Monitoring Arterial Blood Pressure: What You May Not Know

Beate H. McGhee and Elizabeth J. Bridges

Crit Care Nurse. 2002;22: 60-79

© 2002 American Association of Critical-Care Nurses
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Critical Care Nurse is the official peer-reviewed clinical journal of the American
Association of Critical-Care Nurses, published bi-monthly by The InnoVision Group,
101 Columbia, Aliso Viejo, CA 92656. Telephone: 949-362-2000. Fax:
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Monitoring Arterial
Blood Pressure:
What You May Not Know
Beate H. McGhee, BSN, MN, APN
Maj Elizabeth J. Bridges, USAF, NC

and mismanagement. The results published and unpublished, indi-

To receive CE
credit for this of a recent pilot study1 at 2 univer- cate a general knowledge deficit in
article, visit the sity-affiliated hospitals suggested pulmonary artery pressure moni-
American Asso-
ciation of Critical- a knowledge deficit in arterial toring. Because of these research
Online Care Nurses’ pressure monitoring and some of findings, in this article, we focus
(AACN) Web site
the most basic aspects of hemo- on areas of particular knowledge
at http://www.aacn
.org, click on dynamic monitoring. A total of deficit related to essential princi-
"Education" and select “Continuing 391 critical care nurses practicing ples of hemodynamic monitoring
Education,” or call AACN’s Fax on
Demand at (800) 222-6329 and in various critical care specialties and ABP monitoring. We discuss
request item No. 1152. were invited to participate in the the physiology of ABP, physiologi-
study. The response rate was cal and pathophysiological factors
17.4% (n = 68). Most of the partici- that affect ABP, and the arterial

A
rterial
blood pres-
sure (ABP)
is a basic
hemody-
n a m i c
index often
utilized to
guide therapeutic interventions,
especially in critically ill patients.
Inaccurate ABP measuring cre-
ates a potential for misdiagnosis
Beate H. McGhee is an adult care
nurse practitioner and a recent
graduate of the master’s program in
the School of Nursing, University of
Washington, Seattle, Wash. Maj
Elizabeth J. Bridges has a doctoral
degree from the School of Nursing,
University of Washington, Seattle.
To purchase reprints, contact The InnoVision
Group, 101 Columbia, Aliso Viejo, CA 92656.
Phone, (800) 809-2273 or (949) 362-2050
(ext 532); fax, (949) 362-2049; e-mail,
reprints@aacn.org.
pants were between the ages of 30
and 39 years (56.1%) and had a
baccalaureate degree as their
basic (61.8%) and highest degree
in nursing (58.8%). Most partici-
pants had more than 4 years of
nursing experience (94.1%) and
critical care experience (83.9%),
and most did direct ABP monitor-
ing at least once or twice each
week (97.1%). The participants
were asked to complete an 18-item,
criterion-referenced question-
naire on ABP physiology, techni-
cal aspects of ABP monitoring,
and ABP waveform interpretation
in selected pathophysiological
conditions. The mean score in
this pilot study was 36.7% (SD,
11.8%). Total scores ranged from
11.1% to 61.1%.
Literature on nurses’ knowl-
edge of hemodynamic monitoring
is limited, but several studies, 2-5
pressure waveform and its inter-
pretation in clinical situations
common in critical care patients.
ABP PHYSIOLOGY
The cardiovascular system has
3 types of pressures 6,7: hemody-
namic, kinetic energy, and hydro-
static. Hemodynamic pressure is
the energy imparted to the blood
by contraction of the left ventricle.
This type of pressure is preserved
by the elastic properties of the
arterial system. Kinetic energy is
the energy associated with motion
and affects the pressure measured
during direct ABP monitoring.
Fluid density and gravity con-
tribute to hydrostatic pressure,
which is the pressure a column of
fluid exerts on the container wall.
For example, in a column of fluid,
the pressure at a given level in the
container is proportional to the

