INTENSIVE CARE SERVICE NURSING POLICY & PROCEDURES

NAME OF POLICY: CENTRAL VENOUS PRESSURE MONITORING GOAL: TO EVALUATE RIGHT-SIDED HEART FUNCTION
Introduction: The central venous catheter is used to obtain intermittent or continuous central venous pressure (CVP) to evaluate right-sided heart function. The CVP catheter is inserted into a large vein by percutaneous or cutdown method. The most common sites for insertion are the jugular (internal or external), subclavian, basilic or femoral veins. Once the catheter is inserted, it is placed so that the tip ends in the superior vena cava, approximately 2cm above the right atrium. The catheter may be single or multilumen, often the choice will be dependent on the amount of medication and fluids required. NB. The distal lumen of the CVP catheter must be labelled at all times to identify that the catheter is venous by connecting the blue coloured transducer tubing. If this is not available a CVP sticker included in the transducer pack must be attached to the distal lumen on the Central line. Equipment: Sterile pack (gown/drape) Trolley Sterile gloves Occlusive dressing Antibacterial solution/swabs (chlorhexidine) Ampoule of normal saline 2ml/10ml syringe 25 gauge needle 21 gauge needle (drawing-up) Suture material 2.0 silk on straight needle Local anaesthetic: Lignocaine 1% Transducer set with blue CVP line or if not available CVP lumen must be labelled/pressure bag 500mls preloaded heparin (1KU) CVP catheter pack (2,3,4 lumen choice) 3/3-way taps The Site Right may be required to locate appropriate vessel Pre-Procedure: Adhere to universal precautions Inform patient and significant other if applicable Inform patient that: head will be covered for the procedure if applicable Ensure all emergency equipment is in working order Patient is continuously monitored Consider pain relief if applicable

ROYAL PRINCE ALFRED HOSPITAL INTENSIVE CARE SERVICE

Prime transducer, zero to atmospheric air, connect cable to transducer and select CVP with appropriate scale Position patient supine with head down (prevents air embolism) Assist the medical officer with the above procedure then follow the responsibilities below. Post-procedure: Order a Chest x-ray to confirm placement of catheter (do not infuse any fluid into the catheter until confirmation of placement has been made by the MO.)

The distal lumen must be transduced immediately with the blue coloured pressure tubing to confirm venous placement using the waveform analysis. The distal lumen (brown) is the preferred choice of lumens.
Adjust scale and set appropriate alarm parameters Allow patient back into semi-fowlers position if applicable Ensure line and insertion site is free of tension Nursing responsibilities: Observe every shift for signs of infection (redness, swelling, pain, pus) Rezero transducer every shift to atmospheric air and ensure no air/bubbles/kinks are in the system Ensure bag is inflated to 300mmHg (3mls/hr) and check fluid level in the bag

Because the CVP may fluctuate, analyze values for trends rather than attaching great significance to isolated values. The CVP value should be interpreted in conjunction with the patients clinical status and history. The waveform may fluctuate with respirations; readings should be taken at end-expiration to minimize the influence of intrathoracic pressure. Increased CVP may be caused by fluid overload or retention, tricuspid or pulmonic valvular disease, or ventricular septal defect with left-to-right shunting. Hypovolemia, excessive diuresis or systemic vasodilation secondary to sepsis, drugs or Neurogenic causes may cause a decreased CVP Use the picture above to locate the phlebostatic axis Be consistent in position when reading the CVP (lay patient supine or at 30 degrees) Use 30 head up in head injured patients

ROYAL PRINCE ALFRED HOSPITAL INTENSIVE CARE SERVICE

Ensure the distal (brown) lumen is used whenever possible Ensure no fluid/medication is running through the lumen when reading the waveform Waveform interpretation: Normal CVP ranges from 5-10cmH20 or 2-6mmHg The mean pressure is monitored because the right atrium is a low-pressure chamber. The waveform has systolic (positive) and diastolic (negative) variations, but the fluctuations are small, therefore the mean is used.

