Update in Anaesthesia 59

CENTRAL VENOUS ACCESS AND MONITORING

Dr Graham Hocking , Frimley Park Hospital, Portsmouth Road, Frimley, Camberley, Surrey, GU16 5UJ

Central venous access is the placement of a venous catheter diameter, number of channels (access ports), method
in a vein that leads directly to the heart. The main reasons of insertion (see below), material and means of
for inserting a central venous catheter are: fixation. Two useful lengths are 20cm catheters for
● measurement of central venous pressure (CVP)
subclavian and internal jugular lines, and 60cm
● venous access when no peripheral veins are
catheters for femoral and basilic lines.
available Different methods of insertion
● administration of vasoactive/inotropic drugs which
There are several basic methods of inserting the catheter
cannot be given peripherally after the vein has been found:
● administration of hypertonic solutions including
● Catheter over the needle. This is a longer version
total parenteral nutrition
● haemodialysis/plasmapheresis
of a conventional intravenous cannula and may be
quickly inserted with a minimum of additional
Which central vein to cannulate? equipment. The catheter is larger than the needle, which
There are a number of central veins and for each of these reduces the leakage of blood from the insertion site,
there are a variety of techniques. It should be remembered but using a larger needle to find the vein makes the
that, with the exception of the external jugular, central veins consequences of accidental arterial puncture more
are often deep and have to be located blindly. This is serious. In addition it is easy to over-insert the
associated with risk to nearby structures, especially in the needle.
hands of the inexperienced operator. Veins commonly lie ● Catheter over guidewire (Seldinger technique).
close to arteries and nerves, both of which can potentially This is the preferred method of insertion. A small
be damaged by a misplaced needle. The subclavian vein diameter needle (18 or 20 gauge) is used to find the
also lies close to the dome of the pleura, damage to which vein. A guidewire is passed down the needle into the
can cause a pneumothorax. The choice of route will vein and the needle removed. The guidewire
therefore depend on a number of factors as listed in commonly has a flexible J-shaped tip to reduce the
table 1. risk of vessel perforation and to help negotiate valves
Types of central venous catheters in the vein e.g the external jugular vein (EJV). Once
the wire is placed in the vein, the catheter is passed
Catheters are available which differ in length, internal
over it until positioned in the vein. The wire should
Table 1. Factors which determine the choice of central vein

Patient: How long will the catheter be required? ie. long term / intermediate / short term
Suitability of the vein for technique chosen e.g. for CVP measurement the tip
of the catheter must be within the thorax. A femoral route therefore needs a long
catheter
Operator: Knowledge and practical experience of the technique –it is be better to have a few
clinicians in each area who perform all the central venous cannulations and gain
experience (a “central venous access team”)
Technique characteristics: Success rate for vein cannulation
Success rate of central placement
Complication rate.
Applicability to patients of different ages
Ease of learning
Puncture of a visible and/or palpable vein or ‘blind’ venepuncture based on
knowledge of anatomy
Equipment available: Availability of suitable apparatus
Cost
Suitability of material for long term cannulation
60 Update in Anaesthesia

not be over-inserted as it may kink, perforate the becoming less popular as the hole made in the vein
vessel wall or cause cardiac arrhythmias. This by the needle is larger than the catheter that is
technique allows larger catheters to be placed in passed leading to some degree of blood leakage
the vein after the passage of appropriate dilators around the site. If a problem is encountered during
along the wire and a small incision in the skin at threading the catheter, withdrawal of it through the
the point of entry. needle risks shearing part of the catheter off with
● Catheter through the needle or catheter through catheter embolisation into the circulation. This
cannula. The catheter is passed through a cannula or technique is mainly reserved for the antecubital
needle placed in the vein. The technique is route.
Update in Anaesthesia 61

