ANESTH ANALC 58:526-527. 1979
Blood Pressure Monitoring Using the Superficial Temporal Artery and a Doppler Ultrasonic Flow Detector Somasundaram Thiagarajah, MB, BS, FFARCS,* Digvijay S. Girnar, MD,* and Keeyong Park, MDT Blood pressure monitoring, a prerequisite to safe anesthetic practice, may be accomplished by intraarterial cannulation, by the Riva-Rocci method employing a stethoscope for detection of the Korotkoff sounds, or by a Doppler ultrasonic flow detector.”’ The Doppler ultrasonic flow detector is particularly useful in patients whose arterial walls do not generate sufficient sound to be heard by a stethoscope and in whom technical difficulties preclude direct arterial cannulation. Commonly, the brachial or radial arteries are chosen for blood pressure monitoring, but the femoral, popliteal, tibial, and dorsalis arteries have also been used. Recently, during the anesthetic management of a patient whose blood pressure could not be monitored at any conventional site, an alternate method was devised using the temporal artery.
Case Report A 68-year-old woman was scheduled for exploratory surgery of an occluded right axillobifemoral bypass graft which had been performed 2 years earlier. She was a chronic smoker and had diabetes of long standing duration treated with diet and tolbutamide. Other medications included codeine, acetaminophen, and amitriptyline. Significant physical findings were limited to bilateral calf tenderness and absence of detectable pulse in the left arm and both lower extremities. Blood pressure in the right arm was 120/ 70 torr. Routine laboratory tests, coagulation studies, and
chest radiogram were within normal limits except for the fasting blood glucose of 350 mg/100 ml. ECG showed sinus rhythm, a rate of 95/min and nonspecific ST-T wave changes in leads I and AVL, similar to those noted 2 years previously. The patient was premedicated intramuscularly with meperidine, 25 mg, hydroxyzine, 25 mg, and atropine, 0.4 mg, 60 minutes preoperatively. On arrival in the operating room, the blood pressure on the right arm obtained by auscultation with a stethescope, was 124/70 torr. However, since the planned surgery involved the right upper extremity, the only site at which the blood pressure was recordable, and because direct arterial cannulation in the other extremities appeared to be difficult if not impossible, the right superficial temporal artery was located by palpation (Figure, A); a Doppler transducer was then positioned over the artery (Figure, B) and fixed in place with adhesive tape (Figure, C). A Kidde tourniquet cuff, 4 inches wide, was placed around the head (Figure, D) taking special care to avoid the eyes, and the transducer and the cuff connected to an ultrasound blood pressure instrument (Arteriosonde 1010) which was Superficial Temporal Artery
A Adhesive
T a ? Q
Assistant Professor.
t Resident in Anesthesiology. Received from the Department of Anesthesiology, Albert Einstein College of Medicine, Bronx, New York 10461. Accepted for publication August 6, 1979. Reprint requests to Dr. Thiagarajah.
526
ANESTHESIA AND ANALGESIA Vol58. No 6. Nov-Dec 1979
FIGURE.Techniques for use of Doppler ultrasonic flow probe over the superficial temporal artery: A, anatomy of superficial temporal artery; B, transducer in place; C, transducer fixed securely with adhesive tape; D. Kidde tourniquet cuff placed on the secured transducer.
CLINICAL REPORTS TABLE Comparison of Blood Pressure at Brachid Artery (by Riva-Roccl Cuff and Stethoscope) and at Superficial Temporal Artery (by Kidde Cuff and Doppler) in Normal Vohmtmm Volunteer no. 1
2
3
4
5
6
7
8
9
10
Sex
F
F
M
M
F
M
M
F
M
M
Age (years)
20
35
30
50
25
35
62
65
30
50
W/70
110/90
126/85
145/90
120/70
135/85
160/100
170/100
120/70
140/90
130/90
150/90
155/100
110/60
125/75
Site of BP determination Brachial artery &pemcialt-poralartery
80/60
110/90
120/80
150/100
utilized for blood pressure measurements throughout anesthesia and surgery. Following denitrogenation and intravenous administration of d-tubocurarine, 3 mg, anesthesia was induced slowly with droperidol, 5 mg, and thiopental, 100 mg, by intravenous injections. Endotracheal intubation was performed following succinylcholine, 100 mg. Maintenance of anesthesia was with nitrous oxide oxygen (60%/409b) and intermittent increments of 0.025 mg of fentanyl. Pancuronium was used for relaxation, and ventilation was controlled with a volume-limited ventilator. Blood pressure was monitored at 10-to 15-minute intervals, except during periods of hemodynamic instability when the recordings were made more frequently. The patient's operative course was uneventful. Blood loss was estimated to be 500 ml. No complications attributable to the technique of blood pressure monitoring were noted p t operatively.
