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Catheterization
PulmCrit.com
From the Department of Cardiology, Cedars-Sinai Medical Center and the Department of Medicine, University of California, Los Angeles
Contraindications
Tricuspid or pulmonary valve prosthesis which
can be damaged
Tricuspid or pulmonary valve vegetations which
can be dislodged
Endocarditis in general
Right heart mass (be it tumor or clot)
The PA Catheter
Usually a 4 lumen catheter 110cm lung with a pressure
transducer:
A temperature thermistor located proximal to balloon
to measure pulmonary artery blood temperature
A proximal port located 30 cm from tip for CVP
monitoring, fluid and drug administration
Distal port at catheter tip for PAP monitoring
+/- Variable infusion port (VIP) for fluid and drug
administration
Balloon at catheter tip
The PA Catheter
Standard PAC is 7.0, 7.5 or 8.0 French in circumference and 110
cm in length divided in 10 cm intervals
The kit includes a syringe that can be filled with only 1.5 mL of air
to prevent overinflation of the balloon
A long plastic sheath that is used to maintain sterility of the PAC as
it is advanced and withdrawn
Cordis/Introducer should be placed prior
Steps to catherization
1. Place Cordis in IJ/Subclavian
2. Connect the distal yellow port to pressure
transducer - continuous monitoring
3. Level the transducer at patients heart level and
zero
4. Insert PAC and when at 20cm mark, inflate the
baloon
5. Advance PAC following waveforms until it wedges
(usually 45-60 cm*) *unless really big heart
Units SD
O2 uptake
Arteriovenous O2difference
4.1 0.6 dL
Cardiac index
Stroke index
46 8.1 mL/beat/m2
205 51 dynes-sec-cm -5
67 23 dynes-sec-cm -5
SD = standard deviation.
Complications of PACs
Arrhythmias
Thrombosis and hemorrhage along the path of the PAC
Intracardiac knotting of catheter
Pulmonary hemorrhage
Infection - CLABSI
IJ/Subclavian stenosis
Distal migration of PAC Pulmonary Infarction
Pulmonary artery rupture
Right sides Endocarditis
RBBB (careful if pre-exisiting LBBB)
Air embolism
Stewart-Hamilton Equation
A bolus of 5-10ml cold 5% dextrose into the right
atrium should decrease the temperature in the
pulmonary artery.
The rate of blood flow is inversely proportional to the
change in temperature over time
Thus, the mean decrease in temperature is inversely
proportional to the cardiac output.
The Stewart-Hamilton Equation describes this
relationship
Thermodilution SH equation
Limitations of Thermodilution
Although thermodilution is Gold standard:
PAC thermo method underestimates CO
Unreliable for changes in CO less than 25-30% (fluid
responsiveness defined as 15% change in SV)
Spontaneous vs Mechanical ventilation affects CO - SV
varies as much as 50%
Unreliable in Tricuspid Regurgitation and arrythmias)
better in transpulmonary thermodilution - longer
transit time
Role of PAC
References
1. Anna Gawlinski,
Measuring Cardiac Output: Intermittent Bolus Thermodilution Method Crit Care
Nurse 2004;24:74-78
2. Toshiaki Nishikawa, Shuji Dohi
Errors in the measurement of cardiac output by thermodilutionCanadian
Journal of Anaesthesia February 1993, Volume 40, Issue 2, pp 142-153