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Monitoring Arterial Blood Pressure: What You May Not Know

Beate H. McGhee and Elizabeth J. Bridges

Crit Care Nurse. 2002;22: 60-79

© 2002 American Association of Critical-Care Nurses
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Critical Care Nurse is the official peer-reviewed clinical journal of the American
Association of Critical-Care Nurses, published bi-monthly by The InnoVision Group,
101 Columbia, Aliso Viejo, CA 92656. Telephone: 949-362-2000. Fax:
949-362-2049. Copyright 2002 by AACN. All rights reserved.

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Monitoring Arterial
Blood Pressure:
What You May Not Know
Beate H. McGhee, BSN, MN, APN
Maj Elizabeth J. Bridges, USAF, NC

and mismanagement. The results published and unpublished, indi-

To receive CE
credit for this of a recent pilot study1 at 2 univer- cate a general knowledge deficit in
article, visit the sity-affiliated hospitals suggested pulmonary artery pressure moni-
American Asso-
ciation of Critical- a knowledge deficit in arterial toring. Because of these research
Online Care Nurses’ pressure monitoring and some of findings, in this article, we focus
(AACN) Web site
the most basic aspects of hemo- on areas of particular knowledge
at http://www.aacn
.org, click on dynamic monitoring. A total of deficit related to essential princi-
"Education" and select “Continuing 391 critical care nurses practicing ples of hemodynamic monitoring
Education,” or call AACN’s Fax on
Demand at (800) 222-6329 and in various critical care specialties and ABP monitoring. We discuss
request item No. 1152. were invited to participate in the the physiology of ABP, physiologi-
study. The response rate was cal and pathophysiological factors
17.4% (n = 68). Most of the partici- that affect ABP, and the arterial

pants were between the ages of 30 pressure waveform and its inter-
and 39 years (56.1%) and had a pretation in clinical situations
blood pres-
baccalaureate degree as their common in critical care patients.
sure (ABP)
is a basic basic (61.8%) and highest degree
hemody- in nursing (58.8%). Most partici- ABP PHYSIOLOGY
n a m i c pants had more than 4 years of The cardiovascular system has
index often nursing experience (94.1%) and 3 types of pressures 6,7: hemody-
utilized to critical care experience (83.9%), namic, kinetic energy, and hydro-
guide therapeutic interventions, and most did direct ABP monitor- static. Hemodynamic pressure is
especially in critically ill patients. ing at least once or twice each the energy imparted to the blood
Inaccurate ABP measuring cre- week (97.1%). The participants by contraction of the left ventricle.
ates a potential for misdiagnosis were asked to complete an 18-item, This type of pressure is preserved
criterion-referenced question- by the elastic properties of the
naire on ABP physiology, techni- arterial system. Kinetic energy is
Beate H. McGhee is an adult care cal aspects of ABP monitoring, the energy associated with motion
nurse practitioner and a recent and ABP waveform interpretation and affects the pressure measured
graduate of the master’s program in
the School of Nursing, University of in selected pathophysiological during direct ABP monitoring.
Washington, Seattle, Wash. Maj conditions. The mean score in Fluid density and gravity con-
Elizabeth J. Bridges has a doctoral this pilot study was 36.7% (SD, tribute to hydrostatic pressure,
degree from the School of Nursing,
University of Washington, Seattle. 11.8%). Total scores ranged from which is the pressure a column of
11.1% to 61.1%. fluid exerts on the container wall.
To purchase reprints, contact The InnoVision
Group, 101 Columbia, Aliso Viejo, CA 92656. Literature on nurses’ knowl- For example, in a column of fluid,
Phone, (800) 809-2273 or (949) 362-2050 edge of hemodynamic monitoring the pressure at a given level in the
(ext 532); fax, (949) 362-2049; e-mail, is limited, but several studies, 2-5 container is proportional to the

