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Pulmonary artery-catheter2

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  • It is difficult to measurelvvolm but lvvol correlates with the lvedp which is indirectly related to rap affected by the various factors.
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    • 1. Pulmonary artery catheter for cardiac pressure monitoring and its role in anesthetic practice Dr. Shalini Saini University College of Medical Sciences & GTB Hospital, Delhi
    • 2. Pulmonary artery catheter • Introduction • Insertion technique • Indications • Complications • Abnormal pulmonary artery and wedge pressure waveform
    • 3. Introduction • In 1970, Swan,Ganz and colleague introduced pulmonary artery catheter
    • 4. Pulmonary artery catheter • Standard : 7-9 Fr circumference • 110cm length at 10cm intervals • Four internal lumen- 1. Distal-pulmonary artery pressure monitoring 2. Proximal-30cm for CVP monitoring 3. It leads to balloon near the tip 4. It houses wires for a temperature thermistor
    • 5. Uses of pulmonary artery catheter • Assessment of volume status in patients undergoing major surgeries • Cardiac output measurement by thermodilution technique • Various hemodynamic parameters-pulmonary artery pressure, pulmonary capillary wedge presssure,CVP,systemic vascular resistance, pulmonary vascular resistance. • Respiratory or oxygen transport measurement-mixed venous oximetry.
    • 6. Insertion Sites of insertion • Right internal jugular vein (preferred) • Left internal jugular vein (2nd choice) • Subclavian vein (disadvantages) • External jugular vein ( superficial location but tortous) • Antecubital vein • Femoral vein *After successful venous cannulation, there might be difficulty in advancement of the catheter due to abnormal venous anatomy. - most common: persistence of left superior vena cava.
    • 7. RA RV PA IJV-right 20cm 30cm 45cm left 25cm 35cm 50cm Antecubital –rt 50cm 65cm 80cm -lt 55cm 70cm 85cm Femoral v 40cm 50cm 65cm Subclavian v 10cm 25cm 40cm Distances to right atrium, right ventricle and pulmonary artery
    • 8. Pressure Average (mm Hg) Range (mm Hg) Right Atrium a wave 6 2-7 v wave 5 2-7 Mean 3 1-5 Right Ventricle Peak systolic 25 15-30 End-diastolic 6 1-7 Pulmonary Artery Peak systolic 25 15-30 End-diastolic 9 4-12 Mean 15 9-19 Pulmonary Artery Wedge Mean 9 4-12 Left Atrium Mean 8 2-12 Left Ventricle Peak systolic 130 90-140 End-diastolic 8 5-12 Normal Cardiovascular Pressures
    • 9. Wave form recorded during passage of pulmonary artery catheter • Right atrial pressure resembles central venous pressure waveform • Right ventricular pressure shows higher systolic pressure • Pulmonary artery pressure shows diastolic step up • Pulmonary artery wedge pressure similar morphology as right atrial pressure but a,c v waves appear later
    • 10. Temporal relationships between systemic arterial pressure,pulmonary artery pressure, central venous pressure and pulmonary artery wedge pressure -PAP upstroke precedes radial artery pressure upstroke -Wedge pressure a wave follows ECG R wave
    • 11. Three-zone model of pulmonary vasculature -described by West and colleague -tip of PAC should lie in zone3 -supine position favours zone3 condition
    • 12. Correlations of RAP to LVEDV
    • 13. Indications 1. Patients undergoing cardiac surgery with • Poor left ventricular compliance(ejection fration <0.4, LVEDP>18mm hg) • Left wall motion abnormality • Recent MI (<6 Months) • Left main coronary lesion • Valvular lesion • Presence of pulmonary artery hypertension
    • 14. 2. Major procedures involving large fluid shifts or blood loss in patients with- • Cardiogenic or septic shock or with multiple organ failure • Hemodynamic instability requiring ionotropes or intra-aortic balloon counterpulsation • Hepatic transplantation • Massive ascites requiring major surgery • Surgery of aorta requiring cross-clamping • Large abdomino-perineal resection etc.
