P R OC E D UR E 1 6

Continuous Venous Oxygen Saturation Monitoring

Jan M. Headley and Karen K. Giuliano

PURPOSE:
Venous oxygen saturation monitoring is performed to measure the oxygen saturation of the venous blood. The
value can be obtained either from the superior vena cava or from the pulmonary artery. Continuous assessment
of the balance between a patient’s oxygen delivery and oxygen consumption can be monitored with a specialized
fiberoptic central venous or pulmonary artery catheter and an associated computer or module.

PREREQUISITE NURSING KNOWLEDGE

• Anatomy and physiology of the cardiopulmonary system should be understood.
• Physiologic principles related to invasive hemodynamic monitoring should be understood.
• Technical aspects of central line placement and pressure monitoring should be understood.
• Technical aspects of pulmonary artery (PA) pressure monitoring should be understood.
• Physiologic concepts of oxygen delivery, oxygen demand, and tissue oxygen consumption should be understood.
• The percent of venous oxygen saturation as measured in the PA (S VO2 ) is flow weighted and represents a true mixing
of all venous blood: inferior vena cava (IVC), superior vena cava (SVC), and coronary sinus.
• Clinically, S VO2 provides an index of overall oxygen balance because it is a reflection of the dynamic relationship
between the patient’s oxygen delivery (DO2 ) and oxygen consumption (VO2 ). Whenever a threat to the oxygen balance
occurs, the body’s primary compensatory mechanisms are to increase oxygen delivery by increasing cardiac output or
to increase oxygen extraction at the tissue level.
• In a critically ill patient, if cardiac output is limited, increased extraction occurs to meet the demand for oxygen at the
tissue level. The result is a decreased level of oxygen returning to the heart and a lower S VO2 measurement. Many
factors can affect the requirements for oxygen and subsequently S VO2 (Table 16-1).2,6,8,13

Table 16-1
Common Conditions and Activities That Affect Venous Oxygen Saturation Values
Decreased Central and Mixed Venous Oxygen Saturation
Decreased Oxygen Delivery
Decreased cardiac output
Decreased hemoglobin
Decreased arterial oxygen saturation
Decreased arterial partial pressure of oxygen
Increased Oxygen Consumption
Fever
Pain
Shivering
Seizures
Increased work of breathing
Agitation
 Infection and sepsis
Vasoactive and beta-agonist medications
Multiple organ failure
Burns
Head injury
Increased musculoskeletal activities
Numerous nursing procedures (e.g., dressing changes, suctioning, turning, and chest physiotherapy)
Increased Central and Mixed Venous Oxygen Saturation
Increased Oxygen Delivery
Increased cardiac output
Increased hemoglobin
Increased arterial oxygen saturation
Increased arterial partial pressure of oxygen
Decreased Oxygen Consumption
Hypothermia
Hypothyroidism
Pharmacologic paralysis and sedation
Anesthesia
Cellular dysfunction
Decreased work of breathing
Decreased musculoskeletal activities

• S VO2 does not correlate directly with any of the determinants of oxygen delivery or oxygen consumption. Because a
critically ill patient is in a dynamic state with rapidly changing oxygen demand and oxygen consumption, S VO2 must
be viewed in the light of these changing determinants and considered an index of oxygen balance.1,2,6,8,13
• A normal S VO2 generally is considered to be 60% to 80%,2,8 and a clinically significant change in S VO2 (5% to 10%) can
be an early indicator of physiologic instability.2,8 S VO2 values of less than 60% may result from either inadequate
oxygen delivery or excess oxygen consumption. S VO2 monitoring is used in critically ill patients for earlier detection of
oxygenation instability than that obtained through traditional PA monitoring.2,6,8,13
• The percent of venous oxygen saturation as measured in the superior vena cava (ScVO2 ) reflects the mixing of venous
blood from the superior half of the body. It does not include blood from the IVC and coronary sinus. ScVO2 , right
atrium (RA), and S VO2 do not correlate absolutely. ScVO2 does trend with S VO2 in a variety of hemodynamic states. In
normal conditions, ScVO2 is slightly less than the RA oxygen saturation and lower than S VO2 . In septic or shock states,
ScVO2 is higher than S VO2 , with a difference that ranges from 5% to 7% and up to 18% in severe shock. This
difference is in part because of a redistribution of blood flow caused by the various pathophysiologies. Therefore,
ScVO2 overestimates S VO2 in shock conditions; a low ScVO2 likely indicates an even lower S VO2 .4,9-11
• Small French size and shorter oximetry catheters have pediatric patient applications for assessment of venous
saturation.9
• Some common proper setup and maintenance steps for the catheters and bedside computer or module are necessary
for accurate monitoring of both ScVO2 and S VO2 .
• Continuous venous saturation monitoring is performed with a three-component system (Fig. 16-1)2,5-7 :
FIGURE 16-1 Oximetry system w ith reflectance spectrophotometry. (From Edwards Lifesciences LLC: Understanding mixed venous oxygen saturation [SVO2]
monitoring using the Swan Ganz TD System, ed 2, Irvine, CA, 2002, Edwards Lifesciences.)

