Pulmonary Artery Catheter

1. Pulmonary Artery Catheter Marie Sankaran Raval M.D. Boston Medical Center Department of Anesthesiology

2. Pulmonary Artery Catheter • What is a pulmonary artery catheter? • Pulmonary Artery Catheterization • Indications • Hemodynamic Parameters • Oxygen Transport Parameters • Benefits • Complications • ASA Guidelines for PA catheterization

3. What is a pulmonary artery catheter (PAC) ?

4. Invented in 1970 by Swan, Ganz and colleagues for hemodynamic assessment of patients with acute myocardial infarction. Standard PAC is 7.0, 7.5 or 8.0 French in circumference and 110 cm in length divided in 10 cm intervals Pulmonary Artery Catheter

5. Pulmonary Artery Catheter • The standard PAC 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of the balloon • a long plastic sheath that is used to maintain sterility of the PAC as it is advanced and withdrawn

6. Pulmonary Artery Catheter • PAC has 4-5 lumens: • Temperature thermistor located proximal to balloon to measure pulmonary artery blood temperature • 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

7. Pulmonary Artery Catheterization • A large-bore introducer catheter is used to facilitate PAC insertion • Inserted through the subclavian or internal jugular vein with the patient in Trendelenburg • Prior to PAC insertion, • Connect the distal port (yellow) to the pressure transducer • Level the transducer at the level of the patient’s heart • Zero the transducer

8. Pulmonary Artery Catheterization • Continuous pressure monitoring during PAC insertion is required to determine location of the catheter tip. • Inflate the balloon when the 20cm mark is at the hub of the introducer. • Advance the PAC until the pulmonary capillary wedge pressure (PCWP) is obtained, usually around 45-55cm at the hub.

9. Pulmonary Artery Catheterization

10. Pulmonary Artery Catheterization PAC as seen on chest x-ray

11. Indications • Assess volume status • Assess RV or LV failure • Assess Pulmonary Hypertension • Assess Valvular disease • Cardiac Surgery

12. Hemodynamic Parameters

13. Hemodynamic Parameters - Measured • Central Venous Pressure (CVP) • recorded from proximal port of PAC in the superior vena cava or right atrium • CVP = RAP • CVP = right ventricular end diastolic pressure (RVEDP) when no obstruction exists between atrium and ventricle • Pulmonary Artery Pressure (PAP) • measured at the tip of the PAC with balloon deflated • reflects RV function, pulmonary vascular resistance and LA filling pressures • Pulmonary Capillary Wedge Pressure (PCWP) • recorded from the tip of the PAC catheter with the balloon inflated • PCWP = LAP = LVEDP (when no obstruction exists between atrium and ventricle) • Cardiac Output (CO) • Calculated using the thermodilution technique • thermistor at the distal end of PAC records change in temperature of blood flowing in the pulmonary artery when the blood temperature is reduced by injecting a volume of cold fluid through PAC into the RA

14. Hemodynamic Parameters - Derived • Cardiac Index (CI) = CO/BSA • Stroke Volume Index (SVI) = CI/HR • Systemic Vascular Resistance (SVR) • reflects impedance of the systemic vascular tree • SVR = 80 x (MAP – CVP) / CO • Pulmonary Vascular Resistance (PVR) • reflects impedance of pulmonary circuit • PVR = 80 x (PAM – PCWP) / CO • Left ventricular stroke work index (LVSWI) = (MAP – PCWP) x SVI x 0.136 • Right ventricular stroke work index (RVSWI) = (PAM – CVP) x SVI x 0.136

15. Oxygen Transport Parameters • Oxygen Delivery (DO2) • Rate of oxygen delivery in arterial blood DO2 = CI x 13.4 x Hgb x SaO2 • Mixed Venous Oxygen Saturation (SVO2) • Oxygen saturation in pulmonary artery blood • Used to detect impaired tissue oxygenation • Oxygen uptake (VO2) • Rate of oxygen taken up from the systemic microcirculation VO2 = CI x 13.4 x Hgb x (SaO2 - SVO2)

16. PAC Benefits • Effect on Treatment Decisions: information gathered from PA catheter data can beneficially change therapy • Preoperative Catheterization: information gathered prior to surgery can lead to cancellation or modification of surgical procedure, thereby preventing morbidity and mortality • Perioperative Monitoring: provides invasive hemodynamic monitoring in the surgical setting

17. PAC Complications • Establishment of central venous access • Accidental puncture of adjacent arteries • Bleeding • Neuropathy • Air embolism • Pneumothorax

18. PAC Complications • Pulmonary artery catheterization • Dysrhythmias • Premature ventricular and atrial contractions • Ventricular tachycardia or fibrillation • Right Bundle Branch Block (RBBB) • In patients with preexistinh LBBB, can lead to complete heart block. • Minor increase in tricuspid regurgitation

19. PAC Complications • Pulmonary catheter residence • Thromboembolism • Mechanical, catheter knots • Pulmonary Infarction • Infection, Endocarditis • Endocardial damage, cardiac valve injury • Pulmonary Artery Rupture • 0.03-0.2% incidence, 41-70% mortality

20. ASA Practice Guidelines for Pulmonary Artery Catheterization (2003) • Appropriateness of PA catheterization depends on the risks associated with the: • (a) Patient: Are there presexisting medical conditions that may increase the risk of hemodynamic instability? • (b) Surgery: Is the procedure associated with significant hemodynamic fluctuations which may cause end organ damage? • (c) Practice setting: Could the complications associated with hemodynamic disturbance be worsened if the technical or cognitive skills of the physicians or nurses caring for the patient are poor?

21. ASA Practice Guidelines for Pulmonary Artery Catheterization (2003) • According to the Task Force on Pulmonary Artery Catheterization, PAC monitoring was deemed appropriate and/or necessary in the following patient groups: • 1) surgical patients undergoing procedures associated with a high risk of complications from hemodynamic changes • 2) surgical patients with advanced cardiopulmonary disease who would be at increased risk for adverse Perioperative events

22. A Randomized, Controlled Trial of the Use of Pulmonary-Artery Catheters in High-RiskSandham et al • Randomized control trial comparing goal directed therapy guided by PAC with standard care without PAC • Patient population: high-risk patients >60 years old with ASA classification III/IV, scheduled for urgent or elective major surgery • Results • Conclusions: No benefit to goal directed therapy by PAC over standard care in elderly, high risk surgery patients