CENTRAL VENOUS PRESSURE MONITORING

Dr. Aidah Abu Elsoud Alkaissi An-Najah National University Nursing College

Diagram of placement of central venous catheter: the catheter is tunneled under skin and enters the superior vena cava into the right side of the heart

Tunneled CVC

CENTRAL VENOUS PRESSURE MONITORING

In central venous pressure monitoring, the physician inserts a catheter through a vein and advances it until its tip lies in or near the right atrium. Because no major valves lie at the junction of the vena cava and right atrium, pressure at end diastole reflects back to the catheter. When connected to a manometer, the catheter measures central venous pressure (CVP), an index of right ventricular function. CVP monitoring helps to assess cardiac function, to evaluate venous return to the heart, and to indirectly gauge how well the heart is pumping. The central venous (CV) line also provides access to a large vessel for rapid, high-volume fluid administration and allows frequent blood withdrawal for laboratory samples.

CVP monitoring can be done intermittently or continuously.

The catheter is inserted percutaneously or using a cutdown method. Typically, a single lumen CVP line is used for intermittent pressure readings. To measure the patients volume status, a disposable plastic water manometer is attached between the I.V. line and the central catheter with a three- or four-way stopcock. CVP is recorded in centimeters of water (cm H2O) or millimeters of mercury (mm Hg) read from manometer markings. Normal CVP ranges from 5 to 10 cm H2O or 2 to 6 mm Hg.

Any condition that alters venous return, circulating blood volume, or cardiac performance may affect CVP.
If circulating volume increases (such as with enhanced venous return to the heart), CVP rises. If circulating volume decreases (such as with reduced venous return), CVP drops.

Equipment

For intermittent CVP monitoring: Disposable CVP manometer set leveling device (such as a rod from a reusable CVP pole holder or a carpenters level or rule) additional stopcock (to attach the CVP manometer to the catheter) extension tubing (if needed) I.V. pole I.V. solution I.V. drip chamber and tubing dressing materials tape.

For continuous CVP monitoring: Pressure monitoring kit with disposable pressure transducer leveling device bedside pressure module continuous I.V. flush solution 1 unit/1 to 2 ml of heparin flush solution pressure bag.
For withdrawing blood samples through the CV line: Appropriate number of syringes for the ordered tests 5- or 10-ml syringe for the discard sample. (Syringe size depends on the tests ordered.) For using an intermittent CV line: Syringe with normal saline solution syringe with heparin flush solution.

For removing a CV catheter: Sterile gloves suture removal set sterile gauze pads povidone-iodine ointment dressing tape.

Implementation

Gather the necessary equipment. Explain the procedure to the patient to reduce his anxiety. Assist the physician as he inserts the CV catheter. (The procedure is similar to that used for pulmonary artery pressure monitoring, except that the catheter is advanced only as far as the superior vena cava.)

Obtaining intermittent CVP readings with a water manometer

With the CV line in place, position the patient flat.

Align the base of the manometer with the previously determined zero reference point by using a leveling device. Because CVP reflects right atrial pressure, you must align the right atrium (the zero reference point) with the zero mark on the manometer. To find the right atrium, locate the fourth intercostal space at the midaxillary line. Mark the appropriate place on the patients chest so that all subsequent recordings will be made using the same location.

If the patient cant tolerate a flat position, place him in semi -Fowlers position. When the head of the bed is elevated, the phlebostatic axis remains constant but the midaxillary line changes. Use the same degree of elevation for all subsequent measurements. Attach the water manometer to an I.V. pole or place it next to the patients chest. Make sure the zero reference point is level with the right atrium.

MEASURING CVP WITH A WATER MANOMETER

To ensure accurate central venous pressure (CVP) readings, make sure the manometer base is aligned with the patients right atrium (the zero reference point).
The manometer set usually contains a leveling rod to allow you to determine this quickly.

After adjusting the manometers position, examine the typical three-way stopcock. By turning it to any position shown at right, you can control the direction of fluid flow. Four-way stopcocks also are available.

All openings blocked

Manometer to patient

I.V. solution to manometer

I.V. solution to patient

I.V. solution bottle

Manometer

Zero point Three-way stopcock

Verify that the water manometer is connected to the I.V. tubing. Typically, markings on the manometer range from 2 to 38 cm H2O.
However, manufacturers markings may differ, so be sure to read the directions before setting up the manometer and obtaining readings. Turn the stopcock off to the patient, and slowly fill the manometer with I.V. solution until the fluid level is 10 to 20 cm H2O higher than the patients expected CVP value. Dont overfill the tube because fluid that spills over the top can become a source of contamination.