    • 15. 3. Intensive care unit • To measure pulmonary artery and pulmonary capillary wedge pressure • To measure cardiac output by thermodilution • To obtain intracavitary electrocardiogram • To perform atrial or ventricular pacing • To allow infusion of drugs • To perform angiography • To detect venous air embolism 4. Continous mixed venous oximetry - To assess the adequacy of perfusion
    • 16. Recommendations for perioperative use of PACs (AHA 2007 guidelines) • Class 2b-(level of evidence:B) Use of PAC is reasonable in patients at risk for major hemodynamic disturbances easily detected by PAC. However, decision must be based on three parameters- a. disease b. surgical procedure c. practice setting (Experience & interpretation) • Class 3-(level of evidence:A) Routine use of PAC perioperatively, especially low risk of hemodynamic disturbances, is not recommended.
    • 17. Pulmonary Artery Catheterisation and outcome controversies • PAC use in 5735 patients in first 24 hrs intensive care associated with increased mortality, hospital stay and cost.(Connors etal,1997) • Three trials including 3468 patients showed no effect on mortality but higher incidence of adverse effects(Harvey etal,2005; The ESCAPE Trial,2005; Sandham etal,2003) • A review of 53312 patients from National Trauma Data Bank showed -No mortality benefit in patients treated with PAC -Injury scale greater: mortality decreased(Friese etal,2006) • In mixed medical and surgical population,APACHE scores <25 -increased mortality >31 -significant benefit (Chittock etal,2004)
    • 18. • A group of experienced cardiac anesthesiologists and surgeons blinded to information from pulmonary artery catheterisation during CABG surgery were unaware of 65% of severe hemodynamic abnormalities.(Waller and Kaplan) • ICU physicians were unable to accurately predict hemodynamic data on clinical grounds and 60% made at least one change in therapy and 33% changed their diagnosis based on PAC data.(Iberti and Fisher)
    • 19. Contraindications (Kaplan) Absolute contraindications • Tricuspid or pulmonary stenosis • Right atrial or ventricular mass • Tetralogy of Fallot Relative contraindications • Severe arrhythmias • Coagulopathy • Newly inserted pacemaker wires
    • 20. Complications 1. Catheterisation a. Arrythmia-primary complication -most common premature ventricular contractions -ventricular fibrillation b. Right bundle branch block c. Complete heart block Treatment- balloon deflated and catheter withdrawn to right atrium
    • 21. 2. Catheter residence a. Catheter knotting -suspected when difficulty in withdrawing -diagnosed with chest x-ray -untied by radiologist b.Thromboembolism –rising incidence -increased with antifibrinolytic drugs c. Pulmonary infarction d. Infection ,endocarditis e. Endocardial damage, cardiac valve injury f. Thrombocytopenia (heparin induced)
    • 22. g. Pulmonary artery rupture -Incidence: 0.064%-0.20% -Increased risk: female sex, hypothermia, anticoagulation, advanced age, pulmonary hypertension, mitral stenosis, coagulopathy, distal placement catheter, balloon hyperinflation -Hallmark:hemoptysis and exsanguination -Treatment: 1. Resuscitation-adequate oxygenation and ventilation 2. If hemorrhage minimal,with coagulopathy-correct coagulopathy 3. Protection of uninvolved lung by-tilting patient to affected side, placement of double lumen endotracheal tube 4. Stop hemorrhage- apply PEEP, Bronchial blockers, resection. 5. Severe hemorrhage with recurrent bleeding-transcatheter coil embolisation.
    • 23. Abnormal pressure waveforms A. Artifact Overwedging occurs when balloon overinflated/distal migration of cathter/eccentric balloon inflation.
    • 24. B.Pathophysiologic changes 1.Mitral regurgitation -Tall v waves in waveform with bifid appearance -PAP upstroke steeper -Wedge pressure prominent v wave with gradual upstroke -Wedge pressure overestimates left ventricular filling pressure -Tall v wave:hypervolemia,CHF, VSD.
