Pulmonary Artery Catheter & Hemodynamic Values

Pulmonary Artery Catheter & Hemodynamic Values Presented by: 12400 High Bluff Drive San Diego, CA 92130 This course has been awarded two (2.0) contact hours. This course expires on March 22, 2010. First Published: March 22, 2007 Copyright 2007 by RN.com. All Rights Reserved. Reproduction and distribution of these materials are prohibited without the express written authorization of RN.com.

Acknowledgements... 2 Purpose & Objectives... 3 Introduction... 4 PA Catheter Use Controversy... 5 Functions of a PA Catheter... 6 Indications/Clinical Relevance... 6 Risks Associated With PA Catheter Use... 7 Risks Associated with PA Catheter... 8 The PA Catheter... 9 Set Up and Insertion of the PA Catheter... 9 The Reference Point & Positioning of the Patient... 13 Performing a Pulmonary Artery Wedge Pressure... 13 Performing a Cardiac Output... 14 Reading Hemodynamic Pressures... 15 PEEP and PAWP... 15 What is the Patient s Real Wedge?... 15 Hemodynamic Values... 16 Troubleshooting... 18 PA Catheter Removal... 19 Conclusion... 20 References... 21 Post Test Viewing Instructions... 23 1

Acknowledgements RN.com acknowledges the valuable contributions of......shelley Polinsky BSN, RN, CCRN, author of Pulmonary Artery Catheter & Hemodynamic Values. Shelley has over 5 years of critical care nursing experience. After completing her Bachelors Degree from Hartwick College, Shelley worked in a variety of intensive care units. She worked in trauma intensive care, medical intensive care, surgical intensive care, cardiovascular intensive care, cardiothoracic intensive care, neurosurgical intensive care and coronary care unit in some of the top hospitals in the United States including: Johns Hopkins Medical Center, Massachusetts General Hospital, New York University Medical Center, Tulane Medical Center, and Beth Israel Deaconess Medical Center. She is the author of RN.com s Thombolytic Therapy for Acute Ischemic Stroke: t-pa/alteplase. Shelley is a member of the American Association of Critical Care Nurses (AACN). She is currently an Advance Cardiac Life Support (ACLS) and Basic Life Support (BLS) instructor. She has her Critical Care Registered Nurse (CCRN) and her Trauma Nurse Core Curriculum (TNCC) certifications....kelly Muck, MPH, contributing author of Pulmonary Artery Catheter & Hemodynamic Values, graduated from Colgate University Summa Cum Laude with a BA in molecular biology. After working for the Onondaga County Health Department as a Public Health Research Technician in Syracuse, NY, Kelly attended Johns Hopkins University Bloomberg School of Public Health where she received her Master of Public Health (MPH). She then worked as an epidemiologist for the HIV/AIDS Administration s Center for Epidemiology and Health Services Research of the Maryland Department of Health and Mental Hygiene. Her recent publications include an article published in the Journal of Urban Health (March 2004) titled Prevalence of HIV, Syphilis, Hepatitis B, and Hepatitis C Among Entrants to Maryland Correctional Facilities, and an editorial in the Journal of Public Health Management and Practice (November 2003) titled The Third Decade of HIV: Responding to an Evolving Epidemic. She also co-authored RN.com s Thombolytic Therapy for Acute Ischemic Stoke: t-pa/alteplase. 2

Purpose & Objectives The purpose of this continuing nursing education course is to inform the healthcare provider about the PA catheter which is commonly used in intensive care units. After successful completion of this course, the participant will be able to: 1. Identify the PA catheter controversy. 2. Define the function of the PA catheter. 3. Describe when a PA catheter is indicated and its clinical relevance. 4. Identify risks associated with the PA catheter. 5. Describe how to assist the physician with insertion of the PA catheter. 6. Define the reference point. 7. Describe how to perform a pulmonary artery wedge pressure. 8. Describe how to perform a cardiac output. 9. Define hemodynamic values. 10. Describe how to safely remove the PA catheter. 11. Identify problems with a PA catheter that may need troubleshooting. Disclaimer RN.com strives to keep its content fair and unbiased. The author(s), planning committee, and reviewers have no conflicts of interest in relation to this course. There is no commercial support being used for this course. There is no "off label" usage of drugs or products discussed in this course. You may find that both generic and trade names are used in courses produced by RN.com. The use of trade names does not indicate any preference of one trade named agent or company over another. Trade names are provided to enhance recognition of agents described in the course. Note: All dosages given are for adults unless otherwise stated. The information on medications contained in this course is not meant to be prescriptive or allencompassing. You are encouraged to consult with physicians and pharmacists about all medication issues for your patients. 3

