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ask an expert

Understanding the
phlebostatic axis
By Chelsea Iversen, MS, RN
Trauma ICU RN Erie County Medical Center Buffalo, N.Y.

Q: Whats the phlebostatic axis and what The device should be zeroed once each
Accurate does it mean when monitoring my pa- day and whenever the accuracy of a read-
measurements tients vital signs? ing has been called into question. Zeroing
are our aim! A: Venous and arterial catheters provide of the device with the patient in an impro-
the most accurate method for hemodynamic per position can lead to inaccurate mea-
monitoring. The nurse must be confident surements. A backrest position of less than
that central venous pressure (CVP) and or equal to 60 degrees with the patients
arterial BP measurements are accurate. back flat against the surface of the bed
The phlebostatic axis is the reference point wont compromise the accuracy of the
for zeroing the hemodynamic monitoring reading. Positioning a patient in a
device. This reference point is important 90-degree lateral position is the only
because it helps to ensure the accuracy of acceptable side-lying position that wont
the various pressure readings. Nurses must affect the reading.
ensure the accuracy of their hemodynamic In this case, the reference points for zero-
monitoring devices. ing the pressure monitoring system change.
Several factors can produce artifacts that In a right lateral position, at 90 degrees with
decrease the accuracy of pressure moni- the backrest flat, the zeroing reference point
toring, which establishes a risk of error in is the intersection of the fourth intercostal
patient management. These factors include space and midsternum. In a left lateral posi-
the length of the pressurized I.V. tubing tion, at 90 degrees with the backrest flat, the
(4 foot-long tubing is preferred to facilitate zeroing reference point is the intersection of
accurate placement and zeroing of devices), the fourth intercostal space and the left para-
air bubbles in the system, and incorrect sternal border.
placement of the device stopcock at an inac- Continuous and accurate hemodynamic
curate reference point. Understanding the measurements may be lifesaving for criti-
phlebostatic axis, particularly its importance cally ill patients. Improper use endangers
as a reference point for stopcock placement, patient outcomes.
helps to ensure accurate readings.
With the head of bed at 60 degrees or
less, the phlebostatic axis is located at the Learn more about it
Bridges EJ. Pulmonary artery pressure monitoring:
fourth intercostal space at the mid-anterior- when, how, and what else to use. AACN Adv Crit Care.
posterior diameter of the chest wall. 2006;17(3):286-303.
This is the location of the right atrium, Cheatham ML. Hemodynamic monitoring: principles to
practice. http://www.surgicalcriticalcare.net/Lectures/
where the tip of a CVP catheter would PDF/hemodynamic%20monitoring%20principles%20
lay. Maintaining the device stopcock at to%20practice.pdf.
the phlebostatic axis will help ensure a Leeper B. Obtaining valid hemodynamic measures:
evidence-based practice. http://www.aacn.org/DM/
proper reading. If the stopcock is posi- CETests/Overview.aspx?TestID=651&mid=2864&Item
tioned below the phlebostatic axis, the ID=64.
The author has disclosed that she has no significant rela-
readings will be erroneously high; if above tionship with or financial interest in any commercial com-
the phlebostatic axis, the readings will be panies that pertain to this educational activity.
erroneously low. Either error can lead to
mismanagement of patients and their care. DOI-10.1097/01.NME.0000403195.75792.a4

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