NIBP Performance with the Advantage Module 2015 White Paper When potential customers evaluate the Advantage NIBP module with a view to develop manufacturing procedures or check the BP results, often an NIBP simulation or group of simulations are performed using an NIBP simulator. Some customers will ask for expected values. These values are dependent on several factors including the type of NIBP simulator, settings, age of the instrument, software version, pneumatic setup and module configuration. Thus it is difficult to provide meaningful min/max values without testing under identical conditions. This technical brief provides general limits expected for 5 simulator brands at various settings with the Advantage 2.0 Module Series. These limits were derived using specific equipment arranged in a precise manner. If these data are to be relied upon, we recommend the test conditions be replicated exactly. Even so, results may vary due to the vagaries of the specific instrument. Additionally, this tech brief will also explain why there are differences between the BP values and the NIBP simulator target values. NIBP Guidelines It is important to remember the following NIBP simulator guidelines when used with oscillometric NIBP modules or monitors: 3. On many NIBP simulators, the Advantage module will output higher BP values on hypertensive settings. This is normal and expected due to differences in oscillation amplitude ratios in NIBP simulators and the Advantage BP algorithm. Many NIBP simulators choose to have the same ratio throughout the entire pressure range. Our clinical evidence shows this is not the case on humans so we developed a dynamic ratio that changes based on pressure. The net effect of this difference is that for some NIBP simulator settings, the Advantage module BP results will be somewhat different than the target values. 4. The Advantage module will provide different results on different NIBP simulators for the same setting. This is normal and expected due to simulator differences. 5. Offset tables are needed when evaluating the performance between an NIBP module or monitor and a certain NIBP simulator (provided in this paper). 6. The Advantage module usually provides measurement values EVEN IF AN ERROR CODE OCCURS. For all error codes, these measurement values should be disregarded and considered unusable during any type of evaluation. 1. NIBP modules from different manufacturers will give different results on the same simulator setting. This is normal and expected primarily due to a number of algorithm differences between manufacturers. THE OEM NIBP MODULE THAT BEST MATCHES TARGET VALUES IS NOT NECESSARILY MORE ACCURATE. Remember, NIBP simulators cannot be used to measure clinical accuracy. 2. NIBP simulator target values should never be considered as a standard of accuracy. All NIBP simulator manuals explain or should explain that the target values are approximations and should only be used for measuring repeatability and agreement. Accuracy is only measured using human subjects and accuracy requirements and test methods are given in published regulatory standards such as ISO 81060-2. These standards include pass criteria that do not apply at all to measurements done with NIBP simulators. Accuracy is determined from a population of humans and the pass criteria in clinical standards only apply to a population of data, never a single measurement. An NIBP simulator is a mechanical substitute for a single data point. Copyright 2010 SunTechMed.com Page 1 of 6
Protocol It is important that the equipment and procedures described in this section be replicated as closely as possible. Deviating from them may result in data inconsistent with these published performance limits. The five NIBP simulators we chose are commonly used by NIBP developers, medical monitoring companies and biomedical engineering departments throughout the world. They are as follows: Pronk Technologies SimCube r5.1 Fluke Biomedical BP Pump 2, V3.21 Fluke Biomedical ProSim8 Rigel Uni-Sim Clinical Dynamics Accupulse Plus Handheld (HH) This is not a comprehensive list as we are aware of others on the market. In the future, we may develop additional information for other instruments. Four preset simulations were chosen hypertensive, normotensive, hypotensive and a neonatal setting. These settings represent a broad spectrum and fit into most evaluation and manufacturing procedures. The actual simulator target values for each setting are in table 1. For most settings, there is a slight variation in target values between simulators due to simulator design. Artifact settings were not selected since they typically are not utilized during general manufacturing or evaluation. Ten Advantage 2.0 modules were used to derive the performance limits for these NIBP simulators. Each simulator setting was performed three times per module for a total of 30 simulations per setting. Statistical analysis was done by calculating the mean (average) and standard deviation for each group of 30 simulations. The mean shows the shift from the target value and the standard deviation was used to determine the span between the minimum and maximum limits. The limits are based on 4 standard deviations. Due to differences in how NIBP simulators re-create oscillometric pulses and the tolerances to which they can be repeated, some NIBP simulators have wider limits than others. Table 1a Hypertensive Sys Dia Map SimCube 1 / 120 BP Pump 2 200 / 150 / 165 80 ProSim8 200 / 150 / 167 130 Uni-Sim 200 / 140 / 153 80 Accupulse HH 200 / 150 80 Table 1b Normotensive Sys Dia Map SimCube 120 / 80 BP Pump 2 120 / 80 / 80 ProSim8 120 / 80 / 93 60 Uni-Sim 120 / 80 / 93 80 Accupulse HH 120 / 80 / 93 80 Table 1c Hypotensive Sys Dia Map SimCube 80 / 40 BP Pump 2 80 / 50 / 60 80 ProSim8 80 / 50 / 60 80 Uni-Sim 80 / 40 / 53 80 Accupulse HH 80 / 50 80 Table 1d Neonatal Sys Dia Map SimCube / 40 95 BP Pump 2 60 / 30 / 40 120 ProSim8 60 / 30 / 40 120 Uni-Sim 60 / 30 / 40 120 Accupulse HH 60 / 30 120 Copyright 2010 SunTechMed.com Page 2 of 6
Setup When applicable, no internal volumes were engaged. For all adult simulations, a 500mL rigid volume was attached to the pneumatic setup. Neonatal simulations were performed with a #3 neonate cuff wrapped tightly around a rigid cylinder within its range. Note 1: For the Accupulse Plus HH, the preset Generic Adult Mode was used for Normotensive setting. Note 2: For Pronk Technologies Sim-Cube and Accupulse Plus HH simulators, the function is not available for these two units. Figure 1 NIBP 6 inches 15.2 cm The NIBP module being tested was connected to the volume and simulator using a 5 ft (1.5m) length of polypropylene tubing patient hose which is the same type of hose provided in the Advantage development kits (black patient hose). It has a durometer of 80 Shore A and inner diameter of 0.125 inches (3.2mm). It is strongly advised not to use tubing that is lower in durometer, has a smaller inner diameter or vary the length by more than 20 inches (0.5m). Tubing to the volume and simulator was 6 inches (15.2 cm) and was the same silicone tubing used as the exit tubing on the Advantage module manifold. This tubing has a durometer of 50 Shore A and inner diameter of 0.094 inches (2.4mm). Similar tubing material, durometer, inner diameter and length should be used. Do not decrease the durometer below 50 Shore A and do not increase each length beyond 10 inches (25.4 cm). Results 4. FT 1.5 meters Module Tee Fitting 6 inches 15.2 cm Volume The performance limits provided are for the latest SunTech firmware (LX3.413) in the Advantage module series. If you are testing modules with previous firmware versions, please contact SunTech Medical to see if these limits apply to your version. Limits are provided for both measured and calculated. The module measures during its data collection process but can output either measured or calculated depending on the customer s preference. This is set at the factory and is not userselectable. Most customers get calculated. Copyright 2010 SunTechMed.com Page 3 of 6
Pronk SimCube, r5.1 Fluke BP Pump 2, SW Ver. 3.21 Setting 1 120 n/a n/a Mean 196 127 150 150 71 Std Dev 2.07 2.03 1.81 1.60 0.88 Setting 200 150 165 n/a 80 Mean 206 154 171 171 80 Std Dev 1.34 1.47 1.19 1.17 0.47 188 204 119 136 143 157 144 157 68 75 201 212 148 160 166 176 167 176 Setting 120 80 n/a n/a Mean 117 84 95 95 71 Std Dev 1.33 1.43 1.12 1.09 0. Setting 120 80 n/a 80 Mean 126 86 81 Std Dev 1.37 1.01 0.82 0.85 0.63 112 122 89 69 73 121 132 82 96 103 96 103 Setting 80 40 n/a n/a Mean 76 46 56 56 71 Std Dev 2.27 1.80 1.38 1.41 0.35 Setting 80 50 60 n/a 80 Mean 87 54 65 65 81 Std Dev 1.38 1.21 1.23 1.18 0. 67 85 53 50 69 72 81 60 60 Setting 40 n/a n/a 95 Mean 68 46 53 53 Std Dev 1.20 2.65 1.95 1.88 0.81 Setting 60 30 40 n/a 120 Mean 64 35 45 45 121 Std Dev 1.84 1.19 1.09 1.09 0. 63 73 35 57 45 46 89 95 57 71 31 40 40 41 119 123 Copyright 2010 SunTechMed.com Page 4 of 6
Fluke ProSim8 Rigel Uni-Sim Setting 200 150 167 n/a 130 Mean 210 1 176 176 131 Std Dev 1.76 1.93 1.46 1.36 1.41 Setting 180 140 153 n/a 80 Mean 180 142 155 155 81 Std Dev 1.36 0. 1.00 0.96 0.57 203 217 1 167 1 182 1 181 126 137 175 186 138 146 1 1 1 158 Setting 120 80 93 n/a 60 Mean 130 87 101 101 Std Dev 1.07 1.13 1.03 1.02 0. Setting 120 80 93 n/a 80 Mean 121 84 96 96 81 Std Dev 0.94 0. 0.85 0.76 0.57 125 134 97 105 97 105 58 63 117 125 80 88 93 93 Setting 80 50 60 n/a 80 Mean 87 56 66 66 81 Std Dev 1. 0.94 1.09 1.01 0.71 Setting 80 40 53 n/a 80 Mean 81 44 56 56 80 Std Dev 0.91 1.84 1.30 1.29 0.57 82 93 52 84 77 85 36 Setting 60 30 40 n/a 120 Mean 58 38 45 45 120 Std Dev 2.24 1.35 1.44 1.42 0.68 Setting 60 30 40 n/a 120 Mean 33 42 42 121 Std Dev 0.52 1.42 1.04 1.03 0.76 67 33 44 118 123 63 27 38 47 38 47 118 124 Copyright 2010 SunTechMed.com Page 5 of 6
Accupulse Plus HH Setting 200 150 n/a n/a 80 Mean 205 152 1 1 81 Std Dev 1.91 2.30 2.02 1. 0.43 198 213 143 1 1 1 1 1 82 Setting 120 80 93 n/a 80 Mean 124 84 97 97 81 Std Dev 1.17 1.53 1.30 1.28 0.50 120 129 103 102 Conclusions Lesser quality NIBP simulators can produce greater variability in a set of measurements which is revealed by the standard deviation. Higher standard deviations will also have wider min/max limits. All simulators used in this evaluation are acceptable for NIBP simulation use with Suntech Medical Advantage series NIBP modules. We provide these limits and recommendations to assist anyone using NIBP simulators with the Advantage series of modules. While we have collaborated in the past with an instrument manufacturer, our performance assessments are completely independent. All recommendations herein are based solely on scientific principles and actual acquired data as well as significant clinical experience with our Advantage series of modules. Setting 80 50 n/a n/a 80 Mean 85 52 63 63 81 Std Dev 1.31 1.36 1.27 1.13 0. 80 47 58 58 68 68 Setting 60 30 n/a n/a 120 Mean 69 19 36 36 121 Std Dev 1.86 1.67 1.36 1.29 1.03 76 13 26 31 41 31 41 117 125 Copyright 2010 SunTechMed.com Page 6 of 6