Comparison of upper and lower blood pressure measurements

Comparison of blood pressure measurements in the upper and lower extremities with blood pressure measurements in children under general anesthesia
Seth Hayes, 1 Rebecca Miller, 1 Ambrish Patel, 2, 3 Dmitry Tumin, 1, 2 Hina Valiya, 1 Mohammed Hakim, 1 Fayzaan Syed, 1 Joseph D. Tobias 1, 2, 41 Department of Anesthesiology and Pain Medicine, National Children's Hospital Columbus, Ohio 43205, USA; 2 Department of Pediatrics, Ohio State University, Columbus, Ohio, 43210, USA; 3 Pediatric Intensive Care Unit, Children's National Hospital, Columbus, Ohio, 43205, USA; 4 Department of Anesthesiology and Pain Management, Ohio State University, Columbus, OH 43210, USA Corresponding author: Seth Hayes Department of Anesthesiology and Pain Management, Children's National Hospital, 700 Children's Drive, Columbus, OH 43205, USATel +1 614 722 4200 Fax +1 614 722 4203 Invasive blood pressure (IBP) tube readings versus non-invasive blood pressure (NIBP) measurements with oscillometric cuffs of the upper and lower extremities in infants and children under general anesthesia. PATIENTS AND METHODS. Our study included patients under the age of 10 years if they received general anesthesia and planned a radial artery catheterization. IBP was measured every 5 minutes with a hydrodynamic transducer, and NIBP was measured with two oscilloscopes with appropriately sized cuffs placed on the upper arm and lower leg, and 10 measurements were taken on each patient. Results: The study involved 18 boys and 12 girls aged 0 to 8 years. At 300 data points, the absolute difference between arm mean arterial pressure (MAP) and invasive measurements was 7 ± 7 mmHg. Art. (range: 0–52 mmHg). The absolute difference between the measurement of SBP on the leg and the invasive method was 8 ± 8 mm Hg. Art. (range: 0–52 mmHg). Although both non-invasive measurement sites demonstrated frequent deviation from invasive measurement, large deviations were more common when BP was measured at the leg (81 of 298 observations (27%) deviating by >10 mmHg) compared to the arm (60 of 300 observations (20%) deviating by >10 mmHg).Conclusion: The frequency of clinically significant NIBP deviation in children under general anesthesia supports the importance of IBP monitoring when hemodynamic fluctuations are likely and would be particularly detrimental. Although both non-invasive measurement sites demonstrated frequent deviation from invasive measurement, large deviations were more common when BP was measured at the leg (81 of 298 observations (27%) deviating by >10 mmHg) compared to the arm (60 of 300 observations (20%) deviating by >10 mmHg).Conclusion: The frequency of clinically significant NIBP deviation in children under general anesthesia supports the importance of IBP monitoring when hemodynamic fluctuations are likely and would be particularly detrimental. Although both non-invasive measurement sites showed frequent deviations from the invasive measurement, large deviations were more common with leg BP measurements (81 of 298 observations (27%), deviating more than 10 mmHg) compared with the arm (60 of 300 observations). (20%), deviating by more than 10 mm Hg. Art.). Conclusion. The frequency of clinically significant NIBP abnormalities in children under general anesthesia confirms the importance of monitoring NIBP when hemodynamic fluctuations are likely and can be particularly detrimental.尽管两个非侵入性测量部位都显示出与侵入性测量的频繁偏差,但与手臂(300 次观察中的60 次)相比,在腿部测量的BP(298 次观察中的81 次(27%)偏差> 10 mmHg)更常见(20%) 偏差> 10 mmHg)。尽管 两 个 非侵入性 测量 部位 都 出 与 侵入性 测量 频繁 偏差 , 但 与 手臂 ((300 次 中 的 的 的 的 次) 相比 , 在 测量 的 的 bp (298 次 中 的 81 次 (27 (27 (27 (27 (27 %)偏差> 10 mmHg)更常见(20%) 偏差> 10 mmHg)。 Хотя оба неинвазивных места измерения показали частые отклонения от инвазивных измерений, АД, измеренное на ноге (81 из 298 наблюдений (27) по сравнению с рукой (60 из 300 наблюдений) %), отклонение> 10 мм рт.ст.) чаще (20% отклонение). Although both non-invasive measurement sites showed frequent deviations from invasive measurements, BP measured on the leg (81 out of 298 observations (27) compared with the arm (60 out of 300 observations) %), deviation > 10 mmHg) more often (20 % deviation). > 10 мм рт.ст.). > 10 mmHg). CONCLUSIONS. The frequency of clinically significant NIBP abnormalities in children under general anesthesia confirms the importance of monitoring NIBP when hemodynamic fluctuations are likely and particularly detrimental. Compared with NIBP values ​​obtained at the upper arm, NIBP measured at the lower leg is more likely to result in a clinically significant deviation from the invasively measured mean arterial pressure. Key words: invasive blood pressure, non-invasive blood pressure, blood pressure cuff.
