background Some observational studies suggest that the use of pulmonary-artery catheters to guide therapy is associated with increased mortality. methods We performed a randomized trial comparing goal-directed therapy guided by a pulmonary-artery catheter with standard care without the use of a pulmonary-artery catheter. The subjects were high-risk patients 60 years of age or older, with American Society of Anesthesiologists (ASA) class III or IV risk, who were scheduled for urgent or elective major surgery, followed by a stay in an intensive care unit. Outcomes were adjudicated by observers who were unaware of the treatment-group assignments. The primary outcome was in-hospital mortality from any cause. results Of 3803 eligible patients, 1994 (52.4 percent) underwent randomization. The baseline characteristics of the two treatment groups were similar. A total of 77 of 997 patients who underwent surgery without the use of a pulmonary-artery catheter (7.7 percent) died in the hospital, as compared with 78 of 997 patients in whom a pulmonary-artery catheter was used (7.8 percent) — a difference of 0.1 percentage point (95 percent confidence interval, i2.3 to 2.5). There was a higher rate of pulmonary embolism in the catheter group than in the standard-care group (8 events vs. 0 events, P=0.004). The survival rates at 6 months among patients in the standard-care and catheter groups were 88.1 and 87.4 percent, respectively (difference, i0.7 percentage point [95 percent confidence interval, i3.6 to 2.2]; negative survival differences favor standard care); at 12 months, the rates were 83.9 and 83.0 percent, respectively (difference, i0.9 percentage point [95 percent confidence interval, i4.3 to 2.4]). The median hospital stay was 10 days in each group. conclusions We found no benefit to therapy directed by pulmonary-artery catheter over standard care in elderly, high-risk surgical patients requiring intensive care.

/pdf/a-randomized-controlled-trial-of-the-use-of-pulmonary-artery-4jhlk0y9mo.pdf

A Randomized, Controlled Trial of the Use of Pulmonary-Artery Catheters in High-Risk Surgical Patients

Management of Spontaneous Pneumothorax: An American College of Chest Physicians Delphi Consensus Statement

Sepsis is an infection-induced syndrome defined as the presence of two or more of the following features of systemic inflammation: fever or hypothermia, leukocytosis or leukopenia, tachycardia, and tachypnea or a supranormal minute ventilation.1 When an organ system begins to fail because of sepsis, the sepsis is considered severe. Each year, sepsis develops in more than 500,000 patients in the United States, and only 55 to 65 percent survive.2,3 Fortunately, the death rates in some subgroups of patients with sepsis-induced organ failure have decreased, even though there is no specific therapy for sepsis.3,4 The reduced mortality may be . . .

Treating Patients with Severe Sepsis

Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial

Background: Intraoperative hypovolemia is common and is a potential cause of organ dysfunction, increased postoperative morbidity, length of hospital stay, and death. The objective of this prospective, randomized study was to assess the effect of goal-directed intraoperative fluid administration on length of postoperative hospital stay. Methods: One hundred patients who were to undergo major elective surgery with an anticipated blood loss greater than 500 ml were randomly assigned to a control group (n 50) that received standard intraoperative care or to a protocol group (n 50) that, in addition, received intraoperative plasma volume expansion guided by the esophageal Doppler monitor to maintain maximal stroke volume. Length of postoperative hospital stay and postoperative surgical morbidity were assessed. Results: Groups were similar with respect to demographics, surgical procedures, and baseline hemodynamic variables. The protocol group had a significantly higher stroke volume and cardiac output at the end of surgery compared with the control group. Patients in the protocol group had a shorter duration of hospital stay compared with the control group: 5 3 versus 7 3 days (mean SD), with a median of 6 versus 7 days, respectively (P 0.03). These patients also tolerated oral intake of solid food earlier than the control group: 3 0.5 versus 4.7 0.5 days (mean SD), with a median of 3 versus 5 days, respectively (P 0.01). Conclusions: Goal-directed intraoperative fluid administration results in earlier return to bowel function, lower incidence of postoperative nausea and vomiting, and decrease in length of postoperative hospital stay. INTRAOPERATIVE hypovolemia is common and may be a potential cause of organ dysfunction, increased postoperative morbidity, and death. 1,2 Goal-directed plasma volume expansion during the intraoperative period is associated with improved outcome and reduction in hospital stay in patients undergoing cardiac and major orthopedic surgery. 3–5 The esophageal Doppler monitor (EDM) is an Food and Drug Administration–approved device that permits rapid, minimally invasive, and continuous estimation of cardiac output. 6 The cardiac output measurements obtained with the EDM have been shown to correlate well with the thermodilution method by different investigators. 7–11 Using the EDM to guide intraoperative plasma volume expansion, Sinclair et al. 4 demonstrated significant improvement in postoperative recovery and shortened hospital stay in patients undergoing proximal femoral neck fracture repair. Mythen and Webb, 3 in a study in cardiac patients, demonstrated a reduction in the incidence of gastrointestinal mucosal hypoperfusion and major complications in patients who received plasma volume optimization. In this study, we investigated whether goal-directed intraoperative plasma volume expansion guided by the EDM would shorten the length of hospital stay and improve postoperative outcomes (gastrointestinal and renal dysfunction) in patients undergoing moderate-risk surgery.

/pdf/goal-directed-intraoperative-fluid-administration-reduces-56uxct9goe.pdf

J. W. Hoyt

Papers

Pulmonary Artery Catheter Consensus Conference: Consensus statement