CENTRAL VENOUS MONITORING Overview:      Central venous pressure (CVP) is an index of right ventricular function The physician inserts

a catheter through a vein and advances it until its tip lies in or near the right atrium Because no major valves lie at the junction of the vena cava and right atrium, pressure at end diastole reflects back the catheter CVP monitoring helps assess cardiac function, evaluate venous return to the heart, and indirectly gauges how well the heart is pumping The central venous line also provides access to a large vessel for rapid, high-volume fluid administration and allows easy blood withdrawal for laboratory samples CVP monitoring can be done intermittently or continuously The catheter is inserted percutaneously or using a cut down method To measure patient s volume status, a disposable plastic water manometer may be attached between the IV line and the central catheter with a three-or-four-way stopcock CVP may also be monitored continuously through a central venous catheter attached to a pressure transducer CVP is recorded in millimeters of mercury (mmHg) Normal CVP ranges from 2 to 6 mmHg Any condition that alters venous return, circulating blood volume, or cardiac performance may affect CVP If circulating CVP volume increases (such as with enhanced venous return to the heart), CVP rises If circulating volume decreases (such as with reduced venous return), CVP drops

  

     

Indication: 1) Monitoring of central venous pressure in the acutely ill patient: this allows the caregiver to have an insight into the fluid balance status of the patient. High CVP would indicate fluid overload or a failing heart. Low CVP would indicate dehydration or blood loss. 2) Total Parenteral Nutrition (TPN) Administration: when an acutely ill patient s GI tract is not able to absorb nutrients, then the treatment team may decide to give the patient nutrition. Generally TPN is administered via a central IV catheter, which is inserted in the subclavian or jugular vein. The rationale for using big deep veins for the administration is the fact that TPN causes phlebitis in peripheral veins because it contains many caustic agents. 3) Medication Administration: drugs that are likely to cause phlebitis include chemotherapeutic agents used in the treatment and management of malignant conditions and Amiodarone that is used extensively in the management and treatment of acute life threatening arrythmias. 4) Lack of peripheral access: in some acutely ill patients, when there is no peripheral venous access, then a CVP line may be inserted. This is usually

done for the purpose of re-hydration, medication administration, administration of blood and blood products Equipment: For intermittent CVP monitoring: Disposable CVP manometer set. Leveling device (such as a rod from a reusable CVP pole holder or a carpenter s level or rule). Additional stopcock (to attach the CVP manometer to the catheter). Extension tubing (if needed). IV solution. IV pole. IV drip chamber and tubing. For continuous CVP monitoring: Pressure monitoring kit with disposable pressure transducer. Leveling device. Bedside pressure module. Continuous IV flush solution. Pressure bag. For withdrawing blood samples through the CV line: Appropriate number of syringes for ordered tests. 5-or10mL for discard syringe for discard sample (syringe size depends on tests ordered). For using intermittent CV line: syringe with normal saline solution. Syringe with heparin flush solution. For removing a CV catheter: sterile gloves. Suture removal set. Sterile gauze pads. Povidone-iodine ointment. Dressing. Tape. Essential Steps:     Gather necessary equipment Explain procedure to the patient to reduce anxiety Assist the physician as he inserts the central venous catheter Procedure is similar to that used for pulmonary artery pressure monitoring, except the catheter is advanced only as far as the superior vena cava

Obtaining intermittent CVP readings with a water manometer        With the central venous 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, you must 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 Mark the appropriate place on the patient s chest so all subsequent recordings will be made using the same location If the patient can t tolerate a flat position, place him in semi-fowler s 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 IV pole or place it next to the patient s chest Make sure the zero reference point is level with the right atrium

 

 

        

Verify that the water manometer is connected to the IV tubing Turn the stopcock off to the patient and slowly fill the manometer with IV solution until the fluid level is 10 to 20 cm H20 higher than the patient s expected CVP value ALERT: don t overfill the tube, fluid that spills over the top can cause contamination Turn the stopcock off to the IV solution and open to the patient The fluid level in the manometer will drop After the fluid level comes to rest, it will fluctuate slightly with respirations Expect the fluid level to drop during inspiration and 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 obtaining the CVP value, turn the stopcock to resume the IV infusion Adjust the IV drip rate as required Place the patient in a comfortable position

Obtaining continuous CVP readings with a water manometer  Make sure stopcock is turned so the IV solution port, CVP column port and patient port are all open ALERT: be aware that with this stopcock position, infusion of the IV solution increases CVP. Therefore, expect higher readings than those taken with the stopcock turned off to the IV solution If the IV solution infuses at a constant rate, CVP will change as the patient s condition changes, although the initial reading will be higher Assess the patient closely for changes

 

Obtaining continuous CVP readings with a pressure monitoring system   Make sure the central venous line or the proximal lumen of a pulmonary artery catheter is attached to the system If the patient has central venous line with multiple lumens, one lumen may be dedicated to continuous CVP monitoring and the others used for fluid administration Set up a pressure transducer system Connect pressure tubing from the CVP catheter hub to the trasducer Connect the flush solution container to a flush device To obtain values, position the patient flat. If the patient can t tolerate this position, use semi-fowler s position Locate the level of the right atrium by identifying the phlebostatic axis Zero the transducer, leveling the transducer air-fluid interface stopcock with the right atrium Read the CVP value from the digital display on the monitor and note the waveform Make sure the patient is still when reading is taken to prevent artifact; be sure to use the same position for all subsequent readings

       

Removing a central venous line    You may assist the physician in removing a central venous line A nurse may be permitted to remove the catheter with a physician s order or when acting under advanced collaborative standards of practice Elevate the head of the bed to minimize risk of air embolism during catheter removal- for instance, place the patient in trendelenburg position if the line was inserted using a superior approach. If he can t tolerate this, position him flat Turn the patient s head to the side opposite the catheter insertion site The physician removes the dressing and exposes the insertion site If sutures are in place. He removes them Turn the IV solution off The physician pulls the catheter out in a slow, smooth motion, then applies pressure to the insertion site Put on sterile gloves Clean the insertion site. Apply povidone-iodine ointment, and cover with a sterile gauze dressing. Remove gloves and wash your hands Assess for signs of respiratory distress, which may indicate an air embolism

        

Central venous pressure (CVP) measurement is essential for monitoring hemodynamics in critically ill patients and during surgery to estimate cardiac preload and circulating blood volume. Clinical estimation of CVP has proven unreliable compared with measurement using a catheter (1). The current standard technique for measurement of CVP is invasive, requiring insertion of a catheter into a subclavian or internal jugular vein, with potential complications (2). A quick and reliable tool for monitoring CVP without need of central venous access would be helpful. Recently published studies have shown good correlation between peripheral venous pressure (PVP) and CVP, which allowed accurate assessment of CVP under a variety of conditions (35). We report on a new tool for noninvasive venous pressure measurement using high-resolution ultrasound imaging combined with a translucent pressure manometer. The controlled compression sonography was applied at the forearm, and results were compared with the gold standard of invasive venous pressure measurement in both healthy subjects and patients from an intensive care unit (ICU).