 Hi, welcome to Nursing School Explained and this video about hemodynamic monitoring that specifically focuses on arterial blood pressure monitoring that sometimes is also referred as an arc line. And really what it does is it is used for critically ill patients who require frequent blood pressure monitoring. And rather than pressing their arm on their leg with a blood pressure cuff, very frequently, maybe every two or three minutes, because it is essential to monitor these patients that frequently an invasive arterial line will be used that then will give us the measurement from directly in the artery. So indications for arterial blood pressure monitoring are critically ill patients such as those with extremely high or low blood pressure. Those on respiratory failure, who might probably will be intubated, any kind of shock states, invasive heart procedures. So bypass surgery, heart transplantation, anything that involves the heart or bowel replacements. And then continuous infusion of vasoactive drugs because we're infusing these vasoactive medications that can have a very quickly changing effect on the patient's blood pressure. So we need to be able to monitor it on a kind of almost a second to second basis. And then the nice thing is that we can also draw ABGs, arterial blood gases from an arterial line. So we don't have to continuously keep inserting a needle into the patient and drawing their ABGs. Sites typically used for arterial blood pressure monitoring are usually femoral or radial arteries. Now let's look at this here. So in general, there will be a provider who will insert the arterial line into one of those arteries I just mentioned. And it is a very sterile procedure because think about it, it is an invasive line in the artery of a patient. So if germs get in there, they will be directly into the patient's bloodstream and that could have detrimental consequences to our patients. And so what do we have here? We have an IV pole with an IV bag with normal saline. Around that IV bag, we have a pressure bag and it's kind of a mesh device that has a bulb, just much like a not like a manual blood pressure cuff, where we inflate around that normal saline bag to a level of 300 millimeters of mercury pressure. It then delivers that normal saline to the patient at approximately three milliliters per hour. And that is because eventually we'll end up in the patient's radial artery and I'll go through the parts of this. So first we have to pressurize normal saline. Then the tubing goes down here to what's called a transducer. And right above the transducer, there is a three-way stopcock that'll allow you to turn the line off in three different directions. The transducer then is hooked up to the monitor and lined up with the patient and we'll get to that in a moment. Right beyond the transducer, there is a flush device that's sometimes also referred to as a pigtail because it is a kind of like a little plastic tail that you would just kind of use to pull and flush it. So it's almost like you're pulling that pigtail. From there, the tubing continues to this specimen collection connection, which is, I drew it out here, it's almost like an accordion. So it's usually, you can draw with this accordion, you can kind of draw the blood back from the patient's radial artery. There's a syringe attachment. You hook your syringe up and you got your ABG sample. So very simple. And then over here, we have the patients, in this case, it's the radial artery site with my Michelangelo drawing over here. And at the insertion site, it's usually sutured in place so it doesn't get dislodged. And the extremity is immobilized because if the patient were to bend their wrist that could kink the tubing and then we wouldn't get an accurate reading. Now, let's look at our patient. So the transducer that we have attached to the IV pole here needs to be lined up with what's called the flabostatic axis. And the landmarks for that are the force intercostal space and the mid chest. So you would walk, march down the force intercostal and then find the mid chest of the patient and line this up with the transducer. If the patient's bed gets elevated or lowered or the head of the bed moves up or down, this will no longer be lined up and will not give us accurate results. So we always need to make sure that this is lined up with the flabostatic axis. And then from the transducer, we have a wire that is hooked up to our monitor that gives us the output of what we are actually monitoring. So over here, I've drawn out the cardiac rhythm. In this case, it's a sinus cordycardia with the rate of 50. And then down here in red, since we're talking about arterial blood pressure, I've drawn up the line that you would see or the waveform. And in order for you to know that this is a correct waveform because there are many different waveforms that can display on a monitor, you look for this dichotic notch. And this is kind of like this little notch that you would see. And all these notches here always line up with the QRS complex of the patient because in the artery, the blood gets pumped out by the ventricle. So as the ventricle is contracting, we're measuring the pressure that it's putting out. And then you will most likely have a reading that'll give you the patient's blood pressure. In this case, this patient is not that critically ill or at least on their way to getting better with the blood pressure of 112 over 60. And then in parentheses, you'll always see the map, the mean arterial pressure. And that really applies to most blood pressure monitoring, not only to the arc line, it'll give you the map as well. And then these lines here on the output of the arterial line. So we talked about the dichotic notch. And then up here, the very tip of this waveform is the patient's systolic blood pressure. And the very bottom of it is the end diastolic blood pressure that we can measure. So now let's look at possible complications and associated nursing care that