Performing an ABI Exam Using your Nicolet Versa

Performing an ABI Exam Using your Nicolet Versa. Lab®

Viewing the Presentation • At any time using your keyboard you can: • Press the “back” arrow to move back to the previous screen. • Press the “forward” arrow to move forward to the next screen. • Once the “forward” arrow is pressed, the presentation will resumes automatically. • Press the “Esc” key twice at any time to exit. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Choose Your Presentation This CD has two separate presentations: • You can view the presentation on operating your Versa. Lab. • You can view the presentation on how to perform an ABI exam using your Versa. Lab. • Or you can view both. • Click on the appropriate link above. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

A Quick Guide to Operating Your Versa. Lab Please see the Versa. Lab Operation

Using the Versa. Lab Control Panel © 2005 VIASYS Healthcare Inc. Performing an ABI

Using the Versa. Lab Control Panel ON/OFF FREEZE • Powers the system on if the unit is off, powers the system off, if it’s on. • Stops the scrolling action, causing the currently displayed waveform to remain on the screen until the FREEZE button is pressed again. • Moves the highlighted menu point up one selection. UP ARROW • If at the top item, it jumps to the bottom. • Selects the next higher value of the item selected. • In FREEZE mode, scrolls display forward 1/3 of the screen width. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Using the Versa. Lab Control Panel DOWN ARROW INVERT • Moves the highlighted menu point down one selection. • If at the bottom item, it jumps to the top. • Selects the next lower value of the item selected. • In FREEZE mode, scrolls display back 1/3 of the screen width. • Mirrors or “flips” the displayed waveform above or below the baseline, thus changing the displayed direction of flow. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Versa. Lab SE Waveforms Normal Inverted Note location of negative numbers. © 2005 VIASYS

Versa. Lab LE Waveforms Normal Inverted Note location of negative numbers. © 2005 VIASYS

Using the Versa. Lab Control Panel SCALE © 2005 VIASYS Healthcare Inc. • Controls the displayed and printed height of the waveform or trace. • Pressing repeatedly steps upward through all available SCALE settings. • To lower the scale, press SCALE repeatedly to cycle to correct setting. Performing an ABI Exam using Nicolet Versa. Lab

SCALE Setting The following waveforms demonstrate examples of incorrect SCALE setting. CLIPPING (Versa. Lab SE) CLIPPING (Versa. Lab LE) Problem: The waveform is being clipped or cut-off at the top or bottom edge of the screen, thereby underestimating values. The correct setting allows the entire waveform to be viewed within the screen display. Solution: Increase the SCALE setting to a higher number to achieve proper results. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Using the Versa. Lab Control Panel GAIN © 2005 VIASYS Healthcare Inc. • Controls the intensity/ darkness of the waveform. • Pressing repeatedly steps upward through all available GAIN settings (1 -5). • To lower the GAIN, press GAIN repeatedly to cycle through to the correct setting. Performing an ABI Exam using Nicolet Versa. Lab

GAIN Setting The following waveforms demonstrate examples of incorrect GAIN settings – GAIN TOO LOW Gain too low (Versa. Lab SE*) Gain too low (Versa. Lab LE) * Note lack of spectral information Problem: There is “drop-out” in the trace, allowing the trace to underestimate the true peak value. The trace should be smooth and uninterrupted. Solution: Increase the GAIN setting to a higher number to achieve proper results. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

GAIN Setting The following waveforms demonstrate examples of incorrect GAIN settings – GAIN TOO HIGH Gain Too High (Versa. Lab SE) Gain Too High (Versa. Lab LE) Problem: There are frequent “spikes” in the envelope trace allowing the trace to over-estimate the true peak value. The trace should be smooth and uninterrupted. Solution: Change the GAIN setting to a lower number to achieve the proper results. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

GAIN Setting Following Example: Demonstrates the GAIN set properly. Notice there is no spike or dropout in the traces. Gain Set Properly (Versa. Lab SE) Gain Set Properly (Versa. Lab LE) Note: SCALE is also set properly. The envelopes are smooth and uninterrupted, closely following the true peak values of the waveform. This shows a proper setting and no adjustment is needed. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Navigating the Versa. Lab Screen © 2005 VIASYS Healthcare Inc. Performing an ABI Exam

About the Versa. Lab Screen 1 – Scale Units Selection: KHz or cm/sec 2 – Date: US or Int’l format 3 – Time: 24 -hour based 4 – Menu: set date, time, screen contrast, etc. 5 – Envelope Setting (see slide 19) 6 – MM/S (millimeters per second): printout speed 7 – Probe: displays active probe 8 – Gain: cycles through settings 1 -5 (see slide 12) 9 – Angle (only in Velocity mode): shows the assumed angle of probe to vessel © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

