Trends in pulmonary artery catheter use for cardiac surgery, 2013-2023: Analysis of Australian medicare data.

To evaluate the association between pulmonary artery catheter (PAC) use and mortality in a large cohort of injured patients. We hypothesized that PAC use is associated with improved survival in critically injured trauma patients. Retrospective database analysis. A total of 268 level 1 trauma centers from across the United States. A total of 53,312 patients admitted to the intensive care units of the trauma centers participating in the National Trauma Data Bank maintained by the American College of Surgeons. The National Trauma Data Bank was queried to identify patients aged 16-90 yrs with complete data on base deficit, and Injury Severity Score (n=53,312). Patients were initially divided into two groups: those managed with a PAC (n=1,933) and those managed without a PAC (n=51,379). Chi-square and Student's t-test analysis were utilized to explore group differences in mortality. In a second analysis, groups were stratified by base deficit, Injury Severity Score, and age to further explore the influence of injury severity on PAC use and mortality. In addition, a logistic regression model was developed to assess the relationship between PAC use and mortality after adjusting for differences in age, mechanism, injury severity, injury pattern, and co-morbidities. Overall, patients managed with a PAC were older (45.8+/-21.3 yrs), had higher Injury Severity Score (28.4+/-13.5), worse base deficit (-5.2+/-6.5), and increased mortality (PAC, 29.7%; no PAC, 9.8%; p<.001). However, after stratification for injury severity, PAC use was associated with a survival benefit in four subgroups of patients. Each of these groups had advanced age or increased injury severity. Specifically, patients aged 61-90 yrs, with arrival base deficit worse than -11 and Injury Severity Score of 25-75, had a decrease in the risk of death with PAC use (odds ratio, 0.33; 95% confidence interval, 0.17-0.62). Three additional groups had a similar decrease in the risk of death with PAC use: odds ratio, 0.60 (95% confidence interval, 0.43-0.83), 0.82 (95% confidence interval, 0.44-1.52), and 0.63 (95% confidence interval, 0.40-0.98). Logistic regression analysis demonstrated a decreased mortality when a PAC was used in the management of patients with the following severe injury characteristics: Injury Severity Score of 25-75, base deficit of less than -11, or age of 61-90 yrs (odds ratio, 0.593; 95% confidence interval, 0.437-0.805). Trauma patients managed with a PAC are more severely injured and have a higher mortality. However, severely injured patients (Injury Severity Score, 25-75) who arrive in severe shock, and older patients, have an associated survival benefit when managed with a PAC. This is the first study to demonstrate a benefit of PAC use in trauma patients.

Pulmonary Artery Catheter Use and Risk of In-hospital Death in Heart Failure Cardiogenic Shock

Randomized trials have demonstrated risks and failed to establish a clear benefit for the use of the pulmonary artery catheter. We assessed rates of pulmonary artery catheter use in multiple centers over 5 yrs, variables associated with their use, and how these variables changed over time (2002-2006). A multicenter longitudinal study using the Hamilton Regional Critical Care Database. A two-level multiple logistic regression analysis was used to determine significant variables associated with pulmonary artery catheter use and whether these varied over time. Academic intensive care units in Hamilton, Canada. We identified patients from five intensive care units who received a pulmonary artery catheter within the first 2 days of intensive care unit admission. Pulmonary artery catheter use over a 5-yr period. Among 15,006 patients, 1,921 (12.8%) had a pulmonary artery catheter. Adjusted rates of pulmonary artery catheter use decreased from 16.4% to 6.5% over 5 yrs. Determinants of pulmonary artery catheter use included Acute Physiology and Chronic Health Evaluation II score (odds ratio [OR], 1.05; confidence interval [CI], 1.04-1.06; p < .0001), elective surgical status (OR, 2.82; CI, 2.29-3.48; p < .0001), postabdominal aortic aneurysm repair (OR, 10.91; CI, 8.24-14.45; p < .0001), cardiogenic shock (OR, 5.31; CI, 3.35-8.42; p < .0001), sepsis (OR, 2.83; CI, 1.94-4.13; p < .0001), vasoactive infusion use (OR, 4.04; CI, 3.47-4.71; p < .0001), and mechanical ventilation (OR, 2.21; CI, 1.86-2.63; p < .0001). Physician's base specialty and local intensive care unit were also associated with pulmonary artery catheter use (p < .0001). The determinants of pulmonary artery catheter use did not change over time. We observed a >50% reduction in the rate of pulmonary artery catheter use over 5 yrs. Patient factors predicting pulmonary artery catheter use were illness severity, specific diagnoses, and the need for advanced life support. Nonpatient factors predicting pulmonary artery catheter use were intensive care unit and the attending physician's base specialty.

