Placement Of Pulmonary Artery Catheter Research Articles

The changes of pulmonary blood flow in non-ventilated lung during one lung ventilation

A pulmonary artery catheter placement is necessary for intrapulmonary shunt fraction evaluation. The purpose of this study was to investigate the feasibility for detecting the changes of regional pulmonary blood flow in non-ventilated lung by transesophageal echocardiography (TEE) during one-lung ventilation (OLV). 22 adult patients for selective thoracic surgery were enrolled in the study. Doppler flow patterns in left upper pulmonary vein (LUPV) were obtained by TEE before switching to right OLV and every 5 min in 30 min OLV period. Systolic peak velocity (Vs), diastolic peak velocity (Vd) and velocity time integral (VTI) were measured respectively. The VTI of LUPV blood flow pattern decreased significantly 5 min after right OLV. The percent of changes in LUPV blood flow decreased rapidly by 78.4 and 67.7% at OLV 5 min and 10 min, respectively. Then it slowly decreased by 60% at OLV 30 min. Provides an alternative method to measure the changes of pulmonary blood flow during OLV. The percent changes of regional pulmonary blood flow decreased immediately after OLV, and decreased by 60% at 30 min OLV.

Relation between coagulation/fibrinolysis and lactate in the course of human septic shock

BackgroundThe pathogenic role of disseminated intravascular coagulation (DIC) during septic shock is incompletely understood.AimTo study the relation between indicators of DIC and lactate concentrations over time to evaluate whether a...

HeartSmart® for routine optimization of blood flow and facilitation of early goal-directed therapy

HeartSmart® for routine optimization of blood flow and facilitation of early goal-directed therapy Kenneth Warring-Davies1, Martin Bland21The Intensive Care Unit, Bradford Royal Infirmary, Bradford, West Yorkshire, UK; 2Department of Health Sciences, University of York, York, North Yorkshire, UKAbstract: The empirical physiological formulae of the new continuous cardiac dynamic ­monitoring HeartSmart® technology, which involves the use of a new inverse square rule of the heart, were investigated with pulmonary artery catheter (PAC) thermodilution in the ­estimation of CI in diverse patients. Clinical trial data collected from 268 adult surgery or intensive care patients requiring PAC placement were obtained from 7 NHS Trust hospitals, providing 2720 paired sets of CI estimations for comparison between HeartSmart® and PAC thermodilution. For 95% of pairs of measurements, HeartSmart® values were between 57% and 164% of PAC measurements; additionally, the larger limit of agreement between HeartSmart® and PAC thermodilution (1.26 L min-1•m-2) suggests that HeartSmart® agrees with PAC thermodilution as closely as PAC thermodilution agrees with itself. HeartSmart® can also estimate CI in the extreme circumstances of shock/sepsis, as indicated by PAC thermodilution CI values that were hypo- or hyperdynamic based on systemic inflammatory response syndrome criteria. In CI measurements for hypo- or hyperdynamic values that were matched between HeartSmart® and PAC thermodilution, the difference in total volumes and average CI measurements between the two methods was less than 5%. For unmatched hypo- or hyperdynamic values, the difference between total volumes and average CI measurements was less than 33% – an acceptable percentage of difference or error even for normal values of CI. HeartSmart® tracked PAC thermodilution CI hypodynamic values 98.2% of the time and hyperdynamic values 97.6% of the time. These findings show that CI estimations provided by the HeartSmart® empirical physiological formulae are comparable to those obtained using PAC thermodilution. HeartSmart® removes many of the technical barriers that prevent the routine adoption and practice of early goal-directed therapy, and represents a simple, reliable method of estimating CI and other hemodynamic variables at the bedside or in departments other than the Intensive Care Unit.Keywords: cardiac index, early goal-directed therapy, HeartSmart®, cardiodynamics, blood flow

Nitroglycerin can facilitate weaning of difficult-to-wean chronic obstructive pulmonary disease patients: a prospective interventional non-randomized study

