Ask the Experts Pulmonary Artery Catheters and Assessment of Pulmonary Artery Wedge Pressure
Q
In routine hemodynamic monitoring with a pulmonary artery catheter in a stable critical care patient, how often should the pulmonary artery wedge pressure be assessed? Any information you could provide related to Swan-Ganz monitoring would be greatly appreciated.
Author Jan M. Headley is director of strategic alliances and professional education at Edwards Lifesciences in Irvine, California. Corresponding author: Jan Headley, RN, BS, Edwards Lifesciences, 1 Edwards Way, Irvine, CA 92614 (e-mail: [email protected]). To purchase electronic and print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. ©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014271
www.ccnonline.org
A
Jan M. Headley, RN, BS, replies:
Clinical use of the pulmonary artery catheter (PAC) may depend on the functionality of the catheter itself. All catheters can be used to obtain and monitor intracardiac and pulmonary artery pressures, provide intermittent or continuous thermodilution cardiac output values, and either to obtain intermittent mixed venous samples from the distal lumen or, if fiber optics are housed in the catheter, to monitor venous oxygen saturation continuously. These parameters are used in diagnosis, selection of therapy, and assessment of the response to interventions. The frequency with which hemodynamic values are obtained from the PAC is determined by the patient’s condition and any standards or protocols that the institution may have. No guidelines for the frequency of repeated measurements have been published; however, after therapeutic interventions, repeated measures are typically warranted.1,2 In the past 2 decades, the reported use of PACs has decreased; however, the decline has not occurred in a uniform fashion.
In a recent publication,3 the major area of decline occurred in nonsurgical intensive care units. Continued PAC use tends to be in surgical patients, those taking vasopressors, and those receiving mechanical ventilation. Potential rationales for the decline include decreased education or a knowledge deficit in obtaining accurate values and appropriate interpretation, the dearth of published evidence-based practice related to use of PACs, and potential complications when PACs are used.4 One potential complication that may have led to less use of PACs is pulmonary artery rupture. This complication, although infrequent, can have catastrophic implications. The mean overall incidence of a pulmonary artery rupture is 0.01% to 0.47%; however, mortality has been reported at between 50% and 75% in patients taking anticoagulants.5 Perforation of the pulmonary artery may occur during insertion of the catheter or subsequent wedging. Patients who are elderly, have pulmonary hypertension, and/or are being treated with anticoagulants may present greater risk.2,5 Pulmonary artery systolic and diastolic pressures are monitored
CriticalCareNurse
Vol 34, No. 4, AUGUST 2014
Downloaded from http://ccn.aacnjournals.org/ at University of Birmingham on June 8, 2015
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profile assessment. However, it may be more important to recognize that monitoring, no matter what type or frequency, improves care unless tied to a therapy that improves outcomes.1 CCN Full inflation with 1.5-mL inflation volume. Appropriate a and v waves noted.
Overinflation of balloon. Note waveform rise on screen.
Financial Disclosures Jan Headley is a paid employee and stockholder of Edwards Lifesciences. This answer is her own work.
References
Catheter too distal. Overdamping of tracing.
Catheter spontaneous wedging. Wedge type tracing with balloon deflated.
Figure Potential tracings with overwedging or spontaneous wedging. Drawing compliments of Edwards Lifesciences LLC.
