Poster 1030: Point-of-Care Ultrasound for Guiding Pulmonary Artery Catheter Placement

Background: Ultrasound is ubiquitous in perioperative and critical care clinical areas. Pulmonary artery catheters (PACs) remain an important part of cardiac assessment in heart failure and can be challenging to place. This is an important role ultrasound can facilitate and despite its having been described in PAC direction for four decades.

Methods: (Fig. 1)
1. Prepare and insert the PAC appropriately, insert it and transduce a distal tip pressure in the superior vena cava.
2. The PAC balloon is inflated. Obtain the right ventricular inflow view with the ultrasound , and the PAC is advanced such that it reads a right atrial pressure and is seen within the right atrium. Confirm the catheter in the right atrium using the pressure tracing and ultrasound.
3. Rotate the view into the parasternal short axis view at the level of the aortic valve. Observe passage of the catheter into the right ventricular outflow tract.
4. From this view advance the catheter through the pulmonary valve into the main pulmonary artery.
5. Move the probe laterally visualizing the main PA and bifurcation. Adjust the catheter tip and engage it to the branch PA orifice and advance the PAC.
6. If wedging the catheter is a goal but not possible bring the catheter back to the pulmonary artery bifurcation and rotate itsuch that it wedges in the other PA.

Outcome: 28 y/o female with heart failure with reduced ejection fraction of 20% presenting at 23 weeks gestation in pregnancy with preeclampsia and worsening respiratory distress. Intubated for flash pulmonary edema, emergency CSXN. Given concerns about heart failure management, decision made to place a PICC. The catheter was inserted to 75cm and would not wedge for a capillary wedge pressure. A chest X-ray revealed looping of the catheter in the right ventricle as well as at the pulmonary artery bifurcation (Fig. 2 left). Using POCUS the catheter was guided across an obstructive pulmonary valve annulus and directed from the left PA to the right PA under direct guidance with successful wedging of the PAC balloon for PCWP (Fig. 2 right).

Conclusion: This short communication describes a basic protocol for using cardiac POCUS in PAC placement and is accompanied by a practical case of a patient. A practical protocol empowers clinicians in placing these uncommon procedures with the possibility of improved success and delivery of therapy.