Pulmonary artery pressure monitoring

PA monitoring

1. PULMONARY ARTERY PRESSURE MONITORING PRINCY FRANCIS M II MSc (N) JMCON

2. PULMONARY ARTERY CATHETER Dr. Swan and Ganz , 1970

3. PULMONARY ARTERY CATHETER Pulmonary artery catheter are balloon tipped flow directed catheters that have distal and proximal lumens used to measure pulmonary artery pressure.

4. PULMONARY ARTERY CATHETER 7.5Fr, 43inch (110 cm) long with 4 or 5 lumens. Distal Lumen : Pulmonary artery Balloon port Proximal lumen : Right atrium , right atrium and right ventricle.

5. Thermistor lumen Atrial electrode Continous cardiac output monitoring Fibre optic sensor

6. TYPES Four lumen catheter – 1 proximal, 1 distal, 1 balloon inflation valve and a thermistor wire connector.

7. Five lumen catheter Five lumen catheter

8. 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

9. 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 pre- ecclampsia Guide to pharmacologic therapy Burns/ Renal Failure/ Heart failure/Sepsis/ Decompensated cirrhosis Assess response to pulmonary hypertension specific therapy

10. NORMAL VALUES Pulmonary artery pressure : Systolic : 15 -25mm Hg , Diastolic: 8-12mm Hg Mean pulmonary artery pressure : 9- 18 mm Hg Pulmonary Artery Wedge Pressure : 6 – 12 mm Hg Central venous pressure : 2 - 6 mm Hg Right ventricular pressure : Systolic : 15- 30 mm Hg , Diastolic : 3 – 8 mm Hg Left Ventricular pressure : Systolic : 100 -140 mm Hg, Diastolic : 3 – 12 mm Hg Cardiac Output : 4- 8 L/mt.

11. EQUIPMENTS Swan Ganz catheter Heparinized saline, pressure bag, IV tubings , transducer, PM line Monitors – cardiac output monitor and cardiac monitor

12. PRE PROCEDURE CARE Get informed consent signed. Patient has to be monitored with continuous ECG throughout the procedure Aseptic precautions must be employed Selection of insertion site Position the patient in Trendelenburg position.

13. Preparation Prepare the patient Explain the procedure and get informed written consent Check for any allergies Remove any prosthesis, if present Keep NPO for 8 hours Get a baseline ECG and blood investigations ready Local preparation Preparation of equipments Heparinized saline in pressure bag with 50 mm Hg pressure Flush transducer, pressure tubing, stopcocks under aseptic technique. Ensure that all air bubbles are removed. Attach pressure tubing to transducer system and reference system to patient’s phlebostatic axis and zero system

14. PROCEDURE 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 Place sheath

15. Pass catheter through sheath with tip curved towards the heart Once tip of catheter passed through introducer sheath inflate balloon at level of right ventricle. The progress of the catheter through right atrium and ventricle into pulmonary artery and wedge position can be monitored by changes in pressure trace After acquiring wedge pressure deflate balloon

16. WAVE FORMS

17. Cather Insertion Landmarks Anatomic Structure Distance Right atrium 20 to 25 cm Right ventricle 30 to 35 cm Pulmonary artery 40 to 45 cm Pulmonary capillary wedge 45 to 55 cm

18. Intra procedure care Assist the procedure Monitor and record HR, rhythm and BP during catheter insertion and passed through each chamber. Balloon should not be inflated more than 8 – 10 sec. Not more than 1.5ml of air should be used to inflate the balloon Keep the emergency medications ready Watch for dysrhythmia

19. Post procedure care Secure the catheter Apply sterile occlusive dressing Obtain a chest X ray Position the patient with supine legs extended, head end elevated to 30 – 60 degree Continuously monitor the patient Adequate flushing of line using heparinized saline Adhere to aseptic technique using dressing After insertion measurement of catheter length in centimeters is documented.

20. Pulmonary artery pressure measurements Systolic , diastolic and mean pressure Measurement should be done at the end of expiration

21. a wave = Left atrial contraction c wave = closure of mitral valve v wave = ventricular contraction against closed mitral valve x descent = left atrial relaxation y descent is caused by mitral valve opening, onset of LV diastole

22. CENTRAL VENOUS OR RIGHT ATRIAL PRESSURE MEASUREMENTS Proximal lumen a wave = R atrial contraction c wave = closure of tricuspid valve v wave = ventricular contraction against closed tricuspid x descent is caused by atrial relaxation y descent is caused by tricuspid valve opening

23. CARDIAC OUTPUT MEASUREMENTS THERMODILUTION CARDIAC OUTPUT METHOD (TDCO) CONTINOUS CARDIAC OUTPUT MEASUREMENT (CCO)

24. THERMO DILUTION METHOD 10 ml of cold saline (0.9% NaCl) under 10° Celsius is injected via proximal lumen port . The thermistor sensor located near the distal tip detects the difference in blood temperature. The Cardiac output is calculated from the area under the temperature curve by the computer.

25. CONTINOUS CARDIAC OUTPUT MEASUREMENT (CCO) Thermal filament in the right atrium Filament emits a pulsed signal in every 30 -60 sec allows mixing of blood with heat as it passes through right ventricle. Thermistor detect change in temperature . Computer displays digital measurements.

26. COMPLICATIONS Dysrrhythmia Pulmonary thromboembolism Air embolization Pulmonary artery rupture Pulmonary infarction Infection and sepsis

27. ADVANTAGES Detect heart failure and sepsis shock Pulmonary artery pressure and wedge pressure Indirectly measure the left heart pressure Monitor effectiveness of therapy Drug effectiveness

28. REFERENCES Susan Woods, Erika S Sivarajan , Sandra Underhill, Elizabeth J Bridges, Cardiac Nursing, 5 th Edition, Lippincott William & Wilkins Sharon L. Lewis, Shannon Ruff Dirksen, Margaret McLean Heitkemper , Linda Bucher. Medical-Surgical Nursing: Assessment and Management of 9 th Edition Smeltzer S C, Bare B , Brunner & Suddarth’s Medical surgical nursing, edition 10 th , ( 2000), Westline Industrial drive, Missouri.