Swan-Ganz Use

[TexRN08]

I'm a brand new nurse and the hospital I did my clinicals in did not use these. I don't want to say they NEVER did, but the general consensus at that hospital was that current research does not support their use, therefore they were pretty much phased out (we didn't even keep the supplies for them in our equipment room). However the hospital I am at now uses them all the time, and many of the nurses are not happy about how often one of the docs here will just put them in everybody (including non-cardiac patients). So my question is how often (if ever) are they used at your facility and what sort guidelines are in place for their use? The docs at my old hospital seemed to do just fine without them, so it confuses me why the doc here is so into using them with all of the risks they pose. Also, in your personal opinions (especially those of you have been nurses for a long time and greater amount of experience using them) do you think that the benefits outweigh the risks??

[flo136]

We use Swans here all the time in Adelaide, Australia.

The docs use them mainly for number-crunching. Seeing the trend in the numbers: SVRI not so much. More CI/CO.

I don't think they are good. I have worked in the UK and larger Aussie cities that have managed on other clinical signs such as urine output and CVP for management.

A lot of our Swans don't wedge. They let junior nurses use them which I find scary.

I find PICCO is not considered an alternative either. It's all numbers here, but looking at the patient is better!

[guest239592]

Here's my take, as many of the posters have previously said, depends on your facility, Docs, and diagnosis. I work at the largest hospital in the state with the largest CVICU in the state taking the most critically sick patients. Since we put a Swan in every CV-Surgical pt, the nurses are experts at managing the system, and interpreting the numbers IN CONJUNCTION to other signs and clinical symptoms. Our Docs are good about not just treating numbers and if they think it's inaccurate they'll have us pull them. We pull swans out of pt's as soon as we can. We also have overflow on our floor if surgical census is down, which I would say about 98% of those pt's don't have Swans and don't need them. CV pt's esp the sick ones in my opinion need them. As a previous poster stated, if interpreted correctly you can start treatment immediately for the correct problem and not just guess. For ex: A fluid challenge for low BPs, then let's try a vasopressor when the real problem all along is a weak pump needing inotropes. Now you just volume overload the pt more who already has a weak heart. The new PICCO and FloTracs are a nice alternative, BUT you have to have a great arterial waveform with an obvious dicrotic notch for it to be accurate (Which as you know isn't always the case). Bottom line, the reasons most studies don't show a difference in M/M is because too many docs without extensive experience with swans will overtreat pt's based on numbers alone. If you look at the whole picture they can be very useful.

[StayLost, BSN, RN]

I was one of those who learned from academia that "Swans are bad", and our university teaching hospital didn't use them b/c they are unsafe & inaccurate.

Now as a nurse in almost every patient on my unit has a swan. There are a lot more reasons to use one than just CO! We use them to monitor patient on nitric oxide, measure efficacy of the IABP, and really bringing pt's with end-stage heart disease back from the [almost] dead. Diagnosing primary vs secondary pulmonary HTN!

[Zombi RN]

You could check out www.pacep.org for more education on the PA Cath.

PACEP is great. A senior nurse I work with told me about it and I LOVE IT.

The facility I work at is in the top 10 in the nation's LVAD programs, for reference. We put a swan in almost every CV surgery patient. Many others have already talked about why they're used where they work, so I'll just put in another voice saying "yes, we use them all the time where I work".

[CCRNDiva, BSN, RN]

It depends upon physician preference at my facility. We used to utilize them more frequently in the past but now they are rarely used on the ICU side. We often noticed that surgeons and physicians were not using the info gleaned from the Swann. Our CT surgeons, however, continue to use them on their patients but a couple of the surgeons are getting away from their routine use. We usually pull them within 24 hrs.

[CRIMSON]

Always had post CABG, usually pulled by 3am if patient stable.

[umcRN, BSN, RN]

I am a new pediatric cardiac ICU nurse. I have never seen PA catheters used and it's still pretty rare in the peds world (at least at my hosp). However I actually had an 18mo old with a PA catheter the last three shifts and it was pretty interesting. (I'm not sure if this is the same as the Swan but I think it's a similar concept?)

She was "late" diagnosed with pulmonary hypertension, secondary to a large ASD (hence the late diagnosis, her asd was never picked up). She had bad pulm hypertension on arrival to the unit but went to cath and it was determined to be reactive so to optimize her chances they made the decision to close her ASD (with a fenestration/pop off valve left if needed). When she came back from OR initially she was pretty solid...MUCH more stable than they anticipated, we were anticipating her to go on ECMO. A few minutes into her arrival though her PA pressures began rising along with her HR. They became suprasystemic and not reactive to sedation or paralysis. Nitric Oxide was quickly initiated and within SECONDS her PA pressures dropped drastically to 1/3 systemic, it was amazing to watch. She never had a true "pulmonary hypertension crisis" because we were able to "see" her pressures rise and fix the problem before systemic effects were seen. As someone who has had quite a bit of experience with pulmonary hypertension in NICU babies (worked two years in the nicu at this hosp and we have a very large pulm hypertension program) it amazed me to be able to see what the process looks like inside before the crisis occurs that we usually see - clamping down, difficult to ventilate, no sats, no HR etc. Really helped me to understand a little bit more about the processes behind pulmonary hypertension. A necessity for every patient? probably not but a great learning opportunity to take advantage of from those patients that do have them.

[Biffbradford]

Is the PA catheter used by Habit Based Medicine or Evidence Based?

Because we've always done it like this no longer holds up in Evidence Based Practice.

http://anestit.unipa.it/mirror/asa2/practice/pulm/pulm_artery.html

Any invasive procedure will now face scutiny and CMS will be taken seriously. These procedures are also no longer the cash cows they once were for physicians. We used to have docs stumbling over themselves for procedures.

We used to put in an Arterial Line into every ventilator patient and now we rarely do an ABG unless there are multiple conditions that exist which warrant one.

That paper was written in 1993. How many years ago was that?

If you were born when that was written, you'd be starting college soon.

[eCCU]

I'm a brand new nurse and the hospital I did my clinicals in did not use these. I don't want to say they NEVER did, but the general consensus at that hospital was that current research does not support their use, therefore they were pretty much phased out (we didn't even keep the supplies for them in our equipment room). However the hospital I am at now uses them all the time, and many of the nurses are not happy about how often one of the docs here will just put them in everybody (including non-cardiac patients). So my question is how often (if ever) are they used at your facility and what sort guidelines are in place for their use? The docs at my old hospital seemed to do just fine without them, so it confuses me why the doc here is so into using them with all of the risks they pose. Also, in your personal opinions (especially those of you have been nurses for a long time and greater amount of experience using them) do you think that the benefits outweigh the risks??

Well, my experience PA catheters are great for post thoracic surgery, CV, sepsis and Cardiogenic shock. The line usually blurrs after that! Physicians have to consider if the benefit outweighs the risk. Plus after about mostly 3 days those suckers stop wedging! CV removes them as soon as the pt is stable from OR. I am glad my cardiologists and pulmunologists donot push it with the blurred line! Any way to familiarize yourself with the use go to pacep.org and the risks CMS will definitely make you see the light! good luck :redbeathe

[AmberJoy36]

We only use them for post-op cardiothoracic surgical patients. Maybe if someone's seriously septic we might put one in. But we have orders NOT to wedge! Basically, with the heart patients, we use the swans to decide on a neo gtt vs dopa/nitro combo vs only fluids. It's a matter of preference for the MDs.