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This medical PowerPoint presentation talks about Swan Gantz Catherter and the Meaning of its Readings.

The Swan-Ganz catheter is a medical device used to measure various cardiovascular parameters such as cardiac output, pulmonary artery pressure, and pulmonary capillary wedge pressure. It consists of a thin, flexible tube that is inserted through a vein and advanced into the right side of the heart and the pulmonary artery.

The catheter has a balloon at its tip, which can be inflated to temporarily block blood flow and measure pulmonary capillary wedge pressure. The catheter is connected to a monitor that displays the readings.

The readings obtained from the Swan-Ganz catheter provide important information about the function of the heart and lungs, and can help diagnose and manage a variety of medical conditions. For example, elevated pulmonary artery pressure can indicate pulmonary hypertension, while low cardiac output can indicate heart failure.

Tags : Swan Gantz Catherter, medical device, cardiovascular parameters, cardiac output, pulmonary artery pressure, pulmonary capillary wedge pressure, cardiology, cardiology PowerPoint presentation

Published on : Mar 19, 2023 | Views : 1069 | Downloads : 2

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Slide 1-

Swan Gantz Catherter and the Meaning of its Readings Justin Chandler Surgical Critical Care Fellow
Slide 2-

The Pulmonary Artery Catheter and Its History
Slide 3-

The Pulmonary Artery Catheter and Its History Cardiac catheterization dates back to Claude Bernard used it on animal models Clinical application begins with Werner Forssmann in the 1930s inserted a catheter into his own forearm, guided it fluoroscopically into his right atrium, and took an X-ray picture of it
Slide 4-

The Pulmonary Artery Catheter and Its History The pulmonary artery catheter introducted in 1972 Frequently referred to as a Swan-Ganz catheter, in honor of its inventors Jeremy Swan and William Ganz, from Cedars-Sinai Medical Center The “sail” or balloon tip was a modification of the simple portex tubing method developed by Ronald Bradley Ganz added the thermistor
Slide 5-

Indications
Slide 6-

Indications Diagnostic indications: Shock states Differentiation of high vs low pressure pulmonary edema Primary pulmonary hypertension Valvular disease Intracardiac shunts Cardiac tamponade Pulmonary embolus Monitoring and management of complicated acute myocardial infarction Assessing hemodynamic response to therapies Management of multiorgan failure Severe burns Hemodynamic instability after cardiac surgery Assessment of response to treatment in patients with primary pulmonary hypertension Therapeutic indications: Aspiration of air emboli
Slide 7-

Placement Place an introducer R IJ > L SC > R SC > L IJ Femoral is an option Hand ports off to RN, inspect and have RN flush catheter if CCO, leave tip in the holder to calibrate Place swandom on catheter Insert about 15cm and the inflate balloon Slowly and steadily advance catheter watching the waveforms NB When wedged, not the volume required
Slide 8-

Placement
Slide 9-

Typical Cather Insertion Landmarks
Slide 10-

Conformation
Slide 11-

Zones of West
Slide 12-

Unused
Slide 13-

Insertion tips Turn CVP off! Once in the RV  advance to PA quickly to avoid coiling, ventricular arrhythmia. Difficulty getting into PA Valsava Calciun iv HOB up
Slide 14-

Basics to Remember Hemodynamic variables should not be interpreted in isolation Integration of variables with the clinical situation increases the accuracy of assessment Trends are generally more useful than isolated variables at a single point in time
Slide 15-

What does a PAC tell us? Direct measurements CVP PA (systolic and diasotolic) PAOP (wedge) SvO2 (mixed) Calculated data Stroke volume (SV/SVI) Cardiac output (CO/CI) Vascular resistance (SVR,PVR) Oxygen delivery Extended calculations CCO Stroke work End diastolic volume, EF
Slide 16-