General preparation to obtain central venous access found, slowly withdraw the needle whilst gently
aspirating; often the vein has been collapsed and
The basic preparation and equipment that is required for
transfixed by the entry of the needle.
central venous cannulation is the same regardless of the
route or technique chosen. Clinicians who insert central ● If using a catheter over or through needle
venous lines should be taught the technique by an technique, thread the catheter into the vein, remove
experienced colleague. If this is not possible then the access the needle, flush with saline and secure it in place
routes associated with the fewest complications are the (see checks below)
basilic vein or femoral vein. ● If using a guidewire (Seldinger technique), pass
General technique for all routes this into the vein, flexible J-shape end first, then
remove the needle. Small single lumen catheters
● Confirm that central venous access is needed and
may pass directly over the wire into the vein. In
select the most appropriate route. Explain the
this case, thread the catheter over it until the end
procedure to the patient
of the wire protrudes from the end of the catheter
● Shave the needle insertion area if very hairy and whilst holding the wire still advance the
● Using a strict aseptic technique, prepare and check catheter into the vein. TAKE CARE not to allow
all the equipment for use. Read instructions with the the wire to be pushed further into the vein whilst
catheter. advancing the catheter
● Sterilise the skin and drape the area ● It may be necessary to dilate up the hole in the
vein when larger catheters are used. Make a small
● Infiltrate the skin and deeper tissues with local incision in the skin and fascia where the wire enters
anaesthetic. In cases where difficulty is anticipated use the patient. Thread the dilator over the wire into
the small local anaesthetic needle to locate the vein the vein with a twisting motion. Excessive force
before using the larger needle. This reduces the risk should not be needed. Remove the dilator taking
of trauma to other structures. care not to dislodge the guidewire. Thread the
● Position the patient as for the specific route catheter over the wire as described above.
described – avoid long periods of head down, ● Check that blood can be aspirated freely from all
particularly in breathless patients lumens of the catheter and flush with saline
● Identify the anatomical landmarks for the chosen ● Secure the catheter in place with the suture and
route and insert the needle at the recommended cover with a sterile dressing. Tape any redundant
point. After the needle has penetrated the skin, tubing carefully avoiding any kinking or loops
aspirate gently whilst advancing the needle as which may snag and pull out the catheter.
directed until the vein is entered. If the vein is not
● Connect catheter to a bag of intravenous fluid

Table 2. Equipment required for central venous access.

● Patient on a tilting bed, trolley or operating table

● Sterile pack and antiseptic solution
● Local anaesthetic – e.g. 5ml lignocaine 1% solution
● Appropriate CV catheter for age/route/purpose
● Syringes and needles
● Saline or heparinised saline to prime and flush the line after insertion
● Suture material – e.g. 2/0 silk on a straight needle
● Sterile dressing
● Shaving equipment for the area if very hairy (especially the femoral)
● Facility for chest X-ray if available
● Additional equipment required for CVP measurement includes: manometer tubing, a 3-way stopcock, sterile saline, a fluid
administration set, a spirit level and a scale graduated in centimeters.
62 Update in Anaesthesia

Checks before using the line Complications

● Ensure fluid runs in freely and that blood flows The main complications that can arise from central
freely back. To observe the latter place the infusion venous cannulation are listed in table 4. The incidence
bag below the level of the bed of each complication varies for each route described.
● If available, take a chest X-ray (ideally erect) to The Subclavian Vein
check the position of the catheter tip and to exclude The subclavian vein (SCV) has a wide calibre (1-2cm
a pneumo, hydro or haemothorax. An early diameter in adults) and is thought to be held open by
radiograph may not show up abnormalities and it surrounding tissue. In severely shocked patients, however,
may be best to wait 3-4 hours unless symptoms it may be safer to perform a venous cutdown (eg. onto the
develop. The tip of the CVP line should lie in the long saphenous vein) or use the EJV which may be
superior vena cava just above its junction with the accessible. In conscious patients the subclavian route is
right atrium. often preferred (since head movement does not affect it)
● Ensure that the patient will be nursed where their and also in trauma patients with suspected cervical spine
CV line can be supervised. Give appropriate injury. Subclavian cannulae are easier to secure which
written instructions regarding how, and what it is reduces subsequent movement and dislodgment. Whilst a
to be used for, and who to contact if there is a high success rate for placement can be achieved, serious
problem complications occur more commonly than with the other
Practical problems common to most techniques of routes. Subclavian puncture should be avoided in
insertion patients with abnormal clotting since it is difficult to
apply pressure to the subclavian artery following
Table 3 lists some problems that can occur with any accidental puncture.
of the routes for central venous access.

