PULMONARY ARTERY PRESSURE MONITORING

LEARNING OBJECTIVES

After review/ study of the CCNS Orientation manual, attendance at the CCNS Orientation Skills Lab, and completion of unit level orientation the orientee will be able to:

1. Collect all necessary equipment/supplies necessary to set-up a triple transducer pressure system.
2. State the correct solutions/medications used at WRAMC for the flush bags.
3. Correctly assemble triple pressure transducer system.
4. Correctly level and zero the transducer.
5. Correctly identify the location and purpose of each port/ lumen of the PA catheter (PA cath).
6. Identify in sequence the normal waveforms observed during PA cath insertion, and state the corresponding pressure.
7. Correctly obtain the following pressures:

Pulmonary artery systolic, diastolic and mean.
• Pulmonary capillary wedge.
• Central venous pressure.

      8. Briefly describe the indications, limitations and complications of PA catheterization guidelines for accurate monitoring, and troubleshooting techniques.

  PURPOSE:

  1. To assess the left ventricular end-diastolic pressure indirectly.
  2. To evaluate the hemodynamic response to fluid therapy, medication and other treatments.
  3. To obtain accurate central vascular pressures in the presence of low cardiac output.
  4. To obtain mixed venous blood samples.
  5. To measure cardiac output.

  INDICATIONS

  	Shock states
  Diagnoses and evaluation of heart disease
  Medical conditions that compromise cardiac output
  To determine fluid volume status
  Complex surgery with potential for compromise

   

  SPECIAL EQUIPMENT

  Flush solution for transducer system              Flush solution for cardiac output system

  Arterial access line                                  Disposable triple pressure transducer system

  Pulmonary artery catheter                                  Monitor, module, electrodes, cables

  Central line kit                                              Transducer holder, I.V. pole, pressure bag

  Emergency resuscitation equipment                      Prepackaged Introducer Kit; sutures

  Sterile gowns, gloves, and masks

  Components:

  1. Proximal port – approximately 30 cm from tip of catheter.

  	also known as CVP port (central venous pressure)
  lies in the right atrium and measures CVP
  can be used for infusion of IV solutions or medications, and for drawing blood
  used for injecting cardiac output boluses
  usually color coded blue

  2. Distal port – opening is at the tip (end) of the catheter.

  	also known as a PA port
  lies directly in the pulmonary artery
  measures the pulmonary artery pressures (PAP), systolic (PAS), and diastolic (PAD)
  also measures pulmonary capillary wedge pressure (PCWP) when balloon is inflated
  PA pressures should always be monitored continuously
  NEVER USE for medication infusion
  Can be used for drawing "mixed venous" blood gas sample
  Usually color coded yellow

  3. Thermistor and connector port

  	the thermistor connector connects the pulmonary catheter to the cardiac output computer
  connector is at the end of a separate catheter lumen outside the patient
  thermistor wire within the lumen transmits blood temperature (core temperature is most accurate reflection of the body temperature)
  used in determining cardiac output
  connector tip should always have a protective covering to protect patient from microshock
  usually color coded yellow with red connector

  4. Balloon port

  	located about < 1 cm from tip of the catheter
  when the balloon is inflated with approximately 0.8 to 1.5 cc of air, catheter will become lodged (wedged) in the pulmonary artery given a wedge tracing.
  Reflects the pressures that are in the left side of the heart when inflated
  DO NOT INFLATE WITH LIQUID---- ALWAYS INFLATE WITH AIR
  when deflated, turn stopcock to off position and leave syringe connect to port
  color coded red

  5. A 5 - lumen Swan Ganz catheter has either an infusion port or a pacing port, allowing insertion of a transvenous pacing wire; usually color coded white.

