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

6 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.

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 0-7  PAS15-30  PAD8-15  PAM10-17  PAOP M6-12

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. 4 th 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