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Introduction

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Pulmonary artery catheterization is a procedure permitting evaluation of pulmonary arterial pressures, pulmonary artery occlusion pressure, cardiac output, mixed venous oxygen saturation, and volumetric measurements on the right side of the heart.

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Definitions and Terms

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  • ▪  Pulmonary artery catheter (PAC): A multilumen, balloon-tipped catheter designed to permit simultaneous measurements of pressure in the vena cava and pulmonary artery, as well as intermitted measurement of pulmonary artery occlusion pressure (also called pulmonary capillary wedge pressure) when the balloon is inflated, and measurement of the blood temperature at the tip of the catheter.
  • ▪  Mixed venous PAC: A PAC equipped with a fiberoptic bundle and designed to permit oximetric analysis of blood at the tip of the catheter—typically in the pulmonary circulation.
  • ▪  Continuous cardiac output PAC: A PAC equipped with a heating element permitting continuous evaluation of cardiac output.
  • ▪  Volumetric PAC: A PAC designed to measure right ventricular ejection fraction.

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Techniques

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  • ▪  Indications (this is a subject of a great deal of dispute in recent medical literature, so these indications will be very limited in scope):
    • —Measurement of pulmonary arterial pressures
    • —Direct measurement of cardiac output
    • —Continuous measurement of cardiac output and/or mixed venous oxygen saturation
    • —Continuous measurement of trends in hemodynamic data
  • ▪  Contraindications:
    • —Coagulopathy
    • —Friable right heart lesions (ie, clot or valvular vegetation)
  • ▪  Access to the central circulation is as described in Chapter 36.
    • —The PAC is inserted through an appropriately sized sheath following balloon testing (Figure 38-1) and placement of a sleeve over the PAC (Figure 38-2), which will permit subsequent manipulation of the PAC without surface contamination.
    • —The PAC is inserted to a depth of approximately 20 cm, at which point the balloon is inflated (Figure 38-3).
    • —The PAC is then advanced through the right ventricle into the pulmonary artery, using waveforms to determine the location of the tip (Figures 38-4, 38-5, 38-6, 38-7, 38-8, 38-9, 38-10, and 38-11).
    • —When the waveform indicates that balloon is wedged (Figures 38-12 and 38-13), it should be deflated and the sleeve extended to cover the catheter and locked in place.
  • ▪  Complications:
    • —See Chapter 36
    • —Pulmonary infarction secondary to prolonged balloon inflation or overinflation
    • —Knotting of catheter

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Figure 38-1.
Graphic Jump Location

PAC prior to insertion laid out with balloon inflated on large drape.

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Figure 38-4.
Graphic Jump Location

Timing of electrocardiographic (ECG) events relative to pulmonary arterial pressure events.

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