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High cardiac output by a continuous cardiac output pulmonary artery catheter
DIAGNOSTIC DILEMMAS Steven Konstadt, MD Section Editor
High Cardiac Output by a Continuous Cardiac Output Pulmonary Artery Catheter Samir G. Sakka, MD, DEAA, and Egbert Huettemann, MD, DEAA
A
60-YEAR-OLD man with an orthotopic heart transplantation 7 months previously for congestive cardiomyopathy developed histologically proven acute transplant rejection and was admitted to the intensive care unit. Initially, he was hemo-
From the Department of Anesthesiology and Intensive Care Medicine, Friedrich-Schiller-University of Jena, Jena, Federal Republic of Germany. Address reprint requests to Samir G. Sakka, MD, DEAA, Department of Anesthesiology and Intensive Care Medicine, Friedrich-SchillerUniversity of Jena, Bachstrasse 18, D-077433 Jena, Federal Republic of Germany. E-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 1053-0770/02/1606-0022$35.00/0 doi:10.1053/jcan.2002.128430 Key words: hemodynamic monitoring, pulmonary artery catheterization, cardiac output measurement, septic shock
dynamically stable while receiving dobutamine and nitroglycerin. After several days of reinforced immunosuppression, however, he developed pneumonia and septic shock. An intraaortic balloon pump was inserted by the cardiac surgeons to improve myocardial perfusion and function. In parallel, a continuous cardiac output (CO)–measuring pulmonary artery catheter was advanced via the internal right jugular vein. Continuous pressure recordings showed correct passage through the superior vena cava, right ventricle, and pulmonary artery. The pulmonary artery pressure curve was obtained after 60 cm, and the catheter was advanced further to 80 cm in an attempt to obtain a wedge pressure tracing, which, however, remained unsuccessful. A mixed venous blood sample was taken and revealed an oxygen saturation of 73%. During fixation of the catheter, measurement of continuous CO was started. Over the first sampling minutes, CO values of about 20 L/min were obtained (Fig 1). What is the diagnosis?
Fig 1. Screen display after connecting the pulmonary artery catheter to a continuous cardiac output and mixed-venous oxygen saturation monitor.
780
Journal of Cardiothoracic and Vascular Anesthesia, Vol 16, No 6 (December), 2002: pp 780-781
DIAGNOSTIC DILEMMAS
781
DIAGNOSIS: MALPOSITION OF THE PULMONARY ARTERY CATHETER WITH COILING IN THE RIGHT MAIN PULMONARY ARTERY
A variety of malpositions and complications have been reported for central and pulmonary artery catheterization.1 Malpositions include catheterization of the pericardiacophrenic or azygos veins and coronary sinus.2-4 Looping of central venous catheters has been described.5 In this case, the chest radiograph revealed coiling of the catheter tip, which turned back in the right main pulmonary artery toward the main pulmonary artery (Fig 2). The fact that wedge pressure could not be obtained is explained by this malposition. This particular position, in which the measuring thermistor and the continuous heating filament faced each other, is responsible for the high CO values. In principle, catheter technology for continuous measurement of CO and oxygen saturation has been validated.6 Technical conditions, as reported in this case, may lead to unexplainable CO values, however, and should be considered. In this case, the catheter was withdrawn and successfully reinserted (x-ray control). Subsequently, CO values between 3.5 and 4 L/min were obtained. The patient developed multiple organ failure despite a broad antibiotic regimen and died as a
Fig 2. Chest radiograph control showing incorrect pulmonary artery catheter position with facing thermistor and heating filament. PAC tip, pulmonary artery catheter tip; IABP, intra-aortic balloon pump.
result of septic shock unresponsive to high vasopressor treatment.
