Pulmonary artery catheters: Insertion technique in adults
- Gerald L Weinhouse, MD
Gerald L Weinhouse, MD
- Assistant Professor of Medicine
- Harvard Medical School
Pulmonary artery catheters (PACs; also called Swan-Ganz catheters) are inserted in the intensive care unit and in the operating room for the evaluation and management of critically ill patients. They are also placed in clinically stable patients (eg, in a coronary catheterization unit), most often for the diagnosis and management of some patients with suspected or known pulmonary hypertension or for unexplained dyspnea.
The insertion of PACs is reviewed here. The indications, contraindications, complications, and interpretation of PAC measurements are discussed separately. (See "Cardiac catheterization techniques: Normal hemodynamics" and "Pulmonary artery catheterization: Interpretation of hemodynamic values and waveforms in adults" and "Pulmonary artery catheterization: Indications, contraindications, and complications in adults".)
INDICATIONS AND CONTRAINDICATIONS
The major hemodynamic indices measured on pulmonary artery catheter (PAC) are pulmonary artery and pulmonary artery occlusion (ie, wedge) pressure, right atrial and right ventricular pressure, cardiac output and cardiac index, systemic and pulmonary vascular resistance, and mixed venous oxyhemoglobin saturation (SvO2). (See "Pulmonary artery catheterization: Indications, contraindications, and complications in adults", section on 'Physiologic measurements'.)
Although the routine use of PACs in critically ill patients has fallen out of favor, hemodynamic measurements obtained by PAC can be helpful in those with unexplained shock or those with unknown volume status despite active fluid resuscitation, as well as in patients with severe cardiogenic shock (eg, acute valvular disease) or those with suspected or known pulmonary artery hypertension (table 1). PACs can also be used to guide fluid resuscitation, titrate vasopressors, assess the hemodynamic effects of changes in mechanical ventilator settings, or assess response to medications (eg, pulmonary hypertension-specific medication). PACs are occasionally inserted preoperatively for high risk cardiopulmonary surgery and in rare cases are inserted for the investigation of unexplained dyspnea. (See "Approach to the patient with dyspnea", section on 'Cardiopulmonary exercise testing with pulmonary artery catheterization'.)
Absolute contraindications include infection at the insertion site, right ventricular assist device, and insertion during cardiopulmonary bypass, as well as lack of consent. Relative contraindications to the placement of a PAC include those with a coagulopathy (international normalized ratio >1.5), thrombocytopenia (platelet count <50,000/microL), electrolyte disturbances (hypo- or hyper-kalemia, -magnesemia, -natremia, -calcemia), and severe acid-base disturbances (eg, pH <7.2 or >7.5).
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- INDICATIONS AND CONTRAINDICATIONS
- Selecting the site
- INSERTION OF THE INTRODUCER
- Patient positioning
- Sterilizing the field
- Analgesia and sedation
- Insertion of the introducer
- INSERTION OF THE PULMONARY ARTERY CATHETER
- Re-sterilizing the field
- Preparing the catheter
- - Flushing and connecting the ports
- - Zeroing and referencing
- - Checking transducer function
- Patient positioning
- Advancing the catheter
- - General rules
- - Advancement through cardiac chambers
- Inserting the catheter into the SVC and RA
- Transitioning from the SVC or RA to the RV
- Transitioning from the RV to the PA
- Identifying the pulmonary occlusion pressure
- Final wedge position
- Checking catheter position
- POST-INSERTION CARE
- SUMMARY AND RECOMMENDATIONS