Swan-Ganz Catheter (Pulmonary Artery Catheter)

History of the Swan-Ganz Catheter

Background

In 1970, the Pulmonary Artery (PA) Catheter was First Developed by Swan and Ganz
- Swan-Ganz Catheter Catheter was Originally Designed to Provide Physiologic Information About Cardiac Function

Indications for Swan-Ganz Catheterization

General Comments

Reasons that Use of the Swan-Ganz Catheter Has Diminished

Risk of Swan-Ganz Catheterization
Variable Technical Proficiency (from Center to Center) in Swan-Ganz Catheter Management and Data Interpretation
Static Variables Obtained from the Swan-Ganz Catheter Poorly Predict Intravenous Fluid Responsiveness
- Study of Hemodynamic Variables in Predicting Fluid Responsiveness (Chest, 2002) [MEDLINE]
  - Static Hemodynamic Parameters were Found to Be Poorly Predictive of Fluid Responsiveness
Studies Have Not Consistently Demonstrated Clinical Benefit from Use of the Swan-Ganz Catheter
- French Study of Swan-Ganz Catheter in Shock and Acute Respiratory Distress Syndrome (ARDS) (JAMA, 2003) [MEDLINE]
  - Early Swan-Ganz Catheter Use Did Not Impact the Mortality in Shock and/or ARDS
- Meta-Analysis of Swan-Ganz Catheter Trials in the Intensive Care Unit (JAMA, 2005) [MEDLINE]
  - Swan-Ganz Catheter Did Not Impact the Mortality or Number of Hospital Days
- PAC-Man Study of Swan-Ganz Catheter Use in the Intensive Care Unit (Lancet, 2005) [MEDLINE]
  - Swan-Ganz Catheter Did Not Impact the Mortality Rate
- Study of Swan-Ganz Catheter vs CVC in Acute Lung Injury/Acute Respiratory Distress Syndrome (ARDS) (NEJM, 2006) [MEDLINE]
  - Swan-Ganz Catheter Did Not Improve Mortality Rate vs Using a Central Venous Catheter, But Was Associated with an Increased Risk of Complications

Cardiac Surgery

Clinical Efficacy

Study of Use of Swan-Ganz Catheter in Coronary Artery Bypass Graft (CABG) Surgery (PLoS One, 2015) [MEDLINE]
- Swan-Ganz Catheter Use in Coronary Artery Bypass Graft Had No Clinical Benefit or Harm, But was Associated with Increased Cost

Determination of Intracardiac Shunt (see Intracardiac and Extracardiac Shunt)

Rationale: utilizing oxygen saturations to detect a “step-up” (due to a left -> right intracardiac shunt)

Diagnosis and Monitoring of Pulmonary Hypertension (see Pulmonary Hypertension)

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Differentiation of Cardiogenic vs Non-Cardiogenic Pulmonary Edema/Management of Acute Respiratory Distress Syndrome (ARDS) (see Pulmonary Edema and Acute Respiratory Distress Syndrome)

Clinical Efficacy

Study of Pulmonary Capillary Wedge Pressure in Acute Respiratory Distress Syndrome (Intensive Care Med, 2002) [MEDLINE]
- Median PCWP was 16.6 mm Hg in ARDS Patients
- Patients Who Met Standard Criteria for ARDS Were More Likely to Have a High PCWP
- PCWP >18 mm Hg was a Strong Predictor of Mortality in ARDS Patients (After Correction of Baseline Differences)
French Study of Swan-Ganz Catheter in Shock and ARDS (JAMA, 2003) [MEDLINE]
- Early Use of Swan-Ganz Catheter Did Not Improve Morbidity or Mortality in Patients with Shock and/or ARDS
Study of Swan-Ganz Catheter to Guide Treatment of Acute Respiratory Distress Syndrome (N Engl J Med, 2006) [MEDLINE]
- Swan-Ganz Catheter-Guided Therapy Did Not Improve Mortality Rate or Organ Function, But was Associated with More Complications than CVC-Guided Therapy

Recommendations (2016 Surviving Sepsis Guidelines; Intensive Care Med, 2017) [MEDLINE]

Swan-Ganz Catheter is Not Routinely Recommended in the Management of Sepsis-Associated ARDS (Strong Recommendation, High Quality of Evidence)

Differentiation of Hypotensive/Shock States (see Hypotension)

