Abstract
Purpose
The pulmonary artery catheter (PAC) is commonly used in anesthesiology and critical care, but its appropriate (where benefit exceeds risk) application is unknown. This study describes current clinical practice attitudes among anesthesiologists in cardiac and vascular surgery in an effort to determine the most appropriate indications for use of the PAC.
Methods
Anonymous, cross-sectional, mailed survey of anesthesiologists in Canada and the USA. Opinions of anesthesiologists about the appropriateness of PAC application were assessed in 36 clinical scenarios, using a nine-point Likert scale. The RAND method was adapted to identify appropriate, inappropriate, and uncertain indications for PAC application.
Results
Seventy-seven percent of 345 anesthesiologists responded. They agreed strongly (87%) that use of the PAC is appropriate in patients with severe ventricular impairment and unstable angina. Agreement was also present with ventricular impairment (74%) or unstable angina (55%) alone, but was less strong. A majority (53%) rated the PAC as not appropriate in the routine patient without complicating risk factors. Those who used the PAC more frequently, who had a greater practice volume, and who practised in Canada rated PAC use to be more appropriate in more scenarios. Those who did more continuing medical education rated PAC use to be less appropriate.
Conclusions
While the ideal evaluation of the PAC in clinical practice would be a randomized controlled trial, such an undertaking is time-consuming, expensive, of limited generalizability, and requires clinical equipoise. This study found strong agreement that PAC application is appropriate in some patient scenarios, and agreement that it is inappropriate in others. Description of current practice using this method may identify scenarios where randomized evaluation of the PAC, or other technologies, is likely unnecessary, and others where it is highly likely to be highly beneficial.
Résumé
Objectif
Le cathéter artériel pulmonaire (CAP) est fréquemment utilisé en anesthésiologie et aux soins intensifs, mais la pertinence (où les avantages dépassent les risques) de son application n’est pas connue. La présente étude décrit les attitudes de pratique courante des anesthésiologistes en chirurgie cardiaque et vasculaire dans le but de déterminer les indications les plus pertinentes de l’usage du CAP.
Méthode
Une enquête anonyme et ponctuelle a été postée à des anesthésiologistes du Canada et des États-Unis. L’opinion des anesthésiologistes sur la pertinence du CAP a été évaluée selon 36 scénarios cliniques en utilisant une échelle de Likert de neuf points. La méthode RAND a été adaptée pour préciser les indications pertinentes, non pertinentes et incertaines de l’application du CAP.
Résultats
Soixante-dix-sept pour cent des 345 anesthésiologistes ont répondu. Une forte majorité (87 %) appuyaient l’usage du CAP dans les cas d’atteinte ventriculaire sévère et d’angine instable. Un accord, moins important, se dessinait également pour l’atteinte ventriculaire (74 %) ou l’angine instable (55 %) seule. Une majorité (53 %) a jugé le CAP non pertinent chez le patient habituel sans facteurs de risque de complications. Ceux qui utilisent le CAP plus souvent, qui ont une clientèle plus importante et qui pratiquent au Canada ont jugé le CAP plus pertinent dans plus de scénarios. Ceux qui ont davantage suivi la formation médicale continue l’ont décrit comme moins pertinent.
Conclusion
L’évaluation idéale du CAP en clinique devrait faire l’objet d’un essai randomisé et contrôlé, mais cela demande du temps, coûte cher, ne présente qu’une généralisabilité limitée et exige une équipoise clinique. La présente étude a montré une adhésion solide à l’application du CAP comme pertinente chez certains patients et non pertinente chez d’autres. La description de la pratique courante fondée sur cette méthode peut définir les scénarios où l’évaluation randomisée du CAP, ou d’autres technologies, serait superflue et d’autres scénarios où il est fort probable qu’elle serait très avantageuse.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Swan HJC, Ganz W, Forrester JS, Marcus H, Diamond G, Chonette D. Catheterization of the heart in man with the use of a flow-directed balloon-tipped catheter. New Engl J Med 1970; 283: 447–51.
Cooper AB, Doig GS, Sibbald WJ. Pulmonary artery catheters in the critically ill. Crit Care Clin 1996; 12: 777–94.
Lowenstein E, Teplick R. To (PA) catheterize or not to (PA) catheterize — that is the question (Editorial). Anesthesiology. 1980; 53: 361–3.
Dalen JE, Bone RC Is it time to pull the pulmonary artery catheter? JAMA 1996; 276: 916–8.
Mimoz O, Rauss A, Rekik N, Brun-Buisson C, Lemaire F, Brochard L. Pulmonary artery catheterization in critically ill patients: a prospective analysis of outcome changes associated with catheter-prompted changes in therapy. Crit Care Med 1994; 22: 573–9.
Gore JM, Goldberg RJ, Spodick DH, Alpert JS, Dalen JE. A community-wide assessment of the use of pulmonary artery catheters in patients with acute myocardial infarction. Chest 1987; 92: 721–7.
Robin ED. Death by pulmonary artery flow-directed catheter. Time for a moratorium? Chest 1987; 92: 727–31.
