Journal of Clinical Monitoring and Computing

, Volume 21, Issue 5, pp 283–293 | Cite as

Change in pulse transit time and pre-ejection period during head-up tilt-induced progressive central hypovolaemia

  • Gregory S. H. Chan
  • Paul M. Middleton
  • Branko G. Celler
  • Lu Wang
  • Nigel H. Lovell
Article

Abstract

Objective

Traditional vital signs such as heart rate (HR) and blood pressure (BP) are often regarded as insensitive markers of mild to moderate blood loss. The present study investigated the feasibility of using pulse transit time (PTT) to track variations in pre-ejection period (PEP) during progressive central hypovolaemia induced by head-up tilt and evaluated the potential of PTT as an early non-invasive indicator of blood loss.

Methods

About 11 healthy subjects underwent graded head-up tilt from 0 to 80°. PTT and PEP were computed from the simultaneous measurement of electrocardiogram (ECG), finger photoplethysmographic pulse oximetry waveform (PPG-POW) and thoracic impedance plethysmogram (IPG). The response of PTT and PEP to tilt was compared with that of interbeat heart interval (RR) and BP. Least-squares linear regression analysis was carried out on an intra-subject basis between PTT and PEP and between various physiological variables and sine of the tilt angle (which is associated with the decrease in central blood volume) and the correlation coefficients (r) were computed.

Results

During graded tilt, PEP and PTT were strongly correlated in 10 out of 11 subjects (median r = 0.964) and had strong positive linear correlations with sine of the tilt angle (median r = 0.966 and 0.938 respectively). At a mild hypovolaemic state (20–30°), there was a significant increase in PTT and PEP compared with baseline (0°) but without a significant change in RR and BP. Gradient analysis showed that PTT was more responsive to central volume loss than RR during mild hypovolaemia (0–20°) but not moderate hypovolaemia (50–80°).

Conclusion

PTT may reflect variation in PEP and central blood volume, and is potentially useful for early detection of non-hypotensive progressive central hypovolaemia. Joint interpretation of PTT and RR trends or responses may help to characterize the extent of blood volume loss in critical care patients.

