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Invasive Hemodynamic Blood Pressure Monitoring: What is it and what are its

technical issues?
What is pressure?
Pressure is force per cross-sectional area. Pressure is measured most often in units
of millimeters of mercury (mm Hg) or centimeters of water (cm H2O). 1 cm H2O is
equivalent to 1.36 mm Hg. Invasive pressures are measured with a transducing system,
which contains an external, disposable, fluid-air interface which detects changes of
pressure in the vessel via a column of fluid between the catheter in the blood vessel and a
diaphragm within the transducer. This diaphragm conveys the fluctuations in pressure to a
silicon chip which, when amplified can be displayed on a monitor as an arterial
waveform with the correlating blood pressure (7).
How to measure pressure?
Three factors have to be considered when using a transducer: (1) calibration, (2)
zero setting and (3) and leveling.
In the process of calibration a known pressure is applied to the membrane and
change in current is related to the applied pressure. For proper function, the response of
the transducer must be linear in the range of measured pressures. This means that
doubling the pressure doubles the voltage change in the range of the measured pressures.
The establishment of the zero value is the concept of making hydrostatic
measurements with fluid-filled systems relative to a reference value, usually atmospheric
pressure (760mm Hg), and then examining the change from that value. The process of
zeroing involves opening the fluid column on the measuring device to the atmosphere
and setting the system such that atmospheric pressure is the starting value.
Just as important as a proper zero is use of the proper level. The measured
pressure is determined by the change in height of the fluid column relative to the
transducer. Therefore the choice of the transducer level is critical. A widely used
reference point is the midpoint of the right atrium (corresponding to the sternal angle),
because this reflects the cardiac preload, though other locations may be chosen based on
clinical interest (the external auditory meatus for intracranial surgery, for example, best
approximates the pressure delivered to the brain) (3). If the sternal angle is used as a
reference point, the system should be arranged such that the stopcock used for zeroing is
at that same level of height. The difference between this height of the stopcock and the
height of the transducer can have a considerable effect on the measured pressure; thus it
is significant which stopcock is chosen for the zeroing (that at the transducer or that at
the catheter entry site). Once the zero and the level are chosen, if the height of either
change in relation to the patient height, the blood pressure reported will be erroneous (for
every 10cm change in height, the pressure will change by approximately 8mm Hg). If
the transducer was zeroed at the level of the patients right atrium then moving the
extremity of which the arterial line is placed in will have no effect on the pressure
reading, because the level of zero and the transducer are the same. If, however, the
system was zeroed at the catheter site, rather than the tranducer site, movement of the

extremity will have an effect on the pressure reading, as the level of the zero and the
transducer are no longer the same.
An additional factor of key importance is the length of the tubing between the
transducer and the cannulae. The tubing must be stiff, non-pliant, less than 120 cm in
length and of a 'large' diameter (6). This is important because the tubing must conduct the
pulsatile fluid movement from the tip of the cannulae to the transducer without being
compressed, and at a similar frequency to the air-fluid interface to remain an accurate
reflected value. If tubing is too long or too short, or if the tubing is soft and pliable, the
accuracy of the readings will be compromised (overdamped or underdamped, discussed
below).
Lastly, the intra-arterial cannulae itself is connected directly to the non-pliant
tubing leading to the transducer. The cannulae is inserted into the artery in the opposite
direction to the flow of the blood. This is so that there is a pulsatile movement in the fluid
column which is detected by the diaphragm in the transducer and converted to a
waveform.
What are the concepts of natural frequency and damping of a transducer system?
Frequencies: Most transducers have frequencies of several hundred Hz (> 200 Hz for
disposable transducers), which is important because the natural frequency of the
measuring system must exceed the natural frequency of the arterial pulse (approximately
16-24 Hz. (8) Ifthemonitoringsystemhasafrequencythatistoolow,frequenciesinthe
monitoredpressurewaveformwillapproachthenaturalfrequencyofthemeasurement
system.Asaresult,thesystemwillresonate,andpressurewaveformsrecordedonthe
monitorwillbeamplifiedversionsoftrueintraarterialpressure.Thisphenomenonisthe
waveformthatdisplaysovershoot,ringing,orresonance.Tachycardiaandsteepsystolic
pressureupstrokespresentthegreatestchallengeforclinicalmonitoringsystemsbecause
thehigherfrequencycontentofthesewaveformsmorelikelyapproachestheresonant
frequencyofthemeasurementsystem.(7)
Damping:Inadditiontoasufficientlyhighnaturalfrequency,thebedsidemonitoring
systemmustalsohaveanappropriatedampingcoefficient. This becomes relevant in
practice because the addition of tubing, stopcocks and air all decrease the frequency of
the system potentially leading to overdamping and underestimating the systolic pressure.
An overdamped arterial pressure waveform is recognized by its slurred upstroke, absent
dicrotic notch, and loss of fine detail. Severely overdamped pressure waves display a
falsely narrowed pulse pressure, although MAP may remain reasonably accurate. In
contrast, underdamped pressure waveforms display systolic pressure overshoot and
contain additional artifacts produced by the measurement system that are not part of the
original intravascular pressure wave. An underdamped waveform can lead to overshoot
and a falsely high BP. (7) A damping coefficient of 0.6-0.7 is optimal and can be
determined by examining tracing oscillations after a high-pressure flush. (8)

