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Episode 168

Episode 168: Pulmonary Artery Catheters: Hemodynamics And Case Management With Nicole Kupchik

May 8, 2024

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In this exclusive Live Podcast Event, we dive into pulmonary artery catheters (PACs), a critical tool in the management of critically ill patients. Often regarded as a cornerstone in the monitoring of hemodynamics, PACs provide invaluable insights into the heart’s function and the pulmonary circulation’s state.

We will unpack the principles behind how they measure key physiological parameters such as pulmonary artery pressure, cardiac output, and mixed venous oxygen saturation. These metrics are vital for diagnosing and managing conditions like heart failure, shock, and pulmonary hypertension.

Featuring leading Critical Care Expert Nicole Kupchik, MN, RN, CCNS, CCRN-CMC, PCCN, CEO – Nicole Kupchik Consulting, this episode brings you the latest research and technological advancements related to pulmonary artery catheters. Whether you’re a CVICU nurse seeking to deepen your understanding of hemodynamic monitoring or simply curious about the science behind the use case of PACs, this episode offers comprehensive insights into the use of pulmonary artery catheters in critical care.

Giveaway! You could WIN a copy of Nicole’s Book “Critical Care Survival Guide” (a $100 value!) in our social media giveaway! Find us on Instagram @crnaschoolprepacademy. We’re running the contest May 8th through 10th so don’t miss out!!

Get a FREE Copy of the Slides Used in this Presentation! Click Here: https://mailchi.mp/kupchikconsulting/cspa-pulmonary-artery-catheter

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Pulmonary Artery Catheters: Hemodynamics And Case Management With Nicole Kupchik

Welcome back to the show. I am so excited for the episode I have for you. The one and only Nicole Kupchik is here to share all about PA catheters. The reason why we chose this topic is I often see CRNA hopefuls put this on their resume where they’ve managed Swans but maybe you’ve only seen a small handful. Maybe only one or two. If you’re asked about your Swan management in the interview process, it’s as I said, it’s fair game to dive deep into Swans.

I felt like this was a great topic to unravel. For those of you who are tempted to put the PA catheters on your resume but maybe you’ve only taken care of one or two in the past. This episode will be so insightful and so helpful for you. Those of you who even use PA catheters routinely, this is a great refresher for you. A lot of people assume CVICU nurses probably see the majority of the Swans and that’s probably still true.

Me, being the medical ICU nurse, I rarely ever saw a Swan. I only had one and I don’t think I even put it on my resume because I hadn’t seen one. I needed help running my numbers because I never truly knew how to manage it. PICU probably sees more of them then CVICU probably sees the most. During my time doing open heart, we had a cardiothoracic surgeon who was nicknamed No Swan Don because his name was Don and he didn’t like Swans.

I do feel like a lot of institutions are getting away from using Swans. They’re becoming less routine, even for open heart patients. Again, this is going to be a great episode to dive deep into PA catheters, help you understand how to run the numbers, the hemodynamics, what they mean, and some treatment modalities around that. Without further ado, let’s go ahead and get into the episode.

One last thing, as a special token of thanks for reading this episode, five lucky winners from the show will be selected to win Nicole Kupchik’s Critical Care CCRN book. It’s critical care knowledge. It’ll help you prepare for your CCRN. It’s not technically designated as a CCRN book. However, it’s a critical care book, but it’s going to be a great addition to your CCRN prep. We are going to be giving away five of those wonderful books to our show readers. If you want to participate in this giveaway, be sure to follow us at CRNA School Prep Academy on social and tune in to the post to participate. Without further ado, let’s get into the show.

Welcome, everyone. I’m so excited for this topic. For those of you who are new to the show, my name is Jenny Finnell. I’ve been a CRNA for many years. I am the Founder of CRNA School Prep Academy. My background in ICU was as a medical ICU nurse. I’m so excited about this topic on PA catheters. If you’re like me, I only saw one PA catheter. I also worked with a cardiothoracic surgeon. They call them no swan don. We had to beg him to put Swans in his cardiac patients. It’s becoming more frequent to do without a Swan. It’s a great topic to get into depth on PA catheters. Welcome, Nicole. We’re so excited to have you here.

Thanks. I’m excited to be here. Jenny, tell me, what does your company do?

CRNA School Prep Academy mentors the hopeful CRNA. If CRNA is on your radar or if you are ready to learn more about becoming a CRNA. Also, we started CRNA School Prep Academy because I found there’s a very large knowledge gap for nurses pursuing this career path. A lot of them are facing rejection and never having any solid advice on how to move forward or even knowing how they could stand out as a competitive applicant.

CRNA School Prep of Academy is designed for as early as nursing school all the way through to physically working on your application for CRNA school. We even do current student mentoring. We have courses and things like that to help a newly accepted student to be able to hit the ground running once they start CRNA school. That is CRNA School Prep Academy in a nutshell. Thank you, Nicole, for reminding me to introduce that aspect.

How competitive is CRNA school?

CRNA school is very competitive. On average, it’s about 12% to 15% acceptance rate. If you look at average who apply. They take about 3,300 students every year, but there’s over 20,000 people who apply to CRNA school. Again, very competitive and it keeps getting more competitive. New schools are popping up. In fact, there’s about fourteen new CRNA schools that’s going to be popping up and opening. That’s exciting but very competitive.

