Swan ganz catheter placement complications of diabetes

The pioneering study of Forrester et al. In the decades that followed, the pulmonary artery catheter PAC became a hallmark of intensive care monitoring despite the lack of data on safety, accuracy and benefits of this technique. However, a neutral result was found in terms of the primary endpoint of days alive out of hospital in the first 6 months. Nonetheless, even if there was an initial progressive reduction in PAC use for the HF setting in general hospitals, it was followed by an increasing trend of usage, especially in large academic centres in the United States.

There are many potential benefits of this technique that may explain the trend. Firstly, echocardiography has a complementary role to invasive monitoring because it allows rapid evaluation of biventricular function and identification of severe valvular, pericardial and large-vessel disease or mechanical complications, helping to put in place adequate aetiological treatments. Moreover, thanks to its wide availability and easy handling, it has been largely proposed and used to non-invasively estimate haemodynamic data.

Jentzer et al. Time-consuming averages of several echo-derived parameters are needed to get a raw range of value. Indeed, several practical problems may limit the suitability of echo-dynamics in the critical care setting and very few studies with small sample sizes have demonstrated reliability in this setting. Additionally, when a trans-aortic ventricular assistance device such as the Impella is used, it is further limited by significant beat-to-beat variability and device-related artefact.

Likewise, minimally invasive techniques have been proposed as alternatives to PAC monitoring. Those based on arterial waveform to estimate CO rely on external calibration e. Despite increasing interest in these devices in recent years following technological improvements, results in terms of CO estimation are controversial and further studies are still in progress e. Finally, transpulmonary thermodilution methods are limited by the inability to discriminate between right- and left-heart dysfunction or to accurately estimate left filling pressures.

Indications and Implications of the Swan-Ganz Catheter in Cardiogenic Shock To date, the use of PAC monitoring in the CS setting is only recommended if there are uncertainties on diagnosis or for the most severe cases that are unresponsive to the first therapeutic attempts. However, it has been shown that the clinically estimated haemodynamic profile is comparable to the invasively derived one in the critical care setting in only half of cases, and non- invasive techniques have several limitations in this setting as previously mentioned.

This was the consequence of higher compensatory vasoconstrictive tone as demonstrated by the higher SVR values. Unfortunately, because of their intrinsic mechanism of action, neither vasopressors nor inotropes alone can ensure this. Detrimental effects on survival have been shown if recovery is not reached soon after aetiological therapy has been established and higher doses and numbers of drugs are needed to maintain perfusion.

Studies Evaluating Association Between Pulmonary Artery Catheter Use and Short-term Outcomes in Cardiogenic Shock Patients Download The adoption of timely mechanical unloading may reduce myocardial oxygen consumption and the infarct area, increasing the opportunity for recovery. After the initial profiling, frequent prospective re-evaluation of the aforementioned parameters will allow the identification of patients who are responding or those who are failing and needing an up-titration or palliation strategy.

Likewise, considering the well-known risk of time-dependent complications, the duration of MCS should be long enough to achieve effective myocardial recovery or stabilisation toward long term replacement therapies, but adequately short to limit the unwanted consequences of these devices. Adequate device selection in the right patient and timely removal may be the keys to the expected prognostic benefits of MCS in CS patients.

In cases of severe and irreversible PH, the implantation of a LVAD as a bridge to candidacy — or even as a destination therapy — can be considered. No monitoring device can improve patient-centred outcomes unless it is coupled with treatment that itself improves outcomes. This is especially true in the extremely heterogeneous and unstable setting of CS. Discussion We present a case report of successful acute and long term treatment of vascular injury leading to pulmonary hemorrhage and formation of a false aneurysm by endovascular stent graft placement.

The risk of pulmonary artery rupture by Swan-Ganz catheterization has been shown to be determined by diverse factors including advanced age, female sex, comorbidities, and medication as well as the handling during catheterization Table 1 [ 2 — 4 ]. In the literature, most of the ruptures occurred in elderly patients and in patients with pulmonary hypertension. This might be explained by remodeling and reduced vessel elasticity [ 4 ]. Further, a large pressure gradient across the balloon leads to wedging in a more peripheral position of the balloon.

