Routine Use Of Pulmonary Artery Catheters Research Articles

The Utility of Invasive Hemodynamics in the Management of Cardiogenic Shock

There is growing interest in the role and utilization of pulmonary artery catheters (PAC) in cardiogenic shock (CS). Observational evidence supports an association between PAC use and improved survival, and specialty societies increasingly advocate for its use. The PAC is useful for early diagnosis, decisions surrounding escalation of care, and daily management. Despite this, its use in Canada is variable. Registries and trials collecting prospective data mandate invasive hemodynamics, and forthcoming evidence-based treatment strategies are likely to be tailored to hemodynamic phenotypes. Herein we present the case for the routine use of PACs in the management of CS.

NATIONAL TRENDS IN THE USE OF PULMONARY CATHETER IN SEPSIS

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: Pulmonary artery catheter (PAC) is used to assess hemodynamic status and guide treatment in critically ill patients. There are strict guidelines for the routine use of PACs as various studies have demonstrated minimal clinical benefit. As per the recent literature, the use of PAC is increasing in heart failure. We aimed to time trend the use of PAC in sepsis using the data from the National Inpatient Sample (NIS). METHODS: We obtained data from years 2002 to 2014 using the International Classification of Diseases (ICD-9) codes for a primary diagnosis of ‘’Sepsis”. We analyzed patients older than 18 years of age and excluded the patients who underwent a right heart catheterization. We identified the PA catheter procedure by using the ICD-9 procedure codes for Pulmonary Artery (PA) Pressure monitoring, PA wedge monitoring, measurement of mixed venous blood gases, monitoring of cardiac output via Fick method and thermodilution. We assessed the time trend analysis of PA Catheter use in sepsis. We also analyzed the data to determine the trend with gender, race, length of stay (LOS), mortality and charges. SAS software was used for statistical analysis. RESULTS: The use of PAC reduced by 82% from 14.03 in 2002 to 2.55 per 1000 admission in 2010 followed by relatively stable use with a downward trend from 2011 to 2014. During the same duration, the number of patients admitted with sepsis increased by 78% from 322889 in 2002 to 1489880 in 2014. The mean age of the patients receiving PAC (PAC +) was lower (64.5 vs. 68 years, p-value <.001). PAC+ group had more prolonged hospital stay (LOS) as compared to PAC-(14.7 vs. 8.1 days) with a similar yearly trend. PAC - group showed a reduction from 8.5 days in 2002 to 7.4 days in 2014, whereas, PAC+ group showed an increase in LOS from 14.65 to 15.27 days from 2002 to 2014. PAC + group had 2.7-fold higher charges and higher in-hospital mortality score. CONCLUSIONS: Our observation indicates a gradual reduction of PAC use in sepsis. The number of patients admitted with sepsis increased significantly. The patients receiving PAC were younger, had higher in-hospital mortality score and length of stay. CLINICAL IMPLICATIONS: Older patients are usually sicker as compared to the younger population. Further studies are needed to analyze the potential reasons for higher mortality score and use of PA catheter in the younger population. DISCLOSURES: No relevant relationships by Kathir Balakumaran, source=Web Response No relevant relationships by Kai Chen, source=Web Response No relevant relationships by Manish Kumar, source=Web Response No relevant relationships by Kimberly Rebello, source=Web Response No relevant relationships by Bryan Stringer, source=Web Response No relevant relationships by Varun Tandon, source=Web Response

NATIONAL TRENDS IN THE USE OF PULMONARY CATHETER IN SYSTOLIC AND DIASTOLIC HEART FAILURE

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: Pulmonary artery catheter (PAC) is used to assess hemodynamic status and guide treatment in critically ill patients. Over the years, the use of PAC in heart failure has gradually reduced with a concomitant reduction in heart failure hospitalization. However, the previous analysis demonstrated increased use of PAC in the last few years. We aimed to time trend the use of PAC in systolic (SHF) and diastolic heart failure (DHF) using the data from National Inpatient Sample (NIS). METHODS: We obtained two datasets from years 2002 to 2014 using the International Classification of Diseases (ICD-9) codes for a primary diagnosis of SHF and DHF. We analyzed patients older than 18 years of age and excluded the patients who underwent a right heart catheterization. We identified the pulmonary artery (PA) catheter procedure by using the ICD-9 procedure codes for PA pressure monitoring, PA wedge monitoring, measurement of mixed venous blood gases, monitoring of cardiac output via Fick method and thermodilution. We assessed the time trend analysis of PA Catheter use in subsets of heart failure and trend with age, race, length of stay, mortality and total hospital charges. SAS software was used for statistical analysis. RESULTS: The use of PAC reduced by 40% from 8.6 in 2002 to 5.15 per 1000 admissions in 2007 followed by a 44% increase from 4.72 in 2010 to 6.81 per 1000 admissions in 2014. PAC use in SHF and DHF showed a similar trend from 2002-2010. From 2011-2014, PAC use in DHF remained fairly stable at 3.3-3.5 per 1000 admissions whereas use in SHF showed an upward trend, from 7.36 in 2010 to 9.81 per 1000 admissions in 2014. Patients receiving PAC were younger in both systolic and diastolic groups (62 and 69 vs 71 and 76, p-value <.01), had longer hospital stays (13.1 and 11.5 vs. 5.28 and 5.18, p-value<0.01) and higher mortality score (8.29 and 7.67 vs 5.65 and 5.64, p-value <.01). CONCLUSIONS: Routine use of PAC in heart failure is not indicated as per guidelines. The overall use of PAC in heart failure has increased due to increased use in SHF. There is a correlation between mortality score and PAC use in both SHF and DHF. CLINICAL IMPLICATIONS: The increasing use of PAC in heart failure patients can be attributed to increased systolic heart failure admissions. However, PAC use is also associated with higher mortality and further studies are needed to observe the factors impacting trend. DISCLOSURES: No relevant relationships by Kathir Balakumaran, source=Web Response No relevant relationships by Kai Chen, source=Web Response No relevant relationships by Manish Kumar, source=Web Response No relevant relationships by Kimberly Rebello, source=Web Response No relevant relationships by Bryan Stringer, source=Web Response No relevant relationships by Varun Tandon, source=Web Response

