If the Central Venous Pressure Is [x], Call Me … Maybe*

Abstract

A s a fellow in critical care, the primary author (D.F.) of this editorial often worked in an ICU where it was common for patients to have a "goal" central venous pressure (CVP) order. He would often get phone calls at night about a patient who had good mentation, a normal blood pressure, and appropriate urine output but a low CVP. The nurses would ask what to do, as the CVP goal was not being met. More often than not, the answer was "nothing." With more rotations in the ICU, the author started to routinely discontinue the goal CVP order prior to retiring to the call room for the night. Of course, he would always want to know about the unstable patient with rapid changes in CVP or a high-risk patient at the extremes of CVP (< 5 or > 20 mm Hg). However, more often than not, when they called, there was no intervention based on the CVP alone. It turns out that was probably a good idea for patient outcome (and even better for the author's sleep).The history of CVP measurement dates back to the late 1950s when Hughes and Magovern (1) described a complicated method to measure CVP and guide fluid administration in thoracotomy patients. All of the major textbooks of anesthesia and critical care state, in various ways, that the CVP is a measure of volume status and cardiac preload and can be used to guide fluid administration. When clinicians administer a volume bolus, it is done in an attempt to increase the cardiac output (CO) and organ perfusion.Understanding the utility of CVP requires a different approach to cardiovascular physiology. We typically think of 'See also p. 1774.

Early Management of Severe Sepsis

“…119 , 120 Consequently, I believe that the CVP should not be used to guide fl uid therapy. 66 The use of Scv o 2 to guide the resuscitation of patients who are septic is equally problematic. Patients who are septic usually have a normal or increased Scv o 2 caused by reduced oxygen extraction.…”

Starling curves and central venous pressure

“…Indeed, important clinical practice guidelines recommend fluid resuscitation of hypoperfused patients until the CVP rises to abnormal levels [ 2 ]. A steady accumulation of investigations, however, has challenged this common practice [ 3 ]. Initially, a report demonstrated that CVP does not correlate with gold standard measurements of total blood volume [ 4 ].…”

The demise of early goal‐directed therapy for severe sepsis and septic shock

“…The central venous pressure (CVP) is the first and most ‘critical’ end point of the ‘quantitative resuscitation protocol’ of both EGDT and the 6 h resuscitation bundle . However, it has been well established that the CVP is unable to predict the hemodynamic response to a fluid challenge and should not be used for this purpose . Furthermore, a CVP > 8 mmHg, the CVP target of both EGDT and the 6 h resuscitation bundle, is associated with impaired microcirculatory perfusion, organ dysfunction and an increased risk of death .…”