An Overview . . .

Measurement of blood pressure Cardiac output Cardiac rate Heart sound Respiratory rate Gas volume Flow rate of Co2, o2 in exhaust air pH of blood, ESR, GSR measurements Plethysmography.

Cardiac Output
It is the amount of blood delivered by the heart to the aorta per minute For normal adults it is 4 -6 litres / minute Any decrease may be due to Low Blood Pressure Reduced Tissue Oxygenation Poor Renal Function Shock Acidosis Methods of cardiac output measurements Ficks Method Indicator Dilution Method Measurement of Cardiac Output by Impedance Change

Ficks Method : Based on analysis of gas - keeping of the organism Cardiac output can be calculated by continuously infusing oxygen into the blood or removing it from the blood and measuring the amount of oxygen in the blood before and after its passage

Ficks Method for Cardiac Output Measurement

Oxygen uptake by Ventilation

Heart Catheter

Q2

Vena Cava

Aorta Q Heart and Lungs

Mixed Venous Blood

Arterial Blood

Let I be the amount of infused or removed oxygen per unit time It is equal to the difference between the amounts in the blood arriving at and departing from the site of measurement I = CAQ CVQ Q= I CA CV where Q cardiac output in litres / minute CA - Concentration of oxygen in the arterial blood in millilitres of oxygen per litre of blood CV - Concentration of oxygen in the mixed venous blood in millilitres of oxygen per litre of blood I - Volume of oxygen uptake by ventilation in millilitres of blood

Indicator Dilution Method Principle A known amount of dye or radioisotope is introduced as an indicator in the blood circulation The concentration of the indicator is measured with respect to time and the volume of blood flow is estimated Let M mg of an indicator be injected into a large vein or preferably into the right heart itself After passing through the right heart, lungs and the left heart, the indicator appears in the arterial circulation The presence of the indicator in the peripheral artery is detected by a detector The output of the detector is directly proportional to the concentration of the indicator

Let an increment volume dV pass through the sampling site in time dt Let the mass of the indicator in dV = dM

herefore the concentration of the indicator, c = dv dt Now But Therefore dM = c dV dt dt dV dt dM = Q = Q c dt

Integrating over the time of the experiment,

t

Q c dt

Considering the flow as constant,

t

M Q

= =

Q
0

c dt M

(or)

t 0

c dt

Here concentration of the indicator c is a function of time By drawing a curve between concentration and time, the area of the

curve gives directly the value of the denominator in the above equation Thus Q = M Area of the curve

Block Diagram of the Thermo Dilution System

Timer/Control

Linearity Amplifier Thermistor for Blood Temperature

Integrator

Linearising Amplifier

Microcomputer

Cardiac Output Display

Thermistor for Thermoindicator Temperature Preset Adjustment Control

 A bolus of about 10 millilitres of 5% Dextrose in water at room temperature is injected as a thermal indicator into the right atrium After mixing it is detected in the pulmonary artery by means of a thermistor mounted at the tip of a miniature catheter probe The temperature difference between the injectate temperature and the circulating temperature in the pulmonary artery is measured The reduction in temperature is integrated with respect to time After applying proper corrections, a meter reads the cardiac output

Cardiac Output Measurement by Impedance Method

Potential Electrodes

Oscillator f = 100kHz

A1

A2

S
Current Electrodes

Amplifier and Demodulator

Differentiator

 Electrodes 1 and 4 are used as current electrodes Electrodes 2 and 3 are used to pick up the voltage across the thorax

If

p - resistivity of the patients haematocrit A - cross sectional area of the thorax L - separation between the potential electrode 2

and 3 pL2 pL2 pL = = R= Then the resistance of the thorax is given by AL V A (or) V = pL2 R (V volume of the thorax)

During ejection of stroke volume, the change in volume is dV and the corresponding decreasing in resistances is dR Differentiating the above expression, dV = - pL2 R
2

dR

Since a.c. excitation is used, R should be replaced by impedance Z Therefore dV = - pL2 Z

2

dZ

Taking

dZ = t

dZ dt

max

where, dZ dt max corresponds to the peak negative value of

(dZ/dt) found during systole and t corresponds to the interval between (dZ/dt) = 0 and

the second heart sound

Thus

dV =

- pL2 Z
2

t.

dZ dt

max

 The voltage signal due to changes in impedance is amplified and demodulated to obtain impedance Z of the thorax The value of (dZ/dt) is calculated using a differentiator and its output is recorded on a recorder From that (dZ/dt)max can be noted By determining dV, the cardiac output can be measured by multiplying dV with heart rate per minute

