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Swan-Ganz catheter (pulmonary artery catheter)

Indications: 1) congestive heart failure# 2) respiratory failure (cardiogenic vs ARDS)* 3) shock* a) cardiogenic b) hypovolemic c) septic 4) complicated myocardial infarction 5) intra- & post-operative fluid management 6) fluid management in trauma patients 7) fluid management in burn patients 8) fluid management in acute renal failure patients 9) fluid management in patients with advanced cirrhosis 10) cardiac tamponade * NO benefit [3,4,6]; # NOT for routine use [5,6] Contraindications: 1) thrombocytopenia 2) increased prothrombin time or partial thromboplastin time 3) infection at venous access site 4) lack of trained personnel 5) when hemodynamic data obtained from the catheter will not affect patient management - monitoring of hemodynamically stable patients [6] - hemodynamic monitoring in patients with decompensated heart failure [6] 6) no absolute contraindications, but no benefit [6] Precautions: 1) continuous ECG monitoring - observe for ventricular ectopy 2) the procedure must be performed using sterile technique 3) ACLS equipment (crash cart) should be available 4) the pulmonary wedge pressure should be measured intermittently; the tip of the catheter should never remain in the wedge position for long Complications: 1) pneumothorax 2) infection 3) bleeding 4) cardiac arrhythmias 5) thrombosis of cannulated vein & thromboembolism from catheter-associated thrombus 6) pulmonary infarction & pulmonary artery rupture 7) damage to tricuspid & pulmonic valve 8) balloon rupture 9) knotting of catheter Procedure: Most Swan-Ganz catheters have 4 lumens & a thermistor device for measuring cardiac output. A catheter sleeve is used at the access site for sterile manipulation of the catheter. The pressure monitor begins to show variation with respiration when the tip of the catheter is in the superior vena cava. The balloon may be partially inflated at this point to assist with further advancement of the catheter. Once the right atrium is reached, the balloon may be fully inflated. Right atrial pressure wave should be seen on the monitor. The catheter is then advanced into the right ventricle & pulmonary artery. Characteristic pressure waves confirm position of the catheter. If the catheter coils in the right atrium, the balloon is deflated & the tip of the catheter drawn back into the right atrium before advancing again. Within the pulmonary artery, the catheter tip is advanced until the waveform changes to one characteristic of a pulmonary artery wedge pressure. The balloon is then deflated & the pulmonary artery pressure should be observed. If not the catheter is advanced too far & should be withdrawn in the deflated state until the characteristic pulmonary artery tracing is observed. The pulmonary wedge pressure should be measured intermittently. The tip of the catheter should never remain in the wedge position for long. Proper placement of the catheter is verified by a chest film. The tip of the catheter should be just lateral to the edges of the vertebral bodies. The catheter lumen are flushed & the balloon locked in the deflated position. See hemodynamic monitoring. Notes: Clinical trials: 1) no benefit in high-risk surgical patients* [2] 2) no benefit in mechanically ventilated patients with acute lung injury [6] * end points: length of hospital stay, 12 month mortality Studies on pulmonary artery catheters: 1) PAC-Man study 2) FACTT study

Related

central venous catheter Evaluation study of congestive heart failure & pulmonary artery catheterization effectiveness( ESCAPE) hemodynamic monitoring

General

cardiac catheterization intravascular catheter (vascular access)

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 249-251
  2. Journal Watch 23(3):22, 2003 Sandham JD et al, N Engl J Med 348:5, 2003 PMID: 12510037
  3. Richard C et al, JAMA 290:2713, 2003 PMID: 14645314
  4. Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D, Brampton W, Williams D, Young D, Rowan K; PAC-Man study collaboration. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial. Lancet. 2005 Aug 6-12;366(9484):472-7. PMID: 16084255
  5. Binanay C, Califf RM, Hasselblad V, O'Connor CM, Shah MR, Sopko G, Stevenson LW, Francis GS, Leier CV, Miller LW; ESCAPE Investigators and ESCAPE Study Coordinators. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA. 2005 Oct 5;294(13):1625-33. PMID: 16204662 - Shah MR, Hasselblad V, Stevenson LW, Binanay C, O'Connor CM, Sopko G, Califf RM. Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials. JAMA. 2005 Oct 5;294(13):1664-70. PMID: 16204666 - Hall JB. Searching for evidence to support pulmonary artery catheter use in critically ill patients. JAMA. 2005 Oct 5;294(13):1693-4. No abstract available. PMID: 16204671
  6. Medical Knowledge Self Assessment Program (MKSAP) 16, 19. American College of Physicians, Philadelphia 2012, 2022
  7. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network; Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med. 2006 May 25;354(21):2213-24. Epub 2006 May 21. PMID: 16714768