NBP cuffs...?mis-used in ICU....

Published

Hey Y'all

I hope y'all don't mind if I drop into your "virtual OR" for a minute. I've got a question thats been bugging me and thought you-guys had some of the highest quality exchanges on the forum. (A little flattery to ease my way in...)

I've observed that the CRITICON NBP cuffs that are virtually universal in this area are frequently mis-used. I think. By that I mean--I find 'em 'up-side-down' (the 'artery' arrow proximal) and in strange locations (around the ankle) and of the wrong size (leg cuffs wrapped around a perfectly normal sized upper arm).

Many of these folks are getting drips for their BPs--Tridil, Neo, Dopamine. And pretty often when I 'correct' the NBP Cuff I can (natually) rapidly wean the drugs. So I am morally certain that the prev ICU nurse was ignorant/negligent in the basic matter of measuring the BP. But I have no way to prove it, so have not said anything.

Would love to suggest that some instruction and policy/procedures be given about this but a google-search today yielded nothing (except a chance to EMail GE Healthcare--who bought CRITICON out, it seems--which I did).

Any feedback from y'all? Any manuals from manufacturer or excerpts from your policy books? Just advice or experiences?

Sure 'preciate ya

Papaw John

Up Vote Up Vote ×
Hey Y'all

I hope y'all don't mind if I drop into your "virtual OR" for a minute. I've got a question thats been bugging me and thought you-guys had some of the highest quality exchanges on the forum. (A little flattery to ease my way in...)

I've observed that the CRITICON NBP cuffs that are virtually universal in this area are frequently mis-used. I think. By that I mean--I find 'em 'up-side-down' (the 'artery' arrow proximal) and in strange locations (around the ankle) and of the wrong size (leg cuffs wrapped around a perfectly normal sized upper arm).

Many of these folks are getting drips for their BPs--Tridil, Neo, Dopamine. And pretty often when I 'correct' the NBP Cuff I can (natually) rapidly wean the drugs. So I am morally certain that the prev ICU nurse was ignorant/negligent in the basic matter of measuring the BP. But I have no way to prove it, so have not said anything.

Would love to suggest that some instruction and policy/procedures be given about this but a google-search today yielded nothing (except a chance to EMail GE Healthcare--who bought CRITICON out, it seems--which I did).

Any feedback from y'all? Any manuals from manufacturer or excerpts from your policy books? Just advice or experiences?

Sure 'preciate ya

Papaw John

Shouldn't they have some type of invasive b/p monitoring device while drugs are being titrated.

Up Vote Up Vote ×

Not sure how much help you're going to get John --- in the OR (most of the time) we flip the NIBP cuff upside down (like you've found them) so the cord runs cephalad and everything comes up towards us. It keeps everything less tangled and the BP is pretty right on. However, if I forsee the need to titrate vasoactives, then I'll start an A-line. When I worked on the unit, I would always keep the cuff the way it should be, but it's a little different now.

Up Vote Up Vote ×

Thanks y'all. I still am hoping to get manufacturer's or academic references. (I'm willing to admit that I'm a hopelessly old fashioned character.)

R/T Art lines: they have their own issues. Have you never seen a drug 'titrated' for an aBP while the transducer is set for the bed in LOW position and the bed actually a foot or 18" higher? Have you tried to get the good wave-form you count on after the ALine is 4 or more days old? Having had those experiences, I don't disagree that the ALine is the 'gold standard' in theory but I don't think they are a magic bullet either.

In my world however--I'm not getting Pt's with ALines, just Pt's with drips. Looking for a little advice.

P- J-

Up Vote Up Vote ×

There are some scholarly papers out there concerning the accuracy of automatic BP cuffs, using them on different extremeties or positions, how they correlate with A-lines and/or auscultation. I've read one or two myself because I have an inherent distrust of BP cuffs due to their tendency to give readings all over the place on the pts. you need it most. One thing that I gathered from the papers and from personal experience is that even though the systolic/diastolic does not always correlate, the MAPs oftentimes do correspond (when comparing BP cuff and A-line). But really, you should be able to find a couple good papers without much problem that would be better able to answer those questions.

Up Vote Up Vote ×

Hey

Could you suggest some key words for the search? Or some search engines?

I'm really not riding a high horse about this and would appreciate a clue or hint--just wanna know the facts (me and JoeFriday).

Google and 'nbp' 'non-invasive blood pressure' and 'critikon' (the brand I see used all over) weren't much help.

thanx

P- J-

Up Vote Up Vote ×

It would be hard to find something useful on google, I'm not sure what keywords would work. You might try a healthcare oriented search engine like medline or uptodate. But I did find something in the journals i have from the past year:

In American Journal of Critical Care, May 2005 Vol 14, No. 3. There is an article titled Clinical Comparison of Automatic, Noninvasive Measurements of Blood Pressure in the Forearm and Upper Arm

It addresses a small part of your original post.

Up Vote Up Vote ×

It doesn't matter if the cuff is "upside-down", nor does it matter where the tubing comes off. The transducer is inside the machine - the cuff and tubing merely transmit those oscillatory pressure waves back to the machine.

As far as using the wrong sized cuffs - that's an education issue that is easily corrected.

However - I agree with the others - vasoactive drips warrant an A-line. If the one you have isn't working well, get it replaced. And as far as having the transducer at the appropriate level, again, that's an education issue, and certainly not a reason to not use an A-line in favor of a BP cuff when using vasoactive drips.

Up Vote Up Vote ×

i have been reading lately where the Alines will eventually be transduced to the "head" because the level of the R atria doesn't really matter if the head isn't perfused... just a thought.

Up Vote Up Vote ×

Here's a slant; there is a following of the concept that blood pressures are a marginal method of collecting data on your ultimate goal--judging tissue perfusion. I heard Tom ---- from Barnes Hosp (St Louis) discuss this a couple of years ago. Their rationale can be found at: http://www.pacep.org/

Basically, they think that stroke volume (via doppler) and a TLC with an oxytip (rough SvO2 reading) is the ultimate (non-swan) monitoring. Sounds too expensive and not practical for the general OR case, but there you go...

Up Vote Up Vote ×
i have been reading lately where the Alines will eventually be transduced to the "head" because the level of the R atria doesn't really matter if the head isn't perfused... just a thought.

In one of the ICUs I worked at a couple of years ago, we always placed the a-line transducer on the pts head (zeroed at the tragus) for all our neuro patients. This was based on that same theory that what was really important was the arterial pressure at the circle of willis.

Up Vote Up Vote ×

Hey Yall

And in particular thanx 'Focker'. The AACN study was available on line ('findarticle') and pretty much documents that my suspicion had some validity. And during the scrounging around I found that the leg BP (taken properly with correctly sized cuff at midthigh and measures at Popliteal Art'y) runs 10-20mm hg > Brachial BP.

At some time I guess I'll bring this up at my Unit.

At the time, I'll suggest using Art Lines (Resp Rx starts 'em here) much more often.

Thanx to everyone

Papaw John

Up Vote Up Vote ×
+ Join the Discussion