CARDIOVASCULAR MONITORING

NON INVASIVE
AND INVASIVE

MODERATORS: DR.AMMINIKUTTY
DR.PRASEETHA
 Introduction
• Cardiac monitoring
1. Noninvasive -Stethoscopy
-Pulse Oximetry
- Non Invasive BP
- ECG
- Trans Esophageal Echo
2. Invasive-Central Venous Pressure
-Invasive BP -Pulmonary Arterial Pressure
• Heart rate monitoring
• SUBJECTIVE METHODS ;
• Palpation of pulse
• Auscultation of heart
•
• OBJECTIVE METHODS
• Non invasive
• electrocardiogram
• pulse plethysmograph
• Invasive
• wave forms of IBP
 STETHOSCOPY

• HR & breath sounds monitored

• Introduced by Laennec in 1818

- Precordial
at 4th ICS near left sternal border
- Oesophageal
Tip 28 -30 cm from incisor
 PULSE OXIMETRY
• Called the 5th vital sign.
• Works by analyzing the pulsatile arterial
component of blood flow
• Two wavelengths of light are used, usually
660 nm (red) and 940 nm (infrared).
• Measuring Hb saturation[SpO2] from the
differential absorption of red [660nm] and
infrared light[940nm] in tissues.
 PULSE OXIMETRY
.
• Reduced Hb absorbs more light in red band
• Oxy Hb absorbs more light in infrared band.
• Photodiode measures amount of light
transmitted
• Ratio between these 2 are related to arterial O2
saturation.
• Combines two techniques-
spectrophotometry(O2 saturation) & optical
plethysmography(pulsatile changes in arterial
blood vol at sensor site).
• Spectrophotometry-based on BEER-LAMBERT law-
relates conc of a solute to intensity of light transmitted
through a solution. Based on the formula
• A =DCE
• A-absorption
• D-distance the light
travelled/path length
• C-concn of the solute(Hb)
• E-extinction coeff of the solute-a constant for
each solute
• Pulse oximeter-parts
• Probe
Contains LEDs [photodiodes] and photo
detectors.
• Processor
• CABLE-probe is connected to oximeter by a
cable.
 Types

• TRANSMISSION PULSE OXIMETRY

– Most common type
• Light beam is transmitted through a vascular bed
and is detected on the opposite side of that bed.
• REFLECTANCE PULSE OXIMETRY
– Relies on light that is reflected back to determine O2
saturation.
MULTIWAVELENGTH PULSE OXIMETRY-helps in detection
of additional Hb
 disadvantages
• Poor function with hypothermia,low
co,vasoconstriction
• Poor function with poor perfusion
• Delayed hypoxic event detection
• Less accuracy with low O2 saturation
• In anaemia-overestimation of O2 saturation
• Deep skin pigmentation and nail polish can result in
reduced signal
• Not useful to assess adequacy of ventillation and gas
exchange
• Optical interference from incident light
• Electrical interference from electrosurgical unit.
NONINVASIVE BLOOD PRESSURE
 BLOOD PRESSURE MONITORING
• Measure of force the circulating blood exerts against
arterial wall
• An increase in the BP - reflect an increase in CO or
SVR
• Pulse Pressure(PP) SBP-DBP
• Mean Arterial Pressure - DBP+ 1/3 PP or
SBP +2DBP/3
 TECHNIQUES

• Palpation

• Doppler probe

• Auscultation

• Oscillometry

• Arterial Tonometry
 PALPATORY METHOD

• Using sphygmomanometer
• Invented by Italian physician – 1896
Riva Rocci
• Measures systolic blood pressure(SBP)

– Riva rocci method - pressure at which pulse

disappears during inflation-SBP.

