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KEY POINTS

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KEY POINTS

  1. There is a core of accurate and reliable hemodynamic information obtained from the pulmonary artery catheter (PAC) not readily available from any other single device.

  2. The most reliable pressure measurements obtained from the PAC are continuous pulmonary artery systolic and diastolic pressures; the least reliable is the pulmonary artery occlusion (or “wedge”) pressure.

  3. Holding rapid fluid infusions via the introducer and proximal PAC ports and turning off the inflation of sequential compression devices (SCDs) improves the accuracy of thermodilution cardiac output (CO).

  4. Svo2 does not correlate with CO in critically ill patients; increases in the P[v-a]co2 gradient are inversely proportional to the CO.

  5. Information from any hemodynamic monitor must be interpreted in the context of the clinical situation (eg, diagnoses, physical examination, laboratory, radiologic), the treatment goal, and the response to treatment.

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The PAC, also called a right heart catheter or named after its creators a Swan-Ganz catheter, was introduced in 1970.1 Made of flexible plastic (polyvinyl chloride) with an inflatable balloon at the tip, the PAC is directed at the bedside, without the need for fluoroscopy, via a central vein, using the flow of blood through the right heart, into the pulmonary artery, guided by pressure waveforms displayed on the bedside monitor. Harry Swan developed the concept of using a flotation device while observing sailboats and initially planned to use a sail-like device, but a balloon proved to be a safer interface within blood vessels and cardiac chambers. Norman Ganz developed the thermodilution CO capability of the PAC.

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Use of the PAC peaked during the 1980s and 1990s, but usage has since trailed off due to its invasive nature and subsequent randomized controlled studies demonstrating no outcome benefit (ie, reduced mortality, organ failure, length of stay, or costs).2,3 Despite this, there remains a core of accurate and reliable hemodynamic information, not readily available from any other single device, which can be obtained from the PAC.

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The lack of demonstrable improvement in patient outcome when using the PAC is multifactorial. The main factors include reliance on inaccurate data (eg, pulmonary artery occlusion pressure [PAOP]) to guide management; the fact that the PAC is a monitoring technology, not a therapeutic technology; and that the critical illnesses the PAC is used to manage such as septic shock, acute respiratory distress syndrome (ARDS), and multiple organ failure are syndromes that have no specific treatment and outcomes are not directly dependent on hemodynamic variables.

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This chapter describes standard PAC anatomy, function, indications for insertion, insertion technique, complications, and obtaining reliable data while guiding bedside hemodynamic management.

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PAC ANATOMY

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A standard triple port VIP 7.5-Fr PAC is described herein. A double-lumen port PAC has identical components, other than lacking the additional infusion lumen.

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The PAC insertion length (Figure 107–1) is 110 cm ...

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