Department of Cardiothoracic Anaesthesia Linköping Heart Centre, University Hospital, Linköping, Sweden*E-mail: zoltan.szabo@lio.se
Accepted for publication: February 10, 2003
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Abstract |
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Methods. The operating table is positioned head up and slightly right side down to position the pulmonary valve at the highest level possible. When the balloon catheter is in the right ventricular outflow tract (indicated by premature ventricular contractions) the ventilator is paused in inspiration and the balloon catheter simultaneously passed into the pulmonary artery.
Results. The manoeuvre shortens the time necessary to pass the catheter into the pulmonary artery and may reduce ventricular arrhythmias. Over 5 yr, 105 PAFCs were inserted with this method without major complications.
Conclusion. This method may reduce the risk of ventricular arrhythmias, and could be particularly useful in high-risk critically ill patients.
Br J Anaesth 2003; 90: 7946
Keywords: equipment, catheters, pulmonary arterial; lung, pulmonary artery; surgery, cardiovascular
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Introduction |
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Methods and results |
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The method was applied using a standardized anaesthetic and catheterization procedure.3 The catheter currently used is the Abbott Opticath (Chicago, IL) or the Edwards Lifesciences Swan-Ganz CCOmbo CCO/SvO2 (Irvine, CA). During 199096, Arrow catheters were also used.
1. After the induction of general anaesthesia and intubation of the trachea an 8Fr introducer is inserted in the right internal jugular vein with a standard Seldinger technique. The side-hole of the introducer sheath and all the infusion ports, except the tip of the catheter, which is used to measure the pressure for guidance, are closed during the entire procedure.
2. The PAFC is placed into the introducer before placing the patient head up.
3. The balloon (previously tested) is fully inflated after insertion to 20 cm.
4. The patients thorax is raised by positioning the operating-table head up 1520° (Fig. 1A) and the table is rotated towards the right 1520° (seen from the head of the patient) (Fig. 1B).
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6. Premature ventricular contractions indicate when the balloon is in the right ventricle particularly in the right ventricular outflow tract. At this moment the ventilator is stopped at end-inspiration: the Servo Ventilator 900D (Siemens Elema Sweden) has an inspiratory pause button. During the inspiratory pause (Fig. 1C) the catheter is advanced from the right ventricle into the pulmonary artery, guided by the pressure curve. The magnitude of the applied intra-thoracic pressure can be adjusted by changing the tidal volume. The inspiratory pause rarely exceeds 1030 s.
7. As the pulmonary catheter passes the pulmonary valve the inspiratory pause is stopped and the PAFC further advanced to the wedge position.
Between 1995 and 2000, I anaesthetized 810 patients for open-heart operations and inserted a PAFC with this method in 105 patients (13%). Descriptive data for these patients are shown in the Table 1. No major complications related to the insertion or presence of the PAFC were recorded in our institutional database (Summit Vista for Windows; Summit Medical Systems Inc. Version 1.98.1). The PAFC catheter was used for standard indications.
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Comment |
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The most common and potentially dangerous complication during the insertion of PAFC is ventricular arrhythmia when the catheter is being passed through the right ventricle. By passing the catheter rapidly into the pulmonary artery this complication can be reduced.4 The insertion of the PAFC especially before induction of the anaesthesia may be time consuming in routine coronary surgery.2
I used two types, Abbott Opticath and Edwards Lifesciences Swan-Ganz CCOmbo CCO/SvO2, with no obvious differences in the difficulty in passing through the pulmonary valve. However, the softer Arrow catheters appeared to be easier to pass through the pulmonary valve.
In a few patients, transoesophageal echocardiography was used to guide the PAFC, in patients for tricuspid annuloplasty, and we did not see any air embolism during the introduction of the PAFC.
This position of the patient places the pulmonary valve at the highest point of the right ventricle. Because the air filled balloon floats upwards it is thus directed more easily by the blood flow to pass directly into the pulmonary artery. The tendency of the balloon to float is more important than the effect of flow direction during insertion of a balloon flotation catheter.5
Probably, our end-inspiratory hold manoeuvre causes congestion of the pulmonary vessels, which may dilate the pulmonary artery opening. This may help to pass the balloon into the pulmonary artery. If a reflex increase in heart rate and contractility is caused, then this would augment forward flow even if venous return were reduced.6 However the exact mechanism of the method is not clear at the moment.
This simple clinical technique can be a used in routine practice to facilitate insertion of a PAFC during anaesthesia. This method may reduce the risk of ventricular arrhythmias, and could be particularly useful in high-risk critically ill patients. The underlying physiological mechanism remains to be clarified.
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Acknowledgements |
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References |
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2 Wall MH, MacGregor DA, Kennedy DJ, et al. Pulmonary artery catheter placement for elective coronary artery bypass grafting: before or after anesthetic induction? Anesth Analg 2002; 94: 140915
3 Szabó Z, Håkanson E, Svedjeholm R. Early postoperative outcome and medium-term survival in 540 diabetic and 2239 nondiabetic patients undergoing coronary artery bypass grafting. Ann Thorac Surg 2002; 74: 7129
4 Iberti TJ, Benjamin E, Gruppi L, Raskin JM. Ventricular arrhythmias during pulmonary artery catheterization in the intensive care unit. Prospective study. Am J Med 1985; 78: 4514[ISI][Medline]
5 Parlow JL, Milne B, Cervenko FW. Balloon flotation is more important than flow direction in determining the position of flow-directed pulmonary artery catheters. J Cardiothorac Vasc Anesth 1992; 6: 203[Medline]
6 Porth CJ, Bamrah VS, Tristani FE, Smith JJ. The Valsalva maneuver: mechanisms and clinical implications. Heart Lung 1984; 13: 50718[ISI][Medline]