As critical medications, corticoids and oral anticoagulation have to be mentioned [ 5 ]. Regarding these risk factors, the patient in the reported case had to be considered as a high risk patient. In order to reduce the risk of catheter induced injury proper catheter placement and management are essential. Table 1 Risk factors for pulmonary hemorrhage after Swan-Ganz catheterization [ 2 — 4 ]. Also, awareness of this complication is essential for the efficient management.

The leading symptom is hemoptysis that may occur immediately after deflation of the catheter or during the later course due to rupture of a false aneurysm. Other symptoms include respiratory insufficiency potentially leading to asphyxia and hypovolemic shock. Asymptomatic pulmonary artery false aneurysm may be discovered by chest radiographs. In view of the low incidence and the lack of controlled studies, there is no gold standard in treatment of pulmonary vascular rupture or false aneurysm.

Treatment strategies vary between watchful waiting [ 6 ], surgery [ 4 , 7 ], or angiographic embolization [ 5 , 8 ]. Stent graft placement has been reported in one previous case report, only, which was also successful for the acute treatment of relevant hemoptysis due to Swan-Ganz catheter induced pulmonary bleeding [ 9 ]. In the reported case, there was no need for blood transfusion; this might be a consequence of early interventional therapy.

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Although some case series reports have noted that outcomes in patients monitored by PA catheter were better than adjusted rates for the general population, 67 the absence of control groups limits the value of the data. A study with historical controls found that mortality, perioperative hypotensive episodes, and renal failure were less common in patients who received an aggressive fluid management protocol that included PA catheterization than in previous patients who did not receive the protocol.

Uncontrolled case series have suggested that low-risk cases can be safely managed without PAC. An uncontrolled case series and an observational study with a comparison group have examined the effectiveness of PA catheterization in patients undergoing neurosurgical procedures.

An uncontrolled observational study of pediatric head trauma patients who underwent monitoring that included PA catheterization reported lower mortality rates than published rates for patients with similar trauma scores. Some studies of limited quality have suggested that hemodynamic monitoring of trauma patients, often including PAC, improves outcomes. For example, a retrospective analysis concluded that patients with life-threatening burns who were monitored by PAC had lower mortality and organ-failure rates than a historical control group in which PAC was used irregularly; patients managed with hyperdynamic endpoints had substantially better outcomes.

Randomized controlled trials examining goal-directed therapy in trauma patients offer encouraging results but suffer from design limitations. A trial involving 67 primarily surgical trauma patients reported significantly fewer organ failures per patient among those receiving PACs in the operating room or postoperatively as part of a protocol to achieve supranormal values. A subsequent trial from the same group reported similar findings, as well as lower mortality rates, but it suffered from additional design limitations.

Obstetric—Gynecologic Procedures. Evidence regarding the effectiveness of PA catheterization in obstetrics and gynecology is lacking. PA catheterization has been recommended for severe preeclampsia, 81 case reports have supported its value, 82 and its use in critical illness seems common, 83 but controlled clinical outcome studies have not been reported.

Case reports have also described PA catheter use in uncommon obstetric settings, 84—86 whereas others have documented its lack of necessity in myocardial infarction during pregnancy. Pediatric Catheterization. PA catheterization is performed in critically ill newborns, infants, and children, 90 but its effect on clinical outcomes is poorly studied.

Uncontrolled case series reports have shown that it is useful in clarifying diagnoses, but these studies have not examined clinical outcomes or included unmonitored controls. A meta-analysis of 16 randomized controlled trials involving PAC, which examined results from studies published between and and which used a random effects model to compensate for study heterogeneity, yielded a relative risk ratio of 0.

The same research team later extended the analysis to include morbidity data from 12 of the 16 trials, calculating a relative risk ratio of 0. Another meta-analysis of PAC, which examined results from four homogeneous randomized controlled trials published between and involving vascular surgery patients yielded an odds ratio of 1.

Evidence regarding the adverse effects of PA catheterization comes from studies that examined multiple complications 96— and from studies of specific complications. The Task Force considered only potentially life-threatening complications. The reported incidence of complications is summarized in table 5.

