Wide pulse pressure

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chicagoguy223

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Anyone ever see an extremely wide pulse pressure with no AI?

I was taking care of healthy 18 y/o male with normal pressures before induction. After induction, BPs were 110/25. Tried different cuffs and switched arms, etc. patient had no history of cardiac abnormalities. Pt woke up completely fine.

Didnt know if this was real or measurement errors. Also gave a 500 ml bonus of LR with no improvement.

Any ideas?

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for the sake of asking, how do you know he had no AI?
 
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Was the monitor programmed correctly? As you know oscillometric cuffs only measure the MAP and guesstimate the SBP/DBP using normative data and proprietary algorithms. On some monitors you can find a submenu to switch between adult, pedi, and neonatal settings... if someone was in the room before you and switched it to neonatal or pedi mode, your SBP/DBP can be way off (happened to me recently)
 
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In Mississippi, they have double wide pulse pressure with a busted washing machine and a trans-camaro up on blocks out front.
TransCamaro4X4.jpg
 
I guess I wasn’t positive no AI. Patient had no murmur and no medical history. I thought it could be a measurement error but both pre-induction and PACU vitals completely normal.
 
I guess I wasn’t positive no AI. Patient had no murmur and no medical history. I thought it could be a measurement error but both pre-induction and PACU vitals completely normal.


Did subsequent patients in the same OR have normal pulse pressures?
 
what was patients pre op pressure

did you try phenylephrine? if so what changes with sbp and dbp did it do?

did you try glyco?

put arterial line and compare
 
Before I put an art line in a healthy 18 yo I’d put a TTE probe on the chest and double check no wide open AI- if it’s severe enough you might not hear a murmur. Unlikely to be that bad without symptoms, but maybe it’s a well compensated unicuspid valve or something
 
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I don’t know about a healthy 18yo, but the last CABG I did in a 70 yr lady had a wide pulse pressure of 120/30 on the art line without any AR or valve issues. I think if it is a healthy 18 yo, I would give some pressers and see what happens, but if it’s a long case or I’m concerned I would take a manual pressure or put in the art line.
 
Stiff arteries in the elderly cause somewhat elevated pulse pressures too, but that doesn't seem as relevant here.
 
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Anyone ever see an extremely wide pulse pressure with no AI?

I was taking care of healthy 18 y/o male with normal pressures before induction. After induction, BPs were 110/25. Tried different cuffs and switched arms, etc. patient had no history of cardiac abnormalities. Pt woke up completely fine.

Didnt know if this was real or measurement errors. Also gave a 500 ml bonus of LR with no improvement.

Any ideas?
I wonder if the patient has a fam history of heart disease. Although unlikely the patient could have hereditary lipohillic disorder resulting in accelerated atherosclerosis. In my environment I would send the patient to their pcm for further follow up. In pp assuming normal bp and vitals send home.
 
Anyone ever see an extremely wide pulse pressure with no AI?

I was taking care of healthy 18 y/o male with normal pressures before induction. After induction, BPs were 110/25. Tried different cuffs and switched arms, etc. patient had no history of cardiac abnormalities. Pt woke up completely fine.

Didnt know if this was real or measurement errors. Also gave a 500 ml bonus of LR with no improvement.

Any ideas?

Yes I’ve seen it. I can recall several instances when I’ve had an aline in and the cuff cycles every now and then and the diastolic is well below the aline or the systolic is well below the aline. I think someone pointed it out already but with the cuff the sbp and the dbp are not measured, but instead calculated based on the measurement of the map and machines algorithm. FurtherMore the maps on the cuffs have a wider margin of error the further the map is away from 70. Combine the machine algorithm with the inherent error of the maps on the cuff and you can get some funny readings. I’ll try to find the article I once read on this and post the link...
 
Yes I’ve seen it. I can recall several instances when I’ve had an aline in and the cuff cycles every now and then and the diastolic is well below the aline or the systolic is well below the aline. I think someone pointed it out already but with the cuff the sbp and the dbp are not measured, but instead calculated based on the measurement of the map and machines algorithm. FurtherMore the maps on the cuffs have a wider margin of error the further the map is away from 70. Combine the machine algorithm with the inherent error of the maps on the cuff and you can get some funny readings. I’ll try to find the article I once read on this and post the link...

And obviously when you have discrepancy between aline and cuff there’s all sorts of errors with the aline as well.
 
Hey guys: SOME young people have very wide pulse pressures on NIBP under GA. My guess is that it has something to do with low SVR and compliant vessels and diastolic runoff --> low diastolic. Follow the systolic. Look at the pulse ox pleth and see that super snappy trace. Please don't put in an art line for this reason.
 
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Hey guys: SOME young people have very wide pulse pressures on NIBP under GA. My guess is that it has something to do with low SVR and compliant vessels and diastolic runoff --> low diastolic. Follow the systolic. Look at the pulse ox pleth and see that super snappy trace. Please don't put in an art line for this reason.

that was my first guess too actually
 
The eternal debate: do you follow the aline or the cuff. Nobody knows...
With the art line, at least, there are some objective tests you can do to reassure yourself that the numbers are probably accurate. If you are motivated enough to care about fast flush tests, resonance, natural frequency, etc. Even if you're a normal well-adjusted human who isn't that motivated, it's easy to tell at a glance if an a-line is over or under damped, if the waveform is good or constantly fading out and needing flushing or repositioning.

The NIBP is just a black box full of voodoo and magic.
 
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With the art line, at least, there are some objective tests you can do to reassure yourself that the numbers are probably accurate. If you are motivated enough to care about fast flush tests, resonance, natural frequency, etc. Even if you're a normal well-adjusted human who isn't that motivated, it's easy to tell at a glance if an a-line is over or under damped, if the waveform is good or constantly fading out and needing flushing or repositioning.

The NIBP is just a black box full of voodoo and magic.

I go with the a-line 100% of the time if it zeroed correctly, all the equipment from the monitor/cable/pressure bag to the pts wrist appears in good order, the square wave flush test is normal, and the pt isn't on crazy dose pressors. It drives me insane when the pt has a garbage BP on the a-line and the nurse tries to say the (likely inaccurately sized, malpositioned) cuff BP is normal.
 
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The eternal debate: do you follow the aline or the cuff. Nobody knows...

Cuff for someone from home. Baseline pressure preop, clinic, PCP are all NIBP. But only if it's higher than the a-line :)
 
Stab the artery with the pen and estimate the blood pressure based on how far it squirts out?

Yeah but you forgot the most important part. You gotta Catch what squirts out in a graduated cylinder and estimate the flow rate based on how long it takes to fill up. Better representation of Oxygen delivery than just pressure.
 
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