PULMONARY ARTERY CATHETERS (PA) STANDARDS

Ensure that patient and health care provider safety standards are met during this procedure including: Risk assessment and appropriate PPE 4 Moments of Hand Hygiene Procedural Safety Pause is performed Two patient identification Safe patient handling practices Biomedical waste disposal policies
Monitor ECG Provide Emergency Equipment Set-Up Hemodynamic Circuit Maintain Accuracy Display Waveforms Monitor PA Pressures Maintain Closed System Prevent Air Embolism Obtain Chest Xray		Select Appropriate Ports for Infusions Obtain Blood Samples Change Dressings Reposition PA Catheter Analyze CVP and PWP Waveform Measure Cardiac Output Document Placement Paceport (TM) Catheter Introducers
Infection Control All vascular devices (peripheral, central venous or arterial) can be a source for blood stream infection and be become the nidus for a central venous infection. Stict aseptic technqiue should be maintained at all times during insertion, dressing changes, medication administration and accessing of intravascular devices. . All central venous and arterial lines that are inserted without strict adherence to sterile techniques/established safety bundles should be changed as soon as possible. Lines inserted during any resuscitation (e.g., trauma resuscusitation, during a crash OR or in another hospital) should be evaluated and considered for replacement. Unless there is clear documentation in the chart to confirm that insertion techniques were maintained, lines should be considered at risk and changed as soon as possible using a new site whenever possible. All peripheral IVs should be inserted using aseptic technique. Site should not be touched unless wearing sterile gloves after prepping. Peripheral IVs should be removed if insertion technique is unknown or within 96 hours. The insertion of all arterial and central venous lines should adhere to the Central Venous and Arterial Line Safety Checklist and Procedure Note. These forms should be completed and placed in the Progress Note of the Clinical Records. Separate insertion trays are available for arterial and central venous lines. Arterial and central venous dressing changes are done using aseptic technique. Special dressing trays for "Arterial and Central Venous Dressing Trays" are available. Maintain Safety Bundle Standards for Insertion, Maintenance, Dressing Changes and Removal: Safety Bundles Procedural Safety Pause Central and Arterial Line Insertion Central and Arterial Line Maintenance Central and Arterial Line Dressing Change Procedure for Removal of Central Venous Catheter
STANDARD OF NURSING CARE		RATIONALE FOR STANDARD
Ensure 4 moments of hand hygiene are met when performing assessments and/or managing monitoring equipment. Perform risk assessment and select appropriate PPE based on patient diagnosis and procedure being performed.
1.	Monitor ECG All CCTC patients with PA catheters will have continuous ECG monitoring. See Standard for ECG Monitoring.	1.	To provide continuous monitoring with prompt detection of changes in heart rhythm. PA catheters can slip into the right ventricle and produce ventricular ectope.
2.	Provide Emergency Equipment Access to ACLS equipment (e.g., defibrillator, drugs) is required for all patients with a PA catheter.	2.	Migration of the right heart catheter into the right ventricle can cause life threatening arrhythmias.
3.	Set-Up Hemodynamic Circuit RNs in CCTC are responsible for the priming, zeroing, leveling, and maintenance of hemodynamic pressure monitoring circuits and for the assessment and monitoring of hemodynamic pressures and waveforms. RNs may flush hemodynamic monitoring circuits as required to maintain patency Exception: left atrial lines and intra-aortic balloon pump lumens are maintained with pressurized heparinized saline BUT are not manually flushed by RNs.	3.	RNs in CCTC have received additional education in the care of invasive monitoring circuits. Refer to Procedure for Hemodynamic Monitoring Circuits or Removal of a Right Heart Catheter. See also: Standard for Care of a Patient on an IABP
4.	Maintain Accuracy Hemodynamic transducers are zeroed at each initial setup, with the air-fluid interface (stopcock above transducer) leveled to the mid-axillary line. Transducer levels should be validated at the beginning of each shift, prior to each PWP or CVP measurement, following position changes, and prn to validate hemodynamic pressures. Document level confirmation in the graphic record. Documentation is required at the start of each shift and q6h, prior to each CVP and PWP measurement, and following transducer repositioning.	4.	Zeroing eliminates the effect of atmospheric pressure on measured hemodyamic values. Leveling eliminates the influence of hydrostatic pressure on the transducer. A transducer that is positioned below the patient's heart will produce falsely elevated pressures and a transducer positioned above the patient's heart will produce falsely low pressures.
