MONITORING OF CENTRAL

VENOUS PRESSURE & ITS

TECHNIQUES
 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
 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

 TYPES OF
CENTRAL LINE

• SINGLE LUMEN
• DOUBLE LUMEN
• TRIPLE LUMEN
• QUADRUPLE LUMEN
• QUINTUPLE LUMEN
• PERIPHERALLY INSERTED CENTRAL
CATHETERS (PICCS)
Single, Double, and Triple Lumen
Central Lines
 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
 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
 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.
 Peripherally Inserted Central
Catheters (PICCs)

• LOCATION OR SITE
OF INSERTION
• INDICATIONS
• CONTRAINDICATIONS
• BENEFITS AND RISKS
 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.
 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
 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)
 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
 Sites for insertion of
CVL
• Internal Jugular
• Subclavian
• Femoral
• External Jugular
• Basilic
• Axillary
 Right IJV is
Preferred
• Consistent, predictable anatomy
• Alignment with RA
• Palpable landmark and high success
rate
• No thoracic duct injury
 CVL
Insertion
• Equipment.
• Patient position.
• Procedure.
• After insertion
 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.
 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.
 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
 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.
Immediately Complications of Insertion CVL

• Hemothorax.
• Pneumothorax (most
common).
• Bleeding
• Arterial puncture.
• Vessel erosion
• Nerve Injury.
• Dysrhythmias.
• Catheter malplacement.
• Embolus.
• Cardiac tamponade.
 Delayed Complications
• Dysrhythmias
• Infection (“Femoral > IJ >
subclavian”)
• Catheter malplacement.
• Vessel erosion.
• Embolus.
• Cardiac tamponade.
• Thrombosis
 Factors Affecting CVP
•Cardiac Function

•Blood Volume

•Capacitance of vessel

•Intrathoracic
Pressure

•Intraperitoneal
pressure
 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.
Causes for Increase in CVP
CONT’
 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.
Decrease of CVP
CONT
CENTRAL VENOUS
PRESSURE
MONITORING
 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.
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
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
 Phlebostatic
Axis

4th intercostal space, mid-

axillary line

Level of the atria

• 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
• Turn the three-way tap
off to the patient and
open to the manometer
• Open the IV fluid
bag and slowly fill
the manometer to a
level higher than the
expected CVP
• Turn off the flow from
the fluid bag and open
the three-way tap
from the manometer
to the patient
The fluid level inside the
manometer should fall
until gravity equals
the pressure in the
central veins
• 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.
• Turn the tap off to
the manometer veins
• Document the
measurement and
report any changes or
abnormalities
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.
• Press the zero
button on the
monitor and wait
while calibration
occurs.
• When 'zeroed' is
displayed on the
monitor, replace the
cap on the three-way
tap and turn the tap on
to the patient.
• 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)
 Interpretation from
Waveform

The CVP waveform consists of

five
phasic events,
three peaks (a, c, v) and two
descents (x, y)
Mechanical
Events
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.
• 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
 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.
 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.
 Steps
1. Explain the procedure to the client and obtain informed consent.
2. Assemble all necessary equipment
3. Place patient in comfortable position
4. Attach manometer to the IV pole. The zero point of the manometer
should e on a level with patient’s right atrium. Mark the mid-axillary line
on the patient with an indelible ink.
5. Surgically cleansed the CVP site using sterile antiseptic solution. The
physician will perform venous cutdown to introduce the CVP catheter to
the site into superior vena cava just efore it enters the right atrium.
6. The CVP catheter is connected to the 3 way stopcock that communicates
to an open intravenous fluid line (NSS or heparin flush) and to the
manometer a measuring device.
7. Start the IV flow and fill the manometer 10cm. Above anticipated reading
or until the level of 20cm water is reached.
8. When the catheter enter the thorax, an inspiratory fall and expiratory rise in
venous pressure are observed.
9. The patient may be monitored by an ECG during catheter insertion
10. Sterile dressing is applied and secured with tape.
11. The infusion is adjusted to flow into the patient’s vein by a slow
continuous drip.
CENTRAL VENOUS PRESSURE
POSITION OF PATIENT

Fluid
Bag

manometer
3-way tap

Central
Venous
Access

Patient in supine position

 Measuring CVP
1. Place the patient in the identified position and confirm zero point.
Intravascular pressures are measured to the atmospheric pressure at the
middle of the right atrium; this is the zero point or external reference point.
Rationale: The zero point or baseline for the manometer should be on level
with the patient’s right atrium. The middle of the right atrium is the
midaxillary line in the 4th intercostals space.

