swan lines

This is straight out of my med/surg text about swan-ganz catheters:

"The pulmonary artery (PA) catheter is a flow directed, balloon tipped catheter first used the early 1970's. The PA catheter is often called a swan-ganz catheter after the physicians who developed it. The PA catheter is used to evaluate left ventricular and overall cardiac function. The PA catheter is inserted into a central vein, usually the internal jugular or subclavian vein, and threaded into the right atrium. A small balloon at the tip of the catheter allows the catheter to be drawn into the right ventricle and from there into the pulmonary artery. The inflated ballon carries the catheter forward until the balloon wedges in a small branch of pulmonary vasculatrue. Once in place, the balloon is deflated, and multiple lumens of the catheter allow measurement of pressures in the right atrium, pulmonary artery, and left ventricle. The normal PA pressure is around 25/10mmHg; normal mean pulmonary artery pressure is about 15mmHg. Pulmonary artery pressure is increased in left sided heart faliure. Inflation of the balloon effectively blocks pressure from behind the balloon and allows measurement of presures generated by the left ventricle. This is known as pulmonary artery wedge pressure (PAWP or PWP) and is used to assess left ventricular function. The normal pulmonary artery wedge pressure is 8-12mmHg. PAWP is increased in left ventricular failure and pericardial tamponade, and decreased in hypovolemia. Cardiac output can also be measured with the PA catheter using a technique called thermodilution. Cardiac output and the cardiac index are used to assess the heart's ability to meet the body's oxygen demands. Because body size effects overall cardiac output, the cardiac index is a more precise measure of output per square meter of body surface area. The normal cardiac index is 2.8-4.2 L/min/m2." (Lemone & Burke, 2004).

I don't have any personal experience with the catheters, I am still a student, but I see them very frequently at the hospital I work at, they are very common. As for why your grandmothers PA ruptured I don't think I am allowed to answer that on here, but if you read the text above I think you may have found the answer.

We check placement on the xray when the patient returns from the OR. The swan also has little markings on it that tell you how far in the swan is. However, everyones anatomy is different as well, some people also have more friable vessels that are more prone to rupture. We always monitor the pa waveform up on the monitor so we can determine if the swan is in a "wedged" position. After each purposeful wedge, we capture the swan coming out of wedge on paper, which we post for documentation. We usually do this Q4 hours, more if necessary or less if the patient is doing well...On occassion, the swan can spontaneously wedge which can cause ischemia or rupture of the pulmonary artery (which is one of the reasons the pa waveform is monitored). The pulm. artery can also be ruptured while obtaining a wedge measurement- it is one of the known risks of using/having a swan. Some facilities do not wedge the swan and just use the pad...my facility does use the wedge measurements. Each facility is different in how often they wedge, etc...

Without knowing more about the situation, it is hard to say whether the RN did something "wrong" (either by using a poor wedging technique or by lack of proper monitoring) or whether it just happened- which sometimes it does.

I feel comfortable using a swan, I use them almost daily- that is not to say though, that I am unaware of the risks of having the swan. Like anything, I think that the more you do something, the more comfortable you are doing it.

I am sorry about your grandmother...I hope that she is doing okay- a ruptured pulmonary artery can be very serious.

do u feel comfortable using swan lines? what is ur hospitals protocol for checking proper placement? reason: grandmothers pulm art was ruptured during a wedge pressure check. i am a nurse, but not ICU knowledgable...just lookin for opinions. THANKS!

Hello,

While I was orienting a new grad to MICU I was going over swan waveforms. In our facility we have to have an order to wedge (our post-op open heart patients do not get wedged) and how often. Well this patient had elevated PA pressures indicating pulmonary htn (mild) other tests confirmed this. The patient was intubated after cardiac arrest on the floor (adm. to the hospital for an MI) and on many pressors and diuretics due to hypotension and ATN. This was the 3rd day that the swan was in and with my new RN I explained this is how you wedge...I never got my wedge waveform with the balloon inflated and lost my PA waveform when I let the syringe deflate. Immediately blood rushed from her ETT and her peak airway pressures on the vent were 70 (previously 18-20) and she once again arrested to v-fib because I just had ruptured her pulm. art.. We did successfully resuscitate her although she did pass a week later. The cxray from that morning showed proper placement of the swan. After I coded the patient I asked "did I do something wrong?" and the response was NO--> sometimes patient's anatomy cannot take the pressure caused when it's inflated repeatedly. This is not to say that in your grandmothers case it was not in the correct position.

Hope this story helps.

LCRN

"sometimes patient's anatomy cannot take the pressure caused when it's inflated repeatedly"

Which is why I'm very uncomfortable with my hospital's policy of wedging every 2 hours! I don't follow the policy for that very reason. I'll wedge every 4 hours and still be uncomfortable but not every 2. I'm not sure the docs are even aware that q2h is the policy; if I have the chance, I'll ask them how often they want it so I can be covered for not following policy (I've never had one ask for q2h!).

A pulmonary artery rupture is a very rare thing! I've been an ICU nurse for thirteen years and I've never seen that happen. It's just one of those freaky complications that can very rarely occur...not the the nurse did anything wrong. I am very comfortable with Swan Ganz caths. We look at the morning CXR's and the waveforms are always key in knowing whether or not your line is in the proper position. And then sometimes when you inflate the balloon, you feel a little resistance. My advice is don't ever force it.

our surgeons rarely order wedging.

Pa rupture is very rare. Beside, the info already stated here, one caveat for wedging was to avoid it in the old and cold pts. The thought being that old and cold vessels are more fragile.

Pulmonary arter ruputure is rare but deadly. Usually it it not due to any fault. However, that being said, I will not wedge without an order. If a Swan is placed I always ask the cardiologist/pulmonologist if we may wedge for the parameters and if they don't write the order I write a verbal. If there is no order, I use the PAD for the wedge and document this. I would not want to be the nurse who wedged the swan without an order and had th PA rupture.

Doris

Pulmonary artery rupture is not always deadly. As I wrote before I had a patient who survived the rupture but complications of her disease process caused her death.

LCRN

There are some good guidelines about wedging swan ganz catheters. Don´t inflate over 15 seconds or over 4 respirations, don´t inflate with over 1 cc of air. Yes, pad correlates to pcwp in some patients but not many that we see in ICUs. I worked in a military hospital when I saw my first pulmonary artery rupture. They actually changed the swan ganz every 3 days!

The doctor should write orders for checking wedge but in a unit that uses swans a lot, the nurse will want to use it to gather information so she just needs to be really savvy. PACEP.org is a great site and an effort to give thorough education on the mangement of swan ganz catheters.

Having moved on to home health, as once worked icu, I thought more hospitals were pulling away from the swan and just using art line readings because of the risks involved with the swan and that the readings were not as valid as once thought?

Sorry LCRN. I did not mean to imply PA rupture was ALWAYS deadly, nor that you did anything wrong by wedging. I only meant that PA rupture is the most dangerous complication (70% mortality rate on a retrospective study from Cedars-Sinai Medical center). That being said, i believe that as long as a nurse has specific orders to wedge, it greatly reduces her liability if said PA rupture happens. Sorry for the mis-communication.

Doris