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The Rational Clinical Examination
David L. Simel, Drummond Rennie
Abnormal Central Venous Pressure
Deborah J. Cook, David L. Simel
Although the abdominojugular reflux test is an insensitive way to diagnose congestive heart...

Topics Discussed: abdominojugular reflex test, central venous pressure, measurement of, central venous pressure-biological function, congestive heart failure, sensitivity, specificity

Excerpt: "We describe 3 studies that have reported the relation between clinical assessments of CVP and the gold standard of simultaneous pressure measurements through an indwelling central venous catheter.4,5,18 When the clinical assessment was reported as low, normal, or high, the pooled overall accuracy was 56%. In one study,4 venous pressure was assessed in each of 50 intensive care unit patients by one of 3 intensive care unit attending physicians, one of 6 medical residents, and one of 6 medical students. Although all groups tended to underestimate venous pressure, only the residents did so to a statistically significant degree. The correlation coefficient between clinical assessment and central line measured CVP was highest for medical students (0.74), slightly lower for residents (0.71), and lowest for staff physicians (0.65), and these correlations improved slightly when patients receiving mechanical ventilation were excluded. The students' data from this study4 (Table 11-3) display the results for 2 clinical questions: "Is the patient's true CVP low?" and "Is the patient's true CVP high?"2 Despite small numbers of participants, it is apparent that a clinically assessed low CVP increases the likelihood by about 3-fold that the measured CVP will be low; no patient clinically assessed as having a high CVP had a low measured CVP. Similar results hold when the clinician considers whether the patient has increased CVP. Clinical assessments of a high CVP increase the likelihood by about 4-fold that the measured CVP will be high; conversely, clinical assessments of a low CVP make the probability of finding a high measured CVP extremely unlikely (likelihood ratio [LR], 0.2). The data demonstrate that clinical assessments of a normal CVP are truly indeterminate, with LRs approaching 1; such estimates provide no information because they neither increase nor decrease the probability of an abnormal CVP.19 Aside from less observer variation, the data suggest that CVP estimates achieve greater accuracy among patients breathing spontaneously. However, the relatively small patient population creates an opportunity for further studies on how mechanical ventilatory assistance affects clinical assessment of CVP...."
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