during
of the probe. Rationale: The explanation may assist in the procedure and comparison with baseline are essential
decreasing patient anxiety during the procedure. to assess the patient’s tolerance of the procedure.
• Explain to the patient he or she will be sedated to decrease • Assess the patient’s baseline pain characteristic, site, and
anxiety, to increase comfort, and for ease in passing the severity. Rationale: Baseline assessment data provide
probe. Rationale: This information may decrease patient information to use as a comparison during and after the
and family anxiety. procedure.
• Describe to the patient he or she will be monitored closely • Assess the patient’s presedation level of consciousness,
during and after the procedure. Rationale: The explana- using an organization-approved scoring system (e.g.,
tion assists in decreasing patient and family anxiety. Modified Aldrete Score).4 Rationale: Using a scoring
• Explain to the patient he or she will require transporta- system for conscious sedation may prevent oversedation,
tion after the procedure and needs to be accompanied by and establish a baseline for postprocedure comparison.
a responsible adult if it is performed in an ambulatory • Assess the patient for medical problems that contraindi-
setting. Rationale: Even short acting medications may cate or increase the risk of conscious sedation. Consider
not be metabolized for a few hours making it unsafe to using the American Association of Anesthesiologists’
drive. Physical Status Classification Score per institution policy.
Rationale: Screening the patient preprocedure may find a • Maintain the prescribed IV infusion during the procedure.
history or evidence of difficult intubation, sleep apnea, Rationale: IV infusion maintenance ensures the IV is
and complications of sedation or anesthesia.4 functioning and available should an emergency arise.
• Have the patient remove any dentures or dental prosthe-
Patient Preparation ses. Rationale: Dentures may interfere with the safe
• Verify that the patient and family understand preproce- passage of the transesophageal probe.
dural teaching. Answer questions as they arise, and rein- • Set up the suction system with the connecting tubing and
force information as needed. Rationale: Understanding of a rigid pharyngeal suction tip device attached and ready
previously taught information is evaluated and reinforced. for use. Check for adequate suction vacuum. Rationale:
Patient and family anxiety may be decreased. This setup is necessary for suctioning the patient’s oral
• Verify that informed consent was obtained, including secretions during the procedure.
consent for anesthesia and agitated saline contrast injec- • Prepare the prescribed local anesthetics (e.g., benzocaine,
tion, if required. Rationale: Informed consent is necessary viscous lidocaine); sedatives (e.g., midazolam, diazepam);
before invasive procedures and the administration of con- analgesics (e.g., fentanyl, morphine sulfate); reversal
scious sedation. Informed consent protects the rights of agents (e.g., naloxone, and flumazenil); medications to
the patient and makes a competent decision possible for decrease salivary secretions as needed; and methylene
the patient; however, in emergency circumstances, time blue (if benzocaine use is planned).4 Rationale: Sedatives
may not allow the form to be signed. and analgesics reduce patient anxiety, promote comfort,
• Instruct the patient to void before the procedure. Ratio- facilitate cooperation during the procedure, and decrease
nale: Voiding before the procedure minimizes disruption myocardial workload. Reversal agents are required for
of the examination. emergencies. Methylene blue is needed to reverse methe-
• Perform a preprocedure verification and time out. Ratio- moglobinemia if it occurs with the use of benzocaine.4
nale: Ensures patient safety. Confirms correct patient, • Have agitated normal saline solution available per orga-
procedure, and equipment availability. nization protocol if prescribed for saline contrast echocar-
• Initiate or continue electrocardiographic monitoring, apply diography (bubble study). Rationale: The contrast agent
an automatic blood pressure cuff (if arterial blood pressure enhances the ability to evaluate cardiac shunt.
monitoring is not already in place), and initiate oxygen satu- • Administer supplemental oxygen as prescribed. Ratio-
ration monitoring and, if prescribed, capnography. Ratio- nale: Administration of oxygen may be needed to main-
nale: These measures allow for close cardiovascular and tain adequate patient oxygenation during the procedure.
respiratory monitoring during the procedure. Follow orga- • Have atropine available at the bedside. Rationale: Atro-
nizational practice regarding capnography monitoring. pine is necessary if a vagal reaction occurs with the inser-
• Ensure the ordered IV access is in place and functional, tion and passage of the transesophageal probe.
usually a 20-gauge or larger IV. Rationale: IV access is • Have an ACLS cart, medications, and airway equipment
needed to administer premedication and for possible available at the patient’s side.4 Rationale: Emergency
emergency medications. A 20-gauge or larger IV is needed equipment is necessary to have close by in case an emer-
for the injection of contrast if prescribed. gency situation should arise.
Procedure for Transesophageal Echocardiography (Assist)

1. HH
2. PE
3. Assist if needed as the physician, Decreases discomfort caused by If possible, allow the patient to sit up
advanced practice nurse, or other passage of the probe. to increase comfort and decrease
healthcare professional anxiety or the feeling of choking.
anesthetizes the patient’s
posterior pharynx with the
topical agent.
4. Assist the patient to the left- The left-lateral decubitus position Patients may be examined in the
lateral decubitus position. Use allows secretions to collect in the supine position if required by
pillows to ensure correct dependent areas of the mouth for anatomy or hemodynamic stability
alignment of the spine with the ease of suctioning and to prevent or if the patient is endotracheally
head and body. aspiration in case the patient intubated.4
vomits.
5. Reassess vital signs, oxygen Closely monitors the patient and
saturation, capnography, determines whether there are any
neurological status, cardiac changes in the patient’s condition.
rhythm, respiratory status, and pain
before administration of IV
medications for moderate sedation.
Procedure for Transesophageal Echocardiography (Assist)—Continued

6. Administer IV medication for Allows the patient to cooperate in Confirm the appropriate antagonists
moderate sedation as prescribed.4 facilitating passage of the probe are readily available.
(Level D*) during the procedure. Continually assess the patient as he or
she may need additional medication
throughout the procedure.
7. Assist the physician, advanced Gag and cough reflexes may be
practice nurse, or other compromised by topical anesthetics,
healthcare professional as needed and the patient may vomit as the
with the insertion of the probe. probe is passed, increasing the risk
A. Prepare to insert a bite guard The bite guard prevents the patient for aspiration.
when directed by the from biting the probe or the fingers
physician, advanced practice of the physician, advanced practice
nurse, or other healthcare nurse, or other healthcare
professional. professional and avoids damage to
the teeth and mouth.
B. Assist the physician, advanced Lubrication of the probe minimizes
practice nurse, or other mucosal injury and irritation, and
healthcare professional as facilitates the ease of passage of
requested with lubrication of the probe. Contact gel transmits
the probe and oropharynx and ultrasound signals.
applying ultrasound contact
gel or viscous lidocaine to the
distal end of the probe.
C. Ask the patient to slightly Proper head position eases insertion
bend his or her head in a of the probe into the esophagus.
forward flex.
D. Alternatively, if needed assist
the physician, advanced
practice nurse, or other
healthcare professional with
the jaw-thrust technique if
required to guide the probe
insertion.
E. Encourage the patient to The swallowing maneuver causes the Some physicians, advanced practice
simulate swallowing while epiglottis to close the trachea and nurses, and other healthcare
the probe is passed if directs the probe into the professionals may not want to draw
requested by the physician, esophagus. attention to the throat and will not
advanced practice nurse, or ask the patient to swallow, but
other healthcare professional. rather will wait for a natural
swallow motion to occur and then
insert the probe.
F. Suction the oral secretions as Removes secretions. This may be Manipulation of the probe may cause
needed to ensure patency of needed due to the patient’s stimulation of secretions.
the airway. diminished gag reflex and the
inability of the patient to swallow
oral secretions.
G. Provide the patient with May decrease patient anxiety and Some patients may be able to tolerate
reassurance and promote patient cooperation. the procedure without analgesia or
encouragement to keep the anesthesia when encouragement is
bite guard in place, maintain provided.4
the required position, hold
still without attempts to
speak, and focus on his or her
breathing pattern.
Procedure for Transesophageal Echocardiography (Assist)—Continued

8. Provide the physician, advanced Keeps the physician, advanced practice
practice nurse, or other nurse, or other healthcare
healthcare professional with professional informed of the
updates of the patient status patient’s condition and possible need
during the TEE procedure. for additional sedation or analgesics.
9. Assist with the administration of The administration of saline contrast Assist with instructing the patient to
the saline contrast agent as enhances the view of the cardiac perform the valsalva maneuver,
prescribed and per institutional structures and function. sniffing, or coughing to enhance
standards.4,6 right-to-left shunting images, if
requested by the physician,
advanced practice nurse, or other
healthcare professional.6
10. Assist if needed with the removal Provides assistance. Anesthetics may be less effective at
of the probe. the end of the procedure, increasing
the gag and cough reflexes, thus
increasing the patient’s risk of
vomiting as the probe is removed.
Using a rigid pharyngeal suction tip
catheter, suction as necessary as the
tube is removed to prevent
aspiration.
11. Place the probe in an appropriate Reduces the transmission of
receptacle for cleaning. microorganisms and prepares the
equipment for sterilization.
12. Continue assessment and Ensures patient safety. Keep the patient on the left side with
monitoring until the patient his or her head slightly elevated
returns to baseline as prescribed; until the gag, swallow, and cough
follow institutional standards. reflexes are intact.
13. Discard used supplies in Removes and safely discards used
appropriate receptacles. supplies using standard precautions.
14. HH

• Clear visualization of cardiac structures and function • Esophageal or gastric perforation
• Immediate preliminary diagnosis • Esophageal, oropharyngeal, or gastric injury or
• Note: Negative study results are helpful in excluding lacerations
cardiac sources of compromise • Oropharyngeal hematoma
• Patent airway • Vasovagal hypotension from esophageal manipulation
• Acceptable level of comfort with no adverse reactions • Substernal chest pain
to sedation or analgesia • Temporary dysphagia
• Aspiration
• Respiratory depression
• Hematoma in the oropharynx
• Unresolved hypotension or hypertension
• Arrhythmias, bradycardia, or tachycardia
• Laryngospasm
• Bronchospasm
• Change in neurological status
• Air embolism in patients with right-to-left shunt with
use of saline contrast
• Heart failure
• Pain
• Methemoglobinemia

interventions.
1. Assess and monitor Changes in vital signs; heart rhythm; Changes in the following:
cardiovascular, respiratory, and capnography values; oxygenation; • Neurological status
neurological status at a minimum and neurological, respiratory, and • Oxygenation
of 5-minute intervals during cardiovascular status may indicate • Capnography
the procedure and 15-minute complications related to the • Heart rate and rhythm
intervals after the TEE procedure, procedure. • Blood pressure
until the patient’s condition returns • Respirations
to baseline, the prescribed • Cardiovascular status
parameters (e.g., vital signs within
10% of baseline),4 and as required
by institutional standards.
2. Maintain IV access and infusions Maintaining IV access and infusions
as prescribed during and after the ensures IV patency in case
procedure. emergency medications are needed.
3. Monitor the patient’s sedation Determines the patient’s response to • Sedation score outside of
score using a tool (i.e., Modified IV moderate sedation and the need prescribed parameters
Aldrete Score)4 during and after for additional sedation. • Worsening sedation score after the
the procedure following discontinuation of sedation
4. Assess pain at a minimum of May indicate a complication of the • New onset of pain
5-minute intervals during and procedure or identify the need for • Unresolved discomfort not
15-minute intervals after the pain interventions. relieved after the probe is removed
TEE procedure until the patient’s Mild throat discomfort is common as • Unusual throat discomfort
condition returns to baseline. the topical anesthetic wears off.
Administer analgesia as
prescribed.
5. Monitor for signs and symptoms Identifies complications. • Dysphagia
of esophageal trauma or • Odynophagia
perforation.2,3,5 • Mackler’s triad: vomiting, pain,
and subcutaneous emphysema
• Fever
• Agitation
• Tachycardia
• Hypotension
• Chest pain
• Tachypnea
• Dyspnea
• Pneumothorax
• Pleural effusions

6. Monitor for intraprocedure Determines the patient’s response to • Patient becomes agitated and is
complications or reasons to the procedure and identifies unable to cooperate with the
terminate the TEE early.4 complications. procedure
• Change in neurological status
• Dental or oropharyngeal trauma
• Apnea
• Hypoxemia
• Hypercapnia
• New arrhythmia
• New hypotension or hypertension
• Perforation or subcutaneous
emphysema
• GI or other bleeding
• Chest pain
• Benzocaine-induced
methemoglobinemia
7. Monitor a patient who received Severe methemoglobinemia is life • Dyspnea
benzocaine for symptoms of threatening. • Nausea
methemoglobinemia. Prepare to • Tachycardia
treat methemoglobinemia with • Cyanosis
supplemental oxygen and • Decreased pulse oximetry levels
methylene blue solution given by
slow IV administration as
prescribed.4
8. Assess the patient for the return The topical anesthesia decreases the • Prolonged absence of gag,
of normal pharyngeal function. If gag, swallow, and cough reflexes swallowing, or cough reflexes
the patient is not upright, keep and increases the patient’s risk of
the patient on his or her left side aspiration.
with the head of the bed elevated
until the gag, swallow, and cough
reflexes are intact.
9. Offer clear liquids and gradually Topical anesthesia decreases the gag • Nausea
progress to solid food after return reflex and increases the risk for • Vomiting
of pharyngeal function as aspiration. • Stomach discomfort
prescribed. • Increase in odynophagia or
dysphagia after 24 hours, may
possibly indicate soft tissue or
esophageal injury.4
10. Ask the patient to repeat his or Having patients repeat the • Patient unable to understand
her understanding of the postprocedure instructions confirms postprocedure instructions
postprocedure instructions. their understanding of what they
should and should not do.

11. Ensure the safety of the This information is provided to
ambulatory patient. Ensure vital patients who are being discharged.
signs have returned to 10% of
baseline before ambulation.4
Have a family member or friend
explain postprocedure education
and sign appropriate documents
as needed. Advise the patient to
refrain from important decisions
and driving while the effects
anesthetic remain (i.e., for the
remainder of the day). Provide
the patient with a copy of the
written discharge instructions,
per institutional standards.
Counsel the patient to call the
physician, advanced practice
professional if odynophagia or
dysphagia persists for 24 hours.4
Ensure the patient is accompanied
by a responsible adult.
Documentation
• Date and time of procedure • Vital signs, pulse oximetry, capnography,
• Initial patient assessment neurological status, respiratory status, and pain
• Patient and family education evaluation immediately before sedation, and during
• Preprocedure verifications and timeout and after the procedure
• Completion of informed consent form • Establishment and assessment of IV patency

80 Transesophageal Echocardiography (Assist) 706.e1
References experience with 1162 patients and recommendations for

1. American College of Cardiology Foundation Appropriate echocardiography. J Am Soc Echocardiogr 26:96–102,
Use Criteria Task Force, American Society of 2013.
Echocardiography; American Heart Association, et al: 7. Nishimura RA, et al: ACC/AHA 2008 guideline update on
ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/ valvular heart disease: focused update on infective
SCMR 2011 Appropriate Use Criteria for endocarditis: a report of the American College of
Echocardiography. A Report of the American College of Cardiology/American Heart Association Task Force on
Cardiology Foundation Appropriate Use Criteria Task Practice Guidelines endorsed by the Society of
Force, American Society of Echocardiography, American Cardiovascular Anesthesiologists, Society for
Heart Association, American Society of Nuclear Cardiovascular Angiography and Interventions, and Society
Cardiology, Heart Failure Society of America, Heart of Thoracic Surgeons. Catheter Cardiovasc Interv 72:
Rhythm Society, Society for Cardiovascular Angiography E1–E12, 2008.
and Interventions, Society of Critical Care Medicine, 8. Practice Guidelines for Preoperative Fasting and the
Society of Cardiovascular Computed Tomography, Society Use of Pharmacologic Agents to Reduce the Risk of
for Cardiovascular Magnetic Resonance American College Pulmonary Aspiration: Application to Healthy Patients
of Chest Physicians. J Am Soc Echocardiogr 24:229–267, Undergoing Elective Procedures: An Updated Report by
2011. the American Society of Anesthesiologists Committee on
2. American Society of Anesthesiologists and Society of Standards and Practice Parameters. Anesthesiology
Cardiovascular Anesthesiologists Task Force on 114:495–511, 2011.
Transesophageal Echocardiography: Practice guidelines for 9. Ramachandran SK, et al: Life-threatening critical
perioperative transesophageal echocardiography. An respiratory events: a retrospective study of postoperative
updated report by the American Society of patients found unresponsive during analgesic therapy.
Anesthesiologists and the Society of Cardiovascular J Clin Anesth 23:207–213, 2011.
Anesthesiologists Task Force on Transesophageal Additional Readings
Echocardiography. Anesthesiology 112:1084–1096, 2010.
3. Derr C, Drake JM: Esophageal rupture diagnosed with Picard MH, et al: American Society of Echocardiography
bedside ultrasound. Am J Emerg Med 30:2093.e1–2093.e3, recommendations for quality echocardiography
2012. laboratory operations. J Am Soc Echocardiogr 24:1–10,
4. Hahn RT, et al: Guidelines for performing a comprehensive 2011.
transesophageal echocardiographic examination: Pislaru SV, Michelena HI, Mankad SV: Interventional
recommendations from the American Society of echocardiography. Prog Cardiovasc Dis 57:32–46,
Echocardiography and the Society of Cardiovascular 2014.
Anesthesiologists. J Am Soc Echocardiogr 26:921–964, Reeves ST: Basic and comprehensive perioperative
2013. transesophageal echocardiography consensus
5. Hilberath JN, et al: Safety of transesophageal statement documents. J Am Soc Echocardiogr 26:25A,
echocardiography. J Am Soc Echocardiogr 23:1115–1127, 2013.
2010. Tsai SK: The role of transesophageal echocardiography in
6. Marriott K, et al: Detection of right-to-left atrial clinical use. J Chin Med Assoc 76:661–672, 2013.
communication using agitated saline contrast imaging:
Section Eleven Vascular Access
PROCEDURE
81
Arterial Puncture
Joel M. Brown II
PURPOSE: Arterial puncture is performed to obtain a sample of blood for arterial
blood gas (ABG) analysis.
PREREQUISITE NURSING • Arterial cannulation is considered for patients who need

KNOWLEDGE frequent arterial blood samples, continuous arterial pres-
sure monitoring, or evaluation of vasoactive medication
• An ABG analysis measures the pH and the partial pres- therapy (see Procedures 58 and 59).
sure of oxygen and carbon dioxide. ABG samples are • The most common complications associated with arterial
also analyzed for oxygen saturation and for bicarbon- puncture include pain, vasospasm, hematoma formation,
ate values. These analyses are done primarily to evalu- infection, hemorrhage, and neurovascular compromise.5,9,16
ate a patient’s oxygenation status, acid-base balance, and • Site selection proceeds as follows:
ventilation.5 Additional laboratory tests (e.g., electrolytes, ❖ Use the radial artery as first choice. The radial artery
ammonia and lactate levels) can be performed on arterial is small and easily stabilized because it passes over a
blood samples. bony groove located at the wrist (see Fig. 81-1).
• Indications for ABGs vary and include patients with ❖ Use the brachial artery as second choice, except in the
chronic and acute respiratory disorders (e.g., chronic presence of poor pulsation from shock, obesity, or scle-
obstructive pulmonary disease, pneumonia, adult respira- rotic vessel (e.g., because of previous cardiac catheter-
tory lung disease) and acute metabolic or shock disorders ization). The brachial artery is larger than the radial
(e.g., sepsis, postcardiac arrest, acute kidney injury). ABG artery. There is risk of median nerve injury due to its
analysis frequently is performed on patients in shock, proximity to the brachial artery. Hemostasis after arte-
receiving oxygen or mechanical ventilation therapies, or rial puncture is enhanced by its proximity to bone if
experiencing changes in respiratory therapy or status.5 the entry point is approximately 1.5 inches above the
• Knowledge of principles of aseptic technique is necessary. antecubital fossa (see Fig. 81-1).
• Knowledge is needed of the anatomy and physiology of ❖ Use the femoral artery in the case of cardiopulmonary
the vasculature and adjacent structures. arrest or altered perfusion to the upper extremities. The
• The brachial artery is a continuation of the axillary artery femoral artery is a large superficial artery located in the
in the upper extremity. It bifurcates just below the elbow groin (see Fig. 81-2). It is easily palpated and punc-
(Fig. 81-1). From the bifurcation, the ulnar artery moves tured. Complications related to femoral artery puncture
down the forearm on the medial side and the radial artery include hemorrhage and hematoma because bleeding
on the lateral side.18 can be difficult to control; inadvertent puncture of the
• The preferred artery for arterial puncture is the radial femoral vein because of the close proximity of the vein
artery. Although this artery is smaller than the ulnar artery, to the artery; infection because aseptic technique in the
it is more superficial and can be stabilized more easily groin area is difficult to maintain; and limb ischemia if
during the procedure.7 The use of the brachial artery is a the femoral artery is damaged.
safe and reliable alternative site for arterial puncture.16 • Ultrasound guidance can be used for arterial puncture if
• At times, the femoral artery is used for arterial puncture. the technology is available.10
The use of this artery can be technically difficult because
of the proximity of the artery to the femoral vein (Fig. EQUIPMENT
81-2).
• One prepackaged ABG kit that contains the following:
❖ One 20- to 25-gauge, 1- to 1.5-inch hypodermic needle

(note: longer needles are needed for brachial and
practice nurses, and other healthcare professionals (including critical care femoral artery puncture)
nurses) with additional knowledge, skills, and demonstrated competence per ❖ One 1- to 5-mL preheparinized (if available) syringe
professional licensure or institutional standard. with a rubber stopper or cap
707
Median nerve PATIENT AND FAMILY EDUCATION

Brachial artery
• Explain the reason for the arterial puncture to the patient
Radial artery and family. Rationale: Clarification of information is an
expressed patient and family need and helps to diminish
anxiety, enhance acceptance, and encourage questions.
• Describe the overall steps of the procedure, including the
patient’s role in the procedure. Rationale: This explana-
tion decreases patient anxiety, enhances cooperation, and
provides an opportunity for the patient to voice concerns,
and prevents accidental movement during the procedure.
Ulnar nerve PATIENT ASSESSMENT AND

Ulnar artery
PREPARATION
Superficial palmar arch
Patient Assessment
Figure 81-1 Anatomical landmarks for locating the radial and • Determine the need for arterial cannulation versus punc-
brachial arteries. ture. Rationale: Repeated arterial punctures increase
patient discomfort and the risk for complications.
• Assess for factors that influence ABG measurements,
including anxiety, endotracheal suctioning, nebulizer
treatment, change in oxygen therapy/ventilator settings,
renal replacement therapy, medications and IV fluid com-
position, patient positioning, body temperature, metabolic
rate, and respiratory status. Rationale: These conditions
or therapies can alter blood gas analysis results.
• Review the patient’s current anticoagulation therapy,
Femoral artery
known blood dyscrasias, and pertinent laboratory values
(e.g., platelets, partial thromboplastin time, prothrombin
Femoral vein
time, and international normalized ratio) before the pro-
Femoral nerve
cedure. Rationale: Anticoagulation therapy, blood dyscra-
sias, or alterations in coagulation studies could prolong
hemostasis at the puncture site and increase the risk for
hematoma formation or hemorrhage.
• Review the patient’s allergy history (e.g., lidocaine, anti-
septic solutions, tape). Rationale: Assessment decreases
the risk for allergic reactions.
Figure 81-2 Anatomical landmarks for locating the femoral • Review the patient’s past surgical history (e.g., use of
artery. radial artery for coronary artery bypass surgery, fistulas,
or shunts). Rationale: Arterial puncture should be avoided
in extremities affected by these conditions.
❖ One 1-mL ampule of sodium heparin, 1 : 1000 concen- • Ascertain the patient’s nondominant hand, if possible.
tration (if preheparinized syringe is not available) Rationale: A complication to the nondominant hand may
❖ Two 2 × 2 gauze pads have fewer consequences.
❖ 2% chlorhexidine-based antiseptic solution
❖ 70% isopropyl alcohol prep pad
Patient Preparation
❖ One plastic bag (for transport of sample to the labora- • Verify that the patient is the correct patient using two identi-
tory) fiers. Rationale: Before performing a procedure, the nurse
❖ One adhesive bandage should ensure the correct identification of the patient for the
• Appropriate laboratory form and specimen label intended intervention.
• One pair of nonsterile gloves and eye protection • Ensure that the patient and family understand prepro-
Additional equipment, to have available as needed, includes cedural teaching. Answer questions as they arise, and rein-
the following: force information as needed. Rationale: Understanding of
• Small, rolled towel (to support the patient’s wrist) previously taught information is evaluated and reinforced.
• Sterile gloves • Perform a preprocedure verification and timeout, if non-
• 1-mL syringe with 25-gauge needle (if lidocaine is used) emergent. Rationale: Ensures patient safety.
• 1% lidocaine (without epinephrine), 1-mL, or eutectic • If the patient is receiving oxygen or mechanical ventila-
mixture of local anesthetics (EMLA) cream tion, check that the current therapy has been underway
• Bedside ultrasound machine with vascular probe for at least 20 to 30 minutes before obtaining ABG.5
• Sterile ultrasound probe cover Rationale: Ensures that the ABG results reflect the
• Sterile ultrasound gel intervention/therapy change.
81 Arterial Puncture 709
• Position the patient appropriately. Rationale: Positioning Elevate and hyperextend the patient’s arm. A small
❖
enhances the accessibility to the insertion site and pro- pillow may be placed under the arm for support. Ratio-
motes patient comfort. nale: This action increases accessibility for puncture.
• Radial artery puncture: ❖ Rotate the patient’s arm and palpate for the presence
❖ Assist the patient to a semirecumbent position. Ratio- of a strong brachial pulse. Rationale: Identification and
nale: A position of comfort decreases anxiety and may localization of the pulse increase the chance of a suc-
facilitate respiratory effort. cessful arterial puncture.
❖ Elevate and hyperextend the wrist. A small rolled towel • Femoral artery puncture:
may be placed under the wrist for support. Rationale: ❖ Assist the patient to a supine, straight-leg position.
This action moves the artery closer to the skin surface, Rationale: This position provides the best position for
making the artery easier to palpate. localizing the femoral artery pulse.
❖ Palpate for the presence of a strong radial pulse. ❖ Palpate for the presence of a strong femoral pulse.
Rationale: Identification and localization of the pulse Rationale: Identification and localization of the pulse
increases the chance of a successful arterial puncture. increase the chance of a successful arterial puncture.
• Brachial artery puncture:
❖ Assist the patient to a semirecumbent position. Ratio-
nale: A position of comfort decreases anxiety and may
facilitate respiratory effort.
Procedure for Arterial Puncture

1. HH Ensure that hospital policy permits
registered nurses to perform radial,
brachial, and femoral arterial
punctures.
2. If the radial artery is to be used, The modified Allen’s test has been The modified Allen’s test does not
perform the modified Allen’s test recommended before a radial artery always ensure adequate flow
before the puncture (Fig. 81-3). puncture to assess the patency of through the ulnar artery.
(Level C*) the ulnar artery and an intact A Doppler ultrasound flow indicator
superficial palmar arch.5,17 can also be used to further verify
blood flow.1–3
A. With the patient’s hand held Forces the blood from the hand. If the patient is unconscious or unable
overhead, instruct the patient to perform the procedure, clench
to open and close the hand the fist passively for the patient.
several times.
B. With the patient’s fist Obstructs the flow of blood to the
clenched, apply direct hand.
pressure on the radial and
ulnar arteries.
C. Instruct the patient to lower Observe for pallor. Perform passively if the patient is
and open the hand. unconscious or unable to assist.
D. Release the pressure over the Return of color within 7 seconds If the test is equivocal or abnormal,
ulnar artery and observe the indicates patency of the ulnar artery the radial artery should not be used
hand for return of color. and an intact superficial palmar and the modified Allen’s test should
arch, and is interpreted as a normal be performed on the opposite hand.
Allen’s test result. If color returns A Doppler ultrasound flow indicator
within between 8 and 14 seconds, can also be used to further verify
the test is considered equivocal and blood flow.1–3
professional must consider the risk
and benefits of continuing with
performing this procedure. If it
takes 15 or more seconds for color
to return, the test results are
considered abnormal and another
site should be considered.

A
Radial artery Ulnar artery B C
Figure 81-3 Modified Allen’s test. Elevate the patient’s hand and instruct the patient to open and
close the fist several times. A, With the patient’s fist clenched, simultaneously occlude the radial
and ulnar arteries. B, Instruct the patient to lower and open his or her fist. Observe for pallor in the
patient’s hand. C, Release the pressure over the ulnar artery and observe the hand for the return of
color. (From Bucher L, Melander SD: Critical care nursing, Philadelphia, 1999, Saunders.)
Procedure for Arterial Puncture—Continued

3. If a preheparinized syringe is not Prevents specimen coagulation. A small-bore needle is less likely to
available, heparinize the syringe cause vasospasm of the artery
and needle. during the procedure.
A. Assemble a 22-gauge needle Prepares the syringe.
on the syringe and prime the
entire syringe barrel and
needle with 1 mL of heparin.
B. Expel the heparin from the Excess heparin in the syringe can
syringe. lower the pH and partial pressure of
carbon dioxide.
C. Eliminate any visible air Maintains the accuracy of ABG
bubbles from the syringe. values.
4. Prepare the site with an antiseptic Limits the introduction of potentially
solution (e.g., 2% chlorhexidine- infectious skin flora into the vessel
based preparation). during the puncture.
seconds.
B. Allow the antiseptic solution
to dry.
5. Locally anesthetize the puncture Provides local anesthesia for arterial Most patients report pain during
site per institutional puncture. arterial puncture.6,8 Patients have
standards.4,7,9,10,13 (Level C*) reported reduced pain when a local,
intradermal anesthetic agent is used
before the arterial puncture.8,9
A. Use a 1-mL syringe with a Minimizes vessel trauma. The Medications such as lidocaine
25-gauge needle to draw up absence of epinephrine decreases ointment, amethocaine gel, and
0.5 mL of 1% lidocaine the risk for peripheral EMLA cream may reduce arterial
without epinephrine. vasoconstriction. puncture pain.11–13,15,19
If these medications are used,
manufacturer’s recommendations
should be followed.
B. Aspirate before injecting the Determines whether a blood vessel
local anesthetic. has been inadvertently entered.
C. Inject intradermally and then Decreases the incidence of localized
with full infiltration around pain with injection of all skin
the artery puncture site. Use layers.
approximately 0.2–0.3 mL for
an adult.

6. Perform the percutaneous Ultrasound technology may be used
puncture of the selected artery. to assist with insertion.
A. Palpate and stabilize the Increases the likelihood of correctly Use sterile gloves if the site of the
artery with the index and locating the artery and decreases artery puncture is palpated after it
middle fingers of the the chance of vessel rolling. is antiseptically prepared.
nondominant hand.
B. With the needle bevel up A slow, gradual thrust promotes entry Enter at an angle that is comfortable;
and the syringe at a 30- to into the artery without inadvertently certainty of position is more
60-degree angle to the radial passing through the posterior wall. important than angle entry. If too
or brachial artery, puncture much force is used, the needle may
the skin slowly (Figs. 81-4 touch the periosteum of the bone
and 81-5). For a femoral and cause considerable pain.
artery puncture, a 60- to
90-degree angle is used
(Fig. 81-6).
Figure 81-4 Radial artery puncture with the syringe at a Figure 81-6 Femoral artery puncture with the syringe at a
30-degree angle to the artery. 60-degree angle to the artery.
Figure 81-5 Brachial artery puncture with the syringe at a

45-degree angle to the artery.

C. Observe the syringe for a Pulsation of blood into the syringe Flashback occurs more easily with a
flashback of blood. verifies that the artery has been glass syringe than a plastic syringe.
punctured. Gentle aspiration may be necessary
with a plastic syringe.
D. If the puncture is Prevents the necessity of a second Excessive probing of the artery may
unsuccessful, withdraw the puncture and changes the needle cause vessel or adjacent nerve
needle to the skin level, angle angle to facilitate the location of injury.
slightly toward the artery, and the artery.
readvance. Do not withdraw
the needle.
7. Obtain 1 mL of blood. An ABG analysis requires a minimum Sample volumes may vary with
of 0.2 mL of blood. equipment used. Obtain more than
1 mL of blood for additional
laboratory tests, as necessary.
8. Withdraw the needle while Prevents inadvertent aspiration of air Equipment may vary. If a safety
stabilizing the barrel of the during withdrawal. guard is available, it should be
syringe. snapped onto the needle with a
one-handed technique by gently
pressing the device against a hard
surface.
9. Press a gauze pad firmly over the Hematomas and hemorrhage can If the patient is receiving
puncture site for at least 5 occur if pressure is not applied and anticoagulation therapy or has a
minutes or until hemostasis is maintained correctly. Hematomas bleeding dyscrasia, pressure may
established. can cause circulatory impedance need to be applied for as long as 15
and pain and can predispose to minutes.
infection.
10. Cover the puncture site with an Covers the site until healing occurs.
adhesive bandage once
hemostasis is achieved.
11. Check the blood sample in the Air bubbles can alter the partial If a safety guard is present, it should
syringe for air bubbles and pressure of oxygen results.6,15 be removed and a blood/air filter
express any air bubbles by slowly should be placed on the syringe.
ejecting the air while covering Excess air should be evacuated
the syringe tip with a 2 × 2 gauze through the blood/air filter.
pad.
12. Seal the needle or tip of the Prevents leakage of blood and air
syringe immediately with a from entering the sample. Mixes
rubber stopper or cap, blood and heparin, thus preventing
respectively. Gently roll the clot formation.
syringe for 30 seconds.
receptacles; dispose of needles Precautions. Safely removes sharp
and other sharp objects in objects.
appropriate containers.
14. HH
15. Label the specimen and complete Helps the laboratory to perform the Policies may vary regarding the type
the laboratory form. Note the analysis accurately. of patient information required for
percentage of oxygen therapy, laboratory analysis.
respiratory rate, and ventilator
settings, if appropriate, and the
patient’s temperature and time the
specimen was drawn.
16. Expedite the delivery of the Ideally, the blood gas analysis should
sample to the laboratory. be performed within 30 minutes of
collection to ensure the accuracy of
results.7,14

• The ABG sample is collected correctly such that the • Pain/severe discomfort during the procedure
accuracy of the results is enhanced • Complications during the puncture or vasospasm
• The puncture site remains free of hematoma, • Complications after the puncture: changes in the
hemorrhage, and infection color, size, temperature, sensation, movement, or
• The peripheral vascular and neurovascular systems pulse of the extremity used for the arterial puncture;
remain intact (free of complications) hematoma, hemorrhage, or infection at the puncture
• Alterations in the ABG results are identified and site
treated accordingly

interventions
1. Observe the puncture site for signs Postpuncture bleeding can occur in • Bleeding
of hemostasis after the procedure. any patient but is more likely to • Hematoma
occur in patients with • Changes in vital signs
coagulopathies or patients who are
receiving anticoagulation therapy.
2. Assess the puncture site and The arterial puncture can result in • Changes in color, size,
involved extremity for signs of peripheral vascular and temperature, sensation, movement,
postpuncture complications. neurovascular compromise of the or pulse in the extremity used for
extremity distal to the puncture site. arterial puncture
3. Assess the puncture site for signs Determines necessity for further • Erythema, warmth, hardness,
or symptoms of infection. treatment. tenderness, or pain at the puncture
site
• Presence of purulent drainage from
the puncture site
4. Follow institutional standards for Identifies need for pain interventions. • Pain at the puncture site or in the
assessing pain. Administer distal extremity
Documentation
• Patient and family education • Pain assessment and interventions
• Results of the modified Allen’s test or Doppler • Appearance of the site
ultrasound scan • Appearance of the limb, color, pulse sensation,
• Preprocedure verification and timeout movement, capillary refill time, and temperature of
• Arterial site accessed the extremity
• Number of attempts • Occurrence of unexpected outcomes
• Local anesthetic used • Nursing interventions taken
• Patient’s tolerance of the procedure • Laboratory results

81 Arterial Puncture 713.e1
References 11. Joly LM, et al: Topical lidocaine-prilocaine cream

1. Abu-Omar Y, et al: Duplex ultrasonography predicts (EMLA) versus local infiltration of anesthesia for radial
safety of radial artery harvest in the presence of an artery cannulation. Anesth Analg 87:403–406, 1998.
abnormal Allen test. Ann Thorac Surg 77:116–119, 12. Hussey VM, Poulin MV, Fain JA: Effectiveness of
2004. lidocaine hydrochloride on venipuncture sites. AORN J
2. Barone JE, Madlinger RV: Should an Allen Test be 66:472–475, 1997.
performed before artery cannulation? J Trauma 61: 13. Lander J, et al: Evaluation of a new topical anesthetic
468–470, 2006. agent: A pilot study. Nurs Res 45:50–52, 1996.
3. Bobia X, et al: Ultrasound guidance for radial arterial 14. National Committee for Clinical Laboratory Standards:
puncture: A randomized controlled trial. Am J Emerg Med Procedures for the collection of arterial blood specimens:
31:810–815, 2013. Approved standards H11-A4, ed 4, Wayne, PA, 2004,
4. Celenski SA, Seneff MG: Arterial line placement and National Committee for Clinical Laboratory Standards.
care. In Irwin RS, et al, editors: Procedures and 15. Nott M, Peacock J: Relief of injection pain in adults:
techniques in intensive care medicine, ed 6, Philadelphia, EMLA cream for 5 minutes before venipuncture.
2008, Lippincott Williams & Wilkins, pp 38–46. Anaesthesia 45:772–774, 1990.
5. Chernecky CC, Berger BJ, editors: Laboratory tests and 16. Okeson GC, Wulbrecht PH: The safety of brachial artery
diagnostic procedures, ed 5, St Louis, 2008, Saunders. puncture for arterial blood sampling. Chest 14:748–751,
6. Clarke S: Arterial lines: An analysis of good practice. 1998.
J Child Health Care 3:22–27, 1999. 17. Oettle AC, et al: Evaluation of Allen’s test in both arms
7. Flynn JC, editor: Procedures in phlebotomy, ed 3, and arteries of left and right-handed people. Surg Radiol
St Louis, 2004, Saunders. Anat 28:3–6, 2006.
8. Giner J, et al: Pain during arterial puncture. Chest 18. Thibodeau GA, Patton KT: Anatomy and physiology, ed 6,
110:1443–1445, 1996. St Louis, 2007, Mosby.
9. Hudson TL, Dukes SF, Reilly K: Use of local anesthesia 19. Tran NQ, Pretto JJ, Worsnop CJ: A randomized controlled
for arterial punctures. Am J Crit Care 15:595–599, 2006. trial of the effectiveness of topical amethocaine in
10. Infusion Nurses Society: Infusion nursing standards reducing pain during arterial puncture. Chest 122:
of practice. J Infus Nurs 34(1S):S6–S110, 2016. 1357–1360, 2002.
PROCEDURE
82
Insertion (Perform)
Susan Yeager
PURPOSE: Central venous catheters (CVCs) are inserted for measurement of
central venous pressure (CVP) with jugular or subclavian catheter placement.
Clinically useful information can be obtained about right-ventricular preload,
cardiovascular status, and fluid balance in patients who do not need pulmonary
artery pressure monitoring. CVCs also are placed for infusion of vasoactive
medications and to provide access for pulmonary artery catheters and transvenous
pacemakers.
• Interpretation of right-atrial/CVP waveforms including
PREREQUISITE NURSING identification of a, c, and v waves is important. The a
KNOWLEDGE wave reflects right-atrial contraction. The c wave reflects
closure of the tricuspid valve. The v wave reflects passive
• Knowledge of the normal anatomy and physiology of the filling of the right atria during right-ventricular systole.
cardiovascular system is needed. • The CVP provides information regarding right-heart
• Knowledge of the anatomy and physiology of the vascu- filling pressures and right-ventricular function and volume.
lature and adjacent structures of the neck, groin, and chest • The CVP is commonly elevated during or after right-
is needed. ventricular failure, ischemia, or infarction because of
• Knowledge of the principles of sterile technique is essen- decreased compliance of the right ventricle.
tial. • The CVP can be helpful in the determination of hypovo-
• Clinical and technical competence in central line insertion lemia. The CVP value is low if the patient is hypovolemic.
and suturing is essential. Venodilation also decreases the CVP value.
• Competence in chest radiographic interpretation is neces- • Electrocardiographic monitoring is essential in the accu-
sary. rate interpretation of the CVP value.
• Advanced cardiac life support (ACLS) knowledge and • Some contraindications of CVC insertion include ana-
skills are needed. tomical problems, venous obstructions, and coagulopa-
• Knowledge of potential complications and associated thies. The subclavian site should be avoided in hemodialysis
interventions/consultations for addressing issues is neces- patients and patients with advanced kidney disease to
sary. avoid subclavian vein stenosis.5
• Follow guidelines regarding institution credentialing. • It is important to weigh the risks and benefits of placing
• Knowledge of ultrasonography technique is needed. a CVC against the risk for mechanical complications (e.g.,
• Indications for CVC placement may include the follow- pneumothorax, vein laceration, thrombosis, air embolism,
ing: misplacement).5,6
❖ Severe blood loss • A subclavian site is recommended rather than a jugular or
❖ Hemodynamic instability femoral site to minimize the risk of infection.5
❖ Administration of vesicant irritant medications • The internal jugular site is recommended to minimize
❖ Administration of total parenteral nutrition catheter cannulation-related risk of injury or trauma.6
❖ Lack of peripheral venous access • Ultrasound guidance is recommended to place CVCs if
❖ Assessment of hypovolemia or hypervolemia the technology is available to reduce the number of can-
❖ Monitoring of CVPs nulation attempts and mechanical complications.4,5,7
❖ Placement of pulmonary artery catheters or placement • Regardless of the site selected, complications may occur
of transvenous pacemakers during or after insertion of a central venous catheter
❖ Hemodialysis access (Table 82-1).
• The normal CVP value is 2 to 8 mm Hg.
• The CVP waveform is identical to the right-atrial wave- EQUIPMENT
form.
• CVC insertion kit
• CVC of choice (single, dual, or triple lumen) usually
practice nurses, and other healthcare professionals (including critical care supplied with insertion needle, dilator, syringe, and
nurses) with additional knowledge, skills, and demonstrated competence per guidewire.
professional licensure or institutional standard. • Full sterile drapes
714
82 Central Venous Catheter Insertion (Perform) 715
TABLE 82-1 Complications of Central Venous Catheter Insertion

Complication Clinical Manifestation Treatment Prevention
Pneumothorax • Sudden respiratory distress • Confirmation with chest • Proper patient preparation
• Chest pain radiograph • Sedation as necessary
• Hypoxia/cyanosis • Symptomatic treatment • Proper patient positioning
• Decreased breath sounds • Small pneumothorax: • Technique and angle of the needle/
• Resonance to percussion ❖ Close monitoring catheter on insertion
❖ Daily chest radiograph • Avoidance of multiple passes with the
❖ O2 needle
• Large pneumothorax: • Healthcare provider is skilled and
❖ Chest tube experienced in insertion technique
❖ Cardiopulmonary • Direct visualization with bedside
support ultrasonography for internal jugular
placement.
Tension • Most likely to occur in patients • Treatment must be rapid • Proper patient preparation
pneumothorax on ventilator support and aggressive • Sedation as necessary
• Respiratory distress • Immediate air aspiration • Proper patient positioning
• Rapid clinical deterioration: followed by chest tube • Reduction of positive end-expiratory
❖ Cyanosis • Cardiopulmonary support pressure to ≤5 cm H2O at the time of
❖ Jugular venous distention venipuncture
(may not be present with • Technique and angle of the needle/
severe hypovolemia) catheter on insertion
❖ Hypotension • Avoidance of multiple passes with the
❖ Decreased cardiac output needle
• Healthcare provider is skilled and
experienced in insertion technique
• Use of peripherally inserted central
venous catheter
Delayed • Slow onset of respiratory • Confirmation with chest • Proper patient preparation
pneumothorax symptoms radiograph • Sedation as necessary
• Subcutaneous emphysema • Chest tube • Proper patient positioning
• Persistent pleuritic chest or • Cardiopulmonary support • Technique and angle of the needle/
back pain catheter on insertion
• Insidious increase in peak • Avoidance of multiple passes with the
airway pressures in ventilated needle
patients • Healthcare provider is skilled and
venous catheter
Hydrothorax • Dyspnea • Stop infusion • Proper patient preparation
hydromediastinum • Chest pain • Confirmation with chest • Sedation as necessary
• Muffled breath sounds radiograph • Proper patient positioning
• High glucose level of chest • Cardiopulmonary support • Technique and angle of the needle/
drainage catheter on insertion
• Low-grade fever • Avoidance of multiple passes with the
needle
• Healthcare provider is skilled and
venous catheter
• Placement of catheter tip in lower
superior vena cava
• Aspiration of blood before catheter
use to confirm vascular placement
Continued
TABLE 82-1 Complications of Central Venous Catheter Insertion—cont’d

Hemothorax • Respiratory distress • Confirmation with chest • Correction of coagulopathies before
• Hypovolemic shock radiograph insertion
• Hematoma in the neck with • Chest tube • Avoidance of multiple passes with the
jugular insertions • Thoracotomy for arterial needle
repair if indicated • Evaluation with Doppler scan studies
or venogram of suspected thrombosis
from prior cannulation before insertion
Arterial puncture/ • Return of bright red blood in • Application of pressure for • Correction of coagulopathies before
laceration the syringe under high 3–5 minutes or as needed insertion
pressure to promote hemostasis • Avoidance of multiple passes with the
• Pulsatile blood flow on after removal of the needle needle
disconnection of the syringe • Elevate the head of the • Evaluation with Doppler scan studies
• Arterial waveform/pressures bed if condition is or venogram of suspected thrombosis
when the catheter is hemodynamically stable from prior cannulation before insertion
connected to the transducer • Chest tube as indicated • Use of small-gauge needle to first
system • Thoracotomy for arterial locate the vein
• Arterial saturation of sample repair if indicated • Direct visualization with bedside
sent for blood gas analysis ultrasonography for femoral vein
• Deterioration of clinical status: placement.
❖ Hemorrhagic shock
❖ Respiratory distress
❖ Bleeding from catheter site
may or may not be

observed
• Deviation of trachea with large
hematoma in the neck
• Hemothorax may be detected
on chest radiograph
Bleeding/hematoma; • Bleeding from insertion site • Application of pressure to • Correction of coagulopathies before
venous or arterial • Hematoma formation not likely the insertion site insertion
bleeding to be seen with subclavian • Thoracotomy for arterial • Avoidance of multiple passes with the
approach repair needle at venipuncture
• Bleeding may occur internally • Tracheostomy for tracheal • Use of a small-gauge needle to first
without visible evidence deviation from hematoma locate the vein
• Tracheal compression • With the femoral approach, • Immediate control of femoral bleeding
• Respiratory distress manual pressure slightly may prevent large blood loss or
• Carotid compression above the inadvertent hematoma formation
• Pain at insertion site arterial puncture site (see
Procedure 76 for femoral
sheath removal)
• If retroperitoneal bleeding
occurs, external signs may
not be apparent except for
signs of hypovolemia.
Computed tomography (CT)
scan of the abdomen may
be required for diagnosis.
Cardiac • Premature atrial complexes • Withdraw the guidewire or • Avoidance of entry into the heart with
dysrhythmias • Atrial fibrillation or flutter catheter from the heart; the guidewire
• Premature ventricular dysrhythmias should stop • Observation of cardiac monitor; tall,
complexes if the cause was peaked P waves can be identified as
• Supraventricular tachycardia mechanical in nature the catheter tip enters the right atrium
• Ventricular tachycardia • Pharmacological treatment
• Sudden cardiovascular of persistent dysrhythmias
collapse

Air embolism • Symptoms depend on amount • Stop airflow • Adequate hydration status
of air drawn in, especially with • Position patient on left side • Head-down tilt or the Trendelenburg
patients who are in the Trendelenburg position during catheter insertion
spontaneously breathing position • Use of small-bore needle for insertion
• Sudden cardiovascular • Oxygen administration • Application of thumb over needle or
collapse • Air aspiration; catheter hub during ventilation; needle
• Tachypnea, apnea, transthoracic needle or or hub should not be exposed longer
tachycardia intracardiac catheter than 1 second
• Hypotension, cyanosis, anxiety • Cardiopulmonary support • Advancement of catheter during
• Diffuse pulmonary wheezes positive-pressure cycle in patients on
• “Mill wheel” churning heart ventilatory support
murmur • Avoidance of nicking of catheter with
• Neurological deficits, paresis, careful suturing technique
stroke, coma • Avoidance of catheter exchange from
• Cardiac arrest large-bore catheter (pulmonary artery)
to smaller catheter
• Use of Luer-Lok connections
• Minimal risk with peripherally inserted
central venous catheter
Catheter malposition • Pain in ear or neck • Ensure that the bevel of • Proper patient positioning
• Swishing sound in ear with the insertion needle is • Avoidance of use of force when
infusion positioned downward advancing the catheter
• Sharp anterior chest pain (toward feet of patient) • Use of a guidewire or blunt-tipped
• Pain in ipsilateral shoulder before placing guidewire stylet
blade • Repositioning of catheter
• Cardiac dysrhythmia with guidewire or new
• Observation on chest venipuncture
radiograph • Catheter removal
• Signs or symptoms may be
absent
• No blood return on aspiration
Catheter embolism • Cardiac dysrhythmias • Location of fragment on • Use of “over a guidewire” (Seldinger)
• Chest pain radiograph insertion technique
• Dyspnea • Transvenous retrieval of • Extreme caution with use of
• Hypotension catheter fragment through-the-needle catheter designs;
• Tachycardia • Thoracotomy never withdraw a catheter through the
• May be clinically silent • Interventional radiology needle
retrieval • Use of guidewire or stylet within a
catheter that is inserted through a
needle
Cardiac tamponade • Retrosternal or epigastric pain • Treatment must be rapid • Catheter tip position: Parallel to the
• Dyspnea and aggressive walls of the superior vena cava
• Venous engorgement of face • Discontinuation of 1–2 cm above the junction of the
and neck infusions through the superior vena cava and right atrium
• Restlessness, confusion central line • Use of soft, flexible catheters
• Hypotension, paradoxical pulse • Aspiration through the • Minimal risk with peripherally inserted
• Muffled heart sounds catheter central venous catheter
• Mediastinal widening • Emergency
• Pleural effusion pericardiocentesis
• Cardiac arrest • Emergency thoracotomy
Tracheal injury • Subcutaneous emphysema • Emergency reintubation • Physician, advanced practice nurse,
• Pneumomediastinum (for punctured or other healthcare professional is
• Air trapping between the chest endotracheal tube cuff) skilled and experienced in insertion
wall and the pleura • Aspiration of air in technique
• Respiratory distress with mediastinum • Use of peripherally inserted central
puncture of endotracheal tube venous catheter
cuff
Continued

Nerve injury • Patient has tingling/numbness • Remove catheter if • Physician, advanced practice nurse,
in arm or fingers brachial plexus injury is or other healthcare professional is
• Shooting pain down the arm suspected skilled and experienced in insertion
• Paralysis technique
• Diaphragmatic paralysis • Minimal risk with peripherally inserted
(phrenic nerve injury) central venous catheter
Sterile • Potential complication of the • Application of heat for • Strict aseptic technique during
thrombophlebitis peripherally inserted central 48–72 hours catheter insertion
venous catheter • Removal of catheter • Adequate skin preparation
• Redness, tenderness, swelling
along the course of the vein
• Pain in the upper extremity or
shoulder
Pulmonary embolism • Potential complication of • Spiral chest CT scan • Avoidance of catheter exchange in
catheter exchange • Lung perfusion scan veins with thrombosis
• Often clinically silent • Cardiopulmonary support
• Chest pain, dyspnea, with large pulmonary
coughing, tachycardia, anxiety, embolism
fever
• 1% lidocaine without epinephrine PATIENT AND FAMILY EDUCATION

• One 25-gauge 5 8-inch needle
• Large package of 4 × 4 gauze sponges • Explain the need for the CVC insertion and assess patient
• Suture kit (hemostat, scissors, needle holder) and family understanding. Rationale: Clarification and
• 3-0 or 4-0 nylon suture with curved needle understanding of information decrease patient and family
• Syringes: one 10- to 12-mL syringe; two 3- to 5-mL anxiety levels.
syringes; two 22-gauge, 1 1 2-inch needles • Explain the procedure and the time involved. Rationale:
• Masks, head coverings, goggles (shield and mask combi- Explanation increases patient cooperation and decreases
nation may be used), sterile gloves, and sterile gowns patient and family anxiety levels.
• No. 11 scalpel • Explain the need for sterile technique and patient position-
• Roll of 2-inch tape ing, and that the patient’s face may be covered. Rationale:
• Dressing supplies The explanation decreases patient anxiety and elicits coop-
• Waterproof pad eration.
• Chlorhexidine-impregnated sponge • Explain the benefits and potential risks for the procedure.
• Antiseptic solution (e.g., 2% chlorhexidine-based prepa- Rationale: Information is offered so that the patient and/
ration) or family can make an informed decision.
• Normal saline flush syringes or 0.9% sodium chloride
vials, 10- to 30-mL PATIENT ASSESSMENT AND
• Bedside ultrasound machine with vascular probe PREPARATION
• Sterile ultrasound probe cover
Additional equipment, to have available as needed, includes Patient Assessment
the following: • Determine the patient’s medical history including neck,
• Hemodynamic monitoring system (see Procedure 75) chest, and groin surgeries and previous vascular access
• Sutureless catheter securement device devices. Rationale: Data obtained will assist with site
• Intravenous (IV) solution with Luer-Lok administration selection.
set for IV infusion • Determine the patient’s medical history of pneumothorax
• Luer-Lok extension tubing or emphysema. Rationale: Patients with emphysematous
• Bedside monitor and oscilloscope with pulse oximetry lungs may be at increased risk for puncture and pneumo-
• Supplemental oxygen supplies thorax, depending on the approach.
• Emergency equipment • Determine the patient’s medical history of anomalous veins.
• Package of alcohol pads or swab sticks Rationale: Patients may have a history of dextroacardia or
• Package of povidone-iodine pads or swab sticks transposition of the great vessels, which leads to greater dif-
• Heparin flushes ficulty in catheter placement.
• Sterile injectable or noninjectable caps • Assess the intended insertion site. Rationale: Scar tissue may
• Skin protectant pads or swab sticks impede placement of the catheter. Permanent pacemakers or
implantable cardioverter defibrillators may preclude place- • Ensure that the patient and family understand preproce-
ment. Previous surgery and previous placement of a CVC dural teaching. Answer questions as they arise, and rein-
may cause a thrombus to be present or there may be stenosis force information as needed. Rationale: Understanding
of a vessel. of previously taught information is evaluated and rein-
• Assess the patient’s neurological, cardiac, and pulmonary forced.
status. Rationale: Aids in determining whether the patient • Obtain informed consent. Rationale: Informed consent pro-
can tolerate Trendelenburg position. tects the rights of the patient and makes a competent decision
• Assess vital signs and pulse oximetry. Rationale: Baseline possible for the patient; however, in emergency circum-
data enable rapid identification of changes. stances, time may not allow for this form to be signed.
• Assess electrolyte levels (e.g., potassium, magnesium, • Perform a preprocedure verification and timeout, if non-
calcium). Rationale: Electrolyte abnormalities may emergent. Rationale: Ensures patient safety.
increase cardiac irritability. • Prescribe sedation or analgesics as needed. Rationale:
• Assess for a coagulopathic state and determine whether The patient may need sedation or analgesics to promote
the patient has recently received anticoagulant or throm- comfort and to ensure adequate cooperation and appropri-
bolytic therapy. Rationale: These patients are more likely ate placement.
to have complications related to bleeding. Therefore site • Place an order for patient restraints and apply if needed.
selection and the need/ability to provide interventions Rationale: In patients with cognitive impairment, restraints
before insertion of the CVC can be determined prospec- may be needed to ensure maintenance of patient positioning
tively.3 and equipment and access site sterility. During the proce-
dure, restlessness and an altered level of consciousness may
Patient Preparation represent a pneumothorax, hypoxia, or placement in the
• Verify that the patient is the correct patient using two carotid artery.
identifiers. Rationale: This increases patient safety by
ensuring correct identification of the patient for the
intended intervention.
Procedure for Performing Central Venous Catheter Insertion

1. Review indications, Enables appropriate site selection and
contraindications, and potential preprocedural intervention if
complications. needed.
2. Obtain ultrasound equipment if Prepares equipment. Assistance may be needed from
time is available to determine the radiology.
most appropriate approach.
3. HH
4. PE All physicians, advanced practice
nurses, and other healthcare
professionals in the room should
have on protective equipment
including head coverings and
masks.5 Persons inserting the
catheter or assisting should use face
shields or googles.
5. Place a waterproof pad beneath Avoids soiling of bed linens.
the site to be accessed.
6. Assist the patient to a position Proper positioning increases vessel
that will optimize access to the access and optimizes comfort of
site selected. patient and physician, advanced
professional throughout the process.
7. Determine the anatomy of the Helps ensure proper placement of the Ultrasound guidance to place CVCs
access site. (Level E*) CVC and guides the area to be (if the technology is available)
prepped.5,6 should be used to reduce the
number of attempts and
complications.5,6

Procedure for Performing Central Venous Catheter Insertion—Continued

8. Prepare skin with an antiseptic Limits the introduction of potentially If there is a contraindication to
solution (e.g., 2% chlorhexidine- infectious skin flora into the vessel chlorhexidine, tincture of iodine, an
based preparation).5,6 (Level A*) during the puncture. iodophor, or 70% alcohol can be
A. Subclavian vein: scrub from used as alternatives.5
shoulder to contralateral
nipple line and neck to nipple
line (Fig. 82-1A).
B. Internal jugular vein: scrub
midclavicle to opposite border
of the sternum and from the
ear to a few inches above the
nipple (Fig. 82-1B).
C. Femoral vein: scrub the
anterior and medial surface of
the proximal thigh to the
inguinal ligament.
9. Discard used supplies, perform Minimizes the risk of infection and
hand hygiene, and apply sterile maintains standard and sterile
gown and gloves. precautions.
10. Place the full drape over the Prepares sterile field. All physicians, advanced practice
patient with exposure of only the nurses, and other healthcare
insertion site. professionals in the room should
masks.5
B
Figure 82-1 Area of skin preparation for central venous catheter insertions. A, Subclavian inser-
tion: scrub from shoulder to contralateral nipple line and neck to nipple line. B, Jugular insertions:
scrub mid clavicle to opposite border of the sternum and from the ear to a few inches above the
nipple. (Courtesy of Suredesign.)

11. Ask critical care nurse or Maintains aseptic technique and
provider assisting to open the prepares the work area.
CVC insertion kit and drop the
sterile items onto the sterile field.
12. Check landmarks again for the Ensures proper placement of the
intended catheter insertion site. catheter.
Site Specific: Internal Jugular Vein (Fig. 82-2)
See steps 1–12 above.
1. Locate the carotid artery. Helps prevent placing the catheter in
the carotid artery.
2. Identify the jugular vein and Identifies the intended insertion site. Localization of the vessel may occur
mark it if necessary. with palpation; however, real-time
ultrasound should be utilized with
the internal jugular approach if
equipment and a trained physician,
healthcare professional are
available.7
3. Instruct the patient to turn his or Helps identify the landmarks. Ensure that there are no
her head slightly away from the contraindications to neck mobility.
insertion site. If there are no contraindications to
neck mobility, the critical care nurse
or another physician, advanced
professional assisting with the
procedure may need to assist the
patient to turn his or her head.
Sternocleidomastoid
Internal jugular vein

Sternocleidomastoid
muscle Innominate
vein
External jugular
vein Carotid artery
Internal jugular
vein 1st rib
Innominate
vein
Subclavian vein
A B
Figure 82-2 Anatomy of the jugular vein. A, Anatomy of the internal jugular vein showing its
lower location within the triangle formed by the sternocleidomastoid muscle and the clavicle.
B, Triangle drawn over the clavicle and sternal and clavicular portions of the sternocleidomastoid
muscle is centered over the internal jugular vein (inset). (From Dailey EK, Schroeder JS: Techniques
in bedside hemodynamic monitoring. St Louis, 1994, Mosby and redrawn from Daily PO, Griepp
RB, Shumway NE: Percutaneous internal jugular vein cannulation, Arch Surg 101:534–536, 1970.
Copyright 1970, American Medical Association.)

4. Ensure that the patient is in the Minimizes the risk for venous air Most patients can tolerate
Trendelenburg position (i.e., 15 to embolus by increasing the pressure Trendelenburg positioning but
25 degrees).1,2 (Level E*) in the large veins above intracranial, respiratory, or cardiac
atmospheric pressure thus reducing compromise may occur. Therefore
the risk of air aspiration. The evaluation for the need for
patient should be positioned so that alternative sites and close
the intended puncture site is at or monitoring are necessary.
below the level of the heart.1,2
5. Identify the internal jugular vein A high entry can be made from a The midanterior approach may be
from the triangle between the posterior approach, a lateral preferred in an obese patient. The
medial aspect of the clavicle, the approach, an anterior approach, or a posterior approach may present a
medial aspect of the sternal head, central approach. slightly higher risk.
and the lateral head of the The internal jugular vein is 3–4 cm
sternocleidomastoid muscle (see above the medial clavicle and
Fig. 82-2). 1–3 cm within the lateral border of
the sternocleidomastoid muscle.
6. Administer an anesthetic: Promotes patient comfort during the
A. Attach a 3- or 5-mL syringe procedure. Helps to anesthetize
with 2 or 3 mL of 1% below the subcutaneous tissue.
lidocaine (without
epinephrine) to an 18-gauge
needle.
B. Align the needle with the
syringe parallel to the medial
border of the clavicular head
of the sternocleidomastoid
muscle.
C. Aim at a 30-degree angle to
the frontal plane over the
internal jugular vein, toward
the ipsilateral nipple.
D. Instill the lidocaine.
7. Prepare the catheter: Removes air from the catheter and
A. Place sterile injectable or prepares for insertion.
noninjectable caps.
B. Flush the catheter and ports
with normal saline.
8. Place the sterile probe over the Maintains sterility. Another physician, advanced practice
ultrasound equipment and locate nurse, or other healthcare
the vessel. professional in sterile attire may
assist with this step.
9. Use Seldinger’s technique This technique is the preferred
for placement of the catheter method of CVC placement; it uses
(Fig. 82-3). a dilator and guidewire.
A. Puncture the skin and advance Slight negative pressure helps to Insert at a 45-degree angle to prevent
the needle while maintaining ensure placement into the vein and pneumothorax. Avoiding a too-
slight negative pressure within decreases the risk for air embolism lateral or too-deep needle insertion
the syringe until free-flowing and pneumothorax. can reduce the risk for
blood is obtained. Without slight negative pressure, pneumothorax. Lateral movement
penetration into the vein will go of an inserted needle can lacerate
unrecognized. vessels and should not be done.
E
Figure 82-3 Basic procedure for Seldinger’s technique. A, The vessel is punctured with the
needle at a 30- to 40-degree angle. B, The stylet is removed, and free blood flow is observed; the
angle of the needle is then reduced. C, The flexible tip of the guidewire is passed through the needle
into the vessel. D, The needle is removed over the wire while firm pressure is applied at the site.
E, The tip of the catheter or sheath is passed over the wire and advanced into the vessel with a
rotating motion. (From Dailey EK, Schroeder JS: Techniques in bedside hemodynamic monitoring.
St Louis, 1994, Mosby.)

B. After a free flow of blood is A free flow of blood indicates a When preparing the syringe and
returned, turn the bevel to the vessel has been entered. needle, line the bevel up with the
3 o’clock position. Once in numbers on the syringe so that you
the vein, have the patient hold know where the bevel is regardless
his or her breath while the of how the syringe is manipulated
syringe is detached and insert during placement.
the soft-tipped guidewire
20–25 cm through the needle.
C. Remove the needle.
D. Wipe the guidewire with the Wiping the guidewire dry may ease The guidewire should always pass
sterile 4 × 4 gauze. manipulation. easily without resistance.
E. Instruct the patient to breathe
normally.
10. With a No. 11 blade, knife edge Eases the insertion of the dilator
up, make a small (2–3-mm) stab through the skin.
wound at the insertion site.

11. Insert the dilator through the skin, The dilator enlarges the subcutaneous Control of the guidewire should be
over the guidewire, until tissue and vessel, easing the maintained at all times to avoid
10–15 cm of wire extends beyond insertion of the catheter and wire embolization.
the dilator, then remove the preventing the formation of a false
dilator while maintaining the channel.
position of the guidewire.
12. Advance the catheter over the Places the catheter. Cover the needle hub between
guidewire until 10–15 cm of the manipulations to avoid air
guidewire extends beyond the embolization.
catheter and then remove the
guidewire.
13. Suture the catheter in place. Secures the catheter. A sutureless catheter-securing device
may be used to stabilize the CVC.
14. Apply an occlusive, sterile Reduces the risk for infection. Consider use of a chlorhexidine-
dressing (see Procedure 66). impregnated sponge dressing.5,6
15. Return the patient to a neutral, or Promotes comfort.
head-up, position.
16. Assess lung sounds and peak Assesses for placement and The radiograph needs to be read
airway pressures (in ventilated complications. before utilization of the catheter for
patients), and obtain a chest administration of IV fluid and
radiograph. medications.
Carotid artery
Subclavian artery
Subclavian vein
Innominate vein
SVC
Figure 82-4 Anatomical location of the subclavian vein and surrounding structures. The subcla-
vian vein joins the internal jugular vein to become the innominate vein at about the manubriocla-
vicular junction. The innominate vein becomes the superior vena cava (SVC) at about the level of
the mid manubrium. (From Dailey EK, Schroeder JS: Techniques in bedside hemodynamic monitor-
ing, St Louis, 1994, Mosby.)

supplies in appropriate microorganisms and minimizes
receptacles. exposure to contaminated sharps.
18. HH
Specific Site: Subclavian Vein (Fig. 82-4)
1. Identify the junction of the Identifies the landmarks for catheter Access from the right side is preferred
middle and medial thirds of the placement. to avoid inadvertent puncture of the
clavicle. The needle insertion thoracic duct.
should be 1–2 cm laterally.
2. Depress the area 1–2 cm beneath Helps identify the landmarks. To avoid the subclavian artery, select
the junction with the thumb of a puncture site away from the most
the nondominant hand and the lateral course of the vein and do not
index finger 2 cm above the aim too posteriorly.
sternal notch.
3. Identify the subclavian vein. May aid in identifying the intended Utilization of real-time ultrasound
insertion site. should be considered with the
subclavian approach if equipment
and a trained physician, advanced
professional are available.7
4. Instruct the patient to turn his or Helps identify the landmarks. Ensure that there are no
her head away from the insertion contraindications to neck mobility.
site. If there are none, the critical care
nurse or another physician,
healthcare professional assisting
with the procedure may need to
assist the patient to turn his or her
head.
5. Position the patient for optimal Minimizes the risk for venous air Most patients can tolerate the
vein access. embolus by increasing the pressure Trendelenburg positioning but
A. Ensure that the patient is in in the large veins above intracranial, respiratory, or cardiac
the Trendelenburg position atmospheric pressure thus reducing compromise may occur. Therefore
(i.e., 15–25 degrees). the risk of air aspiration. The evaluation for the need for
B. Adduct the patient’s arms. patient should be positioned so that alternative sites and close
C. Consider placing a rolled the intended puncture site is at or monitoring are necessary.
towel between the patient’s below the level of the heart.1,2
shoulder blades.
6. Administer a local anesthetic. Promotes patient comfort during the
lidocaine (without
needle.
B. Inject the lidocaine into the
area surrounding the intended
insertion site.
A. Flush the catheter and ports prepares for insertion.
with normal saline.
B. Place sterile injectable or
noninjectable caps.
Clavicle
Subclavian
vein
Figure 82-5 Puncture of the subclavian vein with the needle inserted beneath the middle third of
the clavicle at a 20- to 30-degree angle aiming medially. (From Dailey EK, Schroeder JS: Techniques
in bedside hemodynamic monitoring. St Louis, 1994, Mosby.)

9. Use Seldinger’s technique for This technique is the preferred
placement of the catheter (see method of CVC placement; it uses
Fig. 82-3). a dilator and guidewire.
A. Insert the needle under the Slight negative pressure helps to Insert at a 45-degree angle to prevent
clavicle and “walk down” ensure placement into the vein and pneumothorax. Avoiding a too-
until it slips below the decreases the risk for air embolism lateral or too-deep needle insertion
clavicle and enters the vein and pneumothorax. Without slight can reduce the risk for
while maintaining negative negative pressure, penetration into pneumothorax. Lateral movement
pressure within the syringe the vein will go unrecognized. of an inserted needle can lacerate
until free-flowing blood is vessels and should not be done.
returned (Fig. 82-5).
B. After a free flow of blood is A free flow of blood indicates a
returned, have the patient hold vessel has been entered.
his or her breath while the
syringe is detached and insert
the soft-tipped guidewire
20–25 cm through the needle
under constant manual
control.

C. Remove the needle. Wiping the guidewire dry may ease
D. Wipe the guidewire with the manipulation.
sterile 4 × 4 gauze.
E. Instruct the patient to breathe
normally.
up, make a small (2-mm to through the skin.
3-mm) stab wound at the
insertion site.
over the guidewire, advancing tissue and vessel, easing the maintained at all times to avoid
under the clavicle until 20–25 cm insertion of the catheter and wire embolization.
of wire extends beyond the preventing the formation of a false
dilator, then remove the dilator channel.
while maintaining the position of
the guidewire.
12. Advance the catheter over the Places the catheter. Cover the needle hub between
guidewire until 20–25 cm of the manipulations to avoid air
guidewire extends beyond the embolization.
guidewire.
14. Apply an occlusive, sterile Provides a sterile environment. Consider use of a chlorhexidine-
dressing to the site (see impregnated sponge dressing.5,6
Procedure 66). Follow institutional standards.
15. Return the patient to a neutral or Promotes comfort.
head-up position.
patients) and obtain a chest administration of IV fluid and
radiograph. medications.
18. HH
Specific Site: Femoral Vein (see Fig. 81-2)
1. Assist the patient to a supine, flat Prepares for the procedure.
position with the intended leg
extended.
2. Locate the femoral artery and Identifies the intended insertion site. Localization of the vessel may occur
mark it if necessary. with palpation; however, real-time
ultrasound should be utilized with
the femoral approach if equipment
and a trained physician, advanced
professional are available.5–7
3. Administer a local anesthetic. Promotes patient comfort during the
lidocaine (without
needle.
B. Inject the lidocaine into the
area surrounding the intended
insertion site.

A. Flush the catheter and ports prepares for insertion.
with normal saline.
B. Place sterile injectable or
noninjectable caps.
6. Use Seldinger’s technique for This technique is the preferred
placement of the catheter (see method of CVC placement; it uses
Fig. 82-3). a dilator and guidewire.
A. Insert the needle at a 20–30 Slight negative pressure helps to Lateral movement of an inserted
degree angle 1–2 cm inferior ensure placement into the vein. needle can lacerate vessels and
to the inguinal ligament and should not be done.
just medial to the femoral Without slight negative pressure,
artery. Maintain slight, penetration into the vein will go
continuous, negative pressure unrecognized.
during insertion and advance
the needle until free-flowing
blood is returned.
B. After a free flow of blood is A free flow of blood indicates a
returned, detach the syringe vessel has been entered.
and insert the soft-tipped
guidewire 25 cm under
constant manual control.
C. Remove the needle.
D. Wipe the guidewire with the Wiping the guidewire dry may ease
sterile 4 × 4 gauze. manipulation.
up, make a small (2-mm to 3-mm) through the skin.
stab wound at the insertion site.
over the guidewire, until 25 cm tissue and vessel, easing the maintained at all times to avoid
of wire extends beyond the insertion of the catheter and wire embolization.
dilator, then remove the dilator preventing the formation of a false
while maintaining the position of channel.
the guidewire.
9. Advance the catheter over the Places the catheter.
guidewire until 25 cm of the
guidewire extends beyond the
guidewire.
11. Apply an occlusive, sterile Decreases the risk for infection. Consider use of a chlorhexidine-
dressing to the site. impregnated sponge dressing.5,6
12. Return the patient to a neutral Facilitates comfort.
position with the head of the bed
slightly elevated.
13. Obtain an x-ray. Assesses for placement and The radiograph needs to be read
complications. before utilization of the catheter for
administration of IV fluid and
medications.

