Utility Of Pulmonary Artery Catheters Research Articles

Short and Mid-Term Economic Impact of Pulmonary Artery Catheter Use in Adult Cardiac Surgery: A Hospital and Integrated Health System Perspective.

ObjectiveA monitoring pulmonary artery catheter (PAC) is utilized in approximately 34% of the US cardiac surgical procedures. Increased use of PAC has been reported to have an association with complication rates: significant decreases in new-onset heart failure (HF) and respiratory failure (RF), but increases in bacteremia and urinary tract infections. We assessed the impact of increasing PAC adoption on hospital costs among cardiac surgery patients for US-based healthcare systems.MethodsAn Excel-based economic model calculated annualized savings for a US hospital with various cardiac surgical volumes and PAC adoption rates. A second model, for an integrated payer-provider health system, analyzed outcomes/costs resulting from the cardiac surgical admission and for the treatment of persistent HF and RF complications in the year following surgery. Model inputs were extracted from published literature, and one-way and probabilistic sensitivity analyses were performed.ResultsFor an acute care hospital with 500 procedures/year and 34% PAC adoption, annualized savings equalled $61,806 vs no PAC utilization. An increase in PAC adoption rate led to increased savings of $134,751 for 75% and $170,685 for 95% adoption. Savings ranged from $12,361 to $185,418 at volumes of 100 and 1500 procedures/year, respectively. For an integrated payer-provider health system with the base-case scenario of 3845 procedures/year and 34% PAC adoption, estimated savings were $596,637 for the combined surgical index admission and treatment for related complications over the following year.ConclusionPAC utilization in adult cardiac surgery patients results in reduced costs for both acute care hospitals and payer-provider integrated health systems.

PSU5 ECONOMIC IMPACT OF PULMONARY ARTERY CATHETER UTILIZATION AMONG CARDIAC SURGERY PATIENTS: PERSPECTIVES FOR AN ACUTE CARE HOSPITAL AND AN INTEGRATED PAYER-PROVIDER HEALTH SYSTEM

A recent study demonstrated pulmonary artery catheter (PAC) use surrounding cardiac surgery is associated with a significant decrease in the incidence of new onset heart failure (HF) and respiratory failure (RF), while bacteremia and urinary infection complication rates significantly increased, as compared to patients that did not receive a PAC. We evaluated the economic impact of perioperative monitoring PAC utilization for adult cardiac procedures to support decision-making regarding PAC adoption for an acute care hospital and an integrated payer-provider health system. An Excel-based model was created to estimate the annualized savings for a US acute care hospital utilizing a monitoring PAC perioperatively for cardiac procedures during the index visit. A second model for an integrated payer-provider included costs for the index visit and for treatment of persistent index visit-related HF and RF complications over the following year (excluding patients with history of these conditions). Complication rates, costs, and healthcare utilization inputs were extracted from literature and a national database. Scenario analyses with varying surgical volume and PAC adoption rates were performed, as were one-way and probabilistic sensitivity analyses. For an acute care hospital, base-case (500 cardiac surgeries/year, 34% PAC adoption) annualized savings for the index visit totaled US$61,806 vs. no PAC utilization. Scenario analyses with cardiac surgical volumes of 100 and 1,500 procedures/year resulted in estimated savings of US$12,361 and US$185,418, respectively. Increased PAC adoption rates (75% and 95%) were associated with increased savings: US$134,751 and US$170,685, respectively, for 500 procedures/year. HF and RF treatment costs had the largest impact on savings. For an integrated payer-provider, base-case (3,845 cardiac surgeries/year, 34% PAC adoption) resulted in estimated savings of US$596,637 for the index visit and treatment of related complications over the following year. Monitoring PAC utilization for adult cardiac surgeries generates significant savings for acute care hospitals and integrated payer-provider systems.

Pulmonary artery catheter use in adult patients undergoing cardiac surgery: a retrospective, cohort study

BackgroundThe utility of pulmonary artery catheters (PACs) and their measurements depend on a variety of factors including data interpretation and personnel training. This US multi-center, retrospective electronic health record (EHR) database analysis was performed to identify associations between PAC use in adult cardiac surgeries and effects on subsequent clinical outcomes.MethodsThis cohort analysis utilized the Cerner Health Facts database to examine patients undergoing isolated coronary artery bypass graft (CABG), isolated valve surgery, aortic surgery, other complex non-valvular and multi-cardiac procedures, and/or heart transplant from January 1, 2011, to June 30, 2015. A total of 6844 adults in two cohorts, each with 3422 patients who underwent a qualifying cardiac procedure with or without the use of a PAC for monitoring purposes, were included. Patients were matched 1:1 using a propensity score based upon the date and type of surgery, hospital demographics, modified European System for Cardiac Operative Risk Evaluation (EuroSCORE II), and patient characteristics. Primary outcomes of 30-day in-hospital mortality, length of stay, cardiopulmonary morbidity, and infectious morbidity were analyzed after risk adjustment for acute physiology score.ResultsThere was no difference in the 30-day in-hospital mortality rate between treatment groups (OR, 1.17; 95% CI, 0.65–2.10; p = 0.516). PAC use was associated with a decreased length of stay (9.39 days without a PAC vs. 8.56 days with PAC; p < 0.001), a decreased cardiopulmonary morbidity (OR, 0.87; 95% CI, 0.79–0.96; p < 0.001), and an increased infectious morbidity (OR, 1.28; 95% CI, 1.10–1.49; p < 0.001).ConclusionsUse of a PAC during adult cardiac surgery is associated with decreased length of stay, reduced cardiopulmonary morbidity, and increased infectious morbidity but no increase in the 30-day in-hospital mortality. This suggests an overall potential benefit associated with PAC-based monitoring in this population.Trial registrationThe study was registered at clinicaltrials.gov (NCT02964026) on November 15, 2016.

