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Table of Contents
LETTER TO EDITOR  
Year : 2016  |  Volume : 19  |  Issue : 4  |  Page : 760-761
Arterialization of central venous pressure waveform


1 Department of Cardiac Anesthesiology, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
3 Department of Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India

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Date of Web Publication7-Oct-2016
 

How to cite this article:
Raut MS, Maheshwari A, Sharma M, Joshi S, Kumar A, Gupta A, Goyal H. Arterialization of central venous pressure waveform. Ann Card Anaesth 2016;19:760-1

How to cite this URL:
Raut MS, Maheshwari A, Sharma M, Joshi S, Kumar A, Gupta A, Goyal H. Arterialization of central venous pressure waveform. Ann Card Anaesth [serial online] 2016 [cited 2019 Dec 11];19:760-1. Available from: http://www.annals.in/text.asp?2016/19/4/760/191556




The Editor,

A 60-year-old female known diabetic and hypertensive presented with fever since 5 days. She was diagnosed to have urinary tract infection with left ventricular systolic dysfunction. Noradrenaline infusion was started to maintain hemodynamics. Right subclavian vein was punctured, and triple lumen central venous catheter (CVC) was inserted for infusion of vasopressor drugs. Central venous pressure (CVP) monitoring was attached to CVC. Monitor showed unusual CVP waveform - resembling arterial upstroke and downstroke [Figure 1]. However, waveform tracing was not showing peak pressure more than 20 mmHg. Noninvasive blood pressure in the right arm was 104/66 mmHg. Blood gas analysis of blood sample derived from CVC confirmed venous origin of blood. Why was there arterial waveform in venous catheter? Chest X-ray of the same patient revealed course of the right subclavian venous catheter into right internal jugular vein (IJV) [Figure 2]. Ultrasound of right side of the neck showed pulsating internal carotid artery (confirmed by ultrasound Doppler) just beside IJV with CVC [Figure 3]. Arterial pulsation of carotid artery might be transmitting to IJV, which was reflected in waveform [Video 1].
Figure 1: Monitor display showing central venous pressure waveform resembling arterial waveform

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Figure 2: Chest X-ray showing the course of central venous catheter from subclavian to internal jugular vein

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Figure 3: Ultrasound image showing internal jugular vein with central venous catheter adjacent to internal carotid artery. Left panel - internal carotid artery with Doppler waveform. Right panel - internal jugular vein with Doppler waveform

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CVP waveform normally consists of three positive waves (a, c, and v waves) and two negative waves (x and y descents). Abnormalities in these waves can be produced by varieties of clinical cardiac conditions.[1],[2] Venous catheter can give arterial waveform as it travels through right ventricle to pulmonary artery, for example,  Swan-Ganz catheter More Details. However, in the present case, venous catheter gave arterial waveform even in the absence of it's entry into cardiac structures or artery. CVC showing airway pressure waveform due to catheter migration has been reported.[3] Arterial waveform showed by a CVC generally indicates inadvertent arterial insertion.[4] Accidental position of CVC in the left internal thoracic vein or the pericardiophrenic vein mimicking as arterial waveform has also been reported.[5] The author concluded the “arterial” waveform by CVC was due to transmission of pulse waves of adjacent cardiac contraction and filling.[5]

Waveform analysis, chest X-ray, and blood gas interpretation can diagnose misplacement of CVC. Pulsatile vascular structure such as artery in the immediate vicinity of vein with catheter can give arterial waveform due to transmissible pulsation. The present case demonstrated arterial waveform in CVC does not always imply arterial placement of catheter.

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Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Barbeito A, Mark JB. Arterial and central venous pressure monitoring. Anesthesiol Clin 2006;24:717-35.  Back to cited text no. 1
[PUBMED]    
2.
Rodes A, Grounds RM, Bennett ED. Hemodynamic monitoring. In: Fink MP, Abraham E, Vincent JL, Kochanek PM, editors. Textbook of Critical Care. 5th ed. Philadelphia, PA: Elsevier Saunders; 2005. p. 736.  Back to cited text no. 2
    
3.
Bangaari A. Airway pressure waveform transduced from central venous catheter indicating catheter migration. Anesth Analg 2010;110:1247-8.  Back to cited text no. 3
[PUBMED]    
4.
Choi YS, Park JY, Kwak YL, Lee JW. Inadvertent arterial insertion of a central venous catheter: Delayed recognition with abrupt changes in pressure waveform during surgery – A case report. Korean J Anesthesiol 2011;60:47-51.  Back to cited text no. 4
[PUBMED]    
5.
Vromans RP, Keurlings PA, van der Hoeven JG. Central venous catheter malposition mimicking an arterial waveform. Neth J Crit Care 2015;21:26-7.  Back to cited text no. 5
    

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Correspondence Address:
Monish S Raut
Department of Cardiac Anesthesiology, Sir Ganga Ram Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.191556

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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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