Download Septic Shock Pulmonary Artery Line

PULMONARY ARTERY PRESSURE MONITORING
LEARNING OBJECTIVES
After review/ study of the CCNS Orientation manual, attendance at
the CCNS Orientation Skills Lab, and completion of unit level
orientation the orientee will be able to:
1. Collect all necessary equipment/supplies necessary to set-up a
triple transducer pressure system.
2. State the correct solutions/medications used at WRAMC for the
flush bags.
3. Correctly assemble triple pressure transducer system.
4. Correctly level and zero the transducer.
5. Correctly identify the location and purpose of each port/ lumen
of the PA catheter (PA cath).
6. Identify in sequence the normal waveforms observed during PA
cath insertion, and state the corresponding pressure.
7. Correctly obtain the following pressures:
Pulmonary artery systolic, diastolic and mean.
Pulmonary capillary wedge.
Central venous pressure.
8. Briefly describe the indications, limitations and complications of PA
catheterization guidelines for accurate monitoring, and troubleshooting
techniques.
PURPOSE:
1. To assess the left ventricular end-diastolic pressure indirectly.
2. To evaluate the hemodynamic response to fluid therapy, medication
and other treatments.
3. To obtain accurate central vascular pressures in the presence of low
cardiac output.
4. To obtain mixed venous blood samples.
5. To measure cardiac output.
INDICATIONS
Shock states
Diagnoses and evaluation of heart disease
Medical conditions that compromise cardiac output
To determine fluid volume status
Complex surgery with potential for compromise
SPECIAL EQUIPMENT
Flush solution for transducer system
output system
Arterial access line
Disposable triple pressure
transducer system
Pulmonary artery catheter
electrodes, cables
Central line kit
Flush solution for cardiac
pressure bag
Emergency resuscitation equipment
Kit; sutures
Monitor, module,
Transducer holder, I.V. pole,
Prepackaged Introducer
Sterile gowns, gloves, and masks
Components:
1. Proximal port – approximately 30 cm from tip of catheter.
also known as CVP port (central venous pressure)
lies in the right atrium and measures CVP
can be used for infusion of IV solutions or medications, and for drawing
blood
used for injecting cardiac output boluses
usually color coded blue
2. Distal port – opening is at the tip (end) of the catheter.
also known as a PA port
lies directly in the pulmonary artery
measures the pulmonary artery pressures (PAP), systolic (PAS), and
diastolic (PAD)
also measures pulmonary capillary wedge pressure (PCWP) when balloon
is inflated
PA pressures should always be monitored continuously
NEVER USE for medication infusion
Can be used for drawing "mixed venous" blood gas sample
Usually color coded yellow
3. Thermistor and connector port
the thermistor connector connects the pulmonary catheter to the cardiac
output computer
connector is at the end of a separate catheter lumen outside the patient
thermistor wire within the lumen transmits blood temperature (core
temperature is most accurate reflection of the body temperature)
used in determining cardiac output
connector tip should always have a protective covering to protect patient
from microshock
usually color coded yellow with red connector
4. Balloon port
located about < 1 cm from tip of the catheter
when the balloon is inflated with approximately 0.8 to 1.5 cc of air,
catheter will become lodged (wedged) in the pulmonary artery given a
wedge tracing.
Reflects the pressures that are in the left side of the heart when inflated
DO NOT INFLATE WITH LIQUID---- ALWAYS INFLATE WITH AIR
when deflated, turn stopcock to off position and leave syringe connect to
port
color coded red
5. A 5 - lumen Swan Ganz catheter has either an infusion port or a pacing
port, allowing insertion of a transvenous pacing wire; usually color coded
white.
PROCEDURE
ACTION
RATIONALE
Prepare for Insertion of PA Line:
1. Check for signed informed consent if not
an emergency.
1. All invasive procedures require
consent.
2. Obtain vital signs and ECG strip.
2. Serves as baseline.
3. Check security and position of
electrodes. Ensure good IV access in place.
