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PULMONARY
ARTERY/CENTRALVENOUS
VENOUSPRESSURE
PRESSURE
MEASUREMENT
MEASUREMENT
Expected Practice:
Verify the accuracy of the invasive pressure monitoring system by performing a square waveform test at the
beginning of each shift and anytime the system is disturbed (e.g., blood draw).
Position the patient supine position (head of bed (HOB) bed between 0 and 60), lateral position 20, 30 or 90 or
prone before pulmonary artery pressure (PAP), pulmonary artery occlusion pressure (PAOP), central venous
pressure (CVP) measurements. HOB elevation can be at any angle from 0 (flat) to 60 if the patient is in the
supine position. Allow the patient to stabilize 5-15 minutes after a position change.
Level and reference the transducer air-fluid interface to the phlebostatic axis (supine or prone position), 4th ICS
AP diameter of the chest or lateral angle specific reference using a laser or carpenters level before
PAP/PAOP/CVP measurements.
Obtain PAP/PAOP/CVP measurements from a graphic (analog) tracing at end-expiration or adjust the
measurement point if the patient is receiving airway pressure release ventilation (APRV) or is actively exhaling.
Use a simultaneous ECG tracing to assist with proper PAP/PAOP/CVP waveform identification.
PA catheters can be safely withdrawn and removed by competent registered nurses.
The square waveform test, or dynamic response test, determines the ability of the transducer system to correctly
reflect invasive pressures.14,15 The dynamic response is affected by system problems, such as air bubbles in the
tubing, excessive tubing length, loose connections, and catheter patency. Removal of microbubbles during system set
up result in an adequate or optimal system in over 95% of cases.16,17 Any of these problems affect the accuracy of
PAP/PAOP/CVP measurements and must be corrected prior to pressure measurement. Perform the square waveform
test: on the initial system setup, at least once each shift, after opening the catheter system (e.g. for rezeroing, drawing
blood, or changing tubing), and whenever the PAP/PAOP/CVP waveform appears to be damped or distorted.14 (Level
A)
Consider the following changes in PA pressures as clinically significant (i.e., not reflective of the normal variability in
PA pressures):
PAS > 4-7 mm Hg; PAEDP > 4-7 mm Hg; PAOP > 4 mm Hg.18-20 (LevelB)
Studies in a variety of patient populations found that PAP/PAOP/CVP measurements are accurate when the HOB is
elevated to any angle between 0o and 60 21-27 or when the patient in a 20 28, 30 20,29 or 90 30 lateral position with the
HOB flat, as long as the correct angle-specific reference is used. PAP/PAOP/CVP measurements should not be
performed in Trendelenburg31 or if the legs are in a dependent position.21 There are no studies to support
PAP/PAOP/CVP measurements in reverse Trendelenburg. Reliable cardiac output (CO) measurements have been
obtained only in the supine position with backrest at 20 32 or 45 33 and in the prone position.34-37 Clinically significant
changes in CO may occur in the 20 lateral position,32,38 which may limit concurrent PAP/PAOP/CVP and CO
measurements. Because there are individual variations in response to a given position, evaluate each patients
PAP/PAOP/CVP compared to the flat, supine position using a standardized approach.17,39 (Level A)
The use of position-specific reference is critical to accurate PAP/PAOP/CVP measurement.20,40-44 In the supine
position the phlebostatic axis (4th ICS at the AP diameter of the chest) is the most commonly used reference
point.45 In the lateral position the following reference points should be used: 30 lateral ( distance from surface of
bed to the left sternal border). 90o right lateral position(4th ICS/midsternum) and in the 90o left position (4th ICS/left
parasternal border).41,42,45 A laser or carpenters level (not the eyeball technique) should be used to correctly
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reference the system.46 Once the correct reference location is identified, a mark should be placed on the chest wall.
(Level A)
Before obtaining PAP/PAOP/CVP measurements, patients may require 5-15 minutes for stabilization depending on
the patients left ventricular function.47 No specific recommendations are available for the stabilization period after
proning; measurements have been performed 20-30 minutes after repositioning from supine to prone for patients with
acute lung injury.35-37 and in patients with ARDS, measurements were performed 20 minutes after stabilization of the
SvO2 (60-90 minutes after proning).34 (Level A)
Changes in intrathoracic pressure during respiration alter intracardiac pressures. PAP/PAOP/CVP measurements are
obtained by convention at end-expiration when pleural pressure is minimal.48 For patients receiving airway pressure
release ventilation (APRV), the PAOP should be measured at the end of the positive pressure plateau, which can be
observed on the ventilator and is the point immediately before the release of airway pressure and the initiation of
inspiration.49 With active exhalation (suspect if respiratory-induced fluctuation in PAOP is greater than 10-15 mm Hg)
read the PAOP at the midpoint between the end-expiratory peak and the end-inspiratory lowpoint.50 The addition of
the airway pressure tracing to the analog strip may further improve measurement accuracy.51 (Level A)
A simultaneous ECG should be used to facilitate correct PAP/PAOP/CVP waveform measurement55-57 and should be
read from analog tracings or using the stop cursor method.52-54 Digital readouts should not be used as they reflect
pressures obtained throughout respiration and may be significantly different from end expiratory pressures. (Level A)
Registered nurses, who demonstrate competency, can safely withdraw and/or remove PA catheters.58,59 Before
incorporating withdrawing and/or removing PA catheters into nursing practice, verify that it is within your states scope
of practice for registered nurses. (Level B)
AACN Evidence Leveling System
Level A
Level B
Level C
Level D
Level E
Level M
Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a
specific action, intervention or treatment.