Blood pressure (BP) monitoring has been important in the safety of general anesthesia since the sphygmomanometer was approved by Dr. Harvey Cushing in the early 1900s. Since 1986, this has been the standard required by the American Society of Anesthesiologists (ASA) during any period of general anesthesia. Because blood pressure measurements drive key decisions about perioperative management, inaccuracy can complicate the timely diagnosis and treatment of hemodynamic instability. Pediatric anesthesiologists often decide to administer fluids, blood products, and inotropes based on deviations from "normal" BP. 1 Because intraoperative hypertension and hypotension have been shown to be associated with postoperative complications, including acute renal failure, encephalopathy, myocardial infarction, stroke, and increased 30-day mortality, inaccurate BP measurements can lead to harmful, unidentifiable BP abnormalities. 2-5
During surgery, blood pressure can be measured non-invasively with an oscillometric blood pressure cuff (NIBP) or invasively with an indwelling arterial cannula (IBP). An oscillometric cuff occludes a patient's artery by inflating it to a pressure above the patient's systolic blood pressure (SBP) and then measuring pressure fluctuations as the cuff gradually deflates. The point at which pressure fluctuates the most is the mean arterial pressure (MAP). SBP and diastolic blood pressure (DBP) are then calculated based on mean arterial pressure and oscillometric models. The algorithms for these calculations are proprietary and depend on the NIBP cuff manufacturer. 6 In contrast, invasive arterial cannulation measures SBP and DBP directly from pressure pulse waves. MAP is derived from these values. 7
Several studies have investigated the association of VBP with NIBP in children with mixed results. In 2010, Meyer et al conducted a study showing low bias (<1 mmHg) on a Bland-Altman analysis of non-invasively measured mean arterial pressures in preterm infants and suggested that the correlation between IBP and NIBP has improved as NIBP technology has advanced.8 However, O'Shea et al noted a tendency toward falsely elevated NIBP values in this patient population despite development of newer, more sophisticated NIBP devices, even when possible confounding factors such as cuff size and level of activity were eliminated.9 Further studies have evaluated BP measurements in critically ill pediatric patients. In 2010, Meyer et al conducted a study showing low bias (<1 mmHg) on ​​a Bland-Altman analysis of non-invasively measured mean arterial pressures in preterm infants and suggested that the correlation between IBP and NIBP has improved as NIBP technology has advanced .8 However, O'Shea et al noted a tendency toward falsely elevated NIBP values ​​in this patient population despite development of newer, more sophisticated NIBP devices, even when possible confounding factors such as cuff size and level of activity were eliminated.9 Further studies have evaluated BP measurements in critically ill pediatric patients. В 2010 г. Meyer и соавторы провели исследование, показывающее низкую погрешность (<1 мм рт. ст.) в анализе Бланда-Альтмана неинвазивно измеренного среднего артериального давления у недоношенных детей и предположили, что корреляция между ИАД и НИАД улучшилась по мере того, как технология НИАД .8 Тем не менее, O'Shea et al. In 2010, Meyer et al conducted a study showing low error (<1 mmHg) in the Bland-Altman analysis of non-invasively measured mean arterial pressure in preterm infants and suggested that the correlation between IBP and NIBP improved as NIBP technology .8 However, O'Shea et al. noted a trend towards falsely high NIBP values ​​in this patient population despite the development of newer, more sophisticated NIBP devices, even when possible confounding factors such as cuff size and activity level have been eliminated. .9 Further studies have evaluated BP measurements in critically ill children. 2010 年,Meyer 等人进行了一项研究,显示Bland-Altman 分析对早产儿无创测量的平均动脉压进行了低偏差(<1 mmHg),并表明随着NIBP 技术的进步,IBP 和NIBP 之间的相关性有所改善.8 然而,O'Shea 等人指出,尽管开发了更新、更复杂的NIBP 设备,但即使消除了袖带尺寸和活动水平等可能的混杂因素,该患者群体的NIBP 值仍有错误升高的趋势。 