Yes professor Halawa
I don’t use CVP to guide fluid management in my critically ill patients
I need to convince some of my colleagues who still use it of its futility
This concept is well known for long time with some debating results, as shown in discussion, first article questioned credibility of CVP was published in 1971.
I am not always depending on CVP to highlight blood volume.
Yes because it is a systematic review with level1 of evidence.
Mohammed Sobair
2 years ago
Introductions:
Central venous pressure :
is the pressure recorded from the right atrium or superior vena cava. CVP is measured (usually hourly) in almost all patients in ICU, ER and after surgery to guide fluid balance.
Since CVP plays such a central role in the fluid management strategy of hospitalized patients, the goal of this study was to systemically review the evidence support this practice. Materials and Methods :
aim was to identify all relevant clinical trials that analyzed the relationship between CVP and measured blood volume as well as those studies that determined the ability of CVP to predict fluid responsiveness (ie, an increase in stroke index/cardiac index following a fluid challenge).
All authors independently searched the National Library of Medicine MEDLINE database for relevant studies in any language published from 1966 to June 2007 using the following medical subject headings and key words; central venous pressure (explode) AND blood volume, or fluid therapy or fluid responsiveness. In addition, we searched Embase and the Cochrane Database of Systematic Reviews. Results:
24 studies included in this analysis, 5 studies compared CVP with the measured circulating blood volume while 19 studies determined the relationship between CVP and change in cardiac performance following a fluid challenge (generally defined as a 10 to 15% increase in stroke index/ cardiac index).
In all, 830 patients across a spectrum of medical and surgical disciplines were studied.
The pooled correlation coefficient between the CVP and measured blood volume was 0.16 (95% CI, 0.03 to 0.28; r 2 0.02).
The pooled correlation coefficient between baseline CVP and change in stroke index/ cardiac index (reported in 10 studies) was 0.18 (95% CI, 0.08 to 0.28).
The pooled area under the ROC curve (reported in 10 studies) was 0.56 (95% CI, 0.51 to 0.61).
The pooled correlation between CVP and change in stroke index/cardiac index (reported in seven studies) was 0.11 (95% CI, 0.01 to 0.21).
The baseline CVP (reported in 11 studies) was 8.7 2.3 mm Hg in the responders, as compared to 9.7 2.2 mm Hg in non responders (not signficant; p 0.3).
The Q statistic was not significant for the pooled correlation and area under the curve statistic. Discussion :
The results of this systematic review are clear:
(1) there is no association between CVP and circulating blood volume.
(2) CVP does not predict fluid responsiveness across a wide spectrum of clinical condition.
In none of the studies included in this analysis was CVP able to predict either of these variables.
The results from this study therefore confirm that neither a high CVP, a normal CVP, a low CVP, nor the response of the CVP to fluid loading should be used in the fluid management strategy of any patient.
Level of evidence 1.
Rehab Fahmy
2 years ago
This article also advice against CVP use in prescribing IVF for patients
Their aim was to identify all relevant clinical trials that
analyzed the relationship between CVP and measured blood
volume as well as those studies that determined the abilitv of
CVP to predict fluid responsiveness (ie, an increase in stroke
index/cardiac index following a fluid challenge). Studies that
compared CVP with volumetric measurements (right and left
ventricular end-diastolic volumes, global left heart volume,
central blood volume) but did not report the ability of CVP to
predict volume responsiveness were not included.
Results:
1)there is no association between CVP and circulatingBblood volume, and
(2) CVP does not predict fluid responsiveness
level II :metanalalysis
Nasrin Esfandiar
2 years ago
This is a systematic review about the value of CVP to guide fluid therapy and fluid responsiveness.
Totally, 24 article with 803 patients that met criteria were included.
There was poor correlation between CVP and change in circulatory blood volume.
In addition, CVP had no predictive value for fluid responsiveness.
ROC curve showed 0.56 for the pooled area that indicated failure of a specific CVP cut off as a diagnostic tool in these situations.
In a recent study, it was shown that using CVP to guide fluid therapy would be misleading because CVP is just a measurement for right atrial pressure not blood volume or preload.
The level of evidence provided by this article is 1.
Last edited 2 years ago by Nasrin Esfandiar
Ghalia sawaf
2 years ago
CVP is measured in almost all patients in ICUs throughout the world, in emergency department patients, as well as in patients undergoing major surgery.
The basis for using CVP to guide fluid management comes from the dogma that CVP reflects intravascular volume;
• low CVP are volume depleted
• high CVP are volume overloaded.
“the most important application of CVP monitoring is to provide an estimate of
the adequacy of circulating blood volume” during anesthesia and surgery
are also useful in estimating fluid or blood loss
and guiding replacement therapy.”
Over 25 years ago, the “5–2” rule for guiding fluid therapy was popularized.
Recently, the idea that the CVP reflects blood volume has been challenged.
The goal of this study was to systemically review the evidence that supports this practice.
Materials and Methods Identification of Trials
identify all relevant clinical trials that analyzed
1. the relationship between CVP and measured blood volume
2. as well as those studies that determined the ability of CVP to predict fluid responsiveness
Criteria of exclusions:
Studies that compared CVP with volumetric measurements but did not report the ability of CVP to predict volume responsiveness
The study restricted this analysis to human adults; however, there was no restriction as to the type of patient or the setting where the study was performed.
All authors independently searched the National Library of Medicine MEDLINE database for relevant studies in any language published from 1966 to June 2007
They searched Embase and the Cochrane Database of Systematic Reviews.
Study Selection and Data Extraction
Only studies that reported either of the following were included in this analysis:
(1) the correlation coefficient between CVP and measured blood volume,
(2) or the correlation coefficient or receiver operator characteristic (ROC) between CVP or change in CVP and change in stroke index/cardiac output following a fluid challenge.
Data were abstracted on
• study design,
• study size,
• study setting,
• patient population,
correlation coefficients and area (including 95% confidence intervals [CIs]) under the ROC curve
the percentage of patients responding to a fluid challenge ( increase in the stoke index or cardiac index 10 to 15%) as well as the baseline CVP in the fluid responders and nonresponders.
The random-effects models was used to determined the pooled area under the curve (AUC) and correlation coefficients.
We calculated the Cochran Q statistic to test for statistical heterogeneity.
When not reported in the primary paper, the correlation coefficients were calculated from the raw data
Results
The initial search strategy generated 206 citations
189 were excluded due to trial design or failure to report an outcome variables of interest.
Seven studies were identified from the bibliographies of the selected articles and review articles.
Of the 24 studies included in this analysis:
• 5 studies compared CVP with the measured circulating blood volume
• 19 studies determined the relationship between CVP and change in cardiac performance following a fluid challenge
5. (830) patients were studied.
• The pooled correlation coefficient between the CVP and measured blood volume was 0.16.
Heterogeneity was present between studies.
Overall 56+/_16% (mean+/_SD) of the patients included in this review responded to a fluid challenge.
• The pooled correlation coefficient between baseline CVP and change in stroke index/ cardiac index (reported in 10 studies) was 0.18 .
The pooled area under the ROC curve (reported in 10 studies) was 0.56 (95%CI,0.51 to0.61).
• The pooled correlation between CVP and change in stroke index/cardiac index (reported in seven studies) was0.11.
The baseline CVP (reported in 11 atudies) was 8.7+/_2.3 mmHg in the responders, as compared to 9.7+/_2.2 mmHg in non responders (not significant; p0.3).
The Q statistic was not significant for the pooled correlation and area under the curve statistic.
Discussion
The results of this systematic review are clear:
(1) There is no association between CVP and circulating blood volume,
(2) And CVP does not predict fluid responsiveness across a wide spectrum of clinical conditions.
.The pooled area under the ROC curve was 0.56.
. In other words, the results suggest that at any CVP the likelihood that CVP can accurately predict fluid responsiveness is only 56%
. an AUC of 0.56 suggests that there is no clear cutoff point that helps the physician to determine if the patient is “wet” or “dry.”
. The results from this study therefore confirm that neither a high CVP, a normal CVP, a low CVP, nor the response of the CVP to fluid loading should be used in the fluid management strategy of any patient.
The strength of this review
includes the rigorous selection criteria used to identify relevant studies as well as the use of quantitative end points.
As demonstrated by this study, only about a half of patients administered a fluid bolus will demonstrate a positive hemodynamic response to the intervention.
If fluid resuscitation is guided by CVP, it is likely that patients will have volume overload and pulmonary edema.
In sepsis cases in adult patients; “fluid infusion should be titrated to a filling pressure” and that “pulmonary edema may occur as a complication of fluid resuscitation and necessitates monitoring of arterial oxygenation.”
Should volume overload and pulmonary edema be the end point of fluid resuscitation?
• a positive fluid balance in both ICU patients and those undergoing surgery has been associated with increased complications and a higher mortality.
• the resuscitation guided by CVP will results in inadequate volume replacement.
• the use of diuretics based on CVP may result in intravascular volume depletion leading to poor organ perfusion and ultimately renal failure and multiorgan failure because a “high” CVP does not necessarily reflect volume overload.
Once the left ventricle is functioning near the “flat” part of the Frank-Starling curve, fluid loading has little effect on cardiac output and only serves to increase tissue edema and to promote tissue dysoxia
The results from this article clearly demonstrate that CVP should not be used for this purpose.
CVP does not reflect intravascular volume and is a misleading tool for guiding fluid therapy is not new.
in 1971, Forrester and colleagues concluded that “CVP monitoring in acute myocardial infarction is at best of limited value and at worst seriously misleading.”
In 1975, Baek and colleagues established that “there was no correlation of blood volume with central venous pressure” and suggest that “inaccurate physiologic evaluation of critically ill patients is likely to jeopardize survival by inviting inappropriate and ineffectual therapy.”
In 1977, Dr. Burch, noted that “to accept no critically the level of central venous pressure as a quantitative index of blood volume can only lead to physiologic and/or therapeutic errors.”
Magder and colleagues reported that the respiratory variation in CVP in spontaneously breathing patients was predictive of fluid responsiveness. Additional studies are required to support using the respiratory variation in CVP to guide fluid management.
In addition, it should be noted that in the ARDS net fluid management trial, those patients randomized to the “CVP conservative strategy” group had significantly more ventilator-free days and a shorter length of ICU stay.
Hughes and Magovern,in 1959 described a complicated technique for right atrial monitoring as a guide to blood volume replacement in post-thoracotomy patents.
These authors described a fall in CVP with blood loss and a relationship between the CVP and blood transfusion.
Based on the results of this systematic review, CVP should no longer be routinely measured in the ICU, operating room, or emergency department.
the CVP may be useful in select circumstances,
• in patients who have undergone heart transplant,
• or in those who have suffered a right ventricular infarction
• or acute pulmonary embolism.
CVP may be used as a marker of right ventricular function rather than an indicator of volume status.
Level 1 systematic review
This study should change my practice However we need to find alternative useful techniques which can be available in my country such as US of thoracic.
Bioimpedance is not available in our center
Jamila Elamouri
2 years ago
Summary:
Does Central Venous Pressure Predict Fluid Responsiveness?
Central venous pressure is the pressure measured from the right atrium or superior vena cava. It is widely used in ICUs, in emergency department, and in patients undergo major surgery to make decision about fluids or diuretics use. CVP is based on the principle of its reflection on intravascular volume status as had been authorized in most medical text book. Recently, the idea that the CVP reflects blood volume has been challenged. Materials and Methods Identification of Trials The aim was to identify all relevant clinical trials that analyzed the relationship between CVP and measured blood volume as well as those studies that determined the ability of CVP to predict fluid responsiveness. They used a multimethod approach to identify relevant studies for this review. The authors searched MEDLINE database for relevant studies in any language published from 1966 to June 2007 using key words; central venous pressure AND blood volume, or fluid therapy or fluid responsiveness. Also, they searched Embase and Cochrane Database of systemic Reviews. This metaanalysis according to guidelines proposed by the quality of reporting of Meta-analyses group. Study Selection and Data Extraction Only studies that include (1) the correlation coefficient between CVP and measured blood volume, or (2) the correlation coefficient or receiver operator characteristic (ROC) between CVP or change in CVP (CVP) and change in stroke index/cardiac output following a fluid challenge were selected. Results: Of the 24 studies included in this analysis, 5 studies compared CVP with the measured circulating blood volume while 19 studies determined the relationship between CVP and change in cardiac performance following a fluid challenge (generally defined as a ˃ 10 to 15% increase in stroke index/ cardiac index). The pooled correlation coefficient between the CVP and measured blood volume was 0.16 (95% CI, 0.03 to 0.28; r2 = 0.02). Overall 56 ± 16% (mean ± SD) of the patients included in this review responded to a fluid challenge. The Q statistic was not significant for the pooled correlation and area under the curve statistic. Discussion: The result of this study includes: 1) there is no association between CVP and circulating blood volume, 2) CVP does not predict fluid responsiveness across a wide spectrum of clinical condition. In other words, our results suggest that at any CVP the likelihood that CVP can accurately predict fluid responsiveness is only 56% which represent AUC. That no clear cutoff point helps the physician to determine if the patient is wet or dry. The results from this study therefore confirm that neither a high CVP, a normal CVP, a low CVP, nor the response of the CVP to fluid loading should be used in the fluid management strategy of any patient. Strength of the study: 1. Rigorous selection criteria. 2. use of quantitative end points. 3. The studies are notable for consistency of their findings. 4. All studies included in this study do not take the positive end-expiratory pressure levels or changes in intrathoracic pressure into account when recording CVP. RV filling depends on right atrium transmural pressure in addition to CVP. If fluid resuscitation is guided by CVP, it is likely that patients will have volume overload and pulmonary edema. If fluid resuscitation is guided by CVP, it is likely that patients will have volume overload and pulmonary edema. Should volume overload and pulmonary edema be the end point of fluid resuscitation? This is so important as excess fluid resuscitation leading to fluid overload is associated with increased complication and higher mortality. CVP guided fluid resuscitation can result in inadequate fluid resuscitation which lead to decreased organ perfusion and organ failure. As well, diuretics use based on CVP may cause intravascular volume depletion with poor perfusion to organs and organ failure. Because high CVP does not mean volume overload. It is critical during resuscitation of critically ill patients to determine whether the patient is fluid responsive or no. according to this study, CVP should not be used for this purpose. Conclusion: CVP should no longer be routinely measured in the ICU, operating room, or emergency department.
Level 1 Metaanalysis
we still use CVP to guide fluid management and after this, I like to change our practice
Tahani Ashmaig
2 years ago
Does Central Venous Pressure Predict Fluid Responsiveness?* A Systematic Review of the Literature and the Tale of Seven Mares ☆Introduction: ▪︎Central venous pressure (CVP) is the pressure recorded from the right atrium or superior vena cava. It is frequently used to make decisions regarding the administration of fluids or diuretics.
