Blood Pressure and Flow

Measurements
Contents
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Blood Pressure Blood Flow
Palpatory Method
(Riva-Rocci Method)
Auscultatory Method
Ultrasonic Method
Oscillometric Method
Tonometry
Extravascular
Sensor
Intravascular Sensor
Ultrasound Doppler
Laser Doppler Flowmetry
Dye Dilution Method
Thermal Dilution Method
Strain Gage Plethysmography
Electric-Impedance Plethysmogr.
Photoelectric Plethysmography
Radioisotopes
Thermal Convection Probes
General on
System Parameters
Blood Pressure (1)
One of the oldest physiological measurements:
Originates from the heart
Value depends on 3 factors:
cardiac output
diameter of arteries
the quantity of blood
Commonly refers to arterial blood pressure
Values should be lower than 120 / 80 mmHg
(systolic pressure (SP) / diastolic pressure (DP))
peripheral
resistance
Observation of blood pressure allows dynamic tracking of pathology and
physiology affecting to the cardiovascular system, which has profound
effects to all other organs of the body
Blood Pressure (2)
Pulse pressure (PP) = SP-DP
MP = DP+PP/3
Mean pressure (MP)
average pressure during one cardiac cycle
driving force of the peripheral perfusion.
an estimate can be done by using an empirical formula:
SP and DP may vary significantly throughout the arterial system but
MP is quite uniform (in normal situations)
High value increases the risk of heart attack and strokes
Low value increases the risk of lower oxygen perfusion e.g. in brains
However, the normal values differ from person to another
General Facts
Indirect measurement = non-invasive measurement
Brachial artery is the most common measurement site
Close to heart
Convenient measurement
Other sites are e.g.:
forearm / radial artery
wrist (tends to give much higher SP)
The most common indirect methods are auscultation
and oscillometry
General Facts (cont.)
An occlusive cuff is placed on arm and inflated to P > SP.
Then the cuff is deflated gradually and the measurement of
blood flow is done
cuff
The occlusive cuff should be of a correct size in order to
transmit the pressure to the artery evenly and thus to obtain
accurate results
A short cuff requires special attention in placement. Longer
cuff reduces this problem.
The cuff should be placed at the heart level in order to
minimize the hydrostatic effects
Palpatory Method (Riva-Rocci Method)
When the cuff is deflated, there is a palpable
pulse in the wrist. P = BP
Several measurements should be done as the
respiration and vasomotor waves modulate the
blood pressure levels
+) The blood pressure can be measured in noisy environment too
ADVANTAGES
-) Only the systolic pressure can be measured (not DP)
DISADVANTAGES
-) The technique does not give accurate results for infants and
hypotensive patients
cuff
+) Technique does not require much equipment
Auscultatory Method
The Korotkoff sounds are
ausculted with a stethoscope or
microphone (automatic measurement)
Pulse waves that propagate
through the brachial artery,
generate Korotkoff sounds.
There are 5 distinct phases in the
Korotkoff sounds, which define SP
and DP

Also with this method, several measurements
should be done.
The frequency range is 20-300 Hz
and the accuracy is +/- 2mmHg (SP)
and +/- 4mmHg (DP)
Auscultatory Method (cont.)
-) The observations differ from observer to another
-) A mechanical error might be introduced into the system e.g. mercury
leakage, air leakage, obstruction in the cuff etc.
-) The observations do not always correspond with intra-arterial pressure
-) Auscultatory tecnique cannot be used in noisy environment
+) Auscultatory technique is simple and does not require much
equipment
ADVANTAGES
DISADVANTAGES
-) The technique does not give accurate results for infants and
hypotensive patients
Automated Indirect methods
MAP is a weighted average of systolic and diastolic pressure.
Generally MAP falls about one third of the way between diastolic low
and systolic peak. A simple formula for calculating MAP is

MAP = 1/3 (systolic diastolic ) + diastolic

It is now generally recognized that MAP is a direct indication of the
pressure available for tissue perfusion and that a continuously
increasing or decreasing MAP can ultimately result in a hypertensive
crisis
Electronic Sphygmomanometer
Dinamap
Ambulatory automatic Blood
Pressure Monitor
This device is a 24 hour automatic noninvasive blood pressure
and Holter monitoring system.

The three major components of this device:
Pressurometer
Electrocardiorecorder
Transducer
Example: Arteriosonde the motion in the artery produces a
Doppler shift, which identifies the instant the artery is opened
and closed with each between systolic and diastolic pressure.

The mean arterial blood pressure is determined by the
oscillometric method.

