Sir, Relying solely on monitor readings for hemodynamic management can, at times, lead to catastrophic outcomes, especially if clinical correlation is overlooked. The aim of this letter is to illustrate how the erroneous readings of a routine-based system like noninvasive blood pressure (NIBP) can lead potential threat to patient’s life. A 39-year-old female with a history of right-sided metastatic breast carcinoma was scheduled for a total laparoscopic hysterectomy. She had a history of severe lower abdominal pain and menorrhagia and was diagnosed with uterine fibroids. During the preoperative evaluation, all routine investigations, including electrocardiogram and two-dimensional echocardiography, were within normal limits. Baseline vital signs were recorded as NIBP of 140/94 mmHg, heart rate (HR) of 88/min. Induction and intubation were uneventful. Postintubation vitals were recorded as NIBP of 112/80 mmHg, HR – 80/min, and end-tidal carbon dioxide of 40 mmHg. For the gynecological procedure, the patient was shifted down onto the operating table, and the arms were adducted alongside the body. Following positioning, a sudden and significant rise in NIBP was observed, reaching 210/110 mmHg. In response, the depth of anesthesia was increased using the volatile agent sevoflurane, along with administration of intravenous propofol and atracurium. However, the NIBP continued to rise, peaking at 220/177 mmHg. To manage the hypertensive response, 10 mg of intravenous esmolol was administered, and the endotracheal tube was refixed at 18 cm to rule out any airway-related stimuli. Despite these interventions, there was no significant change in the elevated NIBP. At this point, the senior consultant anesthetist was called to assess the situation. Noting that the HR remained stable at 82/min, identical to the preinduction value, and that pulse volume and rate on palpation were normal, the consultant suspected that the extremely high NIBP readings were erroneous. A new blood pressure (BP) cuff was applied, but no significant change in the readings was observed. The consultant then examined the positioning and draping of the patient and noticed that the arms, which had been adducted and tightly draped alongside the body, might be contributing to artefactual BP measurements Figure 1. On loosening and releasing the tightly secured arms, a repeat NIBP reading dropped to 89/50 mmHg, indicating hypotension. Subsequent NIBP readings continued to remain on the lower side, confirming the initial suspicion of inaccurate high readings due to improper cuff positioning and limb compression.Figure 1: Intraoperative image showing the patient’s arms adducted and tightly secured alongside the body using surgical drapes. Circle showing a wrong procedure was followedThis case highlights the importance of maintaining basic clinical vigilance, having a working understanding of monitoring technologies, and developing an awareness of both human and instrumental limitations in anesthesia care.1-3 The probable error in our case arose due to the oscillometric nature of NIBP monitoring, which can be compromised by external compression – such as a tightly tucked arm – leading to distorted or lost pressure oscillations.2-4 Anesthesia equipment plays a vital role in ensuring the safe conduct of anesthesia; however, equipment malfunction or erroneous readings can contribute significantly to patient morbidity and mortality.1-4 In addition, human errors–whether due to inexperience, oversight, or fatigue – can further compound these risks. In conclusion, vigilance helps detect unusual signs early, which might otherwise be missed. If a vital sign seems unreliable, findings should be cross-checked with other parameters and assessed quickly within the clinical context. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Balhara et al. (Sat,) studied this question.