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Fox WE, Marshall M, Walters SM, Mangunta VR, Ragosta M, Kleiman AM, McNeil JS. Bedside Clinician's Guide to Pulmonary Artery Catheters. Crit Care Nurse 2023; 43:9-18. [PMID: 37524367 DOI: 10.4037/ccn2023133] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
BACKGROUND Pulmonary artery catheters provide important information about cardiac function, mixed venous oxygenation, and right-sided pressures and potentially provide temporary pacing ability. OBJECTIVE To provide bedside clinicians with guidance for techniques to insert right heart monitors and devices, describe risk factors for difficult insertion and contraindications to placement, and provide updates on new technologies that may be encountered in the intensive care unit. METHODS An extensive literature review was performed. Experienced clinicians were asked to identify topics not addressed in the literature. RESULTS Advanced imaging techniques such as transesophageal echocardiography or fluoroscopy can supplement traditional pressure waveform-guided insertion when needed, and several other techniques can be used to facilitate passage into the pulmonary artery. Caution is warranted when attempting insertion in patients with right-sided masses or preexisting conduction abnormalities. New technologies include a pacing catheter that anchors to the right ventricle and a remote monitoring device that is implanted in the pulmonary artery. DISCUSSION Bedside clinicians should be aware of risk factors such as atrial fibrillation with dilated atria, decreased ventricular function, pulmonary hypertension, and right-sided structural abnormalities that can make pulmonary artery catheter insertion challenging. Clinicians should be familiar with advanced techniques and imaging options to facilitate placement. CONCLUSION The overall risk of serious complications with right heart catheter placement and manipulation is low and often outweighed by its benefits, specifically pressure monitoring and pacing.
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Affiliation(s)
- W Everett Fox
- W. Everett Fox is an anesthesiology resident, Department of Anesthesiology, University of Virginia Health System (UVA Health), Charlottesville, Virginia
| | - Michael Marshall
- Michael Marshall is a charge and bedside registered nurse, coronary care unit, UVA Health
| | - Susan M Walters
- Susan M. Walters is a cardiothoracic anesthesiologist and an assistant professor of anesthesiology, Department of Anesthesiology, UVA Health
| | - Venkat R Mangunta
- Venkat R. Mangunta is a cardiothoracic and intensive care anesthesiologist and an assistant professor of anesthesiology, Department of Anesthesiology, UVA Health
| | - Michael Ragosta
- Michael Ragosta is a professor of cardiology and the Medical Director of the cardiac catheterization laboratory and interventional cardiology fellowship, Cardiology Division, Department of Internal Medicine, UVA Health
| | - Amanda M Kleiman
- Amanda M. Kleiman is a cardiothoracic anesthesiologist and an associate professor of anesthesiology, Department of Anesthesiology, UVA Health
| | - John S McNeil
- John S. McNeil is a cardiothoracic anesthesiologist and an associate professor of anesthesiology, Department of Anesthesiology, UVA Health
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Josan E, Pastis N, Shaman Z. Ultrasound guided pulmonary artery catheter insertion: An alternative to fluoroscopic guidance. Respir Med Case Rep 2022; 38:101678. [PMID: 35656092 PMCID: PMC9151730 DOI: 10.1016/j.rmcr.2022.101678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/19/2022] [Indexed: 11/01/2022] Open
Abstract
Pulmonary artery catheters (PACs) can provide extremely valuable objective data in select patients. They are usually advanced by floatation of balloon tip along the normal blood flow and their placement is confirmed under pressure waveform guidance. Imaging such as fluoroscopy is often employed in low flow states and in cardiac catheterization suite to reduce the failure rate and time to wedge; but is not readily available at bedside. In critically ill patient, bedside insertion is feasible but can be complicated by repeated attempts to float the balloon tip through various cardiac chambers. Point of care ultrasound can be used to visualize the balloon tip of PAC inside the cardiac chambers alongside the confirmatory pressure waveform changes.
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Choi H, Jeon JP, Huh J, Kim Y, Hwang W. Cephalad misplacement of a pulmonary artery catheter in a patient with a preexisting Hickman catheter. BMC Anesthesiol 2021; 21:73. [PMID: 34059000 PMCID: PMC8168018 DOI: 10.1186/s12871-021-01254-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 01/24/2021] [Indexed: 11/19/2022] Open
Abstract
Background Pulmonary artery catheter insertion is a routine practice in high-risk patients undergoing cardiac surgery. However, pulmonary artery catheter insertion is associated with numerous complications that can be devastating to the patient. Incorrect placement is an overlooked complication with few case reports to date. Case presentation An 18-year-old male patient underwent elective mitral valve replacement due to severe mitral valve regurgitation. The patient had a history of synovial sarcoma, and Hickman catheter had been inserted in the right internal jugular vein for systemic chemotherapy. We made multiple attempts to position the pulmonary artery catheter in the correct position but failed. A chest radiography revealed that the pulmonary artery catheter was bent and pointed in the cephalad direction. Removal of the pulmonary artery catheter was successful, and the patient was discharged 10 days after the surgery without complications. Conclusions To prevent misplacement of the PAC, clinicians should be aware of multiple risk factors in difficult PAC placement, and be prepared to utilize adjunctive methods, such as TEE and fluoroscopy.
