Published Jun 27, 2009
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?
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.
ghillbert, MSN, NP
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.
geekgolightly, BSN, RN
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.
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.
I found this article while looking for something on SvO2: http://www.uptodate.com/home/content/topic.do?topicKey=cc_medi/16828
criticalHP, MSN, RN
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
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:banghead:. If CHF and resp distress is a concern intubate. Hope this helped.:redbeathe
dorimar, BSN, RN
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....
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!
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.
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.
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!
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