Spirometer

Linkage o

L VOL

h kR

VBB

+ r VOUT Patient air into Bellows

Spirometer
Used for respiratory volume measurements All lung volumes and capacities can be measured Consists of light weight bellows These bellows are mechanically articulated to a biased potentiometer such that the wiper voltage is proportional to volume of the bellows The maximum volume of the bellows is given by VOLmax = L(Pi)r2 If k is the proportionality constant giving the fractional position of the wiper arm on the potentiometer R such that

k = Vout = VOL VBB VOLmax

Therefore

VOL = Vout (VOLmax) VBB

Better Linearity can be obtained in measuring respiratory volumes

Gas Analysers
Used to Determine the quantitative composition of inspired and expired gas Assess the lung function Types Infrared Gas Analyser based on infrared absorption of carbon dioxide Paramagnetic Oxygen Analyser - based on paramagnetic behaviour of oxygen Thermal Conductivity Gas Analyser based on thermal conductivity of carbon dioxide

Block Diagram of Infrared CO2 Analyzer

Mirror Infra red Source o Mirror

Sample Tube

Motor

Reference Tube

Sample Cell Detector Unit Diaphragm Amplifier

Panel Meter

Recorder

By means of mirror assembly two infrared beams with same intensity are produced A high speed rotating chopping disc is present which occludes each beam twice per motion

The chopped lights pass through the reference and sample tubes When the opaque portions of the choppers are not in the way, the beam falls on the balanced condenser microphone detector after passing the gas

The sample beam falling on the detector will be weaker than the reference beam since there is absorption in the sample cell by the component of interest

The heating of the gas in the detector situated in the reference beam side will cause rise in pressure

The diaphragm vibrates at the chopping frequency The diaphragm forms one half of the capacitor Thus, the change in position of the diaphragm produces a periodic change in the capacity of the capacitor

This change is amplified and demodulated and the output is displayed on a meter or a recorder in terms of concentration of the wanted component

Simplified Block Diagram of Oxygen Analyzer

SCALE

MIRROR

DUMB CELL

O2

 There is a small glass dumb cell shaped assembly containing a weakly diamagnetic gas such as nitrogen It is suspended from a platinum iridium thread between the poles of a powerful permanent magnet The pole pieces are wedge shaped in order to produce a non linear field If the gas surrounding the dumb shell is also nitrogen there will be no force acting on the dumb shell If oxygen is added to the gas, the oxygen molecules experience a force, displacing the diamagnetic dumb shell The resulting rotation of the suspension turns a small mirror and deflects a small beam of light over a scale calibrated in percentages by volume of oxygen or partial pressure of

Hot Wire Cell Thermal Conductivity Analyzer

Reference Gas Flow S1

Sample Gas Flow

R1

uA

S2

R
2

 There are four platinum filaments as heat sensing elements Each of these is placed in a brass black These are maintained at constant temperature and form the four arms of a bridge Two filaments R1 and R2 act as reference gas arms S1 and S2 act as sample gas arms Initially reference gas is made to flow through all the filament cells and the bridge is balanced When the sample gas flows through the sample gas filament cells, the temperature of the filaments in those cells are changed If the thermal conductivity of the sample gas is more, then cooling of the filaments takes place This changes the resistances of the filaments The bridge becomes unbalanced and a current flows through the meter

Digital pH Meter

-Er ( From Reference )

+ EIN ( From Solution ) Reference Electrode Electrical Conductor o YT -10 mV / oC From Temperature Sensor + + . VOUT Digital Voltmeter

Buffer Solution

Glass Membrane VOUT = Er EIN - YT Analyzed Solution

 Used to measure pH at a given temperature and also at different temperature Consists of a glass electrode terminal and reference terminal The calomel or silver silver chloride in potassium chloride electrolyte acts as the reference terminal A salt bridge consisting of a fiber wick saturated with KCl is at the tip of the reference electrode This keeps the reference terminal potential the same regardless of the solution under test The active terminal is sealed with common glass except for the tip The tip is made of sensitive glass consisting of hydrated gelatinous glass layer Its membrane potential is proportional to the pH of the solution under test

 The electronic circuitry is adopted to increase the sensitivity and accuracy It consists of an external reference voltage to compensate the various errors To determine the pH at different temperatures , a voltage from the temperature regulator circuit corresponding to a given temperature is also added with the output from pH electrode The operational amplifiers amplify these voltages in the required manner The final output is given to a digital voltmeter In the digital voltmeter the display is obtained in terms of pH as discrete numerals

Plethysmography
Used to measure the volume changes in any part of the body that result from the pulsations of blood occurring with each heart beat Used to measure Total Lung Capacity (TLC) Consists of a rigid cup or chamber placed over any part of the body in which the volume changes are to be measured The cup is tightly sealed The changes in the volume reflect the pressure changes of air inside the chamber The pressure change is measured at constant volume or vice versa

