PA Catheters

[fakin' the funk]

---

Members don't see this ad.

Ok folks, my first-ever clinical thread.

I'm currently interning away in a cardiac ICU and we use a lot of PA catheters. The population is pretty much only chronic cardiomyopathy or acute MI patients, so pretty much everyone has one.

I like using them, I think the principles and data collection involved are pretty cool.

So as this pertains to anesthesia: for which cases do anesthesiologists use PA catheters? In those cases, which parameters are the most closely followed? What patient characteristics figure into using/placing one for a case? Any common pitfalls in placement or use, or complications that I can learn to avoid or minimize?

 

[proman]

I'll take a stab with at least a partial answer.

The case is less important than the patient. PA-Cs used to be used extensively in almost all cardiac surgery cases. With the advancement of TEE, PA-Cs have been less frequently placed. Much of the information provided by a PA-C and more (ie true volume status) is provided by TEE. I'd say most of the PA-Cs placed are for the benefit of the ICUs, where echo isn't an easy option. The most important thing to remember with PA catheters is that it's a diagnostic monitor, not a treatment (Marino makes this point). Our surgical colleagues frequently miss this point. Just because a patient is hypotensive doesn't mean they need a PA-C.

So, for cases:
Cardiac cases in patients with low EF, sometimes diastolic dysfunction, pulmonary hypertension, need to pace. We probably place them in ~40% of our cardiac cases. Continuous cardiac output PA-Cs are nice too. Our CSICU likes to titrate inotropes to a cardiac index >2, and likes to use PA pressures as a measure of volume. I don't really agree with that.
Vascular cases: open AAA in patients who don't have normal hearts. Every thoracoabdominal aneurysm because of the large hemodynamic fluctuations.
Other: Routine cases in patients with compromised cardiac function (ie lap colectomy in a heart transplant candidate).
Liver transplants: hemodynamic derangements that the PA-C can quantify (like vasodilation, reperfusion etc).
Septic patients: similar to livers, and to assess volume status.
Labs: being able to check a mixed venous saturation is sometimes useful.
Again, most of the evidence on PA-Cs don't show a significant difference in outcome. Definitely read the FACTT trial in NEJM, 2006 I think.

In interpreting the findings, I think it's really important to consider the whole picture. Not just cardiac output, but knowing the mixed venous, lactate, hemoglobin, responsiveness in SV, CVP, PA pressures vs a baseline and following the trends. Also vital is knowing the outcome of your intervention. Seeing the SV go from 50 to 80 with a bolus doesn't mean the patient needs more crystalloid without also knowing the hemoglobin, output, mixed venous sat etc.
We almost never wedge the catheter, but leave it somewhere after the main PA. Cardiac output, I'd guess, is the single most important parameter. Pulmonary pressures are also looked. For volume status, stroke volume responsiveness to a fluid bolus is somewhat useful information. Getting a PAOP by wedging it allows you to calculate the pulmonary vascular resistance. But SVR/PVR etc are simply calculated (you do need to know the formulas), so they aren't necessarily that valuable.

PA-Cs can also detect ischemia, usually before EKG changes (ventricular V waves). TEE is most sensitive for ischemia.With the spread of TEE there is a much lower impact of intraoperative PA-Cs.

Complex topic, be sure to go through the tutorials at www.pacep.org

 

[bigdan]

Funk -

I agree the info obtained can be very cool.

I can't hold a candle to proman's post or experience, but during my cardiac ICU month, it was constantly reinforced that while "hemorrhage" is the most commonly quoted complication, "misinterpretation of data" is the most commonly seen complication. It seems that at times there was too much information (or at least too much for my pea-brain); for some cases, it looked like someone could pick a few data points to make things "fit" a scenerio, and someone else could do the same - on the same patient - and make a case for something else...

dc

 

[sevoflurane]

I only use them for cardiac cases. Probably not necessary, but cardiac surgeons like to follow CCO/SVO2 and PA pressures in the ICU. I guess it's nice to see what the PA's are doing as the protamine is going in. Surgeons at my institution think they pick up on temponade a lot earlier with a swan as evidenced by decreasing CO and equalization of intracardiac pressures. I think a good exam is just as good. Where I trained we'd used them occasionally for AAA's. I never use them for AAA' nowadays. Comlications are pretty rare despite the literature. Our cardiac surgeons insist on floating a swan even with newly placed pacer wires (same day). I do get a little uncomfortable with that scenerio, but I've yet to have a problem.... yet.

 

[sevoflurane]

I rarely used them for liver transplants. CO are always high, SVR is low and PA's are high nml or high. Good access though. x2 ric's, mac catheter, 2 a-lines. Anyone using thromboelastastograms for cases other than livers?

 

[sevoflurane]

Vigileo or CardioQ are pretty nice devices to obtain CO. Much less invasive.

