CENTRAL VENOUS PREASURE

By:
ENGKUS KUSNADI, S.Kep., M.Kes
Central Venous Vressure

 Central venous pressure (CVP) describes the

pressure of blood in the thoracic vena cava, near the
right atrium of the heart. CVP reflects the amount of
blood returning to the heart and the ability of the
heart to pump the blood into the arterial system. It is
a good approximation of right atrial pressure, which is
a major determinant of right ventricular end diastolic
volume. Normal CVP is 4-8 cm H20.
 CVP can be measured by connecting the patient's
central venous catheter to a special infusion set which
is connected to a small diameter water column
(Manometer). If the water column is calibrated
properly the height of the column indicates the CVP.
Location of CVP
 In medicine, a central venous catheter
(CVC or central venous line) is a catheter
placed into a large vein in the neck, chest
or groin, this is inserted by a physician
when the patient needs more intensive
cardiovascular monitoring, for assessment
of fluid status, and for increased viability of
intravenous drugs/fluids. The most
commonly used veins are the internal
jugular vein, the subclavian vein and the
femoral vein. This is in contrast to a
peripheral line which is usually placed in
the arms or hands.
Indications and uses
Indications for the use of central lines include:
 Monitoring of the central venous pressure (CVP) in
acutely ill patients to quantify fluid balance
 Parenteral nutrition
 Drugs that are prone to cause phlebitis in peripheral
veins (caustic), such as:
 Calcium chloride
 Chemotherapy
 Potassium chloride
 Amiodarone
 Need for intravenous therapy when peripheral venous
access is impossible
 Blood
 Medication
 Rehydration
Contra indications

 Uncooperative patient
 Uncorrected bleeding diathesis
 Skin infection over the puncture site
 Distortion of anatomic landmarks from any
reason
 Pneumothorax or hemothorax on the
contralateral side
Procedure Step-by-Step

 Explain the procedure to the patient and

obtain a written informed consent, if
possible. Explain the risks, benefits and
alternatives (RBA).
 Get to know the equipment in the standard
central line placement kit. We will use the
terms central line and triple lumen catheter
(TLC) interchangeably in this article.

Fig. 1. Equipment needed for TLC.

Assisting with CVP placement
 Adhere to institutional Policy and Procedure.
 Obtain history and assess the patient.
 Explain the procedure to the patient, include:
 local anesthetic
 trendelenberg positioning
 draping
 limit movement
 need to maintain sterile field.
 post procedure chest X-ray
 Obtain a sterile, flushed and pressurized transducer assembly
 Obtain the catheter size, style and length ordered.
 Obtain supplies:
 Masks
 Sterile gloves
 Line insertion kit
 Heparin flush per policy
 Position patient supine on bed capable of trendelenberg
position
 Prepare for post procedure chest X-ray
CVP Monitoring
 The CVP catheter is an important tool
used to assess right ventricular
function and systemic fluid status.
 CVP is elevated by :
 overhydration which increases venous
return
 heart failure or PA stenosis which limit
venous outflow and lead to venous
congestion
 positive pressure breathing, straining,
CVP decreases with:
 hypovolemic shock from hemorrhage, fluid shift,
dehydration
 negative pressure breathing which occurs when the
patient demonstrates retractions or mechanical
negative pressure which is sometimes used for high
spinal cord injuries.

The CVP catheter is also an important

treatment tool which allows for:
 Rapid infusion
 Infusion of hypertonic solutions and medications that
could damage veins
 Serial venous blood assessment
Complications

Potential complications include:

 Pneumothorax (for central lines placed in
the chest) - this is why doctors routinely
order a chest X-ray (CXR) after insertion of
a subclavian or internal jugular line. The
incidence is thought to be higher with
subclavian vein catheterization. In
catheterization of the internal jugular vein,
the risk of pneumothorax can be minimized
by the use of ultrasound guidance. For
experienced clinicians, the incidence of
pneumothorax is about 1%.
* Sepsis. All catheters can introduce bacteria
into the bloodstream, but CVCs are known
for occasionally causing Staphylococcus
aureus and Staphylococcus epidermidis
sepsis. A patient with a central line, fever,
and no obvious cause of the fever may
have catheter-related sepsis. Generally,
antibiotics are used, and occasionally the
catheter will have to be removed. To
prevent infection, some central lines are
now coated or impregnated with antibiotics
or silver (specifically silver sulfadiazine).
 Air embolism
 Haemorrhage
 Arrhythmia. This is typically caused
during the insertion process when the
wire comes in contact with the
endocardium. It typically resolved
when the wire is pulled back.
 Arterial injury
Pemasangan CVP
 Tehnik Seldinger adalah pemasangan
CVP menggunakan mandrin yang
dimasukan melalui jarum, jarum
kemudian dilepaskan dan kateter CVP
dimasukan melalui mandrin tersebut
 Jika kateter sudah mencapai atrium
kanan, mandrin ditarik dan kateter
disambungkan dengan IV set
 Lakukan penjahitan daerah insersi
Langkah Pemasangan :
 Siapkan alat
 Lakukan cuci tangan steril
 Gunakan sarung tangan steril
 Tentukan daerah penusukan
 Atur posisi klien : trendelenberg
 Lakukan desinfeksi daerah penusukan
 Lakukan anesthesi lokal (lidocain)
 Pasang duk bolong steril di daerah
penusukan
 Sebelum penusukan, anjurkan klien
nafas dalam dan menahan nafas
 Masukan jarum cateter, ujung kateter
harus tetap berada pada vena cava,
jangan sampai masuk ke dalam
jantung
 Setelah selesai, sambungkan dengan
slang IV set dan slang manometer
 Lakukan fiksasi / dressing pada
daerah penusukan agar posisi
kateter terjaga dengan baik
 Rapihkan alat dan cuci tangan
kembali
 Catat laporan pemasangan : respon
klien, lokasi, petugas pemasangan,
hasil CVP dan cairan yang digunakan
 Setelah pemasangan, sebaiknya
lakukan rontgent dada untuk
memastikan posisi kateter,
memastikan tidak adanya
hemothorax atau pneumothorax
sebagai akibat pemasangan
Pengukuran Nilai CVP

 Tehnik pengukuran CVP :

1. Computerized melalui bedside
monitor
2. Manual melalui manometer
Pengukuran Manual
 Tentukan titik nol yang sejajar
dengan posisi jantung (zero point)
dengan cara :
1. Letakan penggaris secara vertikal
pada ICS V, selanjutnya letakan
penggaris secara horizontal
sepanjang 10 cm
2. Tarik garis sejajar dengan mid
axilaris pada ICS V
 Tandai titik nol pada pasien tersebut
 Sejajarkan titik nol pada pasien
dengan titik nol pada manometer
dengan menggunakan water pass
 Tutup three way ke arah CVP catheter
dan isi manometer dengan cairan IV
 Tutup three way ke arah IV line,
selanjutnya buka ke arah manometer
dan CVP catheter
 Perhatikan undulasi cairan pada
manometer
 Catat nilai CVP pada saat cairan
manometer stabil
 Tutup kembali three way ke arah
manometer dan buka ke arah IV line
dan CVP catheter
 Dokumentasikan hasil pengukuran :
nilai, waktu, pemeriksa, dan tanda
tangan.