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CENTRAL VENOUS PRESSURE MONITORINGG.pptx

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Balamurugan Muthuram
Balamurugan Muthuram

Central venous pressure monitoring

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CVP MONITORING PRESENTER- MAJ ANKUSH MALHOTRA MODERATOR- COL JOSEMINE DAVIS
Definition Central venous pressure is considered as a direct measurement of the blood pressure in the right atrium and it is used to determine preload and the filling pressure of heart. Normal value- 8-12 mm of Hg
Physiology behind CVP monitoring ` Two prerequisites must be met in order to correctly interpret the information provided by the CVP monitor: (a) The clinician must possess a thorough understanding of all the variables that affect right atrial pressure. (b) Measurements need to be made with extreme attention to detail. CVP is determined by the interaction of the venous return function of the circulatory system and the cardiac function.
Physiology behind CVP monitoring An increase in cardiac function with an increase in venous return will result in an increase in cardiac output and rise in CVP. An increase in cardiac function without an increase in venous return will result in an increase in cardiac output and a fall in CVP. An isolated CVP measurement has very little meaning unless the information is interpreted in the context of some estimation of cardiac function.
CVP and Venous Return Venous return is mostly determined by the gradient between the mean circulatory filling pressure (MCFP) and CVP. MCFP results from the elastic recoil pressure from distended small veins and venules and is the force that drives blood back to the right atrium. Two important corollaries emerge: right atrial pressure is key for maintaining cardiac output. The body will compensate through the mechanisms described above and others to preserve venous return.
CVP and Venous Return This explains why a patient may lose 10% to 12% of his circulating blood volume without exhibiting changes in blood pressure or CVP. The difference between MCFP and CVP is only 6 to 8 mm Hg, and hence small changes in CVP may have profound hemodynamic consequences.
CVP and Cardiac Function Changes in CVP may be the sole result of changes in inotropic state or compliance of the ventricle, independent of the total circulating volume or venous return to the heart. CVP is the result of a complex and diverse interplay among many different physiologic variables, many of which are impossible to measure in the operating room or ICU. It is therefore not surprising that studies assessing the value of CVP as a predictor of volume status or fluid responsiveness have failed to demonstrate a relationship.
Waveform of CVP Waveform Component Phase of Cardiac Cycle Mechanical Event a wave End diastole Atrial contraction c wave Early systole Isovolumic ventricular contraction, tricuspid motion toward right atrium v wave Late systole Systolic filling of atrium h wave Mid to late diastole Diastolic plateau x wave Mid systole Atrial relaxation, descent of the base, systolic collapse y wave Early diastole Early ventricular filling, diastolic collapse
Normal CVP waveform
Normal CVP Waveform The CVP waveform consists of five phasic events, three peaks (a, c, v) and two descents (x, y). a wave -The most prominent wave is the a wave of atrial contraction, which occurs at end-diastole following the ECG P wave. c-wave-This wave is a transient increase in atrial pressure produced by isovolumic ventricular contraction, which closes the tricuspid valve and displaces it toward the atrium. x descent - Atrial pressure continues its decline during ventricular systole, owing to continued atrial relaxation and changes in atrial geometry produced by ventricular contraction and ejection that draw the tricuspid annulus toward the cardiac apex.
Normal waveform of CVP v wave- Caused by venous filling of the atrium during late systole while the tricuspid valve remains closed. The v wave usually peaks just after the ECG T wave. y descent- It is due to the diastolic decrease in atrial pressure due to flow across the open tricuspid valve.
Atrial fibrillation- a wave disappears and the c wave becomes more prominent because atrial volume is greater at end-diastole and onset of systole, owing to the absence of effective atrial contraction. Atrioventricular dissociation- Atrial contraction now occurs during ventricular systole when the tricuspid valve is closed, thereby inscribing a tall cannon a wave in the CVP waveform. Abnormal waveform of CVP
Abnormal waveform of CVP Tricuspid regurgitation- It produces abnormal systolic filling of the right atrium through the incompetent valve. A broad, tall systolic c-v-wave results, beginning in early systole and obliterating the systolic x descent in atrial pressure. Tricuspid stenosis-Produces a diastolic defect in atrial emptying and ventricular filling. The a wave is unusually prominent and they descent is attenuated, owing to the impaired diastolic egress of blood from the atrium.
Atrial fibrillation Loss of a wave prominent c wave A-V dissociation Cannon a wave Tricuspid regurgitation Tall systolic c-v wave Loss of x decent Tricuspid stenosis Tall a wave Attenuation of y descent Right ventricular ischemia Tall a and v waves Steep x and y descent M or W configuration Pericardial constriction Tall a and v waves Steep x and y descent M or W configuration Cardiac temponade Dominant x descent Attenuated y descent Abnormal waveform of CVP
Physiological Pressure Monitoring Multilumen central venous catheter (15-20 cm in length) that is inserted in the subclavian or internal jugular veins and advanced into superior vena cava. The CVP is hydrostatic pressure, so it is important that fluid filled transducer is at the same level as right atrium. Reference point - intersection of midaxillary line and fourth intercostal space.
Physiological Pressure Monitoring Components of physiological Pressure measurement Invasive catheter Pressure transducer Normal saline flush Pressure infusion bag Reusable pressure cable Bedside physiological monitor
Levelling pressure transducer system Intravascular monitoring should be at the level of heart or phlebostatic axis. Should be done with a Carpenters level. Errors in pressure reading may occur if alignment with phlebostatic axis is not maintained. For every inch (2.5 cm) the heart is offset from the reference point of the transducer, a 2 mmHg of error will be introduced.
Levelling pressure transducer system
Levelling pressure transducer system
Zeroing Zero referencing eliminates the effects of atmospheric and hydrostatic pressure Open the reference stopcock to air by removing the non-vented cap, keeping sterility intact After removing non-vented cap, turn stopcock off to the patient Initiate Zero function on bedside monitor and confirm pressure waveform and numeric value display 0 mmHg Once the zero is observed, turn the stopcock back to the vent port and replace the non-vented cap
Square wave test and damping 1. Activate snap or pull tab on flush device 2. Observe square wave generated on bedside monitor 3. Count oscillations after square wave 4. Observe distance between the oscillations
Square wave test and damping
Pressure monitoring system
CVP values provide important information about the cardiocirculatory status of the patient and should not be abandoned. Use of CVP to guide fluid resuscitation has many limitations, but we believe it is wiser to understand and take into account these limitations rather than to discard CVP completely.
Thank you
Indication Measurement of right heart filling pressure to assess intravascular volume and right heart function. Presence of persistent hypotension despite of fluid resuscitation despite fluid resuscitation Vasopressor therapy Extensive third space losses Oliguria Or Anuria Trauma Sepsis Major surgeries Burns Heart failure
Complications of CVP Mechanical Arterial Venous Cardiac tamponade Pneumothorax Airway compression from hematoma Nerve injury Arrhythmias Thromboembolic Venous thrombosis Pulmonary embolism Arterial thrombosis and embolism Catheter or guidewire embolism Infectious Insertion site infection Catheter infection Bloodstream infection Endocarditis