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height of the fluid column above rect indicator of left ventricular a wide range of mean pressures
that level. The pressure is highest contractile force), systemic arterial (60-150 mm Hg) to protect func-
at the bottom of the column. In resistance, the distensibility of the tioning of the organ.7,20 MAP is the
the vascular system, hydrostatic aortic and arterial walls, the vis- product of SVR and cardiac output
pressure is proportional to the cosity of blood, and the left ven- (MAP=SVR×cardiac output).7,10
height of the column of blood tricular preload (end-diastolic As indicated previously, a main
between the heart and the periph- volume).11-13 The blood pressure in determinant of SVR is the radius of
eral vasculature. In a standing the aorta during systole is a clinical arterial, and particularly arteriolar,
person, the pressure in the leg is indicator of afterload (the sum of vessels. Changes in cardiac output
higher than the pressure in the the forces the left ventricle must are related to heart rate and stroke
arm by the difference in hydro- overcome to eject blood).14,15 The volume. Stroke volume, in turn, is
static pressure. In summary, arte- diastolic pressure is affected by determined by several factors,
rial blood pressure represents the blood viscosity, arterial distensibil- including heart rate, preload, after-
force exerted by the blood per ity, systemic resistance, and the load, cardiac contractility, and syn-
unit area on the arterial wall6-8 and length of the cardiac cycle.11,16 ergy of cardiac contraction (related
is the sum of hemodynamic, Pulse pressure is the difference to ventricular dilatation, abnormal-
kinetic, and hydrostatic pressure. between systolic and diastolic ities in ventricular wall motion, and
The arterial tree starts with the pressure. A normal pulse pressure ventricular arrhythmias).10,11 MAP is
aorta and the major branches of in the brachial artery is approxi- generally closer to diastolic pres-
this vessel. The aorta and its mately 40 mm Hg. An increased sure because diastole represents
branches stretch to receive blood pulse pressure may be the result of about two thirds of the cardiac
from the left ventricle and recoil increased stroke volume or ejec- cycle when the mean heart rate is
to distribute the blood and to tion velocity and is common dur- close to 60/min. This relationship
maintain arterial pressure. Art- ing fever, exercise, anemia, and is expressed in the well-known for-
eries and arterioles control blood hyperthyroidism.11 Other causes of mulas MAP = DBP + (SBP -DBP)/3
pressure through vasoconstric- increased pulse pressure include and MAP = [SBP + (DBP x 2)]/3.
tion or vasodilation. 6 Arterioles bradycardia (increased stroke vol- However, the proportion of
are the primary sites that con- ume), aortic regurgitation, and diastole in the cardiac cycle
tribute to systemic vascular resis- arterial stiffening, which is most changes with changes in heart
tance (SVR). 6,9-11 In addition, noticeable after the age of 50 to 60 rate. In calculations of MAP for a
adrenergic control of the arteri- years. 11,17-19 An acute decrease in manually obtained ABP, these for-
oles is a major determinant of pulse pressure may indicate an mulas must be used with caution,
blood flow into the capillaries. In increase in vascular resistance, because they provide a good esti-
the skin, for instance, blood can decreased stroke volume, or mate of MAP only when the heart
be shunted from the capillary decreased intravascular volume.11-13 rate is close to 60/min. 10 Fortu-
beds to flow directly from arteri- Systemic mean arterial pres- nately, MAP is provided by most
oles into the venous system. 9 sure (MAP) is defined as the mean automatic ABP measuring devices
Arteriovenous shunting occurs in perfusion pressure throughout the and direct ABP monitoring sys-
shock states and helps to redirect cardiac cycle. MAP is sensed by tems, each of which uses a system-
blood flow to vital organs. Arterio- baroreceptors located in the specific method to directly
venous shunting is one reason carotid sinuses and the arch of the determine MAP.
measurements of blood pressure aorta. These receptors control arte- In summary, because of the
alone are not a good indicator of rial pressure mainly by adjusting multiplicity of factors that con-
peripheral tissue perfusion. heart rate and arteriolar vessel tribute to ABP and the complexity
Arterial pressure is measured at radius. MAP is also the basis for of their interrelationships, inter-
its peak, which is the systolic blood autoregulation by some organ sys- preting changes in arterial pres-
pressure (SBP), and at its trough, tems such as the kidney, heart, and sure and its components (SBP,
which is the diastolic blood pres- brain. Autoregulation is the auto- DBP, MAP, and pulse pressure) as
sure (DBP). The SBP is determined matic adaptation of the radius of indicative of any single factor may
by the stroke volume, the velocity an arteriolar vessel in an organ to lead to an erroneous assessment
of left ventricular ejection (an indi- maintain constant blood flow over of a patient’s condition. When SBP

