Is the described bedside Swan-Ganz (Pulmonary Artery Catheter) placement procedure in a critically ill, intubated patient in the ICU, using sterile precautions and continuous monitoring of the pressure waveform, accurate and following standard medical protocols?

Accuracy Assessment of Swan-Ganz Catheter Placement Procedure

The described Swan-Ganz catheter placement procedure is accurate and follows standard medical protocols, with appropriate sterile precautions, correct waveform interpretation, and proper safety measures throughout the insertion. 1

Sterile Technique and Access Site

The procedure correctly employed full sterile barriers as recommended:

• The provider appropriately wore sterile gown, gloves, mask, and cap, with a large sterile drape covering the patient's chest and neck, which aligns with standard central venous access protocols. 1
• The observer also correctly wore protective equipment (gown, head covering, gloves, and mask), demonstrating proper infection control practices. 1
• Subclavian vein access is an acceptable approach, though it carries approximately twice the complication rate (17%) compared to internal jugular access (8%). 2

Pressure Transducer Setup

The zeroing and leveling of the pressure transducer at the mid-thoracic line (phlebostatic axis) before catheter insertion was essential and correctly performed to ensure accurate pressure readings relative to the heart. 1

Balloon Testing

The pre-insertion balloon testing was performed correctly and is a critical safety step:

• Testing the balloon with 1.5 mL of air outside the body to confirm smooth expansion without leaking is mandatory before insertion to verify balloon integrity. 1
• This prevents the catastrophic complication of balloon rupture or air embolism during intracardiac manipulation. 3

Waveform-Guided Advancement

The continuous waveform monitoring and interpretation described was accurate and represents best practice:

Right Atrial Placement (15-20 cm depth):

• The observation of low pressures with characteristic "a" and "v" waves correctly identified right atrial placement. 1
• Normal right atrial pressure ranges from 2-8 mmHg. 1
• Inflating the balloon with 1.5 mL of air at this point to allow flow-directed advancement rather than pushing was the correct technique. 1, 4

Right Ventricular Waveform:

• The description of a tall, sharp systolic pressure spike with very low diastolic pressure nearly matching right atrial pressure accurately characterizes the right ventricular waveform. 1
• This waveform change confirms passage through the tricuspid valve. 1

Pulmonary Artery Waveform:

• The appearance of increased diastolic pressure and a distinct dicrotic notch (representing pulmonic valve closure) correctly confirmed pulmonary artery placement. 1
• This is the definitive waveform indicating proper catheter position. 5, 6

Critical Safety Measure: Immediate Balloon Deflation

The immediate deflation of the balloon after confirming pulmonary artery placement was absolutely correct and represents a critical safety measure to prevent the catheter from advancing too far or remaining in a wedged position, which could cause pulmonary artery rupture. 1

This is one of the most serious potential complications and the emphasis on this step demonstrates proper understanding of catheter safety. 3

Catheter Securing and Documentation

• Confirming catheter depth at the skin and securing with sutures and sterile dressing prevents migration and is standard practice. 1
• The depth documentation allows for detection of any subsequent catheter movement. 5

Emphasis on Continuous Waveform Monitoring

The providers' emphasis on watching the waveform continuously throughout advancement is essential, as advancing without observing the tracing or inflating the balloon in the wrong chamber can cause ventricular arrhythmias or serious complications such as pulmonary artery injury. 1, 3

This represents appropriate teaching and adherence to safety protocols. 7

Catheter Lumen Understanding

The description of catheter lumens was accurate:

• The proximal lumen opening in the right atrium (30 cm from tip) measures central venous pressure (CVP). 1
• The distal lumen at the catheter tip measures pulmonary artery pressure (PAP) continuously and pulmonary capillary wedge pressure (PCWP) when the balloon is inflated. 1
• Normal PCWP ranges from 6-12 mmHg, with values >15 mmHg indicating elevated left ventricular filling pressures. 1

Ultrasound Visualization

The ability to identify the right atrium, tricuspid valve, and right ventricle on ultrasound during the procedure represents advanced monitoring and is increasingly used to guide catheter placement, though not universally required. 2

Common Pitfalls Appropriately Avoided

The procedure avoided several critical errors:

• Excessive balloon inflation was avoided (using the correct 1.5 mL volume), preventing spuriously high pressure measurements and potential vessel injury. 5
• The balloon was never inflated without first confirming appropriate waveform, preventing distal migration and vessel rupture. 1
• The catheter was not advanced blindly without waveform guidance, avoiding ventricular arrhythmias and cardiac perforation. 3

Post-Procedure Considerations

While not mentioned in the contact log, important ongoing management includes:

• Limiting catheter residence time to 5-7 days maximum due to increasing infection and vessel injury risk. 1
• Routine chest radiograph following placement to confirm position and exclude pneumothorax (occurs in approximately 2% of cases with subclavian approach). 2
• Never inflating the balloon without first checking for waveform damping, which indicates distal migration. 1