Hines RL. Pulmonary artery catheters: what’s the controversy? J Card Surg 1990; 5: 237–9.
Robin ED. The cult of the Swan-Ganz catheter. Overuse and abuse of pulmonary flow catheters Ann Intern Med 1985; 103: 445–9.
Trottier SJ, Taylor RW. Physicians’ attitudes toward and knowledge of the pulmonary artery catheter: society of critical care medicine membership survey. New Horiz 1997; 201–6.
Iberti TJ, Fischer EP, Leibowitz AB, Panacek EA, Silverstein JH, Albertson TE, and The Pulmonary Artery Catheter Study Group. A multicentre study of physicians’ knowledge of the pulmonary artery catheter. JAMA 1990; 264: 2928–32.
Gnaegi A, Feihl F, Perret C. Intensive care physicians’ insufficient knowledge of right-heart catheterization at the bedside: time to act? Crit Care Med 1997; 25: 213–20.
Conners AF Jr, Speroff T, Dawson NV, et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA 1996; 276: 889–97.
Conners AF, Dawson NV, McCaffree DR, et al. Assessing hemodynamic status in critically ill patients: do physicians use clinical information optimally? J Crit Care. 1987; 2: 174–80.
Roizen MF, Berger DL, Gabel RA, et al. Practice guidelines for pulmonary artery catheterization. A report by the American Society of Anesthesiologists Task Force on pulmonary artery catheterization. Anesthesiology. 1993; 78: 380–94.
Naylor CD, Sibbald WJ, Sprung CL, Pinfold SP, Calvin JE, Cerra FB. Pulmonary artery catheterization. Can there be an integrated strategy for guideline development and research promotion? JAMA 1993; 269: 2407–11.
Roizen MF. Pulmonary artery catheterization: developing guidelines (Letter). JAMA 1993; 270: 1933.
American College of Physicians/American College of Cardiology/American Heart Association Task Force Members. Clinical competence in hemodynamic monitoring. A statement for physicians from the ACP/ACC/AHA Task Force on clinical privileges in cardiology. J Am Coll Cardiol 1990; 15: 1460–4.
Feldman R, Hillson SD, Wingert TD. Measuring the dimensions of physician work. Med Care. 1994; 32: 943–57.
Park RE, Fink A, Brook RH, et al. Physician Ratings of Appropriate Indications for Three Procedures. AJPH. 1989; 79: 445–7.
Node Negative Breast Cancer and Adjuvant Systemic Treatment Study Group. Institute for Clinical and Evaluative Sciences: Sunnybrook Health Science Centre, 1994.
Adams JG, Clifford EJ, Henry RS, et al. Selective monitoring in abdominal aortic surgery. Am Surg 1993; 59: 559–63.
Joyce WP, Provan JL, Ameli FM, McEwan MM, Jelenich S, Jones DV. The role of central haemodynamic monitoring in abdominal aortic surgery. A prospective randomised study. Eur J Vasc Surg 1990; 4: 633–6.
Bush HL, LoGerfo FW, Weisel RD, Mannick JA, Hechtman HB. Assessment of myocardial performance and optimal volume loading during elective abdominal aortic aneurysm resection. Arch Surg 1977; 112: 1301–6.
Silverstein PR, Caldera DL, Cullen DJ, Davidson JK, Darling RC, Emerson CW. Avoiding the hemodynamic consequences of aortic cross-clamping and unclamping. Anesthesiology 1979; 50: 462–6.
Whittemore AD, Clowes AW, Hechtman HB, Mannick JA. Aortic aneurysm repair. Reduced operative mortality associated with maintenance of optimal cardiac performance. Ann Surg 1980; 192: 414–21.
Rice CL, Hobelman CF, John DA, et al Central venous pressure or pulmonary capillary wedge pressure as the determinant of fluid replacement in aortic surgery. Surgery 1978; 84: 437–40.
Isaacson IJ, Lowdon JD, Berry AJ, et al. The value of pulmonary artery and central venous monitoring in patients undergoing abdominal aortic reconstruction surgery: a comparative study of two selected, randomized groups. J Vasc Surg 1990; 12: 754–60.
Bennett D, Bolbt J, Brochard L, et al. Expert panel: the use of the pulmonary artery catheter. Int Care Med. 1991; 17: I-VIII.
Ivanov RI, J Allen, JD Sandham JE Calvin. Pulmonary artery catheterization: a narrative and systematic critique of randomized controlled trials and recommendations for the future. New Horiz 1997; 5: 268–76.
Anonymous. Selected Health Technologies in Canada, ICES Working Papers, 1994.
Spodick DH. Physiologic and prognostic implications of invasive monitoring: undetermined risk/benefit ratios in patients with heart disease. Am J Cardiol 1980; 46:173–5.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Jacka, M.J., Cohen, M.M., To, T. et al. The appropriateness of the pulmonary artery catheter in cardiovascular surgery. Can J Anesth 49, 276–282 (2002). https://doi.org/10.1007/BF03020527
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03020527