Insertion of Swan-Ganz catheters

INTRODUCTION

Flow-directed pulmonary artery (or Swan-Ganz) catheters allow direct measurement of intravascular pressures in the right heart and pulmonary artery, as well as sampling of mixed venous blood [1]. Left atrial pressure can be assessed indirectly with these catheters using the pulmonary artery wedge pressure, also referred to as pulmonary artery occlusion or pulmonary capillary wedge pressure. In addition, most commercially available catheters can calculate a range of other hemodynamic variables, including cardiac output and vascular resistances, on the basis of automated thermodilution analysis. (See "Swan-Ganz catheterization: Interpretation of tracings".)

The insertion of Swan-Ganz catheters will be presented here. Indications for pulmonary artery catheterization, normal hemodynamics, and complications of this procedure are reviewed elsewhere. (See "Swan-Ganz catheterization: Indications and complications" and "Cardiac catheterization techniques: Normal hemodynamics".)

INSERTION TECHNIQUE

The placement of a pulmonary artery catheter can be a time-consuming process. As an example, one study of 120 catheter insertions found that the median time elapsed from the decision to use a pulmonary artery catheter to the onset of catheter-based treatment was 120 minutes [2]. Thus, adequate personnel must be available to permit catheter placement and simultaneous execution of other responsibilities in the critical care unit. Pulmonary artery catheterization is a diagnostic procedure, and should not be undertaken in the setting of acute cardiac or respiratory arrest. Furthermore, resuscitation equipment should be present at the bedside during pulmonary artery catheterization, given the possibility of mechanically-induced arrhythmia or vascular complication. (See "Advanced cardiac life support (ACLS) in adults" and "Basic life support (BLS) in adults".)

The choice of insertion site should be determined individually according to the risks and benefits of each location (table 1). Although the left subclavian and the right internal jugular approaches probably permit easiest passage of the catheter into the pulmonary artery because of the curvature of the catheter, a subclavian, internal jugular, femoral, or antecubital (basilic or brachial) vein may be used [3,4]. (See "Indications for and complications of central venous catheters".)

Fluoroscopy should be considered in patients with marked right atrial or ventricular dilatation or severe tricuspid regurgitation. Fluoroscopic guidance also is recommended when the femoral or brachial approach is used, or in the setting of a left bundle branch block. Prior to the actual procedure, all equipment should be gathered both for the catheter insertion and for pressure monitoring. Pressure lines and transducers should be set up, calibrated, and zero-balanced. (See "Swan-Ganz catheterization: Interpretation of tracings", section on 'Zeroing and referencing'.)