Procedure
|
Rationale |
1. |
A
persistent wedge waveform is identified on the PA tracing.
-
the
pulmonary wedge pattern will have two low pressure waves per cardiac cycle
("a" and "c") if the patient is in a sinus rhythm
-
the
pulmonary artery waveform will typically have evidence of a dicrotic notch
(blue arrow), and produce one tall waveform following each QRS.
|
1. |
- A persistent
wedged pattern indicates that the catheter has migrated into the pulmonary
arterial circulation to a position where the lumen of the artery is equal
to the diameter of the catheter.
- This
obstructs blood flow and may compromise blood flow to the lung tissue.
|
|

Figure 1: Pulmonary Artery Wedge |
|

Figure 2: Pulmonary Artery |
2. |
Troubleshoot
system to confirm pulmonary wedge versus damp or low pressure system:
-
assess
circuit from top to bottom for loose connections, air or clot
- evaluate
volume of fluid in Tycos infuser and ensure pressure is adequately tightened
-
perform
a dynamic response test by opening the flush device and observing the monitor
for a dampened waveform
-
check
systemic BP for generalized hypotension
- check
transducer position and rezero
|
2. |
An
overdamp system will produce a low amplitude waveform as a result of pressure
transmission interference.
-
air,
clot or a "leak" in the pressure circuit will diminish the ability to transmit
clear waveforms
-
inadequate
pressure on the circuit will dampen the waveform (generally both arterial
and PA tracings will dampen as they share a common infuser)
-
in
a patent system, instead of a brisk "square wave" configuration, the pressure
upstroke is sloped, and the recovery is delayed
dampened
pulmonary and arterial waveforms generally display a slow upstroke or rise
(anacrotic limb)
-
If
the transducer is placed above the heart, pressures will be falsely low.
If the transducer is placed below the heart, pressures will be falsely
high.
|
3. |
If
the tracing is confirmed as "wedged", check to ensure that the balloon
is not locked in the inflated position:
-
when
the balloon lumen is locked, the red line along the lumen tubing will be
disrupted (i.e. will not show a continuous line)
|
3. |
The
balloon should never be left in the locked position because it is impossible
to differentiate between "locked inflated" and "locked deflated". |
4. |
Attempt
to have catheter return to a PA position spontaneously:
-
have
patient cough or suction the patient
- reposition
the patient
|
4. |
The
catheter may move back on own by:
- a sudden
intense elevation in intrathoracic pressure
- patient
repositioning
|
5. |
If
the pulmonary wedge pattern persists, observe the distance that the catheter
is inserted by evaluating the black markings. |
5. |
Each
wide band represents 50 cm and each narrow band 10 cm from the distal tip. |
6. |
Gently
aspirate the balloon port prior to withdrawal to ensure deflation. |
6. |
- The
balloon automatically deflates with disconnection of the syringe from the
balloon gate.
- Prior
to withdrawal, the balloon must in the deflated position to prevent injury
to the pulmonary or tricuspid valves.
- The
likelihood that the balloon would remain inflated if the gate is unlocked
is remote, however, it should be evaluated.
- Only
gentle aspiration is necessary to confirm that the balloon is deflated;
vigorous aspiration can lead to balloon rupture by invaginating the balloon
into the lumen of the wedge port.
|
7. |
Slowly
withdraw the catheter while continuously observing for a change in the
waveform to the pulmonary artery position. As soon as a PA tracing is observed,
stop withdrawing. |
7. |
The
catheter may only need a very slight withdrawal to return it to a PA position. |
8. |
- Following
return of the pulmonary artery tracing, slowly inflate the balloon and
assess the pulmonary artery wedge pressure.
-
If
it takes less than 1 cc to inflate the balloon, carefully withdraw the
catheter an additional .5 - 1 cm.
-
Recheck
the pulmonary wedge.
|
8. |
When
a spontaneous wedge pattern develops, the catheter is too distal.
The catheter needs to be withdrawn enough to ensure adequate blood flow
continues around the catheter following balloon deflation. When the
catheter is optimally positioned, it should take 1 - 1.5 cc to produce
a pulmonary wedge; smaller volumes suggest that the catheter is too distal. |
9. |
Monitor
waveform closely for right ventricular or spontaneous wedge tracing.
If
a right ventricular tracing is noted, withdraw the catheter to the right
atrium as per procedure below. |
9. |
- If
the catheter is withdrawn too far, it could slip into the right ventricle.
-
prompt
withdrawal to the right atrium ensures that the catheter is "safe".
-
The
catheter could return to a spontaneous wedge pattern, requiring further
adjustment.
|
10. |
Notify
the physician. |
10. |
At
the earliest opportunity, the physician should assess the catheter for
placement. |
11. |
Document
in the clinical record. |
11. |
To
record event and intervention. |
Procedure |
Rationale |
1. |
Identify
right ventricular tracing on monitor.
The
right ventricular waveform can be differentiated from the pulmonary artery
waveform by the following criteria:
-
the
PA and RV waveforms have the same systolic pressures but the RV has a much
lower diastolic pressure (compare the hourly PA systolic/diastolic pressures
- if the catheter slips into the right ventricle, the systolic will remain
the same but the PA diastolic will fall)
-
the
RV diastolic will be similar to the right atrial diastolic pressure (compare
the suspected RV diastolic with the right atrial (CVP) diastolic
-
the
rise in the RV pressure will be closer to the QRS than the rise in the
pulmonary artery rise
-
the
pulmonary artery tracing should have a dicrotic notch
-
ventricular
arrhythmias may develop if the pulmonary artery catheter is in the right
ventricle
|
1. |
The
catheter can soften and coil backward so that the tip is sitting in the
right ventricle. Irritation of the ventricular endocardium can result in
ventricular arrhythmias. |