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and DBP are measured using dif- though clinicians have little con- of the most frequent and impor-
ferent (oscillometric or direct) trol over the electronic compo- tant sources of error in hemody-
monitoring methods, the values nents such as the monitor, correct namic monitoring. Air bubbles
can differ significantly. When MAP setup and maintenance of the most often blunt or damp propa-
is measured using different moni- tubing system and the pressure gation of the mechanical signal,
toring methods, however, the val- transducer are absolutely crucial causing a damped analog wave-
ues are very similar, because MAP to avoid error. With an improperly form and erroneous pressure
is little affected by the phenom- prepared or inadequately func- readings.27 Even tiny air bubbles
enon of wave reflection.21-25 Wave tioning monitoring system, not only 1 mm in diameter can cause
reflection and other factors that only the actively measured hemo- serious waveform distortion. 28
affect measurement of SBP and dynamic indices but also any Therefore, air-free priming of the
DBP are discussed later. derived variables will be errone- entire tubing system is one of the
ous, 26 potentially invalidating a most important steps to avoid
PRINCIPLES OF patient’s entire hemodynamic pro- technical error.
HEMODYNAMIC file. Three procedural steps should Air-free priming starts with
MONITORING be followed to prepare the moni- removal of all air from the flush
Three Conventions of toring tubing system and ensure its solution to prevent air from going
Cardiovascular Pressure continued accuracy: priming of the into the solution as a result of the
Measurement pressure tubing, leveling and zero- pressure applied by the external
For measurement of cardio- ing, and dynamic response testing. pressure cuff. Then, the entire
vascular pressures, 3 conventions Priming of the Pressure Tubing. tubing system should be flushed.
are observed 6,7,20 : (1) Cardio- The generation and recording of all Stopcocks, Luer-Lok interconnec-
vascular pressures are expressed arterial waveforms (systemic arteri- tions, and the transducer are com-
in millimeters of mercury, with al pressure and pulmonary artery mon locations of air entrapment27
the exception of central venous pressure) are based on the same and deserve special attention
pressure, which may be measured basic principles. The invasive throughout priming and use of the
in millimeters of mercury or in catheter provides access to the catheter system. In order to main-
centimeters of water. For convert- arterial system being monitored tain the air-free status after the
ing values in centimeters of water and is designed to pick up the pres- initial setup of the system, the fol-
to values in millimeters of mer- sure waves generated in the arterial lowing measures are important:
cury, the value given in centime- system by cardiac contractions. ■ After opening the system for
ters of water is divided by the The catheter is connected to the blood sampling or zeroing, briefly
factor 1.36. (2) Most cardiovascu- fluid-filled tubing of the monitor- fast-flush the tubing system,
lar pressures, such as ABP, central ing system. The fluid column in the including the proximal access
venous pressure, and pulmonary tubing system carries the mechan- stopcock or the air-fluid interface
artery pressure, are referenced to ical signal created by the pressure stopcock.
the heart or, more specifically, to wave to the diaphragm of the elec- ■ Tighten all connections, and
the atria, to eliminate hydrostatic trical pressure transducer. The ensure that the stopcocks are
pressure. (3) All cardiovascular transducer creates the link between closed to air.
pressure monitoring devices are the fluid-filled tubing system and ■ Avoid adding stopcocks and
zeroed to ambient atmospheric the electronic system, and converts line extensions.
pressure, so that the actual pres- the mechanical signal into an elec- ■ Keep the flush solution bag
sure measured reflects the pres- trical signal. The electrical signal is adequately filled, and keep the
sure above atmospheric pressure. transmitted to the monitor and external pressure cuff at 300 mm Hg.
then is amplified and displayed as ■ Periodically flick the tubing
The Hemodynamic an analog waveform and digital system and flush the tubing sys-
Monitoring System output. tem and stopcocks to eliminate
A hemodynamic monitoring Air as a medium transmits tiny air bubbles escaping the
system contains 2 compartments: mechanical impulses much dif- flushing solution.
the electronic system and the ferently than does fluid. Air bub- Leveling and Zeroing. The
fluid-filled tubing system. Al- bles in the tubing system are one arterial pressure monitoring sys-

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tem must be referenced to heart central arterial pressure is the Zeroing consists of 2 steps.
level, technically the level of the pressure of interest, because it is First, the air-fluid interface is
left atrium, and set at atmospher- a key determinant in cardiac and opened to atmospheric pressure.
ic pressure as the zero reference cerebral perfusion. In order to Then the monitor’s zeroing func-
point. These criteria can be met monitor central arterial pressure, tion key or button is pressed.
through leveling and zeroing. the monitoring system must be Zeroing in this fashion has several
Leveling or referencing of the leveled to the heart by using the purposes. Zeroing electronically
catheter system is accomplished phlebostatic axis. Research indi- establishes for the monitor atmo-
by aligning the air-fluid interface cates that the phlebostatic axis spheric pressure as the atmospher-
of the monitoring system (eg, the most accurately reflects the level ic zero reference point. Zeroing
stopcock on top of the transduc- of the atrium in both supine and establishes the interface level as
er) with the external reference upright patients.29-31 The midaxil- the hydrostatic zero reference
point of the heart. The external lary line, which has also been point. Zeroing also eliminates zero-
reference point of the heart is the used as an external reference drift. Zero-drift is the potential, but
phlebostatic axis, which can be point for the heart, is not accurate usually minimal, transducer offset
located by finding the junction of in all chest configurations and or distortion occurring over time.33
2 lines: a vertical line drawn out thus is not recommended.31 When Two key practice objectives are
from the fourth intercostal space the monitoring system is refer- related to referencing and zeroing:
at the sternum and a horizontal enced to the tip of the catheter, accuracy and consistency. In order
line drawn through the midpoint then the transmural pressure of a to ensure accuracy, leveling and
of a line going from the anterior to particular point in the arterial tree zeroing must be done whenever
the posterior side of the chest.29,30 is monitored and not central arte- the relationship between the air-
Where to level the air-fluid rial pressure. Peripherally mea- fluid interface and the reference
interface is a matter of discussion. sured transmural pressure is point is changed. The reason is
The answer depends on which markedly increased by hydrostat- hydrostatic pressure. For every 1
vascular bed is to be monitored. ic pressure unless the patient is cm the air-fluid interface is above
In most clinical situations, the supine.32 or below the actual level of the left

