An analysis of prior experience influencing quality of pulmonary artery catheter placement in residents

Bedside Clinician's Guide to Pulmonary Artery Catheters

BACKGROUND

Pulmonary artery catheters provide important information about cardiac function, mixed venous oxygenation, and right-sided pressures and potentially provide temporary pacing ability.

OBJECTIVE

To provide bedside clinicians with guidance for techniques to insert right heart monitors and devices, describe risk factors for difficult insertion and contraindications to placement, and provide updates on new technologies that may be encountered in the intensive care unit.

METHODS

An extensive literature review was performed. Experienced clinicians were asked to identify topics not addressed in the literature.

RESULTS

Advanced imaging techniques such as transesophageal echocardiography or fluoroscopy can supplement traditional pressure waveform-guided insertion when needed, and several other techniques can be used to facilitate passage into the pulmonary artery. Caution is warranted when attempting insertion in patients with right-sided masses or preexisting conduction abnormalities. New technologies include a pacing catheter that anchors to the right ventricle and a remote monitoring device that is implanted in the pulmonary artery.

DISCUSSION

Bedside clinicians should be aware of risk factors such as atrial fibrillation with dilated atria, decreased ventricular function, pulmonary hypertension, and right-sided structural abnormalities that can make pulmonary artery catheter insertion challenging. Clinicians should be familiar with advanced techniques and imaging options to facilitate placement.

CONCLUSION

The overall risk of serious complications with right heart catheter placement and manipulation is low and often outweighed by its benefits, specifically pressure monitoring and pacing.

An analysis of factors influencing pulmonary artery catheter passage through the tricuspid and pulmonary valves

Purpose

A pulmonary artery catheter (PAC) has to pass the tricuspid and pulmonary valves for its proper placement. Although several factors were reported to hinder the placement, there have been no reports to identify the factors that prolong the individual time for passing through each valve.

Method

We individually measured the time required for a PAC to pass through the tricuspid and pulmonary valves. We examined the effect of the following factors on those times: the patient’s age, sex, height, weight, cardiothoracic ratio, tricuspid regurgitation, left ventricular ejection fraction, and the diameters of the sinus of Valsalva and of the sinotubular junction divided by the body surface area which represent the diameter of the aorta. Data were analyzed by multiple linear regression analysis after univariate analysis.

Results

The placement of a PAC was successful in all of 100 patients. The time required to pass through the pulmonary valve was significantly longer than that through the tricuspid valve (15 [10–28] s vs 9 [5–16] s, median [range], P < 0.01). The incidence of ventricular arrhythmias during passage through the pulmonary valve was significantly higher than that through the tricuspid valve (17% vs 0%, P < 0.01). Tricuspid regurgitation and the diameter of sinotubular junction had a significant positive association with the time required to advance a PAC through the pulmonary valve, although there was no significant factors that increased the time required to advance a PAC through the tricuspid valve.

Conclusion

The time required to advance a PAC through the pulmonary valve is much longer than that to pass through the tricuspid valve. The diameter of aortic root and tricuspid regurgitation are significant factors that increased the time required to advance a PAC through the pulmonary valve.

Analysis of difficulty in placement of pulmonary artery catheter through the left internal jugular vein

Purpose

The left internal jugular vein may be an alternative route for the placement of a pulmonary artery catheter when the right jugular vein is not available. Although the placement through the left internal jugular vein is expected to be more difficult, little has been written regarding difficulties in achieving proper placement of the catheter through the left internal jugular vein.

Methods

This prospective and observational study includes patients undergoing cardiac surgery with the catheter placement by monitoring the pressure waveform for 2 years. We measured the time required for the catheter to pass through the tricuspid and pulmonary valves, respectively. The data were analyzed by Mann-Whitney. P < 0.05 was considered significant.

Results

The catheter placement through the right and left internal jugular vein was done in 285 (group R) and 10 patients (group L), respectively. The time duration through the tricuspid valve in group L was significantly longer than that in group P (8 [5–14] s vs 70 [19.8–138] s, median [range], P < 0.01), whereas the time duration through the pulmonary valve was comparable between the two groups (15 [10–27.75] s vs 15 [10.25–19] s, median [range], P = 0.62).

Conclusion

These results indicate that the difficulty in the catheter placement through the left jugular vein may be to pass through the tricuspid valve, not the pulmonary valve.