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Excerpt
Key Words: acute lung injury; acute respiratory distress syndrome; acute respiratory failure; afterload; aortic aneurysm; aortic surgery; balloon flotation catheter; cardiac index; cardiac output; cardiac surgery; cardiogenic shock; cardiopulmonary physiology; catheter; catheterization; circulatory shock, complications; congenital heart surgery; congestive heart failure; Consensus Conference; continuous cardiac output; continuous venous oximetry; coronary artery surgery; clinical equipoise; heart catheterization; hemodynamic monitoring; hemodynamic monitoring in childhood; monitoring device; moratorium; multiple organ dysfunction syndrome; myocardial dysfunction; myocardial infarction; oxygen consumption; oxygen delivery; oxygen transport; perioperative risk; peripheral vascular surgery; physiologic monitoring device; preload; pulmonary artery catheter; pulmonary artery flow-directed catheter; pulmonary artery occlusion pressure; pulmonary capillary wedge pressure; pulmonary arterial hypertension; pulmonary hypertension; respiratory failure; resuscitation; right-heart catheter; right ventricular ejection fraction; sepsis; septic shock; shock; supranormal oxygen delivery; Swan-Ganz catheter; systemic inflammatory response syndrome; technology assessment; thermodilution cardiac output; trauma; wedge pressure
Pulmonary artery catheterization was introduced into clinical practice in 1970. Initially, its use was limited primarily to patients with acute cardiac disease [1]. Since that time, its use in a variety of cardiac and noncardiac critical illnesses has become widespread. Over two million catheters are sold annually worldwide [2]. A majority of clinicians who practice in critical care environments believe that information provided by the pulmonary artery catheter (PAC) is helpful in guiding therapy and improving outcome in selected critically ill patients [3-6]. Without the PAC, the ability to accurately assess cardiac output and left ventricular filling pressure in the critically ill patients is poor, despite knowledge of the medical history and careful physical examination [7,8]. Thus, the PAC provides hemodynamic information that cannot be supplied by clinical diagnosis alone, while allowing diagnostic classification of patients with cardiovascular dysfunction and other diseases. As with other diagnostic modalities, the clinical utility of the PAC depends on proper interpretation of the data. Unambiguous proof that information derived from the PAC improves patient outcome measures is scarce, however. Several factors account for this inconsistency. Rigorous scientific assessment of the benefit of the PAC is clearly hampered by the lack of prospective, randomized, controlled clinical trials in well-defined study populations. On the other hand, complications directly associated with the PAC have been well described [9-12]. Incorrectly collected hemodynamic data after pulmonary artery catheterization may furthermore lead to clinical complications owing to improper therapeutic strategies. Another factor complicating analysis of available data is the documented significant interobserver variability in interpretation of pulmonary artery pressure tracings [13]. Although this issue has not been consistently addressed in most published data concerning the PAC, disturbing evidence exists suggesting that knowledge of these and other basic principles of pulmonary artery catheterization by physicians and nurses engaged in routine use of these devices is suboptimal [3,14-17]. Such consistent findings raise many important training and credentialing issues.
As with any technology, data obtained from the PAC are only as good as the clinicians' application of the information. A possibility exists that the accuracy of data obtained from the PAC is often variable, potentially inaccurate, and the information obtained may not be applied appropriately. Due to the probability that information from the PAC is being suboptimally employed, no study can validly question the effectiveness of the PAC without first controlling for these variables. Without controlling for clinicians' knowledge and application of information, one cannot differentiate questions about the value of the technology (PAC) or the clinicians' skills in using the technology.
Over the past decade, there has been vigorous debate concerning the indications for, and clinical utility of, the PAC [18-26]. Recently, Connors et al.
