CLINICAL MEASUREMENT

Prof. Serban Bubenek MD

E.S.A. - EDAIC Basic Sciences Course

Stockholm 2014
 TODAY we speak about :
Arterial Pressure Measurement

Cardiac Output Measurement

Pulseoximetry
 Clinical measurement
is limited by 4 major constraints:

1. Feasibility

2. Reliability

3. Interpretation

4. Value
 4 mandatory steps in clinical measurement:

• Detection : sensing device ( biological signal : mechanical, electrical,

electromagnetic, chemical or thermal energy)

• Transduction : the output is converted into another form, usually to a

continuous electrical signal

• Amplification and signal processing :

- extract and magnify the relevant features of the signal and reduce unwanted
noise

• Display and Storage : the output of the instrument is presented to the operator
 Mechanical versus Digital instruments

Mechanical instruments ;

- use the natural signal energy to drive a display,with minimal intermediate

processing

Digital instruments
- non-electrical signals are converted by a transducer to an electrical signal
suitable for electronic processing by digital computers.

- higher accuracy and precision

Essential requiremets for CLINICAL MEASUREMENT

Accuracy is the difference between the measurements and the real

biological signal, or in practice, between a certain techique and a superior
'gold standard‘ technique.

Precision describes the reproducibility of repeated measurements of the

same biological signal.

- calibration is important
( against predetermined signals or for absolute measurements to zero)
 MECHANICAL SIGNALS:
MEASUREMENT OF ARTERIAL PRESSURE

a wide range of instruments are used to measure pressure :

liquid column manometers : height, zero point, fluid density

mechanical pressure gauges : aneroid manometer

diafragm gauges (coupled to transducers)

 MEASUREMENT OF ARTERIAL PRESSURE

INDIRECT measurement (non-invasive)

- signals generated by the occlusion of a major artery using a cuff
- gives not continous but intermittent measurements

- palpation method ( Riva Rocci)

- auscultation of the Korotkoff sounds
- osccilometry method

DIRECT measurement (invasive and continous)

o Indirect Methods of BP measurement (1)

1. Riva Rocci: simplest method of BP measurement,

estimating only the SBP, is by palpating the return of
arterial pulse as cuff is deflated.

2. Auscultation of the Korotkoff sounds (1905)

on deflation created by the turbulent blood flow in the artery
(providing both SBP and DBP)
Mean Arterial Pressure (MAP) = DBP + 1/3(SBP – DBP)
 Indirect Methods of BP measurement (2)
3. OSCCILOMETRY
- a microprocessor controlled oscillometer. DINAMAP
- a pressure transducer that digitalizes signals ( microprocesor).
- rapid, accurate (± 9 mmHg) measurements of SBP, DBP, MAP and HR

- SAP corresponds to the onset of rapidly increasing oscillations

- MAP corresponds to the maximal oscillation at the lowest cuff pressure
- DAP corresponds to the onset of rapidly decreasing oscillations

LIMITATIONS:
- tendency to overestimate at low pressures and underestimate at high
pressures
- errors : movements, arrhythmias or BP fluctuations
- compressive peripheral nerve injuries (repeated measurements )
 Cuff Size
Too small cuff will result in false high blood pressure reading

Too large cuff will result in false low blood pressure reading

f
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m

B
 DIRECT Measurement of the BP
invasive : catheter into the artery

METHODS

1. open Liquid column method (obsolete) , measures only MAP

13.4 cm. H2O = 10 mm.Hg.

2. Liquid manometers (obsolete)

3. Electromechanical transducers :
- conversion of mechanic signal into an electric signal
- and then electronically converted and displayed as :

SAP,DAP and MAP .

 Electromechanical - TRANSDUCERS

The diaphragm :
- is moved by arterial pulsations which push the saline column
- should be thin, small and rigid !