Variables of Hemodynamics
Slide 17-

Normal Values
Slide 18-

Additional Values
Slide 19-

Equations to Remember CO = SV x HR or SV = CO / HR SV = EDV – ESV or EDV x EF C = ΔV/ΔP SVR = (MAP – CVP) x 80 / CO LSW = (MAP – LVEDP) x SV x 0.0136 To convert to index: divide by BSA BSA = [Ht + Wt-60]/100 (in cm & kg)
Slide 20-

Cardiac Output Major determinate of oxygenation delivery to tissue Abnormalities are viewed in the context of SV/SI and SvO2 Remember: a normal CO/CI may be associated with a low SV/SI in the presence of tachycardia
Slide 21-

Factors Affecting CO Physiologic Dysrhythmias Septal defects Tricuspid regurg Respirations Technical Bolusing technique Themistor malfunction Factors not affecting CO: Iced vs room temp NSS vs D5 Pt elevation (<45o) 5 cc vs 10 cc
Slide 22-

CO Measurement Typically done with thermodilution method A cold solution of fixed volume is injected and a thermsitor measures the change in temperature The area under the curve is integrated to calculate the CO The waveform should be examined to determine if the technique was good If the accuracy is in doubt, the Fick method may be used
Slide 23-

CO Waveforms
Slide 24-

Fick Method CO = VO2 / [CaO2 – CvO2] * 10 SaO2 and SvO2 often substituted CO = VO2 / [SaO2 – SvO2] * Hgb * 1.34* 10 VO2 is not usually measured Can use 3.5 mL/kg or 125 mL/m2 If metabolic rate is abnormal, the calculation may be incorrect
Slide 25-

Stroke volume If low Inadequate volume (hypovolemia) Impaired ventricular contraction (ischemia/infarction) Increased SVR (drugs) Valve dysfunction (MVR) If high Low vascular resistance (sepsis, drugs)
Slide 26-

CVP Reflects R heart diastolic function and volume status 60-70% of blood volume is in venous system Abnormalities are viewed in the context of SV/SI If high (>6) implies right ventricular dysfunction, especially if SV is low If low (< 2) implies hypovolemia especially if SV is low
Slide 27-

CVP High Hypervolemia RV failure Tricupid stenois/regurg Cardiac tamponade Cardiac pericarditis Pulm HTN Chronic LV failure Low Hypovolemia Venodiliation
Slide 28-

PAOP Reflects left ventricular end diastolic volume Assumes a static column of blood from ventricle to catheter during diastole and consistent compliance Abnormalities are viewed in the context of SV/SI If high (>18) implies left ventricular dysfunction, especially if SV is low If low (< 8) implies hypovolemia especially if SV is low
Slide 29-

PAOP High Hypervolemia LV failure Cardiac tamponade Cardiac pericarditis Mitral stenosis/regurg Atrial myxoma Pulmonary diseases Low Hypovolemia Aortic regurg Elevated LVEDP (>25mmHg) with decreased compliance
Slide 30-

PAOP Conditions in Which PAD Does Not Equal PAOP (1 – 4 mm Hg) Increased PVR Pulmonary hypertension Cor pulmonale Pulmonary embolus Eisenmenger’s syndrome
Slide 31-

Filling Pressures If low, but other parameters are normal may only require observation If CO/CI are also low, treatment may be warranted If SvO2 and/or SV/SI are also low treatment is needed Pulmonary congestion also warrants treatment
Slide 32-

SvO2 Reflects the balance between oxygen delivery and utilization The larger the abnormality, the greater the risk of hypoxemia Remember: a normal or high SvO2 may represent a threat to tissue oxygenation
Slide 33-

SvO2 A low SvO2 usually warrants investigation Evaluate: SV/SI May require treatment, even if CVP/PAOP are normal Hb/Hct SaO2 (>90%) Reasons for oxygen consumption to be elevated Abnormally high SvO2 may be indicative of a septal defect
Slide 34-

