Rwwcitution, 16 w2S) 221-220

Elsevier Scientific Publishers Ireland Ltd.

INACCURACIES

221

IN MANOMETRIC

CENTRAL VENOUS PRESSURE

MEASUREMENT

D.G. CLAYTON*
Intonsivs Care Unit, Royal A&hide
lAwtrald

Hoapita4 North Termce, Adekde, S. Awtndia SO00

(Received July 20th. 1287)

(Revision received November 1st. 1987)
(Accepted November 12th, 1987)

SUMMARY

Manometric measurement of CVP was compared to electronic measurement

in ten patients. Manometric measurementwas found to give readings of up to 5
cm&O greater than electronic, with a mean difference of 2.4 cmH,O. This was
shown to he due to two factors. Firstly, a r@eniscus effect caused an error of 1.07
cmH,O in the manometers used. Secondly, an error attributed to the way mean
values of CVP are commonly read from manometers caused a further over estimate of 1.33 cmH,O. In intensive care units, where it is important to recognise
and treat small changes in CVP, the use of electronic transducers to measure
CVP is recommended.

Key words: Clinical measurement

- Intensive care - Central venous pressure

INTRODUCTION

Manometric measurement of central venous pressure (CVPl continues to he

used widely. In a critically ill patient, the choice of treatment may depend on
the CVP measurement. It is thus important that measurements should be as
accurate as possible. When changing from manometric to electronic measurement, a clinical impression was formed that values obtained with the manometer have been higher than those found electronically. The relative inaccuracy of
manometers has been previously noted [l-3]. It was therefore decided to confirm the presence of this discrepancy between manometric and electronic measurement of CVP, and to elucidate the causative factors.
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MATERIALS AND METHODS

The investigation was conducted in three parts. The first part studied
whether a meniscus effect could be demonstrated in CVP manometers. The
second part was designed to eliminate any meniscus effect and determine
whether any further discrepancy between electronic and manometric CVP
existed. The third part was to demonstrate whether electronic or manometric
measurement gave the most accurate mean readings.
To assess whether a meniscus effect existed with the CVP manometers used
in this unit (Tuta laboratories), 11 manometers from eight different batches
were examined. Each set was primed with 5% dextrose, and care taken to
exclude air bubbles. The end of the measuring set which would normally be
connected to the central venous cannula was left open to air, and held consecutively at the four positions on the manometer column (Fig. 11. In all cases an
approximately hemispherical meniscus formed at the open end of the measuring set. Thus surface tension forces at the orifice should have been constant,
and no effect due to a hanging drop was allowed to occur. The level at which the
meniscus in the manometer settled was noted and the height difference
between the meniscus and the end of the measuring set recorded. In total, 44
observations were made.

.
E.

Fig. 1. Method of demonstrating meniscus effect.

223

To confirm that a meniscus effect was present commercial detergent was

added to the 5% dextrose to form a 0.05% solution. The experiment was then
repeated, again with care being taken to standardise the shape of drop formed
at the orifice open to air. The internal diameter of the manometer column was
determined by injecting 0.8 ml of 5% dextrose into the manometer column,
measuring the height of the column of liquid formed, and calculating a mean
diameter assuming the column was a uniform cylinder. Finally, once the diameter of the manometer was known, this value was used to calculate the predicted
meniscus effect. The expected meniscus effect is calculated using the formula
below, quoted in standard textbooks on physics, which relates size of meniscus
effect for a given solution to the surface tension of that solution, and the dimensions of its container.

& =

4 x ST x case

dxw
where: h is the height of meniscus effect; ST is the surface tension of 5% dextrose; 8 is the wetting angle - assumed to be 25O; d is the diameter of the
column; w is the specific weight of 6% dextrose.
To determine if the meniscus effect completely explained the discrepancy
between manometric and electronic CVP readings which had previously been
noted, ten patients with subclavian central venous cannulae in situ were studied. The cannulae were all 16 gauge and either Angioguides or Intracaths. The
tip position was in either low superior vena cava, or right atrium and was
confirmed radiologically. Kinking of the cannula or positioning against a vessel
wall was also excluded. Both spontaneously breathing and mechanically ventilated patients were included. No patient was receiving PEEP or CPAP. The
reference point for readings was the mid-axillary line. A three-way tap and
short connection were connected to the cannula hub. One port of the three-way
tap was connected to a Tuta CVP measuring set. The second port was connected to a Gould Pressure Transducer and on to a Siemens pressure module,
Sirecust 404, with frequency response 0 - 20 Hz (Fig. 21. Care was taken in zeroing the transducer against the manometer to eliminate the error due to the
meniscus effect. This was done by filling the manometer up to 20 cm of water
and allowing it to vent to air through a three-way tap in line with the
transducer. When the manometer level had settled, the tap was turned so that
the manometer was connected to the transducer, and the transducer set to
zero. When the transducer was zeroed it was connected only to the manometer
column and no other taps were open, thus eliminating any errors due to meniscus effects at open taps, or in the manometer itself. The CVP manometer was
then used to confirm linearity and gain of the transducer by filling it to 10.20
and 30 cmH,O, and checking the values recorded by the transducer. As the
transducer was calibrated against the manometer, any inaccuracies due to
patient position, and reference point on the body were eliminated. When