105/80
the technique, a narrow inflatable cuff must be firmly fixed in the fronto-occipital plane avoiding the eyes. In length it must be at least 1% times the circumference of the head if it is to remain securely in place when inflated. The Kidde cuff satisfies these requirements. In using the Doppler on the superficial temporal artery, the values obtained for the systolic and diastolic pressure were within -15 to +10 torr of the values obtained in the arm using a stethescope in 10 volunteers (Table). In summary, a method is described for recording blood pressure by Doppler principle using the superficial temporal artery. This method is accurate, simple, non-invasive and specially applicable to patients in whom the conventional sites cannot be utilized. ACKNOWLEDGMENTS
Discussion The method described, that of recording the blood pressure with a Doppler device at the superficial temporal artery, is simple, non-invasive, and easily applicable to any adult patient. Although not frequently indicated, the method can be most useful in the care of bum patients whose burned extremities cannot be used or whose unaffected extremities are being used for graft tissue. With regard to details of
We thank Dn. Gertie F. Marx and James Marin for help in the preparation of this manuscript. The continued encouragement of Dr. Louis R. Orkin is gratefully acknowledged.
REFERENCES 1. Lowry RL, Lichti EL, Eggers GWN: The Doppler, an aid in monitoring blood pressure during anesthesia. Anesth Analg 52531-535,1973 2. Watemath CL,Preuss DD: Determination of blood pressure in
low-flow states by the Doppler technique. Anesthesiology 34: 77-79,197l
ANESTHESIA AND ANALGESIA VOI 58, NO 6. Nw-D~C1979
527
Blood Pressure Monitoring Using the Superficial Temporal Artery and a Doppler Ultrasonic Flow Detector Somasundaram Thiagarajah, MB, BS, FFARCS,* Digvijay S. Girnar, MD,* and Keeyong Park, MDT Blood pressure monitoring, a prerequisite to safe anesthetic practice, may be accomplished by intraarterial cannulation, by the Riva-Rocci method employing a stethoscope for detection of the Korotkoff sounds, or by a Doppler ultrasonic flow detector.”’ The Doppler ultrasonic flow detector is particularly useful in patients whose arterial walls do not generate sufficient sound to be heard by a stethoscope and in whom technical difficulties preclude direct arterial cannulation. Commonly, the brachial or radial arteries are chosen for blood pressure monitoring, but the femoral, popliteal, tibial, and dorsalis arteries have also been used. Recently, during the anesthetic management of a patient whose blood pressure could not be monitored at any conventional site, an alternate method was devised using the temporal artery.
Case Report A 68-year-old woman was scheduled for exploratory surgery of an occluded right axillobifemoral bypass graft which had been performed 2 years earlier. She was a chronic smoker and had diabetes of long standing duration treated with diet and tolbutamide. Other medications included codeine, acetaminophen, and amitriptyline. Significant physical findings were limited to bilateral calf tenderness and absence of detectable pulse in the left arm and both lower extremities. Blood pressure in the right arm was 120/ 70 torr. Routine laboratory tests, coagulation studies, and
chest radiogram were within normal limits except for the fasting blood glucose of 350 mg/100 ml. ECG showed sinus rhythm, a rate of 95/min and nonspecific ST-T wave changes in leads I and AVL, similar to those noted 2 years previously. The patient was premedicated intramuscularly with meperidine, 25 mg, hydroxyzine, 25 mg, and atropine, 0.4 mg, 60 minutes preoperatively. On arrival in the operating room, the blood pressure on the right arm obtained by auscultation with a stethescope, was 124/70 torr. However, since the planned surgery involved the right upper extremity, the only site at which the blood pressure was recordable, and because direct arterial cannulation in the other extremities appeared to be difficult if not impossible, the right superficial temporal artery was located by palpation (Figure, A); a Doppler transducer was then positioned over the artery (Figure, B) and fixed in place with adhesive tape (Figure, C). A Kidde tourniquet cuff, 4 inches wide, was placed around the head (Figure, D) taking special care to avoid the eyes, and the transducer and the cuff connected to an ultrasound blood pressure instrument (Arteriosonde 1010) which was Superficial Temporal Artery
A Adhesive
T a ? Q
Assistant Professor.
