Normal CVP?

  1. 1 I recently had a patient who had orders to give a 250 ml NS bolus if her CVP dropped below 12. She was on a vent, and 10 mcg of levophed with systolic of 100-115. She had ascities with a lot of fluid in her abdomen. Can someone please explain the physiology behind this? I thought normal CVP was 5-10. Why would we want it above 12?
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  3. Visit  nursingdude78 profile page

    About nursingdude78

    Joined Sep '08; Posts: 21; Likes: 1.

    20 Comments so far...

  4. Visit  MrBubbles profile page
    2
    That's hard to answer without getting a better pic of the pt. If a pt is on higher peep than their cvp will be elevated. If they have asities then I assume there is liver failure going on. You may have heard that we don't go clamping down on a pt with levo if they are dry. The cvp of 12 may be a cushion to make sure that is not happening. Often you may see an order for checking cvp Q4hr and if it's below X then treat with 250cc bolus. Then if it's low 4hrs later treat with albumin, and alternate these therapies as needed.
    MEDICJOHN and yesdog like this.
  5. Visit  ghillbert profile page
    2
    Did she have heart failure? People with bigger, floppier hearts need a higher filling pressure since their pump is weak. If she had severe heart failure, that could cause hepatic congestion and ascites too.
    CCL RN and yesdog like this.
  6. Visit  geekgolightly profile page
    1
    fulminant hepatic failure increases IAP which can give a CVP a falsely elevated reading. he might have been trying to compensate for this change in pressure readings.
    yesdog likes this.
  7. Visit  love-d-OR profile page
    1
    Was this a post liver transplant pt? If so, it is not unusual to see that kind of CVP favored. We like them tanked. Give a better picture of the patient : What disease? comorbidities? Where was the line? femoral lines are not as accurate.
    yesdog likes this.
  8. Visit  WalkieTalkie profile page
    1
    I found this article while looking for something on SvO2: http://www.uptodate.com/home/content...=cc_medi/16828
    yesdog likes this.
  9. Visit  criticalHP profile page
    8
    From what you are describing this order is what I would expect for a patient in severe sepsis. For a ventilated pt you bolus 500ml fluid for the first 12 hrs for a CVP <12. Levophed is usually the drug of choice for BP support then adding vasopressin if BP remains inadquate after 4 hrs of being on levo.

    The physio in a nutshell: In severe sepsis inflammatory mediators are released into the blood stream. Vessels are damaged and as a result the capillaries become leaky, hence the edema in presence of profound low bp and intavascular dehydration. Multiple organ systems are affected, usually first a tachycardia followed by sl drop in BP (slight d/t compensation), markedly decreased renal function/failure, then a decrease in LOC. The damage to the vessel walls from the inflammatory mediators stimulates production of platelets to the affected areas causing widespread clotting of microvasculature. By that time severe sepsis has progressed to severe septic shock syndrome, end organ perfusion is severely compromised, multiple organ systems have or begin to fail which is now clinically detectable and pts mortality rates skyrocket. Respiratory failure ensues followed by cardiovascular collapse if not treated. Your pt has ascites which may indicate liver damage d/t hypoperfusion, which will be further exacerbated by abdominal compartment syndrome. The goal of sepsis is early detection, massive fluid replacement for the first 12-24 hrs, and BP support with levophed, vasopressin, and dobutamine if scvo2 is WDL. Also blood products are used when hct is less than 30, scvo2 down, and bp/cvp remains low. I've seen coutless pts not receive adequate fluids because of the 'fear of CHF, presnece of edema and so on. If CHF and resp distress is a concern intubate. Hope this helped.
    kimmie4476, FutureFNP2B, bdanders, and 5 others like this.
  10. Visit  dorimar profile page
    0
    Yeah critical HP,

    but usually it is a goal of CVP > 8.

    Also, nursingdude78, how old is this order? Is it something that was ordered days ago when the patient may have been in severe shock, that may not apply to the patient situation right now? Some orders stay on the MAR inappropriately....
  11. Visit  whip65 profile page
    1
    Hmmm?? Liver failure + sepsis?? Sorry I don't have my cheat sheet handy but usually if trying to fluid resuscitate to a CVP of 12 the pt is septic and then you start titrating your norepi. Plus ascites already present could be a sign of liver disease. We have a sepsis 'protocol' where you are supposed to keep the CVP > than whatever (12) and then blood/urine/sputum cultures etc. and then start your antibiotics ASAP. Maybe you will have to progress to CRRT if the kidneys took a hit from hypotension and if the liver was already cirrhotic or the pt has MODS with liver and lung involvment you will progress to administering multiple blood products, more fluid, and starting low volume lung protective ventilation strategies. I'm relatively new but work with a lot of Heme/liver tx patients and this is my limited input. Systolics > 100 sound fantastic though After reading the other posts, fluid resuscitation usually depends on the CVP and once you are at goal- whatever research says- pressors are added (mrbubbles explains this well). Also, as a nurse I notice that residents constantly ask me if the CVP is "accurate"...... make sure that you have your transducers leveled and zeroed so that everyone can make informed decision. Another thing that I constantly hear at my 'teaching' hospital is the benefit of colloid vs. crystalloid in pts with septic shock d/t the capillary leak etc. Especially in these hard economic times where we are talking about reforming healthcare we need to advocate for therapies that are proven and cost effective. Remember residents are learning just as we as RNs are constantly keeping up with current research!
    yesdog likes this.
  12. Visit  nursingdude78 profile page
    0
    Thank you all for the great input. This was a new order at the time to keep the CVP above 12. The patient did have sepsis.
  13. Visit  criticalHP profile page
    2
    Quote from dorimar
    Yeah critical HP,

    but usually it is a goal of CVP > 8.

    Also, nursingdude78, how old is this order? Is it something that was ordered days ago when the patient may have been in severe shock, that may not apply to the patient situation right now? Some orders stay on the MAR inappropriately....

    Yes, the goal is CVP>8 for non-vented pts; but CVP>12 for intubated pts.
    CCL RN and Sue Damones like this.
  14. Visit  Sue Damones profile page
    0
    Quote from criticalHP
    Yes, the goal is CVP>8 for non-vented pts; but CVP>12 for intubated pts.



    Is this due to the extra PEEP when someone is intubated? Our sepsis orders have a goal of 8-12, regardless of vented/not vented. Thanks!
  15. Visit  criticalHP profile page
    0
    Quote from Sue Damones
    Is this due to the extra PEEP when someone is intubated? Our sepsis orders have a goal of 8-12, regardless of vented/not vented. Thanks!
    Sue, I've been searching a while for the answer to this--I just can't find it. It certainly seems to make sense though. Intubation and added peep increases intrathoracic pressure which results in decreased venous return and subsequently decreased CO. I'll post the link to Manny Rivers Paper on severe sepsis; I couldn't find anything there but this is the paper that began early goal directed therapy protocols that our ICU (and many others) have adopted. Many hospitals have modified this as new knowledge is discovered (which happens every couple of years it seems). If the link doesn't work I used a basic google search for "Manny Rivers sepsis paper".
    Sorry I couldn't anser your question more directly. It is quite possible too, Sue, that as most hospitals will adopt a modified version of the original recommendations, the higher CVP requirements at my institution were implemented based on the infectious desease medical control policy.
    http://www.nimbot.com/EGDT/Early%20G...ic%20Shock.pdf


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