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J Anaesth Clin Pharmacol 2006; 22(4) : 335-345 335

REVIEW

Swan-Ganz Catheter in Hemodynamic Monitoring


Lailu Mathews, R. K. Kalyan Singh

ABSTRACT
Swan, Ganz and colleagues introduced pulmonary artery catheterization for hemodynamic monitoring
into clinical practice in 1970. The pulmonary artery catheter, also known as Swan Ganz catheter, allowed
accurate measurement of important cardiovascular physiological variables at the bedside and became
increasingly popular as they were used in critically ill patients. Proper use of Swan Ganz catheter discloses a
wide range of pertinent cardiovascular data that cannot be predicted from standard clinical signs and
symptoms. The present article deals with the physiologic basis for pulmonary artery pressure monitoring,
method of catheterization, clinical applications and complications associated with Swan Ganz catheter use. In
addition to pressure monitoring the basis of intermittent cardiac output monitoring using Swan Ganz catheter,
namely, indicator dilution, thermodilution, Fick's method, and continuous cardiac output monitoring are
discussed. The article also describes the monitoring of right ventricle using Swan Ganz catheter equipped
with a rapid response thermistor and electrodes for intracardiac ECG recording, and measurement of mixed
venous oxygen saturation using Swan Ganz catheter incorporated with fiber-optic bundles. The controversies
regarding the use of Swan Ganz catheter, including the evidence for and against is also dealt with.

KEYWORDS : Catheter : Swan Ganz, Monitoring : Hemodynamic

Hemodynamics is defined as the study behind the as global or regional perfusion that is not adequate to
forces involved in blood circulation. Hemodynamic support normal organ function. This definition recognizes
monitoring started with the estimation of heart rate the anesthesiologist's or the intensivist's obligation to
using the simple skill of 'finger on the pulse' and then ensure adequate organ perfusion during the perioperative
moved on to more and more sophisticated techniques period. The two variables that most directly reflect
like stethoscope, sphygmomanometer, ECG etc. The organ perfusion are blood pressure and cardiac output
hemodynamic status of critically ill patients can be which are intimately intertwined. Because of limits on
assessed either from non-invasive single parameter coronary and cerebral auto-regulation, hypotension may
indicators or various invasive techniques that provide compromise adequate perfusion of the brain and heart.
multi-parameter hemodynamic measurements. As a
The basic tenet of hemodynamic monitoring is the
result, comprehensive data can be provided for the
control of adequate oxygen delivery to tissues. The
clinician to proactively address hemodynamic crisis and
primary physiologic response to an increased demand
safely manage the patient instead of reacting to late
in tissue oxygen or to a reduced content in arterial
indicators of hemodynamic instability. Because of the
oxygen is to increase cardiac output. However, most
risks and costs associated with invasive monitoring
cardiovascular disorders limit the heart's ability to
techniques, a large fraction of high-risk patients are
respond to those needs. As a result, tissues rely on a
left underserved.1 Hemodynamic instability is defined

Drs. Lailu Mathews, Associate Professor, Department of Anesthesiology and Critical Care, R. K. Kalyan
Singh, Senior Consultant, Anesthesiologist and Medical Superintendent, Pondicherry Institute of Medical
Sciences, Pondicherry, India.
Correspondence : Lailu Mathews
MATHEWS L; ET AL: SWAN-GANZ CATHETER : HEMODYNAMIC MONITORING 336

