CVP Monitoring

NURSING EDUCATION SERVICES
Fundamentals of
Hemodynamic
Monitoring
Hemodynamic monitoring
Hemodynamics, by definition, is the study of the motion of blood
through the body.
In simple clinical application this may include the assessment of a
patient’s heart rate, pulse quality, blood pressure, capillary refill, skin
color, skin temperature, and other parameters.
Invasive hemodynamic monitoring include waveform and numeric
data derived from the central veins, right atrium, pulmonary artery,
left atrium, or peripheral arteries
Pressure Monitoring Systems
•Catheter Semi-rigid pressure tubing (The tubing must be more rigid than
standard IV tubing, also be as short as reasonably possible
•Transducer converts the pressure waves generated by vascular blood flow into
electrical signals
•Transducer cable displays a pressure waveform and numeric readout.
•flush system
•Intraflow valve maintains a continuous flow of flush solution (approximately 3-
5 ml/hr)
•fast flush device
Principles of hemodynamic
monitoring Angles
45°
LEVELING AND ZEROING 30° Supine

Head of bed: 0-60°
Ensure air-fluid interface of the transducer is leveled

at Phlebostatic axis before zeroing and/or obtaining
pressure readings. 0°
Level of left atrium 4th ICS & ½ AP diameter Mark

the chest with washable felt pen.
Zeroing eliminates effects of hydrostatic forces on
the observed hemodynamic pressures.
Principles of hemodynamic monitoring
Leveling of the catheter system is accomplished by aligning the air-fluid interface of the
monitoring system (eg stopcock on the top of the transducer) with the external reference
point to the heart. The external reference point of the heart is phlebostatic axis.
ZEROING
Dynamic testing
Fast flush test Normal Response
Activate the fast flush device for 1-2 seconds or four fast flushes a few seconds
apart each time you record them.
Ideally, you should observe a sharp rapid upstroke with a flat line extending
briefly (1-2 seconds) to a sharp rapid down stroke that extends below the
baseline.
The behavior of this waveform reflects the dynamics of the system and
indicates the accuracy with which it is reflecting the patient’s pressures.
To evaluate the system’s response to pressures, determine how fast the
oscillations are (the frequency between them) and how high the waves are
(amplitude). Generally, the smaller the distance between the oscillations the
better. The first two oscillations are the primary focus. The second oscillation
should be about 1/3 the height of the first one. This indicates that the system is
able to go back to baseline quickly and does not have distortion when subjected
to pressures.
Over damped system
Reduced waveform magnitude and loss of

some waveform components or waves that are
sluggish and far apart.
This can lead to a false low systolic pressure

and a false high diastolic pressure reading.
Causes of over damped system
Distensible tubing. use only the semi-
rigid standard tubing
Overly long extension tubing.
Extension tubing should never exceed 3
– 4 feet in length
Air bubbles in the circuit
Catheter diameter, length and
stiffness - small diameter catheters, long
catheters, and soft, compliant catheters
can all cause over damping
Under damped system
In an underdamped system, the square wave will be
followed by multiple large oscillations.
Underdamping will cause a false high systolic