224

40

30

20

10

-10

Fig. 2. Method used for obtaining paired readinga of manometric and electronic CVP.

readings were being made any other infusions were stopped and the line
flushed with 6% dextrose. Paired readings of CVP were then made as follows.
The patients were laid flat, and measurements taken from the mid-axillary line.
For the manometric CVP a swing of at least 1 cm was required to confirm
catheter patency before readings were taken. With only the manometer open
to the patient a mean value of CVP was estimated without stopping ventilation,
from the maximum and minimum values recorded over 1 min. This is believed
to reflect clinical practice. The manometer was then switched off and the transducer opened to the patient and an electronic mean value for CVP was read off
the pressure module, again with ventilation continuing. Each reading was
taken twice and an average value obtained. A total of 31 pairs of readings were
made. Value measurements in mmHg from the pressure transducer were converted to cmH,O by multiplying by 1.36.
To demonstrate which of the two methods of measuring CVP was the more
accurate, a third study was conducted. A range of pressure wave forms generated by a Bio-Tek Model 6OlA blood pressure systems monitor were used. The
mean values of these wave forms were measured using the method employed in
the second part of this study. Each reading was taken three times and an aver-

age value obtained. The wave forms used were: a square wave, a sine wave, a
right ventricular wave, two pulmonary artery waves, and a pulmonary artery
wedge pressure wave. In addition to measuring the mean value of these waves
with the manometer and Siemens pressure module, a third, more sophisticated
measuring system was employed to obtain a more accurate response, and
derive a reference mean. This comprised a Hewlett-Packard pressure amplifier
model 8805 with filter set at 450 Hz, connected to a Honeywell 1508 ultraviolet
paper recorder, with a frequency response of 800 Hz. Having recorded the generated pressure wave forms using this third system, a true arithmetical mean
was determined by measuring the area under the waveform using 2 mm
squared graph paper.
Statistical analysis of the manometrically and electronically determined
CVPs was by paired t-testing, and of differences in error at low, normal, and
high CVP by one-way analysis of variance.
RESULTS

The results of the investigation to detect any meniscus effect are shown in
Table I. With the manometer primed with 5% dextrose and open to air, the
mean of 44 manometer readings was 1.07 f 0.43 cmH,O. With detergent added
to the dextrose the manometer reading was 0 + 0 cmH,O. A meniscus effect
was thus clearly demonstrated. The mean internal diameter of the manometer
column was found to be 1.70 f 0.02 mm in the 11 sets used. Calculation of the
expected meniscus error in a manometer column of diameter 1.7 mm gave a
result of 1.53 cm.
In the second investigation with the meniscus effect eliminated, the results
of paired CVP readings taken with the manometer and with an electronic transducer are shown in Tables II, III and IV. The range of CVP readings was from
- 1 to +20 cmH,O and range of difference in readings from - 0.8 to + 3.4
cmH,O. The manometer gave values greater than the transducer in 29 of the 31
cases (93.5%). Breakdown of these results showed the error to be significantly
greater in ventilated than spontaneously breathing patients, and greatest at
low CVPs (Tables III and IV). Therefore a second error affected by mode of

TABLE I
DEMONSTRATION
OF MENISCUS EFFECT WITH 5% DEXTROSE
WHEN DETERGENT WAS ADDED TO THE PRIMING SOLUTION

AND

ITS ABSENCE

Priming solution

No. observations

Mean manometer reading

open to air f S.D. cmH,O

Statistical
significance

5% Dextrose
0.06% detergent
in 6% Dextrose

44
44

1.07 f 0.43
o+o

P< 0.0001

t = 109;

31
31

Fluid manometer
Electronic
transducer

10.5 + 5.1
9.2 f 5.1

Pressure readings
cmH,O f SD.
1.33 f 1.1

Mean difference between

paired readings cmH,O + S.D.
-o.sto

+ 3.4

Range of
difference cmH,O

P< 0.001

t=39;

Statistical
significance

0.933 f 1.12
1.326 f 0.68

18

12

Spontaneous
ventilation
Positive pressure
ventilation

Mean difference between

paired readings cmq0 f S.D.