2. Position the zero point of the manometer at the level of the right atrium.
Rationale: All personal taking the CVP measurement use the same zero point.
3. Turn the stopcock so that the IV solution flows into the manometer filling
to about the 20-25cm level. Then turn the stopcock so that the solution in
manometer flows into the patient.
Rationale: The reading is reflected by the height of a column of fluid in the
manometer when there’s open communication between the catheter and the
manometer.
4. Observe the fall in the height of the column of fluid in the manometer.
Record the level at which the solution stabilizes or stops moving downward.
This is the central venous pressure. Record CVP and the position of the
patient.
5. The CVP my range from 5-12cm. HOH.
Rationale: The change in CVP is a more useful indication of adequacy of
venous blood volume and alterations of cardiovascular function.
6. Assess patient’s clinical condition. Frequent changes in measurements
(interpreted within the context of the clinical situation) will serve as a guide
to detect whether the heart can handle its fluid load and whether hypovolemia
or hypovolemia is present.
Rationale: A CVP zero indicates that patient is hypovolemia (verified if rapid
infusion causes patient to improve).
- A CVP above 15-20cm. HOH may be due to either hypervolemic or poor
cardiac contractility.
7. Turn the stopcock again to allow IV solution to flow from solution bottle
into the patient’s veins.
Rationale: When readings are not being made, flow is from a very slow
microdrip to the catheter, by-passing the manometer.
8. Chart or record the location of insertion site, type of needle, time of
insertion, appearance of insertion site.
CVP monitoring using manometer

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CVP monitoring using transducer

Copyright © 2014 by Elsevier Inc. All

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CYSTOCLYSI
S
 CYSTOCLYSIS/BLADDER IRRIGATION

• process of flushing the

bladder with normal
saline to prevent or
treat clot formation.
✔ Bladder irrigation may
also be used to instill
medications such as
antibiotics for treating
bladder infections

✔ This is done over a

period of time, and runs
continuously.
✔ A special catheter is
used for the above
procedure.
 Purpose:

• To prevent blood clot

formation
• allow free flow of urine
and maintain IDC patency,
by continuously irrigating
the bladder with Normal
Saline
 Purpose:
• To drain the bladder when
acute urinary retention is
present

• To relieve bladder spasm

• To free blockage in the

urinary catheter or tubing
 EXPECTED
OUTCOMES

1. The urinary catheter remains patent

and urine is able to drain freely via the
indwelling catheter (IDC)

2. The patients comfort is maintained

 EXPECTED
OUTCOMES

3.Clot formation within the bladder or IDC is

prevented or minimized

4.The patient’s risk of Urinary Tract Infection is

minimized, through use of aseptic technique
when connecting bladder irrigation to IDC
 TYPES OF IRRIGATING CYSTOCLYSIS

1. OPEN BLADDER
IRRIGATION SYSTEM
❑ also called MANUAL IRRIGATION
❑ This is used when bladder
irrigations are required less
frequently and there are no blood
clots or large mucous fragments
 TYPES OF IRRIGATING CYSTOCLYSIS

2. CLOSED BLADDER
IRRIGATION SYSTEM
❑involves instilling sterile
irrigation solution into the
bladder allowing the fluid to
drain out
❑ NOTE: CONTINUOUS BLADDER IRRIGATION
should not go beyond in weeks
❑ Failure to recognize that the fluid is not
draining can result in severe bladder injury, as
large volumes of irrigation solution are
typically instilled.

