• Knowledge of the normal anatomy and physiology of the cardiovascular system is needed.

• Knowledge of the normal anatomy and physiology of the vasculature and adjacent structures of the neck is necessary.

• Knowledge of the principles of sterile technique is essential.

• Clinical and technical competence in central line insertion and suturing is important.

• Clinical and technical competence in pulmonary artery (PA) catheter insertion is essential. Competence in chest radiograph interpretation is needed.

• Basic dysrhythmia recognition and treatment of life-threatening dysrhythmias should be understood.

• Advanced cardiac life support knowledge and skills are needed.

• Understanding of PA pressure monitoring (see Procedure 73) is necessary.

• Hemodynamic information obtained with a PA catheter is routinely used to guide therapeutic interventions, including administration of fluids and diuretics and titration of vasoactive and inotropic medications.1–3^,10,11

• Understanding is needed of a, c, and v waves. The a wave reflects atrial contraction. The c wave reflects closure of the atrioventricular valves. The v wave reflects passive filling of the atria during ventricular systole.

• Information can be gathered regarding cardiac output (CO), cardiac index (CI), systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), stroke volume/stroke index (SV/SI), mixed venous oxygenation (SvO₂), right heart pressures (pulmonary artery pressure [PAP] and right atrial pressure [RAP]), and a reflection of left ventricular end-diastolic pressure (LVEDP) and volume (LVEDV). Also, information regarding right ventricular ejection fraction (RVEF) and end-diastolic volume (RVEDV) can be determined with certain catheters.

• CO and SvO₂ can be obtained intermittently or continuously.

• There are several types of PA catheters with different functions (e.g., pacing, mixed venous oxygenation saturation monitoring, continuous CO or right ventricular volume monitoring). Catheter selection is based on patient need.

• The PA catheter contains a proximal lumen port, a distal lumen port, a thermistor lumen port, and a balloon inflation lumen port (see Fig. 73-1). Some catheters also have additional infusion ports that can be used for the infusion of medications and intravenous fluids.

• The distal lumen port is used for monitoring systolic, diastolic, and mean pressures in the PA. The proximal lumen (or injectate) port is used for monitoring the right atrial pressure and injection of the solution used to obtain cardiac outputs. The balloon inflation lumen port is used to obtain the pulmonary artery occlusion pressure (PAOP) or pulmonary artery wedge pressure (PAWP).

• The standard 7.5F PA catheter is 110 cm long and has black markings at 10-cm increments and wide black markings at 50-cm increments to facilitate insertion and positioning (see Fig. 73-1). The catheter should reach the PA after advancing 40 to 55 cm from the internal jugular vein, 35 to 50 cm from the subclavian vein, 60 cm from the femoral vein, 70 cm from the right antecubital fossa, and 80 cm from the left antecubital fossa.

• Central venous access may be obtained in a variety of places (see Procedure 81).

• The right subclavian vein is a more direct route than the left subclavian vein for placement of a PA catheter because the catheter does not cross the midline of the thorax.^1,2,9,13

• Use of an internal jugular vein minimizes the risk for a pneumothorax. The preferred site for catheter insertion is the right internal jugular vein. The right internal jugular vein is a “straight shot” to the right atrium.¹³

• Knowledge of West’s lung zones helps attain proper placement of the PA catheter (Fig. 72-1).

• Common indications for insertion of a PA catheter include the following^{1,2,7,8,12,14,16}: