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 Definitions

• Central venous pressure (CVP) describes the pressure of

blood in the thoracic vena cava, near the right atrium of the
heart.
• CVP reflects the amount of blood returning to the heart and
the ability of the heart to pump the blood into the arterial
system.
• Central Venous Pressure is a more accurate and reliable way
of monitoring the patient’s fluid balance and cardiac status.

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 CVP
• A central venous access device is a single or
triple lumen catheter which is passed via
direct entry into the subclavian, jugular or
anticubital vein.
• The tip of the catheter is placed into the
vena cava or right atrium of the heart.

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 When should CVP be measured?

Paients with hypotension who are not responding to

basic clinical management.
Continuing hypovolaemia secondary to major fluid
shifts or loss.
Patients requiring infusions of inotropes.

Function of Central Venous

Pressure:

The CVP is often used to make estimates of circulatory

function, in particular cardiac function and blood volume.
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 Various values of CVP
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 :
oDecreased cardiac output .
oIncreased blood volume.
oVenous constriction.
oChanging from standing to supine body posture.
oArterial dilation.
oForced expiration (e.g., Valsalva).
oMuscle contraction (abdominal and limb).
CVP decreases with:
ohypovolemic shock from hemorrhage, fluid shift, dehydration
onegative pressure breathing which occurs when the patient
demonstrates retractions or mechanical negative pressure
which is sometimes used for high spinal cord injuries.
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oDeep inhalation .
 Assisting with CVP placement:
Adhere to institutional Policy and Procedure.
Obtain history and assess the patient.
Explain the procedure to the patient, include:
olocal anesthetic
otrendelenberg positioning
odraping
olimit movement
oneed to maintain sterile field.
opost procedure chest X-ray

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Assisting with CVP placement: (continue..)
Obtain a sterile, flushed and pressurized transducer
assembly
Obtain the catheter size, style and length ordered.
Obtain supplies:
oMasks
oSterile gloves
oLine insertion kit
oHeparin flush per policy
Position patient supine on bed capable of trendelenberg
position
Prepare for post procedure chest X-ray
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 Indications for using CV catheter
Central venous access is the placement of a venous catheter in a vein
that leads directly to the heart. The main reasons for inserting a
central venous catheter are:
measurement of central venous pressure (CVP) .
venous access when no peripheral veins are available .
administration of vasoactive/inotropic drugs which cannot be
given peripherally .
administration of hypertonic solutions including total
parenteral nutrition (TPN) .
haemodialysis/plasmapheresis.
Provide long term access for :
a) Hydration or electrolyte maintenance
b )Repeated administration of drugs such as antibiotics or
cytotoxic drug.
c )Repeated transfusion of blood or blood products
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d )Repeated Specimen Collection
 Contraindications for using CV catheter

absolute
a) SVC syndrome.
Superior vena cava syndrome (SVCS) is obstruction of blood flow
through the superior vena cava (SVC). It is a medical emergency
and most often manifests in patients with a malignant disease
process within the thorax

b) Infection at the site of insertion .

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Contraindications for using CV catheter

Relative:
a) Coagulopathies .
b) Newly inserted pacemaker wire .
c) Presence of carotid disease .
d) Recent cannulation of the internal jugular
vein.
e) Contra lateral diaphragmatic dysfunction .
f) Thyromegaly or prior neck surgery.

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 General preparation to obtain central venous
access
• The basic preparation and equipment that is
required for central venous cannulation is the
same regardless of the route or technique chosen.
• Clinicians who insert central venous lines should
be taught the technique by an experienced
colleague.
• If this is not possible then the access routes
associated with the fewest complications are the
basilic vein or femoral vein.

