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      Comparison of the non-invasive Nexfin® monitor with conventional methods for the measurement of arterial blood pressure in moderate risk orthopaedic surgery patients

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          Abstract

          Objective

          Continuous invasive arterial blood pressure (IBP) monitoring remains the gold standard for BP measurement, but traditional oscillometric non-invasive intermittent pressure (NIBP) measurement is used in most low-to-moderate risk procedures. This study compared non-invasive continuous arterial BP measurement using a Nexfin® monitor with NIBP and IBP monitors.

          Methods

          This was a single-centre, prospective, pilot study in patients scheduled for elective orthopaedic surgery. Systolic BP, diastolic BP and mean arterial blood pressure (MAP) were measured by Nexfin®, IBP and NIBP at five intraoperative time-points. Pearson correlation coefficients, Bland–Altman plots and trending ability of Nexfin® measurements were used as criteria for success in the investigation of measurement reliability.

          Results

          A total of 20 patients were enrolled in the study. For MAP, there was a sufficient correlation between IBP/Nexfin® (Pearson = 0.75), which was better than the correlation between IBP/NIBP (Pearson = 0.70). Bland–Altman analysis of the data showed that compared with IBP, there was a higher percentage error for MAP NIBP (30%) compared with MAP Nexfin® (27%). Nexfin® and NIBP underestimated systolic BP; NIBP also underestimated diastolic BP and MAP. Trending ability for MAP Nexfin® and MAP NIBP were comparable to IBP.

          Conclusion

          Non-invasive BP measurement with Nexfin® was comparable with IBP and tended to be more precise than NIBP.

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          Most cited references37

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          Statistical methods for assessing agreement between two methods of clinical measurement.

          J Bland, D Altman (1986)
          In clinical measurement comparison of a new measurement technique with an established one is often needed to see whether they agree sufficiently for the new to replace the old. Such investigations are often analysed inappropriately, notably by using correlation coefficients. The use of correlation is misleading. An alternative approach, based on graphical techniques and simple calculations, is described, together with the relation between this analysis and the assessment of repeatability.
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            Fifteen years experience with finger arterial pressure monitoring: assessment of the technology.

            K Wesseling, Ben Imholz, Odile van den Heuvel … (1998)
            We review the Finapres technology, embodied in several TNO-prototypes and in the Ohmeda 2300 and 2300e Finapres NIBP. Finapres is an acronym for FINger Arterial PRESsure, the device delivers a continuous finger arterial pressure waveform. Many papers report on the accuracy of the device in comparison with intra-arterial or with noninvasive but intermittent blood pressure measurements. We compiled the results of 43 such papers and found systolic, diastolic and mean accuracies, in this order, ranging from -48 to 30 mmHg, from -20 to 18 mmHg, and from -13 to 25 mmHg. Weighted for the number of subjects included pooled accuracies were -0.8 (SD 11.9), -1.6 (8.3) and -1.6 (7.6) mmHg respectively. Subdividing the pooled group according to criteria such as reference blood pressure, place of application, and prototype or commercial device we found no significant differences in mean differences or SD. Measurement at the finger allows uninterrupted recordings of long duration. The transmission of the pressure pulse along the arm arteries, however, causes distortion of the pulse waveform and depression of the mean blood pressure level. These effects can be reduced by appropriate filtering, and upper arm 'return-to-flow' calibration to bring accuracy and precision within AAMI limits. For the assessment of beat-to-beat changes in blood pressure and assessment of blood pressure variability Finapres proved a reliable alternative for invasive measurements when mean and diastolic pressures are concerned. Differences in systolic pressure are larger and reach statistical significance but are not of clinical relevance. Finger arteries are affected by contraction and dilatation in relation to psychological and physical (heat, cold, blood loss, orthostasis) stress. Effects of these phenomena are reduced by the built-in Physiocal algorithm. However, full smooth muscle contraction should be avoided in the awake patient by comforting the patient, and covering the hand. Arterial state can be monitored by observing the behaviour of the Physiocal algorithm. We conclude that Finapres accuracy and precision usually suffice for reliable tracking of changes in blood pressure. Diagnostic accuracy may be achieved with future application of corrective measures.
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              Hospital stay and mortality are increased in patients having a "triple low" of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia.