No. observations

Method of
ventilation

+ 0.3 to + 3.4

-O.Sto +2.3

Range of
difference cm%0

P< 0.001

t = 35;

Statistical
significance

COMPARISON OF DIFFERENCE BETWEEN MANOMETRIC AND ELECTRONIC READINGS FOR SPONTANEOUSLY BREATHING AND
VENTILATED PATIENTS

TABLE III

Number of
readings

Method of
measurement

COMPARISON OF PAIRED READINGS OF CVP FROM THE MANOMETER AND ELECTRONIC TRANSDUCER

TABLE II

227

TABLEN
COMPARISON
OFDIFFERENCE
BETWEEN
MANOMETRIC
ANDELECTRONIC
READINGS
AT LOW(<6 cm&O);NORMAL(S- 12cmH,O),
ANDHIGH(> 12 cmH,O) CVP, BY ONE-WAY
ANALYSIS OF VARIANCE
*Difference in low CVP group statistically

greater than normal CVP group, but not high CVP

group.
CVP cmH,O

No. of observations

Mean difference
f S.D. cmH,O

Statistical
significance

<6

5
13
13

228 f 0.57*
0.86 zt 1.08
1.42 f 0.93

P = 0.03
NS

6-12
>12

ventilation was demonstrated to be causing over-reading of the manometer.

The largest total error recorded, due to meniscus effect plus this second effect,
was 6 cmH,O, and the least error 0.5 cmH,O.
The results of the third study to determine a reference mean value as
accurately as possible and compare it to the manometric and electronic means
are shown in Table V. It is seen that for the simple wave forms of square wave
and sine wave the three systems were in close agreement. However, with the
more complex wave forms, of the type found in patients, marked differences
were found. In these four cases the reference mean was closer to the electronically determined mean than the manometrically determined mean. In each case
the electronic mean was within 1 cmH,O of the reference mean, while the manometer mean was more than 1 cmH,O different, and always greater than the reference mean.
DISCUSSION
This investigation shows that a manometric determination of CVP with a
commercially available set of 1.7 mm diameter may differ by an average 2.4
TABLE V
COMPARISON OF MANOMETRIC. ELECTRONIC AND,REFERENCE
SIX GENERATED WAVE FORMS AT 1 Hz

MEAN VALUES FOR

Waveform

Manometric
mean cm%0

Electronic
mean cmH%O

Reference
mean cmH,O

Square wave
Sine wave
Right ventricular
Pulmonary artery
Pulmonary artery
with catheter whip
pulmonary artery
wedge with vwave

28.5
13.5
6.0
9.0
9.0

28.5
13.6
4.1
8.2
8.2

28.0

7.0

5.4

14.1
4.1
7.8
7.3
5.9

cmH,O from an electronic determination. The error range for any given patient
varied by as much as 5 cmH,O, could not be predicted, and varied at different
times in the same patient. Manometric readings were always higher than electronic readings when the meniscus effect was taken into account. The error was
due to at least two factors. Firstly, a meniscus or surface tension effect of 1.07
cmH,O was found in the manometers tested. Secondly, another factor, or factors led to a further over-estimate of 1.33 cmH,O.
The method of demonstrating the meniscus effect may be criticized because
any meniscus effect existing at the manometer orifice held open to air was not
taken into account. The measured value for meniscus effect was less than, but
close to, the calculated value. Thus pressure effects at this orifice tended to
reduce the observed meniscus effect, and did not introduce a major error. The
same criticism may be used when considering the method of zeroing the transducer. Again, the error was not large and tended to reduce errors from the
manometer, not increase them.
The second error of 1.33 cmH,O could have been due to either of two
possibilities. Firstly, that the manometer was over-reading, or secondly that
the meaning process in the electronic system led to under-reading. The third
method used to determine a reference mean using more accurate equipment,
and a mathematically calculated mean suggested that the manometer was in
error. It thus remains to be explained why the Tuta manometers used in this
study should over-estimate mean CVP. This has been ascribed to resonance
wave fronts, bends in the catheter, and the low frequency response rate of the
fluid manometer by Mann et al. [2]. These factors, however, would not be
expected to affect the mean pressure. A possible explanation is that the method
of reading by eye, a mean CVP from a manometer column, fluctuating with both
pulse and respiration, caused this error. The CVP waveform is a complex phasic
signal, and as with arterial waveforms, the true mean value is closer to the
lowest point of the waveform than the highest. Thus reading a middle value
between highest and lowest swings on the manometer, as is common clinical
practice, will cause over-reading of manometric CVP. This argument is
supported by the findings using generated waveforms. There was good
agreement between the two systems, and also with the mathematically determined mean with the sine and square waves. This suggests that there was no
intrinsic fault in the experimental set-up. These two signals are symmetrical.
The phasic physiological signals used however caused marked differences between the measuring systems. Here the systolic diastolic ratio is less than 1 : 1,
and thus the short systolic spike would cause an over-reading of mean pressure,
where the mean pressure is read as the half way point between highest
and lowest oscillation of the manometer. Further support for this argument
comes from the comparison of results for spontaneously breathing, and
ventilated patients. In ventilated patients with an inspiratory to expiratory
ratio of 1 : 2, as used in this investigation, the short inspiration causes a short
peak in the CVP, followed by a longer trough during expiration. Having a
shorter peak time than trough time causes over-reading of the mean value, in

