Transcript Hypertension In Children
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
Little Rock is the capitol of State of Arkansas A.
B.
False True 7/19/07
Distribution of Hypertensive Patients
Adults Children 2.5 million 47.5 million 7/19/07
Tracking of Blood Pressure
Bogalusa Heart Study showed 40% individuals with SBP > 80 th 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) 7/19/07
Overweight and Hypertension in Children Prevalence of Overweight in Children
16% 14% 12% 10% 8% 6% 4% 2% 0% 6 to 11 years
Age Group
12 to 19 years Ogden CL et al.
JAMA
2002 1971-1974 1999-2000 5.00%
Prevalence of Hypertension in School Children
4.50% 4.00% 3.50% 3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00%
1989 2004 Year
Sorof JM et al.
Pediatrics
2004 7/19/07
Blood Pressure, in children, is most commonly measured by: A.
B.
Physicians Nurses 7/19/07
Blood Pressure Measurement Training
Why to train already trained personnel? 7/19/07
Effect of Training on Observer Errors
7/19/07 Bruce NG et al. J Hypertens 1988; 6:375- 380
Outline
History (brief)
Blood pressure measurement devices
Procedure
Definition of hypertension
Practice cases
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Blood Pressure Measurement
Stephen Hales 1733 Hollow glass tube in neck artery of horse Blood rose 9 feet in glass tube 7/19/07 Medicine, an Illustrated History 1987
History of Blood Pressure Measurement
1896. Scipione Riva Rocci Only Systolic BP measured by palpation Medicine, an Illustrated History 1987 7/19/07
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
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Which blood pressure apparatus is the “Gold standard” for BP measurement in children above age 3 A.
DINAMAP B.
C.
D.
E.
Oscillometric wrist BP monitor Ambulatory BP monitor Mercury sphygmanometer Aneroid BP monitor 7/19/07
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Mercury Sphygmomanometer
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Mercury Sphygmomanometry
1998: EPA and the American Hospital Association agreed to virtually eliminate mercury from hospitals by 2005
In the absence of a mercury manometer, which is preferred method to measure BP in children above age 3 A.
B.
C.
D.
Oscillometric wrist BP monitor Auscultatory aneroid BP monitor Oscillometric arm BP monitor DINAMAP 7/19/07
Aneroid Manometer
Mercury pressure gauge replaced by mechanical spring Gauges are often small Accuracy varies among manufacturers Requires frequent calibration 7/19/07
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Aneroid Manometers
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Mercury and Aneroid Manometer
How often should an aneroid BP monitor be calibrated?
A.
B.
C.
D.
E.
Once a day Once a week Once every 6 months Once a year Once every 5 years 7/19/07
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 7/19/07
Which is preferred method to measure BP in neonates and infants?
A.
B.
C.
D.
E.
Oscillometric wrist BP monitor Auscultatory aneroid BP monitor Oscillometric finger BP monitor DINAMAP Mercury sphygmanometer 7/19/07
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 7/19/07
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Dinamap
®
Oscillometric Device
Dinamap ® is an acronym for: D evice for I ndirect N oninvasive M ean A rterial P ressure
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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
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 7/19/07
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 7/19/07
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Oscillometric Devices
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
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Ambulatory BP Monitoring
Oscillometric or acoustic methods 24 hour monitoring Individual measurements not more accurate Readings downloaded into PC Cost: $2500-4500 7/19/07
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Ambulatory Blood Pressure Monitoring
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White Coat Hypertension
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Ambulatory Blood Pressure Monitoring
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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 7/19/07
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 7/19/07
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Blood Pressure Cuff size
Blood Pressure Cuff Size
Index line Cuff length = 80% of MAC Bladder length (80%) 20% 7/19/07 MAC Largest allowable mid arm circumference for bladder (100%) Cuff width = 40% of MAC
Blood Pressure Cuff Size NHANES 99-2002 Children Child Adult Large adult Thigh (%) 80 70 60 50 40 30 20 10 0 71 25 3 0.5
3-8 yrs 37 51 11 0.7
9-14 yrs 57 30 9 15-19 yrs 4
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35% of 4 th and 8 th graders needed large adult cuff in Marianna
Recommended Dimensions for BP Cuff Bladders
Age range Newborn Infant Child Small adult Adult Large adult Thigh
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Width (cm)
4 6 9 10 13 16 20
Length (cm)
8 12 18 24 30 38 42
Max. AC (cm)
10 15 22 26 34 44 52
Blood pressure is measured in children preferably on A.
B.
C. D.
E.
Right lower leg Left upper arm Right upper arm Left wrist Right wrist 7/19/07
What is the optimal position for a patient’s arm to be in when taking the blood pressure?
