To Float a Swan

Insertion of a Swan-Ganz catheter (Pulmonary Artery Catheterization)? I not sure if that is within the scope of a CRNA.

Yes. It is very much within the CRNA scope of practice. Done every day, all over the country, by CRNAs, everywhere. Having said that, there are less, and less Swan lines being placed. There are so many new and different technologies out there now that give very similar data, and do so with non-invasive technology. As to the OP, that is a very old term, but I am guessing it has something to do with putting up the wedge balloon during the last portion of placement, and letting the balloon "float" into position.

The greater the indication for a PA catheter, the more difficult they are to place. Anymore they are reserved for severe LV systolic failure and RV failure secondary to severe PHTN generally speaking. Issues with placement include atrial enlargement and dilated RV where the catheter can coil or there is such poor RV out flow, there isn't much to carry the balloon and catheter into the PA. Add to that the ventricular irritation of having a catheter poke and prod a sick RV and the potential for lethal arrhythmias.

Not for the novice at all and should be reserved for those practitioners that regularly care for cardiac CC and CT surgery patients.

FWIW, The VERY experienced CVICU nurses at my work (as in 10 to 20+ years in CV recovering open hearts) are the go-to's when figuring out how to get all of the CVP/Swann's/etc to work/read pressures right.

Of course the lines are already placed but the terminology of this post is familiar/similar with what they use when describing how they maneuver the lines to get them to read correctly when not working properly. Definitely out of my experience bubble.

Digging deep from my past in the CVICU (been awhile since I've assisted in a PA cath insertion) -- floating the swan is when the wedge balloon is inflated as it passes through the right atrium into the PA on insertion (the circulation "floats" it to where it needs to go -- and you can watch the ECG waveform change as it passes through the anatomy-- cool!). It can be tricky on initial insertion and even problems can happen getting a wedge pressure after insertion. Basically, it's very invasive and can set off unpleasant electrical activity in even the most careful and skilled of insertions.

Yes, placing pulmonary artery catheter/swan is within the CRNA scope of practice. Everything to do with anesthesia is within a CRNA scope of practice. I just placed a swan not to long ago.

I am not a CRNA, so I did not know if it was in the scope of practice (no offense intended). I worked in surgery many, many years ago and haven't heard the term "Swan" in a long time. I wasn't sure if that was what the OP was referring to or if Swans were still being used.

Yes, placing pulmonary artery catheter/swan is within the CRNA scope of practice. Everything to do with anesthesia is within a CRNA scope of practice. I just placed a swan not to long ago.

For the sake of the conversation, what was wrong with the patient?

Digging deep from my past in the CVICU (been awhile since I've assisted in a PA cath insertion) -- floating the swan is when the wedge balloon is inflated as it passes through the right atrium into the PA on insertion (the circulation "floats" it to where it needs to go -- and you can watch the ECG waveform change as it passes through the anatomy-- cool!). It can be tricky on initial insertion and even problems can happen getting a wedge pressure after insertion. Basically, it's very invasive and can set off unpleasant electrical activity in even the most careful and skilled of insertions.

Ummm.Ok.No.

It doesn't pass through the right atrium into the PA. It goes from RA to RV then to PA.

ECG waveforms don't change when it passes through. You read the pressure from the tip of the catheter to see determine when you pass from RA, to RV, to PA, to wedge.

It's usually not hard to get a wedge, but you may have to move the catheter in and out a little bit. It migrates, so getting a wedge once doesn't mean it will wedge agin a couple of hours later. Unless you manipulate the catheter a little. Pro tip - Don't wedge and then inflate the balloon. That would be bad.

As far as invasive, I guess it depends on your definition. PA catheters are done in cardiothoracic surgery and cardiac cath lab all the time. The only "unpleasant" electrical activity is a little v-tach when you are in the RV. Just let the catheter settle and wait for the v-tach to stop. Don't grab for the paddles, the patient won't like that.

Ummm.Ok.No.

It doesn't pass through the right atrium into the PA. It goes from RA to RV then to PA.

ECG waveforms don't change when it passes through. You read the pressure from the tip of the catheter to see determine when you pass from RA, to RV, to PA, to wedge.

It's usually not hard to get a wedge, but you may have to move the catheter in and out a little bit. It migrates, so getting a wedge once doesn't mean it will wedge agin a couple of hours later. Unless you manipulate the catheter a little. Pro tip - Don't wedge and then inflate the balloon. That would be bad.

As far as invasive, I guess it depends on your definition. PA catheters are done in cardiothoracic surgery and cardiac cath lab all the time. The only "unpleasant" electrical activity is a little v-tach when you are in the RV. Just let the catheter settle and wait for the v-tach to stop. Don't grab for the paddles, the patient won't like that.

You are totally right. Thanks for paying attention and correcting. I left out some pretty important anatomy... and yes, of course the ECG waveform doesn't change (unless there's ectopy or something) rather it is the pressures that change (yes being read from the tip of cath) as you pass through. I must have not had my coffee yet.

and you're right-- CT and Cath folks do this all the time but our little CVICU got them infrequently enough to make me a little anxious about them. I've seen the v tach happen -- I also saw it resolve when doc pulled back but you better believe I had the paddles in hand.

Anyway, like anything else, comfort level with swans increase the more you use them.

As far as invasive, I guess it depends on your definition. PA catheters are done in cardiothoracic surgery and cardiac cath lab all the time. The only "unpleasant" electrical activity is a little v-tach when you are in the RV. Just let the catheter settle and wait for the v-tach to stop. Don't grab for the paddles, the patient won't like that.

We've cut our use in CT surgery by 90% because the risk outweighs the benefits so often. A "little" v tach in a patient with severe AS can be lethal, even on the OR table.

Late to the party, but I've inserted two swans this week as a student