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CENTRAL VENOUS PRESSURE MONITORINGG.pptx

  • 1. CVP MONITORING PRESENTER- MAJ ANKUSH MALHOTRA MODERATOR- COL JOSEMINE DAVIS
  • 2. Definition Central venous pressure is considered as a direct measurement of the blood pressure in the right atrium and it is used to determine preload and the filling pressure of heart. Normal value- 8-12 mm of Hg
  • 3. Physiology behind CVP monitoring ` Two prerequisites must be met in order to correctly interpret the information provided by the CVP monitor: (a) The clinician must possess a thorough understanding of all the variables that affect right atrial pressure. (b) Measurements need to be made with extreme attention to detail. CVP is determined by the interaction of the venous return function of the circulatory system and the cardiac function.
  • 4. Physiology behind CVP monitoring An increase in cardiac function with an increase in venous return will result in an increase in cardiac output and rise in CVP. An increase in cardiac function without an increase in venous return will result in an increase in cardiac output and a fall in CVP. An isolated CVP measurement has very little meaning unless the information is interpreted in the context of some estimation of cardiac function.
  • 5. CVP and Venous Return Venous return is mostly determined by the gradient between the mean circulatory filling pressure (MCFP) and CVP. MCFP results from the elastic recoil pressure from distended small veins and venules and is the force that drives blood back to the right atrium. Two important corollaries emerge: right atrial pressure is key for maintaining cardiac output. The body will compensate through the mechanisms described above and others to preserve venous return.
  • 6. CVP and Venous Return This explains why a patient may lose 10% to 12% of his circulating blood volume without exhibiting changes in blood pressure or CVP. The difference between MCFP and CVP is only 6 to 8 mm Hg, and hence small changes in CVP may have profound hemodynamic consequences.
  • 7. CVP and Cardiac Function Changes in CVP may be the sole result of changes in inotropic state or compliance of the ventricle, independent of the total circulating volume or venous return to the heart. CVP is the result of a complex and diverse interplay among many different physiologic variables, many of which are impossible to measure in the operating room or ICU. It is therefore not surprising that studies assessing the value of CVP as a predictor of volume status or fluid responsiveness have failed to demonstrate a relationship.
  • 8. Waveform of CVP Waveform Component Phase of Cardiac Cycle Mechanical Event a wave End diastole Atrial contraction c wave Early systole Isovolumic ventricular contraction, tricuspid motion toward right atrium v wave Late systole Systolic filling of atrium h wave Mid to late diastole Diastolic plateau x wave Mid systole Atrial relaxation, descent of the base, systolic collapse y wave Early diastole Early ventricular filling, diastolic collapse
  • 10. Normal CVP Waveform The CVP waveform consists of five phasic events, three peaks (a, c, v) and two descents (x, y). a wave -The most prominent wave is the a wave of atrial contraction, which occurs at end-diastole following the ECG P wave. c-wave-This wave is a transient increase in atrial pressure produced by isovolumic ventricular contraction, which closes the tricuspid valve and displaces it toward the atrium. x descent - Atrial pressure continues its decline during ventricular systole, owing to continued atrial relaxation and changes in atrial geometry produced by ventricular contraction and ejection that draw the tricuspid annulus toward the cardiac apex.
  • 11. Normal waveform of CVP v wave- Caused by venous filling of the atrium during late systole while the tricuspid valve remains closed. The v wave usually peaks just after the ECG T wave. y descent- It is due to the diastolic decrease in atrial pressure due to flow across the open tricuspid valve.
