Original Article
277
Oscillometric and Intra-arterial Blood Pressure in Preterm and Term Infants: Extent of Discrepancy and Factors Associated with Inaccuracy Tomoyuki Shimokaze, MD1
Kazuhiro Akaba, MD, PhD1
1 Department of Pediatrics, Saiseikai Yamagata Hospital,
Yamagata, Japan
Emi Saito, MD1
Address for correspondence Tomoyuki Shimokaze, MD, Department of Pediatrics, Saiseikai Yamagata Hospital, 79-1 Okimachi, Yamagata 990-8545, Japan (e-mail: [email protected]).
Abstract
Keywords
► noninvasive blood pressure ► arterial line ► discomfort ► sedation ► light-for-gestationalage
Objective Securing an arterial line to monitor continuous blood pressure (BP) is difficult in infants. We aimed to reveal the extent of discrepancies between oscillometric and direct BP. Study Design Infants who required continuous BP monitoring were prospectively enrolled. Direct and indirect BP were simultaneously recorded. Disposable BP cuffs matching one-half to two-thirds of the upper arm circumference were used. Results A total of 74 infants were studied (gestational age [GA], 24–42 weeks). The correlation coefficients of systolic, diastolic, and mean arterial BP of indirect and direct measurements were 0.87, 0.82, and 0.84, respectively (p < 0.001). The mean differences in systolic, diastolic, and mean arterial BP (indirect minus direct BP) were 2.2 5.7, 6.0 5.8, and 1.3 5.7 mm Hg, respectively. Oscillometric measurements significantly underestimated systolic BP in light-for-gestational-age infants and diastolic BP in infants without fentanyl administration. There were no significant correlations between discrepant BP measurements and edema, vasopressor administration, arterial line location, GA, postnatal age, body weight, pulse rate, or hemoglobin level. In 4.1% of infants, systolic BP increased by 10 to 15 mm Hg at the time of cuff expansion. Conclusion We recommend intra-arterial BP measurement when the BP values seriously influence the therapeutic protocol.
Measurement of blood pressure (BP) is important in the management of critically ill infants. An arterial line is essential for continuous monitoring of BP. However, securing a peripheral arterial line may be difficult or impossible, especially in preterm infants.1 There is an increased risk of thrombosis and infection associated with the total catheterization duration in infants.2 Although placement of an umbilical artery catheter may be relatively easy, the total duration of catheterization has been recommended not to exceed 5 days.3 When an arterial line
does not exist, BP measurement is performed noninvasively using oscillometric or ultrasound techniques. Discrepancies between noninvasive BP (NIBP) and intraarterial BP (IABP) measurements have a stronger influence on interpretation in infants than in adolescents because arterial BP is low in infants.4 For accurate interpretation of oscillometric BP measurements, it is important to recognize the extent of discrepancies and identify any factors that cause inaccuracy. Therefore, direct and indirect systolic, diastolic, and mean arterial BP were simultaneously recorded to study the features of oscillo-
received March 16, 2014 accepted after revision May 27, 2014 published online June 27, 2014
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1383851. ISSN 0735-1631.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Am J Perinatol 2015;32:277–282.
NIBP and IABP in Infants: Extent of Discrepancy and Factors Related to Inaccuracy metric BP measurement in our neonatal intensive care unit. We studied the factors that have been previously reported to have or that potentially have an influence on the discrepancies between NIBP and IABP measurements.
Methods All infants admitted to our neonatal intensive care unit who required continuous BP monitoring for appropriate management as well as intermittent BP measurement after stopping IABP measurement were included. Infants with any of the following were excluded: major congenital anomalies, critically unstable condition, severe edema, or a peripherally inserted central catheter for NIBP measurement. This study was approved by the institutional review board, and written informed consent was obtained from the parents of all infants. The patients were enrolled between 0 and 70 days postnatal age. An arterial line (DTX Plus Disposable Pressure Transducer Set; Argon Critical Care Systems, Singapore or JELCO Plus I.V. Catheter, 24 G, 0.7 19.0 mm; Smiths Medical, Tokyo, Japan) was placed in the radial or posterior tibial artery. Arterial pressure was recorded with a bedside monitor (Life Scope TR BSM-6000; Nihon Kohden, Tokyo, Japan). Before data collection, air bubbles were removed from the system, the zero level was determined to be the mid-chest level, and a rapid flush test was performed to evaluate the adequacy of the waveform. NIBP measurements were obtained with a clinically approved automated oscillometric BP meter (BP-8800; Omron Colin, Tokyo, Japan); only one BP meter was used throughout the study. Manufacturer-provided disposable BP cuffs matching one-half to two-thirds of the upper arm circumference were used. Three cuffs were used; their width and applicable circumference as recommended by the manufacturer were 2.5 and 3.5 to 6.0 cm (No. 10), 3.0 and 5.0 to 7.5 cm (No. 11), and 4.0 and 7.5 to 10.5 cm (No. 12), respectively. The pulse rate and direct and indirect systolic, diastolic, and mean arterial BP were simultaneously recorded. The direct BP value was adopted from the blinking of the measurement indicator of the automated BP meter. The indirect BP was measured in the contralateral upper arm or leg in which the arterial line was not in place because the BP was not different between the right and left sides.5 To minimize infant discomfort, NIBP was measured one to five times. This number of measurements is the same as that used in our everyday clinical practice in the neonatal intensive care unit. We studied the factors that have been previously reported to influence or that may potentially influence the discrepancies between NIBP and IABP measurements. Previously reported factors included gestational age (GA), body weight, age at measurement, pulse rate, arterial line location, and vasopressor medication (dopamine and/or dobutamine). Factors with potential influence included size for GA, edema, the hemoglobin level, and fentanyl administration. Light for gestational age (LGA) and heavy for gestational age were defined by comparison with the 10th and 90th percentiles in the 2001 infant physical development research report of the Ministry of Health, Labor and Welfare of Japan. Edema was American Journal of Perinatology
Vol. 32
No. 3/2015
Shimokaze et al.
defined as cutaneous pitting secondary to cuff placement after the BP measurement.
Statistical Analysis The overall measurements of direct and indirect systolic, diastolic, and mean arterial BP are presented as Bland–Altman plots.6 Unless stated otherwise, the data are expressed as mean standard deviation. Values with significant deviation from normality are presented as median and interquartile range or range. Spearman and Pearson correlation coefficients were used to identify relationships within and between different outcome measures according to the distribution of the variables. Student unpaired t-test was used to compare normally distributed data. The average of the measured BP values for each infant was used for the correlation coefficients and unpaired Student t-test. A p value of < 0.05 was considered to be statistically significant. Statistical analyses were performed using SPSS software, version 20 (IBM, Armonk, NY).
