Fluid Overload Essentials
Get your clinical juices flowing and master the diagnosis and management of patients with fluid overload with this course.
3 CME credits
When you suspect fluid imbalance, looking at jugular venous distention without assessing jugular venous pulse (JVP) is not enough. In this video, watch our expert break down the notoriously difficult JVP exam for you.
With this video, you'll get your clinical juices flowing and master the diagnosis and management of patients with fluid overload. Many diseases can lead to symptomatic fluid overload in hospitalized and ambulatory patients. This course will make you a pro at the diagnosis and management of patients with fluid overload. You’ll learn how to manage complex patients, including those with kidney or other organ dysfunction, and by the end, you will be able to care for patients with fluid overload better than your colleagues can!
As discussed in the previous lesson, the check of the venous pulse needs to be measured while developing a differential diagnosis for fluid overload. Let's dive into what exactly the jugular venous pulse is, and how we can study it in order to help patients experiencing fluid overload. The jugular venous pulses of venous pulsation found in the jugular neck veins. These veins directly communicate with the right atrium of the heart, we can use the height of the jugular venous pulsations to estimate the right atrial pressure. By doing this we can determine if someone has fluid overload associated with high right ventricular filling pressures.
This can help narrow down the differential for bilateral leg edema, as well as guide therapeutic decisions. The internal jugular vein is located in the neck alongside the carotid artery, it descends posteriorly between the two heads of the sternocleidomastoid muscle. The vein merges with the subclavian vein to form the brachiocephalic vein, which drains into the superior vena cava into the right atrium. The external jugular vein runs in the subcutaneous tissue of the neck and is superficial to the sternocleidomastoid muscle.
This vein drains blood from the outer part of the cranium, face and neck into the subclavian vein. Let's go through the steps needed to identify and measure the jugular venous pulse. Step one is to position the patient. Ensure the patient has a relaxed neck, you do not want the sternocleidomastoid muscle to be tense. Then position the patient's head so that it is elevated at about 30 to 45 degrees. To look at the right jugular veins, ask the patient to gently turn to the left and relax the neck.
Because jugular venous pulsations can be very rapid and subtle. You can see them best by turning down the room lights and using a tangential light source to accentuate skin shadows. For example, to look at the right internal or external jugular veins, shining a light source slightly from behind will generate a shadow that allows you to see the jugular venous pulse. If it is difficult to see the internal jugular vein, it is acceptable to use the external jugular vein. This would appear as a medium diameter vein coursing on top of the sternocleidomastoid muscle.
Direct measurements of central venous pressures and jugular venous pulse measurements by physical exam have shown that the JVP can be measured using either the right internal jugular, left internal jugular or external jugular veins. Any of these veins are adequate to use as long as you can visualize venous pulsations. As a general rule, it is recommended to start on the right neck because right sided jugular veins have a more direct course to the right atrium. Step two, identify the jugular venous pulse. Because these are venous pulsations it is a low pressure system.
You identify the vein by how it distends the soft tissue around the vein. Therefore, you can only see jugular venous pulsations in the neck window above the clavicle and below the mandible. You are looking for a rapid, fluttery, collapsing type of pulse. The venous pulsation should be at a two to one ratio with every cardiac cycle, I recommend feeling the radial pulse simultaneously while examining pulsations in the neck. While examining the neck you will need to discriminate between the arterial pulse of the carotid artery and the venous pulsations of the jugular veins.
Here's the criteria used to distinguish the two. The arterial pulse will have a single peak that is quick and sharp and has a one to one ratio with the cardiac cycle. Venous pulsations will have two peaks for every cardiac cycle. In terms of the quality of the movements, arterial pulses have a more sudden outward force, while venus pulsations have a more sudden collapsing quality to them. Next, the patient position in elevation of the head will not affect the location of arterial pulsations, but the height of the jugular venous pulsations will change with position. Inspiration should not affect arterial pulsations, but jugular venous pulsations will collapse with inspiration. This is because a sudden decrease in intrathoracic pressure will increase ventricular filling and temporarily reduce the JVP.
Arterial pulses in the carotid artery can be readily palpable, while jugular vein pulses are not palpable and even can be eliminated completely with very light palpation proximally. This video shows jugular venous pulsations in a patient who had a measured right atrial pressure of 32 millimeters of mercury. You should be able to see rapid collapsing pulsations in the neck between the mandible and the clavicle. On physical exam, I was feeling the radial pulse and these neck vein pulsations were at a rate of two to one for every cardiac cycle.
