Measuring Central Venous Pressure

What is Central Venous Pressure?

The central venous pressure (CVP) is the pressure measured in the central veins close
to the heart. It indicates mean right atrial pressure and is frequently used as an
estimate of right ventricular preload. The CVP does not measure blood volume
directly, although it is often used to estimate this. In reality the CVP value is
determined by the pressure of venous blood in the vena cava and by the function of
the right heart, and it is therefore influenced not only by intravascular volume and
venous return, but also by venous tone and intrathoracic pressure, along with right
heart function and myocardial compliance.

Underfilling or overdistention of the venous collecting system can be recognised by

CVP measurements before clinical signs have become apparent. Under normal
circumstances an increased venous return results in an augmented cardiac output,
without significant changes in CVP. However with poor right ventricular function, or
an obstructed pulmonary circulation, the right atrial pressure rises, therefore causing a
resultant rise in measured CVP. Similarly, although it is possible for a patient with
hypovolaemia to exhibit a CVP reading in the normal range due to venoconstriction,
loss of blood volume or widespread vasodilation will result in reduced venous return
and a fall in right atrial pressure and CVP.

In a normal patient the mean right atrial pressure measured by the CVP closely
resembles the mean left atrial pressure (LAP). At end diastole left atrial pressure is
assumed to equal left ventricular end diastolic pressure (LVEDP), which in turn is
assumed to reflect left ventricular end diastolic volume (LVEDV). Thus, in normal
patients, CVP is assumed to be a reflection of left ventricular preload. However, in
patients with cardiac or pulmonary disease the right and left ventricles may function
independently. In these cases left ventricular preload should be estimated by
measuring the pulmonary capillary 'wedge' pressure, using a pulmonary artery
catheter (PAC), as this is a better guide to the venous return to the left side of the heart
than CVP. The PAC may also be connected to a computer to calculate the cardiac
output using a thermodilution technique and further guide patient management.

PAC are therefore sometimes used to measure left atrial pressure in patients with
significant right sided valve disease, right heart failure or lung disease as the CVP
may be unreliable in predicting the left atrial pressure in these cases.

When should CVP be measured?

Patients with hypotension who are not responding to basic clinical management.
 Continuing hypovolaemia secondary to major fluid shifts or loss.
Patients requiring infusions of inotropes.

How to measure the CVP ?

The CVP can be measured either manually using a manometer (Diagram 1) or

electronically using a transducer (Diagram 4). In either case the CVP must be
zeroed at the level of the right atrium. This is usually taken to be the level of the 4th
intercostal space in the mid-axillary line while the patient is lying supine. Each
measurement of CVP should be taken at this same zero position. Trends in the serial
measurement of CVP are much more informative than single readings. However if the
CVP is measured at a different level each time then this renders the trend in
measurement inaccurate.

1. Using the manometer

A 3-way tap is used to connect the manometer to an intravenous drip set on one side,
and, via extension tubing filled with intravenous fluid, to the patient on the other
(Diagram 1). It is important to ensure that there are no air bubbles in the tubing, to
avoid administering an air embolus to the patient. You should also check that the CVP
catheter tubing is not kinked or blocked, that intravenous fluid can easily be flushed in
and that blood can easily be aspirated from the line. The 3-way tap is then turned so
that it is open to the fluid bag and the manometer but closed to the patient, allowing
the manometer column to fill with fluid (Diagram 2). It is important not to overfill the
manometer, so preventing the cotton wool bung at the manometer tip from getting
wet. Once the manometer has filled adequately the 3-way tap is turned again this
time so it is open to the patient and the manometer, but closed to the fluid bag
(Diagram 3). The fluid level within the manometer column will fall to the level of the
CVP, the value of which can be read on the manometer scale which is marked in
centimetres, therefore giving a value for the CVP in centimetres of water (cmH2O).
The fluid level will continue to rise and fall slightly with respiration and the average
reading should be recorded.

2. Using the transducer

The transducer is fixed at the level of the right atrium and connected to the patient's
CVP catheter via fluid filled extension tubing. Similar care should be taken to avoid
bubbles and kinks etc as mentioned above. The transducer is then 'zeroed' to
atmospheric pressure by turning its 3-way tap so that it is open to the transducer and
to room air, but closed to the patient. The 3-way tap is then turned so that it is now
closed to room air and open between the patient and the transducer. A continuous
CVP reading, measured in mmHg rather than cmH2O, can be obtained. (Diagram 4)
 Diagram 1
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Diagram 2
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 Diagram 3
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 Diagram 4
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CVP

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central
[sentral]

pertaining to a center; located at the midpoint.

central cord syndrome injury to the central portion of the cervical spinal cord resulting in dispro
portionately moreweakness or paralysis in the upper extremities than in the lower; pathological c
hange is caused by hemorrhage oredema.