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 Equipment required for central venous access.
1)Patient on a tilting bed, trolley or operating table
2)Sterile pack and antiseptic solution
3)Local anaesthetic - e.g. 5ml lignocaine 1% solution
4)Appropriate CV catheter for age/route/purpose
5)Syringes and needles
6)Saline or heparinised saline to prime and flush the line after
insertion
7)Suture material - e.g. 2/0 silk on a straight needle
8)Sterile dressing
9)Shaving equipment for the area if very hairy (especially the
femoral)
10)Facility for chest X-ray if available
11)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
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 General technique for all routes
 Confirm that central venous access is needed and select the most
appropriate route.
 Explain the procedure to the patient.
 Shave the needle insertion area if very hairy
 Using a strict aseptic technique, prepare and check all the equipment for
use. Read instructions with the catheter.
 Sterilize the skin and drape the area
 Infiltrate the skin and deeper tissues with local anaesthetic. In cases where
difficulty is anticipated use the small local anaesthetic needle to locate the
vein before using the larger needle. This reduces the risk of trauma to other
structures.
 Position the patient as for the specific route described - avoid long periods of
head down, particularly in breathless patients
 Identify the anatomical landmarks for the chosen route and insert the
needle at the recommended point.
 After the needle has penetrated the skin, aspirate gently whilst advancing
the needle as directed until the vein is entered.
 If the vein is not found, slowly withdraw the needle whilst gently aspirating;
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often the vein has been collapsed and transfixed by the entry of the needle.
Technique of CL inserting

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 Checks before using the line:

Ensure fluid runs in freely and that blood flows freely back.
To observe the latter place the infusion bag below the level of
the bed .
If available, take a chest X-ray (ideally erect) to check the
position of the catheter tip and to exclude a pneumo, hydro
or haemothorax. An early radiograph may not show up
abnormalities and it may be best to wait 3-4 hours unless
symptoms develop. The tip of the CVP line should lie in the
superior vena cava just above its junction with the right
atrium.
Ensure that the patient will be nursed where their CV line can
be supervised. Give appropriate written instructions regarding
how, and what it is to be used for, and who to contact if there
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 How to measure the CVP?
• The CVP is measured using a manometer filled with intravenous fluid attached
to the central venous catheter.
• It needs to be 'zeroed' at the level of the right atrium, approximately the mid-
axillary line in the 4th interspace supine.
• Measurements should be taken in the same position each time using a spirit
level and the zero point on the skin surface marked with a cross.
• Check that the catheter is not blocked or kinked and that intravenous fluid
runs freely in, and blood freely out.
• Open the 3-way tap so that the fluid bag fills the manometer tubing (check
there is no obstruction to fluid flow and that the cotton wool in the top of the
manometer is not blocked or wet).
• Turn the tap to connect the patient to the manometer. The fluid level will drop
to the level of the CVP which is usually recorded in centimeters of water
(cmH2O).
• It will be slightly pulsatile and will continue to rise and fall slightly with
breathing - record the average reading.
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 How to measure the CVP?

• An alternative to the manometer and 3-way tap is a butterfly needle inserted

into the rubber injection port of ordinary intravenous tubing.
• In Intensive Care Units or theatres, electronic transducers may be connected
which give a continuous readout of CVP along with a display of the
waveform.
• Useful information can be gained by studying the electronic waveform.
• The CVP reading from an electronic monitor is sometimes given in mmHg
(same as blood pressure).
• The values can easily be converted knowing that 10cmH20 is equivalent to
7.5mmHg (which is also 1kPa) .

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How to measure the CVP?

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 Care of the Central venous Catheter:
 Use an aseptic technique when inserting the catheter and any subsequent
injections or changing fluid lines
 Keep the entry site covered with a dry sterile dressing
 Ensure the line is well secured to prevent movement (this can increase risks
of infection and clot formation)
 Change the catheter if there are signs of infection at the site.
 Remember to remove the catheter as soon as it is no longer needed. The
longer the catheter is left in, the greater the risks of sepsis and thrombosis
 Some people suggest changing a catheter every 7 days to reduce the risks
of catheter related sepsis and thrombosis.
 However, providing that the catheter is kept clean (sterile injections and
connections) and there are no signs of systemic sepsis, routine replacement
may not be necessary.
 Repeated cannulation to change lines on a routine basis, rather than based
on clinical need, can increase the risks to the patient.