Jugular venous pulses have a characteristic waveform with an A wave, C Wave, X descent, V wave in the white acsent. This biphasic quality is due to the sequence of right atrial contraction, tricuspid valve closure, right atrial relaxation, early right atrial filling, and finally passive right ventricular filling. What is likely to happen is that you may not always see jugular venous pulsations when you have the patient at 30 to 45 degrees. This means that the jugular veins pulsations are either lower than you think and somewhere under the clavicle, or they're higher than what you think and somewhere above the mandible.
In order to make the jugular venous pulse visible, you'll need to either lower or elevate the angle of the patient's head and neck with respect to the right atrium. A patient suspected to be volume depleted, probably needs the head of the bed lowered in order to see the JVP. A patient suspected of being fluid overloaded needs the head of the bed elevated more in order to bring the JVP into the neck window. Step three. Now you need to measure the distance of the JVP from the right atrium. What we really care about is the vertical distance of the JVP from the right atrium. While we cannot measure from the right atrium directly, we measure from the sternal angle, which is also known as the angle of Louis.
When the patient is supine the distance from the right atrium to the sternal angle is about five centimeters. Normal jugular pressure should be less than eight centimeters. Therefore, the patient with a normal JVP would have jugular venous pulsations about three centimeters above the sternal angle. Five plus three equals eight. A patient with an elevated JVP would have jugular venous positions greater than three centimeters from the sternal angle. You can measure this by placing a ruler vertically at the sternal angle and then drawing a tangential line from the jugular venous pulsations you see to that ruler to measure this vertical distance above the sternal angle.
To be clear, you can only measure the JVP using a horizontal line from the neck out to a vertical ruler. Of course, you may not always have a ruler handy. One workaround is to measure the width of your hand and commit that number to memory. Then you could place your hands vertically on the sternal angle and use a pin or a straightedge to bring the horizontal line from the JVP out to your hand. This can help you estimate the JVP without a ruler. One thing that complicates this measurement is that the distance from the sternal angle to the right atrium changes according to position. As mentioned before, when the patient is supine the distance from the right atrium to the sternal angle is five centimeters.
When a patient has the head elevated to 30 degrees, the distance from the right atrium to the sternal angle is closer to eight centimeters. And when a patient is elevated to 45 degrees or more, the distance from the right atrium to the sternal angle is 10 centimeters. This does require committing a few more numbers to memory. Basically, if you can easily see the JVP with a patient elevated to 45 degrees or greater, you can be confident that the JVP is high. The main message here is that if you're having difficulty seeing the JVP you'll have to reposition the elevation of the patient's head until you do see it. You may hear or use the term jugular venous distension.
What is jugular venous distension? Jugular venous distension just means that one or more of the jugular veins are enlarged, dilated or in gorged. To me the term may not communicate much information. For example, jugular venous distension can occur in someone who has central vein obstruction. If someone has superior vena cava occlusion or stenosis, then the jugular veins may be dilated to. The jugular veins then should not be used at all for observing jugular venous pulsations and estimation of right atrial pressure.
The conduit between the right atrium and the jugular veins needs to be patent and unobstructed in order to estimate right atrial pressures. It is the unique biphasic quality of the jugular vein pulsations that tell you that the veins are in direct communication with the right atrium. If you don't see them then there could be a venous obstruction. Reporting jugular vein distension without estimation of the jugular venous pressure does not provide clinically useful information. For example, observing distended jugular veins without seeing jugular venous pulsations could also indicate that the JVP is much higher than you thought.
If the jugular venous pulsations are actually above the mandible, then you may not see them and you'll then need to adjust the patient position by having them sit upright with a very steep angle. In other words, if you see jugular vein distension without pulsations continue to elevate the head of the bed until you see jugular venous pulsations fall below the mandible. The last thing you want to do is miss critically elevated right atrial pressures. This video demonstrates something important. This is the same patient from the video earlier, while lying at a flatter angle of around 45 degrees rather than 90 degrees, her jugular vein pulsations were now visible in the superficial veins on her forehead. In other words, if you suspect elevated right atrial pressures from fluid overload, make sure you inspect other dilated veins in the upper head and neck which could give you important clues.