• 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.

Figure 1: Pulmonary Artery Wedge

Figure 2: Pulmonary Artery

• 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 

• 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. 

• when the balloon lumen is locked, the red line along the lumen tubing will be disrupted (i.e. will not show a continuous line)

• have patient cough or suction the patient
• reposition the patient 

• a sudden intense elevation in intrathoracic pressure 
• patient repositioning 

• 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. 

• 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.

If a right ventricular tracing is noted, withdraw the catheter to the right atrium as per procedure below. 

• 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.

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

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

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.

• Have patient cough or suction them.
• Reposition the patient

• 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. 

• 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. 

• 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. 

• Carefully withdraw catheter while continuously monitoring the distal waveform. 
• Withdraw until a right atrial tracing appears. 
• Continue withdrawing for another 5 cm.

• 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.