Scope and Impact of the Problem
Pulmonary artery pressure (PAP), pulmonary artery occlusion pressure (PAOP), and central venous pressure (CVP) may aid in the differential diagnosis in pulmonary hypertension1-4 and may be beneficial in complex shock states.5 Less invasive hemodynamic methods, in conjunction with the patient’s medical history, may also be useful in the differential diagnosis of cardiogenic shock.6
The appropriate use of pulmonary artery catheter (PAC)–guided therapy is associated with decreased mortality in patients with refractory heart failure/cardiogenic shock7 but is not associated with improved outcomes in patients with less severe heart failure. In trauma patients, PAC-guided therapy may benefit older, more severely injured patients, but use of a PAC is not associated with improved outcomes in other trauma populations.8,9 Use of a PAC is not associated with improved outcomes in other populations, including high-risk cardiothoracic surgery10 and general intensive care unit (ICU) patients, although many studies are more than 20 years old.11
The addition of CVP monitoring to guided therapy is not associated with improved outcomes in patients with severe sepsis and septic shock.12-16 The PAOP and CVP are not accurate for identifying which patients will respond to a fluid bolus with an increase in stroke volume, and alternative methods such as functional hemodynamic indicators should be used.17-19 Although the CVP has been identified as a fixed target for resuscitation, debate remains about whether CVP, if used at all, should more appropriately be considered a stopping point.20,21
Use of PACs has decreased, particularly in nonsurgical ICUs.22 This decreased use indicates a need for alternative training methods, such as simulation, to maintain proficiency in PAP monitoring if continued use of PACs is anticipated.