External Jugular Venous Pressure Research Articles

External Jugular Venous Pressure versus Central Venous Pressure Measurement as a Clinical Predictor among Critically Ill Mechanically Ventilated Patients

Background: Continuous changes in central venous pressure monitoring among critically ill patients was allied to fluid response. External jugular venous pressure may be a reliable estimation method to central venous pressure and have the advantages of being less invasive. Setting: This study was conducted at the anesthesia Intensive Care Unit at Emergency Hospital affiliated to Tanta University Hospitals, Egypt. The aim of the study was to estimate external jugular venous pressure versus central venous pressure measurement as a clinical predictor among critically ill mechanically ventilated patients Method: A prospective comparative study design was utilized in the current study. A purposive sample of 30 adults mechanically ventilated patients was included in this study. Two tools were utilized to collect data: Tool (I): Mechanically ventilated patient assessment and Tool II: Central venous pressure and External jugular venous pressure assessment. Results: It was observed that there was a highly positive and significant correlation between central venous pressure and external jugular venous pressure reading r= 0.813 and p=0,000. Conclusions: External jugular venous pressure measurement represented a real value of central venous pressure. A positive statistical correlation between central venous pressure and external jugular venous pressure measurements seems to be a reliable method to differentiate mechanically ventilated patients with high or low central venous pressure monitoring. Recommendations: Measurement of external jugular venous pressure should be integrated within the critically ill patient's routine care Measurement. Also Measuring central venous pressure may be replaced with external jugularvenous pressure (EJVP) when indicated. Further studies will be needed to confirm reliability of the EJVP on a larger probability sample.

Comparison of Conventional Central Venous Pressure with Peripheral Venous Pressure and External Jugular Venous Pressure in Patients with Sepsis

Comparison of Conventional Central Venous Pressure with Peripheral Venous Pressure and External Jugular Venous Pressure in Patients with Sepsis

Positive end-expiratory pressure-induced increase in external jugular venous pressure does not predict fluid responsiveness in laparoscopic prostatectomy.

Dynamic change in central venous pressure (CVP) was associated with fluid responsiveness. External jugular venous pressure (EJVP) may reliably estimate CVP and have the advantages of being less invasive. We investigated whether increase in EJVP induced by positive end-expiratory pressure (PEEP) could be a reliable predictor of fluid responsiveness in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). Fifty patients who underwent RALP with steep Trendelenburg position were enrolled. PEEP of 10cmH2O was applied for 5min and then 300ml of colloid was administered. EJVP, stroke volume variation (SVV), and cardiac index calculated by pulse contour method were measured before and after the PEEP challenge and colloid administration. Increase in cardiac index>10% was used to define the fluid responsiveness. Twenty-six patients were fluid responders. Neither the increase in EJVP after the initial PEEP nor SVV was significantly different between responders and non-responders. They were not significantly correlated with an increase in cardiac index. The areas under the receiver operating characteristic curve (AUC) of these two variables were not significantly greater than 0.5. However, a post hoc analysis revealed that AUC of a decrease in EJVP after removal of PEEP was significantly greater than 0.50. Our study results suggested that SVV and increase in EJVP after applying PEEP were not accurate predictors of fluid responsiveness during RALP. Further studies are required to find an adequate preload index in robot-assisted urologic surgery with steep Trendelenburg position.

Endotracheal tube securements: Effectiveness of three techniques among orally intubated patients