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atrium, 0.74 mm Hg of hydrostatic correct determination of trends in of the catheter system must be
pressure is subtracted or added to a patient’s hemodynamic status. tested. Only when system accura-
the measured pressure. If the air- Whether the same body position cy, also termed fidelity, has been
fluid interface is placed 10 cm must be used for consecutive confirmed, can the analog wave-
below the phlebostatic axis, the measurements may be debatable. form be accepted as an accurate
measured pressure will be an over- Although several studies on pul- reflection of a patient’s status.
estimation of the actual hemody- monary artery pressure monitor- The dynamic response of a
namic pressure by 7.4 mm Hg. This ing indicated no significant hemodynamic monitoring system
example illustrates that though changes in pulmonary artery is defined by its natural frequency
accurate referencing and zeroing pressures related to certain bed and the damping coefficient. The
are important for all hemodynamic positions, according to a recent natural frequency indicates how
monitoring, they become even research abstract, 35 ABP values fast the pressure monitoring sys-
more crucial when small hemody- obtained with various bed posi- tem vibrates when shock excited by
namic pressures, such as pul- tions differed even when the phle- a signal such as the arterial pres-
monary artery wedge pressure bostatic axis was used as the sure pulse or the pressure signal
(6-12 mm Hg) and central venous external reference point. The sta- caused by a fast-flush test. The
pressure (2-6 mm Hg) are being tistical significance of differences damping coefficient of a monitor-
monitored. In these instances, in ABP values for monitoring sys- ing system is a measure of how
small offsets from the phlebostatic tems referenced to the phlebo- quickly the oscillations of a shock-
axis and the zero reference point static axis was not addressed in excited system dampen and even-
can cause large errors34 and may the abstract. tually come to rest.23,26,36
prompt inappropriate treatment. Dynamic Response Testing. In Dynamic response testing is a
In order to ensure consistency, order to determine if a hemody- 3-step procedure: determining
once the external reference point namic monitoring system can natural frequency, determining
has been selected, it should be adequately reproduce a patient’s the amplitude ratio of 2 consecu-
marked on the patient for easy cardiovascular pressures, the tive fast-flush oscillations (as an
identification. Consistency allows dynamic response characteristics indirect way of determining the

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damping coefficient), and deter- square waveform and fast-flush demarcated by the dicrotic notch,
mining the dynamic response oscillations may look adequate representing closure of the aortic
characteristics of the monitoring when the natural frequency and valve and subsequent retrograde
system (eg, optimal, adequate, amplitude ratio of the system flow. The location of the dicrotic
underdamped, overdamped, or actually make the system inade- notch varies according to the tim-
unacceptable). These steps are quate (underdamped, over- ing of aortic closure in the cardiac
summarized in Figure 1. damped, or unacceptable). Or, the cycle. For example, aortic closure
Dynamic response testing may arterial waveform may look dis- is delayed in patients with hypov-
seem complicated at first. Clinical torted because of physiological olemia. Consequently, the dicrot-
experience has shown, however, variations, yet the dynamic re- ic notch occurs farther down on
that with proper training, dynam- sponse characteristics of the sys- the dicrotic limb in hypovolemic
ic response testing can be per- tem assure a faithful recording of patients. The dicrotic notch also
formed in less than 2 minutes. A the arterial pressure.36 When accu- appears lower on the dicrotic
few simple observations provide racy is needed for clinical decision limb when arterial pressure is
almost as much information and making, the ideal method of deter- measured at more distal sites in
may serve as a close estimate. (1) mining if the measured ABP, or the arterial tree (Figure 3). The
If the period between 2 oscilla- any other directly monitored shape and proportion of the dias-
tions of the fast-flush test is less hemodynamic parameter, is true tolic runoff wave that follows the
than 1.2 mm, then natural fre- is to determine the dynamic re- dicrotic notch changes with arte-
quency will be at least 21, and the sponse characteristics of the moni- rial compliance and heart rate.
system will most likely be ade- toring system.26,36 Examples of the Diastolic pressure is measured
quate. If the period between 2 importance of formally assessing just before the beginning of the
oscillations is 1 mm or less, then the response characteristics are next systolic upstroke.
the natural frequency is 25 or discussed in more detail later. The analog waveform visible
higher, and the system will almost on the monitor or recorded on a
always function properly with any COMPONENTS OF strip chart is not only caused by
degree of damping. As a rule-of- THE NORMAL ABP the forward pressure pulse but is
thumb, the higher the natural fre- WAVEFORM also a result of a phenomenon
quency (or the smaller the Left ventricular contraction known as wave reflection. Wave
period), the better is the dynamic creates a pressure pulse or pulse reflection is related to the im-
response of the monitoring sys- wave. It is the pressure pulse that pedance of blood flow by the nar-
tem. (2) The system is over- a clinician feels when determin- rowing and bifurcation of the
damped if the fast-flush produces ing a patient’s pulse by palpation. arterial vessels; the impedance
sluggish or no oscillations. If the The pressure pulse is also what is leads to backward or retrograde
square wave shows undulations sensed by the intra-arterial reflection of the pressure wave.23,38-40
or if ringing occurs after the catheter. 34,35 The normal arterial In a manner similar to waves on
release of the fast-flush device, the pressure waveform is shown in the beach, the forward or ante-
system is most likely under- Figure 2. The systolic upstroke or grade pressure waves and the
damped. Overdamping and under- anacrotic limb mainly reflects the reflected waves collide. The com-
damping both indicate that the pressure pulse produced by left bination of the 2 types of waves
dynamic response characteristics ventricular contraction. The pres- increasingly augments the SBP
of the monitoring system are sure pulse is followed slightly the farther down the blood pres-
unsatisfactory. later by the flow wave caused by sure is measured in the arterial
Simple visual evaluation of the the actual displacement of blood circuit. In other words, the contri-
arterial waveform, the square volume. The anacrotic shoulder, bution of reflected waves to the
waveform, and oscillations gener- that is, the rounded part at the top measured systolic pressure occurs
ated by the fast-flush has been of the waveform, reflects primari- earlier in the periphery, particu-
suggested as a suitable method ly volume displacement. 22,37 The larly in the radial and dorsalis
for determining the dynamic systolic pressure is measured at pedis arteries (Figure 3), where
response characteristics of a the peak of the waveform. The the measured SBP may be 20 to 25
monitoring system. However, the dicrotic (or downward) limb is mm Hg higher than central aortic

