Critical Care Obstetrics part 23 doc

This study defi ned the normative ranges for middle cerebral artery velocity, resistance indices, and cerebral perfusion pressure during normal human pregnancy using longitudinally colle

that increased atrial distension in pre - eclampsia triggered a diuretic response

These data have been contested The most detailed study, to date, by Borghi et al [15] described detailed cardiac fi ndings among 40 women with mild pre - eclampsia compared to a control cohort of pregnant women and non - pregnant controls This study showed a progressive rise in left ventricular mass between non - pregnant women compared to normal pregnancy with a further increase in mass among women with pre - eclampsia Ejection fraction and fractional shortening decreased in normal pregnancy while not reaching statistical signifi cance However, women with pre - eclampsia had a signifi cant reduction in both these parameters in comparison to non - pregnant women In addition, left ventricular end - diastolic volume rose signifi cantly

in pre - eclampsia Together with a fall in cardiac output in the pre - eclamptic group, these fi ndings suggest a compensatory increase in ventricular size to maintain cardiac output against an elevated systemic vascular resistance

The latter study also showed changes in the peak fi lling velocities of the left ventricle during diastole The E/A ratio fell signifi -cantly during pregnancy, partly refl ecting increased preload In pre - eclamspsia further augmentation of the A - wave peak velocity resulted in further signifi cant reduction in the ratio Collectively these data support the notion of changes in both cardiac systolic and diastolic function The authors also measured ANP levels In keeping with previous studies elevated levels of ANP were found

in pregnancy with further increments occurring in pre - eclampsia These could not be accounted for by differences in atrial size although a signifi cant correlation was found between left ven-tricular mass and volume in women with pre - eclampsia [15]

Doppler ultrasound and cardiomyopathy

Doppler ultrasound has an important role in the management and evaluation of women with impaired ventricular function Echocardiography is used to delineate impaired left ventricular systolic function in women with suspected peripartum cardiomy-opathy It plays a further role in the ongoing evaluation of women once this diagnosis has been made Specifi cally the prognosis has been related to the normalization of left ventricular size and func-tion within 6 months of delivery [16] Currently accepted opinion

is that approximately 50% of affected women will recover normal function Those who have persistently impaired function face a signifi cant risk of mortality [16]

Subsequent pregnancies in women with a prior diagnosis of cardiomyopathy demand careful echocardiographic assessment Although no clear agreement exists regarding risk, those with persistently abnormal left ventricular function have been advised against pregnancy Confl icting reports have been made concern-ing those who become pregnant De Souza et al report on the evaluation of seven women who became pregnant after develop-ing peripartum cardiomyopathy in a previous pregnancy All pregnancies were well tolerated without signifi cant change in

patients The fi ndings of this study showed a high correlation

between invasive and non - invasive techniques in the

measure-ment of stroke volume and cardiac output Ventricular fi lling

pressures and pulmonary artery pressures also showed a similar

signifi cant correlation with invasive techniques [11]

The specifi c choice of echocardiographic technique for

esti-mating stroke volume and ejection fraction was explored in the

same group of patients Comparisons between M - mode and

two - dimensional Doppler techniques revealed similar fi ndings,

although M - mode echocardiography was not possible in 2 out of

11 subjects secondary to body habitus and paradoxical motion of

the intraventricular septum This study also allowed calculation

of the ejection fraction by dividing the stroke volume by the

end - diastolic volume Using this equation, similar results were

obtained by all the methods employed for estimating left

ven-tricular function in pregnant women [12]

Belfort et al have reported a series of 14 patients with an

indi-cation for invasive hemodynamic monitoring in whom Doppler

ultrasound was used as a guide to clinical management These 14

women had a spectrum of pathologies ranging from intractable

hypertension to complex cardiac lesions and included women

with oliguria and pulmonary edema This pilot study concluded

that the non - invasive monitoring had facilitated management

and only two patients went on to have invasive monitoring in

order to allow continuous monitoring Large volumes of fl uid

were administered to some of these patients (up to 8 L of

crystal-loid) without the development of fl uid overload or pulmonary

edema To date this is the only study that has indicated the

poten-tial utility of routine rapid echocardiographic assessment of left

ventricular function in critically ill obstetric patients [13]

Doppler ultrasound and pre - eclampsia

Doppler echocardiography has provided a ready means of

study-ing women at risk for developstudy-ing hypertensive complications

during pregnancy Longitudinal studies have demonstrated that

women with non - proteinuric or gestational hypertension

main-tain a hyperdynamic circulation with a high cardiac output

throughout pregnancy By contrast women destined to develop

pre - eclampsia have signifi cantly elevated cardiac output without

any change in systemic resistance in the preclinical phase of the

disease This is followed by a fall in cardiac output and increasing

resistance coincident with the onset of clinical disease [14]

