UMEM Educational Pearls

 

The Role of the CVP in a Post- “7 Mares” Era
 

The role for using central venous pressure (CVP) as a measure of volume responsiveness has largely fallen out of favor over the years.1 There are certainly better indices for fluid responsiveness, but don’t be fooled – the CVP isn’t a one trick pony.  In fact, a high or rapidly rising CVP should raise a significant concern for impending cardiovascular collapse.

Consider the following differential diagnosis in the patient with an abnormally high or rising CVP ( >10 cm H2O).

  • Excessive pressures outside of the heart or impediments to venous return (juxta-cardiac pressures)
    • Cardiac tamponade
    • Auto PEEP or breath stacking during mechanical ventilation
    • Tension pneumothorax
  • Venous return that’s more than the right ventricle can handle
    • RV failure
    • Severe tricuspid valve disease
    • Massive increase in pulmonary vascular resistance (massive PE, pulmonary hypertension, ARDS, LV failure)

Bottom Line: In a time where the utility of the CVP has been largely dismissed, remember that an abnormal CVP offers great deal of information beyond a simple measure of volume status.

 

References

  1. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134(1):172-8.
  2. Berlin DA, Bakker J. Starling curves and central venous pressure. Critical Care. 2015;19(1):55.

Follow me on Twitter: @JohnGreenwoodMD