This document discusses monitoring central venous pressure through central venous catheters. It describes the types of central lines, their indications and contraindications, and techniques for insertion. Factors that affect central venous pressure are outlined, as are methods to measure pressure directly through transducers or indirectly by inspecting jugular veins. The document interprets central venous pressure waveforms and describes how pressure changes with respiration.

1. MONITORING OF CENTRAL VENOUS
PRESSURE & ITS TECHNIQUES
Dr. PURAM SRINIVAS
KAMINENI INSTITUTE OF MEDICAL SCIENCES,TELANGANA

2. OVERVIEW
• Introduction
• Types Of Central Line
• Indications & Relative Contraindications Of
Central Venus Line (CVL)
• PICC Line Indications & Contraindications
• CVL Insertion
• Factors Affecting CVP
• Central Venous Pressure
Monitoring
• Interpretation Of Waveforms
• Summary

3. INTRODUCTION
• 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.
• CVP reflects the amount of blood returning to the
heart and the ability of the heart to pump the blood
into the arterial system

4. INTRODUCTION Cont’
• It is the pressure measured at the junction of the
superior vena cava and the right atrium.
• It reflects the driving force for filling of the right
atrium & ventricle.
• Normal CVP in an awake spontaneously breathing
patient : 1-7 mmHg or 5-10 cm H2O.
• Mechanical ventilation : 3-5 cm H2O higher

5. TYPES OF CENTRAL LINE
• SINGLE LUMEN
• DOUBLE LUMEN
• TRIPLE LUMEN
• QUADRUPLE LUMEN
• QUINTUPLE LUMEN
• PERIPHERALLY INSERTED CENTRAL CATHETERS
(PICCS)

6. Single, Double, and Triple Lumen
Central Lines

7. Indications Central Venus Line (CVL)
• Major operative procedures involving large fluid
shifts or blood loss
• Intravascular volume assessment when urine output
is not reliable or unavailable
• Temporary Hemodialysis
• Surgical procedures with a high risk for air embolism,
CVP catheter may be used to aspirate intracardiac air

8. Indications Central Venus Line (CVL) CONT’
• Frequent venous blood sampling, Inadequate
peripheral intravenous access
• Temporary pacing
• Venous access for vasoactive or irritating drugs &
Chronic drug administration
• Rapid infusion of intravenous fluids (using large
cannulae)
• Total parenteral nutrition

9. Relative Contraindications
• Bleeding disorders (platelet counts <50,000,
bleeding is uncommon and easily managed).
• Anticoagulation or thrombolytic therapy.
• Combative patients.
• Distorted local anatomy.
• Cellulitis, burns, severe dermatitis at site.
• Vasculitis.

10. Peripherally Inserted Central
Catheters (PICCs)
• LOCATION OR SITE OF
INSERTION
• INDICATIONS
• CONTRAINDICATIONS
• BENEFITS AND RISKS

12. PICC LINE INTRODUCTION
• A Peripherally Inserted Central Catheter (PICC)
is a small gauge catheter that is inserted
peripherally but the tip sits in the central
venous circulation in the lower 1/3 of the
superior vena cava.
• It is suitable for long term use and there are
no restrictions for age, or gender.

13. SITE’S OF INSERTION OF PICC LINE
• PICCs are commonly placed at or above the
antecubital space in the following veins;
 Cephalic vein
 Basilic vein
 Medial-cubital vein

14. INDICATIONS FOR PICC LINE
INSERTION
• PICC lines are suitable for many situations when
access is limited or expected to last longer than 2
weeks.
• Compromised/Inadequate peripheral access
• Infusion of hyperosmolar solutions or solutions with
high acidity or alkalinity
(e.g. Total Parenteral Nutrition)
• Infusion of vesicant or irritant agents
(Inotropes, Chemotherapy)
• Short or long term intravenous therapy
(e.g. Antibiotics)