To determine the association of intraoperative pulmonary artery catheter (PAC) use with in-hospital outcomes in cardiac surgical patients. MEDLINE, Embase, and Cochrane Library (Wiley) databases were screened for studies that compared cardiac surgical patients receiving intraoperative PAC with controls and reporting in-hospital mortality. Secondary outcomes included intensive care unit length of stay, cost of hospitalization, fluid volume administered, intubation time, inotropes use, acute kidney injury (AKI), stroke, myocardial infarction (MI), and infections. Seven studies (25853 patients, 88.6% undergoing coronary artery bypass graft surgery) were included. In-hospital mortality was significantly increased with PAC use [odds ratio (OR) 1.57; 95% confidence interval (CI) 1.12-2.20, P = 0.04]; PAC use was also associated with greater intraoperative inotrope use (OR 2.61; 95% CI 1.54-4.41) and costs [standardized mean difference (SMD) = 0.20; 95% CI 0.16-0.23], longer intensive care unit stay (SMD = 0.29; 95% CI 0.25-0.33), and longer intubation time (SMD = 0.44; 95% CI 0.12-0.76). PAC use is associated with significantly increased odds of in-hospital mortality, but the amount and quality of the available evidence is limited. Prospective randomized trials testing the effect of PAC on the outcomes of cardiac surgical patients are urgently needed.

To determine the association of pulmonary artery catheter (PAC) use with in-hospital mortality. Prospective, observational study. The medical intensive care units (MICU) of two teaching hospitals. The study included 751 adults who were admitted to the MICU, excluding those who stayed for <24 hrs. Demographics and the worst Acute Physiology and Chronic Health Evaluation (APACHE) II score within the first 24 hrs of MICU admission were obtained. Daily logistic organ dysfunction system (LODS) scores were calculated. The associations of in-hospital mortality with the admission source, admission disease category, APACHE II scores, the worst LODS scores, mechanical ventilation, and PAC use were determined using chi-square, Mann-Whitney U, and multiple logistic regression analysis tests. p Values < 0.05 were considered significant. Mean patient age was 52.6 +/- 17.1 yrs; 425 (57%) were male; 464 (62%) were African-American, 275 (37%) Caucasian, 6 (1%) Asian, and 6 (1%) Hispanic. PAC was used in 119/751 (16%). The median APACHE II and worst LODS scores were 19 and 4, respectively. The in-hospital mortality rate was 159/751 (21%). The median APACHE II score for survivors was 17.5, compared with 28.0 for nonsurvivors (p <.0001). The worst median LODS score was 4 for survivors, compared with 11 for nonsurvivors (p <.0001). Sixty-four (54%) of the 119 patients with PAC died, compared with 95 (15%) of the 632 without PAC (p <.0001). Multiple logistic regression analysis showed that higher APACHE II-predicted mortality rate (p =.0088) and worst daily LODS score (p <.0001) were associated with increased mortality. The admission source, admission disease category, PAC use, and mechanical ventilation were not associated with in-hospital mortality. This study could not detect an association between PAC use and mortality. The APACHE II-predicted mortality rate and the development of multiple organ dysfunction were the main determinants of poor outcome in critically ill patients admitted to MICU.