2010 年 , meyer 等 进行 了 一 研究 , 显示 显示 bland-altman 分析 早产儿 无 创 测量 的 动脉压 进行 了 低 偏差 (<1 mmhg) , 表明 随着 nibp 技术 的 , , b 和 nibp 之间 nibp 之间 nibp 之间 nibp 之间 nibp 之间 nibp 之间 nibp 之间 nibp 之间的 相关性 有所 改善 .8 然而 , o'Shea 等 指出 , 尽管 开发 了 更新 、 更 复杂 nibp 设备 , 即使 消除 了 袖带 尺寸 活动 等 可能 的 混杂 , 该 患者 群体 nibp 值 值 的 nibp 值 值 nibp 值 值 nibp 值 值 nibp 值 值 nibp 值仍有错误升高的趋势。 В 2010 г. Мейер и др. провели исследование, показывающее, что анализ Бланда-Альтмана дает низкую погрешность (<1 мм рт. ст.) для неинвазивно измеренного среднего артериального давления у недоношенных детей, и показал, что с развитием технологии НИАД существует значительная разница между ИАД. In 2010, Meyer et al. conducted a study showing that the Bland-Altman analysis gives a low error (<1 mmHg) for non-invasively measured mean arterial pressure in preterm infants and showed that with the development of NIBP technology, there is a significant difference between IAD. and NIBP, correlations improved. of the population The trend towards an increase in the number of errors continues. 9 Another study assessed blood pressure in critically ill children. Two of them found "big differences" between invasive and non-invasive monitoring methods and concluded that underestimating hypertension and hypotension in PICU patients could lead to undertreatment. 10,11 In contrast, Ray et al. studied blood pressure values ​​in two pediatric intensive care units and, based on a trend towards lower mean and diastolic NIBP values, concluded that overtreatment of hypotension could be in the range up to 40%% of the time. 12
It is well known that an appropriately sized cuff must be used to obtain the most accurate non-invasive readings. The American Heart Association (AHA) recommends that the width and length of the cuffed bladder be 40% and 80% of the mid-arm circumference, respectively. 13 It is well known that NIBP is affected by the movement and activity of the subject, since external stimuli can affect the accuracy of BP measurements. 13,14 Although these potential sources of error in NIBP measurements are well recognized, the extent of bias in NIBP measurements in children has not been well characterized. If non-invasive monitoring tends to overestimate or underestimate blood pressure, it may give falsely reassuring values ​​in hemodynamically unstable patients. When studying NIBP values ​​in children under general anesthesia, movements and actions of subjects are excluded, which can lead to more accurate measurements. Therefore, we performed this prospective observational study to compare arterial cannulation IBP with NIBP measured with upper and lower limb oscillometric cuffs in children under general anesthesia. Our main hypothesis is that NIBP readings overestimate BP compared to invasive devices. There is little data to compare upper and lower extremity NIBP readings, so the decision to use a particular limb is often a practical one based on ease of access and the need to avoid peripheral IV catheters. Therefore, our secondary goal was to investigate the correlation and bias between NIBP measurements of the shoulder and lower leg.
The study was approved by the Institutional Review Board (IRB) of the National Children's Hospital (Columbus, Ohio, USA) and was conducted in accordance with the Declaration of Helsinki. The study is registered with Clinicaltrials.gov (NCT03220906). Depending on the availability of the investigator, 30 patients were recruited to complete the study. Oral informed consent was obtained from the patient's parents prior to participation in the study (a waiver of written consent was obtained from the IRB). Patients younger than 10 years old, American Society of Anesthesiologists (ASA) classification 1-3, were included in our study if they were to receive general anesthesia with elective radial artery cannulation. IBP was measured using a hydrodynamic pressure transducer (Edwards Lifesciences TruWave) with continuous BP display (Philips Intellivue). NIBP was measured using two separate oscilloscopes of the same brand (Philips Intellivue) with appropriately sized cuffs (according to AHA guidelines) applied to the upper arm and lower leg.
