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The Value of Invasive Monitoring in Shock patients: Truth or Myth? Dr Jack Tan Consultant Interventional Cardiologist National Heart Centre Singapore MBBS, MRCP(UK), FAMS(Cardiology), RPVI Speaker's name: Dr Jack Tan ❒ I do not have any potential conflict of interest Focus on pulmonary artery catheterization (PAC) The Evidence? What are the truths or myths surrounding it’s usage currently? Is it finally time for a Swan song? Flow‐directed balloon‐tipped pulmonary artery catheter (PAC) Also known as the Swan‐Ganz or right heart catheter Inventors are Jeremy Swan and William Ganz, from Cedars Sinai MC The idea for a sail or balloon tip modification of the portex tubing came about from Swan's observation at the Santa Monica shore of sail boats. One with a spinnaker was able to make reasonable headway even in calm waters Ganz added the thermistor after Swan showed him the initial balloon design, fabricated by Edwards Laboratories In use since 1970, initially for MI patients Preload‐Left ventricular preload is reflected by the PCWP, Right ventricular preload is reflected by the CVP [RA] Cardiac Output/Index‐: heart rate and stroke volume over one minute. CI is the cardiac output adjusted for body surface area (BSI) Afterload‐How hard the heart has to push to get the blood out, or the “ resistance to flow” Derived values of SVR, PVR SBP < 80mmHg CI < 1.8 L/min/m₂ PCWP > 18mmHg In patient mortality rate 50‐90% Management of complicated myocardial infarction Ventricular septal rupture (VSR) or acute mitral regurgitation Severe left ventricular failure Right ventricular infarction Assessment of respiratory distress Cardiogenic vs non-cardiogenic pulmonary edema Primary vs secondary severe pulmonary hypertension Assessment of therapy Afterload reduction, vasopressors, IABP Assessment of fluid requirement in critically ill patients Hemorrhage, sepsis, ARF ,burns Management of postoperative open heart surgical patients Assessment of valvular heart disease, cardiac tamponade/constriction Note: No study has definitively demonstrated improved outcome in critically ill patients managed with PA catheters. Therefore, the primary justification has been on the basis of clinic experience. JAMA. 2005 Oct 5;294(13):1664‐70. Shah MR, Hasselblad V, Stevenson LW, Binanay C, O'Connor CM, Sopko G, Califf RM. Department of Cardiology, Columbia University Medical Center, New York, NY, USA. CONCLUSIONS: In critically ill patients, use of the PAC neither increased overall mortality or days in hospital nor conferred benefit. Despite almost 20 years of RCTs, a clear strategy leading to improved survival with the PAC has not been devised. The neutrality of the PAC for clinical outcomes may result from the absence of effective evidence‐based treatments to use in combination with PAC information across the spectrum of critically ill patients. Crit Care Med. 1997 Feb;25(2):213‐20. Gnaegi A, Feihl F, Perret C. Institute of Clinical Physiopathology, Lausanne University Hospital, Switzerland. OBJECTIVE: To evaluate French, Swiss, and Belgian intensive care physicians' knowledge about the pulmonary artery catheter. MEASUREMENTS AND MAIN RESULTS:It was impossible to identify any subcategory of physicians with a uniformly good knowledge of the pulmonary artery catheter. The proportion of incorrect answers to some basic items was disturbingly high. For instance, approximately 50% of the respondents, whether trained or in training, did not correctly identify pulmonary artery occlusion pressure from a clear chart recording. CONCLUSIONS: Knowledge of right‐heart pulmonary artery catheterization is not uniformly good among ICU physicians. Accreditation policies and teaching practices concerning this technique need urgent revision. Cochrane Database Syst Rev. 2006 Jul 19;3:CD003408. Harvey S, Young D, Brampton W, Cooper AB, Doig G, Sibbald W, Rowan K. MAIN RESULTS: We identified 12 studies. Of the eight studies of high‐ risk surgery patients, five evaluated the effectiveness of pre‐operative optimization but there was no difference in mortality when these studies were examined separately. Pulmonary artery catheterization did not affect intensive care unit (reported by 10 studies) or hospital (reported by nine studies) length of stay. Four studies, conducted in the United States, measured costs based on hospital charges billed to patients, which on average were higher in the PAC groups. CONCLUSIONS: Efficacy studies are needed to determine optimal management protocols and patient groups who could benefit from management with a PAC. OBJECTIVES: To evaluate the clinical and cost‐effectiveness of managing critically ill patients in adult, general intensive care with or without pulmonary artery catheters (PACs). RESULTS: There was no difference in hospital mortality for patients managed with (68.4%) or without (65.7%) a PAC. There was no difference in the median length of stay in ICU, the median length of stay in an acute hospital or mean organ‐days of support in ICU between the two groups. The economic evaluation found that the expected cost per QALY gained from the withdrawal of PAC was 2985 pounds. The expected cost per life gained from the withdrawal of PAC was 22,038 pounds. CONCLUSIONS: Clinical management of critically ill patients with a PAC, as currently practised in the UK, neither improves hospital survival for adult, general intensive care patients nor reduces length of stay in hospital. The lack of demonstrable benefit from a device previously believed to be beneficial could be explained by statistical chance, by misinterpretation of PAC‐derived data, by ineffective treatment strategies based on data correctly interpreted using the current paradigm or by subsequent inaction following insertion of