Table 5. View Large In summary, complications from PA catheterization can occur with the establishment of central venous access, the catheterization procedure, and catheter residence. Complications of establishing central venous access include malpositioning, unintentional puncture of nearby arteries, e.

Minor dysrhythmias, such as premature ventricular and atrial contractions, occur often with catheter insertion or withdrawal but usually resolve spontaneously after the catheter is advanced or withdrawn through the right heart chambers. Complications of catheter residence include venous thrombosis, thrombophlebitis, and pulmonary embolism and infarction. Sepsis is a potential complication of PA catheter residence, but its exact incidence is uncertain. Positive cultures of indwelling PA catheter tips are common — and are often due to incidental contamination from skin flora, but in the context of septic patients it is frequently unclear whether positive cultures reflect colonization from another source or the primary nidus of infection.

Incidence rates for culture-positive catheters, positive blood cultures, and catheter-related sepsis, therefore, vary considerably in the literature. In general, the incidence of infection increases with the duration of placement , ; the risk seems to increase significantly when catheters are in place for more than 72—96 h. Skin flora are a common source of infection. For example, invasive hemodynamic monitoring during placement of prosthetic aortic grafts does not seem to be associated with graft infection after 4 yr.

Patients who are monitored by PA catheter have high mortality rates, but in few cases is it possible to attribute their deaths specifically to PA catheterization and not the underlying illness. Expert Opinion of Effectiveness Currently available evidence from published research provides incomplete information about the effectiveness of PA catheter monitoring and the incidence of complications.

Gaps in the evidence occur at several levels. First, surgical procedures that have been examined in studies of PA catheterization e. Second, available studies generally suffer from poor design and lack the statistical power to demonstrate benefit. In its review, the Task Force called for randomized controlled trials to offer more compelling evidence about the effectiveness of PAC. Although a number of such trials have since been published, they have not settled the issue, in part because of inadequate documentation and design flaws; Ivanov et al.

Because of deficiencies in the evidence, it is difficult to draw meaningful conclusions about the effectiveness and safety of PA catheterization based on currently available data. In general, the evidence suggests that the routine use of PA catheters in low-risk patients does not reduce mortality, length of stay, or other surrogate markers for severity of illness. In some settings, the risks from the procedure may outweigh its benefits.

The evidence does not exclude the possibility that PA catheterization improves outcomes in select clinical circumstances. Post hoc data analyses in the above literature, although an inadequate evidence base for drawing firm conclusions, suggest that patient subgroups do benefit from interventions that include or require PA catheter monitoring.

There is a great need for additional research to provide this information. In the meantime, important insights about the benefits and harms of PA catheterization can be obtained from clinical experience. The Task Force acknowledges the limitations of expert opinion, which include subjectivity, recall bias, nonuniformity of measures, and confounding.

With these caveats in mind, the following observations about the benefits and harms of PA catheterization are offered: Clinical experience suggests that PA catheter monitoring of selected surgical patients can reduce the incidence of perioperative complications, primarily by providing immediate access to critical hemodynamic data. The expert opinion of the Task Force is that access to these data for selected indications and settings, coupled with accurate interpretation and appropriate treatment tailored to hemodynamic status, can reduce perioperative mortality and morbidity through reduced cardiac complications e.

The Task Force also believes that, in selected cases and settings, PA catheter use may reduce length of stay in the hospital and ICU, enhance postoperative functional status, and reduce the need for transfused blood products through optimization of fluid therapy. The Task Force believes the use of PA catheters in selected obstetric patients may reduce maternal and neonatal morbidity and mortality.

Although these benefits may not be realized in every surgical patient who is catheterized, the Task Force believes that having immediate access to PA catheter data allows important preemptive measures for that subset of patients who encounter hemodynamic disturbances that require immediate and precise decisions about fluid management and drug treatment.

The exact proportion of patients for whom this applies and the magnitude of benefit from PA catheterization are uncertain. However, the Task Force believes that reliance on clinical assessment or alternative devices e. The delay associated with PA catheter placement after complications have developed may endanger certain patients and may increase the risk of complications from insertion. Emergency catheterization under hastily prepared conditions may increase the risk of vascular injury and catheter-related sepsis.