Introduction Thirty years ago, Swan and Ganz developed the Pulmonary Artery catheter to be used as a hemodynamic monitoring device (Swan, Ganz & Forester, 1970). The catheter is also referred to as the PA catheter, Right Heart catheter and/or Swan Ganz. The term PA catheter will be used during this course. The PA catheter was initially used to help guide therapy following acute myocardial infarction; however, it is now utilized worldwide for the diagnosis, management, and prognosis of a variety of critically ill patients. The use of the PA catheter is most safely used in critical care settings. Currently, no other technology can provide the same amount, detail, and quality of hemodynamic data. The use of the PA catheter is controversial due to a lack of studies clearly concluding that patient outcomes improve following its use, yet it continues to be commonly used in the critical setting (Ivanov, Allen, & Calvin, 2000). Nurses play a critical role is assisting physicians to insert a PA catheter, as well as collect, communicate, and interpret the hemodynamic data provided by the catheter. Therefore, it is important that nurses understand the basic function of the PA catheter, its indications and risks, and the technical knowledge required to collect accurate hemodynamic measurements. In addition, developing an understanding of the most common hemodynamic values that can be obtained with the PA catheter and their normal ranges will translate into better patient management. Parts of the Internal Heart Superior Vena Cava Aorta Right atrium Pulmonary Artery Tricuspid valve Right ventricle Chordae tendonae Pulmonary valve Left atrium Mitral valve Left ventricle Papillary muscle Interventricular septum 4

PA Catheter Use Controversy One important factor to know about regarding PA catheters is that there is widespread controversy and debate regarding the use of PA catheters in the critically ill. The debate was seriously raised by Conners et al. (1996). The group indicated that an increase in mortality, cost, and length of hospital stay was related to PA catheter utilization. However, more recent results have been published that affirm the use of PA catheters is not detrimental (Richard et al., 2003; Harvey et al., 2005). Nevertheless, there remains a lack of clear evidence demonstrating significant improvement to patient outcome following PA catheter guided therapy. It is unclear why this is, but it may have to do with the fact that both physicians and nurses are often inadequately trained in its use and thus incorrectly measure and/or misinterpret the data obtained from the PA catheter. This subsequently leads to making inappropriate clinical decisions. Ultimately, the outcome of the patient is based on the proper use of the technology and accurate clinical interpretation of data provided, not on the technology that is providing the information. There continues to be studies investigating the use of the PA catheter, but in the meantime, it continues to be popular. Especially because the benefit is still being debated, physicians and nurses need to have a thorough understanding of PA catheter function, indications, and risks prior to using the catheter. Proper procedural competence (as will be reviewed in the later sections) is also needed so that the PA catheter is not unnecessarily employed. With increased knowledge and skill associated with the use of the catheter, the accuracy of the data, the interpretation of the data and the clinical application will improve, thus making the benefits of PA catheter use more readily identifiable and conclusive. 5

Functions of a PA Catheter The PA catheter provides hemodynamic information that can not be obtained by simple physical assessment. PA catheters are designed to output precise hemodynamic measurements of stroke volume, cardiac output, intracardiac and pulmonary artery pressures, estimates of systematic and pulmonary vascular resistance, and mixed venous oxygenation data from its blood sampling ability (Prentice & Ahrens, 2001). Since the catheter is a continuous monitoring device, it can amass a large amount of hemodynamic data. Other less invasive hemodynamic assessment techniques do exist (e.g. echocardiography, esophageal Doppler assessments of blood flow), however they offer neither the same quality of data nor the extent of data as does the PA catheter (Prentice & Ahrens, 2001). Based on the interpretation of the information collected with the PA catheter, a patient diagnosis can be made, therapy can be modified, or the status of a patient s response to a clinical intervention can be better understood. Indications/Clinical Relevance The presence of a debate over the absence of definitive benefits from PA catheter use underscores the importance of understanding when it is indicated. There is no consensus on standards for PA catheter use, although some practice recommendations and guidelines do exist. It is largely agreed upon that PA catheters should only be used when a specific clinical question regarding a patient s hemodynamic status can not be satisfactorily investigated by clinical or noninvasive assessments. Additionally, PA catheter should only be used when the clinician is in need of knowing an in-depth and continuous assessment of hemodynamics in order to properly guide changes in the management of a patient. PA catheters are traditionally used in the management of high risk patients during and after cardiac and major non-cardiac surgery. The PA catheter is also helpful in determining the etiology of various possible conditions. Such conditions include the etiology of shock, the differentiation between mechanisms of pulmonary edema (cardiogenic versus noncardiogenic), pulmonary hypertension, and the diagnosis of multiple cardiac abnormalities such as mitral regurgitation and cardiac tamponade (Summerhill & Baram, 2005). It can be used in management of patients with conditions where hemodynamic stability is important for improving an outcome or guiding therapy decisions (e.g. renal failure, sepsis, burns). It is also useful in determining fluid and vasoactive therapy during the acute phase of a patient s care (Leatherman & Marini, 1998). The most common contraindications related to the use of PA catheters are conditions where there is a high risk of side effects that include: Known pulmonary hypertension. Hypotension. Unstable arrhythmias. Bleeding disorder. Anticoagulation therapy. Prior pneumonectomy. Pacemaker. Prosthetic heart valves. A valuable source of more thorough and detailed information on expert recommendations for the use of PA catheter is provided by the American College of Cardiology (Mueller et al., 1998). 6