15. HH

• Successful placement of the CVC • Failure to place catheter
• If infusing IV solution, the solution infuses without • Arterial puncture
problems • Catheter embolization
• The a, c, and v waves are identified if hemodynamic • Vascular injury
monitoring is used • Pain or discomfort during the insertion procedure
• CVP measurements are obtained • Pneumothorax, tension pneumothorax, hemothorax,
or chylothorax
• Nerve injury
• Sterile thrombophlebitis
• Infection
• Malposition
• Inadvertent lymphatic or thoracic duct perforation
• Hemorrhage
• Hematoma

interventions.
1. Perform respiratory, cardiovascular, Determines whether signs or • Abnormal level of consciousness
peripheral vascular, and symptoms of complications are • Abnormal vital signs
hemodynamic assessments present, for example, an air • Abnormal waveforms or pressures
immediately before and after the embolism may present with • Declining oxygen saturation
procedure and as the patient’s restlessness. • Increasing peak airway pressures
condition necessitates.
2. If the catheter was placed for CVP Ensures that the catheter is in the • Abrupt and sustained changes in
measurement, assess the proper location for monitoring. CVP
waveform. Allows assessment of a, c, and v • Abnormal waveform
waves and measurement of
pressure.
3. Assess the insertion site for Determines the presence of • Bleeding that does not stop
presence of a hematoma or complications. • Hematoma or expanding
hemorrhage. hematoma
4. Assess heart and lung sounds Abnormal heart or lung sounds may • Diminished or muffled heart
before and after the procedure. indicate cardiac tamponade, sounds
pneumothorax, chylothorax, or • Absent or diminished breath
hemothorax. sounds unilaterally
5. Assess the results of the chest Ensures accurate placement and may • Abnormal radiograph results
radiograph. aid in identification of
complications.
6. Monitor for signs of complications. May decrease mortality and morbidity • Signs and symptoms of
if recognized early. complications

assessing pain. Prescribe analgesia interventions
as needed.
immediately place the patient in left-lateral Trendelenburg position • Coughing
the left-lateral Trendelenburg prevents air from passing into the • Tachypnea
position. (Level E*) left side of the heart and traveling • Altered mental status (agitation,
into the arterial circulation.1,2 restlessness)
• Cyanosis
• Gasp reflex
• Petechiae
• Chest pain
• Hypotension
Documentation
• Patient and family education • Right-atrial pressure and CVP waveform in the event
• Completion of informed consent of pressure monitoring
• Preprocedure verifications and timeout • Centimeter marking at the skin
• Insertion of central venous catheter • Patient response to the procedure
• Insertion site of central venous catheter • Pain assessment, interventions, and effectiveness
• Date and time of procedure • Confirmation of placement (e.g., chest radiograph)
• Catheter type • Occurrence of unexpected outcomes
• Lumen size • Additional nursing interventions

82 Central Venous Catheter Insertion (Perform) 730.e1
References 7. Troianos CA, et al: Guidelines for performing ultrasound

1. Infusion Nurses Society: Policies and procedures for guided vascular cannulation: Recommendations of the
infusion nursing, ed 5, 2016, Infusion Nurses Society. American Society of Echocardiography and the Society of
2. Infusion Nurses Society: Infusion nursing standards of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr
practice. J Infus Nurs 39(1S):S1–S159, 2016. 24(12):1291–1318, 2011.
3. Malloy PC, et al: Consensus guidelines for periprocedural Additional Readings
management of coagulation status and hemostasis risk in
percutaneuous image-guided interventions. J Vasc Interv Eggimann P, et al: Impact of a prevention strategy targeted at
Radiol 20(Suppl 7):S240–S249, 2009. vascular-access care on incidence of infections acquired in
4. Martin M, Husain F, Piesman M: Is routine ultrasound intensive care. Lancet 355:1864–1868, 2000.
guidance for central line placement beneficial? A Lorente L, et al: Central venous catheter-related infection in a
prospective analysis. Curr Surg 61(1):71–74, 2004. prospective and observational study of 2,595 catheters.
5. O’Grady NP, et al: Guidelines for the prevention of Crit Care 9:R631–R635, 2005.
intravascular catheter-related infections, Atlanta, 2011, Lough M: Hemodynamic monitoring: Evolving technologies
Centers for Disease Control and Prevention. and clinical practice, 2015, Elsevier.
6. Practice guidelines for central venous access: A report by
the American Society of Anesthesiologists Task Force on
Central Venous Access. Anesthesiol 116(3):539–573, 2012.
PROCEDURE
83
Insertion (Assist)
Susan Yeager
PURPOSE: Central venous catheters (CVCs) are inserted for measurement of
central venous pressure (CVP) with jugular or subclavian catheter placement.
Clinically useful information can be obtained about right-ventricular preload,
cardiovascular status, and fluid balance in patients who do not need pulmonary
artery pressure monitoring. CVCs also are placed for infusion of vasoactive
medications and to provide access for pulmonary artery catheters and transvenous
pacemakers.
• The CVP can be helpful in the determination of hypovo-

PREREQUISITE NURSING lemia. The CVP value is low if the patient is hypovolemic.
KNOWLEDGE Venodilation also decreases the CVP value.
• Electrocardiographic monitoring is essential in the accu-
• Knowledge of the normal anatomy and physiology of the rate interpretation of the CVP value.
cardiovascular system is needed. • Some contraindications of CVC insertion include ana-
• Knowledge of the anatomy and physiology of the vascu- tomical problems, venous obstructions, and coagulopa-
lature and adjacent structures of the neck, groin, and chest thies. The subclavian site should be avoided in hemodialysis
is needed. patients and patients with advanced kidney disease to
• Knowledge of the principles of sterile technique is essen- avoid subclavian vein stenosis.5
tial. • It is important to weigh the risks and benefits of placing
• Advanced cardiac life support (ACLS) knowledge and skills a CVC against the risk for mechanical complications (e.g.,
are needed. pneumothorax, vein laceration, thrombosis, air embolism,
• Knowledge of potential complications and associated inter- misplacement).5,6
ventions/consultations for addressing issues is necessary. • A subclavian site is recommended rather than a jugular or
• Indications for CVC placement may include the follow- femoral site to minimize the risk of infection.5
ing: • The internal jugular site is recommended to minimize
❖ Severe blood loss catheter cannulation-related risk of injury or trauma.6
❖ Hemodynamic instability • Ultrasound guidance is recommended to place CVCs if
❖ Administration of vesicant irritant medications the technology is available to reduce the number of can-
❖ Administration of total parenteral nutrition nulation attempts and mechanical complications.4,5,7
❖ Lack of peripheral venous access • Regardless of the site selected, complications may occur
❖ Assessment of hypovolemia or hypervolemia during or after insertion of a central venous catheter (see
❖ Monitoring of central venous pressures Table 82-1).
❖ Placement of pulmonary artery catheters or placement
of transvenous pacemakers EQUIPMENT
❖ Hemodialysis access
• The normal CVP value is 2 to 8 mm Hg. • CVC insertion kit
• The CVP waveform is identical to the right-atrial wave- • CVC of choice (single, dual, or triple lumen) usually sup-
form. plied with insertion needle, dilator, syringe, and guidewire.
• Interpretation of right-atrial/CVP waveforms including • Full sterile drapes
identification of a, c, and v waves is important. The a • 1% lidocaine without epinephrine
wave reflects right-atrial contraction. The c wave reflects • One 25-gauge 5 8 -inch needle
closure of the tricuspid valve. The v wave reflects passive • Large package of 4 × 4 gauze sponges
filling of the right atria during right-ventricular systole. • Suture kit (hemostat, scissors, needle holder)
• The CVP provides information regarding right-heart • 3-0 or 4-0 nylon suture with curved needle
filling pressures and right-ventricular function and volume. • Syringes: one 10- to 12-mL syringe; two 3- to 5-mL
• The CVP is commonly elevated during or after right- syringes; two 22-gauge, 1 1 2-inch needles
ventricular failure, ischemia, or infarction because of • Masks, head coverings, goggles (shield and mask combi-
decreased compliance of the right ventricle. nation may be used), sterile gloves, and sterile gowns
731
• No. 11 scalpel or the Trendelenburg position for extended periods of time

• Roll of 2-inch tape due to increased intracranial pressure or cardiopulmonary
• Dressing supplies compromise.
• Waterproof pad • Assess vital signs and pulse oximetry. Rationale: Baseline
• Chlorhexidine-impregnated sponge data can be compared with data obtained during and after
• Antiseptic solution (e.g., 2% chlorhexidine-based prepa- the procedure.
ration) • Assess electrolyte levels (e.g., potassium, magnesium,
• Nonsterile gloves calcium). Rationale: Electrolyte abnormalities may
• Normal saline flush syringes or 0.9% sodium chloride increase cardiac irritability.
vials, 10- to 30-mL • Assess for a coagulopathic state and determine whether
• Bedside ultrasound machine with vascular probe the patient has recently received anticoagulant or throm-
• Sterile ultrasound probe cover bolytic therapy. Rationale: These patients are more likely
Additional equipment, to have available as needed, includes to have complications related to bleeding. Therefore,
the following: site selection and the need/ability to provide interven-
• Hemodynamic monitoring system (see Procedure 75) tions before insertion of the CVC can be determined
• Sutureless catheter securement device prospectively.3
• Intravenous (IV) solution with Luer-Lok administration
set for IV infusion Patient Preparation
• Luer-Lok extension tubing • Verify that the patient is the correct patient using two
• Bedside monitor and oscilloscope with pulse oximetry identifiers. Rationale: This increases patient safety by
• Supplemental oxygen supplies ensuring correct identification of the patient for the
• Emergency equipment intended intervention.
• Package of alcohol pads or swab sticks • Ensure that the patient and family understand prepro-
• Package of povidone-iodine pads or swab sticks cedural teaching. Answer questions as they arise, and
• Heparin flushes reinforce information as needed. Rationale: Understand-
• Sterile injectable or noninjectable caps ing of previously taught information is evaluated and
• Skin protectant pads or swab sticks reinforced.
• Ensure informed consent has been obtained. Rationale:
PATIENT AND FAMILY EDUCATION Informed consent protects the rights of the patient and
makes a competent decision possible for the patient;
• Explain the need for the CVC insertion, and assess patient however, in emergency circumstances, time may not
and family understanding. Rationale: Clarification and allow for this form to be signed.
understanding of information decrease patient and family • Assist in performing a preprocedure verification and
anxiety levels. timeout, if nonemergent. Rationale: Ensures patient
• Explain the procedure and the time involved. Rationale: safety.
Explanation increases patient cooperation and decreases • Request and administer sedation or analgesics as pre-
patient and family anxiety levels. scribed and as needed. Rationale: The patient may need
• Explain the need for sterile technique and patient position- sedation or analgesics to promote comfort and to ensure
ing and that the patient’s face may be covered. Rationale: adequate cooperation and appropriate placement.
The explanation decreases patient anxiety and elicits • Apply patient restraints if ordered and if needed. Ratio-
cooperation. nale: In patients with cognitive impairment, restraints
• Explain the benefits and potential risks for the procedure. may be needed to ensure maintenance of patient position-
Rationale: Information is offered so that the patient and/ ing and equipment and access site sterility. During the
or family can make an informed decision. procedure, restlessness and an altered level of conscious-
ness may represent a pneumothorax, hypoxia, or place-
ment in the carotid artery.
PATIENT ASSESSMENT AND • Depending on the site selected and the patient’s body
PREPARATION habitus, specific positioning may be necessary. Assist with
this positioning as needed. (i.e., subclavian vein, assist
Patient Assessment with placing a towel posteriorly between the shoulder
• Assess the patient’s neurological, cardiac, and pulmonary blades.) Rationale: Specific positioning techniques for
status. Rationale: Some patients may not tolerate a supine each site assists with optimal vessel access.
83 Central Venous Catheter Insertion (Assist) 733
Procedure for Assisting with Central Venous Catheter Insertion

1. HH
2. PE All physicians, advanced practice
professionals in the room should
masks.5
3. Prepare the IV solution or flush Prepares the infusion system.
solution.
4. Prime the IV tubing or flush the Removes air bubbles. Air bubbles
entire pressure-transducer system introduced into the patient’s
if pressure monitoring is circulation can cause air embolisms.
anticipated (see Procedure 75). Air bubbles within the tubing
dampen the waveform and can alter
pressure results.
5. Apply and maintain pressure in Each flush device delivers 1–3 mL/hr
the pressure bag or device at to maintain patency of the
300 mm Hg. hemodynamic system.
6. Place a moisture-proof pad under Avoids soiling of the bed.
the patient’s back.
7. Assist as needed with patient Proper positioning increases vessel
positioning. access and optimizes comfort of the
patient and physicians, advanced
practice nurses, and other
healthcare professionals throughout
the process.
8. If needed remove gloves, wash Limits the introduction of potentially If there is a contraindication to
hands and apply sterile gown and infectious skin flora into the vessel chlorhexidine, tincture of iodine, an
gloves. Then assist as needed during the puncture. iodophor, or 70% alcohol can be
with the preparation of the skin used as alternatives.5
with an antiseptic solution (e.g.,
2% chlorhexidine-based
preparation).5,6 (Level A*)
A. Subclavian vein: scrub from
shoulder to contralateral
nipple line and neck to nipple
line (see Fig. 82-1, A).
B. Internal jugular vein: scrub
midclavicle to opposite border
of the sternum and from the
ear to a few inches above the
nipple (see Fig. 82-1B).
C. Femoral vein: scrub the
anterior and medial surface of
the proximal thigh to the
inguinal ligament.
Procedure for Assisting with Central Venous Catheter Insertion—Continued

9. While the physician or advanced Reduces anxiety and encourages Continue providing support and
practice nurse completes the skin cooperation. comfort throughout the procedure.
preparation, ensure patient
comfort by explaining what is
happening at the time.
A. Application of the antiseptic
solution is cold and wet.
B. Injection of the local
anesthetic may burn or sting
as the tissue is infiltrated.
10. Assist as needed with applying a Minimizes the risk of infection;
full drape to the patient with maintains aseptic and sterile
exposure of only the insertion precautions.
site.
11. Assist as needed with placement Provides help as needed.
of the sterile ultrasound probe
cover.
12. Place the bed in the Minimizes the risk for venous air Most patients can tolerate
Trendelenburg position (i.e., embolus by increasing the pressure Trendelenburg positioning but
15–20 degrees). (Level E*) in the large veins above intracranial, respiratory, or cardiac
atmospheric pressure, thus reducing compromise may occur. Therefore
the risk of air aspiration. The evaluation for the need for
patient should be positioned so that alternative sites and close
the intended puncture site is at or monitoring are necessary.
below the level of the heart.1,2
13. Monitor the heart rate, respiratory Assessment may indicate occurrence Assess patient comfort throughout the
rate and rhythm, pulse oximetry, of complications (see Table 82-1). procedure.
intracranial pressure, and any
patient response to the procedure.
14. Observe the cardiac monitor Advancement of the guidewire or Tall, peaked P waves may be
while the guidewire and catheter catheter into the heart may induce observed as the catheter tip enters
are advanced, and inform the cardiac dysrhythmias. the right atrium or if the guidewire
physician or advanced practice has been advanced too far into the
nurse immediately if a right atrium. Dysrhythmias may
dysrhythmia occurs. resolve with withdrawal of the
guidewire or catheter. If the
dysrhythmia continues,
antidysrhythmic medications may
be necessary.
15. Once the catheter is placed and Maintains aseptic technique and Ensure a tight connection to prevent
blood return is ensured, assist if maintains catheter patency. accidental disconnection. Luer-Lok
needed with flushing the lumen(s) devices prevent an accidental
with normal saline solution. disconnection.
16. Assist as needed with applying a Reduces the risk for infection. A sutureless catheter-securing device
sterile, occlusive dressing (see may be used to stabilize the CVC.
Procedure 66). Consider use of a chlorhexidine-
impregnated sponge dressing.5,6
Procedure for Assisting with Central Venous Catheter Insertion—Continued

17. If monitoring: Prepares the hemodynamic
A. Connect the hemodynamic monitoring system and assesses the
monitoring tubing to the CVP waveform.
catheter.
B. Level the CVP air-fluid
interface (zeroing stopcock) to
the phlebostatic axis (see
Procedure 75).
C. Zero the system by turning
the stopcock off to the patient,
opening it to air, and zeroing
the monitoring system (see
Procedure 75).
D. Place a sterile injectable or
port of the stopcock, turn the
stopcock open to the patient,
and observe the waveform
(see Procedure 67).
E. Obtain a waveform strip.
F. Measure the pressure.
G. Set the alarms.
18. Reposition the patient in a Promotes comfort.
comfortable position.
patients), and if assistance is administration of IV fluid and
needed with obtaining a chest medications.
radiograph as prescribed.
20. Remove PE and assist as needed Reduces the transmission of The physician or advanced practice
with discarding used supplies in microorganisms and minimizes nurse who inserted the catheter
appropriate receptacles. exposure to contaminated sharps. should dispose of all sharp objects
into sharps containers.
21. HH

• Successful placement of the CVC • Failure to place catheter
• If infusing IV solution, the solution infuses without • Arterial puncture
problems • Catheter embolization
• The a, c, and v waves are identified if hemodynamic • Vascular injury
monitoring is used • Pain or discomfort during the insertion procedure
• CVP measurements are obtained • Pneumothorax, tension pneumothorax, hemothorax,
or chylothorax
• Nerve injury
• Sterile thrombophlebitis
• Infection
• Malposition
• Inadvertent lymphatic or thoracic duct perforation
• Hemorrhage
• Hematoma

interventions.
1. Assess the patient’s vital signs, Identifies signs and symptoms of • Abnormal vital signs
oxygenation saturation, and level complications and allows for • Abnormal pulse oximetry value
of consciousness before the immediate interventions. • Changes in level of consciousness
procedure, after the procedure, and
as needed during the procedure.
2. If the catheter was placed for CVP Ensures that the catheter is in the • Abrupt and sustained changes in
measurement, assess the proper location for monitoring. CVP
waveform. Allows assessment of a, c, and v • Abnormal waveform
waves and measurement of
pressure.
3. Observe the catheter site for Postinsertion bleeding may occur in a • Bleeding that does not stop
bleeding or hematoma every 15–30 patient with coagulopathies or • Hematoma or expanding
minutes for the first 2 hours after arterial punctures, with multiple hematoma
insertion. attempts at vein access, or with the
use of through-the-needle
introducer designs for insertion.
4. Assess heart and lung sounds Abnormal heart or lung sounds may • Diminished or muffled heart
before and after the procedure. indicate cardiac tamponade, sounds
pneumothorax, chylothorax, or • Absent or diminished breath
hemothorax. sounds unilaterally
immediately place the patient in left-lateral Trendelenburg position • Coughing
the left lateral Trendelenburg prevents air from passing into the • Tachypnea
position. (Level E*) left side of the heart and traveling • Altered mental status (agitation,
into the arterial circulation.1,2 restlessness)
• Cyanosis
• Gasp reflex
• Petechiae
• Chest pain
• Hypotension
Documentation
• Patient and family education • Patient response to the procedure
• Universal Protocol requirements • Pain assessment, interventions, and effectiveness
• Catheter location • Fluids administered
• Medications administered • Type of dressing applied
• Right-atrial pressure and CVP waveform if monitored • Occurrence of unexpected outcomes
• Centimeter marking at the skin • Additional nursing interventions

83 Central Venous Catheter Insertion (Assist) 737.e1
References on Central Venous Access. Anesthesiol 116(3):539–573,

1. Infusion Nurses Society: Policies and procedures for 2012.
infusion nursing, ed 5, 2016, Infusion Nurses Society. 7. Troianos CA, et al: Guidelines for performing ultrasound
2. Infusion Nurses Society: Infusion nursing standards of guided vascular cannulation: Recommendations of the
practice. J Infus Nurs 39(1S):S1–S159, 2016. American Society of Echocardiography and the Society of
3. Malloy PC, et al: Consensus guidelines for periprocedural Cardiovascular Anesthesiologists. J Am Soc Echocardiogr
management of coagulation status and hemostasis risk in 24(12):1291–1318, 2011.
percutaneuous image-guided interventions. J Vasc Interv
Radiol 20(7 Suppl):S240–S249, 2009. Additional Readings
4. Martin M, Husain F, Piesman M: Is routine ultrasound Eggimann P, et al: Impact of a prevention strategy targeted at
guidance for central line placement beneficial? A vascular-access care on incidence of infections acquired in
prospective analysis. Curr Surg 61(1):71–74, 2004. intensive care. Lancet 355:1864–1868, 2000.
5. O’Grady NP, et al: Guidelines for the prevention of Lorente L, et al: Central venous catheter-related infection in a
intravascular catheter-related infections, Atlanta, 2011, prospective and observational study of 2,595 catheters.
Centers for Disease Control and Prevention. Crit Care 9:R631–R635, 2005.
6. Practice guidelines for central venous access: A report Lough M: Hemodynamic monitoring: Evolving technologies
by the American Society of Anesthesiologists Task Force and clinical practice, 2015, Elsevier.
PROCEDURE
84
Implantable Venous Access
Device: Access, Deaccess,
and Care
Anne Delengowski
PURPOSE: Implantable venous access devices or ports are surgically placed and
used for delivery of medications, including cytotoxic agents, parenteral solutions,
blood products, and for blood sampling for patients who need long-term venous
access.
need a longer needle for access. Too short a needle may

PREREQUISITE NURSING cause the flanges to press against the skin surrounding the
KNOWLEDGE portal chamber, leading to patient discomfort and possibly
resulting in damage to the skin overlying the venous
• Understanding of the implantable venous access device, access device. Too long a needle may result in a rocking
including the septum and outer borders, is needed. motion that can cause discomfort, possible migration out
• Knowledge of the anatomy of the venous system is needed. of the portal septum, or damage to the integrity of the
• Understanding is needed of the principles of medication septum, impairing it for further use.
delivery. Intermittent use necessitates flushing with normal • Power port implantable ports allow for venous access and
saline (NS) solution after each use and instillation of the ability for power-injected contrast-enhanced com-
heparin as prescribed when the medication infusion is puted tomography (CECT) scans.1 If the patient has a
completed. power-injectable port, the noncoring needle set used must
• Understanding of the principles of aseptic and sterile tech- be labeled as power injectable compatible.
niques is necessary.
• Knowledge of the consequences of infiltration of a vesi- EQUIPMENT
cant substance is needed.
• There are single- and double-lumen ports. All ports are • Nonsterile gloves
designed with a portal body and a catheter. The portal • Sterile gloves
body contains a septum and reservoir, which is made • Mask
of plastic, titanium, polysulfone, or a combination.4 A • Noncoring needle, winged with 90-degree angle and
slim tube or catheter is connected to the reservoir, which extension tubing (ensure that the appropriate size and
is covered by a disc 2 to 3 cm in width (Figs. 84-1 and length of needle is used; also confirm that the port is a
84-2). Provided a noncoring needle is used to access the power port if being used for power injection and that the
septum, the septum is capable of resealing when deac- correct noncoring needle is being used for access)4
cessed. The internal catheter is connected to the patient’s • Dressing supplies
venous system and may consist of either silicone or • Antiseptic solution (e.g., 2% chlorhexidine–based solution)
polyurethane.5,6,13 • Two 10-mL syringes
• Implanted vascular access ports are accessed using a • Luer-Lok vial access device
noncoring safety needle. A noncoring needle allows for • Needleless injection cap
repeated access of the venous device without damage to • Single-use 30-mL vial of NS
the silicone core. • 1 2 -inch Steri-Strips or stabilization device
• The noncoring needle chosen should be of optimal length • Heparin flush, 100 units/mL concentration, if deaccessing
(0.5–2 inches), with the most commonly used gauge being • Central venous catheter dressing change kit
19–22.4 Patients with increased subcutaneous tissue may Additional equipment, to have available as needed, includes
the following:
• Topical anesthetic if prescribed
• 10% betadine solution and 70% alcohol solution
practice nurses, and other healthcare professionals (including critical care • Supplies for obtaining blood samples for laboratory
nurses) with additional knowledge, skills, and demonstrated competence per analysis
professional licensure or institutional standard. • Needleless blood sampling access device
738
84 Implantable Venous Access Device: Access, Deaccess, and Care 739
• Explain site care and signs and symptoms of infection and

infiltration. Rationale: Explanation enables the patient
and family to participate in care and the patient is encour-
aged to report untoward events to physicians, advanced
practice nurses, and other healthcare professionals.

PREPARATION
Patient Assessment
• Review the patient’s medical history specifically related
to the type of port, problems with device implantation,
complications with previous access, and allergies to anti-
septic solutions. Rationale: Baseline data are provided.
Figure 84-1 Port placement. (Courtesy of Bard Corporation.) • Obtain the patient’s vital signs. Rationale: Baseline data
are provided.
• Review the patient’s current laboratory status, including
coagulation results. Rationale: Baseline coagulation
studies are helpful in determining the risk for bleeding. If
PATIENT AND FAMILY EDUCATION results are abnormal, consult with the patient’s physician
or advanced practice nurse before accessing the device.2
• Assess patient and family readiness to learn, and iden- • Determine if the patient has a power port by palpating the
tify factors that affect learning. Rationale: Assessment top of the port to identify three palpations (bumps) on the
allows the nurse to individualize teaching and maximize septum, arranged in a triangle. Also, palpate the sides of
understanding. the port to identify if the device is in the shape of a tri-
• Provide information about the type of implantable venous angle.1 Rationale: Determines the type of device in place
access device placed and the methods used for accessing and guides the use of the correct noncoring needle set.
and deaccessing it. Rationale: Information assists the
patient and family in understanding the procedure and Patient Preparation
decreases patient and family anxiety. • Verify that the patient is the correct patient using two
• Encourage the patient to carry a card describing the type of identifiers. Rationale: Before performing a procedure, the
port implanted. Rationale: This provides important infor- nurse should ensure the correct identification of the patient
mation that may be needed by other physicians, advanced for the intended intervention.
practice nurses, and other healthcare professionals. • Ensure that the patient and family understand prepro-
• Explain the patient’s role during the procedure and cedural teaching. Answer questions as they arise, and
expected outcomes. Rationale: The patient is able to par- reinforce information as needed. Rationale: Understand-
ticipate in care, and cooperation is encouraged. ing of previously taught information is evaluated and
• Explain the anticipated sensations during the access pro- reinforced.
cedure and infusion of therapies. Rationale: Explanation • Assist the patient to a supine position with the head of the
allows the patient to alert the physician, advanced practice bed elevated up to a 30-degree angle. Rationale: Position-
nurse, or other healthcare professional to unusual or unex- ing prepares the patient and allows optimal access to the
pected sensations. implanted venous access device.
Figure 84-2 PORT-A-CATH reservoir with self-sealing septum and catheter. (Courtesy of Smiths
Medical ASD, Inc., St. Paul, MN.)
Procedure for Implantable Venous Access Device: Access, Deaccess, and Care
Accessing an Implantable Venous Access Device
1. HH
2. PE
3. Remove the patient’s gown away Optimizes the viewing area.
from the venous access device.
4. Assess the venous access device: Allows for identification of the type
A. Palpate the subcutaneous of port that was implanted and
tissue to determine the whether the port is single or double
borders of the access device.4,6 lumen.
B. Palpate the venous access
device borders and locate the
septum and the center of the
septum. (Level M*)
5. Assess the site for signs and Minimizes the risk of accessing an Before accessing, examine the chest
symptoms of infection or other infected area. for complications, including
complications (e.g., erythema, evidence of thrombosis (veins of
induration, pain, or tenderness at ipsilateral chest and neck),
the site). erythema, swelling, or tenderness,
which may indicate system leakage.
A radiograph is recommended if
leakage is suspected.3,5
6. Discard gloves in the appropriate Removes and safely discards used
receptacle. supplies.
7. HH
8. Carefully open the central venous Maintains asepsis and prepares Disinfect the table as needed.
catheter dressing kit with the supplies. Creates a sterile field. Venous access devices have the
sterile inner surface of the wrap. lowest risk for catheter-related
blood system infections, provided
that aseptic and sterile techniques
are used throughout care delivery.5
The kit should include sterile gloves
and masks.
9. Prepare supplies:
A. With sterile technique, remove Places equipment within reach during If prefilled saline syringes are
the wrapper from two 10-mL the procedure. provided in a sterile package, they
syringes and place them on can be dropped onto the field and
the sterile field. Steps 9-11 can be skipped.
B. Remove the packaging and Maintains the sterility of the
place the winged or safety- procedure.
noncoring needle with
extension tubing, needleless
injection cap, and Steri-Strips
or stabilization device on the
sterile field.
10. Remove the cap from the NS Reduces microorganisms.
vial; wipe the top of the NS vial
with an alcohol wipe and allow it
to dry.

Procedure for Implantable Venous Access Device: Access, Deaccess, and Care—Continued
11. Prepare additional supplies: Prepares for the procedure.
A. Put on face mask.
B. Put a sterile glove on your
dominant hand.
C. With sterile gloved hand, pick
up a sterile 10-mL syringe.
D. With the nonsterile hand, pick
up the NS vial.
E. Use the sterile gloved hand to
withdraw 10 mL of NS
solution, touching only the
sterile syringe.
F. Repeat the above to fill the
second sterile syringe with
10 mL of saline.
G. As described previously, use
the sterile gloved hand to
withdraw 10 mL of NS.
12. Apply the remaining sterile Maintains asepsis.
glove.
13. With sterile technique: Prepares the equipment.
A. Attach the needleless injection
cap to the extension tubing on
the noncoring needle.
B. Attach the 10-mL NS syringe
to the needleless cap.
C. Prime the tubing with NS Removes air from the extension
solution away from the sterile tubing, preventing possible air
field. embolism.
14. Retain the priming syringe on the
needleless cap, and return the
primed equipment to the sterile
field.
15. Cleanse the implanted venous Reduces the risk of infection. Administer topical anesthetic if
access device site or port with a prescribed to reduce discomfort.4
2% chlorhexidine–based
antiseptic solution. Cleanse the
site using a back-and-forth
motion while applying friction
for 30 seconds. Allow the
antiseptic to remain on the
insertion site and to dry
completely before catheter
insertion.4,5,8,9
(Level D*)
16. Pick up the noncoring needle
with the NS syringe attached with
the dominant hand and remove
the protective cap.
17. Use the nondominant hand to
stabilize the borders of the
venous access device.

18. Triangulate the venous access Stabilizes the venous access device
device between the thumb and within the chest wall and prevents
first two fingers of the slippage.
nondominant hand (Fig. 84-3). Protects the physician, advanced
professional from a potential needle
injury.
19. With the dominant hand, firmly
grasp the protective cap or wings
of the noncoring needle and
insert it firmly into the center of
the port septum using a 90-degree
angle perpendicular to the skin
surface (Fig. 84-4).
20. Advance the needle through the With use of a noncoring safety
skin and septum until reaching needle, grasp the vertical fin
the base of the portal reservoir between the thumb and middle
when you feel portal backing finger and press downward with the
(Fig. 84-5). index finger.4,5,10
21. Note that resistance is felt as the Once the septum is punctured, avoid
needle reaches the base of the tilting or rocking the needle, which
reservoir. may cause fluid leakage or damage
to the system.2
22. Flush the venous access device Determines the patency of the venous Avoid use of syringes with less than a
with 5 mL of NS solution. access device. 10-mL volume for flushing or
administration of infusate.
Smaller syringes exert pressure
exceeding 40 psi and may cause
catheter rupture or fragmentation
with possible embolization.2,6
23. Observe the skin surrounding the Assesses for potential access
noncoring needle for leakage of problems.
fluid or infiltration at the access
site.
Figure 84-3 Triangulating the PowerPort Implanted Port with

the nondominant hand. (Courtesy of Bard Corporation.)
Figure 84-4 Needle access of the PowerPort Implanted Port with

a noncoring PowerLoc Needle. (Courtesy of Bard Corporation.)
Figure 84-5 The noncoring PowerLoc Needle is inserted until the base of the port reservoir is
felt. (Courtesy of Bard Corporation.)
24. Gently aspirate blood, then flush Verifies placement. If a blood return is not evident, gently
with the remaining 5 mL of NS. flush with the push-pull method and
reposition the patient.
If a blood return is still not evident,
continue the access procedure and
apply a dressing to minimize the
risk of infection.
Contact the patient’s physician or
advance practice nurse.
Administer a lytic agent and obtain a
radiographic or dye shadow study
as prescribed.4,13
25. Position the wings flush with the Anchoring minimizes discomfort for
patient’s skin. the patient.
26. Stabilize the needle by attaching Stabilizes the needle inserted in the Follow institutional standards.
Steri-Strips in a cross or star septal core and minimizes rocking
pattern over the wings of the of the needle, which can cause
noncoring needle or use of the damage to the septum and patient
stabilizing device as per protocol. discomfort.
Also, minimizes needle movement in
the septum, thereby ensuring
integrity of the septal core for
future use.
27. Apply a sterile, occlusive Maintains asepsis. A gauze dressing is preferred if
dressing. oozing or blood seepage occurs at
the insertion site.
28. Label the dressing with the date, Provides important clinical If the accessed device is not to be
time of cannulation, needle gauge information. used immediately, flush it with
and length, and initial. heparin as prescribed.
29. Initiate continuous or intermittent Begins therapy. Attach intravenous (IV) tubing to the
infusion. catheter hub for continuous infusion
or injection cap for intermittent
infusions.
receptacles.
31. HH
Deaccessing an Implantable Venous Access Device
1. HH
2. PE
3. Flush the venous access device Prepares and optimizes catheter
with 20 mL of NS, followed by patency while not in use.
heparin flush as prescribed (e.g.,
5 mL of 100 units/mL heparin).2,4
4. Loosen the transparent or gauze Facilitates removal.
dressing and Steri-Strips or the
stabilization device from the site.
5. Use the thumb and forefinger of Prepares for needle removal.
the dominant hand to grasp the
dressing and the Steri-Strips or
the stabilization device along with
the winged flanges of the needle.
6. With the nondominant hand, Minimizes patient discomfort and With use of a noncoring safety
apply gentle stabilizing pressure ensures controlled withdrawal of needle, grasp the horizontal
to the venous access device while a sharp object. flanges securely, pull up, and
removing the needle by pulling squeeze the flanges together. The
straight up and out in a firm, flanges fold together, forcing the
continuous motion. needle inside the locked wings
and covering the needle. The
wings will lock in place.
7. Assess the site for redness or Identifies possible complications.
drainage.
8. Discard the noncoring needle in a Safely removes sharp objects.
designated container.
9. Apply a dressing to the site if Provides absorption.
oozing occurs.
10. Remove PE and discard supplies Removes and safely discards used
in appropriate receptacles. supplies.
11. HH
Obtaining a Blood Specimen From an Implantable Venous Access Device
1. HH
2. PE
3. If present, shut off the IV Maintains asepsis.
infusion and disconnect the IV
tubing from the extension tubing
on the noncoring needle.
4. Place a sterile cap on the end of Maintains asepsis.
the IV tubing.
5. Thoroughly cleanse the injection Minimizes infection and exposure of
cap with an alcohol wipe and the physician, advanced practice
allow it to dry. Do not remove nurse, or other healthcare
the cap.4,9,11 (Level D*) professional to blood and body
fluids.6
6. Attach a 10-mL syringe with NS Clears the catheter of medication or
and flush the venous access IV fluid.
device.
7. Attach a new sterile 10-mL Prepares supplies.
syringe or a needleless blood
sampling access device.
8. Determine the appropriate discard Clears the catheter of solution. The Blood for coagulation tests should not
volume. (Level E*) discard volume includes the dead be withdrawn through a heparinized
space and the blood diluted by the catheter if the results will be used
flush solution. Portal reservoirs to monitor anticoagulant therapy or
average 0.5 mL volume; catheters to determine whether a patient has
average 0.6 mL for single-lumen a coagulopathy.
systems.2 Blood specimens should be redrawn
Recommendations are that at least peripherally when results are
three times the dead space be abnormal.8
withdrawn.7 Discard 5-10 mL of Follow institutional standards.
blood.4,7
9. Gently aspirate the discard Withdraws the discard. Minimizes needlestick injury and
volume into the syringe or exposure to blood, and decreases
engage a blood specimen tube infection risk to the patient by
into the needleless blood reducing the incidence of opening
sampling access device to obtain the catheter system.
the discard volume and allow the
tube to passively fill.7
10. Remove the discard syringe or Prepares for blood sampling.
the blood specimen tube.
11. Insert a new syringe into the Prepares for removal of the specimen
injection cap or place a new sample.
blood specimen tube into the
needleless blood sampling access
device.
12. Slowly and gently aspirate blood Obtains the blood specimen.
or engage the blood specimen
tube into the needleless blood
sampling access device.
13. Remove the syringe or the blood Removes the specimen.
specimen tube.
14. After the blood specimen is Clears blood from the system. Flush with an additional 10–20 mL of
obtained, flush the port with NS if the blood does not clear
10-20 mL of NS.4 completely from the extension
tubing.
15. Clamp the extension tubing.
16. Apply a new injection cap with Reduces infection.
strict aseptic technique.
17. Reconnect the IV and continue Resumes therapy. If the IV infusion is completed,
the infusion. administer heparin as prescribed.
receptacles.
19. HH
20. Label the specimen(s) and the Properly identifies the patient and
laboratory form. laboratory tests to be performed.
21. Send the laboratory specimen(s) Expedites determination of laboratory
for analysis. results.


• Site without redness, pain, or tenderness • Port reddened, tender, or painful on palpation
• Venous access device stable • Skin erosion
• Venous access device is accessed without difficulty • Implanted device unstable in chest wall with
• Venous access device flushes easily without evidence palpation
of resistance or infiltration • Catheter migration
• No evidence of leakage at the septal site • Catheter “pinch-off” (compression of catheter
• Blood specimens are obtained as prescribed between clavicle and first rib)
• Venous access device is deaccessed without difficulty • Portal body inversion or “twiddler’s syndrome”
• Patient describes burning sensation in the
subcutaneous tissue with flushing or infusion
• Sluggish or no blood return with aspiration
• Evidence of leakage of flush solution at the septal
site
• Patient describes pain at site, chest, ear, or shoulder
with flushing
• Signs or symptoms of local or systemic infection
• Swollen neck or arm14,15

interventions.
1. During IV infusions, assess the Determines adequate functioning of • Signs or symptoms of infiltration
venous access device for patency the venous access device. at the venous access site
and signs of infiltration every 4
hours and as needed.
2. Replace gauze dressings every 2 Decreases the risk for infection at the • Signs or symptoms of infection
days and transparent dressings at catheter site.
least every 7 days.8,9,12 Follow The dressing should be changed if it
institutional standards. (Level D*) becomes damp, loosened, or soiled
necessary.4,12
4. Follow-up care for deaccessed Maintains catheter patency.
device includes reaccessing the
device to administer monthly flush
with 5 mL of 100 units of heparin
as prescribed.2,4,10,12
5. Assess for signs and symptoms of Determines the presence of infection. • Redness, pain, or drainage at the
infection. site; fever, elevated white blood
cell count
Documentation
• Assessment of the site before accessing and • Specimens obtained and sent for analysis
deaccessing the port • Laboratory results
• Location and cannulation of the device • Pain assessment, interventions, and effectiveness
• Needle length and gauge, and rationale for selection • Unexpected outcomes
including patient’s body habitus • Additional interventions
• Appearance of blood return before, during, and after • Patient’s response to procedure and therapy
infusion • Education of patient and family to procedure and
• Date and time of therapy administration therapies administered

84 Implantable Venous Access Device: Access, Deaccess, and Care 747.e1
References 14. Polovich M, Olsen M: LeFebvre Oncology Nurses

1. Bard CRPowerport, PowerLoc: Feel the new standard of Society: Chemotherapy and BioTherapy Guidelines and
care. Accessed at <http://www.powerportadvantage.com/ Recommendations for Practice, ed 4, Pittsburgh, 2014,
clinicians.html9/18/2016>. Oncology Nursing Press, Inc.
2. Beck SL, et al: Standards of care for the patient with a 15. Schulmeister L: Management of non-infectious central
venous access device, Salt Lake City, UT, 1990, American venous access device complications. Semin Oncol Nurs
Cancer Society, Utah Division. 26(2):132–141, 2010.
3. Camp-Sorrell D: Accessing and deaccessing ports: where Additional Readings
is the evidence? Clin J Oncol Nurs 13:587–590, 2009.
4. Camp-Sorrell D, Oncology Nursing Society: Access Camp-Sorrell D, et al: The efficacy of chlorhexidine-
device guidelines: recommendations for nursing practice impregnated sponge (BioPatch) for the prevention of
and education, ed 2, Pittsburgh, 2012, Oncology Nursing intravascular catheter related infection: a prospective,
Press, Inc. randomized, controlled multi-center trial, abstract of the
5. Camp-Sorrell D: State of the science of oncology vascular 40th Interscience Conference on Antimicrobial Agents and
access devices. Semin Oncol Nurs 26(2):80–87, 2010. Chemotherapy 422, 2000.
6. Deltec Incorporated: Clinician information Port-A-Cath, Rosenthal K: Pinpointing intravascular device complications.
Port-A-Cath II and P.A.S. Port systems, St. Paul, MN, Nurs Manage June:37–42, 2003.
2002, Deltec, Inc, pp 1–24. Sabel M, Smith J: Principles of chronic venous access:
7. Frey AM: Drawing blood from vascular access devices. Recommendations based on the Roswell Park experience.
J Infus Nurs 26:285–293, 2003. Surg Oncol 6:171–177, 1988.
8. Gorski L, et al: Infusion therapy. Standards of practice. Seemann S, Reinhardt A: Blood sample collection from a
J Infus Nurs 39(Suppl 1S):2016. peripheral catheter system compared with phlebotomy.
9. Gorski L, et al: Policies and procedures for infusion J Intraven Nurs 23:290–297, 2000.
nursing, ed 5, Norwood, MA, 2016, Infusion Nurses Smith L: Implanted ports, computed tomography, power
Society. injectors, and catheter rupture. Clin J Oncol Nurs
10. Johnson K: Power injectable portal systems. J Radiol 12(5):809–812, 2008.
Nurs 28:27–31, 2009. Sterba K: Controversial issues in the care and maintenance of
11. Mayo DJ, et al: Discard volumes necessary for clinically vascular access devices in the long-term/subacute care
useful coagulations studies from heparinized Hickman client. J Infus Nurs 24:249–254, 2001.
catheters. Oncol Nurs Forum 23(4):671–675, 1996. Wu P-Y, et al: Spontaneous migration of a Port-A-Cath
12. Menyhay S, Maki D: Disinfection of needleless catheter catheter into ipsilateral jugular vein in two patients with
connectors and access ports with alcohol may not prevent severe cough. Ann Vasc Surg 19:734–736, 2005.
microbial entry: The promise of a novel antiseptic-barrier
cap. Infect Control Hosp Epidemiol 27(1):23–27, 2006.
13. O’Grady NP, et al: Guidelines for the prevention of
intravascular catheter-related infections, Atlanta, 2011,
Centers for Disease Control and Prevention.
PROCEDURE
85
Intraosseous Devices
Michael W. Day
PURPOSE: Intraosseous access is indicated when intravenous (IV) access cannot
be obtained or cannot be obtained in a timely manner and access to venous
circulation is needed for the administration of medications or fluids.
PREREQUISITE NURSING • IO blood can be used for many laboratory tests, including
KNOWLEDGE typing and screening, electrolyte values, chemistries,
blood gas values, drug levels, and hemoglobin levels.7,20
• Intraosseous (IO) access is a safe and reliable access point ❖ However, specimen samples from the marrow have a
into the noncollapsible marrow cavity that allows direct lower correlation to serum levels after 30 minutes of
access to the venous circulation.6–8 Indications for IO resuscitation.4
20
access include status epilepticus, extensive burns, morbid ❖ IO samples may be used for point-of-care testing.
obesity (which may prevent peripheral or central line ❖ In addition, drawing of blood from an IO device may
placement),6 sepsis, and multiple traumatic injuries.8 not be recommended by specific manufacturers and has
• IO is significantly faster than central venous placement the potential of occluding the device.11
during actual resuscitation15 and in simulation.19 • The onset of action for medications is similar to that of
• Use of IO devices may decrease the use of emergency IV medications.7,8 However, administration via the IO
femoral access, with its attendant complications.8 “Despite route may result in lower serum concentrations versus the
recommendations from a number of specialty societies on IV route for the following medications: ceftriaxone, chlor-
the use of IO access when IV access has failed in emergent amphenicol, phenytoin, tobramycin, and vancomycin.4
patients, IO access appears to be an underutilized access • Marrow-toxic medications should not be infused via the
tool in the hospital ED (emergency departments).”21 IO route.13
• The Volkmann’s canals that are located throughout the • There is some research to support the use of IO devices
bone connect with the medullary canal and the blood for IV contrast.1,12
vessels of the periosteum (Fig. 85-1). When medications • All resuscitation medications, isotonic fluids, and blood
and fluids are introduced into the medullary canal, they products may be given via the IO route5; however, myo-
flow through the vascular plexi directly into the vascular necrosis has been reported with the infusion of hypertonic
system.6,7 saline solution via the IO route.17
• Mechanical insertion devices are available for insertion of • Medications administered via the IO route should be fol-
IO needles.6 These devices include the bone injection gun lowed by a 5- to 10-mL flush of normal saline solution.
(BIG; Waismed, a Persys Medical Co, Houston, TX; Fig. Resistance to the manual flush will be felt but does NOT
85-2), the FASTResponder adult IO infusion system indicate incorrect placement. If swelling or infiltration is
(Pyng Medical Corp, Vancouver, BC, Canada, Fig. 85-3), observed, remove the device and attempt IO access in
and the EZ-IO (Teleflex, Shavano Park, TX; Fig. 85-4). another bone.6,7
These three devices are approved by the US Food and • Fluids running into an IO line should be administered with
Drug Administration (FDA) for IO access in adult patients. a pressure bag inflated to 300 mm Hg because the pressure
Two of the devices (BIG, Arrow EZ-IO) use a specially needed to push the fluid into the bone marrow may exceed
designed needle with a stylet or trocar. The third device that of volumetric IV pumps. Flow rates can be managed
(FASTResponder) uses a metal-tipped plastic catheter. with the IV tubing roller clamp.6
The attributes of the three devices of this procedure are • Complications of IO access include compartment syn-
summarized in Table 85-1. drome, osteomyelitis, fracture, extravasation,5 necrosis,5,10
• In adults, the available IO access sites, depending on the and infection.8
specific device and following each manufacturer’s guide- • A syringe should not be attached directly to the hub of the
lines,3 include the following: IO needle because it could cause dislodgment, increase
❖ Tibial plateau: 1 to 2 cm distal to the tibial tuberosity the size of the hole, and cause extravasation or loss of the
❖ Distal tibia: 1 to 2 cm above the medial malleolus IO site. To extend access to the IO needle, attach extension
❖ Manubrium: 1.5 cm below the sternal notch tubing to the hub of the IO needle and secure it to the skin.
❖ Greater tubercle of the proximal humerus Some device insertion kits come with extension tubing.
• A recent study using the EZ-IO device found that there • Absolute contraindications to attempting an IO access
was a significantly higher success rate with proximal tibial include previous attempts or fractures of the targeted
compared with humeral placement.18 bone.
748
85 Intraosseous Devices 749
Figure 85-1 Intraosseous circulation. (From Day MW: Intraosseous devices for intravenous
access in adult trauma patients, Crit Care Nurs 31[2]:76–90.)
Figure 85-2 Bone injection gun (BIG; adult). (From Day MW:
Intraosseous devices for intravenous access in adult trauma
patients, Crit Care Nurs 31[2]:76–90.)
Figure 85-4 EZ-IO power driver. (From Day MW: Intraosseous

devices for intravenous access in adult trauma patients, Crit Care
Nurs 31[2]:76–90.)
• Relative contraindications to IO access include infection

at the access site, artificial joint replacement at the inser-
tion site,8 fractures above the insertion site, inability to
locate landmarks,5 and bone disorders, such as osteoporo-
sis and osteogenesis imperfecta. Another relative contra-
indication to the FASTResponder is skin damage at the
insertion site, which may preclude the adherence of the
target foot patch used to secure the device.
• IO access in obese patients may be more difficult. The
Figure 85-3 The FASTResponder. (Courtesy Pyng Medical, Arrow EZ-IO has a needle set specifically designed for
Richmond, British Columbia.) the patient with “excessive tissue” at the insertion site.
TABLE 85-1 Intraosseous (IO) Device Comparison Table

Big EZ-IO FASTResponder
Insertion sites • Proximal tibia • Proximal tibia • Manubrium
• Proximal humerus • Distal tibia
• Proximal humerus
Insertion process • Activated by manual pressure • Battery-operated power driver • Activated by manual pressure
Advantages • Small • Color coded, weight-based needle • Small
• Color coded (blue, adult; red, sets (PD, 3–39 kg; AD, >40 kg; LD, • Lightweight
pediatric) >40 kg and “excess tissue” over • Single insertion site
• Lightweight insertion site) (consistent site = less
• Multiple insertion sites (total of four) • Multiple insertion sites (total of six) training)
Disadvantages • May cause “scatter” artifact in • Large device and packaging • No alternative insertion site
chest or cervical spine CT when • Requires visualization of needle skin • Requires two hands to exert
placed in humerus depth before insertion in bone pressure needed to activate
• May be overlooked during transport • May cause “scatter” artifact in chest the device
or transition from one level of care or cervical spine CT when placed in • May preclude use of a
to another humerus cervical collar (towel rolls
• May be overlooked during transport and taping the patient’s head
or transition from one level of care to to a backboard may be
another substituted)
Contraindications • Insertion in limbs with fractures • Insertion in limbs with fractures • Severe osteoporosis or other
• Insertion in limbs with prosthetic • Insertion in limbs with prosthetic bone pathology
joints near insertion site joints near insertion site • Inability to secure target
• Insertion at sites with previous IO • Insertion at sites with previous IO patch to skin over
attempt attempt manubrium (i.e., burns,
• Severe osteoporosis or other bone • Severe osteoporosis or other bone wounds, infection)
pathology pathology
• Infection present over insertion site • Infection present over insertion site
• Inability to identify pertinent • Inability to identify pertinent insertion
insertion landmarks landmarks
Removal • Grasp needle hub with safety latch • Attach syringe • Stabilize target foot
• Pull and twist • Pull and twist counterclockwise (if • Grasp infusion tube and pull
hub separates, grasp needle with it out perpendicular to the
large needle forceps, pull, and twist manubrium
counterclockwise)
Adapted from Day MW: Intraosseous devices for intravenous access in adult trauma patients, Crit Care Nurs 31(2):76–90, 2011.
• IO access is meant to be a temporary venous access; IO • Isotonic crystalloid fluid, as prescribed

lines should be removed as soon as other venous access • Two 5- to 10-mL syringes
is obtained or within 24 hours of insertion.8 • Prescribed medications
• Magnetic resonance imaging is not an option when an IO • Pressure bag for IV solution
device is present,8 whereas an IO humeral placement may • Dressing supplies
interfere with chest, low cervical, or high thoracic com- Additional equipment, to have available as needed, includes
puterized tomography (CT).6 the following:
• Sternal IO devices may interfere with the placement of a • Blood-specimen tubes
cervical collar in trauma patients, requiring alternative • 1% or 2% preservative free lidocaine without
methods to maintain cervical stabilization.6 epinephrine
• Sterile 2 × 2 gauze pads
EQUIPMENT • Large needle forceps
• Nonsterile gloves PATIENT AND FAMILY EDUCATION

• Antiseptic solution (e.g., 2% chlorhexidine-based
preparation) • If the clinical situation permits, explain to the patient and
• IO insertion device (follow manufacturer’s guidelines for family the reason for the IO access. Rationale: Clarifica-
information that may be age or weight based) tion of information is an expressed patient need and helps
• Tape to diminish anxiety, enhance acceptance, and encourage
• IV tubing and extension tubing questions.
• Describe the major steps of the procedure, including the • Obtain the patient’s baseline vital signs and cardiac
patient’s role in the procedure. Rationale: Explanation rhythm. Rationale: Baseline data facilitate the identifica-
decreases patient anxiety, enhances cooperation, provides tion of clinical problems and identify the urgency of
an opportunity for the patient to voice concerns, and pre- obtaining IO access.
vents accidental contamination of the sterile field and • If possible, determine the patient’s allergy history (e.g.,
equipment. lidocaine, antiseptic solutions). Rationale: This assess-
• Explain the expected outcomes of the procedure. Ratio- ment decreases the risk for allergic reactions by avoiding
nale: Explanation reduces anxiety and clarifies the dura- known allergenic products.
tion and goals of IO access.
Patient Preparation
PATIENT ASSESSMENT AND • Verify that the patient is the correct patient using two
PREPARATION identifiers. Rationale: Before performing a procedure, the
Patient Assessment for the intended intervention.
• Assess the patient for fractures or infections at the inser- • Ensure that the patient and family understand preprocedural
tion site, for previous bone surgeries at the site, and for a teaching. Answer questions as they arise, and reinforce
history of osteoporosis or fractures of the target bone. information as needed. Rationale: Understanding of previ-
Rationale: An alternate site should be accessed to avoid ously taught information is evaluated and reinforced.
possible complications associated with the previous • Perform a preprocedure verification and time out, if non-
conditions. emergent. Rationale: Ensures patient safety.
Procedure for Intraosseous Access

1. HH
2. PE
3. Assist the patient to a position of Prepares the patient for the procedure
comfort for access of the and allows for optimal
appropriate insertion site. visualization.
4. Palpate the intended insertion Guides IO device placement.
site.
A. Proximal tibia:
i. Identify the tibial
tuberosity.
ii. Move 2 cm medially and
1 cm proximally.
B. Distal tibia:
i. Identify the medial
malleolus.
ii. Move two finger widths
proximally at the midline
of the medial aspect of the
leg.
C. Manubrium:
i. Identify the sternal notch.
ii. Align the target foot with
the sternal notch.
D. Humerus:
i. Identify the greater
tubercle.
ii. Move one finger width
lateral from the greater
tubercle.
5. Cleanse the intended site and Limits the introduction of potentially
surrounding area with antiseptic infectious skin flora into the
solution (e.g., 2% chlorhexidine- insertion site.
based preparation).
Procedure for Intraosseous Access—Continued

6. For those devices placed in Prevents movement of the limb Ensure that the nondominant hand is
extremities, stabilize the insertion during insertion. NOT in line with IO placement to
site with the nondominant hand. prevent inadvertent injury.
7. FASTResponder9 insertion (see Inserts the IO device. Follow manufacturer’s guidelines.
Fig. 85-3): It is critical that the FASTResponder
A. The FASTResponder is be held perpendicular to the
inserted into the manubrium. manubrium and not the patient’s
B. Place the patient in a flat, body.
supine position. Attempting to place the
C. Assume a position at the FASTResponder device with the
patient’s head. patient in a sitting position, from
D. Remove the locking pin and the patient’s side, or using one hand
pull away from the device; is NOT recommended because it
identify the sternal notch with may move the physician, advanced
the thumb of the nondominant practice nurse, or other healthcare
hand. professional away from
E. Align the target foot with the perpendicular to the manubrium.
sternal notch and press to Removing the locking pin exposes the
apply. adhesive surface of the target foot
F. Grasp the device with both and readies the device for insertion.
hands, with the thumbs side
by side.
G. Ensure that the device is
perpendicular with the
manubrium and NOT the
patient’s body.
H. Apply steady pressure until
the device is heard and felt to
deploy the infusion tube.
I. Stabilize the target foot with
the nondominant hand and
slowly withdraw the device
with the dominant hand, while
remaining perpendicular to the
manubrium.
J. Remove the antibuckle device
from the infusion tube.
K. After correct placement has
been confirmed, connect the
strain relief hook to the hook
on the target foot.
L. Remove covering from the
protective dome and apply
over the target foot and
infusion tube.
(Level M*)


8. BIG insertion3 (see Fig. 85-2): Inserts the IO needle. The BIG device is color coded.
A. The BIG can be inserted into The adult device is blue.
the proximal tibia or the
humerus.
B. Palpate the appropriate
landmarks with the dominant
hand, and with the
nondominant hand place the
barrel of the BIG on the skin
perpendicular to the intended
insertion site.
C. With the dominant hand,
squeeze and remove the red
safety latch.
D. Grasp the “shoulders” of the
BIG with the fingers of the
dominant hand while the palm
presses down into the BIG
and deploys the needle and
trocar.
E. Remove the BIG and stabilize
the needle.
F. Remove the trocar from the
needle and secure the needle
to the skin by taping the red
safety latch around it.
(Level M*)
9. Arrow EZ-IO2 insertion (see Inserts the IO needle. Follow manufacturer’s guidelines for
Fig. 85-4): selection of the size of the needle
A. The Arrow EZ-IO can be based on patient weight.
inserted into the proximal If the 5-mm mark is not visible, the
tibia, the distal tibia, or the needle is withdrawn and a larger
humerus. size is attached and advanced into
B. Connect the appropriately the insertion site.
sized needle to the power
driver (Fig. 85-5).
C. Palpate the appropriate
landmark.
D. Stabilize the limb and
advance the needle at a
90-degree angle through the
skin until the bone is felt.
E. When the 5-mm mark is
visible, apply steady, firm
pressure and activate the power
driver until the needle hub
contacts the skin or a sudden
decrease in resistance is noted.
F. Stabilize the needle and
remove the power driver.
G. Remove the stylet from the
needle by turning it
counterclockwise while
withdrawing it.
(Level M*)

PD
AD
LD
Figure 85-5 EZ-IO needle sets. (From Day MW: Intraosseous devices for intravenous access in
adult trauma patients, Crit Care Nurs 31[2]:76–90.)

10. Secure the IO catheter or needle Prevents the needle from moving.
as recommended by the
manufacturer.
(Level M*)
11. Apply a sterile, occlusive Promotes a sterile environment.
dressing.
12. Confirm placement by: Verifies needle placement in the Follow institutional standards.
A. Aspirating blood or marrow. marrow cavity. If blood specimens are needed, attach
B. Flushing the needle with a 5-mL syringe and aspirate bone
10 mL of normal saline marrow and blood from the site.8,14
solution. Aspiration of marrow may occlude
the IO device with bone.
Lack of marrow aspirate does not
indicate improper placement.8
Resistance to the manual flush will be
felt but does NOT indicate incorrect
placement.
If swelling or infiltration is observed,
remove the device and attempt IO
access in another bone.7
13. Securely attach the tubing and Secures the tubing system. Care should be taken when
tape it to the patient’s skin. positioning and transferring the
patient to avoid dislodgment of the
IO device.
14. Infuse IV fluids with a pressure IO lines often need pressure to ensure The resistance of fluid flow through
bag or manual pressure. adequate flow. an IO may exceed the pressure
limits on infusion pumps.
15. If the patient is alert, slowly Promotes comfort. The infusion of fluids and
(over 60 seconds)8 infuse medications can be painful to the
lidocaine (without epinephrine) conscious patient.
into the IO device as prescribed.


16. Administer prescribed Following medications with a saline Resistance to the manual flush will be
medications via the IO device solution flush ensures delivery of felt but does NOT indicate incorrect
and follow each medication with medication into the marrow cavity placement.
a 5–10-mL normal saline solution and blood vessels. If swelling or infiltration is observed,
flush as prescribed.16 (Level E*) remove the device and attempt IO
access in another bone.7
receptacles.
18. HH
Procedure for Removal of the Intraosseous Access
1. HH
2. PE
3. Replace the IO site within 24 IO access is a temporary access site. For minimization of the risk of
hours or as soon as venous access complications, the IO device should
is obtained. be removed as soon as alternate
vascular access is obtained or
within 24 hours.
4. Follow manufacturer’s guidelines IO device is no longer needed. Follow manufacturer’s guidelines.
for removal: Be sure to pull perpendicular to the
(Level M*) patient’s manubrium, not the
patient’s body.
A. FASTResponder9: Inspect the infusion tube upon
i. Remove the protective removal to ensure that the metal tip
dome and stabilize the has been removed.
target foot with the If the metal tip separates from the
nondominant hand. infusion tube, contact the physician.
ii. Grasp the infusion tube as
close as possible to the tip
and fold it around the
finger.
iii. Pull back in a steady
motion until the infusion
tube is removed.
B. BIG removal3:
i. Grasp the IO device hub
with the red safety latch.
ii. Simultaneously rotate and
withdraw the IO device.
C. Arrow EZ-IO removal2:
i. Attach a 5–10-mL syringe
to the hub of the IO
device.
ii. Stabilize the limb.
iii. Simultaneously rotate
clockwise and pull the IO
device out.
iv. If the hub separates from
the body of the IO device,
grasp the body with large
(8-inch) needle forceps and
simultaneously rotate the
body and pull to remove.6


5. Apply an occlusive, sterile Promotes a sterile environment.
dressing to the site.
receptacles. Precautions. Safely remove sharp
objects.
7. HH

• Access to venous circulation for the administration of • Inability to infuse medications or fluids
medications and fluids • Infection
• The IO line remains patent • Extravasation
• The tip of the IO needle lies in the marrow cavity • Complications such as compartment syndrome,
• The insertion site, catheter, and systemic circulation fractures, osteomyelitis, and necrosis
remain free of infection • Pain

interventions.
1. Observe for signs and symptoms Identifies possible complications. • Edema around the site
of infection. • Pain, tenderness, or erythema
around the site
• Drainage from the site
• Increased temperature
2. Observe the IO insertion site for A misplaced device or excessive • Increased circumference of the
signs and symptoms of movement after insertion may lead extremity
extravasation or compartment to a leakage of fluids outside of the • Increased pain in the extremity
syndrome. marrow cavity and can impair • Change in extremity sensation,
circulation to the extremity. temperature, or pulses
Documentation
• Patient and family education • Type and amount of anesthetic used
• Preprocedure verification and timeout • Assessment of insertion site
• Site of insertion • Method of securing the IO needle in place
• Number of IO insertion attempts • Problems encountered during or after the procedure
• Sites of previous IO insertion attempts • Pain assessment, interventions, and effectiveness
• Brand of the IO device inserted and, if appropriate, • Vital signs and cardiac rhythm
manufacturer’s needle description • Date and time the IO device is removed
• Confirmation of IO needle placement • Assessment of site after the IO device is removed
• Date and time of insertion

85 Intraosseous Devices 757.e1
References 14. Hunsaker S, Hill D: Intraosseous vascular access for

1. Ahrens KL, et al: Successful computed tomography alert patients. Am J Nurs 113(11):34–39, 2013.
angiogram through tibial intraosseous access: A case 15. Leidel BA, et al: Comparison of intraosseous versus
report. J Emerg Med 45(2):182–185, 2012. central venous vascular access in adults under
2. Arrow EZ-IO Training Manual: Retrieved November 23, resuscitation in the emergency department with
2014 from <http://www.teleflex.com/en/usa/ezioeducation/ inaccessible peripheral veins. Resuscitation 83:40–45,
documents/EZ-IO_SAFIOVA-M-607%20Rev%20B 2012.
-PrintVersion.pdf>. 16. Neumar RW, et al: Part 8: Adult advanced cardiac life
3. Pediatric Bone Injection Gun Instructions: Retrieved support—2010 American Heart Association guidelines
November 23, 2014 from <http://www.waismed.com/ for cardiopulmonary resuscitation and emergency
Documents/Brochures/wwUSA%2015062008.pdf>. cardiovascular care science. Circulation 122(Suppl 3):
4. Buck ML, Wiggins BS, Sesler JM: Intraosseous drug S729–S767, 2010.
administration in children and adults during 17. Ong MEH, et al: An observational, prospective study
cardiopulmonary resuscitation. Ann Pharmacother comparing tibial and humeral intraosseous access using
41:1679–1686, 2007. the EZ-IO. Am J Emerg Med 27:8–15, 2009.
5. Consortium of Intraosseous Vascular Access in Healthcare 18. Reades R, et al: Comparison of first attempt success
Practice: Recommendations for the use of intraosseous between tibial and humeral intraosseous insertions during
vascular access for emergent and nonemergent situations out-of-hospital cardiac arrest. Prehosp Emerg Care
in various healthcare settings: A consensus paper. J Emerg 15:278–281, 2010.
Nurs 36:551–556, 2010. 19. Reiter D, Strother CG, Weingart SD: The quality of
6. Day MW: Intraosseous devices for intravenous access in cardiopulmonary resuscitation using supraglottic airways
adult trauma patients. Crit Care Nurse 31(2):76–90, 2011. and intraosseous devices: A simulation trial. Resuscitation
7. Dev SP, et al: Insertion of an intraosseous needle in 84:93–97, 2013.
adults. N Engl J Med 370(24):e35, 2014. 20. Strandberg G, et al: Analysis of intraosseous samples
8. Faminu F: Intraosseous vascular access. Nursing using point of care testing technology: An experimental
44(8):60–64, 2014. study in the anaesthetised pig. Resuscitation 83:1381–
9. Pyng Medical: FASTResponder sternal IO. Retrieved 1385, 2012.
November 23, 2014 from <http://www.pyng.com/ 21. Voight J, Waltzman M, Lottenberg L: Intraosseous
fastresponder>. vascular access for in-hospital emergency use: A
10. Fetissof H, et al: Amines on intraosseous vascular access: systematic clinical review of the literature and analysis.
A case of skin necrosis. Ann Fr Anesth Reanim 32: Pediatr Emerg Care 28:185–199, 2012.
e89–e90, 2013. Additional Readings
11. Fowler RL, Lippman MJ: Benefits vs. risks of
intraosseous vascular access. WebM&M: Morbidity and Brenner T, et al: Comparison of two intraosseous infusion
mortality rounds on the web. Retrieved September 18, systems for adult emergency medical use. Resuscitation
2014 from <http://webmm.ahrq.gov/case.aspx?caseID 78:314–319, 2008.
=331>. Gunal I, Kose N, Gurer D: Compartment syndrome after
12. Grossman VA: Hot topics: CT contrast and intraosseous intraosseous infusion: An experimental study in dogs.
lines: Friends or enemies? J Radiol Nurs 32:41–44, 2013. J Pediatr Surg 31(11):1491–1493, 1996.
13. Holleran RS: Procedure 67 intraosseous access. In Proehl
J, editor: Emergency nursing procedures, ed 4, St. Louis,
2009, Elsevier.
PROCEDURE
86
Midline Catheters
Debra L. Wiegand
PURPOSE: Midline catheters are peripheral catheters used to provide venous
access for patients who have limited peripheral venous access and who require
intravenous (IV) therapy for approximately 2 weeks. Midline catheters can be used
to administer any infusate that can be administered peripherally such as IV fluid
therapy, analgesics, and specific antibiotics.
PREREQUISITE NURSING • Midline catheters are available as single-lumen or double-

KNOWLEDGE lumen catheters.
• A midline catheter can be inserted with or without the use
• Successful completion of specialized education in ultra- of the modified Seldinger technique. When a modified
sound-guided midline catheter insertion, utilizing a modi- Seldinger technique is used, venous access is achieved
fied Seldinger technique, and demonstrated competency with a microintroducer needle. A guidewire is introduced
are necessary.3,4 In addition, opportunities to demonstrate and threaded into the microintroducer needle which is
clinical competency on a regular basis (e.g., yearly) may then removed and the dilator/introducer is inserted over
be needed. the guidewire. The dilator and guidewire are removed,
• Knowledge of the principles of sterile technique is essen- leaving the introducer in the vein to allow for passage of
tial. the midline catheter into the vein. Once the midline cath-
• Knowledge is necessary of the anatomy and physiology eter is in place, the introducer is removed.
of the vasculature and adjacent structures in the upper • There are alternate midline placement techniques and the
extremity, neck, and chest. manufacturer’s guidelines should be followed.
• Knowledge is necessary of assessment of upper extremity • A variety of safety-engineered introducers are available
venous access using ultrasound. and should be used to reduce the risk for blood exposure
• Midline catheters do not enter the central vasculature. and needlestick injury.4,5,7
• Midline catheters are inserted into the upper arm via the • Ultrasound guidance is recommended to place midline
basilic, cephalic, or brachial vein (see Figure 87-1); the catheters if the technology is available; it is associated
catheter tip is located at or near the level of the axilla and with improvement in insertion success rates, reduced
below the level of the shoulder.5 number of needle punctures, and decreased insertion com-
• The basilic vein is often the larger vessel and is the vein plication rates.4
of choice for insertion of a midline catheter.5 • Longitudinal or transverse views can be used when placing
• Patient indications for the insertion of a midline catheter the midline catheter with ultrasound. The needle tip should
include administration of IV solutions, analgesic infu- remain in view at all times. If the tip of the needle cannot
sions, and specific antibiotics. be visualized, the probe, not the needle, should be moved
• Therapies that should not be administered through a midline to reestablish visibility.4
catheter include vesicant therapy and parenteral nutrition.5
• If IV access is needed for more than 2 weeks, consider EQUIPMENT
placement of a central vascular access device (CVAD).5
• Midline catheter placement should be avoided in an • Catheter-insertion kit
extremity on the same side that the patient had a mastec- • Midline catheter of choice
tomy with axillary node resection, fistula, shunt, or radial • Single-use tourniquet
artery surgery. • Sterile and nonsterile measuring tape
• Relative contraindications to placement of a midline cath- • Waterproof underpad/linen saver
eter include upper extremity edema, AV fistulas, and a • Sterile gown
prolonged bleeding time.5 • Head cover
• Mask
• Goggles or eye protection
• Two pairs of nonpowdered sterile gloves
• Sterile drapes and towels, including one fenestrated full bar-
practice nurses, and other healthcare professionals (including critical care rier drape
nurses) with additional knowledge, skills, and demonstrated competence per • Antiseptic solution (e.g., 2% chlorhexidine–based prepa-
professional licensure or institutional standard. ration)
758
86 Midline Catheters 759
• 10-mL vial of heparin (concentration and use per institu- PATIENT ASSESSMENT AND
tional standard) PREPARATION
• 30-mL vial of normal saline (NS) solution
• Needleless connector with/without short extension tubing Patient Assessment
• One to three 10-mL, 20-gauge, 1-inch needle syringes • Assess the patient’s medical history for mastectomy with
(blunt needles recommended), depending on the number axillary node dissection, fistula, shunt, or radial artery sur-
of lumens gery. Rationale: Midline catheter insertion should be avoided
• Sterile 4 × 4 gauze pads or sponges in extremities affected by these conditions to preserve veins
• Sterile 2 × 2 gauze pads or sponges for future needs and because the risk for complications is
• Sterile, transparent, semipermeable dressing increased.
• Bedside ultrasound machine with vascular probe • Obtain the patient’s baseline vital signs. Rationale: Pro-
• Sterile ultrasound probe cover vides baseline data.
• Sterile ultrasound gel • Assess the vasculature of the antecubital space of both
• Catheter securement device arms, focusing on the basilic and cephalic veins. A tour-
Additional equipment, to have available as needed, includes niquet should be applied on the mid–upper arm for vein
the following: assessment and then removed. Rationale: Proper vein
• One 1-mL, 25-gauge, 5 8 -inch needle syringe (if intrader- selection increases the success of insertion and decreases
mal lidocaine is used) the incidence of postinsertion complications.
• 1% lidocaine without epinephrine, or 1 to 2 mL of a eutec- • Determine the patient’s allergy history (e.g., lidocaine,
tic mixture of local anesthetics (EMLA) cream heparin, EMLA cream, antiseptic solutions, tape, latex).
Rationale: Assessment decreases the risk for allergic
PATIENT AND FAMILY EDUCATION reactions with avoidance of known allergenic products.
• Explain the reason for the midline catheter, the benefits Patient Preparation
and risks associated with the catheter, and the alternatives • Verify that the patient is the correct patient using two
to midline catheter placement. Rationale: Clarification identifiers. Rationale: Before performing a procedure, the
of information is an expressed patient need and helps nurse should ensure the correct identification of the patient
diminish anxiety, enhance acceptance, and encourage for the intended intervention.
questions. • Ensure that the patient and family understand preprocedural
• Describe the major steps of the procedure, including the teaching. Answer questions as they arise, and reinforce
patient’s role in the procedure. Rationale: Explanation information as needed. Rationale: Understanding of previ-
decreases patient anxiety, enhances cooperation, provides ously taught information is evaluated and reinforced.
an opportunity for the patient to voice concerns, and pre- • Ensure that informed consent has been obtained. Ratio-
vents accidental contamination of the sterile field and nale: Informed consent protects the rights of the patient
equipment. and allows the patient to make a competent decision.
• Instruct the patient and family to refuse injections, veni- • Perform a preprocedure verification and timeout. Ratio-
puncture, and blood pressure measurements on the arm nale: Ensures patient safety.
with the midline catheter. Rationale: The risk for • Assist the patient to a supine position with the head of bed
catheter-related complications and catheter damage is elevated. Rationale: Promotes a position of comfort.
minimized. • Measure the mid–upper arm circumference of the selected
• Provide appropriate patient and family discharge educa- extremity. Rationale: Measurement provides a baseline
tion regarding the care and maintenance of the midline for evaluation of suspected catheter-associated venous
catheter if the patient will be discharged with the midline thrombosis. Post-placement presence of pitting or non-
catheter. Rationale: Education reduces the risk for pitting edema may be indicative for venous thrombosis.
catheter-related complications from lack of knowledge • Stabilize the position of the arm with a towel or pillow.
and skills needed to care for the midline catheter after Rationale: Stabilization increases patient comfort, secures
discharge. the work area, and facilitates access to the selected vein.
Procedure for Peripherally Inserted Central Catheter

radiology.
2. HH
3. PE
selected arm.
5. Determine the anatomy of the Helps ensure proper placement of the Ultrasound is used to assess veins for
access site. midline catheter and guides the area vessel size, path, round shape, and
(Level E*) to be prepped.4,5 compressibility.
6. Wash the insertion area with soap Prepares insertion site.
and water.
7. Discard used supplies and remove Discards used supplies.
gloves.
8. HH
9. Don head cover and mask.
10. Open the midline catheter Maintains aseptic technique; prepares
insertion tray and drop the the work area, including
remaining sterile items onto the procurement of all necessary
sterile field. equipment; avoids interruption of
the procedure and contamination of
the work area.
11. HH
12. Apply sterile gown and sterile Midline catheter insertion is a sterile Personal protective equipment (e.g.,
gloves. procedure. head cover, mask, goggles) is
needed as well as sterile equipment.
Blood splashing may occur with the
use of guidewires, stylets, and
breakaway or peel-away
introducers.
13. Prepare the catheter according to Each manufacturer recommends a
manufacturer’s recommendations. specific preparation protocol for
each type of catheter.
14. Fill the 10-mL syringe with Prepares the equipment. If inserting a double-lumen catheter,
normal saline. Add the needleless prime the additional lumen of the
connector to the short extension catheter with normal saline.
tubing and prime it with normal
saline. Leave the syringe
attached.
15. Prepare the site with a 2% Limits the introduction of potentially
chlorhexidine–based antiseptic infectious skin flora into the vessel
solution.4,5,9 during the puncture.
seconds.
B. Allow the antiseptic to remain
on the insertion site and to
air-dry completely before
catheter insertion.4,5,9
(Level D*)
Procedure for Peripherally Inserted Central Catheter—Continued

17. HH
18. Apply the tourniquet snugly on Provides vasodilation of the vein for Constriction should effectively cause
the upper arm away from the venipuncture. venous distention without arterial
sterile field. occlusion.
19. HH
20. Apply a new pair of sterile Midline catheter insertion is a sterile
gloves. procedure.
21. Instruct the patient to lift his or Maintains the sterile field and Ultrasound scan technology may be
her arm; place a sterile drape facilitates aseptic technique. used to assist with catheter
underneath and the fenestrated Maximal sterile barrier precautions insertion.
drape over the entire patient, are recommended for midline
leaving the venipuncture site catheter placement.5
exposed. Place a sterile 4 × 4
gauze pad over the tourniquet.
22. Instruct the patient to turn his or Prevents contamination of the field by If the patient is not intubated ensure
her head away from the insertion organisms from the patient’s that the patient has on a mask.
site. respiratory tract.
23. Inject a skin weal of Provides local anesthesia for Patients report less pain when a local
approximately 0.5 mL of 1% venipuncture with large-gauge anesthetic agent is used before
lidocaine without epinephrine at needles and introducers. venipuncture.2,3
or adjacent to the venipuncture Local anesthesia should be Lidocaine may produce stinging,
site. administered with insertion of a burning, obscuring the vein, or
(Level B*) midline catheter.2–6,8 venospasm.
The use of EMLA (a topical
anesthetic cream) before
venipuncture has been
researched.2,6,8
If it is used, manufacturer’s
recommendations should be
followed.
24. Perform the venipuncture Catheters vary according to design Relocate the intended vein with the
according to catheter design and and introducing techniques. ultrasound probe, and use the
manufacturer’s instructions. ultrasound images to guide the
insertion process.4,5
25. Perform the modified Seldinger Use of a guidewire enhances the Place a finger over the opening of the
technique: advancement of the dilator/ catheter to limit blood loss and risk
A. Insert a microintroducer introducer. for air embolism.
needle through the skin and If no blood return is found, the
into the vein and confirm procedure should be terminated and
venous blood return. an alternate access site selected.
B. Insert the guidewire at least A small skin nick may be performed
10 cm into the at the venipuncture site to facilitate
microintroducer needle, not to the advancement of the dilator/
exceed a position beyond the introducer.
axillary line.5 If a scalpel is not provided in the
C. Remove the IV midline catheter insertion kit, a No.
microintroducer needle and 11 blade should be used.
insert the dilator/introducer
over the guidewire.
D. Gently advance the dilator/
introducer, while securing the
guidewire, until the tip is well
within the vein.


E. Slowly advance the catheter Place a finger over the opening of the
through the introducer to the introducer to limit blood loss and
measured length. the risk for air embolism.
F. Insert the catheter. Establishes venous access.
26. Release the tourniquet with sterile Continued vasodilation may not be
technique (e.g., with a sterile 4 × necessary for catheter advancement.
4 gauze pad).
27. Pull the introducer out of the vein The introducer sheath is not needed Methods of removing the introducer
and away from the insertion site once the catheter is in place. vary according to the manufacturer.
and remove.
28. Measure the length of the Ensures proper catheter tip position. The ultrasound can guide placement.
catheter remaining outside the
skin and reposition, if necessary,
to the predetermined length.
29. Attach the primed extension Use of extension tubing provides
tubing with the needleless easier access to the catheter and
connector to the catheter; aspirate reduces local trauma at the insertion
for evidence of blood, and flush site.
with normal saline with use of a Aspiration affirms patency of the
push/pause technique. catheter.
The push/pause technique during
flushing optimizes catheter long-
term patency.4,5
30. Inject the recommended amount Maintains catheter patency and Recommendations vary regarding the
and concentration of heparin as prevents backflow of blood in the use, amount, and concentration of
prescribed into the catheter, catheter. heparin to maintain catheter
clamp the extension tubing, and patency.1,9
remove the syringe. Contraindicated in persons with
Repeat the procedure with use of known allergies to heparin.
a double-lumen catheter. Institutional standards should be
followed.
31. Secure the catheter at the Prevents inward or outward migration Follow institutional standards.
insertion site by applying an of the catheter.
alternate catheter securement
device.
32. Apply a dressing: Decreases catheter-related infections. A 2 × 2 gauze pad can be folded and
A. If bleeding is noted, cover the placed immediately below the
insertion site with a sterile, 2 insertion site to act as a “wick” for
× 2 gauze pad and then cover any drainage in the first 24 hours.
the site with a sterile, If a chlorhexidine impregnated
transparent, semipermeable sponge or gel dressing is applied at
dressing.4 the insertion site, the dressing can
B. If there is no bleeding, omit remain for 7 days before changing.
the gauze and apply a
chlorhexidine impregnated gel
dressing or sponge to the site
and then cover it with a sterile
membrane dressing.4
33. Remove PE and sterile Reduces the transmission of Ensure that sharps are safely
equipment, and discard used microorganisms; Standard discarded.
supplies in appropriate Precautions.
receptacles.
34. HH

• The midline catheter is successfully inserted • Pain or discomfort during the procedure
• The midline catheter remains patent • Complications on insertion, such as catheter
• The insertion site and upper extremity remain free of embolism, arterial puncture, and nerve (brachial
phlebitis and thrombophlebitis plexus) injury
• The insertion site, catheter, and systemic circulation • Complications after insertion, such as phlebitis,
remain free of infection thrombophlebitis, catheter occlusion, infection (e.g.,
insertion site, catheter, systemic), and infiltration

interventions.
1. Observe the dressing and insertion Postinsertion bleeding may occur in • Excessive bleeding
site every 30 minutes for the first 4 patients with coagulopathies or with • Hematoma
hours after insertion. arterial punctures, multiple attempts
at venipuncture, or use of the
through-the-needle introducer
design for insertion.
2. Assess the insertion site and upper Mechanical phlebitis is the most • Pain along the vein
extremity every shift for signs and common complication within the • Edema at the puncture site
symptoms of phlebitis, first 72 hours after insertion. • Erythema
thrombophlebitis, or infiltration. Thrombophlebitis may occur at any • Ipsilateral swelling of the arm,
time after catheter insertion. neck, or face
• Venous occlusion (changes in arm
circumference >2 cm from
baseline)
• Infiltration
3. Assess the catheter for venous Verifies the position of the catheter in • Catheter occlusion (failure to
blood return and patency before the vascular space and patency obtain blood return on aspiration
initiating infusions. before initiation of infusions. or resistance to irrigation)
A. Connect a 10-mL syringe filled
with 10 mL of normal saline to
the extension tubing.
B. Release the clamp and aspirate
slowly to verify blood return.
C. Flush with 10 mL of NS (with
a push/pause technique) and
then administer the infusion.
4. Assess the catheter for dislodgment The catheter may no longer be • Change in external catheter length
or migration by measuring the properly positioned if the length of • Catheter occlusion
length of the external catheter. the external catheter is longer or • Pain or burning during infusions
shorter than the length measured at • Infiltration
the time of insertion.

5. If there was insertional bleeding, Policies may vary regarding the type • Redness, warmth, hardness,
the initial dressing should be left of dressing and frequency of tenderness or pain, or swelling at
in place for 24 hours.4 After this: dressing changes after the initial the insertion site
A. Assess the insertion site and dressing change. • Presence of purulent drainage from
upper forearm while the insertion site
performing a sterile dressing • Local rash or pustules
change.
B. Transparent, semipermeable
dressings should be changed at
least weekly.9
C. Sterile gauze dressings should
be changed every 48 hours.4,5
E. Dressings should be changed if
they become damp, loosened,
or visibly soiled.9
(Level E*)
6. Monitor the insertion site and the The incidence of infection related to • Redness, warmth, hardness,
patient for signs and symptoms of the catheter may result from failure tenderness or pain, or swelling at
local or systemic infection. to maintain asepsis during insertion, the insertion site
failure to comply with dressing • Presence of purulent drainage from
change protocols, the insertion site
immunosuppression, frequent • Local rash or pustules
access to the catheter, and long- • Fever, chills, or elevated white
term use of a single IV access site. blood cell count
• Nausea and vomiting
7. Avoid measuring blood pressure, Minimizes the risk for catheter-related
performing venipuncture, or complications and catheter damage.
administering injections in the
extremity with a midline catheter.
Consider placing a sign at the
patient’s bedside to alert clinicians
to avoid use of the extremity with
the midline catheter.
8. Follow institutional standards for Identifies the need for pain • Continued pain despite pain
Documentation
• Patient and family education • The location of the midline catheter insertion site and
• Completion of informed consent the vein accessed
• Preprocedure verification and timeout • The method of securing the catheter
• Known allergies • Confirmation of the catheter tip placement
• Mid–upper arm circumference • Problems encountered during or after the procedure
• Date and time of the procedure or nursing interventions
• Catheter type, size, and length, including the length of • Patient tolerance of the procedure
catheter remaining outside the insertion site • Pain assessment, interventions, and effectiveness
• Type and amount of local anesthetic (if used) • Vital signs and cardiac rhythm
• Assessment of the insertion site

86 Midline Catheters 765.e1
References 7. National Committee on Safer Needle Devices: Using safer

1. Phillips L, Gorski LA: Manual of IV therapeutics: needle devices: The time is now, Washington, DC, 1997,
Evidence based practice for infusion therapy, ed 6, National Committee on Safer Needle Devices.
Philadelphia, 2014, F.A. Davie. 8. Nott M, Peacock J: Relief of injection pain in adults:
2. Fetzer SJ: Reducing venipuncture and intravenous insertion EMLA cream for 5 minutes before venipuncture.
pain with eutectic mixture of local anesthetic: Anaesthesia 45:772–774, 1990.
A meta-analysis. Nurs Res 51:119–124, 2002. 9. O’Grady NP, et al: Guidelines for the prevention of
3. Hussey VM, Poulin MV, Fain JA: Effectiveness of intravascular catheter-related infections, Atlanta (FA),
lidocaine hydrochloride on venipuncture sites. AORN J 2011, Centers for Disease Control and Prevention.
66:472–475, 1997.
4. Infusion Nurses Society: Policies and procedures Additional Readings
for infusion nursing, ed 5. Infusion Nurses Society, Alexander M, et al, editors: Infusion Nurses Society: Infusion
2016. Nursing: An evidence-based approach, ed 3, St. Louis,
5. Infusion Nurses Society: Infusion nursing standards of 2010, Saunders.
practice. J Infus Nurs 34(1S):S6–S110, 2016. Weinstein S, Hagle ME: Plumer’s principles and practice of
6. Lander J, et al: Evaluation of a new topical anesthetic infusion therapy, ed 9, Philadelphia, 2014, Wolters Kluwer
agent: A pilot study. Nurs Res 45:50–52, 1996. Health.
PROCEDURE
87
Peripherally Inserted
Central Catheter
Debra L. Wiegand
PURPOSE: Peripherally inserted central catheters are used to deliver central
venous therapy to provide venous access for patients who require infusates that are
not peripherally compatible (e.g., vesicants, irritants). Peripherally inserted central
catheters can be used for all types of infusion therapy including chemotherapy, total
parenteral nutrition, analgesia, blood products, intermittent inotropic medications,
and long-term antibiotics.
PREREQUISITE NURSING • Patient indications for the insertion of a PICC are not
KNOWLEDGE limited to inpatient therapies. A PICC is also placed for
patients who require intravenous (IV) therapy in the
• Successful completion of specialized education in home setting for chronic heart failure, cancer treat
ultrasound-guided peripherally inserted central catheter ment, chronic pain management, nutritional support, fluid
(PICC) insertion utilizing a modified Seldinger technique replacement (e.g., hyperemesis gravidarum) and long-
and demonstrated competency are necessary.3,4 In addi- term antibiotics.
tion, opportunities to demonstrate clinical competency on • PICCs may be preferred over percutaneously inserted
a regular basis (e.g., yearly) may be needed. central venous catheters for patients with trauma of the
• Knowledge of the principles of sterile technique is essen- chest (e.g., burns) or certain pulmonary disorders (e.g.,
tial. chronic obstructive pulmonary disease, cystic fibrosis).7
• Knowledge is necessary of the anatomy and physiology PICCs eliminate the risks associated with insertion of
of the vasculature and adjacent structures in the upper percutaneously inserted central venous catheters in the
extremity, neck, and chest. neck or chest (e.g., pneumothorax).1
• Knowledge is necessary of assessment of upper-extremity • PICCs are contraindicated in patients with sclerotic veins,
venous access using ultrasound. chronic kidney disease stages 4 and 5, lymphedema, mas-
• A patient receiving a PICC should have a peripheral vein tectomy with lymph node dissection, arteriovenous graft,
that can accommodate a 22-gauge microintroducer needle fistula, radial artery surgery, or extremities affected by
to perform the modified Seldinger technique. The smallest cerebral vascular accident. Other access devices may be
device in the largest vein allows for maximal hemodilu- a better choice in patients with altered upper extremity
tion of the infusate and minimizes the risk of phlebitis skin integrity, or upper extremity fractures where PICC
and thrombosis.1 The catheter-vein ratio should be 45% complications could compromise wound healing.
or less.5 • The most common complications associated with PICCs
• The basilic, medial cubital, cephalic, and brachial veins are phlebitis, thrombosis, and catheter occlusion.5,9
should be considered for cannulation with a PICC (Fig. • A variety of PICCs are available for use. PICCs are flex-
87-1). The basilic vein is the larger vessel and is the vein ible catheters that are made of silicone or polyurethane.
of choice for insertion of a PICC. Brachial veins are a Catheter diameters range from 2 Fr to 6 Fr, and the cath-
second choice due to close proximity to the brachial artery eter length ranges from 40 cm to 65 cm. For adults, 4 Fr
and nerve structures. The cephalic vein has been associ- to 5 Fr catheters that are 60 cm in length are typical.
ated with an increased risk of thrombosis. Patient prefer- • PICCs are available as single-lumen, double-lumen, and
ence for arm selection (e.g., nondominant hand, lifestyle, triple-lumen catheters, with and without valves. Some
activity restrictions, ability to care for the catheter) should PICCs are designed to handle power injections (e.g., con-
be considered with selection of the insertion site.2 Once trast media for computed tomographic scans).
inserted, the PICC is advanced to the lower segment of • A PICC can be inserted with or without the use of a modi-
the superior vena cava at or near the cavoatrial junction.4,5 fied Seldinger technique. When a modified Seldinger tech-
nique is used, venous access is achieved with a small-gauge
(20- or 22-gauge) peripheral IV catheter. Once the IV
practice nurses, and other healthcare professionals (including critical care catheter is inserted, the stylet is removed and the guide-
nurses) with additional knowledge, skills, and demonstrated competence per wire is threaded through the IV catheter. The IV catheter
professional licensure or institutional standard. is then removed, and the dilator/introducer is inserted over
766
87 Peripherally Inserted Central Catheter 767
Figure 87-1 Location of the veins of the right shoulder and upper arm. (From Jacob SW, Fran-
cone CA: Elements of anatomy and physiology, ed 2. Philadelphia, 1989, Saunders.)
the guidewire. The dilator and guidewire are removed, technology using ECG and Doppler can be utilized to
leaving the introducer in the vein to allow for passage of further assist the clinician in confirming tip location in the
the PICC into the vein. Once the PICC is in place, the superior vena cava. This technology can be used in lieu
introducer is removed. Care must be taken with the use of of chest x-ray for verification of tip location.
a guidewire. Although advancement of the introducer is • Longitudinal or transverse views can be used when placing
enhanced by the firmness provided by the guidewire, the the PICC with ultrasound. The needle tip should remain
guidewire can inadvertently traumatize the vessel.5 in view at all times. If the tip of the needle cannot be
• There are alternate PICC placement techniques and the visualized, the probe, not the needle, should be moved to
manufacturer’s guidelines should be followed. reestablish visibility.4
• A variety of safety-engineered introducers are available
and should be used to reduce the risk for blood exposure EQUIPMENT
and needlestick injury.4,5,7
• PICCs can be placed at the patient’s bedside, in interven- • Catheter-insertion kit
tional radiology, or in specialized rooms dedicated for • PICC catheter of choice
PICC insertions. • Single-use tourniquet
• Ultrasound guidance is recommended to place PICCs if • Sterile and nonsterile measuring tape
the technology is available and it is associated with • Waterproof underpad/linen saver
improvement in insertion success rates, reduced number • Sterile gown
of needle punctures, and decreased insertion complication • Head cover
rates.4 • Mask
• Ultrasound scan technology can be used to assist with vein • Goggles or eye protection
assessment and PICC insertion (Fig. 87-2). Tip-locating • Two pairs of nonpowdered sterile gloves
A B
Figure 87-2 Use of ultrasound scan technology to assist with vein location. A, Ultrasound scan
probe is positioned over the insertion site. B, Depiction of ultrasound scan–assisted catheter inser-
tion. (Courtesy of Bard Access Systems, Salt Lake City.)
• Sterile drapes and towels, including one fenestrated full bar- decreases patient anxiety, enhances cooperation, provides
rier drape an opportunity for the patient to voice concerns, and pre-
• Antiseptic solution (e.g., 2% chlorhexidine–based prepa- vents accidental contamination of the sterile field and
ration) equipment.
• 10-mL vial of heparin (concentration and use per institu- • Instruct the patient and family to refuse injections, veni-
tional standard) puncture, and blood pressure measurements on the arm
• 30-mL vial of normal saline (NS) solution with the PICC. Rationale: The risk for catheter-related
• Needleless connector with/without short extension tubing complications and catheter damage is minimized.
• One to three 10-mL, 20-gauge, 1-inch needle syringes (blunt • Provide appropriate patient and family discharge educa-
needles recommended), depending on the number of lumens tion regarding the care and maintenance of the PICC if
• Sterile 4 × 4 gauze pads or sponges the patient will be discharged with the PICC in place.
• Sterile 2 × 2 gauze pads or sponges Rationale: Education reduces the risk for catheter-related
• Sterile, transparent, semipermeable dressing complications from lack of knowledge and skills needed
• Bedside ultrasound machine with vascular probe to care for the PICC after discharge.
• Sterile ultrasound probe cover
• Sterile ultrasound gel PATIENT ASSESSMENT AND
• Catheter securement device PREPARATION
the following: Patient Assessment
• One 1-mL, 25-gauge, 5 8 -inch needle syringe (if intrader- • Assess the patient’s medical history for mastectomy,
mal lidocaine is used) fistula, shunt, CVA, or radial artery surgery. Rationale:
• 1% lidocaine without epinephrine or 1 to 2 mL of eutectic PICC insertion should be avoided in extremities affected
mixture of local anesthetics (EMLA) cream (optional) by these conditions to preserve veins for future needs and
because the risk for complications is increased.
PATIENT AND FAMILY EDUCATION • Obtain the patient’s baseline vital signs and cardiac
rhythm. Rationale: Cardiac dysrhythmias can occur if the
• Explain the reason for the PICC, the benefits and risks catheter is advanced into the heart. Baseline data facilitate
associated with the catheter, and the alternatives to PICC the identification of clinical problems and the efficacy of
placement. Rationale: Clarification of information is an interventions.
expressed patient need and helps to diminish anxiety, • Assess the vasculature of the proposed extremity for appro-
enhance acceptance, and encourage questions. priate vessel size, round shape, normal path, and compress-
• Describe the major steps of the procedure, including the ibility. These assessments should be performed without a
patient’s role in the procedure. Rationale: Explanation tourniquet to establish the appropriate vein-to-catheter ratio
A B
Figure 87-3 Measurement of the catheter length for placement in the superior vena cava. A, First,
measure the distance from the selected insertion site to the shoulder. B, Continue measuring from
the shoulder to the sternal notch and add 3 inches (7.5 cm) to this number.
and to ensure there is adequate blood flow around the cath- the selected insertion site to the shoulder (Fig. 87-3, A)
eter in situ. Rationale: Placing a catheter in a healthy vein and from the shoulder to the sternal notch (Fig. 87-3, B).
with adequate blood flow around the catheter will optimize Add 3 inches (7.5 cm, or the measured distance from the
catheter function and decrease the risk of thrombosis. sternal notch to the third intercostal space) to this number
• Determine the patient’s allergy history (e.g., lidocaine, for catheter placement in the superior vena cava. Ratio-
heparin, EMLA cream, antiseptic solutions, tape, latex). nale: Accurate measurement ensures proper tip position
Rationale: Assessment decreases the risk for allergic in the distal portion of the superior vena cava at the
reactions with avoidance of known allergenic products. cavoatrial junction and determines the length of the cath-
eter to be inserted.
Patient Preparation • Measure the mid–upper arm circumference of the selected
• Verify that the patient is the correct patient using two extremity. Rationale: Measurement provides a baseline
identifiers. Rationale: Before performing a procedure, the for evaluation of suspected thrombosis after PICC inser-
nurse should ensure the correct identification of the patient tion. Increases of greater than 2 cm over baseline may be
for the intended intervention. indicative of venous thrombosis. A diagnostic ultrasound
• Ensure that the patient and family understand preprocedural should be obtained.
teaching. Answer questions as they arise, and reinforce • Stabilize the position of the arm with a towel or pillow.
information as needed. Rationale: Understanding of previ- Rationale: Stabilization increases patient comfort, secures
ously taught information is evaluated and reinforced. the work area, and facilitates access to the selected vein.
• Ensure that informed consent has been obtained. Ratio- • Instruct the patient on proper head positioning. The head
nale: Informed consent protects the rights of the patient is positioned to the contralateral side (away from the
and allows the patient to make a competent decision. insertion site) throughout the procedure, except when the
• Perform a preprocedure verification and timeout. Ratio- catheter is advanced from the axillary vein to the superior
nale: Ensures patient safety. vena cava. At this point, the patient is instructed to posi-
• Assist the patient to a supine position with the head of bed tion his or her head toward the ipsilateral side (toward the
elevated. Rationale: Ensures patient comfort. insertion site) with the chin dropped to the shoulder.
• For catheter placement in the superior vena cava, use the Rationale: Proper positioning limits the risk for the cath-
nonsterile measuring tape to measure the distance from eter being inadvertently directed into the jugular vein.
Procedure for Peripherally Inserted Central Catheter

radiology.
2. HH
3. PE
selected arm.
5. Determine the anatomy of the Helps ensure proper placement of the
access site. PICC and guides the area to be
(Level E*) prepped.4,5
6. Wash the insertion area with soap Prepares insertion site.
and water.
7. Discard used supplies and remove Removes and safely discards used
gloves. supplies.
8. HH
9. With the measuring tape, perform Catheters are provided at various This can be guided by ultrasound.
the preinsertion anatomical lengths. Make a note of the required catheter
measurements (see Fig. 87-3). length.
10. Position the tourniquet high on Placement high on the extremity
the upper extremity, near the avoids contamination of the sterile
axilla, but do not constrict venous field.
blood flow at this time.
11. Open the PICC insertion tray and Maintains aseptic technique; prepares
drop the remaining sterile items the work area, including
onto the sterile field. procurement of all necessary
equipment; avoids interruption of
the procedure and contamination of
the work area.
12. HH
13. Apply sterile gown and sterile PICC insertion is a sterile procedure. Personnel protective equipment (e.g.,
gloves. head cover, mask, goggles) is
needed as well as sterile equipment.
Blood splashing may occur with the
use of guidewires, stylets, and
breakaway or peel-away
introducers.
14. Prepare the catheter according to Each manufacturer recommends a
manufacturer’s recommendations. specific preparation protocol for
each type of catheter.
15. Fill the 10-mL syringe with Prepares the system. If inserting a double-lumen or
normal saline. Add the needleless triple-lumen catheter, prime the
connector to the short extension additional lumen(s) of the catheter
tubing and prime it with normal with normal saline.
saline. Leave the syringe
attached.