IntroductionBoth experimental and clinical data give convincing evidence to acute cardiac dysfunction as the origin or a cofactor of weaning failure in patients with chronic obstructive pulmonary disease. Therefore, treatment targeting the cardiovascular system might help the heart to tolerate more effectively the critical period of weaning. This study aims to assess the hemodynamic, respiratory and clinical effects of nitroglycerin infusion in difficult-to-wean patients with severe chronic obstructive pulmonary disease.MethodsTwelve difficult-to-wean (failed ≥ 3 consecutive trials) chronic obstructive pulmonary disease patients, who presented systemic arterial hypertension (systolic blood pressure ≥ 140mmHg) during weaning failure and had systemic and pulmonary artery catheters in place, participated in this prospective, interventional, non-randomized clinical trial. Patients were studied in two consecutive days, i.e., the first day without (Control day) and the second day with (Study day) nitroglycerin continuous intravenous infusion starting at the beginning of the spontaneous breathing trial, and titrated to maintain normal systolic blood pressure. Hemodynamic, oxygenation and respiratory measurements were performed on mechanical ventilation, and during a 2-hour T-piece spontaneous breathing trial. Primary endpoint was hemodynamic and respiratory effects of nitroglycerin infusion. Secondary endpoint was spontaneous breathing trial and extubation outcome.ResultsCompared to mechanical ventilation, mean systemic arterial pressure, rate-pressure product, mean pulmonary arterial pressure, and pulmonary artery occlusion pressure increased [from (mean ± SD) 94 ± 14, 13708 ± 3166, 29.9 ± 4.8, and 14.8 ± 3.8 to 109 ± 20mmHg, 19856 ± 4877mmHg b/min, 41.6 ± 5.8mmHg, and 23.4 ± 7.4 mmHg, respectively], and mixed venous oxygen saturation decreased (from 75.7 ± 3.5 to 69.3 ± 7.5%) during failing trials on Control day, whereas they did not change on Study day. Venous admixture increased throughout the trial on both Control day and Study day, but this increase was lower on Study day. Whereas weaning failed in all patients on Control day, nitroglycerin administration on Study day enabled a successful spontaneous breathing trial and extubation in 92% and 88% of patients, respectively.ConclusionsIn this clinical setting, nitroglycerin infusion can expedite the weaning by restoring weaning-induced cardiovascular compromise.

The Hemodynamics of Human Septic Shock Relate to Circulating Innate Immunity Factors

The role of innate immunity, e.g., complement activation and cytokine release in the hemodynamic alterations in the course of human septic shock is largely unknown. We prospectively studied 14 consecutive septic shock patients with a pulmonary artery catheter in place. For 3 days after admission, hemodynamic variables and plasma levels of C3a, a product of complement activation, and interleukin (IL)-6 and tumor necrosis factor alpha (TNF-α) were measured 6-hourly. Doses of vasoactive drugs were recorded. Of the 14 patients, 8 died in the ICU. Patients had a hyperdynamic circulation with tachycardia, mild hypotension, increased cardiac index, peripheral vasodilation and myocardial depression. C3a, IL-6 and TNF-α plasma levels were supranormal in 123 of 138 (89%), 132 of 138 (96%) and 83 of 111 (75%) measurements, respectively. Independently of blood culture results, treatment with vasoactive drugs and outcome, mean arterial blood pressure and systemic vascular resistance index were lower when IL-6 levels were higher and left ventricular function was less depressed when C3a levels were higher in the course of septic shock. The TNF-α levels did not invariably relate to peripheral vascular and myocardial function parameters. Our serial observations suggest that, in human septic shock, peripheral vasodilation is most strongly and independently, of all inflammatory factors, associated with IL-6 release, whereas complement activation partly offsets the myocardial depression of the syndrome. Innate immunity factors may thus differ in their contribution to the course of hemodynamic abnormalities of septic shock.

Universal Consent Practice in Academic Intensive Care Units (ICUs)

The purpose of this study was to determine national practice for obtaining consent in academic adult intensive care units (ICUs) for routine bedside procedures and to define universal consent rates by patient demographics within our own institution's ICUs. A 10-question survey was sent to the program directors for all U.S. surgical and pulmonary critical care directors regarding consent practices. Further, the adoption of a universal consent protocol in an academic county hospital was studied. Cross-sectional study: Thirty-seven percent of program directors completed the survey. Consent rates varied from 35% to 97% by procedure, with only 14% using a universal consent document. Providers in Medical ICUs obtained consent more often than in Surgical ICUs for both central line and pulmonary artery catheter placement (82.8% and 93.1% vs. 52.6% and 52.6%, respectively). Prospective cohort study: At our institution, 90% of 363 patients or their proxies signed universal consent for procedures, 4.4% consent with exemptions, while 5.2% refused. Insured patients were 2.7 times more likely to sign full universal consent for bedside ICU procedures than uninsured patients. There was a national variation in ICU consent practices with an interest in a wider usage of universal consent protocols. The latter was adopted differentially based on patient demographics. Universal consent was widely accepted at our institution.