              Andrea Kurz, S Sameah-Greenwald, P Manberg … (2012)
              Low mean arterial pressure (MAP) and deep hypnosis have been associated with complications and mortality. The normal response to high minimum alveolar concentration (MAC) fraction of anesthetics is hypotension and low Bispectral Index (BIS) scores. Low MAP and/or BIS at lower MAC fractions may represent anesthetic sensitivity. The authors sought to characterize the effect of the triple low state (low MAP and low BIS during a low MAC fraction) on duration of hospitalization and 30-day all-cause mortality. Mean intraoperative MAP, BIS, and MAC were determined for 24,120 noncardiac surgery patients at the Cleveland Clinic, Cleveland, Ohio. The hazard ratios associated with combinations of MAP, BIS, and MAC values greater or less than a reference value were determined. The authors also evaluated the association between cumulative triple low minutes, and excess length-of-stay and 30-day mortality. Means (±SD) defining the reference, low, and high states were 87 ± 5 mmHg (MAP), 46 ± 4 (BIS), and 0.56 ± 0.11 (MAC). Triple lows were associated with prolonged length of stay (hazard ratio 1.5, 95% CI 1.3-1.7). Thirty-day mortality was doubled in double low combinations and quadrupled in the triple low group. Triple low duration ≥60 min quadrupled 30-day mortality compared with ≤15 min. Excess length of stay increased progressively from ≤15 min to ≥60 min of triple low. The occurrence of low MAP during low MAC fraction was a strong and highly significant predictor for mortality. When these occurrences were combined with low BIS, mortality risk was even greater. The values defining the triple low state were well within the range that many anesthesiologists tolerate routinely.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Int Med Res
                Journal ID (iso-abbrev): J. Int. Med. Res
                Journal ID (publisher-id): IMR
                Journal ID (hwp): spimr
                Title: The Journal of International Medical Research
                Publisher: SAGE Publications (Sage UK: London, England )
                ISSN (Print): 0300-0605
                ISSN (Electronic): 1473-2300
                Publication date (Electronic): 2 May 2016
                Publication date (Print): August 2016
                Volume: 44
                Issue: 4
                Pages: 832-843
                Affiliations
                [1 ]Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Charitéplatz, Berlin, Germany
                [2 ]Department of Anaesthesiology and Intensive Care Medicine, Universitätsklinikum Giessen und Marburg GmbH, Rudolf-Buchheim-Straße, Giessen, Germany
                [3 ]Department of Internal Medicine, Klinikum Starnberg, Oßwaldstraße, Starnberg, Germany
                [4 ]Centre for Musculoskeletal Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité- Universitätsmedizin Berlin, Charitéplatz, Berlin, Germany
                Author notes
                [*]

                These authors contributed equally.

                [*]Sascha Treskatsch, Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte, Charité – Universitätsmedizin Berlin, Chariteplatz 1, 10117 Berlin, Germany. Email: sascha.treskatsch@ 123456charite.de
                Article
                Publisher ID: 10.1177_0300060516635383
                DOI: 10.1177/0300060516635383
                PMC ID: 5536626
                PubMed ID: 27142436
                SO-VID: 60451737-b9c6-40a6-97aa-b03a5384b7a5
                Copyright © © The Author(s) 2016
                License:

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License ( http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                Date received : 23 September 2015
                Date accepted : 3 February 2016
                Categories
                Subject: Research Reports

                Keywords: blood pressure,monitoring,non-invasive arterial pressure,invasive arterial pressure,nexfin® trial registration: clingov. nct01263990
                Data availability:
                Keywords: blood pressure, monitoring, non-invasive arterial pressure, invasive arterial pressure, nexfin® trial registration: clingov. nct01263990

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