When to advance Swan?

[Dantrolene FC]

I have heard from almost all attendings that you should advance the Swan 1 cm at a time during systole. They say to listen to the pulse ox tone and advance with each beep.

However, one attending says that’s not real. He says the Swan is flow directed and the the tone is delayed due to computer processing. So he just advances at random timing.

Does anyone know if you should advance with each pulse ox beep, or is this dogma?

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[Xman5678]

I have heard from almost all attendings that you should advance the Swan 1 cm at a time during systole. They say to listen to the pulse ox tone and advance with each beep.



Does anyone know if you should advance with each pulse ox beep, or is this dogma?

You can make the grass grow greener with that advice.

 

[nimbus]

I have heard from almost all attendings that you should advance the Swan 1 cm at a time during systole. They say to listen to the pulse ox tone and advance with each beep.

However, one attending says that’s not real. He says the Swan is flow directed and the the tone is delayed due to computer processing. So he just advances at random timing.

Does anyone know if you should advance with each pulse ox beep, or is this dogma?

Never heard of that.

 

[D P356]

I have heard from almost all attendings that you should advance the Swan 1 cm at a time during systole. They say to listen to the pulse ox tone and advance with each beep.

However, one attending says that’s not real. He says the Swan is flow directed and the the tone is delayed due to computer processing. So he just advances at random timing.

Does anyone know if you should advance with each pulse ox beep, or is this dogma?

I don’t perform cardiac cases presently. During residency we just advanced the swan and would see the associated pressures within each chamber/pulmonary artery. It’s an unwelcome feeling when everyone and their mother is staring at you struggle to place a swan-ganz catheter.

If you’re a really having a hard time you, assuming you have a sheath to keep the catheter sterile, lock the swan at 15cm of your MAC line and advance it using the TEE when it is placed.

Though it could give good information, my understanding has been the swan is more for the post op ICU management (cardiac output/svr and pvr calculations) rather than intraoperative management.

 

[Radetzky]

I have heard from almost all attendings that you should advance the Swan 1 cm at a time during systole. They say to listen to the pulse ox tone and advance with each beep.

However, one attending says that’s not real. He says the Swan is flow directed and the the tone is delayed due to computer processing. So he just advances at random timing.

Does anyone know if you should advance with each pulse ox beep, or is this dogma?

People always making things more complicated than they need to be. You just push until you get the right waveform.

 

[cchoukal]

The time delay between systole and the SOUND of systole on the monitor and when you hear it, process it, and push, is long and unpredictable, rendering the advice you've been given unlikely to be true or helpful. The true answer for "when to advance the swan" is almost certainly "never." the question reminds me of those meme videos about the proper way to eat a pineapple pizza, and the video is of a guy unboxing the pizza, rolling it up, and throwing it unceremoniously into the trash.

*cue swan defenders' indignation*

 

[woopedazz]

Put your finger on a patient's pulse and tell me:

Does the pulse ox beep correlate exactly with the palpated pulse?
Are arteries non-elastic and is blood an ideal fluid? I.e. even if the beep was accurate (it isn't), would your peripheral pulse ox correlate exactly with LV ejection?

Weird.

 

[pgg]

The time delay between systole and the SOUND of systole on the monitor and when you hear it, process it, and push, is long and unpredictable, rendering the advice you've been given unlikely to be true or helpful. The true answer for "when to advance the swan" is almost certainly "never." the question reminds me of those meme videos about the proper way to eat a pineapple pizza, and the video is of a guy unboxing the pizza, rolling it up, and throwing it unceremoniously into the trash.

*cue swan defenders' indignation*

I hear you but the surgeons want them for postop management, and placing one is a 4 minute procedure that's worth a nonzero number of units. So I no longer really argue against them.


To the OP's question, I just steadily advance without regard to where I think the cardiac cycle happens to be at the moment. If getting in is troublesome, before giving up, locking it at 15-20, and messing with the TEE to help guide it later, what I'll do is tilt the bed a bit to the right. That often seems to help the catheter go the right way.

 

[dabears505]

This could be a classic case of all the attendings at an institution coming out of that very same institution propagating nonsense.

 

[vector2]

I have heard from almost all attendings that you should advance the Swan 1 cm at a time during systole. They say to listen to the pulse ox tone and advance with each beep.

