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Osman B, Hafez B, El Madani A, Panossian VS, Dirany O, Sfeir P. Bedside management of a knotted Swan-Ganz catheter - A case report and literature review. Int J Surg Case Rep 2025; 128:111013. [PMID: 39914015 PMCID: PMC11847547 DOI: 10.1016/j.ijscr.2025.111013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2024] [Accepted: 02/03/2025] [Indexed: 02/26/2025] Open
Abstract
INTRODUCTION AND IMPORTANCE Pulmonary artery catheters use remain invaluable in continuous invasive hemodynamic monitoring for patients with severe cardiopulmonary dysfunction and those undergoing major cardiac surgeries. It detects cardiac dysfunction and guides treatment decisions. Its utilization has declined due to common complications associated with its insertion. This article highlights a rare, rather an important complication of pulmonary artery catheter knotting and reviews techniques for its management. Prompt recognition of this rare complication by the clinicians allow immediate intervention minimizing morbidity and optimizing the outcomes. This manuscript follows the SCARE guidelines. CASE PRESENTATION A case of a 61-year-old man who was initially admitted to the cardiothoracic unit for mitral valve replacement for symptomatic severe mitral regurgitation secondary to a bi-leaflet prolapse. Intra-operatively, a pulmonary artery catheter was inserted for invasive continuous hemodynamic monitoring. It was noted on a routine postoperative chest X-ray coiling of the pulmonary artery catheter in the right atrium. The catheter was not repositioned. On postoperative day one, significant resistance was encountered while removing the catheter. A chest x-ray was done and showed a knotted catheter in the superior vena cava. After contingency planning, bedside removal was opted as the preferred management approach. The catheter was carefully pulled out to tighten the knot and decrease its diameter, allowing successful extraction through the insertion site at the neck. CLINICAL DISCUSSION Pulmonary artery catheter utilization remains essential; however its insertion is prone to complications, which includes pulmonary artery catheter knotting a rare but an important complication that warrants immediate recognition and management. Numerous approaches for the management of knotted catheter were described in the literature. Bedside removal of the knotted catheter may be considered if the knot is simple and more proximal. This approach carries the risk of venous injury and hematoma formation, thus thorough planning and preparation are needed to avoid complications. An endovascular approach is opted in more complex cases and has largely supplanted surgical methods. Innovative methods were described in the literature and include the introduction of guide wires or specialized catheters to untangle knots under fluoroscopic guidance. Retrieval baskets may also be used. Surgery is reserved for complex cases, when endovascular attempts fail. CONCLUSION While pulmonary artery catheter use provides significant benefits, its use demands meticulous planning and preparation to avoid complications. Catheter knotting requires immediate attention. If bedside maneuvers fail, endovascular or surgical approaches may be necessary.
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Affiliation(s)
- Bassam Osman
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Bassel Hafez
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Aya El Madani
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Vahe S Panossian
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Olga Dirany
- Division of Cardiothoracic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Pierre Sfeir
- Division of Cardiothoracic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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Renberg M, Karlsson T, Dahlquist A, Luckhurst C, Gustavsson J, Arborelius U, Risling M, Günther M. The anesthesiologist's guide to swine trauma physiology research: a report of two decades of experience from the experimental traumatology laboratory. Eur J Trauma Emerg Surg 2024; 50:1879-1889. [PMID: 38780782 PMCID: PMC11458652 DOI: 10.1007/s00068-024-02542-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/29/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE Swine are one of the major animal species used in translational research, with unique advantages given the similar anatomic and physiologic characteristics as man, but the investigator needs to be familiar with important differences. This article targets clinical anesthesiologists who are proficient in human monitoring. We summarize our experience during the last two decades, with the aim to facilitate for clinical and non-clinical researchers to improve in porcine research. METHODS This was a retrospective review of 337 swine with a mean (SD) weight 60 (4.2) kg at the Experimental Traumatology laboratory at Södersjukhuset (Stockholm south general hospital) between 2003 and 2023, including laboratory parameters and six CT-angiography examinations. RESULTS Swine may be ventilated through the snout using a size 2 neonatal mask. Intubate using a 35 cm miller laryngoscope and an intubating introducer. Swine are prone to alveolar atelectasis and often require alveolar recruitment. Insert PA-catheters through a cut-down technique in the internal jugular vein, and catheters in arteries and veins using combined cut-down and Seldinger techniques. Cardiopulmonary resuscitation is possible and lateral chest compressions are most effective. Swine are prone to lethal ventricular arrhythmias, which may be reversed by defibrillation. Most vital parameters are similar to man, with the exception of a higher core temperature, higher buffer bases and increased coagulation. Anesthesia methods are similar to man, but swine require five times the dose of ketamine. CONCLUSION Swine share anatomical and physiological features with man, which allows for seamless utilization of clinical monitoring equipment, medication, and physiological considerations.
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Affiliation(s)
- Mattias Renberg
- Department of Clinical Science and Education Södersjukhuset, Section of Anesthesiology and Intensive care, Stockholm, Sweden
| | - Tomas Karlsson
- Department of Clinical Science and Education Södersjukhuset, Section of Anesthesiology and Intensive care, Stockholm, Sweden
| | - Albin Dahlquist
- Department of Clinical Science and Education Södersjukhuset, Section of Anesthesiology and Intensive care, Stockholm, Sweden
| | - Claire Luckhurst
- Department of Clinical Science and Education Södersjukhuset, Section of Anesthesiology and Intensive care, Stockholm, Sweden
| | - Jenny Gustavsson
- Department of Neuroscience, Section of Experimental Traumatology, Karolinska Institutet, Biomedicum- 8B, SE-171 77, Stockholm, Sweden
| | - Ulf Arborelius
- Department of Neuroscience, Section of Experimental Traumatology, Karolinska Institutet, Biomedicum- 8B, SE-171 77, Stockholm, Sweden
| | - Mårten Risling
- Department of Neuroscience, Section of Experimental Traumatology, Karolinska Institutet, Biomedicum- 8B, SE-171 77, Stockholm, Sweden
| | - Mattias Günther
- Department of Clinical Science and Education Södersjukhuset, Section of Anesthesiology and Intensive care, Stockholm, Sweden.
- Department of Neuroscience, Section of Experimental Traumatology, Karolinska Institutet, Biomedicum- 8B, SE-171 77, Stockholm, Sweden.
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Fox WE, Marshall M, Walters SM, Mangunta VR, Ragosta M, Kleiman AM, McNeil JS. Bedside Clinician's Guide to Pulmonary Artery Catheters. Crit Care Nurse 2023; 43:9-18. [PMID: 37524367 DOI: 10.4037/ccn2023133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
BACKGROUND Pulmonary artery catheters provide important information about cardiac function, mixed venous oxygenation, and right-sided pressures and potentially provide temporary pacing ability. OBJECTIVE To provide bedside clinicians with guidance for techniques to insert right heart monitors and devices, describe risk factors for difficult insertion and contraindications to placement, and provide updates on new technologies that may be encountered in the intensive care unit. METHODS An extensive literature review was performed. Experienced clinicians were asked to identify topics not addressed in the literature. RESULTS Advanced imaging techniques such as transesophageal echocardiography or fluoroscopy can supplement traditional pressure waveform-guided insertion when needed, and several other techniques can be used to facilitate passage into the pulmonary artery. Caution is warranted when attempting insertion in patients with right-sided masses or preexisting conduction abnormalities. New technologies include a pacing catheter that anchors to the right ventricle and a remote monitoring device that is implanted in the pulmonary artery. DISCUSSION Bedside clinicians should be aware of risk factors such as atrial fibrillation with dilated atria, decreased ventricular function, pulmonary hypertension, and right-sided structural abnormalities that can make pulmonary artery catheter insertion challenging. Clinicians should be familiar with advanced techniques and imaging options to facilitate placement. CONCLUSION The overall risk of serious complications with right heart catheter placement and manipulation is low and often outweighed by its benefits, specifically pressure monitoring and pacing.