Well-designed, controlled studies with results that consistently support a specific action, intervention or treatment.
Qualitative studies, descriptive or correlational studies, integrative review, systematic reviews, or randomized
controlled trials with inconsistent results.
Peer-reviewed professional organizational standards with clinical studies to support recommendations.
Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational
standards without clinical studies to support recommendations.
Manufacturers recommendations only.
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References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
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26. Laulive JL. Pulmonary artery pressure and position changes in the
critically ill adult. Dimens Crit Care Nurs. 1982;1:28-34.
27. Clochesy J, Hinshaw A, Otto C. Effects of change in position on
pulmonary artery and pulmonary capillary wedge pressures in
mechanically ventilated patients. NITA. 1984;7:223-5.
28. Whitman GR. Comparison of pulmonary artery catheter
measurements in 20 supine and 20 right and left lateral
recumbent positions [abstract]. In: Halfman MA, editor.
Proceedings of the AACN International Intensive Care Nursing
Conference; 1982 Aug 31-Sep 3; London, England. Irvine:
American Association of Critical-Care Nurses; c1982. p. 120.
29. Duke P. Effects of Two-Sidelying Positions on the Measurement
of Pulmonary Artery Pressures in Critically Ill Adults [thesis].
Seattle: University of Washington; 1994.
30. Kennedy G, Bryant A, Crawford M. The effects of lateral body
positioning on measurement of pulmonary artery and pulmonary
artery wedge pressure. Heart Lung. 1984;13:155-8.
31. Reuter DA, Felbinger TW, Schmidt C, et al. Trendelenburg
positioning after cardiac surgery: effects on intrathoracic blood
volume index and cardiac performance. Eur J Anaesthesiol.
2003;20:17-20.
32. Whitman G, Verga T. Comparison of cardiac output
measurements in 20-degree supine and 20-degree right and left
lateral recumbent positions. Heart Lung. 1982;11:256-7.
33. Giuliano KK, Scott SS, Brown V, et al. Backrest angle and cardiac
output measurement in critically ill patients. Nurs Res.
2003;52:242-8.
34. Blanch I, Mancebo J, Perez M, et al. Short-term effects of prone
position in critically ill patients with acute respiratory distress
syndrome. Intensive Care Med. 1997;23:1033-9.
35. Jolliet P, Bulpa P, Chevrolet JC. Effects of the prone position on
gas exchange and hemodynamics in severe acute respiratory
distress syndrome. Crit Care Med. 1998;26:1977-85.
36. Vollman K, Bander J. Improved oxygenation using a prone
positioner in patients with acute respiratory distress syndrome.
Intensive Care Med. 1996;22:1105-11.
37. Toyota S, Amaki Y. Hemodynamic evaluation of the prone
position by transesophageal echocardiography. J Clin Anesth.
1998;10:32-5.
38. Doering L, Dracup K. Comparisons of cardiac output in supine
and lateral positions. Nurs Res. 1988;37:114-8.
39. Gawlinski A. Facts and fallacies of patient positioning and
hemodynamic measurement. J Cardiovasc Nurs. 1997;12(1):1-15.
Erratum in: J Cardiovasc Nurs. 1998; 12(3): preceding 1.
40. Bartz B, Maroun C, Underhill S. Differences in midanteroposterior
level and midaxillary level of patients with a range of chest
configurations. Heart Lung. 1988;17:309.
41. Kee LL, Simonson JS, Stotts NA, et al. Echocardiographic
determination of valid zero reference levels in supine and lateral
positions. Am J Crit Care .1993;2:72-80.
42. VanEtta D, Gibbons E, Woods S. Estimation of left atrial location
in supine and 30 lateral position. Am J Crit Care. 1993;2:264.
43. Ross C, Jones R. Comparisons of pulmonary artery pressure
measurements in supine and 30 degree lateral positions. Can J
Cardiovasc Nurs. 1995;6:4-8.
44. Courtois M, Fattal P, Kovacs S, et al. Anatomically and
physiologically based reference level for measurement of
intracardiac pressures. Circulation. 1995;92:1994-2000.
45. Paolella L, Dortman G, Cronan J, et al. Topographic location of
the left atrium by computed tomography: Reducing pulmonary
artery catheter calibration errors. Crit Care Med. 1988;16:1154-6.
46. Bisnaire D, Robinson L. Accuracy of leveling hemodynamic
transducer systems. Off J Can Assoc Crit Care Nurs. 1999;10:169.
47. Doering LV. The effect of positioning on hemodynamics and gas
exchange in the critically ill: a review. Am J Crit Care. 1993;2:20816.
48. Berryhill R, Benumof J, Rauscher L. Pulmonary vascular pressure
reading at the end of exhalation. Anesthesiology. 1978;49:365368.
49. Kaplan L, Bailey H. A comparison of pulmonary artery occlusion
pressure (PaOP) measurements using pressure controlled
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50.
51.
52.
53.
54.
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