Q Who should remove a pulmonary artery catheter (PAC) if an implantable cardioverter-defibrillator or pacemaker is present? What are the guidelines for PAC removal?A Elizabeth Bridges, PhD, RN, replies:The American Association of Critical-Care Nurses practice guideline1 identifies the following contraindications to percutaneous removal of the PAC: Although this guideline specifies that the catheter should be removed by a provider, current community standards vary. There is limited evidence related to entanglement of the PAC with intracardiac devices.To address the issue of removal of the PAC in the presence of intracardiac devices, the first question is “What is the incidence of catheter entanglement?” Overall, the incidence of PAC-related complications (ie, entanglement, knotting, entrapment) is rare (0.03%-1%),2 although much of the literature on these complications is relatively old. There are more case reports of knotting and kinks of the PAC than of entanglement.3–5 In the presence of a knotted or kinked catheter, the catheter must be removed using a radiologic-guided or vascular procedure; thus, this procedure supports the recommendation that the catheter should be removed by a provider.The literature on PAC and device entanglement is scarce, although the incidence of entanglement may be higher than reported with the increased use of intracardiac devices. I found only 3 published case studies related to entanglement of a device with pacing wires (see Table).2,6,7 A review by Fox et al8 suggests that the presence of recently inserted pacing leads (<4 weeks) may be a contraindication to PAC placement because of the risk of dislodgment of newly placed pacing leads. A previous Ask the Experts column9 addressed whether there was a time frame after implantation of implantable cardioverter-defibrillator wires that would preclude removal by nurses. Although the greatest risk for lead dislodgment is within the first 4 to 6 weeks after implantation, the conclusion was that there was insufficient evidence for a specific recommendation; rather, physicians/nurses should adhere to safe practice procedures.The cases in the Table demonstrate that the period of greatest risk for entanglement and knotting occurs during catheter or device insertion, with a major risk factor being excessive insertion length potentially resulting in looping of the catheter, particularly in patients with cardiac enlargement. Thus, the first step to preventing these complications is careful PAC insertion, potentially under fluoroscopy or transesophageal echocardiography, followed by chest radiography to detect excessive length, looping, or entanglement.4,8 In general, the optimal insertion length from the right internal jugular vein to the pulmonary artery is 40 to 50 cm.8 When using alternate sites, add additional depth: left internal jugular vein, + 5 cm; femoral vein, + 15 cm; antecubital fossa, + 30 cm. As demonstrated in the case reported by Egbuche et al,6 in which the PAC wrapped around the pacing wires, no pulmonary artery waveform was observed at 50 cm, which necessitated repeated positioning that lead to catheter looping. An excellent review by Fox et al8 outlines care considerations during PAC insertion.The following recommendation should be considered: A registered nurse must be approved to reposition or remove a PAC. Policies vary regarding whether a registered nurses should remove a PAC when an intracardiac device is present. Refer to local policies and your state’s nurse practice act.Regardless of who is removing the PAC (physician, advanced practice provider, or registered nurse), the following safety measures should be considered for patients who have concurrent intracardiac catheters, wires, or devices: The American Association of Critical-Care Nurses practice guidelines indicate that a provider should remove the PAC if it is knotted or if there are additional catheters terminating in the right atrium.1 The reported incidence of PAC entanglement with other intracardiac devices is rare,2 and there is limited evidence to inform recommendations on PAC removal under these conditions.2,6,7 A registered nurse must be approved to reposition or remove the PAC. Policies vary regarding whether a nurse can remove a PAC when an intracardiac device is present. The need for fluoroscopy or other radiological or vascular procedure for repositioning or removal of the PAC may determine which type of provider can perform the procedure.Safe practices to mitigate the risk of catheter entanglement should focus first on catheter insertion, as the major risk factor for looping and entanglement is excessive catheter insertion length.2,6–8 Regardless of which care provider is removing the PAC, safety considerations should include the review of a chest radiograph before catheter removal to confirm absence of looping, kinking, or entanglement and careful monitoring for resistance during catheter withdrawal. The medical team should be consulted to determine the optimal steps for safe catheter removal. If a patient has an intracardiac device, particularly if they are dependent on the device, consider which members of the medical team need to be aware of the procedure and who are present at the bedside during catheter removal. Increased monitoring and emergency equipment should also be available.
Elizabeth Bridges (Mon,) studied this question.