BP cuff sizes

Clinical (archive)
1

Hi all,

Advice from clever clinicians please:

In OBSERVATION.blood_pressure.v1 BP cuff sizes are currently:

· Neonatal

· Paediatric

· Adult

· Wide adult

· Thigh

I’m wondering if they should be slightly different ie:

· neonatal,

· infant,

· child and/or paediatric,

· small adult,

· adult, and

· large adult (or thigh) cuff

Can anyone clarify for me?

Thanks

Heather

2

Guidelines are available at

http://www.bhsoc.org/

see

http://www.bmj.com/cgi/content/full/328/7440/634?ecoll

but the bhsoc server appears to be down at present

Ian

3

Hi Heather
The attatched reference from The American Heart Association may be of some help.
Hope you are well
Regards
Jag

(attachments)

print_presenter.jhtml;jsessionid=OME…pdf (17.8 KB)

4

Thanks Ian and Jag – clearly the Scots are experts on BP cuff sizes, or just modelling similar things to me!

Cheers

Heather

5

Hi Heather,

Just a (non clinician’s) note on the cuff size issue.

The clinical focus for recording cuff sizes seems to be :-

  • The clinical need to demonstrate the measurements were performed appropriately, or not.
  • The ability to replicate measurement methods
  • Clinical audit

I suggest
1/ ‘Adult’ should not be use but rather ‘Standard adult’.
2/ The addition of Extra Large adult (per previous communications)

Finally, its worth noting that the dimensional ranges which these classes map to are different depending not least on the manufacturer e.g
Classified Size Ranges:
Small adult (17-22) or Small adult 22-26 or Small adult (18-26)
Standard adult (22-32) or Adult 27-34 or Medium adult (26-34) or Standard adults (27.5-36.5)
Large adult (32-42) or Large Adult 35-44 or Large adult (34-43) or Large adults (35-46)
.. etc.

Tom Seabury

6

Dear Tom,

I agree with your observations - especially about the variation in
sizing description.

The snag, in use, is that a neonatal arm cuff works nicely on an adult
finger, an adult thigh cuff equally nicely on a large adult arm, etc.

So, in order to be sure that the clinical focus is adequately fulfilled,
it may be necessary (perhaps only by exception) to drill back to
operational data that provides, site of measurement, weight /age of
patient at time of measurement, measurement technology used
(oscillometric, doppler, auscultatory,...), etc.

As someone else observed on this list a while back - you could spend
(and I have) your life in this quagmire. The key thing seems to be
getting enough (defined by use case / archetype) clinical information
into the long-term record, whilst ensuring that the operational data is
accessible and semantically comparable if required. That's where the
SNOMED enterprise environment needs to have clean link (as being
investigated in the IOTA work) to the more granular operational EN
ISO/IEEE 11073 semantics of devices - and thence into clusters and
archetypes? Oh, and then the different regulatory and 'ordering'
semantics have to be accommodated... joy!

Regards,

Melvin.

In mail of Fri, 4 Jan 2008 12:00:06,

7

I am impressed by Tom’s dedictaiton to detail!! but I’m not sure that, at least in GP-land, such considerations of variations in cuff-size definition amount to very much when set against the huge number of other confounding variables such as patient anxiety/anger, doctors rounding down to the nearest 10mmHg, constricting clothing etc,etc,etc

I am happy with the broad defs of cuff sizes and don’t feel we need to be, or indeed can be, overly precise in this area.

Ian

8

Hi to all,

Cuff size names are the problem?

To me its simple:
All cuffs have a size.
Sizes are expressed as …, mm, cm, m, dm, hm, km, …

What terms people have for a cuff size is decided among them selves.
It changes from context to the next, from community to the next, from one language to the next, even from one dialect to the next.
Are pigmee adults as big as Masai or Dutchman?

But the cuff size is and always be expressed in xxx centimeters.

GF

– –
Gerard Freriks, MD
Huigsloterdijk 378
2158 LR Buitenkaag
The Netherlands

T: +31 252544896
M: +31 620347088
E: gfrer@luna.nl

Those who would give up essential Liberty, to purchase a little temporary
Safety, deserve neither Liberty nor Safety. Benjamin Franklin 11 Nov 1755

9

In the US, in primary care, we used large, normal, and pediatric.

Ed

10

Medicine is not an exact science in many ways!! Different names, different brands etc as Gerard points out. Presumably there is not a BP bladder sizing standard.

