Pulmonary artery catheter (PAC), insertion of. : Colligative - Practical Wisdom in Anesthesia, Surgery, and Medicine.

Jan 14, 2013

Indications:

For differentiation amongst the causes of shock or pulmonary edema, for estimation of severity of pulmonary hypertension, or diagnosis of a left-to-right intracardiac shunt. refl.in/86

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Mar 26, 2013

This 2005 meta-analysis suggested that there was no improvement in outcomes with the use of pulmonary artery catheters in a selection of "critically ill patients".

dx.doi.org/10.1001/jama.2...
JAMA. 2005 Oct 5;294(13):1664-70.
Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials.
Shah MR

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Jan 14, 2013

Complications, Contraindications

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An upsloping trace (first image) during diastole indicates positioning in the RV. Try either inflating the balloon to see whether it floats into the PA by itself, or inflate balloon and advance further.

The downlsloping trace (second image) is what you expect to see if the catheter tip is in the pulmomary artery.

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Jan 14, 2013

Excessively deep insertion of the pulmonary artery catheter can lead to formation of a catheter knot which will require surgical or fluoroscopic removal. refl.in/j3

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Sep 24, 2011

If resistance on withdrawing the PAC is encountered, do not apply excessive force. If it is knotted, this will tighten the knot further making it difficult for a radiologist to remove it intravascularly, leaving surgical removal as the only option.

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Sep 24, 2011

If the RV trace isn't reached by 40cm, or the PA trace reached by 50cm, deflate the balloon, withdraw to 20cm and repeat the insertion. (these distances are for insertion from the RIJ) The former probably represents coiling in the RA, the latter, coiling in the RV. Further advancement risks formation of a knot that may require fluorosopic removal.

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Sep 24, 2011

LBBB is a relative contraindication. At risk of complete heart block as 5% patients will develop transient RBBB. Keep pacing equipment nearby if this is to be performed.

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May 27, 2011

Minor complications are common, but major complications leading to morbidity or mortality are rare. Minor complications include misinterpretation of data, haematoma, transient dysrhythmia during floatation, and transient right bundle branch block. Major complications include major vessel damage, pneumothorax, knotting of the catheter, dislodgment of temporary pacing wires, pulmonary artery rupture, thrombosis, catheter related infection, and tricuspid valve injury. The following list is from the ASA Practice Guidelines for Pulmonary Artery Catheterization refl.in/j8

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Sep 24, 2011

Prior to inserting catheter, occlude the end of catheter (pulmonary artery lumen) and look for a rise in the PA pressure to ensure the distal lumen is connected to the PA transducer rather than a more proximal lumen. If it is not, you may inadvertantly advance the catheter too far.

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Sep 23, 2011

Pulmonary pseudoaneurism can rupture up to 3mths later. #ref

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May 18, 2011

The PAC may kink as it exits the introducer sheath, making an acute angle between the sheath and vessel wall. This should be suspected whenever there is a damped appearance of the pressure trace or difficulty injecting fluids or aspirating blood through one of the catheter lumens.

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Sep 24, 2011

To decrease the likelihood that you insert the catheter too far, position the end of the catheter contamination shield at the 55cm mark (eg if placing in the right IJ) as a distance reminder. #safety

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Mar 22, 2012

With patients <5'2" tall, there is an elevated risk of damage to SVC from the swan sheath dilator. Do not advance the sheath to the hilt with the dilator inside.

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(1 comment)

Dec 10, 2011

AR #MMC

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Preoperative Optimisation

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Assessment, Workup

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Consent, Discussion

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Coordinating

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Medication management, Premed

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Equipment, Preparation

Before inserting PAC into sheath, check that all lumens flush well, that the balloon inflates, stays inflated, and deflates. Following this, advance the PAC to 20cm before then inflating balloon and floating the catheter into the pulmonary artery.

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Sep 24, 2011

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Duration

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Anatomy

Distance to insert the catheter:
From the right internal jugular vein puncture site, the right atrium should be reached at 20-25 cm, the right ventricle at 30-35 cm, the pulmonary artery at 40-45 cm, and the wedge position at 45-55 cm.
When inserting from the left internal jugular or left and right external jugular veins, add an extra 5-10 cm.
Add an additional 15 cm when inserting from the femoral veins, and 30-35 cm from the antecubital veins.
From "Pulmonary artery pressure". Mark JB: Atlas of Cardiovascular Monitoring. New York, Churchill Livingstone, 1998 p27-37

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Mar 22, 2012

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IV access

Suture attached to eyelets on sheath, & anchored at insertion point at skin. Allows for a sandwich dressing underneath line.

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(1 comment)

Mar 12, 2012

BI MMC

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To float catheter, advance purposefully in smooth continuous motion. Use blood flow to guide catheter. Pausing in RV risks triggering ectopics which may interrupt flow and make passage of the balloon into the PA more difficult.

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Jun 11, 2012

Use a sandwich dressing with two adhesive dressings. This minimises the risk that top of the sheath becomes exposed with downward tension on the line.

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Jun 11, 2012

BI MMC

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Positioning, Surgical access

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Monitoring

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Special drugs

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Airway, Ventilation

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If catheter doesn't float into the pulmonary artery, roll the patient right side down 15 degrees and head up to encourage the correct passage from the RV.

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Sep 24, 2011

Air-filled balloon may hinder positioning in right sided failure. 1 mL sterile saline in balloon & with more upright position, use gravity to cause the PAC to fall into position refl.in/5s

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May 22, 2011