CLINICAL TEACHING

ON
CENTRAL VENOUS
(CATHETER INSERTION AND
CVP MONITORING)
Prepared by
Vipin Singh
M.Sc. nursing 1st year
Hcn,srhu
 INTRODUCTION

Central venous catheters are inserted to measure and obtain right atrial
pressure and central venous pressure with jugular or subclavian catheter
placement. Clinically useful information can be obtained about right
ventricular preload, cardiovascular status, and fluid balance in patients. Central
venous catheters also are placed for infusion of vasoactive medications, total
parenteral nutrition, hemodialysis
 SITE OF INSERATION

Right subclavian vein

Internal jugular vein
Femoral vein
 INDICATION
 Blood loss
 Hypotension after major surgery
Right ventricular ischemia or infarction
Hemodialysis access
Administration of total parenteral nutrition or other hyperosmolar
solutions
Lack of peripheral venous access
Assessment of hypovolemia or hypervolemia
 INDICATION
Monitoring of central venous catheter (CVC) pressure
Long-term infusion of medications
 Placement of pulmonary artery catheters
 Placement of transvenous pacemakers
 CONTRINDICATION

 Fever
Coagulopathies

Presence of a permanent pacemaker

Persistent shock

 Obstruction of the superior or inferior vena cava, innominate vein,

subclavian veins, or internal jugular veins
 Respiratory distress
• CVC insertion kit
EQUIPEMENT
• Roll of 2-inch tape
• CVC of choice (single, dual, or triple lumen) • Dressing supplies
usually supplied with insertion needle , dilator, • Chlorhexidine-impregnated sponge
syringe, and guidewire • Moisture-proof underpad
• Antiseptic solution (e.g., 2% chlorhexidine-based
• Large sterile drapes or towels
preparation)
• 1% lidocaine without epinephrine
• Nonsterile gloves
• One 25-gauge, %8-inch needle • Hemodynamic monitoring system
• Large package of 4 X 4 gauze sponges • saline flushes or 0.9% sodium chloride vials, 10 to 30
• Suture kit (hemostat, scissors, needle holder) mL Additional equipment as needed includes the
• 3-0 or 4-0 nylon suture with curved needle following:
• Three-way stopcock • Hemodynamic monitoring system
• Syringes: One 10-mL to 12-mL syringe; two 3- • Intravenous (IV) solution with Luer-Lok
to 5-mL syringes; two 22-gauge, 1 1/2-inch administration
• set for IV infusion
needles
• Luer-lok extension tubing
• Face masks, head coverings, goggles (shield and
• Bed side monitor
mask combination may be used), sterile gloves, and
• Supplemental oxygen supplies
sterile gowns
• Emergency equipment
• No. 11 scalpel
• Heparin flushes
• Skin protectant pads or swab sticks
• Needleless caps
 PATIENT AND FAMILY EDUCATION

 Explain the need for the CVC insertion and assess patient and family understanding.

Explain the required positioning for the procedure and the importance of the patient not
moving during the insertion.
 Explain the need for sterile technique and that the patient's face may be covered.
PATIENT ASSESSMENT AND PREPARATION
Assess the patient's vital signs and pulse oximetry.
 Assess the patient's cardiac and pulmonary status.
Assess electrolyte levels (e.g., potassium, magnesium, calcium).
Assess the patient's coagulopathy status and determine whether the patient has recently
received anticoagulant or thrombolytic therapy.
 Patient Preparation
 Verify correct patient with two identifiers.

 Ensure that the patient and family understand preprocedural teaching.

Ensure that informed consent was obtained.

Perform a pre-procedure verification and time out, if non emergent.

Administer prescribed sedation or analgesics as needed.

