Transcript Pulmonary Artery Catheterization and Interpretation

Pulmonary Artery Catheterization
and Interpretation
Evan T. Lukow
IM – Residency Lecture Series
July 7, 2004
Goal: To gain a basic knowledge of
Pulmonary Artery Catheterization in the ICU
• Objectives:
• The Resident will:
– Understand the basic structure of the Swan-Ganz
Catheter.
– Develop a basic knowledge of how to place a PAC.
– Understand when and why to place a Swan-Ganz
catheter.
– Determine what hemodynamic parameters a SwanGanz catheter can generate (measured and derived).
– Apply these parameters to make appropriate diagnoses
of clinical scenarios.
The Swan-Ganz (Pulmonary Artery) Catheter
•
•
•
110 cm long, outside diameter of
2.3mm (7 Fr).
The tip of the catheter has a 1.5 cc
capacity balloon, that when inflated
covers the distal tip of the catheter.
Ports:
– Balloon Inflation – 1.5 cc syringe.
– Distal port (at the tip) – to
measure CVP.
– Thermistor port (4 cm from distal
port) – to measure CO.
– Proximal port (30 cm form distal
port) – to measure PAP and PAWP.
•
Additional Features: Temporary
pacer leads, fiberoptics for svO2,
rapid response thermistor for
RVEF, and continous
thermodilution CO sensor.
PAC Insertion
• Insertion of a PA catheter is usually via the subclavian
(left) or internal jugular (right), but may sometimes be
placed in the femoral vein if needed (preference given to
the most direct access to the right atrium).
• Once into the RA, the balloon is inflated at the tip to allow
for the catheter to follow the flow of blood from the RA,
through the tricuspid valve, into the RV, through the
pulmonic valve and into the pulmonary artery.
• When properly positioned the catheter’s distal tip lies in
the pulmonary artery and the proximal port lies in the RA,
thus allowing for the measure of RAP and PAWP,
simultaneously.
PAC Insertion
• The catheter's position can be monitored indirectly by the
pressure tracing on the monitor and its relationship to
specific areas of the heart and vasculature.
• Once in the pulmonary artery and in the wedged position,
the classic PAWP waveform will be seen, and all of the
hemodynamic parameters can be obtained yielding a
profile for interpretation and eventual treatment of a
patients particular condition.
Why place a Swan-Ganz?
• Cardiac Intensive Care:
– Cardiogenic Shock (LV/RV
infarct, Acute MR)
– Cardiac tamponade
– Constrictive pericarditis
– Guiding inotropic therapies
• Non-Cardiac Intensive
Care:
– Determining “fluid status”
– Guiding fluid resuscitation
– Characterizing shock states
• Hypovolemic (hemorrhage,
dehydration)
• Distributive (sepsis, SIRS,
anaphylaxis)
• Cardiogenic (failure, infarct)
• Obstructive (PE, tamponade,
PTX)
Note: Always used for diagnosis and evaluation of
treatment.
Consequences
• Cautions/Contraindications:
– Coagulopathy – use
compressible site such as R
internal jugular or femoral
– LBBB – may progress to
complete heart block
– Aberrant anatomy –
recommend radiographic
guidance
– “If you think of it use it”
• Complications:
– Vascular:
• Arterial rupture
• PTX
• Nerve injury (Horner’s,
brachial plexus, phrenic)
• Air embolism
• Hemorrhage/Infection
– Catheter:
•
•
•
•
•
Arrhymias/Heart Block
Thrombosis/Embolism
Sepsis/Endocarditis
PA rupture (0.2%)
Pulmonary infarction
(1.4%) - overwedging
Hemodynamic Parameters Measured
By Swan-Ganz
• Central Venous Pressure
(CVP)
– CVP = RAP = RVEDP
• Pulmonary Artery
Pressure (PAP)
• Pulmonary Artery Wedge
Pressure (PAWP)
– PAWP = LAP = LVEDP
• Cardiac Output (CO)
– Via thermoditulion
• Intra-arterial blood
pressure (Art. Line)
• Mixed venous Saturation
(SVO2)
Hemodynamic Parameters Derived
by Swan-Ganz
• Cardiac Index
• Systemic Vascular
Resistance (SVR)
• Pulmonary Vascular
Resistance (PVR)
• Systemic Oxygen
Transport Data (see next
slide)
• CI = CO/BSA
• SVR = CI/HR
• PVR = (PAP – PAWP) x
80/CI
Other parameters such as RVEDV, RVEF, R and L SWI, can be
determined depending on the type of catheter used and monitors
available.