5.	Display Waveforms The tip of the PA catheter must be connected to a monitor that provides a continuous waveform display. Continuous monitoring with waveform display is required during transport. Right atrial waveform is measured and waveform assessed intermittently via the bridge.	5.	The waveform from the tip of the right heart catheter must be displayed continually to demonstrate the catheter tip location within the heart. Continuous monitoring is required to promptly detect catheter migration into the right ventricle or pulmonary wedge position.
6.	Monitor Pulmonary Artery Pressures Monitor the pulmonary artery waveform continuously and record pressures (Pulmonary Systolic/ Diastolic/ Mean) q1H. Monitor heart rate and rhythm continuously and observe for ventricular ectope.. During insertion, print and post the right atrial, right ventricle, pulmonary artery and pulmonary wedge pressures into the chart. These can be obtained after insertion by selecting the "full disclosure" feature of the central station and choosing hemodynamci waveforms.	6.	To promptly identify spontaneous migration of the catheter tip or to identify ventricular irritability. Posting the baseline insertion pressures to the chart provides a comparison for future assessments and can help to determine if a catheter is spontaneously wedged or has recoiled to the right ventricle. Identificaiton of an RV tracing from the proximal injectate port (blue) suggests that the catheter has been advanced too distally (increasing the risk for pulmonary infarction or hemorrhage).
7.	Maintain Closed System All stopcocks must have dead-end (non-vented) luer lock caps or luer lock connected infusions. This includes stopcocks located on transducers. Alohol impregnated sampling port caps should be maintained on all sampling ports/needless access devices.. Hemodynamic circuits are changed with each new line and prn. Flush thoroughly after blood sampling and maintain adequate counter pressure to prevent thrombus formation.	7.	To prevent accidental entry of air or contaminants. Accidental movement of a stopcock that does not have a dead end luer lock cap can result in hemorrhage/air embolus. PA catheters are 110 cm with 5 lumens divided through a 7.5 F catheter (usual adult model). Prolonged flushing using the flush device is required to prevent thrombosis. Thrombosis increases risk for infection and may cause pulmonary embolism.
A8.	Prevent Air Embolism Maintain luer-lock connections on all central venous devices. Clamp lumens/lines before disconnecting IVs or accessing a port. Avoid piggybacking infusions that are not running on another infusion pump into Y sites that are located below the air detection devices. Infusions pumps have air detectors up to the level of the pump. Patients with intracardiac shunts are at increased risk for venous to arterial air embolization. TPN tubing includes an air elimination filter than can be used if additional support is needed. Trendelenburg positioning and breath holding techniques are used during insertion and removal of central venous catheters to prevent air entry. If air inadvertently enters a central venous catheter, immediately aspirate from the line and place the patient left side down in a trendelenburg position. Upright positioning and hypotension increases the risk for air entry into central venous lines. During removal, catheter tract must be immediately occluded to prevent air entrying the tract. See Procedure for Removal of Central Venous Line and Removal of Pulmonary Artery Catheter.	8.	Venous air embolism can create an "air lock" that blocks the flow of blood from the right side to the left side of the heart, leading to cardiorespiratory collapse. CPR can break air into smaller bubbles to restore circultation. If venous air is broken into smaller bubbles or there is a persistent formen ovale, air can enter the left side and embolize to the brain or other organs. Careful technique to avoid the entry of air in to the circuit is essential. Left lateral trendelenburg positioning may trap air bubbles within the right ventricle in an emergency. Strategies that increase cardiac pressures above atmospheric pressure reduce the gradient for air to move into the central venous catheter (e.g. breath holding or head down positioning). Conversely, condition that lower intracardiac pressures in relation to atmospheric pressure increase the gradient for air entry into the catheter site (upright positioing or hypotension).
9.	Obtain Chest Xray Obtain chest xray upon insertion and daily or if the right heart catheter is advanced > 5 cm.	9.	To identify complications including: pneumothorax, hemothorax, hydrothorax, catheter kinking, catheter placement (e.g. right atrial placement of CVP catheters or distal placement of right heart catheter), pulmonary infarction or hemorrhage. Chest xrays do not need to be repeated for simple catheter withdrawals, unless there is ongoing concern regarding placement. Daily and post-advancement xrays are done to assess for spontaneous catheter migration and to rule out distal placement, or to monitor for complications (e.g., hemorrhage, infarction, pneumothorax). Distal placement may be detected on xray, in the absence of a spontaneous wedge tracing.
10.	Select Appropriate Ports for Infusions Continuous infusions that affect BP or cardiac output should not be administered via the blue proximal injectate port of the PA catheter. RECOMMENDED: Administer vasoactive drugs via the introducer. This allows urgent removal or withdrawal fo the catheter if ventricular ectope develops without having to disrupt the vasoactive drug infusion. If the proximal injectate port is the only site available for the administration of vasoactive drugs, utilize the proximal port but do not perform cardiac output measurements. Although blood products can be infused through any central line, it is preferable that the blue injection port of the right heart catheter be avoided.	10.	During cardiac output measurements, 10 ml of fluid is administered into the proximal injectate port. This would result in the administration of a bolus of vasoactive drug. While performing the cardiac output injections, the infusion would be disrupted. After completion of the cardiac output measurement, a delay would occur before the infusion would reach the patient. If the PA tip should slip into the right ventricle, withdrawal or removal is the urgent treatment. If vasoactive drugs are running into a proximal port (proximal injection - blue, venous infusion - white or Paceport - orange), the infusion may back up into the sleeve because the proximal port may be out of the blood vessel).This would cause a disruption in the administration of the vasoactive medications. If fluid or blood backs up into the sleeve, the catheter must be changed. . Administration of a vasoactive drug via a peripheral vessel places the limb at risk for injury. This risk outweighs the potential benefit associated with PA catheter monitoring. Blood products may reduce patency of this lumen making measurement of cardiac outputs impossible.
11.	Obtain Blood Samples RNs may draw blood from the pulmonary artery catheter using a stopcock.	11.	See Procedure for Blood Withdrawal and Blood Gases Venous.
12.	Dressings and Safety Bundles Central venousl line dressings are changed q 7 days and PRN when using CHG transparent dressings, or Q 24 H when using gauze. Dressings should be changed prn if occlusivity is disrupted or if the CHG pad becomes boggy. For IJ insertion sites, ensure dressing occlusivity is maintained and that endotracheal securement devices do not disrupt dressing integrity. Record any redness or abnormal findings in the AI record and report to the physician. Dressing changes should be performed aseptically. Arterial and Central Venous Dressing Trays are available for ease of collecting supplies. See Standard for Central Venous and Arterial Line Dressings. Non-sterile cap, gown and mask with face shield plus sterile gloves are required.	12.	Transparent dressing allow for inspection of insertion site. If gauze dressing is required (oozing at site), daily dressing change is rrequired to faciliate inspection.
13.	Reposition PA Catheter RNs may not insert or advance a right heart catheter. RNs in CCTC may partially withdraw a right heart catheter from a persistent PWP or RV position without a physician's order. RNs may remove a PA catheter with a physician's order. Prior to withdrawal of a PA catheter tip from an RV to RA placement, turn off or switch proximal infusions to the introducer site.	13.	Currently, the College of Nurses does not permit advancement of a right heart catheter. RNs in CCTC have received additional education in the care of right heart catheters. Refer to Procedure for Partial Withdrawal or Removal of a right heart catheter. During withdrawal of the PA catheter, or manipulation by the resident, the proximal ports (right atrial, right ventricular ports) may infuse into the introducer or the sleeve. This can cause fluid or blood to backup into the sleeve, with disruption of drug delivery.
14.	Analyze CVP and PWP Waveform CVP and PWP measurements are obtained from a waveform printout. Waveforms are printed and analyzed to identify the right atrial pressure at end-expiration and the base of the "V" wave. Waveform analysis is identified on a paper recording of each right atrial and PWP tracing. Each waveform is posted in the clinical record.	14.	The goal for right atrial pressure and PWP monitoring is to identify the pressures during end-expiration and end-diastole. Although the pre-C wave best reflects the end-diastolic pressure, it is often difficult to identify, reducing inter-rater reliability. For consistency, we measure the pressure during mid-diastole (during diastasis) because it is easy to find and reflects a pressure that is similar to the pressure at end-diastole.
15	Measure Cardiac Output Measure cardiac output q 6 h and prn following changes in vasoactive drugs, fluid administration or to reassess changes in the patients hemodynamic status. Measure arterial and venous gases with each cardiac output, and enter data into the Critbase program. Measure hemoglobin OD and prn if indicated (e.g., to assess potential bleeding, following blood transfusion), and utilize most recent value to determine oxygen content variables. Measure CVP and PWP prior to cardiac output measurement. Obtain a minimum of 3 injections, editing measurements to average 3 samples that have a variance of +/-10%.	15.	See Procedure for Measuring Cardiac Output. See Procedure for Blood Withdrawal; Blood Gases Arterial.and Blood Gases Venous.