16. Prepare the site with a 2% Limits the introduction of potentially
chlorhexidine–based antiseptic infectious skin flora into the vessel
solution.4,5,9 during the puncture.
seconds.
B. Allow the antiseptic to remain
on the insertion site and to
air-dry completely before
catheter insertion.4,5,9
(Level D*)
18. HH
19. Apply the tourniquet snugly, Provides vasodilation of the vein for Constriction should effectively cause
approximately 6 inches (15 cm) venipuncture. venous distention without arterial
near the axilla well outside of the occlusion.
sterile field.
21. HH
20. Apply a new pair of sterile PICC insertion is a sterile procedure.
gloves.
22. Instruct the patient to lift his or Maintains the sterile field and Ultrasound scan technology can be
her arm; place a sterile drape facilitates aseptic technique. used to assist with catheter insertion
underneath and the fenestrated (see Fig. 87-2).
drape over the entire patient,
leaving the venipuncture site
exposed. Place a sterile 4 × 4
gauze pad over the tourniquet.
23. Instruct the patient to turn his or Prevents contamination of the field by If the patient is not intubated ensure
her head away from the insertion organisms from the patient’s the patient has on a mask.
site. respiratory tract.
24. Inject a skin weal of Provides local anesthesia for Patients report less pain when a local
approximately 0.5 mL of 1% venipuncture with large-gauge anesthetic agent is used before
lidocaine without epinephrine at needles and introducers. venipuncture.2,3
or adjacent to the venipuncture Local anesthesia should be Lidocaine may produce stinging,
site. administered with insertion of a burning, obscuring of the vein, or
(Level B*) PICC.2–6,8 venospasm.
The use of EMLA (a topical
anesthetic cream) before
venipuncture has been
researched.2,6,8
If it is used, manufacturer’s
recommendations should be
followed.
25. Perform the venipuncture Catheters vary according to design Relocate the intended vein with the
according to catheter design and and introducing techniques. ultrasound probe and use the
manufacturer’s instructions. ultrasound images to guide the
insertion process.4,5


26. Perform the modified Seldinger Use of a guidewire enhances the Place a finger over the opening of the
technique (Fig. 87-4): advancement of the dilator/ catheter to limit blood loss and risk
A. Insert a microintroducer introducer. for air embolism (see Fig. 87-4, 2).
needle or cannula and observe If unable to access the vein, the
for blood return in the procedure should be terminated and
flashback chamber (see Fig. an alternate access site selected.
87-4, 1). A small dermatotomy or nick in the
B. Advance the floppy tipped skin using a sterile scalpel adjacent
guidewire 2 to 4 inches to the guidewire may facilitate the
(5–10 cm) through the needle advancement of the dilator/
or cannula (see Fig. 87-4, 2).5 introducer (see Fig. 87-4, 3).
C. Remove the needle or cannula If a scalpel is not provided in the
back over the guidewire and PICC insertion kit, a No. 11 blade
insert the dilator/introducer should be used.
over the guidewire (see
Fig. 87-4, 4).
D. Gently advance the dilator/
introducer until the tip is well
within the lumen of the vein
(see Fig. 87-4, 5).
E. Remove the guidewire and Place a finger over the opening of the
then the dilator leaving the introducer to limit blood loss and
introducer in place (see the risk for air embolism (see Fig.
Fig. 87-4, 6). 87-4, 6).
F. Insert the catheter Establishes venous access. Sterile forceps may be used to insert
approximately 6–8 inches the catheter into the introducer and
(15–20 cm). advance the catheter into the vein
(see Fig. 87-4, 7).
27. Release the tourniquet with sterile The tourniquet may inhibit catheter
technique (e.g., with a sterile 4 × advancement.
4 gauze pad).
28. Instruct the patient to turn his or Changes the angle of the jugular vein
her head toward the cannulated and decreases the potential for
arm and to drop his or her chin to malpositioning of the catheter in
the chest. the jugular vein.
29. Advance the remainder of the Cardiac dysrhythmias may occur if Never advance the catheter if
catheter until approximately 4 the catheter is advanced into the resistance is felt.
inches (10 cm) remain while heart. Excessive pushing could lead to
observing the heart rate and perforation of the vein, catheter
rhythm. malposition, or pericardial
perforation.
30. Instruct the patient to return his Prevents contamination of the field by
or her head to the contralateral organisms from the patient’s
side (away from the insertion respiratory tract.
site).
31. Pull the introducer out of the vein The introducer sheath should remain Methods of removing the introducer
and away from the insertion site in place until the catheter is vary according to the manufacturer.
and remove (see Fig. 87-4, 8 and properly positioned.
9).
32. Measure the length of the Ensures proper catheter tip position. The catheter should be advanced to
catheter remaining outside the the zero mark.
skin and reposition, if necessary, Optimally, no more than 2 cm should
to the predetermined length. remain external to the insertion site.
Approximately 1 inch (2.5 cm)
of the catheter should remain
externally.
Figure 87-4 Modified Seldinger technique. 1, Insertion of the peripheral intravenous catheter.
2, Advancement of the guidewire through the catheter. 3, Small skin nick to facilitate the advance-
ment of the dilator/introducer. 4, Insertion of the dilator/introducer over the guidewire. 5, Advance-
ment of the dilator/introducer. 6, Removal of the dilator and guidewire. 7, Insertion of the catheter
using sterile forceps. 8, Removal of the introducer. 9, Introducer peeled apart and removed. (Courtesy
Bard Access Systems, Salt Lake City, UT.)

33. Attach the primed extension Use of extension tubing provides Most PICCs have their own extension
tubing (with injection port) to the easier access to the catheter and sets and only require a needleless
catheter; aspirate for evidence of reduces local trauma at the insertion connector.
blood, and flush with normal site.
saline with use of a push/pause Aspiration affirms patency of the
technique. catheter.
The push/pause technique during
flushing optimizes catheter long-
term patency.4,5
34. Inject the recommended amount Maintains catheter patency and Recommendations vary regarding the
and concentration of heparin as prevents backflow of blood in the use, amount, and concentration of
prescribed into the catheter, catheter. heparin to maintain catheter
clamp the extension tubing, and patency.1,9
remove the syringe. Contraindicated in persons with
Repeat the procedure with use of known allergies to heparin.
a double-lumen or triple-lumen Institutional standards should be
catheter. followed.
35. Secure the catheter at the Prevents inward or outward migration Follow institutional standards.
insertion site by applying a of the catheter.
catheter securement device
(Fig. 87-5).
Figure 87-5 PICC Statlock device. 1, Insertion of the wings of the PICC onto the device. 2,
Placement of the device on the forearm. 3, Application of the sterile, transparent, semipermeable
dressing over the device. 4, Device properly secured. (Courtesy Bard Access Systems, Salt Lake City
UT.)

36. Apply a dressing: Decreases catheter-related infections. A 2 × 2 gauze can be folded and
A. If bleeding is noted, cover the placed immediately below the
insertion site with a sterile, insertion site to act as a “wick” for
2 × 2 gauze pad and then any drainage in the first 24 hours.
cover the site with a sterile, If the chlorhexidine impregnated
transparent, semipermeable sponge or gel dressing is applied at
dressing.4 the insertion site, the dressing can
B. If there is no bleeding, omit remain for 7 days before changing.
the gauze and apply a
chlorhexidine impregnated gel
dressing or sponge to the site
and then cover it with a sterile
membrane dressing.4
37. Remove PE and sterile equipment Reduces the transmission of Ensure that sharp objects are safely
and discard used supplies in microorganisms; Standard removed.
38. HH
39. Prepare the patient for a chest Confirms placement of the catheter tip Some PICCs require contrast media
radiograph to determine tip and detects any complications. for good visualization.
location if a tip-locating Infusions should not be initiated until
technology was not used. the catheter tip placement is
confirmed.

• The PICC tip is positioned in the distal portion of the • Pain or discomfort during the procedure
superior vena cava at the cavoatrial junction. • Complications on insertion, such as cardiac
• The PICC remains patent dysrhythmias, pericardial tamponade, air embolism,
• The insertion site and upper extremity remain free of catheter embolism, arterial puncture, and nerve
phlebitis and thrombophlebitis (brachial plexus) injury
• The insertion site, catheter, and systemic circulation • Complications after insertion, such as phlebitis,
remain free of infection thrombophlebitis, thrombosis, infection (e.g.,
insertion site, catheter, systemic), and infiltration

interventions.
1. Observe the patient for signs or Cardiac dysrhythmias may occur if • Cardiac dysrhythmias
symptoms of cardiac the catheter is advanced into the • Hemodynamic instability (changes
dysrhythmias and pericardial heart. in vital signs, level of
tamponade during the procedure. Pericardial tamponade may occur if consciousness, peripheral pulses,
If cardiac dysrhythmias occur, the catheter penetrates the atrium. narrow pulse pressure, jugular
pull the catheter back and venous distention)
reassess the patient.
2. Assess the patient and obtain the Ensures accurate catheter tip • Abnormal chest radiographic
chest radiographic report placement and aids in identification report
confirming proper catheter tip of potentially life-threatening • Change in lung sounds
placement before initiating any complications. • Chest pain
intravenous solutions. • Respiratory distress

3. Observe the dressing and Postinsertion bleeding may occur in • Excessive bleeding
insertion site every 30 minutes patients with coagulopathies or with • Hematoma
for the first 4 hours after arterial punctures, multiple attempts
insertion. at venipuncture, or use of the
through-the-needle introducer
design for insertion.
4. Assess the insertion site and Mechanical phlebitis is the most • Pain along the vein
upper extremity every shift for common complication within the • Edema at the puncture site
signs and symptoms of phlebitis, first 72 hours after insertion. • Erythema
thrombophlebitis, or infiltration. Thrombophlebitis may occur at any • Ipsilateral swelling of the arm,
time after catheter insertion. neck, or face
• Venous occlusion (changes in arm
circumference >2 cm from
baseline)
• Infiltration
5. Assess the catheter for venous Verifies position of the catheter in the • Catheter occlusion (failure to
blood return and patency before vascular space and patency before obtain blood return on aspiration
initiating infusions. initiation of infusions. or resistance to irrigation)
A. Connect a 10-mL syringe
filled with 10 mL of NS to the
extension tubing.
B. Release the clamp and
aspirate slowly to verify blood
return.
C. Flush with 10 mL of NS (with
a push/pause technique) and
then administer the infusion.
6. Assess the catheter for The catheter may no longer be • Change in external catheter length
dislodgment or migration by properly positioned if the length of • Catheter occlusion
measuring the length of the the external catheter is longer or • Cardiac dysrhythmias
external catheter. shorter than the length measured at • Pain or burning during infusions
the time of insertion. • Palpation of the catheter in the
internal jugular vein
• Palpation of a coiled catheter
• Infiltration
7. If there was insertional bleeding, Policies may vary regarding the type • Redness, warmth, hardness,
the initial dressing should be left of dressing and frequency of tenderness, pain, or swelling at the
in place for 24 hours.4 After this: dressing changes after the initial insertion site
A. Assess the insertion site and dressing change. • Presence of purulent drainage from
upper forearm while the insertion site
performing a sterile dressing • Local rash or pustules
change.
B. Transparent, semipermeable
dressings should be changed
at least weekly.9
C. Sterile gauze dressings should
be changed every 48 hours.4,5
D. Dressings should be changed
if they become damp,
loosened, or visibly soiled.9
(Level D*)

8. Monitor the insertion site and The incidence of infection related to • Redness, warmth, hardness,
patient for signs and symptoms of the catheter may result from failure tenderness, pain, or swelling at the
local or systemic infection. to maintain asepsis during insertion, insertion site
failure to comply with dressing • Presence of purulent drainage from
change protocols, the insertion site
immunosuppression, frequent • Local rash or pustules
access to the catheter, and long- • Fever, chills, or elevated white
term use of a single IV access site. blood cell count
• Nausea and vomiting
9. Avoid measuring blood pressure, Minimizes the risk for catheter-related
performing venipuncture, or complications and catheter damage.
administering injections in the
extremity with a PICC.
Follow institutional standards
regarding placing a sign at the
patient bedside regarding
avoiding use of the extremity
with the PICC.
Documentation
• Patient and family education • The location of the PICC insertion site and the vein
• Completion of informed consent accessed
• Preprocedure verification and timeout • The method of securing the catheter
• Known allergies • Confirmation of the catheter tip placement
• Mid–upper arm circumference • Problems encountered during or after the procedure
• Date and time of the procedure or nursing interventions
• Catheter type, size, and length, including the length of • Patient tolerance of the procedure
catheter remaining outside the insertion site • Pain assessment, interventions, and effectiveness
• Type and amount of local anesthetic (if used) • Vital signs and cardiac rhythm
• Assessment of the insertion site

87 Peripherally Inserted Central Catheter 777.e1
References 7. National Committee on Safer Needle Devices: Using safer

1. Phillips L, Gorski LA: Manual of IV therapeutics: needle devices: The time is now, Washington, DC, 1997,
Evidence based practice for infusion therapy, ed 6, National Committee on Safer Needle Devices.
Philadelphia, 2014, F.A. Davis. 8. Nott M, Peacock J: Relief of injection pain in adults:
2. Fetzer SJ: Reducing venipuncture and intravenous insertion EMLA cream for 5 minutes before venipuncture.
pain with eutectic mixture of local anesthetic: Anaesthesia 45:772–774, 1990.
A meta-analysis. Nurs Res 51:119–124, 2002. 9. O’Grady NP, et al: Guidelines for the prevention of
3. Hussey VM, Poulin MV, Fain JA: Effectiveness of intravascular catheter-related infections, Atlanta (FA),
lidocaine hydrochloride on venipuncture sites. AORN J 2011, Centers for Disease Control and Prevention.
66:472–475, 1997.
4. Infusion Nurses Society: Policies and procedures Additional Readings
for infusion nursing, ed 5, 2016, Infusion Nurses Alexander M, et al, editors: Infusion Nurses Society: Infusion
Society. Nursing: An evidence-based approach, ed 3, St. Louis,
5. Infusion Nurses Society: Infusion nursing standards of 2010, Saunders.
practice. J Infus Nurs 34(1S):S6–S110, 2016. Weinstein S, Hagle ME: Plumer’s principles and practice of
6. Lander J, et al: Evaluation of a new topical anesthetic infusion therapy, ed 9, Philadelphia, 2014, Wolters Kluwer
agent: A pilot study. Nurs Res 45:50–52, 1996. Health.
Unit III Neurologic System
Section Twelve Neurologic Monitoring
PROCEDURE
88
Bispectral Index Monitoring
Richard B. Arbour
PURPOSE: The bispectral index (BIS) is a processed electroencephalogram
(EEG)-derived parameter used in critically ill patients for assessing level of
consciousness and brain arousal state(s) as well as response to sedative,
hypnotic, and anesthetic agents.4–6,8,9,31 Thorough neurological assessment and
judicious interpretation of the single EEG channel and other available parameters
may give early indication of progressive brain injury and inform care
decisions.3,4,18,19,22–24,34,38,39,50–52
❖ The monitoring level of sedation and cortical arousal

PREREQUISITE NURSING is a CNS-mediated phenomenon evaluated by clinical
KNOWLEDGE assessment of consciousness and responsiveness. Level
of sedation and brain arousal state(s) may also be eval-
• It is necessary to understand cerebral physiology, includ- uated by a processed EEG parameter such as the BIS.
ing how brain physiology is altered consequent to meta- Medication effects evaluated include CNS depressants,
bolic and/or structural injury as well as central nervous such as propofol, barbiturates, benzodiazepines, and
system (CNS) depressants.4–6,13,16,29,35 opioids at higher doses.
• Sedative, hypnotic, anesthetic, and analgesic agents ❖ The monitoring level of neuromuscular blockade is a
produce clinical effects as a result of binding, in a dose- phenomenon mediated by the peripheral nervous
related manner, with specific receptors in the brain modu- system (PNS) and measures the effects of neuromus-
lating cerebral physiology.16,43,45 Appropriate understanding cular blocking agents at the myoneural junction pro-
of these agents is necessary, including side effects and ducing varying degrees of skeletal muscle relaxation.
their effects on BIS monitoring parameters. The degree of neuromuscular blockade is evaluated
❖ Opioids may decrease BIS values in a dose-related two ways. The primary means include clinical assess-
manner (with the side effect of sedation at higher ment of ventilator synchrony, resolution of life-
doses) and decrease BIS values related to attenuation threatening agitation, and the degree to which clinical
of the arousal response from pain. goals and end points are met. Secondary means include
❖ Benzodiazepines decrease BIS values in a dose-related peripheral nerve stimulation and assessment of the
manner. evoked response. Peripheral nerve stimulation is com-
❖ Propofol decreases BIS values in dose-related monly performed at the ulnar nerve in the wrist. After
manner. nerve localization and electrode placement, an electri-
❖ Single-agent therapy with ketamine may not result in cal stimulus is applied and the localized response of
a dose-related decrease in BIS values. Ketamine results the target muscle is assessed (see Procedure 32).
in increased cerebral blood flow and activation of ❖ Risk of awareness and pain during paralysis should be
the EEG, specifically in higher frequencies.43 Higher understood.
EEG frequencies are associated with lighter levels of ❖ Clinical goals for aggressive sedation and analgesia
sedation. BIS values may remain elevated in the pres- during paralysis should be known.
ence of deeper sedation, as determined with clinical ❖ Knowledge of monitoring parameters (central versus
assessment. peripheral nervous system) is needed.
• Knowledge of neuromuscular blockade and monitoring ❖ Hemodynamic changes (marginal value at best in
issues is necessary. assessing level of sedation and analgesia and affected
❖ Differentiation between the monitoring level of seda- by multiple factors) should be understood.
tion and cortical arousal versus the monitoring level of ❖ Diaphoresis (affected by multiple factors) should be
neuromuscular blockade is important. understood.
778
88 Bispectral Index Monitoring 779
❖ Knowledge of EEG-based monitoring (BIS) is

TABLE 88-1 Bispectral Index Monitoring
necessary.
• Indications and contraindications of specific medication Terminology
classes should be understood.14,16,31,35,43 Bispectral index (BIS) Processed EEG that assesses level of
• Knowledge of sedative and analgesic therapy is needed.14,16 consciousness and response to
• Specific medication therapies (e.g., opioids, benzodiaze- sedative, hypnotic, and analgesic
pines, propofol) should be understood.14,16,31,35,43 therapy.
• Understanding of the interrelationship between the electrical Digital signal converter Amplifies, filters, and digitizes the
activity of the brain and cerebral metabolism is necessary. (DSC) patient’s EEG signals.
• Understanding of factors that affect cerebral metabolism
Electroencephalogram Measures electrical activity of the
and EEG activity is needed. (EEG) brain.
❖ Sedation (dose-related): Related to the modulation of
Electromyograph Measures the presence of muscle
the EEG state and level of consciousness from medica-
(EMG) activity or detects high frequency
tion administration.4–8,13,35,41,47
artifact from patient care devices.
❖ Analgesic agents (dose-related): Related to attenuation
Signal quality index A measure of the signal quality for
of the arousal response or sedation as a side effect of
(SQI) the EEG channel source and is
opioid analgesia in higher doses.4,5,21
20,47 calculated based on impedance to
❖ Anesthetic agents (dose-related).
electronic signal, electrode contact
❖ Cerebral injury or hypoperfusion (hemodynamic sta-
artifact and other variables.
bility, global neurological injury, severe hypoxemia):
Suppression ratio (SR) Percentage of EEG suppression
Related to direct alterations in cerebral metabolic
(isoelectric EEG) over the past 63
stability.4,7,19,24,32
seconds of collected data.
• Understanding effects of temperature extremes (hypother-
mia versus hyperthermia) on brain physiology.4,27
• EEG tracings are obtained and recorded through the appli-
cation of scalp electrodes and electrical activity in the
brain is displayed and recorded.4,5,31,32,45,47
• Evaluation of EEG waveforms provides a complement to
CNS evaluation in context with information obtained
through clinical neurological assessment.4,18
• EEG activity reflects brain physiology and requires suc-
cessive, energy-using steps. These steps include electrical
impulse discharge at the thalamus, impulse transmission
to the cerebral cortex, presynaptic neurotransmitter
release, and postsynaptic neurotransmitter uptake.4,6,7,45
• Any clinical state or drug therapy affecting cerebral
metabolism may be reflected in EEG waveforms.4,5,7,18,29,39
• See Table 88-1 for terminology associated with BIS
technology.
• The close relationship between BIS and EEG activity
should be understood.4,13,32,45,47
• Goals of care should be known and communicated clearly Figure 88-1 BIS sensor in place illustrating anatomical land-
among all members of the multidisciplinary team. marks for optimal sensor placement. BIS Extend sensor in place.
• Clinical assessment for establishing therapeutic goals and Sensor may be placed on right or left side. Circle 1 is positioned at
endpoints should be integrated within the plan of care as center of forehead approximately 2 inches (5 cm) above nose.
appropriate. Circle 4 is placed directly above and parallel to the eyebrow. Circle
• BIS monitoring also may indicate an arousal response to 3 is placed on the temple area between the hairline and the outer
canthus of the eye. Circle 2 is placed between circles 1 and 4 on
painful stimulation.20–22,28,31,36 the patient’s forehead.
• Information derived from monitoring may be used to
guide sedative, hypnotic, and metabolic suppression and
analgesic therapies.4–8,13,31 ❖ Artifacts (low-frequency and high-frequency) are
• When BIS monitoring is initiated, a sensor is placed eliminated.4,6,13,32,45,47
across the patient’s forehead per manufacturer recommen- ❖ Multiple processing steps are applied for the calcula-
dations to detect one channel of EEG activity across either tion of BIS values based on the EEG state (frequency
the right or left frontal-temporal montage (Fig. 88-1).4,6,9,11,13 and amplitude) associated with the level of sedation,
• A single channel of EEG data is then subjected to multiple brain arousal, or anesthesia.4,6,13,32,45,47
processing steps.4,32,45,47 ❖ Levels of EEG suppression versus near suppression are
❖ The EEG signal is filtered and digitized within the determined.4,6,13,32,45,47
digital signal converter (DSC)4,6,9,11,13 or BISx near the ❖ The BIS value is derived based on the previous 10 to
patient’s head (Figs. 88-2A and 88-3A). 30 seconds of EEG data (depending on the smoothing
780 Unit III Neurologic System
BIS Sensor
Signal
Alarm Battery Quality Electromyograph
Icon Icon Indicator Indicator
BIS VIEW Monitor
Patient
Interface Cable BIS
(PIC) Number
Monitor Interface Case ID

Cable
A BISx
B
Current Date and Time
BIS Number Display and Sensor Status
C D
BIS Trend Line Trend Time Scale BIS Trend Display Screen with EEG
Figure 88-2 BIS View (A and B) monitoring system, including location of menu and power
control keys, BISx, (C and D) BIS index/trend, EMG, EEG, and sensor status displays. (Courtesy
Aspect Medical Systems, Norwood, MA.)
rate setting on the monitoring system) and is updated ❖ The BIS value is a single number on a linear (0 to 100)
at intervals. As such, changes in BIS value may lag scale that reflects the level of sedation or cerebral
behind clinical changes. arousal. BIS values correspond with specific clinical
❖ BIS monitoring provides a single channel of EEG endpoints, indicating arousal and consciousness. A BIS
tracing from the right or left frontal-temporal montage value at or near 100 typically corresponds with an
electrode placement (BIS Vista, BIS View; see Figs. awake state. A BIS value at or near 0 corresponds with
88-2 and 88-3). an isoelectric or near-isoelectric EEG reading and a
• BIS may be utilized for bilateral EEG data acquisition deeply comatose patient, highly suppressed EEG,
from concurrent right and left frontal-temporal electrode minimal to no EEG activity.4–6,8–11,13,32,47 (Description of
placement (BIS Vista bilateral monitoring system).10 BIS values and corresponding clinical and EEG states
• Knowledge is needed to interpret the the BIS display are found in Table 88-2)
screen, monitor controls, and information array displayed ❖ The suppression ratio (SR) is defined as the percentage
on BIS monitoring system. Information can be on the of suppressed EEG over the previous 63 seconds of
device (BIS monitor as a stand-alone view) or integrated collected EEG data. An SR of 15 indicates that the
systems in which data displays are incorporated within EEG signal was isoelectric over an interval of 15% of
critical care monitoring systems (see Figs. 88-2, 88-3, the previous 63 seconds of collected data. This param-
88-4).9–11 eter may be elevated in patients receiving high-dose
• Knowledge of data obtained from BIS monitoring is propofol, barbiturates or other CNS depressants. The
necessary. SR may also be elevated in a patient with severe
BIS VISTA Monitor BIS Sensor
Patient Interface
Cable (PIC)
Monitor
Interface
Cable
ON/Standby
Button BISx
A
B C
D E
Figure 88-3 BIS Vista monitoring system illustrating display, BISx, and location of menu and
power control keys (A). B, System after activation/patient connection and following successful
sensor check. C, System initial menu options including choice of secondary variable, frequency of
charting data and alarm settings. D, Choices for secondary parameter (SR, EMG, burst count, SQI).
E, BIS monitoring utilizing BIS trend and SR as secondary variable. Single EEG channel visible at
top right of image. (A, Courtesy Aspect Medical Systems, Norwood, MA.)
A B
C D
Figure 88-4 Illustration of setup and configuration of BIS monitoring within General Electric
(GE) critical care monitoring system. A, Placement of BIS module within bedside monitor to estab-
lish availability of parameter. B, Initial EEG signal and monitor start-up with initial BIS sensor
impedance check. In this setup screen, smoothing rate, sensor check, EEG sweep speed and addi-
tional options for BIS setup may be determined. C, Satisfactory completion of sensor check on all
electrodes with impedances within acceptable parameters for acquisition of EEG data. D, Comple-
tion of sensor check, availability of single-channel EEG tracing (EEG tracing at 6.25 mm/sec sweep
speed), SQI indicating adequate signal for BIS determination, EMG and BIS value (91). Graphic
trending (BIS, EMG, SR) available by selecting parameters and time indices. This may be utilized
for observing data over time and in response to therapies, alterations in clinical state such as shiver-
ing during therapeutic hypothermia. BIS technology is licensed to multiple patient monitoring
vendors. This illustration using GE monitors is one of multiple options available.
cerebral injury, such as encephalopathy or catastrophic frequency range includes electrical activity from
brain trauma, indicating the onset or progression of muscle artifact and patient care devices.4–6,8–12
severe brain injury.4–6,8–11 • Initial monitoring and setup of the sensor and equipment
❖ The EMG displays the power (in decibels) within the includes appropriate setup and configuration of stand-
range of 70 to 110 Hz (cycles per second). This alone BIS monitoring systems (BIS View, BIS Vista) as
TABLE 88-2 BIS Values, Corresponding Level of Sedation, and EEG State4,6,7,31,32,47
BIS Value Corresponding Level of Sedation Descriptors
100 Awake state; patient able to respond appropriately to verbal Baseline state before sedation
stimulation Anxiolysis
80 Patient able to respond to loud verbal, limited tactile High-frequency EEG activity (Beta augmentation)
stimulation, such as mild prodding/shaking Moderate sedation
60 Low probability of explicit recall; patient unresponsive to Low-frequency EEG activity
verbal stimulation Deep sedation
40 Patient unresponsive to verbal stimulation, less responsive to Deep hypnotic state
physical stimulation Drug-induced coma; burst-suppression EEG pattern
20 Minimal responsiveness
0 No responsiveness mediated by brain function; spinal Isoelectric or completely suppressed EEG
reflexes may be present
Note: Levels of sedation and responsiveness, and corresponding BIS value and EEG state, occur on a continuum.
(Adapted from Arbour R: Continuous nervous system monitoring: EEG, the bispectral index and neuromuscular transmission, AACN Clin Iss 14[2]:192, 2003.)
well as appropriate setup and configuration of BIS modular BIS of zero/less than 25, and/or high suppression
systems integrated within critical care patient monitoring ratio, may provide early indication of potential poor
systems (see Figs. 88-2, 88-3, and 88-4). outcome.26,34,37,50,51,53–55,58
❖ Signal quality index (SQI) is displayed on the monitor Isoelectric EEG channel or significant ECG artifact
screen. The SQI bar that extends to the right side of the indicates significant EEG suppression.4 Consider
SQI bar graph display indicates optimal (100%) EEG reevaluation of hypothermia protocol and neurologi-
signal quality. The BIS value on the numeric region of cal evaluation, including diagnostic EEG when clini-
the monitor display is shown as a solid number. SQI cally appropriate, in determining direction of care.23
less than 50% (SQI less than the middle range of the • Factors that affect the BIS value:
2,4,5,25
display) is indicated by a BIS value shown as an out- ❖ Sedation: Decrease in BIS value.
lined number. If SQI is inadequate for calculation of a ❖ BIS value may decrease before impending cardiovas-
BIS value, no data are displayed. cular collapse.33
• Potential indications for BIS monitoring include: ❖ Analgesia: Decrease in BIS value from attenuation of
❖ Use of neuromuscular blockade: BIS monitoring may cerebral arousal or sedation occurring as a side effect
help in identification of patients at risk for awareness, of higher doses of opioids.2,4,5
recall, and pain during paralysis.2,4,6,31,32,56,57 ❖ Electromyographic (EMG) activity (high-frequency
❖ BIS data may reflect the onset or progression of brain activity from muscle activity across the forehead) may
injury not apparent on clinical examination. cause increase in BIS value independent of hypnotic
❖ Use of BIS values to guide sedation and analge- state.1,4,6,12,15,56,57
sia.2,4–6,19,21,31,35,36,41,44,48 ❖ Neuromuscular blocking agents: If EMG activity is
❖ Titration of sedation or analgesia in patients receiving causing false elevation in BIS value due to high-
controlled ventilation. frequency muscle activity across the patient’s forehead,
❖ Avoidance of extremes of undersedation and neuromuscular blockade administration will decrease
oversedation. BIS value in a dose-related manner.1,4,6,12,15
❖ Titration of medications for drug-induced coma/ ❖ Painful (noxious) stimulation: If analgesia is inade-
metabolic suppression therapies.4,7,13,46 quate and CNS/sensory pathways are intact, an arousal
❖ Procedural sedation. response may be produced within the cerebral cortex
❖ Determination of the dosage of sedation or analgesia reflected in the EEG state, resulting in an elevation in
during end-of-life care. Using BIS in this setting may BIS value.20,21
be appropriate if concern exists regarding adequacy of ❖ Sleep: BIS range is lower (20 to 70) during deep sleep,
sedation and analgesia and clinical assessment is and BIS range is higher (75 to 92) during rapid eye
inconclusive on the patient’s level of comfort.4,17 movement (REM) sleep.4,17
❖ Therapeutic hypothermia ❖ Hypothermia: Decrease in BIS value from attenuation
To titrate sedation and analgesia in real time during of brain metabolism.4,27
hypothermia induction, maintenance and rewarm- ❖ Cerebral ischemia: Decrease in BIS value from
ing accounting for temperature-related pharmacoki- deprivation of blood/oxygen supply to affected
netics.14 watershed.4,7,24,39,52
Monitoring BIS value(s)/additional parameters during ❖ Neurological injury: Decrease in BIS value depending
hypothermia/postcardiopulmonary arrest may give on location of injury and degree to which overall cere-
early indications of poor outcome.19,34,40,49–51,53–55 bral metabolism is affected.4,29
❖ Progressive brain injury, including terminal brain Deeper sleep stages.

herniation/brain death, may produce early indication Hemodynamic instability (compromised blood/
on BIS monitoring (increased SR, critically low BIS oxygen to brain).33
value, possibly isoelectric EEG channel).22,38 Onset or progression of neurological injury.
❖ Seizure activity can alter/increase BIS value and can
be reflected on single EEG channel.18,40 EQUIPMENT
❖ Encephalopathic states: Severe anoxic/ischemic
encephalopathy or hepatic encephalopathy (decrease in • BIS monitor (or module if using system integrated with
BIS value).4,19,30,34,42 the bedside monitor).
❖ High-frequency electrical artifact from patient care • Digital signal converter/BISx
equipment, such as pacemaker, or muscle activity, such • Patient interface cable
as rapid head or eye movement (increase in BIS • BIS sensor
value).1,4,12,59 • Detachable power cord
• Interpretation of BIS value: • Alcohol pads
❖ BIS is interpreted over time, in response to stimulation • Gauze pads
and within the context of whether therapeutic end- • Nonsterile gloves
points and overall goals of therapy are met.4,9,11,31 Additional equipment, to have available as needed, includes
❖ Decisions to increase or decrease titration of sedative the following:
or analgesic therapy should be based on the patient’s • Soap and water
plan of care, clinical assessment, judgment, goals of • Emergency equipment
therapy, and BIS value.
❖ Reliance on BIS alone for sedation and analgesia man- PATIENT AND FAMILY EDUCATION
agement is not recommended.9,11,31
❖ Movement such as in response to painful stimulation • Assess factors that affect the patient’s (if still awake) and
may occur with low BIS values. This movement may family’s readiness to learn. Rationale: Teaching is indi-
include that produced by spinal reflexes.20 vidualized to specific patient and family needs.
❖ BIS values should be interpreted with caution and in • Explain the purpose of BIS monitoring, including content
context with clinical assessment in patients with meta- regarding specific information obtained, how it may be
bolic or structural brain injury and in those receiving used, and an explanation of the equipment. Rationale:
psychoactive medications.15 The patient (if still awake) and family may experience less
❖ BIS monitoring is not intended for regional cerebral anxiety and have increased understanding of the patient
ischemia monitoring. With use of BIS in the presence equipment at the bedside.
of known CNS injury, a baseline BIS value is recom- • Explain to the patient (if appropriate) and family what will
mended before administration of sedative, analgesic, or happen with the initiation of BIS monitoring (skin prepa-
anesthetic agents.29 ration, placement of electrodes, moderate pressure for
❖ Elevation in BIS value may result from: electrode contact). Rationale: The explanation prepares
Sources of noxious stimuli (arousal response and the patient and family for events associated with initiation
potential increase in EMG activity). of BIS monitoring and also provides an opportunity to
Decrease in level of neuromuscular blockade reinforce preprocedural teaching and assess level of
(affecting EMG activity).1,4 understanding.
Interruption in sedative therapy (particularly short- • Although rare, some patients may have mild skin irritation
acting agents), development of tolerance. develop in the area in contact with the sensor. This irrita-
Interruption in analgesic therapy, development of tion typically resolves within 1 hour after sensor removal.
tolerance. Rationale: The patient and family are prepared for the
REM sleep.4 possible minor issue with sensor application and the pos-
Seizure activity (potentially).18 sible need for removal or repositioning of the sensor.
Shivering (particularly in combination with EMG • Explain that BIS monitoring and electrode placement pose
activity). no risk to the patient beyond that of mild skin irritation
Increased auditory stimulation from environmental (in rare instances) and that the patient experiences no
noise may cause cerebral arousal and possible BIS discomfort as part of monitoring procedure. Rationale:
elevation. Anxiety may be decreased.
Decrease in BIS value may result from:
Attenuation of arousal response or EMG activity PATIENT ASSESSMENT AND
after opioid administration.36 PREPARATION
Administration of a neuromuscular blocking agent
and attenuation of EMG activity. Patient Assessment
Excessive sedative dose. • Assess the patient’s level of sedation, responsiveness, and
Excessive analgesic dosing producing deep sedation arousal. Rationale: Baseline data are provided.
as a side effect. • In collaboration with other healthcare physicians,
Hypothermia (patient cooling). advanced practice nurses, and other healthcare
professionals, establish overall goals and endpoints of obtain a baseline BIS value before initiating therapy with
sedative and analgesic therapy. Rationale: A coordinated sedative, analgesic, or anesthetic agents.
plan is established with integration of the BIS data into
decision making regarding sedation and analgesia. Patient Preparation
• Assess the skin at the intended sites for sensor placement. • Verify that the patient is the correct patient using two
Rationale: Provides baseline information regarding the identifiers. Rationale: Before performing a procedure, the
patient’s skin. nurse should ensure the correct identification of the patient
• Assess the patient’s neurological status. Rationale: Base- for the intended intervention.
line data are provided. BIS values may be decreased with • Determine anatomical landmarks for the BIS sensor
significant neurological injury, which needs to be deter- placement. Rationale: Landmarks provide for accurate
mined before initiation of BIS monitoring. If possible, placement of the sensor.
Procedure for Bispectral Index Monitoring

1. Connect the power cord to the Prepares the equipment. Equipment may vary because a
monitor and plug it into the stand-alone monitor may be used or
electrical wall outlet. a module may be used that is
incorporated into the bedside
monitoring system.
2. With use of the BIS View or Prepares the equipment.
BIS Vista monitoring systems,
connect the BISx and related
cable to the monitor (see Figs.
88-2A and 88-3A).
3. Turn on the monitor and observe The system initiates a self-test to If a hardware problem exists, such as
as a system check is run. ensure that the equipment and DSC failure, a message appears on
(Level M*) connections are operating the display, indicating the need for
effectively. hardware part replacement or
service. If a problem exists, an
error message appears. Refer to the
operator manual. If needed, remove
the device from service and refer to
biomedical engineering.
4. Cleanse the intended sensor area A thorough skin preparation removes Mild soap and water is an acceptable
with alcohol pads and dry with debris and oily residue from the alternative. Ensure that the skin is
gauze. (Level M) skin and facilitates optimal dry before applying the sensors.
electrical contact for EEG data
acquisition.
5. HH
6. PE

Procedure for Bispectral Index Monitoring—Continued

7. Apply the BIS sensor to the Ensures consistency of the anatomical The conductive parts of the
patient’s forehead (see Fig. 88-1). location for sensor placement and electrodes, sensor, or connectors
A. Position circle 1 electrode at optimizes the electrical contact should not contact other conductive
the center of the forehead, between the monitoring system and parts of the monitoring system. The
approximately 2 inches above the skin for facilitation of EEG data patient interface cable should be
the patient’s nose. acquisition. EEG data acquisition carefully placed and secured.
B. Position circle 4 electrode begins shortly after optimal Data acquisition begins when
directly above and parallel to connection is established between impedances are acceptable.
the eyebrow. the patient and the monitoring Electrodes that show high
C. Position circle 3 electrode on system. impedance are highlighted on the
the temple area between the sensor check display seen at
hairline and the outer canthus startup. For electrodes identified as
of the eye. having high impedance, repeat
D. Position circle 2 electrode pressing of electrodes to optimize
between the first and fourth electrical contact. If significant
sensors on the patient’s artifact is present, the DSC should
forehead. be moved away from sources of
E. Press the edges of the sensors external electrical or mechanical
to ensure adhesion and seal in artifact. Sources of artifact include
the conductive gel. fluid or forced-air warming
F. Press each of the electrodes systems, ventricular assist devices,
with continuous direct high-frequency ventilation, suction,
pressure for 5 seconds to pacemakers, and oscillating
ensure optimal skin contact. mattresses. Sensor check is initiated
G. With use of the BIS VISTA automatically. In the event of an
bilateral monitoring systems, error message, such as high
refer to operator’s manual. impedance or sensor removal,
(Level M*) repreparation, and replacement of
the sensor may be necessary.
8. Insert the sensor tab into the Connects the BIS sensor and the
patient interface cable until it is patient interface cable.
engaged.
9. Secure the DSC to an accessible The digital signal converter amplifies,
location near the patient’s head filters, and digitizes the patient’s
(e.g., patient’s pillow or sheet), EEG signals. It is located close to
avoiding close proximity to the patient’s head to minimize the
sources of mechanical or vulnerability of the EEG signal to
electrical interference. interference from other electronic
equipment or patient care devices.
10. Access the setup menu by Settings such as display type and BIS A 10- or 15-second smoothing rate
pressing “MENU” on the monitor smoothing rate (in seconds) may be provides increased sensitivity and
to select the specific monitor chosen. expedited feedback to altered
settings, including BIS smoothing hypnotic or arousal states. A
rate, event markers, and display 30-second smoothing rate generates
type (see Figs. 88-2 and 88-3). a smoother trend with less
This also provides access to the variability, is less sensitive to
advanced setup menu. artifact, and is often chosen for
The touch keys may be used to long-term monitoring; 10-second,
choose options. (Level M) 15-second, and 30-second
smoothing rate options are
available.


11. As noted previously, access the Used to select secondary parameters If BIS is used to monitor a patient’s
advanced setup menu by initially displayed with BIS trend, such as sedation level during neuromuscular
pressing “MENU” and then EMG activity, SR, and SQI, and to blockade, selection of EMG as a
highlighting “Advanced Setup” alter settings that may be changed secondary parameter may provide
by using the up or down arrows. less frequently. SQI of 100% early information regarding
Press select when “Advanced indicates an optimal EEG signal. “lightening” of the blockade (EMG
Setup” is highlighted (see Figs. SR is the percentage of suppressed activity may increase). If used
88-2 and 88-3). (isoelectric) EEG over the previous during deep sedation for controlled
63 seconds within the EEG data ventilation, EMG may indicate a
sample. pain/arousal response and indicate
the need for analgesia.
Increased EMG activity may also
indicate a lighter state of sedation
or increased muscle activity. If BIS
is used to monitor a patient in a
drug-induced coma, SR may be
monitored as a secondary parameter
for continuous evaluation of the
degree of EEG suppression.
12. Select additional settings as The settings, such as the interval for The density spectral array display
needed, including: recording of the BIS log values, log shows changes and trends in the
A. Intervals for collection of data displays, alarm limits, and power spectrum of the EEG over
in the BIS log. alternative displays such as EEG time. The BIS log display shows
B. “Advanced Setup” as outlined density spectral array, may be BIS numeric values averaged over
earlier to change the alarm changed based on clinical or other the previous minute and can be
limits, display type, time needs for data collection. displayed at varying intervals such
intervals and secondary as 1, 5, 15, or 60 minutes.
parameters. Approximately 1200 hours of data
may be stored in the BISx for later
retrieval and review.9 The EEG
display provides a single channel of
raw EEG from a frontal montage.
13. When the monitor settings have BIS data collection can proceed after
been adjusted to a specific all preparatory steps and monitor
patient, BIS data collection can settings are completed
begin. appropriately. This ensures optimal
electrical contact between the
patient and the monitoring system
and optimal electrical safety. In
addition, confirmation of display
settings and secondary parameters
at the outset of monitoring
effectively tailors the monitor
display and data acquisition to the
specific patient.

14. Observe the monitor display for: Data acquisition begins when A sensor check is initiated
A. High impedance alarm (it is impedances are acceptable. automatically during the system
highlighted on the sensor start-up (see Figs. 88-2, 88-3, and
check display at start-up): If 88-4).
displayed, press each
electrode again to optimize
electrical contact. Remove the
sensor, cleanse the skin, and
place a new sensor if
necessary.
B. Lead off alarm (it is displayed
as “LDOFF”): If present,
check whether the sensor has
loosened. Remove the sensor,
cleanse the skin, and apply
another sensor.
C. Artifact: If artifact is present, Artifact may result from use of fluid
move the digital signal or forced-air warming systems,
converter away from sources ventricular assist devices, high-
of external electrical or frequency ventilation, suction,
mechanical artifact. pacemakers, and oscillating
mattresses.
15. For a patient receiving A BIS value <60 is associated with a If the BIS value exceeds 60 in a
neuromuscular blockade, low probability of explicit recall. A patient receiving neuromuscular
sedation, or analgesia therapy, the patient with a BIS value <45 is blockade in association with
medication should be titrated for approaching a deep hypnotic stimulation such as airway
a BIS value between 45 and 60. state.4,6 suctioning or chest physiotherapy,
(Level C*) additional analgesics are indicated.
If the BIS value decreases to
<40–45, downward titration of
sedative therapy may be indicated.
In addition, the patient should be
evaluated for additional clinical
changes such as hypotension,
hypothermia, or cerebral ischemia,
which may cause a decrease in the
BIS value.4,7,19,24,32
16. For a patient receiving deep Correlation of the BIS value with With increased agitation and a BIS
sedation for controlled clinical goals of therapy identifies value <60, movement may be
ventilation, correlate the goal for patients who may be progressing to related to pain or reflex responses
the BIS value with specific deeper levels of sedation and those to noxious stimulation. Additional
clinical endpoints of therapy. who may be at risk for impending analgesia should be considered.
breakthrough agitation.
17. Discard used supplies in an Removes and safely discards used
appropriate receptacle. supplies.
18. HH

• Optimal placement of the BIS sensor consistent with • Skin irritation in the area of the BIS sensor
anatomical landmarks and manufacturer placement
recommendations • SQI significantly <50, indicating suboptimal EEG
• Skin remaining intact in the area of the BIS sensor signal acquisition
placement • A sudden decrease in the BIS value independent of
• Data acquisition and display after monitor setup and changes in sedative or analgesic therapy (may
completion of self-test indicate hemodynamic compromise, cerebral
• SQI of more than 50, indicating optimal EEG data ischemia, or the onset or progression of significant
acquisition neurological injury)
• Clear EEG waveform visible on the monitor display • A sudden rise in the BIS independent of stimulation,
• BIS decrease in response to sedative administration in increased EMG activity, or an outward change in the
dose-related manner patient’s condition (may indicate seizure activity or
• BIS decrease after analgesia administration shivering).
• BIS value increase after significant noxious stimulation • BIS completely unresponsive to noxious stimulation
• BIS values equal between right and left frontal- such as endotracheal suctioning or invasive
temporal montage EEG sensor placement procedures
• BIS data effective in providing feedback on the state • BIS values significantly unequal between the right
of the brain in response to sedative, analgesic, or and left frontal-temporal montage sensor placement
hypnotic administration that can be used to direct (may indicate unilateral cerebral injury or ischemia)
therapy • BIS values that do not correlate with clinical
assessment of sedation level and respond
inconsistently to administration of sedative, hypnotic,
or analgesic agents

interventions.
2. Assess the skin condition in the Ensures that the skin is intact. • Altered skin integrity or irritation
area of the sensor placement. after sensor placement
3. Maintain the digital signal Decreases the vulnerability of the
converter (DSC or BISx) in close EEG signals to electrical
proximity to the patient’s head. interference from other sources.
4. Monitor the BIS values and Identifies trends in BIS and secondary • Increase in EMG activity without a
secondary parameters, including parameters. change in medication therapy (may
SQI, EMG, and SR, as determined Decrease in SQI to <50% may indicate increased arousal response
by goals of care, clinical status, indicate suboptimal EEG data [pain] or lightening of
and response to interventions. For acquisition. neuromuscular blockade and result
example, during rapid in increase in BIS independent of
administration of sedative or hypnotic state or decreasing level
analgesic agents before the of sedation or analgesia)
anticipated use of neuromuscular • Significant difference in BIS value
blockade therapy, it may be between right and left frontal
appropriate to monitor and record montage EEG (may indicate
the BIS value multiple times per unilateral cerebral injury)
hour. As therapy is stabilized, BIS • BIS value absolutely invariant to
can be monitored hourly. significant noxious stimulation (may
indicate significant cerebral injury)
• Increased suppression ratio (may
indicate onset or evolution of
cerebral injury, hemodynamic
compromise, ischemia, or
excessively deep hypnotic state)

5. Identify goals or endpoints of Patient outcomes are improved with • Not progressing toward
therapy at the beginning of BIS an organized, evidence-based achievement of goals or endpoint
monitoring. approach to care. of therapy
6. Observe BIS values at least hourly Determines changes in BIS values in • Abnormal BIS values or trends:
and in response to titration of response to medication therapy and • BIS value not decreasing in
medication therapy. interventions. Also provides the response to upward titration of
ability to use “event marker” to sedative or hypnotic therapy
closely correlate changes in BIS • BIS value not increasing after
and secondary parameters for later downward titration of sedative
review. or hypnotic therapy
7. Change the BIS sensor at least Maintains optimal electrical contact
every 24 hours or more frequently between the patient and the
as needed (e.g., diaphoresis, loose monitoring system.
electrodes).
8. Observe the EEG channel as The EEG amplitude and frequency • A decrease in EEG frequency or
determined by the patient’s clinical change based on the patient’s amplitude (e.g., if this occurs with
state and therapeutic interventions. clinical state, evolving injury, and a decrease in the BIS value, may
Significant decrease in EEG medication therapy. The EEG also indicate neurological injury)
amplitude and/or frequency may (under normal conditions) changes • A significant decrease in the BIS
become visible and reportable. in response to varying levels and value that is inconsistent with the
types of stimulation. In most medication therapy may indicate
conditions, electrocardiographic critical pathology and warrant
(ECG) artifact is not visible in an further evaluation with
EEG waveform. ECG artifact visible neuroimaging diagnostic EEG or
in the EEG channel may indicate clinical examination
significant EEG suppression.
9. Observe the BIS value in response The BIS value should, in most • Significant ECG artifact in the
to stimulation. patients, rise in response to EEG channel
stimulation. The EEG, on which the • A BIS value that is unresponsive
BIS is based, normally responds to to noxious stimulation
external stimulation. An EEG • A significant difference in BIS
unresponsive to stimulation may values or suppression ratio (SR)
indicate significant neurological between the right and left frontal-
injury and possibly poor prognosis. temporal montage (may indicate
unilateral cerebral injury)
Documentation
• Goals and endpoints of sedative or analgesic therapy • SQI and EMG activity (as appropriate)
• Family education regarding BIS monitoring • Documentation of left versus right frontal montage
• Clinical assessment (if appropriate) of level of sedation (location of the BIS sensor on the right or the left
• BIS value at start of monitoring and with changes or side)
titration of therapy • BIS value before and after noxious stimulation and
• BIS value recording in patient medical record at least the difference between these two values
hourly and more frequently as indicated (Fig. 88-5) • Change in the BIS value in response to noxious or
• Pain assessment, interventions, and evaluation of painful stimulation
interventions • For case reviews to track, BIS values or trends and
• Occurrence of skin irritation at the site of the BIS response to stimulation or therapeutic interventions
sensor placement with action taken over time may be downloaded from the monitoring
• Unexpected outcomes and interventions system or be tracked by electronic medical record
• Sudden changes in BIS value (increase or decrease) systems. These may require validation by the nurse in
independent of obvious clinical changes or alterations order to be permanently entered into the medical
of medication therapy record (see Fig. 88-5)
• Suppression ratio (SR) (as appropriate) for BIS use in
medication-induced coma or monitoring during
therapeutic hypothermia
Figure 88-5 Documentation of BIS values in an electronic medical record over time on a patient
receiving therapeutic hypothermia. From 0845 to1030 BIS values were significantly elevated and
inconsistent with clinical assessment. EMG parameter was also significantly elevated raising suspi-
cion of subclinical shivering. Following collaboration with the clinical nurse specialist, the patient
received (per order), a neuromuscular blocking agent at 1030. The patient’s BIS value rapidly
declined to zero with elimination of EMG interference. BIS was recorded at 15 to 30 minute inter-
vals. BIS data were obtained via a BIS module integrated within the patient monitoring system.
Depending on system configuration, BIS data may be entered manually or be transmitted automati-
cally from the monitoring system into the electronic medical record, requiring validation for data to
permanently become part of the patient medical record.

88 Bispectral Index Monitoring 791.e1
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45. Rampil IJ: A primer for EEG signal processing in with sedation scales in brain-injured patients. Crit Care
anesthesia. Anesthesiology 89:980–1002, 1998. Med 32:2403–2406, 2004.
46. Riker RR, Fraser GL, Wilkins ML: Comparing the March K, Wellwood J, Arbour R: Technology. In Bader MK,
bispectral index and suppression ratio with burst Littlejohns LR, editors: AANN core curriculum for
suppression of the electroencephalogram during neuroscience nursing, St Louis, 2004, Saunders, pp
pentobarbital infusions in adult intensive care patients. 199–204.
Pharmacotherapy 23:1087–1093, 2003. Markand ON: Pearls, perils and pitfalls in the use of the
47. Rosow C, Manberg PJ: Bispectral index monitoring. electroencephalogram. Semin Neurol 23:7–46, 2003.
Anesthesiol Clin North Am 19:946–966, 2001. Nasraway SA: The bispectral index: Expanded performance
48. Russel IF: The ability of bispectral index to detect for everyday use in the intensive care unit? Crit Care Med
intra-operative wakefulness during total intravenous 33:685–687, 2005.
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Anaesthesia 68:502–511, 2013. perioperative management and postoperative outcomes.
49. Seder DB, et al: Feasibility of bispectral index monitoring Cleve Clin J Med 73(Suppl 1):S13–S17, 2006.
to guide early post-resuscitation cardiac arrest triage. Tonner PH, et al: Comparison of two bispectral index
Resuscitation 85:1030–1036, 2014. algorithms in monitoring sedation in postoperative
50. Seder DB, et al: The bispectral index and suppression intensive care patients. Crit Care Med 33:580–584, 2005.
ratio are very early indicators of neurological outcome Watson BD, Kane-Gill SL: Sedation assessment in critically ill
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51. Selig C, et al: Bispectral index (BIS) and suppression Welsby IJ, et al: The bispectral index in the diagnosis of
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PROCEDURE
89
Brain Tissue Oxygen Monitoring:
Insertion (Assist), Care,
and Troubleshooting
Megan T. Moyer and Eileen Maloney Wilensky
PURPOSE: Brain tissue oxygen monitoring is performed in patients with, or at
high risk of, cerebral ischemia and/or hypoxia. It is used for measurement and
continuous monitoring of regional brain tissue oxygenation for prevention and
detection of secondary brain injury. Monitoring of brain tissue oxygen provides
important information relative to the delivery of oxygen to cerebral tissue of the
injured brain.
PREREQUISITE NURSING • Pbo2 monitoring provides information that reflects brain

KNOWLEDGE tissue oxygen levels associated with cerebral oxygen
demand and systemic oxygen delivery, therefore identify-
• Incorporated as an adjunct monitor of trends in concert ing cerebral ischemia.1,6
with concurrent neurological multimodality monitoring • Pbo2 values are relative within an individual and vary
parameters (intracranial pressure [ICP], cerebral perfusion depending on a range of factors including precondition,
pressure [CPP], systemic jugular venous oxygen [Sjvo2], duration, location, tissue condition, and sensor type.
cerebral microdialysis) brain tissue oxygen monitoring Establishing and following the patient’s cerebral oxygen
reflects the oxygenation of cerebral tissue local to the trends provides the physicians, advanced practice nurses,
sensor placement.1,7,8,10,14,16,18 and other healthcare professionals with information that
• Each of the devices described in this chapter denotes will aid in the assessment and treatment of cerebral
partial pressure of the brain tissue differently, for example hypoxia and preventing further secondary brain damage.
Pbto2, Pbro2, Ptio2, tio2, Pto2. For the remainder of the text Brain hypoxia is associated with increased mortality and
in this chapter brain oxygen will be referred to as Pbo2. poor outcome.1,6,10,13
The tables that represent the individual devices will denote • Indications for Pbo2 monitoring include patients at risk for
the nomenclature adopted by that manufacturer. secondary injury from cerebral edema. Conditions most
• In institutions where Sjvo2 is used as a monitoring param- likely to cause cerebral edema include severe traumatic
eter, the difference between Sjvo2 measurements and Pbo2 brain injury, aneurysmal and traumatic subarachnoid
values must be noted. Sjvo2 is a measure of the oxygen hemorrhage, brain tumor, stroke, and any condition that
contained in the blood draining from the cerebral venous increases ICP.6
sinuses into the jugular bulb (a measure of global brain • Contraindications for Pbo2 monitoring include patients
oxygenation), whereas Pbo2 measures regional (local to with a coagulopathy, those receiving anticoagulation
the catheter placement in the cerebral white matter) brain therapy, and those with an insertion site infection.
tissue oxygenation. Sjvo2 monitoring accuracy can be • Pbo2 probes are safe with computed tomography (CT).
influenced by poor sampling technique, positioning, and Consult manufacturer’s guidelines for magnetic resonance
clot formation on the catheter, making this method of imaging specificity by probe.
monitoring less reliable than Pbo2 monitoring. A normal • Cerebral oxygen data are accurate and reliable when the
Sjvo2 range is between 55% and 75%, making cerebral Pbo2 probe is located in the deep white matter of the brain,
ischemia any number less than 55%. The choice of moni- the location where oxygen availability is most stable.1
toring device depends on the patient’s pathology.1,8 • Insertion depth affects the cerebral blood flow values
• Understanding of neuroanatomy and physiology, specifi- obtained due to values differing between the cerebral
cally intracranial dynamics, is needed. cortex and subcortical white matter.1
• Cellular death is preceded by a cascade of events follow- • Parameters such as ICP and brain tissue temperature can
ing low brain oxygen levels that result in anaerobic metab- be measured immediately at the time of probe placement,
olism, lactic acid accumulation, and release of excitatory but may be delayed up to 2 hours because time is needed
neurotransmitter causing neurotoxicity.1,7,11 for the brain tissue to settle after the microtrauma caused
• Knowledge of sterile and aseptic technique is necessary. by probe placement.5,17
• A brain tissue oxygen probe may be inserted into the brain • Pbo2 monitoring has been demonstrated to be safe and
parenchyma through an intracranial bolt or tunneled.1 effective in both the clinical and laboratory settings.6
792
89 Brain Tissue Oxygen Monitoring: Insertion (Assist), Care, and Troubleshooting 793
TABLE 89-1 Management of Increased or Decreased PbO2 Values

Decreased Pbo2 Values
Increased oxygen Increased ICP Treat the increased ICP with osmotic diuretics, cerebrospinal fluid drainage, sedation (e.g.,
demand barbiturates, propofol), craniotomy.
Pain Administer analgesics.
Shivering Rewarm, if needed, or administer agents to stop shivering (e.g., demerol, thorazine,
paralytic agents). If a cooling device in use, perform skin counterwarming).
Agitation Administer sedation agents.
Seizures Administer benzodiazepines and adjunct anticonvulsant agents.
Fever Treat the underlying cause of the fever, initiate a cooling device, if needed, and administer
antipyretic agents.
Decreased oxygen Hypotension Administer isotonic fluids (normal saline or hypertonic saline solution) or vasopressors.
delivery Hypovolemia Administer isotonic fluids (normal saline or hypertonic saline solution), blood replacement.
Anemia Administer blood-replacement products.
Hypoxia Increase FiO2, PEEP, and interventions to mobilize pulmonary secretions and maximize
pulmonary function.
Increased Pbo2 values
Increased oxygen Hyperdynamic Consider sedation agents, temperature management, and/or positioning to treat elevated
delivery (elevated ICP) ICP
Decreased oxygen Hypothermia Rewarm to achieve normothermia or mild hypothermia as prescribed for management of
demand cerebral metabolism.
Sedatives Decrease sedation, anesthesia, or paralysis as prescribed.
Anesthesia
Neuromuscular
blockade agents
FiO2, fraction of inspired oxygen; ICP intracranial pressure; PbO2, brain oxygen; PEEP, positive end-expiratory pressure.
• The normal range for brain tissue oxygen values is potential for secondary brain injury. Pbo2 can detect subtle
between 20 and 35 mm Hg.7 Treatment goals usually aim changes that can lead to the early identification of cerebral
to keep the Pbo2 equal to or greater than 20 mm Hg. hypoxia and ischemia.6,8 Table 89-1 outlines interventions
• A Pbo2 of less than 20 mm Hg is when an intervention for increased or decreased Pbo2.
should be considered due to potentially compromised • Increases in Pbo2 values denote decreased oxygen uptake
brain oxygen.1,3,8–10 A Pbo2 of less than 15 represents by cerebral cells that may be caused by states of increased
impending brain hypoxia.1,9 oxygen delivery or decreased oxygen utilization.8
• A Pbo2 of less than 10 mm Hg is directly associated with • Pbo2 monitoring is accurate and safe, and can provide
increased lactate and glutamate, severe disability, poor reliable data for up to 10 days with measured responses
outcome at discharge, and death.1 to interventions.8,15 However, both manufacturers’ recom-
• A Pbo2 of less than 5 mm Hg is indicative of increased cere- mendations suggest device placement should not exceed
bral levels of glutamate, glycerol, or the lactate/pyruvate 5 days to continue to receive accurate measurement.
ratio, indicating a critical level of brain tissue oxygen.16 • Pbo2 probe placement: The physician, advanced practice
• Brain tissue oxygen values can be used to manage poten- nurse, or other healthcare professional placing the probe
tial cerebral hypoxia. Clinical interventions can be aimed device determines the catheter placement location after
at increasing oxygen delivery or decreasing cerebral review of the CT scan and after consideration of the most
oxygen demand, including but not limited to ventilator appropriate monitoring area based on diagnosis, pathol-
manipulation, CPP augmentation, sedation, head reposi- ogy, and technical feasibility, avoiding areas of infarct or
tioning, intravenous fluid boluses, airway suctioning, and hematoma.3,8 Placement of the probe may be ipsilateral or
blood transusions.1,2,4 Simultaneously increasing the contralateral to the pathology.
number of Pbo2 interventions has been shown to worsen ❖ The probe may be placed in the nondominant hemi-
the time to correcting Pbo2; instead implementing one sphere (e.g., right frontal region) to minimize risk of
intervention at a time may have a better impact.12 injury from catheter insertion. The right hemisphere
• Decreases in Pbo2 values occur when cerebral blood is a safer location for probe placement than the left
flow or cerebral oxygen delivery is inadequate or states hemisphere because speech function is located in the
of increased metabolic demands exist, indicating the left hemisphere in most individuals.
❖ Placement may be near a lesion when the clinical goal which is required for the calculation of Pto2 measure-
is to monitor oxygen availability to damaged but sal- ments, may also be continuously measured with an
vageable tissue. accuracy of ±1v °C. To measure Pto2 and temperature
❖ If a patient has a subarachnoid hemorrhage, the probe tissue compensation continuously, the Integra Licox
may be placed in the area of the brain expected to Pto2 Monitor supports a series of minimally invasive
develop vasospasm. Placement is determined by the probes that are inserted directly into the patient.
distribution of subarachnoid blood on CT scan and by ❖ The Pto2 probe uses an electrochemical (polarographic)
aneurysm location. microcell for oxygen measurements.
• When interpreting the Pbo2 data, the clinician should be ❖ The temperature probe uses a thermocouple (type K)
aware of the catheter probe location.13 for temperature measurements.
• Neurological outcome and Pbo2 may be affected by the ❖ In place of a temperature probe, the monitor also pro-
location of the probe.7,13 vides an option for entering tissue temperature com-
• Currently, two brain tissue oxygen-monitoring systems pensation values manually for the calculation of Pto2
are available, the Integra Licox monitor and the RAU- measurements.
MEDIC Neurovent-PTO; both are invasive monitors that ❖ o2 measurement window
provide continuous direct Pbo2 monitoring.1,15 ❖ Probe storage: temperature, 2 to 10 °C; humidity, 25%
• The Licox Pto2 Monitor (Figs. 89-1, A–G) and Licox CMP to 80%; relative humidity, noncondensing.
Monitor (Figs. 89-2, A–C)5:
❖ Contraindications for needle insertion into the body
❖ Catheter: Two catheters, three parameters (one, ICP; include coagulopathy and/or susceptibility to infections
two, oxygen and temperature) or infected tissue. A platelet count of less than 50,000
❖ Provides functionality for continuously monitoring per µL is considered a contraindication. This value may
Pto2 in brain tissue. Tissue temperature compensation, differ according to different hospital protocols.
A
B
C D
Figure 89-1 A, The Integra Licox Pto2 Monitor with card inserted into slot. B, Smart card.
C, The Integra Licox Pto2 Monitor right panel. D, The Integra Licox Pto2 Monitor back panel.
G
Figure 89-1, cont’d E, The Integra Licox Pto2 Monitor left panel. F and G, Connecting the
Pto2 probe and temperature probe to their probe cables. (Courtesy Integra Neurosciences, Plains-
boro, NJ.)
• The RAUMEDIC NEUROVENT-PTO Monitor17: ❖ O2 measurement window

❖ 5-Fr catheter: one catheter, three parameters (ICP, tem- ❖ Temperature accuracy is ±0.1 °C.
perature, and oxygen) ❖ ICP drift is less than 1 mm Hg during the first 24 hours
❖ Determines the oxygen partial pressure of the available at 37 °C.
oxygen in the brain tissue. At the same time, the paren- ❖ Storage is at room temperature and it has a sterility
chyma pressure and the temperature are measured in shelf life of 2 years.
one measuring catheter providing information about ❖ Contraindications include coagulopathy, those receiving
three parameters: the ICP, the temperature, and the anticoagulation therapy, and those with an insertion site
oxygen partial pressure, in one catheter. infection. Blood coagulation must be carefully moni-
❖ The NEUROVENT-PTO catheter uses oxygen quench- tored during therapeutic hypothermia, hepatic coma, or
ing to measure oxygen partial pressure. other conditions that impair blood coagulation.
❖ The catheter is precalibrated during manufacturing and ❖ Monitoring of Pbto2 values may be delayed as long
therefore does not require zeroing. as 2 hours because time is needed for the brain tissue
A B
C
Figure 89-2 A, Model IM3 triple-lumen introducer. B, Smart card where calibration data for the
oxygen probe is electronically stored. C, Licox CMP monitor, AC 3.1. (Courtesy Integra Neurosci-
ences, Plainsboro, NJ.)
to settle after the microtrauma caused by catheter and stress by increasing awareness of Pbto2 monitoring
placement.7 duration and therapy goals.

PREPARATION
• Assess patient or family understanding of the purpose of
Pbo2 monitoring. Most patients who need brain tissue Patient Assessment
oxygen monitoring have an altered level of consciousness • Assess the patient’s neurological status. Rationale: Per-
with a score of 8 or less on the Glasgow Coma Scale; forming a baseline neurological assessment enables the
education is then directed toward the family. Rationale: nurse to identify changes that may occur as a result of the
Understanding may reduce anxiety and stress, stimulates Pbo2 probe insertion.
requests for clarification or additional information, and • Assess the patient for signs or symptoms of local infection
increases awareness of the goals, duration, and expecta- at the intended insertion location. Rationale: Evidence of
tions of the monitoring system. local infection is a contraindication to brain tissue oxygen
• Explain the insertion process, patient monitoring, and catheter placement.
care involving the Pbo2 monitoring system. Rationale: • Obtain and review coagulation laboratory results (e.g.,
Explanation may alleviate anxiety and stress and stimu- complete blood count, platelet count, prothrombin time,
lates requests for clarification or additional information. partial thromboplastin time, bleeding time, international
• Explain the expected outcomes of the Pbo2 system. Ratio- normalized ratio) as prescribed. Rationale: Assessment
nale: Explanation may decrease patient and family anxiety identifies the patient’s risk for bleeding.
Patient Preparation • Shave preparation kit

• Verify that the patient is the correct patient using two • Antiseptic solution
identifiers. Rationale: Before performing a procedure, the • EASY logO Monitor and connecting fiber optic, yellow,
nurse should ensure the correct identification of the patient blue, gray, and red cables
for the intended intervention. • NEUROVENT-PTO catheter (1)
• Ensure that the patient and family understand the proce- • RAUMEDIC BOLT KIT PTO
dure teaching. Answer questions as they arise, and rein- • RAUMEDIC DRILL KIT CH5
force information as needed. Most patients who need • Cranial access kit (use the hand drill, not the drill bit)
brain tissue oxygen monitoring are in an altered level of • 4 × 4 gauze (2)
consciousness with a Glasgow Coma Scale score of 8 or • Large Tegaderm (2)
less. Rationale: Previously taught information is evalu- • Arm board folded in half (1)
ated and reinforced. • 2-inch tape
• Ensure that informed consent has been obtained. Ratio-
nale: Informed consent protects the rights of the patient For the Integra Licox PtO2 Monitor
and makes a competent decision possible for the patient; • Sterile gowns, sterile drapes, sterile gloves, nonsterile
however, in emergency circumstances, time may not gloves, caps, goggles, and face masks
allow for the consent form to be signed. • Shave preparation kit
• Participate in a preprocedure verification and timeout. • Antiseptic solution
Rationale: Ensures patient safety. • Pbto2 monitor (see Fig. 89-1, A) or module
• Administer sedation or analgesia as prescribed before • Connecting cables
beginning the insertion procedure. Rationale: Sedation or • Cranial access tray; use the drill, but use the Licox bit in
analgesia facilitates the insertion process. the Licox kit
• Assist the patient to the semi-Fowler’s position with the • Pbto2 probe
head in the neutral position and the head of the bed ele- • Scalpel
vated 30 to 45 degrees. Rationale: Patients who are can- • Dressing supplies, including 4 × 4 gauze and tape
didates for brain tissue oxygen monitoring may have • Sterile dry gauze; may be placed at the insertion site
increased ICP. Elevating the head of the bed and placing Additional equipment, to have available as needed, includes
the head in the neutral position act to decrease ICP by the following:
enhancing jugular venous outflow and provides for • An intravenous (IV) arm board may be used to stabilize
optimal insertion accessibility. the monitor probe and cable
• Intracranial bolt system
EQUIPMENT • Extra transparent and soft-cloth adhesive dressing or a
dry, sterile occlusive dressing
For the RAUMEDIC Neurovent-PTO • A compatible fiber-optic ICP catheter may be inserted
Monitoring System through the intracranial bolt system, as well, and will
• Sterile gown, sterile drapes, sterile gloves, caps, face require a separate monitor to measure ICP
masks with eye shield
Procedure for Brain Tissue Oxygen Monitoring for the Integra Licox Pto2 Monitor:
Insertion (Assist) and Care
1. HH
2. Plug the monitor power cord into Provides the power source. On the back of the monitor, attach the
an AC power outlet. red connector end of the AC power
cord into the red port labeled Input
18V. Insert the plug end of the AC
power adapter into an AC wall
outlet.
3. Attach the cables (e.g., oxygen Prepares the equipment. Refer to manufacturer’s guidelines as
cable, temperature cable) to the needed. Monitors and cables may
Pbto2 monitor. be color coded.
Insertion (Assist) and Care—Continued
4. Turn on the monitor. On the front Prepares the monitor.
of the monitor, press the power
button. Once the button
illuminates, the Integra logo will
appear on the touch screen for a
few seconds before initiating the
setup process.
5. After the setup process Verifies the audio alarms are There is a short beep when the
completes, listen for a 1-second functioning correctly; verifies the monitor is first turned on; this is not
startup tone. monitor’s screen displays the main the 1-second startup tone.
panel.
6. Wash hands and apply goggles or Prepares for sterile procedure.
masks with face shields, caps,
and gowns, and assist with sterile
procedure.
7. Assist as needed with site Prepares for sterile procedure. Antiseptic solution choice should be
preparation (e.g., shave determined by institutional policy.
preparation and cleansing with Use of povidone-iodine versus
antiseptic solution). chlorhexidine is controversial. The
antiseptic solution should be
allowed to dry before the initial
incision is made.8 Studies suggest
chlorhexidine is neurotoxic.8
8. Assist as needed in draping the Prepares a sterile environment for the
head, neck, and chest of the insertion process.
patient.
9. Assist as needed with opening of Facilitates efficiency of the insertion
the sterile trays and probes. process.
10. Insert the calibration card for The Licox monitor requires insertion Do not discard Pto2 probe packaging
calibration of the monitor unique of a calibration card referred to as before removing the smart card.
to each Pto2 probe.5 (Level M*) the “smart card,” which has Each card contains calibration data
numbers on it that match those on specific to that that probe. Inserting
the oxygen probe that is being a new smart card during the
inserted. This card is placed into a recording of trend data will reset
card slot located on the right side of the trend data. Only use the smart
the monitor by aligning the arrow card supplied with the Pto2 probe.
on the card with the arrow on the If the calibration card is lost,
monitor. The calibration card can another corresponding Pbto2 probe
only be used with the probe that and smart card must be used.
has the same numbers on it and is
included in the same packaging (see
Fig. 89-1, A–G).
11. Assist as needed with insertion of May be inserted before Pto2 probe Use the bit from the Licox kit.
an intracranial bolt (see insertion. It is critical for dural opening to
Procedure 92). assure accurate parenchymal probe
placement.
12. Assist as needed with insertion of Facilitates the insertion process. The oxygen probe and temperature
the oxygen probe and temperature probe may be separate (triple-lumen
probe. bolt system) or may be combined
(double-lumen bolt system). The
additional lumen is for the ICP
probe.

13. Connect the oxygen and Prepares for monitoring.
temperature probes to the monitor
cables.
14. Observe the temperature and Pto2 Initiates monitoring. The temperature
values. values should be accurate; however,
time is needed for the brain tissue
to settle after the microtrauma
caused by catheter placement.
15. If possible, use a cable to transfer Allows integration of the monitoring Refer to monitor guidelines for
the values from the Pto2 monitor systems. The currently available specific information.
to the bedside monitor. Set the brain tissue oxygen monitoring
upper and lower alarm limits. system does not have an alarm
system. Integrating the monitoring
system with the bedside monitor
allows (1) a larger display of the
numeric values and (2) audible
upper and lower alarm limits.10
16. After the system has been placed, Prevents contamination of the A dressing (formed with dry sterile
assist with placing a sterile, insertion site by microorganisms gauze) provides a base to secure the
occlusive dressing at the insertion and protects the site. device to an arm board or other
point. securing method.
17. Secure the Pto2 monitor cables
with two points of tension to
avoid tension on the Pto2 and
ICP probes.
A. Anchor the cables at the The monitoring cables need to be
patient’s head and at the secured so that no tension or
shoulder. disruption of the device occurs at
the insertion site.
B. Secure the cables so that they Supports the entire mechanism. One method to secure the monitor
do not get entangled in the cables is as follows:
side rails and do not touch the A. Place an IV arm board or
floor. stability anchor to a conical
gauze dressing where the device
and cables can be secured.
B. Anchor the cables from the
patient’s head to the shoulder in
place with a transparent or
soft-cloth adhesive dressing.
The first tension point is
directly on the patient’s head
where the dressing is anchored
to the skin at the point of
insertion. The second tension
point is at the patient’s shoulder.
C. Place rolled towels under the
secured system.
C. Allow enough slack to Prevents gravity drag and tension on
accommodate patient the cables and the device.
movement and turning.
appropriate receptacles. supplies. Safely removes sharp
objects.
19. HH
Connecting a Single Pto2 Probe
1. Connect the Pto2 Probe cable to Allows integration of the monitoring Refer to monitor guidelines for
the monitor. systems. specific information.
2. Insert the Pbo2 probe’s smart card Prepares the equipment. Each bedside monitor may have its
into the monitor. own unique labels for parameters
that are being added (e.g., brain
oxygen).
3. Insert the Pto2 probe into the Prepares the equipment. Depending on hospital protocol, you
patient and connect the probe to may either insert the Pbo2 probe
the monitor. into the patient before or after
connecting the Pto2 probe to the
monitor. The purpose of connecting
the Pto2 probe to the monitor before
implantation is to verify the
functionality of the probe before
clinical use.
4. Allow stabilization time for Prepares the monitor to adjust to This normally applies to the first 20
microtrauma. measurements obtained on insertion minutes after insertion and the Pto2
and the continuous monitoring. values may not display optimal
information about tissue
oxygenation due to tissue injury
during insertion of the probe.
5. Enter the tissue temperature The calculations for Pto2
compensation value manually. measurements require tissue
A. Enter the tissue temperature temperature compensation. If you
compensation that will be are not measuring the tissue
used during Pto2 temperature with a probe, the
measurements. temperature has to be entered
B. On the temperature manual manually. Make sure to check the
panel, adjust the manual patient’s temperature either hourly
temperature input arrows to or before recording the Pto2 value
the designated temperature to for intervention. If any changes in
the nearest whole number. temperature occur, use the manual
temperature input arrows to specify
the new temperature value
accordingly.
Connecting a Single Pto2 Probe with a Single Temperature Probe
1. Connect the Pto2 probe cable to Prepares the monitor. On the monitor’s right side, connect
the monitor. the large plug of the blue Pto2
probe cable into the blue port
labeled Pto2.
2. Connect the temperature probe Prepares the equipment/cables On the monitor’s right side, connect
cable to the monitor. connection to the monitor. the green temperature probe cable
into the green port labeled
“Temperature.”
3. Insert the Pto2 probe’s smart card Prepares the monitor. On the monitor’s right side, insert the
into the monitor. smart card slot by aligning the
arrow on the card with the arrow on
the label.
4. Insert the Pto2 and temperature Prepares the equipment/cables Depending on hospital protocol, you
probes into the patient and connection to the monitor. may either insert the Pto2 probe and
connect the probes to monitor. temperature probe into the patient
before or after connecting the two
probes to the monitor.
5. Allow stabilization time for Prepares monitor to adjust to This normally applies to the first 20
microtrauma. measurements obtained on insertion minutes after insertion and the Pto2
and the continuous monitoring. values may not display optimal
information about tissue
oxygenation due to tissue injury
during insertion of the probe.
6. Check Pto2 and temperature Initiates monitoring. The temperature When using a temperature probe, the
values. values should be accurate. temperature measurement being
continuously reported by the
monitor, with an accuracy of ±1 °C,
will be applied to the calculation
for Pto2 measurements.
Procedure for Brain Tissue Oxygen Monitoring for the Integra Licox CMP Monitor:
Insertion (Assist) and Care
1. HH
2. Plug the Pbto2 monitor power Provides the power source.
cord into an AC wall outlet.
3. Attach the cables (e.g., oxygen Prepares the equipment. Refer to manufacturer’s guidelines as
cable, temperature cable) to the needed. Monitors and cables may
Pbto2 monitor. be color coded.
4. HH
5. Apply goggles or masks with Prepares for sterile procedure.
face shields, caps, gowns, and
sterile gloves.
preparation and cleansing with Use of povidone-iodine versus
antiseptic solution). chlorhexidine is controversial. The
antiseptic solution should be
allowed to dry before the initial
incision. Studies suggest
7. Assist as needed in draping the Prepares a sterile environment for the
patient.
the sterile trays and probes. process.
9. Turn on the Pbto2 monitor. Prepares the monitor.
10. Insert the calibration card for The Licox monitor requires insertion If the calibration card is lost, another
calibration of the monitor unique of a calibration card referred to as corresponding Pbto2 probe and
to each Pbto2 probe. the smart card, which has numbers smart card must be used.
on it that match those on the
oxygen probe that is being inserted.
This card is placed into a card slot
located on the front of the monitor.
The calibration card can only be
used with the probe that has
the same numbers on it and is
included in the same packaging
(see Fig. 89-1, A–G).
11. Assist as needed with insertion May be inserted before Pbto2 probe
of an intracranial bolt (see insertion.
Procedure 92).
12. Assist as needed with insertion of Facilitates the insertion process. The oxygen probe and temperature
the oxygen probe and temperature probe may be separate (triple-lumen
probe. bolt system) or may be combined
(double-lumen bolt system). The
additional lumen is for the ICP
probe.
13. Connect the oxygen and Prepares for monitoring.
temperature probes to the monitor
cables.
14. Observe the temperature and Initiates monitoring. The temperature
Pbto2 values. values should be accurate; however,
time is needed for the brain tissue
to settle after the microtrauma
caused by catheter placement.
15. If possible, use a cable to transfer Allows integration of the monitoring Refer to monitor guidelines for
the values from the Pbto2 monitor systems. The currently available brain specific information.
to the bedside monitor. Set the tissue oxygen monitoring system
upper and lower alarm limits. does not have an alarm system.
Integrating the monitoring
system with the bedside monitor
allows (1) a larger display of the
numeric values and (2) audible upper
and lower alarm limits.10
16. After the system has been placed, Prevents contamination of the A dressing (formed with dry sterile
apply a sterile occlusive dressing insertion site by microorganisms gauze) provides a base to secure the
at the insertion point. and protects the site. device to an arm board or other
securing method.
17. Secure the Pbto2 monitor cables
with two points of tension to
avoid tension on the Pbto2 and
ICP probes.
A. Anchor the cables at the The monitoring cables need to be
patient’s head and at the secured so that no tension or
shoulder. disruption of the device occurs at
the insertion site.
B. Secure the cables so that they Supports the entire mechanism. One method to secure the monitor
do not get entangled in the cables is as follows:
side rails and do not touch the A. Place an IV arm board or
floor. stability anchor to a conical
gauze dressing where the device
and cables can be secured.
B. Anchor the cables from the
patient’s head to the shoulder in
place with a transparent or
soft-cloth adhesive dressing.
The first tension point is
directly on the patient’s head
where the dressing is anchored
to the skin at the point of
insertion. The second tension
point is at the patient’s shoulder.
C. Place rolled towels under the
secured system.
C. Allow enough slack to Prevents gravity drag and tension on
accommodate patient the cables and the device.
movement and turning.
appropriate receptacles. supplies. Safely removes sharp
objects.
19. HH
Brain Tissue Oxygenation Monitor Setup With the Bedside Monitor
1. Connect the brain oxygen Allows integration of the monitoring Refer to monitor guidelines for
monitor to the bedside monitor systems. specific information.
with the attached cable.
2. Select a pressure module, and Prepares the equipment. Each bedside monitor may have its
label the parameter. A waveform own unique labels for parameters
need not be displayed, only a that are being added (e.g., brain
numeric display. oxygen).
3. Manually adjust the temperature Prepares the equipment. Follow institutional guidelines.
on the front of the monitor to the If a separate brain temperature probe
established number of degrees or combined brain tissue oxygen
Celsius determined by the and brain temperature probe is not
institution. in use, the temperature on the front
of the monitor must be adjusted
manually every hour to equal the
patient’s core temperature for
accurate determination of the Pbto2.
4. Disconnect the blue and green Prepares the equipment.
cables from the brain oxygen
monitor.
5. Select the designated pressure Prepares the equipment.
module and zero the bedside
monitor.
6. Plug the blue and green cables Allows integration of the monitoring
back into the front of the brain systems.
oxygen monitor.
7. Note the difference between the Confirms that data on the brain
brain oxygen monitor reading and oxygen monitor accurately correlate
the bedside monitor reading. with the bedside monitor.
8. Readings should be within Confirms that data on the brain Monitoring of Pbo2 values may be
1 mm Hg when the blue and oxygen monitor accurately correlate delayed as long as 2 hours because
green cables are connected to the with the bedside monitor. time is needed for the brain tissue
Licox system at the head of the to settle after the microtrauma
patient and after the brain tissue caused by probe placement.
has had time to settle (20–120
minutes) after Licox insertion.

