Skip to main content
Download PDF

Accuracy of four indirect methods of blood pressure measurement, with hemodynamic correlations

Journal of Clinical Monitoring volume 6, pages 284–298 (1990)Cite this article

Abstract

In 38 adults undergoing cardiac surgery, 4 indirect blood pressure techniques were compared with brachial arterial blood pressure at predetermined intervals before and after cardiopulmonary bypass. Indirect blood pressure measurement techniques included automated oscillometry, manual auscultation, visual onset of oscillation (flicker) and return-to-flow methods. Hemodynamic measurements or calculations included heart rate, cardiac index, stroke volume index, and systemic vascular resistance index. Indirect and intraarterial blood pressure values were compared by simple linear regression by patient and measurement period. Measurement errors (arterial minus indirect blood pressure) were calculated, and stepwise regression assessed the relationship between measurement error and heart rate, cardiac index, stroke volume index, and systemic vascular resistance index. Indirect to intraarterial blood pressure correlation coefficients varied over time, with the strongest correlations often occurring at the first and last measurement periods (preinduction and 60 minutes after cardiopulmonary bypass), particularly for systolic blood pressure. Within-patient correlations between indirect and arterial blood pressure varied widely—they were consistently high or low in some patients. In other patients, correlations were especially weak with a particular indirect blood pressure method for systolic, mean, or diastolic blood pressure; in some cases indirect blood pressure was inadequate for clinical diagnosis of acute blood pressure changes or trends. The mean correlations between indirect and direct blood pressure values were, for systolic blood pressure: 0.69 for oscillometry, 0.77 for auscultation, 0.73 for flicker, and 0.74 for return-to-flow; for mean blood pressure: 0.70 for oscillometry and 0.73 for auscultation; and for diastolic blood pressure: 0.73 for oscillometry and 0.69 for auscultation. The mean measurement errors (arterial minus indirect values) for the individual indirect blood pressure methods were, for systolic: 0 mm Hg for oscillometry, 9 mm Hg for auscultation, -5 mm Hg for flicker, 7 mm Hg for return-to-flow; for mean: -6 mm Hg for oscillometry, and -3 mm Hg for auscultation; and for diastolic: -9 mm Hg for oscillometry and -8 mm Hg for auscultation. Mean measurement error for systolic blood pressure was thus least with automated oscillometry and greatest with manual auscultation, while standard deviations ranging from 9 to 15 mm Hg confirmed the highly variable nature of single indirect blood pressure measurements. Except for oscillometric diastolic blood pressure, a combination of systemic hemodynamics (heart rate, stroke volume index, systemic vascular resistance index, and cardiac index) correlated with each indirect blood pressure measurement error, which suggests that particular numeric ranges of these variables minimize measurement error. This study demonstrates that striking variability occurs in the relationship between indirect and arterial blood pressure measurements, and that the systemic hemodynamic state influences accuracy of indirect blood pressure measurements. When the reproducibility of repeated indirect blood pressure measurements appears unsatisfactory or inconsistent with other clinical observations, clinicians may find that an alternative indirect blood pressure method is a better choice. Of the methods tested, no single indirect blood pressure technique showed precision superior to the others, but two methods yielded data only for systolic pressure. These findings lend support to intraarterial blood pressure measurement in conditions of hemodynamic variability, and suggest the theoretical benefits of continuous indirect blood pressure measurements.

References

  1. Borow KM, Newburger JW. Noninvasive estimation of central aortic pressure using the oscillometric method for analyzing systemic artery pulsatile blood flow: comparative study of indirect systolic, diastolic, and mean brachial artery pressure with simultaneous direct ascending aortic pressure measurements. Am Heart J 1982;103:879–886

    PubMed  Article  CAS  Google Scholar 

  2. Cohn JN. Blood pressure measurement in shock. Mechanism of inaccuracy in auscultatory and palpatory methods. JAMA 1967;199:118–122

    PubMed  Article  CAS  Google Scholar 

  3. Chyun DA. A comparison of intra-arterial and auscultatory blood pressure readings. Heart Lung 1985, 14:223–228

    PubMed  CAS  Google Scholar 

  4. Finnie KJC, Watts DG, Armstrong PW. Biases in the measurement of arterial pressure. Crit Care Med 1984; 12:965–968

    PubMed  CAS  Article  Google Scholar 

  5. Whalen P, Ream AK. A quantitative evaluation of the Hewlett-Packard 78354A noninvasive blood pressure meter. J Clin Monit 1988;4:21–30

    PubMed  Article  CAS  Google Scholar 

  6. Green M, Paulus DA, Roan VP, van der Aa J. Comparison between oscillometric and invasive blood pressure monitoring during cardiac surgery. Int J Clin Monit Comput 1984;1:21–26

