Tips, Tricks, Troubleshooting PA catheter placement

[bubbleboy123]

OK go

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[dchz]

Saline in the balloon, x-plane through RV inflow outflow view to get bicaval. float it with the two views and watch the tip go through the right holes. Giggity

 

[GassYous]

Leave it in the general vicinity of the heart and let the surgeon put it in the pa

 

[ryanjmy]

Make sure the curve is somewhere between 6 and 9 o'clock. After a couple of unsuccessful attempts pull it out and flush it. As the catheter heats up it loses its curve.

reverse t-burg, tilt right.

If you can't get it after 5 mins abort. Other ways to diagnose shock.

 

[vector2]

OK go

Take a look at this

As you can see, by anatomic orientation the RV is anterior and lateral to the TV and the RA. And beyond the RV the RVOT and main PA are cephalad. So I agree with the previous poster....after your line is in but before you do the PAC, put the pt in reverse tburg and right tilt and let buoyancy do the work for you.

That being said, easiest way to troubleshoot a difficult one is with TEE. I mix a half cc of air with saline in the balloon which really helps with its echogenicity.

 

[dchz]

Or put saline in and let the flow of blood do the work for you. Just be patient slowly inflate the balloon and deflate even slower.

 

[bigdan]

An ephedrine (or Epi) sprinkle can provide that extra oomph to cross the PV

 

[MirrorTodd]

An ephedrine (or Epi) sprinkle can provide that extra oomph to cross the PV

My attending last month would use dobutamine. Like 1 or 2 cc's from our premixed bags.
Another trick he taught was PA cath to 20 cm, inflate balloon, advance into RV and once the wave changes, twist the catheter clockwise 90 degrees, so like 9 o'clock to 12 o'clock. Seemed to work pretty reliably.

 

[Twiggidy]

Saline in the balloon, x-plane through RV inflow outflow view to get bicaval. float it with the two views and watch the tip go through the right holes. Giggity

Key words.....you don't have to ram it through. I was taught a smooth constant motion until you're in the RV then slowly beat to beat into the PA.

 

[vector2]

Key words.....you don't have to ram it through. I was taught a smooth constant motion until you're in the RV then slowly beat to beat into the PA.

I’ve always been a bit skeptical of the ‘advance with each beat‘ advice. I’m pretty sure even when folks are listening to the EKG their hand isn’t actually advancing perfectly in sync with the beginning of physical systole. For me, anecdotally it seems like easy ones go in easy whether I’m going in fast or slow and difficult ones are difficult whether I’m fast or slow.

 

[Hork Bajir]

Use fluoro. Short learning curve but pretty easy, already available in the hybrid rooms, and helps a ton.

For patients with bad TR and dilated RA, can also float the PA over a wire (need a long exchange length wire which you might have to steal from the cath lab). Generally just need to get the wire into the RV, not all the way into PA

 

[dchz]

Use fluoro. Short learning curve but pretty easy, already available in the hybrid rooms, and helps a ton.

For patients with bad TR and dilated RA, can also float the PA over a wire (need a long exchange length wire which you might have to steal from the cath lab). Generally just need to get the wire into the RV, not all the way into PA

Why would you increase your radiation risk just to flow something that doesn't change management much anyways?

 

[Hork Bajir]

Why would you increase your radiation risk just to flow something that doesn't change management much anyways?

The question posed in this thread wasn’t “is it worth floating a PA line”- it was asking for tips and tricks for difficult PA placement. Fluoro can be extremely helpful, don’t knock it until you try it. My experience using it comes from liver transplants, where my group was using fluoro to assist with veno-veno bypass inflow cannula placement (15-17Fr ECMO cannula either in R IJ or L subclav). We routinely double stick for an introducer with a PAC, and many of us started using the fluoro to help float the PA line since it was already there and draped into the field.

When used properly, the “increase to radiation risk” is not a concern. It’s not like I’m doing this for hours at a time, every day of the week, not wearing lead, sticking my hands right underneath it, etc.

If you want to argue that we place tons of unnecessary PA lines, I’ll be the first one to agree with you. But institutional culture dictates that they are placed for certain cases/indications, and if you’re going to place them at all you might as well have an arsenal of techniques to troubleshoot getting it done safely

 

[dchz]

The question posed in this thread wasn’t “is it worth floating a PA line”- it was asking for tips and tricks for difficult PA placement. Fluoro can be extremely helpful, don’t knock it until you try it. My experience using it comes from liver transplants, where my group was using fluoro to assist with veno-veno bypass inflow cannula placement (15-17Fr ECMO cannula either in R IJ or L subclav). We routinely double stick for an introducer with a PAC, and many of us started using the fluoro to help float the PA line since it was already there and draped into the field.

