Journal of critical care · 2026
Agreement between central venous pressure and right atrial pressure in critically ill patients: In search of the optimal external reference point - A prospective clinical study.
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Sjödin Carl, Oras Jonatan, Svensson Carl Johan, Persson Per, Olausson Sepideh, Holmqvist Jacob, Ille Alexandru, Vidovic Nevio, Johansson Lotta
Аннотация
BACKGROUND: Right atrial pressure (RAP) is a key determinant of venous return in critically ill patients. Central venous pressure (CVP) is commonly used as a surrogate, but accuracy depends on correct transducer leveling. Evidence on the optimal external reference point, particularly across body positions, remains limited.
METHODS: In this prospective study, 16 sedated, mechanically ventilated ICU patients underwent direct RAP measurement using a solid-state catheter positioned in the mid-right atrium. CVP was recorded using three external reference points: one-third and one-half of the anteroposterior (AP) chest diameter at the fourth intercostal space, and 5 cm below the sternal angle. Measurements were obtained in supine, semi-recumbent (30°), and Trendelenburg (-10°) positions. Agreement between CVP and RAP was assessed using Bland-Altman analysis, intraclass correlation coefficients (ICC), and coverage within ±2 mmHg.
RESULTS: CVP referenced to one-third of the AP chest diameter showed the closest agreement with RAP across body positions (bias -0.9 to -0.1 mmHg; ICC 0.79-0.90; 94-100% of values within ±2 mmHg). CVP referenced to one-half of the AP chest diameter consistently overestimated RAP by approximately 1-2 mmHg, with variable agreement across positions. The sternal-angle reference showed greater position-dependent error, with wide limits of agreement in the semi-recumbent position (-7.8 to +2.2 mmHg) and only 31-44% of measurements within ±2 mmHg in the semi-recumbent and Trendelenburg positions. RAP decreased in the semi-recumbent position and increased in Trendelenburg (both p < 0.01).
CONCLUSIONS: In sedated, mechanically ventilated ICU patients, referencing CVP to one-third of the AP chest diameter showed the closest agreement with directly measured RAP across body positions, whereas fixed sternal angle referencing introduced greater variability and position-dependent error.
METHODS: In this prospective study, 16 sedated, mechanically ventilated ICU patients underwent direct RAP measurement using a solid-state catheter positioned in the mid-right atrium. CVP was recorded using three external reference points: one-third and one-half of the anteroposterior (AP) chest diameter at the fourth intercostal space, and 5 cm below the sternal angle. Measurements were obtained in supine, semi-recumbent (30°), and Trendelenburg (-10°) positions. Agreement between CVP and RAP was assessed using Bland-Altman analysis, intraclass correlation coefficients (ICC), and coverage within ±2 mmHg.
RESULTS: CVP referenced to one-third of the AP chest diameter showed the closest agreement with RAP across body positions (bias -0.9 to -0.1 mmHg; ICC 0.79-0.90; 94-100% of values within ±2 mmHg). CVP referenced to one-half of the AP chest diameter consistently overestimated RAP by approximately 1-2 mmHg, with variable agreement across positions. The sternal-angle reference showed greater position-dependent error, with wide limits of agreement in the semi-recumbent position (-7.8 to +2.2 mmHg) and only 31-44% of measurements within ±2 mmHg in the semi-recumbent and Trendelenburg positions. RAP decreased in the semi-recumbent position and increased in Trendelenburg (both p < 0.01).
CONCLUSIONS: In sedated, mechanically ventilated ICU patients, referencing CVP to one-third of the AP chest diameter showed the closest agreement with directly measured RAP across body positions, whereas fixed sternal angle referencing introduced greater variability and position-dependent error.