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CCPACatheter Basics 07 Medicine
CCPACatheter Basics 07 Medicine
CCPACatheter Basics 07 Medicine
What is a Swan?
• Full name: Swan-Ganz Catheter
• Pulmonary Artery (PA) Catheter = right heart catheter
• Used it to monitor a patient’s hemodynamics when we
cant answer the question using noninvasive/clinical
measures
• Useful to measure right atrial, pulmonary artery, right
ventricular pressures and indirectly measure left atrial
pressures, cardiac output and systemic vascular resistance
Why use a Swan?
• Differentiation between causes of shock>cardiogenic,
hypovolemic, septic
• Differentiation between causes of pulmonary
edema>cardiogenic versus noncardiogenic
• Diagnosis of pericardial tamponade
• Diagnosis of intracardiac shunt
• Evaluation/Management of pulmonary hypertension
• Diagnosis of lymphangitic spread of tumor and fat
embolism
• Management of complicated MI, HF
• Determine need for vasopressor/inotropic therapy
• Fluid Status>in GI bleed, renal failure, sepsis
• Ventilator management>determining the best PEEP
Some history…
• First pulm catheters were placed in 1940s
• 1970-William Ganz and Harold Swan introduced this
catheter. Pulmonary artery Catheter that is balloon-tipped
and flow directed, placed bedside
• Revolutionized catheters>moved from diagnosis only to
help in management. No clinical trials were done to see if
they improved mortality. Benefit was assumed
• 1987- nonrandomized trials:showed mortality was higher
in patients with an acute MI who had a Swan placed
• 1990s-Ontorio Intensive Care Group attempted a RCT for
use of Swans>not done b/c many clinicians felt unethical
to withhold Swan placement because accurate
diagnosis=accurate treatment=better prognosis????
Is it unethical to withhold Swan Placement?
And are they better at predicting clinical outcomes?
• 1996 observational study of RHC in first 24 hours said NO.
1. Placement led to worse patient outcomes b/c of
complications of placement or misinterpretation of data
2. Use of catheter might be a marker of more aggressive care,
which is associated with higher mortality
3. Changes in therapy in response to the information might
have led to high mortality (i.e. using pressors)
4. Study might not have adequately adjusted for confounding
factors
5. Only looked at SGC placed in first 24 hours.
• Connors AF Jr, Speroff T, Dawson NV, et al. The effectiveness of right heart catheterization in the
initial care of critically ill patients. JAMA 1996;276:889-897
Randomized, Controlled Trial of the Use of Pulmonary-Artery
Catheters in High-Risk Surgical Patients. Sandman et al. NEJM-
Jan, 2003
JAMA. 2005;294:1625-1633.
To Swan or Not to
Swan?
INDIVIDUALIZE CARE
a=atrial contraction.
c=sudden motion of the AV ring toward
the right atrium
x descent=atrial relaxation
v=pressure generated by venous filling
of the right atrium
y descent=rapid emptying of the RA
into RV
What Elevates the Right Atrial Pressure?
• RV infarct
• Pulmonary hypertension
• Pulmonary stenosis
• Left to right shunt
• Tricuspid valvular disease
• Left heart failure
How do you know you are in the right ventricle?
30cm
RV systolic=17-30
RV diastolic=0-6
RV O2 content=15%
RV O2 saturation 75%
What Increases RV Pressures?
• RV failure
• Pulmonary hypertension
• Pulmonary stenosis
• Pulmonary Embolism
• Cardiomyopathy
• Cardiac tamponade
• Cardiac constriction
How do you know you are in the pulmonary artery?
Normal PA pressure,
systolic 15-30
Normal PA pressure,
diastolic 5-13
O2 content 15%
O2 saturation 75%
What Elevates PA pressure?
RA tracing:
WHAT DOES THIS PT HAVE?