Use Of Pulmonary Artery Catheter Research Articles

IN PATIENTS WITH SEVERE ADVANCED HEART FAILURE, NON RESPONSE TO DECREASE LV FILLING PRESSURE IS NOT ASSOCIATED WITH WORSE SURVIVAL AND OUTCOMES: INSIGHTS FROM THE ESCAPE (EVALUATION STUDY OF CONGESTIVE HEART FAILURE AND PULMONARY ARTERY CATHETERIZATION EFFECTIVENESS) TRIAL

Data ESCAPE trial showed the use of pulmonary artery catheter (PAC) did not improve outcomes in patients with severe left ventricular (LV) dysfunction. We sought to determine whether patients who had improvement in filling pressures (responders) differed from patients who did not (non responders)

Use of pulmonary artery catheter in coronary artery bypass graft. Costs and long-term outcomes.

BackgroundPulmonary artery catheters (PAC) are used widely to monitor hemodynamics in patients undergoing coronary bypass graft (CABG) surgery. However, recent studies have raised concerns regarding both the effectiveness and safety of PAC. Therefore, our aim was to determine the effects of the use of PAC on the short- and long-term health and economic outcomes of patients undergoing CABG.Methods1361 Chinese patients who consecutively underwent isolated, primary CABG at the Cardiovascular Institute of Fuwai Hospital from June 1, 2012 to December 31, 2012 were included in this study. Of all the patients, 453 received PAC during operation (PAC group) and 908 received no PAC therapy (control group). Short-term and long-term mortality and major complications were analyzed with multivariate regression analysis and propensity score matched-pair analysis was used to yield two well-matched groups for further comparison.ResultsThe patients who were managed with PAC more often received intraoperative vasoactive drugs dopamine (70.9% vs. 45.5%; P<0.001) and epinephrine (7.7% vs. 2.6%; P<0.001). In addition, costs for initial hospitalization were higher for PAC patients ($14,535 vs. $13,873, respectively, p = 0.004). PAC use was neither associated with the perioperative mortality or major complications, nor was it associated with long-term mortality and major adverse cardiac and cerebrovascular events. In addition, comparison between two well-matched groups showed no significant differences either in baseline characteristics or in short-term and long-term outcomes.ConclusionsThere is no clear indication of any benefit or harm in managing CABG patients with PAC. However, use of PAC in CABG is more expensive. That is, PAC use increased costs without benefit and thus appears unjustified for routine use in CABG surgery.

Reliable assessment of perfusion is the Holy Grail of intensive care.

Reliable assessment of perfusion is the Holy Grail of intensive care.

Survey of critical care nurses knowledge in pulmonary artery catheterization: A pilot study

Background: Pulmonary artery catheterization (PAC) has been used in a Heart Specialist Medical Centre in the Eastern Province in the Kingdom of Saudi Arabia, for Intensive Care Unit (ICU) patients more frequently compared to other similar establishments elsewhere. Critical care nurse's knowledge toward using PAC was, therefore, surveyed to rectify this matter and ultimately form guidance, update practice, and future usage policies. Methodology: This survey included 48 ICU–Critical care nurses. A questionnaire has been designed and validated, and that was distributed to collect information on participants' relevant backgrounds and the PAC use. The raw test scores were converted to percentages and median test scores also interquartile range were calculated. The median knowledge score was compared among different attributes using Mann–Whitney U-test. The value P Results: The questionnaire has been sent to 48 participants, and all participants answered the questionnaire. The median knowledge score of handling PAC is significantly related to earlier received training, their ICU experience, and their confidence of handling PAC. Conclusions: This survey highlighted the interesting statistical facts about the extent of lack of knowledge and skills among participants. More importantly, the survey also determined the important shortfalls in practice of some experienced medical practitioners. More research is needed to identify why such shortfalls exist and how they have developed. The survey finally highlights the importance of having policies and protocols for all PAC-related procedures, and the regularly associated training to guarantee patients' welfare and well-being is met.