▪︎CVP reflects intravascular volumeand it is used almost universally to guide fluid therapy in hospitalized patients. ☆ The Objective of the study: A systematic review of the literature to determine the following:
(1) the relationship between CVP and blood volume,
(2) the ability of CVP to predict fluid responsiveness, and
(3) the ability of the change in CVP (_CVP) to predict fluid responsiveness. ☆Data sources: MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles. ☆Study selection: Reported clinical trials that evaluated either the relationship between CVP and blood volume or reported the associated between CVP/_CVP and the change in stroke volume/cardiac index following a fluid challenge.
– From 213 articles screened, 24 studies met our inclusion criteria and were included for data extraction.
– The studies included human adult
subjects, healthy control subjects, and ICU and operating room patients. ☆Data extraction: Data were abstracted on study design, study size, study setting, patient population, correlation coefficient between CVP and blood volume, correlation coefficient (or receive operator
characteristic [ROC]) between CVP/_CVP and change in stroke index/cardiac index, percentage of patients who responded to a fluid challenge, and baseline CVP of the fluid responders and nonresponders.
– Metaanalytic techniques were used to pool data. ☆Data synthesis: The 24 studies included 803 patients; 5 studies compared CVP with measured circulating blood volume, while 19 studies determined the relationship between CVP/_CVP and change in cardiac performance following a fluid challenge.
– The pooled correlation coefficient
between CVP and measured blood volume was 0.16 (95% confidence interval [CI], 0.03 to 0.28).
Overall, 56 _ 16% of the patients included in this review responded to a fluid challenge. — –The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 (95%
CI, 0.08 to 0.28).
– The pooled area under the ROC curve was 0.56.
– The pooled correlation between _CVP and change in stroke index/cardiac index was 0.11.
– Baseline CVP was 8.7 _ 2.32 mm Hg [mean _ SD] in the responders as compared to 9.7 _ 2.2 mm Hg in nonresponders (not significant).
☆The strength of our review:
1. The rigorous selection criteria used to identify relevant
2. The use of quantitative end points.
3. The studies are notable for the consistency of their findings.
☆The results of this study are most disturbing considering that 93% of intensivists report using CVP to guide fluid management.
☆ Conclusions: ▪︎This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/_CVP to predict the hemodynamic response to a fluid challenge.
▪︎ CVP should not be used to make clinical decisions regarding fluid management.
Wael Jebur
2 years ago
A metanalysis study conducted to verify the validity of central venous pressure in reflecting blood volume status. Correlation between central venous pressure and circulatory volume is performed via measuring blood volume in relation to CVP or estimating stroke volume and cardiac index after fluid replacement. There was a staggering hypothesis, debating the sensitivity and specificity of CVP in reflecting the blood volume and this study was initiated to verify this hypothesis.
24 studies were analyzed regarding the blood volume status correlated to CVP and response to volume replacement.
5 studies compared CVP with blood volume and 19 studies verified CVP/Delta CVP by measuring stroke volume and cardiac index changes after fluid challenge.
The finding was inconclusive and did not demonstrate a direct correlation between fluid replacement and changes in CVP.
The putative explanation is entirely dependent on the assumption that cardiac output will be increased as per ascending state of Frank -starling law when fluid volume is replaced. However, when Frank Starling curve is flat, fluid replacement would be futile in unsuccessful in increasing the cardiac output, and excess fluid would be accumulated in extra-vascular tissues and spaces.
Therefore, CVP is not a sensitive tool to assess blood volume status.
This study is metanalysis study with level of evidence 5
Rihab Elidrisi
2 years ago
The study concluded that there was no association between CVP and circulating blood volume, and CVP does not predict fluid responsiveness hence CVP should not be used for strategizing fluid management in any patient. CVP may be useful in certain specific conditions like a heart transplant, pulmonary embolism, and right ventricular infarction, as a marker of right ventricular function (and not as a marker of fluid status).
The strengths of the study include well-defined stringent selection criteria involving quantitative endpoints, and consistent findings of the involved studies. Limitations of the study include non-utilization of positive end-expiratory pressure levels or alteration in intrathoracic pressure while calculating CVP by the studies involved.
The article is a systematic review of the literature: level 1 evidence.
Mohamad Habli
2 years ago
Introduction: The central venous pressure, also known as CVP, is a measurement that is used in intensive care units all over the world to monitor and direct fluid management.
The purpose of this systematic review was to investigate the relationship between central venous pressure (CVP) and blood volume; to determine how accurately CVP can predict fluid responsiveness; and to investigate how variations in CVP can predict fluid responsiveness.
Methodology: In their search for the pertinent papers, they searched the MEDLINE, Embase, and Cochrane data bases.
Only 24 of the 213 studies were selected for inclusion because they satisfied the requirements for recruitment.
The pooled correlation coefficient between CVP and blood volume was 0.16 (95% confidence interval [CI], ranging from 0.03 to 0.28).
The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 (with a 95% confidence interval ranging from 0.08 to 0.28).
The area under the ROC curve was calculated to be 0.56 (confidence interval, 95%: 0.51 to 0.61)
The pooled correlation between changes in cardiac output and stroke index or cardiac index was 0.11 (95% confidence interval: 0.015 to 0.21)
In all, 56 +/- 16% of the subjects reacted to a fluid challenge, and the baseline CVP was 8.7 +/- 2.32 mmHg in the responders, whereas it was 9.7 +/- 2.22 mmHg in the non responders.
In conclusion, the results of this investigation showed that there is a very weak association between CVP and blood volume, and that changes in CVP are unable to accurately predict fluid responsiveness. For this reason, central venous pressure should not be utilized as a guidance for fluid therapy.
Marius Badal
2 years ago
Summarise this article
What is the evidence provided by this article?
There has always been controversy as to which method is better to determine central venous pressure (CVP) to predict fluid responsiveness. Different articles show different results but this article, will focus on central venous pressure does it predict fluid responsiveness through a systematic review of the literature and the tale of seven mares. CVP is the pressure that is measured from the right atrium and the superior vena cava. In patients that are found in ICU, it is important and it is measured hourly. Initially, it was used as a marker to determine if a patient is dehydrated that is it measures the intravascular volume. This study was to systematically review the supporting evidence for the practice.
The material and methods:
1) The aim of the study was to review all the studies that analyzed the relationship between CVP and measuring blood volume.
2) The study also included studies that determine the ability of CVP to predict fluid responsiveness
3) The study was based on a period from 1966 to June 2007. A specified form was used to abstract the data needed for the study.
The Results:
1) There were about 24 studies included in the article of such, 5 of the studies were comparing CVP to measure circulating blood volume, and 19 of the studies were used to know the relation between CVP and change in cardiac performance following a fluid challenge.
2) The correlation coefficient that was found between the CVP and measured blood volume was 0.16.
3) It was noted that 56% of the patients responded to the fluid challenge.
4) The pooled correlation between the change in CVP measurements and the change in stroke volume was about 0.11
Discussion:
Based on the results obtained, there was no association between CVP and the circulating blood volume, and the CVP does not predict fluid responsiveness. There is evidence that the patient is likely to respond to a fluid challenge with either low or high CVP. CVP cannot determine if the patient has sufficient fluid.
The article’s strength was:
1) Identifying all relevant studies and to use as them as a quantitative endpoint.
2) It was consistent with the findings
Limitations of the article:
1) The study never included PEEP levels and intrathoracic pressure while recording the CVP.
In conclusion, it was noted that there was a poor correlation between the CVP and the blood volume as also the ratio of the CVP to the delta CVP to predict the patient hemodynamic response to the fluid challenge test. It should not be routinely used in ICU and other emergency departments but has it positive in elaborating if the patient has suffered left ventricular infarction or acute PE which is a marker of right ventricular function rather than a volume status.
The article is a systematic review of the literature: level 1 evidence.
We used to use CVP level to follow the fluid status.
Manal Malik
2 years ago
Summary ofDoes central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares
CVP is the pressure recorded from the right atrium or superior vena cava. It is used to make decision of fluid administration or diuretic.
Recently, the idea that the CVP reflects blood volume has been challenged since CVP has a role in fluid management of hospitalized patients. The goal of this study was to systematically review the evidence that support this practice. Study selection and data extraction:
Studies that are including in this analysis:
The correlation coefficient between CVP and measured blood volume or (2) the correlation coefficient or receiver operator characteristic between CVP and change in stroke index /cardiac output following fluid challenge, in general an increase in the stroke index or cardiac output >10 to 15% was used as an index of fluid responsiveness.
The random effects models was used to determined the pooled area under the curve and corelation coefficient Results.
24 hours studies included in this analysis, 5 studies compared cardiac output with the measured circulating blood volume while 19 studies determined the relationship between CVP and change in cardiac performance following a fluid challenge >10 or >15% increase in stroke index/cardiac index. Discussion:
The result of this systemic review are clear:
1. There is no association between CVP and circulating blood volume
2. CVP dose not predict fluid responsiveness across mide spectrum of clinical condition.
There is no clear cut of point that help the physician to determine if the patient is wet or dry. The strength of our review:
1. The rigorous selection criteria used to identify relevant studies as well as the use of quantitative end point.
2. Further-more, the studies are notable for the counselling of their finding are likely to be true.
3. The result from this article clearly demonstrated that CVP should not be used for this purpose.
Limited data support using CVP to guide fluid therapy
Additional studies are needed to support using the respiratory variation in CVP to guide fluid therapy. Management:
The CVP is a measure of right atrial pressure alone and not a measured of blood volume or ventricular preload.
Based on the result of asystemic review, we believe that CVP should no longer be routinely measured
Selected condition CVP can be useful:
1. Recent transplant patient
2. Right ventricular infraction
3. Acute pulmonary embolism
In this condition is a marker of right ventricular rather than indication of volume status.
evidence of this systemic review is level one
Zahid Nabi
2 years ago
CVP for decades have been considered as the best way to assess volume status of patients and in most of ICUs fluid therapy was CVP guided. This concept has already been challenged and currently this is not considered as the standard. This article which was published way back in 2008 has also challenged this concept.
Material and Methods Aim of the study was to identify all relevant clinical trials that analyzed the relationship between CVP and measured blood volume as well as those studies that determined the ability of CVP to predict fluid responsiveness (ie, an increase in stroke index/cardiac index following a fluid challenge).
They used a multimethod approach to identify relevant studies for this review. All authors indepen- dently searched the National Library of Medicine MEDLINE database for relevant studies in any language published from 1966 to June 2007 using the following medical subject head- ings and key words; central venous pressure (explode) AND blood volume, or fluid therapy or fluid responsiveness. In addition, we searched Embase and the Cochrane Database of Systematic Reviews. Bibliographies of all selected articles and review articles that included information on hemodynamic monitoring were reviewed for other relevant articles. In addition, the authors reviewed their personal files and con- tacted experts in the field. From 213 articles screened, 24 studies met inclusion criteria and were included for data extraction. The studies included human adult subjects, healthy control subjects, and ICU and operating room patients.
Data extraction: Data were abstracted on study design, study size, study setting, patient population The 24 studies included 803 patients; 5 studies compared CVP with measured circulating blood volume, while 19 studies determined the relationship between CVP/CVP and change in cardiac performance following a fluid challenge. The pooled correlation coefficient between CVP and measured blood volume was 0.16 (95% confidence interval [CI], 0.03 to 0.28). Overall, 56 +-16% of the patients included in this review responded to a fluid challenge. The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 (95% CI, 0.08 to 0.28). The pooled area under the ROC curve was 0.56 (95% CI, 0.51 to 0.61). The pooled correlation between CVP and change in stroke index/cardiac index was 0.11 (95% CI, 0.015 to 0.21). Baseline CVP was 8.7+- 2.32 mm Hg [mean +- SD] in the responders as compared to 9.7+- 2.2 mm Hg in nonresponders (not significant). CONCLUSION Based on the results of this systematic review, the authors believe that CVP should no longer be routinely measured in the ICU, operating room, or emergency department. However, measurement of the CVP may be useful in select circumstances, such as in patients who have undergone heart transplant, or in those who have suffered a right ventricular infarction or acute pulmonary embolism. In these cases, CVP may be used as a marker of right ventricular function rather than an indicator of volume status. Level of evidence Systemic review LEVEL 3
OUR PRACTICE We no longer use CVP to guide fluids therapy in our transplant patients
Amit Sharma
2 years ago
Summarise this article
Central venous pressure (CVP), the pressure at right atrium or superior vena cava, is used very frequently to decide about fluid therapy in patients. The study was conducted to assess the effect of CVP on blood volume as well as fluid responsiveness, and effect of change in CVP on fluid responsiveness.
A total of 24 studies were included in the study out of 206 citations. 5 studies dealt with relationship between CVP and blood volume, while 19 studies dealt with CVP and change in cardiac performance following a fluid challenge. The study included 830 patients across wide spectrum of medical and surgical scenarios. The pooled correlation coefficient was 0.16 between CVP and measured blood volume, 0.18 between baseline CVP and change in stroke index/cardiac index, and 0.11 between change in CVP and change in stroke index/cardiac index. The pooled area under the ROC curve was 0.56%, implying that at any CVP, only 56% of the patients responded to fluid challenge, and there is no cutoff point to help determine whether the patient is ‘wet’ or ‘dry’.
The study concluded that there was no association between CVP and circulating blood volume, and CVP does not predict fluid responsiveness and hence CVP should not be used for strategizing fluid management in any patient. CVP may be useful in certain specific conditions like heart transplant, pulmonary embolism, and right ventricular infarction, as a marker of right ventricular function (and not as marker of fluid status).
The strengths of the study include well defined stringent selection criteria involving quantitative end points, and consistent findings of the involved studies.
Limitations of the study include non-utilization of positive end-expiratory pressure levels or alteration in intrathoracic pressure while calculating CVP by the studies involved.
What is the evidence provided by this article?
Level of evidence: Level 1 – systematic review
Mohammad Alshaikh
2 years ago
Summarise this article Introduction: The CVP is the pressure measured from right atrium or superior vana cava, it was widely used to guide fluid therapy in hospital settings, it was measured during anesthesia and surgery and though it was useful in estimating fluid or blood loss and guiding replacement therapy. This study conducted to evaluate the evidence behind this practice.
Method: All articles reviewing the relationship between CVP and measurement of blood volume and those studies that determined the ability of CVP to predict fluid responsiveness were cited. Studies included in analysis are those showing: (1) the correlation coefficient between CVP and measured blood volume. (2) the correlation coefficient or receiver operator characteristic (ROC) between CVP or change in CVP (CVP) and change in stroke index/cardiac output following a fluid challenge. Out of 189 articles, 24 were included in the systemic review, 5 studies compared CVP with the measured circulating blood volume, and 19 studies determines relationship between CVP and change in cardiac performance following a fluid challenge (generally defined as a 10 to 15% increase in stroke index/ cardiac index).
