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
- prevent further pulmonary haemorrhage
- stop bleeding
- 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 – Pulmonary Artery Catheters
- CCC – Pulmonary Artery Wedge Pressure and Wedging
- CCC – Troubleshooting PAC insertion
- CCC – Troubleshooting PAC measurement
- CCC – Pulmonary haemorrhage after PAOP measurement
- CCC – Pulmonary Artery Catheter Literature Summaries
- CCC – History of the Pulmonary Artery Catheter
- DerangedPhysiology.com — Pulmonary Artery Catheter (highly recommended)
- DerangedPhysiology.com — Troubleshooting the insertion of the Pulmonary Artery Catheter
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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