A.
B.
C.
D.
Cubital fossa at the heart level Elbow at heart level Elbow supported with midpoint of upper arm at heart level Elbow by the side of the body 7/19/07
Auscultatory Method
Fourth 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 7/19/07
What is the optimal rate of deflation of blood pressure cuff?
A.
B.
C.
D.
1 mm Hg / sec 2-3 mm Hg / sec 5 mm Hg / sec 10 mm Hg / sec 7/19/07
Auscultatory Method
Fourth 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 7/19/07
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Auscultatory Sounds
Auscultatory Method
Fourth 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
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Blood Pressure In Children
Auscultation is preferred method Elevated BP must be confirmed on repeated visits BP readings >90 th obtained by oscillometric devices, should be repeated by auscultation
Fourth report on BP. Pediatrics August 2004
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7/19/07 Definition
Hypertension- Definition
Normal blood pressure: Pre-hypertension: Hypertension: Stage 1: Stage 2: less than 120/ 80 mmHg 120 – 139/ 80 - 89 mmHg 140 to 159 /90 to 99 mmHg 160 mmHg / 100 mmHg The JNC 7 report. JAMA 2003; 289:2560.
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Pediatric BP Standards
Blood pressure correlates with: Age Gender Height percentile Standards Ages 1-12 months: 1987 task force Ages 1-17 years: Fourth BP report
Fourth report on BP. Pediatrics August 2004
7/19/07
Definitions
Normal SBP and DBP <90 th age, and height percentiles for gender, Pre-hypertension Average SBP or DBP between 90 th percentiles or > 120/80 mm Hg and 95 th Hypertension Average SBP and/or DBP > 95 th for gender, age, and height on more than 3 occasions
Fourth Report on BP. Pediatrics August 2004
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5 yrs old Girl BP 121/80 Height 90 th percentile 7/19/07
Fourth Report on BP. Pediatrics August 2004 90 th : 109/69 95 th : 112/73
Definitions
Stage I hypertension Average SBP and/or DBP between 95 th and 99 th percentile plus 5 mm Hg Stage II hypertension Average SBP and/or DBP > 99 th percentile plus 5 mm Hg
Fourth Report on BP. Pediatrics August 2004
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5 yrs old Girl BP 121/80 Height 90 th percentile 7/19/07
Fourth Report on BP. Pediatrics August 2004 90 th : 109/69 95 th : 112/73 99th : 120/81 Stage II: >125/86
A 7 years old boy had average BP 110/60 mm Hg. Similar BP readings were documented on three separate occasions. His height is at 95 th percentile. This boy has A.
B.
C.
D.
Normal blood pressure Pre-hypertension Stage I hypertension Stage II hypertension 7/19/07
A 8 years old girl has average BP 130/90 mm Hg. Similar BP readings were documented on three separate occasions. Her height is at 75 th percentile This girl has A.
B.
C.
D.
Normal blood pressure Pre-hypertension Stage I hypertension Stage II hypertension 7/19/07
A 11 years old boy had average BP 140/95 mm Hg. Similar BP readings were documented on three separate occasions. His height is at 5 th percentile This boy has A.
B.
C.
D.
Normal blood pressure Pre-hypertension Stage I hypertension Stage II hypertension 7/19/07
A 18 years old young man had average BP 150/95 mm Hg. Similar BP readings were documented on three separate occasions. His height is at 50 th percentile This young man has A.
Normal blood pressure B.
C.
D.
Pre-hypertension Stage I hypertension Stage II hypertension 7/19/07
Blood Pressure Screening in Marianna
May 2005 Volunteers and school nurse was trained for BP measurement 81, 4th grader (89% AA) First screening Normal 80% Pre-htn 9% Hypertension 11% Third screening Hypertension 3.7% 7/19/07
School Blood Pressure Screening
Purpose To find undiagnosed hypertensive school children and adolescents Refer these children to primary care physicians Help primary care physicians in the management of these children if required 7/19/07
Summary
Accurate blood pressure measurement is the corner stone of diagnosis of hypertension in children Oscillatory method can be used for screening but elevated blood pressure should be confirmed with auscultatoy method Appropriately sized cuff is mandatory and measure mid arm circumference to choose the cuff size Calibrate BP measurement apparatus semiannually 7/19/07
Thanks
Ms. Paula Smith Department of Pediatrics-UAMS Office of education Minority Health Commission Marianna School 7/19/07
Hypertension Clinic-ACH
Dr. Karen McNiece, M.D
Dr. Thomas Wells, M.D.
Dr. Mohammad Ilyas, M.D.
Jona Plummer, RNP Wendy Davis, RN Contact Number (501) 364-1847 7/19/07