-Return to flow technique - systolic BP-pressure at

which pulse reappears during deflation
 AUSCULTATORY METHOD
• Russian surgeon – Nikolai Korotkoff discovered
that sounds were present as cuff was deflated
• Sounds produced by turbulent flow beyond the
partially occluding cuff
• KOROTKOFF SOUNDS-
SBP-appearance of first korotkoff sound
DBP- muffling/disappearance of sound.
 DIMENSIONS OF CUFF
• Bladder length 80% &
width 40% of arm
circumference.
• Cuff too large - produce
• Cuffs too small -
overestimation of BP
• Cuff deflation rate -
3mm of Hg/sec
 Automated Intermittent Technique

• Described by Von reckling haussen in 1931.

• Based on oscillometry.
• Variations in cuff pressure from arterial
pulsations during cuff deflation are sensed by
the monitors
• Only the mean arterial BP is determined by
oscillatory BP devices
 BP monitoring

• Auscultatory method = measure SBP and DBP

and estimate MAP
• Oscillometric method = measure MAP and
estimate SBP and DBP
• Oscillometric method can also be used
determine BP manually using a standard cuff
and aneroid manometer
• If the cuff is deflated slowly until the
needle on the aneroid gauge begins to
flicker or oscillate, this pressure value will
provide a close estimate for systolic blood
pressure.
 Automated Continuous Technique
• Measures finger BP by an arterial clamp method
– Designed by Penaz in 1973.
– Inflatable,flexible cuff secured around middle phalanx of a
finger or base of thumb.
– Plethysmograph continually measures diameter of digital
artery by transillumination
– It measures the distal arterial pressure.
– It may be higher than brachial artery pressure in adults with
atherosclerosis & lower than brachial artery pressure in
young pts.
– Disadvantage-
potential for circulatory impairment of distal end of finger.
 COMPLICATIONS
• Pain

• Petechiae & Ecchymosis

• Limb edema

• Venous stasis & Thrombophlebitis

• Peripheral neuropathy

• Compartment syndrome
 ECG
• Graphical record of electrical activity of heart.
• Invented by William Einthoven in 1901.
• Perioperative settings 2 functions
Diagnosis & Monitoring
 ECG-BASIC PRINCIPLE
• Electric currents by the electrical activity of
cardiac muscle be recorded at various sites on the
surface of the body as electrocardiographic
signals.

• Potentials reaching the skin are recorded by

electrodes (leads) placed at specific locations

• And the output of these leads is amplified,

filtered, and displayed on various electronic
devices.
 ECG Leads
• 2 Types of ECG Leads
-Bipolar-standard limb leads
-Unipolar-augmented limb leads
• Bipolar2 electrodes placed at different sites
to measure difference in potential between
them.
• Unipolar absolute electrical potential at one
site in relation to a reference or remote site at
which potential is deemed to be zero.
 ECG Leads
Standard clinical ECG recording from 12
leads.
-Bipolar(LI, LII, LIII)
-Unipolar precordial (V1-V6)
-Modified unipolar limb leads-augmented
limb leads (a VR, a VL, a VF).
 WAVES AND INTERVALS OF ECG

• P wave- atrial depolarization

• QRS complex - ventricular

depolarization

• T wave - ventricular
repolarization.

• U wave – slow & late

repolarization of intraventricular
Purkinje system.
WAVES AND INTERVALS OF ECG
Modified Three Electrode Systems
• Simplest and most common mode of ECG monitoring in operating
rooms and intensive care units.

• It allows monitoring of three bipolar leads by recording the

potential difference between each of three pairs of electrodes
lead I , lead II , lead III or other modified chest leads.
 FIVE-ELECTRODE MONITORING
• 4 limb leads- LA, RA, LL, RL
• Fifth chest electrode placed in
V1 through V6 locations
• V1 preferred for arrhythmia
monitoring
• V3 to V5 preferred for ischemia
monitoring.
• Currently Standard for
monitoring in suspected
perioperative myocardial
ischemia.
 TEN-ELECTRODE MONITORING
• Mason and Likar in 1966
• ST-segment monitoring software-
analyze all 12 leads - sound alarm
for ST-segment changes
• >1 precordial lead displayed at same
time.
Disadvantages
• 10 electrodes are required
• 6 precordial electrodes interfere with
diagnostic & emergency procedures.
• the precordial sites are difficult to
maintain on patients with large
breasts or hirsute chest
 DETECTION OF MYOCARDIAL ISCHEMIA