Prospective studies have found that the relative risk for catheter-related sepsis is 2. This enables immediate execution of treatment decisions that are tailored to the patient's physiologic state. The Task Force believes that these benefits have not been demonstrated in currently available research because of deficiencies in study design and performance. It is suggested that a properly designed randomized controlled trial with adequate sample size, well-trained physicians and nurses, well-defined interventions, and meaningful outcome measures would reveal the benefits observed in practice.

To do this, trials must be carefully designed to distinguish between the incremental benefits offered by PAC and those attributable to other treatment interventions with which PAC is associated e. It is recognized that the performance of such a study might be difficult because of logistical and ethical considerations, but calls for such research have intensified in recent years.

For example, the Task Force believes that outcomes for experienced clinicians may differ significantly from published rates, because catheterizations in clinical studies were often performed under conditions in which interventions were not adequately standardized or implemented according to protocol, or in early years, when outmoded techniques and materials were used. The white or clear lumen terminates close to the prior lumen, at 31 cm from the tip of the catheter and lies in the right atrium.

This port is used for infusion. The yellow lumen or PA distal is the pulmonary artery lumen is the distal port at the tip of the catheter. This port does the measurement of the pulmonary artery pressure. Mixed venous can be drawn from this port too. The terminal portion of the wire is called the thermistor bead, and it rests in a main pulmonary artery when the catheter tip is positioned correctly. The connection of the thermistor port to cardiac output CO monitor allows determination of a CO using thermodilution.

The red port is the balloon port. Air is introduced to inflate the balloon and removed when needs to be deflated. The pulmonary artery catheter has a balloon that can be inflated and helps the clinician place the tip of the catheter in the pulmonary artery. Within the catheter, there are black lines that help to measure the length of the catheter. One thin line is 10 cm, and a thick black line indicated 50 cm. Preparation Preparation for the pulmonary artery catheter is similar for the placement of every invasive procedure.

Verbal consent is necessary before the procedure. Detail explanation of the procedure, risk, and benefits need to be done before starting the procedure. Selection of the site of insertion of the catheter needs to be selected before starting the procedure. Especial consideration needs to be taken when selecting the site of insertion as skin or site infection, prior vein thrombosis or anatomical abnormalities to prevent complications. Proper catheter selection according to the insertion site is necessary.

Sterile barriers and techniques need to be done during the procedure. Proper cleaning of the site of insertion and draping of the patient is necessary. Also, the person doing the procedure needs to be wearing protective equipment and sterile barrier as sterile gloves, mask, and surgical gown.

Pulmonary artery catheterization can be done under fluoroscopy most common or at the bedside with use of ultrasound and echocardiography for catheter placement. Complications Complications related to catheter placement are similar to the placement of central catheter placement [8]. Infection of the site of insertion can occur. Pneumothorax or hemothorax can be a complication after insertion when the catheter is placed in the subclavian vein.

Air embolism caused by entrainment of air from the infusion ports. Complications related to catheter insertion include the occurrences of atrial or ventricular arrhythmias due to irritation or contact of the catheter with the cardiac walls [9]. Valve rupture or cardiac wall perforation can occur but it is rare. Misplacement of the catheter can occur due to looping of the catheter in the right chambers. This can be prevented with the placement of the catheter under fluoroscopy and paying attention to the waveforms in the monitor.

Vessel rupture can happen at the moment of balloon inflation into the pulmonary artery. Pulmonary infarction can occur when the balloon is inflated for long period or migration to the catheter to the distal branches. Thromboembolism can also occur secondary to inflammation or infection of the catheter that acts as a nidus for thrombus.

Clinical Significance As mentioned before, placement of the PAC helps for diagnosis of multiple conditions [2] [3]. PAC can help to determine causes of shock, as cardiogenic versus other causes as septic shock or distributive shock by obtaining SvO2 PAC is used to determine the cause of pulmonary hypertension for proper treatment after classification in the different groups of pulmonary hypertension.

