title: Non-invasive bedside assessment of central venous pressure: scanning into the future.
abstract: BACKGROUND
  Noninvasive evaluation of central venous pressure (CVP) can be achieved by assessing the Jugular Venous Pressure (JVP), Peripheral Venous Collapse (PVC), and ultrasound visualization of the inferior vena cava. The relative accuracy of these techniques compared to one another and their application by trainees of varying experience remains uncertain. We compare the application and utility of the JVP, PVC, and handheld Mini Echo amongst trainees of varying experience including a medical student, internal medicine resident, and cardiology fellow. We also introduce and validate a new physical exam technique to assess central venous pressures, the Anthem sign.
  
  
  METHODS
  Patients presenting for their regularly scheduled echocardiograms at the hospital echo department had clinical evaluations of their CVP using these non-invasive bedside techniques. The examiners were blinded to the echo results, each other's assessments, and patient history; their CVP estimates were compared to the gold standard level 3 echo-cardiographer's estimates at the completion of the study.
  
  
  RESULTS
  325 patients combined were examined (mean age 65, s.d. 16 years). When compared to the gold standard of central venous pressure by a level 3 echocardiographer, the JVP was the most sensitive at 86%, improving with clinical experience (p<0.01). The classic PVC technique and Anthem sign had better specificity compared to the JVP. Mini Echo estimates were comparable to physical exam assessments.
  
  
  CONCLUSIONS
  JVP evaluation is the most sensitive physical examination technique in CVP assessments. The PVC techniques along with the newly described Anthem sign may be of value for the early learner who still has not mastered the art of JVP assessment and in obese patients in whom JVP evaluation is problematic. Mini Echo estimates of CVPs are comparable to physical examination by trained clinicians and require less instruction. The use of Mini Echo in medical training should be further evaluated and encouraged.
authors.affiliation: Department of Medicine, section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Jacques
authors.initials: J
authors.lastname: Rizkallah
authors.affiliation: University of Manitoba Medical School, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Megan
authors.initials: M
authors.lastname: Jack
authors.affiliation: Department of Medicine, section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Mahwash
authors.initials: M
authors.lastname: Saeed
authors.affiliation: Department of Medicine, Health Sciences Center, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Leigh Anne
authors.initials: LA
authors.lastname: Shafer
authors.affiliation: Department of Medicine, section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Minh
authors.initials: M
authors.lastname: Vo
authors.affiliation: Department of Medicine, section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: James
authors.initials: J
authors.lastname: Tam
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002496:Central Venous Pressure; D004452:Echocardiography / Q000379:methods / Q000639:trends; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019095:Point-of-Care Systems / Q000639:trends*; D014682:Vena Cava, Inferior / Q000000981:diagnostic imaging; D014690:Venous Pressure