BackgroundInvasive ventilation is a common practice in intensive care units (ICUs). Once a patient is intubated, maintenance of the endotracheal tube placement is essential. When the ETT is not secured effectively, even basic nursing management can cause tube slippage which is a major factor in causing airway trauma. Aim of the studyThis study was aimed at comparing the effectiveness of three endotracheal tube securement techniques (Twill, Adhesive and Simple bow) on endotracheal tube slippage, external jugular venous pressure measurement, oral mucosa and facial skin integrity, pain intensity and on patient satisfaction after the fixation method. Subjects and methodsA randomized clinical trial was conducted at the intensive care units in Ain Shams University Specialized Hospital. It included a sample of 90 patients, randomly allocated to the three equal groups: Twill, Adhesive and Simple bow groups, 30 subjects for each. The tools used for data collection included demographic and clinical data sheet, the time profile of ETT fixation method sheet and scales for endotracheal tube (ETT) slippage, external jugular venous pressure (EJVP) measurement, oral assessment guide (OAG) for oral mucosa, Facial Skin Integrity, pain intensity and patient satisfaction procedure scale. The study maneuvers were applied according to the group. ResultsBoth ETT slippage and EJVP were measured at 15, 30, 60 and 120min post fixation method. At 120min, 73% of patients in the Twill group had no slippage compared to Simple bow (50%) and (36%) in Adhesive groups. However, at 30min post fixation method 90% of patients in the Twill group had normal EJVP measurement compared to Simple bow and Adhesive groups (70% and 57%, respectively), with a statistically significant difference between the three groups. At 60min, only 10% of patients in the Twill group had high EJVP compared to Simple bow (37%) and Adhesive groups (47%) with a statistically significant difference among them. As well, at 120min post fixation method, most patients in the Twill group (97%) had normal EJVP measurement, compared to the Adhesive (60%) and Simple bow (57%) groups. Oral mucosa and facial skin integrity assessment was done for all patients in the three study groups at 2, 6, 12, and at 24h post fixation method. For oral mucosa at 24h post fixation method, 80% of patients in the Twill group had healthy oral mucosa compared to Simple bow and Adhesive groups (47% and 37%, respectively), with a statistically significant difference between the three groups (P=0.07). For facial skin integrity, at 6h, no one of patients in the Twill and Simple bow groups had severe facial skin reaction compared to patients in the Adhesive group (7%) and the difference was statistically significant, (P=0.01). As well, a statistically significant difference was revealed among the three groups, at 12 and 24h post fixation method, (P=0.04 and 0.02, respectively). The Twill technique had the shortest time taken for application and removal of securement method than other groups. Additionally, the Twill group had the lowest scores of pain at all three assessment times (5, 10 and 20min), whereas those in the Adhesive group had the highest scores. All these differences were statistically significant, (P<0.001). Overall, 80% of patients in the Twill group were satisfied, compared to 57% in the Simple bow group, and 37% only in the Adhesive group. ConclusionIt is concluded that Twill technique is an ETT securement technique in ICUs for orally intubated patients. RecommendationsIt is recommended to use this method, with development of strategies to prevent slippage aiming at increasing patient safety after securement technique intervention.

Monitoring pulmonary artery pressure in children undergoing the Fontan procedure

To compare external and internal jugular venous pressures to monitor pulmonary artery pressure during the Fontan procedure. During the Fontan procedure, the internal jugular vein is used to assess pulmonary artery pressure. The risk of venous thrombosis in the low-pressure Fontan circuit may compromise the long-term success of cavopulmonary anastomosis. This study compared external and internal jugular venous pressures, femoral venous pressure, and actual pulmonary artery pressure during the Fontan procedure. 32 children undergoing a single-stage Fontan on cardiopulmonary bypass were monitored for mean external and internal jugular venous pressures and femoral venous pressure pre- and post-cardiopulmonary bypass. Pulmonary artery pressure was also recorded directly after cardiopulmonary bypass. The pressure data were analyzed using analysis of variance, and the coefficient of correlation was found. The differences between external jugular, internal jugular, and femoral venous pressure pre-cardiopulmonary bypass, and between the 3 venous pressures and the pulmonary artery pressure after cardiopulmonary bypass were found to be non-significant. The coefficient of correlation of external jugular venous pressure and internal jugular venous pressure was 0.8163 (p < 0.0001) pre-cardiopulmonary bypass, and 0.6465 (p = 0.0001) post-cardiopulmonary bypass. The external jugular venous pressure correlates well with both internal jugular venous pressure and femoral venous pressure as a marker of pulmonary artery pressure in children undergoing the Fontan procedure. The use of external jugular venous pressure may also preclude the risk of thrombosis.