More recently, studies have focused on echocardiographically

described cardiac structure and function in pre - eclampsia,

espe-cially in relation to levels of atrial and brain natriuretic peptide

(ANP, BNP) Initial work had related elevated ANP levels to

increased left atrial dimensions following delivery in normal

pregnancies These increased ANP levels did not lead to any

demonstrable diuresis in normal postpartum women Women

with pre - eclampsia had bigger atria and higher ANP levels in the

early puerperium and these changes were associated with

natri-uresis and dinatri-uresis The hypothesis related by these fi ndings was

abosorbs the infrared light more strongly (Figure 15.1 ) This allows the simultaneous acquisition of peripheral signals from which the ratio of oxy - to deoxyhemoglobin can be calculated and expressed as a percentage of oxyhemoglobin saturation Oximetry may be based on transcutaneous measurements or can be derived from mixed venous blood via a probe located in

a pulmonary artery catheter The peripheral pulse oximetry devices rely on detection of pulsed alterations in light transmitted between transmitter and a photodetector This fi ltered signal is necessary to eliminate the signal arising from venous blood that would contain more deoxyhemoglobin

Although oximetry is regarded as an effective method of moni-toring oxygenation, some limitations are recognized They include the assumptions that methemoglobin and carboxyhemo-globin are not present in signifi cant concentrations Mixed venous oxygen saturation monitoring is less frequently used than peripheral oxygen saturation monitoring It also shows greater spontaneous variation than peripheral monitors but has a clinical role to play in determining the balance between peripheral oxygen delivery and peripheral oxygen consumption This is a robust measurement that will refl ect changes in cardiac output, hemo-globin concentration, arterial and venous hemohemo-globin oxygen saturation This provides useful clinical information in many clinical circumstances A number of the determinants of the ulti-mate mixed venous oxygen saturation value have the potential to change at any given moment (hemoglobin, oxygen saturation, and cardiac output) It is therefore important to understand that

it is only when all other parameters remain stable that changes in the mixed venous oxygen saturation refl ect changes in cardiac output

Capnometery

Exhaled gas can be evaluated using an infrared probe and a pho-todetector set to detect carbon dioxide This is usually found in

symptomatology Echocardiographic studies showed no change

in left ventricular end - diastolic diameters, with an increase

occur-ring in left ventricular fractional shortening [17] Other studies

have reported similarly successful pregnancies [18] However,

there are papers suggesting a risk of recurrent cardiomyopathy

and impaired contractile reserve, even in those with apparently

normal left ventricular function before pregnancy [19,20]

Doppler ultrasound and other medical disorders

Echocardiocardiography is an essential investigation in women

with structural heart disease due to valvular damage or congenital

malformation [21 – 27] Echocardiography will also contribute to

the diagnosis of Libman – Sacks endocarditis, which occurs,

though not frequently, among women suffering from systemic

lupus erythematosus, with or without antiphospholipid

anti-bodies [28,29]

The management of Marfan ’ s syndrome also requires

echocar-diographic assessment because of the risk of catastrophic aortic

dissection Transesophageal echocardiography is the preferred

method for evaluating the ascending aorta The risk of dissection

correlates with an aortic root diameter greater than 4 cm [30]

Aortic dissection may also occur under other circumstances and

may follow the use of crack cocaine [31,32]

The role of transesophageal D oppler

Esophageal Doppler monitoring of hemodynamic data has been

carried out in adult intensive care units and found to be

equiva-lent to data derived from pulmonary artery catheter

measure-ments [33] Pregnancy data are few, and to date only one study

has reported the use of transesophageal Doppler monitoring in

pregnancy compared to pulmonary artery catheters This study

showed that the Doppler consistently underestimated cardiac

output by 40% in women under the age of 35 years [34] This

error may be due to the assumptions implicit in the algorithm

used to calculate output These assumptions include a fi xed aortic

diameter during systole and a fi xed percentage of blood perfusing

upper and lower parts of the body Pregnancy physiological

changes probably invalidate these assumptions The authors

nev-ertheless conclude that esophageal Doppler may contribute to the

estimation of trends in cardiac output over time in pregnancy

Oximetry in the intensive care environment

Spectrophotometry is the detection of specifi c light frequencies

refl ected by a range of molecules Specifi c molecules refl ect

spe-cifi c frequencies and their refl ective properties differ with changes

in molecular conformation Oximetry is the detection of

oxygen-ated and deoxygenoxygen-ated blood Deoxygenoxygen-ated hemoglobin absorbs

more light at 660 nm whereas at 940 nm oxygenated hemoglobin

600 700

(RED)