 

[lfesiam]

I'll bite. ASA 2003 Practice Parameters...probably should be updated.

http://www.asahq.org/publicationsAndServices/pulm_artery.pdf

Great TABLE#4 listing different old school studies & outcome from 1990-2000

Study 1 Critical Illness in ICU = Higher M&M, Lenth of stay
Study 2 Septic Shock = Lower M&M, Length of stay
Study 3 Surgical Pts = Lower 28 day M&M
Study 4 ICU Pts with PAC 85% surgical, w/ sepsis and ARDS = No difference
Study 5 Hi risk CC Pts who did not reach target values with fluid resus = Higher M&M
Study 6 Hi risk 56 ICUs = No difference
Study 7 Low risk elective abd arotic resonstruction = Increase intraop complication
Study 8 Hi risk pts Major Elective Surg = lower M&M and length of stay
Study 9 Consecutive elective cardiac surgery = shorter stay, faster discharge, fever pts with organ dysfnx
Study 10 Gen surg in Hi Risk Pts = lower post op M&M, mean ICU stay, Vent use
Study 11 Vein graft arterial bypass for limb salvage = fewer intraoperative heme disorders and post op graft thrombosis
Study 12 Elective infrarenal aortic recons or lower limb revasc = NONE
Study 13 Non cardiac surg in Pt with prior MI = lower periop reinfarction & Mortality rates in study cohort
Study 14 Elective cardiac surg = None
Study 15 Elective CABG = mean icu stay greater in PAC hi risk group then CVC group
Study 16 CABG meeting criteria for CVC = increase overall complications, longer intubation time
Study 17 Nonemergent CABG at 56 hosp = higher M&M + length of stay
Study 18 Abd aortic reons = No difference
Study 19 AAA repair = ICU stay longer in CVC and hi risk pts than PA cath
Study 20 AAA repair = lower periop hypotensive episodes and mortality
Study 21 Trauma patients with EBL of atleast 2000ml, mostly surgical = fewer organ falures, vent days, icu stays
Study 22 Trauma patients with EBL of atleast 2000ml, pelvic fx = lower M&M, icu stays
Study 23 Truama patients critically ill = None
Study 24 Life threatening burn = lower M&M and organ failure
Study 25 Critically injured pt with PAC = lower organ dysfunction

for the specific "n", stats, comment, please visit the paper.

 

[Arch Guillotti]

Other: Routine cases in patients with compromised cardiac function (ie lap colectomy in a heart transplant candidate).

Interesting. I never put one in for these type of cases. I have probably only seen a small handful of post transplant patients and they all seem to have have pretty good hearts. I do see people with poor hearts more frequently including EF's in the teens and bi-ventricular pacers, etc. I don't routinely place an introducer on these folks. Most of the time I get by with good peripherals and an a line.

 

[Arch Guillotti]

I'd say most of the PA-Cs placed are for the benefit of the ICUs, where echo isn't an easy option.[/URL]

agree, many of the times I place one is because the primary team would like it for post op management (whether or not it will truly be needed).

 

[sevoflurane]

Interesting. I never put one in for these type of cases. I have probably only seen a small handful of post transplant patients and they all seem to have have pretty good hearts. I do see people with poor hearts more frequently including EF's in the teens and bi-ventricular pacers, etc. I don't routinely place an introducer on these folks. Most of the time I get by with good peripherals and an a line.

Yep👍

 

[aredoubleyou]

Interesting. I never put one in for these type of cases. I have probably only seen a small handful of post transplant patients and they all seem to have have pretty good hearts. I do see people with poor hearts more frequently including EF's in the teens and bi-ventricular pacers, etc. I don't routinely place an introducer on these folks. Most of the time I get by with good peripherals and an a line.

the original post said "heart transplant candidate"...which to me means somebody with end-stage heart failure on ionotropic support. In that case I'd agree with proman.

 

[periopdoc]

I find them to be particularly useful in patients with Bi-directional Glenn's and non-fenestrated Fontans.

-pod

 

[proman]

Interesting. I never put one in for these type of cases. I have probably only seen a small handful of post transplant patients and they all seem to have have pretty good hearts. I do see people with poor hearts more frequently including EF's in the teens and bi-ventricular pacers, etc. I don't routinely place an introducer on these folks. Most of the time I get by with good peripherals and an a line.

Yeah this woman was listed for a heart transplant and as part of her screening, was found to have a mass isolated in her right colon. It was felt that she would be a candidate after the colon was resected. She wasn't quite to continuous inotrope support but was close.

We wanted the PA catheter for a couple of reasons. First, the surgeon thought he could do it lap. We didn't know what would happen to her PA pressures closed, or if it turned into a bigger operation. Second, our plan was to start empiric dobutamine. That worked really well and she was completely stable.

 

[Licoricestick]

Yeah this woman was listed for a heart transplant and as part of her screening, was found to have a mass isolated in her right colon. It was felt that she would be a candidate after the colon was resected. She wasn't quite to continuous inotrope support but was close.

We wanted the PA catheter for a couple of reasons. First, the surgeon thought he could do it lap. We didn't know what would happen to her PA pressures closed, or if it turned into a bigger operation. Second, our plan was to start empiric dobutamine. That worked really well and she was completely stable.

