Pulmonary Artery Catheter

Pulmonary Artery Catheter
St. Mary Medical Center
Emergency Medical Services

Learning Objectives
• Identify the appropriate indications for invasive
hemodynamic pressure monitoring.
• Recall the significance of each connection on
the Swan-Ganz Swan Ganz ® hemodynamic catheter.
• Differentiate between In-Vitro In Vitro and In-Vivo In Vivo
calibration with the Vigilance Monitor.
• Recall the normal pressure readings for each
hemodynamic component (RAP, RVP, PAP,
PAWP, CO, CI).

Learning Objectives
• Differentiate between the various invasive
hemodynamic waveforms.
• Recognize the significance of the phlebostatic
axis on invasive hemodynamic monitoring.
• Recall the various complications associated
with invasive hemodynamic monitoring.

PA Catheter
• A Pulmonary Artery (PA) Catheter provides an
assessment of the patient’s circulatory status.
It provides specific measurements on
pulmonary artery and pulmonary capillary
wedge pressure, central venous pressure,
cardiac output, and cardiac indexing.

Indications For Pressure
Monitoring
• Right atrial pressure monitoring (CVP or RAP)
• Pulmonary artery pressure monitoring (PAP)
• Cardiac Output procedure/Thermodilution
method (CO) (Hemodynamic Profile)
• Continuous Cardiac Output (CCO)/ Mixed
Venous Oxygen Saturation (SvO2 ) monitoring

Vigilance Monitor

SAFESET Blood Sampling System
• Closed blood sampling
system
• May reduce risk and
expense associated with
blood waste
• Reduces potential for line
contamination
• Minimizes blood
exposure to the patient
and the clinician
• Needleless access

Setting up the pressure bag
• The standard flush solutions and
pressure line set-ups set ups will be utilized in
the following manner:
• Multiple Set-up: Set up: a sterile disposable
multiple transducer pressure line system
with 1000 cc .9NS when more than one
pressure is to be monitored.

Arrow Introducer Kit
• Used with the insertion of the Swan-Ganz
Swan Ganz
catheter. It is a sterile kit, size 9 fr., that
contains many supplies for the procedure.
The major components included in the kit
are a percutaneous sheath introducer, an
accessory IV line (side port), and a cath- cath
guard contamination shield (sleeve). A sterile
central line (the introducer with side port) can
be maintained, if needed, once the Swan- Swan
Ganz catheter is removed.

SWAN-GANZ Catheters®
• A flow-directed, flow directed, balloon-tipped, balloon tipped, multi-lumen
multi lumen
catheter, allowing for ease of right heart
catheterization at the bedside and permitting
continuous monitoring of the right and left
ventricular function, pulmonary artery
pressures, cardiac output (CCO), mixed
arterial venous oxygen difference (SvO2),
and measuring the patient’s hemodynamic
profile.

SWAN-GANZ Catheters®
• The catheter is 110 cm long, marked at
increments of 10 cm and is available in sizes
7.5 fr./CCO VIP and 8 fr CCO/ SvO2 VIP

• The Swan-Ganz Swan Ganz is
“fed” through the
arrow introducer.
• Remember the
Swan-Ganz Swan Ganz needs
to be a smaller size
catheter in order to
fit through the
introducer.
Catheter

• Physicians should
check the integrity of
the balloon before
placement.
• Slowly inflate to get
wedge pressure
Balloon

Swan-Ganz CCO
Pulmonary Artery Catheter
• When used with
the Vigilance
monitors, CCO
catheters allow for
continuous
calculation and
display of cardiac
output.

What connects to what???

• Located just above
the distal tip of
catheter in the
pulmonary artery
and is used to
measure the PCWP;
it comes with a
locking guard and a
pre-calibrated 1.5ml
syringe
Balloon (wedge)

Balloon (wedge) precautions
• Do NOT use a regular
syringe as replacement
if needed
• Maximum inflation
volume only enough to
see a change
(dampened) waveform
• Maximum inflation time
is 4 – 15 seconds (until
wedge pressure is
seen).

