Swan

Ganz/Pulmonary
Artery Catheter
Dr. Zulfiqar Ali khan
Department of Anesthesiology
Tabba Heart Institute

Pulmonary Artery Catheter

What

is a pulmonary artery catheter?

Pulmonary Artery Catheterization
Indications
Hemodynamic Parameters
Oxygen Transport Parameters
Benefits
Complications
ASA Guidelines for PA catheterization

What is a pulmonary artery

catheter (PAC) ?

Pulmonary Artery Catheter

Invented in 1970 by Swan,

Ganz and colleagues for
hemodynamic assessment
of patients with acute
myocardial infarction.

Standard PAC is 7.0, 7.5 or

8.0 French in
circumference and 110 cm
in length divided in 10 cm
intervals

Pulmonary Artery Catheter

The standard PAC kit

includes:
a syringe that can be
filled with only 1.5 mL
of air to prevent
overinflation of the
balloon
a long plastic sheath
that is used to maintain
sterility of the PAC as it
is advanced and
withdrawn

Pulmonary Artery Catheter

PAC has 4-5 lumens:

Temperature thermistor located
proximal to balloon to measure
pulmonary artery blood
temperature
Proximal port located 30 cm from
tip for CVP monitoring, fluid and
drug administration
Distal port at catheter tip for PAP
monitoring
+/- Variable infusion port (VIP) for
fluid and drug administration
Balloon at catheter tip

Anatomy of the Catheter

Pre-insertion Precautions
Coagulation

tests
ECG for left bundle branch block
Pacemaker
Right and left shunt

Pulmonary Artery Catheterization

A large-bore introducer
catheter is used to
facilitate PAC insertion

Inserted through the

subclavian or internal
jugular vein with the
patient in Trendelenburg

Prior to PAC insertion,

Connect the distal port
(yellow) to the pressure
transducer
Level the transducer at the
level of the patients heart
Zero the transducer

Pulmonary Artery Catheterization

Continuous pressure
monitoring during PAC
insertion is required to
determine location of the
catheter tip.

Inflate the balloon when

the 20cm mark is at the
hub of the introducer.

Advance the PAC until the

pulmonary capillary
wedge pressure (PCWP) is
obtained, usually around
45-55cm at the hub.

Normal Resting Pressures

Obtained During Right Heart
Catheterization

Right atrium
0-6 mmHg (Range), Mean 3
mmHg
Right ventricle
Systolic
17-30 mmHg
Diastolic
0-6 mmHg
Pulmonary artery
Systolic
15-30 mmHg
Diastolic
5-13 mmHg
Mean
10-18 mmHg
Pulmonary artery wedge pressure 2-12 mmHg

Pulmonary Artery Catheterization

Pulmonary Artery Catheterization

PAC as seen on chest x-ray

Indications
Assess

volume status
Assess RV or LV failure
Assess Pulmonary Hypertension
Assess Valvular disease
Cardiac Surgery

Hemodynamic Parameters

Hemodynamic Parameters Measured

Central Venous Pressure (CVP)

recorded from proximal port of PAC in the superior vena cava or right atrium
CVP = RAP
CVP = right ventricular end diastolic pressure (RVEDP) when no obstruction
exists between atrium and ventricle

Pulmonary Artery Pressure (PAP)

measured at the tip of the PAC with balloon deflated

reflects RV function, pulmonary vascular resistance and LA filling pressures

Pulmonary Capillary Wedge Pressure (PCWP)

recorded from the tip of the PAC catheter with the balloon inflated
PCWP = LAP = LVEDP (when no obstruction exists between atrium and
ventricle)

Cardiac Output (CO)

Calculated using the thermodilution technique

thermistor at the distal end of PAC records change in temperature of blood
flowing in the pulmonary artery when the blood temperature is reduced by
injecting a volume of cold fluid through PAC into the RA

Hemodynamic Parameters Derived

Cardiac Index (CI) = CO/BSA

Stroke Volume Index (SVI) = CI/HR

Systemic Vascular Resistance (SVR)

reflects impedance of the systemic vascular tree

SVR = 80 x (MAP CVP) / CO

Pulmonary Vascular Resistance (PVR)

reflects impedance of pulmonary circuit
PVR = 80 x (PAM PCWP) / CO

Left ventricular stroke work index (LVSWI)

= (MAP PCWP) x SVI x 0.136

Right ventricular stroke work index (RVSWI)

= (PAM CVP) x SVI x 0.136

Oxygen Transport Parameters

Oxygen Delivery (DO2)

Rate of oxygen delivery in arterial blood

DO2 = CI x 13.4 x Hgb x SaO2

Mixed Venous Oxygen Saturation (SVO2)

Oxygen saturation in pulmonary artery blood

Used to detect impaired tissue oxygenation

Oxygen uptake (VO2)