Keywords

pulse transit time (PTT) pulse transmission time pre-ejection period head-up tilt hypovolaemia blood loss 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    American College of Surgeons. Shock. In: ATLS Instructors Manual. Chicago: First Impressions; 1993. p. 75–94Google Scholar
  2. 2.
    McGee S, Abernethy WB III, Simel DL. The rational clinical examination. Is this patient hypovolemic? JAMA 1999;281(11):1022–9PubMedCrossRefGoogle Scholar
  3. 3.
    Evans RG, Ventura S, Dampney RA, Ludbrook J. Neural mechanisms in the cardiovascular responses to acute central hypovolaemia. Clin Exp Pharmacol Physiol 2001;28(5–6):479–87PubMedCrossRefGoogle Scholar
  4. 4.
    Hainsworth R, Drinkhill MJ. Regulation of blood volume. In: Jordan D, Marshall J, eds. Cardiovascular regulation. London: Portland, 1995: p. 77–91Google Scholar
  5. 5.
    Secher NH, Van Lieshout JJ. Normovolaemia defined by central blood volume and venous oxygen saturation. Clin Exp Pharmacol Physiol 2005;32(11):901–10PubMedCrossRefGoogle Scholar
  6. 6.
    Cooke WH, Ryan KL, Convertino VA. Lower body negative pressure as a model to study progression to acute hemorrhagic shock in humans. J Appl Physiol 2004;96(4):1249–61PubMedCrossRefGoogle Scholar
  7. 7.
    Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV. Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Ann Surg 2006;244(3):371–80PubMedGoogle Scholar
  8. 8.
    Anderson ID, Woodford M, de Dombal FT, Irving M. Retrospective study of 1000 deaths from injury in England and Wales. Br Med J (Clin Res Ed) 1988;296(6632):1305–8CrossRefGoogle Scholar
  9. 9.
    Foo JY, Lim CS. Pulse transit time as an indirect marker for variations in cardiovascular related reactivity. Technol Health Care 2006;14(2):97–108PubMedGoogle Scholar
  10. 10.
    Naschitz JE, Bezobchuk S, Mussafia-Priselac R, Sundick S, Dreyfuss D, Khorshidi I, Karidis A, Manor H, Nagar M, Peck ER et al. Pulse transit time by R-wave-gated infrared photoplethysmography: review of the literature and personal experience. J Clin Monit Comput 2004;18(5–6):333–42PubMedCrossRefGoogle Scholar
  11. 11.
    Stafford RW, Harris WS, Weissler AM. Left ventricular systolic time intervals as indices of postural circulatory stress in man. Circulation 1970;41(3):485–92PubMedGoogle Scholar
  12. 12.
    Boudoulas H. Systolic time intervals. Eur Heart J 1990;11(Suppl I):93–104PubMedGoogle Scholar
  13. 13.
    Lewis RP, Rittogers SE, Froester WF, Boudoulas H. A critical review of the systolic time intervals. Circulation 1977;56(2):146–58PubMedGoogle Scholar
  14. 14.
    Bendjelid K, Suter PM, Romand JA. The respiratory change in preejection period: a new method to predict fluid responsiveness. J Appl Physiol 2004;96(1):337–42PubMedCrossRefGoogle Scholar
  15. 15.
    Feissel M, Badie J, Merlani PG, Faller JP, Bendjelid K. Pre-ejection period variations predict the fluid responsiveness of septic ventilated patients. Crit Care Med 2005;33(11):2534–9PubMedCrossRefGoogle Scholar
  16. 16.
    Ahlstrom C, Johansson A, Uhlin F, Lanne T, Ask P. Noninvasive investigation of blood pressure changes using the pulse wave transit time: a novel approach in the monitoring of hemodialysis patients. J Artif Organs 2005;8(3):192–7PubMedCrossRefGoogle Scholar
  17. 17.
    Ochiai R, Takeda J, Hosaka H, Sugo Y, Tanaka R, Soma T. The relationship between modified pulse wave transit time and cardiovascular changes in isoflurane anesthetized dogs. J Clin Monit Comput 1999;15(7–8):493–501PubMedCrossRefGoogle Scholar
  18. 18.
    Matzen S, Perko G, Groth S, Friedman DB, Secher NH. Blood volume distribution during head-up tilt induced central hypovolaemia in man. Clin Physiol 1991;11(5):411–22PubMedGoogle Scholar
  19. 19.
    Pawelczyk JA, Matzen S, Friedman DB, Secher NH. Cardiovascular and hormonal responses to central hypovolaemia in humans. In: Secher NH, Pawelczyk JA, Ludbrook J, eds. Blood loss and shock. London: Edward Arnold; 1994. p. 25–36Google Scholar
  20. 20.
    Blomqvist CG, Stone HL. Cardiovascular adjustments to gravitational stress. In: Shepherd JT, Abboud FM, eds. Handbook of physiology, The cardiovascular system, Peripheral circulation and organ blood flow. Sect. 2, vol. 3. Bethesda: American Physiological Society, 1983: p. 1025–63Google Scholar
  21. 21.
    Iwase S, Mano T, Saito M. Effects of graded head-up tilting on muscle sympathetic activities in man. Physiologist 1987;30(1 Suppl):S62–3PubMedGoogle Scholar
  22. 22.
    Laszlo Z, Rossler A, Hinghofer-Szalkay HG. Cardiovascular and hormonal changes with different angles of head-up tilt in men. Physiol Res 2001;50(1):71–82PubMedGoogle Scholar
  23. 23.
    Patterson RP, Wang L, Raza B, Wood K. Mapping the cardiogenic impedance signal on the thoracic surface. Med Biol Eng Comput 1990;28(3):212–6PubMedCrossRefGoogle Scholar
  24. 24.
    Toska K, Walloe L. Dynamic time course of hemodynamic responses after passive head-up tilt and tilt back to supine position. J Appl Physiol 2002;92(4):1671–6PubMedGoogle Scholar
  25. 25.
    Cook LB. Extracting arterial flow waveforms from pulse oximeter waveforms apparatus. Anaesthesia 2001;56(6):551–5PubMedCrossRefGoogle Scholar
  26. 26.
    Chiu YC, Arand PW, Shroff SG, Feldman T, Carroll JD. Determination of pulse wave velocities with computerized algorithms. Am Heart J 1991;121(5):1460–70PubMedCrossRefGoogle Scholar
  27. 27.
    Lababidi Z, Ehmke DA, Durnin RE, Leaverton PE, Lauer RM. The first derivative thoracic impedance cardiogram. Circulation 1970;41(4):651–8PubMedGoogle Scholar