Results: The correlation coefficient between the CVP and measured blood volume was not significant, and 56 -/+ 16% responded to fluid challenge. The pooled correlation coefficient between baseline CVP and change in stroke index/ cardiac index was 0.18 (95% CI, 0.08 to 0.28). The pooled area under the ROC curve was 0.56 (95% CI, 0.51 to 0.61). The pooled correlation between CVP and change in stroke index/cardiac index was 0.11 (95% CI, 0.01 to 0.21). The baseline CVP was 8.7 +/-2.3 mm Hg in the responders, as compared to 9.7 +/-2.2 mm Hg in nonresponders (not significant; P=0.3).
The strength of study: The rigorous selection criteria used to identify relevant studies as well as the use of quantitative end points.
The limitations of study: No control groups with no CVP measured in these studies. No respiratory variations effect on CVP were obtained. Conclusion: The CVP does not reflect circulating blood volume, and does not predict fluid responsiveness, so it should not routinely measured in the ICU, operating room, or emergency department. The CVP may be used as a marker of right ventricular function in patients who have undergone heart transplant, those with a right ventricular infarction or acute pulmonary embolism. What is the evidence provided by this article? Level of evidence is IIa – Meta-analysis of cohort studies.
Abhijit Patil
2 years ago
Summary:
Background:
Central venous pressure (CVP) is used almost universally to guide fluid therapy in
hospitalized patients.
But, this approach needs re-evaluation.
Objective:
A systematic review of the literature to determine the following:
(1) the relationship between CVP and blood volume,
(2) the ability of CVP to predict fluid responsiveness,
(3) the ability of the change in CVP to predict fluid responsiveness.
Data sources:
MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of
relevant primary and review articles.
Study selection:
From 213 articles screened, 24 studies met inclusion criteria and were included for data extraction.
The 24 studies included 803 patients; 5 studies compared CVP with measured
circulating blood volume
Results:
The pooled correlation coefficient between CVP and measured blood volume was 0.16
Overall, 56 +/- 16% of the patients included in this review responded to a fluid challenge.
The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18
The pooled area under the ROC curve was 0.56 (95% CI, 0.51 to 0.61).
The pooled correlation between change in CVP and change in stroke index/cardiac index was 0.11
Baseline CVP was 8.7+/- 2.32 mm Hg in the responders as compared to 9.7 +/- 2.2 mm Hg in nonresponders (not significant).
Conclusions:
This systematic review demonstrated a
very poor relationship between CVP and blood volume
inability of CVP /change in CVP to predict the hemodynamic response to a fluid challenge.
CVP should not be used to make clinical decisions regarding fluid management
Sir, we have stopped using CVP for fluid management in general urological and kidney transplant patients.
Assafi Mohammed
2 years ago
Summary of the article “Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares”
This is a systematic review of literature between 1966 and June 2007, to determine the followings: · the relationship between CVP and blood volume. · the ability of CVP to predict fluid responsiveness. · the ability of the change in CVP to predict fluid responsiveness.
Study’s Outcome · There is no association between CVP and circulating blood volume. · CVP does not predict fluid responsiveness across a wide spectrum of clinical conditions. · The likelihood that CVP can accurately predict fluid responsiveness is only 56% (no better than flipping a coin). · The results from this study, confirm that neither a high CVP, a normal CVP, a low CVP, nor the response of the CVP to fluid loading should be used in the fluid management strategy of any patient.
CVP may be used as a marker of right ventricular function rather than an indicator of volume status, in select circumstances: · Heart transplant surgery. · Right ventricular infarction. · Acute pulmonary embolism. Strengths of the study · the rigorous selection criteria used to identify relevant studies as well as the use of quantitative end points. · The studies are notable for the consistency (both in magnitude and direction) of their findings. Limitations of the study · None of the studies included in this analysis took the positive end-expiatory pressure levels or changes in intrathoracic pressure into account when recording CVP.
What is the evidence provided by this article?
This is a retrospective analysis(systematic review)
Level of evidence grade 3.
Huda Al-Taee
2 years ago
Summary:
Aim of the study:
to determine:
the relationship between CVP and blood volume.
the ability of CVP to predict fluid responsiveness.
the ability of the change in CVP to predict fluid responsiveness.
Methods:
Design: a systematic review of the literature.
Data sources: MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles.
Study selection: Reported clinical trials that evaluated either the relationship between CVP and blood volume or reported the association between CVP/delta CVP and the change in stroke volume/cardiac index following a fluid challenge.
From 213 articles screened, 24 studies met the inclusion criteria and were included for data extraction. The studies included human adult subjects, healthy control subjects, and ICU and operating room patients.
Data extraction: Data were abstracted on study design, study size, study setting, patient population, the correlation coefficient between CVP and blood volume, correlation coefficient (or receive operator characteristic [ROC]) between CVP/delta CVP and change in stroke index/cardiac index, percentage of patients who responded to a fluid challenge, and baseline CVP of the fluid responders and nonresponders. Meta-analytic techniques were used to pool data.
Results:
The 24 studies included 803 patients; 5 studies compared CVP with measured circulating blood volume, while 19 studies determined the relationship between CVP/delta CVP and change in cardiac performance following a fluid challenge. The pooled correlation coefficient between CVP and measured blood volume was 0.16. Overall, 56 +-16% of the patients included in this review responded to a fluid challenge. The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18. The pooled area under the ROC curve was 0.56. The pooled correlation between delta CVP and change in stroke index/cardiac index was 0.11. Baseline CVP was 8.7+- 2.32 mm Hg in the responders as compared to 9.7+- 2.2 mm Hg in nonresponders (not significant).
Conclusion:
This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/delta CVP to predict the hemodynamic response to a fluid challenge. CVP should not be used to make clinical decisions regarding fluid management.
Level of evidence:
Level 1 (systematic review).
mai shawky
2 years ago
Club 5; CVP in intravascular volume assessment in KT Summary
· CVP is most commonly used tool to assess the volume status intraoperative and in critically ill patients, it measures the venous pressure in right atrium and SVC and frequently used to determine the clinical decision to give IV fluids or diuretics. As it was thought that lower CVP means hypovolemia and volume depletion and vice versa.
· The current study aimed to find the correlation between changes in the CVP and volume status and fluid responsiveness, to predict the fluid responsiveness in patients.
· The CVP was not indicator of the volume status, not correlated with blood volume, and change in CVP did not reflect the fluid resuscitation or predicted the fluid responsiveness. Level of evidence: systematic review (level I)
Hussam Juda
2 years ago
· CVP is measured in almost all patients in ICUs throughout the world, and frequently used to make decisions about giving fluids or diuretics
· Recently, the idea that the CVP reflects blood volume has been challenged
· the goal of this study was to evaluate the role of CVP in fluid management
Materials and Methods
· Inclusion criteria: 1) all relevant clinical trials that analyzed the relationship between CVP and measured blood volume.
2) studies that determined the ability of CVP to predict fluid responsiveness
· Exclusion criteria: Studies that compared CVP with volumetric measurements but did not report the ability of CVP to predict volume responsiveness
· All authors used the National Library of Medicine MEDLINE database for relevant studies published from 1966 to June 2007
· An increase in the stroke index or cardiac index 10 to 15% was used as an index of fluid responsiveness
Discussion
· The results of the study:
1.There is no association between CVP and circulating blood volume
2.CVP does not predict fluid responsiveness across a wide spectrum of clinical conditions.
The strength of the review
· Strict selection criteria used to identify relevant studies and the use of quantitative end points
· the studies are notable for the consistency (both in magnitude and direction) of their findings Limitation:
none of the studies included in the analysis took the PEEP levels or changes in intrathoracic pressure into account when recording CVP
CONCLUSIOS
· CVP should not be routinely measured in the ICU, operating room, or emergency department.
· CVP measurement can be helpful in:
1) patients who have undergone heart transplant,
2) patients with right ventricular infarction or acute pulmonary embolism.
As CVP may be used as a marker of right ventricular function.
This is a systemic review, evidence 1
Huda Mazloum
2 years ago
● Central venous pressure (CVP) is the pressure recorded from the right atrium or superior vena cava.
● CVP is frequently used to make decisions regarding the administration of fluids or diuretics.
● Recently, the idea that the CVP reflects blood volume has been challenged.
● studies included in this analysis:
(1) the correlation coefficient between CVP and measured blood volume
(2) the correlation coefficient or receiver operator characteristic (ROC) between CVP or change in CVP (-CVP) and change in stroke index/cardiac output following a fluid challenge.
● The results of this systematic review are clear:
(1) there is no association between CVP and circulating blood volume
(2) CVP does not predict fluid responsiveness across a wide spectrum of clinical conditions.
● there is no clear cutoff point that helps the physician to determine if the patient is “wet” or “dry.”
● The strength of review includes
* the rigorous selection criteria used to identify relevant studies
* the use of quantitative end points
* studies are notable for the consistency
(both in magnitude and direction) of their findings.
● 93% of intensivists use CVP to guide fluid therapy. I
● right ventricular filling is dependent on the transmural right atrial pressure gradient rather than the CVP alone.
● CVP is a measure of right atrial pressure alone; and not a measure of blood volume or ventricular preload.
● CVP should no longer be routinely measured in the ICU, operating room, or emergency department.
● measurement of the CVP may be useful in select circumstances:
** patients who have undergone heart transplant
** who have suffered a right ventricular infarction or acute pulmonary embolism.
● Level 1
● I notice that cvp is not accurate in assessment the state of volume in our patients but can you suggest other tools ?
KAMAL ELGORASHI
2 years ago
Summary of the article; Central venous pressure, (CVP) is the pressure of the right atrium and superior vena cava. Measured hourly in indicated patient in ICU. The CPV when applied , it was design as a marker of intravascular volume (whethwer volume depleted or overloaded). Over 25 years the rule 5-2 used to guide fluid therapy, and it widely used till now, and the goal of this study is to systematically review the evidence to support this practice. Material and methods;
A Trial that nalyse the relationship between CVP and measured blood volume, and the ability of CVP to predict fluid responsiveness.
A trial that compared CVP with volumetric measures ( Rt and Lt ventricular end diastolic volume, global Lt heart volume, central blood volume, but didnot report the predictivity of CVP for volume responsiveness.
Study designed to predict fluid responsiveness of CVP.
Study stricted to human adults, with no restriction to patient type or setting where the study is performed.
The Author collect all data from all relavent studies from 1966 to 2007.
Study use the relevant data from oher study, comparing CVP and measured blood volume, CVP and change in stroke/COP index.
Results;
Over 24 studies included in this article, 5 studies compared CVP to measured circulating blood volume, 19 studies for relation between CVP and change in cardiac performance following a fluid challenge. Discussion;
Results found that, no assocaiation between CVP and blood volume.
CVP does not predict fluid responsiveness to a fluid challenge.
CVP cannot tell us that the patient is wet or dry.
Strengths;
Rigerous selection of all relevant studies, and use of quantitative end points.
The study was notable for consistently of their finding.
None of studies included took the positive end-expiratory pressure levels or changes in intrathoracic pressure into account when recording CVP .
Studies and articles;
Forrester and colleague; article in 1971, CVP in acute MI is at best of limited vlue and at worst seriously misleading.
Baek and colleagues; in 1975; no correlation between CVP and venous pressure.
Dr Burch in 1977; to accept non critical CVP measurement as a quantitativele index of blood volume can lead to physiologic and therapeutic error.
Magder and colleagues; reported that the respiratory variation in CVP in spontaneously breathing patient was predictive of fluid responsiveness.
Level of evidence ((V)) Review ariticle
Heba Wagdy
2 years ago
CVP is commonly used to guide fluid therapy, the need for diuretics and to determine the endpoint of fluid resuscitation.
It is believed that CVP reflect intravascular volume and the volume status, changes in CVP following fluid challenge is used to guide fluid management.
This study aims to systemically review the evidence about using CVP in fluid management.
It included clinical trials studying the relation between CVP and measured blood volume, those that assessed the ability of CVP to predict fluid responsiveness and studies that compared CVP and volumetric measurements.
The meta analysis showed no association between CVP and circulating blood volume, CVP does not predict fluid responsiveness in various clinical conditions
It showed that at any CVP, the possibility of CVP to accurately predict fluid responsiveness is only 56%
It suggested that CVP should not be used in fluid management plan in any patient.
The use of IV fluids guided by CVP will result in inadequate volume replacement, also, using diuretics based on CVP may result in intravascular volume depletion leading to renal failure and poor organ perfusion.
CVP should not be used to determine whether critically ill patients are fluid responsive or not.
The study suggested that CVP should not be used and is useful only in certain conditions as patients who undergo heart transplantation, those with right ventricular infarction or acute pulmonary embolism.
CVP should be considered as a marker of right ventricular function rather than a marker of volume status.
Strength of the study was inclusion of relevant studies and use of quantitative endpoints.
Level of evidence: 1 (meta-analysis and systemic review)
Hussein Bagha baghahussein@yahoo.com
2 years ago
Introduction
Central venous pressure (CVP) is the pressure measurement recorded from the right atrium or superior vena cava. CVP measurements are important to assess the requirements of fluid therapy and diuretics, and it is especially useful in critically ill patients. The theory is that it reflects the intravascular volume. The goal of the study was to systematically review the evidence that supports this practice.
Methods
The aim was to review all the studies that analyzed the relationship between CVP and measured blood volume. It also included studies that determined the ability of CVP to predict fluid responsiveness. The studies picked were between 1966 to June 2007. A standardized form was used to abstract the data.
Results
Out of the initial 206 citations, 24 studies were included in this trial. 5 studies compared CVP with the measured circulating blood volume. 19 studies determined the relationship between CVP and change in cardiac performance after a fluid challenge. The correlation coefficient between CVP and measured blood volume was 0.16. Overall, 56% of the patients responded to the fluid challenge. The pooled correlation between change in CVP measurements and change in stroke volume was 0.11.
Discussion
According to the results, there is no association between CVP and circulating blood volume, and CVP does not predict fluid responsiveness.
It is important to note that the patient is likely to respond to a fluid challenge with a low or high CVP.
Strengths:
Strict selection criteria to identify the relevant studies
The studies were notable for their consistency.
Conclusion:
There was poor correlation between CVP and blood volume as well as the ratio of the CVP to the delta CVP to predict the hemodynamic response to a fluid challenge
CVP should not be used to guide clinical decisions for fluid management It may be useful in a particular set of patients, such as patients who have undergone heart transplants or patients suffering from acute pulmonary embolism, as a marker of right ventricular function.
Limitations:
Positive end-expiratory pressure levels or change in intra thoracic pressure was not taken into account.
This is a systematic review of the literature – Level I evidence
Mohamed Saad
2 years ago
Does Central Venous Pressure Predict Fluid Responsiveness? A Systematic Review. Introduction:
CVP was considered one of the important markers to assess blood volume and volume status of critically hospitalized patients , simple rule that low CVP with dehydrated patients and high CVP with overloaded patients, this one of the old Dogma, the goal of this study was to systemically review the evidence that supports this practice. Materials and Methods.
