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Central Venous Pressure (CVP) Monitoring (Pediatric) (1.45)

Central Venous Pressure (CVP) Monitoring (Pediatric) (1.45) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Cardiovascular and Infusion

1.45

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
July 29, 2016

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 1.45P

Original
Revision

Page
1
of 5

Title: Central Venous Pressure (CVP)
Monitoring (Pediatric)

I. PURPOSE

To establish guidelines for obtaining central venous pressure measurements in
pediatric patients.

NOTE: For adult information, please refer to UWHC Nursing Patient Care
Policy 1.45A, Central Venous Pressure (CVP) Monitoring (Adult).

II. POLICY

A. Central venous pressure (CVP) monitoring can be performed through central line
catheters
1. Central line is defined as any venous catheter that ends in a major vein
close to the heart.
a. Umbilical venous catheter (neonatal)
b. Peripherally Inserted Central Catheters (PICCs)
2. CVP monitoring may not be accurate when measured through implanted
ports and tunneled catheters.
B. CVP monitoring is to be performed through the most distal port of the catheter
except with pulmonary artery catheters.
C. Central Venous Pressure monitoring lumen should be dedicated for monitoring
and for intermittent infusions and maintenance fluids if needed.
D. Avoid infusing continuous medications through the CVP lumen (to prevent a
bolus of medication).
E. Refer to For an accurate reading, the transducer needs to be placed at the
phlebostatic axis (fourth intercostal space (ICS), mid axillary line that is in line
with the right atrial level).

III. EQUIPMENT

A. Pressure module and cable
B. Monitoring kit with disposable transducer
C. Heparinized saline syringe
D. Syring pump tubing
E. Monitor extension kit (optional)
F. IV pole with transducer holder (optional)
G. Syringe pump
H. Central line access kit


Page 2 of 5

IV. PROCEDURE

A. Gather supplies
B. CVP line setup should be assembled in the patient room.
C. Don clean gloves
D. Clean surface with hospital approved disinfectant.
E. Perform hand hygiene
F. Open “Central Line Access Kit”- use the inner liner as a sterile surface.
G. Put on mask
H. Open the packages of the CVL line set up onto the opened liner of the central line
access kit
I. Put on sterile gloves
J. Connect the transducer to the syringe tubing
1. Tighten all connections
2. Connect syringe of Heparinized fluid to the tubing that is connected to the
transducer.
3. Prime the tubing and all stopcocks.
a. Turn stopcock off to the distal end.
b. Flush the tubing and transducer by squeezing the two (2) clips until
the flush solution flows out through the white vented cap on the
stopcocks distal to the transducer to flush all parts of the tubing.
i. NOTE: Rapid flushing/filling of tubing contributes to air
bubble formation. Make sure all air bubbles have been
expelled. The presence of air bubbles in the transducer or
tubing may cause inaccurate pressure measurement.
ii. A monitor extension may be added to the distal Luer
connection.
4. Replace the vented caps with dead-end caps. These are provided in the
tubing package.
K. Place syringe into IV pump and program at ordered rate of infusion.
L. Connect cable to transducer.
M. Attach distal end of pressure tubing to distal port of central venous catheter.
N. Identify phlebostatic axis of patient's lateral chest wall to ensure a constant
baseline. This corresponds with the level of the right atrium.
O. During continuous monitoring the alarm should be on at all times

V. PROCEDURE FOR ZEROING, READING, MAINTENANCE, AND
TROUBLESHOOTING OF CVP

A. Zeroing CVP Transducer
1. Position transducer at phlebostatic axis (right atrial level fourth ICS, mid
axillary line), before zeroing. It is recommended to use a pole or transducer
holder to maintain the location of the transducer at the phlebostatic axis.