Results A total of 74 patients (36 males and 38 females) with a mean GA of 31.2 weeks (range, 24–42 weeks) and median body weight of 1,453 g (range, 585–3,936 g) were enrolled in this study from October 2011 to January 2014. The demographic characteristics of our study infants are presented in ►Table 1. Their median postnatal age was 2 days (range, 0–70 days). The birth weight of 38 of the 74 infants was < 1,500 g. The arterial line was placed in the radial (n ¼ 69) or posterior tibial (n ¼ 5) artery. No infants underwent BP measurement using an umbilical arterial catheter. No infants were diagnosed with or treated for an infection during the BP measurement period. The median number of oscillometric BP measurements was 3 (interquartile range, 3–4). The median maximal intermeasurement difference in the arterial BP in each infant with interquartile range was systolic, 2 mm Hg (1–4 mm Hg); diastolic, 2 mm Hg (1–3 mm Hg); and mean arterial, 2 mm Hg (1–4 mm Hg). The Bland–Altman plots of the differences between NIBP and IABP (74 infants, 249 pairs of measurements in each plot) are shown in ►Fig. 1A–C. The correlation coefficients (r) of systolic, diastolic, and mean arterial BP obtained by the indirect and direct measurements were 0.87, 0.82, and 0.84, respectively (p < 0.001). The mean difference in the systolic, diastolic, and mean arterial BP (NIBP minus IABP) was 2.2 5.7 mm Hg (4.7 11.1%), 6.0 5.8 mm Hg ( 19.4 17.5%), and 1.3 5.7 mm Hg ( 2.4 15.8%), respectively (►Table 2). Statistically significant differences were found between diastolic NIBP and IABP measurements. Oscillometric measurements underestimated diastolic BP. Systolic and median BP showed a small discrepancy between the two measurements. Overall, a clear relationship was not found between the arterial BP level (from low to high BP) and the measurement accuracy (►Fig. 1A–C). ►Tables 3 and 4 show the mean difference and correlation coefficients between the two BP measurements according to each factor.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
278
NIBP and IABP in Infants: Extent of Discrepancy and Factors Related to Inaccuracy
Shimokaze et al.
279
Table 1 Demographic data n (%) Gestational age (wk)
31.2 5.8
Age at measurement (d), median (IQR)
2.0 (1.0–4.0)
Male
36 (48.6)
Body weight (g), median (IQR)
1453 (916–2204)
Heavy for gestational age
3 (4.1)
Light for gestational age
10 (13.5)
Radial artery
69 (93.2)
Posterior tibial artery
5 (6.8)
Number of oscillometric BP measurements, median (IQR)
3 (3–4)
Maximal intermeasurement difference in arterial BP in each infant, median (IQR) Systolic (mm Hg)
2 (1–4)
Diastolic (mm Hg)
2 (1–3)
Mean arterial (mm Hg)
2 (1–4)
Medication Vasopressor
10 (13.5)
Fentanyl
43 (58.1)
Edema
10 (13.5)
Ventilator support
73 (98.6)
Abbreviation: BP, blood pressure; IQR, interquartile range.
An LGA status and the absence of fentanyl administration were associated with discrepant BP measurements (►Table 3). Oscillometric measurements significantly underestimated systolic BP in LGA infants (NIBP minus IABP: 2.2 5.6 mm Hg) compared with the overall difference (NIBP minus IABP: 2.2 5.7 mm Hg). LGA and non-LGA infants had a mean systolic BP of 52.3 5.9 and 52.2 11.6 mm Hg (p ¼ 0.97), mean diastolic BP of 32.5 5.0 and 31.3 9.4 mm Hg (p ¼ 0.54), and mean arterial BP of 40.6 4.8 and 39.5 10.2 mm Hg (p ¼ 0.58), respectively. We did not analyze heavy-for-GA infants (n ¼ 3) because of the small number of such infants. Oscillometric measurements more accurately estimated the diastolic BP in infants with fentanyl administration (NIBP minus IABP: 4.6 5.3 mm Hg) than shown by the overall difference (NIBP minus IABP: 6.0 5.8 mm Hg) (►Table 3). The mean value of any IABP measurement was lower in infants with fentanyl administration. Infants with and without fentanyl administration had a mean systolic BP of 50.4 10.8 and 54.7 10.8 mm Hg (p ¼ 0.10), diastolic BP of 29.8 9.3 and 33.6 8.1 mm Hg (p ¼ 0.07), and mean arterial BP of 38.1 9.6 and 41.8 9.5 mm Hg (p ¼ 0.10), respectively. There was no significant correlation between discrepant BP measurements and the following factors: edema, vasopressor administration, arterial line location, GA, age at
Fig. 1 Bland–Altman plots showing agreement between oscillometric and intra-arterial blood pressure measurements. (A) Systolic, (B) diastolic, and (C) mean arterial blood pressure. The line represents mean bias with upper and lower limits of agreement. IABP, intraarterial blood pressure; NIBP, noninvasive blood pressure.
measurement, body weight, pulse rate, or hemoglobin level (►Tables 3 and 4). In 3 of the 74 infants (4.1%), the systolic BP increased by 10 to 15 mm Hg at the time of cuff expansion. Two of these three infants were born at 29 and 32 weeks GA (postnatal age, 3 and 1 days, respectively) without fentanyl administration, and one of the three infants was born at 29 weeks GA (postnatal age, 1 day) with fentanyl administration.
Discussion We compared the NIBP and IABP measurements in early postnatal age infants born at 24 to 42 weeks GA with birth American Journal of Perinatology
Vol. 32
No. 3/2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Location of arterial line
NIBP and IABP in Infants: Extent of Discrepancy and Factors Related to Inaccuracy
Shimokaze et al.
Table 2 Systolic, diastolic, and mean arterial BP (NIBP and IABP) and correlation coefficients (r) for NIBP and IABP NIBP (mm Hg)
IABP (mm Hg)
p value
Correlation coefficient (r)
Systolic
54.3 11.7
52.1 11.0
0.24
r ¼ 0.87 (p < 0.001)
Diastolic
25.4 9.8
31.3 9.0
< 0.001
r ¼ 0.82 (p < 0.001)
Mean arterial
38.3 10.2
39.6 9.7
0.44
r ¼ 0.84 (p < 0.001)
Abbreviations: BP, blood pressure; IABP, intra-arterial blood pressure; NIBP, noninvasive blood pressure. Note: Pearson correlation coefficient was used.