Hypovolemic Shock (see Hypovolemic Shock)
Hemorrhagic Shock (see Hemorrhagic Shock)
Distributive Shock
- Septic Shock (see Sepsis)
- Systemic Inflammatory Response Syndrome (SIRS)
- Anaphylactic Shock (see Anaphylaxis)
- Endocrine/Nutritional Deficiency-Associated Hypotension/Shock
- Hematologic Disease-Associated Hypotension/Shock
- Neurogenic Shock (see Neurogenic Shock)
- Drug/Toxin-Associated Hypotension/Shock
- Other Types of Distributive Shock
Cardiogenic Shock/Severe Congestive Heart Failure (CHF) (see Cardiogenic Shock)
- Arrhythmogenic
- Cardiomyopathic
- Mechanical
Obstructive Shock
- Mechanical
- Pulmonary Vascular

Management of Cardiogenic Shock

Clinical Efficacy

Systematic Review of Impact of Use of Swan-Ganz Catheter in the Management of Cardiogenic Shock (J Crit Care, 2022) [MEDLINE]; n = 1,166,762 (from 6 observational studies)
- The Most Frequent Etiology of Cardiogenic Shock was Post-Myocardial Infarction (75% [95% CI 55-89%] in Swan-Ganz Catheter Group and 81%[95% CI 47-95%] in Non-Swan-Ganz Catheter Group)
- Overall, Swan-Ganz Catheter was uUed in 33% (95% CI 24-44%) of Cases
- Pooling Data Adjusted for Confounders, a Significant Association Between the Swan-Ganz Catheter Group and a Reduction in Short-Term Mortality Emerged When Compared to the Nn-Swan-Ganz Catheter Group (36% [95% CI 27-45%] vs 47% [95% CI 35-59%]; Adjusted Odds Ratio 0.71, 95% CI 0.59-0.87, p < 0.01)
- Mechanical Circulatory Support Use was Significantly Higher in Swan-Ganz Catheter vs Non-Swan-Ganz Catheter Group (59% [95% CI 54-65%]) vs 48% [95% CI 43-53%]); Odds Ratio 1.60 [95% CI 1.27-2.02, p < 0.01])

Multiple Trauma/Burns (see Burns)

Clinical Efficacy

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Perioperative Optimization/Operative Management of Hemodynamics for High-Risk Non-Cardiac Surgery (see Hemodynamics)

Surgical Procedures (Especially in Patients with Suboptimal Cardiac Function)

Pneumonectomy

Clinical Efficacy

Systematic Review and Meta-Analysis of Swan-Ganz Catheter in the Outcome of Moderate to High-Risk Surgical Patients (Anesth Analg, 2011) [MEDLINE]
- Preemptive Strategy of Swan-Ganz Catheter Hemodynamic Monitoring and Coupled Therapy Decreased Surgical Mortality and Morbidity

Research Purposes

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Ventricular Pacing

When Using a Swan-Ganz Catheter with Pacing Capabilities

General Principles of the Swan-Ganz Catheter

Swan-Ganz Catheter is Used to Measure Hemodynamic Parameters (see Hemodynamics)
- Cardiac Output (CO)
- Pulmonary Artery-Systolic Pressure (PA-Systolic Pressure) and Pulmonary Artery-Diastolic Pressure (PA-Diastolic Pressure): these are used to derive the pulmonary artery-mean pressure (PA-Mean Pressure)
- Central Venous Pressure (CVP)
- Pulmonary Capillary Wedge Pressure (PCWP)
Swan-Ganz Catheter-Derived Data and Mean Arterial Pressure are Subsequently Utilized to Calculate Hemodynamic Parameters (see Hemodynamics)
- Systemic Vascular Resistance (SVR)
- Pulmonary Vascular Resistance (PVR)

Swan-Ganz Catheter Structure

Catheter and Lumens: PA catheter is an approximate 110 cm radiopaque polyvinylchloride catheter with 2-3 internal lumens
- The distal lumen terminates at the tip of the catheter (Distal Port)
- The proximal lumen terminates at about 30 cm from the tip (Proximal Port)
- An optional third lumen terminates at about 20-30 cm from the tip
Thermistor: PA catheter has a thermistor device approximately 3-5 cm from the tip
- Thermistor measures temperature and allows calculation of cardiac output (by thermodilution technique) and sometimes RV ejection fraction
Balloon: 1.5 inflatable balloon is located near the tip of the catheter
- Balloon guides passage and occludes the pulmonary capillary when catheter is “wedged”

