Bedside Pulmonary Artery Catheterization

Published on 22/03/2015 by admin

Filed under Critical Care Medicine

Last modified 22/03/2015

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W5 Bedside Pulmonary Artery Catheterization

Jean-Louis Vincent

image Before Procedure

Indications

• Need for continuous monitoring of pulmonary artery and right atrial (RA) pressures, cardiac output, and mixed venous oxygen saturation (SvO2) providing that:

• The data collected will help in the management of the patient
• The same measurements cannot be obtained by a less invasive method

Contraindications

• Absolute contraindications:

• Tricuspid or pulmonary valve endocarditis

• Relative contraindications:

• Tricuspid or pulmonary valve mechanical prosthesis
• Right heart mass (thrombus and/or tumor)
• Complete left bundle branch block
• Severe clotting abnormalities

Equipment

• Sterile gowns, gloves, and masks
• 8F to 9F gauge introducer
• Sterile saline solution for flushing
• Volume-limited syringe for pulmonary artery catheter (PAC) balloon
• Pressure monitor transduction system and connector tubing

image Anatomy

The inflated balloon of the PAC facilitates the catheter progression through a branch of the pulmonary artery. The distal lumen of the PAC measures the pressure downstream. It is assumed that there is a continuous column of blood between the distal lumen and the left ventricle (LV), and therefore the balloon-occluded pressure (PAOP) is equal to left ventricular end-diastolic pressure (LVEDP). PAOP reflects the pressure where the nonflowing blood (in the obstructed vessel) joins the blood flowing from the nonoccluded branches of the pulmonary artery. PAOP is actually intermediate between pulmonary capillary pressure and left atrial (LA) pressure. There are conditions, however, in which this theoretical continuous column of blood is interrupted, and in these circumstances PAOP no longer reflects LVEDP.

image Procedure

• Check the patient’s electrocardiogram (ECG), coagulation profile, and serum electrolytes panel. One should consider correcting major clotting disorders. If the patient already has a pacemaker, it may be better to place the catheter under radiographic guidance to avoid dislodging it.
• Inflate the catheter balloon as a test prior to catheter insertion.
• Connect the distal lumen to the pressure-monitoring system, and flush all lumens with sterile saline solution.
• Zero-reference the pressure transducer to the mid-chest position.
• Slide the protective sleeve onto the catheter to maintain sterility for further manipulations.
• Place sterile field.
• Provide local anesthesia.
• Insert introducer into a central vein, preferably the internal jugular or subclavian, using the Seldinger technique.
• Pass the catheter through the hemostatic valve of the introducer.
• Inflate the balloon once the catheter tip has passed about 15 cm.
• Advance the catheter for another 15 cm. It should pass into the right ventricle (RV) and give an RV pressure waveform.
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