A comparison of external and internal jugular venous pressures to monitor pulmonary artery pressure after superior cavopulmonary anastomosis

The internal jugular vein continues to be the preferred site for cannulation to monitor central venous pressure despite the reported evidence of the accuracy of external jugular venous pressure (EJVP) to reliably predict internal jugular venous pressure (IJVP). Internal jugular venous cannulation carries a risk of thrombosis that can be life-threatening in children undergoing superior cavopulmonary anastomosis and a subsequent Fontan procedure. The present study compared IJVP and EJVP in children undergoing superior cavopulmonary anastomosis and found no statistical and clinical difference between IJVP and EJVP. Thus, external jugular vein cannulation reliably predicts IJVP and pulmonary artery pressures in children undergoing superior cavopulmonary anastomosis, and may obviate the risk of life-threatening cavopulmonary thrombosis.

Ultrasound Accurately Reflects the Jugular Venous Examination but Underestimates Central Venous Pressure

Bedside ultrasound examination could be used to assess jugular venous pressure (JVP), and thus central venous pressure (CVP), more reliably than clinical examination. The study was a prospective, blinded evaluation comparing physical examination of external jugular venous pressure (JVPEXT), internal jugular venous pressure (JVPINT), and ultrasound collapse pressure (UCP) with CVP measured using an indwelling catheter. We compared the examination of the external and internal JVP with each other and with the UCP and CVP. JVPEXT, JVPINT, UCP, and CVP were compared graphically using Bland-Altman plots, and correlation coefficients were calculated. The correlation coefficients comparing CVP to UCP, JVPEXT, and JVPINT were 0.62, 0.57, and 0.50, respectively. When UCP was compared with JVPEXT and JVPINT, correlation coefficients were 0.91 and 0.81, respectively. Last, the correlation coefficient comparing JVPEXT and JVPINT was 0.98. The Bland-Altman graphical comparison of methods technique revealed that CVP was often underestimated by UCP, and clinical examination of JVPEXT and JVPINT. In contrast, there was no systematic bias between UCP and either JVPEXT or JVPINT, nor between JVPEXT and JVPINT. Ultrasound examination is capable of measuring accurately the JVP as judged from the internal or external jugular vein. However, like the JVP, ultrasound typically underestimates CVP. A systematic bias between UCP and CVP suggests the presence of a variable degree of venous tone, possibly signaling contraction of jugular venous smooth muscle. ClinicalTrials.gov; No.: NCT01099241; URL: clinicaltrials.gov.

Is External Jugular Venous Pressure a Good Predictor of Volume Status in Kidney Graft Recipients?

To ensure appropriate function of the transplanted organ, it is necessary to adequately maintain vascular volume during the kidney transplantation procedure. For this purpose, central venous pressure (CVP) is monitored through a catheter inserted into the superior vena cava (SVC). Central venous cannulation is associated with a risk of serious complications. An objective of this study was to investigate whether there was a correlation between pressures measured in the SVC and in the external jugular vein (EJV). We studied 33 chronically dialyzed patients who had a short catheter placed in the EJV because of difficulties in peripheral vein cannulation in the limbs. In each case, general anesthesia was induced and a central catheter inserted into the SVC. Every 10 minutes venous pressure measurements were obtained simultaneously at both sites. A significant ( P < .001) correlation was observed between external jugular vein pressure (EJVP) and CVP. CVP could be described as a function of EJVP by the equation CVP = {0.90299 × EJVP} − 0.8361. The results of this study indicated that monitoring the EJVP allows equally efficient evaluation of vascular volume as the CVP. In our opinion, EJVP is sufficient to evaluate vascular volume during kidney transplantation in patients with difficult vascular access.

