What is Central Venous Pressure?

The central venous pressure (CVP) is the pressure

measured in the central veins close to the heart.
It indicates mean right atrial pressure and is
frequently used as an estimate of right
ventricular preload. The CVP does not measure
blood volume directly, although it is often used to
estimate this. In reality the CVP value is
determined by the pressure of venous blood in
the vena cava and by the function of the right
heart, and it is therefore influenced not only by
intravascular volume and venous return, but also
by venous tone and intrathoracic pressure, along
with right heart function and myocardial
compliance.

Underfilling or overdistention of the venous

collecting system can be recognised by CVP
measurements before clinical signs have become
apparent. Under normal circumstances an
increased venous return results in an augmented
cardiac output, without significant changes in
CVP. However with poor right ventricular function,
or an obstructed pulmonary circulation, the right
atrial pressure rises, therefore causing a resultant
rise in measured CVP. Similarly, although it is
possible for a patient with hypovolaemia to
exhibit a CVP reading in the normal range due to
venoconstriction, loss of blood volume or
widespread vasodilation will result in reduced
venous return and a fall in right atrial pressure
and CVP.

In a normal patient the mean right atrial pressure

measured by the CVP closely resembles the mean
left atrial pressure (LAP). At end diastole left atrial
pressure is assumed to equal left ventricular end
diastolic pressure (LVEDP), which in turn is
assumed to reflect left ventricular end diastolic
volume (LVEDV). Thus, in normal patients, CVP is
assumed to be a reflection of left ventricular
preload. However, in patients with cardiac or
pulmonary disease the right and left ventricles
may function independently. In these cases left
ventricular preload should be estimated by
measuring the pulmonary capillary 'wedge'
pressure, using a pulmonary artery catheter
(PAC), as this is a better guide to the venous
return to the left side of the heart than CVP. The
PAC may also be connected to a computer to
calculate the cardiac output using a
thermodilution technique and further guide
patient management.

PAC are therefore sometimes used to measure

left atrial pressure in patients with significant
right sided valve disease, right heart failure or
lung disease as the CVP may be unreliable in
predicting the left atrial pressure in these cases.

When should CVP be measured?

Patients with hypotension who are not responding

to basic clinical management.
Continuing hypovolaemia secondary to major
fluid shifts or loss.
Patients requiring infusions of inotropes.
How to measure the CVP ?

The CVP can be measured either manually using

a manometer (Diagram 1) or electronically using
a transducer (Diagram 4). In either case the CVP
must be zeroed at the level of the right atrium.
This is usually taken to be the level of the 4th
intercostal space in the mid-axillary line while the
patient is lying supine. Each measurement of CVP
should be taken at this same zero position. Trends
in the serial measurement of CVP are much more
informative than single readings. However if the
CVP is measured at a different level each time
then this renders the trend in measurement
inaccurate.

1. Using the manometer

A 3-way tap is used to connect the manometer to
an intravenous drip set on one side, and, via
extension tubing filled with intravenous fluid, to
the patient on the other (Diagram 1). It is
important to ensure that there are no air bubbles
in the tubing, to avoid administering an air
embolus to the patient. You should also check
that the CVP catheter tubing is not kinked or
blocked, that intravenous fluid can easily be
flushed in and that blood can easily be aspirated
from the line. The 3-way tap is then turned so
that it is open to the fluid bag and the
manometer but closed to the patient, allowing
the manometer column to fill with fluid (Diagram
2). It is important not to overfill the manometer,
so preventing the cotton wool bung at the
manometer tip from getting wet. Once the
manometer has filled adequately the 3-way tap is

turned again this time so it is open to the

patient and the manometer, but closed to the
fluid bag (Diagram 3). The fluid level within the
manometer column will fall to the level of the
CVP, the value of which can be read on the
manometer scale which is marked in centimetres,
therefore giving a value for the CVP in
centimetres of water (cmH2O). The fluid level will
continue to rise and fall slightly with respiration
and the average reading should be recorded.

CVP decreases with:

2. Using the transducer

The transducer is fixed at the level of the right
atrium and connected to the patient's CVP
catheter via fluid filled extension tubing. Similar
care should be taken to avoid bubbles and kinks
etc as mentioned above. The transducer is then
'zeroed' to atmospheric pressure by turning its 3way tap so that it is open to the transducer and
to room air, but closed to the patient. The 3-way
tap is then turned so that it is now closed to room
air and open between the patient and the
transducer. A continuous CVP reading, measured
in mmHg rather than cmH2O, can be obtained.
(Diagram 4)

overhydration which increases venous

return
heart failure or PA stenosis which limit
venous outflow and lead to venous
congestion
positive pressure breathing, straining,

hypovolemic shock from hemorrhage,

fluid shift, dehydration
negative pressure breathing which
occurs when the patient demonstrates
retractions or mechanical negative
pressure which is sometimes used for
high spinal cord injuries.

The CVP catheter is also an important

treatment tool which allows for:

Rapid infusion
Infusion of hypertonic solutions and
medications that could damage veins
Serial venous blood assessment

http://www.rnceus.com/hemo/cvp.htm
http://www.anaesthesia.hku.hk/LearNet/meas
ure.htm

Central venous pressure is considered a

direct measurement of the blood pressure in
the right atrium and vena cava. It is acquired
by threading a central venous catheter
(subclavian double lumen central line shown)
into any of several large veins. It is threaded
so that the tip of the catheter rests in the
lower third of the superior vena cava. The
pressure monitoring assembly is attached to
the distal port of a multilumen central vein
catheter.
The CVP catheter is an important tool used to
assess right ventricular function and
systemic fluid status.

Normal CVP is 2-6 mm Hg.

CVP is elevated by :

Central Venous Pressure

CVP has been used for many years as a

monitor of central venous blood volume and
represents the back-pressure to systemic
venous return. It is unclear whether the use
of CVP alone as a target of quantitative
resuscitation has a mortality benefit, and the
validity of CVP measurements in patients
with sepsis is widely debated. There is no
threshold value of CVP that identifies
patients whose cardiac output (CO) will
increase in response to fluid resuscitation;
[56] however, it is commonly accepted that a
very low CVP is indicative of low
intravascular volumes. In contrast, an
elevated CVP does not always correlate with
adequate intravascular volume. A recent
systematic review found no significant
relationship between CVP and other
measurements of blood volume; however,

the analysis did not differentiate between

elevated and low CVP, and mortality was not
an outcome of the analysis.[57] Despite
these limitations, CVP, especially when low,
in conjunction with other measurements is
often used successfully to assess and guide
resuscitation in patients with sepsis.[35] The
current SSC guidelines recommend during
the initial 6-hour resuscitation period
targeting a CVP of 8 to 12 mm Hg.[14] It is
important to recognize that within this
recommendation CVP is being used as both a
functional and a dynamic measure of preload
responsiveness. The initial absolute static

CVP measurement is not as important as the

response to fluid resuscitation over time,
mainly in patients with very low CVP. Based
on more recently published data, it is likely
that newer methods for assessing preload
responsiveness, including monitoring
variations in arterial pulse pressure or aortic
flow variation in response to vena cava
collapse during positive pressure ventilation
or passively leg raising, will be incorporated
into clinical practice with improved predictive
value.[58]
http://www.medscape.com/viewarticle/74920
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