Use Of Pulmonary Artery Catheter Research Articles

Inadvertent transection of a pulmonary artery catheter during thoracic surgery

A WIDE VARIETY of complications have been associated with insertion and use of pulmonary artery catheters (PAC). They include arrhythmias, which are commonly seen during insertion of the PAC, and more serious events, such as rupture of the pulmonary artery or pulmonary infarctions. A case is reported of inadvertent transection of the tip of the PAC by the surgical stapler during a left pneumonectomy, which is a complication unique to lung resection and has not been previously reported. It is important to emphasize the possible consequences that may follow if this event is unrecognized. This complication is preventable, but should it occur, a method of safe repair is necessary.

Pulmonary artery catheterization. Can there be an integrated strategy for guideline development and research promotion?

To review the evidence regarding indications for pulmonary artery catheterization (PAC) in critically ill patients, and to propose a guideline-generating process that would encourage randomized controlled trials of PAC. Computerized and manual search for randomized trials involving PAC as an integral part of the protocol, published as of October 1992. Manual search for guidelines endorsed by specialty societies and/or proposed by expert panels following an explicit group process. Four trials suggest benefit from PAC for pre- or perioperative management of high-risk surgical patients. Two others indicate that PAC for low-risk aortic aneurysm surgery confers no advantages. Use of PAC to guide therapy aimed at improved mixed venous oxygen saturation was beneficial compared with usual care with PAC in two small trials among patients with septic shock and severe trauma. Other PAC indications are either untested or inadequately tested by small trials. Large trials are needed, but trials to date have been impeded by clinicians' uncertainty about PAC and unwillingness to randomize critically ill patients. No published guidelines for PAC have used a formal group process and/or a hierarchical review of evidence to demarcate proven from unproven indications. We propose a research-promoting expert panel on indications for PAC. Aided by a critical literature review, experts would rate case scenarios on the need for routine PAC with or without a specified intervention strategy. Future trials should test indications where there is either consensus about the uncertainty of need for PAC, or interpanelist disagreement owing to inconclusive evidence. This process could facilitate practice guideline development, utilization management, and large trials of PAC and related interventions.

Pulmonary Artery Catheterization

Objectives. —To review the evidence regarding indications for pulmonary artery catheterization (PAC) in critically ill patients, and to propose a guideline-generating process that would encourage randomized controlled trials of PAC. Data Sources. —Computerized and manual search for randomized trials involving PAC as an integral part of the protocol, published as of October 1992. Manual search for guidelines endorsed by specialty societies and/or proposed by expert panels following an explicit group process. Data Synthesis. —Four trials suggest benefit from PAC for pre- or perioperative management of high-risk surgical patients. Two others indicate that PAC for low-risk aortic aneurysm surgery confers no advantages. Use of PAC to guide therapy aimed at improved mixed venous oxygen saturation was beneficial compared with usual care with PAC in two small trials among patients with septic shock and severe trauma. Other PAC indications are either untested or inadequately tested by small trials. Large trials are needed, but trials to date have been impeded by clinicians' uncertainty about PAC and unwillingness to randomize critically ill patients. No published guidelines for PAC have used a formal group process and/or a hierarchical review of evidence to demarcate proven from unproven indications. Conclusions. —We propose a research-promoting expert panel on indications for PAC. Aided by a critical literature review, experts would rate case scenarios on the need for routine PAC with or without a specified intervention strategy. Future trials should test indications where there is either consensus about the uncertainty of need for PAC, or interpanelist disagreement owing to inconclusive evidence. This process could facilitate practice guideline development, utilization management, and large trials of PAC and related interventions. ( JAMA . 1993;269:2407-2411)