• ST segment - most important portion ECG for

evaluating ischemia
Other signs
• T-wave inversion
• QRS and T-wave axis alterations,
• R- or U-wave changes
• Development of previously undocumented
arrhythmias /ventricular ectopy.
None of these is as specific as ST-segment
depression/elevation.
 Ischemia monitoring
• >1 mm (0.1 mV) of
horizontal or down-
sloping ST-segment
depression measured 60
to 80 msec after the J
point in at least three
consecutive beats with a
stable baseline.
• may be accompanied by
T-wave flattening or
inversion
11/03/2023 06:08 AM 36
 WHY ST SEGMENT
• Easy to locate.
• Usually isoelectric.
• ST segment - phase 2 of repolarization
• Ischemia - repolarization is affected- downsloping
or horizontal ST-segment depression.
• Subendocardial injury - the ST segment is
depressed in the surface leads.
• Epicardial or transmural injury- the ST segment is
elevated
 ST SEGMENT MONITORING
Sensitivity of leads to detect ST changes
• V5 – 75%
• V4 – 61%
• V5 & V4 - 90%
• II & V5 – 80%
• II, V4 & V5- 98%
 TRANS ESOPHAGEAL ECHO
• Provides extremely valuable information about
cardiac anatomy and function during surgery.

• Two dimentional multiplane Transesophageal Echo

can detect regional and global ventricular
abnormalities, chamber dimensions valvular anatomy
and presence of intracardiac air.

• Uses principle of compression and rarefaction, using

a transducer generating vibrations
 IMAGING TECHNIQUES
• M mode-density & position of all tissues in a
narrow beam of ultrasound are displayed as a
scroll on a video screen
• 2D mode-repetitive scanning along different
radii with in an area in the shape of a fan—
generates 2D sections of heart.
• DOPPLER-doppler is combined with 2D
images- Blood flow velocity, direction &
accelerations can be determined.
 TEE APPLICATION
• Assessing ventricular function.
• Assessing valvular function
• Examination of residual air in all open heart
surgeries.
• Assessment of other cardiac structures and
abnormalities like ASD,VSD, pericardial
disease.
 PROBE PLACEMENT
• Patient is anaesthetised
• Trachea is intubated,
contents of stomach are
suctioned.
• Patent’s neck is then
extended
• A well lubricated TOE
probe is introduced into the
midline of hypopharynx with
transducer side facing
anteriorly.
 INDICATIONS OF TEE

• Intraoperative evaluation of acute persistent and life

threatening hemodynamic disturbances.
• Intra operative monitoring in
1. Valve repair
2. HOCM
3. Congenital heart surgery
4. Endocarditis
5. Aortic dissection
6. Pericardial window procedure
 INDICATIONS OF TEE

• Preoperative use in unstable patients with suspected

thoracic aortic aneurysms, dissections or disruption.

• Use in ICU for unstable patients with un explained

hemodynamic disturbances, suspected valve dis or
thromboembolic problems.
 CONTRAINDICATIONS
ABSOLUTE RELATIVE

• Esophageal spasm/ • Large diaphragmatic

stricture/ hernia
laceration/perforation • Atlanto axial disease and
• Esophageal diverticula severe generalized cervical
arthritis.
• Poor airway control
• Patients who received
• Unrepaired TEF
extensive radiation to the
• Severe respiratory mediastinum.
depression
• Upper gastrointestinal
bleeding,
• Significant dysphagia and
odynophagia
• Severe coagulopathy
INVASIVE CARDIAC MONITORING
 INVASIVE ARTERIAL PRESSURE
MONITORING
• Accepted reference standard for blood
pressure monitoring