Systemic Oxygen Transport Data
Derived by Swan-Ganz
•
•
•
•
Mixed Venous Oxygen Saturation (SvO2): 65-75%
– A measure of the oxygen sat. in blood obtained form the pulmonary
arterial circulation and is used to determine the amount of oxygen used in
the peripheral microcirculation.
Oxygen Delivery (DO2): 520-570 mL/min.m2
– A measure of the rate of oxygen transport in the blood, a product of CO
and arterial oxygen concentration.
Oxygen Uptake (VO2): 110-160 ml/min.m2
– The rate of oxygen uptake in the systemic microcirculation, the product of
CO and difference oxygen content in arterial and mixed venous blood.
Oxygen Extraction Ratio (O2ER): 20-30%
– The fractional uptake of oxygen from the systemic microcirculation,
equivalent to the ratio between Oxygen delivery and uptake.
Hemodynamic Profiles
in Heart Failure
• Right Heart Failure
–
–
–
–
High RAP
Low CI
High PVR
Normal VO2
• Left Heart Failure
–
–
–
–
High PAWP
Low CI
High SVR
Normal VO2
Note: Heart Failure has
appropriate oxygen uptake
(VO2) as opposed to
clinical shock states.
Hemodynamic Profiles
in Shock
Hypovolemic
Cardiogenic
Distributive
Obstructive
(vasogenic)
Hemorrhage,
Dehydration
Heart Failure,
Infarct
Sepsis, SIRS,
Anaphylaxis,
Adrenal dys.
PE, PTX,
Cardiac
Tamponade
Low CVP
Low PAWP
Low CO
High SVR
High CVP
High PAWP
Low CO
High SVR
High CO
Low SVR
Low PAWP
CT – RAP =
PAWP = RVEDP
PE – High RAP,
High PAP
ALL shock states are characterized by
inadequate tissue oxygenation and a low
oxygen uptake (VO2)
Practical Cases
Case 1:
• 75 yo female with lung CA, s/p R pneumonectomy has
acute desaturation and requires reintubation. Temp 100.4,
resp. 36, BP 120/75, HR 120. Rales on L, no BS on R,
cardiac normal. CXR – diffuse infiltrates on L.
• PAC Data:
The most likely diagnosis is:
–
–
–
–
–
RAP 10 (2-6)
PAP 45/28 (25/12)
PAWP 10 (8-12)
CI 3.8 (2.5-4)
SVR 1700 (2000)
A.
B.
C.
D.
PE
AMI
ARDS
Fluid Overload
Case 1:
• PAC Data:
–
–
–
–
–
RAP 10 (2-6)
PAP 45/28 (25/12)
PAWP 10 (8-12)
CI 3.8 (2.5-4)
SVR 1700 (2000)
The most likely diagnosis is:
A. PE
B. AMI
C. ARDS
D. Fluid Overload
• This patient has increased right sided pressures and normal
left sided pressures, and with correlation to clinical
presentation, suggests acute lung pathology (ARDS) as the
cause of her respiratory distress.
Case 2:
• 57 yo smoker is admitted to hospital with CP, N + V, JVD
is noted, extremities are cool to touch, T - 98.6, BP 80/60, HR – 112, R - 24, lungs are clear, heart – RRR
without murmur, ECG – ST elevation in inferior leads.
• PAC Data:
The most likely diagnosis is:
–
–
–
–
–
RAP 15 (2-6)
PAP 30/10 (25/12)
PAWP 8 (8-12)
CI 2.1 (2.5-4)
SVR 2200 (2000)
A.
B.
C.
D.
E.
Inf. MI with PE
Inf. MI with RV infarct
Inf. MI with ^ fluid vol.
Inf. MI with LV Failure
Inf. MI with MR
Case 2:
• PAC Data:
–
–
–
–
–
RAP 15 (2-6)
PAP 30/10 (25/12)
PAWP 8 (8-12)
CI 2.1 (2.5-4)
SVR 2200 (2000)
The most likely diagnosis is:
A. Inf. MI with PE
B. Inf. MI with RV infarct
C. Inf. MI with ^ fluid vol.
D. Inf. MI with LV Failure
E. Inf. MI with MR
• This pt. has ECG changes consistent with an acute Inferior
wall MI, and PAC pressures (decreased CI, and RAP >
PAWP) consistent with RV failure, which occurs in 25% of
Inferior wall MI’s.
Case 3:
• 67 yo with COPD intubated for respiratory failure and
sepsis, after CVP, pt. became hypoxic, acidotic,
tachycardic, BP fell from 130/80 to 70/45.
• PAC Data:
The most likely diagnosis is:
–
–
–
–
–
–
RAP 26 (2-6)
PAP 55/28 (25/12)
PAWP 24 (8-12)
CI 1.8 (2.5-4)
SVR 3000 (2000)
SvO2 55% (65-75%)
A.