Introduction: Randomized controlled trials and systematic reviews evaluating the use of pulmonary artery catheters in the critically ill population have not shown beneficial effects on survival. However, many of those studies have excluded patients in cardiogenic shock. We address this evidence gap by providing a comprehensive meta-analysis to investigate the association between pulmonary artery catheter use and outcomes in patients with cardiogenic shock Hypothesis: Pulmonary artery catheter use in patients with cardiogenic shock is associated with improved mortality. Methods: We performed an extensive literature search using PubMed, MEDLINE, SCOPUS, and the Cochrane databases from January 1990 through June 2021. Data for final analysis was pooled using a random effects model. Odds ratios were used for effect size. Information on eligibility criteria, outcomes, and methodological quality was extracted by two independent reviewers. Primary study outcome was in-hospital mortality rate. Results: 16 studies were included in the analysis comprising 2,400,618 patients. Of those, 212,122 were managed with a pulmonary artery catheter (8.8%) and 2,188,496 were managed without one (91.2%). In patients with cardiogenic shock, pulmonary artery catheter use was associated with a statistically significant decrease in mortality (OR 0.82 [95% CI 0.73-0.92; p = 0.001]. The pulmonary artery catheter cohort was more likely to receive mechanical circulatory support (OR 2.16 [95% CI 1.90-2.45; p&lt;0.001]), left ventricular assist device (OR 3.09 [95% CI 1.96-4.86; p&lt;0.001]), and renal replacement therapy (OR 1.44 [95% CI 1.17-1.77; p=0.001]). Interestingly, when studies looking only at patients who developed cardiogenic shock due to acute myocardial infarction were analyzed, there was no statistically significant improvement in mortality (OR 0.945 [95% CI 0.75-1.20; p=0.64]). Conclusions: Pulmonary artery catheter use in patients with cardiogenic shock is associated with lower in-hospital mortality. Future studies differentiating pulmonary artery catheter use among various cardiogenic shock stages and phenotypes are needed.

Use of the Pulmonary Artery Catheter Is Not Associated With Worse Outcome in the ICU

Commentary: Has pulmonary artery catheter ship sailed?

To examine the relationship of pulmonary artery catheter (PAC) use to patient outcomes, including mortality rate and resource utilization, in patients with severe sepsis in eight academic medical centers. Case-control, nested within a prospective cohort study. Eight academic tertiary care centers. Stratified random sample of 1,010 adult admissions with severe sepsis. None. The main outcome measures were in-hospital mortality, total hospital charge, and length of stay (LOS) for patients with and without PAC use. The case-matched subset of patients included 141 pairs managed with and without the use of a PAC. The mortality rate was slightly but not statistically significantly lower among the PAC use group compared with those not using a PAC (41.1% vs. 46.8%, p =.34). Even this trend disappeared after we adjusted for the Charlson comorbidity score and sepsis-specific Acute Physiology and Chronic Health Evaluation (APACHE) III (adjusted odds ratio, 1.02; 95% confidence interval, 0.61-1.72). In linear regression models adjusted for the Charlson comorbidity score, sepsis-specific APACHE III, surgical status, receipt of a steroid before sepsis onset, presence of a Hickman catheter, and preonset LOS, no significant differences were found for total hospital charges (139,207 US dollars vs. 148,190, adjusted mean comparing PAC and non-PAC group, p =.57), postonset LOS (23.4 vs. 26.9 days, adjusted mean, p =.32), or total LOS in intensive care unit (18.2 vs. 18.8 days, adjusted mean, p =.82). Among patients with severe sepsis, PAC placement was not associated with a change in mortality rate or resource utilization, although small nonsignificant trends toward lower resource utilization were present in the PAC group.

