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Pulmonary Artery

Catheterization
PulmCrit.com

Pulmonary Artery Catheter History


In 1929, Dr. Warner Forssmann introduced a
catheter into his right atrium
Drs Andre Cournand & Dickinson Richards developed
catheters that could be advanced into the pulmonary
arteries a
Drs Forssmann, Cournand, and Richards shared the
1956 Nobel Prize in medicine for these discoveries

Pulmonary Artery Catheter History


Pulmonary Artery Catheter (PAC) aka Swan
Ganz catheter first described in 1970 NEJM
Initially used for management of acute MIs

Catheterization of the Heart in Man with Use


of a Flow-Directed Balloon-Tipped Catheter
H. J. C. Swan, M.B., Ph.D., F.R.C.P., William Ganz, M.D., C.Sc., James Forrester, M.D., Harold Marcus, M.D., George Diamond, M.D., and David Chonette
N Engl J Med 1970; 283:447-451August 27, 1970DOI: 10.1056/NEJM197008272830902

From the Department of Cardiology, Cedars-Sinai Medical Center and the Department of Medicine, University of California, Los Angeles

What Dr. Swan & Dr. Ganz did


Inserted a 5 French double lumen balloon
catheter into the RA
The baloon was inflated with 0.8cc of air
Carried by blood flow to the right ventricle
and PA
When in smaller branches of PA, baloon
inflated fully and wedge obtained

Indications: When to use PACs?


Not indicated as routine pulmonary artery catheterization in highrisk cardiac and noncardiac patients
Indicated in patients with cardiogenic shock during supportive therapy
Indicated in patients with discordant right and left ventricular failure
Indicated in patients with severe chronic heart failure requiring inotropic,
vasopressor, and vasodilator therapy
Indicated in patients with suspected pseudosepsis (high cardiac output,
low systemic vascular resistance, elevated right atrial and pulmonary
capillary wedge pressures)
Indicated in some patients with potentially reversible systolic heart failure
such as fulminant myocarditis and peripartum cardiomyopathy
Indicated for the hemodynamic differential diagnosis of pulmonary
hypertension
Indicated to assess response to therapy in patients with precapillary and
mixed types of pulmonary hypertension
Indicated for the transplantation workup
Table. Current Indications for Use of the Swan-Ganz Catheter

Circulation January 6/13, 2009 vol. 119 no. 1147-152

PAC seen on X-Ray

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

Contraindications for PACs


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)

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

Right heart catherization waveforms

Normal Values for Cardiac Index and Related Measurements


Measurement

Units SD

O2 uptake

143 14.3 mL/min/m 2

Arteriovenous O2difference

4.1 0.6 dL

Cardiac index

3.5 0.7 L/min/m 2

Stroke index

46 8.1 mL/beat/m2

Total systemic resistance

1130 178 dynes-sec-cm-5

Total pulmonary resistance

205 51 dynes-sec-cm -5

Pulmonary arteriolar resistance

67 23 dynes-sec-cm -5

SD = standard deviation.

Calculated VS Measured values


Measured values
Q: 4-8L/min
CI: 2.5-4L/min
CVP: 2-6mmHg
PAWP: 8-12mmHg
PAP: 25/10mmHg
SvO2: 0.65-0.70
Temperature
Derived values use of formula: Q = MAP-CVP/SVR
SV: 50-100mL/beat
SVI: 25-45mL/beat/m2
SVR: 900-1300 dynes-sec/cm5
SVRI: 1900-2400 dyne-sec/cm5
PVR: 40-150 dyne-sec/cm5
PVRI: 120-200 dynes-sec/cm5

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

Cardiac output and temperature


curves
Minimum 3 measurements with 15% difference
between

Controversies in PAC use


In 1980s, 20-40% of critically ill patients had PACs
1996, Connors published prospective Observation study: increased
30 d mortality (OR 1.24), increased cost.
2003: Sandham RCT surg pts to usual care vs PAC - more PEs in
PAC
2005: ESCAPE Trial: In patients with HF, PAC use doesnt increase
6 month mortality or LOS. More adverse effects associated with
PAC
2006: Cochrane meta-analysis of PACs in ICUs - 5686 pts - 13 RCT
- no diff in mortality, LOS, but increased cost in PAC group

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

Diagnosing patients with PH


Managing perioperative patients
Intracardiac shunts
Amniotic fluid embolism

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