A systematic review of the literature which determine the relationship between CVP and blood volume, the ability of CVP to predict fluid responsiveness, and the ability of the change in CVP (delta CVP) to predict fluid responsiveness.
Data collected from MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles. Results.
Twenty four studies included in this analysis, 5 studies compared CVP with the measured circulating blood volume while 19 studies determined the relationship between CVP and change in cardiac performance following a fluid challenge (generally defined as a >10 to 15% increase in stroke index/
cardiac index).
1-The pooled correlation coefficient between the CVP and measured blood volume was 0.16.
2-The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index (reported in 10 studies) was 0.18. This signify that there is no association between CVP and circulating blood volume, and CVP does not predict fluid responsiveness across a wide spectrum of clinical conditions. Conclusion:
CVP is considered a measure of right atrial pressure alone; and not a measure of blood volume or ventricular preload. This systematic review shown that CVP should no longer be routinely measured in the ICU, operating room, or emergency department, But can be used in special circumstances such as in patients who have undergone heart transplant, or in those who have suffered a right ventricular infarction or acute pulmonary embolism which is considered a marker of right ventricular function rather than an indicator of volume status. Level I (systematic review)
Eusha Ansary
2 years ago
Summary:
CVP is usually measured in ICU, emergency, patients undergoing major surgery to measure of right atrial pressure.
In this systemic review 213 studies were screened and 24 studies were included. This study aimed to analyze the relation between CVP, measure blood volume and assess the ability of CVP to predict fluid responsiveness.
This study found a very poor relationship between CVP and blood volume as well as the inability of CVP to predict the hemodynamic response to a fluid challenge. CVP should not be used to make clinical decisions regarding fluid management.
Level of evidence: 5
Mohamed Mohamed
2 years ago
V. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares 1.Summarise this article Introduction
CVP is widely used to guide fluid therapy in hospitalized patients. However, the idea that the CVP reflects blood volume has been challenged by both historical & recent data.
The goal of this study was to systemically review the evidence that supports this practice.. Objective:
A systematic literature review to assess:
A.The relationship between CVP & blood volume.
B.The ability of CVP to predict fluid responsiveness C. The ability of the change in CVP to predict fluid responsiveness. Methodology Data:
MEDLINE, Embase, Cochrane Register of Controlled Trials, & citation review of articles.
Out of 213 articles screened, 24 studies met the inclusion criteria & were included for data extraction.
The studies included adult subjects, healthy controls, & ICU & OR patients.
Meta-analysis techniques were used to pool data.
The 24 studies (803 patients) were as follows:
·Five studies compared CVP with measured circulating blood volume
·19 studies determined the relationship between CVP/file:///C:/Users/TOSHIBA/AppData/Local/Temp/msohtmlclip1/01/clip_image002.gifCVP & change in cardiac performance following a fluid challenge (defined as >10 to 15% increase in stroke index/cardiac index). Results
Overall, 56 ± 16% of the patients included responded to a fluid challenge.
The pooled correlation coefficient between baseline CVP & change in stroke index/cardiac index was 0.18.
The pooled area under the ROC curve was 0.56.
The pooled correlation between ΔCVP & change in stroke index/cardiac index was 0.11.
Baseline CVP was 8.7 ± 2.32 mm Hg in the responders versus 9.7 ± 2.2 mmHg in non-responders (insignificant). Discussion
No association was seen between CVP & circulating
blood volume & CVP does not predict fluid responsiveness across a wide spectrum of clinical conditions.
In none of the studies was CVP able to predict either of these two variables. The pooled area under the ROC curve was 0.56 (ROC curve is a statistical tool
that helps assess the likelihood of a result being a
true +ve versus a false +ve).
In conclusion, the results suggest that at any CVP the likelihood that CVP can accurately predict fluid responsiveness is only 56% (no better than tossing a coin). Strength of the study
1.The rigorous selection criteria used to identify relevant studies.
2.The use of quantitative end points.
3.Consistency of the findings of the studies (both in magnitude & direction) suggesting that the findings are likely to be true. ///////////////////////////////// 2.What is the evidence provided by this article? Level I
CVP plays such a central role in the fluid management strategy of hospitalized patients, as it is reflects the intravascular volume. This idea has been challenged recently.
Objective: A systematic review of the literature to determine the relationship between CVP and blood volume, ability of CVP and its changes to predict fluid responsiveness.
Relevant studies that address any of the above objectivesinvolved adult human with no restriction of patients’ type or setting included.
Data source: MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles
Results
24 studies included in this analysis. In all, 830 patients were studied.
Heterogeneity was present between studies
The pooled correlation coefficient between CVP and measured blood volume was 0.16.
Overall, 56 % of the patients included in this review responded to a fluid challenge.
The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18
The pooled area under the ROC curve was 0.56.
The pooled correlation between CVP and change in stroke index/cardiac index was 0.11.
Baseline CVP was 8.7 mm Hg in the responders as compared to 9.7 mm Hg in nonresponders (not significant).
Conclusions:
This SR clearly demonstrated a very poor relationship between CVP and blood volume.
inability of CVP/change in CVP to predict fluid responsivness across a wide spectrum of clinical condition.
CVP should not be used alone to make clinical decisions regarding fluid management, taking in account the whole clinical condition.
Level of evidence: 1 systematic review.
In practice it still has been used, now we are trying to use POCUS for better guidance
I liked reading your summary and analysis .I appreciate that you may like to change your practice based on this article by using POCUS. Ajay
ISAAC BUSAYO ABIOLA
2 years ago
SUMMARY
Introduction
Central venous pressure has been used for many decades as a measurement of intravascular volume in critically ill patients in ICU or those undergoing surgeries. It is defined as the pressure measure from superior vena cava or right atrium and believe to be accurate enough in diagnosing fluid overload or dehydration during resuscitation of patients. However, the reliability of CVP as an accurate measurement of fluid management has been debated.
Aim of the study
to identify all clinical trials that shows relationship between CVC and measured blood volume
Materials and Methods
study search was on only human adult
studies from National Library of Medicine between 1966 – 2007 with the required search were recruited
MEDLINE, Cochrane and Embase were used to search for
-correlation co-efficient between CVP and measured blood volume
-receiver operator coefficient between CVP or change in CVP and change in – stroke index
Results
of the 206 citations, 189 were removed for not meeting the criteria
19 studies were found to determine the relationship between CVP and increase stroke volume
total of 839 patients were used in the study
pooled correlation coefficient between the CVP and measured blood volume was 0.16 and only 56-+16% responded to fluid challenge
pooled correlation coefficient between baseline CVP and change in stroke index/ cardiac index was 0.18 as reported in ten studies
The pooled area under the ROC curve (reported in 10 studies) was 0.56 which indicate failure in diagnosing accuracy of a test
Strengths of the study
extensive rigorous criteria for studies that fit into the study
use of quantitative end point
the consistency of the study both in magnitude and direction
Limitation of the study
none of the used study used took positive end expiratory pressure level or changes in intrathoracic pressure into consideration
Outcome of the study
no relationship between CVP and circulating blood volume
CVP cannot reliably predict good response to fluid management across a wide spectrum of condition
the diagnosing accuracy of CVP for fluid management was very low
the possibility of predicting fluid response is not better than flipping a coin
CVP measurement may be useful in patients that has undergone heart transplant suffered right ventricular infarction and acute PE
Thank you, All Will you change your practice based on this article?
Mahmoud Wadi
2 years ago
V. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares
Summarise this article
What is the evidence provided by this article?
—————————————————————————————————————
Introduction
Central venous pressure (CVP) is used almost universally to guide fluid therapy in hospitalized patients.
Central venous pressure gives clinically relevant information about volume status.
The most important application of CVP monitoring is to provide an estimate of the adequacy of circulating blood volume”, and“[that] trends in CVP during anesthesia and surgery are also useful in estimating fluid or blood loss and guiding replacement therapy.
Aim of the stud
Analyze the relationship between CVP and measured blood volume
Ability of CVP to predict fluid responsiveness.
Ability of the change in CVP (CVP) to predict fluid responsiveness.
Methods
MEDLINE database for relevant studies in any from 1966 – 2007.
To evaluated the relationship between CVP and blood volume or reported the associated between CVP/CVP and the change in stroke volume/cardiac index following a fluid challenge.
From 213 articles screened, 24 studies met our inclusion criteria and were included for data extraction.
The studies included human adult subjects, healthy control subjects, and ICU and operating room patients.
Results
The pooled correlation coefficient between the CVP and measured blood volume was 0.16 (95% CI,0.03 to 0.28; ).
The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index (reported in 10 studies) was 0.18 (95% CI, 0.08 to 0.28).
The pooled area under the ROC curve (reported in 10 studies) was 0.56 (95% CI, 0.51 to 0.61).
The pooled correlation between CVP and change in stroke index/cardiac index (reported in seven studies) was 0.11 (95% CI, 0.01 to 0.21).
The baseline CVP (reported in 11 studies) was 8.7 2.3 mm Hg in the responders, as compared to 9.7 2.2 mm Hg in nonresponders (not signficant; p 0.3).
Conclusions:
This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/CVP to predict the hemodynamic response to a fluid challenge.
CVP should not be used to make clinical decisions regarding fluid management.
Summary
CVP representing the right atrial pressure or SVC pressure was used to guide for the fluid therapy particularly in ICU patients.
The concept that CVP reflects intravascular blood volume thereby low CVP indicates volume depletion and high CVP indicates volume overload is revised .
The aim of this study is to revaluate the evidence of CVP applications. Methods
A multimethod approach analysing studies that
compared CVP with volumetric measurements and studies assessing the relationship between CVP or CVP change and change in stroke index/cardiac output
after a fluid challenge but it did not included studies that stated the CVP ability of detection of volume responsiveness. Results
24 studies were included , 5 compared CVP with the measured circulating blood volume while 19 assessed the relationship between CVP and cardiac performance variation after fluid challenge.
The CVP and measured blood volume correlation coefficient was 0.16 and that of CVP and change in stroke index/cardiac index was 0.18 and that of change in CVP and change in stroke index/cardiac index was 0.11. Discussion
CVP did not show any association with circulating blood volume, and did not predict the response to the fluid therapy mean fact it’s accuracy to predict was 56% indicating that either a high or low CVP renders the patient responsive to fluid therapy. Strength of this study
Included having quantitative end points ,and precise selection criteria for those studies rendering the findings valid.
Limitations
None of the studies considered the positive end-expiatory pressure levels or changes in intrathoracic pressure while assessing the CVP.
Transmural right atrial pressure gradient affects right ventricular filling and not CVP alone.
CVP guidance was prone to lead to volume overload and pulmonary oedema.
Positive fluid balance in ICU cases and surgical cases can cause hazardous outcomes and lead to mortality.
High CVP is not a must to mean fluid overload .
If the left ventricle was functioning near the “flat” part of the Frank-Starling curve , the fluid replacement will cause oedema and won’t increase the cardiac output that is why it is important to know whether the patient is fluid responsive or not.
Multiple old studies published the inaccuracy of CVP to represent volume status .
One study published that the respiratory variation in CVP in spontaneously breathing cases was predictive of
fluid responsiveness but it was not conclusive.
This study revealed the need of revising the Campaign guidelines ,in 2004 for management of severe
sepsis and septic shock which adviced that for hypoperfusion caused by sepsis, the CVP of 8 to 12
mm Hg need to be the goal of the initial resuscitation and a higher targeted CVP of 12–15 mm Hg for cases on mechanical ventilation. Conclusion
CVP must not be routinely used as measure of volume status meanwhile it can be beneficial in some cases as in cases undergoing heart transplant, or in those who have suffered a right ventricular infarction or acute pulmonary embolism.
Thank you, All Will you change your practice based on this article?
Mohammed Abdallah
2 years ago
Summarise this article
Introduction
CVP still used worldwide to guide fluid therapy but both historical and recent data suggest that this approach may be wrong
Aim of the study
A systematic review of the literature with the aim of:
1. Analyze the relationship between CVP and measured blood volume
2. The ability of CVP to predict fluid responsiveness
3. The ability of the change in CVP (CVP) to predict fluid responsiveness
Materials and Methods
The study was restricted to adults
Studies including either of the following were included:
1. The correlation coefficient between CVP and measured blood volume
2. The correlation coefficient or receiver operator characteristic (ROC) between CVP or change in CVP and change in stroke index/cardiac output following a fluid challenge
3. fluid responsiveness.6,7
Fluid responsiveness was defined as an increase in the stoke index or cardiac index > 10-15%
Results
Only 24 studies (total of 213 citations) met the inclusion criteria
Of the 24 studies (830 patients): 5 studies compared CVP with the measured blood volume and 19 studies determined the relationship between CVP and change in cardiac performance following a fluid challenge
The pooled correlation coefficient between the CVP and measured blood volume was 0.16
The pooled correlation coefficient between baseline CVP and change in stroke index/ cardiac index was 0.18
The pooled correlation between change CVP and change in stroke index/cardiac index was 0.11
Discussion
There is no association between CVP and circulating blood volume
CVP does not predict fluid responsiveness
The likelihood that CVP can accurately predict fluid responsiveness is only 56% (no better than flipping a coin)
The strength of the study includes the rigorous selection criteria used to identify relevant studies as well as the use of quantitative end points. Also, the studies are notable for the consistency of their findings (findings are likely to be true)
Conclusion
Poor relationship between CVP and blood volume
CVP/change in CVP fails to predict the hemodynamic response to a fluid challenge
CVP should not be used to make clinical decisions of fluid therapy
What is the evidence provided by this article?
Level 1 (systemic review)
The goal was to find all relevant clinical trials that evaluated the connection between CVP and measured blood volume and fluid responsiveness.
Introduction:
Hospitalized patients’ fluid treatment is virtually always guided by CVP. Recent and historical evidence demonstrates this method is faulty.
Method:
-A systematic review to assess the association between CVP and blood volume, CVP’s capacity to predict fluid responsiveness, and CVP’s ability to predict fluid responsiveness change.
-Clinical investigations that assessed the connection between CVP and blood volume or CVP/CVP and stroke volume/cardiac index after a fluid challenge. 24 research were considered for data extraction from 213 publications.
Adults, healthy controls, ICU, and OR patients participated in the trials.
-Data extraction: Data were abstracted on Study design, study size, study environment, patient population, and the correlation coefficient between CVP and blood volume.
Results:
-Pooled correlation between CVP and blood volume was 0.16 (95% CI, 0.03 to 0.28; r 2 0.02). Studies differed.
-10 studies revealed a 0.18 (95% CI) connection between baseline CVP and change in stroke index/cardiac index.
-The pooled ROC area was 0.56 (95% CI, 0.51 to 0.61). Seven studies revealed a 0.11 (95% CI) connection between CVP and stroke index/cardiac index change. Responders’ baseline CVP was 8.7 2.3 mm Hg, compared to 9.7 2.2 mm Hg in nonresponders (p = 0.3).