Table 3. Problems during CV cannulation

Arterial puncture Usually obvious but may be missed in a patient who is hypoxic or hypotensive. If unsure, connect a
length of manometer tubing to the needle / catheter and look for blood flow which goes higher than
30cm vertically or is strongly pulsatile. Withdraw the needle and apply firm direct pressure to the site
for at least 10 minutes or longer if there is continuing bleeding. If there is minimal swelling then retry
or change to a different route.
Suspected pneumothorax If air is easily aspirated into the syringe (note that this may also occur if the needle is not firmly
attached to the syringe) or the patient starts to become breathless. Abandon the procedure at that
site. Obtain a chest radiograph and insert an intercostal drain if confirmed. If central access is
absolutely necessary then try another route ON THE SAME SIDE or either femoral vein. DO NOT
attempt either the subclavian or jugular on the other side in case bilateral pneumothoraces are
produced.
Arrhythmias during Usually from the catheter or wire being inserted too far (into the right ventricle).
the procedure The average length of catheter needed for an adult internal jugular or subclavian approach is
15cm. Withdraw the wire or catheter if further than this.
Air embolus This can occur, especially in the hypovolaemic patient, if the needle or cannula is left in the vein
whilst open to the air. It is easily prevented by ensuring that the patient is positioned head down (for
jugular and subclavian routes) and that the guidewire or catheter is passed down the needle promptly.
The wire will not thread Check that the needle is still in the vein. Flush it with saline. Try angling the needle so the end of it
down the needle lies more along the plane of the vessel. Carefully rotate the needle in case the end lies against the
vessel wall. Reattach the syringe and aspirate to check that you are still in the vein. If the wire has
gone through the needle but will not pass down the vein it should be very gently pulled back. If any
resistance is felt then the needle should be pulled out with the wire still inside, and the procedure
repeated. This reduces the risk of the end of the wire being cut off by the needle tip.
Persistent bleeding at the Apply firm direct pressure with a sterile dressing. Bleeding should usually stop unless there is a
of entry coagulation abnormality. Persistent severe bleeding may require surgical exploration if there is an
arterial or venous tear
Update in Anaesthesia 63

Anatomy. The SCV lies in the lower part of the notch. The needle should be inserted into the skin 1cm
supraclavicular triangle (figure 2.) and drains blood below and lateral to the midclavicular point. Keeping
from the arm. It is bounded medially by the posterior the needle horizontal, advance posterior to the clavicle
border of the sternocleidomastoid muscle, caudally by aiming for the sternal notch. If the needle hits the
the middle third of the clavicle, and laterally by the clavicle withdraw and redirect slightly deeper to pass
anterior border of the trapezius muscle. The SCV is beneath it. Do not pass the needle further than the
the continuation of the axillary vein and begins at the sternal head of the clavicle.
lower border of the first rib. Initially the vein arches Complications. Any of the complications described
upwards across the first rib and then inclines medially, above can occur but pneumothorax (2-5%) or rarely
downwards and slightly forwards across the insertion haemothorax or chylothorax (fatty white fluid in the
of the scalenus anterior muscle into the first rib to enter pleural cavity due to leakage of lymph from thoracic
the thorax where it joins with the IJV behind the duct) are more common with this route than the others.
sternoclavicular joint. Occasionally the catheter may pass up into either
Anteriorly, the vein is covered throughout its entire jugular or the opposite SCV rather than into the chest.
course by the clavicle. It lies anterior to, and below This will not give reliable CVP readings and infusion
the subclavian artery as it crosses the first rib. Behind of some drugs (hypertonic solutions/vasoconstrictors)
the artery lies the cervical pleura which rises above may be contra-indicated.
the sternal end of the clavicle.
Table 4. Potential complications.
Preparation and positioning. The patient should be
supine, both arms by the sides, with the table tilted head Early Late
down to distend the central veins and prevent air embolism. Arterial puncture Venous thrombosis
Turn the head away from the side to be cannulated unless Bleeding Cardiac perforation
there is cervical spine injury. Normally the right SCV Cardiac arrhythmias and tamponade
is cannulated since the thoracic duct is on the left and Injury to the thoracic duct Infection
may occasionally be damaged during SCV Injury to surrounding nerves Hydrothorax
cannulation. Air embolism
Technique. Stand beside the patient on the side to be Catheter embolus
cannulated. Identify the midclavicular point and the sternal Pneumothorax

Practical problems specific to the

subclavian route
● Keep hitting the clavicle: Check that
you are starting from the correct position.
Redirect the needle slightly more posterior
whilst being careful not to enter the chest.
Try bending the needle slightly to
encourage it to pass beneath the clavicle.
Try placing a pillow under the shoulders
or getting someone to pull gently down
on the arms.
● Cannot find the vein: direct the needle
a little more cephalad
● Fail after repeated attempts: DO NOT
PERSIST since the likelihood of
complications increase. Try an alternative
route ON THE SAME SIDE unless chest
radiography is available to exclude any
possible pneumothorax.
64 Update in Anaesthesia