Based on the feedback last year on this topic I had enhanced the BP archetype. One of the provided references defined a cuff name with an approximate bladder size for the cuff which seemed to make good sense to me – see attached.

In protocol the cuff options are included as internal codes with ‘nominal names’ and the explanation (try double clicking on each cuff entry) includes the bladder size. I remember someone else objecting to ‘Standard Adult’ – so now we have Small Adult, Adult and Large Adult – with ‘Adult’ being the usual/standard size available, I guess.

I thought this was a pragmatic way to give a reasonable choice on cuff size.

Finger is not currently available as a location – I have had mixed advice about its use. However if there are people out there taking their blood pressure with a home system on their finger then we should be capturing that data, and should add it – and avoid getting into the advisability of taking a BP from a finger reading argument. Also will allow Melvin to use an infant cuff on the finger if he wants!

Cheers

Heather

(attachments)

openEHR-EHR-OBSERVATION.blood_pressure.v3draft.adl (22.6 KB)

11

Hi Heather.

Happy New year and the best wishes for a great 2008

Finger is not currently available as a location – I have had mixed advice about its use.

I’m not aware of a finger cuff, but there are certainly pulse cuffs and these are widely used when it comes to ‘home measurements’. Please also add pulse to the location of measurement. In that respect: it also might be of interest to now whether it is measured at the left or at the right side of the body. For plain arm BP measurements le/ri differences are well known, so it’s necessary to be able to discriminate between them

Why do you talk about ‘adult thigh’ at one hand and ‘large adult’ at the other. If one visually see this in a pop-up choose box it might be handier to put adult in front all the time, so it becomes easier to see all of the variables at once:

adult (normal)
adult large
adult small
adult thigh

It might also be wise, as Gerard suggested, to put the cm range behind it, so to be able to discriminate between cuff sizes on a more ‘scientific ground’.

While thinking about it: what is the purpose off these different cuff sizes? IMO it is to make sure that the cuff fits well and is not to loose and not to tight. So might it not be better to add another parameter: Cuff fits well y/n. This seems the only parameter (with regard to cuff size) that is relevant in order to asses if the measurement is performed correctly
This also solves the issue brought up by Melvin if one uses a neonatal cuff to measure BP at a finger:-). As long as the cuff fits properly that is possible (provided that BP measured at a finger in itself is reliable)

What is the difference between a pediatric/child and a infant cuff?

Cheers,

Stef

12

In a message dated 4-1-2008 19:37:18 W. Europe Standard Time, melvin_r@amsc.demon.co.uk writes:

The snag, in use, is that a neonatal arm cuff works nicely on an adult
finger, an adult thigh cuff equally nicely on a large adult arm, etc.

So, in order to be sure that the clinical focus is adequately fulfilled,
it may be necessary (perhaps only by exception) to drill back to
operational data that provides, site of measurement, weight /age of
patient at time of measurement, measurement technology used
(oscillometric, doppler, auscultatory,…), etc.

Melvin, I agree with this, … however, you are now moving from the BP archetype to the template for a specific purpose of drilling back to operational data and combining different archetypes.

Sincerely yours,

dr. William TF Goossen
director
Results 4 Care b.v.
De Stinse 15
3823 VM Amersfoort
email: Results4Care@cs.com
phone + 31654614458
fax +3133 2570169
Dutch Chamber of Commerce number: 32121206

13

Hi Heather,

I agree with most of your comments except the following:

In a message dated 5-1-2008 4:59:53 W. Europe Standard Time, heather.leslie@oceaninformatics.com writes:

and avoid getting into the advisability of taking a BP from a finger reading argument.

I do not think we should avoid this. In the Dutch care information models / detailed clinical models, content areas as indication for doing, proper instructions in use (to avoid the confounders as much as possible), and interpretations of values against a specific context of use are considered important parts beside the variable, datatype, coding, cardinality, algorithm and so on of the technical description. These are to me additional functional requirements for the archetype editor (s).

Sincerely yours,

dr. William TF Goossen
director
Results 4 Care b.v.
De Stinse 15
3823 VM Amersfoort
email: Results4Care@cs.com
phone + 31654614458
fax +3133 2570169
Dutch Chamber of Commerce number: 32121206

14

Hi

I think we are missing a point here and drifting away from the main purpose.