• Example:
• 100cc is irrigated + 30cc urine
output/hr=130cc is expected
❖ if output is less than NOTIFY THE
PHYSICIAN
 MATERIALS/ EQUIPMENT
NEEDED
• 3 way catheter
• 0.9% sodium chloride
irrigation bags as per facility
policy
• continuous bladder irrigation
set and closed urinary
drainage bag with anti-reflux
valve.
MATERIALS/ EQUIPMENT
NEEDED
• Chlorhexidane 0.5% with 70%
alcohol wipes
• Non sterile gloves
• Personal protective
equipment
• Underpad (bluey)
• IV pole
 Procedure:
• 1. Explain procedure to the
patient and ensure patient
privacy
• 2. Position the patient for
easy access to the catheter
whilst maintaining patient
comfort
 Procedure:

• 3. Ensure that the patient has

a three-way urinary catheter.
– If not, a three-way catheter
needs to be inserted
 Procedure:
• 4. Hang irrigation flasks on IV pole and prime
irrigation set maintaining asepsis of irrigation
set.

• Note: Only one of the irrigation flask clamps

should be open when priming the irrigation set
otherwise the fluid can run from one flask to
another.
– After priming the irrigation set ensure that all clamps on
the irrigation set are closed.
 Procedure:

• 5. Don goggles and impervious gown , place

underpad underneath catheter connection
• 6. Attend hand wash and don non sterile
gloves
• 7. Swab IDC irrigation and catheter ports with
chlorhexidine swabs and allow drying
 Procedure:

• 8. Remove the spigot from the irrigation

lumen of the catheter using sterile gauze
and discard spigot

• 9. Connect the irrigation set to the irrigation

lumen of the catheter, maintaining clean
procedure
 Procedure:
• 10. Remove spigot or old drainage bag from
the catheter lumen using sterile gauze and
apply catheter drainage bag maintaining clean
procedure.
• Note: Do not commence Bladder Irrigation
until urine is draining freely
 Procedure:

• 11. Unclamp the irrigation flask that was

used to prime the irrigation set and set
the rate of administration by adjusting
the roller clamp

• Note: The aim of the bladder irrigation

is to keep the urine rose’ coloured and
free from clots.
8. As irrigation is completed, clamp the tubing. Do not allow the drip
chamber to empty. Disconnect the empty bottle and attach a full irrigation
bottle. Continue as ordered y the physician.
9. Wash your hands.
10. Record the amount of irrigation used on the intake and output and
subtract the drainage collected to ensure accurate recording of urine output.
BLADDER IRRIGATION
 Nursing
Responsibilities:

• Saline flasks for bladder irrigation do not need

to be ordered by a Medical Officer

• Continue irrigation as necessary depending on

the degree of hematuria
– (ensure adequate supply of irrigant nearby)
 Nursing
Responsibilities:
• After each flask is complete
– empty urine drainage bag and record urine
output on the FLUID BALANCE CHART, prior to
commencement of the next irrigation flask

• Regular catheter care is required in order to

minimize the risk of catheter related
urinary tract infection
 Nursing
Responsibilities:
• Catheter care provided should be documented in the
progress notes

• Also the nursing care plan including:

– patient comfort
– urine colour/degree of hematuria
– urine output
– Also presence of clots if any and if manual
bladder washout was necessary
 Nursing Consideration
▣ Use aseptic technique when irrigating the bladder to prevent infection.
▣ Review the physician’s order for the type and amount of solution to be
used and the type of irrigation to be performed.
▣ Do not forced irrigation against any resistance; notify the physician.
▣ Refer for signs of active bleeding by assessing the color of the
drainage, presence of pain or tenderness over the hypogastrium.
▣ If the inflow slow down, assess for patency of tubing's, check for kinks or
milk the tubing's to remove clots and refer if measures failed. Prepare
equipment needed for flushing the catheter.
Cystoclysis monitoring

Copyright © 2014 by Elsevier Inc. All

rights reserved. Slide 97
Copyright © 2014 by Elsevier Inc. All
rights reserved. Slide 98