Pulmonary Artery Pulmonary Artery CatheterCatheter

Marie Sankaran Raval M.D.Marie Sankaran Raval M.D.Boston Medical CenterBoston Medical Center

Department of AnesthesiologyDepartment of Anesthesiology

Pulmonary Artery CatheterPulmonary Artery Catheter What is a pulmonary artery catheter? What is a pulmonary artery catheter? Pulmonary Artery CatheterizationPulmonary Artery Catheterization IndicationsIndications Hemodynamic ParametersHemodynamic Parameters Oxygen Transport ParametersOxygen Transport Parameters BenefitsBenefits ComplicationsComplications ASA Guidelines for PA catheterizationASA Guidelines for PA catheterization

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

Pulmonary Artery CatheterPulmonary Artery Catheter

Invented in 1970 by Swan, Invented in 1970 by Swan, Ganz and colleagues for Ganz and colleagues for hemodynamic assessment hemodynamic assessment of patients with acute of patients with acute myocardial infarction.myocardial infarction.

Standard PAC is 7.0, 7.5 or Standard PAC is 7.0, 7.5 or 8.0 French in 8.0 French in circumference and 110 cm circumference and 110 cm in length divided in 10 cm in length divided in 10 cm intervalsintervals

Pulmonary Artery CatheterPulmonary Artery Catheter The standard PAC kit The standard PAC kit

includes:includes:

– a syringe that can be a syringe that can be filled with only 1.5 mL filled with only 1.5 mL of air to prevent of air to prevent overinflation of the overinflation of the balloonballoon

– a long plastic sheath a long plastic sheath that is used to maintain that is used to maintain sterility of the PAC as it sterility of the PAC as it is advanced and is advanced and withdrawnwithdrawn

Pulmonary Artery CatheterPulmonary Artery Catheter PAC has 4-5 lumens:PAC has 4-5 lumens:

– Temperature thermistor located Temperature thermistor located proximal to balloon to measure proximal to balloon to measure pulmonary artery blood pulmonary artery blood temperaturetemperature

– Proximal port located 30 cm from Proximal port located 30 cm from tip for CVP monitoring, fluid and tip for CVP monitoring, fluid and drug administrationdrug administration

– Distal port at catheter tip for PAP Distal port at catheter tip for PAP monitoringmonitoring

– +/- Variable infusion port (VIP) +/- Variable infusion port (VIP) for fluid and drug administrationfor fluid and drug administration

– Balloon at catheter tip Balloon at catheter tip

Pulmonary Artery CatheterizationPulmonary Artery Catheterization A large-bore introducer A large-bore introducer

catheter is used to catheter is used to facilitate PAC insertionfacilitate PAC insertion

Inserted through the Inserted through the subclavian or internal subclavian or internal jugular vein with the jugular vein with the patient in Trendelenburg patient in Trendelenburg

Prior to PAC insertion, Prior to PAC insertion, – Connect the distal port Connect the distal port

(yellow) to the pressure (yellow) to the pressure transducer transducer

– Level the transducer at Level the transducer at the level of the patient’s the level of the patient’s heart heart

– Zero the transducerZero the transducer

Pulmonary Artery CatheterizationPulmonary Artery Catheterization Continuous pressure Continuous pressure

monitoring during PAC monitoring during PAC insertion is required to insertion is required to determine location of the determine location of the catheter tip.catheter tip.

Inflate the balloon when Inflate the balloon when the 20cm mark is at the the 20cm mark is at the hub of the introducer.hub of the introducer.

Advance the PAC until the Advance the PAC until the pulmonary capillary pulmonary capillary wedge pressure (PCWP) is wedge pressure (PCWP) is obtained, usually around obtained, usually around 45-55cm at the hub.45-55cm at the hub.