Incidence, risk factors and outcomes of new-onset atrial fibrillation in patients with sepsis: a systematic review.

IntroductionCritically ill patients with sepsis are prone to develop cardiac dysrhythmias, most commonly atrial fibrillation (AF). Systemic inflammation, circulating stress hormones, autonomic dysfunction, and volume shifts are all possible triggers for AF in this setting. We conducted a systematic review to describe the incidence, risk factors and outcomes of new-onset AF in patients with sepsis.MethodsMEDLINE, EMBASE and Web Of Science were searched for studies reporting the incidence of new-onset AF, atrial flutter or supraventricular tachycardia in patients with sepsis admitted to an intensive care unit, excluding studies that primarily focused on postcardiotomy patients. Studies were assessed for methodological quality using the GRADE system. Risk factors were considered to have a high level of evidence if they were reported in ≥2 studies using multivariable analyses at a P value <0.05. Subsequently, the strength of association was classified as strong, moderate or weak, based on the reported odds ratios.ResultsEleven studies were included. Overall quality was low to moderate. The weighted mean incidence of new-onset AF was 8% (range 0 to 14%), 10% (4 to 23%) and 23% (6 to 46%) in critically ill patients with sepsis, severe sepsis and septic shock, respectively. Independent risk factors with a high level of evidence included advanced age (weak strength of association), white race (moderate association), presence of a respiratory tract infection (weak association), organ failure (moderate association), and pulmonary artery catheter use (moderate association). Protective factors were a history of diabetes mellitus (weak association) and the presence of a urinary tract infection (weak association). New-onset AF was associated with increased short-term mortality in five studies (crude relative effect estimates ranging from 1.96 to 3.32; adjusted effects 1.07 to 3.28). Three studies reported a significantly increased length of stay in the ICU (weighted mean difference 9 days, range 5 to 13 days), whereas an increased risk of ischemic stroke was reported in the single study that looked at this outcome.ConclusionsNew-onset AF is a common consequence of sepsis and is independently associated with poor outcome. Early risk stratification of patients may allow for pharmacological interventions to prevent this complication.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0688-5) contains supplementary material, which is available to authorized users.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Fluid management: Not just a problem in preeclampsia.

The recently published review on fluid management in pre-eclampsia1 highlights the lack of evidence to support clinical decision making in this area. It is important to appreciate that many of these knowledge gaps are not specific to preeclampsia, but common to all critically ill patients, despite ongoing research. Fluid management in the critically ill has been a constant source of debate, for example keeping patients “wet” versus “dry”, crystalloids versus colloids, pulmonary artery (PA) catheter, or not. The goal directed therapy approach proposes fluid resuscitation aimed at acute physiological goals. However, over the past decade the adverse effects of this aggressive fluid approach has become evident. Although pulmonary edema is a concern, this is usually easily managed with diuretics and transient noninvasive positive pressure ventilation. Excess fluid may also cause edema of other organs and flood the peritoneal cavity, resulting in reduced organ perfusion and even aggravating renal dysfunction and increasing mortality.2,3 Fortunately, there has been progress in some of these areas. The PA line issue seems to have been put to rest with several studies showing a lack of benefit of this technology for routine use.4 Unfortunately, there are no clear guidelines when use of PA catheters is appropriate, and no acceptable alternatives for the assessment of fluid status in the critically ill. The crystalloid–colloid debate has been addressed by several large studies outside of pregnancy. The SAFE study5 and the CRISTAL study6 have shown no difference in outcome using crystalloid versus colloid in large groups of intensive care unit patients. A signal toward improved outcome with albumin in patients with sepsis is being addressed by a large Italian study (ALBIOS). Dopamine no longer has a role in the management of renal dysfunction in the critically ill – although this drug has diuretic properties and glomerular filtration rate improves in proportion to the increase in cardiac output, there is no protective effect on renal function.7 Similar conclusions have been reached in pre-eclamptic women.8