Circulatory Anatomy and Pressure Waveforms from the Swan-Ganz Catheter

Normal Pressure Values

Right Atrial Pressure (RA)/Central Venous Pressure (CVP): 0-8 mm Hg
Right Ventricular Pressure (RV): 15-30 mm Hg/ 0-8 mm Hg
Pulmonary Artery Systolic Pressure (PA-Systolic): 15-30 mm Hg
Pulmonary Artery Diastolic Pressure (PA-Diastolic): 4-12 mm Hg
Pulmonary Artery Mean Pressure (PA-Mean): 9-16 mm Hg
Pulmonary Capillary Wedge Pressure (PCWP): 12 mm Hg
- By Convention, the Pulmonary Capillary Wedge Pressure (PCWP) is Measured at End-Expiration
  - For a Patient Not on the Ventilator, End-Expiration Corresponds to the Highest Point in the Respiratory Cycle (Since Intrathoracic Pressure Decreases During Inspiration While Spontaneously Ventilating)
  - For a Patient on a Positive-Pressure Ventilator (“Vent = Valley”), End-Expiration Corresponds to the Lowest Point in the Respiratory Cycle (Since Intrathoracic Pressure Increases During Inspiration on While on Positive-Pressure Ventilation)
- Note: the Pulmonary Capillary Wedge Pressure (PCWP) is Always Less than the PA-Mean Pressure and is Usually Less than the PA-Diastolic Pressure (Unless Large “v” Waves are Present, Due to Mitral Regurgitation, etc)

Pressure Transduction with the Swan-Ganz Catheter

Lumens of PA Catheter: connected to pressure transducers, which provide continuous pressure tracings of RA pressure and PA pressure
Balloon Inflation (“wedging the catheter”): causes migration of catheter tip into a pulmonary capillary -> PA pressure waveform changes to the Pulmonary Capillary Wedge Pressure (PCWP) waveform

Measurement of Cardiac Output (CO) with the Swan-Ganz Catheter

Thermodilution Method

Technique: utilizes thermistor on end of Swan-Ganz catheter to measure clearance of cold, injected saline (clearance is proportional to the blood flow rate) -> thermodilution method (based on principles developed by Fick in the late Nineteenth Century) utilizes the temperature change after injection as a function of CO
- When the CO is high, the injectate is rapidly dispersed and the area under the curve is small -> therefore, area under the thermodilution curve is inversely related to the CO value
Variability: variability in CO calculations by thermodilution is approximately 10% (thus, changes in CO should generally be on the order of 15% to be regarded as valid)
Falsely Decreased CO
- Tricuspid Regurgitation (TR) (see Tricuspid Regurgitation): local “recirculation” of injectate -> mimics slow injectate clearance
- Pulmonic Regurgitation (see Pulmonic Regurgitation): same as for TR
- Erroneously High Injectate Volume
Falsely Increased CO
- Intracardiac Shunt (in Either Direction) (see Intracardiac and Extracardiac Shunt): alters curve and makes CO calculation less accurate
- Low Cardiac Output State: injectate can disperse into the surrounding tissue, mimics rapid injectate clearance
- Erroneously Low Injectate Volume
Early Recirculation on Thermodilution Curve: suggests presence of L->R intracardiac shunt
“Continuous” Cardiac Output Measurement: PA catheters with capability to measure CO “continuously” (actually averages the CO over a few minute window) are commercially available

Fick Method

Technique: utilizes arterial-venous (A-V O2) difference
- Fick Cardiac Output: Fick CO = O2 Consumption/(10 x A-V O2 Diff)
  - O2 Consumption (Estimated) Can Be Obtained from a Nomogram Which Utilizes Age, Sex, Height, and Weight
  - O2 Consumption Can Also Be Determined Using Breath Analysis
Method: based on the concept of the extraction ratio
- Therefore, changes in peripheral extraction may falsely be interpreted as changes in the CO

Adverse Effects/Complications of Swan-Ganz Catheterization

Complications Related to Placement of the Cordis/Introducer (see Central Venous Catheter)

Air Embolism (see Air Embolism)
Arteriovenous Fistula
Central Venous Catheter-Associated Bloodstream Infection (CLABSI) (see Central Venous Catheter)
- Prevention
  - Avoid Long Periods of Swan-Ganz Catheter Placement
Local Hematoma
- Mechanism
  - Coagulopathy (see Coagulopathy)
  - Inadvertent Arterial Puncture
Local Nerve Injury
Pneumothorax (see Pneumothorax)
Venous Thrombosis
- Clinical
  - Internal Jugular Vein Deep Venous Thrombosis (DVT) (see Internal Jugular Vein Thrombosis)