660nm (INFRARED)910nm

800 900 1000 WAVELENGTH (nm)

Hb HbO2

0.1 10

Figure 15.1 Oximetry in the intensive care environment The oxygenated

hemoglobin refl ects more light at 660 nm whereas at 940 nm deoxyhemoglobin refl ects infrared light more strongly

dinally (at 4 - week intervals) during normal gestation The resis-tance index (RI), pulsatility index (PI), and cerebral perfusion pressure (CPP) were calculated using the velocity and blood pres-sure data The mean value, and the 5% and 95% percentiles, were defi ned and it was noted that the middle cerebral artery (MCA) velocities and the resistance and pulsatility indices decrease, while the CPP increases, during normal pregnancy Figure 15.2 shows the CPP change during normal pregnancy This study defi ned the normative ranges for middle cerebral artery velocity, resistance indices, and cerebral perfusion pressure during normal human pregnancy using longitudinally collected data

Women with pre - eclampsia and hypertensive women with superimposed pre - eclampsia have been studied using TCD ultrasound Findings among these subjects include globally elevated cerebral perfusion pressures and lower cerebral vascular resistance compared to normotensive controls [38,39] The increased pressures were not directly related to blood pressure alone [39]

Doppler ultrasound, bias and confounders

There are a number of confounding infl uences that can affect the interpretation of Doppler cerebral velocity data These include any factors that may: (i) increase the CO 2 or H + tension in the cerebral circulation; (ii) decrease or increase the hemoglobin con-centration; (iii) independently alter the diameter of the vessel being studied at the point of insonation; and (iv) introduce error, such as cigarette smoking and changes in posture In pregnant women (v) gestational age is another important factor that requires consideration, since as the pregnancy progresses there are signifi cant hemodynamic changes

Increased CO 2 tension leads to cerebral vasodilation, as does acidosis Patients undergoing cerebral Doppler studies should, ideally, be studied in a steady state or should have their end - tidal

CO 2 tension measured in order to control for fl uctuations Even

the expiratory limb of a ventilator circuit Expired gas shows a

pattern of increasing carbon dioxide concentration related to the

sequential expiration of air in the upper airway followed by air

from the alveoli The end - expiratory (or end - tidal) carbon

dioxide concentration should approximate the partial pressure of

carbon dioxide in arterial blood The development of a gradient

between these measurements refl ects an increase in anatomical

or physiological dead space In the latter event, low cardiac output

and pulmonary embolism may both affect the measurement

Changes in end - tidal partial pressure of carbon dioxide have been

correlated to changes in cardiac output and may be used as a

means of monitoring the effi cacy of resuscitation

Transcranial D oppler ultrasound

Compared to the physiologic alterations in other vascular beds

during gestation the normal cerebral blood fl ow changes of

preg-nancy are poorly documented This is due, partly, to technical

diffi culties associated with in vivo studies of blood fl ow in the

human brain Angiography, the gold standard in the evaluation

of the cerebral vasculature, is an invasive test and presents obvious

ethical concerns for its use in normal pregnant women Very little

data exist on the physiologic adaptations of the brain to

preg-nancy in the current literature and most texts dealing with the

changes of pregnancy do not address this issue at all There are

also ethical problems with using angiography and other

method-ologies involving radiation, as well as magnetic resonance imaging

during pregnancy The advent of Doppler ultrasound, and in

particular transcranial Doppler (TCD) ultrasound, has changed

this It is now possible to acquire Doppler - derived velocity

infor-mation from most of the basal brain arteries (including almost

all of the circle of Willis branches) using a non - invasive

tech-nique Using these data, it is possible to diagnose arterial

malfor-mations, functional abnormalities, and physiological changes in

brain blood velocity One can detect direction and velocity of

blood fl ow, and from this infer the presence of distal or proximal

arterial constriction or dilatation In addition, TCD can be used

to determine real - time changes over very short time intervals and

to continuously monitor cerebral blood velocity during surgical

procedures, or experimental drug protocols TCD has been

extensively used in the clinical scenario by neurologists and

neu-rosurgeons to detect and follow cerebral vasospasm in patients

with subarachnoid hemorrhage [35] TCD has also been used for

neurological monitoring during cardiopulmonary bypass in

pediatric cardiac surgeries [36] Investigators are beginning to use

TCD to defi ne pregnancy - induced/associated changes in the

cerebral circulation

Belfort et al [37] have recently defi ned the hemodynamic

changes, specifi cally velocity, resistance indices, and cerebral

per-fusion pressure, in the middle cerebral artery distribution of the

brain during normal pregnancy TCD ultrasound was used to

determine the systolic, diastolic, and mean blood velocities in the

middle cerebral arteries in non - laboring women studied

Figure 15.2 Cerebral perfusion pressure (CPP) changes during a normal

pregnancy as detected by middle cerebral artery (MCA) velocity

tone also tends to close the arterioles when pressure falls during the pulse cycle Under conditions of low vascular resistance, the arterioles remain open throughout the pulse cycle and the active smooth muscle tone never causes them to close completely However, even a slight increase in arteriolar tone will narrow the diameter of open arterioles and, in some cases, cause them to close completely when the pressure within them falls at the end