● The catheter tip is not in the chest: Usually the artery, insert the needle at an angle of 30-40o to the
detected on chest X-ray, or if the fluid level in the skin and advance it downward towards the nipple on
CVP manometer does not rise and fall with the same side (in a woman guess where the nipple
breathing. A simple test that may increase the would be if she were a man). Always direct the needle
suspicion of jugular placement is to rapidly inject away from the artery under your finger. The vein is
10ml of fluid into the catheter whilst listening with usually within 2-3cm of the skin. If the vein is not
a stethoscope over the neck. An audible ‘whoosh’ found, redirect the needle more laterally.
or thrill under the fingers suggests the catheter has Complications. With experience this route has a low
entered the jugular vein. If this is positive, in the incidence of complications. Arterial puncture is easily
presence of a CVP reading which does not change managed by direct pressure. Pneumothorax is rare
with respiration, then the position of the cannula providing the needle is not inserted too deeply.
must be questioned.
Practical problems
The Internal Jugular Vein
● Cannot feel the artery. Check the patient! Try
The internal jugular vein (IJV) is a potentially large the carotid on the other side. It is safer to consider
vein commonly used for central venous access which a different approach rather than ‘blindly’ try to find
drains blood from the brain and deep facial structures. the jugular.
Cannulation is associated with a lower incidence of
complications than the subclavian approach. Unlike ● Arterial puncture. Remove needle and apply firm
the subclavian route, failure on one side does not pressure over the puncture site for 10 minutes.
prevent the operator from trying the other side although ● Cannot find the vein. Recheck your position.
this should be discouraged if arterial puncture had Ensure that you are not pressing firmly on the
occurred. Many approaches have been described artery as this can compress the vein next to it. Try
depending upon the level in the neck where the vein tipping the patient further head down if possible.
is entered. High approaches reduce the risk of If the patient is hypovolaemic, and central venous
pneumothorax but increase the risk of arterial puncture access is not immediately required to correct it,
the opposite being true of a low approach. A middle give intravenous fluids and wait until the veins are
level approach is described below. fuller. Try inserting the needle a little closer to the
Anatomy. The sigmoid venous sinus passes through artery but beware of puncture.
the mastoid portion of the temporal bone, emerging The External Jugular Vein
from the jugular foramen at the base of the skull as
Since the external jugular vein (EJV) lies superficially in
the IJV. It passes vertically down through the neck
the neck and is often visible or palpable, complications
within the carotid sheath. The vein initially lies
associated with ‘blind’ venepuncture of deep veins are
posterior to the internal carotid artery, before becoming
avoided. The EJV is preferred when expertise is lacking,for
lateral and then anterolateral to the artery. It is able to
emergency intravenous fluid administration and in cardiac
expand laterally to accommodate increased blood
arrests, when the carotid pulsation cannot be felt.
volume. It joins the SCV behind the sternal end of the
However, because of the way the EJV joins the SCV there
clavicle to enter the chest as the innominate vein (figure
is a 10-20% chance that a cannula will not pass into the
2).
SVC. In this situation it will not be suitable for CVP
Preparation and positioning. The patient should be measurements but can still provide central access for other
supine, both arms by the sides, with the table tilted purposes as described at the beginning.
head down to distend the central veins and prevent air
Anatomy. The EJV is formed from the junction of the
embolism. Slightly turn the head away from the side
posterior division of the posterior facial vein and the
to be cannulated for better access (turning it too far
posterior auricular vein, draining blood from the superficial
increases the risk of arterial puncture).
facial structures and scalp. It passes down in the neck
Technique. Stand at the head of the patient. Locate from the angle of the mandible, crosses the
the cricoid cartilage and palpate the carotid artery sternocleidomastoid muscle obliquely, and terminates
lateral to it at this level. Keeping a finger gently over behind the middle of the clavicle where it joins the SCV.
Update in Anaesthesia 65