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Affiliation(s)
- W Everett Fox
- W. Everett Fox is an anesthesiology resident, Department of Anesthesiology, University of Virginia Health System (UVA Health), Charlottesville, Virginia
| | - Michael Marshall
- Michael Marshall is a charge and bedside registered nurse, coronary care unit, UVA Health
| | - Susan M Walters
- Susan M. Walters is a cardiothoracic anesthesiologist and an assistant professor of anesthesiology, Department of Anesthesiology, UVA Health
| | - Venkat R Mangunta
- Venkat R. Mangunta is a cardiothoracic and intensive care anesthesiologist and an assistant professor of anesthesiology, Department of Anesthesiology, UVA Health
| | - Michael Ragosta
- Michael Ragosta is a professor of cardiology and the Medical Director of the cardiac catheterization laboratory and interventional cardiology fellowship, Cardiology Division, Department of Internal Medicine, UVA Health
| | - Amanda M Kleiman
- Amanda M. Kleiman is a cardiothoracic anesthesiologist and an associate professor of anesthesiology, Department of Anesthesiology, UVA Health
| | - John S McNeil
- John S. McNeil is a cardiothoracic anesthesiologist and an associate professor of anesthesiology, Department of Anesthesiology, UVA Health
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4
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Shaik FA, Slotwiner DJ, Gustafson GM, Dai X. Intra-procedural arrhythmia during cardiac catheterization: A systematic review of literature. World J Cardiol 2020; 12:269-284. [PMID: 32774779 PMCID: PMC7383354 DOI: 10.4330/wjc.v12.i6.269] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/03/2020] [Accepted: 05/26/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cardiac catheterization is among the most performed medical procedures in the modern era. There were sporadic reports indicating that cardiac arrhythmias are common during cardiac catheterization, and there are risks of developing serious and potentially life-threatening arrhythmias, such as sustained ventricular tachycardia (VT), ventricular fibrillation (VF) and high-grade conduction disturbances such as complete heart block (CHB), requiring immediate interventions. However, there is lack of systematic overview of these conditions. AIM To systematically review existing literature and gain better understanding of the incidence of cardiac arrhythmias during cardiac catheterization, and their impact on outcomes, as well as potential approaches to minimize this risk. METHODS We applied a combination of terms potentially used in reports describing various cardiac arrhythmias during common cardiac catheterization procedures to systematically search PubMed, EMBASE and Cochrane databases, as well as references of full-length articles. RESULTS During right heart catheterization (RHC), the incidence of atrial arrhythmias (premature atrial complexes, atrial fibrillation and flutter) was low (< 1%); these arrhythmias were usually transient and self-limited. RHC associated with the development of a new RBBB at a rate of 0.1%-0.3% in individuals with normal conduction system but up to 6.3% in individuals with pre-existing left bundle branch block. These patients may require temporary pacing due to transient CHB. Isolated premature ventricular complexes or non-sustained VT are common during RHC (up to 20% of cases). Sustained ventricular arrhythmias (VT and/or VF) requiring either withdrawal of catheter or cardioversion occurred infrequently (1%-1.3%). During left heart catheterizations (LHC), the incidence of ventricular arrhythmias has declined significantly over the last few decades, from 1.1% historically to 0.1% currently. The overall reported rate of VT/VF in diagnostic LHC and coronary angiography is 0.8%. The risk of VT/VF was higher during percutaneous coronary interventions for stable coronary artery disease (1.1%) and even higher for patients with acute myocardial infarctions (4.1%-4.3%). Intravenous adenosine and papaverine bolus for fractional flow reserve measurement, as well as intracoronary imaging using optical coherence tomography have been reported to induce VF. Although uncommon, LHC and coronary angiography were also reported to induce conduction disturbances including CHB. CONCLUSION Cardiac arrhythmias are common and potentially serious complications of cardiac catheterization procedures, and it demands constant vigilance and readiness to intervene during procedures.
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Affiliation(s)
- Fatima A Shaik
- Division of Cardiology, New York Presbyterian Queens Hospital, Flushing, NY 11355, United States
| | - David J Slotwiner
- Division of Cardiology, New York Presbyterian Queens Hospital, Flushing, NY 11355, United States
| | - Gregory M Gustafson
- Division of Cardiology, New York Presbyterian Queens Hospital, Flushing, NY 11355, United States
| | - Xuming Dai
- Division of Cardiology, New York Presbyterian Queens Hospital, Flushing, NY 11355, United States.
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5
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Satoh H, Miyata Y, Hayasaka T, Wada T, Hayashi Y. An analysis of the factors producing multiple ventricular arrhythmias during pulmonary artery catheterization. Ann Card Anaesth 2017; 20:141-144. [PMID: 28393771 PMCID: PMC5408516 DOI: 10.4103/aca.aca_18_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: The development of arrhythmias during placement of a pulmonary artery catheter (PAC) is common. Aims: This study was designed to examine factors influencing development of ventricular arrhythmias in adult patients undergoing cardiovascular operations during the catheter placement. Settings and Designs: Prospective, observational, cohort study. Methods: We prospectively studied 174 patients undergoing cardiovascular operations. A PAC was inserted through the right internal jugular vein by staff anesthesiologists. Electrocardiography tracings were recorded as the catheter was advanced from the right atrium to the pulmonary artery. Arrhythmias were classified as absent, single, or multiple (two or more consecutive) ventricular arrhythmias. We examined risk factors to produce ventricular arrhythmias during the placement. Statistical Analysis: The data were analyzed using logistic regression analysis to assess factors for the occurrence of ventricular arrhythmias after univariate analyses. Results: Ventricular arrhythmias (single and multiple) occurred in 149 patients (85.6%) and multiple arrhythmias were observed in 78 patients (44.8%). There were no factors to facilitate the ventricular arrhythmias (single and multiple), whereas it showed that valvular diseases (P = 0.049) and the placement time (P < 0.001) are significant factors to produce multiple arrhythmias. Conclusion: Both valvular diseases and long placement time were significant risk factors to produce multiple ventricular arrhythmias during placement of a PAC.
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Affiliation(s)
- Hajime Satoh
- Department of Anaesthesia Service, Sakurabashi-Watanabe Hospital, Osaka, Japan
| | - Yuka Miyata
- Department of Anaesthesia Service, Sakurabashi-Watanabe Hospital, Osaka, Japan
| | - Tomohiko Hayasaka
- Department of Anaesthesia Service, Sakurabashi-Watanabe Hospital, Osaka, Japan
| | - Tsutomu Wada
- Department of Anaesthesia Service, Sakurabashi-Watanabe Hospital, Osaka, Japan
| | - Yukio Hayashi
- Department of Anaesthesia Service, Sakurabashi-Watanabe Hospital, Osaka, Japan
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6
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Abstract
Pulmonary artery (PA) catheters are widely used in the care of the critically ill. Numerous catheter designs are available, and the list of indications for their use is con stantly expanding. Extensive physiological data are sup plied by catheters. Right atrial, right ventricular, PA, and PA wedge pressure waveforms, as well as cardiac output and several derived parameters (e.g., systemic vascular resistance, pulmonary vascular resistance) are easily measured. Clinical application of these data may aid in diagnosis and management of acutely ill patients. Physi cians using catheters need to be aware of the numerous complications associated with their use. Scrupulous at tention to insertion and maintenance techniques will minimize the incidence of many of these complications. The undefined risk/benefit ratio of PA catheterization has caused controversy among physicians. Prospective studies to define better the risks versus benefits of PA catheters are currently being planned. Physicians using PA catheters should recognize that the catheters have no direct therapeutic benefit and that PA catheterization should neither replace bedside clinical evaluation nor delay treatment of the patient.