of the pulse cycle The pressure at which an arteriole closes is called its “ critical closing pressure ” [35,42] Critical closing pres-sure explains why arterioles close as prespres-sure falls during the pulse cycle and why fewer arterioles are open at the end of the pulse cycle than earlier, when pressure is at its systolic maximum Thus, pressure at the end of a pulse cycle is less effective in perfusing the capillary bed than that early in the cycle In the brain, CPP is reduced as arteriolar resistance rises abruptly due to more and more arterioles reaching their critical closing pressure Another feature of arteriolar tone is its effect in delaying the fl ow of blood from arteries to capillaries When arteriolar tone is high it reduces the rate of blood fl ow from arteries to capillaries This maintains the arterial blood pressure at a higher level for a longer portion

of the pulse cycle than if the arteriolar tone was low and there was a rapid run - off of blood Blood pressure distends the arterial segments and blood is effectively stored in the arteries while the pressure decays during the pulse cycle The amount stored in each segment depends on the compliance of the artery and the pres-sure gradient between the lumen and the region outside the artery The result of storing blood in the arteries and reducing the rate of fl ow through arterioles is to slow the deceleration of blood

fl ow during the pulse cycle The more compliant the arterial segment, the slower the deceleration during the pulse cycle This feature of arteriolar tone interacting with arterial pressure and arterial compliance affects the shape of the velocity profi le during the pulse cycle When arteriolar tone is low, blood velocity rapidly rises to a maximum and falls quickly to a minimum In contrast, when arteriolar tone is high, the blood fl ow velocity falls more slowly The area under the pulsatile amplitude of the velocity waveform, and the height of the pulse velocity wave, may be used

to estimate the proportion of blood fl ow stored in arterial seg-ments during the peak of the pulse cycle and released when pres-sure falls during the cycle

One of the major problems with the currently used Doppler indices is that they were initially developed for use in peripheral vascular examination of large - diameter arteries such as the femoral, dorsalis pedis, and brachial arteries Indices such as the

PI and RI focus on the systolic component of the velocity profi le The traditional Doppler indices of hemodynamics (i.e the RI and PI) provide limited data regarding arteriolar tone when applied

to the cerebral circulation Both the RI, defi ned as:

velocitysystolic−velocitydiastolic velocitysystolic

and the PI, defi ned as:

velocitysystolic−velocitydiastolic velocitymean

the minimal increases in tidal volume and respiratory rate

associ-ated with labor contractions may be of importance Labor itself

has been shown to be associated with decreases in mean middle

cerebral artery fl ow velocity

Hemoconcentration and hemodilution are also important and

attention should be paid to the hematocrit level in studies where

blood loss or volume infusion may have altered the hemoglobin

content of the blood during the study period

The segmental nature of the vasospasm seen in some

condi-tions, notably pre - eclampsia, is of concern as well, since the same

segment of artery can show completely different velocity profi les

depending on its state of contraction Thus, if the region of vessel

being insonated is apt to change, its diameter velocity readings

may be inaccurate, particularly if some indication of downstream

vascular condition is being extrapolated In this regard, the M1

portion of the middle cerebral artery has been shown to be

unlikely to change diameter [40] , since it is well supported by

alveolar tissue in its bony canal The angle of insonation is critical

since the velocity is related to the cos of the angle of insonation

( q ) If q is less than 10 ° the error involved is almost negligible and

quite acceptable for most purposes Because of the anatomy of

the bony canal through which the M1 portion of the MCA runs,

the angle of insonation very rarely exceeds 10 ° This ensures that,

in almost all cases, once the optimum signal is obtained the angle

of insonation is less than 10 °

The effect of maternal cigarette smoking on middle cerebral

artery blood fl ow velocities during normal pregnancy was

described by Irion et al [41] They found that the systolic,

dia-stolic, and mean velocities of the middle cerebral artery, detected

in both the left lateral decubitus and sitting positions, were

sig-nifi cantly higher at 18 and 26 weeks gestation in women who

smoked cigarettes They determined that the number of cigarettes

smoked positively correlated with increased middle cerebral

artery velocities This factor must be taken into account when

studying women known to smoke, and is an important

con-founding factor in some of the earlier studies published Posture

should be taken into account when studying pregnant, and in

particular, pre - eclamptic pregnant women A change from lying

to sitting has been shown to signifi cantly increase both systolic

and diastolic velocities in the middle cerebral artery in such

patients

Another important variable that must be taken into account

when studying pregnant women is the gestational age As

preg-nancy advances there is a reduction in middle cerebral artery

velocity which should be controlled for when comparing women

of different gestational ages

Cerebral perfusion pressure

Under normal conditions, the arterioles in the cerebrovascular

system are responsible for about 80% of the vascular resistance

Because arterioles have active smooth muscle tone, they do not

behave simply like tubes of variable dimension Smooth muscle

tone in the arterioles reduces their diameter when systolic

pres-sure is transmitted into them via the arteries In addition, this

eclamptics routine use of this modality is not recommended until further research has confi rmed the fi ndings However, in those cases of refractory seizure activity unresponsive to conventional therapy, TCD may offer another diagnostic option In those cases where CPP is shown to be signifi cantly elevated, drug therapy can

be tailored to lowering the CPP (i.e with labetalol) versus those rare cases where there is a low CPP and presumably cerebral ischemia from underperfusion, a cerebral vasodilator such as nimodipine can be used

Conclusion

Non - invasive techniques of monitoring will become increasingly utilized as an alternative to the invasive techniques currently practiced in most intensive care units This technology, however, requires expertise in the application and interpretation of data Even correctly interpreted data are of unknown utility and strin-gent evaluation is necessary before this (often) expensive technol-ogy is incorporated into routine clinical practice

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are signifi cantly infl uenced by the systolic velocity which refl ects

large - caliber arterial constriction These indices were originally

developed using older technology and larger diameter arteries

(femoral artery and aorta) The typical waveform shape from

such arteries has a tall peaked systolic component, a steep

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were used They expressed their calculations as:

CPP=V ×ABP

V

0

1

1

where V 0 is the mean and V 1 is the amplitude of the fi rst harmonic

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arterial pressure wave Their experimental results confi rmed the

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of 40 mmHg, and the mean deviation was only 1 mmHg

Belfort et al [44] have adapted the method of Aaslid et al [43]

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amplitude of the fl ow velocity and arterial blood pressure

wave-forms rather than the fi rst harmonic Their equation, using areas

under pulsatile amplitudes, is as follows [44] :

mean

=

Recently Belfort et al [45] have suggested that elevated CPP,

rather than decreased CBF, is the key determinant of cerebral

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26 Barbosa PJ , Lopes AA , Feitosa GS et al Prognostic factors of

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Critical Care Obstetrics, 5th edition Edited by M Belfort, G Saade,

M Foley, J Phelan and G Dildy © 2010 Blackwell Publishing Ltd.

1 Women ’ s and Children ’ s Clinical Services, Hospital Corporation of America, Nashville, TN, USA

2 Maternal - Fetal Medicine, Mountain Star Division, Hospital Corporation of America, Salt Lake City, UT and Department of

Obstetrics and Gynecology, LSU Health Sciences Center, School of Medicine in New Orleans, New Orleans, LA, USA

Introduction

Following its introduction into clinical medicine three decades

ago, the pulmonary artery catheter was shown to play an

impor-tant role in the management of critically ill patients in a number

of specialties, including obstetrics [1 – 6] Several early prospective

trials demonstrated the benefi ts of pulmonary artery

catheteriza-tion in select critically ill patients Such benefi ts include a

reduc-tion in operative morbidity and mortality in certain complicated

surgical patients and a signifi cant mortality reduction in patients

in shock in whom catheter - obtained parameters led to changes

in therapy [7,8] In one study, management recommendations

changed as a direct result of knowledge obtained by pulmonary

artery catheter placement in 56% of patients admitted to an

intensive care unit [9] In patients with major burn injuries,

survival is predicted by early response to pulmonary artery

catheter - guided resuscitation [10] This technique, however, was

not without its critics [11] In a non - randomized observational

study, Califf and colleagues [12] demonstrated increased

mortal-ity and cost associated with pulmonary artery catheterization,

and suggested that a randomized trial aimed at better patient

selection was needed An subsequent randomized controlled trial

(n = 201) of the pulmonary artery catheter in critically ill patients

concluded that its use is not associated with increased mortality

[13]

