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.

The Pleth Variation Index (PVI) is similar to PPV but is an automated measure of the dynamic change in the perfusion index that occurs during a respiratory cycle. Perfusion index is the ratio of nonpulsatile to pulsatile blood flow through the peripheral bed, measured noninvasively with a pulse oximeter probe. The PVI can predict positive fluid response in mechanically ventilated patients. However, PVI has the same limitations as PPV, the patient must be in sinus rhythm, and PVI cannot be used in patients who are breathing spontaneously.²³

Ultrasonographic Assessment

Bedside ultrasonography is noninvasive, can be performed rapidly, and provides real-time clinically relevant data. There is much evidence that ultrasonography is effective in evaluating hemodynamic and volume status, and it may be used to assess fluid responsiveness during resuscitation.

Most importantly, ultrasonography can be repeated and used to guide resuscitation efforts and direct plan of care including decisions about administration of more fluids versus starting vasoactive agents. Bedside ultrasound can provide multiple data points to give a more complete view of a patient’s volume status. Right atrial pressure and CVP can be monitored during fluid resuscitation using the visualization of dynamic changes in the IVC diameter during inspiration and expiration. Afterload can also be assessed using left ventricular outflow tract stroke volume variation. Additionally, ultrasound can be used to estimate ejection fraction to ensure that the cardiac physiology can handle needed resuscitation.

As there is growing awareness of sepsis and fluid resuscitation, IVC measurements have grown in popularity as a noninvasive approach for such monitoring.²⁴ IVC collapsibility in spontaneously breathing patients and caval index in mechanically ventilated patients can be determined rapidly at the bedside. There are two views that most easily allow access to measure the IVC: subxyphoid and right upper quadrant. Using the phased array probe or a curvilinear probe, the IVC can be seen traversing through the liver with the hepatic vein joining the IVC just before the diaphragm and emptying into the right atrium. Interrater reliability is often questioned when ultrasound is used. However, Fields et al²⁵ were able to show that there was a high degree of interrater reliability among EPs when measuring IVC collapsibility.

A systematic review by Zhang et al,²⁶showed change in IVC measured with point-of-care ultrasonography can reliably predict fluid responsiveness, particularly in patients that are mechanically ventilated. A caval index of 0.72 corresponds to CVP less than 7 cm water; a caval index of 1.23 corresponds to CVP 8 to 12 cm water; and a caval index of 1.59 corresponds to CVP greater than 13 cm water. The distensibility index is similar and calculated based on the IVC diameter at end-expiration (IVCDmax) and end-inspiration (IVCDmin).²⁷ The ratio of (IVCDmax - IVCDmin)/IVCDmin is expressed as a percentage (dIVC%) in mechanically ventilated patients. A distensibility index less than 18% may indicate that the patient is not volume responsive (Tables 2 and 3; Figure 1).

Caval Index

A more widely utilized method for IVC evaluation is described by Nagdev et al.²⁹ The caval index is calculated as the relative decrease in inferior vena cava diameter during one respiratory cycle. A caval index greater than or equal to 50% is strongly associated with a low CVP with 91% sensitivity and 94% specificity.²⁹ It is important to remember, however, that IVC collapsibility is only useful at the extremes. Nevertheless, IVC measurement is limited by increased PEEP, increased TV, and increased intraabdominal pressure.

While IVC is the most commonly used vessel for sonographic volume status assessment, other vessels can also be used. Kent et al³⁰ describe using the internal jugular vein as well as the femoral vein. Guarracino et al³¹ achieved similar results when using the internal jugular vein for distensibility index for assessing fluid responsiveness. When compared to the invasive CVP measurements, new CVP quantification methods could be used as a reliable approach for monitoring hemodynamic status.

Stroke Volume Variation

Stroke volume can be assessed using pulse contour analysis as well as via ultrasonography.³² In the apical five (apical four plus left ventricular outflow tract), pulsed-wave Doppler can be used via a phased array probe. The Doppler gate is placed in the left ventricular outflow tract and stroke velocity is used to assess respiratory variability in the stroke volume. The percent change in velocity can be inferred as stroke volume variability (SVV). An SVV greater than 13% correlates with fluid responsiveness with an odd ratio of 18.4, sensitivity and specificity of 81% and 80%, respectively (Figure 2). The use of SVV is limited by atrial fibrillation, mitral valve abnormalities, and aortic valve abnormalities.³³

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

Ultrasonographic Assessment

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Stroke Volume Variation

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Caval Index