Pulmonary Catheterization and Controversy:

Does Pulmonary Artery Catheterization Improve Patient Outcome?

 

        Currently, a long-standing argument exists within the medical community concerning the efficacy of pulmonary artery catheterization.  Pulmonary artery catheterization is an expensive and invasive monitoring technique which has not yet conclusively proven beneficial to patient outcome.  Both small and large studies investigating this matter have both proven and refuted the benefits of PAC use in overall patient morbidity and mortality.  One observational study of 1000+ general surgery patients concluded that monitoring with pulmonary artery catheters resulted in lower patient perioperative mortality rates and lower re-infarction rates.  A large prospective cohort study of 5000+ patients in multiple medical centers looked at PAC use within the 24 hours of intensive care, and subsequent patient survival.  Even after adjusting for discrepancies in patient’s medical and surgical conditions, the study found increased rates of mortality, increased days in the hospital, and increased cost with the patients who underwent pulmonary artery catheterization and monitoring.  These discrepancies may have to do with the specific population studied during the course of the investigation; i.e., patients with acute MI vs. those undergoing cardiac surgery vs. critically ill patients with diverse medical and surgical issues.

         Randomized controlled trials have been recommended to examine these issues further, however the logistics of a study concerning pulmonary artery catheterization have hindered any investigations.  It would be difficult to obtain the required consent from critically ill patients, keep physicians within the guidelines of the study, be able to avoid selection bias, and make provisions for numerous crossover patients.  And so, the controversy continues.

         The American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization have identified three main factors for physicians to consider when faced with the decision of whether or not to catheterize a patient. Physicians should consider using PAC monitoring in the setting of:

  1. High risk patients with severe underlying cardiopulmonary disease
  2. An operation which, by its extent or nature, places the patient at high risk
  3. An environment or institution which is experienced and knowledgeable in PAC placement and monitoring

          For example, a patient with severe coronary vascular disease undergoing a simple procedure such as cataract surgery would not require pulmonary artery catheterization, whereas a patient with mild, stable angina undergoing a large abdominal surgery may need PAC monitoring.  While the debate continues, pulmonary artery catheterization should best be used conservatively, until more definitive studies can provide better guidelines for their beneficial application.

 

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