I am fan of using of PACs long time ago. I am just try to utilize the cardiac cycle to move it. It looks like a boat floating through the heart. First; i have to think if i really need it and it will affect the patient’s outcome? Are there any alternatives? Second; I noticed that you are using for liver transplant recipients. Those unique patients might have significant pulmonary hypertension with functional pulmonary and moderate to severe tricuspid regurgitations. This might explain failure to float the PCA in half of them. Third; could you tell us where was the exact site of most of these problems? Fourth; the golden basic rule is to advance the PAC in a steady and relatively fast manner to avoid its softness from the blood temperature.
I am utilizing the tricks in textbooks and it works well, as follows:
– If the PAC failed to float through the tricuspid valve after 30-35 cm according to preoperative Echo derived diameters of the right atrium, I first ensure intactness of the balloon, reinsert it with its natural curve at 11′ o’clock, retry; if it fails; i withdraw it back to 20 cm after deflation of the balloon and i put the patient, as you are doing, in head down position and re-float it again. If it does not go ahead, I deflate the ballon, re-withdraw it back to 20 cm, put the patient’s table in head down position, and fill the balloon with 1.5 cc of saline rather than air. Then i replace the saline with air. The latter is usually helpful in patients with tricuspid regurgitation.
– if the PAC failed to advance to the pulmonary artery (PA); I do one or more of the followings: I withdraw the PAC to 35-40 cm according to diameters of the RV after deflation of balloon; inject cold saline to stiff it, put the patient’s table with right side up and head up, inject 100-300 mg of calcium chloride in the pulmonary artery branch of the PAC during flotation to augment forward flow from the RV to the PA and use fluoroscopic guidance with C-Arm to avoid coiling or knotting of the PAC.
– If I could not get the wedging waveform after advancement to a distance of 50-60 cm, I withdraw it back 3-5 cm after deflation and I use the diastolic pulmonary pressure minus 2 mm Hg as the PA occlusion pressure; except in cases when its exact value is mandatory. BTW, the incidence of this is about 20-30% of cases in textbooks.
However, sometimes, it was not my day, so i got it out and thought about alternatives.
Paul Marino; The ICU Book
Shoemaker’s Critical Care Textbook