As the pressure in the cuff is decreased, pressure oscillations
increase in amplitude and reach a max as the pressure passes
through the pressure equal to the mean arterial blood pressure. o

This can be observed as it produces the pulsations in the
mercury column of a conventional sphygmomanometer.
Direct Measurements

Direct measurement or BP is usually obtained by one of three methods :


Percutaneous insertion.
Catheterization (vessel cut down)
Implantation of a transducer in a vessel or in the heart
Specific Direct Measurement
Techniques
A catherization method involving the placement of the transducer through a
catheter at the actual site of measurement in the blood stream

A catherization method involving the sensing of blood pressure through
liquid column.

Percutaneous methods in which the blood pressure is sensed in the vessel
just under the skin by the use of needle or catheter.

Implantation technique in which the transducer is more permanently placed
in the blood vessel or the heart by surgical methods.

Blood Pressure Waveform
Four kinds of
pressure:
T
2
: Peak Pressure
(systolic)
T
f
: Minimum pressure
(diastolic)
Dynamic Average (1/2
peak minus
minimum)
Average pressure
(arterial)

Measurement at the Site

To avoid the problems inherent in measuring blood pressures through a
liquid column, a catheter tip manometer can be fed through a catheter to
the site at which blood pressure is to be measured.

A bonded strain gage sensor built into the tip of a cardiac catheter.The
resistance changes in the strain gage are a result of pressure variations at
the site itself rather than through a fluid column.
Floating Catheter
Floating catheter made insertion
and continous monitoring of
pulmonary artery pressures
feasible.


The basic catheter is approx. 110
cm in length and consists of a
double-lumentube with an
inflatable balloon tip.
Percutaneous Transducers
It is having a transducer connected to a hypodermic needle that has been
placed in a vessel of aem.The three way stopcock dome permits:
Flushing of the needle
Administering of drugs
Withdrawing of blood samples.

It can measure arterial or venous pressures or the pressure of other
physiological fluids by direct attachment to a needle at apoint of
measurement.

The meter scale is calibrated directly into millimeters of mercury.
Implantable transducers
It can be implanted into the wall
of blood vessel or into the wall of
heart itself

The transducers body is made up
of titanium, which has excellent
corrosion resistance
characteristics, low modulus of
elasticity, low thermal coefficient
of expansion.
Measurement of Blood Flow and
Cardiac Output
The rate of flow of a liquid or gas in a pipe is expressed as the volume of the
substance that passes through the pipe in a given unit of time. Flow rates are usually
expressed in liters per minute or milliliters per minute.

Methods used in industry for flow measurement of liquids , the turbine flowmeter,
the rotameter are not suitable for the measurement of blood flow because they
require cutting the blood vessel.

Blood flow meters used in clinical and research applications are based on following
physical principles:
Electromagnetic induction
Ultrasound Reflection
Thermal Convention
Radiographic principle
Indicator Dilution


Magnetic Blood Flow meters
They are based on the principle of
magnetic induction. When an
electrical conductor is moved
through a magnetic field, a
voltage is induced in the
conductor prop to the velocity of
its motion.


The output voltage of a magnetic blood
flow transducer is very small, typically
in the order of a few microvolts.

In early blood flowmeters, a constant
magnetic field was used, which caused
difficulties with electrode polarization
and amplifier drift.

To minimize the problem, several
different waveforms have been
advocated for the magnet current.
Ultrasonic Blood Flow meters
In the transit time ultrasonic
flowmetr, a pulsed beam is
directed through a blood vessel at
a shallow angle and its transit
time is then measured.


Doppler effect states that the
frequency of a wave reflected off
a an object moving away from the
source is lower than the frequency
of the source signal.


In the Doppler (Reflection) technique two methods are used as:
continuous wave and pulsed

Reflection depends on the existence of cells in the blood.

Reflection is due to change in acoustical impedance. Reflected beam
moves in all directions.

Because of the velocity profile of the flowing blood , the Doppler signal
is not a pure sine wave, but has more the foam of narrow-band noise.

The doppler signal of the pulsating blood flow can be heard as a
characteristic swish-swish