place an enormous burden on all hospital services


especially intensive care. Although the exact
pathophysiology of multiple organ dysfunction syndrome
is not yet definitely known, alterations in systemic
hemodynamics, organ perfusion and tissue
microcirculation resulting in tissue hypoxia appear to
play a key role in the onset and maintenance of this
syndrome. Introduction of hemodynamic monitoring had
a revolutionary impact on evaluation and management
of critically ill. However, optimal monitoring of the
critically ill patient remains a challenge. Controversy
continues as to whether the patient will benefit from a
more aggressive monitoring.2
Cardiac filling pressures are monitored to estimate
Figure-1 cardiac filling volumes, which, in turn, determine the
Typical waveform progression as the PAC floats through stroke outputs of the left and right ventricles. According
the cardiac chambers. Monitoring these waveforms tells to Frank-Starling principle, the force of cardiac
the anesthesiologists where in the heart the catheter is as
contraction is directly proportional to end-diastolic muscle
it advances
fibre length at any given level of intrinsic contractility
second compensatory mechanism by drawing on the or inotropy.3,4 This muscle fibre length or preload is
venous oxygen reserve. Consequently, when the tissue proportional to end-diastolic chamber volume. Cardiac
oxygen supply becomes inadequate, even for brief filling pressures are measured directly from a number
episodes, lactic acidosis and tissue damage may arise. of sites in the vascular system.
The primary objective in the management of critically
ill patients is to prevent such tissue hypoxia. Pulmonary Artery Pressure Monitoring
While an adequate blood pressure may ensure Swan, Ganz and colleagues introduced pulmonary
adequate coronary and cerebral perfusion, it does not artery catheterization (PAC) for hemodynamic
ensure renal and mesenteric perfusion. While a good monitoring into clinical practice in 1970 using the balloon-
cardiac output cannot assure us that the kidneys and tipped, flow-directed, pulmonary artery catheter.5
lungs are being perfused, it certainly seems evident
that a poor cardiac output will put renal and mesenteric
perfusion in jeopardy. Inadequate mesenteric perfusion
with breakdown of gut endothelium may allow
translocation of bacteria, initiating gram negative sepsis.
It is prudent to look at multiple indicators of adequate
perfusion, such as cardiac output, mixed venous oxygen
saturation and lactate concentration.
Indications of hemodynamic monitoring are
decreased cardiac output due to dehydration,
hemorrhage, gastro-intestinal bleed, burns, all types of
shock - hypovolemic, septic, cardiogenic, neurogenic,
anaphylactic, any deficit or loss of cardiac function as
in acute myocardial infarction, cardiomyopathy,
congestive cardiac failure. Multiple organ dysfunction Figure-2
syndrome accounts for most deaths in the intensive Physiologic lung zones. For pulmonary capillary wedge
care units. Patients who develop these complications pressure to be reliable, the catheter tip must lie in zone 3.
J Anaesth Clin Pharmacol 2006; 22(4) : 335-345 337

Despite its widespread use, no formally reviewed thermistor, approximately 4 cm proximal to the balloon.
recommendations exist for its general use. Many This thermistor is used to monitor pulmonary artery
publications present only individual authors' suggestions blood temperature as part of the thermo dilution method
for indications and contraindications to the use of the for cardiac output monitoring. Some catheters are coated
Swan Ganz catheter (SGC). However, the American with heparin to reduce thrombogenicity and have
College of Cardiology has developed a consensus connections for temporary ventricular pacing.
statement regarding its use. Indications are broadly
The SGC is inserted percutaneously in a major
classified as diagnostic and therapeutic. The diagnostic
vein (internal jugular, subclavian) via an introducer
indications are: shock states, differentiation of high
sheath. After inserting the SGC as far as the 20 cm
versus low pressure pulmonary edema, primary
mark, the balloon is inflated with air. Inflation should be
pulmonary hypertension, valvular disease, intracardiac
slow and controlled and should not surpass the
shunts, cardiac tamponade, and pulmonary embolus,
recommended volume (1.5 cc). Always inflate the
monitoring and management of complicated acute
balloon before advancing the SGC and always deflate
myocardial infarction, assessing hemodynamic response
the balloon before withdrawing the SGC. Use continuous
to therapies, management of multiorgan failure, severe
pressure monitoring from the distal lumen. Watch the
burns, and hemodynamic instability after cardiac surgery,
monitor for changes in the waveform and abnormal
assessment of response to treatment in patients with
cardiac rhythm. When the catheter is inserted through
primary pulmonary hypertension. The therapeutic
either the subclavian or the internal jugular vein, the
indication is aspiration of air emboli. PAC is
typical distances required are as follows: right atrium
contraindicated in patients with tricuspid or pulmonary
20 to 25 cm, right ventricle 30 to 35 cm, pulmonary
valve mechanical prosthesis, right heart mass (thrombus,
artery 40 to 45 cm and pulmonary capillary wedge 45
tumor) and tricuspid or pulmonary valve endocarditis.
to 55 cm. As the balloon floatation catheter is advanced
PAC is performed to measure hemodynamic through the heart, characteristic pressure waveforms
variables like PAP, pulmonary artery wedge pressure are obtained that indicate the position of the catheter's
(PAWP), mixed venous oxygen saturation and cardiac distal port7 (Figure-1). Simultaneous ECG monitoring is
output in critically ill patients, and oxygen saturation in essential to ensure that ventricular arrhythmias are
the right heart chambers to assess the presence of an detected as the catheter traverses the right ventricle.
intracardiac shunt. The pressure measurements are used When a pulmonary artery catheter floats to the wedge
to estimate left ventricular filling pressure (LVP) and position, the inflated balloon at its tip isolates the distal
help guide fluid and vasoactive drug administration when pressure monitoring from upstream PAP. Blood flow
clinical signs, symptoms or other monitored variables
are felt to be inadequate or unreliable.6 Using these
measurements, other variables can be derived, including
pulmonary or systemic vascular resistance and the
difference between arterial and venous oxygen content.
The standard pulmonary artery catheter has 7.0,
7.5 or 8.0 French circumferences. It is a multilumen
catheter, 110 cm in length, marked at 10 cm intervals,
with extra connecting tubes for attachment to the
pressure transducer. One lumen leads to the distal port
of the catheter tip and is used for PAP monitoring. The
second leads to a proximal port, located approximately
30 cm from the catheter tip and is used for CVP
monitoring as well as intravenous fluid and drug
administration. The third leads to a 1.5 cc balloon near Figure-3.
the catheter tip and the fourth has a temperature A normal thermodilution curve
MATHEWS L; ET AL: SWAN-GANZ CATHETER : HEMODYNAMIC MONITORING 338

