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

1. Pulmonary Artery Catheter
R.Srihari

2. • Introduction
• Physiologic Measurements
• Indications
• Contraindications
• Preparation
• Technique
• Interpretation of hemodynamic values and
waveforms
• Complications

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. 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. • Indirect measurements that are possible:
– Systemic Vascular Resistance
– Pulmonary Vascular Resistance
– Cardiac Index
– Stroke volume index
– Oxygen delivery
– Oxygen uptake

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. • 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. 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. 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. 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. • 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

14. 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

15. 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

18. • 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

19. Interpretation of hemodynamic values
and waveforms
• Ensuring accurate measurements:
– Zeroing and Referencing
– Correct placement
– Fast flush test

20. • 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

21. • Rapid flush test:

22. Catheter waveforms and pressures
• Pressure waveforms can be obtained from
– Right atrium
– Right ventricle
– Pulmonary artery

23. • 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

25. • Elevated RA pressure:
– Diseases of RV( infarction/ cardiomyopathy)
– Pulmonary hypertension
– Pulmonic stenosis
– Left to right shunts
– Pericardial diseases
– LV systolic failure
– Hypervolemia

26. • 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

27. • 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

30. • 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

31. • 2 pressures are typically measured in right
ventricular pressure waveform
– Peak RV systolic pressure  15-25mmHg
– Peak RV diastolic pressure  3-12 mmHg

33. • 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

34. • 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

35. • 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)

37. • 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

38. • Types of PHT:
– Primary
– Due to Heart Disease
– Due to Lung Disease
– Due to chronic venous thromboembolism
– Miscellaneous ( Sickle Cell Anemia)

39. 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

40. • 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

41. • 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

44. • 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

45. • 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

46. • Calculation of cardiac output:
– 2 methods
• Thermodilution method
• Fick’s Method
– Better measurement with Cardiac index
• Normal – 2.8- 4.2 l/min/m2

47. • Decreased CO:
– Systolic HF
– Diastolic HF
– MR
– Hypovolemia
– Pulmonary HT
– RVF
• Increased CO:
– Systemic A-V fistulas
– Anemia
– Beriberi
– Renal Disease
– Sepsis

48. • Other uses of pulmonary artery catheter:
– Detection of Left to right shunts
– Estimation of systemic and pulmonary vascular
resistance

49. Complications
• General:
– Immediate:
• Bleeding
• Arterial Puncture
• Air embolism
• Thoracic duct injury ( L side)
• Pneumothorax/hemothorax
– Delayed:
• Infections
• Thrombosis

50. • 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

51. Thank You