This came up in Question 2 from the second paper of 2002.
Anatomy of the pulmonary artery catheter is discussed in greater detail elsewhere.
Indications
- Cardiac output measurement especially in a patient with arrhythmia or aortic balloon pump, where PiCCO cant be used
- Unequal right and left ventricular failure
- Complex hemodynamic instability, some combination of obstructive, distributive, cardiogenic and hypovolemic shock
- To differentiate cardiogenic pulmonary edema from non-cardiogenic
- To guide use of vasopressors, inotropes, fluids and diuretics – when the patient has a hemodynamic problem combined with pulmonary oedema and ventricular dysfunction.
- To titrate pulmonary antihypertensives in ARDS (like nitric oxide and prostacyclin)
Complications
Same as CVC:
- Perforation of SVC
- Hemothorax, pneumothorax
- Atrial fibrillation
Unique to PA catheter
- Ventricular Arrhythmia
- 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
- If you are lucky, it is a transient phenomenon and you only need to pace them transcutaneously for a brief period. If you are unlucky, you have injured the AV node, and the patient needs prolonged transvenous pacing
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 or the heart
- Never pull the catheter back with the balloon inflated! You could tear the valve leaflets
- The RV can be perforated, particularly a dilated weak-walled RV
- The RA can be perforated (perhaps even more easily)
Pulmonary artery rupture: 0.2% risk, 30% mortality
- Risk factors: pulmonary hypertension, mitral valve disease, anticoagulants and age over 60
References
This a full-text version of the seminal paper from 1970:
Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D (August 1970). "Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter". N. Engl. J. Med. 283 (9): 447–51.
A manufacturer (Edwards) offers some free information about the PA catheter on their product page.
The PA catheter section from The ICU Book by Paul L Marino (3rd edition, 2007) is a valuable read.
Armstrong, Ehrin J., James M. McCabe, and Melvin D. Cheitlin. "Pulmonary artery catheterization in the intensive care unit: just numbers floating by?."Archives of internal medicine 171.12 (2011): 1110-1111.
Additionally, UpToDate has an article on PA catheter complication