Clinical Review

Review: Pitfalls in Using Central Venous Pressure as a Marker of Fluid Responsiveness

Emergency Medicine. 2016 January;48(1):18-28 | DOI: 10.12788/emed.2016.0004

References

- Pitfalls in Using Central Venous Pressure as a Marker of Fluid Responsiveness

Chatterjee K. The Swan-Ganz catheters: past, present, and future. A viewpoint. Circulation. 2009;119(1):147-52.
Shoemaker WC, Appel PL, Waxman K, Schwartz S, Chang P. Clinical trial of survivors’ cardiorespiratory patterns as therapeutic goals in critically ill postoperative patients. Crit Care Med. 1982;10(6):398-403.
Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest. 1988;94(6):1176-1186.
Rivers E, Nguyen B, Havstad S, et al; Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377.
Dellinger RP, Levy MM, Carlet JM, et al; International Surviving Sepsis Campaign Guidelines Committee; American Association of Critical-Care Nurses, American College of Chest Physicians, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36(1):296-327.
ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of Protocol-based care for Early Septic Shock. N Engl J Med. 2014;370(18):1683-1693.
Peake SL, Delaney A, Bellomo R; ARISE Investigators. Goal-directed resuscitation in septic shock. N Engl J Med. 2015; 372(2):190-191.
Mouncey PR, Osborn TM, Power GS, et al; ProMISe Trial Investigators. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372(14):1301-1311.
Akmal AH, Hasan M, Mariam A. The incidence of complications of central venous catheters at an intensive care unit. Ann Thorac Med. 2007;2(2):61–63.
Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: internal jugular versus subclavian access—a systematic review. Crit Care Med. 2002;30(2):454–460.
Magder S. How to use central venous pressure measurements. Curr Opin Crit Care. 2005;11(3):264-270.
Bafaqeeh F, Magder S. CVP and volume responsiveness of cardiac output. Am J Respir Crit Care Med. 2004;169:A344.
Schummer W. Central venous pressure. Validity, informative value and correct measurement [in German]. Anaesthesist. 2009;58(5):499-505.
Marik PE, Baram M, Vahid B. Does the central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134(1):172-178.
Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013;41(7):1774-1781.
Magder S, Georgiadis G, Cheong T. Respiratory variations in right atrial pressure predict the response to fluid challenge. J Crit Care. 1992;7(2):76-85.
Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med. 2009;37(9):2642-2647.
Reuter DA, Kirchner A, Felbinger TW, et al. Usefulness of left ventricular stroke volume variation to assess fluid responsiveness in patients with reduced cardiac function. Crit Care Med. 2003;31(5):1399-1404.
Perel A, Pizov R, Cotev S. Systolic blood pressure variation is a sensitive indicator of hypovolemia in ventilated dogs subjected to graded hemorrhage. Anesthesiology. 1987;67(4):498-502.
De Backer D, Heenen S, Piagnerelli M, Koch M, Vincent JL. Pulse pressure variations to predict fluid responsiveness: influence of tidal volume. Intensive Care Med. 2005;31(4):517-523.
Charron C, Fessenmeyer C, Cosson C, et al. The influence of tidal volume on the dynamic variables of fluid responsiveness in critically ill patients. Anesth Analg. 2006;102(5):1511-1517.
Galas F, Hajjar L, Polastri T, et al. Passive leg raising predicts fluid responsiveness after cardiac surgery. Crit Care. 2008;12(suppl 2):P89
Cannesson M, Desebbe O, Rosamel P, et al. Pleth variability index to monitor the respiratory variations in the pulse oximeter plethysmographic waveform amplitude and predict fluid responsiveness in the operating theatre. Br J Anaesth. 2008;101(2):200-206.
