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Under Pressure: Practical blood pressure assessment and management.

Blood pressure monitoring is a vital part of patient care, unfortunately, many veterinary practices still don’t routinely monitor blood pressure and if they do they don’t have an in-house protocol to treat their findings. It is the veterinary nurse who needs to drive its routine use forwards to improve patient care and outcomes.

Blood pressure monitoring and hypotension during anaesthesia

General anaesthesia is a common procedure, performed on a daily basis in general small animal practice. During anaesthesia our aim should be to maintain our patients as close to their physiological normal as possible.

 Hypotension is reportedly one of the most common complications associated with general anaesthesia in dogs and cats occurring in about 22% of anaesthetised cats and 33% of anaesthetised dogs (Wagner2006).

Too frequently, however, hypotension, hypoperfusion, and potential end-organ damage are not recognised in anesthetised patients as a result of the unavailability or underutilisation of monitoring equipment, improper use of that equipment, or failure to recognise limitations in its technology.

Blood pressure monitoring is now far more achievable with the wide variety of monitoring systems available.  Making sure values are accurate and knowing what the numbers mean will enable the veterinary team to assess hypotension during the intraoperative phase; prevent it occurring or worsening and treating as necessary.

What is blood pressure?

Blood Pressure (BP) is the pressure exerted by blood on the wall of a blood vessel. BP is made up of a systolic and diastolic component. Systolic pressure is created at the end of the cardiac cycle when the ventricles are contracting and the pressure in the arteries are at its highest. Diastolic pressure is when the ventricles are relaxing and the pressure is at its lowest at the beginning of each cardiac cycle.

Arterial blood pressure is the product of systemic vascular resistance (SVR) and cardiac output (CO) (Ettinger and Feldman, 2005) and this is the driving force behind tissue oxygenation.  By multiplying the SVR and CO together you get an estimation of BP.

Systemic vascular resistance (SVR) is the resistance that blood "sees" as it travels throughout the circulatory system of the body and reflects the degree of peripheral resistance by assessing the degree of dilation (vasodilation) or constriction (vasoconstriction) of the systemic blood vessels.

Cardiac output (CO) is the amount of blood pumped by the heart over a given time period and is the product of two separate components:

  • Stroke volume (SV) - the amount of blood pumped by the left ventricle of the heart in one contraction.
  • Heart rate (HR) - the number of heartbeats occurring within a minute

As the stroke volume increases, so does the cardiac output. Over time if the heart has been required to work harder for a longer period of time a plateau is reached and further increases in HR will result in a decrease in CO (Ettinger and Feldman, 2005) 

The components of blood pressure

When we break down the components that make up blood pressure we can see that stroke volume (SV) is made up of three parts:

  1. Cardiac preload – the force acting to stretch the ventricle fibres at the end of diastole and is estimated to be the volume of blood in the ventricle at the end of diastole and therefore represents the blood volume remaining in the heart after contraction.
  2. Cardiac contractility – the strength or ability of the heart to contract.
  3. Cardiac afterload – is the resistance against the vasculature which the left ventricle must overcome for blood to leave the heart during contraction.

Cardiac output not only represents the amount of blood pumped by the heart over a given time period but is also a specific component to how oxygen is delivered to tissues. The delivery of oxygen to the tissues is determined by the cardiac output and how much oxygen is in the arteries. 

Defects in any of the components of blood pressure can lead to a reduction in overall BP, decreased systemic oxygen to the tissues (hypoxia) and systemic hypoperfusion.

Why monitor blood pressure under anaesthesia?

Hypotension during anaesthesia can occur in any anaesthetised patient, no matter what the age, health status or drugs used.

Arterial blood pressure gives us information on our patient’s cardiac output and tissue perfusion. During anaesthesia we should monitor trends in a graphical format. Regular BP monitoring throughout the whole anaesthetic process can indicate anaesthetic depth, give us information on volume status and pain response.

What is hypotension?

Blood pressure is measured in millimetres of mercury (mmHg).  Normal arterial blood pressure is approximately 120/80 mmHg, with the normal mean arterial pressure between 70-90 mmHg.

Hypotension is defined as a systolic blood pressure (SBP) less than 90mmHg or a mean arterial pressure (MAP) less than 60mmHg. General opinion suggests that during anaesthesia, systolic arterial pressure should be maintained above 90mmHg and mean above 60 mmHg in order to ensure sufficient tissue perfusion for the brain, kidneys and heart.

Causes of hypotension

During anaesthesia, the most common cause of hypotension is excessive anaesthetic depth.  Many anaesthetic drugs, particularly the inhaled anaesthetics isoflurane, and sevoflurane, tend to reduce arterial blood pressure as a result of decreased cardiac contractility and vasodilation (Mutoh, 1997). Other causes include hypovolaemia due to intra-operative bleeding or pre-operative dehydration, hypothermia, hypoxia or decreased surgical stimulation.

