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What is Central Venous Pressure (CVP) CVP is the pressure measured at the junction of the superior venae cavae

e and the right atrium. It indicates mean atrial pressure and is frequently used as an estimate of right ventricular preload. It reflects the driving force for filling of the right atrium & ventricle. It reflects the relationship of blood volume to the capacity of the venous system. Normal CVP in an awake , spontaneously breathing patient - 1-7 mmHg or 5-10 cm H2O. Mechanical ventilation- 3-5 cm H2O higher. WHY WE NEED INVASIVE CVP MONITORING? Central venous pressure (CVP) measurements are readily obtainable in most critically ill patients and are commonly measured In central venous pressure monitoring, catheter is inserted through a vein and advanced it until its tip lies in or near the right atrium. When connected to a manometer, the catheter measures central venous pressure (CVP), an index of right ventricular function. The central venous (CV) line also provides access to a large vessel for rapid, high-volume fluid administration and allows frequent blood withdrawal for laboratory samples. Normal CVP ranges from 5 to 10 cm H2O or 2 to 6 mm Hg.

ADVANTAGES OF CENTRAL LINE High blood flow to the superior vena cava promote rapid dilution of the fluid which decrease the risk of inflammation and thrombosis that occur in the central line. Stable access for the venous system risk of infiltration and tissue damage CVC may shorter hospital stay by access to treatment as an outpatient Physical and psychological damage of repeating IV puncture INDICATIONS FOR CENTRAL VENOUS CANNULATION 1. Central venous pressure monitoring 2. Pulmonary artery catheterization & monitoring 3. Transvenous cardiac pacing 4. Temporary hemodialysis 5. Drug administartion Conc. Vasoactive drugs Hyperalimentation Chemotherapy Agents irritating to peripheral veins Prolong antibiotic therapy

6.Rapid infusion of fluids Trauma Major surgery 7.Aspiration of air emboli 8.Inadequate peripheral intravenous access 9.Sampling site for repeated blood testing CONTRAINDICATIONS ABSOLUTE Renal Cell tumour extension into right atrium. Fungating tricuspid valve vegetations RELATIVE They relate to the site e.g. IJV cannulation is relatively contraindicated in pts on anticoagulants or who had an ipsilateral carotid endarterectomy Subclavian cannulation in relatively contraindicated case of pts having increased risk of pneumothorax and poor chest condition. TYPES OF CENTRAL LINES Single lumen Double lumen Triple lumen Quadruple lumen

METHOD, CATHETER, AND SITE FOR CENTRAL VENOUS CANNULATION Full Barrier Precautions Full barrier precautions include The operator wearing a sterile gown, sterile gloves, cap, and mask The use of a large sterile sheet to establish the sterile field Operator wearing protective eyewear. Chlorhexidine Skin Preparation Skin preparation with 2% chlorhexidine has been demonstrated to be superior to povidine-iodine (Betadine) in reducing subsequent catheterrelated infection. This clear substance is applied from the anticipated point of skin puncture outwards

Techniques of central venous cannulation 1. Catheter over the needle Longer version of a conventional intravenous cannula. Catheter is larger than needle reduces the leakage of blood from the insertion site. Accidental arterial puncture can occur d/t larger needle. Over insertion can damage the vein. 2. Catheter over guidewire ( Seldinger technique) Preferred method of insertion. 18-20 G, small diameter needle is used. A guide wire passed down the needle in to the vein and needle removed. Guidewire commonly has flexible J shaped tip. Reduces the risk of vessel perforation. Helps negotiate valves in vein . Once the wire is placed in the vein catheter is passed over it. 3. Catheter through the needle or through cannula. Catheter passed through a cannula or needle placed in the vein. Hole made in the vein by the needle larger than the catheter some degree of blood leakage around the site. Withdrawal of catheter through needle risks shearing off catheter. Catheter embolisation

VEIN OR ARTERY? Artery Colour of blood Pressure Bright red High Plunger push back Rapid back flow of blood Vein Dark red Low

Blood gas

High PaO2

Selecting the best site for safe and effective central venous cannulation ultimately requires that the physician consider the purpose of

catheterization (pressure monitoring versus drug or fluid infusion) patient's underlying medical condition intended operation skill and experience of the physician performing the procedure.

