On-line Pulmonary Artery Catheter Tutorial...

[hermanodequeso]

In response to Vent's ? for good background info on the interpretation of pulmonary artery catheter data, I'd recommend the following website from the pulmonary artery catheter education project.....

www.pacep.org

After a free on-line registration, you run through several power-point presentations and quizzes that start from the beginning and run through just about everything you'll ever want to know about PACs. The final project is supposed to have 4 levels, though I think there are only 2 up and running right now. My SICU attending in medical school had all of the residents and medical students run through these lectures during the rotation....personally, I found them extremely helpful, given the widespread confusion surrounding the interpretation of PAC numbers by medical professionals.

Good stuff..... 👍

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[greets fr. nyc]

schweet !

just checked it out..... good stuff!

👍

 

[militarymd]

Well, why don't we get started with this. The pac yields an incredible amount of data....both directly measured and calculated.

We collect the data, interpret it, then formulate treatment plans for our patients based on what we think the information means.

It is quite clear that many physicians don't know squat about the data and on how you interpret it.

It is also quite clear that even when used by physicians who know what they are doing....the treatment plans based on pac data don't necessarily improve outcome....as demonstrated in a number of studies published over the last 10 years...some very recent and well done.

So, let's hear it...how does everyone who use it, use it.

 

[jetproppilot]

Well, why don't we get started with this. The pac yields an incredible amount of data....both directly measured and calculated.

We collect the data, interpret it, then formulate treatment plans for our patients based on what we think the information means.

It is quite clear that many physicians don't know squat about the data and on how you interpret it.

It is also quite clear that even when used by physicians who know what they are doing....the treatment plans based on pac data don't necessarily improve outcome....as demonstrated in a number of studies published over the last 10 years...some very recent and well done.

So, let's hear it...how does everyone who use it, use it.

I use it sparingly. I think once in the last eight years I placed a PAC for a non cardio-vascular case. I don't put them in AAAs/CABGs unless the the EF is severely bad (like less than whatever arbitrary number at the time sounds good, like 25%...somewhere around there) or PAPs are really high.
Especially during open heart cases, my feeling is that there is no better indicator of how the heart is doing than....the heart. The chest is open and you can see if it needs volume, if it is volume overloaded, if the contraction is nice and snappy, if the contraction is poor and needs an inotrope, etc.
After you see several hundred hearts, you get pretty good at knowing whats going on just by looking at the heart. Looking at the heart is my largest clinical guide coming off pump. I've learned to not chase out-of-wack PAC numbers, if the patient is hemodynamically stable and the heart LOOKS fine.


If pre-op PAPs are high, like 65/35 or something like that, I feel better being able to see the pulmonary pressures, especially coming off bypass when you're repleting volume. Usually by that time, though, in that clinical scenerio, I've bolused and started an infusion of a phosphodiesterase inhibitor. I guess high pre-op pulmonary pressures concern me the most, more than a low pre-op EF, cuz fighting right ventricular failure coming off pump is a bitch. As a result I'm very aggressive with pharmacologic intervention (early enough so a good serum level is present by the time you're ready to come off), keeping the CO2 lower than normal (although I'm not sure if this really works or not), being judicious with after-coming-off volume transfer, as opposed to just rolling in the volume like in a patient with normal EF/normal PAPs, etc.

 

[VentdependenT]

In response to Vent's ? for good background info on the interpretation of pulmonary artery catheter data, I'd recommend the following website from the pulmonary artery catheter education project.....

www.pacep.org

After a free on-line registration, you run through several power-point presentations and quizzes that start from the beginning and run through just about everything you'll ever want to know about PACs. The final project is supposed to have 4 levels, though I think there are only 2 up and running right now. My SICU attending in medical school had all of the residents and medical students run through these lectures during the rotation....personally, I found them extremely helpful, given the widespread confusion surrounding the interpretation of PAC numbers by medical professionals.

Good stuff..... 👍

I'll start lightly goofen around with this when I have some of the basics down. I'm so inundated right now its mind boggeling. Danka however.

 

[militarymd]

Here's how I use it...although I also rarely use it.

I place it only when there is a high likelihood of organ hypoperfusion during a case or there is already evidence of organ hypoperfusion (icu), and I want something to guide my fluid therapy so that i don't over do it.

I actually do not look at the PA pressures at all. The number that I'm specifically interested in is the Stroke Volume Index, and only when there is evidence of systemic organ hypoperfusion....anion gap metabolic acidosis, low SVO2 (need a pac to measure that), anuria/oliguria, low pHi, persistant hypotension, etc....

I give volume and rasie filling pressures until the SVI doesn't improve any more, and than reassess....if hypoperfusion state is not resolving, than I start with inotropes to improve SVI...and global perfusion.


Funny how everyone uses it differently....anyone else.

 

[jetproppilot]

Chi,

I agree SVO2 is useful- coming off pump, essentially 2 parameters of the 3-variables in SVO2....Hb and CO... can be questioned and optimized if one experiences problems coming off...but lets say you've gotta dude that worries me the most...high pre-op PAPs...and its time to come off, the pump tech has 1500mL left in the resevoir and the hearts lookin marginal but acceptable...are you still looking at SVI as your guide to volume repletion over PAPs?

 

[militarymd]

Chi,

I agree SVO2 is useful- coming off pump, essentially 2 parameters of the 3-variables in SVO2....Hb and CO... can be questioned and optimized if one experiences problems coming off...but lets say you've gotta dude that worries me the most...high pre-op PAPs...and its time to come off, the pump tech has 1500mL left in the resevoir and the hearts lookin marginal but acceptable...are you still looking at SVI as your guide to volume repletion over PAPs?

It would depend on whether I think there is enough O2 getting around to all the places that it needs to get to. Ultimately, CO is only needed to feed O2 to the rest of the body, so if the rest of the body is OK, then I don't worry too much about any of the pac parameters. Unfortunately, assessing whether enough O2 is getting around can sometimes be hard...

Anyways, if the heart looked kind of crappy, and the RV looks kind of full, but blood pressure is ok, SVO2 OK, pH, OK, I would probably leave things alone, and wait to give the volume later....when you know they'll probably need it in the CTICU.