Regional cerebral tissue blood flow measured by the colored microsphere method during retrograde cerebral perfusion

Brain tissue blood flow was measured precisely by the colored microsphere method during retrograde cerebral perfusion in 10 normothermic mongrel dogs. The average tissue blood flow rates to the cerebral cortex, cerebral medulla, brain stem, cerebellum, and spinal cord during retrograde cerebral perfusion at 25 mm Hg of external jugular venous pressure were 10.5 ± 10.3, 4.2 ± 4.6, 11.1 ± 9.8, 12.3 ± 8.6, and 9.1 ± 5.8 ml/min per 100 gm, respectively. The brain was perfused wholly by retrograde cerebral perfusion without lateralization. Total cerebral blood flow was calculated as the sum total rates of blood flow to each area. Total cerebral blood flow during retrograde cerebral perfusion at 25 mm Hg was 7.8 ± 4.4 ml/min, which represented 3.5% ± 1.9% of whole body blood flow and one third of the total cerebral blood flow (28.0 ± 4.2 ml/min) during cardiopulmonary bypass at a flow rate of 1000 ml/min. Oxygen consumption and carbon dioxide elimination by the total cerebrum during retrograde cerebral perfusion at 25 mm Hg were 0.54 ± 0.23 ml/min and 34 ± 15 μmol/min, respectively, or 8.6% ± 3.6% and 7.0% ± 3.1% of the corresponding whole body value and represented about one third of that measured during cardiopulmonary bypass (1.21 ± 0.39 ml/min and 96 ± 15 μmol/min). Total cerebral blood flow, total cerebral oxygen consumption, and carbon dioxide elimination increased as the external jugular venous pressure increased from 15 to 25 mm Hg; however, no further increase occurred once the external jugular venous pressure exceeded 25 mm Hg. (J T HORAC C ARDIOVASC S URG 1995;109:772-9)

Comparative experimental study between retrograde cerebral perfusion and circulatory arrest

To evaluate the efficacy of retrograde cerebral perfusion in protecting the brain, we comparatively studied retrograde cerebral perfusion and total circulatory arrest in 18 hypothermic (20 degrees C) mongrel dogs (retrograde cerebral perfusion, n = 10; total circulatory arrest, n = 8). Retrograde cerebral perfusion was performed, maintaining an external jugular venous pressure of 25 mm Hg for 60 minutes. Retrograde cerebral perfusion provided half the cerebral blood flow and a third of the oxygen that was supplied during hypothermic cardiopulmonary bypass, which had a flow rate of 100 ml/min per kilogram. Oxygen consumption and carbon dioxide exudation did not increase on resuming cardiopulmonary bypass after retrograde cerebral perfusion, whereas they increased after total circulatory arrest (oxygen consumption 10.7 +/- 5.3 versus 19.1 +/- 8.6 ml/min, p < 0.05; carbon dioxide exudation, 0.92 +/- 0.54 versus 1.64 +/- 0.78 mmol/min, p < 0.05). Therefore, oxygen debt during retrograde cerebral perfusion was smaller than during total circulatory arrest. Retrograde cerebral perfusion also cooled the brain better than did total circulatory arrest (20.4 degrees +/- 1.5 degrees C versus 22.7 degrees +/- 0.7 degrees C, p < 0.01). Cerebral tissue oxygen tension decreased slightly (27.5 +/- 7.7 versus 12.3 +/- 3.0 mm Hg, p < 0.01), and cerebral tissue carbon dioxide tension increased slowly during retrograde cerebral perfusion (95 +/- 34 versus 147 +/- 44 mm Hg, p < 0.05). These changes were smaller than those seen in total circulatory arrest. Tissue concentrations of adenosine triphosphate in the brain remained relatively high during retrograde cerebral perfusion but decreased rapidly during total circulatory arrest (0.49 +/- 0.16 versus 0.21 +/- 0.05 mmol/gm, p < 0.01, just before resuming cardiopulmonary bypass). Retrograde cerebral perfusion cannot maintain aerobic metabolism but may reduce ischemic damage of the brain and may safely extend the cerebral circulation interruption time.