When used properly, the “increase to radiation risk” is not a concern. It’s not like I’m doing this for hours at a time, every day of the week, not wearing lead, sticking my hands right underneath it, etc.

If you want to argue that we place tons of unnecessary PA lines, I’ll be the first one to agree with you. But institutional culture dictates that they are placed for certain cases/indications, and if you’re going to place them at all you might as well have an arsenal of techniques to troubleshoot getting it done safely

My point is that the information from fluoro is not worth wearing lead and irradiating the entire room. But you have the right to disagree.

 

[deleted697535]

My attending last month would use dobutamine. Like 1 or 2 cc's from our premixed bags.
Another trick he taught was PA cath to 20 cm, inflate balloon, advance into RV and once the wave changes, twist the catheter clockwise 90 degrees, so like 9 o'clock to 12 o'clock. Seemed to work pretty reliably.

Isnt that standard technique?
Just use echo to float.

But.. if one is skilled enough with tee to get it in, then theyve also probably done so many swans that they dont need tee
There is always one tricuspid you cant get thru because of a ring or some stenosis. Most of the time if flies

If it doesnt, just do vti's on the rvot. Thats basically CO

 

[FiO2@21]

Isnt that standard technique?
Just use echo to float.

But.. if one is skilled enough with tee to get it in, then theyve also probably done so many swans that they dont need tee
There is always one tricuspid you cant get thru because of a ring or some stenosis. Most of the time if flies

If it doesnt, just do vti's on the rvot. Thats basically CO

Why RVOT vs LVOT?

 

[AdmiralChz]

I’m not sure I’ve ever placed a PAC in the Hybrid Room, fortunately. Cases there typically don’t require it (TAVR, TEVAR). I’ve used fluoro once randomly to do a PAC, it’s darn cumbersome and as @dchz alludes, won’t win you any friends as the whole OR will rush to snag lead.

 

[bubbleboy123]

Anyone ever witness / cause PA rupture or other injury from floating Swan?

Let's hear about the complications.

 

[nimbus]

Anyone ever witness / cause PA rupture or other injury from floating Swan?

Let's hear about the complications.

I did in 1997. I was relatively inexperienced at the time and inadvertently floated it out to 60cm from the RIJ. Thankfully blood started coming up his ETT before incision and before heparin. Left him intubated. Bleeding stopped after 30-60min. Extubated after 24 hours. Patient came back for his uneventful CABG 5 days later. I felt very lucky. Overall TEE guidance has made it easier and safer.

Had another case around 2010. There was a small hemopericardium when surgeon opened the chest and pericardial sac. And lo and behold a small hole in the RV. I must have punctured the RV with the wire or the dilator. She was a tiny elderly lady. After that I have made a point of not advancing the dilator more than 3-4cm beyond skin and feeding the cordis off it rather than advancing the whole thing.

 

[dchz]

Anyone ever witness / cause PA rupture or other injury from floating Swan?

Let's hear about the complications.

Not my case but I was in there.

One of the big established anesthesiologist hit it really hard in the RVOT vs Coronary sinus (we will never know) and caused V tach. Shocked the patient out of it. The case proceeded fine but it's one of those cases that really puts hair on your chest.

Now I check to have defib pads on every case.

 

[anaesthetic]

.

 

[Maverikk]

Wow. I've placed a lot of PA caths in fellowship, less so in my current job and haven't seen this yet. VF during placement or removal I've been involved with, thankfully reversible. A warmed up catheter piercing the RV (even a thinned out one) or vein in my imagination would take a lot of motivation, more than the upper limits of common sense of stop after resistance.
90 degree rotation after RV placement to get into PA is a great tip for thread, best to do after first attempt at advance fails

 

[Drwine]

I am a big fan of the "double barrel intubation" for heart cases but make sure the the ETT goes in trachea. The only thing not mentioned is to make note of the relation of the curve of the Swan in relation to the proximal port.

 

[WheezyBaby]

Anyone ever witness / cause PA rupture or other injury from floating Swan?

Let's hear about the complications.

Not my procedure, but a patient I was consulting on several years ago died overnight related to PA rupture from a swan

 

[drmwvr]

Not my procedure, but a patient I was consulting on several years ago died overnight related to PA rupture from a swan

Had 1 or 2 of those in my "community" over the years...resulted in a broad abandonment of routine PA cath placement for cardiac procedures. As the institutional memory of those specific events wanes over time, the threshold for PA cath placement for these procedures is becoming lower and lower...

 

[Consigliere]

OK go

Ok....best and only tip you'll ever need - don't place a PA catheter....they are worthless.

 

[sevoflurane]

TEE guided 100% . If hiccups lock it at 25 cm and just wait until the chest is open- for some reason a difficult PA cath floats easier when the chest is open.

I guess fluoro would help- that is how I do all my temp pacers. Can’t say I have used fluoro for a PA cath though (currently place more temp pacers than pa caths).

 

[Hork Bajir]

@sevoflurane I'm very curious why and under what circumstances are you placing temp pacing wires? On the rare occasion that I need temporary trans-venous pacing I'll just float an AV-paceport swan (though tbh I've only had to do this once in recent memory, for a liver transplant that went into 3rd degree HB after reperfusion)

 

[sevoflurane]

@sevoflurane I'm very curious why and under what circumstances are you placing temp pacing wires? On the rare occasion that I need temporary trans-venous pacing I'll just float an AV-paceport swan (though tbh I've only had to do this once in recent memory, for a liver transplant that went into 3rd degree HB after reperfusion)

https://www.jacc.org/doi/pdf/10.1016/j.jcin.2017.06.012

RBBB + TAVR (or intuity valve) can lead to significant conduction abnormalities which can lead to significant morbidity and mortality.

 

[sevoflurane]

We preselect these patients and place a temp pacer before deployment.

Lost one patient early on when a nurse on the floor prematurely pulled a temp pacer.

 

[sevoflurane]

RBBB in TAVR Recipients - American College of Cardiology

Debabrata Mukherjee, MD, FACC

www.acc.org

 

[sevoflurane]

“At this time, prolonged monitoring or prophylactic pacemaker may be considered in selected TAVR cases with pre-existing RBBB.“

 

[drmwvr]

We preselect these patients and place a temp pacer before deployment.

Lost one patient early on when a nurse on the floor prematurely pulled a temp pacer.

It's different than the pacing cath that is floated for valve placement?

 

[sevoflurane]

It's different than the pacing cath that is floated for valve placement?

yes

 

[sevoflurane]

same kit cards uses... smaller.

Arrow® Temporary Pacing Catheters and Kits | US | Teleflex

www.teleflex.com

 

[GassYous]

We preselect these patients and place a temp pacer before deployment.

Lost one patient early on when a nurse on the floor prematurely pulled a temp pacer.

Yea we normally don't place cvls for these cases but we place one for these patients for pacing.

 

[drmwvr]

pretty much don't use the intuity anymore and if the rare patient develops a block its straight to EP for PPM from the hybrid room using the case pacing cath...very rare situation to need a TPM to go.....

 

[sevoflurane]

pretty much don't use the intuity anymore and if the rare patient develops a block its straight to EP for PPM from the hybrid room using the case pacing cath...very rare situation to need a TPM to go.....

We dropped intuity due to it's high degree of post pacer requirements. Our cards servcie line is super busy. We select our patients, temp pace them and see how they do. If they need a pacer, we fit them during the day but have a temp pacer placed by us to allow for this.

 

[sevoflurane]

We pull all of our groin lines out at the end of the case.

 

[Chowda]

If it doesn't go in 2 tries I lock it up, scrub out, then float with echo so the circulators can start prepping.

 

[sethco]

@sevoflurane I'm very curious why and under what circumstances are you placing temp pacing wires? On the rare occasion that I need temporary trans-venous pacing I'll just float an AV-paceport swan (though tbh I've only had to do this once in recent memory, for a liver transplant that went into 3rd degree HB after reperfusion)

In addition to the TAVRs that @sevoflurane mentioned, we also place them sometimes for Redo Heartport Mitrals and some TEVARs

 

[Ronin786]

Saline in the balloon, x-plane through RV inflow outflow view to get bicaval. float it with the two views and watch the tip go through the right holes. Giggity

Anybody mind walking me through this in more detail? Bicaval is going to prove to you it's not going into the IVC, but what adjustments do you make to make sure you're going the right way.

