Wanted to share a recent case with all of you and would love some feedback. In our OHS we routinely place Pulmonary Artery Catheters(PAC's). Earlier this week we did an 80 y/o male ASA 4 with an EF of 20% for a Mitral Valve Annuloplasty and a 3 jump CABG. I (the CRNA) placed the PAC (note: we do do this under[B ]direct supervision)[/B] without any difficulty using the standard Seldinger technique. The catheter floated freely and good wave forms were noted. We do not wedge our catheters, just get the PA tracing and leave it there. This PAC was locked at 48cm which was appropriate for this patient. The catheter was without problem for the first 90 minutes. The surgeon asked for Heparin to be given and it was. He cannulated shortly thereafter and manipulated the heart in the process - all routine so far right? Thereabouts, the perfusionist and I noted that we could not maintain blood pressure. She kept giving the patient volume via cannula and I kept increasing the vasopressors. Still a problem, and I notify the surgeon that there is an issue as we can't maintain pressure. At which time I note MAJOR bleeding from the ETT. An obvious sign of deep doodoo. The MDA and I place a bronchial blocker and isolate that it is coming from the right lung - we attach suction to the blocker and have a continuous bloody return. We proceed with the case (the patient was already heparinized) and attempted to separate from bypass 3 times without success. The PAC was never touched after initial insertion.

Needless to say the patient expired as a result of this. Because the family refused an autopsy we can't know for sure what occurred but an educated guess would be that the PAC ruptured a pulmonary vessel either just by "bumping" it with insertion or as a result of manipulation of the heart. Now it is a known complication of inserting a PAC however, let me be honest here and say that I have gotten sort of complacent about it - but it does happen. Was it there prior to heparinization? Not likely, b/c we would have seen blood from the ETT a lot sooner, this had a sudden onset 90 minutes after insertion. Did it have a small puncture hole from insertion and then got worse with manipulation - also possible and heparinization made it worse.

Treatment options are limited and we could not choose any of them. Because the patient was already heparinized and cannulated we couldn't just close up shop, flip the patient and do a pneumonectomy and the patient had emphysema anyway and probably couldn't have survived on one lung. Could we have isolated the lung utilizing the bronchial blocker, recannulated the groins and closed the chest and then flipped the patient, also an option but again a pneumonectomy would not have been a viable option for this patient. Any other suggestions or thoughts?

Anyone else seen complications from PAC insertions and would you be willing to share? I need to shake off the complacency and relook at the possibilities. Thanks.

Karen