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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