• Provides beat to beat information on

hemodynamic status
 INDICATIONS
1. Major or complicated surgery and periopertive
period –hemodynamic instability & major fluid shift
anticipated
2. Critical state requiring intensive care& life support
systems
3. Planned pharmacological or mechanical
cardiovascular manipulation
4. Repeated blood sampling
5. Failure of indirect arterial blood pressure
measurement
6. Supplementary diagnostic information arterial wave
form
 CONTRAINDICATIONS
1. Local infection

2. Coagulopathy

3. Proximal obstruction

4. Peripheral vascular diseases

 ROUTES OF CANNULATION
1. Radial artery—most common site
2. Ulnar artery
3. Brachial artery
4. Axillary artery
5. Dorsalis pedis & post tibial artery
6. Femoral artery
7. Superficial temporal artery
 RADIAL ARTEY CANNULATION
TECHNIQUE
• Hand is supinated, dorsiflexed to a 50 degree angle

• A small roll of towel placed under the wrist

• Radial artery palpated proximal to the wrist

• Skin prepared with alcohol/iodine

• Awake patient-skin is infiltrated with local

anaesthetic
 RADIAL ARTEY CANNULATION
TECHNIQUE
• Catheter over needle assembly advanced
towards the palpated artery at an angle of 30
degree
• As artery is punctured, bright red blood
flashes back within the reservoir
• Angle of cannula reduced to 10 degree &
needle-catheter assembly advanced I or 2 mm
• Needle is fixed and cannula advanced into the
artery
 RADIAL ARTEY CANNULATION
TECHNIQUE
• Radial artery is occluded proximally, needle is
removed

• Cannula is connected to the monitoring

system
 TECHNIQUES OF CANNULATION

• 1.Direct cannulation

– Arterial puncture and threading of the cannula

performed directly
– Without the aid of guide wire
 2.Transfixation
• Both needle and catheter are advanced through
and through the artery

• Needle is completely withdrawn then

• Catheter is slowly withdrawn –pulsatile blood

flow emerges when tip is in the lumen

• Catheter is advanced into the artery

 3.Seldinger technique
• Artery is localized with a needle

• A guide wire is passed through the

needle into the artery

• Needle withdrawn, guide wire

retained

• A catheter is passed over the wire

into the artery

• Guide wire removed then

• Routinely performed for femoral

artery cannulation
• 4.Doppler –assisted technique

– Artery is localised using Doppler flow probe

– Used in small children&infants

• 5.Surgical cut down

 COMPLICATIONS OF ARTERIAL
CANNULATION
1. Distal ischemia
2. Infection
3. Arterial embolisation
4. Hemorrhage
5. Peripheral neuropathy, skin necrosis
6. Retained guidewire requiring extraction
7. Late vascular complications-Pseudo aneurysm ,
arteriovenous fistula
8. Misinterpretation of data
9. Misuse of equipment
 PRESSURE MONITORING
SYSTEM

• 4 main sub systems

1. Fluid mechanical coupling system

2. Transducer
3. Electronic components
4. Display
FLUID MECHANICAL COUPLING
SYSTEM
 TRANSDUCER SETUP
ZEROING,CALIBRATING&LEVELLING
• Before initiating patient monitoring,
Pressure transducer must be zeroed , calibrated
and leveled to appropriate position on the
patient.
• Static calibration—calibration against a known
static pressure
-expose the transducer to atmospheric pressure
by opening the stopcock to air
-electrical zero by pressing zero pressure button
 CALIBRATION OF TRANSDUCER

• Performed by exposing the transducer to a

known pressure—usually mercury manometer
 LEVELLING
• The pressure monitoring zero point is leveled to appropriate
position on the patient
• In supine patient leveled to midchest position in the midaxillary line
• False low or high value as transducer kept above or below the level
of heart
 ARTERIAL PRESSURE WAVEFORM

