This document discusses central venous pressure (CVP), including indications for CVP monitoring, measurement, waveform interpretation, and techniques for central venous cannulation. It notes that CVP can be used to assess intravascular volume status, right ventricular function, and is indicated for major procedures involving fluid shifts. The internal jugular vein and subclavian vein are common access sites, and ultrasound guidance can help with cannulation. Potential complications include arterial puncture, pneumothorax, and infection.

1. CENTRAL VENOUS
PRESSURE
Dr. Davis Kurian

2.  Measure RV filling pressure.
 Estimation of intravascular volume status.
 Assessment of RV function
CVP

3.  Major procedures involving large fluid shifts and/or blood loss.
 Intravascular volume assessment when urine output is not reliable.
 Major trauma.
 Surgeries with high risk of air embolism.
 Frequent venous blood sampling.
 Venous access for vasoactive/irritating drugs & for long term drug
administration.
 Inadequate IV access
 Rapid infusion of IV fluids.
 Transvenous pacing
 Temporary hemodialysis
INDICATIONS

4.  The distal end of the catheter – in one of the large
intrathoracic veins/ RA.
 Zero point – taken at the centre of RA – important –
height can influence CVP measurement.
 3 upward deflections : a,c,v
 2 downward deflections : x,y
 Trends are more important than individual values.
 Influenced by IVC thrombosis and alterations of
intrathoracic pressure.
MEASUREMENT

7. WAVEFORM

8.  Irregular rhythm with loss of a wave – AF/Afl.
 Cannon a waves – junctional rhythm, complete heart block,
ventricular arrythmias, tricuspid stenosis, RVH, pulmonary stenosis,
Pulmonary hypertension.
 Early/holosystolic cannon v waves – significant TR.
 Large v waves – RVF/incompliant ventricle due to ischemia
 Pericardial constriction – decreased venous return – prominent a and
v waves & steep x and y descents (M /Wconfig).
 RV ischemia – tall a and v waves, steep x and y descent.
 Cardiac tamponade – dominant x descent, attenuated y descent
PATHOLOGICAL CONDITIONS

9.  Site chosen depends on patient condition, skill and
experience of the personnel and the indication.
 Sites chosen include:
 IJV
 SUBCLAVIAN
 EJV
 ANTECUBITAL APPROACH
 FEMORAL VEIN
TECHNIQUES & INSERTION SITES

10.  1st described by English et.al (1969)
 Advantages:
 High success rate
 Short straight course of vein
 Easy access from head
 Fewer complications
 Easy compressibility in patients with bleeding diathesis.
IJV APPROACH

11.  Location – under the medial border of lateral head of SCM.
 Right IJV preferred – leads straight to SVC and RA – minimises
injury to thoracic duct, pneumothorax.
 Position :
 Supine with head down position
 Head turned to opposite side
 Techniques:
 Middle approach
 Anterior high approach
 Posterior approach
 USG guided
IJV APPROACH

12. IJV APPROACH

13. IJV APPROACH

14. IJV APPROACH

15. IJV APPROACH

16.  USG guided – advantages :
 Minimises injury to carotid artery
 Helps to identify the anatomy
 Especially advantageous in patients with difficult neck
anatomy, prior neck surgeries and anticoagulated
patients.
IJV APPROACH

17.  Tortuous path – reduced success rate
 Advantages – avoids advancement of needle into
deeper structures.
EJV APPROACH

18.  Supraclavicular and infraclavicular approach
 High incidence of complications – esp pneumothorax.
 Site of choice in patients undergoing surgeries of
head and neck and in trauma patients immobilised
with cervical collar
 Useful in parentral nutrition/prolonged CVP
monitoring
SUBCLAVIAN VEIN

19. INFRACLAVICULAR APPROACH
Supine, head down
Folded sheet between scapulae
Head turned to opposite side

20. SUPRACLAVICULAR APPROACH

21.  Advantage –
 Decreased complications
 Ease of access
 Disadvantage –
 Difficult to ensure correct central venous placement of
cathether.
 Caridac perforation and arrythmias
ANTECUBITAL VEINS

22.  Ideally in SVC – parallel to vessel wall – below the
inferior border of clavicle – above 3rd rib, T4 – T5
interspace, azygos vein, tracheal carina and or above
the take off of the right main bronchus.
CONFIRMING CATHETHER POSITION

23.  Increased success rate
 2 cm below inguinal ligament – medial to pulsation of
femoral artery.
 Increased chances of infection when placed for a long
time , thromboembolic events & vascular injury.
 Especially indicated in patients with SVC obstruction.
FEMORAL VEIN

24.  ABSOLUTE
 SVC syndrome – CI to upper extremity placement
 Infection at the site of insertion
 RELATIVE
 Coagulopathies
 Newly inserted pacemaker wires
CONTRAINDICATIONS- CENTRAL
VENOUS CANNULATION

25.  COMPLICATIONS OF CENTRAL VENOUS
CANNULATION
 Arterial puncture with hematoma
 A-V fistula
 Hemothorax, chylothorax, pneumothorax
 Brachial plexus injury
 Horner’s syndrome
 Air embolism
 Catheter/wire shearing
COMPLICATIONS

26.  COMPLICATIONS OF CATHETHER PRESENCE
 Thrombosis/thromboembolism
 Infection, sepsis, thromboembolism
 Arrythmias
 Hydrothorax
COMPLICATIONS

27.  KAPLAN’S TEXTBOOK OF CARDIAC ANAESTHESIA – 4TH EDN
 MILLER’S TEXTBOOK OF ANAESTHESIA – 8TH EDN
REFERENCES