Central venous pressure

CVP

1. CENTRAL VENOUS PRESSURE Dr. Davis Kurian

2. Measure RV filling pressure. Estimation of intravascular volume status. Assessment of RV function CVP

3. Major procedures involving large fluid shifts and/or blood loss. Intravascular volume assessment when urine output is not reliable. Major trauma. Surgeries with high risk of air embolism. Frequent venous blood sampling. Venous access for vasoactive/irritating drugs & for long term drug administration. Inadequate IV access Rapid infusion of IV fluids. Transvenous pacing Temporary hemodialysis INDICATIONS

4. The distal end of the catheter – in one of the large intrathoracic veins/ RA. Zero point – taken at the centre of RA – important – height can influence CVP measurement. 3 upward deflections : a,c,v 2 downward deflections : x,y Trends are more important than individual values. Influenced by IVC thrombosis and alterations of intrathoracic pressure. MEASUREMENT

5. WAVEFORM

6. Irregular rhythm with loss of a wave – AF/ Afl . Cannon a waves – junctional rhythm, complete heart block, ventricular arrythmias , tricuspid stenosis, RVH, pulmonary stenosis, Pulmonary hypertension. Early/ holosystolic cannon v waves – significant TR. Large v waves – RVF/incompliant ventricle due to ischemia Pericardial constriction – decreased venous return – prominent a and v waves & steep x and y descents ( M / W config ). RV ischemia – tall a and v waves, steep x and y descent. Cardiac tamponade – dominant x descent, attenuated y descent PATHOLOGICAL CONDITIONS

7. Site chosen depends on patient condition, skill and experience of the personnel and the indication. Sites chosen include: IJV SUBCLAVIAN EJV ANTECUBITAL APPROACH FEMORAL VEIN TECHNIQUES & INSERTION SITES

8. 1 st described by English et.al (1969) Advantages: High success rate Short straight course of vein Easy access from head Fewer complications Easy compressibility in patients with bleeding diathesis. IJV APPROACH

9. Location – under the medial border of lateral head of SCM. Right IJV preferred – leads straight to SVC and RA – minimises injury to thoracic duct, pneumothorax . Position : Supine with head down position Head turned to opposite side Techniques: Middle approach Anterior high approach Posterior approach USG guided IJV APPROACH

10. IJV APPROACH

11. IJV APPROACH

12. IJV APPROACH

13. IJV APPROACH

14. USG guided – advantages : Minimises injury to carotid artery Helps to identify the anatomy Especially advantageous in patients with difficult neck anatomy, prior neck surgeries and anticoagulated patients. IJV APPROACH

15. Tortuous path – reduced success rate Advantages – avoids advancement of needle into deeper structures. EJV APPROACH

16. Supraclavicular and infraclavicular approach High incidence of complications – esp pneumothorax. Site of choice in patients undergoing surgeries of head and neck and in trauma patients immobilised with cervical collar Useful in parentral nutrition/prolonged CVP monitoring SUBCLAVIAN VEIN

17. INFRACLAVICULAR APPROACH Supine, head down Folded sheet between scapulae Head turned to opposite side

18. SUPRACLAVICULAR APPROACH

19. Advantage – Decreased complications Ease of access Disadvantage – Difficult to ensure correct central venous placement of cathether . Caridac perforation and arrythmias ANTECUBITAL VEINS

20. Ideally in SVC – parallel to vessel wall – below the inferior border of clavicle – above 3 rd rib, T4 – T5 interspace, azygos vein, tracheal carina and or above the take off of the right main bronchus. CONFIRMING CATHETHER POSITION

21. Increased success rate 2 cm below inguinal ligament – medial to pulsation of femoral artery. Increased chances of infection when placed for a long time , thromboembolic events & vascular injury. Especially indicated in patients with SVC obstruction. FEMORAL VEIN

22. ABSOLUTE SVC syndrome – CI to upper extremity placement Infection at the site of insertion RELATIVE Coagulopathies Newly inserted pacemaker wires CONTRAINDICATIONS- CENTRAL VENOUS CANNULATION

23. COMPLICATIONS OF CENTRAL VENOUS CANNULATION Arterial puncture with hematoma A-V fistula Hemothorax , chylothorax , pneumothorax Brachial plexus injury Horner’s syndrome Air embolism Catheter/wire shearing COMPLICATIONS

24. COMPLICATIONS OF CATHETHER PRESENCE Thrombosis/thromboembolism Infection, sepsis, thromboembolism Arrythmias Hydrothorax COMPLICATIONS

25. KAPLAN’S TEXTBOOK OF CARDIAC ANAESTHESIA – 4 TH EDN MILLER’S TEXTBOOK OF ANAESTHESIA – 8 TH EDN REFERENCES

26. Thank you