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PA Line etiquette
Sharon /Penny
Presentation Objectives
1. Review indications for the use of PA catheter with heart failure patients.
2. The difference of the four major types of PA catheters.
3. Review the pressure data collected for the PA and catheter.
4. Review the risks of the use of the PA catheter.5. Understand the general rules of handling an
inserted PA catheter.
Invented the PA Cath
• Dr Swan • Dr Ganz
Indications
• “There are no universally accepted indications for pulmonary artery catheterization because pulmonary artery catheters have not been shown to improve outcomes.”
• However, there are situations in which pulmonary artery catheterization may be helpful to manage and assess patients
• www.UpToDate.com
6
Invasive hemodynamic monitoring can be useful for carefully selected patients with acute HF who have persistent symptoms despite empiric adjustment of standard therapies, and
a. whose fluid status, perfusion, or systemic orpulmonary vascular resistances are uncertain;b. whose systolic pressure remains low, pr is associated with symptoms, despite initialtherapy;c. whose renal function is worsening with therapy;d. who require parenteral vasoactive agents; ore. who may need consideration for advanced device therapy or transplantation.
Invasive Hemodynamic Monitoring
Indications for PA Line
• Diagnostic = Right Heart Cath• -Differentiate cause of shock• Cardiogenic/Hypovolemic /Septic
• -Differentiate mechanism of pulm edema• Cardiogenic/noncardiogenic
• -Evaluate pulmonary hypertension
Indications for PA Line
• Therapy• Heart Failure• Complicated MI• Cardiac Surgery• Pharmacological therapy • -Vasopressors, Inotropes, Vasodilators
• Nonpharmacological therapy• -fluid management ie Ultrafiltration
Contra-indications
• R.BBB• Tricuspid/pulmonic valve stenosis• Artificial tricuspid/pulmonic valves • Right Atrial/Ventricular mass• New pacemaker • Coagulopathy
Types of PA Lines available
• Standard• VIP• CCO• Pacing
PA Catheter
PA Catheter
• Flow directed/balloon tipped catheter • 110cm in length, markings every 10cm• Tip of catheter in the pulmonary artery• Measures intra-cardiac pressures• Sample blood
Color coded
• Yellow – distal – pulmonary artery (PAP)
• Blue – proximal – right atrium (CVP)
• White – VIP – venous infusion port• Red – balloon inflates with 1.5cc gated syringe• Thermistor – measures blood temp• Continuous Cardiac Output (CCO)
• Optical module – mixed venous oximetry (SvO2)
Hemodynamic Information
• Central Venous Pressure• Pulmonary Artery Pressure• Pulmonary Artery Occlusion Pressure (wedge)• Cardiac Output/Index• Mixed venous saturation• SVR, PVR, Stroke volume
Risks associated with PA Line
• Complicated vascular access (pneumothorax, hematoma, arterial puncture, Right ventricle perforation)
• Arrhythmias (heart block, ventricular tachycardia/fibrillation)• Catheter knotting / Catheter migration• Pulmonary thrombosis and infarction• Tricuspid/Pulmonary Valve damage• Infection• Pulmonary artery rupture
Arrhythmias
• PVC’s and V.tach when in R. Ventricle• L.BBB + R.BBB = CHB
PA Pressures
Text Book LevelsCVP 0-7PAS 15-30PAD 8-15PAM 10-17PAOP M 6-12
Catheter knotting
Catheter migration
• Know your waveforms!!!• Forward -> wedge -> pulmonary infarction• Backward -> fall into RV -> VT
Pulmonary Artery Rupture
• Usually fatal• Hemoptysis, hypoxia -> cardiac arrest• Intubate, PEEP -> surgery
Right Heart Cath/PA Insertion
Right Heart Cath/PA Insertion
• YouTube - Swan Ganz Catheter Placement
Errors
• Incorrect transducer location• Inaccurate calibration• Over/under-damping of transducer• Incorrect catheter position
• ***Incorrect interpretation of information***
Incorrect transducer location
Stopcock at phlebostatic axis. 4th intercostal space /midpoint of anterior-posterior chest
External & Internal PA
Improper Leveling
Square wave test• Under-damping• Excessive tubing or stopcocks• systolic overshoot (the artificial
exaggeration of systolic pressure)• Caused by the patient: hypertension,
atherosclerosis, vasoconstriction, aortic regurgitation, or hyperdynamic ie sepsis
• Over-damping• Air bubbles, blood, kinked or non-pressure
tubing• Caused by the patient: aortic stenosis,
vasodilatation, or low cardiac output state
Correct Placement
• Correct Placement is in Zone 3 because
Do
• Ensure accuracy of your numbers • Measure waveforms• Draw blood out of correct port• Aseptic technique
What is the wave forms looking at?
Don’t
• Throw away syringe or replace syringe• Put more air in balloon• Get heart failure patient out of bed without
MD order• Infuse anything through the yellow port• Manipulate PA
Heparin-coated
• Do you know if the PA lines are heparin coated at this facility?
• Can you use a heparin coated PA line on a patient with HIT?
Reference
• Invasive Hemodynamic Monitoring: Physiological Principles and Clinical Applications
• Quick Guide to Cardiopulmonary Care 2nd Edition