1. Systolic upstroke
2. Systolic peak pressure
3. Systolic decline
4. Dicrotic notch
5. Diastolic run off
6. End diastolic pressure
 ARTERIAL PRESSURE WAVEFORM

• Systolic components follows R wave

• Systolic upstroke, systolic peak,& decline
--Corresponds to LV ejection
• Dicrotic notch—related to aortic valve closure
– incisura-recorded from central aorta
– Sharply defined
– Peripheral arterial waveform-later, smoother one
• Diastolic decline follows T wave
• End diastolic pressure
 ARTERIAL PRESSURE WAVEFORM
PERIPHERAL ARTERY
• Systolic upstroke begins 60
millisec after aortic upstroke
• Arterial upstroke steeper
• Systolic peaks becomes
higher
• Dicrotic notch appears later
• Dicrotic wave more
prominent
• End diastolic pressure
becomes lower
• MAP does not differ
 ARTERIAL PRESSURE WAVEFORM
(ABNORMAL)
1. Aortic stenosis

2. Aortic regurgitation-Bisferien’s pulse

3. Hypertrophic cardiomyopathy-Spike and dome

pulse

4. Systolic LV failure-Pulsus alternans

5. Cardiac tamponade-Pulsus paradoxus

CVP
 Central Venous Pressure (CVP)
• CVP is the filling pressure of the right atrium
• Correlates with Left heart filling pressure only
when good LV function
• Important determinant of CO& Venous return
 INDICATIONS FOR CENTRAL
VENOUS CANNULATION
• CVP monitoring
• Pulmonary artery catheterization & monitoring
• Transvenous cardiac pacing
• Temporary hemodialysis
• Drug administration
– chemotherapy
– drugs irritating to peripheral veins
– prolonged antibiotic therapy
(endocarditis)
 INDICATIONS FOR C V C
• Rapid fluid infusion
• trauma
• major surgery
• Aspiration of air emboli
• Inadequate peripheral iv access
• Sampling site for repeated blood testing
 CONTRAINDICATIONS
• ABSOLUTE
– Superior venacaval syndrome
• RELATIVE
– Infection at site of insertion
– Coagulopathies
– Newly inserted pacemaker wires –may get
dislodged
 CVC CANNULATION SITES
• 6 MAJOR SITES:
1) BASILIC VEIN
2) EJV
3) IJV
4) SUBCLAVIAN
5) AXILLARY
6) FEMORAL
 ANATOMICAL LANDMARKS

• Sternal notch

• Clavicle

• Sternocleidomastoid muscle
Figure 40-20 Technique for central venous cannulation of the right internal jugular vein. A,
Important surface landmarks are identified. B, The course of the
internal carotid artery is palpated. C, The internal jugular vein is punctured at the apex of
the triangle formed by the two heads of the sternocleidomastoid
muscle, with the needle tip directed toward the ipsilateral nipple. D, A guidewire is
introduced through the thin-walled needle into the vein. E, The central
venous cannula is inserted over the guidewire while making sure that the proximal end of
the guidewire protrudes beyond the catheter and is controlled by
 Monitoring

– SPO2

– NIBP

– ECG
 Procedure
• Palpate Carotid Artery
– Lateral to Trachea
– Under medial head of sternocleidomastoid
• Internal Jugular Vein
– In the groove between sternal & clavicular Head
– Lateral & slightly anterior to the carotid
 Methods for confirmation

• Chest X ray
• Colour of the aspirated blood
• Pressure monitoring using transducer.
• The use of ultrasound.
 Why Right IJV is preferred?
• Short straight course to SVC
• Predictable anatomic location
• Readily identifiable
• Palpable surface landmarks
• More accessible to anaesthetist
• High success rate.(90-99%)
 LEFT I J V
Problems
• Left cupola of the pleura is higher
• Thoracic duct injury
• Left IJV is of smaller diameter than Right IJV
• Vascular injury
 ADVANTAGE OF SUBCLAVIAN
CANNULATION