CRITICAL CARE NURSE Vol 22, No. 2, APRIL 2002 67

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Fast flush

A1 = 7 mm

A2 =
3 mm

Period (t) = 1.2 mm

1. Determining natural frequency (Fn)

At the end of a waveform
a. Perform the fast-flush maneuver (square waveform test): pull and release the pigtail or compress and release
the button of the fast-flush device of the monitoring system.

b. Record the resulting square waveform and subsequent oscillations on calibrated strip chart paper.

c. Measure the distance (period, t, of 1 cycle) in millimeters between 2 oscillations. (One small box on the
calibrated strip chart paper equals 1 mm.)

d. Calculate Fn by using the formula

Fn = paper speed (mm/s)/t of 1 cycle (mm)
(The standard paper speed is 25 mm/s.)
Example: paper speed = 25 mm/s; t = 1 mm; Fn = (25 mm/s)/1 mm = 25 Hz

2. Determine the amplitude ratio

a. Measure the amplitude (A) in millimeters of 2 successive oscillations (A1, A2).
b. Calculate the amplitude ratio: divide A2 by A1 (A2/A1).

3. Determine the dynamic response characteristics

On the Fn-versus-amplitude ratio graph

a. Plot Fn along the x-axis (result of step 1)

b. Plot the amplitude ratio along the y-axis on the right (result of step 2)
c. Find the intersection of the 2 lines. Where the 2 lines intersect on the Fn-versus-amplitude ratio graph determines
if the system is able to correctly reproduce the hemodynamic waveform (adequate, optimal) or if the system is not
functioning at a desirable level (overdamped, underdamped, unacceptable).

Figure 1 The 3 steps of dynamic response testing. A, The fast-flush test. B, The frequency-versus-damping coefficient
A, Adapted from Bridges and Middleton,36 with permission. B, Reprinted from Gardner and Hollingsworth,28 with permission; adapted from Bridges and Middleton,36
with permission.

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Anacrotic limb Dicrotic limb
120 Systolic=115 mm Hg ARTIFACT AND
Pulse pressure
=35 mm Hg
Diastolic=80 mm Hg WAVEFORM
Dicrotic notch
=97 mm Hg
Damping, Overdamping, and
Figure 2 The normal arterial pressure waveform.
MAP indicates mean arterial pressure.
A common scenario when
Reprinted from Darovic,10 with permission.
working with arterial catheters is
comparing the blood pressure
pressure.22,23 Under normal condi- Pharmacological vasoconstriction recorded by the arterial catheter
tions, 80% of the original wave is can similarly increase wave reflec- with the blood pressure obtained
thought to be reflected.22 tion and cardiac workload.23,39 manually or with an oscilloscope.
Clinically, wave reflection plays The contribution of reflected If a discrepancy occurs, the arterial
an important role in left ventricu- waves to the measured systolic catheter is often said to be some-
lar workload and cardiac oxygen pressure is diminished during how “damped,” with the underly-
consumption. In young adults ing understanding that pressure
hypovolemia, hypotension, the
with elastic arteries, the reflected readings obtained with the cath-
Valsalva maneuver, and vasodi-
wave returns to the heart during eter cannot be trusted. Such an
latation. 23 In pharmacologically
the diastolic phase of the cardiac interpretation may be premature
induced vasodilation, such as
cycle and thus augments coronary and probably disregards several
occurs with nitroglycerin for
artery perfusion. In elderly patients important facts. Differences exist
instance, peripherally measured
or patients with stiff, atheroscle- between (1) damping, overdamp-
systolic pressure may not change
rotic vessels, the reflected wave ing, and underdamping; (2) over-
in proportion to the actual degree
returns to the heart during systole damped and underdamped pres-
of reduction in central aortic pres-
and thus increases systolic pres- sure waveforms caused by over-
sure.39,40 The effect of nitroglycerin
sure and left ventricular afterload.39 damped or underdamped moni-
may be visible in the appearance
toring systems and overdamped-
of reflected waves after the systolic
or underdamped-appearing
peak (Figure 4), but reduced aortic
waveforms that reflect the true
Central pressure, afterload, and cardiac physiological status of a patient;
work load may be more evident and (3) blood pressures obtained
Brachial through clinical improvement of via direct versus indirect monitor-
the patient. During shock with ing methods.
Radial vasoconstriction, wave reflection All hemodynamic monitoring
can lead to the overestimation of systems are damped. Damping is
central aortic pressure, because desired, because without damp-
peripheral SBP may be 20 mm Hg ing the vibrations of the system’s
Dorsalis higher than aortic pressure. 36,39 fluid column caused by the arteri-
pedis Peripherally measured SBP could al pressure pulse would go on
in this situation provide a false indefinitely and no accurate
Figure 3 Changes of the arterial sense of security that the patient is
pressure waveform configuration
waveform could be recorded.
throughout the arterial tree. Note maintaining adequate perfusion Conversely, both overdamped
the increasing steepness and pressures. A slower systolic up- and underdamped systems exist,
amplitude of the systolic upstroke stroke and a prominent diastolic and their recordings are indeed
and the changing location of the
dicrotic notch. waveform with reflected waves erroneous. With an overdamped
may be visual indicators of shock system, the waveform loses its
Reprinted from Gorny,8 with permission.
with vasoconstriction39 (Figure 5). characteristic landmarks and

