Central Venous Pressure and

Central lines

Hery Prayitno, M.Kep

ICU RS IMMANUEL
BANDUNG
 Challenging Knowledge
Before starting this module; Answer the
following questions
(1) What sites are used to site a CVL?
(2) What is the normal CVP?
(3) What are the basic treatments for a CVP
of -1cm of H20
(4) What are the essential items required to
measure a CVP?
 Learning Outcomes
By the end of this module you should
(1) Be aware of factors which affect the CVP
(2) Recognise normal and abnormal CVP values
(3) Be able to set up the manometer system to
measure a patients CVP
(4) Be able to measure a CVP and interpret the
value
(5) Be aware of the initial management for high and
low values
 Factors affecting the CVP
The central venous pressure reflects the right atrial pressure
(RAP) and is similar to measuring the JVP clinically

The factors which affect the CVP are:-

Systemic vasodilatation and hypovolaemia, which leads to
reduced venous return in the vena cava and reduced RAP
Right ventricular failure
Tricuspid and Pulmonary valve disease
Pulmonary hypertension

Right ventricular dysfunction and pulmonary hypertension leads

to raised right atrial pressure, as does tricuspid and pulmonary
stenosis.
 Central venous line (CVL)
Indications for CVL
Severe hypovolaemia requiring rapid infusion
(although initial resuscitation may be peripheral through wide bore cannulae)
Infusion of drugs which may cause peripheral
problems e.g. vasoconstriction, phlebitis
Measurement of central venous pressure (CVP)
Confirmation of diagnosis e.g. Right heart failure
Insertion of a pacing wire.

Sites for insertion Internal jugular, subclavian

and femoral vein; Long lines are also inserted in
the brachial vein.
 How to measure the CVP using a manometer system
The CVP system
A bag of saline or dextrose = reservoir
Three way tap - connected to
manometer, reservoir and patients CVL
by tubing; System is primed with fluid
before starting
Patient
Patient is lying supine if possible positioned
Manometer has spirit level at zero; supine on
Zero point is aligned with right atrium the bed
using the mid axillary line / 4th ICS
Measurements should be taken with the
patient in the same position each time
using the spirit level; the zero point on
the skin surface is marked for
consistency of measurement Three way tap
 How to measure the CVP using a manometer system
Turn the three way tap OFF to the
patient.
Fill the manometer to the top from the
reservoir
Turn the three way tap OFF to the
reservoir
This means the column of fluid is
supported only by the RAP / CV
pressure
The column will fall according to
CVP
The column swings with respiration -
conventionally the level is taken as the
mean.
Three way tap OFF to the Three way tap OFF to the
patient allowing the reservoir allowing the
manometer to be filled CVP to be measured
 Normal CVP measurements
The normal CVP is between 5 10 cm of
H2O (it increases 3 5 cm H2O when
patient is being ventilated)
In high dependency areas an electronic
transducer is connected instead of the
manometer system. This gives a continuous
readout of CVP along with a display of the
waveform. This may be measured in
mmHg.
(Note:10 cmH20 = 7.5mmHg =1kPa)
CVP Reading Other clinical Diagnosis Treatment
features
Low Tachycardia Hypovolaemia Fluid challenge until CVP
Low normal or hypotension within normal limits and
Urine output oligo or anuria treat underlying cause

Low Tachycardia Fluid resuscitation (if low)

Sepsis
Signs of infection Antibiotics
( may be normal or Pyrexia
high due to Vasodilatation is most common but May require inotrope
severe sepsis maybe associated with support
venoconstriction) constriction

Normal due to Tachycardia

Hypovolaemia Fluid challenge and treat
Urine output underlying cause
venoconstriction falling below 30ml /hr
Poor capillary refill

High Dyspnoea with pulmonary Diuretics, GTN infusion,

crepitations
Heart failure
may require inotropes
Tachycardia with third heart sound
Tender hepatomegaly
Ascites
Peripheral Oedema

Very High Venous congestion and SVC obstruction Treat underlying

dilatation of face and Cardiac tamponade
neck; associated signs Tension pneumothorax
cause
 Case (1) How low can you go?
A 32 year old woman with known
alcohol associated liver disease
presents with melaena. Initially she
is haemodynamically stable and
well perfused. She suddenly
decompensates with fresh blood
and clots being passed PR. Initial
resuscitation with several litres of
crystalloid and some colloid fails to
bring her systolic BP back above
100 mm Hg. A CVP line is inserted
and shows her CVP to be +1
cmH2O.

(a) What is the likely diagnosis?

(b) List your further management
including investigations and
medications
 Case (2) CVP Pat pending
A 31 year old man presents to
A&E with a 3 month history of
night sweats and weight loss. On
examination he is unwell, pyrexial
and has several large cervical
lymph nodes. He is noted to have
poorly palpable radial pulse, a
positive Kussmauls sign and
poorly heard heart sounds. The
SHO decides to site a CVP which
is measured at 28 cm of H2O.

(a) What is the likely underlying

diagnosis?
(b) What is the initial treatment?
(c) How will you prove the
diagnosis?
 Case (3)
A 48 year old poorly controlled Type 2 diabetic man is
admitted from the Diabetes clinic with a deep, infected foot
ulcer. His observations are: pulse 120bpm, BP 70/40, CVP +6
cm of H20 and he is noted to be sweaty and vasodilated.
Despite initial resuscitation with 3 litres of crystalloid in 4
hours, his BP and pulse fail to respond. He is electively
ventilated and admitted to ITU where he is started on
inotropes.

(1)What is the descriptive term given to this clinical state?

(2)List your further management?
 Learning Outcomes
At the end of this module you should
(a) Be aware of the factors affecting the CVP.
(b) Be able to set up a CVP manometer
system.
(c) Be able to measure a CVP from a patient.
(d) Be able to interpret the result.
(e) Be able to institute initial management
based on the result.