A fiberoptic central venous (CV) or PA catheter contains two fiberoptic filaments that exit at the distal lumen. One
filament serves as a sending fiber for the emission of light; the other serves as a receiving fiber for the light reflected
back from the blood in the vessel (Fig. 16-2).
 FIGURE 16-2 Oximetry catheters. A, Small French size for pediatric applications. B, Central venous catheter. C, Pulmonary artery catheter. (From Edwards
Lifesciences LLC, Irvine, CA, 2008.)

The optic module houses the light-emitting diodes (LEDs), which transmit various wavelengths of light, and a
photodetector, which receives light back. The light wavelengths are shone through a blood sample. Desaturated
hemoglobins, saturated hemoglobins (oxyhemoglobin), and dyshemoglobins (carboxyhemoglobin,
methemoglobin) have different light absorption characteristics. The ratio of hemoglobin to oxyhemoglobin is
determined and reported as a percentage value.2,5,7 All previous patient data, including calibration of saturation
values and patient identification information, are stored in this component. This module should not be
disconnected. If the module must be disconnected, refer to the manufacturer’s instructions for a disconnection
procedure that does not result in memory loss.
An oximeter computer, which can be a stand-alone unit or a module for a bedside monitoring system, has a
microprocessor that converts the light information from the optic module into an electrical display, updated every
few seconds for continuous monitoring. This information is displayed as a continuous graphic trend, a numeric
display, or both, depending on the manufacturer.
Proper calibration of the monitor and catheter ensures accuracy of venous saturation values. The two types of
calibration are in vitro, in which the catheter and optics module are calibrated before insertion; and in vivo, where
the venous saturation value is compared with a laboratory co-oximeter value from a blood sample. Follow
manufacturer recommendations for performing calibration procedures. Daily in vivo calibrations are
recommended. In addition, proper blood sampling techniques from the distal port of the PA catheter are necessary
for ensuring accurate values for calibration.2,5,7,8

EQUIPMENT
 • Fiberoptic PA catheter for S VO2 (various sizes, 4 Fr to 8 Fr; various lumens, 2 Fr to 7 Fr; various lengths, 25 to 110 cm)
• Fiberoptic CV catheter for ScVO2 (various sizes for pediatric to adult use, 4.5 Fr to 8.5 Fr; various lengths, 5 to 20 cm;
single, double, or triple lumen)
• Fiberoptic probe for ScVO2
• Optic module
• Oximeter computer or bedside monitoring system module
• Equipment required for CV monitoring (see Procedure 70) or PA catheterization and pressure monitoring (see
Procedure 73)
Additional equipment (to have available depending on patient need) includes the following:
• Printer

PATIENT AND FAMILY EDUCATION

• Assess patient and family understanding of the clinical benefits of venous oximetry monitoring. Rationale: For
information to be the most appropriate, assessment of the level of patient and family understanding of need for ScVO2
or S VO2 monitoring is important.
• Explain the continuous nature of this monitoring system and the significance of the alarms. Rationale: Explanation
of the procedure to the patient and family helps to alleviate fears and concerns. Additional monitors may produce
increased anxiety in the patient and family.

PATIENT ASSESSMENT AND PREPARATION

Patient Assessment
• Indications for use of ScVO2 /S VO2 monitoring include the following1-3,5-13 :
High-risk cardiovascular surgery
Heart failure
Myocardial infarction
Respiratory failure
Severe burns
Sepsis
Anemia and hemorrhage
Multisystem organ dysfunction
Trauma
Acute respiratory distress syndrome
Use of positive end-expiratory pressure (PEEP)
As a component of early goal-directed therapy for severe sepsis and septic shock Rationale: ScVO2 /S VO2
monitoring is useful in the early detection of oxygenation imbalance, which can facilitate the use of early and more
appropriate interventions.

Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Answer patient questions as they arise, and reinforce information as needed. Rationale: This communication
evaluates and reinforces understanding of previously taught information.
Procedure for Continuous Mixed Venous Oxygen Saturation Monitoring
References
1. Bishop, MH, et al, Prospective, randomized trial of survivor values of cardiac index, oxygen delivery, and
oxygen consumption as resuscitation endpoints in severe trauma . J Trauma 1995; 38:780–787.
2. Darovic, GO. Handbook hemodynamic monitoring, ed 2. St Louis: Saunders; 2004.
3. Dellinger, RP, Levy, MM, Carlet, JM, et al, Surviving sepsis campaign . international guidelines for the
management of severe sepsis and septic shock. Crit Care Med 2008; 36:296–327.
4. Edwards, JD, Mayall, RM. Importance of the sampling site for measurement of mixed venous oxygen
saturation in shock. Crit Care Med. 1998; 26:1356–1360.
5. Edwards Lifesciences LLC, Vigilance. continuous cardiac output and Svo2 monitoring system. Operations
manual. Edwards Lifesciences: Irvine, CA, 2003.
6. Headley, JM. Strategies to optimize the cardiorespiratory status of the critically ill. AACN Clin Issues Crit Care
Nurs. 1995; 6:121–134.
7. Hospira, Inc. Q2Plus SO2 /CO computer (system operating manual. North Chicago: Hospira; 2004.
8. Jesurum, JT, Svo2 monitoring. AACN protocols for practice . hemodynamic monitoring. American
Association of Critical-Care Nurses: Aliso Viejo, CA, 1998.
9. Liakopoulos, OJ, Ho, JK, Yezbick, A, et al. An experimental and clinical evaluation of a novel central venous
catheter with integrated oximetry for pediatric patients undergoing cardiac surgery. Anesth Analg. 2007;
I105(6):1598–1604.
10. Reinhart, K, Kuhn H-J, Hartog, C, et al, Continuous central venous and pulmonary artery oxygen saturation
monitoring in the critically ill. Intensive Care Med. 2004; 30:1572–1578.
11. Rivers, EP, Cobra, V, Whitmill, M, Early goal-directed therapy in severe sepsis and septic shock. a contempory
review of the literature. Curr Opin Anesthesiol 2008; 21:128–140.
12. Vedrinne, C, et al. Predictive factors for usefulness of fiberoptic pulmonary artery catheter for continuous
oxygen saturation in mixed venous blood monitoring in cardiac surgery. Anesth Analg. 1997; 85:2–10.
13. White, KM. Using continuous Svo2 to assess oxygen supply/demand balance in the critically ill patient. AACN
Clin Issues Crit Care Nurs. 1993; 4:134–147.

Additional Readings
AACN. S evere sepsis. from www.aac n.org/WD/Prac tic e/Doc s/S evere_S epsis_04-2006.pdf. [ac c essed].
AACN. Pulmonary artery pressure measurement. www.aac n.org/WD/Prac tic e/Doc s/PAP_Measurement_05-2004.pdf. [ac c essed].
Antonelli M, Levy, M, Andrews, PJD, et al. Hemodynamic monitoring in shoc k and implic ation for management, International Consensus Conferenc e, Paris,
Franc e 27-28 April 2006. Intensive Ca re Med. 2007; 33(4):1–16.
Carc illo, JA, Fields, AI, Americ an College of Critic al Care Medic ine Task Forc e Committee Members. Clinic al -prac tic e parameters for hemodynamic support of
paediatric and neonatal patients in septic shoc k. Crit Care Med 2002; 30:1365–1378.
De Oliveira, CF, de Oliveira, DS F, Moura, JDGet al. ACCM/PALS haemodynamic support guidelines for paediatric septic shoc k. an outc omes c omparison with
and without monitoring c entral venous oxygen saturation. Intensive Care Med. 2008; 34(6):1065–1075.
Edwards Lifesc ienc es LLC. Understanding c ontinuous mixed venous oxygen saturation (S vo2) monitoring with the S wan-Ganz oximetry TD system. ed 2, Irvine,
CA: Edwards Lifesc ienc es; 2002.
Goodric h, C. Continuous c entral venous oximetry monitoring. Crit Ca re Nurs Clin North Am. 2006; 18:203–209.
Kec keisen, M Pulmonary artery pressure monitoring. In AACN protoc ols for prac tic e. hemodynamic monitoring. Americ an Assoc iation of Critic al-Care Nurses,
Aliso Viejo, CA, 1998.
Rivers, EP, Ander, DS , Powell, D. Central venous oxygen saturation monitoring in the c ritic ally ill. Curr Opin Ca re. 2001; 7(3):204–211.