Pulmonary artery catheterization
In addition to the risks of central venous catheterization listed above, pulmonary artery (PA) catheterization has caused catastrophic pulmonary artery rupture and comes with the increased risk of arrhythmias, complete heart block (particularly if the patient has a pre-existing left bundle branch block), pulmonary embolism, and cardiac valve damage.
Thus, this invasive technique requires rigorous justifi-cation. Do you really need to have PA pressure, PA occlusion pressure (PAOP, also known as pulmonary capillary wedge pressure, PCWP), or cardiac output? And how will it affect your management?
After placing an introducer (a special large-bore central venous catheter) via the central venous access technique above, a PAC is sterilely inserted through the introducer.
(i) Prepare the catheter: flush and cap the PAC ports. Test the balloon for symmet-ric inflation and passive deflation on release of the syringe pressure. Connect the PA distal port to a pressure transducer with the monitor in view. Cover the catheter with the clear plastic sheath3 that maintains internal sterility for subsequent manipulation of catheter depth.
(ii) Advance the catheter through the introducer to 20 cm and confirm the CVP waveform on the monitor (see below). Instruct an assistant to inflate the balloon.
(iii) Advance the catheter while keeping track of its depth as well as the waveform transduced from its tip (Fig. 3.2). The RV tracing should appear before the catheter has been advanced about 30 cm, and the PAOP before 50 cm. If they do not, deflate the balloon, pull back the catheter 10 cm or so, reinflate the balloon and try again. Over-insertion can result in a knot, necessitating a vascular procedure to remove the catheter.
(iv) Once the PAOP tracing is obtained, deflate the balloon and confirm reappear-ance of the PA trace. If this does not occur, you must withdraw the catheter a few centimeters. Continue manipulation until the PA trace with the balloon deflated becomes the PAOP (or wedge) trace on inflation. Always inflate the balloon to just barely occlude the PA pressure in order to avoid rupturing the vessel. And remember . . . balloon up on catheter advancement, balloon downon withdrawal.
(v) Aspirate to confirm intravascular location, and flush all ports. Obtain a chest radiograph to confirm proper location (within the mediastinal shadow).