60 CRITICAL CARE NURSE Vol 22, No. 2, APRIL 2002

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height of the fluid column above
that level. The pressure is highest
at the bottom of the column. In
the vascular system, hydrostatic
pressure is proportional to the
height of the column of blood
between the heart and the periph-
eral vasculature. In a standing
person, the pressure in the leg is
higher than the pressure in the
arm by the difference in hydro-
static pressure. In summary, arte-
rial blood pressure represents the
force exerted by the blood per
unit area on the arterial wall6-8 and
is the sum of hemodynamic,
kinetic, and hydrostatic pressure.
The arterial tree starts with the
aorta and the major branches of
this vessel. The aorta and its
branches stretch to receive blood
from the left ventricle and recoil
to distribute the blood and to
maintain arterial pressure. Art-
eries and arterioles control blood
pressure through vasoconstric-
tion or vasodilation. 6 Arterioles
are the primary sites that con-
tribute to systemic vascular resis-
tance (SVR). 6,9-11 In addition,
adrenergic control of the arteri-
oles is a major determinant of
blood flow into the capillaries. In
the skin, for instance, blood can
be shunted from the capillary
beds to flow directly from arteri-
oles into the venous system. 9
Arteriovenous shunting occurs in
shock states and helps to redirect
blood flow to vital organs. Arterio-
venous shunting is one reason
measurements of blood pressure
alone are not a good indicator of
peripheral tissue perfusion.
Arterial pressure is measured at
its peak, which is the systolic blood
pressure (SBP), and at its trough,
which is the diastolic blood pres-
sure (DBP). The SBP is determined
by the stroke volume, the velocity
of left ventricular ejection (an indi-
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rect indicator of left ventricular
contractile force), systemic arterial
resistance, the distensibility of the
aortic and arterial walls, the vis-
cosity of blood, and the left ven-
tricular preload (end-diastolic
volume).11-13 The blood pressure in
the aorta during systole is a clinical
indicator of afterload (the sum of
the forces the left ventricle must
overcome to eject blood).14,15 The
diastolic pressure is affected by
blood viscosity, arterial distensibil-
ity, systemic resistance, and the
length of the cardiac cycle.11,16
Pulse pressure is the difference
between systolic and diastolic
pressure. A normal pulse pressure
in the brachial artery is approxi-
mately 40 mm Hg. An increased
pulse pressure may be the result of
increased stroke volume or ejec-
tion velocity and is common dur-
ing fever, exercise, anemia, and
hyperthyroidism.11 Other causes of
increased pulse pressure include
bradycardia (increased stroke vol-
ume), aortic regurgitation, and
arterial stiffening, which is most
noticeable after the age of 50 to 60
years. 11,17-19 An acute decrease in
pulse pressure may indicate an
increase in vascular resistance,
decreased stroke volume, or
decreased intravascular volume.11-13
Systemic mean arterial pres-
sure (MAP) is defined as the mean
perfusion pressure throughout the
cardiac cycle. MAP is sensed by
baroreceptors located in the
carotid sinuses and the arch of the
aorta. These receptors control arte-
rial pressure mainly by adjusting
heart rate and arteriolar vessel
radius. MAP is also the basis for
autoregulation by some organ sys-
tems such as the kidney, heart, and
brain. Autoregulation is the auto-
matic adaptation of the radius of
an arteriolar vessel in an organ to
maintain constant blood flow over
CRITICAL CARE NURSE Vol 22, No. 2, APRIL 2002 61
a wide range of mean pressures
(60-150 mm Hg) to protect func-
tioning of the organ.7,20 MAP is the
product of SVR and cardiac output
(MAP=SVR×cardiac output).7,10
As indicated previously, a main
determinant of SVR is the radius of
arterial, and particularly arteriolar,
vessels. Changes in cardiac output
are related to heart rate and stroke
volume. Stroke volume, in turn, is
determined by several factors,
including heart rate, preload, after-
load, cardiac contractility, and syn-
ergy of cardiac contraction (related
to ventricular dilatation, abnormal-
ities in ventricular wall motion, and
ventricular arrhythmias).10,11 MAP is
generally closer to diastolic pres-
sure because diastole represents
about two thirds of the cardiac
cycle when the mean heart rate is
close to 60/min. This relationship
is expressed in the well-known for-
mulas MAP = DBP + (SBP -DBP)/3
and MAP = [SBP + (DBP x 2)]/3.
However, the proportion of
diastole in the cardiac cycle
changes with changes in heart
rate. In calculations of MAP for a
manually obtained ABP, these for-
mulas must be used with caution,
because they provide a good esti-
mate of MAP only when the heart
rate is close to 60/min. 10 Fortu-
nately, MAP is provided by most
automatic ABP measuring devices
and direct ABP monitoring sys-
tems, each of which uses a system-
specific method to directly
determine MAP.
In summary, because of the
multiplicity of factors that con-
tribute to ABP and the complexity
of their interrelationships, inter-
preting changes in arterial pres-
sure and its components (SBP,
DBP, MAP, and pulse pressure) as
indicative of any single factor may
lead to an erroneous assessment
of a patient’s condition. When SBP
and DBP are measured using dif-
ferent (oscillometric or direct)
monitoring methods, the values
can differ significantly. When MAP
is measured using different moni-
toring methods, however, the val-
ues are very similar, because MAP
is little affected by the phenom-
enon of wave reflection.21-25 Wave
reflection and other factors that
affect measurement of SBP and
DBP are discussed later.
PRINCIPLES OF
HEMODYNAMIC
MONITORING
Three Conventions of
Cardiovascular Pressure
Measurement
For measurement of cardio-
vascular pressures, 3 conventions
are observed 6,7,20 : (1) Cardio-
vascular pressures are expressed
in millimeters of mercury, with
the exception of central venous
pressure, which may be measured
in millimeters of mercury or in
centimeters of water. For convert-
ing values in centimeters of water
to values in millimeters of mer-
cury, the value given in centime-
ters of water is divided by the
factor 1.36. (2) Most cardiovascu-
lar pressures, such as ABP, central
venous pressure, and pulmonary
artery pressure, are referenced to
the heart or, more specifically, to
the atria, to eliminate hydrostatic
pressure. (3) All cardiovascular
pressure monitoring devices are
zeroed to ambient atmospheric
pressure, so that the actual pres-
sure measured reflects the pres-
sure above atmospheric pressure.
The Hemodynamic
Monitoring System
A hemodynamic monitoring
system contains 2 compartments:
the electronic system and the
fluid-filled tubing system. Al-
62 CRITICAL CARE NURSE Vol 22, No. 2, APRIL 2002