In response to concerns of increased morbidity and mortality

associated with the pulmonary catheter in observational studies,

the National Heart, Lung, and Blood Institute (NHLBI) and the

US Food and Drug Administration (FDA) conducted the

Pulmonary Artery Catheterization and Clinical Outcomes

work-shop in 1997 to develop recommendations to improve

pulmo-nary artery catheter utility and safety [14] They concluded that

a “ need exists for collaborative education of physicians and

nurses in performing, obtaining, and interpreting information from the use of pulmonary artery catheters This effort should be led by professional societies, in collaboration with federal agen-cies, with the purpose of developing and disseminating standard-ized educational programs ” Areas given high priority for clinical trials were pulmonary artery catheter use in persistent/refractory congestive heart failure, acute respiratory distress syndrome, severe sepsis and septic shock, and low - risk coronary artery bypass graft surgery

Since this conference, several investigators have attempted to better defi ne benefi ts and risks of pulmonary artery catheteriza-tion both in general categories of critical illness, and in specifi c subsets of critically ill patients Most studies that used broad and non - specifi c patient inclusion criteria (such as “ critically ill patients ” or “ high - risk surgical patients ” ) have, not surprisingly, generally detected neither benefi cial nor detrimental effects of pulmonary artery catheterization on mortality rates [15 – 17] and the use of pulmonary artery catheterization has decreased in the United States over the past decade [18] On the other hand, studies directed at specifi c subsets of critically ill patients have proven much more informative It would appear, for example, that such monitoring techniques are not typically associated with improved survival in patients with acute lung injury and acute respiratory distress syndrome [19,20] On the other hand survival benefi t has been demonstrated in patients with severe trauma or illness, those admitted in severe shock and in older trauma patients [21,22] Another study demonstrating lack of benefi t of pulmonary artery catheterization in patients with severe septic shock does not address the question of whether patients so managed before late or end - stage disease may benefi t from the information provided by these techniques [23] Interpretation of such data is further compounded by the general lack of uniform, evidence - based management protocols for most patients in whom pulmonary artery catheters are utilized No diagnostic testing modality can improve outcomes in any disease in the absence of effective therapy [15,24] Thus, at present, the pulmo-nary artery catheter should be viewed neither as a panacea for all seriously ill patients, nor as a technique lacking diagnostic value

punctured at the junction of the two clavicular heads, and the needle is directed with constant aspiration toward the ipsilateral nipple at an angle approximately 30 ° superior to the plane of the skin Free fl ow of venous blood confi rms the position of the internal jugular vein Next, the needle is withdrawn and the vein once again entered with a 16 - gauge needle and syringe Then a guidewire is placed through the needle and into the jugular vein This placement is perhaps the most crucial part of the entire procedure, and it is vital that the guidewire passes freely without any resistance whatsoever Free passage confi rms entrance into the vein

Next, the needle is removed with the guidewire left in place The incision is widened with a scalpel, and the introducer sheath/ vein dilator apparatus is introduced over the guidewire During introduction of the introducer sheath/vein dilator, it is crucial that the proximal tip of the guidewire be visible at all times, to avoid inadvertent loss of the guidewire into the central venous system The introducer sheath/vein dilator apparatus is advanced with a slight turning motion along the guidewire In general, the point of entry into the vein is felt clearly by a sudden decrease in resistance The sheath apparatus then is advanced to the hilt The conscious patient is instructed to hold her breath to prevent nega-tive intrathoracic pressure and air embolism, and the guidewire and trocar are quickly removed with the sheath left in place Occasionally, portable real - time sonography may be helpful in guiding central venous cannulation [28,29]

Most current introducer systems contain an accessory port, which attaches to the proximal end of the introducer sheath and includes a one - way valve that prevents air introduction into the central venous system during removal of the guidewire and trocar To keep the line open, the sheath then is infused with a crystalloid solution containing 1 unit of heparin per milliliter and secured in place with suture

Insertion of the c atheter

Phase two involves the actual placement of the pulmonary artery catheter (Figure 16.1 ) Careful attention must be paid to main-taining sterile technique as the catheter is removed from the package The distal and proximal ports are fl ushed to assure patency The balloon then is tested with 1 mL of air When the catheter has been attached to the physiologic monitor and the air

in any patient In a recent review article focusing on the use of

this technique in pregnant patients, Fujitani and Baldisseri [25]

concluded “ Invasive monitoring remains useful when the

patho-physiology of critically ill obstetric patients cannot be explained

by non - invasive monitoring, and the patient fails to respond

to conservative medical management; invasive hemodynamic

monitoring may be helpul to guide management ” As emphasized

by Harvey et al, future studies will need to be adequately powered

and focus on specifi c patient subsets receiving targeted therapies

in order to better defi ne the proper role of this technique in the

management of critically ill patients [26]

This chapter provides an overview of placement techniques

and complications; indications for the use of this diagnostic tool

in the obstetric patient are examined in more detail in the ensuing

chapters

Catheter p lacement

The procedure for catheter placement involves two phases The

initial phase of pulmonary artery catheterization is establishing

venous access with a large - bore sheath Access is most commonly

obtained via the internal jugular or subclavian veins; however,

under certain circumstances (e.g where access to the neck or

thoracic region is diffi cult or in a patient with a coagulopathy

where bleeding from a major artery could be hazardous),

peri-pheral veins – including cephalic or femoral – can be used [27]

