[HSF] Pulmonary Artery Catheters !

Sun Nov 5 22:15:02 EST 2006

One of the most irritating things to see is to have a measuring device 
placed and unused. We call it the red cap syndrome.
I usually have to tell my residents if you place a monitoring device use 
it or disprove the reliability of its measurements.It need not be for PA 
catheters it can be even "damped arterial lines" , lactate levels etc 
etc.Even a simple ABG.
I do not think that a "routine" PA catheter is really useful but 
definitely useful in OPCAB's, patients with severe pulmonary 
hypertension to manage postoperative therapy and in patients with left 
right discordance eg a stiff left ventricle or more importantly 
dysfunctional RV with a better LV. Some people may use a PA catheter as 
a surrogate for some lesser care. For eg I put it or PICCO when our ABG 
machine conks or for any other reason like Hal does for lack of 
"resident" monitoring.
I think that this may be more institutional rather than based on any 
hard evidence.
Having said that I had a peculiar problem once.
Patient was not doing well and I went to see the PA pressure was low but 
the CVP was showing a massive V wave.
 I did an Echo and could see a massive TR which disappeared on 
withdrawing the PA catheter !! It was probably lying in some manner so 
as to induce severe TR. There was a dramatic improvement in the patients 
hemodynamics in minutes of withdrawal of the catheter.with resolution of 
the TR.
Prasanna

Ani Anyanwu wrote:
> 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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