Table 3 Mean difference (noninvasive blood pressure minus intra-arterial blood pressure) according each factor Systolic (mm Hg)
Diastolic (mm Hg)
Mean arterial (mm Hg)
Overall
2.3 5.8
6.0 5.9
1.2 5.7
LGA (n ¼ 10)
2.2 5.6
Not LGA (n ¼ 64)
2.9 5.0
Fentanyl (n ¼ 43)
2.1 5.4
No fentanyl (n ¼ 31)
2.3 6.3
Edema (n ¼ 10)
3.0 5.6
No edema (n ¼ 64)
2.1 5.8
Vasopressor (n ¼ 6)
1.8 9.0
No vasopressor (n ¼ 68)
2.2 5.5
Radial artery (n ¼ 69)
2.2 5.8
Posterior tibial artery (n ¼ 5)
2.4 4.7
p < 0.01
6.1 7.0
p ¼ 0.95
6.0 5.7 p ¼ 0.88
4.6 5.3
7.5 6.7
p < 0.05
4.2 9.6
p ¼ 0.39
5.7 5.8 9.6 6.7
p ¼ 0.08
0.5 5.5
p ¼ 0.65
1.4 5.8 p ¼ 0.64
6.2 5.5 p ¼ 0.94
0.3 4.9 2.7 6.6
5.8 5.7 p ¼ 0.92
p ¼ 0.14
0.9 5.9
7.9 6.2 p ¼ 0.64
3.8 3.8
0.3 6.3
p ¼ 0.68
1.4 5.8 p ¼ 0.16
1.1 5.8
p ¼ 0.40
3.4 6.1
Abbreviation: LGA, light for gestational age.
weights of 585 to 3,936 g. The mean difference among the systolic, diastolic, and mean arterial BP was within 6 mm Hg. With respect to clinical factors, discrepancies between the NIBP and IABP measurements were found in association with an LGA status and the absence of fentanyl administration. Previous studies that compared oscillometric with invasive arterial measurements of systolic, diastolic, and mean arterial BP in neonates and infants reported correlation coefficients of 0.7 to 0.9, similar to our results.7–12 NIBP accurately reflects the actual BP, but discrepancies were often seen in the Bland–Altman plots of previous reports. Although one report showed a low correlation (correlation coefficient of < 0.3), the BP was not necessarily measured simultaneously in that report.13 Factors that contribute to discrepancies have been examined. In adults, an ideal cuff length and width of 80 and 40% of the arm circumference, respectively, have been recommended because cuff size is a major contributor to error.14 In one neonatal study, cuffs with widths of 45 to 70% of the infant’s mid-upper arm resulted in highly accurate systolic, diastolic, and mean arterial oscillometric BP American Journal of Perinatology
Vol. 32
No. 3/2015
measurements. 9 However, oscillometric measurements using cuffs with widths of two-thirds and three quarters of the upper arm length without consideration of the arm circumference underestimated the systolic and diastolic BP. 15 Based on these reports, we chose cuffs with standard widths of one-half to two-thirds of the upper arm or leg circumference to reduce discrepancies caused by the cuff dimensions. Previous studies that compared NIBP with IABP in infants performed measurement using the umbilical artery.7,9,11–13,16,17 In adults, the radial systolic IABP has been shown to be approximately 10% higher than the aortic systolic IABP, and the radial diastolic and mean IABP are reportedly identical to those in the aorta.18,19 The difference in BP between the umbilical artery and peripheral artery has not been elucidated. A difference in BP may be induced in highly positioned umbilical and peripheral arteries. However, this factor did not require consideration in our study because we only evaluated the radial and posterior tibial arteries. We also found no differences between the upper arm and leg measurements.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
280
NIBP and IABP in Infants: Extent of Discrepancy and Factors Related to Inaccuracy
Shimokaze et al.
281
Table 4 Correlation coefficient differences between noninvasive blood pressure and intra-arterial blood pressure measurements according to each factor
Gestational age
a
Postnatal ageb Body weight Pulse rate
b
a
Hemoglobin levela a
Systolic
Diastolic
Mean arterial
r ¼ 0.08 (p ¼ 0.95)
r ¼ 0.14 (p ¼ 0.24)
r ¼ 0.13 (p ¼ 0.26)
r ¼ 0.15 (p ¼ 0.21)
r ¼ 0.19 (p ¼ 0.10)
r ¼ 0.09 (p ¼ 0.43)
r ¼ 0.06 (p ¼ 0.61)
r ¼ 0.12 (p ¼ 0.32)
r ¼ 0.14 (p ¼ 0.24)
r ¼ 0.04 (p ¼ 0.73)
r ¼ 0.10 (p ¼ 0.38)
r ¼ 0.02 (p ¼ 0.89)
r ¼ 0.10 (p ¼ 0.40)
r ¼ 0.08 (p ¼ 0.48)
r ¼ 0.01 (p ¼ 0.99)
Pearson correlation coefficients were used. Spearman correlation coefficients were used.
Earlier reports describing NIBP measurements overestimated the mean arterial BP by less than 30 to 40 mm Hg.11,12,16 However, there was no obvious tendency toward a difference between the NIBP and IABP measurements according to the IABP level in our study. In our study, the systolic BP in LGA infants was significantly underestimated. According to our cuff size selection criterion, the use of an inappropriately large cuff in relation to the upper arm or leg length in LGA infants may explain our result, as in a previous report showing substantial bias among overweight adult patients.20 However, neither the length nor circumference of the arm or leg was measured in this study to reduce infant discomfort and the risk of infection. No reports to date have described an association between sedation and BP measurement discrepancies. NIBP measurements underestimated the diastolic BP in our infants without fentanyl administration. In studies limited to general anesthesia, systolic and diastolic BP showed higher correlation coefficients between NIBP and IABP than in other studies, including ours.10,17 BP was low at the time of fentanyl administration, and an influence on the arterial BP itself was observed. Measurement accuracy was improved by sedation. One study reported large BP measurement discrepancies with the use of vasopressors, but this association was not clear in our study.7 However, vasopressors were used in a relatively small number of infants in our study. Further research is necessary to elucidate this association. Our results showed that body weight, GA, and postnatal age were not associated with NIBP and IABP discrepancies. These findings are similar to those in previous studies on infants.7,12,21 Because of the need for an arterial line, many studies on infants were performed shortly after birth.7,10,11,13,22 The incidence of edema in neonates appears to be proportional to prematuarity.23 Although we excluded infants with severe edema that could have led to dermatopathy by cuff expansion, the development of edema with cutaneous pitting by cuff inflation after BP measurement was unrelated to bias. A previous study analyzed 18 factors among 38 infants and revealed that the following factors were associated with discrepant NIBP and IABP measurements by multiple linear regression: cuff size, body temperature, sepsis, heart rate, age after birth, hydrocortisone administration, and dopamine