16.	Document Document all newly inserted peripheral and central venous and arterial lines in the Line Tracking Section of the 24 hour CCTC Flowsheet. Refer to documentation standards. At the start of each shift, identify PA catheter placement and record the distance marker at the entrance point to the introducer hub in the intravascular device section of the flow sheet. Each single black line represents 10 cm, while each thick line represents 50 cm. The markings at the insertion site represents the amount of catheter "in" the patient. Assess catheter patency and document in the intravascular devices section of the flow sheet at the start of each shift and q 4 h. Document catheter repositioning procedures in the AI record and record changes to the distance marking in the intravascular device section of the flow sheet. Monitor waveform continuously. Determine CVP and PWP q 6 h and prn as per #14. Document pressures in the graphic record. Document intravenous infusion in the 24 hour assessment record and sign for all infusions in the MAR, including heparinized flush solution. Record IV infusion volumes in the fluid balance record. Record vasoactive drug doses in the graphic record section of the flow sheet. Document dressing changes in flow sheet and * and DAR abnormal findings.	16.	To assist in recognizing when catheter migration has occurred and to ensure distal placements are recognized and corrected. Waveforms identify the location of the catheter tip. The catheter tip can spontaneously retract into the right ventricle and cause ventricular ectope, or advance into the distal pulmonary circulation and compromise blood flow. Catheter tip movement can occur without a change in the insertion point markings. Note: Consistent catheter markings do not rule out tip migration. The catheter may migrate forward or loop back without the actual insertion site changing. Dilation or contraction of the ventricular volume and patient repositioning can change the amount of "slack" in the catheter tubing and allow the tip to migrate or recoil.
17.	Paceport (TM) Catheters If a Paceport(TM) catheter is being used to pace a patient, the right ventricular side arm patency must be maintained as per any central line. Luer lock connections must be used, and a continuous IV infusion administered via infusion pump (5 mL hour is adequate) to maintain patency. Saline lockign is not recommended. The right ventricular lumen can be used to administer medications that require central venous access, including vasoactive agents. Following insertion of a pacemaker wire, wedging should be performed cautiously, observing for any loss of capture of the pacemaker. If capture issues occur, do not use the catheter to perform PWP measurements during pacing. Cardiac output measurements may be performed as long as capture issues do not occur during injection.	17.	The RV is an excellent location to introduce drugs that require central administration due to the large volume of blood for rapid dilution. The higher RV pressure increases the potential for line thrombosis. Volumetric pumps at a low flow rate are usually sufficient to maintain the positive pressure that prevents line blockage. Saline lock may be inadequate. During wedging, the right heart catheter migrates forward at the tip. In some patients, this can cause movement of the pacemaker wire. In some patients, positioning of the right heart catheter to facilitate pacing results in poor placement for wedging; it may not be possible to perform both functions. Assessment should be done on a patient-to-patient basis.
18	Introducer and Pulmonary Artery Catheters Use: Introducers are used as stand alone IVs (e.g., for rapid infusions) or to facilitate the insertion of a temporary transvenous pacemaker, pulmonary artery catheter or central venous catheter. An introducer is a central venous catheter and should be treated with the same central line insertion, maintenance and removal precautions (e.g., risk for air, central line infection, thrombosis). Pulmonary artery catheters are all inserted through an introducer that is at least 1F larger than the PA catheter. Vasopressors and PA Catheter: When a pulmonary artery catheter is in place, the introducer is the preferred location for the administration of vasoactive agents. The introducer is independent of the pulmonary artery catheter. If a pulmonary artery catheter is advanced or withdrawn, infusions that are being administered via the blue (proximal injectate), white (proximal infusion) or orange (right ventricle port of Paceport(TM) model) lumens must be stopped to prevent inadvertend administration of fluid into the sleeve or disruption of life-supporting medication. Patency/IV Therapy: Introducers with pulmonary artery, central venous or tranvenous pacing catheters require a continuous flow of IV fluid via infusion pump (5 ml per hour is sufficient). Saline lock should not be used (increased risk for thrombosis). Any patent introducer with confirmed placement can be used for the administration of medication that requires central venous access, including vasopressors.	18.	Introducers are central venous catheters that carry the same risk and benefit as other central venous catheters. The larger bore size of a 9 F introducer can increase the risk for complications and leave a larger potential tract following removal. When a catheter is inserted through an introducer the flow rates are decreased and the potential for thrombosis around the catheter tip increased. The introducer is independent of the pulmonary artery catheter. If a pulmonary artery catheter is advanced or withdrawn, infusions that are being administered via the blue (proximal injectate), white (proximal infusion) or orange (right ventricle port of Paceport(TM) model) lumens must be stopped to prevent inadvertend administration of fluid into the sleeve or disruption of life-supporting medication. Administration of life supporting medication via the introducer ensures uninterupted administration during advanacement, withdrawal or removal of the pulmonary artery catheter. .