Impact of pulmonary artery catheter on outcome in patients with acute heart failure syndromes with hypotension or receiving inotropes: From the ATTEND Registry

BackgroundRandomized controlled trials concerning pulmonary artery catheters (PACs) use have yielded little evidence of their beneficial effects on survival. This study aimed to evaluate the association between PACs and in-hospital mortality in patients with acute heart failure syndromes (AHFS). MethodsThe Acute Decompensated Heart Failure Syndromes (ATTEND) Registry is a prospective, observational, multicenter cohort study performed in Japan, since April 2007. We analyzed data from the ATTEND Registry and evaluated the effectiveness of PAC in AHFS treatment using propensity score-matching and the Cox proportional hazards model. ResultsFinal follow-up examinations of the 4842 patients were conducted in December 2012. During the study period, 813 patients (16.8%) were managed with PACs, of which 502 patients (PAC group) were propensity score-matched with 502 controls (Control group). Of the 1004 score-matched patients, 22 (4.4%) patients from the Control group and 7 (1.4%) from the PAC group died. The risk of all-cause death was lower in the PAC group than that in the Control group [hazard ratio (HR), 0.3; 95% confidence interval (CI), 0.13–0.70; p=0.006]. PAC-guided therapy decreased all-cause mortality in patients with lower systolic blood pressure (SBP≤100mmHg; HR, 0.09; 95% CI, 0.01–0.70; p=0.021) or inotropic therapy (HR, 0.22; 95% CI, 0.08–0.57; p=0.002). ConclusionsThis study revealed that appropriate PAC use effectively decreases in-hospital mortality in AHFS patients, particularly those with lower SBP or receiving inotropic therapy, suggesting that real-world PAC use could improve AHFS management.

Understanding Changes in Established Practice

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.

Monitorização hemodinâmica no paciente crítico

Hemodynamic monitoring has crucial role in critically ill patients, especially if associated with a known therapy that improves the prognosis of these patients. The reduction in the use of pulmonary artery catheter, due to its low impact on mortality, enabled the emergence of new forms of less invasive measurement of cardiac output as data based on analysis of the pulse contour, esophageal Doppler, transthoracic echocardiography, electrical Bioimpedance and Bioreactance. The monitors based on pulse wave can use the calibration by thermodilution, by dilution dye (lithium) or using a preset algorithm for data calibration. Despite been increasingly used, it’s utilization in unstable critically ill patients is a matter of debate. The use of esophageal Doppler monitoring also permits a minimally invasive monitoring, despite the need for frequent adjustments in positioning in addition to continuous analgesia and sedation. The use of transthoracic echocardiography in the management of critically ill patients is gaining ground, despite requiring specific training and proper equipment despite of not allowing continuous recording data. The use of electrical Bioimpedance or Bioreactance has little use in unstable ill patients. The use of hemodynamic monitoring associated with dynamic variable scan predict which patients will possibly benefit from intravascular volume expansion therapy, a finding highly relevant in handling the hypotensive patient in the ICU. Finally, it is important to emphasize that the choice of a particular type of monitoring should respect the severity of the critically ill patient, the degree of experience of the institution with certain equipment and must be associated with goal-directed therapies in patients with hemodynamic instability.