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Benefits a. Effect on Treatment Decisions. Studies have found no association with mortality among patients whose therapy is altered based on PA catheter data. The conclusions are based largely on self-reported data in questionnaires, which are subject to measurement and recall biases. Most studies were unblinded and, in many cases, judgments about whether treatment was altered based on PA catheter data were made subjectively. Sample sizes were inadequate to conclude that alterations in treatment had no effect on mortality, and clinical outcomes beside mortality were generally not examined.

Preoperative Catheterization. Uncontrolled case series reports have shown that preoperative PA catheterization is associated with cancellation or modification of surgical procedures and with altered hemodynamic management, and investigators have concluded that it therefore prevents morbidity and mortality. Post hoc data analysis in one trial demonstrated a lower mortality rate in patients who were monitored preoperatively than in patients who were first monitored after surgery, but control for confounding was limited.

In summary, no high-quality evidence exists to infer that routine, or even selective, preoperative catheterization improves outcomes regarding hemodynamic optimization. Perioperative Monitoring. For many years, the principal evidence regarding the benefits of hemodynamic monitoring in the surgical setting was limited to nonrandomized observational studies. For example, a historical control study of patients found that patients with previous myocardial infarction who underwent noncardiac surgery during a period when invasive hemodynamic monitoring was common had lower reinfarction and mortality rates than patients in previous years during which invasive monitoring was less common.

A subsequent randomized controlled trial involving patients found no difference in intraoperative mortality, length of hospital stay, length of intensive care unit ICU stay, ventilator use, or postoperative mortality when surgical patients monitored by PA catheter were compared with central venous catheter CVC -monitored patients.

Patients monitored by PA catheter who were managed with the goal of achieving supranormal metabolic goals seemed to have significantly lower postoperative mortality, length of ICU stay, and ventilator use. Goal-directed therapy. Most studies of goal-directed therapy have been conducted in the ICU and have included, primarily or exclusively, surgical patients monitored by PAC. One randomized trial involving high-risk surgical patients found that a pre- and postoperative protocol to achieve high oxygen delivery rates was associated with significantly lower day mortality and complication rates.

Two trials from the same center reported no reduction in mortality, organ dysfunction, or length of stay, although they failed to achieve a difference in oxygen delivery between the two groups. Another trial examined the benefits of increased oxygen delivery in high-risk, critically ill patients who did not reach target values with volume expansion.

The authors reported increased in-hospital mortality rates and no significant improvements in surrogate outcomes days of ventilation, length of stay. The largest trial involved high-risk patients admitted to 56 ICUs; surgical patients comprised only one of five subgroups. The trial reported no difference in mortality, organ dysfunction, or length of stay when the goals of normal cardiac index, supranormal cardiac index, and normal mixed venous oxygen saturation were compared.

The PAC group had significantly more intraoperative but not postoperative complications, but complication rates even in the control group exceeded current norms, raising questions about the external validity of the study. A special mixed venous oxygen sensing central venous catheter was used in this study; therefore, this article does not fit the evidence model as described above, nor does it describe the effect of PAC guided therapy.

A trial in Britain involving patients undergoing major elective surgery reported positive results, including a significant reduction in mortality, for patients who underwent PAC-guided preoperative optimization as part of a protocol that included return to a high-dependency or intensive care unit following surgery.

Other outcomes, including prolonged stays in intensive care and mortality rates, did not differ between groups. Hemodynamic monitoring. Hemodynamic disturbances, for which PAC is often useful in the perioperative setting, have been the context for studies of PAC involving medical patients who did not necessarily undergo surgery.

Some of these studies are reviewed here because the hemodynamic disorders that prompted PA catheter use e. Uncontrolled studies have produced inconsistent findings. The data therefore do not clarify whether patients who underwent PA catheterization were sicker than unmonitored patients. The most careful effort to control for this form of confounding was a cohort study of the effects of PAC in 5, critically ill medical patients who entered a trial during the initial 24 h of their ICU stay.