How to set up an Arterial Line:


1. Prepare a 500 ml bag of normal saline. Most institutions no longer use heparinized
solution (explanation below). Connect the saline solution and the transducer
administration set. Pressurize the bag to 300 mmHg, and flush the solution through
completely, taking great care to remove all air from the tubing and transducer set ports.
As discussed above, even the smallest air bubble can compromise transducer accuracy.
2. Maintain the bag pressure at 300 mm Hg. The purpose of this is to provide
backpressure to prevent blood from contaminating the transducer.
3. With the transducer connected to the monitor, select arterial monitor, and perform a
square wave test by fast flushing the line and observing a change in the waveform
(waveform becomes a flat line at a high pressure then dips down to a low pressure, before
ensuing with the actual pressure tracing).
4. Zero the transducer and monitor by placing the transducer at the phlebostatic axis of
the patient. Close the stopcock to the patient and open it to air. Press zero on the monitor.
To monitor pressure, close the stopcock to air and open it to the patient.
5. Connect the patient catheter and fast flush to clear the catheter of blood.
6. An arterial waveform and pressure readings should be displayed on the monitor screen.
Check for good waveform with optimal damping.
**Gamby and Bennet (1995) have concluded that this is unnecessary. They conducted a
study comparing heparinized and non-heparinized flush bags and concluded that "it is the
constant flush under pressure which maintains patency of the cannulae rather than
heparinization of the flush. This research demonstrates that the flush bag does not need
to be heparinized, just pressurized.
References used (included PubMed ID when possible):
1. Baigrie RS, Morgan CD. Hemodynamic monitoring: catheter insertion
techniques, complications and trouble-shooting. Can Med Assoc J. 1979 Oct
6;121(7):885-92.
2. Magder, S. Invasive Intravascular Hemodynamic Monitoring: Technical Issues.
Critical Care Clinics. 23(3), 2007.
3. Courtois M., Fattal P.G., Kovacs S.J., et al: Anatomically and physiologically
based reference level for measurement of intracardiac pressures. Circulation 92.
1995.
4. Fessler H.E., Shade D.: Measurement of vascular pressure. In: Tobin M.J., ed.
Principles and practice of intensive care monitoring, McGraw-HillNew
York1997: 91-106.

5. Murray DJ, Boulet JR, Kras JF, Woodhouse JA, Cox T, McAllister JD. Acute care
skills in anesthesia practice: a simulation-based resident performance assessment.
Anesthesiology. 2004 Nov;101(5)1084-95.
6. Gaba DM, Fish KJ, Howard SK. Hypotension: Crisis Management in
Anesthesiology. New York: 1994:77-79.
7. Sprague DH, Just PW. High and low Blood Pressure-when to treat? Probl Anesth.
1987. 1:273.