Does Central Venous Pressure Predict Fluid

Responsiveness? * : A Systematic Review of

the Literature and the Tale of Seven Mares
Paul E. Marik, Michael Baram and Bobbak Vahid

Chest 2008;134;172-178
DOI 10.1378/chest.07-2331
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 CHEST Special Feature

Does Central Venous Pressure Predict

Fluid Responsiveness?*
A Systematic Review of the Literature and the Tale
of Seven Mares
Paul E. Marik, MD, FCCP; Michael Baram, MD, FCCP; and Bobbak Vahid, MD

Background: Central venous pressure (CVP) is used almost universally to guide fluid therapy in
hospitalized patients. Both historical and recent data suggest that this approach may be flawed.
Objective: A systematic review of the literature to determine the following: (1) the relationship
between CVP and blood volume, (2) the ability of CVP to predict fluid responsiveness, and (3) the
ability of the change in CVP (⌬CVP) to predict fluid responsiveness.
Data sources: MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of
relevant primary and review articles.
Study selection: Reported clinical trials that evaluated either the relationship between CVP and
blood volume or reported the associated between CVP/⌬CVP and the change in stroke
volume/cardiac index following a fluid challenge. From 213 articles screened, 24 studies met our
inclusion criteria and were included for data extraction. The studies included human adult
subjects, healthy control subjects, and ICU and operating room patients.
Data extraction: Data were abstracted on study design, study size, study setting, patient population,
correlation coefficient between CVP and blood volume, correlation coefficient (or receive operator
characteristic [ROC]) between CVP/⌬CVP and change in stroke index/cardiac index, percentage of
patients who responded to a fluid challenge, and baseline CVP of the fluid responders and
nonresponders. Metaanalytic techniques were used to pool data.
Data synthesis: The 24 studies included 803 patients; 5 studies compared CVP with measured
circulating blood volume, while 19 studies determined the relationship between CVP/⌬CVP and
change in cardiac performance following a fluid challenge. The pooled correlation coefficient
between CVP and measured blood volume was 0.16 (95% confidence interval [CI], 0.03 to 0.28).
Overall, 56 ⴞ 16% of the patients included in this review responded to a fluid challenge. The pooled
correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 (95%
CI, 0.08 to 0.28). The pooled area under the ROC curve was 0.56 (95% CI, 0.51 to 0.61). The pooled
correlation between ⌬CVP and change in stroke index/cardiac index was 0.11 (95% CI, 0.015 to 0.21).
Baseline CVP was 8.7 ⴞ 2.32 mm Hg [mean ⴞ SD] in the responders as compared to 9.7 ⴞ 2.2 mm
Hg in nonresponders (not significant).
Conclusions: This systematic review demonstrated a very poor relationship between CVP and blood
volume as well as the inability of CVP/⌬CVP to predict the hemodynamic response to a fluid
challenge. CVP should not be used to make clinical decisions regarding fluid management.
(CHEST 2008; 134:172–178)

Key words: anesthesia; blood volume; central venous pressure; fluid responsiveness; fluid therapy; hemodynamic monitoring;
ICU; preload; stroke volume

Abbreviations: AUC ⫽ area under the curve; CI ⫽ confidence interval; CVP ⫽ central venous pressure; ⌬CVP ⫽ change in
central venous pressure; ROC ⫽ receiver operator characteristic

C recorded
entral venous pressure (CVP) is the pressure
from the right atrium or superior vena
department patients, well as in patients undergoing
major surgery. CVP is frequently used to make
cava. CVP is measured (usually hourly) in almost all decisions regarding the administration of fluids or
patients in ICUs throughout the world, in emergency diuretics. Indeed, internationally endorsed clinical