Procedure for Brain Tissue Oxygen Monitoring for the RAUMEDIC NEUROVENT-PTO
Monitor: Insertion (Assist) and Care
Procedure Rationale Special Considerations
1. HH
2. Attach the cables to the Prepares the equipment.
RAUMEDIC EASY logO (fiber
optic cable to Po2 port, yellow
cable P/T port, gray out ICP, blue
out Po2, red power) (Fig. 89-3).
3. Plug EASY logO monitor power Provides the power source.
cord into an AC wall outlet.
4. HH Standard aseptic techniques.
5. PE
6. Assist as needed with site Prepares for sterile procedure.
preparation, opening of sterile
trays, draping of head and neck,
etc.
7. Assist as needed with insertion of Facilitates insertion. Keep screwing in tool (wrench) for
the RAUMEDIC bolt (see BOLT physician, advanced practice nurse,
Kit PTO IFU) (Fig. 89-4). or other healthcare professional to
remove bolt when therapy is no
longer needed.
8. Assist physician, advanced Facilitates insertion of catheter by
practice nurse, or other healthcare physician, advanced practice nurse,
professional as needed during or other healthcare professional.
insertion of the pressure/
temperature/oxygen catheter (see
NEUROVENT-PTO catheter
IFU) (Fig. 89-5).
Figure 89-3 (Courtesy Raumedic Inc., Mills River, NC.)

Monitor: Insertion (Assist) and Care—Continued
9. Connect PTO catheter to monitor Prepares for monitoring.
cables (Fig. 89-7, A and B).
A. Fiber-optic connection on
PTO catheter to Cable LWL
(fiber optic) (Figs. 89-6 and
89-7, A and B).
B. Blue plug on PTO catheter
connects to Cable PTO: gold
dot to gold dot (Fig. 89-8).
10. Observe ICP, temperature, and Initiates monitoring. The temperature You may document Pbto2 during this
Pbto2 values. and ICP values should be accurate; time with a comment: “dwell time.”
however, a dwell time is needed
(up to 2 hours) for accurate Pbto2
monitoring as it is necessary for the
brain tissue to settle after
microtrauma caused by catheter
placement.
11. After the system has been placed, Maintains sterile environment to
apply a sterile occlusive dressing prevent infection.
at the insertion point.
12. Discard used supplies.
13. HH
Linking to the Bedside Monitor
1. Connect the EASY logO to the Allows integration of the monitoring
pressure ports on the bedside systems.
monitor using the gray out ICP
and blue out Po2 cable.
A B
Figure 89-7 A & B (Courtesy Raumedic Inc., Mills River, NC.)

2. Select the pressure port labels on Prepares the equipment and
the bedside monitor for ICP and establishes alarm parameters for
Po2. For Po2, a waveform does monitoring.
not need to be displayed; only
a value needs to be displayed. Set
alarm parameter from 20 mm Hg
to 40 mm Hg or as prescribed.
3. To have ICP and Po2 values on Prepares the equipment to integrate
the bedside monitor, select Menu. with bedside monitoring systems.
4. Select “OUT.” Allows integration of the monitoring
systems.
5. Once the cables have been Allows integration of the monitoring
connected to the bedside monitor, systems.
press “OK.”
6. Zero the bedside monitor for both Prepares the bedside monitor.
ICP and Po2 pressure ports. When
zero appears on the bedside
monitor, press “OK.”
7. Checking the sensitivity: when Allows integration of the monitoring
20 mm Hg is displayed on the systems.
bedside monitor, press “OK.”
8. It is not necessary to rezero the It is only necessary to rezero after
bedside monitor daily. It is only patient transport.
necessary when the EASY logO
is disconnected and then
reconnected to the bedside
monitor.
Preparing RAUMEDIC NEUROVENT-PTO ICP Monitoring for Transport
1. Disconnect the PTO catheter Oxygen is not monitored during Do not let cables drag or lay on the
from the EASY logO, leaving all transport. floor to prevent accidental removal
cables attached to the EASY of the catheter.
logO. Attach the catheter (blue
plug, gold dot to gold dot) to the
transport cable that has the NPS2
(Fig. 89-9).
2. Plug the NPS2 into the pressure Provides a connection to the transport
port on the transport monitor. monitor.
3. Press and continue holding the Allows integration of monitoring
blue zero button on NPS2 and systems.
then press “zero ICP” on the
transport monitor. Continue
holding the blue button until zero
is on the transport monitor.
4. Upon return to the patient’s Allows integration of the monitoring
bedside, attach the PTO catheter systems for continued monitoring.
to the EASY logO and follow the
OUT procedure of the EASY
logO to get ICP and Pbto2 values
onto the bedside monitor.
Procedure Rationale
Monitor: Insertion (Assist) and Care—Continued Special Considerations
Troubleshooting RAUMEDIC NEUROVENT-PTO
Catheter Implantation Migration
1. Assess for catheter placement. Correct catheter insertion and no Questionable data or data inconsistent
Catheter pulls easily out of the dislodgement of catheter after with patient presentation suggest
bolt when implanted. The placement. that the catheter may be dislodged.
professional will ensure the
catheter is fully inserted and
tighten the fixing cap (see Fig.
89-5).
Catheter Connections to Easy Logo Monitor Disconnections
1. Error: Cable PTO cable not Ensures correct cable connections and
connected to the catheter. that connections are secure.
Connect Cable PTO blue plug,
gold dot to gold dot. Make sure
Cable PTO is connected to the
yellow socket on EASY logO.
2. Error: Cable LWL (fiber optic) Ensures correct cable connection and Avoid forceful locking of cables
not connected/locked to PTO locking the cable tightly to prevent because it may result in cable
catheter. disconnection. breakage.
3. Questionable O2 value Ensures cable is clean and has a good Critically assess oxygen values with
Clean inside Cable LWL (fiber connection with catheter patient assessment. Evaluate
optic) connection to remove dust. clinical indications for increase/
decrease in Po2.
Troubleshooting Pbo2 Monitoring Systems
1. Perform an oxygen challenge test After the brain tissue has had time to Follow manufacturer guidelines for
as prescribed.7,8 settle from the initial insertion, an error codes that are specific to the
A. Place the ventilator fraction of oxygen challenge is performed, Pbto2 monitoring system.
inspired oxygen (Fio2) setting particularly if the Pbto2 reading is The physician, advanced practice
on 100% for 2–5 minutes. unexpectedly low or a question of nurse, or other healthcare
B. Observe the monitor; an probe accuracy exists.7,8 professional may order a head CT
accurate probe will show an scan after insertion to check
increase in Pbto2. catheter placement. Follow
C. If no response to the increased hospital-specific guidelines.
Fio2 is seen, inform the
physician, because a head CT
scan may be prescribed to
confirm correct probe
placement. (Level D*)
2. Assess if an electrical disturbance Strong electromagnetic disturbances These disturbances may occur when a
has occurred. can result in Pbto2 measurement high-frequency scalpel or cautery is
errors. Errors can continue for a used or during cardioversion.
few seconds after the disturbance.
3. Assess cable for damage. If the probe cable or the extension Replace damaged cables.
cable is damaged, measured values
can be incorrect or the
measurement can be interrupted.
4. Avoid changes in the temperature The temperature measurement may be
of the temperature probe inaccurate if the connector of the
connector: temperature probe is subjected to
significant changes in temperature
or if the temperature of the
connector is beyond the defined
range of 18° to 30° C.10
A. Avoid holding the temperature If the probe connector is held with a
probe connector. warm hand, the temperature
measurement may be inaccurate
until it is released.
B. Protect the temperature Warming of the connector can cause
probe connector from direct inaccurate temperature readings.10
sunlight or warming devices.
(Level M*)
Removal of the Brain Tissue Oxygen Monitoring System
1. HH
2. PE
3. Position the patient in a semi- Facilitates the procedure.
Fowler’s position.
4. Turn off the monitor. Facilitates the removal process.
5. Assist with removal of the Prepares for removal of the catheter.
dressing.
6. Assist the physician, advanced The physician, advanced practice
practice nurse, or other healthcare nurse, or other healthcare
professional as needed with professional will remove catheter
removal of monitoring probes. and may request assistance.
7. Apply an occlusive sterile Reduces the risk of infection. Assess for signs of infection,
dressing to the site. bleeding, and cerebrospinal fluid
leakage.
appropriate receptacles. supplies.
9. HH

• Pto2 probe placed in the correct position • Brain tissue oxygen reading low, with no response to
• Monitoring is able to begin after brain tissue has had oxygen challenge
time to settle (20 minutes to 2 hours) • Signs and symptoms of infection
• Pto2 value is between 20 and 35 mm Hg, or as • Hematoma from placement
determined by the physician to be an acceptable value • Worsened neurological assessment
for the individual patient
• Accurate and reliable Pbo2 monitoring
• Early detection of cerebral hypoxia
• Immediate intervention and management of
compromised cerebral oxygenation hypoxia

interventions.
1. Assess the patient’s baseline Provides assessment of patient status • Changes in neurological status
neurological status, vital signs, and before and during the procedure. • Changes in vital signs
ICP every 15 minutes and more • Changes in ICP and CPP
frequently if necessary during and
immediately after the procedure.
2. Perform an oxygen challenge test After the brain tissue has had time to • Lack of variation response to
as prescribed. settle from the initial insertion, oxygen challenge
A. Place the ventilator Fio2 setting perform an oxygen challenge, • Oxygen challenge tests confirm
on 100% for 2–5 minutes. particularly if the Pbo2 reading is correct placement of the probe as
B. An accurate probe shows an unexpectedly low or a question well as probe functioning
increase in Pbo2.1,6 (Level C*) exists of probe accuracy, reliability,
or validity.
3. Obtain the patient’s temperature Provides a comparison of cerebral and • Abnormal temperatures
every 1–2 hours or as prescribed. body temperatures. Although the
temperature measurements do not
correlate exactly, a parallel trend
should be seen.
4. Maintain the Pto2 value between Represents normal values. • Elevated Pbo2 values
20 and 35 mm Hg or as • Decreased Pbo2 values
prescribed.6,8 (Level D*)

Documentation
• After placement of Pbo2 monitor: • Neurological assessments
• Patient and family education • Hourly values, including Pbo2, brain tissue
• Preprocedure verifications and time out temperature, and neurological multimodality
• Completion of informed consent monitoring in use (e.g., ICP, CPP, Sjvo2).
• Insertion of the Pbto2 probe • Occurrence of unexpected outcomes and
• Patient tolerance of the procedure interventions
• Site assessment • Pain assessment, interventions, and effectiveness

89 Brain Tissue Oxygen Monitoring: Insertion (Assist), Care, and Troubleshooting 810.e1
References 11. Narotam P, et al: Physiological complexity of acute

1. Beynon C, et al: Brain tissue oxygen monitoring and traumatic brain injury in patients treated with a brain
hyperoxic treatment in patients with traumatic brain oxygen protocol: Utility of symbolic regression in
injury. J Neurotrauma 29:2109–2123, 2012. predictive modeling of a dynamical system.
2. Bohman L, et al: Medical management of compromised J Neurotrauma 31:630–641, 2014.
brain oxygen in patients with severe traumatic brain 12. Pascual J, et al: Reduced brain tissue oxygen in traumatic
injury. Neurocrit Care 14:361–369, 2011. brain injury: Are most commonly used interventions
3. Cyrous A, O’Neal B, Freeman W: New approaches to successful? J Trauma 70:535–546, 2011.
bedside monitoring in stroke. Expert Rev 12(8):915–928, 13. Ponce L, et al: Position of probe determines prognostic
2012. information of brain tissue Po2 in severe traumatic brain
4. Harutyunyan G, Mangoyan H, Mkhoyan G: Brain tissue injury. Neurosurgery 70(6):1492–1502, 2012.
oxygen reactivity: Clinical implications and 14. Prabhakar H, et al: Current concepts of optimal cerebral
pathophysiology. Front Pharmacol 5:100, 2014. perfusion pressure in traumatic brain injury. J
5. Integra LifeSciences Corp: Integra LICOX PtO2 monitor Anaesthesiol Clin Pharmacol 30(3):318–327, 2014.
user’s manual oxygen partial pressure and temperature 15. Purins K, et al: Brain tissue oxygen monitoring: A study
monitor for neurosurgical application, Plainsboro, NJ, of in vitro accuracy and stability of Neurovent-PTO and
2013, Integra Life Sciences Corp. Licox sensors. Acta Neurochir 152:681–688, 2010.
6. Keddie S, Rohman L: Reviewing the reliability, 16. Purins K, et al: Brain tissue oxygenation and cerebral
effectiveness and applications of Licox monitoring in metabolic patterns in focal and diffuse traumatic brain
traumatic brain injury. Nurs Crit Care 17(4):204–212, injury. Front Neurol 5(64):1–10, 2014.
2012. 17. Raumedic, Lifeline to Health, Inc: Advanced
7. Lazaridis C, Andrews C: Brain tissue oxygenation, neuromonitoring solutions, oxygen partial pressure,
lactate-pyruvate ratio and cerebrovascular pressure intracranial pressure and temperature measurement,
reactivity monitoring in severe traumatic brain injury: Leesburg, VA, 2014, Raumedic, Inc.
Systematic review and viewpoint. Neurocrit Care 18. Spiotta A, et al: Brain tissue oxygen-directed management
21(2):345–355, 2014. and outcome in patients with severe traumatic brain
8. LeRoux P, et al: Consensus summary statement of the injury. J Neurosurg 113:571–580, 2010.
International Multidisciplinary Consensus Conference
on Multimodality Monitoring in Neurocritical Care: Additional Readings
A statement for healthcare professionals from the Eriksson E, et al: Cerebral perfusion pressure and intracranial
Neurocritical Care Society and the European Society pressure are not surrogates for brain tissue oxygenation in
of Intensive Care Medicine. Neurocrit Care 2014. traumatic brain injury. Clin Neurophys 123:1255–1260,
doi: 10.1007/s12028-014-0041-5. 2012.
9. Lipp L: Brain perfusion and oxygenation. Crit Care Nurs Rosenthal G, et al: Assessment of noninvasive cerebral
North Am 26:389–398, 2014. oxygenation monitor in patients with severe traumatic
10. Nangunoori R, et al: Brain tissue oxygen-based therapy brain injury. J Neuosurg 120:901–907, 2014.
and outcome after severe traumatic brain injury: Rostami E: Glucose and the injured brain-monitored in
Systematic literature review. Neurocrit Care 17(1): the neurointensive care unit. Front Neurol 5(91):1–8,
131–138, 2012. 2014.
PROCEDURE
90
Cerebral Blood Flow Monitoring
Tracey M. Berlin
PURPOSE: Adequate cerebral blood flow (CBF) is essential for the delivery
of oxygen and glucose to brain tissue and for maintenance of normal cerebral
metabolic processes. CBF monitoring is performed in the patient with acute brain
injury for quantitative measurement and continuous monitoring of regional brain
perfusion. Monitoring of regional CBF using thermal diffusion flowmetry provides
important information related to the delivery of nutrients to brain tissue,
autoregulatory status, and cerebral vasoreactivity.
• CBF values above 55 to 60 mL/100 g/min may indicate a

PREREQUISITE NURSING state of hyperemia.11 Hyperemia may be a physiological
KNOWLEDGE response as the brain attempts to perfuse injured tissue or
when the delivery of blood to the brain exceeds demand.
• Understanding of neuroanatomy and physiology, specifi- Hyperemia may result in increased ICP due to vascular
cally intracranial dynamics, is needed. congestion (Table 90-1).
• Knowledge of sterile and aseptic technique is necessary. • Globally, failure of electrical activity and neurological
• Although representing only 2% of our body tissues, the dysfunction occur when CBF falls below 18 to 20 mL/
central nervous system receives 15% of the total cardiac 100 g/min, indicating a state of ischemia. Although CBF
output and uses approximately 20% of the total oxygen between 10 and 20 mL/100 g/min may be tolerated for
consumed by the body.13 minutes to hours before infarction, CBF of less than
• The brain depends on a constant supply of oxygen and 10 mL/100 g/min leads rapidly to neuronal death and irre-
glucose through CBF to maintain functional and structural versible brain damage (see Table 90-1).7,13,19
integrity.15 • Ischemia is defined as a decrease in blood flow below the
• If CBF falls below a certain threshold and oxygen extrac- level necessary to sustain normal cellular structure and
tion has been maximized, certain metabolic and electrical function. Ischemia can be global, as seen in severe hypo-
functions may be lost leading to ischemia, infarction and perfusion caused by cardiac arrest or intracranial hyper-
irreversible brain damage.3,15 tension. Ischemia can also be focal, as seen in occlusion
• Used as an adjunct monitor of trends along with other of an intracranial vessel by embolism or thrombus. Focal
neurological parameters (intracranial pressure [ICP], cere- ischemia does not necessarily lead to irreversible ischemic
bral perfusion pressure [CPP], and brain tissue oxygen damage in the entire area of reduced perfusion because of
[PbtO2]), CBF monitoring provides a direct measurement collateral blood flow.13,19
of regional cerebral perfusion. • CBF may vary depending on metabolic demands of the
• Direct monitoring of CBF could provide the opportu- brain, factors effecting delivery of blood flow, and factors
nity to diagnose and to correct insufficient CBF before effecting vasoreactivity, such as carbon dioxide and
deficits in tissue oxygenation and metabolism are oxygen levels.1,13
recognized.15,17 • A change of 1 mm Hg Paco2 results in a 2% to 3% change
• Measurement of CBF is relevant in conditions where in CBF between 20 and 80 mm Hg.11 Hypercapnia, and
alterations in CBF may lead to cerebral ischemia and the resulting decrease in extracellular pH, causes vasodila-
infarction. Indications for CBF monitoring include patients tion and increased CBF, while hypocapnia leads to vaso-
at risk for secondary brain injury, including severe trau- constriction and decreased CBF.8
matic brain injury, aneurysmal and traumatic subarach- • Regional measurements of CBF reflect a local area. Sig-
noid hemorrhage, brain tumor, stroke, and any condition nificant variation of CBF occurs in different locations
that potentially alters CBF.3,7 within one hemisphere as well as between hemispheres.7
• Globally, average CBF in adults is considered to be • Thermal diffusion flowmetry (TDF), based on the math-
around 50 to 60 mL/100 g/min.1,13 The normal range ematical separation of the thermal conductive and the
for CBF in white matter tissue is 18 to 35 mL/100 g/ perfusion components of thermal diffusion in brain tissue,
min.9 In gray, more metabolically active, cortical tissue, allows for continuous quantitative measurement of blood
CBF is higher, ranging from 50 to 80 mL/100 g/ flow at the patient’s bedside. TDF provides absolute
min.11 When measured in white matter, treatment goals values of CBF expressed as mL/100 g/min and has been
usually aim to keep CBF between 18 and 50 mL/100 g/ validated by comparison with Xenon Flow CT (XeCT)
min. (Table 90-2).2,3,7,15,17
811
TABLE 90-1 Global Cerebral Blood Flow (CBF) Thresholds in Adults

CBF (mL/100 g/min) Threshold Consequences
>55–60 Hyperemia Hyperemia
Possible increased intracranial pressure due to vascular congestion
30–55 Average CBF Normal cellular structure and function
20–30 Neurological function Start of neurological symptoms
Altered mental status
16–20 Ischemic threshold Isoelectric electroencephalogram
Electrical failure Loss of evoked potentials
Loss of consciousness
10–16 Ionic pump failure Na+ and K+ pump failure
Cytotoxic edema
Conversion to anaerobic metabolism
<10 Metabolic failure Complete metabolic failure
Compromise of cellular membrane integrity
Neuronal death
Note: Changes occur sooner when global CBF is compromised compared with regional changes in CBF. Tissue infarction is related not only to quantity of CBF but to
the duration of decreased perfusion.19
From Kirkness C: Cerebral blood flow monitoring. In Bader MK, Littlejohns LR, editors: AACN AANN protocols for practice: monitoring technologies in critically ill
neuroscience patients, Boston, 2009, Jones and Bartlett, 145–174; March K: Intracranial pressure concepts, cerebral blood flow, and metabolism. In Bader MK,
Littlejohns LR, editors: AANN core curriculum for neuroscience nursing, ed 5, Glenview, Ill, 2010, American Association of Neuroscience Nurses, 79–85; Noble KA:
Traumatic brain injury and increased intracranial pressure, J Perianesth Nurs 25(4):242–250, 2010; Zacharia BE, Connolly ES: Principles of cerebral metabolism and
blood flow, In Le Roux PD, Levine JM, Kofke WA, editors: Monitoring in neurocritical care, Philadelphia, 2013, Elsevier, 2–7.
TABLE 90-2 Technologies Available for Measuring Cerebral Blood Flow

Technology Area of Measurement Data Type Pros/Cons
Xenon-enhanced computed tomography Global Quantitative • Useful, comprehensive data
Single-photon emission computed tomography Global Quantitative • Expensive
• Requires patient transport
Positron emission tomography Global Quantitative • Radiation exposure
Computed tomography & magnetic resonance Global Qualitative • Cannot give continuous trendable
perfusion data
• Qualitative data cannot be used
Angiography Global Qualitative
to establish threshold levels of
Computed tomography angiography Global Qualitative perfusion for treatment decisions.
Functional magnetic resonance imaging Global Qualitative
Laser Doppler Focal Qualitative
Thermal diffusion flowmetry Focal Quantitative • Real-time, continuous data at the
bedside
• Absolute, quantitative data
• Can be used to set thresholds for
treatment decisions.
Courtesy Hemedex, Inc., Cambridge, MA.
• Currently only one direct regional CBF monitor using flow over a range of perfusion pressures, so that CBF
thermal diffusion flowmetry is available (from Hemedex, remains constant despite alterations in CPP.18 Associated
Inc., Cambridge, MA) (Figs. 90-1 and 90-2). with a poorer outcome, impaired autoregulation may
• TDF may be useful following traumatic brain injury (TBI) make the brain more vulnerable to increased ICP during
and subarachnoid hemorrhage (SAH) to detect changes in times of hypertension and to secondary ischemic injury
regional CBF and to monitor response to therapy. Follow- during times of hypotension.7,10
ing aneurysmal SAH, TDF allows for detection and moni- • TDF allows the assessment of cerebrovascular reactivity
toring of decreases in CBF due to cerebral vasospasm that to Paco2 changes and can be of great utility to target
may lead to ischemia and/or infarction (Fig. 90-3). 3,7,10 moderate hyperventilation, particularly in patients with
• TDF may be useful in assessing cerebral autoregulation. altered cerebral autoregulation.3,14
With intact autoregulation, arterial diameter can increase • The absolute values provided by TDF allow clinicians to
or decrease to actively control CBF and maintain constant distinguish between elevations of ICP associated with
90 Cerebral Blood Flow Monitoring 813
Figure 90-1 Photograph of the Bowman Perfusion Monitor and thermal diffusion probe used to
measure cerebral blood flow. (Courtesy Hemedex, Inc., Cambridge, MA.)
Figure 90-2 Screen shot from the Bowman Perfusion Monitor Figure 90-3 Screen shot from the Bowman Perfusion Monitor
showing graphic trend and numeric display of normal cerebral showing graphic trend of declining cerebral blood flow in a patient
blood flow (perfusion) in white matter. The k value shows normal developing vasospasm after aneurysmal subarachnoid hemorrhage.
thermal conductivity (4.8 to 5.9) and the Probe Placement Assistant The gap in data from 05:35 to 05:40 represents a normal period of
(PPA) shows low probe pulsatility (PPA is “0” and green). Brain automatic recalibration. Vasospasm was later confirmed by angiog-
temperature (temp °C) and the temperature difference between the raphy. This screen shot was taken in review mode where data stored
active and passive thermistors (δ temp °C) are also displayed. on the monitor can be scrolled backward and forward at any scale
(Courtesy Hemedex, Inc., Cambridge, MA.) for review. (Courtesy Hemedex, Inc., Cambridge, MA.)
ischemia or with hyperemia.15 Absolute values also allow • TDF works by insertion of a perfusion probe into brain
clinicians to assess the effectiveness of therapeutic inter- tissue either through an intracranial bolt, or by tunneling.
ventions and utilize goal-directed therapies (Fig. 90-4).17,18 The perfusion probe is inserted 2.5 to 3.0 cm into white
• TDF regional CBF values are associated with outcome. matter and should be placed so that the probe tip is
Patients demonstrating a significant regional CBF increase approximately 1 cm away from other probe tips.6 Perfu-
from the baseline tend to have a good outcome, whereas sion probes are safe with computed tomography (CT) but
very low initial values with no increase from the baseline not currently with magnetic resonance imaging (MRI)
are associated with a poor outcome.9 (Fig. 90-5).6
A B
Figure 90-4 A, A screen shot from the Bowman Perfusion Monitor (BPM) showing a graphic
trend of the decline and subsequent recovery of cerebral blood flow (CBF) in a patient who received
a routine dose of nimodipine. This medication is frequently used as standard of care for prevention
of vasospasm after aneurysmal subarachnoid hemorrhage. The sharp increase in CBF just after the
time of nimodipine administration represents a motion spike when the patient was repositioned. The
gap in data, occurring when CBF was at its lowest, represents a period of recalibration as the BPM
verifies the drastic change in perfusion. B, The graph shows this patient’s mean arterial pressure
(MAP) and cerebral perfusion pressure (CPP) in the corresponding timeframes. The decline and
recovery of CBF that mirrors the decline and recovery of MAP and CPP indicate a loss of cerebral
autoregulation. This screen shot was taken in review mode where data stored on the monitor can be
scrolled back and forward at any scale for review. (Courtesy Hemedex, Inc., Cambridge, MA.)
A B
Figure 90-5 Illustrations of placement options for the thermal diffusion probe. A, Shows place-
ment of the probe through a single lumen bolt. B, Shows tunneling of the probe. Hemedex recom-
mends bolting. One, two, and four lumen bolts are available. (Courtesy Hemedex, Inc., Cambridge,
MA.)
Figure 90-6 Illustrations of the thermal dilution probe showing the active (distal) thermistor that
heats brain tissue and measures cerebral blood flow along with the passive (proximal) thermistor
that measures baseline tissue temperature.
• Placement of the probe may be ipsilateral or contralateral • A thermistor at the tip of the probe heats surrounding brain
to the pathology. The physician placing the probe deter- tissue ≈2 to 3 °C above baseline tissue temperature (mea-
mines the catheter placement location after review of the sured by a more proximal thermistor) (Fig. 90-6). The
CT scan and after consideration of the most appropriate power dissipated by the heated thermistor provides a
monitoring area based on diagnosis and pathology, avoid- measure of the tissue’s ability to carry heat by thermal
ing areas of infarct or hematoma.4 conduction in the tissue and by thermal convection due to
• Contraindications for CBF monitoring include patients tissue blood flow.12,16 Therefore, the greater the blood
with a coagulopathy, those receiving anticoagulation flow, the higher the thermal dissipation and the greater the
therapy, and those with an insertion site infection.7 power required to maintain the temperature elevation.
• Accuracy of the probe is dependent on placement of the CBF is measured and displayed on the monitor as a perfu-
probe into white matter. The probe must be positioned in sion value of mL/100 g/min.6,12
an area not affected by cardiac-induced vessel pulsatility • To prevent thermal injury to brain tissue, the probe tip will
that may introduce artifact. The monitor has a built-in not heat above 41 °C. Clinically, perfusion will not be
pulse detector (PPA). PPA should be low (between 0 and measureable if the patient’s brain tissue temperature is
2.0) with a green indicator box. As pulsatility rises, values ≥39.5 °C.
of 2.1 to 5.0 are displayed with a yellow indicator box; • The probe is approved for 10 days of single-patient use.
and values of 5.1 to 10.0 are displayed with a red indicator The monitor stores 15 days of data. Data can also be
box along with a message that the probe should be repo- downloaded for long-term storage and analysis.6
sitioned away from the pulsating vessel by withdrawing • The monitor has three phases: (1) temperature stabiliza-
the probe approximately 1 mm. The monitor is pro- tion—establishes baseline tissue temperature and ensures
grammed to not provide a perfusion measurement if the tissue has returned to baseline since previous measure-
PPA is red (>5). ment (may take 2 to 7 minutes), (2) calibration—
• In white matter, tissue thermal conductivity (displayed on calculation of the K value and PPA (10 seconds), and (3)
the monitor as the K value) is 4.8 to 5.9. If K is abnormally perfusion measurement for a default period of 30 minutes.
high above this range, it indicates that the probe is in a All phases occur automatically when the probe and cable
ventricle. If it is abnormally low, it indicates that the probe are connected and also during automatic recalibration
temperature sensor is dislodged outside the brain. Thermal periods which occur every 30 minutes (Fig. 90-7).
conductivity of white matter varies with the amount of • Limitations to TDF monitoring include the following: loss
water content (edema) in the brain. The K value and PPA of perfusion calculations during periodic recalibration
function as reliability indicators for the perfusion value (i.e., reassessment of tissue thermal conductivity and pul-
displayed.6 satility), patient movement, or patient fever above 39.5 °C;
• Explain the insertion process, patient monitoring, and care

involved with CBF monitoring. Rationale: Explanation
may alleviate anxiety and stress and stimulates requests
for clarification or additional information.

PREPARATION
Patient Assessment
• Assess the patient’s neurological status. Rationale: Per-
forming a baseline neurological assessment enables the
nurse to identify changes that may occur as a result of
Figure 90-7 Three phases of the perfusion measurement cycle. probe insertion.
• Assess the patient for signs or symptoms of local infection
at the intended insertion location. Rationale: Evidence of
local infection is a contraindication to probe insertion.
probe displacement; and lack of global information • Obtain and review coagulation laboratory results (e.g.,
because of small volume of tissue being monitored.3,9 complete blood count, platelet count, prothrombin time,
• Transcranial Doppler (TCD) monitoring may also be per- partial thromboplastin time, bleeding time, and interna-
formed to measure blood flow velocities of the major tional normalized ratio). Rationale: Assessment identifies
vascular branches of the brain. TCD monitoring is a non- the patient’s risk for bleeding.
invasive ultrasound technology that penetrates the skull • Assess patient’s temperature and institute measures
providing blood flow velocity measurement to assess according to orders from the physician, advanced practice
vasospasm severity, location of intracranial stenosis, nurse, or other healthcare professional to reduce fever.
occlusions, or emboli, and monitor hemodynamic changes Rationale: Thermal diffusion flowmetry technology will
associated with impaired intracranial perfusion.7,8 By not provide perfusion values while the patient’s baseline
measuring blood flow velocity, TCD provides an indirect brain temperature exceeds 39.5 °C.
measure of CBF and is best used in conjunction with other
parameters for making treatment decisions.7 Patient Preparation
EQUIPMENT identifiers. Rationale: Before performing a procedure, the
• Cranial access kit for the intended intervention.
• Cranial bolt kit (if using to secure the probe) • Ensure that the patient and family understand the proce-
• Thermal diffusion probe dure. Answer questions as they arise, and reinforce infor-
• Bowman perfusion monitor (BPM) with cables mation as needed. Most patients who need CBF monitoring
• Sterile gloves and drapes have an altered level of consciousness. Rationale: Infor-
• Masks, caps, and nonsterile gloves mation previously taught is evaluated and reinforced.
• Sterile surgical pen • Ensure that informed consent has been obtained. Ratio-
• Sterile dressing supplies nale: Informed consent protects the rights of the patient
Additional equipment, to have available as needed, includes and makes a competent decision possible for the patient.
the following: However, in emergency circumstances, time may not
• Bedside table allow for the consent form to be signed.
• IV pole • Perform a preprocedure verification and time out. Ratio-
nale: Ensures patient safety.
PATIENT AND FAMILY EDUCATION • Administer sedation and/or analgesia as prescribed before
beginning the insertion procedure. Rationale: Sedation
• Assess patient and family understanding of the purpose of and/or analgesia facilitate the insertion process.
cerebral perfusion monitoring. Most patients who need • Assist the patient to the semi-Fowler’s position with the
cerebral perfusion monitoring have an altered level of head in the neutral position and the head of bed elevated
consciousness with a Glasgow Coma Score of 8 or less, 30 to 45 degrees. Rationale: Patients who are candidates
so education is typically directed toward the family. for CBF monitoring may have increased ICP. Elevating
Rationale: Understanding may reduce anxiety and stress, the head of the bed and placing the head in the neutral
stimulate requests for clarification or additional informa- position act to decrease intracranial pressure by enhancing
tion, and increase awareness of the goals, duration, and jugular venous outflow and provide optimal accessibility
expectations of the monitoring system. for probe insertion.
Procedure for Cerebral Blood Flow Monitoring: Insertion (Assist), Care, Troubleshooting,
and Removal
1. HH
2. PE
3. Place the perfusion monitor near Secures the monitor and allows the
the head of the bed; either on a monitor cable to reach the patient’s
flat surface or mounted on a head.
sturdy pole.
4. Plug the power cord into an AC Provides the power source.
wall outlet.
5. Attach the cable (umbilical cord) Prepares the equipment. The cable connection has a twist
to the perfusion monitor. collar for proper alignment and
connection.
6. Turn on the perfusion monitor Prepares the monitor.
using the toggle switch on the
right front of the monitor.
7. HH
8. Apply masks, eye protection, Prepares for sterile procedure.
caps, sterile gowns, and sterile
gloves.
preparation, cleansing with Use of povidone-iodine versus
antiseptic solution). chlorhexidine is controversial.
The antiseptic solution should be
allowed to dry before initial
incision. Studies suggest that
10. Assist as needed with draping the Prepares a sterile environment for the
patient.
the sterile trays and perfusion process.
probe.
12. Assist as needed with insertion of Bolt system must be inserted before Physician, advanced practice nurse, or
an intracranial bolt (see probe. other healthcare professional must
Procedure 92). use the drill bit provided in the bolt
kit (not the one provided with the
drill) to assure proper sized hole to
accommodate the bolt.
Bolt systems may have additional
lumens for insertion of other
monitoring probes (e.g., ICP, PbtO2
etc.).
13. Assist as needed with insertion of Facilitates the insertion process. Physician, advanced practice nurse, or
the perfusion probe. other healthcare professional must
be sure to fully incise the dura for
correct placement of the probe into
brain tissue.
Physician, advanced practice nurse, or
other healthcare professional should
consult the enclosed instructions for
use for information on proper depth
markings to assure accurate probe
placement.
14. Connect the perfusion probe to Initiates monitoring. Blue connectors must be completely
the perfusion monitor cable. dry. Moisture in the connectors can
cause monitoring to fail.
and Removal—Continued
15. Observe the message bar on the Initiates monitoring.
perfusion monitor screen. If
directed to, press the Start button
(top soft blue button) to begin
monitoring.
16. Observe the monitor through the Assures adequacy of probe placement Full cycle takes approximately 6
first full cycle of temperature if K value is 4.8–5.9 and if PPA is minutes. The physician should
stabilization, calibration, and close to zero. remain at the bedside, in sterile
perfusion calculation. Take note attire until the cycle is complete.
of the initial brain temperature, K This allows the opportunity for
value, and PPA. (Level M*) repositioning of the probe to
achieve better placement if
necessary.
17. Assist as needed to mark and Allows visualization of insertion level A sterile surgical pen should be used
secure the probe. and immediate detection if the to mark the probe where it exits the
probe migrates. bolt.
18. Secure the probe and cable with Secures the cable and probe to
two points of tension: tape the prevent tension at the insertion site.
probe to the bolt lumen and
anchor the cable to the shoulder.
19. Assist as needed with applying a Protects the insertion site and
sterile dressing to the insertion site prevents contamination.
according to hospital protocol.
20. Secure the cable to the patient’s Supports the entire system and Use provided cable clip to secure the
shoulder so that it does not get reduces the risk of pulling on the cable to the patient’s gown taking
entangled in the side rails and probe. care to avoid contact with or
does not touch the floor. pressure on the patient’s skin.
21. Discard used supplies in Removes and safely discards supplies
appropriate receptacles. and sharp objects.
22. HH
23. Ensure a CT scan is obtained as CT scan is recommended to assess CT scan also helps detect possible
prescribed. probe placement. complications from insertion (e.g.,
hemorrhage).
Care of the Perfusion Monitor and Probe
1. HH
2. PE
3. Visually inspect the probe and Alerts caregiver to potential problems Notify physician, advanced practice
insertion site dressing with each with the probe or insertion site. nurse, or other healthcare
neurological assessment. professional if probe has moved or
A. Note the probe marking where if there are signs of infection at the
it exits the bolt. insertion site.
B. Check the security of the
probe at the insertion site.
C. Assure that the cable remains
taped to the patient’s shoulder.
D. Assess the insertion site for
signs of drainage, redness, or
swelling.7
4. Assess the perfusion trends on Allows correlation of perfusion with If autoregulation is altered, treatments
the perfusion monitor screen and clinical condition/treatments and and medications that affect blood
correlate the trends with helps to individualize care. pressure (e.g., Nimodipine) may
neurological examinations, affect cerebral perfusion.
patient activity, and treatments
(e.g., medications), etc.

5. Note regular gaps in data Probe periodically assesses the tissue Default recalibration period is every
representing probe recalibration. environment and characteristics to 30 minutes. This can be changed
assure accurate data. using the Options soft button on the
monitor and changing the Perfusion
Period.
6. Patient transport: Pauses monitoring for patient The probe is CT compatible.
A. Disconnect the probe from the transport. The probe is not MRI compatible.
cable. The monitor is typically left behind
B. Pause monitoring by pushing for transport. However, some
the Stop button (top blue soft physicians, advanced practice
button). nurses, and other healthcare
C. Resume monitoring upon professionals wish to monitor
return by reconnecting the perfusion during surgery or other
probe and cable, and pressing procedures, such as angiography.
the same button (now labeled
Start).
Troubleshooting the Monitor
1. HH
2. PE
3. If the screen is blank, check the Assures power to the monitor.
On/Off switch and the power
supply. The perfusion monitor
does not have a battery and must
be connected to AC outlet for
power.
4. Look for paper printout of error Perfusion monitor provides report of
code from front of monitor. monitoring errors.
5. Check status bar at the top of the Indicates possible reasons for data
monitor screen for message. disruption.
6. Assess insertion site for security Provides information about possible If the probe has moved, the monitor
of the probe—the exit mark, probe movement and slippage from will have difficulty with
tightness of compression cap, etc. the bolt. temperature stabilization and may
Note PPA. display a high PPA. Because
sterility cannot be assured, the
probe should not be reinserted if it
has become dislodged.
7. Assess patient’s brain temperature Assures that active thermistor will not Once brain temperature is below
reading on the perfusion monitor heat brain tissue above 41 °C. 39.5 °C, the perfusion probe will
screen. The probe is instructed to resume normal operation.
not operate if brain temperature is
≥39.5 °C.
8. Assess patient activity. The probe Limited patient movement reduces
is sensitive to relative probe-brain motion artifact by reducing relative
tissue motion and may not work probe-brain tissue motion.
well in a patient who is restless
without a well-secured probe.
9. Assess whether the cable is If the probe cable is damaged, values Take care when inserting or removing
damaged; if so, replace the cable. can be incorrect or measurement the cable from the monitor—do not
can be interrupted. pull/push the cable straight in or
out. The cable has a twist collar to
assure secure connection to the
monitor.
Removal of the Probe
1. HH
2. PE
3. Position the patient in a semi- Prepares patient for device removal.
Fowler’s position.
4. Turn off the monitor. Facilitates device removal. If the message bar indicates that data
storage is full, notify your
supervisor. The perfusion monitor
stores 15 days of data. Data will
need to be uploaded to the
Hemedex web manager or deleted
for additional data storage to occur.
5. Assist as needed with removal of Facilitates device removal. If multiple probes have been inserted
the dressing, perfusion probe, and into the bolt system, it is important
bolt system. to remove the probes before
removing the bolt to prevent injury
to brain tissue with the twisting
action of bolt removal.
6. Assist if needed with applying an Reduces risk for infection. Assess for signs of bleeding,
occlusive sterile dressing to the cerebrospinal fluid (CSF) leak, and
site. signs and symptoms of infection.
7. Discard used supplies Removes and safely discards used
appropriately. supplies.
8. HH
9. Clean monitor, cable, and power Disinfects equipment and prepares it
cord according to hospital for use on next patient.
protocol.
PE

• Perfusion probe is placed in the correct position as • Perfusion probe not placed correctly as evidenced by
evidenced by: poor visualization on CT scan
• K value is 4.8–5.9 • K value <4.8 or >5.9
• PPA box appears “green” with a pulsatility index • PPA box appears “red” with a PI of 5–10
(PI) of 0–2 • Perfusion values in white matter are <15 mL/100 g/
• CT scan verifies proper probe position and no min or >50 mL/100 g/min
evidence of hemorrhage or hematoma • Failure to identify low perfusion or high perfusion
• Monitoring is able to begin with first perfusion cycle conditions
• Perfusion values are acceptable: • Inability to adequately perfuse the brain according to
• Perfusion in white matter is between 18 and metabolic demand
50 mL/100 g/min or as indicated by patient • Adverse events such as hemorrhage and infection
condition occur
• Detection and monitoring of low perfusion states • Pain
• Detection and monitoring of hyperemia
• Assessment of treatment effects (e.g., medications) on
perfusion
• Immediate intervention and management of
compromised CBF
• Ability to individualize patient care by maintaining
adequate perfusion according to cerebral metabolic
demand
• No adverse events (e.g., hemorrhage, infection) as a
result of monitoring

interventions.
1. Assess the patient’s baseline Provides assessment of patient status • Changes in neurological status
neurological status, vital signs, and before, during, and after the • Changes in vital signs
ICP every 15 minutes and more procedure. • Changes in ICP and CPP
frequently if necessary during and
immediately after the procedure,
then hourly or according to
2. Maintain perfusion values between Represents normal values. • Decreased perfusion values
18 and 50 mL/100 g/min or as • Increased perfusion values
prescribed. • Perfusion values that change in
response to patient activity or
treatment (e.g., a decrease in
perfusion following medication
administration or adjustment of
mechanical ventilator settings)
3. In states of low perfusion, assess Provides assessment of factors that • Uncontrolled pain/agitation
for and treat factors that may may reduce CBF. • Fever
increase demand for blood flow • Shivering
(pain, fever, agitation, shivering, • Seizure
and seizure) and/or decrease • Bradycardia
delivery of flow (cardiac issues, • Hypotension
bradycardia, hypotension - • Hypovolemia
particularly during loss of cerebral • Hypocapnia
autoregulation, hypovolemia,
hypocapnia, and
vasoconstriction).7,10–12 (Level D*)
4. In states of high perfusion, assess Provides assessment of factors that • Hypothermia
for and treat factors that may may increase CBF. • Excessive sedation
decrease demand for blood flow • Hypervolemia
(hypothermia, sedation, paralysis, • Hypercapnia
and anesthesia) and/or increase
delivery of flow (hypervolemia,
hypercapnia/vasodilation).7,10–12
(Level D)
Documentation
Documentation should include the following: • Hourly values, including perfusion, K-value, PPA,
• Patient and family education perfusion temperature, and other hemodynamic
• Preprocedure verifications and time out parameters (e.g., vital signs, cardiac output [CO],
• Completion of informed consent cardiac index [CI], systemic vascular resistance
• Insertion of the CBF probe [SVR]), and neurological parameters (e.g., ICP, CPP,
• Patient tolerance of the procedure PbtO2, ETCO2)
• Insertion site assessment • Occurrence of unexpected outcomes and
• Neurological assessments interventions
• Pain assessment, interventions, and effectiveness

90 Cerebral Blood Flow Monitoring 822.e1
References 15. Pennings FA: Laser doppler flowmetry, thermal diffusion

1. Barazangi N, Hemphill J III: Advanced cerebral flowmetry, and orthogonal polarizing spectral imaging.
monitoring in neurocritical care. Neurol India 56(4): In Le Roux PD, Levine JM, Kofke WA, editors:
405–414, 2008. Monitoring in neurocritical care, Philadelphia, 2013,
2. Bhatia A, Gupta AK: Neuromonitoring in the intensive Elsevier, pp 314–319.
care unit I: Intracranial pressure and cerebral blood flow 16. Rosenthal G, et al: Incorporating a parenchymal thermal
monitoring. Intensive Care Med 33:1263–1271, 2007. diffusion cerebral blood flow probe in bedside assessment
3. Bouzat P, et al: Beyond intracranial pressure: Optimization of cerebral autoregulation and vasoreactivity in patients
of cerebral blood flow, oxygen, and substrate delivery with severe traumatic brain injury. J Neurosurg
after traumatic brain injury. Ann Intens Care 3:23, 2013. 114(1):62–70, 2010.
4. De Georgia MA, Deogaonkar A: Multimodal monitoring 17. Vajkoczy P, et al: Monitoring cerebral blood flow in
in the neurological intensive care unit. Neurologist neurosurgical intensive care. Eur Neurol Dis 1(2):8–10,
11:45–54, 2005. 2007.
5. Hebl JR: The importance and implications of aseptic 18. Vidgeon SD, Strong AJ: Multimodal cerebral monitoring
techniques during regional anesthesia. Reg Anesth Pain in traumatic brain injury. J Intens Care Soc 12(2):
Med 31:311–323, 2006. 126–133, 2011.
6. Hemedex: BPM neuromonitoring guide, Cambridge, 2011, 19. Zacharia BE, Connolly ES: Principles of cerebral
Hemdex. metabolism and blood flow. In Le Roux PD, Levine JM,
7. Kirkness C: Cerebral blood flow monitoring. In Bader Kofke WA, editors: Monitoring in neurocritical care,
MK, Littlejohns LR, editors: AACN AANN protocols for Philadelphia, 2013, Elsevier, pp 2–7.
practice: Monitoring technologies in critically ill Additional Readings
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pp 145–174. Alexandrov AW: Transcranial doppler monitoring. In Weigand
8. Krejza J, Arkuszewski M: Neurosonology: Transcranial DLM, editor: AACN procedure manual for critical care,
Doppler and transcranial color-coded duplex sonography. ed 6, Philadelphia, PA, 2011, WB Saunders, pp 849–860.
In Le Roux PD, Levine JM, Kofke WA, editors: Ko SB, et al: Real time estimation of brain water content in
Monitoring in neurocritical care, Philadelphia, 2013, comatose patients. Ann Neurol 72(3):344–350, 2012.
Elsevier, pp 300–313. Le Roux PD, Levine JM, Kofke WA, editors: Monitoring in
9. Le Roux P: Physiological monitoring of the severe neurocritical care, Philadelphia, PA, 2013, Elsevier.
traumatic brain injury patient in the intensive care unit. Panczykowski DM, Shutter L: Brain tissue perfusion
Curr Neurol Neurosci Rep 13:331–347, 2013. monitoring. In Miller CM, Torbey MT, editors:
10. Le Roux P, et al: Consensus summary statement of the Neurocritical care monitoring, New York, 2014, Demos
international multidisciplinary consensus conference on Medical, pp 59–69.
multimodality monitoring in neurocritical care. Neurocrit Rosenthal G, et al: Incorporating a parenchymal thermal
Care September 2014. doi: 10.1007/s12028-014-0041-5. diffusion cerebral blood flow probe in bedside assessment
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2012.
PROCEDURE
91
Cerebral Microdialysis
Sandy Cecil
PURPOSE: Cerebral microdialysis is a minimally invasive technique for
continuous sampling of the interstitial fluid chemistry of tissues and organs. It is a
well-established brain monitoring technology in neurocritical care and can be used
in specific regions of the brain to analyze brain tumor substances,
neurotransmitters, or other aspects of brain tissue chemistry.3,7 Microdialysis
improves our understanding of energy metabolism in patients with traumatic brain
injury or subarachnoid hemorrhage.3,7 In these patients, microdialysis can provide
an early warning sign of impending ischemia by measuring the chemical markers of
metabolism and ischemia (glucose, pyruvate, and lactate) as well as markers of cell
damage (glutamate and glycerol).2,6,7
PREREQUISITE NURSING glucose and oxygen as the main components of cell

KNOWLEDGE energy.1-4,7 Glucose is broken down to pyruvate during
glycolysis. When oxygen is available, pyruvate goes
• A fundamental understanding of neuroanatomy and physi- through the citric acid cycle (aerobic metabolism), gener-
ology is needed. ating high production of adenosine triphosphate (ATP).
• A basic understanding of bioenergetics of hypoxia and/or ATP is also produced (minimal amounts) in glycolysis.
ischemia of the brain is necessary. During ischemia, a lack of oxygen and glucose results in
• A basic understanding of the ISCUSflex and its use for the conversion of pyruvate to lactate during anaerobic
analyzing microdialysis samples is necessary. metabolism. Glucose is a primary source of energy to the
• A basic understanding of catheter positioning within the brain and is an important marker of changes in brain
brain is needed because positioning can influence the metabolism. Cerebral glucose levels account for approxi-
sample results. mately two thirds of systemic glucose.
• A basic understanding of cerebral perfusion pressure • Normal pyruvate: 166 ± 47 µm. Pyruvate and lactate
(CPP) is important. CPP provides the necessary blood reflect cell metabolism. Pyruvate decreases with inade-
flow for the metabolic needs of the injured brain and for quate glucose supply.
avoiding the exacerbation of ischemic insults. • Normal lactate: 2.9 ± 0.9 µm. Lactate increases with
• A basic understanding of cerebral autoregulation is ischemia. During ischemia, a lack of oxygen and glucose
needed. results in anaerobic metabolism, reduced levels of pyru-
• The microdialysis system3,4 is composed of the microdi- vate, and increased levels of lactate. Lactate alone is insuf-
alysis catheter, perfusion syringe, perfusion pump, micro- ficient as a marker of brain ischemia.
vials, and the tissue chemistry analyzer. The catheter • Normal lactate/pyruvate ratio (LPR): 23 ± 4 µm. Ischemia
(surrounded by a semipermeable distal end membrane) is is defined by the combined criteria of LPR >40 and
placed into brain tissue through a bolt or burr hole or glucose <0.2 mmol/L. The LPR reflects anaerobic metab-
is implanted during an open craniotomy. The catheter is olism and increases with ischemia. The LPR is a good
attached to a microdialysis syringe filled with sterile per- indicator of ischemic and hypoxic conditions as well as
fusion fluid (artificial cerebrospinal fluid [CSF]). The possible mitochondrial damage.
syringe is placed in a battery-operated pump that is cali- • Normal glycerol: 20 to 50 µm. The biochemical markers
brated to pump the perfusion fluid through the catheter of cellular damage are reflected in glycerol and glutamate.
at a rate of 0.3 µL/min. The chemical substrates pass Glycerol reflects cell injury and lysis and is a marker of
from brain tissue through the catheter’s semipermeable cell membrane function. Levels increase when cells do not
membrane and are collected with the perfusion fluid in a have sufficient energy to maintain homeostasis.
small vial attached to the catheter (the microvial). The vial • Normal glutamate: 10 µm. Glutamate is an early indirect
is then placed in a point of care (POC) analyzer of the marker of cell damage and reflects cell membrane break-
chemical substrates. down. It increases with ischemia.
• The analyzer can accommodate multiple vials, allowing • Continual assessment of patient’s neurological status with
testing on multiple patients at the same time. continuous sampling of the interstitial fluid chemistry of
• Normal glucose: 1.7 ± 0.9 mmol/L. The biochemical the brain tissue provides focused information for markers
markers of metabolism and ischemia are reflected in of ischemia and cell damage.
823
EQUIPMENT information about the biochemistry of the brain and how

seriously brain cells are affected by injury to the brain.
• Sterile gowns, sterile drapes, sterile gloves, nonsterile • Explain the use of the ISCUSflex equipment. Rationale:
gloves, caps, gloves, and face masks Explaining how the samples from the brain are transferred
• Shave preparation kit to the microdialysis analyzer will allay fears and reduce
• Antiseptic solution anxiety regarding the equipment utilized.
• The CMA 70 Brain Microdialysis Catheter or CMA 70 • Explain to the patient and family that continual assess-
Microdialysis Bolt Catheter ment of the patient’s neurological status, along with con-
• Cranial access tray tinuous sampling of the interstitial fluid chemistry of the
• Scalpel brain tissue, will be completed hourly and as needed.
• Dressing supplies, including 4 × 4 gauze Rationale: Use of microdialysis neurointensive care is
• Sterile dressing supplies focused on tissue ischemia and cell damage and requires
• The ISCUSflex frequent assessment and sampling.
• The CMA 106 Microdialysis Pump
• Artificial CSF fluid PATIENT ASSESSMENT AND
• Batteries (2 × 3 v) PREPARATION
• Microvials
• Microvial racks Patient Assessment
• CMA pump syringe • Assess the patient’s neurological status. Rationale: Per-
• Perfusion fluid forming a baseline neurological assessment enables the
• Reagents nurse to identify changes that may occur as a result of the
Additional equipment, to have available as needed, includes insertion of the microdialysis catheter.
the following: • Assess the patient for signs or symptoms of local infection
• Bedside table at the intended insertion location. Rationale: Evidence of
local infection is a contraindication to microdialysis cath-
PATIENT AND FAMILY EDUCATION eter insertion.
• Assess patient and family understanding of complex brain Patient Preparation

injuries that require vigilant monitoring of multiple param- • Verify that the patient is the correct patient using two
eters in hopes of preventing secondary brain injuries. Ratio- identifiers. Rationale: Before performing a procedure, the
nale: This assessment may help identify patient and family nurse should ensure the correct identification of the patient
educational needs. for the intended intervention.
• Explain to the patient and family that the procedure may • Perform a preprocedure verification and time out. Ratio-
be performed in the intensive care unit (ICU). Rationale: nale: This ensures patient safety.
This may reduce patient and family anxiety. • Ensure that informed consent has been obtained. Ratio-
• Explain the basic principles of cerebral metabolites. nale: Informed consent protects the rights of the patient
Rationale: This information may answer patient and and makes a competent decision possible for the patient;
family questions and reduce anxiety. however, in emergency circumstances, time may not
• Explain the insertion of the brain microdialysis catheter allow for the consent form to be signed.
and the region of the brain where the catheter will be • Administer preprocedural analgesia or sedation as pre-
inserted (e.g., at-risk penumbra). Rationale: Explain scribed. Rationale: The patient needs to remain still
that monitoring areas of the brain may give us crucial during microdialysis catheter insertion.
Procedure for Performing Cerebral Microdialysis

1. HH
2. PE Sterile procedure in which the
or other healthcare professional
dons full sterile PE. The critical
care nurse assisting will don a
surgical hat and mask.
91 Cerebral Microdialysis 825
Procedure for Performing Cerebral Microdialysis—Continued

3. The microdialysis catheter may Placing the catheter through an This is surgical procedure that is most
be introduced through an existing existing intracranial bolt system optimally completed in an operating
intracranial bolt system or be must be a sterile procedure if room.
surgically placed. performed at the bedside. Typically a dressing is not required at
If not using an intracranial bolt The patient may also be taken to the the catheter insertion site.
system, the physician will insert operating room for surgery with
the microdialysis catheter into removal of the bone flap and
brain tissue and secure the placement of the catheter under
catheter to the scalp. visual inspection.
4. If using an intracranial bolted The sterile, single-use CMA 70 The intracranial catheters may be
catheter, the critical care nurse Microdialysis Bolt Catheter is inserted in the ICU or the operating
assists with the procedure. designed for implantation in brain room.
A. The physician will place the tissue through an intracranial access The catheter is location sensitive.
bolt and secure it to the skull. device that is fixed to the skull. Data will differ depending on the
B. The physician, advanced Tightening the compression screw proximity of catheter to the area of
practice nurse, or other will help to secure the catheter. injury.
healthcare professional will Typically a dressing is not required at
insert the catheter into the the catheter insertion site.
intracranial bolt or designated
microdialysis port/lumen and
fix the catheter at the Luer
Lok connector.
5. Ensure that once the catheter is Determines the position of the
placed, a brain computed catheter in relation to the tissue
tomography (CT) scan is obtained pathology.
as prescribed.
6. Fill and connect the syringe. The artificial CSF perfusion fluid (no Use only the artificial CSF provided
Once the microdialysis catheter is more than 2.5 mL) primes the by the manufacturer.
implanted and the wound is tubing/system.
closed the critical care nurse will:
A. Fill the microdialysis syringe
with 2.5 mL of artificial CSF
perfusion fluid. Ensure there
are no air bubbles.
B. Connect the syringe to the
catheter.
7. Prepare the pump: Prepares the system. The pump is portable, small, and
A. Place the syringe in the The pump is a small battery-driven lightweight and is self-controlled
microdialysis pump tip first pump with a flow of 0.3 µL/min. with LED function signals.
and piston second. Closing the lid starts a flush sequence The battery will need to be changed
B. Place the battery in the pump. that removes all air from the tubing after 5 days of use (or with every
C. Close the lid, which will start and the catheter and initiates the new patient).
a flush sequence. A blinking microdialysis process.
light on the syringe pump Prevents dislodgement.
indicates the stage in the
pump sequence.
D. Secure the pump near the
patient’s head.

8. Place a microvial in the vial Discard the first sample because it is If there is no fluid in the microvial,
holder of the catheter: diluted by the flush solution. check the pump’s flashing diodes
A. Discard the first vial after The microvial is the collection vial for malfunction. Check the battery,
30–60 minutes. for the interstitial fluid. and make sure that the pump lid is
B. Place a new vial in the holder closed, there is perfusion fluid in
to collect the first sample for the syringe, and the catheter tubing
analysis. is not kinked. If the problem
persists, open and close the lid of
the pump to initiate a flush.
9. Prepare the system. Refer to the Prepares the system for sample
user manual of ISCUSflex analysis and correct patient
Microdialysis Analyzer (CMA identification of samples analyzed.
Microdialysis AB, 2011) for
detailed instructions on:
A. How to start the ISCUSflex
analyzer.
B. Loading rinsing fluid.
C. Preparing and loading
reagents and control samples.
D. Registering the patient in the
analyzer.
E. Adding a new patient: select
an empty patient position
and add the patient’s name.
(Level M*)
10. Prepare the reagents: glucose, Prepares the equipment. Allow up to an hour for the analyzer
lactate, pyruvate, glycerol, and to calibrate the new reagents and
glutamate. run the controls. Follow all POC
A. Mix the solution and powder and clinical laboratory regulations.
of each reagent (respectively). Reagents and perfusion fluid must
B. Mix the solution and powder be replaced every 5 days.
by first opening the vial with
powder.
C. Remove and discard the
stopper.
D. Mix the powder and liquid of
each reagent together.
E. Set each one aside as you mix
the other four reagents.
F. Load into the analyzer in the
specified position per the user
manual.
11. Analyze the microdialysis Results appear in about 8 minutes. You do not need to reactivate the
samples: pump as you remove microvials.
A. Change the microvial every Generally samples are run every hour.
60 minutes or as prescribed. Samples may be run more
frequently as indicated by changes
in patient’s condition; samples can
be run every 10 minutes if
necessary.

91 Cerebral Microdialysis 827

B. Remove the microvial from Prepares equipment. Data are not provided continuously in
the microvial holder of the real time. Clinicians must look for
catheter and insert a new trends.
microvial into the microvial
holder of the catheter.
C. Choose the position of the Prepares equipment. You may use up to 16 different vial
vial for a specified patient positions for one patient.
position by adding a catheter
name at the preferred vial
position in the lower menu of
the patient screen.
13. HH

• Optimal placement of microdialysis catheter confirmed • Difficult to interpret if the microdialysis catheter ends
by CT scan; gold catheter tip is visible on CT scan5 up in normal tissue, in penumbra tissue surrounding a
• Ability to evaluate interventions4 contusion, or in dead tissue
• Provides information to assist in delivery of targeted • Cerebral hypoglycemia due to increased consumption
therapy for prevention of secondary ischemic injury (hyperglycolysis) and decreased delivery due to
• Identifies changes in chemistry that may develop into lower cerebral blood flow (CBF) after vasospasm or
secondary damage before clinical signs and symptoms intracranial hypertension
appear7 • Infection
• Ability to see effects of clinical therapies (for example, • Metabolic crisis as indicated by an elevated lactate-
tight vs. loose glycemic control) on brain metabolism2,3 pyruvate ratio (LPR), reduced glucose, and/or the
presence of glutamate or glycerol indicating ischemia
and cell death

interventions.
1. Assess the patient’s neurological Provides continual neurological • Change in level of consciousness
status every hour or more assessment and the ability to note (LOC), intracranial pressure (ICP),
frequently if neurological changes changes. CPP, pupil response, response to
are noted. stimuli, blood pressure, and heart
rate that suggest compromise in
neurological function
2. Monitor the cerebral microdialysis Provides trending data and allows • Changes to LPR after medication
trends (results have [at minimum] assessment of changes that may changes or mobility
a 1-hour lag time). result from procedures, medication • Abnormal trends in LPR
adjustments, mobility, and patient • Neurological changes such as
care needs. change in LOC, ICP, CPP, pupil
Evaluates changes in CPP, blood response, response to stimuli,
glucose levels, and oxygen blood pressure, and heart rate that
saturation against changes in tissue suggest compromise in
chemistry. neurological function
• Alert the physician if the chemical
condition of the tissue changes,
especially when levels and trends
are out of normal range

3. Assess the catheter site every 4 Provides an opportunity to assess the • Redness or swelling at catheter site
hours or more often if indicated.1,3 placement of the catheter and for • Leakage around microdialysis
(Level D*) signs and symptoms of infection. catheter
• Catheter dislodgement
Documentation
• Initial documentation (date and time) of catheter • Patient and family education
insertion, reagent activation, loading of syringe pump, • Insertion site assessment
loading of batteries in pump, and registration of patient • Hourly vital signs, laboratory values, hemodynamic
data into analyzer monitoring
• Ensure informed consent was obtained • Assessment of pain and response to pain medication
• Document glucose, lactate, pyruvate, glycerol, and • Sedation levels
glutamate levels in medical record every hour or as • Neurological assessments
prescribed by the physician • Patient tolerance of procedure

91 Cerebral Microdialysis 828.e1
References 5. Stahl N, Schalen W, et al: Bedside biochemical monitoring

1. Andrews PJ, Citerio G, et al: NICEM consensus on of the penumbra zone surrounding an evacuated acute
neurological monitoring in acute neurological disease. subdural hematoma. Acta Anaesthesiol Scand 108:211–
Intensive Care Med 34(8):1362–1370, 2008. 215, 2003.
2. Cecil S, Chen PM, et al: Traumatic brain injury: Advanced 6. Tisdall NM, Smith M: Cerebral microdialysis: Research
multimodal neuromonitoring from theory to clinical technique or clinical tool. Br J Anaesth 97(1):18–25,
practice. Crit Care Nurse 31:25–37, 2011. 2008.
3. Oliveira M, Cairalla AC, et al: Cerebral microdialysis in 7. Ungerstedt U: Microdialysis: principles and applications
traumatic brain injury and subarachnoid hemorrhage: State for studies in animal and man. J Intern Med 230:365–373,
of the art. Neurocrit Care 21(1):152–162, 2014. 1991.
4. Rostami E: Glucose and the injured brain monitored in the
neurointensive care unit. Front Neurol 5(91):1–5, 2014.
PROCEDURE
92
Intracranial Bolt and
Fiberoptic Catheter Insertion
(Assist), Intracranial Pressure
Monitoring, Care,
Troubleshooting, and Removal
Tess Slazinski
PURPOSE: The fiberoptic catheter is a device utilized for continuous
measurement of intracranial pressure (ICP). The fiberoptic catheter is placed in the
brain parenchyma and reflects pressure exerted by the intracranial contents, brain
tissue, blood, and cerebrospinal fluid (CSF) within the skull. The fiberoptic catheter
is inserted through a bolt. Unlike a ventricular catheter, which is attached to an
external transducer and drainage system, the fiberoptic catheter does not allow for
CSF drainage.
PREREQUISITE NURSING as 20 mm Hg but are short lasting and without clinical
KNOWLEDGE significance.1–3,7
• Cerebral perfusion pressure (CPP) is the pressure at which
• A fundamental understanding of neuroanatomy and physi- the brain is perfused. CPP is calculated by subtracting the
ology is needed. ICP from the mean arterial pressure. Normal CPP is
• Knowledge of aseptic and sterile technique is necessary. thought to be approximately 80 mm Hg.13 In severe trau-
• Proper equipment assembly and setup specific to the fiber- matic brain injury, the CPP for adults should range
optic ICP monitoring device must be understood. between 50 and 70 mm Hg.4 Patients with other neuro-
• ICP is the pressure exerted by the intracranial contents, logical injuries may require individualized CPP parame-
brain tissue, blood, and CSF. Increased ICP occurs when ters reflective of the neuropathology and brain perfusion
the intracranial volume exceeds the brain’s ability to com- needs. Research continues regarding the relationship
pensate for increased volume.15 between cerebral blood flow and CPP.
• Normal ICP ranges from 0 to 15 mm Hg; sustained ICPs • ICP and CPP must be considered together in management
of greater than 20 mm Hg are generally considered neu- of the patient. Cerebral autoregulation is the intrinsic
rological emergencies.5,6,12 ability of the cerebral vessels to constrict and dilate as
• ICP is measured via a catheter inserted into the brain needed to maintain adequate cerebral perfusion. Cerebral
parenchyma. The catheter is inserted through an intracra- autoregulation is impaired with brain injury and the cere-
nial bolt (Fig. 92-1). bral blood flow becomes passively dependent on the sys-
• The normal ICP waveform has three or four peaks with temic blood pressure. The cerebral blood vessels are no
P1 of greater amplitude than P2 and P3. P1 is thought to longer able to react to maintain CPP in response to a
reflect arterial pressure; P2, P3, and P4 (when present) have change in blood pressure.5,8
been described as choroid plexus or venous in origin (Fig. • Sustained ICP elevations of 20 mm Hg or greater
92-2).15 The amplitude of P2 may exceed P1 with increased necessitate immediate reporting and intervention. ICP
ICP or decreased intracranial compliance (Fig. 92-3). waveform changes that indicate loss of cerebral com-
• ICP waveform trends include a, b, and c waves. The a pliance or cerebral autoregulation should be reported
waves, also referred to as plateau waves, are associated immediately.5,10,12,15
with ICP values of 50 to 100 mm Hg and last 5 to 20 • ICP monitoring is indicated for the following:
minutes. The a waves (Fig. 92-4) are associated with ❖ Traumatic brain injury with a Glasgow Coma Scale
abrupt neurological deterioration and herniation. The b score of less than or equal to 8 and abnormal computed
waves (Fig. 92-5), with ICP values of 20 to 50 mm Hg tomography (CT) scan results or normal CT scan
and lasting 30 seconds to 2 minutes, may become a waves. results with two of the following: hypotension, greater
The c waves (Fig. 92-6) may coincide with ICPs as high than 40 years of age, and motor posturing4
829
mm Hg
100
90
80
70
60
50
40
30
20
10
0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Minutes
Figure 92-4 a or plateau waves. Open arrows indicate plateau
elevations in intracranial pressure. Note that when intracranial pres-
sure falls, it does not return to baseline preceding the first wave
(closed arrow). (From Marshall SB, et al: Neuroscience critical
care: Pathophysiology and patient management. Philadelphia,
1990, Saunders.)
Figure 92-1 Intracranial bolt inserted into the parenchyma.
(From Littlejohns L, Bader MK: AACN-AANN protocols for prac- mm Hg
tice: Monitoring technologies in critically ill neuroscience patients. 80
Sudbury, MA, 2009, Jones and Bartlett, p. 35.)
70
60
50
40
30
P1
P2 20
P3
10
Figure 92-2 Components of the intracranial pressure waveform: 0
P1, P2, and P3. 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Minutes
Figure 92-5 Elevations in intracranial pressure represent b
waves. The intracranial pressure rise is steep and rapid but to heights
less than those observed with a waves and is also much briefer.
(From Marshall SB, et al: Neuroscience critical care: Pathophysiol-
ogy and patient management. Philadelphia, 1990, Saunders.)
A B
C
Figure 92-3 Example of intracranial pressure waveforms with P2 elevation indicating decreased
cerebral compliance.
92 Intracranial Bolt and Fiberoptic Catheter Insertion (Assist), ICP Monitoring 831
mm Hg ❖ Preamp fiberoptic catheter connector cable

100
❖ Monitoring cable to connect to bedside monitor
90
• Sterile dressing supplies
80
70 PATIENT AND FAMILY EDUCATION
60
50 • Assess patient and family understanding of fiberoptic
40 catheters and management of elevated ICP. Rationale:
Explanations to patient and family concerning their spe-
30
cific needs may allay fears.
20
• Explain the fiberoptic catheter–insertion procedure.
10 Review normal parameters and patient care after insertion.
0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Review the family’s role in maintenance of an optimal
ICP with limitation of patient stimulation. Rationale:
Minutes
Explanation of expected interventions may allay patient
Figure 92-6 c waves. The intracranial pressure changes are
much less impressive than those in a or b waves and reflect changes
and family anxieties, encourage questions, and promote
in arterial blood pressure. (From Marshall SB, et al: Neuroscience therapeutic family interaction.
critical care: Pathophysiology and patient management. Philadel-
phia, 1990, Saunders.)
Intracranial hemorrhage15
❖
PREPARATION
15
❖ Subarachnoid hemorrhage
❖ Hydrocephalus
15 Patient Assessment
15
❖ Fulminant hepatic failure with encephalopathy • Assess the patient’s neurological status and vital signs.
15
❖ Ischemic stroke with massive edema Rationale: Performing a baseline neurological assessment
15
❖ Meningitis enables the nurse to identify changes that may occur
15
❖ Cysts during or as a result of the fiberoptic catheter placement.
• Contraindications for inserting ICP monitoring devices • Assess the patient’s current laboratory profile, including
include infection and coagulopathies.17 complete blood count or platelet count, prothrombin time,
• Concerns with accuracy of ICP monitoring values primar- international normalized ratio, and partial thromboplastin
ily relate to displacement, misplacement, or breakage of time. Rationale: Baseline coagulation study results deter-
the catheter and drift (especially after 5 days).13,15 mine the risk for bleeding during intracranial bolt and
• Management of the patient with increased ICP and catheter insertion.
decreased CPP is a multitiered approach that includes • Assess for allergies. Rationale: Assessment minimizes
positioning, maintaining normothermia and normocarbia, the risk of allergic reaction.
administration of pharmacological agents, and surgical
procedures.2,8,11 Patient Preparation
EQUIPMENT identifiers. Rationale: Before performing a procedure, the
• Antiseptic solution for the intended intervention.
• Sterile gloves, surgical caps, masks, goggles or face • Perform a preprocedure verification and time out, if non-
shields, and sterile surgical gowns emergent. Rationale: Ensures patient safety.
• Sterile towels, half-sheets, and drapes • Ensure that informed consent has been obtained. Ratio-
• Local anesthetic (lidocaine 1% or 2% without epineph- nale: Informed consent protects the rights of the patient
rine), 5-mL or 10-mL Luer-Lok syringe with 18-gauge and makes a competent decision possible for the patient;
needle (for drawing up lidocaine), and 23-gauge or however, in emergency circumstances, time may not
25-gauge needle (for administration of lidocaine) allow for the consent form to be signed.
• Shave preparation kit • Administer preprocedural analgesia or sedation as pre-
• Cranial access tray scribed. Rationale: The patient needs to remain still
❖ Scalpel during fiberoptic catheter insertion. In an emergency situ-
❖ Scalpel retractor ation, the patient may already be receiving continuous
❖ Forceps analgesia and sedation.
❖ Needles/needle holders • Assist the patient to a supine position with the head of the
• Monitoring equipment bed at 30 to 45 degrees and the neck in a midline, neutral
❖ Pressure box (bedside monitor) position. Rationale: This position provides access for
❖ Pressure cable fiberoptic catheter insertion and enhances jugular venous
❖ Stand-alone monitor (for interpretation of fiberoptic outflow, contributing to possible reduction in intracranial
data) pressure.
Procedure for Intracranial Bolt and Fiberoptic Catheter Insertion (Assist), Intracranial
Pressure Monitoring, Care, Troubleshooting, and Removal
1. HH
2. Apply goggles or masks with face Prepares for sterile procedure.
shields, caps, gowns, and sterile
gloves.
3. Assist as needed with identifying the Facilitates catheter placement.
optimal area for placement of the Catheters placed adjacent to
catheter. the intracranial pathology
are more likely to identify
increased ICP earlier.15,18,19,21
4. Assist as needed with shaving and Reduces transmission of The choice of povidone-iodine or
cleansing the insertion site with an microorganisms and chlorhexidine as an antiseptic
antiseptic solution. minimizes the risk of agent is an unresolved issue.16
infection. Both should be allowed to dry
completely.
5. Assist as needed with covering the Protects the insertion site
patient’s head and upper thorax with a from contamination.
sterile half-sheet and drape.
6. Preparation of the fiberoptic system: The catheter is zeroed before
A. Ensure that the preamp cable insertion and never
connects from the catheter to the rezeroed.15
stand-alone monitor.
B. Follow manufacturer’s instructions
for zeroing the catheter before
insertion. (Level M*)
7. Assist as needed with insertion of the Facilitates the insertion Manually assisting in maintaining
intracranial bolt and fiberoptic process. head positioning may be required
catheter. during cranial drilling while
maintaining the sterile field.
8. Assist as needed with applying a Reduces the transmission of
sterile occlusive dressing. microorganisms.
9. Secure the catheter and preamp cable Lessens the likelihood of
to the patient in such a way as to dislodgment and breakage
prevent accidental removal. of the catheter.
10. After fiberoptic catheter placement, Ensures accurate fiberoptic
follow the manufacturer’s instructions data at the bedside monitor
for the “synchronize to monitor” and allows printing of ICP
interface. (Level M) tracing.
11. Set the appropriate ICP scale for the Necessary for visualization of
measured pressure. the complete ICP waveform
and to obtain readings.
12. Set the monitor alarms. Goals for ICP management
are individualized for each
patient based on pathology.
13. Discard used supplies in an Removes and safely discards
appropriate receptacle. used supplies; safely
removes sharp objects.
14. HH

92 Intracranial Bolt and Fiberoptic Catheter Insertion (Assist), ICP Monitoring 833
Procedure for Intracranial Bolt and Fiberoptic Catheter Insertion (Assist), Intracranial
Pressure Monitoring, Care, Troubleshooting, and Removal—Continued
Troubleshooting
1. HH
2. PE
3. Assess the integrity of the fiberoptic Occlusion or dislocation may Intracranial device manipulation is
device. Note the location and require manipulation or not a nursing responsibility in
presence of any markers on the replacement. most institutions. Notify the
fiberoptic catheter system that identify physician if the device is
location (depth of the catheter). occluded or dislocated.
4. Observe for messages or numeric Breakage requires
values that indicate a broken catheter. replacement.
5. Correct the ICP monitoring device Fiberoptic catheters may Follow manufacturer’s instructions
malfunction. become damaged or and troubleshooting manuals for
dislodged, requiring identifying and correcting
catheter replacement. common problems.
6. Change the monitoring system, if Replaces a malfunctioning
needed. system.
8. HH
Fiberoptic Catheter Removal
1. HH
2. Ensure physicians, advanced practice Minimizes the risk of
nurses, and other healthcare infection; maintains aseptic
professionals who are assisting with and sterile precautions.
catheter removal apply sterile gloves
and mask with face shield or goggles.
3. Assist with the removal of the Facilitates the removal
fiberoptic catheter. process.
4. Assist as needed with applying a Minimizes contamination by Observe for any CSF drainage or
sterile occlusive dressing. microorganisms. blood from insertion site.
6. HH

• Accurate and reliable ICP monitoring, CPP calculation, • CSF infection14,16,17
and assessment of cerebral compliance9,12 • CSF leakage15
• Maintenance of ICP within the range of 0 to 15 mm • Dislodgment or damage of the fiberoptic catheter15
Hg or as prescribed9,12,15 • Dislodgment of the bolt15
• Early detection of elevated ICP trends9,12,15 • Pneumocephalus (rare)15
• Management of increased ICP and decreased CPP9,12,15 • Cerebral hemorrhage (rare)4,15
• Protection of cerebral perfusion with maintenance of • Sequelae of sustained increased intracranial pressure
CPP within prescribed parameters9,12 and decreased cerebral perfusion pressure: cerebral
infarction, herniation, and brain death8,9,13

interventions.
1. Assess the patient’s Evaluates the patient’s response to the • Changes in neurological status
neurological status and vital procedure. • Abnormal vital signs
signs during the procedure.

