Search

The year 2020 marks the 50th anniversary of the landmark publication on the bedside clinical use of a flow-directed catheter. The catheter, now known as the Swan-Ganz catheter, truly revolutionized practice and care of the critically ill. Use of the catheter proliferated nearly without rigorous validation or evidence base until a moratorium was called in regard to its use. This article describes the history of the development of the Swan-Ganz catheter, its uses, and its near downfall. The authors, both involved in educating clinicians in the use of the pulmonary artery catheter, hope that telling this story shares tribal knowledge and lessons learned with newer generations of nurses who did not experience the explosion of development and knowledge in the area of hemodynamic monitoring. Partly because of advances in technology, and the catheter’s application for heart failure in particular, use of the pulmonary catheter is being resurrected.

The pulmonary artery catheter is a valuable tool available to the clinician for use in deciphering complex hemodynamic scenarios. Patients in shock, particularly those who are elderly or have premorbid conditions such as heart failure, may have atypical presentations. Additional hemodynamic data may help identify interventions that might seem counterintuitive, such as the use of vasoconstrictors in patients with low cardiac output. Interpretation of pulmonary artery hemodynamic data is a skill that should not be relegated to the past. This article reviews the use of a pulmonary artery catheter in mixed shock states. A case study is used to demonstrate how pulmonary artery catheter hemodynamic values can guide the care of these patients.

Background Early mobilization of patients in the intensive care unit can be beneficial, but evidence is insufficient to indicate whether allowing patients with an indwelling pulmonary artery catheter to walk is safe. Objective To describe the physiological and emotional responses to ambulation in patients with heart failure and a pulmonary artery catheter. Methods This prospective, descriptive study included 19 patients with heart failure monitored with a pulmonary artery catheter in a cardiac intensive care unit. Each patient, accompanied by a nurse, walked with continuous observation of heart rate and rhythm and pulmonary artery tracing on a transport monitor. Pulmonary artery catheter position and waveform, arrhythmias, and perceived levels of exertion and fatigue were recorded before and after each walk. The distance ambulated was documented. One to 3 times per week, nurses administered a questionnaire addressing patients’ sense of well-being. Results The 19 patients had 303 walks (range, 1–68; median, 7). During 7 patient walks (2.4%), catheter migration of 1 to 5 cm occurred, but no arrhythmias or waveform changes were observed. Changes in exertion and fatigue were significant (P < .001, paired t test), but levels of both were minimal after walking. Patients expressed physical and emotional benefits of walking. Conclusions This study provides preliminary evidence that for hemodynamically stable patients with heart failure, ambulating with a pulmonary artery catheter is safe and enhances their sense of well-being. The presence of an indwelling pulmonary artery catheter should not preclude walking.

• Background Pulmonary artery catheters are widely used invasive monitoring devices in critically ill patients. Clinicians disagree about whether daily chest radiographs are needed or clinical parameters alone are sufficient to verify catheter placement.• Objectives To determine whether daily chest radiographs are needed to assess migration of pulmonary artery catheters.• Methods One hundred consecutive patients with pulmonary artery catheters were prospectively evaluated. Clinical criteria for optimal position of the pulmonary artery catheters and findings on chest radiographs were compared. Optimal clinical criteria were (1) amount of air required to measure pulmonary capillary wedge pressure: 1.25 to 1.5 mL and (2) pulmonary artery catheter migrated 1 cm or less from initial position.• Results Three hundred ninety comparisons of clinical criteria and radiographic findings were done. Chest radiographs indicated the catheter required repositioning in 15 (4%) of 390 instances but in only 4 (1%) of 310 instances in which bedside clinical findings indicated adequate catheter position. In 69 (18%) of the 390 cases, the clinical criteria for adequate catheter position were not met, but radiographs showed the catheter in an appropriate position. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of abnormal clinical criteria were 73%, 82%, 81%, 14%, and 99%, respectively.• Conclusions Chest radiographs indicated that about 4% of catheters required repositioning. Catheter malposition can be reliably excluded (negative predictive value, 99%) by close observation of specific clinical criteria, so routine daily chest radiographs do not seem justified.