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© 2008 American College of Chest Physicians
guidelines1 recommend using CVP as the end point study was performed. We used a multimethod approach to
of fluid resuscitation. The basis for using CVP to identify relevant studies for this review. All authors indepen-
dently searched the National Library of Medicine MEDLINE
guide fluid management comes from the dogma that database for relevant studies in any language published from
CVP reflects intravascular volume; specifically, it is 1966 to June 2007 using the following medical subject head-
widely believed that patients with a low CVP are ings and key words; central venous pressure (explode) AND
volume depleted while patients with a high CVP are blood volume, or fluid therapy or fluid responsiveness. In
volume overloaded. This concept is taught to medi- addition, we searched Embase and the Cochrane Database of
Systematic Reviews. Bibliographies of all selected articles and
cal students as well as to residents and fellows across review articles that included information on hemodynamic
a wide range of medical and surgical disciplines. monitoring were reviewed for other relevant articles. In
Indeed an authoritative textbook2 of cardiovascular addition, the authors reviewed their personal files and con-
physiology states as a key concept that “[the] central tacted experts in the field. This search strategy was done
venous pressure gives clinically relevant information iteratively until no new potential citations were found on
review of the reference lists of retrieved articles. We per-
about circulatory [and volume] status.” The chapter formed this metaanalysis according to the guidelines proposed
on cardiovascular monitoring in a standard anesthe- by the Quality of Reporting of Meta-analyses group.5
siology text3 states that “the most important applica-
tion of CVP monitoring is to provide an estimate of Study Selection and Data Extraction
the adequacy of circulating blood volume”, and
“[that] trends in CVP during anesthesia and surgery Only studies that reported either of the following were in-
are also useful in estimating fluid or blood loss and cluded in this analysis: (1) the correlation coefficient between
CVP and measured blood volume, or (2) the correlation coeffi-
guiding replacement therapy.” Over 25 years ago, cient or receiver operator characteristic (ROC) between CVP or
the “5–2” rule for guiding fluid therapy was popu- change in CVP (⌬CVP) and change in stroke index/cardiac output
larized.4 According to this rule, the change in CVP following a fluid challenge. All authors independently abstracted
following a fluid challenge is used to guide subse- data from all studies using a standardized form. Data were
quent fluid management decisions. This rule is still abstracted on study design, study size, study setting, patient
population, correlation coefficients and area (including 95%
widely used today. Recently, the idea that the CVP confidence intervals [CIs]) under the ROC curve, the percentage
reflects blood volume has been challenged. Since of patients responding to a fluid challenge as well as the baseline
CVP plays such a central role in the fluid manage- CVP in the fluid responders and nonresponders. In general, an
ment strategy of hospitalized patients, the goal of this increase in the stoke index or cardiac index ⬎ 10 to 15% was used
study was to systemically review the evidence that as an index of fluid responsiveness.6,7
The random-effects models (Comprehensive Meta-analysis
supports this practice. 2.0; Biostat; Englewood NJ) was used to determined the pooled
area under the curve (AUC) and correlation coefficients.8,9
Summary effects estimates are presented with 95% CIs. We
calculated the Cochran Q statistic to test for statistical heteroge-
Materials and Methods neity. Values of Q significantly ⬎ 0 (p ⬍ 0.1) were considered
evidence of heterogeneity. When not reported in the primary
Identification of Trials paper, the correlation coefficients were calculated from the raw
data (when available) [NCSS 2007; NCSS; Kaysville, UT].
Our aim was to identify all relevant clinical trials that
analyzed the relationship between CVP and measured blood
volume as well as those studies that determined the ability of
CVP to predict fluid responsiveness (ie, an increase in stroke Results
index/cardiac index following a fluid challenge). Studies that
compared CVP with volumetric measurements (right and left The initial search strategy generated 206 citations;
ventricular end-diastolic volumes, global left heart volume, of these, 189 were excluded due to trial design or
central blood volume) but did not report the ability of CVP to
failure to report an outcome variables of interest. An
predict volume responsiveness were not included. We re-
stricted this analysis to human adults; however, there was no additional seven studies were identified from the
restriction as to the type of patient or the setting where the bibliographies of the selected articles and review
articles. Of the 24 studies included in this analysis, 5
*From the Division of Pulmonary and Critical Care Medicine, studies compared CVP with the measured circulat-
Thomas Jefferson University, Philadelphia, PA. ing blood volume while 19 studies determined the
The authors have no financial conflicts of interest in any of the
products mentioned in this article. relationship between CVP and change in cardiac
Manuscript received September 20, 2007; revision accepted performance following a fluid challenge (generally
November 14, 2007. defined as a ⬎ 10 to 15% increase in stroke index/
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal. cardiac index). In all, 830 patients across a spectrum
org/misc/reprints.shtml). of medical and surgical disciplines were studied10 –33
Correspondence to: Paul Marik, MD, FCCP, Chief, Pulmonary and (Tables 1, 2). In three studies,10,15,33 the correlation
Critical Care Medicine, Thomas Jefferson University, 834 Walnut St,
Suite 650, Philadelphia, PA 19107; e-mail: [email protected] coefficients were not reported in the article but were
DOI: 10.1378/chest.07-2331 calculated from the raw data.