That’s awesome. This is right up their alley. That’s why you wanted to do this, because they have to know a little about hemodynamics.

I always encourage ICU nurses, especially those pursuing CRNA, is treat your ICU time as being a scientist. Ask why. Don’t accept the status quo. You always want to understand why are they putting my patient on this drip? What is this disease process? What are the modalities to treat this disease process? How is this all working together?

If you take that approach to your ICU time, not only will you learn and grow substantially, but you’re going to be well prepared to enter the realm of CRNA because that is essentially what we do in our day-to-day job. We are the scientists behind why is this happening and what’s causing this chemo-dynamic shift. How can we treat it? What are the options we have? How can we stabilize them through this critical aspect of the surgery?

If you love pathophysiology or pharmacology, CRNA is a nice blend of that. You get to essentially control someone’s hemodynamics under critical surgeries and massive fluid shifts during those surgeries. Even traumas where people are having massive blood loss and things of that nature. All exciting fun things. I would love to brief Nicole. I’m sure most of you are familiar with Nicole Kupchik, but I would love, Nicole, for you to share about your offerings and how you help critical care nurses navigate this challenging career path through your education.

I’m a Clinical Nurse Specialist and I’ve worked for decades. It’s going to be my 31-year anniversary of being a nurse. Anyway, I worked with PA catheters for a lot of years. I used to work with Dr. Ganz of Swan-Ganz. That’s my claim to fame. Anyway, if this is to say super brief, I’ve got a case that we’re going to go through and talk about how PA catheters are being used now.

If you want like more in-depth, I do have a hemodynamics course. I offer CCRN. If you guys are applying to anesthesia school, you need to get your CCRN. Even the cardiac surgery certification will help set you ahead of a lot of the other applicants. I offer lots of things to help you. Are you folks are giving away some stuff?

Thank you for the reminder on that as well. During this presentation, we are excitingly giving away fifteen of Nicole Kupchik’s Critical Care Survival Guidebook. You folks participate, ask questions, encourage each other, and help answer each other’s questions. We will also be giving away five MORE copies on social media when this episode airs. If you see questions in the comment that you want to chime in on, we welcome all the activity. We want this to be engaging. We are going to select fifteen of you at the end. You’ll be notified via email. We will also announce at the end if you’re not live anymore, but you will be notified after the fact, too if you win Nicole Kupchik’s book, which is so exciting.

CRNA School Prep Academy Podcast| Nicole Kupchik | Pulmonary Artery Catheters

Critical Care Survival Guide

That was a fun one to write. Anyway, are you we ready? All right, we are going to chat about the pulmonary artery catheter. I’m going to do a case study. I’m not going to be lecturing and be all boring. We do a case. so let’s get started. I’m a clinical nurse specialist. I’ve been in critical care since day one of my career and I’ve had a blast with it.

I put a lot of stuff on social media. If you’re one of the people who loves videos, TikTok and Instagram. I store a lot of videos on YouTube. As you’re going through life, it’ll help with anything. I’ve got a lot of videos online. We’re going to do some polls and I’m praying I don’t screw this up. I want to know first of all, what’s your comfort level with hemodynamics and pulmonary artery catheters? There’s no wrong answer to this.

I want to know what’s your comfort level with hemodynamics and pulmonary catheters. It’s all anonymous. I can’t see how anyone’s answering, know that as well, too. A lot of you were saying C. It looks like about 19% of you are like, “Yes, I love it. I get it all the time.” Good for you because most people don’t.

You’re probably working on cardiac surgery unit or maybe like a CCU or CMIs and cardiac genetic shock. About half of you are like, “I know a few things I can muddle my way through,” then 35% are saying you got limited experience to hit invasive human inventory. That’s probably what most of the country is looking at.

PA Catheter Case Study

Let’s do a case. You’ve got a 63-year-old female who’s admitted from the CAF lab to your unit. This is her initial twelve-lead ECG. You can see there is some badness. She’s got ST elevation lead V1, V2, V3, and V4. Looks like V5 and V6 are depressed. It looks like she’s having maybe even some high lateral issues. These are reciprocal changes. The ST depression is a reciprocal change. Her main issue is she’s having an anteroseptal with maybe some high lateral involvement but anteroseptal myocardial infarction.

Needless to say, chew an aspirin. She’s going to the cath lab. You get into the cath lab and this is what they see, so a big occlusion right there. She’s got an occlusion and this is in the LAD. The LAD is that order that comes along the front of the heart. It perfusion is your pump. It infuses two walls of the heart. If it’s more proximal, you might even see more involvement. That’s a significant occlusion there.

This is the before and I’ll show you after stenting. You see after, get her LAD open. It looks nice and gorgeous. You can see the catheter on the right-hand side still and that left anterior descending artery. To get her open, she did great. She did awesome. Now, she gets admitted to your unit. Her maps been drifting down below 60s, her heart rates creeping up. It’s in the 90s. Two hours later after admission, her urine output drops off 15 to 20 mils an hour. Not on any drip.

She’s not any drips, no inotropes, and no IV fluids but now her heart rates starting to creep up. It’s like 104. The blood pressures taken a bit of a drop. That’s starting to come down and breathing 22 a minute. That’s going up a little bit. That’s not good. Now our lungs have crackles at the bases and up in the mid lung fields. You ask her to cough and they don’t clear with coughing.