administration.13 Another study of 20 infants analyzed factors including sex, respiratory support, and measurement site concluded that birth weight, present weight, and arm circumference were associated with discrepant NIBP and IABP measurements by mixed linear regression.22 In our study of 74 infants, our multiple linear regression model was considered to be inappropriate because too many predictors may have led to meaningless results, and some predictors were not normally distributed.24 No infants required arterial BP monitoring to manage their postoperative state, infection, or congenital anomalies. Our infants had a relatively homogeneous background that mostly comprised prematurity and respiratory morbidity in conjunction with a preterm birth. Therefore, the BP measurement discrepancies were examined with every considerable predictor. An increase in BP presumed to be associated with discomfort caused by cuff expansion was seen in 4.1% of infants in the present study. We cannot deny the possibility that this phenomenon occurred accidentally. Its evaluation may be subjective. However, it was a larger change than the maximal intermeasurement difference in the arterial BP in each infant. This reaction was observed in preterm infants who were supposed to have weak reactions to stimulation.25 Changes in arterial BP with cuff expansion are not apparent without continuous IABP measurement. This phenomenon should be carefully considered when interpreting the NIBP value. Some limitations of our study must be discussed. Our research was confined to critically ill infants who required continuous BP monitoring. Physical activity decreases according to the severity of illness. Our results indicate that the accuracy of oscillometric measurement improves with sedation. Therefore, our results are not necessarily applicable to well infants who do not maintain a resting state during NIBP measurement. In conclusion, an LGA status and the absence of fentanyl administration were associated with discrepant BP measurements. There was no significant correlation between discrepant BP measurements and the following factors: GA, postnatal age, body weight, hemoglobin level, pulse rate, presence of edema, vasopressor administration, or measurement site. In critically ill preterm and term infants of early postnatal age, oscillometric measurement using cuffs of one-half to twothirds of the upper arm or leg circumference is useful to American Journal of Perinatology
Vol. 32
No. 3/2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
b
NIBP and IABP in Infants: Extent of Discrepancy and Factors Related to Inaccuracy estimate the IABP. However, the mean difference in the diastolic BP was approximately 6 mm Hg. This difference may seriously change therapeutic decision making in clinical situations, such as treatment of ductus arteriosus in preterm infants. In addition, interpretation of increases in BP accompanying oscillometric measurements requires caution, regardless of the low frequency of their occurrence. Therefore, we recommend IABP measurement when the BP values seriously influence the therapeutic protocol.
11 Takci S, Yigit S, Korkmaz A, Yurdakök M. Comparison between
12
13
14
References 1 Schindler E, Kowald B, Suess H, Niehaus-Borquez B, Tausch B,
2
3
4
5
6
7
8
9
10
Brecher A. Catheterization of the radial or brachial artery in neonates and infants. Paediatr Anaesth 2005;15(8):677–682 Scheer B, Perel A, Pfeiffer UJ. Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care 2002;6(3):199–204 O’Grady NP, Alexander M, Burns LA, et al; Healthcare Infection Control Practices Advisory Committee. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 2011;39(4, Suppl 1):S1–S34 Versmold HT, Kitterman JA, Phibbs RH, Gregory GA, Tooley WH. Aortic blood pressure during the first 12 hours of life in infants with birth weight 610 to 4,220 grams. Pediatrics 1981;67(5):607–613 Gould BA, Hornung RS, Kieso HA, Altman DG, Raftery EB. Is the blood pressure the same in both arms? Clin Cardiol 1985;8(8): 423–426 Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986; 1(8476):307–310 Meyer S, Sander J, Gräber S, Gottschling S, Gortner L. Agreement of invasive versus non-invasive blood pressure in preterm neonates is not dependent on birth weight or gestational age. J Paediatr Child Health 2010;46(5):249–254 Park MK, Menard SM. Accuracy of blood pressure measurement by the Dinamap monitor in infants and children. Pediatrics 1987; 79(6):907–914 Kimble KJ, Darnall RA Jr, Yelderman M, Ariagno RL, Ream AK. An automated oscillometric technique for estimating mean arterial pressure in critically ill newborns. Anesthesiology 1981;54(5): 423–425 Cua CL, Thomas K, Zurakowski D, Laussen PC. A comparison of the Vasotrac with invasive arterial blood pressure monitoring in children after pediatric cardiac surgery. Anesth Analg 2005;100(5):1289–1294
American Journal of Perinatology
Vol. 32
No. 3/2015
Shimokaze et al.
15
16
17
18
19
20
21
22
23 24
25
oscillometric and invasive blood pressure measurements in critically ill premature infants. Acta Paediatr 2012;101(2):132–135 Chia F, Ang AT, Wong TW, et al. Reliability of the Dinamap noninvasive monitor in the measurement of blood pressure of ill Asian newborns. Clin Pediatr (Phila) 1990;29(5):262–267 Troy R, Doron M, Laughon M, Tolleson-Rinehart S, Price W. Comparison of noninvasive and central arterial blood pressure measurements in ELBW infants. J Perinatol 2009;29(11):744–749 Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation 2005;111(5):697–716 Clark JA, Lieh-Lai MW, Sarnaik A, Mattoo TK. Discrepancies between direct and indirect blood pressure measurements using various recommendations for arm cuff selection. Pediatrics 2002; 110(5):920–923 Diprose GK, Evans DH, Archer LN, Levene MI. Dinamap fails to detect hypotension in very low birthweight infants. Arch Dis Child 1986;61(8):771–773 Friesen RH, Lichtor JL. Indirect measurement of blood pressure in neonates and infants utilizing an automatic noninvasive oscillometric monitor. Anesth Analg 1981;60(10):742–745 Pauca AL, O’Rourke MF, Kon ND. Prospective evaluation of a method for estimating ascending aortic pressure from the radial artery pressure waveform. Hypertension 2001;38(4):932–937 Pauca AL, Wallenhaupt SL, Kon ND, Tucker WY. Does radial artery pressure accurately reflect aortic pressure? Chest 1992;102(4): 1193–1198 Araghi A, Bander JJ, Guzman JA. Arterial blood pressure monitoring in overweight critically ill patients: invasive or noninvasive? Crit Care 2006;10(2):R64 Gevers M, van Genderingen HR, Lafeber HN, Hack WW. Accuracy of oscillometric blood pressure measurement in critically ill neonates with reference to the arterial pressure wave shape. Intensive Care Med 1996;22(3):242–248 Dannevig I, Dale HC, Liestøl K, Lindemann R. Blood pressure in the neonate: three non-invasive oscillometric pressure monitors compared with invasively measured blood pressure. Acta Paediatr 2005;94(2):191–196 Lund C, Kuller J, Lane A, Lott JW, Raines DA. Neonatal skin care: the scientific basis for practice. Neonatal Netw 1999;18(4):15–27 Babyak MA. What you see may not be what you get: a brief, nontechnical introduction to overfitting in regression-type models. Psychosom Med 2004;66(3):411–421 Fitzgerald M, McIntosh N. Pain and analgesia in the newborn. Arch Dis Child 1989;64(4 Spec No):441–443
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
282
Copyright of American Journal of Perinatology is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Copyright of American Journal of Perinatology is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
277
Oscillometric and Intra-arterial Blood Pressure in Preterm and Term Infants: Extent of Discrepancy and Factors Associated with Inaccuracy Tomoyuki Shimokaze, MD1
Kazuhiro Akaba, MD, PhD1
1 Department of Pediatrics, Saiseikai Yamagata Hospital,
Yamagata, Japan
Emi Saito, MD1
Address for correspondence Tomoyuki Shimokaze, MD, Department of Pediatrics, Saiseikai Yamagata Hospital, 79-1 Okimachi, Yamagata 990-8545, Japan (e-mail: [email protected]).