Transducers :

- based upon strain gauge principle : stretching (by PRESSURE ) a

wire or silicone crystal changes its electrical resistance

- connected to a wheatstone bridge circuit : so that the voltage

output is proportionate to the pressure applied it
 The ARTERIAL PRESSURE Waveform
The damping coefficient (DC) is a measure of how quickly an
oscillating system comes to rest

method to test the DC: the fast-flush test ( square wave test)

optimal damping

- underdamping = overestimates SAP and underestimates DAP

- overdamping = underestimates SAP and overestimates DAP

- both cases however MAP is relatively accurate

 REDUCING ARTIFACTS IN A-LINES
Lines free of kinks and clots

Air Bubbles : small amount may augment systolic pressure reading,

while large amount cause an over-damped system

One stopcock per line

Heparinized saline flushed maintaining patency

Transducer should be electronically balanced or re-zeroed because the

zero point may drift if the room temperature changes

to have an adequate damping = flushing TEST

Short and rigid : catheter and lines

MEASUREMENT OF BLOOD FLOW:
CARDIAC OUTPUT
Potential Methods To Measure Cardiac Output

Fick metdod
Indicator dilution
Pulse waveform ( pulse contour) methods
ULTRASOUNDS ( 2D-Echo and Doppler techique)
Bioimpedance

ANGIOGRAPHY
MRI
 Ideal Cardiac Output Monitoring Technique

Precise and No bias

Non-invasive
Continous and instantaneous
Automatic
Operator independent
Cheap
Easy available in the ICU
Leads to treatment changes / improvement in outcome

IT DOES NOT EXIST !

Use the Best Compromise : feasibility –precision – patient !

 The FICK principle

defines flow by the ratio of the uptake or clearance of a tracer within an

organ to the arterio-venous difference in concentration

VO2 per minute using a spirometer + Douglas bag

CvO2 is taken from the pulmonary artery
CaO2 a cannula in a peripheral artery
 The FICK method
considered to be the most accurate method for CO

but : - invasive, time consuming

- accurate VO2 samples are difficult to acquire

discontinous CO : Deltatrac (Datex)

continous CO : possible, but no integrated system available

modified Fick equation : continous CO by NICO2 apparatus

 INDICATOR DILUTION

Chemical indicator dilution (dye)

Thermal indicator dilution

( Thermodilution )

the widest used : PAC = Swan Ganz

 INDICATOR DILUTION

CO measurement by indicator dilution has 3 phases :

(a) an indicator is brought into the circulation (injection)

(b) the indicator mixes with the bloodstream

(mixing and dilution)

(c) the concentration of the indicator is measured downstream

(detection).
 The Thermodilution (TD) method

Thermodilution = indicator is the change in blood temperature

An injectate of known volume and temperature is injected into the

right atrium and the cooled blood traverses a thermistor in a major
vessel branch downstream over a duration of time.

TD Methods :

1. PULMONARY Thermodilution (P-TD)

1. TRANSPULMONARY Thermodiution (TP-TD)

 PAC-Thermodilution

The change of the blood’s temperature in is measured in the pulmonary

artery using the PAC thermistor

The thermistor records the temperature change and the monitor

electronically displays a temperature/time curve.

The CO is inversely proportional to :

- the temperature change
- the area under the curve
( PAC measures the Pulm.CO = Global CO if no intracardiac shunt )
 Sources of measurement error for P-TD

Loss of indicator
Variation of injectate temperature and volume
Recirculation - IC shunts : false high CO values
Tricuspid regurgitation : false low CO values
Fluctuations in baseline temperature
PULMONARY Thermodilution TRANSPULMONARY Thermodiution

The pulmonary artery TD curve appears earlier and has a higher peak
temperature than the femoral artery TD curve.

TP-TD is less invasive than P-TD, but does NOT give : SvO2 an PAP
values !

,
 The Clinical USE of TP-TD

Mainly : as a “ calibration method” for other

systems : PiCCO, LiDCO-Pulse CO

PiCCO and LiDCO-Pulse CO are able after the initial

calibration, to measure in a continous manner
( beat by beat ) the C.O, using :

the Pulse Contour method

 The Pulse Contour method

1. CALIBRATED techniques
PiCCO
LiDCO – Pulse CO

2. NON-CALIBRATED techniques
Flow-Track VIGILEO
Nexfin
 CCO by the pulse contour method
The area under the systolic part of the AP waveform correlates :
- directly with Left Ventricular STROKE VOLUME
- inversely with aortic impedance

SV

For calibrated techiques : the Aortic impedance is estimated from AP and

CO pre-measured values
( calibration : CO is ussualy measured by TP-TD)
 LiDCO – Pulse CO
the independent calibration technique is : Lithium indicator Dilution

safe and minimally invasive : peripheral venous and arterial catheters

The PulseCO algorithm used by LiDCO is based on pulse power

derivation.

