Pulmonary artery catheter

Pulmonary artery catheter- indications ,contraindications, technique, interpretation of hemodynamic parameters and waveforms, complications

1. Pulmonary Artery Catheter R.Srihari

2. Introduction Physiologic Measurements Indications Contraindications Preparation Technique Interpretation of hemodynamic values and waveforms Complications

3. Introduction Pulmonary artery catheters (also called as Swan- Ganz catheter) are used for evaluation of a range of condition Although their routine use has fallen out of favour , they are still occasionally placed for management of critically ill patients

4. Physiological Measurements Direct measurements of the following can be obtained from an accurately placed pulmonary artery catheter(PAC) Central Venous Pressure(CVP) Right sided intracardiac pressures(RA/V) Pulmonary artery pressure(Pap) Pulmonary artery occlusion pressure (PAOP) Cardiac Output Mixed Venous Oxygen Saturation(SvO2)

5. Indirect measurements that are possible: Systemic Vascular Resistance Pulmonary Vascular Resistance Cardiac Index Stroke volume index Oxygen delivery Oxygen uptake

6. Indications Diagnostic: Differentiation among causes of shock Differentiation between mechanisms of pulmonary edema Evaluation of pulmonary hypertension Diagnosis of pericardial tamponade Diagnosis of right to left intracardiac shunts Unexplained dyspnea

7. Therapeutic: Management of perioperative patients with unstable cardiac status Management of complicated myocardial infarction Management of patients following cardiac surgery/high risk surgery Management of severe preecclampsia Guide to pharmacologic therapy Burns/ Renal Failure/ Heart failure/Sepsis/ Decompensated cirrhosis Assess response to pulmonary hypertension specific therapy

8. Contraindications Absolute: Infection at insertion site Presence of RV assist device Insertion during CPB Lack of consent Relative: Coagulopathy Thrombocytopenia Electrolyte disturbances (K/Mg/Na/Ca) Severe Pulmonary HTN

9. Making decision to place pulmonary artery catheter In critically ill or perioperative patients decision to place a pulmonary artery catheter should be based on patient’s hemodynamic status or diagnosis that cannot be answered satisfactory by clinical or non-invasive assessment

10. Preparation Patient has to be monitored with continuous ECG throughout the procedure, in supine position regardless of the approach Aseptic precautions must be employed Cautions should be taken while cannulating via IJV/ Subclavian vein

11. Equipments: 2 % chlorhexidine skin preparation solution Sterile gown, gloves, face shield and cap Sterile gauze pads 1% lidocaine -5 cc Seeker needle  23G Introducer needle  18G J-tip guidewire Transduction tubing Sterile catheter flush solution Sheath Pulonary catheter Sterile sleeve for catheter 2-0 silk suture Sterile dressing

12. Technique Aseptic precautions undertaken Local infiltration done Check balloon integrity by inflating with 1.5ml of air Check lumens patency by flushing with saline 0.9% Cover catheter with sterile sleeve provided Cannulate vein with Seldinger technique Place sheath Pass catheter through sheath with tip curved towards the heart

13. 9. Once tip of catheter passed through introducer sheath  inflate balloon at level of right ventricle 10. The progress of the catheter through right atrium and ventricle into pulmonary artery and wedge position can be monitored by changes in pressure trace 11. After acquiring wedge pressure  deflate balloon

14. Important tip: When advancing catheter- always inflate tip When withdrawing catheter- always deflate Once in pulmonary artery - NEVER INFLATE AGAINST RESISTANCE - RISK OF PULMONARY ARTERY RUPTURE

15. Interpretation of hemodynamic values and waveforms Ensuring accurate measurements: Zeroing and Referencing Correct placement Fast flush test

16. Zeroing and Referencing: PAC must be appropriately zeroed and referenced to obtain accurate readings  in supine position/30 degrees semi-recumbent position Correct placement : By either pressure waveform/ fluoroscopic guidance

17. Rapid flush test:

18. Catheter waveforms and pressures Pressure waveforms can be obtained from Right atrium Right ventricle Pulmonary artery

19. Right atrium: In presence of a a competent tricuspid valve, RA pressure waveform reflect both Venous return to RA during ventricular systole RV E nd Diastolic Pressure Normal RA pressure: 0-7 mmHg

20. Elevated RA pressure: Diseases of RV( infarction/ cardiomyopathy ) Pulmonary hypertension Pulmonic stenosis Left to right shunts Pericardial diseases LV systolic failure Hypervolemia

