1. Pulmonary Artery Catheter
Marie Sankaran Raval M.D.
Boston Medical Center
Department of Anesthesiology

2. 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

3. What is a pulmonary artery catheter (PAC) ?

4. 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

5. 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a long plastic sheath that is used to maintain sterility of the PAC as it is advanced and withdrawn

6. 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

7. 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

8. 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 cm at the hub.

9. Pulmonary Artery Catheterization

10. Pulmonary Artery Catheterization
PAC as seen on chest x-ray

11. Indications Assess volume status Assess RV or LV failure
Assess Pulmonary Hypertension
Assess Valvular disease
Cardiac Surgery

12. Hemodynamic Parameters

13. 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

14. 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

15. 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)

16. 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

17. PAC Complications Establishment of central venous access
Accidental puncture of adjacent arteries
Bleeding
Neuropathy
Air embolism
Pneumothorax

18. 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

19. PAC Complications Pulmonary catheter residence Thromboembolism
Mechanical, catheter knots
Pulmonary Infarction
Infection, Endocarditis
Endocardial damage, cardiac valve injury
Pulmonary Artery Rupture
% incidence, 41-70% mortality

20. 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?

21. 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

22. 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
Conclusions: No benefit to goal directed therapy by PAC over standard care in elderly, high risk surgery patients
PAC group
Standard care Group
Death
7.8%
7.7%
Pulmonary Embolism 8
6 month Survival
87.4%
88.1%
12 month Survival
83.0%
83.9%