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though clinicians have little con-
trol over the electronic compo-
nents such as the monitor, correct
setup and maintenance of the
tubing system and the pressure
transducer are absolutely crucial
to avoid error. With an improperly
prepared or inadequately func-
tioning monitoring system, not
only the actively measured hemo-
dynamic indices but also any
derived variables will be errone-
ous, 26 potentially invalidating a
patient’s entire hemodynamic pro-
file. Three procedural steps should
be followed to prepare the moni-
toring tubing system and ensure its
continued accuracy: priming of the
pressure tubing, leveling and zero-
ing, and dynamic response testing.
Priming of the Pressure Tubing.
The generation and recording of all
arterial waveforms (systemic arteri-
al pressure and pulmonary artery
pressure) are based on the same
basic principles. The invasive
catheter provides access to the
arterial system being monitored
and is designed to pick up the pres-
sure waves generated in the arterial
system by cardiac contractions.
The catheter is connected to the
fluid-filled tubing of the monitor-
ing system. The fluid column in the
tubing system carries the mechan-
ical signal created by the pressure
wave to the diaphragm of the elec-
trical pressure transducer. The
transducer creates the link between
the fluid-filled tubing system and
the electronic system, and converts
the mechanical signal into an elec-
trical signal. The electrical signal is
transmitted to the monitor and
then is amplified and displayed as
an analog waveform and digital
output.
Air as a medium transmits
mechanical impulses much dif-
ferently than does fluid. Air bub-
bles in the tubing system are one
of the most frequent and impor-
tant sources of error in hemody-
namic monitoring. Air bubbles
most often blunt or damp propa-
gation of the mechanical signal,
causing a damped analog wave-
form and erroneous pressure
readings.27 Even tiny air bubbles
only 1 mm in diameter can cause
serious waveform distortion. 28
Therefore, air-free priming of the
entire tubing system is one of the
most important steps to avoid
technical error.
Air-free priming starts with
removal of all air from the flush
solution to prevent air from going
into the solution as a result of the
pressure applied by the external
pressure cuff. Then, the entire
tubing system should be flushed.
Stopcocks, Luer-Lok interconnec-
tions, and the transducer are com-
mon locations of air entrapment27
and deserve special attention
throughout priming and use of the
catheter system. In order to main-
tain the air-free status after the
initial setup of the system, the fol-
lowing measures are important:
■ After opening the system for
blood sampling or zeroing, briefly
fast-flush the tubing system,
including the proximal access
stopcock or the air-fluid interface
stopcock.
■ Tighten all connections, and
ensure that the stopcocks are
closed to air.
■ Avoid adding stopcocks and
line extensions.
■ Keep the flush solution bag
adequately filled, and keep the
external pressure cuff at 300 mm Hg.
■ Periodically flick the tubing
system and flush the tubing sys-
tem and stopcocks to eliminate
tiny air bubbles escaping the
flushing solution.
Leveling and Zeroing. The
arterial pressure monitoring sys-
tem must be referenced to heart
level, technically the level of the
left atrium, and set at atmospher-
ic pressure as the zero reference
point. These criteria can be met
through leveling and zeroing.
Leveling or referencing of the
catheter system is accomplished
by aligning the air-fluid interface
of the monitoring system (eg, the
stopcock on top of the transduc-
er) with the external reference
point of the heart. The external
reference point of the heart is the
phlebostatic axis, which can be
located by finding the junction of
2 lines: a vertical line drawn out
from the fourth intercostal space
at the sternum and a horizontal
line drawn through the midpoint
of a line going from the anterior to
the posterior side of the chest.29,30
Where to level the air-fluid
interface is a matter of discussion.
The answer depends on which
vascular bed is to be monitored.
In most clinical situations, the
64 CRITICAL CARE NURSE Vol 22, No. 2, APRIL 2002
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central arterial pressure is the
pressure of interest, because it is
a key determinant in cardiac and
cerebral perfusion. In order to
monitor central arterial pressure,
the monitoring system must be
leveled to the heart by using the
phlebostatic axis. Research indi-
cates that the phlebostatic axis
most accurately reflects the level
of the atrium in both supine and
upright patients.29-31 The midaxil-
lary line, which has also been
used as an external reference
point for the heart, is not accurate
in all chest configurations and
thus is not recommended.31 When
the monitoring system is refer-
enced to the tip of the catheter,
then the transmural pressure of a
particular point in the arterial tree
is monitored and not central arte-
rial pressure. Peripherally mea-
sured transmural pressure is
markedly increased by hydrostat-
ic pressure unless the patient is
supine.32
Zeroing consists of 2 steps.
First, the air-fluid interface is
opened to atmospheric pressure.
Then the monitor’s zeroing func-
tion key or button is pressed.
Zeroing in this fashion has several
purposes. Zeroing electronically
establishes for the monitor atmo-
spheric pressure as the atmospher-
ic zero reference point. Zeroing
establishes the interface level as
the hydrostatic zero reference
point. Zeroing also eliminates zero-
drift. Zero-drift is the potential, but
usually minimal, transducer offset
or distortion occurring over time.33
Two key practice objectives are
related to referencing and zeroing:
accuracy and consistency. In order
to ensure accuracy, leveling and
zeroing must be done whenever
the relationship between the air-
fluid interface and the reference
point is changed. The reason is
hydrostatic pressure. For every 1
cm the air-fluid interface is above
or below the actual level of the left
atrium, 0.74 mm Hg of hydrostatic
pressure is subtracted or added to
the measured pressure. If the air-
fluid interface is placed 10 cm
below the phlebostatic axis, the
measured pressure will be an over-
estimation of the actual hemody-
namic pressure by 7.4 mm Hg. This
example illustrates that though
accurate referencing and zeroing
are important for all hemodynamic
monitoring, they become even
more crucial when small hemody-
namic pressures, such as pul-
monary artery wedge pressure
(6-12 mm Hg) and central venous
pressure (2-6 mm Hg) are being
monitored. In these instances,
small offsets from the phlebostatic
axis and the zero reference point
can cause large errors34 and may
prompt inappropriate treatment.
In order to ensure consistency,
once the external reference point