3. Safety.
4. Prepare disposable triple transducer
pressure system same as "Single Pressure
Transducer System" except flush each
additional tubing and port separately.
4. Ensure all tubing and ports clear of
air.
5. Position patient. Trendelenberg for
jugular or subclavian route, if tolerated.
May be flat in bed with rolled towel
5. To engorge vessels and prevent
potential air emboli.
between shoulder blades.
6. Maintain aseptic technique in compliance
with "Central Line Insertion Checklist" IAW
Infection Control Manual.
6. WRAMC DON Policy – to reduce risk
of infection.
7. Assist physician in flushing each port of
the PA catheter and checking balloon tip.
Attach flush solution to distal lumen.
7. Ensure patency and integrity. Allow
for visualization of waveforms.
8. Monitor patient response during PA
catheter insertion:
8.
a. Monitor for continuous sterile technique
during insertion.
b. Monitor for ventricular dysrhythmias.
c. Ensure proper central line dressing
applied in compliance with "Central Line
Dressing Checklist" IAW Infection Control
Manual.
d. Observe waveforms – record opening
pressures:
(1) Right Atrial Pressure (RAP or CVP)
(2) Right Ventricular Pressure (RVP):
RVP Systolic = 20-30 mmHg
RVP Diastolic = 0 – 5 mmHg
(3) Pulmonary Artery Pressure (PAP)
PAP Systolic = 20-30 mmHg
PAP Diastolic = 8-12 mmHg
PAP Mean = 25 mmHg
(4) Pulmonary Artery Wedge Pressure
a. Break in aseptic technique is the
greatest cause of catheter infection.
b. Irritation of ventricles.
c. Reduce risk of infection.
d. Serve as baseline.
1- Elevated RAP= volume overload, RV
failure, tricuspid stenosis or
regurgitation, LV failure or constrictive
pericarditis.
2- Elevated RVP = pulmonary
hypertension, RV failure, constrictive
pericarditis, chronic CHF, heart failure
with septal defect, hypoxia.
3- Elevated PAP = left-to-right shunt,
LV failure, mitral stenosis or pulmonary
hypertension.
4- Elevated PAWP = LV failure, mitral
insufficiency or stenosis.
e. Manual aspiration causes premature
balloon rupture. If left inflated can
(PAWP)
cause PA ischemia and necrosis.
PAWP = 4- 12 mmHg
f. For consistency.
e. Passively deflate balloon by removing
syringe from balloon stopcock. Check for
return of PA tracing.
g. Overfilling may cause rupture of
balloon. To prevent inadvertent
injection of air or fluid into balloon
lumen.
f. All pressures should be recorded with
patient flat or in no greater than a 15-20
degree angle.
h. To confirm position and rule out any
complications.
g. Use a 3cc syringe with 1.5cc of air.
Inflate balloon slowly observing for a PAWP
waveform. It should take 1.25 to 1.5 cc.
Any amount less, indicates that catheter is
too far into PA. Close gate valve to syringe.
h. Obtain a chest x-ray.
9. System care and general precautions:
9.a. Reduce risk of infection and air
emboli. Ensure accurate pressures.
a. Continuously monitor hemodynamic
system for air. Ensure connections secure.
Ensure monitor alarms on at all times.
b. Reduce risk of infection. Compliance
with WRAMC policies.
b. Label and change flush bag, tubing,
dressing and stopcocks IAW Infection
Control Manual. (bags q. 24hrs, tubing and
dressing q. 72 hrs., and stopcocks after
every blood draw or at least q. 72 hrs.)
c. Maintain pressure bag at 300 mmHg.
d. Do not flush catheter for longer than 2
seconds.
e. Use aseptic technique when withdrawing
from or flushing catheter.
f. Remove all traces of blood from catheter,
tubing, and stopcocks are blood sampling
c. Prevents clot formation.
d. PA rupture may occur with
prolonged flush of high pressure fluid.
e. Prevents bacterial contamination of
system.
f. Blood is a medium for bacterial
growth. May result in emboli in line.