She’s got a new S3 heart sound and knee modeling. That’s not good. Poor cath briefill and knee modeling. This sounds like she’s hypoperfused. You get an X-ray and she’s got major pulmonary edema that’s starting yet. She’s in a lot of trouble. We’re going to go to our second poll and I’m going to again, try not to screw this up.

Decision is made to get an echo and insert a pulmonary artery catheter. In addition to low cardiac output and blood pressure, which are the fine human parameters are consistent with cardiogenic shock. Get your votes in. What do we see with cardiogenic shock? This is question number two in your polls. It’s like a lot of you are voting those votes in. It looks like a lot of you answered B. You’re saying the pulmonary artery pressure is going up and her wedge. Her pulmonary artery inclusive pressure is going to go up.

It is because the left ventricle is failing, so blood is going to back up. When you get a pulmonary artery-inclusive pressure, you’re estimating pressure of the left atrium so that’s going up. Her SVR is increasing. It will increase and her SvO2 will go down. That’s what we know happens but we don’t have quantitative values for her. She only has a peripheral IV. We’re going to put in a pulmonary catheter. She’s for sure going to get a catheter.

A couple of things you have to understand about a pulmonary catheter. It is a right heart catheter. When you obtain the cardiac output, it’s a right ventricular cardiac output. You have to understand that. There are some limitations to that. What do we directly measure? There’s things we directly measure. We directly measure right ventricular cardiac output. There’s a gold filament on the catheter. We’ll measure your cardiac output.

You can get SvO2. Either you can use a continuous cardiac output oximetry catheter, where you can continuously measure SvO2 or saturation venous action or you can just pull blood off the distal port. We can get a right atrial pressure. That’s obtaining pressure in the right atrium. A pulmonary artery systolic and diastellix, you’re getting the pressure in the pulmonary artery. When we inflate the balloon on the catheter, you can get a wedge pressure or pulmonary occlusive pressure, which estimates pressure of the left atrium.

Now every other number you get from these catheters is a calculated number. When we look at cardiac output, we always should look at the index because the index takes into consideration the patient’s body surface area. Why would I want to do that? Here’s an example. Does anyone follow @YourHeartDoc, Dr. Ali Haider? He’s amazing. If you don’t follow him on Instagram, please do.

A nurse giving a patient an exam

Pulmonary Artery Catheters: When we look at the cardiac output, we should always look at the index because the index takes into consideration the patient’s body surface area.

He’s an awesome cardiologist out of New York City. Should we both have the same cardiac output? No, but should our index be about the same? Yes, our index should be about the same, but our cardiac output is going to be different. Again, the indexing, you can index cardiac output and stroke volume. You can index SVR and PVR, but we should be treating the cardiac index.

In normal ballpark 2.2 to 4 liters per minute per meter squared. This just ballpark. I will say stroke volume is one of those numbers you should pay attention to. You’re going to see changes in the stroke volume, especially stroke volume index, before you see it in the cardiac output. Why? If you think about the equation, cardiac output is what times what? Heart rate times stroke volume.

When the stroke volume drops, the heart rate goes up to compensate. The cardiac output will stay normal a lot longer. Whereas when the stroke, you’ll see stroke volume changes much earlier than you will see cardiac output and cardiac index changes. Let’s take this catheter. I want to go through the waveforms in the heart.

Waveforms In The Heart

We’ve got this catheter. Balloon is up. We first insert a cordis. If you want the handouts, I put my email at the end. I’ll send you the handouts from this. We’ve got the balloon up so the catheter goes through a cordis. Once it clears the cordis, we’ll say, “Balloon up.” With the balloon up in the right atrium, you get A, C and V wave and a pretty low pressure. The right side of the heart’s got low pressures. We don’t hang out in the right ventricle. The catheter in the right ventricle can cause ectopy. It can cause a bundle branch block if it tickles that septum.

When you are in the right ventricle, you see a distinct systolic and diastolic value. The diastolic value is normally pretty darn low like 0 to 8. Right ventricle or systolic is like 15 to 30-ish. When you get into the pulmonary artery, the one thing that changes is you get a diachronic notch. The diachronic notch on your PA waveform signifies closure of the pulmonic valve. That’s how you know you’re in the pulmonary artery.

You inflate the balloon on insertion. It’s still inflated, but let’s say it’s not insertion. You want to check a wedge. How do you know you’re going to wedge? You know you’re in wedge. if the waveform does that, but a lot of patients who have these catheters are sick. They’ve got sick hearts. Their waveforms don’t look all nice and pretty. You know you’re in wedge when you lose the dichotic notch. That’s how you know you’re in wedge. For some safety things to think about when you take care of these patients with these catheters is the balloon on the wedge will hold 1.5 mils.

The maximum amount of time you should leave it inflated is fifteen seconds, so 1.5 mils for fifteen seconds. It always allow that balloon to passively deflate. You don’t want to pull back on that balloon. If you pull back on the balloon, you can rupture the balloon. The next time you go to get a wedge, you’re blousing with air. Who likes money? Does anyone like money? I like money. Do you folks like money? We all like money. Why would we be doing any of this stuff?