Abstract
Keywords
► noninvasive blood pressure ► arterial line ► discomfort ► sedation ► light-for-gestationalage
Objective Securing an arterial line to monitor continuous blood pressure (BP) is difficult in infants. We aimed to reveal the extent of discrepancies between oscillometric and direct BP. Study Design Infants who required continuous BP monitoring were prospectively enrolled. Direct and indirect BP were simultaneously recorded. Disposable BP cuffs matching one-half to two-thirds of the upper arm circumference were used. Results A total of 74 infants were studied (gestational age [GA], 24–42 weeks). The correlation coefficients of systolic, diastolic, and mean arterial BP of indirect and direct measurements were 0.87, 0.82, and 0.84, respectively (p < 0.001). The mean differences in systolic, diastolic, and mean arterial BP (indirect minus direct BP) were 2.2 5.7, 6.0 5.8, and 1.3 5.7 mm Hg, respectively. Oscillometric measurements significantly underestimated systolic BP in light-for-gestational-age infants and diastolic BP in infants without fentanyl administration. There were no significant correlations between discrepant BP measurements and edema, vasopressor administration, arterial line location, GA, postnatal age, body weight, pulse rate, or hemoglobin level. In 4.1% of infants, systolic BP increased by 10 to 15 mm Hg at the time of cuff expansion. Conclusion We recommend intra-arterial BP measurement when the BP values seriously influence the therapeutic protocol.
Measurement of blood pressure (BP) is important in the management of critically ill infants. An arterial line is essential for continuous monitoring of BP. However, securing a peripheral arterial line may be difficult or impossible, especially in preterm infants.1 There is an increased risk of thrombosis and infection associated with the total catheterization duration in infants.2 Although placement of an umbilical artery catheter may be relatively easy, the total duration of catheterization has been recommended not to exceed 5 days.3 When an arterial line
does not exist, BP measurement is performed noninvasively using oscillometric or ultrasound techniques. Discrepancies between noninvasive BP (NIBP) and intraarterial BP (IABP) measurements have a stronger influence on interpretation in infants than in adolescents because arterial BP is low in infants.4 For accurate interpretation of oscillometric BP measurements, it is important to recognize the extent of discrepancies and identify any factors that cause inaccuracy. Therefore, direct and indirect systolic, diastolic, and mean arterial BP were simultaneously recorded to study the features of oscillo-
received March 16, 2014 accepted after revision May 27, 2014 published online June 27, 2014
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1383851. ISSN 0735-1631.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Am J Perinatol 2015;32:277–282.
NIBP and IABP in Infants: Extent of Discrepancy and Factors Related to Inaccuracy metric BP measurement in our neonatal intensive care unit. We studied the factors that have been previously reported to have or that potentially have an influence on the discrepancies between NIBP and IABP measurements.
Methods All infants admitted to our neonatal intensive care unit who required continuous BP monitoring for appropriate management as well as intermittent BP measurement after stopping IABP measurement were included. Infants with any of the following were excluded: major congenital anomalies, critically unstable condition, severe edema, or a peripherally inserted central catheter for NIBP measurement. This study was approved by the institutional review board, and written informed consent was obtained from the parents of all infants. The patients were enrolled between 0 and 70 days postnatal age. An arterial line (DTX Plus Disposable Pressure Transducer Set; Argon Critical Care Systems, Singapore or JELCO Plus I.V. Catheter, 24 G, 0.7 19.0 mm; Smiths Medical, Tokyo, Japan) was placed in the radial or posterior tibial artery. Arterial pressure was recorded with a bedside monitor (Life Scope TR BSM-6000; Nihon Kohden, Tokyo, Japan). Before data collection, air bubbles were removed from the system, the zero level was determined to be the mid-chest level, and a rapid flush test was performed to evaluate the adequacy of the waveform. NIBP measurements were obtained with a clinically approved automated oscillometric BP meter (BP-8800; Omron Colin, Tokyo, Japan); only one BP meter was used throughout the study. Manufacturer-provided disposable BP cuffs matching one-half to two-thirds of the upper arm circumference were used. Three cuffs were used; their width and applicable circumference as recommended by the manufacturer were 2.5 and 3.5 to 6.0 cm (No. 10), 3.0 and 5.0 to 7.5 cm (No. 11), and 4.0 and 7.5 to 10.5 cm (No. 12), respectively. The pulse rate and direct and indirect systolic, diastolic, and mean arterial BP were simultaneously recorded. The direct BP value was adopted from the blinking of the measurement indicator of the automated BP meter. The indirect BP was measured in the contralateral upper arm or leg in which the arterial line was not in place because the BP was not different between the right and left sides.5 To minimize infant discomfort, NIBP was measured one to five times. This number of measurements is the same as that used in our everyday clinical practice in the neonatal intensive care unit. We studied the factors that have been previously reported to influence or that may potentially influence the discrepancies between NIBP and IABP measurements. Previously reported factors included gestational age (GA), body weight, age at measurement, pulse rate, arterial line location, and vasopressor medication (dopamine and/or dobutamine). Factors with potential influence included size for GA, edema, the hemoglobin level, and fentanyl administration. Light for gestational age (LGA) and heavy for gestational age were defined by comparison with the 10th and 90th percentiles in the 2001 infant physical development research report of the Ministry of Health, Labor and Welfare of Japan. Edema was American Journal of Perinatology
Vol. 32
No. 3/2015
Shimokaze et al.
defined as cutaneous pitting secondary to cuff placement after the BP measurement.
Statistical Analysis The overall measurements of direct and indirect systolic, diastolic, and mean arterial BP are presented as Bland–Altman plots.6 Unless stated otherwise, the data are expressed as mean standard deviation. Values with significant deviation from normality are presented as median and interquartile range or range. Spearman and Pearson correlation coefficients were used to identify relationships within and between different outcome measures according to the distribution of the variables. Student unpaired t-test was used to compare normally distributed data. The average of the measured BP values for each infant was used for the correlation coefficients and unpaired Student t-test. A p value of < 0.05 was considered to be statistically significant. Statistical analyses were performed using SPSS software, version 20 (IBM, Armonk, NY).
