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Pulmonary Artery Catheter
R.Srihari
• Introduction
• Physiologic Measurements
• Indications
• Contraindications
• Preparation
• Technique
• Interpretation of ...
Introduction
• Pulmonary artery catheters (also called as
Swan-Ganz catheter) are used for evaluation
of a range of condit...
Physiological Measurements
• Direct measurements of the following can be
obtained from an accurately placed pulmonary
arte...
• Indirect measurements that are possible:
– Systemic Vascular Resistance
– Pulmonary Vascular Resistance
– Cardiac Index
...
Indications
• Diagnostic:
– Differentiation among causes of shock
– Differentiation between mechanisms of
pulmonary edema
...
• Therapeutic:
– Management of perioperative patients with unstable
cardiac status
– Management of complicated myocardial ...
Contraindications
• Absolute:
• Infection at insertion
site
• Presence of RV assist
device
• Insertion during CPB
• Lack o...
Making decision to place pulmonary
artery catheter
• In critically ill or perioperative patients
decision to place a pulmo...
Preparation
• Patient has to be monitored with continuous
ECG throughout the procedure, in supine
position regardless of t...
• Equipments:
– 2% chlorhexidine skin preparation solution
– Sterile gown, gloves, face shield and cap
– Sterile gauze pad...
Technique
1. Aseptic precautions undertaken
2. Local infiltration done
3. Check balloon integrity by inflating with 1.5ml ...
9. Once tip of catheter passed through
introducer sheath inflate balloon at level of
right ventricle
10. The progress of ...
• Important tip:
– When advancing catheter- always inflate tip
– When withdrawing catheter- always deflate
– Once in pulmo...
Interpretation of hemodynamic values
and waveforms
• Ensuring accurate measurements:
– Zeroing and Referencing
– Correct p...
• Zeroing and Referencing:
– PAC must be appropriately zeroed and referenced
to obtain accurate readings  in supine
posit...
• Rapid flush test:
Catheter waveforms and pressures
• Pressure waveforms can be obtained from
– Right atrium
– Right ventricle
– Pulmonary ar...
• Right atrium:
– In presence of a a competent tricuspid valve, RA
pressure waveform reflect both
• Venous return to RA du...
• Elevated RA pressure:
– Diseases of RV( infarction/ cardiomyopathy)
– Pulmonary hypertension
– Pulmonic stenosis
– Left ...
• Differentiating among etiologies depends on
– Clinical
– Radiographical
– Echocardiographic features
+
PAC findings
Eg: ...
• Abnormal RA waveforms:
– Tall v waves: Tricuspid Regurgitation
– Giant/ cannon a waves:
• Ventricular tachycardia
• Vent...
• Right Ventricle:
– Transitioning from SVC or RA to RV:
• Once balloon is inflated in the SVC/RA  the catheter is
slowly...
• 2 pressures are typically measured in right
ventricular pressure waveform
– Peak RV systolic pressure  15-25mmHg
– Peak...
• As a general rule  elevations in RV pressure:
– Diseases increasing pulmonary artery pressure
– Pulmonic valve disorder...
• Pulmonary artery:
– The risk of arrhythmias is greatest while catheter
tip is in RV
Thus, catheter should be advanced fr...
• Normal pulmonary artery pressures:
– Systolic  15-25mmHg
– Diastolic  8-15 mmHg
– Mean  16 (10-22mmHg)
• Main compone...
• Increase in mean pulmonary pressure:
– Acute:
• Venous Thromboembolism
• Hypoxemia induced Pulmonary Vasoconstriction
– ...
• Types of PHT:
– Primary
– Due to Heart Disease
– Due to Lung Disease
– Due to chronic venous thromboembolism
– Miscellan...
Pulmonary arterial occlusion pressure
• Once catheter tip has reached PA, it should be
advanced until PAOP is identified b...
• Final position of the catheter within PA must
be such that PCOP tracing is obtained
whenever 75-100% of 1.5ml maximum
vo...
• PCWP/PAOP  interprets Left atrial pressures
more importantly – LVEDP
– Best measured in
• Supine position
• At end of e...
• Abnormal PAOP:
– Increased LVEDP  Increased PAOP
• LV systolic HF
• LV Distolic HF
• Mitral and Aortic valve disease
• ...
• Decreased PCWP:
– Hypovolemia
– Obstructive shock due to large pulmonary embolus
• Abnormal waveforms
– Large a waves:
•...
• Calculation of cardiac output:
– 2 methods
• Thermodilution method
• Fick’s Method
– Better measurement with Cardiac ind...
• Decreased CO:
– Systolic HF
– Diastolic HF
– MR
– Hypovolemia
– Pulmonary HT
– RVF
• Increased CO:
– Systemic A-V fistul...
• Other uses of pulmonary artery catheter:
– Detection of Left to right shunts
– Estimation of systemic and pulmonary vasc...
Complications
• General:
– Immediate:
• Bleeding
• Arterial Puncture
• Air embolism
• Thoracic duct injury ( L side)
• Pne...
• Related to insertion of PAC:
– Arrhythmias (most common- Ventricular/ RBBB)
– Misplacement
– Knotting
– Myocardial/valve...
Thank You
Pulmonary artery catheter
Pulmonary artery catheter
Pulmonary artery catheter
Pulmonary artery catheter
Pulmonary artery catheter
Pulmonary artery catheter
Pulmonary artery catheter
Pulmonary artery catheter
Pulmonary artery catheter
Pulmonary artery catheter
Pulmonary artery catheter
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Pulmonary artery catheter

