CENTRAL VENOUS PRESSURE

INTRODUCTION

First described in 1952, central venous catheterization, or central line placement, is a time-
honored and tested technique of quickly accessing the major venous system. Its benefits over
peripheral access include greater longevity without infection, line security in situ, avoidance of
phlebitis, larger lumens, multiple lumens for rapid administration of combinations of drugs, a
route for nutritional support, fluid administration, and central venous pressure (CVP) monitoring.
Central venous catheterization was first performed in 1929. Since then, central venous access has
become a mainstay of modern clinical practice.

DEFINITION
A central venous catheter (CVC), also known as a central line, central venous line, or central
venous access catheter, is a catheter placed into a large vein. It is a form of venous access.
Placement of larger catheters in more centrally located veins is often needed in critically ill
patients, or in those requiring prolonged intravenous therapies, for more reliable vascular access
INDICATIONS FOR CENTRAL VENOUS CATHETERISATION
 Volume resuscitation.
 Emergency venous access.
 Nutritional support.
 Administration of caustic medications (eg, vasopressors)
 CVP monitoring.
 Transvenous pacing wire introduction.
 Hemodialysis
CONTRAINDICATIONS
 Distorted local anatomy (such as for trauma)
 Infection overlying the insertion site
 Thrombus within the intended vein.
 Relative contraindications include coagulopathy
 Hemorrhage from target vessel
 Suspected proximal vascular injury, or combative patients
SITES OF INSERTION
These catheters are commonly placed in veins in the neck (internal jugular vein), chest
(subclavian vein or axillary vein), groin (femoral vein), or through veins in the arms (also known
as a PICC line, or peripherally inserted central catheters).

TYPES OF CATHETERS

Four types of central venous catheter are available

 Non-tunnelled
 Tunnelled (fig 1a),
 Peripherally inserted (fig 1c), and
 Totally implantable (fig 2) catheters.
 Specialist nontunnelled catheters enable interventions such as intravascular temperature
control, continuous monitoring of venous blood oxygen saturation, and the introduction
of other intravascular devices (such as pulmonary artery catheters and pacing wires).
 The catheter type is selected according to the indication for insertion and the predicted
duration of use.
PROCEDURE

 Before the procedure, a discussion should be held with the patient to explain the
procedure, in particular with regard to its benefits, risks, and complications. Signed
informed consent must be obtained.

Articles
Equipment required for central venous access via the subclavian (or infraclavicular or
subclavicular) approach to the subclavian vein includes the following:
 Central venous catheter tray (line kit)
 Sterile gloves
 Antiseptic solution with skin swab
 Sterile drapes or towels
 Sterile gown
 Sterile saline flush, approximately 30 ml
 Lidocaine 1% (obtain additional vial of lidocaine 1% if needed)
 Gauze
 Dressing
 Scalpel, No. 11
 Place the patient in the supine position. If possible, the bed should be raised to a height
that is comfortable for the operator, so that bending over will be unnecessary. Do not
place towels between the shoulder blades or turn the head; these have been shown to
decrease the size of the subclavian vein. 
 Place the patient in 15º of Trendelenburg position to reduce the risk of air embolism.
Increasing this angle does not alleviate vessel distention, because the subclavian vein is
fixed within surrounding tissue.
 Position the patient. Identify anatomic landmarks (including the clavicle, the
deltopectoral groove, and the sternal notch) to facilitate appropriate insertion of the
needle .
 Numerous landmarks have been described for determining the needle insertion site. The
following are some of the options mentioned, any of which will work:
 1 cm inferior to the junctions of the middle and medial third of the clavicle
 Inferior to the clavicle at the deltopectoral groove
 Just lateral to the midclavicular line, with the needle perpendicular along the
inferior lateral clavicle.
 One fingerbreadth lateral to the angle of the clavicle
 Open the line kit, and position the equipment so that it is easy to reach. One may want to
retract the curved J-tip wire into the plastic loop sheath to facilitate direction into the
introducer needle. Also, uncap the distal lumen, which is commonly the brown lumen.
 Prepare the insertion site with the iodine or alcohol solution provided in the kit. This
amount of preparation is often inadequate, and a wide area around the insertion site
should be liberally prepared with 4 × 4 in. (10 × 10 cm) gauze soaked in a povidone-
iodine solution.
 Prepare the neck as well, in case the subclavian approach fails and another approach must
be attempted.
 Put on sterile mask, gown, and gloves. Drape the patient in a sterile fashion, with the
insertion site exposed. Using a generous amount of lidocaine 1%, infiltrate the skin,
subcutaneous tissue, and, possibly, the clavicular periosteum.
 Position the bevel of the introducer needle in line with the numbers on the syringe. Upon
insertion, orient the bevel to open caudally; this facilitates smooth caudal progression of
the guide wire down the vein toward the right atrium.
 Insert the introducer needle at the desired landmark while gently withdrawing the plunger
of the syringe.
  Advance the needle under and along the inferior border of the clavicle, making sure that
the needle is virtually horizontal to the chest wall.
 Once under the clavicle, the needle should be advanced toward the suprasternal notch
until the vein is entered. If the vein is difficult to locate, remove the introducer needle,
flush it clean of clots, and try again.
 Change insertion sites after three unsuccessful passes with the introducer needle.
 When venous blood is freely aspirated, disconnect the syringe from the needle,
immediately occlude the lumen to prevent air embolism, and reach for the guide wire.
 Insert the guide wire through the needle into the vein with the J-tip directed caudally to
improve successful placement into the subclavian vein.
 If the kit used is one that allows the wire to be placed directly through a port on the
syringe, then it is not necessary to disconnect the syringe.
 Be aware that disconnecting the syringe gives the added benefit of allowing verification
of nonpulsatile flow of venous blood.
 Advance the wire until it is mostly in the vein or until ectopy is seen on the cardiac
monitor.
 Then, retract the wire 3-4 cm holding the wire in place, withdraw the introducer needle
and set it aside.
COMPLICATIONS
 Immediate: Failure of procedure. Pneumothorax. Haemothorax. Retroperitoneal
haematoma. Arterial puncture
 Early: Catheter blockage. chylothorax. catheter knots.
 Late: Infection, catheter fracture, vascular erosion, vessel stenosis,thrombosis.

