ARTERIAL LINE by Nick Mark MD ONE onepagericu.

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UTILITY
Arterial lines permit continuous invasive blood
pressure measurement, frequent arterial blood
sampling, and analysis of the waveform can be
used to estimate cardiac output, predict volume
responsiveness, and identify specific pathologies.
Systolic BP
Dicrotic
notch
most current
@nickmmark version →
PULSE PRESSURE VARIATION (PPV)
Pulse pressure is proportional to stroke volume. Pulse CARDIAC ARREST
Pressure Variation (PPV) represents an interaction During cardiac arrest, an arterial line can be used to gauge
between lungs and heart. Ventilation (either spontaneous adequacy of CPR (e.g. DBP > 25mmg on waveform), to
or mechanical) alters the intrathoracic pressure and identify ROSC, and to differentiate PEA from pseudo-PEA.
causes stroke volume to vary. Greater variability in stoke See Cardiac Arrest OnePager for more.
volume (increased PPV) may suggest fluid responsiveness.
PRINCIPLE
Low PPV High PPV
A continuous column of

pressure pressure
fluid between indwelling

Airway Arterial
Diastolic BP catheter and a pressure
MAP calculated transduce allows arterial
Systole Diastole from the AUC pressure measurement.
For patients on pressors,
SQUARE WAVE TEST
The arterial line can measure BP inaccurately 𝑷𝑷𝒎𝒂𝒙 "𝑷𝑷𝒎𝒊𝒏 femoral MAP may be
IV fluid in
unless properly calibrated. Rapidly flushing the PPV = slightly higher than radial
𝑷𝑷𝒎𝒆𝒂𝒏 pressure bag
line (by pulling the release on the flush device) MAP measurements.
Specifically, a PPV > 12% is suggestive that there will be an at 300 mmHg
generates a square wave. Counting oscillations increase in stroke volume with fluid challenge. However in
after the square wave indicates if the arterial line order to interpret PPV 3 conditions must be met: Pressure
is working properly. 1. Sinus rhythm (consistent filling time) transducer
Normal = accurate BP 2. Mechanically ventilated w/o spontaneous respirations; Flush
1.5 - 2 oscillations TV= 8 cc/kg (consistent effect of ventilator) device
3. Must not have an open chest (heart/lungs interacting) ‘Zero’ defined by the phlebostatic
In contrast to an increase in BP with respiration causing high axis (mid-axillary line at the 4th IC
PPV, pulsus pardoxus is the decrease in SBP > 10 mmHg with approximating the aortic root)
Square wave
respiration, associated with tamponade & other conditions.
OVERdamped = falsely LOW BP Absence SPECIFIC ARTERIAL WAVEFORM PATTERNS
<1.5 oscillations of dicrotic
notch

Pulsus alternans - alternating strong and weak pulses; Arterial

Fix: Remove extra tubing & any air bubbles. seen in low cardiac output shock states catheter

UNDERdamped = falsely HIGH BP Additional Closed blood Sampling

>2 oscillations artifactual sampling port
spikes Pulsus bisfirens - double Pulsus tardus - late peaking system
peaked pulse in severe AR ± AS pulse; seen in severe AS Closed blood sampling systems enable blood draws

CARDIAC OUTPUT ESTIMATION
Several techniques can be used to estimate cardiac output
using an algorithm to analyze the waveform. There are two
Fix: Adjust filter settings on monitor
types: uncalibrated and calibrated. None is proven superior.
v1.0 (2020-09-14)
with minimal waste. They are associated with lower
risk of bacterial contamination and when combined
with smaller size sample tubes and decreased lab
frequency they can reduce blood transfusions.