Despite widespread use for more than three decades, the clinical utility of pulmonary-artery catheters remains controversial. Two systematic reviews of small, randomized clinical trials did not demonstrate any overall benefit from the use of these catheters, and some observational studies have even noted possible adverse effects on outcomes. Sandham and colleagues conducted a multicenter, randomized, controlled clinical trial to compare pulmonary-artery catheter use with standard therapy in high-risk elderly patients who underwent surgery followed by a hospital stay.
Results of trials of the use of pulmonary-artery catheters have been limited by methodologic problems, such as patient selection bias. Eligible patients were older than 60 years, classified as high risk (American Society of Anesthesiologists class III or IV), and scheduled for urgent surgery. Of the 3,803 eligible patients, 1,994 (52.4 percent) underwent randomization. The most common reasons that patients were not enrolled in the study were decline of consent by the patient (1,074 patients); unavailability of a monitoring bed in the intensive care unit (370 patients); and lack of referral by the physician (365 patients).
Enrolled patients were randomized to either standard care without the use of pulmonary-artery catheter (most used a central venous catheter) or presurgical placement of a pulmonary-artery catheter. In patients with pulmonary-artery catheters, medication and fluid management was based on prespecified goals for oxygen-delivery index, cardiac index, pulmonary capillary wedge pressure, heart rate, hematocrit level, and other clinical variables. Crossover from standard care to the placement of a pulmonary-artery catheter occurred in 24 (2.4 percent) of the patients in the standard-care group. All patients were followed postoperatively for a minimum of 24 hours in the intensive care unit.
The median length of hospital stay was 10 days in both treatment groups. In-hospital mortality also was similar in the two groups. In the standard care group, 77 patients (7.7 percent) died without being discharged compared with 78 patients (7.8 percent) in the pulmonary-artery catheter group. Patients with pulmonary-artery catheters were more likely than patients in the standard-care group to receive inotropic agents, vasodilators, antihypertensive medications, and blood transfusions. The incidence of myocardial infarction, congestive heart failure, supraventricular tachycardia, ventricular tachycardia, hepatic insufficiency, sepsis from the catheter, and pneumonia and arrhythmias was not significantly different between the two groups. Pulmonary embolism occurred in eight of 997 patients (0.8 percent) with pulmonary-artery catheters, compared with none of the patients receiving standard care.
The authors conclude that the use of a pulmonary-artery catheter is not associated with any clinical advantage over standard care in the perioperative management of high-risk surgical patients.