I feel like I had an odd experience working in an ICU that reg used PA catheters. . I was always gathering Ficks and CardiacOutputs #s. At this facility, nurses were not allowed to wedge a patient (unless under direct MD supervision and only if that MD was a specialist with permission to do wedges themselves). Nurses also reg assisted these MDs with inserting PA caths at the bedside in the ICU.
From what I have read on this site, nurses USED to work with PA caths more often. Why did they get phased out in so many places? Personally, I like them for the super sick heart patients. Could gather some very useful information early on with the labs + there's continuous monitoring of the patients PA pressures, which would reflect responses to treatments or let us know sooner vs later that the patient was not doing well. (Note: we had A LOT of pulm htn patients on remodulin, and others with very sick hearts)
What are your experiences in working with Swanz and how do you feel about them?
The old Edwards CCO monitor didn't have all the (useless) bells and whistles for SVV/PPV and CCO from the arterial line like the Hemosphere does. That seems to be what the company wants to sell and the PA catheter based cardiac indices capabilities are secondary. We only switched to the Hemosphere because they stopped servicing the old one and we also said 'no thanks' to anything other than the PA catheter capabilities (CCO/SvO2 etc.) The CCO/CI capabilities are plenty accurate enough and you can display new measurements every 20 seconds to get a very good idea of any variability. The old Edwards had a 'stat box' display that would give CO measurements about every 75 seconds, so in that sense the new ones are better.
The rate of pulmonary artery rupture with each balloon inflation is 0.2%, or about 1 in 500. Half of those patients, even when taken emergently to the OR, will die. So that's one death for every 1000 balloon inflations. That may not sound that bad, but consider a medium sized OHS program might do 500 cases per year, if wedge pressures are obtained on these patients 4 times during their recovery then that will kill 2 of them per year. For a not particularly useful number.
I'd be interested in the source for that number. Seems crazy high. Are you sure that is balloon inflations or actual catheter placement? It would make more sense if the risk of arterial rupture is 1/500 for each individual inflation. If it were 2 ruptures per 1000 inflations, we would have abandoned wedge pressures long before we did I personally would have seen at least one or two in the course of my career and I have never seen one personally. There was one in my hospital many years ago that I'm aware of but that's it.
@MunoRN It never gets old reading your content. I truly appreciate your educational posts. This all makes sense, my facility uses manual thermodilution with PA catheters for open-heart patients. At my old hospital PA catheters were rare, mostly for PAH, but they did use Flo-Trac for lots of septic patients. Since moving to a facility that is a little behind my old one in terms of equipment, I can actually see that there are benefits to using manual methods, and all of our cardiac surgery patients have Swans for a day or two post-op. Plus you have to really understand your numbers, you don't have a flo-trac machine yelling at you when your CO or CI steps outside of parameters for a moment. I'm just starting to get into training for our open-heart recovery patients and learning more about how we actually use these numbers, so it's cool to come read these threads.
@MunoRN It never gets old reading your content. I truly appreciate your educational posts. This all makes sense, my facility uses manual thermodilution with PA catheters for open-heart patients. At my old hospital PA catheters were rare, mostly for PAH, but they did use Flo-Trac for lots of septic patients. Since moving to a facility that is a little behind my old one in terms of equipment, I can actually see that there are benefits to using manual methods, and all of our cardiac surgery patients have Swans for a day or two post-op. Plus you have to really understand your numbers, you don't have a flo-trac machine yelling at you when your CO or CI steps outside of parameters for a moment. I'm just starting to get into training for our open-heart recovery patients and learning more about how we actually use these numbers, so it's cool to come read these threads.
The 'cutting edge' of critical care lately has been that "less is more". The most common example is that it's we too often have too much information, and end up making clinical decisions that actually do more harm than good.
This is of course bad news for corporations that make all their money off of selling increasingly complex, yet increasingly clinically meaningless, monitoring systems.
I find that facilities and organizations that are more susceptible to aggressive marketing are clearly more likely to adopt these systems, where organizations that have practice groups (MDs, outcome focused CNS's, etc) that have the upper hand are far less likely to fall for these marketing ploys.
At the bedside though it gets pretty simple. Lets say I've got a post-op open heart who has a low CI and a HR of 55. Some epicardial lead pacemaker placements are better than others, and it's possible that pacing at 70 or 80 bpm will increase my CI, although it's also possible it may make it worse. They only way to find out is to pace the patient and check a CI. With a manual thermodilution, I can start pacing and check a CI in a minute or two and find out. With a continuous CI I can start pacing and wait 15 minutes to find out. It's possible that the CI reflects the change to pacing prior to 15 minutes but the Edwards monitor isn't going to tell me that. So then clearly there's no advantage to the Edwards system.
The 'cutting edge' of critical care lately has been that "less is more". The most common example is that it's we too often have too much information, and end up making clinical decisions that actually do more harm than good.
This is of course bad news for corporations that make all their money off of selling increasingly complex, yet increasingly clinically meaningless, monitoring systems.
I find that facilities and organizations that are more susceptible to aggressive marketing are clearly more likely to adopt these systems, where organizations that have practice groups (MDs, outcome focused CNS's, etc) that have the upper hand are far less likely to fall for these marketing ploys.
At the bedside though it gets pretty simple. Lets say I've got a post-op open heart who has a low CI and a HR of 55. Some epicardial lead pacemaker placements are better than others, and it's possible that pacing at 70 or 80 bpm will increase my CI, although it's also possible it may make it worse. They only way to find out is to pace the patient and check a CI. With a manual thermodilution, I can start pacing and check a CI in a minute or two and find out. With a continuous CI I can start pacing and wait 15 minutes to find out. It's possible that the CI reflects the change to pacing prior to 15 minutes but the Edwards monitor isn't going to tell me that. So then clearly there's no advantage to the Edwards system.
Certainly this makes a lot of sense. I sometimes think about how I became a nurse at a time when we have all this crazy monitoring equipment and wonder if I'd be good enough if I had to do these things for myself manually. I learned about the basics in my critical care training but then never had to use them, especially since I worked for a place that had all the bells and whistles. But I want to be an amazing critical care nurse that can actually do the calculations and have a deep understanding of it! Thanks for always offering your perspective!
We use swans all the time in my SICU. Not so much for routine open hearts, unless they are known low EFs. More for cardiogenic shock, cardiac support devices, CTEPH, liver transplants.
Well, I'm old school. Over 40 years in ICU and still working. We had SG caths a lot. I never had or seen a balloon rupture. Thank God. Yes, there was a lot of literature that terminated the cath as a frequent monitoring device in the ICU. They are also a high risk for infection. However, I do think that they are useful. As mentioned earlier, the flotrack only measures the art line with algorithms. We do see them from time to time. I personally like them.
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Tegridy
583 Posts
I am on a cardiac anesthesia rotation and saw probably the second one since I started residency. Only certain ct surgeons even use them anymore