Pulmonary Artery Catheterization (General Surgery)

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SAMPLE EXCERPT
- Full procedure text, video and illustrations available with the full product
PRE-PROCEDURE
INDICATIONS

Surgery

  • High risk for hemodynamic compromise or significant volume changes
    • Trauma to the heart, major vessels, kidneys, liver, lungs, or brain
    • Transplant operations, especially heart, lung, liver transplant
    • Cardiac surgery
    • Thoracic surgery in high risk patients

Patient Factors

  • Increased risk for hemodynamic disturbances during procedures anticipated to have increased risk for significant fluid shifts or other hemodynamic consequences
    • Significant cardiovascular disease with cardiac compromise
    • Severe pulmonary dysfunction
    • Severe hypoxemia
    • Advanced renal insufficiency
    • Sepsis
    • Trauma
    • Burns
    • Pulmonary hypertension

Intraoperative and/or Postoperative Care

  • Hemodynamic monitoring in patients anticipated to have significant hemodynamic or pulmonary compromise in the postoperative period
  • Management of fluids and vasopressor therapy
CONTRAINDICATIONS

Absolute Contraindications

  • Patient or surrogate decision-maker refusal
  • Infection at the insertion site
  • The presence of a right ventricular assist device
  • Insertion during cardiopulmonary bypass

Relative Contraindications

(These may be overlooked in the instance that the benefit outweighs the risk.)

  • Presence of left bundle branch block (PA catheter placement can precipitate right bundle branch block and may result in acute onset of complete heart block.)
  • Presence of transvenous pacer or defibrillator electrodes, especially if recently placed. Can cause obstruction to PA catheter placement or dislodging of the wires and pacer/defibrillator malfunction.
  • Tricuspid or pulmonary stenosis—difficult to float catheter past the valve orifice
  • Prosthetic tricuspid or pulmonic valves—mechanical valves will not allow passage of a balloon.
  • Latex allergy—most catheters contain latex.
  • Right atrial or ventricular masses—difficulty advancing catheter past mass
  • Persistent left superior vena cava—catheter will traverse the coronary sinus.
  • Previous pneumonectomy
  • Patient at risk for arrhythmias—catheters can induce arrhythmias during placement.
  • Coagulopathy or systemic anticoagulation
EQUIPMENT
  • Sterile drapes, mask, gown and gloves
  • Standard patient monitors, including pulse oximeter, blood pressure cuff, ECG
Clinical Pearls: PA catheter placement is ideally done in patients with invasive arterial pressure monitoring, particularly if significant mitral regurgitation is present. The comparison of the two pressure tracings (systemic and pulmonary arterial pressures) allows the operator to distinguish between a PA tracing and a pulmonary capillary wedge pressure tracing and thus avoid “over-wedging” the catheter with attendant risks for pulmonary infarction or perforation.

  • Sterile prep solution—preferably chlorhexidine solution
  • Introducer sheath insertion kit (placement covered in central line section)
    • 1% lidocaine, 5-mL syringe and small gauge (25- or 30-gauge needle) for local skin infiltration
    • 22-gauge, 1.5-inch “search” needle
    • 18- or 20-gauge IV catheter over a needle, connected to a syringe
    • Guidewire
    • #11 scalpel blade
    • Vein dilator and large-bore (8.5-French) cannula
    • 3.0 suture on cutting needle
  • Pulmonary artery catheter (PAC).
  • Sterile catheter sheath
  • Pressure monitor transduction system and connector tubing
  • 1.5-mL volume-limited syringe for PAC balloon
  • Sterile syringe with sterile fluid to flush PAC ventricular infusion port
ANATOMY

The pulmonary artery catheter may be placed through an introducer in any of the central venous cannulation sites. Typically, these sites include the internal jugular veins (IJV), the subclavian veins (SCV), and the femoral veins. The ideal location is the right internal jugular vein because it is closest to the heart and provides a direct route to the right atrium.


The IJV drains blood from the brain and superficial face and neck. Its course follows a line from the inferior aspect of external acoustic meatus to the medial aspect of the clavicle. This line becomes less oblique when the head is turned to the opposite side. The IJV courses inferiorly through the neck lateral to the carotid artery in the carotid sheath with the vagus nerve posterior. The IJV passes deep to the sternocleidomastoid muscle between the two heads and joins the subclavian vein to form the brachiocephalic vein posterior to the clavicle closest to the sternum. The right IJ takes a straight course toward the right atrium as the subclavian vein joins it while the left IJV takes an acute angle as it forms the left brachiocephalic vein (innominate vein) with the left subclavian vein.


The subclavian vein is a continuation of the axillary vein draining the arm. It begins at the lateral border of the first rib and ends at the thoracic inlet where it meets the IJV to form the brachiocephalic vein. The SCV passes over the first rib and apical pleura and runs along the underside of the clavicle parallel with the subclavian artery but is separated from the artery at the anterior scalene muscle with the vein passing over the muscle.


Central venous catheterization via the IJV has a lower incidence of pneumothorax compared to catheterization via the SCV and can be easily compressed after catheter removal or after unintentional arterial puncture. Ultrasound can easily identify the IJV in most patients, which is important, as the incidence of anatomic variants may be as high as 8.5%. The subclavian vein has the advantage of being more comfortable for awake patients and less prone to contamination from respiratory secretions, particularly in patients with tracheotomies.


The large central veins drain into their respective vena cava (superior vena cava for the IJV and SC, and inferior vena cava for the femoral veins). Both the inferior and superior vena cava empty into the right atrium. The right atrium ejects blood through the tricuspid valve into the right ventricle during the diastolic phase of the cardiac cycle, and finally blood is ejected into the pulmonary artery from the right ventricle through the pulmonic valve.


PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Flush lumens in catheter with saline.
  • Obtain chest radiograph to confirm position of catheter and to rule out pneumothorax.
  • Use sterile technique when injecting drugs or connecting tubing to lumens of catheter.
  • Dressings should be changed routinely with use of sterile prep.
  • Examine the insertion site for signs of infection daily.
  • Catheter-related infection of the pulmonary catheter is a potential major complication of pulmonary arterial catheterization. If the catheter is left in place for more than 72 hours, the risk for infection rises significantly.
  • For catheter removal, place the patient in slight Trendelenburg position. Remove the catheter during exhalation in a spontaneously breathing patient or during inspiration in a patient undergoing positive pressure ventilation to prevent air embolism. Apply pressure at the site for 1 to 2 minutes with the patient in flat or slight reverse Trendelenburg position to ensure hemostasis.
  •   Do NOT withdraw the catheter against resistance. Resistance during catheter withdrawal may indicate that the catheter is entangled in cardiac structures. Consultation with an invasive cardiologist should be sought if the catheter does not withdraw easily. It is possible to disentangle the catheter in most cases with the use of special catheters used in cardiac catheterization techniques.
COMPLICATIONS
  • Common
    • Minor dysrhythmias
    • Severe dysrhythmias (ventricular tachycardia or fibrillation)
    • Minor increase in tricuspid regurgitation
  • Infrequent
    • Right bundle branch block—may be detected by ECG
    • Venous thrombosis
    • Catheter knotting
  • Serious, rare complications
    • Pulmonary artery rupture
    • Pulmonary infarction
    • Coronary sinus rupture
    • Thrombophlebitis
    • Venous thrombosis
    • Mural thrombus
    • Endocarditis
    • Catheter-related sepsis
    • Complete heart block when right bundle branch block occurs in a patient with preexisting left bundle branch block
    • Trauma to intracardiac structures
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