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Hemodynamic monitoringAll about the Swan
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Indications for pulmonary artery
catheterization in the ICU:
Establish diagnosis of shock and/or respiratoryfailure
Guide therapy of shock and/or respiratory failure
By improving oxygen delivery
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Information derived from PA catheter
Directly measured
CVP
PAOP
Pulmonary artery
pressure
SvO2
Cardiac output
Calculated
Systemic vascular
resistance
Pulmonary vascularresistance
Stroke volume
Oxygen delivery
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Normal values
Directly measured
CVP 2-4 mm Hg
PA 25/10 PAOP 8-12
SvO2 60-75%
Cardiac output 4-8
L/m
Cardiac index 2.5-4.0
L/min/M2
Calculated
SVR 900-1200 dynes
sec/cm5
PVR 50-140
SV = 50-100mL
SV index 25-45
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Insertion of Swan Ganz
Ask why?
Then immediately ask why not:
Coagulopathy Ventricular ectopy
LBBB
Pacemaker? Defibrillator?
Large pulmonary embolism
Severe pulmonary arterial hypertension
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Swan complications
Associated with cordis placement
Ventricular arrhythmias requiring treatment 1.3 1.5%
Right bundle branch block ~0.5 -5%
Pulmonary artery rupture ~0.06 to 0.2% Pulmonary artery pseudoaneurysm formation
Pulmonary infarction ~ 1.4%
Thromboembolic events ~1.6%
Mural thrombi Sterile cardiac valve vegetation
Endocarditis esp of the pulmonic valve
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So much information, why dont weSwan more often?
1996 observational study Swan within the first 24 hours of ICU admission associated with
increased 30d hospital mortality (OR 1.24)
Association with poor outcome highest in the least sick pts
Meta-analysis of RCTs: no benefit but no harm ESCAPE trial in patients with heart failure: no mortality
benefit
RCT of peri-operative use in high risk pts undergoingcardiac, vascular or orthopedic surgery: no benefit
FACCT study of ARDS pts: no benefit of Swan v. CVPmonitoring in managing vasoactive agents and fluidstatus
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Nevertheless
PAC can be occasionally useful in the
carefully selected patient
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Insertion sites
Insertion
site
RA RV PA PAOP
Comments
IJ 15-20
30 40 45-50 Easy to float especially from right.Carotid puncture/PTX
SC 15-
20
30 40 45-50 Easy to float esp from left.Highest risk PTX
Fem 40-45
50-55
60-65
65-70 Most difficult to floatHighest risk of infection and DVT
Rule of 10s
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Musts
Full barrier precautions for maximal sterile technique
Flush and zero catheter prior to insertion at the phlebostatisaxis
Remember catheter sheath
Once catheter tip is in the right atrium, always advance thecatheter with the balloon inflated.
Always watch the waveforms transduced from the distal endof the catheter while advancing
Always withdraw catheter with the balloon deflated Advance the catheter quickly while in the right ventricle
Advance slowly once the distal tip is in the pulmonary artery
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Waveforms
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X descent: fall n right atrial pressure following atrial contraction
Y descent: call in right atrial pressure following opening of the tricuspid valve and
passive ventricular filling
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ECG correlation is mandatory for correct identification of the right atrial wave forms
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Elevations in RAP
Hypervolemia
Right ventricular infacrtion
Impaired RV contraction Pulmonary hypertension
Pulmonic stenosis
Left to right shunts
Tricuspid valve disease
Cardiac tamponade
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Overwedging
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Abnormal waveforms
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Seen with non compliant ventricle Mitral or tricuspid stenosis
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Seen with tricuspid valve regurgitation Ventricular ischemia
Ventricular failure
Hypervolemia
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Right ventricular pressure
Peak systolic pressure
RV end-diastolic pressure
Early rapid filling (~60% of filling) Slow phase (25% filling)
Atrial systolic phase
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Left to right shunts
Arterial sampling from RA, RV, and PA
Detection og an oxygen saturation step-
up allows confirmation and determinationof its location
Definition of step-up = >10% rise in
oxygen saturation
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Equalization of pressures
RAP = RVed= PCWP
Cardiac tamponade
Constrictive pericardial disease
Restrictive cardiomyopathies
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Cardiac output
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Thermodilution
Saline injected through the proximal port
Thermistor at the distal end of catheter
measures the change in blood temperatureover time
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Area under the curve is inversely proportional to the rate of bloodflow past the pulmonary artery
This rate is equivalent to cardiac output
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Should not differ by more than 10%
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Factors that decrease accuracy ofthermodilution cardiac output
Tricuspid regurgitation
Septal defects
Technical issues Sensor malfunction
Improper injectate
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Continuous thermodilution cardiacoutput
10 cm thermal filament located 15-25 cm
from the catheter tip.
It generates low-energy head pulsestransmitted to surrounding blood
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Interpretation of the data
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Case 2
30F with flank pain, dysuria, fever to 104.
T 104 BP 70/35 HR 140
Exam: Flushed, warm, bounding pulses
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MAP 47
CVP 2
PA 20/5
PAOP 5 CO 7
SvO2 75%
SV ?
SVR ?
What kind of shock?
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Case 3
55M intermittent chest pains for last 24
hours presents with progressive shortness
of breath and weakness
T 96 BP 80/60 HR 120 RR 28 SpO2 88%
Exam: Dyspneic, diaphoretic. Poor capillary
refill. He has JVD, a gallop, soft murmur.
Very little edema
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Case 4
60M feeling bad and losing weight last 8
months. Hasnt seen an MD in 30 years.
Present with progressive weakness,
shortness of breath, and edema.
T 96 BP 75/60 HR 120 RR 24 SpO2 92%
Exam: Cachectic. JVD. Distant heart
sounds. Generalized edema. Thready
pulses, poor capillary refill
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MAP = 70
CVP 24
PA 40/24
PAOP 24 CO 2.4
SvO2 45%
SV?
SVR?
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Case 5
46 F presents with worsening shortness of breath
and chest pains over a 5 days period.
T 98 BP 78/62 HR 130 RR 28 pulse ox 84%
Exam: Tachypneic, dyspneic. JVD. Lungs clear.
Heart sounds tacycardic with RV heave,
pronounced S2, II/VI systolic murmur at LLSB.
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MAP = 67
CVP 14
PA 60/28
PAOP 6 CO 3.5
SvO2 48%
SVR?
PVR?
SV?
What is going on?
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Case 6
36M admitted to the ICU with lobar pneumonia,septic shock.
Given 8 Liters of normal saline over 3 hours, butremains in refractory shock, requiring initiation ofnorephinephrine. Develops progressivehypoxemia and intubated. Post intubation CXRdemonstrates bilateral pulmonary infiltrates
Exam T 103 BP 95/50 HR 120 RR 28 on vent
SpO2 98% Intubated, sedation. Warm and flushed with brisk
capillary refill and bounding pulses.
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MAP 65
CVP 9
PA 35/18
PAOP 16 CO 9.0
SvO2 80%
SVR?
SV?
Clinical scenario?