About the Versa. Lab Screen 10 – Freeze Indicator: flashes when FREEZE is pressed 11 – Low battery Indicator: flashes when battery level is low 12 – Parameters: P. I. , R. I. , FMAX, FMIN, IWM. See Chapter 6, pg. 23 of the User’s Manual 13 – Time Markers: marks the number of seconds displayed on the screen 14 – Zero Baseline: indicates “zero” flow state 15 – Scale Units Measurement: changes height of displayed units of measure © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Set Envelope Changes the trace displayed from: - PEAK - MEAN - TOP - CMBD for Versa. Lab LE or - NONE for Versa. Lab SE See Operation Manual for more specific information on how envelopes are calculated. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

PEAK • Displays envelope at PEAK frequency above and below the baseline simultaneously. • Examples shown are the PEAK envelopes that follow the maximum velocities/ frequencies for flow in both directions toward and away from the probe. • Calculations are performed using both envelopes. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Peak Envelopes Versa. Lab SE Versa. Lab LE © 2005 VIASYS Healthcare Inc. Performing

MEAN • Examples shown are traces for the average frequencies/velocities of flow in directions toward and away from the probe. • Calculations are performed on both traces. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Mean Waveforms Versa. Lab SE Versa. Lab LE Note mean envelope is below the

TOP • The following examples are of the TOP envelope which only follows the PEAK velocities/frequencies displayed above the zero baseline. • Calculations are only performed on the trace data, and nothing below the baseline is calculated. Although displayed, flow below the baseline is ignored for calculations. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Top Envelopes Versa. Lab SE Versa. Lab LE © 2005 VIASYS Healthcare Inc. Performing

COMBINED -Versa. Lab LE ONLY • The following example shows the COMBINED (CMBD) trace mode. • This is the typical format of a “zero crossing” Doppler system. • All calculations are performed on this trace using components of both flow toward and flow away from the probe. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Combined Trace (Versa. Lab LE ONLY) © 2005 VIASYS Healthcare Inc. Performing an ABI

NONE (Versa. Lab SE Only) Spectral display has no envelope, and no calculations. ©

How To Display and Print a Waveform (#1) • Turn system on. • Make sure the appropriate frequency probe is connected and activated. • Apply ultrasound gel to the tip of the probe. • Place the probe over the vessel to be examined. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

How To Display and Print a Waveform (#2) • Angle the probe at 45 to 60 degrees to the vessel. • Make small position adjustments until a flow signal is heard. • Optimize the probe position for the loudest possible signal. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

How To Display and Print a Waveform (#3) • Look at the color display or waveform trace on the screen. • Use the GAIN key. • Optimize the signal so a smooth Doppler waveform trace is displayed. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

How To Display and Print a Waveform (#4) • The best waveform is obtained when the GAIN is set to provide a small amount of red in the spectral waveform (SE model only). • Or the waveform trace is smooth and uninterrupted (LE model only). © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

How To Display and Print a Waveform (#5) • Look at the color display or waveform trace on the screen. • If the waveform is “clipping” or going off the screen use the SCALE key. • Select a setting that displays the entire waveform/trace on the screen. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

How To Display and Print a Waveform (#6) • Use the INVERT key if it is necessary to change the orientation of the waveform/trace on the display. • Select FREEZE to temporarily stop the image. • When in FREEZE mode, use the DOWN ARROW key to scroll back to previous screens. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

How To Display and Print a Waveform (#7) • Use the UP ARROW key to scroll forward to more recent screens. • To print the currently displayed data, press the PRINT button. • Or simply select PRINT to stop the image. • Make a printout. • Resume scrolling. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

The ABI Exam • The Ankle/Brachial Index (ABI) is a systolic blood pressure comparison between the arms and ankles. • This procedure is similar to taking a standard blood pressure, but the Doppler on the Nicolet Versa. Lab is used to listen to blood flow instead of a stethoscope. In addition, a printout can be obtained. • You will only need to determine the systolic pressures for this simple procedure. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Why Do an ABI Exam? • It is a fast, effective tool for screening for Peripheral Arterial Disease (PAD), a potentially life threatening disease. • It is non-invasive, simple and inexpensive. • Obtaining an ABI is recommended for any patient with the following risk factors: • 65+ years old • diabetic • high blood pressure • overweight • inactive or bedridden • high cholesterol • family history of heart attack or stroke © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