  28. 28.
    DeMarzo AP, Lang RM. A new algorithm for improved detection of aortic valve opening by impedance cardiography. Comput Cardiol 1996;373–76Google Scholar
  29. 29.
    Newlin DB. Relationships of pulse transmission times to pre-ejection period and blood pressure. Psychophysiology 1981;18(3):316–21PubMedCrossRefGoogle Scholar
  30. 30.
    Pawelczyk JA, Raven PB. Reductions in central venous pressure improve carotid baroreflex responses in conscious men. Am J Physiol 1989;257(5 Pt 2):H1389–95PubMedGoogle Scholar
  31. 31.
    Nichols WW, O’Rourke MF, eds. McDonald’s blood flow in arteries: theoretical, experimental, and clinical principles. 4th ed. London: Arnold; New York: Oxford University Press; 1998Google Scholar
  32. 32.
    Nurnberger J, Opazo Saez A, Dammer S, Mitchell A, Wenzel RR, Philipp T, Schafers RF. Left ventricular ejection time: a potential determinant of pulse wave velocity in young, healthy males. J Hypertens 2003;21(11):2125–32PubMedCrossRefGoogle Scholar
  33. 33.
    Spodick DH, Meyer M, St Pierre JR. Effect of upright tilt on the phases of the cardiac cycle in normal subjects. Cardiovasc Res 1971;5(2):210–4PubMedCrossRefGoogle Scholar
  34. 34.
    Mukai S, Hayano J. Heart rate and blood pressure variabilities during graded head-up tilt. J Appl Physiol 1995;78(1):212–6PubMedCrossRefGoogle Scholar
  35. 35.
    Tuckman J, Shillingford J. Effect of different degrees of tilt on cardiac output, heart rate, and blood pressure in normal man. Br Heart J 1966;28(1):32–9PubMedGoogle Scholar
  36. 36.
    Konig EM, Sauseng-Fellegger G, Hinghofer-Szalkay H. Comparison of hemodynamic and volume responses to different levels of lower body suction and head-up tilt. Physiologist 1993;36(1 Suppl):S53–5PubMedGoogle Scholar
  37. 37.
    Kitano A, Shoemaker JK, Ichinose M, Wada H, Nishiyasu T. Comparison of cardiovascular responses between lower body negative pressure and head-up tilt. J Appl Physiol 2005;98(6):2081–6PubMedCrossRefGoogle Scholar
  38. 38.
    Chen W, Kobayashi T, Ichikawa S, Takeuchi Y, Togawa T. Continuous estimation of systolic blood pressure using the pulse arrival time and intermittent calibration. Med Biol Eng Comput 2000;38(5):569–74PubMedCrossRefGoogle Scholar
  39. 39.
    Payne RA, Symeonides CN, Webb DJ, Maxwell SR. Pulse transit time measured from the ECG: an unreliable marker of beat-to-beat blood pressure. J Appl Physiol 2006;100(1):136–41PubMedCrossRefGoogle Scholar
  40. 40.
    Taneja I, Moran C, Medow MS, Glover JL, Montgomery LD, Stewart JM. Differential effects of lower body negative pressure and upright tilt on splanchnic blood volume. Am J Physiol Heart Circ Physiol 2007;292(3):H1420–6PubMedCrossRefGoogle Scholar
  41. 41.
    Kubitz JC, Kemming GI, Schultheib G, Starke J, Podtschaske A, Goetz AE, Reuter DA. The influence of cardiac preload and positive end-expiratory pressure on the pre-ejection period. Physiol Meas 2005;26(6):1033–8PubMedCrossRefGoogle Scholar
  42. 42.
    Lomas-Niera JL, Perl M, Chung CS, Ayala A. Shock and hemorrhage: an overview of animal models. Shock 2005;24(Suppl 1):33–9PubMedCrossRefGoogle Scholar
  43. 43.
    Adamicza A, Tarnoky K, Nagy A, Nagy S. The effect of anaesthesia on the haemodynamic and sympathoadrenal responses of the dog in experimental haemorrhagic shock. Acta Physiol Hung 1985;65(3):239–54PubMedGoogle Scholar
  44. 44.
    Kubicek WG. On the source of peak first time derivative (dZ/dt) during impedance cardiography. Ann Biomed Eng 1989;17(5):459–62PubMedCrossRefGoogle Scholar
  45. 45.
    Balasubramanian V, Mathew OP, Behl A, Tewari SC, Hoon RS. Electrical impedance cardiogram in derivation of systolic time intervals. Br Heart J 1978;40(3):268–75PubMedGoogle Scholar
  46. 46.
    Pinsky MR. Functional hemodynamic monitoring. Intensive Care Med 2002;28(4):386–8PubMedCrossRefGoogle Scholar
  47. 47.
    Rex S, Brose S, Metzelder S, Huneke R, Schalte G, Autschbach R, Rossaint R, Buhre W. Prediction of fluid responsiveness in patients during cardiac surgery. Br J Anaesth 2004;93(6):782–8PubMedCrossRefGoogle Scholar
  48. 48.
    Anonymous. Heart rate variability: standards of measurement, physiological interpretation and clinical use. Task force of the European society of cardiology and the North American society of pacing and electrophysiology. Circulation 1996;93(5):1043–65Google Scholar
  49. 49.
    Teng XF, Zhang YT. The effect of applied sensor contact force on pulse transit time. Physiol Meas 2006;27(8):675–84PubMedCrossRefGoogle Scholar
  50. 50.
    Zhang XY, Zhang YT. The effect of local mild cold exposure on pulse transit time. Physiol Meas 2006;27(7):649–60PubMedCrossRefGoogle Scholar
  51. 51.
    Foo JY, Wilson SJ, Williams GR, Harris MA, Cooper DM. Pulse transit time changes observed with different limb positions. Physiol Meas 2005;26(6):1093–102PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2007

Authors and Affiliations

  • Gregory S. H. Chan
    • 1
    • 2
  • Paul M. Middleton
    • 1
    • 3
  • Branko G. Celler
    • 1
  • Lu Wang
    • 1
  • Nigel H. Lovell
    • 1
    • 2
    • 4
  1. 1.Biomedical Systems Laboratory, School of Electrical Engineering and TelecommunicationsUniversity of New South WalesSydneyAustralia
  2. 2.Graduate School of Biomedical EngineeringUniversity of New South WalesSydneyAustralia
  3. 3.Prince of Wales Clinical SchoolUniversity of New South WalesSydneyAustralia
  4. 4.National Information and Communications Technology Australia (NICTA)EveleighAustralia

Personalised recommendations