Effect of pulmonary hypertension on clinical outcomes in advanced heart failure: Analysis of the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) database

Pulmonary hypertension has been shown to predict hospitalizations and mortality in patients with heart failure. We aimed to define the prevalence of mixed pulmonary hypertension (MPH; mean pulmonary artery pressure > or = 25 mm Hg, pulmonary capillary wedge pressure >15 mm Hg, and pulmonary vascular resistance > or = 3 Wood units), identify clinical predictors of MPH, and determine whether MPH predicts adverse outcomes in patients hospitalized with severe heart failure. This is a subgroup analysis of patients assigned to pulmonary artery catheter placement in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial. Patients with and without MPH were compared with respect to baseline characteristics and clinical outcomes, including NYHA class, 6-minute walk distance, quality of life, days hospitalized, and 6-month mortality. Of the 171 patients studied, 80 (47%) had MPH. Older age was the only significant predictor of MPH. MPH patients had lower cardiac index (1.8 +/- 0.5 L/min vs 2.1 +/- 0.5 L/min, P = .001) and higher systemic vascular resistance index (3,179 +/- 1,454 vs 2,550 +/- 927 dynes x s/cm5 x m2, P < .001) compared to those without MPH. Importantly, right ventricular function was relatively preserved (median RVSWI 8.7 gm-m/m2/beat) in MPH patients. There were no significant differences in clinical outcomes between the two groups. Mixed pulmonary hypertension is common in patients hospitalized with advanced heart failure and is not associated with adverse short-term clinical outcomes over and above the poor prognosis of ADHF patients without MPH.

The epidemiology of, and risk factors for, mortality from severe sepsis and septic shock in a tertiary-care university hospital setting

This study investigated the clinical characteristics of, and outcomes and risk factors for hospital mortality of 390 patients admitted with severe sepsis or septic shock in an intensive care unit (ICU). Prospectively collected data from patients collected between 1 July 2004 and 30 June 2006 were analysed. Overall hospital mortality was 49.7% and comorbidities were found in 40.3% of patients, the most common of which was haematological malignancy. The respiratory tract was the most common site of infection (50%). Hospital-acquired infections accounted for 55.6% of patients with Gram-negative bacteria predominant (68%). Multivariate analysis showed that acute respiratory distress syndrome, pulmonary artery catheter placement, comorbidities, hospital-acquired infection, APACHE II score and maximum LOD score, were independent risk factors for hospital mortality. In conclusion, severe sepsis and septic shock are common causes of ICU admission. Patients with risk factors for increased mortality should be carefully monitored and aggressive treatment administered.

Adequate agreement between venous oxygen saturation in right atrium and pulmonary artery in critically ill children*

To determine the agreement between venous oxygen saturation in right atrium (Srao2) and pulmonary artery (Svo2) in critically ill pediatric patients. Retrospective, observational study. Multidisciplinary pediatric intensive care unit from a general university hospital. Thirty critically ill children in whom a pulmonary artery catheter (PAC) was inserted for catecholamine refractory shock (septic and cardiogenic, n = 18) and postoperative management (liver and cardiac transplant, n = 12). Ninety measurements of Srao2 and Svo2 were obtained after placement of PAC and every 6 hrs for the first 12 hrs of pediatric intensive care unit admission. The agreement between Srao2 and Svo2 was determined through Bland and Altman methodology, concordance correlation coefficient, and the frequency of differences between Srao2 and Svo2. The frequency of differences between both saturations was evaluated in three categories: +/-1%-5%, +/-6%-9%, and higher than +/-10%. The first category was the threshold to consider both variables interchangeable. Changes of Srao2 related to clinically significant (>5%) increases and drops of Svo2 were analyzed. Srao2 and Svo2 were not significantly different: median (interquartile range) 83% (75%-86%) and 81% (75%-85%), respectively (p = 0.23). The frequency of differences between Srao2 and Svo2 was +/-1%-5%, 71 (79%); +/-6%-9%, 14 (15.5%); and higher than +/-10%, 5 (5.5%). Bland and Altman analysis showed a 2% bias with a 95% limits of agreement of -6.9% to 10.9%. The concordance correlation coefficient was 0.90. Svo2 increased in 11/90 measurements and Srao2 followed it 82% of the times. Svo2 decreased in 7/90 measurements and Srao2 followed it 100% of the times. The concordance analysis performed allows to conclude that there is an appropriate agreement between Svo2 and Srao2. This finding may become clinically relevant considering the difficulties associated to the use of PAC in children.