-Pooled correlation and area under the curve Q statistics were not significant.
Conclusion:
-CVP measures right atrial pressure, not blood volume or ventricular preload.
– CVP shouldn’t be regularly assessed in the ICU, OR, or ED. CVP may be effective in individuals who have had a heart transplant, right ventricular infarction, or acute pulmonary embolism.
-CVP may be utilized as a marker of right ventricular function in some circumstances.
Thankyou ,logic conclusions but no suggestions for a practical alternative other than clinical assessment of fluid status.
Sherif Yusuf
2 years ago
There is a trend in using CVP as a guide to evaluate the volume state of the patients with volume depletion is diagnosed if the CVP is low and volume overload diagnosed if the CVP is high, moreover the change in CVP reading will affect the decision of subsequent fluid management
The Surviving Sepsis Campaign guidelines recommended a CVP of 8 to 12 mm Hg in non-mechanically ventilated patients and 12-15 mm Hg in mechanically ventilated patients
This is a systematic review (level of evidence I) evaluation 24 studies including 803 adult healthy, ICU and OR patients regarding the relation between CVP readings and measured blood volume and CVP, if baseline CVP can predict fluid responsiveness and to assess the correlation between change in the CVP and the change in stroke volume/cardiac index after fluid challenge
Results
No correlation was found between CVP readings and measured blood volume.
CVP was unable to predict fluid responsiveness, with mean baseline CVP reading of 8.7 2.32 mm Hg in those who respond to fluid challenge compared to 9.7 2.2 mm in non-responder, and the failure rate of CVP in assessment of fluid responsiveness is 44%
Explanation of the finding
CVP measure only the Right atrial pressure and not the blood volume
CVP can be affected by the cardiac condition and intrathoracic pressure
Conclusion
CVP measurement should not be used to guide fluid therapy since it correlated poorly with fluid volume and even cannot predict fluid responsiveness and only half of the patients can be predicted using CVP
CVP can be used as a marker of right ventricular pressure
The recommendation of using CVP as a goal of therapy of severe sepsis should be revised
Thankyou for the summary and conclusion
The title of the paper states Avery odd experiment of (bleeding 7 mares ! female horses to try to find the relation between the blood vol and ?? cvp measured) No comment!,
Ban Mezher
2 years ago
CVP is measuring of right atrium or SVC pressure
CVP usually measured in ICU, emergency & patients undergoing major surgery.
Guidelines recommend to measure CVP as the end point of fluid resuscitation.
Materials & methods:
This study aimed to analyze the relation between CVP & measured blood volume & assess the ability of CVP to predict fluid responsiveness.
Studies that compare CVP with volumetric measurement but didn’t report the ability of CVP to predict volume responsiveness were excluded from analysis.
Included studies analyse:
correlation coefficient between CVP & measured blood volume.
Correlation coefficient or ROC between CVP or change in CVP & change in stroke index/COP after fluid challenge.
Results:
There was no association found between CVP & circulatory blood volume.
CVP didn’t predict fluid responsiveness.
Strength of the study:
Strict selection criteria that used to identify relevant studies.
Central venous pressure(CVP) is utilized in many places across the globe for monitoring and guiding fluid management in ICUs
This systematic review was aimed at examining the correlation between CVP and blood volume, how good the CVP to predict fluid responsiveness, and the changes in CVP to predict fluid responsiveness
Methodology;
They looked at MEDLINE,Embase, and Cochrane data base for the relevant articles
Out of 213 studies, only 24 were included as they met the recruitment criteria
Results ;
The pooled correlation coefficient between CVP and blood volume was 0.16(95% CI, 0.03 to 0.28)
The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18( 95% CI, 0.08 to 0.28)
The pooled area under the ROC curve was 0.56(95% CI, 0.51 to 0.61)
The pooled correlation between change in CVP and change in stroke index/cardiac index was 0.11( 95% CI, 0.015 to 0.21)
In total, 56+/- 16% of the participants responded to a fluid challenge and the baseline CVP was 8.7 +/- 2.32 mmHg in the responders while it was 9.7 +/- 2,2 mmHg in non responders
In summary; This study revealed, a very poor correlation between CVP and blood volume, the failure of change in CVP to predict fluid responsiveness. Therefore, CVP should not be used as a guide for for fluid therapy
Thank you, All
Will you change your practice based on this article?
Do you still using the CVP to guide your fluid management in transplant patients?
Yes professor Halawa
I don’t use CVP to guide fluid management in my critically ill patients
I need to convince some of my colleagues who still use it of its futility
CVP is not more used in our setting.
For the last few years I never rely on CVP measurement, while ICU doctors and cardiologist still mention it as important.
Yes, we still using CVP as a guide for fluid management at my institute.
According to this systematic review, we need to change this practice.
We already not using CVP for volume status evaluation, we rely on clinical status, daily weight of the patient.
CVP is not used to guide fluid management in our transplant unit.
From the article, I will definitely change my concept and practice. It is still being used in the ICU setting.
This concept is well known for long time with some debating results, as shown in discussion, first article questioned credibility of CVP was published in 1971.
I am not always depending on CVP to highlight blood volume.
Yes because it is a systematic review with level1 of evidence.
Introductions:
Central venous pressure :
is the pressure recorded from the right atrium or superior vena cava. CVP is measured (usually hourly) in almost all patients in ICU, ER and after surgery to guide fluid balance.
Since CVP plays such a central role in the fluid management strategy of hospitalized patients, the goal of this study was to systemically review the evidence support this practice.
Materials and Methods :
aim was to identify all relevant clinical trials that analyzed the relationship between CVP and measured blood volume as well as those studies that determined the ability of CVP to predict fluid responsiveness (ie, an increase in stroke index/cardiac index following a fluid challenge).
All authors independently searched the National Library of Medicine MEDLINE database for relevant studies in any language published from 1966 to June 2007 using the following medical subject headings and key words; central venous pressure (explode) AND blood volume, or fluid therapy or fluid responsiveness. In addition, we searched Embase and the Cochrane Database of Systematic Reviews.
Results:
24 studies included in this analysis, 5 studies compared CVP with the measured circulating blood volume while 19 studies determined the relationship between CVP and change in cardiac performance following a fluid challenge (generally defined as a 10 to 15% increase in stroke index/ cardiac index).
In all, 830 patients across a spectrum of medical and surgical disciplines were studied.
The pooled correlation coefficient between the CVP and measured blood volume was 0.16 (95% CI, 0.03 to 0.28; r 2 0.02).
The pooled correlation coefficient between baseline CVP and change in stroke index/ cardiac index (reported in 10 studies) was 0.18 (95% CI, 0.08 to 0.28).
The pooled area under the ROC curve (reported in 10 studies) was 0.56 (95% CI, 0.51 to 0.61).
The pooled correlation between CVP and change in stroke index/cardiac index (reported in seven studies) was 0.11 (95% CI, 0.01 to 0.21).
The baseline CVP (reported in 11 studies) was 8.7 2.3 mm Hg in the responders, as compared to 9.7 2.2 mm Hg in non responders (not signficant; p 0.3).
The Q statistic was not significant for the pooled correlation and area under the curve statistic.
Discussion :
The results of this systematic review are clear:
(1) there is no association between CVP and circulating blood volume.
(2) CVP does not predict fluid responsiveness across a wide spectrum of clinical condition.
In none of the studies included in this analysis was CVP able to predict either of these variables.
The results from this study therefore confirm that neither a high CVP, a normal CVP, a low CVP, nor the response of the CVP to fluid loading should be used in the fluid management strategy of any patient.
Level of evidence 1.
This article also advice against CVP use in prescribing IVF for patients
Their aim was to identify all relevant clinical trials that
analyzed the relationship between CVP and measured blood
volume as well as those studies that determined the abilitv of
CVP to predict fluid responsiveness (ie, an increase in stroke
index/cardiac index following a fluid challenge). Studies that
compared CVP with volumetric measurements (right and left
ventricular end-diastolic volumes, global left heart volume,
central blood volume) but did not report the ability of CVP to
predict volume responsiveness were not included.
Results:
1)there is no association between CVP and circulatingBblood volume, and
(2) CVP does not predict fluid responsiveness
level II :metanalalysis
This is a systematic review about the value of CVP to guide fluid therapy and fluid responsiveness.
Totally, 24 article with 803 patients that met criteria were included.
There was poor correlation between CVP and change in circulatory blood volume.
In addition, CVP had no predictive value for fluid responsiveness.
ROC curve showed 0.56 for the pooled area that indicated failure of a specific CVP cut off as a diagnostic tool in these situations.
In a recent study, it was shown that using CVP to guide fluid therapy would be misleading because CVP is just a measurement for right atrial pressure not blood volume or preload.
The level of evidence provided by this article is 1.
CVP is measured in almost all patients in ICUs throughout the world, in emergency department patients, as well as in patients undergoing major surgery.
The basis for using CVP to guide fluid management comes from the dogma that CVP reflects intravascular volume;
“the most important application of CVP monitoring is to provide an estimate of
Over 25 years ago, the “5–2” rule for guiding fluid therapy was popularized.
Recently, the idea that the CVP reflects blood volume has been challenged.
The goal of this study was to systemically review the evidence that supports this practice.
Materials and Methods
Identification of Trials
identify all relevant clinical trials that analyzed
1. the relationship between CVP and measured blood volume
2. as well as those studies that determined the ability of CVP to predict fluid responsiveness
Criteria of exclusions:
Studies that compared CVP with volumetric measurements but did not report the ability of CVP to predict volume responsiveness
The study restricted this analysis to human adults; however, there was no restriction as to the type of patient or the setting where the study was performed.
All authors independently searched the National Library of Medicine MEDLINE database for relevant studies in any language published from 1966 to June 2007
They searched Embase and the Cochrane Database of Systematic Reviews.
Study Selection and Data Extraction
Only studies that reported either of the following were included in this analysis:
(1) the correlation coefficient between CVP and measured blood volume,
(2) or the correlation coefficient or receiver operator characteristic (ROC) between CVP or change in CVP and change in stroke index/cardiac output following a fluid challenge.
Data were abstracted on
• study design,
• study size,
• study setting,
• patient population,
correlation coefficients and area (including 95% confidence intervals [CIs]) under the ROC curve
the percentage of patients responding to a fluid challenge ( increase in the stoke index or cardiac index 10 to 15%) as well as the baseline CVP in the fluid responders and nonresponders.
The random-effects models was used to determined the pooled area under the curve (AUC) and correlation coefficients.
We calculated the Cochran Q statistic to test for statistical heterogeneity.
When not reported in the primary paper, the correlation coefficients were calculated from the raw data
Results
5. (830) patients were studied.
• The pooled correlation coefficient between the CVP and measured blood volume was 0.16.
Heterogeneity was present between studies.
Overall 56+/_16% (mean+/_SD) of the patients included in this review responded to a fluid challenge.
• The pooled correlation coefficient between baseline CVP and change in stroke index/ cardiac index (reported in 10 studies) was 0.18 .
The pooled area under the ROC curve (reported in 10 studies) was 0.56 (95%CI,0.51 to0.61).
• The pooled correlation between CVP and change in stroke index/cardiac index (reported in seven studies) was0.11.
The baseline CVP (reported in 11 atudies) was 8.7+/_2.3 mmHg in the responders, as compared to 9.7+/_2.2 mmHg in non responders (not significant; p0.3).
The Q statistic was not significant for the pooled correlation and area under the curve statistic.
Discussion
The results of this systematic review are clear:
(1) There is no association between CVP and circulating blood volume,
(2) And CVP does not predict fluid responsiveness across a wide spectrum of clinical conditions.
.The pooled area under the ROC curve was 0.56.
. In other words, the results suggest that at any CVP the likelihood that CVP can accurately predict fluid responsiveness is only 56%
. an AUC of 0.56 suggests that there is no clear cutoff point that helps the physician to determine if the patient is “wet” or “dry.”
. The results from this study therefore confirm that neither a high CVP, a normal CVP, a low CVP, nor the response of the CVP to fluid loading should be used in the fluid management strategy of any patient.
The strength of this review
includes the rigorous selection criteria used to identify relevant studies as well as the use of quantitative end points.
As demonstrated by this study, only about a half of patients administered a fluid bolus will demonstrate a positive hemodynamic response to the intervention.
If fluid resuscitation is guided by CVP, it is likely that patients will have volume overload and pulmonary edema.
In sepsis cases in adult patients; “fluid infusion should be titrated to a filling pressure” and that “pulmonary edema may occur as a complication of fluid resuscitation and necessitates monitoring of arterial oxygenation.”
Should volume overload and pulmonary edema be the end point of fluid resuscitation?
• a positive fluid balance in both ICU patients and those undergoing surgery has been associated with increased complications and a higher mortality.
• the resuscitation guided by CVP will results in inadequate volume replacement.
• the use of diuretics based on CVP may result in intravascular volume depletion leading to poor organ perfusion and ultimately renal failure and multiorgan failure because a “high” CVP does not necessarily reflect volume overload.
Once the left ventricle is functioning near the “flat” part of the Frank-Starling curve, fluid loading has little effect on cardiac output and only serves to increase tissue edema and to promote tissue dysoxia
The results from this article clearly demonstrate that CVP should not be used for this purpose.
CVP does not reflect intravascular volume and is a misleading tool for guiding fluid therapy is not new.
in 1971, Forrester and colleagues concluded that “CVP monitoring in acute myocardial infarction is at best of limited value and at worst seriously misleading.”
In 1975, Baek and colleagues established that “there was no correlation of blood volume with central venous pressure” and suggest that “inaccurate physiologic evaluation of critically ill patients is likely to jeopardize survival by inviting inappropriate and ineffectual therapy.”
In 1977, Dr. Burch, noted that “to accept no critically the level of central venous pressure as a quantitative index of blood volume can only lead to physiologic and/or therapeutic errors.”
Magder and colleagues reported that the respiratory variation in CVP in spontaneously breathing patients was predictive of fluid responsiveness. Additional studies are required to support using the respiratory variation in CVP to guide fluid management.
In addition, it should be noted that in the ARDS net fluid management trial, those patients randomized to the “CVP conservative strategy” group had significantly more ventilator-free days and a shorter length of ICU stay.
Hughes and Magovern,in 1959 described a complicated technique for right atrial monitoring as a guide to blood volume replacement in post-thoracotomy patents.
These authors described a fall in CVP with blood loss and a relationship between the CVP and blood transfusion.
Based on the results of this systematic review, CVP should no longer be routinely measured in the ICU, operating room, or emergency department.
the CVP may be useful in select circumstances,
• in patients who have undergone heart transplant,
• or in those who have suffered a right ventricular infarction
• or acute pulmonary embolism.
CVP may be used as a marker of right ventricular function rather than an indicator of volume status.
Level 1 systematic review
This study should change my practice However we need to find alternative useful techniques which can be available in my country such as US of thoracic.
