Aortic Valve Surgery Clinical Trial
Official title:
Use of the SonoSite Probe for Measuring Jugular Venous Pressure
This prospective study will be performed in the Cardiothoracic (Chesterman) Department at
Sheffield Teaching Hospitals NHSFT, Northern General Hospital. Pre-operative patients
undergoing surgical valvular intervention, breathing both spontaneously and mechanically will
be included in the trial. All patients will already have a central venous catheter inserted
as part of their ongoing care. Patients will be eligible for the study irrespective of
diagnosis or neck size. Patient demographical data will be recorded by Sam Jenkins following
written consent, the day before the trial.
The goal of this study is to determine if ultrasound assessment of Jugular Venous Pressure
(JVP) accurately predicts Central Venous Pressure (CVP). Secondary objectives aim to identify
if using the angle of Louis to approximate the location of the right atrium produces
inaccuracies when measuring JVP. Comparing results in patients breathing spontaneously or
under positive pressure ventilation will identify if the form of ventilation impacts on JVP
and CVP recording. Correlating results between physical JVP examination and ultrasound
assessment of JVP to measure CVP will conclude if ultrasound is a more appropriate tool, in
an era where the physical examination of the cardiovascular system is becoming less valuable.
Initial exploratory investigations will compare left-sided and right-sided Jugular Venous
Pressure (JVP) using ultrasonography. Should results show that they are the same, the central
line is to be placed into the right internal jugular vein when required.
To begin the trial and whilst the patient is spontaneously breathing, a physical examination
of the right JVP will be performed. A central line will be inserted with the patient awake
into the right internal jugular vein. Left-sided ultrasound of JVP and Central Venous
Pressure (CVP) will be measured using the right-sided catheter will be recorded
simultaneously. The tip of the catheter attached to the transducer (which is zeroed to the
reference point) will be placed at the point of venous collapse, identified by
ultrasonography, to identify if the JVP and CVP match. The tip of the catheter will then be
placed at the angle of Louis. Measurement of the pressure difference between the angle of
Louis and the reference point will identify if this value shows variability compared to
previous approximations of 5cm above the right atrium. With the patient anaesthetised and
mechanically breathing, left JVP and CVP will be measured once more. Twenty-four hours
post-surgery, ultrasound of the JVP and CVP will be measured with the patient breathing
spontaneously.
The physical JVP examination will be recorded from the opposite side to the central venous
catheter. The bed will be adjusted to an angle between 30 and 60 degrees, that most clearly
identifies the collapsing vein. Differentiation between the JVP and the carotid pulse must be
distinguished. Tangential lighting using a flashlight should be used to correctly identify
and note the apex of the jugular venous pulsations. Recordings will be taken at
end-expiration allowing the vertical distance between the venous meniscus and phlebostatic
axis to be measured. JVP will be measured in millimetres of water.
Ultrasound recordings will be made using the SonoSite ultrasound probe by Sam Jenkins. The
equipment and gels required are used routinely on site and will be supplied by Sheffield
Teaching Hospitals. The SonoSite probe will be calibrated prior to each use, based on the
recommendations of the manufacturer. The angle of the bed is kept constant and the patient
will remain in the same position following the physical JVP examination. Ultrasound gel will
be applied, again on the opposite side to the central venous catheter. Locating the area of
venous collapse will be identified following visualisation from both longitudinal and
transverse planes. The apex of venous collapse at end-expiration will be marked using the
longitudinal view. Corroboration of the correct position of the probe by looking at the
transverse view will be performed prior to marking of venous collapse.
CVP will be measured once the central venous catheter has been zeroed. The reference point of
the transducer will be placed at the 4th intercostal space, mid-axillary line. The bed should
still be kept at a constant angle for this measurement. The mean of the 'a' wave upon
end-expiration will be taken. Converting the CVP from millimetres of mercury to millimetres
of water will allow direct comparison to prior findings of JVP.
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