Catheter-induced pulmonary artery rupture: haemodynamic compromise necessitates surgical repair
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Pulmonary artery haemorrhage is thankfully a very rare complication following pulmonary artery catheter insertion. It carries a significant mortality of 50%, and most cases are managed conservatively or with embolization therapy. We present an occult case, in which a patient presented with haemodynamic compromise without haemoptysis or significant haemothorax, who required surgical intervention. We discuss surgical treatment management options and the need for a high index of clinical suspicion to prevent mortality from this condition.Keywords:
Occult
Pulmonary artery catheter
It is recognized that exercise produces abnormally large increases in pulmonary artery pressure in patients with pulmonary vascular disease as a consequence of a variety of disorders, but the relationship between pressure and cardiopulmonary exercise performance is poorly understood. This lack of understanding is due (in part) to difficulty making measurements of pulmonary haemodynamics using conventional fluid filled catheters. This article seeks to improve understanding by comparing variables measured during formal exercise testing with simultaneous measurements of pulmonary artery pressure using a micro-manometer tipped catheter. Ten patients with suspected pulmonary hypertension were studied using a micromanometer tipped pulmonary artery catheter, during cardiopulmonary exercise testing. Ventilatory equivalents for oxygen and carbon dioxide correlated with the pulmonary artery pressure measured on exercise, but oxygen pulse and oxygen uptake did not. Ventilatory equivalents, noninvasively measured during exercise, may merit further study as potential surrogates of pulmonary artery pressure and hence be useful in identifying individuals at risk of developing pulmonary hypertension.
Pulmonary artery catheter
Pulmonary wedge pressure
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Pulmonary artery catheter
Arterial catheter
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Tolazoline
Pulmonary artery catheter
Fetal circulation
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Invasive hemodynamic monitoring with a pulmonary catheter has been relatively routine in cardiovascular and complex surgical operations as well as in the management of critical illnesses. However, due to multiple potential complications and its invasive nature, its use has decreased over the years and less invasive methods such as transesophageal echocardiography and hemodynamic sensors have gained widespread favor. Unlike these less invasive forms of hemodynamic monitoring, pulmonary artery catheters require an advanced understanding of cardiopulmonary physiology, anatomy, and the potential for complications in order to properly place, manage, and interpret the device. We describe a case wherein significant resistance was encountered during multiple unsuccessful attempts at removing a patient's catheter secondary to kinking and twisting of the catheter tip. These attempts to remove the catheter serve to demonstrate potential rescue options for such a situation. Ultimately, successful removal of the catheter was accomplished by simultaneous catheter retraction and sheath advancement while gently pulling both objects from the cannulation site. In addition to being skilled in catheter placement, it is imperative that providers comprehend the risks and complications of this invasive monitoring tool.
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Specimen cultures were evaluated in 49 catheterized patients who had a known focus of infection (primarily intra-abdominal peritonitis). Bacteria were recovered from 2% of flush solutions, 14% of transducer domes, 18% of diaphragms, and 24% of cardiac output fluids; however, these bacteria were not found in cultures of the pulmonary artery (PA) catheter segments. The rates of positive PA catheter-aspirate cultures were 30.6% on day 1, 20.4% on day 2, and 32.7% on day 3 (not statistically different). PA catheter-aspirate cultures had a sensitivity of 5.7% and a positive predictive value of 30% for catheter-related infection, and 15% sensitivity and 40% positive predictive value for peripheral bacteremia. While 95% (55 of 58) of the catheter- aspirate cultures were false-positives, only 0.5% (3 of 588) were true-positives. Peripheral blood cultures were positive in 10% of the patients, but the catheter segments were sterile or grew different organisms. Arterial line cultures had zero sensitivity and predictive value to detect catheter-related infection, and 15% sensitivity and 40% predictive value to detect peripheral bacteremia. Thus, PA catheter-aspirate cultures, routine peripheral blood cultures, and arterial cultures cannot be recommended to detect PA catheter-related infection. Catheter-related infection confirmed by catheter-segment cultures was 10.2% when the PA catheters were removed after 73 ± 6.5 (SD) h. Bacteria from catheter- segment cultures corresponded to those from the primary infection site.
