In the care and management of the 

critically ill patient.

It is important to have available at the patient's 

bedside.

Certain diagnostic information 

about his cardiovascular system over 

the past several years,

since the early 19 sixties,

this has been accomplished primarily through the use 

of central venus pressure catheters.

However,

it has been shown that the central venus 

catheter and central venus 

pressure reflect principally 

volume states.

And this method has had its greatest 

application in hypovolemic shot 

and volume depletion states.

It has also been shown that it does not correlate 

well with left 

ventricular performance and 

left ventricular hemodynamics.

For example,

in the patient with cardiogenic shock,

the primary problem is due 

to decreased contractility of the 

left ventricle which has been damaged by the heart 

attack.

This is reflected 

by an increase in the 

left ventricular and 

diastolic pressure or the so called 

filling pressure of the left ventricle.

And this in turn is transmitted to the 

left atrium.

The left atrial pressure is then 

transmitted to the pulmonary circulation 

where if this becomes sufficiently 

high fluid is forced 

across capillary basement 

membranes.

And pulmonary edema develops 

prior to that the 

pulmonary artery pressure and most 

importantly,

the pulmonary artery occluded pressure 

or so called pulmonary wedge 

pressure increases first,

if the strain is 

sufficient,

right heart failure develops 

and it is only at that point 

that the central venus pressure will become 

abnormally elevated.

Therefore,

it would be impossible if one were 

monitoring only central venus pressure 

to intervene at a sufficiently early 

point to reverse this path of 

physiologic process before 

the central venus pressure 

increased due to right heart failure.

Therefore,

it would be very important and very useful 

in the management of such patients.

If it were possible to know the pulmonary artery 

pressure in such 

individuals,

we can apply this information 

to the critically ill patient.

In order to make decisions regarding volume 

expansion,

the use of diuretics and the use of 

inotropic drugs or the 

use of various combinations of these.

Since we know that the pulmonary 

artery eluded pressure 

is a reflection of and estimate 

of the left atrial pressure,

which is an estimate of the left 

ventricular filling pressure.

We can predict the 

sequence of events of the 

patients,

cardiovascular events and make 

early therapeutic interventions 

if it were possible to know 

these values from the pulmonary 

artery pressure.

In 1972 physicians,

Swan and Gams 

developed and introduced a new type of 

cardiac catheter.

This is a lightweight multiple lumen 

catheter which has at its end,

a small inflatable balloon.

This catheter can be passed at the vet side 

and is positioned in the pulmonary 

artery by inflating the 

balloon.

The catheter is 

wedged by eluding a 

small branch of the pulmonary artery 

and thereby records a 

pulmonary capillary wedge 

pressure,

which is a measure of the left atrial or 

left ventricular and diastolic pressure.

The balloon at the tip of the catheter is then 

deflated and the 

catheter then springs back into the main 

pulmonary artery with the 

catheter in the proper position.

Serial determinations can then be made 

of pulmonary artery pressure,

pulmonary artery oxygen saturation and 

content and serial 

cardiac output determinations made 

by the thermodilution method.

The purpose of this film is to review 

the rationale and use 

of the technique of pulmonary 

artery pressure monitoring and to 

demonstrate the technique of 

insertion and the application of this 

method to the critically ill patient.

This diagrammatic 

graphic of the human torso shows the entry site 

of the catheter from the right 

medium basilic vein.

Other sites may be used.

For example,

the femoral vein,

the subclavian or the external jaguar system.

The nurse takes the patient's blood pressure at the 

bedside and the patient's right arm 

in this instance,

has been draped in,

prepped in usual standard sterile fashion 

and the skin has been infiltrated 

with either one or 2% 

lidocaine.

This is the pulmonary artery catheter and this 

particular one is a seven fringe.

The catheter is filled with Heiny saline 

and the balloon on the tip of the catheter is an 

inflated and check for any 

leaks 

in this instance,

we are infighting with air.

However,

if a right to left shunt is 

suspected,

one should use carbon dioxide.

A small incision is then made over the 

medium basilic vein in the Annabi FASA 

and the medium basilic vein is isolated 

prior to this time,

a transducer has been calibrated 

and zeroed and has been placed at the mid 

thorax level of the patient.

So that accurate pressure 

recordings may be obtained.

This transducer converts the 

hydraulic fluid waveform to an 

electrical signal which is then displayed 

on the oscilloscope,

which is at the patient's bedside.

The area is kept cleansed and sterile.

And the patient is observed under continuous 

electrocardiographic monitoring with periodic 

blood pressure determinations.

The distal portion of the vein is then ligated 

to prevent any oozing.

A small incision is then made in the vein.