Continuous, real-time cardiovascular monitoring

Pulse Contour NON-CALIBRATED techniques

Flow-Track VIGILEO
- only arterial line

NEXFIN
- totally non-invasive
 BIOIMPEDANCE
bio tissues (bone, muscle,blood, etc) have different electric proprieties
blood is the most conductive tissue ( Na+ and Cl-)
pulsatile modification of ITBV → Δ TB
Δ TB ~ Δ stroke volume

SV = K x (dZ / dt) / Zo x TEV

Δ TB is measured by : producing and transmiting electricity

( high υ = 70 kHz low A = 2,5 mA ) betwwen 2 pairs of electrodes
Echocardiography for measuring the CO

2 D – method

Doppler - method
 Ultrasounds (1.)
US techniques can detect : the shape, size and movement of
tissue interfaces, especially soft tissues and blood (RBC)

US are defined by :
- amplitude of oscillation (delta pressure : ambient to peak) dB
- the wavelength (distance between successive peaks)
- frequency (inversely proportional to wavelength, nr. of cycles / second )

human ear can detect frequencies : 20-20,000 Hz.

US have frequencies > 20,000 cycles /sec ( 20 KHz)
diagnostic US uses frequencies in the range of 1-10 MHz.
 2-D Method
Principle

Stroke volume= End diastolic volume – End systolic volume

LV volumes estimated by Simpson’s method, which is the summation of
the volume of stacked cylinders within the LV at end-diastole and end-
systole

150 ml - 52 ml= 98 ml
 Doppler Effect (1)
frequency of US waves reflected from a stationary object is the
same as that transmited

frequency of transmitted US is altered as it is reflected from a

moving object

there is an increase in the observed frequency of a

signal when the signal source approaches the observer

e.g. ambulance siren

 Doppler Effect - 3
Doppler effect represented by:

V= _ΔF . c _
2 F0 cos θ

Where V = velocity of object

ΔF = frequency shift
c = speed of sound in medium (body tissue here)
F0 = frequency of emitted sound
cos θ = angle between sound wave and flow (RBC)

cos 90◦ = 0 so the US beam should be parallel to RBC

Maximum angle = 20◦
 PULSEOXIMETRY

Principle : Spectrophotometry & Plethysmography

relies on the differing absorption of light, at different wavelengths by the

various states of haemoglobin

- HbO2 absorbs more infrared (blue light) 940 nm

- Hb absorbs more red (red light) 660 nm

the light signal following transmission through

the tissues has a pulsatile component
- two LEDs : one emitting red light (660 nm) and
the other a blue light (940nm) on the finger nail

- on the other side of the finger : photo sensor

(photocell) detects the transmitted light

- the LEDs are switched on and off at 30 Hz to

detect the cyclical changes in the signal due to
pulsatile arterial blood flow

- by calculating the absorption at the two

wavelengths the processor can compute the
proportion of haemoglobin which is oxygenated

CHbO2
S pO2 
CHbO2  CHb
 Pulse oximeters measure:

1. The oxygen saturation of haemoglobin in arterial blood

SpO2

2. The pulse rate - in beats per minute, averaged over 5 to

20 seconds.
(the pleth waveform consist of the IR tracing)
 A pulse oximeter is affected by :

• ambient light
• shivering

• abnormal haemoglobins
( carboxyhaemoglobin, methaemoglobin, dyes as methylene blue )

• pulse rate and rhythm

• vasoconstriction
• poor tissue perfusion ( shock, low CO, cold extremities )
• nail polish
A pulse oximeter gives no information about :

•The oxygen content (CaO2)of the blood

•The amount of oxygen dissolved in the blood
•The respiratory rate or tidal volume i.e. ventilation

•The cardiac output or blood pressure !?