Risks Associated With PA Catheter Use The PA catheter is an invasive monitoring device and its use carries associated risks. Due to the current controversy and lack of data that supports clear outcome benefits related to PA catheters, it is important that the risks related to the PA catheter use is seriously evaluated for each patient on an individual basis. Studies examining the risks of PA catheter use have generally concluded that it is relatively safe as overall incidence of complications is low (Prentice & Ahrens, 2001). Even though the more serious complications are rare, it is important that these risks be discussed with the patient. The risks associated with PA catheter fall into a few categories: The insertion and maintenance of the catheter. Inaccuracies in the measurements. Difficulties in interpreting PA catheter parameters. Minor complications from PAC insertion and maintenance include hematoma, catheter related infection, and pneumothorax. Serious complications are rare but include ventricular tachycardia, pulmonary infarct, and pulmonary artery rupture. The most common complication of PA catheterization itself is ventricular arrhythmias, ranging from an estimated incidence of 11%-68%. Critically ill patients have been found to be more prone to ventricular arrhythmias than others (Summerhill & Baram, 2005). The most feared and serious complication with the use of PA catheters is pulmonary artery rupture; it can be fatal. All potential complications however are reduced when the healthcare worker is experienced with its operation. Complications are also related to the length of time the PA catheter remains insitu (Monnet, Richard, & Teboul, 2004). Incorrect measurements and misinterpretation of data is a significant risk because clinical decisions will be based on wrong data, leading to the mismanagement of the patient, perhaps to their detriment. In order to obtain accurate measurements, the equipment must be set up according to manufacturers recommendations and the catheter must be positioned perfectly within the heart. In addition, it is generally accepted that due to interobserver variability in data interpretation, even among experienced clinicians, misinterpretation of accurately measured data is common. The risks associated with clinical misinterpretation and misapplication of data can be drastically reduced by encouraging clinicians to abstain from PA catheter use unless they have been trained on how to modify patient therapy based on PA catheter data output. Educational programs and refresher courses are essential to ensure accurate collection and interpretation of hemodynamic parameters. 7

Risks Associated with PA Catheter Complications of central Venous access: Arrhythmias: Catheter-induced injury: Bleeding Hematoma Arterial puncture or cannulation Infection Pneumothorax Hemothorax Atrial tachyarrhythmia s Ventricular tachyarrhythmias Right bundle branch block Complete heart block Myocardial perforation Valvular injury Pulmonary artery rupture Pulmonary infarction Catheter entrapment on intravascular devices Catheter knotting Thrombosis and embolism Air embolism Thrombocytopenia Inaccurate measurements: Misinterpretation of data: Mismanagement of patient Mismanagement of patient (Summerhill & Baram, 2005) 8

