Ray Raper examines the continued use of the pulmonary artery catheter in critical care. Are alternative monitors up to the task ?

1. Pulmonary artery catheters:
Charming the yellow snake
Pulmonary artery catheters:
‘Charming the yellow snake’
Raymond Raper RNSH

7. Multilumen
catheter

11. PAoP = PCWP = PvP = LAP = LVEDP
LVEDP ~ LVED fibre length = preload

12. Invasive V’s Non-invasive Monitoring
 Clinical examination unreliable
 PAoP
 CI
 Significant change in management with PAC
 management change
improved prognosis
Iberti 1983, Connors 1983, Mimoz 1994

13. Pulmonary artery catheterisation
 common procedure
 >1 million per year (USA)
 procedural fees and the ‘red cap
phenomenon’
 (declining usage past 5 years)
 characterisation of haemodynamics
 optimisation of haemodynamics
 myocardial infarction
 sepsis and other acute illnesses

14. Survival Proportional to
Cardiac Output
 Trauma
 Sepsis
 Cardiac
 Critically Ill
 ARDS

15. Mortality in Septic Shock
Related to persistent, low
vascular resistance
Parker et al 1987
Groenveld et al 1988

16. Oxygen Transport and Survival in
Critical Illness
 Survival proportional to cardiac output
 Oxygen debt in non-survivors
Bihari et al 1987
 Increased survival with CV support and
antibiotics in canine septic model
Natanson et al 1992
 Survival benefit with supranormal DO2
Shoemaker1988, Boyd 1993
‘Goal-directed therapy’

17. The Cult of the Swan-Ganz
catheter
Overuse and Abuse of Pulmonary
Flow-directed catheters?
Robin ED. Ann Intern Med 1985

18. Death by Pulmonary Artery
flow - directed catheter
Time for a Moratorium ?
Robin ED. Chest 1987

19. Pulmonary Artery Catheterisation
Excess Mortality
 Acute Myocardial Infarction
Gore et al 1987
 Critically Ill Patients
Connors et al 1996

20. Complications of PA Catheters
 Dysrhythmias
 Pneumothorax, haemothorax
 Infection
 Endocarditis
 PA Rupture
 Pulmonary infarction and embolisation
 Valvular and myocardial injury
 Wrong numbers Bad treatment

21. Physicians knowledge of the PA
catheter
 Multiple choice examination
 496 physicians
 31 questions
 Results:
 mean score 20.7 (67% )
 range 6 - 31 (19% - 100% )
Iberti et al, 1990

22. Nurses knowledge of the PA catheter
 Multiple choice questionnaire
 216 nurses at AACCN NTI
 37 questions
 Results:
 mean score 16.5 (48.5 % )
Iberti et al, 1994

23. The Swan - Ganz Catheter
and Left Ventricular Preload
Misled by the Wedge ?
Raper and Sibbald, Chest 1986

26. Pressure measurement
 dynamic pressure measurement, resonance
 inaccuracy of systolic and diastolic
pressures
 zero reference point
 ‘phlebostatic axis’
 transducer function, balancing
 transmural pressure and respiration
 end-expiratory reference point
 ventricular interdependence and acute cor
pulmonale

27. Increased Right Ventricular
Compliance
in Response to
Continuous Positive Airway Pressure
Raper RF and Sibbald WJ, Am Rev Respir Dis; 1992

28. Monitoring v Outcome
 Appropriate parameter
 useful V’s measurable
 Accuracy of measurement
 Correct interpretation
 Appropriate therapeutic intervention
 Patient response

29. Complications of PA Catheters
 Dysrhythmias
 Pneumothorax, haemothorax
 Infection
 Endocarditis
 PA Rupture
 Pulmonary infarction and embolisation
 Valvular and myocardial injury
 Wrong numbers Bad treatment
 Correct numbers Bad treatment

30. Beta stimulation and outcome

31. Beta stimulation and outcome
 beta blockers in heart failure

32. Beta stimulation and outcome
 beta blockers in heart failure
 increased mortality with dobutamine in heart
failure

33. Beta stimulation and outcome
 beta blockers in heart failure
 increased mortality with dobutamine in heart
failure
 reduced cardiac events with peri-operative
beta blockers

