First Things First (assess & treat for the following)

• Indications
  • 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
• Contraindications
  • 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.