Systolic, diastolic and mean arterial pressure (MAP) at 3 points (radial artery, arm cuff and leg cuff) were recorded at 5-minute intervals with 10 measurements per patient. For patients undergoing intraoperative cardiopulmonary bypass (CPB), 5 indications were obtained before the start of CPB and 5 indications were obtained after completion of the bypass. A preliminary power analysis was performed for the one-sample proportion test. We calculated that the study would require a power of 80% in 185 cases to demonstrate an error rate greater than 10% for non-invasive measurements, with a maximum error rate of 5% and a statistical significance level of 95%. Enrollment was reduced after 30 patients were recruited for a total of 300 BP observations.
The primary outcome was clinically significant bias as defined by the deviation of BP of >5 mmHg between IBP and NIBP. The primary outcome was clinically significant bias as defined by the deviation of BP of >5 mmHg between IBP and NIBP. Первичным исходом была клинически значимая систематическая ошибка, определяемая отклонением АД> 5 мм рт. The primary outcome was clinically significant bias, defined as a BP deviation >5 mmHg. Art. between IBP and NIBP.主要结果是临床上显着的偏差,定义为IBP 和NIBP 之间的BP 偏差> 5 mmHg。主要结果是临床上显着的偏差, 定义为Первичной конечной точкой было клинически значимое отклонение, определяемое как отклонение АД> 5 мм рт. The primary endpoint was clinically significant deviation, defined as BP deviation >5 mmHg. Art. between IBP and NIBP. We also investigated the occurrence of deviations greater than 10 mmHg. Continuous data between sites were compared using Bland-Altman analysis. 15 In a multivariate analysis, we used mixed effects to model the absolute difference between NIBP and IBP as a function of NIBP, age, gender, weight, and patient position (prone or supine) linearly with random recurrence at patient level. The patient-level random intercept was used to account for patient factors which were not explicitly included in the model, but that still varied between patients.16 Data analysis was performed using Stata/IC 14.2 (College Station, TX: StataCorp, LP), and p<0.05 was considered statistically significant. The patient-level random intercept was used to account for patient factors which were not explicitly included in the model, but that still varied between patients.16 Data analysis was performed using Stata/IC 14.2 (College Station, TX: StataCorp, LP), and p<0.05 was considered statistically significant. Случайный перехват на уровне пациента использовался для учета факторов пациента, которые не были явно включены в модель, но все же различались между пациентами.16 Анализ данных был выполнен с использованием Stata/IC 14.2 (College Station, TX: StataCorp, LP), и p<0,05 считалось статистически значимым. Patient-level random intercept was used to account for patient factors that were not explicitly included in the model but still differed between patients.16 Data analysis was performed using Stata/IC 14.2 (College Station, TX: StataCorp, LP), and p <0.05 was considered statistically significant. Patient-level random intercepts were used to account for patient factors that were not explicitly included in the model but still varied by patient. 16 使用Stata/IC 14.2(College Station,TX:StataCorp,LP)进行数据分析, p<0.05 被认为具有统计学意义。 16 使用Stata/IC 14.2(College Station,TX:StataCorp,LP)进行数据分析, p<0.05 被认为具有统计学意义。 16 Анализ данных проводили с использованием Stata/IC 14.2 (College Station, TX: StataCorp, LP), p<0,05 считалось статистически значимым. 16 Data analysis was performed using Stata/IC 14.2 (College Station, TX: StataCorp, LP), p<0.05 was considered statistically significant. Researchers/authors will not share personal data of participants.
The study included 30 patients, 18 boys and 12 girls aged 0 to 8 years. Surgery included 28 (93%) thoracic surgeries, 1 (3%) neurosurgery, and 1 (3%) orthopedic surgery. Tables 1 and 2 summarize the study population demographics and mean SBP, DBP, and SBP values ​​at each location. Ten BP measurements or approximately 50 minutes were analyzed for each patient, for a total of 300 measurements or 15,000 minutes of monitoring.
