Continuous CVP and infusions

[RN RN RN]

Hi. I am an ICU trainee and I was taking care of a patient who had a LIJ x3 lumen who required continuous CVP monitoring (pt was retaining fluids) and was on multiple infusions (continuous & scheduled) as well. The proximal port was connected to the pt's heparin gtt, the middle one to the TPN and the distal port was connected to four 3-way-stopcocks and to CVP monitoring. The first two stopcocks were connected to an octreotide drip and a d5w infusion. My preceptor and I have checked the compatibility of our IV medications.

I understand the concept of turning the stopcocks off to the infusions to be able to obtain an accurate reading of the CVP. However, I am not quite sure what the effect of leaving the stopcocks open to the infusions and to CVP will have on my patient being able to receive the full dose of his/her infusion (i.e. will some of the meds travel down the CVP tubing instead of traveling upwards to the IJ port). We were unable to obtain PIVs on the pt because he/she was very swollen. Are there instances when it's okay to monitor CVP continuously (though not quite accurate) and infusing meds at the same time through the same port?

Thank you!

[Cuddleswithpuddles]

Yes, sometimes this is the only option available especially if you have no PIVs.

I save the three way stopcock with the CVP monitoring for intermittent infusions like IV antibiotics so that I minimize interruptions in accurate CVP monitoring.

I do not think the meds are likely to travel up the CVP line if you have the pressure bag fully inflated.

[TXLvn07]

In those cases, I'll usually do a PIV with ultrasound guidance. But just like previous post stated, I would usually just use the stopcock for intermittent infusions to enable somewhat continuous CVP accuracy.

[ktliz]

I'm not sure what you mean by having the stopcocks open to both the CVP and the infusions. If you are getting a CVP reading, the stopcock should be turned "off" toward the infusion. If you are infusing, it is off toward transducer/pressure bag, and if you are zeroing the CVP it is off to the patient. The CVP will not be accurate while anything is infusing through it (other than the pressure bag).

[Mully]

I'm not sure what you mean by having the stopcocks open to both the CVP and the infusions. If you are getting a CVP reading, the stopcock should be turned "off" toward the infusion. If you are infusing, it is off toward transducer/pressure bag, and if you are zeroing the CVP it is off to the patient. The CVP will not be accurate while anything is infusing through it (other than the pressure bag).

There is a fourth option of having the stopcock turned off to nothing and all three ports open. This will allow you to infuse medications, while still obtaining a cvp number (which is inaccurate as the OP pointed out) with a crazy waveform sometimes. I agree, in that I just turn the CVP off when it's not in use accurately. Some say that it will help you trend the CVP if you leave it open all the time, but I disagree. And often, nurses forget that their number isn't accurate and pull over their inaccurate CVP numbers into the chart without thinking.

As far as meds traveling into the CVP... I'm almost certain this doesn't happen, although I don't have any research to back that up. Because the pressure pack is on the other end, it should prevent any backflow of medication. Also if there was a significant amount of backflow, it would reflect in your CVP number because the CVP would theoretically pick up that pressure and give you a number for it!

In my opinion, it's just best to leave it off like ktliz does, this ensures no backflow, and prevents anyone from treating inaccurate CVP numbers. What is the benefit of leaving the CVP open? There really isn't any.

[Esme12, ASN, BSN, RN]

If your CVP is hooked up to the transducer with a pressure bag medications will not flow up the CVP pressure line unless the pressure bag is not inflated. The pumps will not pump against the pressure in the line. Leaving the CVP open to monitor during infusion isn't a real accurate reading.

[StayLost, BSN, RN]

Sometimes we transduce a CVP just because we can.. a patient has a central line or even a PICC, so ... why not? In this patient population, I probably would leave it open to CVP, DRIP, & PT. I would intermittently check an accurate CVP by turning the stopcock off to Drip.

Since your patient was on Oxtreotide, sounds like he/she may have had a GI bleed. This is a clinical scenario the CVP is very important- we need to monitor fluid status. Using the CVP for IVPB infusions is no big deal, but I would try not to use it for Continuous IV infusions.

[PNW_NPstudent]

Why is a continous CVP needed? How is the order for CVP written? How often do you chart it? Why not run whatever you need to run and hourly turn off fluids to take the reading?