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BLOOD PRESSURE MEASUREMENT IN CHILDREN

BLOOD PRESSURE MEASUREMENT IN CHILDREN

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BLOOD PRESSURE MEASUREMENT IN CHILDREN

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  1. BLOOD PRESSURE MEASUREMENT IN CHILDREN Mohammad Ilyas, M.D. Director Hypertension Clinic Arkansas Children’s Hospital Division of Nephrology, Department of Pediatrics. UAMS Little Rock School Health Conference, Little Rock

  2. Little Rock is the capitol of State of Arkansas A. False B. True

  3. Distribution of Hypertensive Patients

  4. Tracking of Blood Pressure • Bogalusa Heart Study showed 40% individuals with SBP > 80th percentile at baseline had levels above that 15 years later • The ability to predict BP levels in adulthood from measurements in childhood would provide the opportunity to intervene before hypertension is established, thereby reducing the CVD risk. (Lane et al. J Human Hypertension 2004)

  5. Overweight and Hypertension in Children Ogden CL et al. JAMA 2002 Sorof JM et al. Pediatrics 2004

  6. Blood Pressure, in children, is most commonly measured by: A. Physicians B. Nurses

  7. Blood Pressure Measurement Training • Why to train already trained personnel?

  8. Effect of Training on Observer Errors Bruce NG et al. J Hypertens 1988; 6:375- 380

  9. Outline • History (brief) • Blood pressure measurement devices • Procedure • Definition of hypertension • Practice cases

  10. Blood Pressure Measurement • Stephen Hales 1733 • Hollow glass tube in neck artery of horse • Blood rose 9 feet in glass tube Medicine, an Illustrated History 1987

  11. History of Blood Pressure Measurement • 1896. Scipione Riva-Rocci • Only Systolic BP measured by palpation Medicine, an Illustrated History 1987

  12. Blood Pressure Measurement - History • Cook and Briggs 1903 • Residents, Johns Hopkins • Single size rubber bladder • Arm size a “small factor” • Systolic BP • Children 75-90 (<2 yr) 90-110 (childhood) • Adults 130 (men) 120 (women) • korotkoff

  13. Devices

  14. Which blood pressure apparatus is the “Gold standard” for BP measurement in children above age 3 A. DINAMAP B. Oscillometric wrist BP monitor C. Ambulatory BP monitor D. Mercury sphygmanometer E. Aneroid BP monitor

  15. Mercury Sphygmomanometer

  16. Mercury Sphygmomanometry 1998: EPA and the American Hospital Association agreed to virtually eliminate mercury from hospitals by 2005

  17. In the absence of a mercury manometer, which is preferred method to measure BP in children above age 3 A. Oscillometric wrist BP monitor B. Auscultatory aneroid BP monitor C. Oscillometric arm BP monitor D. DINAMAP

  18. Aneroid Manometer • Mercury pressure gauge replaced by mechanical spring • Gauges are often small • Accuracy varies among manufacturers • Requires frequent calibration

  19. Aneroid Manometers

  20. Mercury and Aneroid Manometer

  21. How often should an aneroid BP monitor be calibrated? A. Once a day B. Once a week C. Once every 6 months D. Once a year E. Once every 5 years

  22. Testing the Aneroid Manometer • Does the needle rest at zero? • Inflate to 200 mm Hg. Wait for 1 minute, if lower than 170 suspect leak • Using the Y connector, connect to mercury device and check readings • If any reading is off by >4 mm, remove from service • Date the calibration

  23. Which is preferred method to measure BP in neonates and infants? A. Oscillometric wrist BP monitor B. Auscultatory aneroid BP monitor C. Oscillometric finger BP monitor D. DINAMAP E. Mercury sphygmanometer

  24. Oscillometric Devices • Office Use • Expensive (approximately $3000) • Many have been validated (BHS, AAMI) • Recommended for children of all ages • Home Use • Relatively inexpensive • Few have been validated in children • Not recommended for ages < 4 years

  25. Dinamap® Oscillometric Device • Dinamap® is an acronym for: Device for Indirect Noninvasive Mean Arterial Pressure

  26. Dinamap® Oscillometric Device • Dinamap® has been widely used in pediatrics • Detects MAP and estimates SBP and DBP • Proprietary algorithms • Accuracy decreases with increased arterial “stiffness” • Possible systematic errors in diabetics