Insertion of the introducer sheath via the right internal jugular

vein is described here

Insertion of the s heath

To catheterize the internal jugular vein, the patient is placed

supine in a mild Trendelenburg position with the head turned to

the left The landmark for insertion is the junction of the

clavicu-lar and sternal heads of the sternocleidomastoid muscle When

this junction is indistinct, its identifi cation can be facilitated by

having the patient raise her head slightly When the landmark has

been identifi ed, 1% lidocaine is infi ltrated into the skin and

superfi cial subcutaneous tissue

The internal jugular vein is entered fi rst with a fi nder needle,

consisting of a 21 - gauge needle on a 10 - mL syringe The skin is

RV-paceport lumen hub

(facing infusion)

PA distal

lumen hub

Proximal injectate hub

Thermistor connector

Balloon inflation valve

RV port

Thermistor Balloon

PA distal lumen

Proximal injectate

Figure 16.1 Pulmonary artery catheter

(Reproduced by permission from American Edwards Laboratories.)

the pulmonary vasculature where the balloon diameter exceeds that of the corresponding pulmonary arterial branch At this point, a wedge tracing is observed If the balloon is defl ated, the tracing should return to a pulmonary artery pattern

Following catheter placement, it is essential that healthcare personnel skilled in the interpretation of these waveforms con-tinuously monitor the waveforms for evidence of catheter migra-tion (spontaneous advancement), which may lead to pulmonary infarction This may be manifest by the appearance of a spontane-ous “ wedge ” tracing at the distal port, rather than the pulmonary artery waveform, which should be continuously manifest on the display monitor Alternately, the appearance of a pulmonary artery waveform in the central venous pressure port will alert the attendant to distal catheter migration and the need for adjust-ment [30] Komadina et al described disturbingly high interob-server variability in the interpretation of waveform tracings, although agreement on numerical wedge pressure readings was high [31] In a similar manner, Iberti et al reported a wide varia-tion in the understanding of pulmonary artery catheter wave-forms and techniques among critical care nurses using this device [32] It would appear that graphic recording at end - expiration is the most reliable means of measuring hemodynamic pressures [33] Clearly, continuous training and credentialing programs are essential for healthcare providers utilizing these techniques Recently described digital output volumetric pulmonary artery catheters have been shown to reduce interoperator interpretation variability and to improve consistency of treatment decisions [34] Normal ranges for hemodynamic parameters in term pregnancy have been described, and are useful in assessing and managing the pregnant woman requiring invasive monitoring techniques [35,36]

completely fl ushed from the system, minute movements in the

catheter tip should produce corresponding oscillations on the

monitor The catheter tip is introduced through the sheath and

advanced approximately 20 cm At this point, the balloon is

infl ated and the catheter advanced through the introducer sheath

into the central venous system Occasionally, portable real - time

sonography may be helpful in guiding central venous cannulation

[29]

Waveforms and c atheter p lacement

Once within the superior vena cava, the balloon on the tip of the

catheter will advance with the fl ow of blood into the heart

Characteristic waveforms and pressures are observed (Figure

16.2 ) Entrance into the right ventricle is signaled by a high

spiking waveform with diastolic pressures near zero This is the

time of maximum potential complications during catheter

place-ment, because most arrhythmias occur as the catheter tip impinges

on the interventricular septum For this reason, the catheter must

be advanced rapidly through the right ventricle and into the

pulmonary artery If premature ventricular contractions occur

during this process and the catheter does not advance promptly

out of the right ventricle, the balloon should be defl ated and the

catheter withdrawn to the right atrium

As soon as the catheter enters the pulmonary artery, the

wave-form has two notable characteristics First, and most important,

is the rise in diastolic pressure from that seen in the right

ven-tricle Second, a notching of the peak systolic waveform often is

seen and represents closure of the pulmonic valve After entrance

into the pulmonary artery has been confi rmed (in most pregnant

women, this occurs between 40 and 45 cm of catheter length), the

catheter is advanced farther until the tip reaches a point within

30 20 10 0

30 20 10 0

Figure 16.2 Pulmonary artery catheter placement

Catheter tip position, corresponding waveforms, and

normal pressure ranges are demonstrated (Reproduced by

permission from American Edwards Laboratories.)

