In early summer 2006, SPN held its first Best Practices Essay Contest to recognize the best practices

of SPN members and share best practices with all SPN members. The top seven essays will be published in SPN News over the next year. The essay printed here tied for first place.

Using Four Limb Blood Pressures as a Screening Tool in Normal Newborns

Ivy Razmus, MSN, RN Lynette Lewis, BSN, RN Saint Francis Health System, Tulsa, OK In our journey to nursing excellence, our institution launched unit based councils (UBC). Each UBC discusses practice issues and ways to improve care in the department that each represents. Our newborn nursery staff asked the question: Why are we doing 4-limb blood pressures? Do they really pick up coarctation of the aorta? Is there a better method of assessment in picking up this heart defect? Nursing started to do 4-limb blood pressures as an assessment tool when a heart defect was suspected, it then became a standard of practice. Obtaining 4-limb blood pressures is labor intensive, and in our experience, was not the integral component leading to further intervention and testing to rule out a heart defect. In order to make a cardiac diagnosis, a cardiac echocardiogram with a cardiology consult was necessary. This essay illustrates the process that changed our practice based on the evidence or lack thereof. Coarctation of the aorta (COA) is narrowing of the aorta close to the junction of the left subclavian artery. This is thought to cause increased blood pressure in the arms and decreased blood pressure in the legs. Many infants initially gain weight and thrive; however, as their patent ductus arteriosis narrows, clinical signs and symptoms emerge. Infants with COA may have completely normal examinations in the newborn nursery. The two-week well-child infant examination was found to be the most critical time to identify cardiac abnormalities (Taylor, 2005). At this time, most infants present with significant clinical distress as the coarctation places significant demands on the heart. Prior to the technological advances of the electronic blood pressure machine, obtaining cuff blood pressures on newborns and young pediatric patients was difficult and had questionable results. Nurses would attempt to palpate blood pressures on these patients, but accuracy was not well established and a crying infant or young child made it difficult to obtain a blood pressure. We were asking the question, Why are we doing this? because we were trying to move forward with family-centered care initiatives. Our nursery was very traditional and the structured routines worked well from an operations standpoint, but families didnt like hospital-induced separation from their babies. The newborn nursery looked at all current practices that took the baby away from the family and back to the nursery.

Park and Lee (1989) found that active neonates had increased blood pressure over quiet neonates. When you place a blood pressure cuff on a newborn infant or young child, he/she may become agitated and upset, making the process difficult and futile. When reviewing the literature, it was difficult to find evidence that supported using 4-limb blood pressures in the newborn nursery as a screening tool for the coarctation of the aorta. The most critical time for identification of coarctation of the aorta is between two days and two weeks after birth. Most well newborns are discharged from the hospital by 48 hours of age; however, one-half of the COA patients will develop symptoms before 14 days of life (Ward, Pryor, Matson, Razook, Thompson, & Elkins, 1990). There can be a difference of up to 20 mm HG in newborn blood pressures which could be due to random variability in measurement. Coarctation can only truly be excluded or confirmed by echocardiography (Crossland, Furness, Abu-Harb, Sadagopan, & Wren, 2004). Kunk and McCain (1996) found no significant differences between arm and calf systolic blood pressure on days of life one, three, and five, but there was a difference at day seven. Studying the difference between upper and lower extremities, Axton and colleagues (1995) compared differences between brachial and calf blood pressures in infants less than one year of age, and they concluded that there was no statistical difference between brachial or calf blood pressure measurements; however, they recommended that calf blood pressures only be compared to calf pressures and brachial pressures only be compared to brachial pressures. Blood pressures were also identical in neonates when comparing calf blood pressures to brachial blood pressures in a study by Park and Lee (1989), while Baker, Maisal, and Marks (1984) reported that blood pressures were virtually identical between calf and brachial pressure for low birth weight infants as well. Other studies found differences between upper and lower extremity blood pressure. Crapanzano and colleagues (1996) found that systolic blood pressure in the calf was significantly lower than systolic blood pressure in the arm and began exceeding it at 6 months of age. Short (2000) found that blood pressures in the leg of children 8 years and younger are significantly lower than those measured in the arm. There was a wide variability of blood pressure parameters in infants and children of all ages. Because of this, variable systolic blood pressures in the calf should be interpreted with caution when evaluating for coarctation of the aorta. University of Michigan Evidence Based Research Center finds pulse oximetry to be a useful method for screening for congenital heart disease. They recommend that if the SpO2 is less than 95, an echocardiogram should be ordered. Reich and colleagues (2000) recommend a pulse oximetry check before discharge for all normal newborns. Using pulse oximetry to detect congenital heart defects such as coarctation of the aorta can also reveal normal upper extremity oxygenation saturations with significantly lower values in the feet (Taylor, 2005). This may result in a significant number of false positives (<95%) of lower saturation and resulting in increased testing and associated costs (cardiac consult and echocardiogram), not to mention the increased emotional drain on parents who are worried their child has a heart defect.

