Pulmonary Artery Catheter Placement

Paul McCarthy, MD
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Subject: Pulmonary Artery Catheter Placement

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Introduction

Pulmonary catheterization is a diagnostic procedure in which a balloon-tipped catheter is placed into a central vein and directed to the right side of the heart to obtain pressures and other measurements for hemodynamic monitoring. Pulmonary artery catheterization, also referred to as Swan-Ganz catheterization, is an invasive procedure usually performed in the intensive care unit, cardiac catheterization laboratory, or operating room. 
Once the catheter is in place, a small balloon is inflated to momentarily block blood flow and allow pressure measurements in the pulmonary artery system. This pressure is called a wedge pressure and is an indirect measurement of left ventricular filling pressure. The catheter can measure mixed venous oxygenation and can also measure cardiac output via thermodilution. The catheter is generally left in place for periods of 24 to 72 hours. 
Because of the invasiveness of the procedure and lack of randomized controlled trials showing improved outcomes in patients with pulmonary artery catheters, their utility is being questioned more and more. Over the past decade, the use of the pulmonary artery catheter has steadily decreased. 

Equipment

  • Sterile towels, drapes, gloves, and gowns

  • Sterile saline for flushes

  • Gauze pads

  • Pulmonary artery catheter kit

    • Introducer

    • Pulmonary artery catheter

    • Dilator

    • Guide wire

    • Syringes

    • Scalpel

    • Suture

Most experts agree that whenever possible, the venous cannulation should be done with ultrasound guidance and the catheter should be advanced with the assistance of fluoroscopy. 

Indications

  • Diagnosis of type of shock

  • Diagnosis of pulmonary hypertension

  • Assessment of hemodynamic response to therapies

  • Diagnosis of cardiac tamponade or constrictive myopathies

  • Diagnosis of intracardiac shunt

  • Differentiating high-pressure versus low-pressure pulmonary edema

  • Assessment of valvular heart disease

  • Continuous measurement of mixed venous oxygen saturation

Contraindications

  • Right-sided heart mass

  • Tricuspid or pulmonary valve prosthesis

  • Tricuspid or pulmonary valve endocarditis

  • Cyanotic heart disease

  • Latex allergy

  • Previous pneumonectomy

  • Arrhythmia (relative)

  • Anticoagulation (relative)

The Procedure

Step 1

Obtain informed consent for the procedure and make sure electrolytes and clotting disorders are corrected. Check the components of the kit. Inflate and deflate the balloon and view for any malfunctions. Flush all lumens with sterile saline solution. Connect the distal lumen to the pressure monitoring system and zero the pressure transducer. 

Step 2

Place the patient in a supine position. Cleanse the skin well around the venipuncture site and drape the area (see Appendix E). Standard precautions of sterile gloves, sterile gown, mask, cap, and eye protection should be followed. 
  • Pearl: When possible, place the patient in a Trendelenburg position of at least 15 degrees down to distend the neck veins and reduce the risk of an air embolism.

Step 3

Apply a local anesthetic subcutaneously and deep at the venipuncture site. Usually 1% lidocaine without epinephrine is the anesthetic agent used. Identify the landmarks, remembering that the subclavian vein is a continuation of the axillary vein and typically runs a fixed course along the undersurface of the clavicle. The insertion site should be at the bisection of the middle and medial thirds of the clavicle. Use a 12-mL syringe filled with 0.5 to 1.0 mL of normal saline attached to a large-caliber needle to puncture the skin at the junction of the middle and medial thirds of the clavicle. 
  • Pearl: The subclavian artery usually lies deep under the vein; to reduce the risk of subclavian artery puncture, avoid deep penetration by the probe needle.

Step 4

Holding the needle and syringe parallel to the frontal plane, direct the needle medially, slightly cephalad, and posteriorly behind the clavicle toward the posterior, superior angle to the sternal end of the clavicle (toward finger placed in the suprasternal notch). Slowly advance the needle while gently withdrawing the plunger of the syringe. When a free flow of blood appears in the syringe, remove the syringe. Pass the guidewire through the needle. 
  • Pearl: To lessen risk of air embolism, occlude the needle with a finger.

Step 5

Remove the needle, leaving the wire in place in the vein. 

Step 6

With a scalpel (no. 11 blade), puncture the skin at the insertion point of the guidewire to facilitate cannulation and lessen resistance when dilating the vessel. 

