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What is Central Venous Pressure?

a.

The pressure in the right atrium

b.

The pressure of venous blood in the vena cava

c.

The central venous pressure is a pressure not a volume

d.

Is considered a direct measurement of the blood pressure in RA and vena cava

e.

The CVP is often used to make estimates of circulatory function, in particular cardiac function and blood volume

Central venous pressure


a.

Is used to assess right ventricular function and systemic fluid status

b.

The CVP does not measure blood volume directly and is influenced by right heart function, venous return, right
heart compliance, intrathoracic pressure and patient positioning

c.

Blood from systemic veins flows into the right atrium : the pressure in the right atrium is the central venous
pressure (CVP)

d.

To measure central venous pressure (CVP), a catheter is used

e.

The catheter is also an important for :

f.

1.

Rapid infusion

2.

Infusion ofhypertonic solutions and medications that could damage veins

3.

Serial venous blood assessment

Normal CVP is 2-6 mm Hg /3-8cm H20

CVP is elevated by
a.

Overhydration which venous return

b.

Vasoconstriction, tricuspid insufisiensi

c.

Tamponade, emboli paru

d.

Heart failure or PA stenosis outflow and


lead to venous congestion

Positive pressure breathing, straining

CVP decreases with


a.

Hypovolemic shock from hemorrhage, fluid shift,


dehydration

b.

Vasodilatation

c.

myocard contractility

The reasons for inserting a catheter are


a.

Measurement of central venous pressure no peripheral veins are available

b.

Administration of vasoactive/inotropic could damage veins

c.

Administration of hypertonic solutions including total parenteral nutrition

d.

Haemodialysis/plasmapheresis

e.

Rapid infusion

f.

Serial venous blood assessment

Which central vein to cannulate?


a.
b.

e.

The fewest complications are the basilic vein or

c.

The Internal Jugular Vein

femoral vein

d.

The Antecubital Veins

The Subclavian Vein

Equipment required for central venous access


a.

Patient on a tilting bed, trolley or table

b.

Sterile pack and antiseptic solution

c.

Local anaesthetic : 5ml lignocaine 1% solution

d.

Appropriate CV catheter for age/route/purpose

e.

Syringes and needles

f.

Saline or heparinised saline to prime and flush the line after insertion

g.

Suture material - e.g. 2/0 silk on a straight needle

h.

Sterile dressing

i.

Shaving equipment for the area if very hairy (especially the femoral)

j.

Facility for chest X-ray if available

k.

Additional equipment required for CVP measurement includes: manometer tubing, a 3-way stopcock, sterile
saline, a fluid administration set, a spirit level and a scale graduated in centimeters

General technique for all routes


a.

Explain the procedure to the patient

b.

Shave the needle insertion area prepare and check all the equipment for use

c.

Sterilise the skin and drape the area use the small local anaesthetic needte to locate the vein before using the
larger needle

d.

Potential complications
a.

Position the patient as for the specific route

Early

g.

Catheter embolus

a.

Arterial puncture

h.

Pneumothorax

b.

Bleeding

c.

Cardiac arrhythmias

a.

Venous thrombosis

d.

Injury to the thoracic

b.

Cardiac perforation and tamponade

e.

Injury to nerves

c.

Infection

f.

Air embolism

d.

Hydrothorax

b.

Late

How to measure the CVP


a.

To be zeroed at mid-axillary line in the 4th ICS

b.

Open the Sway tap fluid fills manometer tubing

c.

Turn the tap to connect the patient, fluid level will drop to the level of the CVP (cmH2O)

d.

It will be slightly pulsatile and will continue to rise and fall slightly with breathing record the average reading

e.

In Intensive Care Units or theatres, electronic transducers may be connected which give a continuous readout
of CVP along with a display of the waveform

f.

The CVP reading from an electronic monitor is sometimes given in mmHg (same as blood pressure)

Guide to interpretation of the CVP in the hypotensive patient


a.

Low hypovolemia
- Give fluid challlenges until CVP rises and

c.

doesnt fall back again

- Rapid pulse

- If CVP rises and stays up but urine output or


blood

pressure

doesnt

improve

consider

inotropes
b.

Very high pericardial tamponade


- Muffled heart sounds

d.

Normal hypovolemia
- Rapid pulse

High heart failure

- Low urine output

Oxygen, diuretics, sit up, consider inotropes

- Poor capilary refill

- Vasodilatation/constriction
f.
e.

High tension pneumothorax

Low or normal or high sepsis

- Unilateral breath sounds

- Rapid pulse

- Assymetrical chest movement

- Signs of infection

- Resonant chest with tracheal deviation

- Pyrexia

- Rapid pulse

Jugular venous pressure


a.

The mean height of this coiumn (averaged over inspiration and expiration) represents the hydrostatic pressure
within the right atrium, the normal magnitude of which is 6 10 cmH2O

b.

Is commonly expressed as the vertical height (in cm) of this column of blood (the head) in relation to the sternal
angle (angle of Louis)

Measuring
a.

With the help of 2 rulers, this vertical height in relation to the sternal angle can be determined by the method of
triangulaton shown below

b.

the heat Of the jugular veanous pulse commonly seen at the level of the clavicle when he/she is reclining at an
angle of 45

c.

the hydrostatic pressure in the right atrium (in cm of H 2O) is equal to the vertical height (in cm) of the column cf
blood above the sternal angle plus 5 cm

Normal JVP is no more than 5 cm above the sternal angle


a.

Raised JVP is most commonly seen in right heart failure

b.

Is also a sign of fluid overload

c.

Can be due to cardiac tamponade or constrictive pericarditis

d.

JVP is also seen in superior vena cava (SVC) obstruction

Hepatojugular reflux
a.

A sign of venous congestion in the liver

b.

By applying pressure to the epigastrium and indirectly to the liver, more venous return is pushed out of the liver
towards the heart

General technique
a.

Lay the patient in a 45 reclining position

b.

Stand on his right side facing him

c.

Use the heel of your right hand to apply steasy pressure of the epigastric region of his abdomen for 15 20
seconds and note the JVP during this procedure

d.

Since breath-straining against a closed glottis can increase intra-thoracic pressure and JVP

e.

To instruct the patient to breath normally during this manouver

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