we can do so that the patient doesn't suffer any of these complications. So number one is hemorrhage. So keep in mind, this again is inserted into an artery and arteries are much more pressurized than veins of patients. So there's a high risk for hemorrhage. So for example, if this is, this luala hook to the patient is loose or comes undone, then the artery would basically leak out blood and we might not know about it and then the patient could be hemorrhaging. That applies to any of the connections in the tubing. So we always wanna make sure that we check all of our connections. Complication, possible complication number two is infection. Again, remember it's a direct access to the patient's bloodstream. So we wanna make sure we use sterile technique for any kind of required dressing changes. And we are very careful and meticulous when we collect ABGs that we wipe the ports appropriately and make sure we use the appropriate technique here to prevent infection, which is also the reason why only especially trained nurses are actually able to draw art lines and lab personnel are unable to because they have not been trained to, although lab personnel can do a regular ABG-6, but they cannot access this line for those reasons. And then a thrombus can form. So before the line is inserted, in this case in our patient's radial artery, we need to make sure that the radial artery is patent. Remember that in your hand gets supplied with two different arteries. We have the radial and the ulnar artery. So typically we check all our radial pulse. And like I said, these art lines are inserted into the patient's radial artery. Now, if there was something to go wrong, like if this line was to clot off, we would have trouble with perfusion to the rest of the hand, which is why the ulnar artery is so important. So we wanna make sure that the ulnar artery is patent before we even insert this art line. Again, this is most likely up to the provider, but it's a very simple test that you could do. And so what you would do is you would take two fingers with each of one of your hands and at the same time occlude the patient's radial and ulnar arteries. And then what'll happen, let me see if I can do this here, is that the patient's hand now lacks blood flow because I'm occluding the radial arteries. I don't think I'm doing a very good job here. It takes a little more pressure. And then what happens if we occlude the blood flow, then the hand will turn pale. But then if I let go of the ulnar artery, the patient's hand returns back to having regular blood flow and turns nice and pink. And then we could theoretically also check the patency of the radial artery by the same method, occluding both at the same time, waiting until the blood flow decreases and then releasing one of them and seeing that the profusion is intact by supplying one or the other arteries. So again, this Allen test is required before even inserting an art line. And this is also a test that a lab personnel is required to do before they do any arterial blood gas sampling. And to prevent the thrombus, we also have this pressure bag that we discussed over here that has this continuous infusion of the normal saline at approximately three milliliters per hour. Because otherwise what happens, the body recognizes this arterial line as being foreign and it kind of wants to claw it off. But if we continuously provide a little small amount of normal saline, it'll kind of keep the line patent and it'll prevent the thrombus from flushing. So it's very important for us to check to make sure that this pressure bag is still at 300 millimeters of mercury because eventually the normal saline, although it's a very low rate, the bag will get lower and lower in volume and then we might have to increase the pressure from that pressure bag here to provide the 300 millimeters of mercury. Now another complication is neurovascular injuries. So maybe a nerve gets injured with the insertion or anything else that could happen here. And whenever we check for distal circulation or distal patency of any kind of extremity, we always check the five P. So make sure that you know what those stand for. And then loss of a limb can also happen. So remember we are in an arterial line. If this now is not working for whatever reason and maybe we haven't taken particular attention to the Allen test that made sure that the ulnar artery is patent, now there is no blood flow to that hand. No blood flow means no oxygen, means that the cells are going to die and the patient could loss a limb, could lose a limb. Let's just see if there's anything else that we need to discuss here. I think this pretty much sums up the arterial line. It looks like a pretty complicated setup, but really once you've laid your hands on it and really understand what it all means, and it's very easy to really follow and get the correct readings here, which are super important in critically ill patients. Remember, however, that this is a highly skilled procedure that only the provider can insert and then ICU nurses are specifically trained to care for. So this is not something that you're going to be required to know in your first nursing job right off the bat. This is not a skill that is typically taught in nursing school. We don't have similar setups that go over arterial lines because again, it is more for the trained ICU nurse a little bit further down the road. However, it is important to have a basic understanding of how they work and how they benefit the staff and the care providers that are taking care of this critically ill patient. Thanks for watching this video on hemodynamic monitoring. There is also a different video that goes more into the details of central venous pressure and pulmonary artery wedge pressure. So I highly encourage you to watch this video as well. Please check out on Instagram, give me a thumbs up if you've liked this video and I'll see you soon right here on Nursing School Explained. Thanks for watching.