The PA Catheter According to Urden, Stacey, & Lough (2002) there are several different types of PA catheters. The most common is called the Swan Ganz (since it was invented by Swan and Ganz). This catheter has four lumens. Variations of the PA catheter are available and are distinguished by having more lumens (up to seven). Some of the purposes of these additional lumens include intravenous infusion, transvenous pacing electrodes, measurement of mixed venous oxygen saturation (SVO2), right ventricle volume, and continuous cardiac output. The four and five lumen catheters differ in that the five lumen catheter has an infusion lumen that rests in the right atrium. In this article, the most common PA catheter, the four-lumen catheter, will be reviewed. The functions and location of a four lumen catheter include: Right Atrial Lumen: This is the proximal lumen which measures the right atrial pressure/central venous pressure. It is located in the right atrium and is used for cardiac output injectate, venous blood sampling, and intravenous infusion. Pulmonary Artery Lumen: This is the distal lumen which measures the pulmonary artery pressure. It is located in the pulmonary artery and is used for SVO2 sampling. Balloon Lumen: This is the third lumen and it is used for measuring the pulmonary artery wedge pressure when the balloon is inflated. It is located at the end of the catheter tip and is a balloon which requires 1.0-1.5 cc of air to inflate. Thermistor Lumen: This is the fourth lumen which measures change in blood temperature. This connector is also connected to a computer. This lumen provides the cardiac output and cardiac index (Urden, Stacey, & Lough, 2002). Set Up and Insertion of the PA Catheter The following discussion of will be a general overview about setting up the equipment required for the insertion of a PA catheter. It may differ between hospitals. The review of the PA catheter was obtained from the AACN Procedure Manual for Critical Care (2003). Setting up the equipment, calibrating the machine, and using the transducer sets should be performed according to your hospital policy and procedure and the type of equipment. As previously discussed, the different types of PA catheters (pacing, mixed venous oxygenation saturation monitoring, or right ventricular volume monitoring) require different types of calibrations depending on the type of information that is needed from the patient. Click on this link to view an animation of a pulmonary artery catheter insertion: http://www.edwards.com/prod ucts/pacatheters/placementvi deo.htm?wbc_purpose=basic &WBCMODE=PresentationU npublished. The first step occurs prior to PA catheter insertion. A signed consent form should be obtained from the patient or health care proxy prior to preparation for the PA catheter. Risks and benefits should be discussed with the patient and/or health care proxy. 9

The second step in the process is to assemble the pressure transducer system. A 500ml bag of normal saline should be used to flush the transducer system. Some facilities use a heparinized saline bag since it helps to prevent thrombosis; however, more research on the use of heparinized solution is needed due to risks of thrombocytopenia and hematologic complication (Chong, 1995). It is very important during the set up that there is no air in the tubing or in the transducer(s). Air left in the system will be at risk of being directly infused into the right atrium lumen and the pulmonary artery lumen. The normal saline flush bag should be placed in a pressure bag with an ometer. The pressure should be pumped up to 300mm Hg unless indicated otherwise. The third step is setting up the patient s room includes: placing the introducer and PA catheter equipment at the bedside along with sterile gloves and gowns. It is important that emergency equipment be placed near by or in the procedure room to facilitate a quick response to any complications. The fourth step is to help the physician by preparing the patient for insertion of the PA catheter. If the patient is not intubated and is awake, inform the patient that a local anesthetic such as lidocaine will be used to numb the area. If the patient is anxious, an anti-anxiety medication can be given under the prescription of the physician. The fifth step is the insertion of the introducer. A large bore catheter is first placed in the insertion area chosen by the physician. The most common places for insertion are the internal jugular and the subclavian. Sterile technique should be used in order to decrease the patient s risk of infection. Assist the physician in donning surgical hat, sterile gown, and sterile gloves as needed. After cleansing the insertion site, sterile drapes should be applied over the patient with the open area over the chosen insertion site. Physicians will often place a small towel between the shoulder blades to open up the subclavian area or extend the neck for insertion into the internal jugular. Turn the patient s head away from the insertion site. The patient s head of the bed should be flat. The physician may instruct you to place the patient in trendelburg if the patient can tolerate it. This will increase blood flow to the subclavian or internal jugular allowing the physician to better insert the introducer catheter. Details about the catheter: Made from polyvinyl chloride PA Catheter can be from 5.0 to 8.0 French PA Catheter is 110cm long For insertion into the Subclavian/Internal Jugular, the pulmonary artery will usually be accessed within 45-55cm The sixth step after the insertion of the introducer is preparing and inserting the PA catheter. The cardiac monitor should be placed so both the physician and nurse can observe the pressure waveform and EKG. After Opening the sterile PA catheter, flush all the lumens of the PA catheter and check the balloon for proper inflation and deflation. The pressure transducer system should be connected to the PA lumen. The transducer should then be zeroed. Before insertion, a sterile sleeve is placed over the PA catheter in order to sterilely readjust the catheter in the case of dislodgement or if the catheter will no longer go into the wedge position. Continuous pressure monitoring helps to confirm where the tip of the swan is in relation to the waveforms present. It is also useful to know at what length of the catheter should be in each area of the heart (see box). 10

If the physician takes a subclavian approach: At 20 cm the catheter should be in the right atrium (RA). Right ventricle 30 cm. PA 40 cm. PCWP 50 cm. It may be easy to remember the rule of 10 s. It is important to note that these measurements change based on the approach used. Site Distance to the: RA RV PA Internal jugular 15-20 cm 30 cm 40 cm Subclavian 15-20 cm 30 cm 40 cm Femora 30 cm 40 cm 50 cm Brachial Right 40 cm 50 cm 60 cm Left 50 cm 60 cm 70 cm The internal jugular and the subclavian are the most common places to float a PA Catheter (Weinhous and Manaker, 2005). The waveforms must be reviewed when the PA catheter is inserted. When inserting the PA catheter, the physician and nurse will know where the tip of the swan is located by the waveform. 11

