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

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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 ?

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  • 1. Pulmonary artery catheters: Charming the yellow snake Pulmonary artery catheters: ‘Charming the yellow snake’ Raymond Raper RNSH
  • 2. Multilumen catheter
  • 3. PAoP = PCWP = PvP = LAP = LVEDP LVEDP ~ LVED fibre length = preload
  • 4. 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
  • 5. 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
  • 6. Survival Proportional to Cardiac Output  Trauma  Sepsis  Cardiac  Critically Ill  ARDS
  • 7. Mortality in Septic Shock Related to persistent, low vascular resistance Parker et al 1987 Groenveld et al 1988
  • 8. 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’
  • 9. The Cult of the Swan-Ganz catheter Overuse and Abuse of Pulmonary Flow-directed catheters? Robin ED. Ann Intern Med 1985
  • 10. Death by Pulmonary Artery flow - directed catheter Time for a Moratorium ? Robin ED. Chest 1987
  • 11. Pulmonary Artery Catheterisation Excess Mortality  Acute Myocardial Infarction Gore et al 1987  Critically Ill Patients Connors et al 1996
  • 12. Complications of PA Catheters  Dysrhythmias  Pneumothorax, haemothorax  Infection  Endocarditis  PA Rupture  Pulmonary infarction and embolisation  Valvular and myocardial injury  Wrong numbers Bad treatment
  • 13. 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
  • 14. 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
  • 15. The Swan - Ganz Catheter and Left Ventricular Preload Misled by the Wedge ? Raper and Sibbald, Chest 1986
  • 16. 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
  • 17. Increased Right Ventricular Compliance in Response to Continuous Positive Airway Pressure Raper RF and Sibbald WJ, Am Rev Respir Dis; 1992
  • 18. Monitoring v Outcome  Appropriate parameter  useful V’s measurable  Accuracy of measurement  Correct interpretation  Appropriate therapeutic intervention  Patient response
  • 19. 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
  • 20. Beta stimulation and outcome
  • 21. Beta stimulation and outcome  beta blockers in heart failure
  • 22. Beta stimulation and outcome  beta blockers in heart failure  increased mortality with dobutamine in heart failure
  • 23. Beta stimulation and outcome  beta blockers in heart failure  increased mortality with dobutamine in heart failure  reduced cardiac events with peri-operative beta blockers
  • 24. 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
  • 25. 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
  • 26. 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
  • 27. Effect of Heart Rate Control with Esmolol on haemodynamic and Clinical Outcomes in Patients with Septic Shock Morelli et al JAMA 2013
  • 28. Pulmonary Artery catheters and outcome?
  • 29. Pulmonary Artery catheters and outcome?  Observational studies suggest harm
  • 30. Pulmonary Artery catheters and outcome?  Observational studies suggest harm  Randomised control studies of use of PAC suggest no harm (and no benefit)
  • 31. Maximising O2 delivery - Meta Analysis 1996
  • 32. Optimising Oxygen delivery Meta analysis Mortality reduction All studies 0.86 ( 0.62 - 1.20 ) Pre-operative 0.20 ( 0.07 - 0.55 )
  • 33. Meta-analysis of RCA’s of PAC use Mortality Shah MR et al JAMA 2005
  • 34. 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
  • 35. 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:
  • 36. 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
  • 37. Hamilton et al Anesthesia & Analgesia.2011. Effects of pre-emptive hemodynamic intervention on mortality
  • 38. Hamilton et al Anesthesia & Analgesia.2011. Effects of pre-emptive hemodynamic intervention on complications
  • 39. Hamilton et al Anesthesia & Analgesia.2011. Effects of pre-emptive hemodynamic intervention on mortality by decade of study
  • 40. PAC in cardiac surgery
  • 41. PAC in cardiac surgery  Commonest use for PACs  very unit specific
  • 42. PAC in cardiac surgery  Commonest use for PACs  very unit specific  Especially low risk cases can be safely conducted without PAC
  • 43. 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
  • 44. Effect of early goal-directed therapy (EGDT) on mortality rate in cardiac surgery Anya H D et al. Br. J. Anaesth. 2013
  • 45. Effect of early goal-directed therapy on postoperative complications in cardiac surgery. Anya H D et al. Br. J. Anaesth. 2013
  • 46. 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
  • 47. PAC usage:  Observed 50% reduction over 10 years Koo et al Crit Care Med 2011
  • 48. 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
  • 49. 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
  • 50. 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
  • 51. 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
  • 52. 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
  • 53. Summary
  • 54. Summary  reliable device with some limitations
  • 55. Summary  reliable device with some limitations  at every bedside 24 / 7
  • 56. Summary  reliable device with some limitations  at every bedside 24 / 7  still the gold standard for CO measurement
  • 57. Summary  reliable device with some limitations  at every bedside 24 / 7  still the gold standard for CO measurement  maybe shouldn’t be
  • 58. 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
  • 59. 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
  • 60. 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
  • 61. 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
  • 62. 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
  • 63. 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
  • 64. 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
  • 65. Thank you Thank you