Reducing Mortality in Severe Sepsis and Septic Shock

Andrew T. Levinson, M.D., M.P.H.; Brian P. Casserly, M.D.; Mitchell M. Levy, M.D.

Disclosures

Semin Respir Crit Care Med. 2011;32(2):195-205. 

In This Article

Central Venous Pressure

CVP has been used for many years as a monitor of central venous blood volume and represents the back-pressure to systemic venous return. It is unclear whether the use of CVP alone as a target of quantitative resuscitation has a mortality benefit, and the validity of CVP measurements in patients with sepsis is widely debated. There is no threshold value of CVP that identifies patients whose cardiac output (CO) will increase in response to fluid resuscitation;[56] however, it is commonly accepted that a very low CVP is indicative of low intravascular volumes. In contrast, an elevated CVP does not always correlate with adequate intravascular volume. A recent systematic review found no significant relationship between CVP and other measurements of blood volume; however, the analysis did not differentiate between elevated and low CVP, and mortality was not an outcome of the analysis.[57] Despite these limitations, CVP, especially when low, in conjunction with other measurements is often used successfully to assess and guide resuscitation in patients with sepsis.[35] The current SSC guidelines recommend during the initial 6-hour resuscitation period targeting a CVP of 8 to 12 mm Hg.[14] It is important to recognize that within this recommendation CVP is being used as both a functional and a dynamic measure of preload responsiveness. The initial absolute static CVP measurement is not as important as the response to fluid resuscitation over time, mainly in patients with very low CVP. Based on more recently published data, it is likely that newer methods for assessing preload responsiveness, including monitoring variations in arterial pulse pressure or aortic flow variation in response to vena cava collapse during positive pressure ventilation or passively leg raising, will be incorporated into clinical practice with improved predictive value.[58]

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