Indcations for the use of pacing pulmonary artery catheters in cardiac surgery

Several varieties of pulmonary artery catheters (PACs) with pacing capabilities are now available. Although specific recommendations for prophylactic perioperative placement of pacemakers have been offered previously, the authors believe that those recommendations warrant further examination, taking into consideration the availability of new pacing modalities. Toward this end, the use of pacing PACs in cardiac surgical patients was prospectively examined. In 600 consecutive adult patients with PACs placed prior to cardiopulmonary bypass (CPB), the cardiac anesthesiologist recorded if a pacing PAC was placed, the indications for placing it, and whether the catheter was used to pace. If a pacing PAC was not chosen, the anesthesiologist indicated whether cardiac pacing was needed prior to CPB. In all patients, the presence and specifics of the following five possible indications were documented: sinus node dysfunction/ bradydysrhythmias, atrioventricular heart block, fascicular or bundle branch block, cardiac reoperation, and/or valvular heart disease. PACs with pacing capability were placed in 180 of the 600 patients (30.0%) and were used in 34 of these 180 patients (18.8%). In 4 of 420 patients (0.95%) without pacing PACs, cardiac pacing was needed prior to CPB. The following preoperative diagnoses were significant predictors ( P < .05) for the use or need for pacing catheters: sinus node dysfunction/bradydysrhythmias, a history of transient complete atrioventricular block, aortic stenosis, aortic insufficiency, and reoperation. The majority of adult patients undergoing cardiac surgery do not require the use of a pacing PAC prior to CPB. The placement of a pacing PAC should be considered in patients undergoing cardiac surgery with symptomatic bradydysrhythmias, a history of transient complete atrioventricular block, aortic insufficiency, aortic stenosis, and in patients undergoing a reoperation with other pacing indications present.

Anesthetic management for myocardial revascularization following bleomycin chemotherapy

B LEOMYCIN (BLM) is a glycoprotein antibiotic synthesized from Streptomyces verticillus that is highly effective against malignancies such as lymphomas, dysgenetic testicular tumors, and squamous cell carcinomas. It is often used in conjunction with other agents because of its low potential for bone marrow suppression or immunosuppression, thereby enhancing the antineoplastic effect at the cost of fewer side effects.’ Pulmonary toxicity that presents as an interstitial pneumonitis that may progress to fibrosis is its major side effect.* Patients more than 65 years of age and those with persisting pulmonary pathology are especially at risk. Pulmonary fibrosis occurs in 3% of patients receiving BLM. A hypersensitivity pneumonitis and fulminant respiratory failure can also occur.3 Asymptomatic changes in pulmonary function that may be construed as milder forms of toxicity are probably more common.4,5 Radiation to the chest and oxygen therapy are believed to potentiate BLM pulmonary toxicity. A high or even modestly elevated F,02 (0.33) has been thought to be responsible for postoperative respiratory failure and subsequent deaths.‘.6 In addition, exacerbations of recognized or occult pulmonary fibrosis may occur with other antineoplastic agents (eg, busulfan, methotrexate, cyclophosphamide) following 0, therapy.‘.’ The anesthesiologist may be required to manage a case for the removal of retroperitoneal lymph nodes or pulmonary metastasis following BLM chemotherapy. Even if the lymph nodes show no metastatic disease, they are large, fibrotic, sclerotic, and often attached to neighboring structures. This makes surgery technically difficult, prolonged, accompanied by considerable blood loss, and may involve the resection of the large bowel, aorta, inferior vena cava, or a kidney.6 Resection of pulmonary metastases has the potential problem of the need for one-lung anesthesia during thoracotomy, and the consequent risk of the use of an increased F,O, to avoid hypoxia. A patient who may have been at risk for reactivation of BLM lung toxicity when he underwent myocardial revascularization during hypothermic cardiopulmonary bypass (CPB) is reported. The use of an Oximetric pulmonary artery catheter (PAC) in combination with peripheral pulse oximetry ensured adequate oxygenation while the patient received restricted 0, therapy during and after surgery.

In vitro reappraisal of the pulmonary artery catheter balloon volume-pressure relationship: comparison of four different catheters

The most serious risk of the use of the flow-directed pulmonary artery (PA) catheter is PA rupture due to high balloon inflation pressure of the catheter. Previously reported measurements of PA catheter intra-balloon pressure and volume during balloon inflation were performed mostly in a static fashion, that is, measurements were performed after a certain volume of air had been injected into the balloon. In this study, simultaneous measurements of pressure and volume, in addition to a static study, were performed in vitro using four PA catheters (Abbott Opticath, Arrow Hands-Off, Baxter Edwards and Spectramed). The peak intra-balloon pressure was recorded immediately before loss of resistance was felt in the inflating syringe. Contrary to previously reported studies, the peak intra-balloon pressure was not the pressure exerted on the pulmonary artery wall unless the tip of the catheter was already in the peripheral pulmonary artery. The loss of resistance volume which was constant for each catheter could be used reliably as an indicator of instantaneous balloon inflation. The slower the rate of injection, the lower were the peak pressure and the injection volume at the peak pressure. The Abbott, Edwards and Spectramed catheters had similar characteristics of inflation volume and intra-balloon pressure. The Arrow catheter had higher balloon opening and plateau pressures, and a smaller balloon volume compared with the other three catheters.