  1. I am not aware of any clinician or any incidence in clinical practice of the cuff size being recorded in ‘mm, cm, m, dm, hm, km’

  2. The importance of the cuff size is to know whether the BP was measured using an appropriate size cuff for that particular individual.

  3. The sizes such as Adult, paediatric etc should refer not to the size in units but with reference to the population/country that it is used in.

  4. eg. For an adult pygmy having his blood pressured measured in Pygmyland would require an adult (pygmy) size cuff for appropriate recording.

A paediatric pygmy would have his blood pressure measured using a paediatric (pygmy) sized cuff.

However, if the pygmy was having his pressure measured in Dutchland or UK the appropriate sized cuff would probably a paediatric (UK) or a young adult(UK) size.

What I am trying to emphasize here is that the recording the cuff size as Adult, paediatric etc sholud be qualitative rather than quantitative.

Regards

Jag

Dr.S.Jagannathan

15

Dear all,

-1-
Medicine is an art.
An art practiced by people.
Using imprecise language to document complex processes.

-2-
The EHR is there to document what needs to be documented.
For now and later.
For here and there.
For us and them.

-3-
Points 1 and 2 describe the problem of semantic interoperability:
The semantic interoperability needs a scientific rigor.
People need semantic freedom to document their art in their community.

Semantic Interoperability demands that we are as precise as we can be,
as language, culture, independent as we can be.
So when we record a size,
we record a size and use international units of measurements.

In Templates the esteemed healthcare providers must be able to attach any name to any size (range).
The main thing is that size is expressed in units of measurement what ever the local name people want to use.

Creating semantic interoperability in diverse cultures is only possible as long as we use the real universal scientific meaning for things and allow, as one of the facets of the thing, as many display names as local communities need.

-4-
Things (measuring devices in this case) have characteristics.
Physical characteristics and non-physical characteristics.
In Archetypes and Templates we must be able to record all of the relevant ones.
Physical things are expressed in physical measurements. Each of these physical measurements will have different names in each culture, language, etc.
Non-Physical things are names for the manufacturer, importer. etc

People use things and give it intention.
By itself things have no intention.
Therefor to use in a list, describing physical characteristics of a thing, we can not include the subjective (human) intentions.

When people give physical things a subjective context dependent name they are free to do this.
Semantic interoperability demands that irrespective of the subjective name we use for physical things we use objective physical things to characterize it unequivocally.

-5-
Archetypes are the essential artifacts that provide stable long term culture, language, geography, temporal, inflexible, independent way to make possible real semantic interoperability between IT-systems that are used by humans for documentation.
Templates are the essential artifacts that provide the unstable, short and long term, culture, language, geography, temporal, very flexible and very dependent way to make in a human way co-operability possible between humans using IT-systems for documentation.

-6-
We must study the work of Ontologists like Barry Smith.
They describe two types of Upper Ontology.
SNAP and SPAN.
http://tinyurl.com/3xdtmx

SNAP and SPAN
stocks and flows
commodities and services
product and process

anatomy and physiology

SNAP and SPAN **SNAP entities** - have continuous existence in time - preserve their identity through change - exist *in toto* if they exist at all **SPAN entities** - have temporal parts - unfold themselves phase by phase - exist only in their phases/stages

Physical things and their characteristics are SNAP.
The way we name them, group them, are SPAN.

-7-
Conclusions
Archetypes must be as precise and scientific as possible.
Archetypes sometimes describe physical things.
Archetypes sometimes describe process things like diagnosis.
Templates must be as imprecise and unscientific as human co-operation demands.
Templates express the human condition building upon the precise and scientific Archetypes.

Archetypes describing physical things in a physical way are SNAP
Archetypes describing process related things are SPAN.
Templates are always SPAN but composed of SPAN and SNAP parts.

Gerard

– –
Gerard Freriks, MD
Huigsloterdijk 378
2158 LR Buitenkaag
The Netherlands

T: +31 252544896
M: +31 620347088
E: gfrer@luna.nl

Those who would give up essential Liberty, to purchase a little temporary
Safety, deserve neither Liberty nor Safety. Benjamin Franklin 11 Nov 1755

16

Hear, hear…

Stef

17

Perhaps measurement of BP is one of the most inexact measurements in medicine.

http://www.nhlbi.nih.gov/health/prof/heart/hbp/bpmeasu.pdf refers to many of the
standards and gives links to other sources.

David de Bhal