Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters

Pulmonary artery catheters:Charming the yellow snakePulmonary artery

catheters:‘Charming the yellow

snake’

Raymond Raper RNSH

Multilumen catheter

PAoP = PCWP = PvP = LAP = LVEDP

LVEDP ~ LVED fibre length = preload

Invasive V’s Non-invasive Monitoring

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

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

Survival Proportional to Cardiac Output

Survival Proportional to Cardiac Output

Trauma Sepsis Cardiac Critically Ill ARDS

Mortality in Septic Shock

Mortality in Septic Shock

Related to persistent, low vascular resistance

Parker et al 1987

Groenveld et al 1988

Oxygen Transport and Survival in Critical Illness

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’

The Cult of the Swan-Ganz catheter

Overuse and Abuse of Pulmonary Flow-directed

catheters?

The Cult of the Swan-Ganz catheter

Overuse and Abuse of Pulmonary Flow-directed

catheters?

Robin ED. Ann Intern Med 1985

Death by Pulmonary Artery flow - directed catheter

Time for a Moratorium ?

Death by Pulmonary Artery flow - directed catheter

Time for a Moratorium ?

Robin ED. Chest 1987

Pulmonary Artery CatheterisationExcess Mortality

Pulmonary Artery CatheterisationExcess Mortality

Acute Myocardial Infarction

Gore et al 1987

Critically Ill Patients Connors et al 1996

Complications of PA Catheters


Dysrhythmias Pneumothorax, haemothorax Infection Endocarditis PA Rupture Pulmonary infarction and

embolisation Valvular and myocardial injury Wrong numbers Bad

treatment

Physicians knowledge of the PA catheter

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

Nurses knowledge of the PA catheter

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

The Swan - Ganz Catheter and Left Ventricular Preload

Misled by the Wedge ?

The Swan - Ganz Catheter and Left Ventricular Preload

Misled by the Wedge ?

Raper and Sibbald, Chest 1986

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

Increased Right Ventricular Compliance

in Response to Continuous Positive Airway

Pressure

Increased Right Ventricular Compliance

in Response to Continuous Positive Airway

Pressure

Raper RF and Sibbald WJ, Am Rev Respir Dis; 1992

Monitoring v OutcomeMonitoring v Outcome

Appropriate parameter useful V’s measurable

Accuracy of measurement Correct interpretation Appropriate therapeutic

intervention Patient response



Dysrhythmias Pneumothorax, haemothorax Infection Endocarditis PA Rupture Pulmonary infarction and

embolisation Valvular and myocardial injury Wrong numbers Bad

treatment Correct numbers Bad

treatment

Beta stimulation and outcome


beta blockers in heart failure


beta blockers in heart failure increased mortality with dobutamine

in heart failure



in heart failure reduced cardiac events with peri-

operative beta blockers




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






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

Effect of Heart Rate Control with Esmolol on haemodynamic and Clinical Outcomes in Patients

with Septic ShockMorelli et al JAMA 2013

Pulmonary Artery catheters and outcome?


Observational studies suggest harm



Randomised control studies of use of PAC suggest no harm (and no benefit)

Maximising O2 delivery - Meta Analysis 1996

Optimising Oxygen deliveryMeta analysis

Optimising Oxygen deliveryMeta analysis

Mortality reduction All studies 0.86 ( 0.62 - 1.20 ) Pre-operative 0.20 ( 0.07 - 0.55 )

Meta-analysis of RCA’s of PAC use

Mortality

Shah MR et al JAMA 2005

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 careRajaram SS et al. Cochrane Collaboration, 2013



Randomised control studies of use of PAC suggest no harm (and ?no benefit)

Meta analyses of studies of goal-directed therapy in surgical patients:

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

Hamilton et al Anesthesia &

Analgesia.2011.

Effects of pre-emptive hemodynamic intervention on mortality


Analgesia.2011.

Effects of pre-emptive hemodynamic intervention on complications


Analgesia.2011.

Effects of pre-emptive hemodynamic intervention on mortality by decade of

study

PAC in cardiac surgery


Commonest use for PACs very unit specific



Especially low risk cases can be safely conducted without PAC



Especially low risk cases can be safely conducted without PAC

Large observational studies suggest possible harm

Schwann et al Anesth Analg 2011

Effect of early goal-directed therapy (EGDT) on mortality rate in cardiac surgery

Anya H D et al. Br. J. Anaesth. 2013

Effect of early goal-directed therapy on postoperative complications in

cardiac surgery.

Anya H D et al. Br. J. Anaesth. 2013

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

PAC usage:

Observed 50% reduction over 10 years

Koo et al Crit Care Med 2011

PAC usage:


Koo et al Crit Care Med 2011 Less use of PAoP, more cardiac

output, oxygen dynamics and SvO2

PAC usage:



output, oxygen dynamics and SvO2 Utility of SvO2

PAC usage:




Better understanding of limitations

PAC usage:




Better understanding of limitations Less familiarity, comfort

PAC usage:




Better understanding of limitations Less familiarity, comfort

Likely to lead to reduced usage

Summary

Summary reliable device with some limitations


at every bedside 24 / 7


at every bedside 24 / 7 still the gold standard for CO

measurement



measurement maybe shouldn’t be




no evidence of significant direct harm




no evidence of significant direct harm only beneficial if married to a

beneficial therapy





beneficial therapy maybe especially useful in surgical

patients






patients good fun and better than ignorance






patients good fun and better than ignorance can provide new insights

taught us about critical illness






patients good fun and better than ignorance can provide new insights

taught us about critical illness easiest way to establish temporary

(dual chamber) pacing

The Pulmonary Artery catheter:

In Medio Virtus

Vincent JL, Pinsky M, Sprung C, Levy M, Marini J, Payen D,

Rhodes A, Takala JCrit Care Med 2008

Thank you

Thank you

Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters

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