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Systemic hemodynamics. 

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Explain the value of invasive hemodynamic monitoring, including a discussion of whether an acute, chronic, or complex-care patient is a candidate for this type of assessment. For a complex-care patient, propose an evidence-based treatment plan regarding the hemodynamic information. What are the risk factors to take into consideration for this patient?

Clinical decision-making about optimizing treatments for complex-care patients can be guided effectively by hemodynamic monitoring with a pulmonary artery catheter (PAC, also known as Swan-Ganz or right heart catheter) (Saxena et al., 2020).

Based on Ingbar & Thiele (2018), pulmonary artery catheter (PAC) use in hemodynamic monitoring is declining because clinical trials have shown no mortality advantage. However, hemodynamic data furnished by a PAC can confirm the presence and severity of cardiogenic shock (CS), involvement of the right ventricle, left-to-right shunting, pulmonary artery pressures and trans-pulmonary gradient, and the pulmonary and systemic vascular resistance. It can support recognizing acute mitral regurgitation (MR), decreased left atrial filling pressure, and secondary occult sepsis and exclude left-to-right shunts. Equalization of diastolic pressures indicates cardiac tamponade, but an echocardiogram is more definitive. The detailed hemodynamic profile can be utilized to individualize and monitor therapy and provide prognostic details, such as cardiac index and cardiac force. The AHA currently recommends using a PAC for potential utilization in diagnostic or CS management uncertainty cases or patients with severe CS who are unresponsive to initial therapy. Therapeutic options for patients in CS include inotropes and vasopressors and mechanical circulatory support (MCS) devices that pump blood from 1 vascular chamber to another to improve systemic hemodynamics.

Winehouse (2021) wrote that common PAC insertion complications include atrial and/or ventricular arrhythmias. Less commonly, catheter misplacement or knotting can happen. Perforation of a cardiac chamber and rupture of a cardiac valve or the pulmonary artery are rare complications that can be fatal. Complications of catheter use include pulmonary artery rupture, pulmonary infarction, thromboembolic events, infection, and data misinterpretation. In addition, the benefit must be balanced against risks, as with any invasive diagnostic tool. Absolute contraindications to PAC placement include infection at the insertion site, right ventricular assist device, insertion during cardiopulmonary bypass, and lack of consent. Relative contraindications include the presence of a coagulopathy (INR >1.5), thrombocytopenia (platelet count <50,000/microL), electrolyte disturbances (hypo/hyper -kalemia, -magnesemia, -natremia, -calcemia), and severe acid-base disturbances (e.g., pH <7.2 or >7.5).

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