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Pulmonary Artery Catheter

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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 Catheter

• 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 Catheter

• 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.

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