A  patient after coronary  artery surgery  develops severe haemoptysis after  inflation  of  the pulmonary artery catheter balloon. A new infiltrate at the tip of the catheter is seen on chest X-Ray. Describe your immediate management

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College Answer

A rapid response in this setting of severe haemoptysis is expected but if there is time an angiogram or bronchoscopy may help to isolate the pulmonary vessel involved.  Immediate management  may be simple. For example: 

(a} Withdraw catheter 2-3cm and then refloat PA catheter with balloon inflated to occlude the pulmonary artery. 

(b) Insert double lumen ETT to secure the airway and attempt to isolate the affected lung. A single lumen tube advanced into the unaffected side may be a quicker and easier option.

(c) Transfer to OR for immediate lobectomy if bleeding does not settle. The application of PEEP has also been reported to stem the bleeding.

Discussion

You have just caused a pulmonary artery rupture with your PA catheter. What do you do?

The savvy candidate will form a structured approach.

A)

Isolate the affected lung.

  • Either insert a dual-lumen tube to isolate the affected lung, or advance the existing tube into the right main bronchus (if this is an option).This should protect the unaffected lung from contamination with blood and clots.

B)

If the lung is not isolated:

  • crank up the PEEP. This may decrease the rate of haemorrhage by putting up a resistance to pulmonary blood flow.
  • Position the patient affected-side down. This way, only one lung fills up with blood.

If the lung is isolated:

  • Increase the FiO2. If a DLT is in position, the pulmonary vasodilation should encourage blood flow into the good lung.
  • Position the patient affected-side up. This way, the affected lung will have decreased blood flow.

C)

Attempt temporary haemostasis.

  • One may try to wedge the balloon in the affected pulmonary artery, thereby preventing further blood loss.

Establish definitive haemostasis

  • Cardiothoracic surgical repair will be the only way this situation can be salvaged.
  • Case reports have demonstrated that angioembolisation is also a viable option if urgent surgery is impossible or undesirable.

Lastly;

Family conference and full disclosure.

The historical mortality rate from these is about 70% according to Kearney & Shabot (1995)

References

Kearney, Thomas J., and M. Michael Shabot. "Pulmonary artery rupture associated with the Swan-Ganz catheter." CHEST Journal 108.5 (1995): 1349-1352.

 

Bossert, Torsten, et al. "Swan‐Ganz Catheter‐Induced Severe Complications in Cardiac Surgery: Right Ventricular Perforation, Knotting, and Rupture of a Pulmonary Artery." Journal of cardiac surgery 21.3 (2006): 292-295.

 

Bussières, Jean S. "Iatrogenic pulmonary artery rupture." Current Opinion in Anesthesiology 20.1 (2007): 48-52.