1. What is the cause of a high venous pressure in a person with low cardiac output?
ANS: a. Increase of venous tone due to sympathetic outflow and catecholamines.
b. Increased blood volume due to salt and water retention, probably at least partly due to the increased sympathetic outflow effect on the kidneys. One may therefore characterize a high venous pressure in heart failure as due to an increase in "tone volume."
2. What can cause a patient with heart failure to have an apparently normal venous pressure, despite an increase in tone volume, besides a diuretic?
ANS: If a patient's normal venous pressure is 1 cm above the sternal angle at 45°, it may rise to only 3 cm; i.e., a 2-cm increase may occur when failure takes place. This is higher than normal for the patient but within normal limits for venous pressure.
3. What is the usual terminology for patients with congestive heart failure who have a high venous pressure and peripheral edema?
ANS: Right ventricular (RV) failure.
4. What is unfortunate about the term RV failure?
ANS: It has two meanings.
a. Taken literally, it means that there is damage to the RV, as in RV infarction or inadequate ejection due to severe pressure overloads, as in severe pulmonary hypertension or stenosis.
b. It is also used when there is a high venous pressure and peripheral edema even with intact RV function, as in patients with low output due to purely left ventricular problems. This latter is better given a different name, such as peripheral venous congestion.
5. How can you tell that a venous pressure below the upper limit of normal is actually high for that particular person?
ANS: Abdominal compression will cause and maintain a rise in the top level of pulsations only if the venous pressure is relatively high. The greater the rise with abdominal compression, the higher the venous pressure. This is called hepatojugular reflux (not reflex).
6. What happens to the top level of jugular pulsations if abdominal compression is applied to a patient without heart failure? Why?
ANS: The jugular venous pressure will fall because pressure on the abdomen obstructs femoral venous return almost as effectively as does venous tourniquets on the thighs. Thus, less blood reaches the right atrium.
Note: Abdominal compression that causes an increase in dyspnea or the use of accessory muscles of respiration implies that the patient's vital capacity is so reduced that he or she cannot tolerate any further decrease produced by pushing up on the diaphragm.
7. What is wrong with the historical term hepatojugular reflux?
ANS: This term was first applied in 1885, when it was thought that pressure on a large liver was an essential part of the test and also that the procedure was a test only for tricuspid regurgitation. Actually, the effect can be achieved with a normal-sized liver and with compression on any part of the abdomen, although pressure on the right upper quadrant produces the greatest response. If the right upper quadrant is tender, do not hesitate to compress other areas instead. The term "hepatojugular reflux" has been retained because it is so widely known that it is useful for indexing and referencing as well as for communication among physicians.
However, the term positive abdominal compression test is preferable when describing the results of abdominal pressure. The term abdominal jugular test has also been proposed, but for teaching purposes, the word compression is more specific.
Note: A positive test has been correlated with a pulmonary capillary wedge pressure (left atrial pressure equivalent) of at least 15 mmHg.
8. Why does abdominal compression cause a sustained rise in pressure in a patient with congestive failure?
ANS: The patient with peripheral venous congestion also commonly has a large RV and right atrium. Right upper quadrant compression transmitted to the RV and right atrium can interfere with their filling, especially if there is increased tone of those chambers and they are near the limit of their compliance. This may account for the fact that right upper quadrant pressure may cause a decrease in cardiac output, despite the apparently higher filling pressure.
9. What are the common causes of a false rise in the height of jugular pulsations with abdominal compression, i.e., not due to cardiac causes?
ANS: a. Inability to tolerate the resistance to downward movement of the diaphragm when pressure on the abdomen raises the diaphragm in patients with severe obstructive pulmonary disease or in any other condition that causes severe loss of vital capacity.
b. Increased blood volume, e.g., polycythemia vera.
c. Increased sympathetic stimulation due to such causes as nervousness, pain, intravenous catecholamines, or an acute infarct.
Note: Abdominal compression often exaggerates the amplitude of the jugular pulsations without actually raising the upper levels, and by merely revealing the true upper level of pulsations, which were difficult to perceive before compression, it may give a false impression of a rise in venous pressure.
10. How should you compress the abdomen in order to prevent false elevations due to sympathetic outflow?
ANS: a. Compress with warm hands or with a garment or sheet between your hand and the abdomen. b. Spread the fingers apart, so that there is as little local pressure as possible.
Spreading the fingers allows you to distribute pressure over a large area, so that more pressure can be applied without producing discomfort. Sometimes, only marked abdominal pressure will raise jugular pulsations enough to show that they are abnormal.
c. Start by pressing gently, and gradually increase the pressure to just below the point of discomfort.
d. Ask the patient to tell you if you are pressing too hard, and warn him or her that it spoils the test if you produce discomfort.
Historically, Kussmaul's sign is the rise in the height of jugular pulsations during inspiration in patients with chronic constrictive pericarditis. However, it is found in only a minority of patients with constrictive pericarditis, and it often occurs with peripheral venous congestion from any cause.
a. Inspiration raises the intraabdominal pressures and can produce an effect like that of abdominal compression. Therefore, in any patient with a high venous pressure, inspiration may cause a further pressure increase.
b. This sign should alert you to the presence of RV infarction in a patient with acute inferior infarction and no signs of left ventricular failure, because it will be present in a majority of such patients.
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