  • 12. Atrial fibrillation- a wave disappears and the c wave becomes more prominent because atrial volume is greater at end-diastole and onset of systole, owing to the absence of effective atrial contraction. Atrioventricular dissociation- Atrial contraction now occurs during ventricular systole when the tricuspid valve is closed, thereby inscribing a tall cannon a wave in the CVP waveform. Abnormal waveform of CVP
  • 13. Abnormal waveform of CVP Tricuspid regurgitation- It produces abnormal systolic filling of the right atrium through the incompetent valve. A broad, tall systolic c-v-wave results, beginning in early systole and obliterating the systolic x descent in atrial pressure. Tricuspid stenosis-Produces a diastolic defect in atrial emptying and ventricular filling. The a wave is unusually prominent and they descent is attenuated, owing to the impaired diastolic egress of blood from the atrium.
  • 14. Atrial fibrillation Loss of a wave prominent c wave A-V dissociation Cannon a wave Tricuspid regurgitation Tall systolic c-v wave Loss of x decent Tricuspid stenosis Tall a wave Attenuation of y descent Right ventricular ischemia Tall a and v waves Steep x and y descent M or W configuration Pericardial constriction Tall a and v waves Steep x and y descent M or W configuration Cardiac temponade Dominant x descent Attenuated y descent Abnormal waveform of CVP
  • 15. Physiological Pressure Monitoring Multilumen central venous catheter (15-20 cm in length) that is inserted in the subclavian or internal jugular veins and advanced into superior vena cava. The CVP is hydrostatic pressure, so it is important that fluid filled transducer is at the same level as right atrium. Reference point - intersection of midaxillary line and fourth intercostal space.
  • 16. Physiological Pressure Monitoring Components of physiological Pressure measurement Invasive catheter Pressure transducer Normal saline flush Pressure infusion bag Reusable pressure cable Bedside physiological monitor
  • 17. Levelling pressure transducer system Intravascular monitoring should be at the level of heart or phlebostatic axis. Should be done with a Carpenters level. Errors in pressure reading may occur if alignment with phlebostatic axis is not maintained. For every inch (2.5 cm) the heart is offset from the reference point of the transducer, a 2 mmHg of error will be introduced.
  • 20. Zeroing Zero referencing eliminates the effects of atmospheric and hydrostatic pressure Open the reference stopcock to air by removing the non-vented cap, keeping sterility intact After removing non-vented cap, turn stopcock off to the patient Initiate Zero function on bedside monitor and confirm pressure waveform and numeric value display 0 mmHg Once the zero is observed, turn the stopcock back to the vent port and replace the non-vented cap
  • 21. Square wave test and damping 1. Activate snap or pull tab on flush device 2. Observe square wave generated on bedside monitor 3. Count oscillations after square wave 4. Observe distance between the oscillations
  • 22. Square wave test and damping
  • 24. CVP values provide important information about the cardiocirculatory status of the patient and should not be abandoned. Use of CVP to guide fluid resuscitation has many limitations, but we believe it is wiser to understand and take into account these limitations rather than to discard CVP completely.
  • 26. Indication Measurement of right heart filling pressure to assess intravascular volume and right heart function. Presence of persistent hypotension despite of fluid resuscitation despite fluid resuscitation Vasopressor therapy Extensive third space losses Oliguria Or Anuria Trauma Sepsis Major surgeries Burns Heart failure
  • 27. Complications of CVP Mechanical Arterial Venous Cardiac tamponade Pneumothorax Airway compression from hematoma Nerve injury Arrhythmias Thromboembolic Venous thrombosis Pulmonary embolism Arterial thrombosis and embolism Catheter or guidewire embolism Infectious Insertion site infection Catheter infection Bloodstream infection Endocarditis