B.
C.
D.
E.
Cardiac Tamponade
Tension PTX
Air embolism
LV failure
Myocardial wall rupture
Case 3:
• PAC Data:
–
–
–
–
–
–
RAP 26 (2-6)
PAP 55/28 (25/12)
PAWP 24 (8-12)
CI 1.8 (2.5-4)
SVR 3000 (2000)
SvO2 55% (65-75%)
The most likely diagnosis is:
A. Cardiac Tamponade
B. Tension PTX
C. Air embolism
D. LV failure
E. Myocardial wall rupture
• Along with clinical evidence of a PTX, this patients PAC
pressure correlate with a tension PTX due to a global
increase in both Right and Left sided heart pressures, a
generalized hypoxemia, and decreased CO.
Case 4:
• 55 yo with COPD who was ventilated becomes anxious 15
minutes after weaning, T-98.6, BP – 160/100, HR – 130, R
– 36, Sat – 87% at FiO2 40%, Chest- diffuse wheezing,
Heart – without murmur, ABG – 7.36, 30, 51.
• PAC Data:
The most likely diagnosis is:
– RAP 14 (2-6)
– PAP 45/27 (25/12)
– PAWP 23 (8-12)
A. Anxiety
B. Bronchospasm
C. LV dysfunction
D. RV dysfunction
Case 4:
• 55 yo with COPD who was ventilated becomes anxious 15
minutes after weaning, T-98.6, BP – 160/100, HR – 130, R
– 36, Sat – 87% at FiO2 40%, Chest- diffuse wheezing,
Heart – without murmur, ABG – 7.36, 30, 51.
• PAC Data:
The most likely diagnosis is:
– RAP 14 (2-6)
– PAP 45/27 (25/12)
– PAWP 23 (8-12)
A. Anxiety
B. Bronchospasm
C. LV dysfunction
D. RV dysfunction
• The increased left sided pressures in this patient suggests
left sided failure, patient was reintubated and PAC values
corrected somewhat, with some residual LVF evidence.
Case 5:
• 55 yo with CAD and RA with a total hip has CP, SOB, and
hypotension on POD #3, T-100.3, BP – 90/60, HR – 125, R
– 32, Chest- bilateral wheezing, Heart – without murmur,
CXR – infiltrates and atelectasis on R base, ECG – diffuse
ST/T changes.
• PAC Data:
The most likely diagnosis is:
–
–
–
–
–
RAP 22 (2-6)
PAP 55/32 (25/12)
PAWP 10 (8-12)
CI 2.2 (2.5-4)
SVR 2600 (2000)
A. PE
B. ARDS
C. MI
D. Right-sided endocarditis
Case 5:
• PAC Data:
–
–
–
–
–
RAP 22 (2-6)
PAP 55/32 (25/12)
PAWP 10 (8-12)
CI 2.2 (2.5-4)
SVR 2600 (2000)
The most likely diagnosis is:
A. PE
B. ARDS
C. MI
D. Right-sided endocarditis
• This patient has clinical evidence of a PE, elevated rightsided pressures, normal left-sided pressures (PAP>PAWP)
and a reduced CO all indicative of PE.
Case 6:
• 41 yo with sinusitis, spontaneous PTX, 3-day admission, 9
day course of antibiotics, develops CP, worse with sitting,
T-101.3, BP – 110/85, HR – 120, R – 32, Sat – 88%, Lungs
– clear, Heart – without murmur, ECG – low-voltage, CXR
– WNL.
• PAC Data:
The most likely diagnosis is:
–
–
–
–
–
RAP 22 (2-6)
PAP 40/22 (25/12)
PAWP 22 (8-12)
CI 2.1 (2.5-4)
SVR 3000 (2000)
A. Tension PTX
B. Cardiac tamponade
C. LV failure
D. PE
Case 6:
• PAC Data:
–
–
–
–
–
RAP 22 (2-6)
PAP 40/22 (25/12)
PAWP 22 (8-12)
CI 2.1 (2.5-4)
SVR 3000 (2000)
The most likely diagnosis is:
A. Tension PTX
B. Cardiac tamponade
C. LV failure
D. PE
• This patient most likely has cardiac tamponade due to an
increase in right-sided filling pressure, decreased CO,
along with clinical evidence of pericardial inflammation.
Along with PAC data, an echo would be indicated to
evaluate the size of the pericardial effusion for possible
drainage.
References
• ICU Book Second Edition, Paul L. Marino – Chapter 10
(1998)
• Critical Care Procedures, XXXXX – Chapter 3 (1995)
• PACs in the ICU, Jonathan D. Truwit – Journal of Critical
Illness, Feb, 2003.
• Principles of Critical Care, J. Hall (1992)