continuously via the distal port of the PAC. Measuring wedge pressure is often part of a profile assessment and is used to indirectly reflect end-diastolic pressure in the left ventricle. This value is used to determine changes in filling pressure for the left ventricle. The normal relationship between the pulmonary artery diastolic pressure (PAD) and the occlusion or wedge pressure (PAOP) is 1 to 4 mm Hg, with the PAD being higher than the PAOP. Upon insertion of the PAC, make note of the relationship between the PAD and the PAOP. If within normal range, the PAD may be monitored to minimize the number of measurements of PAOP obtained subsequently.6,7 Techniques to minimize the potential for pulmonary artery rupture include proper PAC placement on insertion by using 1.5 mL of air to inflate the balloon to obtain a wedge tracing. The pulmonary
86
CriticalCareNurse
artery tracing should be checked carefully to ensure that spontaneous migration into a wedge position does not occur. This is noted by a pulmonary artery tracing that can become “overdamped” or a wedge tracing. In addition, if a wedge tracing is obtained subsequently, do not use more than 1.5 mL of air in the syringe; stop inflating as soon as a wedge tracing is observed regardless of the amount of air used. Note the amount of air required to obtain a clear wedge tracing. If the amount is less than 1.25 mL, the PAC may be positioned too far distally and repositioning may be necessary2,6,7 (see Figure). Standards based on the evidence for optimal pressure accuracy are available from the American Association of CriticalCare Nurses.8 More research needs to be done in the area of evidencebased practice for hemodynamic
1. Vincent J-L, Rhodes A, Perel A, et al. Clinical review: update on hemodynamic monitoring: a consensus of 16. Crit Care. 2011;15:229. http://ccforum.com/content/15/4/229. Accessed May 19, 2014. 2. Gonce Morton P, Reck K, Hamel J, Walther AS, Von Rueden KT, Headley JM. Patient assessment: cardiovascular system: hemodynamic monitoring page. In: Gonce Morton P, Fontaine D, eds. Critical Care Nursing: A Holistic Approach. 10th ed. Philadelphia, PA: Wolters Kluwer Lippincott Williams & Wilkins; 2013:263-292. 3. Gershengorn HB, Wunsch H. Understanding Changes in established practice: pulmonary artery cather use in critically ill patients. Crit Care Med. 2013;41:2667-2627. 4. Marik P. Obituary: pulmonary artery catheter 1970 to 2013. Ann Intensive Care. 2013;3:38. http://www.annalsofintensivecare.com /content/3/1/38. Accessed May 19, 2014. 5. Bossert T, Gummert JF, Bittner HB, et al. Swan-Ganz catheter-induced severe complications in cardiac surgery: right ventricular perforation, knotting, and rupture of a pulmonary artery. J Card Surg. 2006;21:292-295. 6. Preuss T, Lynn-McHale Wiegand D. Procedure 73: pulmonary artery catheter insertion (assist) and pressure monitoring. In: LynnMcHale Wiegand D, ed. AACN Procedure Manual for Critical Care. 6th ed. Philadelphia, PA: Saunders Elsevier; 2011:626-647. 7. Preuss T, Lynn-McHale Wiegand D. Procedure 75: pulmonary artery catheter and pressure line troubleshooting. In: LynnMcHale Wiegand D, ed. AACN Procedure Manual for Critical Care. 6th ed. Philadelphia, PA: Saunders Elsevier; 2011:655-670. 8. Bridges E. AACN Practice Alert: Pulmonary Artery/Central Venous Pressure Measurement. 2009. http://www.aacn.org/wd /practice/docs/pap-measurement.pdf. Accessed May 19, 2014.
Ask the Experts Do you have a clinical, practical, or legal question you’d like to have answered? Send it to us and we’ll pass it on to our Ask the Experts panel. Questions may be mailed to Ask the Experts, Critical Care Nurse, 101 Columbia, Aliso Viejo, CA 92656; or sent by e-mail to [email protected]. Questions of the greatest general interest will be answered in this department each and every issue.
Vol 34, No. 4, AUGUST 2014
Downloaded from http://ccn.aacnjournals.org/ at University of Birmingham on June 8, 2015
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ at University of Birmingham on June 8, 2015
Pulmonary Artery Catheters and Assessment of Pulmonary Artery Wedge Pressure Jan M. Headley Crit Care Nurse 2014, 34:85-86. doi: 10.4037/ccn2014271 © 2014 American Association of Critical-Care Nurses Published online http://www.cconline.org
Subscription Information http://ccn.aacnjournals.org/subscriptions Information for authors http://ccn.aacnjournals.org/misc/ifora.xhtml
Submit Manuscript www.editorialmanager.com/ccn
E-mail alerts http://ccn.aacnjournals.org/subscriptions/etoc.xhtml
Critical Care Nurse is the official peer-reviewed clinical journal of the American Association ofCritical-Care Nurses, published bi-monthly by The InnoVision Group 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2011 by AACN. All rights reserved. Downloaded from http://ccn.aacnjournals.org/ at University of Birmingham on June 8, 2015
Q
In routine hemodynamic monitoring with a pulmonary artery catheter in a stable critical care patient, how often should the pulmonary artery wedge pressure be assessed? Any information you could provide related to Swan-Ganz monitoring would be greatly appreciated.
