| Abstract|| |
There has been considerable controversy regarding the use of pulmonary artery catheter (PAC) in clinical practice. Some studies have indicated poor outcome in patients who were monitored with PAC. However, these studies, which have condemned the use of PAC, were conducted on patients in intensive care units, where the clinical scenarios with regard to patients' status are somewhat different as compared to those of a cardiac operating room. This study was designed to identify the indications of PAC use in cardiac operating rooms. A questionnaire was mailed to anasthesiologists in cardiac centers and the response was analyzed.The practicing cardiac anesthesiologists recommended the use of PAC for following indications in cardiac surgery: coronary artery bypass grafting (CABG) with poor left ventricular (LV) function, LV aneurysmectomy, recent myocardial infarction (MI), pulmonary hypertension, diastolic dysfunction, acute ventricular septal rupture and insertion of left ventricular assist device (LVAD).The analysis of responses from practicing anesthesiologists clearly indicates that use of a PAC cannot be recommended as a matter of routine, but a definite role is suggested in selected groups of patients undergoing cardiac surgery.
Keywords: Acute ventricular septal rupture, diastolic dysfunction, myocardial infarction, pulmonary artery catheter, pulmonary hypertension
|How to cite this article:|
Kanchi M. Do we need a pulmonary artery catheter in cardiac anesthesia? - An Indian perspective. Ann Card Anaesth 2011;14:25-9
|How to cite this URL:|
Kanchi M. Do we need a pulmonary artery catheter in cardiac anesthesia? - An Indian perspective. Ann Card Anaesth [serial online] 2011 [cited 2019 Jul 16];14:25-9. Available from: http://www.annals.in/text.asp?2011/14/1/25/74396
| Introduction|| |
The introduction of the flow-directed pulmonary artery catheter (PAC) into clinical practice is one of the most important and popular advances in the field of cardiac anesthesia and intensive care. The PAC measures the systolic, diastolic and mean pulmonary artery pressures and the pulmonary capillary occlusion pressure and provides a means to derive many hemodynamic and oxygenation variables. There are several important reasons why a PAC should be used in cardiac anesthesia. Firstly, a cardiac surgical patient has an underlying cardiac pathology; such pathology can affect intra-cardiac pressures and myocardial ability to sustain adequate cardiac output. In fact, placement of a PAC is an intraoperative right heart catheterization procedure.  The PAC provides clinical data on heart chamber pressure, blood flow and vascular resistance - similar to the information obtained in a cardiac catheterization laboratory. Secondly, there is a lack of correlation between central venous pressure and left-sided filling pressures in patients with moderate-to-severe cardio-pulmonary diseases. It is rather common to observe a significant change in pulmonary capillary wedge pressure (PCWP) with no reflection in central venous pressure (CVP).  Thirdly, a PAC gives access to derive multiple hemodynamic and oxygen delivery parameters, which are of critical importance in a high-risk cardiac surgical patient.  And finally, the control of perioperative hemodynamic profile with the use of cardiovascular drugs, which influence the myocardial contractility and induce pulmonary and systemic vasodilatation/ constriction, mandates the use of a PAC for comprehensive management.
Despite the above definite reasons to use a PAC in a cardiac surgical setting, there has been a controversy regarding its use; the use of PAC in a cardiac surgical setting varies considerably - from a routine application to no application at all. To be able to provide comprehensive guidelines and clearly identify the possible indications, we conducted a survey among the practicing cardiac anesthesiologists in major cardiac centers in India.
| Materials and Methods|| |
After obtaining the approval of the Institutional review Board (IRB), a census of cardiac anesthesiologists with at least 5 years of experience in a moderate-to-large-sized cardiac surgical setup was undertaken. One hundred cardiac anesthesiologists were short listed for the survey. The anesthesiologists included those in private corporate setup and in academic institutions. Care was taken to ensure that the participating respondents were drawn from institution/ hospital with a minimum of 500 cardiac operations annually. The participating anesthesiologists were requested to answer a questionnaire, a template of which is shown in [Table 1].
The first questionnaire was mailed to the respondents in December 2008. Those who did not respond by February 2009 were contacted on telephone to encourage response, and second/ final telephonic call was made in March 2009 to obtain a response from the practitioners who did not respond. The responses to each question were entered into a database and analyzed using simple descriptive statistics. In addition, the numbers of complications with the use of PAC (Q. No. 6.1) were added up to provide complication rate in terms of the number of complications per 1000 pulmonary artery PA catheterizations.
| Results|| |
One hundred cardiac anesthesiologists from 35 centers across India participated in the survey. The response rate was 100%. The only criterion considered to qualify to be a respondent was at least 5 years of experience in cardiac anesthesia, and hence there were more than one respondent in some of the shortlisted hospitals. Their responses, however, were practitioner-based and included individual preferences within a particular institution. In terms of percentage, 35% and 8% of the anesthesiologists used pulmonary artery catheter and transesophageal echocardiography (TEE), respectively, routinely in all their CABG surgeries irrespective of preoperative status. The routine use of TEE for adult cardiac surgery was very low (8%); and the routine use of PAC varied widely, from none to all adult patients. Sixty-three percent of the respondents felt that the use of PAC in cardiac surgery does not increase the risk, and 67% felt that surgeon's request influenced in floating a PAC. Eighty-three percent of the anesthesiologists preferred using a PAC that has continuous cardiac-output-monitoring facility and felt that derived parameters like systemic vascular resistance are useful in clinical management of cardiac surgical patients. Regarding the utility of additional features in a PAC, 75% of the respondents felt that continuous monitoring of mixed venous oxygen saturation (SvO 2 ) is a useful adjunct, while 50% opined that measurement of right ventricular ejection fraction (RVEF) is a useful option in the perioperative setting. Presence of a TEE was reported to be available in 85% of the cardiac operative rooms, though only 8% of these used it routinely in all their CABG patients. All respondents felt that PAC and TEE are complementary and not competitive; they would like to use both if the clinical situation so demanded. The recommended use and complications of PAC as opined by the respondents are mentioned in [Table 2]. This table lists complications encountered in 1000 pulmonary artery catheterizations, based on the responses received from the respondents.