Pulmonary Artery CatheterizationPulmonary Artery Catheterization

Pulmonary Artery CatheterizationPulmonary Artery Catheterization

PAC as seen on chest x-ray PAC as seen on chest x-ray

IndicationsIndications Assess volume statusAssess volume status Assess RV or LV failureAssess RV or LV failure Assess Pulmonary HypertensionAssess Pulmonary Hypertension Assess Valvular diseaseAssess Valvular disease Cardiac SurgeryCardiac Surgery

Hemodynamic ParametersHemodynamic Parameters

Hemodynamic Parameters - Hemodynamic Parameters - MeasuredMeasured

Central Venous Pressure (CVP)Central Venous Pressure (CVP)– recorded from proximal port of PAC in the superior vena cava or right atriumrecorded from proximal port of PAC in the superior vena cava or right atrium– CVP = RAPCVP = RAP– CVP = right ventricular end diastolic pressure (RVEDP) when no obstruction CVP = right ventricular end diastolic pressure (RVEDP) when no obstruction

exists between atrium and ventricleexists between atrium and ventricle

Pulmonary Artery Pressure (PAP)Pulmonary Artery Pressure (PAP) – measured at the tip of the PAC with balloon deflatedmeasured at the tip of the PAC with balloon deflated– reflects RV function, pulmonary vascular resistance and LA filling pressuresreflects RV function, pulmonary vascular resistance and LA filling pressures

Pulmonary Capillary Wedge Pressure (PCWP)Pulmonary Capillary Wedge Pressure (PCWP) – recorded from the tip of the PAC catheter with the balloon inflatedrecorded from the tip of the PAC catheter with the balloon inflated– PCWP = LAP = LVEDP (when no obstruction exists between atrium and PCWP = LAP = LVEDP (when no obstruction exists between atrium and

ventricle)ventricle)

Cardiac Output (CO)Cardiac Output (CO) – Calculated using the thermodilution techniqueCalculated using the thermodilution technique– thermistor at the distal end of PAC records change in temperature of blood 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 flowing in the pulmonary artery when the blood temperature is reduced by injecting a volume of cold fluid through PAC into the RAinjecting a volume of cold fluid through PAC into the RA

Hemodynamic Parameters - Hemodynamic Parameters - DerivedDerived

Cardiac Index (CI) = CO/BSACardiac Index (CI) = CO/BSA

Stroke Volume Index (SVI) = CI/HRStroke Volume Index (SVI) = CI/HR

Systemic Vascular Resistance (SVR)Systemic Vascular Resistance (SVR)– reflects impedance of the systemic vascular treereflects impedance of the systemic vascular tree– SVR = 80 x (MAP – CVP) / COSVR = 80 x (MAP – CVP) / CO

Pulmonary Vascular Resistance (PVR)Pulmonary Vascular Resistance (PVR)– reflects impedance of pulmonary circuitreflects impedance of pulmonary circuit– PVR = 80 x (PAM – PCWP) / COPVR = 80 x (PAM – PCWP) / CO

Left ventricular stroke work index (LVSWI)Left ventricular stroke work index (LVSWI)= (MAP – PCWP) x SVI x 0.136= (MAP – PCWP) x SVI x 0.136

Right ventricular stroke work index (RVSWI)Right ventricular stroke work index (RVSWI)= (PAM – CVP) x SVI x 0.136= (PAM – CVP) x SVI x 0.136

Oxygen Transport ParametersOxygen Transport Parameters Oxygen Delivery (DOOxygen Delivery (DO22))

– Rate of oxygen delivery in arterial bloodRate of oxygen delivery in arterial bloodDODO22 = CI x 13.4 x Hgb x S = CI x 13.4 x Hgb x SaO2aO2

Mixed Venous Oxygen Saturation (SMixed Venous Oxygen Saturation (SVO2VO2))– Oxygen saturation in pulmonary artery bloodOxygen saturation in pulmonary artery blood– Used to detect impaired tissue oxygenationUsed to detect impaired tissue oxygenation

Oxygen uptake (VOOxygen uptake (VO22))– Rate of oxygen taken up from the systemic Rate of oxygen taken up from the systemic

microcirculationmicrocirculation VOVO2 2 = CI x 13.4 x Hgb x (S= CI x 13.4 x Hgb x (SaO2aO2 - S - SVO2VO2))

PAC BenefitsPAC Benefits Effect on Treatment DecisionsEffect on Treatment Decisions: information : information

gathered from PA catheter data can gathered from PA catheter data can beneficially change therapybeneficially change therapy

Preoperative CatheterizationPreoperative Catheterization: information : information gathered prior to surgery can lead to gathered prior to surgery can lead to cancellation or modification of surgical cancellation or modification of surgical procedure, thereby preventing morbidity and procedure, thereby preventing morbidity and mortalitymortality

Perioperative MonitoringPerioperative Monitoring: provides invasive : provides invasive hemodynamic monitoring in the surgical hemodynamic monitoring in the surgical settingsetting

