II. Pulmonary Artery Pressure Monitoring Flashcards by B C

The PA catheter is also known as a:

Swan-Ganz catheter

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The Swan PA catheter is used as a ____ procedure to assess critically ill patients

Diagnostic

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The PA catheter is most commonly inserted through the ____ vein.

Right internal jugular

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The PA catheter is ultimately placed into the ____ in order to estimate____.

Pulmonary artery
Left ventricular, preload and functions

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Capabilities of the PA catheter include:

Measures right heart filling pressures
Estimates left heart preload and function
Estimates cardiac output (themodilution)
Evaluates, heart valves, shunts and pulmonary vascular resistance

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Pulmonary catheter, wedge pressure (PCWP) is correlated with ____.

Left ventricular End diastolic pressure (LVEDP)

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LVEDP gives an estimation of ____.

LV preload & function

not always a direct indicator, but a reasonable estimation

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4 Major indications for pulmonary arterial catheters:

Cardiac disease.
Pulmonary disease.
Complex fluid management/hemodynamic instability
Specific surgeries.

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What are a few specific surgeries that are indications for PAC?

Aortic cross clamping.
Hepatic or heart transplantation.
CABG

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Absolute contraindications for PAC:

Right atrial or right ventricular mass.
Tricuspid or pulmonary stenosis.
Mechanical tricuspid, pulmonary valve prosthesis

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Relative contraindications for PAC:

Recently placed pacemaker or defibrillator wires (w/i 6 weeks)
Left bundle branch block (risk of complete AV block)
Severe coagulopathy.
Significant thrombocytopenia.
Infection at cannulation site.

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What is the most common complication of PAC insertion?

Arrhythmia

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Induced right bundle branch block can cause:

Complete AV block if left bundle branch block is present

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What may the PA catheter become entangled with?

Chordae Tendineae

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A heparin coated catheter may be used to decrease risk of thrombosis. How long is this effective for?

Up to 72 hours

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What two factors can precipitate pulmonary infarction pertaining to a PA catheter?

Distal placement.
Prolonged balloon inflation.

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What is the mortality rate associated with pulmonary artery rupture?

41 to 70%

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What are the risk factors associated with pulmonary artery rupture?

Hypothermia.
Old age.
Cardio pulmonary bypass
Pulmonary hypertension.
Female.
Anticoagulation.

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The standard pulmonary artery catheter is what size and length?

7.5 Fr

110 cm

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What is the maximum balloon volume for a PAC?

1.5cc

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what is the incident of pulmonary artery rupture when placing PACs?

0.03-1.5%

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What is the most common number of ports on a PA catheter?

Five

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What portion of the PA catheter allows us to transduce the pressures (PA & Wedge) as the catheter is floated through the heart?

Distal lumen hub (yellow)

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What portion of the PAC contains temperature wires designed to measure the temperature of PA blood?

Thermistor Connector

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How far is the thermistor located from the distal end of the catheter?

Approximately 4 cm

The volume infusion port (white) is located how far from the distal tip of the catheter? Where is it situated within the heart?

- 19cm - RV

The proximal injectate port (blue) is located how far from the distal tip of the catheter? Where is it located within the heart?

- Approximately 30 cm - Right atrium

Which PAC port is used to estimate the CVP?

Proximal injectate port (blue) situated in the right atrium

Thin black dashes are equal to ____ cm

One thick, black dash is equal to ____ cm

50 cm

What are the colors for arterial, pulmonary artery, and CVP lines on the transducer?

- Arterial is red - Pulmonary artery is yellow - CVP is blue *all three must be flushed, zero, and labeled prior to insert*

T/F: fill the balloon before entering the right ventricle.

True

T/F: always deflate the balloon before withdrawing the catheter.

True

Over what time Should the balloon be inflated?

Slowly over three seconds

T/F: If PCWP wave form is noted, continue inflating the balloon.

FALSE, adjust the catheter position

T/F: the balloon should never remain inflated once placed correctly in the pulmonary artery.

True

For what reason is the PA catheter inflated intermittently once placed in the pulmonary artery?

