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UHNT ICU
How it works
How it works
An arterial vessel is cannulated under aseptic conditions with a 20 guage cannula using seldinger (guideline) technique. There are 2 types of cannula in the UHH & UHNT trust flow switch or vygon (vygon cannulas are used for more difficult cannulation). The arterial catheter is connected to a 1000ml flush bag of NaCl and pressurised to 300mmHg (also required for KVO running @ 3ml/hr). At the mid point in the pressurised connecting tube there is a transducer point and this is connected directly to the patients monitoring device. The pressure transducer converts the patients arterial blood pressure oscillations into an electrical waveform that is readable on the monitoring device. The resulting arterial pressure wave differs depending on the site of vascular cannulation i.e. radial, femoral, etc. this is due to several factors including
Fluid status Vessel pathology Cannulation quality (including thrombus, phlebitis and/ or vasospasm) Reflection waves throughout the arterial tree (more evident in the more distal catheters).
The following slide shows the effects of wave reflection/deflection on the systolic and diastolic arterial blood pressure. Note that the mean arterial blood pressure is fairly constant. Wave reflection/deflection occurs as the blood passes through the arterial tree under pressure. If all of the vessels were straight, and had no branches, then the flow of blood would be direct and the pressure at each end would be the same. However, as arteries are under constant pressure adjustment (musclular wall adjustment) and as they have bends and many branches, the flow of blood becomes less laminar it becomes turbulent and its this turbulance that causes the systolic pressure to rise and the diastolic pressure to fall slightly in the more distal arteries.
Is it accurate?
Now we know how the arterial pressure monitoring system works, we need to be able to decide whether or not the trace (and BP in numerical format) is accurate. Failure to notice this may lead to unnecessary, or missed treatments for our patients. There are 2 main abnormal tracing problems that can occur once the monitor gain is set correctly.
Dampened trace
Resonant trace
If in doubt: NIBP!
Waveform Anatomy
Anacrotic limb
The anacrotic limb represents the first phase of the arterial pulse cycle It occurs as the ventricles eject the blood into the arterial tree and gives a visual record of the arterial pressure rising to that of the end systole. The steepness of the ascending phase can be affected by heart rate, increased systemic vascular resistance, and through the use of vasopressors such as noradrenaline (more steep incline) and vasodilators such as GTN (less steep incline). Myocardial contractility also effects the steepness of the anacrotic limb during impaired contractility (post MI for example) the up-sweep, or the rate of pressure increase can be prolonged (see next slide). As the pressure reaches maximum, and the wave makes sharp turn to level off, this is called the anacrotic notch
Bisferiens tracing
a
Dicrotic limb
Descending limb of the arterial pressure trace as the pressure falls to that of the end diastolic pressure Dicrotic means twice beating meaning that this phase of the arterial pressure pulse should have a second, smaller wave, known as the dicrotic notch
Dicrotic notch
Can occur at any point that there is a fluctuation in pressure during the descending arterial limb. The most common time for this to occur is when the aortic and pulmonary valves snap shut causing pressure reverberations through the arterial system this is displayed visually on the next 2 slides (the first slide is by far the easiest!)..
Dicrotic limb: 2
The rate of dicrotic fall-off, or the rate at which the arterial line trace falls from end-systole to early-diastole changes in relation to systemic vascular resistance. In patients with a severely reduced arteriolar resistance, fall-off time is rapid. This occurs as soon as end-systole finishes due to the greatly reduced pressure in the arterial tree (representing reduced afterload). The arterial waveform in this clinical state looks thin and pointed (dont confuse this with resonance). In patients with increased vascular resistance, such as main vessel stenosis for example, the dicrotic fall-off time is greatly increased. This occurs due to the length of time it takes to return to end-diastolic pressure. The arterial waveform in this clinical state may be normal, or quite fat!
If in doubt: NIBP!
Arterial swing
sv = stroke volume
If in doubt: NIBP!
The end.
08.04.2008 UHNT ICU