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Affiliation(s)
- Stephen J. Voyce
- Division of Cardiovascular Medicine, University of Massachusetts Medical Center, 55 Lake Ave North, Worcester, MA 01655
| | - James M. Rippe
- Division of Cardiovascular Medicine, University of Massachusetts Medical Center, 55 Lake Ave North, Worcester, MA 01655
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7
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Rotenberg MY, Gabay H, Etzion Y, Cohen S. Feasibility of Leadless Cardiac Pacing Using Injectable Magnetic Microparticles. Sci Rep 2016; 6:24635. [PMID: 27091192 PMCID: PMC4876985 DOI: 10.1038/srep24635] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 04/01/2016] [Indexed: 12/11/2022] Open
Abstract
A noninvasive, effective approach for immediate and painless heart pacing would have invaluable implications in several clinical scenarios. Here we present a novel strategy that utilizes the well-known mechano-electric feedback of the heart to evoke cardiac pacing, while relying on magnetic microparticles as leadless mechanical stimulators. We demonstrate that after localizing intravenously-injected magnetic microparticles in the right ventricular cavity using an external electromagnet, the application of magnetic pulses generates mechanical stimulation that provokes ventricular overdrive pacing in the rat heart. This temporary pacing consistently managed to revert drug-induced bradycardia, but could only last up to several seconds in the rat model, most likely due to escape of the particles between the applied pulses using our current experimental setting. In a pig model with open chest, MEF-based pacing was induced by banging magnetic particles and has lasted for a longer time. Due to overheating of the electromagnet, we intentionally terminated the experiments after 2 min. Our results demonstrate for the first time the feasibility of external leadless temporary pacing, using injectable magnetic microparticles that are manipulated by an external electromagnet. This new approach can have important utilities in clinical settings in which immediate and painless control of cardiac rhythm is required.
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Affiliation(s)
- Menahem Y. Rotenberg
- The Avram and Stella Goldstein-Goren Department of Biotechnology
Engineering, Ben-Gurion University of the Negev, Beer-Sheva,
Israel
| | - Hovav Gabay
- Cardiac Arrhythmia Research Laboratory, Department of Physiology
and Cell Biology, Ben-Gurion University of the Negev,
Beer-Sheva, Israel
| | - Yoram Etzion
- Cardiac Arrhythmia Research Laboratory, Department of Physiology
and Cell Biology, Ben-Gurion University of the Negev,
Beer-Sheva, Israel
- Regenerative Medicine & Stem Cell Research Center,
Ben-Gurion University of the Negev, Beer-Sheva,
Israel
| | - Smadar Cohen
- The Avram and Stella Goldstein-Goren Department of Biotechnology
Engineering, Ben-Gurion University of the Negev, Beer-Sheva,
Israel
- Regenerative Medicine & Stem Cell Research Center,
Ben-Gurion University of the Negev, Beer-Sheva,
Israel
- Ilse Katz Institute for Nanoscale Science and Technology,
Ben-Gurion University of the Negev, Beer-Sheva,
Israel
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8
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Vondran M, Rastan AJ, Tillmann E, Seeburger J, Schröter T, Dhein S, Bakhtiary F, Mohr FW. Intra-Aortic Balloon Pump Malposition Reduces Visceral Artery Perfusion in an Acute Animal Model. Artif Organs 2015; 40:334-40. [PMID: 26366459 DOI: 10.1111/aor.12563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Visceral artery perfusion can be potentially affected by intra-aortic balloon pump (IABP) catheters. We utilized an animal model to quantify the acute impact of a low balloon position on mesenteric artery perfusion. In six pigs (78 ± 7 kg), a 30-cc IABP was placed in the descending aorta in a transfemoral procedure. The celiac artery (CA) and the cranial mesenteric artery (CMA) were surgically dissected. Transit time blood flow was measured for (i) baseline, (ii) 1:1 augmentation with the balloon proximal to the visceral arteries, and (iii) 1:1 augmentation with the balloon covering the visceral arteries. Blood flow in the CMA and CA was reduced by 17 and 24%, respectively, when the balloon compromised visceral arteries compared with a position above the visceral arteries (flow in mL/min: CMA: (i) 1281 ± 512, (ii) 1389 ± 287, (iii) 1064 ± 276, P < 0.05 for 3 vs. 1 and 3 vs. 2; CA: (i) 885 ± 370, (ii) 819 ± 297, (iii) 673 ± 315; P < 0.05 for 3 vs. 1). The covering of visceral arteries by an IABP balloon causes a significant reduction of visceral artery perfusion; thus, the positioning of this device during implantation is critical for obtaining a satisfactory outcome.
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Affiliation(s)
- Maximilian Vondran
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Ardawan J Rastan
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Eugen Tillmann
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Jörg Seeburger
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Thomas Schröter
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Stefan Dhein
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Farhad Bakhtiary
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Friedrich-Wilhelm Mohr
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
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9
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Min J, Choi JS, Oh SJ, Seong YW, Moon HJ, Lee JS. Postoperative life-threatening recurrent ventricular arrhythmia triggered by the swan-ganz catheter in a patient undergoing off-pump coronary artery bypass surgery. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 47:416-9. [PMID: 25207256 PMCID: PMC4157510 DOI: 10.5090/kjtcs.2014.47.4.416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 11/19/2013] [Accepted: 11/21/2013] [Indexed: 11/16/2022]
Abstract
Recurrent ventricular arrhythmia can be fatal and cause serious complications, particularly when it is caused immediately after an operation. Incorrect placement of a Swan-Ganz catheter can trigger life-threatening ventricular arrhythmia, but even intensive care specialists tend to miss this fact. Here, we report a case of recurrent ventricular arrhythmia causing a severe hemodynamic compromise; the arrhythmia was induced by a severely angulated Swan-Ganz catheter. The recurrent ventricular arrhythmia was not controlled by any measures including repositioning of the catheter, until the complete removal of the Swan-Ganz catheter. It is necessary to keep in mind that the position of the pulmonary artery catheter should be promptly checked if there is intractable recurrent ventricular arrhythmia.
