Excessive catheter length in a heart chamber causes coiling and a risk of knotting. No more than 15-20cm should be passed before the waveform changes. If not, deflate balloon, withdraw catheter, repeat. A knot can be managed by (i) 'unknotting' with an intraluminal wire, (ii) pulling taut and removing catheter + introducer sheath together, or (iii) surgical or angiographic intervention.

If catheter fails to advance to next chamber, consider 'stiffening' catheter by injecting iced crystalloid through distal lumen, rolling patient to left lateral position or advancing catheter slowly with balloon deflated.

The catheter should never be withdrawn with the balloon inflated.

Arrhythmias on insertion usually occur when the catheter tip is at the tricuspid valve. These usually resolve on withdrawing the catheter or, occasionally, after a slow bolus of 1.5mg/kg lidocaine.


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