Bioimpedance is not available in our center
Summary:
Does Central Venous Pressure Predict Fluid Responsiveness?
Central venous pressure is the pressure measured from the right atrium or superior vena cava. It is widely used in ICUs, in emergency department, and in patients undergo major surgery to make decision about fluids or diuretics use. CVP is based on the principle of its reflection on intravascular volume status as had been authorized in most medical text book. Recently, the idea that the CVP reflects blood volume has been challenged.
Materials and Methods
Identification of Trials
The aim was to identify all relevant clinical trials that analyzed the relationship between CVP and measured blood volume as well as those studies that determined the ability of CVP to predict fluid responsiveness.
They used a multimethod approach to identify relevant studies for this review.
The authors searched MEDLINE database for relevant studies in any language published from 1966 to June 2007 using key words; central venous pressure AND blood volume, or fluid therapy or fluid responsiveness. Also, they searched Embase and Cochrane Database of systemic Reviews. This metaanalysis according to guidelines proposed by the quality of reporting of Meta-analyses group.
Study Selection and Data Extraction
Only studies that include (1) the correlation coefficient between CVP and measured blood volume, or (2) the correlation coefficient or receiver operator characteristic (ROC) between CVP or change in CVP (CVP) and change in stroke index/cardiac output following a fluid challenge were selected.
Results:
Of the 24 studies included in this analysis, 5 studies compared CVP with the measured circulating blood volume while 19 studies determined the relationship between CVP and change in cardiac performance following a fluid challenge (generally defined as a ˃ 10 to 15% increase in stroke index/ cardiac index). The pooled correlation coefficient between the CVP and measured blood volume was 0.16 (95% CI, 0.03 to 0.28; r2 = 0.02). Overall 56 ± 16% (mean ± SD) of the patients included in this review responded to a fluid challenge.
The Q statistic was not significant for the pooled correlation and area under the curve statistic.
Discussion:
The result of this study includes: 1) there is no association between CVP and circulating blood volume, 2) CVP does not predict fluid responsiveness across a wide spectrum of clinical condition. In other words, our results suggest that at any CVP the likelihood that CVP can accurately predict fluid responsiveness is only 56% which represent AUC. That no clear cutoff point helps the physician to determine if the patient is wet or dry.
The results from this study therefore confirm that neither a high CVP, a normal CVP, a low CVP, nor the response of the CVP to fluid loading should be used in the fluid management strategy of any patient.
Strength of the study:
1. Rigorous selection criteria.
2. use of quantitative end points.
3. The studies are notable for consistency of their findings.
4. All studies included in this study do not take the positive end-expiratory pressure levels or changes in intrathoracic pressure into account when recording CVP.
RV filling depends on right atrium transmural pressure in addition to CVP.
If fluid resuscitation is guided by CVP, it is likely that patients will have volume overload and pulmonary edema.
If fluid resuscitation is guided by CVP, it is likely that patients will have volume overload and pulmonary edema.
Should volume overload and pulmonary edema be the end point of fluid resuscitation?
This is so important as excess fluid resuscitation leading to fluid overload is associated with increased complication and higher mortality.
CVP guided fluid resuscitation can result in inadequate fluid resuscitation which lead to decreased organ perfusion and organ failure. As well, diuretics use based on CVP may cause intravascular volume depletion with poor perfusion to organs and organ failure. Because high CVP does not mean volume overload.
It is critical during resuscitation of critically ill patients to determine whether the patient is fluid responsive or no. according to this study, CVP should not be used for this purpose.
Conclusion:
CVP should no longer be routinely measured in the ICU, operating room, or emergency department.
Level 1 Metaanalysis
we still use CVP to guide fluid management and after this, I like to change our practice
Does Central Venous Pressure Predict
Fluid Responsiveness?* A Systematic Review of the Literature and the Tale
of Seven Mares
☆Introduction:
▪︎Central venous pressure (CVP) is the pressure recorded from the right atrium or superior vena cava. It is frequently used to make decisions regarding the administration of fluids or diuretics.
▪︎CVP reflects intravascular volume and it is used almost universally to guide fluid therapy in hospitalized patients.
☆ The Objective of the study:
A systematic review of the literature to determine the following:
(1) the relationship between CVP and blood volume,
(2) the ability of CVP to predict fluid responsiveness, and
(3) the ability of the change in CVP (_CVP) to predict fluid responsiveness.
☆Data sources: MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles.
☆Study selection: Reported clinical trials that evaluated either the relationship between CVP and blood volume or reported the associated between CVP/_CVP and the change in stroke volume/cardiac index following a fluid challenge.
– From 213 articles screened, 24 studies met our inclusion criteria and were included for data extraction.
– The studies included human adult
subjects, healthy control subjects, and ICU and operating room patients.
☆Data extraction: Data were abstracted on study design, study size, study setting, patient population, correlation coefficient between CVP and blood volume, correlation coefficient (or receive operator
characteristic [ROC]) between CVP/_CVP and change in stroke index/cardiac index, percentage of patients who responded to a fluid challenge, and baseline CVP of the fluid responders and nonresponders.
– Metaanalytic techniques were used to pool data.
☆Data synthesis: The 24 studies included 803 patients; 5 studies compared CVP with measured circulating blood volume, while 19 studies determined the relationship between CVP/_CVP and change in cardiac performance following a fluid challenge.
– The pooled correlation coefficient
between CVP and measured blood volume was 0.16 (95% confidence interval [CI], 0.03 to 0.28).
Overall, 56 _ 16% of the patients included in this review responded to a fluid challenge. — –The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 (95%
CI, 0.08 to 0.28).
– The pooled area under the ROC curve was 0.56.
– The pooled correlation between _CVP and change in stroke index/cardiac index was 0.11.
– Baseline CVP was 8.7 _ 2.32 mm Hg [mean _ SD] in the responders as compared to 9.7 _ 2.2 mm Hg in nonresponders (not significant).
☆The strength of our review:
1. The rigorous selection criteria used to identify relevant
2. The use of quantitative end points.
3. The studies are notable for the consistency of their findings.
☆The results of this study are most disturbing considering that 93% of intensivists report using CVP to guide fluid management.
☆ Conclusions:
▪︎This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/_CVP to predict the hemodynamic response to a fluid challenge.
▪︎ CVP should not be used to make clinical decisions regarding fluid management.
A metanalysis study conducted to verify the validity of central venous pressure in reflecting blood volume status. Correlation between central venous pressure and circulatory volume is performed via measuring blood volume in relation to CVP or estimating stroke volume and cardiac index after fluid replacement. There was a staggering hypothesis, debating the sensitivity and specificity of CVP in reflecting the blood volume and this study was initiated to verify this hypothesis.
24 studies were analyzed regarding the blood volume status correlated to CVP and response to volume replacement.
5 studies compared CVP with blood volume and 19 studies verified CVP/Delta CVP by measuring stroke volume and cardiac index changes after fluid challenge.
The finding was inconclusive and did not demonstrate a direct correlation between fluid replacement and changes in CVP.
The putative explanation is entirely dependent on the assumption that cardiac output will be increased as per ascending state of Frank -starling law when fluid volume is replaced. However, when Frank Starling curve is flat, fluid replacement would be futile in unsuccessful in increasing the cardiac output, and excess fluid would be accumulated in extra-vascular tissues and spaces.
Therefore, CVP is not a sensitive tool to assess blood volume status.
This study is metanalysis study with level of evidence 5
The study concluded that there was no association between CVP and circulating blood volume, and CVP does not predict fluid responsiveness hence CVP should not be used for strategizing fluid management in any patient. CVP may be useful in certain specific conditions like a heart transplant, pulmonary embolism, and right ventricular infarction, as a marker of right ventricular function (and not as a marker of fluid status).
The strengths of the study include well-defined stringent selection criteria involving quantitative endpoints, and consistent findings of the involved studies.
Limitations of the study include non-utilization of positive end-expiratory pressure levels or alteration in intrathoracic pressure while calculating CVP by the studies involved.
The article is a systematic review of the literature: level 1 evidence.
Introduction: The central venous pressure, also known as CVP, is a measurement that is used in intensive care units all over the world to monitor and direct fluid management.
The purpose of this systematic review was to investigate the relationship between central venous pressure (CVP) and blood volume; to determine how accurately CVP can predict fluid responsiveness; and to investigate how variations in CVP can predict fluid responsiveness.
Methodology: In their search for the pertinent papers, they searched the MEDLINE, Embase, and Cochrane data bases.
Only 24 of the 213 studies were selected for inclusion because they satisfied the requirements for recruitment.
The pooled correlation coefficient between CVP and blood volume was 0.16 (95% confidence interval [CI], ranging from 0.03 to 0.28).
The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 (with a 95% confidence interval ranging from 0.08 to 0.28).
The area under the ROC curve was calculated to be 0.56 (confidence interval, 95%: 0.51 to 0.61)
The pooled correlation between changes in cardiac output and stroke index or cardiac index was 0.11 (95% confidence interval: 0.015 to 0.21)
In all, 56 +/- 16% of the subjects reacted to a fluid challenge, and the baseline CVP was 8.7 +/- 2.32 mmHg in the responders, whereas it was 9.7 +/- 2.22 mmHg in the non responders.
In conclusion, the results of this investigation showed that there is a very weak association between CVP and blood volume, and that changes in CVP are unable to accurately predict fluid responsiveness. For this reason, central venous pressure should not be utilized as a guidance for fluid therapy.
There has always been controversy as to which method is better to determine central venous pressure (CVP) to predict fluid responsiveness. Different articles show different results but this article, will focus on central venous pressure does it predict fluid responsiveness through a systematic review of the literature and the tale of seven mares. CVP is the pressure that is measured from the right atrium and the superior vena cava. In patients that are found in ICU, it is important and it is measured hourly. Initially, it was used as a marker to determine if a patient is dehydrated that is it measures the intravascular volume. This study was to systematically review the supporting evidence for the practice.
The material and methods:
1) The aim of the study was to review all the studies that analyzed the relationship between CVP and measuring blood volume.
2) The study also included studies that determine the ability of CVP to predict fluid responsiveness
3) The study was based on a period from 1966 to June 2007. A specified form was used to abstract the data needed for the study.
The Results:
1) There were about 24 studies included in the article of such, 5 of the studies were comparing CVP to measure circulating blood volume, and 19 of the studies were used to know the relation between CVP and change in cardiac performance following a fluid challenge.
2) The correlation coefficient that was found between the CVP and measured blood volume was 0.16.
3) It was noted that 56% of the patients responded to the fluid challenge.
4) The pooled correlation between the change in CVP measurements and the change in stroke volume was about 0.11
Discussion:
Based on the results obtained, there was no association between CVP and the circulating blood volume, and the CVP does not predict fluid responsiveness. There is evidence that the patient is likely to respond to a fluid challenge with either low or high CVP. CVP cannot determine if the patient has sufficient fluid.
The article’s strength was:
1) Identifying all relevant studies and to use as them as a quantitative endpoint.
2) It was consistent with the findings
Limitations of the article:
1) The study never included PEEP levels and intrathoracic pressure while recording the CVP.
In conclusion, it was noted that there was a poor correlation between the CVP and the blood volume as also the ratio of the CVP to the delta CVP to predict the patient hemodynamic response to the fluid challenge test. It should not be routinely used in ICU and other emergency departments but has it positive in elaborating if the patient has suffered left ventricular infarction or acute PE which is a marker of right ventricular function rather than a volume status.
The article is a systematic review of the literature: level 1 evidence.
We used to use CVP level to follow the fluid status.
Summary ofDoes central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares
CVP is the pressure recorded from the right atrium or superior vena cava. It is used to make decision of fluid administration or diuretic.
Recently, the idea that the CVP reflects blood volume has been challenged since CVP has a role in fluid management of hospitalized patients. The goal of this study was to systematically review the evidence that support this practice.
Study selection and data extraction:
Studies that are including in this analysis:
The correlation coefficient between CVP and measured blood volume or (2) the correlation coefficient or receiver operator characteristic between CVP and change in stroke index /cardiac output following fluid challenge, in general an increase in the stroke index or cardiac output >10 to 15% was used as an index of fluid responsiveness.
The random effects models was used to determined the pooled area under the curve and corelation coefficient
Results.
24 hours studies included in this analysis, 5 studies compared cardiac output with the measured circulating blood volume while 19 studies determined the relationship between CVP and change in cardiac performance following a fluid challenge >10 or >15% increase in stroke index/cardiac index.
Discussion:
The result of this systemic review are clear:
1. There is no association between CVP and circulating blood volume
2. CVP dose not predict fluid responsiveness across mide spectrum of clinical condition.
There is no clear cut of point that help the physician to determine if the patient is wet or dry.
The strength of our review:
1. The rigorous selection criteria used to identify relevant studies as well as the use of quantitative end point.
2. Further-more, the studies are notable for the counselling of their finding are likely to be true.
3. The result from this article clearly demonstrated that CVP should not be used for this purpose.
Limited data support using CVP to guide fluid therapy
Additional studies are needed to support using the respiratory variation in CVP to guide fluid therapy.
Management:
The CVP is a measure of right atrial pressure alone and not a measured of blood volume or ventricular preload.
Based on the result of asystemic review, we believe that CVP should no longer be routinely measured
Selected condition CVP can be useful:
1. Recent transplant patient
2. Right ventricular infraction
3. Acute pulmonary embolism
In this condition is a marker of right ventricular rather than indication of volume status.
evidence of this systemic review is level one
CVP for decades have been considered as the best way to assess volume status of patients and in most of ICUs fluid therapy was CVP guided. This concept has already been challenged and currently this is not considered as the standard. This article which was published way back in 2008 has also challenged this concept.
Material and Methods
Aim of the study was to identify all relevant clinical trials that analyzed the relationship between CVP and measured blood volume as well as those studies that determined the ability of CVP to predict fluid responsiveness (ie, an increase in stroke index/cardiac index following a fluid challenge).
They used a multimethod approach to identify relevant studies for this review. All authors indepen- dently searched the National Library of Medicine MEDLINE database for relevant studies in any language published from 1966 to June 2007 using the following medical subject head- ings and key words; central venous pressure (explode) AND blood volume, or fluid therapy or fluid responsiveness. In addition, we searched Embase and the Cochrane Database of Systematic Reviews. Bibliographies of all selected articles and review articles that included information on hemodynamic monitoring were reviewed for other relevant articles. In addition, the authors reviewed their personal files and con- tacted experts in the field.
From 213 articles screened, 24 studies met inclusion criteria and were included for data extraction.
The studies included human adult subjects, healthy control subjects, and ICU and operating room patients.
Data extraction: Data were abstracted on study design, study size, study setting, patient population
The 24 studies included 803 patients;
5 studies compared CVP with measured circulating blood volume,
while 19 studies determined the relationship between CVP/CVP and change in cardiac performance following a fluid challenge.
The pooled correlation coefficient between CVP and measured blood volume was 0.16 (95% confidence interval [CI], 0.03 to 0.28).