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Affiliation(s)
- Jooncheol Min
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Jae-Sung Choi
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Se Jin Oh
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Yong Won Seong
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Hyun Jong Moon
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Jeong Sang Lee
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
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10
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Bergmann L, Großwendt T, Kahlert P, Konorza T, Wendt D, Thielmann M, Heusch G, Peters J, Kottenberg E. Arrhythmogenic risk of pulmonary artery catheterisation in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation. Anaesthesia 2012; 68:46-51. [DOI: 10.1111/anae.12069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2012] [Indexed: 12/15/2022]
Affiliation(s)
- L. Bergmann
- Klinik für Anästhesiologie und Intensivmedizin; Essen; Germany
| | - T. Großwendt
- Klinik für Anästhesiologie und Intensivmedizin; Essen; Germany
| | | | | | - D. Wendt
- Klinik für Thorax-und Kardiovaskuläre Chirurgie; Essen; Germany
| | - M. Thielmann
- Klinik für Thorax-und Kardiovaskuläre Chirurgie; Essen; Germany
| | - G. Heusch
- Institut für Pathophysiologie; Universität Duisburg-Essen; Universitätsklinikum Essen; Essen; Germany
| | - J. Peters
- Klinik für Anästhesiologie und Intensivmedizin; Essen; Germany
| | - E. Kottenberg
- Klinik für Anästhesiologie und Intensivmedizin; Essen; Germany
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11
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Wiese AJ, Barter LS, Ilkiw JE, Kittleson MD, Pypendop BH. Cardiovascular and respiratory effects of incremental doses of dopamine and phenylephrine in the management of isoflurane-induced hypotension in cats with hypertrophic cardiomyopathy. Am J Vet Res 2012; 73:908-16. [DOI: 10.2460/ajvr.73.6.908] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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Pipanmekaporn T, Bunchungmongkol N, Pin on P, Punjasawadwong Y. Impact of patients' positions on the incidence of arrhythmias during pulmonary artery catheterization. J Cardiothorac Vasc Anesth 2011; 26:391-4. [PMID: 22209175 DOI: 10.1053/j.jvca.2011.10.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The complication of cardiac arrhythmias during pulmonary artery catheterization (PAC) may be related to the position of the patient. Therefore, the purpose of this study was to determine the effects of patients' positions on incidence of arrhythmias and the time required to place the pulmonary artery catheter. DESIGN A prospective, double-blind, randomized, controlled study. SETTING A tertiary university hospital. PARTICIPANTS One hundred forty patients undergoing elective coronary artery bypass graft surgery. INTERVENTIONS Patients were divided into 2 groups. In the study group (n = 70), patients were positioned with their head down at 10° first and then 10° up and tilted right laterally when the PACs were passed from the right atrium to the right ventricle and then the right ventricle to the pulmonary capillary wedge position, respectively. In the control group (n = 70), patients remained in a supine position during pulmonary artery catheterization. MEASUREMENT AND MAIN RESULT During the catheterization, arrhythmias were recorded and classified into benign (1-3 premature ventricular contractions) and severe (more than 3 premature ventricular contractions or nonsustained ventricular tachycardia). The time for PACs to pass from the right atrium to the right ventricle and the right ventricle to the pulmonary capillary wedge position was measured as T1 and T2, respectively. The incidence of benign arrhythmias between groups was not significantly different (49% for study and 34% for control group, p = 0.196), whereas the incidence of severe arrhythmias was significantly higher in the control group (20% v 5.8%, p = 0.036). The time used for each technique (T1 and T2) in both groups was not significantly different (p = 0.362 and 0.468, respectively). One patient in the study group was excluded because of difficulty in passing the catheter from the right atrium to the right ventricle. CONCLUSIONS Adjusting patients in the head-up and right lateral position while passing the PAC can reduce the incidence of severe arrhythmias, but not in the time taken to place it. This position may have clinical implications, particularly in high-risk patients.
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Affiliation(s)
- Tanyong Pipanmekaporn
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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13
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Hadjizacharia P, O'Keeffe T, Brown CVR, Inaba K, Salim A, Chan LS, Demetriades D, Rhee P. Incidence, risk factors, and outcomes for atrial arrhythmias in trauma patients. Am Surg 2011; 77:634-9. [PMID: 21679600 DOI: 10.1177/000313481107700526] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study is to determine the incidence, risk factors, and outcomes after the development of an atrial arrhythmia (AA) in trauma patients admitted to the intensive care unit (ICU). We performed a retrospective study of more than 7 years of trauma patients admitted to the ICU at an urban, academic Level I trauma center. Patients with AA, defined as atrial fibrillation, atrial flutter, or paroxysmal supraventricular tachycardia, were compared with patients without AA. Groups were compared by univariate and multivariate analysis. Three thousand, four hundred and ninety-nine trauma patients were admitted to the ICU during the study period and 210 (6%) developed an AA. AA patients were more likely to sustain blunt trauma, were older, more often female, more severely injured, and sustained more head injuries. The only independent risk factor for developing an AA was age > 55 years (odds ratio = 4.6, P < 0.01). Mortality was higher in the AA group (33% vs. 14%, P < 0.01) and AA was an independent risk factor for mortality (odds ratio = 1.7, P = 0.01). Twenty-eight per cent (n = 59) of AA patients received beta-blockers in the postinjury period, and these patients had lower mortality (22% vs. 37%, P = 0.04). AA occurs in 6 per cent of trauma patients admitted to the ICU. Developing an AA is an independent risk factor for mortality after trauma. Beta-blocker therapy was associated with decreased mortality in trauma patients with AA.
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Ang DN, Rivara FP, Nathens A, Jurkovich GJ, Maier RV, Wang J, MacKenzie EJ. Complication rates among trauma centers. J Am Coll Surg 2009; 209:595-602. [PMID: 19854399 PMCID: PMC2768077 DOI: 10.1016/j.jamcollsurg.2009.08.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2009] [Revised: 08/04/2009] [Accepted: 08/07/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND The goal of this study was to examine the association between patient complications and admission to Level I trauma centers (TC) compared with nontrauma centers (NTC). STUDY DESIGN This was a retrospective cohort study of data derived from the National Study on the Costs and Outcomes of Trauma (NSCOT). Patients were recruited from 18 Level I TCs and 51 NTCs in 15 regions encompassing 14 states. Trained study nurses, using standardized forms, abstracted the medical records of the patients. The overall number of complications per patient was identified, as was the presence or absence of 13 specific complications. RESULTS Patients treated in TCs were more likely to have any complication compared with patients in NTCs, with an adjusted relative risk (RR) of 1.34 (95% CI, 1.03, 1.74). For individual complications, only the urinary tract infection RR of 1.94 (95% CI, 1.07, 3.17) was significantly higher in TCs. TC patients were more likely to have 3 or more complications (RR, 1.83; 95% CI, 1.16, 2.90). Treatment variables that are surrogates for markers of injury severity, such as use of pulmonary artery catheters, multiple operations, massive transfusions (> 2,500 mL packed red blood cells), and invasive brain catheters, occurred significantly more often in TCs. CONCLUSIONS Trauma centers have a slightly higher incidence rate of complications, even after adjusting for patient case mix. Aggressive treatment may account for a significant portion of TC-associated complications. Pulmonary artery catheter use and intubation had the most influence on overall TC complication rates. Additional study is needed to provide accurate benchmark measures of complication rates and to determine their causes.
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Affiliation(s)
- Darwin N Ang
- Department of Surgery, University of Washington, Seattle, WA
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15
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Husain S, Pamboukian SV, Tallaj JA, McGiffin DC, Bourge RC. Invasive monitoring in patients with heart failure. Curr Cardiol Rep 2009; 11:159-66. [PMID: 19379635 DOI: 10.1007/s11886-009-0024-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The syndrome of heart failure is characterized by symptoms that are relatively insensitive and nonspecific. Physical diagnosis may be unreliable even in the hands of experienced clinicians, despite the presence of significantly elevated filling pressures or a significantly depressed cardiac output. Instrumentation and devices such as the insertion of a pulmonary artery catheter and the implantable hemodynamic monitor have a major role in the diagnosis and management of cardiovascular disease. They provide a means of measuring intracardiac pressures for point-in-time measurements (cardiac catheterization), short term in an acute situation (insertion of a pulmonary arterial catheter), and, more recently, a long-term assessment increasing our understanding of the nuances of the hemodynamic derangements associated with heart failure and other conditions. With improved ability to accurately assess and monitor filling pressures, clinicians can more precisely adjust therapy with the goal of improving patient symptoms and possibly outcomes.
