Photoplethysmographic characterization of vascular tone mediated changes in arterial pressure: an observational study

AbstractTo determine whether a classification based on the contour of the photoplethysmography signal (PPGc) can detect changes in systolic arterial blood pressure (SAP) and vascular tone. Episodes of normotension (SAP 90–140 mmHg), hypertension (SAP > 140 mmHg) and hypotension (SAP < 90 mmHg) were analyzed in 15 cardiac surgery patients. SAP and two surrogates of the vascular tone, systemic vascular resistance (SVR) and vascular compliance (Cvasc = stroke volume/pulse pressure) were compared with PPGc. Changes in PPG amplitude (foot-to-peak distance) and dicrotic notch position were used to define 6 classes taking class III as a normal vascular tone with a notch placed between 20 and 50% of the PPG amplitude. Class I-to-II represented vasoconstriction with notch placed > 50% in a small PPG, while class IV-to-VI described vasodilation with a notch placed < 20% in a tall PPG wave. 190 datasets were analyzed including 61 episodes of hypertension [SAP = 159 (151–170) mmHg (median 1st–3rd quartiles)], 84 of normotension, SAP = 124 (113–131) mmHg and 45 of hypotension SAP = 85(80–87) mmHg. SAP were well correlated with SVR (r = 0.78, p < 0.0001) and Cvasc (r = 0.84, p < 0.0001). The PPG-based classification correlated well with SAP (r = − 0.90, p < 0.0001), SVR (r = − 0.72, p < 0.0001) and Cvasc (r = 0.82, p < 0.0001). The PPGc misclassified 7 out of the 190 episodes, presenting good accuracy (98.4% and 97.8%), sensitivity (100% and 94.9%) and specificity (97.9% and 99.2%) for detecting episodes of hypotension and hypertension, respectively. Changes in arterial pressure and vascular tone were closely related to the proposed classification based on PPG waveform. Clinical Trial Registration NTC02854852.

[1]  J. Bander,et al.  Arterial blood pressure monitoring in overweight critically ill patients: invasive or noninvasive? , 2006, Critical care.

[2]  Marina Krol,et al.  Intraoperative tachycardia and hypertension are independently associated with adverse outcome in noncardiac surgery of long duration. , 2002 .

[3]  S. Bohm,et al.  Advanced Uses of Pulse Oximetry for Monitoring Mechanically Ventilated Patients , 2017, Anesthesia and analgesia.

[4]  N. Westerhof,et al.  Reliability of stroke volume to pulse pressure ratio for estimating and detecting changes in arterial compliance. , 1986, Journal of hypertension. Supplement : official journal of the International Society of Hypertension.

[5]  M. O'Rourke,et al.  Physiological and pathophysiological implications of ventricular/vascular coupling , 2006, Annals of Biomedical Engineering.

[6]  J. D. Trefford,et al.  What does photoplethysmography measure? , 1984, Medical and Biological Engineering and Computing.

[7]  V. Džavík,et al.  Inotropes and Vasopressors: Review of Physiology and Clinical Use in Cardiovascular Disease , 2008, Circulation.

[8]  T. Lindsay,et al.  Association between Intraoperative Hypotension and Myocardial Injury after Vascular Surgery , 2016, Anesthesiology.

[9]  John Allen.  Photoplethysmography and its application in clinical physiological measurement , 2007, Physiological measurement.

[10]  E. Mascha,et al.  Relation between Perioperative Hypertension and Intracranial Hemorrhage after Craniotomy , 2000, Anesthesiology.

[11]  R. Thiele,et al.  Blood Pressure Monitoring for the Anesthesiologist: A Practical Review , 2016, Anesthesia and analgesia.

[12]  A. Murray,et al.  Age-related changes in the characteristics of the photoplethysmographic pulse shape at various body sites , 2003, Physiological measurement.

[13]  Nigel H. Lovell,et al.  Fingertip photoplethysmographic waveform variability and systemic vascular resistance in intensive care unit patients , 2011, Medical & Biological Engineering & Computing.

[14]  P. Talke,et al.  Does measurement of systolic blood pressure with a pulse oximeter correlate with conventional methods? , 2008, Journal of Clinical Monitoring.

[15]  J. Grignola,et al.  The increase of vasomotor tone avoids the ability of the dynamic preload indicators to estimate fluid responsiveness , 2013, BMC Anesthesiology.

[16]  Helmut Baumgartner,et al.  The 2013 ESH/ESC guidelines for the management of arterial hypertension , 2013 .

[17]  Kirk H. Shelley,et al.  How Does the Plethysmogram Derived from the Pulse Oximeter Relate to Arterial Blood Pressure in Coronary Artery Bypass Graft Patients? , 2001, Anesthesia and analgesia.

[18]  R. Beale,et al.  Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution , 2000, Intensive Care Medicine.

[19]  S. M. Finkelstein,et al.  Non-invasive studies of peripheral vascular compliance using a non-occluding photoplethysmographic method , 1998, Medical and Biological Engineering and Computing.

[20]  G. Natalini,et al.  Arterial Versus Plethysmographic Dynamic Indices to Test Responsiveness for Testing Fluid Administration in Hypotensive Patients: A Clinical Trial , 2006, Anesthesia and analgesia.

[21]  T. Ohkubo,et al.  Pulse wave velocity and the second derivative of the finger photoplethysmogram in treated hypertensive patients: their relationship and associating factors , 2002, Journal of hypertension.

[22]  G. Fischer,et al.  Vasoplegia during cardiac surgery: current concepts and management. , 2010, Seminars in thoracic and cardiovascular surgery.