 

[deleted697535]

Anybody mind walking me through this in more detail? Bicaval is going to prove to you it's not going into the IVC, but what adjustments do you make to make sure you're going the right way.

Relative to the right IJ the tricuspid isapprox 30 cm and posteromedial ish. ie roll the swan up, or indeed leave it rolled up but rolled so that the tip points down and to the left until you pop into the RV thru the tricuspid.

In bicaval just watch for the swan coming down, then turn it around until it pops into the RV

Once in the RV, the PA must now be turned counter clockwise about 125 degrees to now point directly up at the ceiling. That should get it out the RVOT and into PA

What we do is aline, piv, tube then pop the tee in and tuck the probe on the chest away from the side of the neck to have the IJ. Then prep the neck and put the IJ line and swan in. Then grab the tee thru the drape with your sterile gloves still sterile and whip it around to bicaval til you can see the wire and swan going down

That way you can live place the swan while still sterile...
Ive not spent more than about 4 minutes floating a swan in the last year or so using this method

Its essential for MICS etc that you ensure your wire is in the SVC, especailly when your putting in those giant MICS cannulae what are they like 19 Fr?

 

[deleted697535]

Ok....best and only tip you'll ever need - don't place a PA catheter....they are worthless.

dont entirely agree...
i think it makes a diff for severe cases esp post op in csicu when you cant exactly leave the tee in for 2 weeks.

Intra-op when you have a tee, i would rarely make a decision based on what a swan tells me.

It certainly does foretell badness however occasionally.

Just last week we did double valve on a lady with mild pHTN from last tte. Now she looked a crock of sh1t so i hung around for induction. First swan reading was Pa Systolic 101. Totally altered my plan for feet up, coffee down all day with the fellow/resident fumbling along... I still did eff all for the day but told the tech start the dob and vaso coming off no matter whats going down

I couldnt really imagine why a medical icu or non cardiac surgery patient would need a swan however, so agreed there

 

[GassYous]

dont entirely agree...
i think it makes a diff for severe cases esp post op in csicu when you cant exactly leave the tee in for 2 weeks.

Intra-op when you have a tee, i would rarely make a decision based on what a swan tells me.

It certainly does foretell badness however occasionally.

Just last week we did double valve on a lady with mild pHTN from last tte. Now she looked a crock of sh1t so i hung around for induction. First swan reading was Pa Systolic 101. Totally altered my plan for feet up, coffee down all day with the fellow/resident fumbling along... I still did eff all for the day but told the tech start the dob and vaso coming off no matter whats going down

I couldnt really imagine why a medical icu or non cardiac surgery patient would need a swan however, so agreed there

I remember we put a swan in a homeless basically dead guy in the sicu one time and they used the numbers to decide to start some nitric. Guy was already using up a ton of nursing with his cvvh, pressors, blah blah blah. He was like that for a week before everyone was like wtf is the point of this and finally the sicu attending let the guy go. Took another week of bsing with risk management though.

 

[vector2]

Anybody mind walking me through this in more detail? Bicaval is going to prove to you it's not going into the IVC, but what adjustments do you make to make sure you're going the right way.

There are three frequent problems that the bicaval and modified bicaval help with. The first is as you mentioned- ruling out traversal into the IVC. Another common problem I've run across is when the balloon gets trapped in the right atrial appendage right after passing the SVC-atrial junction/crista terminalis. And finally, severe TR just blowing the balloon away from where it needs to be whenever it gets close to the annulus. Without echo, though, you might've thought you were just going into IVC even when these latter problems were occurring.

As far as adjustments, the utility from TEE comes from being able to track the balloon in real time (put a half cc of saline plus half cc of air in there). Now that it's echogenic, get a second set of hands who can float as you're directing. Watch the balloon enter the RA and then while advancing slowly determine where things are going wrong. Depending on orientation, it's simply a matter of telling the person floating to make a clockwise or counterclockwise adjustment to point or steer the tip in the direction it needs to be going. And with severe TR, many times it's just you increasing your luck a bit by getting the balloon close to the TV and shouting go go go go right at early diastole.

 

[hankbb02]

Make sure you are out of T berg. If you can't get in the RV pull it back and rotate it while advancing. Pause once you get into the RV to allow it to straighten out and then advance. If you curl in the RV pull back to the depth you entered the RV and twist and advance. Rarely do I need the echo to guide me with these "tricks"