Table 1
Normal Values of Hemodynamic Parameters

Right atrial pressure Mean 0 to 6 mm Hg


Right ventricular pressure Systolic 15 to 30 mm Hg
End-diastolic 1 to 7 mm Hg
Pulmonary artery pressure Systolic 15 to 30 mm Hg
End-diastolic 4 to 12 mm Hg
Mean 9 to 19 mm Hg
Pulmonary artery wedge pressure Mean 4 to 12 mm Hg
Arterial pressure (intra-arterial) Peak systolic 90 to 140 mm Hg
End-diastolic 60 to 90 mm Hg
Mean 70 to 105mm Hg

ceases between the catheter tip and a junction point little relation to the downstream pulmonary venous
where pulmonary veins draining the occluded pulmonary pressure or left ventricular filling pressure. Under these
vascular region join other veins in which blood still circumstances, alveolar or airway pressures are being
flows towards the left atrium. A continuous static monitored rather than the intended vascular pressure in
column of blood now connects the wedged pulmonary the left atrium or ventricle. In general, zones 1 and 2
artery catheter tip to this junction point in the pulmonary become more extensive when LAP is low, when the
veins near the left atrium. Thus wedging the pulmonary pulmonary artery catheter tip is vertically above the
artery catheter functionally extends the catheter tip to left atrium or when the alveolar pressure is high. Only
measure the pressure at the point at which blood flow in zone 3 is there an uninterrupted column of blood
resumes on the venous side of the pulmonary circuit.8 between the catheter and the left atrium.3 Decreased
Because resistance to flow in the large pulmonary veins airway pressures change the ventilation-perfusion
is negative, PAWP provides an accurate, indirect relationship, producing a relative increase in zone 3.
measurement of both pulmonary venous pressure and Indicators of proper tip placement include a decline in
LAP.3,9,10 Once PAWP is obtained and the catheter pressure as the catheter moves from the pulmonary
sleeve secured, make sure the PAWP pattern is artery into the wedged position, ability to aspirate blood
reproducible before removing the sterile field. Also, from the distal port, and a decline in end-tidal CO2
determine the volume of air in the balloon required to concentration with inflation of the balloon (produced by
obtain a PAWP waveform. Volume less than half the a rise in alveolar dead space).
balloon maximum may indicate that the tip is far too
The PAWP estimates left ventricular end diastolic
distal. When the procedure is complete, obtain a chest
pressure and thus serves as an estimate of left
x-ray to check the position of the SGC and to assess
ventricular preload. Because the pulmonary vasculature
for central venous access complications like
forms a low resistance circuit, the pulmonary end
pneumothorax.
diastolic pressure is only 1 to 3 mmHg higher than the
The final position of the catheter tip within the mean PAWP and can be used to estimate left ventricular
pulmonary artery is critical. This may be described pressure when the PAWP is not available-in the absence
with reference to the physiological model of the of severe lung disease.12 Pulmonary capillary filtration
pulmonary vasculature, which is divided into three zones pressure (Pcap) is a measure of the potential difference
based on the gravitationally determined relation between that drives fluid from the pulmonary vasculature to the
PAP, pulmonary venous pressure (Pv) and alveolar perivascular interstitial and alveolar spaces. The equation
pressure (PA)11 as shown in Figure-2. relating mean PAP, PAWP and Pcap is
A pulmonary artery catheter positioned in zone 1 Pcap = PAWP + 0.4 x (PAP- PAWP ) (1)
and 2 will be influenced by alveolar pressure and bear
Acute respiratory distress syndrome widens the
J Anaesth Clin Pharmacol 2006; 22(4) : 335-345 339