Observe for the right atrial (RA) waveform. This waveform is seen when the catheter reaches the RA. Observe for the right ventricle (RV) waveform. This waveform is seen when the catheter reaches the RV. In order to float the catheter to the PA, the physician will (or will instruct the nurse to) fill the balloon tip with air then advance the catheter until the tip is properly wedged in the pulmonary artery. This is called a wedge pressure. 12

According to AACN, the nurse should be monitoring the patient throughout this procedure. The catheter has the potential to circle around in the right ventricle and cause ventricular tachycardia. This is often resolved by pulling back the PA catheter. It is important to keep close watch on the EKG rhythm as well as the PA catheter waveforms throughout insertion. The seventh step is to obtain a chest x-ray and have it read by a physician before using the PA catheter. When the catheter is in the final position, a chest x-ray should be performed to confirm that the tip of the catheter is no more than 3-5 cm from the midline. Daily chest x- rays to assess for migration of the PA catheter should also be performed (Weinhous & Manaker, 2005). The eighth and final step is to place a sterile, occlusive dressing over the insertion site. The nurse should record the length that the PA catheter is inserted in order to routinely assess if the catheter has been dislodged. The catheter should be securely attached to the patient. Occasionally the physician may suture the catheter in place. The transducers should be securely placed on the patients arm or on an intravenous pole. The Reference Point & Positioning of the Patient In order to obtain accurate PA measurements, a reference point that approximates the anatomic level of the left and right atria and pulmonary artery is established (Winsor, 1945). The area where these lines intersect is called the phlebostatic axis. The phlebostatic axis is determined by drawing an imaginary vertical line from the fourth intercostal space at the sternal border to the right side of the chest. A second imaginary line is drawn horizontally at the level of the midpoint between the anterior and posterior surfaces of the chest. The nurse should always zero the transducer(s) at the phlebostatic axis. In most facilities, the transducers are placed in a holder and placed on an IV pole. The transducers need to be leveled with the phlebostatic axis for accurate waveform readings. As long as the pulmonary catheter has been referenced and zeroed, the position of the patient is irrelevant (angled at 0, 30, 45, 60 degrees) (Keckeisen, 2004). A nurse should write the degree of head of bead with her/his documented numbers, although the accuracy of hemodynamic numbers is not generally affected. The nurse should also document the location in centimeters (the catheter is marked with lines- thin lines are 10 and the thick line is 50) of the PA Catheter. Performing a Pulmonary Artery Wedge Pressure A pulmonary artery wedge pressure (PAWP) is usually routinely performed every two to four hours. More frequent wedge pressures may be obtained with more critically ill patients or to assess the progress of titrating intravenous medications that can affect the wedge pressure. PAWP is routinely referred to as a wedge pressure. 13

According to AACN procedure manual, a wedge pressure is performed by first placing the patient in supine position. Place the head of bed at 0-45 degrees, making sure to document the head of the bed on the chart. Print an EKG rhythm strip, respirations, and PAWP pressure. Open the gate or stopcock on the balloon port. Next, slowly inflate the balloon with 1-1.5ml of air. Only a slight resistance should be felt. Often, the entire amount of air in the syringe is not needed. Only enough air should be inserted until the waveform is a PAWP waveform. Keep the balloon inflated for a maximum of eight to fifteen seconds to prevent balloon rupture. Measure the PAWP at the patient s end-expiratory phase. Deflate the balloon by allowing the air to passively escape the balloon back into the syringe. Close the gate or stopcock. Making sure to remove all the air out of the balloon secures that it will not be accidentally re-inflated. In order to measure the PAWP, the nurse must know what the a, c, and v waves are on both the PAP and PAWP. They need to compare these waveforms along with the EKG. Align the end of the QRS of the EKG with the PAWP at end expiration. This should line up with the a wave (contraction in atrial systole, the c and v waves follow) (Ahren & Taylor, s). This is the exact PAWP. According to one research article by Kearney (1995), the incidence rate of a rupture of the pulmonary artery with a PA catheter is 0.031%. In order to prevent an often fatal complication from pulmonary artery rupture, the provider should minimize time in the wedge position, refrain from flushing the catheter while the balloon is inflated, and deflate the balloon prior to withdrawing the catheter tip (Kearney, 1995). Performing a Cardiac Output Illustration depicts a PA catheter with the balloon in the wedge position. Cardiac output is the amount of blood ejected by the left ventricle in one minute. It is the product of stroke volume and heart rate. Stoke volume is the amount of blood ejected from both ventricles with each heart beat. Cardiac outputs are usually performed every 4 hours or more frequently if ordered. More frequent cardiac outputs maybe performed with very critically ill patients or to assess outcome of titration CO= SV X HR of intravenous medications that affect the cardiac output. The following procedure outlines how to perform a closed method cardiac output using the AACN Procedure Manual for Critical Care (2003). Use 5% dextrose in water (D5W) and connect the intravenous tubing with the D5W injectate in a 10 ml syringe using a three way stopcock to the right atrial lumen/proximal lumen. Withdraw 10 ml of D5W into the syringe. Follow your facility policy to instruct you with the procedure. When the computer prompts you to begin pushing the injectate, steadily and rapidly inject the patient with the 10 ml bolus. It should take 4 seconds or less. Wait until the computer calculates your patients cardiac output. Perform this three more times and average the three measurements within a 10% median value. Note the degree of the patient s head of bed. It is important to remember to add the amount of injected ml s to your patient s fluid intake. 14