Continuous Cardiac Output Newer generation catheter Uses continuous cardiac output measurements without need for bolusing Allows for right heart “volumetric” data RVEDV, RVEF, and RVSV RVSW and RVSWI Also provides continuous SvO2 measurements
Slide 35-

Additional Reference Numbers
Slide 36-

Waveform Analysis Changes in pressure waveforms are due to: Blood entering or leaving a chamber Changes in wall tension (contraction/relaxation) Are always preceded by electrical stimulation Waveforms are also affected by changes in intrathoracic pressure (present as rhythmic changes)
Slide 37-

The Waves
Slide 38-

The Waves - CVP/RA The a wave occurs with atrial contraction It occurs after the P wave in the PR-interval The c wave occurs with closure of the tricuspid valve It occurs at the end of the QRS (RST junction) The v wave occurs with filling of the atria with the tricupid valve closed Occurs after the T wave The mean of the a wave is the CVP
Slide 39-

The Waves - RV Has a sharp, rapid upstroke and a rapid down stroke Falls to near zero
Slide 40-

The Waves - PA Characteristics Rapid up stroke and down stroke Dicrotic notch (closure of pulmonic valve) Smooth runoff End systolic wave occurs after the T wave End diastolic occurs after the QRS
Slide 41-

The Waves - PAOP Characteristics May contain 3 waves a atrial contraction Found after the QRS c closure of mitral valve (often absent) v filling of atria with mitral valve closed Found well after the T Mean PAOP Average the a wave
Slide 42-

a Wave Differential Large Tricuspid or mitral regurg Decreased ventricular compliance Loss of A-V synchrony Junctional rhythms Tachycardia (>130) Absent A-fib Junctional rhythms Paced rhythms Ventricular rhythms
Slide 43-

v Wave Differential Large Tricuspid or mitral regurg Noncompliant atrium Ventricular ischemia/failure Absent V-fib Asystole PEA
Slide 44-

Diagnosis by Waveform Mitral insuffiency Prominent v wave Proximity of v and a waves Returns to a more normal configuration after afterload reduction
Slide 45-

Diagnosis by Waveform VSD Presents with increased SvO2 Note the delay in the v wave May respond to afterload reducers
Slide 46-

Diagnosis by Waveform Cardiac Tamponade As with constrictive pericarditis, there is equalization of diastolic pressures Note the loss of the y descent in cardiac tamponade
Slide 47-

Diagnosis by Waveform Constrictive pericarditis Note the equalization of the diastolic pressures Unlike tamponade, there is an exaggeration of the y descent due to a more rigid pericardium
Slide 48-

Points to remember Intrathoracic pressure during inhalation and exhalation cause pressures in the heart to vary Therefore all pressures should be measured at end-expiration when intrathoracic pressure is closest to zero
Slide 49-

Points to Remember Limitations in hemodynamic monitoring Ventricular filling pressures do not always accurately reflect ventricular filling volume The pressure-volume relationship depends upon ventricular compliance If compliance changes, the pressure-volume relationship changes The PAOP is normally slightly (1-5 mm Hg) less than the PAD pressure This relationship stills exists with pulm hypertension due to LV failure However, with an ↑ PVR or tachycardia (>125 bpm) this relationship may breakdown and the PAD becomes significantly higher than the PAOP The PAOP may not equal LVEDP when there is high alveolar pressures when the catheter tip is above the left atrium severe hypovolemia tachycardia (130 bpm) in mitral stenosis.
Slide 50-

Points to remember Calculated variables (e.g. SVR, PVR & SV/SI) are limited in value due to assumptions made in their calculations
Slide 51-

Complications Air embolism S&S: hypoxemia, cyanosis, hypotension/syncope, “machinery murmur”, elevated CVP, arrest Tx: place in left lateral trendelenburg, FiO2 of 100%, attempt aspiration of air, CPR Arrhythmias Prevention: keep balloon inflated, minimize insertion time Tx: removal of catheter, ACLS Heart blocks Typically RBBB occurs, so avoid PACs in LBBB Tx: transvenous/transcutaneous pacers, PACs with pacer
Slide 52-