PAP to PAWP gradient and increases Pcap, contributing impaired throughout diastole, causing equalization of all
to pulmonary edema.12 Correlation between CVP and diastolic pressures. The RAP approximates the RV
PAWP may be poor in critically ill patients with diastolic pressure, which approximates the PA diastolic
cardiopulmonary disease because of differences pressure and also approximates PAWP.
between right and left ventricular function. PAWP
Other cardiac abnormalities that can be evaluated
correlates best with LAP when the latter is less than
during hemodynamic monitoring using SGC are
25 mm Hg. When LAP increases to more than 25 mm
constrictive pericarditis, mitral stenosis, aortic stenosis
Hg that may occur after acute myocardial infarction-
and aortic regurgitation.
PAWP tends to underestimate left ventricular end-
diastolic pressure (LVEDP). As left ventricular function Constrictive pericarditis can occur in patients with
deteriorates, the contribution that atrial contraction rheumatic diseases, tuberculosis, metastatic cancer, prior
makes to left ventricular filling is increased, and LVEDP chest radiation or open heart surgery. PAWP may be
can be significantly higher than PAWP. High positive as high as 20-25 mm Hg and appears similar to the RA
airway pressures (PEEP more than 15 mmHg) result waveform.
in pulmonary vascular collapse, causing PAWP to
reflect airway pressure instead of LAP.11 The normal In severe mitral stenosis, LAP, and thus PAWP, is
pressure values are given in Table 1. elevated. Pulmonary hypertension also develops as the
severity of the valve lesion progresses. This leads to
increase in RV systolic pressure and in the RA A wave.
Clinical applications of SGC
RV diastolic pressure may increase if RV failure or
SGC is used frequently in the management of tricuspid regurgitation develops. Atrial fibrillation is a
various forms of shock like hypovolemic, cardiogenic, common complication in mitral stenosis and results in
septic and obstructive. The changes that occur in the loss of A waves in both the RA and PAWP tracings.
pressure values measured using SGC are characteristic
of each form of shock. In aortic stenosis the RA, RV, and PA wave forms
are usually normal unless congestive heart failure is
Hypovolemic shock is due to a reduction in present. PAWP may show large A waves in severe
circulating blood volume resulting from either cases because of poor LV compliance.
hemorrhage or fluid depletion. Preload is markedly
decreased, leading to inadequate ventricular filling. The In acute aortic regurgitation there is modestly
overall SGC pressure tracing has a damped appearance. elevated RAP, elevated RV systolic and diastolic
pressures, PA systolic and diastolic pressures, and
Cardiogenic shock is characterized by systolic PAWP.
blood pressure less than 80 mm Hg, cardiac index less
than 1.8 L/min./m2 and PAWP greater than 18 mm Cardiac output monitoring
Hg. This form of shock occurs in acute myocardial
infarction, severe cardiomyopathy, acute severe mitral Apart from its pressure monitoring capabilities,
regurgitation and acute ventricular septal defect. undoubtedly the most important feature of PAC is its
ability to measure cardiac output using the thermodilution
Septic shock is characterized profoundly by method. Cardiac output is the primary compensatory
peripheral vasodilatation. Although the cardiac output mechanism that responds to an oxygenation challenge.
may be normal or elevated in septic shock, organ and It is thus a clinical parameter ensuring the adequacy of
tissue perfusion are inadequate. SGC measurements tissue oxygenation. It provides a global assessment of
demonstrate low filling pressures in this condition. the circulation including the neurohumoral influences
on it. Cardiac output is the product of stroke volume
Extracardiac obstructive shock occurs in cardiac
and heart rate. Stroke volume is determined by preload
tamponade, massive pulmonary embolism and tension
that is the left ventricular end-diastolic volume,
pneumothorax. The increased pericardial pressure
myocardial contractility and afterload that is the
impairs ventricular diastolic filling, decreasing preload,
resistance against which the left ventricle ejects. Cardiac
stroke volume and cardiac output. Ventricular filling is
MATHEWS L; ET AL: SWAN-GANZ CATHETER : HEMODYNAMIC MONITORING 340