COMPARISON OF PULMONARY ARTERY CATHETER USE IN CARDIOGENIC SHOCK VERSUS SEPTIC SHOCK

There is a controversy about the utility of pulmonary artery catheters (PAC) in the management of shock. We hypothesized that invasive hemodynamic monitoring with the use of PAC may be beneficial in the management of shock depending on the etiology (septic versus cardiogenic). Using weighted data

Invasive Hemodynamic Assessment of Patients with Heart Failure and Pulmonary Hypertension

Right heart catheterization (RHC) with a pulmonary artery (PA) catheter is a minimally invasive method of obtaining hemodynamic data (e.g., right atrial and pulmonary pressures, cardiac output, pulmonary vascular resistance), which are used to diagnose and manage patients with advanced heart failure (HF), HF with preserved ejection fraction, and pulmonary hypertension (PH). Invasive hemodynamic data obtained from RHC can aid in the prognostication of HF and PH patients and are important in guiding decisions of implanting mechanical circulatory support devices and listing patients for heart and/or lung transplantation. The basis of RHC has also paved the way for implantable hemodynamic devices to monitor pulmonary artery pressures in the outpatient setting, which can reduce rates of HF-related hospitalizations. We will discuss the utility of PA catheters in the diagnosis and management of the aforementioned disease states, the role of implantable hemodynamic monitors, and the complications associated with RHC procedures.

Nonsurgical Removal of Knotted Pulmonary Artery Catheter

Though controversy exists regarding the utility of pulmonary artery catheters (PAC), their use persists in select patients. Knotting of these catheters upon insertion is a rare but serious complication. We present 2 cases of coagulopathic patients undergoing orthotopic liver transplantation complicated by PAC knotting on attempted line placement. Both knotted PAC were successfully removed nonsurgically in the operating room, allowing for timely continuation of the planned transplantations. It is essential for the clinician to recognize knotted PAC and understand strategies for safe removal. J Med Cases. 2013;4(3):163-165 doi: https://doi.org/10.4021/jmc1016e

Nonsurgical Removal of Knotted Pulmonary Artery Catheter

Though controversy exists regarding the utility of pulmonary artery catheters (PAC), their use persists in select patients. Knotting of these catheters upon insertion is a rare but serious complication. We present 2 cases of coagulopathic patients undergoing orthotopic liver transplantation complicated by PAC knotting on attempted line placement. Both knotted PAC were successfully removed nonsurgically in the operating room, allowing for timely continuation of the planned transplantations. It is essential for the clinician to recognize knotted PAC and understand strategies for safe removal. doi: http://dx.doi.org/10.4021/jmc1016e

Pulmonary artery catheterization in patients with acute coronary syndromes

There are limited recent data evaluating the use of the pulmonary artery catheter (PAC) in patients hospitalized with an acute coronary syndrome (ACS). Using data from the multinational Global Registry of Acute Coronary Events, we examined trends in PAC use among patients hospitalized for an ACS and the association between PAC and hospital outcomes. Trends in PAC utilization between 2000 and 2007 were examined through the review of data contained in hospital medical records. We identified factors associated with PAC utilization and compared differences in the length of hospitalization and in-hospital death rates between patients undergoing PAC during the index hospitalization (PAC+, n = 2,879) and those managed without PAC (PAC-, n = 56,091). The utilization of PAC during hospitalization for an ACS declined over time such that 3.0% of patients underwent PAC in 2007 compared with 5.4% in 2000. Admission Killip classification was the strongest factor associated with PAC insertion. The duration of hospitalization was significantly longer among PAC+ (median = 10.0 days) as compared with PAC- patients (median = 5.0 days). In-hospital death rates were significantly higher among PAC+ patients after adjustment for differences in baseline characteristics (odds ratio 4.00, 95% CI 3.41-4.70). The frequency of PAC utilization in "real-world" patients hospitalized with ACS has declined during recent years. Our finding of increased in-hospital mortality among patients undergoing PAC is consistent with prior studies and may further challenge the efficacy of PAC in the setting of ACS.

