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Central Venous Pressure and Central lines

Big Lines for

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Challenging Knowledge

Before starting this module; Answer following questions

(1)What sites are used to site a CVL?(2)What is the normal CVP?(3)What are the basic treatments of -1cm of H20(4)What are the essential measure a

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Learning Outcomes

By the end of this module you should

(1)Be aware of factors which affect the CVP(2)Recognise normal and abnormal CVP (3)Be able to set up the manometer measure a patients CVP(4)Be able to measure a CVP value(5)Be aware of the initial low values

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Factors affecting the CVP

The central venous pressure reflects the right atrialpressure(RAP) and is similar to measuring the JVP clinically

The factors which affect the CVP are:-

Systemic vasodilatation and hypovolaemia, reduced venous return in the vena

Right ventricular failure

Tricuspid and Pulmonary

Pulmonary hypertension

Right ventricular to raised right as does stenosis.

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Central venous line (CVL)

Indications for CVL

Severe hypovolaemiarequiring rapid infusion

(although initial resuscitation may be peripheral through

Infusion of drugs which may cause problems e.g. vasoconstriction, Measurement of central venous Confirmation of diagnosis Insertion of a pacing wire.

Sites for insertionInternal jugular, femoral also inserted the brachial

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How to measure the CVP using a manometer

Patient positionedsupineonthe bed

The CVP systemA bag of saline or dextrose = reservoirThree way tap -connected to manometer, reservoir and patients CVL by tubing; System is primed with fluid before startingPatient is lying supine if possible Manometer has spirit level at zero; Zero point is aligned with right using the mid axillaryline / 4thICSMeasurements should be patient in the same position using the spirit level; the skin surface consistency way tap

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How to measure the CVP using a manometer system

Turn the three way tap OFF to the patient.Fill the manometer to the top from the reservoirTurn the three way tap OFF to the reservoirThis means the column of fluid is supported only by the RAP / CV pressureThe column will fall according to CVPThe column swings with respiration conventionally the level mean.

Three way tap OFF to the patient allowing themanometer to be filled

Three way tap OFF to the reservoir allowing theCVP to be measured

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Normal CVP measurements

The normal CVP is between 5 10 cm ofH2O (it increases 3 5cm H2O whenpatient is being ventilated)In high dependency areas transducer is connected manometer system. readout of CVP along waveform. This mmHg.

(Note:10 = 7.5mmHg

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CVP Reading

Other clinical features

Diagnosis

Treatment

Low

Tachycardia

Low normalor hypotension

Urine outputoligoor anuria

Hypovolaemia

Fluid challenge until CVP within normal limitsand treat underlying cause

Low

( may be normal or high due to venoconstriction)

Tachycardia

Signsof infectionPyrexiaVasodilationismostcommonbut

severesepsismaybeassociated withconstriction

Sepsis

Fluid resuscitation (if low)

Antibiotics

May require inotropesupport

Normal due to venoconstriction

Tachycardia

Urine outputfallingbelow 30ml/hr

Poor

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capillaryrefill

Hypovolaemia

Fluid challenge and treatunderlying cause

High

Dyspnoea with pulmonarycrepitations

Tachycardia withthirdheartsoundTender hepatomegaly

Ascites

Peripheral Oedema

Heart failure

Diuretics, GTN infusion, may requireinotropes

Very High

Venous congestion dilatation neck; associated signs

SVC obstruction

Cardiac tamponade

Tension

Treat underlying cause

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Case (1) How low can you go?

A 32 year old woman with known alcoholassociated liver disease presents with melaena. Initially she is haemodynamicallystable and well perfused. She suddenly decompensateswith fresh blood and clotsbeing passed PR. Initial resuscitation with several litres of crystalloid and some colloid fails to bring her systolic BP back above 100 mm Hg. A CVP line is inserted and shows her CVP to be +1 cmH2O.

(a) What is the likely

(b) List your further including investigations medications

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Case (2) CVP Pat pending

A 31 year old man presents to A&E with a 3 month history of night sweats and weight loss. On examination he is unwell, pyrexialand has several large cervical lymph nodes. He is noted to have poorly palpableradial pulse, apositive Kussmaulssign and poorly heard heart sounds. The SHO decides to site a CVP which is measured at 28 cm of H2O.

(a) What is the likely diagnosis?

(b) What is the

(c) Howwill you prove diagnosis?

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Case (3)

A 48 year old poorly controlled Type 2 diabetic admitted from the Diabetes clinic with a ulcer. His observations are: pulse 120bpm, cm of H20 and he is noted tobe sweaty and Despite initial resuscitation with hours, his BP and pulse fail ventilated and admitted to he is started oninotropes.

(1)What is the given to this clinical (2)List your

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Learning Outcomes

At the end of this module you should

(a)Be aware of the factors affecting (b)Be able to set up a CVP manometer system.(c)Be able to measure a (d)Be able to interpret (e)Be able to institute based on

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