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July 2000
Clinical and economic effects of pulmonary artery catheterization in nonemergent coronary artery bypass graft surgery.
Ramsey SD, Saint S, Sullivan SD et al. J Cardiothorac Vasc Anesth 14(2) April 2000 113-118
[see abstract below]
Commentary by David Lubarsky, M.D.
Clinical and Economic Effects of Pulmonary Artery Catheterization
The authors evaluated (retrospectively) outcomes from almost 14,000 coronary artery bypass graft (CABG) surgeries, and correlated these outcomes with the use of a pulmonary artery catheter (PAC). Just as the ICU study demonstrated an increased mortality, so did this one. Patients were twice as likely to die in the hospital if they had had a PAC placed on or before the date of surgery. Not exactly a ringing endorsement of clinical benefit! In hospitals where PAC use was lowest, the risk was more than 3 fold higher of dying in-hospital. Both the issue of disease severity (more = worse expected outcome) and volume of CABG surgeries (less = worse expected outcome) seemed to be well accounted for in their data analysis. Hospital stay was slightly longer in the PAC group, and cost was significantly higher (not counting the insertion fee, having one averaged an extra $1,400 per patient).
Since this study was retrospective, it is not really possible to make specific conclusions - which is why this paper did not appear in The New England Journal of Medicine, and why a prospective study is essential. Did the recorded secondary diagnoses of importance totally reflect patient disease? Were all indicators of ejection fraction and myocardial function (key indicators for PA catheter placement) well reflected in the database approach used? It is important to note that EF is never in large databases, just a relative diagnosis of severity of cardiomyopathy.
So should you abandon PA catheter use? A definite maybe. Should these results make you pause and think about when YOU will choose to employ one? Absolutely. Hard reasons need to be present for placement of a PA catheter. Only two real reasons exist
- Large fluid shifts that need to be measured in a timely fashion, and right and left sided heart pressure that may not be equal (severe COPD, left heart failure, valvular disease)
- Need to optimize something that can only be accurately measured using a PA catheter: cardiac output, SVR, PVR, LVEDP.
Having said that, an article appearing in the same issue of the same journal details alternatives to the PA catheter for measuring CO or volume [1]. So, soon, there may be no indications for a monitor that has some suggesting it causes more harm than good.
I believe that careful patient selection, and placement by experienced individuals helps patient management. Indiscriminate use without regard for the technical or cognitive skill of the user may actually cause harm.
Reference:
- Sakka SG, Reinhart K, Wegscheider K, Meier-Hellmann A: Is the placement of a pulmonary artery catheter still justified solely for the measurement of cardiac output? J Cardiothorac Vasc Anesth 14(2):119-24, 2000
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ABSTRACTS
Clinical and economic effects of pulmonary artery catheterization in nonemergent coronary artery bypass graft surgery.
AUTHORS:
Ramsey SD, Saint S, Sullivan SD et al
SOURCE:
J Cardiothorac Vasc Anesth 14(2) April 2000 113-118
OBJECTIVE: To examine the association between use of pulmonary artery catheteriza5ionh with hospital outcomes and costs in non-emergent coronary artery bypass graft (CABG) surgery.
DESIGN: Retrospective cohort study.
SETTING: Fifty-six community-based hospitals in 26 states.
PARTICIPANTS: A total of 13, 907 patients undergoing non-emergent CABG surgery between January 1, 1997, and December 31, 1997.
MEASUREMENTS AND MAIN RESULTS: Discharge abstracts for each patient were examined. Stratifies and multivariate analyses were used to assess the impact of pulmonary artery catheters (PACs) on in-hospital mortality, length of stay in the intensive care unit, total length of stay, and hospital costs. Outcomes were adjusted for patient demographic factors, hospital characteristics, and hospital volume of {AC use in the year of analysis. Fifty-eight percent of the patients received a PAC. After adjustment, the relative risk of in-hospital mortality was 2.10 of the PAC group compared with the patients who did not receive a PAC (95% confidence interval [CI], 1.40 to 3.14; p < 0.001). The mortality risk was significantly higher in hospitals with the lowest third of PAC use (odds ratio, 3.35; 95% confidence interval [CI], 1.74 to 6.47; p < 0.001) and not significantly increased in the highest two thirds of users (odds ratio, 1.62; 95% CI, 0.99 to 2.66; p = 0.09). Days spent in critical care were similar; however, total length of hospital stay was 0.26 days longer in the PAC group (p < 0.001). Hospital costs were $1,402 higher in the PAC group.
CONCLUSION: in the setting of nonemergent CABG surgery, pulmonary artery catheterization was associated with an increased risk of in-hospital mortality, greater length of stay, and higher total costs, particularly in hospitals with low volume of PAC use.
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