2. Note the ICP waveform and Provides baseline data. • P2 of greater amplitude than P1
numeric values during the
insertion procedure.
3. Assess the patient’s Provides clinical confirmation of and • Changes in neurological status
neurological status hourly or correlation with the monitored ICP
more often as indicated.15 data.
4. Assess the ICP hourly. Determines the neurological status. • Increased ICP
• ICP waveform abnormalities
• Immediately report sustained
ICP elevations of 20 mm Hg or
greater15
5. Calculate the CPP hourly (or A CPP of 50–70 mm Hg should be • Changes in CPP
more often as indicated). maintained for adult patients with • CPP less than the lowest
traumatic brain injury. CPP prescribed parameter may put
parameters should be individualized the patient at risk for cerebral
to meet patient perfusion needs. ischemia.4,6
6. Set the bedside alarm limits The ICP limit is usually set to sound • Abnormal ICP
based on the parameter goals. an alarm when the ICP is >20 mm • Abnormal waveforms
Hg; however, this needs to be
individualized for each patient.
7. Assess the catheter system Ensures accuracy and safety of
hourly. monitoring.
8. Change the insertion site Provides an opportunity to assess • Significant drainage on ICP
dressing as needed or based catheter insertion site and observe insertion site dressing or head
on institutional standards. for signs and symptoms of dressing
infection.16 • Signs and symptoms of infection
9. Provide a safe environment, Catheter dislodgment results in the • Dislodged device
preventing inadvertent inability to effectively monitor ICP • Abnormal ICP
dislodgment of the fiberoptic and may require reinsertion. If • Abnormal ICP waveform
catheter through appropriate intrahospital transportation is • Increased ICP may occur when
catheter positioning, sedation, required, ICP should be monitored.20 patient is lying flat for diagnostic
and analgesia as needed and study
as prescribed.
10. Follow institutional standard Identifies need for pain interventions. • Continued pain despite pain
Documentation
• Insertion time and patient response to procedure • Patient and family education
• Completion of informed consent • Initial ICP tracing (include ICP waveform
• Preprocedure verifications and time out morphology) and any changes in the waveform12,15
• Procedural and sedation monitoring • Nursing interventions used to treat ICP or CPP
• Initial and hourly ICP1,12,15 deviations and expected or unexpected outcomes12,15
• Initial and hourly CPP calculation1,12,15 • Pain assessment, interventions, and effectiveness
• Insertion site assessment

92 Intracranial Bolt and Fiberoptic Catheter Insertion (Assist), ICP Monitoring 834.e1
References 11. March K: Application of technology in the treatment of

1. American Association of Neuroscience Nurses: Guide to traumatic brain injury. Crit Care Nurs Q 23:26–37, 2000.
the care of the patient with intracranial pressure 12. March K: Intracranial pressure monitoring and assessing
monitoring. In AACN Clinical Practice Guideline, intracranial compliance in brain injury. Crit Care Nurs
Glenview, IL, 2014, American Association of Clin North Am 12:429–436, 2002.
Neuroscience Nurses. 13. March K: Technology. In Bader MK, Littlejohns LR,
2. Amin N, Greene-Chandos D: Intracranial pressure editors: AANN core curriculum for neuroscience nursing,
monitoring. In Miller CM, Torbey MT, editors: ed 4, St. Louis, 2004, Saunders, pp 199–202.
Neurocritical care monitoring, New York, 2015, 14. March K: Intracranial pressure monitoring: Why monitor?
DemosMEDICAL, pp 1–17. AACN Clin Issues 16:456–475, 2005.
3. Bershad EM, Humphreis WE, Suarez JI: Intracranial 15. March K, Madden L: Intracranial pressure management.
hypertension. Semin Neurol 28:690–702, 2008. In Littlejohns LR, Bader MK, editors: AACN-AANN
4. Bratton SL, et al: Guidelines for the management of protocols for practice: Monitoring technologies in
severe traumatic brain injury: A joint project of the Brain critically ill neuroscience patients, Sudbury, MA, 2009,
Trauma Foundation, American Association of Jones and Bartlett, pp 35–69.
Neurological Surgeons (AANS), Congress of Neurological 16. O’Grady NP, et al: Guidelines for the prevention of
Surgeons (CNS), AANS/CNS Joint Section on intravascular catheter-related infections. Am J Infect
Neurotrauma and Critical Care. J Neurotrauma Control 39(4):S1–S34, 2011.
24(Suppl 1):S1–S106, 2007. 17. Reynolds F: Neurologic infection after neuraxial
5. Cecil S, et al: Traumatic brain injury: Advanced anesthesia. Anesthesiol Clin 26:23–52, 2008.
multimodal neuromonitoring from theory to clinical 18. Sahuqillo J, et al: Interhemispheric supratentorial
practice. Crit Care Nurse 31(2):25–36, 2011. intracranial pressure gradients in head-injured patients:
6. Davis JW, et al: Placement of intracranial pressure Are they clinically important? J Neurosurg 90:16–26,
monitors: Are “normal” coagulation parameters 1999.
necessary? J Trauma 57:1173–1177, 2004. 19. Slavin KV, Misra M: Infratentorial intracranial pressure
7. Fan J-Y, et al: Intracranial pressure waveform morphology monitoring in the neurosurgical intensive care unit. Neurol
and intracranial adaptive capacity. Am J Crit Care Res 25:880–884, 2003.
17:545–554, 2008. 20. Tu H: Intrafacility transportation of patient with acute
8. Hickey JV, Olson DM: Intracranial hypertension: Theory brain injury. J Neurosci Nurs 46(3):E12–E16, 2014.
and management of increased intracranial pressure. In 21. Wolfla CE, et al: Brain tissue pressure gradients created
Hickey JV, editor: The clinical practice of neurological by expanding frontal epidural mass lesion. J Neurosurg
and neurosurgical nursing, ed 6, Philadelphia, 2009, 84:642–647, 1996.
Lippincott Williams & Wilkins, pp 270–307.
9. Josephson L: Management of increased intracranial Additional Reading
pressure. Dimens Crit Care Nurs 23:194–207, 2004. Zhong J, et al: Advances in ICP monitoring techniques.
10. Kirkness CJ, et al: Intracranial pressure waveform Neurol Res 25:339–350, 2003.
analysis: Clinical and research implications. J Neurosci Miller CM, Torbey MT: Neurocritical care monitoring,
Nurs 32:271–277, 2000. New York, 2015, DemosMEDICAL.
PROCEDURE
93
Intraventricular/Fiberoptic
Catheter Insertion (Assist),
Monitoring, Nursing Care,
Troubleshooting, and Removal
Tess Slazinski
PURPOSE: The combination intraventricular/fiberoptic catheter combines the
capability of external ventricular drainage of cerebrospinal fluid with monitoring of
intracranial pressure. This hybrid device can be used to monitor intracranial
pressure intermittently or continuously and to drain cerebrospinal fluid intermittently
or continuously.
PREREQUISITE NURSING cal reference point for the foramen of Monro. In addition,
KNOWLEDGE the combination catheter allows for CSF drainage but still
requires attention to the level of the reference point of
• A fundamental understanding of neuroanatomy and physi- the drip chamber to the anatomical reference point for the
ology is needed. foramen of Monro and setting of the pressure level at the
• Knowledge of aseptic and sterile technique is necessary. top of the graduated burette (drip chamber) to prevent
• Proper equipment assembly and setup specific to fiberop- underdrainage or overdrainage of CSF.1
tic intracranial pressure monitoring device should be • The anatomical reference point for the foramen of Monro
understood. is the external auditory canal.1,11
• Intracranial pressure (ICP) is the pressure exerted by the • Normal ICP ranges from 0 to 15 mm Hg; sustained ICPs
intracranial contents, brain tissue, blood, and cerebrospi- of greater than 20 mm Hg are generally considered neu-
nal fluid (CSF) within the cranium. Increased ICP occurs rological emergencies.6,17
when the intracranial volume exceeds the brain’s ability • The normal ICP waveform has three or four peaks, with
to compensate for increased volume.16,18 Increased ICP P1 being of greater amplitude than P2, and P2 of greater
contributes to secondary neuronal injury. amplitude than P3. P1 is thought to reflect arterial pressure;
• The ventricular catheter with external strain gauge trans- P2, P3, and P4 (if present) have been described as choroid
ducer is considered the gold standard for ICP monitor- plexus or venous in origin (see Fig. 92-2).18 The amplitude
ing.3,4 The external ventricular drain is considered the of P2 may exceed P1 with increased ICP or decreased
most accurate and reliable method of monitoring ICP and intracranial compliance (see Fig. 92-3).
ICP waveform and allows for CSF drainage.3 However, • ICP waveform trends include a, b, and c waves. The a
the fluid-filled system of the external ventricular catheter waves, also referred to as plateau waves, are associated
has the greatest infection rate1,2,12 and hemorrhage rate, with ICP values of 50 to 100 mm Hg and last 5 to 20
and requires repeated zeroing and leveling with the ana- minutes. The a waves (see Fig. 92-4) are associated with
tomical reference point for the foramen of Monro.3 abrupt neurological deterioration and herniation. The b
• The parenchymal fiberoptic catheter provides quality ICP waves (see Fig. 92-5) with ICP values of 20 to 50 mm Hg,
monitoring but cannot be rezeroed once inserted, cannot lasting 30 seconds to 2 minutes, may become a waves.
be used for CSF drainage, and is subject to drift, particu- The c waves (see Fig. 92-6) may coincide with ICPs as
larly after 5 days.3 high as 20 mm Hg but are short lasting and without clini-
• The combination catheter has some of the advantages and cal significance.3,7,9,18
disadvantages of both the ventricular catheter with an • Cerebral perfusion pressure (CPP) is a derived mathe-
external strain gauge transducer and the fiberoptic trans- matic calculation that indirectly reflects the adequacy of
ducer tipped catheter. The combination catheter can only cerebral blood flow. The CPP is calculated by subtracting
be zeroed before insertion. However, because the trans- the ICP from the mean arterial pressure (MAP); thus CPP
ducer is in the tip of the fiberoptic catheter, there is no = MAP − ICP. The normal CPP range for adults is approxi-
external strain gauge transducer and therefore no repeti- mately 60 to 100 mm Hg, or a mean of 80 mm Hg. The
tive zeroing and leveling of a transducer with the anatomi- optimal CPP for a given patient and clinical condition is
835
not entirely known. ICP and CPP should be managed nursing interventions (e.g., positioning, maintaining nor-
concomitantly. According to the Brain Trauma Founda- mothermia) and the administration of pharmacological
tion Guides, an acceptable CPP for an adult with a severe agents and surgical procedures.4,9,16
traumatic brain injury (Glasgow Coma Scale [GCS] score • If intrahospital transportation of the patient is required,
≥8) lies between 50 and 70 mm Hg.4 Patients with aneu- ICP should be continuously monitored during transport.22
rysmal subarachnoid hemorrhage vasospasm may need
higher CPPs to maintain adequate perfusion through vaso- EQUIPMENT
spastic cerebral blood vessels. Patients with strokes, aneu-
rysmal subarachnoid hemorrhage, or other neurological • Antiseptic solution
injuries may require higher or individualized CPP param- • Sterile gloves, surgical caps, masks, goggles or face
eters reflective of the neuropathology and brain perfusion shields, and sterile surgical gowns
needs. Research continues regarding the relationship • Sterile towels, half-sheets, and drapes
between cerebral blood flow and CPP. • Local anesthetic (lidocaine 1% or 2% without epineph-
• ICP and CPP must be considered together in management rine), 5- or 10-mL Luer-Lok syringe with 18-gauge needle
of the patient. (for drawing up of lidocaine), and 23- or 25-gauge needle
• Cerebral autoregulation is the intrinsic ability of the cere- (for administration of lidocaine)
bral vessels to constrict and dilate as needed to maintain • Shave preparation kit
adequate cerebral perfusion. Cerebral autoregulation is • Cranial access tray
impaired with brain injury, and the cerebral blood flow ❖ Scalpel
becomes passively dependent on the systemic blood ❖ Scalp retractor
flow. The cerebral blood vessels are no longer able to ❖ Forceps
react to maintain CPP in response to a change in blood ❖ Needles/needle holders
pressure. ❖ Intraventricular/fiberoptic catheter
• Sustained ICP elevations of 20 mm Hg or greater ❖ Calibration screwdriver (single use)
necessitate immediate reporting and intervention. ICP • Monitoring equipment
waveform changes that indicate loss of cerebral com- ❖ Pressure module (bedside monitor)
pliance or cerebral autoregulation should be reported ❖ Pressure cable
immediately.11,16 ❖ Stand-alone monitor (for interpretation of fiberoptic
• ICP monitoring is indicated for the following4,18: data)
❖ Traumatic brain injury with a GCS score less than 8 ❖ Preamp connector cable
and abnormal computed tomographic (CT) scan or ❖ Monitoring cable to connect to bedside monitor
normal CT scan with two of the following: hypoten- • External ventricular drainage system
sion, age more than 40 years, and posturing • Sterile dressing supplies
❖ Intracranial hemorrhage
❖ Aneurysmal subarachnoid hemorrhage PATIENT AND FAMILY EDUCATION
❖ Hydrocephalus
❖ Fulminant hepatic failure with encephalopathy • Assess patient and family understanding of the purpose of
❖ Ischemic stroke with massive edema the intraventricular and fiberoptic catheter and manage-
❖ Meningitis ment of elevated ICP. Rationale: Explaining the purpose
❖ Cysts of the procedure may decrease patient and family anxiety.
• CSF drainage is indicated for the following1: • Explain the intraventricular and fiberoptic catheter inser-
❖ Acute hydrocephalus tion procedure. Review normal parameters and patient
❖ Subarachnoid hemorrhage care after insertion. Review the family’s role in mainte-
❖ Intracerebral hemorrhage nance of an optimal ICP with limitation of patient stimula-
❖ Traumatic brain injury tion. Rationale: Explanation of expected interventions
❖ Postoperative craniotomy may allay patient and family anxieties, encourage ques-
❖ Meningitis tions, and promote therapeutic family interaction.
• Consequences of CSF underdrainage include headache,
neurological deterioration, hydrocephalus, increased
intracranial pressure, secondary neuronal injury, hernia- PATIENT ASSESSMENT AND
tion, and death. PREPARATION
• Consequences of CSF overdrainage include headache,
subdural hematoma, pneumocephalus, ventricular col- Patient Assessment
lapse, herniation, and death. • Assess the patient’s neurological status. Rationale: A
• A contraindication for ICP monitoring is coagulopathies. baseline neurological assessment enables the nurse to
• Issues regarding accuracy primarily relate to displace- identify changes that may occur during or as a result of
ment, misplacement, or breakage of the fiberoptic catheter the intraventricular/fiberoptic catheter placement.
and drift (especially after 5 days).3,16 • Assess the patient’s current laboratory profile, including
• Management of the patient with increased ICP and complete blood count, platelet count, prothrombin time,
decreased CPP is a multitiered approach that includes international normalized ratio, and partial thromboplastin
93 Intraventricular/Fiberoptic Catheter Insertion (Assist) 837
time. Rationale: Baseline coagulation studies determine and makes a competent decision possible for the patient;
the risk for bleeding during intraventricular catheter however, in emergency circumstances, time may not
insertion. allow for the consent form to be signed.
• Assess for allergies. Rationale: Insertion of the intraven- • Perform a preprocedure verification and timeout, if non-
tricular fiberoptic catheter may necessitate local anes- emergent. Rationale: Ensures patient safety.
thetic, an antiseptic to clean the site, and analgesia and • Administer preprocedural analgesia or sedation as pre-
sedation. Assessment minimizes the risk of allergic scribed. Rationale: The patient needs to remain still
reaction. during catheter insertion. In an emergency situation, the
patient may already be receiving continuous analgesia and
Patient Preparation sedation.
• Verify that the patient is the correct patient using two • Assist the patient to a supine position with the head of the
identifiers. Rationale: Before performing a procedure, the bed at 30 to 45 degrees and the neck in a midline, neutral
nurse should ensure the correct identification of the patient position. Rationale: This position provides access for
for the intended intervention. intraventricular/fiberoptic catheter insertion and enhances
• Ensure that informed consent has been obtained. Ratio- jugular venous outflow, contributing to possible reduction
nale: Informed consent protects the rights of the patient in intracranial pressure.
Procedure for Combination Intraventricular/Fiberoptic Catheter Insertion (Assist),

Monitoring, Nursing Care, Troubleshooting, and Removal
1. HH
2. Attach the external drainage Preparation of the external External ventricular drainage systems
system to an intravenous (IV) pole. ventricular drainage system are either pole-mount or panel
allows for stability when systems. Both systems require
priming the tubing. attachment to an IV pole for
stability.
3. Ensure that all pressure tubing Ensures integrity and sterility of
connections on the ventricular the closed system.
drainage system are tightened.
4. Prime the external ventricular Air needs to be removed from the This system does not require an
drainage system before patient pressure tubing. external strain gauge flushless
attachment. Use preservative-free transducer because the fiberoptic
normal saline solution to prevent portion of this catheter is measuring
neuronal damage8 (see Figs. 94-1 ICP. Use of a syringe filled with
and 94-2). sterile, preservative-free normal
saline solution to prime the external
ventricular drainage system tubing
rather than a bag of flush solution
lessens the risk of flush solution
being administered through the
ventricular catheter into the brain.13
5. Apply goggles or masks with face Ensures aseptic and sterile
shields, caps, gowns, and sterile technique.
gloves.
6. Assist as needed with identifying Facilitates catheter placement. A ventricular catheter is most
the optimal area for placement of commonly placed in the
the catheter. nondominant, anterior horn portion
of the lateral ventricle.2
7. Assist as needed with clipping the Reduces the microorganisms and The choice of povidone iodine or
hair12 and cleansing the insertion minimizes the risk of infection. chlorhexidine as an antiseptic agent
site with an antiseptic solution. is an unresolved issue.19 Both
should be allowed to dry
completely. In addition, the use of
prophylactic antibiotics is an
unresolved issue.21

Monitoring, Nursing Care, Troubleshooting, and Removal—Continued
8. Assist as needed with covering the Protects the insertion site from
patient’s head and upper thorax contamination.4,15,16
with sterile drapes.
9. Fiberoptic system: Prepares the system. The catheter
A. Ensure that the preamp cable is zeroed before insertion and is
connects the catheter to the never rezeroed.17,18
stand-alone monitor.
B. Follow manufacturer’s
instructions for zeroing the
catheter before insertion.
10. Assist with the insertion of the Facilitates the insertion process.
intraventricular/fiberoptic catheter.
11. After intraventricular/fiberoptic Ensures accurate fiberoptic data at Ensure proper CSF drainage amount
catheter placement: the bedside monitor and allows to prevent ventricular collapse and
A. Follow the manufacturer’s printing of ICP tracing. possible herniation.1,4
instructions for the The anatomical reference point
“synchronize to the monitor” for the foramen of Monro is the
interface. external auditory canal.1,4
B. Attach the external ventricular
drainage device to the proper
Y-port. (Refer to Procedure 93.)
C. Place the zero reference at the
appropriate external anatomical
landmark1 of the external
ventricular drainage device (see
Fig. 94-2). (Level D*)
12. Increase or decrease the height of Ensures proper CSF drainage. When adjusting the height of the
the graduated burette to the pressure level, the stopcock should
prescribed pressure level.1 be “off” to the patient.23
13. The provider will prescribe the If the physician prescribes
desired ICP parameter (see the ICP to be maintained at
Procedure 93). <15 mm Hg, drainage of CSF
will be initiated if the patient’s
ICP is >15 mm Hg.
14. Monitor the ICP and CPP as Assesses ICP waveform and
prescribed. values and CPP value.
15. Set the appropriate ICP scale for Necessary for visualization of the
the measured pressure. complete ICP waveform.
16. Set the monitor alarms. Goals for ICP management are
individualized for each patient
based on pathology.
appropriate receptacles. supplies; safely removes sharp
objects.
18. HH

Monitoring, Nursing Care, Troubleshooting, and Removal—Continued
Troubleshooting
1. HH
2. PE
3. Assess the integrity of the Brain tissue or blood may Intracranial device manipulation is
intraventricular/fiberoptic device. occlude any of the various not a nursing responsibility in most
intracranial devices, institutions. Notify the provider for
resulting in a dampened assistance as needed.
waveform. Occlusion may
necessitate manipulation or
replacement.
4. Correct the ICP monitoring Fiberoptic catheters may Follow manufacturer’s instructions
device malfunction. become damaged or and troubleshooting manuals for
dislodged, requiring catheter identifying and correcting common
replacement. problems.
5. Change the monitoring system, if Ensures a functional system.
needed.
7. HH
Combination Intraventricular/Fiberoptic Catheter Removal
1. HH
2. Ensure physicians, advanced
practice nurses, and other
healthcare professionals who
are assisting with catheter
removal don sterile gloves and
masks with face shields or
goggles.
3. Assist with the removal of the Facilitates the removal Culture the tip of the intraventricular
intraventricular/fiberoptic process. catheter as prescribed.
catheter.
4. Apply a sterile occlusive Minimizes contamination by
dressing after the device is microorganisms.
removed.
5. Dispose of used supplies and Removes and safely discards
the device in the appropriate used supplies; safely
receptacle. removes sharp objects.
6. HH

• Accurate and reliable ICP monitoring, CPP calculation, • CSF infection5,10,12,14,19,20
and assessment of cerebral compliance1,18 • CSF leakage
• Maintenance of ICP within the range of 0–15 mm Hg • Dislodging of the interventricular/fiberoptic catheter15
or as prescribed1,18 • Dislodging of the fiberoptic bolt15
• Early detection of elevated ICP trends1,18 • Pneumocephalus1
• Management of increased ICP and decreased CPP1,18 • Cerebral hemorrhage (rare)1
• Protection of cerebral perfusion with maintenance of • Sequelae of sustained increased ICP and decreased
CPP within prescribed parameters1,18 CPP: cerebral infarction, herniation, and brain
death16,18

interventions.
1. Assess the patient’s Evaluates the patient’s response to • Changes in neurological status
neurological status and vital the procedure. • Abnormal vital signs
signs during the procedure.
2. Note the ICP waveform and Provides baseline data. • P2 of greater amplitude than P1
numeric values during the
insertion procedure.
3. Assess the patient’s Provides clinical confirmation of • Changes in neurological status
neurological status hourly or and correlation with the • Changes in vital signs
more often as indicated. monitored ICP data.
4. Assess the ICP hourly. Determines the neurological status. • Increased ICP
• ICP waveform abnormalities
• Immediately report sustained ICP
elevations of 20 mm Hg or greater
5. Calculate the CPP hourly (or A CPP of 50–70 mm Hg should be • Changes in CPP
more often as indicated). maintained for adult patients with • CPP less than the lowest
traumatic brain injuries.4 CPP prescribed parameter may put the
parameters should be patient at risk for cerebral
individualized to meet the ischemia4
patient’s perfusion needs.
6. Set the bedside alarm limits ICP limit is usually set to alarm • Abnormal ICP
based on the parameter goals. when the ICP is >20 mm Hg;
however, this needs to be
individualized for each patient.
7. Assess the catheter system Ensures accuracy and safety of • Frank blood or clots in the CSF
hourly. monitoring. drainage bag may indicate
intracranial bleeding
• Absence of CSF drainage may
indicate an occluded catheter,
dislodged catheter, cerebral
swelling, or overdrained ventricles
• Excessive drainage may lead to
infarction and herniation
8. Change the insertion site Provides an opportunity to assess • Significant drainage on ICP
dressing per institutional insertion site and observe for insertion site dressing or head
policy.19 signs and symptoms of infection. dressing
• Signs and symptoms of infection
9. Provide a safe environment, Inadvertent dislodgement of the • Dislodged device
preventing inadvertent catheter must be avoided because • Abnormal ICP
dislodgement of the it can result in • Abnormal ICP waveform
intraventricular/fiberoptic pneumoencephalopathy or
catheter through appropriate excessive CSF drainage.
catheter positioning, sedation,
and analgesia as needed.
11. Change the CSF drainage Practices for changing CSF drainage • Inadvertent disconnection
collection device per collection devices vary
institutional policy. considerably. Maintain closed
system.
12. Elevate the head of the May decrease ICP. • Elevated ICP
patient’s bed to 30 degrees or
as prescribed.
Documentation
• Completion of informed consent • Insertion site assessment
• Preprocedure verifications and time out • Patient and family education
• Insertion time and patient response to procedure • Initial ICP tracing (include ICP waveform
• Procedural monitoring documentation including vital morphology) and any changes in waveform
signs and sedation monitoring • Nursing interventions used to treat ICP or CPP
• Initial and hourly ICP reading deviations and expected or unexpected outcomes
• Initial and hourly CPP calculation • Hourly amount of CSF drainage
• CSF color and clarity • Pain assessment, interventions, and effectiveness

93 Intraventricular/Fiberoptic Catheter Insertion (Assist) 841.e1
References 12. Kubilay Z, et al: Decreasing ventricular infections through

1. American Association of Neuroscience Nurses: Guide the use of a ventriculostomy placement bundle: Experience
to the care of the patient with an external ventricular at a single institution. J Neurosurg 118(3):514–520, 2013.
drain/lumbar drain. In AACN Clinical Practice Guideline, 13. Littlejohns LR, Trimble B: Our policy on external
Glenview, IL, 2011, AANN. ventricular drainage systems includes the procedure for
2. Arbour R: Intracranial hypertension: Monitoring priming the system. Does it really have to be primed? Crit
and nursing assessment. Crit Care Nurse 24:19–32, Care Nurse 25:57–59, 2005.
2004. 14. Lozier AP, et al: Ventriculostomy-related infections: A
3. Bershad EM, Humphreis WE, Suarez JI: Intracranial critical review of the literature. Neurosurgery 51:170–181,
hypertension. Semin Neurol 28:690–702, 2008. 2002.
4. Bratton SL, et al: Guidelines for the management of 15. March K: Application of technology in the treatment of
severe traumatic brain injury: A joint project of the Brain traumatic brain injury. Crit Care Nurs Q 23:26–37, 2000.
Trauma Foundation, American Association of 16. March K: Intracranial pressure monitoring and assessing
Neurological Surgeons (AANS), Congress of Neurological intracranial compliance in brain injury. Crit Care Nurs
Surgeons (CNS), AANS/CNS Joint Section on Clin North Am 12:429–436, 2000.
Neurotrauma and Critical Care. J Neurotrauma 24 17. March K: Technology. In Bader MK, Littlejohns LR,
(Suppl 1):S1–S106, 2007. editors: Core curriculum for neuroscience nursing, ed 4,
5. Lo CH, et al: External ventricular drain infections are Chicago, American Association of Neuroscience Nurses.
independent of drain duration: An argument against St Louis, 2004, Saunders, pp 199–226.
elective revision. J Neurosurg 106:378–383, 2007. 18. March K, Madden L: Intracranial pressure management.
6. Davis JW, et al: Placement of intracranial pressure In Littlejohns LR, Bader MK, editors: AACN-AANN
monitors: Are “normal” coagulation parameters protocols for practice: Monitoring technologies in
necessary? J Trauma 57:1173–1176, 2004. critically ill neuroscience patients, Sudbury, MA, 2009,
7. Fan JY, et al: Intracranial pressure waveform morphology Jones and Bartlett, pp 35–69.
and intracranial adaptive capacity. Am J Crit Care 19. O’Grady NP, et al: Guidelines for the prevention of
17:545–554, 2008. intravascular catheter-related infections. Am J Infect
8. Hetherington NJ, Dooley MJ: Potential for patient harm Control 39(4):S1–S34, 2011.
from intrathecal administration of preserved solutions. 20. Reynolds F: Neurologic infections after neuraxial
Med J Aust 173:141–143, 2000. anesthesia. Anesthesiol Clin 26:23–52, 2008.
9. Hickey JV, Olson DM: Intracranial hypertension: Theory 21. Sonabend A, et al: Prevention of ventriculostomy-related
and management of increased intracranial pressure. In infections with prophylactic antiobiotics and antibiotic-
Hickey JV, editor: The clinical practice of neurological coated external ventricular drains: A systematic review.
and neurosurgical nursing, ed 6, Philadelphia, 2009, Neurosurgery 68(4):996–1005, 2011.
Lippincott Williams & Wilkins, pp 270–307. 22. Tu H: Intrafacility transportation of patient with acute
10. Kim J, et al: Factors contributing to ventriculostomy brain injury. J Neurosci Nurs 46(3):E12–E16, 2014.
infection. World Neurosurg 77(1):135–140, 2012. 23. Wilkinson HA, et al: Erroneous measurement of
11. Kirkness CJ, et al: Intracranial pressure waveform intracranial pressure caused by simultaneous ventricular
analysis: Clinical and research implications. J Neurosci drainage: A hydrodynamic model study. Neurosurgery
Nurs 32:271–277, 2000. 24:348–354, 1989.
PROCEDURE
94
Intraventricular Catheter
with External Transducer
for Cerebrospinal Fluid
Drainage and Intracranial
Pressure Monitoring
Stephanie Cox
PURPOSE: An intraventricular catheter with an external transducer is used to
monitor intracranial pressure and, in the presence of pathology, to alleviate
increased intracranial pressure by draining cerebrospinal fluid (CSF) from the
ventricular system.
PREREQUISITE NURSING hemorrhage vasospasm may need higher CPPs to main-

KNOWLEDGE tain adequate perfusion through vasospastic cerebral
blood vessels.7 Patients with other neurological injuries
• Knowledge of neuroanatomy and physiology is needed. require individualized CPP parameters reflective of the
• Understanding is needed regarding the assembly and neuropathology and brain perfusion needs.
maintenance of the intraventricular catheter with an exter- • Elevations in ICP result when one or more intracranial
nal transducer and drainage system, care of the insertion components—blood, CSF, or brain tissue—increase
site, and drainage techniques. without an accompanying decrease in one or two of the
• Principles of aseptic technique should be understood. Of other intracranial components. This is known as the
all the intracranial pressure monitoring devices, external Monro-Kellie doctrine or hypothesis.1,20
ventricular drains (EVDs) have the greatest risk of • Clinical conditions that frequently result in increased
infection.1,4 intracranial pressure include traumatic brain injury,
• Institutional standards may vary with regard to antiseptic ischemic stroke,36 subarachnoid hemorrhage,7 intraparen-
choice—follow your institutional standard. Although the chymal hemorrhage,30 brain tumor, meningitis, and hydro-
package insert for chlorhexidine warns against use before cephalus.1,27 An EVD may be indicated in the management
any neuraxial procedures, a large retrospective study and of intracranial pressure in each of these conditions.2
several anesthesiology societies recommend chlorhexi- • Fiberoptic catheters and the microsensors that are placed
dine as an antiseptic.14,15,18,33 during surgery in the surgical site or through a bolt in the
• The normal range for intracranial pressure (ICP) is 0 to skull are also used to monitor the ICP. They may be placed
15 mm Hg.1,26,29 This measurement reflects the pressure in the epidural, subdural, subarachnoid, ventricular, and
exerted by the intracranial contents within the skull, intraparenchymal spaces.28,29 These catheters are sentinels
including brain, blood, and cerebrospinal fluid.26 for increased ICP but may not be designed for treatment
• Cerebral perfusion pressure (CPP) is a derived mathe- of increased ICP with CSF drainage.28,29 When a ventricu-
matic calculation that indirectly reflects the adequacy of lar catheter is inserted and transduced at the level of the
cerebral blood flow. The CPP is calculated by subtracting foramen of Monro, approximately at the level of the exter-
the ICP from the mean arterial pressure (MAP); thus, nal auditory canal, it produces a value and a waveform
CPP = MAP − ICP.1,28 The normal CPP range for adults is that reflects the ICP. The EVD is considered the most
approximately 60 to 100 mm Hg22 or a mean of 80 mm accurate ICP monitor.1,4
Hg.20,29 The optimal CPP for a given patient and clinical • CSF is formed within the lateral ventricles of the cerebral
condition is not entirely known. ICP and CPP should be hemispheres by the choroid plexus. From the lateral ven-
managed concomitantly and recorded. According to the tricles, fluid drains into the foramen of Monro, the intra-
Brain Trauma Foundation Guidelines, an acceptable CPP ventricular foramina, and into the third ventricle adjacent
for an adult with a severe traumatic brain injury (Glasgow to the thalamus. Although most of the CSF is made in the
Coma Scale [GCS] score of ≤8) lies between 50 and choroid plexus of the lateral ventricles, the third ventricle
70 mm Hg.4 Patients with aneurysmal subarachnoid contributes some CSF, which then passes through the
842
94 Intraventricular Catheter With External Transducer for CSF Drainage and ICP Monitoring 843
aqueduct of Sylvius into the fourth ventricle at the pons monitoring (or EEG-based consciousness/sedation moni-
and medulla. The choroid plexus in the roof of the fourth toring) for burst suppression is necessary to achieve the
ventricle and the brain parenchyma itself5 contribute an desired decrease in cerebral oxygen consumption and
additional small amount of CSF. The fluid then enters into electrical stimuli.12 Additional strategies include decom-
the subarachnoid space, with the major portion of the fluid pressive craniectomy and hemispherectomy.1,11,28,35
moving through the foramen of Magendie, where it is • Underdrainage of CSF may result in sustained increased
dispersed around the spinal cord and through the foramen intracranial pressure and herniation.22,25,28,29
of Luschka, where it flows around the brain. CSF is • Over drainage of CSF may result in headache, subdural
absorbed by the arachnoid villi, also known as arachnoid hematoma, pneumocephalus, and herniation.22,25,28,29
granulations, where it drains into the venous system to be
returned to the heart.3,6 EQUIPMENT
• CSF is a clear colorless liquid of low specific gravity with
no red blood cells and only 0 to 5 white blood cells • Cranial access tray with drill
(WBCs). Approximately 150 mL of CSF circulates within • Ventricular catheter
the CSF pathways in the brain and spinal subarachnoid • Pressure monitor tubing kit, including pressure tubing,
space. CSF is secreted at the rate of 0.35 mL/min or transducer, a three-way stopcock, or a flushless transducer
approximately 20 mL/hr.3 with stopcock
• ICP waveform morphology reflects transmission of arterial • Nonvented sterile caps
and venous pressure through the CSF and brain paren- • External drainage system, including tubing, collection
chyma. The normal ICP waveform has three or four peaks, chamber, and drainage bag
with P1 being of greater amplitude than P2, and P2 of greater • Preservative-free normal saline solution
amplitude than P3. P1 is thought to reflect arterial pressure; • Pressure monitoring cable and module
P2, P3, and P4 (when present) have been described as origi- • Sterile syringes
nating from the choroid plexus or veins (see Fig. 92-2).1,28 • Skin/site preparation with antiseptic solution
The amplitude of P2 may exceed P1 with increased ICP or • Sterile towels, drapes
decreased intracranial compliance (see Fig. 92-3). • Local anesthetic (e.g., lidocaine 1% or 2% without
• During ICP elevations, pathological (Lundberg) wave- epinephrine)
form trends include a, b, and c waves. The a waves, also • Sutures or staples
referred to as plateau waves, are associated with ICP • Sterile dressing
values of 50 to 100 mm Hg and last 5 to 20 minutes. The • Tape
a waves are associated with abrupt neurological deteriora- • Laboratory forms and specimen labels (for CSF
tion and herniation and are the most ominous1 (see specimens)
Fig. 92-4). The b waves (see Fig. 92-5), with ICP values • CSF specimen tubes (for collection of CSF)
of 20 to 50 mm Hg, last 30 seconds to 2 minutes and may • Caps, masks, sterile drapes, gloves, and gowns
become a waves. The c waves (see Fig. 92-6) may coin- • Cautery as required by institutional standard (for bedside
cide with ICPs as high as 20 mm Hg but are short lasting insertion)
and without clinical significance (see Fig. 92-6).1 • Leveling device (e.g., carpenter’s, laser, or line level)
• Some external ventricular drainage systems may also • Intravenous (IV) pole
provide simultaneous drainage and trending of the intra- Additional equipment, to have available as needed, includes
cranial pressure. the following:
• Management of acute brain injury is aimed at decreasing • Suction
secondary brain injury from increased intracranial pres-
sure, decreased cerebral perfusion pressure, impaired auto- PATIENT AND FAMILY EDUCATION
regulation, hypotension, hypoxemia, cerebral ischemia,
hypercarbia, hyperthermia, hypoglycemia, hyperglyce- • Explain the procedure to the patient/family. This proce-
mia, seizures or abnormalities in cerebral blood flow. dure may be performed at the bedside and require the
Interventions should include strict blood pressure manage- patient to be sedated, paralyzed, and intubated. Rationale:
ment, decreased environmental stimuli, elevation of the Patient cooperation during cranial access is of utmost
head of the bed, alignment of the head and neck in a importance. The patient and family should be aware that
straight position to promote venous drainage, the avoid- the patient may need to be intubated to maintain a patent
ance of constrictive devices about the neck that might airway, ensure adequate oxygenation, and maintain a
impede arterial flow to the brain and venous drainage from normal ICP and an adequate CPP.
the brain, seizure prophylaxis, glucose control, and attain- • Assess the patient and the family for understanding of ICP
ing and maintaining normothermia without shivering.1,26 pressure monitoring. Rationale: Knowledge and informa-
• In addition to CSF drainage, management of increased tion may lessen anxiety.
ICP frequently requires the use of certain pharmacological • Explain the potential need for low environmental stimula-
agents to lessen intracranial pressure, including sedation tion, especially during periods of ICP elevations (decreased
and analgesia, osmotic diuretics, hypertonic saline, neu- noise, decreased tactile stimulation, and low lighting).
romuscular blockade, and barbiturates. In the case of bar- Rationale: Knowledge and information may lessen
biturate coma, continuous electroencephalographic (EEG) anxiety and present expectations of potential events.
• Explain the waveforms on the bedside monitor and how cleanse the site, local anesthetic, and possibly systemic
this pressure is continually observed for signs of increased analgesia and sedation. External ventricular catheters
ICP. In the case of increased ICP, the drain is opened to may be impregnated with antibiotics (e.g., clindamycin,
drain CSF continuously or intermittently as prescribed to rifampin, and minocycline), or systemic antibiotics may
alleviate the pressure. Rationale: This explanation pre- be given periprocedurally or prophylactically.4,22,27
sents to the patient and family a more realistic expectation
of the events to come. Patient Preparation
PATIENT ASSESSMENT AND identifiers. Rationale: Before performing a procedure, the
PREPARATION nurse should ensure the correct identification of the patient
for the intended intervention.34
Patient Assessment • Ensure that the patient and family understand preproce-
• Obtain a baseline assessment to include level of con- dural information. Answer questions as they arise, and
sciousness, mental status, motor capability, sensation, reinforce information as needed. Rationale: Understand-
cranial nerves, and vital signs. Rationale: This assessment ing of previously taught information is evaluated and
provides baseline data. reinforced.
• Obtain the patient’s medical and surgical history to include • Ensure that informed consent has been obtained. Ratio-
use of aspirin, anticoagulants, prior craniotomies, the nale: Informed consent protects the rights of the patient
presence of aneurysm clips, embolic materials, permanent and makes a competent decision possible for the patient.
balloon occlusions, detachable coils, or a ventriculoperi- However, in emergency circumstances, time may not
toneal shunt. Obtain laboratory results to assess coagula- allow for the consent form to be signed.
tion status as needed. Rationale: The information obtained • Initiate IV access or assess the patency of the IV access.
determines and guides future treatment based on the neu- Rationale: Readily available IV access is necessary if the
rological examination results and evidence from radiology patient needs to be sedated or paralyzed or needs other
and angiography. medications.
• Assess for allergies. Rationale: Insertion of an external • Perform a preprocedure verification and time out, if non-
ventricular catheter requires the use of an antiseptic to emergent. Rationale: Ensures patient safety.34
Procedure for Pressure Monitoring and Drainage

External Ventricular Drainage (EVD) System Assembly
1. HH
2. Open the outer package of the Ensures sterile technique.
sterile supplies. Apply sterile
gloves, gown, and mask with eye
shield.16
3. With aseptic technique, flush Prepares the drainage system for use; Use of a syringe filled with sterile,
through the pressure tubing flushes air from the system. If air is preservative-free normal saline
and drainage system with left in the tubing, it may alter the solution to prime the external
preservative-free saline solution, numeric value or prevent the flow ventricular drainage system tubing
turning the stopcocks as needed of CSF.9,23 rather than a bag of flush solution
to prime the entire system. The preservative in normal saline may lessens the risk of flush solution
Remove the syringe and replace cause cortical necrosis.15 being administered through the
with a sterile nonvented cap. ventricular catheter into the brain.
In addition, the use of a flushless
transducer at the zero reference on
the drainage system eliminates
lengthy tubing that may dampen the
waveform (Fig. 94-1).
4. Connect the end of the EVD Ensures that the system is secure and
drainage system tubing to the is a sterile closed system.
distal stopcock of the pressure
monitor tubing (Fig. 94-2) if not
already included in the drainage
system. Tighten all the
connections.16,17,24
Figure 94-1 External ventricular drainage system with flushless transducer at zero reference level.
(Courtesy of Integra Lifesciences Corporation, Plainsboro, NJ.)
cm H2o
Distal stopcock mm Hg
CSF sampling
stopcock CSF
sampling
External drainage port
system tubing
Ventriculostomy
Distal tip catheter
Air fluid
interface
(zeroing
stopcock)
Transducer
with flush
Drainage
device system
Sterile External stopcock
cap Foramen
auditory Drip
Monroe chamber
meatus
(interventricular
foramen) 4th ventricle
Choroid
plexus
External
drainage
collection
bag
Figure 94-2 External ventricular drainage system. (Drawing by Paul Schiffmacher, Thomas Jef-
Procedure for Pressure Monitoring and Drainage—Continued

5. Close the clamp or stopcock Ensures the ability to measure hourly
between the drip chamber and drainage in the drip chamber.
the external ventricular drainage
collection bag (see Fig. 94-2).
6. Replace all vented caps with Vented caps are used by the
nonvented caps. manufacturer to permit sterilization
of the entire system. These caps
need to be replaced with sterile
nonvented caps to prevent bacteria
and air from entering the system.
7. After flushing the pressure The stopcock in this position readies Prevents the backflow of fluid into the
monitor tubing and the external the entire system for connection to drip chamber.
ventricular drainage system the ventriculostomy catheter.
tubing, turn the distal stopcock
off to the distal tip of the pressure
monitor tubing (Fig. 94-3).
8. Position the reference level of the The relationship of the reference level The reference level of the drip chamber
drip chamber as prescribed. of the drip chamber to the may need to be adjusted after
anatomical reference point alters insertion of the ventricular catheter
the rate of CSF drainage. and the initial ICP is obtained and is
individualized for each patient based
on etiology, pathophysiology, and
management strategies.
9. Discard used supplies. Removes and safely discards used
supplies.
10. HH
Assisting With Insertion of an Intraventricular Catheter
1. HH
2. Apply nonsterile gloves, gowns, Reduces transmission of
and masks with eye shields. After microorganisms and body
opening outer packaging, apply secretions; Standard Precautions.
sterile gloves to handle sterile
supplies.
3. Ensure the patient is in position Facilitates the insertion of the The usual position is supine, with the
for ventricular catheter catheter. head of bed elevated.
placement. Administer sedation and analgesia
as prescribed and monitor patient
per institutional standards for
procedural sedation monitoring.
4. Assist as needed with the Reduces the transmission of The choice of povidone iodine or
antiseptic preparation of the microorganisms into the ventricles. chlorhexidine as an antiseptic agent
insertion site. is controversial.14,18 Both should be
allowed to dry completely. Observe
for initiation of CSF drainage, and
obtain an opening ICP.
Distal stopcock
To
transducer
Distal tip of
pressure monitoring
tubing
External ventricular Ventriculostomy

drainage system catheter
tubing
Figure 94-3 Distal stopcock turned off to the distal tip of the pressure monitor tubing. (Drawing
by Paul Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)

5. Connect the drainage/monitoring Establishes draining system.
system to the distal tip of the
catheter after it is inserted.
6. Assist as needed with application Reduces the risk of infection.
of a sterile, occlusive dressing or
as per hospital standards. Secure
the catheter to minimize
manipulation and the risk of
inadvertent removal.16,25 (Level E*)
7. Discard supplies.
8. HH
Connecting the EVD Transducer with Bedside Monitor
1. Turn on the bedside monitor. Prepares the monitor.
2. Plug a pressure cable into the The signal is transmitted to the
appropriate pressure module or bedside monitor so that it may be
port in the bedside monitor (see transmitted to the oscilloscope for
Fig. 94-2). display.
3. Attach the pressure cable to the Prepares the equipment.
transducer connection on the
pressure tubing of the drainage
system.
4. Turn on the ICP parameter. Visualizes correct waveform.
5. Set the appropriate scale for the It is necessary to visualize the The normal ICP for an adult is within
measured pressure.27,29 complete waveform and to obtain the range of 0–15 mm Hg.8,12
corresponding numerical values.
Waveforms vary in amplitude,
depending on the pressure within
the system.
6. Set the monitor alarm limits for Goals for ICP management are
ICP and CPP. individualized for each patient
based on etiology, pathophysiology,
and management strategies.
Leveling the Transducer
1. Perform hand hygiene.
2. PE
3. Position the patient in the supine Prepares the patient. The head of the bed is usually placed
position with the head of the bed at 30 degrees to aid in increasing
elevated as prescribed by the venous return.12,27
professional.26,28,31 (Level E)
4. Place the air-fluid interface The external auditory meatus Some institutions use the tragus or a
(zeroing stopcock) at the level of approximates the level of the line drawn from the outer canthus
the external auditory meatus (see foramen of Monro (intraventricular of the eye.2,22 Follow institutional
Fig. 94-2).2,31 (Level B*) foramen).2,8 policy.
5. Discard supplies.
6. HH
*Level B: Well-designed, controlled studies with results that consistently support a specific action, intervention or treatment.

Zeroing the Transducer
1. HH Follow institutional standard.
2. PE
3. Turn the transducer stopcock off Prepares the system for the zeroing
to the patient. procedure.
4. If indicated for the drainage/ Allows the monitor to use Follow institutional standard.
monitoring system in use: remove atmospheric pressure as a reference
the nonvented cap from the for zero.
stopcock, thus opening the
stopcock to air.
(Some drainage systems may not
require removing a cap but
simply adjusting the drip chamber
to 0 mm Hg, pressing zero on the
bedside monitor, and retuning the
drip chamber to the level
prescribed.)
5. Push and release the zeroing The monitor automatically adjusts Some monitors require that the zero
button on the bedside monitor. itself to zero. Zeroing negates the be turned and adjusted manually.
Observe the digital reading until effects of atmospheric pressure.
it displays a value of zero.
6. Place a new, sterile, nonvented Maintains sterility.
cap on the stopcock.
7. Turn the stopcock so that it is Permits pressure monitoring.
open to the transducer. Observe
the ICP waveform and the
corresponding numerical value.
9. HH
Monitoring Intracranial Pressure
1. HH
2. PE
3. Position the head of the bed as Allows for accurate and consistent Ensure that the EVD system is at the
prescribed. monitoring of the ICP. prescribed level for ICP
measurement (e.g., level with
external auditory meatus).
4. Turn the distal stopcock off to the Decreases artifact from simultaneous
external ventricular drainage drainage. Allows for accurate
system (Fig. 94-4).22 monitoring of the ICP.
5. Record the ICP value and Provides a value for ongoing The normal ICP waveform has at
waveform per institutional assessment. Allows analysis of the least three distinct pressure
standard. ICP waveform. oscillations or peaks. These are
referred to as P1, P2, and P3 (see
Fig. 92-2).19,25
Distal stopcock
To
transducer
Distal tip of
pressure monitoring
tubing
External ventricular
Ventriculostomy
drainage system
catheter
tubing
Figure 94-4 Distal stopcock turned off to the external drainage system tubing. (Drawing by Paul
Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)

6. Monitor and record ICP and CPP Assesses ICP waveform and values If continuous drainage is prescribed,
as prescribed. and CPP value. the risk of overdrainage is
increased. If the drainage system
allows, turn the stopcock to
simultaneously drain and to trend
the ICP. Set alarms. To obtain an
accurate ICP, the stopcock must be
turned off to the drain with the
catheter open to the transducer only
and the waveform and numeric
value of the ICP given time to
stabilize. The waveform and
numeric value of the ICP should
correspond.
Deviations in ICP and CPP may
require immediate intervention and
should be reported to the physician,
healthcare professional. If an EVD
is in the monitoring position (and
off to CSF drainage), special care
must be paid to the bedside
neurological examination with
regard to the potential for
deterioration. The catheter may
become obstructed with clot, tissue,
or protein. Note any changes in
CSF flow. Notify the physician,
healthcare professional who may
need to irrigate the catheter
to reestablish patency. Other
maneuvers may include turning
or stimulating a cough. Some
institutional policies may allow the
critical care nurse to irrigate the
catheter with a limited amount of
preservative-free saline solution.
Follow institutional standard.
7. PE
8. HH
Draining CSF from the EVD
1. HH
2. PE
3. The physician, advanced practice If the physician, advanced practice Assess patency of the system when
nurse, or other healthcare nurse, or other healthcare applicable by lowering the system
professional will prescribe the professional prescribes the ICP to briefly to assess for CSF dripping
desired ICP parameter and the be maintained at <15 mm Hg, into the burette (then return to
reference level of the drip drainage of CSF will be initiated if ordered anatomical point).32
chamber. the patient’s ICP is >15 mm Hg.
4. To drain the CSF, turn the distal Allows the flow of CSF from the Never leave a draining EVD
stopcock of the pressure ventricles. unattended. Excessive drainage may
monitoring tubing off to the cause overdrainage and a possible
transducer (Fig. 94-5).22 collapse of the ventricles, resulting
in tearing of the bridging veins of
the brain causing a subdural
hematoma.
Distal stopcock
To
transducer
Distal tip of
pressure monitoring
tubing
External ventricular
Ventriculostomy
drainage system
catheter
tubing
Figure 94-5 Distal stopcock turned off to the transducer. (Drawing by Paul Schiffmacher, Thomas

5. Allow 2–5 mL of CSF to enter Prevents overdrainage of CSF. Never leave a draining EVD
the drip chamber (see Fig. 94-5). unattended.
6. When drainage is completed, turn Check the ICP value to determine If the patient’s CSF is being
the distal stopcock off to the whether the parameter is met. continuously drained, note and
external ventricular drainage record the amount of drainage
system (see Fig. 94-4) and record every hour. In general, no more
the amount drained and the ICP than 20 mL, the amount of CSF
value. produced in 1 hour,3 should be
drained each hour.
7. If the goal was not met, repeat Allows gradual draining of CSF.
Steps 3–5 until the ICP parameter
is met.
CSF Sampling
1. HH
2. Obtain from a physician, Prepares for the test. CSF sampling may include glucose,
advanced practice nurse, or other cell count, protein, culture and
healthcare professional an order sensitivity, and gram stain. If a
for a CSF sample, including the comparison of serum glucose and
frequency. CSF glucose is prescribed, a serum
glucose sample should be obtained
at the same time as the CSF
sampling. Normal CSF glucose is
two thirds of blood glucose.3,6
3. Obtain the supplies for sampling: Prepares the equipment.
sterile 3-mL syringes, CSF tubes,
antiseptic solution, sterile gloves,
mask with face shield, laboratory
forms, and specimen labels.
4. Apply sterile gloves and mask Reduces the transmission of
with face shield. microorganisms and body fluids;
Standard Precautions.
5. Cleanse the CSF sampling port Reduces the transmission of Follow institutional standard.
with an antiseptic solution (Fig. microorganisms into the ventricles.
94-6). Allow solution to dry.
6. Turn the distal stopcock of the Allows for direct sampling of CSF
pressure monitor tubing off to the from the ventriculostomy catheter.
transducer and turn the drainage
system stopcock off to the drop
chamber (see Fig. 94-5).
CSF sampling port
CSF sampling
stopcock
Figure 94-6 CSF sampling port. (Drawing by Paul Schiffmacher, Thomas Jefferson University,
Philadelphia, PA.)

7. Slowly withdraw two 1- to 2-mL Obtains the prescribed sample. One sample may be used for
samples from the designated CSF laboratory studies, and the other
Y-site or sampling port and inject for culture and Gram stain, if
each into a specimen tube. If prescribed by the physician,
resistance is met during advanced practice nurse, or other
aspiration, notify physician, healthcare professional. Follow
advanced practice nurse, or other institutional standards.
healthcare professional.
8. Turn the distal stopcock to Continues monitoring and drainage as
resume monitoring or open to prescribed.
drainage as prescribed.
9. Label the CSF specimen tubes Prepares the specimen for analysis.
and send to the laboratory for
analysis.
10. Discard used supplies. Removes and safely discards used
supplies.
11. HH

• Aseptic drainage system21,25,27 • Loose connections within the external ventricular
• Air-fluid interface of the transducer is leveled at the drainage system
foramen of Monro for accurate ICP and CPP • Stopcocks left open to air without nonvented caps
monitoring22,26,28 • Air bubbles within the system23
• The monitoring system is zeroed • CSF infection1,10,30
• Drainage chamber at prescribed level • CSF leak
• Intermittent or continuous drainage as prescribed • Lack of CSF flow6
• Accurate and reliable monitoring of ICP and CPP22,26,28 • Dislodgment or occlusion of the EVD
• Continuous flow of CSF when drainage is initiated; • Headache from overdrainage31
appropriate amount of CSF drainage22,26,28 • Pneumocephalus from overdrainage
• Immediate management of increased ICP and • Rebleed from subarachnoid hemorrhage13,21
decreased CPP22,26,28 • Subdural hematoma from overdrainage27
• Improvement or stabilization of neurological • EVD-related hemorrhage27
function22,28,31 • Herniation from underdrainage or overdrainage

interventions.
1. Monitor each of the following Assesses neurological status. • Any gradual or sudden increase in
parameters continuously or the ICP, with or without
intermittently as prescribed: ICP, accompanying neurological
CPP, and CSF drainage, amount, changes
color, clarity, and patency of the • Lack of drainage in the presence of
system. significantly increased ICP requires
immediate reporting to the
or other healthcare professional;
this may indicate an occlusion of
the catheter21,27
• Lack of drainage in the presence of
significantly increased ICP may
also indicate occlusion of the
drainage system from persistent
contact of CSF catheter with the
ventricular wall8
• Persistent large volumes of CSF
may indicate the need for a CSF
shunt30
2. Zero the external ventricular Ensures the accuracy of the
drainage system during the initial monitoring process.
setup or before insertion, then
after insertion and again if
connections between the
cable become dislodged, if
connections between the
monitoring cable and the monitor
become dislodged, and when the
values do not fit the clinical
picture.
3. During position changes, clamp Minimizes the risk for underdrainage, • Increase or decrease in CSF
the EVD. After changing the overdrainage, or erroneous ICP drainage
patient’s position, maintain the values. • The inability to obtain CSF
reference level of the EVD at the drainage
external auditory meatus and • Changes in ICP or neurological
ensure system is patent. assessment
4. Maintain the reference level of The relationship of the reference for • Underdrainage
the drip chamber as prescribed. CSF drainage and ICP monitoring • Overdrainage
level of the drip chamber to the
anatomical reference point alters
the rate of CSF drainage.
5. Check the system every hour and Ensures that all connections are
as needed. tightly secured and that no cracks
occur in the system. Ensures that
the system is closed with nonvented
caps on all stopcocks. Ensures that
the system is free of air bubbles.23

6. Set the alarm parameters relative Provides immediate alarm for high • Changes in ICP or neurological
to the ICP and CPP goals pressures (and an immediate alarm assessment
established by the physician, for low pressures associated with
advanced practice nurse, or other inadvertent overdrainage).
healthcare professional.
7. All drainage should be measured Assesses CSF drainage. Amount, • Increase or decrease in CSF
and recorded as part of the intake color, and character should be drainage; change in CSF color,
and output. noted.26 presence of blood or blood-tinged
CSF
8. If continuous drainage is used, Assesses CSF drainage. • Increase or decrease in CSF
record and monitor the output drainage; underdrainage or
every 1–2 hours. Maintain the overdrainage
reference point at the foramen of
Monro.
9. Change the dressing at the Maintains sterility and provides an • Signs or symptoms of infection
insertion site daily or as opportunity for insertion site • Loosened sutures
prescribed with aseptic technique. assessment.24
Follow institutional standard.
10. Change bag and drainage system Practices for changing CSF drainage • Inadvertent disconnection
as needed by institutional collection device vary considerably.
standard. Maintain closed system.
11. Follow institutional standard Identifies need for pain interventions. • Continued pain despite pain
analgesia as prescribed
(Fig. 94-7).
Documentation
• Initial opening ICP and CPP • Insertion site assessment
• Level of the drip chamber and anatomical landmark • Hourly to every 2 hours output or amount drained
for zeroing intermittently22,29
• Patency of drainage system • Hourly ICP and CPP22,29
• Analysis of waveform19,26,28,29 • Neurological assessment22,29
• Description of CSF to include amount, clarity and • Site care and change of drainage system or bag
color • Pain assessment, interventions, and evaluation
Monitoring ICP with a Ventricular Drain
To Drain CSF To drip

Transducer chamber
• Master System Stopcock
Transducer system
is off to the transducer
Stopcock
• Drainage line is open
between the patient and Master
the drip chamber System
Stopcock
• When the stopcock is open
to drain it is critical that
neither the height of the
patient nor that of the
drainage system be To patient
changed to avoid over
drainage of CSF
To Zero Transducer To drip

• Requires hand hygiene, Transducer chamber
sterile gloves and new Transducer system
sterile dead-ender Stopcock
• Turn the Transducer Master
Stopcock off to the patient System
(off to the Master System Stopcock
Stopcock)
• Remove dead-ender
cap from side port of
Transducer Stopcock To patient
• The Transducer is OPEN
TO AIR and isolated from
any pressures
• Press ZERO on the ICP
monitor
• Replace dead-ender cap
with NEW STERILE CAP
and turn stopcock back OFF
to side port
To Monitor ICP To drip

• Turn the Master System Transducer chamber
Stopcock off to the drip Transducer system
chamber Stopcock
• The drainage line is open Master
between the patient and the System
transducer Stopcock
To patient
NEVER! To drip
Transducer chamber
• NEVER turn the stopcock
Transducer system
open three ways to try to
drain and monitor at the Stopcock
same time!
• This gives a false ICP
reading – the system is
open to drain and therefore
also open to air Figure 94-7 Alternate exter-
nal ventricular drainage moni-
toring system. (Drawing by
To patient Lorna Prang, Littleton, CO).

94 Intraventricular Catheter With External Transducer for CSF Drainage and ICP Monitoring 855.e1
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PROCEDURE
95
Lumbar Subarachnoid Catheter
Insertion (Assist) for
Cerebrospinal Fluid Drainage
and Pressure Monitoring
Nicolle Schraeder
PURPOSE: Patients with a variety of central nervous system conditions and
thoracoabdominal aneurysms may benefit from the monitoring of intraspinal
pressure and maintenance of therapeutic levels of cerebrospinal fluid (CSF)
drainage. Lumbar subarachnoid catheters may be used for CSF pressure monitoring
and drainage.
PREREQUISITE NURSING spinal cord edema and to improve impaired spinal cord
KNOWLEDGE perfusion related to spinal cord edema.
• Lumbar subarachnoid catheters may be used instead of or
• Knowledge of the anatomy and physiology of the verte- with an external ventricular drain to decrease intracranial
bral column, spinal meninges, spinal cord, nerve roots, pressure and remove blood from the subarachnoid space,
and CSF circulation and intracranial and intraspinal which may lessen aneurysmal subarachnoid hemorrhage
dynamics is needed. vasospasm.17,20,25–27,35,39 When ventricular and lumbar
• Knowledge of aseptic techniques is necessary. drainage are used simultaneously, the ventricular drainage
• Normal intraspinal pressure in the adult is 0 to 20 cm H2O output should exceed the lumbar drainage output to lessen
(0 to 15 mm Hg or 50 to 150 mm H2O) and usually the risk of herniation.11,16,25,39
corresponds with intracranial pressure.28 Intraspinal pres- • Paraplegia remains the most dreaded neurological com-
sure may be influenced by a number of factors includ- plication following thoracoabdominal aortic repair.2,11,41
ing edema and positioning. Further research is needed • For patients having thoracic aorta or thoracoabdominal
to ascertain therapeutic levels after various surgical surgery, CSF drainage to maintain pressures less than
interventions.25 10 mm Hg in conjunction with other neuroprotective strat-
• Lumbar subarachnoid catheters, also referred to as lumbar egies minimizes the risk of neurological sequelae, allow-
drains or intrathecal catheters, require lumbar puncture ing for adequate perfusion pressure to the spinal cord.2–4
(LP) for insertion.20 Lumbar subarachnoid catheters permit • Lumbar subarachnoid catheters may be use in the manage-
monitoring of CSF pressure. CSF pressure may be moni- ment of communicating hydrocephalus related to intra-
tored intermittently or continuously, and CSF drainage ventricular, intracerebral hemorrhage.11,21,22
may be performed intermittently or continuously.11,28,29 • Complications related to the use of lumbar subarachnoid
• Lumbar subarachnoid catheters may be used in the pre- catheters include infection, headache, nerve root irrita-
vention or management of spontaneous, traumatic, or sur- tion, retained fragments of broken catheters, paraplegia,
gical CSF fistulas to allow any tears in the dura mater to and neurological deterioration related to overdrainage,
heal.5,11,38,40,41 The catheter reduces moisture and pressure including subdural hematomas, pneumocephalus, and
at the tear and may be placed before, during, or after herniation.1,31–34
surgery.4,5,10,11,14 • Lumbar subarachnoid catheters have been used, with
• Lumbar subarachnoid catheters may be used in the diag- extreme caution, in the management of patients with
nostic workup and management of normal pressure hydro- meningitis.24,36,37
cephalus instead of serial lumbar punctures.16,19 • Lumbar subarachnoid catheter drainage is contraindicated
• Lumbar subarachnoid catheters may be used in the peri- with midline mass effect. A computed tomographic (CT)
operative management of intraspinal pressure during and scan before lumbar subarachnoid catheter insertion to
after thoracoabdominal aortic aneurysmal repair to provide confirm discernible basal cisterns and absence of a mass
adequate room in the intraspinal space to accommodate lesion may lessen the risk of herniation.1,20,25,26
856
95 Lumbar Subarachnoid Catheter Insertion (Assist) for Cerebrospinal Fluid Drainage and Pressure Monitoring 857
• A variety of products are available for lumbar subarach- PATIENT ASSESSMENT AND
noid catheter drainage systems, making it essential to PREPARATION
follow the manufacturer’s guidelines for management of
the patient,28 including the type of pressure measurement Patient Assessment
unit used for patient monitoring (e.g., monitoring pres- • Assess the patient’s neurological status, including level
sures in units mm Hg or cm H2O). of consciousness, cranial nerves, sensory and motor func-
tion in the upper and lower extremities, vital signs, and
EQUIPMENT bowel and bladder function. Rationale: Baseline data are
provided.
• Antiseptic solution • The procedure may be performed on an awake patient.
• Caps, masks with face shields, sterile gowns, and sterile Rationale: By having the patient awake, this allows the
gloves patient to provide feedback in relation to paresthesis and
• Sterile towels, half-sheets, and drapes can assist with placement by adjusting positioning; this
• Local anesthetic (lidocaine 1% or 2% without epinephrine) further allows for ongoing assessments during the proce-
• 5- or 10-mL Luer-Lock syringe with 18-gauge needle for dure, which allows for detection of changes in patient
drawing of lidocaine and 23-gauge needle for administra- condition.
tion of lidocaine • Assess the patient’s current laboratory profile, including
• Sutures (2-0 nylon, 3-0 silk) complete blood count, with platelets, partial thromboplas-
• Forceps tin time, prothrombin time, and international normalized
• Sterile scissors ratio. Rationale: Baseline coagulation study results deter-
• Sterile needle holder mine the risk for bleeding during and after lumbar sub-
• Preservative-free sterile normal saline solution (vial, bag, arachnoid catheter insertion.20,30,35
or prefilled syringe) • Assess the patient’s medication profile. Rationale: Recent
• Lumbar catheter tray containing a sterile catheter and, anticoagulants or antiplatelet agents may increase the risk
depending on the tray, additional connection devices of bleeding during and after lumbar subarachnoid catheter
• Lumbar puncture tray insertion.
• Sterile occlusive dressing • Assess known allergies. Notify the physician and/or
• Tape (1- and 2-inch rolls) advance practice nurse of allergies. Rationale: Usual
• External stand-alone transducer with three-way stopcock medications used during the procedure may be contrain-
• Pressure cable if monitoring pressures is indicated dicated by allergy.
• External CSF drainage system
• Nonvented sterile caps Patient Preparation
Additional equipment, to have available as needed, includes • Verify that the patient is the correct patient using two
the following: identifiers. Rationale: Before performing a procedure, the
• Leveling device nurse should ensure the correct identification of the patient
• Rolled towels or small pillows to support the patient for the intended intervention.
during positioning • Ensure that informed consent is obtained. Rationale:
Informed consent protects the rights of the patient and
PATIENT AND FAMILY EDUCATION makes competent decision-making possible for the patient;
however, in emergency circumstances, time may not
• Assess the patient and family understanding of the allow for the consent form to be signed.
lumbar subarachnoid catheter system. Rationale: Any • Administer preprocedural analgesia or sedation as pre-
necessary clarification may limit anxiety for the patient scribed. Rationale: The patient must be correctly posi-
and family. tioned and immobile during lumbar subarachnoid catheter
• Explain insertion, monitoring, and care involving the insertion and therefore may need sedation or analgesia to
lumbar subarachnoid catheter. Rationale: Knowledge of tolerate the procedure.
expectations can minimize anxiety and encourage ques- • Administer preprocedural antibiotics as prescribed. Ratio-
tions regarding goals, duration, and expected outcomes of nale: Prophylactic intravenous antibiotics may reduce the
the lumbar subarachnoid catheter. risk of infection for those patients that are at high risk. Pro-
• Explain to the patient that the nurse will help with position phylactic antibiotics are not recommended for all patients.
changes so that the drainage system is protected Ratio- • Perform a preprocedure verification and time out, if non-
nale: Prepares the patient for what to expect. This will emergent. Rationale: Ensures patient safety; Joint Com-
also decrease the risk of overdrainage which can result in mission’s Universal Protocol for Invasive and Surgical
subdural hematoma or 6th nerve palsy. Procedures.
Procedure for Lumbar Subarachnoid Catheter Insertion (Assist)

1. HH Check latest coagulation laboratory
works. Ensure the patient is not on a
heparin drip. This will decrease the
risk of bleeding and complications.
and other healthcare professionals
involved in the procedure need to
apply goggles or masks with face
shields, caps, sterile gowns, and sterile
gloves.
3. If pressure monitoring is prescribed, Facilitates monitoring after Do not attach a pressurized intravenous
assemble a fluid-filled transducer catheter insertion. fluid bag to the transducer.
with stopcock and nonvented cap. Preservative in normal
Using sterile techniques, flush the saline solution may cause
external standalone transducer with cortical necrosis.28
preservative-free sterile normal
saline solution. (Level E*)
4. Using sterile techniques, assemble Prepares the equipment. Allowing the CSF to flush the system
and flush the sterile CSF drainage after insertion of the catheter may
system compatible with the lumbar allow air in the fluid-filled system,
subarachnoid catheter device with resulting in a damped waveform,
preservative-free sterile normal inaccurate intraspinal pressure values,
saline solution. Ensure the filter and decreased drainage. Priming the
located at the top of the drainage drainage system with preservative-free
chamber does not get wet during sterile normal saline solution, not CSF,
priming because this will affect before connecting the system to the
drainage.11,25 (Level E) lumbar catheter, is recommended.11
Follow institutional standards. It is of
note that some physicians prefer and
are trained to allow CSF to flush the
system once the drain is connected to
the catheter.30
5. Attach the fluid-filled transducer to Prepares the equipment. The transducer may be attached to the
the CSF drainage system. CSF drainage system before either is
primed, and the transducer may be
flushed at the same time the CSF
drainage system is primed. Ensure that
the tail/cable part of the transducer is
facing away from the drainage system.
6. Connect the fluid-filled transducer to Facilitates insertion and Ensure that the waveform chosen for
the pressure cable and bedside immediate lumbar CSF monitoring is read on the “mean”
monitor. subarachnoid CSF pressure setting.
monitoring on insertion.
7. Set the reference line of the drip Prepares the CSF drainage
chamber at the level of the system for use.
transducer, which is typically at zero
reference (Figs. 95-1 and 95-2).
8. Level the transducer and the zero Ensures accurate readings on The anatomical reference point will be
reference to the anatomical which to base therapy. determined by the physician and may
reference point of the patient as be the external auditory meatus,
prescribed or as per institutional shoulder height, or the level of
standards (see Fig. 95-1). (Level E) catheter insertion.28
Procedure for Lumbar Subarachnoid Catheter Insertion (Assist)—Continued

Figure 95-1 Drip chamber at the level

of the transducer and the external auditory
meatus.
Figure 95-2 Top of the drip chamber with reference line.
9. To zero the system before attaching Allows the monitor to use The membrane at the top of the drip
to the patient, turn the stopcock off atmospheric pressure as a chamber may allow zeroing without
to the patient port, remove the reference for zero. opening the fluid-coupled system to
nonvented cap on the stopcock, and air.
zero the monitoring system at the
anatomical reference point. Replace
the sterile nonvented cap. Follow
manufacturer’s directions.23
(Level M*)
10. Position the reference level of the The relationship of the
drip chamber as prescribed. reference level of the drip
chamber to the anatomical
reference point alters the
rate of CSF drainage.

Procedure for Lumbar Subarachnoid Catheter Insertion (Assist)—Continued

11. Assist the patient to a lateral The intervertebral space The patient may be placed in a sitting
decubitus (side-lying) position with widens in this position, position for the procedure, allowing
neck, hips, and knees flexed (knees facilitating the entry of the for easier location of midline
to chest; see Fig. 96-1 and spinal needle into the structures.8,11,33 In this position the
97-1).7,8,11,34 subarachnoid space. patient can be assessed more readily
during the procedure.
12. Assist the physician or advanced Minimizes the risk for The choice of povidone-iodine or
practice nurse as needed with infection and protects the chlorhexidine as an antiseptic agent is
cleansing the intended insertion site insertion site from controversial. Both should be allowed
with antiseptic solution.10,15,16,31,32 recontamination. to dry completely. Studies suggest
(Level C*) chlorhexidine may be neurotoxic.18,30,32
13. Assist as needed with draping the Prepares for catheter
patient with sterile sheets and insertion.
opening sterile trays.
14. Provide supplies as needed during Facilitates insertion. Surgeons may insert the catheter during
catheter insertion. surgery.
15. Note the opening CSF pressure Provides baseline data.
(initial), color, and clarity.
16. Assist with the application of an Reduces contamination of
occlusive sterile dressing to the the insertion site by
catheter insertion site. microorganisms.
17. Secure the catheter with tape, with Reduces the potential for Some institutions prefer transparent
care taken not to alter the catheter catheter dislodgment. dressing (e.g., Tegaderm™, Opsite™).
position. This provides visualization of the
catheter insertion site.
18. Attach the CSF drainage system to
the lumbar drain.
19. If the intraspinal pressure is to be Ensures accurate data on
monitored, turn the stopcock off to which to base therapy.
the patient and zero the transducer.
20. If intraspinal pressure is to be Provides initial baseline data. Lumbar subarachnoid CSF pressure
monitored, observe the waveform Confirms correct placement waveform data are similar to
morphology, obtain a strip of the of the catheter. traditional intracranial pressure
waveform, and measure the CSF waveform data. Research supports
pressure. maintenance of an intraspinal pressure
of less than 10 mm Hg after thoracic
abdominal aortic resection.2,9,12,25
21. Position the head of the bed as Prevents overdrainage or Follow institutional standards and the
prescribed. Reassess the level of the underdrainage of CSF. physician’s order (e.g., drain based on
transducer, zero reference, and level volume, level, or specific pressure).
line of drip chamber. Relevel and Hourly drainage amount is generally
rezero as needed. Observe the rate 10–20 mL/hr.34,39 Follow orders
of drainage. regarding when to notify the physician
regarding trouble shooting and
overdraining.
22. Turn the stopcock to continuously The stopcock must be turned Set alarms if continuously monitoring to
monitor with intermittent drainage off to the drain to obtain minimize underdrainage or
or to intermittently monitor with an accurate intraspinal overdrainage.10
continuous drainage. Set alarm pressure.
limits. Follow institutional standards
and physician orders.
appropriate receptacle. used supplies; safely
removes sharp objects.
24. HH
Procedure for Troubleshooting Lumbar Subarachnoid Catheter Insertion (Assist)

1. HH
2. PE
3. If the CSF waveform is damped: Damping of the waveform can Catheter occlusion may result from
indicate catheter occlusion or risk precipitate in the CSF.
for catheter displacement.
A. Assess the integrity of the Loose connections may cause
lumbar subarachnoid catheter damped waveforms and increase
device and correct problems if the risk for infection.
possible.
B. Assess the monitoring system Loose cables and connecting
for disconnections and devices may contribute to
reconnect the system if mechanical failure.28,30
needed.
C. Assess the level of the The membrane at the top of the Changing the drip chamber involves
transducer, the zero reference drip chamber may allow zeroing changing the entire CSF drainage
point, and the reference line without opening the fluid-coupled system. Responsibility for
on the drip chamber for the system to air. However, one-way changing the CSF drainage system
correct position, and readjust valves in the drainage system varies among institutions and may
the position and rezero if may affect calibration.23 Also, if not be a nursing responsibility in
needed (see Figs. 95-1 and the membrane becomes wet, it most institutions. Notify the
95-2). may no longer permit accurate physician or advanced practice
readings and the drip chamber nurse for assistance as needed.
must be changed.
D. Assess the lumbar drain site. The lumbar drain might have Notify physician of a broken,
migrated or have been pulled dislodged, or disconnected
accidentally. catheter.
4. Assess for the sudden absence of Ensures accurate measurement of Notify the physician or advanced
the pressure waveform or CSF pressure.28,39 practice nurse if a reversible cause
significant changes in pressure cannot be identified. The CSF
measurements without an drainage system or the catheter
apparent clinical cause. may need to be replaced because
A. Ensure connections are tight. of catheter dislodgment or
B. Ensure leveling is correct. blockage.
C. Rezero the system.
5. Assess the flow of CSF through Avoids increases in CSF pressure Flushing or changing the system may
the drainage system by briefly caused by equipment be necessary. Follow institutional
lowering the drip chamber. malfunction.28,39 standards as to who is responsible
for flushing the system.
6. Discard uses supplies.
7. HH
Procedure for Removal of a Lumbar Subarachnoid Catheter (Assist)

1. HH Check the latest coagulation
laboratory works. Ensure the
patient is not on heparin drip.
2. PE Universal personal protection
equipment including eye
protection should be worn.
3. Assist the physician or advanced Facilitates catheter removal. Culture the catheter tip as
practice nurse as needed with prescribed.
removal of the catheter.
Procedure for Removal of a Lumbar Subarachnoid Catheter (Assist)—Continued

4. Apply a sterile occlusive Reduces the risk of contamination
dressing. by microorganisms.
appropriate receptacle. supplies; safely removes sharp
objects.
6. HH
7. Continue to assess the patient’s Removal of the catheter may result
neurological status and dressing in neurological deterioration
after removal of the catheter for related to increased CSF pressure.
CSF leak. An overt CSF leak may indicate
increased CSF pressure.1,6

• Accurate and reliable CSF pressure monitoring • CSF leak or symptoms associated with excessive
• CSF pressure within the range of 0–15 mm Hg28 drainage11–13,25
(0–20 cm H2O) • CSF infection16,34
• Early detection and management of elevated CSF • Dislodgment or occlusion of the lumbar subarachnoid
pressure through CSF drainage1,15,39 catheter32
• Resolution of any CSF leak14,32 • Tension pneumocephalus1,32
• Resolution of symptoms associated with normal • Motor function deficits along the myotome
pressure hydrocephalus5,15 distribution of thoracic or lumbar spinal cord2,9,11,12,25
• Prevention of spinal cord damage or reversal of • Catheter site pain
late-onset symptoms associated with thoracoabdominal • Sensory dysfunction involving dermatome
aneurysm repair.2,9,11,12,25 distribution of thoracic or lumbar spinal cord2,9,11,12,25
• Monitor CSF chemistry, cytology physiology • Bladder or bowel dysfunction2,9,11,12,25
• Drain subarachnoid hematoma blood from CSF; this • Decreased level of consciousness in association with
may decrease risk of vasospasms.20,26,27 herniation1,6
• Headache
• Subdural hematoma

interventions.
1. Monitor the patient’s Neurological status changes may • Change in level of consciousness
neurological status and vital result from irritation of spinal • Change in cranial nerve function
signs per physician orders and nerves associated with • Change in sensation of upper
institutional policy. subarachnoid catheter and lower extremities
placement,3,25,28,39 spinal cord • Change in motor function of
damage related to upper and lower extremities
thoracoabdominal aneurysm • Changes in bowel and bladder
repair,3,6,11,25,28,39 subdural function
hematoma formation, herniation, or • Changes in vital signs
tension pneumocranium resulting
from overdrainage of CSF.1,20,26,32

3. Assess the lumbar subarachnoid Ensures accurate measurement of • Changes in CSF pressure
CSF waveform and pressure, CSF pressure and monitoring.28,39 • Changes in CSF drainage
and the color, clarity, and • Changes in the CSF waveform
amount of CSF drainage every morphology
hour or as prescribed.
4. Maintain CSF pressure and In the management of intraspinal • Abnormal CSF pressure
drainage as prescribed. pressure after abdominal aortic
aneurysm repair, a CSF pressure of
<5 mm Hg is recommended.2,25,29
5. Assess the integrity of the Determines accurate functioning of • Loose connections or other
lumbar subarachnoid catheter the system. openings in the catheter system
system at least hourly.
6. Zero the monitoring system Ensures accuracy of the monitored
with insertion, disconnection, or data.
position changes; when the
values do not fit the clinical
picture; and according to
7. Assess the insertion site and Maintaining an occlusive dressing • Signs or symptoms of infection
change the dressing when loose reduces the risk of infection. • Significant drainage at the
or soiled. Follow institutional catheter insertion site
standards for dressing changes.
8. Continue ongoing assessment of Changes in neurological status or • Change in level of consciousness
neurological status hourly, as comfort level may indicate • Change in cranial nerve function
prescribed, or per institutional dislodgment of the lumbar • Change in sensation of upper
standards: subarachnoid catheter, spinal cord and lower extremities
A. Level of consciousness. damage related to • Change in motor function of
B. Cranial nerves. thoracoabdominal aneurysm repair, upper and lower extremities
C. Sensation. or poorly managed CSF • Changes in bowel and bladder
D. Motor function of lower drainage.28,29,39,41 function
extremities. • Headache
E. Bowel and bladder function.
F. Comfort level (including
headache).
9. Monitor patient mobility as Patients may be permitted to sit or • Overdrainage or underdrainage
prescribed to avoid ambulate with specific guidelines with mobility restrictions
overdrainage or for placement or clamping of the • Headache
underdrainage.10,11,20 drainage system.
10. Prevent dislodgment of the Catheter dislodgment may result in • Dislodged catheter
catheter through ongoing patient excessive drainage of CSF.
education. Ensure that the
catheter and drainage system
are secured. Provide sedation
and analgesia as prescribed.
11. Change the CSF pressure Reduces the risk of infection.
monitoring and drainage
systems aseptically according to

12. Obtain or assist with obtaining Currently, insufficient data exist to • Elevated white blood cell
CSF specimens as prescribed by guide or support decisions on the (WBC) count
accessing the sampling port on necessary frequency of routine • Elevated protein
the CSF drainage system with CSF sampling from lumbar • Decreased glucose in CSF fluid
strict aseptic techniques. Follow subarachnoid catheters.32 • Positive gram stain
institutional standards. • Positive culture and sensitivity
• Positive/elevated CSF cytokines
(interleukin [IL]–6) may predict
bacterial infection earlier than
elevated WBC count, elevated
protein, and decreased
glucose36,37
13. Administer antibiotics as Currently, insufficient data are
prescribed. available to guide or support
routine prophylactic antibiotic
therapy.10,12,31
14. If overdrainage is suspected, The patient may be at increased risk • Change in neurological status
clamp the drain, lower the head of herniation with overdrainage. and vital signs
of the bed,5,11,16,20,32 and assess • Overdrainage
neurological status. (Level E*)
Notify the physician of change
of condition and to get any
further orders.
Documentation
• Completion of informed consent • Vital signs (intraprocedural) per institutional policy
• Preprocedure verifications and time out • Waveform tracing at insertion and with continuous
• Insertion site assessment monitoring according to institutional standards
• Insertion of the lumbar subarachnoid catheter, • Description of expected or unexpected outcomes
including opening CSF pressure, any difficulties or • Nursing interventions used to treat elevated CSF
abnormalities, and patient tolerance pressure and expected or unexpected outcomes
• CSF description (e.g., clarity, color, characteristics) • Pain assessment, interventions, and effectiveness
• Hourly measurement of CSF pressure and amount of
drainage

95 Lumbar Subarachnoid Catheter Insertion (Assist) for Cerebrospinal Fluid Drainage and Pressure Monitoring 864.e1
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Section Thirteen Special Neurologic Procedures
PROCEDURE
96
Lumbar Puncture (Perform)
Susan Chioffi
PURPOSE: A lumbar puncture (LP) is performed for access to the subarachnoid
space to obtain a cerebrospinal fluid (CSF) sample, measure CSF pressure, drain
CSF, infuse medications or contrast agents, or place a CSF drainage catheter.1,3,4,7
PREREQUISITE NURSING • Normal CSF values include the following19,22,24,29:

❖ Opening pressure, 0 to 15 mm Hg
KNOWLEDGE
❖ White blood cell count, less than 5/mm
• Knowledge of the anatomy and physiology of the verte- ❖ Glucose, 60% to 70% of serum blood glucose
bral column, spinal meninges, and CSF circulation, ❖ Protein, 15 to 45 mg/dL
including the location of the lumbar cistern, is needed. ❖ Clear colorless appearance
• Technical and clinical competence in performing LPs is ❖ Negative culture results
necessary. • Recommended CSF tests include the following19,22,25,29:
• Knowledge of sterile technique is needed. ❖ Tube #1: Biochemistry:
• The presence of meningeal irritation caused by either Glucose
infectious meningitis or subarachnoid hemorrhage may Protein
promote discomfort when the patient is placed in the Protein electrophoresis (if clinically indicated)
flexed, lateral decubitus position for the LP.4-6,18 ❖ Tube #2: Bacteriology:
• Computed tomography (CT) scan or magnetic resonance Gram stain
imaging supersedes the routine use of LP for many Bacterial culture
diagnoses.6,8,19,29 Fungal culture (if clinically indicated); requires
• Indications for LP include the following5,6,19,29: larger volume
❖ Suspected central nervous system infection Tuberculosis culture (if clinically indicated);
❖ Clinical examination results suggestive of subarach- requires larger volume
noid hemorrhage accompanied by negative CT scan ❖ Tube #3: Hematology:
findings Cell count
❖ Suspected Guillain-Barré syndrome Differential
❖ Suspected multiple sclerosis ❖ Tube #4: Optional studies as indicated:
❖ Intrathecal administration of medications Venereal disease research laboratory test
❖ Imaging procedures that require infusion of contrast Oligoclonal bands
agents Myelin protein
❖ Measurement of CSF pressure Cytology
❖ CSF drainage in hydrocephalus, pseudotumor cerebri,
or CSF fistula EQUIPMENT
• Contraindications for LP include the following4,19,29,30:
❖ Increased intracranial pressure (ICP) with mass effect • Sterile gloves, caps, masks with eye shields or goggles,
❖ Superficial skin infection localized to the site of entry and sterile gowns
❖ Bleeding diathesis (relative contraindication) • Sterile drapes
4
❖ Platelet count less than 50,000/mm • Sterile gauze pads
❖ International normalized ratio greater than 1.5 • Antiseptic solution
❖ Anticoagulation therapy (e.g., heparin, warfarin) • Fenestrated drape
• Noncommunicating hydrocephalus • Manometer with three-way stopcock
• Infection in the region to be used for LP • Lidocaine, 1% to 2% (without epinephrine)
• 3- to 5-mL syringe
• 20-, 22-, and 25-gauge needles
practice nurses, and other healthcare professionals (including critical care • 18-, 20-, or 22-gauge spinal needles
nurses) with additional knowledge, skills, and demonstrated competence per • Four numbered capped test tubes
professional licensure or institutional standard. • Adhesive strip or sterile dressing supplies
865
• Specimen labels of a number of neurological disease processes (see previ-

• Laboratory forms ous indications for LP).
• Glucometer/phlebotomy equipment for serum or whole • Obtain a baseline neurological assessment, including
blood glucose assessment for increased ICP, before performing the LP.
• Lumbar tray (may contain many of the above supplies) Rationale: Increased ICP during the LP may place the
Additional equipment, to have available as needed, includes patient at risk for a downward shift in intracranial contents
the following: (brain herniation) when the pressure is suddenly released
• Rolled towels or small pillows to support the patient from the lumbar subarachnoid space.4,19,25,29
during positioning • Assess for coagulopathies, active treatment with heparin
• Alcohol pads or swab sticks or warfarin, local skin infections in close proximity to the
• Two overbed tables (one for the sterile field; one to posi- site, or pertinent medication allergies. Rationale: This
tion the patient, if necessary) assessment identifies potential risks for bleeding, infec-
tion, and allergic reactions.3-6
PATIENT AND FAMILY EDUCATION • Assess the patient’s ability to cooperate with the proce-
dure. Rationale: Sudden, uncontrolled movement may
• Explain the purpose of the LP procedure to the patient and result in needle displacement with associated injury or
family. Rationale: Explanation may decrease patient and need for reinsertion.
family anxiety. • Identify through history and clinical examination verte-
• Explain the need for the patient to remain still and quiet bral column deformities or tissue scarring that may inter-
in a lateral decubitus position with the neck, knees, and fere with the ability to successfully carry out the procedure.
hips flexed (knees to chest); the axis of the hips vertical; Rationale: Scoliosis, lumbar surgery with fusion, and
the back close to the edge of the bed; the head of the bed repeated LP procedures may interfere with successful can-
flat; and no more than one pillow under the head (Figs. nulation of the subarachnoid space.4,23
96-1 and 97-1). If the LP is not successful in this position, • Assess for signs and symptoms of meningeal irritation,
or the patient cannot tolerate this position, explain that which include the following. Rationale: A baseline
the patient may also be positioned leaning over a bed assessment of neurological function is established
side table or stand.6,20,23,25 Rationale: Patient cooperation before the introduction of the needle into the subarachnoid
during the examination is elicited; the intervertebral space space.
widens in these positions, facilitating entry of the spinal ❖ Nuchal rigidity
needle into the subarachnoid space.3,4,6,7 ❖ Photophobia
• Explain that the procedure may produce some discomfort ❖ Brudzinski’s or Kernig’s sign
and that local anesthesia will be injected to minimize pain. ❖ Fever
Also, explain that the patient may receive some mild analge- ❖ Headache
sic and anxiolytic agents as prescribed and needed. Ratio- ❖ Nausea or vomiting
nale: The patient and family are prepared for what to expect. ❖ Nystagmus
• Explain that the patient may find it helpful to lie flat for
1 to 4 hours after the LP. Rationale: A flat position may Patient Preparation
promote dural closure; the position was previously thought • Verify that the patient is the correct patient using two
to reduce the possibility of postprocedure headache, but identifiers. Rationale: Before performing a procedure, the
studies suggest it is not helpful in the prevention of a nurse should ensure the correct identification of the patient
headache after the procedure.1,6,13,26 for the intended intervention.
• Ensure that the patient and family understand prepro-
PATIENT ASSESSMENT AND cedural teaching. Answer questions as they arise, and
PREPARATION reinforce information as needed. Rationale: Understand-
Patient Assessment reinforced.
• Note any pertinent patient history. Rationale: An LP is • Obtain informed consent.16 Rationale: Informed consent
performed to assist with the diagnosis and management protects the rights of the patient and makes competent
decision making possible for the patient; however, in
emergency circumstances, time may not allow for the
consent form to be signed.
• Perform a preprocedure verification and time out, if non-
emergent. Rationale: Ensures patient safety.
• Obtain the patient’s history of allergic reactions. Ratio-
nale: History can rule out an allergy to lidocaine, the
antiseptic solution, and the analgesia or sedation.
Figure 96-1 The lateral decubitus position appropriate for • Prescribe an analgesic medication and/or an anxiolytic
lumbar puncture. The patient flexes the neck, hips, and knees, and medication. Rationale: These medications may be needed
the knees are drawn up tightly to the chest. This increases the intra- to promote comfort and to decrease anxiety so that posi-
spinous space for facilitation of needle insertion. tioning can be achieved during the procedure.
96 Lumbar Puncture (Perform) 867
Procedure for Lumbar Puncture (Perform)

1. HH
2. PE
3. Position or assist the critical care The intervertebral space widens in If the LP is not successful in this
nurse with positioning the patient this position, facilitating the entry position, or the patient cannot
in the lateral recumbent position of the spinal needle into the tolerate this position, the patient
near the side of the bed with subarachnoid space. may also be positioned leaning
neck, hips, and knees flexed over a bedside table or
(knees to chest), head of the bed stand.4,20,24,26 Also consider
flat, and no more than one small performing the LP with
pillow under the head (see Figs. fluoroscopy if the patient is
96-1 and 97-1). Ask the critical morbidly obese or has vertebral
care nurse to assist the patient in column deformities.
attaining and maintaining the
position. The critical care nurse
should place an arm behind the
patient’s head and then the other
arm around the knees.
4. With the patient in the lateral The LP is performed below the level An imaginary vertical line is drawn
decubitus position for of the conus medullaris, which in the midline through the
examination, identify the ends at the L1-L2 in the adult. spinous processes between the
intervertebral spaces of L3-L4, The most common site used for an two iliac crests. A second line is
L4-L5, and L5-S1; the L3-L4 LP is the L4-L5 interspace, but the imagined horizontally at the top
intervertebral space is level with L3-L4 or the L5-S1 interspace of the iliac crests and across the
the top of the iliac crests (Fig. may be used when cannulation of spinous processes by the
96-2).4,19 (Level E*) the L4-L5 interspace is not healthcare provider. These lines
possible.5,6,19,28 should intersect the L3-L4 area,
and the puncture can be
performed at the L3-L4, L4-L5,
or L5-S1 interspace.4,5
L2-3 SPACE
(Distal limit
of spinal cord)
L4-5 SUBARACHNOID
SPACE
(Enclosing cauda
equina fibers)
Figure 96-2 The body of the spinal cord
DISTAL LIMIT OF ends at L2-L3. The region below, L4-L5,
SUBARACHNOID encloses the cauda equina (a bundle of
SPACE lumbar and sacral nerve roots) within the
subarachnoid space. It is this area that is
EXTRA- appropriate for lumbar puncture.
DURAL
SPACE

Procedure for Lumbar Puncture (Perform)—Continued

5. Remove PE , wash hands, and Minimizes the risk of infection;
apply sterile gowns and gloves. maintains sterile precautions.
6. Set up a sterile field on the Prepares equipment for use in the Have the critical care nurse or
bedside stand. procedure. assistant prepare the numbered
A. Preassemble the manometer, labels for the test tubes; ensure
attaching the three-way that the tubes are labeled in the
stopcock; set it to the side. order in which they are filled, to
B. Open the test tubes and place facilitate laboratory differentiation
them in order of use in the of a traumatic tap versus a
tray slots. subarachnoid hemorrhage.4,21
C. Draw approximately 3 mL of
1% lidocaine with a 20-gauge
needle. Change to a 25-gauge
needle for a superficial
injection; change to a
22-gauge, 1.5-inch needle for
a deeper injection.4,6,8,29
7. Cleanse the skin over the L4-L5 Reduces transmission of The choice of povidone-iodine or
puncture site, including one microorganisms and minimizes the chlorhexidine as an antiseptic
intervertebral space above and risk of infection. agent is controversial. Both
below the site with the antiseptic should be allowed to dry
solution.11,12,17,18 (Level C*) completely. Some physicians,
advanced practice nurses, and
other healthcare professionals
have found chlorhexidine to
be safe in practice,26 although
other studies have suggested
chlorhexidine is neurotoxic.11,18
8. Drape the patient with exposure Minimizes the risk of infection;
of the insertion site. maintains sterile precautions.
9. Administer a local anesthetic with Reduces discomfort associated with
a 25-gauge needle, raising a needle insertion.
wheal in the skin. Inject a small
amount into the posterior spinous
region with a 22-gauge needle.6,29
10. Insert a 22-, 20-, or 18-gauge Facilitates the passage of the needle If bone is encountered on needle
spinal needle bevel up9 through between intervertebral spaces insertion, pull back slightly,
the skin into the intervertebral toward the dura mater. The use of correct the angle to between 15
space of L4-L5, with the needle a smaller atraumatic spinal needle and 40 degrees cephalad, and
at an angle of 15 degrees has been associated with a reduced reinsert.5,6,29 Use the interspace
cephalad, aiming toward the incidence rate of post-LP above (L3-L4) or below (L5-S1)
umbilicus and level with the headache.9,10,14,15,30 the original L4-L5 insertion site
sagittal midplane of the body.4,19 should difficulty with
(Level E*) advancement of the needle be
encountered despite correction of
the insertion angle.4,5 Variations in
the anatomical configuration of the
vertebral column, a history of
vertebral column surgery, or repeat
LPs may necessitate needle
insertion at a different level.4

11. Once the needle has been In most adults, a 3–4-cm insertion A “popping” sensation is often
advanced approximately 3–4 cm, depth is sufficient to enter the associated with penetration of the
withdraw the stylet, and check subarachnoid space. dura mater.4,6,19
the hub for CSF. If CSF is not
present, replace the stylet and
advance slightly. Once CSF is
draining, advance the needle
another 1–2 mm.4,19 (Level E*)
12. Attach the stopcock of the Flexing the legs or straining to If the patient was sitting on the side
manometer to the needle. Have maintain a position may artificially of the bed leaning over the
the patient straighten his or her elevate the CSF pressure.4,8,19 bedside table for the LP, have the
legs and relax his or her position. Opening pressure or normal CSF patient lie down on his or her
Measure the opening pressure, pressure measurements taken at side for the CSF pressure
and note the color of the fluid in the lumbar area range from measurement.5
the manometer.4,19 (Level E*) 0–20 cm H2O (0–15 mm Hg or
50–150 mm H20).
13. Consider performing the The Queckenstedt test is used if an Normal findings reflect a sharp
Queckenstedt test. obstruction in the spinal increase in spinal subarachnoid
A. Ask the critical care nurse to subarachnoid space is suspected. A CSF pressure on compression of
simultaneously compress the normal response indicates that the the jugular veins; on release,
jugular veins for 10 seconds, pathway between the skull and the pressure returns to
if not contraindicated and lumbar needle is patent. This precompression levels. A lack of
within institutional policy for maneuver is contraindicated in change in CSF pressure indicates
the critical care nurse to patients with known or suspected an obstruction of CSF flow. The
perform. elevated ICP; a sudden release of Queckenstedt test is
B. Watch for a change in CSF pressure distally can result in contraindicated in patients with
subarachnoid CSF pressure on herniation.6,19 increased ICP.6,19
the manometer.6,18
14. Obtain laboratory samples: By draining CSF from the In subarachnoid hemorrhage, CSF
A. Position the first test tube over manometer into the test tubes, the with the same consistency of
the stopcock port. CSF volume withdrawn is blood is drained in all four test
B. Turn the stopcock and drain minimized.4,6 Allows for tubes. In the case of a traumatic
CSF from the manometer into progressive clearing of CSF blood tap, progressive clearing of
the first test tube. in the case of a traumatic bloody CSF occurs as drainage
C. Continue filling test tubes tap.5,6,25,29 continues. Also, the supernatant
from the hub of the spinal of centrifuged CSF should be
needle; a minimum of 1–2 mL clear if the tap was traumatic and
CSF should be collected in xanthochromic if blood has been
each of the first three test present for several hours and has
tubes. The second and fourth undergone hemolysis.5,6,25,29
test tubes may require up to
8 mL CSF depending on the
tests ordered (e.g., fungal or
tuberculosis testing).5,6
D. Return the stopcock to the off
position and discard the
manometer.


