Recent Middle Tennessee School of Anesthesia graduate Mindy Mullins, DNAP, CRNA, received the inaugural President’s Medal for her innovative capstone project that focused on improving the accuracy of blood pressure measurement for obese patients.
Mullins, who works as a CRNA at Baptist Memorial Hospital – North Mississippi in Oxford, said the idea stemmed from her experience working in her hospital’s Bariatric Center of Excellence. “We care for a high percentage of individuals who are obese. The simple task of blood pressure measurement is difficult at times,” she said.
Due to the extra weight impacting the upper arm’s shape and size that causes poor blood pressure cuff fitting, Mullins said it is common to place the cuff on the forearm. “Either the cuff doesn’t wrap properly around the upper arm, or it extends below the antecubital fossa,” she noted. “Because CRNAs rely on the blood pressure measurement to assess a patient’s hemodynamic status and anesthetic depth perioperatively, I became curious. Is the blood pressure measurement from the alternate approach valid?”
For her capstone project, Mullins reviewed 42 studies and honed in on an additional 15 studies dating from 1956-2013 focused on upper arm vs. forearm noninvasive blood pressure measurement and found concerns about accurate readings are warranted. Her research uncovered:
The findings of extant evidence and manufacturers of oscillometric monitoring devices discourage a forearm approach in obtaining blood pressure measurements.
The quality of evidence strongly warrants further investigation of the approach in obtaining valid measurements with unified measurement methods, data collection procedures, and validated tools.
In the presence of numerous comorbidities or complex positioning with improper noninvasive blood pressure measurement technique, invasive monitoring should be considered in patients who are obese to avoid perioperative complications.
Mullins is now conducting a study to compare the accuracy of GE Critikon radial cuffs – a cuff validated for forearm blood pressure measurement – with the correct-sized upper arm cuff in obese individuals. Her study could potentially be the first to use a validated tool on the forearm versus a validated tool on the upper arm and impact best practices going forward.
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