Overall, 56 +-16% of the patients included in this review responded to a fluid challenge. The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 (95% CI, 0.08 to 0.28).
The pooled area under the ROC curve was 0.56 (95% CI, 0.51 to 0.61). The pooled correlation between CVP and change in stroke index/cardiac index was 0.11 (95% CI, 0.015 to 0.21). Baseline CVP was 8.7+- 2.32 mm Hg [mean +- SD] in the responders as compared to 9.7+- 2.2 mm Hg in nonresponders (not significant).
CONCLUSION
Based on the results of this systematic review, the authors believe that CVP should no longer be routinely measured in the ICU, operating room, or emergency department. However, measurement of the CVP may be useful in select circumstances, such as in patients who have undergone heart transplant, or in those who have suffered a right ventricular infarction or acute pulmonary embolism. In these cases, CVP may be used as a marker of right ventricular function rather than an indicator of volume status.
Level of evidence
Systemic review LEVEL 3
OUR PRACTICE
We no longer use CVP to guide fluids therapy in our transplant patients
Central venous pressure (CVP), the pressure at right atrium or superior vena cava, is used very frequently to decide about fluid therapy in patients. The study was conducted to assess the effect of CVP on blood volume as well as fluid responsiveness, and effect of change in CVP on fluid responsiveness.
A total of 24 studies were included in the study out of 206 citations. 5 studies dealt with relationship between CVP and blood volume, while 19 studies dealt with CVP and change in cardiac performance following a fluid challenge. The study included 830 patients across wide spectrum of medical and surgical scenarios. The pooled correlation coefficient was 0.16 between CVP and measured blood volume, 0.18 between baseline CVP and change in stroke index/cardiac index, and 0.11 between change in CVP and change in stroke index/cardiac index. The pooled area under the ROC curve was 0.56%, implying that at any CVP, only 56% of the patients responded to fluid challenge, and there is no cutoff point to help determine whether the patient is ‘wet’ or ‘dry’.
The study concluded that there was no association between CVP and circulating blood volume, and CVP does not predict fluid responsiveness and hence CVP should not be used for strategizing fluid management in any patient. CVP may be useful in certain specific conditions like heart transplant, pulmonary embolism, and right ventricular infarction, as a marker of right ventricular function (and not as marker of fluid status).
The strengths of the study include well defined stringent selection criteria involving quantitative end points, and consistent findings of the involved studies.
Limitations of the study include non-utilization of positive end-expiratory pressure levels or alteration in intrathoracic pressure while calculating CVP by the studies involved.
Level of evidence: Level 1 – systematic review
Summarise this article
Introduction:
The CVP is the pressure measured from right atrium or superior vana cava, it was widely used to guide fluid therapy in hospital settings, it was measured during anesthesia and surgery and though it was useful in estimating fluid or blood loss and guiding replacement therapy.
This study conducted to evaluate the evidence behind this practice.
Method:
All articles reviewing the relationship between CVP and measurement of blood volume and those studies that determined the ability of CVP to predict fluid responsiveness were cited.
Studies included in analysis are those showing:
(1) the correlation coefficient between CVP and measured blood volume.
(2) the correlation coefficient or receiver operator characteristic (ROC) between CVP or change in CVP (CVP) and change in stroke index/cardiac output following a fluid challenge.
Out of 189 articles, 24 were included in the systemic review, 5 studies compared CVP with the measured circulating blood volume, and 19 studies determines relationship between CVP and change in cardiac performance following a fluid challenge (generally defined as a 10 to 15% increase in stroke index/ cardiac index).
Results:
The correlation coefficient between the CVP and measured blood volume was not significant, and 56 -/+ 16% responded to fluid challenge.
The pooled correlation coefficient between baseline CVP and change in stroke index/ cardiac index was 0.18 (95% CI, 0.08 to 0.28).
The pooled area under the ROC curve was 0.56 (95% CI, 0.51 to 0.61).
The pooled correlation between CVP and change in stroke index/cardiac index was 0.11 (95% CI, 0.01 to 0.21).
The baseline CVP was 8.7 +/-2.3 mm Hg in the responders, as compared to 9.7 +/-2.2 mm Hg in nonresponders (not significant; P=0.3).
The strength of study:
The rigorous selection criteria used to identify relevant studies as well as the use of quantitative end points.
The limitations of study:
No control groups with no CVP measured in these studies.
No respiratory variations effect on CVP were obtained.
Conclusion:
The CVP does not reflect circulating blood volume, and does not predict fluid responsiveness, so it should not routinely measured in the ICU, operating room, or emergency department.
The CVP may be used as a marker of right ventricular function in patients who have undergone heart transplant, those with a right ventricular infarction or acute pulmonary embolism.
What is the evidence provided by this article?
Level of evidence is IIa – Meta-analysis of cohort studies.
Summary:
Background:
Central venous pressure (CVP) is used almost universally to guide fluid therapy in
hospitalized patients.
But, this approach needs re-evaluation.
Objective:
A systematic review of the literature to determine the following:
(1) the relationship between CVP and blood volume,
(2) the ability of CVP to predict fluid responsiveness,
(3) the ability of the change in CVP to predict fluid responsiveness.
Data sources:
MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of
relevant primary and review articles.
Study selection:
From 213 articles screened, 24 studies met inclusion criteria and were included for data extraction.
The 24 studies included 803 patients; 5 studies compared CVP with measured
circulating blood volume
Results:
Conclusions:
This systematic review demonstrated a
Sir, we have stopped using CVP for fluid management in general urological and kidney transplant patients.
Summary of the article
“Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares”
This is a systematic review of literature between 1966 and June 2007, to determine the followings:
· the relationship between CVP and blood volume.
· the ability of CVP to predict fluid responsiveness.
· the ability of the change in CVP to predict fluid responsiveness.
Study’s Outcome
· There is no association between CVP and circulating blood volume.
· CVP does not predict fluid responsiveness across a wide spectrum of clinical conditions.
· The likelihood that CVP can accurately predict fluid responsiveness is only 56% (no better than flipping a coin).
· The results from this study, confirm that neither a high CVP, a normal CVP, a low CVP, nor the response of the CVP to fluid loading should be used in the fluid management strategy of any patient.
CVP may be used as a marker of right ventricular function rather than an indicator of volume status, in select circumstances:
· Heart transplant surgery.
· Right ventricular infarction.
· Acute pulmonary embolism.
Strengths of the study
· the rigorous selection criteria used to identify relevant studies as well as the use of quantitative end points.
· The studies are notable for the consistency (both in magnitude and direction) of their findings.
Limitations of the study
· None of the studies included in this analysis took the positive end-expiatory pressure levels or changes in intrathoracic pressure into account when recording CVP.
What is the evidence provided by this article?
This is a retrospective analysis(systematic review)
Level of evidence grade 3.
Summary:
Aim of the study:
to determine:
Methods:
Design: a systematic review of the literature.
Data sources: MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles.
Study selection: Reported clinical trials that evaluated either the relationship between CVP and blood volume or reported the association between CVP/delta CVP and the change in stroke volume/cardiac index following a fluid challenge.
From 213 articles screened, 24 studies met the inclusion criteria and were included for data extraction. The studies included human adult subjects, healthy control subjects, and ICU and operating room patients.
Data extraction: Data were abstracted on study design, study size, study setting, patient population, the correlation coefficient between CVP and blood volume, correlation coefficient (or receive operator characteristic [ROC]) between CVP/delta CVP and change in stroke index/cardiac index, percentage of patients who responded to a fluid challenge, and baseline CVP of the fluid responders and nonresponders. Meta-analytic techniques were used to pool data.
Results:
The 24 studies included 803 patients; 5 studies compared CVP with measured circulating blood volume, while 19 studies determined the relationship between CVP/delta CVP and change in cardiac performance following a fluid challenge. The pooled correlation coefficient between CVP and measured blood volume was 0.16. Overall, 56 +-16% of the patients included in this review responded to a fluid challenge. The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18. The pooled area under the ROC curve was 0.56. The pooled correlation between delta CVP and change in stroke index/cardiac index was 0.11. Baseline CVP was 8.7+- 2.32 mm Hg in the responders as compared to 9.7+- 2.2 mm Hg in nonresponders (not significant).
Conclusion:
This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/delta CVP to predict the hemodynamic response to a fluid challenge. CVP should not be used to make clinical decisions regarding fluid management.
Level of evidence:
Level 1 (systematic review).
Club 5; CVP in intravascular volume assessment in KT
Summary
· CVP is most commonly used tool to assess the volume status intraoperative and in critically ill patients, it measures the venous pressure in right atrium and SVC and frequently used to determine the clinical decision to give IV fluids or diuretics. As it was thought that lower CVP means hypovolemia and volume depletion and vice versa.
· The current study aimed to find the correlation between changes in the CVP and volume status and fluid responsiveness, to predict the fluid responsiveness in patients.
· The CVP was not indicator of the volume status, not correlated with blood volume, and change in CVP did not reflect the fluid resuscitation or predicted the fluid responsiveness.
Level of evidence: systematic review (level I)
· CVP is measured in almost all patients in ICUs throughout the world, and frequently used to make decisions about giving fluids or diuretics
· Recently, the idea that the CVP reflects blood volume has been challenged
· the goal of this study was to evaluate the role of CVP in fluid management
Materials and Methods
· Inclusion criteria: 1) all relevant clinical trials that analyzed the relationship between CVP and measured blood volume.
2) studies that determined the ability of CVP to predict fluid responsiveness
· Exclusion criteria: Studies that compared CVP with volumetric measurements but did not report the ability of CVP to predict volume responsiveness
· All authors used the National Library of Medicine MEDLINE database for relevant studies published from 1966 to June 2007
· An increase in the stroke index or cardiac index 10 to 15% was used as an index of fluid responsiveness
Discussion
· The results of the study:
1.There is no association between CVP and circulating blood volume
2.CVP does not predict fluid responsiveness across a wide spectrum of clinical conditions.
The strength of the review
· Strict selection criteria used to identify relevant studies and the use of quantitative end points
· the studies are notable for the consistency (both in magnitude and direction) of their findings
Limitation:
none of the studies included in the analysis took the PEEP levels or changes in intrathoracic pressure into account when recording CVP
CONCLUSIOS
· CVP should not be routinely measured in the ICU, operating room, or emergency department.
· CVP measurement can be helpful in:
1) patients who have undergone heart transplant,
2) patients with right ventricular infarction or acute pulmonary embolism.
As CVP may be used as a marker of right ventricular function.
This is a systemic review, evidence 1
● Central venous pressure (CVP) is the pressure recorded from the right atrium or superior vena cava.
● CVP is frequently used to make decisions regarding the administration of fluids or diuretics.
● Recently, the idea that the CVP reflects blood volume has been challenged.
● studies included in this analysis:
(1) the correlation coefficient between CVP and measured blood volume
(2) the correlation coefficient or receiver operator characteristic (ROC) between CVP or change in CVP (-CVP) and change in stroke index/cardiac output following a fluid challenge.
● The results of this systematic review are clear:
(1) there is no association between CVP and circulating blood volume
(2) CVP does not predict fluid responsiveness across a wide spectrum of clinical conditions.
● there is no clear cutoff point that helps the physician to determine if the patient is “wet” or “dry.”
● The strength of review includes
* the rigorous selection criteria used to identify relevant studies
* the use of quantitative end points
* studies are notable for the consistency
(both in magnitude and direction) of their findings.
● 93% of intensivists use CVP to guide fluid therapy. I
● right ventricular filling is dependent on the transmural right atrial pressure gradient rather than the CVP alone.
● CVP is a measure of right atrial pressure alone; and not a measure of blood volume or ventricular preload.
● CVP should no longer be routinely measured in the ICU, operating room, or emergency department.
● measurement of the CVP may be useful in select circumstances:
** patients who have undergone heart transplant
** who have suffered a right ventricular infarction or acute pulmonary embolism.
● Level 1
● I notice that cvp is not accurate in assessment the state of volume in our patients but can you suggest other tools ?
Summary of the article;
Central venous pressure, (CVP) is the pressure of the right atrium and superior vena cava.
Measured hourly in indicated patient in ICU.
The CPV when applied , it was design as a marker of intravascular volume (whethwer volume depleted or overloaded).
Over 25 years the rule 5-2 used to guide fluid therapy, and it widely used till now, and the goal of this study is to systematically review the evidence to support this practice.
Material and methods;
Results;
Over 24 studies included in this article, 5 studies compared CVP to measured circulating blood volume, 19 studies for relation between CVP and change in cardiac performance following a fluid challenge.
Discussion;
Strengths;
Studies and articles;
Level of evidence ((V)) Review ariticle
CVP is commonly used to guide fluid therapy, the need for diuretics and to determine the endpoint of fluid resuscitation.
It is believed that CVP reflect intravascular volume and the volume status, changes in CVP following fluid challenge is used to guide fluid management.
This study aims to systemically review the evidence about using CVP in fluid management.
It included clinical trials studying the relation between CVP and measured blood volume, those that assessed the ability of CVP to predict fluid responsiveness and studies that compared CVP and volumetric measurements.
The meta analysis showed no association between CVP and circulating blood volume, CVP does not predict fluid responsiveness in various clinical conditions
It showed that at any CVP, the possibility of CVP to accurately predict fluid responsiveness is only 56%
It suggested that CVP should not be used in fluid management plan in any patient.
The use of IV fluids guided by CVP will result in inadequate volume replacement, also, using diuretics based on CVP may result in intravascular volume depletion leading to renal failure and poor organ perfusion.
CVP should not be used to determine whether critically ill patients are fluid responsive or not.
The study suggested that CVP should not be used and is useful only in certain conditions as patients who undergo heart transplantation, those with right ventricular infarction or acute pulmonary embolism.
CVP should be considered as a marker of right ventricular function rather than a marker of volume status.
Strength of the study was inclusion of relevant studies and use of quantitative endpoints.
Level of evidence: 1 (meta-analysis and systemic review)
Introduction
Central venous pressure (CVP) is the pressure measurement recorded from the right atrium or superior vena cava. CVP measurements are important to assess the requirements of fluid therapy and diuretics, and it is especially useful in critically ill patients. The theory is that it reflects the intravascular volume. The goal of the study was to systematically review the evidence that supports this practice.
Methods
The aim was to review all the studies that analyzed the relationship between CVP and measured blood volume. It also included studies that determined the ability of CVP to predict fluid responsiveness. The studies picked were between 1966 to June 2007. A standardized form was used to abstract the data.
Results
Out of the initial 206 citations, 24 studies were included in this trial. 5 studies compared CVP with the measured circulating blood volume. 19 studies determined the relationship between CVP and change in cardiac performance after a fluid challenge. The correlation coefficient between CVP and measured blood volume was 0.16. Overall, 56% of the patients responded to the fluid challenge. The pooled correlation between change in CVP measurements and change in stroke volume was 0.11.
