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Central Venous Pressure and Blood Volume Relationships = a A, 9 Central venous pressure Blood volume and blood volume relationships ALBERT A. WITTE, D.O. Detroit, Michigan Blood volume measurements and Both central venous pressure (CVP) monitor- central venous pressure monitoring ing and blood volume measurements are ac- cepted and commonly practiced procedures in have become established procedures. the management of hypovolemic and hypervo- This article reviews the physiologic lemic states. Both modalities are readily avail- basis of central venous pressure and able in most hospitals today. blood volume measurements and Experimental and research use of the cen- correlates the determinations tral venous pressure dates back many years, made in fifteen patients. but only in the last several years has it become an established procedure in clinical The measurements were performed in a medicine. Techniques for insertion of CVP routine manner in a general hospital. catheters and instrumentation vary widely but Central venous pressure varied with the development of disposable units, some independently of the red blood standardization is promising.2-4 cell volume in most cases. The CVP is an index of circulating blood The central venous pressure and volume in relation to the total cardiovascular capacity. The pressure arises primarily from plasma volume changes complemented the arterial pressure and is transmitted each other in any one patient through the capillary bed; the CVP at any one but had no quantitative relationship instant is the result of a complex interaction in terms of a given number of cubic of blood volume, cardiac action, and vascular centimeters blood volume per unit of alteration.5 central venous pressure. The central HalUric summarized four major areas which influence the CVP; namely, (1) the force be- venous pressure measures the ability hind the venous pressure at the capillary bed of the right heart to handle a load which represents the end of left ventricular presented to it, that is, contractile force; (2) lateral pressure along it determines whether compensatory the vein, both extramural and intramural, mechanisms are adequate. The which is increased by muscular pumping in the simultaneous use of the two parameters extremities and affected by intra-abdominal and intrathoracic pressures; (3) the venous is of more clinical value than when blood volume; and (4) forward resistance. A each is used independently. decrease in cardiac competence in emptying the right atrium is one of the most common causes of a marked increase in venous pres- sure in shock. Vascular frictional resistance, obstructions, and intracardiac defects are ad- ditional factors. When cardiovascular function is stable, then the CVP will vary directly with alteration in blood volume. When blood volume is constant and vascular dynamics are stable, the CVP 382/118 should vary inversely with the cardiac pump One of the earliest methods employing dilu- efficiency. tion of labeled red cells was the administra- Another basic principle is that alterations tion of carbon monoxide, still occasionally used of blood volume and cardiac action occur in- in research. With minor exceptions, most of dependently of each other, and it is impossible the success in labeling red cells with test sub- to depend on the CVP alone as an index of stances other than carbon monoxide has been blood volume or pump action. Basically, the largely restricted to the use of radioactive iso- CVP will reflect the ability of the right heart topes. to handle a load which is presented to it. Most successful of the dilution techniques There are various ways to assess blood vol- for plasma volume was T-1824 (Evans blue ume. Early methods for estimating the quan- dye) , which can be estimated colorimetrically tity of blood volume were based on clinical cri- or spectrophotometrically. Before the advent of teria (pulse, blood pressure, urinary output, radioactive isotopes as labeling substances, skin, et cetera) and are grossly inadequate and plasma dilution methods for plasma volume frequently misleading. The use of hematocrit employed hemoglobin, antitoxin material, dex- values did provide something measurable but a tran serum albumin, and various dyes. fall in hematocrit value did not prove an ac- Modern measurement of blood volume by curate reflection of blood volume. radioisotope dilution methods began in 1943 Another method, which has become stand- with Fine and Seligman,7 who labeled serum ard, is a direct attempt to measure blood loss. proteins with isotopes. The use of radioactive This is the familiar estimation of surgical tracer elements is the most common method blood loss in sponges, suction bottles, et cetera. employed clinically. Albert and co-workers8 This method is inaccurate and, in addition, im- stated that the methodology has been reduced possible to use with trauma, medical diseases, to a few simple steps but that this denies the shock, et cetera. user a basic understanding and leads to