  

  PROCEDURE

  ACTION	RATIONALE
  Prepare for Insertion of PA Line:
  1. Check for signed informed consent if not an emergency.	1. All invasive procedures require consent.
  2. Obtain vital signs and ECG strip.	2. Serves as baseline.
  3. Check security and position of electrodes. Ensure good IV access in place.	3. Safety.
  4. Prepare disposable triple transducer pressure system same as "Single Pressure Transducer System" except flush each additional tubing and port separately.	4. Ensure all tubing and ports clear of air.
  5. Position patient. Trendelenberg for jugular or subclavian route, if tolerated. May be flat in bed with rolled towel between shoulder blades.	5. To engorge vessels and prevent potential air emboli.
  6. Maintain aseptic technique in compliance with "Central Line Insertion Checklist" IAW Infection Control Manual.	6. WRAMC DON Policy – to reduce risk of infection.
  7. Assist physician in flushing each port of the PA catheter and checking balloon tip. Attach flush solution to distal lumen.	7. Ensure patency and integrity. Allow for visualization of waveforms.
  8. Monitor patient response during PA catheter insertion: a. Monitor for continuous sterile technique during insertion. b. Monitor for ventricular dysrhythmias. c. Ensure proper central line dressing applied in compliance with "Central Line Dressing Checklist" IAW Infection Control Manual. d. Observe waveforms – record opening pressures: (1) Right Atrial Pressure (RAP or CVP) (2) Right Ventricular Pressure (RVP): RVP Systolic = 20-30 mmHg RVP Diastolic = 0 – 5 mmHg (3) Pulmonary Artery Pressure (PAP) PAP Systolic = 20-30 mmHg PAP Diastolic = 8-12 mmHg PAP Mean = 25 mmHg (4) Pulmonary Artery Wedge Pressure (PAWP) PAWP = 4- 12 mmHg e. Passively deflate balloon by removing syringe from balloon stopcock. Check for return of PA tracing. f. All pressures should be recorded with patient flat or in no greater than a 15-20 degree angle. g. Use a 3cc syringe with 1.5cc of air. Inflate balloon slowly observing for a PAWP waveform. It should take 1.25 to 1.5 cc. Any amount less, indicates that catheter is too far into PA. Close gate valve to syringe. h. Obtain a chest x-ray.	8. a. Break in aseptic technique is the greatest cause of catheter infection. b. Irritation of ventricles. c. Reduce risk of infection.   d. Serve as baseline. 1- Elevated RAP= volume overload, RV failure, tricuspid stenosis or regurgitation, LV failure or constrictive pericarditis. 2- Elevated RVP = pulmonary hypertension, RV failure, constrictive pericarditis, chronic CHF, heart failure with septal defect, hypoxia. 3- Elevated PAP = left-to-right shunt, LV failure, mitral stenosis or pulmonary hypertension. 4- Elevated PAWP = LV failure, mitral insufficiency or stenosis. e. Manual aspiration causes premature balloon rupture. If left inflated can cause PA ischemia and necrosis. f. For consistency. g. Overfilling may cause rupture of balloon. To prevent inadvertent injection of air or fluid into balloon lumen. h. To confirm position and rule out any complications.