Author Jan M. Headley is director of strategic alliances and professional education at Edwards Lifesciences in Irvine, California. Corresponding author: Jan Headley, RN, BS, Edwards Lifesciences, 1 Edwards Way, Irvine, CA 92614 (e-mail: [email protected]). To purchase electronic and print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. ©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014271
www.ccnonline.org
A
Jan M. Headley, RN, BS, replies:
Clinical use of the pulmonary artery catheter (PAC) may depend on the functionality of the catheter itself. All catheters can be used to obtain and monitor intracardiac and pulmonary artery pressures, provide intermittent or continuous thermodilution cardiac output values, and either to obtain intermittent mixed venous samples from the distal lumen or, if fiber optics are housed in the catheter, to monitor venous oxygen saturation continuously. These parameters are used in diagnosis, selection of therapy, and assessment of the response to interventions. The frequency with which hemodynamic values are obtained from the PAC is determined by the patient’s condition and any standards or protocols that the institution may have. No guidelines for the frequency of repeated measurements have been published; however, after therapeutic interventions, repeated measures are typically warranted.1,2 In the past 2 decades, the reported use of PACs has decreased; however, the decline has not occurred in a uniform fashion.
In a recent publication,3 the major area of decline occurred in nonsurgical intensive care units. Continued PAC use tends to be in surgical patients, those taking vasopressors, and those receiving mechanical ventilation. Potential rationales for the decline include decreased education or a knowledge deficit in obtaining accurate values and appropriate interpretation, the dearth of published evidence-based practice related to use of PACs, and potential complications when PACs are used.4 One potential complication that may have led to less use of PACs is pulmonary artery rupture. This complication, although infrequent, can have catastrophic implications. The mean overall incidence of a pulmonary artery rupture is 0.01% to 0.47%; however, mortality has been reported at between 50% and 75% in patients taking anticoagulants.5 Perforation of the pulmonary artery may occur during insertion of the catheter or subsequent wedging. Patients who are elderly, have pulmonary hypertension, and/or are being treated with anticoagulants may present greater risk.2,5 Pulmonary artery systolic and diastolic pressures are monitored
CriticalCareNurse
Vol 34, No. 4, AUGUST 2014
Downloaded from http://ccn.aacnjournals.org/ at University of Birmingham on June 8, 2015
85
profile assessment. However, it may be more important to recognize that monitoring, no matter what type or frequency, improves care unless tied to a therapy that improves outcomes.1 CCN Full inflation with 1.5-mL inflation volume. Appropriate a and v waves noted.
Overinflation of balloon. Note waveform rise on screen.
Financial Disclosures Jan Headley is a paid employee and stockholder of Edwards Lifesciences. This answer is her own work.
References
Catheter too distal. Overdamping of tracing.
Catheter spontaneous wedging. Wedge type tracing with balloon deflated.
Figure Potential tracings with overwedging or spontaneous wedging. Drawing compliments of Edwards Lifesciences LLC.