  27. What is being measured? • Auscultatory method: relies on relationship between audible Korotkoff sounds and pressure at systole and diastole • Oscillometric method: relies on the amplitude of oscillations in the arterial wall to determine MAP (maximum amplitude); complex and proprietary algorithms used to estimate SBP and DBP

  28. Evaluation of the Dinamap 8100 • Rose et al (2000)* • Noted from review of data from NHLBI studies that Dinamap algorithm skipped certain values • ARIC Study: More than 180,000 individual BP measurements • Never recorded SBP of 89, 119, 124, 125, 130, 140, 141, 150, 160, 170, 180, 190, 200 mmHg • No skip pattern for DBP • Skipped HR of 95, 99, 103, 106, 109 bpm Rose KM et al Hypertens (2000); 35:1032-1036

  29. Oscillometric Devices

  30. Validated Monitors • British Hypertension Society • www.hyp.ac.uk/bhs/blood_pressure_list • Association for the Advancement of Medical Instrumentation (AAMI) • www.aami.org • dabl Educational trust • www.dableducational.com

  31. Ambulatory BP Monitoring • Oscillometric or acoustic methods • 24 hour monitoring • Individual measurements not more accurate • Readings downloaded into PC • Cost: $2500-4500

  32. Ambulatory Blood Pressure Monitoring

  33. White Coat Hypertension

  34. Ambulatory Blood Pressure Monitoring

  35. Procedure

  36. What effect would you expect when taking the blood pressure on an obese child with a small BP cuff? A. No effect B. Higher blood pressure C. Lower blood pressure

  37. Case History • 12 years old boy • Admitted for cellulitis of left lower leg • BP= 210/110 mm Hg • Blood pressure rechecked • Physical examination, Wt. 587 pounds

  38. Blood Pressure Cuff size

  39. Blood Pressure Cuff Size Index line Cuff length = 80% of MAC Bladder length (80%) 20% Cuff width = 40% of MAC MAC Largest allowable mid arm circumference for bladder (100%)

  40. Blood Pressure Cuff SizeNHANES 99-2002 Children (%) 35% of 4th and 8th graders needed large adult cuff in Marianna

  41. Recommended Dimensions for BP Cuff Bladders

  42. Blood pressure is measured in children preferably on A. Right lower leg B. Left upper arm C. Right upper arm D. Left wrist E. Right wrist

  43. What is the optimal position for a patient’s arm to be in when taking the blood pressure? A. Cubital fossa at the heart level B. Elbow at heart level C. Elbow supported with midpoint of upper arm at heart level D. Elbow by the side of the body

  44. Auscultatory MethodFourth Report on BP in Children 2004 • Sitting quietly for 5 minutes • Back supported and feet on the floor • Right arm supported, cubital fossa at heart level • Estimate systolic BP by palpation, re-inflate cuff to 20 mmHg higher Pediatrics. August 2004

  45. What is the optimal rate of deflation of blood pressure cuff? A. 1 mm Hg / sec B. 2-3 mm Hg / sec C. 5 mm Hg / sec D. 10 mm Hg / sec

  46. Auscultatory MethodFourth Report on BP in Children 2004 • Deflate cuff at 2-3 mmHg/sec • Systolic BP= onset tapping sounds* • Diastolic BP= disappearance of sounds (fifth Korotkoff sound) • Record BP twice on each occasion as right arm, sitting, SBP/DBP(K5), average used to estimate BP level Pediatrics1996;98:649-658

  47. Auscultatory Sounds

  48. Auscultatory MethodFourth Report on BP in Children 2004 • DBP is determined by disappearance of Krotkoff sounds (K5) • Sometime Krotkoff sounds heard till 0 mm Hg • Try less pressure on the head of stethoscope • If K5 still persists K4 should be recorded as DBP Fourth report on BP. Pediatrics August 2004

  49. Blood Pressure In Children • Auscultation is preferred method • Elevated BP must be confirmed on repeated visits • BP readings >90th obtained by oscillometric devices, should be repeated by auscultation Fourth report on BP. Pediatrics August 2004