When an ABI Exam Should Not be Performed • A blood pressure should not be taken on a patient where it would be medically contraindicated. • If you have any questions regarding whether or not an ABI should be performed, please consult a physician before proceeding. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

When an ABI Exam Cannot be Performed • In some patients, ankle pressures may not be obtainable due to calcified (hardened) arteries. • In these patients, even high cuff pressures will not be able to stop the blood flow. • The ABI will not be diagnostic in these cases. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

What You’ll Need to Perform the ABI Exam • Nicolet Versa. Lab w/ 8 MHz probe • Ultrasound gel • Proper size cuffs • Sphygmomanometer • Pen, paper and Nicolet ABI chart © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Choose Proper Cuffs • The AHA recommends the cuff bladder size be 20% wider than the limb diameter. • Generally, a 10 cm cuff is fine for use at both the ankle and arm sites. • Use a 12 cm cuff for patients with larger limbs or a 6. 5 cm cuff for smaller limbs. Be sure to use the same size cuffs on both the arms and ankles. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Obtaining Brachial Pressures (#1) • Have the patient lie supine for a few minutes prior to test. • Feet should be bare (but kept warm), with access to the ankles. • Place the appropriate size blood pressure cuff about midway up the patient’s upper arm above the elbow. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Obtaining Brachial Pressures (#2) • Attach the sphygmomanometer. • Place ultrasound gel at the right arm brachial location. • Hold the probe like a pen or pencil, angling it so it points up the patient’s arm. Typically the angle will be 45 -60 degrees. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Obtaining Brachial Pressures (#3) • To steady the probe, you may choose to rest your hand on the patient’s arm. • Slowly move the probe across the brachial area until the pulsating, “whooshing” sound of the artery is heard. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Distinguish Arterial Sounds • It is very important to distinguish arterial from venous sounds. • Arterial sounds: – are synchronized with every heartbeat. – have a rhythmic “whooshing” sound. • Make sure that you always use an artery to take blood pressures! Please note: If this computer has sound capabilities, you should hear an arterial sound using Doppler. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Distinguish Venous Sounds • It is very important to distinguish venous from arterial sounds. • Venous sounds are significantly different from arterial sounds, they: - are spontaneous and vary with respiration. - sound like the wind blowing through the trees. • Make sure that you always use an artery to take blood pressures! Please note: If this computer has sound capabilities, you should hear a venous sound using Doppler. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Obtaining Brachial Pressures (#4) • Once you find an arterial sound, adjust the probe to find the loudest possible signal. • Hold this position and signal for the rest of the procedure. • Now is a good time to print a waveform. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Sample Brachial Waveforms Waveform with Spectral Analysis. Simple Waveform Trace Example. Note smooth, uninterrupted pulsatile trace. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Obtaining Brachial Pressures (#5) • Begin inflating the blood pressure cuff by squeezing the bulb of the sphygmomanometer repeatedly. • Continue inflating, the flow sound will cease as the cuff pressure stops the blood flow. • Stop inflating at about 10 - 20 mm. Hg past this point. Note: If this computer has sound, you should hear the sound of arterial blood flow stopping as cuff pressure increases. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Obtaining Brachial Pressures (#6) • Slowly deflate the cuff using the red trigger until the sound returns. • At the point the sound returns, note the location of the gauge needle. That is the arm’s systolic pressure. • Quickly deflate the blood pressure cuff to 0 mm. Hg. Note: If this computer has sound, you should hear the sound of the arterial blood flow returning as cuff pressure is reduced. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Sample Waveform of Returning Flow • If desired, press PRINT on the Versa. Lab for a waveform print out. • Shown at right: Example waveform of returning blood flow using Versa. Lab SE. Waveform With Spectral Analysis © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Recording Pressures • Record the pressure on your Nicolet ABI report form shown at the right or on the Versa. Lab printout. • We recommend attaching the printout to the back of the ABI form. • Repeat the procedure for the other arm. ABI Report Form (Catalog #ABI 12) © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Obtaining Ankle Pressures (#1) • Use the same size cuff that was used for the arm. • Wrap the cuff snugly around the patient’s ankle, just above the foot. • Attach the sphygmomanometer. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Obtaining Ankle Pressures (#2) • There are two locations suitable for obtaining the ankle pressure: either the posterior tibial artery or the dorsalis pedis artery. • Most clinicians try the posterior tibial (PT) artery first. • If you cannot find a good signal, use the dorsalis pedis (DP) artery. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Obtaining Ankle Pressures (#3) • Place gel at the posterior tibial or the dorsalis pedis artery. • Have the patient rotate their ankle outward. • Hold the probe like a pen or pencil, angling it 4560 degrees and pointing up the patient’s leg. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Using the Posterior Tibial Artery • To take an ankle pressure using the posterior tibial artery, position the probe tip just behind the ankle bone. You may choose to rest your hand on the patient’s leg to steady the probe. • Slowly move the probe around the ankle’s center point under the ankle bone. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Using the Dorsalis Pedis Artery • To take an ankle pressure using the dorsalis pedis artery, position the probe on top of the foot in between the big toe and second toe, and halfway up the foot. • Press lightly because this artery can be easily compressed against the bone, stopping the flow of blood. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Obtaining Ankle Pressures (#4) • Very slowly move the probe across the dorsalis pedis or posterior tibial until the pulsating sound of the artery is heard. • Once you find an arterial sound, adjust the probe to find the loudest possible signal. • Hold this position and Doppler signal for the rest of the procedure. • Now is a good time to print a waveform, if desired. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Sample Ankle Waveforms Versa. Lab SE Waveform With Spectral Analysis. Versa. Lab LE Simple Waveform Trace. Note smooth uninterrupted pulsatile trace. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Obtaining Ankle Pressures (#5) • Begin inflating the blood pressure cuff by squeezing the sphygmomanometer bulb. • Continue inflating, the flow sound will cease as the cuff pressure stops the blood flow. • Stop inflating 10 -20 mm. Hg past this point. Note: If this computer has sound, you should hear the sounds of arterial blood flow stopping as cuff pressure increases. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Obtaining Ankle Pressures (#6) • Now slowly deflate the cuff until the sound returns. • Note the location of the gauge needle at the point the sound returns. That is the ankle’s systolic pressure. • Quickly deflate the blood pressure cuff to 0 mm. Hg. Note: If this computer has sound, you should hear the sounds of the arterial blood flow returning as cuff pressure is reduced. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Obtaining Ankle Pressures (#7) • If desired, press the PRINT button on the Versa. Lab for a waveform print out. • Record the pressure on your Nicolet ABI report form or the Versa. Lab printout. • We recommend attaching the printout to the back of the ABI form. • Repeat the procedure for the other ankle. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Calculating the ABI • Select the highest brachial value and use that number in determining the ABI for both the right and left sides. • If values for both ankle sites are obtained (DP and PT), use the highest value for the index. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Calculating the Right Side ABI (#1) • In the left column of the ABI chart, find the brachial pressure closest to the one you selected. • Then in the row at the top of the ABI chart, find the closest right ankle pressure. • The box where the column and row intersect shows the Ankle/Brachial Index for the right side. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Calculating the Right Side ABI (#2) • Or using a calculator, divide the pressure for the right ankle by the highest brachial pressure. • Right Ankle Pressure Highest Brachial Pressure = Right ABI © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Calculating the Left Side ABI (#1) • In the left column of the ABI chart, find the brachial pressure closest to the one you selected. • Then in the row at the top of the ABI chart, find the closest left ankle pressure. • The box where the column and row intersect shows the Ankle/Brachial Index for the left side. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Calculating the Left Side ABI (#2) • Or using a calculator, divide the pressure for the left ankle by the highest brachial pressure. • Left Ankle Pressure Highest Brachial Pressure = Left ABI © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

ABI Results Determine the severity of disease: • • ABI Value* Indication 0. 96 or Above 0. 81 - 0. 95 0. 51 - 0. 80 0. 31 - 0. 50 Generally Normal Mild Disease Moderate to Severe Disease • 0. 30 or below * Always use the highest ABI value obtained. Daigle, R. J. , BA, RVT. Techniques in Noninvasive Vascular Diagnosis. Summer Publishing, 2002. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

Important Tips to Remember • The patient should be supine for a few minutes prior to the test, warm and comfortable. • Hold the probe at an angle like a pen or pencil. This will be 45 -60 degrees. • Steady your hand on the patient. Practice holding the probe steady to maintain a good signal while you inflate and deflate the cuff. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab

More Tips • Move the probe slowly until you hear an arterial sound, then stop and slowly “fine tune” your position to obtain the clearest signal. • When the flow sound begins to disappear, keep the probe as steady as possible so you don’t lose the returning signal. • We recommend attaching the printouts to the ABI form. © 2005 VIASYS Healthcare Inc. Performing an ABI Exam using Nicolet Versa. Lab