Preinsertion Pulmonary Artery Catheter Flushing

To the Editor:- Since the introduction of central venous and pulmonary artery catheters into clinical practice, foreign body embolization from either guidewires [1]or catheter shearing [2]has been reported. We present this occurrence as the first reported case of potential foreign body embolization, unrelated to wires or catheter shearing, during pulmonary artery catheter insertion.

A 63-yr-old man was scheduled for sternal debridement, rewiring, and flap closure. The patient had sustained a recent myocardial infarction and a ventricular fibrillation arrest before surgery. He was now 10 days status after coronary artery bypass grafting (CABG), which was complicated by postoperative congestive heart failure (CHF). Current medications included lasix, digoxin, vasotec, potassium chloride, and aspirin.

Given the patient's significant cardiac history and also the magnitude of the surgery, pulmonary artery catheter insertion was planned. After securing adequate intravenous and intraarterial access, the right internal jugular vein was cannulated uneventfully. While routinely flushing the catheter ports before insertion into the patient, a yellow core was noted to be protruding from the distal right ventricular lumen of a Paceport[R] pulmonary artery catheter (Baxter, Irvine, CA). This core did not come out with flushing using the flush valve of the transducer setup; rather it took a manual “power flush” from a syringe to fully dislodge the core from the distal right ventricular lumen (Figure 1). The core was a solid cylindrical object that was 2.6 cm in length, 1 mm in diameter, with smooth flat ends. The core appeared to be made of the same yellow plastic used to make the catheter itself. This core was most likely a remnant from the manufacturing process. Another catheter was obtained, flushed, and inserted without incident. The rest of the anesthetic and surgery were uneventful.

We were fortunate that the lumen core was extruded during the flushing of the catheter ports before insertion into the patient. Had this not occurred until the catheter was inserted into the patient, it could have resulted in any one of several complications. Closer examination of the catheter revealed no additional problems. The manufacturer has no reports of a similar nature involving the same model and lot number. Moreover, the manufacturer has implemented several process improvements to prevent the type of occurrence reported herein. The Product Insert Data Sheet, included with each catheter, strongly recommends preinsertion testing of the catheter.

It is imperative that we pay close attention to the pulmonary artery catheter itself when flushing the ports because they may contain more that just heparinized saline solution.

The authors thank Drs. Roberta L. Hines and Paul G. Barash for their editorial review.

Jane C. K. Fitch, M.D.

Assistant Professor of Anesthesiology; Yale University School of Medicine; New Haven, Connecticut

Xiao-En Fang, M.D.

Associate Attending; Baylor University Medical Center; Dallas, Texas

Michael L. Dewar, M.D.

Assistant Clinical Professor of Cardiothoracic Surgery; Yale University School of Medicine; New Haven, Connecticut