DEFINITION OF TERMS

Aneroid - Containing no liquid or actuated without the use of liquid

Arm - A human limb; technically the part of the superior limb between the shoulder and
the elbow but commonly used to refer to the whole superior limb
Auscultation - Listening to sounds within the body
Cuff - The lap consisting of a turned-back hem encircling the end of the sleeve or leg
Diastolic - Of or relating to a diastole or happening during a diastole
Heart - The hollow muscular organ located behind the sternum and between the lungs
Systolic - Of or relating to a systole or happening during a systole

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.

Consistently overestimating low blood pressure could increase the number of

people suffering from hypertension leading to being exposed to inappropriate therapy.
Whereas underestimating diastolic pressure could keep people having hypertension,
from life saving treatment. These factors reinforce the importance of accurate blood
pressure measurements.
There are two types of sphygmomanometers:

Manual sphygmomanometers require a stethoscope for auscultation. They are

used by trained practitioners. It is possible to obtain a basic reading through
palpation alone, but this only yields the systolic pressure.
o Mercury sphygmomanometers are considered to be the gold standard.
They measure blood pressure by observing the height of a column of
mercury, which do not require recalibration. Due to their accuracy, they are
often required in clinical trials of pharmaceuticals and for clinical
evaluations of determining blood pressure for high-risk patients including
pregnant women.
o Aneroid sphygmomanometers are in common use; they may require
calibration

checks,

unlike

mercury

manometers.

Aneroid

sphygmomanometers are considered safer than mercury based, although

inexpensive ones are less accurate. A major cause of departure from
calibration is mechanical jarring. Aneroids mounted on walls or stands are
not susceptible to this particular problem.

Digital, using oscillometric measurements and electronic calculations rather than

auscultation. They may use manual or automatic inflation. These are electronic,
easy to operate without training, and can be used in noisy environments; they are
not as accurate as mercury instruments. They measure systolic and diastolic
pressures by oscillometric detection, using apiezoelectric pressure sensor and
electronic components including a microprocessor. They do not measure systolic
and diastolic pressures directly, per se, but calculate them from the mean
pressure and empirical statistical oscillometric parameters. Calibration is also a
concern for these instruments. Most instruments also display pulse rate. Digital
oscillometric monitors are also confronted with several "special conditions" for
which

they

are

not

designed

to

as: arteriosclerosis; arrhythmia; preeclampsia; pulsus

be

used,

alternans;

such

and pulsus

paradoxus. Such people should use analog sphygmomanometers, as they are

more accurate when used by a trained person. Digital instruments may use a cuff
placed, in order of accuracy and inverse order of portability and convenience,
around the upper arm, the wrist, or a finger. The oscillometric method of
detection used gives blood pressure readings that differ from those determined
by auscultation, and vary subject to many factors, for example pulse
pressure, heart rate and arterial stiffness. Some instruments claim also to
measure arterial stiffness. However such machines are not recommended for
regular users as machines that claim to have 3% accuracy rate, are usually
inaccurate to over 7%, and even provided two different readings when checked
at the same time. Some of these monitors also detect irregular heart beats.

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.

3. A number of aneroid and oscillometric devices onthe market have not

been validated by their manufacturers and others do not perform as
manufacturers

claim.

Consumers

of

these

devices

should

review

compliance of particular devices with available independent validation

protocols.
4. Routine calibration of mercury and aneroid devices should occur on an
annual basis and consideration should be given to checking portable
devices, which are more prone to bumping and dropping, on a biannual
schedule.
5. The Emergency Care Research Institute (ECRI) recommends calibration
with a digital pressure gauge as the most accurate manometric device. This
organization also makes specific recommendations for pressure gauge
type/brand. The American Heart Association recommends that the
calibration standard be a either a mercury sphygmomanometer or an
electronic pressure gauge. Despite the apparent 10-fold improvement in
accuracy when the pressure gauge is used, the British Hypertension
Society to this point recommends using a mercury sphygmomanometer as
the comparison standard for calibration. Moreover, WHOs 2005 position
paper on Mercury in Health Care (WHO 2005) provides that in the short
term, Before final replacement has taken place, and to ensure that new
devices conform to recommended validation protocols, health-care

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

necessary for calibration, validation, or measurement of blood pressure in

clinical or research settings. Alternative devices are either equally or more
accurate when maintained properly and are likely to have far less
occupational or environmental toxicity.

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.