output measurements are combined with other


hemodynamic measurements to calculate systemic and
pulmonary vascular resistance.

Thermodilution
The thermodilution technique has become the
defacto clinical standard for cardiac output
determination. This technique relies on principle similar
to indicator dilution but uses heat instead of colour as
an indicator. A pulmonary artery catheter with multiple
ports is advanced into the pulmonary artery. Ice cold
saline bolus of known volume (5 - 10 ml) is injected
through the proximal (RA) lumen and a thermistor at
the end of the SGC measures the change in blood
temperature as a function of time. The temperature -
time curve (Figure-3) so obtained allows calculation of Figure-4
blood flow. This method is simpler and its accuracy is Right Ventricle thermodilution curve (the circles indicate
reasonable. It requires an SGC. The area under the the temperature plateau which occur with each beat of
time - temperature difference curve is inversely the heart. The ratio of successive plateau is used to
proportional to cardiac output. A high cardiac output calculate RVEF)
will have a small area under the curve. This is due to constant blood volume, absence of recirculation and
the rapid blood flow through the heart. In low cardiac constant indicator distribution time. Therefore cardiac
output the opposite is true. Cardiac output is calculated out put measurement using thermodilution techniques is
using the modified Stewart-Hamilton indicator dilution not the recommended method for any patient with
equation: intracardiac shunt. Right-to-left shunt will result in loss
of the indicator, resulting in a falsely elevated cardiac
output. Left-to-right shunts permit recirculation of
indicator that has already passed through the lungs
giving rise to multiple peaks in the time - temperature
curve. When tricuspid regurgitation occurs, blood and
indicator mix, resulting in prolongation of transit time.
The curve obtained will have a slow upstroke and decay
resulting in increased area under the curve. This leads
to under estimation of the true cardiac output.

where VI is the volume injectate (ml) and TB, TI, Continuous Cardiac Output Monitoring
SB, SI, CB, CI, are temperature, specific gravity, The usefulness of cardiac output monitoring has
specific heat of blood (B) and indicator (I) respectively. now been further enhanced by the recent development
Either iced or room temperature thermal boluses can of reliable continuous cardiac output monitoring devices.
be used although the use of iced fluid improves the These methods utilize electrical impulses to generate
signal - to - noise ratio. For best results the difference heat in coils mounted on the right atrial portion of the
between the temperatures of the blood and that of the pulmonary artery catheter. Multiple small heat signals
injectate should be at least 120C. Bolus injection speed are generated that result in a corresponding pattern of
and warming of the indicator as it passes through the changes in pulmonary arterial blood temperature,
catheter have only minimal effects.13,14 Thermo dilution measured by the pulmonary arterial thermistor. Utilizing
techniques have the requirement of stable blood flow, computer algorithms, the monitoring devices are
J Anaesth Clin Pharmacol 2006; 22(4) : 335-345 341