ASSESSMENT of patient 1. Information Regarding procedures, alternative procedures, adv. & disadv., risk involved, care of the device & removal of device. 2. Informed consent. 3. Allergies 4. Physical examination General physique, height, weight, physical features- bull neck, breasts, goitre, stoma, open wounds.

5. Vascular assessment Anatomy of peripheral & central veins & their variants. H/o previous CVP catheterisation. Any evidence of venous thrombosis caused by presence of CVAD. Thorax, abdomen, upper & lower limbs, neck dilated collaterals, swelling 6. Respiratory function assessment Chest X- ray. CT chest. 7. CVS assessment Implanted pacemakers & defibrillators r/o catheters interfering To r/o emphysema/ COPD Large effusion/ collapse. presence of

s/o thrombosis or stenosis of veins.

with the position of leads of these devices & infection of such devices. 8. Neurological assessment Level of conciousness. Effects of sedatives & analgesic drugs. Paralysed limb- inc risk of unrecognised extravasation of drugs. 9. Fractures & arthritis Fracture clavicle- CVAD should be placed on opp. side or jugular approach should be used. Fracture of UL bones- C/I for PICC. 10. Laboratory assessment

S.E. with in normal range. S. K+ - Risk of arrhythmias. 11.Coagulation assessment APTT- 22-34 sec PT 10.5- 13.5 sec Platelets 150-400 * 109 /l Warfarin therapy- either stopped or converted to heparin 3 days beforehand. INR- 1.5 or below should be achieved I/V unfractionated heparin- stopped 3 hrs before insertion & restarted when haemostatis is achieved. LMWH- 12-24 hrs.

RIGHT INTERNAL JUGULAR VEIN CANNULATION Careful positioning will make the patient comfortable, improve identification of surface landmarks, and increase the likelihood of successful venipuncture. The patient should be calm, receiving supplemental oxygen if necessary, and monitored with an ECG, blood pressure monitor, and pulse oximeter. Strict aseptic technique should be followed. The right internal jugular vein is preferred because: Consistent, predictable anatomic location of the internal jugular vein. Readily identified, palpable surface landmarks.

Short, straight course to the superior vena cava, which facilitates right heart catheterization. An internal jugular vein catheter is more accessible intraoperatively to the anaesthesiologist. Alternative Central Venous Cannulation Sites Left Internal Jugular Vein Subclavian Vein External Jugular Vein Femoral Vein Axillary ( anterior & lateral approach ) Brachial ( mid- upper arm approach ) Cephalic ( ante- cubital fossa approach ) Brachio cephalic ( supra clavicular approach )

Left Internal Jugular Vein PROBLEMS The cupola of the pleura is higher on the left The thoracic duct may be injured The left internal jugular vein is often smaller than the right Catheters traverse the innominate(i.e., left brachiocephalic) vein and enter the superior vena cava perpendicularly More difficult, more time consuming, and associated with more complications

Subclavian Vein ADVANTAGES Lower risk of infection than with internal jugular or femoral sites. Ease of insertion in trauma patients who may be immobilized in a cervical collar. Increased patient comfort especially for long-term intravenous therapy such as hyperalimentation and chemotherapy. The most common technique used for subclavian vein cannulation is the infraclavicular approach. PROCEDURE The patient is placed in a slight head-down position with the arms fully adducted The head is turned slightly away from the side of venipuncture, and a small bedroll is placed between the shoulder blades to fully expose the infraclavicular area. The skin is punctured 2 to 3 cm caudad to the midpoint of the clavicle. The needle tip is directed toward the suprasternal notch If the subclavian vein is not entered in the first pass, the needle may be withdrawn and a second pass attempted in a slightly more cephalad direction

Once the subclavian vein is punctured,catheterization proceeds in a manner similar to that described for jugular vein catheterization.rd attempt. Complications particularly the incidence of pneumothorax and subclavian artery puncture, are directly related to the number of attempts and are more common when venipuncture is unsuccessful. Bilateral attempts at subclavian venipuncture should rarely be undertaken because of the potential serious morbidity of bilateral pneumothorax.