• Low risk of infection

• Ease of insertion in trauma patients
• Patient comfort for long term iv therapy
– hyperalimentation
– chemotherapy
 INFRACLAVICULAR APPROACH
• Patient lied in
trendelenberg
position ,arms fully
adducted,head is turned
away from side
• Folded sheet between
shoulder blades to fully
expose the area
• Skin is punctured 2-3 cm
caudal to midpoint of
clavicle
• Tip directed towards
suprasternal notch
• Once subclavian vein
punctured catheterisation
proceeds
 EXTERNAL JUGULAR VEIN
• Superficial vein
• Presence of two sets of valves within it &
acute angle at the junction with subclavian
vein
• Safe technique in bleeding diathesis
 Peripherally Inserted Central Venous
Catheters
• Placed under local anaesthesia
• Low risk of insertion related complications
• Slightly higher pressure than the pressure
measured with centrally inserted catheters.
• For long-term therapeutic indications
(chemotherapy or parenteral nutrition)
• Use very flexible, non thrombogenic silicone
catheters.
 CENTRAL VENOUS PRESSURE
WAVEFORM
• Related to phases
&mechanical events of
cardiac cycle
• 3 peaks-a,c,v
• 2 descents-x,y
• a-wave of atrial contraction
occurs at end diastole after
P’wave
• c-wave occurs in early
systole -tricuspid valve
displaced towards atrium in
isovolumetric
contraction .Follows R wave
 CENTRAL VENOUS PRESSURE
WAVEFORM
• x descent-midsystolic
collapse of atrial pressure
• v wave- venous filling of
atrium in late systole ,while
tricuspid valve remains
closed. After T wave
• y descent –in early diastole
—tricuspid valve opens &
blood flows from atrium to
ventricle
 ABNORMAL CVP WAVEFORMS

• ATRIAL FIBRILLATION
• a’ wave disappears , c’wave more prominent

• ATRIOVENTRICULAR DISSOCIATION
• Tall cannon a’waves –atrial contraction occurs
during ventricular systole
 Tricuspid regurgitation and Tricuspid
stenosis
• Tricuspid regurgitation-Broad& tall systolic c-v
wave ,loss of x’descent

• TRICUSPID STENOSIS-Tall a wave, attenuation

of y descent
Abnormal CVP Waveforms
 Complications of CVP monitoring
• Mechanical
• Vascular injury
– Arterial
– Venous
– Cardiac tamponade
• Respiratory compromise
– Airway compression from hematoma
– pneumothoax
• Nerve injury
 Complications of CVP monitoring
• Arrhythmias
• Thromboembolic
– Venous thrombosis
– Pulmonary embolism
– Arteial thrombosis&embolism
• Infectious
– Insertion site infection
– Catheter infection
– Blood stream infection
– Endocarditis
 Complications of CVP monitoring
• Misinterpretation of data

• Misuse of equipment
PULMONARY ARTERY CATHETER
 PULMONARY ARTERY CATHETER
MONITORING
• Introduced in 1970 by Swan,Gans& collegues

• Provides measurements of variables that

cannot be accurately predicted from standard
clinical signs & symptoms
 PULMONARY ARTERY CATHETER

• STANDARD PAC
• 7.0,7.5,8.0 French
circumference
• 110 cm length.
• Distance marked at 10cm
interval

• Introducer sheath throgh

which inserted is 7.5-
9French
 PULMONARY ARTERY CATHETER

• 4 separate internal lumens.