34. Beta stimulation and outcome
 beta blockers in heart failure
 increased mortality with dobutamine in heart
failure
 reduced cardiac events with peri-operative
beta blockers
 improved outcome with vasopressin in less
severely ill group in VAST trial
 reduced heart rate

35. Beta stimulation and outcome
 beta blockers in heart failure
 increased mortality with dobutamine in heart
failure
 reduced cardiac events with peri-operative
beta blockers
 improved outcome with vasopressin in less
severely ill group in VAST trial
 reduced heart rate
 increased mortality with high dose
dobutamine in sepsis Hayes et al NEJM 1994

37. Beta stimulation and outcome
 beta blockers in heart failure
 increased mortality with dobutamine in heart
failure
 reduced cardiac events with peri-operative
beta blockers
 improved outcome with vasopressin in less
severely ill group in VAST trial
 reduced heart rate
 increased mortality with high dose
dobutamine in sepsis Hayes et al NEJM 1994
 better outcomes with esmolol in septic shock
Morelli et al. JAMA, 2013

38. Effect of Heart Rate Control with Esmolol on haemodynamic
and Clinical Outcomes in Patients with Septic Shock
Morelli et al JAMA 2013

39. Pulmonary Artery catheters and
outcome?

40. Pulmonary Artery catheters and
outcome?
 Observational studies suggest harm

41. Pulmonary Artery catheters and
outcome?
 Observational studies suggest harm
 Randomised control studies of use
of PAC suggest no harm (and no
benefit)

42. Maximising O2 delivery - Meta Analysis 1996

43. Optimising Oxygen delivery
Meta analysis
Mortality reduction
All studies 0.86 ( 0.62 - 1.20 )
Pre-operative 0.20 ( 0.07 - 0.55 )

44. Meta-analysis of RCA’s of PAC use
Mortality
Shah MR et al JAMA 2005

45. Meta-analysis of RCA’s of PAC use
Figure 5. Forest plot of comparison: 5 PAC versus no PAC (combined medical and surgical patients), outcome: 5.1
Combined mortality of all studies.
Pulmonary artery catheters for adult patients in intensive care
Rajaram SS et al. Cochrane Collaboration, 2013

46. Pulmonary Artery catheters and
outcome?
 Observational studies suggest harm
 Randomised control studies of use
of PAC suggest no harm (and ?no
benefit)
 Meta analyses of studies of goal-
directed therapy in surgical
patients:

47. Maintaining Tissue Perfusion in High-Risk
Surgical Patients: A Systematic Review of
Randomized Clinical Trials
Category Mortality Organ
Dysfunction
All RCTs 0.67 (0.55 - 0.82) 0.62 (0.55 - 0.70)
High Quality 0.79 (0.64 – 0.99) 0.66 (0.58 – 0.75)
High control
mortality
0.32 (0.21 – 0.47) 0.38 (0.26 – 0.56)
Using PAC 0.67 (.054 – 0.84)
Gurgel and Nascimento Anesth Analg ;2011

48. Hamilton et al Anesthesia & Analgesia.2011.
Effects of pre-emptive hemodynamic
intervention on mortality

49. Hamilton et al Anesthesia & Analgesia.2011.
Effects of pre-emptive hemodynamic
intervention on complications

50. Hamilton et al Anesthesia & Analgesia.2011.
Effects of pre-emptive hemodynamic
intervention on mortality by decade of study

51. PAC in cardiac surgery

52. PAC in cardiac surgery
 Commonest use for PACs
 very unit specific

53. PAC in cardiac surgery
 Commonest use for PACs
 very unit specific
 Especially low risk cases can be
safely conducted without PAC

54. PAC in cardiac surgery
 Commonest use for PACs
 very unit specific
 Especially low risk cases can be
safely conducted without PAC
 Large observational studies suggest
possible harm
Schwann et al Anesth Analg 2011

55. Effect of early goal-directed therapy (EGDT)
on mortality rate in cardiac surgery
Anya H D et al. Br. J. Anaesth. 2013

