Anita F. LopesMSN,BSN,RN

ABP AND CVP MONITORING

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CENTRAL VENOUS

PRESSURE MONITORING

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MEANING

The Central venous pressure (CVP) is the pressure in the vena cava or the right atrium, is used to assess right ventricular functioning and venous blood return to the right side of the heart . This pressure reflects the right ventricular pre load.

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SITES FOR INSERTION OF CVP CATHETERS

Subclavian veinInternal or external jugular vein

Median basalic veinFemoral vein

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INDICATIONS

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Rapid administration of IV fluids and blood products in patients with any form of shock

Administration of vasoactive and Inotropic drugs

Administration of parental nutrition, electrolytes or hypertonic solutions

Venous access of monitoring CVP and assessing the response to fluid or vasoactive drug therapy

Insertion of intravenous pacemaker Lack of accessible peripheral veins Hemodynamic instabilityTo obtain blood sample

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Relative contraindication Coagulopathies and bleeding disorder (monitor

platelet count, PT/PTT )Current or recent use of fibrinolytics or

anticoagulantsInsertion sites that are infected or burned, or

where previous vascular surgery has been performed, or involve catheter placement through vascular grafts

Patients with a high risk of pneumothorax (such as those with COPD, or those on mechanical ventilation with high PEEP or CPAP

Patient with suspected or confirmed vena cava injury9

CENTRAL VENOUS WAVEFORM

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Patient Position

Zeroing of transducer

Patency drip

Series of readings

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PHLEBOSTATIC AXISThe approximate anatomic location of the

right atrium, located at the fourth intercostal space, halfway between the anterior and posterior chest wall.

The purpose of leveling is to line up the air fluid interface with left atrium to correct for changes in hydrostatic pressure in blood vessels above & below the level of the heart.

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Aspects of leveling and zeroing

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Hydrostatic pressure This pressure is result in the combination of

factors that include gravity height and weight of the fluid column, fluid density and position of the transducer

Atmospheric pressure This is the force that exerted at the earth’s

surface by the weight of air that surrounds the earth

LEVELLINGPLACE MENT OF THE TRANCDUCER AT THE EXACT HEIGHT OF THE PHLEBOSTATIC AXIS IS LEVELLING.

WHY?To eliminate effects of hydrostatic pressure in the

transducer.When to level?

Level before and after the pressure system is attached to the patient

After any change in bed height / patient positionChange in waveforms and its valuesWhen the system is disconnectedAt the beginning of each shift

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ZEROING ZEROING IS DONE SO AS TO ELIMINATE THE EFFECT OF ATMOSPHERIC PRESSURE ON THE TRANSDUCER, USING ZERO TO REPRESENT THE CURRENT ATMOSPHERIC PRESSURE .

It is required to negate the effects of the atmospheric pressure.

Done before and after the pressure system is attached to the patient

When significant change in waveforms and values is noted

When the system is disconnectedAt the beginning of each shift

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TRANSDUCERThe transducer is a device that converts

the pressure waves generated by vascular blood flow into electrical signals that can be displayed on electronic monitoring equipment.

The transducer cable attaches the transducer to the monitor, which displays a pressure waveform and numeric readout.

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Care of patient with central line

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Assessment PatencyMonitor CVP in every shift (normal CVP 2 –

8 mm of hg or 5 – 10 cm of water)Change the dressingMaintain pressureDocumentation

REMOVAL OF CENTRAL VENOUS LINE

Keep Suture Removal tray ready/Wash hands/ Explain Procedure/Disconnect Fluids.

Give Position to patient (Supine to 45 degree)Wear Gloves/Remove the dressing/ Clean site with

normal saline. Using an aseptic technique cut the stitches

holding the central venous catheter in place.Explain and ask patient to perform the Valsalva

manoeuvre and/or hold his or her breath during catheter removal and/or time catheter removal to coincide with end inspiration/beginning expiration.

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REMOVAL OF CENTRAL VENOUS LINEUse one hand to cover the insertion site with sterile

gauze swabs and with the other hand firmly but gently remove the catheter. Apply gentle pressure as catheter is being removed, taking care not to massage the exit site. If resistance is felt stop and contact medical staff. •

Once the catheter is removed press firmly with sterile gauze swabs until haemostasis is achieved (approximately five minutes)

Apply air-occlusive dressing which should remain in place for at least 24 hrs

The catheter tip should be sent for culture and sensitivity if patient shows signs and symptoms of infection, as per hospital protocol.

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ARTERIAL BLOOD PRESSURE

MONITORING22

MEANING Insertion of a catheter into an artery for direct measurement of systolic , diastolic and mean arterial pressure (MAP).

MAP = SBP+(2xDBP)3

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INDICATIONFailure of direct arterial blood pressure

measurement; cuff BP is unreliable.Hypotension : continuous monitoringMajor surgeries including bypass surgeriesCritically ill patientsIntra aortic balloon pumpExcessive peripheral vaso constrictionFrequent blood samplesIonotrope administrationDetermination of volume responsiveness from

systolic pressures or pulse pressure variation Supplementary diagnostic information from

arterial waveform24

SITES FOR INSERTION OF CATHETERSRadial arteryUlnar arteryFemoral arteryDorsalis pedis arteryBrachial arteryAxillary artery

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ALLEN’S TEST

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ARTERIAL WAVEFORMSystolic wave - rapid ejection of blood into the aorta

Dicrotic notch - closure of aortic valve & end of systole

Diastolic wave - resistance in

the vessel valves 28

WAVE FORM OF INTRA ARTERIAL BLOOD PRESSURE MONITORING

SYSTOLIC WAVE

DICROTIC NOTCH DIASTO

LIC WAVE

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TROUBLE SHOOTINGS

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PROCEDURE Pre- procedurePrepration of nurseAssemble all the equipmentsPrepare a transducer kit.Explain the procedure to the patient & ensure

informed consent is obtainedMaintain proper position, draping. Skin preprationAsk for any history of allergiesLocal anesthesia before procedureMonitor lab values( PT/PTT, Hb, CBC, )Post procedure chest X ray

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PREPRATION OF PATIENT

Maintain proper positionLimited movement to prevent injury & maintain

sterile fieldAttachment to cardiac monitorDo Allen’s test

PREPRATION OF ENVIRONMENTAdequate lightingPrivacy

PREPRATION OF ARTICLES32

ARTICLES

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Supplies to GatherArterial Catheter

Pressure Tubing

Pressure Cable

Pressure Bag

Flush – 500cc NS

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Supplies to GatherSterile Gown (2)

Sterile Towels (3)

Sterile Gloves

Suture (silk 2.0)

Chlorhexidine Swabs

Mask

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DURING PROCEDUREMonitor vitals Monitor the waves, ECG.Attach transducer kit & check the wave

formMonitor the CVP .

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POST PROCEDURE Position the patientDo Chest X-rayRecord and report the procedureAdminister medicines and chart it.Care of site, sutures and label it .Monitor vitals Replace articlesWatch for bleedingAvoid kinking of catheterWatch for trouble shooting errors.Monitor of complicationsChange of dressings as prescribed

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COMPLICATIONS OF CATHETERS :CVC AND CATHETERS:PNEUMOTHORAXHEMOTHORAXAIR EMBOLISMHEMATOMACARDIAC TAMPONADEINFECTIONAIR EMBOLISM CENTRAL VENOUS THROMBOSIS

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ARTERIAL LINE :Blood loss (200 ml in 4-5 min)HematomaInfectionAir embolismUlceration Gangrene leading to amputationThrombus formationArterial spasmsPseudoanuerysmsExtravasationVascular insufficiency

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