PA monitoring

1. PULMONARY ARTERY PRESSURE MONITORING
PRINCY FRANCIS M
II MSc (N)
JMCON

2. PULMONARY ARTERY CATHETER
• Dr. Swan and Ganz , 1970

3. PULMONARY ARTERY CATHETER
Pulmonary artery catheter are balloon tipped flow directed catheters
that have distal and proximal lumens used to measure pulmonary
artery pressure.

4. PULMONARY ARTERY CATHETER
• 7.5Fr, 43inch (110 cm) long with 4 or
5 lumens.
Distal Lumen : Pulmonary artery
Balloon port
Proximal lumen : Right atrium , right
atrium and right ventricle.

5. • Thermistor lumen
• Atrial electrode
• Continous cardiac output monitoring
• Fibre optic sensor

6. TYPES
• Four lumen catheter – 1 proximal, 1 distal, 1 balloon inflation valve
and a thermistor wire connector.

7. Five lumen catheter
• Five lumen catheter

8. INDICATIONS
• Diagnostic:
– Differentiation among causes of shock
– Differentiation between mechanisms of pulmonary edema
– Evaluation of pulmonary hypertension
– Diagnosis of pericardial tamponade
– Diagnosis of right to left intracardiac shunts
– Unexplained dyspnea

9. Therapeutic
• Management of perioperative patients with unstable cardiac status
• Management of complicated myocardial infarction
• Management of patients following cardiac surgery/high risk surgery
• Management of severe pre-ecclampsia
• Guide to pharmacologic therapy
• Burns/ Renal Failure/ Heart failure/Sepsis/ Decompensated cirrhosis
• Assess response to pulmonary hypertension specific therapy

10. NORMAL VALUES
Pulmonary artery pressure : Systolic : 15 -25mm Hg , Diastolic: 8-12mm Hg
Mean pulmonary artery pressure : 9- 18 mm Hg
Pulmonary Artery Wedge Pressure : 6 – 12 mm Hg
Central venous pressure : 2 - 6 mm Hg
Right ventricular pressure : Systolic : 15- 30 mm Hg , Diastolic : 3 – 8 mm Hg
Left Ventricular pressure : Systolic : 100 -140 mm Hg, Diastolic : 3 – 12 mm Hg
Cardiac Output : 4- 8 L/mt.

11. EQUIPMENTS
• Swan Ganz catheter
• Heparinized saline, pressure bag, IV tubings, transducer, PM line
• Monitors – cardiac output monitor and cardiac monitor

12. PRE PROCEDURE CARE
 Get informed consent signed.
 Patient has to be monitored with continuous ECG
throughout the procedure
 Aseptic precautions must be employed
 Selection of insertion site
 Position the patient in Trendelenburg position.

13. Preparation
• Prepare the patient
• Explain the procedure and get informed written consent
• Check for any allergies
• Remove any prosthesis, if present
• Keep NPO for 8 hours
• Get a baseline ECG and blood investigations ready
• Local preparation
• Preparation of equipments
• Heparinized saline in pressure bag with 50 mm Hg pressure
• Flush transducer, pressure tubing, stopcocks under aseptic technique.
Ensure that all air bubbles are removed.
• Attach pressure tubing to transducer system and reference system to
patient’s phlebostatic axis and zero system

14. PROCEDURE
• Aseptic precautions undertaken
• Local infiltration done
• Check balloon integrity by inflating with 1.5ml of air
• Check lumens patency by flushing with saline 0.9%
• Cover catheter with sterile sleeve provided
• Cannulate vein
• Place sheath

15. • Pass catheter through sheath with tip curved towards the heart
• Once tip of catheter passed through introducer sheath inflate balloon
at level of right ventricle.
• The progress of the catheter through right atrium and ventricle into
pulmonary artery and wedge position can be monitored by changes
in pressure trace
• After acquiring wedge pressure deflate balloon

17. WAVE FORMS

18. Cather Insertion Landmarks
Anatomic Structure Distance
Right atrium 20 to 25 cm
Right ventricle 30 to 35 cm
Pulmonary artery 40 to 45 cm
Pulmonary capillary wedge 45 to 55 cm

19. Intra procedure care
• Assist the procedure
• Monitor and record HR, rhythm and BP during catheter insertion and
passed through each chamber.
• Balloon should not be inflated more than 8 – 10 sec.
• Not more than 1.5ml of air should be used to inflate the balloon
• Keep the emergency medications ready
• Watch for dysrhythmia

20. Post procedure care
• Secure the catheter
• Apply sterile occlusive dressing
• Obtain a chest X ray
• Position the patient with supine legs extended, head end elevated to
30 – 60 degree
• Continuously monitor the patient
• Adequate flushing of line using heparinized saline
• Adhere to aseptic technique using dressing
• After insertion measurement of catheter length in centimeters is
documented.

21. Pulmonary artery pressure measurements
• Systolic , diastolic and mean pressure
• Measurement should be done at the end of expiration

22. • a wave = Left atrial contraction
• c wave = closure of mitral valve
• v wave = ventricular contraction against closed mitral valve
• x descent = left atrial relaxation
• y descent is caused by mitral valve opening, onset of LV diastole

23. CENTRAL VENOUS OR RIGHT ATRIAL
PRESSURE MEASUREMENTS
• Proximal lumen
• a wave = R atrial contraction
• c wave = closure of tricuspid valve
• v wave = ventricular contraction against closed tricuspid
• x descent is caused by atrial relaxation
• y descent is caused by tricuspid valve opening

24. CARDIAC OUTPUT MEASUREMENTS
• THERMODILUTION CARDIAC OUTPUT METHOD (TDCO)
• CONTINOUS CARDIAC OUTPUT MEASUREMENT (CCO)

25. THERMO DILUTION METHOD
• 10 ml of cold saline (0.9% NaCl) under 10° Celsius is injected via proximal
lumen port .
• The thermistor sensor located near the distal tip detects the difference in
blood temperature.
• The Cardiac output is calculated from the area under the temperature curve
by the computer.

26. CONTINOUS CARDIAC OUTPUT
MEASUREMENT (CCO)
• Thermal filament in the right atrium
• Filament emits a pulsed signal in every 30 -60 sec allows mixing of blood
with heat as it passes through right ventricle.
• Thermistor detect change in temperature .
• Computer displays digital measurements.

27. COMPLICATIONS
• Dysrrhythmia
• Pulmonary thromboembolism
• Air embolization
• Pulmonary artery rupture
• Pulmonary infarction
• Infection and sepsis

28. ADVANTAGES
• Detect heart failure and sepsis shock
• Pulmonary artery pressure and wedge pressure
• Indirectly measure the left heart pressure
• Monitor effectiveness of therapy
• Drug effectiveness

29. REFERENCES
• Susan Woods, Erika S Sivarajan, Sandra Underhill, Elizabeth J Bridges,
Cardiac Nursing, 5th Edition, Lippincott William & Wilkins
• Sharon L. Lewis, Shannon Ruff Dirksen, Margaret McLean
Heitkemper , Linda Bucher. Medical-Surgical Nursing: Assessment and
Management of 9th Edition
• Smeltzer S C, Bare B , Brunner & Suddarth’s Medical surgical nursing,
edition 10th, ( 2000), Westline Industrial drive, Missouri.