To check the PCWP

Steps in order to insert the pulmonary arterial catheter:

1. Maintain Sterility. 2. Flush all ports before insertion. *(Distal to Proximal)* 3. Test the balloon and integrity *(attach the PA and CVP pressure cables and zero)* 4. Connect the distal port to the transducer *(this allows visualization of waveforms)* 5. Advance the PAC through the introducer sheath (previously placed) and into the IJV. 6. At **20 cm, the distal tip should enter the right atrium, and a central Venus tracing is seen**. 7. The balloon is inflated with 1.5 mL of air *(once in RA at 20cm; here pressure is usually less than 5 mmHg)*. 8. The catheter is advanced to about 30 cm, a sudden increase in the systolic pressure (~25 mmHg) indicates a right ventricular location. 9. **entry into the pulmonary artery occurs at about 40 to 45 cm, and a sudden increase in diastolic pressure (~10mmHg) is noted *(systolic remains ~25 mmHg)*.** This increase in diastolic pressure occurs due to closure of pulmonary valve 10. At about 45 to 50 cm a pulmonary capillary wedge pressure weight form is seen. 11. Deflate the balloon to see the pulmonary artery tracing (waveform) re-appear.

At what depth should the distal tip enter the right atrium, creating a central venous tracing?

20cm

At what depth is the distal tip located within the right ventricle, coinciding with an increase in systolic pressure?

30cm

Entry into the pulmonary artery occurs at what depth on the PAC, coinciding with an increase in diastolic pressure?

40-45cm

At what depth should a pulmonary capillary, wedge pressure (PCWP) waveform be seen?

40-45cm

CVP pressures in the right atrium

0-6 mmHg

PCWP is normally ____ mmHg

4-12 mmHg

The final resting place of the pulmonary arterial catheter is where?

- Wedged into smaller pulmonary capillary of the pulmonary artery. - annotate this depth. - Deflate balloon. - Pull back three or 4 cm (leave here in PA) - When we want to check PCWP, re-inflate, balloon again, and advance to previously annotated depth. - **never leave balloon inflated, this will cause pulmonary infarction!**

PCWP is an indirect measurement of ____.

Left Atrial Pressure *the whole point of using the PAC*

What can the side port on the introducer sheath be used for?

Rapid infusion of fluids

Wedged waveform appearance:

- lack of waveform, more linear in appearance

PAC must be inserted into what West zone?

What can be done if the PC will not float into the right ventricle?

- This is possibly due to tricuspid regurgitation. - Fill the balloon with 1.5 mL of normal saline and reposition the patient left side down.

What should we do if the PAC will not float into the pulmonary artery?

- This is usually due to a coiled PAC in the right ventricle or possibly pulmonary hypertension - Withdraw the PAC and advance again, slowly and continuously, reposition the patient left side and head up.

What should we do if the PAC entered the coronary sinus?

- This may happen with a dilated coronary sinus (hi CVP, tricuspid, regurgitation, cardiac anomalies) - To confirm, location is coronary sinus, check the SVO2 (levels are low, 20 mmHg, due to high O2 extraction ratio, 55-65%); fluoroscopy can also be used to confirm location. - Withdraw PAC tip and try to advance again; reposition the patient right side up when crossing the tricuspid valve.

What should we do if complete heart block is persistent?

1. Remove the PAC. 2. Emergency transvenous pacing.

Why is West zone three the preferred placement of a PAC?

- Pa>Pc>PA - There is a continuous column of blood flow to this region of the lungs - there is less of an effect of respirations on arterial weight form in this zone compared to one and two.

How to confirm west zone three placement of PAC:

- chest x-ray: below level of left atrium - PCWP < PADP by 1-5 mmHg - PCWP alters PEEP < 50% on increase in PEEP - PCWP increases by <50% of changes in alveolar pressure - O2 saturation in wedged position is greater than un wedged position (pulling back of oxygenated blood)

Left lateral decubitus position increases blood flow to west zone ____

Left lateral to cubitus position increases ____ pressure

Intra-thoracic

PCWP = PAOP = PAWP

Pulmonary capillary wedge pressure = pulmonary artery occlusion pressure = pulmonary artery wedge pressure

Calculated information from a PAC includes:

1. CO 2. CI 3. SV 4. SVR 5. PVR

Directly measured information from a PAC:

1. CVP 2. PAP 3. PCWP = PAOP = PAWP

Inferred information gathered from a PCWP (via PAC):

1. LAP 2. LVEDP & LVEDV

Other capabilities of a PAC (gathered info):

1. Blood temp 2. PvO2 3. SvO2 4. AV Venous Pacing

SvO2 normal value

60-75%

Cardiac output, normal value

4-8 L/min

Cardiac index normal value:

