Indications, contraindications and complications of pulmonary artery catheter insertion

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