Clinical paperA new noninvasive method to determine central venous pressure☆
Introduction
Although cardiac filling pressures have their limitations in assessing cardiac preload, central venous pressure (CVP) is frequently used in clinical practice to assess volume status and cardiac preload. Knowledge of a patient's CVP can be helpful in the diagnosis and management of a variety of critical illnesses and injuries including trauma, burns, sepsis, congestive heart failure, cardiogenic shock, traumatic brain injury and others.1, 2, 3, 4, 5, 6, 7 This may become increasingly important as the general patient population ages and patients have a variety of pre-existing chronic disease states such as hypertension, heart failure, diabetes, and chronic obstructive pulmonary disease which may make assessment of haemodynamics even more difficult.
The limitations of the physical examination in estimating volume status and CVP has been clearly shown demonstrating that its accuracy is no better than 50–60%.5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 Consequently, patients are at great risk for clinical misdiagnosis and/or institution of either inadequate or frankly contraindicated therapies, which may result in adverse outcomes. Routine placement of central venous catheters for CVP measurement is impractical and even when indicated can be associated with significant risks.19, 20, 21, 22, 23, 24, 25, 26 Its use in the outpatient setting, is of course, not an option.
For these reasons, numerous methods have been studied and reported which attempt to measure CVP either noninvasively or in a minimally invasive manner.27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 Completely noninvasive methods have not been reported to have the accuracy and precision necessary for routine use and interchangeability with traditional invasively measured CVP. Minimally invasive methods involving cannulating peripheral limb veins or the internal or external jugular vein followed by transducing venous pressure, have met with mixed results with some methods demonstrating the potential for interchangeability with traditional CVP.28, 29, 36, 38 This study reports on the use of a noninvasive methodology of CVP measurement based on the rate of volume change in the upper extremity in response to low pressure cuff inflation and deflation.
Section snippets
Methods
This study was approved by the Virginia Commonwealth University Institutional Review Board. Patients who were having their CVP monitored as a part of their routine care were eligible for enrollment. All central venous access had been obtained from either an internal jugular or subclavian vein site.
A physiologic data acquisition system (MP100 Biopac System Inc., Goleta, CA) was used to monitor the variables of interest continuously. This included CVP, forearm volume changes, and upper arm cuff
Results
A total of 16 subjects were studied (11 males and 5 females). The reasons for CVP monitoring included cardiogenic shock (2), post coronary artery bypass graft surgery (2), severe sepsis (6), trauma (3), and surgical catastrophes (3). Average age was 61 (range from 40 to 82 years). The average forearm circumference was 26 ± 5 cm, the average upper arm circumference was 31 ± 7 cm, the average weight was 79 ± 25 kg, and average body fat was 26 ± 6%. Ten patients had NICVP measured using the right arm and six
Discussion
Although controversy exists as to the value of using cardiac filling pressure as indicators of cardiac preload or circulating volume status, CVP is a frequently used invasive measure in clinical practice to understand and follow a patient's haemodynamic status for diagnostic and treatment purposes. Its true value will not be debated in this report, but as indicated earlier, the physical examination has been demonstrated to perform extremely poorly as a tool to estimate CVP. Unfortunately, it is
Conclusion
The noninvasive determination of CVP performed in this study, may provide clinically acceptable values that potentially may be used in place of invasively measured CVP in both mechanically ventilated and spontaneously breathing subjects. Additional methods of detecting and monitoring changes in arm volume should be explored to make the technique more readily applicable and automated. More study is needed to understand the limitations of this promising method.
Conflict of interest statement
The authors of this study and the Virginia Commonwealth University have filed for intellectual property protection for this noninvasive method of CVP determination.
Acknowledgement
This work was supported by Grant Number 01-02 from the Commonwealth Health Research Board of Virginia.
References (51)
- et al.
Importance of hemodynamic response to therapy in predicting survival with ejection fraction less than or equal to 20% secondary to ischemic or nonischemic dilated cardiomyopathy
Am J Cardiol
(1990) - et al.
The value of pulmonary artery and central venous monitoring in patients undergoing abdominal aortic reconstructive surgery: a comparative study of two selected, randomized groups
J Vasc Surg
(1990) - et al.
Relationship between right and left-sided filling pressures in 1000 patients with advanced heart failure
J Heart Lung Transplant
(1999) Clinical assessment of central venous pressure in the critically ill
Am J Med Sci
(1990)- et al.
Hemodynamic status in critically ill patients with and without acute heart disease
Chest
(1990) - et al.
Hemodynamic profiles of advanced heart failure: association with clinical characteristics and long-term outcomes
J Card Fail
(2001) - et al.
Comparison of clinical signs and hemodynamic state in the early hours of transmural myocardial infarction
Am Heart J
(1982) - et al.
Clinical, radiographic, and hemodynamic correlations in chronic congestive heart failure: conflicting results may lead to inappropriate care
Am J Med
(1991) Physical examination of venous pressure: a critical review
Am Heart J
(1998)- et al.
Estimation of central venous pressure by ultrasound
Resuscitation
(2005)
Correlation of peripheral venous pressure and central venous pressure in surgical patients
J Cardiothorac Vasc Anesth
Noninvasive measurement of central venous pressure by neck inductive plethysmography
Chest
Does inferior vena cava size predict right atrial pressures in patients receiving mechanical ventilation?
J Am Soc Echocardiogr
Estimation of central venous pressure by ultrasound of the internal jugular vein
Am J Emerg Med
A comparison of jugular and central venous pressure measurements during anaesthesia
Br J Anaesth
Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock
Crit Care Med
Traumatic brain injury, hemorrhagic shock, and fluid resuscitation: effects on intracranial pressure and brain compliance
J Neurosurg
Early goal-directed therapy in the treatment of severe sepsis and septic shock
N Engl J Med
The limited reliability of physical signs for estimating hemodynamics in chronic heart failure
JAMA
Effect of pulmonary artery catheterization on outcome in patients undergoing coronary artery surgery
Anesthesiology
The Rational Clinical Examination. Does this patient have abnormal central venous pressure?
JAMA
Hemodynamic assessment in managing the critically ill: is physician confidence warranted?
Med Decis Making
Central venous pressure monitoring for the critically ill in Zambia
Trop Doct
Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients
Crit Care Med
Central venous access catheters: radiological management of complications
Cardiovasc Intervent Radiol
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A Spanish translated version of the summary of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2005.12.013