The vein is variable in size and has valves above the complications. The femoral vein (FV) should not be
clavicle and just before its junction with the SCV which used for more than a few days due to the risk of
may obstruct the passage of CV catheters. If a contamination and infection from the groin area. With
guidewire with a J shaped tip is used the wire can often pelvic or intra-abdominal injury an alternative central
pass through these valves by rotating it at the lower vein is preferred. Remember that the femoral route is
end of the EJV. Natural variations and disease states not a good choice for CVP monitoring since the value
are responsible for the wide range in the degree on will be altered by the intra-abdominal pressure unless
prominence of the EJV. a long catheter is used to pass above the level of the
Preparation and positioning. The patient should be diaphragm.
supine, both arms by the sides, with the table tilted head Anatomy. The FV starts at the saphenous opening in the
down to distend the central veins and prevent air embolism. thigh and accompanies the femoral artery ending at the
Turn the head away from the side to be cannulated for inguinal ligament, where it becomes the external iliac vein.
better access. In the femoral triangle the FV lies medial to the artery.
Technique. Stand at the head of the patient and identify Here it occupies the middle compartment of the femoral
the EJV as it crosses the sternocleidomastoid muscle. If it sheath, lying between the artery and the femoral canal.
is not palpable or visible (see problems) then choose an The femoral nerve lies lateral to the artery. The vein is
alternative vein for catheterisation. Insert the needle in line separated from the skin by superficial and deep fasciae.
with the vein where it is most easily seen or palpated. Preparation and positioning. Abduct and externally
Thread the guidewire and then the catheter. rotate the thigh slightly.
Complications Performance of the technique. Identify the pulsation of
If the vein is easily seen or palpated this route carries a the femoral artery 1-2 cm below the inguinal ligament. Insert
very low risk. the needle about 1cm medial to the pulsation and aim it
towards the head and medially at an angle of 20-30o to
Practical problems the skin. In adults, the vein is normally found 2-4cm from
● Cannot see the vein: Ask the patient to take a big the skin. In small children reduce the elevation on the needle
o
breath in and strain as if trying to go to the toilet to 10-15 since the vein is more superficial.
(Valsalva manoeuvre). If mechanically ventilated briefly Complications. Arterial puncture is possible if the needle
hold the lungs in inspiration. Press on the skin above is directed too lateral. Femoral nerve damage may follow
the midpoint of the clavicle where the vein enters the incorrect lateral insertion of the needle. Infection is the
chest. If none of these make the EJV visible then use commonest problem with femoral catheters and they are
a different vein. not recommended for long-term use.
● Catheter will not pass into chest: Press on the Practical problems
skin where the vein enters the chest. Try rotating
the catheter or flushing it with saline as you insert ● Cannot feel the artery: Try the other side. Check
it. If using a guidewire, rotate the wire when it the blood pressure. Treat any hypotension and retry.
reaches the bottom of the vein. Try slowly turning If there is no other venous access then it may be
the head in either direction. It may be useful to acceptable to try to locate the FV with a small needle
insert a normal plastic cannula into the vein first, starting medially to avoid the femoral nerve. Once
then thread the guidewire down this. By doing this, found, change to the normal needle and continue the
the wire can be pushed, pulled and rotated without procedure. If the artery is accidentally punctured,
the risk of it being cut which could occur if the apply direct pressure with your fingers and insert the
wire is manipulated through a needle. normal needle medial to the puncture site.
● Cannot locate the vein: Recheck the anatomical
The Femoral Vein
landmarks. It is possible for the femoral vein to be
This may be the safest and most accessible central vein in compressed by the fingers on the artery. Release
children requiring resuscitation where peripheral access pressure but leave the fingers resting on the skin over
has failed. It is also a preferred route for inexperienced the artery and retry. Cautiously redirect the needle
operators, due to the minimal risk of serious closer to the artery and in a more lateral direction.
66 Update in Anaesthesia

