The Vitals: Pulmonary Artery Catheter

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The Pre-brief

The pulmonary artery catheter (PAC), AKA Swan-Ganz catheter is a balloon-tipped, thermodilution catheter that is inserted percutaneously into a proximal, or central vein (jugular, subclavian, or femoral), then “floated” through the right ventricle and into the pulmonary artery.^1,2 PACs can aid in the diagnosis and management of complex circulatory disease processes, such as pulmonary hypertension or undifferentiated shock by measuring select cardiopulmonary pressures. These pressures include:

These measurements, when integrated with clinical observations and other non-invasive studies, such as focused cardiac ultrasound (FoCUS),³ may provide a detailed picture of the patient’s hemodynamic state.⁴ PA catheters remain an pragmatic tool for assessment of patients with various cardiovascular illnesses, and is a core procedure for critical care practitioners.⁵ Indications and Contraindications There are no definitive indications for PA catheter use, per se. However, like any monitoring device, the decision to place a PA catheter depends on one question- “Do I have a specific question about my hemodynamically unstable patient, which can’t be answered non-invasively?” ⁶ Some examples of PAC indication include: ¹¹

Cardiac output measurement, especially in a patient with:
- Arrhythmia
- Intra-aortic balloon pump
Unequal right and left ventricular failure
Diagnosis and management of “mixed” or undifferentiated shock states (some combination of obstructive, distributive, cardiogenic or hypovolemic shock)
Differentiating cardiogenic from non-cardiogenic pulmonary edema
Titration of vasopressors, inotropes, fluids, diuretics, and pulmonary vasodilators (including nitric oxide and prostacyclin)
Diagnosis and management of pulmonary hypertension
Titration of support in the perioperative period for patients undergoing cardiac surgery

Potential contraindications for PA catheter placement include:^6,7,12

Severe coagulopathy or thrombocytopenia
Left bundle branch block (catheter placement may precipitate complete heart block)
Ability for non-invasive measurements to answer your clinical question or direct management
Insertion of the catheter through a site with an active infection
Pathology of the right heart, including:
- Presence of a right sided ventricular assist device
- Tricuspid or pulmonary valve prosthesis
- Right-sided masses (endocarditis, tumors, or blood clots)
- Presence of endocardial pacing leads
- Right-sided valve disease (e.g. tricuspid or pulmonary regurgitation)

Anatomy of a Pulmonary Artery Catheter
The PA catheter is essentially a four lumen (or more) catheter with a thermodilution sensor (Figure 1).^13–15 The PA catheters range from 60 to 110 cm in length, and 4 to 8 French in diameter.¹

While many PA catheters have additional ports or connections, the basic components include the following:^1,14,15

Proximal injectate hub (blue lumen): The blue lumen, or CVP port, lies 30 cm from the tip of the PA catheter in the right atrium. It is used to assess right atrial pressure and central venous pressure. You can also infuse medications through this lumen, or the injectate for cardiac output studies.
Volume infusion port (white lumen): The white lumen lies approximately 31 cm from the distal PA catheter tip and is used to infuse medications.

PA distal lumen hub (yellow lumen): The yellow lumen, or PA distal hub, is the distal port of the PA catheter. This lumen measures the pulmonary artery pressure, and may be used to draw a mixed venous sample. Caustic or hyperosmotic solutions must not be infused through the yellow lumen.

Thermistor connector and Thermal filament connector: These ports include a temperature-sensitive wire that lies in the main pulmonary artery. These connectors allow the measurement of cardiac output via thermodilution.

Balloon inflation valve (red lumen): The red lumen is the distal balloon port, which connects to a syringe (note that the plunger only withdraws to 1.5ml)

PA catheters may include other technology, including a transvenous pacemaker, fiberoptics that can continually monitor mixed venous oxygen saturation or cardiac output.

References

Rodriguez Ziccardi M, Khalid N. Pulmonary Artery Catheterization. In: StatPearls. StatPearls Publishing; 2020. Accessed June 27, 2020. http://www.ncbi.nlm.nih.gov/books/NBK482170/
Biswas S, Pellegrin K, Allen B. Pulmonary Artery Catheter Placement. In: Demetriades D, Inaba K, Lumb PD, eds. Atlas of Critical Care Procedures. Springer International Publishing; 2018:117-124. doi:10.1007/978-3-319-78367-3_14
Neskovic AN, Skinner H, Price S, et al. Focus cardiac ultrasound core curriculum and core syllabus of the European Association of Cardiovascular Imaging. Eur Heart J – Cardiovasc Imaging. 2018;19(5):475-481. doi:10/gg3d35
Vincent J-L. A reappraisal for the use of pulmonary artery catheters. Crit Care Lond Engl. 2006;10 Suppl 3:S1. doi:10/cp57v9
Kelly CR, Rabbani LE. Pulmonary-Artery Catheterization. N Engl J Med. 2013;369(25):e35. doi:10/gbfb7r
Yartsev A. Indications, contraindications and complications of pulmonary artery catheter insertion. Deranged Physiology. Published January 8, 2020. Accessed June 27, 2020. https://derangedphysiology.com/main/cicm-primary-exam/required-reading/cardiovascular-system/Chapter%20804/indications-contraindications-and-complications-pulmonary-artery-catheter-insertion
Chatterjee K. The Swan-Ganz Catheters: Past, Present, and Future: A Viewpoint. Circulation. 2009;119(1):147-152. doi:10/b5gr7j
Rapoport J, Teres D, Steingrub J, Higgins T, McGee W, Lemeshow S. Patient characteristics and ICU organizational factors that influence frequency of pulmonary artery catheterization. JAMA. 2000;283(19):2559-2567. doi:10/fcqksz
Koo KKY, Sun JCJ, Zhou Q, et al. Pulmonary artery catheters: evolving rates and reasons for use. Crit Care Med. 2011;39(7):1613-1618. doi:10/c7rhpm
Connors AF, Speroff T, Dawson NV, et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators. JAMA. 1996;276(11):889-897. doi:10/fc9whj
Chittock DR, Dhingra VK, Ronco JJ, et al. Severity of illness and risk of death associated with pulmonary artery catheter use. Crit Care Med. 2004;32(4):911-915. doi:10/bcw97h
Evans DC, Doraiswamy VA, Prosciak MP, et al. Complications associated with pulmonary artery catheters: a comprehensive clinical review. Scand J Surg SJS Off Organ Finn Surg Soc Scand Surg Soc. 2009;98(4):199-208. doi:10/gg3d4v
Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D. Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter. N Engl J Med. 1970;283(9):447-451. doi:10/fm76s6
Yartsev A. Anatomy of the pulmonary artery catheter. Deranged Physiology. Published January 8, 2020. Accessed June 27, 2020. https://derangedphysiology.com/main/cicm-primary-exam/required-reading/cardiovascular-system/Chapter%20801/anatomy-pulmonary-artery-catheter
Nickson C. Pulmonary Artery Catheter. Life in the Fastlane. Published September 14, 2019. Accessed June 27, 2020. https://litfl.com/pulmonary-artery-catheter/
Rodriguez Ziccardi M, Khalid N. Pulmonary Artery Catheterization. In: StatPearls. StatPearls Publishing; 2020. Accessed June 27, 2020. http://www.ncbi.nlm.nih.gov/books/NBK482170/
Advanced Hemodynamic Monitoring Swan-Ganz Pulmonary Artery Catheter. Published online January 1, 2018. Accessed June 27, 2020. https://educationgb.edwards.com/swan-ganztm-double-sided-brochure/347979#