has been selected, it should be
marked on the patient for easy
identification. Consistency allows
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correct determination of trends in
a patient’s hemodynamic status.
Whether the same body position
must be used for consecutive
measurements may be debatable.
Although several studies on pul-
monary artery pressure monitor-
ing indicated no significant
changes in pulmonary artery
pressures related to certain bed
positions, according to a recent
research abstract, 35 ABP values
obtained with various bed posi-
tions differed even when the phle-
bostatic axis was used as the
external reference point. The sta-
tistical significance of differences
in ABP values for monitoring sys-
tems referenced to the phlebo-
static axis was not addressed in
the abstract.
Dynamic Response Testing. In
order to determine if a hemody-
namic monitoring system can
adequately reproduce a patient’s
cardiovascular pressures, the
dynamic response characteristics
of the catheter system must be
tested. Only when system accura-
cy, also termed fidelity, has been
confirmed, can the analog wave-
form be accepted as an accurate
reflection of a patient’s status.
The dynamic response of a
hemodynamic monitoring system
is defined by its natural frequency
and the damping coefficient. The
natural frequency indicates how
fast the pressure monitoring sys-
tem vibrates when shock excited by
a signal such as the arterial pres-
sure pulse or the pressure signal
caused by a fast-flush test. The
damping coefficient of a monitor-
ing system is a measure of how
quickly the oscillations of a shock-
excited system dampen and even-
tually come to rest.23,26,36
Dynamic response testing is a
3-step procedure: determining
natural frequency, determining
the amplitude ratio of 2 consecu-
tive fast-flush oscillations (as an
indirect way of determining the
damping coefficient), and deter-
mining the dynamic response
characteristics of the monitoring
system (eg, optimal, adequate,
underdamped, overdamped, or
unacceptable). These steps are
summarized in Figure 1.
Dynamic response testing may
seem complicated at first. Clinical
experience has shown, however,
that with proper training, dynam-
ic response testing can be per-
formed in less than 2 minutes. A
few simple observations provide
almost as much information and
may serve as a close estimate. (1)
If the period between 2 oscilla-
tions of the fast-flush test is less
than 1.2 mm, then natural fre-
quency will be at least 21, and the
system will most likely be ade-
quate. If the period between 2
oscillations is 1 mm or less, then
the natural frequency is 25 or
higher, and the system will almost
always function properly with any
degree of damping. As a rule-of-
thumb, the higher the natural fre-
quency (or the smaller the
period), the better is the dynamic
response of the monitoring sys-
tem. (2) The system is over-
damped if the fast-flush produces
sluggish or no oscillations. If the
square wave shows undulations
or if ringing occurs after the
release of the fast-flush device, the
system is most likely under-
damped. Overdamping and under-
damping both indicate that the
dynamic response characteristics
of the monitoring system are
unsatisfactory.
Simple visual evaluation of the
arterial waveform, the square
waveform, and oscillations gener-
ated by the fast-flush has been
suggested as a suitable method
for determining the dynamic
response characteristics of a
monitoring system. However, the
Downloaded from ccn.aacnjournals.org by on September 8, 2010
square waveform and fast-flush
oscillations may look adequate
when the natural frequency and
amplitude ratio of the system
actually make the system inade-
quate (underdamped, over-
damped, or unacceptable). Or, the
arterial waveform may look dis-
torted because of physiological
variations, yet the dynamic re-
sponse characteristics of the sys-
tem assure a faithful recording of
the arterial pressure.36 When accu-
racy is needed for clinical decision
making, the ideal method of deter-
mining if the measured ABP, or
any other directly monitored
hemodynamic parameter, is true
is to determine the dynamic re-
sponse characteristics of the moni-
toring system.26,36 Examples of the
importance of formally assessing
the response characteristics are
discussed in more detail later.
COMPONENTS OF
THE NORMAL ABP
WAVEFORM
Left ventricular contraction
creates a pressure pulse or pulse
wave. It is the pressure pulse that
a clinician feels when determin-
ing a patient’s pulse by palpation.
The pressure pulse is also what is
sensed by the intra-arterial
catheter. 34,35 The normal arterial
pressure waveform is shown in
Figure 2. The systolic upstroke or
anacrotic limb mainly reflects the
pressure pulse produced by left
ventricular contraction. The pres-
sure pulse is followed slightly
later by the flow wave caused by
the actual displacement of blood
volume. The anacrotic shoulder,
that is, the rounded part at the top
of the waveform, reflects primari-
ly volume displacement. 22,37 The
systolic pressure is measured at
the peak of the waveform. The
dicrotic (or downward) limb is
CRITICAL CARE NURSE Vol 22, No. 2, APRIL 2002 67
demarcated by the dicrotic notch,
representing closure of the aortic
valve and subsequent retrograde
flow. The location of the dicrotic
notch varies according to the tim-
ing of aortic closure in the cardiac
cycle. For example, aortic closure
is delayed in patients with hypov-
olemia. Consequently, the dicrot-
ic notch occurs farther down on
the dicrotic limb in hypovolemic
patients. The dicrotic notch also
appears lower on the dicrotic
limb when arterial pressure is
measured at more distal sites in
the arterial tree (Figure 3). The
shape and proportion of the dias-
tolic runoff wave that follows the
dicrotic notch changes with arte-
rial compliance and heart rate.
Diastolic pressure is measured
just before the beginning of the
next systolic upstroke.
The analog waveform visible
on the monitor or recorded on a
strip chart is not only caused by
the forward pressure pulse but is
also a result of a phenomenon
known as wave reflection. Wave
reflection is related to the im-
pedance of blood flow by the nar-
rowing and bifurcation of the
arterial vessels; the impedance
leads to backward or retrograde
reflection of the pressure wave.23,38-40
In a manner similar to waves on
the beach, the forward or ante-
grade pressure waves and the
reflected waves collide. The com-
bination of the 2 types of waves
increasingly augments the SBP
the farther down the blood pres-
sure is measured in the arterial
circuit. In other words, the contri-
bution of reflected waves to the
measured systolic pressure occurs
earlier in the periphery, particu-
larly in the radial and dorsalis
pedis arteries (Figure 3), where
the measured SBP may be 20 to 25
mm Hg higher than central aortic
 Fast flush