Coen D, Cortellaro F, Pasini S, et al. Towards a less invasive approach to the early goal-directed treatment of septic shock in the ED. Am J Emerg Med. 2014;32(6):563-568.
Fields JM, Lee PA, Jenq KY, Mark DG, Panebianco NL, Dean AJ. The interrater reliability of inferior vena cava ultrasound by bedside clinician sonographers in emergency department patients. Acad Emerg Med. 2011;18(1):98-101.
Zhang Z, Xu X, Ye S, Xu L. Ultrasonographic measurement of the respiratory variation in the inferior vena cava diameter is predictive of fluid responsiveness in critically ill patients: systematic review and meta-analysis. Ultrasound Med Biol. 2014;40(5):845-853
Sefidbakht S, Assadsangabi R, Abbasi HR, Nabavizadeh A. Sonographic measurement of the inferior vena cava as a predictor of shock in trauma patients. Emerg Radiol. 2007;14(3):181-185.
Rudski LW, Lai WW, Afilalo J, et al. Guidelines of the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2013;23(7):658-713.
Nagdev AD, Merchant RC, Tirado-Gonzalez A, Sisson CA, Murphy MC. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. Ann Emerg Med. 2010;55(3):290-295.
Kent A, Patil P, Davila V, et al. Sonographic evaluation of intravascular volume status: Can internal jugular or femoral vein collapsibility be used in the absence of IVC visualization? Ann Thorac Med. 2015;10(1):44-49.
Guarracino F, Ferro B, Forfori F, Bertini P, Magliacano L, Pinsky MR. Jugular vein distensibility predicts fluid responsiveness in septic patients. Crit Care. 2014;18(6):647.
Chin JH, Jun IG, Lee J, Seo H, Hwang GS, Kim YK. Can stroke volume variation be an alternative to central venous pressure in patients undergoing kidney transplantation? Transplant Proc. 2014;46(10):3363-3366.
Zhang Z, Lu B, Sheng X, Jin N. Accuracy of stroke volume variation in predicting fluid responsiveness: a systematic review and meta-analysis. J Anesth. 2011;25(6):904-916.
Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Chest. 2001;119(3):867-873.
Davies SJ, Minhas S, Wilson RJ, Yates D, Howell SJ. Comparison of stroke volume and fluid responsiveness measurements in commonly used technologies for goal-directed therapy. J Clin Anesth. 2013;25(6):466-474.
Marik PE, Monnet X, Teboul JL. Hemodynamic parameters to guide fluid therapy. Ann Intensive Care. 2011;1(1):1.
Monnet X, Rienzo M, Osman D, et al. Esophageal Doppler monitoring predicts fluid responsiveness in critically ill ventilated patients. Intensive Care Med. 2005;31(9):1195-1201.
Monnet X, Rienzo M, Osman D, et al. Passive leg raising predicts fluid responsiveness in the critically ill. Crit Care Med. 2006;34(5):1402-1407.
Lamia B, Ochagavia A, Monnet X, Chemla D, Richard C, Teboul JL. Echocardiographic prediction of volume responsiveness in critically ill patients with spontaneously breathing activity. Intensive Care Med. 2007;33(7):1125-1132.
Benomar B, Ouattara A, Estagnasie P, Brusset A, Squara P. Fluid responsiveness predicted by noninvasive bioreactance-based passive leg raise test. Intensive Care Med. 2010;36(11):1875-1881.
Marik PE, Levitov A, Young A, Andrews L. The use of bioreactance and carotid Doppler to determine volume responsiveness and blood flow redistribution following passive leg raising in hemodynamically unstable patients. Chest. 2013;143(2):364-370.
Kupersztych-Hagege E, Teboul JL, Artigas A, et al. Bioreactance is not reliable for estimating cardiac output and the effects of passive leg raising in critically ill patients. Br J Anaesth. 2013;111(6):961-966.