  9. System care and general precautions: a. Continuously monitor hemodynamic system for air. Ensure connections secure. Ensure monitor alarms on at all times. b. Label and change flush bag, tubing, dressing and stopcocks IAW Infection Control Manual. (bags q. 24hrs, tubing and dressing q. 72 hrs., and stopcocks after every blood draw or at least q. 72 hrs.) c. Maintain pressure bag at 300 mmHg. d. Do not flush catheter for longer than 2 seconds. e. Use aseptic technique when withdrawing from or flushing catheter. f. Remove all traces of blood from catheter, tubing, and stopcocks are blood sampling and flush completely. g. Maintain sterility of plastic sleeve over catheter, and avoid placing tape over it. h. Do not infuse viscous fluids via catheter lumens (i.e. whole blood, albumin). i. Monitor and record trends in pressure readings. j. Integrate data with hemodynamic profile and clinical assessment of patient. k. Assess circulation to extremities. l. Administer medication only through the proximal port. Never use the distal or PA port. m. Keep number of PAWP reading to a minimum. If PAD and PAWP are similar (< 4 mmHg difference), then PAD can be substituted for PAWP. n. If strong resistance is met during inflation, do not inflate balloon, notify physician. o. If air goes in freely (without resistance) or if blood comes back, disconnect syringe and close off lumen. Label gate valve with sign that says, "Do not inject air". Notify physician. p. Never flush catheter when in a wedged position. q. If suspect wedged position is due to catheter migration, notify physician immediately.	9.a. Reduce risk of infection and air emboli. Ensure accurate pressures. b. Reduce risk of infection. Compliance with WRAMC policies. c. Prevents clot formation. d. PA rupture may occur with prolonged flush of high pressure fluid. e. Prevents bacterial contamination of system. f. Blood is a medium for bacterial growth. May result in emboli in line. g. Tears will break sterile barrier, making catheter manipulation no longer possible. h. May occlude catheter. The largest lumen of PA catheter is too small for blood and will damage RBC’s and reduce effectiveness of transfusion. i. Isolated results need further evaluation. j. Ensure that these correlate. k. Reduced circulation may result in tissue ischemia.       n. May rupture balloon. o. Balloon may be ruptured. p. May rupture balloon. q. Danger of pulmonary artery rupture. Only physician may move catheter.
  10. Obtain a blood sample of mixed venous blood by aspirating from distal port with balloon deflated: a. Attach 5-ml syringe to stopcock nearest distal port of PA catheter. b. Open stopcock to syringe and aspirate 5 ml to clear catheter of flush solution. c. Close stopcock halfway; remove syringe and discard. d. Add blood gas syringe to stopcock and gently aspirate blood sample over one minute. Place immediately on ice. e. Flush stopcock port and replace deadhead cap.	10. Mixed venous blood gases are frequently analyzed along with arterial blood in order to calculate the shunt fraction or the degree to which blood is bypassing unoxygenated from the lungs to the left side of the hear. d- Ice ensures that results are accurate.
  11. Assist with removal of PA catheter: a. Close pressurized flush system to patient. Disconnect from monitor. b. Position patient in flat or slight Trendelenberg. c. Obtain vital signs. d. Monitor for dysrhythmias while physician removes catheter. e. Apply firm pressure until bleeding stops. f. Apply occlusive dressing. g. Check site and extremities frequently to ascertain bleeding or embolic complications.	11. Physicians remove the PA catheters at WRAMC. a. Safety measure to protect patient from emboli. d. Ventricular dysrhythmias may occur.

  INTEPRETATION of PA WAVEFORMS and VALUES

  

  OTHER PRECAUTIONS

  1. See precautions for "Single Pressure Transducer System".
  2. Set alarms at all times, approximately 20 mmHg above and below the patient’s readings.
  3. If balloon is down and you find PA catheter tracing in wedge position, you may ask the patient to deep breathe and cough, or reposition patient in bed to dislodge it. However, notify physician immediately to reposition catheter by pulling back gently; then, get chest x-ray to confirm proper placement. Do not attempt to flush!
  4. If patient coughs up blood or it is suctioned via endotracheal tube, suspect PA rupture and notify physician immediately.
  5. Respect electrical safety guidelines. (review Electrical Safety under Pacing Section).

  POTENTIAL COMPLICATIONS

  Same as arterial pressure monitoring plus the following:

  Air emboli	Cardiac tamponade
  Thromboembolism	Dysrhythmias
  Catheter displacement/dislodgement	Balloon rupture
  Infection	Lung ischemia
  Inaccurate pressures	Electromicroshock
  Equipment malfunction	Pulmonary artery rupture
  Pneumothorax/Hemothorax	Frank Hemorrhage
  Loss of balloon integrity	Altered skin integrity
  Pulmonary artery extravasation	PA hemorrhage or infarction
  Altered circulation to extremities	Cardiac arrest

  This page last updated 07/25/10

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