How is central venous pressure measured in sepsis/septic shock and how is a crystalloid fluid challenge used in treatment?

Updated: Oct 07, 2020
  • Author: Andre Kalil, MD, MPH; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM  more...
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Patients with suspected septic shock require an initial crystalloid fluid challenge of 30 mL/kg (1-2 L) over 30-60 minutes, with additional fluid challenges. (A fluid challenge consists of rapid administration of volume over a particular period, followed by assessment of the response.) (See Fluid Resuscitation.)

Administration of crystalloid solution is titrated to a goal of adequate tissue perfusion. CVP should not be used to target resuscitation; it should be used as a stopping rule. If, during fluid resuscitation, CVP rapidly increases by more than 2 mm Hg, absolute CVP greater than 8-12 mm Hg, or signs of volume overload (dyspnea, pulmonary rales, or pulmonary edema on the chest radiograph) occur, fluid infusion as primary therapy needs to be stopped. Patients with septic shock often require a total of 4-6 L or more of crystalloid solution. However, CVP measurement should not be entirely relied upon, because it does not correlate with intravascular volume status or cardiac volume responsiveness. [79]

Some studies have used noninvasive means of estimating CVP—for example, ultrasonography to measure inferior vena cava diameter as a surrogate for volume status. Nagdev et al used the difference between inspiratory and expiratory caval diameter (the caval index) to predict CVP and found that a 50% difference predicted a CVP lower than 8 mm Hg with both a sensitivity and a specificity greater than 90%. [80] Similarly, variations in this diameter change with respiration correlated with volume responsiveness.

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