elated Policies and Procedures: Pressure Line Management Insertion, Removal, and Care of an Indwelling Urinary Catheter Approved by: Nursing Practice Guidelines Sucommittee Critical Care !uality Im"rovement Committee !ffective# $%&' evised# (%)$*%)+ "escription: ,his guideline descries the im"lementation, nursing care, and documentation of Intra-adominal Pressure .I/P0 monitoring1 / consistent standard method of monitoring intra- adominal "ressure .I/P0 is necessary to o"timi2e "atient care1 I/P can e monitored with either a two-way or three-way indwelling urinary catheter1 Pressure trends are to e monitored and treated accordingly to avoid organ failure1 Accountability: University of Colorado 3os"ital Critical Care 4e"artment Physicians and Nursing Staff, who are res"onsile for the care, assessment, and documentation of the "atient with intra-adominal "ressure monitoring1 "efinitions: Intra-adominal "ressure .I/P0# the "ressure concealed within the adominal cavity1 Normal I/P is a""ro5imately &-* mm3g1 Intra-adominal 3y"ertension .I/30# a sustained or re"eated "athologic elevation of I/P 67 )+mm3g /dominal Com"artment Syndrome ./CS0# a sustained I/P 6+&mm3g .with or without an /PP 8 (& mm3g0 that is associated with new organ dysfunction % failure /dominal Perfusion Pressure ./PP0# Mean /rterial Pressure .M/P0 9 Intra-adominal Pressure .I/P01 Su"erior to other end "oints in "redicting survival and should e maintained 6*&-(&1 Indications# Critically-ill "atients with new or "rogressive organ dysfunction should e screened for I/3%/CS ris: factors1 If two or more ris: factors .see a""endi5 /0 are "resent, a aseline I/P measurement should e otained y chec:ing I/P every )-+ hours until a aseline trend is estalished1 If I/3 is "resent, serial I/P measurements should e "erformed until organ function has im"roved1 Patients receiving aggressive fluid resuscitation .6* L%+$ hours0 and%or have significant ca"illary lea: are at significant ris: of I/3 and should have I/P monitoring1 See a""endi5 /1 I/3 /ssessment /lgorithm and ;1 I/3%/CS Management /lgorithm1 Contraindications: Ris: versus enefit should e discussed with the "hysician efore measurements are ta:en in these s"ecific "atients# ladder trauma, ladder surgery, and neurogenic ladder1 G&<+N)+ .Previous Policy = c+$'*))0 ) of > Intra-Abdominal Pressure Monitoring Nursing Practice Guidelines: A# Monitoring IA$P using Abvisor %# !&uipment needed for Abviser 'recommended (ay): a) ) ag of *&&mL Normal Saline b) ) /viser ?it c) ) edside monitor interface "ressure module and cale d) $5$@s if connecting transducer to "atient e) ) chloro"re" *# Procedural +tep for Abviser a0 Gather a""ro"riate eAui"ment1 0 Utili2e ody sustance isolation and ase"tic techniAue1 c0 Connect "ressure monitoring module and cale into edside monitor1 d0 B"en /viser :it1 e0 Place sterile dra"e under foley1 f0 ,a:e saline s"i:e and insert into *&&ml normal saline ag and "rime the system1 g0 Using ase"tic techniAue, disconnect foley drainage ag from foley catheter and connect to the ared end of the /viser autovalve1 h0 Connect the foley drainage ag to o""osite side of /viser autovalve1 i0 Mount transducer to either the "atient or to a "ole1 If attaching to "atient "lace $5$ underneath the transducer to "rotect the s:in1 C0 Dero the transducer y "lacing atmos"heric "ort at the level of the iliac crest in the mid-a5illary line1 Mar: this level on the "atient with an EFG for consistency1 :0 /ssure urinary catheter is draining freely and ladder is em"ty1 l0 Position the "atient su"ine and ensure the "atient is free of active adominal contractions1 If the "atient cannot tolerate su"ine "ositioning, the angle of the head of ed should e recorded on the electronic health record .H3R0 and re"eat measurements must e ta:en at the same angle every time1 m0 Retract the "lunger of the syringe on the system to as"irate +& ml of saline solution1 Instill +&ml of saline into the urinary catheter in )& seconds1 n0 /llow the measurement to eAuilirate and read "ressure '&-(& seconds "ost instillation at end