Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters
Upcoming SlideShare
Loading in...5
×
 

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

on

  • 921 views

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

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

Statistics

Views

Total Views
921
Views on SlideShare
277
Embed Views
644

Actions

Likes
0
Downloads
12
Comments
0

1 Embed 644

http://intensivecarenetwork.com 644

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

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

  • Pulmonary artery catheters: Charming the yellow snake Pulmonary 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  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  Trauma  Sepsis  Cardiac  Critically Ill  ARDS
  • 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  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? Robin ED. Ann Intern Med 1985
  • Death by Pulmonary Artery flow - directed catheter Time for a Moratorium ? Robin ED. Chest 1987
  • Pulmonary Artery Catheterisation Excess 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  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  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 ? 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 Raper RF and Sibbald WJ, Am Rev Respir Dis; 1992
  • Monitoring v Outcome  Appropriate parameter  useful V’s measurable  Accuracy of measurement  Correct interpretation  Appropriate therapeutic intervention  Patient response
  • 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
  • Beta stimulation and outcome
  • Beta stimulation and outcome  beta blockers in heart failure
  • Beta stimulation and outcome  beta blockers in heart failure  increased mortality with dobutamine in heart failure
  • Beta stimulation and outcome  beta blockers in heart failure  increased mortality with dobutamine in heart failure  reduced cardiac events with peri-operative beta blockers
  • 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
  • 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
  • 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
  • Effect of Heart Rate Control with Esmolol on haemodynamic and Clinical Outcomes in Patients with Septic Shock Morelli et al JAMA 2013
  • Pulmonary Artery catheters and outcome?
  • Pulmonary Artery catheters and outcome?  Observational studies suggest harm
  • 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 delivery Meta 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 care Rajaram SS et al. Cochrane Collaboration, 2013
  • 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:
  • 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
  • Hamilton et al Anesthesia & Analgesia.2011. Effects of pre-emptive hemodynamic intervention on complications
  • Hamilton et al Anesthesia & Analgesia.2011. Effects of pre-emptive hemodynamic intervention on mortality by decade of study
  • PAC in cardiac surgery
  • PAC in cardiac surgery  Commonest use for PACs  very unit specific
  • PAC in cardiac surgery  Commonest use for PACs  very unit specific  Especially low risk cases can be safely conducted without PAC
  • 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
  • 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:  Observed 50% reduction over 10 years Koo et al Crit Care Med 2011  Less use of PAoP, more cardiac output, oxygen dynamics and SvO2
  • 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
  • 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
  • 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
  • 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
  • Summary
  • Summary  reliable device with some limitations
  • Summary  reliable device with some limitations  at every bedside 24 / 7
  • Summary  reliable device with some limitations  at every bedside 24 / 7  still the gold standard for CO measurement
  • Summary  reliable device with some limitations  at every bedside 24 / 7  still the gold standard for CO measurement  maybe shouldn’t be
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • Thank you Thank you