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 Complications
The main complications that can arise from central venous cannulation
are listed in table 2. The incidence of each complication varies for each
route described.
Table 2. Potential complications.
Early Late

1)Arterial puncture
2)Bleeding
1)Venous thrombosis
3)Cardiac arrhythmias
2)Cardiac perforation and
4)Injury to the thoracic duct
tamponade
5)Injury to surrounding nerves
3)Infection
6)Air embolism
4)Hydrothorax
7)Catheter embolus
8)Pneumothorax
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 Practical problems common to most techniques of insertion

Table 3 lists some problems that can occur with any of the routes
for central venous access.
Table 3. Problems during CV cannulation
Arterial Usually obvious but may be missed in a patient who is hypoxic or
puncture hypotensive.
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
Suspected site. Obtain a chest radiograph and insert an intercostal drain if
pneumothorax 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.
Usually from the catheter or wire being inserted too far (into the
Arrhythmias
right ventricle). The average length of catheter needed for an adult
during the
internal jugular or subclavian approach is 15cm. Withdraw the wire
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or catheter if further than this.
 Practical problems common to most techniques of insertion:
(continued…)

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
Air embolus 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.
Check that the needle is still in the vein. Flush it with saline. Try
angling the needle so the end of it lies more along the plane of the
vessel. Carefully rotate the needle in case the end lies against the
The wire will not vessel wall. Reattach the syringe and aspirate to check that you
thread down the are still in the vein. If the wire has gone through the needle but
needle 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.
Apply firm direct pressure with a sterile dressing. Bleeding should
Persistent bleeding usually stop unless there is a coagulation abnormality. Persistent
at the of entry severe bleeding may require surgical exploration if there is an
arterial or venous tear
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 Some of the risks of central venous catheterization
Table 4. Some of the risks of central venous catheterization include:
Discomfort can result from the needle stick and placement of the
Pain
catheter at the time it is inserted. Doctors try to lessen the pain with a
during
local numbing medicine (anesthetic like novocaine). The discomfort is
placement
usually mild and goes away once the catheter is in place.
This is called a pneumothorax. The lung is very close to the veins of
the neck or chest. If the needle passes through the vein, it could pierce
the lung causing it to leak and collapse on that side. If this happens,
Collapsed the doctor can place a tube between the ribs into the chest to suck out
lung the air that is leaking from the lungs. This complication is particularly
dangerous when a patient is on a breathing machine. Rarely, collapse
of the lung can cause death. This complication can even happen when
everything is done correctly.
Any tube (catheter) entering the body can make it easier for bacteria
to get in and infect the patient. The longer a catheter remains in the
body, the more likely it is to become infected. Special care in
Infection bandaging the skin at the needle site and changing the connecting
tubes and fluids help to decrease this risk. With great care, these
catheters can remain in the body for several weeks without becoming
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infected.
 Some of the risks of central venous catheterization
cont...)

Bleeding around holes in the veins is usually mild and seals

on its own. Since the major arteries run alongside the major
veins, the arteries can be punctured by accident. Even
Bleeding bleeding from an artery can stop on its own before serious
problems occur. Rarely, the chest fills with blood, which can
be life-threatening. In that situation, it may be necessary to
place a tube between the ribs to drain out the blood .
Blood clots can commonly form in and around these
catheters inside the veins. Such clots usually do not cause
Clotting problems. Once the catheter is removed, the body can often
around the dissolve the clot over time. Sometimes, clots can break off
catheter and travel out into the lungs. This is called a pulmonary
embolism. A blood clot in the lungs can cause breathing
problems and, very rarely, death.
Rarely, air enters the catheter as it is being inserted. The air
Air entering
bubbles can travel through the heart and cause lung injury
through the
and low blood pressure. This problem is called an air
catheter [email protected]
.embolism. Special care is taken to avoid air entry
 Interpretation of the CVP:
• As previously stated, the CVP does not measure blood
volume directly and is influenced by right heart
function, venous return, right heart compliance,
intrathoracic pressure and patient positioning.
• It should always be interpreted alongside other
measures of cardiac function and fluid state (pulse, BP,
urine output etc.).
• The absolute value is not as important as serial
measurements and the change in response to therapy.