A1 = 7 mm

A2 =
3 mm

Period (t) = 1.2 mm

1. Determining natural frequency (Fn)

At the end of a waveform
a. Perform the fast-flush maneuver (square waveform test): pull and release the pigtail or compress and release
the button of the fast-flush device of the monitoring system.

b. Record the resulting square waveform and subsequent oscillations on calibrated strip chart paper.

c. Measure the distance (period, t, of 1 cycle) in millimeters between 2 oscillations. (One small box on the
calibrated strip chart paper equals 1 mm.)

d. Calculate Fn by using the formula

Fn = paper speed (mm/s)/t of 1 cycle (mm)
(The standard paper speed is 25 mm/s.)
Example: paper speed = 25 mm/s; t = 1 mm; Fn = (25 mm/s)/1 mm = 25 Hz

2. Determine the amplitude ratio

a. Measure the amplitude (A) in millimeters of 2 successive oscillations (A1, A2).
b. Calculate the amplitude ratio: divide A2 by A1 (A2/A1).

3. Determine the dynamic response characteristics

On the Fn-versus-amplitude ratio graph

a. Plot Fn along the x-axis (result of step 1)

b. Plot the amplitude ratio along the y-axis on the right (result of step 2)
c. Find the intersection of the 2 lines. Where the 2 lines intersect on the Fn-versus-amplitude ratio graph determines
if the system is able to correctly reproduce the hemodynamic waveform (adequate, optimal) or if the system is not
functioning at a desirable level (overdamped, underdamped, unacceptable).

Figure 1 The 3 steps of dynamic response testing. A, The fast-flush test. B, The frequency-versus-damping coefficient
graph.
A, Adapted from Bridges and Middleton,36 with permission. B, Reprinted from Gardner and Hollingsworth,28 with permission; adapted from Bridges and Middleton,36
with permission.

