(p. 608) Blood pressure monitoring in the ICU 

Two major systems are available for measuring blood pressure (BP)—the indirect cuff method and direct arterial cannulation. In critically-ill patients admitted to the intensive care unit, the invasive blood pressure is the ‘gold standard’ as a tight control of BP values, and its change over time is important for choosing therapies and drugs titration. Since artefacts due to the inappropriate dynamic responses of the fluid-filled monitoring systems may lead to clinically relevant differences between actual and displayed pressure values, before considering the BP value shown as reliable, the critical care giver should carefully evaluate the presence/absence of artefacts (over- or under-damping/resonance). After the arterial pressure waveform quality has been verified, the observation of each component of the arterial wave (systolic upstroke, peak, systolic decline, small pulse of reflected pressure waves, dicrotic notch) may provide a number of useful haemodynamic information. In fact, changes in the arterial pulse contour are due the interaction between the heart beat and the whole vascular properties. Vasoconstriction, vasodilatation, shock states (cardiogenic, hypovolaemic, distributive, obstructive), valve diseases (aortic stenosis, aortic regurgitation), ventricular dysfunction, cardiac tamponade are associated with particular arterial waveform characteristics that may suggest to the physician underlying condition that could be necessary to investigate properly. Finally, the effects of positive-pressure mechanical ventilation on heart–lung interaction, may suggest the existence of an absolute or relative hypovolaemia by means of the so-called dynamic indices of fluid responsiveness.