SWAN GANZ CATHETERS The flow-directed balloon-tipped pulmonary artery catheter (PAC) right heart catheter The Swan-Ganz Catheter 1-Diagnostic - Diagnosis of shock states - Differentiation of high- versus low-pressure pulmonary edema - Diagnosis of idiopathic pulmonary hypertension - Diagnosis of valvular disease, intracardiac shunts, cardiac tamponade, and pulmonary embolus (PE) - Monitoring and management of complicated AMI - Assessing hemodynamic response to therapies - Management of multiorgan system failure and/or severe burns - Management of hemodynamic instability after cardiac surgery - Assessment of response to treatment in patients with idiopathic pulmonary hypertension 2- Therapeutic - Aspiration of air emboli Basic Catheter Features • • • • Made of polyvinylchloride and has a pliable shaft that softens at body temperature Catheter is 110 cm and external diameter is either 5 or 7 French Balloon is fastened 1-2mm from the tip and when inflated it guides the catheter (using fluid dynamic drag) from greater intrathoracic veins through tight heart into pulmonary artery Thermistor-4cm proximal to the tip, measures temperature>important for determining cardiac output • Typically catheters have 4 ports: 1. White port with blue wire is the proximal port> terminates at 30cm from tip of catheter and is used to measure right atrium pressures 2. White port, yellow wire is the PAD distal port 3. White port with red wire is for balloon inflation 4. Last port has the connection to the thermodilution cardiac output computer> contains the electrical leads for thermistor. Insertion Techniques • Average time from decision to use PA catheter until onset of catheter based treatment is 120 minutes • Goal: get the catheter to the pulmonary artery • Cordis into right internal jugular vein or left subclavian allows easiest passage • Swan should be oriented ex-vivo to approximate the course in the body • Catheter goes through an introducer and into the vein. The balloon stays closed until we reach the right atrium. • When we reach the right atrium (20cm), balloon should be inflated to reduce possibility of injury to the myocardium. • Then the balloon should be moved quickly through the right ventricle (30cm)> and then pulmonary artery (40cm) and PCWP (50cm) FROM SUBCLAVIAN/IJ APPROACH Nursing responsibilities during insertion of a Swan Ganz Catheter. • 1. Ensure the comfort of the patient • 2. Make sure the transducer is flushed and re zeroed and ready to read P.A. • 3. Observe the monitor for signs of dysrhythmias • 4. Observe the waveforms as the catheter passes through the different chambers of the heart Nursing Care :• 1. Prevention of infection is paramount • 2. The position of the tip may change forward migration will be indicated by a wedge trace with a deflated balloon spontaneous wedging, this may cause pulmonary infarction. Notify a doctor to reposition the catheter. • 3. Over inflation of the balloon may cause the PA to rupture, prolonged inflation may result in pulmonary infarction and insertion of air into a ruptured balloon could cause an air embolus. • 4. Inflation of the balloon should be done slowly while observing the pressure tracing on the monitor. When the pressure changes from PA to Wedge no more air should be inserted. There should be a slight resistance felt, if there is no resistance and a wedge trace can not be obtained then a balloon rupture should be suspected. The syringe should be therefore labeled as ruptured and medical staff informed. • 5. After wedging the catheter always make sure the monitor returns to a PA trace. How do you know you are in the Right Atrium?>>20 cm Normal right atrial presssure is 0-6mmHg. Normal oxygen content 15% Normal O2 saturation 75% a=atrial contraction. c=sudden motion of the AV ring toward the right atrium x descent=atrial relaxation v=pressure generated by venous filling of the right atrium y descent=rapid emptying of the RA into RV How do you know you are in the right ventricle? 30cm RV systolic=17-30 RV diastolic=0-6 RV O2 content=15% RV O2 saturation 75% How do you know you are in the pulmonary Normal PA pressure, systolic 15-30 Normal PA pressure, diastolic 5-13 O2 content 15% O2 saturation 75% artery? What Elevates PA pressure? • • • • • • Volume Overload (backflow) Primary lung disease Primary pulmonary hypertension Pulmonary Embolism Left to right shunt Mitral Valve Disease What is the Pulmonary Artery Wedge Pressure? The measurement is obtained when the inflated balloon impacts into a slightly smaller branch of the pulmonary artery. This is where the arterial pressure exceeds the venous pressure and the venous pressure exceeds the alveolar pressure, thereby creating a continuous column of blood from the catheter tip to the left atrium when the balloon is inflated. Pulmonary venous pressure is the best indicator of left atrial pressure except when there is venoocclusive disease. Inflation of the Balloon for PCWP Tracing Pulmonary artery wedge 2-12 Pulmonary vein O2 content 20% Pulmonary vein O2 sat 98% What Increases PCWP? • • • • • • PEEP (minimally) LV failure Cardiac tamponade Aortic Insufficiency Mitral regurgitation VSD Effects of PEEP • Effects of positive end-expiratory pressure — Alveolar pressure will not return to atmospheric pressure at end-expiration in the presence of positive end-expiratory pressure (PEEP), a change that can affect the measurement of intravascular pressures. • The effects of PEEP are generally felt not to be clinically significant. • PEEP does affect right sided pressures (i.e. RA or CVP). • Complications Incidence % • • • of vascular Access • • • • – Arterial puncture – Bleeding at cutdown site – Pneumothorax – Air Embolism 1.1 – 1.3 5.3 0.3 – 4.5 0.5 • • of placement • • • – Minor dysrrhythmia – Severe dysrrhythmia – CHB • • • • • • – PA rupture – Catheter related sepsis – Thrombophlebitis – Venous thrombosis • • • • • Endocarditis/valvular or Endocardial vegetation • Deaths Attributed to PA Catheter 4.7 – 68.9 0.3 – 62.7 0 – 8.5 of catheter residence Pul. infarction 0.1 – 1.5 0.7 – 11.4 6.5 0.5 – 66.7 0.1 – 5.6 2.2 – 100 0.02 – 1.5