Now we're going to be discussing pulmonary
artery catheter risks and complications.
I put these into three
different groups for you.
The first group is complications
with assessing a central vein.
You can have bleeding,
a hematoma, arterial puncture,
Anytime we access a large vein,
we can always have the risk
of bleeding or hematoma.
But how do we get
Well, remember, the artery and the
vein run really close to each other,
and sometimes they run
on top of each other.
So it does happen that we puncture
the artery rather than the vein.
Infection is a big risk
for these patients.
So make sure we take all precautions
to reduce a central line infection.
And then pneumothorax
So we're putting in a line but
how do we affect the lungs?
Well, sometimes we go
into the subclavian vein,
if we go a little bit lower into
the pleural space by accident,
then we can puncture that long and cause
a pneumothorax and possible hemothorax.
The second group I
have is arrhythmias,
you can cause atrial tachyarrhythmias,
a right bundle branch block
or a complete heart block.
Though in my practice, I've never
caused a right bundle branch block
or complete heart block by
a pulmonary artery catheter.
I have caused patients to go
into ventricular tachycardia.
That's because the tip of the catheter
when it goes into the right ventricle,
irritates the wall and causes the patient
to go into a ventricular tachycardia.
You may see premature
ventricular contractions happen.
And that's okay, that just let you
know you're in the right ventricle.
You want to make sure that you start
going into the pulmonary artery soon,
don't let it sit there because you can
cause a patient to have the attack.
The third group we have are
Those are myocardial
perforations, valvular injuries,
pulmonary rupture or
or an embolism or
even an air embolism.
Now, how do we get
Well, sometimes that right
ventricle wall is called friable.
After a heart attack,
the tissue becomes really friable,
which kind of looks like cook roast beef,
and which you can shred it pretty easily.
So if that tip of that catheter
hits that wall hard enough,
it can actually go through it
and that's a medical emergency,
we need to take that patient
immediately to surgery to repair that.
Valvular injuries happen, remember,
when the balloon is inflated,
and we try to take out the
pulmonary artery catheter,
we can actually involute the leaflets
of the valves and cause them to rupture.
Pulmonary rupture infarction
happens when we inflate the balloon,
which is in the
If it's in a smaller branch,
it can actually rupture that artery
and cause serious risks and
complications to the patient even death.
So we want to be careful
whether inflating that balloon.
And then thrombosis and embolism
can happen when a foreign object
or when air goes through that pulmonary
artery catheter into the lungs.
So it acts like it's a pulmonary
embolism just like a blood clot.
So we need to be super cautious
with what we're putting
into this pulmonary
Make sure there's no air in it,
make sure we have no foreign
objects, it's just saline.
There's a rare complication which
is thrombocytopenia which is caused
because some of these pulmonary
artery catheters are heparin-coated.
So these patients who have a history
of heparin-induced thrombocytopenia
that can occur again with these,
so we may need to make sure
that they have no history of
or that the pulmonary artery catheter
that you're using is not heparin-coated.
Now let's discuss some potential
errors that you can encounter
with a pulmonary
The first error is
This could be the numbers that you're
seeing on the monitor are not accurate.
This could be because the transducer is
not in line with the phlebostatic axis
or there could be bubbles
in the pressure tubing
causing it to have
a dampened waveform.
Why is this an error?
Because when you're reading those,
you think that those might be accurate,
and you're titrating medications that
offer those inaccurate measurements,
so you're mismanaging
Our next potential error that we could
have is misinterpretation of the data.
The numbers that you're
seeing are correct,
but we're not understanding what they
are telling us or what they mean.
So this could also be
mismanagement of the client.
Next, let's talk about some
cues that you can recognize
that may indicate we're
having a complication.
The first one involves
When you look at your PA waveform and
it doesn't look like a PA waveform,
it actually looks like an RV
waveform, right ventricular waveform.
Remember that waveform has the same
systolic but the diastolic is really low
and it really doesn't
have a dicrotic notch.
If you see that, what has happened as
that PA catheter has gotten pulled out
so the tip of it is now
in the right ventricle,
or when it was placed,
it was right past a pulmonic valve
and it has actually migrated back or
slipped back into the right ventricle.
This can cause PVCs,
which would be another indication
that it's in the
If this happens,
we need to contact a physician
so they can float it further
into the pulmonary artery
and into the correct position.
Our next cue is the PA waveform
looks like it's stuck in wedge.
So we look up and it looks
like that wedge waveform,
or even that CVP waveform,
make sure your CVP and your PA
is not switched on the monitor.
And if that's not it,
then you're stuck in wedge.
This is actually an emergency
because you're blocking blood flow
going into the left
side of the lungs.
So what happens with that is the line
get migrates further into the lungs.
When we first place a
pulmonary artery catheter,
you'll have slack in
that right ventricle.
So really, the physician should pull
it back 2-3 cm to reduce that slack
so that it doesn't migrate
farther into the pulmonary artery
and cause a stuck
in wedge waveform.
If this happened,
we have to immediately contact a physician
for them to pull it
back just a little bit
so we get a PA waveform.
you're blocking blood flow
so you may cause
which is a serious
condition for the patient.
The last one is PA
catheter does not wedge.
So we inflate the balloon and
we don't get a wedge waveform.
This isn't an emergency.
This just means that
the catheter needs to be
positioned correctly to
get that wedge waveform.
So if the physician just needs to come
in and float it a little bit further
until we do achieve a wedge waveform so we
can get a pulmonary artery wedge pressure.
The last issue that we may have with our
waveforms is called an overwedged waveform,
an overwedged waveform.
This is where the PA
catheter is too far distal
in a very free very small
branch of the pulmonary artery,
and we inflate the balloon
to the full 1 1/2 mLs.
What happens is basically that puts so
much pressure on that pulmonary artery
that it actually bends
the balloon around the tip
of the catheter
blocking the PA port.
So then you just see 300 mm Hg
which is from the pressure bag.
What you'll see on the
on the screen is that
instead of it dropping
down into a wedge waveform,
you'll see it take off on the
screen all the way up to 300.
Kind of like if we were turning
the stopcock off to the patient.
This is also an emergency
because if we leave it like this,
we can call it pulmonary
infarction or pulmonary rupture.
All that needs to happen is to make
sure that we pulled the air back
and that we pull the PA catheter to a more
proximal position in that pulmonary artery.
So it's a bigger artery that rather than a
really, really small branch of the artery.