On the Bland-Altman plot (Fig. 1), the error and accuracy of NIBP (SBP) measured on the arm, in relation to IBP, were -2 and 10 mm Hg. Art. respectively (95% compliance limits: -21, +17 mmHg). The bias and accuracy of mean arterial pressure relative to leg IBP was -5 and 11 mmHg. Art. respectively (95% of the boundaries of agreement: -26, +16 mmHg). When comparing IBP to NIBP at the arm, the absolute difference in MAP was 7±7 mmHg (range: 0–52 mmHg) with 143 of 300 observations (48%) deviating by >5 mmHg and 60 of 300 observations (20%) deviating by >10 mmHg. When comparing IBP to NIBP at the arm, the absolute difference in MAP was 7±7 mmHg (range: 0–52 mmHg) with 143 of 300 observations (48%) deviating by >5 mmHg and 60 of 300 observations (20%) deviating by >10 mmHg. When comparing IBP and NIBP on the arm, the absolute difference in SBP was 7±7 mm Hg. Art. (диапазон: 0–52 мм рт. ст.) при 143 наблюдениях из 300 (48 %) с отклонением > 5 мм рт. (range: 0–52 mmHg) with 143 observations out of 300 (48%) with a deviation > 5 mmHg. Art. and 60 observations out of 300 (20%). отклонение >10 мм рт.ст. deviation >10 mmHg比较手臂上的IBP 和NIBP 时,MAP 的绝对差异为7±7 mmHg(范围:0-52 mmHg),300 次观察中的143 次(48%)偏差>5 mmHg,300 次观察中的60 次(20%)偏差> 10 mmHg。比较 手臂 上 的 IBP 和 nibp 时 , map 的 差异 为 为 为 为 为 为 7 mmhg (范围 : 0-52 mmhg) 300 次 中 的 143 ((48%) 偏 差> 5 mmhg , 300 次 中 中 的 60 次 60 次 60 次 60 次 60 次 60 次 60 次 60 次 60 次 60 次 60 次 60 次 60 次 60 (20%)偏差> 10mmHg。 When comparing IBP and NIBP on the arm, the absolute difference in SBP was 7±7 mm Hg. (диапазон: 0-52 мм рт.ст.), с отклонениями >5 мм рт.ст. (range: 0-52 mmHg), with deviations >5 mmHg. в 143 из 300 наблюдений (48%) и 60 из 300 наблюдений (20% ) Отклонение > 10 мм рт.ст. in 143 out of 300 observations (48%) and 60 out of 300 observations (20%) Deviation > 10 mm Hg. When comparing IBP to NIBP at the leg, the absolute difference in MAP was 8±8 mmHg (range: 0–52 mmHg) with 169 of 298 observations (57%) deviating by >5 mmHg and 81 of 298 observations (27%) deviating by >10 mmHg. When comparing IBP to NIBP at the leg, the absolute difference in MAP was 8±8 mmHg (range: 0–52 mmHg) with 169 of 298 observations (57%) deviating by >5 mmHg and 81 of 298 observations (27%) deviating by >10 mmHg. When comparing VBP with NIBP on the leg, the absolute difference in SBP was 8±8 mm Hg. Art. (range: 0–52 mmHg), with 169 of 298 observations (57%) deviating by more than 5 mmHg. Art. и 81 из 298 наблюдений (27%) отклонение >10 мм рт.ст. and 81 out of 298 observations (27%) deviation >10 mmHg.将IBP 与腿部的NIBP 进行比较时,MAP 的绝对差异为8±8 mmHg(范围:0-52 mmHg),298 次观察中的169 次(57%)偏差> 5 mmHg,298 次观察中的81 次(27%)偏差> 10 mmHg。将 IBP 与 腿部 nibp 进行 时 , , map 的 差异 为 为 为 8 ± 8 mmhg (范围 : 0-52 mmhg) , 298 次 中 的 的 的 169 次 (((偏 差> 5 mmhg , 298 次 观察 的 的 中 中 中 中 中 中 中 中 中 中 中 中 中 中 中 中 中 中 中 HIP 81 次(27%)偏差> 10mmHg。 When comparing VBP with NIBP in the leg, the absolute difference in SBP was 8 ± 8 mm Hg. Art. (диапазон: 0–52 мм рт. ст.), при этом 169 из 298 наблюдений (57%) имели отклонение > 5 мм рт. (range: 0–52 mmHg), with 169 of 298 observations (57%) having a deviation > 5 mmHg. Art. и 1 из 298 наблюдений 81 (27%) отклонения > 10 мм рт.ст. and 1 of 298 observations 81 (27%) deviations > 10 mmHg.