Pulmonary Artery Catheters

Since 1970, pulmonary artery catheters (PACs) have been used in clinical practice to monitor the hemodynamic status of critically ill and injured patients. This technology was introduced and commercialized without considerable testing to determine safety and efficacy. After years of common clinical use, investigators identified potential increases in mortality associated with PAC use. For the past decade, investigators have studied various patient populations to elucidate the safety and efficacy of the PAC. This article reviews the historical context of PAC use, findings from recent clinical trials intended to determine safety and efficacy, issues with reliability and validity of PAC use, and complications associated with PAC use. Data from recent clinical trials do not support routine use of PACs, and the authors suggest that PAC-guided therapy should be the focus of study in future trials.

IS ROUTINE PULMONARY ARTERY CATHETERIZATION REQUIRED IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFTING SURGERY?

Introduction. It is still unclear whether therapeutic interventions based on findings from pulmonary artery catheter (PAC) measurements alter outcome in cardiac surgical patients. [1] We conducted a prospective observational clinical trial to clarify the frequency of PAC data requirements for clinical intervention and determine the incidence of modified patient management based on this data during surgery and in the immediate postoperative period. Methods. After ethical approval a written informed consent was obtained from 72 patients with preoperative left ventricular (LV) function grade 1-3 scheduled for coronary artery bypass grafting (CABG) surgery. Past medical history included recent myocardial infarction (MI) in 25, diabetes mellitus in 27 and renal impairment in 4 patients. Routine 'fast-track' anesthetic management [2] was employed. Central venous pressure (CVP) was displayed at all times. Baseline PAC data was recorded by the investigator. The attending anesthesiologist and surgeon were blinded to numerical values of PAC. This was only revealed in the presence of at least two of the following criteria: systolic blood pressure (SBP) < 90mmHg-1, CVP > 15mmHg-1, urine output < 0.5ml.kg-1.h-1, pH < 7.35 / HCO-3 < 18mmol.L-1, SaO2 < 95% / FiO2 > 0.8 or ST changes +/- 2mm. Initial treatment consisted of administration of colloid challenge, phenylephrine and/or dopamine (5[micro sign].kg.min (-1)) If this failed to restore normal hemodynamics within 10min period a preliminary diagnosis and potential treatment plan was documented by the attending anesthesiologist. Following this the numerical PAC data was obtained and actual treatment instituted. Results. There were 54 male and 18 female patients with a mean age of 61 +/- 10 years. The PAC was unblinded in 9 patients due to suspicion of low cardiac output state [cardiac index (CI) < 2.1 L.min-1]. The diagnosis was based on a low SBP/high CVP in 6 patients and low SBP/ST changes in 3 cases. Low CI was confirmed only in 2 patients who as a result required inotropic support. The remaining 7 patients received further fluid challenges (Table 1) with ensuing elevation in SBP. Atrial and ventricular dysrhythmias were observed during insertion of PAC in 28% of patients, however treatment was not required. One patient sustained perioperative MI but there were no perioperative deaths.Table 1Discussion. Information acquired from unblinding PAC data changed clinical management in 10% of patients. This did not appear to be related to patients preoperative LV function. Preliminary results of our study suggest that routine use of PAC for CABG patients with LV grade 1-3 it may not be warranted and can be delayed until the need arises.

Effectiveness of pulmonary artery catheters in aortic surgery: A randomized trial

Purpose: To evaluate the routine use of pulmonary artery catheters (PAC) in patients who undergo aortic surgery. Methods: One hundred twenty patients were randomized to placement of PACs for perioperative monitoring and hemodynamic optimization (tune up) in the intensive care unit on the night before aortic operation, or to intravenous hydration in the ward and perioperative monitoring without PACs. Before randomization, all patients underwent routine adenosine thallium-201 scintigraphy. Results: To meet predetermined endpoints, 30 PAC patients (50%) received nitrates, inotropic agents, or both. PAC patients received more fluid in the preoperative period ( p < 0.001) and in the first 24 hours after operation ( p = 0.002) than control subjects. Eleven PAC patients (18%) and three control subjects (5%) had adverse intraoperative events ( p = 0.02). There were 20 adverse postoperative events in 15 PAC patients (25%; nine cardiac, seven pulmonary, four acute tubular necrosis), which was not different compared with 11 postoperative events in 10 control subjects (17%; five cardiac, five pulmonary, one acute tubular necrosis). There were also no differences in duration of mechanical ventilation, intensive care unit stay, or hospital stay between groups. Postoperative cardiac complications were more common among patients who had a history of congestive heart failure ( p = 0.02; odds ratio, 3.75; confidence interval, 1.3 to 11) or reperfusion defects on adenosine thallium scintigraphy ( p = 0.01; odds ratio, 3.4; confidence interval, 1.2 to 9.4), regardless of group. Conclusions: Routine use of PACs for perioperative monitoring with the above protocol during aortic surgery is not beneficial and may be associated with a higher rate of intraoperative complications. Preoperative tune up does not prevent postoperative cardiac, renal, and other complications. Variables such as cardiac risk factors and adenosine thallium scintigraphy may be more important predictors of cardiac events in patients who undergo aortic operations. (J Vasc Surg 1998;27:203-12.)