Figure 1: Right ventricular tracing from a pulmonary artery catheter |

Figure 2: Pulmonary artery tracing from a pulmonary artery catheter |

Figure 3: PA catheter advanced from right ventricle to pulmonary artery |
|
See
also Edubriefs:
Differentiating
right ventricle and pulmonary artery |
|
|
Procedure |
Rationale |
2. |
Inflate
the balloon and observe the monitor for a change to a pulmonary artery
waveform. |
2. |
Balloon
inflation can facilitate flotation from the right ventricle to the pulmonary
artery. A prompt change to a pulmonary "wedge" pattern indicates the catheter
was likely in the right ventricle and floated back into the pulmonary artery.
If
the catheter does not float into the pulmonary artery position, inflation
of the balloon "rounds out" the tip of the balloon and decreases the irritation
to the ventricular endocardium. |
3. |
Attempt
to have catheter spontaneously migrate to the pulmonary artery position.
-
Have
patient cough or suction them.
-
Reposition
the patient
|
3. |
-
A sudden
intense rise in intrathoracic pressure may force the catheter to migrate
with blood flow.
- A change
in the patient's position may facilitate movement into the pulmonary artery.
|
4. |
- Ensure
balloon is deflated.
-
Turn
any infusions that are being administered via the injectate (blue), VIP
(white) or Paceport (orange) lumens "OFF" and administer any critical infusions
via the introducer side arm.
|
4. |
- Withdrawal
of catheter with inflated balloon could cause injury to the tricuspid valve.
-
When
the tip is withdrawn to the right atrium, any proximal infusions will back
up into the sleeve. The patient may be without important infusions,
therefore, critical infusions should be connected to the introducer until
the catheter is repositioned.
|
5. |
- Carefully
withdraw catheter while continuously monitoring the distal waveform.
- Withdraw
until a right atrial tracing appears.
-
Continue
withdrawing for another 5 cm.
Note:
If
necessary, the distal (yellow) lumen can be used as a CVP line for administration
of IV fluids, once catheter tip location in the proximal right atrium has
been confirmed by the waveform. |
5. |
- When
the right atrial tracing initially appears, the catheter tip will be situated
in the right atrium and may be close to the tricuspid valve.
-
The
tip of the catheter should be withdrawn to maintain a proximal placement
to the atrial lumen. This decreases the risk of endocardial injury
from the catheter tip.
|
8. |
Notify
the physician as soon as possible. |
8. |
For
catheter repositioning. |
9. |
Document
in the clinical record. |
9. |
To
record the event and intervention. |