DR JYOTHSNA

CHAI RPERSON DR SUNI L CHHABRI A

Central venous pressure monitoring.
CENTRAL VENOUS PRESSURE MONITORING.
Cannulation of a large central vein is the standard
clinical method for monitoring CVP.

The following are the indications
Central venous pressure monitoring
PAC and monitoring
Transvenous cardiac pacing
Drug administration vasoactive drugs,
hyperalimentation, Chemotherapy, Drugs that
cannot be given in peripheral line.
Central venous pressure monitoring.
Prolonged antibiotic therapy ,Rapid infusion of fluids through
the canula.
Trauma ,Major Surgery , Aspiration of air emboli ,
Inadequate peripheral venous access
Sampling site for repeated blood testing.

Preferred sites for cannulation :

RIJV, LIJV, Sub Clavian Vein ,External Jugular ,Femoral ,
Axillary vein and other peripheral veins.
Central Venous Pressure Monitoring
Contraindications.

SVC syndrome and infection at the site of insertion.

Relative Contraindication
Coagulopathies , Newly inserted pacemaker wires , Presence
of carotid disease , Recent cannulation of IJV , Contralateral
diaphragmatic dysfunction , Thyromegaly or recent neck
surgery.
Central Venous Pressure Monitoring.
Technique for RIJV cannulation.
Seldinger technique.
Pt to be connected to all routine monitoring and supplemental
O2 to be given.
Can be done under sedation and local infiltration or after
induction of the patient.
CDC guidelines.
Landmarks assessed Sternal notch ,clavicle , Strenomastoid ,ICA
should be palpated.
ICA is palpated close or under the medial head of the
sternocleidomastoid. The vein lies just lateral or sometimes
anterior to it.
Central Venous Pressure Monitoring.
Head turned laterally and pillow removed
Use of local anesthetic for skin infiltration.
Finder needle from the apex of the triangle towards
ipsilateral nipple at 30deg to the skin.
Use of the finder needle improves the safety of the
technique.
In c/o failure to locate the needle moved in a fanwise
direction laterally never medially.
Once located venipuncture with an 18G needle till free flow
of venous blood into the syringe.
J tipped guide wire advanced and watching on the monitor
continuosly for the appearance of ectopic.
Central Venous Pressure Monitoring.
Skin and venous dilator is used
Catheter is inserted .Should be inserted to a depth of 15-
18cms.
Sutured in place
Guidelines suggest all 4 sutures to be put.
No antibiotic ointment should be applied ,due to
colonisation by drug resistant bacteria and candida.
Should always be confirmed radiographically.
Should lie within the SVC positioned below the inferior
border of the clavicle.
Should be at or above the level of the tracheal carina.

Central Venous Pressure Monitoring.
Cannulation of RIJV is by default the first choice as the
surface landmarks are easily identified.
Selecting the best site for safe and effective central venous
cannulation depends on the purpose of catheterisation ,pts
undelying medical condition,pts intended operation and
skill and experience of the physician performing the
procedure.
Eg In patients with bleeding diathesis EJV is best over the
IJV or subclavian.
In patients with emphysema IJV is preferred over
subclavian as there is higher risk for pneumothorax in these
group of patients.
Patients with cervical injury or suspected head injury
Central Venous Pressure Monitoring.
femoral or subclavian is a choice and lastly physician choice
and comfort.

Advantages of Ultrasound Guided Technique

fewer needle passes are required
Reduces the time required for catheterisation ,increase
overall success rates and results in fewer complications.
Studies showed there is a reduced risk of carotid A puncture
(1.7% vs 8.3%)
Brachial plexus irritation (0.4% vs 1.7%)
Hematoma formation(0.2% vs 3.3%)

Central Venous Pressure Monitoring
Large veins are easily recognised by their proximity to the
arteries ,no pulsatality ,enlarged by valsalva manouver and
compressibility using the ultrasound probe.

ALTERNATIVE SITES.

Left IJV similar technique of cannulation as the right The
disadvantages are Cupola of the pleura is higher on the left
,Thoracic duct may be injured during venepuncture
,Anatomically smaller than the RIJV left sided catheters
traverse a longer distance.
Central Venous Pressure Monitoring
Subclavian
Owing to the large size used in emergency rooms for large
volume fluid resucitation , Long term IV therapy ,Lower
risk of infection compared to IJV or femoral sites ,increased
patient comfort especially for long term therapy ,
hyperalimentation and chemotherapy.

The infralavicular approach is commonly used where the
arms are adducted ,head turned away,small bedroll to fully
expose the infraclavicular area ,
Skin puncture is done 2-3 cms caudad to the midpoint of
the clavicle ,needle tip is advanced towards the suprasternal
notch advancing below the posterior surface of the clavicle.
Central Venous Pressure Monitoring.
B/L should never be tried.
Procedure to be aborted after 3 needle passes .

EJV
Good alternative and because the vein is more superficial
there is no risk of pneumothorax or arterial puncture.
A J wire is used so as to negotiate under the clavicle and
procedure is made easy by abducting the ipsilateral
shoulder beyond 90 deg.