Ifthe patient is obese or muscular and the preferred site is the internal jugular vein or
subclavian vein , assist with placing a towel posteriorly between tne shoulder blades.
 PROCEDURE

1. Prepare the IV solution or flush solution.

2. Prime the IV tubing or flush the entire pressure transducer system
3. Apply and maintain pressure in the pressure bag or device at 300 mm Hg.
4. Place a moisture-proof pad under the patient's back.
5. Apply sterile gown and gloves.
6. Assist, if needed, with preparing the site using 2% chlorhexidine based antiseptic
solution.2,3,5 Cleanse the site with a back-and-forth motion while applying friction for
30 seconds. Allow the antiseptic to remain on the insertion site and to air-dry completely
before catheter insertion.
7. While the physician or advanced practice nurse completes the skin preparation, ensure
patient con fort by explaining what is happening at the time.
A. Application of the antiseptic solution is cold and wet.
B. Injection of the local anesthetic may burn or sting as the tissue is infiltrated.
8. Assist as needed with applying a full drape to the patient with exposure of only the
insertion site.
9. Place the bed in a 15- to 25-degree Trendelenburg's position.
10. Monitor the heart rate, respiratory rate and rhythm, pulse oximetry, and any patient
response to the procedure.
11. Observe the cardiac monitor While the guidewire and catheter are advanced, and inform
the physician or advanced practice nurse immediately if a dysrhythmia occurs.
12. Once the catheter is placed and blood return is ensured, assist with flushing the lumens
with normal saline solution and connecting the IV or hemodynamic monitoring tubing
to the catheter.
13. Assist as needed with applying a sterile, occlusive dressing
14. Reposition the patient in a comfortable position.
15. Assist as needed with obtaining a chest radiograph as prescribed
16. Discard used supplies in appropriate receptacles.
IF
MONITORING(MANOMETER)
1. Place the patient flat in a supine
position if possible. Alternatively,
measurements can be taken with the
patient in a semi-recumbent position.
The position should remain the same
for each measurement taken to ensure
an accurate comparable result.
2. Line up the manometer arm with the
phlebostatic axis ensuring that the
bubble is between the two lines of the
spirit level
3. Move the manometer scale up and down to allow
the bubble to be aligned with zero on the scale. This is
referred to as 'zeroing the manometer‘

4. Turn the three-way tap off to the patient and open to

the manometer.

5. Open the IV fluid bag and slowly fill the manometer

to a level higher than the expected CVP
6. Turn off the flow from the fluid bag
and open the three way tap from the
manometer to the patient

7. The fluid level inside the manometer

should fall until gravity equals the
pressure in the central veins

8. When the fluid stops falling the CVP

measurement can be read. If the fluid
moves with the patient's breathing, read
the measurement from the lower number
9. Turn the tap off to the manometer

Transducer
1. The CVC will be attached to intravenous
fluid within a pressure bag. Ensure that the
pressure bag is inflated up to 300mmHg.
2. Place the patient flat in a supine position if
possible. Alternatively, measurements can be
taken with the patient in a semi-recumbent
position. The position should remain the same
for each measurement taken to ensure an
accurate comparable result.
3. Catheters differ between manufacturers,
however, the white or proximal lumen is suitable
for measuring CVP

4. Tape the transducer to the phlebostatic axis or

as near to the right atrium as possible

5. Turn the tap off to the patient and open to the

air by removing the cap from the three-way port
opening the system to the atmosphere.
6. Press the zero button on the monitor and wait while
calibration occurs
7. When 'zeroed' is displayed on the monitor, replace
the cap on the three-way tap and turn the tap on to the
patient.

8. Observe the CVP trace on the monitor. The

waveform undulates as the right atrium contracts and
relaxes, emptying and filling with blood. (light blue
in this image)
9. Document the measurement and report any
changes or abnormalities
The normal range for CVP is 5-10cm H2O (2-
6mmHg) when taken from the mid-axillary line at the
fourth intercostal space
Expected Outcomes Unexpected Outcomes
 Successful placement of a CVC Pain or discomfort during or after the
Infusion of IV solution insertion procedure
 The a, c, and v waves are identified with  Pneumothorax, tension pneumothorax
hemodynamic monitoring Misplacement of the catheter (e.g., carotid
CVP measurements are obtained artery, subclavian artery
Hemorrhage
Hematoma
Venous embolism
Heparin induced thrombocytopenia or
thrombosis