| Discussion|| |
Despite the fact that PAC enjoys reasonable popularity, there has been opinion that its use is associated with increased mortality. ,, Two systematic reviews that analyzed small randomized clinical trials showed no overall benefit of use of PAC. ,,,, A prospective cohort study by Connors et al. that involved a mixed population of medical and surgical patients in intensive care units showed increased mortality, length of stay and costs associated with the use of PAC. Sandham et al. performed a randomized trial comparing goal-directed therapy guided by PAC with standard care without the use of a PAC. Subjects were high-risk patients 60 years of age or older who were scheduled for urgent/ elective major surgery, followed by a stay in ICU. They did not find any benefit of therapy directed by PAC over standard care in these elderly, high-risk surgical patients requiring intensive care.  The evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness (ESCAPE) was done by a randomized trial where patients were assigned to receive therapy guided by PAC or clinical assessment. Use of PAC increased anticipation of adverse events but did not affect overall morbidity and hospitalization.  PAC-guided therapy did not improve survival or organ function but was associated with more complications than was central venous catheter-guided therapy in 1000 patients with established acute lung injury in a randomized trial comparing therapy using hemodynamic management-guided PAC with that using a central venous catheter.  In critically ill patients, there was no clear evidence of benefit or harm with the use of PAC in a randomized controlled trial in a UK study.  In a multi-center randomized study of 676 patients with shock, acute respiratory distress syndrome (ARDS) or both; use of a PAC did not significantly affect mortality and morbidity. 
Polonen et al. in a prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients have demonstrated that increasing oxygen delivery to achieve normal SvO 2 values and lactate concentration during immediate postoperative period after cardiac surgery shortens the length of hospital stay. 
Significant problems with PAC study outcomes are (i) flaw in study design in the form of lack of therapeutic protocols, treatment algorithms and inadequate randomization  ; (ii) insufficient statistical power  ; (iii) lack of competency in interpreting PAC-derived data; (iv) some studies left the management decisions at the discretion of treating clinicians; (v) eligibility criteria had tendency to focus on patients that were critically ill but not on patients in whom invasive hemodynamic monitoring was thought of particular value; (vi) most studies included patients who were 65 years and older; (vii) studies were conducted on heterogeneous population; (viii) 9 studies have reported about "cross-over," e.g., assignment to the control/ CVP group but received PAC, nevertheless, because of "deteriorating status" - with significant monitoring in these patients; (ix) subgroups analysis difficult as the number of available studies in all meta-analyses was too small to perform. In addition, Harput et al. observed that patients in the ICU might have disease too far advanced to make invasive hemodynamic monitoring useful. Heyland et al pointed out that "maximizing oxygen delivery" in the perioperative setting (i.e., before the onset of physiological derangement) is more effective in comparison with the chronic ICU setting.
In view of the reports quoted, does the PAC have a role in cardiac surgical patients? We believe that PAC is, as of today, a useful technique for monitoring physiological function, especially if used before the onset of derangement prior to the surgical procedure. PAC is a monitoring tool, and a tool is only as good as the user, who may derive benefit from the data. Though routine use of PAC in all adult cardiac surgical patients may be unwarranted, based on the findings of the survey, we recommend the use of PAC in the situations mentioned in [Table 2] in a cardiac surgical setting. When results of studies are analyzed, it is clear that there are at least two major differences in the outcome studies - the ICU use versus use of cardiac surgical operating room. In the cardiac operating room, the PAC is inserted prior to the onset of surgical insult / derangement due to cardiopulmonary bypass (CPB). There is a baseline reference value, and the variables are monitored in a more stringent manner. The second aspect is the presence of a physician throughout the procedure. Hence it is not really reasonable to extrapolate the results of PAC use in intensive care units vis-ΰ-vis those found in the cardiac operating rooms. Other considerations supporting the use of PAC in cardiac anesthesia include the following: a) the risks are mainly due to insertion of a central catheter, not a pulmonary artery catheter; b) continuous monitoring of left ventricular filling pressures, pulmonary vascular pressures and mixed venous oxygen saturation is a unique feature; c) additional costs are minimal relative to the cost of surgical/ intensive care; d) measurement errors require ongoing program-related educational efforts; e) pulmonary artery catheter-derived data need to be used within the context of a defined treatment protocol; and f) no monitoring device, no matter how simple or sophisticated, will improve patient-centered outcomes unless coupled with a treatment that itself improves outcome. Pinky and Vincent stated - "let us use the PAC correctly and only when we need it."  This statement appears apt in the current scenario. However, the definition of what represents correct use and correct need will depend on institutional policy, economic considerations, patient population, and the expertise of medical and nursing staff. Potential benefits of PAC can be realized only when we avoid possible misuse or misinterpretation.
Editors comments: Based on the results of the survey and the available evidence, the Indian Association of cardiovascular and thoracic anaesthesiologists is very soon bringing out the guidelines for the practitioners about the use of PAC in cardiac surgery.
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Narayana Hrudayalaya Institute of Medical Sciences, #258/A, Bommasandra Industrial Area, Anekal Taluk, Bangalore - 560 099
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]