Normal CVP? - page 2
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... Read More
Jun 10, '10Occupation: Clinical Nurse Consultant Specialty: Critical Care Nursing ; Joined: Nov '08; Posts: 53; Likes: 28many oz docs refer to CVP as a random number generator and many posters have identified all the things (abdominal ascites, ventilation, PEEP) which interfere with a 'correct' reading. Additionally this patient is losing protein into the abdomen so NS replacement?? Anyway fluid replacement for liver failure is like poring fluid into a sieve. If the patient still has significant SIRS or sepsis then they require proper haemodynamic monitoring such a PICCO or [biting my tongue] PA catheter.
Jun 17, '10Occupation: ICU/CCU RN, BSN Specialty: 4 year(s) of experience in ICU/CCU ; From: US ; Joined: Dec '08; Posts: 6; Likes: 3When a patient is mechanically ventilated this increases the inter-thoracic pressures thus giving the appearance of an elevated CVP. So if a patient has a a CVP of 15 when ventilated, it is coomparable to a CVP of 12 in the non-ventilated patient.
Jun 17, '10Joined: Jan '02; Posts: 2,593; Likes: 1,418Quote from reyfrescoDepends on the amount of peep/PS.So if a patient has a a CVP of 15 when ventilated, it is coomparable to a CVP of 12 in the non-ventilated patient.
Jun 18, '10Specialty: CVICU ; From: US ; Joined: Sep '08; Posts: 263; Likes: 126Quote from meandragonbrettI agree, I don't think that the "keep CVP >12 for vented pts" is necessarily correcting a falsely elevated CVP because like meandragonbrett said, the amount false elevation depends on the amount of ps and peep. I think it's more d/t the fact that when using positive pressure ventilation in a septic patient with a low svr you are going to have profound drops in your preload every time they receive a vent breath. They need to be tanked up a bit so that the vena cava wont collapse everytime the vent blasts a bunch of pressure into the thorax.Depends on the amount of peep/PS.
Jun 29, '10Occupation: Clinical Nurse Consultant Specialty: Critical Care Nursing ; Joined: Nov '08; Posts: 53; Likes: 28Dear all
on aussie forum we have also been discussing CVP. Below is a posting from a senior ICU specialist about the physiology of CVP.
This is the Achilles heel of the CVP. Like all intravascular measurements the baseline MUST be checked prior to every recording. if using the centre of the RA always use a spirit level or other manometer to a zero permanently marked on the patients lateral chest wall. Neglect of this basic prerequisite is the commonest cause of fluctuating
incorrect CVP readings.A simple alternative is to use a" centrally measured JVP". This is done by taping the transducer to the patients manubrium sterni. With the catheter in the SVC the normal reading is +/- 2mm Hg . This reading is done with the patient at 30 degrees to give a little hydrostatic stress to the circulation and to reduce the effect of raised intra-abdominal pressure. The beauty of this technique is that the baseline is a constant bony landmark and a spirit level is not necessary. Also observation of the patients JVP allows direct comparison and helps reinforce clinical skills in measuring this critical sign.
This "central"JVP is my preference
CVP is determined by 4 factors
1. Blood volume
2. R heart function
This includes conditions such as a.Pericardial tamponade b.RV dysfunction c.Tricuspid and pulmonary valve pathology d.Pulmonary hypertension due to pulmonary embolism, lung disease, acute sepsis, many but not all cases of LV failure etc
3. Pleural pressure with IPPV, PEEP, tension pneumothorax
4. Venous tone --Be aware that with acute hypovolaemia there is acute sympathetic induced venoconstriction that takes considerable time to wear off. The CVP can be quite high during the initial stages of fluid resuscitation before it drops.All these factors must be considered when assessing the CVP. In the majority of cases it is the
relatively simple problem of adjusting blood volume.
In summary A low CVP is due to
1. Low blood volume
2. Venodilatation with peripheral vasodilatation from various causes
A high CVP is due to
1. High blood volume - overtransfusion
2. Impaired R heart function
3. Raised pleural pressure
Because of these varying influences one must relate both the actual level of the CVP and the relative changes that occur during the course of a patients illness. It must also be correlated with other observations such as temperature, pulse, BP, fluid administration, urine output, CXR, cardiac output and ECHO to name the key ones.
It is a shame that folks cannot think of patients in physiological terms and and utilise this simple measurement which for 50 years has been one of the key vital signs of clinical Intensive Care.
I dont take credit for the review
Jun 29, '10Occupation: RN Specialty: 28 year(s) of experience in critical care, dialysis ; From: US ; Joined: Dec '07; Posts: 745; Likes: 1,161
Feb 10, '11Occupation: RN Specialty: Paramedic 15 years, RN now ; Joined: Mar '09; Posts: 144; Likes: 106Man, you ICU nurses make us look like blubbering idiots!!! That answer sounded like an MD! Impressive