Determination of optimum retrograde cerebral perfusion conditions

Retrograde cerebral perfusion through a superior vena caval cannula is a new technique used to protect the brain during operations on the aortic arch. We measured cerebral tissue blood flow, oxygen consumption, and cerebrospinal fluid pressure under various perfusion conditions in hypothermic (20° C) mongrel dogs ( n = 18, 12.8 ± 0.6 kg) to determine the optimum conditions for retrograde cerebral perfusion. Retrograde cerebral perfusion was performed by infusion via the superior vena caval cannula and drainage via the ascending aortic cannula while the inferior vena cava and azygos vein were clamped. Retrograde cerebral perfusion was performed as the external jugular venous pressure was changed from 15 to 35 mm Hg in increments of 5 mm Hg. Cerebral tissue blood flow was measured by the hydrogen clearance method. Hypothermic retrograde cerebral perfusion with an external jugular venous pressure of 25 mm Hg provided about half the cerebral tissue blood flow of hypothermic (20° C) cardiopulmonary bypass with a flow rate of 1000 ml/min (13.7 ± 7.9 versus 32.7 ± 8.5 ml/min per 100 gm). It decreased significantly as the external jugular venous pressure was decreased from 25 to 15 mm Hg but did not increase significantly as the external jugular venous pressure was increased from 25 to 35 mm Hg. Whole-body oxygen consumption during hypothermic retrograde cerebral perfusion with an external jugular venous pressure of 25 mm Hg was one quarter of that during hypothermic cardiopulmonary bypass (3.4 ± 0.7 versus 12.7 ± 5.6 ml/min) and varied in proportion to external jugular venous pressure. The cerebrospinal fluid pressure was a little lower than the external jugular venous pressure (19.2 ± 4.5 mm Hg versus 24.8 ± 2.4 mm Hg) but also varied with the external jugular venous pressure. The cerebrospinal fluid pressure remained lower than 25 mm Hg so long as the external jugular venous pressure remained lower than 25 mm Hg. High external jugular venous pressure was associated with high intracranial pressure, which restricts cerebral tissue blood flow and may cause brain edema. We believe that a venous pressure of 25 mm Hg is the optimum condition for retrograde cerebral perfusion. (J T HORAC C ARDIOVASC S URG 1994;107:300-8)

Cerebral Metabolism and Function during Normothermic Retrograde Cerebral Perfusion

Retrograde cerebral perfusion through a superior vena cava (SVC) cannula is a new technique used to protect the brain during circulatory arrest. Cerebral blood flow, oxygen consumption, blood sugar consumption and auditory brain stem responses were measured at various rates (100, 200 and 300 ml min-1) of retrograde cerebral perfusion in normothermic mongrel dogs (n = 12, body-weight 13-15 kg). During perfusion about 20% of the perfusate from the SVC was returned via the aorta, while the rest drained into the inferior vena cava. External jugular venous pressure increased as the perfusion rate increased (mean(s.d.) 26.0(6.4) mmHg at a rate of perfusion of 300 ml min-1). Oxygen and blood sugar consumption also increased as the rate of perfusion increased. Retrograde cerebral perfusion at 300 ml min-1 provided half of the cerebral blood flow (mean(s.d.) 14.7(6.4) versus 34.3(7.8)ml min-1) of antegrade cardiopulmonary bypass (CPB). Analysis of the blood returned through the aorta during perfusion at a rate of 300 ml min-1 showed that mean(s.d.) oxygen consumption was about one-third (4.4(2.1) versus 12.3(7.1) ml min-1) and blood sugar consumption about 15% (17(22) versus 114(54)mg min-1) of that seen in blood returned through the SVC during CPB. Auditory brain stem responses disappeared immediately when perfusion was started but recovered completely as soon as CPB was resumed. Although the oxygen provided by perfusion was not sufficient to maintain cerebral function, it should help protect the brain during circulatory arrest.

