CENTRAL VENOUS PRESSURE MONITORING- IACTACON 2018

IT IS BRIEF PRESENTATION FOR CENTRAL VENOUS PRESSURE MONITORING.

1. Central Line Interpretation of waveform & Clinical application in Cardiac Surgeries and ICU Dr. Harshil Joshi DM Chief - Cardiac Anesthesia Century Super speciality Hospita l Prerna Anesthesia &Critical Care Services 01/02/2018

2. What is CVP The central venous pressure (CVP) is the pressure measured in the central veins close to the heart. It is the pressure measured at the junction of the superior vena cava and the right atrium. And No valve in between. It indicates mean right atrial pressure and is frequently used as an estimate of right ventricular preload. 01/02/2018

3. It reflects the driving force for filling of the right atrium & ventricle It indicates the relationship of blood volume to the capacity of the venous system . 01/02/2018

4. Indication 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 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 01/02/2018

5. Common Insertion Site Internal Jugular Subclavian Femoral External Jugular Basilic Axillary 01/02/2018

6. Right IJV is Preferred Consistent, predictable anatomy Alignment with RA Palpable landmark and high success rate No thoracic duct injury 01/02/2018

7. Complication Complications of Central Venous Access and Cannulation Arterial puncture with hematoma Arteriovenous fistula Hemothorax , Chylothorax or Pneumothorax Nerve injury Air embolus Catheter or wire shearing Right atrial or right ventricular perforation Complications of Catheter Presence Thrombosis, thromboembolism Infection, sepsis, endocarditis Arrhythmias Hydrothorax 01/02/2018

8. Factors Affecting CVP Cardiac Function Blood Volume Capacitance of vessel Intrathoracic & Intraperitoneal pressure 01/02/2018

9. Interpretation from Numbers CVP is recorded in centimetres of water (cm H2O) or millimetres of mercury (mm Hg) read from manometer markings. Normal CVP ranges from 5 to 10 cm H2O or 2 to 6 mm Hg. Single value has no value. Trend is important. CVP is surrogate marker. 01/02/2018

10. Series Circulation Right Atrium Right Ventricle Pulmonary Circulation TV PV Left Ventricle Left Atrium MV 01/02/2018

11. Physiologic Consideration of CVP Diastolic Pressure-Volume Relationships Frank-Starling principle 01/02/2018

12. Physiology… It would be ideal to monitor cardiac chamber volumes continuously in critically ill patients, this goal remains elusive in clinical practice. The relationship between ventricular volume and filling pressure depends on the portion of the pressure-volume curve over which the patient's heart is operating and the shape or slope of the curve. Commonly termed ventricular compliance 01/02/2018

13. Transmural Pressure The cardiac chambers are all contained within the pericardium and thorax. Changes in pressure in the structures surrounding the heart will influence pressures recorded within the heart. Transmural pressure is the difference between chamber pressure and juxtacardiac or pericardial pressure. 01/02/2018

14. Measurement The phlebostatic axis is the reference point for zeroing the hemodynamic monitoring device. 4th intercostal space, mid-axillary line 1 mmHg = 1.36 cm H2O. the first step in pressure transducer setup is to zero the transducer by exposing it to atmospheric pressure Thus, a cardiac filling pressure of 10 mm Hg is 10 mm Hg higher than ambient atmospheric pressure. 01/02/2018

15. Respiratory Effect 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 . 01/02/2018

16. 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. 01/02/2018

17. Responders 01/02/2018

18. Fluid Responsiveness: inspiratory fall of CVP > 1 mmHg is high predictive of fluid responders Keeping CVP > 5 mmHg in renal transplant surgery is associated with good graft function In first 3 post op days Post cardiac surgery CVP > 15 mmHg is associated with poor outcome 01/02/2018

19. Decrease in CVP is relatively late sign of depletion of intravascular volume CVP is better measurement of volume status in anesthetised patient whose autonomic reflexes are abolished Goal directed fluid therapy has not shown good results in critically ill patients. Increasing availability of non-invasive and apparently better measurement of preload and circulatory filling will decrease dependence on CVP. 01/02/2018

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22. Role of CVP monitoring for stabilizing critically ill patient in ICU will be secondary… because we put central line not to monitor cvp but for other reasons. So monitoring CVP become risk free. 01/02/2018

23. Interpretation from Waveform The CVP waveform consists of five phasic events, three peaks (a, c, v) and two descents (x, y) 01/02/2018

24. Mechanical Events Waveform Component Phase of Cardiac Cycle Mechanical Events ‘a’ wave End Diastole Atrial Contraction(after P wave) ‘c’ wave Early Systole Isovolumic right ventricle contraction, TV bow in RA(after QRS) ‘x’ descent Mid Systole Atrial Relaxation, Descent of RV base(TV annulus) ‘v’ wave Late Systole Filing of RA with venous blood(just after T wave) ‘y’ descent Early Diastole Early ventricular filling, opening of TV ‘h’ wave Mid to Late Diastole Diastole plateau 01/02/2018

25. ‘a’ wave Atrial Contraction(after P wave) End Diastole Prominent a wave: resistance in RV filling- RVH, TS, Temponade , PS, Pulmonary hypertension Absent a wave: Atrial fibrillation or flutter Cannon A waves occur as the RA contracts against a closed TV: junctional rhythm, CHB,ventricular arrhythmias 01/02/2018

