CVP MONITORING

PRESENTER- MAJ ANKUSH MALHOTRA

MODERATOR- COL JOSEMINE DAVIS

Definition
Central venous pressure is considered as a direct measurement of the blood
pressure in the right atrium and it is used to determine preload and the filling
pressure of heart.
Normal value- 8-12 mm of Hg
Physiology behind CVP monitoring `
Two prerequisites must be met in order to correctly interpret the information
provided by the CVP monitor:
● (a) The clinician must possess a thorough understanding of all the variables
that affect right atrial pressure.
● (b) Measurements need to be made with extreme attention to detail.
CVP is determined by the interaction of the venous return function of the
circulatory system and the cardiac function.
Physiology behind CVP monitoring
● An increase in cardiac function with an increase in venous return will result in
an increase in cardiac output and rise in CVP.

● An increase in cardiac function without an increase in venous return will

result in an increase in cardiac output and a fall in CVP.

● An isolated CVP measurement has very little meaning unless the information
is interpreted in the context of some estimation of cardiac function.
CVP and Venous Return
● Venous return is mostly determined by the gradient between the mean
circulatory filling pressure (MCFP) and CVP.
● MCFP results from the elastic recoil pressure from distended small veins and
venules and is the force that drives blood back to the right atrium.

● Two important corollaries emerge:

○ right atrial pressure is key for maintaining cardiac output.
○ The body will compensate through the mechanisms described above and others to preserve
venous return.
CVP and Venous Return

● This explains why a patient may lose 10% to 12% of his circulating blood
volume without exhibiting changes in blood pressure or CVP.

● The difference between MCFP and CVP is only 6 to 8 mm Hg, and hence
small changes in CVP may have profound hemodynamic consequences.
CVP and Cardiac Function
● Changes in CVP may be the sole result of changes in inotropic state or
compliance of the ventricle, independent of the total circulating volume or
venous return to the heart.
● CVP is the result of a complex and diverse interplay among many different
physiologic variables, many of which are impossible to measure in the
operating room or ICU.
● It is therefore not surprising that studies assessing the value of CVP as a
predictor of volume status or fluid responsiveness have failed to demonstrate
a relationship.
Waveform of CVP

Waveform Component Phase of Cardiac Cycle Mechanical Event

a wave End diastole Atrial contraction

c wave Early systole Isovolumic ventricular

contraction, tricuspid motion
toward right atrium

v wave Late systole Systolic filling of atrium

h wave Mid to late diastole Diastolic plateau

x wave Mid systole Atrial relaxation, descent of

the base, systolic collapse

y wave Early diastole Early ventricular filling,

diastolic collapse
Normal CVP waveform
Normal CVP Waveform
The CVP waveform consists of five phasic events, three peaks (a, c, v) and two
descents (x, y).
● a wave -The most prominent wave is the a wave of atrial contraction, which
occurs at end-diastole following the ECG P wave.
● c-wave-This wave is a transient increase in atrial pressure produced by
isovolumic ventricular contraction, which closes the tricuspid valve and displaces it
toward the atrium.
● x descent - Atrial pressure continues its decline during ventricular systole, owing
to continued atrial relaxation and changes in atrial geometry produced by
ventricular contraction and ejection that draw the tricuspid annulus toward the
cardiac apex.
Normal waveform of CVP
v wave- Caused by venous filling of the atrium during late systole while the
tricuspid valve remains closed. The v wave usually peaks just after the ECG T
wave.
y descent- It is due to the diastolic decrease in atrial pressure due to flow across
the open tricuspid valve.
Abnormal waveform of CVP

● Atrial fibrillation- a wave

disappears and the c wave becomes
more prominent because atrial
volume is greater at end-diastole and
onset of systole, owing to the
absence of effective atrial contraction.
● Atrioventricular dissociation- Atrial
contraction now occurs during
ventricular systole when the tricuspid
valve is closed, thereby inscribing a
tall “cannon” a wave in the CVP
waveform.
Abnormal waveform of CVP
● Tricuspid regurgitation- It produces
abnormal systolic filling of the right atrium
through the incompetent valve. A broad, tall
systolic c-v-wave results, beginning in early
systole and obliterating the systolic x
descent in atrial pressure.

● Tricuspid stenosis-Produces a diastolic

defect in atrial emptying and ventricular
filling. The a wave is unusually prominent
and they descent is attenuated, owing to
the impaired diastolic egress of blood from
the atrium.
Abnormal waveform of CVP

Atrial fibrillation Loss of a wave prominent c wave

A-V dissociation Cannon a wave

Tricuspid regurgitation Tall systolic c-v wave

Loss of x decent

Tricuspid stenosis Tall a wave

Attenuation of y descent

Right ventricular ischemia Tall a and v waves

Steep x and y descent
M or W configuration

Pericardial constriction Tall a and v waves

Steep x and y descent
M or W configuration

Cardiac temponade Dominant x descent

Attenuated y descent
Physiological Pressure Monitoring
● Multilumen central venous catheter (15-20 cm in length) that is inserted in the
subclavian or internal jugular veins and advanced into superior vena cava.
● The CVP is hydrostatic pressure, so it is important that fluid filled transducer
is at the same level as right atrium.
● Reference point - intersection of midaxillary line and fourth intercostal space.
Physiological Pressure Monitoring

Components of physiological
Pressure measurement
● Invasive catheter
● Pressure transducer
● Normal saline flush
● Pressure infusion bag
● Reusable pressure cable
● Bedside physiological monitor
Levelling pressure transducer system
● Intravascular monitoring should be at the level of heart or phlebostatic axis.
● Should be done with a Carpenter’s level.
● Errors in pressure reading may occur if alignment with phlebostatic axis is not
maintained.
● For every inch (2.5 cm) the heart is offset from the reference point of the
transducer, a 2 mmHg of error will be introduced.
Levelling pressure transducer system
Levelling pressure transducer system
Zeroing
● Zero referencing eliminates the effects of atmospheric and hydrostatic
pressure
● Open the reference stopcock to air by removing the non-vented cap, keeping
sterility intact
● After removing non-vented cap, turn stopcock off to the patient
● Initiate “Zero” function on bedside monitor and confirm pressure waveform
and numeric value display 0 mmHg
● Once the “zero” is observed, turn the stopcock back to the vent port and
replace the non-vented cap
Square wave test and damping
1. Activate snap or pull tab on flush device

2. Observe square wave generated on bedside monitor

3. Count oscillations after square wave

4. Observe distance between the oscillations

Square wave test and damping
Pressure monitoring system
CVP values provide important information about
the cardiocirculatory status of the patient and
should not be abandoned. Use of CVP to guide
fluid resuscitation has many limitations, but we
believe it is wiser to understand and take into
account these limitations rather than to discard
CVP completely.
Thank you
Indication
● Measurement of right heart filling pressure to assess intravascular volume and right heart
function.
● Presence of persistent hypotension despite of fluid resuscitation despite fluid resuscitation
● Vasopressor therapy
● Extensive third space losses
● Oliguria Or Anuria
● Trauma
● Sepsis
● Major surgeries
● Burns
● Heart failure
Complications of CVP
Mechanical Thromboembolic Infectious

● Arterial ● Venous thrombosis ● Insertion site

● Venous ● Pulmonary infection
● Cardiac tamponade embolism ● Catheter infection
● Pneumothorax ● Arterial thrombosis ● Bloodstream
● Airway compression and embolism infection
from hematoma Catheter or ● Endocarditis
● Nerve injury guidewire embolism
● Arrhythmias