Pulmonary Artery Catheterization Periprocedural Care

Updated: Nov 20, 2016
  • Author: Bojan Paunovic, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
  • Print
Periprocedural Care

Equipment

Pulmonary artery catheter

Typically, a multilumen catheter, 110 cm long, with extra connecting tubes for attachment to the pressure transducer (see image below)

A pulmonary artery catheter is shown here. A pulmonary artery catheter is shown here.

At the tip is the PA lumen, or distal lumen. A 1.5-cc balloon is located just proximal to the tip. Approximately 4 cm proximal to the balloon is the thermistor used to measure temperature changes for calculation of CO.

Two additional lumens usually are present at 19 cm and 30 cm from the tip. Depending on the degree of right heart enlargement and the position of the catheter (ie, distance advanced into the patient), these lumina reside within the right ventricle (RV), right atrium (RA), or the superior vena cava (SVC).

Some catheters are coated with heparin to reduce thrombogenicity and have connections for temporary ventricular pacing. The former is important to remember in case the patient develops heparin-induced thrombocytopenia, because only a small amount of heparin is necessary to sustain this process.

Proper attachment of the PAC to the monitoring equipment is essential for accurate measurements.

Transmission of pressures from the body to the display system is accomplished via semirigid, noncompliant tubing filled with fluid, usually isotonic saline with a small amount of heparin. This, in turn, is connected to a fluid-filled pressure transducer.

Often, a constant infusion or "interflow" device is placed into the connecting pressure line. This device does not alter the pressure and provides a small constant infusion of fluid through the catheter to prevent backup of blood. Because the fluid is incompressible and the tubing noncompliant, this system fairly accurately transmits intracardiac pressures to the transducer, causing small amounts of movement in the transducer membrane. Deformation of this membrane generates a proportional electric current that is amplified and transmitted to the monitor.

A guide wire catheter may be useful in patients with large RVs and a lot of tricuspid regurgitation.

Next:

Monitoring & Follow-up

Complications associated with PAC use relate to the initial venous access, insertion of the PAC, and maintenance of the catheter in the PA. The incidence of complications varies on the basis of operator skill and patient status. Even with the use of ultrasonography-guided approaches, venous access complications may still occur, including arterial puncture, which may manifest immediately (eg, carotid artery hematoma if inserted via the internal jugular [IJ] route) or insidiously (eg, hemothorax via subclavian route). Also, the risk of pneumothorax relates to the selection of the access route, occurring more often in the subclavian than in the IJ site. However, it is important to note that low IJ approaches also carry this risk. Keep in mind that in ventilated patients, tension pneumothorax can develop rapidly.

Arrhythmias constitute the most common complication associated with PAC insertion. The majority of these are premature ventricular contractions (PVCs) or nonsustained ventricular tachycardia (VT) which resolve either with advancement of the catheter from the RV into the PA, or with prompt withdrawal of the catheter into the RA. Significant VT or ventricular fibrillation requiring treatment occurs in less than 1% of patients, usually those with concurrent cardiac ischemia or electrolyte distubances.

Right bundle-branch block (RBBB) can occur during PAC insertion and is usually transient after positioning the catheter into the PA. However, the presence of a preexisting left bundle-branch block (LBBB) puts the patient at risk for complete heart block should RBBB occur. In these patients, temporary pacing equipment should be kept nearby on standby. The incidence of knotting of the PAC on itself or on intracardiac structures is rare. This risk is potentially increased in patients with dilated cardiac chambers or in situations in which there is a persistent RV tracing despite further advancement (20 cm) of the PAC.

Of the complications associated with maintenance of the PAC, PA rupture is most catastrophic, with a mortality rate of 50%. Fortunately, it is a rare occurrence (< 1%). Patients at risk are those who have pulmonary hypertension, are older than 60 years, or are receiving anticoagulation therapy. The sudden onset of hemoptysis (especially after inflation of the PAC balloon) indicates this possibility. Immediate management includes lateral decubitus positioning (bleeding side down), intubation with a double-lumen endotracheal tube (ETT), and increasing PEEP. Embolization via bronchoscopy or angiography or lobectomy may be necessary if bleeding continues or is massive. A case report describes the use of a vascular plug to tamponade the culprit breach of the pulmonary artery. [31]

PAC-related infection is a fairly common complication. The incidence of positive catheter tip culture result is 45% in some series. Although sterile plastic sleeves have been used to decrease infection risk with PACs, a prospective observational study found positive cultures from the sleeve in some patients; these investigators warn that the sleeve should not be considered a sterile barrier. [32] Fortunately, the risk for clinical sepsis is less than 0.5% per day of catheter use.

The risk for significant catheter colonization increases after 4 days of catheterization. [33] The US Centers for Disease Control and Prevention (CDC) recommends against the routine replacement of PACs to prevent catheter-related infection. [33]

The incidence of pulmonary infarction is low. Unintentional distal migration of the PAC tip is the usual cause. Some evidence indicates that catheter-related thrombi also may be a significant cause. While postmortem studies have shown that rate of endocardial lesions (eg, thrombi, hemorrhage, vegetations) related to PAC use is significant, correlation with clinical events has not been established.

Previous