ImportanceRecent studies have observed an increase in the rate of pulmonary artery catheter (PAC) use in heart failure admissions. Little is known about the national trends in other previously common indications for PAC placement, PAC use overall, or outcomes associated with PAC placement.ObjectiveTo determine national trends in PAC use overall as well as across sociodemographic groups and key clinical conditions, including acute myocardial infarction, heart failure, and respiratory failure.Design, Setting, and ParticipantsCenters for Medicare and Medicaid Services inpatient claims data and International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to conduct a serial cross-sectional cohort study between January 1, 1999, and December 31, 2013, identifying hospitalizations during which a PAC was placed. Data analysis was conducted from September 25, 2015, to April 10, 2017.Main Outcomes and MeasuresRate of use of a PAC per 1000 admissions, 30-day mortality, and length of stay.ResultsAmong the 68 374 904 unique Medicare beneficiaries in the study, there were 469 582 hospitalizations among 457 193 patients (204 232 women and 252 961 men; mean [SD] age, 76.3 [6.9] years) during which a PAC was placed. There was a 67.8% relative decrease in PAC use (6.28 per 1000 admissions in 1999 to 2.02 per 1000 admissions in 2013; P < .001), with 2 distinct trends: significant year-on-year decreases from 1999 to 2011, followed by stable use through 2013. There was variation in rates of PAC use across race/ethnicity, age, and sex, but use decreased across all subgroups. Although there were sustained decreases in PAC use for acute myocardial infarction (20.0 PACs placed per 1000 admissions in 1999 to 5.2 in 2013 [74.0% reduction]; P < .001 for trend) and respiratory failure (29.9 PACs placed per 1000 admission in 1999 to 2.3 in 2013 [92.3% reduction]; P < .001 for trend) during the study period, there was an initial decrease in PAC use in heart failure, with a nadir in 2009 followed by a subsequent increase (9.1 PACs placed per 1000 admissions in 1999 to 4.0 in 2009 to 5.8 in 2013). In-hospital mortality, 30-day mortality, and length of stay decreased during the study period.Conclusions and RelevanceIn the wake of mounting evidence suggesting a lack of benefit to the routine use of PACs, there has been a de-adoption of PAC use overall and across sociodemographic groups but heterogeneity in patterns of use across clinical conditions. The clinical outcomes of patients with PACs have significantly improved. These findings raise important questions about the optimal use of PACs and the drivers of the observed trends.

To review the problems associated with pulmonary artery catheter use in the intensive care unit; to discuss the need for clinical trials to assess its benefits; and to present original data on the use of the pulmonary artery catheter in European countries. Selected relevant articles from the literature and data from a recent multicenter European study. It has recently been suggested that pulmonary artery catheter use increases mortality. As a result, some have recommended placing a moratorium on pulmonary catheter use or suggested conducting large multicenter trials to assess the positive and negative effects of pulmonary catheter use. Although there is limited evidence showing an improved outcome with pulmonary artery catheter use, many leaders in intensive care medicine feel that the pulmonary catheter is a useful tool, when used correctly. We believe that misuse of the pulmonary artery catheter is common. The incidence of complications is low and, with improved training of insertion techniques, the frequency of complication would decrease further. The pulmonary artery catheter is a monitoring tool and, as such, is only as good as the interpretation of the data it generates. Clinical trials on such an accepted technique are difficult to conduct and their cost/benefit ratio is debatable. A moratorium on pulmonary artery catheter use is not necessary and clinical trials in heterogeneous ICU populations are not warranted. Improved training in the insertion, interpretation, and implementation of the pulmonary artery catheter and the data it generates is required. As an alternative to expensive clinical trials on the pulmonary artery catheter, we propose that our limited financial resources for clinical investigation be invested in the development of innovative techniques that may reduce the need for pulmonary artery catheter in the future.