Drugs such as acepromazine which is a long acting tranquiliser commonly used in small animal practice, may contribute to hypotension as it causes a vasodilation which can result in a reduction in systemic vascular resistance and for this reason is best avoided in critical and hypovolaemic patients.

What’s wrong with a low blood pressure?

If blood pressure is too low, certain vital organs (brain, kidney, heart) may not receive sufficient blood to meet their metabolic needs, and organ damage may occur, or, in rare cases, death may result.  Vital organs such as the brain and kidneys have the ability to adjust blood supply for their metabolic needs through autoregulation of their vascular beds. This autoregulation is effective only if the mean arterial blood pressure is between 60 and 160 mm Hg (Wagner2006). 

A mean arterial blood pressure (MAP) below 60mmHg (Systolic <90mmg) for over 30mins can lead to:

  • Renal failure
  • Delayed recovery
  • Neuromuscular complications
  • Decreased hepatic metabolism of drugs
  • CNS abnormalities such as blindness 

Dr Grauer, an expert on renal disease in animals, suggests that measuring arterial blood pressure during anaesthesia would help reduce the likelihood of renal ischemia (Grauer, 1996).

A study of anaesthetic management of people in the United States concluded that intraoperative hypotension was a significant predictor of increased mortality during the year after an anaesthetic episode, suggesting that "intraoperative anaesthetic management may affect outcomes over longer time periods than previously appreciated." (Monk, 2005).

How can we measure blood pressure?

Whilst we can make a crude assessment of blood pressure status by monitoring perfusion status through clinical hands on examinations, hypotension cannot be reliably detected without measuring blood pressure.  Simply feeling an animal’s pulse is not enough.  A strong, palpable pulse indicates only that difference between systolic and diastolic blood pressures, not necessarily that mean blood pressure, or blood flow to vital organs, is optimal, therefore during anaesthesia patients may have “normal pulses” whilst actually having a low blood pressure.

We have two methods of measuring blood pressure in our patients:

  • Direct (invasive) monitoring
  • Indirect (non – invasive) monitoring
    • Oscillometric
    • Doppler
    • High Definition Oscillometry (HDO)

While direct arterial blood pressure (DABP) measurement is considered the gold standard, it is technically demanding, as it requires placement of an arterial catheter and the use of a transducer and monitor.  The dorsal pedal artery is commonly used for catheter placement. DABP is recommended for critically ill patients or those that are at risk of developing major blood losses during surgery.

The Oscillometric method, involves placing a cuff around a limb or the tail and activating a machine that automatically inflates and deflates the cuff at programmed intervals. By sensing changes in oscillations of the arterial wall as the cuff is inflated and deflated, the monitor can determine blood pressure.  Oscillometric devices that were developed for humans may not work as efficiently as veterinary specific machines.

The Doppler ultrasonic flow detector and sphygmomanometer has a cuff and a Doppler ultrasonic crystal which must be placed over an artery to create an audible signal.  The reading is obtained when you manually inflate and then deflate the cuff, and watch the sphygmomanometer needle drop while listening for the return of pulse sounds, as pulse sounds return this is your systolic BP.

In one clinical study in dogs, sensitivity of Doppler BP for hypotension was around 67% and specificity was 87%, which gives us confidence in knowing that when the doppler is reading low the patient’s blood pressure is actually low and we should be doing something about it. It does however indicate that a normotensive reading especially if a borderline reading, may actually mean the patient is hypotensive (Bourazak & Hofmeister, 2018), which highlights the importance of being proactive to prevent hypotension.

There are a number of studies in anaesthetised cats that suggests that there is a large variability in doppler measurement accuracy (Cunha et al, 2014). Whilst not 100% accurate it should be used to monitor trends and proactively treat.

Whether using the oscillometric or Doppler method of blood pressure monitoring, cuff size selection is important. The length of the cuff doesn’t matter, but the width of the cuff should be 40% the circumference of the leg/tail.  

The cuff should be positioned level with the heart as arterial pressures will be grossly high if below the heart and low if above the heart. This can be particularly challenging in the anaesthetised patient who is positioned in dorsal recumbency so this is when monitoring trends becomes very important alongside your hands on observations.

High definition oscillometry (HDO) is a non- invasive blood pressure device which measures systolic, mean, diastolic pressures and heart rate. The data can be transferred straight to a computer and displays a real-time pulse wave.

Prevention and treatment of hypotension

In a patient experiencing hypotension during anaesthesia we should ask ourselves a series of questions so that we can initiate the correct treatment.

  • Are we using the correct size cuff and is it positioned correctly?
  • Is the depth of anaesthesia appropriate?
  • Is circulating blood volume adequate?
  • Is the patient normothermic?
  • Is the patient’s heart rate appropriate?
  • Is the patient excessively vasodilated?
  • Is there compromised myocardial contractility?

Please click here to download your useful Quick Reference Guide for the treatment of hypotension.