Rice. 1. Bland-Altman plot of the correspondence between invasive mean arterial pressure (MAP) measurements and non-invasive SBP measurements.
Table 3 shows the results of comparing SBP and DBP between sites. Although both NIBP sites showed deviations from NIBP, larger deviations were more common when NIBP was obtained in the legs. Table 4 shows a multivariate model predicting the amount of deviation of SBP from IBP values ​​using NIBP measurements in the arms and legs. Gender, age, weight, and patient location were not associated with bias in invasive MAP measurements. Compared to arm NIBP measurements, the absolute deviation of SBP from IBP measurements was 1.5 mmHg. Art. more in the legs (95% CI: 0.4, 2.6; p = 0.009). Direct comparison of arm NIBP with leg NIBP (Fig. 2) showed an absolute difference in SBP of 2.5 ± 10 mmHg. Art. (95% limits of agreement: -17.1, +22.0 mmHg).
Table 3 Comparison of mean arterial, systolic, and diastolic blood pressure in arms and legs with arterial cannulation
Table 4 Range of deviation between predicted mean arterial pressure and invasive measurement using a mixed effects linear regression model
Rice. 2. Bland-Altman plot of the correspondence between non-invasive measurements of mean arterial pressure (MAP) in the arms and legs.
Previous studies comparing NIBP and IBP measurements in anesthetized children are limited. Although data in neonates are conflicting, some studies indicate a trend towards elevated blood pressure when measured non-invasively. Joffe et al. found that in a critical population of children, differences between NIBP and IBP measurements in 100 children were small on average, but standard deviations, interquartile ranges, and Bland-Altman plots had a wide range of agreement. These studies were not performed on patients under general anesthesia, a potentially useful feature of our study that may reduce patient errors in movement or activity. However, similar to Ioffe's results, our results show that although IBP and NIBP measurements in anesthetized children often correlate with each other, individual NIBP measurements are often inaccurate, indicating both overestimation and underestimation of BP. Clinically significant differences in NIBP use frequently emerged during the study period. These deviations in IBP obtained from NIBP measurements of the lower leg were larger and more frequent than deviations obtained from measurements of the NIBP of the shoulder.
A comparison of NIBP measurements in the arms and legs in children has been previously reported. In 2000, Short et al. studied NIBP in 50 children under anesthesia. In children age 8 years and under, BP obtained from the lower leg was significantly lower than that measured from the upper arm (p<0.05).17 In contrast to this, our study compared arm and leg NIBP to IBP measurements. In children age 8 years and under, BP obtained from the lower leg was significantly lower than that measured from the upper arm (p<0.05).17 In contrast to this, our study compared arm and leg NIBP to IBP measurements. У детей в возрасте 8 лет и младше АД, измеренное на голени, было значительно ниже, чем измеренное на плече (p<0,05).17 В отличие от этого, в нашем исследовании НИАД руки и ноги сравнивали с измерениями НИАД. In children aged 8 years and younger, blood pressure measured at the lower leg was significantly lower than that measured at the upper arm (p<0.05).17 In contrast, in our study, arm and leg NIBP was compared with NIBP measurements.在8 岁及以下儿童中,从小腿测得的血压显着低于从上臂测得的血压(p<0.05)。 8 У детей 8 лет и младше артериальное давление, измеренное на голени, было значительно ниже, чем на плече (p<0,05). In children aged 8 years and younger, blood pressure measured at the lower leg was significantly lower than at the upper arm (p<0.05). 17 In contrast, our study compared NIBP of the arms and legs with measurements of IBP. Our results showed that BP and BP were more common in the legs, which may indicate that calf NIBP is less reliable than upper arm NIBP.