15. Cover the opening of the needle Covering the opening of the needle Minimizes post procedure
with a sterile gloved finger. with a sterile gloved finger headache.1,3,4 If a lumbar
Replace the stylet and withdraw reduces the contamination by subarachnoid catheter is inserted,
the needle.1,4,8 (Level E*) microorganisms. Replacing the refer to Procedure 95.
stylet before withdrawing the
needle prevents unnecessary CSF
loss and facilitates needle
withdrawal without traction on the
spinal nerve roots. Reinsertion of
the stylet before withdrawal of the
spinal needle has also been
associated with a reduced
incidence rate of post-LP
headaches.7,9,14,30
16. Apply an occlusive sterile Decreases the incidence of infection.
dressing to the puncture site.
17. Place the patient in a supine or In the supine position, the patient’s Whether either the prone or supine
prone position immediately after weight acts as site pressure. In the position facilitates closure of the
the procedure.1,6 (Level E*) prone position, the increased dura mater after the LP remains
abdominal pressure transmits unclear. Neither the supine nor
pressure to the site.27 Some prone position has been shown to
physicians, advanced practice prevent postdural puncture
nurses, and other healthcare headaches.1,4,5,27
professionals advocate placing the
patient in a supine or prone
position for 1–4 hours.1,2,6
18. Label and send specimens to the Obtains CSF analysis and assists Hyperglycemia or hypoglycemia
laboratory. If there is no same- with the differential affects CSF glucose values and
day serum glucose measurement, diagnosis.5,19,25,29 can interfere with interpretation
consider obtaining a serum of results.6,19,25,29
glucose sample.
appropriate receptacles. supplies; safely removes sharp
objects.
20. HH

• Determination of the characteristics of the CSF that • In cases of a supratentorial mass or severely elevated
supports establishment of the diagnosis ICP, a shift in intracranial contents (brain herniation)
• Recommendation for definitive treatment that promotes may be promoted by the sudden decrease in pressure
restoration of health or optimal functional status incurred with LP4,6,19,25
• Postprocedure headache may occur in up to 70% of • Injury of the periosteum or spinal ligaments may
patients undergoing LP and is usually self- produce local back pain6,27
limiting9,10,14,19; the incidence of headache may be • Infectious meningitis may result from an improper
reduced with the use of smaller-gauge spinal needles technique that produces contamination5,6,18,19
and reinsertion of the stylet before the needle is • Traumatic taps may result from inadvertent puncture
withdrawn4,7,14,15,19,30 of the spinal venous plexuses; usually this is a
• No change in neurological status after the procedure self-limiting process, but it may result in a hematoma
in patients with bleeding disorders4-6,29
• Transient lower-extremity pain may occur from
irritation of a spinal nerve6,29
• Persistent CSF leak from the puncture site associated
with nonclosure of the dura4,13
• Inability to obtain a CSF specimen because of
healthcare provider skill level, patient intolerance of
the procedure, pathological blockage of CSF flow, or
aberrant anatomy4
• Persistent headache despite interventions4,13-15

interventions.
1. Monitor the patient’s neurological Changes in neurological status may • Deterioration in neurological status
status, including the development be related to sudden intracranial • Transient lower-extremity motor or
of a change in level of decompression with brain sensory changes associated with
consciousness, pupil size and herniation or local irritation of a spinal nerve irritation or hematoma
reactivity, new onset of pain, spinal nerve by the needle or formation
motor weakness, or numbness in hematoma formation at the
the lower extremities, and the puncture site.3-5,18
patient’s procedural tolerance
throughout and after the procedure.
2. Monitor for postprocedure Headache occurs in up to 70% of • Intractable postprocedure headache
headache. patients after an LP.9,10,27,29
3. Monitor for drainage from the Persistent drainage may indicate an • Drainage from the LP site
puncture site. unresolved CSF leak.1,19,27 • Dural tear that necessitates a patch
or closure
4. Monitor the patient’s neurological Lower extremity motor or sensory • Spinal hematoma that necessitates
status at a minimum of every 4 changes may indicate a emergent surgical evacuation
hours for 24 hours after the LP. hematoma at the puncture site.19
5. Monitor the effectiveness of Determines level of comfort. • Unrelieved headache
measures taken to prevent or treat
postprocedure headache.14
6. Follow institutional standards for Additional treatment measures may • Intractable postprocedure headache
assessing pain. Consider be necessary to manage • Dural tear that necessitates
administration of a mild analgesic postprocedure headache.24 patch10,12,28 or closure27
agent and encourage the patient to Although recent studies do not
remain supine or prone until the support either the prone or supine
headache improves. position to prevent postdural
puncture headache, lying in one
of these positions may relieve the
headache once it develops.1,7,9,13,30
Documentation
Documentation Should Include the Following:
• Patient and family education • Change in neurological status associated with the
• Completion of informed consent procedure
• Preprocedure verifications and timeout • CSF specimens obtained
• Performance of the procedure, significant findings, • Pain assessment, interventions, and effectiveness
CSF appearance, and opening pressure • Unexpected outcomes
• Amount of CSF removed • Additional interventions
• Patient tolerance of the procedure

96 Lumbar Puncture (Perform) 872.e1
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82:713–716, 2006. 2003.
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Prevention of post-lumbar puncture headaches: Report of .washington.edu/content.aspx?aID=3630099>.
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4. Boon JM, et al: Lumbar puncture: Anatomical review of a following blood patch of post dural headache. Pain
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PROCEDURE
97
Lumbar Puncture (Assist)
Susan Chioffi
PURPOSE: A lumbar puncture (LP) is performed for access to the subarachnoid
space to obtain a cerebrospinal fluid (CSF) sample, measure CSF pressure, drain
CSF, infuse medications or contrast agents, or place a CSF drainage catheter.1,3,4,8
PREREQUISITE NURSING formed with fluoroscopy for patients with marked obesity
KNOWLEDGE or spinal deformities. Optimal positioning is necessary to
avoid the risk for a “dry tap” or an unsuccessful puncture
• Knowledge of neuroanatomy and physiology is needed. attempt. Repeated attempts at puncture increase the risk
• LP at L3-L4 or L4-L5 in an adult is usually performed to for infection and patient discomfort.4,19
obtain a CSF sample.19 • Proper positioning for an LP widens the interspinous
• Indications for LP are as follows: process space and facilitates the passage of the needle.3,4,6,7
❖ CSF analysis may be indicated in the differential diag-
nosis of subarachnoid hemorrhage, central nervous EQUIPMENT
system infection, central nervous system autoimmune
processes, and some malignant diseases.5,6,17,26 • Sterile gloves, caps, masks with eye shield, and sterile
❖ Therapeutically, an LP may be used to treat hydro- gowns
cephalus, CSF fistulas, and pseudotumor cerebri; to • Sterile drapes
deliver medications or contrast material into the sub- • Sterile gauze pads
arachnoid space; or to access the subarachnoid space • Antiseptic solution
for placement of a lumbar subarachnoid drain.5,6,19,27 • Fenestrated drape
• Contraindications for LPs are as follows5,19,26,27: • Manometer with a three-way stopcock
❖ LPs are contraindicated if the patient has a known or • Lidocaine, 1% to 2% (without epinephrine)
suspected intracranial mass or elevated intracranial • 3- to 5-mL syringe
pressure (ICP), noncommunicating hydrocephalus, or • 18-, 20-, 22-, and 25-gauge needles
infection in the region to be used for LP, or is coagu- • 18-, 20-, or 22-gauge spinal needles
lopathic or therapeutically anticoagulated. If CSF anal- • Four consecutively numbered, capped test tubes
ysis is necessary, the patient may need pretreatment • Adhesive strip or sterile dressing supplies
with fresh-frozen plasma, platelets, cryoprecipitate, or • Specimen labels
the specific factor needed to correct a hematologic • Laboratory forms
abnormality.6,19,26,27 • Glucometer/phlebotomy supplies for concurrent testing of
❖ LPs are cautioned against in patients suspected of serum or whole blood glucose
aneurysmal subarachnoid hemorrhage and in patients • Lumbar tray (some of the supplies above will be in the
with complete spinal blocks. In such cases, an LP may tray)
be performed if the computed tomographic scan of the Additional equipment, to have available as needed, includes
patient’s head does not indicate signs of increased ICP, the following:
such as significant cerebral swelling, hematoma, intra- • Alcohol pads or swab sticks
cranial tissue shifts, or herniation.6,19,26,27 • Two overbed tables (one for the sterile field; one to posi-
❖ Brain herniation may occur after punctures in the tion the patient, if necessary)
presence of an intracranial mass lesion or increased • Rolled towels or small pillows to support the patient
ICP.4,19 during positioning
• The preferred positioning for an LP is lateral decubitus
with the neck, hips, and knees flexed (knees to chest); the PATIENT AND FAMILY EDUCATION
axis of the hips vertical; the back close to the edge of the
bed; the head of the bed flat; and no more than a small • Explain the purpose of the procedure to the patient and
pillow under the head (see Figs. 96-1 and 97-1).20 If the family. Rationale: Understanding of the procedure is rein-
LP is not successful in this position, or if the patient forced, and anxiety may be decreased.
cannot tolerate this position, the patient may also be posi- • Explain positioning requirements for the LP. Rationale:
tioned sitting on the side of the bed, leaning over a bedside Cooperation with positioning requirements facilitates the
table or stand.20,22,23,27 This procedure may also be per- procedure.
873
normalized ratio. Rationale: Baseline values are established,

and any coagulopathies that necessitate intervention before
the cisternal or LP are identified.
• Assess for signs and symptoms of meningeal irritation,
including the following. Rationale: Baseline neurological
function is established before introduction of a needle into
the subarachnoid space.
❖ Nuchal rigidity
❖ Photophobia
❖ Brudzinski’s sign (flexion of the knee in response to
Figure 97-1 Proper positioning of the patient for a lumbar punc-
flexion of the neck)
ture. (From Ellenby MS, Tegtmeyer K, Lai S, et al: Lumbar punc-
❖ Kernig’s sign (pain in the hamstrings on extension of
ture, N Engl J Med 355:e12, 2006. Copyright © 2006, Massachusetts
Medical Society. All rights reserved.) the knee with the hip at 90-degree flexion)
❖ Fever
❖ Headache
• Explain that the procedure may cause some mild discom- ❖ Nausea or vomiting
fort; the patient will receive local anesthesia and may also ❖ Nystagmus
receive some mild analgesia and an anxiolytic. Rationale: • Assess for allergies to local anesthetic, antiseptic, and
This lets the patient know what to expect. any analgesic or sedative medications. Rationale: Risk of
allergic reaction is decreased.3-6
PREPARATION PATIENT PREPARATION
Patient Assessment • Verify that the patient is the correct patient using two
• Obtain vital signs. Rationale: Baseline values for the identifiers. Rationale: Before performing a procedure, the
patient are established. nurse should ensure the correct identification of the patient
• Perform a neurological assessment, including level of for the intended intervention.
consciousness, pupil size and reactivity, and motor and • Ensure that the patient and family understand prepro-
sensory function. Rationale: Baseline neurological func- cedural teaching. Answer questions as they arise, and
tion is established before the insertion of a needle into the reinforce information as needed. Rationale: Understand-
proximity of sensitive neurological tissue. ing of previously taught information is evaluated and
• Assess for signs and symptoms of increased ICP. Ratio- reinforced.
nale: Increased ICP during the LP may place the patient • Ensure that informed consent is obtained.16 Rationale:
at risk for a downward shift in intracranial contents (brain Informed consent protects the rights of the patient and
herniation) when the pressure is suddenly released from makes competent decision making possible for the patient;
the lumbar subarachnoid space. however, in emergency circumstances, time may not
• Assess the patient’s current laboratory profile, including allow for the consent form to be signed.
complete blood cell count, platelets, prothrombin time, • Perform a preprocedure verification and time out, if non-
partial thromboplastin time, bleeding time, and international emergent. Rationale: Ensures patient safety.
Procedure for Lumbar Puncture (Assist)

1. HH
2. PE
3. Ensure that the patient is in the The intervertebral space widens in For LPs, to help the patient
proper lateral decubitus position, this position, facilitating the maintain this position, an arm can
near the side of the bed with the entry of the spinal needle into be placed behind the patient’s
neck, hips, and knees flexed (knees the subarachnoid space. head and then the other arm
to chest). The head of the bed around the knees.
should be flat, and no more than If difficulty is encountered, an
one small pillow should be under alternative position is to have the
the head (see Figs. 96-1 and 97-1). patient sit on the edge of the bed,
If difficulty is encountered, an leaning over the bed table (see
alternative position is to have the Fig. 97-1).4,20,27
patient sit on the edge of the bed,
leaning over the bed table.4,20,27
97 Lumbar Puncture (Assist) 875
Procedure for Lumbar Puncture (Assist)—Continued

4. Administer analgesia and/or May be needed to facilitate
anxiolytic medications as prescribed. positioning of the patient and to
relieve anxiety.
5. Apply goggles or masks with face Minimizes the risk of infection;
shields, caps, sterile gowns, and maintains aseptic and sterile
sterile gloves. precautions.
6. Assist as needed with skin Reduces microorganisms and helps The use of povidone-iodine versus
preparation with antiseptic prevent infection. chlorhexidine as an antiseptic
solution.11,12,17,18 (Level C*) solution before LP is
controversial. Chlorhexidine may
be neurotoxic. Allowing the site
to air dry increases the
effectiveness of antiseptic
solutions and minimizes contact
with nervous system tissue.11,12,17,18
7. Assist as needed with the Decreases the risk for
application of sterile drapes. contamination and provides a
sterile field for the procedure.
8. Assist if needed in identifying the The LP in an adult is performed An imaginary line is drawn
appropriate anatomical site for below the level of L3 to prevent vertically between the iliac crests,
puncture. damage to the spinal cord (the and a second line is imagined
body of the spinal cord ends at horizontally at the top of the
L2-L3). spinous processes. These lines
should intersect the L3-L4 area,
and the puncture can be
performed here or one level
below at the L4-L5 interspace.3,4
9. Assist with the preparation of local Prevents or decreases the pain
anesthesia as needed. Hold from the needle insertion.
medication vials as needed for
removal of local anesthetic to
assist the provider in maintaining
sterile technique.
10. Once the needle is in place, Increased muscle tension or Patients undergoing LP may also
instruct the patient to relax and intrathoracic pressure may straighten their legs because leg
breathe normally, and to avoid falsely elevate CSF pressure.4,8,19 flexion can increase intrathoracic
holding his or her breath. Assist pressure.4,8,19
the patient to straighten his or her
legs when indicated by the
provider.4,8,19 (Level E*)
11. With aseptic technique, assist with Secures the position of the
holding the manometer in place manometer.
when it is attached to the spinal
needle via a three-way stopcock.


12. Assist with obtaining the CSF Opening pressure or normal CSF The meniscus should show minimal
pressure measurement. pressure measurements taken at fluctuation related to pulse and
the lumbar area range from respiration.
0–20 cm H2O (0–15 mm Hg or
50–150 mm H20). The opening
pressure in a traumatic tap is
within normal limits, compared
with the opening pressure in
patients with subarachnoid
hemorrhage and meningitis.
13. Assist as needed in performing the The Queckenstedt test is used if an Normally, a rapid increase in CSF
Queckenstedt test, if not obstruction in the spinal pressure occurs with resultant
contraindicated or prohibited by subarachnoid space is suspected. decrease when compression is
institutional policy, by A normal response indicates that released. If a complete or partial
simultaneously compressing the the pathway between the skull spinal block exists, the level does
jugular veins for 10 seconds while and the lumbar needle is patent. not rise, or it rises slowly, and
observing for a change in This maneuver is contraindicated remains elevated when the jugular
subarachnoid CSF pressure on the in patients with known or veins are released. No increase in
manometer.6,19 Follow institutional suspected elevated ICP; a sudden CSF pressure may be caused by
policy regarding who may perform release of CSF pressure distally improper needle placement.6,19
the Queckenstedt test. can result in herniation.5,18
14. Assist with the collection of CSF Obtains needed CSF specimens.
specimens as needed:
A. Assist in stabilizing the
manometer with one hand.
B. Assist with the handoff of each
tube as needed (if not placed
upright and in order in the LP
tray). Tighten the cap of each
tube.
15. Label each tube in order of Differentiates between Red blood cell (RBC) dissipation
collection with the type of subarachnoid hemorrhage and through consecutive samples is
specimen, patient name, and the traumatic tap by evaluating each indicative of a traumatic tap;
order in which the specimen was numbered specimen.5,6,23,26 consistent RBC presence is
collected (i.e., “#1 of 3”). indicative of a subarachnoid
hemorrhage. Also, the supernatant
of centrifuged CSF should be
clear if the tap was traumatic and
xanthochromic if blood has been
present for several hours and has
undergone hemolysis.5,6,23,26
16. Obtain a serum or whole blood Allows for comparison of the Hyperglycemia increases CSF
glucose value from the patient as serum glucose value and the glucose concentration, and
prescribed. CSF glucose concentration. A hypoglycemia decreases CSF
normal CSF glucose value is glucose concentration. Either may
approximately two thirds of the interfere with the interpretation of
blood glucose value.20,21 the CSF results.5,6,19,23,26

17. Assist the patient to a supine or In the supine position, the patient’s Whether either the prone or supine
prone position.1,5 (Level E*) weight acts as site pressure. In position facilitates closure of the
the prone position, the increased dura mater after the LP remains
abdominal pressure transmits unclear. Neither the supine or
pressure to the site.24 Some prone position has been shown to
clinicians advocate placing the prevent postdural puncture
patient in a supine or prone headache.2,4,7,24
position for 1–4 hours.2,9,10,13,15
18. Observe the puncture site, May indicate continued CSF loss
dressing, and linen for CSF after the procedure. Drainage
leakage or bleeding. Reinforce the after LP from the insertion site
dressing as needed. should be minimal.
appropriate receptacle. supplies; safely removes sharp
objects.
20. HH
21. Send the specimens to the Ensures the specimens are sent for
laboratory. laboratory analysis.

• LP completed • Significant change in vital signs (respiratory changes,
• CSF samples and results obtained bradycardia, and increased systolic blood pressure)
• Patient’s vital signs and level of consciousness stable • Change or deterioration in neurological status (signs
before, during, and after the procedure of brain herniation, which may include a decrease in
• No change or deterioration in neurological examination the level of consciousness, pupil changes, and motor
• Puncture site clean and dry or sensory impairment)4,6,19,23
• No headache, neck stiffness, local pain at puncture • Inability to void spontaneously (if able to before
site, leg spasms, or elevated temperature related to the procedure)
procedure • Abnormal CSF results
• CSF not obtained or inability to complete procedure
• Prolonged headache, stiff neck, photophobia, and an
acute increase in temperature related to the
procedure5,6,18,19
• Excessive drainage at the puncture site14,15
• Persistent headache or low back pain despite
interventions
• New and persistent symptoms of pain, numbness,
tingling, weakness, or paralysis in the lower
extremities4-6,26
• Spinal or paraspinal abscess
• Hematoma formation4-6,26
• Implantation of epidermal tumors5
• Vasovagal syncope
• Seizure
• Pneumocephalus

These changes should be reported if
interventions.
1. Monitor the patient’s neurological, Pain or abnormal sensation radiating • Respiratory depression
respiratory, and cardiovascular down one or both legs may result • Changes in level of consciousness
status during the procedure. from spinal nerve irritation, which • Pupil changes
may necessitate a change in • Motor or sensory changes
patient or needle position. • Change in vital signs
Respiratory depression or an • Bowel or bladder dysfunction
altered level of consciousness may
result from brain herniation3-5,20 or
analgesia and sedation.
2. Assess vital signs and perform A change in vital signs or • Change in vital signs
systematic neurological neurological assessment could • Changes in level of consciousness
assessments every 15 minutes for indicate brain herniation, acute • Pupil changes
the first hour, every 30 minutes hematoma formation at the • Motor or sensory changes
twice, then every hour for the insertion site, injury to a spinal
next 4 hours, and at a minimum nerve, or infection.4,5,19,20
of every 4 hours for the following
24 hours after the procedure.
3. Monitor the needle puncture site. Identifies complications at the site. • Persistent bleeding at the site
• Drainage of clear serous fluid
4. Monitor the patient for headache Identifies traumatic complications of • Severe, persistent back or leg pain
or back or leg pain or discomfort. needle placement. Identifies need not evident before the procedure
Follow the institutional standards for management of discomfort. • Inability to manage pain
for assessing pain. Administer • Persistent headache despite
analgesia as prescribed. interventions2
5. Instruct the patient to remain In the supine position, the patient’s • Unrelieved headache
supine or prone in bed for 1–4 weight acts as site pressure. In the
hours or for the length of time prone position, the increased
prescribed.10,13-15 (Level E*) abdominal pressure transmits
pressure to the site.25 Some
physicians, advanced practice
professionals advocate placing the
patient in a supine or prone
position for 1–4 hours.2,6,7,24
6. Ensure adequate oral or May facilitate repletion of CSF. • Intravascular fluid overload or
intravenous fluid intake.2,6,24 deficit
Documentation
• Patient and family education • Amount and character of CSF collected
• Completion of informed consent • CSF laboratory results
• Preprocedure verifications and time out • Patient’s baseline vital signs and neurological
• Date and time of procedure assessment and tolerance of procedure
• Opening pressure • Pain assessment, interventions, and effectiveness
• Status of puncture site • Any unexpected outcomes
• Specimens sent to the laboratory for analysis • Additional interventions

97 Lumbar Puncture (Assist) 879.e1
References 16. Manthous CA, et al: Informed consent for medical

1. Ahmed SV, Jayawarna C, Jude E: Post-lumbar puncture procedures: Local and national practices. Chest 124:
headache: Diagnosis and management. Postgrad Med J 1978–1984, 2003.
82:713–716, 2006. 17. Milstone AM, Passaretti CL, Perl TM: Chlorhexidine:
2. Arevalo-Rodriguez I, et al: Posture and Fluids for Expanding the armamentarium for infection control and
Preventing Post-dural Headache. Cochrane Database prevention. Clin Infect Dis 46:274–281, 2008.
Syst Rev (3):CD009199, 2016. doi: 10.1002/14651858. 18. Reynolds F: Neurological infections after neuraxial
CD009199.pub3. anesthesia. Anesthesiol Clin 26:23–52, 2008.
3. Armon C, Evans RW: Addendum to assessment: 19. Roos KL: Lumbar puncture. Semin Neurol 23:105–114,
Prevention of post-lumbar puncture headaches: Report of 2003.
the Therapeutics and Technology Assessment 20. Ropper AH, Samuel MA: Special techniques for
Subcommittee of the American Academy of Neurology. neurological diagnosis. In Adams and Victor’s principles
Neurology 65:510–512, 2005. of neurology, ed 9, New York, 2009, McGraw-Hill.
4. Boon JM, et al: Lumbar puncture: Anatomical review of a 21. Seehusen DA, Reeves MM, Fomin DA: Cerebrospinal
clinical skill. Clin Anat 17:544–553, 2004. fluid analysis. Am Fam Physician 68:1103–1108, 2003.
5. Ellenby MS, et al: Lumbar puncture. N Engl J Med 22. Shah KH, et al: Predicting difficult and traumatic lumbar
355:e12, 2006. punctures. Am J Emerg Med 25:608–611, 2007.
6. Euerle B: Spinal puncture and cerebrospinal fluid 23. Straus SE, Thorpe KE, Holroyd-Leduc J: How do I
examination. In Roberts JR, Hedges JR, Chanmugam AS, perform a lumbar puncture and analyze the results to
editors: Clinical procedures in emergency medicine, ed 4, diagnose bacterial meningitis? JAMA 296:2012–2022,
St Louis, 2003, Elsevier, pp 1197–1222. 2006.
7. Evans RW, et al: Assessment: Prevention of post-lumbar 24. Turnbull DK, Shepherd DB: Post-dural puncture
puncture headaches: Report of the Therapeutics and headache: Pathogenesis, prevention, and treatment. Br J
Technology Assessment Subcommittee of the American Anaesth 91:718–729, 2003.
Academy of Neurology. Neurology 55:909–914, 2000. 25. van Kooten F, et al: Epidural blood patch in post dural
8. Farley A, McLafferty E: Lumbar puncture. Nurs Stand puncture headache: A randomised, observer-blind,
22:46–48, 2008. controlled clinical trial. J Neurol Neurosurg Psychiatry
9. Frank RL: Lumbar puncture and post-dural puncture 79:553–558, 2008.
headaches: Implications for the emergency physician. 26. Weaver JP: Cerebrospinal fluid aspiration. In Irwin RS,
J Emerg Med 35:149–157, 2008. Rippe JM, editors: Irwin and Rippe’s intensive care
10. Gaiser R: Postdural puncture headache. Curr Opin medicine, ed 7, Philadelphia, 2011, Lippincott Williams &
Anaesthesiol 19:249–253, 2006. Wilkins, pp 151–158.
11. Hebl JR: The importance and implications of aseptic 27. Williams J, Lye DCB, Umapathi T: Diagnostic lumbar
techniques during regional anesthesia. Reg Anesth Pain puncture: Minimizing complications. Intern Med J
Med 31:311–323, 2006. 38:587–591, 2008.
12. Kinirons B, et al: Chlorhexidine versus povidone iodine in
preventing colonization of continuous epidural catheters Additional Readings
in children. Anesthesiology 94:239–244, 2001. Allen SH: How to perform lumbar puncture with the
13. Levine DN, Rapalino O: The pathophysiology of lumbar patient in a seated position. Br J Hosp Med 67:M46–M47,
puncture headache. J Neurol Sci 192:1–8, 2001. 2006.
14. Lowery S, Oliver A: Incidence of postdural puncture Matata C, et al: Lumbar puncture: Diagnosing acute central
headache and backache following diagnostic/therapeutic nervous system infections. Nurs Stand 27(8):49–56,
lumbar puncture using a 22G cutting spinal needle, and 2012.
after introduction of a 25G pencil point spinal needle. Wilson RK, Williams MA: Normal pressure hydrocephalus.
Paediatr Anaesth 18:230–234, 2008. Clin Geriatr Med 22:935–951, 2006.
15. Luostarinen L, et al: Diagnostic lumbar puncture: Ziai WC, Lewin JJ: Update in the diagnosis and management
Comparative study between 22-gauge pencil point and of central nervous system infections. Neurol Clin 26:
sharp bevel needle. J Headache Pain 6:400–404, 2005. 427–468, 2008.
PROCEDURE
98
Pupillometer
DaiWai M. Olson and John C. Bazil
PURPOSE: The pupillometer is a noninvasive, handheld device that is used to
provide an objective measurement of the pupils before and after a light stimulus, as
well as the pupillary reactivity to light. The pupillometer is capable of providing
automated measurement of one pupil at a time and therefore may not be an
adequate substitute for evaluating the presence of anisocoria (unequal pupils).
However, after completing paired measurements of both pupils within 30 seconds,
the device displays data that allow for comparison of pupillary size and reaction.
PREREQUISITE NURSING on a healthy control population.5 All variables represent-

KNOWLEDGE ing the pupil dynamics were used to create a multidi-
mensional, normative model. These variables are the
• A fundamental understanding of the neuroanatomy and maximum size, the latency, the constriction (average
function of the optic cranial nerve (CN II) and the oculo- and maximum), and the dilation velocity (Fig. 98-2).
motor cranial nerve (CN III) provides clinical correlates The NPi quantifies the distance between the single mea-
for interpreting the outcome of readings obtained with the surement and the model. A normal NPi is >3.0. An index
pupillometer.1,2 equal to or above 3 indicates that the pupil measurement
❖ The pupil is an opening in the center of the iris of the falls within the boundaries of the NPi model and is
eye. Light passes through the pupil to the lens where defined as normal. A score below 3 means the reflex falls
images are reversed before going through the vitreous outside the boundaries and is defined as abnormal—that
humor to the rods and cones embedded throughout the is, weaker than a normal pupil response as defined by
retina. the NPi model. The NPi is reported as zero when no
❖ Images are then converted into electrical signals that constriction is detected. An NPi less than 3 may be
travel along the optic cranial nerve (CN II) to the optic reflective of increasing intracranial pressure.6
chiasm, optic tracts, and lateral geniculate nucleus ❖ The constriction velocity is measured in mm/sec and
where the images are sorted and then relayed to the calculated as the amount of constriction (size change)
visual cortex in the occipital lobe. divided by the duration (time in seconds) during which
❖ The size and shape of the pupil determines the amount the pupil remains constricted. There are medications
of light that can enter the eye. The intrinsic muscles in with known effects on the pupillary response. Alcohol
the iris (sphincter pupillae and dilator pupillae) control (EtOH) and opioids will generally cause a constriction
the size and shape of the eye. The pupillary light reflex of the pupil whereas atropine, amphetamines, and
is a brisk, protective mechanism (reflex) that triggers many hallucinogens (e.g., psilocybin [mushrooms],
the intrinsic muscles in the iris to contract and thereby LSD) will cause pupillary dilation. It is important to
decrease the size of the pupil and reduce the amount remember that the medication’s influence will occur in
of light reaching the retina. Testing the pupillary light both pupils. If a patient has had a recent ophthal-
reflex evaluates components of the second and third mological examination, determine whether specific
cranial nerve (Fig. 98-1).2 The electrical signal created anticholinergic medications such as cyclopentolate
from light entering the eye travels along CN II (affer- (Cyclogyl) have been used to dilate the pupils.7
ent) to the Edinger-Westphal nucleus and triggers an ❖ The presence of cataracts, or a history of cataract
efferent signal to travel along CN III from the Edinger- surgery, may influence pupillary reactivity.
Westphal nucleus to the intrinsic muscles of both eyes
(OU). Thus a normal response to light entering either EQUIPMENT
eye is OU pupil constriction.3
❖ The modern pupillometer is a handheld device that • Nonsterile gloves
uses video recording to analyze the size and reactivity • Pupillometer device (Fig. 98-3A)
of the pupil to light.4 • Pupillometer docking station (see Fig. 98-3A)
❖ Proper equipment assembly of the pupillometer requires • Pupillometer SmartGuard (see Fig. 98-3B)
attaching an aseptic SmartGuard to the device with the Additional equipment to integrate data into an Electronic
knowledge that each device is assigned to and linked Medical Record (EMR)
with a single patient. The neuropupillary index (NPi) is • Pupillometer Scanner
based on a collection of pupil measurements conducted • Pupillometer Reader
880
98 Pupillometer 881
A C
Figure 98-3 NPi-200 Pupillometer shown in docking (A) and
with SmartGuard (B) attached and being held in proper position
(C) with pad of SmartGuard on zygomatic bone (cheekbone).
• Provide patient and family teaching explaining how the

pupillary examination will be completed. Rationale: A
Figure 98-1 CN II and CN III pathways to Edinger-Westphal bright light is used to examine the pupils and may startle
nuclei. or frighten a patient/family if prior instruction is not
provided.

PREPARATION
Patient Assessment
• Assess patient and family understanding of information.
Rationale: Provides an opportunity to clarify information,
answer questions, and possibly reduce fear and anxiety
associated with a device being used near the face and eyes.
• Assess the patient’s ability to maintain eye opening.
Rationale: The paitent must maintain eye opening. If the
patient is unable to maintain eye opening during the exam-
ination, the provider will be required to manually lift the
eyelid and keep the eye open during the examination.
• If the patient is conscious, determine whether photophobia
Figure 98-2 Graphic representation of the pupillary light reflex is present. Rationale: Patients with photophobia will
and variables used to calculate the NPi for the left and right pupils.
benefit from instructions and warning that a bright light
will be used to assess their pupil reactivity.
PATIENT AND FAMILY EDUCATION Patient Preparation
• Explain the purpose of serial neurological assessment to • Verify that the patient is the correct patient using two
the patient and family. Rationale: The pupillary examina- identifiers. Rationale: Before performing a procedure, the
tion is a key assessment element performed during serial nurse should ensure the correct identification of the patient
neurological examinations. for the intended intervention. The SmartGuard in the
• Provide education that the pupillometer is an automated pupillometer will automatically upload data to the EMR
assessment device that will be used to track how fast based on the code entered into the SmartGuard.
the patient’s pupils respond to light. Rationale: Assessing • Identify and confirm the correct SmartGuard is available.
pupils is a standard component of the neurological exami- Rationale: To reduce the risk of cross contamination, a
nation. However, patient and family may be unfamiliar separate reusable SmartGuard is used for each patient.
with automated pupil assessment. The SmartGuard should remain with the patient.
Procedure for Automated Pupillometer Use

HH
PE
1. Remove pupillometer from Prepares the equipment. Docking station also charges the
docking/charging station battery of the pupillometer.
If in sleep mode: If not previously docked, the
• NPI 100 model: press and hold pupillometer will be in sleep mode.
the UP arrow to turn device
on.
• NPI 200 model: touch the
screen to turn device on.
If the device has been off for
more than 30 minutes, press and
hold the UP arrow to turn on the
device.
2. Obtain correct SmartGuard. SmartGuard is single-patient multiuse. If this is a new patient, the
SmartGuard must scan the patient
ID band.
3. Connect the SmartGuard to the The pupillometer device must be Gently squeeze the SmartGuard slide
pupillometer as shown in Fig. connected to a SmartGuard to tabs to position on to the NPI 200
98-3A. obtain a reading. The device will model. You will feel a click as the
not operate if the connection is not SmartGuard engages the device.
made or is not secure.
• For new patients, start with
Step 6.
• For patients with prior
examinations done during this
admission, start with Step 7.
4. New patients: The SmartGuard is single-patient use The NPI 100 model does not have the
• NPI 100: Obtain and label a and scanning the SmartGuard pairs/ scanning feature. Some units place
SmartGuard links the SmartGuard to an a sticker with the patient name on
• NPI 200: Scan the SmartGuard individual patient. the SmartGuard.
(see Fig. 98-3 B), and scan the If using the NPI 200, the SmartGuard If there is no barcode scanner, the
patient ID band using the must be paired to the patient. patient ID number can be manually
infrared Pupillometer Scanner entered.
5. Confirm that the patient is the Verify the patient’s ID (displayed on
correct patient. screen) by selecting “Accept.”
The screen will display “Ready to
scan.”
6. Press the LEFT button on the This procedure is written to first If starting with OD, select RIGHT
pupillometer. assess the left eye (OS) and then button on pupillometer.
assess the right eye (OD). However, Do not hold the button down.
this is an arbitrary decision and the
examiner may start with OD and
then assess OS.
7. Determine whether the patient is The patient who is awake and
able to follow commands. cooperative will be asked to
• For awake and cooperative participate in the examination.
patients, start with Step 10. If the patient is unresponsive or
• For unresponsive patients, start uncooperative, the examiner will
with Step 11. need to maintain the patient’s eye
open throughout the examination
(approximately 3–5 seconds).
8. Awake/cooperative patients:
A. Ask patients to open their Patient should focus on a distant point Focusing on nearby objects will cause
eyes. (at least 6 feet away). a reflexive pupillary dilation.
B. Ask them to look straight
ahead.
98 Pupillometer 883
Procedure for Automated Pupillometer Use—Continued

9. Unresponsive patient:
A. Open the patient’s eye by The entire pupil must be visible or the Inability to raise the eyelid is a
lifting the eyelid gently with pupillometer will not provide an reportable condition (e.g.,
your finger or thumb. accurate reading. periorbital edema).
B. Make sure that the eye is
open enough to see the entire
pupil.
10. Holding the pupillometer upright, Start with one pupil and then move to The choice to start with OS or OD is
place the pad of the SmartGuard the other pupil. arbitrary; practitioners should
against the patient’s left or right The ideal position to hold the consider asking patients which eye
zygomatic process (cheek bone) pupillometer is perpendicular to the they would prefer to start with.
as shown in Fig. 98-3C. eye.
11. Target the pupil by pressing and This step ensures that the Novice practitioners may benefit from
holding the LEFT button. pupillometer has located the pupil. practice to ensure that the device is
A. Look at the display screen on pointed directly at the pupil.
the pupilometer.
B. Ensure that there is a green
circle around the pupil.
12. Provide a light impulse by The pupillometer will emit a bright Press LEFT when examining OS and
releasing the LEFT button (when light for 0.8 seconds and video- press RIGHT when examining OD.
observing the OS). record the change in pupil size in
response to the light.
Hold pupillometer in place until
the measurement is completed.
13. Ensure that reading was obtained. Device should see the results display If device reads “Fail” then repeat
on the screen. Steps 12 and 13.
The device will display the word
“Rescan” if a reading was not
obtained.
14. Repeat the previous step for the Provides systematic evaluation of This procedure is written to first
right eye. both eyes. assess the OS and then assess the
OD. However, this is an arbitrary
decision and the examiner may start
with OD and then assess OS. See
Step 9 for clarity.
15. Tap the base of the pupillometer This step of the procedure uploads Optional step for hospitals/
against the pupillometer reader. readings from the pupillometer practitioners that document findings
directly into the EMR. in the EMR.
Manually input in the document
flowsheet NPi readings (for
hospitals where interfacing feature
is not yet available).
16. Remove and store the The SmartGuard is a patient-specific Store in a clean (nonsterile) dry
SmartGuard device and should not be used with location.
other patients. Clean pupillometer according to
hospital policy.
17. Dock the pupillometer in the The pupillometer charges when Ensure that the docking station is
charging station docked. plugged into an electrical source.
19. HH

• Accurate and reliable monitoring of the pupil size and • Inability to measure pupil response with pupillometer
the NPi for each pupil (OS and OD)8 (e.g., periorbital edema, cataract, prosthetic eye)
• The pupils will be of equal size and reactivity2 • Nonreactive pupil (NPi = 0)
• Early detection of elevated intracranial pressure • NPi of <3.0 (indicative of slower than normal
associated with oculomotor nerve compression5 pupillary response)5
• Unequal pupil size before light stimulus (anisocoria)7

interventions.
1. Assess the pupils with each serial Pupillary examination is considered a • Changes in pupillary reaction
neurological examination.2 normal and vital component of the noted from pervious examination
neurological examination.9 • Unreactive pupils
2. Note the waveform for each pupil. Similar shape waveform indicates • Unequal pupils or abnormal
equal responsiveness of OS and OD waveform
pupils.
3. Note NPi value. Normal is >3.0. • NPi <3.0
• Fixed pupils
4. Upload to the EMR by tapping the The NPi-200, links to most EMRs • Inability to upload data
base of the NPi-200 against the and the results from the pupil
pupillometer reader. examination can be directly
uploaded to autopopulate the EMR.
5. Report any abnormal values or Changes in pupillary reactivity should • Abnormal values (NPi <3)
significant changes of the pupils to be correlated over time.
professional.
Documentation
• Document findings for each eye • Comparison of left/right symmetry
• Date and time of examination • Minimum size
• Initial size (rounded to nearest mm) • Constriction velocity
• NPi • Note that the pupillometer is programmed to
• Inability to obtain examination. If unable to obtain document the findings automatically into the EMR.
examination, document the reason (e.g., periorbital When using compatible systems, documentation will
edema, combative, etc.) occur when the upload is completed.

98 Pupillometer 884.e1
References brain injury: Implications for treatment paradigms.

1. Wilson-Pauwels L, Akesson EJ, Stewart PA: Cranial Springerplus 3:548, 2014.
nerves: Anatomy and clinical comments, Toronto, 6. Chen JW, et al: Pupillary reactivity as an early indicator of
Philadelphia, Saint Louis, 1988, BC Decker; Mosby increased intracranial pressure: The introduction of the
(distributor). Neurological Pupil index. Surg Neurol Int 2:82, 2011.
2. Adoni A, McNett M: The pupillary response in traumatic 7. Singhal NS, Josephson SA: A practical approach to
brain injury: A guide for trauma nurses. J Trauma Nurs neurologic evaluation in the intensive care unit. J Crit Care
14(4):191–198, 2007. 29(4):627–633, 2014.
3. Blumenfeld H: Neuroanatomy through clinical cases, 8. Zafar SF, Suarez JI: Automated pupillometer for
Sunderland, MA, 2002, Sinauer. monitoring the critically ill patient: A critical appraisal.
4. Meeker M, et al: Pupil examination: Validity and clinical J Crit Care 29(4):599–603, 2014.
utility of an automated pupillometer. J Neurosci Nurs 9. Mahanes D: Neurologic system. In Burns SM, American
37(1):34–40, 2005. Association of Critical Care Nurses, editors: AACN
5. Chen JW, et al: Infrared pupillometry, the Neurological essentials of critical care nursing, New York, 2014,
Pupil index and unilateral pupillary dilation after traumatic McGraw Hill.
PROCEDURE
99
RotoRest Lateral Rotation
Surface
Theresa Nino and Mary Beth Flynn Makic
PURPOSE: The purpose of kinetic therapy is to decrease complications
associated with immobility. Rotation therapy can aid redistribution of blood flow to
pulmonary circulation with the goal of improving oxygenation.16 Kinetic therapy
provides dynamic rotation and benefits pulmonary status by enhancing mobilization
and removal of pulmonary secretions, and assisting in preventing and treating
physiological complications of immobility. The RotoRest lateral rotation surface is a
unique kinetic therapy surface that can be perceived to be technically challenging
and requires a coordinated effort for use. This rotation therapy is ideal for patients
with traumatic injury, unstable spine, and traction and for patients who need
aggressive rotation therapy.
PREREQUISITE NURSING • The RotoRest kinetic therapy surface can be used for
KNOWLEDGE those patients that require spinal immobilization and the
prevention of complications due to immobility.3,5,10,14,18
• Principles of prevention of pressure-induced injury should ❖ Preventive interventions, such as providing skin pro-
be understood, including high-risk areas for tissue injury tectants, monitoring nutrition, containing excessive
in the critically ill patient.7,8,16,20,21 Pressure points and moisture, and preventing shear and friction, are indi-
locations where moisture or incontinence may occur cated with the use of the RotoRest surface.
require special attention to prevent skin break- ❖ Layers of linen placed on the surface should be
down.1,7,8,13,16,19,20,21 Prolonged external pressure over bony limited to allow maximal benefit of the surface for the
prominences, shear and friction forces, and excessive patient’s skin.
moisture increase the risk of pressure ulcers.1,7,8,16,17,20,21 • The term kinetic therapy refers to a 40-degree or greater
• Pressure injury may occur while a patient is on a specialty rotation.1,9,10,15,18
surface. Assess all at-risk areas of the patient’s skin, • The RotoRest lateral rotation surface is a kinetic therapy
especially the face, ears, occiput, shoulders, and coccyx surface that does not incorporate low air loss into its tech-
areas. nology, but if the patient is in continuous motion (rota-
• With use of a validated pressure ulcer risk–assessment tion), pressure over bony prominences may be relieved
tool such as the Braden Scale, a patient’s risk for a pres- during the continuous turning therapy. However, because
sure ulcer should be assessed on admission to the inten- of the aggressive degree of the turn, possible shear and
sive care unit and at least every 12 to 24 hours thereafter, friction injuries of the skin can occur during rotation.
or with changes in the patient’s condition. Interventions • For maximal benefit, the support surface should be in
to prevent pressure ulcer development should target char- rotation more than 18 hours per day and at optimal
acteristics that put the patient at risk.2,4,7,16,19 rotation.1,9–12,15,18
• Knowledge is needed concerning the physiological effects ❖ The support surface should provide continuous rotation
of immobility on body systems, including factors that at varying degrees.
contribute to impaired circulation. Potential complications ❖ Serial skin assessments per institutional protocols
in the critically ill patient include the following: are required when patients are on rotational therapy
19
❖ Venous stasis and thrombosis surfaces.
22
❖ Pulmonary and urinary stasis ❖ The clinician should evaluate the patient’s tolerance of
❖ Pressure ulcer formation with potential associated fric- kinetic therapy and consider sedation and analgesics as
tion, moisture, and shear injury2,6,13,16,17 appropriate.
• The RotoRest kinetic therapy bed is based on a platform • Indications include critically ill patients who are at
that provides rotation and pressure relief by continuous a higher risk of pulmonary complications such as the
rotation. The use of this therapy includes frequent assess- following:
ments of patient skin, and safety of lines, drains, ❖ Patients with increasing ventilatory support
and tubes.1,6,11 requirements
885
• Patients who have clinical indications for acute lung ❖ The gel pads prevent the patient from bottoming out
injury or adult respiratory distress syndrome3,9,22 and transfer body heat evenly; they are radiographi-
❖ Worsening partial pressure of O2 in arterial blood to cally transparent.
fraction of inspired oxygen ratio ❖ The bed provides continuous, slow, side-to-side turning
❖ Presence of fluffy infiltrates via chest radiograph of the patient by rotating the bed frame. Keeping the
concomitant with pulmonary edema patient in maximal rotation assists with prevention of
❖ Refractory hypoxemia skin breakdown and provides the most effective therapy
• Patients should be placed on a lateral rotation support for pulmonary indications. The bed can turn up to 62
surface as soon as possible to prevent the negative effects degrees on each side, either intermittently or con-
of immobility and possible pulmonary complications.3,9,15,22 stantly, providing unilateral or bilateral rotation.
• When ordering kinetic therapy, the clinician should assess ❖ The amount of time the patient is held at the rotation
the properties of the pressure redistribution surface and limit before rotating in the opposite direction can be
evaluate patient skin/tissue redistribution needs (i.e., adjusted from 7 seconds to 30 minutes.
moisture control, pressure redistribution). ❖ Head and shoulder packs provide cervical stability but
• Trauma diagnosis and spinal cord injury should be under- should not be used as the primary means of stabilizing
stood. Pressure ulcer–related risks associated with trau- cervical spine fractures. Cervical traction, halo, and
matic and spinal cord injury should be understood related vest or internal fixation may be required. Lateral arm
to prolonged immobility.3,9,15,22 Low air-loss surfaces are and leg hatches facilitate range of motion.
contraindicated for patients with unstable spine or pelvic ❖ Hatches underneath the bed (located in the cervical,
injuries until the injury is stabilized. The RotoRest sur thoracic, and rectal areas) provide access for skin care,
face may be used with spinal injuries; additional care catheter maintenance, and bladder and bowel manage-
is necessary to place unstable spinal cord injuries or ment. Do not open thoracic and sacral hatches at the
patients with pelvic instability on a RotoRest surface that same time.
has a firm, flat surface. Cervical traction and skeletal trac- ❖ The bed has a built-in scale with a maximal patient
tion may be used with a RotoRest therapy surface (see weight of 300 lbs.1,7 Overall width of the bed is 34
Procedure 100). inches with a height of 94 inches.1
• The RotoRest Delta Advanced Kinetic Therapy bed is ❖ An optional vibrator pack is available to provide
shown in Figure 99-1. chest physiotherapy to further mobilize pulmonary
• Noted principles in caring for a patient receiving kinetic secretions.
therapy on a RotoRest Delta Advanced Kinetic Therapy
bed include technical and clinical competence in the EQUIPMENT
following:
❖ The surface below the patient and the positioning packs • Nonsterile gloves
consist of pressure-redistributing foam and a pad of • Sheet or slide board to assist with moving the patient onto
nonliquid polymer gel with a low-friction, low-shear the surface
nylon fabric with moisture-permeable backing cover • Transparent or foam protective dressings for areas prone
that does not absorb body fluids. to friction or shear
Foam arm support

Head and shoulder
support assembly
Thoracic side support
Head pack
Knee assembly
Shoulder pack
Base pack
Abductor pack
Disposable leg support Safety strap
Arm support
Side leg support
Safety strap
Drive
Foot support
Figure 99-1 Kinetic Concepts Inc. RotoRest Delta Advanced Kinetic Therapy bed. (Courtesy
KCI Licensing, Inc, San Antonio, TX, 2008.)
99 RotoRest Lateral Rotation Surface 887
• Appropriate support surface and positioning packs for the for thromboembolism.22 Rationale: Baseline data are pro-
RotoRest lateral rotation surface vided for serial assessment and if necessary to treat the
adverse effects of immobility.
PATIENT AND FAMILY EDUCATION • Assess the patient’s pulmonary status to include the
quality and presence of adventitious breath sounds, the
• Explain to the patient and family the adverse effects of rate and depth of respirations, cough, cyanosis, dyspnea,
critical illness and immobility, including pulmonary com- nasal flaring, arterial blood gas results, chest radiograph,
plications, tissue pressure, and excessive moisture of the mental status, and restlessness. Rationale: Provides base-
skin. Rationale: Providing an explanation promotes under- line data for additional comparisons. Lateral movement
standing of the need for prevention, interventional strate- provides postural drainage, mobilizes secretions, and
gies and the specialty devices that are utilized based on enhances air exchange.10
patient risk assessment. The patient and family are able to • Assess the patient’s bladder for complications associated
share understanding of the plan of care and ask questions with urinary stasis from immobility to include the pres-
• Describe the goals of RotoRest kinetic therapy and how ence of bladder distention, incomplete bladder emptying,
the therapy can aid in maintaining patient alignment in or urinary infrequency. Rationale: Baseline data are pro-
patients with spinal injuries. Rationale: The patient and vided before implementation of lateral movement that
family are able to share understanding of the plan of care decreases urinary stasis and associated complications.22
and ask questions • Discuss goals for rotation therapy with the interprofes-
• Explain how the therapy can serve as both a prevention sional team as part of the daily plan of care. Rationale:
and an interventional care strategy. Rationale: Under- The principles of therapy are evaluated to match patient
standing and cooperation are increased. factors related to type of injury, moisture, and need for
• Explain to the patient and family the pulmonary benefit redistribution of pressure on skin and wounds.
of rotation in promoting dynamic movement of pulmo- • Reassess every 12 to 24 hours for the need to continue,
nary secretions. Rationale: Facilitates the understanding change, or discontinue rotational therapy. Rationale:
of the role of pulmonary secretion mobility in the criti- Reevaluation of the benefit of the therapy is important in
cally ill. creating an individualized plan of care.
Patient Preparation
PATIENT ASSESSMENT AND • Ensure that the patient and family understand preproce-
PREPARATION dural teaching. Answer questions as they arise, and rein-
force information as needed. Rationale: Understanding of
Patient Assessment previously taught clinical information and rationale is
• Assess the patient’s risk for a pressure ulcer with an evaluated and reinforced.
evidence-based practice assessment tool (i.e., Braden • Evaluate the properties of the support surface to meet
score).2,4,16 Rationale: Valid assessment tools assist in the pulmonary needs, skin factors related to the type of injury,
identification of patient risk for alterations in skin. moisture, and need for redistribution of pressure on skin
• Assess the patient’s skin for evidence of pressure ulcer and wounds. Order and inspect the bed functions before
formation or alterations in skin on admission and through- the patient is placed on the surface. Rationale: Support
out care based on institutional policy. Rationale: Baseline surface selection should match the clinical indication for
and ongoing skin status data are provided. patient therapy. Relief of external pressure may decrease
• Assess the patient’s wounds: location, size, stage of pres- the risk of pressure ulcer formation and facilitate wound
sure ulcer, description of tissue in the wound bed, type healing.
and amount of drainage, maceration and inflammation in • Verify that the patient is the correct patient using two
the surrounding skin, and pain on palpation of surround- identifiers. Rationale: Before performing a procedure, the
ing skin. Rationale: Objective and thorough assessment nurse should ensure the correct identification of the patient
of wounds on admission and throughout the course of for the intended intervention.
illness is necessary for measuring the effectiveness of • Organize moving the patient to the special surface,
therapy and interventions. ensuring adequate personnel are available. Rationale:
• Assess and ensure hemodynamic stability; assess for the Transfer of the patient from one bed to another is
presence of edema in lower extremities and the potential potentiated.
Procedure for Lateral Rotation Therapy

Procedure for Kinetic Therapy With the RotoRest Surface
1. Obtain the bed that will be used for Rental beds may require a These beds are U.S. Food and Drug
kinetic lateral rotation. physician’s order. Administration (FDA) regulated.
Ensures the properties of the
specialty surface meet the patient’s
specific needs.
2. Follow manufacturer guidelines for Prepares the equipment. The RotoRest kinetic therapy surface
setting up the bed to include patient is considered more challenging to
height, weight, and rotation settings. use and thus is described in this
section.
3. HH
4. PE
Prepare for Patient Placement
5. Ensure that the bed is locked in the Ensures patient safety.
horizontal position and that the drive
is disengaged.
6. Check all hatches to be certain they Prevents unplanned movement
are properly latched; be sure castors of the bed.
are locked.
7. Zero the bed scale system. Prepares bed for patient daily
weight.
8. Prepare the surface: Allows for smooth transfer of
A. Remove all vertical packs. the patient onto the bed and
B. Cover support brackets with a protects the patient from
wash cloth. discomfort.
C. Slide thoracic and foot packs. to Prepares for safe management
the side and ends of the unit. of lines, drains, and tubes.
D. Consider routing for any patient-
specific drains/tubes.
Prepare for Patient Transfer and Positioning on Kinetic Therapy Surface
1. Using a draw sheet or slide board, Bouncing of the patient can Pillar bars can be covered with a
gently move the patient to the center result in skin abrasions and towel or folded paper sheet to avoid
of the surface while maintaining body progression of injury. the possibility of abrasion. Assess
alignment.1 (Level M*) the security of all lines, drains, and
tubes to accommodate a full
62-degree turn.
2. Center the patient on the bed by Facilitates proper balance. Traction equipment may be installed
aligning the nose, umbilicus, and Rotating to one side once the patient is centered.
pubis with the center posts.1 Align indicates that the patient is
both head and shoulder pack posts not centered.
vertically and horizontally. (Level M)
3. Pack installation for one side of the Packs are the main supporting Packs and supports are labeled for the
patient is repeated and mirrored on apparatus. Packs provide patient’s right and left sides.
the opposite side. support to prevent lateral
movement within the bed,
which can lead to skin
breakdown.

Procedure for Lateral Rotation Therapy—Continued

4. Install shoulder and head pack Provides support and protects Maintain a 1-inch clearance from the
assemblies by sliding onto head and ears from pressure. Proper shoulder; use passing of hand
shoulder posts. Slide head and shoulder and head support between the shoulder and pack to
shoulder packs inward to lightly help to prevent lateral verify the clearance. Verify that the
touch patient head. movement within the bed, pack is not pressing against the
which can lead to ear skin ears. If cervical traction causes the
breakdown and cervical patient to slide up on the bed during
injury. rotation, place the patient in the
reverse Trendelenburg’s position.
5. Place thoracic side supports in Provides support to prevent The holes in the frame in which the
appropriate holes provided in the lateral movement within the side supports fit are near the surface
frame and ensure that they are bed, which may lead to of the base packs. Packs are labeled
tightened securely. Lock cam handles shearing skin injury. “Right” and “Left.” The thicker side
to hold the pack in position. of the pack is always against the
patient.
Maintain a 1-inch clearance between
the end of the pack and the axilla.
6. Adjust the knee assembly to a Provides support.
position slightly above the patient’s
knee. Lock cam handles to hold the
pack in position.
7. Place the disposable leg support Decreases external pressure on Leg supports should be changed with
under the thigh and calf so that it fits the heels. excessive moisture or when soiled.
under the ankle and knee but not
beneath the heel.
8. Place the foot supports in the foot Maintains each foot in proper The foot supports should not be left in
bracket assembly. The assembly anatomical position and place for longer than 2 hours at a
should be positioned so that the prevents migration. time. A schedule of 2 hours on and
footrest is in anatomical position. 2 hours off should be maintained
Tighten the foot assembly.1 Lock continuously. Side-to-side motion
cam handles to hold the position. does not relieve pressure on the
(Level M*) soles of the feet.
9. Install the abductor packs into the Provides support. Adjust and lower if extra space is
preset metal brackets. required at the groin.
10. Place the side leg supports snugly Provides support.
against the patient’s hips. Lock cam
handles to hold the positon.
11. Install the knee pack by pressing the Prevents pressure on the knee. Maintain a 1-inch clearance between
pin on the support tube while the foam and the skin. Knee packs
inserting the support tube into the can be adjusted to allow for
knee pack assembly. Tighten the knob variation in abduction and flexion
to hold the assembly in position.1 of the patient’s legs. They maintain
(Level M) proper posture of the lower limbs
in the patient with spasticity,
discouraging contracture formation.
12. Install the disposable foam arm Ensures that the patient’s hands Disposable arm supports should be
supports.7 (Level M) are in a position of function changed with excessive moisture or
and that the ulnar nerve and when soiled.
elbows are protected.
13. Secure the arm supports in the holes Provides support and promotes
provided on the frame. safety.
14. Place a hand on the patient’s shoulder Prevents pressure ulcers. A 1-inch (2.54-cm) clearance should
and adjust the shoulder pack to always exist between the patient’s
lightly touch your hand.1 (Level M) shoulders and the shoulder packs.

Procedure for Lateral Rotation Therapy—Continued

15. Verify that all packs are in position, Provides support. Remove any obstructions from the
all hatches are closed, all cam area that may impede the unit
handles are locked, and brakes are rotation cycle.
locked.
16. Fasten the restraining straps. Safety Prevents falls and patient
straps must be in place at all times. injury.
One safety strap is used to hold down
the shoulder assembly. Place the
other strap across the hip region.
17. Initiate therapy. Determine whether the Observe the patient through a full
equipment and positioning rotation cycle; ensure that all packs
works. are appropriately set, pressure
points are protected, drains and
lines are not pulled or pinched
during rotation, and there are no
obstructions during the cycle.
18. Monitor patient hemodynamics with Determines the patient’s Changes in hemodynamics are
rotation therapy. response to therapy. expected; monitor the patient’s
tolerance and hemodynamic goals
(e.g., urine output, mentation, mean
arterial pressure, intracranial
pressure, etc.). The patient may
need time to acclimate to kinetic
therapy. Interpret vital signs with
knowledge of fixed transducer
variation caused by degree of
rotation (i.e., level may change,
providing false data).10
19. Remove PE and discard used Reduces transmission of
Precautions.
20. HH

• Intact skin integrity • Friction, shearing, motion sickness, agitation,
• Wound healing disorientation, and falls from lateral movement of the
• Absence of friction and shearing table if the patient is not strapped in properly
• Absence of excessive skin moisture or dryness • Pressure ulcer formation or further deterioration of
• Improved peripheral circulation existing pressure ulcers
• Improved urinary elimination • Desaturation or hemodynamic instability with
• Maximal pulmonary function achieved rotation
• Dislodged invasive lines or tubes
• Development of urinary tract infection
• Development of worsening pulmonary status

interventions.
1. To initiate cardiopulmonary resuscitation A flat, firm surface is • Need for emergency care
(CPR): necessary for CPR.
A. Return the bed to the horizontal
position by disengaging rotation and
manually rotating.
B. Pull the crank arm handle (the clutch)
and lock it in place with the lock.
C. Follow the manufacturer’s guidelines
regarding if a back board is needed
for CPR.
2. Evaluate the patient’s existing pressure Relief of external pressure • New breakdown
areas and ulcers, wounds, flaps, and facilitates healing. • Impaired healing
grafts for evidence of healing according
to institutional guidelines. Monitor skin
regularly, and provide extra attention to
any pressure points and locations where
moisture or incontinence may
occur.2,6,7,13,16
3. Assess the skin for evidence of pressure Kinetic therapy surface • Development of pressure ulcers
(especially on the occiput, sacrum, and alone does not protect or skin breakdown
heels), friction, shearing, or moisture per from pressure ulcer
hospital policy. Consider applying formation. Ensure that
protective dressing to areas prone to adequate skin assessment
friction or shear (i.e., transparent continues throughout
semiocclusive, hydrocolloid, or foam therapy.
dressings).
4. Evaluate the patient’s peripheral vascular Lateral movement • Edema
circulation. Follow hospital policy for discourages venous stasis. • Decreased or absent pulses
prevention of thromboembolism. • Discoloration
• Pain
5. Evaluate the patient’s pulmonary Lateral movement provides • Adventitious breath sounds
function. continuous postural • Decreased respiratory rate and
drainage and mobilization depth
of secretions. • Cough
• Cyanosis
• Dyspnea
• Nasal flaring
• Abnormal blood gases
• Decreased mental acuity
• Restlessness
• Abnormal chest radiograph results
6. Evaluate the patient for urinary retention. Lateral movement decreases • Decreased urine output
urinary stasis. • Bladder distention
7. Evaluate the patient’s acceptance of and Increases cooperation and • Intolerance to device
adaptation to the device (motion sickness, decreases anxiety.
agitation, disorientation).

8. Monitor patient’s tolerance and Lateral movement may alter • Increased or decreased blood
hemodynamic goals (e.g., urine output, hemodynamics because of pressure
mentation, mean arterial pressure, the degree of rotation • Increased or decreased heartrate
intracranial pressure, etc.). The patient (turn) and changes in • Elevation in intracranial pressure
may need time to acclimate to kinetic transducer positioning.
therapy.
assessing pain. Administer analgesia as interventions. interventions
prescribed.
10. Maintain bed in motion for 18 hours of Provides proper rotation and • Inability to rotate as per schedule
every 24-hour period.5,6 Target rotation on adequate mobility.
a kinetic therapy surface is 62 degrees.
11. Maintain safety straps and positioning Prevents falls and patient • Falls or injury
packs at all times. injury.
12. Maintain schedule for foot supports: 2 Side-to-side movement does • Breakdown on the soles of the
hours on and 2 hours off continuously. not relieve pressure on the feet
soles of the feet.
13. Determine when therapy should be Lateral rotation therapy is • Need for discontinuation of
discontinued. Reassess need every no longer required. therapy
12–24-hour period.
Documentation
• Patient and family education • Status of wound healing, if applicable
• Date and time therapy is instituted • Patient’s response to therapy
• Rationale for use of lateral rotation therapy surface • Any unexpected outcomes and interventions taken
• Number of hours patient is in rotation mode per • Phone number and name of company representative
24-hour period and degree of rotation achieved • Pain assessment and management according to
• Patient tolerance of therapy institutional guidelines
• Safety straps in place, bed alarms engaged
• Complete skin assessments of pressure areas and
wound assessments per institutional standards and as
necessary

99 RotoRest Lateral Rotation Surface 892.e1
References 12. Higgens Martin A: Should continuous lateral rotation

1. Arjohuntleigh.us. RotoRest Delta Advanced Kinetic therapy replace manual turning? Nurs Manage 32(8):
Therapy System user manual. P/N 208137-AH Rev C 41–45, 2001.
02/2014. From: <http://www.arjohuntleigh.us/usah/ 13. Makic MBF, et al: Evidence-based practice habits: Putting
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01.01.2015. 31(2):38–62, 2011.
2. Ayello EA, Lyder CH: Protecting patients from harm: 14. McInnes E, et al: Support surfaces for treating pressure
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37(10):36–40, 2007. 2011.
3. Bein T, et al: Continuous lateral rotation therapy and 15. McLean B: Rotatinal kinetic therapy for ventilation
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lung injury: Results from a prospective randomized study. 2001.
Injury 43:1893–1897, 2012. 16. National Pressure Ulcer Advisory Panel: Prevention
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scale for predicting pressure sore risk. Decubitus 2(3): From: <www.npuap.org>, Retrieved 01.01.2015.
44–46, 50–51, 1989. 17. Padula WV, et al: A framework of quality improvement
5. Bernard GR: Acute respiratory distress syndrome: interventions to implement evidence-base practices for
A historical perspective. Am J Respir Crit Care Med pressure ulcer prevention. Adv Skin Wound Care
172:798–802, 2005. 27(6):280–284, 2014.
6. Brienza DM, Geyer J: Using support surfaces to manage 18. Prasarn ML, et al: Is it safe to use a kinetic therapy bed
tissue integrity. Adv Skin Wound Care 18(3):151–157, 2005. for care of patients with cervical spine injuries? Injury
7. Cooper KL: Evidence-based prevention of pressure ulcers 46(2):388–391, 2015.
in the intensive care unit. Crit Care Nurse 33(6):57–67, 19. Rauen CA, Makic MB, Bridges E: Evidence-based
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Pressure sores. Plast Reconstr Surg 132:1720–1729, 2013. 20. Thompson P, et al: Support surfaces: Definitions and
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PROCEDURE
100
Thermoregulation: External
and Intravascular Warming/
Cooling Devices
Karen A. Lovett
PURPOSE: An external surface or hydrogel pad temperature-management device
may be used to increase or decrease the body temperature. An intravascular
warming and cooling device may be inserted to increase or decrease the body
temperature. External surface-cooling devices or intravascular cooling catheters are
also used as a therapeutic treatment modality to reduce the body temperature after
acute injury (such as global cerebral ischemia, cardiac arrest, or hypoxia) to
decrease cellular oxygen consumption and intracranial pressure. Decreasing
cerebral blood flow improves the discrepancy between oxygen supply and oxygen
demand.30
PREREQUISITE NURSING ❖ Radiation occurs when heat (thermal energy) is trans-

KNOWLEDGE ferred through air or space between separated surfaces
without direct contact between the objects.27
• The hypothalamus is the primary thermoregulatory center ❖ Evaporation occurs when heat loss accompanies water
for the body and where the central sensors for the body evaporated from the skin and respiratory tract to the
core temperature are located; it maintains normothermia surrounding air.4,27
through internal regulation of heat production or heat loss. • Knowledge of terms associated with temperature is needed
Information is sent from the brain, spinal cord, deep (Table 100-1).
abdominal and thoracic tissue, and thermosensors under- • Alteration in thermoregulation can result from a primary
neath the skin to the hypothalamus.37,40 central nervous system injury or disease (e.g., subarach-
• In the preoptic area of the hypothalamus are thermosensi- noid hemorrhage, traumatic brain injury, spinal cord
tive neurons that incorporate information from the periph- injury, or neoplasm) and metabolic conditions (e.g.,
eral and blood receptors and compare it to the body’s set diabetes mellitus; toxic levels of ethanol alcohol or
point. The body reacts when there is a difference between other drugs, such as barbiturate and phenothiazine
the set point and the actual temperature.38 agents).
• Through a negative feedback loop, the warm and cold • Body temperature is the measurement of the presence or
sensory neurons respond to feedback from the peripheral absence of heat. Body heat is generated, conserved, redis-
sensors and balance their signals to maintain a set point tributed, or dissipated during all physiological processes.
of 37.0°C (98.6°F).21,40 Factors such as age, circadian rhythm, and hormones
• When the thermal area of the hypothalamus senses heat influence body temperature.
gain or a warmer temperature than the set point, the body • Body temperature may be measured with a variety of
vasodilates and sweats to assist in lowering the body tem- thermometers and at several body sites. Electronic or
perature. Conversely, when the neurons sense a tempera- digital thermometers are used to obtain rectal, oral, and
ture below the set point (heat loss), vasoconstriction and axillary temperatures. Thermistors within catheters or
shivering occur to increase catabolism, conserve heat, and probes measure rectal, nasopharyngeal, esophageal,
raise body temperature.4,21,28,36,37 bladder, brain, and pulmonary artery temperatures. Infra-
• Thermoregulation is influenced by several factors, such red thermometers measure tympanic membrane and
as cellular metabolism, exercise, diurnal variation, and temporal artery temperatures. Choose the method of tem-
ambient temperature.36 perature monitoring that best meets the patient’s clinical
• The body has mechanisms to dissipate heat: condition and obtains results that are reliable, accurate,
❖ Conduction occurs when heat is lost by direct transfer and safe to support clinical decisions.23,29,34,37,38
from one surface to a second adjacent cooler object.4,27 • When assessing body temperature, some basic aspects
❖ Convection is the transfer of heat from a surface to have to be considered that influence normal thermoregula-
surrounding air.27 tion, such as age, gender, and site of measurement.
893
TABLE 100-1 Terms Associated With Temperature

Term Definition
Normothermia/euthermia Optimal range of body temperature associated with health.
Hypothermia Subnormal core body temperature equal to or below 35°C.20,24
Induced hypothermia Intentional reduction of body temperature to decrease the cerebral metabolic rate of oxygen, intracranial
pressure, cerebral blood volume, thereby improving the oxygen supply and demand mismatch.32 This may
be accomplished by surface means (transfer of heat from the skin to the cooling device) or central means
(circulatory heat exchange in a cardiopulmonary bypass machine or cooling catheter)
Fever Fever is a response to either endogenous or exogenous pyrogens, or direct effects upon the hypothalamic
temperature-control centers.21
Hyperthermia The body temperature is out of control due to failed thermoregulation. The body temperature is high, usually
resulting from infection, medication, or head injury.20
• The best evaluation of body temperature uses the core

TABLE 100-2 Bedside Shivering
temperature; it is the least influenced by environmental
and other factors and maintains a stable temperature.21 Assessment Scale (BSAS)
• The most accurate core temperature monitoring methods Score Term Description
are intravascular (e.g., pulmonary artery catheter), esoph-
ageal, and bladder.34,40 0 None No shivering noted on palpation of
• The pulmonary artery catheter is the best representation masseter, neck, or chest wall, and no
of core temperature and the “gold standard” for clinical electrophysiological evidence of
shivering (using electrocardiographs)
thermometry.12,16,21,23,33,37,40,42
• Variations in temperatures normally occur in the body. No 1 Mild Shivering localized to neck or thorax only
accurate conversion table exists that converts the tempera- 2 Moderate Shivering involves gross movement of
ture from one site to another. Trying to adjust between the upper extremities (in addition to
sites only contributes to misunderstanding.38 neck and thorax)
• Site choice for temperature monitoring is based on the 3 Severe Shivering involves gross movements of
clinical data needed; the patient’s condition, safety, and trunk, upper, and lower extremities
comfort; environmental factors (e.g., room temperature);
the indication for a catheter or a probe (e.g., pulmonary
artery catheter); and the availability of equipment. • The Bedside Shivering Assessment Scale (BSAS) is a
• Regardless of method and site chosen, the same site and simple and reliable tool for evaluating the metabolic stress
same method should be used repeatedly to trend the serial of shivering (Table 100-2).2,25
measurements during the application of warming or • Shivering may be visible on the Bispectral Index Monitor
cooling therapy.4,20 in the form of an increase in electromyogram activity (see
• Trend with two sites, use caution, and question differences Procedure 88).
in temperature that are >0.3°C, or a temperature difference • Shivering increases the metabolic rate, carbon dioxide
that would drive a clinical decision to change therapy and/ (CO2) production, resting energy expenditure, oxygen
or cause an intervention.16,21,40 consumption, and myocardial work, and lowers brain
• An esophageal temperature probe can be inserted into the tissue oxygen levels.8,15,18,28 The overall metabolic conse-
esophagus. Accurate placement of the temperature probe quences of shivering may eliminate many of the clinical
is necessary to obtain results similar to monitoring the benefits of temperature control.5,28
temperature from the pulmonary artery. • At a body temperature <35°C, the basal metabolic rate can
• Shivering is an involuntary shaking of the body generated no longer supply sufficient body heat and an exogenous
to maintain thermal homeostasis. Shivering causes rhyth- source of heat is needed.
mic tremors that result in skeletal muscle contraction and • Table 100-3 outlines techniques to increase heat gain.
is a normal physiological mechanism to generate heat • Hypothermia may be categorized as mild (34 to 35.9°C),
production.28 moderate (30 to 33.9°C), or severe/deep (<30°C).10,28
• Early detection of shivering can be accomplished by pal- The American Heart Association (AHA) recommends
pating the mandible and feeling a humming vibration. that if ventricular fibrillation or ventricular tachycardia
Electrocardiographic artifacts from skeletal muscle move- are present with severe hypothermia defibrillation should
ment is seen on the bedside monitor. If not detected early, be attempted. The value of subsequent defibrillations is
shivering can progress from visible twitching of the head uncertain; therefore, active rewarming should occur and
or neck to visible twitching of the pectorals or trunk, and the AHA suggests that it may be reasonable to further
then to generalized shaking of the entire body and teeth defibrillate, following the basic life support (BLS)
chattering. algorithm.10
100 Thermoregulation: External and Intravascular Warming/Cooling Devices 895
• Overshoot occurs when the thermoregulatory mechanisms