Page 3 of 5



2. Zero the transducer. Zeroing the transducer equalizes the transducer to
atmospheric pressure and gives an accurate known reference point. Zero the
transducer a minimum of once per shift and PRN:
a. Open the transducer to air by turning stopcock to an off position to the
patient and removing the dead-end cap from that stopcock.
b. To zero on monitor: touch ‘zero’ button on pressure module. Or touch
‘parameter’ key, select CVP, then select zero. Monitor will indicate
when zero is complete. If the system does not zero, check all stopcocks
and connections and re-attempt zeroing. The transducer may need to
be changed, or an alternate pressure channel used on the monitor (if
available) if still unable to zero.
c. Set system to obtain pressure readings.
d. Place new dead end caps on open ports with every zeroing and every
blood draw.
e. Close stopcock to air. Open stopcock to patient.
3. For continuous CVP monitoring verify that the alarm is activated. NEVER
leave a bedside without turning the alarms on.
B. Obtaining CVP Readings
1. CVP readings can be obtained with the head of bed flat (zero) or elevated up
to 45 degrees. Ensure transducer is at phlebostatic axis. Document the bed
angle on the flowsheet so all subsequent readings can be taken in the same
position.
2. Zero transducer at the phlebostatic axis. See section VI, A above.
3. Obtain CVP reading by making sure all fuses are open to patient/catheter
and transducer. Observe the monitor for a CVP waveform.
4. Temporarily suspend infusions going through the CVP monitoring lumen
for CVP reading.
5. Measure CVP at end expiration.
6. Repeat CVP as ordered or as patient condition indicates. If using
intermittent readings, turn fuse off to transducer and open to patient infusion
and resume infusion.

Page 4 of 5

7. Intermittent and maintenance fluids can be infused through the catheter
lumen used for CVP monitoring if needed. It is preferred they are infused
through another lumen if possible to avoid boluses and interruption of the
infusion.
8. Continuous medication infusions should not be infused through the CVP
monitoring lumen unless another central line lumen is not available because
a bolus of the medication will occur when you flush the lumen for CVP
monitoring. If continuous medications must be infused through the CVP
monitoring lumen, the medication will be paused while the measurement is
obtained.
9. The central line lumen, when used for intermittent CVP readings, should be
flushed according to UWHC Guidelines for Flushing/Locking Venous
Access Devices in Pediatric/Adult- Inpatient/Ambulatory Patients.
C. Maintenance of a Central Venous Catheter/CVP Monitoring System
1. At the start of each shift:
a. Assess the line for air bubbles
b. Ensure all connections are tight
c. Ensure that the transducer is at the phlebostatic axis
d. Ensure alarms are on and parameters are set appropriate to the
patient
2. Accuracy of the system will be assessed once a shift and PRN by:
a. Zeroing the transducer
3. Flush solution, pressure tubing and disposable transducers are changed
every 72 hours.
4. For dressing change and catheter maintenance for the central venous
catheter, please refer to Nursing and Patient Care Policy, 1.56 AP, Central
Vascular Access Device Use, Maintenance and Removal (Adult &
Pediatric)Assess for catheter complications (thrombus, infection,
migration).
D. Troubleshooting a CVP Pressure System
1. Tighten loose connections.
2. Assess for a defect in the tubing system. Leakage of fluid from a loose
connection or defect in the system that impairs the transmission of the
pressure waveform and can result in blood backup.
3. Alleviate catheter kinks.
4. Prevent gradual catheter occlusion
a. Maintain continuous flow at ordered rate
5. Notify provider if dampened waveform continues.
6. Absence of waveform.
a. Check that transducer is plugged into monitor cable.
b. Zero – change transducer if unable to zero Ensure stopcocks are
open to patient and transducer.
c. Assess integrity of transducer and tubing system.
7. Documentation:
a. Document per provider order and document the status of the line.





Page 5 of 5

VI. UWHC CROSS REFERENCES

A. Nursing Patient Care Policy 1.14AP, Invasive and Non-invasive Hemodynamic
Monitoring (Adult & Pediatric)
B. Nursing Patient Care Policy 1.45A, Central Venous Pressure (CVP) Monitoring
(Adult)
C. Nursing Patient Care Policy 1.56 AP, Central Vascular Access Device Use,
Maintenance and Removal (Adult & Pediatric)
D. UW Health Flushing/Locking of Venous Access Devices - Pediatric/Adult
Inpatient/Ambulatory Clinical Practice Guideline

VII. REFERENCES

A. Centers for Disease Control and Prevention (2011). Guidelines for the prevention
of intravascular catheter-related infections. http://www.cdc.gov/hicpac/bsi/bsi-
guidelines-2011.html
B. Verger, J. T., & Lebet, R. M. (2008). AACN Procedure Manual for Pediatric
Acute and Critical Care. St. Louis, MO: Elsevier Saunders Co.
C. Verklan, M. T., & Walden, M. (2009). Core curriculum for neonatal intensive
care nursing (4th Ed.). St. Louis, MO: Elsevier Saunders Co.

VIII. REVIEWED BY

Clinical Nurse Specialist, Pediatric Intensive Care
Clinical Nurse Specialist, Neonatal Intensive Care
Director, Pediatric Nursing
Nursing Patient Care Policy and Procedure Committee, July 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer