CHF
Pulmonary artery catheter in critically ill has neutral effect
By JAMA
Oct 6, 2005, 21:44

A meta-analysis of previous studies indicates that use of a pulmonary artery catheter in critically ill patients neither increases risk of death or hospital stay or adds benefit, according to another article in this issue of JAMA.

The PAC is used to diagnose various diseases and physiological states, monitor the progress of critically ill patients, and guide the selection and adjustment of medical therapy, according to background information in the article. The PAC is often considered a cornerstone of critical care and a hallmark of the intensive care unit (ICU). Approximately 1 million PACs are used annually in the United States. However, despite widespread use of these devices, there is conflicting data about their effectiveness, and whether they increase risk of illness and death. Since the mid-1980s, randomized clinical trials (RCTs) have been conducted to evaluate the efficacy of the PAC. However, none of these trials have been persuasive individually, because they are limited by small sample sizes in heterogeneous populations. Despite the overwhelmingly negative outcomes of the literature, clinicians continue to use the PAC in ICUs based on personal experience and the belief that careful monitoring will improve decision making and clinical outcomes.

Monica R. Shah, M.D., M.H.S., of Columbia University Medical Center, New York, and colleagues performed a meta-analysis of recently published clinical trials testing the safety and efficacy of the PAC. The researchers located the RCTs, in which patients were randomly assigned to PAC or no PAC, from several databases. Eligible studies included patients who were undergoing surgery, in the ICU, admitted with advanced heart failure, or diagnosed with acute respiratory distress syndrome and/or sepsis; and studies that reported death and the number of days hospitalized or the number of days in the ICU as outcome measures. The researchers found 13 RCTs that included 5,051 patients.

"Our meta-analysis of 13 RCTs evaluating the safety and efficacy of the PAC demonstrates that use of the catheter neither improves outcomes in critically ill patients nor increases mortality or days in hospital. This provides a broader confirmation of the recent results of the ESCAPE trial, which showed that the routine use of the PAC in patients with advanced heart failure did not reduce or increase death or days in hospital," the authors write.

"During the past 60 years, the PAC has evolved from a simple diagnostic tool to a device that is used for monitoring and determining goal-directed therapy. Our meta-analysis shows that despite the widespread acceptance of the PAC, use of this device across a variety of clinical circumstances in critically ill patients does not improve survival or decrease the number of days hospitalized. ... These results suggest that the PAC should not be used for the routine treatment of patients in the ICU, patients with decompensated heart failure, or patients undergoing surgery until or unless effective therapies can be found that improve outcomes when coupled with this diagnostic tool," the authors conclude.

In an accompanying editorial, Jesse B. Hall, M.D., of the University of Chicago, comments on the articles in this week's JAMA on PAC.

"What is the evidence for the broader issue of PAC use in the ICU and perioperative setting? The data collected to date certainly do not support routine use of the catheter in any patient group, and the currently available information could be viewed as justifying 'pulling the pulmonary artery catheter' from routine use, a suggestion made almost 10 years ago. One important additional trial is nearing completion and evaluates the use of PAC in patients with adult respiratory distress syndrome."

"Should there be a positive result attributable to PAC in this trial, a specific niche for this technology may remain in critical care. If the results of this soon-to-be-completed trial show no benefit of PAC monitoring, it is likely that the available data will indicate that it is time to remove the catheter from widespread use, or at the very least relegate this former common monitoring tool to salvage therapy of an extremely small and select number of patients. The need to question the routine use of this monitoring modality was quite real and the results of the last 5 years of study most valuable. Once again the community of critical care physicians has been edified by the approach of 'Don't just do something, stand there! And then think about it. ...'" Dr. Hall concludes.

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