68 CRITICAL CARE NURSE Vol 22, No. 2, APRIL 2002

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 Anacrotic limb
120
97
80
40
Dicrotic notch
0 FOR CLINICAL
BASE
Figure 2 The normal arterial pressure waveform.
MAP indicates mean arterial pressure.
Reprinted from Darovic,10 with permission.
pressure.22,23 Under normal condi-
tions, 80% of the original wave is
thought to be reflected.22
Clinically, wave reflection plays
an important role in left ventricu-
lar workload and cardiac oxygen
consumption. In young adults
with elastic arteries, the reflected
wave returns to the heart during
the diastolic phase of the cardiac
cycle and thus augments coronary
artery perfusion. In elderly patients
or patients with stiff, atheroscle-
rotic vessels, the reflected wave
returns to the heart during systole
and thus increases systolic pres-
sure and left ventricular afterload.39
Central
aorta
Brachial
Radial
Femoral
Dorsalis
pedis
Figure 3 Changes of the arterial
pressure waveform configuration
throughout the arterial tree. Note
the increasing steepness and
amplitude of the systolic upstroke
and the changing location of the
dicrotic notch.
Reprinted from Gorny,8 with permission.
Downloaded from ccn.aacnjournals.org by on September 8, 2010
Dicrotic limb
Systolic=115 mm Hg
Pulse pressure
=35 mm Hg
Diastolic=80 mm Hg
MAP=Area + Base
=97 mm Hg
Pharmacological vasoconstriction
can similarly increase wave reflec-
tion and cardiac workload.23,39
The contribution of reflected
waves to the measured systolic
pressure is diminished during
hypovolemia, hypotension, the
Valsalva maneuver, and vasodi-
latation. 23 In pharmacologically
induced vasodilation, such as
occurs with nitroglycerin for
instance, peripherally measured
systolic pressure may not change
in proportion to the actual degree
of reduction in central aortic pres-
sure.39,40 The effect of nitroglycerin
may be visible in the appearance
of reflected waves after the systolic
peak (Figure 4), but reduced aortic
pressure, afterload, and cardiac
work load may be more evident
through clinical improvement of
the patient. During shock with
vasoconstriction, wave reflection
can lead to the overestimation of
central aortic pressure, because
peripheral SBP may be 20 mm Hg
higher than aortic pressure. 36,39
Peripherally measured SBP could
in this situation provide a false
sense of security that the patient is
maintaining adequate perfusion
pressures. A slower systolic up-
stroke and a prominent diastolic
waveform with reflected waves
may be visual indicators of shock
with vasoconstriction39 (Figure 5).
CRITICAL CARE NURSE Vol 22, No. 2, APRIL 2002 69
SOURCES OF
ARTIFACT AND
CHANGES IN
WAVEFORM
MORPHOLOGY:
RECOMMENDATIONS
PRACTICE
Damping, Overdamping, and
Underdamping
A common scenario when
working with arterial catheters is
comparing the blood pressure
recorded by the arterial catheter
with the blood pressure obtained
manually or with an oscilloscope.
If a discrepancy occurs, the arterial
catheter is often said to be some-
how “damped,” with the underly-
ing understanding that pressure
readings obtained with the cath-
eter cannot be trusted. Such an
interpretation may be premature
and probably disregards several
important facts. Differences exist
between (1) damping, overdamp-
ing, and underdamping; (2) over-
damped and underdamped pres-
sure waveforms caused by over-
damped or underdamped moni-
toring systems and overdamped-
or underdamped-appearing
waveforms that reflect the true
physiological status of a patient;
and (3) blood pressures obtained
via direct versus indirect monitor-
ing methods.
All hemodynamic monitoring
systems are damped. Damping is
desired, because without damp-
ing the vibrations of the system’s
fluid column caused by the arteri-
al pressure pulse would go on
indefinitely and no accurate
waveform could be recorded.
Conversely, both overdamped
and underdamped systems exist,
and their recordings are indeed
erroneous. With an overdamped
system, the waveform loses its
characteristic landmarks and
 aortic regurgitation, or hyperdy-
namic states such as fever. 23 In
these conditions, typically a rapid
rise in the systolic slope occurs,
frequently exceeding the dynam-
ic response characteristics of the
monitoring system. A heart rate
greater than 150/min may also
cause systolic overshoot, because
Figure 4 Example of a waveform common in patients with hypertension
(arterial blood pressure, 192/84 mm Hg; pulse pressure, 108 mm Hg). Note
of the rapid succession of
the narrow systolic tip, the position of the dicrotic notch (D), and the impulses.26
reflected waves (R). A reflected wave like the first reflected wave after the The variable natural frequency
systolic upstroke may appear with the initiation of nitroglycerin therapy.40 of available monitoring systems
Overall, the arterial waveform appears underdamped, but the dynamic
response characteristic is adequate, close to optimal. Natural frequency, explains why with different moni-
25/1 = 25 Hz; amplitude ratio, 3.5/8 = 0.44. toring systems, different hemody-
namic pressures can be measured
even though the patient’s condi-
appears unnaturally smooth, with tend to have a low natural fre- tion has not changed.22 The often
a diminished or absent dicrotic quency and consequently are observed discrepancies between
notch. Overdamping results in often underdamped. 22,36 Anec- directly and indirectly obtained
falsely low systolic and falsely high dotal reports of manufacturers of SBP and DBP readings are also
diastolic pressure readings 26 an improved natural frequency partly caused by underdamping.22
(Figures 6 and 7). An overdamped- often do not hold up in clinical Clinically, recognition of pos-
appearing (often simply called practice. Typically, the natural sibly overdamped and under-
damped) waveform can also be the frequency of hemodynamic mon- damped waveforms and an
result of aortic stenosis, vasodi- itoring systems currently on the awareness of physiological situa-
latation, or low cardiac output market is less than 25 Hz. An tions when each type of wave-
states such as cardiogenic shock, underdamped system will record form may occur are important.
sepsis, or severe hypovolemia falsely high systolic pressures Then the question to be
(Figure 5). In order to determine if (15-30 mm Hg) and falsely low answered is whether the cause of
the waveform is a result of an over- diastolic pressures26 (Figures 8-10). the waveform is the patient’s
damped system or is an accurate Underdamping, most often in condition or the monitoring sys-
reflection of a patient’s status, the the form of systolic overshoot tem. Practically, the intervention
dynamic response characteristics (the artificial exaggeration of sys- for both overdamped and under-
must be tested. tolic pressure), must be suspect- damped systems is the same:
Today’s commercially avail- ed in patients with hypertension, maximizing natural frequency.
able catheter-transducer systems atherosclerosis, vasoconstriction,
Techniques for Maximizing
Natural Frequency
As mentioned earlier, air bub-
bles are a main factor in wave-
form blunting or overdamping. In
addition to air bubbles, other fac-
tors may alter the natural fre-
quency of a monitoring system
and distort the recorded signal.
These factors include narrow,
Figure 5 Waveform in a patient in shock with vasoconstriction. Note slow compliant, and long tubing; pres-
systolic upstroke and relatively high diastolic wave with reflection waves (R). ence of additional stopcocks; and
The waveform appears overdamped. loose connections. Translated into
D indicates dicrotic notch. practice, the monitoring system

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Figure 6 Overdamped waveform due to an overdamped monitoring system.
Note the absence of fast-flush oscillations.
should (1) be primed air-free, (2)
consist of wide-bore, high-pres-
sure tubing with its length limited
to 122 cm (48 in), (3) not be
extended with tubing or added
stopcocks, and (4) have tightly
secured connections.27,36 In addi-
tion, the continuous flush bag
should be cleared of any air and
be maintained adequately filled,
and the external pressure cuff sur-
rounding the flush solution bag
should be maintained at a pres-
sure of 300 mm Hg. This practice
will not only prevent air from
going into the solution but also
help prevent catheter clotting.
Catheter clotting is a rare, but
possibly serious, complication of
intra-arterial monitoring. One of
the first indications of clotting may
be a waveform that looks over-
damped. Whenever waveform
overdamping is observed, the
patient should be assessed
for signs and symptoms of hypo-
tension or low cardiac output.
Then, the potential clot should
be removed by aspirating blood
from the distal stopcock before
performing any flushing maneuver
for the dynamic response test. 37
Fluids with viscosities higher than
the viscosity of normal isotonic
sodium chloride solution also lead
to overdamping of the hemody-
namic waveform.23 For example,
blood in the arterial catheter (due
to blood backup or insufficient
flushing) should be cleared from
the system. As a general rule, the
catheter-tubing system and stop-
cocks should be flushed before any
hemodynamic measurement is
performed, especially when clini-
cal decisions are to be made. The
Table summarizes the most
important recommendations for
optimizing the natural frequency
of the monitoring system and
dynamic response testing.
In general, overdamping and
underdamping affect mostly SBP
and DBP. MAP is less sensitive to
these sources of waveform distor-
tion and is therefore less depen-
dent on the dynamic response
characteristics of the catheter sys-
tem. 26 When all steps have been
taken to maximize the natural
frequency of a system, yet the
dynamic response test indicates
overdamping or underdamping,
then either MAP should be
followed or an alternative method
of monitoring (eg, oscillometric
blood pressure monitoring)
should be used.
End-Hole Artifact
The arterial catheter of the
ABP monitoring system points
upstream. The forward-flowing
blood contains kinetic energy.
When the flowing blood is sud-
denly stopped by the tip of the
catheter, the kinetic energy of the
blood is partially converted into
pressure. This converted pressure
may add 2 to 10 mm Hg to the
systolic pressure measured by an
intra-arterial monitoring system.23
The artificial augmentation of
directly monitored systolic pres-

Figure 7 Example of an overdamped-appearing waveform. The dynamic Figure 8 Example of an

response characteristic of the system gives an answer to the question, is the underdamped waveform. Natural
waveform overdamped because of the monitoring system or is it a correct frequency, 25/1.5 = 16.7 Hz;
reflection of the patient’s condition? amplitude ratio, 7/14 = 0.5.

