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Central Venous Pressure

Monitoring
. .

Email:

thananchairama@hotmail.com

CVP Monitoring
1. CVP ?
1.1
1.2
1.3
1.4
1.5
1.6

Blood volume
Right ventricular venous return
RV preload
RV pump function
LV preload
Risk of pulmonary edema

2. CVP ?
3. CVP ?
4. CVP ?

CVP Monitoring
5. CVP ?
6. CVP ?
CVP ?
IV fluid keep CVP 8-12 cm H2O ?
7. central veous line ?
8. Central line
peripheral line ?
9. central line ? ?
10. CVP ?
11. CVP ?

CVP Monitoring
12. ?
CVP ?
13. 0 (zero level)
?
14. CVP ?
15. CVP ?
16. ?
17. ?
18. monitor CVP ?

CVP and Blood Volume (BV)


CVP BV status
Normal CVP
- Normovolemia
- Hypovolemia c venoconstriction, ventricular dysfunction
- Hypervolemia c hyperdynamic heart function
Low CVP
- Absolute or relative hypovolemia (vasodilatation)
- Hyper-, hypo-, or normovolemia c hyperdynamic heart or negative ITP
High CVP
- Hypervolemia
- Hypo- or normovolemia c positive ITP, ventricular dysfunction,
obstruction of blood flow (TS, PS, cardial tamponade)

CVP and Venous Return (VR)


VR to right ventricle
VRRV RVFP
RVFP = RAP RVDP

= CVP RVDP

CVP VR
CVP VR
CVP VR

CVP as RV Preload
SWI,
SV

fiber length
RVEDV

RVEDP
RAP
CVP

-- RV compliance
-- Tricuspid valve function, ITP
-- Catheter tip location, technical errors

CVP and RV Pump Function


CVP ventricular pump function

CVP RV function dysfunction


LV function dysfunction
Rt-Lt discrepancy

PAOP as LV Preload
SWI,
SV

LVEDV
LVEDP
LAP
PVP
PAOP
PADP

-- LV compliance
-- Mitral valve function, ITP

-- ITP. venous obstruction


-- location, high Palv (PPV,PEEP), low PVP
-- Increased PVR, occlusive PVD, HR>120

RAP (CVP) vs LAP (PAOP)


PAOP

CVP

Rt-Lt discrepancy: CVP cannot be used to assess PAOP.


1. Absence of pericardium
2. RV dysfunction predominates
3. Decreased LV compliance

Optimal Preload
PCWP
CVP

Acute MI

15
15

mm Hg
cm H2O

PAOP 20-22 mm Hg

CVP & Risk of Pulmonary Edema


PCWP
CVP

>22 mm Hg
>20-25 cm H2O

Rt-Lt discrepancy

CVP

1. Force from behind


2. Pressure from in front
3. Internal force: volume vs capacitance
4. External force

Venous Capacitance and Volume


A

point of
min. capacitance

point of
max. capacitance

Normal Value for RAP & CVP


RAP

CVP

0 mm Hg
-5 to 15 mm Hg

5-12 cm H2O
-5 to 15-20 cm H2O can be normal
- catheter tip location
- individuals compensated normal

Clinical Uses of CVP


1. As a guideline for volume therapy (RV pump

funcion, RV preload): fluid challenge test


2. To assess BV status, LV preload, risk of PE ?
3. CVP waveform to detect cardiac abnormalities

Normal CVP Waveform

systole

diastole

CVP as a Guideline for Volume Therapy


Indication: Need for + Risk of volume therapy
Method;

Fluid challenge test

volume loading
CVP PAOP loading
equilibration of venous pressure
volume rate volume therapy
CVP PAOP

Fluid Challenge Test


Initial CVP
PAOP

<8
<12

Volume & Rate

8-15
12-16

200 mL/10 min

>15 cm H2O
>16 mm Hg

100 mL/10 min

50 mL/10 min

During infusion, CVP rises >5 cm H2O


or PAOP rises >7 mm Hg
Yes
No
Stop challenge
Complete the volume
Wait 10 min
Wait 10 min
CVP change
PAOP change

>5
>7

3-5
4-7

<2
<3

3-5
4-7

<2
<3

Central Venous Line


1.
2.
3.
4.

CVP measurement and monitoring


Lack of peripheral vein
Rapid venous access
Administration of drugs
4.1 Hyperosmolar solution: TPN, hypertonic glucose
4.2 Irritating solution: extreme pH, cancer chemotherapy, KCl >40 mEq/L
4.3 Vasopressor: high dose dopamine, NE, adrenaline

5. Frequent blood sampling


6. Insertion of other catheters: hemodialysis catheter, right heart
catheterization (aspiration of air emboli), temporary pacing electrode,
PA catheter (PA pressure monitoring, cardiac output, PA angiography,
mixed venous blood sampling)

Methods of CVP Line Establishment


1. Percutaneous venepuncture and catheterization
1.1 Over-the-needle catheter
1.2 Through-the-needle/plastic catheter
1.3 Seldinger technique
1.1 Centrally-inserted: subclavian, internal jugular
1.2 Peripherally-inserted central catheter
2. Venous cut down (venotomy, phlebotomy, venesection)
2.1 Central
2.2 Peripheral

Methods of CVP Measurement


1. Manometer
1.1 Fluid column: water mercury
1.2 Aneroid manometer

2. Pressure transducer: mm Hg, cm H2O

Reliability of CVP Measurement


1. Bed side test
-

Free flow from aspiration


Rapid falling water column
Fluctuation with respiration
No fluctuation with heart beat
Small oscillation at top of water column

2. CVP waveform
3. Chest X-ray: carina,
head of clavicle, medial 1/3 clavicle

Reference Level or Zero Level


Phlebostatic axis = mid-AP diameter, ICS 4 RSB
Phlebostatic level
= level horizontal to phlebostatic axis
= reference or zero level for CVP & IBP
: ICS 4 RSB mid-AP
ICS 6 mid-AP

(
)


1. PPV CVP
absolute value
2.
- ITP

- ITP

3.


4.

?
end-expiration


cycle

CVP Monitoring
1. CVP ?
1.1
1.2
1.3
1.4
1.5
1.6

Blood volume
Right ventricular venous return
RV preload
RV pump function
LV preload
Risk of pulmonary edema

2. CVP ?
3. CVP ?
4. CVP ?

CVP Monitoring
5. CVP ?
6. CVP ?
CVP ?
IV fluid keep CVP 8-12 cm H2O ?
7. central veous line ?
8. Central line
peripheral line ?
9. central line ? ?
10. CVP ?
11. CVP ?

CVP Monitoring
12. ?
CVP ?
13. 0 (zero level)
?
14. CVP ?
15. CVP ?
16. ?
17. ?
18. monitor CVP ?

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