Discussion
According to the results, there is no association between CVP and circulating blood volume, and CVP does not predict fluid responsiveness.
It is important to note that the patient is likely to respond to a fluid challenge with a low or high CVP.
Strengths:
Conclusion:
There was poor correlation between CVP and blood volume as well as the ratio of the CVP to the delta CVP to predict the hemodynamic response to a fluid challenge
CVP should not be used to guide clinical decisions for fluid management
It may be useful in a particular set of patients, such as patients who have undergone heart transplants or patients suffering from acute pulmonary embolism, as a marker of right ventricular function.
Limitations:
Positive end-expiratory pressure levels or change in intra thoracic pressure was not taken into account.
This is a systematic review of the literature – Level I evidence
Does Central Venous Pressure Predict
Fluid Responsiveness? A Systematic Review.
Introduction:
CVP was considered one of the important markers to assess blood volume and volume status of critically hospitalized patients , simple rule that low CVP with dehydrated patients and high CVP with overloaded patients, this one of the old Dogma, the goal of this study was to systemically review the evidence that supports this practice.
Materials and Methods.
A systematic review of the literature which determine the relationship between CVP and blood volume, the ability of CVP to predict fluid responsiveness, and the ability of the change in CVP (delta CVP) to predict fluid responsiveness.
Data collected from MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles.
Results.
Twenty four studies included in this analysis, 5 studies compared CVP with the measured circulating blood volume while 19 studies determined the relationship between CVP and change in cardiac performance following a fluid challenge (generally defined as a >10 to 15% increase in stroke index/
cardiac index).
1-The pooled correlation coefficient between the CVP and measured blood volume was 0.16.
2-The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index (reported in 10 studies) was 0.18.
This signify that there is no association between CVP and circulating blood volume, and CVP does not predict fluid
responsiveness across a wide spectrum of clinical conditions.
Conclusion:
CVP is considered a measure of right atrial pressure alone; and not a measure of blood volume or ventricular preload. This systematic review shown that CVP should no longer be routinely measured in the ICU, operating room, or emergency department, But can be used in special circumstances such as in patients who have undergone heart transplant, or in those who have suffered a right ventricular infarction or acute pulmonary embolism which is considered a marker of right ventricular function rather than an indicator of volume status.
Level I (systematic review)
Summary:
CVP is usually measured in ICU, emergency, patients undergoing major surgery to measure of right atrial pressure.
In this systemic review 213 studies were screened and 24 studies were included. This study aimed to analyze the relation between CVP, measure blood volume and assess the ability of CVP to predict fluid responsiveness.
This study found a very poor relationship between CVP and blood volume as well as the inability of CVP to predict the hemodynamic response to a fluid challenge. CVP should not be used to make clinical decisions regarding fluid management.
Level of evidence: 5
V. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares
1.Summarise this article
Introduction
CVP is widely used to guide fluid therapy in hospitalized patients. However, the idea that the CVP reflects blood volume has been challenged by both historical & recent data.
The goal of this study was to systemically review the evidence that supports this practice..
Objective:
A systematic literature review to assess:
A.The relationship between CVP & blood volume.
B.The ability of CVP to predict fluid responsiveness C. The ability of the change in CVP to predict fluid responsiveness.
Methodology
Data:
MEDLINE, Embase, Cochrane Register of Controlled Trials, & citation review of articles.
Out of 213 articles screened, 24 studies met the inclusion criteria & were included for data extraction.
The studies included adult subjects, healthy controls, & ICU & OR patients.
Meta-analysis techniques were used to pool data.
The 24 studies (803 patients) were as follows:
·Five studies compared CVP with measured circulating blood volume
·19 studies determined the relationship between CVP/file:///C:/Users/TOSHIBA/AppData/Local/Temp/msohtmlclip1/01/clip_image002.gifCVP & change in cardiac performance following a fluid challenge (defined as >10 to 15% increase in stroke index/cardiac index).
Results
Overall, 56 ± 16% of the patients included responded to a fluid challenge.
The pooled correlation coefficient between baseline CVP & change in stroke index/cardiac index was 0.18.
The pooled area under the ROC curve was 0.56.
The pooled correlation between ΔCVP & change in stroke index/cardiac index was 0.11.
Baseline CVP was 8.7 ± 2.32 mm Hg in the responders versus 9.7 ± 2.2 mmHg in non-responders (insignificant).
Discussion
No association was seen between CVP & circulating
blood volume & CVP does not predict fluid responsiveness across a wide spectrum of clinical conditions.
In none of the studies was CVP able to predict either of these two variables. The pooled area under the ROC curve was 0.56 (ROC curve is a statistical tool
that helps assess the likelihood of a result being a
true +ve versus a false +ve).
In conclusion, the results suggest that at any CVP the likelihood that CVP can accurately predict fluid responsiveness is only 56% (no better than tossing a coin).
Strength of the study
1.The rigorous selection criteria used to identify relevant studies.
2.The use of quantitative end points.
3.Consistency of the findings of the studies (both in magnitude & direction) suggesting that the findings are likely to be true.
/////////////////////////////////
2.What is the evidence provided by this article?
Level I
Thank you, see my question above.
CVP plays such a central role in the fluid management strategy of hospitalized patients, as it is reflects the intravascular volume. This idea has been challenged recently.
Objective: A systematic review of the literature to determine the relationship between CVP and blood volume, ability of CVP and its changes to predict fluid responsiveness.
Relevant studies that address any of the above objectives involved adult human with no restriction of patients’ type or setting included.
Data source: MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles
Results
24 studies included in this analysis. In all, 830 patients were studied.
Heterogeneity was present between studies
The pooled correlation coefficient between CVP and measured blood volume was 0.16.
Overall, 56 % of the patients included in this review responded to a fluid challenge.
The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18
The pooled area under the ROC curve was 0.56.
The pooled correlation between CVP and change in stroke index/cardiac index was 0.11.
Baseline CVP was 8.7 mm Hg in the responders as compared to 9.7 mm Hg in nonresponders (not significant).
Conclusions:
This SR clearly demonstrated a very poor relationship between CVP and blood volume.
inability of CVP/change in CVP to predict fluid responsivness across a wide spectrum of clinical condition.
CVP should not be used alone to make clinical decisions regarding fluid management, taking in account the whole clinical condition.
Level of evidence: 1 systematic review.
In practice it still has been used, now we are trying to use POCUS for better guidance
I liked reading your summary and analysis .I appreciate that you may like to change your practice based on this article by using POCUS.
Ajay
SUMMARY
Introduction
Central venous pressure has been used for many decades as a measurement of intravascular volume in critically ill patients in ICU or those undergoing surgeries. It is defined as the pressure measure from superior vena cava or right atrium and believe to be accurate enough in diagnosing fluid overload or dehydration during resuscitation of patients. However, the reliability of CVP as an accurate measurement of fluid management has been debated.
Aim of the study
Materials and Methods
-correlation co-efficient between CVP and measured blood volume
-receiver operator coefficient between CVP or change in CVP and change in – stroke index
Results
Strengths of the study
Limitation of the study
Outcome of the study
It is level 1 evidence
Thank you, All
Will you change your practice based on this article?
V. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares
—————————————————————————————————————
Introduction
Aim of the stud
Methods
Results
Conclusions:
What is the evidence provided by this article?
The level of evidence is 1.
Thank you, All
Will you change your practice based on this article?
Thank very much our Prof.Halawa
Yes, Prof.
Summary
CVP representing the right atrial pressure or SVC pressure was used to guide for the fluid therapy particularly in ICU patients.
The concept that CVP reflects intravascular blood volume thereby low CVP indicates volume depletion and high CVP indicates volume overload is revised .
The aim of this study is to revaluate the evidence of CVP applications.
Methods
A multimethod approach analysing studies that
compared CVP with volumetric measurements and studies assessing the relationship between CVP or CVP change and change in stroke index/cardiac output
after a fluid challenge but it did not included studies that stated the CVP ability of detection of volume responsiveness.
Results
24 studies were included , 5 compared CVP with the measured circulating blood volume while 19 assessed the relationship between CVP and cardiac performance variation after fluid challenge.
The CVP and measured blood volume correlation coefficient was 0.16 and that of CVP and change in stroke index/cardiac index was 0.18 and that of change in CVP and change in stroke index/cardiac index was 0.11.
Discussion
CVP did not show any association with circulating blood volume, and did not predict the response to the fluid therapy mean fact it’s accuracy to predict was 56% indicating that either a high or low CVP renders the patient responsive to fluid therapy.
Strength of this study
Included having quantitative end points ,and precise selection criteria for those studies rendering the findings valid.
Limitations
None of the studies considered the positive end-expiatory pressure levels or changes in intrathoracic pressure while assessing the CVP.
Transmural right atrial pressure gradient affects right ventricular filling and not CVP alone.
CVP guidance was prone to lead to volume overload and pulmonary oedema.
Positive fluid balance in ICU cases and surgical cases can cause hazardous outcomes and lead to mortality.
High CVP is not a must to mean fluid overload .
If the left ventricle was functioning near the “flat” part of the Frank-Starling curve , the fluid replacement will cause oedema and won’t increase the cardiac output that is why it is important to know whether the patient is fluid responsive or not.
Multiple old studies published the inaccuracy of CVP to represent volume status .
One study published that the respiratory variation in CVP in spontaneously breathing cases was predictive of
fluid responsiveness but it was not conclusive.
This study revealed the need of revising the Campaign guidelines ,in 2004 for management of severe
sepsis and septic shock which adviced that for hypoperfusion caused by sepsis, the CVP of 8 to 12
mm Hg need to be the goal of the initial resuscitation and a higher targeted CVP of 12–15 mm Hg for cases on mechanical ventilation.
Conclusion
CVP must not be routinely used as measure of volume status meanwhile it can be beneficial in some cases as in cases undergoing heart transplant, or in those who have suffered a right ventricular infarction or acute pulmonary embolism.
-Level of evidence is 1 as systematic review
Thank you, All
Will you change your practice based on this article?
Summarise this article
Introduction
CVP still used worldwide to guide fluid therapy but both historical and recent data suggest that this approach may be wrong
Aim of the study
A systematic review of the literature with the aim of:
1. Analyze the relationship between CVP and measured blood volume
2. The ability of CVP to predict fluid responsiveness
3. The ability of the change in CVP (CVP) to predict fluid responsiveness
Materials and Methods
The study was restricted to adults
Studies including either of the following were included:
1. The correlation coefficient between CVP and measured blood volume
2. The correlation coefficient or receiver operator characteristic (ROC) between CVP or change in CVP and change in stroke index/cardiac output following a fluid challenge
3. fluid responsiveness.6,7
Fluid responsiveness was defined as an increase in the stoke index or cardiac index > 10-15%
Results
Only 24 studies (total of 213 citations) met the inclusion criteria
Of the 24 studies (830 patients): 5 studies compared CVP with the measured blood volume and 19 studies determined the relationship between CVP and change in cardiac performance following a fluid challenge
The pooled correlation coefficient between the CVP and measured blood volume was 0.16
The pooled correlation coefficient between baseline CVP and change in stroke index/ cardiac index was 0.18
The pooled correlation between change CVP and change in stroke index/cardiac index was 0.11
Discussion
There is no association between CVP and circulating blood volume
CVP does not predict fluid responsiveness
The likelihood that CVP can accurately predict fluid responsiveness is only 56% (no better than flipping a coin)
The strength of the study includes the rigorous selection criteria used to identify relevant studies as well as the use of quantitative end points. Also, the studies are notable for the consistency of their findings (findings are likely to be true)
Conclusion
Poor relationship between CVP and blood volume
CVP/change in CVP fails to predict the hemodynamic response to a fluid challenge
CVP should not be used to make clinical decisions of fluid therapy
What is the evidence provided by this article?
Level 1 (systemic review)
Thank you, All
Will you change your practice based on this article?
Yes, definitely
Aim of the study:
The goal was to find all relevant clinical trials that evaluated the connection between CVP and measured blood volume and fluid responsiveness.
Introduction:
Hospitalized patients’ fluid treatment is virtually always guided by CVP. Recent and historical evidence demonstrates this method is faulty.
Method:
-A systematic review to assess the association between CVP and blood volume, CVP’s capacity to predict fluid responsiveness, and CVP’s ability to predict fluid responsiveness change.
-Clinical investigations that assessed the connection between CVP and blood volume or CVP/CVP and stroke volume/cardiac index after a fluid challenge. 24 research were considered for data extraction from 213 publications.
Adults, healthy controls, ICU, and OR patients participated in the trials.
-Data extraction: Data were abstracted on Study design, study size, study environment, patient population, and the correlation coefficient between CVP and blood volume.
Results:
-Pooled correlation between CVP and blood volume was 0.16 (95% CI, 0.03 to 0.28; r 2 0.02). Studies differed.
-10 studies revealed a 0.18 (95% CI) connection between baseline CVP and change in stroke index/cardiac index.
-The pooled ROC area was 0.56 (95% CI, 0.51 to 0.61). Seven studies revealed a 0.11 (95% CI) connection between CVP and stroke index/cardiac index change. Responders’ baseline CVP was 8.7 2.3 mm Hg, compared to 9.7 2.2 mm Hg in nonresponders (p = 0.3).
-Pooled correlation and area under the curve Q statistics were not significant.
Conclusion:
-CVP measures right atrial pressure, not blood volume or ventricular preload.
– CVP shouldn’t be regularly assessed in the ICU, OR, or ED. CVP may be effective in individuals who have had a heart transplant, right ventricular infarction, or acute pulmonary embolism.
-CVP may be utilized as a marker of right ventricular function in some circumstances.
Level of evidence 1
Thankyou ,logic conclusions but no suggestions for a practical alternative other than clinical assessment of fluid status.
There is a trend in using CVP as a guide to evaluate the volume state of the patients with volume depletion is diagnosed if the CVP is low and volume overload diagnosed if the CVP is high, moreover the change in CVP reading will affect the decision of subsequent fluid management
The Surviving Sepsis Campaign guidelines recommended a CVP of 8 to 12 mm Hg in non-mechanically ventilated patients and 12-15 mm Hg in mechanically ventilated patients
This is a systematic review (level of evidence I) evaluation 24 studies including 803 adult healthy, ICU and OR patients regarding the relation between CVP readings and measured blood volume and CVP, if baseline CVP can predict fluid responsiveness and to assess the correlation between change in the CVP and the change in stroke volume/cardiac index after fluid challenge
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Thankyou for the summary and conclusion
The title of the paper states Avery odd experiment of (bleeding 7 mares ! female horses to try to find the relation between the blood vol and ?? cvp measured) No comment!,
Materials & methods:
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Level of evidence is 1
Hi Dr Ban,
I liked reading your summary and analysis, Will you change your practice based on this article?
Ajay
Absolutely yes
Hi Dr Ben,
I liked reading your summary and analysis, Will you change your practice based on this article?
Ajay