I have an easy way called Nickel, Dime, Quarter, and Dollar, an easy way to remember, normal intracardiac pressures. If we start on the right side of the heart, I’m going to go through the heart pressures using money as an easy way to remember what normal is. I want to be super clear on this. When I say normal, I mean normal in a healthy person. The people we take care of are not healthy, especially if they have these catheters. Remember, these are normal values in a healthy person.

Let’s start on the right side of the heart. The normal right atrial pressure is about a nickel or 2 to 6 millimeters of mercury. We don’t measure RV pressure at the bedside. A normal pulmonary pressure is about a quarter over a dime or 25 over 10. When we inflate the balloon on the catheter, we estimate left atrial pressure. The normal is about a dime or 8 to 12 millimeters of mercury. Your wedge should run a few points higher than your right atrial pressure or CVP. It should run a bit higher.

The only chamber in the heart that’s got high pressure is the left ventricle. A normal left ventricular pressure is at least a dollar or a hundred systolic. Nickel, dime, quarter and dollar is an easy peasy to remember normal intracardiac pressures. SvO2 or saturation of venous oxygen tells how we’re utilizing oxygen. We’re measuring oxygen in the heart at the most distal point we can before the blood goes to the lungs to exchange CO2 for O2.

You’re measuring deoxygenated blood and a normal there is about three quarters or 60% to 80%. That would be a normal oxygenation in the pulmonary artery right before the blood goes to the lungs to exchange CO2 for O2. We put in a catheter and here her numbers. She’s got an index of 1.62. Do we need to do something? Yes. Her stroke volume index is on the low side, so it’s only 21. Her SvO2, remember normal is like $0.3. It’s only 46%. That’s low.

I’m going to assume, when you’ve got a low SvO2 in a shock state, your lactate is going up. Her right atrial pressure, remember the normal is about a nickel, it’s fourteen. Her wedge is 22. Remember, normal is about a dime or 8 to 12 millimeters. That’s elevated. Her SVR is 1,642. When about what her blood vessels do, they’re vasoconstricted. Her cardiac output is dropping and her heart rate is going up to compensate.

If you need a visual, let’s take these numbers with a diagram of the heart and talk about what’s happening. Coming out of her left ventricle is very poor cardiac output. Her stroke volume index is pretty low and her map is low. She’s got low output because her left ventricle is failing because she had an anterior septal wall MI. Two walls of that left ventricle infarcted. Now the contractility is bad and her heart rate’s going up to compensate. Remember, cardiac output equals what times what? Heart rate times stroke volume. The stroke volume is dropping, so heart rate goes up to compensate.

Her right initial pressure is fourteen. That’s pretty elevated. Her pulmonary pressure is 42 over 20. The normal is like a quarter over a dime, then the wedge is 22. Remember, the normal wedge is about a dime. What’s happening is this left ventricle is failing and is blood backing up. Remember, she had crackles up through her mid lung fields with an S3 heart sound.

Those are both signs of fluid overload. Basically, there’s a lack of forward flow because that left ventricle has infarcted and now everything’s backing up. Her SvO2 is only 46%, so her tissues are taking as much oxygen as they can. It’s sending back less oxygen to the right side of the heart. Her SVR, or systemic vascular resistance is 1,642 because she’s vasoconstricted. Why is she vasoconstricted? There’s decrease perfusion to the kidneys, so the kidneys activate the RAZ and the sympathetic nervous system.

The RAZ system says, “vasoconstric by converting angiotensin into angiotensin 2,” which is a potent vasoconstrictor. Also, it’s basically activating aldosterone, which says, “Hold on to sodium and water so urine output’s dropping.” The sympathetic nervous system is going to release catecholamine that causes vasoconstriction but also causes their heart rate to go up. None of this is magic. It’s all physiology, if you understand it.

The Five Stages Of Cardiogenic Shock

Now, in 2019, there were a few different cardiology organizations that came together and published the SCAI classification of cardiogenic shock. SCAI is the Society for Cardiovascular Angiography and Interventions. Many of you may not even be aware of these but we need to be aware of these if we work with cardiac patients. A class or a stage A means that you’re at risk of cardiogenic shock. A B means that you’re at the beginning stages of shock so your JVP or jugular venous pressure is going to be elevated because everything’s backing up.

It might be crackles in your lungs. She’s already in that stage. Now a stage C, patients are starting to get modeled and dusky. They may need mechanical ventilation. Her lactate’s going to elevate. I’m going to tell you, she’s already at a C. I would argue that she’s a C and going into D. You’ve got a patient who’s near pulses. This is a patient who only thinks going to help them is ECMO.

These are the five stages of cardiogenic shock. Why should we care? The cardiogenic shock mortality is through the roof. I would call her a C to a D. Now, let me make sure our poll is active. We’re going to go to poll number three. Heart rates 108. You can see she’s got a map of 61. These were all her numbers, low index, high preload, and high afterload. What are some options to consider? Look at these options and get your votes in on what would you do now?

Some of you might be like, “E: None of the above. Get her to the cath and put an impala device in.” I would agree with you but we got to get something started so get your votes in. It looks like 79% of you said D. That’s the best option of these options here. She needs dopamine. She’s got a low index. Her index is 1.62. She needs some dobutamine or milrinone. It’s for that matter.

