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INTRODUCTION
The accurate measurement and control of blood pressure are key elements in
the prevention of cardiovascular disease and stroke. Mercury sphygmomanometers,
first developed over 100 years ago and largely unchanged since, are used in both
hospital and ambulatory settings. They have been considered the gold standard blood
pressure measuring devices from which treatment guidelines are developed.
However, mercury has been found to be a potent human neurotoxin.
Environmental mercury pollution, mainly from industrial sources such as coal-fired
power plants and trash incineration, enters waterways via industrial run-off or settling of
airborne particulate matter. It is metabolized by microorganisms into methyl mercury,
which then accumulates in fish. In the United States, this has contaminated 30% of U.S.
lakes and wetlands, causing 44 states to issue fish advisories recommending limits on
the ingestion of locally caught fish by pregnant and nursing women and children. As
health care facilities contribute to mercury pollution via breaks and spills and the burning
of medical waste, an international effort has developed over the last several years to
eliminate the most common health care sources of mercury the thermometer and
sphygmomanometer.
The first indirect blood pressure device utilizing a mercury manometer was
developed by Italian physician Scipione Riva-Rocci in 1896 (Roguin 2006). In 1905,
Nikolai Korotkoff introduced the auscultory technique, which replaced arterial palpation
and established the presence of the diastolic pressure. Indirect blood pressure
monitoring has not changed much since that time. Mercury sphygmomanometers are of
relatively simple design, consisting of a column of mercury connected by rubber tubing
to a manually inflated cuff. Blood pressure is read using the auscultatory technicque,
using Korotkoff sounds I and V to identify systolic and diastolic pressure readings.
The two commonly used alternatives to mercury sphygmomanometers are the
aneroid and oscillometric devices. Aneroid (meaning without fluid) sphygmomanometers use mechanical parts to transmit the pressure in the cuff to a dial. As the cuff
pressure rises, a thin brass corrugated bellows expands, triggering movement of a pin
resting on the bellows. This movement is amplified by a series of gears and transmitted
to the dial where the blood pressure is read. As with mercury devices, the cuff is inflated
and deflated manually and the traditional auscultatory technique is used to identify
systolic and diastolic pressures.
TOPIC PRESENTATION
Blood pressure is measured through the use of a medical instrument called
Sphygmomanometer. It is a quick, painless test. A compression cuff is wrapped around
a person's upper arm and inflated. The large artery in the arm is compressed and the
flow of blood is momentarily stopped. As the air in the cuff is released, the person
measuring the blood pressure listens with a stethoscope. When the blood starts to pulse
through the artery, it makes a sound. This sound is heard continuously until pressure in
the artery exceeds the pressure in the cuff. As the person listens and watches the
sphygmomanometer scale, he or she records two measurements. The systolic pressure
is the pressure of the blood flow when the heart beats. The diastolic pressure is the
pressure between heartbeats. This sound is called as Korotkoff sound as it was
discovered by Dr. Korotkoff. Blood pressure is measured in millimeters of mercury,
which is abbreviated mm Hg. The harder it is for blood to flow, the higher the numbers
will be. Diagnosis of hypertension affects the life of an individual at various levels. A
continual monitoring and treatment follows the detection of hypertension. This has
psychological and socioeconomic implications on the patient. Thus people identified
incorrectly as having hypertension may have adverse effects of medication and have
increased treatment cost and insurance. On the other hand if a truly hypersensitive
patient is not diagnosed, it can lead to catastrophic event. Thus these reasons result in
leaving no room for error in blood pressure measurements.
checks,
unlike
mercury
manometers.
Aneroid
they
are
not
designed
to
be
used,
alternans;
such
and pulsus
Technical Operation
In humans, the cuff is normally placed smoothly and snugly around an
upper arm, at roughly the same vertical height as the heartwhile the subject is seated
with the arm supported. Other sites of placement depend on species, it may include the
flipper or tail. It is essential that the correct size of cuff is selected for the patient. Too
small a cuff results in too high a pressure, while too large a cuff results in too low a
pressure. For clinical measurements it is usual to measure and record both arms in the
initial consultation to determine if the pressure is significantly higher in one arm than the
other. A difference of 10 mm Hg may be a sign of coarctation of the aorta. If the arms
read differently, the higher reading arm would be used for later readings. The cuff is
inflated until the artery is completely occluded.