Cardiac Index is the cardiac output divided by the patient s body surface area. This is a more precise measurement because it reflects cardiac performance per square meter. A new trend in continuous cardiac outputs (CCO) is frequently performed in many cardio-thoracic intensive care units. CCO swans require no injectates and offer continuous cardiac outputs monitoring. CI = CO per square meter Reading Hemodynamic Pressures When measuring hemodynamic pressures, accurate valves should be obtained at endexpiration (and compared to the EKG for the PCWP and PAP). According to the AACN Procedure manual, end-expiration is when atmospheric and alveolar pressures are approximately equal. When measuring at end-expiration, pulmonary pressures have minimal effect on intracardiac pressures. This makes end-expiration pressures the most accurate. PEEP and PAWP PAWP is not affected by PEEP pressures (when patient is on the ventilator) less than 10cm H20. With PEEP pressures greater than 10, the pulmonary vasculature is compressed and the pressure of the alveolar and intrathoracic is increased; thereby affecting the accuracy of the PAWP measurement (Keckeisen, 2004). Calculation of PAWP with high levels of PEEP 1. Convert the applied PEEP from centimeters of water to millimeters of mercury (1.36 cm H2O = 1 mm Hg) 2. Subtract half the applied PEEP in millimeters of mercury from the measured PWCP (Marini, et al, 1982). What is the Patient s Real Wedge? A nurse obtains her patient s PCWP pressure. It is 34. She notes that the PEEP on the ventilator is 20. What is the patient s real wedge? 1. First convert PEEP from centimeters of water to millimeters of mercury 1.36 cm H2O = 20 cm H2O 1 mm Hg x mm Hg 14.7 mm Hg 2. Second take 1/2 PEEP in mm Hg 14.7 divided by 2 = 7.35 mm Hg 15

3. Third subtract PEEP in mm Hg from the measured PWCP 34-7. 35 mm Hg = 26.65 ANSWER: The Patient s real PCWP is 26.65. Rounded: 27 The nurse receives the patient s PCWP. It is 20. She notes that the PEEP on the ventilator is set at 8. What is the patient s real wedge? Since the PEEP is less than 10, the wedge pressure is not affected by the PEEP. The real wedge is 20. Hemodynamic Values The normal range of the hemodynamic parameters varies by facility. Nurses need to follow the parameters set by their hospitals. It is also important to ask the physicians what they consider normal ranges for the individual patient and when they would like to be notified. The nurse should always set patient alarms so that she is immediately aware of any deviation from normal for her patient. The following definitions and values represent a standard range of hemodynamic parameters. RAP/CVP: RAP is the right atrial pressure or central venous pressure. The normal range is 2-6 mm Hg. RVP: RVP is the right ventricular pressure. The normal systolic range is 20-30 mm Hg. The normal diastolic range is 0-5 mm Hg. PAP: PAP is the pulmonary artery pressure. The normal systolic range is 20-30 mm Hg. The normal diastolic range is 8-12 mm Hg. The normal mean range is 10-20 mm Hg. PCWP: PAWP (PWCP/PAOP) is the pressure in the pulmonary artery. This is performed by inflating a balloon in the pulmonary artery catheter as previously reviewed. The normal range is 4-12 mm Hg. CO/CI: Cardiac output is heart rate times the stroke volume. The normal range is 4-8 L/min. The cardiac index is cardiac output divided by body surface area. The normal range is 2.5-4 L/min. CO = HR X SV 16