TABLE 100-3 Techniques to Increase
rebound or overcompensate.
Heat Gain • Termination of active external rewarming at 36 to 36.5°C
Mechanism of may prevent temperature overshoot.
Heat Transfer Techniques to Increase Heat Gain • Rewarming acidosis results from the increase in CO2 pro-
duction associated with the temperature increase and from
Radiation Warming lights, warm environment, room the return of accumulated acids in the peripheral circula-
temperature, blankets
tion to the heart.
Conduction Warm blankets, circulating water blanket, • Rewarming shock occurs when hypothermic vasocon-
continuous arteriovenous rewarming, striction masks hypovolemia. If the patient’s circulating
cardiopulmonary bypass volume is insufficient during rewarming vasodilation,
Convection Thermal fans, circulating air blanket sudden decreases in blood pressure, systemic vascular
Evaporation Head and body covers; warm, humidified resistance, and preload occur. In cases of severe to pro-
oxygen found hypothermia, peripheral rewarming with external
devices should be used with extreme caution. Core
methods of rewarming should be considered.
• Hypothermia may be caused by an increase in heat loss, • Hyperthermia occurs when the thermoregulatory system
a decrease in heat production, an alteration in thermoregu- of the body absorbs or produces more heat than it is able
lation, and a variety of clinical conditions. to dissipate.
• An increase in heat loss may occur from the following: • Malignant hyperthermia is a rare, life-threatening heredi-
❖ Accidental (e.g., cold water drowning) tary condition of the skeletal muscle that occurs on expo-
❖ Environmental exposure sure to a triggering agent or agents.14 The triggering agents
❖ Induced vasodilation caused by high levels of ethanol most commonly associated with malignant hyperthermia
alcohol, barbiturates, phenothiazines, or general are volatile anesthetic agents, particularly halogenated
anesthesia inhalation anesthetics and/or the depolarizing muscle
❖ Central nervous system dysfunction (e.g., spinal cord relaxant succinylcholine.31 Malignant hyperthermia
injury) involves instability of the muscle cell membrane, which
❖ Dermal dysfunction (e.g., burns) causes a sudden increase in myoplasmic calcium and skel-
❖ Iatrogenic conditions (e.g., administration of cold etal muscle contractures.
intravenous fluids, hemodialysis, cardiopulmonary • The earliest indication of malignant hyperthermia is an
bypass) increase in end-tidal carbon dioxide level or hyperventila-
❖ Trauma tion while breathing spontaneously. Additional symptoms
• A decrease in heat production is associated with the could include tachycardia, supraventricular or ventricular
following: arrhythmia, masseter spasm, or generalized muscular
❖ Endocrine conditions (e.g., hypothyroidism) rigidity.13,31
❖ Malnutrition • A rapid temperature increase of 1°C every several minutes
❖ Diabetic ketoacidosis may occur and that rapid rise is more significant in
❖ Neuromuscular insufficiency (e.g., resulting from a diagnosing malignant hyperthermia than a peak tempera-
pharmacological paralysis caused by a neuromuscular ture. The treatment of hyperthermia should be either the
blocking agent or anesthetic agents) use of an internal cooling or specific surface cooling
• Clinical conditions associated with hypothermia are device.14,31
sepsis, hepatic coma, prolonged cardiac arrest, and sys- • Treatment includes discontinuation of the triggering agent
temic inflammatory response syndrome. and administration of a muscle relaxant (e.g., dantrolene
• Severe hypothermia may mimic death; resuscitative sodium).The muscle relaxant inhibits the release of
efforts should be initiated despite the absence of vital calcium from the sarcoplasmic reticulum without affect-
signs. ing calcium uptake.31 Refer to hospital protocol for storage
• Rewarming for cardiac arrest survivors who have under- and administration of muscle relaxant.
gone therapeutic hypothermia should not occur faster than • Heat stroke is characterized as a rectal temperature greater
0.25 to 0.50°C per hour.10,22,30,33,35 Rapid rewarming can than 40.0°C (104°F) and central nervous system dysfunc-
cause rewarming acidosis, electrolyte shifts, shivering, tion. It occurs when the outdoor temperature and humidity
hypovolemic shock, temperature core afterdrop, and tem- are excessive and heat is transferred to the body. Increased
perature overshoot.8,41 humidity prevents the body from cooling by evaporation.
• Core afterdrop is a decrease in core temperature after Other signs of heat stroke include hypotension, tachycar-
rewarming is discontinued secondary to redistribution of dia, tachypnea, mental status changes from confusion to
body heat to colder peripheral areas. coma, and possibly seizures. The skin is hot and dry, and
• Rapid rewarming could cause an increase in insulin sen- sweating may occur. Initial interventions include support
sitivity and electrolyte disorders caused by shifts from the of airway, breathing, and circulation. Rapid cooling of
intracellular to the extracellular compartment.8,41 the patient is the main treatment priority, with a goal of
• Rapid rewarming could lead to loss of some or even all reducing the temperature to 38.9°C (102°F) as soon as
of the protective effects of hypothermia.8,41 possible.
• Fever occurs in response to a pyrogen and is defined as a • Temperature probe, cable, and module to monitor the
temperature more than 38.3°C.24 During fever, the hypo- patient’s temperature (varies based on the type of site and
thalamus retains its function, and shivering and diaphore- thermometer selected and available)
sis occur to gain or lose body heat. Fever may be an • Hydrogel pads, external wraps or blankets needed by the
adaptive response and may be considered beneficial in the equipment which is going to be used
absence of neurological disease processes. However, a • Cardiac monitoring (see Procedure 54)
febrile state increases the heart rate and metabolic rate and • Appropriate skin-care products (refer to hospital policy)
may be detrimental to a critically ill patient. The question Additional equipment, to have available as needed, includes
of whether to reduce or treat a fever still remains unan- the following:
swered and needs to be based on the patient’s physical and • Hemodynamic monitoring (see Procedure 72)
hemodynamic stability and provider preference.21,24 • Sterile or distilled water (see manufacturer’s
• Fever worsens neurological outcome and increases mor- recommendations)
tality in neurological patients.28,39 • Intravascular cooling/warming central venous catheter
• It is thought that fever occurs in approximately 50% of • Startup tubing kit
patients in the intensive care unit and is associated with • Console, including cable for monitoring temperature
adverse outcomes, including death with high fever.21 • Central venous catheter insertion tray
• Some external warming or cooling devices transfer • Antiseptic solution
warmth or coolness to the patient via conduction. Warmed • Sterile drape
or cooled fluids circulate through coils or channels in a • Masks with eye shields, hair cover, sterile gloves, and
thermal blanket or pad that is commonly placed under the sterile gowns
patient. • Occlusive dressing
• Additional warming and cooling systems are available. • Antimicrobial (e.g., chlorhexidine gluconate)–impreg-
Hydrogel pads or external wraps can be placed on the nated disc/dressing
patient’s skin in the trunk and upper leg regions. These • Normal saline solution
external systems are controlled through a feedback loop • Water-soluble lubricant
system with a core temperature (e.g., a bladder probe, an
esophageal probe) that is attached to a central console and PATIENT AND FAMILY EDUCATION
automatically regulates temperature according to pro-
grammed temperature target points. The feedback of • Explain the reason for the use of a warming or cooling
patient temperature is compared with the set target tem- device and standard of care, including monitoring of the
perature and the circulating water temperature is adjusted temperature, expected length of therapy, comfort measures,
to ensure the target temperature is maintained. and parameters for discontinuation of the device. Ratio-
• Other external devices transfer warmth to the patient via nale: Explanation encourages the patient and family to ask
convection. A device used for warming blows warm air questions and verbalize concerns about the procedure.
through microperforations on the underside of a blanket • Assess the patient and family understanding of the
that is placed over the patient. The air is directed through warming or cooling therapy. Rationale: Clarification and
the blanket onto the patient’s skin. reinforcement of information are needed during times of
• Intravascular cooling and warming devices currently in stress and anxiety.
use include central venous catheters with temperature- • Encourage the patient to notify the nurse of any discom-
controlled saline solution balloons or distal metallic heat- fort. If the patient is unable to verbalize discomfort, look
transfer elements that cool and warm the blood as it flows for signs and symptoms of discomfort such as grimacing,
by the catheter. The saline solution is not in direct contact restlessness, diaphoresis, and etc. Rationale: Identifica-
with the systemic circulation. These devices may be tion of discomfort facilitates early intervention and pro-
inserted in the subclavian, internal jugular, or femoral motes comfort.
vein. They are attached to a console with an automatic
temperature-control device that adjusts the pressure, tem-
perature, and flow rate of the circulating saline solution PATIENT ASSESSMENT AND
based on the patient’s continuously monitored tempera- PREPARATION
ture (e.g., rectal, bladder, esophageal) and the set points
established by the healthcare provider.8,27 Patient Assessment
• Specific information about controls, alarms, troubleshoot- • Assess risk factors, medical history, the cause of
ing, and safety features is available from each manufac- the patient’s underlying condition, and the type and
turer and must be understood by the nurse before using the length of temperature exposure. Rationale: Assess-
the equipment. ment assists in anticipating, recognizing, and responding
to the patient’s responses and potential side effects to
EQUIPMENT therapy.
• Assess the patient’s medication therapy. Rationale: Medi-
• Warming or cooling device cations such as vasopressors and vasodilators may affect
• Sheet or bath blanket heat transfer, increase the potential for skin injury, and
• Nonsterile gloves contribute to an adverse hemodynamic response.
• Obtain a core temperature (e.g., pulmonary artery, esopha- emia, atelectasis, and pneumonia. Hypothermia shifts the
geal, bladder). Rationale: Assessment determines base- oxygenation-dissociation curve to the left, and less oxygen
line temperature and determines when a warming or is released from oxyhemoglobin to the tissues. Because of
cooling device is needed. peripheral vasoconstriction, digit-based pulse oximetry is
• Obtain vital signs and hemodynamic values. Rationale: often unreliable. Hyperthermia shifts the oxygenation dis-
Assessment determines baseline cardiovascular data. Ini- sociation curve to the right, and oxygen is readily released
tially, tachycardia and hypertension can occur as a result from oxyhemoglobin.27
of cutaneous vasoconstriction and shivering with attempts • Assess the patient’s bowel sounds, abdomen, and gastro-
at heat conservation.32 Rewarming may cause hypotension intestinal function. Rationale: Assessment determines
from vasodilatation.6 baseline status. Patients with hypothermia may develop
• Monitor the patient’s cardiac rhythm. Rationale: Monitor- an ileus because of decreased intestinal motility. Vomiting
ing determines the baseline cardiac rhythm. Most common and diarrhea may occur with hyperthermia.
and well-known electrocardiographic changes include • Assess the patient’s skin integrity. Rationale: Assessment
presence of J (Osborn) waves, interval prolongation, and provides baseline data. An externally applied warming or
atrial and ventricular arrhythmias.3 Tachycardia and cooling device can cause or exacerbate skin injury. Pre-
hypertension may occur as a result of cutaneous vasocon- existing conditions such as diabetes and peripheral vascu-
striction and shivering as the patient attempts to conserve lar disease increase the patient’s risk for skin injury.
heat.6,27 Once patients begin to cool, bradycardia is the
most common arrhythmia, together with PR prolongation, Patient Preparation
sinus bradycardia, and even junctional or ventricular • Ensure that the patient and family understand prepro-
escape rhythms. Bradycardia should be treated only if it cedural education. Answer questions as they arise, and
is associated with hypotension. Hypothermia also pro- reinforce information as needed. Rationale: Understand-
longs the QT interval.8,28,32 Tachycardia and ventricular ing of previously taught information is evaluated and
dysrhythmias may occur if the patient is hyperthermic.27 reinforced.
• Assess the patient’s electrolyte, glucose, arterial blood • Verify that the patient is the correct patient using two
gas, and coagulation study results. Rationale: Alterations identifiers. Rationale: Before performing a procedure, the
in temperature balance may result in acid-base imbalance, nurse should ensure the correct identification of the patient
coagulopathy, electrolyte imbalance, glycemic imbalance, for the intended intervention.
and hypoxemia.1,11,27,28,32 Close monitoring of metabolic • If a warm air device will be used, remove the patient’s
parameters with careful consideration of replacement gown and top sheet. Rationale: The warm air device
during cooling and warming therapy is necessary.11,27,28 works via convection and should be in direct contact with
• Assess the patient’s level of consciousness and neurologi- the patient’s skin for optimal results.
cal function. Rationale: Assessment determines baseline • If the patient is unintentionally hypothermic, cover the
neurological status. A change in mental status, level of patient’s head with a blanket or towel or an aluminum cap.
consciousness, or impaired neurological function may Rationale: This action minimizes additional heat loss.
occur because of an undesirable high or low temperature • Ensure that informed consent has been obtained for inser-
or from the condition causing the alteration in mental tion of intravascular catheters. Rationale: Informed
status. Fatigue, muscle incoordination, poor judgment, consent protects the rights of the patient and makes a
weakness, hallucinations, lethargy, and stupor may competent decision possible for the patient; however, in
occur with hypothermia. Seizures may occur with emergency circumstances, time may not allow for the
hyperthermia. consent form to be signed.
• Assess the patient’s ventilatory function. Rationale: • Perform a preprocedure verification and timeout with
Hypoventilation, suppression of cough, and mucociliary placement of intravascular catheters, if nonemergent.
reflexes associated with hypothermia may lead to hypox- Rationale: Ensures patient safety.
Procedure for External Warming/Cooling Devices

Procedure for Obtaining Core Temperatures
1. HH
2. PE
3. Pulmonary artery:
A. Connect the cardiac output Measures the temperature of the Invasive placement risk for infection
temperature cable from the bedside blood in the pulmonary artery. or puncture-related
monitor to the pulmonary artery complications.33,40
catheter.
B. Observe the temperature display on Provides a temperature value.
4. Bladder:
A. Connect the bladder temperature Measures the temperature of the The accuracy of bladder temperatures
cable from the bedside monitor to urine in the patient’s bladder. may be influenced by urine flow
the bladder probe. rate.7,28,30,33,34
B. Observe the temperature display on Provides a temperature value. Refer to manufacturer’s guidelines
the bedside monitor. and follow institutional policy
regarding whether the temperature-
sensing indwelling urinary catheter
is magnetic resonance imaging safe.
5. Esophageal:
A. Assess that the patient does not Ensures that the esophageal Follow institutional policy regarding
have any contraindications for temperature probe is inserted whether nurses are able to insert
placement of an esophageal safely. esophageal temperature probes.
temperature probe for temperature Contraindications for placement of
monitoring. the esophageal temperature probe
B. Measure from the opening of the Correct measurement for probe include patients with known
patient’s mouth to the earlobe and placement is necessary for esophageal strictures or who have a
from the earlobe to the upper part accurate core temperature history of esophageal cancer,
of the sternum (manubrium), about monitoring. Eases insertion of esophageal perforation, and
two finger widths below the sternal the probe. end-stage liver disease and
notch for accurate probe varicies.28 If resistance is met,
placement. Mark the measurement withdraw the probe and gently
on the tube. Lubricate the tip of the advance again; this may indicate
catheter with water-soluble tracheal intubation of the probe.
lubricant. Never force the probe. If the patient
C. Insert the esophageal temperature Initiates the procedure. exhibits signs of respiratory
probe into the oral cavity and distress, such as coughing or
advance. gasping, immediately withdraw the
D. Continue to advance the catheter Positions the probe. temperature probe.
until the placement marked on the
probe reaches the patient’s lips.
E. Secure the esophageal temperature Reduces the risk of inadvertent
sensor to the patient. displacement.
F. Connect the cable from the Measures the esophageal
esophageal probe to the bedside temperature.
monitor.
G. Observe the temperature display on Provides a temperature value.
H. Placement may be verified with Most catheters have a radiopaque
radiograph.17 tip visible on radiograph.
6. Discard used supplies in appropriate Safely discards supplies.
receptacles.
7. HH
Procedure for External Warming/Cooling Devices—Continued

Initiation of a Warming or Cooling Device
1. Plug the device into a grounded Establishes a power source.
outlet.
2. HH
3. PE
4. Select a method for continuously Continuous core temperature Some warming or cooling devices
monitoring the patient’s core monitoring is necessary with have an adapter for connecting a
temperature.11,26 (Level D*) use of warming or cooling temperature probe from the patient
devices.11,26 directly to the device.
Use of Traditional Warming or Cooling Fluid Device
1. Place a dry absorbent sheet between A dry absorbent sheet placed Avoid applying additional sheets or
the patient and the blanket when using between the patient and the blankets because efficient heating
all-vinyl blankets. (Level M*) hypothermia/hyperthermia or cooling occurs with maximal
blanket to provide a sanitary contact between the thermal pad
barrier and absorb perspiration. and the patient’s skin.
It will also promote more
uniform distribution of heat.
2. Vinyl blankets with nonwoven fabric
surfaces do not require an absorbent
sheet when using the nonwoven side.
(Level M)
3. Fill the reservoir in the unit to the The reservoir must contain
indicated full level. Follow enough water for the machine
manufacturer’s recommendation on to function properly.
water type.
4. Attach the hoses to the circulating Allows the flow of warmed or
fluid blanket. cooled water to the blanket.
A. Check that the clamps are closed Prevents water leakage.
before connecting the hoses from
the device to the blanket.
B. After connecting the hoses, ensure
that all of the connections are tight
before unclamping the hoses.
C. Check for kinks in the hoses.
5. Press the start switch on. Activates the device.
6. Set the controls. Follow institutional standards
regarding the use of manual or
automatic modes.
A. Manual control of blanket
temperature.
i. Press the manual control switch
on.
ii. Choose the set point for the The device maintains the The patient’s temperature must be
temperature of the circulating circulating fluid in the blanket continuously monitored.24
fluid based on the prescribed at the temperature set point.
patient body temperature and
the manufacturer’s directions.
iii. Turn the warming or cooling The temperature goal is Closely monitor the patient’s
device off when the desired achieved. temperature for fluctuation.
temperature is reached.


B. Automatic control of patient
temperature.
i. Connect the patient Prevents triggering of the Most warming or cooling devices
temperature probe to the unit temperature probe alarm. sound an alarm if the probe relays a
before pressing a control low temperature; this may be
mode switch. indicative of probe dislodgment.
ii. Select the automatic mode and In the automatic mode, the unit The unit operates only if the patient’s
the set-point based on the warms or cools the circulating temperature probe is connected to
prescribed patient body fluid in the blanket based on the unit. Lights on the display panel
temperature and the the set-point (desired indicate whether the unit is heating
manufacturer’s directions. temperature) for the patient. A or cooling at any given time.
temperature probe connected
to the unit monitors the
patient’s temperature.
iii. Obtain the patient’s Indicates the patient’s
temperature from the readout temperature.
on the display unit.
iv. Verify the patient’s Ensures the warming or cooling
temperature with another device’s temperature probe is
source and compare it with the functioning and correlates with
readout on the device’s the patient’s temperature
display unit. obtained with another method.
v. When the desired patient The temperature goal is May continue to monitor the patient’s
temperature is reached, the achieved. temperature by pressing on the
warming or cooling device monitor only switch.
will maintain that set point
temperature until the machine
is turned off.
Warming or Cooling Fluid Devices That Use Hydrogel Pads or External Wraps
1. Apply the adhesive hydrogel pads or The pads or the wraps should Pads and wraps should be placed over
the external wraps to the body per cover approximately 40% of clean, dry, intact skin. Inspect and
manufacturer recommendations. the patient. prepare skin according to
2. Connect the hoses from the pads or Prepares the system.
wraps to the warming or cooling fluid
device.
3. Set the patient’s target temperature as Sets the desired temperature.
prescribed.
4. Activate the automatic mode. The system will automatically
adjust to achieve the target
temperature.
5. Set the time to target per institutional Prepares the system.
standards.
6. Follow provider’s prescriptions and Ensure safe patient monitoring.
follow manufacturer’s
recommendations for warming/cooling
device maintenance.
Use of a Warm Air Device
1. Remove the patient’s gown, sheet, and Prepares the equipment.
blankets. Then place the circulating
air blanket on top of the patient.
2. Place a cotton blanket or sheet over Aids in keeping the air blanket Maintains privacy.
the circulating air blanket. in place.

3. Connect the air blanket to the hose The blanket inflates as air flows
attached to the device. from the hose into it.
4. Turn the device on and select the The device warms the patient by The patient’s temperature must be
temperature of the air that will flow directing warm airstreams continuously monitored.
through the blanket. directly onto the patient’s skin.
After the Warming or Cooling System Is Initiated
2. HH
Procedure for Intravascular Warming/Cooling Devices

1. Assist the provider with Facilitates the insertion process. The healthcare provider performing the
insertion of the intravascular procedure and those assisting with
catheter (see Procedure 82). the procedure should use full aseptic
technique to include hand washing,
sterile gloves, masks, hats, gowns,
drapes, and proper use of suitable
skin antiseptic. All physicians,
advanced practice nurses, and other
healthcare professionals in the room
during the procedure should have on
a mask.
2. Connect the tubing from the Prepares the system.
warming or cooling fluid device
to the intravascular catheter.
3. Set the patient’s target Sets the desired temperature.
temperature as prescribed.
4. Select the treatment mode. Sets the desired mode of therapy.
5. Activate the warming or Initiates the system.
cooling system.
6. If the intravascular catheter Provides venous access for Follow manufacturer’s
device includes lumens for intravenous fluids and recommendations for warming/
intravenous fluid administration, medication administration. cooling device maintenance.
maintain patency with
intravenous fluids or saline
solution flush as ordered.
7. Follow provider’s orders for Ensure safe patient monitoring.
desired patient temperature
therapy, duration of therapy,
and monitoring parameters.
8. Ensure that a postinsertion chest Confirms placement.
x-ray is obtained if the catheter
was placed in the subclavian or
internal jugular vein.
9. Discard used supplies in Removes and safely discards
appropriate receptacles. used supplies; safely removes
sharp objects.
10. HH


• External warming or cooling device applied • Inability to achieve desired core body temperature
• Desirable core body temperature achieved • Hemodynamic instability
• Acid-base, electrolyte, glucose, and coagulation
imbalance
• Intolerable discomfort
• Shivering
• Skin injury

interventions.
1. Perform a physical assessment Alterations in temperature affect • Significant changes in assessment
of all systems every 1–2 hours every system. The condition that
and as needed. caused the change in temperature
may worsen or be refractory to
treatment.
2. Continuously monitor the Assesses the patient’s response to • Continued hypothermia or
patient’s temperature.26 warming or cooling. Some hyperthermia (temperature outside
institutions require two methods of prescribed target temperature).
of monitoring the patient’s
temperature when cooling or
warming. At least one should have
audible alarms for temperatures
above and below the desired limit.
Follow institutional policy.
3. Measure the patient’s blood Vasodilation occurs with rewarming, • Hypotension or hypertension
pressure as frequently as and vasoconstriction may occur
indicated by the patient’s with cooling. Maintain perfusion
condition and according to and prevent recurrent hypotension
4. Palpate the patient’s mandible Aids in the early detection and • Shivering
for humming vibration and prompt treatment of shivering. • Decreased mixed venous
observe for shivering. Shivering may contribute to the oxygenation saturation
inability to maintain core • Continued shivering despite
temperature goals. prescribed medications
5. Examine the patient’s skin Detects signs or symptoms of skin • Signs or symptoms of skin
condition hourly. Follow irritation so that the temperature irritation or injury
manufacturer’s of the device can be adjusted or
recommendations for assessing padding can be placed between
the patient’s skin under hydrogel the skin and the device.
pads and external wraps (e.g., at
least every 4 hours). (Level M*)
6. Continuously monitor the Detects cardiac dysrhythmias • Cardiac dysrhythmias
patient’s cardiac rate and associated with warming or
rhythm. cooling therapy.


7. Obtain arterial blood gas results Detects hypoxemia and acid-base • Decreased oxygen saturation
as prescribed and as indicated. imbalances. Maintains adequate • Elevated partial pressure of
Continuously monitor the oxygenation and minimizes oxygen in arterial blood
patient’s oxygen saturation and fraction of inspired oxygen. • Elevated or decrease partial
end-tidal carbon dioxide as pressure of CO2 in arterial blood
prescribed. • Abnormal arterial blood gas results
8. Obtain blood samples as Detects electrolyte shifts associated • Hyper/hypokalemia
prescribed. with warming and cooling • Alterations in magnesium and
therapy. phosphate levels
• Hyperglycemia11
• Coagulation study results28
9. Assess for venous Intravascular cooling devices have • VTE or pulmonary emboli
thromboembolism (VTE) in been associated with increased
vessels that contain intravascular risk of VTE.28
cooling/warming devices.19
(Level C*)
Documentation
• Patient and family education • Mode of cooling or warming device (automatic or
• Patient’s temperature and site(s) of temperature manual), patient’s set-point or water temperature (as
assessment required by institutional standard)
• Vital signs, cardiac rhythm, and hemodynamic status • Time external warming or cooling is initiated and
• Physical assessment findings terminated
• Neurological examination findings • Pain assessment, interventions, and effectiveness of
• Skin assessment and/or preventative measures interventions
• Mechanical ventilator settings • Sedation assessment, interventions, and effectiveness
• Postinsertion chest radiograph (intravascular devices of interventions
placed in the subclavian or internal jugular veins, • Shiver assessment, interventions, and effectiveness of
confirm secure airway) interventions
• Acid-base, electrolyte, glucose, lactate, and • Unexpected outcomes
coagulation assessment and interventions • Additional interventions
• Type of warming or cooling device used

100 Thermoregulation: External and Intravascular Warming/Cooling Devices 903.e1
References therapeutic hypothermia in survivors of cardiac arrest.

1. Anderson KB, Poloyac SM: Therapeutic hypothermia: Resuscitation 82(8):1100–1103, 2011.
Implications on drug therapy, 2013, INTECH Open 19. Maze R, Le May MR, Froeschl M: Endovascular cooling
Access Publisher. catheter related thrombosis in patients undergoing
2. Badjatia N, et al: Metabolic impact of shivering during therapeutic hypothermia for out of hospital cardiac arrest.
therapeutic temperature modulation the Bedside Shivering Resuscitation 85(10):1354–1358, 2014.
Assessment Scale. Stroke 39(12):3242–3247, 2008. 20. McCallum L, Higgins D: Measuring body temperature.
3. Chhabra L, et al: Electrocardiographic changes in Nurs Times 108(45):20–22, 2011.
hypothermia: A review. Ther Hypothermia Temp Manage 21. Munro N: Fever in acute and critical care—a diagnostic
3(2):54–62, 2013. approach. AACN Adv Crit Care 25(3):237–248, 2014.
4. Childs C: Maintaining body temperature. In Brooker C, 22. Nielsen N, et al: Targeted temperature management at
Nicol M, editors: Alexander’s Nursing Practice, Oxford, 33° C versus 36° C after cardiac arrest. N Engl J Med
UK, 2011, Elsevier. 369(23):2197–2206, 2013.
5. Choi HA, et al: Prevention of shivering during 23. Nonose Y, et al: Accuracy of recorded body temperature
therapeutic temperature modulation: The Columbia of critically ill patients related to measurement site: A
anti-shivering protocol. Neurocrit Care 14(3):389–394, prospective observational study. Anaesth Intensive Care
2011. 40(5):820–824, 2012.
6. Cocchi MN, Giberson B, Donnino MW: Rapid rewarming 24. O’Grady NP, et al: Guidelines for evaluation of new fever
of hypothermic patient using arctic sun device. J Intensive in critically ill adult patients: 2008 update from the
Care Med 27(2):128–130, 2012. American College of Critical Care Medicine and the
7. Fallis WM: The effect of urine flow rate on urinary Infectious Diseases Society of America. Crit Care Med
bladder temperature in critically ill adults. Heart Lung 36:1330–1349, 2008.
34(3):209–216, 2005. 25. Olson DM, et al: Interrater reliability of the bedside
8. Ferreira Da Silva IR, Frontera JA: Targeted temperature shivering assessment scale. Am J Crit Care 22(1):70–74,
management in survivors of cardiac arrest. Cardiol Clin 2013.
31(4):637–655, 2013. 26. Peberdy MA, et al: Part 9: Post-cardiac arrest care 2010:
9. Gaieski DF, et al: Haemodynamic management strategies American Heart Association Guidelines for
are not explicitly defined in the majority of therapeutic Cardiopulmonary Resuscitation and Emergency
hypothermia implementation studies. Resuscitation Cardiovascular Care. Circulation 122(18 Suppl 3):
83(7):835–839, 2012. S768–S786, 2010.
10. Hoek TLV, et al: Part 12: Cardiac arrest in special 27. Polderman KH: Application of therapeutic hypothermia in
situations. 2010 American Heart Association Guidelines the ICU: Opportunities and pitfalls of a promising
for Cardiopulmonary Resuscitation and Emergency treatment modality: Part 2: Practical aspects and side
Cardiovascular Care. Circulation 122(18 Suppl 3): effects. Intensive Care Med 30:757–769, 2004.
S829–S861, 2010. 28. Polderman KH, Ingeborg H: Therapeutic hypothermia
11. Holzer M: Targeted temperature management for and controlled normothermia in the intensive care unit:
comatose survivors of cardiac arrest. N Engl J Med Practical considerations, side effects, and cooling
363(13):1256–1264, 2010. methods. Crit Care Med 37:1101–1119, 2009.
12. Jefferies S, et al: A systematic review of the accuracy of 29. Rubia-Rubia J, et al: Measurement of body temperature in
peripheral thermometry in estimating core temperatures adult patients: Comparative study of accuracy, reliability
among febrile critically ill patients. Crit Care Resuscitat and validity of different devices. Int J Nurs Stud
13(3):194, 2011. 48(7):872–880, 2011.
13. Larach MG, et al: Clinical presentation, treatment, and 30. Sato H, et al: Urinary bladder and oesophageal
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America from 1987 to 2006. Anesth Analg 110(2): than low urinary flow rates during non-cardiac surgery.
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942–950, 2013. measurements in bladder, rectum and pulmonary artery
39. Vespa PM: Fever in critical neurologic illness. JAMA in patients after cardiac surgery. Open J Nurs 2:307,
312(14):1456–1457, 2014. 2012.
Section Fourteen Traction Management
PROCEDURE
101
Cervical Tongs or Halo Ring:
Application for Use in Cervical
Traction (Assist)
Jennifer Massetti
PURPOSE: Cervical tongs or a halo ring is inserted into the skull so that
weighted traction can be applied to the cervical spine. Cervical traction
decompresses the spinal cord and immobilizes and realigns the cervical spine.
Realignment and immobilization of the cervical spine may decrease the severity of
secondary spinal cord injury. Spinal realignment and immobilization allow spinal
fractures and supportive structures to heal properly.
PREREQUISITE NURSING fractures depends on the injury classification and provider

KNOWLEDGE or institutional preference.
• Tongs consist of a body with one pin attached at each end
• The nurse must be knowledgeable about the anatomy and (Fig. 101-2). Tong pins are applied to the outer table of
physiology of the spinal column, the anatomy of the cervi- the skull on both sides of the skull. Cervical tongs are
cal vertebrae, the spinal cord, the cervical spinal nerves, available in a variety of types, such as Crutchfield,
and the areas of peripheral innervation. In addition, it is Gardner-Wells, and Vinke tongs.
important that the nurse understands the pathophysiology ❖ The shape, features, insertion site, and placement vary
and manifestations of spinal cord injury, including ascend- slightly, but the purpose, principles, and care are the
ing edema, spinal shock, and neurogenic shock. same. Preference of the physician, advanced practice
• The nurse should observe the patient for signs of shock, nurse, or other healthcare professional is an important
understand the phases of neurogenic and spinal shock, and deciding factor in choosing the specific device to be
know the appropriate interventions to implement. used.2,11
• The nurse needs to continuously monitor the patient for ❖ The insertion of Crutchfield and Vinke tongs necessi-
changes in motor and sensory function during and after tates an incision to expose the skull. Two holes are
the procedure. made in the outer table of the skull with a twist drill,
• The nurse should continuously assess for changes in res- and the pins are inserted and tightened until there is a
piration during the procedure and continue to monitor firm fit.2,11
while the patient is in traction. ❖ Gardner-Wells tongs are inserted by placing the razor-
• Cervical spine traction is provided to realign, immobilize, sharp pin edges to the prepared areas of the scalp and
and stabilize the cervical spine when it has become unsta- tightening the screws until the spring-loaded mecha-
ble as a result of a cervical spine fracture or dislocation nism indicates that the correct pressure has been
caused by trauma or disease, degenerative processes of achieved. To decrease the possibility of tong displace-
the cervical vertebrae, or spinal surgery (Fig. 101-1).3,4 ment, all types of pins are well seated into the outer
After initial medical stabilization of the patient and assess- table of the skull and angled inward.2,6,11
ment and documentation of neurological function, cervi- ❖ Tongs are made of stainless steel or a graphite body
cal skeletal traction with the tongs or halo ring can be with titanium pins. The graphite body with titanium
applied to realign the cervical spine. Traction is used to pins is compatible with magnetic resonance imaging
reduce cervical dislocation before the patient undergoes (MRI).
surgery. Occasionally, an unstable cervical spinal injury • Traction can be applied with the use of a rope and
may necessitate long-term cervical traction for a period of pulley system or a cable and alignment bracket. Weights
weeks to attain realignment and immobilization to stabi- are added gradually and followed with radiographic
lize the spine. The definitive method used to treat cervical imaging. The physician, advanced practice nurse, or other
904
101 Cervical Tongs or Halo Ring: Application for Use in Cervical Traction (Assist) 905
SAFE ZONE (a)
a.
Figure 101-1 Continuous traction provided by weight applied to Figure 101-3 Placement of halo pins and ring. The anterior
a cervical external fixation device via a rope and pulley system. pins are placed anterolaterally 1 cm above the orbital ridge. This
(From McRae R: Practical fracture treatment, ed 2, Edinburgh, “safe zone” avoids the temporalis muscle laterally and an orbital
1989, Churchill Livingstone.) nerve plexus and frontal sinus medially. (From Batte M, Garfin SR,
Byrne TP, et al: The halo skeletal fixator: Principles of applications
and maintenance, Clin Orthop 239:14, 1989.)
molded body jacket. The patient then is able to move

while the head and neck remain immobile.
A
B EQUIPMENT
• Tongs or halo ring
• Insertion tray, including either the specific type of tongs
to be used or the halo ring with insertion pins
• Local anesthetic: lidocaine, 1% to 2% (with or without
epinephrine, depending on the preference of the phy
C sician, advanced practice nurse, or other healthcare
Figure 101-2 All three types of cervical tongs consist of a stain- professional)
less steel body and a pin with a sharp tip attached to each end. • Needles (18- and 23-gauge)
A, Crutchfield tongs are placed about 5 inches apart in line with
• Sterile and nonsterile gloves
the long axis of the cervical spine. B, Vinke tongs are placed on
the parietal bones, near the widest transverse diameter of the • Gowns, masks, and eye shields
skull. C, Gardner-Wells tongs are inserted slightly above the • Antiseptic solution
patient’s ears. • Sterile sponges
• Sterile drill and bits (for insertion of Crutchfield and
Vinke tongs)
healthcare professional uses serial radiographs of the cer- • Rope and traction assembly for the bed (if a RotoRest
vical spine to assist in determining the optimal amount of Delta Kinetic Therapy™ bed is used, a cable and bracket
traction (measured in pounds) needed to reduce a fracture alignment system is needed; see Procedure 99)
and provide optimal alignment. Excessive traction may • S and C hooks (to attach to the distal end of the rope for
result in stretching of the spinal cord and subsequent weight application)
damage.2–4 • Weights to attach to the traction
• Cervical traction also may be applied with a halo ring • Torque wrench for the halo apparatus as well as the halo
device. This is a stainless steel or graphite ring that is vest if this is the definitive treatment
attached to the skull by four stabilizing pins (two anterior Additional equipment, to have available as needed, includes
and two posterolateral; Fig. 101-3). Skull pins can be the following:
made of stainless steel, titanium, or ceramic material.1,2,5,7 • Hair clippers
Pins are threaded through holes in the ring, screwed into • Emergency equipment
the outer table of the skull, and locked into place. Traction
can be applied to the ring device with the use of a rope PATIENT AND FAMILY EDUCATION
and pulley system or a cable and bracket alignment
system. Weights are added gradually. After alignment of • Explain the procedure and the reason for cervical traction.
the cervical spine is achieved, the spine can be immobi- Clarify or reinforce information as needed by the patient
lized by attaching the ring to a body vest or a custom or family. Discuss use of any special equipment, such as
a special bed, that may be needed. Rationale: Patient and • Inspect the scalp for abrasions, lacerations, or sites of
family anxiety is decreased. infection. Rationale: Any potential sites of infection that
• Explain the patient’s role in assisting with insertion of the may contraindicate the insertion of a cervical fixation
tongs. Rationale: Explanation elicits patient cooperation device into the infected area are identified.
and facilitates insertion. The nonintubated patient should • Assess the level of pain or discomfort and anxiety. Ratio-
be communicating with the team during traction if he or nale: Assessment establishes data for decision making
she feels any changes in sensation, new or worsening pain, regarding the need for analgesia or anxiolytics for comfort
or new or worsening change in motor function. and cooperation during the insertion procedure.
• Explain that the procedure can be uncomfortable when • Assess for any allergies to an antiseptic agent, local anes-
the incisions are made but that an anesthetic will be thetic, or analgesia and anxiolytics. Rationale: Review of
administered by the physician, advanced practice nurse, medication allergies before administration of a new medi-
or other healthcare professional. Rationale: This informa- cation decreases the chances of an allergic reaction.
tion prepares the patient for what to expect.
Patient Preparation
PATIENT ASSESSMENT AND • Ensure that the patient and family understand prepro-
PREPARATION cedural teaching. Answer questions as they arise, and
Patient Assessment ing of previously taught information is evaluated and
• Conduct a complete neurological assessment that includes reinforced.
evaluation of cranial nerve function, motor strength of • Verify that the patient is the correct patient using two
major muscles, sensation (assessment of light touch, pain, identifiers. Rationale: Before performing a procedure, the
and proprioception, noting highest dermatome level), and nurse should ensure the correct identification of the patient
deep tendon reflexes (biceps, triceps, patella, and Achil- for the intended intervention.
les) and superficial reflexes (abdominal and anal wink). • Ensure that informed consent has been obtained. Ratio-
Rationale: Baseline data are provided for comparison of nale: Informed consent protects the rights of the patient
postinsertion assessments to determine the presence of and makes a competent decision possible for the patient.
neurological compromise or extension of spinal cord • Perform a preprocedure verification and time out, if non-
injury. emergent. A time out (per institutional practice) should be
• Assess the patient’s vital signs. Rationale: Baseline performed before placement of cervical tongs or halo ring
data are provided for comparison with assessments after and traction. Rationale: Ensures patient safety.
insertion. • Ensure that the head of the bed is flat and that the patient’s
• Assess the patient’s respiratory pattern and auscultate lung head is in a neutral position by whatever approved means
sounds. Note the use of accessory respiratory muscles and (e.g., hard/rigid collar) have been instituted. Rationale:
any signs or symptoms of dyspnea. Rationale: Baseline This measure prevents movement of the neck, which may
data are established to determine any compromise to increase the risk of injury or extension of spinal cord
respiratory function as a result of the procedure. injury.
Procedure for Assisting With Application of Tongs or Halo Ring for Cervical Traction
1. Obtain a bed with an orthopedic Traction must be ready to May require assistance from other
traction frame, weights, and rope and reduce the potential for departments; therefore, plan ahead
pulley system attached to the bed or, movement of the head and to coordinate.
if prescribed, obtain a RotoRest neck.
Kinetic Therapy™ bed with the wire
and bracket alignment device.
2. HH
3. PE All healthcare personnel involved in
the procedure need to apply
personal protective and sterile
attire (e.g., fluid shield masks, eye
shields, gowns, and sterile gloves).
Procedure for Assisting With Application of Tongs or Halo Ring for Cervical
Traction—Continued
4. Assist the physician, advanced Facilitates the procedure. Because of the high risk for
practice nurse, or other healthcare extension of cervical injury, this
professional with tong or halo ring procedure usually is performed by
insertion: a neurosurgeon, who can respond
rapidly if neurological deterioration
becomes evident.
A. Assist as needed with preparation Clipping the hair may prevent
of the pin sites (clipping a small it from being trapped when
area of scalp hair if indicated and the pins are inserted.
cleansing with antiseptic solution). Cleansing decreases skin
surface bacteria.
B. Assist if needed with draping the Aids in maintaining sterility.
patient, leaving insertion sites
exposed.
C. Assist as needed with local Decreases patient discomfort
anesthesia administration. during pin insertion.
D. Stabilize the patient’s head and Maintains alignment of the Cervical stabilization can be
neck during the procedure. cervical spine and provides maintained with the use of a rigid
support to the injured areas. collar or other devices that prevent
head rotation and neck flexion or
extension. A soft collar is not
considered a stabilizing device.
The head and shoulder packs of the
RotoRest Kinetic Therapy™ bed
provide some cervical stability but
should not be used as the primary
means of stabilizing cervical spine
fractures before, during, or after
tong or halo insertion. Utmost care
must be taken to prevent head and
neck flexion or extension. Be
prepared for the possibility of
respiratory insufficiency,
respiratory arrest, hypotension,
bradycardia or cardiac arrest.
E. Carefully follow institutional Institutional policies may Follow institutional policy for
policies regarding manual provide strict guidelines for confirmatory radiographic studies
cervical spine immobilization. nursing role in manual following the procedure.
cervical spine immobilization
during traction placement.
5. Monitor the patient for changes in Identifies evidence of untoward In addition to untoward effects, the
respiratory function, neurogenic effects or complications patient may need additional
shock, spinal shock, changes in motor related to the procedure, and reassurance, support, sedation, and
function, and changes in sensation and identifies the need for analgesia.
pain. analgesia.
6. Follow hospital policy for pin site Maintains asepsis.
care (see Procedure 104).
7. Assist with application and connection
to traction as needed (see
Procedure 102).
A. Maintain the patient’s head in a Ensures accurate and safe use
neutral position. of the traction.
Procedure for Assisting With Application of Tongs or Halo Ring for Cervical
Traction—Continued
B. Assist if needed with the Provides assistance.
application of prescribed weights.
C. Ensure that weights are Ensures safe use of equipment
unobstructed and hanging and maintains principles of
freely.2,8–11 (Level E*) traction.
9. HH

• Tong or halo ring device inserted • Slippage of tongs or halo pins
• Head and neck immobilized to allow for alignment, • Extension or deterioration of neurological deficits or
stabilization, and healing of fractures spinal cord injury
• Prescribed amount of weight applied to tongs or halo • Respiratory compromise or arrest
• Traction weights unobstructed and hanging freely • Hypotensive episode, bradycardia, cardiac arrest
• Improved or stable neurological function (motor and • Pain
sensory) • Bleeding at pin site
• Patient discomfort minimized

1. Assess neurological status every Facilitates early recognition of • Any deterioration or extension
5 minutes during the procedure, neurological deterioration. of baseline neurological function
including assessment of level of Bitemporal tongs may interfere with • Increased or new loss of
consciousness, movement in arms mastication and eyelid closure.2,5,7 sensation
and legs, sensation, mastication, • New or worsening decrease in
and eyelid closure.2,5,7 (Level E) motor strength
2. Assess respiratory function Early identification of hypoxia or • Changes in respiratory function
(respiratory rate, pulse oximetry, respiratory distress from (e.g., decrease in oxygen
lung sounds) before, during, and neurological deterioration or other saturation [Sao2], increase in end
after the procedure. potential complications such as tidal carbon dioxide [Etco2];
aspiration or sedation. increase or decrease in
Decrease in peripheral oxygen respiratory rate, abnormal lung
saturation may be an early indicator sounds)
of respiratory compromise. • Oversedation
3. Assess for neurogenic shock. Neurogenic shock can occur rapidly • Hypotension
and requires prompt intervention. • Bradycardia
• Decreased vascular tone
• Hypoxia
• Poikilothermia
4. Provide emotional support and Decreases anxiety and facilitates • Unrelieved anxiety
reassurance to the patient during patient cooperation.
the procedure.

5. Monitor pin sites for hemostasis The scalp is vascular, and continued • Unresolved bleeding
immediately after the procedure, bleeding may occur at the pin sites
every 15 minutes × four, every 30 that requires assessment and
minutes × two, and hourly, or as cleansing.5,6
indicated by institutional policy.
6. Check the security of the traction, The traction frame is attached to the • Break in the integrity of the
bed frame, and bed. bed and must be secure. traction equipment or the bed
frame
7. Maintain the patient’s head flat The head must be flat on the bed to • Neck or head out of neutral
on the bed and ensure that the maintain a neutral position. alignment
bed is flat. The head of the bed Countertraction is often provided to
frame may be on shock blocks or prevent the patient from being
placed in reverse Trendelenburg’s pulled toward the top of the bed.
position to provide
countertraction.8,9
8. If the knot on the traction rope The knot of the traction rope must • Evidence of loss of effective
nears the pulley or the wire band not be resting against the pulley for traction
nears the bracket, several effective traction. The cover over
physicians, advanced practice the wire and bracket alignment
nurses, or other healthcare device must not be against the
professionals may slowly pull the alignment screw (head of the bed)
patient down in bed. The patient for effective traction.
should never be pulled up in the
bed or traction will be released.
Do not remove the weights to
move the patient toward the foot
of the bed.8–11 (Level E*)
9. If cervical traction is lost for Immediate intervention is needed to • Changes in motor and/or sensory
whatever reason (e.g., the loop in immobilize the patient’s head and assessment
traction rope holding the weights neck. • Changes in respiratory effort,
slips or the pins dislodge), signs of respiratory distress
maintain manual cervical spine • Evidence of loss of effective
immobilization, place the patient traction
in a hard/rigid cervical collar, and
notify the physician, advanced
professional. Elicit the patient’s
cooperation to minimize
extraneous movement.
10. Prepare the patient for a bedside A radiograph is taken to verify • Abnormal radiographic results
confirmatory radiograph of the alignment of the cervical spine.
cervical spine immediately after
insertion and application of
weights and as prescribed by the
professional.


11. If additional weights are added or Monitors for possible risk of • Changes in motor and/or sensory
removed by the physician, secondary spinal cord injury. assessment
advanced practice nurse, or other • Changes in respiratory effort,
healthcare professional in an signs of respiratory distress
attempt to realign the cervical
spine, increase the frequency of
neurological checks. Expect more
frequent cervical radiographs or
MRIs to verify alignment.2,3
Documentation
• Patient and family education • Ongoing comprehensive assessment data and action
• Completion of informed consent taken for abnormal response
• Preprocedure verifications and time out • Verification of proper functioning and security of
• Type of cervical traction applied traction equipment
• Date and time traction is applied • Documentation of radiographic confirmation of
• Local anesthetic used alignment
• Sedation and analgesia used • Occurrence of unexpected outcomes
• Amount of weight applied to the traction • Patient response to care
• Weights hanging freely • Additional interventions
• Pins secure • Pain assessment, interventions, and effectiveness
• Appearance of pin-insertion site and care

101 Cervical Tongs or Halo Ring: Application for Use in Cervical Traction (Assist) 910.e1
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5. Hayes VM, et al: Complications of halo fixation of the Additional Readings
cervical spine. Am J Orthop 34:271–276, 2005. Aebi M: Surgical treatment of upper, middle and lower
6. Hickey JV: Vertebral and spinal cord injuries. In cervical injuries and non-unions by anterior procedures.
Hickey JV, editor: The clinical practice of neurological Eur Spine J 19(Suppl 1):S33–S39, 2010.
and neurosurgical nursing, ed 6, Philadelphia, 2009, Jerome Cervical Spine System: Application instructions for
Wolters Kluwer Health/Lippincott Williams & Wilkins, Jerome Halo Traction Systems, Morristown, NJ, 2003,
pp 410–453. Jerome Cervical Spine System.
PROCEDURE
102
Cervical Traction Maintenance
Jennifer Massetti
PURPOSE: Once cervical traction has been established, the nurse cares for the
patient who is immobilized on complete bed rest. Traction must be maintained on a
continuous basis until realignment and stabilization with surgical management or
orthoses is attained or healing is completed.
PREREQUISITE NURSING Additional equipment, to have available as needed, includes

KNOWLEDGE the following:
• Positioning devices or protective dressings
• The nurse must be knowledgeable about the anatomy and • Specialty bed
physiology of the spinal column, the anatomy of the cervi-
cal vertebrae, the spinal cord, the cervical spinal nerves, PATIENT AND FAMILY EDUCATION
and the area of peripheral innervation.
• It is important that the nurse understands the pathophysiol- • Explain the procedure and the reason for the traction.
ogy and manifestations of spinal cord injury, including Rationale: Patient and family anxiety may be decreased.
ascending edema, spinal shock, and neurogenic shock. • Explain the patient’s role in maintaining the traction.
Continual assessment of changes in motor, sensory, and Rationale: Patient cooperation is elicited. The nonintu-
respiratory associated with ascending edema, spinal shock, bated patient should be communicating with the team
and neurogenic shock is essential in the care of the patient during traction if he or she feels any changes in sensation,
requiring cervical traction. new or worsening pain, or new or worsening change in
• After the cervical tongs are inserted, traction is applied by motor function.6
adding weights to a rope and pulley or cable and bracket • Explain how the patient’s basic needs will be met during
alignment device attached to the tongs (see Fig. 100-1). the confinement to bed and the maintenance of traction.
Additional weight may be added gradually, followed by Rationale: The patient and family are reassured that the
radiographic imaging. The physician uses serial radio- patient will be cared for and his or her needs met.
graphs of the cervical spine to assist in determining the
optimal amount of traction (measured in pounds) needed
to reduce a fracture and provide optimal alignment. Exces- PATIENT ASSESSMENT AND
sive traction may cause stretching of and damage to the PREPARATION
spinal cord; the addition of weight to the traction is
managed by the physician.3,5,6,9 Patient Assessment
• Once the traction is in place, the patient is maintained on • Conduct a complete neurological assessment that includes
strict bed rest. For facilitation of turning, the patient may motor strength of the major muscles and sensory function.
be placed on a special bed or turning frame. (Assess light touch, pain, and proprioception. Note the
• The principles of skeletal traction are the foundation of highest dermatome level with impaired sensation.) Assess
management of any patient in cervical traction. One must deep tendon reflexes (biceps, triceps, patellar, and Achil-
follow key points: (1) never raise/lift the traction weights, les), superficial reflexes, and cranial nerves. Rationale:
(2) never disconnect the traction, (3) never allow the trac- Baseline data are established for determination of any
tion weights to rest on the floor, and (4) never allow other change in neurological function.
objects to compromise freely hanging weights. • Assess the patient’s vital signs. Rationale: Baseline data
are provided for comparison with assessments after
EQUIPMENT insertion.
• Inspect the scalp for abrasions, lacerations, or sites of
• Cervical traction system in place, including rope and infection. Rationale: Any potential sites of infection that
pulley system or cable and bracket alignment device and may contraindicate the insertion of a cervical fixation
weights for the RotoRest™ Delta Kinetic™ Therapy Bed device into the infected area are identified.
(see Figs. 99-1, 102-1). • Assess the patient’s comfort. Rationale: Spinal injuries
• Pillows are often painful. Changes in pain in the head or neck or
911
Patient Preparation
• Ensure that the patient and family understand preproce-
dural teaching. Answer questions as they arise, and rein-
force information as needed. Rationale: Understanding
of previously taught information is evaluated and
reinforced.
• Ensure that body alignment is maintained and that the
patient is positioned in the middle of the bed. Rationale:
Positioning facilitates comfort and even distribution of the
traction.
• Check the orthopedic traction frame, rope knot, and pulley
or cable and bracket alignment device for secure attach-
Figure 102-1 Closer view of the tension system for cervical
ment and function. Rationale: Ineffective traction or loss
traction. of traction may result in loss of realignment and stabiliza-
tion of the vertebral column, resulting in spinal cord
injury.
at the pin sites may suggest misalignment, pin-site infec- • Check the ropes and weights to be sure that they are
tion, or slippage of traction. hanging freely. Check the cable and alignment bracket
• Assess the location and skin around pins. Rationale: device for patients treated on a kinetic therapy bed. Ratio-
Pins can slip and pin sites can become irritated and/or nale: Assessment maintains function and prevents slip-
infected.7 page of the orthopedic equipment.
Procedure for Traction Maintenance

1. HH
2. PE
3. Ensure that the orthopedic frame Promotes patient safety.
and traction equipment are intact.
4. Maintain the weights so that they Obstruction to the free hanging of Inform the physician immediately
hang freely at all times.1,4,8,10 the weights eliminates traction of any interruption of the traction
(Level E*) and could precipitate adverse because a cervical radiograph
neurological responses in the may be necessary to assess
patient. Do not raise the cervical alignment.
traction at any time.4,6,8
5. Ensure that the rope is able to slide The knot resting on the pulley If the knot on the traction rope
freely through the pulley and that interferes with the adequacy of nears the pulley or the wire band
the knot in the rope is not resting on the weights and traction. The nears the bracket, several
the pulley. If using the cable and cable must slide freely through healthcare providers may slowly
bracket alignment device, ensure the bracket to maintain pull the patient down in bed. The
that the cable is able to slide freely adequacy of the weights and patient should never be pulled up
through the bracket (ensure the band traction.4,6,8 in the bed or traction will be
at the end of the cable is not resting released.
on the bracket).4,8,10 (Level E)
102 Cervical Traction Maintenance 913
Procedure for Traction Maintenance—Continued

6. Maintain the patient in a straight Alignment ensures optimal Reposition as necessary; ensure
line (centered on the bed), in a traction that is balanced (does adequate help to prevent
neutral position and aligned with the not pull on one side of the extension of a cervical injury.
pulley and rope or cable and bracket body more than on the other
alignment device. Lock the bed side) and prevents traction
controls so the patient and/or slippage and pain.
visitors cannot accidently move the
head of the bed.
7. Follow the physician, advanced Maintains alignment. Begin turning only when prescribed
practice nurse, and other healthcare by the physician, advanced
professionals’ prescription regarding practice nurse, or other healthcare
turning. When turning manually, professional.
logroll with at least three healthcare Turning or moving the patient in a
providers. Follow institutional neutral position with a triple
policy for maintaining cervical log-rolling technique requires
spinal alignment during coordination of turning and
repositioning. When turning preplanning.
automatically with kinetic therapy,
increase the angle gradually while
assessing how the patient responds
to turning.
8. Use pillows and special positioning Prevents misalignment and Do not use pillows under the
devices to maintain the patient in possible extension of a cervical patient’s head; maintain the
body alignment. injury. patient flat on the bed; use
pillows to support alignment and
maintenance of a neutral position.
10. HH

• The orthopedic traction frame and all traction • Slippage of tongs, pins, or external fixation device
equipment are secure and functional • Interruption of continuous traction
• Proper body alignment of the patient is maintained • Extension or deterioration of neurological deficits or
• The patient is comfortable and safe spinal cord injury
• The patient’s neurological function is stable or • Pain
improved
• The patient tolerates turning

interventions.
1. Perform a neurological assessment Determines neurological • Any deterioration or extension of
after cervical traction is initiated status and assesses for baseline neurological function (e.g.,
and then a minimum of every 2–4 changes due to edema or loss of more dermatomal sensation,
hours, as prescribed or according spinal shock. decrease in motor strength, loss of
to institution standard. reflexes, difficulty breathing)
• Bitemporal tongs may also interfere
with eyelid close and mastication11
TABLE 102-1 Acute Physiological Responses to Immobility and Spinal Cord Injury
Body Physiological Response Physiological Response to
System to Immobility Spinal Cord Injury Assessment Parameters
Integumentary Pressure → ischemia → Protective motor and sensory Inspect bony prominences.
integumentary disruption functions lost or impaired below Identify preexisting skin disruptions.
the level of the lesion Assess specific pressure areas related to
traction devices and positioning.
Pulmonary Decreased chest expansion Lost or impaired neuromuscular Observe the thorax for symmetrical chest
Secretions pool stimulus to the diaphragm, internal expansion.
CO2 retention → respiratory and external intercostals, Identify breathing patterns.
acidosis abdominal muscles, and accessory Auscultate breath sounds.
muscles Respiratory parameters (NIF/FVC).
Supplemental O2 ABG/pulse oximetry.
Identify associated pulmonary injury.
Cardiovascular Increased cardiac workload Decreased vasomotor tone Monitor vital signs, rhythm interpretation,
Thrombus formation Loss of sympathetic response blood pressure, heart rate, and perfusion.
Orthostasis Poor venous return Monitor body/skin temperature
Poikilothermia Organ perfusion assessment: level of
Spinal shock → autonomic dysreflexia consciousness and urine output.
Musculoskeletal Muscle atrophy Loss/impairment of voluntary motor Identify level of lesion.
Joint immobility → function Serial motor/sensory examinations.
Contractures Flaccid → spastic paralysis Assess joint mobility (flaccidity/spasticity).
Confirm that the traction and weights are
applied correctly.
Neurological Increased vasovagal response, Neurogenic shock After spinal shock, assess for autonomic
bradycardia, hypotension Spinal shock dysreflexia.
Gastrointestinal Paralytic ileus Neurogenic bowel Monitor for absent to hypoactive bowel
sounds, inability to tolerate enteral nutrition.
Genitourinary Bladder atony Neurogenic bladder Monitor urine output. Assess for bladder
Areflexic to eventually reflex voiding distension.
NIF, negative inspiratory force; FVC, forced vital capacity; ABG, arterial blood gas.

2. Obtain vital signs after cervical Determines cardiovascular • Changes in vital signs (hypotension,
traction is initiated and then a stability. bradycardia, respiratory distress), or
minimum of every 2–4 hours, as neurogenic shock will require prompt
prescribed or according to intervention
institutional standards. Continue to
assess the patient for neurogenic
shock.
3. Assess respiratory status after Provides early identification • Abnormal lung sounds
cervical traction is initiated and of atelectasis, pneumonia, • Abnormal respiratory rate or pattern
then at a minimum of every 2–4 respiratory distress, or of breathing
hours, as prescribed or according extension of neurological • Decreased oxygen saturation
to institutional standards deterioration. • Decreased ventilation parameters
(Table 102-1). (e.g., tidal volume, vital capacity)
• Increased sputum
• Yellow-green sputum
• Use of accessory muscles
102 Cervical Traction Maintenance 915

4. Assess cardiac status after cervical Provides early identification • Dysrhythmias
traction is initiated and then at of cardiac dysrhythmias or • Abnormal heart sounds
minimum every 2–4 hours, as decompensation. • Hemodynamic instability
institutional standards (see
Table 102-1).
5. Perform peripheral vascular Provides early identification • Peripheral vascular changes
assessment after cervical traction is of peripheral vascular • Signs of DVT
initiated and then at a minimum of insufficiency and DVT.
every 2–4 hours, as prescribed, or
according to institutional standards.
Consider deep venous
thromboembolism (DVT)
prophylaxis (e.g., anticoagulation
therapy and sequential compression
devices).2,10
6. Perform gastrointestinal assessment Provides early identification • Abdominal distention
after cervical traction is initiated of paralytic ileus and • Nausea
and then at a minimum of every gastric distention; • Vomiting
2–4 hours, as prescribed, or prevention of gastric • Decreased bowel sounds
according to institutional standards; hemorrhage. • Constipation
consider gastric prophylaxis.2,12
7. Perform genitourinary assessment Provides early identification • Decreased urine output
after cervical traction is initiated of urinary tract infection • Increased urine output
and then at a minimum of every and neurogenic bladder. • Distended bladder
2–4 hours, as prescribed or • Signs and symptoms of urinary tract
according to institutional infection
standards.2,12
8. Perform skin assessment after Provides early recognition of • Evidence of skin breakdown
cervical traction is initiated and skin breakdown.
then at a minimum of every 2–4
hours, as prescribed or according
to institutional standards (see
Table 102-1).2,12
9. Perform musculoskeletal Provides early recognition of • Increased spasticity or malpositioning
assessment every 8 hours (see musculoskeletal of an extremity
Table 102-1).2,12 contractures.
10. Perform nutritional assessment at Determines nutritional status. • Decreased intake, poor skin turgor,
least once a day.1,2 intolerance of nutrition
11. Assess anxiety level, pain, and Provides early recognition of • Anxiety, depression, agitation, pain,
coping.1,2 anxiety, depression, or other untoward responses
agitation, and pain.
12. Perform pin care (see Procedure Monitors skin and assesses • Evidence of infection
104). for infection.
13. Reposition and turn, maintaining Maintains skin integrity. • Impaired skin integrity
neutral body alignment.1,2 Follow Prevents complications of
institutional standards. immobility.
14. Perform respiratory management Supports respiratory function • Decreased or increased respirations
(e.g., supplemental oxygen, deep and oxygenation of all body • Abnormal lung sounds
breathing, suctioning, incentive organs. • Decreased oxygen saturation
spirometer, quad coughing, chest • Change in pulmonary secretions
physical therapy, bronchoscopy, • Fever
tracheostomy).2,12
15. Initiate bladder and bowel Supports adequate emptying • Bladder distension
programs.2,12 of bladder and pattern of • Constipation
bowel activity. • Decrease in or absence of bowel signs

16. Perform range of motion every 2 Maintains intact motor • Evidence of contractures, deformities,
hours and apply splints and other function. functional loss
positioners.1,2
17. Offer emotional support and other Supports patient and family
diversional therapy.1,2 through the continuum of
care and keeps them
actively involved.
18. Consult support services as Support services can provide
needed.1,2 items such as prism glasses
to help the patient see, read,
and increase visual field.
Documentation
• Patient and family education band at end of cable, and bracket alignment device
• Ongoing comprehensive assessment data and not resting on bracket)
interventions for abnormal findings • Occurrence of unexpected outcomes
• Verification of proper functioning and security of • Patient response to care
traction equipment (e.g., total weight applied, weights • Additional interventions
hanging freely, traction rope knot not against pulley, • Pain assessment, interventions, and effectiveness

102 Cervical Traction Maintenance 916.e1
References 8. Osmond T: Clinical update: Principles of traction.

1. Blissitt PA: Spinal cord injury. In Carlson KK, editor: Aust Nurs J 6:S1–S4, 1999.
Advanced critical care nursing, Philadelphia, 2009, 9. Patterson MM: Multicenter pin care study. Orthop Nurs
Saunders/Elsevier, pp 637–680. 24:349–360, 2005.
2. Consortium for Spinal Cord Medicine: Early acute 10. Styrcula L: Traction basics: Part I. Orthop Nurs 13:71–74,
management in adults with spinal cord injury: A clinical 1994.
practice guideline for health-care professionals, 11. Wood G: Cervical spine injuries. In Canale ST, Beaty JH,
Washington, DC, 2008, Paralyzed Veteran’s Association. editors: Campbell’s operative orthopaedics, ed 11, St
3. Gupta MC, Benson DR, Keenen TL: Initial evaluation and Louis, 2008, Mosby, pp 1761–1810.
emergency treatment of the spine-injured patient. In 12. Wuermser LA, et al: Spinal cord injury medicine: 2:
Browner BD, et al, editors: Skeletal trauma, ed 4, Acute care management of traumatic and nontraumatic
Philadelphia, 2008, Saunders, pp 794–798. injury. Arch Phy Med Rehabil 88:S55–S61, 2007.
4. Harvey CV: Challenges of traction in critical care: A case Additional Reading
study. Crit Care Nurs Q 21:1–13, 1998.
5. Gelb DE, Aarabi B, Dhall SS: Treatment of subaxial Aebi M: Surgical treatment of upper, middle and lower
cervical spine injuries. Neurosurgery 72(Suppl 2): cervical injuries and non-unions by anterior procedures.
187–194, 2013. Eur Spine J 19(Suppl 1):S33–S39, 2010.
6. Gelb DE, Hadley MN, Aarabi B: Initial closed reduction Lauweryns P: Role of conservative treatment of cervical spine
of cervical spinal fracture-dislocation injuries. injuries. Eur Spine J 19(Suppl 1):S23–S26, 2010.
Neurosurgery 72(Suppl 2):73–83, 2013. Sponseller PD, et al: The use of traction in the treatment of
7. Lethaby A, Temple J, Santy J: Pin site care for preventing severe spinal deformity. Spine 33:2305–2309, 2008.
infections associated with external bone fixators and pins.
Cochrane Database Syst Rev (4):CD004551, 2008.
PROCEDURE
103
Halo Ring and Vest Care
Cara Diaz
PURPOSE: A halo ring attached to a halo vest (commonly referred to as a halo)
is designed to immobilize and stabilize the cervical spine. A halo ring and vest may
be used alone or in conjunction with surgery for the patient with an unstable
cervical spine as a result of spinal fracture or dislocation; degenerative processes,
such as C1-C2 changes from rheumatoid arthritis; or spinal surgery. The halo ring
and vest stabilizes the vertebral column’s movement, reducing subsequent risk of
spinal cord injury.2
PREREQUISITE NURSING in the ring, screwed into the outer table of the skull, and
KNOWLEDGE locked into place.
• Direct traction may be applied to the halo ring device with
• Knowledge of neuroanatomy and physiology of the a rope and pulley or cable and bracket alignment system
cervical spine—including the spinal column, vertebrae, and weights (see Procedures 101 and 102). Patients with
the spinal cord, and spinal nerves with their areas of a halo ring, pins, and traction applied with weights are
innervation—is necessary. cared for similarly to patients in cervical traction with
• The nurse must understand the pathophysiology and man- tongs (see Procedures 101 and 102).
ifestations of spinal cord trauma, including spinal shock, • When alignment of the cervical spine is achieved, long-
ascending edema, and related impairment of respiratory term immobilization of the spine can be achieved by
function, vasomotor tone, and autonomic nervous system attaching the ring to a body vest or a custom-molded
function, including signs and symptoms of autonomic body jacket, which allows for mobility of the patient
dysreflexia. (Fig. 103-1).2,3
• The nurse must be familiar with the components of the • With the halo ring and pins in place, traction can be dis-
halo-vest device, including the halo ring and pins, anterior continued and a halo vest and struts added for long-term
and posterior posts, vest screws, front and back panels of immobilization of the cervical neck (see Fig. 103-1). The
the vest, and shoulder and side buckles. advantage of this approach is that the patient can sit
• The halo ring and vest may be used as a primary definitive upright, mobilize out of bed, and ambulate, if able, while
treatment to stabilize the cervical spine, before surgery to the cervical spine remains stable.
reduce spine deformity, or after surgery as an adjunct to • The nurse should know how to access the patient’s
interval cervical fixation. anterior chest to administer cardiopulmonary resuscita-
• Although the conventional halo has been used since 1959 tion (CPR) if cardiac arrest occurs. Refer to informa-
and is regarded as a standard of care for external stabilization from the manufacturer of the halo vest for specific
tion of the injured cervical spine, new pinless and nonin- information on emergency access to the chest. Some
vasive halo options have been introduced to preliminary vests have a hinged closure; the vest can be lifted up at
stages of research, showing promise for future patient the hinge to allow quick access to the chest. Other vests
options.13 This procedure focuses on the management of are not hinged and require a wrench. The wrench must
the patient who needs immobilization with a halo ring and be available at all times and, depending on institutional
vest. policy, may be maintained on the front of the vest for
• Basic cardiac life support knowledge and skills are essen- instant access to the chest. If the patient needs defibril-
tial. lation, avoid touching the bars of the traction with the
• The nurse must be knowledgeable about the signs and defibrillator.
symptoms of new injury or extension of spinal cord injury • Proper management and monitoring of a patient in a halo-
and the needed interventions. vest device can prevent minor complications that could
• The nurse should have knowledge regarding the indica- lead to more serious morbidity and mortality.9
tions for halo use in the patient and the risks and signs of
halo failure. EQUIPMENT
• A halo ring device is a graphite ring attached to the skull
with four stabilizing pins (two anterior and two posterolat- • Halo device (in place)
eral; see Fig. 101-3). The pins are threaded through holes • Soap and a basin of warm water
917
Halo ring requiring adaptations for performing activities of daily

living (ADLs).10
• If the patient is ambulatory, explain modifications in
meeting basic needs such as bathing, toileting, eating,
Skull pins dressing, ambulation precautions, and safety needs. Ratio-
nale: Self-care skills and awareness of special safety pre-
Struts cautions are developed.
• For patients who will be discharged home wearing a
halo-vest device, begin a comprehensive teaching pro
gram with the patient and family. Rationale: The patient
Vest and family are prepared for care in the home
environment.
• Explain to the patient and family that the patient cannot
be turned with the struts (posts) of the halo-vest device.
Rationale: The patient and family are prepared for care
in the home environment.
• Explain that precautions must be used when the ambula-
tory patient with a halo-vest device gets in and out of a
car and walks up and down stairs. Rationale: The patient
cannot move the head in the halo-vest device to look
down.
• Explain that driving, riding a motorcycle or bicycle, and
Figure 103-1 Halo-vest apparatus. Supportive struts and ring are operating machinery are unsafe with a halo-vest device.
attached to a plastic vest, applying cervical traction while allowing Rationale: Patients recognize that they cannot turn their
for patient mobility. (From Urden LD, Stacy KM, Lough ME: Criti-
cal care nursing, ed. 7, St. Louis, 2014, Elsevier.) head.
• Explain that the pins of the halo transmit vibration and
cold sensation to the patient’s skull. Rationale: The
patient and family are alerted to possible sensations during
• Washcloth and towel ADLs.
• Nonsterile gloves • Explain that if the pins in the skull become loose, the
• Flashlight patient should contact the physician immediately. Inform
Additional equipment, to have available as needed, includes the patient and family not to adjust the pins in the skull.
the following: Family members may be taught how to tighten the halo
• Sheepskin liner washers and bolts with the wrench before discharge as
• Emergency wrench prescribed. Rationale: The patient and family are pre-
• Lidocaine for subcutaneous administration at pin site pared for care in the home and can identify when emer-
during placement/adjustments gency care may be needed.
• Explain that if the patient has any decline in neuro-
PATIENT AND FAMILY EDUCATION logical function (i.e., decreased or abnormal sensory func-
tion, decline in motor ability, or increase in pain), the
• Explain that the reason for the halo ring and vest device physician should be contacted immediately. Rationale:
is to maintain cervical immobilization. Rationale: Patient Decline in neurological function may indicate extension
and family anxiety is decreased. of spinal cord injury and the need for immediate
• Describe turning, positioning, and skin care procedures interventions.
before performing them. Rationale: Patient and family
anxiety is decreased. PATIENT ASSESSMENT AND
• Explain to the patient and family that the halo vest’s side PREPARATION
panels should only be opened as prescribed by the physi-
cian, advanced practice nurse, or other healthcare profes- Patient Assessment
sional and according to the manufacturer’s guidelines. If • Perform a complete neurological assessment (Fig. 103-2;
the side panels are opened the patient needs to be flat and Box 103-1). Rationale: This assessment provides baseline
supine.2,6,10 Rationale: Integrity of the halo-vest device data.5
and safety of the patient is maintained. Unbuckling of the • Assess skin integrity along the patient’s scalp. Rationale:
halo vest may result in loss of spine alignment and neu- This assessment ensures that there is no skin breakdown
rological compromise.10 near the areas where the screws will be placed.
• Because the halo vest limits movement of the head, • Obtain vital signs before halo ring and vest placement.
patients must be taught to scan the environment for objects Rationale: Baseline data are provided.
in their path that could lead to falls. Rationale: Patient • Assess for difficulty swallowing and risk for aspiration.4,14
safety and independence are maintained. The halo vest Rationale: Assessment identifies a patient at high risk and
changes the center of gravity and limits movement, thus the need to modify oral intake.
103 Halo Ring and Vest Care 919
Trifacial nerve
(fifth cranial nerve) BOX 103-1 Muscle Strength Grading
C2
Scale
C3 0/5—No movement or muscle contraction
C3
C4
C4
T1
1/5—Trace contraction
T2 T2
T3 2/5—Active movement with gravity eliminated
T3 T4
T4 T5 3/5—Active movement against gravity
T5 T6
C5
T2 T6
T7
T2
C5
T2 T7 T2 4/5—Active movement with some resistance
C5 T8 C5
T8 T9 5/5—Active movement with full resistance
T9 T10
T10 T11
C6 T11 C6 C6 T12 C6
T1
T12
T1 T1 L1 T1 (From Urden LD, Stacy KM, Lough ME: Priorities in critical care nursing, ed. 7,
L1
L3 St. Louis, 2016, Elsevier.)
L2 L2
C8 C8 S5
C8 C8
S4
L2 L2 S3 S3
C7 C7 C7 C7
S2
L3 L3
S2
• Ensure the emergency wrench is in the packet and attached
L3 L3
to the vest after placement. Rationale: Allows for emer-
gent removal if necessary.
L4 L4
• Ensure all pins, screws, bolts and washers are intact on
L4 L4 L5
L5 L5
L5
the device and no stripping has occurred or pieces are
missing. Rationale: Tight connections are necessary to
ensure stabilization of the device for effective immobiliza-
S1 S1 tion of the spine.
S1 S1
Patient Preparation
Figure 103-2 Dermatomes. (From Nagelhout JJ, Plaus KL:
Nurse anesthesia, ed 5, St. Louis, 2014, Saunders.)
• Ensure that the patient and family understand preproce-
dural information. Answer questions as they arise, and
reinforced.
• Assess the skin at the edges of the vest and where the vest • Verify that the patient is the correct patient using two
may overlap for redness or abrasion, especially over bony identifiers. Rationale: Before performing a procedure, the
prominences.10,14 Rationale: Skin irritation related to the nurse should ensure the correct identification of the patient
halo-vest device is identified. for the intended intervention.
• Check the fit of the vest for tightness or looseness. Ratio- • Assist patients, as they lie supine in a neutral position, with
nale: The need for change or modification of the vest is proper body alignment for the purpose of halo vest applica-
identified. Patient weight loss and position changes (sitting tion, liner change, and routine skin care. Rationale: Patients
to standing) may contribute to vest looseness. are kept safe and accessible for inspection.
• Check the halo vest for loose straps or screws, dirt, odor, • Observe the sides and back of the vest and adjacent skin
or evidence of the need to repair the vest. Rationale: The with the patient standing, if possible. Rationale: Observa-
vest may need to be repaired or the sheepskin liner tion provides an opportunity to inspect all areas in which
changed. the skin and vest come in contact.
Procedure for Halo Ring and Vest Care

1. HH
2. PE
3. If unbuckling is prescribed for Gains access to the underlying skin. Review the manufacturer’s
vest care, position the patient flat recommendations with regard to
in bed on his or her side; then vest care. Follow institutional
unbuckle one side of the halo policy with regard to vest care.
vest while maintaining cervical
spinal alignment.2,10 (Level E*)

Procedure for Halo Ring and Vest Care—Continued

4. Assess the patient’s skin. Use a Determines skin integrity.10,14 Insensate patients may be more
flashlight while pressing the liner vulnerable to skin breakdown. The
toward the vest to facilitate halo vest should fit snugly but not
assessment of the skin. cause skin breakdown or discomfort
over pressure areas. The fit of the
halo and the sheepskin liner is
checked daily. The sheepskin
should be smooth and without
wrinkles and extend to the edges of
the vest to protect the skin from
abrasions.
The sternum, ribs, scapulae, and
clavicle areas are especially at high
risk for skin breakdown.
5. Bathe the skin with soap and Cleanses the skin. Allows for skin Dry the skin thoroughly and avoid
water. Minimize moisture to assessment. excessive lotion or powder; these
avoid wetting the liner of the agents tend to mat the sheepskin
vest. If unbuckling the vest is not liner.
recommended by manufacturer or
institutional policy, pass a damp
thin towel between the skin and
sheepskin, reaching all skin
surfaces.10
6. Auscultate lung sounds. Identifies adventitious breath sounds. Lung sounds may be decreased at the
bases in patients with poor
diaphragm and intercostal muscle
function.1
7. Perform anterior and posterior May enhance secretion maintenance A slight decrease in vital capacity
chest physiotherapy, if indicated. and facilitate airway clearance. related to vest placement may be
seen.14
8. Rebuckle the vest.8,10 (Level E*) Maintains cervical immobilization. Ensure that the buckle is secured for
proper fit.
9. Turn the patient to the opposite Facilitates assessment of the opposite
side without using the struts of side of the patient’s body.
the halo, keep the head of the bed
flat, and repeat Steps 3–8.1,2,10,14
(Level E)
10. If unbuckling is prescribed, Provides comfort and cleanliness and Follow institutional standards for liner
change or assist with changing protects the skin. change. The anterior portion of the
the anterior sheepskin liner as sheepskin liner may require
needed: frequent changes because of
secretions or drainage from a
tracheostomy or from spills during
eating.10 Protect the sheepskin liner
during meals and use towels and
plastic when washing the hair to
minimize the need to change the
liner.10 Follow manufacturer’s
recommendations and institutional
policy regarding washing, reusing,
or discarding the liner.
A. Place the patient supine with Provides support and alignment.
the head of the bed flat.

B. Unbuckle one side strap on the Provides access to the sheepskin.
vest while maintaining cervical
spine alignment and
immobilization.
C. Roll the soiled liner on the Simplifies the liner change.
unbuckled portion of the
anterior vest to the center of
the vest to facilitate removal
of the sheepskin.
D. Match half the clean liner to
the corresponding portion of
the anterior vest and roll the
remainder to the center of the
vest.
E. Buckle the side strap of the Maintains cervical immobilization.
vest.
F. Unbuckle the other side strap
and remove the remainder of
the soiled liner.
G. Unroll the clean liner and
match to the corresponding
Velcro strips on the vest.
H. Buckle the side strap.
11. Change or assist with changing Promotes comfort and protects the Follow institutional standards for liner
the posterior sheepskin liner as skin. change.
needed:
A. Position the patient with the Provides support and protects the
head of the bed flat and the skin.
patient turned to the side-
lying position. Alternately, the
patient can be turned prone,
with a pillow under the chest
and a pillow under the head,
if the patient’s respiratory
status tolerates this position.
B. Unbuckle one side strap of the Provides support and alignment.
halo vest while maintaining
cervical spine alignment and
immobilization.
C. Roll the soiled liner on the Simplifies the liner change.
unbuckled portion of the
posterior vest to the center of
the vest to facilitate removal
of sheepskin.
D. Match half the clean liner to Provides comfort and protects the
the corresponding portion of skin.
the posterior vest and roll the
remainder to the center of the
vest.
E. Buckle the side strap of the Maintains cervical immobilization.
vest.
F. Roll the patient to the Maintains cervical spine alignment.
opposite side.
G. Unbuckle the side strap on the Accesses the opposite side of the
vest while maintaining liner.
cervical spine alignment and
immobilization. Remove the
remainder of the soiled liner.

