Elsevier

Resuscitation

Volume 70, Issue 2, August 2006, Pages 238-246
Resuscitation

Clinical paper
A new noninvasive method to determine central venous pressure

https://doi.org/10.1016/j.resuscitation.2005.12.013Get rights and content

Summary

Knowledge of central venous pressure (CVP) is considered valuable in the assessment and treatment of various states of critical illness and injury.

Objectives

We tested a noninvasive means of determining CVP (NICVP), by monitoring forearm volume changes in response to externally applied circumferential pressure to the upper arm veins.

Methods

Sixteen patients who were undergoing CVP monitoring as a part of their care had NICVP determined and compared with CVP. Volume changes were measured in the forearm with mercury-in-silastic strain gauge plethysmography. A pressure cuff is placed in the upper extremity. The cuff is inflated over 5 s to a pressure above CVP but below diastolic arterial pressure (40 mmHg). This allows blood into the forearm but prevents venous return. After 45–60 s the cuff is rapidly deflated. NICVP was determined as the cuff pressure noted at the maximum derivative of the forearm volume decrease during deflation. NICVP was then compared to invasively measured CVP taken during the same period.

Results

A total of 48 trials (three per subject) were performed on 16 patients. The range of CVP recorded was 0–22 mmHg. The correlation between CVP and NICVP was 0.98 (95% CI: 0.95–0.98) (p < 0.001). The bias between methods was 0.26 mmHg with the limits of agreement being 3.4 to −2.89 mmHg. When the average of three trials per patients was analysed the bias stayed at 0.26 mmHg but the limits of agreement improved to 2.54 and −2.03 mmHg.

Conclusion

NICVP as determined in this study may be a clinically useful substitute for traditional CVP measurement and may offer a valid tool for early diagnosis and treatment of acute states in which knowledge of CVP would be helpful.

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.

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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

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