CRITICAL CARE NURSE Vol 22, No. 2, APRIL 2002 69

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aortic regurgitation, or hyperdy-
namic states such as fever. 23 In
these conditions, typically a rapid
rise in the systolic slope occurs,
frequently exceeding the dynam-
ic response characteristics of the
monitoring system. A heart rate
greater than 150/min may also
cause systolic overshoot, because
Figure 4 Example of a waveform common in patients with hypertension
(arterial blood pressure, 192/84 mm Hg; pulse pressure, 108 mm Hg). Note
of the rapid succession of
the narrow systolic tip, the position of the dicrotic notch (D), and the impulses.26
reflected waves (R). A reflected wave like the first reflected wave after the The variable natural frequency
systolic upstroke may appear with the initiation of nitroglycerin therapy.40 of available monitoring systems
Overall, the arterial waveform appears underdamped, but the dynamic
response characteristic is adequate, close to optimal. Natural frequency, explains why with different moni-
25/1 = 25 Hz; amplitude ratio, 3.5/8 = 0.44. toring systems, different hemody-
namic pressures can be measured
even though the patient’s condi-
appears unnaturally smooth, with tend to have a low natural fre- tion has not changed.22 The often
a diminished or absent dicrotic quency and consequently are observed discrepancies between
notch. Overdamping results in often underdamped. 22,36 Anec- directly and indirectly obtained
falsely low systolic and falsely high dotal reports of manufacturers of SBP and DBP readings are also
diastolic pressure readings 26 an improved natural frequency partly caused by underdamping.22
(Figures 6 and 7). An overdamped- often do not hold up in clinical Clinically, recognition of pos-
appearing (often simply called practice. Typically, the natural sibly overdamped and under-
damped) waveform can also be the frequency of hemodynamic mon- damped waveforms and an
result of aortic stenosis, vasodi- itoring systems currently on the awareness of physiological situa-
latation, or low cardiac output market is less than 25 Hz. An tions when each type of wave-
states such as cardiogenic shock, underdamped system will record form may occur are important.
sepsis, or severe hypovolemia falsely high systolic pressures Then the question to be
(Figure 5). In order to determine if (15-30 mm Hg) and falsely low answered is whether the cause of
the waveform is a result of an over- diastolic pressures26 (Figures 8-10). the waveform is the patient’s
damped system or is an accurate Underdamping, most often in condition or the monitoring sys-
reflection of a patient’s status, the the form of systolic overshoot tem. Practically, the intervention
dynamic response characteristics (the artificial exaggeration of sys- for both overdamped and under-
must be tested. tolic pressure), must be suspect- damped systems is the same:
Today’s commercially avail- ed in patients with hypertension, maximizing natural frequency.
able catheter-transducer systems atherosclerosis, vasoconstriction,
Techniques for Maximizing
Natural Frequency
As mentioned earlier, air bub-
bles are a main factor in wave-
form blunting or overdamping. In
addition to air bubbles, other fac-
tors may alter the natural fre-
quency of a monitoring system
and distort the recorded signal.
These factors include narrow,
Figure 5 Waveform in a patient in shock with vasoconstriction. Note slow compliant, and long tubing; pres-
systolic upstroke and relatively high diastolic wave with reflection waves (R). ence of additional stopcocks; and
The waveform appears overdamped. loose connections. Translated into
D indicates dicrotic notch. practice, the monitoring system

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optimizing the natural frequency
of the monitoring system and
dynamic response testing.
In general, overdamping and
underdamping affect mostly SBP
and DBP. MAP is less sensitive to
these sources of waveform distor-
tion and is therefore less depen-
dent on the dynamic response
characteristics of the catheter sys-
Figure 6 Overdamped waveform due to an overdamped monitoring system.
Note the absence of fast-flush oscillations. tem. 26 When all steps have been
taken to maximize the natural
frequency of a system, yet the
should (1) be primed air-free, (2) patient should be assessed dynamic response test indicates
consist of wide-bore, high-pres- for signs and symptoms of hypo- overdamping or underdamping,
sure tubing with its length limited tension or low cardiac output. then either MAP should be
to 122 cm (48 in), (3) not be Then, the potential clot should followed or an alternative method
extended with tubing or added be removed by aspirating blood of monitoring (eg, oscillometric
stopcocks, and (4) have tightly from the distal stopcock before blood pressure monitoring)
secured connections.27,36 In addi- performing any flushing maneuver should be used.
tion, the continuous flush bag for the dynamic response test. 37
should be cleared of any air and Fluids with viscosities higher than End-Hole Artifact
be maintained adequately filled, the viscosity of normal isotonic The arterial catheter of the
and the external pressure cuff sur- sodium chloride solution also lead ABP monitoring system points
rounding the flush solution bag to overdamping of the hemody- upstream. The forward-flowing
should be maintained at a pres- namic waveform.23 For example, blood contains kinetic energy.
sure of 300 mm Hg. This practice blood in the arterial catheter (due When the flowing blood is sud-
will not only prevent air from to blood backup or insufficient denly stopped by the tip of the
going into the solution but also flushing) should be cleared from catheter, the kinetic energy of the
help prevent catheter clotting. the system. As a general rule, the blood is partially converted into
Catheter clotting is a rare, but catheter-tubing system and stop- pressure. This converted pressure
possibly serious, complication of cocks should be flushed before any may add 2 to 10 mm Hg to the
intra-arterial monitoring. One of hemodynamic measurement is systolic pressure measured by an
the first indications of clotting may performed, especially when clini- intra-arterial monitoring system.23
be a waveform that looks over- cal decisions are to be made. The The artificial augmentation of
damped. Whenever waveform Table summarizes the most directly monitored systolic pres-
overdamping is observed, the important recommendations for