Lap, in someone nearly requiring inotrope support before she was anaesthetised....I know it's cool and fun to push boundaries, but a pneumoperitoneum sounds rather scary in that scenario. 😱

I've being taught that, if possible, we should avoid cannulating the RIJV in heart transplant candidates (or near candidates) as that is the biopsy route post op....that said I haven't actually done any cardiac transplant candidates for non transplant ops (or transplant either, but that's cause we don't actually do cardiac transplants in my city). Thoughts on avoiding RIJV...or do you consider getting the data more important at the time?

 

[proman]

Lap, in someone nearly requiring inotrope support before she was anaesthetised....I know it's cool and fun to push boundaries, but a pneumoperitoneum sounds rather scary in that scenario. 😱

I've being taught that, if possible, we should avoid cannulating the RIJV in heart transplant candidates (or near candidates) as that is the biopsy route post op....that said I haven't actually done any cardiac transplant candidates for non transplant ops (or transplant either, but that's cause we don't actually do cardiac transplants in my city). Thoughts on avoiding RIJV...or do you consider getting the data more important at the time?

The surgeon used lower pressures than normal, and the dobutamine offset the cardiac depressant effects of the volatile anesthetic. It was a very smooth case.

We'll do left sided IJs for our lines for the actual transplant. Speaking of which, does anyone use short introducers for left IJ?

 

[countingdays]

I rarely used them for liver transplants. CO are always high, SVR is low and PA's are high nml or high. Good access though. x2 ric's, mac catheter, 2 a-lines. Anyone using thromboelastastograms for cases other than livers?

We use TEG for pedi hearts, avoiding the unnecessary volume of the usual 'give some platelets... give ffp... more platelets... prbcs... cryo, ffp, etc.' 🙄

We do PA catheters for off-pump cabgs and liver tx. It's mainly for ICU use post-op with the hearts as mentioned above, but also for continuous cardiac output intraop.

 

[Hockeyguy]

I've being taught that, if possible, we should avoid cannulating the RIJV in heart transplant candidates (or near candidates) as that is the biopsy route post op....that said I haven't actually done any cardiac transplant candidates for non transplant ops (or transplant either, but that's cause we don't actually do cardiac transplants in my city). Thoughts on avoiding RIJV...or do you consider getting the data more important at the time?

This is absolutely true. We are a busy transplant center and this comes up sometimes with our transplant patients. If you need a PA catheter just fire it in from the left sub-clavian. Do your cardiology colleuges a favor and leave the RIJ alone.

 

[MTGas2B]

I would emphasize to the younger residents on this forum to take advantage of the chances you have to place and use a PA catheters. After being a critical care fellow this year I've realized that PA catheters have fallen so far out of use that many folks just don't know how to use them. The rash of literature that showed them to be harmful or of no benefit has become self fulfilling; as people use them less and less they become less comfortable placing and interpreting them, and they become even more dangerous.

I would agree the indications for PA catheter placement has gotten appropriately smaller that what it was, however, they still represent a useful monitor in certain patients...

like bidirectional glens and non-fenestrated fontans

I'm joking with that list line, they can still be useful

 

[periopdoc]

Just a thought

PA catheter = 10 units + 4 units for the sheath to place the PAC into

TEE with insertion of probe, image acquisition and interpretation etc 6 units.

hmmm


- pod

 

[periopdoc]

We'll do left sided IJs for our lines for the actual transplant. Speaking of which, does anyone use short introducers for left IJ?

We have had enough misadventures with normal introducers in the left IJ that our cardiac group has gone to exclusively using the short introducer sheaths when accessing the left IJ. I cannot speak for the general OR at UW as that is a mixed bag of attendings who have very different anesthesia philosophies from our fairly uniform cardiac group.

- pod

 

[fakin' the funk]

I would emphasize to the younger residents on this forum to take advantage of the chances you have to place and use a PA catheters. After being a critical care fellow this year I've realized that PA catheters have fallen so far out of use that many folks just don't know how to use them. The rash of literature that showed them to be harmful or of no benefit has become self fulfilling; as people use them less and less they become less comfortable placing and interpreting them, and they become even more dangerous.

I have seen them so infrequently in a general medical population, and used very sparingly in a MI/heart failure population, I can't even imagine how rare they are in a noncardiac surgical population. My early impression is, there is a lot of fear of PA catheters. I think there is also a lot of fear that people will get tied up doing a line for 2+ hours (yes, that's how long it takes sometimes) so they avoid doing so. The end result - boxed kidneys. Ouch.

 

[Bertelman]

I have seen them so infrequently in a general medical population, and used very sparingly in a MI/heart failure population, I can't even imagine how rare they are in a noncardiac surgical population. My early impression is, there is a lot of fear of PA catheters. I think there is also a lot of fear that people will get tied up doing a line for 2+ hours (yes, that's how long it takes sometimes) so they avoid doing so. The end result - boxed kidneys. Ouch.

On the flip side, in my recent SCU month I removed 2, or 75% of the PAC's on our service in a matter of days for tachyarrhythmias, one of which required cardioversion.

I'm not aware of any studies demonstrating PAC use decreases renal dysfunction in the critically ill.