e5"iration1 If reading is otained too soon after instillation the I/P may e falsely elevated due to refle5ive contraction of the ladder1 o0 /fter + minutes the fluid will drain automatically from the catheter, confirm that the autovalve has o"ened and urine is draining normally1 "0 4ocument value on H3R1 Sutract +& ml from urine out"ut for the hour1 A0 Notify "rovider of elevated "ressure readings .I/P I)+ mm3g01 Serial measurements should e ta:en so increases in "ressure can e detected1 4iscuss a""ro"riate monitoring intervals with "rovider1 r0 If I/P I)+mm3g, discuss with the "rovider initial treatment o"tions .See /""endi5 ;01 If considering surgical intervention, re-evaluate I/P with the use of a neuromuscular loc:ing agent or muscle rela5ant efore a surgical consult is reAuested1 G&<+N)+ .Previous Policy = c+$'*))0 + of > Intra-Abdominal Pressure Monitoring $# IA$P monitoring (,en not using Abvisor: C#%# !&uipment needed if not using Abviser -it: a0 ) ag *&& ml Normal Saline 0 ) "ressure monitoring transducer with tuing and "ressure ag c0 ) edside monitor interface "ressure module and cale d0 ) '& ml luer loc: syringe e0 ) hemostat f0 ) three-way sto"coc: .not for three-way catheter0 g0 ) lue IJ line ada"ter .only for three-way catheter0 h0 ) alcohol swa $# *# Procedural steps 'for not using Abviser and a t(o-(ay ind(elling urinary cat,eter): a0 Gather a""ro"riate eAui"ment1 0 Utili2e ody sustance isolation and ase"tic techniAue1 c0 Connect "ressure monitoring module and cale into the edside monitor1 d0 /ttach three-way sto"coc: and '& ml syringe into "ressure line distal to transducer1 e0 Prime transducer circuit, and attach transducer to edside monitor "ressure module1 f0 Dero the transducer y "lacing the atmos"heric "ort at the level of the iliac crest mid-a5illary line1 Mar: this level on the "t with an E5G for consistency1 g0 /ssure urinary catheter has een draining freely and the ladder is em"ty1 h0 Clean luer loc: sam"ling "ort with alcohol swa and attach three-way sto"coc:1 i0 Clam" indwelling catheter immediately distal to sam"ling "ort1 C0 ,urn sto"coc: off to urinary catheter1 :0 Instill +* ml of Normal Saline into '& ml syringe y flushing the "ressure system1 l0 Position the "atient su"ine and ensure the "atient is free of active adominal contractions1 If the "atient cannot tolerate su"ine "ositioning, the angle of the head of ed should e recorded on electronic record and re"eated measurements must e ta:en at the same angle every time1 m0 ,urn sto"coc: off to transducer1 Instill +* mL of Normal Saline into the urinary catheter1 Larger instillations of volumes were found to falsely elevate I/P y over distending the ladder .Cheatham01 n0 ,urn sto"coc: off to syringe and o"en to monitor "ressure waveform1 Read the "ressure '& to (& seconds "ost instillation at end e5"iration1 If reading is otained too soon after NS instillation the I/P may e falsely elevated due to refle5ive contraction of the ladder1 o0 Release hemostat and set three-way sto" coc: to "revent additional fluid from entering the ladder1 Kor serial measurements :ee" system closed1 "0 4ocument value on electronic record1 Sutract +* ml from urine out"ut for the hour1 A0 Notify "rovider of elevated "ressure readings .I/P I)+ mm3g01 Serial measurements should e ta:en so increases in "ressure can e detected1 4iscuss a""ro"riate monitoring intervals with "rovider1 G&<+N)+ .Previous Policy = c+$'*))0 ' of > Intra-Abdominal Pressure Monitoring r0 If I/P I)+mm3g, discuss with the "rovider initial treatment o"tions .See /""endi5 ;01 If considering surgical intervention, re-evaluate I/P with the use of a neuromuscular loc:ing agent or muscle rela5ant efore a surgical consult is reAuested1 C# Procedural steps 'for t,ree-(ay ind(elling urinary cat,eter): a0 Kollow aove ste"s e5ce"t re"lace three way sto"coc: with lue IJ line ada"tor1 eferences: )1 Gould, C1 J1, Umscheid, C1 /1, /garwal, R1 ?1, ?unt2, G1, Pegues, 41 /1, L 3ealthcare Infection Control Practices /dvisory Committee .3ICP/C01 .