CRITICAL CARE NURSE Vol 22, No. 2, APRIL 2002 73

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 for hemodynamic pressure mea-
surement is to use the analog
strip-chart recording.43,44

Figure 9 Example of an underdamped waveform. Natural frequency, 25/2 =
12.5 Hz; amplitude ratio, 4/11 = 0.36. Note the normal-appearing fast-flush
oscillations.
sure by converted kinetic energy
is referred to as the end-hole arti-
fact or the end-pressure product.
Movement Artifact
Motion of the tubing system
enhances the fluid oscillations of
the system. Although the clinical
significance of movement artifact
is not known, it is recommended
that extrinsic movement of the
tubing system be kept at an abso-
lute minimum.10
Monitor Artifact
The differences (>5 mm Hg)
between the digital pressure out-
put displayed on the monitor and
pressures directly read from analog
or strip chart recordings are poten-
tially important.43 These differences
can lead to erroneous data collec-
tion and are especially notable in
patients with hypotension, hyper-
Figure 10 Example of an overdamped-appearing waveform. However, the
dynamic response test places the system on the border between
underdamped and adequate. Natural frequency, 25/1.8 = 13.9 Hz; amplitude
ratio, 9/19 = 0.47.
tension, dysrhythmias, or pulsus
paradoxus.43 The monitoring sys-
tem cannot discriminate between
pressure readings during zeroing,
obtaining blood samples, and
fast-flushing and real arterial
pressure readings. Consequently,
all readings are incorporated into
pressure trends.43 Monitoring arti-
fact (ie, monitoring noise caused
by movement of the patient and
disturbances in a monitoring sys-
tem due to, for example, electrical
heating or cooling blankets) may
also be superimposed on the
patient’s pressure waveform.
Experienced clinicians can recog-
nize and eliminate some of these
error sources and use a represen-
tative set of waveform tracings on
a calibrated strip-chart recording
to obtain the most valid assess-
ment of a patient’s hemodynamic
status.43 Thus, the optimal method
Respiratory Variation
Normal breathing leads to
changes in intrathoracic pressure,
which affect cardiac output and
systemic pressure. With sponta-
neous inspiration, intrathoracic
pressure decreases. The de-
creased pressure is recognizable
on the ABP tracing as a downward
displacement of the waveform
baseline. Concurrently, during in-
spiration, venous return to the
right side of the heart is increased,
augmenting right ventricular
stroke volume. The increase in
right ventricular stroke volume is
offset by increased pulmonary vas-
cular compliance and blood pool-
ing during inspiratory thoracic
expansion. Consequently, left ven-
tricular stroke volume is decreased.
Heart rate and SVR both increase
as a compensatory reflex. The net
result of this chain of reflexes is the
phenomenon known as physiolog-
ical pulsus paradoxus (a decrease
in ABP of usually <10 mm Hg dur-
ing spontaneous, unassisted inspi-
ration).45 An inspiratory decrease in
ABP greater than 10 mm Hg (pul-
sus paradoxus) may indicate car-
diac tamponade or restrictive
pericarditis. Pulsus paradoxus also
occurs in patients with obstructive
lung disease, pulmonary em-
bolism, and severe heart failure
and can be induced by mechanical
ventilation.46,47
During positive-pressure venti-
lation, the inspiratory increase in
intrathoracic pressure can be rec-
ognized in the upward displace-
ment of the baseline of the arterial
pressure waveform. If a patient
receiving mechanical ventilation is
hypovolemic, the increase in

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 Recommendations for optimizing the natural frequency of the arterial pressure monitoring system and dynamic response
testing

Feature Recommendations

Natural frequency of the monitoring System requirements

system23,27,41 Use wide-bore, high-pressure tubing no longer than 122 cm (48 in)
Avoid tubing extensions and minimize stopcocks
Ensure that all connections are tightened
Eliminate air from the flush fluid and air bubbles from the tubing system
Keep continuous flush bag filled and keep external pressure cuff at 300 mm Hg
pressure
Clear access catheter and tubing system of any fluid other than isotonic sodium
chloride solution
Prevention of catheter clotting
Maintain continuous flush device as described
Use heparinized flush solution42
Prevention of catheter kinking
Keep cannulated extremity in a neutral or slightly extended position