PAC ComplicationsPAC Complications Establishment of central venous Establishment of central venous

accessaccess

– Accidental puncture of adjacent arteriesAccidental puncture of adjacent arteries– BleedingBleeding– NeuropathyNeuropathy– Air embolismAir embolism– PneumothoraxPneumothorax

PAC ComplicationsPAC Complications Pulmonary artery catheterizationPulmonary artery catheterization

– DysrhythmiasDysrhythmias Premature ventricular and atrial contractionsPremature ventricular and atrial contractions Ventricular tachycardia or fibrillationVentricular tachycardia or fibrillation

– Right Bundle Branch Block (RBBB)Right Bundle Branch Block (RBBB) In patients with preexistinh LBBB, can lead In patients with preexistinh LBBB, can lead

to complete heart block.to complete heart block.

– Minor increase in tricuspid regurgitationMinor increase in tricuspid regurgitation

PAC ComplicationsPAC Complications Pulmonary catheter residencePulmonary catheter residence

– ThromboembolismThromboembolism– Mechanical, catheter knotsMechanical, catheter knots– Pulmonary InfarctionPulmonary Infarction– Infection, EndocarditisInfection, Endocarditis– Endocardial damage, cardiac valve injuryEndocardial damage, cardiac valve injury– Pulmonary Artery Rupture Pulmonary Artery Rupture

0.03-0.2% incidence, 41-70% mortality0.03-0.2% incidence, 41-70% mortality

ASA Practice Guidelines for Pulmonary ASA Practice Guidelines for Pulmonary Artery Catheterization (2003)Artery Catheterization (2003)

AAppropriateness of PA catheterization depends on the ppropriateness of PA catheterization depends on the risks associated with the: risks associated with the:

– (a) (a) PatientPatient: Are there presexisting medical conditions : Are there presexisting medical conditions that may increase the risk of hemodynamic instability?that may increase the risk of hemodynamic instability?

– (b) (b) SurgerySurgery: Is the procedure associated with significant : Is the procedure associated with significant hemodynamic fluctuations which may cause end organ hemodynamic fluctuations which may cause end organ damage?damage?

– (c) (c) Practice settingPractice setting: Could the complications associated : Could the complications associated with hemodynamic disturbance be worsened if the with hemodynamic disturbance be worsened if the technical or cognitive skills of the physicians or nurses technical or cognitive skills of the physicians or nurses caring for the patient are poor?caring for the patient are poor?

ASA Practice Guidelines for Pulmonary ASA Practice Guidelines for Pulmonary Artery Catheterization (2003)Artery Catheterization (2003)

According to the Task Force on Pulmonary According to the Task Force on Pulmonary Artery Catheterization, PAC monitoring was Artery Catheterization, PAC monitoring was deemed appropriate and/or necessary in the deemed appropriate and/or necessary in the following patient groups:following patient groups:

– 1) surgical patients undergoing procedures 1) surgical patients undergoing procedures associated with a high risk of complications associated with a high risk of complications from hemodynamic changesfrom hemodynamic changes

– 2) surgical patients with advanced 2) surgical patients with advanced cardiopulmonary disease who would be at cardiopulmonary disease who would be at increased risk for adverse Perioperative eventsincreased risk for adverse Perioperative events

A Randomized, Controlled Trial of the Use of A Randomized, Controlled Trial of the Use of Pulmonary-Artery Catheters in High-RiskPulmonary-Artery Catheters in High-Risk

Sandham et alSandham et al Randomized control trial comparing goal directed therapy Randomized control trial comparing goal directed therapy

guided by PAC with standard care without PACguided by PAC with standard care without PAC Patient population: high-risk patients >60 years old with Patient population: high-risk patients >60 years old with

ASA classification III/IV, scheduled for urgent or elective ASA classification III/IV, scheduled for urgent or elective major surgerymajor surgery

ResultsResults

Conclusions: No benefit to goal directed therapy by PAC Conclusions: No benefit to goal directed therapy by PAC over standard care in elderly, high risk surgery patientsover standard care in elderly, high risk surgery patients

PAC groupPAC group Standard care Standard care GroupGroup

DeathDeath 7.8%7.8% 7.7%7.7%Pulmonary Pulmonary EmbolismEmbolism

88 00

6 month Survival6 month Survival 87.4%87.4% 88.1%88.1%12 month Survival12 month Survival 83.0%83.0% 83.9%83.9%