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To test the ability of a modified pulmonary artery (PA) monitoring catheter to detect distal catheter migration.Prospective nonrandomized trial.Surgical ICU patients requiring invasive hemodynamic monitoring.Eight patients received PA catheters modified to include a right ventricular (RV) pressure monitoring port located 7 cm from the tip. Fifteen patients received catheters with an RV port located 10 cm from the tip. Guided by the RV port pressure waveform, catheters were initially positioned so that the RV port was located just proximal to the pulmonic valve.Pulmonary capillary occlusion pressure (PAOP) could not be obtained in six of the eight patients receiving the 7-cm RV port catheter unless the RV port was advanced into the PA. PAOP was consistently obtained in all 15 patients receiving the 10-cm RV port catheter, with the RV port positioned in the RV. Chest radiographs confirmed a central PA catheter position. In this group, distal migration of the catheter occurred 14 times in eight patients, as detected by appearance of a PA pressure waveform at the RV port. Distal migration was corrected by withdrawal of the catheter until an RV waveform reappeared at the RV port.We conclude that distal catheter migration occurs frequently with PA monitoring catheters, but can be detected at the bedside with a catheter modified to include an RV port 10 cm from the tip. This new catheter may add a margin of safety to PA monitoring and lower its overall cost by eliminating the need for chest radiographs ordered solely to confirm catheter tip location.
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Port (circuit theory)
Pulmonary wedge pressure
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Objective: To clarify the issues related to the use of the pulmonary artery catheter within a rational clinical perspective. Results: Barriers include a) increased patient risk of pulmonary artery catheter placement; b) ability to measure similar variables via central venous catheterization, echocardiography, or other less invasive techniques; c) increased cost; d) inaccurate measurements; e) incorrect interpretation and application of pulmonary artery catheter-derived variables; and f) lack of proven benefit of pulmonary artery catheter use in the overall management of patients. Interpretation: a) The risks are mainly due to insertion of a central catheter, not a pulmonary artery catheter; b) continuous monitoring of left ventricular filling pressures, pulmonary vascular pressures, and mixed venous oxygen saturation is a unique feature; c) additional costs are minimal relative to the cost of intensive care; d) measurement errors require ongoing programmatic educational efforts; e) pulmonary artery catheter-derived data need to be used within the context of a defined treatment protocol; and f) no monitoring device, no matter how simple or sophisticated, will improve patient-centered outcomes unless coupled with a treatment that, itself, improves outcome. Conclusion: A treatment protocol for the use of pulmonary artery catheter-derived variables is proposed that could serve as a basis for a prospective clinical trial.
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Central venous catheter
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Pulmonary wedge pressure
Main Pulmonary Artery
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Abstract For years, the pulmonary artery catheter (PAC, better known as Swan-Ganz catheter) has been used largely to estimate and optimize hemodynamics according to the wedge pressure of the pulmonary artery. Its use dramatically declined after reports of complications and increased costs without benefit to patients. In the absence of reliable noninvasive devices, the catheter is used in severe cases and in cardiac surgery intensive care units.
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Pulmonary artery catheter
Cardiac catheterization
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A microcomputer program is described which facilitates the calculation of data from physiological variables measured using a flow directed, balloon-tipped thermal dilution pulmonary artery catheter. Eleven variables may be calculated and left ventricular function may be displayed graphically using as coordinates left ventricular stroke work index and pulmonary artery wedge pressure. Successive measurements may be easily compared and the program has proved valuable in the management of patients monitored with a right heart catheter.
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Pulmonary wedge pressure
Micro computer
Cardiac index
Balloon catheter
Heart catheterization
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