Dynamic response test27,41 Implementation of test

Whenever the waveform seems overdamped or underdamped
Whenever physiological changes of the patient (increased heart rate,
vasoconstriction) place higher demands on the monitoring system
After opening the system
Before implementing interventions or changes of interventions
Whenever the accuracy of the arterial blood pressure measurement is in doubt
At least every 8-12 hours

intrathoracic pressure may lead to
artificial augmentation of directly
monitored SBP.
Current monitoring systems
determine the mean of pressure
readings at predetermined inter-
vals. Respiratory artifact could lead
to erroneous digital output data.
The unpredictable effect of respira-
tory variation on arterial pressure
provides a strong argument for
reading and recording arterial pres-
sure, like any other hemodynamic
index, at the end of expiration by
using a freeze-frame picture or,
best, a strip-chart recording.48,49
resulting in a high pulse pressure
and late high systolic peak, often
39
manifested as a narrow systolic
peak in the peripheral ABP wave-
form tracing. 10,38
In addition, the
diastolic wave may be reduced or
disappear. Figures 4 and 11 show
39
peripheral ABP tracings typical in
patients with hypertension or
atherosclerosis. In each instance,
the small and narrow tip of the
waveform may be an overesti-
mation of systolic pressure and
thereby central aortic pressure. As
explained earlier, hypertension
and atherosclerosis place high
demands on the monitoring sys-
tem. The arterial waveforms
shown in Figures 4 and 11 could
also be the result of systolic over-
shoot due to inadequate dynamic
response characteristics of the

Hypertension and
Atherosclerosis
Hypertension is due to age-
related arterial stiffening, athero-
sclerotic narrowing, or renin-
related vasoconstriction, all of
Figure 11 Example of a waveform common in patients with hypertension
which increase the magnitude of (arterial blood pressure, 150/45 mm Hg). Note steep systolic upstroke,
reflected waves. In these physiolog- narrow systolic peak, diminished diastolic run-off wave, and relative decrease
ical conditions, reflected waves in the diastolic proportion of the waveform due to a heart rate of 100/min.
The waveform appears underdamped.
fuse with the systolic upstroke,

76 CRITICAL CARE NURSE Vol 22, No. 2, APRIL 2002

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monitoring system. The result of
the dynamic response test provides
reassurance that the recorded ABP
tracing is correct.
MAP is measured as the area
under the pressure curve divided
by the width of the base of the
pressure curve (the time interval
of a single cardiac cycle) 10,37
(Figure 2). A small and narrow
systolic tip such as the ones in
Figures 4 and 11 adds relatively
little to the total area under the
pressure curve, whereas it can
add significantly to measured
SBP. Consequently, the measured
MAP is less affected by wave
reflection and the response char-
acteristics of the monitoring sys-
tem than is measured SBP. The
MAP remains relatively constant
when measured at different sites
throughout the arterial circuit,
whereas measured SBP and DBP
may differ.10 In general, MAP is a
more stable hemodynamic para-
meter and provides a more accu-
rate interpretation of a patient’s
hemodynamic status.10,34,36,38
INDIRECT VERSUS
DIRECT ABP
MONITORING
A discussion of the various
methods of indirect ABP mea-
surement and how they compare
with direct ABP monitoring is
beyond the scope of this article.
However, several key principles
should be emphasized in this
context. Direct ABP monitoring
measures pressure pulse, whereas
all indirect methods of ABP mea-
surement are related to blood
flow. No absolute relationship
exists between these 2 phenome-
na because they follow different
laws of physics and physiology. In
low-flow conditions, such as
hypotension and vasoconstricted
states, indirect methods yield
78 CRITICAL CARE NURSE Vol 22, No. 2, APRIL 2002
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lower pressure readings than does
direct ABP monitoring. 22,36 Con-
versely, if SVR is low, in patients
with sepsis for instance, the rela-
tively high flow results in an indi-
rect ABP reading that is higher
than the directly measured
ABP. 22,36 Factors such as under-
damping, end-hole artifact, and
wave reflection contribute to
direct systolic pressure readings
that are often higher than indi-
rectly obtained pressure values.
In other words, when obtaining
ABP readings by using different
measuring methods, different
results should be expected. More
specifically, a “good” correlation
between the oscilloscope and the
arterial pressure monitoring sys-
tem is not a gauge for the proper
functioning of the pressure moni-
toring system. MAP, on the con-
trary, is closely approximated
when oscillometric and direct
measurements are compared.21-25,36
Although both the oscillomet-
ric and the direct ABP monitoring
methods are generally accurate in
clinical practice, direct ABP moni-
toring has a distinct advantage.
Direct ABP monitoring is the only
scientifically and clinically vali-
dated method that allows real-
time and continuous monitoring
of a patient’s ABP. With strip-
chart recording, beat-to-beat
analysis of a patient’s ABP is pos-
sible. This feature may be of clini-
cal relevance when evaluating the
effect of positive end-expiratory
pressure during mechanical ven-
tilation or the effect of changing
stroke volume in atrial fibrillation
or other arrhythmias.
SUMMARY
Hemodynamic monitoring is a
costly procedure, both materially
and with regard to nursing time
involved to ensure proper func-
tioning of the monitoring system
and correct interpretation of the
data obtained. Dynamic response
testing is the ideal method of con-
firming the ability of a monitoring
system to accurately reproduce
hemodynamic waveforms. MAP is
a stable hemodynamic parameter,
because it is least affected by moni-
toring method, catheter insertion
site, the dynamic response charac-
teristics of the catheter system, and
wave reflection. MAP provides the
best estimate of central aortic pres-
sure and is the main hemodynamic
parameter monitored by the neu-
rohormonal system to control
blood pressure. The superior infor-
mational value of MAP provides
strong support for its preferred use
in clinical practice, especially when
use of vasoactive drugs is started or
the dosages of these drugs are
titrated.10,21 However, numerically
satisfactory ABP or MAP values are
not necessarily related to adequate
peripheral tissue perfusion and
organ system function. For optimal
management of patients, data
obtained from assessment tools
such as hemodynamic monitoring
devices must be integrated with
information gained from clinical
assessment of patients’ status. ✙
Acknowledgments
I (B.H.M.) am grateful to Maj Bridges for
sharing her expertise and for her help and
support in preparing this article.
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