    PubMed  Article  CAS  Google Scholar 

  7. Snyder NC, Lichtor JL, Schreider B. Evaluation of an automatic blood pressure monitor in children. Anesthesiology 1984;61:A174

    Article  Google Scholar 

  8. van Egmond J, Hasenbos M, Crul JF. Invasive v. non-invasive measurement of arterial pressure: comparison of two automatic methods and simultaneously measured direct intra-arterial pressure. Br J Anaesth 1985;57:434–444

    PubMed  Article  Google Scholar 

  9. Gourdeau M, Martin R, Lamarche Y, Tetreault L. Oscillometry and direct blood pressure: a comparative clinical study during deliberate hypotension. Can Anaesth Soc J 1986;33:300–307

    PubMed  CAS  Google Scholar 

  10. Yelderman M, Ream AK. Indirect measurement of mean blood pressure in the anesthetized patient. Anesthesiology 1979;50:253–256

    PubMed  Article  CAS  Google Scholar 

  11. Hutton P, Dye J, Prys-Roberts C. An assessment of the Dinamap 845. Anaesthesia 1984;39:261–267

    PubMed  Article  CAS  Google Scholar 

  12. Bruner JMR, Krenis LJ, Kunsman JM, Sherman AP. Comparison of direct and indirect methods of measuring arterial blood pressure. Med Instrum 1981;15:11–21, 97–101, 182–188

    PubMed  CAS  Google Scholar 

  13. Kirkendall WM, Feinleib M, Freis ED, Mark AL. Recommendations for human blood pressure determination by sphygmomanometers: subcommittee of the AHA Post-graduate Education Committee. Stroke 1981;4:555A-564A

    Google Scholar 

  14. Gardner RM. Direct blood pressure measurement— dynamic response requirements. Anesthesiology 1981;54: 227–236

    PubMed  Article  CAS  Google Scholar 

  15. Wood EH. Physical response requirements of pressure transducers for the reproduction of physiological phenomena. Trans Am Institute Electrical Engineers [part I] 1956;75:32–40

    Google Scholar 

  16. Rothe CF, Kim KC. Measuring systolic arterial blood pressure: possible errors from extension tubes or disposable transducer domes. Crit Care Med 1980;8:683–689

    PubMed  Article  CAS  Google Scholar 

  17. Gravlee GP, Wong AB, Adkins TG, et al. A comparison of radial, brachial, and aortic pressures after cardiopulmonary bypass. J Cardiothorac Anesth 1989;3:20–26

    PubMed  Article  CAS  Google Scholar 

  18. Runciman WB, Rutten AJ, Ilsley AH. An evaluation of blood pressure measurement. Anaesth Intesive Care 1981; 9:314–325

    CAS  Google Scholar 

  19. O’Callaghan WG, Fitzgerald DJ, O’Malley K, O’Brien E. Accuracy of indirect blood pressure measurement in the elderly. Br Med J 1983, 286:1545–1546

    CAS  Google Scholar 

  20. Park MK, Robotham JL, German VF. Systolic pressure amplification in pedal arteries in children. Crit Care Med 1983;11:286–289

    PubMed  Article  CAS  Google Scholar 

  21. Park MK, Menard SM. Accuracy of blood pressure measurement by the Dinamap monitor in infants and children. Pediatrics 1987;79:907–914

    PubMed  CAS  Google Scholar 

  22. Gloyna DF, Huber P, Abston P, Arens JF. A comparison of blood pressure measurement techniques in the hypotensive patient (abstr). Anesth Analg 1984;63:222

    Google Scholar 

  23. Breit SN, O’Rourke MF. Comparison of direct and indirect arterial pressure measurements in hospitalized patients. Aust N Z J Med 1974;4:485–491

    PubMed  CAS  Google Scholar 

  24. Davis RF. Clinical comparison of automated auscultatory and oscillometric and catheter-transducer measurements of arterial pressure. J Clin Monit 1985;1:114–119

    PubMed  Article  CAS  Google Scholar 

  25. Pereira E, Prys-Roberts C, Dagnino J, et al. Auscultatory measurement of arterial pressure during anaesthesia: a reassessment of Korotkoff sounds. Eur J Anaesthesiol 1985;2:11–20

    PubMed  CAS  Google Scholar 

  26. Ramsey M. Noninvasive automatic determination of mean arterial pressure. Med Biol Eng Comput 1979; 17: 11–18

    PubMed  Article  Google Scholar 

  27. Venus B, Mathru M, Smith RA, Pham CG. Direct versus indirect blood pressure measurements in critically ill patients. Heart Lung 1985;14:228–231

    PubMed  CAS  Google Scholar 

  28. Colan SD, Fujii A, Borow KM, et al. Noninvasive determination of systolic, diastolic, and end-systolic blood pressure in neonates, infants and young children: comparison with central aortic pressure measurements. Am J Cardiol 1983;52:867–870