Central Venous Pressure Measurement

A CVC must be placed in a sterile fashion with the tip of the catheter at the junction between the right atrium and superior vena cava. After the catheter has been properly secured and placement has been confirmed, a pressure transducer is connected from the most distal port of the CVC to the monitor. The use of CVP in the treatment of critically ill patients has logistical, mechanical, and placement issues that can complicate the clinical picture. Additionally, placement of a CVC is an invasive procedure with a set of complications that can compromise an already complex patient picture.^9,10

The mechanical issues are numerous. The transducer is a water column that must be calibrated and set to zero at the level of the heart along the same plane of the right atrium (phlebostatic axis). The tip of the catheter inadvertently can be moved easily by health care workers, and a slight change in position may cause reading errors. The monitor must be recalibrated after the patient undergoes care by ancillary staff or is logrolled, moved, or repositioned in a way that affects the level of the heart. Some staff may not have adequate experience using the equipment. Misplacement of the catheter may cause erroneous and inaccurate measurements. The catheter tip must be in the right atrium, but using a catheter that is too long or short may have the catheter tip located in the superior vena cava, ventricle, or inferior vena cava (IVC). All these conditions will cause false reading of CVP.

Central Venous Pressure Interpretation

Normal CVP is 2 to 4 mm Hg, but interpretation of the value may vary. Low CVP typically indicates intravascular volume depletion and need for fluid replacement. However, caution is required with this approach. Depending on the cardiac compliance, some never have adequate volume with a low CVP and others with an elevated CVP may still augment cardiac output with additional fluid therapy (ie, a patient with hypertrophic Cardiomyopathy or advanced Pulmonary HTN).^11,12

CVP as a trend may be more useful when compared to a single reading. Patients may vary on an individual basis, thereby making CVP a poor static marker. It should be used in the context of the patient’s clinical condition as it indicates the relationship between circulating blood volume and the capacity of the heart at a given time. As a trend, it is more sensitive to guide continued resuscitation efforts.¹³

Dynamic Techniques to Monitor Cardiac Output and Determine Fluid Responsiveness

Central venous pressure can be affected by anatomical and physiological factors such as valvular heart disease, right heart failure, poor lung compliance, or arrhythmias. In 2008, Marik et al¹⁴ performed a systematic review of 24 studies reviewing the benefits of CVP in the management of fluid therapy. In 2013, Marik et al^14,15 repeated the meta-analysis of the literature which included 43 articles, and again concluded that there were no data to support the use of CVP to guide fluid therapy, and both papers conluded that CVP should not be used for fluid resuscitation. Static measures of fluid responsiveness such as CVP may not be the most appropriate measures, and may be less accurate physiologically than dynamic measures.

Dynamic measurements based on the Frank-Starling principle use the changes in the venous return (preload) and stroke volume as a marker of fluid responsiveness and may be more useful. There are several dynamic methods to assess fluid responsiveness. The first such method is the measurement of right atrial pressure. In a case series of 33 medical and surgical intensive care unit (ICU) patients who had pulmonary artery catheters, it was hypothesized that right atrial pressure predicted the response to fluid pressure as right atrial pressure should not decrease during spontaneous inspiration in patients who had a heart that was not volume responsive. Patients were classified as having a positive response test when right atrial pressure decreased ≥1 mm Hg during inspiration, or a negative response when right atrial pressure decreased <1 mm Hg. A positive response correlated with cardiac output increase of 250 mL/h.16

Evaluation of Pulse Pressure and Stroke Volume Variation

Pulse pressure variation (PPV), stroke volume variation (SVV), and variation of the amplitude of pulse oximeter plethysmographic waveform are highly predictive of fluid responsiveness in mechanically ventilated patients who have septic or hemorrhagic shock.^17,18 The PPV is derived from the analysis of the arterial waveform, and SVV is derived from pulse contour analysis. The PPV uses the physiologic changes that occur during positive pressure ventilation. The delivery of a mechanical breath increases pleural pressure on inspiration, causing the following: (1) a decrease in RV preload because of decreased venous return; and (2) increase in RV afterload because of increased transpulmonary pressure. These changes lead to decreased RV stroke volume, which is at a minimal level at the end of inspiration. The inspiration reduction in RV ejection leads to a decrease in LV filling after a phase lag of two to three heart beats because of long pulmonary transit time. Thus, the LV preload reduction may induce a decrease in LV stroke volume, which is at its minimum volume during the inspiratory period of mechanical ventilation.¹⁸ The variation between the RV and LV stroke volume are greatest when the ventricles operate on the steep part of the Frank-Starling curve (rather than the flat portion). The PPV is calculated as the difference between maximum and minimum pulse pressures divided by the average of their sum, and multiplied by 100%. A variation in PPV of greater than 13% is highly predictive of volume responsiveness.¹⁹ The use of PPV is feasible in the ED because the only requirements include arterial access, measurement of the minimum and maximum pulse pressures during 30 seconds, and performance of the calculation. The PPV has been validated in different patient populations. However, the use of PPV is limited to a conventional volume control mode of ventilation and restricted to tidal volumes (TVs) over 7 mL/kg, this method of measurement was validated in patients receiving tidal volumes of at least 8 cc/kg ideal body weight—which may be higher than seen in contemporary clinical practice with more restrictive TV, ventilation strategies in patients with acute respiratory distress syndrome.²⁰ Furthermore, patients must be ventilated passively, with heavy sedation or chemical paralysis to prevent spontaneous breathing. They must also have a normal heart rhythm. Most acute lung injury states are managed with lung protective strategy with TV of 4 to 6 mL/kg, PPV values obtained using lower TVs are less reliable and their use is not recommended.^20-22