Control of blood gas measurements in intensive-care units

The frequency of blood gas measurement in two adult intensive-care units was assessed for 7 months before and 12 months after introduction of a protocol of indications for such investigation. Demographic, diagnostic, outcome, and intervention data were collected prospectively. There were no differences in demographic characteristics, severity or type of illness, survival, or frequency of arterial or pulmonary artery catheter use between the two observation periods, but the frequency of blood gas analysis fell by 44% (p<0·001) after the protocol was introduced.

Increased pulmonary artery perforating potential of pulmonary artery catheters during hypothermia

The rate of major complications from the use of pulmonary artery (PA) catheters has been reported to be as high as 9%, 0.2% of which may be attributed to PA perforation, a catastrophe with a fatal outcome more than 50% of the time. Although an uncommon event generally, more than one third of catheter-related PA perforations occur during cardiac surgery. Several factors act to advance the balloon-tipped PA catheter into the distal PA, where, during hypothermia, the catheter hardens and, thus, may be more likely to perforate the vessel. The relative contribution of hypothermia, itself, to the perforating potential of previously used, triple-lumen PA catheters (n = 5) was examined in vitro by mounting them in a temperature-controlled testing chamber, at a 90° incident angle to a polyethylene membrane, which represented the PA wall. The membrane was made to pulsate 80 times/min against the PA catheter until it was perforated. Each catheter was tested 5 times each at 3 temperatures. At 35°C, 30°C, and 25°C, the number of pulsations to produce perforation (perforation rate) was 488 ± 280, 309 ± 242, and 97 ± 234, respectively. The perforation rates differed significantly between temperatures ( P < 0.01), but not between catheters or tests at the same temperature. This study demonstrates that perforation of a model PA by a triple-lumen PA catheter is 500% more likely during hypothermia.

Detection of venous air embolism by continuous mixed venous oximetry in dogs.

Continuous mixed venous oxygen saturation (SvO 2) was evaluated as a monitor of venous air embolism in a canine model. Nineteen dogs were anesthetized, paralyzed, and mechanically ventilated. Invasive monitoring included SvO 2, systemic and pulmonary artery blood pressures, and thermodilution cardiac outputs. Air boluses of 0.25 and 0.5 ml/kg were injected in six dogs and 1 ml/kg in all. All 1 ml/kg emboli were detected by greater than or equal to 5% decreases in the SvO 2. The SvO 2 decreased from 82 +/- 8% to 72 +/- 11% (mean +/- SD), an average decrease of 9 +/- 5% (p = 0.004). Time to the SvO 2 nadir was 2.6 +/- 2.5 min. Of the 0.5 and 0.25 ml/kg emboli, 50% and 17% were detected, respectively. Cardiac output decreased from 2.9 +/- 0.8 to 2.1 +/- 0.8 L/min after the 1 ml/kg emboli (p = 0.02). The 1 ml/kg emboli increased pulmonary artery pressures and decreased systemic blood pressure in 100% and 75% of animals, respectively. Peak changes in pulmonary artery pressure occurred at 1.2 +/- 0.8 min. In the present study, time to maximum change was greater for SvO 2 than for pulmonary artery pressure changes. Use of fiberoptic pulmonary artery catheters for continuous measurement of SvO 2 can add a new diagnostic modality to venous air embolism detection in patients who require a pulmonary artery catheter for other medical indications.

