ALTERNATIVE METHODS TO CENTRAL VENOUS PRESSURE FOR ASSESSING VOLUME STATUS IN CRITICALLY ILL PATIENTS Authors: Lisa Stoneking, MD, Lawrence A. DeLuca, Jr, EdD, MD, Albert B. Fiorello, MD, RDMS, Brendan Munzer, BS, Nicola Baker, MD, and Kurt R. Denninghoff, MD, Tucson, AZ Earn Up to 7.5 CE Hours. See page 205. Introduction: Early goal-directed therapy increases survival in persons with sepsis but requires placement of a central line. We evaluate alternative methods to measuring central venous pressure (CVP) to assess volume status, including peripheral venous pressure (PVP) and stroke volume variation (SVV), which may facilitate nurse-driven resuscitation protocols. Methods: Patients were enrolled in the emergency department or ICU of an academic medical center. Measurements of CVP, PVP, SVV, shoulder and elbow position, and dichotomous variables Awake, Movement, and Vented were measured and recorded 7 times during a 1-hour period. Regression analysis was used to predict CVP from PVP and/or SVV, shoulder/elbow position, and dichotomous variables. Results: Twenty patients were enrolled, of which 20 had PVP measurements and 11 also had SVV measurements. Multiple regression analysis demonstrated significant predictive relationships for CVP using PVP (CVP = 6.7701 + 0.2312 × PVP – 0.1288 × Shoulder + 12.127 × Movement – 4.4805 × Neck line), SVV (CVP = 14.578 – 0.3951 × SVV + 18.113 × Movement), and SVV and PVP (CVP = 4.2997 – 1.1675 × SVV + 0.3866 × PVP + 18.246 × Awake + 0.1467 × Shoulder = 0.4525 × Elbow + 15.472 × Foot line + 10.202 × Arm line). Discussion: PVP and SVV are moderately good predictors of CVP. Combining PVP and SVV and adding variables related to body position, movement, ventilation, and sleep/wake state further improves the predictive value of the model. The models illustrate the importance of standardizing patient position, minimizing movement, and placing intravenous lines proximally in the upper extremity or neck. Key words: Central venous pressure; Volume status; Hemodynamics; Stroke volume variation E arly Goal-Directed Therapy (EGDT) has been shown to improve survival in persons with severe sepsis and septic shock. 1-24 However, despite a sig- nificant survival benefit from EGDT, barriers exist to compliance with the protocol. One major obstacle is the requirement for central line placement to allow measure- ment of central venous pressure (CVP) and central venous oxygen saturation (ScvO 2 ) monitoring. 4,6,10,12,25,26 Jones and Kline 27 propose that simplified protocols with less invasive monitoring may facilitate compliance. Lisa Stoneking is Assistant Professor of Emergency Medicine, Arizona Emer- gency Medicine Research Center, University of Arizona Department of Emer- gency Medicine, Tucson, AZ. Lawrence A. DeLuca, Jr, is Assistant Professor of Emergency Medicine, Arizona Emergency Medicine Research Center, University of Arizona De- partment of Emergency Medicine, Tucson, AZ. Albert B. Fiorello is Associate Professor of Emergency Medicine, Arizona Emergency Medicine Research Center, University of Arizona Department of Emergency Medicine, Tucson, AZ. Brendan Munzer is Medical Student, Arizona Emergency Medicine Research Center, University of Arizona Department of Emergency Medicine, Tucson, AZ. Nicola Baker is Emergency Medicine Resident, Arizona Emergency Medicine Research Center, University of Arizona Department of Emergency Medicine, Tucson, AZ. Kurt R. Denninghoff is Professor of Emergency Medicine, Arizona Emer- gency Medicine Research Center, University of Arizona Department of Emergency Medicine, Tucson, AZ. Edwards Life Sciences donated the FloTrac arterial pressure sensors and Vigileo monitors used in this study. For correspondence, write: Lawrence A. DeLuca, Jr, EdD, MD, 1609 N Warren Ave, PO Box 245057, Tucson, AZ 85724; E-mail: ldeluca@aemrc. arizona.edu. J Emerg Nurs 2014;40:115-23. Available online 22 October 2012. 0099-1767/$36.00 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2012.04.018 RESEARCH March 2014 VOLUME 40 • ISSUE 2 WWW.JENONLINE.ORG 115