Pulmonary Artery Catheter Use and Outcomes in Patients With ST-Elevation Myocardial Infarction and Cardiogenic Shock Treated With Impella (a Nationwide Analysis from the United States)

Multiple studies suggest that routine use of pulmonary artery catheters is not beneficial in critically ill patients. Little is known about the patterns of "uptake" of practice change that involves removal of a device previously considered standard of care, rather than adoption of a new technique or technology. Our objective was to assess recent pulmonary artery catheter use across ICUs and identify factors associated with high use. Cohort study. U.S. ICUs in Project IMPACT. Adult ICU admissions from 2001 to 2008. None. Trends in pulmonary artery catheter use from 2001 to 2008 were assessed. For 2006-2008, we compared pulmonary artery catheter use across ICUs. We assessed characteristics of ICUs and hospitals in the top quartile for in-ICU pulmonary artery catheter placement (vs the bottom quartile) using chi-square and t tests and factors associated with in-ICU pulmonary artery catheter insertion using multilevel mixed effects logistic regression. Total pulmonary artery catheter use decreased from 10.8% of patients (2001-2003) to 6.2% (2006-2008; p < 0.001); insertion of pulmonary artery catheters in ICU decreased from 4.2% to 2.2% (p < 0.001). In 2006-2008, ICUs in the top quartile for in-ICU pulmonary artery catheter insertion (3.4-25.0% of patients) were more often surgical (54.2% vs 21.7% in the lowest quartile, p = 0.070), teaching hospitals (54.2% vs 4.3%, p = 0.001), and had surgeon leadership (40.9% vs 13.0%, p = 0.067). After multivariable regression, surgical patients (p < 0.001) and all patients in surgical ICUs (p = 0.057) were more likely to have pulmonary artery catheters placed in ICU. Use of pulmonary artery catheters in ICU patients has declined but with significant variation across units. Removal of this technology has occurred most in nonsurgical ICUs and patients.

Hemodynamic monitoring of patients with a pulmonary artery catheter is controversial because there are few data confirming its effectiveness, and patient and intensive care unit (ICU) organizational factors associated with its use are unknown. To determine pulmonary artery catheter use in relationship to type of ICU organization and staffing, and patient characteristics, including severity of illness and insurance coverage. Retrospective database study of 10,217 nonoperative patients who received treatment at 34 medical, mixed medical and surgical, and surgical ICUs at 27 hospitals during 1998 (patients were enrolled in Project IMPACT). Pulmonary artery catheter use based on severity of illness measured by the Simplified Acute Physiology Score, resuscitation status at ICU admission, and ICU organizational variables, including type, size, and model. A pulmonary artery catheter was used for 831 patients (8.1%) in the ICU. In multivariate analysis adjusted for severity of illness, age, diagnosis, and do-not-resuscitate status, full-time ICU physician staffing was associated with a two-thirds reduction in the probability of catheter use (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.28-0.45). Higher catheter use was associated with white race (OR, 1.38; 95% CI, 1.10-1.72) and private insurance coverage (OR, 1.33; 95% CI, 1.10-1.60). Admission to a surgical ICU was associated with a 2-fold increase in probability of catheter use (OR, 2.17; 95% CI, 1.70-2.76) compared with either medical or mixed medical and surgical ICUs. Organizational characteristics of ICUs, insurance reimbursement, and race, as well as clinical variables, are associated with variation in practice patterns regarding pulmonary artery catheter use. Understanding such influences, combined with studies measuring clinical and economic outcomes, can contribute to the development of policies for the rational use of pulmonary artery catheters. JAMA. 2000;283:2559-2567

Pressures in the right side of the heart and pulmonary capillary wedge can be obtained by cardiac catheterization without the aid of fluoroscopy. A No. 5 French double-lumen catheter with a balloon just proximal to the tip is inserted into the right atrium under pressure monitoring. The balloon is then inflated with 0.8 ml of air. The balloon is carried by blood flow through the right side of the heart into the smaller radicles of the pulmonary artery. In this position when the balloon is inflated wedge pressure is obtained. The average time for passage of the catheter from the right atrium to the pulmonary artery was 35 s in the first 100 passages. The frequency of premature beats was minimal, and no other arrhythmias occurred.