mis- Experimental methods to utilize dilution conceptions of what and how blood volume techniques to measure blood volume date back is measured. The radioactive tracers are one to the early 1800s when Valentin measured of two types, plasma-bound or red-blood- the concentration of solids in blood samples cell-bound tracers. The plasma-bound tracers, before and after injection of a known quanti- such as radioiodinated serum albumin, meas- ty of distilled water. The principle in this ex- ure the plasma space. The ratio and the extent periment is the estimation of volume from of loss here are minimal over a 10-minute inter- changes in concentration of whole blood after val, approximately 10 per cent per hour, but infusion of relatively large known quantities in pathologic states may be more significant. of distilled water. Labeled red blood cells normally do not pass The further development of dilution methods the capillary membrane and here the red cell utilized the dilution of labeled cells and of test volume is measured. Normally, equilibration is substances in plasma. Each of these two ap- complete in 5 minutes, but may be delayed un- proaches measures only its own fraction of der certain conditions. the blood, cells or plasma, and each provides The simplest method using radioisotopes in- only a blood volume estimation based on the volves the use of serum albumin tagged with blood fraction affected. radioiodine to obtain the plasma volume, and Journal AOA/vol. 61. December 1961 383/119 CVP and blood volume relationships then the calculation of the blood volume from when each is used individually. the plasma volume and peripheral hematocrit With a realization of the limitations of both value. This method is based on the assump- modalities, as well as compensatory mecha- tion that the hematocrit value of peripheral nisms, as just noted, a study was made to as- venous blood is the same as the total body he- certain the correlation between the two param- matocrit value. Some authors have questioned eters as well as common complications. this assumption and hold that the same objec- tion is valid for methods based on tagging Methods and materials erythrocytes and calculating the blood volume Fifteen patients, randomly selected, had both from the red cell volume and peripheral hema- CVP and blood volume measurements per- tocrit value. formed in a routine manner in a general hos- Gurney and Bolt, 9 with the simultaneous use pital. The central venous pressure catheters of chromium-labeled erythrocytes and I131-tag- were inserted via various routes. The medial ged human serum albumin in blood volume de- basilic vein approach was the most commonly terminations, reported that in every case, the used, followed by the femoral and jugular vein blood volume obtained from the sum of the routes. Here, we feel that the subclavian ap- plasma volume and erythrocyte volume was proach has hazards and should be used as a last less than the blood volume obtained using tag- resort. ged albumin alone, and greater than that The disposable Plexitron R86 venous pres- obtained by using tagged erythrocytes and di- sure set (Baxter) was used routinely along viding the red blood cell volume by the periph- with the Bardic radiopaque intracath in both eral hematocrit. These authors, therefore, feel 23 and 36-inch lengths for the CVP monitor- that the greatest accuracy in blood volume de- ing. With jugular vein punctures, a standard terminations requires separate determination 8 inch 17 gauge radiopaque Intracath (Bardic) of the two vascular fractions without reliance was utilized. CVP catheter positions were sub- on hematocrit. stantiated by routine use of chest x-ray in all The theoretical or predicted normal values cases. have to be modified for certain variables. For Blood volume determinations were perform- example, if a marked weight loss has occurred ed using the Volemetron Model 600 counter within 6 months, then normal values should be (Ames Atomium, Inc.) and the standardized estimated at the original weight. But, if weight Voletron Radioiodinated (1131 ) Serum Albu- loss has been gradual over a long period, then min (Human) dose syringes (Ames) . The the present weight should be used, and the standard dose as prepared is approximately 5 values raised 10-15 per cent. In the obese pa- microcuries of I 131 activity. tient and the short subject, normal values The predicted or theoretical patient blood should be reduced by 10 per cent. Normal volume values were determined from the tables values for the elderly patient should also be re- reported by Nadler and co-workers," based on duced by 10 per cent.9 height and weight. The theoretical patient red There is general agreement that the com- blood cell volume was obtained by using bined use of CVP monitoring and blood volume a standardized hematocrit value of 45 per measurements gives more information as to cent for males and 40 per cent for females, and the hemodynamics at any one instant than the standard correction factors.
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