Central Venous Pressure AND Capillary Blood Glucose Monitoring

Randolph G. Napoles UI CN-SN

Central venous pressure. Central venous catheterization insertion of an indwelling catheter into a central vein for administering fluid and medications and for measuring CENTRAL VENOUS PRESSURE. The most common sites of insertion are the jugular and subclavian veins; however, such large peripheral veins as the saphenous and femoral veins can be used in an emergency even though they offer some disadvantages. The procedure is performed under sterile conditions and placement of the catheter is verified by x-rays before fluids are administered or central venous pressure measurements are made.

Selection of a large central vein in preference to a smaller peripheral vein for the administration of therapeutic agents is based on the nature and amount of fluid to be injected. Central veins are able to accommodate large amounts of fluid when shock or hemorrhage demands rapid replacement. The larger veins are less susceptible to irritation from caustic drugs and from hypertonic nutrient solutions administered during PARENTERAL NUTRITION. PATIENT CARE. Patients who have central venous lines are subject to a variety of complications. Air embolism is most likely to occur at the time a newly inserted catheter is connected to the intravenous tubing. Introduction of air into the system can be avoided by having the patient hold his breath and contract the abdominal muscles while the catheter and tubing are being connected. This maneuver increases intrathoracic pressure; if the patient is not able to cooperate, the connection should be made at the end of exhalation.

Sepsis is a potential complication of any intravenous therapy. It is especially dangerous for patients with central venous lines because they are seriously ill and less able to ward off infections. Careful cleansing of the insertion site, sterile technique during insertion, periodic changing of tubing and catheter, and firmly anchoring the catheter to prevent movement and irritation are all essential for the prevention of sepsis. Formation of a clot at the tip of the catheter is indicated if the rate of flow of intravenous fluids decreases measurably or if there is no fluctuation of fluid in the fluid column. Preventive measures include maintaining a constant flow of intravenous fluids by IV pump or controller, periodic flushing of the catheter, heparin as prescribed, and looping and securing the catheter carefully to avoid kinks that impede the flow of fluids. Cardiac arrhythmias can occur if the tip of the catheter comes into contact with the atrial or ventricular wall. Changing the patient's position may eliminate the problem, but if ectopic rhythm persists, additional interventions are warranted.

central venous pressure (CVP) the pressure of blood in the right atrium. Measurement of central venous pressure is made possible by the insertion of a catheter through the median cubital vein to the superior vena cava. The distal end of the catheter is attached to a manometer (or transducer and monitor) on which can be read the amount of pressure being exerted by the blood inside the right atrium or the vena cava. The manometer is positioned at the bedside so that the zero point is at the level of the right atrium. Each time the patient's position is changed the zero point on the manometer must be reset. For a multilumen catheter the distal port is used to measure central venous pressure; for a pulmonary artery catheter the proximal port is used. An arterial line can also be used to monitor the central venous pressure. The waveform for a tracing of the pressure reflects contraction of the right atrium and the concurrent effect of the ventricles and surrounding major vessels. It consists of a, c, and v ascending (or positive) waves and x and y descending (or negative) waves. Since systolic atrial pressure (a) and diastolic (v) pressure are almost the same, the reading is taken as an average or mean of the two.

The normal range for CVP is 0 to 5 mm H2O. A reading of 15 to 20 mm usually indicates inability of the right atrium to accommodate the current BLOOD VOLUME. However, the trend of response to rapid administration of fluid is more significant than the specific level of pressure. Normally the right heart can circulate additional fluids without an increase in central venous pressure. If the pressure is elevated in response to rapid administration of a small amount of fluid, there is indication that the patient is hypervolemic in relation to the pumping action of the right heart. Thus, CVP is used as a guide to the safe administration of replacement fluids intravenously, particularly in patients who are subject to pulmonary EDEMA. Central venous pressure indirectly indicates the efficiency of the heart's pumping action; however, pulmonary artery pressure is more accurate for this purpose. A high venous pressure may indicate congestive HEART FAILURE, HYPERVOLEMIA, cardiac TAMPONADE in which the heart is unable to fill, or VASOCONSTRICTION, which affects the heart's ability to empty its chambers. Conversely, a low venous pressure indicates HYPOVOLEMIA and possibly a need to increase fluid intake.

MONITORING/TESTS OF GLYCEMIA Monitoring of CBG is a strategy that allows caregivers and people with diabetes to evaluate diabetes management regimens. The frequency of monitoring will vary by patients glycemic control and diabetes regimens. Patients with type 1 diabetes are at risk for hypoglycemia and should have their CBG monitored three or more times daily. Patients with type 2 diabetes on insulin need to monitor at least once daily and more frequently based on their medical plan. Patients treated with oral agents should have CBG monitored with sufficient frequency to facilitate the goals of glycemic control, assuming that there is a program for medical review of these data on an ongoing basis to drive changes in medications. Patients whose diabetes is poorly controlled or whose therapy is changing should have more frequent monitoring. Unexplained hyperglycemia in a patient with type 1 diabetes may suggest impending DKA, and monitoring of ketones should therefore be performed.

Glycated hemoglobin (A1C) is a measure of long-term (2- to 3-month) glycemic control. Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control) and quarterly in patients whose therapy has changed or who are not meeting glycemic goals. Discrepancies between CBG monitoring results and A1C may indicate a hemoglobinopathy, hemolysis, or need for evaluation of CBG monitoring technique and equipment or initiation of more frequent CBG monitoring to identify when glycemic excursions are occurring and which facet of the diabetes regimen is changing.

