Chapter 3

INTRODUCTION

The first peer-reviewed, journal publication describing the clinical utility of the pulmonary artery catheter (i.e., PA catheter, Swan–Ganz catheter) dates its roots to H. J. Swan’s original publication in the New England Journal of Medicine in 1970, although the experimental concept of the catheter was described much earlier by Lategola and Rahn in 1953. Since its inception, the clinical use of the PA catheter has become a prevalent intra-operative monitoring modality during complex cardiovascular, thoracic, and organ transplant operations, as well as during the postoperative period in the management of critically ill patients. The PA catheter allows clinicians to easily and rapidly transduce a patient’s central venous pressure (CVP), pulmonary artery pressure (PAP), as well as measure a patient’s temperature, pulmonary capillary wedge pressure, mixed venous oxygen saturation (MVO2), systemic and pulmonary vascular resistance (SVR and PVR), and calculate a patient’s cardiac output (CO) and cardiac index (CI).

PULMONARY ARTERY CATHETER ANATOMY

The modern PA catheter is 7.5 FR, 110 cm long, typically made of polyvinylchloride and consists of multiple ports to access the central venous and pulmonary artery circulation. Typically, a thermistor (located 4 cm from the most distal port, tip of the catheter) facilitates the continuous measurement of the core blood temperature and also serves as the basis for the calculation of a patient’s CO and CI via the thermodilution technique (Figure 3-1). The distal port (located at 0 cm, tip of the catheter) allows the clinician to directly transduce the PAP, while assessing the left ventricular function indirectly based on the left ventricular end-diastolic pressure (LVEDP) and pulmonary capillary wedge pressure. The proximal port (located 30 cm from the most distal port, tip of the catheter) facilitates the continuous administration of fluids and medications at the level of the right atrium (RA), while transducing a patient’s right atrial pressure (RAP) as well as CVP. The proximal injectate lumen also marks the exit point for the cold injectate used in the determination of a patient’s CO and CI via the thermodilution technique.

FIGURE 3-1

Anatomical representation of the PA catheter. (Reproduced with permission from Butterworth JF, Mackey DC, Wasnick JD, eds. Morgan & Mikhail’s Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill Education, Inc.; 2013: Fig. 5-20.)

CLINICAL INDICATIONS

Possible clinical indications for the placement of a PA catheter include:

1. Neurological

1. Posterior fossa surgery (i.e., sitting craniotomy)

2. Venous air embolism

2. Cardiovascular

1. Impaired left ventricular systolic function (ejection fraction < 35%)

2. Hemodynamically significant cardiac valvular disease

3. Intraoperative management of surgical patients requiring the application of an aortic clamp/cardiac pulmonary bypass/deep hypothermic circulatory arrest

4. Significant coronary artery disease/unstable angina

5. Recent myocardial infarction

6. Congestive heart failure, cardiomyopathy or cor pulmonale

7. Thoraco-abdominal aneurysm repair

8. Liver/multivisceral transplantation

3. Pulmonary

1. Severe chronic obstructive pulmonary disease

2. Acute respiratory distress syndrome

3. Lung transplantation

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