Swan-Ganz Usage

  1. In my 2 years of ICU, I have very, very little experience with Swans. My old hospital rarely used them except for in CVICU for post-cardiac surgery. I'm trying to find out if this was abnormal or not. They say Swans are a dying thing due to infection rates, risk for improper placement/dislodgement, etc. When I studied for my CCRN, I felt like Swan parameters were drilled into the material as being useful tools for critically ill patients, but none of the units I worked in (despite both being combined CCU units) utilized them. (In MICU we'd be lucky to have an art line but that's a different story).

    So I'm just wondering: was this abnormal or is this becoming the trend? I am transitioning to a CVICU in another state where I know I will see them (but even when I toured the unit, I only saw a few), and I somewhat feel like I missed out on experience with Swans. I understand the numbers and how they work thanks to the CCRN but textbook is different from the real world, so I just am curious!
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  2. 21 Comments

  3. by   Rose_Queen
    I believe it's becoming a trend, even with cardiac surgery patients. I know that with several of the newer anesthesia providers that have come to my facility recently, they did not routinely place a swan for every cardiac patient. My facility seems to be a bit of a holdout when it comes to that- I'd say about 95% of our cardiac surgery patients do have a swan placed.
  4. by   applewhitern
    My previous hospital used them all the time. The cardiac and pulmonary doctors loved them. I have heard that some places don't use them that often, but this particular hospital I worked at placed them on at least half of our patients. We nurses use to joke that the doctors must get paid a large sum to put one in. Working with them was easy; it was setting them up that was time-consuming. We had doctors that would show up in the middle of night shift, saying set up for a swan. It was irritating because on nights, we operated with a skeleton crew.
  5. by   PresG33
    Use is definitely declining. I think a large part of the studies showing no benefit is confounded by providers misinterpreting the data. There was a large study done in Australia in which 50% of intensivists did poorly on a test about application of PA cath data. As with any device, from a thermometer to a ecg to an Aline, you need to think about the numbers you're getting in the clinical context. A large part of the decline of PA caths is the increase in TEE for big OR cases. However these are rarely left in so it leaves the ICU to manage with less data.
  6. by   SubieRN
    We're a 25-bed, mixed ICU in a community hospital. 5% of our patients end up with Swan lines during their stay; I track our unit statistics, so I just happen to know this. Most of our Swan lines are used for CV surgery/recovery, but we occasionally use them for patients with pulmonary HTN as well. We almost never wedge our Swans.

    Stroke volume monitoring is highly useful for septic shock patients, but we rarely use Swans for sepsis management. I've been talking to a sales rep about piloting non-invasive hemodynamic monitoring on our unit for this patient population, but it's a very hard sell to the finance department.

    I teach a class on hemodynamics and I consider it one of my clinical strengths. I can't imagine recovering a CABG or valve surgery without hemodynamic data, but I agree with PresG33 that many clinicians (nurses and physicians) struggle to meaningfully interpret data from the Swan for effective management of patient care. I see a lot of drip titrations occur without a true understanding of the problem at hand (e.g., titrating up levophed for hypotension when the numbers indicate that hypovolemia is the real issue).
  7. by   offlabel
    Data derived from PA catheters, unless used for a specific purpose such as PHTN don't improve outcomes, introduce another level of risk and are inferior to other indices of volume responsiveness such as PPV and PLR. More numbers doesn't mean effective management.
  8. by   johosa12
    The unit I work on can have anywhere up to 9 cardiac surgery cases/day. I agree with one of the posters above that 95% of them come out from the OR with them in. I would say that the team usually has us pull them within 12 hours of coming out of the OR as well.
  9. by   offlabel
    Quote from johosa12
    The unit I work on can have anywhere up to 9 cardiac surgery cases/day. I agree with one of the posters above that 95% of them come out from the OR with them in. I would say that the team usually has us pull them within 12 hours of coming out of the OR as well.
    This kind of makes the point. There is no problem that a PA catheter will be useful for that will go away within 12 hours of admission to the unit. Begs the question of why they're placing them at all. Every now and then, a patient won't have read the book and throw a curve ball, but to place a PA catheter "just in case" is 20th century medicine.
  10. by   ghillbert
    I don't know that this is true. There are many pathophysiologic changes after cardiac surgery that are ameliorated within 12 hrs postop. My large tertiary center CTICU and our CCU uses
    pa catheters very frequently in our population.
  11. by   offlabel
    Quote from ghillbert
    I don't know that this is true. There are many pathophysiologic changes after cardiac surgery that are ameliorated within 12 hrs postop. My large tertiary center CTICU and our CCU uses
    pa catheters very frequently in our population.
    Sure there are, but at the end of the day, the outcomes are no different without pa catheters in those situations. If a patient only "needs" a pa catheter for 12 hours, he never really needed it.
  12. by   ghillbert
    Well, that's your opinion. Surveys tend to show that a majority of cardiac surgeons continue to use them in certain patients; apparently they disagree.
  13. by   MunoRN
    PA caths feed our thirst for numbers, but even proficient management of those numbers doesn't change patient outcomes in most of the patients we've used PA caths for. Many years ago they were common for severe sepsis, then it was just OHS patients, now they're only considered useful in OHS patients with marked LV dysfunction, otherwise even open hearts don't benefit from them. Wedging the PA cath carries a high risk of complications and death, at my current facility wedging is only allowed on initial placement, even by MDs.
  14. by   PresG33
    The bottom line is that any device, including PA caths, are only reliable and useful if you understand how they work and apply the data appropriately. You need to understand that thermodilution cardiac output is less accurate with tricuspid regurgitation and every pt with a PA catheter has a degree of TR from the simple fact that there is a PA cath passing through the valve. Also, the calculations of SVR and PVR are just that, calculations, with errors that are associated. Anyone who says a pt "always" or "never" needs something is usually wrong. Putting a PA cath in every heart pt is as misguided as putting them in none. My belief is that, in general, relatively simple CABGs do not need one, valves with some comorbitiies do.

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