To run infusion with CVP or not... That tis the question..

  1. So, this past week some coworkers of mine had gotten into a heated debate as to whether or not it's okay to run an infusion of something other than NS (3%, sedation, etc.) with your CVP line if you've run out of access. One of the arguments was that you could possibly bolus your patient with whatever gtt you were running with the CVP line.
    What do you guys think? Do you ever run fluids/gtts with your CVP? Do you have policy on this?
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  2. 17 Comments

  3. by   VANurse2010
    I would only do intermittent infusions with CVP (like antibiotics or electrolytes), not drips. CVPs are of dubious validity under perfect circumstances, so I would avoid monkeying with them.
  4. by   offlabel
    So, running drips when actually measuring a pressure? Obviously, the pressure you see will be affected to one degree or another by the continuous infusion, but if you want an accurate number, just pause the gtt for the 7 seconds it takes to measure accurately. No big deal.

    As to the "bolus" concern, I'd say it was a little misplaced because the priming volume of the lumen is so small, whatever effect that would be seen from the "bolus" would be insignificant and short lived. It's a half cc or less. Check the package insert. Non-issue as far as I'm concerned

    As to the value of the CVP/RAP, I'm well aware of the nearly wholesale dismissal of this number by broad swaths of providers, but I can assure you, as someone that uses this pressure on a nearly daily basis, if you know what it really means and how to use it, you'd find it far more valuable than the current conventional wisdom holds.
  5. by   Ruby Vee
    Quote from offlabel
    So, running drips when actually measuring a pressure? Obviously, the pressure you see will be affected to one degree or another by the continuous infusion, but if you want an accurate number, just pause the gtt for the 7 seconds it takes to measure accurately. No big deal.

    As to the "bolus" concern, I'd say it was a little misplaced because the priming volume of the lumen is so small, whatever effect that would be seen from the "bolus" would be insignificant and short lived. It's a half cc or less. Check the package insert. Non-issue as far as I'm concerned

    As to the value of the CVP/RAP, I'm well aware of the nearly wholesale dismissal of this number by broad swaths of providers, but I can assure you, as someone that uses this pressure on a nearly daily basis, if you know what it really means and how to use it, you'd find it far more valuable than the current conventional wisdom holds.
    I think the bonus concern is if you're using thermaldilution cardiac outputs. I've done it in a pinch, when I had to, and as you say you can pause the infusion for 7 seconds or so to get an accurate CVP. (The problem there is that too many people just click down the number the monitor is reading and are documenting inaccurate numbers.). But if you're using the line to shoot cardiac outputs, it becomes a bigger issue. Better make sure the drip is something long-acting or not vasoactive so you can pause the drip, clear the line of drug and then shoot your cardiac outputs.
  6. by   offlabel
    Quote from Ruby Vee
    I think the bonus concern is if you're using thermaldilution cardiac outputs. I've done it in a pinch, when I had to, and as you say you can pause the infusion for 7 seconds or so to get an accurate CVP. (The problem there is that too many people just click down the number the monitor is reading and are documenting inaccurate numbers.). But if you're using the line to shoot cardiac outputs, it becomes a bigger issue. Better make sure the drip is something long-acting or not vasoactive so you can pause the drip, clear the line of drug and then shoot your cardiac outputs.
    Do places still do manual CO injections? Haven't seen one of those in years. All CCO now where I am.
  7. by   Ruby Vee
    Quote from offlabel
    Do places still do manual CO injections? Haven't seen one of those in years. All CCO now where I am.
    Yes, some pretty famous big name teaching hospitals still do thermodilution cardiac outputs.
  8. by   offlabel
    Quote from Ruby Vee
    Yes, some pretty famous big name teaching hospitals still do thermodilution cardiac outputs.

    Must be cheaper...sure not better.
  9. by   Wolf at the Door
    Quote from offlabel
    Must be cheaper...sure not better.
    pre heart transplants do thermodilution. walkie talkies benefit from thermodilution and so does the staff.
  10. by   offlabel
    Quote from Bottomed out
    pre heart transplants do thermodilution. walkie talkies benefit from thermodilution and so does the staff.
    I don't know what that means.
  11. by   Ruby Vee
    Quote from offlabel
    I don't know what that means.
    It means that dismissing thermodilution cardiac outputs out of hand is short sighted. Yes, it's cheaper than the fancy CCO machines that I enjoyed a dozen years ago when I worked on the west coast. But it still gives you valuable information when done correctly and taken in context with everything else.
  12. by   offlabel
    Quote from Ruby Vee
    It means that dismissing thermodilution cardiac outputs out of hand is short sighted. Yes, it's cheaper than the fancy CCO machines that I enjoyed a dozen years ago when I worked on the west coast. But it still gives you valuable information when done correctly and taken in context with everything else.
    Not dismissing them out of hand in the least. When cardiac function needs to be followed and they're all you have, they're as good as the CCO systems for getting a number. All things being equal, though, CCO is better. More information for less moving parts, less lines, less bag changes, less injecting stuff into the patient, that's all.

    I've used both very extensively as well. A Geo will get you to work as well as a Lexus.
  13. by   MunoRN
    While CCO has advantages I don't think you can really say that overall it's better than bolus thermodilution. The biggest problem is that people falsely assume it's in real time, even though the CI that appears on the screen is actually the CI from 5 to 15 minutes ago. And while there are some studies that suggest comparable accuracy, the overall body of evidence finds CCO to be less accurate than bolus thermodilution, which is why there are manufacturers that incorporate the ability to shoot "old school" CI's with their CCO catheters. It would just based on how they work that bolus thermodilution would be more accurate since pulsed heat CCO catheters are producing a small blood temperature change at the RA which is then makes for a much small curve to measure in the PA, generally smaller things are harder to measure accurately.
  14. by   offlabel
    Quote from MunoRN
    While CCO has advantages I don't think you can really say that overall it's better than bolus thermodilution. The biggest problem is that people falsely assume it's in real time, even though the CI that appears on the screen is actually the CI from 5 to 15 minutes ago. And while there are some studies that suggest comparable accuracy, the overall body of evidence finds CCO to be less accurate than bolus thermodilution, which is why there are manufacturers that incorporate the ability to shoot "old school" CI's with their CCO catheters. It would just based on how they work that bolus thermodilution would be more accurate since pulsed heat CCO catheters are producing a small blood temperature change at the RA which is then makes for a much small curve to measure in the PA, generally smaller things are harder to measure accurately.
    Our Edwards device gives CO's every 2 minutes which, for cardiac output, is for all practical purposes real time. But that is way overkill in any other setting besides the CVOR and immediate post op hearts. And we don't use them nearly as often as we use to. As to the accuracy, even assuming the old catheters are, in perfect conditions more accurate, the difference in numbers are not clinically significant, ie, it's not enough of a difference to change the therapy, especially given the variability between different operators of the injectate catheters.

    I still say, all things, including cost (which it isn't) being equal, I'd choose the CCO for what I do for a living. Very sick hearts and lungs benefit from having the continuous SvO2 as well.

    Your results may vary.

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