However, one attending says that’s not real. He says the Swan is flow directed and the the tone is delayed due to computer processing. So he just advances at random timing.

Does anyone know if you should advance with each pulse ox beep, or is this dogma?

It's dogma. The best advice is to make sure the swan's natural curl is going counterclockwise (pointing toward patient left) and that you've leveled the bed +- right tilt before floating.

 

[T-burglar]

Lmao just jam that bitch in there.

 

[ear-ache]

It's dogma. The best advice is to make sure the swan's natural curl is going counterclockwise (pointing toward patient left) and that you've leveled the bed +- right tilt before floating.

^^this!

Don't fight the "curve" of the swan.

 

[Angus Avagadro]

It's dogma. Kinda like laying flat will.prevent a spinal headache. Not worth arguing over with flat earthers.

 

[anaesthetic]

I’ve advanced a ton of PACs (100% of cardiac cases in residency, fellowship, and 98% in PP).

In residency, I was taught to do it with every beat. In fellowship, I was told that it doesn’t matter.

In private practice, the answer for me has been “it probably doesn’t matter.” It takes me about 3 seconds to advance it in 70% of patients regardless of the cardiac cycle. Takes me another 3 seconds to redirect in 20% of patients. Takes me about 20-30 seconds in 5% of patients where I slow down, redirect, rotate, re-flush, advance with systole based on the arterial line waveform, etc. In 4%, I park it at 20 cm and float under TEE guidance or call on an available partner to help (different set of hands matter, IMO). In 1% of patients, I use fluoro (if the PAC is a “must”—heart transplants, complex valves, etc.) or call cardiology to come down and overwire under fluoro if they really want the PAC.

In short, it probably doesn’t matter, but it may.

 

[vector2]

. Takes me about 20-30 seconds in 5% of patients where I slow down, redirect, rotate, re-flush, advance with systole based on the arterial line waveform, etc.

I do the same thing, but something I've been thinking about:

Normal intraventricular conduction delay can be 120-200ms right off the bat. And with LV ejection...

...the onset to arterial wave upslope is even more prolonged by the time it reaches the radial.

So even advancing with a radial a-line may not truly reflect RV to PA ejection (unless you're pre-timing your push)

 

[anaesthetic]

I do the same thing, but something I've been thinking about:

Normal intraventricular conduction delay can be 120-200ms right off the bat. And with LV ejection...

View attachment 362764

...the onset to arterial wave upslope is even more prolonged by the time it reaches the radial.

So even advancing with a radial a-line may not truly reflect RV to PA ejection (unless you're pre-timing your push)

I actually do pre-time my push based on the arterial waveform because of precisely that—delayed upstroke with peripheral art lines. Whether or not those milliseconds actually matter is anyone’s guess.

 

[RemyMcswain]

The time delay between systole and the SOUND of systole on the monitor and when you hear it, process it, and push, is long and unpredictable, rendering the advice you've been given unlikely to be true or helpful. The true answer for "when to advance the swan" is almost certainly "never." the question reminds me of those meme videos about the proper way to eat a pineapple pizza, and the video is of a guy unboxing the pizza, rolling it up, and throwing it unceremoniously into the trash.

*cue swan defenders' indignation*

You know when I actually love a Swan? Non cardiac surgery shock patients whom I’m getting conflicting info on why they’re in shock. Crappy TTE windows. Dont want to intubate and pass TEE probe(which only gives you a snap shot of their hemodynamics).

I think it has its place

 

[pgg]

You know when I actually love a Swan? Non cardiac surgery shock patients whom I’m getting conflicting info on why they’re in shock. Crappy TTE windows. Dont want to intubate and pass TEE probe(which only gives you a snap shot of their hemodynamics).

I think it has its place

Nice

Every time I want to hate on PA catheters I remind myself we get paid to put them in, and I like money.


Truestory:

I put a PA catheter in a case the other day. There was a lot of artifact (resonance) in the waveform. I took a picture:

Obviously the PA pressure is about 45/20. Of course, the monitor is dumb and puts 40/-1 up on the monitor. It's a heart room so there are monitors everywhere.

Someone may have asked "Why's the PA diastolic so low?"

I may have said "That's an artifact, actual PA diastolic is around 20"

Later in the ICU someone may have said "PA diastolic is low, he probably needs fluid"

This is why some studies say PA catheters harm patients.