g. Tears will break sterile barrier,
making catheter manipulation no
longer possible.
h. May occlude catheter. The largest
lumen of PA catheter is too small for
and flush completely.
g. Maintain sterility of plastic sleeve over
catheter, and avoid placing tape over it.
h. Do not infuse viscous fluids via catheter
lumens (i.e. whole blood, albumin).
i. Monitor and record trends in pressure
readings.
blood and will damage RBC’s and
reduce effectiveness of transfusion.
i. Isolated results need further
evaluation.
j. Ensure that these correlate.
k. Reduced circulation may result in
tissue ischemia.
j. Integrate data with hemodynamic profile
and clinical assessment of patient.
k. Assess circulation to extremities.
l. Administer medication only through the
proximal port. Never use the distal or PA
port.
m. Keep number of PAWP reading to a
minimum. If PAD and PAWP are similar (< 4
mmHg difference), then PAD can be
substituted for PAWP.
n. May rupture balloon.
o. Balloon may be ruptured.
p. May rupture balloon.
q. Danger of pulmonary artery rupture.
Only physician may move catheter.
n. If strong resistance is met during
inflation, do not inflate balloon, notify
physician.
o. If air goes in freely (without resistance)
or if blood comes back, disconnect syringe
and close off lumen. Label gate valve with
sign that says, "Do not inject air". Notify
physician.
p. Never flush catheter when in a wedged
position.
q. If suspect wedged position is due to
catheter migration, notify physician
immediately.
10. Obtain a blood sample of mixed venous
10. Mixed venous blood gases are
blood by aspirating from distal port with
balloon deflated:
a. Attach 5-ml syringe to stopcock nearest
distal port of PA catheter.
frequently analyzed along with arterial
blood in order to calculate the shunt
fraction or the degree to which blood is
bypassing unoxygenated from the
lungs to the left side of the hear.
b. Open stopcock to syringe and aspirate 5
ml to clear catheter of flush solution.
d- Ice ensures that results are
accurate.
c. Close stopcock halfway; remove syringe
and discard.
d. Add blood gas syringe to stopcock and
gently aspirate blood sample over one
minute. Place immediately on ice.
e. Flush stopcock port and replace
deadhead cap.
11. Assist with removal of PA catheter:
a. Close pressurized flush system to patient.
Disconnect from monitor.
b. Position patient in flat or slight
Trendelenberg.
c. Obtain vital signs.
d. Monitor for dysrhythmias while physician
removes catheter.
e. Apply firm pressure until bleeding stops.
f. Apply occlusive dressing.
g. Check site and extremities frequently to
ascertain bleeding or embolic complications.
11. Physicians remove the PA catheters
at WRAMC.
a. Safety measure to protect patient
from emboli.
d. Ventricular dysrhythmias may occur.
INTEPRETATION of PA WAVEFORMS and VALUES
OTHER PRECAUTIONS
1. See precautions for "Single Pressure Transducer System".
2. Set alarms at all times, approximately 20 mmHg above and below the
patient’s readings.
3. If balloon is down and you find PA catheter tracing in wedge position,
you may ask the patient to deep breathe and cough, or reposition
patient in bed to dislodge it. However, notify physician immediately to
reposition catheter by pulling back gently; then, get chest x-ray to
confirm proper placement. Do not attempt to flush!
4. If patient coughs up blood or it is suctioned via endotracheal tube,
suspect PA rupture and notify physician immediately.
5. Respect electrical safety guidelines. (review Electrical Safety under
Pacing Section).
POTENTIAL COMPLICATIONS
Air emboli
Cardiac tamponade
Thromboembolism
Dysrhythmias
Catheter
displacement/dislodgement
Balloon rupture
Infection
Lung ischemia
Inaccurate pressures
Electromicroshock
Equipment malfunction
Pulmonary artery rupture
Pneumothorax/Hemothorax
Frank Hemorrhage
Loss of balloon integrity
Altered skin integrity
Pulmonary artery extravasation
PA hemorrhage or infarction
Altered circulation to extremities
Cardiac arrest