We might be hesitant to start milrinone because it’s a pretty potent vasodilator. She’s got a map of 61 and it’s got a two and a half hour half life. Maybe a little more hesitant. The reason we use dobutamine a lot in shock is that it’s quick on and quick off. The half-life is only a couple of minutes. Although, I will say milrinone and dobutamine have been studied head to head a couple of times now and they’re about equivocal in shock.

Lasix has got high preload. She’s got a lot of volume backing up. We got to get some of that off. Her map is 61 and some of you might be like, “That SVR is so high. I don’t know if I want to start norepinephrine.” I agree with you, but if she’s hypoperfused, she’s going to go into kidney injury pretty quickly. It’s a double-edged sword.

You have to understand, every time you start a vasopressor, that’s going to increase the workload of their heart. That might be okay in some conditions like sepsis or anaphylaxis, but in cardiogenic shock, that’s tough. D is the best answer here. A few of you answered dopamine fluid and beta blocker. This combination would kill her. She’s like fluid. You’ll drown her if you give more fluid. Dopamine, all I can say is the 1990s called. They want their dopamine back.

A nurse holding a model of the interior of a human heart

Pulmonary Artery Catheters: You have to understand that every time you start a vasopressor, it will increase the workload of the heart. That might be okay in some conditions, like sepsis or anaphylaxis, but in cardiogenic shock, that’s tough.

The reason is it costs a lot of tachycardia. We don’t use dopamine a lot anymore. Beta blockers should not be given in decompensated states. It has negative inotropic effects. She’s in an decompensated state. Milrinone, you could but is now the time for an ACE inhibitor? Maybe long-term. She’s probably going to go home on one or in Tresto but not now. C is not the answer. D is the answer there. Hopefully, that made sense.

We give her 40 Lasix, had 800 mils of urine output in the first 90 minutes. We do an echo and it shows that she’s got very poor left ventricular wall motion. Her EF is estimated at 28%. She’s got mild to moderate mitral valve rigors. What’s next? This isn’t good. We get her dobutamine and for her left ventricular failure and signs of decreased perfusion. Now let’s go to poll four and see what you folks have to say there.

Poll four, she started under dobutamine for signs of LV failure and decreased perfusion. Which of the following parameters would indicate that your dobutamine is effective? Get your votes in. It looks like most of you said D. That her cardiac output’s going to go up. You could say A, C, or D would be correct. Her stroke volume’s going to go up and her SvO2 should go up as well. She’s going to utilize oxygen a lot better and her lactate will come down too. Her wedge shouldn’t go up.

Her SvO2 and cardiac output will go up. That’s why A is not correct. B isn’t correct because her cardiac output will go up and not down. Her SVR won’t go up. It’ll come down. Dobutamine has some vasodilatory effects. Not as much as milrinone, but it does have some vasodilatory effects. I do expect her afterload to come down a bit but D is the best answer. You expect her cardiac output, stroke volume, and SvO2 to go up. Expect her afterload to come down a little bit.

Now we give her more Lasix. You started to pop her with a little bit more Lasix. We get a dobutamine started. Her epinephrine is at very low dose got started to support her blood pressure. Now she’s struggling to breathe. Her SpO2 is dropping down to 86%. She’s on 100% non-rebreather mask. Tried to bypass but she couldn’t tolerate it.

We get a gas 728. Her PaCO2 is 68. PO2 is 85. PO2 of 85 on room air would be amazing but a PO2 of 85 on 100% oxygen is terrible. Anytime you interpret your PaO2, you should always be looking at how much oxygen they’re receiving to get them there. She’s got a bicarb of 18. She’s got a mixed respiratory and metabolic acidosis. I’m going to guess this is from the elevated lactate and kidney injury.

Her lactate’s 4.2. That’s not good. Now what? This is terrible. Can she keep breathing with a pH of 702 and a CO2 of 68? No. What does she need? Intubation. Let’s get her intubated. We got her intubated and you see heart rate now is 116. Her map is dropping a little bit more. She’s breathing 18 with the ventilator. SPO2 is 90% on 80%. We’re able to get her oxygen down because now she’s diureticing like crazy. She had that initial output. Now she’s had over a liter and a half now. Skin is still cool.

She’s got poor cap refill and knee modeling. Her index, it’s not heading the right direction. We started dobutamine. I said a tiny dose, but not heading in the right direction or stroke volume index isn’t either. Either is her SPO2. Even with the Lasix and the dobutamine. Her right atrial pressure is getting up there. She’s clamped down. None of this is good. My question is, now what do you want to do? Let’s go to poll five.

Mechanical Circulatory Support

Poll five, what do you want to do now? Do you want to increase the dobutamine and give more Lasix? Do you add vasopressin? Do you want to start dopamine? The 1990s called, don’t do it. She’ll get more tachycardic. Start milrinone or should we consider mechanical circulatory support? What do you folks think we should do? Get your votes in. It looks like most of you are saying, “Consider mechanical circulatory support.” I agree with you.

She needs help. Now, with a pulmonary catheter, we can do some calculations that are more quantitative to tell us she needs help. These are her current vitals. We gave her even more Lasix. She’s had another 1,200 of urine output. She had her initial urine output, and now she’s another 1,200. She’s over two liters now. Map is 60 and heart rate’s coming down. Skin is still cool-ish but cap refill is a little bit better.