Related note: for some reason, about 80%+ of the PA catheters I've put in over the last month have this same artifact. Here's another one:

I've tried
- adding a length of tubing
- removing a length of tubing
- adding an expansion chamber
- adding a bubble (helped a little bit)

I wonder if we just have a new supplier/model catheter that just happens to be designed badly such that its length/etc has the wrong resonant frequency.

I wouldn't care so much, if different people eyeballing the monitors didn't keep piping up about how my PA catheter is in the RV (it's not) or how low the PA diastolic pressure is (it's not) ...

 

[anaesthetic]

Nice

Every time I want to hate on PA catheters I remind myself we get paid to put them in, and I like money.


Truestory:

I put a PA catheter in a case the other day. There was a lot of artifact (resonance) in the waveform. I took a picture:

View attachment 362776

Obviously the PA pressure is about 45/20. Of course, the monitor is dumb and puts 40/-1 up on the monitor. It's a heart room so there are monitors everywhere.

Someone may have asked "Why's the PA diastolic so low?"

I may have said "That's an artifact, actual PA diastolic is around 20"

Later in the ICU someone may have said "PA diastolic is low, he probably needs fluid"

This is why some studies say PA catheters harm patients.



Related note: for some reason, about 80%+ of the PA catheters I've put in over the last month have this same artifact. Here's another one:

View attachment 362777

I've tried
- adding a length of tubing
- removing a length of tubing
- adding an expansion chamber
- adding a bubble (helped a little bit)

I wonder if we just have a new supplier/model catheter that just happens to be designed badly such that its length/etc has the wrong resonant frequency.

I wouldn't care so much, if different people eyeballing the monitors didn't keep piping up about how my PA catheter is in the RV (it's not) or how low the PA diastolic pressure is (it's not) ...

I’ve had that happen with faulty cables and faulty transducers (especially after zeroing multiple times with frequent pressure drifts). I’ve changed out entire setups just to find out that one of the three hubs are bad on either side of the wires. Somehow the same faulty cables eventually make it back into the rotation despite me flagging them.

 

[anaesthetic]

Is a PA catheter a must in a heart transplant? You’re just gonna slam the right heart with as much support as possible coming off pump anyway and hope it doesn’t fail, idk what info it’s gonna give you to get you through a case. Post op I guess is most important but same thing applies with advent of POCUS being common in ICUs now.

Then again I’d say the same for complex valves. TEE gives you 99% of what you’ll ever need imo

Post-op ICU care where 90% of the ICU RNs are 1-2 years out of nursing school. Also serves as another set of numbers to help guide management intra-op and assuage surgeons/nurses/NPs. Not completely useless, IMO, despite having minimal/no impact on M/M.

You ever try to do POCUS on a fresh heart with dressings/tubes in place on a hefty patient? I have. It’s not easy. We do ICU TEEs as well, but that’s a headache for everyone involved and delays care by a couple of hours compared to a set of numbers from a PAC/CCO monitor.

Surgeons like them, ICU likes them, cardiology likes them, and I don’t mind placing them. As soon as I try to change the culture based on “data,” the sooner they throw me under the bus for not placing one.

 

[anaesthetic]

I get all that, the way you talked about the 1% of cases requiring fluoro seemed extreme is all. Unless the surgeon won’t go ahead until it’s done, I don’t see much reason to make such a production of it.

Oh yeah. I once brought a fresh heart transplant to the ICU without a PAC, and the HF cardiologist flipped out. Said I should have called them to float it intra-op since they wanted fluoroscopic guidance which required an ICU-cath lab transport. I shrugged and said “okay.”

I called them in around 2AM for the next one I couldn’t float. To their credit, they did come (begrudgingly) after 1-2 hours of being paged and overwired it under fluoro prior to ICU transport. On the other occasion, they just said “we’ll float it later, thanks for calling us,” as I suspect coming in late night/early morning to float a PAC wasn’t very appealing.

 

[nimbus]

I’ve had that happen with faulty cables and faulty transducers (especially after zeroing multiple times with frequent pressure drifts). I’ve changed out entire setups just to find out that one of the three hubs are bad on either side of the wires. Somehow the same faulty cables eventually make it back into the rotation despite me flagging them.

That’s when you cut the cable and throw it in the trash.

 

[Dantrolene FC]

It's dogma. Kinda like laying flat will.prevent a spinal headache. Not worth arguing over with flat earthers.