programmed to analyze these patterns of temperature Cardiac index = Cardiac output / Body
to calculate a cardiac out put value, which reflects the surface area
average cardiac output for the previous 3 - 5 minutes.
Systemic vascular = [(Mean arterial pressure -
The continuous data may be coupled with arterial and
resistance CVP)/Cardiac output] x 80
mixed venous oximetry to provide continuous data
reflecting oxygen delivery and oxygen consumption. Pulmonary = [(PAP - PAWP) / Cardiac
vascular resistance output] x 80
Fick's Cardiac Output Measurement
Stroke volume = Stroke volume / body surface
This is a form of indicator dilution method in which index area
exogenous indicators are not required but, instead
transported oxygen serves this purpose. The Right ventricular = 0.0136 (PAP - CVP) x Stroke
conventional Fick method is based on the principle that stroke-work index volume index
O2 consumption is proportional to the rate of blood Left ventricular = 0.0136 x (Mean arterial
pumped by the heart through the lungs, and monitoring stroke-work index pressure - PAWP) x Stroke
gas exchange and invasively sampling blood gases can volume index
measure it. Cardiac output may be calculated by relating
oxygen consumption to arterial and mixed venous Monitoring of right ventricle
oxygen content using the equation The focus of interest in hemodynamic
monitoring has been on the dominant left side of the
heart. The tendency to overlook the right ventricle as
an important part of the circulatory system occurred
because it was traditionally regarded as a passive
VO2 is the oxygen consumption, CaO2 is oxygen conduit, responsible for accepting venous blood and
content of arterial blood and CvO2 is oxygen content pumping it through the pulmonary circulation to the left
of mixed venous blood.15 Calculation of cardiac output ventricle. 16 Maintenance of normal circulatory
using Fick's equation is a reference with which all homeostasis depends on an adequate function of both
other techniques are compared. The arterio-venous ventricles. Changes in dimension and performance of
oxygen content difference requires that a pulmonary one ventricle influences the geometry of the other. There
artery catheter be placed to obtain mixed venous blood. is growing interest in the importance of the neglected
Oxygen consumption is calculated by measuring the right side of the heart, particularly in patients suffering
oxygen content difference between inspired and exhaled from sepsis and acute respiratory distress syndrome,
gas. A disadvantage of Fick's method is that the patient and in heart-transplanted patients.17 CVP, right atrial
must remain in a stable metabolic state, outside the pressure or right ventricular pressure have been
sphere of sudden intervening variables like shivering, demonstrated to be invalid for judging right ventricular
pain, extreme emotional stress etc. Such variables can function or right ventricular loading conditions. 18
affect oxygen consumption and arterial and mixed Hoffmann et al.19 demonstrated no correlation between
venous oxygen content, thereby, interfering with an CVP and right ventricular end-diastolic volume
accurate reflection of cardiac output. Though it is not a (RVEDV) and they emphasized that the preload factor
practical bedside method, it is the most accurate method in the original Frank-Starling hypothesis had nothing to
available to evaluate patients with low cardiac output. do with pressure but concerned volume.19
The introduction of rapid response time thermistors
Derived Parameters into clinical practice led to the development of thermal
Cardiac output measurements may be combined dilution techniques for the estimation of right ventricular
with systemic arterial, venous, and PAP determinations end-diastolic volume (RVEDV), end-systolic volume
to calculate a number of variables useful in assessing (RVESV) and ejection fraction (RVEF). The method
the overall hemodynamic status of the patient. They are, is based on the observation that if a thermal indicator is
MATHEWS L; ET AL: SWAN-GANZ CATHETER : HEMODYNAMIC MONITORING 342