And in this instance,

we are using a number 11 blade,

a silk suture has been placed approximately 

and this will be used to secure the catheter in place 

to be honest.

The outside of the catheter is marked 

with black markings and each mark 

represents 10 centimeters.

Therefore,

it is possible to tell precisely how 

far the catheter has been advanced 

inside the body.

From previous measurements,

we know that once the catheter has been inserted 

approximately 40 centimeters,

the tip of the catheter then lies 

within the thorax.

Yeah.

This graphic diagram shows the positions 

of the catheter in the heart.

The catheter enters the heart from the superior vena cava and 

enters the right atrium.

It then crosses the tricuspid valve and enters the right 

ventricle and then is 

advanced across the pulmonic valve by the flow 

of blood into the main pulmonary artery.

It is then advanced to a branch of the pulmonary 

artery and produces a pulmonary 

wedge or occluded pulmonary artery pressure.

The catheter is an advanced from the medium basilic vein.

In this instance to the heart,

the catheter has advanced to the 

intrathoracic position 

and the balloon is inflated.

Commonly,

this procedure is done at the bedside without 

benefit of fluoroscopy or X 

ray.

However,

in this instance,

we are utilizing X ray 

cinematography to demonstrate 

the actual appearance and course of 

the catheter in the body and in the heart,

it is then carried to the right atrium where a 

characteristic waveform is produced,

which has typical A and B 

waves in the 

phasic pressure curve.

Both phasic and mean values are recorded 

and the normal right of pressure is 2 to 

5 millimeters of mercury with a mean of 

approximately 2 to 3 millimeters of mercury.

The catheter is then slowly advanced to the 

right ventricle 

where a characteristic ventricular pressure 

curve is recorded in 

this waveform is usually 

25 over zero millimeters of mercury 

as the catheter is advanced across the pulmonic 

valve to the pulmonary artery.

Again,

a characteristic waveform is produced 

and it should be noted that the diastolic 

pressure does not reach zero.

This localizes the position of the tip of the 

catheter in the pulmonary artery.

The normal pulmonary artery pressure 

is 25/12 to 15.

The mean value is also important 

and is normally 

16 to 18 millimeters of mercury.

The catheter is advanced with the balloon 

inflated and produces 

a characteristic waveform 

which is very similar to that 

scene from the right atrium with characteristic A and B 

waves,

but with a higher pressure reading.

So the pulmonary capillary wedge 

pressure has previously described as a 

very accurate estimate of left 

atrial pressure,

which is a very accurate estimate of the left 

ventricular and diastolic pressure,

which normally is approximately 12 millimeters 

of mercury.

The pulmonary artery wedge pressure and left atrial 

pressure are virtually identical except 

that the pulmonary artery wedge pressure 

is delayed in time.

The balloon on the tip of the catheter is then deflated,

allowing the tip of the catheter to spring back 

to the main pulmonary artery.

This produces a very characteristic change in the wave 

form which can be seen on the monitor,

changing from a capillary wedge pressure to a 

pulmonary artery pressure.

Blood samples can be drawn from the pulmonary artery for 

determinations.

As previously described.

The catheter is then flushed and connected to the 

transducer.

The catheter is then secured in place and the incision 

closed in standard surgical 

fashion.

And in this instance,

we have used 40 silk,

the catheter is then left in the main pulmonary 

artery for subsequent measurements 

of pressure,

cardiac output and 

oxygen saturation and other biochemical 

determinations.

A sterile bandage is then placed over the incision 

and the cat that are secured,

the catheter is then connected to the monitor 

and continuous monitoring of the pressure and electric 

cardiogram are then recorded.

Yes.

At the patient's bedside,

frequent recordings and observations are made of the 

patient's electrocardiographic monitoring 

and the pressure wave form 

and these pressures are recorded.

The intervals and limits are indicated by the 

physician.

Yeah,

it is important to notice the waveform 

on the pulmonary artery and pulmonary artery 

wed pressures.

If the waveform completely disappears,

it suggests that the tip of the catheter 

is occluded or against the wall of a vessel 

and requires repositioning if a 

persistently dampened pressure is 

recorded with the balloon 

deflated.

It suggests that the catheter has migrated 

peripherally and requires repositioning.

These are indications to notify the 

physician in charge with 

the pulmonary artery catheter.

Now,

in the proper position,

it is possible to have available at the patient's 

bedside information 

about serial cardiac output by the 

thermal dilution method,

pulmonary artery pressure and pulmonary artery of clued 

pressure.

And next Venus,

pulmonary artery oxygen saturation and 

content in 

this film.

We have reviewed the rationale and theory 

of pulmonary artery catheterization 

and pressure monitoring and we have 

demonstrated its practical application in the 

care and management of the critically ill patient