Commentary: Trzeciak S et al. (2006). Translating research to clinical practice: a 1‐year experience with implementing early goal‐directed therapy for septic shock in the emergency department

AbstractEarly goal‐directed therapy (EGDT) has been shown to decrease mortality in patients with severe sepsis and septic shock. Consensus guidelines now advocate EGDT for the first 6 h of sepsis resuscitation. However, EGDT has not yet been widely adopted in practice. A need for effective collaboration between emergency medicine and critical care medicine services has been identified as an obstacle to implementation. We aimed to determine if EGDT end‐points could reliably be achieved in real‐world clinical practice. EGDT was implemented as a collaborative emergency medicine/critical care quality improvement initiative. EGDT include the following: intravenous (IV) fluids (IVF) targeting central venous pressure ≥8 mmHg, vasopressors targeting mean arterial pressure ≥65 mmHg, and (if necessary) packed RBCs (PRBCs) and/or dobutamine targeting central venous oxygen saturation ≥70%. A retrospective analysis was performed of emergency department (ED) patients with persistent sepsis‐induced hypotension (systolic blood pressure &lt;90 mmHg despite 1.5 L of IVF) treated with EGDT during the first year of the initiative. Primary outcome measures included successful achievement of EGDT end‐points and time to achievement. A secondary analysis was performed, comparing EGDT cases to historical control cases (non‐protocolized control subjects without invasive monitoring). All end‐points were achieved in 20 of 22 cases (91%). The median time to reach end‐point was ≤6 h. In the secondary analysis, patients (n = 38; EGDT, n = 22; pre‐EGDT, n = 16) had similar age, do‐not‐resuscitate status, severity scores, hypotension duration and vasopressor requirement (p = not significant). In the ED, EGDT used more IVF and included PRBC/dobutamine utilization, without any effect on the overall use of these therapies through the first 24 h in the ICU. EGDT was associated with decreased intensive care unit pulmonary artery catheter (PAC) utilization (9.1% versus 43.7%, p = 0.01). With effective emergency medicine/critical care collaboration, we demonstrate that EGDT end‐points can reliably be achieved in real‐world sepsis resuscitation. ED‐based EGDT appears to decrease ICU PAC utilization. Abstract reprinted from the Chest volume 129, Trzeciak et al., ‘Translating research to clinical practice: a 1–year experience with implementing early goal‐directed therapy for septic shock in the emergency department.’, pages 225–232. © 2006, with permission from Blackwell Publishing Ltd.

Translating Research to Clinical Practice: A 1-Year Experience With Implementing Early Goal-Directed Therapy for Septic Shock in the Emergency Department

Objective Early goal-directed therapy (EGDT) has been shown to decrease mortality in patients with severe sepsis and septic shock. Consensus guidelines now advocate EGDT for the first 6 h of sepsis resuscitation. However, EGDT has not yet been widely adopted in practice. A need for effective collaboration between emergency medicine and critical care medicine services has been identified as an obstacle for implementation. We aimed to determine if EGDT end points could reliably be achieved in real-world clinical practice. Methods EGDT was implemented as a collaborative emergency medicine/critical care quality improvement initiative. EGDT included the following: IV fluids (IVF) targeting central venous pressure ≥ 8 mm Hg, vasopressors targeting mean arterial pressure ≥ 65 mm Hg, and (if necessary) packed RBCs (PRBCs) and/or dobutamine targeting central venous oxygen saturation ≥ 70%. A retrospective analysis was performed of emergency department (ED) patients with persistent sepsis-induced hypotension (systolic BP Results All end points were achieved in 20 of 22 cases (91%). The median time to reach each end point was ≤ 6 h. In the secondary analysis, patients (n = 38; EGDT, n=22; pre-EGDT, n=16) had similar age, do-not-resuscitate status, severity scores, hypotension duration, and vasopressor requirement (p = not significant). In the ED, EGDT used more IVF and included PRBC/dobutamine utilization, without any impact on the overall use of these therapies through the first 24 h in the ICU. EGDT was associated with decreased ICU pulmonary artery catheter (PAC) utilization (9.1% vs 43.7%, p=0.01). Conclusions With effective emergency medicine/critical care collaboration, we demonstrate that EGDT end points can reliably be achieved in real-world sepsis resuscitation. ED-based EGDT appears to decrease ICU PAC utilization.

The Utility of Hemodynamic Measurements Acquired by Pulmonary Artery Catheterization

Background: Concerns about the utility of pulmonary artery catheters (PAC) stimulated us to assess the impact of one of the parameters measured by the PAC, the pulmonary capillary wedge pressure (PCWP), on our clinical practice. Methods: The PCWP was recorded at 4- to 6-hour intervals on 50 patients for the first 48 hours following aortic aneurysm repair. We then reviewed the patients’ records looking for evidence that the PCWP measurements were used to guide therapy. For the purpose of the study, we anticipated the administration of diuretics for PCWP ≥18 mm Hg and volume resuscitation for PCWP ≤8 mm Hg. Data were correlated using Pearson rank correlation coefficient using a P <0.05 to determine statistical significance. Results: Patients with PCWPs <8 mm Hg were more likely to be treated with volume resuscitation ( P <0.05). There was no other correlation between PCWP measurements and fluid or pharmacologic management. Conclusions: Data derived from the PAC are infrequently used to guide therapy in patients who undergo abdominal aortic reconstructive surgery.