Arterial and Central Venous Pressure Monitoring James A. L. Pittman, MD, BSc, FRCA John Sum Ping, MD, FRCA Jonathan B. Mark, MD “… the information that the pulse affords is of so great importance and so often consulted, surely it must be to our advantage to appreciate fully all it tells us, and draw from it every detail that it is capable of imparting.” F. A. Mahomed, 18721 The pulsatile arterial pressure wave is a fundamental clinically monitored variable that is used commonly to determine heart rate and rhythm and to provide the principle cardiovascular parameter indicative of adequate tissue perfusion. Detailed analysis of the pressure wave reveals that it has more to offer than this, and careful observation of its more subtle char- acteristics can provide additional useful diagnostic information. It is there- fore surprising that it is given so little attention. There is a similar ten- dency to overlook the added information obtainable from close analysis of the central venous pressure (CVP) waveform. In both measurements, cli- nicians tend to concentrate on the numeric values rather than the more qualitative data that are available. The shape and timing of the pressure waves and the changes that occur during the respiratory cycle should not be overlooked. In the first half of this chapter, we describe how some additional clinically important information can be obtained easily from close study of the arterial pressure waveform. The second part of the chapter has a similar focus on the CVP wave. We begin by identifying some technical considerations relevant to all pressure monitoring that are necessary to ensure that the high-resolution monitoring displays now available in the operating room and intensive-care unit can be readily and correctly used for this purpose. A clear understanding of the properties and limitations of monitoring systems is necessary to ensure accurate analysis of pressure waveforms. Reprints: Jonathan B. Mark, MD, Anesthesiology Service (112C), Veterans Affairs Medical Center, 508 Fulton Street, Durham, NC 27705 (e-mail: [email protected]). 13 14 Ⅲ Pittman et al Ⅲ Technical Considerations For Direct Pressure Measurement Arterial cannulation with continuous pressure waveform display re- mains the accepted reference standard for blood pressure monitoring of hemodynamically unstable patients. The arterial pressure waveform is a complex wave that represents the summation of a series of mechanical pressure signals of different frequencies. It has a characteristic periodicity, termed the fundamental frequency, which equals the pulse rate.2 The waveform displayed on the bedside monitor can be derived from Fourier analysis and described as the summation of a series of waves that are multiples or harmonics of the fundamental frequency. In clinical moni- toring systems, 6 to 10 harmonics are required to provide a clinically acceptable reproduction of the true intraarterial pressure waveform (Fig. 1).3 Monitoring systems are designed to have dynamic response charac- teristics that allow accurate reproduction of pressure waveforms across the wide range of heart rates and frequency contents of arterial pressure waves commonly recorded in clinical practice. The monitoring system will have its own natural resonant frequency, and it is important that this does not overlap the harmonic frequencies present in the monitored pressure waveform. When this occurs, the monitoring system will resonate, and the output pressure signal will be distorted and exaggerated. Although similar technical issues apply to the measurement of CVP waveforms, these are not typically a problem in clinical practice. Unlike arterial pressure waveforms, CVP waves do not contain high-frequency components. As a result, the pressure measurement system does not re- quire a high-frequency response to measure the CVP waveform accurately. The dynamic response characteristics of catheter transducer systems not only depend on system frequency response, but also the system- Figure 1. The arterial pressure waveform as a sum of sine waves by Fourier analysis. Summation of the top and middle sine waves produces a waveform with the morphologic characteristics of an arterial blood pressure trace. Arterial Central Venous Pressure Monitoring Ⅲ 15 damping coefficient that describes the absorption of oscillatory energy by frictional forces. A monitoring system must be adequately damped so that it dissipates energy produced by the components of the measurement system, reducing potential artifacts that could distort waveform morphol- ogy. If a system is overdamped, signal definition will be lost, and the pressure peaks and troughs will be attenuated, although mean arterial pressure values remain reasonably accurate. In clinical practice, most monitoring systems are underdamped but have a natural frequency that is sufficiently high that the effect on the monitored waveform is limited.4 The pressure monitoring system should consist of a short length of stiff tubing free of air and clot, thereby assuring that the system will have an acceptable natural frequency that exceeds 12 Hz. Problems arise when air bubbles or blood clots become trapped in the connections or tubing of the monitoring system. These expose the patient to risk of embolism and distort the measured pressure signal in an unpredictable fashion. A small air bubble can lower the natural resonant frequency and cause the moni- toring system to resonate or ring, resulting in a spuriously elevated systolic blood pressure. On the other hand, a large air bubble will lead to exces- sive signal damping and cause underestimation of the true systolic blood pressure.5 The natural frequency and damping coefficient of a measurement system can be evaluated to predict when pressure signal distortion is likely. This is done conventionally using the “fast flush test,” which determines the dynamic response of the measuring system through an examination of the artifact that follows a pressurized flush of the manometer system.6,7 The natural frequency and damping coefficient of the system can then be determined (Fig. 2).8 A plot of natural frequency and damping coefficient provides a visual display of the dynamic response characteristics of cath- eter-tubing-transducer monitoring systems and a means to determine if the system has the physical characteristics that will result in accurate pres- sure waveform measurement. (Fig. 3).4 Note that the higher the natural frequency, the wider the range of damping coefficients that will still pro- vide an accurate arterial pressure waveform. In clinical practice, it appears that most arterial pressure monitoring systems are underdamped, and this leads to the systolic arterial pressure “overshoot” typically seen in arterial pressure traces.9 In summary, interpretation of invasive pressure measurements re- quires consideration of the dynamic response of the system, and an un- derstanding and assessment of damping and natural frequency. If the dynamic response of the system is suboptimal, the pressure measurement will be affected, leading to an incorrect diagnosis of hypotension or hy- pertension. Limiting pressure tubing length and stopcocks, avoidance of air bubbles, clots, or catheter kinking will improve the signal and the accuracy of pressure measurement. Because most clinical pressure moni- toring systems are underdamped, direct intraarterial systolic pressure val- 16 Ⅲ Pittman et al Figure 2. The arterial pressure artifact resulting from a fast flush test allows calculation of the natural resonant frequency and the damping coefficient of the monitoring system. The time between adjacent pressure peaks determines the natural frequency and the height or amplitude ratio of adjacent peaks allows determination of the damping coefficient. ues generally exceed those obtained by noninvasive measurement meth- ods. Mean arterial pressures measured by direct and indirect methods should remain relatively comparable and are often more appropriate for clinical decision-making. Pressure Transducer Setup Before invasive arterial or venous pressure monitoring, the pressure transducer must be zeroed, calibrated, and placed in the appropriate position relative to the patient. Intravascular pressures are referenced against ambient atmospheric pressure by exposing the pressure trans- ducer to air through an open stopcock and pressing the zero pressure button on the monitor. Transducer calibration is not required with the current generation of disposable transducers that are designed to meet acceptable standards for accuracy. On the other hand, positioning of the pressure transducer is crucial and, in the authors’ experience, represents the part of the transducer setup process most prone to error. The trans- ducer must be leveled or horizontally aligned with a specific position on the patient’s body that represents the upper fluid level in the chamber or vessel from which pressure is to be measured. It is important to recognize that when fluid-filled catheter systems are used for pressure measurement, this horizontal level is the only factor that contributes to the measured pressure. In contrast, the position of the catheter tip within the chamber or vessel does not influence the pressure reading.10 Arterial Central Venous Pressure Monitoring Ⅲ 17 Figure 3. The relation between the natural frequency and damping coefficient. Monitoring systems that have dynamic response characteristics that fall within the shaded area will provide accurate pressure waveforms. Proper positioning of the pressure transducer