Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters
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The document discusses pulmonary artery catheters (PACs), highlighting their use in hemodynamic monitoring and potential complications. Despite a declining trend in usage, PACs remain a common procedure with confirmed reliability for cardiac output measurement, but there's debate regarding their associated harms and benefits, particularly in surgical settings. Evidence suggests that while PACs can provide valuable insights into critical illness management, their effectiveness is contingent upon appropriate therapeutic interventions.
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Raper, Ray — Charming the Yellow Snake: Pulmonary Artery Catheters
- 1. Pulmonary artery catheters: Charming the yellow snake Pulmonary artery catheters: ‘Charming the yellow snake’ Raymond Raper RNSH
- 11. PAoP = PCWP = PvP = LAP = LVEDP LVEDP ~ LVED fibre length = preload
- 12. 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
- 13. 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
- 14. Survival Proportional to Cardiac Output Trauma Sepsis Cardiac Critically Ill ARDS
- 15. Mortality in Septic Shock Related to persistent, low vascular resistance Parker et al 1987 Groenveld et al 1988
- 16. 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’
- 17. The Cult of the Swan-Ganz catheter Overuse and Abuse of Pulmonary Flow-directed catheters? Robin ED. Ann Intern Med 1985
- 18. Death by Pulmonary Artery flow - directed catheter Time for a Moratorium ? Robin ED. Chest 1987
- 19. Pulmonary Artery Catheterisation Excess Mortality Acute Myocardial Infarction Gore et al 1987 Critically Ill Patients Connors et al 1996
- 20. Complications of PA Catheters Dysrhythmias Pneumothorax, haemothorax Infection Endocarditis PA Rupture Pulmonary infarction and embolisation Valvular and myocardial injury Wrong numbers Bad treatment
- 21. 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
- 22. 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
- 23. The Swan - Ganz Catheter and Left Ventricular Preload Misled by the Wedge ? Raper and Sibbald, Chest 1986
- 26. 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
- 27. Increased Right Ventricular Compliance in Response to Continuous Positive Airway Pressure Raper RF and Sibbald WJ, Am Rev Respir Dis; 1992
- 28. Monitoring v Outcome Appropriate parameter useful V’s measurable Accuracy of measurement Correct interpretation Appropriate therapeutic intervention Patient response
- 29. 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
- 30. Beta stimulation and outcome
- 31. Beta stimulation and outcome beta blockers in heart failure
- 32. Beta stimulation and outcome beta blockers in heart failure increased mortality with dobutamine in heart failure
- 33. Beta stimulation and outcome beta blockers in heart failure increased mortality with dobutamine in heart failure reduced cardiac events with peri-operative beta blockers
- 34. 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
- 35. 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
- 37. 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
- 38. Effect of Heart Rate Control with Esmolol on haemodynamic and Clinical Outcomes in Patients with Septic Shock Morelli et al JAMA 2013
- 39. Pulmonary Artery catheters and outcome?
- 40. Pulmonary Artery catheters and outcome? Observational studies suggest harm
- 41. Pulmonary Artery catheters and outcome? Observational studies suggest harm Randomised control studies of use of PAC suggest no harm (and no benefit)
- 42. Maximising O2 delivery - Meta Analysis 1996
- 43. Optimising Oxygen delivery Meta analysis Mortality reduction All studies 0.86 ( 0.62 - 1.20 ) Pre-operative 0.20 ( 0.07 - 0.55 )
- 44. Meta-analysis of RCA’s of PAC use Mortality Shah MR et al JAMA 2005
- 45. 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
- 46. 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:
- 47. 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
- 48. Hamilton et al Anesthesia & Analgesia.2011. Effects of pre-emptive hemodynamic intervention on mortality
- 49. Hamilton et al Anesthesia & Analgesia.2011. Effects of pre-emptive hemodynamic intervention on complications
- 50. Hamilton et al Anesthesia & Analgesia.2011. Effects of pre-emptive hemodynamic intervention on mortality by decade of study
- 51. PAC in cardiac surgery
- 52. PAC in cardiac surgery Commonest use for PACs very unit specific
- 53. PAC in cardiac surgery Commonest use for PACs very unit specific Especially low risk cases can be safely conducted without PAC
- 54. 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
- 55. Effect of early goal-directed therapy (EGDT) on mortality rate in cardiac surgery Anya H D et al. Br. J. Anaesth. 2013
- 56. Effect of early goal-directed therapy on postoperative complications in cardiac surgery. Anya H D et al. Br. J. Anaesth. 2013
- 57. 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
- 58. PAC usage: Observed 50% reduction over 10 years Koo et al Crit Care Med 2011
- 59. 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
- 60. 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
- 61. 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
- 62. 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
- 63. 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
- 64. Summary
- 65. Summary reliable device with some limitations
- 66. Summary reliable device with some limitations at every bedside 24 / 7
- 67. Summary reliable device with some limitations at every bedside 24 / 7 still the gold standard for CO measurement
- 68. Summary reliable device with some limitations at every bedside 24 / 7 still the gold standard for CO measurement maybe shouldn’t be
- 69. 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
- 70. 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
- 71. 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
- 72. 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
- 73. 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
- 74. 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
- 75. 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