Central cord syndrome. From Ignatavicius andWorkman, 2002.

central fever sustained fever resulting from damage to the thermoregulatory centers of the hyp
othalamus.

central nervous system the portion of the NERVOUS SYSTEM consisting of the BRAIN and SPINAL
CORD. See also Plate 14.

central venous catheterization insertion of an indwelling catheter into a central vein for admini
stering fluid andmedications and for measuring CENTRAL VENOUS
PRESSURE. The most common sites of insertion are the jugular andsubclavian veins; however, s
uch large peripheral veins as the saphenous and femoral veins can be used in an emergencyev
en though they offer some disadvantages. The procedure is performed under sterile conditions
and placement of thecatheter 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 isbased on the nature and amount of fluid to be injected. Central veins are
able to accommodate large amounts of fluidwhen shock or hemorrhage demands rapid replace
ment. The larger veins are less susceptible to irritation from causticdrugs and from hypertonic n
utrient solutions administered during PARENTERAL NUTRITION.

PATIENT CARE. Patients who have central venous lines are subject to a variety of complications.
Air embolism is mostlikely to occur at the time a newly inserted catheter is connected to the intra
venous tubing. Introduction of air into thesystem can be avoided by having the patient hold his b
reath and contract the abdominal muscles while the catheterand tubing are being connected. Th
is maneuver increases intrathoracic pressure; if the patient is not able tocooperate, the connecti
on should be made at the end of exhalation.

Sepsis is a potential complication of any intravenous therapy. It is especially dangerous for patie
nts with centralvenous lines because they are seriously ill and less able to ward off infections. C
areful cleansing of the insertion site,sterile technique during insertion, periodic changing of tubin
g and catheter, and firmly anchoring the catheter to preventmovement and irritation are all esse
ntial 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 de
creases measurablyor if there is no fluctuation of fluid in the fluid column. Preventive measures i
nclude maintaining a constant flow ofintravenous fluids by IV pump or controller, periodic flushin
g of the catheter, heparin as prescribed, and looping andsecuring the catheter carefully to avoid
kinks that impede the flow of fluids. Cardiac arrhythmias can occur if the tip ofthe catheter come
s 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 centr
al venous pressure ismade possible by the insertion of a catheter through the median cubital vei
n to the superior vena cava. The distal end ofthe catheter is attached to a manometer (or transd
ucer and monitor) on which can be read the amount of pressure beingexerted by the blood insid
e 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 mustbe reset. For a multilumen catheter the distal port is used to measure ce
ntral venous pressure; for a pulmonary arterycatheter the proximal port is used.

An arterial line can also be used to monitor the central venous pressure. The waveform for a tra
cing of the pressurereflects contraction of the right atrium and the concurrent effect of the ventri
cles and surrounding major vessels. Itconsists of a, c, and v ascending (or positive) waves and
x and y descending (or negative) waves. Since systolic atrialpressure (a) and diastolic (v) press
ure 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 toaccommodate the current BLOOD
VOLUME. However, the trend of response to rapid administration of fluid is more significantthan t
he specific level of pressure. Normally the right heart can circulate additional fluids without an in
crease in centralvenous pressure. If the pressure is elevated in response to rapid administration
of a small amount of fluid, there isindication that the patient is hypervolemic in relation to the pu
mping action of the right heart. Thus, CVP is used as aguide to the safe administration of replac
ement fluids intravenously, particularly in patients who are subject to pulmonaryEDEMA. Central
venous pressure indirectly indicates the efficiency of the heart's pumping action; however, pulm
onary arterypressure is more accurate for this purpose.

A high venous pressure may indicate congestive HEART

FAILURE, HYPERVOLEMIA, cardiac TAMPONADE in which the heart isunable to fill, or VASOCONSTRI
CTION, which affects the heart's ability to empty its chambers. Conversely, a low venouspressure
indicates HYPOVOLEMIA and possibly a need to increase fluid intake.

pressure
(P) [preshur]

force per unit area.

arterial pressure (arterial blood pressure) BLOOD PRESSURE (def. 2).

atmospheric pressure the pressure exerted by the atmosphere, usually considered as the dow
nward pressure of aironto a unit of area of the earth's surface; the unit of pressure at sea level is
one ATMOSPHERE. Pressure decreases withincreasing altitude.
barometric pressure atmospheric p.

blood pressure

1. see BLOOD PRESSURE.