Her repeat lactates 4, so it’s coming down but not at a rate that I would like to see it. Still hypoperfused. Stroke volume index is looking a little bit better. Right atrial pressure looks a lot better. Wedge is coming down, but she’s still not there yet. One of the things we can calculate if a patient has a pulmonary catheter is what’s called CPO or Cardiac Power Output.

The CPO calculation can help us drive if a patient needs left ventricular mechanical circulatory system. In a normal CPR, I don’t want to say normal. Normal would be much higher than 0.6 to 0.7. At least 0.8 would be normal. If anything below 0.6, they’re going to need MCS or Mechanical Circulatory Support. We do the calculation and she scores a 0.42 watts, which means she needs help.

One of the things we can calculate if a patient has a pulmonary catheter is CPO or cardiac power output. The CPO calculation can help us drive if a patient needs left ventricular mechanical circulatory support. Share on X

That left ventricle needs some definite help. What about the wrong ventricle? Does the right ventricle need help too? We calculate what’s called a PAPI score, Pulmonary Artery Pulsatility Index. Greater than one is normal. Her right ventricle looks okay. It’s her left ventricle that needs help because her CPO is so low. Now, what would you want to do? At this point, it’s time. She needs an impala.

What I did was I put some norms like things that help us drive if a patient needs mechanical circulatory support. The CPO and cardiogenic shock is going to be low. Anything below 0.6, we need to put in an impala device or I’ll help show you other options we have as well. Now, a PAPI, normal is greater than normal. If the right ventricle is failing, then that’s going to drop. Hers was 1.6, so her right ventricle looks okay. It’s her left ventricle that needs help, which is not surprising because she had an interior septal with some high lateral involvement myocardial infarction. Not good.

These are numbers that are calculated often in the cath lab, but if the patient’s now in your unit, either postoperative from cardiac surgery or if it’s after the cath lab. We can calculate these numbers if they have a pulmonary catheter. Some guidance and this is rough. This is not medical advice. I want to be super clear. This is a rough guide of like what do you do. This is not medical advice.

If the CPO is less than six, like her left ventricle is going to need some help. Impala is going to give a lot more assistance to the left ventricle than a bloom pump would. If she’s hypoxic with a low CPO, then that’s when ECMO may be considered but a lot of facilities don’t do ECMO. In the larger Impala catheter gives up to like five and a half liters per minute of cardiac output assistance. If her right ventricle is failing, we could do a right-sided. If the pappy was low, we could do a right-sided impala device.

CPO was okay but there was LV dysfunction, then that’s when like a balloon pump may be considered or maybe a smaller catheter. Impala would be considered in that case. The cardiogenic shock is tough and the key thing is recognize it early. Remember those SCAI stages and definitions. I will tell you a lot of cardiogenic shock is found late. It’s found very late. We wonder why the mortality of cardiogenic shock is over 40%.

A lot of what we do is supportive. You need to let that left ventricle rest. We support blood pressure with pressers, but anytime you give pressers, you’re going to increase the workload of the heart. I will say low dose epinephrine can be also used as an inotrope. I have dobutamine and milrinone but low-dose epinephrine can also be used as a positive inotrope.

When you’re using higher-dose epinephrine, that’s where you’re getting more vasoconstriction. Diuretics, we’ve got to fluid offload her. If she’s got some pressure to play with, we might start like a little nitro to afterload and preload reduce. It’s tough and patients end up in this downward spiral in cardiogenic shock.

Bloom pump is going to give you about a half liter to a liter per minute assistance with cardiac output. Where we use balloon pumps more is with a left main that’s going to go to surgery or if you’ve got a heart failure patient who’s exacerbated that needs after load reduction. When that balloon deflates, there’s less resistance to pump against and that’s where balloon pumps can be helpful. When the balloon inflates, it improves coronary perfusion, cerebral perfusion, and renal perfusion.

When it deflates, it reduces afterload. Impala, there’s two sizes and it can give us up to five and a half liter per minute assistance then ECMO, VA ECMO or Venous Arterial ECMO can give full support to a patient if they need it. The last thing I’m going to finish up with here is a recently published study that looked at utilization of pulmonary of the catheters. The question was this, in the studies, does a PA catheter and monitoring hemodynamics make a difference on mortality in cardiogenic shock?

Secondary outcomes that were evaluated was this. If we put in a PA catheter is more mechanical circulatory support used when we look at the hemodynamics. This was a meta-analysis, which is one of the highest levels of evidence of six observational studies. I have to say that’s what makes the level of evidence like a little less, but still pretty powerful.

This meta-analysis evaluated over a million patients. They looked at in cardiogenic shock, specifically, PA catheter use. It is only used about one-third of the time. We know that mortality, I have 30% to 50%, but there’s some references that say over 40% mortality of cardiogenic shock and that’s a problem. Our cardiogenic shock outcomes have not improved a whole lot in the last decade or so. What they found in this study, they looked at like, who gets cardiogenic shock? It’s mostly men. About 65 % of men develop cardiogenic shock from these studies.

What they found is that cardiac surgery uses a lot more pa catheters than non-cardiac surgery patients, which I’m sure a lot of you are not surprised about. What they found bottom line was that when patients had pulmonary catheters, 59% of them use mechanical circulatory support. Whereas if you didn’t have a PA catheter, only 48% got received mechanical circulatory support.