continuously via the distal port of the PAC. Measuring wedge pressure is often part of a profile assessment and is used to indirectly reflect end-diastolic pressure in the left ventricle. This value is used to determine changes in filling pressure for the left ventricle. The normal relationship between the pulmonary artery diastolic pressure (PAD) and the occlusion or wedge pressure (PAOP) is 1 to 4 mm Hg, with the PAD being higher than the PAOP. Upon insertion of the PAC, make note of the relationship between the PAD and the PAOP. If within normal range, the PAD may be monitored to minimize the number of measurements of PAOP obtained subsequently.6,7 Techniques to minimize the potential for pulmonary artery rupture include proper PAC placement on insertion by using 1.5 mL of air to inflate the balloon to obtain a wedge tracing. The pulmonary
86
CriticalCareNurse
artery tracing should be checked carefully to ensure that spontaneous migration into a wedge position does not occur. This is noted by a pulmonary artery tracing that can become “overdamped” or a wedge tracing. In addition, if a wedge tracing is obtained subsequently, do not use more than 1.5 mL of air in the syringe; stop inflating as soon as a wedge tracing is observed regardless of the amount of air used. Note the amount of air required to obtain a clear wedge tracing. If the amount is less than 1.25 mL, the PAC may be positioned too far distally and repositioning may be necessary2,6,7 (see Figure). Standards based on the evidence for optimal pressure accuracy are available from the American Association of CriticalCare Nurses.8 More research needs to be done in the area of evidencebased practice for hemodynamic
1. Vincent J-L, Rhodes A, Perel A, et al. Clinical review: update on hemodynamic monitoring: a consensus of 16. Crit Care. 2011;15:229. http://ccforum.com/content/15/4/229. Accessed May 19, 2014. 2. Gonce Morton P, Reck K, Hamel J, Walther AS, Von Rueden KT, Headley JM. Patient assessment: cardiovascular system: hemodynamic monitoring page. In: Gonce Morton P, Fontaine D, eds. Critical Care Nursing: A Holistic Approach. 10th ed. Philadelphia, PA: Wolters Kluwer Lippincott Williams & Wilkins; 2013:263-292. 3. Gershengorn HB, Wunsch H. Understanding Changes in established practice: pulmonary artery cather use in critically ill patients. Crit Care Med. 2013;41:2667-2627. 4. Marik P. Obituary: pulmonary artery catheter 1970 to 2013. Ann Intensive Care. 2013;3:38. http://www.annalsofintensivecare.com /content/3/1/38. Accessed May 19, 2014. 5. Bossert T, Gummert JF, Bittner HB, et al. Swan-Ganz catheter-induced severe complications in cardiac surgery: right ventricular perforation, knotting, and rupture of a pulmonary artery. J Card Surg. 2006;21:292-295. 6. Preuss T, Lynn-McHale Wiegand D. Procedure 73: pulmonary artery catheter insertion (assist) and pressure monitoring. In: LynnMcHale Wiegand D, ed. AACN Procedure Manual for Critical Care. 6th ed. Philadelphia, PA: Saunders Elsevier; 2011:626-647. 7. Preuss T, Lynn-McHale Wiegand D. Procedure 75: pulmonary artery catheter and pressure line troubleshooting. In: LynnMcHale Wiegand D, ed. AACN Procedure Manual for Critical Care. 6th ed. Philadelphia, PA: Saunders Elsevier; 2011:655-670. 8. Bridges E. AACN Practice Alert: Pulmonary Artery/Central Venous Pressure Measurement. 2009. http://www.aacn.org/wd /practice/docs/pap-measurement.pdf. Accessed May 19, 2014.
Ask the Experts Do you have a clinical, practical, or legal question you’d like to have answered? Send it to us and we’ll pass it on to our Ask the Experts panel. Questions may be mailed to Ask the Experts, Critical Care Nurse, 101 Columbia, Aliso Viejo, CA 92656; or sent by e-mail to [email protected]. Questions of the greatest general interest will be answered in this department each and every issue.
Vol 34, No. 4, AUGUST 2014
Downloaded from http://ccn.aacnjournals.org/ at University of Birmingham on June 8, 2015
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ at University of Birmingham on June 8, 2015
Pulmonary Artery Catheters and Assessment of Pulmonary Artery Wedge Pressure Jan M. Headley Crit Care Nurse 2014, 34:85-86. doi: 10.4037/ccn2014271 © 2014 American Association of Critical-Care Nurses Published online http://www.cconline.org
Subscription Information http://ccn.aacnjournals.org/subscriptions Information for authors http://ccn.aacnjournals.org/misc/ifora.xhtml
Submit Manuscript www.editorialmanager.com/ccn
E-mail alerts http://ccn.aacnjournals.org/subscriptions/etoc.xhtml
Critical Care Nurse is the official peer-reviewed clinical journal of the American Association ofCritical-Care Nurses, published bi-monthly by The InnoVision Group 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2011 by AACN. All rights reserved. Downloaded from http://ccn.aacnjournals.org/ at University of Birmingham on June 8, 2015