Results A total of 74 patients (36 males and 38 females) with a mean GA of 31.2 weeks (range, 24–42 weeks) and median body weight of 1,453 g (range, 585–3,936 g) were enrolled in this study from October 2011 to January 2014. The demographic characteristics of our study infants are presented in ►Table 1. Their median postnatal age was 2 days (range, 0–70 days). The birth weight of 38 of the 74 infants was < 1,500 g. The arterial line was placed in the radial (n ¼ 69) or posterior tibial (n ¼ 5) artery. No infants underwent BP measurement using an umbilical arterial catheter. No infants were diagnosed with or treated for an infection during the BP measurement period. The median number of oscillometric BP measurements was 3 (interquartile range, 3–4). The median maximal intermeasurement difference in the arterial BP in each infant with interquartile range was systolic, 2 mm Hg (1–4 mm Hg); diastolic, 2 mm Hg (1–3 mm Hg); and mean arterial, 2 mm Hg (1–4 mm Hg). The Bland–Altman plots of the differences between NIBP and IABP (74 infants, 249 pairs of measurements in each plot) are shown in ►Fig. 1A–C. The correlation coefficients (r) of systolic, diastolic, and mean arterial BP obtained by the indirect and direct measurements were 0.87, 0.82, and 0.84, respectively (p < 0.001). The mean difference in the systolic, diastolic, and mean arterial BP (NIBP minus IABP) was 2.2 5.7 mm Hg (4.7 11.1%), 6.0 5.8 mm Hg ( 19.4 17.5%), and 1.3 5.7 mm Hg ( 2.4 15.8%), respectively (►Table 2). Statistically significant differences were found between diastolic NIBP and IABP measurements. Oscillometric measurements underestimated diastolic BP. Systolic and median BP showed a small discrepancy between the two measurements. Overall, a clear relationship was not found between the arterial BP level (from low to high BP) and the measurement accuracy (►Fig. 1A–C). ►Tables 3 and 4 show the mean difference and correlation coefficients between the two BP measurements according to each factor.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
278
NIBP and IABP in Infants: Extent of Discrepancy and Factors Related to Inaccuracy
Shimokaze et al.
279
Table 1 Demographic data n (%) Gestational age (wk)
31.2 5.8
Age at measurement (d), median (IQR)
2.0 (1.0–4.0)
Male
36 (48.6)
Body weight (g), median (IQR)
1453 (916–2204)
Heavy for gestational age
3 (4.1)
Light for gestational age
10 (13.5)
Radial artery
69 (93.2)
Posterior tibial artery
5 (6.8)
Number of oscillometric BP measurements, median (IQR)
3 (3–4)
Maximal intermeasurement difference in arterial BP in each infant, median (IQR) Systolic (mm Hg)
2 (1–4)
Diastolic (mm Hg)
2 (1–3)
Mean arterial (mm Hg)
2 (1–4)
Medication Vasopressor
10 (13.5)
Fentanyl
43 (58.1)
Edema
10 (13.5)
Ventilator support
73 (98.6)
Abbreviation: BP, blood pressure; IQR, interquartile range.
An LGA status and the absence of fentanyl administration were associated with discrepant BP measurements (►Table 3). Oscillometric measurements significantly underestimated systolic BP in LGA infants (NIBP minus IABP: 2.2 5.6 mm Hg) compared with the overall difference (NIBP minus IABP: 2.2 5.7 mm Hg). LGA and non-LGA infants had a mean systolic BP of 52.3 5.9 and 52.2 11.6 mm Hg (p ¼ 0.97), mean diastolic BP of 32.5 5.0 and 31.3 9.4 mm Hg (p ¼ 0.54), and mean arterial BP of 40.6 4.8 and 39.5 10.2 mm Hg (p ¼ 0.58), respectively. We did not analyze heavy-for-GA infants (n ¼ 3) because of the small number of such infants. Oscillometric measurements more accurately estimated the diastolic BP in infants with fentanyl administration (NIBP minus IABP: 4.6 5.3 mm Hg) than shown by the overall difference (NIBP minus IABP: 6.0 5.8 mm Hg) (►Table 3). The mean value of any IABP measurement was lower in infants with fentanyl administration. Infants with and without fentanyl administration had a mean systolic BP of 50.4 10.8 and 54.7 10.8 mm Hg (p ¼ 0.10), diastolic BP of 29.8 9.3 and 33.6 8.1 mm Hg (p ¼ 0.07), and mean arterial BP of 38.1 9.6 and 41.8 9.5 mm Hg (p ¼ 0.10), respectively. There was no significant correlation between discrepant BP measurements and the following factors: edema, vasopressor administration, arterial line location, GA, age at
Fig. 1 Bland–Altman plots showing agreement between oscillometric and intra-arterial blood pressure measurements. (A) Systolic, (B) diastolic, and (C) mean arterial blood pressure. The line represents mean bias with upper and lower limits of agreement. IABP, intraarterial blood pressure; NIBP, noninvasive blood pressure.
measurement, body weight, pulse rate, or hemoglobin level (►Tables 3 and 4). In 3 of the 74 infants (4.1%), the systolic BP increased by 10 to 15 mm Hg at the time of cuff expansion. Two of these three infants were born at 29 and 32 weeks GA (postnatal age, 3 and 1 days, respectively) without fentanyl administration, and one of the three infants was born at 29 weeks GA (postnatal age, 1 day) with fentanyl administration.
Discussion We compared the NIBP and IABP measurements in early postnatal age infants born at 24 to 42 weeks GA with birth American Journal of Perinatology
Vol. 32
No. 3/2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Location of arterial line
NIBP and IABP in Infants: Extent of Discrepancy and Factors Related to Inaccuracy
Shimokaze et al.
Table 2 Systolic, diastolic, and mean arterial BP (NIBP and IABP) and correlation coefficients (r) for NIBP and IABP NIBP (mm Hg)
IABP (mm Hg)
p value
Correlation coefficient (r)
Systolic
54.3 11.7
52.1 11.0
0.24
r ¼ 0.87 (p < 0.001)
Diastolic
25.4 9.8
31.3 9.0
< 0.001
r ¼ 0.82 (p < 0.001)
Mean arterial
38.3 10.2
39.6 9.7
0.44
r ¼ 0.84 (p < 0.001)
Abbreviations: BP, blood pressure; IABP, intra-arterial blood pressure; NIBP, noninvasive blood pressure. Note: Pearson correlation coefficient was used.