If lying flat helps, then slight Trendelenburg must be better and steep Trendelenburg even better! Ha

 

[vector2]

The newish SCAI cardiogenic shock classification paper recommends PAC placement for the higher stages of cardiogenic shock (maybe a class Ic rec now). Still awaiting randomized trials but the largest observational metanalysis to come out do show a mortality benefit for PACs in CS. And you won't find a a heart failure cardiologist nowadays who doesn't want a PAC (or at least frequent ScvO2/MVO2) once a pt meets ICU/CCU criteria.

Anecdotally, I do find PAPI, CVP, CPO, MVO2, and continuous CO/CI helpful in pts who are not following post-op plan A after cardiac surgery.

 

[Radetzky]

I think a PAC is pretty useful post op night 1 in terms of the cardiac index. If the pt craps out and I’m adding some additional tropes I want some easy way of knowing what effect they’re having.

Trouble is people start getting smart and trying to interpret the pressure numbers when they have no clue what they mean (but think they do)

 

[Ronin786]

PACs help in patients that are really sick and hurt/are useless in patients that aren't actually very sick.

I'd venture the reason newer literature showed a benefit in CS patients is because the pendulum swung away from placing them in every ICU patient out there.

 

[abolt18]

I have heard from almost all attendings that you should advance the Swan 1 cm at a time during systole. They say to listen to the pulse ox tone and advance with each beep.

However, one attending says that’s not real. He says the Swan is flow directed and the the tone is delayed due to computer processing. So he just advances at random timing.

Does anyone know if you should advance with each pulse ox beep, or is this dogma?

One attending gave the advice, that has been nearly foolproof, advance slowly (like 1-2cm/sec) until you get arrhythmia (persistent, not just one beat), then push fast and BAM you're in.

His argument for the slow initially is just to let the blood carry/pull the air filled balloon. Obviously also align the curvature correctly as others noted. No big tricks. Can try rotating 90° one way or another when you get into the RV to try and turn it if you're getting held up in the RV.

Besides, going with the heartbeat doesn't make sense until you're actually in the RVOT/PA. Because everything prior to that has forward flow during diastole!

 

[vector2]

I think a PAC is pretty useful post op night 1 in terms of the cardiac index. If the pt craps out and I’m adding some additional tropes I want some easy way of knowing what effect they’re having.

Trouble is people start getting smart and trying to interpret the pressure numbers when they have no clue what they mean (but think they do)

PACs help in patients that are really sick and hurt/are useless in patients that aren't actually very sick.

I'd venture the reason newer literature showed a benefit in CS patients is because the pendulum swung away from placing them in every ICU patient out there.

Probably even likely having a PAC in relatively healthy post-op hearts worsened morbidity or mortality in many cases. Just imagine the number of people who had typical SIRS/capillary leak after bypass, became hypovolemic, cardiac index dropped (but CVP remained normalish d/t PPV), and someone started dobutamine instead of giving volume. That kinda thing still happens, but I bet it happened much more frequently in the days where every institution swanned everyone

 

[Radetzky]

Oh yeah. I once brought a fresh heart transplant to the ICU without a PAC, and the HF cardiologist flipped out. Said I should have called them to float it intra-op since they wanted fluoroscopic guidance which required an ICU-cath lab transport. I shrugged and said “okay.”

I called them in around 2AM for the next one I couldn’t float. To their credit, they did come (begrudgingly) after 1-2 hours of being paged and overwired it under fluoro prior to ICU transport. On the other occasion, they just said “we’ll float it later, thanks for calling us,” as I suspect coming in late night/early morning to float a PAC wasn’t very appealing.

Cardiologists managing the cvicu.. yuck 🤢

 

[deleted1147063]

Cardiologists managing the cvicu.. yuck 🤢

Cardiologists managing any ICU-level unit...

 

[T-burglar]

If you don’t think PA catheters are useful you either don’t actually take care of sick patients, or you’re one of the people that would hurt patients because you don’t understand the device

Believing that TEE images fully replace the information obtained from PA catheters means you also do not understand TEE either

 

[deleted1147063]

If you don’t think PA catheters are useful you either don’t actually take care of sick patients, or you’re one of the people that would hurt patients because you don’t understand the device

Believing that TEE images fully replace the information obtained from PA catheters means you also do not understand TEE either

Believing that a PCWP is more valuable than a TEE, or even a TTE, means that one doesn't understand how a PA catheter works, and the assumptions built into wedge pressure measurement. The PCWP and CVP don't mean much in modern critical care, thank you, definitely not more than a good echo.