Complications Related to Swan-Ganz Catheter Itself

Air Embolism (see Air Embolism): due to balloon rupture
- Prevention
  - Avoid Balloon Overinflation
Arrhythmia
- Mechanisms
  - Catheter Irritation of Myocardium
- Clinical
  - Atrial Fibrillation (AF) (see Atrial Fibrillation)
  - Ventricular Fibrillation (VF) (see Ventricular Fibrillation)
  - Ventricular Tachycardia (VT) (see Ventricular Tachycardia)
Catheter Knotting in Ventricle
- Prevention
  - Close Attention to the Length of Insertion While Floating (Inserting) the Swan-Ganz Catheter
Endocardial/Valve Damage
- Mechanisms
  - Inadvertent Withdrawal of Swan-Ganz Catheter with the Balloon Inflated
- Prevention
  - Withdrawal of Swan-Ganz Catheter with the Balloon Deflated
Infection
- Clinical
  - Endocarditis (see Endocarditis)
  - Central Venous Catheter-Associated Bloodstream Infection (CLABSI) (see Central Venous Catheter)
- Prevention
  - Avoid Long Periods of Swan-Ganz Catheter Placement
Pulmonary Artery Rupture (see Pulmonary Artery Rupture)
- Mechanism
  - Balloon Overinflation (Particularly within a Pulmonary Artery Branch Which is Smaller than the Balloon)
- Prevention
  - Close Observation of Ballon Inflation with Exactly 1.5 ml of Air and Measurement of the Pulmonary Capillary Wedge Pressure Waveform at That Volume
    - Most Swan-Ganz Catheters Come with a Syringe Which Has a Built-In “Lock” Which Disallows Injection of >1.5 mL of Air
Pulmonary Infarction (see Pulmonary Infarction)
- Mechanism
  - Prolonged Balloon Inflation
  - Inadvertent Distal Migration of Swan-Ganz Catheter
- Prevention
  - Deflate the Balloon After Wedging
  - Evacuate Air from the Syringe and Close Valve After Measuring the Pulmonary Capillary Wedge Pressure (to Prevent Inadvertent Balloon Inflation)

References

Indications

Cardiac Surgery

Use of pulmonary artery catheter in coronary artery bypass graft. Costs and long-term outcomes. PLoS One. 2015 Feb 17;10(2):e0117610. doi: 10.1371/journal.pone.0117610 [MEDLINE]
Prognostic implications of pulmonary artery catheter monitoring in patients with cardiogenic shock: A systematic review and meta-analysis of observational studies. J Crit Care. 2022 Mar 25;69:154024. doi: 10.1016/j.jcrc.2022.154024 [MEDLINE]

General

Inaccuracy of cardiac output by thermodilution during acute tricuspid regurgitation. Ann Thorac Surg 1992; 53:706-708 [MEDLINE]
The thermodilution method for the clinical assessment of cardiac output. Intensive Care Med 1995; 21:691-697 [MEDLINE]
The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators. JAMA 1996; 276:889–897 [MEDLINE]
Magder S. Cardiac output. In: Tobin MS, ed. Principles and practice of intensive care monitoring. New York: McGraw-Hill, 1998; 797-810
A randomised, controlled trial of the pulmonary artery catheter in critically ill patients. Intensive Care Med 2002; 28:256–264 [MEDLINE]
Predicting fluid responsiveness in ICU patients: A critical analysis of the evidence. Chest 2002; 121:2000–2008 [MEDLINE]
French Pulmonary Artery Catheter Study Group: Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: A randomized controlled trial. JAMA 2003; 290:2713–2720 [MEDLINE]
Impact of the pulmonary artery catheter in critically ill patients: Meta-analysis of randomized clinical trials. JAMA 2005; 294:1664–1670 [MEDLINE]
PAC-Man study collaboration: Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): A randomised controlled trial. Lancet 2005; 366:472–477 [MEDLINE]
Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med 2006; 354:2213–2224 [MEDLINE]
Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008; 134:172–178 [MEDLINE]
Fluid therapy in resuscitated sepsis: Less is more. Chest 2008; 133:252–263 [MEDLINE]
Functional hemodynamic monitoring and dynamic indices of fluid responsiveness. Minerva Anestesiol 2008; 74:123–135 [MEDLINE]
A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg 2011; 112:1392–1402 [MEDLINE]
Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013 Feb;41(2):580-637. doi: 10.1097/CCM.0b013e31827e83af [MEDLINE]
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017 Jan 18. doi: 10.1007/s00134-017-4683-6 [MEDLINE]