+&&M01 Guideline for prevention of catheter-associated urinary tract infections 2009. Retrieved /"ril )$, +&)+, from the Centers for 4isease Control and Prevention wesite# htt"#%%www1cdc1gov%hic"ac%"df%C/U,I%C/U,Iguideline+&&Mfinal1"df .LBH >J0 +1 Lynn-Mc3ale Niegand, 4, L Gallagher, O1 .+&))01 Cha"ter )&(# Intra-adominal "ressure monitoring1 American Association of Critical Care Nurses (AACN) Procedure anual for Critical Care! "i#th $dition, M(>-M<&1 .LBH <JI0 '1 Norld Society of the /dominal Com"artment Syndrome1 .+&&>01 %ntra-a&dominal 'ypertension (%A') Assessment Al(orithm. Retrieved /"ril )$, +&)+, from htt"#%%wsacs1org%Images%I/3Palgorithm1"df .LBH <JI0 $1 Norld Society of the /dominal Com"artment Syndrome1 .+&&>01 %ntra-a&dominal 'ypertension (%A') ) A&dominal Compartment "yndrome (AC") ana(ement Al(orithm. Retrieved /"ril )$, +&)+, from htt"#%%wsacs1org%Images%/CSPmanagement1"df .LBH <JI0 *1 3ersherger, R1 C1, 3unt, O1 L1, /rnoldo, ;1 41, L Purdue, G1 K1 .+&&>01 /dominal com"artment syndrome in the severely urned "atient1 *ournal of +urn Care and ,esearch! 2-.*0, >&<->)$1 .LBH $III0 (1 4e Naele, O1 O1, 4e laet, I1, 4e ?eulenaer, ;1, Nidder, S1, ?ir:"atric:, /1 N1, Cresswell, /1 ;1, et al1 .+&&<01 ,he effect of different reference transducer "ositions on intra-adominal "ressure measurement# / multicenter analysis1 %ntensive Care edicine! ./.>0, )+MM-)'&'1 .LBH $III0 >1 Malrain, M1 L1 N1 G1, Cheatham, M1 L1, ?ir:"atric:, /1, Sugrue, M1, Parr, M1, 4e Naele, O1, et al1 .+&&(01 Results from the International Conference of H5"erts on Intra-adominal 3y"ertension and /dominal Com"artment Syndrome# I1 4efinitions1 Intensive Care Medicine, '+.))0, )>++-)>'+1 Retrieved Bctoer )&, +&)), from htt"#%%wsacs1org%consensus1"h" .LBH7<JI0 <1 Cheatham, M1 L1, Malrain, M1 L1 N1 G1, ?ir:"atric:, /1, Sugrue, M1, Parr, M1, 4e Naele, O1, et al1 .+&&>01 Results from the International Conference of H5"erts on Intra-adominal 3y"ertension and /dominal Com"artment Syndrome# II Recommendations1 Critical Care edicine! ...(0, M*)-M(+1 Retrieved Bctoer )&, +&)), from htt"#%%wsacs1org%concensus1"h" .LBH <7JI0 G&<+N)+ .Previous Policy = c+$'*))0 $ of > Intra-Abdominal Pressure Monitoring M1 Malrain, M1 L1 N1 G1, Chiumello, 41, Pelosi, P1, ;ihari, 41, Innes, R1, Ranieri, J1 M1, et al1 .+&&*01 Incidence and "rognosis of intraadominal hy"ertension in a mi5ed "o"ulation of critically ill "atients# / multi"le-center e"idemiological study1 Critical Care edicine ...+0, ')*-'++1 .LBH $III0 )&1 Gallagher, O1 .+&)&01 Intra-adominal hy"ertension# 4etecting and managing a lethal com"lication of critical illness1 AACN Advanced Critical Care 20.+0, +&*-+)>1 .LBH >J0 ))1 Lee, R1 ?1 .+&)+01 Intra-adominal hy"ertension and adominal com"artment syndrome# / com"rehensive overview1 Critical Care Nurse! .2.)0, )M-')1 .LBH >J0 )+1 Cheatham, M1 L1, L Safcsa:, ?1 .+&)&01 Is the evolving management of intra-adominal hy"ertension and adominal com"artment syndrome im"roving survivalQ Critical Care edicine! .-.+0, $&+-$&>1 Retrieved Novemer )*, +&)), from M4 Consult dataase1 .LBH $III0 )'1 Shuster, M1 31, 3aines, ,1, Se:ula, L1 ?1, ?ern, O1, L JasAue2, O1 /1 .+&)&, Ouly01 Reliaility of intraladder "ressure measurement in intensive care1 American *ournal of Critical Care! 09, e+M-e'M1 Retrieved Bctoer )&, +&)), from //CN dataase1 .LBH $III0 )$1 Jidal, M1 G1, Neisser, O1 R1, Gon2ale2, K1, ,oro, M1 /1, Loudet, C1, ;alasini, C1, et al1 .+&&<01 Incidence and clinical effects of intra-adominal hy"ertension in critically ill "atients1 Critical Care edicine! .1.(0, )<+'-)<')1 Retrieved Novemer )*, +&)), from M4 Consult dataase1 .LBH $III0 )*1 Cam"ell, M1L1 .+&))0 /merican /ssociation of Critical Care Nurses# Procedure Manual for Critical Care1 Procedure )&( 1 St Louis, MB# Saunders# Hlsevier1 .LBH )0 )(1 Convatec1 .+&)+01 /viser, Intra-/dominal Monitoring System1 Retrieved from htt"#%%aviser1com1 .LBH <0 G&<+N)+ .Previous Policy = c+$'*))0 * of > Intra-Abdominal Pressure Monitoring G&<+N)+ .Previous Policy = c+$'*))0 ( of > Intra-Abdominal Pressure Monitoring G&<+N)+ .Previous Policy = c+$'*))0 > of >