In the presence of a physician with good echo skills and a patient with decent echo windows, the main application of a PA catheter is to measure... the exact pressure in the PA (which one doesn't need for most cases of PHTN, which are type 2). Meaning it's mostly worthless in the ICU, except when people can't even do a focused echo and measure a LVOT VTI.

Now if I need a lot of CO measurements (e.g. from nurses, at night), or I'm dealing with some echo uneducated people around me (e.g. non-intensivists), or I can't get good windows, I may float a Swan.

 

[T-burglar]

Just to cherry-pick your nonsense statement about the CVP. A high fidelity CVP trace is my gold standard for advising the surgeon on whether to intervene on a tricuspid valve en passant in cardiac surgery. There are some imaging elements to consider but by and large if there are no significant V waves or elevated CVP then there is no benefit to be expected from intervening on a tricuspid. There are many reasons that it is tough to be sure about the severity of TR by imaging alone. I’d also place way more emphasis on the CVP trace than the TEE in evaluating RV systolic and diastolic function, presence of significant pericardial disease, whether I’m overloading the RV with my rate of volume administration.

The list goes on. Do you do cardiac surgery? Or just read articles about how the CVP is useless .

 

[deleted1147063]

Just to cherry-pick your nonsense statement about the CVP. A high fidelity CVP trace is my gold standard for advising the surgeon on whether to intervene on a tricuspid valve en passant in cardiac surgery. I’d also place way more emphasis on the CVP trace than the TEE in evaluating RV systolic and diastolic function, presence of significant pericardial disease, whether I’m overloading the RV with my rate of volume administration.

The list goes on. Do you do cardiac surgery? Or just read articles about how the CVP is useless .

I was talking about the modern ICU, where good intensivists don't give fluid based on atrial compliance and a particular number.

And most of the time, when the RV fails, it's because of the LV. Isolated RV failure is rare outside of the OR.

And the fact that there are many-many places in this country where advanced cardiac surgery is done just with TEE suggests that the PAC is not necessary intra-op either.

Let me put it this way: if I need frequent CO monitoring in the ICU, I will put one in (rarely). Otherwise, my experience is also that people rely too much on treating numbers and not the patient, especially surgeons (this is where echo helps). I'm also a salaried employee, so I have zero financial incentives. Even in the OR, I don't do blocks if I don't really see the benefit.

 

[deleted1147063]

You articulated this better than I could on a Saturday. A directly calculated/observed cardiac output is superior to a derived one imo.

Having said that the old line about PA being useful to differentiate cardiogenic/septic shock holds true I think. If a person with EF 10% has endocarditis then that PA May give me a picture of whether the heart of the vasculature is failing

Personally, I prefer therapeutic trials before going crazy with procedures. Also, physical exam is underrated and underused (e.g. capillary refill, skin mottling over the knee), because nobody likes to touch the patient nowadays (and nobody has time to read evidence-based physical exam texts anymore).

If I can get a good CO approximation from echo, I could calculate an SVR range even without a Swan. Better to be approximately right than exactly wrong. But I also don't have to deal with the kind of patient you described.

 

[Radetzky]

Just to cherry-pick your nonsense statement about the CVP. A high fidelity CVP trace is my gold standard for advising the surgeon on whether to intervene on a tricuspid valve en passant in cardiac surgery. There are some imaging elements to consider but by and large if there are no significant V waves or elevated CVP then there is no benefit to be expected from intervening on a tricuspid. There are many reasons that it is tough to be sure about the severity of TR by imaging alone. I’d also place way more emphasis on the CVP trace than the TEE in evaluating RV systolic and diastolic function, presence of significant pericardial disease, whether I’m overloading the RV with my rate of volume administration.

The list goes on. Do you do cardiac surgery? Or just read articles about how the CVP is useless .

So do you make an attempt at calculating intrathoracic pressure when you use CVP and subtracting it from the CVP?

To me this is the biggest flaw in using CVP for anything- an internal pressure is a meaningless value. Pressure gradients are what convey information.

I mean for your example it probably doesn’t matter because everyone is paralyzed and getting similar Vt. But in the ICU it’s a different ballgame.