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Affiliation(s)
- Saima Husain
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 311 THT, 1900 University Boulevard, Birmingham, AL 35294, USA
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16
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Hadjizacharia P, Salim A, Brown C, Inaba K, Chan LS, Mascarenhas A, Margulies DR. Does the use of pulmonary artery catheters increase the number of organs available for transplantation? Clin Transplant 2009; 24:62-6. [PMID: 19222506 DOI: 10.1111/j.1399-0012.2009.00980.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Aggressive donor management, including the placement of a pulmonary artery catheter (PAC) to monitor hemodynamic status and tissue perfusion, has been associated with a significant increase in the number of organs recovered for transplantation. Nonetheless, there has been growing scrutiny over the use of PACs because of their known complications and lack of therapeutic effect. The purpose of this study is to evaluate the use of PACs in the management of organ donors. The records of all patients who successfully donated organs between January 1, 2002 and December 31, 2005 were reviewed. A total of 96 patients underwent successful organ donation during the four-yr study period. Of these, 49 (51.0%) were managed with a PAC. Compared with donors managed without a PAC, there were significantly more hearts recovered from donors managed with a PAC (71.4% vs. 44.7%; p = 0.0079) with no difference in the daily administration of fluids and vasopressors between the two groups. The management of organ donors with a PAC can help maximize cardiac procurement.
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Affiliation(s)
- Pantelis Hadjizacharia
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, USA
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17
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Yokote J, Watanabe I, Usui A, Oshima H, Kato W, Takahashi H, Ueda Y. Renal injury caused by pulmonary artery catheter repositioning. J Cardiothorac Vasc Anesth 2008; 23:379-80. [PMID: 18834801 DOI: 10.1053/j.jvca.2008.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2007] [Indexed: 11/11/2022]
Affiliation(s)
- Jun Yokote
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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18
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Gwak MS, Kim JA, Kim GS, Choi SJ, Ahn H, Lee JJ, Lee S, Kim M. Incidence of severe ventricular arrhythmias during pulmonary artery catheterization in liver allograft recipients. Liver Transpl 2007; 13:1451-4. [PMID: 17902132 DOI: 10.1002/lt.21300] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Liver allograft recipients may develop a hyperdynamic circulation and cardiac electrophysiologic abnormalities. The incidence of severe ventricular arrhythmias in liver allograft recipients during pulmonary artery (PA) catheterization was determined. One hundred five liver allograft recipients were studied prospectively; 5 of the patients with preexisting valvular heart disease, ischemic heart disease, or arrhythmias were excluded. Severe ventricular arrhythmia, defined as 3 or more consecutive ventricular premature beats occurring at a rate of >100 per minute, was observed in 37.0% of the patients during insertion of the catheter and in 25.0% of the patients during removal of the catheter. Two patients developed ventricular tachycardia, and 2 developed ventricular fibrillation; the arrhythmias in these 4 patients did not respond to appropriate pharmacological treatment but resolved promptly after removal of the PA catheter. The catheter transit time from the right ventricle to the pulmonary capillary wedge position was longer in patients with severe ventricular arrhythmia than in those without this arrhythmia (91.6+/-103.6 s versus 53.3+/-18.4 s, P<0.05). In conclusion, patients undergoing liver transplantation have a high risk of developing a ventricular arrhythmia during PA catheterization.
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Affiliation(s)
- Mi Sook Gwak
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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19
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Hadian M, Pinsky MR. Evidence-based review of the use of the pulmonary artery catheter: impact data and complications. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 10 Suppl 3:S8. [PMID: 17164020 PMCID: PMC3226129 DOI: 10.1186/cc4834] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The pulmonary artery catheter (PAC) was introduced in 1971 for the assessment of heart function at the bedside. Since then it has generated much enthusiasm and controversy regarding the benefits and potential harms caused by this invasive form of hemodynamic monitoring. This review discusses all clinical studies conducted during the past 30 years, in intensive care unit settings or post mortem, on the impact of the PAC on outcomes and complications resulting from the procedure. Although most of the historical observational studies and randomized clinical trials also looked at PAC-related complications among their end-points, we opted to review the data under two main topics: the impact of PAC on clinical outcomes and cost-effectiveness, and the major complications related to the use of the PAC.
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Affiliation(s)
- Mehrnaz Hadian
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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20
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Abreu AR, Campos MA, Krieger BP. Pulmonary artery rupture induced by a pulmonary artery catheter: a case report and review of the literature. J Intensive Care Med 2004; 19:291-6. [PMID: 15358948 DOI: 10.1177/0885066604265255] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Placement and use of pulmonary artery catheters (PACs) carry potential risks. The authors describe a case of a patient who developed massive hemoptysis after placement of a PAC that caused a rupture of the pulmonary artery with pseudoaneurysm formation. Treatment was successfully achieved with transcatheter coil embolization. Pulmonary artery rupture and pseudoaneurysm formation are among the most serious complications of PAC use because of the associated risk of mortality. Patients with this complication may be asymptomatic or may present with variable amounts of hemoptysis immediately or days after using a PAC. The gold standard diagnostic test is pulmonary angiography, and the treatment of choice for most patients is transcatheter embolization. Physicians and other health care personnel handling these catheters should be familiar with the specific PAC balloon's inflation limits to avoid complications that may injure the patient.
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Affiliation(s)
- Alexandre R Abreu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Miami School of Medicine, Miami, Florida, USA
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21
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Lopes MC, de Cleva R, Zilberstein B, Gama-Rodrigues JJ. Pulmonary artery catheter complications: report on a case of a knot accident and literature review. ACTA ACUST UNITED AC 2004; 59:77-85. [PMID: 15122422 DOI: 10.1590/s0041-87812004000200006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A particular event concerning a Swan-Ganz catheter complication is reported. A 41-year-old woman was admitted at the emergency room of our hospital with massive gastrointestinal bleeding. A total gastrectomy was performed. During the postoperative period in the intensive care unit, the patient maintained hemodynamic instability. Invasive hemodynamic monitoring with a pulmonary artery catheter was then indicated. During the maneuvers to insert the catheter, a true knot formation was identified at the level of the superior vena cava. Several maneuvers by radiological endovascular invasive techniques allowed removal of the catheter. The authors describe the details of this procedure and provide comments regarding the various techniques that were employed in overcoming this event. A comprehensive review of evidence regarding the benefits and risks of pulmonary artery catheterization was performed. The consensus statement regarding the indications, utilization, and management of the pulmonary artery catheterization that were issued by a consensus conference held in 1996 are also discussed in detail.