Complications Knotting Prevention: minimize insertion time, avoid pushing agaist resistance, verify RA to RV transition Tx: check CXR, attempt to unknot Pulmonary artery rupture S&S: hypoxemia, hemoptysis, circ collapse Prevention: withdraw PAC if spontaneously wedges or wedges with < 1.25 cc of air Tx: stop anti-coagulation, affected side down, selective bronchial intubation, PEEP, surgical repair (CPB or ECMO)
Slide 53-

Complications Pulmonary infarction Prevention Avoid distal positioning of catheter Check CXR Monitor PA EDP instead of PAOP Pull back if spontaneous wedge occurs Limit air in cuff (pull back if < 1.25 cc) Tx CXR Check cath position, deflate and withdraw Observe
Slide 54-

Complications Infection Prevention! Aseptic technique Dead-end caps Sterile sleeve (swandom) Minimize entry into system Avoid glucose containing fluid Avoid over changing of tubing, etc (72-96 hr) Remove catheter ASAP Thrombus Prevention – continuous flush +/- heparin Tx – lytic agent ; remove catheter
Slide 55-

Emerging Technology Devices exist that use arterial pressure waveform to continuously measure cardiac output Variations of the arterial pressure are proportional to stroke volume Several studies demonstrate that SVV has a high sensitivity and specificity in determining if a patient will respond (increasing SV) when given volume (“preload responsiveness”) Limitations Only used in mechanically ventilated pts Wildly inaccurate when arrhythmias are present
Slide 56-

Emerging Technology Impedance Cardiography (ICG) Converts changes in thoracic impedance to changes in volume over time ICG offers noninvasive, continuous, beat-by-beat measurements of: Stroke Volume/Index (SV/SVI) Cardiac Output/Index (CO/CI) Systemic Vascular Resistance/Index (SVR/SVRI) Velocity Index (VI) Thoracic Fluid Content (TFC) Systolic Time Ratio (STR) Left Ventricular Ejection Time (LVET) Pre-Ejection Period (PEP) Left Cardiac Work/Index (LCW/LCWI) Heart Rate
Slide 57-

In a Nutshell Right heart failure Low CI, high PVR Left heart failure High PAOP, low CI, high SVR Tamponade High PAOP, low CI, CVP ≈ POAP Hypotension Hypovolemia Low CVP, PAOP, CI High SVR Cardiogenic High CVP,PAOP, SVR Low CI Sepsis Low CVP, PAOP, SVR High CI
Slide 58-

References Pulmonary Artery Catheter Education Project http://www.pacep.org Chatterjee, The Swan-Ganz Catheters: Past, Present, and Future: A Viewpoint. Circulation 2009;119;147-152 Edwards Scientific http://ht.edwards.com/presentationvideos/powerpoint/strokevolumevariation/strokevolumevariation.pdf
Slide 59-

Question #1 Which one of the following statements is most correct?A) A CVP <2 mmHg usually reflects hypovolemia if the SVI is>45 mL/beat/M2B) A CVP >6 mmHg usually reflects RV failure if the SVI is <25 mL/beat/M2C) A PAOP >18 mmHg usually reflects LV failure if the SVI is >45 mL/beat/M2D) A PAOP <8 mmHg usually reflects hypovolemia if the SVI is >25 mL/beat/M2
Slide 60-

Answer #1 Which one of the following statements is most correct?A) A CVP <2 mmHg usually reflects hypovolemia if the SVI is>45 mL/beat/M2B) A CVP >6 mmHg usually reflects RV failure if the SVI is <25 mL/beat/M2C) A PAOP >18 mmHg usually reflects LV failure if the SVI is >45 mL/beat/M2D) A PAOP <8 mmHg usually reflects hypovolemia if the SVI is >25 mL/beat/M2
Slide 61-