 

[sanityonleave]

I have heard from almost all attendings that you should advance the Swan 1 cm at a time during systole. They say to listen to the pulse ox tone and advance with each beep.

However, one attending says that’s not real. He says the Swan is flow directed and the the tone is delayed due to computer processing. So he just advances at random timing.

Does anyone know if you should advance with each pulse ox beep, or is this dogma?

I'll put myself in the "silly dogma" camp. I can't imagine that we're accurate at actually pushing during RV systole (which I assume is the theory here). Put the balloon up and advance steadily while you watch the monitor. If you don't make it after a couple attempts bring your image guidance of choice in. Agreed with others that make sure your J is facing the right direction so you don't make it any harder than it has to be.

One thing I haven't seen mentioned here is insertion site matters. As a non-CV person, I float swans almost exclusively in livers -- and they can be a total dog show to get in from the LIJ, especially when the patient has an indwelling large bore RIJ line (e.g. HD line, which is the most common reason people go to the LIJ anyway). If the RIJ is not available (don't forget double-stick is an option), go to an u/s guided LSCV approach. Troubleshoot with fluoro or TEE depending on your skillset.

I also don't float fem swans (obvious reasons), so if that's a possibility might also be an option, but you'll have to ask someone else for tips.

 

[Iso4ane]

One attending gave the advice, that has been nearly foolproof, advance slowly (like 1-2cm/sec) until you get arrhythmia (persistent, not just one beat), then push fast and BAM you're in.

His argument for the slow initially is just to let the blood carry/pull the air filled balloon. Obviously also align the curvature correctly as others noted. No big tricks. Can try rotating 90° one way or another when you get into the RV to try and turn it if you're getting held up in the RV.

Besides, going with the heartbeat doesn't make sense until you're actually in the RVOT/PA. Because everything prior to that has forward flow during diastole!

That’s my thought process too, try to sneak it it when the tricuspid is open (which if you go on the beat is perfect, since you would be pushing during diastole), but once you’re in the RV go fast so you don’t piss it off and have constant arrhythmias.

 

[Beeftenderloin]

That’s my thought process too, try to sneak it it when the tricuspid is open (which if you go on the beat is perfect, since you would be pushing during diastole), but once you’re in the RV go fast so you don’t piss it off and have constant arrhythmias.

It’s interesting how we glom onto these ideas from personal experience. Once I hit RV I actually slow down a bit, start advancing with every other heart beat. This allows blood flow to keep the balloon leading the way and prevents coiling in RV (or at least that’s what I tell myself).

 

[abolt18]

It’s interesting how we glom onto these ideas from personal experience. Once I hit RV I actually slow down a bit, start advancing with every other heart beat. This allows blood flow to keep the balloon leading the way and prevents coiling in RV (or at least that’s what I tell myself).

This is what I was saying. Slow until I get arrhythmia, then fast.

 

[Iso4ane]

This is what I was saying. Slow until I get arrhythmia, then fast.

I feel that we’re all thinking along the same lines; you get arrhythmias when you are inside the RV, so to hopefully minimize arrhythmias, go fast once you’re in the RV.

 

[LaryngoSpazz]

What’s the consensus on what to do when you get a significant arrhythmia? Let’s say pre-existing LBBB and you cause asystole with the swan for example?

 

[vector2]

What’s the consensus on what to do when you get a significant arrhythmia? Let’s say pre-existing LBBB and you cause asystole with the swan for example?

Pre-existing LBBB is a relative contraindication for swan placement. But I always put zoll pads on when putting on monitors for the vast majority of cases requiring a swan, so I'd just transcutaneously pace +- chemically pace (depending on rhythm) until spontaneous resolution, hopefully giving enough time for sternotomy /epicardial lead placement or TVP placement if underlying rhythm is still asystole

 

[LaryngoSpazz]

Pre-existing LBBB is a relative contraindication for swan placement. But I always put zoll pads on when putting on monitors for the vast majority of cases requiring a swan, so I'd just transcutaneously pace +- chemically pace (depending on rhythm) until spontaneous resolution, hopefully giving enough time for sternotomy /epicardial lead placement or TVP placement if underlying rhythm is still asystole

CT surgeon wanted swan despite LBBB. Had pads on. Was difficult to float but ended up with a LOOONG pause when just entering PA. I deflated balloon and pulled it back quickly. After about 10 sec or so when we were just about to start ACLS got an a-line tracing back. Surgeon wanted to keep floating so I made him come in the room. Was uneventful after that. Got me thinking though, if arrhythmia I deflate and pull back but you guys are all saying push faster. What about in this case?