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 Table 1—Summary of Studies of Blood Volume*
Patients,
Source Setting Type No. Methodology r, Blood Volume
10 125
Baek et al, 1975 ICU General surgery 69 I-albumin 0.19
Shippy et al,11 1984 ICU ICU 118 125
I-albumin 0.27
Hoeft et al,12 1994 OR/ICU CABG 11 Indocyanine green 0.12
Oohashi et al,13 2005 ICU Esophagectomy 16 Indocyanine green 0.17
Kuntscher et al,14 2006 ICU Burns 16 COLD system† 0.02
Pooled value 0.16
*OR ⫽ operating room; CABG ⫽ coronary artery bypass graft surgery.
†COLD Z-021 system (Pulsion Medical Systems; Munich, Germany).

The pooled correlation coefficient between the seven studies) was 0.11 (95% CI, 0.01 to 0.21). The
CVP and measured blood volume was 0.16 (95% CI, baseline CVP (reported in 11 studies) was 8.7 ⫾ 2.3
0.03 to 0.28; r2 ⫽ 0.02). Heterogeneity was present mm Hg in the responders, as compared to 9.7 ⫾ 2.2
between studies. Figure 1 illustrates the relationship mm Hg in nonresponders (not signficant; p ⫽ 0.3).
between CVP and measured blood volume from the The Q statistic was not significant for the pooled
study of Shippy et al.11 Overall 56 ⫾ 16% (mean ⫾ SD) correlation and area under the curve statistic.
of the patients included in this review responded to
a fluid challenge. The pooled correlation coefficient
between baseline CVP and change in stroke index/ Discussion
cardiac index (reported in 10 studies) was 0.18 (95%
CI, 0.08 to 0.28). The pooled area under the ROC The results of this systematic review are clear: (1)
curve (reported in 10 studies) was 0.56 (95% CI, 0.51 there is no association between CVP and circulating
to 0.61). The pooled correlation between ⌬CVP and blood volume, and (2) CVP does not predict fluid
change in stroke index/cardiac index (reported in responsiveness across a wide spectrum of clinical

Table 2—Summary of Studies of Volume Challenge*

Patients,
Source Setting Type No. Methodology AUC† r, CVP/SI r, ⌬CVP/SI CVP-R CVP-NR
15
Calvin et al, 1981 ICU Mixed ICU 28 PAC/Scint 0.16 0.26 4.7 4.8
Reuse et al,16 1990 ICU ICU 41 PAC 0.21 8.5 8.4
Godje et al,17 1998 ICU CABG 30 PAC, COLD system‡ 0.09
Wagner and Leatherman,18 ICU ICU 25 PAC 0.44 7.4 10.1
1998
Wiesenack et al,19 2001 OR CABG 18 PAC, TPT 0.09
Berkenstad et al,20 2001 OR Neurosurgery 15 TPT 0.49 0.05 0.08 9.3 9.3
Michard et al,21 2000 ICU ICU 40 PAC 0.51
Reuter et al,22 2002 ICU CABG 20 TPT 0.42
Reuter et al,23 2003 ICU CABG 26 PAC, TEE 0.71
Barbier et al,24 2004 ICU Sepsis 20 TEE 0.57 10 9
Kramer et al,25 2004 ICU CABG 21 PAC 0.49 0.13 13.5 13.3
Marx et al,24 2004 ICU Sepsis 10 PAC, TPT 0.41 0.28
Preisman et al,27 2005 OR CABG 18 TPT, TEE 0.61 8.7 10
Perel et al,28 2005 ICU Vascular surgery 14 TEE 0.27 9.6 12.2
Hofer et al,29 2005 OR CABG 40 PAC, TEE 0.54 0.02 0.2
De Backer et al,30 2005 ICU ICU 60 PAC 0.54 10 12
Kumar et al,31 2004 ICU Healthy volunteers 12 PAC/Scint 0.32 0.22
Osman et al,32 2007 ICU Septic 96 PAC 0.58 8 9
Magder and Bafaqeeh,33 ICU CABG 66 PAC 0.36 5.9 8.7
2007
Pooled 0.56 0.18 0.11 8.7 9.7
*PAC ⫽ pulmonary artery catheter; TEE ⫽ transesophageal echocardiography; Scint ⫽ radionuclide scintography; TPT ⫽ transpulmonary
thermodilution; CVP-R ⫽ baseline CVP of responders; CVP-NR ⫽ baseline CVP of nonresponders; SI ⫽ fluid responsiveness; see Table 1 for
expansion of abbreviations.
†Area under ROC curve of CVP and fluid responsiveness.
‡COLD Z-021 system (Pulsion Medical Systems; Munich, Germany).

