Are swans going "out of style?"

[TemperStripe]

Just heard from a coworker who returned from a conference that there are a bunch of new, really cool, much less invasive way to measure cardiac output and such, and that we are going to be swanning people less and less in the very near future. Anyone have any experience with any of these? Are you actually seeing fewer swans?

[IABP4U]

I'd say, yes, swans have gone out of style. However, you'd probably find the majority of them used in management of patients after cardiac surgery. What always amuses me is the number of times I have called a surgeon about bad hemodynamics only to get a response like, "I don't care. Why are you calling me about that?" Alot of research has shown questionable patient outcomes with having a swan vs not having a swan. In my personal experience, I'm convinced that there are many doctors/nurses who misinterpret the numbers obtained from a swan. So is the issue the actual piece of plastic sitting in the pulmonary artery or the provider making poor decisions based off the numbers? Food for thought....

[armyicurn]

We just started with flowtrac and I really like it. Real time readings. Less messing around with a PA cath and pushing injectate to get CO numbers. On top of all this, I do not get paid enough and I have a lot of charting to do. It is time to put less invasive lines in people!

[murphyle, BSN, RN]

I'm in a cardiovascular surgical ICU, so every post-op heart comes back with a Swan. We have rather a love/hate relationship with them; they're great for accurate hemodynamics, but as long as the Swan stays in, the patient has to stay in bed, which makes us look bad on early mobility goal measures. Hence, we're seeing a few of our docs and midlevels start pushing for Vigileo FloTrac on patients whom they want mobilized but still want hemodynamic monitoring. Therein lies the rub.

My issue with FloTrac, and by extension most of the minimally invasive devices (whether they run off a radial A-line or a bioimpedance method) has to do with the accuracy of the system under one of the reps' biggest selling points - namely that such systems claim to provide hemodynamic profiling that doesn't require the patient to be vented and bedbound. For an intubated, vented, bedbound patient on a pile of drips (i.e. your average MICU player), Swan and FloTrac are probably going to come up with pretty similar numbers, and FloTrac might well be the better choice. However, once your patent is extubated and starting to get mobile, the FloTrac becomes less and less reliable, to the point where it eventually starts giving you voodoo numbers. If you have a patient who still needs hemodynamic profiling at that point (worried about low CO/CI r/t hx systolic failure or hx cardiogenic shock, need to titrate inotropes, whatever), the machine starts turning from a friend into a frenemy. FloTrac's accuracy also suffers if your patient is arrhythmic for whatever reason (A-fib, higher order AV blocks, other sinus and supraventricular arrhythmias, etc). As a result, I've seen nurses, midlevels and physicians all trying to manage patients - and erring badly - as a result of inaccurate FloTrac data.

In a case of serendipity, I had an extensive discussion with our local Edwards Lifesciences rep yesterday about just this issue. According to her, there's a next generation system coming out Real Soon Now that aims to address all those issues and more. Personally, I won't be holding my breath.

[CVmursenary]

We get patients into the chair with a swan.

[murphyle, BSN, RN]

You do? Interesting. Policy here is that any Swanned patient has to stay on SBR, due to concerns about accidental migration of the catheter (either RV whip or PA occlusion).

[meandragonbrett]

Our PA Caths get OOBTC as well!

[Esme12, ASN, BSN, RN]

I get swanned patients up as well....have for YEARS.....you just have to be careful. Sounds like there was an issue at your facility

[chudder]

Swans are definitely on the way out. We only see them in hearts, and plenty of places are doing hearts without swans these days, too. The evidence for their use just isn't there.

I would LOVE to get my hands on one of these

!

Most of the non-invasive options have one limitation or another. Esophageal doppler is great but not for conscious patients and it only looks at flow in the descending aorta. SVV, SPV etc is, AFAIK, only really validated in patients who are not breathing spontaneously.

Here is a fantastic review article on some current noninvasive monitoring techniques, written by Dr. Marik. His 2008 systematic review of the utility of CVP as a guide for fluid resuscitation is a very good read.

[ICUPrincessNurse]

Everyone of our hearts gets a swan and they all come out POD 1 unless we're having problems. We'll swan our MICU to look at fluid needs, LV function and PA pressures. Our SI patients RARELY get them unless they've just gone into total collapse and even then, it's basically never. I put a swan in a SI patient ONCE...and it wasn't so much an SI patient as it was a LifeGift patient and my options were "float a swan or go to cath lab". I chose to float a swan and stay on the unit with my not quite so stable donor. I wasn't sure my trauma guys actually knew how to float the thing!!!

For most patients, MI, SI, neuro we use a vigileo to look at CO or a presept catheter to look at ScVO2. But sometimes you just need a bigger, more complete picture...then the swan comes out to play.