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      Non-Invasive Method for the Rapid Assessment of Central Venous Pressure: Description and Validation by a Single Examiner


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          This study describes a means of assessing the external jugular venous pressure (JVP) as an indicator of normal or elevated central venous pressure (CVP).


          Intensive care unit patients having CVP monitoring were examined. With patients in bed, the external jugular vein (EJV) was occluded at the base of the neck and observed to distend. The occlusion was then removed and the vein observed for collapse. Complete collapse was hypothesized to indicate a non-elevated CVP (≤8cm of water). In those patients whose EJV collapsed incompletely, the vein was then occluded with the finger near the angle of the jaw. With the occlusion maintained, the vein was milked downwards with the other hand to cause its emptying and was then observed for filling from below. Filling from below was hypothesized to indicate an elevated CVP (>8cm of water).


          In 12 of the 40 patients examined, the EJV could not be assessed (EJV not seen at all: 5, and difficult to visualize: 7). For the remaining 28 patients 11 had a CVP > 8 cm, while 17 had a CVP patients, of ≤ 8. EJV assessment was 100% accurate (95% Confidence Interval 88–100) in predicting whether or not a patient’s CVP was greater or less than 8 cm of water.


          EJV assessment, when visible, is accurate to clinically assess a patient’s CVP in the hands of the author. Further studies are needed to see if they are reproducible by other observer.

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          The limited reliability of physical signs for estimating hemodynamics in chronic heart failure.

          The cardiovascular physical examination is used commonly as a basis for diagnosis and therapy in chronic heart failure, although the relationship between physical signs, increased ventricular filling pressure, and decreased cardiac output has not been established for this population. We prospectively compared physical signs with hemodynamic measurements in 50 patients with known chronic heart failure (ejection fraction, .18 +/- .06). Rales, edema, and elevated mean jugular venous pressure were absent in 18 of 43 patients with pulmonary capillary wedge pressures greater than or equal to 22 mm Hg, for which the combination of these signs had 58% sensitivity and 100% specificity. Proportional pulse pressure correlated well with cardiac index (r = .82), and when less than 25% pulse pressure had 91% sensitivity and 83% specificity for a cardiac index less than 2.2 L/min/m2. In chronic heart failure, reliance on physical signs for elevated ventricular filling pressure might result in inadequate therapy. Conversely, the adequacy of cardiac output is assessed reliably by pulse pressure. Our results facilitate decisions regarding treatment in chronic heart failure.
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            Clinical, radiographic, and hemodynamic correlations in chronic congestive heart failure: conflicting results may lead to inappropriate care.

            Clinical and radiographic examinations are commonly used for estimating severity and titrating therapy of chronic congestive heart failure. The purpose of this study was to establish the relationship between findings on history, physical examination, chest roentgenogram, and pulmonary capillary wedge pressure (PCWP). Fifty-two consecutive patients with chronic congestive heart failure, referred for evaluation for heart transplantation, were studied; all patients underwent history, physical examination, upright chest roentgenogram, and cardiac catheterization. The mean left ventricular ejection fraction was 0.19 +/- 0.06. Patients were divided into three groups according to their PCWP: Group 1, normal PCWP (less than or equal to 15 mm Hg, n = 19); Group 2, mild to moderately elevated PCWP (16 to 29 mm Hg, n = 15); Group 3, markedly elevated PCWP (greater than or equal to 30 mm Hg, n = 18). Physical and radiographic signs of congestion were more common in the groups with higher PCWP, but they could not be used to reliably separate patients with different filling pressures. Physical findings (orthopnea, edema, rales, third heart sound, elevated jugular venous pressure) or radiographic signs (cardiomegaly, vascular redistribution, and interstitial and alveolar edema) had poor predictive value for identifying patients with PCWP values greater than or equal to 30 mm Hg. These findings had poor negative predictive value to exclude significantly elevated PCWP (greater than 20 mm Hg). Radiographic pulmonary congestion was absent in eight (53%) patients in Group 2 and seven (39%) in Group 3. In patients in Group 2 and 3, those without radiographic congestion were in a better New York Heart Association functional class (3.5 +/- 0.5 versus 2.8 +/- 0.6, p less than 0.01). There was good correlation between right atrial pressure and PCWP (r = 0.64, p less than 0.001). A normal right atrial pressure had no predictive value, but a pressure greater than 10 mm Hg was seen in all but one patient with a PCWP value greater than 20 mm Hg. Clinical, radiographic, and hemodynamic evaluations of chronic congestive heart failure yield conflicting results. Absence of radiographic or physical signs of congestion does not ensure normal PCWP values and may lead to inaccurate diagnosis and inadequate therapy. It is not known whether therapy aimed at normalizing PCWP is superior to relieving clinical and radiographic signs of congestion.
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              The clinical role of central venous pressure measurements.

              Central venous pressure (CVP) is commonly measured, but its clinical use is still not clear. We argue that the interpretation of the CVP needs to be considered in conjunction with an assessment of cardiac output. The objective of this study was to define an elevated CVP as one in which there is a low probability for cardiac output to increase with a volume infusion through a Starling mechanism by relating the initial CVP (measured relative to a reference point 5 cm below the sternal angle) to the response in cardiac output with volume infusion. The authors studied consecutive patients who had pulmonary artery catheters in place and who had a volume challenge as part of routine management as ordered by the treating physician. To ensure an adequate test of the Starling mechanism, data were included only if the volume infusion increased CVP by > or = 2 mm Hg. Responders were defined a priori as those with an increase in cardiac index > or = 300 and nonresponders as 10 mm Hg, physicians prescribed less fluid challenges, and when they did, a positive response was much less likely. Change in blood pressure or changes in urine output with volume infusion correlated poorly with change in cardiac index. A CVP of > 10 mm Hg should be considered high, and the probability of an increase in cardiac output with volume infusion is low. This value is a reasonable upper limit for algorithms for empiric fluid challenges.

                Author and article information

                West J Emerg Med
                Western Journal of Emergency Medicine
                Department of Emergency Medicine, University of California, Irvine School of Medicine
                November 2008
                : 9
                : 4
                : 201-205
                [* ] University of Colorado School of Medicine, Division of Emergency Medicine, Department of Surgery
                [] Royal Victoria Hospital, Department of Pulmonology
                Author notes
                Address for Correspondence: Jeffrey Sankoff MD. Division of Emergency Medicine, Department of Surgery, University of Colorado School of Medicine, Leprino Office Building, 7th Floor, 12401 E. 17th Avenue, B-215, Aurora, CO 80045. Email: Jeffrey.sankoff@ 123456uchsc.edu .

                Supervising Section Editor: H. Bryant Nguyen, MD, MS

                Copyright © 2008 the authors.

                This is an Open Access article distributed under the terms of the Creative Commons Non-Commercial Attribution License, which permits its use in any digital medium, provided the original work is properly cited and not altered. For details, please refer to http://creativecommons.org/licenses/by-nc/3.0/. Authors grant Western Journal of Emergency Medicine as well as the National Library of Medicine a nonexclusive license to publish the manuscript.

                Critical Care
                Orginal Research

                Emergency medicine & Trauma
                Emergency medicine & Trauma


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