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 Figure 1. Fifteen hundred simultaneous measurements of blood volume and CVP in a heterogenous
cohort of 188 ICU patients demonstrating no association between these two variables (r ⫽ 0.27). The
correlation between ⌬CVP and change in blood volume was 0.1 (r2 ⫽ 0.01). This study demonstrates
that patients with a low CVP may have volume overload and likewise patients with a high CVP may be
volume depleted. Reproduced with permission from Shippy et al.11

conditions. In none of the studies included in this 1 (0.8 to 0.9 indicates adequate accuracy with 0.7 to
analysis was CVP able to predict either of these 0.8 being fair, 0.6 to 0.7 being poor, and 0.5 to 0.6
variables. Indeed, the pooled area under the ROC indicating failure). In other words, our results sug-
curve was 0.56. The ROC curve is a statistical tool gest that at any CVP the likelihood that CVP can
that helps assess the likelihood of a result being a accurately predict fluid responsiveness is only 56%
true positive vs a false positive. As can be seen from (no better than flipping a coin). Furthermore, an
Figure 2, an ROC of 0.5 depicts the true-positive AUC of 0.56 suggests that there is no clear cutoff
rate equal to the false-positive rate; graphically, this point that helps the physician to determine if the
is represented by the straight line in Figure 1. The patient is “wet” or “dry.” It is important to emphasize
higher the AUC, the greater the diagnostic accuracy that a patient is equally likely to be fluid responsive
of a test. Ideally, the AUC should be between 0.9 to with a low or a high CVP (Fig 1). The results from
this study therefore confirm that neither a high CVP,
a normal CVP, a low CVP, nor the response of the
CVP to fluid loading should be used in the fluid
management strategy of any patient.
The strength of our review includes the rigorous
selection criteria used to identify relevant studies as
well as the use of quantitative end points.8,9,34 Fur-
thermore, the studies are notable for the consistency
(both in magnitude and direction) of their findings.
This suggests that the findings are likely to be
true.8,9,34 The results of our study are most disturb-
ing considering that 93% of intensivists report using
CVP to guide fluid management.35 It is likely that a
similar percentage (or more) of anesthesiologists,
nephrologists, cardiologists, and surgeons likewise
use CVP to guide fluid therapy. It is important to
note that none of the studies included in our analysis
Figure 2. Comparison of ROC curves showing tests with took the positive end-expiatory pressure levels or
different diagnostic accuracies. changes in intrathoracic pressure into account when