References

- Pitfalls in Using Central Venous Pressure as a Marker of Fluid Responsiveness

Chatterjee K. The Swan-Ganz catheters: past, present, and future. A viewpoint. Circulation. 2009;119(1):147-52.
Shoemaker WC, Appel PL, Waxman K, Schwartz S, Chang P. Clinical trial of survivors’ cardiorespiratory patterns as therapeutic goals in critically ill postoperative patients. Crit Care Med. 1982;10(6):398-403.
Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest. 1988;94(6):1176-1186.
Rivers E, Nguyen B, Havstad S, et al; Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377.
Dellinger RP, Levy MM, Carlet JM, et al; International Surviving Sepsis Campaign Guidelines Committee; American Association of Critical-Care Nurses, American College of Chest Physicians, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36(1):296-327.
ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of Protocol-based care for Early Septic Shock. N Engl J Med. 2014;370(18):1683-1693.
Peake SL, Delaney A, Bellomo R; ARISE Investigators. Goal-directed resuscitation in septic shock. N Engl J Med. 2015; 372(2):190-191.
Mouncey PR, Osborn TM, Power GS, et al; ProMISe Trial Investigators. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372(14):1301-1311.
Akmal AH, Hasan M, Mariam A. The incidence of complications of central venous catheters at an intensive care unit. Ann Thorac Med. 2007;2(2):61–63.
Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: internal jugular versus subclavian access—a systematic review. Crit Care Med. 2002;30(2):454–460.
Magder S. How to use central venous pressure measurements. Curr Opin Crit Care. 2005;11(3):264-270.
Bafaqeeh F, Magder S. CVP and volume responsiveness of cardiac output. Am J Respir Crit Care Med. 2004;169:A344.
Schummer W. Central venous pressure. Validity, informative value and correct measurement [in German]. Anaesthesist. 2009;58(5):499-505.
Marik PE, Baram M, Vahid B. Does the central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134(1):172-178.
Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013;41(7):1774-1781.
Magder S, Georgiadis G, Cheong T. Respiratory variations in right atrial pressure predict the response to fluid challenge. J Crit Care. 1992;7(2):76-85.
Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med. 2009;37(9):2642-2647.
Reuter DA, Kirchner A, Felbinger TW, et al. Usefulness of left ventricular stroke volume variation to assess fluid responsiveness in patients with reduced cardiac function. Crit Care Med. 2003;31(5):1399-1404.
Perel A, Pizov R, Cotev S. Systolic blood pressure variation is a sensitive indicator of hypovolemia in ventilated dogs subjected to graded hemorrhage. Anesthesiology. 1987;67(4):498-502.
De Backer D, Heenen S, Piagnerelli M, Koch M, Vincent JL. Pulse pressure variations to predict fluid responsiveness: influence of tidal volume. Intensive Care Med. 2005;31(4):517-523.
Charron C, Fessenmeyer C, Cosson C, et al. The influence of tidal volume on the dynamic variables of fluid responsiveness in critically ill patients. Anesth Analg. 2006;102(5):1511-1517.
Galas F, Hajjar L, Polastri T, et al. Passive leg raising predicts fluid responsiveness after cardiac surgery. Crit Care. 2008;12(suppl 2):P89
Cannesson M, Desebbe O, Rosamel P, et al. Pleth variability index to monitor the respiratory variations in the pulse oximeter plethysmographic waveform amplitude and predict fluid responsiveness in the operating theatre. Br J Anaesth. 2008;101(2):200-206.
Coen D, Cortellaro F, Pasini S, et al. Towards a less invasive approach to the early goal-directed treatment of septic shock in the ED. Am J Emerg Med. 2014;32(6):563-568.