Acute myocardial infarction complicated by cardiogenic shock: What changed over a 10-year time span

BackgroundDespite improvements in treatment, mortality associated with cardiogenic shock (CS) following acute myocardial infarction remains high. AimTo compare two groups of patients admitted with CS over a 10-year time span. MethodsWe performed a retrospective analysis of two patient populations presenting with CS admitted in the periods May 1998-May 2001 (group A) and May 2008-May 2011 (group B). Clinical characteristics, diagnostic methods, treatment and outcomes were compared, and independent predictors of death at six months were analyzed. ResultsThe incidence of CS was 3.7% in group A (n=25) and 4.8% in group B (n=42). There were no significant differences in clinical characteristics except for age (60.2±12.3 vs. 66.5±11.3 years; p=0.043) and the proportion of patients admitted within six hours of symptom onset (29.2% vs. 54.8%, p=0.045). There was a reduction in use of pulmonary artery catheterization (52.0% vs. 19.0%, p=0.005) but an increase in dialysis (4.0% vs. 28.6%, p=0.014). There was no difference in the proportion of patients reperfused within 12 hours or revascularized, but use of percutaneous coronary intervention (PCI) increased (75.0% vs. 92.9%, p=0.042). There were no differences in outcomes, including mortality at 30 days (32.0 vs. 35.7%; p=0.757) and six months (36.0 vs. 42.9%; p=0.683). Diabetes was the sole baseline characteristic identified as an independent predictor of death at six months (hazard ratio [HR] 3.02; 95% confidence interval [CI] 1.38-6.60; p=0.006) and mortality was lower among revascularized patients (HR 0.11; 95% CI 0.03-0.42; p=0.001). ConclusionsOver a 10-year time span, despite earlier hospital admission and increased use of support therapies and PCI, short- and medium-term mortality remained unchanged.

Increasing Use of Less-Invasive Hemodynamic Monitoring in 3 Specialty Surgical Intensive Care Units

Less-invasive hemodynamic monitoring (eg, esophageal doppler monitoring [EDM] and arterial pressure contour analysis, FloTrac) is increasingly used as an alternative to pulmonary artery catheters (PACs) in critically ill intensive care unit (ICU). The decrease in use of PACs is not associated with increased mortality. Five-year retrospective review of 1894 hemodynamically monitored patients admitted to 3 surgical ICUs in a university-affiliate, tertiary care urban hospital. Data included the number of admissions, diagnosis-related group discharge case mix, length of stay, insertion of monitoring devices (PAC, EDM, and FloTrac probes), administered intravenous vasoactive agents (β-predominant agonists--dobutamine, epinephrine, and dopamine; vasopressors--norepinephrine and phenylephrine), and mortality. Data from hospital administrative databases were compiled to create patient characteristic and monitoring variables across a 5-year time period, 2005 to 2009 inclusive. Chi-square for independent proportions, 1-way analysis of variance, and Kruskal-Wallis tests were used; tests for trend were conducted. An α level of .05 was considered significant. Statistical Package for the Social Sciences v14 was used for all statistical testing. There was a significant change in the type of hemodynamic monitors inserted in 2 of the 3 surgical ICUs (in the general surgery and neurointensive care but not in the cardiac ICU) from PACs to less-invasive devices (FloTrac or EDM) during the 5-year study period (P < .001). There was no change in mortality rate over the time period (P = .492). There was an overall increase in the proportion of monitored patients who received intravenous vasoactive agents (P < .001) with a progressive shift from β-agonists to vasopressors (P < .002). Multivariate analyses indicated that age, case mix, and use of vasoactive agents were all independent predictors of inhospital mortality (P = .001) but that type of monitoring was not (P = .638). In a 5-year period, the decreased insertions of PACs were replaced by increased utilization of less-invasive hemodynamic monitoring devices. This change in practice did not adversely impact mortality.

Choque cardiogénico no enfarte agudo do miocárdio: o que mudou nos últimos 10 anos?