access Such events include pneumothorax and insertion site infection and occur in 1 – 5% of patients undergoing this proce-dure [50 – 52] Potential complications of pulmonary artery cath-eterization per se include air embolism, thromboembolism, pulmonary infarction, catheter - related sepsis, direct trauma to the heart or pulmonary artery, postganglionic Horner ’ s syn-drome, and catheter entrapment [53 – 58] Such complications occur in 1% or less of patients More recently, a pressure release balloon has been described to limit overinfl ation and potentially reduce the risk of vessel rupture [59] Arrhythmias, consisting

of transient premature ventricular contractions, occur during catheter insertion in 30 – 50% of patients and are generally of

no clinical consequence

The remaining complications can be minimized or eliminated

by careful attention to proper insertion maintenance and removal techniques [37] ) In patients with right - to - left shunts, the use of this catheter is hazardous; when its placement is deemed manda-tory, the use of carbon dioxide instead of air for balloon infl ation may minimize the risk of systemic air embolism [60] A Food and Drug Administration task force has summarized recommenda-tions regarding methods to minimize complicarecommenda-tions of central venous catheterization procedures [61] A recent study suggested that with proper attention to aseptic technique of placement and catheter maintainance, a pulmonary artery catheter may be left

in place for up to 7 days before replacement becomes mandatory [62]

Numerous studies have documented the frequent discrepancy between measurements of pulmonary capillary wedge pressure and central venous pressure during pregnancy [4,63 – 65] In such circumstances, clinical use of the central venous pressure would

be misleading Both techniques entail the risks of obtaining central venous access, the principal source of complication for either procedure For these reasons, in a modern perinatal inten-sive care unit, central venous monitoring is uncommonly utilized Where proper equipment and personnel exist, the vast amount of additional information obtainable by pulmonary artery catheterization often outweighs the slight potential increase

in risk attributable to catheter placement itself When the hemo-dynamic status of the critically ill pregnant woman is unclear, pulmonary artery catheterization is nearly always preferable

Non - i nvasive t echniques

Despite the small risks associated with properly managed pulmo-nary artery catheterization, the search continues for non - invasive methods of central hemodynamic assessment of the critically ill patient Such techniques generally focus on sonographic or bio-impedance techniques to estimate cardiac output, and have been described in both pregnant and non - pregnant patients [66 – 70]

In addition, investigation continues into techniques to allow non invasive central pressure determination [71] These techniques appear to be useful in a research setting or in patients requiring only a single evaluation of hemodynamics in order to classify

Caution also is advised during pulmonary artery catheter

removal; techniques to avoid complications have been described

[37]

Cardiac o utput d etermination

Once in place, cardiac output is obtained with the use of a cardiac

output computer connected to a terminal on the pulmonary artery

catheter This instrument derives cardiac output from

thermodi-lution curves created by the injection of cold or room - temperature

saline into the proximal central venous port of the catheter The

resultant fl ow - related temperature changes detected at the distal

thermistor are converted into cardiac output by the computer and

correlate well in pregnant women with those obtained by the more

precise, but clinically cumbersome, oxygen extraction (Fick)

tech-nique [35] Nevertheless, it should be emphasized that cardiac

output determinations are of most value in following trends in

individual patients; caution is advised in relying on absolute

cardiac output values, and sound clinical judgment is essential in

data interpretation [38] One study suggests that the

thermodilu-tion technique may overestimate cardiac output, especially with

very low values [39] In addition, meticulous attention must be

paid to technique if reliable information regarding cardiac output

is to be obtained The exact injectate temperature must be known,

the proximal injectate port must have advanced beyond the

intro-ducer sheath, and the introintro-ducer sheath sidearm must be closed

[40] If the central venous port line becomes non - functional,

room - temperature thermodilution cardiac outputs can be used

with saline injection into the sideport, with the understanding that

a slight overestimation of cardiac output will occur [41] Additional

issues that affect the validity of cardiac output measurements

include the rate of injection, the timing of injection during the

respiratory cycle, the position of the patient, and the presence of

other, concurrent infusions [42] More recently, techniques have

been evaluated for continuous cardiac output measurement, both

by thermodilution and with the use of a special fl ow - directed

Doppler pulmonary artery catheter [43,44] Penny et al [45]

demonstrated that esophageal Doppler monitoring consistently

underestimates cardiac output in patients with pre - eclampsia by

approximately 40%, compared to direct measurements with

pulmonary artery catheters

With appropriate modifi cation of technique, right ventricular

ejection fraction measurements also may be obtained with the

pulmonary artery catheter [46,47] Specially designed fi beroptic

catheters allow continuous assessment of mixed venous oxygen

saturation in critically ill patients Newer techniques for

continu-ous thermodilution measurement compare well with

conven-tional methods [48,49]

Complications

Most complications encountered in patients undergoing

pulmo-nary artery catheterization are a result of obtaining central venous