Abstract 4576: Validation and Clinical Outcome of Less Invasive Goal-Directed Hemodynamic Management by the Transpulmonary Thermodilution in Patients after Subarachnoid Hemorrhage

Assessment of cardiac output (CO) and intravascular volume is of high importance for adequate cerebral perfusion and oxygen delivery in patients suffering from cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH), but is often precluded by the invasiveness and complexity of a pulmonary artery catheter (PAC) placement. We sought to evaluate the utility of less invasive goal-directed volumetric and hemodynamic monitoring by advanced transpul-monary thermodilution (PiCCO ™ , Pulsion, Germany) utilizing only central venous and peripheral arterial catheters compared with standard circulatory management after SAH. One-hundred fourteen patients with SAH treated within 24 hours of ictus were investigated. Validation of transpulmonary dilution-derived intermittent and calibrated continuous CO (TPCO and PCCO) and cardiac preload (GEDV, global end-diastolic volume) were compared with PAC-derived reference CO (PACO), pulmonary capillary wedge pressure (PCWP), or central venous pressure (CVP) in 14 patients diagnosed with vasospasm. In a subsequent prospective trial of 100 cases, the clinical course and outcome of this method (n=53) was compared to those of CVP or PCWP and PACO guided conventional therapy (n=47), after the establishment of each fluid protocol for treatment of vasospasm (triple-H therapy). TPCO and PCCO (indexed to the BSA) showed excellent correlation ( r = .91 and .86) and small bias (+0.07 and +0.24 L/min/m 2 ) with a low percentage error (10.2 and 12.4%), when compared to PACO. The relationship between GEDV and stroke volume in response to defined volume loading was stronger ( r = .71) than that between CVP or PCWP and stroke volume ( r = .16 and .26). Frequency of cardiopulmonary complications (0 vs 10%) and vasospasm-related cerebral infarction (9 vs 17%), amount of daily fluid intake (4,210±968 vs 5,681±1,019 mL), and length of ICU stay (14±2 vs 17±2 days) were significantly reduced (p&lt;0.05) in the transpulmonary themodilution group. Transpulmonary thermodilution enables clinically acceptable monitoring in patients following SAH. Goal-directed therapy guided by the volumetric and hemodynamic parameters with this method has a potential advantage over conventional methods.

The Effects of Intravenous Hyperoxygenated Solution Infusion on Systemic Oxygenation and Intrapulmonary Shunt During One-Lung Ventilation in Pigs

