Swan-Ganz Usage

Specialties Critical

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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!

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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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.

I'm not interested in surveys as they have nothing to do with 30, 60, 360 day (whatever) morbidity and mortality. Neither should any APRN be. The modifier "certain patients" indicates agreement with all of the points I've made. Routine use of a PA catheter is unwarranted.

Now, a tricuspid repair with a mitral replacement with impaired LV function? Different story. Routine cab or avr getting a PA catheter? Criminal.

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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.

I'd argue that the co-morbidities would need to be more than "some". Remember that "some" co-morbidities go away with a competent repair. Now, if your surgeons are just average....

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Specializes in ICU.

It doesn't matter what I think, it is up to the doctors whether they put one in or not. I hate setting them up; it takes up too much of my time between getting the patient ready, and getting the equipment set up, and having to be sterile. I wish they WOULD stop using them so much! It must be a money-maker for the doc. They will call us up and say set up for a swan, and it seems like the most inopportune moment in time, usually.

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Its rare to see a PA catheter in my unit maybe once a month. And even rarer to get it to wedge. We use the NICOM for our sepsis studies and flow tracs are more utilized with our trauma/surgical unit/patients.

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Specializes in CGRN.

I work in general ICU/CCU and I have seen one Swan in the last year. Definitely just about phased out in my hospital, although we don't do open hearts.

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I'm not interested in surveys as they have nothing to do with 30, 60, 360 day (whatever) morbidity and mortality. Neither should any APRN be. The modifier "certain patients" indicates agreement with all of the points I've made. Routine use of a PA catheter is unwarranted.

Now, a tricuspid repair with a mitral replacement with impaired LV function? Different story. Routine cab or avr getting a PA catheter? Criminal.

Do you mind going into a little more detail about the kinds of situations where you see PA catheters as justified, exactly what kinds of things you're looking for from the readings it provides, and what kinds of clinical decisions said readings would guide?

I understand the basic interpretation of the different swan-ganz values, but I don't really understand what situations justify their usage these days and exactly what you're looking for with them that you can't get from other tests and methods. For example, I get that patients with problems in multiple valves can be pretty complicated to manage after cardiac surgery; but what kinds of decisions would a swan guide more easily than some combination of floTrac, CVP, PLR, echocardiography, etc?

thanks in advance

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Do you mind going into a little more detail about the kinds of situations where you see PA catheters as justified, exactly what kinds of things you're looking for from the readings it provides, and what kinds of clinical decisions said readings would guide?

I understand the basic interpretation of the different swan-ganz values, but I don't really understand what situations justify their usage these days and exactly what you're looking for with them that you can't get from other tests and methods. For example, I get that patients with problems in multiple valves can be pretty complicated to manage after cardiac surgery; but what kinds of decisions would a swan guide more easily than some combination of floTrac, CVP, PLR, echocardiography, etc?

thanks in advance

Generally speaking, where I am anyway, PA catheters are most often used for 2 reasons. Bad pulmonary hypertension and in those patients in whom severe acute LV failure is likely after cardiac surgery. Ours give CCO and SvO2 as well. But even those times, unless the patient's PHTN is being actively managed (NO, for example) it is up for grabs whether outcomes are any different. Different people put them to use in different ways, some good and some not.

PA catheters are only as good as the folks putting the data to use and only in some situations. They are not indicators of volume responsiveness. Out of all the things you noted above, the gold standard is TTE/TEE followed by PPV/SVV, then PLR, IMO.

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Specializes in CTICU.
I'm not interested in surveys as they have nothing to do with 30, 60, 360 day (whatever) morbidity and mortality. Neither should any APRN be. The modifier "certain patients" indicates agreement with all of the points I've made. Routine use of a PA catheter is unwarranted.

Now, a tricuspid repair with a mitral replacement with impaired LV function? Different story. Routine cab or avr getting a PA catheter? Criminal.

Nice hyperbole.

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They are rarely used anymore in our CTICU.

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