the device. It is also possible that detailed data on haemodynamics, however used, cannot modify the disease process sufficiently to influence disease outcome. The economic evaluation, using decision analysis techniques rather than conventional hypothesis testing, suggests that the withdrawal of the PAC from routine clinical practice in the NHS would be considered cost‐effective in the current decision‐making climate, and might result in lives or life‐years being saved at modest cost. With the declining use of PACs in the UK and the findings of this report indicating no overall benefit from management with a PAC, it should now be possible to examine protocolised management with a PAC in selected groups of critically ill patients against appropriate controls, something that was difficult while PACs were the considered standard of care. The use of pulmonary artery catheters probably needs re‐evaluation but they should not be banned Connors et al retrospectively reviewed 5735 critically ill patients. The results strongly suggest that in all groups mortality, the length of intensive care, and hospital costs were higher when a pulmonary catheter was used. Over the past 20 years the pulmonary artery catheter has become to the intensivist what the stethoscope is to the resident. It is a badge of office which is often used diagnostically and therapeutically as both first and last resort It is easier to argue for placing a catheter for potential, albeit nebulous, benefits than to argue that it is not necessary. The PAC is both used and abused, the expectations from its use often exceed the reality, and it is time that its use was re‐evaluated and rationalised. The use of pulmonary artery catheters, as with most aspects of management of the critically ill, is not “evidence based.” We also need to contemplate the possibility that it is not the catheter but the treatment resulting from its use that is at fault. Only a bad workman blames his tools. There have now been at least six randomized controlled trials of PAC use in general or specialist intensive care, none of which has shown the PAC to be of harm or benefit. Nonetheless, PAC use continues, with no standardized agreement about what represents appropriate use. As with the thermometer, which assigns a number to a clinical condition relatively easily assessed by clinical examination, the benefit may be to the physician (in terms of ease of management) rather than the patient (in terms of outcome). While an effect on mortality has not been seen in these PAC trials, complications have been reported. Consistently showed lack of effect on mortality associated with pulmonary artery catheterization use in ICU Led to an overall decrease in use of 65%, from 5.66 to 1.99 pulmonary artery catheterizations per 1000 medical admissions from 1993 to 2004 Nurses and physicians were insufficiently knowledgeable to adequately interpret the PA catheter measurements. The benefits might be reduced by the complications from the use of the PAC. Furthermore, using information from the PAC might result in a more aggressive therapy causing the detrimental effect. Or, it could give rise to more harmful therapies (i.e. achieving supra‐normal values could be associated with increased mortality). i.e Become a number treater Increased risk of infections Thrombosis and embolization Catheter hyper‐wedges‐ causing pulmonary infarct Ventricular irritation The use of PAC in ICUs is still prevalent despite lack of any efficacy studies Randomized studies have not detected any mortality hazard with the use of the PAC but have also failed to establish any clinical benefit Clinicians may have lost the expertise to correctly interpret information obtained from a PAC and thus its use may be associated with inappropriate therapeutic decision making. Novel non‐invasive monitoring provides increasingly sophisticated information that makes some of the information obtained by PAC redundant in select cases The use of PAC is increasingly limited to patients too ill to be impacted upon by hemodynamic manipulations, paradoxically causing harm Studies have not borne out the use of this instrument to improve mortality, but the idea of studying a DIAGNOSTIC TOOL to change mortality is inherently flawed Probably beneficial in the correct situation, though less use begets less experience with its use Inferior RV infarction with shock and poor LV function End stage heart failure with cardio‐renal syndrome receiving inotropes Oliguric renal failure patients with poor LV function going to surgery, where massive fluid shifts are to be expected May also be helpful in early ARDS with oliguric renal failure, though studies have not borne this out. Mixed shock states with poor LV function. Combination of hypovolemia, sepsis Training my juniors… Most patients do not need a PAC for management. Justified if supervised and done without harm to patients I use it when I think it will change clinical course, not as a wistful last resort. Most often early when patients are not yet that ill, NOT after I have missed the bus Case‐by‐case basis, not as routine I would shift away from using information from PA catheter alone but combine it with echocardiography Drop the procedure altogether in centers where pulmonary artery catheterization is only rarely used But remain skeptical of alternate hemodynamic monitoring devices until tested in clinical trials PAC is completely useless and even harmful PAC is life saving Useful only in experienced hands? i.e not idiot proof PAC helps improve hemodynamics and therefore outcomes Having a PAC for high risk operations improve outcomes There are no absolutes in life, especially in the ICU Thank you Thermodilution Pulse waveform methods Esophageal Doppler Bioimpedance Echocardiography Clinical Examination