Blood pressure monitoring is a vital part of patient care, unfortunately, many veterinary practices still don’t routinely monitor blood pressure and if they do they don’t have an in-house protocol to treat their findings. It is the veterinary nurse who needs to drive its routine use forwards to improve patient care and outcomes.

Article by
Claire Roberts

Claire has been veterinary nursing for over 24 years her main interests include anaesthesia, ECC, patient care and infection control. In 2006 she gained the Diploma in Advanced Veterinary Nursing (Surgical) and in 2013 she gained the VN certificate in Emergency and Critical care. Claire went on to successfully pass the post graduate certificate in veterinary anaesthesia and analgesia in 2018.

In February 2020 Claire joined Linnaeus as Professional Development Manager alongside running her own CPD company called SynergyCPD which consists of a team of specialist nurses who provide bespoke in house CPD for the whole veterinary team. 

Originally published: Tuesday, 11th February 2020


Bourazak & Hofmeister (2018). Bias, sensitivity, and specificity of Doppler ultrasonic flow detector measurement of blood pressure for detecting and monitoring hypotension in anesthetized dogs. JAVMA. 253(11): 1433-1438.

Da Cunha AF, Saile K; Beaufrere H; Wolfson W; Seaton D; Acierno MJ (2014) Measuring level of agreement between values obtained by directly measured blood pressure and ultrasonic Doppler flow detector in cats. J Vet Emerg Crit Care. 24(3): 272-8. doi: 10.1111/vec.12161. Epub 2014 Apr 3.

Ettinger, S. J., & Feldman, E. C. (2005). Textbook of veterinary internal medicine (6th ed.). St. Louis, MO: Elsevier Saunders.

Grauer, G. F. (1996). Prevention of acute renal failure. Veterinary Clinics of North America: Small Animal Practice, 26: 1447–1459

Monk,T. G., Saini,V.,Weldon, B. C., & Sigl, J. L. (2005). Anesthetic management and one-year mortality after noncardiac surgery. Anesthesia and Analgesia, 100: 4–10.

Ramsay I (ed). (2014). BSAVA Small Animal Formulary 8th Edition. BSAVA, Gloucester, UK.

Wagner AE (2006). Anesthesia-related hypotension in small animal practice. Journal of Veterinary Medicine Series A. 01(1): 22-26  

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In this second article of the capnography series, James provides a guide to a few of the most common traces that you will encounter during surgery. Scroll to the end of the article to download a printable capnography cheatsheet. 

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Pain, what a Pain! (Part 2) – Practical Tips On How To Perform Dental Nerve Blocks In Companion Animal Practice

In this second article of the Pain, what a Pain! series, Dan takes us through the LRA techniques associated with dental and oral surgery. In this article, you will find practical tips and pictures on common dental nerve blocks as well as safety concerns to consider.

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​Peri-anaesthetic mortality and nonfatal gastrointestinal complications in pet rabbits

This recent retrospective study looks at the cases of 185 pet rabbits admitted for sedation or general anaesthetic and evaluates the incidence and risk factors contributing to peri-anaesthetic mortality and gastrointestinal complications.

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Pain, what a Pain! How Locoregional Anaesthesia can Improve the Outcome and Welfare of Veterinary Patients (Part 1)

In this first article out of a series of two, Dan takes us through an introduction and practical tips for appropriate local anaesthesia delivery. Find out why these anaesthesia techniques, that are well recognised in human medicine, have seen an increase in popularity in veterinary medicine over the recent years

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Perspectives on Premeds – Opioids

Perspectives on Premeds is a series of articles touching on different pharmacological, physiological and clinical aspects of pre-anaesthetic medication. This second article aims to provide a refresher on opioids.

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Effects of Dexmedetomidine with Different Opioid Combinations in Dogs

Read the highlights of a recently published research paper that evaluates cardiorespiratory, sedative and antinociceptive effects of dexmedetomidine alone and in combination with morphine, methadone, meperidine, butorphanol, nalbuphine and tramadol. 

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Preoxygenation Study Highlights

This study evaluates the effectiveness of two methods of preoxygenation in healthy yet sedated dogs and the impact of these methods on time taken to reach a predetermined haemoglobin desaturation point (haemoglobin saturation (SpO2) of 90%) during an experimentally induced period of apnoea.

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Capnography – Not Just a Load of Hot Air

Capnography is the measurement of inhaled and exhaled carbon dioxide (CO2) concentration. The graphical illustration of CO2 within respired gases versus times is known as the capnogram.

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Perspectives on Premeds – Alpha-2 Agonists

Perspectives on Premeds is a series of articles touching on different pharmacological, physiological and clinical aspects of pre-anaesthetic medication. This first article aims to provide a refresher on α2 agonists.

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Alfaxan - now licensed for use in pet rabbits

Jurox Animal Health is delighted to announce that Alfaxan is now licensed for cats, dogs and pet rabbits. This is an exciting advance and could change the way rabbits are anaesthetised in the U.K.

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