The authors noted the limitations of the study. Although the propensity score held up under several sensitivity analyses, it retained wide confidence intervals and the authors could not exclude the possibility of a missing covariate. They noted, however, that for PAC to have a true hazard ratio of 0. Some contend that subtle clinical variables not addressed in the propensity score, such as physiologic trends over time and response to treatment, do have such an effect.

Cardiac surgery. Uncontrolled observational studies that examined outcomes in cardiac surgery patients who were monitored by PA catheter 55—61 have been limited by the lack of comparison data from unmonitored patients.

A small study that included historical controls found that 28 patients who underwent PA catheterization for repair of the left main coronary artery stenosis had lower rates of perioperative myocardial infarction, ventricular fibrillation, and deaths than 20 patients from the previous year who were monitored by CVC. Studies that included internal controls found little benefit. A controlled prospective observational study of 1, patients found no difference in measured outcomes e.

Other observational studies have suggested an adverse association between PAC and health outcomes. A retrospective study compared outcomes among patients who met predetermined criteria for CVC, a third of whom were monitored by PAC to accommodate physician preference; the PAC-monitored patients had increased complications and duration of mechanical ventilation.

Another study retrospectively reviewed administrative data on 13, patients who underwent nonemergent coronary artery bypass surgery at 56 hospitals in the United States. The 8, patients who received PAC, even after adjustment for case mix and other covariables, had significantly higher in-hospital mortality rates and length of stay than those who did not receive PAC. The association was strongest for hospitals that inserted fewer PACs per year.

One such trial involving patients found no difference in measured outcomes deaths, length of ICU stay, use of vasopressors between coronary artery bypass graft patients monitored by PA catheter and CVC, but this may have been attributable to the small sample size and selection biases. Peripheral vascular surgery. A randomized controlled trial found that patients undergoing peripheral vascular surgery were less likely to experience intraoperative disorders tachycardia, hypotension, arrhythmia if PA catheters were placed preoperatively and if hemodynamic status was optimized.

This was due mainly to a higher incidence of postoperative graft thrombosis in the control group, which was attributed to poor cardiac output. Postoperative morbidity and mortality otherwise did not differ between groups. The study was limited by discrepancies in data reporting and by uncertain methods for group assignment. Abdominal aortic reconstruction. Although some case series reports have noted that outcomes in patients monitored by PA catheter were better than adjusted rates for the general population, 67 the absence of control groups limits the value of the data.

A study with historical controls found that mortality, perioperative hypotensive episodes, and renal failure were less common in patients who received an aggressive fluid management protocol that included PA catheterization than in previous patients who did not receive the protocol. Uncontrolled case series have suggested that low-risk cases can be safely managed without PAC. An uncontrolled case series and an observational study with a comparison group have examined the effectiveness of PA catheterization in patients undergoing neurosurgical procedures.

An uncontrolled observational study of pediatric head trauma patients who underwent monitoring that included PA catheterization reported lower mortality rates than published rates for patients with similar trauma scores. Some studies of limited quality have suggested that hemodynamic monitoring of trauma patients, often including PAC, improves outcomes.

For example, a retrospective analysis concluded that patients with life-threatening burns who were monitored by PAC had lower mortality and organ-failure rates than a historical control group in which PAC was used irregularly; patients managed with hyperdynamic endpoints had substantially better outcomes. Randomized controlled trials examining goal-directed therapy in trauma patients offer encouraging results but suffer from design limitations.

A trial involving 67 primarily surgical trauma patients reported significantly fewer organ failures per patient among those receiving PACs in the operating room or postoperatively as part of a protocol to achieve supranormal values. A subsequent trial from the same group reported similar findings, as well as lower mortality rates, but it suffered from additional design limitations.

Obstetric—Gynecologic Procedures. Pulmonary artery catheterization remains an excellent tool for the assessment of patients with pulmonary hypertension, cardiogenic shock, or unexplained dyspnea. It can be used to assess right-sided cardiac chamber filling pressures, to estimate cardiac output, to evaluate intracardiac shunts, to evaluate cardiac valves, or to assess vascular resistance.

This activity describes the indications and techniques involved in pulmonary artery catheterization and highlights the role of the interprofessional team in the care of patients undergoing this procedure. Objectives: Identify the anatomical structures pertinent to pulmonary artery catheterization.