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recording CVP. This is important because right venous pressure” and suggest that “inaccurate phys-
ventricular filling is dependent on the transmural iologic evaluation of critically ill patients is likely to
right atrial pressure gradient rather than the CVP jeopardize survival by inviting inappropriate and
alone.36 However, in the real world, transmural ineffectual therapy.” In 1977, Dr. Burch,44 a well-
filling pressures are rarely if ever calculated. respected cardiologist, noted that “to accept non-
As demonstrated by this study, only about a half of critically the level of central venous pressure as a
patients administered a fluid bolus will demonstrate quantitative index of blood volume can only lead to
a positive hemodynamic response to the interven- physiologic and/or therapeutic errors.” The observa-
tion. With an ROC of 0.56, the play of chance (or a tions of Forrester et al,43 Baek and colleagues,10 and
dice) will be as helpful as CVP in predicting which Burch44 have now been confirmed by 23 more
patients will respond to a fluid challenge. If fluid recent studies. Indeed, limited data support using
resuscitation is guided by CVP, it is likely that patients CVP to guide fluid therapy. The only study45 we
will have volume overload and pulmonary edema. could find demonstrating the utility of CVP in
Indeed the practice parameters for hemodynamic sup- predicting volume status was performed in seven
port of sepsis in adult patients concludes that “fluid standing, awake mares undergoing controlled hem-
infusion should be titrated to a filling pressure” and that orrhage! In addition, Magder and colleagues46 re-
“pulmonary edema may occur as a complication of fluid ported that the respiratory variation in CVP in
resuscitation and necessitates monitoring of arterial spontaneously breathing patients was predictive of
oxygenation.”37 Should volume overload and pulmo- fluid responsiveness. Additional studies are required
nary edema be the end point of fluid resuscitation?38 to support using the respiratory variation in CVP to
This is clinically important because a positive fluid guide fluid management. In addition, it should be
balance in both ICU patients and those undergoing noted that in the ARDSnet fluid management trial,47
surgery has been associated with increased complica- those patients randomized to the “CVP conservative-
tions and a higher mortality.39 – 41 It is however equally strategy” group had significantly more ventilator-free
likely that resuscitation guided by CVP will results in days and a shorter length of ICU stay. It is unclear
inadequate volume replacement. Furthermore, the from this study whether CVP or the conservative
use of diuretics based on CVP may result in intra- fluid strategy was the important intervention because
vascular volume depletion leading to poor organ there was no “no-CVP” study arm. It should also be
perfusion and ultimately renal failure and multiorgan recognized that CVP was a component of early
failure because a “high” CVP does not necessarily goal-directed therapy in the landmark article by
reflect volume overload. Rivers and colleagues.48 However, both the control
Fundamentally the only reason to give a patient a and intervention groups had CVP targeted to 8 to 12
fluid challenge is to increase the stroke volume.6 This mm Hg. Based largely on the results of the early
assumes that the patient is on the ascending portion goal-directed therapy study, the Surviving Sepsis
of the Frank-Starling curve and has “recruitable” Campaign guidelines1 for management of severe
cardiac output. Once the left ventricle is functioning sepsis and septic shock recommend a CVP of 8 to 12
near the “flat” part of the Frank-Starling curve, fluid mm Hg as the “goal of the initial resuscitation of
loading has little effect on cardiac output and only sepsis-induced hypoperfusion” and “a higher tar-
serves to increase tissue edema and to promote geted central venous pressure of 12–15 mm Hg” in
tissue dysoxia. It is therefore crucial during the patients receiving mechanical ventilation. The re-
resuscitation phase of all critically ill patients to sults of our study suggest that these recommenda-
determine whether the patient is fluid responsive or tions should be revisited.
not; this determines the optimal strategy of increas- The origins of CVP monitoring can be traced
ing cardiac output and oxygen delivery.42 The results back to Hughes and Magovern,49 who in 1959
from this article clearly demonstrate that CVP described a complicated technique for right atrial
should not be used for this purpose. monitoring as a guide to blood volume replace-
The notion that CVP does not reflect intravascular ment in post-thoracotomy patents. These authors
volume and is a misleading tool for guiding fluid described a fall in CVP with blood loss and a
therapy is not new. In an article published in 1971, relationship between the CVP and blood transfu-
Forrester and colleagues,43 the pioneers of hemody- sion. The technique of CVP monitoring was fur-
namic monitoring, concluded that “CVP monitoring ther popularized by Wilson and Grow50 and soon
in acute myocardial infarction is at best of limited became routine in patients undergoing thoracic
value and at worst seriously misleading.” In their surgery. Based on scarce data, CVP became the
landmark article that was published in 1975, Baek standard tool for guiding fluid therapy, initially in the
and colleagues10 convincingly established that “there operating room and then in the ICU. However, what
was no correlation of blood volume with central was not generally appreciated is that the CVP is a

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© 2008 American College of Chest Physicians
measure of right atrial pressure alone; and not a tween cardiac output, stroke volume, central venous pressure,
measure of blood volume or ventricular preload. Based intra-abdominal pressure and total circulating blood volume
in resuscitation of major burns. Resuscitation 2006; 70:37– 43
on the results of our systematic review, we believe that
15 Calvin JE, Driedger AA, Sibbald WJ. The hemodynamic
CVP should no longer be routinely measured in the effect of rapid fluid infusion in critically ill patients. Surgery
ICU, operating room, or emergency department. How- 1981; 90:61–76
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circumstances, such as in patients who have undergone ventricular volumes during fluid challenge. Chest 1990; 98:
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17 Godje O, Peyerl M, Seebauer T, et al. Central venous
ventricular infarction or acute pulmonary embolism. In pressure, pulmonary capillary wedge pressure and intratho-
these cases, CVP may be used as a marker of right racic blood volumes as preload indicators in cardiac surgery
ventricular function rather than an indicator of volume patients. Eur J Cardiothorac Surg 1998; 13:533–539
status. 18 Wagner JG, Leatherman JW. Right ventricular end-diastolic
volume as a predictor of the hemodynamic response to a fluid
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“Moose” Ahmed for his insight into animal physiology, and Dr 19 Wiesenack C, Prasser C, Keyl C, et al. Assessment of
“JVP” De Caro for his valuable clinical perceptiveness. intrathoracic blood volume as an indicator of cardiac preload:
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pulmonary artery catheter. J Cardiothorac Vasc Anesth 2001;
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178 Special Feature

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 Does Central Venous Pressure Predict Fluid Responsiveness?* : A
Systematic Review of the Literature and the Tale of Seven Mares
Paul E. Marik, Michael Baram and Bobbak Vahid
Chest 2008;134; 172-178
DOI 10.1378/chest.07-2331
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