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Affiliation(s)
- Marcelo Cruz Lopes
- Intensive Care Unit of the Department of Gastroenterology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo--São Paulo,/SP, Brazil
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22
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Youngberg JA, Kaye AD, Anwar M. Do anticoagulation with heparin and protamine reversal alter thrombogenicity of coated and noncoated pulmonary artery catheters? J Cardiothorac Vasc Anesth 1999; 13:405-9. [PMID: 10468252 DOI: 10.1016/s1053-0770(99)90211-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To clarify the role of anticoagulation with heparin and protamine reversal on the effectiveness of heparin bonding or coating of pulmonary artery catheters in preventing thrombus formation in the Rhesus monkey. DESIGN A controlled, unblinded, open-labeled study. SETTING A research laboratory at Tulane School of Medicine (New Orleans, LA). PARTICIPANTS Twenty-four anesthetized Rhesus monkeys. INTERVENTIONS The monkeys were assigned to one of four groups. In the first group (group A), non-heparin-coated catheters were inserted into a femoral vein through an incision, advanced proximally for a distance of 30 cm, and left in place for 1 hour. In the second group (group B), heparin-coated catheters were placed and evaluated in the same manner as in group A. In the third group (group C), the primates received 3 mg/kg of heparin intravenously (i.v.) before insertion of a non-heparin-coated pulmonary artery catheter. After the catheter had been in place for 1 hour, protamine, 3 mg/kg i.v., was administered, and the catheter was left in place for an additional hour. In the final group (group D), the primates received 3 mg/kg of heparin i.v. before insertion of a heparin-coated pulmonary artery catheter. After the catheter had been in place for 1 hour, protamine, 3 mg/kg i.v., was administered, and the catheter was left in place for an additional hour. In each group, the catheter was withdrawn with the balloon inflated to minimize any stripping of thrombus from the surface of the catheter. Thrombus was removed from the catheter through a femoral vein cutdown and weighed. Laboratory values were determined for each animal, and clot formation was evaluated in each group. After completion of the study, the animals were returned to the primate breeding colony. MEASUREMENTS AND MAIN RESULTS There were no significant differences in hematocrit, prothrombin time, partial thromboplastin time, or platelet levels among the four groups; therefore, the data were pooled. Clots were observed on five of six catheters in both groups A and C; however, clot formation was seen in one of six catheters in group B and three of six catheters in group D. There was a statistically significant difference (p < 0.01) in mean clot weight in group A (265 +/- 68 mg; range, 0 to 447 mg) compared with 13 +/- 13 mg in group B (range, 0 to 80 mg). There was no significant difference in mean clot weight in group C (104 +/- 35 mg; range, 0 to 202 mg) compared with group D (24 +/- 16 mg, range, 0 to 98 mg). Additionally, in group C, the mean clot weight was significantly less than in group A. CONCLUSION Anticoagulation of primates with heparin before catheter insertion imparts some protection to non-coated catheters, and protamine reversal of anticoagulation with heparin may partially negate the protective effect seen with heparin-coated pulmonary artery catheters.
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Affiliation(s)
- J A Youngberg
- Department of Anesthesiology, Tulane Medical Center, New Orleans, LA 70112, USA
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23
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Abstract
The uses of the pulmonary artery catheter have been expanded from its original use, helping to assess the cardiac output and left ventricular filling pressure of patients with cardiac disease, to include the management of patients with trauma, septic shock, respiratory failure, and those undergoing high-risk surgeries. Although more than 1 million pulmonary artery catheters are inserted each year in the United States, clear evidence establishing that they improve outcome remains hard to find. This article discusses the complications of invasive hemodynamic monitoring.
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Affiliation(s)
- T D Coulter
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Ohio, USA
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24
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Kaye AD, Anwar M, Youngberg JA. Introducers and protective sleeves may increase thrombogenicity of pulmonary artery catheters. J Cardiothorac Vasc Anesth 1999; 13:139-42. [PMID: 10230945 DOI: 10.1016/s1053-0770(99)90076-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate the cause of clot formation on the surface of non-heparin coated/bonded pulmonary artery catheters. DESIGN A controlled, unblinded, open-labeled study. SETTING Research laboratory at Tulane School of Medicine, New Orleans, LA. PARTICIPANTS Rhesus and African Green monkeys. INTERVENTIONS Anesthetized monkeys (n = 24) were assigned to one of two groups. The first group (group A) had a pulmonary artery catheter inserted into a femoral vein through a cutdown without passage through an introducer or protective sleeve before insertion. In the second group (group B), the pulmonary artery catheter was passed through an introducer and protective sleeve before insertion in the femoral vein. After the study, the animals were returned to the primate breeding colony. Laboratory values were measured for each animal, and electron micrographs were taken of selected pulmonary artery catheters before and after passage of these catheters through the introducer sheath and/or protective sleeve. MEASUREMENTS AND MAIN RESULTS Between the two groups, there was a significant difference in fibrinogen level, but not in hematocrit, prothrombin time, partial thromboplastin time, and platelet count. Clots were visible on 11 of 12 catheters in group B, which was statistically significant (p < 0.01), compared with only 3 of 12 catheters in group A. The average clot weight was 0.014+/-0.014 g in group A (range, 0.00 to 0.170 g), which was statistically significant (p < 0.01), compared with 0.216 < 0.058 g in group B (range, 0.000 to 0.620 g). Electron micrographs taken after catheters were passed through an introducer and/or protective sleeve showed that both significantly altered the surface of the catheter. The surface of the catheter was smooth and homogenous in appearance before insertion. Conversely, both the introducer and protective sleeve produced marked furrowing and a nodular appearance on the catheter surface, as shown by electron micrographs. CONCLUSION The data from this study show that the incidence of clot formation and amount of clot formed on the surface of non-heparin-coated pulmonary artery catheters are significantly greater after passage through an introducer and/or protective sleeve. The electron micrographs also show that both introducers and protective sleeves abraded the catheters and were associated with thrombus formation on the catheter. Designing less traumatic valves on these devices is warranted and recommended.
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Affiliation(s)
- A D Kaye
- Department of Anesthesiology, Tulane Medical Center, New Orleans, LA, USA
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25
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Kodavatiganti R, Hearn CJ, Insler SR. Bleeding from a pulmonary artery catheter temperature connection port. J Cardiothorac Vasc Anesth 1999; 13:75-7. [PMID: 10069290 DOI: 10.1016/s1053-0770(99)90179-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- R Kodavatiganti
- Department of Cardiothoracic Anesthesia, The Cleveland Clinic Foundation, OH, USA
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26
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Daccache G, Depoix JP, Provenchere S, Philip I, Enguerand D, Desmonts JM, Hvass U. Pulmonary artery catheter during cardiac surgery: a rare but severe adverse effect. J Cardiothorac Vasc Anesth 1998; 12:125-6. [PMID: 9509370 DOI: 10.1016/s1053-0770(98)90083-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Nakayama M, Aimono M, Kawana S, Oomori H, Watanabe H, Namiki A. Cardiac arrest during removal of a pulmonary artery catheter. Can J Anaesth 1996; 43:972-4. [PMID: 8874918 DOI: 10.1007/bf03011814] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
PURPOSE This case report describes an asystolic cardiac arrest that occurred during removal of a pulmonary artery (PA) catheter. CLINICAL FEATURES A 70-yr-old man underwent elective hepatectomy because of hepatic carcinoma with a combination of thoracic epidural blockade and general anaesthesia. After the conclusion of the operation, the PA catheter was removed and immediately after, the patient developed profound sinus bradycardia and hypotension followed by asystolic cardiac arrest. Two minutes after the onset of asystole, cardiac rhythm was detected following the administration of epinephrine and atropine. He had no further episodes of bradycardia or neurological deficit. CONCLUSION Removal of a PA catheter has the potential of inducing asystole requiring cardiac resuscitation and availability of emergency drugs.
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Affiliation(s)
- M Nakayama
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Japan
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28
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Abstract
The PAC has allowed physicians to obtain information that was unavailable prior to its introduction into clinical medicine. There are numerous pitfalls, however, in obtaining and interpreting this information. Even if these pitfalls are avoided, changing therapy to the patient's benefit based on PAC data is not guaranteed. In addition, application of new technologies, particularly TEE, has led to the suspicion that PA catheterization may frequently yield an incorrect assessment of the patient. Can PA catheterization lead to an improved outcome in an individual patient? If the patient is chosen carefully, the catheter inserted successfully and safely, the data obtained meticulously and interpreted correctly, and this interpretation leads to a change in therapy to which the patient responds appropriately, then the patient will experience an improved outcome based on PAC use. Does this happen often enough in the millions of catheterizations that are performed each year to improve the outcome of the group significantly as a whole? Almost certainly not.