Table 3 Mean difference (noninvasive blood pressure minus intra-arterial blood pressure) according each factor Systolic (mm Hg)
Diastolic (mm Hg)
Mean arterial (mm Hg)
Overall
2.3 5.8
6.0 5.9
1.2 5.7
LGA (n ¼ 10)
2.2 5.6
Not LGA (n ¼ 64)
2.9 5.0
Fentanyl (n ¼ 43)
2.1 5.4
No fentanyl (n ¼ 31)
2.3 6.3
Edema (n ¼ 10)
3.0 5.6
No edema (n ¼ 64)
2.1 5.8
Vasopressor (n ¼ 6)
1.8 9.0
No vasopressor (n ¼ 68)
2.2 5.5
Radial artery (n ¼ 69)
2.2 5.8
Posterior tibial artery (n ¼ 5)
2.4 4.7
p < 0.01
6.1 7.0
p ¼ 0.95
6.0 5.7 p ¼ 0.88
4.6 5.3
7.5 6.7
p < 0.05
4.2 9.6
p ¼ 0.39
5.7 5.8 9.6 6.7
p ¼ 0.08
0.5 5.5
p ¼ 0.65
1.4 5.8 p ¼ 0.64
6.2 5.5 p ¼ 0.94
0.3 4.9 2.7 6.6
5.8 5.7 p ¼ 0.92
p ¼ 0.14
0.9 5.9
7.9 6.2 p ¼ 0.64
3.8 3.8
0.3 6.3
p ¼ 0.68
1.4 5.8 p ¼ 0.16
1.1 5.8
p ¼ 0.40
3.4 6.1
Abbreviation: LGA, light for gestational age.
weights of 585 to 3,936 g. The mean difference among the systolic, diastolic, and mean arterial BP was within 6 mm Hg. With respect to clinical factors, discrepancies between the NIBP and IABP measurements were found in association with an LGA status and the absence of fentanyl administration. Previous studies that compared oscillometric with invasive arterial measurements of systolic, diastolic, and mean arterial BP in neonates and infants reported correlation coefficients of 0.7 to 0.9, similar to our results.7–12 NIBP accurately reflects the actual BP, but discrepancies were often seen in the Bland–Altman plots of previous reports. Although one report showed a low correlation (correlation coefficient of < 0.3), the BP was not necessarily measured simultaneously in that report.13 Factors that contribute to discrepancies have been examined. In adults, an ideal cuff length and width of 80 and 40% of the arm circumference, respectively, have been recommended because cuff size is a major contributor to error.14 In one neonatal study, cuffs with widths of 45 to 70% of the infant’s mid-upper arm resulted in highly accurate systolic, diastolic, and mean arterial oscillometric BP American Journal of Perinatology
Vol. 32
No. 3/2015
measurements. 9 However, oscillometric measurements using cuffs with widths of two-thirds and three quarters of the upper arm length without consideration of the arm circumference underestimated the systolic and diastolic BP. 15 Based on these reports, we chose cuffs with standard widths of one-half to two-thirds of the upper arm or leg circumference to reduce discrepancies caused by the cuff dimensions. Previous studies that compared NIBP with IABP in infants performed measurement using the umbilical artery.7,9,11–13,16,17 In adults, the radial systolic IABP has been shown to be approximately 10% higher than the aortic systolic IABP, and the radial diastolic and mean IABP are reportedly identical to those in the aorta.18,19 The difference in BP between the umbilical artery and peripheral artery has not been elucidated. A difference in BP may be induced in highly positioned umbilical and peripheral arteries. However, this factor did not require consideration in our study because we only evaluated the radial and posterior tibial arteries. We also found no differences between the upper arm and leg measurements.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
280
NIBP and IABP in Infants: Extent of Discrepancy and Factors Related to Inaccuracy
Shimokaze et al.
281
Table 4 Correlation coefficient differences between noninvasive blood pressure and intra-arterial blood pressure measurements according to each factor
Gestational age
a
Postnatal ageb Body weight Pulse rate
b
a
Hemoglobin levela a
Systolic
Diastolic
Mean arterial
r ¼ 0.08 (p ¼ 0.95)
r ¼ 0.14 (p ¼ 0.24)
r ¼ 0.13 (p ¼ 0.26)
r ¼ 0.15 (p ¼ 0.21)
r ¼ 0.19 (p ¼ 0.10)
r ¼ 0.09 (p ¼ 0.43)
r ¼ 0.06 (p ¼ 0.61)
r ¼ 0.12 (p ¼ 0.32)
r ¼ 0.14 (p ¼ 0.24)
r ¼ 0.04 (p ¼ 0.73)
r ¼ 0.10 (p ¼ 0.38)
r ¼ 0.02 (p ¼ 0.89)
r ¼ 0.10 (p ¼ 0.40)
r ¼ 0.08 (p ¼ 0.48)
r ¼ 0.01 (p ¼ 0.99)
Pearson correlation coefficients were used. Spearman correlation coefficients were used.
Earlier reports describing NIBP measurements overestimated the mean arterial BP by less than 30 to 40 mm Hg.11,12,16 However, there was no obvious tendency toward a difference between the NIBP and IABP measurements according to the IABP level in our study. In our study, the systolic BP in LGA infants was significantly underestimated. According to our cuff size selection criterion, the use of an inappropriately large cuff in relation to the upper arm or leg length in LGA infants may explain our result, as in a previous report showing substantial bias among overweight adult patients.20 However, neither the length nor circumference of the arm or leg was measured in this study to reduce infant discomfort and the risk of infection. No reports to date have described an association between sedation and BP measurement discrepancies. NIBP measurements underestimated the diastolic BP in our infants without fentanyl administration. In studies limited to general anesthesia, systolic and diastolic BP showed higher correlation coefficients between NIBP and IABP than in other studies, including ours.10,17 BP was low at the time of fentanyl administration, and an influence on the arterial BP itself was observed. Measurement accuracy was improved by sedation. One study reported large BP measurement discrepancies with the use of vasopressors, but this association was not clear in our study.7 However, vasopressors were used in a relatively small number of infants in our study. Further research is necessary to elucidate this association. Our results showed that body weight, GA, and postnatal age were not associated with NIBP and IABP discrepancies. These findings are similar to those in previous studies on infants.7,12,21 Because of the need for an arterial line, many studies on infants were performed shortly after birth.7,10,11,13,22 The incidence of edema in neonates appears to be proportional to prematuarity.23 Although we excluded infants with severe edema that could have led to dermatopathy by cuff expansion, the development of edema with cutaneous pitting by cuff inflation after BP measurement was unrelated to bias. A previous study analyzed 18 factors among 38 infants and revealed that the following factors were associated with discrepant NIBP and IABP measurements by multiple linear regression: cuff size, body temperature, sepsis, heart rate, age after birth, hydrocortisone administration, and dopamine
