Pulmonary artery catheters:
Charming the yellow snake
Pulmonary artery catheters:
‘Charming the yellow snake’
Raymond Rape...
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...
Pulmonary artery catheterisation
 common procedure
 >1 million per year (USA)
 procedural fees and the ‘red cap
phenome...
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...
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
...
Complications of PA Catheters
 Dysrhythmias
 Pneumothorax, haemothorax
 Infection
 Endocarditis
 PA Rupture
 Pulmona...
Physicians knowledge of the PA
catheter
 Multiple choice examination
 496 physicians
 31 questions
 Results:
 mean sc...
Nurses knowledge of the PA catheter
 Multiple choice questionnaire
 216 nurses at AACCN NTI
 37 questions
 Results:
 ...
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 ref...
Increased Right Ventricular
Compliance
in Response to
Continuous Positive Airway Pressure
Raper RF and Sibbald WJ, Am Rev ...
Monitoring v Outcome
 Appropriate parameter
 useful V’s measurable
 Accuracy of measurement
 Correct interpretation
 ...
Complications of PA Catheters
 Dysrhythmias
 Pneumothorax, haemothorax
 Infection
 Endocarditis
 PA Rupture
 Pulmona...
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
 red...
Beta stimulation and outcome
 beta blockers in heart failure
 increased mortality with dobutamine in heart
failure
 red...
Beta stimulation and outcome
 beta blockers in heart failure
 increased mortality with dobutamine in heart
failure
 red...
Beta stimulation and outcome
 beta blockers in heart failure
 increased mortality with dobutamine in heart
failure
 red...
Effect of Heart Rate Control with Esmolol on haemodynamic
and Clinical Outcomes in Patients with Septic Shock
Morelli et a...
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 su...
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 - ...
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 ...
Pulmonary Artery catheters and
outcome?
 Observational studies suggest harm
 Randomised control studies of use
of PAC su...
Maintaining Tissue Perfusion in High-Risk
Surgical Patients: A Systematic Review of
Randomized Clinical Trials
Category Mo...
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 w...
PAC in cardiac surgery
 Commonest use for PACs
 very unit specific
 Especially low risk cases can be
safely conducted w...
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. 2...
PAC usage:
 Haemodynamic monitoring
 pressure
 flow
 oxygenation including SvO2
 derived parameters
 monitoring the ...
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,
ox...
PAC usage:
 Observed 50% reduction over 10 years
Koo et al Crit Care Med 2011
 Less use of PAoP, more cardiac output,
ox...
PAC usage:
 Observed 50% reduction over 10 years
Koo et al Crit Care Med 2011
 Less use of PAoP, more cardiac output,
ox...
PAC usage:
 Observed 50% reduction over 10 years
Koo et al Crit Care Med 2011
 Less use of PAoP, more cardiac output,
ox...
PAC usage:
 Observed 50% reduction over 10 years
Koo et al Crit Care Med 2011
 Less use of PAoP, more cardiac output,
ox...
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
 m...
Summary
 reliable device with some limitations
 at every bedside 24 / 7
 still the gold standard for CO measurement
 m...
Summary
 reliable device with some limitations
 at every bedside 24 / 7
 still the gold standard for CO measurement
 m...
Summary
 reliable device with some limitations
 at every bedside 24 / 7
 still the gold standard for CO measurement
 m...
Summary
 reliable device with some limitations
 at every bedside 24 / 7
 still the gold standard for CO measurement
 m...
Summary
 reliable device with some limitations
 at every bedside 24 / 7
 still the gold standard for CO measurement
 m...
Summary
 reliable device with some limitations
 at every bedside 24 / 7
 still the gold standard for CO measurement
 m...
The Pulmonary Artery catheter:
In Medio Virtus
Vincent JL, Pinsky M, Sprung C, Levy
M, Marini J, Payen D, Rhodes A,
Takala...
Thank you
Thank you
Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters
Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters
Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters
Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters
Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters
Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters
Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters
Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters
Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters
Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters
Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters
Upcoming SlideShare
Loading in...5
×

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

1,646

Published on

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

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,646
On Slideshare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
26
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

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

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

    Clipping is a handy way to collect important slides you want to go back to later.

×