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Impact of the Pulmonary Artery Catheter in Critically Ill Patients Meta-analysis of Randomized Clinical Trials

Monica R. Shah, MD, MHS, MSJ; Vic Hasselblad, PhD; Lynne W. Stevenson, MD; Cynthia Binanay, RN, BSN; Christopher M. O’Connor, MD; George Sopko, MD, MPH; Robert M. Califf, MD
JAMA. 2005;294(13):1664-1670. doi:10.1001/jama.294.13.1664.
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Context Randomized clinical trials (RCTs) evaluating the pulmonary artery catheter (PAC) have been limited by small sample size. Some nonrandomized studies suggest that PAC use is associated with increased morbidity and mortality.

Objective To estimate the impact of the PAC device in critically ill patients.

Data Sources MEDLINE (1985-2005), the Cochrane Controlled Trials Registry (1988-2005), the National Institutes of Health ClinicalTrials.gov database, and the US Food and Drug Administration Web site for RCTs in which patients were randomly assigned to PAC or no PAC were searched. Results from the ESCAPE trial of patients with severe heart failure were also included. Search terms included pulmonary artery catheter, right heart catheter, catheter, and Swan-Ganz.

Study Selection Eligible studies included patients who were undergoing surgery, in the intensive care unit (ICU), admitted with advanced heart failure, or diagnosed with acute respiratory distress syndrome and/or sepsis; and studies that reported death and the number of days hospitalized or the number of days in the ICU as outcome measures.

Data Extraction Information on eligibility criteria, baseline characteristics, interventions, outcomes, and methodological quality was extracted by 2 reviewers. Disagreements were resolved by consensus.

Data Synthesis In 13 RCTs, 5051 patients were randomized. Hemodynamic goals and treatment strategies varied among trials. A random-effects model was used to estimate the odds ratios (ORs) for death, number of days hospitalized, and use of inotropes and intravenous vasodilators. The combined OR for mortality was 1.04 (95% confidence interval [CI], 0.90-1.20; P = .59). The difference in the mean number of days hospitalized for PAC minus the mean for no PAC was 0.11 (95% CI, −0.51 to 0.74; P = .73). Use of the PAC was associated with a higher use of inotropes (OR, 1.58; 95% CI, 1.19-2.12; P = .002) and intravenous vasodilators (OR, 2.35; 95% CI, 1.75-3.15; P<.001).

Conclusions In critically ill patients, use of the PAC neither increased overall mortality or days in hospital nor conferred benefit. Despite almost 20 years of RCTs, a clear strategy leading to improved survival with the PAC has not been devised. The neutrality of the PAC for clinical outcomes may result from the absence of effective evidence-based treatments to use in combination with PAC information across the spectrum of critically ill patients.

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Figure 1. MEDLINE Articles Evaluated for Inclusion in the Meta-analysis
Graphic Jump Location

PAC indicates pulmonary artery catheter; ARDS, acute respiratory distress syndrome.
*Results from the ESCAPE trial10 and the recently published PAC-Man trial14 were also included.

Figure 2. Odds Ratio (PAC vs No PAC) for Mortality of RCTs Evaluating the Safety and Efficacy of the PAC
Graphic Jump Location

CI indicates confidence interval; NA, not available; PAC, pulmonary artery catheter; RCT, randomized clinical trial. P for heterogeneity = .36.

Figure 3. Mean Difference in the Average Number of Days Hospitalized in PAC Randomized Controlled Trials (Mean for PAC − Mean for No PAC)
Graphic Jump Location

CI indicates confidence interval; PAC, pulmonary artery catheter. P for heterogeneity = .91.



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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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