BackgroundDespite improvements in treatment, mortality associated with cardiogenic shock (CS) following acute myocardial infarction remains high. AimTo compare two groups of patients admitted with CS over a 10-year time span. MethodsWe performed a retrospective analysis of two patient populations presenting with CS admitted in the periods May 1998-May 2001 (group A) and May 2008-May 2011 (group B). Clinical characteristics, diagnostic methods, treatment and outcomes were compared, and independent predictors of death at six months were analyzed. ResultsThe incidence of CS was 3.7% in group A (n=25) and 4.8% in group B (n=42). There were no significant differences in clinical characteristics except for age (60.2±12.3 vs. 66.5±11.3 years; p=0.043) and the proportion of patients admitted within six hours of symptom onset (29.2% vs. 54.8%, p=0.045). There was a reduction in use of pulmonary artery catheterization (52.0% vs. 19.0%, p=0.005) but an increase in dialysis (4.0% vs. 28.6%, p=0.014). There was no difference in the proportion of patients reperfused within 12 hours or revascularized, but use of percutaneous coronary intervention (PCI) increased (75.0% vs. 92.9%, p=0.042). There were no differences in outcomes, including mortality at 30 days (32.0 vs. 35.7%; p=0.757) and six months (36.0 vs. 42.9%; p=0.683). Diabetes was the sole baseline characteristic identified as an independent predictor of death at six months (hazard ratio [HR] 3.02; 95% confidence interval [CI] 1.38-6.60; p=0.006) and mortality was lower among revascularized patients (HR 0.11; 95% CI 0.03-0.42; p=0.001). ConclusionsOver a 10-year time span, despite earlier hospital admission and increased use of support therapies and PCI, short- and medium-term mortality remained unchanged.

Imperfect ‘Swan’

Despite widespread clinical use of pulmonary artery (PA) catheters, structural defects in these catheters have been reported rarely.1-3 One of the reasons for underreporting the issues regarding defective structural defects could be due to the fact that some defects are obvious to the clinician checking the catheter prior to insertion.4 There are only a few reports of structural defects in PA catheters.4-7 We describe a rare structural defect, probably for the first time, in a volumetric PA catheter with continuous mixed venous oximetry (SvO2) monitoring capability, which if not discovered early would have resulted in data misinformation, electric short circuitry, complications, and potential improper patient treatment.

Assessing Pulmonary Arterial Hypertension in Infants With Severe Chronic Lung Disease of Infancy: A Role for a Pulmonary Artery Catheter?

The treatment of pulmonary arterial hypertension (PAH) associated with chronic lung disease of infancy (CLDI) is becoming commonplace. However, an optimal approach to the monitoring of this treatment has not been clearly established, and data suggest that such therapy may not be without risk. This study assessed the feasibility and safety of pulmonary artery catheter (PAC) placement and its role in the management of PAH associated with CLDI. The medical records of 12 infants with CLDI requiring chronic mechanical ventilation who underwent PAC monitoring were reviewed. Data analyzed included demographics, hemodynamic data, PAH pharmacological therapy, respiratory support, echocardiographic data, sedation level, complications related to PAC use, and mortality. In this analysis, PAC placement and monitoring was found to be feasible, appeared safe, and was associated with the ability to wean inspired oxygen, decrease sedation, and titrate PAH therapy without untoward effect. However, no definitive conclusions can be drawn from this report given its small sample size and uncontrolled, retrospective design. It is hoped that these data will renew interest in PAC monitoring for CLDI and foster prospective study where its true value can be ascertained.

Pulmonary Artery Catheter Knotting and its Successful Removal.

Pulmonary artery catheter(PAC) was introduced by Swan Ganz and colleagues in 1970 for hemodynamic assessment of patients with acute myocardial infarction. PAC's provide invasive monitoring of many hemodynamic parameters which cannot be reliably estimated by clinical signs and symptoms. Use of PAC's is associated with many different complications and various studies have been done to weigh its advantages and disadvantages. Here we report one of the rarer complications of PAC knotting and its method of removal.

Building the evidentiary framework for pharmacogenetic testing: is it time to move beyond randomized controlled trials?

