1 Monitoring of Central Venous Pressure & Its Techniques

1 Monitoring of Central Venous Pressure & Its Techniques

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

11. 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.

12. 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

13. 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)

14. 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

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

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

17. CVL Insertion Equipment. Patient position. Procedure. After insertion

18. 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.

19. 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.

20. 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

21. 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.

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

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

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

25. 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.

26. Causes for Increase in CVP CONT’

27. 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.

28. Decrease of CVP CONT

29. CENTRAL VENOUS PRESSURE MONITORING

30. 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.

31. 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

32. 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

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

34. 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

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

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

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

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

39. 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.

40. Turn the tap off to the manometer veins

41. Document the measurement and report any changes or abnormalities

42. 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.

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

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

45. 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)

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

47. Mechanical Events

48. ‘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

49. ‘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

50. ‘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

51. ‘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

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

53. 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.

54. 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

55. 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.

56. 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.

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

58. THANK YOU