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Affiliation(s)
- Hoon Choi
- Department of Anesthesiology and Pain, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Joon Pyo Jeon
- Department of Anesthesiology and Pain, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Jaewon Huh
- Department of Anesthesiology and Pain, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Youme Kim
- Department of Anesthesiology and Pain, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Wonjung Hwang
- Department of Anesthesiology and Pain, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
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Weinberg L, Yii BBiomed M, Li BBiomed M, Louis BBiomed M, Lee DK, Doolan L. Image intensification - A solution for difficult guidewire insertion for central venous access: A case report. Ann Med Surg (Lond) 2020; 50:31-34. [PMID: 31956408 PMCID: PMC6956676 DOI: 10.1016/j.amsu.2019.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/19/2019] [Accepted: 12/31/2019] [Indexed: 11/18/2022] Open
Abstract
Presentation of case A 56-year old male presented for an elective redo-sternotomy, aortic valve replacement, tricuspid valve annuloplasty, and coronary artery bypass grafting. During central vascular access using a standard Seldinger technique, resistance to two spring-wire guide wires was encountered when the wires were advanced through the patient's internal jugular vein. Ultrasound provided limited views of the anatomical path of the guidewires and was unable to provide visualisation of the level or cause of obstruction. We describe the application of continuous image intensification to successfully identify the anatomical location and safe circumnavigation of guidewire obstruction during the insertion of a central venous and pulmonary artery catheter for cardiac surgery. Discussion The use of x-ray image intensification enabled the immediate identification of the cause of obstruction, minimising further attempts at guidewire insertion and subsequent complications. The direct real-time visualisation allowed for manoeuvres such as wire manipulation, rotation and advancement to be safely performed. Conclusion Image intensification may decrease malposition rates and mechanical complications associated with difficult central venous catheterisation. Further research comparing the safety and efficiency of ultrasound-guided and fluoroscopy-guided CVC insertion should be contemplated. Multiple attempts at central line placement are associated with higher rates of complications. Image intensification can be used with ultrasound to facilitate the safe placement of central venous/pulmonary artery catheters. Image intensification can provide continuous and real-time visualisation of the guidewire along the vessel's anatomical course. Image intensification may decrease malposition and mechanical complications associated with difficult central venous access.
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Affiliation(s)
- Laurence Weinberg
- Department of Anesthesia, Austin Health, 145 Studley Road, Heidelberg, 3084, Australia
- Corresponding author. Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia.
| | - Matthew Yii BBiomed
- Department of Anesthesia, Austin Health, 145 Studley Road, Heidelberg, 3084, Australia
| | - Michael Li BBiomed
- Department of Anesthesia, Austin Health, 145 Studley Road, Heidelberg, 3084, Australia
| | - Maleck Louis BBiomed
- Department of Anesthesia, Austin Health, 145 Studley Road, Heidelberg, 3084, Australia
| | - Dong Kyu Lee
- Dept. of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Guro-Gu, Seoul, 08308, Republic of Korea
| | - Laurie Doolan
- Department of Anesthesia, Austin Health, 145 Studley Road, Heidelberg, 3084, Australia
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Oh DK, Song JM, Park DW, Oh SY, Ryu JS, Lee J, Lee SD, Lee JS. The effect of a multidisciplinary team on the implementation rates of major diagnostic and therapeutic procedures of chronic thromboembolic pulmonary hypertension. Heart Lung 2018; 48:28-33. [PMID: 30115494 DOI: 10.1016/j.hrtlng.2018.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 07/16/2018] [Accepted: 07/16/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although guidelines have recommended that patients with chronic thromboembolic pulmonary hypertension (CTEPH) should be managed by a multidisciplinary team (MDT), there is a lack of clinical data indicating that the MDT improves CTEPH management. OBJECTIVES The study aimed to identify the effect of an MDT on CTEPH management. METHODS We divided the study period into pre-MDT and post-MDT eras and compared the implementation rates of major diagnostic and therapeutic procedures. RESULTS Of 116 patients with CTEPH, 42 (36.2%) were diagnosed in the post-MDT era. The implementation rates of right heart catheterization (10.8% vs. 97.6%, p < 0.001) and pulmonary endarterectomy (32.4% vs. 59.5%, p < 0.005) were significantly increased in the post-MDT era. Balloon pulmonary angioplasty was not performed in the pre-MDT era but was performed in the post-MDT era. CONCLUSIONS The MDT appears to be associated with improved CTEPH management.
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Affiliation(s)
- Dong Kyu Oh
- Department of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jong-Min Song
- Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea; Pulmonary Hypertension and Venous Thrombosis Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Duk-Woo Park
- Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea; Pulmonary Hypertension and Venous Thrombosis Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sang Young Oh
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea; Pulmonary Hypertension and Venous Thrombosis Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jin-Sook Ryu
- Department of Nuclear Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea; Pulmonary Hypertension and Venous Thrombosis Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jaewon Lee
- Department of Thoracic and Cardiovascular Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea; Pulmonary Hypertension and Venous Thrombosis Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sang Do Lee
- Department of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jae Seung Lee
- Department of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea; Pulmonary Hypertension and Venous Thrombosis Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
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