ARTERIAL PRESSURE WAVEFORM
69. Arterial pressure
waveform
What are the indications for
direct arterial blood pressure
measurement?
What are the components of an
arterial line used to measure blood > Tubing: usually less than 120 cm, filled with 0.9% saline, connects
pressure?
What factors determine the shape
of the arterial waveform?
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> When non-invasive BP measurements are inaccurate – in obese
patients, arrhythmias and during ambulance transfers.
> When extreme changes in blood pressure are expected – massive
haemorrhage, cardiovascular instability and induced hypotension.
> When frequent arterial blood samples are required.
> When using pulse-contour cardiac output monitoring (e.g. LiDCO).
> Arterial cannula: short, stiff and 20 G size in adults.
cannula to transducer, must be free of kinks, clots and air bubbles.
> Three-way tap and flushing device.
> Pressurised fluid bag: usually 0.9% saline, pressurised to 300 mmHg,
with a drip rate of 4 mL/h to prevent clot formation within the cannula.
> Diaphragm: very thin membrane acts as an interface between the
transducer and the fluid column.
> Piezoresistive strain gauge transducer connected to a
Wheatstone bridge circuit (a null-deflection system consisting of a
galvanometer, two constant resistors, one variable resistor and a strain
gauge): must be zeroed to atmospheric pressure and kept at the level of
the right atrium.
> Microprocessor, amplifier and display unit
> Volume of blood ejected
> Speed at which this blood is ejected during each beat
> Ability of the vascular tree to distend and accommodate this ejected
blood (i.e. compliance of arterial tree)
> Rate at which this ejected blood is able to flow from central arterial
component into the peripheral tissues (i.e. systemic vascular resistance)
Arterial Pressure (mmHg)
120
80
Dicrotic notch
Time
Fig. 69.1  Arterial pressure waveform
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 02 PHYSICS
What information can be derived
from a direct arterial pressure
wave?
In what ways can a direct arterial
pressure transducer system give
you false information?
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> Systolic blood pressure: this is primarily influenced by stroke volume
and compliance. This explains why elderly patients have a higher
systolic pressure due to a reduced vascular compliance secondary to
atherosclerosis while neonates have a lower systolic pressure because of
a very compliant arterial tree.
> Diastolic blood pressure: this is primarily influenced by arterial recoil. This
explains why elderly patients have a lower diastolic pressure as their stiff
arteries are not able to recoil effectively while neonates have a higher
diastolic pressure due to their good arterial elastic recoil.
> Pulse pressure
> Mean arterial pressure
> Heart rate
> Rhythm
> Dicrotic notch: this represents the nadir point that occurs immediately
after the aortic valve closes and is usually seen one-third of the way
down the descending limb of the pressure wave (i.e. when pressure
in aorta is greater than the pressure in left ventricle). The position
of this notch reflects peripheral vascular resistance. In presence of
vasodilatation (e.g. sepsis or epidural), there is a downward shift of the
dicrotic notch. Characteristic features of vasodilatation of the arterial
wave form include a low systolic pressure, low diastolic pressure, wide
pulse pressure and delayed dicrotic notch.
> Left ventricular contractility: this can be estimated from the gradient of
the upstroke of the arterial waveform.
> Compliance of the arterial tree: this can be estimated from the gradient
of the downstroke of the arterial waveform.
> Stroke volume: this can be estimated from the area under the systolic
portion of the arterial waveform (i.e. from the start of the upstroke to the
dicrotic notch).
> Heart–lung interactions and fluid responsiveness: the changes in arterial
pressure waveforms in response to changes in intra-thoracic pressures
during mechanical ventilation (i.e. ‘swing’) can be used to determine fluid
responsiveness.
> Pulse contour analysis can be used to determine stroke volume and
cardiac output (for more details, see Chapter 70, ‘Cardiac output
monitoring’).
> Calibration error: one-point calibration is suitable for highly accurate
devices to remove the offset error. Two-point calibration is required for
less accurate devices but with an assumed linear response, in order to
remove offset and gain errors. Three-point calibration is used for devices
that are not very accurate or that have a very non-linear response.
Arterial lines undergo a one-point calibration by zeroing the transducer to
atmospheric pressure. However, despite calibration, drift of zero and gain
can occur over time.
> Transducer height: this must be at the level of the patient’s right
atrium (an error reading equivalent to 7.5 mmHg occurs for each 10 cm
discrepancy in height).
> Natural frequency and resonance: every system has a tendency
to oscillate. When a system is given a small oscillation (an external
push), it will start to swing and the frequency at which it swings is
the natural frequency (also called resonant frequency) of that system.
Natural frequency is directly related to resonance. It is important for the
natural frequency of the arterial transducer to be significantly different
from the frequency of the arterial pressure wave or else it could amplify
the signal (natural frequency should be at least 10 times fundamental
frequency).
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 ARTERIAL PRESSURE WAVEFORM
Natural frequency is:
• Directly related to catheter diameter
• Inversely related to square root of the system compliance
• Inversely related to the square root of the length of tubing
• Inversely related to square root of the density of the fluid in the tubing.
> Frequency response: arterial pressure waveform is a complex sine
wave. Fourier analysis allows this complex waveform to be broken
down into a series of simple sine waves of different amplitudes and
frequencies. The fundamental frequency (or first harmonic) is equal to
the heart rate (HR of 60 bpm = 1 Hz, HR of 120 bpm = 2 Hz and so
on). The first 10 harmonics of the fundamental frequency contribute to
the waveform, and therefore, in order to display the arterial waveform
correctly, the transducer should have a frequency response range
(i.e. bandwidth) of 0.5–40 Hz.
> Damping: this is the tendency of an object to resist oscillating (see
Chapter 52, ‘Principles of measurement’, for more details). Over-
damping underestimates SBP, overestimates DBP but MAP remains
the same (e.g. blood clot, air bubble or excessive tubing compliance).
Under-damping overestimates SBP, underestimates DBP but MAP
remains the same (e.g. tubing too long and non-compliant). In order to
minimise these errors, the monitoring system should apply an optimal
damping value of 0.64.
What are some of the > Cannula disconnection leading to blood loss
complications associated > Arterial thrombosis
with arterial lines? > Ischaemia distal to the cannula (this is rare but can occur so collateral
circulation should be checked, e.g. Allen’s test)
> Infection
> Inadvertent drug administration: this can cause distal vascular occlusion
and ischaemia. A-lines should be clearly labelled and colour-coded.

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