Is the central venous pressure reading equally reliable if the central line is inserted via the femoral vein
Date First Published:
August 30, 2002
Last Updated:
September 5, 2003
Report by:
Joel Desmond, RSC Research Fellow (Manchester Royal Infirmary)
Search checked by:
Mahmoud Megahed, Manchester Royal Infirmary
Three-Part Question:
In [patients requiring central venous pressure monitoring] is [a femoral vein central line as good as a jugular or subclavian line] at [reliability assessing right atrial filling pressure]?
Clinical Scenario:
You have been called to the resuscitation room to see a 67 year old woman who has walked out in front of a bus while shopping in town. She has an obvious closed fracture of her left arm and she is complaining of abdominal pain and central neck pain. You elicit from her husband that she has had two heart attacks in the past and the drugs in her handbag are bendrofluazide, frumil, and lisinopril. Her blood pressure is 90/52 and her pulse is 105. You are concerned that she may be hypovolaemic, but you are aware of the dangers of giving too much fluid to a patient with probable heart failure. You elect to insert a central line for central venous pressure monitoring but she has a neck collar on and so you wonder if placing this via the femoral vein would affect your readings.
Search Strategy:
Medline 1966-06/03 using the OVID interface
Search Details:
[(exp Central Venous Pressure OR Central Venous pressure.mp) AND (exp Vena Cava, Inferior OR vena cava.mp)] LIMIT to human.
Outcome:
Out of 141 papers 9 were found to be relevant. These papers are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Accuracy of central venous pressure measurements in the inferior vena cava in the ventilated child. Murdoch IA, Rosenthal E, Huggon IC, et al. 1994, UK | 12 children with cardiac pathology undergoing cardiac catheterisation while on assisted ventilation. Mean age 13mth (range 0.5-56mths) SVC, IVC and right atrial measurements |
Observational cohort study | Comparison of IVC pressure readings compared to SVC and right atrial pressures | SVC to IVC readings were all within 1.2mmHg. Right atrial pressure to IVC pressure was always less than 0.7mmHg apart | Young children only, small group of healthy outpatients coming for cardiac catheterisation Supine patients only Range of readings not given |
| Inferior vena caval pressure reliably predicts right atrial pressure in pediatric cardiac surgical patients. Chait HI, Kuhn MA, Baum VC. 1994, USA | 33 paediatric cardiac -surgical patients age 2 days to 9 years. Insertion of femoral venous catheter, and transthoracic right atrial catheter Mechanical and spontaneous ventilation |
Observational cohort study | Comparison of right atrial and inferior venal caval pressure | 23 of 31 paired patient readings were the same, 5 were within 2mmHg, 3 within 3 mmHg. All spontaneously breathing readings were within 2 mmHg. IVC pressures were a mean of 0.71mmHg higher than RA pressure | Study contained only children with congenital cardiac abnormalities |
| Inferior vena cava pressure as an estimate of central venous pressure. Yung M, Butt W. 1995, Australia | 39 children with both SVC and IVC central venous catheters in place in a paediatric ICU Age range 5 days to 14 years CVP range 3-17mmHg |
Observational cohort study | SVC compared to IVC pressure | mean difference 0.33mmHg. 22 of 39 pressure readings were equal. 33 of 39 pressures were within 1mmHg. 37 of 39 pressures were within 2mmHg | Position of femoral lines not verified radiologically and short lines used 3 children spontaneously breathing. 36 ventilated |
| Effect of airway pressure on inferior vena cava pressure as a measure of central venous pressure in children. Reda Z, Houri S, Davis AL, et al. 1995, USA | 44 children in ICU with mechanical ventilation Group 1 had no evidence of abdominal distension Group 2 had evidence of abdominal distension |
Observational cohort study | SVC pressure compared to IVC pressure | Mean difference 0.93, max difference 3mmHg (unaffected by high PEEP or mean airway pressures | The diagnosis of abdominal distension was entirely subjective No attempt was made to measure intra-abdominal pressure |
| Normal abdomen | 50% of SVC to IVC measurements were >3mmHg | ||||
| Abdominal distension | |||||
| A comparison between continuous central venous pressure measurement from right atrium and abdominal vena cava or common iliac vein. Nahum E, Dagan O, Sulkes J, et al. 1996, Israel | 9 children in a paediatric ICU. 8 were mechanically ventilated Age 6mths –14yrs Measurement of right atrial pressure and abdominal vena cava or common iliac vein. CVP ranged from 3-30mmHg |
Observational cohort study | Right atrial pressure compared to IVC or Common iliac vein pressure | Mean difference 0.22mmHg+/-1.52mmHg. 99.2% of readings were less than 2mmHg apart. | This is a study in children only 1 patient was excluded due to unreliable venous waveform of the right atrial catheter 7 patients had congenital heart defects |
