European Journal of Cardiovascular Medicine

Non-invasive blood pressure monitoring is a standard ASA monitor used in Operation Theater for monitoring. Regardless of non-invasive in nature, frequent inflation of blood pressure cuff can cause petechial rash, venous stasis, thrombophlebitis, infection, rash, formation of hematoma in patient on blood thinners, compartment syndrome, nerve injury due to compression and skin necrosis.1 Reported literature for carpopedal spasm due to cycling of sphygmomanometer cuff are scarce. 

We are reporting a case of carpopedal spasm happened over right arm distal to the BP cuff during a routine OT procedure caused due to repeated cycling of NIBP used for monitoring. We briefly discussed about the carpopedal spasm and its management during perioperative period.

A thirty-eight-year-old woman weighing around 55 kg, BMI approximately 21 kg/m2 posted in urology OT for excision of urinary bladder cyst. The medical, surgical and personal history found to be insignificant. We ruled out history of any previous episodes of carpopedal spasm. Her laboratory examination was also within normal limits. Ultrasound finding showed a 4cm cyst arising from lateral wall of urinary bladder near to round ligament. On evaluation for pre-anesthetic checkup, patient was accepted under ASA grade 1. Baseline pulse of 72 bpm, blood pressure of 120 /80 mmHg and room air saturation was 99%. She was breathing comfortably and heart sounds were normal. She was advised for adequate fasting as per the standard guidelines. After explaining informed and written consent, patient shifted to Operation Theater.

Fig1 : Image showing carpopedal spasm of hand

The patient was prepared as per the standard ASA monitoring guidelines. On her right arm, an appropriate size BP cuff was placed above the elbow. Her BP monitoring was done at 3-minute interval following regional anesthesia and then changed to 5-minute cycling. Vital parameters were within normal range. Regional anesthesia was planned for the procedure. As per the institutional protocols, patient was prepared and a subarachnoid block was performed with 25 G quincke needle and 2.4 ml of 0.5% H bupivacaine was given. After achieving of adequate level of anesthesia, surgery was started in lithotomy.

Intra-operatively, as the cycling of NIBP started, patient had pain and spasmodic contraction in right arm in which BP cuff was wrapped. We suspected of hypo-calcemia by seeing the carpopedal spasm in right hand as showed in fig 1. We removed the BP cuff and injection calcium gluconate started for carpopedal spasm and pain was managed by giving injection Paracetamol (1gm). To rule out the causes, arterial blood gas analysis and calcium level was done and found to be inconclusive (Ca: 11 mg/dl). We checked the pulse volume clinically to look out for any episode of hypotension. Surgery was completed and patient was shifted to PACU for further observation.

Blood pressure (BP) is a vital sign and its monitoring is an essential part of medical care in OT. BP monitoring can be done either non-invasively with the help of a cuff-based oscillometric method or invasively by arterial line manometric measurement. As per the standardized protocol, BP monitoring is cycled intermittently roughly around 5 min. Invasive arterial line monitoring are typically used in ICU, critically ill patients and major surgeries with significant fluid shifts and blood loss.

Frequent measuring of NIBP monitoring can lead to serious problems. The Rumpel-Leede (RL) phenomenon is the appearance of petechial rash following application of continuous pressure on blood vessels such as by a tourniquet for 10 min or less. This was initially used in past to assess thrombocytopenia and capillary fragility related to diabetic microangiopathy. Jeon et al1 reported a case report in which petechiae occurred in patient due to vascular fragility and microangiopathy caused by DM and prolonged steroid supplementation. Prolonged hypoperfusion of the skin can lead to pressure necrosis. In critical ill patients with low cardiac output and critical hypoperfusion with the use of ionotropes and vasoconstrictors can cause potentially serious skin necrosis. Devbhandari et al Suggested to avoid tight girthing of BP cuff, avoid application of a BP cuff over prominent bony parts or superficial nerve, select the maximum cycle time, inspect periodically and alternated the cuff site; consider use of a thin layer of padding and keep device alarms enabled for proper use of NIBP devices.2 Neuropathies have been described after the use of arterial pressure measuring during the prolonged surgical procedures.3

Tetany is also another possibility with this case report. Tetany is characterized with wrist and ankle joints flexion (carpopedal spasm), muscle twitching, cramps and convulsions due to hyper excitability of nerves and muscles. Trousseau’s sign is positively seen with hypocalcemia which is observed as carpopedal spasm secondary to inflation of BP cuff to 20mmHg above systolic blood pressure.4 Various aetiology is described in the literature such as hypocalcemia, hypomagnesemia, hypokalemia, alkalosis, hyperventilation secondary to anxiety and malabsorption.5

Carpopedal spasm can be precipitated due to low calcium level. Hypocalcemia presents with nausea, perioral numbness, headache and carpopedal spasm. Carpopedal spasm is characterized by involuntary contractions of limbs. Hyperventilation due to anxiety, stress or fear can result in to respiratory alkalosis because of washing of carbon dioxide as an autonomic response. Dissociation of hydrogen ions from albumin which binds to free ionized calcium results in to decrease in serum calcium level by 0.05mmol/l for every 0.1 increase in pH.  As in this patient, cramping and pain precipitated with cycling of NIBP monitoring in spite of having normal serum calcium level.6,7 As NIBP monitoring is one of the essential vital sign we used during perioperative period to avoid any hypo-perfusion related events. As an anesthesiologist, we all should be aware about all these complications and should be vigilant during perioperative period. Through knowledge of complications and vigilance during perioperative period can helps us to avoid this devastating experience both for the patient and the clinician. In case of prolonged duration of surgery, another alternative approach for monitoring should be used. We can switch over the site of BP cuff alternatively on both arms as per the feasibility. Invasive arterial line can also be used as per the type of surgery. Invasive arterial line monitoring has its own complication and should be used cautiously especially in neonates, elderly and patient with peripheral vascular diseases.8

New modalities for NIBP such as Cuff-less devices also have been emerged for continuous beat to beat monitoring. Cuff-less devices used mechanical and optical sensors which help to determine transit time and contour of pulse, pulse wave velocity, or the acceleration pulse to extract BP values. In Arterial applanation tonometry, a pressure transducer placed at a pulsating point and tries to estimate the arterial wall tension and quantify the arterial pulse. Pyrames and Vena Vitals uses capacitive sensing mechanism to capture pulse waveform signals to derive BP values. Because of high sensitivity, it enables us to use it newborns and elderly patients where placement of invasive lines can be problematic because of fragile skin.9

NIBP is considered as a very safe monitoring tool commonly used during perioperative period. Certain population are prone to carpopedal spasm even with non-invasive monitoring. In these situations, anesthesiologist can use advance monitors as per the availability or clinically by palpation of pulse volume. Through knowledge of complications and vigilance during perioperative period can helps us to avoid them.

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