Use of Pulmonary Artery Catheterization in Parturients With Eisenmengerʼs Syndrome

Use of Pulmonary Artery Catheterization in Parturients With Eisenmengerʼs Syndrome

High-Tech Predicament: Pulmonary Artery Catheter

There have been few, if any, studies to evaluate interpretation and application of pulmonary artery catheter (PAC) data. The information presented in the article by Iberti et al 1 in this issue of JAMA is important to both intensivists and to all practitioners whose patients undergo these procedures. The authors document that physician understanding of the use of the PAC is extremely variable and frighteningly low. Mean scores on their multiple-choice examination designed to measure knowledge about the PAC varied independently by training, frequency of use of PAC data in patient management, frequency of inserting a PAC, and whether the respondent's hospital was a primary medical school affiliate. There was an increase in correct responses with increased training and frequency of PAC use, but 47% of respondents to the questionnaire were unable to determine pulmonary capillary wedge pressure from a clear tracing. Furthermore, 44% of respondents could not correctly identify

Use of Pulmonary Artery Catheters in Patients with Acute Myocardial Infarction: Analysis of Experience in 5,841 Patients in the SPRINT Registry

This study analyzes the use of PAC in a registry comprising 5,841 hospitalized patients with AMI. A total of 371 patients received PAC. In-hospital mortality was higher in patients with CHF who received PAC, while there was no difference in patients with cardiogenic shock or persistent hypotension. Mortality in patients receiving PAC was higher irrespective of the presence or absence of "pump failure." A separate analysis of discharge summaries of 364 patients with CHF showed that PAC was used more frequently in sicker patients and that when severity of CHF was assessed, no difference in mortality was found in patients with mild or moderate CHF. We conclude that while a higher in-hospital mortality is found in patients receiving PAC, this excess is likely related to difference in severity of CHF, which had not been assessed in every individual. It is unlikely that PAC increases mortality.

Use of Pulmonary Artery Catheterization in Parturients With Eisenmenger??s Syndrome

Use of Pulmonary Artery Catheterization in Parturients With Eisenmenger??s Syndrome

Con: Perioperative continuous monitoring of mixed venous oxygen saturation should not be routine in high-risk cardiac surgery

M OST CLINICIANS accept that invasive hemodynamic monitoring facilitates diagnosis and treatment of complex cardiovascular disorders, and would use a pulmonary artery catheter (PAC) in the management of patients during high-risk cardiac surgery. Perioperative mixed venous oxygen saturation (SSO,) monitoring via a fiberoptic PAC oximeter seems a small additional step to take in these patients, but this step cannot yet be justified. The increasing cost of health care demands the critical evaluation of all new monitoring technologies and places us more and more in the unfamiliar position of an epidemiologist assessing screening techniques. The problem in question should be common and important, with an accepted backup test, and it should have a well-defined transition from a latent to an overt phase, with evidence that early detection will reduce morbidity or mortality. The test should have an acceptable sensitivity and specificity, and the costs of testing must be balanced against competing health care priorities. Just as laboratory screening has in its time been intuitively felt to be a good thing, without need of rigorous proof, there is a similar danger of uncritical acceptance of new patient monitoring technology. The incorporation of continuous SVO, measurement as an option with PAC use has produced interesting physiological insights, and thus has made the transition to “a major advance,” without fulfilling any of the previous criteria. The authors believe that its usefulness is still unproven in any area of patient care, and that anecdotal reports of mishap detection with its use are insufficient reason for its adoption. The problem is that cardiac output (CO), a measurement of total flow, does not reflect adequacy of tissue perfusion. Just as arterial CO, tension is the parameter that determines the adequacy of minute ventilation in relation to metabolic rate, SSO, was considered to be the parameter by which to assess the adequacy of tissue oxygen supply, and thus indirectly the adequacy of CO, in relation to demand. The validity of SSO, monitoring as an indirect correlate of CO is based on certain assumptions, in particular the body’s ability to maintain a constant oxygen consumption (q02) by compensating for decreases in delivery (DO,) through increased 0, extraction. Oxygen consumption equals the product of CO and arteriovenous oxygen difference:

Risk factors of nosocomial bacteremia associated with pulmonary artery catheters in a critical care unit.