SV/SVI: Stroke volume is the cardiac output divided by heart rate. The normal range is 60-120 ml/beat. The SVI is the stroke volume divided by the body surface area. The normal range is 36-56 ml/beat. SV = CO HR SVRI = SV BSA SVR/SVRI: SVR is systemic vascular resistance. The normal range is 800-1200 dynes/sec/cm-5. SVR is the resistance to ejection from the left side of the heart. The SVRI is the SVR divided by the body surface area. The normal range is 1600-3000 dynes/sec/cm-5. SVR = 80 X (MAP - RAP) Cardiac Output SVRI = SVR BSA PVR: PVR is the pulmonary venous pressure. The normal range is 37-250 dynes/sec/cm-5. PVR is the resistance to ejection from the right side of the heart. The PVRI is the PVR divided by the body surface area. The normal range is <400. PVR = 80 X (mean PAP mean PAWP) Cardiac Output PVRI = PVR BSA Body Surface Area: The body surface area is the body surface area. The formula was calculated by Mosteller (1987): BSA (m2) = [(Height (cm) x Weight (lbs)]/ 3131) 1/2 17

Hemodynamic Parameters: Normal ranges may differ between hospitals; therefore, check your hospital s normal ranges. -Right Atrial Pressure (RAP) or Mean: 2-6 mm Hg Central Venous Pressure (CVP) -Right Ventricular Pressure Systolic: 20-30 mm Hg End-diastolic: 0-5mm Hg -Pulmonary Artery Pressure Systolic: 20-30 mm Hg End diastolic: 8-12 mm Hg Mean: 10-20 mm Hg -Pulmonary Artery Wedge Pressure (PAWP) Mean: 4-12 mm Hg Pulmonary Wedge Capillary Pressure (PCWP) Pulmonary Artery Occluded Pressure (PAOP) -Cardiac Output 4-8 L/min -Cardiac Index 2.5-4 L/min -Mixed Venous Oxygen Saturation (Svo2) 60-80% -Systemic Vascular Resistance (SVR) 800-1200 dynes/sec/cm-5 -Systemic Vascular Resistance Index (SVRI) 1600-3000 dynes/sec/cm-5 -Pulmonary Vascular Resistance (PVR) 37-250 dynes/sec/cm-5 -Pulmonary Vascular Resistance Index (PVRI) <400 dynes/sec/cm-5 -Stroke Volume (SV) 60-120 ml/beat -Stroke Volume Index (SVI) 36-56 ml/beat -Ejection Fraction (EF) 55-70% (Brunner, 1998) Troubleshooting Troubleshooting the PA catheter takes knowledge, practice, and experience. When first dealing with a PA catheter, a nurse may need to ask advice and guidance from more experienced nurses and/or their hospitals procedure manual/aacn Procedure Manual for Critical Care. PA Catheter Problems to Troubleshoot An overwedged balloon An absent waveform An overdampened waveform A continuous wedged waveform A catheter in the right ventricle Inability to wedge the PA Catheter Unexpected changes in PAP Blood backup into the PA Catheter or pressure transducer system Patient coughs up blood or develops bloody secretions from endotrachial tube during PA Catheter monitoring (AACN) Click on the following link for step by step troubleshooting information: http://www.edwards.com/products/pacatheters/hdmtroubleshooting.htm?wbc_purpose=basic&wb CMODE=PresentationUnpublished. 18

PA Catheter Removal According to the AACN Procedure Manual for Critical Care (2003) prior to removing a PA catheter, place the patient in supine position and turn the patient s head away from the catheter site. Turn stopcocks off to the patient and discard all intravenous solution and flushes. Wear a mask with a face shield (to prevent splashing) and don gloves. Remove the old dressing and unlock the sheath from the introducer. To minimize the risk of venous air embolus, ask the patient to take a deep breath and hold it while you gently withdraw the PA catheter while securing the introducer. View the catheter to make sure the entire catheter has been removed. If your patient has been diagnosed with an unknown infection, cut off the catheter tip with sterile scissors and place it in a sterile container for analysis. If the introducer is to be removed, follow the same steps. When pulling the introducer out, apply gauze pressure over the insertion site until bleeding has stopped. Place an occlusive dressing over the site. During the procedure observe the patients cardiac monitor reading and record their response and vital signs after the catheter has been removed. Once again follow your facility policy and procedure for post PA catheter removal. 19

