PAC Literature Summaries

OVERVIEW

  • RCTs have not shown any benefit from PAC use
  • early data showed increase harm
  • PACMAN trial subsequently showed no change in inhospital mortality, suggesting it can be used safely
  • probably better to use PACs in ‘really sick’ patients
  • PAC insertion and use is an invasive procedure with highly morbid complications (e.g. bleeding on insertion, PA rupture, arrhythmia, PE)
  • PAC use does have the potential change management in sick patients in the early resuscitation phase

KEY PAPERS

Connors AF Jr, et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators. JAMA. 1996 Sep 18;276(11):889-97. PubMed PMID: 8782638.

  • prospective multicentre cohort study
  • n = 5735
  • PA catheterisation and specific outcomes measured
    -> increase mortality and resource utilisation found in the catheter group
    -> moratorium of PA catheter usage took place -> use continued however

Harvey S, et al; PAC-Man study collaboration. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial. Lancet. 2005 Aug 6-12;366(9484):472-7. PubMed PMID: 16084255.

  • MCRCT
  • 64 UK centres
  • n = 1041
  • 519 PAC vs 522 without PAC
  • inclusion criteria: those where the clinician deemed beneficial to insert a PAC
    -> PAC altered treatments within 2 hours in 80% of patients (vasoactives or fluid)
    -> no difference in hospital mortality between patients with or without device (no harm but no good)
    -> complications were with cannulation (none of which were fatal)

National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wheeler AP, et al. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med. 2006 May 25;354(21):2213-24. Epub 2006 May 21. PubMed PMID: 16714768. [Free Fulltext]

  • n = 1000
  • aka FACTT (Fluid and catheter treatment trial)
  • evaluated the benefits/risks of catheter insertion for guidance of fluid therapy
    -> no improvement on survival or organ dysfunction
    -> increase in catheter related complications in PA group

Sandham JD, Hull RD, Brant RF, Knox L, Pineo GF, Doig CJ, Laporta DP, Viner S, Passerini L, Devitt H, Kirby A, Jacka M; Canadian Critical Care Clinical Trials Group. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med. 2003 Jan 2;348(1):5-14. PubMed PMID: 12510037. [Free Fulltext]

  • MCRCT
  • n = 1994
  • inclusion criteria: elderly, high risk, urgent/elective major surgery -> ICU admission
  • PA catheter + goal directed therapy VS standard care (CVL + no strict haemodynamic goals)
    -> no difference in in-hospital, 6 or 12 month mortality
    -> no difference in length of stay in hospital
    -> increase PE’s in PAC group
    -> PAC did improve outcomes in patients who one would think would benefit from them!

Richard C, et al; French Pulmonary Artery Catheter Study Group. Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2003 Nov 26;290(20):2713-20. PubMed PMID: 14645314. [Free Fulltext]

  • MCRCT
  • n = 676
  • early shock, ARDS or both
    -> no difference in mortality or hospitalisation

Rajaram SS, et al. Pulmonary artery catheters for adult patients in intensive care. Cochrane Database Syst Rev. 2013 Feb 28;2:CD003408. doi: 10.1002/14651858.CD003408.pub3. Review. PubMed PMID: 23450539. [Free Fulltext]

  • 13 studies
  • n =5686
  • use of a PAC did not alter the mortality, general ICU or hospital LOS, or cost for adult patients in intensive care.
  • studies needed on specific PAC protocols in specific patient groups

References and Links


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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