Chapter 9 Pulmonary Artery Catheterization
INTRODUCTION
Pulmonary artery catheterization (PAC) has been the subject of enormous controversy regarding its utility since its introduction by Swan and Ganz and coworkers in 1970.1 Detailed discussion regarding this controversy is beyond the scope of this chapter. However, a study performed by Connors and colleagues in 19962 comparing outcomes of critically ill patients managed with or without a PAC within the first 24 hours after admission to an intensive care unit (ICU) revealed an association between PAC and an increased relative risk of hospital mortality and increased utilization of resources. This paper reignited the controversy and made clinicians reevaluate the efficacy and safety of the pulmonary artery (PA) catheter. Many studies show no benefit or harm from PAC3–5; others show decreased mortality.6,7 Amid the controversy, physicians continue to use PAC in critically ill patients, although no validated indications exist for its use.
PA catheters are used to provide various hemodynamic parameters. Directly measured data include heart rate, waveforms, cardiac output, pulmonary artery pressures, right atrial pressure (central venous pressure [CVP]), pulmonary arterial occlusion pressure (PAOP; wedge), and mixed venous oxygen saturation. In addition, using these parameters, many other values—including mean arterial blood pressure, body surface area, stroke volume, systemic and pulmonary vascular resistance, ventricular stroke work, and oxygen delivery and consumption—can be calculated.8
INDICATIONS9
As with any other invasive procedure, PAC has its own inherent technical complications during insertion. The overall risks of complications have been reported to be anywhere from 5% to 15%. These include complications related to venous access and to right heart catheterization and PAC as well as infectious and thrombotic complications.10
OPERATIVE STEPS
OPERATIVE PROCEDURE
The first step in PAC is to obtain venous access. A PA catheter can be introduced most commonly through internal jugular, subclavian, and femoral sheath intro-ducers. If needed, the external jugular vein or antecubital fossa can be used. Each site has specific risks. Review Chapter 8, Central Vein Catheterization, for insertion of introducer sheaths and complications in accessing these sites. Each site has its own advantages and disadvantages for subsequently placing a PA catheter.
Complications of central vein catheterization are discussed in Chapter 8, Central Vein Catheterization. These include pneumothorax, hemothorax (grade 2), thoracic duct injury (grade 2/3), arterial puncture, possible pseudoaneurysm formation or arteriovenous fistula formation (grade 1/2/3), air embolism (grade 2/5), cardiac perforation with associated cardiac tamponade (grade 3/4/5), thrombus (grade 1/2/5), and infections (grade 1).
Once central vein catheterization is achieved, one can prepare for PAC. Many different PA catheters exist; they all have some similarities (Fig. 9-1):
In addition to these general guidelines, specialized catheters are increasingly available. These include pacing PA catheters, right ventricular function catheters, continuous cardiac output catheters, and oximetric catheters for continuous mixed venous oxygen saturation monitoring.
Prior to floating the catheter, the following must be done:
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