introduced into the ventricle during the diastolic interval, intermittently or continuously using PA catheter. A
then fractional washout of the indicator occurs in a specially designed PA catheter can provide SvO2 reliably
stepwise fashion with each subsequent beat of the heart. and continuously. Fiberoptic bundles incorporated into
This thermal washout could be detected as a series of the PA catheter determine the oxygen saturation in the
temperature plateau in the main pulmonary artery pulmonary artery blood based on the principles of
(Figure-4). Each plateau reflects the intraventricular reflectance oximetry. A special computer connected to
temperature during the previous beat of the heart. The this PA catheter displays SvO2 continuously and allows
ratio between the temperature changes of two standard cardiac output measurements. Blood in the
successive plateaus can be used to calculate RVEDV pulmonary artery is normally unoxygenated, having not
when suitable correction factors are applied. yet traveled through the lungs, with a saturation of 60 -
80%. SvO2 is clinically important as a function of supply
In intraoperative and critical care environments,
and demand; how much oxygen is being extracted from
based on the above principle, specially designed PAC
the blood by the organs, before this blood is returned to
offers a method for measurement of RVEF and
the right heart. SvO2, therefore, serves us in evaluating
evaluation of right ventricular function.20,21 In this
the supply and demand of oxygen to the tissues.28 It is
technique, the SGC equipped with a rapid response
influenced by oxygen delivery (hemoglobin, SaO2,
thermistor and electrodes for intracardiac ECG
CO) as well as oxygen consumption (VO2) and is
recording, detects and quantifies changes in pulmonary
expressed as :
artery blood temperature with each heart beat down
the thermodilution exponential curve.20,22 A temperature SvO2 = SaO2 - [VO2 / (1.36 x Hb x CO)] (6)
plateau is observed with each diastole. The ratio
To the extent that arterial oxygen saturation, oxygen
between the temperature changes of two successive
consumption and hemoglobin remain stable, mixed
plateaus represents the fraction of blood remaining in
venous oxygen saturation may be used as an indirect
the right ventricle (residual fraction RF). A
indicator of cardiac output. When cardiac output falls,
microprocessor calculates this residual fraction. RVEF
tissue oxygen extraction increases and the mixed venous
is calculated as 1 minus average residual fraction.
blood will become more desaturated. As shown in the
Clinical use of the RVEF PAC has the greatest equation, an increase in VO2 and a decrease in Hb,
application in critically ill patients, especially in those CO and arterial oxygenation will result in a decrease in
with respiratory failure.23-27 The right ventricular end SvO2.
diastolic volume (RVEDV) correlates better with
cardiac output than standard preload measurements, Complications
such as CVP or PAWP.23,25,26 RVEDV is calculated Complications associated with SGC use relate to
using the formula, the initial venous access, insertion of the SGC and
RVEDV = Stroke Volume / RVEF (5) maintenance of the catheter in the PA. Significant
venous access complications include inadvertent arterial
and right ventricular end-systolic volume is the puncture, pneumothorax and hemothorax. Complications
difference between RVEDV and stroke volume. associated with insertion of SGC are arrhythmias like
Further development of computer techniques allow premature ventricular contractions, nonsustained
continuous monitoring of right ventricular ventricular tachycardia, ventricular fibrillation or right
hemodynamics. However, no large clinical trials are bundle branch block. Those associated with
available showing a beneficial impact of RVEF maintenance of catheter in the PA are pulmonary artery
monitoring on patient outcome.17 rupture which is the most catastrophic, pulmonary
infarction, air embolism, venous thrombosis, pulmonary
Mixed venous oxygen saturation (SvO2) embolism, cardiac tamponade from perforation of
superior venacava, right atrial, or right ventricle, infection
Mixed venous oxygen saturation, or the saturation and mechanical problems like catheter coiling or knotting,
of the blood in the pulmonary artery, can be measured catheter tip migration, balloon rupture.6,29-34
J Anaesth Clin Pharmacol 2006; 22(4) : 335-345 343

Controversies is essential to minimize potential deleterious effects and


Hemodynamic monitoring using SGC has been the maximize potential benefits. The malfunctioning monitor
gold standard for evaluation of circulatory function for and the wrongly trained intensivist may be a great risk
several years. The controversy regarding the use of for the patient! Nevertheless, in the critically ill ICU
SGC on the outcome of critically ill patients still patients there is a need for something more than the
continues.35,36 In the study by Connors et al37 a higher senses to monitor the patients hemodynamics, although
mortality rate was reported in patients in whom SGC some opponents of invasive hemodynamic monitoring
was inserted than in those managed without SGC. wish to turn back the clock to the old days of a "finger
However, the study was retrospective and not on the pulse".2 The properly trained intensivist is a
randomized. In a medline based meta-analysis38 a conditio sine qua non for managing the critically ill.
significant reduction in mortality was reported when
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