Bratisl Lek Listy 2008; 109 (4)

185 – 187

REVIEW

Central venous pressure – evaluation, interpretation,

University of Iowa, Mercy Hospital, Iowa, USA. [email protected]

Abstract: Physicians need to understand, evaluate and address hemodynamics in every patient and even
more importantly in patients that are critically ill. Being able to determine and interpret central venous pressure
is one of the most useful bedside evaluation skills, even in the 21st century (Fig. 3). Full Text (Free, PDF)
www.bmj.sk.
Key words: central venous pressure, hemodynamic monitoring.

Central venous pressure (CVP) is a number that describes + c wave: This wave is caused by a slight elevation of the
the pressure of the blood in the thoracic vena cava near the right tricuspid valve into the right atrium during early ventricular con-
atrium of the heart. It can be simplified that CVP equals right traction. It correlates with the end of the QRS segment on an
atrial pressure. CVP reflects the amount of the blood returning EKG.
to the heart and the ability of the heart to pump the blood in the - x descent: This wave is probably caused by the downward
arterial system. It is a good approximation of right atrial pres- movement of the ventricle during systolic contraction. It occurs
sure, which is a major determinant of right ventricular end dias- before the T wave on an EKG.
tolic volume and right ventricular preload. Change in CVP = + v wave: This wave arises from the pressure produced when
change in VOLUME / change in venous COMPLIANCE. In other the blood filling the right atrium comes up against a closed tri-
words CVP is increased by venous blood volume or by increase cuspid valve. It occurs as the T wave is ending on an EKG.
in venous tone (Fig. 1). - y descent: This wave is produced by the tricuspid valve
Some of the case scenarios for increased CVP are hyperv- opening in diastole with blood flowing into the right ventricle. It
olemia, forced exhalation (transient), being on ventilator (PEEP), occurs before the P wave on an EKG.
tension pneumothorax, pleural effusion and heart failure. De-
creased CVP is usually seen in hypovolemia, septic shock, deep Noninvasive measurement of CVP is quick, practical and
inhalation (transient) and increased venous compliance. The in- useful, but not exact. The examiner should use the internal jugu-
halation/exhalation variance is even more important in patients lar vein when possible and be able to identify this structure based
with chronic obstructive pulmonary disease (COPD) or any pa- on the waveform of CVP as opposed to the waveform of the
tients that have to strain to exhale. Physicians should be aware arterial pressure, which is different. It is important to distinguish
that during exhalation in a patient with asthma or COPD the that the venous waveform disappears upon gentle pressure on
CVP will be elevated due to straining and should be evaluated
during the inhalation phase of respiratory cycle during non-forced
inhalation to avoid falsely elevated readings.
There are several waves on the CVP tracing that are related
to the cardiac cycle (Fig. 2):
+ a wave: This wave is due to the increased atrial pressure
during right atrial contraction. It correlates with the P wave on
an EKG.

University of Iowa, Iowa City, Iowa, and Des Moines University, Des
Moines, Iowa, USA
Address for correspondence: M. Izakovic, MD, FACP, Medical Direc-
tor, Hospitalist Program, Mercy Hospital, 500 East Market Street, Iowa
City, Iowa 52245, USA. Fig. 1. Klabundle R: Cardiovascular Physiology Concepts. http://
Phone: +1.319.6887349, Fax: +1.319.6887350 www.cvphysiology.com.

185
Bratisl Lek Listy 2008; 109 (4)
185 – 187

Fig. 2. http://www.healthysystem.virginia.edu/internet/
anesthesiology-elective/cardiac/cvcphys.cfm.