An epidemiologic investigation at a community teaching hospital identified 17 cases of endemic primary nosocomial bacteremias associated with the use of pulmonary artery catheters (PACs). A matched-case control study was undertaken to identify risk factors associated with these bacteremias. Factors significantly associated with bacteremia were length of hospitalization; length of stay in the critical care unit; length of time the PAC introducer was left in place and used as an intravenous (IV) access device after PAC withdrawal; respiratory compromise; PAC site infection; prior infections at other sites; concomitant hyperalimentation; and number of IV piggyback administrations per day prior to onset of bacteremia. Pathogens isolated included coagulase-negative Staphylococcus species (55.6%), Staphylococcus aureus (22.2%), Candida albicans (14.8%), and enterococci (7.4%). These pathogens were generally resistant to antibiotics given before the development of bacteremia. Bacteremia was associated with significant mortality, a prolonged hospital stay, and increased hospital charges. This study identifies important risk factors to consider in formulating guidelines to prevent and control PAC-associated nosocomial infections.

Use of Fiberoptic vs Conventional Pulmonary Artery Catheters

To the Editor .—We read with interest the recent report by Rajput and coworkers 1 comparing the use of fiberoptic vs conventional pulmonary artery (PA) catheters. The authors remind us that measurements of mixed-venous oxygen (MvO 2 ) levels may inadequately assess tissue oxy( Continued on p 2142 .) ( Continued from p 2139 .) genation in the adult respiratory distress syndrome (ARDS) and in septic shock. They also report the wide fluctuations in MvO 2 saturation detected with fiberoptic catheters during periods of agitation or suctioning. These fluctuations in MvO 2 saturation have recently been reported to influence hemodynamics. 2 These points may be directing our attention toward a more focused study of fiberoptic catheters. If continuous assessment of MvO 2 saturation is not helpful in ARDS or in septic shock, fiberoptic catheters should not be used in these situations, but not necessarily abandoned entirely. Could the rapid detection of decreasing MvO 2

The cost-effectiveness of oximetrix pulmonary artery catheters in the postoperative care of coronary artery bypass graft patients

As cost-containment pressures continue to escalate in the health care industry, the cost-effectiveness of new technologies must be verified if their use in the care of patients is to be justified. Oximetrix fiberoptic pulmonary artery catheters (Abbott Critical Care Systems, North Chicago, IL) are used for the continuous measurement of mixed venous oxygen saturation, and have been promoted as a cost-effective, early, and accurate indicator of hemodynamic changes in critically ill patients and patients undergoing major surgical procedures. This retrospective study analyzed two groups of patients undergoing routine, elective coronary artery bypass grafting. In the first group, fiberoptic catheters were not used, whereas these catheters were used routinely in the second group. Multiple variables were analyzed in each group in an attempt to document cost-effectiveness or salutary effect on outcome as a result of the use of these catheters. Neither could be confirmed. It was concluded that the use of Oximetrix pulmonary artery catheters is not cost-effective and had no effect on outcome in this group of patients.

A community-wide assessment of the use of pulmonary artery catheters in patients with acute myocardial infarction: Gore JM, Goldberg RJ, Spodick DH, Alpert JS, Dalen JE. Chest 92:721, 1987

A community-wide assessment of the use of pulmonary artery catheters in patients with acute myocardial infarction: Gore JM, Goldberg RJ, Spodick DH, Alpert JS, Dalen JE. Chest 92:721, 1987

Use of the pacing pulmonary arterial catheter to detect endocardial electrical activity during hypothermic cardioplegic arrest.

The pacing Swan-Ganz catheter was evaluated for its ability to monitor atrial and ventricular electrical activity during cardioplegic arrest on cardiopulmonary bypass. This endocardial electrical activity was compared with the activity found on the standard electrocardiogram (ECG). The atrial electrodes detected activity that was noted also by visual inspection. The ventricular electrodes detected recurring electrical activity in 7 of 18 patients. Three of these 7 patients did not have simultaneous standard ECG activity, indicating that, in the usual monitoring circumstances, this ventricular electrical activity would not have been treated with repeat cardioplegia. If the pacing Swan-Ganz catheter is used for clinical care, it can be used also to monitor myocardial electrical activity during cardioplegic arrest.

A community-wide assessment of the use of pulmonary artery catheters in patients with acute myocardial infarction: Gore JM, Goldberg RJ, Spodick DH, et al: Chest 92:721–731, 1987

A community-wide assessment of the use of pulmonary artery catheters in patients with acute myocardial infarction: Gore JM, Goldberg RJ, Spodick DH, et al: Chest 92:721–731, 1987