Observations of hemodynamics during human cardiopulmonary resuscitation

To evaluate hemodynamics during human CPR, 32 patients with witnessed cardiac arrest were studied during manual and mechanical conventional CPR. In eight patients during manual conventional CPR, peak systolic radial artery, right atrial (RAP), and pulmonary artery pressures were found to be similar (59.8 +/- 4.3, 70.8 +/- 4.7, 71.2 +/- 8.2 mm Hg) and higher than external jugular venous pressure (33.8 +/- 1.9 mm Hg, p less than .0001). The diastolic radial artery to RAP gradient was found to be only 10.7 +/- 2.1 mm Hg. In four patients, maneuvers that avoid chest compression and thus obviate cardiac compression, i.e., rhythmic compression of the abdomen, yielded arterial pressures comparable to those generated by conventional CPR (48 +/- 6.4 vs. 52.8 +/- 3.4 mm Hg, NS). In 13 other patients during mechanical conventional CPR at constant chest compression force, radial artery pressure was higher during the first compression after ventilation as compared with subsequent chest compressions (67.5 +/- 5.0 vs. 61.9 +/- 4.8 mm Hg, p less than .007). These hemodynamic observations are similar to those reported in large dogs during CPR and support the generation of vascular pressures during CPR by an increase in intrathoracic pressure. They also suggest that despite anatomic differences, the similarity of hemodynamics in dogs and humans justifies the use of large dogs as a human model during acute resuscitation studies.

Observations of hemodynamics during human cardiopulmonary resuscitation

To evaluate hemodynamics during human CPR, 32 patients with witnessed cardiac arrest were studied during manual and mechanical conventional CPR. In eight patients during manual conventional CPR, peak systolic radial artery, right atrial (RAP), and pulmonary artery pressures were found to be similar (59.8 +/- 4.3, 70.8 +/- 4.7, 71.2 +/- 8.2 mm Hg) and higher than external jugular venous pressure (33.8 +/- 1.9 mm Hg, p less than .0001). The diastolic radial artery to RAP gradient was found to be only 10.7 +/- 2.1 mm Hg. In four patients, maneuvers that avoid chest compression and thus obviate cardiac compression, i.e., rhythmic compression of the abdomen, yielded arterial pressures comparable to those generated by conventional CPR (48 +/- 6.4 vs. 52.8 +/- 3.4 mm Hg, NS). In 13 other patients during mechanical conventional CPR at constant chest compression force, radial artery pressure was higher during the first compression after ventilation as compared with subsequent chest compressions (67.5 +/- 5.0 vs. 61.9 +/- 4.8 mm Hg, p less than .007). These hemodynamic observations are similar to those reported in large dogs during CPR and support the generation of vascular pressures during CPR by an increase in intrathoracic pressure. They also suggest that despite anatomic differences, the similarity of hemodynamics in dogs and humans justifies the use of large dogs as a human model during acute resuscitation studies.

External jugular vein cannulation and its use for cvp monitoring

The techniques of external jugular vein (EJV) cannulation and central venous pressure (CVP) catheter placement using a J-tipped wire guide is described in detail. This technique has a high success rate with virtually no complications.

A Starling resistor regulates cerebral venous outflow in dogs.

This investigation was undertaken to determine whether a Starling resistor or venous waterfall effect exists between the sagittal sinus and the cerebral veins such that increases in sagittal sinus pressure (Pss) do not abolish cerebral venous outflow and to examine two possible contributions of extracranial venous valves in regulating outflow. Anesthetized dogs were subjected to positive end-expiratory pressure (PEEP) before and after intracranial pressure (Pic) was elevated by inflation of an epidural balloon. PEEP raised Pss equally in all animals, but Pic and cerebral venous pressure (Pcv) increased less in the presence of intracranial hypertension. When Pss was low, passage of a catheter in the cerebral vein in and out of the sagittal sinus demonstrated an abrupt drop in pressure as the sinus was entered. When Pss was raised and lowered independently of superior vena caval pressure (Psvc) the changes in Pic and Pcv were less when Pss was decreased than when it was increased. Sustained increases and decreases in Psvc caused increases and decreases in Pcv, Pic, Pss, and external jugular venous pressure (Pejv) regardless of whether external jugular venous valves were present or absent. We conclude that a Starling resistor between the sagittal sinus and the cerebral veins regulates cerebral venous outflow when Pss is increased by PEEP and other maneuvers that raise Psvc. The waterfall maintains Pcv and Pic at normal levels when Psvc and Pss are reduced. Extracranial venous valves are not essential to this mechanism.

Evaluation of external jugular venous pressure as a reflection of right atrial pressure.

Evaluation of external jugular venous pressure as a reflection of right atrial pressure.