Transcript Pulmonary Artery Catheter

Pulmonary Artery
Catheter
Marie Sankaran Raval M.D.
Boston Medical Center
Department of Anesthesiology
Pulmonary Artery Catheter
What is a pulmonary artery catheter?
 Pulmonary Artery Catheterization
 Indications
 Hemodynamic Parameters
 Oxygen Transport Parameters
 Benefits
 Complications
 ASA Guidelines for PA catheterization

What is a pulmonary artery
catheter (PAC) ?
Pulmonary Artery Catheter

Invented in 1970 by Swan,
Ganz and colleagues for
hemodynamic assessment of
patients with acute myocardial
infarction.

Standard PAC is 7.0, 7.5 or 8.0
French in circumference and
110 cm in length divided in 10
cm intervals
Pulmonary Artery Catheter

The standard PAC kit
includes:
– a syringe that can be filled
with only 1.5 mL of air to
prevent overinflation of the
balloon
– a long plastic sheath that is
used to maintain sterility of
the PAC as it is advanced
and withdrawn
Pulmonary Artery Catheter

PAC has 4-5 lumens:
– Temperature thermistor located
proximal to balloon to measure
pulmonary artery blood temperature
– Proximal port located 30 cm from
tip for CVP monitoring, fluid and
drug administration
– Distal port at catheter tip for PAP
monitoring
– +/- Variable infusion port (VIP) for
fluid and drug administration
– Balloon at catheter tip
Pulmonary Artery Catheterization

A large-bore introducer
catheter is used to
facilitate PAC insertion

Inserted through the
subclavian or internal
jugular vein with the
patient in Trendelenburg

Prior to PAC insertion,
– Connect the distal port
(yellow) to the pressure
transducer
– Level the transducer at the
level of the patient’s heart
– Zero the transducer
Prior to Insertion:

Before insertion, check the PAC for cracks and kinks. Then, check
balloon function (see image below), connect all lumens to stopcocks,
and flush them to eliminate air bubbles. Flick the PAC tip to check
frequency response. Finally, the PAC is threaded through a sterile
sleeve (be sure to check orientation) to ensure sterility of the PAC
after insertion and allow some adjustment of position.
Pulmonary Artery Catheterization

Continuous pressure
monitoring during PAC
insertion is required to
determine location of the
catheter tip.

Inflate the balloon when the
20cm mark is at the hub of
the introducer.

Advance the PAC until the
pulmonary capillary wedge
pressure (PCWP) is
obtained, usually around
45-55cm at the hub.
Pulmonary Artery Catheterization
Pulmonary Artery Catheterization
PAC as seen on chest x-ray
Indications
Assess volume status
 Assess RV or LV failure
 Assess Pulmonary Hypertension
 Assess Valvular disease
 Cardiac Surgery

Hemodynamic Parameters
Hemodynamic Parameters - Measured

Central Venous Pressure (CVP)
– recorded from proximal port of PAC in the superior vena cava or right atrium
– CVP = RAP
– CVP = right ventricular end diastolic pressure (RVEDP) when no obstruction exists
between atrium and ventricle

Pulmonary Artery Pressure (PAP)
– measured at the tip of the PAC with balloon deflated
– reflects RV function, pulmonary vascular resistance and LA filling pressures

Pulmonary Capillary Wedge Pressure (PCWP)
– recorded from the tip of the PAC catheter with the balloon inflated
– PCWP = LAP = LVEDP (when no obstruction exists between atrium and ventricle)

Cardiac Output (CO)
– Calculated using the thermodilution technique
– thermistor at the distal end of PAC records change in temperature of blood flowing
in the pulmonary artery when the blood temperature is reduced by injecting a
volume of cold fluid through PAC into the RA
Hemodynamic Parameters - Derived

Cardiac Index (CI) = CO/BSA

Stroke Volume Index (SVI) = CI/HR

Systemic Vascular Resistance (SVR)
– reflects impedance of the systemic vascular tree
– SVR = 80 x (MAP – CVP) / CO

Pulmonary Vascular Resistance (PVR)
– reflects impedance of pulmonary circuit
– PVR = 80 x (PAM – PCWP) / CO

Left ventricular stroke work index (LVSWI)
= (MAP – PCWP) x SVI x 0.136

Right ventricular stroke work index (RVSWI)
= (PAM – CVP) x SVI x 0.136
Oxygen Transport Parameters

Oxygen Delivery (DO2)
– Rate of oxygen delivery in arterial blood
DO2 = CI x 13.4 x Hgb x SaO2

Mixed Venous Oxygen Saturation (SVO2)
– Oxygen saturation in pulmonary artery blood
– Used to detect impaired tissue oxygenation

Oxygen uptake (VO2)
– Rate of oxygen taken up from the systemic
microcirculation
VO2 = CI x 13.4 x Hgb x (SaO2 - SVO2)
PAC Benefits

Effect on Treatment Decisions: information
gathered from PA catheter data can beneficially
change therapy

Preoperative Catheterization: information
gathered prior to surgery can lead to
cancellation or modification of surgical
procedure, thereby preventing morbidity and
mortality

Perioperative Monitoring: provides invasive
hemodynamic monitoring in the surgical setting
PAC Complications

Establishment of central venous access
– Accidental puncture of adjacent arteries
– Bleeding
– Neuropathy
– Air embolism
– Pneumothorax
PAC Complications

Pulmonary artery catheterization
– Dysrhythmias
 Premature ventricular and atrial contractions
 Ventricular tachycardia or fibrillation
– Right Bundle Branch Block (RBBB)
 In patients with preexistinh LBBB, can lead to
complete heart block.
– Minor increase in tricuspid regurgitation
PAC Complications

Pulmonary catheter residence
– Thromboembolism
– Mechanical, catheter knots
– Pulmonary Infarction
– Infection, Endocarditis
– Endocardial damage, cardiac valve injury
– Pulmonary Artery Rupture
 0.03-0.2% incidence, 41-70% mortality
ASA Practice Guidelines for Pulmonary Artery
Catheterization (2003)

Appropriateness of PA catheterization depends on the risks
associated with the:
– (a) Patient: Are there presexisting medical conditions that may
increase the risk of hemodynamic instability?
– (b) Surgery: Is the procedure associated with significant
hemodynamic fluctuations which may cause end organ damage?
– (c) Practice setting: Could the complications associated with
hemodynamic disturbance be worsened if the technical or
cognitive skills of the physicians or nurses caring for the patient
are poor?
ASA Practice Guidelines for Pulmonary
Artery Catheterization (2003)

According to the Task Force on Pulmonary Artery
Catheterization, PAC monitoring was deemed
appropriate and/or necessary in the following patient
groups:
– 1) surgical patients undergoing procedures associated
with a high risk of complications from hemodynamic
changes
– 2) surgical patients with advanced cardiopulmonary
disease who would be at increased risk for adverse
Perioperative events
A Randomized, Controlled Trial of the Use of
Pulmonary-Artery Catheters in High-Risk
Sandham et al



Randomized control trial comparing goal directed therapy guided by
PAC with standard care without PAC
Patient population: high-risk patients >60 years old with ASA
classification III/IV, scheduled for urgent or elective major surgery
Results
PAC group
Standard care Group
Death
7.8%
7.7%
Pulmonary Embolism
8
0
6 month Survival
87.4%
88.1%
12 month Survival
83.0%
83.9%

Conclusions: No benefit to goal directed therapy by PAC over
standard care in elderly, high risk surgery patients