The Antecubital Veins cubital vein. It then ascends along the lateral surface
of the biceps muscle to the lower border of pectoralis
A palpable vein in the antecubital fossa provides the safest major muscle, where it turns sharply to pierce the
route for central venous access. A long 60cm catheter is clavipectoral fascia and pass beneath the clavicle. It
required. There are a number of veins in the antecubital then usually terminates in the axillary vein although it
fossa – use one on the medial side. can join the EJV. There are valves at the termination
Anatomy. Venous blood from the arm drains through two of the cephalic vein. The sharp angle and the valves
intercommunicating main veins, the basilic and the cephalic frequently obstruct the passage of a catheter along
as illustrated in figure 3. the cephalic system.
Basilic vein. Ascends from the hand along the medial Median cubital vein. The median cubital vein is a large
surface of the forearm draining blood from that area and vein that arises from the cephalic vein just below the bend
medial side of the hand. Near the elbow the vein changes in the elbow and runs obliquely upwards to join the basilic
to a position in front of the medial epicondyle where it is vein just above the bend in the elbow. It receives veins
joined by the median cubital vein. It then runs along the from the front of the forearm which themselves may be
medial margin of the biceps muscle to the middle of the suitable for catheterisation. It is separated from the brachial
upper arm where it pierces the deep fascia to run alongside artery by a thickened portion of the deep fascia (bicipital
the brachial artery becoming the axillary vein. aponeurosis).
Cephalic vein. Ascends on the front of the lateral side of Preparation and positioning. Apply a tourniquet to the
the forearm to the front of the elbow, where it upper arm to distend the veins and select the best one.
communicates with the basilic vein through the median The order of preference for veins are:
● A vein on the medial side of the antecubital fossa
– the basilic or median cubital vein. Even when
not visible, these veins are often easily palpable
when engorged
● A vein on the postero-medial aspect of the forearm
– a tributary of the basilic vein. Rotation of the
arm may be required.
● The cephalic vein
Lie the patient supine with the arm supported at 45o to the
body and the head turned towards you (helps prevent the
catheter passing into the IJV on that side).
Technique. Stand on the same side of the patient.
Estimate the length of catheter needed to reach the
SVC. Puncture the chosen vein with the needle and
cannula and remove the needle. Insert the catheter
through the cannula and advance it a short distance
(2-4cm in adults, 1-2cm in children) then release the
tourniquet. Steadily advance the catheter along the vein
until it is estimated to be in the correct position.
Complications. Local bleeding since the catheter is
smaller diameter than the needle used to puncture the vein.
Apply direct pressure with a sterile swab.
Practical problems
● Cannot thread the catheter along the vein. Do
not use force to pass it. If using a catheter-through-
needle technique and you are sure that the catheter
Update in Anaesthesia 67

is in the vein, remove the needle from the vein signs useful information can be gained. The supply of
and slide it to the end of the catheter. This will blood to the systemic circulation is controlled by the
allow you to advance and withdraw the catheter left ventricle. In a normal patient the CVP closely
without risk of cutting it on the needle. Try flushing resembles the left atrial pressure and is usually used
the catheter with saline whilst advancing. Try the to predict it. However in patients with cardiac disease
arm in different positions. Rotate the catheter the right and left ventricles may function differently –
whilst inserting. this can only be detected clinically by measuring the
Care of the Central venous Catheter pulmonary capillary wedge pressure (see later).

● Use an aseptic technique when inserting the When should CVP be measured?
catheter and any subsequent injections or changing ● Patients with hypotension who are not responding
fluid lines to basic clinical management.
● Keep the entry site covered with a dry sterile ● Continuing hypovolaemia secondary to major fluid
dressing shifts or loss.
● Ensure the line is well secured to prevent ● Patients requiring infusions of inotropes.
movement (this can increase risks of infection and How to measure the CVP
clot formation)
The CVP is measured using a manometer filled with
● Change the catheter if there are signs of infection
intravenous fluid attached to the central venous catheter.
at the site. It needs to be ‘zeroed’ at the level of the right atrium,
● Remember to remove the catheter as soon as it is approximately the mid-axillary line in the 4th interspace
no longer needed. The longer the catheter is left supine. Measurements should be taken in the same position
in, the greater the risks of sepsis and thrombosis each time using a spirit level and the zero point on the skin
● Some people suggest changing a catheter every 7
surface marked with a cross. Check that the catheter is
days to reduce the risks of catheter related sepsis not blocked or kinked and that intravenous fluid runs freely
and thrombosis. However, providing that the in, and blood freely out. Open the 3-way tap so that the
catheter is kept clean (sterile injections and fluid bag fills the manometer tubing (check there is no
connections) and there are no signs of systemic obstruction to fluid flow and that the cotton wool in the
sepsis, routine replacement may not be necessary. top of the manometer is not blocked or wet). Turn the tap
Repeated cannulation to change lines on a routine to connect the patient to the manometer. The fluid level
basis, rather than based on clinical need, can will drop to the level of the CVP which is usually recorded
increase the risks to the patient. in centimeters of water (cmH2O). It will be slightly pulsatile
and will continue to rise and fall slightly with breathing -
What is Central Venous Pressure ? record the average reading. An alternative to the
Blood from systemic veins flows into the right atrium; the manometer and 3-way tap is a butterfly needle inserted
pressure in the right atrium is the central venous pressure into the rubber injection port of ordinary intravenous tubing
(CVP). CVP is determined by the function of the right (figure. 4). In Intensive Care Units or theatres, electronic
heart and the pressure of venous blood in the vena cava. transducers may be connected which give a continuous
Under normal circumstances an increased venous return readout of CVP along with a display of the waveform.
results in an augmented cardiac output, without significant Useful information can be gained by studying the electronic
changes in venous pressure. However with poor right waveform. The CVP reading from an electronic monitor
ventricular function, or an obstructed pulmonary circulation, is sometimes given in mmHg (same as blood pressure).
the right atrial pressure rises. Loss of blood volume or The values can easily be converted knowing that 10cmH20
widespread vasodilation will result in reduced venous return is equivalent to 7.5mmHg (which is also 1kPa)
and a fall in right atrial pressure and CVP. Interpretation of the CVP
The CVP is often used to make estimates of circulatory As previously stated, the CVP does not measure blood
function, in particular cardiac function and blood volume. volume directly and is influenced by right heart function,
Unfortunately the CVP does not measure either of these venous return, right heart compliance, intrathoracic
directly, but taken in the context of the other physical
68 Update in Anaesthesia