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 Interpretation of the CVP:

• A normal value in a spontaneous breathing patient is 5-

10cm water cmH2O, rising 3-5cmH2O during
mechanical ventilation.
• The CVP measurement may still be in the normal range
even with hypovolaemia due to venoconstriction.
• A guide to interpretation is shown in table 4.

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 Interpretation of the CVP: (continued…)
Table 4. Guide to interpretation of the CVP in the hypotensive patient
Other
CVP features that Diagnosis to
Treatment
reading may be consider
present
Rapid pulse
Blood pressure
normal or low Give fluid challenges* until CVP rises and does not fall
Low Low urine Hypovolaemia back again. If CVP rises and stays up but urine output or
output blood pressure does not improve consider inotropes
Poor capillary
refill
Rapid pulse
Signs of
Low or
infection Ensure adequate circulating volume (as above) and
normal Sepsis
Pyrexia consider inotropes or vasoconstrictors
or high
Vasodilation/c
onstriction
Rapid pulse
Low urine Treat as above. Venoconstriction may cause CVP to be
Normal output Hypovolaemia normal. Give fluid challenges* and observe effect as
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Poor capillary above.
 Interpretation of the CVP: (continued…)
Unilateral
breath
sounds
Assymetrical
chest
Tension
High movement Thoracocentesis then intercostal drain
pneumothorax
Resonant
chest with
tracheal
deviation
Rapid pulse
Breathlessness
Third heart
sound
High Pink frothy Heart failure Oxygen, diuretics, sit up, consider inotropes
sputum
Oedema
Tender liver

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 Interpretation of the CVP: (continued…)

Rapid pulse
Very Pericardial
Muffled Pericardiocentesis and drainage
High tamponade
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.

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 Central Venous Pressure waveform:
There are two ways to read a CVP waveform:

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 Central venous Insertion
The aim is to place a catheter into the superior or inferior vena cava,
just above the right atrium.
The sites of choice are the:
- Subclavian vein
- Jugular vein.
These allow easiest access and impede patient mobility least. Other
potential sites are the:
- Brachial vein
- Femoral vein
- Median basilic vein.

For these sites, catheters of varying lengths must be used to

achieve the final position.
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 Hazards of CVP line
insertion
1. Sepsis
2. Hydrothorax
3. Brachial Plexus injury
4. Catheter embolism
5. Air Embolism
6. Haemorrhage
7. Thoracic duct trauma
8. Thrombosis
9. Pneumothorax
10. Haemothorax
11. Misdirection or kinking of the catheter
12. Cardiac Tamponade
13. Cardiac [email protected]
 Access To The Subclavian Vein :

Preparation and positioning: The patient should be supine, both arms

by the sides, with the table tilted head down to distend the central veins
and prevent air embolism. Turn the head away from the side to be
cannulated unless there is cervical spine injury. Normally the right SCV
is cannulated since the thoracic duct is on the left and may occasionally
be damaged during SCV cannulation.
Technique: Stand beside the patient on the side to be cannulated.
Identify the midclavicular point and the sternal notch. The needle
should be inserted into the skin 1cm below and lateral to the
midclavicular point. Keeping the needle horizontal, advance posterior
to the clavicle aiming for the sternal notch. If the needle hits the
clavicle withdraw and redirect slightly deeper to pass beneath it. Do not
pass the needle further than the sternal head of the clavicle.
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Complications: Any of the complications described above can occur but
pneumothorax (2-5%) or rarely haemothorax or chylothorax (fatty white fluid
in the pleural cavity due to leakage of lymph from thoracic duct) are more
common with this route than the others.
Practical problems specific to the subclavian route:
 Keep hitting the clavicle.
 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.
 The catheter tip is not in the chest: Usually detected on chest X-ray, or
if the fluid level in the CVP manometer does not rise and fall with
breathing. A simple test that may increase the suspicion of jugular
placement is to rapidly inject 10ml of fluid into the catheter whilst
listening with a stethoscope over the neck. An audible 'whoosh' or thrill
under the fingers suggests the catheter has entered the jugular vein. If this
is positive, in the presence of a CVP reading which does not change with
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respiration, then the position of the cannula must be questioned.
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 Access To The Femoral Vein:

Preparation and positioning: Abduct and externally rotate the thigh

slightly.

Performance of the technique: Identify the pulsation of the femoral

artery 1-2 cm below the inguinal ligament. Insert the needle about 1cm
medial to the pulsation and aim it towards the head and medially at an
angle of 20-30° to the skin. In adults, the vein is normally found 2-4cm
from the skin. In small children reduce the elevation on the needle to
10-15° since the vein is more superficial.

Complications: Arterial puncture is possible if the needle is directed

too lateral. Femoral nerve damage may follow incorrect lateral insertion
of the needle. Infection is the commonest problem with femoral
catheters and they are not recommended for long-term use.
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Practical problems:
Cannot feel the artery: Try the other side. Check the blood
pressure. Treat any hypotension and retry. If there is no other
venous access then it may be acceptable to try to locate the FV
with a small needle starting medially to avoid the femoral
nerve. Once found, change to the normal needle and continue
the procedure. If the artery is accidentally punctured, apply
direct pressure with your fingers and insert the normal needle
medial to the puncture site.
Cannot locate the vein: Recheck the anatomical landmarks.
It is possible for the femoral vein to be compressed by the
fingers on the artery. Release pressure but leave the fingers
resting on the skin over the artery and retry. Cautiously redirect
the needle closer to the artery and in a more lateral direction.

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 Access To The External Jugular Vein:

Preparation and positioning: The patient should be

supine, both arms by the sides, with the table tilted head
down to distend the central veins and prevent air
embolism. Turn the head away from the side to be
cannulated for better access.
Technique: Stand at the head of the patient and identify
the EJV as it crosses the sternocleidomastoid muscle. If it
is not palpable or visible (see problems) then choose an
alternative vein for catheterisation. Insert the needle in line
with the vein where it is most easily seen or palpated.
Thread the guidewire and then the catheter.
Complications: If the vein is easily seen or palpated this
route carries a very low risk.
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Practical problems:
Cannot see the vein: Ask the patient to take a big breath in
and strain as if trying to go to the toilet (Valsalva manoeuvre).
If mechanically ventilated briefly hold the lungs in inspiration.
Press on the skin above the midpoint of the clavicle where the
vein enters the chest. If none of these make the EJV visible
then use a different vein.
Catheter will not pass into chest: Press on the skin where
the vein enters the chest. Try rotating the catheter or flushing it
with saline as you insert it. If using a guidewire, rotate the
wire when it reaches the bottom of the vein. Try slowly
turning the head in either direction. It may be useful to insert a
normal plastic cannula into the vein first, then thread the
guidewire down this. By doing this, the wire can be pushed,
pulled and rotated without the risk of it being cut which could
occur if the wire is manipulated through a needle.
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 Access To The Internal Jugular Vein :
Preparation and positioning: The patient should be supine, both arms by
the sides, with the table tilted head down to distend the central veins and
prevent air embolism. Slightly turn the head away from the side to be
cannulated for better access (turning it too far increases the risk of arterial
puncture).
Technique: Stand at the head of the patient. Locate the cricoid cartilage
and palpate the carotid artery lateral to it at this level. Keeping a finger
gently over the artery, insert the needle at an angle of 30-40o to the skin and
advance it downward towards the nipple on the same side (in a woman
guess where the nipple would be if she were a man). Always direct the
needle away from the artery under your finger. The vein is usually within
2-3cm of the skin. If the vein is not found, redirect the needle more
laterally.
Complications: With experience this route has a low incidence of
complications. Arterial puncture is easily managed by direct pressure.
Pneumothorax is rare providing the needle is not inserted too deeply.
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Practical problems:
Cannot feel the artery. Check the patient! Try the carotid on
the other side. It is safer to consider a different approach
rather than 'blindly' try to find the jugular.
Arterial puncture. Remove needle and apply firm pressure
over the puncture site for 10 minutes.
Cannot find the vein. Recheck your position. Ensure that
you are not pressing firmly on the artery as this can compress
the vein next to it. Try tipping the patient further head down
if possible. If the patient is hypovolaemic, and central venous
access is not immediately required to correct it, give
intravenous fluids and wait until the veins are fuller. Try
inserting the needle a little closer to the artery but beware of
puncture.
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 EQUIPMENT USED FOR Placing OF
Central Venous Catheter in the
Right Internal Jugular Vein