Question #2 Identify the condition most consistent with the following hemodynamic profile:SvO2 ... 0.50 ... PAOP ... 21 mmHgCI ... 2.2 L/min/M2 ...CVP/RA ... 4 mmHgSVI ... 23 ml/beat M2 ... HR ... 98A) HypovolemiaB) HypervolemiaC) LV dysfunction/failureD) Bilateral ventricular failure
Slide 62-

Answer #2 Identify the condition most consistent with the following hemodynamic profile:SvO2 ... 0.50 ... PAOP ... 21 mmHgCI ... 2.2 L/min/M2 ...CVP/RA ... 4 mmHgSVI ... 23 ml/beat M2 ... HR ... 98A) HypovolemiaB) HypervolemiaC) LV dysfunction/failureD) Bilateral ventricular failure
Slide 63-

Question #3 Identify the condition most consistent with the following hemodynamic profile: SvO2 ... 0.47 ... PAOP ... 4 mm HgCI ... 2.0 L/min/M2 ... CVP/RA ... 2 mm HgSVI ... 19 ml/beat/M2 ... HR ... 111 A) HypovolemiaB) HypervolemiaC) LV dysfunction/failureD) Bilateral ventricular failure
Slide 64-

Answer #3 Identify the condition most consistent with the following hemodynamic profile: SvO2 ... 0.47 ... PAOP ... 4 mm HgCI ... 2.0 L/min/M2 ... CVP/RA ... 2 mm HgSVI ... 19 ml/beat/M2 ... HR ... 111 A) HypovolemiaB) HypervolemiaC) LV dysfunction/failureD) Bilateral ventricular failure
Slide 65-

Question #4 Which of the combined set of hemodynamic values is of greatest concern?A) CO = 6.9 L/min; CI = 3.8 L/min/M2 SV = 63 mL/beat; SVI = 34 mL/beat/M2 BP = 102/52 mm Hg SvO2 = 0.83 B) CO = 4.3 L/min; CI = 2.5 L/min/M2 SV = 43 mL/beat; SVI = 25 mL/beat/M2 BP = 94/62 mm Hg SvO2 = 0.64 C) CO = 6.3 L/min; CI = 3.7 L/min/M2 SV = 64 mL/beat; SVI = 37 mL/beat/M2 BP = 90/56 mm Hg SvO2 = 0.75 D) CO = 3.8 L/min; CI =2.3 L/min/M2 SV = 73 mL/beat; SVI = 43 mL/beat/M2 BP = 100/58 mm Hg SvO2 = 0.72
Slide 66-

Answer #4 Which of the combined set of hemodynamic values is of greatest concern?A) CO = 6.9 L/min; CI = 3.8 L/min/M2 SV = 63 mL/beat; SVI = 34 mL/beat/M2 BP = 102/52 mm Hg SvO2 = 0.83 B) CO = 4.3 L/min; CI = 2.5 L/min/M2 SV = 43 mL/beat; SVI = 25 mL/beat/M2 BP = 94/62 mm Hg SvO2 = 0.64 C) CO = 6.3 L/min; CI = 3.7 L/min/M2 SV = 64 mL/beat; SVI = 37 mL/beat/M2 BP = 90/56 mm Hg SvO2 = 0.75 D) CO = 3.8 L/min; CI =2.3 L/min/M2 SV = 73 mL/beat; SVI = 43 mL/beat/M2 BP = 100/58 mm Hg SvO2 = 0.72
Slide 67-

Question #5 Immediate treatment of pulmonary artery rupture may include all of the following except:A) Discontinuation of anticoagulationB) Placing patient in lateral position with unaffected side down.C) Selective bronchial intubationD) PEEP
Slide 68-

Answer #5 Immediate treatment of pulmonary artery rupture may include all of the following except:A) Discontinuation of anticoagulationB) Placing patient in lateral position with unaffected side down.C) Selective bronchial intubationD) PEEP E) Hire a lawyer
Slide 69-

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