Fields JM, Lee PA, Jenq KY, Mark DG, Panebianco NL, Dean AJ. The interrater reliability of inferior vena cava ultrasound by bedside clinician sonographers in emergency department patients. Acad Emerg Med. 2011;18(1):98-101.
Zhang Z, Xu X, Ye S, Xu L. Ultrasonographic measurement of the respiratory variation in the inferior vena cava diameter is predictive of fluid responsiveness in critically ill patients: systematic review and meta-analysis. Ultrasound Med Biol. 2014;40(5):845-853
Sefidbakht S, Assadsangabi R, Abbasi HR, Nabavizadeh A. Sonographic measurement of the inferior vena cava as a predictor of shock in trauma patients. Emerg Radiol. 2007;14(3):181-185.
Rudski LW, Lai WW, Afilalo J, et al. Guidelines of the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2013;23(7):658-713.
Nagdev AD, Merchant RC, Tirado-Gonzalez A, Sisson CA, Murphy MC. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. Ann Emerg Med. 2010;55(3):290-295.
Kent A, Patil P, Davila V, et al. Sonographic evaluation of intravascular volume status: Can internal jugular or femoral vein collapsibility be used in the absence of IVC visualization? Ann Thorac Med. 2015;10(1):44-49.
Guarracino F, Ferro B, Forfori F, Bertini P, Magliacano L, Pinsky MR. Jugular vein distensibility predicts fluid responsiveness in septic patients. Crit Care. 2014;18(6):647.
Chin JH, Jun IG, Lee J, Seo H, Hwang GS, Kim YK. Can stroke volume variation be an alternative to central venous pressure in patients undergoing kidney transplantation? Transplant Proc. 2014;46(10):3363-3366.
Zhang Z, Lu B, Sheng X, Jin N. Accuracy of stroke volume variation in predicting fluid responsiveness: a systematic review and meta-analysis. J Anesth. 2011;25(6):904-916.
Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Chest. 2001;119(3):867-873.
Davies SJ, Minhas S, Wilson RJ, Yates D, Howell SJ. Comparison of stroke volume and fluid responsiveness measurements in commonly used technologies for goal-directed therapy. J Clin Anesth. 2013;25(6):466-474.
Marik PE, Monnet X, Teboul JL. Hemodynamic parameters to guide fluid therapy. Ann Intensive Care. 2011;1(1):1.
Monnet X, Rienzo M, Osman D, et al. Esophageal Doppler monitoring predicts fluid responsiveness in critically ill ventilated patients. Intensive Care Med. 2005;31(9):1195-1201.
Monnet X, Rienzo M, Osman D, et al. Passive leg raising predicts fluid responsiveness in the critically ill. Crit Care Med. 2006;34(5):1402-1407.
Lamia B, Ochagavia A, Monnet X, Chemla D, Richard C, Teboul JL. Echocardiographic prediction of volume responsiveness in critically ill patients with spontaneously breathing activity. Intensive Care Med. 2007;33(7):1125-1132.
Benomar B, Ouattara A, Estagnasie P, Brusset A, Squara P. Fluid responsiveness predicted by noninvasive bioreactance-based passive leg raise test. Intensive Care Med. 2010;36(11):1875-1881.
Marik PE, Levitov A, Young A, Andrews L. The use of bioreactance and carotid Doppler to determine volume responsiveness and blood flow redistribution following passive leg raising in hemodynamically unstable patients. Chest. 2013;143(2):364-370.
Kupersztych-Hagege E, Teboul JL, Artigas A, et al. Bioreactance is not reliable for estimating cardiac output and the effects of passive leg raising in critically ill patients. Br J Anaesth. 2013;111(6):961-966.

Review: Pitfalls in Using Central Venous Pressure as a Marker of Fluid Responsiveness

References

Central Venous Pressure Measurement

Central Venous Pressure Interpretation

Dynamic Techniques to Monitor Cardiac Output and Determine Fluid Responsiveness

Evaluation of Pulse Pressure and Stroke Volume Variation

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