Step 7

Thread the dilator catheter over the guidewire, creating a larger tract for catheter placement. Remove the dilator, keeping the guidewire in place. 

Step 8

Advance the introducer over the guidewire into the blood vessel, and if possible, monitor for rhythm abnormalities with an electrocardiogram. Remove the guidewire. 

Step 9

Pass the pulmonary artery catheter past the introducer. 

Step 10

Inflate the balloon once the catheter tip has traveled past the end of the inducer. Advance the catheter. A right atrial waveform should be seen after advancing 15 to 20 cm if the subclavian or internal jugular approach is used. For the femoral approach, the catheter will be advance approximately 30 cm before a right atrial waveform is seen. 
Step 10
Step 10

Step 11

Continue to advance the catheter approximately 10 cm, and a right ventricular waveform will be seen. 
Step 11
Step 11

Step 12

Continue to advance the catheter approximately 10 cm to visualize a pulmonary artery waveform. Continue to advance the catheter until a pulmonary artery wedge pressure waveform is seen. 
Step 12
Step 12

Step 13

Deflate the balloon and confirm the presence of a pulmonary artery waveform. Extend the protective sleeve and lock to proximal and distal ends. Confirm placement of the catheter with a chest x-ray. The catheter tip should be about 2 cm from the cardiac shadow. Usually the catheter is in the right lung; however, the left side is acceptable. 
  • Pearl: Pressures should be measured at end expiration.

Step 13
Step 13

Complications

  • Standard risks of central venous cannulation

  • Pneumothorax

  • Pulmonary hemorrhage

  • Pulmonary infarction

  • Pulmonary artery rupture

  • Arrhythmias

  • Infection

  • Valvular damage

  • Thrombosis

  • Balloon rupture

Pediatric Considerations

Pulmonary artery catheterization is performed with much less frequency in children than in adults. When used in children, it is usually in patients undergoing cardiac surgery. If the catheter is being placed in a patient with cyanotic heart disease, the lumens must be de-aired and carbon dioxide should be used for balloon inflation. 
The pulmonary catheter may be difficult or impossible to place in patients with certain congenital cardiac pathology. For this and several other reasons, echocardiography is used more often in the pediatric population. 

Postprocedure Instructions

Once the catheter is in place, several measurements can be made. Cardiac output can be monitored via thermodilution, and left ventricular pressure can be approximated by measuring the pulmonary artery occlusion pressure (wedge pressure). Mixed venous oxygenation, stroke volume, and systemic and pulmonary vascular resistance can all be measured. 
When the catheter is in place, daily monitoring is required, and steps should be followed to safely manage the catheter. The trace display should always be on the monitor when the catheter is in place. The catheter should not be withdrawn unless the balloon is deflated; always look for pressure changes when repositioning the catheter. The catheter should be removed as soon as it is not needed or if it is not working. The catheter should also be removed in the event of unexplained fever or apparent infection. 
The pulmonary artery catheter should be removed from the insertion catheter after the balloon is deflated. Once the pulmonary artery catheter is removed, the insertion catheter should be removed in a fashion similar to the removal of a standard central venous catheter. Once the insertion catheter is removed, pressure may be held for a few minutes to control bleeding, and a small dressing can be placed. 

Coding Information and Supply Sources

ICD-9 Codes

Supplier

  • Edwards Lifesciences, 1 Edwards Way, Irvine, CA 92614. Phone: 1-800-424-3278. Web site: http://www.edwards.com.

Bibliography

Harvey S, Harrison DA, Singer M, et al. Assessment of the clinical effectiveness of pulmonary artery catheter in the management of patients in intensive care (PAC-Man): a randomized controlled trial. Lancet.  2005;366(9484):472–477. [View Abstract]
Marino PL. The pulmonary artery catheter. In: The ICU Book . 3rd ed. Philadelphia: Lippincott Williams & Wilkins;  2007:163–177.
Rubenfeld GD, McNamara-Aslin E, Rubinson L. The pulmonary artery catheter, 1967–2007. JAMA .  2007;298(4):458–461. [View Abstract]
Wiener RS, Welch HG. Trends in the use of the pulmonary artery catheter in the United States, 1993–2004. JAMA.  2007;298(4):423–428. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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