Many anesthetic methods have been applied to maintain acceptable oxygenation during one-lung ventilation (OLV). However, the optimal management has not been definitely determined. The aim of this study was to investigate whether intravenous hyperoxygenated solution (HOS) infusion would improve systemic oxygenation and reduce intrapulmonary shunt during OLV. Sixteen pigs (25-35 kg) were anesthetized, tracheally intubated, and mechanically ventilated. After placement of femoral artery and pulmonary artery catheters, a left-sided double-lumen tube (DLT) was placed via tracheotomy. The animals were allocated randomly to one of the two study groups (n = 8 each); control group (C group) and hyperoxygenated solution group (H group). Animals in H group received intravenous HOS infusion immediately after the beginning of OLV via internal right jugular vein with an infusion pump, and the rate of infusion was 15 mL.kg(-l).h(-l); and in C group, the same amount of lactate Ringer's solution (LRS) was used in place of HOS. Arterial and venous blood gases analysis were recorded in three phases: during two-lung ventilation just before beginning OLV (TLV), 30 min after beginning OLV (OLV + 30), and 60 min after beginning OLV (OLV + 60). We measured arterial oxygen saturation (SaO(2)), mixing venous oxygen saturation (S(V)O(2)), partial pressure of arterial oxygen (PaO(2)), partial pressure of mixing venous oxygen (PvO(2),) oxygen contents in systemic arterial and mixed venous blood (CaO(2), CvO(2)), and venous admixture percentage (Qs/Qt%). Heart rate (HR), mean arterial pressure (MAP), mean pulmonary artery pressure (MPAP), and cardiac output (CO) were also recorded. After 30 and 60 min OLV, there was a significant decrease in PaO(2), SaO(2), PvO(2), SvO(2), CaO(2), and CvO(2), and a significant increase of Qs/Qt% in both groups (P < 0.01). The values of PaO(2), SaO(2), PvO(2), SvO(2), and CvO(2) in H group at both OLV + 30 and OLV + 60 were significantly higher than those in C group (P < 0.05, P < 0.01). Although the values of CaO(2) in H group were higher than those in C group at OLV + 30 and OLV + 60, there were no significant differences. Comparing the values of Qs/Qt% between the two groups at OLV + 30 and OLV + 60, there were also no significant differences. Intravenous HOS infusion led to minimal changes in intrapulmonary shunt, nevertheless, it could ameliorate arterial oxygenation obviously during OLV. This might be a new strategy to improve systemic oxygenation during OLV.

Relative value of pressures and volumes in assessing fluid responsiveness after valvular and coronary artery surgery

Cardiac function may differ after valvular (VS) and coronary artery (CAS) surgery and this may affect assessment of fluid responsiveness. The aim of the study was to compare VS and CAS in the value of cardiac filling pressures and volumes herein. There were eight consecutive patients after VS and eight after CAS, with femoral and pulmonary artery catheters in place. In each patient, five sequential fluid loading steps of 250 ml of colloid each were done. We measured central venous pressure (CVP), pulmonary artery occlusion pressure (PAOP) and, by transpulmonary thermodilution, cardiac index (CI) and global end-diastolic (GEDVI) and intrathoracic blood volume (ITBVI) indices. Fluid responsiveness was defined by a CI increase >5% or >10% per step. Global ejection fraction was lower and PAOP was higher after VS than CAS. In responding steps after VS (n=9-14) PAOP and volumes increased, while CVP and volumes increased in responding steps (n=12-19) after CAS. Baseline PAOP was lower in responding steps after VS only. Hence, baseline PAOP as well as changes in PAOP and volumes were of predictive value after VS and changes in CVP and volumes after CAS, in receiver operating characteristic curves. After VS, PAOP and volume changes equally correlated to CI changes. After CAS, only changes in CVP and volumes correlated to those in CI. While volumes are equally useful in monitoring fluid responsiveness, the predictive and monitoring value of PAOP is greater after VS than after CAS. In contrast, the CVP is of similar value as volume measurements in monitoring fluid responsiveness after CAS. The different value of pressures rather than of volumes between surgery types is likely caused by systolic left ventricular dysfunction in VS. The study suggests an effect of systolic cardiac function on optimal parameters of fluid responsiveness and superiority of the pulmonary artery catheter over transpulmonary dilution, for haemodynamic monitoring of VS patients.

Accuracy of Cardiac Function and Volume Status Estimates Using the Bedside Echocardiographic Assessment in Trauma/Critical Care