With a manual instrument, listening with a stethoscope to the brachial artery at
the elbow, the examiner slowly releases the pressure in the cuff. As the pressure in the
cuffs falls, a "whooshing" or pounding sound is heard when blood flow first starts again
in the artery. The pressure at which this sound began is noted and recorded as
the systolic blood pressure. The cuff pressure is further released until the sound can no
longer be heard. This is recorded as the diastolic blood pressure. In noisy environments
where auscultation is impossible, systolic blood pressure alone may be read by
releasing the pressure until a radial pulse is palpated. In veterinary medicine,
auscultation is rarely of use, and palpation or visualization of pulse distal to the
sphygmomanometer is used to detect systolic pressure.
Digital instruments use a cuff which may be placed, according to the instrument,
around the upper arm, wrist, or a finger, in all cases elevated to the same height as the
heart. They inflate the cuff and gradually reduce the pressure in the same way as a
manual meter, and measure blood pressures by the oscillometric method.
Significance
By observing the mercury in the column while releasing the air pressure with a
control valve, one can read the values of the blood pressure in mm Hg. The peak
pressure in the arteries during the cardiac cycle is the systolic pressure, and the lowest
pressure is the diastolic pressure. A stethoscope is used in the auscultatory method.
Systolic pressure is identified with the first of the continuous Korotkoff sounds. Diastolic
pressure is identified at the moment the Korotkoff sounds disappear.
Measurement of the blood pressure is carried out in the diagnosis and treatment
of hypertension, and in many other healthcare scenarios.
CONCLUSION
Mercury is converted to an environmental neurotoxic hazard at extremely
low levels, and therefore its use is discouraged where possible. The World Health
Organization and other international bodies are committed to removing mercurycontaining devices from health care settings. Several countries have completely
replaced mercury sphygmomanometers with alternative devices that soon will
become the norm worldwide. Yet, are mercury sphygmomanometers necessary
for calibration, validation, or measurement of blood pressure in clinical or
research settings? Based on this review of alternative devices, their mechanisms
and accuracy, and current validation protocols, we conclude that:
1. Properly calibrated and maintained aneroid sphygmomanometers are
likely to be equally or more accurate than mercury devices. While
calibration should be more frequent than with mercury devices the
obstacles are minor and add little to the cost of use at the institutional
level.
2. Validated oscillometric devices with digital displays have been
demonstrated to be accurate and provide the possibility of removing interobserver differencesin blood pressure measurement. While early data is
promising, as yet these devices have not been validated for certain clinical
conditions includingarrhythmias.
claim.
Consumers
of
these
devices
should
review
facilities will need to keep mercury as the gold standard to ensure proper
calibration of mercury sphygmomanometers.
However, it now appears that an electronic pressure gauge provides
consi derably more reliability than a mercury manometer in repetitive
measurements of pressure for purposes of device calibration. The
precision of these gauges is superior to all three types of pressurerecording gauges for blood pressure measurement, including the glass
mercury manometer as a stand-alone display. This device therefore should
be substituted for the mercury manometer for calibration and validation
purposes. At this point it appears that the most accurate calibrating
protocol utilizes a digital pressure gauge which should be adapted for use
by validating organizations.
In
sum,
mercury
sphygmomanometers
are
not
scientifically
BIBLIOGRAPHY
Dr. Gelfer, Mark, Medical Director, VSM MedTech Ltd. 2003. Addressing the Need for
Accurate Blood Pressure Measurements - A Review of the Evidence.
Business Briefing. Global Healthcare.
Internet Resources:
Dr. Blood Pressure. November, 2003. All about High blood pressure [online]; available
from http://www.drbloodpressure.com; Internet; accessed 5th November 2003.
W.A. Baum Co., Inc. November, 2003. Importance of Blood Pressuremeasurement,
[online]; available from http://www.wabaum.com/baum/: Internet; accessed 14th
November 2003.