An old assessment for coarctation of the aorta may be the most cost effective and least labor intensive of all strategies. Palpation of pulses demonstrate strong and full carotid, brachial, and radial pulses and weak or absent femoral, popliteal, dorsalis, and pedal pulses (Taylor, 2005). Clinical findings of particularly weak or absent femoral pulses should cause suspicion of coarctation of the aorta and prompt a referral to a cardiologist (Piazza et al. 1984). Ward and colleagues (1990) reported that there were absent femoral pulses or femoral/brachial discrepancies in 88% of the studied newborn patients with coarctation of the aorta. Other symptoms may include, but are not limited to, poor feedings and symptoms of metabolic acidosis. After the newborn nursery UBC identified the practice question, a literature search was initiated. The literature did not support routine 4-limb blood pressure measurements in all newborns. We also contacted other hospitals in the community, and they did not consistently obtain 4-limb blood pressures. Many did not even obtain one blood pressure. When best performers in our peer group were contacted, they did not routinely obtain 4-limb blood pressures, and a single blood pressure was not consistently measured on their newborns. This information was brought back to our Multidisciplinary Committee, and they reviewed the information and recommended neonatal and cardiology input. All committee members reviewed the literature and feedback from the sub-specialists. The Multidisciplinary Committee proposed doing a lower extremity pulse oximetry check just prior to discharge instead of 4-limb blood pressures. If there was a question of a heart defect, then the 4 extremity blood pressures could be obtained. In the final step of the approval process this proposal was brought forward to the various pediatric multidisciplinary committees and was approved through each committee. In the final committee there was an active debate among the members as to the use of blood pressures or pulse oximetry as a screening tool for coarctation of the aorta. They argued that the best assessment criteria in screening for coarctation is the palpation of a pulse or lack of pulse in the lower extremities. Currently, our assessment of the newborn includes palpation of lower extremity pulses on admission and throughout the hospital stay to help us identify newborn patients who are at risk. This is especially so since the most likely time that blood pressures would detect a coarctation is after discharge from the hospital from day 3 to day 14. In response to the committees recommendations, the UBC proposed doing 4-limb blood pressures and oximetry readings as a secondary screening when congenital heart problems are suspected or when there is an abnormal assessment with the lower extremity pulses. We do things for years because that is what we have always done. Questioning our practice is important in doing the best thing for the patient. With a nursing shortage, we need nurses to be involved in their practice and use their time and energy in worthwhile activities. Unless new evidence is available more is not better. The UBC provided a framework for shared decision making. This enabled the staff to partner with physicians, other disciplines, and the manager to keep decision making at the

bedside. Because there was not a sufficient research base to support the practice of 4limb blood pressures on all newborns, changes were made based on expert opinions, scientific principles, and recognized theory. Using palpation of lower extremity pulses appears to be a more effective method of assessment for coarctation of the aorta especially when you consider nursing resources and reliability of the methods. References Axton, S. E., Smith, L.F., Bertrand, S., Dye, E., & Liehr, P. (1995). Comparison of brachial and calf blood pressures in infants. Pediatric Nursing, 21(4), 323-326. Baker, M. D., Maisels, M.J., & Markes, K. H. (1984). Indirect BP monitoring in the newborn. Evaluation of a new oscillatometer and comparison of upper and lower limb measurements. American Journal of Diseases in Children, 138(8), 775-778. Campanzano, M.S., Strong, W. B., Newman, I.R., Hixson, R. L., Casal, D., & Linder, C. W. (1996). Calf blood pressure: Clinical implications and correlations with arm blood pressure in infant and young children. Pediatrics, 97(2), 220-224. Crossland, D. S., Furness, J. C., Abu-Harb, M., Sadagopan S. N., & Wren, C. (2004). Archives of Diseases in Children Fetal Neonatal Ed, 89(4), F325-F327. Kunk, R., & McCain, G. C. (1996). Comparison of upper arm and calf oscillometric blood pressure measurement in preterm infants. Journal of Perinatology, 16(2), 89-92. Park, M. K., & Lee, D. H. (1989). Normative arm and calf blood pressures in the newborn. Pediatrics, 83(2), 240-243. Piazza, S. F., Chandra, M., Harper, R. G., Sia, C. G., Vicar, M., & Huange, H., (1985). Upper-vs lower-limb systolic blood pressure in full-term normal newborns. American Journal of Diseases in Children, 139(8), 797-799. Reich, J. D, Miller, S. & Brogdon B., Casatelli, J., Gompf, T. C. & Sullivan, K. (2003). The use of pulse oximetry to detect congenital heart disease. Journal of Pediatrics, in infancy, 142(3):268-272. Short, J. A. (2000). Noninvasive blood pressure measurement in the upper and lower limbs of anesthetized children. Pediatric Anesthesia,10(6), 591-593. Taylor, M. L., (2005). Coarctation of the aorta: The critical catch for newborn wellbeing. Nurse Practitioner, 30(12), 34-43. Ward, K. E., Pryor, R. W., Matson, J. R., Razook, J. D., Thompson, W. M., & Elkins, R. C. (1990). Delayed detection of coarctation in infancy: Implication of timing of newborn follow-up. University of Michigan Department of Pediatrics Evidencebased Web site, 86(6).

Author Acknowledgment: The authors acknowledge the UBC members in this process: Angie Barton, Nicole Marth, Diana Dailey, Carol Moore, Fondra Crooms, Jeneen Bird, Denise McCullough, Shannon Filosa (director) and Julia Jackson (facilitator). It was through their inquiry and efforts that this practice change was initiated.