H. Unroll the clean liner and Secures the liner in place.
match to the corresponding
Velcro strips on the vest.
I. Buckle the side strap. Maintains cervical immobilization.
appropriate receptacle. supplies.
13. HH

• Cervical alignment is maintained • Loose pins4,7
• The underlying skin remains intact and free of • Pin site infection, osteomyelitis, or intracranial
irritation abscess4,7,12
• The vest is functional, fits well, and is clean and • Poor fit (too loose or too tight) of halo vest or body
odorless jacket
• The pin sites are clean • Skin breakdown or irritation under or around the
• Mobility and sensation are maintained if the patient is vest4,7
neurologically intact • Persistent spinal instability and loss of vertebral
• The patient’s safety is maintained alignment4,7
• New or worsened injury to the spinal cord caused by
spine mobility4,7
• New or additional loss of neurological function
• Orthostatic hypotension
• Injury from fall during ambulation with a halo vest

interventions.
1. Assess motor and sensory Determines neurological status. • Any deterioration from baseline
function immediately after neurological function (e.g., loss of
application of the halo vest and more dermatomal sensation;
every 2–4 hours per institutional decrease in motor strength)
standard.
2. Monitor for dyspnea, hypoxia, or Assesses for hypoxia or respiratory • Decreased oxygen saturation
decreasing tidal volumes (monitor distress from extension of • Decreased tidal volumes from
pulse oximetry, and measure tidal neurological dysfunction or baseline
volumes). compromised respiratory function • Dyspnea
from vest constriction. A decrease
in peripheral oxygen saturation or a
decrease in tidal volume may be
early indicators of respiratory
compromise and risk for pneumonia
or mortality.2,9,12
4. Monitor for dysphagia. Dysphagia is a possible side effect of • Dysphagia
cervical immobilization with a halo
vest and can be associated with
altered nutritional status and
aspiration or risk for
pneumonia.3,4,7,9,12

5. Check the fit of the vest, The vest may be too big if significant • Inability to securely fit the vest
especially if the patient has lost weight loss occurs or too small if
or gained a significant amount of improperly fitted originally or if the
weight.2,10 patient gains weight.
6. At least once each shift, observe Promotes comfort and skin integrity. • Skin irritation noted; the liner is
the skin at the edges of the vest wet or dirty and needs replacement
and where the vest may overlap. • Call the physician to replace the
Replace the vest liner if it is wet liner per institutional standard
or soiled.2,10
7. Wash exposed skin with warm Maintains cleanliness of the skin and • Any assistance needed with the
water and soap; rinse well and protects the liner. liner replacement
dry. Be careful not to wet the
liner.
8. Provide pin care (see Procedure Monitors pin sites and prevents • Evidence of infection
104).7,11,12 infection.
9. Check the integrity of the halo, Provides for safe use of equipment • Any break in the integrity of the
pins, struts, and vest.10 and appropriate therapy. equipment
10. Move the patient and the halo Prevents dislodgment of pins and • Evidence of dislodgment of pins or
vest as a unit to avoid pressure injury. the halo
that may dislodge the pins. Never
use the anterior or posterior struts
(posts) that attach the halo to the
vest for moving a patient.11
11. Support the patient with pillows Provides comfort and prevents • Evidence of dislodgment of the
when positioning the patient in dislodgment of the halo-vest device. pins or halo
the proper body alignment. A pillow behind the patient’s head
decreases the patient’s sensation of
being suspended.
12. Discuss possible changes in body A dramatic change in body image • Maladaptation to altered body
image related to the halo-vest occurs with the wearing of the image
device; provide emotional halo-vest device and needs to be
support.11 acknowledged.
13. Discuss safety in ambulation and Because of the immobilization of the • Patient instability
fall prevention (e.g., scanning head and neck, the patient is at risk
with eyes to compensate for for falls.
inability to move head; walking
more slowly).11 Consider
recommendation of a physical
therapy consult.
14. Follow manufacturer’s Supports basic safety procedures. • Hemodynamic instability
recommendations and necessitating opening the vest
institutional policies for obtaining
immediate access to the chest in
event of an emergency. (Some
devices have an anterior vest with
a bendable CPR hinge, and some
require a wrench for vest removal
in emergencies. Keep the wrench
readily available at all times.)
Documentation
• Patient and family education • Liner changes
• Date, time, and name of the physician applying halo vest • Date and time of chest physiotherapy performed
• Skin and pin assessment • Occurrence of unexpected outcomes
• Integrity of the vest • Patient response to care
• Neurological (motor/sensory assessment) and • Additional interventions
pulmonary assessment (tidal volume, pulse oximetry) • Pain assessment, interventions, and effectiveness

103 Halo Ring and Vest Care 924.e1
References A prospective, descriptive cohort study of 239 patients.

1. Blissitt PA: Spinal cord injury. In Carlson KK, editor: J Bone Joint Surg 91(1):71–79, 2009.
Advanced critical care nursing, Philadelphia, 2009, 10. Patchen SJ, Timyan L, Atherton S: Your life in a halo
Saunders. made easier, Miami and Moorestown, NJ, 2002,
2. Bono CM: The halo fixator. J Am Acad Orthop Surg University of Miami School of Medicine and Jerome
15:728–737, 2007. Medical.
3. Canale ST, Beaty JH: Cervical spine injuries. In Canale 11. Patterson MM: Multicenter pin care study. Orthop Nurs
ST, Beaty JH, editors: Campbell’s operative orthopaedics, 24:349–360, 2005.
ed 11, Philadelphia, 2008, Mosby. 12. Saeed MU, Dacuycuy MA, Kennedy DJ: Halo pin
4. Hayes VM, et al: Complications of halo fixation of the insertion-associated brain abscess: Case report and review
cervical spine. Am J Orthop 34:271–276, 2005. of the literature. Spine 32:E271–E274, 2007.
5. Ho CH, et al: Monitoring the use of halo fixation device 13. Sawers A, DiPaola C, Rechtine G: Suitability of the
through an assessment form. J Orthop Surg 19(3):322– noninvasive halo for cervical spine injuries: A
325, 2011. retrospective analysis of outcomes. Spine J 9(3):216–220,
6. Jerome Medical: Application instructions for Jerome halo 2009.
traction systems, Moorestown, NJ, 2003, Jerome Medical. 14. Taitsman LA, et al: Complications of cervical halo-vest
7. Kang M, Vives MJ, Vaccaro AR: The halo vest: Principles orthoses in elderly patients. Orthopedics 31:446, 2008.
of application and management of complications. J Spinal Additional Reading
Cord Med 26:186–192, 2003.
8. Lethaby A, Temple J, Santy J: Pin site care for preventing Bernardo LM: Evidence-based practice for pin site care in
infections associated with external bone fixators and pins. injured children. Orthop Nurs 20:29–34, 2001.
Cochrane Database Syst Rev (4):CD004551, 2008.
9. Middendorp J, et al: Incidence of and risk factors for
complications associated with halo-vest immobilization:
PROCEDURE
104
Pin-Site Care: Cervical Tongs
and Halo Pins
Cara Diaz
PURPOSE: Cervical devices (tongs or halo ring) require special care of the skin
at the pin-insertion sites (pin-site care) to prevent and monitor for complications.
Because the pins are inserted through the skin and into the bone, local infections
can develop and proliferate into cranial osteomyelitis. Loosening of the pins may
also occur.3–6
Pin loosening occurs in 36% to 60% of patients with crown/halo vest, and
infection in 20%.11 Tong and halo pin-site care is provided to cleanse and remove
exudate from the sites to minimize the risk of infection and improve patient
comfort. In addition, pin-site care allows for better assessment of the pin sites for
pin loosening or displacement.
PREREQUISITE NURSING terial soap and water, alcohol, and povidone-iodine. None
KNOWLEDGE have been found superior.5,8–10,12
• Definitive guidelines for the frequency of pin-site care,
• The nurse should be knowledgeable about the anatomy cleansing agents, removal of crust, and the application of
and physiology of the spinal column, the cervical verte- dressings have not been established and depend on insti-
brae, the spinal cord, the cervical spinal nerves, and their tutional policies.8,9
areas of peripheral innervation. In addition, the nurse must • The goal is to keep pin sites clean and monitor for loosen-
understand the pathophysiology and manifestations of ing, infection, breakage, or other complications.
spinal cord injury, including the concepts of primary and
secondary spinal cord injury and spinal shock. EQUIPMENT
• The nurse needs to be able to assess and recognize acute
changes in spinal cord examination that may indicate • Cotton-tipped applicators
extension of recent spinal cord injury or new injury caused • Nonsterile gloves
by a complication. This includes changes in motor or • Cleansing or antiseptic solution
sensory function, respiratory function, or autonomic • Sterile container for cleansing solution
nervous system dysfunction. • Rinsing solution (as needed)
• The nurse needs to be knowledgeable about treatment • Second sterile container for rinsing solution (as needed)
options available to manage cervical injuries with tongs Additional equipment, to have available as needed, includes
or a halo ring. Tongs (see Fig. 101-2) are applied to the the following:
outer table of the cranium on both sides of the skull and • Hair clippers
attach to a set of weights hanging by a pulley system • Dressing supplies
(amount of weight determined by physician).3 This places • Light source to assist with visualization of posterior pin
traction along the spine to stabilize various conditions sites
including fractures and trauma. Tongs differ from a halo
ring (Procedure 101). A halo ring device can also be used PATIENT AND FAMILY EDUCATION
for traction although most often it is used for immobiliza-
tion. This device is a graphite ring that is attached to the • Explain the procedure and the reason for pin care. Ratio-
skull with four stabilizing pins (two anterior and two nale: Patient and family anxiety may be decreased.
posterolateral). The pins are threaded through holes in the • Explain the patient’s role in assisting with the procedure.
ring, screwed into the outer table of the skull, and locked Rationale: Explanation elicits patient cooperation and
into place. This device can also be attached to traction facilitates the procedure.
equipment or, in cases of external stabilization as defini- • Teach the family how to perform pin-site care for the
tive treatment, a vest with struts/posts (Procedure 103). patient and monitor for infection (e.g., redness, edema,
• Various cleansing agents for pin-site care have been used, odor, discharge) after discharge. Rationale: Education
including, but not limited to, 2% chlorhexidene solution, elicits family cooperation and comfort and prevents
hydrogen peroxide, sterile normal saline solution, antibac- complications.
925
• Teach the family to notify the physician, advanced prac- • Assess the patient’s pain and anxiety levels. Rationale:
tice nurse, or other healthcare professional if the pins are Interventions may be needed before the procedure to
loose or look infected. Rationale: This may lead to promote patient comfort and decrease anxiety.
informing the physician, advanced practice nurse, or other
healthcare professional of a potential problem. Patient Preparation
• Teach the family not to adjust the pins. Rationale: This • Ensure that the patient and family understand prepro-
helps maintain the stability of the pins. cedural teaching. Answer questions as they arise, and
PATIENT ASSESSMENT AND ing of previously taught information is evaluated and
PREPARATION reinforced.
• Assess the patient’s scalp for signs and symptoms of skin nurse should ensure the correct identification of the patient
irritation; carefully inspect the pin sites for signs and for the intended intervention.
symptoms of infection (e.g., redness, edema, or purulent • Assist the patient to a supine position. The patient in
drainage). Rationale: Assessment identifies skin break- a halo vest may be sitting up in a position of comfort.
down, irritation, or pin-site infection. Rationale: Access to the pins is facilitated for care.
• Assess the pin sites for any signs of dislodged or loose
pins including sheering of skin near pin. Rationale:
Assessment identifies pin loosening.
Procedure for Pin-Site Care: Cervical Tong and Halo Pins

1. HH
2. PE
3. Prepare the cleansing or antiseptic Prepares the cleansing or Solutions may be kept in a
solution as defined by institutional antiseptic solution for pin care. covered sterile container for 24
policy in a sterile container. Recent studies have shown hours. Label with the name of
Recent recommendations include chlorhexidine reduces risk of the solution and the date and
chlorhexidine as a possible infection.7,8 time the solution was prepared.
antiseptic solution.7,8 (Level B*)
4. Cleanse the area around each Removes drainage, prevents Serous drainage may be present
pin-insertion site with a cotton- excessive exudates, and the first 2–3 days after insertion.
tipped swab saturated with cleanses the area. A recent study showed a
cleansing solution. Clean in a statistically significant decrease
single sweeping motion, and then in infection rates dressing the
discard the swab. Gently repeat as pins with chlorhexidine-soaked
needed with a new swab each gauze for the first 7 days after
time. Use separate swabs for each placement, changing the
site to decrease the chance of dressing daily, and cleaning
cross contamination.1 with chlorhexidine each day.7
5. Apply a dry dressing if excessive Chlorhexidine-soaked gauze
drainage exists and notify the dressed around pin sites during
physician. Generally this is not the first week has been shown
necessary. to decrease infection rates.7
7. HH
104 Pin-Site Care: Cervical Tongs and Halo Pins 927

• Pin or tong sites remain intact • Infection at pin or tong sites, which may be local or
• Pin or tong sites remain free of infection may extend into bone (causing osteomyelitis),
through the skull (causing intracranial abscess), or
into the bloodstream (causing systemic infection)4,6,10
• Loose pins4,6,10
• Skin irritation, injury, or scarring4,6,10
• Bleeding at the pin site4,6,10
• Pain at the pin site4,6,10
• Loss of cervical spine immobilization related to loose
pins4,6,10

interventions.
1. Administer pin care as directed by Keeps pin sites clean and provides • Evidence of infection
institution policy. Evidence-based an opportunity for assessment • Pin dislodgement
recommendations about the of pin sites.
frequency of site care have not
been universally developed.
Regimens range from daily pin-site
care to every other day to weekly.7,8
2. Examine each pin site for evidence Determines the presence of • Evidence of bleeding
of bleeding, swelling, drainage, infection or slippage of pins. • Infection
redness, or pin loosening.2,4,7,8,10 • Drainage
• Pin dislodgment
3. Obtain a sample of drainage if Identifies the presence of • Culture results from exudate;
signs and symptoms of infection infectious organisms for further signs and symptoms of infection
are present.4 treatment.
4. Discuss possible changes in body Acknowledges a change in body • Maladaptation to body image
image related to placement of tongs image that occurs when external
or a halo ring; provide emotional traction or immobilization
support. devices are applied.
5. Monitor for discomfort at the pin Determines evidence of possible • Continued discomfort or signs of
sites. Follow institutional standards infection or slippage of pins.4,5 infection
for assessing pain. Administer Identifies need for pain • Continued pain despite pain
analgesia as prescribed. interventions. interventions
6. Check pin torque every other day Periodically checking pin torque • One study recommends checking
for the first week by using the can prevent dislodgement early torque every other day for week
manufacturer’s recommended tools and avoid irritation or possible 1, weekly for week 2, and
and torque level.7 (Level B*) pin replacement. monthly for the remainder of
crown wearing7

Documentation
• Patient and family education • Neurological assessment of sensation and motor
• Condition of the skin on the scalp function
• Condition of the skin at pin or tong sites • Occurrence of unexpected outcomes
• Evidence of redness or edema and amount and • Patient response to care
character of drainage at the pin sites • Additional interventions
• Loose pins • Pin-site care performed
• Body temperature • Pain assessment, interventions, and effectiveness

104 Pin-Site Care: Cervical Tongs and Halo Pins 928.e1
References 9. Patterson MM: Multicenter pin care study. Orthop Nurs

1. Bell A, Leader M, Lloyd H: Care of pin sites. Nurs Stand 24:349–360, 2005.
22:44–48, 2008. 10. Saeed MU, Dacuycuy MA, Kennedy DJ: Halo pin
2. Bono CM: The halo fixator. J Am Acad Orthop Surg insertion-associated brain abscess: Case report and review
15:728–737, 2007. of the literature. Spine 32:E271–E274, 2007.
3. Canale ST, Beaty JH: Cervical spine injuries. In Canale 11. Sarro A, et al: Developing a standard of care for halo vest
ST, Beaty JH, editors: Campbell’s operative orthopaedics, and pin site care including patient and family education:
ed 11, Philadelphia, 2008, Mosby, pp 1776–1777. A collaborative approach among three greater Toronto
4. Hayes VM, et al: Complications of halo fixation of the area teaching hospitals. Am Assoc Neurosci Nurses
cervical spine. Am J Orthop 34:271–276, 2005. 42(3):169–173, 2010.
5. Holmes SB, Brown SJ: Skeletal pin site care: National 12. Wu SC, et al: Use of chlorhexidine-impregnated patch at
Association of Orthopaedic Nurses guidelines for pin site to reduce local morbidity: The ChiPPS pilot trial.
orthopaedic nursing. Orthop Nurs 24:99–107, 2005. Int Wound J 5:416–422, 2008.
6. Kang M, Vives MJ, Vaccaro AR: The halo vest: Principles
of application and management of complications. J Spinal Additional Readings
Cord Med 26:186–192, 2003. Bernardo LM: Evidence-based practice for pin site care in
7. Kazi H, de Matas M, Pillay R: Reduction of halo pin site injured children. Orthop Nurs 20:29–34, 2001.
morbidity with a new pin care regiment. Asian Spine J Davis P, et al: Pin site management: Towards a consensus:
7(2):91–95, 2013. Part 2. J Orthop Nurs 5:125–130, 2001.
8. Lethaby A, Temple J, Santy-Tomlison J: Pin site care for Lee-Smith J, et al: Pin site management: Towards a consensus:
preventing infections associated with external bone Part 1. J Orthop Nurs 5:37–42, 2001.
fixators and pins. Cochrane Database Syst Rev McKenzie LL: In search of a standard for pin site care.
(12):CD004551, 2013. Orthop Nurs 18:73–78, 1999.
Section Fifteen Pain Management
PROCEDURE
105
Epidural Catheters:
Assisting with Insertion
and Pain Management
Kimberly Williams
PURPOSE: Epidural catheters are used to provide regional anesthesia and
analgesia by delivering medications directly into the epidural space surrounding the
spinal cord. Medications injected into the epidural space are capable of providing
dose-related, site-specific anesthesia and analgesia.
clonidine), and other agents.13,17 All medications should

PREREQUISITE NURSING be preservative-free for epidural administration.4,7,13,14
KNOWLEDGE • Opioids used for neuraxial analgesia include fentanyl, suf-
entanil, morphine, and hydromorphone.
• State boards of nursing may have detailed guidelines • All opioids administered via the epidural route can cause
involving the management of epidural analgesia. Each respiratory depression, sedation, nausea, vomiting, pruri-
institution that provides this therapy also has policies and/ tus, and urinary retention.
or guidelines pertaining to epidural therapy. It is important • Fentanyl and sufentanil are lipophilic opioids which can
that the nurse is aware of state guidelines and institutional have a more rapid onset and a shorter duration than mor-
policies. phine and hydromorphone, which are hydrophilic.34
• The nurse must have an understanding of the principles • The lowest efficacious dose of neuraxial opioids should
of aseptic technique.13,22,23,27 be administered to minimize risk of respiratory depres-
• The epidural catheter placement and the continuing pain sion.11
management of the patient should be under the supervi- • The pharmacology of agents given for epidural analgesia,
sion of an anesthesiologist, nurse anesthetist, or acute pain including side effects and duration of action, must be
service to ensure positive patient outcomes.1,13 understood. Nurses should be familiar with the psychoso-
• The spinal cord and brain are covered by three mem- cial and physiological implications for the appropriate
branes, collectively called the meninges. The outer layer treatment of pain and consequences for undertreatment of
is the dura mater. The middle layer is the arachnoid mater, acute pain.
which lies just below the dura mater and, with the dura, • Epidural analgesia provides a number of well-documented
forms the dural sac. The innermost layer is the pia mater, advantages in the postoperative period, including attenu-
which adheres to the surface of the spinal cord and the ation of the surgical/trauma stress response, excellent
brain. The cerebrospinal fluid (CSF) circulates in the sub- analgesia, earlier extubation, less sedation, decreased
arachnoid space, which is also called the intrathecal incidence of pulmonary complications, earlier return of
space.30 bowel function, decreased deep venous thrombosis,
• The epidural space lies between the dura mater and the earlier ambulation, earlier discharge from high-acuity
bone and ligaments of the spinal canal (Fig. 105-1). units,13,15,20,31 and potentially shorter hospital stays.1,2,20
• The epidural space (potential space) contains fat, blood
vessels, connective tissue, and spinal nerve roots. EQUIPMENT
• Epidural catheters can be used effectively for short-term
(e.g., acute, obstetrical, postoperative, trauma) or long- • One epidural catheter kit or the following supplies:
term (e.g., chronic, advanced cancer) pain management.7,20 ❖ One 25-gauge, 5 8 -inch (0.5 × 16 mm) injection needle
• Analgesia via an epidural catheter may be given with a ❖ One 23-gauge, 1 1 4-inch (0.6 × 30 mm) injection needle
continuous, intermittent, or patient-controlled (PCEA) ❖ One 18-gauge, 1 1 2-inch (1.2 × 40 mm) injection needle
pump system.17,30 A variety of medication options are ❖ One 5-mL locking tip syringe
available, including local anesthetics, opiates, mixtures of ❖ One 20-mL locking tip syringe
local anesthetics and opiates, α2-adrenergic agonists (e.g., ❖ One locking tip loss-of-resistance syringe
929
• Equipment for monitoring blood pressure, heart rate, and

pulse oximetry
the following:
• Ice or alcohol swabs for demonstrating level of block
• Capnography equipment
• Emergency medications (e.g., naloxone for respiratory
depression, intravenous colloids, and a vasoconstrictor
such as ephedrine for hypotension and Intralipid, a 20%
fat emulsion for local anesthetic toxicity)
• Bag-valve-mask device and oxygen
• Intubation equipment

• Review the principles of epidural use with the patient and
family members. If the patient’s pain needs are not met,
an assessment of the therapy will be completed and the
physician, advanced nurse practitioner, or other healthcare
Figure 105-1 Spinal anatomy. The spinal cord is a continuous professional may change the dosage or therapy to meet
structure that extends from the foramen magnum to approximately those needs. If available, supply easy-to-read written
the first or second lumbar vertebral interspace. (From Lewis SL, information. Rationale: This information prepares the
Dirksen SR, Heitkemper MM, et al: Medical-surgical nursing: patient and family for what to expect and may reduce
Assessment and management of clinical problems, ed 9, St. Louis, anxiety and preconceptions about epidural use.
2014, Elsevier.) • Explain to the patient and family that the insertion proce-
dure can be uncomfortable but that a local anesthetic will
❖ One 18-gauge, 3 1 4-inch (1.3 × 80 mm) epidural needle be used to facilitate comfort. Rationale: Explanation pro-
(pink) motes patient cooperation and comfort, facilitates inser-
❖ One 0.45 × 0.85–inch epidural catheter tion, and decreases anxiety and fear.
• One introducer stabilizing catheter guide • During insertion and therapy, instruct the patient to imme-
• One screw-cap locking tip catheter diately report adverse side effects, such as ringing in
• One 0.2-μm screw-cap locking tip catheter connector the ears, a metallic taste in the mouth, or numbness or
• One epidural flat filter tingling around the mouth, because these are signs indica-
• Topical skin antiseptic, as prescribed tive of local anesthetic toxicity.13,30,33 Rationale: Immedi-
• Sterile towels ate reporting identifies side effects and impending serious
• Sterile forceps complications.
• Sterile gauze, 4 × 4 pads • Review an appropriate pain rating scale with the patient.
• Face masks with eye shields The physician, advanced practice nurse, or other health-
• Sterile gloves and gowns care professional and the patient need to establish a mutu-
• 20 mL normal saline solution ally agreeable pain level goal. Rationale: Review ensures
• 5 to 10 mL local anesthetic as prescribed (e.g., 1% lido- that the patient understands the pain rating scale and
caine; local infiltration) enables the nurse to obtain a baseline assessment. Estab-
• 5 mL local anesthetic as prescribed to establish the block lishing a pain level goal allows the physician, advanced
• Test dose (e.g., 3 mL 2% lidocaine with epinephrine, practice nurse, or other healthcare professional to know
1:200,000) an acceptable goal for pain management.
• Gauze or transparent dressing to cover the epidural cath- • During insertion and therapy, instruct the patient to report
eter entry site changes in pain management (e.g., suboptimal analgesia),
• Tape to secure the epidural catheter to the patient’s back numbness of extremities, loss of motor function of lower
and over the patient’s shoulder extremities, acute onset of back pain, loss of bladder and
• Labels stating “Epidural only” and “Not for intravenous bowel function, itching, and nausea and vomiting.4,13,14,17
injection” Rationale: Education regarding adverse side effects
• Pump for administering analgesia (e.g., volumetric pump, allows for more rapid assessment and management of
dedicated for epidural use with rate and volume limited, potential complications.
which has the ability to be locked to prevent tampering • If the epidural infusion is patient-controlled, ensure that
and preferably is a color-coded [e.g., yellow] or patient- patient and family understand that only the patient is to
controlled epidural analgesia pump) activate the medication release. Rationale: The patient
• Dedicated yellow-lined, epidural portless administration should remain alert enough to administer his or her own
set dose. A safeguard to oversedation is that a patient cannot
• Prescribed medication analgesics and local anesthetic administer additional medication doses if he or she is
medications sedated.
105 Epidural Catheters: Assisting with Insertion and Pain Management 931
PATIENT ASSESSMENT AND • Review the patient’s medication allergies. Rationale: This
PREPARATION information may decrease the possibility of an allergic
reaction.
Patient Assessment
• Assess the patient for local infection and generalized Patient Preparation
sepsis. Rationale: Assessment decreases the risk for epi- • Ensure that the patient and family understand preproce-
dural infection (e.g., epidural abscess).31 Septicemia and dural information. Answer questions as they arise, and
bacteremia are contraindications for epidural catheter reinforce information as needed. Rationale: Understand-
placement.4,8,23,27 ing of previously taught information is evaluated and
• Assess the patient’s concurrent anticoagulation therapy. reinforced.
Rationale: Heparin (unfractionated) or heparinoids (e.g., • Verify that the patient is the correct patient using two
low-molecular-weight heparin) administered concurrently identifiers. Rationale: Before performing a procedure, the
during epidural catheter placement increases the risk for nurse and team members should ensure the correct iden-
epidural hematoma and paralysis. Care must be taken with tification of the patient for the intended intervention.
insertion and removal of the epidural catheter when • Ensure that informed consent has been obtained. Ratio-
patients have received anticoagulation therapy. Antico- nale: Informed consent protects the rights of the patient
agulant and fibrinolytic medications may increase the risk and makes a competent decision possible for the patient.
for epidural hematoma and spinal cord damage and paral- • Perform a preprocedure verification and time out includ-
ysis. If used, anticoagulants must be withheld before ing all team members. Rationale: This action ensures
insertion and removal of the epidural catheter.21,25,26 patient safety.
Removal of the epidural catheter should be directed by • Wash the patient’s back with soap and water and open the
the physician. According to Kleinman and Mikhail,13 gown in the back. Rationale: This action cleanses the skin
aspirin or nonsteroidal antiinflammatory medications and allows easy access to the patient’s back.
(NSAIDs) by themselves do not pose an increased risk for • Consider nothing by mouth (NPO), especially if sedation
epidural hematoma, assuming the patient’s coagulation or general anesthesia is to be used. Rationale: NPO status
profile is within normal limits. Therefore aspirin or decreases the risk for vomiting and aspiration.
NSAIDs may be administered while the epidural catheter • Establish IV access, or ensure the patency of IV catheters,
is in place.13 However, epidural hematomas have been and administer IV fluids as prescribed before epidural
associated with the concurrent administration of the catheter insertion. Rationale: IV access ensures that medi-
NSAIDs, ketorolac, and anticoagulants.12,21 Assessment of cations can be given quickly if needed. The administration
sensory and motor function must be regularly performed of IV fluids may decrease hypotension that may occur
during epidural analgesia for all patients. during epidural infusions.4,13
• Obtain the patient’s vital signs. Rationale: Baseline data • Reassure the patient. Rationale: Anxiety and fears may
are provided. be reduced.
• Assess the patient’s pain. Rationale: Baseline data are
provided.
Procedure for Pain Management: Epidural Catheters (Assisting With Insertion and
Initiating Continuous Infusion)
1. HH
2. PE Physicians, advanced practice nurses,
should apply personal protective
equipment (e.g., face masks with
eye shields). All physicians,
advanced practice nurses, and other
healthcare professionals present
during epidural insertion should
wear a hat and mask. The
individual performing the procedure
should wear hat, mask, sterile
gown, and gloves.
3. Obtain the prescribed epidural The medication should be prepared All epidural solutions are
medication infusion from the with aseptic technique by the preservative-free to avoid neuronal
pharmacy. pharmacy with laminar flow or injury.30
prepared commercially to decrease
the risk for an epidural
infection.23,27,28
Initiating Continuous Infusion)—Continued
4. Connect the epidural tubing to Removes air from the infusion
the prepared epidural medication system.
infusion and prime the tubing.
5. Ensure that the patient is in Facilitates ease of insertion of the Movement of the back may inhibit
position for catheter placement. epidural catheter. Both positions placement of the catheter.
Assist with holding the patient in open up the interspinous spaces,
position (lateral decubitus knee-to- aiding in epidural catheter insertion
chest position or leaning over (see Fig. 105-2).
bedside table) and consider
preprocedure analgesia or
sedation, if necessary (Fig. 105-2).
6. Assist as needed with the Reduces the transmission of The choice of povidone-iodine or
antiseptic preparation of the microorganisms into the epidural chlorhexidine as an antiseptic agent
intended insertion site. space. for neurological procedures is
(Level C*) controversial. Both should be
allowed to dry completely. Studies
suggest chlorhexidine is
neurotoxic.10,18,24
7. Assist if needed with draping the Aids in maintaining sterility.
patient with exposure only of the
insertion site.
8. Assist the physician or advanced Provides needed assistance.
practice nurse as needed as the
epidural catheter is placed.
Pillow between
legs and knees
drawn up to chest
Hips vertical Head in a
comfortable
position
Back straight and right Shoulders vertical

up to edge of table
L3
Iliac
L4
crest
L5
Figure 105-2 Patient positioned for catheter placement. This figure shows two positions patients
can assume for the epidural catheter placement procedure. (From Pasero C, McCaffery M: Pain
assessment and pharmacologic management, St. Louis, 2011, Elsevier.)
9. Monitor the patient as the To confirm proper placement of the An immediate increase in heart rate
physician or advanced practice epidural catheter indicates the catheter has
nurse administers 2–3 mL of 1% inadvertently penetrated an epidural
lidocaine containing 1:200,000 vein. If this occurs the physician,
epinephrine as a test dose. advanced practice nurse, or other
healthcare professional inserting the
catheter should withdraw the
catheter slightly or remove it and
insert a new catheter.29
10. After the epidural catheter is Reduces the incidence of infection. Use of a transparent dressing allows
inserted, assist as needed with for ongoing assessment of the
application of a sterile, occlusive insertion site for infection, leakage,
dressing. or dislodgment.
11. Secure the epidural filter to the Avoids disconnection between the
patient’s shoulder with gauze epidural catheter and filter. Gauze
padding. padding prevents discomfort and
skin pressure from the filter.
12. The physician or advanced Facilitates a therapeutic level of If a local anesthetic is used for the
practice nurse administers a bolus analgesia and confirms correct bolus, monitor the blood pressure
dose of medication. catheter position.9 frequently, with assessment for
possible hypotension. Some
analgesia medications (e.g.,
morphine) may take up to 1 hour to
be effective.13,14,30
13. Connect the prescribed Prepares the infusion system.
medication infusion system.
14. Initiate therapy:
A. Place the system in the No other solution or medication (e.g., Responses to epidural analgesia vary
epidural pump or PCEA pump antibiotic or total parenteral individually, and epidural analgesia
and set the rate and volume to nutrition) should be given through is tailored according to individual
be infused. the epidural catheter.33 responses.
B. Attach an “Epidural only” Inadvertent intravenous administration
label to the epidural tubing. of some epidural solutions can
Use a portless system.4,33 cause serious adverse reactions,
(Level E*) including hypotension and
cardiovascular collapse.11,28
C. Lock the key pad on the This is an important safety feature.
epidural or PCEA pump.
15. Assess the effectiveness of the Identifies the need for additional pain
analgesia. Follow institutional medication and interventions.
standards for assessing pain.
A. Determine the pain score. Tolerable pain scores should be
reported at rest, and very little pain
should be experienced with deep
breathing, coughing, and
movement.
B. Assess the level of the The ideal epidural block should be
epidural block with ice or an just above and just below the
alcohol swab.6 surgical incision or the trauma site
(see the dermatomes described in
Fig. 105-3).

Figure 105-3 Dermatomes. Segmental dermatome distribution of spinal nerves to the front, back,
and side of the body. Dermatomes are specific skin surface areas innervated by a single spinal nerve
or group of spinal nerves. Dermatome assessment is done to determine the level of spinal anesthesia
for surgical procedures and postoperative analgesia when epidural local anesthetics are used. C,
Cervical segments; T, thoracic segments; L, lumber segments; S, sacral segments; CX, coccygeal
segment. (From Patton KT, Thibodeau GA: Anatomy and physiology, ed 9, St. Louis, 2016,
Elsevier.)
16. Remove PE and sterile equipment Removes and safely discards used
and discard used supplies in an supplies.
17. HH
Procedure for Epidural Catheter (Bolus Dose Administration) Without a

Continuous Infusion
1. HH
2. PE
3. Boldly label the epidural catheter Reduces the risk for administration of
used for intermittent bolus medication into intravenous lines.
dosing (suggest color coding).4,33
(Level E*)
Procedure for Epidural Catheter (Bolus Dose Administration) Without a Continuous

Infusion—Continued
4. Verify the correct medication Before performing a procedure, the
with the five rights of medication nurse should ensure that the correct
administration. medication is being administered.
5. Prepare the bolus dose as Use only preservative-free solution to Do not use multidose vials because
prescribed. dilute assuring a decreased risk of they increase the risk for
neuronal injury.4,13 contamination and the risk for an
epidural infection.4,14
6. Prepare and cleanse the epidural Do not use an alcohol-based Preparations with alcohol are
port with an antiseptic agent. preparation. Use aqueous neurotoxic to the epidural space.
(Level C*) chlorhexidine or povidone-iodine. The choice of povidone-iodine or
chlorhexidine as an antiseptic agent
is controversial. Both should be
allowed to dry completely. Studies
suggest chlorhexidine is
neurotoxic.10,18,14
7. Use aseptic technique to Administers the medication for Follow state and institutional
administer the epidural bolus: injection. guidelines as to who is able to
A. Connect an empty syringe to provide bolus doses.
the catheter port.
B. Aspirate the epidural catheter, If blood is obtained, the epidural Administration of epidural
limited by the amount allowed catheter may have migrated into an medications into the epidural vein
by institutional policy. If epidural vessel. An amount of only or into the subarachnoid space may
blood is aspirated, do not 1–2 mL of blood may be result in increased sedation,
reinject the aspirate. Do not inconclusive because any blood respiratory depression, hypotension,
inject the medication. Notify from an epidural vein may have and bradycardia.
the physician or advanced mixed with blood from the trauma
practice nurse. If clear fluid is of inserting the catheter. If more
obtained, it may be CSF. Do than 3 mL is aspirated, the catheter
not reinject the aspirate. Do is most likely in an epidural vein.30
not inject the medication. If 5 mL or more of CSF is obtained,
Notify the physician or the catheter may have migrated into
advanced practice nurse.6,9,19,30 the subarachnoid space.30
C. Connect the syringe with the Prepares for the injection.
bolus medication to the
catheter port.
D. Administer the medication Some resistance will be felt because Excessive pressure may be more
slowly. Note: If excessive the diameter of the epidural space pronounced if the epidural catheter
pressure occurs, assess for is small and the epidural filter is in is placed at the lumbar dermatome
kinks in the catheter or place. as opposed to the thoracic
reposition the patient. dermatome.
If resistance continues to impair
administration of a bolus dose,
contact the physician or advanced
practice nurse.
8. Assess the effectiveness of the Identifies need for pain interventions. Report continued pain despite pain
medication. Follow institutional Pain should be relieved or interventions.
standards for assessing pain. decreased.
9. Monitor vital signs. An epidural bolus may cause Report untoward decreases in blood
hypotension, bradycardia, pressure, heart rate, respirations,
respiratory depression, or increased oxygen saturation, and sedation.
sedation.11,28

Procedure for Epidural Catheter (Bolus Dose Administration) Without a Continuous

Infusion—Continued
10. Monitor for increased motor and Allows for the early identification of
or sensory block, and signs and signs and symptoms of local
symptoms of local toxicity related anesthetic toxicity which include
to the epidural medications. lightheadedness, tinnitus, metallic
taste, visual disturbances, perioral
numbness loss of consciousness,
seizure, arrhythmia, and asystole.4
supplies.
12. HH
Procedure for Assisting With Removal of the Epidural Catheter

1. HH
gear (e.g., face masks with eye
shields), and sterile gloves may be
worn by the physician, advanced
professional removing the catheter.
3. Assist the physician or advanced Facilitates catheter removal.
practice nurse as needed with
removal of the catheter.
4. Assist if needed with applying a Reduces contamination by
sterile occlusive dressing. microorganisms.
5. Remove personal protective Removes and safely discards used
equipment and discard used supplies.
supplies in an appropriate
receptacle.
6. Assess neurological status, pain, Motor or sensory loss in the Assess for a change in sensory or
and insertion site after removal of extremities may be an early motor function in extremities,
the epidural catheter. warning sign of an epidural abscess sudden onset of back pain with
or hematoma or may indicate an increasing motor weakness, and
excessive dose of a local loss in bladder and bowel function.
anesthetic.26,27
An epidural hematoma is a rare but
serious complication; if undetected,
it may result in permanent
paralysis.14,16,22,32
A. Monitor sensory and motor Identifies potential adverse effects of
status of lower extremities and epidural analgesia.
ability to void up to 24 hours
after removal of the catheter
(see Fig. 105-3).2,8,14,16
B. Monitor insertion site for Identifies adverse effects of epidural
drainage or infection. analgesia such as infection.
C. Continue to assess pain. Identifies need for ongoing
interventions to manage pain.
7. HH

• The epidural catheter is inserted into the epidural space • Inability to insert the epidural catheter
• Pain is decreased and maintained at a tolerable level • Suboptimal pain relief13
• The patient experiences minimal sedation • Oversedation or drowsiness11,28
• The patient experiences minimal numbness and no • Opioid-induced respiratory depression or hypoxia11,28
motor loss in the limbs • Hypotension14,19,30
• Hemodynamically stable • Motor blockade of limbs; lower extremity
• No opioid-related respiratory depression or decreased weakness13,19,30
respiratory blockade from local anesthetic affecting the • Sensory loss in the limbs13,19,30
diaphragm or ancillary muscles required for inspiration • Patchy block (e.g., uneven pain relief)13
and expiration • Unilateral block (e.g., pain relief on the contralateral
side of the body only)13
• Nausea and vomiting8,14,17,28
• Pruritus1,8,14,17,28
• Urinary retention1,8,14,16,28
• Accidental dural puncture into the subarachnoid
space13,33
• Dural puncture headache13,33
• Epidural catheter tip migration into a vessel or
adjacent structure13
• Redness or signs of skin breakdown at pressure area
sites (e.g., sacrum, heels) from decreased sensation
• High epidural block— epidural local anesthetic block
above the thoracic fourth vertebrae (T4)14
• Total spinal blockade13
• Occlusion of epidural catheter13
• Accidental epidural catheter dislodgment13
• Dressing disruption exposing insertion site
• Leakage from the epidural catheter insertion site13,33
• Cracked epidural filter
• Local anesthetic toxicity13
• Anaphylaxis14
• Epidural hematoma8,25,26,28
• Epidural abscess8,25,27,28
• Local erythema or drainage at insertion site32
• Nerve or spinal cord injury13
• Accidental connection of the epidural solution to the
intravenous fluids33
• Accidental connection of intravenous fluids to the
epidural catheter.
• Local anesthetic toxicity13,14
• Cardiopulmonary arrest13

interventions.
1. Assess the patient’s level of pain Describes patient response to pain • Moderate to severe pain scores
with use of a pain scale.9,14,30 The therapy. A low pain score is
frequency of assessments is expected both at rest and during
determined by institutional movement.
standards. Record the patient’s Analgesic goal is safe, steady pain
subjective level of pain, with use control at a low level that is
of the institution’s standard pain acceptable to the patient.
assessment tool.

2. Assess the patient’s level of Sedation precedes opioid-related • Increasing sedation and drowsiness
sedation9,14,30 with use of the respiratory depression. A sudden or sudden change in sedation scale
institution’s standard assessment change in sedation scale may
scale and frequency standard. indicate that the epidural catheter
has migrated into an epidural blood
vessel or the intrathecal space.11
3. Assess respiratory rate the first 20 Provides data for diagnosis of • Increasing respiratory depression
minutes after administration of respiratory depression. or sudden change in respiratory
the epidural medication, and/or rate combined with increasing
bolus then every 1–2 hours and somnolence
as needed (prn).11,14,28 (Level D*)
4. Assess heart rate14,28 with vital Tachycardia may indicate a condition • Change in heart rate
signs every 2 hours, then every 4 such as shock. Bradycardia may • Abnormal heart rate
hours when stable. indicate opioid overmedication and • Abnormal cardiac rhythm
sympathetic blockade by the local
anesthetic.13,19
5. Assess blood pressure with vital Epidural solutions that contain a local • Hypotension
signs every 2 hours, then every 4 anesthetic may cause peripheral and
hours when stable. If hypotension venous dilation, providing a
occurs: “sympathectomy.”14 The
A. Turn off the epidural infusion; hypotensive effect of a local
notify the physician, advanced anesthetic is most common when a
practice nurse, pain relief patient’s fluid status is decreased.
service. Epidural analgesia may not be the
B. Place the patient in a supine, sole cause of hypotension but may
flat position. reveal hypovolemia.
C. Administer IV fluids as
protocol.
D. Administer vasopressor
medications as prescribed.14,28
E. Use caution when raising
patient from lying to sitting or
sitting to standing positions.31
6. Monitor the infusion rate with Ensures that the medication is
vital signs. Ensure that the administered safely.
control panel is locked if using
the volumetric infuser or ensure
that the PCEA program is locked
in via key or code access.
7. Monitor oxygen saturation and Assesses oxygenation. A decrease in • Oxygen saturation <93% or a
end-tidal carbon dioxide if oxygen saturation is a late sign of decreasing trend in oxygenation
prescribed or continuously opioid oversedation and should not • Note: Decreased oxygen saturation
as per institutional policy.11,14 be solely relied on to detect is a late sign of opioid
(Level E*) oversedation. oversedation and should not be
solely relied on to detect
oversedation.
8. Obtain the patient’s Fever may signify an epidural space • Temperature >101.3°F (38.5°C)
temperature11,14 every 4 hours; infection or systemic infection that
assess more often if febrile. is a potential risk when an epidural
(Level E*) catheter is in place.14,17,27,32

9. Assess the epidural catheter site Identifies site complications and • Redness
every 4 hours or according to infection. An epidural abscess is a • Tenderness or increasing diffuse
established institutional rare but serious complication. back pain
standards.14,32 Patient recovery without • Pain or paresthesia during epidural
neurological injury depends largely injection induration
on early recognition.14,17,27,32 • Swelling or presence of exudate
10. Monitor ability to void and Provides data regarding urinary • Urinary retention
ability to completely empty retention and possible early signs of • Change in bladder function
bladder.1,8,14 (Level E*) epidural abscess or epidural • Lack of urination for >6–8 hours
hematoma.8,14,26,27,32
11. Monitor for sensory and or motor Motor or sensory loss in the • Change in sensory or motor
loss (e.g., leg numbness or extremities may be an early function in extremities
inability to bend knees) at least warning sign of an epidural abscess • Sudden onset of back pain with
every 4 hours and prn (see Fig. or hematoma or may indicate an decreasing motor weakness
105-3).2,8,14,16 (Level E*) excessive dose of a local • Loss in bladder and bowel function
anesthetic.26,27 An epidural (e.g., incontinence)
hematoma is a rare but serious
complication; if undetected, it may
result in permanent
paralysis.14,16,17,32
12. Assess for ringing in the ears, If a local anesthetic is used in the • Ringing in the ears, tingling
tingling around lips, or a metallic epidural solution, ringing in the around the lips, or a metallic taste
taste.5,13,14 (Level E*) ears, tingling around the lips, or a
metallic taste may indicate
impending local anesthetic
toxicity.5,13,14
13. Monitor and check skin integrity If a local anesthetic is used in the • Altered skin integrity
of the sacrum and the heels every epidural solution, check for • Increasing redness or blistering of
2 hours and as needed. Change pressure points and decubitus the skin on the sacrum or heels
the patient’s position as needed. ulceration (patient may have
sensory loss in lower limbs).13,19,30
14. Change the epidural catheter Provides an opportunity to cleanse the • Swelling
insertion site dressing as area around the catheter and to • Site pain
prescribed or if soiled, wet, or assess for signs and symptoms of • Redness
loose. Call physician or advanced infection that may indicate early • Leakage of epidural solution or
practice nurse if catheter site is signs of an epidural abscess.14,27 drainage
exposed. Follow institutional
standards.
15. Assess for the presence of nausea Antiemetics may need to be • Unrelieved nausea and vomiting
or vomiting.8 administered; the medication may • Note: Nausea and vomiting may be
need adjustment (e.g., opiates may a sign of severe hypotension.
need to be decreased or stopped if
nausea and vomiting are not well
controlled).


16. Assess for the presence of Epidural opiates may cause itching. • Itching
pruritus.2,8 Medications such as antihistamines • Redness
may cause sedation and are • Rashes
ineffective for spinally mediated
itching. Low-dose opioid
antagonists may be necessary to
relieve pruritus. Small doses of
naloxone (e.g., 0.04 mg) are
effective for pruritus without
reversing the analgesia.13,19
Diphenhydramine or hydroxyzine can
also be effective for itching
associated with dehydration but
may cause increased sedation.13,19
17. Label the epidural pump and May aid in minimizing the risk for • Infusion of IV fluid into the
tubing33 and consider placing the mistaking the epidural infusion for epidural space
epidural pump on one side of the an IV infusion system. • Infusion of epidural solution into
patient’s bed and all other pumps Cardiopulmonary arrest and the IV
on the other side of the bed. seizures may occur if the epidural
Consider the use of a different solution is infused intravenously.13
colored label for the epidural
pump and the tubing to
differentiate it from pumps and
tubing for intravenous fluids and
medications.
Documentation
• Patient and family education • Vital signs and oxygen saturation11
• Completion of informed consent • Epidural analgesic medication and medication
• Preprocedure verifications and time out concentration being infused and infusion rate per
• Any difficulties associated with insertion hour
• Type of dressing used • Bolus dose administration and patient response after
• Confirmation of epidural catheter placement (e.g., bolus dose, including effectiveness of pain relief
decrease in blood pressure, demonstrable block to ice; • Occurrence of unexpected outcomes or side effects
see Fig. 105-3) • Nursing interventions taken
• Site assessment • Pump settings when programmed for PCEA
• Preintervention and serial pain assessment, including • Medication concentrations, continuous infusion rate,
levels of motor and sensory blockade (documented on bolus dose, lockout interval, limit for 1 or more hours
an appropriate flow chart at regular intervals; see Fig. according to institutional standards
105-3) and effectiveness of interventions30 • Pain assessment, interventions, and effectiveness
• Sedation score assessment

105 Epidural Catheters: Assisting with Insertion and Pain Management 940.e1
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PROCEDURE
106
Patient-Controlled Analgesia
Lorie Ann Meek
PURPOSE: Intravenous patient-controlled analgesia empowers patients to
manage their pain by allowing them to administer smaller analgesic doses more
frequently. Nurses are responsible for ensuring appropriate patient selection,
maintaining the intravenous delivery system, and ensuring that patients are able to
safely meet their own needs for pain management through frequent assessment
and patient education.
PREREQUISITE NURSING PCA may be used for both acute and chronic pain,26,30
KNOWLEDGE although IV administration of opioids is most often used
for acute pain.26
• Pain is defined as an “unpleasant sensory and emotional • IV PCA can be an effective method of pain relief for
experience that arises from actual or potential tissue pediatric and adult patients.16,27,32,38 Table 106-1 lists
damage” by the International Association for the Study of dosing guidelines. PCA is not recommended in situations
Pain20,29 According to the National Institutes of Health, in which oral opioids can readily manage pain (e.g.,
more Americans are affected by pain than by diabetes, chronic and relatively stable cancer pain).26
heart disease, and cancer combined.29 • IV PCA can be administered as a continuous (basal) infu-
• The most common reason for unrelieved pain in hospitals sion along with patient-initiated boluses or as patient-
is the failure of staff to routinely and adequately assess initiated boluses exclusively. Use caution with continuous
pain and pain relief.2 infusion because of accumulation of the medication.1
• Additional perceived barriers to adequate pain manage- • Patient assessment at frequent, regular intervals7,14 (at
ment are poor pain assessment, patient reluctance to report least every 4 hours) should include an evaluation of the
pain and take analgesics, and physician reluctance to pre- patient’s vital signs, sedation level with a valid and reli-
scribe opioids.2 able scale, pain level with a valid and reliable scale, and
• Tables 106-1 and 106-2 list guidelines for dosing and common opioid side effects, such as pruritus, nausea,6
considerations for selection of opioids. constipation, and urinary retention.21 Table 106-2 lists side
• Unrelieved postoperative pain may result in clinical and effects associated with PCA opioids. Patients need more
psychological changes, an increase in morbidity and frequent assessments during the first 24 hours after initia-
mortality, an increase in costs, and a decrease in quality tion of IV PCA and during the night.9,10,18,21
of life. Negative clinical outcomes related to ineffective • PCA pump settings should be confirmed at regular inter-
pain management for patients after surgery include deep vals.9,10,18,21 See Box 106-1 for common terms used
vein thrombosis, pulmonary embolism, coronary isch- when administering patient-controlled analgesia. Adverse
emia, myocardial infarction, pneumonia, poor wound events during IV PCA may include sedation, respiratory
healing, impairment of the immune system, insomnia, depression, and hypoxemia. Opioid antagonists should be
readmissions, and negative emotions.2,3,32 Unrelieved pain readily available.
may delay recovery and prolong hospital stays.2,32,33 • Adjuvant medications can be used to improve pain man-
• The Agency for Healthcare Research and Quality (AHRQ) agement,6,41 such as nonsteroidal antiinflammatory drugs
urges healthcare professionals to accept the patient’s self- (NSAIDs)1 and cyclooxygenase (COX-2) inhibitors1,21,29,40
report as “the single most reliable indicator of the exis- or to improve opioid side effects.22,27,28
tence and intensity” of pain.2 • The Joint Commission does not support PCA by proxy
• Although pain is prevalent, underdiagnosed and under- (someone other than the patient pushing the PCA button)
treated populations include racial and ethnic minorities, on the recommendation of the Institute of Safe Medication
people with lower levels of education and income, women, Practices (ISMP). According to ISMP, patients have expe-
older adults, military veterans, postsurgical and cancer rienced oversedation, increased respiratory depression,
patients, and patients nearing the end of life.17 and death from PCA by proxy.10,18,37,38 A safety feature of
• Studies and meta-analyses have shown that patients PCA therapy is that an oversedated patient cannot press
receiving patient-controlled analgesia (PCA) report an the button to obtain additional pain medication.
increased satisfaction level with pain management and an • PCA by an authorized user (typically nurse or designated
improvement in pain control.3,5,8,19,23,35,38 Intravenous (IV) family member of patient) is a potential alternative to
941
TABLE 106-1 Guidelines for Patient-Controlled Intravenous Opioid Administration for

Opioid-Naive Adults and Children With Acute Pain
Adults >50 kg
Usual Starting Usual Dose Typical Starting Usual Lockout
Drug* Dose After Loading Range Lockout (min) Range (min)
Morphine (1 mg/mL) 1.0 mg 0.5–2.5 mg 6 5–10
Hydromorphone (0.2 mg/mL) 0.2 mg 0.05–0.4 mg 6 5–10
Fentanyl (50 mcg/mL) 20 mcg 10–50 mcg 6 5–8
*Typical concentrations are listed in parentheses.

Children <50 kg
Usual
Usual Starting Lockout
Usual Starting Usual Dose Lockout Range Usual Basal
Drug Dose After Loading Range (doses/h) (min) Rate
Morphine (1.0 mg/mL) 0.02 mg/kg/dose 0.01–0.03 mg/kg 5 6–8 0.0–0.03 mg/kg/hr
Hydromorphone (0.2 mg/mL) 0.003–0.004 mg/kg/dose 0.003–0.005 mg/kg 5 6–10 0.00–0.004 mg/kg/hr
Fentanyl (50 mcg/mL) 0.5–1.0 mcg/kg/dose 0.5–1.0 mcg/kg/dose 5 6–8 0.0–0.5 mcg/kg/hr
From Miaskowski C, Blair M, Chou R, et al: Principles of analgesic use in the treatment of acute pain and cancer pain, ed 6, Glenview, IL, 2008, American Pain Society.
TABLE 106-2 Patient-Controlled Analgesia: Considerations in Opioid Selection

Cautions/
Opioid Side Effects Advantages Disadvantages Contraindications
Morphine Nausea Vast clinical experience Slow onset: 15 min Allergy (use fentanyl)
Sedation Less expensive than other Histamine release Renal dysfunction
Pruritus opioids Active metabolite (M6G) Hepatic dysfunction
Reduced peristalsis accumulates in renal patients Asthma (histamine release)
Respiratory depression and causes excessive sedation
and other side effects.
Hydromorphone Nausea Faster onset than morphine More expensive than morphine Allergy (use fentanyl)
(Dilaudid) Sedation Less sedation Less clinical experience than High doses can result in
Pruritus No active metabolites morphine excitation with impaired
Reduced peristalsis Higher potential for abuse renal dysfunction
Respiratory depression
Fentanyl Nausea Rapid onset More expensive than morphine Allergy
(Sublimaze) Sedation No active metabolites Less clinical experience than Rapid administration of drug
Pruritus Less constipation as with morphine can result in “stiff chest,”
Reduced peristalsis compared with morphine Short duration of action making ventilation difficult
Respiratory depression
From Institute for Safe Medication Practices: Patient-controlled analgesia: Making it safer for patients, Horsham, PA, 2006, Institute for Safe Medication Practices.
PCA by proxy. Healthcare institutions that use PCA by an • Patients with an increased risk for complications during
authorized user need to have the following in place before IV PCA use include those with:
this practice is initiated10,11,18,37,39: ❖ Age more than 61 (greater incidence of desatura-
❖ Policies that guide the practice, including the patient tion)21,31,38
population ❖ Morbid obesity (greater incidence of desatura-
❖ Definition of PCA by an authorized user tion)21,31,34,35
❖ Education plan for the authorized user ❖ Sleep apnea, sleep disorder or asthma, and
❖ Documentation of the authorized user and education snoring10,19,21,34,35,38
given ❖ Concurrent medications that potentiate opiates (e.g.,
• Serious adverse events from errors with opioids include sedation)10,18
25
“failure to control pain, oversedation, respiratory depres- ❖ Impaired organ function
sion, seizures and death.”13,14 ❖ No recent opioid use
21
106 Patient-Controlled Analgesia 943
• PCA is available in various routes, including IV, epidural

BOX 106-1 Key Terms for Patient-
(patient-controlled epidural analgesia [PCEA]; see Proce-
Controlled Analgesia dure 105), subcutaneous, peripheral nerve catheter (see
• Basal rate: The amount of analgesic administered continuously. Procedure 107), oral, intranasal, and transdermal.24,26 The
• Breakthrough dose: A bolus dose administered by the nurse, focus of this procedure is IV PCA.
similar to a loading dose when pain is inadequately managed • An interdisciplinary team approach is beneficial for pain
with the current PCA settings. management.22
• Cumulative dose limit: The predetermined maximum drug
amount that can be delivered over either 1 or more (usually 4) EQUIPMENT
hours.
• Demand or PCA dose: The amount of drug administered each • PCA pump
time the patient activates the pump. • PCA tubing with antisiphon valve (may also include a
• Loading dose: A bolus dose given before initiation of PCA plunger for insertion into PCA medication syringe barrel)
therapy, usually higher than the dose administered when the • IV pump
patient activates the pump. • IV tubing
• Lockout interval: Predetermined period during which the patient • Prescribed medication (may be in a syringe, bag, or
cannot initiate doses. cassette)
• Antiseptic pad
From Miaskowski C: Patient-controlled modalities for acute postoperative pain • Nonsterile gloves
management, J Perianesth Nurs 20:255-267, 2005; Miaskowski C, Bair M, Chou
• Electrocardiogram (ECG) and blood pressure monitoring
R: Principles of analgesic use in the treatment of acute pain and cancer pain, ed
6, Glenview, IL, 2008, American Pain Society; Sharma S, Balireddy RK,
equipment
Vorenkamp KE, et al: Beyond opioid patient-controlled analgesia: A systematic • Pulse oximetry equipment
review of analgesia after major spine surgery, Reg Anesth Pain Med, 37:79-98, • Normal saline solution or other compatible IV fluid
2012. Additional equipment, to have as needed, includes the
following:
❖ Postsurgery, especially if upper abdominal or thoracic, • Emergency medications, including an opioid reversal
and longer times receiving anesthesia21 agent to reverse oversedation or respiratory depression
21
❖ Increased opioid requirement • Bag-valve-mask device and oxygen
21
❖ Preexisting cardiac and pulmonary disease • End-tidal carbon dioxide monitoring equipment
• Careful patient selection is imperative for effective pain
management.13,14,21 PATIENT AND FAMILY EDUCATION
• Patient assessment for management of pain helps prevent
adverse events.1 • Review an appropriate pain rating scale with the patient.
❖ Screen for those with increased risk of complications. The physician, advanced practice nurse, or other health-
❖ Assess the patient’s analgesic use and abuse potential. care professional and patient need to establish a mutually
• Individualize pain treatment plans, and use multimodal agreeable pain level goal. Rationale: Review ensures that
strategies (pharmacology, nonpharmacology, psychosocial the patient understands the pain rating scale and enables
support, and complementary and behavioral approaches).29,38 the nurse to obtain a baseline assessment. Establishing a
• Extra precautions to prevent complications, such as a pain level goal allows the physician, advanced practice
short-term trial to determine the patient’s response and nurse, or other healthcare professional to know an accept-
sufficient time for assessment of patient and pain able goal for pain management.
• Patients who may be poor candidates for PCA include the • Review the principles of PCA use with the patient and
following: family members.1,14 If a basal rate has been prescribed,
❖ Anyone with cognitive abilities that prohibit under- inform the patient that pain medication will be infusing at
standing and following directions for IV PCA (e.g., all times. Explain that if the pain is not relieved with the
patients with a decreased level of consciousness or steady dose, extra medicine can be delivered by pressing
developmental disabilities)10,11,18,22 the patient bolus button. Be sure the patient understands
❖ Anyone without the physical ability to push the PCA what the lockout interval is. If the patient’s pain needs
button that controls the dose administration10,11,18,22 are not met, an assessment of the therapy will be com-
❖ Anyone with a psychological reason that prohibits pleted and the physicians, advanced practice nurses, or
using the PCA button for pain management (e.g., psy- other healthcare professionals may change the dosage or
chological disability, refusal to operate the PCA admin- therapy to meet those needs. Rationale: This review may
istration button)10,11,18 reduce anxiety and preconceptions about PCA use.
• A number of medication errors have been reported • IV PCA is designed for the patient to administer the pain
with IV PCA. Factors associated with errors include medication. The patient should be the only one to deliver
improper patient selection, inadequate monitoring, inad- the demand dose. The Institute for Safe Medication Prac-
equate patient education, medication product mix-ups, tices (ISMP), the American Society for Pain Management
programming errors, PCA by proxy, inadequate medical Nursing (ASPMN), and The Joint Commission do not
and nursing staff education, prescription errors, and PCA support PCA by proxy because of adverse events, such
pump design flaws.10,13–15,18 as oversedation, respiratory depression, cardiopulmonary
arrest, and deaths, that have occurred with PCA by • Assess the patient’s level of sedation with the use of a
proxy.10,11,18,19,39 Rationale: The patient should remain sedation scale.7,21,29 Rationale: Sedation generally pre-
alert enough to administer his or her own dose. A safe- cedes respiratory depression; a patient who is less alert
guard to oversedation is that a patient cannot administer should be closely monitored if PCA is prescribed.
additional medication doses if sedated. • Review the patient’s medication allergies. Rationale:
• Instruct the patient and family members to report common Review of medication allergies before administration of a
side effects, such as oversedation, pruritus, nausea or new medication decreases the chances of an allergic
vomiting, constipation, or urinary retention. Rationale: reaction.
Side effects are identified by the patient and family.
Patient Preparation
PATIENT ASSESSMENT AND • Verify that the patient is the correct patient using two
PREPARATION identifiers. Rationale: Before performing a procedure, the
Patient Assessment for the intended intervention.
• Assess the patient’s ability to properly use IV PCA as a • Ensure that the patient understands the teaching. Having
method for pain management. Rationale: The patient will the patient demonstrate the procedure helps evaluate
not achieve adequate pain management if unable to use patient education. Answer questions as they arise, and
the PCA. reinforce information as needed.1 Rationale: Understand-
• Assess the patient’s pain and document the intensity, loca- ing of previously taught information is evaluated and
tion, and characteristics.2,28 Rationale: A baseline assess- reinforced.
ment permits an accurate evaluation of the efficacy of • Obtain IV access and ensure patency of the IV. Rationale:
the PCA. Analgesia is delivered intravenously.
Procedure for Initiating Intravenous Patient-Controlled Analgesia

1. HH
2. PE
3. Review the prescription for the Ensures correct PCA prescription is Ensure coverage for common side
PCA, including the medication, administered to patient. effects, such as pruritus,
concentration, basal rate, loading constipation, or nausea.
dose, demand PCA dose, lockout Follow institutional standards.
interval, cumulative dose limit A medication such as naloxone may
(over 1 or more hours), and basal be prescribed. Naloxone is an
rate as prescribed.10,18,33 opioid reversal agent that is used to
reverse oversedation or respiratory
depression.
Ensure that the patient is physically,
psychologically, and cognitively
able to use the PCA for pain
management.
The use of a basal rate is
controversial and may result in
oversedation in patients who are
opioid naive.26
4. Check for medication allergies or Prevents allergic or adverse reactions.
sensitivities. Check for
medications that may potentiate
the opioid and for adverse effects
of the opioid.10,19 (Level E*)
5. Attach the antisiphon valve of the Prepares the equipment. Many PCA pumps use syringe
tubing to the medication syringe. delivery of the medication. Other
PCA pumps use bags and cassettes
rather than syringe delivery.
Procedure for Initiating Intravenous Patient-Controlled Analgesia—Continued

6. Purge the PCA tubing of air. Removes air from the system. If the injector is the plunger of the
syringe, attach the antisiphon valve
on the tubing to the syringe and
manually purge.
The PCA may offer the option of
purging via the PCA pump before it
is attached to the patient.
7. Insert the syringe into the PCA Prepares the PCA system. Place the syringe barrel into the pump
pump by first placing the bottom within the area provided by the
of the syringe in the lower upper and lower flanges of the
flanges of the cradle and then cradle. If a cassette system is used
place the top portion of the unlock the system and place the
syringe in place. If using a new cassette into the bottom of the
cassette system, snap and lock the infusion pump where it can be
cassette in place on the infusion snapped into place and then locked.
pump.
8. Position the medication syringe Ensures ready identification of the
or cassette so that the name and medication.
concentration of the drug and the
volume markings are visible.
9. Secure the syringe in the cradle. Ensures proper positioning of the
syringe.
10. Occlude the PCA tubing with the Contains the medication until the
slide clamp. infusion begins.
11. Insert the IV tubing of the Prepares the infusion pump.
continuous IV solution into the
IV pump.
12. Connect the IV tubing of the Prepares the system and prevents an
continuous IV solution to the air bolus.
lowest Y-site on the PCA
medication tubing, and ensure the
tubing from Y-site to the end of
the PCA medication tubing is
purged with the IV fluid.
13. Program the PCA pump with the Prepares the system.
medication name and
concentration, the loading dose
(as prescribed), PCA dose,
lockout interval, cumulative dose
limit (over 1 or more hours), and
basal rate (as prescribed).
14. Independently verify the patient’s Adverse events can occur as a result Independent verification of patient
identification, medication and of programming errors. identification, medication and
medication concentration, PCA concentration, PCA pump settings,
pump settings, and tubing4,10,15,18 and the line attachment before use
with another physician, advanced and before pump refill or
practice nurse, or other healthcare programming change may lessen
professional. (Level E*) the risk of programming error.10,15,18

Procedure for Initiating Intravenous Patient-Controlled Analgesia—Continued

15. Program the compatible IV Ensures the delivery of the prescribed The medication’s basal rate combined
solution at a rate to provide not medication. Highly concentrated with any other IV fluids should
less than the minimal acceptable medications, such as total the prescribed hourly IV rate.
rate for a continuous IV solution hydromorphone, may be If the PCA is programmed for bolus
per institutional standards. administered in bolus doses of dosing only, set the IV solution on
<1 mL, but do not reach the patient no less than the minimal rate for
quickly through most IV tubing the maintenance IV.
without a continuous IV infusion.
Some PCA pumps do not use
continuous IV solution; however,
the PCA tubing is much smaller,
increasing the likelihood that the
medication will reach the patient
although the infused volume is
small.
16. Cleanse the IV catheter cap with Connects the PCA to the IV access. Verify patent IV access before
appropriate antiseptic cleanser connecting or infusing medication.
and connect the PCA tubing Extension tubing may result in
directly to the patient’s IV line.36 errors in the medication delivery
Release the slide clamp from the and should not be used.
PCA tubing. Initiate continuous
IV delivery and PCA therapy.
17. Label the PCA pump and the IV Ensures quick and clear identification
infusion pump. of IV fluids and PCA medications.
18. Label the IV tubing and the PCA Ensures identification of IV fluids and
tubing. PCA medications infusing via each
IV tubing.
19. Secure the PCA tubing at two Prevents accidental removal of the IV.
points of tension.
supplies in an appropriate supplies.
receptacle.
21. HH

• Pain is minimized or relieved (at an acceptable level • Extravasation
for the patient) • Oversedation or respiratory depression
• No unmanaged side effects • Loss of IV access and interruption of medication
• Continuous IV access delivery
• Pain not relieved

interventions
1. Ensure that the medication is New infusions may precipitate • Extravasation
infusing properly through the IV. extravasation; an IV catheter may
become dislodged through patient
movement.
2. Assess the patient’s pain and level Monitors effectiveness of therapy; • Pain is unrelieved
of sedation.7,10 Follow institutional identifies need for adjustment. • Altered level of sedation
standards. Institutional assessment policies
should take into account the
expected.

3. Monitor the patient’s vital signs, Determines the presence of potential • Change in sedation level,
including heart rate, blood complications. respiratory status or other vital
pressure, respirations, oxygen signs (e.g., respiratory rate,
saturation (Sao2), and end-tidal oxygenation via pulse oximetry,
CO2 (if prescribed) according to end-tidal CO2)
institutional standards.12,14,21
4. Verify all PCA prescription Decreases the risk of a medication • Medication dosage and/or
changes and pump changes with error or programming error. programming errors
another registered nurse
(independent double-check
verification).10,14,15,18 (Level E*)
5. Ensure patient comprehension of Comprehension can be assessed with • Patient unable to use PCA
PCA use and analgesic goal. patient report, with review of the • Inability to achieve analgesia goal
Reinforce patient education. PCA history for frequency of
attempts and through return patient
demonstration.
6. Assess for the presence of side Many side effects from opioid use can • Nausea
effects, such as nausea, pruritus, be managed. • Pruritus
urinary retention, or constipation. • Constipation
• Urinary retention
7. Prevention of constipation by This is a significant complication of • Unresolved constipation despite
encouraging mobilization and opiod use and can lead to other prevention measures
adequate fluid intake, adding fiber complications.
to the diet if applicable, and using
stool softeners if indicated.
8. Ensure patient continues to be Pain management may be ineffective • Patient is cognitively,
appropriate candidate for IV PCA. and patient may be at higher risk psychologically, or physically
for adverse events if patient not an unable to manage IV PCA
appropriate candidate.
Documentation
• Medication, concentration, basal rate, loading dose, • Total dose of medication administered, per
any breakthrough dosing, demand dose, lockout institutional standards
interval, and cumulative dose (independent double • Time the PCA pump was cleared, per institutional
check verification by another registered nurse after policy
initiation of treatment and with all changes • Patient teaching and any reinforcement needed
thereafter)10,14,15,18,33 • Side effects of opioids
• Pain assessment, interventions, and effectiveness of • Unexpected outcomes
PCA and other adjunctive pain management • Vital signs, oxygen saturation, and if used, end-tidal
• Patient’s baseline and follow-up pain scores using a carbon dioxide level
valid and reliable scale • Appearance and patency of the IV site
• Patient’s baseline and follow-up sedation scores using • Additional interventions that were needed
a valid and reliable scale

106 Patient-Controlled Analgesia 947.e1
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37. The Joint Commission: Sentinel event alert: patient has a positive effect on the prognosis of delirium in
controlled analgesia by proxy, Oakbrook Terrace, IL, patients undergoing orthopedic surgery. Korean J Pain
2004, The Joint Commission, Retrieved from 27:271–277, 2014.
<www.jointcommission.org/sentinelevents/ Thorson D, et al: Institute for Clinical Systems Improvement.
sentineleventalert/sea_33.htm>. Acute pain assessment and opioid prescribing protocol.
38. The Joint Commission: Sentinel event alert: safe use of Published January 2014. Retrieved August 26, 2016, from
opioids in hospitals, Oakbrook Terrace, IL, 2012, The <https://www.icsi.org/_asset/dyp5wm/Opioids.pdf>.
PROCEDURE
107
Peripheral Nerve Blocks:
Assisting with Insertion and
Pain Management
Kimberly Williams
PURPOSE: Peripheral nerve blocks are administered as single local anesthetic
injections or continuously through a catheter placed into a precise anatomical area
to provide site-specific analgesia or anesthesia.
PREREQUISITE NURSING • The anatomical position of the specific catheter should be

KNOWLEDGE clearly defined and documented after insertion by the phy-
sician or advanced practice nurse (e.g., femoral, axillary
• State boards of nursing may have detailed guidelines [Figs. 107-1 and 107-2], brachial plexus [Fig. 107-3],
involving peripheral nerve blockade. Each institution that intrapleural, extrapleural, paravertebral, tibial, sciatic,
provides this therapy also has policies and guidelines per- lumbar plexus).5,32 Radiological confirmation6 of the cath-
taining to peripheral nerve blockade. It is important that eter position may be necessary to avoid suboptimal out-
the nurse is aware of state guidelines and institutional comes (e.g., pneumothorax). Catheters may be placed by
policies.15 the surgeon, anesthesiologist, or certified nurse anesthetist
• The nurse must have an understanding of the principles under direct vision, via ultrasound scan–guided tech-
of aseptic technique.9,12,19,23,39 niques or with the use of a peripheral nerve stimulator,
• The nurse assisting with the insertion of peripheral nerve either adjacent to or directly into the nerve sheath (e.g.,
blocks requires specific skills and knowledge.15 sciatic or tibial nerve during surgery for lower-limb ampu-
• Catheter placement and management of the patient should tation).16,19,21,23,29,31 Catheters may also be placed after
be under the direct supervision of an anesthesiologist, surgery (e.g., intercostal, intrapleural, axillary, brachial
nurse anesthetist, or the acute pain service.24,26,39 Periph- plexus, femoral, paravertebral; Table 107-1).
eral nerve blocks are used as part of a preemptive and • A three-in-one peripheral nerve block can be used for
multimodal analgesic technique to provide safe and effec- analgesia after proximal lower-limb orthopedic surgery.
tive postoperative pain management with minimal side A three-in-one peripheral nerve block provides analgesia
effects.10,12,14,18,21 to block three nerves, including the lateral femoral cuta-
• Peripheral nerve blocks are site specific (e.g., femoral, neous, femoral, and obturator nerves.4,26 This block is as
brachial plexus, axillary, intrapleural, extrapleural, para- effective as epidural analgesia, with fewer side effects
vertebral, tibial, sciatic, lumbar plexus) and provide pro- than epidural analgesia (e.g., urinary retention, nausea,
longed anesthesia or analgesia for postoperative and risk for epidural hemorrhage in patients with anticoagula-
trauma pain management.4,26 tion).6,7,16,26,27 Some forms of plexus analgesia (e.g., bra-
• Peripheral nerve blocks in the outpatient setting have chial plexus analgesia) in the postoperative setting may
facilitated early patient ambulation and discharge by serve two purposes: pain relief and sympathetic blockade,
decreasing side effects, such as drowsiness, nausea, and the latter of which increases blood flow and may improve
vomiting.3,11,13,18 In addition, unlike general anesthesia, outcomes in some cases (i.e., digit reimplantation).5,16,23,34
peripheral nerve blocks do not directly alter the level of • Analgesia via a catheter may be administered as a continu-
consciousness. By preserving the patient’s level of con- ous infusion with the use of a volumetric pump system,
sciousness, the patient’s protective airway reflexes (e.g., a patient-controlled regional infusion system, or a dis-
cough and gag) are maintained and the need for airway posable pump device (e.g., elastomeric). An elastomeric
manipulation and intubation is negated. Furthermore, with pump is one type of disposable infusion pump designed to
the use of peripheral nerve blockade, the complications provide a constant rate of infusion from a filled reservoir.
of general anesthesia are avoided.3 Continuous periph- The infusion rates may or may not be adjustable (Fig.
eral nerve blockade improves postoperative analgesia, 107-4).21,30,34 Medication administered is usually a local
patient satisfaction, and rehabilitation compared with anesthetic (e.g., bupivacaine, ropivacaine). Other agents
intravenous (IV) opioids for upper- and lower-extremity have been used on an adjunctive basis as a bolus, includ-
procedures.11,13,18,26,31 ing opioids, clonidine, epinephrine,16,17 and neostigmine.18
948
107 Peripheral Nerve Blocks: Assisting with Insertion and Pain Management 949
Axillary artery Median nerve

Biceps muscle
Coracobrachialis muscle
Musculocutaneous nerve
Median nerve
Axillary fascia
Ulnar nerve
Radial nerve
Ulnar nerve
Figure 107-1 Location for needle insertion for an axillary block. (From Sinatra RS: Acute pain:
Mechanisms & management, St Louis, 1992, Mosby.)
Midclavicular point
Infraclavicular injection site
Axillary artery
Figure 107-2 Needle insertion for an axillary block. (From Sinatra RS: Acute pain: Mechanisms
& management, St Louis, 1992, Mosby.)
• The pharmacokinetics and pharmacodynamics of local concentration of the medication, site of injection, and
anesthetics and other agents used, including side effects absorption. The addition of a vasoconstrictor, such as epi-
and duration of action, should be clearly understood. nephrine, constricts blood vessels and reduces vascular
Local anesthetic medications used for peripheral nerve uptake, which further prolongs the duration of action of
blocks provide surgical analgesia (i.e., loss of pain sensa- the local anesthetic.16,17 Epinephrine is not recommended
tion) and anesthesia (i.e., loss of all sensation). The dura- with peripheral nerve blocks in areas with end arteries,
tion of action for each anesthetic medication depends such as ear lobes, the nose, digits, and the penis.39 Vaso-
on several factors, including the volume injected, constrictor medications may cause spasm of blood vessels,
External
jugular vein
Middle scalene muscle
Trunks of the Cricoid

brachial plexus cartilage
Subclavian
artery Anterior scalene muscle
Figure 107-3 Landmarks for interscalene brachial plexus block. (From Sinatra RS: Acute pain:
Mechanisms & management, St Louis, 1992, Mosby.)
TABLE 107-1 Single-Shot (One-Time, Single Injection) and Continuous Peripheral

Nerve Blocks
Block Indications Practical Problems
Interscalene Shoulder/arm pain (e.g., shoulder dislocation/fractures, humeral • Horner’s syndrome may obscure neurological
fracture) assessment
• Block of ipsilateral phrenic nerve
• Close proximity to tracheostomy and jugular
vein line sites
Cervical Shoulder/elbow/wrist pain (e.g., shoulder fractures, humeral • Horner’s syndrome may obscure neurological
paravertebral fracture, elbow fractures, wrist fractures) assessment
(continuous • Block of ipsilateral phrenic nerve
catheter only) • Patient positioning
Infraclavicular Arm/hand pain (e.g., elbow fractures, wrist fractures) • Pneumothorax risk
• Steep angle for catheter placement
• Interference with subclavian lines
Axillary Arm/hand pain (e.g., elbow fractures, wrist fractures) • Arm positioning
• Catheter maintenance
Intercostal Blockade used for management of pain due to traumatic rib • Catheter malposition
fractures. Commonly an elastomeric infusion pump, which is a • Risk of pneumothorax
balloon filled with local anesthetic attached to a catheter
placed at the site of injury. This delivery system results in slow
infusion of local anesthetic for pain control. This provides pain
relief so that patients are able to ventilate more effectively.
Paravertebral Unilateral chest or abdominal pain restricted to a few • Patient positioning
dermatomes (e.g., rib fractures) • Stimulation success sometimes hard to visualize
Combination of Unilateral leg pain (e.g., femoral neck fracture [femoral], tibial • Patient positioning
femoral and and ankle fractures [sciatic])* • Interference of femoral nerve catheters with
sciatic block femoral lines
*Caution: Compartment syndrome.
Modified from Schulz-Stubner S: The critically ill patient and regional anesthesia, Curr Opin Anaesthesiol 19:538–544, 2006.
• Pump for administration of analgesia (e.g., volumetric

pump, dedicated for peripheral nerve block infusion with
rate and volume limited, and preferably a different color
from the epidural and IV infusion pumps; patient-controlled
analgesic pump or a portable infusion device such as a
disposable elastomeric continuous infusion pump
• Specific observation chart for patient monitoring of the
peripheral nerve block infusion
• Prescribed analgesics and local anesthetics
• Equipment for monitoring blood pressure, heart rate, and
pulse oximetry
the following:
• Ice or alcohol swabs for demonstrating sensory block
Figure 107-4 An elastomeric infusion pump. Parts include 1, • Emergency medications (e.g., 20% fat emulsion/intralipids
filling port; 2, elastomeric balloon (drug-containing reservoir); and for local anesthetic toxicity)
3, outer protective shell. (Originally published in Skryabina E, • Bag-valve-mask device and oxygen
Dunn TS: Disposable infusion pumps, Am J Health Syst Pharm • Equipment for end-tidal carbon dioxide monitoring
63:1260-1268, 2006.) © 2006, American Society of Health-System • Intubation equipment
Pharmacists, Inc. All rights reserved. Reprinted with permission
(R1002).
• Peripheral nerve stimulator and/or ultrasound to facilitate
placement
resulting in necrosis.9 Knowledge of signs and symptoms
of profound motor and sensory blockade, or overmedica- PATIENT AND FAMILY EDUCATION
tion, is essential.5,9,10,17
• Sensory and motor blockade may be acceptable or desir- • Explain the reason and purpose of the catheter. If avail-
able, depending on the goals and preferences of the inter- able, supply easy-to-read patient information. Rationale:
disciplinary team. The loss of sensation at the site is often The patient and the family know what to expect; anxiety
the primary goal of blocks, and although motor loss is may be reduced.
often acceptable, it is not desirable.3 • Explain to the patient and family that the procedure can
• Relative contraindications to peripheral nerve blockade be uncomfortable but that a local anesthetic will be used
include a history of coagulopathy, preexisting neuropa- to facilitate comfort. Rationale: Explanation elicits the
thies, anatomical or pathological deviations at the injec- patient’s cooperation and comfort, and facilitates inser-
tion site, and systemic disease or infection.5,7,10,22,26,27,39 tion; anxiety and fear may be decreased.
• Local anesthetic toxicity can result from inadvertent injec- • During therapy, instruct the patient to report side effects
tion of local anesthetic into the vascular system or rapid or changes in pain or sensation. Observe for suboptimal
absorption of the agent from the tissue into the vascular analgesia, profound numbness of extremities (beyond the
system. Intralipids/20% fat emulsion should be immedi- goal of therapy), patient report of lightheadedness, metal-
ately available for IV infusion, to help restore cardiovas- lic taste, circumoral numbness, dizziness, blurred vision,
cular stability.8 tinnitus, loss of hearing, and seizures.5,9,17,23 Rationale:
Reporting of pain aids the patient’s comfort level and
EQUIPMENT identifies side effects. Recognition of early signs and
symptoms of local anesthetic toxicity can prevent cardiac
• One peripheral nerve catheter kit arrhythmias, arrest, and death.
• Infusion set for continuous plexus anesthesia with or • Teach the patient to protect the affected extremity from
without an adaptor for a nerve stimulator injury and trauma (e.g., burns).3,5,23 Rationale: Patient
• Peripheral nerve stimulator safety is increased, and the limb is protected from injury
• Topical skin antiseptic, as prescribed and trauma.
• Sterile towels • If a volumetric pump for patient-controlled regional anal-
• Sterile forceps gesia (PCA) is used, educate the patient and family on its
• Sterile gauze 4 × 4 pads use. Reinforce this education throughout the duration of
• Sterile gloves and gowns regional PCA therapy. Rationale: This may decrease
• Fluid shield face masks anxiety and assists the patient in effectively using the
• 20-mL normal saline solution infusion system.
• 5- to 10-mL local anesthetic as prescribed (1% lidocaine)
for local infiltration PATIENT ASSESSMENT AND
• Local anesthetic as prescribed (to establish the block) PREPARATION
• Occlusive dressing supplies to cover the catheter entry site
• Gauze and tape to secure the catheter to the patient’s body Patient Assessment
• Labels stating “Local anesthetic only” and “Not for intra- • Observe the patient for signs and symptoms of local infec-
venous injection” tion or generalized sepsis. Rationale: This decreases the
risk for infection at the site of catheter insertion. Septi-

cemia and bacteremia are contraindications for periph- Patient Preparation
eral nerve block catheter placement or continuation of • Verify that the patient is the correct patient using two
therapy.10,12 identifiers. Rationale: Before performing a procedure, the
• Assess the patient’s concurrent anticoagulant and fibrino- nurse should ensure the correct identification of the patient
lytic therapy.6,7,39 Rationale: Heparin (unfractionated and for the intended intervention.
low–molecular-weight heparin), heparinoids, and fibrino- • Ensure that the patient and family understand the planned
lytic agents administered concurrently increase the risk procedure. Answer questions as they arise, and reinforce
for vessel trauma (e.g., hematoma). Care must be taken information as needed. Rationale: Understanding of pre-
with insertion and removal of the peripheral nerve block viously taught information is evaluated and reinforced.
catheter when patients are on anticoagulant and fibrino- • Ensure that informed consent has been obtained. Ratio-
lytic therapy.9,27 Special institutional guidelines must be nale: Informed consent protects the rights of the patient
observed.3,5–7,19,25,27 Insertion and removal of the peripheral and makes a competent decision possible for the patient.
nerve catheter should be directed by the physician or • Perform a preprocedure verification and time out, if non-
advanced practice nurse.5–7,27 emergent. Rationale: This ensures patient safety.
• Obtain the patient’s vital signs. Rationale: This provides • Wash the specific anatomical area of the patient’s body
baseline data. with soap and water, and open the gown to expose the site
• Assess the patient’s pain and anxiety. Rationale: This for injection while maintaining the patient’s privacy and
provides baseline data and helps determine whether pre- dignity. Rationale: This action cleanses the skin and
medication is required. allows easy access to the specific anatomical area of the
• Reassure the patient. Rationale: Anxiety and fears may patient’s body.
be reduced. • Establish IV access or ensure the patency of IV catheters.
• Review the patient’s medication allergies. Rationale: Rationale: Medications may be needed if side effects
Review of medication allergies before administration of a occur (i.e., hypotension).
new medication decreases allergic reactions. • Position the patient as appropriate, according to which
• Consider instructions for nothing by mouth, especially if anatomical area of the body is to be blocked. Rationale:
sedation or general anesthesia is to be used. Rationale: This prepares the patient for the procedure.
The risk for vomiting and aspiration is decreased.
Procedure for Peripheral Nerve Blocks

1. HH
gear (e.g., face masks with eye
shields) and sterile attire (e.g.,
sterile gowns, sterile gloves).
3. Obtain the prescribed peripheral The medication should be prepared All peripheral nerve block solutions
nerve block medication. with aseptic technique by the are preservative free to avoid
pharmacy with laminar flow or neuronal injury.7
prepared commercially.
4. Connect the correct tubing to the Removes air from the infusion
prepared infusion and prime the system.
tubing.
5. Ensure that the patient is in Facilitates ease of insertion of the Assist with holding the patient in
position for catheter placement. peripheral nerve block catheter. position or consider sedation, if
necessary.
6. Assist as needed with the Reduces the transmission of The choice of povidone-iodine or
antiseptic preparation of microorganisms into the nerve chlorhexidine as an antiseptic agent
the intended insertion site. sheath or plexus space.12,23 for neurological procedures is
(Level C*) controversial. Both should be
allowed to dry completely.
Chlorhexidine may be neurotoxic.20
7. Assist if needed with draping the Aids in maintaining sterility.
patient with exposure of the
insertion site.
Procedure for Peripheral Nerve Blocks—Continued

8. Assist the physician or advanced Facilitates catheter insertion. Use of a Ultrasound guidance may be used to
practice nurse as needed with the peripheral nerve stimulator assists place the continuous peripheral
catheter placement and with identification of the nerve.23,28 nerve block catheter. If ultrasound
manipulation of the controls on has print capability, print a reading
the peripheral nerve stimulator if and include it in the chart for
used).3,23 (Level C*) documentation.
9. After the peripheral nerve Reduces the incidence of infection.12,23
catheter is inserted, assist as
needed with the application of a
sterile, occlusive dressing.
10. Secure the filter to the patient’s Avoids disconnection between the
body with a gauze padding and peripheral nerve catheter and the
tape. filter. The gauze padding prevents
discomfort and skin pressure from
the filter.
11. The physician or advanced Facilitates a therapeutic level of An initial test dose of local anesthetic

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Arterial Catheter Insertion (Assist), Care, Defibrillation (Internal) Perform , 310

and Removal, 508 Donor-Site Care, 1136

Procedure Manual for

AACN PROCEDURE MANUAL FOR HIGH ACUITY, PROGRESSIVE, ISBN: 978-0-323-37662-4

Previous editions copyrighted 2011, 2005, 2001, 1994, 1985.

Library of Congress Cataloging-in-Publication Data

Executive Content Strategist: Lee Henderson

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Richard B. Arbour, MSN Kathleen Berns, MS, APRN, CNS, CFRN

Roger Casey, MSN, CEN, TCRN, FAEN Janice Y. Dawson, BSN

Megan T. Moyer, MSN Mark Puhlman, RN, MSN

Nicolle Schraeder, RN, MSN, ACNPC-AG Valerie Spotts, BSN, RN

Lisa Woods, MSN, BSN, BA

Lillian Aguirre, MSN, CNS, CCRN, CCNS Kimberly Bush, MSN, RN

Myra F. Ellis, MSN, RN, CCRN-CSC Amy Howell, CNRN

Level A: Meta-analysis of quantitative studies or meta-

17 Extracorporeal Life Support (ECLS) and

29 Invasive Mechanical Ventilation (Through

32 Peripheral Nerve Stimulators, 268

68 Esophageal Cardiac Output Monitoring: 86 Midline Catheters , 758

117 Peritoneal Lavage (Perform) , 1041

105 Epidural Catheters: Assisting with Insertion

Unit IV Gastrointestinal System SECTION NINETEEN: Special Hematologic

SECTION TWENTY-ONE: Special Integumentary Unit VIII Nutrition

Figure 1-4 Combitube in tracheal position.

• Medications delivered via endotracheal tube cannot be

PATIENT AND FAMILY EDUCATION

PATIENT ASSESSMENT AND

Procedure for Combitube Insertion

*Level M: Manufacturer’s recommendations only.

Procedure continues on following page

Procedure for Combitube Insertion—Continued

*Level M: Manufacturer’s recommendations only.

Procedure for Combitube Insertion—Continued

Procedure continues on following page

Procedure for Combitube Insertion—Continued

Procedure for Combitube Removal

Expected Outcomes Unexpected Outcomes

Patient Monitoring and Care

References and Additional Readings

References 10. Lavery G, McCloskey B: The difficult airway in adult

PREREQUISITE NURSING • Videolaryngoscopy is gaining increased popularity as a

2 predict a routine laryngoscopy, class 3 predicts dif-

• Explain the procedure and the reason for intubation, if the

Procedure for Performing Endotracheal Intubation

Procedure for Performing Endotracheal Intubation—Continued

Procedure continues on following page

Procedure for Performing Endotracheal Intubation—Continued

Figure 2-4 Technique of orotracheal intubation. The laryngoscope

Procedure for Performing Endotracheal Intubation—Continued

Procedure for Performing Endotracheal Intubation—Continued

Figure 2-7 The endotracheal

Procedure for Performing Endotracheal Intubation—Continued

Procedure continues on following page

Procedure for Performing Endotracheal Intubation—Continued

Procedure for Performing Endotracheal Intubation—Continued

Procedure continues on following page

Procedure for Performing Endotracheal Intubation—Continued

Expected Outcomes Unexpected Outcomes

Patient Monitoring and Care

References and Additional Readings

References 13. Kill C, et al: Videolaryngoscopy with glidescope reduces

References 13. Kill C, et al: Videolaryngoscopy with glidescope reduces

References 13. Kill C, et al: Videolaryngoscopy with glidescope reduces

References 6. Nelson J, et al: Evaluation of the Storz CMAC,