The a wave indicates right atrial systole; it is followed by the x decent, which indicates the drop in pressure that occurs during right atrial relaxation. The c wave, which may not be distinguishable on the waveform is caused by bulging of the closed tricuspid valve into the atrium during right ventricular systole; the x decent following the c wave. The v wave indicates right atrial diastole, when blood is filling the atrium; it is followed by the y decent, which indicates the passive right atrial emptying of blood into the right ventricle through the open tricuspid valve. Various changes in the CVP waveform can indicate pathophysiological changes in the heart and pulmonary vasculature. An elevated a wave is seen in tricuspid stenosis, right ventricular hypertrophy secondary to pulmonic valve stenosis, or pulmonary hypertension, constrictive pericarditis and cardiac tamponade, all of which impede right atrial emptying. An elevated v wave is caused by tricuspid insufficiency, with backflow of blood into the right atrium during ventricular systole thus causing an increase in pressure. Tricuspid insufficiency can also cause an absence of the c wave, since the valve is incompetent and will not bulge back into the right atrium during ventricular systole. Cannon waves (combined a and c waves) occur whenever the atrium contracts against a closed valve; for example, when junctional or ventricular beats occur, the atria contract out of sequence and the valve is closed because of ventricular systole. The cannon waves are large and obscure the v wave,

ROYAL PRINCE ALFRED HOSPITAL INTENSIVE CARE SERVICE

Change of line and dressing: Every 72hr (The catheter is change every 7 days) Use aseptic technique Adhere to universal precautions Inform patient and significant others if applicable Dressing pack Antiseptic solution/swabs (chlorhexidine) Appropriate number of 3-way taps Coloured Transducer with blue pressure tubing set to identify that the catheter is venous (prime prior to dressing change) 500mls preloaded heparin bag Occlusive clear dressing Whenever lumens are not in use or when patient transfer is required, heparin lock the lumen as follows: Use 50units in 5mls of heparinised saline, inject 3mls into lumen via the 3-way tap Label lumen with date/time/amount of heparin used. Within the ICU/HDU a pressurized flush device may be used to keep the line patent Procedure: Remove soiled dressing Clean area with antiseptic solution Apply new occlusive dressing ensuring no tension on the line or insertion site Observe of signs of infection (see above) inform RMO if required Record time and date of change on Careplan Discard old line appropriately Removal of CVP: Inform patient and significant other if applicable Assemble equipment as for line change above plus stitch cutter Place Patient in Trendelenburg position to prevent air embolism from jugular or subclavian veins If applicable instruct the patient to hold a breath and remove the catheter slowly, observe for dysrhythmias if monitored Apply pressure with gauze to site until bleeding has subsided Apply occlusive dressing Send catheter tip to appropriate laboratory for culture and sensitivity analysis Record time and date of removal Observe the site frequently for bleeding or haematoma Removal of blood sampling: Wash hands/adhere to universal precautions Isolate the distal lumen (brown) ensure no fluid is infusing With 5mls syringe insert to 3-way tap, withdraw 5mls and discard Apply 10/20mls syringe to 3-way tap and withdraw appropriate specimen amount Inject blood into appropriate laboratory tubes Flush lumen and close tap Complication of a central venous catheter: Pneumothorax or haemothorax. Xray is required to rule this out Hydrothorax can occur if large amounts of fluids are infused through the catheter before a radiograph rules out the possibility of a pneumothorax Catheter migration may move forward to the right ventricle and irritate the endocardium, causing ventricular dysrhythmias. If the tip migrates far enough that the heart wall is perforated, cardiac tamponade can result if bleeding into the pericardial sac occurs Infection Air embolism

ROYAL PRINCE ALFRED HOSPITAL INTENSIVE CARE SERVICE

REFERENCES: Diethorn, M. L. et al (1993). Monitoring Critical Function. Springhouse Corporation. Stillwell, S. B. (1999) critical Care Nursing Reference. Mosbys, St Louis Bucher, L & Melander, S. (1999). Critical Care Nursing. W. B. Saunders company, Philadelphia
Occupational Health and Safety: Universal precautions taken in the preparation, administration of drug and disposal of equipment and sharps. Cross Referenced: RPAH Occ. Health & Safety Manual and Infection Control Manual NSW Infection Control Policy 98/99 Revised by: Chanelle Innes, CNC, February 2003 Authorised and reviewed by: Dr. R. Herkies March 2003 Revision: February 2005

With the introduction of Powerchart online ordering, a clinical agreement has been set up with the Director of ICS and other Staff Specialists. Nursing Management, with the agreement of the hospital executive, have made arrangement that allows all permanently employed RPAH Nursing Staff to place orders for a variety of tests on their behalf. It is a Health Insurance Commission (HIC) directive that all orders placed by nursing staff are countersigned by the responsible MO within 14 days.

ROYAL PRINCE ALFRED HOSPITAL INTENSIVE CARE SERVICE