Conclusion The use of the PA catheter is a common procedure in many critical care settings. It is therefore important for health care professionals working in these areas to understand the background of the PA catheter, its risks and benefits. Healthcare professionals working with PA catheters should be thoroughly trained in safely and efficiently inserting, maintaining, collecting the hemodynamic values, and removing the PA catheter. Competency in regard to PA catheter use is especially important given that the benefits associated with the catheter are still being widely debated. Fortunately, the risks of complications from its use is low, however since real potential risks do exist, it should only be used for specific clinical purposes. Knowledge and skill associated with the PA catheter is very important to prevent inaccurate readings that could result in the mismanagement of the patient, perhaps to their detriment. It is the responsibility of clinicians in critical settings to keep up to date in regards to PA catheter uses, especially in areas where the PA catheter is routinely used (e.g. performing a PWCP pressure and CO). Please Read: This publication is intended solely for the use of healthcare professionals taking this course, for credit, from RN.com. It is designed to assist healthcare professionals, including nurses, in addressing many issues associated with healthcare. The guidance provided in this publication is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold RN.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication. The contents of this publication may not be reproduced without written permission from RN.com. 20

References Ahrens, T. S., & Taylor, L. A. (1992). Hemodynamic Waveform Analysis (1st ed.). Saunders. Brunner, C. (1998). Little Rock Critical Care Course. Hemodynamic Monitoring Overview. Lecture Notes. Chong, B.H. (1995). Heparin-induced thrombocytopenia. Journal of Haematology; 89,431-439. Conners, AF Jr, Speroff T, Dawson NV, Thomas C, Harrell FE Jr, Wagner D, et al. (1996) The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA; 276: 889-897. Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D, Brampton W, Williams D, Young D, Rowan K. (2005). Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): A randomized controlled trial. Lancet; 366(9484):472-7. Ivanov, R., Allen, J., Calvin, J.E. (2000). The incidence of major morbidity in critically ill patients managed with pulmonary artery catheters: A meta-analysis. Critical Care Medicine; 28, 615. Kearney, T.J. & Shabut, M.M. (1995). Pulmonary Artery Rupture Associated with the Swan-Ganz Catheter. American College of Chest Physicians; 84, 243-249. Keckeisen, M. (2004). Monitoring Pulmonary Artery Pressure. Critical Care Nurse; 24, 67-69. Leatherman, JW, Marini JJ. (1998). Clinical use of the pulmonary artery catheter. In: Hall JB, Schmidt GA, Wood LDH (eds) Principles of Critical Care 2nd ed. McGraw-Hill, New York. pp 155-176. Lynn-McHale, D. & Carlson, L. (2003) AACN Procedure Manual for Critical Care, 4th Edition. Philadelphia, PA: Saunders. Marini, J.J., O Quinn, R., Culver, B.H., & Butler, J. (1982). Estimation of transmural cardiac pressure during ventilation with PEEP. Journal of Applied Physiology; 53, 384-391. Monnet X, Richard C, Teboul J-L. (2004). The pulmonary artery catheter in critically ill patients. Does it change outcome? Minerva Anestesiology; 70, 219-24. Mosteller, R.D. (1987). Simplified Calculation of Body Surface Area. New England Journal of Medicine; 17, 317. Mueller HS, Chatterjee K, Davis KB, et al. (1998). ACC expert consensus document. Present use of beside right heart catheterization in patients with cardiac disease. American College of Cardiology. J Am Coll Cardiol; 32:840. Prentice D, Ahrens T. (2001). Controversies in the use of the pulmonary artery catheter (hemodynamic monitoring). Journal of Cardiovascular Nursing; 15(2):1-5. Richard D, Warszawski J, Anguel N, Deye N, Combes A, Barnoud D, et al. for the French Pulmonary Artery Catheter Study Group. (2003). Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome. JAMA; 290:2713-2720. 21

Summerhill EM, Baram M. (2005). Principles of pulmonary artery catheterization in the critically ill. Lung; 183:209-219. Swan HJC, Ganz W, Forester J. (1970). Catheterization of the heart in man with use of a flowdirected balloon tipped catheter. New England Journal of Medicine; 283:447-51. Urden, L., Stacey, K., & Lough, M. (2002). Thelan s Critical Care Nursing Diagnosis and Management. 4th Edition. Philadelphia, PA: Mosby. Weinhous, G., Manaker, S. (2005). Insertion of Swan-Ganz Catheters. Up-To-Date. Winsor, T., Burch, G.E. (1945). Phlebostatic Axis and Phlebostatic Level: Reference Levels For Venous Pressure Measurements in Man. Proc Soc Exp Biol Med; 58, 165-169. Copyright 2007, AMN Healthcare, Inc. 22

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