Invasive blood pressure

monitoring in critical care

Presented by Ri

Outline

Introduction
Arterial pressure waveform
Controversial aspect of IBP
monitoring
Conditions that affect arterial
waveform morphology
Pros and cons of various cannulation
sites

History

First invasive blood pressure

monitoring: Stephen Hales horse
(1733)
First attempt in human: Faivres
amputee (1856)
Clinical use: Lambert and Wood (1947)
Modern cannulation technique: Barr
(1961)
CV surgery in the 60s

Indications

Continuous monitoring of BP
Serial external monitoring inadequate
Hypotension or hypertension requiring
vasoactive drugs
Respiratory illness or mechanical
ventilation requiring frequent blood gases:
>3X/D for arterial sticks
>5X/D for combined arterial and/or
venous sticks
Major Surgery: Especially CV or neuro.
procedures

Contraindications

Absence of collateral flow

Raynaud's disease and cold infusions
Angiopathy, coagulopathy (recent anti-coag. or
thrombolytic infusion increases risk of hematoma
and compressive neuropathy), atherosclerosis:
Use Caution!
Avoid locating near A-V fistula, and inserting
through synthetic graft
Diabetics at increased risk of complications
Avoid local infection, burn or traumatic sites
Avoid extremities with carpal tunnel syndrome

The Pressure-pulse

1st shoulder (the Inotropic Component):

early systole, opening of aortic valve, transfer
of energy from contracting LV to aorta
2nd shoulder (the Volume Displacement
Component): produced by continuous
ejection of stroke volume from LV,
displacement of blood, and distention of the
arterial wall
Diastole: when the rate of peripheral runoff
exceeds volume input to the arterial circulation

Possible Information gained

from a pressure waveform

Systolic, diastolic, and mean

pressure
Myocardial contractility (dP/dt)
Peripheral vascular resistance (slope
of diastolic runoff)
Stroke volume (area under the pulse
pressure curve)
Cardiac output (SV x HR)

Is arterial waveform predictive of

cardiac contractility?

It is only aortic arch pressure that

can be used to measure LV
contractility, not peripheral
pressure

As BP is measured farther into

periphery:

The anacrotic and dicrotic notches

disappear
The waveform appears narrower
The systolic and pulse pressure
increase
The upstroke becomes steeper
The diastolic and mean pressure
decrease

Morphology changes as a result of

peripheral reflexions:

Reflexion of waves due to the

tapering diameter
Reflexion due to changing content of
the arterial wall
Reflexion also occur at branching
points of vessels

Is the arterial waveform predictive

of stroke volume?

The pressure does not predict flow

The distensible aortic arch act as a
fixed-capacity, high pressure
reservoir
Flow in the arterial tree is
continuous, with 10-20 percent of LV
power being pulsitile

Cullen et al: Correlation coefficient of

0.82 between changes in stroke volume
and changes in peripheral systolic
pressure in halothane-induced
anesthesia status, where peripheral
vascular resistance remained essentially
unchanged
Interpretation of blood pressure measurement in anesthesia
Anesthesiology, 40:6 1974

Role of direct arterial pressure

monitoring

Provides trends over a wide range

Unreliable as absolute hemodynamic
values
As a reminder
A needle in an artery does not
guarantee a pressure or accuracy
any more than an endotracheal tube
guarantee a patent airway.

Conditions that affect arterial

waveform morphology
Hyperdynamic pulse
Pulsus paradoxus
Reverse pulsus paradoxus
Pulsus alternans
Pulsus bisferens

Hyperdynamic pulse

Aortic regurgitation
AV fistula
Thyrotoxicosis
Anemia
Pregnancy
sepsis

Pulsus paradoxus

Cause of pulsus paradoxus

Change in pleural pressure

associated with breathing
Anatomic relationship between two
ventricle chambers

D/D of Pulsus paradoxus

Constrictive pericarditis or cardiac

tamponade
COPD
Asthma
Tension pneumothorax

Reverse pulsus paradoxus

An exaggeration of the rise in

systolic BP during mechanical
ventilation
A sensitive indicator of hypovolemia
in mechanically ventilated pt

Pulsus alternans

Cause of pulsus alternans

A sign of decreased myocardial

contractility (deletion of the number
of myocardial cells contracting on
alternate beats)
An alteration in diastolic volume
leading to beat-to-beat variation in
preload

D/D of pulsus alternans

LV dysfunction
Pericardial effusion

Pulsus bisferens

Pulsus bisferens

Hypertrophic cardiomyopathy
Aortic regurgitation

Advantages and disadvantages

on various cannulation sites
Radial artery
Brachial artery
Femoral artery
Axillary artery
Dorsalis pedis artery

Radial artery

Advantages: easy to cannulate,

accessible during most type of
surgery, good collateral circulation,
patient comfort, Allens test
Disadvantages: thormbus formation,
possible injury to nerve,
augmentation of SBP,

Brachial artery

Advantages: easy to cannulate,

larger catheter, less SBP
augmentation, collateral vessels
Disadvantage: uncomfortable for pt,
median nerve damage

Femoral artery

Advantages: prolonged use, useful in

shock pt, largest catheter
Disadvantages: atherosclerotic
plaque may break off, massive
hematoma, difficult to immobilize

Axillary artery

Advantages: large size, useful in

peripheral artery dz and shock,
proximity to aorta,
Disadvantages: neurologic
complication, technically difficult

Dorsalis pedis artery

Advantages: dual circulation

Disadvantages: greatest SBP
augmentation, thrombus formation,
difficult to immobilize, impossible to
walk

Take home message

The arterial system functions as a

damped, resonant, transmission line,
transmitting various frequencies with
different degrees of attenuation.
The clinician must dissuade himself
from the belief that the peripheral
pressure accurately reflects aortic
arch pressure.

reference

Monitoring in Anesthesia and Critical Care

Medicine, 2nd edition. 1990
Hemodynamic monitoring: Invasive and
Noninvasive Clinical application, 2nd edition.1995
Cullen et al: Interpretation of blood pressure
measurement in anesthesia. Anesthesiology, 40:6
1974

Thanks for your attention!