 

[Beeftenderloin]

CT surgeon wanted swan despite LBBB. Had pads on. Was difficult to float but ended up with a LOOONG pause when just entering PA. I deflated balloon and pulled it back quickly. After about 10 sec or so when we were just about to start ACLS got an a-line tracing back. Surgeon wanted to keep floating so I made him come in the room. Was uneventful after that. Got me thinking though, if arrhythmia I deflate and pull back but you guys are all saying push faster. What about in this case?

In this case I would just lock it at 20cm then float it once the chest was open. With the chest open they can defib with paddles if needed, perform open cardiac massage, cannulate and crash on pump, etc. Plus, sometimes it’s just easier to float with chest open.

I usually don’t make more than 2-3 attempts while scrubbed-in placing the line. If it’s not going easily, even if no arrhythmia, I’ll just lock it and wait for the chest to be open. If they have a LBBB +/- right fascicular block, I’ll prob make 1 attempt with closed chest (pads on) then wait til open.

 

[abolt18]

In this case I would just lock it at 20cm then float it once the chest was open. With the chest open they can defib with paddles if needed, perform open cardiac massage, cannulate and crash on pump, etc. Plus, sometimes it’s just easier to float with chest open.

I usually don’t make more than 2-3 attempts while scrubbed-in placing the line. If it’s not going easily, even if no arrhythmia, I’ll just lock it and wait for the chest to be open. If they have a LBBB +/- right fascicular block, I’ll prob make 1 attempt with closed chest (pads on) then wait til open.

This is exactly what I was going to say. If LBBB pre-existing, I'm not going to float the swan until chest is open.

 

[vector2]

Just to cherry-pick your nonsense statement about the CVP. A high fidelity CVP trace is my gold standard for advising the surgeon on whether to intervene on a tricuspid valve en passant in cardiac surgery. There are some imaging elements to consider but by and large if there are no significant V waves or elevated CVP then there is no benefit to be expected from intervening on a tricuspid. There are many reasons that it is tough to be sure about the severity of TR by imaging alone. I’d also place way more emphasis on the CVP trace than the TEE in evaluating RV systolic and diastolic function, presence of significant pericardial disease, whether I’m overloading the RV with my rate of volume administration.

The list goes on. Do you do cardiac surgery? Or just read articles about how the CVP is useless .

Today reminded me of your post

 

[PpfSuxTube]

Just to cherry-pick your nonsense statement about the CVP. A high fidelity CVP trace is my gold standard for advising the surgeon on whether to intervene on a tricuspid valve en passant in cardiac surgery. There are some imaging elements to consider but by and large if there are no significant V waves or elevated CVP then there is no benefit to be expected from intervening on a tricuspid. There are many reasons that it is tough to be sure about the severity of TR by imaging alone. I’d also place way more emphasis on the CVP trace than the TEE in evaluating RV systolic and diastolic function, presence of significant pericardial disease, whether I’m overloading the RV with my rate of volume administration.

The list goes on. Do you do cardiac surgery? Or just read articles about how the CVP is useless .

What?
You would tell a surgeon to intervene on a tricuspid valve based on cvp?
Is that real?
Im struggling with this...

 

[vector2]

What?
You would tell a surgeon to intervene on a tricuspid valve based on cvp?
Is that real?
Im struggling with this...

He's saying hemodynamics would be a major deciding factor on whether to tell a surgeon if significant TR on echo needs intervention (much in the same way PASP > 50 mmHg supports the diagnosis of severe MR).

In the assessment of valvular disease, we have all sorts of quantitative and semiquantitative measures informing us of severity, but ultimately the doppler derived regurgitant volume or the vena contracta of the regurgitant jet or X other echo parameter is not nearly as important as pt symptomatology, adverse cardiac remodeling, or other end-organ dysfunction caused by the lesion. CVP of 20 with large V waves (i.e. holosystolic reversal of flow in the hepatic veins) is telling us that the TR will have deleterious effects upon the liver, kidneys, bowels, and heart if left untreated long enough.

 

[T-burglar]

Nice man, want to share the case details?