    PubMed  Article  CAS  Google Scholar 

  29. Friesen RH, Lichtor JL. Indirect measurement of blood pressure in neonates and infants utilizing an automatic noninvasive oscillometric monitor. Anesth Analg 1981; 60:742–745

    PubMed  Article  CAS  Google Scholar 

  30. Loubser PG. Comparison of intra-arterial and automated oscillometric blood pressure measurement methods in postoperative hypertensive patients. Med Instrum 1986; 20:255–259

    PubMed  CAS  Google Scholar 

  31. Nystrom E, Reid KH, Bennett R, et al. A comparison of two automated indirect arterial blood pressure meters: with recordings from a radial arterial catheter in anesthetized surgical patients. Anesthesiology 1985;62:526–530

    PubMed  Article  CAS  Google Scholar 

  32. Glantz SA. Primer of biostatistics. New York: McGraw Hill, 1981:210–217

    Google Scholar 

  33. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;1:307–310

    PubMed  CAS  Google Scholar 

  34. Vardan S, Mookherjee S, Warner R, Smulyan H. Systolic hypertension. Direct and indirect BP measurements. Arch Intern Med 1983;143:935–938

    PubMed  Article  CAS  Google Scholar 

  35. Hausman D, Rommelsheim K. Automatic non-invasive blood pressure determination-comparative determinations and experiences with the DINAMAP Vital Data 845 XT monitor in the intensive care station. Anasth Intensivther Notfallmed 1983;18:93–97

    Google Scholar 

  36. Holland WW, Humerfelt S. Measurement of blood-pressure: comparison of intra-arterial and cuff values. Br Med J 1964;2:1241–1243

    PubMed  CAS  Google Scholar 

  37. Hunyor SN, Flynn JM, Cochineas C. Comparison of performance of various sphygmomanometers with intra-arterial blood-pressure readings. Br Med J 1978;2:159–162

    PubMed  CAS  Article  Google Scholar 

  38. Raftery EB, Ward AP. The indirect method of recording blood pressure. Cardiovasc Res 1968;2:210–218

    PubMed  CAS  Google Scholar 

  39. Kimble KJ, Darnall RA, Yelderman M, et al. An automated oscillometric technique for estimating mean arterial pressure in critically ill newborns. Anesthesiology 1981; 54:423–425

    PubMed  Article  CAS  Google Scholar 

  40. Berliner K, Fujiy H, Lee DH, et al. The accuracy of blood pressure determinations: a comparison of direct and indirect measurements. Cardiologia 1960;37:118–128

    Google Scholar 

  41. Rutten AJ, Ilsley AH, Skowronski GA, Runciman WB. A comparative study of the measurement of mean arterial blood pressure using automatic oscillometers, arterial cannulation and auscultation. Anaesth Intensive Care 1986; 14:58–65

    PubMed  CAS  Google Scholar 

  42. Van Bergen FH, Weatherhead DS, Treloar AE, et al. Comparison of indirect and direct methods of measuring arterial blood pressure. Circulation 1954;10:481–490

    Google Scholar 

  43. Stern DH, Gerson JI, Allen FB, Parker FB. Can we trust the direct radial artery pressure immediately following cardiopulmonary bypass? Anesthesiology 1985;62:557–561

    PubMed  Article  CAS  Google Scholar 

  44. Hutton P, Prys-Roberts C. The oscillotonometer in theory and practice. Br J Anaesth 1982;54:581–591

    PubMed  Article  CAS  Google Scholar 

  45. Sy WP. Ulnar nerve palsy possibly related to use of automatically cycled blood pressure cuff. Anesth Analg 1981; 60:687–688

    PubMed  Article  CAS  Google Scholar 

  46. Showman A, Betts EK. Hazard of automatic noninvasive blood pressure monitoring (letter). Anesthesiology 1981; 55:717–718

    PubMed  CAS  Article  Google Scholar 

Download references

Author information

Affiliations

  1. Departments of Anesthesia and Public Health Sciences, Bowman Gray School of Medicine of Wake Forest University, NC, Winston-Salem

    Glenn P. Gravlee MD & Joni K. Brockschmidt MS

Authors
  1. Glenn P. Gravlee MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Joni K. Brockschmidt MS
    View author publications

    You can also search for this author in PubMed Google Scholar

Additional information

Annual meeting of the American Society of Anesthesiologists, New Orleans, LA, Oct 1984.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Gravlee, G.P., Brockschmidt, J.K. Accuracy of four indirect methods of blood pressure measurement, with hemodynamic correlations. J Clin Monitor Comput 6, 284–298 (1990). https://doi.org/10.1007/BF02842488

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF02842488

Key Words

  • Blood pressure: measurement
  • Monitoring: blood pressure, arterial
  • Measurement techniques: oscillometry