Figure 7 Example of an overdamped-appearing waveform. The dynamic Figure 8 Example of an

response characteristic of the system gives an answer to the question, is the underdamped waveform. Natural
waveform overdamped because of the monitoring system or is it a correct frequency, 25/1.5 = 16.7 Hz;
reflection of the patient’s condition? amplitude ratio, 7/14 = 0.5.

CRITICAL CARE NURSE Vol 22, No. 2, APRIL 2002 73

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for hemodynamic pressure mea-
surement is to use the analog
strip-chart recording.43,44

Respiratory Variation
Normal breathing leads to
changes in intrathoracic pressure,
which affect cardiac output and
systemic pressure. With sponta-
Figure 9 Example of an underdamped waveform. Natural frequency, 25/2 = neous inspiration, intrathoracic
12.5 Hz; amplitude ratio, 4/11 = 0.36. Note the normal-appearing fast-flush
oscillations. pressure decreases. The de-
creased pressure is recognizable
on the ABP tracing as a downward
sure by converted kinetic energy tension, dysrhythmias, or pulsus displacement of the waveform
is referred to as the end-hole arti- paradoxus.43 The monitoring sys- baseline. Concurrently, during in-
fact or the end-pressure product. tem cannot discriminate between spiration, venous return to the
pressure readings during zeroing, right side of the heart is increased,
Movement Artifact obtaining blood samples, and augmenting right ventricular
Motion of the tubing system fast-flushing and real arterial stroke volume. The increase in
enhances the fluid oscillations of pressure readings. Consequently, right ventricular stroke volume is
the system. Although the clinical all readings are incorporated into offset by increased pulmonary vas-
significance of movement artifact pressure trends.43 Monitoring arti- cular compliance and blood pool-
is not known, it is recommended fact (ie, monitoring noise caused ing during inspiratory thoracic
that extrinsic movement of the by movement of the patient and expansion. Consequently, left ven-
tubing system be kept at an abso- disturbances in a monitoring sys- tricular stroke volume is decreased.
lute minimum.10 tem due to, for example, electrical Heart rate and SVR both increase
heating or cooling blankets) may as a compensatory reflex. The net
Monitor Artifact also be superimposed on the result of this chain of reflexes is the
The differences (>5 mm Hg) patient’s pressure waveform. phenomenon known as physiolog-
between the digital pressure out- Experienced clinicians can recog- ical pulsus paradoxus (a decrease
put displayed on the monitor and nize and eliminate some of these in ABP of usually <10 mm Hg dur-
pressures directly read from analog error sources and use a represen-
ing spontaneous, unassisted inspi-
or strip chart recordings are poten- tative set of waveform tracings on
ration).45 An inspiratory decrease in
tially important.43 These differences a calibrated strip-chart recording
ABP greater than 10 mm Hg (pul-
can lead to erroneous data collec- to obtain the most valid assess-
sus paradoxus) may indicate car-
tion and are especially notable in ment of a patient’s hemodynamic
diac tamponade or restrictive
patients with hypotension, hyper- status.43 Thus, the optimal method
pericarditis. Pulsus paradoxus also
occurs in patients with obstructive
lung disease, pulmonary em-
bolism, and severe heart failure
and can be induced by mechanical
During positive-pressure venti-
lation, the inspiratory increase in
intrathoracic pressure can be rec-
ognized in the upward displace-
Figure 10 Example of an overdamped-appearing waveform. However, the ment of the baseline of the arterial
dynamic response test places the system on the border between pressure waveform. If a patient
underdamped and adequate. Natural frequency, 25/1.8 = 13.9 Hz; amplitude receiving mechanical ventilation is
ratio, 9/19 = 0.47.
hypovolemic, the increase in

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Recommendations for optimizing the natural frequency of the arterial pressure monitoring system and dynamic response

Feature Recommendations

Natural frequency of the monitoring System requirements

system23,27,41 Use wide-bore, high-pressure tubing no longer than 122 cm (48 in)
Avoid tubing extensions and minimize stopcocks
Ensure that all connections are tightened
Eliminate air from the flush fluid and air bubbles from the tubing system
Keep continuous flush bag filled and keep external pressure cuff at 300 mm Hg
Clear access catheter and tubing system of any fluid other than isotonic sodium
chloride solution
Prevention of catheter clotting
Maintain continuous flush device as described
Use heparinized flush solution42
Prevention of catheter kinking
Keep cannulated extremity in a neutral or slightly extended position