Rate of oxygen taken up from the systemic

microcirculation
VO2 = CI x 13.4 x Hgb x (SaO2 - SVO2)

PAC Benefits

Effect on Treatment Decisions: information

gathered from PA catheter data can beneficially
change therapy

Preoperative Catheterization: information

gathered prior to surgery can lead to
cancellation or modification of surgical
procedure, thereby preventing morbidity and
mortality

Perioperative Monitoring: provides invasive

hemodynamic monitoring in the surgical setting

PAC Complications
Establishment

access

of central venous

Accidental puncture of adjacent arteries

Bleeding
Neuropathy
Air embolism
Pneumothorax

PAC Complications
Pulmonary

artery catheterization

Dysrhythmias
Premature ventricular and atrial contractions
Ventricular tachycardia or fibrillation

Right Bundle Branch Block (RBBB)

In patients with preexistinh LBBB, can lead to
complete heart block.

Minor increase in tricuspid regurgitation

PAC Complications
Pulmonary

catheter residence

Thromboembolism
Mechanical, catheter knots
Pulmonary Infarction
Infection, Endocarditis
Endocardial damage, cardiac valve injury
Pulmonary Artery Rupture
0.03-0.2% incidence, 41-70% mortality

Complications Incidence %
OF VASCULAR ACCESS
Arterial puncture
1.1 1.3
Bleeding at cutdown site 5.3
Pneumothorax
0.3 4.5
Air Embolism
0.5
OF PLACEMENT
Minor dysrrhythmia
4.7 68.9
Severe dysrrhythmia
0.3 62.7
CHB
0 8.5

Complications Incidence %
OF CATHETAR RESIDENCE

PA rupture 0.1 1.5

Catheter related sepsis 0.7 11.4
Thrombophlebitis 6.5
Venous thrombosis 0.5 66.7
PULMONARY INFARCTION
0.1 5.6

ENDOCARDITIS/VALVULAR OR ENDOCARDIAL
VEGETATIONS 2.2 100
DEATHS ATTRIBUTED TO PA CATHETAR

0.02 1.5

ASA Practice Guidelines for Pulmonary

Artery Catheterization (2003)

Appropriateness of PA catheterization depends on the

risks associated with the:

(a) Patient: Are there presexisting medical conditions

that may increase the risk of hemodynamic instability?
(b) Surgery: Is the procedure associated with significant
hemodynamic fluctuations which may cause end organ
damage?
(c) Practice setting: Could the complications associated
with hemodynamic disturbance be worsened if the
technical or cognitive skills of the physicians or nurses
caring for the patient are poor?

ASA Practice Guidelines for Pulmonary

Artery Catheterization (2003)

According to the Task Force on Pulmonary

Artery Catheterization, PAC monitoring was
deemed appropriate and/or necessary in the
following patient groups:
1) surgical patients undergoing procedures
associated with a high risk of complications from
hemodynamic changes
2) surgical patients with advanced
cardiopulmonary disease who would be at
increased risk for adverse Perioperative events

A Randomized, Controlled Trial of the Use of

Pulmonary-Artery Catheters in High-Risk
Sandham et al

Randomized control trial comparing goal directed therapy

guided by PAC with standard care without PAC
Patient population: high-risk patients >60 years old with ASA
classification III/IV, scheduled for urgent or elective major
surgery
Results
PAC group
Standard care
Group

Death

7.8%

7.7%

Pulmonary
Embolism

6 month Survival

87.4%

88.1%

12 month Survival
83.0%
83.9%
Conclusions: No benefit to goal directed therapy by PAC over
standard care in elderly, high risk surgery patients

Meta-Analysis for effectiveness

of PAC

- 12 RCT, 1610 Pts.

- Morbidity events observed in 62.7% of
PAC group
74.3% Control group. (p= 0.0168)
- Statistically significant reduction in
morbidity using PAC
guided strategies.
Ivanov R et al CCM 2000

Effect of Pulmonary Artery

Catheter on intensive Care
4182 Pts
Mortality in all Pts. Admitted to an ICU
in a British Hospitalexamined.
No increased mortality attributable to
use of PAC demonstrated.

Murdoch SD Br J Anaes
2000

Sepsis/Septic Shock

outcome better in patients with septic shock

unresponsive to fluid resuscitation and vasopressors,
if
PAC prompts change in therapy
Mimoz et al CCM 1994

However, PAC placed in first 24 hrs. of ICU admission

not shown to significantly alter outcome in general
population of sepsis/septic shock.
No benefit in MOF and sepsis
Connors et al JAMA 1996

Case Control Study

141 pairs Mx with/without PAC
Severe sepsis
PAC use not associated with change in
mortality rate or resource utilization

Yu DT et al. CCM 2003

THANK YOU