21. Differentiating among etiologies depends on Clinical Radiographical Echocardiographic features + PAC findings Eg : Increased RA Pressure and Mean pulmonary Pressure  PAH Increased RAP and Normal Pa pressures  RV disease/ Pulmonary stenosis

22. Abnormal RA waveforms: Tall v waves: Tricuspid Regurgitation Giant/ cannon a waves: Ventricular tachycardia Ventricular pacing Complete heart block Tricuspid stenosis Loss of a waves: Atrial fibrillation/ Atrial flutter

23. Right Ventricle: Transitioning from SVC or RA to RV: Once balloon is inflated in the SVC/RA  the catheter is slowly advanced When catheter tip is across tricuspid valve pressure waveform changes and systolic pressure increases

24. 2 pressures are typically measured in right ventricular pressure waveform Peak RV systolic pressure  15-25mmHg Peak RV diastolic pressure  3-12 mmHg

25. As a general rule  elevations in RV pressure: Diseases increasing pulmonary artery pressure Pulmonic valve disorders Diseases affecting right ventricle Pulmonary vascular and pulmonary valve disorders a/w increased RV systolic pressures RV disorders – ischemia/infarction/failure – a/w increased RV End diastolic pressure

26. Pulmonary artery: The risk of arrhythmias is greatest while catheter tip is in RV Thus, catheter should be advanced from RV to PA without delay When catheter tip passes pulmonary valve  Diastolic pressure increases and characteristic dichrotic notch appears in waveform

27. Normal pulmonary artery pressures: Systolic  15-25mmHg Diastolic  8-15 mmHg Mean  16 (10-22mmHg) Main components of PA tracing: Systolic and Diastolic pressure Dichrotic notch(due to closure of pulmonic valve)

28. Increase in mean pulmonary pressure: Acute: Venous Thromboembolism Hypoxemia induced Pulmonary Vasoconstriction Acute on Chronic: Hypoxemia induced pulm VC in patient with chronic cardiopulmonary disease Chronic: Pulmonary hypertension

29. Types of PHT: Primary Due to Heart Disease Due to Lung Disease Due to chronic venous thromboembolism Miscellaneous ( Sickle Cell Anemia)

30. Pulmonary arterial occlusion pressure Once catheter tip has reached PA, it should be advanced until PAOP is identified by decrease in pressure and change in waveform The balloon should then be deflated and PA tracing should reappear If PCOP tracing persists catheter should be withdrawn with definitive PA tracing obtained

31. Final position of the catheter within PA must be such that PCOP tracing is obtained whenever 75-100% of 1.5ml maximum volume of balloon is insufflated If < 1ml of air is injected and PAOP is seen then it is overwedged  needs to be withdrawn If after maximal inflation fails to result in PCOP tracing or after 2-3 seconds delay  too proximal – advanced with balloon inflated

32. PCWP/PAOP  interprets Left atrial pressures more importantly – LVEDP Best measured in Supine position At end of expiration Zone 3 (most dependent region) Normal PCWP- 6-15 mmHg ; Mean :9mmHg

33. Abnormal PAOP: Increased LVEDP  Increased PAOP LV systolic HF LV Distolic HF Mitral and Aortic valve disease Hypertrophic cardiomyopathy Hypervolemia Large R-L shunts Pericardial disease

34. Decreased PCWP: Hypovolemia Obstructive shock due to large pulmonary embolus Abnormal waveforms Large a waves: MS LV systolic /diastolic function LV volume overload MI Large v waves - MR

35. Calculation of cardiac output: 2 methods Thermodilution method Fick’s Method Better measurement with Cardiac index Normal – 2.8- 4.2 l/min/m2

36. Decreased CO: Systolic HF Diastolic HF MR Hypovolemia Pulmonary HT RVF Increased CO: Systemic A-V fistulas Anemia Beriberi Renal Disease Sepsis

37. Other uses of pulmonary artery catheter: Detection of Left to right shunts Estimation of systemic and pulmonary vascular resistance

38. Complications General: Immediate: Bleeding Arterial Puncture Air embolism Thoracic duct injury ( L side) Pneumothorax / hemothorax Delayed: Infections Thrombosis

39. Related to insertion of PAC: Arrhythmias (most common- Ventricular/ RBBB) Misplacement Knotting Myocardial/valve/vessel rupture Related to maintenance and use of PAC: Pulmonary artery perforation Thromboembolism Infection

40. Thank You