External Jugular Vein No risk of pneumothorax or unintended arterial puncture. A J-tipped guidewire should always be used because it may be advanced under the clavicle into the central circulation more successfully than a straight-tipped wire. Only factors that preclude use of the external jugular veins for CVP monitoring are an inability to visualize and cannulate the vessel in the neck and advance the catheter into the central circulation. Femoral Vein Useful site for CVP monitoring when other sites are not accessible. Obviates many of the common complications of central venous catheterization. Disadvantages of the femoral venous route include an increased risk of thromboembolic and infectious complications , femoral arterial or venous

injury during attempted cannulation may result in intraabdominal hemorrhage. Axillary and Other Peripheral Veins Advantages of PICCs Bedside placement under local anesthesia Low risk of major insertion-related complications Safe placement by nonphysicians (i.e., registered nurses and physician assistants). Cost-effective Venous access for a PICC is obtained through an antecubital vein, preferably the basilic vein ULTRASOUND-GUIDED CENTRAL VENOUS CANNULATION ADVANTAGES Fewer needle passes are required for successful venous cannulation. Reduces the time required for catheterization. Increases overall success rates. Results in fewer complications. Helpful when landmark-based methods are unsuccessful. Used in cases of anticipated difficulty with vascular access. DISADVANTAGES The additional cost

Inconvenience of acquiring and using an ultrasound device Concern that reliance on ultrasoundguided catheterization will prevent trainees from acquiring adequate skills for landmark-based central venous cannulation. METHOD The large central veins are readily distinguished from their accompanying arteries by: Their lack of pulsatility Marked enlargement during a Valsalva maneuver Easy compressibility with the ultrasound probe.

Methods to measure cvp 1. Indirect assessment Inspection of jugular venous pulsations in neck.

2.

Direct assessment Fluid filled manometer connected to central venous catheter. Caliberated transducer.

1. Inspection of jugular venous pulsations in neck. No valves b/w rt. atrium & IJV. Degree of distention & venous wave form information about cardiac function. 2. Fluid filled manometer connected to central venous cathetermeasured using a column of water in a marked manometer. CVP is the height of the column in cms of H2O when the column is at the level of right atrium. Advantage- simplicity to measure. Disadvantage- Inability to analyze the CVP waveform. -Relatively slow response of the water column to changes in intrathoracic pressure. 3. Caliberated transducer. Automated, electronic pressure monitor. Pressure wave form displayed on an oscilloscope or paper. Advantages More accurate. Direct observation of waveform.

Pressure transducer Relationship between water manometer and caliberated transducer in terms of pressure 1cm H2O = 0.73 mmHg. 1.36 cm H2O = 1 mmHg. Cvp measurement & intrathoracic pressure CVP measurement is influenced by changes in intrathoracic pressure. It fluctuates with respiration. Decreases -spontaneous inspiration. Increases -positive pressure ventilation. CVP should be taken at the end- expiration. PEEP applied to the airway at the end of exhalation , may be partially transmitted to the intrathoracic structures higher. CVP measured will be

Equipment For intermittent CVP monitoring: Disposable CVP manometer set leveling device (such as a rod from a reusable CVP pole holder or a carpenters level or rule) additional stopcock (to attach the CVP

manometer to the catheter) extension tubing (if needed) I.V. pole I.V. solution I.V. drip chamber and tubing dressing materials tape. For continuous CVP monitoring: Pressure monitoring kit with disposable pressure transducer leveling device bedside pressure module continuous I.V. flush solution 1 unit/1 to 2 ml of heparin flush solution pressure bag. Measuring CVP with a water manometer With the CV line in place, position the patient flat. Align the base of the manometer with the previously determined zero reference point by using a leveling device. Because CVP reflects right atrial pressure, align the right atrium (the zero reference point) with the zero mark on the manometer. To find the right atrium, locate the fourth intercostal space at the midaxillary line. If the patient cant tolerate a flat position, place him in semi-Fowlers position. When the head of the bed is elevated, the phlebostatic axis remains constant but the midaxillary line changes. Use the same degree of elevation for all subsequent measurements. Attach the water manometer to an I.V. pole or place it next to the patients chest. Make sure the zero reference point is level with the right atrium. After adjusting the manometers position, examine the typical three -way stopcock.

