The CVP catheter is an important tool used to assess right ventricular function and systemic fluid status. Normal CVP is 2-6 mm Hg. CVP is elevated by : overhydration which increases venous return.

1. DR. PALLAVI
CENTRAL VENOUS
PRESSURE
MONITORING

2. WHAT IS A CENTRAL LINE
 It is a catheter that
provides venous
access via the
superior vena cava or
right atrium

3. Central line insertion sites
 An important factor in choosing the best site is the
operator's own knowledge and experience.
 Other factors are:
 Suitability of the vein for the job required
 Accessibility of alternative sites
(eg. multiple previous punctures; current infection at
puncture site)
 Duration of catheter use
(eg. femoral vein not suitable for long term use due to
high infection risk in groin)
 Success rate
 Complication rate
 Ease of learning
 Urgency of cannulation

4. Central line insertion sites

5. INSERTION SITES
Central Vein Pros Cons
Internal
Jugular Vein
•Consistent, predictable anatomy
•Easily palpable landmarks
•Short straight course to SVC
•Valveless
•High success rate (>90%)
•Carotid artery directly
compressable (with care) if
punctured
•Awkward for patients
(lines drag at neck)
•Accidental pnuemothorax during insertion
(mainly with ‘low approach' to IJV)
•Damage to neck anatomy eg.
carotid artery
stellate ganglion
phrenic nerve
Subclavian
Vein
•More comfortable for patients than
IJV
•Good for long term cannulation
•Higher incidence of pneumothorax than IJV
•Accidental puncture of subclavian artery
during insertion
•Difficult to apply direct pressure if artery
punctured – haemothorax /
haemomediastinum possible

6. INSERTION SITES
Femoral Vein •Low complication rate
•Femoral artery easy to
compress if accidentally
punctured
•Groin area subject to infection
•Impairs patient mobility
•Requires long catheter to reach
thorax (eg. for CVP
measurement)
External Jugular Vein •Superficial vein – can be
cannulated under direct vision
•Less risk of damage to neck
anatomy
•Rapid cannulation possible
•Venous valves may prevent
smooth insertion of cannula into
central circulation
•Smaller vessel – large sheaths
may tear vessel wall

7. PERIPHERAL INSERTION
SITES
 Peripherally inserted central catheters (PICC)
which are inserted via the antecubital veins
(basilic vein is the best) in the arm and is
advanced into the central veins.
Antecubital Vein
(Basilic and Cephalic)
•Low complication rate •High failure rate
•Increased risk of thrombosis
and thrombophlebitis
•Smaller vessels – large sheaths
may tear vessel walls

8. WHAT IS CENTRAL VENOUS
PRESSURE
 The central venous pressure (CVP) is the
pressure measured in the central veins
close to the heart.
 The pressure within the superior vena cava
or the right atrium
 It indicates mean right atrial pressure and
is frequently used as an estimate of right
ventricular preload.
 Normal CVP ranges from 5 to 10 cm H2O
or 2 to 6 mm Hg.

9.  CVP is elevated by :
 over hydration which increases venous return
 heart failure or PA stenosis which limit venous
outflow and lead to venous congestion
 positive pressure breathing, straining
 CVP decreases with:
 hypovolemic shock from haemorrhage, fluid
shift, dehydration
 negative pressure breathing which occurs when
the patient demonstrates retractions or
mechanical negative pressure which is
sometimes used for high spinal cord injuries.

10. CVP READINGS ARE USED
 Serve as a guide to fluid balance in critically
ill patients
 Estimate the circulating blood volume
 Assist in monitoring circulatory failure
 CVP monitoring helps to assess cardiac
function, to evaluate venous return to the
heart, and to indirectly gauge how well the
heart is pumping.
 Allows frequent blood withdrawal for
laboratory samples.

11. METHODS OF CVP
MONITORING
 There are two methods of CVP monitoring
 manometer system: enables intermittent
readings and is less accurate than the
transducer system
 transducer system: enables continuous
readings which are displayed on a monitor.

12. Equipment
 For intermittent CVP monitoring: Disposable CVP
manometer set, leveling device (such as a rod from a
reusable CVP pole holder or a carpenter’s 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.)

13. 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 patient’s chest so that all subsequent recordings
will be
made using the same location.
 If the patient can’t tolerate a flat position, place him in semi-Fowler’s 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 patient’s chest.
 Make sure the zero reference point is level with the right atrium.

15. 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
 It is important to ensure that there are no air
bubbles in the tubing, to avoid administering an
air embolus to the patient.
 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

17.  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

19.  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.

21. 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.
 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

23. Removing a CV line
 You may assist the physician in removing a CV line.
 If the head of the bed is elevated, minimize the risk of air
embolism during catheter removal—for instance, by
placing the patient in Trendelenburg’s position if the line
was inserted using a superior approach.
 If he can’t tolerate this, position him flat.

24.  Turn the patient’s 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.

25.  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.

26. Special considerations
 As ordered, arrange for daily chest X-rays to
check catheter placement.
 Care for the insertion site according to your
facility’s policy.
 Typically, you’ll 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.

27.  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.

28.  If the patient’s 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.

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

30. Documentation
 Document all dressing, tubing, and solution
changes.
 Document the patient’s 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.

31. THANK YOU.