15. CONTRAINDICATIONS FOR PICC
INSERTION
• Previous upper extremity venous thrombosis (DVT)
• Trauma or vascular surgeries at or near the site of
insertion
• Presence of a device related infection, cellulitis, or
bacteremia at or near the insertion site
• Lymphedema.
• Mastectomy surgery with axillary dissection +/-
lymphedema on affected side (unless urgent
condition requires it)
• Allergy to materials
• Irradiation of insertion site

16. Sites for insertion of CVL
• Internal Jugular
• Subclavian
• Femoral
• External Jugular
• Basilic
• Axillary

17. Right IJV is Preferred
• Consistent, predictable anatomy
• Alignment with RA
• Palpable landmark and high success rate
• No thoracic duct injury

18. CVL Insertion
• Equipment.
• Patient position.
• Procedure.
• After insertion

19. Equipment
• Sterile gloves, gown, suture pack.
• Iodine solution.
• 10 ml syringe, 2% lidocaine, 10 ml N.S.
• Catheter special size.
• H2O manometer.
• Flush solution with complete CVP line.
• Dressing set.

21. Patient Position
• Patient is moved to the side of the bed so physician
would not lean over.
• The bed is high enough so physician would not have
to stoop over.
• Patient should be flat without a pillow,
Trendelenburg position if patient is hypovolemic.
• The head is turned away from the side of the
procedure.
• Wrist restraints if necessary.

23. Procedure
Skin preparation:
• Prepare before putting sterile gloves
• Allow time for the sterilizing agent to dry
Drape:
• Large enough and Handed sterilely by the assistant.
• Hole in the area of placement.
Prepare the tray:
• Prepare the equipment before starting.
Anesthesia:
• Use local anesthesia with lidocaine

25. USING THE CENTRAL LINE
• Flush it, before and after use( with NS).
• Some places also require heparin flush.
• Close clamps when not in use.
• Dressing is usually changed every days.
• Line can be used for blood drawing –withdraw
and waste 10 cc, then withdraw blood for
samples.
• If port becomes clotted, do not use – sometimes
ports can be opened up.

26. Immediately Complications of
Insertion CVL
• Hemothorax.
• Pneumothorax (most common).
• Bleeding
• Arterial puncture.
• Vessel erosion
• Nerve Injury.
• Dysrhythmias.
• Catheter malplacement.
• Embolus.
• Cardiac tamponade.

27. Delayed Complications
• Dysrhythmias
• Infection (“Femoral > IJ > subclavian”)
• Catheter malplacement.
• Vessel erosion.
• Embolus.
• Cardiac tamponade.
• Thrombosis

28. Factors Affecting CVP
•Cardiac Function
•Blood Volume
•Capacitance of vessel
•Intrathoracic Pressure
•Intraperitoneal
pressure

29. Causes for Increase in CVP
• Over hydration.
• Right-sided heart failure.
• Cardiac tamponade.
• Constrictive pericarditis.
• Pulmonary hypertension.
• Tricuspid stenosis and regurgitation.
• Stroke volume is high.

30. Causes for Increase in CVP CONT’

31. Decrease of CVP
• Hypovolemia.
• Decreased venous return.
• Excessive veno or vasodilation.
• Shock.
• If the measure is less than 5 cm water that
mean that the circulating volume is decrease.

32. Decrease of CVP CONT

33. CENTRAL VENOUS PRESSURE
MONITORING

34. Methods to measure CVP
Indirect assessment:
• Inspection of jugular venous pulsations in the
neck.
Direct assessment:
• Fluid filled manometer connected to central
venous catheter.
• Calibrated transducer.

35. Inspection of jugular venous pulsations in the
neck.
• No valve between Right atrium & Internal
Jugular Vein.
• Degree of distention & venous wave form
reflects information about cardiac function

39. Measuring central venous pressure
Using a manometer
• Line up the manometer
arm with the
phlebostatic axis
ensuring that the
bubble is between the
two lines of the spirit
level

40. Phlebostatic Axis
4th intercostal space, mid-
axillary line
Level of the atria

41. • 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

42. • Turn the three-way tap
off to the patient and
open to the manometer

43. • Open the IV fluid bag
and slowly fill the
manometer to a level
higher than the
expected CVP

44. • Turn off the flow from
the fluid bag and open
the three-way tap from
the manometer to the
patient

45. The fluid level inside the
manometer should fall
until gravity equals the
pressure in the central
veins

46. • 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.

