Indications, Contraindications and Complications of Pulmonary Artery Catheter Insertion

Created on Mon, 06/29/2015 - 18:17
Last updated on Mon, 06/29/2015 - 18:18

Is it safe, doctor?

One may feel an understandable reluctance to subject one's fragile patient to an investigation which has received such terrible publicity. However, one must remember: PACs don't kill people, people kill people.

In the wrong hands even a peripheral cannula is a lethal weapon.

Indications for insertion of a PA catheter

There are no hard indications, per se. The decision should rest on the need to answer a specific question about the hemodynamically unstable patient, which cant be answered with a less invasive technique.

Essentially, you would ask of the PAC, “Why is my patient hypotensive? Should I fill my patient more, or should I try to push the vasopressors? Is there room to move with fluids?”

  • Cardiac output measurement especially in a patient with arrhythmia or aortic balloon pump, where PiCCO cant be used
  • Unequal right and left ventricular failure
  • Complex hemodynamic instability, some combination of obstructive, distributive, cardiogenic and hypovolemic shock
  • To differentiate cardiogenic pulmonary edema from non-cardiogenic
  • To guide use of vasopressors, inotropes, fluids and diuretics – when the patient has a hemodynamic problem combined with pulmonary oedema and ventricular dysfunction.
  • To titrate pulmonary antihypertensives in ARDS (like nitric oxide and prostacyclin)

A good 2009 review article on the historical changes in the utility of the PA catheter presents a list of "modern" indications, which resembles the following:

  • Cardiogenic shock during supportive therapy
  • Discordant right and left ventricular failure
  • Severe chronic heart failure requiring inotropic, vasopressor, and vasodilator therapy
  • Suspected “pseudosepsis” (high cardiac output, low systemic vascular resistance, elevated right atrial and pulmonary capillary wedge pressures)
  • Potentially reversible systolic heart failure such as fulminant myocarditis and peripartum cardiomyopathy
  • Haemodynamic differential diagnosis of pulmonary hypertension
  • To assess response to therapy in patients with precapillary and mixed types of pulmonary hypertension
  • Cardiac / pulmonary transplantation workup

Contraindications

    • Tricuspid or pulmonary valve prosthesis  which can be damaged
    • Tricuspid or pulmonary valve vegetations  which can be dislodged
    • Endocarditis in general
    • Right heart mass (be it tumor or clot)

Complications

  • Same as CVC:
    • Perforation of SVC
    • Hemothorax, pneumothorax
    • Atrial fibrillation
  • Unique to PA catheter
    • Ventricular Arrhythmia
    • Thromboembolic events (the catheter is a nidus for clot formation)
    • Mural thrombi in the right heart (up to 30%)
    • Air embolism from ruptured balloon
    • Pulmonary infarction
    • Endocarditis of the pulmonary valve ( 2%)

    • Right bundle branch block
      • If you already have LBBB, this causes complete heart block
      • If you are lucky, it is a transient phenomenon and you only need to pace them transcutaneously for a brief period. If you are unlucky, you have injured the AV node, and the patient needs prolonged transvenous pacing
    • Knotting on structures or on itself ( ~ 1%)
      • If it has gone into the right ventricle by 25-30cm and its still not in the pulmonary artery, you start to worry
    • Damage to the valves
      •  Never pull the catheter back with the balloon inflated! You could tear the valve leaflets
    • Pulmonary artery rupture: 0.2% risk,  30% mortality
      • Risk factors: pulmonary hypertension, mitral valve disease, anticoagulants and age over 60
      • Management:
        • Lay the patient ruptured side down
        • Intubate them with a double-lumen tube
        • Increase the PEEP to put pressure on the wound
        • Repair in cardiothoracic theatre

 

References

This a full-text version of the seminal paper from 1970:

Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D (August 1970). "Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter"N. Engl. J. Med. 283 (9): 447–51.

A manufacturer (Edwards) offers some free information about the PA catheter on their product page.

Chatterjee, Kanu. "The swan-ganz catheters: past, present, and future a viewpoint." Circulation 119.1 (2009): 147-152.

The PA catheter section from The ICU Book by Paul L Marino (3rd edition, 2007) is a valuable read.

Additionally, UpToDate has an article on PA catheter complications.