CVP MONITORING
DEFINITION
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 lumen central line 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.
INDICATIONS
 Measurement of right heart filling pressures to assess intravascular volume and right
heart function.
 Drug administration to the central circulation.
 Intravenous access for patients with poor peripheral access.
 Indicator injection for cardiac output determination.

ARTICLES
 Normal Saline 500 ml
 3 way
 CVP scale – 2
 100 cm extension
PROCEDURE
 Inform patient regarding procedure
 Wash hands and apply gloves
 Position client in supine or flat position with no pillows under head mask the level of
right atrium in the 4th intercostals space with an “X” mark using indelible ink pen.
 Fix manometer on an IV pole such that it is zeroed at the X-mark
 Connect IV fluid (usually normal saline) to a three way stop cock and flush the other
two ports
 Apply sterile gloves and mask
 Connect CVP tubing monometer to the upper port of the stop cock
 Connect CVP tubing from the client to the second side port of the cock.

 Turn stopcock off to client and fill monometer with normal saline to the 20cm mark
above the anticipated reading.

 Hold manometer at the phlebostatic axis and turn the stopcock off to the normal
saline.

 Watch as the fluid falls in the manometer take the central venous pressure reading
when the fluid stabilizes
 Turn the stop cock off to the manometer
  Reposition the patient.
 Keep the monometer in an upright position to prevent air bubbles from client and to
prevent contamination of the manometer.
 Wash & dry hands.
 Document the reading obtained in the client’s medical record.

NURSES RESPONSIBILITY
 Monitor  Assess for patency
 Watch for the signs of complications.  
 CVP  Sterile dressing should be done to prevent infection
 CVP  The length of the indwelling catheter should be recorded and
 Regularly care per the hospital protocol

AV FISTULA
Introduction
A surgeon connects an artery to a vein, usually in your arm, to create an AV fistula. The AV
fistula is a blood vessel made wider and stronger by a surgeon to handle the needles that allow
blood to flow out to and return from a dialysis machine.
Definition
Subcutaneous anastomosis (communications) of an artery to a vein, allowing blood flow directly
moves from artery to vein.
  Usually the anastomosis is made at the wrist between the radial artery and the cephalic
vein
Advantages of AVF
 Lower risk of infection
 Lower tendency to clot - fewer 2ry interventions
 Lower hospitalization rates (lower complication rates ,lower morbidity and mortality)
 Allows for greater blood flow
 Long-term patency (improved performance with time)
 Less cost of implantation and maintenance
Disadvantages of AVF
 Slow maturation and failure of maturation
 More difficult to needle.
 Increase in size with age and aneurysm formation.
 Cosmetic appearance of dilated veins.
Types of common arteriovenous fistula according to method of anastomosis

Types of common arteriovenous fistula according to its site in the upper limb
Forearm
AVF
 Radial artery to cephalic vein
 Radial artery to basilic vein
 Radial artery to any other transposition
Arm AVF
 Brachial artery to cephalic vein
 Brachial artery to basilic vein
 Brachial artery to any other transposition
Pre-operative care in hand for AVF
 This begins as soon as finish vascular assessment and site for access was decided.
 Don’t insert peripheral IV catheters or cardiac pacemaker
 Don’t use for blood draws or IV drugs.
 Don’t use for taking blood pressure or try any surgical procedures
 Surgeon may ask for duplex ultrasound.
Post-Operative care of AVF or AVGs
Immediately following surgery (half-hourly at first),the site of AVF should be checked for :
 Excessive bleeding, haematoma, swelling, pain and later signs of infection such as raised
temperature.
 Check radial pulse, colour, movement, warmth, and sensitivity of affected limb to ensure
blood flow reaches extremities (peripheral circulation).
 Assess the access patency: palpate (thrill) or listen (bruit)
 Monitor BP and hydration status, to prevent access clotting.
 Elevate the access arm to help minimize oedema and swelling.
 Assess patient for pain
 Report any abnormality to medical team ASAP
Patient Education (Daily Care)
 Good fistula care will help maintain the patency of the vascular access.
 Education is the responsibility of the nurse
 Check the thrill at least once daily
 Avoid tight clothing , jewellery or watch
 Avoid carrying heavy object
  Avoid exposure to extremes of heat/cold
 Avoid check BP, venipuncture or IV drugs , sleeping on the access arm
 Use the access site only for dialysis
 Wash the access with soap and water pre-dialysis

 Signs of infection (pain, swelling, rednes)