the base of the neck (pressure generated with the back of the
extended index finger just above the clavicle). The pulsation of
the carotid artery persists, as the pressure in the carotid arteries
is much higher as in the jugular veins. One can speculate that the
distance between the right atrium and the sternal angle (angle
between manubium and corpus sterni) varies with position. For
Fig. 3. Ratika S, Magner P, Matzinger F, Van Walraven C. How Far
the purpose of the estimation of CVP it can be regarded as con-
Is the Sternal Angle from the Midright Atrium? J Gen Intern Med
stant and to be 5 cm (Fig. 3). The examiner needs to know the 2002; 17 (11): 861–865.
anatomical location where to look. We should aim for the inter-
nal jugular vein but may use external jugular vein instead, as it is
sometimes easier to spot. The difference is usually minimal but patient has normal or high CVP it is very unlikely that he or she
we should always look on both sides to make valid measure- is having significant hypovolaemia. On the other hand if the CVP
ment. Positioning of the patient and proper light is critical. Start is low it is useful to perform orthostatic blood pressure measure-
at 45% angle of the whole torso elevation (not only head and ments and after confirming severe hypovolaemia start aggres-
neck) and position as needed to achieve visualization for the CVP sive volume resuscitation. Many times CXR is having diffuse
(if CVP is elevated may need to erect patient more, if it is de- interstitial infiltrates and differential diagnosis includes pulmo-
creased might need to flatten patient further). In a healthy indi- nary congestion/edema. If patient has normal or low CVP this
vidual at a 45 % angle of the upper body the CVP will be ap- diagnosis can be excluded with very high level of confidence.
proximately in the middle of the neck (distance between the Similar case applies to elevated BNP, marker widely used to con-
clavicle and the mandible). This will be approximately 6–9 cm firm or rule-out congestive heart failure (CHF). In patients with
of water column, which ultimately equals the vertical distance normal or low CVP it is very unlikely that elevated BNP is due
in centimeters from the right atrium. Measurement consists of to CHF exacerbation, more likely it is due to different condi-
drawing a virtual horizontal line at the sternal angle and another tions such as pulmonary embolism (also creating heart strain) or
one at the level of the CVP (upper level of the blood filling the renal insufficiency (BNP is cleared via kidneys). It is essential
jugular vein). The vertical difference between those 2 lines in to be able to determine the volume status of patients presenting
centimeters should be added to the arbitrary distance between with common clinical problems such as hyponatremia and syn-
the right atrium and sternal angle (5 cm). cope. Patient with hyponatremia, hypovolaemia and low serum
Cardiac function is determined by preload (CVP), afterload, osmolality (hypovolaemic hypoosmolal hyponatremia) who is
heart rate and cardiac contractility. Being able to evaluate CVP on diuretics has most probably low sodium as a side effect of
at the bedside (at least estimate) is very useful skill and saves diuretics. The same goes for syncope in such patients, as it is
time as well as simplifies differential diagnosis process in vari- very common that overdiuresed patients experience othostatic
ous clinical situations. CVP evaluation puts light and sense to syncopal spells. In cases with low-normal or decreased CVP it is
managing patients with indeterminate chest X-ray/radiographs very useful to use orthostatic blood pressure measurements.
(CXR) findings, elevated beta natriuretic peptide (BNP) levels, When should CVP be measured exactly using invasive me-
shortness of breath complaints and evaluating volume status. If thods? In patients with hypotension who are not responding to

186
 Izakovic M. Central venous pressure…
XX
initial intravenous fluid resuscitation, in continuing hypovolaemia tient to a target CVP. “Normal CVP” = 5–10 cmH2O. While treat-
secondary to major fluid shifts or loss and in patients requiring ing septic patients clinicians should use ~10 cmH2O in non-ven-
infusions of inotropes or vasopressors. Those are the patients tilated patient, and ~15 cmH2O, if the patient is on positive pres-
usually admitted to critical care units. Exact measurement of CVP sure ventilation (CPAP, BiPAP). If there is a question of cardiac
involves inserting central venous catheters and using hemody- disease, cardiac hypertrophy or dilatation or if the patient is older,
namic monitors. Catheters are usually introduced either in sub- aim higher ~15plus cmH2O. In many young patients, it is often
clavian or internal jugular vein with the tip positioned in vena not possible to raise the CVP above 10 cmH2O because of high
cava just before right atrium. CVP, measured invasively, is suf- efficiency of the cardiovascular system.
ficient to guide fluid therapy in the majority of patients (may In conclusion, it is imperative in today’s practice of medi-
elect to use Swan-Ganz catheter but there is conflicting evidence cine to be time efficient and to use modern diagnostic methods.
in recent literature). It is hard to set normal or average CVP num- For example, diagnosing a cause of a cardiac murmur based on
ber. The measurement is determined by venous return, influenced auscultation alone is almost unheard of in current practice and
by intrathoracic pressure and right ventricular compliance. Com- every patient with such problem is evaluated with echocardio-
plete heart block, atrial fibrillation, tricuspid stenosis and regur- graphy, which is very appropriate. On the other hand it is essen-
gitation will lead to an inaccurate reading, although the diag- tial not to forget the “art of medicine” and the bedside skills.
nosis of these disorders can be made from the CVP waveform Measuring CVP (noninvasive) is a good, simple, reliable bed-
(Fig. 2). side test that saves time and helps interpret different and some-
Central venous pressure should be regarded as a trend. Mul- times conflicting findings. Evaluating and addressing hemody-
tiple fluid boluses might be necessary before the CVP reaches namics (invasive monitoring) is essential in majority of patients
the target range and patient can be switched to a maintenance hospitalized in critical care units. Aim of this article was to em-
fluid infusion. In patient with sepsis it is imperative to replenish phasize importance of hemodynamic monitoring in clinical prac-
vascular volume sufficiently before starting vasopressors. It is tice as well as to motivate the audience to “brush-up” on this
not uncommon to volume under-load and under-resuscitate pa- essential and very valuable skill.

Received January 14, 2008.

187