47. • Turn the tap off to the
manometer veins

48. • Document the
measurement and
report any changes or
abnormalities

49. Measuring central venous pressure
Using a transducer
• 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.

50. • Press the zero button
on the monitor and
wait while calibration
occurs.

51. • When 'zeroed' is
displayed on the
monitor, replace the
cap on the three-way
tap and turn the tap on
to the patient.

52. • 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)

53. Interpretation from Waveform
The CVP waveform consists of five
phasic events,
three peaks (a, c, v) and two
descents (x, y)

55. Mechanical Events

56. ‘a’ wave
• Atrial Contraction(after P wave)
• Prominent a wave: resistance in
RV filling- RVH, TS,
Temponade,PS, Pulmonary
hypertension.
• Cannon A waves occur as the
RA contracts against a closed
TV: junctional rhythm,
CHB,ventricular arrhythmias
• Absent a wave: Atrial
fibrillation or
• • flutter

57. ‘c’ wave
• Isovolumic right
ventricle contraction,
TV bow in RA(after QRS)
• Early Systole
• TR: Tall Systolic c-v wave
• It is call holosystolic
cannon v waves

58. ‘x’ descent
• Atrial Relaxation
• Mid Systole
• Dominant x descent –
good RV function and
vice versa
• Cardiac Tamponade- X
descent is steep & Y
descent is diminished

59. ‘v’ wave
• Filing of RA with venous
blood(just after T wave)
• Late Systole
• Prominent v wave with
increase venous return. ASD,
PAPVC or TAPVC, A-V
malformation
• Large V waves may also
appear later in systole if the
ventricle becomes
noncompliant because of
ischemia or RV failure.
• Decrease in RA emptying. TS

60. ‘y’ descent
• Early ventricular filling,
opening of TV
• Early Diastole
• Attentuation of y
descent: TS,
Tachycardia, RVF,
Tamponade,PS

61. CVP Changes with Respiration
• A, During spontaneous
ventilation, the onset of
inspiration (arrows) causes a
reduction in intrathoracic
pressure, which is transmitted
to both the CVP and
pulmonary artery pressure
(PAP) waveforms. CVP should
be recorded at end-expiration.
• B, During positive-pressure
ventilation, the onset of
inspiration (arrows) causes an
increase in intrathoracic
pressure. CVP is still recorded
at end-expiration.

62. • Kussmaul sign is a paradoxical rise in jugular venous
pressure (JVP) on inspiration, or a failure in the
appropriate fall of the JVP with inspiration.
• It can be seen in some forms of heart disease and is
usually indicative of limited right ventricular filling
due to right heart dysfunction.
• Hepatojugular Reflex: A positive result is variously
defined as either a sustained rise in the JVP of at
least 3 cm or more or a fall of 4 cm or more after the
examiner releases pressure

64. REMOVAL OF CENTRAL LINE
• This is an aseptic procedure.
• The patient should be supine with head tilted
down.
• Ensure no drugs are attached and running via the
central line.
• Remove dressing.
• Cut the stitches.
• If there is resistant then call for assistance.
• Apply digital pressure with gauze until bleeding
stops.
• Dress with gauze and clear dressing.

65. SUMMARY
• Central Venous Line becomes the key element
in managing critically ill patients
• One should have decent amount of
knowledge & Skill about insertion and
maintanance of central lines.

66. REFERENCES
• Millar’s Anesthesia 8th Edition
• Samson Wrights Textbook of Applied
Physiology 13th Edition
• Marino’s The ICU Book 4th Edition
• Measuring central venous pressure Elaine Cole
Senior lecturer ED/Trauma, City University
Bartsand the London NHS Trust.

67. •THANK YOU