Pulmonary Artery (Swan-Ganz) Catheterization and Hemodynamic Parameters
First Things First (assess & treat for the following)
- Clinical need to determine measured & calculated hemodynamic parameters
- Optimize treatment for shock.
- Distinguish between pulmonary & cardiac causes of dyspnea.
- Perioperative volume mgt in high-risk pts
- Diagnosis of pulmonary HTN
- Delineation of the hemodynamic consequences of cardiac disorders such as valvular disease & left ventricular dysfunction
- Unstable pt. The PA catheter is a diagnostic tool, not a resuscitation tool. This is a common error. Be aware that during the time for placement, it is very difficult to provide resuscitative efforts.
- Stable pt in whom the data are really not needed. The risks of the procedure do not justify prophylactic use.
- Relative contraindications
- Inadequate clinical support. This includes the nursing & technical staff’s experience & reliability of the electronic system as well as the physician’s experience & expertise.
- Anticoagulation, coagulopathies, antithrombotics, thrombolytics
- System components
- Catheter: Balloon-tipped for flow direction, variable number of infusion/pressure ports, thermodilution cardiac output thermistor, distal catheter curve to allow directional manipulation
- Connecting pressure lines & stopcocks
- Pressure transducers
- Hemodynamic monitor
- Access sites
- Internal jugular vein
- Advantages: relatively safe, avoids risk of pneumothorax
- Disadvantages: uncomfortable for pt, more prone to being inadvertently pulled out of position
- Subclavian vein
- Advantages: more comfortable for pt, more secure position
- Disadvantages: higher risk for pneumothorax & intrathoracic bleeding
- Femoral vein
- Advantages: venous access is simpler & has lower risk
- Disadvantages: requires fluoroscopy, uncomfortable for pt, difficult to keep clean, easier to dislodge, more difficult to place
- Antecubital vein (rarely used)
- Advantages: fairly secure, comfortable for pt
- Disadvantages: requires a venous cut-down, may be difficult to access the central circulation, catheter may be difficult to manipulate
- Catheter placement
- Pressure-guided placement is possible, particularly in pts w/ near-normal or normal cardiac output & normal-sized chambers.
- Connect catheter to transducer prior to insertion & test the waveform by tapping on tip of catheter.
- Inflate balloon after 10-15 cm is inserted & look for an atrial waveform.
- Advance slowly another 5-10 cm, looking for a ventricular waveform. If it is not seen, withdraw the catheter 5-10 cm, torque it ¼ to ½ turn & advance again. Repeat until a ventricular waveform is seen. If the RV waveform cannot be achieved, stop until fluoroscopy is available.
- Once the RV is entered, advance 5-10 cm looking for a PA waveform. If one is not seen, withdraw the catheter & torque as previously described, then advance again. If the PA waveform cannot be achieved after a few attempts, stop until fluoroscopy is available.
- Once PA pressure is seen, advance until pulmonary artery occlusive pressure (PAOP) waveform is seen, then deflate balloon & withdraw 2-3 cm & reinflate balloon. Repeat until PAOP is not seen when balloon is reinflated, then advance 2-3 cm & verify that PAOP is seen w/ balloon inflation & PA pressure is seen w/ balloon deflation.
- Get CXR.
- Fluoroscopy allows visualization & manipulation of catheter while in transit.
- Inflate balloon when 10-15 cm of the catheter has been inserted.
- Advance under fluoroscopic guidance. Measurements may be made in each chamber if needed.
- On achieving PAOP, deflate balloon & observe the position.
- Be certain that catheter does not remain in the occlusive position. Since the catheter tends to drift distally in the pulmonary artery as the material warms to body temp & becomes more flexible, try to attain the most proximal position in which the catheter will achieve measurement of PAOP when balloon is inflated & will retract to demonstrate PA pressure when deflated.
- Get CXR.
Pulmonary Artery (Swan-Ganz) Catheterization and Hemodynamic Parameters has been found in Pocket ICU Management
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