Types based on nature of sensor Capacitance Plethysmograph Impedance Plethysmograph Photoelectric Pltehysmograph Mercury Strain Gauge Plethysmograph

Measurement of Total Lung Capacity

The principle operation is the Boyles Law which states that at a Kelvin Temperature, the pressure of a given mass of gas is inversely proportional to its volume i.e. P * (VOL) = k1T where k1 is a constant

Since the patient is made to sit inside an air tight chamber whose

Partially Differentiating the above equation

d (P VOL)

(PVOL) P

dP

(PVOL) VOL

dVOL

(or)

VOL dP

+ dP dVOL

P dVOL P VOL

= -

Now the door of the air tight chamber is sealed with the patient inside and the valve on the mouthpiece is closed

The patient cannot breathe with the valve closed, so the air pressure in the mouthpiece is equal to the lung pressure PT In the body, d TLC d PT = TLC PT

where

TLC = Thorax Volume PT = Thorax Pressure VOLC PC

In the chamber,

d (VOLC) d PC

= -

where

VOLC = Chamber Volume PC = Chamber Pressure

Since the chamber is closed, any increase in the thoracic volume causes a decrease in the chamber volume of air , i.e. d (VOLC) TLC PT = - d (TLC) VOLC PC

d PT

= -

d PC

Since the changes in pressure induced by breathing motions are small when the patient is sitting normally, PC = PT Therefore TLC = - VOLC d PC d PT

Procedure First mouthpiece valve is closed when the patient is sitting inside the sealed chamber Now the patient is asked to make breathing motions The change in pressure reading in the pressure gauge 1 is noted down, this gives dPT The change in pressure reading in the pressure gauge 1 is noted down, this gives dPC Thus knowing the value of VOLC, the TLC can be calculated using the formula, TLC = VOLC d PC d PT

Blood Pressure
Blood pressure(BP) is aforceexerted by circulatingbloodon the walls ofblood vessels The termblood pressureusually refers to the pressure measured at a person'supper arm. For each heartbeat, BP varies between systolic and diastolic pressures. Systolic pressure is peak pressure in the arteries, which occurs near the end of thecardiac cyclewhen theventriclesare contracting. Diastolic pressure is minimum pressure in the arteries, which occurs near the beginning of the cardiac cycle when the ventricles are filled with blood. A person's BP is usually expressed in terms of the systolic pressure

Measurement
Noninvasive measurement Palpation method Auscultatory method Oscillometric method White-coat hypertension Home monitoring Invasive measurement

Auscultatory method
Uses astethoscopeand a sphygmomanometer Comprises an inflatable (Riva-Rocci)cuffplaced around the upperarmat roughly the same vertical height as the heart, attached to a mercury or aneroidmanometer The mercury manometer measures the height of a column of mercury giving an absolute result A cuff of appropriate size is fitted smoothly and snugly, then inflated manually by repeatedly squeezing a rubber bulb until the artery is completely occluded. Listening with the stethoscope to thebrachial arteryat theelbow, the examiner slowly releases the pressure in the cuff When blood just starts to flow in the artery, theturbulent flowcreates a "whooshing" or pounding (firstKorotkoff sound). The pressure at which this sound is first heard is the systolic BP. The cuff pressure is further released until no sound can be heard (fifth

Auscultatorymethod aneroid sphygmomanometer with stethoscope

Mercury manometer

Invasive measurement
Arterial blood pressure (BP) is most accurately measured invasively through anarterial line. Involves direct measurement of arterial pressure by placing a cannula needle in an artery (usuallyradial,femoral,dorsalis pedis orbrachial) The cannula must be connected to a sterile, fluid-filled system, which is connected to an electronic pressure transducer The advantage of this system is that pressure is constantly monitored beat-by-beat, and a waveform (a graph of pressure against time) can be displayed Regularly employed in human and veterinary intensive care medicine,anesthesiology, and for research purposes

Classification of blood pressure for adults

Category Hypotension Normal Prehypertension Stage1Hypertension Stage2Hypertension systolic,mmHg <90 90120 121139 140159 160 diastolic,mmHg <60 and6080 or8189 or9099 or100

Heart sounds
Theheart soundsare the noises (sound) generated by the beatingheart and the resultant flow of blood through it. In healthy adults, there are two normal heart sounds often described as aluband adub(ordup), that occur in sequence with each heart beat. These are produced by the closing of theAV valvesand semilunar valves respectively In addition to these normal sounds, a variety of other sounds may be present includingheart murmurs,adventitious sounds, andgallop rhythms Heart murmursare generated by turbulent flow of blood, which may occur inside or outside the heart. Abnormal murmurs can be caused bystenosisrestricting the opening of a heart valve, resulting in turbulence as blood flows through it. Abnormal murmurs may also occur with valvularinsufficiency which allows backflow of blood when the incompetent valve closes with only partial