Central Venous Pressure

• is an accurate indicator of the amount of blood returning to the heart from the
head, body and limbs via the superior and inferior vena cava. If and when
there is blood loss then the CVP reading will be altered (will fall) almost
immediately as the amount of blood returning to the heart will have
decreased.
• an accurate indicator of the ability of the heart (myocardial pump strength) to
pump out blood to maintain normal blood pressure and tissue perfusion.
• an accurate indicator of right ventricular end diastolic volume. In most
institutions CVP is measured in cm of water (H2O). On this scale the normal
value of CVP is 5 to 10 cm H2O. Some, (very few) institutions measure CVP in
mm. Hg (millimetres of mercury). On this scale the normal value is
approximately 4 to 8 mm Hg.

Indications for Central Venous Pressure Lines

A central venous catheter is inserted by a qualified person into one of the central or
peripheral veins and then threaded to the exterior of the right atrium where the
superior vena cava meets the inferior vena cava. This is only done where medically
indicated and qualified nursing staff is available to care, manage, and support the
patient. Reading the CVP correctly is essential for the results to be useful
therapeutically. The following are some of the general indications for inserting a CVP
line.

1. Monitoring of Central Venous Pressure in the acutely ill patient. This allows the
care giver to have an insight into the fluid balance status of the patient. High
CVP would indicate fluid overload or a failing heart. Low CVP would indicate a
degree of dehydration or blood loss. Exact fluid status can only be evaluated
by correlating Hb, Cardiac Functioning and all other lab results and clinical
history of the patient.
2. Total Parenteral Nutrition (TPN) Administration. When an acutely ill patient’s GI
tract is not able to absorb nutrients then the treatment team may decide to
give the patient nutrition. This is called TPN and TPN can be given safely only
via a CVP line or a peripherally inserted central line (PICC). Generally TPN is
administered via a central intravenous catheter which is inserted in the
subclavian or jugular vein. In infants the Umbilical vein is used most
frequently. The rationale for using big deep veins for the administration is the
fact that TPN causes phlebitis in peripheral veins because it is contains many
caustic components. Examples include Calcium Chloride and Potassium
chloride.
3. Medication Administration. Certain medications can be given safely only via a
central line. Hence a CVP may be inserted for this purpose. Drugs that are
likely to cause phlebitis include Chemotherapeutic Agents used in the
treatment and management of malignant conditions. Amiodarone is used
extensively in the management and treatment of acute life-threatening
arrhythmias as well as for the suppression of chronic arrhythmias. It is useful
both for supraventricular and ventricular arrhythmias because it has a low
incidence of pro-arrhythmic effects. In arrest trials amiodarone has shown to
improve survival rates (when compared to placebo) in individuals who suffer a
cardiac arrest.
4. Lack of peripheral access. In some acutely ill patients, when there is no
peripheral venous access, then a CVP line may be inserted. This is usually
 done for the purposes of re-hydration, medication administration,
administration of blood and blood products.

Standard Equipment

Prior to insertion of a CVC catheter it is good practice to clean and set up a trolley
with the following equipment.

1. CVP catheter
2. Sterile gown for physician or practitioner
3. Sterile gloves and masks.
4. Local anaesthetic
5. Hypodermic needles
6. Silk sutures with needle.
7. CVP insertion kit (with drape, chlorohexidine).
8. Manometer or transducer with monitor and pressure bag
9. Normal saline or heparinised saline according to Hospital policy.
10. Sterile Scissors
11. Op site or other transparent dressing(s).
12. Writing (non-lead) pen
13. Patient’s chart

After the procedure has been explained to the patient and the patient has agreed to
it draw the curtains to insure privacy. Push the equipment trolley to the patient’s
bedside. When the physician has put on his mask and goggles he will need to wash
his hands. When he is doing that the nurse can open the contents of the different
packs and set up the trolley. There should be a sterile gown on the trolley or in the
pack along with sterile towels for the physician to dry his hands. It is the Nurses’
responsibility to tie the back of the physician’s gown.

When the physician is inserting the CVC catheter the nurse may need to elevate the
foot of the bed to increase venous distension so that the physician is able to visualise
the blood vessel better. Further, the draped patient may need emotional support too
because he may be anxious and it is not comfortable lying there with the face
covered and the bright lights shining on the face.

The CVC insertion procedure is completed when the CVC is inserted, has been
verified with a chest x-ray, adequately secured (stitched in placed) and covered with
a sterile dressing. It is the physician’s responsibility to place all sharps in the sharps
container.

Commonly Used Sites for CVP Insertion

As stated previously the CVC catheter is inserted peripherally into one of the big
veins. The vein used is chosen according to the patient’s needs and suitability. Unit
and Physician preference do play a minor role. The following vessels are used most
frequently.

1. Internal jugular vein: This site is one of the most frequently chosen because it
is easily located and has low probability of complications like pneumothorax.
The internal jugular veins (left and right) are short, straight and large.
Therefore they facilitate easy insertion of the CVC catheter. Catheter occlusion
 is the most complication and this is due to head movement. This may cause
irritation in the conscious patient.
2. Subclavian veins, left and right. This is the site which is most often used. It is
chosen because there are easily recognisable anatomical landmarks which
make insertion of the CVC easier. Since the subclavian arteries are located
beneath the clavicle the risk of pneumothorax is always present. Subclavian
CVCs are most frequently recommended and inserted because they are
considered to be more comfortable for the patients (Woodrow 2002).
3. Left and right Femoral veins. These sites are used because they provide rapid
central
access in an emergency. A cardiac arrest is one such example. However, as
most nursing students know, the femoral veins are located in the groin. This
site is associated with high bacterial counts and high infection rates.
Additionally, the femoral veins are also considered to be uncomfortable for
mobility purposes.

CENTRAL VENOUS PRESSURE MEASUREMENT

• The water manometer is connected to the plastic intravenous catheter

• Place the patient supine and flat and the zero point of the manometer is held
at the midaxillary line. This should be marked to ensure a constant base line.
• This is to balance the water column in the manometer against the pressure in
the catheter.
• The manometer is filled with fluid from the intravenous bottle.
• The fluid in the column is allowed to fall by closing the solution arm until it
balance the central venous pressure in the superior vena cava. The fluid level
indicates the central venous pressure in cm. H2O
• The height of the water column above this point equals the central venous
pressure.

Removal of the CVP Cannula

This is only done on the express directions of the treatment team. This is an aseptic
technique and must be done after fully explaining the procedure to the patient. First
remove all dressings and sutures. Then request the patient to take a deep breath and
exhale completely. At this point remove the catheter by steadily pulling it out while
the patient is holding his breath. Finally apply firm pressure to the puncture site and
ask the patient to resume normal breathing. Keep the firm pressure for at least 5
minutes. This will stop the bleeding. Only a moderate amount of force will be needed
to remove the catheter. If it does not come out request a physician to do it. An
experienced physician will (most likely) try rotating the CVP catheter while pulling it
out gently. If this intervention fails then cover the CVP insertion site with a sterile
dressing and arrange for the surgical registrar to evaluate the removal.

Conclusion

Central venous pressure measurements are often associated with Intensive and
critical care settings of major treatment centres. However an ever increasing number
of critically ill patients are being cared for on medical and surgical wards and in
remote communities with limited resources. It is therefore essential that all nursing
staff are able to help with the procedure and record central venous pressure
measurement accurately and safely. They also need to be able to recognise normal
and abnormal parameters. The normal parameters have been given in this article.