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Prepared by : Mrs. Sohad Noorsaeed, RN,MSN
Objectives: Identify central venous catheter and its purposes.
Illustrate the anatomical insertion sites.
Recognize the central venous catheter equipment’s.
Demonstrate line set up, measurement,, and nursing care.
Outlines: Indications of central venous catheter.
Overview for possible insertion sites.
Advantages and disadvantages for each insertion site.
Overview of commonly used equipment.
Manometer and Transducer measurement methods.
Normal range for CVP and reading implications.
Nursing care and considerations.
Contraindications and Complications.
Introduction - Central venous catheter (CVC)is one of the
invasive hemodynamic monitoring through
insertion of the catheter in large vein to right
atrium (tip of catheter should be in the right
atrium) , it is used to provide a good assessment
of right side cardiac function, indirect method to
determining right ventricles filling pressure
(preload).
Purposes of central venous catheter : • Serve as a guide for fluid replacement and
medication administration in critically ill patients. • Monitor the pressure and volume in the right
atrium. • Obtain venous access when peripheral vein sites
are inadequate. • Administer blood product(frequent need with
poor peripheral access) and TPN. • Insert pacemaker. • Obtain blood sample.
Insertion Sites: Measuring central venous pressure(CVP) requires
insertion of a catheter in to large central vein:
Internal jugular vein.
Subclavian vein.
Femoral vein.
Internal jugular veins: This site is chosen
frequently as there is a high rate of successful insertion and a low incidence of complications. Internal jugular veins are short, straight and relatively large allowing easy access.
however, catheter occlusion may occur as a result of head movement and may cause irritation in conscious patients.
:Subclavian veins This site is often chosen as
there are more recognizable anatomical landmarks, making insertion of the device easier.
A subclavian CVC is generally recommended as it is more comfortable for the patient.
Because this site is positioned beneath the clavicle there is a risk of pneumothorax during insertion.
Femoral veins: This site provides rapid
central access during an emergency such as a cardiac arrest.
As the CVC is placed in a vein near the groin there is an increased risk of associated infection.
reported to be uncomfortable and may discourage the conscious patient from moving.
Equipment: Manometer or Monitor with Pressure cable and pressure
bag.
Transducer line (tubing) and holder for the monitor method.
1 liter normal saline (Heparinized).
3-way stopcock (usually comes with the CVP insertion kit).
Wards generally use manometers.
Note: Both CVP measurement methods are reliable
when used correctly.
The transducer is used to convert the pressure from right
atrium into electrical signal (Accident and Emergency
departments, High Dependency areas and Intensive Care
units use transducers for measuring CVPs).
Tranduced CVP
waveform
Nursing role( Preparatory phase) : Explain procedure to the patient and obtain consent
Evaluate patient PT,PTT,CBC before procedure
Position patient appropriately:
Place patient in trendelenburg position (the body is laid flat on the back
(supine position) with the feet higher than the head by 15-30 degrees ) this position promote the venous return and facilitate the insertion .
Prepare the insertion site(shaving, cleaning)
Establish sterile field on table
Prepare 3 ml syringe and 25 G needle using sterile technique for lidocain injection
Prepare the I.V administration set
Zero transducer & level port with patient right atrium.
Place ECG monitoring.
Trendelenburg position
:Performance phase ( by physician ) The CVP site is surgically cleaned Ask the patient to do valsalva
maneuver during insertion to increase the intrathoracic pressure and decrease the risk of air embolism.
Monitor for dysrhythmias, tachypnea,
tachycardia. Connect primed IV tubing to catheter and
allow IV solution to flow (regular flushing with NS containing heparin) why?
The catheter should be sutured in place. Place a sterile transparant occlusive
dressing over site. Obtain a chest x-ray.
Line set-up: If the insertion happened while you are
present, you should prime IV line to be
attached to the catheter. Heparinized IV
solution is often used to maintain the patency
of the catheter. “ check the hospital policy”.
Demonstration.
CVP measurement:
Phlebostatic
axis
CVP is usually recorded at the phlebostaticaxis
(Zero level), This is where the fourth intercostal
space and mid-axillary line cross each other
allowing the measurement to be as close to the
right atrium as possible.
Patient Positioning: Place the patient flat in a supine position if
possible. Alternatively, measurements can
be taken with the patient in a semi-
recumbent position. The position should
remain the same for each measurement
taken to ensure an accurate comparable
result.
Explain the procedure to the patient to gain informed consent.
If IV fluid is not running, ensure that the CVC is patent by flushing the catheter.
1) Using Manometer:
Line up the manometer arm with the
phlebostaticaxis ( Zero level).
Turn the three-way tap off to the
patient and open to the
manometer.
Open the IV fluid bag and slowly fill the manometer to a level higher than the expected CVP.
Turn off the flow from the fluid
bag and open the three-way
tap from the manometer to the
patient.
The fluid level inside the manometer
should fall until gravity equals the
pressure in the central veins.
When the fluid stops falling the CVP
measurement can be read. If the fluid
moves with the patient's breathing, read
the measurement from the lower number.
Turn the tap off to the manometer.
Document the measurement and report any changes or abnormalities.
Normal Range of CVP:
5-12cm H2O using manometer or 2-6mmHg using transducer
(monitor); when taken from the mid-axillary line at the fourth
intercostalspace.
If increased (hypervolemia) ;decreased (hypovolemia).
2) Using Transducer: Explain the procedure to the patient to gain informed consent. The CVC will be attached to intravenous fluid within a pressure bag. Ensure that the pressure bag is inflated up to 300mmHg.Place the patient flat in a supine position if possible.
Catheters differ between manufacturers, however, the white or proximal lumen is suitable for measuring CVP.
Tape the transducer to the phlebostaticaxis or as near to the right atrium as possible.
Turn the tap off to the patient and open to the air by removing the cap from the three-way port opening the system to the atmosphere.
Press the zero button on the monitor and wait while calibration occurs.
When 'zeroed' is displayed on the monitor, replace the cap on the three-way tap and turn the tap on to the patient.
Observe the CVP trace on the monitor.
Post care:
Patient: Return the patient to comfortable position.
Nurse: Hand wash.
Environment: Return equipment.
Documentation: Document the reading.
Contraindications : Patients who have a severe infection or sepsis
Patients having Coagulopathic conditions
Patients who have had thrombolytic or anticoagulant therapy
Patients with superior vena cava syndrome.
Patients with tumor or thrombus in the right atrium.
Complications:
• Bleeding
• Pneumothorax
• Air Embolism
• Thrombus formation
• Infection or sepsis
• Other vessel or organ perforation
Special considerations:
After the initial CVP reading ,reevaluate reading frequently to
establish abase line for the patient
Chang I.V solution every 24 hours according to hospital policy.
Care for the insertion site according to your facility policy, and
observe for signs of infection.
References: Nettina S. The Lippincott Manual of Nursing
Practice. 8th Edition, Williams &Wilkins Lippincott, 2006
Hand book of Clinical Procedure for Medical Surgical I.
Elaine Cole: Senior lecturer ED/Trauma, City University
Bartsand the London NHS Trust.
Thank you