pressure and patient positioning. It should always be 2. A 32 year old man was involved in a road
interpreted alongside other measures of cardiac accident sustaining chest and leg injuries. After
function and fluid state (pulse, BP, urine output etc.). initial resuscitation he was found to have a
The absolute value is not as important as serial pneumothorax on the right which was drained
measurements and the change in response to therapy. with an underwater seal drain. Initially his
A normal value in a spontaneous breathing patient is respiratory function improved but despite fluid
5-10cm water cmH 2O, rising 3-5cmH 2O during loading he remained hypotensive and a CVP line
mechanical ventilation. The CVP measurement may was inserted to guide fluid replacement for his
still be in the normal range even with hypovolaemia leg injuries. After insertion he had a pulse of
due to venoconstriction. A guide to interpretation is 120/min and BP90/60 and a CVP reading of
shown in table 5. +15cm H2O. His neck veins were distended
Short case examples of CVP interpretation suggesting a high venous pressure. He was
reassessed clinically and was found to have
1. A 20 year old woman had a large post-partum developed a tension pneumothorax on the left
bleed. Despite initial resuscitation her BP side which was drained with improvement in his
remained low and did not respond to large condition.
volumes of intravenous fluids. A CVP line was
3. A 19 year old man was admitted with an infected
inserted. Her observations after insertion were:
pulse 130/min, BP 90/70, and a CVP +1 cmH2O. wound on his leg. His observations are: pulse
The CVP confirmed continuing hypovolaemia. 135/min, BP 80/30, CVP 7, hyperdynamic
After further IV fluid her pulse rate began to circulation. His pulse and BP does not respond
to 2 fluid challenges so inotropes are started to
come down and her BP and CVP started to
support his circulation. His hypotension is due
improve.
to septicaemia.
Update in Anaesthesia 69

Table 5. Guide to interpretation of the CVP in the hypotensive patient

CVP Other features that Diagnosis to consider Treatment

reading may be present
Low Rapid pulse Hypovolaemia Give fluid challenges* until
Blood pressure normal or low CVP rises and does not fall
Low urine output back again. If CVP rises and
Poor capillary refill stays up but urine output or
blood pressure does not
improve consider inotropes
Low or normal or high Rapid pulse Sepsis Ensure adequate circulating
Signs of infection volume (as above) and
Pyrexia consider inotropes or
Vasodilation/constriction vasoconstrictors
Normal Rapid pulse Hypovolaemia Treat as above.
Low urine output Venoconstriction may cause
Poor capillary refill CVP to be normal.
Give fluid challenges* and
observe effect as above.
High Unilateral breath sounds Tension pneumothorax Thoracocentesis then
Assymetrical chest movement intercostal drain
Resonant chest with tracheal
deviation
Rapid pulse
High Breathlessness Heart failure Oxygen, diuretics, sit up,
Third heart sound consider inotropes
Pink frothy sputum
Oedema
Tender liver
Very High Rapid pulse Pericardial tamponade Pericardiocentesis and drainage
Muffled heart sounds

*Fluid challenge. In hypotension associated with a CVP in the normal range give repeated boluses of intravenous fluid (250 –
500mls). Observe the effect on CVP, blood pressure, pulse, urine output and capillary refill. Repeat the challenges until the CVP
shows a sustained rise and/or the other cardiovascular parameters return towards normal. With severe blood loss, blood transfusion
will be required after colloid or crystalloid have been used in initial resuscitation. Saline or Ringers lactate should be used for
diarrhoea/bowel obstruction/vomiting/burns etc.