REFERENCES 1. Muhm M, Sunder-Plassmann G, Apsner R, et al: Malposition of central venous catheters: Incidence, management and preventive practices. Wien Klin Wochenschr 109:400-405, 1997 2. Khan F, Khan F: A rare misplacement of a central venous catheter. Eur J Anaesthesiol 17:527-528, 2000 3. Bankier AA, Mallek R, Wiesmayr MN, et al: Azygos arch cannulation by central venous catheters: Radiographic detection of malposition and subsequent complications. J Thorac Imaging 12:64-69, 1997
4. Sarti A, Calamandrei M, Messeri A, Busoni P: Malposition of a central venous catheter in the coronary sinus of an 8-month-old infant. Can Anesthesiol 36:571-573, 1988 5. Malatinsky J, Kadlic T, Majek M, Samel M: Misplacement and loop formation of central venous catheters. Acta Anaesthesiol Scand 20:237-247, 1976 6. Yelderman ML, Ramsay MA, Quinn MD, et al: Continuous thermodilution cardiac output measurement in intensive care unit patients. J Cardiothorac Vasc Anesth 6:270-274, 1992
High Cardiac Output by a Continuous Cardiac Output Pulmonary Artery Catheter Samir G. Sakka, MD, DEAA, and Egbert Huettemann, MD, DEAA
A
60-YEAR-OLD man with an orthotopic heart transplantation 7 months previously for congestive cardiomyopathy developed histologically proven acute transplant rejection and was admitted to the intensive care unit. Initially, he was hemo-
From the Department of Anesthesiology and Intensive Care Medicine, Friedrich-Schiller-University of Jena, Jena, Federal Republic of Germany. Address reprint requests to Samir G. Sakka, MD, DEAA, Department of Anesthesiology and Intensive Care Medicine, Friedrich-SchillerUniversity of Jena, Bachstrasse 18, D-077433 Jena, Federal Republic of Germany. E-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 1053-0770/02/1606-0022$35.00/0 doi:10.1053/jcan.2002.128430 Key words: hemodynamic monitoring, pulmonary artery catheterization, cardiac output measurement, septic shock
dynamically stable while receiving dobutamine and nitroglycerin. After several days of reinforced immunosuppression, however, he developed pneumonia and septic shock. An intraaortic balloon pump was inserted by the cardiac surgeons to improve myocardial perfusion and function. In parallel, a continuous cardiac output (CO)–measuring pulmonary artery catheter was advanced via the internal right jugular vein. Continuous pressure recordings showed correct passage through the superior vena cava, right ventricle, and pulmonary artery. The pulmonary artery pressure curve was obtained after 60 cm, and the catheter was advanced further to 80 cm in an attempt to obtain a wedge pressure tracing, which, however, remained unsuccessful. A mixed venous blood sample was taken and revealed an oxygen saturation of 73%. During fixation of the catheter, measurement of continuous CO was started. Over the first sampling minutes, CO values of about 20 L/min were obtained (Fig 1). What is the diagnosis?
Fig 1. Screen display after connecting the pulmonary artery catheter to a continuous cardiac output and mixed-venous oxygen saturation monitor.
780
Journal of Cardiothoracic and Vascular Anesthesia, Vol 16, No 6 (December), 2002: pp 780-781
DIAGNOSTIC DILEMMAS
781
DIAGNOSIS: MALPOSITION OF THE PULMONARY ARTERY CATHETER WITH COILING IN THE RIGHT MAIN PULMONARY ARTERY
A variety of malpositions and complications have been reported for central and pulmonary artery catheterization.1 Malpositions include catheterization of the pericardiacophrenic or azygos veins and coronary sinus.2-4 Looping of central venous catheters has been described.5 In this case, the chest radiograph revealed coiling of the catheter tip, which turned back in the right main pulmonary artery toward the main pulmonary artery (Fig 2). The fact that wedge pressure could not be obtained is explained by this malposition. This particular position, in which the measuring thermistor and the continuous heating filament faced each other, is responsible for the high CO values. In principle, catheter technology for continuous measurement of CO and oxygen saturation has been validated.6 Technical conditions, as reported in this case, may lead to unexplainable CO values, however, and should be considered. In this case, the catheter was withdrawn and successfully reinserted (x-ray control). Subsequently, CO values between 3.5 and 4 L/min were obtained. The patient developed multiple organ failure despite a broad antibiotic regimen and died as a
Fig 2. Chest radiograph control showing incorrect pulmonary artery catheter position with facing thermistor and heating filament. PAC tip, pulmonary artery catheter tip; IABP, intra-aortic balloon pump.
result of septic shock unresponsive to high vasopressor treatment.
REFERENCES 1. Muhm M, Sunder-Plassmann G, Apsner R, et al: Malposition of central venous catheters: Incidence, management and preventive practices. Wien Klin Wochenschr 109:400-405, 1997 2. Khan F, Khan F: A rare misplacement of a central venous catheter. Eur J Anaesthesiol 17:527-528, 2000 3. Bankier AA, Mallek R, Wiesmayr MN, et al: Azygos arch cannulation by central venous catheters: Radiographic detection of malposition and subsequent complications. J Thorac Imaging 12:64-69, 1997
4. Sarti A, Calamandrei M, Messeri A, Busoni P: Malposition of a central venous catheter in the coronary sinus of an 8-month-old infant. Can Anesthesiol 36:571-573, 1988 5. Malatinsky J, Kadlic T, Majek M, Samel M: Misplacement and loop formation of central venous catheters. Acta Anaesthesiol Scand 20:237-247, 1976 6. Yelderman ML, Ramsay MA, Quinn MD, et al: Continuous thermodilution cardiac output measurement in intensive care unit patients. J Cardiothorac Vasc Anesth 6:270-274, 1992