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Affiliation(s)
- A B Leibowitz
- Department of Anesthesiology, Mount Sinai School of Medicine of the City University of New York, New York, USA
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29
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Abstract
OBJECTIVES This study was designed to determine the incidence rate, define risk factors, and suggest proper management protocols for pulmonary artery (PA) rupture associated with Swan-Ganz catheters. DESIGN This is a retrospective chart-review study. SETTING This study involved 32,442 inpatients requiring hemodynamic monitoring with Swan-Ganz catheters in the operating rooms and ICUs at a large, private teaching hospital over a 17-year period (1975 to 1991). RESULTS Ten patients sustained PA rupture, yielding an observed rupture rate of 0.031% of catheter insertions. All ten patients had hemoptysis and five (50%) had pulmonary hypertension. Two patients (20%) had undergone anticoagulation at the time of rupture. Four of the six surgical patients were still in surgery at the first sign of rupture. A thoracotomy was performed in five patients. We noted a trend toward survival with thoracotomy, but it was not statistically significant. The overall mortality rate was 70%. When data from our 10 patients were combined with 65 patients from the literature, we found that thoracotomy was essential for survival in patients with hemothorax. There were no survivors among seven patients with hemothorax simply observed, compared with eight (50%) survivors in 16 patients undergoing thoracotomy (p = 0.026). Thirty-nine (75%) of 52 patients without hemothorax survived, whether or not a thoracotomy was performed. CONCLUSIONS Our study suggested that the incidence of Swan-Ganz catheter-associated PA rupture is 0.031% and that an urgent thoracotomy should be performed if hemothorax is present at any point.
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Affiliation(s)
- T J Kearney
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, USA
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30
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Affiliation(s)
- L R Golden
- Department of Anesthesia, Maimonides Medical Center, Brooklyn, NY 11219, USA
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31
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Han DG, Rosenblatt MA, Reed AP. Adenosine for the treatment of sustained sinus nodal reentrant tachycardia during general anesthesia. J Anesth 1995; 9:188-191. [PMID: 28921292 DOI: 10.1007/bf02479855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/1994] [Accepted: 11/09/1994] [Indexed: 10/24/2022]
Affiliation(s)
- Don G Han
- Department of Anesthesiology, The Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1010, 10029-6574, New York, NY, USA
| | - Meg A Rosenblatt
- Department of Anesthesiology, The Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1010, 10029-6574, New York, NY, USA
| | - Allan P Reed
- Department of Anesthesiology, The Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1010, 10029-6574, New York, NY, USA
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32
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Abstract
Complications from Swan-Ganz catheters during insertion, long-term placement, or removal have been known since its development. I describe the unusual presentation of a pacing Swan-Ganz catheter mispositioned into the hepatic vein producing vascular obstruction, yet with adequate cardiac pacing.
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Affiliation(s)
- M S Davis
- Department of Medicine, Doctors Hospital of Manteca, Calif., USA
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33
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Abstract
There are a number of different methods by which the impedance waveform can at least partly predict ventricular function. Of these methods, the measurement of systolic time intervals has been best validated. However, much work still needs to be done on a wide variety of ICU and non-ICU patients to validate a stable and predictable relationship between PEP/VET and EF. Further work may also validate the other indices discussed above, but less confidence can be expressed as to their eventual clinical use at present. All of the work to date has examined the relationship between impedance and LV function. Although the impedance tracing is known to largely reflect LV ejection and aortic root flow, there may be some contribution from right ventricular function. To further evaluate this contribution, work using first-pass radionuclear techniques to selectively look at right ventricular EF will need to be done.
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Affiliation(s)
- H D Fuller
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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34
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Coles NA, Hibberd M, Russell M, Love T, Ory D, Field TS, Dec GW, Eagle KA. Potential impact of pulmonary artery catheter placement on short-term management decisions in the medical intensive care unit. Am Heart J 1993; 126:815-9. [PMID: 8213436 DOI: 10.1016/0002-8703(93)90693-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The purpose of this study was to examine the potential impact of pulmonary artery (PA) catheter placement on short-term management decisions in the medical intensive care unit (ICU). One hundred three patients were examined over an 18-month period. The predominant indications for PA-catheter placement included refractory congestive heart failure, airspace disease, uncertain cardiac filling pressures, or hypotension. In 58 (56%) of the 103 patients, management recommendations changed as a direct result of knowledge gained by PA catheter placement. These changes involved fluid therapy recommendations in 41 patients, vasopressor use in 17 patients, intravenous vasodilator use in 24 patients, and recommendations for the use of inotropic agents in 15 patients. Although 18 patients experienced early or late complications, major events were limited to a single pneumothorax requiring chest tube insertion and four episodes of bacteremia. No deaths were directly attributable to the catheter insertion. In critically ill patients in the medical intensive care unit, PA-catheter placement leads to changes in recommendations for management in a substantial portion of patients with little risk of life-threatening complications in those who receive such invasive monitoring.
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Affiliation(s)
- N A Coles
- Cardiac Unit, Massachusetts General Hospital, Boston 02114
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35
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Abstract
Despite several prospective, randomized trials that demonstrated reductions in operative morbidity and mortality rates, routine use of invasive monitoring has not achieved widespread acceptance. This probably comes from skepticism about the validity of some of the studies along with known complications of the pulmonary artery catheter. The major studies are reviewed and a rational approach to monitoring is presented.
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Affiliation(s)
- J E Sola
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
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36
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Berlauk JF, Abrams JH, Gilmour IJ, O'Connor SR, Knighton DR, Cerra FB. Preoperative optimization of cardiovascular hemodynamics improves outcome in peripheral vascular surgery. A prospective, randomized clinical trial. Ann Surg 1991; 214:289-97; discussion 298-9. [PMID: 1929610 PMCID: PMC1358649 DOI: 10.1097/00000658-199109000-00011] [Citation(s) in RCA: 223] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The hypothesis that optimizing hemodynamics using pulmonary artery (PA) catheter (preoperative 'tune-up') would improve outcome in patients undergoing limb-salvage arterial surgery was tested. Eighty-nine patients were randomized to preoperative tune-up either in the surgical intensive care unit (SICU) (group 1) or the preinduction room (group 2) or to control (group 3). The tune-up consisted of fluid loading, afterload reduction, and/or inotropic support to achieve predetermined endpoints. Patients with a PA catheter had significantly fewer adverse intraoperative events (p less than 0.05), less postoperative cardiac morbidity (p less than 0.05), and less early graft thrombosis (p less than 0.05) than the control group. The overall study mortality rate was 3.4%, with a mortality rate of 9.5% in the control group and 1.5% in the PA catheter groups. There were no differences in ICU length of stay (LOS), hospital LOS, or total hospital costs, although the percentage of cost from complications was higher in group 3 (p greater than 0.05). In this group of patients, preoperative cardiac assessment and optimization is associated with improved outcome.
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Affiliation(s)
- J F Berlauk
- Department of Anesthesiology, University of Minnesota, Minneapolis 55455
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37
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López-Sendón J, López de Sá E, González Maqueda I, Coma-Canella I, Ramos F, Domínquez F, Martín Jadraque L. Right ventricular infarction as a risk factor for ventricular fibrillation during pulmonary artery catheterization using Swan-Ganz catheters. Am Heart J 1990; 119:207-9. [PMID: 2296867 DOI: 10.1016/s0002-8703(05)80109-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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38
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39
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Pingleton SK. Complications of acute respiratory failure. THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1988; 137:1463-93. [PMID: 3059862 DOI: 10.1164/ajrccm/137.6.1463] [Citation(s) in RCA: 255] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- S K Pingleton
- Department of Medicine, University of Kansas Medical Center, Kansas City
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40
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Abstract
Patients in intensive care units (ICUs) are subject to many complications connected with the advanced therapy required for their serious illnesses. Complications of ventilatory support include problems associated with short-term and long-term intubation, barotrauma, gastrointestinal tract bleeding, and weaning errors. Cardiac tachyarrhythmias can arise from a patient's intrinsic cardiac disease, as well as from drug therapy itself. Hemodynamic monitoring is crucial to careful patient management, but it is associated with technical complications during insertion such as pneumothorax, as well as interpretive errors such as those caused by positive end-inspiratory pressure. Acute renal failure can develop as a result both of therapy with drugs such as aminoglycosides and hypotension of many etiologies, as well as the use of contrast media. Nosocomial infection, which is a dreaded complication in ICU patients, usually arises from sources in the urinary tract, bloodstream, or lung. Complications frequently can arise if the interactions of drugs commonly used in the ICU are not recognized. Further, the ICU patient is subject to nutritional complications, acid base problems, and psychological disturbances. This monograph deals with the frequency, etiology, and prevention of these common ICU complications.