Femoral Vein identified by palpating the femoral A below the
inguinal ligament and going medial to it.
40-70cms catheter introduced under ECG guidance at the
cavoatrial junction.


Central Venous Pressure Monitoring.
15 to 20 cms into the common iliac vein.
Both reflect intra abdominal pressures and in conditions
where it is raised will give false readings.

Disadvantages
Increased risk of thromboembolic and infectious
complications.
Injury to the femoral A

Axillary vein
Good alternative in patients with extensive burns as axilla is
usually spared.
20cms cvp catheters are used


Central Venous Pressure Monitoring.
Disadvantage

Patient discomfort , easy kinking and misplacement of lines.

Peripherally introduced central catheters.
Popular alternative to central veins.
Advantage is that can be done as a bedside procedure under
local anesthesia ,low risk of complications.
Antecubital vein is used bascilic is preferred over the cephalic
vein.
These are silicone catheters which are very flexible , non
thrombogenic and safely used when long term therapeutic
indications are there.
Central Venous Pressure Monitoring.
When a PICC line is in place the clinician should exercise
caution when placing any additional central venous catheters
because of the risk of shearing the PICC line within the
central venous circulation.

Central Venous Pressure Monitoring.
Physiological Considerations ,Normal and Abnormal
waveforms.
Acc to the Frank Starling Law the force of cardiac contraction
is directly proportional to the end diastolic muscle fibre
length which is directly proportional to the preload or end
diastolic chamber volume.

P/V Ventricular Compliance change in pressure for a
change in volume , reciprocal of compliance and is termed
ventricular elastance ,distensibility or stiffness.
Stiff ventricles will have greater pressure changes for a small
change in volumes.
Central Venous Pressure Monitoring
measure of changes in the right atrium which reflects changes
in the right ventricular end diastolic pressure.
Estimate cardiac function and blood volume indirectly.
Determined by the function of the right heart.

CVP and Left Heart
In a normal patient it reflects the left tarial pressures closely
assuming that there is no right ventricular disease and
normal pulmonary vascular resistance.
Central Venous pressure monitoring.
The inserted lines are transduced and a waveform obtained
and cvp is measured.

Normal cvp ranges between 3-8mmHg or 5 -10cm of H2O in
a spontaneously breathing adult and 1-7 mmHg in children.

Normal central venous pressures.

Right Atrium 2-7mmHg
Right Ventricles 15-30mmHg
Pulmonary A 9-19mmHg
PAWP 4-12mmHg
Left Atrium 4-16mmHg
Left Ventricle 90-140mmHg
Central Venous Pressure Monitoring.
Aorta 90-140mmHg
Central Venous Pressures are highly dependant on the intravascular
blood volume and the vascular tome of these capacitance vessels.

Normal Waveform has 3 peaks a,c,v and 2 descents x and y.

a End Diastole Atrial contraction just after the p wave on
ECG
c Early Systole Isovolumic ventricular contraction
tricuspid motion towards right atrium
v late systole systolic filling up of the right atrium
x mid systole Atrial relaxation, tricuspid pulled away
from the right atrium during RV ejection
y early diastole early ventricular filling diastolic collapse.
Central venous Pressure Monitoring.
h mid to late diastole Diastolic plateau.
h wave is not normally seen unless the heart rate is slow and
venous pressures are elevated.

3 systolic components c wave ,x descent and the v wave
2 diastolic components y descent and a wave.

Variations
a-c wave When PR interval is short the a wave seems to
merge with the c HR and conduction abnormalities alter the
normal pattern.
Central Venous Pressure Monitoring
Respiration and CVP

During spontaneous ventillation , a decrease in pleural and
pericardial pressures occur during inspiration ,these are
pressures transmitted to the right atrium.
Causes a decrease in the measured cvp
Mechanical ventillation causes the opposite effect
Pleural and pericardial pressures are almost equal to
atmospheric pressures at end expiration
This is true with spontaneous and mechanical ventillation
This point provides the best estimate of the pressures and
cardiac preload
Central Venous Pressure Monitoring.
Atrial fibrillation

Atrioventricular dissociation
Tricuspid regurgtation

Tricuspid stenosis

Right ventricular ischemia


Pericardial constriction
Loss of a wave and
prominent c waves
Cannon a wave
Tall systolic c-v wave and
loss of x descent
Tall a wave ,Attenuation of
y descent
Tall a and v waves Steep x
and y descents and M or W
pattern
Tall a and v waves
Central Venous Pressure Monitoring
Cardiac tamponade

Respiratory variation during
spontaneous or IPPV
Dominant x descent and
attenuated y descent.
Measures pressures at end
expiration
Central Venous Pressure Monitoring
Complications

Vascular injuries Arterial 2 % of patients,Venous or Cardiac
tamponade resulting from intrapericardial injusry to SVC right
atrium or ventricle and inadvertant fluid administration.
Vascular perforation into pleural space or mediastinum resulting in
hydrothorax , hemothorax , chylothorax ,pneumothorax (common
during subclavian cannulation)
Nerve injury to brachial plexus and Horners syndrome.
Thromboembolic complications catheter related ,occurs in 15% of the
patients.
Catheter ,guidewire or air embolism.
Infectious complications. Sepsis endocarditis.