• Distal tip of the
catheter, positioned
in the pulmonary
artery, connected to
a pressure line, &
used for monitoring
and recording PAP
and PCWP
pressures
Distal Lumen

• Located at about the
30cm mark, positioned
in the right atrium, & is
used for CVP
monitoring; it can also
be used for
administering IV fluids
injecting iced solution
for cardiac output
measurements, blood
samples; a stopcock is
usually connected to
this lumen
Proximal Injectate

Proximal Infusion (PI)
• Located lateral to
the Proximal
Injectate port at
about the 30cm
mark, positioned in
the right atrium, & is
used for
administration of IV
fluids or blood
sampling

• Located above the
Thermister and below
the 20cm area on the
catheter in the
pulmonary artery, used
to calculate and display
continuous cardiac
output (CCO) on the
monitor.
Thermal Filament

• A temperature sensor at
about 14cm mark above
the distal lumen that is
positioned in the
pulmonary artery and is
used to measure the
patient’s core blood
temperature; it is used
also in calculating a
cardiac output.
Thermister (CO)

• Accessory IV line
that is attached to
the introducer
sheath (it ( it comes
with the Arrow
Introducer Kit)
Side Port

Swan-Ganz CCOmbo Pulmonary
Artery Catheter (CCO/SvO2)
• Designed to
continuously monitor
both cardiac output and
mixed venous oxygen
saturation when used
with the Vigilance
monitors

Thermal Filament Connector
• Connect to Optical
Module for
displaying
continuous mixed
venous oxygen
saturation (SVO2)

But Wait... Could it be that simple?
NO...

In-Vitro Calibration
• Calibration procedure must be done
PRIOR to catheter preparation and
insertion for mixed venous oxygen
saturation monitoring.

In-Vivo Calibration
• Calibration procedure must be done
AFTER to catheter insertion for mixed
venous oxygen saturation monitoring
and to periodically recalibrate the
monitor.

Waveforms During Insertion
• Right Atrial Pressure (RAP)
• Normal 2-8 2 8 mmHg (mean pressure)

Waveforms During Insertion
• Right Ventricular Pressure (RVP)
• Normal 20-30/2 20 30/2-8 8 mmHg

Waveforms During Insertion
• Pulmonary Artery Pressure (PAP)
• Normal 20-30/8 20 30/8-15 15 mmHg

Waveforms During Insertion
• Pulmonary Artery Wedge Pressure
(PAWP)
• Normal 5-12 5 12 mmHg (mean pressure)

Cardiac Output

Cardiac Output
• Continuous Cardiac Output monitoring
using technology that has
thermodilution method via a modified
Edwards Swan-Ganz Swan Ganz catheter.

Insertion Documentation
• Run a continuous rhythm strip and
document the patients rhythm changes
as the catheter goes into wedge and
returns out of wedge.
• Length of insertion

Phlebostatic Axis
Leveling

Zeroing Arterial Line
• Turn stopcock off
towards the patient and
remove the dead end
cap.
• Press and hold the zero
button on the red box
and wait for the
waveform to go to zero
(0) and then flush the
line and reapply the
dead end cap.

Catheter Displacement
• The pulmonary artery catheter MUST NOT be
repositioned routinely by the Critical Care
Nurse or Critical Care Paramedic.
• When the pulmonary artery catheter is
identified in the right ventricle and
arrhythmias are present, the Critical Care
Nurse shall withdraw the catheter into the
right atrium and notify receiving facility ASAP

Cardiac Output Monitoring
• Values are
updated
approximately
every 60
seconds
depending on
the patients
condition

Wedge
CVP
Cardiac Index
Hemodynamic Profile
SVR PVR

Wedging
• When improper balloon inflation or
wedging is identified by the Critical Care
Nurse, the procedure will be
discontinued and the receiving facility
notified at an appropriate time.

