Perioperative Automated Noninvasive Blood Pressure- (NIBP-) Related Peripheral Nerve Injuries: An Anesthetist’s Dilemma—A Case Report and Review of the Literature

Abstract

Peripheral nerve injury following regional or general anesthesia is a relatively uncommon entity but, potentially, a serious complication of anesthesia. Most nerve injuries are related to either regional anesthesia or position-related complications, and they are rarely seen in association with the use of automated blood pressure monitoring. We describe a patient who developed neurological dysfunction of all the three major nerves, median, ulnar, and radial, after general anesthesia. The distribution of sensory motor deficit along with the nerve conduction study demonstrated the location of the anatomical nerve lesions coinciding with the automatic noninvasive blood pressure (NIBP) cuff. No other cause of nerve injury was identified except for the use of the NIBP cuff. In the absence of another identifiable cause, we strongly suspected the NIBP cuff compression as a possible cause for the nerve injuries. In this article, we will discuss the possible risk factors, mechanisms, diagnosis, and prevention of perioperative nerve injury.

Biceps muscle injury associated with non-invasive automatic blood pressure monitoring

“…There are two case reports of compartment syndrome due to excessive blood pressure cuff cycling, excessive pressure and improper cuff positioning 15 16. Multiple case reports have noted compressive nerve injuries following the use of automatic NIBP monitoring 3 17–21. The relationship between duration of compression and complications of cuff inflation has been better described in arterial tourniquets used during orthopaedic surgeries, where cuff inflation pressures can be up to 250 mm Hg for the upper arm and 300 mm Hg for the thigh for up to 2 hours 18.…”

Factors Associated with Variability in Pulse Wave Transit Time Using Pulse Oximetry: A Retrospective Study

“…Anesthesiologists can resolve this issue through manual assessments, which may however be subjective. Frequent measurements may also cause discomfort, trauma, and nerve injury to the patient [ 4 ].…”

“…The pulse wave propagates through the arterial vessel toward the peripheral measurement site, where it appears as a time delay (milliseconds). The length of the PWTT is directly proportional to the BP [ 4 ]. When blood volume is high or vessels are constricted, pulse waves travel faster because blood flow reaches the peripheral site with high speed.…”

Advances in Non-Invasive Blood Pressure Monitoring

“…Cuff measurements can be time consuming if taken manually, and placement can be critical to the accuracy of the results. Frequent use of cuff devices is uncomfortable and carries risk of complications such as damage to the skin (e.g., petechiae, acute dermis capillary rupture, or skin necrosis) or peripheral nerves (e.g., compressive neuropathy, crush syndrome, or nerve ischemia) [ 52 , 53 , 54 ]. Cuffs are also less accurate at children’s lower BP values [ 55 ].…”

“…However, they provide only intermittent BP data. Moreover, frequent use of cuff devices can cause skin or nerve damage [ 52 , 53 , 54 ]. Importantly, like conventional cuff-based methods, these devices lose accuracy when mean arterial pressure (MAP) is <30 mmHg [ 83 ], a level very common in sick neonates.…”