Turn the stopcock off to the I.V. solution and open to the patient.
The fluid level in the manometer will drop. When the fluid level comes to rest, it will fluctuate slightly with respirations. Expect it to drop during inspiration and to rise during expiration. Record CVP at the end of expiration, when intrathoracic pressure has a negligible effect. Depending on the type of water manometer used, note the value either at the bottom of the meniscus or at the midline of the small floating ball. After youve obtained the CVP value, turn the stopcock to resume the I.V. infusion. Adjust the I.V. drip rate as required. Place the patient in a comfortable position.

Obtaining continuous CVP readings with a water manometer

Make sure the stopcock is turned so that the I.V. solution port, CVP column port, and patient port are open.
Be aware that with this stopcock position, infusion of the I.V. solution increases CVP. Therefore, expect higher readings than those taken with the stopcock turned off to the I.V. solution.

If the I.V. solution infuses at a constant rate, CVP will change as the patients condition changes, although the initial reading will be higher. Assess the patient closely for changes.

Obtaining continuous CVP readings with a pressure monitoring system

Make sure the CV line or the proximal lumen of a pulmonary artery catheter is attached to the system. (If the patient has a CV line with multiple lumens, one lumen may be dedicated to continuous CVP monitoring and the other lumens used for fluid administration.) Set up a pressure transducer system. Connect noncompliant pressure tubing from the CVP catheter hub to the transducer. Then connect the flush solution container to a flush device. To obtain values, position the patient flat.

If he cant tolerate this position, use semi-Fowlers position.

Locate the level of the right atrium by identifying the phlebostatic axis. Zero the transducer, leveling the transducer air-fluid interface stopcock with the right atrium.

Read the CVP value from the digital display on the monitor, and note the waveform.
Make sure the patient is still when the reading is taken to prevent artifact. Be sure to use this position for all subsequent readings.

Removing a CV line

You may assist the physician in removing a CV line.

(In some states, a nurse is permitted to remove the catheter with a physicians order or when acting under advanced collaborative standards of practice.) If the head of the bed is elevated, minimize the risk of air embolism during catheter removalfor instance, by placing the patient in Trendelenburgs position if the line was inserted using a superior approach. If he cant tolerate this, position him flat.

Turn the patients head to the side opposite the catheter insertion site.
The physician removes the dressing and exposes the insertion site. If sutures are in place, he removes them carefully. Turn the I.V. solution off. The physician pulls the catheter out in a slow, smooth motion and then applies pressure to the insertion site.

Clean the insertion site, apply povidone-iodine ointment, and cover it with a dressing as ordered.
Assess the patient for signs of respiratory distress, which may indicate an air embolism.

Special considerations

As ordered, arrange for daily chest X-rays to check catheter placement.

Care for the insertion site according to your facilitys policy. Typically, youll change the dressing every 24 to 48 hours.

Be sure to wash your hands before performing dressing changes and to use aseptic technique and sterile gloves when re-dressing the site.

When removing the old dressing, observe for signs of infection, such as redness, and note any patient complaints of tenderness.
Apply ointment, and then cover the site with a sterile gauze dressing or a clear occlusive dressing. After the initial CVP reading, reevaluate readings frequently to establish a baseline for the patient. Authorities recommend obtaining readings at 15-, 30-, and 60-minute intervals to establish a baseline.

If the patients CVP fluctuates by more than 2 cm H2O, suspect a change in his clinical status and report this finding to the physician
Change the I.V. solution every 24 hours and the I.V. tubing every 48 hours, according to facility policy. Expect the physician to change the catheter every 72 hours. Label the I.V. solution, tubing, and dressing with the date, time, and your initials.

Complications

Complications of CVP monitoring include: pneumothorax (which typically occurs upon catheter insertion) sepsis thrombus vessel or adjacent organ puncture, and air embolism

Documentation

Document all dressing, tubing, and solution changes. Document the patients tolerance of the procedure, the date and time of catheter removal, and the type of dressing applied.

Note the condition of the catheter insertion site and whether a culture specimen was collected. Note any complications and actions taken.

Film of CVC

http://www.youtube.com/watch?v=Lb1Z3bndmA8 &NR=1 http://www.youtube.com/watch?v=p_0MQ75PK5U &NR=1

http://www.youtube.com/watch?v=m7ppMf3JnoE& NR=1 http://www.youtube.com/watch?v=nBNnS_0kC6o &NR=1 http://www.youtube.com/watch?v=Lb1Z3bndmA8

Film of CVC

http://www.youtube.com/watch?v=ycJPmyHLuM&NR=1 http://www.youtube.com/watch?v=FXJvv SbgVTE&NR=1