In our study, the degree of BP shift was assessed using threshold values ​​of 5 and 10 mm Hg. Art., which have precedent in assessing the accuracy of automatic devices for measuring blood pressure. 18 While a difference in SBP of 5 or 10 mmHg Art. is adequate for adults with perfusion BP, these abnormalities may be more pronounced in children, especially those with borderline high or low BP, as their normal BP is lower. Waking blood pressure in 2-year-old children (mean age of the study population) was 90-105/55-70. Normal blood pressure in infants aged 0-3 months is 65-85/45-55. Art. in the latter patients can lead to severe hyperperfusion or hypoperfusion, a problem that can lead to damage and dysfunction of target organs. In addition, these normal waking blood pressure values ​​will be further lowered under general anesthesia. twenty
Although there are no consistent trends in MAP over or under measurement at the two NIBP measurement sites, our results extend the findings of previous studies comparing invasive and non-invasive BP measurements in children, which noted that differences between NIBP and IBP are common. Importantly, our study eliminated NIBP measurement errors caused by patient movement or activity while our patients were under general anesthesia. Our results highlight the need for further development of accurate, non-invasive blood pressure monitors and hemodynamic functions. The frequency of clinically significant changes also confirms the importance of invasive monitoring when hemodynamic instability or mild hypertension or hypotension is expected to be of particular concern to patients.
The results of the current study may be limited by potential sources of error. We consider IBP our gold standard for comparing NIBP measurements. When measuring invasive blood pressure with a fluid-coupled transducer, over- or under-measurement inaccuracies may occur depending on the size of the intra-arterial catheter, air bubbles in the system, kinked or compressed tubing, or displaced arterial cannula. 9 Initial Calibration Or errors may occur when positioning the transducer at the level of the patient's right atrium. NIBP measurements can be affected by an incorrectly sized BP cuff or external stimuli. While it is recommended to follow the recommendations for AHA cuff selection, the choice of cuff size is ultimately at the discretion of the staff anesthetist. This approach creates a cuff selection process consistent with our standard clinical practice. The resulting pressure biases are clinically significant biases that are expected to occur outside the scope of this study. In addition, there is no AHA recommendation for sizing a calf blood pressure cuff, so providers have referred to AHA's arm size recommendations when using calf cuffs. The patient's activity level is unlikely to change under general anesthesia, but external compression of the cuff by the surgeon, equipment, or OR personnel is possible.
Our study compared mean arterial pressure measurements obtained directly from cuff oscillation measurements and those obtained from invasive pressure pulse waveforms. Similarly, the obtained SBP and DBP of the oscillating cuff were compared with directly measured values ​​of the pulse pressure wave. We did not account for potential confounding factors such as the use of vasopressors, and radial vasoconstriction may increase the error between IBP and NIBP. It is also important to note that blood pressure can vary in different parts of the body. The deviations found between NIBP in the legs and BP in the arms (invasive or non-invasive) may reflect the true differences in blood pressure in these places. In addition, many of our patients undergo thoracic surgery, which can have a greater impact on blood pressure in the arms than in the legs. Although we did not explicitly control whether NIBP and IBP measurements were performed at the same or different patient sites, we used mixed effects regression to account for patient-level factors not explicitly included in our model. Thus, random effects absorbed these patient-level differences, which were constant between observations of the same patient. Although our inclusion criteria for the study were children under the age of 10, in fact most of our patients were much younger. Therefore, our results may not generalize to older children. Our results were also limited by the monitoring equipment used. There are differences in blood pressure readings between different monitor manufacturers. Oscillometric cuff manufacturers use various proprietary algorithms and our results are only applicable to the devices used in our study. 13:21–24
The fact that some values ​​differ from IBP readings by more than 30-40 mmHg points to the possibility of such a source of error. Because the data was recorded by the researchers, it was impossible to determine what caused such a large change and determine if the readings were accurate. To preserve the integrity of the study, these values ​​were recorded and included in the study cohort. In addition, we manually recorded BP data at 5-minute intervals, but we suspect that analysis of electronically collected continuous NIBP monitoring data may reveal more frequent inconsistencies between IBP and NIBP measurements.
Our data are new as they come from patients under general anesthesia, but they are consistent with previous studies comparing the correlation of invasive and non-invasive blood pressure measurements. The frequency of clinically significant NIBP abnormalities confirms the importance of monitoring NIBP when hemodynamic fluctuations are likely or when these fluctuations are especially dangerous. In addition, lower leg NIBP was more likely to result in a clinically significant deviation from invasively measured mean arterial pressure than upper arm NIBP. Given our results, decisions regarding cuff placement should not be arbitrary, but rather we recommend using the arm whenever possible during intraoperative blood pressure monitoring.