Blood glucose monitoring Blood glucose monitoring refers to the ongoing measurement of blood sugar (glucose). Monitoring can be done at any time using a portable device called a glucometer. How the Test is Performed The traditional glucose meter comes with test strips, small needles called lancets, and a logbook for recording your numbers. There are many different kinds of these meters, but they all work essentially the same way. A complete testing kit can be purchased from a pharmacy without a prescription. Your doctor or nurse can help you choose the equipment that's right for you, help you set it up, and teach you how to use it. You will prick your finger with the lancet and place a drop of blood on a special strip. This strip uses a chemical substance to determine the amount of glucose in the blood. (Newer monitors can use blood from other areas of the body besides the fingers, reducing discomfort.) The meter displays your blood sugar results as a number on a digital display.

How to re are for t e est Ha e all test ite s wit in reac efore starting -- timing is important. lean t e nee le prick area wit soap and water or an alcohol swa . ompletel dr the skin efore pricking. How the est Will eel here is a sharp prick. Why the est is erformed This test re eals your lood sugar le el. If you ha e dia etes, you can use it to carefully monitor your lood sugar le els at home. egularly checking your lood sugar le el is one of the most important steps you can take in managing the disease. It provides your doctor with important information regarding the control of your lood sugar.

When you keep track of your blood sugar you will: Start to see patterns that will help you plan meals, activities, and what time of day to take your medications Learn how certain foods affect your blood sugar levels See how exercise can improve your numbers Testing allows you to respond quickly to high blood sugar (hyperglycemia) or low blood sugar (hypoglycemia). This might include diet adjustments, exercise, and insulin (as instructed by your health care provider). Your doctor may order a blood sugar test to screen for diabetes. For more information, see blood glucose test. Normal Results Before meals: 70 - 130 milligrams per deciliter (mg/dL) After meals: Less than 180 mg/dL Values can vary depending on physical activity, meals, and insulin administration. Normal value ranges may vary slightly among different laboratories. Talk to your doctor about the meaning of your specific test results.

What Abnormal Results Mean Low levels indicate hypoglycemia. Have something to eat. You may need to change the next insulin dose, and possibly future insulin doses as well. If levels are too high, this indicates hyperglycemia. You may need additional insulin. Risks There is a slight chance of infection at the puncture site. A small amount of bleeding may occur after the puncture. Considerations The correct procedure must be followed or the results will not be accurate. Alternative Names Home glucose monitoring; Self monitoring of blood glucose

CBG SUGGESTED EQUIPMENT: Antiseptic gel or soap and water Gloves Test Strips Lancet Device Glucometer Control Solution Sharps Container Cotton Balls

PROCEDURE: 1. Wash hands thoroughly with soap and water or an antiseptic gel and make sure they are dry. 2. Put on gloves. 3. Cock lancet device by pushing down on plastic holder until it clicks. 4. Insert the test strip with the three contact bars, facing up, into the monitor test port. 5. The glucometer should turn on. It will remain on until the strip is removed. 6. Check the number that appears against the lot number of the strip. If they are the same, then proceed with the test. If they are different, proceed to the PREPARATION portion of this protocol. 7. Remove the cover from the lancet and place it firmly on the tip of a finger. Push the button on the end to pierce the finger.

8. Apply a drop of blood to the end of the test strip. It will absorb the correct amount of blood and show - - - in the reading. Give the patient a cotton ball to absorb any residual blood. 9. The glucometer will count down to display the results. 10. Put the lancet device into the sharps container. 11. Remove the test strip from the meter and place it into the sharps container. 12. Put the cotton ball tissue into the trash bag. 13. Remove your gloves and wash your hands with soap and water or with the antiseptic gel cleanser. 14. Record the results and give a copy of the results to the patient. VIM PATIENT CARE PROCEDURES VIM Clinic - Eugene, OR April 2006

PREPARATION AND QUALITY CONTROL: 1. Glucometer Calibration a. Remove the plastic test strip from the strip box b. Insert the plastic test strip into the glucometer to set the Lot Number. This number should match the strip number. 2. Control TestingTo be done daily before testing patients a. Insert the test strip as above. b. After Apply Blood Appears in the window, press and hold the button until Control appears in the window. Release the button. c. Gently mix the control solution by inverting the control bottle 3-4 times. d. While the bottle is inverted, tap the cap once or twice to remove any bubbles in the bottles nozzle. Remove the cap and apply a drop of control solution to the end of the test strip. e. Move the bottle away once - - - appears in the window. The meter will begin counting down from 20 and then the results will appear. f. Compare the glucose control result to the correct value printed on the test strip package insert.

g. If the results are not within range, repeat the test. If they are still not in the range, then do not use the glucometer. Label the glucometer as Not Accurate and put it off to the side. Use a different glucometer 3. Battery Replacement a. Open the batter door by pushing the tab up and swinging the door open. b. Remove the old batteries. c. Replace the batteries by following the diagram in the bottom of the battery compartment to see which direction they are to be placed. Use 2 AAA alkaline batteries. d. Hook the battery door back onto the monitor. Swing it into place. Push on the door until it clicks closed. 4. Cleaning Use only a damp cloth to wipe the monitordo not immerse the monitor in water. Do not use alcohol on the monitor.

5. Results a. CBGs that are 20 and below, are recorded as Low on the glucometer. b. CBGs that are 500 and above are recorded as Hi on the glucometer. c. If the test is reading this high or low, alert the Clinic Manager or the Medical Director as this is a medical emergency.