Let us use the pulmonary artery catheter correctly and only when we need it

Clinical Outcomes in Patients Undergoing Elective Coronary Artery Bypass Graft Surgery With and Without Utilization of Pulmonary Artery Catheter–Generated Data

OBJECTIVE

The purpose of this study was to determine the frequency of pulmonary artery catheter (PAC) quantitative data requirements for modifying patient management during and after elective coronary artery bypass graft (CABG) surgery.

DESIGN

A prospective observational clinical trial.

SETTING

University tertiary referral center.

PARTICIPANTS

Two hundred patients undergoing elective CABG surgery.

INTERVENTIONS

Attending anesthesiologist and surgeon were blinded to PAC numeric values. These data could be revealed in the presence of at least 2 of the following criteria: (1) systolic blood pressure <90 mmHg, (2) central venous pressure >15 mmHg, (3) urine output <0.5 mL/kg/h, (4) pH <7.35/HCO(3) <18 mmol/L, (5) SaO(2) <95%/F(I)O(2) >80%, and (6) ST changes +/- 2 mm if the empiric treatment failed to restore normal hemodynamics within 10 minutes. All patients were classified into either blinded or unblinded PAC groups.

MEASUREMENTS AND MAIN RESULTS

PAC data were unblinded in 46 (23%) patients. Preliminary diagnosis was confirmed in 28 (14%), and treatment was modified in 18 (9%) of these patients. Four (2%) patients were given additional fluid challenges, 10 (5%) patients received a combination of fluid challenges and inotropic support, 3 (1.5%) patients were started on vasoconstrictors, and 1 (0.5%) patient required insertion of an intra-aortic balloon pump. Patients in the unblinded PAC group had a higher prevalence of perioperative myocardial infarction, atrial fibrillation, and inotropic support; longer intubation times; and increased intensive care unit (ICU) and hospital lengths of stay.

CONCLUSIONS

This study confirmed the contention that insertion of a PAC can be safely delayed until the clinical need arises either in the operating room or in the ICU after elective CABG surgery.

Intensive Care and Emergency Medicine

Over the last quarter of a century, intensive care medicine has developed into an established hospital specialty with its own unique identity and characteristics. Significant advances have occurred, mostly in a succession of small steps rather than any dramatic leap, with many being linked to advances in health care across other disciplines. In addition, many changes have resulted from the scientific identification of the detrimental effects of certain traditional practices once thought to be therapeutic. Here, in an attempt to learn from the past and offer guidance for future progress, we detail some of the key changes in various aspects of intensive care medicine including respiratory, cardiovascular, metabolic, and nutritional care, as well as sepsis, polytrauma, organization, and management.

The Last 100 Years of Sepsis

Over the last 100 years, huge advances have been made in the field of sepsis in terms of pathophysiology, epidemiology, diagnosis, monitoring, and therapeutics. Here, we offer our perspective of the key changes and current situation in each of these areas. Despite these changes, mortality rates remain unacceptably high and continued progress, particularly in early diagnosis and therapy, is urgently needed.

The Pulmonary Artery Catheter: Gold Standard or Redundant Relic

Pulmonary artery catheter (PAC) technology has changed significantly and use has decreased over the last 20 years. Barriers to use include: (a) increased patient risk with placement; (b) ability to measure similar variables via less invasive measures; (c) increased cost; (d) inaccurate measurement leading to misuse of PAC-derived variables; (e) incorrect interpretation and clinical application; and (f) lack of proven benefit for patient management. Advances in technology have allowed for continuous trending of hemodynamic parameters measured via the PAC. Patient risk is similar to that of central line placement; however risks associated with pulmonary artery infarction and rupture are inherent to the PAC. Less invasive assessment of cardiac output equals that of the PAC, whereas pulmonary capillary wedge pressure and mixed venous oxygen saturation monitoring are unique features of the PAC. Effective use of PAC data will require ongoing standardized education. More studies are needed on the cost-effectiveness of PAC monitoring as well as outcome benefits. Much of the data available from the PAC can be obtained via less invasive methods. However, the PAC continues to be useful in specific situations and remains the gold standard for comparison of new technologies. This paper discusses use of the PAC during the past 2 decades and reviews studies affecting its use in clinical practice.