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LA and PA Catheters in PICU

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 General points

  1. Direct trans-thoracic left atrial (LA) catheters are placed intra-operatively in most children having cardiopulmonary bypass. In addition children at risk of pulmonary hypertension may have a pulmonary artery (PA) catheter placed.
  2. Flush solutions should run at 1ml/hr with 50u heparin/50ml 5% glucose. If the waveform repeatedly dampens, check the transducer and line connections (if loose they may entrain air which dampens the waveform). The rate may be increased to 2ml/hr if dampening remains a problem.
  3. The decision to remove or cap lines will be made on the 0800 cardiac ward round. The timing of removal depends on the child's parameters and progress. Usually it is after most inotropes have been stopped and the child is off the ventilator.
  4. Standard scenarios for removal are:
    1. 'Routine' children who have been weaned and extubated over the first night will have drains and LA/PA catheters removed on day 1.
    2. Where the plan on day 1 is to wean and extubate over the next 24 hours drains will be left another 24hours and catheters/drains removed on day 2.
    3. LA/PA catheters will be removed at least 30mins before the drains.
    4. Where the drains have been removed on day 1 or 2 and LA/PA catheters kept, the LA/PA catheters can be removed once no longer transduced.
    5. If LA/PA catheters are capped they are to be removed with pacing wires on day 4-5. Once capped they are not to be flushed and reused.
  5. LA/PA catheters should not be removed after 5pm. They are not to be removed in infants <5kg on weekends/public holidays. On these days the lines are to be capped.
  6. At time of LA/PA removal the patient must have:
    1. Patent IV access
    2. Normal coagulation
    3. Normal platelet count
    4. Current group and hold
    5. Heparin infusion at time of removal: If APTT normal remove LA/PA catheters without stopping heparin infusion. If APTT abnormal, stop heparin infusion for 2 hours and re-check APTT.
    6. The catheters should be removed by holding the actual catheter and not just the hub.
  7. Post removal the patient:
    1. Must be continuously cardiovascularly monitored for 4 hours.
    2. Should not be transferred between areas for 2 hours.
    3. Do NOT routinely order a cardiac echo BUT, any concerns should trigger the request for an echo to exclude a collection. Tachycardia, cooling of the peripheries and/or respiratory distress are all indications for urgent echo and involvement of the cardiac consultants.
  8. LA catheters may be used for long term access. Direct lines may be useful for long term access in infants with single ventricle physiology. This reduces the chance of SVC or IVC thrombosis from central lines. In this situation the infants should have a continuous infusion of low dose heparin via the LA catheter. These catheters may remain for many days and be removed as per the protocol above. The decision to use an LA catheter for long term access is at the discretion of the cardiac surgeon, intensivist and cardiologist.

Normal Values and Interpretation

  1. LA pressure provides a useful measure of preload. It should be viewed in context of the congenital heart lesion and the pressure needed to wean off bypass.
  2. A normal LA pressure is 1-2mmHg higher than the RA pressure.
  3. A normal post-op LA is ~ 5-10mmHg. Unless there is left ventricular dysfunction (especially diastolic function) or a significant residual anomaly (e.g. L to R shunt or mitral insufficiency or stenosis) the LA rarely needs to exceed 12-14mmHg.
  4. An LA trace is also useful for assessing if a patient is in sinus rhythm.
  5. PA pressure is most useful for assessing post-operative pulmonary reactivity and for pulmonary hypertensive crises.

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Document Control

  • Date last published: 18 May 2015
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Owner: D Buckley
  • Editor: John Beca
  • Review frequency: 2 years