Critically ill patients often require invasive monitoring to evaluate and optimize cardiac function and preload. With questionable outcomes associated with pulmonary artery catheters (PACs), some have evaluated the role of less invasive monitors. We hypothesized that the Bedside Echocardiographic Assessment in Trauma (BEAT) examination would generate cardiac index (CI) and central venous pressure (CVP) estimates that correlate with that of a PAC. BEAT was performed on all SICU patients with a PAC in place. Prospective data included stroke volume and the inferior vena cava (IVC) diameter. The CI was calculated and correlated with that from the PAC. Each CI was then categorized as low, normal, or high. The IVC diameter was used to estimate the CVP. The association between the BEAT and PAC estimates of CI and CVP was evaluated using chi. Eighty-five BEAT examinations were performed, 57% on trauma and 37% on general surgery patients. Fifty-nine percent of the CI examinations and 97% of the IVC examinations contained quality images. Of these, the overall correlation coefficient was 0.70 (p < 0.0001). When CI was categorized, there was a significant association between the BEAT and PAC (p = 0.021). There was a significant association between the CVP estimate from the BEAT examination and the PAC (p = 0.031). Our data show a significant correlation between the CI and CVP estimates obtained from the BEAT examination and that from a PAC. BEAT provides a noninvasive method of evaluating cardiac function and volume status. Bedside echocardiography is teachable and should become a part of future critical care curricula.

Plasma B-type natriuretic peptide monitoring to evaluate cardiovascular function prior to organ procurement in patients with brain death

The natriuretic peptide system plays an active role in the regulation of fluid balance and systemic vascular resistance. Assays of plasma concentrations of B-type natriuretic peptide (BNP) may have a diagnostic role in evaluating myocardial function. We present our experience with BNP monitoring to assess myocardial function after the proclamation of brain death in potential organ donors. After the proclamation of brain death and prior to organ donation, a plasma BNP or aminoterminal pro-BNP level was obtained. Additional information from the donor included shortening fraction (SF) or ejection fraction, central venous pressure (CVP) reading, and renal function including blood urea nitrogen and creatinine. When available, data from the pulmonary artery (PA) catheter including pulmonary capillary wedge pressure (PCWP) and cardiac index were also collected. The cohort for the study included eight patients (age range: 6 months to 21 years). The diagnosis of brain death by clinical or radiological examination had been completed in all patients and the patients were scheduled for organ procurement. Myocardial contractility as assessed by echocardiogram using SF was within normal limits. The CVP varied from 7 to 12 mmHg (9 +/- 2) and the PCWP was 10-11 mmHg in the two patients who had PA catheters in place. No patient was receiving inotropic medications. In five of the six patients, the BNP value was above the upper limit of normal (100 pg x ml(-1)). In two patients, an NT-pro-BNP value was obtained and found to be higher than the upper limits of normal (450 pg x ml(-1)). All eight patients were acceptable cardiac donors and the transplanted hearts functioned without difficulty in the recipients. Assays of plasma BNP concentrations have been shown to be helpful in differentiating myocardial dysfunction from primary lung disease in both the adult and pediatric population. However, our data demonstrate that mechanisms other than myocardial performance may regulate BNP levels in patients with severe central nervous system injury who progress to brain death. Our preliminary data suggest that these assays appear to be of limited value in assessing myocardial performance in this population.

Reliability of a new ultrasonic cardiac output monitor in recipients of living donor liver transplantation

The ultrasonic cardiac output monitor (USCOM) is a new Doppler device for noninvasive hemodynamic monitoring. The aim of this prospective nonrandomized study was to test the feasibility, perioperative reliability, and clinical applicability of using USCOM as an alternative to pulmonary artery catheterization in recipients of living donor liver transplantation. Thirteen patients scheduled to receive living donor liver transplants were initially recruited. Three were subsequently excluded prior to the commencement of surgery because of technical difficulties in obtaining diagnostic-quality images with USCOM. Ten patients proceeded to be studied. Cardiac output measurements by thermodilution and USCOM were compared at 30-minute intervals throughout the procedure and at 10 specific procedural reference points during the surgery when hemodynamic changes were most likely to be observed. The data were analyzed with Lin's concordance coefficient and Bland-Altman analysis. Two hundred ninety paired cardiac output values were obtained from the 10 patients. The concordance between both methods was excellent in 8 patients and satisfactory in 2. Bland-Altman analysis of all data produced a mean bias of - 0.02 L/minute for USCOM, and the 95% limits of agreement were -1.06 to +1.10 L/minute. Further analysis of the 10 reference time points showed minimal bias and high levels of agreement between the methods. We conclude that USCOM provides an accurate and noninvasive method for cardiac output measurement during liver transplantation. It may therefore represent an alternative to pulmonary artery catheter placement with consequent reduction in patient's risk and morbidity associated with catheterization. Liver Transpl 14:1029-1037, 2008. (c) 2008 AASLD.