26. ‘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 01/02/2018

27. ‘x’ descent Atrial Relaxation, Descent of RV base(TV annulus) Mid Systole Dominant x descent –good RV function and vice versa Cardiac Tamponade- X descent is steep & Y descent is diminished Early diastolic runoff is impaired by the pericardial fluid collection . 01/02/2018

28. ‘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 01/02/2018

29. ‘y’ descent Early ventricular filling, opening of TV Early Diastole Attentuation of y descent: TS, Tachycardia, RVF, Tamponade,PS 01/02/2018

30. Constrictive Pericarditis This causes prominent A and V waves and steep X and Y descents (creating an M configuration) like decreased RV compliance. Blood from the RA to the right ventricle is initially rapid during early diastolic filling of the right ventricle (creating a steep Y descent) but is short-lived and abruptly halted by the restrictive, noncompliant right ventricle. The right atrial pressure then increases rapidly and reaches a plateau until the end of the A wave, at the end of diastole. This portion of the waveform is analogous to the ventricular diastolic dip-and-plateau sign . 01/02/2018

31. Heart Block two-to-one heart block is recognized by A waves, that occur with twice the frequency of the artery pulse. PR interval prolongation is recognized by an increase in the interval between the jugular A wave and the arterial pulse 01/02/2018

32. LVH ( AS,Coarctation,LVOTO ) Directing attention to the amplitude of the jugular venous A wave in subjects with isolated obstruction to left ventricular outflow is seemingly paradoxical. However, left ventricular hypertrophy serves to decrease right ventricular distensibility, so the right atrium contracts with greater force and the amplitude of the jugular venous A wave increases in the absence of pulmonary hypertension 01/02/2018

33. Pulmonary Stenosis The jugular venous A wave is distinctive and increases progressively as the stenosis increases, culminating in a giant A wave. Attenuates y descent Powerful right atrial contraction generates a giant A wave via the superior vena cava and a presystolic liver pulse via the inferior cava. With the advent of right ventricular failure and tricuspid regurgitation, the large A wave is accompanied by an increase in the V wave. 01/02/2018

34. Ebstein’s Anomaly Prominent C wave that coincides with mobility of the anterior tricuspid leaflet. The interval between the jugular A wave and the carotid pulse is often prolonged, reflecting prolongation of the PR interval . Prominent A waves are seldom seen in the jugular pulse. A stenotic or imperforate tricuspid orifice is accompanied by A waves that may be giant. An attenuated X descent and a systolic venous V wave of tricuspid regurgitation seldom appear in the jugular pulse despite severe regurgitant flow because of the damping effect of the commodious right atrium and the thin-walled toneless atrialized right ventricle and because tricuspid regurgitation is low-pressure and hypokinetic . 01/02/2018

35. ASD Most important is left atrialization of the jugular venous wave form. The crests of the A and V waves tend to be equal as they are in the left atrium because the two atria are in common communication through a nonrestrictive atrial septal defect. The A wave amplitude varies with heart rate and compliance of ventricle as in healthy subjects. Pulmonary vascular disease results in an increased force of right atrial contraction and a dominant, if not giant, A wave 01/02/2018

36. Lutembacher’s syndrome The right and left atrium function as a common chamber when the atrial septal defect is nonrestrictive , so the height and contour of the left atrial pressure pulse are transmitted into the right atrium and into the internal jugular vein. Elevated mean jugular venous pressure in the absence of right ventricular failure and for an elevated jugular venous A wave in the absence of pulmonary hypertension. Post ASD closure-- Don’t Target CVP 01/02/2018

37. AVCD The V wave is dominant in the jugular venous pulse because the right atrium receives left ventricular systolic flow across an incompetent left AV valve directly through the atrioventricular septal defect or indirectly through an ostium primum atrial septal 01/02/2018

38. VSD Moderately restrictive and nonrestrictive ventricular septal defects with congestive heart failure are accompanied by an elevated mean jugular venous pressure and an increase in A and V waves. However, the jugular venous pulse in Eisenmenger’s syndrome(PDA, AP window) is normal or nearly so, with a small dominant A wave 01/02/2018

39. TOF Normal- RV will offload in to LV Restrictive VSD - RV pressure will increase more then systemic: large a wave in CVP Absent PV: initially large a wave, and after development of TR large v wave 01/02/2018

40. Univentricular physiology The right atrial A wave, V wave, and mean pressure are elevated Post BDG : IJV attached to PA and IVC attached to RA which is affected by common ventricle pressure. Post Fontan : no longer CVP, only PA pressure. 01/02/2018

41. Case Scenario 1 Post OP CABG, extubated Breathlessness, hypotension, tachycardia BP responding to fluid bolus Drain- 400 ml Lungs – clear Swing in arterial trace Prominent x descent 01/02/2018

42. Case Scenario 2 Post MVR, Female patient Breathlessness, hypotension, tachycardia Bilateral crepitation A wave disappear C wave more prominent 01/02/2018

43. Case Scenario 3 Young male patient with weakness, jaundice, fatigue and dependant odema Systolic thrill and murmur in neck Tender hepatomegaly Prominet c & v wave 01/02/2018

44. Summary Individual CVP waveforms provide unique diagnostic clues about the circulation. Trends in CVP over time may also be useful in estimating fluid or blood loss and guiding replacement therapy. It is important to remember that there is a significant range of normal values and that a small change in CVP may reflect a significant alteration in circulating blood volume and right ventricular preload. Additional useful information may be derived from examining how a fluid bolus simultaneously alters CVP and other variables of clinical interest, such as blood pressure, urine output, and so forth. 01/02/2018

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