ArticlesAssessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial
Introduction
No monitoring device has polarised opinion as much as the pulmonary artery catheter (PAC).1, 2, 3, 4, 5 Introduced 30 years ago, it is widely used in critically ill patients, yet there has been no formal assessment of either its clinical effectiveness or cost-effectiveness. Proponents4, 5 argue that its unique ability to allow accurate measurement of cardiac output and other haemodynamic variables enables improved diagnosis and management of circulatory instability. Critics, however, point to complications associated with its insertion and use,1, 2, 6, 7 inaccuracies in measurement, and difficulties with interpretation of data.8, 9, 10 Furthermore, a lack of positive outcome benefits in the critically ill and some suggestions of increased mortality from retrospective analyses11, 12 indicate potential problems with this device.
In 1996, a large, non-randomised, risk-adjusted study13 indicated an increased 30-day mortality associated with PAC use within the first 24 h after admission to intensive care. This fresh uncertainty encouraged governments in both Europe and North America to provide funding to enable large, randomised controlled trials of PAC use in intensive care. We designed the PAC-Man study as a pragmatic, randomised controlled trial to address the hypothesis that hospital mortality is reduced in critically ill patients managed with a PAC.
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Patients
Between Oct 15, 2001, and March 29, 2004, we enrolled patients admitted to adult intensive care and identified by the treating clinician as someone who should be managed with a PAC. We invited all adult intensive care units (ICUs) in the UK to participate. Our only exclusion criteria were: age younger than 16 years; elective admission for preoperative optimisation; presence of a PAC on admission to intensive care; previous enrolment to the study; or haemodynamic optimisation before organ
Results
65 ICUs (from 13 university, eight university-affiliated, and 44 non-university hospitals) participated. 42 ICUs decided to join stratum B (option to use alternative cardiac output monitoring technologies in control group). A further five ICUs swapped to stratum B during recruitment; we considered patients randomly assigned after this point as stratum B patients.
Figure 1 shows the trial profile. We randomly assigned 1041 patients. Of the 522 patients allocated to the control group, 24 (5%) were
Discussion
Our results indicate no difference in hospital mortality between critically ill patients managed with or without a PAC. Similarly, length of stay in either intensive care or hospital, or organ-days of support did not differ between groups.
The pragmatic design of our study reflected the lack of consensus on a specific management protocol. Though some argue strongly for a structured approach, the lack of supportive data meant that no common strategy could be agreed with respect to timing or
References (30)
Death by pulmonary artery flow-directed catheter: time for a moratorium?
Chest
(1987)Complications of invasive monitoring
Anesthesiol Clin North Am
(2002)- et al.
Complications of hemodynamic monitoring
Clin Chest Med
(1999) - et al.
A community-wide assessment of the use of pulmonary artery catheters in patients with acute myocardial infarction
Chest
(1987) - et al.
Use of pulmonary artery catheters in patients with acute myocardial infarction
Chest
(1990) - et al.
Multiorgan failure is an adaptive, endocrine-mediated, metabolic response to overwhelming systemic inflammation
Lancet
(2004) Defenders of the pulmonary artery catheter
Chest
(1988)- et al.
Is it time to pull the pulmonary artery catheter?
JAMA
(1996) - et al.
Is the pulmonary artery catheter misused? A European view
Crit Care Med
(1998) Pulmonary Artery Catheter Consensus Conference: consensus statement
Crit Care Med
(1997)
A multi-center study of physicians' knowledge of the pulmonary artery catheter
JAMA
Assessment of critical care nurses' knowledge of the pulmonary artery catheter
Crit Care Med
Intensive care physicians' insufficient knowledge of right-heart catherization at the bedside: time to act?
Crit Care Med
The effectiveness of right heart catheterization in the initial care of critically ill patients
JAMA
APACHE II: a severity of disease classification system
Crit Care Med
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Study group listed at end of article