• 1.-leads to distal port at catheter tip-for PAP monitoring
• 2.leads to a proximal port approximately 30cm from catheter
tip -intended for CVP monitoring& fluid and drug
administration
• 3.leads to a baloon near catheter tip
• 4.contains fine wires leading to a temp thermistor,just
proximal to the baloon-to monitor pulmonary artery blood
temp as part of CO monitoring--thermodilution
 Pulmonary Artery Catheter:
Indications
• Hemodynamically
Shock of all types ifunstable patients
severe or prolonged

• Complex, acute hearttrauma

Severe, multisystem diseaseor large-area burn
injury
• Acute, severe pulmonary disease
• Major systems dysfunction undergoing
extensive operative procedures
 TECHNIQUE

• Pulmonary Artery Catheter can be placed from

any major central vein –usually Right IJV
• Introducer sheath is placed in central vein as
CVP catheter
• Introducer has a hemostatic valve at outer end
–PAC introduced through this
 TECHNIQUE
• PAC introduced through hemostatic valve with curvature
pointing to 11’o clock position
• After 20 cm insertion, a CVP tracing seen
• Once catheter inside RA, baloon is inflated with 1.5 ml air
• Catheter is advanced into RV through tricuspid valve
• Then into pulmonary artery & finally in the wedge position
• Characteristic waveform confirm proper catheter placement
 Pulmonary Artery Catheter:
Waveform
• As the pulmonary artery catheter is being inserted, its
movement can be followed on the bedside monitor by
observing various pressure waveforms as the catheter
passes freely from the right atrium to a wedged
position in the pulmonary artery

• When the tip of the catheter reaches the great vessels,

a CVP waveform appears on the monitor

• Right Atrial Pressure (RAP) normal: 1 to 5 mmHg

 Pulmonary Artery Catheter:
Waveform
- When the tip of the catheter passes through the
tricuspid valve into the right ventricle we see a
rapid increase in the height of the pressure
waveform
• Right Ventricular Pressure (RVP) normal: 15-
30/1-7 mmHg
• The tricuspid valve opens and blood begins to
flow into the ventricle, causing the pressure
wave to increase gradually
 Pulmonary Artery Catheter:
Waveform

Entry into the pulmonary artery is recognized by a change in the

diastolic portion of the waveform
• Pulmonary Artery Pressure (PAP) Normal: 15-30/4-12 mmHg

• The waveform is a miniature of the peripheral arterial waveform,

with a dicrotic notch and a gradual diastolic runoff that does not
drop to zero

• Pulmonary Capillary Wedge Pressure (PCWP, PA occlusion P)

normal: 4-12 mmHg
• The pulmonary artery waveform should return when the balloon is
deflated
 Pulmonary Artery Catheter:
Insertion
• Insertion: Subclavian or
internal jugular vein

Superior vena cave

Right atrium
– Normal pressure:
1 to 5 mmHg
 Pulmonary Artery Catheter:
Insertion
• Right ventricle • Pulmonary Artery
Normal pressure: 15-30 Normal Pressure: 15-30
mmHg mmHg

1-7 4-
12
 Pulmonary Artery Catheter:
Insertion
• “Wedge”
Location
– BranchPressure:
Normal 4-12 mmHg
of pulmonary artery
Pulmonary Artery Catheter:
Waveform
 Pulmonary Artery Catheter:
Complications
• Catheterization
1. Arrhythmias, ventricular fibrillation
2. Right bundle branch block, complete heart block
• Catheter residence
1. Mechanical, catheter knots
2. Thromboembolism
3. Pulmonary infarction
4. Infection, endocarditis
5. Endocardial damage, cardiac valve injury
6. Pulmonary artery rupture
7. Pulmonary artery pseudoaneurysm
• Misinterpretation of data
• Misuse of equipment
 NORMAL PULMONARY ARTERY WEDGE
PRESSURE WAVEFORMS
• Follows R wave of ECG
• Preceeds Radial Artery
upstroke
• Tall v wave
• Left atria less distenible
• Interval between atrial and
ventricular contraction is
longer on right 40millisec
• Composite a-c wave
Mitral Regurgitation-PAWP TRACING
• Tall v’ wave in early systole-
merges with c’ wave

• x descent is obliterated
 Mitral Stenosis-PAWP
• Raised mean PAWP

• Tall a wave

• Diastolic y descent
markedly attenuated