PA catheter use perhaps drove mechanical circulatory support. Did that equate to a difference in mortality? The answer is yes. If you had a PA catheter and got MCS, your mortality was 36%. If you didn’t have a PA catheter, the mortality was 47%. This is tricky. That was an overview using a case of pulmonary artery catheters. Now what I would love to do is go to the chat and see what questions you all have. I’ll send the slides to you.

Ashley, you’re saying you work at a trauma surgical unit and almost never had PA catheter. You don’t unless they like, “Ashley, here’s the issue in-patients in your unit. They had an MI or a cardiac arrest while driving and they crash into a tree.” That’s when you might see them. Melissa’s asking, “Is there a better diagnostic tool to differentiate sepsis versus cardiogenic shock? You had a few cases where a patient went into shock post-surgery and cardiogenic shock wasn’t diagnosed until it was too late.”

Echo is going to be probably one. Do echoes. Do them early. Echo can be super helpful, but the problem though is in septic shock. Patients do develop a component of cardiogenic shock. It can be quite challenging to differentiate. As a traveler, she’s seen a lot of CVICs move away from pulmonary catheters, both that.

For sure but you wonder with this new study if you’re going to start seeing more and more if them. Mia, I agree. It is interesting that outcomes have not changed much over the years. A lot of it is late recognition. Late recognition is true. “When you have this one doctor scheduled for the week, almost all of your patients have PA catheters and possibly balloon bumps.” A lot of them. I agree. It’s like it’s provider dependent. Quite a difference in mortality. I agree, Kelly. It was it was very interesting.

Pulmonary Artery Catheters: Q&A

Are there any questions? What other resources would be good to utilize for getting more comfortable with PA catheters? Unfortunately, there’s not a whole lot out there. I have a class. I’ll give you folks a discount code if you want to take it. There’s not a whole lot out there, to be quite frankly honest. There used to be a this grant funded. It’s called Pulmonary Artery Catheter Education. It’s called PACE and they lost funding for that. That’s not even around anymore either.

It’s tough if you don’t see them. Mia, you don’t use pulmonary catheters but you’ve seen them more CPP in your PICU. What do you mean by CPP? Can you explain poll number one? Ashley is saying, “Now that we’re gone over PA catheters, could you explain poll number one answer and why other answers were incorrect?” Did you mean poll one? Poll one was the one where I asked you how comfortable you were. Do you mean poll two? That’s what I’m going to assume, so let’s go back.

I’m assuming you meant poll two. Is this the one you meant, Ashley? I want to get back to where your comment was. The answer here, this woman’s in cardiogenic shock because she had an anterior septal wall in mind. Her pulmonary artery pressure is going to increase and here’s why. Her left ventricle is failing. Let’s go here. This left ventricle is failing. If this left ventricle can’t pump effectively, there’s less blood making it out of the heart. What will happen to cardiac output? It’s going to drop and because this ventricle can’t pump, blood’s going to back up.

Where does it back up to? The left atrium, so your wedge is going to go up. It backs up to the lungs and to the right side of the heart. Basically, everything backs up. All the pressure and blood backs up. That’s why patients get crackles. That’s why they get fluid overloaded. That was the answer and because there’s less blood getting out to the periphery. Whatever the tissues get, they’re going to take. Tissues are going to take as much oxygen as they can. That’s why your SvO2 coming back is going to be a lot lower and because the tissues are so hypoxic, that lactate goes up.

That’s the answer to that. I hope that made sense. If you want the handouts, I put some little extras in there, too. Are PA catheters using the OR setting? They’re used in cardiac surgery for sure. Jenny, you might be able to answer that question better in surgery. Maybe Jenny will chime in. Do you see PA catheters much in OR other than CT surgery?

Not unless it’s for open heart. That would be the primary way we use it. Even then, it was very specific to what surgeon. As I said, we had a surgeon. His name is Don so we called him No Swan Don. We had to fight with him. It wouldn’t be appropriate to fight with him to get one. Otherwise, I’m trying to think of it ever same. Even in big traumas, we typically don’t do one.

In the septic shock, the sepsis guidelines recommend not to use PA catheters. Luckily, we have other options. We do have like art line technologies like Lingco and Flowtrack. A lot of CT surgeons love Flowtrack, especially. We’ve got Bioreactance, the Starling cheetah device. We do have other things we can use.

Bianca is asking, “Have you seen an increase in PA catheter use outside the CVICU?” I’m going to say no. I feel pretty confident about that answer. Billy is asking, “Would you see attempts at trying to get this patient back to the cath lab to see if there’s re-occlusion?” I’m going to say that like, a patient crumping like that, get a 12-lead ECG and see if there’s any ST elevation, but that is a patient who could go back to the cath lab early.

What is a barrier for not using PA catheters? Honestly, a lot of it is discomfort. I’m a clinical nurse specialist and I’ve always been super involved with hemodynamics. I will tell you, the hospital I worked at, so I work at a big level in trauma center. In 2001, we used over 1,000 pulmonary artery catheters a year. Nurses were up on it, but then there was a study published right around that time saying, “Patients have higher mortality when they have PA catheters.”

