CVP

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