When may the CVP reading be unreliable? experienced person for advice.
The use of CVP readings to estimate cardiac function Pulmonary artery flotation catheters (PAFC)
and blood volume rely on the fact that there is no right catheters
ventricular disease and normal pulmonary vascular A PAFC or Swan-Ganz catheter is a central venous
resistance. Table 6 lists some situations when CVP catheter with a small inflatable balloon at the end. An
readings may be unreliable. introducing catheter is sited in a central vein and the
Catheter removal catheter is then ‘floated’ along the central vein with
Remove any dressing and suture material. Ask the patient the balloon inflated, through the right atrium and
to take a breath and fully exhale. Remove the catheter ventricle until it lies in a branch of the pulmonary
with a steady pull while the patient is breath holding artery. The position of the PAFC can be predicted as it
and apply firm pressure to the puncture site for at least moves through the circulation by the pressure
5 minutes to stop the bleeding. Excessive force should waveform obtained by measuring the pressure at the
not be needed to remove the catheter. If it does not tip of the PAFC. Once correctly positioned, when the
come out, try rotating it whilst pulling gently. If this balloon is inflated it occludes the branch of the
still fails, cover it with a sterile dressing and ask an pulmonary artery and measures the pressure distal to
70 Update in Anaesthesia

Table 6

Problem Effect on CVP

Pulmonary embolus High pulmonary vascular resistance – left sided pressure and function may be
High intrathoracic pressure normal. A higher than normal CVP may be needed to ensure adequate return
of blood to the left side of the heart.
Left heart failure Resulting rise in pulmonary venous pressure and right sided heart strain.
Initially CVP may be normal but will increase with significant failure.
Constrictive pericardial disease Paradoxical rise in CVP on inspiration and fall on expiration (opposite of normal
in a spontaneously breathing patient). The absolute level will be higher due to
impeded filling of the heart
Blocked cotton wool at top of manometer Fluid will not move in the tube to give a correct reading
Complete heart block ‘Cannon waves’ on CVP reading – the reading will have a strong pulsatile
element when the atrium contracts against a closed tricuspid valve sending
the pressure wave back into the SVC
Tricuspid stenosis/regurgitation Mean CVP will be higher

it (pulmonary artery occlusion pressure or ‘wedge’ pressure. When connected to a computer a PAFC may
pressure since it is ‘wedged’ in the artery). With the be used to calculate the cardiac output using a
balloon inflated there is a continuous column of fluid thermodilutional technique and further guide patient
between the tip of the PAFC and the left atrium, management. However PAFC have not been shown
without interference from heart valves and lung to improve patient survival (see Further Reading).
pathology. It is therefore a better guide to the venous Further Reading
return to the left side of the heart than CVP. However, Handbook of Percutaneous Central Venous Catheterisation.
it is a more invasive monitor, requires more expertise Rosen M, Latto IP, Shang Ng W. WB Saunders Company Ltd.
to insert, has a greater complication rate and is more 1981
expensive. Watters DA, Wilson IH. The practice of central venous pressure
monitoring in the tropics. Tropical Doctor 1990; 20(2): 56-60
PAFC are sometimes used in patients with significant right
Connors AF et al. The effectiveness of right heart catheterization
sided valve disease, right heart failure or lung disease as in the initial care of critically ill patients. JAMA 1996; 276(11):
the CVP may be unreliable in predicting the left atrial 889-97

2nd ALL AFRICA ANAESTHESIA CONGRESS

International Convention Centre,
Durban, South Africa
23-26 September 2001

The above meeting is a WFSA African Regional Section Congress and will be held in conjunction with
the Annual Meeting of the South African Society of Anaesthesiologists. The meeting will be preceded
by a two day refesher course in anaesthesia (22nd & 23rd September 2001)

Contact Details:
SASA 2001/AAAC Congress Secretariat
Department of Anaesthetics
Private Bag 7, Congella 4013
Durban, South Africa
Tel/Fax: +27 31 260 4472 Email: aaac@nu.ac.za Website: www.aaac.nu.ac.za