Surgical Removal of a Knotted Intravascular Pulmonary Artery Catheter

A pulmonary artery (PA) catheter was placed in a 60-year-old patient with congestive heart failure, undergoing lumbar spinal surgery. In the prone position, no wedge pressure wave could be obtained, and multiple attempts at repositioning were unsuccessful. Fluoroscopy showed a catheter knot in the right internal jugular vein, which was removed surgically through the original venotomy site. The knot was thought to be caused by excessive manipulation at too great an insertion depth, with low cardiac output. We conclude it is important to follow the guidelines for PA catheter placement, using step-wise gentle manual attempts. If knotted, radiological interventions and surgical extrication must be considered.

Advanced practice organ procurement techniques: placement of pulmonary artery catheters

Insertion of pulmonary artery catheters by organ procurement coordinators may be incorporated into donor management to optimize organ perfusion. As invasive procedures are added to coordinator roles, the organ procurement organization must include didactic instruction and supervised clinical experience as part of any training program. Policies and procedures guiding the use of the pulmonary artery catheter and the measurements obtained must be provided by the organization to guide practitioners. This article focuses on methods for insertion and basic troubleshooting of a pulmonary artery catheter.

Advanced Practice Organ Procurement Techniques: Placement of Pulmonary Artery Catheters

Insertion of pulmonary artery catheters by organ procurement coordinators may be incorporated into donor management to optimize organ perfusion. As invasive procedures are added to coordinator roles, the organ procurement organization must include didactic instruction and supervised clinical experience as part of any training program. Policies and procedures guiding the use of the pulmonary artery catheter and the measurements obtained must be provided by the organization to guide practitioners. This article focuses on methods for insertion and basic troubleshooting of a pulmonary artery catheter.

A 5-Year Survey of Nitric Oxide Use in a Pediatric Intensive Care Unit

The authors retrospectively reviewed their experience with nitric oxide (NO) in a pediatric ICU. Given its cost ($3000/d), ongoing evaluations are required to ensure its effective use and avoid inappropriate applications. NO use included 4 categories: (1) hypoxemic respiratory failure, (2) pulmonary hypertension following surgery for congenital heart disease (CHD), (3) intraoperatively for surgical procedures such BT shunt placement or 1-lung ventilation, and (4) during ECMO. In the 19 patients with respiratory failure, NO resulted in an increase in oxygenation in 15 of 19 patients (Pao2/Fio2 ratio increased from 83 +/- 60 mm Hg to 188 +/- 105 mm Hg, P = 0.0007). In 4 patients, NO did not improve oxygenation. The 15 patients that responded to NO survived, whereas the 4 patients who did not respond died (P = 0.0003). NO was used to treat pulmonary hypertension in 19 patients following cardiopulmonary bypass (CPB) and surgery for CHD. In 13 of 19 patients, a high pulmonary artery (PA) pressure was documented by direct measurement with a needle inserted into the PA while the chest was open (n = 9) or a postoperative transthoracic PA catheter (n = 4). NO resulted in a decrease in the PA pressure in 9 of 13 patients (37 +/- 5 mm Hg to 21 +/- 3 mm Hg, P < 0.0001). In the one patient in whom NO did not lower intraoperative PA pressure, it was not possible to wean from CPB. For the 10 patients in whom NO was started in the PICU, 4 had PA catheters in place and documented elevated PA pressure. NO resulted in a significant decrease in the PA pressure in only 1 of these 4 patients. The survival of responders was 9 of 9 versus 1 of 4 for nonresponders (P = 0.014). No significant adverse effects requiring therapy other than decreasing the inhaled NO concentration were noted. Potential interventions and practices to limit the unwarranted use of this costly agent are discussed.

Pro: Is the Pulmonary Artery Catheter Dead?

MAYBE IT IS NOT DEAD, but it does appear to be mortally wounded. In the last 10 years, several large studies have been published showing either no benefit or actual harm with the use of the pulmonary artery catheter (PAC). We are getting used to this message. When we visit most of our intensive care units (ICUs), we find few patients with PACs in place, and the general consensus in this era of “evidence-based medicine” is there is no evidence that its use improves outcome. Therefore, why use this invasive device?