pressure reading and a false low diastolic pressure
reading,
Tips for Maintaining an Accurate
Hemodynamic Monitoring System
•Use as simple system as possible.
•Use short, non-compliant connecting tubing.
•Maintain tight connections. Maintain the fast flush system.
•Inspect for bubbles.
•Keep tubing away from areas of patient movement.
Central venous pressure
CVP determines the preload or filling pressure of the heart.
The CVP is the pressure of the blood emptying into the right ventricle
during diastole (the right ventricular end-diastolic pressure, or RVEDP).
This pressure reflects what is known as right ventricular preload.
Filling pressure of the left heart is dependent on the output of the right
heart through the pulmonary circulation, the filling pressure of the left
ventricle is dependent on CVP as a factor in determining its preload.
CVP as a marker of left ventricular preload depends on several
assumptions. It assumes that pulmonary resistance and right heart
function are normal and unimpaired and that intra-thoracic pressures do
not vary significantly.
It is important to take into consideration clinical assessment and tissue
perfusion variables while interpreting CVP to help guide fluid
management.
CVP and its correlation with Stroke
volume
Central Venous Pressure
Indications for the Use of Central Venous Catheters
•Rapid administration of fluids and blood products in patients with any form of shock
•Administration of vasoactive and caustic drugs
•Administration of parenteral nutrition, electrolytes or hypertonic solutions
•Venous access for monitoring CVP and assessing the response to fluid or vasoactive
drug therapy
•Insertion of transvenous pacemaker
•Lack of accessible peripheral veins
•Hemodynamic instability
Central venous pressure
Normal value 2–8 mm Hg.
Target values differ depending on clinical condition.
Severs sepsis/Septic shock 8–12 mm Hg.
Static measurements vs dynamic monitoring.

Manometer versus electronic (continuous) CVP monitoring.
Central venous pressure monitoring
Location of catheter in the superior vena cava as it opens into the right atrium
Priming, Leveling and Zeroing.
CVP can be measured with the patient in the supine position with the head of bed
elevated anywhere between 0 and 60 degrees. It is essential that all
measurements be taken from the same patient position for trends to be valid.
When taking the initial CVP measurement, record the head of bed position along
with the reading.
Elevated CVP
Fluid overload
Conditions other than Hypervolemia that Elevate CVP
Intra-abdominal hypertension
Mechanical Ventilation with positive end-expiratory
pressure (PEEP).
Pericardial tamponade, Myocardial infarction,
cardiogenic shock, heart failure,
Right-sided valvular disorders such as tricuspid
regurgitation and pulmonic stenosis may also elevate the
CVP reading
Pneumothorax, Hemothorax, Pulmonary edema, COPD,
pulmonary embolus, pulmonary hypertension.
Decreased CVP
Absolute hypovolemia caused by dehydration, hemorrhage, vomiting or diarrhea.
Relative hypovolemia caused by fluid losses from the intravascular space due to an
alteration in capillary membrane permeability, caused by conditions such as peritonitis,
bowel obstruction or the systemic inflammatory response syndrome (SIRS).
Vasodilation may allow blood to pool within the blood vessels and decrease venous
return and CVP; vasodilatation may be a result of medications, anaphylaxis, sepsis or
neurogenic shock.
Absolute hypovolemia, Relative hypovolemia, vasodilation. In any case, the numeric
CVP value alone is meaningless without correlation with the patient’s diagnosis, history
and thorough physical assessment.
Removal of Catheter
Instruct the patient to take a deep breath and hold it. If the patient is unable to
perform a breath hold, time the removal of the catheter to coincide with a period
of positive intrathoracic pressure. In spontaneously breathing patients this will
occur during exhalation. In mechanically ventilated patients positive intrathoracic
pressure occurs when the ventilator delivers a breath.
If the catheter is removed during a period of negative intrathoracic pressure, an

air embolus could be drawn in through the open tract.
Complications of CVP catheters
•Up to 15% of patients experience 1 or more complications from central line insertion.
•Bleeding and hematoma
•Arterial puncture
•Pneumothorax
•Hemothorax
•Cardiac arrhythmias
•Venous or cardiac perforation
•Cardiac tamponade
•Embolism caused by air, particulate matter, catheter tip, or clot formation.
•Local infection and CRBSI.

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NURSING EDUCATION SERVICES

LEVELING AND ZEROING 30° Supine

Ensure air-fluid interface of the transducer is leveled

Level of left atrium 4th ICS & ½ AP diameter Mark

Reduced waveform magnitude and loss of

This can lead to a false low systolic pressure

Underdamping will cause a false high systolic

Static measurements vs dynamic monitoring.

If the catheter is removed during a period of negative intrathoracic pressure, an

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