Dynamic response test27,41 Implementation of test

Whenever the waveform seems overdamped or underdamped
Whenever physiological changes of the patient (increased heart rate,
vasoconstriction) place higher demands on the monitoring system
After opening the system
Before implementing interventions or changes of interventions
Whenever the accuracy of the arterial blood pressure measurement is in doubt
At least every 8-12 hours

intrathoracic pressure may lead to resulting in a high pulse pressure waveform may be an overesti-
artificial augmentation of directly and late high systolic peak, often
mation of systolic pressure and
monitored SBP. manifested as a narrow systolic thereby central aortic pressure. As
Current monitoring systems peak in the peripheral ABP wave- explained earlier, hypertension
determine the mean of pressure form tracing. 10,38
In addition, the and atherosclerosis place high
readings at predetermined inter-
diastolic wave may be reduced or demands on the monitoring sys-
vals. Respiratory artifact could lead
disappear. Figures 4 and 11 show
tem. The arterial waveforms
to erroneous digital output data.
peripheral ABP tracings typical in shown in Figures 4 and 11 could
The unpredictable effect of respira-
tory variation on arterial pressure patients with hypertension or also be the result of systolic over-
provides a strong argument for atherosclerosis. In each instance, shoot due to inadequate dynamic
reading and recording arterial pres- the small and narrow tip of the response characteristics of the
sure, like any other hemodynamic
index, at the end of expiration by
using a freeze-frame picture or,
best, a strip-chart recording.48,49

Hypertension and
Hypertension is due to age-
related arterial stiffening, athero-
sclerotic narrowing, or renin-
related vasoconstriction, all of
Figure 11 Example of a waveform common in patients with hypertension
which increase the magnitude of (arterial blood pressure, 150/45 mm Hg). Note steep systolic upstroke,
reflected waves. In these physiolog- narrow systolic peak, diminished diastolic run-off wave, and relative decrease
ical conditions, reflected waves in the diastolic proportion of the waveform due to a heart rate of 100/min.
The waveform appears underdamped.
fuse with the systolic upstroke,

76 CRITICAL CARE NURSE Vol 22, No. 2, APRIL 2002

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monitoring system. The result of lower pressure readings than does involved to ensure proper func-
the dynamic response test provides direct ABP monitoring. 22,36 Con- tioning of the monitoring system
reassurance that the recorded ABP versely, if SVR is low, in patients and correct interpretation of the
tracing is correct. with sepsis for instance, the rela- data obtained. Dynamic response
MAP is measured as the area tively high flow results in an indi- testing is the ideal method of con-
under the pressure curve divided rect ABP reading that is higher firming the ability of a monitoring
by the width of the base of the than the directly measured system to accurately reproduce
pressure curve (the time interval ABP. 22,36 Factors such as under- hemodynamic waveforms. MAP is
of a single cardiac cycle) 10,37 damping, end-hole artifact, and a stable hemodynamic parameter,
(Figure 2). A small and narrow wave reflection contribute to because it is least affected by moni-
systolic tip such as the ones in direct systolic pressure readings toring method, catheter insertion
Figures 4 and 11 adds relatively that are often higher than indi- site, the dynamic response charac-
little to the total area under the rectly obtained pressure values. teristics of the catheter system, and
pressure curve, whereas it can In other words, when obtaining wave reflection. MAP provides the
add significantly to measured ABP readings by using different best estimate of central aortic pres-
SBP. Consequently, the measured measuring methods, different sure and is the main hemodynamic
MAP is less affected by wave results should be expected. More parameter monitored by the neu-
reflection and the response char- specifically, a “good” correlation rohormonal system to control
acteristics of the monitoring sys- between the oscilloscope and the blood pressure. The superior infor-
tem than is measured SBP. The arterial pressure monitoring sys- mational value of MAP provides
MAP remains relatively constant strong support for its preferred use
tem is not a gauge for the proper
when measured at different sites in clinical practice, especially when
functioning of the pressure moni-
throughout the arterial circuit, use of vasoactive drugs is started or
toring system. MAP, on the con-
whereas measured SBP and DBP the dosages of these drugs are
trary, is closely approximated
may differ.10 In general, MAP is a titrated.10,21 However, numerically
when oscillometric and direct
more stable hemodynamic para- satisfactory ABP or MAP values are
measurements are compared.21-25,36
meter and provides a more accu- not necessarily related to adequate
Although both the oscillomet-
rate interpretation of a patient’s peripheral tissue perfusion and
ric and the direct ABP monitoring
hemodynamic status.10,34,36,38 organ system function. For optimal
methods are generally accurate in
management of patients, data
clinical practice, direct ABP moni-
INDIRECT VERSUS obtained from assessment tools
toring has a distinct advantage.
DIRECT ABP such as hemodynamic monitoring
Direct ABP monitoring is the only
MONITORING devices must be integrated with
scientifically and clinically vali-
A discussion of the various information gained from clinical
dated method that allows real-
methods of indirect ABP mea- assessment of patients’ status. ✙
surement and how they compare time and continuous monitoring
with direct ABP monitoring is of a patient’s ABP. With strip- Acknowledgments
I (B.H.M.) am grateful to Maj Bridges for
beyond the scope of this article. chart recording, beat-to-beat sharing her expertise and for her help and
However, several key principles analysis of a patient’s ABP is pos- support in preparing this article.

should be emphasized in this sible. This feature may be of clini-

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