administration.13 Another study of 20 infants analyzed factors including sex, respiratory support, and measurement site concluded that birth weight, present weight, and arm circumference were associated with discrepant NIBP and IABP measurements by mixed linear regression.22 In our study of 74 infants, our multiple linear regression model was considered to be inappropriate because too many predictors may have led to meaningless results, and some predictors were not normally distributed.24 No infants required arterial BP monitoring to manage their postoperative state, infection, or congenital anomalies. Our infants had a relatively homogeneous background that mostly comprised prematurity and respiratory morbidity in conjunction with a preterm birth. Therefore, the BP measurement discrepancies were examined with every considerable predictor. An increase in BP presumed to be associated with discomfort caused by cuff expansion was seen in 4.1% of infants in the present study. We cannot deny the possibility that this phenomenon occurred accidentally. Its evaluation may be subjective. However, it was a larger change than the maximal intermeasurement difference in the arterial BP in each infant. This reaction was observed in preterm infants who were supposed to have weak reactions to stimulation.25 Changes in arterial BP with cuff expansion are not apparent without continuous IABP measurement. This phenomenon should be carefully considered when interpreting the NIBP value. Some limitations of our study must be discussed. Our research was confined to critically ill infants who required continuous BP monitoring. Physical activity decreases according to the severity of illness. Our results indicate that the accuracy of oscillometric measurement improves with sedation. Therefore, our results are not necessarily applicable to well infants who do not maintain a resting state during NIBP measurement. In conclusion, an LGA status and the absence of fentanyl administration were associated with discrepant BP measurements. There was no significant correlation between discrepant BP measurements and the following factors: GA, postnatal age, body weight, hemoglobin level, pulse rate, presence of edema, vasopressor administration, or measurement site. In critically ill preterm and term infants of early postnatal age, oscillometric measurement using cuffs of one-half to twothirds of the upper arm or leg circumference is useful to American Journal of Perinatology
Vol. 32
No. 3/2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
b
NIBP and IABP in Infants: Extent of Discrepancy and Factors Related to Inaccuracy estimate the IABP. However, the mean difference in the diastolic BP was approximately 6 mm Hg. This difference may seriously change therapeutic decision making in clinical situations, such as treatment of ductus arteriosus in preterm infants. In addition, interpretation of increases in BP accompanying oscillometric measurements requires caution, regardless of the low frequency of their occurrence. Therefore, we recommend IABP measurement when the BP values seriously influence the therapeutic protocol.
11 Takci S, Yigit S, Korkmaz A, Yurdakök M. Comparison between
12
13
14
References 1 Schindler E, Kowald B, Suess H, Niehaus-Borquez B, Tausch B,
2
3
4
5
6
7
8
9
10
Brecher A. Catheterization of the radial or brachial artery in neonates and infants. Paediatr Anaesth 2005;15(8):677–682 Scheer B, Perel A, Pfeiffer UJ. Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care 2002;6(3):199–204 O’Grady NP, Alexander M, Burns LA, et al; Healthcare Infection Control Practices Advisory Committee. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 2011;39(4, Suppl 1):S1–S34 Versmold HT, Kitterman JA, Phibbs RH, Gregory GA, Tooley WH. Aortic blood pressure during the first 12 hours of life in infants with birth weight 610 to 4,220 grams. Pediatrics 1981;67(5):607–613 Gould BA, Hornung RS, Kieso HA, Altman DG, Raftery EB. Is the blood pressure the same in both arms? Clin Cardiol 1985;8(8): 423–426 Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986; 1(8476):307–310 Meyer S, Sander J, Gräber S, Gottschling S, Gortner L. Agreement of invasive versus non-invasive blood pressure in preterm neonates is not dependent on birth weight or gestational age. J Paediatr Child Health 2010;46(5):249–254 Park MK, Menard SM. Accuracy of blood pressure measurement by the Dinamap monitor in infants and children. Pediatrics 1987; 79(6):907–914 Kimble KJ, Darnall RA Jr, Yelderman M, Ariagno RL, Ream AK. An automated oscillometric technique for estimating mean arterial pressure in critically ill newborns. Anesthesiology 1981;54(5): 423–425 Cua CL, Thomas K, Zurakowski D, Laussen PC. A comparison of the Vasotrac with invasive arterial blood pressure monitoring in children after pediatric cardiac surgery. Anesth Analg 2005;100(5):1289–1294
American Journal of Perinatology
Vol. 32
No. 3/2015
Shimokaze et al.
15
16
17
18
19
20
21
22
23 24
25
oscillometric and invasive blood pressure measurements in critically ill premature infants. Acta Paediatr 2012;101(2):132–135 Chia F, Ang AT, Wong TW, et al. Reliability of the Dinamap noninvasive monitor in the measurement of blood pressure of ill Asian newborns. Clin Pediatr (Phila) 1990;29(5):262–267 Troy R, Doron M, Laughon M, Tolleson-Rinehart S, Price W. Comparison of noninvasive and central arterial blood pressure measurements in ELBW infants. J Perinatol 2009;29(11):744–749 Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation 2005;111(5):697–716 Clark JA, Lieh-Lai MW, Sarnaik A, Mattoo TK. Discrepancies between direct and indirect blood pressure measurements using various recommendations for arm cuff selection. Pediatrics 2002; 110(5):920–923 Diprose GK, Evans DH, Archer LN, Levene MI. Dinamap fails to detect hypotension in very low birthweight infants. Arch Dis Child 1986;61(8):771–773 Friesen RH, Lichtor JL. Indirect measurement of blood pressure in neonates and infants utilizing an automatic noninvasive oscillometric monitor. Anesth Analg 1981;60(10):742–745 Pauca AL, O’Rourke MF, Kon ND. Prospective evaluation of a method for estimating ascending aortic pressure from the radial artery pressure waveform. Hypertension 2001;38(4):932–937 Pauca AL, Wallenhaupt SL, Kon ND, Tucker WY. Does radial artery pressure accurately reflect aortic pressure? Chest 1992;102(4): 1193–1198 Araghi A, Bander JJ, Guzman JA. Arterial blood pressure monitoring in overweight critically ill patients: invasive or noninvasive? Crit Care 2006;10(2):R64 Gevers M, van Genderingen HR, Lafeber HN, Hack WW. Accuracy of oscillometric blood pressure measurement in critically ill neonates with reference to the arterial pressure wave shape. Intensive Care Med 1996;22(3):242–248 Dannevig I, Dale HC, Liestøl K, Lindemann R. Blood pressure in the neonate: three non-invasive oscillometric pressure monitors compared with invasively measured blood pressure. Acta Paediatr 2005;94(2):191–196 Lund C, Kuller J, Lane A, Lott JW, Raines DA. Neonatal skin care: the scientific basis for practice. Neonatal Netw 1999;18(4):15–27 Babyak MA. What you see may not be what you get: a brief, nontechnical introduction to overfitting in regression-type models. Psychosom Med 2004;66(3):411–421 Fitzgerald M, McIntosh N. Pain and analgesia in the newborn. Arch Dis Child 1989;64(4 Spec No):441–443
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
282
Copyright of American Journal of Perinatology is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Copyright of American Journal of Perinatology is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