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

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Pulmonary artery catheter

  1. 1. Pulmonary Artery Catheter R.Srihari
  2. 2. • Introduction • Physiologic Measurements • Indications • Contraindications • Preparation • Technique • Interpretation of hemodynamic values and waveforms • Complications
  3. 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. 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. 5. • Indirect measurements that are possible: – Systemic Vascular Resistance – Pulmonary Vascular Resistance – Cardiac Index – Stroke volume index – Oxygen delivery – Oxygen uptake
  6. 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. 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. 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. 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. 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. 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. 12. Technique 1. Aseptic precautions undertaken 2. Local infiltration done 3. Check balloon integrity by inflating with 1.5ml of air 4. Check lumens patency by flushing with saline 0.9% 5. Cover catheter with sterile sleeve provided 6. Cannulate vein with Seldinger technique 7. Place sheath 8. Pass catheter through sheath with tip curved towards the heart
  13. 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. 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. 15. Interpretation of hemodynamic values and waveforms • Ensuring accurate measurements: – Zeroing and Referencing – Correct placement – Fast flush test
  16. 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. 17. • Rapid flush test:
  18. 18. Catheter waveforms and pressures • Pressure waveforms can be obtained from – Right atrium – Right ventricle – Pulmonary artery
  19. 19. • Right atrium: – In presence of a a competent tricuspid valve, RA pressure waveform reflect both • Venous return to RA during ventricular systole • RV End Diastolic Pressure – Normal RA pressure: 0-7 mmHg
  20. 20. • Elevated RA pressure: – Diseases of RV( infarction/ cardiomyopathy) – Pulmonary hypertension – Pulmonic stenosis – Left to right shunts – Pericardial diseases – LV systolic failure – Hypervolemia
  21. 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. 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. 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. 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. 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. 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. 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. 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. 29. • Types of PHT: – Primary – Due to Heart Disease – Due to Lung Disease – Due to chronic venous thromboembolism – Miscellaneous ( Sickle Cell Anemia)
  30. 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. 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. 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. 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. 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. 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. 36. • Decreased CO: – Systolic HF – Diastolic HF – MR – Hypovolemia – Pulmonary HT – RVF • Increased CO: – Systemic A-V fistulas – Anemia – Beriberi – Renal Disease – Sepsis
  37. 37. • Other uses of pulmonary artery catheter: – Detection of Left to right shunts – Estimation of systemic and pulmonary vascular resistance
  38. 38. Complications • General: – Immediate: • Bleeding • Arterial Puncture • Air embolism • Thoracic duct injury ( L side) • Pneumothorax/hemothorax – Delayed: • Infections • Thrombosis
  39. 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. 40. Thank You

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