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ITU Journal Club:

ITU Journal Club:. Dr. Clinton Jones. ST4 Anaesthetics. Haemodynamic monitoring: “ optimise tissue oxygenation and help prevent multiorgan failure “. Central Haemodynamic monitoring: PAC LIDCO PICCO ODM USCOM TTE TOE CVP. Peripheral Haemodynamic monitoring: Microcirculation

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ITU Journal Club:

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  1. ITU Journal Club: Dr. Clinton Jones. ST4 Anaesthetics.

  2. 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.

  3. 2009 JICS Debate: CO monitoring in ITU Intensivists 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.

  4. 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.

  5. 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?

  6. Objective: To provide an up-to-date assessment of the effectiveness of a PAC on: Primary outcomes: • All types of hospital mortality (28 days, 30 days, 60 days or ICU mortality). Secondary outcomes: • LOS in ICU • LOS in hospital • Cost of hospital care

  7. 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

  8. 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

  9. 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).

  10. RESULTS

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

  12. LOS: • General ICU LOS 4 studies with n=2723 assessed. No significant difference detected. • ICU LOS: High risk surgery Heterogeneity high and meta-analysis not appropriate. • Hospital LOS Overall 9 studies reported hospital LOS. 2 studies, n=1689. Management with vs without PAC (p=0.30).

  13. 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.

  14. Quality of Evidence: • Mortality outcome is robust. • Hospital and ICU LOS is high. • Cost analysis low.

  15. 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.

  16. 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.

  17. 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.

  18. Many Thanks. Any questions?

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