Ultrasonic Method
A transcutaneous (through the skin)
Doppler sensor is applied here.
The motion of blood-vessel walls
in various states of occlusion is
measured.
The frequency difference between
transmitted (8 MHz) and received
signal is 40-500 Hz and it is
proportional to velocities of the wall motion and the blood.
The vessel opens and closes with
each heartbeat when
DP < P < SP
cuff
Ultrasonic Method (cont.)
+) Can be also used in noisy environment
ADVANTAGES & DISADVANTAGES
+) Can be used with infants and hypotensive individuals
-) Subjects movements change the path from sensor to vessel
As the cuff pressure is increased, the time between opening and closing
decreases until they coincide Systolic pressure
Again as the cuff pressure is decreased, the time between opening and
closing increases until they coincide Diastolic pressure
Radioisotopes
A rapidly diffusing, inert radioisotope of lipid-soluble gas ( Xe or Kr) is
injected into the tissue or passively diffused
133 85
The elimination of the radioisotope from microcirculatory bed is related to
the blood flow:
( ) kt C t C = exp ) (
0
2 / 1
/ 2 ln t k =
Thermal Convection Probe
The rate of heat removal from the tissue under probe is measured
The concentric rings are
isolated thermally & electrically
from each other
The central disk is heated
1 2 C over the temperature
of tissue
A temperature difference of
2- 3 C is established between
the disks
o
o
The method is not very common due extreme nonlinear properties and difficulties
in practical use (e.g. variable thermal characteristics of skin)
This is one of the earliest techniques for blood flow measurements
Indicator Dilution Methods (1)
Dye Dilution Method
A bolus of indicator, a colored dye (indocyanine green), is rapidly injected in
to the vessel. The concentration is measured in the downstream
The blood is drawn through a colorimetric cuvette
and the concentration is measured using the
principle of absorption photometry
( ) | |dt t C
m
F
t
}
A
=
1
0
amount of
dye
1% peak C
Avg.
flow
( )dt t T c
Q
F
t
b b b
}
A
=
1
0

Indicator Dilution Methods (2)

Thermal Dilution Method
A bolus of chilled saline solution is
injected into the blood circulation system
(right atrium). This causes decrease in the
pulmonary artery temperature.
A standard technique for measuring cardiac output in critically ill patients
An artery puncture is not needed in this technique
heat content
of injectate
Several measurements can be done in relatively short time
density of blood
(e.g. 1060 kg/m3)
specific heat of blood
(e.g. 3640 J/(kg*K)
Plethysmography
in
Blood Flow Measurements
Plethysmography (1)
Strain Gage Method
Plethysmography means the methods for recording volume changes of an
organ or a body part (e.g. a leg)
Strain gage is made of silicone rubber
tubes, which are filled with conductive
liquid (e.g. mercury) whose impedance
changes with volume.
Venous occlusion cuff is inflated to 40
50 mmHg. In this way there will be
the arterial inflow into the limb but no
venous outflow.
If only a segment of limb is measured, there is a need for arterial occlusion
cuff also.
Plethysmography (2)
Chamber Method
Chamber plethysmograph is the only accurate non-invasive way to
measure changes in the blood volume
As the volume of the leg increases, the leg
squeezes some kind of bladder and decreases
its volume
Volume transducer can be e.g. water filled tube
(level) or air (pressure)
The speed of the return of the
venous blood is measured
Plethysmography (3)
Electric-Impedance Method
Different tissues in a body have a different resistivity. Blood is one of the best
conductors in a body ( = 1,5 m)
A constant current is applied via skin
electrodes
The change in the impedance is
measured
The accuracy is often poor or unknown
I = 0,5 4 mA rms (SNR)
f = 50 100 kHz
(Zskin-electrode+shock)
Z
Z
L
Vol A = A
2
0
2

Plethysmography (4)
Photoelectric Method
A beam of IR-light is directed to the
part of the tissue which is to be
measured for blood flow (e.g. a finger
or ear lobe)
The light that is transmitted / reflected is
collected with a photodetector
The blood flow modulates the attenuated
/ reflected light which is recorded.
Poor measure for changes in volume
Very sensitive to motion artefacts
Method is simple
Heart rate is clearly seen
Four Electrode Plethysmography

Current is injected through two outer
electrodes, and voltage is sensed
between two inner electrodes.

Ampl + demod = Z+Z


AC current at about 100 kHz is used.
Why?Electrode impedance drops
drastically with f;

Use a constant amplitude AC current
and measure the voltage


Summary (1)
BLOOD PRESSURE
Describes the physiology and pathology of cardiocvascular system
Normal values are 120 / 80 mmHg
High values may lead to heart attack and strokes
Low values may lead to low oxygen perfusion
All direct methods require skin punctuation and a use
of catheter. Methods are used only when continuous and
accurate measurements are needed.
Almost all indirect methods rely on an occlusive
cuff which is placed on the bracial artery. The actual
measurement is done when the cuff is deflated
Summary (2)
BLOOD FLOW
Used for understanding physiological processes (e.g. medicine
dissolution). Also used for locating clots in arteries
Usually more invasive methods are used than with blood
pressure measurements
Normal velocity is 0,5 - 1 m/s
Indirect measurements are done by using ultrasound or
plethysmographic method
Direct measurements are done by dilution methods (dye / thermal)