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24. Philips medical systems. 510(k) Presale notice for Intellivue Information Center software. Silver Springs, MD: US Department of Health and Human Services Food and Drug Administration; 2019. Available from: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?start_search=1&Center=&Panel=&ProductCode=DSI&KNumber=&Applicant=PHILIPS%20MEDICAL%20SYSTEMS&DeviceName=&Type=&ThirdPartyReviewed=&ClinicalTrials=&Decision=&DecisionDateFrom=&DecisionDateTo=07%2F24%2F2019&IVDProducts=&Redact510K=&CombinationProducts=&ZNumber=&PAGENUM=10&SortColumn=dd%5Fdesc. 2019. Available from: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?start_search=1&Center=&Panel=&ProductCode=DSI&KNumber=&Applicant=PHILIPS%20MEDICAL%20SYSTEMS&DeviceName=&Type=&ThirdPartyReviewed =&ClinicalTrials=&Decision=&DecisionDateFrom=&DecisionDateTo=07%2F24%2F2019&IVDProducts=&Redact510K=&CombinationProducts=&ZNumber=&PAGENUM=10&SortColumn=dd%5Fdesc. 2019. Доступно по адресу: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?start_search=1&Center=&Panel=&ProductCode=DSI&KNumber=&Applicant=PHILIPS%20MEDICAL%20SYSTEMS&DeviceName=&Type=&ThirdPartyReviewed =&ClinicalTrials=&Decision=&DecisionDateFrom=&DecisionDateTo=07%2F24%2F2019&IVDProducts=&Redact510K=&CombinationProducts=&ZNumber=&PAGENUM=10&SortColumn=dd%5Fdesc. 2019. Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?start_search=1&Center=&Panel=&ProductCode=DSI&KNumber=&Applicant=PHILIPS%20MEDICAL%20SYSTEMS&DeviceName=&Type= &ThirdPartyReviewed =&ClinicalTrials=&Decision=&DecisionDateFrom=&DecisionDateTo=07%2F24%2F2019&IVDProducts=&Redact510K=&CombinationProducts=&ZNumber=&PAGENUM=10&SortColumn=dd%5Fdesc. 2019. 可从:https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?start_search=1&Center=&Panel=&ProductCode=DSI&KNumber=&Applicant=PHILIPS%20MEDICAL%20SYSTEMS&DeviceName=&Type=&ThirdPartyReviewed =&ClinicalTrials=&Decision=&DecisionDateFrom=&DecisionDateTo=07%2F24%2F2019&IVDProducts=&Redact510K=&CombinationProducts=&ZNumber=&PAGENUM=10&SortColumn=dd%5Fdesc。 2019. 可从:https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?start_search=1&Center=&Panel=&ProductCode=DSI&KNumber=&Applicant=PHILIPS%20MEDICAL%20SYSTEMS&DeviceName=&Type=&ThirdPartyReviewed =&ClinicalTrials=&Decision=&DecisionDateFrom=&DecisionDateTo=07%2F24%2F2019&IVDProducts=&Redact510K=&CombinationProducts=&ZNumber=&PAGENUM=10&SortColumn=dd%5Fdesc。 2019. Доступно по адресу: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?start_search=1&Center=&Panel=&ProductCode=DSI&KNumber=&Applicant=PHILIPS%20MEDICAL%20SYSTEMS&DeviceName=&Type=&ThirdPartyReviewed =&ClinicalTrials=&Decision=&DecisionDateFrom=&DecisionDateTo=07%2F24%2F2019&IVDProducts=&Redact510K=&CombinationProducts=&ZNumber=&PAGENUM=10&SortColumn=dd%5Fdesc. 2019. Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?start_search=1&Center=&Panel=&ProductCode=DSI&KNumber=&Applicant=PHILIPS%20MEDICAL%20SYSTEMS&DeviceName=&Type= &ThirdPartyReviewed =&ClinicalTrials=&Decision=&DecisionDateFrom=&DecisionDateTo=07%2F24%2F2019&IVDProducts=&Redact510K=&CombinationProducts=&ZNumber=&PAGENUM=10&SortColumn=dd%5Fdesc. As of August 14, 2019

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