Noninvasive Hemodynamic Monitoring Devices

New Tools or Just Another Toy?

Stefan De Hert, M.D., Ph.D.

N this months issue of Anes, Kim etal.1 report

on a systematic review and metaanalysis of studies assessing the
accuracy and precision of continuous noninvasive arterial pressure
monitoring devices. The question
is of interest and has clinical relevance in view of the growing
trend in the area of hemodynamic
monitoring to obtain a maximum
of information using minimally
invasive devices.
This trend has first appeared
in the noninvasive (or minimally
invasive) assessment of cardiac
output and its derived variables.
Such new devices have been developed to replace direct measurements obtained via cannulation
of arterial and/or central venous
vessels. Basically, these devices
rely on computer software and
algorithms developed by industry
to provide an estimation of the
different variables. Although successive software versions progressively yielded more reliable data,
there are still clinical situations in which data obtained with
noninvasive cardiac output measurements not truly reflect
the patients hemodynamic condition.2 In the last few years,
this trend of noninvasively estimating hemodynamic variables has extended to the assessment of arterial pressures.3
The reasons for such development are straightforward. On
the one hand, patients undergoing high-risk surgery and/
or presenting with multiple comorbidities may require
close hemodynamic monitoring with beat-to-beat arterial
pressure analysis. On the other hand, potential occurrence
of mechanical, thrombotic, and infectious complications
described with invasive cannulation of an artery may warrant the search for a less invasive approach.
Currently, the continuous noninvasive arterial pressure
monitoring systems that are commercially available are Nexfin (BMEYE B.V., Amsterdam, The Netherlands), CNAP
thesiology

(CNSystems, Graz, Austria), and

T-line (Tensys Medical Inc., San
Diego, CA). The first two are
based on the principle of volume
clamp already developed in 1973
by Penaz,4 whereas the latter is
based on the principle of arterial
tonometry.5 From the analysis by
Kim etal. it seems that the studies published on the commercially available technologies (n =
14) show an overall pooled bias
of 1.812.4 mmHg for systolic
arterial pressure, 6.08.6 mmHg
for diastolic arterial pressure, and
3.98.7 mmHg for mean arterial
pressure. These limits do not satisfy
the standards that have been established for the validation of automatic arterial pressure monitoring
by the Association for the Advancement of Medical Instrumentation.6
It is therefore concluded that both
accuracy (closeness of a measurement value to its actual true value)
and precision (the degree to which
repeated measurements under
unchanged conditions show the
same results, i.e., reproducibility) mayfor the moment
not be sufficient to allow for reliable clinical decision making.
It is to be expected that in the future further development of software and refining of the algorithms used will
enhance reliability of the different noninvasive systems for
continuous arterial blood pressure measurements. Nevertheless, a number of considerations need to be taken into
account when deciding to implement such devices in daily
clinical practice.
First, the type of patients who need continuous blood
pressure measurements also frequently necessitates regular
blood sampling for the assessment of various biochemical
variables. The presence of an arterial line greatly facilitates
such sampling, and the use of a noninvasive system for continuous blood pressure monitoring will not avoid the necessity for arterial blood sampling in a majority of cases.

Perspective: both accu

racy ... and precision [on
noninvasive arterial pres
sure monitors] ... mayfor
the momentnot be suf
ficient to allow for reliable
clinical decision making.

Image: J. P. Rathmell.
Corresponding article on page 1080.
Accepted for publication December 11, 2013. From the Department of Anesthesiology, Ghent University Hospital, Faculty of Medicine
and Health Sciences, Ghent University, Ghent, Belgium.
Copyright 2014, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2014; 120:1065-6

Anesthesiology, V 120 No 5

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May 2014

Editorial Views

Second, the analysis of signals processed by the noninvasive continuous arterial pressure measurement systems is
based on algorithms and software programs which are developed by the technical staffs of the different manufacturers
involved. The clinical anesthesiologist isat the bestaware
of a number of variables that are included in the design of
the software but has no knowledge on the exact algorithms
used in the different devices. Hence, it is virtually impossible
for the random anesthesiologist to have an insight in how
the incoming signals are processed and finally result in the
number displayed on the screen. This is in sharp contrast
to the signals obtained by regular invasive blood pressure
analysis, where every anesthesiologist is capable of assessing
and appreciating technical pitfalls such as damping and/or
oscillations of the signal.7,8 Although it is probably a normal
evolution that the design of monitoring tools moves away
from the basic understanding of the clinical anesthesiologist,
we should realize that we are increasingly using tools that are
designed for us and not anymore by us.
Third, despite the general feeling that especially the very
sick patient may benefit from continuous extensive hemodynamic monitoring, there are little data showing that
such monitoring substantially improves patient outcome.2
Nevertheless, integrating information of several monitoring tools may help in better guiding therapeutic interventions. Recently, Wax etal. demonstrated that invasive and
noninvasive (cuff) blood pressure measurements may yield
differential results, especially during periods of hypotension
and hypertension. Noninvasively measured blood pressure
tended to be higher than radial artery blood pressure during periods of hypotension and lower during periods of
hypertension. Interestingly, the use of noninvasive blood
pressure measurement to supplement arterial blood pressure measurements was associated with a decreased use of
blood transfusions, vasopressor or inotrope infusions, and
antihypertensive medications compared with the use of
arterial blood pressure measurement alone.9 It remains to
be established whether data from continuous noninvasive
blood pressure monitoring are indeed capable of replacing
direct arterial blood pressure measurement or whether they
simply will provide additional information that may help in
tailoring therapeutic interventions.
It is therefore essential that parallel to the further design
of noninvasive monitoring tools, the impact of data from

such systems on clinical decision making and ultimately the

impact on patients outcome are evaluated. In the end, it is
not the availability of a multitude of numbers, coming from
different monitoring tools that will improve clinical management and outcome of the patient, but the correct interpretation of these data integrated in the entire clinical picture of
the particular patient.

Competing Interests
The author is not supported by, nor maintains any financial
interest in, any commercial activity that may be associated
with the topic of this article.

Correspondence
Address correspondence to Dr. De Hert: stefan.dehert@
ugent.be

References
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Cannesson M: Accuracy and precision of continuous noninvasive arterial pressure monitoring compared to invasive
arterial pressure: A systematic review and meta-analysis.
Anesthesiology 2014; 120:108097
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the-art review. JCardiothorac Vasc Anesth 2013; 27:12134
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Stefan De Hert