| Causes of increased difference | None of Increased CVP, mechanical ventilation and abdominal fluid collection increased difference. | ||||
| Comparison of intrathoracic and intra-abdominal measurements of central venous pressure. Joynt GM, Gomersall CD, Buckley TA, et al. 1996, Hong Kong | 19 critically ill patients mechanically ventilated in ICU Femoral catheter placed close to right atrium in IVC Confirmed by chest radiograph |
Observational cohort study | SVC pressure compared to IVC pressure. | Mean difference is 0.45mmHg (CI 0.30-0.60) | Patients all supine and ventilated Non-standard – 40-70cm multi-lumen catheters used Interestingly – an intra-abdominal pressure change of 2-22cmH20 did not significantly change the differences observed |
| Causes of increased difference | Small tendency for increased PEEP and Mean airway pressure to increase observed difference | ||||
| A comparison of central venous pressure and common iliac venous pressure in critically ill mechanically ventilated patients. Ho KM, Joynt GM, Tan P. 1998, Hong Kong | 20 patients who were mechanically ventilated in ICU Simultaneous monitoring of SVC and common iliac venous pressure, (at L5) using commonly available 20cm central venous catheters SVC range 3-36mmHg |
Observational cohort study | SVC pressure and common iliac vein pressure (CIVP) | Mean difference 0.1mmHg 1.06(SD)mmHg | Patients all supine and ventilated |
| Mesure comparee de la pression dans la veine cave inferieure abdominale et dans la veine cave superieure chez l'adulte. Yazigi A, Richa F, Madi S. 1996, Lebanon | 30 patients post-coronary arterial bypass grafts Common iliac vein catheter placed at L4 level Measurements pre and post extubation |
Observational cohort study | SVC pressure compared to IVC pressure | Mean difference was 0.79mmHG +/- 0.68(SD) mmHg | Common iliac vein rather than IVC measurement |
| Before intubation | Mean difference was 0.6mmHG +/- 0.93(SD) mmHg | ||||
| After extubation | |||||
| Comparison of central venous and inferior vena caval pressures. Walsh JT, Hildick-Smith DJ, Newell SA, et al. 2000, UK | 60 adult patients undergoing right heart studies or angioplasty 28 had impaired LV function and 38 had valvular heart disease |
Observational cohort study | Difference between end expiratory right atrial pressure and SVC or IVC measurement | SVC mean difference -0.08mmHg (CI –2.2 to 0.38)<br><br> IVC Mean difference -0.23mmHg (CI –1.2 to 0.58) | The variability to acute changes were not assessed Range of right atrial pressures found were not reported Inadequate recordings obtained at all recording sites for 5 patients |
Author Commentary:
There is extensive and consistent evidence that right atrial pressure can be reliably measured using both inferior vena cava and common iliac venous pressure measurements in supine patients. This has been proved in ventilated and spontaneously breathing adults and children. The readings of inferior vena caval measured pressures seem to be around 0.5 mm Hg lower than superior vena caval measured pressure on average and rarely more than 3 mm Hg different. This may not apply to patients with raised intra-abdominal pressure but applies to patients with high PEEP or raised mean airway pressures.
Bottom Line:
Inferior vena caval or common iliac venous pressure can be used reliably to measure right atrial pressure and may be regarded as equivalent to readings of superior vena caval pressure.
References:
- Murdoch IA, Rosenthal E, Huggon IC, et al.. Accuracy of central venous pressure measurements in the inferior vena cava in the ventilated child.
- Chait HI, Kuhn MA, Baum VC.. Inferior vena caval pressure reliably predicts right atrial pressure in pediatric cardiac surgical patients.
- Yung M, Butt W.. Inferior vena cava pressure as an estimate of central venous pressure.
- Reda Z, Houri S, Davis AL, et al.. Effect of airway pressure on inferior vena cava pressure as a measure of central venous pressure in children.
- Nahum E, Dagan O, Sulkes J, et al.. A comparison between continuous central venous pressure measurement from right atrium and abdominal vena cava or common iliac vein.
- Joynt GM, Gomersall CD, Buckley TA, et al.. Comparison of intrathoracic and intra-abdominal measurements of central venous pressure.
- Ho KM, Joynt GM, Tan P.. A comparison of central venous pressure and common iliac venous pressure in critically ill mechanically ventilated patients.
- Yazigi A, Richa F, Madi S.. Mesure comparee de la pression dans la veine cave inferieure abdominale et dans la veine cave superieure chez l'adulte.
- Walsh JT, Hildick-Smith DJ, Newell SA, et al.. Comparison of central venous and inferior vena caval pressures.