[23]  T. Akata.  General Anesthetics and Vascular Smooth Muscle: Direct Actions of General Anesthetics on Cellular Mechanisms Regulating Vascular Tone , 2007, Anesthesiology.

[24]  T. Shiga,et al.  Do induced hypertension and hypotension affect stroke volume variation in man? , 2012, Journal of clinical anesthesia.

[25]  YUKIO MORIKAWA,et al.  Characteristic Pulse Wave caused by Organic Nitrates , 1967, Nature.

[26]  Jeroen J. Bax,et al.  2007 ESH-ESC Guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). , 2007, Blood pressure.

[27]  T. Dawber,et al.  Characteristics of the Dicrotic Notch of the Arterial Pulse Wave in Coronary Heart Disease , 1973, Angiology.

[28]  J. Peňáz.  Criteria for set point estimation in the volume clamp method of blood pressure measurement. , 1992, Physiological research.

[29]  W. Milnor,et al.  Arterial impedance as ventricular afterload. , 1975, Circulation research.

[30]  P. Chowienczyk,et al.  Determination of age-related increases in large artery stiffness by digital pulse contour analysis. , 2002, Clinical science.

[31]  Rein Raamat,et al.  Recording of dynamic arterial compliance changes during hand elevation , 2005, Clinical physiology and functional imaging.

[32]  Ramakrishna Mukkamala,et al.  Error Mechanisms of the Oscillometric Fixed-Ratio Blood Pressure Measurement Method , 2012, Annals of Biomedical Engineering.

[33]  S. Bagshaw,et al.  Fluid balance as a biomarker: impact of fluid overload on outcome in critically ill patients with acute kidney injury , 2008, Critical care.

[34]  G D Pinna,et al.  Estimation of arterial blood pressure variability by spectral analysis: comparison between Finapres and invasive measurements. , 1996, Physiological measurement.

[35]  M. Steinfath,et al.  Variation of left ventricular outflow tract velocity and global end-diastolic volume index reliably predict fluid responsiveness in cardiac surgery patients. , 2012, Journal of critical care.

[36]  L Dolezal,et al.  Parameters describing the pulse wave. , 2009, Physiological research.

[37]  A. Garg,et al.  Relationship between Intraoperative Mean Arterial Pressure and Clinical Outcomes after Noncardiac Surgery: Toward an Empirical Definition of Hypotension , 2013, Anesthesiology.

[38]  Kirk H. Shelley,et al.  The relationship between the photoplethysmographic waveform and systemic vascular resistance , 2007, Journal of Clinical Monitoring and Computing.

[39]  Ettore Ambrosioni,et al.  ESH/ESC guidelines for the management of arterial hypertension: how to implement in daily clinical practice , 2004 .

[40]  K. Bendjelid.  The pulse oximetry plethysmographic curve revisited , 2008, Current opinion in critical care.

[41]  H. Lindorf.  Investigation of the vascular effect of newer local anesthetics and vasoconstrictors. , 1979, Oral surgery, oral medicine, and oral pathology.

[42]  K. Takazawa,et al.  Assessment of vascular aging and atherosclerosis in hypertensive subjects: second derivative of photoplethysmogram versus pulse wave velocity. , 2000, American Journal of Hypertension.

[43]  J. Matsuzaka,et al.  Plethysmographic Study of Effects of Alcohol , 1968, Nature.

[44]  Christina Holcroft,et al.  Fluid Overload after Coronary Artery Bypass Grafting Surgery Increases the Incidence of Post-Operative Complications , 2011 .

[45]  Maxime Cannesson,et al.  Relation between respiratory variations in pulse oximetry plethysmographic waveform amplitude and arterial pulse pressure in ventilated patients , 2005, Critical care.

[46]  Harald Herkner,et al.  Factors influencing the accuracy of oscillometric blood pressure measurement in critically ill patients , 2003, Critical care medicine.

[47]  Nigel H Lovell,et al.  Multivariate classification of systemic vascular resistance using photoplethysmography , 2011, Physiological measurement.

[48]  R. Bellomo,et al.  Norepinephrine for hypotensive vasodilatation after cardiac surgery: impact on renal function , 2003, Intensive Care Medicine.

[49]  D. Reich,et al.  Intraoperative Tachycardia and Hypertension Are Independently Associated with Adverse Outcome in Noncardiac Surgery of Long Duration , 2002, Anesthesia and analgesia.

[50]  Karel G M Moons,et al.  Incidence of Intraoperative Hypotension as a Function of the Chosen Definition: Literature Definitions Applied to a Retrospective Cohort Using Automated Data Collection , 2007, Anesthesiology.

[51]  N. Wisely,et al.  Arterial flow waveforms from pulse oximetry compared with measured Doppler flow waveforms , 2001, Anaesthesia.

[52]  Xavier Monnet,et al.  Hemodynamic parameters to guide fluid therapy , 2011, Annals of intensive care.

[53]  G C van den Bos,et al.  Pulse Wave Reflection: Can It Explain the Differences Between Systemic and Pulmonary Pressure and Flow Waves? A Study in Dogs , 1982, Circulation research.

[54]  Christer Svensén,et al.  Epidural Anesthesia, Hypotension, and Changes in Intravascular Volume , 2004, Anesthesiology.

[55]  John B. Dillon,et al.  The form of the volume pulse in the finger pad in health, arteriosclerosis, and hypertension , 1941 .

[56]  R. E. Kerns,et al.  Comparison of blood pressure measurement by Doppler and by pulse oximetry techniques. , 1987, Anesthesia and analgesia.