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Affiliation(s)
- C M Wollschlager
- Department of Medicine, Nassau County Medical Center, East Meadow, New York
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41
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Wholey MH, Zikria EA, Boyle B. Inadvertant atrial fixation of a Swan-Ganz catheter by suture and a method for its percutaneous removal. Cardiovasc Intervent Radiol 1987; 10:171-4. [PMID: 3111700 DOI: 10.1007/bf02577996] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
A patient with type I dissection of the thoracic aorta inadvertently had a Swan-Ganz catheter sutured to the right atrium during surgical repair of the dissection. A method for its removal using percutaneous passage of a No. 15 scalpel blade is described. The hazards of Swan-Ganz catheters are explored, and the changing roles of nonsurgical interventional procedures are discussed.
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42
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Robin ED. Overuse and abuse of Swan-Ganz catheters. INTERNATIONAL JOURNAL OF CLINICAL MONITORING AND COMPUTING 1987; 4:5-9. [PMID: 3572196 DOI: 10.1007/bf02919569] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The widespread use of the Swan-Ganz catheter is a result of a general misconception. It is widely accepted that the collection of data is a way of practicing scientific medicine. That is simply not true. The data must on balance contribute to a better outcome for patients as established by a scientific trial. The present widescale use of the catheter provides a striking example of the misuse or even mindless use of technology. Because of a tenuous risk-benefit balance, it is not at all certain that the general use of the Swan-Ganz catheter is justifiable and its use at best is semi-scientific. A reasonable approach would be to suspend its use pending an appropriate clinical trial which established safety and efficacy. Although the prospects for a clinical trial are bright, the prospects for a moratorium are not at all bright. While awaiting the results of an appropriate trial, individual physicians should only use the catheter when the probability is high that the data obtained by its use will provide more effective decision making. Such an approach by itself should result in a near-moratorium. Its present use is not a form of scientific medicine but at best a form of semi-scientific clinical practice.
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43
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Panacek E, Rutherford WF. Central vessel cannulation. Intensive Care Med 1986; 12:435. [PMID: 3794062 DOI: 10.1007/bf00254678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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44
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45
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Damen J, Bolton D. A prospective analysis of 1,400 pulmonary artery catheterizations in patients undergoing cardiac surgery. Acta Anaesthesiol Scand 1986; 30:386-92. [PMID: 3766094 DOI: 10.1111/j.1399-6576.1986.tb02436.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
During 1983 and 1984, 1305 patients underwent 1,400 pulmonary artery (PA) catheterizations. Successful placement was achieved in 1397 (99.6%) of 1,403 attempts. The catheters were inserted via the right internal jugular vein on 1364 occasions. The median duration of monitoring was 28 h with a range from 3 to 220 h. Central venous puncture complications included carotid artery puncture in 67 instances (4.8%) and pneumothorax in one patient. Insertion of the catheters was associated with supraventricular arrhythmias on 11 occasions, ventricular arrhythmias on 930 (66.4%), right bundle branch block on two and a total heart block on one occasion. Eighteen (2.3%) of the 794 cultured catheter tips were positive. An in situ time of more than 72 h was associated with a significantly higher percentage (7.2%) of positive tip cultures compared with an in situ time of less than 72 h (P less than 0.01). Repeated PA catheterization was not associated with significantly more complications than the initial catheterization. The results show that monitoring with a PA catheter in cardiac surgical patients is associated with a low incidence of morbidity.
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46
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Abstract
The incidence and significance of the development of ventricular arrhythmias during insertion and removal of pulmonary artery monitoring catheters were determined in stable postcardiac surgical patients. Insertion of 173 (69 percent) of 250 catheters was associated with ventricular arrhythmias and removal in 158 (63 percent) of these catheters (p greater than 0.05). All arrhythmias resolved spontaneously. Patients who underwent valve replacement showed significantly fewer arrhythmias during withdrawal than those who underwent a coronary artery bypass operation (p less than 0.025). Factors significantly influencing the incidence of ventricular arrhythmias during removal were increased postoperative CK-MB levels (p less than 0.025) and cardiac index (p less than 0.025).
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47
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Iberti TJ, Benjamin E, Gruppi L, Raskin JM. Ventricular arrhythmias during pulmonary artery catheterization in the intensive care unit. Prospective study. Am J Med 1985; 78:451-4. [PMID: 3976703 DOI: 10.1016/0002-9343(85)90337-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The balloon-tipped, flotation pulmonary artery catheter is frequently utilized in the management of intensive care unit patients. Advanced ventricular arrhythmias (three or more consecutive premature ventricular contractions) have been reported in 25 to 68 percent of intensive care unit patients undergoing catheterizations. A group of 56 intensive care unit patients who received a pulmonary artery catheter were prospectively studied to determine the incidence of catheter-induced arrhythmias and the time required for catheterization. The mean age of the patients was 69.8 +/- 11 years. Indications for catheterization included septic shock (n = 10), congestive heart failure (n = 8), hypovolemia (n = 12), respiratory failure (n = 2), preoperative cardiac evaluation (n = 20), and miscellaneous (n = 4). Advanced ventricular arrhythmias were recorded in seven of the 56 patients (12.5 percent), the longest arrhythmia being a run of seven consecutive premature ventricular contractions. No patient required treatment with lidocaine for their arrhythmias and all arrhythmias resolved with catheter movement. The mean time of catheterization for the 56 patients was 175.9 seconds (SD 263.2), and was not significantly different for patients with or without arrhythmias. There was no statistical difference in catheterization times or incidence of arrhythmias between critically ill patients and the preoperative patients. It is concluded that pulmonary artery catheterization can be performed in critically ill patients with a lower incidence of arrhythmias than has previously been reported. The decreased incidence of arrhythmias may be secondary to the decreased catheterization times.
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48
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Thomas SJ, Boyd AD. In Reply: Pulmonary Artery Catheterization. Chest 1984. [DOI: 10.1378/chest.85.6.840-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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49
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Sprung CL, Elser B, Pons G. Pulmonary artery catheterization. Chest 1984; 85:839-40. [PMID: 6723408 DOI: 10.1378/chest.85.6.839b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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50
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Wiedemann HP, Matthay MA, Matthay RA. Cardiovascular-pulmonary monitoring in the intensive care unit (Part 2). Chest 1984; 85:656-68. [PMID: 6713975 DOI: 10.1378/chest.85.5.656] [Citation(s) in RCA: 36] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Proliferation of technology in the ICU likely will continue at a rapid pace. This presents a strong challenge to the clinician's task of "above all, do not harm." While invasive techniques carry obvious direct risks, both invasive and noninvasive monitoring present a more subtle threat. Pitfalls in the acquisition and interpretation of data must be recognized before appropriate therapeutic decisions can be made. Advanced monitoring devices and techniques must supplement and not supplant clinical assessment.
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