t Resident in Anesthesiology. Received from the Department of Anesthesiology, Albert Einstein College of Medicine, Bronx, New York 10461. Accepted for publication August 6, 1979. Reprint requests to Dr. Thiagarajah.
526
ANESTHESIA AND ANALGESIA Vol58. No 6. Nov-Dec 1979
FIGURE.Techniques for use of Doppler ultrasonic flow probe over the superficial temporal artery: A, anatomy of superficial temporal artery; B, transducer in place; C, transducer fixed securely with adhesive tape; D. Kidde tourniquet cuff placed on the secured transducer.
CLINICAL REPORTS TABLE Comparison of Blood Pressure at Brachid Artery (by Riva-Roccl Cuff and Stethoscope) and at Superficial Temporal Artery (by Kidde Cuff and Doppler) in Normal Vohmtmm Volunteer no. 1
2
3
4
5
6
7
8
9
10
Sex
F
F
M
M
F
M
M
F
M
M
Age (years)
20
35
30
50
25
35
62
65
30
50
W/70
110/90
126/85
145/90
120/70
135/85
160/100
170/100
120/70
140/90
130/90
150/90
155/100
110/60
125/75
Site of BP determination Brachial artery &pemcialt-poralartery
80/60
110/90
120/80
150/100
utilized for blood pressure measurements throughout anesthesia and surgery. Following denitrogenation and intravenous administration of d-tubocurarine, 3 mg, anesthesia was induced slowly with droperidol, 5 mg, and thiopental, 100 mg, by intravenous injections. Endotracheal intubation was performed following succinylcholine, 100 mg. Maintenance of anesthesia was with nitrous oxide oxygen (60%/409b) and intermittent increments of 0.025 mg of fentanyl. Pancuronium was used for relaxation, and ventilation was controlled with a volume-limited ventilator. Blood pressure was monitored at 10-to 15-minute intervals, except during periods of hemodynamic instability when the recordings were made more frequently. The patient's operative course was uneventful. Blood loss was estimated to be 500 ml. No complications attributable to the technique of blood pressure monitoring were noted p t operatively.
105/80
the technique, a narrow inflatable cuff must be firmly fixed in the fronto-occipital plane avoiding the eyes. In length it must be at least 1% times the circumference of the head if it is to remain securely in place when inflated. The Kidde cuff satisfies these requirements. In using the Doppler on the superficial temporal artery, the values obtained for the systolic and diastolic pressure were within -15 to +10 torr of the values obtained in the arm using a stethescope in 10 volunteers (Table). In summary, a method is described for recording blood pressure by Doppler principle using the superficial temporal artery. This method is accurate, simple, non-invasive and specially applicable to patients in whom the conventional sites cannot be utilized. ACKNOWLEDGMENTS
Discussion The method described, that of recording the blood pressure with a Doppler device at the superficial temporal artery, is simple, non-invasive, and easily applicable to any adult patient. Although not frequently indicated, the method can be most useful in the care of bum patients whose burned extremities cannot be used or whose unaffected extremities are being used for graft tissue. With regard to details of
We thank Dn. Gertie F. Marx and James Marin for help in the preparation of this manuscript. The continued encouragement of Dr. Louis R. Orkin is gratefully acknowledged.
REFERENCES 1. Lowry RL, Lichti EL, Eggers GWN: The Doppler, an aid in monitoring blood pressure during anesthesia. Anesth Analg 52531-535,1973 2. Watemath CL,Preuss DD: Determination of blood pressure in
low-flow states by the Doppler technique. Anesthesiology 34: 77-79,197l
ANESTHESIA AND ANALGESIA VOI 58, NO 6. Nw-D~C1979
527
