[HSF] Pulmonary Artery Catheters !

[Ani Anyanwu]

NFA

How frequently surgeons use PA catheters is more a reflection of habit and myth rather than of science and bears little correlation to the real questions raised by the article you appended(and others) which are

1) How useful are PA catheters

2) How necessary are PA catheters in routine application

3) Is routine use of PA catheters harmful

4) Is routine application of PA catheters cost-effective?

We use PA catheters very liberally though I am not sure why and personally doubt they are useful in most acquired adult cardiac cases. I walk around ICU and see fancy measurements (for that is what they are) and derivations (even worse than the measurements) being charted religiously and on direct questioning I rarely get a reliable answer on what the usefulness of these measurements have been in managing a said patient. I have always questioned for example why doctors want to measure repeated  cardiac output in patients with a VAD, when the device gives a direct measure of this output - and they often attempt to treat these figures while ignoring the VAD output. In my experience there are only specific circumstances where the PA catheter actually changes management above which can be achieved by examining a patient, measuring CVP and following urine output and acid-base balance. 


Whether they are necessary is another question. For the occasional patient who is troublesome, the additional information may help guide management. The question then is whether everyone should receive this therapy for the few who will benefit or whether it should be selectively applied to those who are more likely to benefit. Clearly it is not necessary for most patients (as there are many units that do not routinely use them and yet deliver good results). Indeed I have seen the other extreme - and ICU that does not uses PAC at all but relies on non-invasive measures as Prasanna alluded to.

Whether they are harmful is difficult to answer. Most studies have been in the general ICU setting and may not transform to the post cardiac surgery setting. Hemorrhagic complications should be rare because of the precautions outlined by others. Sepsis is difficult to quantitate. The main harm I see (and I do not know the degree to which this exists) is misapplication of the information derived and also delay in progression of recovery because of desire to normalize some measured variables. It is amazing how fast a patient will recover and be discharged from ICU if you walk in and pull out the PA catheter.

PA catheters are definitely not cost effective. Aside from the cost of the catheter, there is the cost of personnel who insert it, the cost of routine measurements and the cost of the interventions they drive. In my institution PAC insertion is billed as a separate procedure (partly why in the US anesthesiologists resist surgeons' pressures to reduce use of PACs). Applying PAC routinely could easily add $1,000 to the cost of a case without tangible benefit in many.

Most of what guides our use (or indeed non-use) of the PAC is personal choice, habits and myths; certainly they are not necessary for most low risk cases, for higher risk cases there is an argument for selective use. In some circumstances (such as transplant, poor LV, pulm HTN) there may be an argument for routine use - but even these are debatable. Maybe there is a role for a randomized trial in the cardiac surgical setting - we may be surprised what we find.

Ani


  ----- Original Message ----- 
  From: Nasser F. Abou'Seada<mailto:nfaabouseada at gmail.com> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Friday, November 03, 2006 5:30 AM
  Subject: RE: [HSF] Pulmonary Artery Catheters !


  How frequently do members of the forum use PA Catheter ? 
  - Comments ??

  NFA

  HEART CATHETERS DO NOT BENEFIT PATIENTS 

  (Editorial: Pulmonary artery catheters)
  http://bmj.com/cgi/content/full/333/7575/930<http://bmj.com/cgi/content/full/333/7575/930> 



  Doctors should probably stop using pulmonary artery catheters because they
  do not benefit patients, say doctors from Australia in this week's BMJ. 

  The pulmonary artery catheter was invented in 1968. It enabled bedside
  monitoring in critically ill patients by measuring heart output and
  capillary pressure in the lungs and became widely used in intensive care
  units. 

  But reports of serious complications soon appeared and arguments for and
  against its use have continued ever since. 

  The most recent evaluation, commissioned by the NHS Health Technology
  Assessment (HTA) programme, found that pulmonary artery catheters do not
  benefit patients and concluded that withdrawing them from UK intensive care
  units would be cost effective. 

  Another recent trial in patients with acute lung injury confirmed these
  findings, while an analysis of 13 trials reported no overall effect of using
  these devices on mortality or length of hospital stay. 

  So what should clinicians do with all this information? 

  Given that the use of pulmonary artery catheters increases the risk of
  important complications, continued use of these devices is difficult to
  defend, say the authors. 

  The onus is now on the proponents of the pulmonary artery catheter and
  related devices to limit their use to clinical trials and to show that
  protocols based on such devices do benefit patients, they conclude.


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