2. pressure of blood on walls of any blood vessel.

capillary pressure the blood pressure in the capillaries.

central venous pressure see CENTRAL VENOUS PRESSURE.

cerebral perfusion pressure the mean arterial pressure minus the intracranial pressure; a mea
sure of the adequacy ofcerebral blood flow.

cerebrospinal pressure the pressure of the cerebrospinal fluid, normally 100 to 150 mm Hg.

continuous positive airway pressure see CONTINUOUS POSITIVE AIRWAY PRESSURE.

filling pressure see mean circulatory filling PRESSURE.

high blood pressure hypertension.

intracranial pressure see INTRACRANIAL PRESSURE.

intraocular pressure the pressure exerted against the outer coats by the contents of the eyeba
ll.

intrapleural pressure (intrathoracic pressure) pleural pressure.

intrinsic positive end-expiratory pressure elevated positive end-

expiratory PRESSURE and dynamic pulmonaryHYPERINFLATION caused by insufficient expiratory
time or a limitation on expiratory flow. It cannot be routinely measured bya ventilator's pressure
monitoring system but is measurable only using an expiratory hold maneuver done by the clinici
an.Its presence increases the work needed to trigger the ventilator, causes errors in the calculati
on of pulmonarycompliance, may cause hemodynamic compromise, and complicates interpretat
ion of hemodynamic measurements.Called also auto-PEEP and intrinsic PEEP.

maximal expiratory pressure maximum expiratory pressure.

maximal inspiratory pressure the pressure during inhalation against a completely occluded air
way; used to evaluateinspiratory respiratory muscle strength and readiness for WEANING from m
echanical ventilation. A maximum inspiratorypressure above 25 cm H2O is associated with suc
cessful weaning.

maximum expiratory pressure (MEP) a measure of the strength of respiratory muscles, obtain
ed by having the patientexhale as strongly as possible against a mouthpiece; the maximum valu
e is near total lung CAPACITY.

maximum inspiratory pressure (MIP) the inspiratory pressure generated against a completely
occluded airway; used toevaluate inspiratory respiratory muscle strength and readiness for wea
ning from mechanical ventilation. A maximuminspiratory pressure above 25 cm H2O is associa
ted with successful WEANING.

mean airway pressure the average pressure generated during the respiratory cycle.

mean circulatory filling pressure a measure of the average (arterial and venous) pressure ne
cessary to cause filling ofthe circulation with blood; it varies with blood volume and is directly pro
portional to the rate of venous return and thus tocardiac output.

negative pressure pressure less than that of the atmosphere.

oncotic pressure the osmotic pressure of a colloid in solution.

osmotic pressure the pressure required to stop osmosis through a semipermeable membrane
between a solution andpure solvent; it is proportional to the osmolality of the solution. Symbol .

partial pressure the pressure exerted by each of the constituents of a mixture of gases.

peak pressure in mechanical ventilation, the highest pressure that occurs during inhalation.

plateau pressure in mechanical ventilation, the pressure measured at the proximal airway durin
g an end-inspiratorypause; a reflection of alveolar pressure.

pleural pressure the pressure between the visceral pleura and the thoracic pleura in the pleural
cavity. Called alsointrapleural or intrathoracic pressure.

positive pressure pressure greater than that of the atmosphere.

positive end-
expiratory pressure (PEEP) a method of control mode ventilation in which positive pressure is
maintainedduring expiration to increase the volume of gas remaining in the lungs at the end of e
xpiration, thus reducing the shuntingof blood through the lungs and improving gas exchange. A
PEEP higher than the critical closing pressure preventsalveolar collapse and can markedly impr
ove the arterial PO2 in patients with a lowered functional residual capacity, as inacute respiratory
failure.

Effects of the application of positive end-

expiratory pressure (PEEP) on the alveoli.A, Atelectatic alveoli before PEEP application. B, Opti
mal PEEP application hasreinflated alveoli to normal volume. C, Excessive PEEP application ov
erdistends thealveoli and compresses adjacent pulmonary capillaries, creating dead space withi
ts attendant hypercapnia. From Pierce, 1995.

pulmonary artery wedge pressure (PAWP) (pulmonary capillary wedge pressure (PCWP))
intravascular pressure,reflecting the left ventricular end diastolic pressure, measured by a SWAN
-GANZ CATHETER wedged into a small pulmonaryartery to block the flow from behind.

pulse pressure the difference between the systolic and diastolic pressures. If the systolic press
ure is 120 mm Hg andthe diastolic pressure is 80 mm Hg, the pulse pressure is 40 mm Hg; the
normal pulse pressure is between 30 and 40mm Hg.

urethral pressure the pressure inwards exerted by the walls of the urethra, which must be coun
teracted in order for urineto flow through; see also urethral pressure PROFILE.

venous pressure the blood pressure in the veins; see also CENTRAL VENOUS PRESSURE.

water vapor pressure the tension exerted by water vapor molecules, 47 mm Hg at normal bod
y temperature.

wedge pressure BLOOD

PRESSURE measured by a small catheter wedged into a vessel, occluding it; see also pulmonar
y capillary wedge pressure and wedged hepatic vein pressure.

wedged hepatic vein pressure the venous pressure measured with a catheter wedged into the
hepatic vein. Thedifference between wedged and free hepatic vein pressures is used to locate t
he site of obstruction in portal hypertension;it is elevated in that due to cirrhosis, but low in cardi
ac ascites or portal vein thrombosis.