THE PA CATHETHER

Dr J Kelliher
• Uses

• Anatomy of PA catheter

• Insertion

• Waveforms

• Interpretation

• Troubleshooting

• Evidence
INFLATE @15cm
Interpretation
• Numbers

• Waveforms
RA waveform CVP
PAOP waveform
PCWP approximates LAP
under Zone 3 conditions

mPAP>mPCWP>alveolar
pressure
How can confirm it is in the third zone?
• On lateral CXR, the tip of the catheter is at or below the left atrium
• The PAWP is less than the PA diastolic pressure
• The PAWP contour has recognizable a and v waves; in Zones 1 and 2 it is
unnaturally smooth.
 Complications

• Dysrhythmia
• Pneumothorax Haemothorax
• Infection

• Thromboembolic events (the catheter is a nidus for clot formation)

• Mural thrombi in the right heart (up to 30%)

• Air embolism from ruptured balloon

• Pulmonary infarction
• Endocarditis of the pulmonary valve ( 2%)

• Right bundle branch block If you already have LBBB, this causes complete heart block
• Knotting on structures or on itself ( ~ 1% ) If it has gone into the right ventricle by 25-30cm and its still not in the
pulmonary artery, you start to worry
• Damage to the valves Never pull the catheter back with the balloon inflated! You could tear the valve leaflet
• Pulmonary artery rupture: 0.2% risk, 30% mortality

• Risk factors: pulmonary hypertension, mitral valve disease, anticoagulants and

age over 60
• Management:
• Lay the patient ruptured side down
• Intubate them with a double-lumen tube
• Increase the PEEP to put pressure on the wound
• Repair in cardiothoracic theatre

• Wrong numbers-> wrong treatment.

Uses PA catheters
• continuous cardiac output monitoring
• central temperature monitoring
• measurement of pulmonary artery pressure (can also measure RA
and RV pressures during insertion)
• measurement of mixed venous saturations
• estimation of diastolic filling of left heart (normal PCWP 2-12mmHg)
Settings

• Post Cardiac surgery – valves

• LV/RV failure
• Pulmonary hypertension
• Shock
Contraindications
• Tricuspid or pulmonary valve prosthesis which can be damaged
• Tricuspid or pulmonary valve vegetation which can be dislodged
• Endocarditis in general
• Right heart mass (be it tumour or clot)
 Assumptions!!! PAOP “wedge pressure”
Pulmonary artery wedge pressure is the same as left atrial pressure
• Not if the catheter is outside of Wests Zone 3
• Not if there is increased or fluctuating pulmonary artery resistance
• How are you going to predict what that resistance is if Zone 3 has consolidated lung or a huge
pneumothorax there, or a chest drain in the pleural cavity applying low wall suction to the system?

Left atrial pressure is the same as left ventricular end-diastolic pressure

• Not if the atrium is scarred and non-compliant
• Not if the mitral valve is incompetent

Left ventricular end-diastolic pressure is a good reflection of LV end-diastolic volume

• Not if the ventricle is scarred and non-compliant
• Not if the mitral valve is incompetent
CPP= Arterial diastolic pressure – LVEDP
PAWP

• Pulmonary artery diastolic pressure is a reasonable surrogate for PAOP

• PADP is usually within about 5mmHg of PAOP
• PADP will be more than 5mmHg different if the patient is tachycardic or
there is a condition which increases pulmonary vascular resistance
• The PADP is usually higher than the PAWP----because of the resistance to
flow in the pulmonary arterial network;
• Thus if the flow is abolished (by occluding the artery) the pressure drops.
• If the PADP is LOWER than the PAWP, the PAWP measurement is probably
wrong…..It may mean your catheter tip position needs to be changed.
Cardiac Output 4-8L CI 2.5-4L
• The Stewart-Hamilton Equation for measuring cardiac output
• If you inject a known amount of a substance upstream, the change in its concentration
downstream is related to the rate of the flow. The flow, or volume over time, in this case is the
cardiac output.
• Fick Principle
The total uptake of (or release of) a substance by the peripheral tissues is equal to the product of
the blood flow to the peripheral tissues and the arterial-venous concentration difference (gradient)
of the substance."
SvO2
• SvO2 = mixed venous oxygen saturation
• Can used in ICU as a measure of O2 extraction by the body
• normal SvO2 = 65-70%
High SvO2
• increased O2 delivery (increased FiO2, hyperoxia, hyperbaric oxygen)
• decreased O2 demand (hypothermia, anaesthesia, neuromuscular blockade)
• high flow states: sepsis, hyperthyroidism, severe liver disease

Low SvO2
• decreased O2 delivery:
1 decreased Hb (anaemia, haemorrhage, dilution)
2. decreased SaO2 (hypoxaemia)
3. Decreased CO (any form of shock, arrhythmia)
4. increased O2 demand (hyperthermia, shivering, pain, seizures)

Causes of High SvO2 despite evidence of End-organ Hypoxia

• microvascular shunting (e.g. sepsis)
• histotoxic hypoxia (e.g. cyanide poisoning)
• abnormalities in distribution of blood flow

Inadequate oxygen delivery to tissues is reflected by a low mixed venous oxygen tension and an increase in the
arteriovenous oxygen content difference.
Right heart failure
• May hint it may be the LV is primary driver –increased LA pressure/MR
• Pulmonary Vascular Resistance may be high ->increased afterload
• May highlight an RVOT obstruction ( RV –PA gradient greater than 25mmHg)
• Or PAWP and PVR may be normal->contractility problem

• The pulmonary artery pulsatility index (PAPi) (sys PAP – diastolic PAP)
CVP
is a novel hemodynamic index that predicts severe RVF in the setting of
acute inferior wall myocardial infarction and was developed with the goal of
identifying patients who will require percutaneous mechanical RVAD
Pulmonary Hypertension
The European Society of Cardiology guidelines have recently defined new cut-offs for pulmonary hypertension
(PH) and pulmonary vasculature resistance (PVR; median pulmonary artery pressure (mPAP) >20 instead of 25
mm Hg and PVR >2 instead of 3 Wood unit).

•Mild = 25-40mmHg
•Moderate = 41-55mmHg
•Severe = > 55mmHg

Idiopathic
Heart Lungs Clots and
Other
•RCT non blinded

•Set in 65 ICUs in UK Oct 2001-March 2014

• END