Pulmonary haemorrhage after PAOP measurement

OVERVIEW

  • a life threatening time-critical emergency
  • pulmonary artery rupture caused by inflation of the pulmonary artery catheter (PAC) balloon during ‘wedging’ (measurement of the pulmonary artery occlusion pressure)
  • some experts advise against measuring PAWP because of the risk of pulmonary artery rupture
  • 0.2% risk,  30% mortality

RISK FACTORS

  • pulmonary hypertension
  • mitral valve disease
  • anticoagulants
  • age >60 years

MANAGEMENT

Goals

  1. prevent further pulmonary haemorrhage
  2. stop bleeding
  3. resuscitate

Call for help

  • ICU consultant
  • anaesthetist/ OT
  • cardiothoracic surgeon
  • interventional radiology

Resuscitation

  • A
    • may have to be emergently intubated if not already
  • B
    • FiO2 1.0
    • controlled ventilation
    • if able to recognize which lung is haemorrhaging may be able to perform lung isolation (insert single lumen tube into unaffected side, exchange for a double lumen tube or use bronchial blocker with bronchoscopic assistance)
    • apply PEEP to tamponade wound
  • C
    • large bore IV cannulae, fluids, blood products, inotropes

Specific therapy

  • Lay the patient ruptured side down
  • withdraw pulmonary catheter 2-3 cm with balloon down then refloat PAC with balloon inflated to occlude pulmonary artery (to try to tamponade bleeding)
  • stop antiplatelet agents and anticoagulants
  • give reversal agents:
    — protamine for heparin
    — platelets for anti-platelet agents
  • give blood products as indicated by FBC, coags and clinical state
  • interventions
    — angiogram or bronchoscopy to isolate pulmonary vessel involved
    — if bleeding doesn’t settle will require lobectomy


References and Links


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the  Clinician Educator Incubator programme, and a CICM First Part Examiner.

He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.

His one great achievement is being the father of three amazing children.

On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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