Proper Wedge

Overinflation of Balloon

Cardiac Index
• More accurate measurement of the
heart’s pumping efficiency.
• CO is adjusted for the individual's body
surface area
• Normal = 2.5 – 4 lpm
• CI = CO ÷ BSA

Central Venous Pressure
• Reflects right atrial pressure which
reflects right ventricular end diastolic
pressure in the absence of tricuspid
valve disease
• Normal = 2-12 2 12 mmHg

Pulmonary Artery Diastolic
Pressure (PAD)
• Reflects the lowest pressure in the
pulmonary vasculature prior to the next
right ventricular ejection.
• Normal = 5 – 15 mmHg

Mean Pulmonary Artery Pressure
(PAM)
• Reflects the average pressure
generated in the pulmonary vasculature
throughout the cardiac cycle.
• Normal 10 – 15 mmHg

Pulmonary Artery Systolic
Pressure (PAS)
• Reflects the peak pressure generated
by the right ventricle as blood is ejected
through an open pulmonic valve into the
pulmonary arterial system
• Normal = 15 – 25 mmHg

Pulmonary Vascular Resistance
(PVR)
• The impedance or resistance met by the
right ventricle with its ejection into the
pulmonary circulation
• Normal = 37 – 250 dynes
• Mean PAP – PCWP x 80
CO

Systemic Vascular Resistance
(SVR)
• The impedance or resistance the left ventricle
must overcome for systole to occur.
Resistance to the arterial circuit – pressure
concept looks at diastolic pressure
• Normal = 800 – 1200 dynes
• MAP – CVP
CO X 80

Troubleshooting
• Check the pressure bag and line, ensure all
connections are secure.
• Solution: tighten all connections and flush in-line in line
• Check tubing for kinks, bubbles, loose connections,
etc.
• Solution: gently aspirate air from the tubing followed by an
in-line in line flush
• Check pressure scale to make sure it is correct
• Solution: adjust pressure scale
• Check to make sure you have the correct label for
that pressure line
• Solution: change the label

Troubleshooting
• Level, zero and recalibrate
• If you suspect the catheter is wedged or
against the vessel wall
• Solution: have patient turn, cough.
• Aspirate catheter if possible if a clot is suspected
• Solution: gently aspirate blood clots from the
tubing followed by a gentle in-line in line flush
• CXR to confirm suspected knots or kinks in
catheter tip
• Solution: CXR to double check and possibly
remove the catheter

Complications
• The major complications associated
with the pulmonary artery monitoring
include: pulmonary infarction, PA
rupture, pulmonary thromboembolism,
pneumothorax, balloon rupture, rhythm
disturbances.

• Causes
Pulmonary Infarction
• Catheter migration
• Overinflation of
balloon
• Prolonged wedging
• Thrombus formation
• Interventions
• Monitor continuously
• Inflate balloon only to
obtain PCWP
• Inflate balloon slow
• Do not inflate balloon
beyond capacity

PA Rupture / Balloon Rupture
• Causes
• Pulmonary
hypertension
• Catheter migration
• Overdistension of
balloon
• Improper inflation
techniques
• Interventions
• Inflate slowly
• Use correct balloon
volume
• Do not overinflate
balloon

Pulmonary Thromboembolism
• Causes
• Thrombus migration
from catheter into
pulmonary
circulation
• Intervention
• Is clotting suspected,
do not flush catheter.
• Anticoagulation therapy
may be needed if
patient is in shock,
hypercoagulable state.

• Causes
Rhythm Disturbances
• Catheter irritation of
endocardium
• Knotting
• Catheter falling back
into ventricle
• Interventions
• Monitor EKG

Removal of Catheter
• The Critical Care nurse may discontinue
a pulmonary artery catheter upon
physician's order.
• EXCEPTION: The physician will discontinue
the swan ganz catheter if the patient has a
permanent pacemaker and/or an ICD. The
RN may remove the swan ganz catheter if
the physician has removed the pacing wire
from the paceport swan.

Removal Complications
• Dysrhythmias
• Myocardial or Valvular damage
• Thrombosis
• Venous air embolism
• Pulmonary artery perforation
• Infection

References
• Headley, J. M. (2002). Invasive hemodynamic
monitoring: Physiological principles and
clinical applications. Irvine, CA: Edwards
Lifesciences.