Sharon /Penny
1. Review indications for the use of PA catheter
with heart failure patients.
2. The difference of the four major types of PA
catheters.
3. Review the pressure data collected for the PA
and catheter.
4. Review the risks of the use of the PA catheter.
5. Understand the general rules of handling an
inserted PA catheter.
• PACEP
• Dr Swan
• Dr Ganz
• “There are no universally accepted indications
for pulmonary artery catheterization because
pulmonary artery catheters have not been
shown to improve outcomes.”
• However, there are situations in which
pulmonary artery catheterization may be
helpful to manage and assess patients
•
www.UpToDate.com
Invasive hemodynamic monitoring can be useful for carefully selected
patients with acute HF who have persistent symptoms despite empiric
adjustment of standard therapies, and
a. whose fluid status, perfusion, or systemic or
pulmonary vascular resistances are uncertain;
b. whose systolic pressure remains low, pr is associated with
symptoms, despite initial
therapy;
c. whose renal function is worsening with therapy;
d. who require parenteral vasoactive agents; or
e. who may need consideration for advanced device
therapy or transplantation.
6
• Diagnostic = Right Heart Cath
• -Differentiate cause of shock
•
Cardiogenic/Hypovolemic /Septic
• -Differentiate mechanism of pulm edema
•
Cardiogenic/noncardiogenic
• -Evaluate pulmonary hypertension
•
•
•
•
•
Therapy
Heart Failure
Complicated MI
Cardiac Surgery
Pharmacological therapy
• -Vasopressors, Inotropes, Vasodilators
• Nonpharmacological therapy
• -fluid management ie Ultrafiltration
•
•
•
•
•
•
R.BBB
Tricuspid/pulmonic valve stenosis
Artificial tricuspid/pulmonic valves
Right Atrial/Ventricular mass
New pacemaker
Coagulopathy
•
•
•
•
Standard
VIP
CCO
Pacing
•
•
•
•
•
Flow directed/balloon tipped catheter
110cm in length, markings every 10cm
Tip of catheter in the pulmonary artery
Measures intra-cardiac pressures
Sample blood
•
•
•
•
•
•
•
Yellow – distal – pulmonary artery (PAP)
Blue – proximal – right atrium (CVP)
White – VIP – venous infusion port
Red – balloon inflates with 1.5cc gated syringe
Thermistor – measures blood temp
Continuous Cardiac Output (CCO)
Optical module – mixed venous oximetry (SvO2)
•
•
•
•
•
•
Central Venous Pressure
Pulmonary Artery Pressure
Pulmonary Artery Occlusion Pressure (wedge)
Cardiac Output/Index
Mixed venous saturation
SVR, PVR, Stroke volume
• Complicated vascular access (pneumothorax, hematoma,
arterial puncture, Right ventricle perforation)
• Arrhythmias (heart block, ventricular tachycardia/fibrillation)
• Catheter knotting / Catheter migration
• Pulmonary thrombosis and infarction
• Tricuspid/Pulmonary Valve damage
• Infection
• Pulmonary artery rupture
• PVC’s and V.tach when in R. Ventricle
• L.BBB + R.BBB = CHB
Text Book Levels
CVP
PAS
PAD
PAM
PAOP M
0-7
15-30
8-15
10-17
6-12
• Know your waveforms!!!
• Forward -> wedge -> pulmonary infarction
• Backward -> fall into RV -> VT
• Usually fatal
• Hemoptysis, hypoxia -> cardiac arrest
• Intubate, PEEP -> surgery
• YouTube - Swan Ganz Catheter Placement
•
•
•
•
Incorrect transducer location
Inaccurate calibration
Over/under-damping of transducer
Incorrect catheter position
• ***Incorrect interpretation of information***
Stopcock at phlebostatic axis.
4th intercostal space /midpoint of anterior-posterior chest
• Under-damping
•
•
Excessive tubing or stopcocks
systolic overshoot (the artificial
exaggeration of systolic pressure)
•
Caused by the patient: hypertension,
atherosclerosis, vasoconstriction, aortic
regurgitation, or hyperdynamic ie sepsis
• Over-damping
•
•
Air bubbles, blood, kinked or non-pressure
tubing
Caused by the patient: aortic stenosis,
vasodilatation, or low cardiac output state
• Correct Placement is in
Zone 3 because
•
•
•
•
Ensure accuracy of your numbers
Measure waveforms
Draw blood out of correct port
Aseptic technique
• Throw away syringe or replace syringe
• Put more air in balloon
• Get heart failure patient out of bed without
MD order
• Infuse anything through the yellow port
• Manipulate PA
• Do you know if the PA lines are heparin coated
at this facility?
• Can you use a heparin coated PA line on a
patient with HIT?
•
Invasive Hemodynamic Monitoring: Physiological Principles and Clinical Applications
•
Quick Guide to Cardiopulmonary Care 2nd Edition