    • 25. 2.Mitral stenosis -Mean wedge pressure increased -y descent slurred due to obstruction to bloood flow -Similar abnormalities-left atrial myxoma, left ventricle infarction, pericardial constriction,aortic stenosis, systemic hypertension
    • 26. 3.Pericardial constriction -prominent a and v waves -steep x and y descent -M or W configuration in CVP trace -diastolic ‘dip and plateau’ pattern or square root sign due to early diastolic ventricular filling -mid diastolic h wave (plateau) due to interruption in flow due to restrictive shell
    • 27. 4.Myocardial ischemia • First time used in patient with acute MI. • PAP normal relatively • PAWP slightly elevated • PAWP morphology abnormal -Tall a waves due to diastolic dysfunction
    • 28. Condition Site of Discrepancy Cause of Discrepancy Positive end-expiratory pressure Mean PAWP > mean LAP Creation of lung zone 1 or 2 or pericardial pressure changes Pulmonary arterial hypertension PADP > mean PAWP Increased pulmonary vascular resistance Pulmonary veno-occlusive disease Mean PAWP > mean LAP Obstruction to flow in large pulmonary veins Mitral stenosis Mean LAP > LVEDP Obstruction to flow across the mitral valve Mitral regurgitation Mean LAP > LVEDP Retrograde systolic v wave raises mean atrial pressure Ventricular septal defect Mean LAP > LVEDP Antegrade systolic v wave raises mean atrial pressure Tachycardia PADP > mean LAP > LVEDP Short diastole creates pulmonary vascular and mitral valve gradients Overestimation of Left Ventricular End-Diastolic Pressure
    • 29. Condition Site of Discrepacy Cause of Discrepancy Diastolic dysfunction Mean LAP < LVEDP Increased end-diastolic a wave Aortic regurgitation LAP a wave < LVEDP Mitral valve closure before end-diastole Pulmonic regurgitation PADP < LVEDP Bidirectional runoff for pulmonary artery flow Right bundle branch block PADP < LVEDP Delayed pulmonic valve opening After pneumonectomy PAWP < LAP or LVEDP Obstruction of pulmonary blood flow Underestimation of Left Ventricular End-Diastolic Pressure
    • 30. Additional uses of pulmonary artery catheter 1. Thermodilution cardiac output monitoring • Principle: Stewart-Hamilton equation Q = V(Tb-Ti)K1.K2 Tb(t)dt Q = Cardiac output V = Injectate volume Tb = Blood temperature Ti = Injectate temperature K1 = Density factor: (sp heat)(sp gravity)injectate (sp heat)(sp gravity)blood K2 = A computation constant which includes heat change in transit,dead space of the catheter,injection rate, adjusts units to l/min Tb(t)dt = change in blood temperature as a function of time
    • 31. 2. Mixed venous oximetry Svo2 = Sao2- Vo2 / Q×1.36×Hb Svo2 = mixed venous hemoglobin saturation(%) Sao2 = arterial hemoglobin saturation(%) Vo2 = oxygen consumption(ml/min) Q = Cardiac output (l/min) Hb = hemoglobin concentration(g/dl) * Mixed venous hemoglobin saturation determined by sampling from PAC either intermittently or continous
    • 32. 3. Right Ventricular Ejection Fraction RVEDV = SV/RVEF RVEDV = Right ventricular end diastolic volume (ml) SV = Stroke volume RVEF = Right ventricular ejection fraction 4. Derived Hemodynamic Variables SVR = MAP-CVP × 80 CO PVR = MPAP-PAWP×80 CO SVR = systemic vascular resistance PVR = pulmonary vascular resistance MAP = mean arterial pressure CVP = central venous pressure MPAP = mean pulmonary artery pressure PAWP = pulmonary artery wedge pressure CO = cardiac output
    • 33. References • Ronald.D.Miller: Pulmonary artery catheter monitoring. Cardiovascular monitoring 7th ed:1297-1314. • Kaplan: Anesthesia techniques for cardiac surgical procedures;399-408. • Circulation. 2007;116:e418-e500 • Blitt: Monitoring. Pulmonary artery cathterisation;221-263.
    • 34. Thank you

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