2.5 - 4 L/min/m^2

Stroke volume normal range

50-100 mL

Stroke index normal value

25-45 mL/m^2

SVR normal value

900 - 1300 dyn/sec cm^-5

PVR normal value

100 - 300 dyn/sec cm^-5

Name of the method used to calculate, cardiac output

Thermodilution

Cardiac index formula

CI = CO/BSA

Stroke volume formula

SV = CO/HR

Stroke volume index formula

SVI= CI/HR

SVR formula

SVR = 80(MAP-RAP)/CO

Systemic, vascular resistance index formula

SVRI = 80(MAP-RAP)/CI

Pulmonary vascular resistance, formula

PVR = 80(PAP-PCWP)/CO

Pulmonary vascular resistance index formula

PVRI = 80(PAP-PCWP)/CO

Normal systolic pulmonary arterial pressure

20-30 mmHg

Normal mean pulmonary arterial pressure

10-20 mmHg

Normal diastolic pulmonary arterial pressure

5-15 mmHg

Mild systolic pulmonary hypertension

Systolic 35-40 mmHg

Mild mean pulmonary hypertension

>25 mmHg

Moderate systolic pulmonary hypertension

50-70 mmHg

Severe systolic pulmonary hypertension

>70 mmHg

Pulmonary hypertension may indicate:

- Left heart disease - Atrial or ventricular failure - Valvular disease (e.g., Mitral stenosis, regurgitation) - Lung disease (COPD, sleep apnea, interstitial lung disease, scleroderma) - Congenital heart disease with intracardiac shunts - acute pulmonary embolism

PCWP ~ LAP ~ LVEDP ~ LVEDV

PEEP, Mitral Stenosis, and Mitral Regurgitation will cause the PCWP to ____ the preload of the left side of heart.

Overestimate

Aortic and Pulmonic, and diastolic dysfunction, will ____ LVEDP (LV preload).

Underestimate

Typical left atrial pressure (a-waves) value when measured by PCWP:

4.0-16 mmHg

Typical mean pressure when measured by PCWP:

2.0-12 mmHg

A wave on a PCWP waveform represents:

- Left atrial contraction - represents an increased left atrial pressure during left atrial contraction - Usually correlates with the PR interval on the ECG

The C-wave on the PCWP waveform represents:

- closure of the mitral valve - Not always apparent

The V wave on the PCWP waveform represents:

- Left atrial chamber filling -

Causes of cannon A waves on a PAC:

- AV dissociation - Mitral stenosis *atria is trying to pump against closed, mitral valve, resulting in high-pressure*

Large V waves indicate:

- Mitral regurgitation - Myocardial ischemia - left ventricular diastolic noncompliance

Describe the process of thermal dilution in order to derive cardiac output

- A cold solution is injected through the proximal port - The thermometer then measures the temperature change that occurs downstream - measures the temperature in the pulmonary artery as that cold fluid travels through the heart and gets re-warmed (thermodilution) - A waveform is created - The area under the curve correlates to cardiac output

Various types of PAC include:

1. Continuous cardiac output measurement. 2. Mixed Venus oxygen saturation measurement. (SvO2) 3. Cardiac pacing. 4. Right ventricular ejection fraction measurement

Which PAC measurement represents the final balance between oxygen supply and demand?

PvO2

When collecting a sample of PvO2, which port is it taken from?

- Distal Port *contains mixed venous drainage from SVC, IVC and heart*

Mixed Venus oxygen tension normal value

40 mmHg

What is SvO2 a measurement of?

- Oxygenation saturation from mixed Venus blood in the pulmonary artery - uses a probe like pulse Ox (not a blood sample)

Which monitoring metric measures the end result of oxygen consumption and delivery?

SvO2

Normal SvO2 value

65-75%

SvO2 varies directly with ____, ____, and ____.

SaO2, Hg, CO

SvO2 varies inversely with ____.

VO2 (Oxygen consumption)

T/F: both CVP & PAC kits can be used for RV pacing.

True

When using a PAC on cardio pulmonary bypass, always:

Withdrawal 3 to 5 cm when going on bypass

What is a common issue when using a pulmonary arterial catheter on cardio pulmonary bypass?

- distal catheter migration may occur due to: 1. Reduction in size of right ventricle. 2. Extra catheter length in the right ventricle. 3. Surgical handling of the heart. 4. Lung deflation.

If PAC becomes dislodged during cardiopulmonary bypass, what should be done

Remove the PAC, do not attempt to refloat it

Why aren’t PACs used more often?

1. Expensive. 2. In increased risk. 3. Difficult to interpret to make clinical judgments. 4. Should be used as one of many tools to help guide the care of critically ill patients. 5. There is no evidence from large controlled studies to date that preoperative PA catheterization improves outcome regarding hemodynamic optimization; in fact, some studies have suggested that patients actually do worse. 6. More non-invasive technology is becoming common.

Swan Ganz catheter picture