Verify that the water manometer is connected to the I.V. tubing. Typically, markings on the manometer range from 2 to 38 cm H2O. Turn the stopcock off to the patient, and slowly fill the manometer with I.V. solution until the fluid level is 10 to 20 cm H2O higher than the patients expected CVP value. Dont overfill the tube because fluid that spills over the top can become a source of contamination. Turn the stopcock off to the I.V. solution and open to the patient. The fluid level in the manometer will drop. When the fluid level comes to rest, it will fluctuate slightly with respirations. Expect it to drop during inspiration and to rise during expiration. Record CVP at the end of expiration, when intrathoracic pressure has a negligible effect. Depending on the type of water manometer used, note the value either at the bottom of the meniscus or at the midline of the small floating ball. After youve obtained the CVP value, turn the stopcock to resume the I.V. infusion. Adjust the I.V. drip rate as required. Place the patient in a comfortable position. Obtaining continuous CVP readings with a water manometer Make sure the stopcock is turned so that the I.V. solution port, CVP column port, and patient port are open.

Be aware that with this stopcock position, infusion of the I.V. solution increases CVP. Therefore, expect higher readings than those taken with the stopcock turned off to the I.V. solution. If the I.V. solution infuses at a constant rate, CVP will change as the patients condition changes, although the initial reading will be higher. Assess the patient closely for changes. (If the patient has a CV line with multiple lumens, one lumen may be dedicated to continuous CVP monitoring and the other lumens used for fluid administration.) THE CVP WAVEFORM The CVP waveform reflects changes in right atrial pressure during the cardiac cycle

Waveform Phase Mechanical Event Component of Cardiac Cycle


a wave End-diastole Atrial contraction

c wave

Early systole Isovolumic ventricular contraction, tricuspid motion toward the right atrium

v wave

Late systole

Systolic filling of the atrium

h wave

Mid to late diastole Midsystole

Diastolic plateau

x descent

Atrial relaxation, descent of the base, systolic collapse Early ventricular filling, diastolic collapse

y descent

Early diastole

MANAGEMENT OF A PATIENT WITH A CVP LINE Monitor the patient for signs of complications Label CVP lines with drugs/fluids etc. being infused in order to minimise the risk of accidental bolus injection If not in use, flush the cannula regularly to help prevent thrombosis. A 500ml bag of 0.9% normal saline should be maintained at a pressure of 300mmHg. Ensure all connections are secure to prevent exsanguination, introduction of infection and air emboli Observe the insertion site frequently for signs of infection. The length of the indwelling catheter should be recorded and regularly monitored.

CVP lines should be removed when clinically indicated REMOVAL OF CENTRAL LINE This is an aseptic procedure The patient should be supine with head tilted down Ensure no drugs are attached and running via the central line Remove dressing Cut the stitches Slowly remove the catheter If there is resistence then call for assistance Apply digital pressure with gauze until bleeding stops Dress with gauze and clear dressing eg. tegaderm COMPLICATIONS Immediate Bleeding Haematoma Inadvertent arterial puncture Vascular injuries Cardiac arrythmias Nerve injury Guide wire Early Pneumothorax Haemothorax

Cardiac tamponade Respiratory compromise/ airway compression from haematoma Late Thromboembolic Venous thrombosis Pulmonary embolism Arterial thrombosis and embolism Catheter or guidewire embolism Infectious Insertion site infection Catheter infection Bloodstream infection Endocarditis

Mechanical Vascular injury Arterial Venous Cardiac tamponade Respiratory compromise

Airway compression from hematoma Pneumothorax Nerve injury Arrhythmias