There is a rapidly expanding evidentiary gap between new molecular markers predictive of drug response and data that supports using such molecular markers (e.g., DNA, RNA or smallmolecule-based tests) in clinical practice. This evidence gap is a barrier to realizing the promise of personalized medicine where treatments are tailored to a patient’s individual characteristics. Randomized controlled trials (RCTs) are the ‘gold-standard’ metric for establishing the evidence that a particular intervention is superior to the current standard of care. However, the RCT is not without limitations and may not be the appropriate level of evidence required to support the clinical use of pharmacogenomic testing. We live in an environment where it is impractical to expect a RCT for each new marker. We should not abandon evidence-based practices when deciding to use a new pharmaco genomic marker; instead, clinicians and researchers must decide the appropriate level of evidence, short of the RCT, that supports the use of a novel pharmacogenomic marker in clinical care.

Gender- and race-based utilization and outcomes of pulmonary artery catheterization in the setting of full-time intensivist staffing

Little is known regarding gender- or race-based differences in critical care. We investigated whether gender or race was associated with pulmonary artery catheter (PAC) utilization or with in-hospital death among patients with a PAC. A particular focus was patients with cardiogenic shock (CS), in whom guidelines recommend PAC use. This was a retrospective cohort analysis from the coronary care unit of a large tertiary-care hospital staffed with full-time cardiac intensivists. We analyzed 8845 consecutive adult patients, of whom 42.1% were women and 40.8% were black. PAC use rates were 11.3% in women and 11.5% in men (P = 0.79), and 11.3% in blacks and 11.5% in whites (P = 0.76). In CS patients, PAC use rates in women and men were 50.3% and 49.1% (P = 0.85) and in blacks and whites were 43.7% and 53.3% (P = 0.05). There was no independent association between gender or race and PAC use overall or in those with CS. Neither gender nor race was a predictor of in-hospital death in patients undergoing PAC. PAC use and in-hospital death were determined not by gender or race but by disease severity. Full-time intensivist staffing and the presence of definitive guidelines may reduce gender- and race-based treatment disparities.

The Role of Tissue Doppler Imaging in Predicting Left Ventricular Filling Pressures in Patients Undergoing Cardiac Surgery: An Intraoperative Study

The perioperative management of patients undergoing cardiac surgery usually requires the accurate assessment of left ventricular filling pressures (LVFP). The gold standard for determining LVFP involves the use of pulmonary artery catheters (PAC). Using tissue Doppler indices (TDI) obtained by transthoracic echocardiography, the ratio of early transmitral filling velocity to the corresponding early mitral annular velocity (E/E') has a strong correlation with pulmonary capillary wedge pressure (PCWP). Little is known, however, on whether this relationship between E/E' and PCWP is valid intraoperatively using transesophageal echocardiography (TEE) during cardiac surgery. The objective of our study was to determine whether TDI obtained by intraoperative TEE during cardiac surgery can accurately estimate PCWP using PAC as the gold standard. A total of 34 patients (26 males, mean age 64 ± 9 years) undergoing cardiac surgery were prospectively enrolled between 2010 and 2011 at a single tertiary care center. Conventional diastolic and tissue Doppler parameters were evaluated using intraoperative TEE with concurrent PAC monitoring before and after cardiopulmonary bypass (CPB) surgery. At both pre- and post-CPB, there was no significant correlation between lateral, septal, and mean E/E' obtained by TEE and PCWP. Intraoperative TEE was unable to accurately predict LVFP in patients undergoing cardiac surgery. PAC may continue to be the gold standard in the assessment of LVFP for this patient population.

Haemodynamic monitoring with Pulse Contour Cardiac Output (PiCCO) is a good surrogate for pulmonary artery catheter in hypothermic post-cardiac arrest patientsStatus: PendingCategory: Post Resuscitation Care

Purpose of the study: Post-cardiac arrest patients often develop complex haemodynamic instability. Evaluating the haemodynamic status can therefore be vital for treatment decision. Due to its invasiveness, the use of pulmonary artery catheter (PAC) – which is considered the gold standard for haemodynamic measurement – has decreased.