|Year : 2007 | Volume
| Issue : 2 | Page : 151
Unusual migration of pulmonary artery catheter
Sanjay Kuravinakop1, Rachel Rouse2
1 FRCA, Senior House Officer, Department of Anaesthetics, Lincoln County Hospital, United Lincolnshire Hospitals NHS Trust, Greetwell Road, Lincoln LN2 4AZ, United Kingdom
2 FRCA, Consultant, Anaesthetics and Intensive care, Department of Anaesthetics, Nevill Hall Hospital, Gwent Healthcare NHS Trust, Brecon Road, Abergavenny, Monmouthshire NP7 7EG, United Kingdom
|Date of Acceptance||15-Mar-2007|
|Date of Web Publication||20-Mar-2010|
FRCA, Senior House Officer Dept. of Anaesthetics Lincoln County Hospital, United Lincolnshire Hospitals NHS Trust Greetwell Road, Lincoln LN2 4AZ
Source of Support: None, Conflict of Interest: None
Pulmonary artery catheter is widely used in intensive care. Distal migration of the catheter is a know complication. Diagnosis of such a migration is made by both clinical criteria and radiographs. A 55 year old septic lady was admitted to the intensive care unit. Pulmonary artery catheter introduced for cardiac output monitoring migrated from right lung to left lung. Diagnosis was made following a chest radiograph the following day of insertion with the clinical criteria remaining unaltered. Migration of pulmonary artery catheter can occur not only distally but from one lung to another. Clinical criteria alone cannot rule out migration. Chest radiographs form an important part in monitoring the position of the pulmonary artery catheter.
Keywords: Phrases, Pulmonary Artery Catheter (PAC), Clinical criteria in monitoring the position of PAC. Radiography for monitoring the position of the PAC tip
|How to cite this article:|
Kuravinakop S, Rouse R. Unusual migration of pulmonary artery catheter. Indian J Anaesth 2007;51:151
| Introduction|| |
Pulmonary artery catheter (PAC) has been extensively used in intensive care permitting qualitative analysis of cardiovascular performance. PAC insertion and monitoring is a potentially complicated and invasive procedure. We wish to present a case of, unusual migration of pulmonary artery catheter in our intensive care unit.
A 55-year-old severely septic lady was admitted to intensive care. PAC was introduced for cardiac output monitoring due to marked deterioration in the condition of the patient. A standard balloon tipped quadrilumen catheter was inserted with a flow directed floatation technique. A satisfactory wedge trace was obtained with 1.5 ml of air.
A chest radiograph was performed which confirmed the tip of the catheter was in the right pulmonary artery as shown in [Figure 1]. An experienced, registered intensive care unit nurse continuously cared for the catheter. Regular physiotherapy for her respiratory infection was continued.
Before recording the vital parameters on day-2, migration of the catheter was excluded to by noting the amount of air required to wedge and distance to skin. To our surprise chest radiograph performed to assess clinical progress showed that the PAC had migrated from the right lung to the left lung as shown in [Figure 2].
The patient unfortunately died few days later due to continuing sepsis and shock. Post-mortem findings did not reveal any abnormal cardio - pulmonary anatomical findings.
| Discussion|| |
PAC is widely invasive monitoring device in critically ill patients despite recent debate about their effectiveness in guiding treatment or improving outcome.  More than 90% of standard quadrilumen balloon tipped catheters float into and wedge in zone-3 of right lung.  Complications associated with pulmonary artery catheter use relate to initial venous access, insertion and maintenance of catheter in place. Of the complications pulmonary artery rupture is the most catastrophic with mortality of 50% though occurrence is < 1%. Incidence of pulmonary infarction is < 7% with unintentional distal migration being the usual cause.
Manufacturers recommend continuous pressure monitoring and chest radiograph immediately after insertion and on regular basis. 
Shoemaker et. al. emphasises the importance of radiography for monitoring the position of the catheter tip to avoid PA rupture. They specifically state that 'avoidance of this complication necessitates close monitoring of catheter tip by means of X-ray, monitoring wave form and ensuring wedge trace is not obtained with <1 to 1.5 ml of air in balloon.  Voyce et.al also recommends daily chest radiographs to rule out distal migration of the catheter. 
However some authors state that after initial position of the catheter is verified, follow up chest radiographs to assess catheter position are not necessary unless clinically indicated i.e. amount of air required to wedge and catheter length at the skin. 
Studies done in the past have shown that, only in small percentage of patients clinical findings meet the criteria of adequate catheter position (amount of air required to wedge and length to skin). In larger group of patients, radiographs are needed to demonstrate the position of the catheter, as clinical criteria for adequate catheter position are not met. 
In our case, PAC was not manipulated after initial insertion and the position of the catheter was confirmed clinically i.e. both by amount of air required to wedge and the length at the skin. Until now only distal migration of PAC has been reported. Unique to our case PAC migrated not distally but to the opposite lung (clinical parameters remaining the same). To our knowledge such a migration has not been anecdotally reported.
We are not sure regarding the factors leading to the migration of the pulmonary artery catheter. Percussion and positive expiratory pressure manoeuvres, change in position of the patient from left lateral to right lateral and vice versa while undergoing physiotherapy, though insignificant could have suddenly flipped the catheter from right to left side.
We would like to highlight the following;
- Migration of PAC from can occur from right lung to left lung.
- Complications after PAC insertion can involve any lung.
- Clinical assessment and radiographs are important to verify the position of the catheter tip. Clinical criteria alone may not rule out migration.
| References|| |
|1.||Houghton D, Cohn S, Schell V, Cohn K, Varon A. Routine daily chest radiography in patients with pulmonary artery catheters; American Journal of critical care 2002 May; 11(3): 261-65. |
|2.||Benumof JL . Where pulmonary artery catheters go; intrathoracic distribution; Anaesthesiology 1977; 46: 336. |
|3.||Directions for use- Flow directed thermodilution PAC ; Abbott Laboratories; Abbott 2002. |
|4.||Shoemaker W, Velhamos G; Demetriades D. Procedure and monitoring for the critically ill; Philadelphia; WB Saunders Co. ; 2002. |
|5.||Voyce S, Lewin R, Cerra F, Rippe J eds. Pulmonary artery catheters in intensive care medicine 4th edition ; Philadelphia; Lippincott- Raven 1999; 46-71. |
|6.||Henschke CL, Yanelevitg DF, Wand A, Davis SD, Shiau M; Accuray and efficicy of chest radiology in intensive care unit; Radiology clinics of North America; 1996; 34: 21-31. |
[Figure 1], [Figure 2]