24 Nov 08
The pulmonary artery catheter, 1967–2007 Rest in peace?
By GD Rubenfeld, E McNamara-Aslin, L Rubinson
In this issue of JAMA, an investigation using a nationally representative administrative database reported a marked decline in the use of pulmonary artery (PA) catheters from 5.66 per 1000 medical admissions in 1993 to 1.99 per 1000 medical admissions in 2004. These significant declines in PA catheter utilization were most prominent for patients with myocardial infarction (81% decrease), but also were significant for surgical patients (63% decrease) and for patients with septicemia (54% decrease).
These national data are consistent with trends at our institution, an academic public hospital and level 1 trauma center with 75 intensive care unit (ICU) beds with a relatively low volume of patients with acute myocardial infarction. For example, from July 2002 to May 2003, the hospital billed patients for 871 PA catheters. Although the ICU census has increased, the use of PA catheters has declined to 262 catheters from July 2006 to May 2007. Recently, nurses and residents gathered around the bedside of the sole patient in the medical ICU with a PA catheter so they could actually observe one in use. If the demise of the PA catheter is more than a rumor, why has this occurred and what are the implications for clinical care and training?
Forty years have passed since the afternoon in 1967 when Jeremy Swan watched boats from a Santa Monica beach and conceived of a bedside procedure that would use cardiac output to sail a catheter into the pulmonary arteries. PA catheterization was initially used to assess patients with acute myocardial infarction, but use of this procedure spread rapidly to the operating department and from there to a broad range of patients in the ICU. The addition of mixed venous oximetry and cardiac output measurement to central venous and pulmonary arterial pressure monitoring provided clinicians with detailed feedback about physiological response to therapy. This information, coupled with clinical evaluation, allowed clinicians to titrate fluids, inotropes, vasopressors, and vasodilators to optimize oxygen delivery to tissues. Twenty years after its invention (in 1987), more than 2 million PA catheters had been sold worldwide annually. However, enthusiasm was not universal, and in the late 1980s concerns were raised about the unknown benefits of PA catheter–guided therapy in the face of potential risks from an invasive procedure.