It’s like, “Did the PA catheter cause the mortality or is it that you don’t know how to interpret the numbers that causes the mortality?” It’s interesting. What happened after that study, though, is everyone pulled back on using them. The next two years, our pulmonary catheter use went down to about 100. We were over a thousand a year, then the next two years went down to 100. Now it’s hard to maintain everyone’s competence in it and confidence as well.

You’ve got a couple of decades now physician, nurse practitioners, and physician assistants who have never seen a PA catheter. It creates this the arm bones connected to the elbow bone. It’s like this downstream effect when you don’t see PA catheters. “Providers are hesitant.” I agree and a lot of it’s comfort. Maryanne, you’re saying that you switched to a level on trauma center and went to the CVICU. You do ECMO and PA catheter. Thank you. You thought it was informative.

It was such a quick little short case. I’m glad you got something out of it because I was always wondering, like, “It’s so short, are they going to get anything out of this?” “In your CVICU, you stop wedging and wonder if they’re going to get rid of them altogether.” Haley, thanks for that comment. Some hospitals don’t wedge. You follow the pulmonary every day as a surrogate of the wedge. I’m going to say this not uncommon.

There are certain patients who I would say like I don’t feel comfortable wedging. For example, if I’ve got someone with pulmonary hypertension who’s got high PA pressures. I will not wedge them. There is no way because I’m worried about damage to the pulmonary artery or rupture. Megan’s saying, “Even in your CVICU, the majority of your cabbage patients don’t have Swans or Tavers, but are you guys you’re seeing them for acute heart failure?”

That’s still where we’re seeing them too. Is heart failure exacerbation? We’re working them up for transplants or trying to fine-tune them with medications. Paige is saying, “You saw Swans during COVID, but now it’s occasional.” That’s interesting. “Where was this meta-analysis study from?” Barbara, I’m not sure what you mean from. I put the reference on the slide. Let me know what you meant by that. Jennifer, you’re saying we advocate in the cath lab as nurses when we know they’re sick. That’s awesome.

Another thing is calculate the CPO. Calculate the PAPI especially if they’ve got a pulmonary catheter or so. Is this used to recognize pulmonary hypertension? Yes. Right heart cath is the gold standard for pulmonary hypertension diagnosis. We do ECHO in those patients as well, but those patients all have right heart caths.

The right-heart cath is the gold standard for pulmonary hypertension diagnosis. Share on X

Whether they decide to keep the catheter in and set the patient to the ICU, that’s another thing. But I will tell you, I worked on a center of excellence for pulmonary hypertension. We would often keep those the catheters in. we would get remodulin started. It might give diuretics as well to get them fine-tuned. We would put a port in and send them home on remodeling. That would be like severe cases. Brooke is saying, “Has anyone noticed any patient family give pushback due to media release from about impala? Mortality rate in this population.”

There was an FDA warning that was issued. I’m going to leave it at that with impala. You can Google it. I’m not going to say anymore because I don’t know the inside scoop about that, but I can tell you what the FDA did issue a warning. You can look that up preferations with issue. “Can we use CE credits?” Everything I offer has CE credits. Every single thing. I’m a CE provider. Everything you do with me gets CE credits.

“Any advice on what to do? We sell them CPA cathers to get the most experience out of your shift.” I would say like have a good reference. A good reference is going to be key. Have a good reference at the bedside so that you know what normal looks like. The other thing is use your trending. You can trend vital signs. I would use your trending to understand is the patient heading in the right direction? Is there cardiac index improving? Is there stroke volume improving? Is there are there preload numbers going down? Is there SvO2 getting better? Trends can be helpful.

Kelly’s asking, “How about a good resource in how to manually calculate or measure PA waveforms?” I’m not sure what you mean by manually calculate, but in my human name, I have a whole lesson that’s dedicated to where to read the wave. I call it riding the wave, like where to read the wave. It can be tricky, especially with the patient’s auto peeping if they’re getting peep on a ventilator. There’s a lot of issues. I’ve seen patients absolutely mismanaged. mismanaged.

Future CRNA, thank you so much for reading. I hope you thoroughly enjoyed the topic. As always, I appreciate you. If you have not yet already, leave a review. We would appreciate hearing from you. I love to always read everything you write. Please go ahead and leave and share comment on the show. As a quick reminder, head over to CRNA School Prep Academy’s Instagram to participate in the Critical Care Survival Guide book giveaway. This is a Nicole Kupchik book. It’s chock full of amazing and valuable information for you.

Again, to participate, we’re giving away five of these books to our readers. You can participate in this giveaway by heading over to our Instagram account at @CRNASchoolPrepAcademy. I’m wishing you the best of luck. I also want to make one last announcement, which is that our show will be going to a bi-weekly format in the near future. We are going to be sharing episodes with you twice a month for the foreseeable future.

 I don’t know if we will go back to weekly posting, but that is potentially the goal in the future. As of now, we’re going a little bit slower. We’re going to be releasing two new episodes a month. I just wanted to make you aware that we weren’t going anywhere. We’re still going to be pumping out great content. We’re still here for you. We’re just going to be taking a slightly different approach to it. Be sure to still follow along and turn on your notifications so you don’t miss an episode. I wanted to make sure I shared that in case you thought we were going somewhere because we’re not. We’re still going to be here. Thank you, folks, until next time. Take care. Bye-bye.

 

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