Summarize the indications for pulmonary artery catheterization. Review the complications associated with pulmonary artery catheterization. Explain interprofessional team strategies for improving care coordination and communication to advance the safe use of pulmonary artery catheters to minimize complications and improve patient outcomes.

Access free multiple choice questions on this topic. Introduction Pulmonary artery catheterization PAC is a procedure in which an intravascular catheter is inserted through a central vein femoral, jugular, antecubital or brachial to connect to the right side of the heart and advance towards the pulmonary artery.

This diagnostic procedure can be utilized to assess right sided cardiac chamber filling pressures, estimation of cardiac output, intracardiac shunt evaluation, valvular studies, and vascular resistance. Despite the decrease in the use of pulmonary artery catheterization for evaluation and management of critically ill patients, it still remains an excellent tool for assessment of patients with pulmonary hypertension, cardiogenic shock, and unexplained dyspnea [1].

Anatomy and Physiology Insertion of the catheter from one of the main central veins subclavian, internal jugular, femoral traverses into the superior or inferior vena cava and reach the right atrium. From the right atrium through the tricuspid valve, the catheter reaches the right ventricle.

From here the catheter is advanced to the right ventricular outflow tract and then to the pulmonary artery after getting across the pulmonary valve. The tip of the catheter lays into the main pulmonary artery, where the balloon can be inflated and deflated for measurement of pressures. Balloon can be inflated here to obtain pulmonary capillary wedge or occlusive pressure which gives an indirect assessment of left sided filling pressures.

During the placement of the catheter, due to the transducer that is in the catheter, a pressure waveform can be seen in the monitor. Each section of the right heart anatomy has a distinctive pattern that can help to assist or helps to determine where is the catheter tips. Indications The most frequent indications for placement of a pulmonary artery catheter are the following [2] [3] : Evaluation or diagnosis of pulmonary hypertension Distinduishing etiology of shock based on mixed venous oxygen saturation SvO2 measurement such as in septic or cardiogenic shock [4] Assessment of volume status in severe shock [5] Evaluation of pericardial illnesses such as cardiac tamponade or constricitve pericarditis Assessment of right-sided valvular disease, congenital heart disease, cardiac shunts, when surgical repair is planned Contraindications Contraindications for placement of right heart catheterization are [6] : Insertion of the catheter through a site where is an active infection Presence of a Right sided ventricular assist device Lack of consent A relative contraindication is the presence of left bundle branch block.

If this is the case, due to the risk of right bundle branch block during catheter insertion, external or transvenous pacer should be placed at the moment of the procedure to prevent complete heart block. Equipment A Swan-Ganz catheter or right heart catheter is a quadruple-lumen catheter with a thermodilution sensor that is attached to a pressure transducer outside the body, with this transducer, is possible to determine the central vein pressure, right atrial pressure, right ventricular pressure, and pulmonary artery pressure [7].

The catheters size range from 60 to cm in length and 4F to 8F in caliber Each of the 4-lumen is placed in a specific distance through the length of the catheter, and each of them has a specific function, as explained [7] : The blue lumen or CVP port represent the right atrial lumen. Ii is at 30 cm from the tip of the catheter and rests within the right atrium.

It is the proximal port and can be used for infusion. This port can assess central venous pressure CVP and right atrial pressure. The white or clear lumen terminates close to the prior lumen, at 31 cm from the tip of the catheter and lies in the right atrium. This port is used for infusion. The yellow lumen or PA distal is the pulmonary artery lumen is the distal port at the tip of the catheter. This port does the measurement of the pulmonary artery pressure.

Mixed venous can be drawn from this port too. The terminal portion of the wire is called the thermistor bead, and it rests in a main pulmonary artery when the catheter tip is positioned correctly. The connection of the thermistor port to cardiac output CO monitor allows determination of a CO using thermodilution. The red port is the balloon port. Air is introduced to inflate the balloon and removed when needs to be deflated.

The pulmonary artery catheter has a balloon that can be inflated and helps the clinician place the tip of the catheter in the pulmonary artery.