the same way as discussed above for phasic pressure waves. During spontaneous ventilation this effect is reversed, and as would be predicted, smaller
errors in the CVP readings were found.
The greatest error in CVP readings occurred in patients with CVPs of <6
cmH,O compared to patients with normal CVPs, who had the smallest error. No
explanation is offered for this finding, but it further emphasises the unreliability of manometric measurement of CVP.
Further problems that arose with the use of manometers were the problems
of de-airing the system, particularly the three-way tap, and with breaks in the
column of fluid in the manometer, The presence of either of these factors can
lead to further errors in reading manometric CVP. One improvement that could
be made would be to increase the internal diameter of the manometer, thus
reducing the meniscus effect.
The result of this investigation
has prompted this department to
increasingly use electronically determined CVPs. Apart from the greater accuracy of this technique, other advantages have been noted. The presence of an
undamped trace confirms cannula patency. When the transducer is used in conjunction with a paper recorder, measurements of end expiratory CVP can be
made without the need for disconnecting the patient from the ventilator. This is
of particular use in the patient with poor compliance or high airways resistance,
and also for dyspnoeic spontaneously breathing patients. Misplacement of the
catheter into the right ventricle can also easily be detected. Furthermore, analysis of the CVP waveform can aid in the diagnosis of such conditions as tricuspid regurgitation, tamponade, and constrictive pericarditis.
It may be argued that the attachment of one more piece of electronic apparatus, particularly to a catheter in the heart, increases the hazard of micro-electrocution. This risk is minimal with modern equipment in a cardiac protected
electrical area, and is reduced further by the use of 5?43dextrose, rather than
normal saline in the system. Often in clinical practice, treatment is based on the
trend of changes in CVP, rather than the absolute value itself, and thus, it may
be argued that inaccuracies in CVP measurement are not of great importance.
However, it has been shown that although the inaccuracy is always in the same
direction+ it is not constant and may vary from 0.5 - 5 cmH,O. Thus the trend of
change is less reliable than may be supposed. In critically ill patients, small
changes in CVP are of great importance, and influence changes in fluid and inotrope management. Where two methods of CVP measurement are available
and one can be shown to be both more accurate and give more information, it is
clear which is to be preferred in the critically ill patient.
CONCLUSION
The use of manometers to measure CVP has been shown to be inaccurate
compared to the use of electronic transducers. An error due to a meniscus
effect in the manometer was clearly shown, and a second error attributed to the
method commonly clinically used for reading mean pressures from a manome-

ter also demonstrated. In intensive care units, where it is important to recognise and treat even small changes in CVP, the use of electronic transducers is
recommended.
ACKNOWLEDGEMENTS

The author would like to thank Dr. W.J. Russell for help with the protocol,
statistics and manuscript, Mr. G. Elsegood of the Biomedical Engineering
Department for help in setting up the experiments, Dr. T.R. Williams of Westminster Hospital, London for helpful criticisms and Miss A. Roberts and Miss
P. King for typing the manuscript.
REFERENCES
1
2
2

J.M. Civetta. Pulmonary artery pressure determination: Electronic Superior to Manometric,

N. Engl. J. Med., 285 (1970) 1146 1140.
RL. Mann, G.C. Carlon and A.D. Turnbull. Comparison of electronic and manometric central
venous pressures, Crit. Care Med., 9 (2) (1991) 99- 100.
J. Werweij, A. Kester, W. Stroes and L.G. Thijs. Comparison of three methods for measuring
central venous pressure, Crit. Care Med., 14 (4) (1996) 288 - 290.