ITU Journal Club:

Dr. Clinton Jones.ST4 Anaesthetics.

Haemodynamic monitoring:“optimise tissue oxygenation and help prevent multiorganfailure “

Central Haemodynamic monitoring:• PAC• LIDCO• PICCO• ODM• USCOM• TTE• TOE• CVP

Peripheral Haemodynamic monitoring:• Microcirculation• Gastric tonometry• Sublingual capnography• Tissue oximetry• Mixed venous or central

venous oxygen saturations.

2009 JICS Debate: CO monitoring in ITUIntensivists shouldn’t use CO monitoring:• It doesn’t make patients better.• All monitoring offers patients risk for no clear benefit.• Distracting and delays or prevents effective interventions –

outcome from sepsis is time related.• Expensive• No evidence exists to show clinicians interpret data and alter

clinical therapy correctly.

• EGDT in sepsis works and does not require measurement of CO.

Debate continues:

Intensivists should use cardiac output monitoring:

• Fluid resuscitation and inotropic support is always performed with specific aims in mind. • Patient & physician specific early goal directed

therapy.• To prevent excessive use of fluids and inotropes

and subsequent harmful effects.

Cochrane Review:

Pulmonary artery catheters for adult patients in intensive care (Review) 2013 The Cochrane Collaboration. Rajaram SS, Desai NK, Kalra, Gajera M et al. 2013, Issue 2.

Does the use of PAC in ICU lead to increased mortality, hospital or ICU LOS and cost?

Objective:

To provide an up-to-date assessment of the effectiveness of a PAC on:Primary outcomes:1. All types of hospital mortality (28 days, 30 days, 60 days or

ICU mortality).

Secondary outcomes:2. LOS in ICU3. LOS in hospital4. Cost of hospital care

Search Methods:• Cochrane Central Register of Controlled Trials• MEDLINE (1954 – 2012)• EMBASE (1980 – 2012)• CINAHL (1982 – 2012)• Liaised with industry• Contacted key people in the field of critical care

Selection criteria:

• Included all RCT’s conducted in adults (16 years and over) ICU’s, comparing management with and without a PAC.

• Screened titles, abstracts and then full texts from an electronic search.

• Two authors independently reviewed reports. Final reports included in paper after consensus agreement.

• Domains for potential risk of bias were identified and assessed:• Selection bias• Performance bias• Detection bias• Attrition bias• Reporting bias

Data Collection:• Included 13 RCT’s.• Total number of patients

5686.• All patients admitted to

ICU and randomised to PAC or control group (+/- CVC line).

RESULTS

Combined Mortality:n=5686, p = 0.73, RR 1.01

LOS:• General ICU LOS

4 studies with n=2723 assessed.No significant difference detected.

• ICU LOS: High risk surgeryHeterogeneity high and meta-analysis not appropriate.

• Hospital LOSOverall 9 studies reported hospital LOS.

2 studies, n=1689.Management with vs without PAC (p=0.30).

Cost:

• 4 studies collected data on cost.• All conducted in US.• Only total costs was analysed in this

review.• Cost for PAC group was demonstrated

higher than for CVC group. • However only 2 studies qualified for

analysis (n=191) and no significant differences was shown.

•Mortality outcome is robust.•Hospital and ICU LOS is high.•Cost analysis low.

Quality of Evidence:

Conclusions:

• Current evidence is a review of all available RCTs to date.• Use of PAC does not increase mortality, ICU LOS

or hospital LOS.• Shock reversal, improvement in organ

dysfunction and less vasopressor use are outcome measures needed to be studied.• Further research assessing PAC with goal

directed therapy protocols is required.

Implications for practice:

• PAC is a safe diagnostic and monitoring tool, not a treatment intervention.• Prior to reintroducing PAC further training is needed.• Further studies are needed to determine optimal PAC

management protocols for specific ICU patients.• Early insertion of PAC in the management of sepsis

may offer the greatest benefit – further study required.• PAC haemodynamicsare best assessed in combination

with the inclusion of clinical indices of perfusion.

Future Research:

• In light of the findings of this paper it should now be possible to examine protocol specific management with a PAC in selected groups of critically ill patients against appropriate controls.

Many Thanks.Any questions?