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• W2912661033 abstract "To the Editor: We read with interest the article by Gore et al on the use of pulmonary artery (PA) catheters and the subsequent call for a moratorium on their use by Dr. Robin. Though we agree that there is need for a prospective, randomized, controlled trial to ascertain the indications for and benefits of PA catheters, a moratorium based on the retrospective study seems to be an extreme measure. The study has major problems common to any retrospective analysis: 1) lack of comparison of truly matched groups; and 2) total lack of the essential data with which the efficacy of therapy, survival and prognosis was evaluated. Data indicate that the severity of acute myocardial infarction was different in both groups. Very likely, the severity of complications was also significantly different. In our institution, a patient who develops a complication of acute myocardial infarction (ie, pulmonary edema, hypotension, congestive heart failure, etc) is treated with diuretics, vasodilators, inotropic drugs, etc. Most improve on a rational therapeutic regimen based on clinical examination. However, a small but significant group of patients still continue to deteriorate. Invasive monitoring is helpful in hemodynamic assessment and optimizing therapy. Needless to say, this small group has high mortality rates due to poor left ventricular function. Physicians working in critical care know that very ill patients with shock and/or multiple organ failure have high morbidity and mortality. Invasive monitoring is done in these patients. A good number of these critically ill patients will die despite aggressive therapy. Should we incriminate the PA catheters for the demise of these patients, or the disease process that brought them to the ICU in the first place? The authors have analyzed selective parameters. They have failed to comment on hemodynamic measurements. How poor was the LV function? What was the preload, afterload, and cardiac output? What was the oxygen delivery and consumption? This information should have been available in the patients chart taken from the teaching institutions. Was this data not analyzed, and if analyzed, why was it not shared with the medical community? The study also raises other questions. How long were these patients in CHF, shock, etc, before the use of a PA catheter? Was it done early or late in the course of their disease? Indeed, it is also important to know if any therapeutic interventions were changed from the hemodynamic data available from the catheters. The complication rate due to PA catheters is not available. How many of the deaths were directly linked to the catheters? This information would have clarified if the mortality was indeed associated with the catheters or was due to the primary heart disease. It is a well-documented fact that the mortality of complicated acute myocardial infarction remains high despite aggressive treatment. It is universal knowledge that complications from procedures is inversely proportional to the experience of the operator (physician). We agree that invasive procedures with a high potential for complications should not be left to junior residents or inexperienced physicians. Did Dr. Gore and his colleagues consider this fact? It would be interesting to know how many of the patients with the PA catheter underwent intra-aortic balloon pump insertion, coronary angiography, or cardiac surgery. This would demonstrate not only the severity of the disease but may be an additional cause for complications and increased mortality. Both groups of patients in the study should have been comparable before the data could be analyzed scientifically. Mortality, average length of hospital stay and long-term survival will depend on the extent of myocardial infarction, ventricular dysfunction and response to and modalities of therapy. How can one implicate the PA catheter for the increased morbidity or mortality from a retrospective study lacking essential data? We concur with Dr. Matthay1Matthay MA. Guidelines for pulmonary artery catheterization in the intensive care unit.Pulmonary Perspectives. 1987; 4: 1-4Google Scholar about guidelines for the use of PA catheters. Therapeutic intervention should be implemented from hemodynamic data. If no major therapeutic changes are required or when patients are improving, PA catheters should be removed as early as possible.6Uhl RR. Current problems in anesthesia and critical care medicine. 1977; 1: 4-9Google Scholar We agree with Dr. Robin that sometimes physicians fail to utilize hemodynamic data properly. This occurs with inexperienced physicians. Optimization of hemodynamic parameters is very important in critically ill patients,1Matthay MA. Guidelines for pulmonary artery catheterization in the intensive care unit.Pulmonary Perspectives. 1987; 4: 1-4Google Scholar, 2Mohsenifar A Goldback P Tashldn DP Campisi DJ. Relationship between oxygen delivery and oxygen consumption in the adult respiratory distress syndrome.Chest. 1983; 84: 267-271Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar, 3Wolf YG Cotev S Perel A Manny J. Dependence of oxygen consumption on cardiac output in sepsis.Crit Care Med. 1987; 15: 198-203Crossref PubMed Scopus (77) Google Scholar especially those who are in shock. Proper administration of fluids, vasoactive drugs, IABP, ventricular assist devices, etc, cannot be done in these patients without hemodynamic monitoring. Clinical examination can be misleading in critically ill patients. Fein et al4Fein AM. Is pulmonary artery catheterization necessary for the diagnosis of pulmonary edema?.Am Rev Respir Dis. 1984; 129: 1006-1009PubMed Google Scholar demonstrated that the diagnosis of pulmonary edema from clinical criteria alone often is inaccurate, and PA catheter placement was needed to make the correct diagnosis and provide appropriate treatment. Startling information was obtained by Eisenbert et al,5Eisenberg PR Jaffe AS Schuster DP Clinical evaluation compared to pulmonary artery catheterization in hemodynamic assessment of critically ill patients.Crit Care Med. 1984; 12: 533-549Crossref Scopus (304) Google Scholar demonstrating that hemodynamic variables were accurately predicted by physicians 50 percent of the time by clinical examination. PAWP was correctly predicted in only 30 percent of patients; both over- and underestimation of PAWP were done, and overestimation of cardiac output predominated. Treatment was altered by hemodynamic data in more than half of the patients and an entirely new therapeutic modality was instituted in nearly one-third of them. Noninvasive techniques (ie, portable echocardiography, Doppler study, radio-nucleotide techniques) are cumbersome, expensive, and not easily available. Information may be operator-dependent, hence not very reliable and not available in some institutions. I would like to draw the attention of the medical community to a historic paper presented by Harvey Cushing in 1903. His paper was entitled, “The Routine Determination of Arterial Tension (BP) In the Operating Room and Clinic”. Subsequently, a committee was appointed to determine whether such information was necessary. The report was published in March, 1904 in the second bulletin of the division of surgery at Massachusetts General Hospital.6Uhl RR. Current problems in anesthesia and critical care medicine. 1977; 1: 4-9Google Scholar It concluded that: “The adoption of blood pressure operations (noninvasive BP monitoring) in surgical patients does not appear necessary as a routine measure.” However, common sense prevailed and monitoring of blood pressure during surgery and in the clinic has remained a cornerstone in the management of patients. This report shows that good intentions do not necessarily translate into good judgment. Naturally, the question arises: Why has the randomized study not been done? The answer is obvious. Ethically, my colleagues and I do not want to deny the benefits of a PA catheter to a patient in a shock state. Until a safe, reliable, good technique is available and acceptable to the medical community, what should we do? Should we go back to the unreliable, inconsistent clinical examination techniques and change therapy randomly? Many physicians may be reluctant to do so or wait for a prospective randomized trial. Since Dr. Robin has suggested putting a moratorium on PA catheters, we urge him to initiate and lead a multi-center randomized controlled trial (if he already has not started one) and substantiate that his call for a moratorium was appropriate. Defenders of the Pulmonary Artery CatheterCHESTVol. 93Issue 5PreviewAs originally conceived, one objective of this column is to provide a platform for contrary opinions. Another (unstated) objective is to provide a written historic record of current medical thinking about certain issues in chest medicine. A recent editorial of mine on the dangers of the pulmonary artery catheter has evoked a number of contrary responses defending the use of the catheter My column this month reproduces these criticisms. As the medical literature has scarcely been starved for favorable comments concerning the use of the instrument, I have taken the liberty of discussing each critical letter My comments appear in italics. Full-Text PDF" @default.
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