Pulmonary Artery Catheterization Guidelines
Primary Recommendation
PAC should not be used routinely in surgical or critically ill patients, but is appropriate only in highly selected cases where hemodynamic instability persists despite initial therapy and when anticipated benefits clearly outweigh the substantial risks of serious complications. 1
Specific Indications for PAC Use
Class I Recommendation (Appropriate Use)
PAC is recommended in hemodynamically unstable patients who are not responding predictably to traditional treatments, particularly those with combined congestion and hypoperfusion. 1 The catheter should be inserted when specific hemodynamic data are needed to guide fluid management, vasoactive therapies, and inotropic agents, and removed as soon as optimization is achieved. 1
Clinical Scenarios Where PAC May Be Considered:
- Acute heart failure patients with severe hemodynamic compromise not resolved by initial therapy 1
- Complex diagnostic situations distinguishing cardiogenic from non-cardiogenic mechanisms in patients with concurrent cardiac and pulmonary disease 1
- Severe diffuse pulmonary pathology requiring estimation of PCWP, cardiac output, and other hemodynamic variables 1
- High-risk surgical patients with significant cardiovascular disease, pulmonary dysfunction, hypoxia, or renal insufficiency when hemodynamic optimization is critical 1
Contraindications and Inappropriate Use
PAC is inappropriate as routine practice in surgical patients and should be avoided in low- or moderate-risk patients (ASA physical status 1 or 2). 1
Evidence Against Routine Use:
- No mortality benefit demonstrated: Multiple randomized trials show no reduction in mortality with PAC use in general intensive care or surgical populations 2, 3
- Increased complications: A large observational study of 4,059 noncardiac surgery patients showed 4-fold increased major cardiac events (15.4% vs 3.6%), increased congestive heart failure (OR 2.9), and increased major noncardiac events (OR 2.2) in PAC patients 1
- Higher pulmonary embolism risk: A multicenter trial of 1,994 elderly surgical patients showed significantly higher pulmonary embolism rates (8 events vs 0 events, P=0.004) with no survival benefit 1
Serious Complications and Risks
Serious complications occur in 0.1-0.5% of PAC-monitored surgical patients, with cardiologists estimating even higher rates (2-5% severe morbidity, 0.5-1.0% mortality). 1
Major Complications:
- Pulmonary artery rupture: 0.03-1.5% incidence with 41-70% mortality 1
- Catheter-related sepsis: 0.7-11.4% incidence 1
- Venous thrombosis: 0.5-66.7% incidence 1
- Complete heart block: 0-8.5% in patients with pre-existing left bundle-branch block 1
- Valvular/endocardial vegetations: 2.2-100% in autopsy studies 1
- Pulmonary infarction: 0.1-5.6% incidence 1
Central Venous Access Complications:
Critical Limitations of PAC Data
Measurement Accuracy Issues:
PCWP does not accurately reflect left ventricular end-diastolic pressure in multiple common conditions: 1
- Mitral stenosis
- Aortic regurgitation
- Ventricular interdependence
- High airway pressure or PEEP ventilation
- Stiff left ventricle (LVH, diabetes, fibrosis, obesity, ischemia)
Cardiac output by thermodilution is unreliable with severe tricuspid regurgitation (frequently present in acute heart failure patients). 1
CVP measurements rarely correlate with left atrial pressures or LV filling pressures in acute heart failure patients and are affected by tricuspid regurgitation and PEEP. 1
Competency Requirements
A critical pitfall is inadequate provider competency in PAC interpretation and management. 1
Evidence of Knowledge Deficits:
- Physician competency: Only 67% of questions answered correctly on PAC knowledge examinations; one-third could not correctly identify PA occlusion pressure on clear tracings 1
- Nursing competency: Only 57% of critical care nurse responses correct; only 39% correctly identified PA wedge measurement from waveform 1
- Variable understanding may account for higher rates of postoperative congestive heart failure and excessive fluid administration observed in PAC studies 1
PAC use should be limited to centers with experienced personnel who maintain regular catheter use and demonstrate competency in both technical insertion and cognitive interpretation skills. 1
Timing and Duration
Because complications increase with duration of use, insert the catheter only when specific hemodynamic data are immediately needed and remove it as soon as therapy is optimized. 1 The infection risk increases significantly with prolonged catheter residence. 1
Cost Considerations
PAC use is associated with significantly higher hospital costs ($667 first day, $541 each additional day; total increase $7,900 in one study), related to longer ICU stays (average 2 days longer) and increased intensity of care. 1 These costs occur without demonstrated mortality benefit. 2, 3
Alternative Monitoring Approaches
Less invasive alternatives should be considered first: 1
- Central venous catheters for CVP and SVC oxygen saturation monitoring 1
- Transesophageal echocardiography (though carries risks of esophageal injury, vocal cord paralysis, dysrhythmias) 1
- Newer less-invasive cardiac output monitoring devices 3
Summary Algorithm for Decision-Making
- Is the patient hemodynamically unstable despite initial standard therapy? If no → Do not use PAC 1
- Is the hemodynamic response to treatment unpredictable? If no → Do not use PAC 1
- Is there combined congestion and hypoperfusion requiring precise fluid/inotrope titration? If no → Consider alternatives 1
- Are experienced personnel available for insertion and interpretation? If no → Do not use PAC 1
- Can the catheter be removed within 24-48 hours once therapy is optimized? If no → Reconsider necessity 1
- Do the anticipated benefits clearly outweigh the 0.1-0.5% risk of serious complications? If no → Do not use PAC 1