Central Venous Catheter Kit:

Most of the instruments and
materials needed for placing
a central venous catheter
come in a prepackaged,
sterile “kit.” Opening one
of these kits for the first
time can be overwhelming –
there are many different
needles and hubs and tubes,
and knowing what each
piece in the kit does what
may help for describing the
exact technique.
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Drapes: These are to keep the site of cannulation
sterile and clean, and to provide a sterile field to
place instrument on.

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 Sharps holder (E, below) : This provides a place to stick the needles when you
are done using them, thus lessening the chance of sticking yourself with a
contaminated needle, and without having to go to the sharps box every time a
needle has been used. Note that once a needle has been stuck into the “foam” of
the holder, it should not be used again, because the plastic reside can stick to the
needle and lodge inside the needle tip.
 A 25 or 26 gauge (remember bigger numbers mean smaller needles!) needle
with a small syringe attached and a vial of 1% lidocaine (A,
below) : This smallest needle is used with the lidocaine to numb the area to be
cannulated.
 A 22 gauge “finder needle” with 5ml syringe (B, right) : This needle does just
that; it is used to find the internal jugular vein initially- its small size makes it
safer to use when in the process of locating the vein. If the carotid artery is
inadvertently punctured with this needle, there is a decreased risk of a large
hematoma forming, and other complications arising.
 An 18 gauge IV needle with a catheter hub attached to a 10 ml syringe
(syringe C with catheter D, right) :This is basically an IV set that is used to
create an opening in the vein large enough to pass the guide-wire through. The
soft plastic IV catheter around the needle is left in the vein while the needle is
withdrawn.
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 Tubing ("D" in main photo at top of page): This long clear tubing is used to
test the venous access. The tubing is filled with sterile saline, attached to the IV
catheter lying within the vein and is lifted straight up. If the column of water
drops, the hub is successfully within the vein.

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Guide wire (below) : This is a long, soft, flexible wire that is mounted
in a plastic loop in order to ease the insertion into the hub of the IV
catheter; the wire helps to direct the central venous catheter the vein. It
has a “J” shaped bend on one end to protect the vein once it is
inserted. The central venous catheter will be fed into the vein using this
wire as a lead.

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 A #11 scalpel (below) : This is used to enlarge the entry into the
vein while the guide wire lies within the vein.
 Suture (below): This is used to attach the body of the catheter to the
skin after insertion. It acts as an added safety measure to prevent the
catheter from being inadvertently pulled out.

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Multiple lumen catheter (below on left, top device): This is the
catheter that will be inserted into the vein. This catheter has three
ports, two that open on the side of the cathter tip, and one that opens at
the very end of the catheter.

 Vessel dilator (above on left, bottom device): This is the

blue length of firm plastic that is part of the body of the catheter
while the catheter is being inserted. As its name implies, it dilates
the vein and helps the catheter pass smoothly into the vein. It is
removed after insertion.
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Thank you
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