56. Effect of early goal-directed therapy on
postoperative complications in cardiac
surgery.
Anya H D et al. Br. J. Anaesth. 2013

57. PAC usage:
 Haemodynamic monitoring
 pressure
 flow
 oxygenation including SvO2
 derived parameters
 monitoring the effect of therapy
 Diagnostic
 differentiating shock
 shunt identification and quantification
 mechanical lesions (valvular, tamponade…)
 Cardiac pacing
 atrial and ventricular

58. PAC usage:
 Observed 50% reduction over 10 years
Koo et al Crit Care Med 2011

59. PAC usage:
 Observed 50% reduction over 10 years
Koo et al Crit Care Med 2011
 Less use of PAoP, more cardiac output,
oxygen dynamics and SvO2

60. PAC usage:
 Observed 50% reduction over 10 years
Koo et al Crit Care Med 2011
 Less use of PAoP, more cardiac output,
oxygen dynamics and SvO2
 Utility of SvO2

61. PAC usage:
 Observed 50% reduction over 10 years
Koo et al Crit Care Med 2011
 Less use of PAoP, more cardiac output,
oxygen dynamics and SvO2
 Utility of SvO2
 Better understanding of limitations

62. PAC usage:
 Observed 50% reduction over 10 years
Koo et al Crit Care Med 2011
 Less use of PAoP, more cardiac output,
oxygen dynamics and SvO2
 Utility of SvO2
 Better understanding of limitations
 Less familiarity, comfort

63. PAC usage:
 Observed 50% reduction over 10 years
Koo et al Crit Care Med 2011
 Less use of PAoP, more cardiac output,
oxygen dynamics and SvO2
 Utility of SvO2
 Better understanding of limitations
 Less familiarity, comfort
 Likely to lead to reduced usage

64. Summary

65. Summary
 reliable device with some limitations

66. Summary
 reliable device with some limitations
 at every bedside 24 / 7

67. Summary
 reliable device with some limitations
 at every bedside 24 / 7
 still the gold standard for CO measurement

68. Summary
 reliable device with some limitations
 at every bedside 24 / 7
 still the gold standard for CO measurement
 maybe shouldn’t be

69. Summary
 reliable device with some limitations
 at every bedside 24 / 7
 still the gold standard for CO measurement
 maybe shouldn’t be
 no evidence of significant direct harm

70. Summary
 reliable device with some limitations
 at every bedside 24 / 7
 still the gold standard for CO measurement
 maybe shouldn’t be
 no evidence of significant direct harm
 only beneficial if married to a beneficial
therapy

71. Summary
 reliable device with some limitations
 at every bedside 24 / 7
 still the gold standard for CO measurement
 maybe shouldn’t be
 no evidence of significant direct harm
 only beneficial if married to a beneficial
therapy
 maybe especially useful in surgical patients

72. Summary
 reliable device with some limitations
 at every bedside 24 / 7
 still the gold standard for CO measurement
 maybe shouldn’t be
 no evidence of significant direct harm
 only beneficial if married to a beneficial
therapy
 maybe especially useful in surgical patients
 good fun and better than ignorance

73. Summary
 reliable device with some limitations
 at every bedside 24 / 7
 still the gold standard for CO measurement
 maybe shouldn’t be
 no evidence of significant direct harm
 only beneficial if married to a beneficial
therapy
 maybe especially useful in surgical patients
 good fun and better than ignorance
 can provide new insights
 taught us about critical illness

74. Summary
 reliable device with some limitations
 at every bedside 24 / 7
 still the gold standard for CO measurement
 maybe shouldn’t be
 no evidence of significant direct harm
 only beneficial if married to a beneficial
therapy
 maybe especially useful in surgical patients
 good fun and better than ignorance
 can provide new insights
 taught us about critical illness
 easiest way to establish temporary (dual
chamber) pacing

75. The Pulmonary Artery catheter:
In Medio Virtus
Vincent JL, Pinsky M, Sprung C, Levy
M, Marini J, Payen D, Rhodes A,
Takala J
Crit Care Med 2008

76. Thank you
Thank you