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
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.
You have just caused a pulmonary artery rupture with your PA catheter. What do you do?
The savvy candidate will form a structured approach.
Isolate the affected lung.
If the lung is not isolated:
If the lung is isolated:
Attempt temporary haemostasis.
Establish definitive haemostasis
Family conference and full disclosure.
The historical mortality rate from these is about 70% according to Kearney & Shabot (1995)
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.